NCLEX-PN Practice Set 1

1. The nurse is caring for a client following an appendectomy. The client reports nausea and complains of surgical site pain at a 6 on a 0 to 10 scale. The client's employer is present in the room and states he is paying for the insurance and wants to know what pain medication has been prescribed by the physician. Which of the following is the appropriate nurse response?

A. Answer any questions the employer may have as he pays for the insurance.
B. Tell the employer his question is inappropriate and that the information is none of his business.
C. Explain to the employer that you cannot release private information and ask the employer to step out while you conduct your assessment of the client.
D. Ask the employer to leave and wait until the client returns home to visit.

2. The nurse is caring for a client with a history of advanced chronic obstructive pulmonary disease (COPD). The client had conventional gallbladder surgery 2 days previously. Which intervention has priority for preventing respiratory complications?

A. Incentive spirometry every 4 hours.
B. Coughing and deep breathing four times daily.
C. Getting the client out of bed 4 times daily as ordered by the physician.
D. Giving oxygen at 4 L/minute according to the physician's order.

3. A nurse is developing a care plan for a client with acute mania. Place the following behaviors in the order in which they occur as the client develops acute mania. Use all of the options.

A. Delusions of grandeur.
B. Relevant, calm speech patterns.
C. Highly productive and competitive in work and leisure activities.
D. Easily irritated.
E. Poor judgment and impulse control.

4. When educating a pregnant client about home safety, which of the following information is appropriate for the nurse to include in the teaching plan? Select all that apply.

A. When taking a shower, place a non-skid mat on the floor of the tub or shower.
B. Avoid climbing stairs.
C. Avoid wearing high heels.
D. Use non-slip rugs on the floors.

5. A client had a C5 spinal cord contusion that resulted in quadriplegia. Two days after the injury occurred, the nurse sees his mother crying in the waiting room. The mother asks the nurse whether her son will ever play football again. Which of the following is the best initial response?

A. "Given time and motivation, your son can return to normal function."
B. "I'm not sure, but I'll call the physician to talk to you right away."
C. "What do you know about your son's injury?"
D. "Getting upset isn't in you son's best interest."

6. The nurse is caring for a client who will undergo surgical repair of a detached retina. Which of the following is the most likely preoperative nursing diagnosis for this client?

A. Anxiety related to loss of vision and potential failure to regain vision.
B. Deficient knowledge (preoperative and postoperative activities) related to lack of information.
C. Acute pain related to tissue injury and decreased circulation to the eye.
D. Risk for infection related to the eye injury.

7. When assessing a client with glaucoma, a nurse expects which of the following findings?

A. Complaints of double vision.
B. Complaints of halos around lights.
C. Intraocular pressure of 15 mm Hg.
D. Soft globe on palpation.

8. A client had a Caesarean delivery and is postpartum day 1. She asks for pain medication when the nurse enters the room to do her shift assessment. The client states that her pain level is an 8 on a scale of 1 to 10. What should be the nurse's priority of care?

A. Give the pain medication and return in an hour for further assessment to allow time for the medication to work.
B. Complete the postpartum assessment and then give the client pain medication.
C. Give the pain medication first, do a quick assessment while administering the medication to ensure the pain is not caused by a complication, and return for the full assessment after the client's pain has subsided.
D. Instruct the patient to do relaxation exercises to relieve her discomfort.

9. The nurse is preparing to teach a client about the effects of isoniazid (INH). Which information is important for the client to understand?

A. Isoniazid should be taken on an empty stomach.
B. Prolonged use of isoniazid produces poorly concentrated urine.
C. Taking aluminum hydroxide (Maalox)® with isoniazid minimizes gastrointestinal upset.
D. Drinking alcohol daily can increase the incidence of drug-induced hepatitis.

10. A one-month old infant in the neonatal intensive care unit is dying. The parents request that the nurse administer an opioid analgesic to their infant, who is crying weakly. The infant's heart rate is 68 beats per minute and the respiratory rate is 18 breaths per minute. The infant is on room air and the oxygen saturation is 92%. The nurse's response is based on which of the following principles?

A. Providing analgesia during the last days and hours is an ethically-appropriate nursing action.
B. Withholding the opioid analgesia during the last days and hours is an ethical duty because administering it would represent assisted suicide.
C. Administering analgesia during the last days and hours is the parent's ethical decision.
D. Withholding the opioid analgesia is clinically appropriate because it will hasten the infant's death.

11. While undergoing hemodialysis, the client becomes restless and tells the nurse he has a headache and feels nauseous. Which of the following complications does the nurse suspect?

A. Infection.
B. Disequilibrium syndrome.
C. Air embolus.
D. Acute hemolysis.

12. An elderly couple is speaking to the nurse about their ambivalence related to sending the client, their adult, dual-diagnosed (bipolar and drug addict) son, into residential placement. They tell the nurse that neither keeping their son at home nor sending him to a facility is a satisfactory solution for them. What information should the nurse keep in mind when discussing this dilemma with the family? Select all that apply.

A. Implement what is best for the couple.
B. Suggest another psychiatric evaluation for the son.
C. Look for all potential options for care.
D. Review the client's treatment history.
E. Consult legal authorities for information.

13. The nurse is caring for a 44-year-old client diagnosed with hypoparathyroidism. Which electrolyte imbalance is closely associated with hypoparathyroidism?

A. Hypocalcemia.
B. Hyponatremia.
C. Hyperkalemia.
D. Hypophosphatemia.

14. The nurse is caring for a client diagnosed with end-stage liver disease. The client has completed an advance directive and a do-not-resuscitate (DNR) document and wishes to receive palliative care. Which of the following would correspond to the client's wish for comfort care?

A. Positioning frequently to prevent skin breakdown and providing pain management and other comfort measures.
B. Carrying out vigorous resuscitation efforts if the client were to stop breathing, but no resuscitation if the heart stops beating.
C. Providing intravenous fluids when the client becomes dehydrated.
D. Providing total parenteral nutrition (TPN) if the client is not able to eat.

15. The nurse is caring for a client receiving warfarin therapy (Coumadin®) following a stroke. The client's PT/INR was completed at 7:00 A.M. prior to the morning meal with an INR reading of 4.0. Which of the following is the nurse's first priority?

A. Call the physician to request an increase in the Coumadin® dose.
B. Administer a vitamin K injection IM and notify the physician of the results.
C. Assess the client for bleeding around the gums or in the stool and notify the physician of the lab results and latest dose of Coumadin®.
D. Notify the next shift to hold the daily dose of Coumadin® scheduled for 5:00 pm.

16. The nurse is checking laboratory values on a patient who has crackling rales in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which of the following laboratory values does the nurse expect to be abnormal?

A. Potassium.
B. B-type natriuretic peptide (BNP).
C. C-reactive protein (CRP).
D. Platelets.

17. A 12-year-old boy has been receiving aggressive treatment for leukemia for the past year. His condition has continued to deteriorate, and the prognosis is poor. The parents would like to implement a "Do Not Resuscitate" plan but inform the nurse that they cannot bring themselves to discuss it with their child and ask the nurse to discuss it with the child instead. When approaching the subject with the child, the nurse must assess which of the following first?

A. What the child knows about the disease and his prognosis.
B. How the child would like to handle the plan of care.
C. What interventions the child would like in the event of cardiac or respiratory arrest.
D. What the child believes about death.

18. The nurse is advising a client with a colostomy. The client reports problems with flatus. Which of the following foods should the nurse recommend?

A. High fiber foods, such as bran.
B. Cruciferous vegetables, such as cabbage, broccoli, and kale.
C. Carbonated beverages.
D. Yogurt.

19. The nurse is reviewing self-care measures for a client with peripheral vascular disease. Which of the following statements indicates proper self-care measures?

A. "I like to soak my feet in the hot tub everyday."
B. "I walk to the mailbox in my bare feet."
C. "I stopped smoking and only use chewing tobacco."
D. "I have my wife examine the soles of my feet each day."

20. A nurse is taking the health history of an 85-year-old client. Which of the following physical findings is consistent with normal aging?

A. Increase in subcutaneous fat.
B. Diminished cough reflex.
C. Long-term memory loss.
D. Myopia.

Answer Key

1. Correct answer: C

Explaining to the employer that the nurse cannot release information and asking the employer to step out while conducting an assessment allows the client privacy while still being respectful of the employer. Although the employer is paying for the insurance, this does not given him a right to confidential information. Providing information to the client's employer without permission is a violation of the right to privacy under HIPAA. Speaking rudely to a visitor by saying something is "none of his business" is never appropriate. Asking the person to leave and to wait until the client returns home to visit wrongly assumes the nurse has the right to speak for the patient.

2. Correct answer: C

Getting the client out of bed prevents pooling of secretions in the lungs and promotes better lung expansion. An incentive spirometer (a device that measures air movement into the lungs and encourages the client to breathe deeply), coughing, and deep breathing are important, but the client needs to perform these more frequently (every 1 to 2 hours) instead of every 4 hours or 4 times daily. Giving oxygen at 4 L/minute could decrease the client's respiratory drive.

3. Correct answer:

Symptoms of acute mania occur in the following sequence:
B. Relevant, calm speech patterns.
C. Highly productive and competitive in work and leisure activities.
D. Easily irritated.
A. Delusions of grandeur.
E. Poor judgment and impulse control.

Relevant and calm speech patterns are indicative of normal behavior. Once mania begins, the client may become highly productive and competitive in all activities. Sleep is not a priority. As mania progresses, emotional manifestations heighten and the client is easily irritated, begins to have delusions of grandeur, and may require medication to reduce restlessness and agitation. Client safety is the primary goal due to poor judgment and impulse control

4. Correct answer: A, C, and D

A woman's center of gravity changes during pregnancy, increasing her risk of falls. She should use a non-skid mat in the tub or shower. Wearing high heels will increase unbalance and can contribute to falls. Non-slip rugs will prevent tripping and falling. There is no reason that a pregnant woman in good health should avoid climbing stairs; in fact, stair climbing is good exercise.

5. Correct answer: C

Asking the mother what she knows about her son's injury is a good way to encourage the mother to express her feelings. It also allows the nurse to gather more data about the mother's understanding of the injury. Providing reassurance that the woman's son will return to normal function may be incorrect because, in many cases, spinal cord contusion results in permanent loss of function. A definitive prognosis isn't possible so soon after a spinal cord contusion, so referring the mother to the doctor would not be helpful. The mother needs to be allowed to voice her concerns without being made to feel guilty.

6. Correct answer: A

A client who perceives a threat to vision, such as a sudden loss of sight, is likely to be anxious about the possibility of permanent blindness. Because severe anxiety impairs the client's ability to process new information, this anxiety must be addressed before teaching is possible. The nurse should encourage the client to talk about her understanding of the surgery and the expected outcomes. A detached retina is not characterized by acute pain and there is little preoperative risk of infection.

7. Correct answer: B

A complaint of halos around lights is a common finding in a client with glaucoma. Symptoms of glaucoma don't include double vision but can include loss of peripheral vision or blind spots, reddened sclera, firm globe, decreased accommodation, and occasional eye pain, but clients may be asymptomatic until permanent damage to the optic nerve and retina has occurred. Normal intraocular pressure is 10 to 21 mm Hg.

8. Correct answer: C

Pain management is a priority, so the nurse should immediately bring pain medication. However, the nurse should do a quick assessment while administering the medication to ensure that a complication, such a hemorrhage, hasn't caused the increased pain. A complete assessment can wait until the pain subsides. Control of pain will enable the client to move, eliminating other potential complications of delivery. Bonding with the infant will be facilitated as well if the client is without discomfort. Relaxation techniques can act as an adjunct therapy but by themselves are not usually useful for pain management during the early post-Caesarean period.

9. Correct answer: D

Drinking alcohol can induce isoniazid-related hepatitis. If hepatic damage occurs, the client's urine may become dark and appear concentrated. GI upset frequently occurs when isoniazid is taken on an empty stomach, so taking this drug with meals decreases GI upset. The client should avoid taking aluminum-containing antacids, such as aluminum hydroxide, with isoniazid as it may decrease the drug's effects.

10. Correct answer: A

All clients, regardless of age, have the right to die with dignity and be free from pain. The parents have the right to request an opioid to relieve the child's distress. Assisted suicide requires some action on the part of the client, and this is not possible for a 1-month old infant. Both the nurse and the parents have an ethical duty to the child. Withholding the opioid analgesic from a dying child is not appropriate because of fear it may hasten death, as opioids can hasten death with dying patients at any age, and this is not considered a contraindication for administration of analgesia.

11. Correct answer: B

Disequilibrium syndrome is caused by a rapid reduction in urea, sodium, and other solutes from the blood. This may lead to cerebral edema and increased intracranial pressure (ICP). Signs and symptoms of increased ICP include headache, nausea, and restlessness as well as vomiting, confusion, twitching, and seizures. Fever and an elevated white blood cell count may indicate infection. Popping or ringing in the ears, chest pain, dizziness, or coughing suggests an air embolus. Chest pain, dyspnea, burning at the access site, and cramping suggest acute hemolysis.

12. Correct answers: C and D

One of the steps in ethical decision-making is to consider all possible options of care, such as outpatient programs, along with the potential results of each option. A review of the client's treatment history is part of the first step in gathering the background information, as this helps to create a clear picture of the client's situation. The nurse would not tell the elderly couple to implement what is best for them since they are concerned about what action is in the best interests of their son, and the nurse's responsibility is to the client. Since the son is dual-diagnosed, he has had a psychiatric evaluation, and another evaluation will not address the couple's dilemma. There is no reason to consult legal authorities.

13. Correct answer: A

The parathyroid glands are responsible for maintaining calcium levels at 8.8 to 10.2 mg/dL. In hypoparathyroidism, parathyroid hormone levels are insufficient to maintain adequate calcium levels. The nurse should monitor clients with hypoparathyroidism for signs and symptoms of hypocalcemia, including muscle spasms, anxiety, seizures, hypotension, and congestive heart failure. Hyponatremia and hyperkalemia aren't associated with hypoparathyroidism. Hyperphosphatemia, not hypophosphatemia, may be seen in the client with hypoparathyroidism as calcium levels decrease.

14. Correct answer: A

Palliative care includes measures to prevent skin breakdown, pain management, management of other symptoms that cause discomfort, and encouraging contact with family and friends. A DNR request precludes all resuscitative efforts related to respiratory or cardiac arrest. Dehydration is a normal part of the dying process, so intravenous fluids are inappropriate. Total parenteral nutrition (TPN) is an invasive procedure meant to prolong life and is not part of palliative care.

15. Correct answer: C

For a client taking Coumadin® following a stroke, the INR should be between 2.0 and 3.0. The elevated INR level should be communicated to the physician along with assessment data regarding possible bleeding. An increased dose of Coumadin® would increase the risk of bleeding. Administration of medications, such as warfarin and vitamin K, requires a physician's order. The nurse should notify the physician and receive an order prior to holding the Coumadin® scheduled for another shift.

16. Correct answer: B

The client's symptoms suggest heart failure. BNP is a neurohormone that is released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/mL is often associated with mild heart failure; and, as the BNP level increases, the severity of heart failure increases. Potassium levels are not affected by heart failure. CRP is an indicator of inflammation. It is used to help predict the risk of coronary artery disease. There is no indication that the client has an increased CRP. There is no indication that the client is experiencing bleeding or clotting abnormalities, such as those seen with an abnormal platelet count.

17. Correct answer: A

When discussing the child's wishes for future care, it is important for the nurse to first identify what the child knows about the disease and his prognosis. Factors such as the perceived severity of the illness will be significant in planing for end-of-life care. If the child does not understand the disease process or prognosis, the plan of care would not be effective or realistic. In addition, asking a child about desired interventions in the event of cardiac or respiratory arrest would not be an appropriate initial area of questioning. If the child does not understand the disease process, these questions may seem frightening or threatening. While exploring the child's belief about death would be important, it would not be the initial area of discussion and should be guided by the child rather than the nurse.

18. Correct answer: D

The client should include yogurt in her diet to reduce gas formation. Other helpful foods include crackers and toast. High-fiber foods, such as bran, stimulate peristalsis and increase flatulence. Cruciferous vegetables tend to increase gas formation, as do beans. The client should also be advised that smoking, chewing gum, and drinking carbonated fluids, and drinking fluids with a straw can increase gas formation.

19. Correct answer: D

A client with peripheral vascular disease should examine his feet daily for redness, dryness, or cuts. If he isn't able to do this, then a caregiver or family member should help him. Hot tubs should be avoided since the client may have decreased sensation in his feet and may not feel when the water is too hot. The client should always wear shoes or slippers on his feet when he is out of bed to help minimize trauma to the feet. Any type of nicotine, either from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities.

20. Correct answer: B

Diminished cough reflex is consistent with normal aging, putting older adults at increased risk for aspiration and atelectasis. A decrease in subcutaneous fat increases risk for pressure ulcers. Long-term memory is usually intact unless the client suffers from dementia, but short-term memory is often impaired. Presbyopia (far-sightedness) is common with aging. Those who have had myopia (near-sightedness) may find their vision improving with age.

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