NCLEX Practice Exam 34 (10 Questions)

1.

A client with a history of abusing barbiturates abruptly stops taking the medication. The nurse should give priority to assessing the client for:

A.

Depression and suicidal ideation
B.

Tachycardia and diarrhea
C.

Muscle cramping and abdominal pain
D.

Tachycardia and euphoric mood

Correct Answer
B. Tachycardia and diarrhea

Explanation
Barbiturates create a sedative effect. When the client stops taking barbiturates. he will experience tachycardia. diarrhea. and tachypnea. Answer A is incorrect even though depression and suicidal ideation go along with barbiturate use; it is not the priority. Muscle cramps and abdominal pain are vague symptoms that could be associated with other problems. Tachycardia is associated with stopping barbiturates. but euphoria is not.

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2.

During the assessment of a laboring client. the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?

A.

Right breech presentation
B.

Right occiput anterior presentation
C.

Left sacral anterior presentation
D.

Left occipital transverse presentation

Correct Answer
A. Right breech presentation

Explanation
If the fetal heart tones are heard in the right upper abdomen. the infant is in a breech presentation. If the infant is positioned in the right occiput anterior presentation. the FHTs will be located in the right lower quadrant. so answer B is incorrect. If the fetus is in the sacral position. the FHTs will be located in the center of the abdomen. so answer C is incorrect. If the FHTs are heard in the left lower abdomen. the infant is most likely in the left occiput transverse position. making answer D incorrect.

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3.

The primary physiological alteration in the development of asthma is:

A.

Bronchiolar inflammation and dyspnea
B.

Hypersecretion of abnormally viscous mucus
C.

Infectious processes causing mucosal edema
D.

Spasm of bronchial smooth muscle

Correct Answer
D. Spasm of bronchial smooth muscle

Explanation
Asthma is the presence of bronchial spasms. This spasm can be brought on by allergies or anxiety. Answer A is incorrect because the primary physiological alteration is not inflammation. Answer B is incorrect because there is the production of abnormally viscous mucus. not a primary alteration. Answer C is incorrect because infection is not primary to asthma.

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4.

A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment. the nurse should:

A.

Serve high-calorie foods she can carry with her
B.

Encourage her appetite by sending out for her favorite foods
C.

Serve her small. attractively arranged portions
D.

Allow her in the unit kitchen for extra food whenever she pleases

Correct Answer
A. Serve high-calorie foods she can carry with her

Explanation
The client with mania is seldom sitting long enough to eat and burns many calories for energy. Answer B is incorrect because the client should be treated the same as other clients. Small meals are not a correct option for this client. Allowing her into the kitchen gives her privileges that other clients do not have and should not be allowed. so answer D is incorrect.

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5.

To maintain Bryant’s traction. the nurse must make certain that the child’s:

A.

Hips are resting on the bed. with the legs suspended at a right angle to the bed
B.

Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed
C.

Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed
D.

Hips and legs are flat on the bed. with the traction positioned at the foot of the bed

Correct Answer
B. Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed

Explanation
Bryant’s traction is used for fractured femurs and dislocated hips. The hips should be elevated 15° off the bed. Answer A is incorrect because the hips should not be resting on the bed. Answer C is incorrect because the hips should not be above the level of the body. Answer D is incorrect because the hips and legs should not be flat on the bed.

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6.

Which action by the nurse indicates understanding of herpes zoster?

A.

The nurse covers the lesions with a sterile dressing.
B.

The nurse wears gloves when providing care.
C.

The nurse administers a prescribed antibiotic.
D.

The nurse administers oxygen.

Correct Answer
B. The nurse wears gloves when providing care.

Explanation
Herpes zoster is shingles. Clients with shingles should be placed in contact precautions. Wearing gloves during care will prevent transmission of the virus. Covering the lesions with a sterile gauze is not necessary. antibiotics are not prescribed for herpes zoster. and oxygen is not necessary for shingles; therefore. answers A. C. and D are incorrect.

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7.

The client has an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that the nurse should contact the lab for them to collect the blood:

A.

15 minutes after the infusion
B.

30 minutes before the infusion
C.

1 hour after the infusion
D.

2 hours after the infusion

Correct Answer
B. 30 minutes before the infusion

Explanation
A trough level should be drawn 30 minutes before the third or fourth dose. The times in answers A. C. and D are incorrect times to draw blood levels.

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8.

The client using a diaphragm should be instructed to:

A.

Refrain from keeping the diaphragm in longer than 4 hours
B.

Keep the diaphragm in a cool location
C.

Have the diaphragm resized if she gains 5 pounds
D.

Have the diaphragm resized if she has any surgery

Correct Answer
B. Keep the diaphragm in a cool location

Explanation
The client using a diaphragm should keep the diaphragm in a cool location. Answers A. C. and D are incorrect. She should refrain from leaving the diaphragm in longer than 8 hours. not 4 hours. She should have the diaphragm resized when she gains or loses 10 pounds or has abdominal surgery.

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9.

The nurse is providing postpartum teaching for a mother planning to breastfeed her infant. Which of the client’s statements indicates the need for additional teaching?

A.

“I’m wearing a support bra.”
B.

“I’m expressing milk from my breast.”
C.

“I’m drinking four glasses of fluid during a 24-hour period.”
D.

“While I’m in the shower. I’ll allow the water to run over my breasts.”

Correct Answer
C. “I’m drinking four glasses of fluid during a 24-hour period.”

Explanation
Mothers who plan to breastfeed should drink plenty of liquids. and four glasses is not enough in a 24-hour period. Wearing a support bra is a good practice for the mother who is breastfeeding as well as the mother who plans to bottle-feed. so answer A is incorrect. Expressing milk from the breast will stimulate milk production. making answer B incorrect. Allowing the water to run over the breast will also facilitate “letdown.” when the milk begins to be produced; thus. answer D is incorrect.

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10.

Damage to the VII cranial nerve results in:

A.

Facial pain
B.

Absence of ability to smell
C.

Absence of eye movement
D.

Tinnitus

Correct Answer
A. Facial pain

Explanation
The facial nerve is cranial nerve VII. If damage occurs. the client will experience facial pain. The auditory nerve is responsible for hearing loss and tinnitus. eye movement is controlled by the Trochlear or C IV. and the olfactory nerve controls smell; therefore. answers B. C. and D are incorrect.

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