NCLEX Practice Exam 4 (10 Questions)

1. 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?

I have bad muscle spasms in my lower leg of the affected extremity.

“I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.”

“I have to use the bedpan to pass my water at least every 1 to 2 hours.”

“It seems that the pain medication is not working as well today.”

The nurse would be concerned about all of these comments. However. the most life threatening is option B. Clients who have had hip or knee surgery are at greatest risk for development of postoperative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Option C may indicate a urinary tract infection. And option D requires further investigation and is not life threatening.

Explanation

The nurse would be concerned about all of these comments. However. the most life threatening is option B. Clients who have had hip or knee surgery are at greatest risk for development of postoperative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Option C may indicate a urinary tract infection. And option D requires further investigation and is not life threatening.

2. While assessing a 1-month-old infant. which finding should the nurse report immediately?

Abdominal respirations

Irregular breathing rate

Inspiratory grunt

Increased heart rate with crying

Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant.

Explanation

Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant.

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?

At least two (2) full meals a day is eaten.

We go to a group discussion every week at our community center.

We have safety bars installed in the bathroom and have 24-hour alarms on the doors.

The medication is not a problem to have it taken three (3) times a day.

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.

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.

4. The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to

Excessive fetal weight

Low blood sugar levels

Depletion of subcutaneous fat

Progressive placental insufficiency

The placenta functions less efficiently as the pregnancy continues beyond 42 weeks. Immediate and long-term effects may be related to hypoxia.

Explanation

The placenta functions less efficiently as the pregnancy continues beyond 42 weeks. Immediate and long-term effects may be related to hypoxia.

5. The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?

Apply dressing using sterile technique

Improve the client’s nutrition status

Initiate limb compression therapy

Begin proteolytic debridement

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.

Explanation

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.

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?

Gravida 4 para 2

Gravida 2 para 1

Gravida 3 para 1

Gravida 3 para 2

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).

Explanation

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).

7. Which of these statements best describes the characteristic of an effective reward-feedback system?

Specific feedback is given as close to the event as possible

Staff is given feedback in equal amounts over time

Positive statements are to precede a negative statement

Performance goals should be higher than what is attainable

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.

Explanation

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.

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?

Raise the side rails on the bed

Place the call bell within reach

Instruct the client to remain in bed

Have the client empty bladder

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.

Explanation

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.

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

Increase the heart rate

Lead to dehydration

Are considered aerobic

May be competitive

The client must take in adequate fluids before and during exercise periods.

Explanation

The client must take in adequate fluids before and during exercise periods.

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?

Weight gain of 5 pounds

Edema of the ankles

Gastric irritability

Decreased appetite

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.

Explanation

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.