NCLEX Practice Exam 2 (10 Questions)

1. The nurse is performing a neurological assessment on a client post right CVA. Which finding. if observed by the nurse. would warrant immediate attention?

Decrease in level of consciousness

Loss of bladder control

Altered sensation to stimuli

Emotional ability

urther decrease in the level of consciousness would be indicative of a further progression of the CVA.

Explanation

urther decrease in the level of consciousness would be indicative of a further progression of the CVA.

2. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should

Place a call to the client’s health care provider for instructions

Send him to the emergency room for evaluation

Reassure the client’s wife that the symptoms are transient

Instruct the client’s wife to call the doctor if his symptoms become worse

s client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client’s best interest.

Explanation

s client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client’s best interest.

3. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?

Trichomoniasis

Chlamydia

Staphylococcus

Streptococcus

amydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.

Explanation

amydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.

4. Which of the following should the nurse implement to prepare a client for a KUB (Kidney. Ureter. Bladder) radiograph test?

Client must be NPO before the examination

Enema to be administered prior to the examination

Medicate client with Lasix 20 mg IV 30 minutes prior to the examination

No special orders are necessary for this examination

special preparation is necessary for this examination.

Explanation

special preparation is necessary for this examination.

5. The nurse is giving discharge teaching to a client seven (7) days post myocardial infarction. He asks the nurse why he must wait six (6) weeks before having sexual intercourse. What is the best response by the nurse to this question?

“You need to regain your strength before attempting such exertion.”

“When you can climb 2 flights of stairs without problems. it is generally safe.”

“Have a glass of wine to relax you. then you can try to have sex.”

“If you can maintain an active walking program. you will have less risk.”

re is a risk of cardiac rupture at the point of the myocardial infarction for about six (6) weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.

Explanation

re is a risk of cardiac rupture at the point of the myocardial infarction for about six (6) weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.

6. When teaching a client with coronary artery disease about nutrition. the nurse should emphasize

Eating three (3) balanced meals a day

Adding complex carbohydrates

Avoiding very heavy meals

Limiting sodium to 7 gms per day

ing large. heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease.

Explanation

ing large. heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease.

7. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working?

The client complains of discomfort at the IV insertion site

The client states “I just can’t get relief from my pain.”

The level of drug is 100 ml at 8 AM and is 80 ml at noon

The level of the drug is 100 ml at 8 AM and is 50 ml at noon

minimal dose of 10 mL per hour which would be 40 mL given in a four (4) hour period. Only 60 mL should be left at noon. The pump is not functioning when more than expected medicine is left in the container.

Explanation

minimal dose of 10 mL per hour which would be 40 mL given in a four (4) hour period. Only 60 mL should be left at noon. The pump is not functioning when more than expected medicine is left in the container.

8. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?

An elderly client who reports having taken a “large crack hit” 10 minutes prior to walking into the emergency room.

ses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opioid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future.

Explanation

ses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opioid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future.

9. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response?

Electrical energy fields

Spinal column manipulation

Mind-body balance

Exercise of joints

theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation.

Explanation

theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation.

10. A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time?

Positive sweat test

Bulky greasy stools

Moist. productive cough

Meconium ileus

sy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus. sweat. saliva and digestive juices. Normally. these secretions are thin and slippery. but in CF. a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant. the secretions plug up tubes. ducts. and passageways. especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.

Explanation

sy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus. sweat. saliva and digestive juices. Normally. these secretions are thin and slippery. but in CF. a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant. the secretions plug up tubes. ducts. and passageways. especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.