NCLEX Practice Exam 6 — Questions and Answers

Question 1: The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:

Call the Board of Nursing
File a formal reprimand (Correct answer)
Terminate the nurse
Charge the nurse with a tort

Correct answer: File a formal reprimand

Charting medication that was not given is a serious professional misconduct and a patient safety violation. The initial and appropriate action for a charge nurse is to address this formally through the facility's disciplinary process, which typically begins with a formal reprimand. This allows for documentation, investigation, and potential further action if necessary.

Question 2: The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective?

The client loses consciousness.
The client vomits.
The client’s ECG indicates tachycardia.
The client has a grand mal seizure. (Correct answer)

Correct answer: The client has a grand mal seizure.

The therapeutic effect of electroconvulsive therapy (ECT) is achieved by intentionally inducing a generalized seizure, often described as a grand mal seizure. This controlled seizure activity is the desired physiological response that leads to the significant therapeutic benefits for severe depression and other mental health conditions.

Question 3: The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority?

Continuing to monitor the vital signs
Contacting the physician (Correct answer)
Asking the client how he feels
Asking the LPN to continue the post-op care

Correct answer: Contacting the physician

The client's vital signs (BP 90/50, pulse 132, respirations 30) are significantly abnormal and indicate potential hemodynamic instability, such as hypovolemic shock or hemorrhage, which are serious post-operative complications. These critical findings require immediate medical evaluation and intervention. Therefore, contacting the physician is the highest priority action.

Question 4: The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?

Treatment is not recommended for children less than 10 years of age.
The entire family should be treated. (Correct answer)
Medication therapy will continue for 1 year.
Intravenous antibiotic therapy will be ordered.

Correct answer: The entire family should be treated.

Enterobiasis, or pinworm infection, is highly contagious and easily spreads among individuals living in close proximity, primarily through the fecal-oral route. To effectively eradicate the infection and prevent rapid reinfection, it is essential to treat all household members simultaneously, regardless of whether they are symptomatic.

Question 5: The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?

The nursing assistant wears gloves while giving the client a bath.
The nurse wears goggles while drawing blood from the client.
The doctor washes his hands before examining the client.
The nurse wears gloves to take the client’s vital signs. (Correct answer)

Correct answer: The nurse wears gloves to take the client’s vital signs.

Routine vital signs, such as temperature, pulse, respirations, and blood pressure, do not typically involve contact with blood, body fluids, or non-intact skin. Therefore, wearing gloves for these routine assessments is generally unnecessary and indicates a misunderstanding of standard precautions and when personal protective equipment is required.

Question 6: A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:

Body image disturbance
Impaired verbal communication
Risk for aspiration (Correct answer)
Pain

Correct answer: Risk for aspiration

Following a tonsillectomy, the primary and most critical concern is the risk of aspiration. Swelling, pain, and potential bleeding at the surgical site can lead to blood or secretions being aspirated into the lungs, compromising the airway and respiratory function. Maintaining a patent airway and preventing aspiration is paramount.

Question 7: The client is having fetal heart rates of 90–110 bpm during the contractions. The first action the nurse should take is:

Reposition the monitor
Turn the client to her left side (Correct answer)
Ask the client to ambulate
Prepare the client for delivery

Correct answer: Turn the client to her left side

Fetal heart rates of 90-110 bpm during contractions indicate fetal bradycardia, which can be a sign of fetal distress, often due to uteroplacental insufficiency or umbilical cord compression. Turning the client to her left side helps to relieve pressure on the vena cava, improve uterine blood flow, and enhance oxygen delivery to the fetus, making it the immediate priority intervention.

Question 8: A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?

Ask the parent/guardian to leave the room when assessments are being performed.
Ask the parent/guardian to take the child’s favorite blanket home because anything from the outside should not be brought into the hospital.
Ask the parent/guardian to room-in with the child. (Correct answer)
If the child is screaming, tell him this is inappropriate behavior.

Correct answer: Ask the parent/guardian to room-in with the child.

For a 2-year-old toddler, hospitalization can be a traumatic experience due to separation anxiety and unfamiliar surroundings. Allowing a parent or guardian to room-in provides essential comfort, security, and continuity of care. This helps to minimize the psychological stress and promotes the child's emotional well-being during their hospital stay.

Question 9: Which of the following is a characteristic of a reassuring fetal heart rate pattern?

A fetal heart rate of 170–180 bpm
A baseline variability of 25–35 bpm
Ominous periodic changes
Acceleration of FHR with fetal movements (Correct answer)

Correct answer: Acceleration of FHR with fetal movements

Fetal heart rate accelerations, which are transient increases in the FHR above the baseline, especially in response to fetal movement, are a highly reassuring sign. They indicate a healthy, well-oxygenated fetus with an intact neurological system. This pattern signifies fetal well-being and adequate oxygenation.

Question 10: George Kent is a 54 year old widower with a history of chronic obstructive pulmonary disease and was rushed to the emergency department with increasing shortness of breath, pyrexia, and a productive cough with yellow-green sputum. He has difficulty in communicating because of his inability to complete a sentence. One of his sons, Jacob, says he has been unwell for three days. Upon examination, crackles and wheezes can be heard in the lower lobes; he has a tachycardia and a bounding pulse. Measurement of arterial blood gas shows pH 7.3, PaCO2 68 mm Hg, HCO3 28 mmol/L, and PaO2 60 mm Hg. How would you interpret this?

Respiratory Acidosis, Uncompensated
Respiratory Acidosis, Partially Compensated (Correct answer)
Metabolic Alkalosis, Uncompensated
Metabolic Acidosis, Partially, Compensated

Correct answer: Respiratory Acidosis, Partially Compensated

The pH of 7.3 indicates acidosis. The PaCO2 of 68 mm Hg is elevated, pointing to a respiratory cause for the acidosis. The HCO3 of 28 mmol/L is also elevated, showing that the kidneys are attempting to compensate by retaining bicarbonate. Since the pH is still outside the normal range, the compensation is partial.

Question 11: Carl, an elementary student, was rushed to the hospital due to vomiting and a decreased level of consciousness. The patient displays slow and deep (Kussmaul breathing), and he is lethargic and irritable in response to stimulation. He appears to be dehydrated—his eyes are sunken and mucous membranes are dry—and he has a two week history of polydipsia, polyuria, and weight loss. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 23 mm Hg, and HCO3 12 mmol/L; other results are Na+ 126 mmol/L, K+ 5 mmol/L, and Cl- 95 mmol/L. What is your assessment?

Respiratory Acidosis, Uncompensated
Respiratory Acidosis, Partially Compensated
Metabolic Alkalosis, Uncompensated
Metabolic Acidosis, Partially Compensated (Correct answer)

Correct answer: Metabolic Acidosis, Partially Compensated

The pH of 7.0 is severely acidic, indicating acidosis. The HCO3 of 12 mmol/L is significantly low, confirming a metabolic cause for the acidosis. The PaCO2 of 23 mm Hg is also low, demonstrating that the respiratory system is attempting to compensate by blowing off CO2 (an acid). Since the pH remains acidic, the compensation is partial.

Question 12: A cigarette vendor was brought to the emergency department of a hospital after she fell into the ground and hurt her left leg. She is noted to be tachycardic and tachypneic. Painkillers were carried out to lessen her pain. Suddenly, she started complaining that she is still in pain and now experiencing muscle cramps, tingling, and paraesthesia. Measurement of arterial blood gas reveals pH 7.6, PaO2 120 mm Hg, PaCO2 31 mm Hg, and HCO3 25 mmol/L. What does this mean?

Respiratory Alkalosis, Uncompensated (Correct answer)
Respiratory Acidosis, Partially Compensated
Metabolic Alkalosis, Uncompensated
Metabolic Alkalosis, Partially Compensated

Correct answer: Respiratory Alkalosis, Uncompensated

The pH of 7.6 is alkaline, indicating alkalosis. The PaCO2 of 31 mm Hg is low, which is characteristic of a respiratory cause (respiratory alkalosis). The HCO3 of 25 mmol/L is within the normal range, meaning there has been no metabolic compensation yet. Therefore, this is an uncompensated respiratory alkalosis.

Question 13: Ricky’s grandmother is suffering from persistent vomiting for two days now. She appears to be lethargic and weak and has myalgia. She is noted to have dry mucus membranes and her capillary refill takes >4 seconds. She is diagnosed as having gastroenteritis and dehydration. Measurement of arterial blood gas shows pH 7.5, PaO2 85 mm Hg, PaCO2 40 mm Hg, and HCO3 34 mmol/L. What acid-base disorder is shown?

Respiratory Alkalosis, Uncompensated
Respiratory Acidosis, Partially Compensated
Metabolic Alkalosis, Uncompensated (Correct answer)
Metabolic Alkalosis, Partially Compensated

Correct answer: Metabolic Alkalosis, Uncompensated

The pH of 7.5 is alkaline, indicating alkalosis. The elevated HCO3 of 34 mmol/L confirms a metabolic cause, likely due to the loss of stomach acid from persistent vomiting. The PaCO2 of 40 mm Hg is within the normal range, indicating no respiratory compensation has occurred. Thus, it is an uncompensated metabolic alkalosis.

Question 14: Mrs. Johansson, who had undergone surgery in the post-anesthesia care unit (PACU), is difficult to arouse two hours following surgery. Nurse Florence in the PACU has been administering Morphine Sulfate intravenously to the client for complaints of post-surgical pain. The client’s respiratory rate is 7 per minute and demonstrates shallow breathing. The patient does not respond to any stimuli! The nurse assesses the ABCs (remember Airway, Breathing, Circulation!) and obtains ABGs STAT! Measurement of arterial blood gas shows pH 7.10, PaCO2 70 mm Hg and HCO3 24 mEq/L. What does this mean?

Respiratory Alkalosis, Partially Compensated
Respiratory Acidosis, Uncompensated (Correct answer)
Metabolic Alkalosis, Partially Compensated
Metabolic Acidosis, Uncompensated

Correct answer: Respiratory Acidosis, Uncompensated

The pH of 7.10 is significantly acidic, indicating acidosis. The very high PaCO2 of 70 mm Hg points to a respiratory cause, specifically hypoventilation due to opioid overdose. The HCO3 of 24 mEq/L is within the normal range, meaning the kidneys have not yet had time to compensate. Therefore, this is an uncompensated respiratory acidosis.

Question 15: Baby Angela was rushed to the Emergency Room following her mother’s complaint that the infant has been irritable, difficult to breastfeed and has had diarrhea for the past 3 days. The infant’s respiratory rate is elevated and the fontanels are sunken. The Emergency Room physician orders ABGs after assessing the ABCs. The results from the ABG results show pH 7.39, PaCO2 27 mmHg and HCO3 19 mEq/L. What does this mean?

Respiratory Alkalosis, Fully Compensated
Metabolic Acidosis, Uncompensated
Metabolic Acidosis, Fully Compensated (Correct answer)
Respiratory Acidosis, Uncompensated

Correct answer: Metabolic Acidosis, Fully Compensated

The pH of 7.39 is within the normal range, but on the acidic side, indicating full compensation. The low HCO3 of 19 mEq/L points to a metabolic acidosis, likely due to severe diarrhea. The low PaCO2 of 27 mmHg shows the respiratory system has fully compensated by hyperventilating to blow off CO2 and bring the pH back to normal.

Question 16: Mr. Wales, who underwent post-abdominal surgery, has a nasogastric tube. The nurse on duty notes that the nasogastric tube (NGT) is draining a large amount (900 cc in 2 hours) of coffee ground secretions. The client is not oriented to person, place, or time. The nurse contacts the attending physician and STAT ABGs are ordered. The results from the ABGs show pH 7.57, PaCO2 37 mmHg and HCO3 30 mEq/L. What is your assessment?

Metabolic Acidosis, Uncompensated
Metabolic Alkalosis, Uncompensated (Correct answer)
Respiratory Alkalosis, Uncompensated
Metabolic Alkalosis, Partially Compensated

Correct answer: Metabolic Alkalosis, Uncompensated

The pH of 7.57 is significantly alkaline, indicating alkalosis. The elevated HCO3 of 30 mEq/L confirms a metabolic cause, likely due to the large loss of gastric acid through the nasogastric tube. The PaCO2 of 37 mmHg is within the normal range, indicating no respiratory compensation has occurred. Therefore, this is an uncompensated metabolic alkalosis.

NCLEX Practice Exam 6

The nurse is suspected of charting medication administration that he did not give.
After talking to the nurse, the charge nurse should: