NCLEX Practice Exam 21 (10 Questions)

1. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurse's next action be?

Obtain a crash cart

Check the calcium level

Assess the dressing for drainage

Assess the blood pressure for hypertension

The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling is due to low calcium levels. The crash cart would be needed in respiratory distress but would not be the next action to take; thus. answer A is incorrect. Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage. so answers C and D are incorrect.

Explanation

The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling is due to low calcium levels. The crash cart would be needed in respiratory distress but would not be the next action to take; thus. answer A is incorrect. Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage. so answers C and D are incorrect.

2. The client is having an arteriogram. During the procedure. the client tells the nurse. "I'm feeling really hot." Which response would be best?

“You are having an allergic reaction. I will get an order for Benadryl.”

“That feeling of warmth is normal when the dye is injected.”

“That feeling of warmth indicates that the clots in the coronary vessels are dissolving.”

“I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing.”

It is normal for the client to have a warm sensation when dye is injected. Answers A. C. and D indicate that the nurse believes that the hot feeling is abnormal. so they are incorrect.

Explanation

It is normal for the client to have a warm sensation when dye is injected. Answers A. C. and D indicate that the nurse believes that the hot feeling is abnormal. so they are incorrect.

3. A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications. the most important measurement in the immediate postoperative period for the nurse to take is:

Blood pressure

Temperature

Output

Specific gravity

Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of infection. decreased output would be a clinical manifestation but would take longer to occur than blood pressure changes. and specific gravity changes occur with other disorders; therefore. answers B. C. and D are incorrect.

Explanation

Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of infection. decreased output would be a clinical manifestation but would take longer to occur than blood pressure changes. and specific gravity changes occur with other disorders; therefore. answers B. C. and D are incorrect.

4. The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?

The nursing assistant wears gloves while giving the client a bath.

The nurse wears goggles while drawing blood from the client.

The doctor washes his hands before examining the client.

The nurse wears gloves to take the client’s vital signs.

It is not necessary to wear gloves to take the vital signs of the client. If the client has active infection with methicillin-resistant staphylococcus aureus. gloves should be worn. The health care workers in answers A. B. and C indicate knowledge of infection control by their actions.

Explanation

It is not necessary to wear gloves to take the vital signs of the client. If the client has active infection with methicillin-resistant staphylococcus aureus. gloves should be worn. The health care workers in answers A. B. and C indicate knowledge of infection control by their actions.

5. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

Place the client in a sitting position with the head hyperextended

Pack the nares tightly with gauze to apply pressure to the source of bleeding

Pinch the soft lower part of the nose for a minimum of 5 minutes

Apply ice packs to the forehead and back of the neck

The client should be positioned upright and leaning forward. to prevent aspiration of blood. Answers A. B. and D are incorrect because direct pressure to the nose stops the bleeding. and ice packs should be applied directly to the nose as well. If a pack is necessary. the nares are loosely packed.

Explanation

The client should be positioned upright and leaning forward. to prevent aspiration of blood. Answers A. B. and D are incorrect because direct pressure to the nose stops the bleeding. and ice packs should be applied directly to the nose as well. If a pack is necessary. the nares are loosely packed.

6. The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?

Treatment is not recommended for children less than 10 years of age.

The entire family should be treated.

Medication therapy will continue for 1 year.

Intravenous antibiotic therapy will be ordered.

Enterobiasis. or pinworms. is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated to ensure that no eggs remain. Because a single treatment is usually sufficient. there is usually good compliance. The family should then be tested again in 2 weeks to ensure that no eggs remain. Answers A. C. and D are incorrect statements.

Explanation

Enterobiasis. or pinworms. is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated to ensure that no eggs remain. Because a single treatment is usually sufficient. there is usually good compliance. The family should then be tested again in 2 weeks to ensure that no eggs remain. Answers A. C. and D are incorrect statements.

7. A client with Addison's disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?

Glucometer readings as ordered

Intake/output measurements

Sodium and potassium levels monitored

Daily weights

IV glucocorticoids raise the glucose levels and often require coverage with insulin. Answer B is not necessary at this time. sodium and potassium levels would be monitored when the client is receiving mineralocorticoids. and daily weights is unnecessary; therefore. answers B. C. and D are incorrect.

Explanation

IV glucocorticoids raise the glucose levels and often require coverage with insulin. Answer B is not necessary at this time. sodium and potassium levels would be monitored when the client is receiving mineralocorticoids. and daily weights is unnecessary; therefore. answers B. C. and D are incorrect.

8. The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client's ECT has been effective?

The client loses consciousness.

The client vomits.

The client’s ECG indicates tachycardia.

The client has a grand mal seizure.

During ECT. the client will have a grand mal seizure. This indicates completion of the electroconvulsive therapy. Answers A. B. and C do not indicate that the ECT has been effective. so are incorrect.

Explanation

During ECT. the client will have a grand mal seizure. This indicates completion of the electroconvulsive therapy. Answers A. B. and C do not indicate that the ECT has been effective. so are incorrect.

9. A 32-year-old mother of three is brought to the clinic. Her pulse is 52. there is a weight gain of 30 pounds in 4 months. and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

Impaired physical mobility related to decreased endurance

Hypothermia r/t decreased metabolic rate

Disturbed thought processes r/t interstitial edema

Decreased cardiac output r/t bradycardia

The decrease in pulse can affect the cardiac output and lead to shock. which would take precedence over the other choices; therefore. answers A. B. and C are incorrect.

Explanation

The decrease in pulse can affect the cardiac output and lead to shock. which would take precedence over the other choices; therefore. answers A. B. and C are incorrect.

10. The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms. the nurse should teach the mother to:

Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep

Scrape the skin with a piece of cardboard and bring it to the clinic

Obtain a stool specimen in the afternoon

Bring a hair sample to the clinic for evaluation

Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus. where they lay up to 17.000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. There is no need to scrape the skin. collect a stool specimen. or bring a sample of hair. so answers B. C. and D are incorrect.

Explanation

Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus. where they lay up to 17.000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. There is no need to scrape the skin. collect a stool specimen. or bring a sample of hair. so answers B. C. and D are incorrect.