NCLEX-RN 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:
The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand. Options A, C, and D: If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but these are not the first actions requested in the stem. A tort is a wrongful act to the client or his belongings and is not indicated in this instance.
The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective?
During ECT, the client will have a grand mal seizure. This indicates completion of the electroconvulsive therapy. Options A, B, and C do not indicate that the ECT has been effective.
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?
The vital signs are abnormal and should be reported immediately. Option A: Continuing to monitor the vital signs can result in deterioration of the client’s condition. Option C: Asking the client how he feels will only provide subjective data. Option D: Assigning an unstable client to an LPN is inappropriate.
The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?
Enterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated to ensure that no eggs remain. Because a single treatment is usually sufficient, there is usually good compliance. The family should then be tested again in 2 weeks to ensure that no eggs remain. Answers A, C, and D are incorrect statements.
The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?
It is not necessary to wear gloves to take the vital signs of the client. If the client has active infection with methicillin-resistant Staphylococcus aureus, gloves should be worn. Options A, B, and C: The health care workers indicate knowledge of infection control by their actions.
A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:
Always remember your ABCs (airway, breathing, circulation) when selecting an answer. Option A: does not apply for a child who has undergone a tonsillectomy. Options B and D: Although these nursing diagnoses might be appropriate for this child, risk for aspiration should have the highest priority.
The client is having fetal heart rates of 90–110 bpm during the contractions. The first action the nurse should take is:
The normal fetal heart rate is 120–160 bpm; 100–110bpm is bradycardia. The first action would be to turn the client to the left side and apply oxygen. Option A: Repositioning the monitor is not indicated at this time. Option C: Asking the client to ambulate is not the best action for clients experiencing bradycardia. Option D: There is no data to indicate the need to move the client to the delivery room at this time.
A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?
The nurse should encourage rooming-in to promote parent-child attachment. It is okay for the parents to be in the room for assessment of the child. Options A and B: Allowing the child to have items that are familiar to him is allowed and encouraged. Option D: Telling the child that screaming is inappropriate behavior is not part of the nurse’s responsibilities.
Which of the following is a characteristic of a reassuring fetal heart rate pattern?
Accelerations with movement are normal. Options A, B, and C: These assessments indicate ominous findings on the fetal heart monitor.
As the client reaches 8 cm dilation, the nurse notes late decelerations on the fetal monitor. The FHR baseline is 165–175 bpm with variability of 0–2bpm. What is the most likely explanation of this pattern?
This information indicates a late deceleration. This type of deceleration is caused by uteroplacental lack of oxygen. Option A: Has no relation to the readings. Option B: Compressed umbilical cord results in a variable deceleration. Option C: A vagal response is indicative of an early deceleration.
A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when:
Luteinizing hormone released by the pituitary is responsible for ovulation. At about day 14, the continued increase in estrogen stimulates the release of luteinizing hormone from the anterior pituitary. The LH surge is responsible for ovulation, or the release of the dominant follicle in preparation for conception, which occurs within the next 10–12 hours after the LH levels peak. Options A, C, and D: Estrogen levels are high at the beginning of ovulation, the endometrial lining is thick, not thin, and the progesterone levels are high, not low.
A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:
The most definitive diagnosis of pregnancy is the presence of fetal heart tones. The signs in answers A, C, and D are subjective and might be related to other medical conditions. Options A and C: Elevated human chorionic gonadotropin and uterine enlargement may be related to a hydatidiform mole. Option D: Breast enlargement and tenderness is often present before menses or with the use of oral contraceptives.
In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect:
The expected effect of Pitocin is cervical dilation. Option A: Pitocin causes more intense contractions, which can increase the pain. Option B: Cervical effacement is caused by pressure on the presenting part. Option C: Infrequent contractions is opposite the action of Pitocin.
The home health nurse is planning for the day’s visits. Which client should be seen first?
The client at highest risk for complications is the client with multiple sclerosis who is being treated with cortisone via the central line. The others are more stable. MRSA is Methicillin-Resistant Staphylococcus Aureus. Vancomycin is the drug of choice and is given at scheduled times to maintain blood levels of the drug. Options A, B, and C: These clients are more stable and can be seen later.
A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the:
The success of the rhythm method of birth control is dependent on the client’s menses being regular. Options A, B, and D: It is not dependent on the age of the client, frequency of intercourse, or range of the client’s temperature.
The client with hyperemesis gravidarum is at risk for developing:
The client with hyperemesis has persistent nausea and vomiting. With vomiting comes dehydration. When the client is dehydrated, she will have metabolic acidosis. Options A and C are incorrect because they are respiratory dehydration. Option D is incorrect because the client will not be in alkalosis with persistent vomiting.
A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
The client should be advised to come to the labor and delivery unit when the contractions are every 5 minutes and consistent. She should also be told to report to the hospital if she experiences rupture of membranes or extreme bleeding. Options A and B: She should not wait until the contractions are every 2 minutes or until she has a bloody discharge. Option C: Has a vague answer and can be related to a urinary tract infection.
The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?
The pregnant client and the client with a broken arm and facial lacerations are the best choices for placing in the same room. Options A, C, and D: The following group of clients needs to be placed in separate rooms due to the serious nature of their injuries.
The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:
The infant of a diabetic mother is usually large for gestational age. After birth, glucose levels fall rapidly due to the absence of glucose from the mother. Option A is incorrect because the infant will not be small for gestational age. Option B is incorrect because the infant will not be hyperglycemic. Option D is incorrect because the infant will be large, not small, and will be hypoglycemic, not hyperglycemic.
Which nurse should be assigned to care for the postpartum client with preeclampsia?
The nurse with 3 years of experience in labor and delivery knows the most about possible complications involving preeclampsia. Option A: The nurse is a new staff to the unit hence lacking the experience needed. Options C and D: These nurses lack sufficient experience with a postpartum client.
The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:
The nurse could be charged with malpractice, which is failing to perform, or performing an act that causes harm to the client. Giving the infant an overdose falls into this category. Option A: Negligence is failing to perform care for the client. a tort is a wrongful act committed Option B: A tort is a wrongful act committed on the client or their belongings Option C: Assault is a violent physical or verbal attack.
A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160–170 bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:
The nurse decides to apply an external monitor because the membranes are intact. Options A, C, and D: The cervix is dilated enough to use an internal monitor, if necessary. An internal monitor can be applied if the client is at 0-station. Contraction intensity has no bearing on the application of the fetal monitor.
A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
If the child has bacterial pneumonia, a high fever is usually present. Option B: Bacterial pneumonia usually presents with a productive cough, not a nonproductive cough. Options C and D: Rhinitis is often seen with viral pneumonia, and vomiting and diarrhea are usually not seen with pneumonia.
The client is admitted to the unit. A vaginal exam reveals that she is 2cm dilated. Which of the following statements would the nurse expect her to make?
Dilation of 2 cm marks the end of the latent phase of labor. Option A is a vague answer. Option B indicates the end of the first stage of labor. Option C indicates the transition phase.
A 25-year-old client with Grave’s disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal?
Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. Options A, B, and D: The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss.
The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:
Clients with HIV should not breastfeed because the infection can be transmitted to the baby through breast milk. Options A, C, and D: The clients with diabetes, hypertension, and thyroid disease—can be allowed to breastfeed.
The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?
Infants of mothers who smoke are often low in birth weight. Option B: Infants who are large for gestational age are associated with diabetic mothers. Option C: Preterm births are associated with smoking, but not with appropriate size for gestation. Option D: Growth retardation is associated with smoking, but this does not affect the infant length.
Which information should be reported to the state Board of Nursing?
The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to care for the client with hepatitis might result in termination, but is not of interest to the Joint Commission.
Which assignment should not be performed by the licensed practical nurse?
The licensed practical nurse should not be assigned to begin a blood transfusion. Options A, B, and C: The licensed practical nurse can insert a Foley catheter, discontinue a nasogastric tube, and collect sputum specimen.
The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction?
Remember the ABCs (airway, breathing, circulation) when answering this question. Answer C because a hotdog is the size and shape of the child’s trachea and poses a risk of aspiration. Options A, B, and D: A white grape juice, grilled cheese sandwich, and ice cream do not pose a risk of aspiration for a child.
The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?
The child with celiac disease should be on a gluten-free diet. Options A, B, and C: These food items all contain gluten.
Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?
The hearing aid should be stored in a warm, dry place. Option A: It should be cleaned daily but should not be moldy. Option C: A toothpick is inappropriate to use to clean the aid; the toothpick might break off in the hearing aid. Option D: Changing the batteries weekly is not necessary.
The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primigravida as she completes the early phase of labor?
Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips may be allowed, but this amount of fluid might not be sufficient to prevent fluid volume deficit. Option A: Impaired gas exchange related to hyperventilation would be indicated during the transition phase. Options B and C: Impaired physical mobility and fluid volume deficit are not correct in relation to the stem.
The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eye drops, the nurse should recognize that it is essential to consider which of the following?
Before instilling eye drops, the nurse should cleanse the area with water. Option B: A 6-year-old child is not developmentally ready to instill his own eyedrops. Option C: Although the mother of the child can instill the eye drops, the area must be cleansed before administration. Option D: Although the eye might appear to be clear, the nurse should instill the eyedrops, as ordered, so answer D is incorrect.
A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?
The best method of birth control for the client with diabetes is the diaphragm. Options A, B, and D: Permanent intrauterine device can cause a continuing inflammatory response in diabetics that should be avoided, oral contraceptives tend to elevate blood glucose levels, and contraceptive sponges are not good at preventing pregnancy.
The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?
All of the choices are tasty, but the pregnant client needs a diet that is balanced and has increased amounts of calcium. This food item contains meat, fruit, potato salad, and yogurt, which has about 360 mg of calcium. Option A: These food items are lacking in fruits and milk. Option B: The potato chips, which contain a large amount of sodium. Option D: These food items are lacking vegetables and milk products.
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immunosuppressed. Option B: the client with diabetes poses no risk to other clients. Option C: The client has an increase in growth hormone and poses no risk to himself or others. Option D: The client has hypothyroidism or myxedema and poses no risk to others or himself.
A gravida 3 para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse be expected to make after the amniotomy?
An amniotomy is an artificial rupture of membranes and normal amniotic fluid is straw-colored and odorless. Options A and C: Fetal heart tones of 160 indicate tachycardia, and greenish fluid is indicative of meconium. Option D: If the nurse notes the umbilical cord, the client is experiencing a prolapsed cord and would need to be reported immediately.
The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first?
Remember the ABCs (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the pulse, oxygen should be applied to increase the oxygen saturation, so answers A and D are incorrect. The normal oxygen saturation for a child is 92%–100%, making answer B incorrect.
The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy travels to the radium department for therapy. The radiation stays in the department, so the client is not radioactive. These clients are radioactive in very small doses, especially upon returning from the procedures. For approximately 72 hours, the clients should dispose of urine and feces in special containers and use plastic spoons and forks. Options B, C, and D: The following clients pose a risk to the pregnant nurse.
The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:
Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. Options B, C, and D: There is no need to scrape the skin, collect a stool specimen, or bring a sample of hair.
The client is having an arteriogram. During the procedure, the client tells the nurse, “I’m feeling really hot.” Which response would be best?
It is normal for the client to have a warm sensation when dye is injected. Options A, C, and D indicate that the nurse believes that the hot feeling is abnormal, so they are incorrect.
A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?
Applying a fetal heart monitor is the correct action at this time. Options A and C: There is no need to prepare for a Caesarean section or to place the client in Genupectoral position (knee-chest). Option D: There is no need for an ultrasound based on the finding.
Which of the following instructions should be included in the nurse’s teaching regarding oral contraceptives?
When the client is taking oral contraceptives and begins antibiotics, another method of birth control should be used. Antibiotics decrease the effectiveness of oral contraceptives. Option A: Approximately 5–10 pounds of weight gain is not unusual. Option C: If the client misses a birth control pill, she should be instructed to take the pill as soon as she remembers the pill. If she misses two, she should take two; if she misses more than two, she should take the missed pills but use another method of birth control for the remainder of the cycle. Option D: Changes in menstrual flow are expected in clients using oral contraceptives. Often these clients have lighter menses.
The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:
Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder will decrease the progression of labor. Answers A, B, and D are incorrect for the stem.
The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:
To provide protection against antibody production, RhoGam should be given within 72 hours. Options B, C, and D: These durations are too late to provide antibody protection. RhoGam can also be given during pregnancy.
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
The initial action by the nurse observing a late deceleration should turn the client to the side—preferably, the left side. Administering oxygen is also indicated. Option A: Notifying the physician might be necessary but not before turning the client to her side. Option B: Starting an IV is not necessary at this time. Option D: Readjusting the fetal monitor is inappropriate since there is no data to indicate that the monitor has been applied incorrectly.
A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to:
The symptoms of painless vaginal bleeding are consistent with placenta previa. Option B: Cervical check for dilation is contraindicated because this can increase the bleeding. Option C: Checking for firmness of the uterus can be done, but the first action should be to check the fetal heart tones. Option D: A detailed history can be done later.
The nurse is caring for a client admitted with epiglottitis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?
For a child with epiglottitis and the possibility of complete obstruction of the airway, emergency tracheostomy equipment should always be kept at the bedside. Options A, C, and D: Intravenous supplies, fluid, and oxygen will not treat an obstruction.