NCLEX Practice Exam 36 (10 Questions)

1. The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?

The presence of scant bloody discharge

Frequent urination

The presence of green-tinged amniotic fluid

Moderate uterine contractions

Green-tinged amniotic fluid is indicative of meconium staining. This finding indicates fetal distress. The presence of scant bloody discharge is normal. as are frequent urination and moderate uterine contractions. making answers A. B. and D incorrect.

Explanation

Green-tinged amniotic fluid is indicative of meconium staining. This finding indicates fetal distress. The presence of scant bloody discharge is normal. as are frequent urination and moderate uterine contractions. making answers A. B. and D incorrect.

2. Which of the following diet instructions should be given to the client with recurring urinary tract infections?

Increase intake of meats.

Avoid citrus fruits.

Perform pericare with hydrogen peroxide.

Drink a glass of cranberry juice every day.

Cranberry juice is more alkaline and. when metabolized by the body. is excreted with acidic urine. Bacteria does not grow freely in acidic urine. Increasing intake of meats is not associated with urinary tract infections. so answer A is incorrect. The client does not have to avoid citrus fruits and peri care should be done. but hydrogen peroxide is drying. so answers B and C are incorrect.

Explanation

Cranberry juice is more alkaline and. when metabolized by the body. is excreted with acidic urine. Bacteria does not grow freely in acidic urine. Increasing intake of meats is not associated with urinary tract infections. so answer A is incorrect. The client does not have to avoid citrus fruits and peri care should be done. but hydrogen peroxide is drying. so answers B and C are incorrect.

3. The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room. a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?

The tube will allow for equalization of the lung expansion.

Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs.

Chest tubes relieve pain associated with a collapsed lung.

Chest tubes assist with cardiac function by stabilizing lung expansion.

Chest tubes work to reinflate the lung and drain serous fluid. The tube does not equalize expansion of the lungs. Pain is associated with collapse of the lung. and insertion of chest tubes is painful. so answers A and C are incorrect. Answer D is true. but this is not the primary rationale for performing chest tube insertion.

Explanation

Chest tubes work to reinflate the lung and drain serous fluid. The tube does not equalize expansion of the lungs. Pain is associated with collapse of the lung. and insertion of chest tubes is painful. so answers A and C are incorrect. Answer D is true. but this is not the primary rationale for performing chest tube insertion.

4. A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the:

Mother’s educational level

Infant’s birth weight

Size of the mother’s breast

Mother’s desire to breastfeed

Success with breastfeeding depends on many factors. but the most dependable reason for success is desire and willingness to continue the breastfeeding until the infant and mother have time to adapt. The educational level. the infant’s birth weight. and the size of the mother’s breast have nothing to do with success. so answers A. B. and C are incorrect.

Explanation

Success with breastfeeding depends on many factors. but the most dependable reason for success is desire and willingness to continue the breastfeeding until the infant and mother have time to adapt. The educational level. the infant’s birth weight. and the size of the mother’s breast have nothing to do with success. so answers A. B. and C are incorrect.

5. The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin. the nurse should monitor for:

Maternal hypoglycemia

Fetal bradycardia

Maternal hyperreflexia

Fetal movement

The client receiving Pitocin should be monitored for decelerations. There is no association with Pitocin use and hypoglycemia. maternal hyperreflexia. or fetal movement; therefore. answers A. C. and D are incorrect.

Explanation

The client receiving Pitocin should be monitored for decelerations. There is no association with Pitocin use and hypoglycemia. maternal hyperreflexia. or fetal movement; therefore. answers A. C. and D are incorrect.

6. The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after:

1900

1200

1000

700

Clients who are being retrained for bladder control should be taught to withhold fluids after about 7 p.m.. or 1 The times in answers B. C. and D are too early in the day.

Explanation

Clients who are being retrained for bladder control should be taught to withhold fluids after about 7 p.m.. or 1 The times in answers B. C. and D are too early in the day.

7. The client with a pacemaker should be taught to:

Report ankle edema

Check his blood pressure daily

Refrain from using a microwave oven

Monitor his pulse rate

The client with a pacemaker should be taught to count and record his pulse rate. Answers A. B. and C are incorrect. Ankle edema is a sign of right-sided congestive heart failure. Although this is not normal. it is often present in clients with heart disease. If the edema is present in the hands and face. it should be reported. Checking the blood pressure daily is not necessary for these clients. The client with a pacemaker can use a microwave oven. but he should stand about 5 feet from the oven while it is operating.

Explanation

The client with a pacemaker should be taught to count and record his pulse rate. Answers A. B. and C are incorrect. Ankle edema is a sign of right-sided congestive heart failure. Although this is not normal. it is often present in clients with heart disease. If the edema is present in the hands and face. it should be reported. Checking the blood pressure daily is not necessary for these clients. The client with a pacemaker can use a microwave oven. but he should stand about 5 feet from the oven while it is operating.

8. The nurse is measuring the duration of the client's contractions. Which statement is true regarding the measurement of the duration of contractions?

Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction.

Duration is measured by timing from the end of one contraction to the beginning of the next contraction.

Duration is measured by timing from the beginning of one contraction to the end of the same contraction.

Duration is measured by timing from the peak of one contraction to the end of the same contraction.

Duration is measured from the beginning of one contraction to the end of the same contraction. Answer A refers to frequency. Answer B is incorrect because we do not measure from the end of one contraction to the beginning of the next contraction. Duration is not measured from the peak of the contraction to the end. as stated in D.

Explanation

Duration is measured from the beginning of one contraction to the end of the same contraction. Answer A refers to frequency. Answer B is incorrect because we do not measure from the end of one contraction to the beginning of the next contraction. Duration is not measured from the peak of the contraction to the end. as stated in D.

9. The client with color blindness will most likely have problems distinguishing which of the following colors?

Orange

Violet

Red

White

Clients with color blindness will most likely have problems distinguishing violets. blues. and green. The colors in answers A. C. and D are less commonly affected.

Explanation

Clients with color blindness will most likely have problems distinguishing violets. blues. and green. The colors in answers A. C. and D are less commonly affected.

10. The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

“I will make sure I eat breakfast within 2 hours of taking my insulin.”

“I will need to carry candy or some form of sugar with me all the time.”

“I will eat a snack around three o’clock each afternoon.”

“I can save my dessert from supper for a bedtime snack.”

NPH insulin peaks in 8–12 hours. so a snack should be offered at that time. NPH insulin onsets in 90–120 minutes. so answer A is incorrect. Answer B is untrue because NPH insulin is time released and does not usually cause sudden hypoglycemia. Answer D is incorrect. but the client should eat a bedtime snack.

Explanation

NPH insulin peaks in 8–12 hours. so a snack should be offered at that time. NPH insulin onsets in 90–120 minutes. so answer A is incorrect. Answer B is untrue because NPH insulin is time released and does not usually cause sudden hypoglycemia. Answer D is incorrect. but the client should eat a bedtime snack.