NCLEX Practice Exam 3 (10 Questions)

1. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is

Verify correct placement of the tube

Check that the feeding solution matches the dietary order

Aspirate abdominal contents to determine the amount of last feeding remaining in stomach

Ensure that feeding solution is at room temperature

Proper placement of the tube prevents aspiration.

Explanation

Proper placement of the tube prevents aspiration.

2. A client is receiving digoxin (Lanoxin) 0.25 mg daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg B.I.D. In assessing the client prior to administering the medications. which of the following should the nurse report immediately to the health care provider?

Blood pressure 94/60

Heart rate 76

Urine output 50 ml/hour

Respiratory rate 16

Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore. the heart rate and blood pressure must be within normal range (HR 60-100; systolic BP over 100) in order to safely administer both medications.

Explanation

Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore. the heart rate and blood pressure must be within normal range (HR 60-100; systolic BP over 100) in order to safely administer both medications.

3. A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help. the first action the nurse should take is:

Start a peripheral IV

Initiate high-quality chest compressions

Establish an airway

Obtain the crash cart

As per new guidelines. the American Heart Association recommends beginning CPR with chest compression (rather than checking for the airway first). Start CPR with 30 chest compressions before checking the airway and giving rescue breaths. Starting with chest compressions first applies to adults. children. and infants needing CPR. but not newborns. CPR can keep oxygenated blood flowing to the brain and other vital organs until more definitive medical treatment can restore a normal heart rhythm.

Explanation

As per new guidelines. the American Heart Association recommends beginning CPR with chest compression (rather than checking for the airway first). Start CPR with 30 chest compressions before checking the airway and giving rescue breaths. Starting with chest compressions first applies to adults. children. and infants needing CPR. but not newborns. CPR can keep oxygenated blood flowing to the brain and other vital organs until more definitive medical treatment can restore a normal heart rhythm.

4. A nurse prepares to care for a 4-year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?

All striated muscles

The cerebellum

The kidneys

The leg bones

Rhabdomyosarcoma is the most common children’s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word and is “myo” which typically means muscle.

Explanation

Rhabdomyosarcoma is the most common children’s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word and is “myo” which typically means muscle.

5. The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to:

Achieve harmony

Maintain a balance of energy

Respect life

Restore yin and yang

For followers of Chinese medicine. health is maintained through the balance between the forces of yin and yang.

Explanation

For followers of Chinese medicine. health is maintained through the balance between the forces of yin and yang.

6. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?

Narrowed QRS complex

Shortened “PR” interval

Tall peaked “T” waves

Prominent “U” waves

A tall peaked T wave is a sign of hyperkalemia. The health care provider should be notified regarding discontinuing the medication.

Explanation

A tall peaked T wave is a sign of hyperkalemia. The health care provider should be notified regarding discontinuing the medication.

7. While planning care for a toddler. the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs?

“I want to protect my child from any falls.”

“I will set limits on exploring the house.”

“I understand the need to use those new skills.”

“I intend to keep control over our child.”

Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.

Explanation

Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.

8. A triage nurse has these four (4) clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

A 2-month-old infant with a history of rolling off the bed and has bulging fontanels with crying

A teenager who got a singed beard while camping

An elderly client with complaints of frequent liquid brown colored stools

A middle-aged client with intermittent pain behind the right scapula

This client is in the greatest danger with a potential of respiratory distress. Any client with singed facial hair has been exposed to heat or fire in close range that could have caused serious damage to the interior of the lungs. Note that the interior linings of the lungs have no nerve fibers so the client will not be aware of swelling.

Explanation

This client is in the greatest danger with a potential of respiratory distress. Any client with singed facial hair has been exposed to heat or fire in close range that could have caused serious damage to the interior of the lungs. Note that the interior linings of the lungs have no nerve fibers so the client will not be aware of swelling.

9. During an assessment of a client with cardiomyopathy. the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to

Increase fluids that are high in protein

Restrict fluids

Force fluids and reassess blood pressure

Limit fluids to non-caffeine beverages

Postural hypotension. a decrease in systolic blood pressure of more than 15 mmHg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicate volume depletion. inadequate vasoconstrictor mechanisms. and autonomic insufficiency.

Explanation

Postural hypotension. a decrease in systolic blood pressure of more than 15 mmHg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicate volume depletion. inadequate vasoconstrictor mechanisms. and autonomic insufficiency.

10. The nurse prepares the client for insertion of a pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about:

Stroke volume

Cardiac output

Venous pressure

Left ventricular functioning

The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated.

Explanation

The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated.