NCLEX Practice Exam 13 (10 Questions)

1. The nurse is educating the lady's club in self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram below. select where the Tail of Spence is.

A

B

C

D

The Tail of Spence is located in the upper outer quadrant of the breast.

Explanation

The Tail of Spence is located in the upper outer quadrant of the breast.

2. The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:

Using oil- or cream-based soaps

Flossing between the teeth

The intake of salt

Using an electric razor

The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth because platelets are decreased. Using oils and cream-based soaps is allowed. as is eating salt and using an electric razor; therefore. answers A. C. and D are incorrect.

Explanation

The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth because platelets are decreased. Using oils and cream-based soaps is allowed. as is eating salt and using an electric razor; therefore. answers A. C. and D are incorrect.

3. The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:

Tire easily

Grow normally

Need more calories

Be more susceptible to viral infections

The toddler with a ventricular septal defect will tire easily. He will not grow normally but will not need more calories. He will be susceptible to bacterial infection. but he will be no more susceptible to viral infections than other children. Therefore. answers B. C. and D are incorrect.

Explanation

The toddler with a ventricular septal defect will tire easily. He will not grow normally but will not need more calories. He will be susceptible to bacterial infection. but he will be no more susceptible to viral infections than other children. Therefore. answers B. C. and D are incorrect.

4. The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to:

Turning the client to the left side

Milking the tube to ensure patency

Slowing the intravenous infusion

Notifying the physician

The output of 300 mL is indicative of hemorrhage and should be reported immediately. Answer: A. does nothing to help the client. Milking the tube is done only with an order and will not help in this situation. and slowing the intravenous infusion is not correct; thus. answers B and C are incorrect.

Explanation

The output of 300 mL is indicative of hemorrhage and should be reported immediately. Answer: A. does nothing to help the client. Milking the tube is done only with an order and will not help in this situation. and slowing the intravenous infusion is not correct; thus. answers B and C are incorrect.

5. The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:

Apply the new tie before removing the old one.

Have a helper present.

Hold the tracheotomy with the nondominant hand while removing the old tie.

Ask the doctor to suture the tracheostomy in place.

The best method and safest way to change the ties of a tracheotomy is to apply the new ones before removing the old ones. Having a helper is good. but the helper might not prevent the client from coughing out the tracheotomy. Answer: C. is not the best way to prevent the client from coughing out the tracheotomy. Asking the doctor to suture the tracheotomy in place is not appropriate.

Explanation

The best method and safest way to change the ties of a tracheotomy is to apply the new ones before removing the old ones. Having a helper is good. but the helper might not prevent the client from coughing out the tracheotomy. Answer: C. is not the best way to prevent the client from coughing out the tracheotomy. Asking the doctor to suture the tracheotomy in place is not appropriate.

6. A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:

Be injected into the deltoid muscle

Be injected into the abdomen

Aspirate after the injection

Clear the air from the syringe before injections

Lovenox injections should be given in the abdomen. not in the deltoid muscle. The client should not aspirate after the injection or clear the air from the syringe before injection. Therefore. answers A. C. and D are incorrect.

Explanation

Lovenox injections should be given in the abdomen. not in the deltoid muscle. The client should not aspirate after the injection or clear the air from the syringe before injection. Therefore. answers A. C. and D are incorrect.

7. The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:

Atrial flutter

A sinus rhythm

Ventricular tachycardia

Atrial fibrillation

The graph indicates ventricular tachycardia. The answers in A. B. and D are not noted on the ECG strip.

Explanation

The graph indicates ventricular tachycardia. The answers in A. B. and D are not noted on the ECG strip.

8. The infant is admitted to the unit with tetrology of falot. The nurse would anticipate an order for which medication?

Digoxin

Epinephrine

Aminophylline

Atropine

The infant with Tetralogy of Fallot involves four heart defects: A large ventricular septal defect (VSD). Pulmonary stenosis. Right ventricular hypertrophy and. An overriding aorta. He will be treated with digoxin to slow and strengthen the heart. Epinephrine. aminophylline. and atropine will speed the heart rate and are not used in this client; therefore. answers B. C. and D are incorrect.

Explanation

The infant with Tetralogy of Fallot involves four heart defects: A large ventricular septal defect (VSD). Pulmonary stenosis. Right ventricular hypertrophy and. An overriding aorta. He will be treated with digoxin to slow and strengthen the heart. Epinephrine. aminophylline. and atropine will speed the heart rate and are not used in this client; therefore. answers B. C. and D are incorrect.

9. The nurse is evaluating the client who was admitted 8 hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?

Instruct the client to push

Perform a vaginal exam

Turn off the Pitocin infusion

Place the client in a semi-Fowler’s position

The monitor indicates variable decelerations caused by cord compression. If Pitocin is infusing. the nurse should turn off the Pitocin. Instructing the client to push is incorrect because pushing could increase the decelerations and because the client is 8cm dilated. making answer A incorrect. Performing a vaginal exam should be done after turning off the Pitocin. and placing the client in a semi-Fowler’s position is not appropriate for this situation; therefore. answers B and D are incorrect.

Explanation

The monitor indicates variable decelerations caused by cord compression. If Pitocin is infusing. the nurse should turn off the Pitocin. Instructing the client to push is incorrect because pushing could increase the decelerations and because the client is 8cm dilated. making answer A incorrect. Performing a vaginal exam should be done after turning off the Pitocin. and placing the client in a semi-Fowler’s position is not appropriate for this situation; therefore. answers B and D are incorrect.

10. The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:

Determine lung maturity

Measure the fetal activity

Show the effect of contractions on fetal heart rate

Measure the wellbeing of the fetus

A nonstress test determines periodic movement of the fetus. It does not determine lung maturity. show contractions. or measure neurological well-being. making answers A. C. and D incorrect.

Explanation

A nonstress test determines periodic movement of the fetus. It does not determine lung maturity. show contractions. or measure neurological well-being. making answers A. C. and D incorrect.