NCLEX Practice Exam 32 (10 Questions)

1. Which observation in the newborn of a diabetic mother would require immediate nursing intervention?

Crying

Wakefulness

Jitteriness

Yawning

Jitteriness is a sign of seizure in the neonate. Crying. wakefulness. and yawning are expected in the newborn. so answers A. B. and D are incorrect.

Explanation

Jitteriness is a sign of seizure in the neonate. Crying. wakefulness. and yawning are expected in the newborn. so answers A. B. and D are incorrect.

2. A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?

Alteration in nutrition

Alteration in bowel elimination

Alteration in skin integrity

Ineffective individual coping

Cancer of the pancreas frequently leads to severe nausea and vomiting and altered nutrition. The other problems are of lesser concern; thus. answers B. C. and D are incorrect.

Explanation

Cancer of the pancreas frequently leads to severe nausea and vomiting and altered nutrition. The other problems are of lesser concern; thus. answers B. C. and D are incorrect.

3. The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?

Inspection of the abdomen for enlargement

Bimanual palpation for hepatomegaly

Daily measurement of abdominal girth

Assessment for a fluid wave

Measuring with a paper tape measure and marking the area that is measured is the most objective method of estimating ascites. Inspecting and checking for fluid waves are more subjective. so answers A and B are incorrect. Palpation of the liver will not tell the amount of ascites; thus. answer D is incorrect.

Explanation

Measuring with a paper tape measure and marking the area that is measured is the most objective method of estimating ascites. Inspecting and checking for fluid waves are more subjective. so answers A and B are incorrect. Palpation of the liver will not tell the amount of ascites; thus. answer D is incorrect.

4. The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?

The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.

The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow.

The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.

The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.

Answer B elicits the triceps reflex. so it is incorrect. Answer C elicits the patella reflex. making it incorrect. Answer D elicits the radial nerve. so it is incorrect.

Explanation

Answer B elicits the triceps reflex. so it is incorrect. Answer C elicits the patella reflex. making it incorrect. Answer D elicits the radial nerve. so it is incorrect.

5. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34. pulse rate 120. and respirations 20. Which is the client's most appropriate priority nursing diagnosis?

Alteration in cerebral tissue perfusion

Fluid volume deficit

Ineffective airway clearance

Alteration in sensory perception

The vital signs indicate hypovolemic shock. They do not indicate cerebral tissue perfusion. airway clearance. or sensory perception alterations. so answers A. C. and D are incorrect.

Explanation

The vital signs indicate hypovolemic shock. They do not indicate cerebral tissue perfusion. airway clearance. or sensory perception alterations. so answers A. C. and D are incorrect.

6. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse's assessment of this data is:

The infant is at low risk for congenital anomalies.

The infant is at high risk for intrauterine growth retardation.

The infant is at high risk for respiratory distress syndrome.

The infant is at high risk for birth trauma.

When the L/S ratio reaches 2:1. the lungs are considered to be mature. The infant will most likely be small for gestational age and will not be at risk for birth trauma. so answer D is incorrect. The L/S ratio does not indicate congenital anomalies. as stated in answer A. and the infant is not at risk for intrauterine growth retardation. making answer B incorrect.

Explanation

When the L/S ratio reaches 2:1. the lungs are considered to be mature. The infant will most likely be small for gestational age and will not be at risk for birth trauma. so answer D is incorrect. The L/S ratio does not indicate congenital anomalies. as stated in answer A. and the infant is not at risk for intrauterine growth retardation. making answer B incorrect.

7. The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:

Likes to play football

Drinks several carbonated drinks per day

Has two sisters with sickle cell tract

Is taking acetaminophen to control pain

The client with osteogenesis imperfecta is at risk for pathological fractures and is likely to experience these fractures if he participates in contact sports. The client might experience symptoms of hypoxia if he becomes dehydrated or deoxygenated; extreme exercise. especially in warm weather. can exacerbate the condition. Answers B. C. and D are not factors for concern.

Explanation

The client with osteogenesis imperfecta is at risk for pathological fractures and is likely to experience these fractures if he participates in contact sports. The client might experience symptoms of hypoxia if he becomes dehydrated or deoxygenated; extreme exercise. especially in warm weather. can exacerbate the condition. Answers B. C. and D are not factors for concern.

8. The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension. the nurse would:

Place her in Trendelenburg position

Decrease the rate of IV infusion

Administer oxygen per nasal cannula

Increase the rate of the IV infusion

If the client experiences hypotension after an injection of epidural anesthetic. the nurse should turn her to the left side. apply oxygen by mask. and speed the IV infusion. If the blood pressure does not return to normal. the physician should be contacted. Epinephrine should be kept for emergency administration. Answer A is incorrect because placing the client in Trendelenburg position (head down) will allow the anesthesia to move up above the respiratory center. thereby decreasing the diaphragm’s ability to move up and down and ventilate the client. In answer B. the IV rate should be increased. not decreased. In answer C. the oxygen should be applied by mask. not cannula.

Explanation

If the client experiences hypotension after an injection of epidural anesthetic. the nurse should turn her to the left side. apply oxygen by mask. and speed the IV infusion. If the blood pressure does not return to normal. the physician should be contacted. Epinephrine should be kept for emergency administration. Answer A is incorrect because placing the client in Trendelenburg position (head down) will allow the anesthesia to move up above the respiratory center. thereby decreasing the diaphragm’s ability to move up and down and ventilate the client. In answer B. the IV rate should be increased. not decreased. In answer C. the oxygen should be applied by mask. not cannula.

9. A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor's order should the nurse question?

Magnesium sulfate 4gm (25%) IV

Brethine 10 mcg IV

Stadol 1 mg IV push every 4 hours as needed prn for pain

Ancef 2gm IVPB every 6 hours

Brethine is used cautiously because it raises the blood glucose levels. Answers A. C. and D are all medications that are commonly used in the diabetic client. so they are incorrect.

Explanation

Brethine is used cautiously because it raises the blood glucose levels. Answers A. C. and D are all medications that are commonly used in the diabetic client. so they are incorrect.

10. The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:

Decreased urinary output

Hypersomnolence

Absence of knee jerk reflex

Decreased respiratory rate

The client is expected to become sleepy. have hot flashes. and be lethargic. A decreasing urinary output. absence of the knee-jerk reflex. and decreased respirations indicate toxicity. so answers A. C. and D are incorrect.

Explanation

The client is expected to become sleepy. have hot flashes. and be lethargic. A decreasing urinary output. absence of the knee-jerk reflex. and decreased respirations indicate toxicity. so answers A. C. and D are incorrect.