NCLEX-PN Practice Set 4

1. A gravida 2, para 0 client at 39 weeks gestation presents to the labor room with complaints of abdominal cramping. The nurse performs an assessment and data collection. Which of the following findings most supports the onset of true labor?

A. The client is experiencing nausea and centrally-located abdominal pains with varying frequency.
B. The client is experiencing abdominal cramps that radiate from the back around to the abdomen.
C. The client reports fatigue and mild abdominal cramping.
D. The client reports abdominal pain that is only relieved with rest.

2. The nurse is caring for a client following gastric bypass surgery. The physician has encouraged the client to increase mobility as soon as possible. The nurse notes edema of the right leg with skin color changes (pallor) to the right lower extremity. The client reports pain at 3 on a 0 to 10 scale to the incision site and pain in the right calf at 7 on a 0 to 10 scale. Which of the following is the most likely cause of the leg pain?

A. Compression of the sciatic nerve.
B. Deep vein thrombosis.
C. Surgical infection and referred pain.
D. Postoperative dehiscence.

3. The nurse is preparing to administer medications to two clients with the same last name. The nurse checks the medication three times before entering the room to administer medications to the first client. While leaving the room following administration, the nurse realizes she did not check the identification of the client prior to administering medication. Which of the following actions should the nurse complete first?

A. Return to the room to check the client identification and complete a variance report if an error was made.
B. Administer the remaining medication to the other client and check the client identification.
C. Alert the charge nurse that a medication error has been committed.
D. Document completion of the variance report and the medication error in the client's chart and notify the physician

4. A nurse is providing education regarding injury prevention to the parents of an 8-year-old child. The parents admit that they keep a gun in their home. Which statement made by the nurse would be most important?

A. "The gun should be kept in a discreet location out of the child's sight."
B. "Your child should attend a gun safety program in the community."
C. "It is a good idea to keep the gun on hand, reminding the child that only a parent can touch the gun."
D. "The gun should be stored in a locked cabinet with the ammunition secured in a separate location."

5. The nurse is assessing a client with chronic bronchospasm, which is treated with oral theophylline. Which of the following serum theophylline levels requires immediate nursing action?

A. 8 µg/mL.
B. 12 µg/mL.
C. 20 µg/mL.
D. 25 µg/mL.

6. After an abdominal resection for colon cancer, the client returns to her room with a Jackson-Pratt drain in place. The client's spouse asks the nurse what the purpose of the drain is. Which of the following is the nurse's best response?

A. "To irrigate the incision with a saline solution."
B. "To prevent bacterial infection of the incision."
C. "To measure the amount of fluid lost after surgery."
D. "To prevent accumulation of drainage in the wound."

7. The nurse is teaching a client with asthma about the proper use of a metered-dose inhaler. Which statement by the client indicates that the teaching was effective?

A. "I'll flex my head forward and breathe out forcefully before inhaling the drug."
B. "As I press down on the canister, I'll inhale slowly over 10 seconds."
C. "I'll hold my breath for 5 seconds after inhaling the drug to allow the drug to reach my lungs."
D. "I'll wait one minute between puffs."

8. A client returns to the clinic 48 hours after receiving a Mantoux skin test. The area of induration at the injection site measures 18 mm. The client has not previously had a reaction to this test. Which of the following actions should the nurse do next?

A. Move the client to a negative pressure room.
B. Have the client put on a facemask.
C. Prepare the client to have a chest x-ray.
D. Draw a blood sample to check his CBC for an elevated white blood cell count.

9. A client is admitted with acute pancreatitis. Which of the following laboratory results is expected for this client?

A. Serum creatinine of 4.3 mg/dL
B. Alanine aminotransferase (ALT) of 125 IU/L.
C. Serum amylase of 306 IU/L.
D. Troponin T level of 3.5 g/L.

10. The nurse is caring for a client who fell from a scaffold 20 feet (6 m) to the ground. He was admitted to the emergency department with multiple abrasions and complaints of shortness of breath. The client's chest X-ray reveals a right pneumothorax. Which of the following actions should the nurse complete first?

A. Help the client turn, cough, and deep breathe.
B. Prepare a chest drainage system.
C. Prepare the client for a computed tomography (CT) scan.
D. Administer a sedative.

11. The nurse is caring for a client diagnosed with respiratory failure. Which of the following orders should the nurse question for this client because of the possibility of adverse effects?

A. Antibiotics.
B. Sedatives.
C. Bronchodilators.
D. Oxygen therapy.

12. A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). His serum glucose level is 926 mg/dL. The nurse observes the client for which complication of HHNS?

A. Dehydration.
B. Hemorrhage.
C. Infection.
D. Pneumonia.

13. An elderly client is recently diagnosed with hypothyroidism. He lives in his own apartment in a community development designed for the elderly. He asks the nurse for advice about his condition. What is the best advice for the nurse to give the client?

A. "Stop attending group activities."
B. "Increase fiber and fluids in your diet."
C. "Stop taking your self-prescribed daily aspirin."
D. "Keep the temperature in your apartment cooler than usual."

14. The nurse is caring for a client with bacterial pneumonia. Of the following, which nursing diagnosis takes top priority?

A. Activity intolerance related to altered respiratory function.
B. Risk for fluid volume deficit related to fever and dyspnea.
C. Ineffective airway clearance related to copious tracheobronchial secretions.
D. Altered nutrition with less than body requirements related to anorexia and dyspnea.

15. The nurse is faxing client information to a nursing home. Which is the appropriate action for the nurse to take before faxing the record?

A. Determine that the client has signed a record release.
B. Make sure the client's name and birth date are displayed on the fax cover sheet.
C. Read all information to the client before faxing.
D. Obtain a written order to fax the information from the client's primary physician.

16. A nurse is having difficulty setting up humidified oxygen at 40% per Venturi mask and does not know how many liters of flow she should use. Which of the following actions is most appropriate to ensure safe oxygen administration?

A. Consult with a respiratory therapist.
B. Look at the package directions and try to figure it out.
C. Ask the nursing assistant how to set it up.
D. Use a regular oxygen mask.

17. An 8-year old girl presents to the office for a routine examination. Considering the child's developmental level, which of the following actions is most appropriate?

A. Allowing the child to change into a gown while you are not in the room.
B. Allowing the child to play with the medical equipment prior to the examination.
C. Asking the parents to leave the room during the examination.
D. Encouraging the child to hold a stuffed animal during the examination.

18. The nurse is providing care needed to support the respiratory function of a client with thick secretions. Which measure is most effective in helping a client with thick secretions mobilize and expectorate them?

A. Drinking salty fluids such as broth and bouillon.
B. Drinking 3 to 4 L of water per day.
C. Inhaling cool mist from a vaporizer daily.
D. Sitting in a tub of warm water three times a day.

19. A client is obtaining a psychiatric evaluation and counseling as a requirement for care while on a mental health, short-term disability leave. The client signs an information release form and requests that the evaluation and counseling records be emailed to the human resource representative at her company. Which of the following is an appropriate response by the nurse?

A. "The administrative policy must be reviewed with the agency director before records can be released."
B. "It is best not to send your records via the Internet, as this may jeopardize your right to privacy."
C. "Think about if you want your entire counseling record to be released to the company where you work."
D. "Before disability related records are released, they must be reviewed by the treatment team."

20. A client suddenly becomes short of breath. Which position is most beneficial for a client experiencing respiratory difficulty?

A. Dorsal recumbent.
B. Lithotomy.
C. Semi-Fowler's.
D. Sims'.

Answer Key

1. Correct answer: B

Abdominal cramping that radiates from the back to the abdomen is most indicative of true labor. Fatigue is associated with the discomforts of later pregnancy but does not signal labor. Nausea may be present during the later weeks of pregnancy but is not a sign of true labor. Centrally located abdominal pain is not a clear sign of labor, and true labor is not relieved by rest.

2. Correct answer: B

Unilateral edema, skin color changes, and calf pain are all possible signs of a deep vein thrombosis, a possible complication of postoperative immobility. Compression of the sciatic nerve would cause pain to radiate down the hip. Surgical infection would not cause referred pain to the calf, and dehiscence would occur at the incision site (abdominal area).

3. Correct answer: A

The nurse should immediately return to the room to compare the client's identification and the medication administration record to ensure the correct client received the medication. If an error was made, the nurse must complete a variance report per the facility policy. The variance report is used to report injury or high-risk events. In this case, failure to follow correct procedure put the client at risk. The nurse should check the remaining medication for the second client prior to administration. The charge nurse should be notified of any variance or medical error. Completion of a variance report for a medical error is not documented on the client's medical record.

4. Correct answer: D

The gun must be kept in a locked cabinet, and it's safest to store the ammunition separately. Keeping the gun out of the child's sight would not be sufficient as the child may be able to locate the gun. A school-aged child should not be referred to a gun safety program. Even if taught gun safety, young children lack an adequate concept of cause and effect and often act impetuously, so the gun should not be kept on hand with the understanding that the child can be trusted not to touch it.

5. Correct answer: D

Serum theophylline levels are therapeutic when they fall between 10 to 20 µg/mL. A serum theophylline level of 25 µg/ml is in the toxic range and can lead to severe adverse reactions, which may be life threatening. The nurse should withhold the next dose of theophylline and notify the physician immediately. A theophylline level of 8 µg/ml is below the therapeutic range; the physician should be notified, but this level doesn't require immediate nursing action. Theophylline levels of 12 µg/ml and 20 µg/ml are within the therapeutic range.

6. Correct answer: D

The accumulation of fluid in a surgical wound interferes with the healing process. A Jackson-Pratt drain promotes wound healing by allowing fluid to escape from the wound. The drain may be placed in the client's incision, or it may be placed in the wound and brought out to the skin surface through a stab wound near the incision. The drain doesn't need to be irrigated. A Jackson-Pratt drain doesn't prevent infection. Fluid from the drain is absorbed into the dressings and can't be measured accurately.

7. Correct answer: D

Waiting a full minute after taking the first puff allows the second puff to reach deeper into the client's lungs. Teach the client to tilt her head back slightly when using an inhaler and to breathe out normally. Breathing out forcefully can cause coughing, close the small airways, and trap air. After pressing down on the canister the client should breathe in slowly over 3 to 5 seconds and then hold her breath for 10 seconds to let the medication reach deep into the lungs.

8. Correct answer: B

A client with an initial positive reaction to a Mantoux test is at higher risk for active tuberculosis. Before taking him to another room or for a procedure such as a chest x-ray, he should be fitted with a mask to decrease the risk of disease transmission to others. It is not necessary to place him in a negative pressure room before further testing indicates the need. Drawing a CBC is not necessary at this point.

9. Correct answer: C

The normal value for serum amylase is 30 to 100 IU/L, so a level of 306 IU/L is indicative of pancreatitis. Pancreatitis involves activation of pancreatic enzymes, such as amylase and lipase. Therefore, serum amylase is often at least twice the normal level and lipase levels can be 5 times the normal level in a client with acute pancreatitis. Serum creatinine level (normal value 0.5 to 1.2 mg/dL) is elevated with kidney dysfunction. Injury or disease of the liver causes elevated ALT level (normal value 7 to 40 IU/L). Troponin T level (normal value <0.2 g/L) is elevated with heart damage, such as a myocardial infarction.

10. Correct answer: B

When a pneumothorax is diagnosed, a chest tube must be inserted to evacuate air from the pleural space. The nurse should prepare the chest drainage system so that it can be attached to the chest tube immediately after insertion. A CT scan of the chest isn't used to diagnose a pneumothorax. Turning, coughing, and deep breathing can be encouraged after the chest tube is inserted. Sedation may be administered right before the chest tube is inserted but after the nurse prepares the chest drainage system.

11. Correct answer: B

In this case, an order for sedatives is questionable. Sedatives could cause decreased respirations and shallow breathing. Giving sedatives to a client with respiratory failure may worsen his already altered respiratory status. Antibiotics may be used to treat respiratory infection, such as pneumonia, a possible cause of the client's respiratory failure. Bronchodilators may be used to open the client's bronchioles to aid breathing. Oxygen therapy is a standard treatment for respiratory failure to relieve dyspnea.

12. Correct answer: A

Hyperglycemia (excess glucose in the blood) of 926 mg/dL causes an increase in serum osmolality. This causes fluid to shift from the interstitial to the intravascular space, causing osmotic diuresis and dehydration. Hemorrhage isn't a complication of HHNS. While pneumonia and infection may occur in clients with HHNS, these conditions aren't direct complications of HHNS.

13. Correct answer: B

Clients with hypothyroidism typically have constipation. A diet high in fiber and fluids can help prevent this. The client doesn't need to stop all group activities, although he may need to limit them until his condition improves. Taking aspirin isn't related to hypothyroidism management and does not interfere with treatment. Clients with hypothyroidism have an intolerance to cold and need an environment warmer than average.

14. Correct answer: C

With bacterial pneumonia, inflammation of the respiratory system causes swelling of the bronchioles and bronchi with increased secretions and production of thick yellow, brown sputum. A client with bacterial pneumonia may have difficulty clearing secretions. Airway clearance always takes the highest priority because the client must breathe to live. Activity intolerance is expected with severe pneumonia because of dyspnea. Fluids and nutrition should be monitored to ensure adequate intake, but this is not the highest priority.

15. Correct answer: A

Client authorization is required before any confidential information may be sent to a nursing home or other facility. The client's name, and other protected information should never be displayed on a fax cover sheet. It is not necessary to read the information to the client before sending it. A physician's order does not give the nurse the right to send a client's confidential information.

16. Correct answer: A

When a problem falls outside a nurse's experience or knowledge, it is appropriate to consult with a specialist in that area. The respiratory therapist is an expert at setting up oxygen delivery systems. Using package directions is not reliable and may cause harm to the client if the nurse sets up the oxygen improperly. A nursing assistant is not considered an expert in oxygen delivery. Using a regular mask would not deliver the correct rate of flow to the client and would be unacceptable.

17. Correct answer: A

School-aged children tend to be very modest, so the child should be allowed to change into a gown while the health care provider is not in the room. Additionally, the child should be allowed to leave her underwear in place. Playing with medical equipment is characteristic of younger children. Parents should not be asked to leave the room unless the child requests that they not be present. The child may feel too old to hold a stuffed animal during the examination and may feel she is being treated "like a baby."

18. Correct answer: B

Adequate fluid intake decreases the viscosity of secretions. The nurse should encourage the client to drink 3 to 4 L of water or other fluids per day. Consuming salty fluids can cause secretions to thicken even further. Inhaling cool mist may help but only if done more than once a day. Sitting in a tub of warm water may be relaxing, but it doesn't loosen secretions.

19. Correct answer: B

The client has a right to ask that her records be released, but there is an increased risk for breach of confidentiality if personal health care records are emailed to a place of employment. Although every health care agency has a policy and procedure related to release of client records, the staff is required to be informed about the policy upon employment. There is no need to review the policy with the agency director when a client requests that records be released. Asking the client to think about her statement is inappropriate and could create apprehension in the client. The review of a client's treatment goals and progress is an ongoing process; it is not initiated when client records are requested for release to a third party.

20. Correct answer: C

Semi-Fowler's position, or sitting at about 45 degrees, facilitates lung expansion. The dorsal recumbent (supine) position doesn't ease the work of breathing. The lithotomy (legs up in stirrups) position is normally used for gynecologic examination but might worsen dyspnea. Sims' position is a lateral position with the top leg flexed toward the chest. This position inhibits lung expansion.

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