NCLEX Practice Exam 4 (10 Questions)
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The nurse is caring for a client who had a total hip replacement four (4) days ago. Which assessment requires the nurse’s immediate attention?
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I have bad muscle spasms in my lower leg of the affected extremity.
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“I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.”
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“I have to use the bedpan to pass my water at least every 1 to 2 hours.”
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“It seems that the pain medication is not working as well today.”
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All questions are shown, but the results will only be given after you’ve finished the quiz. You are given 1 minute per question, a total of 10 minutes in this quiz.
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- 2.
While assessing a 1-month-old infant. which finding should the nurse report immediately?
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Abdominal respirations
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Irregular breathing rate
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Inspiratory grunt
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Increased heart rate with crying
Correct Answer
A. Inspiratory gruntExplanation
Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant.Rate this question:
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- 3.
During the evaluation of the quality of home care for a client with Alzheimer’s disease. the priority for the nurse is to reinforce which statement by a family member?
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At least two (2) full meals a day is eaten.
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We go to a group discussion every week at our community center.
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We have safety bars installed in the bathroom and have 24-hour alarms on the doors.
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The medication is not a problem to have it taken three (3) times a day.
Correct Answer
A. We have safety bars installed in the bathroom and have 24-hour alarms on the doors.Explanation
Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are correct statements. However. safety is most important to reinforce.Rate this question:
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- 4.
The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to
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Excessive fetal weight
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Low blood sugar levels
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Depletion of subcutaneous fat
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Progressive placental insufficiency
Correct Answer
A. Progressive placental insufficiencyExplanation
The placenta functions less efficiently as the pregnancy continues beyond 42 weeks. Immediate and long-term effects may be related to hypoxia.Rate this question:
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- 5.
The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
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Apply dressing using sterile technique
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Improve the client’s nutrition status
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Initiate limb compression therapy
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Begin proteolytic debridement
Correct Answer
A. Improve the client’s nutrition statusExplanation
The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other answers are correct. but without proper nutrition. the other interventions would be of little help.Rate this question:
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- 6.
A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history. which includes 3-year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?
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Gravida 4 para 2
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Gravida 2 para 1
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Gravida 3 para 1
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Gravida 3 para 2
Correct Answer
A. Gravida 3 para 1Explanation
Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus. for this woman. she is now pregnant. had 2 prior pregnancies. and 1 viable birth (twins).Rate this question:
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- 7.
Which of these statements best describes the characteristic of an effective reward-feedback system?
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Specific feedback is given as close to the event as possible
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Staff is given feedback in equal amounts over time
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Positive statements are to precede a negative statement
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Performance goals should be higher than what is attainable
Correct Answer
A. Specific feedback is given as close to the event as possibleExplanation
Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback. and it is easier to modify problem behaviors if the standards are clearly understood.Rate this question:
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- 8.
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg. atropine sulfate (Atropisol) 0.4 mg. and promethazine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?
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Raise the side rails on the bed
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Place the call bell within reach
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Instruct the client to remain in bed
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Have the client empty bladder
Correct Answer
A. Have the client empty bladderExplanation
The first step in the process is to have the client void prior to administering the pre-operative medication. The other actions follow this initial step in this sequence: D. C. A and then B.Rate this question:
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- 9.
A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise. the nurse should caution the client to avoid activities which
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Increase the heart rate
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Lead to dehydration
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Are considered aerobic
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May be competitive
Correct Answer
A. Lead to dehydrationExplanation
The client must take in adequate fluids before and during exercise periods.Rate this question:
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- 10.
A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?
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Weight gain of 5 pounds
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Edema of the ankles
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Gastric irritability
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Decreased appetite
Correct Answer
A. Decreased appetiteExplanation
Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia. fatigue. nausea. decreased GI motility. muscle weakness. dysrhythmias.Rate this question:
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Aug 22, 2023Quiz Edited by
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May 01, 2017Quiz Created by
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