NCLEX Practice Exam 25 (10 Questions)

1. The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?

Hamburger pattie. green beans. French fries. and iced tea

Roast beef sandwich. potato chips. baked beans. and cola

Baked chicken. fruit cup. potato salad. coleslaw. yogurt. and iced tea

Fish sandwich. gelatin with fruit. and coffee

All of the choices are tasty. but the pregnant client needs a diet that is balanced and has increased amounts of calcium. Answer A is lacking in fruits and milk. Answer B contains the potato chips. which contain a large amount of sodium. Answer C contains meat. fruit. potato salad. and yogurt. which has about 360 mg of calcium. Answer D is not the best diet because it lacks vegetables and milk products.

Explanation

All of the choices are tasty. but the pregnant client needs a diet that is balanced and has increased amounts of calcium. Answer A is lacking in fruits and milk. Answer B contains the potato chips. which contain a large amount of sodium. Answer C contains meat. fruit. potato salad. and yogurt. which has about 360 mg of calcium. Answer D is not the best diet because it lacks vegetables and milk products.

2. A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the:

Age of the client

Frequency of intercourse

Regularity of the menses

Range of the client’s temperature

The success of the rhythm method of birth control is dependent on the client’s menses being regular. It is not dependent on the age of the client. frequency of intercourse. or range of the client’s temperature; therefore. answers A. B. and D are incorrect.

Explanation

The success of the rhythm method of birth control is dependent on the client’s menses being regular. It is not dependent on the age of the client. frequency of intercourse. or range of the client’s temperature; therefore. answers A. B. and D are incorrect.

3. A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:

Elevated human chorionic gonadotropin

The presence of fetal heart tones

Uterine enlargement

Breast enlargement and tenderness

The most definitive diagnosis of pregnancy is the presence of fetal heart tones. The signs in answers A. C. and D are subjective and might be related to other medical conditions. Answers A and C may be related to a hydatidiform mole. and answer D is often present before menses or with the use of oral contraceptives.

Explanation

The most definitive diagnosis of pregnancy is the presence of fetal heart tones. The signs in answers A. C. and D are subjective and might be related to other medical conditions. Answers A and C may be related to a hydatidiform mole. and answer D is often present before menses or with the use of oral contraceptives.

4. A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when:

Estrogen levels are low.

Luteinizing hormone is high.

The endometrial lining is thin.

The progesterone level is low.

Luteinizing hormone released by the pituitary is responsible for ovulation. At about day 14. the continued increase in estrogen stimulates the release of luteinizing hormone from the anterior pituitary. The LH surge is responsible for ovulation. or the release of the dominant follicle in preparation for conception. which occurs within the next 10–12 hours after the LH levels peak. Answers A. C. and D are incorrect because estrogen levels are high at the beginning of ovulation. the endometrial lining is thick. not thin. and the progesterone levels are high. not low.

Explanation

Luteinizing hormone released by the pituitary is responsible for ovulation. At about day 14. the continued increase in estrogen stimulates the release of luteinizing hormone from the anterior pituitary. The LH surge is responsible for ovulation. or the release of the dominant follicle in preparation for conception. which occurs within the next 10–12 hours after the LH levels peak. Answers A. C. and D are incorrect because estrogen levels are high at the beginning of ovulation. the endometrial lining is thick. not thin. and the progesterone levels are high. not low.

5. The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:

The bladder fills more rapidly because of the medication used for the epidural.

Her level of consciousness is such that she is in a trancelike state.

The sensation of the bladder filling is diminished or lost.

She is embarrassed to ask for the bedpan that frequently.

Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder will decrease the progression of labor. Answers A. B. and D are incorrect for the stem.

Explanation

Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder will decrease the progression of labor. Answers A. B. and D are incorrect for the stem.

6. The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy?

Painless vaginal bleeding

Abdominal cramping

Throbbing pain in the upper quadrant

Sudden. stabbing pain in the lower quadrant

The signs of an ectopic pregnancy are vague until the fallopian tube ruptures. The client will complain of sudden. stabbing pain in the lower quadrant that radiates down the leg or up into the chest. Painless vaginal bleeding is a sign of placenta previa. abdominal cramping is a sign of labor. and throbbing pain in the upper quadrant is not a sign of an ectopic pregnancy. making answers A. B. and C incorrect.

Explanation

The signs of an ectopic pregnancy are vague until the fallopian tube ruptures. The client will complain of sudden. stabbing pain in the lower quadrant that radiates down the leg or up into the chest. Painless vaginal bleeding is a sign of placenta previa. abdominal cramping is a sign of labor. and throbbing pain in the upper quadrant is not a sign of an ectopic pregnancy. making answers A. B. and C incorrect.

7. The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:

Hypoglycemic. small for gestational age

Hyperglycemic. large for gestational age

Hypoglycemic. large for gestational age

Hyperglycemic. small for gestational age

The infant of a diabetic mother is usually large for gestational age. After birth. glucose levels fall rapidly due to the absence of glucose from the mother. Answer A is incorrect because the infant will not be small for gestational age. Answer B is incorrect because the infant will not be hyperglycemic. Answer D is incorrect because the infant will be large. not small. and will be hypoglycemic. not hyperglycemic.

Explanation

The infant of a diabetic mother is usually large for gestational age. After birth. glucose levels fall rapidly due to the absence of glucose from the mother. Answer A is incorrect because the infant will not be small for gestational age. Answer B is incorrect because the infant will not be hyperglycemic. Answer D is incorrect because the infant will be large. not small. and will be hypoglycemic. not hyperglycemic.

8. The client with hyperemesis gravidarum is at risk for developing:

Respiratory alkalosis without dehydration

Metabolic acidosis with dehydration

Respiratory acidosis without dehydration

Metabolic alkalosis with dehydration

Hyperemesis gravidarum is characterized by severe nausea and vomiting during pregnancy, leading to significant fluid and electrolyte loss. As a result, the client is at risk for metabolic alkalosis with dehydration. The excessive vomiting leads to the loss of gastric acid (hydrochloric acid), which can raise the blood pH and cause alkalosis. Dehydration also occurs due to fluid loss. Therefore, both metabolic alkalosis and dehydration are common in this condition.

Explanation

Hyperemesis gravidarum is characterized by severe nausea and vomiting during pregnancy, leading to significant fluid and electrolyte loss. As a result, the client is at risk for metabolic alkalosis with dehydration. The excessive vomiting leads to the loss of gastric acid (hydrochloric acid), which can raise the blood pH and cause alkalosis. Dehydration also occurs due to fluid loss. Therefore, both metabolic alkalosis and dehydration are common in this condition.

9. Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives?

Weight gain should be reported to the physician.

An alternate method of birth control is needed when taking antibiotics.

If the client misses one or more pills. two pills should be taken per day for 1 week.

Changes in the menstrual flow should be reported to the physician.

When the client is taking oral contraceptives and begins antibiotics. another method of birth control should be used. Antibiotics decrease the effectiveness of oral contraceptives. Approximately 5–10 pounds of weight gain is not unusual. so answer A is incorrect. If the client misses a birth control pill. she should be instructed to take the pill as soon as she remembers the pill. Answer C is incorrect. If she misses two. she should take two; if she misses more than two. she should take the missed pills but use another method of birth control for the remainder of the cycle. Answer D is incorrect because changes in menstrual flow are expected in clients using oral contraceptives. Often these clients have lighter menses.

Explanation

When the client is taking oral contraceptives and begins antibiotics. another method of birth control should be used. Antibiotics decrease the effectiveness of oral contraceptives. Approximately 5–10 pounds of weight gain is not unusual. so answer A is incorrect. If the client misses a birth control pill. she should be instructed to take the pill as soon as she remembers the pill. Answer C is incorrect. If she misses two. she should take two; if she misses more than two. she should take the missed pills but use another method of birth control for the remainder of the cycle. Answer D is incorrect because changes in menstrual flow are expected in clients using oral contraceptives. Often these clients have lighter menses.

10. A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?

Intrauterine device

Oral contraceptives

Diaphragm

Contraceptive sponge

The best method of birth control for the client with diabetes is the diaphragm. A permanent intrauterine device can cause a continuing inflammatory response in diabetics that should be avoided. oral contraceptives tend to elevate blood glucose levels. and contraceptive sponges are not good at preventing pregnancy. Therefore. answers A. B. and D are incorrect.

Explanation

The best method of birth control for the client with diabetes is the diaphragm. A permanent intrauterine device can cause a continuing inflammatory response in diabetics that should be avoided. oral contraceptives tend to elevate blood glucose levels. and contraceptive sponges are not good at preventing pregnancy. Therefore. answers A. B. and D are incorrect.