NCLEX-RN Practice Exam 7
The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?
Halo traction will be ordered for the client with a cervical fracture. Options A and B: Russell’s traction is used for bones of the lower extremities, as is Buck’s traction. Option D: Crutchfield tongs are used while in the hospital and the client is immobile.
The nurse is assessing the client with a total knee replacement 2 hours post-operative. Which information requires notification of the doctor?
The client with a total knee replacement should be assessed for anemia. A hematocrit of 26% is extremely low and might require a blood transfusion. Options A: Bleeding of 2cm on the dressing is not extreme. Circle and date and time the bleeding and monitor for changes in the client’s status. Option B: A low-grade temperature is not unusual after surgery. Ensure that the client is well hydrated, and recheck the temperature in 1 hour. If the temperature is above 100.6°F (38.1°C), report this finding to the doctor. Tylenol will probably be ordered. Option D: Voiding after surgery is also not uncommon and no need for concern.
After the physician performs an amniotomy, the nurse’s first action should be to assess the:
When the membranes rupture, there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones, such as bradycardia or tachycardia, should be reported. Options A, C, and D: After the fetal heart tones are assessed, the nurse should evaluate the cervical dilation, vital signs, and level of discomfort.
A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge teaching?
Cox II inhibitors have been associated with heart attacks and strokes. Any changes in cardiac status or signs of a stroke should be reported immediately, along with any changes in bowel or bladder habits because bleeding has been linked to use of Cox II inhibitors. Options A, C, and D: The client does not have to take the medication with milk, remain upright, or allow 6 weeks for optimal effect.
A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:
The infant of an addicted mother will undergo withdrawal. Snugly wrapping the infant in a blanket will help prevent the muscle irritability that these babies often experience. Options A and D: Teaching the mother to provide tactile stimulation or provide for early infant stimulation are incorrect because he is irritable and needs quiet and little stimulation at this time. Options C: Placing the infant in an infant seat is incorrect because this will also cause movement that can increase muscle irritability.
The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:
Bleeding is a common complication of orthopedic surgery. The blood-collection device should be checked frequently to ensure that the client is not hemorrhaging. Option B: The client’s pain should be assessed, but this is not life-threatening. Options C and D: When the client is in less danger, the nutritional status should be assessed and an immobilizer is not used.
A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:
Following epidural anesthesia, the client should be checked for hypotension and signs of shock every 5 minutes for 15 minutes. Option A: The client can be checked for cervical dilation later after she is stable. Option B: The client should not be positioned supine because the anesthesia can move above the respiratory center and the client can stop breathing. Option D: Fetal heart tones should be assessed after the blood pressure is checked.
The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?
The client with a hip fracture will most likely have misalignment. Options A, C, and D: All fractures cause pain, and coolness of the extremities and absence of pulses are indicative of compartment syndrome or peripheral vascular disease.
The nurse is aware that the best way to prevent postoperative wound infection in the surgical client is to:
The best way to prevent post-operative wound infection is hand washing. Option A: Use of prescribed antibiotics will treat infection, not prevent infections. Options C and D: Wearing a mask and asking the client to cover her mouth are good practices but will not prevent wound infections.
A client with a total knee replacement has a CPM (continuous passive motion device) applied during the post-operative period. Which statement made by the nurse indicates understanding of the CPM machine?
The controller for the continuous-passive-motion device should be placed away from the client. Many clients complain of pain while having treatments with the CPM, so they might turn off the machine. The CPM flexes and extends the leg. Option A: The client is in the bed during CPM therapy. Option C: The client will experience pain with the treatment. Option D: Use of the CPM does not alleviate the need for physical therapy.
Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse’s teaching?
The client’s family member should be taught to flush the tube after each feeding and clamp the tube. Options B and C: The placement should be checked before feedings, and indigestion can occur with the PEG tube, just as it can occur with any client. Option D: Medications can be ordered for indigestion, but it is not a reason for alarm. A percutaneous endoscopy gastrostomy tube is used for clients who have experienced difficulty swallowing. The tube is inserted directly into the stomach and does not require swallowing.
The nurse is assigned to care for the client with a Steinmann pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?
The nurse is performing the pin care correctly when she uses sterile gloves and Q-tips. Options B, C, and D: A licensed practical nurse can perform pin care, there is no need to clean the weights, and the nurse can help with opening the packages but it isn’t required.
The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to:
After menopause, women lack hormones necessary to absorb and utilize calcium. Options A and C: Doing weight-bearing exercises and taking calcium supplements can help to prevent osteoporosis but are not causes. Option D: Body types that frequently experience osteoporosis are thin Caucasian females, but they are not most likely related to osteoporosis.
A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5 cm dilated with 75% effacement. Based on the nurse’s assessment the client is in which phase of labor?
The active phase of labor occurs when the client is dilated 4–7cm. Options B and D: The latent or early phase of labor is from 1cm to 3cm in dilation. Options C: The transition phase of labor is 8–10cm in dilation.
A 2-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly?
The infant’s hips should be off the bed approximately 15° in Bryant’s traction. Option A is incorrect because this does not indicate that the traction is working correctly, nor does C. Option D is incorrect because Bryant’s traction is a skin traction, not a skeletal traction.
A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?
A body cast or spica cast extends from the upper abdomen to the knees or below. Bowel sounds should be checked to ensure that the client is not experiencing a paralytic ileus. Options B, C, and D: Checking the blood pressure is a treatment for any client, offering pain medication is not called for, and checking for swelling isn’t specific to the stem.
When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:
The client with a prolapsed cord should be treated by elevating the hips and covering the cord with a moist, sterile saline gauze. The nurse should use her fingers to push up on the presenting part until a cesarean section can be performed. Options A, B, and D: The nurse should not attempt to replace the cord, turn the client on the side, or cover with a dry gauze.
A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse indicates understanding of a plaster-of-Paris cast? The nurse:
A plaster-of-Paris cast takes 24 hours to dry, and the client should not bear weight for 24 hours. Option A: The cast should be handled with the palms, not the fingertips. Option B: Petaling a cast is covering the end of the cast with cast batting or a sock, to prevent skin irritation and flaking of the skin under the cast. Option C: The client should be told not to dry the cast with a hair dryer because this causes hot spots and could burn the client. This also causes unequal drying.
The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?
There is no reason that the client’s friends should not be allowed to autograph the cast; it will not harm the cast in any way, so answers B, C, and D are incorrect.
Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell’s traction?
The 6-year-old should have a roommate as close to the same age as possible, so the 12-year-old is the best match. Option A: The client is too old and is female. Option C: The 10-year-old with sarcoma has cancer and will be treated with chemotherapy that makes him immune suppressed Option D: The 6-year-old with osteomyelitis is infectious.
A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:
The client’s palms should rest lightly on the handles. The elbows should be flexed no more than 30° but should not be extended. Option B: A 0° is not a relaxed angle for the elbows and will not facilitate correct walker use. Option C: The client should walk to the middle of the walker, not to the front of the walker. Option D: The client should be taught not to carry the walker because this would not provide stability.
An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:
Narcan is the antidote for narcotic overdose. Option A: If hypoxia occurs, the client should have oxygen administered by mask, not cannula. Options C and D: There is no data to support the administration of blood products or cardiac resuscitation.
The nurse is caring for the client with a 5-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?
Plumbism is lead poisoning. One factor associated with the consumption of lead is eating from pottery made in Central America or Mexico that is unfired. The child lives in a house built after 1976 (this is when lead was taken out of paint), and the parents make stained glass as a hobby. Stained glass is put together with lead, which can drop on the work area, where the child can consume the lead beads. Option A: Traveling out of the country does not increase the risk of plumbism. Option C: The house was built after the lead was removed with the paint. Option D: Having several siblings is unrelated to the stem.
A client with a fractured hip has been placed in Buck’s traction. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
Balanced skeletal traction uses pins and screws. A Steinman pin goes through large bones and is used to stabilize large bones such as the femur. Option B: Only the affected leg is in traction. Option C: Kirschner wires are used to stabilize small bones such as fingers and toes. Option D: Buck's traction is not used for fractured hips.
A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with activities of daily living?
The equipment that can help with activities of daily living is the high-seat commode. The hip should be kept higher than the knee. Option B: The recliner is good because it prevents 90° flexion but not daily activities. Option C: A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain management. Option D: An abduction pillow is used to prevent adduction of the hip and possibly dislocation of the prosthesis.
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