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.

A client with a bowel resection and anastomosis returns to his room with an NG tube attached to intermittent suction. Which of the following observations indicates that the nasogastric suction is working properly?

Correct! Wrong!

Nasogastric suction decompresses the stomach and leaves the abdomen soft and nondistended. Answer B is incorrect because it does not relate to the effectiveness of the NG suction. Answer C is incorrect because it relates to peristalsis, not the effectiveness of the NG suction. Answer D is incorrect because it relates to wound healing, not the effectiveness of the NG suction.

The nurse is teaching the client with insulin-dependent diabetes the signs of hypoglycemia. Which of the following signs is associated with hypoglycemia?

Correct! Wrong!

Tremulousness is an early sign of hypoglycemia. Answers B, C, and D are incorrect because they are symptoms of hyperglycemia.

Which of the following symptoms is associated with exacerbation of multiple sclerosis?

Correct! Wrong!

The most common sign associated with exacerbation of multiple sclerosis is double vision. Answers A, B, and D are not associated with a diagnosis of multiple sclerosis; therefore, they are incorrect.

Which of the following conditions is most likely related to the development of renal calculi?

Correct! Wrong!

Gout and renal calculi are the result of increased amounts of uric acid. Answer B is incorrect because it does not contribute to renal calculi. Answers C and D can result from decreased calcium levels. Renal calculi are the result of excess calcium; therefore, answers C and D are incorrect.

A client with AIDS is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract?

Correct! Wrong!

Providing small, frequent meals will improve the client’s appetite and help reduce nausea. Answer A is incorrect because it does not compensate for limited absorption. Foods and beverages containing live cultures are discouraged for the immune-compromised client; therefore, answer B is incorrect. Answer C is incorrect because forcing fluids will not compensate for limited absorption of the intestine.

The treatment protocol for a client with acute lymphatic leukemia includes prednisone, methotrexate, and cimetidine. The purpose of the cimetidine is to:

Correct! Wrong!

A common side effect of prednisone is gastric ulcers. Cimetidine is given to help prevent the development of ulcers. Answers A, B, and C do not relate to the use of cimetidine; therefore, they are incorrect.

Which of the following meal choices is suitable for a 6-month-old infant?

Correct! Wrong!

Rice cereal, apple juice, and formula are suitable foods for the 6-month-old infant. Whole milk, orange juice, and eggs are not suitable for the young infant; therefore, they are incorrect.

The LPN is preparing to administer an injection of vitamin K to the newborn. The nurse should administer the injection in the:

Correct! Wrong!

The nurse should administer the injection in the vastus lateralis muscle. Answers A and C are not as well developed in the newborn; therefore, they are incorrect. Answer D is incorrect because the dorsogluteal muscle is not used for IM injections until the child is 3 years of age.

The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephrotic syndrome. The nurse should:

Correct! Wrong!

The client taking Cytoxan should increase his fluid intake to prevent hemorrhagic cystitis. Answers B, C, and D do not relate to the question; therefore, they are incorrect.

The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal?

Correct! Wrong!

Benzodiazepines are ordered for the client in alcohol withdrawal to prevent delirium tremens. Answer A is incorrect because it is a medication used in aversive therapy to maintain sobriety. Answer B is incorrect because it is used for the treatment of benzodiazepine overdose. Answer C is incorrect because it is the treatment for opiate withdrawal.

A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:

Correct! Wrong!

The client taking NPH insulin should have a snack midafternoon to prevent hypoglycemia. Answers A and B are incorrect because the times are too early for symptoms of hypoglycemia. Answer D is incorrect because the time is too late and the client would be in severe hypoglycemia.

The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?

Correct! Wrong!

The client with a detached retina will have limitations in mobility before and after surgery. Answer A is incorrect because a detached retina produces no pain or discomfort. Answers C and D do not apply to the client with a detached retina; therefore, they are incorrect.

The primary purpose for using a CPM machine for the client with a total knee repair is to help:

Correct! Wrong!

The primary purpose for the continuous passive-motion machine is to promote flexion of the artificial joint. The device should be placed at the foot of the client’s bed. Answers A, C, and D do not describe the purpose of the CPM machine; therefore, they are incorrect.

Which of the following statements reflects Kohlberg’s theory of the moral development of the preschool-age child?

Correct! Wrong!

According to Kohlberg, in the preconventional stage of development, the behavior of the preschool child is determined by the consequences of the behavior. Answers A, B, and C describe other stages of moral development; therefore, they are incorrect.

A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:

Correct! Wrong!

The client should be assessed following completion of antibiotic therapy to determine whether the infection has cleared. Answer A would be done if there are repeated instances of otitis media; therefore, it is incorrect. Answer B is incorrect because it will not determine whether the child has completed the medication. Answer D is incorrect because the purpose of the recheck is to determine whether the infection is gone.

A factory worker is brought to the nurse’s office after a metal fragment enters his right eye. The nurse should:

Correct! Wrong!

The nurse should cover both of the client’s eyes and transport him immediately to the ER or the doctor’s office. Answers A, B, and D are incorrect because they increase the risk of further damage to the eye.

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