NCLEX-PN Practice Exam 16

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A client is admitted with burns of the right arm, chest, and head. According to the Rule of Nines, the percent of burn injury is:

Correct! Wrong!

Burn injury of the arm (9%), chest (9%), and head (9%) accounts for burns covering 27% of the total body surface area. Answers A, C, and D are incorrect percentages.

A client who was admitted with chest pain and shortness of breath has a standing order for oxygen via mask. Standing orders for oxygen mean that the nurse can apply oxygen at:

Correct! Wrong!

With standing orders, the nurse can administer oxygen at 6L per minute via mask. Answer A is incorrect because the amount is too low to help the client with chest pain and shortness of breath. Answers C and D have oxygen levels requiring a doctor’s order.

The nurse is caring for a client with an ileostomy. The nurse should pay careful attention to care around the stoma because:

Correct! Wrong!

Stool from the ileostomy contains digestive enzymes that can cause severe skin breakdown. Answer B contains contradictory information; therefore, it is incorrect. Answers C and D contain inaccurate statements; therefore, they are incorrect.

The physician has ordered aspirin therapy for a client with severe rheumatoid arthritis. A sign of acute aspirin toxicity is:

Correct! Wrong!

Tinnitus is a sign of aspirin toxicity. Answers A, B, and D are not related to aspirin toxicity; therefore, they are incorrect.

A client is admitted to the emergency room with symptoms of delirium tremens. After admitting the client to a private room, the priority nursing intervention is to:

Correct! Wrong!

The client with delirium tremens has an increased risk for seizures; therefore, the nurse should provide seizure precautions. Answer A is not a priority in the client’s care; therefore, it is incorrect. Answer C is incorrect because the client should be kept in a dimly lit, not dark, room. Answer D is incorrect because thiamine and multivitamins are given to prevent Wernicke’s encephalopathy, not delirium tremens.

The nurse is providing dietary teaching for a client with gout. Which dietary selection is suitable for the client with gout?

Correct! Wrong!

Steak, baked potato, and tossed salad are lower in purine than the other choices. Liver, crab, and chicken are high in purine; therefore, answers A, B, and C are incorrect.

A newborn has been diagnosed with exstrophy of the bladder. The nurse should position the newborn:

Correct! Wrong!

Placing the newborn in a side-lying position helps the urine to drain from the exposed bladder. Answer A is incorrect because it would position the child on the exposed bladder. Answers B and D are incorrect because they would allow the urine to pool.

The mother of a 3-month-old with esophageal reflux asks the nurse what she can do to lessen the baby’s reflux. The nurse should tell the mother to:

Correct! Wrong!

Burping the baby frequently throughout the feeding will help prevent gastric distention that contributes to esophageal reflux. Answers A and B are incorrect because they allow air to collect in the baby’s stomach, which contributes to reflux. Answer C is incorrect because the baby should be placed side-lying with the head elevated, to prevent aspiration.

A child is hospitalized with a fractured femur involving the epiphyseal plate. Epiphyseal fractures are serious because:

Correct! Wrong!

Growth plates located in the epiphysis can be damaged by epiphyseal fractures. Answers A, B, and C are untrue statements; therefore, they are incorrect.

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