NCLEX Practice Exam 33 (10 Questions)

1. A client being treated with sodium warfarin has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?

Assess for signs of abnormal bleeding

Anticipate an increase in the Coumadin dosage

Instruct the client regarding the drug therapy

Increase the frequency of neurological assessments

The normal Protime is 12–20 seconds. A Protime of 120 seconds indicates an extremely prolonged Protime and can result in a spontaneous bleeding episode. Answers B. C. and D may be needed at a later time but are not the most important actions to take first.

Explanation

The normal Protime is 12–20 seconds. A Protime of 120 seconds indicates an extremely prolonged Protime and can result in a spontaneous bleeding episode. Answers B. C. and D may be needed at a later time but are not the most important actions to take first.

2. Which selection would provide the most calcium for the client who is 4 months pregnant?

A granola bar

A bran muffin

A cup of yogurt

A glass of fruit juice

The food with the most calcium is the yogurt. Answers A. B. and D are good choices. but not as good as the yogurt. which has approximately 400 mg of calcium.

Explanation

The food with the most calcium is the yogurt. Answers A. B. and D are good choices. but not as good as the yogurt. which has approximately 400 mg of calcium.

3. The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?

Order a chest x-ray

Reinsert the tube

Cover the insertion site with a Vaseline gauze

Call the doctor

If the client pulls the chest tube out of the chest. the nurse’s first action should be to cover the insertion site with an occlusive dressing. Afterward. the nurse should call the doctor. who will order a chest x-ray and possibly reinsert the tube. Answers A. B. and D are not the first action to be taken.

Explanation

If the client pulls the chest tube out of the chest. the nurse’s first action should be to cover the insertion site with an occlusive dressing. Afterward. the nurse should call the doctor. who will order a chest x-ray and possibly reinsert the tube. Answers A. B. and D are not the first action to be taken.

4. The nurse working the organ transplant unit is caring for a client with a white blood cell count of During evening visitation. a visitor brings a basket of fruit. What action should the nurse take?

Allow the client to keep the fruit

Place the fruit next to the bed for easy access by the client

Offer to wash the fruit for the client

Tell the family members to take the fruit home

The client with neutropenia should not have fresh fruit because it should be peeled and/or cooked before eating. He should also not eat foods grown on or in the ground or eat from the salad bar. The nurse should remove potted or cut flowers from the room as well. Any source of bacteria should be eliminated. if possible. Answers A. B. and C will not help prevent bacterial invasions.

Explanation

The client with neutropenia should not have fresh fruit because it should be peeled and/or cooked before eating. He should also not eat foods grown on or in the ground or eat from the salad bar. The nurse should remove potted or cut flowers from the room as well. Any source of bacteria should be eliminated. if possible. Answers A. B. and C will not help prevent bacterial invasions.

5. The nurse is evaluating nutritional outcomes for a with anorexia nervosa. Which data best indicates that the plan of care is effective?

The client selects a balanced diet from the menu.

The client’s hemoglobin and hematocrit improve.

The client’s tissue turgor improves.

The client gains weight.

The client with anorexia shows the most improvement by weight gain. Selecting a balanced diet does little good if the client will not eat. so answer A is incorrect. The hematocrit might improve by several means. such as blood transfusion. but that does not indicate improvement in the anorexic condition; therefore. answer B is incorrect. The tissue turgor indicates fluid stasis. not improvement of anorexia. so answer C is incorrect.

Explanation

The client with anorexia shows the most improvement by weight gain. Selecting a balanced diet does little good if the client will not eat. so answer A is incorrect. The hematocrit might improve by several means. such as blood transfusion. but that does not indicate improvement in the anorexic condition; therefore. answer B is incorrect. The tissue turgor indicates fluid stasis. not improvement of anorexia. so answer C is incorrect.

6. The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?

Pain beneath the cast

Warm toes

Pedal pulses weak and rapid

Paresthesia of the toes

At this time. pain beneath the cast is normal. The client’s toes should be warm to the touch. and pulses should be present. Paresthesia is not normal and might indicate compartment syndrome. Therefore. Answers A. B. and C are incorrect.

Explanation

At this time. pain beneath the cast is normal. The client’s toes should be warm to the touch. and pulses should be present. Paresthesia is not normal and might indicate compartment syndrome. Therefore. Answers A. B. and C are incorrect.

7. A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?

Hypovolemia

Laryngeal edema

Hypernatremia

Hyperkalemia

The nurse should be most concerned with laryngeal edema because of the area of burn. The next priority should be answer A. as well as hyponatremia and hypokalemia in C and D. but these answers are not of primary concern so are incorrect.

Explanation

The nurse should be most concerned with laryngeal edema because of the area of burn. The next priority should be answer A. as well as hyponatremia and hypokalemia in C and D. but these answers are not of primary concern so are incorrect.

8. A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The physician has written an order to transfuse 2 units of whole blood. When discussing the treatment. the child's mother tells the nurse that she does not believe in having blood transfusions and that she will not allow her child to have the treatment. What nursing action is most appropriate?

Ask the mother to leave while the blood transfusion is in progress

Encourage the mother to reconsider

Explain the consequences without treatment

Notify the physician of the mother’s refusal

If the client’s mother refuses the blood transfusion. the doctor should be notified. Because the client is a minor. the court might order treatment. Answer A is incorrect. Because it is not the primary responsibility for the nurse to encourage the mother to consent or explain the consequences. so answers B and C are incorrect.

Explanation

If the client’s mother refuses the blood transfusion. the doctor should be notified. Because the client is a minor. the court might order treatment. Answer A is incorrect. Because it is not the primary responsibility for the nurse to encourage the mother to consent or explain the consequences. so answers B and C are incorrect.

9. The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of the possible side effects of magnesium sulfate?

The nurse places a sign over the bed not to check blood pressure in the right arm.

The nurse places a padded tongue blade at the bedside.

The nurse inserts a Foley catheter.

The nurse darkens the room.

The client receiving magnesium sulfate should have a Foley catheter in place. and hourly intake and output should be checked. There is no need to refrain from checking the blood pressure in the right arm. A padded tongue blade should be kept in the room at the bedside. just in case of a seizure. but this is not related to the magnesium sulfate infusion. Darkening the room is unnecessary. so answers A. B. and D are incorrect.

Explanation

The client receiving magnesium sulfate should have a Foley catheter in place. and hourly intake and output should be checked. There is no need to refrain from checking the blood pressure in the right arm. A padded tongue blade should be kept in the room at the bedside. just in case of a seizure. but this is not related to the magnesium sulfate infusion. Darkening the room is unnecessary. so answers A. B. and D are incorrect.

10. The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale. with a BP of 90/40 systolic. The initial nurse's action should be to:

Place the client in Trendelenburg position

Increase the infusion of Dextrose in normal saline

Administer atropine intravenously

Move the emergency cart to the bedside

In clients who have not had surgery to the face or neck. the answer would be answer A; however. in this situation. this could further interfere with the airway. Increasing the infusion and placing the client in supine position would be better. Answers C is incorrect because it is not necessary at this time and could cause hyponatremia and further hypotension. Answer D is not necessary at this time.

Explanation

In clients who have not had surgery to the face or neck. the answer would be answer A; however. in this situation. this could further interfere with the airway. Increasing the infusion and placing the client in supine position would be better. Answers C is incorrect because it is not necessary at this time and could cause hyponatremia and further hypotension. Answer D is not necessary at this time.