NCLEX RN Comprehensive Question And Answers Part 10.3, NCLEX Style Exam Sample

1. A client with diabetic ketoacidosis, who is receiving intravenous fluids and insulin, complains of tingling and numbness of the fingers and toes and shortness of breath. The cardiac monitor shows the appearance of a U wave. The nurse concludes that these symptoms indicate:

Hypercalcemia.

Hypoglycemia.

Hypernatremia.

Hypokalemia.

These are classic signs of hypokalemia that occur when potassium levels are reduced as potassium reenters cells with glucose.

Explanation

These are classic signs of hypokalemia that occur when potassium levels are reduced as potassium reenters cells with glucose.

2. A 79-vear-old client is admitted for dehydration, and an IV infusion of normal saline at 125 mL/hr is started. One hour later the client begins screaming, "I can't breathe." The nurse should:

Assess for allergies and change the IV to an intermittent infusion device.

Discontinue the IV and call the practitioner.

Elevate the head of the bed and obtain vital signs.

Call the practitioner and obtain an order for a sedative.

The client’s ability to speak indicates that the client is breathing. Elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm. Checking the vital signs after this is the first step in assessing the cause of the distress.

Explanation

The client’s ability to speak indicates that the client is breathing. Elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm. Checking the vital signs after this is the first step in assessing the cause of the distress.

3. A client who sustained a severe head injury in a diving accident remains unconscious. In addition, the nurse observes bleeding from the left ear and rhinorrhea. The nurse concludes that drainage from the ear and nose indicates a:

Contusion.

Concussion.

Nose fracture.

Basilar fracture.

A fracture at the base of the cranium can tear meninges, causing nasal leakage of cerebrospinal fluid (rhinorrhea) and bleeding from the ear.

Explanation

A fracture at the base of the cranium can tear meninges, causing nasal leakage of cerebrospinal fluid (rhinorrhea) and bleeding from the ear.

4. The nurse is teaching a client, who is formula feeding her infant, how to care for her engorged breasts. The statement that indicates that the client understands the teaching is, "I am:

Drinking 10 glasses of liquid every day."

Letting warm water run over my breasts when I am showering."

Wearing a well-fitting, tight brassiere."

Expressing milk from my breasts every 4 hours."

Wearing a well-fitting tight brassiere gives the body the message that milk production is not needed.

Explanation

Wearing a well-fitting tight brassiere gives the body the message that milk production is not needed.

5. Before discharging a client who had an inguinal herniorrhaphy, the nurse teaches the client about exercising to prevent venous stasis. For best results the nurse should:

Advise against sitting for prolonged periods.

Suggest that the client change position frequently.

Suggest frequent moving of the legs.

Demonstrate specific exercises.

Seeing the exercises demonstrated win reinforce the verbal explanations.

Explanation

Seeing the exercises demonstrated win reinforce the verbal explanations.

6. A 49-year-old female is admitted to the hospital with a possible diagnosis of Addison's disease. What is an important nursing responsibility during a 24-hour urine collection for the client suspected of having Addison's disease?

Keep the client quiet and reduce stress.

Monitor the client for an elevation in blood pressure.

Restrict the client’s fluid intake during the day of the test.

Assess the client for signs and symptoms of edema.

Stress and activity increase the secretion of ACTH and adrenocortical hormones, elevating the urine values for the byproducts of these hormones, thus invalidating the test results.

Explanation

Stress and activity increase the secretion of ACTH and adrenocortical hormones, elevating the urine values for the byproducts of these hormones, thus invalidating the test results.

7. Which sign indicates adequate intravenous fluid replacement for a client with a 30% total body surface area burn?

Increasing hematocrit level.

Central venous pressure progressing from 5 to 1 mm water.

Slowing of a previously rapid pulse rate.

Urinary output of 15 to 20 mL/hr.

The pulse rate is one indicator of optimum vascular fluid volume: the pulse rate decreases as intravascular volume normalizes.

Explanation

The pulse rate is one indicator of optimum vascular fluid volume: the pulse rate decreases as intravascular volume normalizes.

8. A nurse is performing range-of-motion exercises with a client who had a brain attack. The nurse places the client's hand in the position exhibited in the picture. This position is known as:

Adduction.

Circumduction.

Extension.

Flexion.

The fingers are flared out in the extended, abducted position.

Explanation

The fingers are flared out in the extended, abducted position.

9. A client who has a hemiglossectomy and right radical neck dissection arrives in the postanesthesia care unit with two portable drainage catheters in the area of the incision, which are attached to Hemovacs. Six hours later one Hemovac accumulates 180 mL of serosanguineous drainage. The priority nursing intervention is to:

Document the output because it is expected.

Turn the client onto the right side.

Notify the practitioner immediately.

Empty the container to reestablish negative pressure.

Serosanguineous drainage of 80 to 120 mL is expected during the first 24 hours; more than this amount of drainage should be reported.

Explanation

Serosanguineous drainage of 80 to 120 mL is expected during the first 24 hours; more than this amount of drainage should be reported.

10. The nurse teaches a client with exophthalmos how to reduce discomfort and prevent corneal ulceration. The nurse evaluates that the teaching is understood when the client states, "I should:

Elevate the head of my bed at night.”

Avoid using a sleeping mask at night.”

Eliminate excessive blinking.”

Not move my extraocular muscles.”

The mask may irritate or scratch the eyes if the mask moves during sleep.

Explanation

The mask may irritate or scratch the eyes if the mask moves during sleep.