NCLEX-RN Practice Exam #14 In Text Mode: All questions and answers are given for reading and answering at your own pace.
Question 1. A client who has glaucoma is to have miotic eyedrops instilled in both eyes. The nurse knows that the purpose of the medication is to:
A). Anesthetize the cornea.
B). Constrict the pupils.
C). Dilate the pupils.
D). Paralyze the muscles of accommodation.
Question 1 Answer: B). Constrict the pupils.
Question 1 Explanation: Miotic eyedrops constrict the pupil and allow aqueous humor to drain out of the Canal of Schlemm. They do not anesthetize the cornea, dilate the pupil, or paralyze the muscles of the eye.
Question 2. The client using a diaphragm should be instructed to:
A). Have the diaphragm resized if she gains 5 pounds.
B). Refrain from keeping the diaphragm in longer than 4 hours.
C). Have the diaphragm resized if she has any surgery.
D). Keep the diaphragm in a cool location.
Question 2 Answer: D). Keep the diaphragm in a cool location.
Question 2 Explanation: The client using a diaphragm should keep the diaphragm in a cool location. She should refrain from leaving the diaphragm in longer than 8 hours, not 4 hours. She should have the diaphragm resized when she gains or loses 10 pounds or has abdominal surgery.
Question 3. The client with a pacemaker should be taught to:
A). Check his blood pressure daily.
B). Monitor his pulse rate.
C). Refrain from using a microwave oven.
D). Report ankle edema.
Question 3 Answer: B). Monitor his pulse rate.
Question 3 Explanation: The client with a pacemaker should be taught to count and record his pulse rate. Other answer choices are incorrect. Ankle edema is a sign of right-sided congestive heart failure. Although this is not normal, it is often present in clients with heart disease. If the edema is present in the hands and face, it should be reported. Checking the blood pressure daily is not necessary for these clients. The client with a pacemaker can use a microwave oven, but he should stand about 5 feet from the oven while it is operating.
Question 4. The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug?
A). Changes in skin color.
B). Urinary frequency.
C). Changes in vision.
Question 4 Answer: A). Changes in skin color.
Question 4 Explanation: Clients taking Amphotericin B should be monitored for liver, renal, and bone marrow function because this drug is toxic to the kidneys and liver, and causes bone marrow suppression. Jaundice is a sign of liver toxicity and is not specific to the use of Amphotericin B. Changes in vision are not related, and nausea is a side effect, not a sign of toxicity; nor is urinary frequency.
Question 5. During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?
A). Right breech presentation.
B). Left occipital transverse presentation.
C). Right occipital anterior presentation.
D). Left sacral anterior presentation.
Question 5 Answer: A). Right breech presentation.
Question 5 Explanation: If the fetal heart tones are heard in the right upper abdomen, the infant is in a breech presentation. If the infant is positioned in the right occipital anterior presentation, the FHTs will be located in the right lower quadrant. If the fetus is in the sacral position, the FHTs will be located in the center of the abdomen. If the FHTs are heard in the left lower abdomen, the infant is most likely in the left occipital transverse position.
Question 6. The nurse is providing postpartum teaching for a mother planning to breastfeed her infant. Which of the client’s statements indicates the need for additional teaching?
A). “I’m drinking four glasses of fluid during a 24-hour period.”.
B). “I’m wearing a support bra.”.
C). “While I’m in the shower, I’ll allow the water to run over my breasts.”.
D). “I’m expressing milk from my breast.”.
Question 6 Answer: A). “I’m drinking four glasses of fluid during a 24-hour period.”.
Question 6 Explanation: Mothers who plan to breastfeed should drink plenty of liquids, and four glasses is not enough in a 24-hour period. Wearing a support bra is a good practice for the mother who is breastfeeding as well as the mother who plans to bottle-feed. Expressing milk from the breast will stimulate milk production. Allowing the water to run over the breast will also facilitate “letdown,” when the milk begins to be produced.
Question 7. The client with color blindness will most likely have problems distinguishing which of the following colors?
Question 7 Answer: A). Violet.
Question 7 Explanation: Clients with color blindness will most likely have problems distinguishing violets, blues, and green. The colors in other answer choices are less commonly affected.
Question 8. A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication:
A). Once per day in the morning.
B). Three times per day with meals.
C). Four times per day.
D). Once per day at bedtime.
Question 8 Answer: B). Three times per day with meals.
Question 8 Explanation: Pancreatic enzymes should be given with meals for optimal effects. These enzymes assist the body in digesting needed nutrients. Other answer choices are incorrect methods of administering pancreatic enzymes.
Question 9. The primary physiological alteration in the development of asthma is:
A). Hypersecretion of abnormally viscous mucus.
B). Bronchiolar inflammation and dyspnea.
C). Spasm of bronchiolar smooth muscle.
D). Infectious processes causing mucosal edema.
Question 9 Answer: C). Spasm of bronchiolar smooth muscle.
Question 9 Explanation: Asthma is the presence of bronchiolar spasms. This spasm can be brought on by allergies or anxiety. Answer choice bronchiolar inflammation and dyspnea is incorrect because the primary physiological alteration is not inflammation. Answer choice hypersecretion of abnormally viscous mucus is incorrect because there is the production of abnormally viscous mucus, not a primary alteration. Answer choice infectious processes causing mucosal edema is incorrect because infection is not primary to asthma.
Question 10. A client with a severe corneal ulcer has an order for Gentamycin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops?
A). The medications should not be used in the same client..
B). The medications should be separated by a cycloplegic drug.
C). Allow 5 minutes between the two medications..
D). The medications may be used together..
Question 10 Answer: C). Allow 5 minutes between the two medications..
Question 10 Explanation: When using eyedrops, allow 5 minutes between the two medications. These medications can be used by the same client but it is not necessary to use a cyclopegic with these medications.
Question 11. To maintain Bryant’s traction, the nurse must make certain that the child’s:
A). Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed.
B). Hips are resting on the bed, with the legs suspended at a right angle to the bed.
C). Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed.
D). Hips and legs are flat on the bed, with the traction positioned at the foot of the bed.
Question 11 Answer: C). Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed.
Question 11 Explanation: Bryant’s traction is used for fractured femurs and dislocated hips. The hips should be elevated 15° off the bed. The hips should not be resting on the bed. The hips should not be above the level of the body. The hips and legs should not be flat on the bed.
Question 12. A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:
A). Allow her in the unit kitchen for extra food whenever she pleases.
B). Encourage her appetite by sending out for her favorite foods.
C). Serve her small, attractively arranged portions.
D). Serve high-calorie foods she can carry with her.
Question 12 Answer: D). Serve high-calorie foods she can carry with her.
Question 12 Explanation: The client with mania is seldom sitting long enough to eat and burns many calories for energy. Encouraging her appetite by sending out for her favorite foods is incorrect because the client should be treated the same as other clients. Small meals are not a correct option for this client. Allowing her into the kitchen gives her privileges that other clients do not have and should not be allowed.
Question 13. The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after:
Question 13 Answer: B). 1900.
Question 13 Explanation: Clients who are being retrained for bladder control should be taught to withhold fluids after about 7 p.m., or 1. The times in other answer choices are too early in the day.
Question 14. A client is admitted for an MRI. The nurse should question the client regarding:
A). Inability to move his feet.
B). Allergies to antibiotics.
D). A titanium hip replacement.
Question 14 Answer: C). Pregnancy.
Question 14 Explanation: Clients who are pregnant should not have an MRI because radioactive isotopes are used. However, clients with a titanium hip replacement can have an MRI. No antibiotics are used with this test and the client should remain still only when instructed.
Question 15. A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?
A). Encourage a high-carbohydrate diet.
B). Encourage fluids.
C). Utilize an incentive spirometer to improve respiratory function.
D). Limit the client’s activity.
Question 15 Answer: B). Encourage fluids.
Question 15 Explanation: Clients taking Acyclovir should be encouraged to drink plenty of fluids because renal impairment can occur. Limiting activity is not necessary, nor is eating a high-carbohydrate diet. Use of an incentive spirometer is not specific to clients taking Acyclovir.
Question 16. The client has an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that the nurse should contact the lab for them to collect the blood:
A). 15 minutes after the infusion.
B). 30 minutes before the infusion.
C). 2 hours after the infusion.
D). 1 hour after the infusion.
Question 16 Answer: B). 30 minutes before the infusion.
Question 16 Explanation: A trough level should be drawn 30 minutes before the third or fourth dose. The times in other answer choices are incorrect times to draw blood levels.
Question 17. Which of the following diet instructions should be given to the client with recurring urinary tract infections?
A). Perform pericare with hydrogen peroxide..
B). Increase intake of meats..
C). Drink a glass of cranberry juice every day..
D). Avoid citrus fruits..
Question 17 Answer: C). Drink a glass of cranberry juice every day..
Question 17 Explanation: Cranberry juice is more alkaline and, when metabolized by the body, is excreted with acidic urine. Bacteria does not grow freely in acidic urine. Increasing intake of meats is not associated with urinary tract infections, so increasing intake of meats is incorrect. The client does not have to avoid citrus fruits and pericare should be done, but hydrogen peroxide is drying.
Question 18. The nurse should visit which of the following clients first?
A). The client with hypertension being maintained on Lisinopril.
B). The client with chest pain and a history of angina.
C). The client with Raynaud’s disease.
D). The client with diabetes with a blood glucose of 95mg/dL.
Question 18 Answer: B). The client with chest pain and a history of angina.
Question 18 Explanation: The client with chest pain should be seen first because this could indicate a myocardial infarction. The client with diabetes with a blood glucose of 95mg/dL has a blood glucose within normal limits. The client with hypertension being maintained on Lisinopril is maintained on blood pressure medication. The client with Raynaud’s disease is in no distress.
Question 19. Which action by the nurse indicates understanding of herpes zoster?
A). The nurse administers oxygen.
B). The nurse wears gloves when providing care..
C). The nurse administers a prescribed antibiotic..
D). The nurse covers the lesions with a sterile dressing..
Question 19 Answer: B). The nurse wears gloves when providing care..
Question 19 Explanation: Herpes zoster is shingles. Clients with shingles should be placed in contact precautions. Wearing gloves during care will prevent transmission of the virus. Covering the lesions with a sterile gauze is not necessary, antibiotics are not prescribed for herpes zoster, and oxygen is not necessary for shingles.
Question 20. A client with a history of abusing barbiturates abruptly stops taking the medication. The nurse should give priority to assessing the client for:
A). Muscle cramping and abdominal pain.
B). Tachycardia and euphoric mood.
C). Depression and suicidal ideation.
D). Tachycardia and diarrhea.
Question 20 Answer: D). Tachycardia and diarrhea.
Question 20 Explanation: Barbiturates create a sedative effect. When the client stops taking barbiturates, he will experience tachycardia, diarrhea, and tachpnea. Even though depression and suicidal ideation go along with barbiturate use; it is not the priority. Muscle cramps and abdominal pain are vague symptoms that could be associated with other problems. Tachycardia is associated with stopping barbiturates, but euphoria is not.
Question 21. Cataracts result in opacity of the crystalline lens. Which of the following best explains the functions of the lens?
A). The lens magnifies small objects..
B). The lens orchestrates eye movement..
C). The lens focuses light rays on the retina..
D). The lens controls stimulation of the retina..
Question 21 Answer: C). The lens focuses light rays on the retina..
Question 21 Explanation: The lens allows light to pass through the pupil and focus light on the retina. The lens does not stimulate the retina, assist with eye movement, or magnify small objects.
Question 22. Which of the following tests should be performed before beginning a prescription of Accutane?
A). Perform a pregnancy test.
B). Obtain a creatinine level.
C). Monitor apical pulse.
D). Check the calcium level.
Question 22 Answer: A). Perform a pregnancy test.
Question 22 Explanation: Accutane is contraindicated for use by pregnant clients because it causes teratogenic effects. Calcium levels, apical pulse, and creatinine levels are not necessary.
Question 23. The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
A). “I will need to carry candy or some form of sugar with me all the time.”.
B). “I will eat a snack around three o’clock each afternoon.”.
C). “I will make sure I eat breakfast within 2 hours of taking my insulin.”.
D). “I can save my dessert from supper for a bedtime snack.”.
Question 23 Answer: B). “I will eat a snack around three o’clock each afternoon.”.
Question 23 Explanation: NPH insulin peaks in 8–12 hours, so a snack should be offered at that time. NPH insulin onsets in 90–120 minutes, so making sure I eat breakfast within 2 hours of taking my insulin is incorrect. Needing to carry candy or some form of sugar all the time is not necessary because NPH insulin is time released and does not usually cause sudden hypoglycemia. Saving dessert from supper for a bedtime snack is incorrect, but the client should eat a bedtime snack.
Question 24. Damage to the VII cranial nerve results in:
A). Facial pain.
B). Absence of eye movement.
D). Absence of ability to smell.
Question 24 Answer: A). Facial pain.
Question 24 Explanation: The facial nerve is cranial nerve VII. If damage occurs, the client will experience facial pain. The auditory nerve is responsible for hearing loss and tinnitus, eye movement is controlled by the Trochear or C IV, and the olfactory nerve controls smell.
Question 25. A client is receiving Pyridium (phenazopyridine hydrochloride) for a urinary tract infection. The client should be taught that the medication may:
A). Cause changes in taste.
B). Change the color of her urine.
C). Cause mental confusion.
D). Cause diarrhea.
Question 25 Answer: B). Change the color of her urine.
Question 25 Explanation: Clients taking Pyridium should be taught that the medication will turn the urine orange or red. It is not associated with diarrhea, mental confusion, or changes in taste. Pyridium can also cause a yellowish color to skin and sclera if taken in large doses.