NCLEX Practice Exam 22 (10 Questions)

1. Which nurse should be assigned to care for the postpartum client with preeclampsia?

The RN with 2 weeks of experience in postpartum

The RN with 3 years of experience in labor and delivery

The RN with 10 years of experience in surgery

The RN with 1 year of experience in the neonatal intensive care unit

The nurse with 3 years of experience in labor and delivery knows the most about possible complications involving preeclampsia. The nurse in answer A is a new nurse to the unit. and the nurses in answers C and D have no experience with the postpartum client.

Explanation

The nurse with 3 years of experience in labor and delivery knows the most about possible complications involving preeclampsia. The nurse in answer A is a new nurse to the unit. and the nurses in answers C and D have no experience with the postpartum client.

2. Which assignment should not be performed by the licensed practical nurse?

Inserting a Foley catheter

Discontinuing a nasogastric tube

Obtaining a sputum specimen

Starting a blood transfusion

The licensed practical nurse should not be assigned to begin a blood transfusion. The licensed practical nurse can insert a Foley catheter. discontinue a nasogastric tube. and collect sputum specimen; therefore. answers A. B. and C are incorrect.

Explanation

The licensed practical nurse should not be assigned to begin a blood transfusion. The licensed practical nurse can insert a Foley catheter. discontinue a nasogastric tube. and collect sputum specimen; therefore. answers A. B. and C are incorrect.

3. The client returns to the unit from surgery with a blood pressure of 90/50. pulse 132. and respirations 30. Which action by the nurse should receive priority?

Continuing to monitor the vital signs

Contacting the physician

Asking the client how he feels

Asking the LPN to continue the post-op care

The vital signs are abnormal and should be reported immediately. Continuing to monitor the vital signs can result in deterioration of the client’s condition. making answer A incorrect. Asking the client how he feels in answer C will only provide subjective data. and the nurse in answer D is not the best nurse to assign because this client is unstable.

Explanation

The vital signs are abnormal and should be reported immediately. Continuing to monitor the vital signs can result in deterioration of the client’s condition. making answer A incorrect. Asking the client how he feels in answer C will only provide subjective data. and the nurse in answer D is not the best nurse to assign because this client is unstable.

4. Which information should be reported to the state Board of Nursing?

The facility fails to provide literature in both Spanish and English.

The narcotic count has been incorrect on the unit for the past 3 days.

The client fails to receive an itemized account of his bills and services received during his hospital stay.

The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.

The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to care for the client with hepatitis might result in termination. but is not of interest to the Joint Commission.

Explanation

The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to care for the client with hepatitis might result in termination. but is not of interest to the Joint Commission.

5. The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions. the baby suffers permanent heart and brain damage. The nurse can be charged with:

Negligence

Tort

Assault

Malpractice

The nurse could be charged with malpractice. which is failing to perform. or performing an act that causes harm to the client. Giving the infant an overdose falls into this category. Answers A. B. and C are incorrect because they apply to other wrongful acts. Negligence is failing to perform care for the client; a tort is a wrongful act committed on the client or their belongings; and assault is a violent physical or verbal attack.

Explanation

The nurse could be charged with malpractice. which is failing to perform. or performing an act that causes harm to the client. Giving the infant an overdose falls into this category. Answers A. B. and C are incorrect because they apply to other wrongful acts. Negligence is failing to perform care for the client; a tort is a wrongful act committed on the client or their belongings; and assault is a violent physical or verbal attack.

6. The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?

The client with Cushing’s disease

The client with diabetes

The client with acromegaly

The client with myxedema

The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immunosuppressed. In answer B. the client with diabetes poses no risk to other clients. The client in answer C has an increase in growth hormone and poses no risk to himself or others. The client in answer D has hypothyroidism or myxedema and poses no risk to others or himself.

Explanation

The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immunosuppressed. In answer B. the client with diabetes poses no risk to other clients. The client in answer C has an increase in growth hormone and poses no risk to himself or others. The client in answer D has hypothyroidism or myxedema and poses no risk to others or himself.

7. The nurse is suspected of charting medication administration that he did not give. After talking to the nurse. the charge nurse should:

Call the Board of Nursing

File a formal reprimand

Terminate the nurse

Charge the nurse with a tort

The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand. If the behavior continues or if harm has resulted to the client. the nurse may be terminated and reported to the Board of Nursing. but these are not the first actions requested in the stem. A tort is a wrongful act to the client or his belongings and is not indicated in this instance. Therefore. Answers A. C. and D are incorrect.

Explanation

The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand. If the behavior continues or if harm has resulted to the client. the nurse may be terminated and reported to the Board of Nursing. but these are not the first actions requested in the stem. A tort is a wrongful act to the client or his belongings and is not indicated in this instance. Therefore. Answers A. C. and D are incorrect.

8. The home health nurse is planning for the day's visits. Which client should be seen first?

The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube

The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension

The 50-year-old with MRSA being treated with Vancomycin via a PICC line

The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter

The client at highest risk for complications is the client with multiple sclerosis who is being treated with cortisone via the central line. The others are more stable. MRSA is methicillin-resistant staphylococcus aureus. Vancomycin is the drug of choice and is given at scheduled times to maintain blood levels of the drug. The clients in answers A. B. and C are more stable and can be seen later.

Explanation

The client at highest risk for complications is the client with multiple sclerosis who is being treated with cortisone via the central line. The others are more stable. MRSA is methicillin-resistant staphylococcus aureus. Vancomycin is the drug of choice and is given at scheduled times to maintain blood levels of the drug. The clients in answers A. B. and C are more stable and can be seen later.

9. The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?

A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis

The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm

A child whose pupils are fixed and dilated and his parents. and a client with a frontal head injury

The client who arrives with a large puncture wound to the abdomen and the client with chest pain

The pregnant client and the client with a broken arm and facial lacerations are the best choices for placing in the same room. The clients in answers A. C. and D need to be placed in separate rooms due to the serious natures of their injuries.

Explanation

The pregnant client and the client with a broken arm and facial lacerations are the best choices for placing in the same room. The clients in answers A. C. and D need to be placed in separate rooms due to the serious natures of their injuries.

10. The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?

The client receiving linear accelerator radiation therapy for lung cancer

The client with a radium implant for cervical cancer

The client who has just been administered soluble brachytherapy for thyroid cancer

The client who returned from placement of iridium seeds for prostate cancer

The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy travels to the radium department for therapy. The radiation stays in the department. so the client is not radioactive. The clients in answers B. C. and D pose a risk to the pregnant nurse. These clients are radioactive in very small doses. especially upon returning from the procedures. For approximately 72 hours. the clients should dispose of urine and feces in special containers and use plastic spoons and forks.

Explanation

The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy travels to the radium department for therapy. The radiation stays in the department. so the client is not radioactive. The clients in answers B. C. and D pose a risk to the pregnant nurse. These clients are radioactive in very small doses. especially upon returning from the procedures. For approximately 72 hours. the clients should dispose of urine and feces in special containers and use plastic spoons and forks.