NCLEX-PN Practice Exam 4

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A client has returned to his room following an esophagoscopy. Before offering fluids, the nurse should give priority to assessing the client’s:

Correct! Wrong!

The client’s gag reflex is depressed before having an EGD. The nurse should give priority to checking for the return of the gag reflex before offering the client oral fluids. Answer A is incorrect because conscious sedation is used. Answers C and D are not affected by the procedure; therefore, they are incorrect.

Which instruction should be included in the discharge teaching for the client with cataract surgery?

Correct! Wrong!

The eye shield should be worn at night or when napping, to prevent accidental trauma to the operative eye. Prescription eyedrops, not over-the-counter eyedrops, are ordered for the client; therefore, Answer A is incorrect. The client might or might not require glasses following cataract surgery; therefore, answer C is incorrect. Answer D is incorrect because cataract surgery is pain free.

An 8-year-old is admitted with drooling, muffled phonation, and a temperature of 102°F. The nurse should immediately notify the doctor because the child’s symptoms are suggestive of:

Correct! Wrong!

The child’s symptoms are consistent with those of epiglottitis, an infection of the upper airway that can result in total airway obstruction. Symptoms of strep throat, laryngotracheobronchitis, and bronchiolitis are different than those presented by the client; therefore, answers A, C, and D are incorrect.

Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should:

Correct! Wrong!

Providing additional fluids will help the newborn eliminate excess bilirubin in the stool and urine. Answer B is incorrect because oils and lotions should not be used with phototherapy. Physiologic jaundice is not associated with infection; therefore, answers C and D are incorrect.

A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client’s plan of care?

Correct! Wrong!

Having a staff member remain with the client for 1 hour after meals will help prevent self-induced vomiting. Answer A is incorrect because the client will weigh more after meals, which can undermine treatment. Answer C is incorrect because the client will need a balanced diet and excess protein might not be well tolerated at first. Answer D is incorrect because it treats the client as a child rather than as an adult.

According to Erikson’s stage of growth and development, the developmental task associated with middle childhood is:

Correct! Wrong!

According to Erikson’s Psychosocial Developmental Theory, the developmental task of middle childhood is industry versus inferiority. Answer A is incorrect because it is the developmental task of infancy. Answer B is incorrect because it is the developmental task of the school-age child. Answer C is incorrect because it is not one of Erikson’s developmental stages.

The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is:

Correct! Wrong!

A side effect of bronchodilators is nausea. Answers A and C are not associated with bronchodilators; therefore, they are incorrect. Answer D is incorrect because hypotension is a sign of toxicity, not a side effect.

The 5-minute Apgar of a baby delivered by C-section is recorded as 9. The most likely reason for this score is:

Correct! Wrong!

Although cyanosis of the hands and feet is common in the newborn, it accounts for an Apgar score of less than 10. Answer B suggests cooling, which is not scored by the Apgar. Answer B is incorrect because conjunctival hemorrhages are not associated with the Apgar. Answer D is incorrect because it is within normal range as measured by the Apgar.

A 5-month-old infant is admitted to the ER with a temperature of 6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:

Correct! Wrong!

Tenseness of the anterior fontanel indicates an increase in intracranial pressure. Answer A is incorrect because periorbital edema is not associated with meningitis. Answer C is incorrect because a positive Babinski reflex is normal in the infant. Answer D is incorrect because it relates to the preterm infant, not the infant with meningitis.

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