NCLEX-RN Practice Exam #18

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Published on February 15, 2017 by NCLEX Exams

NCLEX-RN Practice Exam #18 In Text Mode: All questions and answers are given for reading and answering at your own pace.

Question 1. A 22 year-old patient in a mental health lock-down unit under suicide watch appears happy about being discharged. Which of the following is probably happening?
A). The patient’s mood is improving..
B). The patient is excited about being around family again..
C). The patient’s suicide plan has probably progressed..
D). The patient’s plans for the future have been clarified..

Question 1 Answer: C). The patient’s suicide plan has probably progressed..
Question 1 Explanation: The suicide plan may have been decided.

Question 2. A 64 year-old male who has been diagnosed with COPD, and CHF exhibits an increase in total body weight of 10 lbs. over the last few days. The nurse should:
A). Encourage the patient to ambulate to reduce lower extremity edema.
B). Contact the patient’s physician immediately..
C). Check the patient’s vitals every 2 hours.
D). Check the intake and output on the patient’s flow sheet..

Question 2 Answer: D). Check the intake and output on the patient’s flow sheet..
Question 2 Explanation: Check the intake and output prior to making any decisions about patient care.

Question 3. A 64 year-old Alzheimer’s patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure?
A). Position the head of the bed at a 45 degree angle..
B). Secure the restraints to the bed rails on all extremities..
C). Notify the physician that restraints have been placed properly..
D). Communicate with the patient and family the need for restraints..

Question 3 Answer: D). Communicate with the patient and family the need for restraints..
Question 3 Explanation: Both the family and the patient should have the need for restraints explained to them.

Question 4. A nurse at outpatient clinic is returning phone calls that have been made to the clinic. Which of the following calls should have the highest priority for medical intervention?
A). A home health patient reports, “I am starting to have breakdown of my heels.”.
B). A patient that received an upper extremity cast yesterday reports, “I can’t feel my fingers in my right hand today.”.
C). A young female reports, ”I think I sprained my ankle about 2 weeks ago.”.
D). A middle-aged patient reports, ”My knee is still hurting from the TKR.”.

Question 4 Answer: B). A patient that received an upper extremity cast yesterday reports, “I can’t feel my fingers in my right hand today.”.
Question 4 Explanation: The patient experiencing neurovascular changes should have the highest priority. Pain following a TKR is normal, and breakdown over the heels is a gradual process. Moreover, a subacute ankle sprain is almost never a medical emergency.

Question 5. A 32 year-old male with a complaint of dizziness has an order for Morphine via. IV. The nurse should do which of the following first?
A). Retake vitals including blood pressure..
B). Perform a neurological screen on the patient..
C). Check the patient’s chest x-ray results..
D). Request the physician on-call assess the patient..

Question 5 Answer: A). Retake vitals including blood pressure..
Question 5 Explanation: Dizziness can be a sign of hypotension, that may a contraindication with Morphine.

Question 6. A high school nurse observes a 14 year-old female rubbing her scalp excessively in the gym. The most appropriate course of action for the nurse to do is:
A). Contact the female’s parents about your observations..
B). Observe the hairline and scalp for possible signs of lice..
C). Request a private evaluation of the female’s scalp from her parents..
D). Contact the student’s physician..

Question 6 Answer: B). Observe the hairline and scalp for possible signs of lice..
Question 6 Explanation: Observation of the student’s hair is the next step

Question 7. A nurse working a surgical unit, notices a patient is experiencing SOB, calf pain, and warmth over the posterior calf. All of these may indicate which of the following medical conditions?
A). Patient may be in the late phases of CHF..
B). Patient may be experiencing anxiety after surgery..
C). Patient may be exhibiting signs of dermatitis..
D). Patient may have a DVT..

Question 7 Answer: D). Patient may have a DVT..
Question 7 Explanation: All of these factors indicate a DVT

Question 8. A nurse is working in an outpatient orthopedic clinic. During the patient’s history the patient reports, “I tore 3 of my 4 Rotator cuff muscles in the past.” Which of the following muscles cannot be considered as possibly being torn?
A). Teres minor.
B). Supraspinatus.
C). Infraspinatus.
D). Teres major.

Question 8 Answer: D). Teres major.
Question 8 Explanation: Teres Minor, Infraspinatus, Supraspinatus, and Subscapularis make up the Rotator Cuff.

Question 9. A nurse has just started on the 7PM surgical unit shift. Which of the following patients should the nurse check on first?
A). A 75 year-old female who is scheduled for an EGD in 10 hours..
B). A 34 year-old male who is complaining of low back pain following back surgery and has an onset of urinary incontinence in the last hour..
C). A 21 year-old male who had a lower extremity BKA yesterday, following a MVA and has phantom pain..
D). A 27 year-old female who has received 1.5 units of RBC’s. via transfusion the previous day..

Question 9 Answer: B). A 34 year-old male who is complaining of low back pain following back surgery and has an onset of urinary incontinence in the last hour..
Question 9 Explanation: The new onset of urinary incontinence may require additional medical assessment, and the physician needs to be notified.

Question 10. A nurse is performing a screening on a patient that has been casted recently on the left lower extremity. Which of the following statements should the nurse be most concerned about?
A). The patient reports, “I have been having pain in my left calf.”.
B). The patient reports, “The arthritis in my wrists is flaring up, when I put weight on my crutches.”.
C). The patient reports, “I didn’t keep my extremity elevated like the doctor asked me to.”.
D). The patient reports, “My left leg has really been itching.”.

Question 10 Answer: A). The patient reports, “I have been having pain in my left calf.”.
Question 10 Explanation: Pain may be indicating neurovascular complication.

Question 11. A patient that has TB can be taken off restrictions after which of the following parameters have been met?
A). Normal body temperature for 48 hours..
B). After 30 days of isolation..
C). Non-productive cough for 72 hours..
D). Negative culture results..

Question 11 Answer: D). Negative culture results..
Question 11 Explanation: Negative culture results would indicate absence of infection.

Question 12. A 13 year old girl is admitted to the ER with lower right abdominal discomfort. The admitting nursing should take which the following measures first?
A). Start a Central Line..
B). Place the patient in right sidelying position for pressure relief..
C). Administer Loritab to the patient for pain relief..
D). Provide pain reduction techniques without administering medication..

Question 12 Answer: D). Provide pain reduction techniques without administering medication..
Question 12 Explanation: Do not administer pain medication or start a central line without MD orders.

Question 13. A 93 year-old female with a history of Alzheimer’s Disease gets admitted to an Alzheimer’s unit. The patient has exhibited signs of increased confusion and limited stability with gait. Moreover, the patient is refusing to use a w/c. Which of the following is the most appropriate course of action for the nurse?
A). Recommend the patient attempt to walk pushing the w/c for safety.
B). Recommend family members bring pictures to the patient’s room..
C). Recommend a speech therapy consult to the doctor..
D). Recommend the patient remain in her room at all times..

Question 13 Answer: B). Recommend family members bring pictures to the patient’s room..
Question 13 Explanation: Stimulation in the form of pictures may decrease signs of confusion.

Question 14. A nurse is covering a pediatric unit and is responsible for a 15 year-old male patient on the floor. The mother of the child states, “I think my son is sexually interested in girls.” The most appropriate course of action of the nurse is to respond by stating:
A). “I will talk to the doctor about it.”.
B). “Teenagers often exhibit signs of sexual interest in females.”.
C). “Has this been going on for a while?”.
D). “How do you know this?”.

Question 14 Answer: B). “Teenagers often exhibit signs of sexual interest in females.”.
Question 14 Explanation: Adolescents exhibiting signs of sexual development and interest are normal.

Question 15. A patient asks a nurse the following question. Exposure to TB can be identified best with which of the following procedures? Which of the following tests is the most definitive of TB?
A). Mantoux test.
B). Sputum culture for gram-negative bacteria.
C). Breath sounds examination.
D). Chest x-ray.

Question 15 Answer: A). Mantoux test.
Question 15 Explanation: The Mantoux is the most accurate test to determine the presence of TB.

Question 16. A nurse teaching a patient with COPD pulmonary exercises should do which of the following?
A). Limit exercises based on respiratory acidosis..
B). Encourage repetitive heavy lifting exercises that will increase strength..
C). Teach purse-lip breathing techniques.
D). Take breaks every 10-20 minutes with exercises..

Question 16 Answer: C). Teach purse-lip breathing techniques.
Question 16 Explanation: Purse lip breathing will help decrease the volume of air expelled by increased bronchial airways

Question 17. A patient that has delivered a 8.2 lb. baby boy 3 days ago via c-section, reports white patches on her breast that aren’t going away. Which of the following medications may be necessary?
A). Loritab.
B). Amoxil.
C). Atropine.
D). Nystatin.

Question 17 Answer: D). Nystatin.
Question 17 Explanation: Thrush may be occurring and the patient may need Nystatin.

Question 18. A nurse is caring for a patient who has recently been diagnosed with fibromyalgia and COPD. Which of the following tasks should the nurse delegate to a nursing assistant?
A). Educating the patient on monitoring fatigue.
B). Transferring the patient to the shower..
C). Ambulating the patient for the first time..
D). Taking the patient’s breath sounds.

Question 18 Answer: B). Transferring the patient to the shower..
Question 18 Explanation: Nursing assistants should be competent on all transfers.

Question 19. A nurse is instructing a person who had a left CVA and right lower extremity hemiparesis to use a quad cane. Which of the following is the most appropriate gait sequence?
A). Place the cane in the patient’s right upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence..
B). Place the cane in the patient’s left upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence..
C). Place the cane in the patient’s right upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence..
D). Place the cane in the patient’s left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence..

Question 19 Answer: D). Place the cane in the patient’s left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence..
Question 19 Explanation: The cane should be placed in the patient’s strong upper extremity, and left arm/right foot go together, for normal gait.

Question 20. A nurse has been instructed to place an IV line in a patient that has active TB and HIV. The nurse should where which of the following safety equipment?
A). Goggles, mask, gloves, and gown.
B). Surgical cap, gloves, mask, and proper shoewear.
C). Sterile gloves, mask, and goggles.
D). Double gloves, gown, and mask.

Question 20 Answer: A). Goggles, mask, gloves, and gown.
Question 20 Explanation: All protective measures must be worn, it is not required to double glove.

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