NCLEX-RN Practice Test 11
A toddler is 26 months old and has been recently admitted to the hospital. According to Erikson, which of the following stages is the toddler in?
Autonomy vs. shame and doubt- 12-18 months old. Existential Question: Is It Okay to Be Me?
A patient’s chart indicates a history of ketoacidosis. Which of the following would you not expect to see with this patient if this condition were acute?
Weight loss would be expected.
A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present?
Weight gain due to fluid accumulation is associated with heart failure and congenital heart defects.
A 5-year-old child and has been recently admitted to the hospital. According to Erik Erikson's psychosocial development stages, the child is in which stage?
Initiative vs. guilt- 3-6 years old. Existential Question: Is it Okay for Me to Do, Move, and Act?
A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4-year-old boy who is non-verbal. This child does not have on any identification. What should the nurse do?
In this case, you can determine the name of the child by the father’s statement. You should not withhold the medication from the child after identification.
A mother has recently been informed that her child has Down’s syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down’s syndrome?
The skin would be dry and not oily.
A patient is getting discharged from a skilled nursing facility (SNF). The patient has a history of severe COPD and PVD. The patient is primarily concerned about his ability to breathe easily. Which of the following would be the best instruction for this patient?
The bronchodilator will allow a more productive cough.
A nurse is putting together a presentation on meningitis. Which of the following microorganisms has not been linked to meningitis in humans?
Cl. difficile has not been linked to meningitis.
A patient tells you that her urine is starting to look discolored. If you believe this change is due to medication, which of the following of the patient’s medication does not cause urine discoloration?
Aspirin is not known to cause discoloration of the urine. Option A: Sulfasalazine may discolor the urine or skin to an orange-yellow color. Option B: Levodopa may discolor the urine, saliva, or sweat to a dark brown color. Option C: Phenolphthalein can discolor the urine to a red color.
A patient tells you that her urine is starting to look discolored. If you believe this change is due to medication, which of the following of the patient’s medication does not cause urine discoloration?
Aspirin is not known to cause discoloration of the urine. Option A: Sulfasalazine may discolor the urine or skin to an orange-yellow color. Option B: Levodopa may discolor the urine, saliva, or sweat to a dark brown color. Option C: Phenolphthalein can discolor the urine to a red color.
The LPN/LVN is gathering information from the mother of a six year old girl who is at the clinic for a well-child visit. The nurse asks if the mother has any special concerns regarding her daughter. The mother states that her daughter has recently been complaining of an itchy scalp and she would like to talk with the doctor about some dandruff treatment. What would be the MOST appropriate response?
Examine the child’s scalp and hair for evidence of small, white, sesame seed size flecks which cannot be brushed away or pulled off of the hair. This is the most appropriate response because you will not be able to provide accurate information to the physician if you do not examine the child’s scalp and hair for evidence of head lice (pediculosis). The child could just have an irritated scalp or dandruff. It is not appropriate to make an assumption or judgment about the patient due to the only symptom reported which is pruritus of the scalp.
A medical care team consists of three RN’s, and a LPN/LVN. Identify the MOST appropriate assignment for the LPN/LVN.
A multiparous C-section patient who is two days post-op should be stable and mobilizing fairly well. Since she is a repeat C-section and multiparous, she has experienced a C-section and most likely is quite comfortable breastfeeding her new infant. Out of all the patient choices, she is the most stable. The primiparous four hour post vaginal delivery patient is still in need of immediate postpartum teaching and will be at a higher risk for complications than some of the other more stable patients. Even though the multiparous C-section patient is stable enough to be discharged, she will require discharge teaching and instructions. The primiparous patient who would like to discuss tubal ligation should be assessed for signs of post-partum depression and she may require counseling and follow up by her treating physician.
A LPN/LVN has received an assignment of four patients on the Medical-Surgical floor. Which patient should she/he go to check on first?
The 70 year old woman who is only one day post-op from ankle surgery has probably been immobile due to her age and the surgery type and is at a greater risk of thrombophlebitis and the subsequent complication of pulmonary embolus. If she is complaining of shortness of breath, her vital signs should be obtained and the physician should be notified. This patient is the highest priority, though all have the potential to have some type of medical complication.
A nurse is planning to reinforce instructions regarding nutrition to a Muslim patient. The nurse should be aware that certain foods are prohibited by this religion. Identify the food which is prohibited.
People who are of the Muslim religion or Islamic faith prohibit pork in their diet. In some sects of Buddhism, Seventh-Day Adventism they are vegetarian. Jewish people adhere to the kosher laws if they are Orthodox believers. People who practice Hinduism are prohibited from eating beef and veal. Spicy foods are normally not a dietary restriction of a particular religion.
A nurse is checking the circulation in the right leg of an Asian American patient who had a total knee replacement two days ago. The patient does not smile, make eye contact and does not speak much. The nurse should:
Asian Americans value silence. Eye contact may be considered inappropriate or disrespectful. It is important for the nurse to be aware of these cultural differences so that he/she does not assume that this is unusual behavior. It would be inappropriate of the nurse to continue talking to the patient to try to “engage” them in conversation. The nurse should not assume that the patient is exhibiting signs of depression or physical instability due to the understanding of this as normal behavior within this culture.
A LPN/LVN is attempting to review and reinforce an African American patient’s Synthroid medication schedule. The patient nods her head up and down throughout the review of instructions. The nurse should understand that:
t is important for the nurse to understand that in the African American, head nodding does not necessarily mean agreement or acceptance or understanding of information presented. The other statements are untrue.