Free NCLEX PN Practice Test 5
1. A client is admitted with a possible bowel obstruction. Which of the following nursing actions is most important for the nurse to perform for a client with a bowel obstruction?
A. Obtain daily weights.
B. Measure abdominal girth.
C. Keep strict intake and output.
D. Encourage the client to increase fluids.
2. An infant is brought to the Emergency Department by the child’s parents. The infant is limp and has central cyanosis, heart rate of 60 beats per minute, respiratory rate of 12 breaths per minute. The parents state that they have an advance directive for their infant because he has a terminal illness. Which of the following is the most appropriate action for the nurse?
A. Ask to see a copy of the advanced directive.
B. Provide oxygen while awaiting further physician’s orders.
C. Provide palliative care for the infant and family.
D. Contact the nursing supervisor for assistance.
A. Intercostal muscle expansion exercises.
B. Isometric leg exercises.
C. Diaphragmatic and pursed-lip breathing exercises.
D. Lumbar sacral strengthening exercises.
4. Parents tell the nurse that they have not been successful in meeting their goal for home management of their 20-year old son with a schizoaffective disorder. They report that the client is posing a threat to their safety. Which of the following is the best initial recommendation?
A. Have the client be evaluated for a voluntary admission to a mental health facility.
B. Discuss what the family can do to chemically restrain the client at home.
C. Tell the family that the client’s behavior releases them from the duty of care.
D. Arrange for respite care as the family could be aggravating the client’s condition.
5. A client comes to the clinic because of low-grade afternoon fevers, night sweats, and a productive cough. The client’s wife was recently diagnosed with pulmonary tuberculosis, and the physician suspects that the client has now contracted the disease. A positive acid-fast bacillus sputum culture confirms the diagnosis. While obtaining the client’s history, the nurse notes that he refers to his diagnosis as “it,” never as tuberculosis, and avoids discussing the disease. What is the nurse’s best response?
A. “It won’t kill you if you take your medications.”
B. “Tell me how you feel about the diagnosis of tuberculosis.”
C. “You shouldn’t be embarrassed that you have tuberculosis.”
D. “Let’s not talk about the tuberculosis. How long have you been having night sweats?”
6. The nurse is giving instructions to a parent of a 13-month-old who weighs 18 lbs. The child is being discharged from the pediatric unit after hospitalization for gastroenteritis. When talking to the parent about car seat safety, the nurse knows the parent understands the teaching when the mother states:
A. “My child can be in a front-facing car seat because he is 1 year old.”
B. “My child can be in a front facing car seat as soon as he weighs 21 pounds.”
C. “As long as I drive a sports utility vehicle, I can have my child rear or front facing.”
D. “My child will need to be in a rear facing care seat until her is three years old.”
7. A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis jiroveci pneumonia. Which nursing diagnosis has the highest priority for the client?
A. Impaired gas exchange.
B. Impaired oral mucous membrane.
C. Imbalanced nutrition: Less than body requirements.
D. Activity intolerance.
8. The nurse is caring for a 2-year-old child admitted for long-term treatment of a chronic illness. The nurse understands the normal growth and development of children. Which of the following is an important nursing action for the child?
A. Allow the child to sleep for at least 12 hours per night.
B. Speak with a play therapist regarding activities the child can participate in.
C. Be sure the child is continuously isolated due to the chronic illness and risk of infection.
D. Maintain a diet that is high in carbohydrates and low in fats.
9. During the assessment interview, a depressed 15-year-old client states that she “can’t ever sleep at night.” When the nurse begins to explore the possible contributing factors by asking the client questions, the client changes the subject and avoids eye contact. The client tenses noticeably when the nurse touches her as part of the exam. Which of the following does the client’s behavior suggest?
A. Sexual abuse.
B. Age-appropriate behavior.
C. Sleep apnea.
10. A client with bipolar disorder who is taking lithium carbonate is instructed by the nurse on proper use of the drug, side effects, and symptoms of lithium toxicity. What statement by the client indicates that additional client teaching is required?
A. “I can still eat my favorite salty foods.”
B. “When my moods fluctuate, I will increase my lithium.”
C. “A good blood level means the drug is working.”
D. “Eating too much watermelon will effect by lithium level.”
11. The nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following treatments should the nurse include?
A. Administering a lactulose enema as ordered.
B. Encouraging a protein-rich diet.
C. Administering sedatives as necessary.
D. Encouraging ambulation at least four times a day.
12. A client is admitted to the medical-surgical floor with an exacerbation of myasthenia gravis. Which intervention is important for the nurse to include in the plan of care for this client?
A. Encouraging independent activities of daily living.
B. Helping the client cope with mood swings.
C. Scheduling the client’s care around periods of rest.
D. Encouraging warm baths before exercise.
13. A client is admitted to the Emergency Department after a three-car accident. He’s exhibiting early signs of increased intracranial pressure. Which of the following groups of symptoms is the nurse most likely to observe?
A. Decreasing pulse, increasing respiratory rate, and decreasing blood pressure.
B. Decreasing pulse, decreasing respiratory rate, and increasing systolic pressure.
C. Increasing pulse, decreasing respiratory rate, and increasing pulse pressure.
D. Decreasing pulse, increasing respiratory rate, and increasing pulse pressure.
14. The nurse is caring for a child who was in a house fire that killed 7 people, including his parents. He is the only survivor. The local newspapers and television stations are at the hospital and are trying to receive information regarding his condition. Which of the following is the correct action for the nurse?
A. The nurse does not give out any information regarding the child’s condition.
B. The nurse does not give the name, only the condition of the patient.
C. The nurse gives a statement about how sad she is for the family and friends of the little boy.
D. The nurse contacts an attorney because of the legal issues regarding caring for the child.
15. The nurse is leading a discussion on home safety to a group of parents with toddler-age children. Which of the following is important to emphasize?
A. Most deaths that occur regarding toddlers are accidental.
B. Overdose of medications is the leading cause of death in toddlers.
C. All children over the age of one can be in a front facing car seat.
D. The risk of injury for toddlers is the same as for adults.
16. The nurse is caring for a client diagnosed with a stroke. Because of the stroke, the client has dysphagia (difficulty swallowing). Which intervention by the nurse is best for preventing aspiration?
A. Placing the client in high Fowler’s position to eat.
B. Offering liquids and solids together.
C. Keeping liquids thinned.
D. Placing food on the affected side of the mouth.
17. The nurse is explaining medication benefits and side effects to a client with a history of psychosis. The client’s brother states to the nurse, “You are wasting your time explaining things to him.” Based on the nurse’s understanding of informed consent, which of the following statements serves as the best guide for the nurse’s response?
A. Informed consent does not apply to clients who experience psychosis.
B. The nurse can assume that the client understands at least some of the information.
C. A third party is necessary when informing clients about treatment options.
D. The use of informed consent is an important part of effective client care for all clients, regardless of age or condition.
18. The nurse is caring for a client who suddenly develops a tonic-clonic seizure. Which nursing action is most appropriate during a seizure?
A. Forcing a padded tongue blade into the client’s mouth.
B. Restraining the client’s limbs.
C. Placing the client in a supine position.
D. Loosening constrictive clothing.
19. The nurse is caring for a 19-month-old with mild dehydration and weight loss. The parent states: “My son doesn’t like to eat, and I hate to make him.” Which of the following nursing actions is appropriate?
A. Contact the social worker on duty and give her information on the situation.
B. Contact the physician to have the child referred to a gastroenterologist.
C. Contact the dietitian and have him come to talk to the parent about toddlers and nutrition.
D. Contact the local police for suspected child abuse.
20. An obese client has returned to the unit after receiving sedation and electroconvulsive therapy. The nurse requests assistance moving the client from the stretcher to the bed. There are 2 people available to assist. Which of the following is the best method of transfer for this patient?
A. Carry lift.
B. Sliding board.
C. Lift sheet transfer.
D. Hydraulic lift.
1. Correct answer: B
With a bowel obstruction, abdominal distention occurs. Measuring abdominal girth provides quantitative information about increases or decreases in the amount of distention. Monitoring daily weights provides information about fluid status. An increase in daily weight usually indicates fluid retention. Measuring intake and output provides no information about abdominal distention or the obstruction although it is to monitor output. A client with a bowel obstruction will have a nothing-by-mouth order.
2. Correct answer: A
The nurse should ask to see a copy of the advance directive for guidance in providing care. Advance directives for infants and children are often prepared by the parents with the assistance of their physicians as part of planning for end-of-life. These advance directives outline the type of care the parents want provided for their child and are especially important to guide care if the parents are not available when questions arise. The advance directive may specify whether oxygen should be used as part of palliative care. Waiting for the supervisor is not necessary since the parents are present, have an advance directive, and can indicate their wishes.
3. Correct answer: C
Clients with COPD are taught to use their diaphragmatic muscles, not their intercostal muscles, to breathe. Because of air trapping due to COPD, pursed-lip breathing exercises are indicated to help expel carbon dioxide. These exercises increase expiratory time, decrease expiratory rate, and increase tidal volume. Isometric leg exercises and lumbar sacral strengthening exercises don’t improve breathing but may be important for general health.
4. Correct answer: A
A voluntary admission is the preferred approach because it involves having the client recognize the problems the family is experiencing and facilitates the client’s involvement in treatment. The client’s rights would be violated by the use of chemical restraints since the client has the right to freedom from the use of restraints and seclusion. The duty of care is a legal relationship that applies only to the nurse-client relationship, not to the family relationship. In this case, the son is legally an adult, so the parents do not have a legal obligation to care for him. Respite care is not an appropriate recommendation at this time. The safety issue must be addressed and effective treatment and care instituted. At a later time, it would be prudent to talk to the family about caregiver burden and the option of using respite care.
5. Correct answer: B
Asking the client how he feels about the diagnosis allows the client to express his feelings about the diagnosis. Saying “it” won’t kill the client if he takes his medications belittles the client and reinforces the idea that he may be at fault. Telling the client he shouldn’t be embarrassed is presumptive and judgmental. Responding with “Let’s not talk about it” ignores the client’s feelings, reinforces the idea that there is something shameful about tuberculosis, and does not help him to accept and deal with his disease.
6. Correct answer: B
Any child under one year of age and/or 20 pounds must be in a rear facing car seat. The make or model of the car does not relate to child safety laws. The general rule for car seat application is that the child must be over one year of age and 20 pounds to move from a rear facing to front facing car seat but must be in the back seat of the car. Older children must use a booster seat until they are 7 to 8 years old, depending upon the state law.
7. Correct answer: A
Pneumocystis jiroveci is a fungus infection that can cause severe pneumonia in those who are immunocompromised. While all these nursing diagnoses are appropriate for the client with AIDS and P jiroveci pneumonia, impaired gas exchange is the priority nursing diagnosis for the client as ensuring a patent airway, breathing, and circulation are critical for life. Patients who are severely ill often have impaired nutrition, oral mucous membranes, and activity intolerance, but these should resolve if the causative condition is adequately treated.
8. Correct answer: B
An important part of growth and development for a child is play. Even when a child has a chronic illness, play should be facilitated. Consulting a play therapist is appropriate for children with special needs. Although it is important for children to maintain adequate sleep, it is not required that toddlers receive 12 hours of sleep per night. Children with chronic illnesses do not need to be continuously isolated. The child might need to be isolated for a period of time; however, she should still have interaction with family. A diet high in carbohydrates and low in fat is not indicated for all toddlers with chronic illness, and the American Heart Association recommends that fat intake should be 30 to 35% of the diet for a 2-year old.
9. Correct answer: A
Often a girl who is being sexually abused refuses to talk about it and changes the subject when questioned. Avoiding eye contact can indicate feelings of shame. While 15 year-old girls may be shy regarding their bodies, this behavior and her reaction when touched coupled with depression suggests abuse. Sleep apnea results in chronic fatigue although the person usually does not have difficulty falling asleep and is often unaware of the apneic periods. A client with narcolepsy has periods of deep sleep at night and falls asleep even during activities in the daytime.
10. Correct answer: B
Increasing the dose of lithium without monitoring dosage through lab values can result in lithium toxicity, overdose, and renal failure. The client must take the medication as prescribed and discuss mood fluctuations with the physician to determine if the dosage should be increased. Clients on lithium must include adequate intake of both sodium and fluids. A low sodium diet causes lithium retention. A therapeutic lithium blood level indicates that the drug concentration has stabilized. Clients are cautioned against eating large amounts of foods that have a diuretic effect. Some examples of these foods are watermelon, cantaloupe, grapefruit juice, and cranberry juice.
11. Correct answer: A
Hepatic encephalopathy is a degenerative disease of the brain that is a complication of cirrhosis. For the client with hepatic encephalopathy, the nurse may administer the laxative lactulose (Chronulac®) to reduce ammonia levels in the colon. Protein intake is usually restricted to reduce serum ammonia levels until the client’s mental status begins to improve. Sedatives are avoided because they can cause respiratory or circulatory failure. Bed rest is encouraged because physical activity increases metabolism, leading to an increased production of ammonia.
12. Correct answer: C
Classic symptoms of myasthenia gravis are weakness and fatigue, so it’s important to schedule care around periods of rest. Drastic mood changes are a symptom of other conditions, such as Cushing’s syndrome, not myasthenia gravis. Encouraging independent activities of daily living is also important but these must be done around periods of rest as well. Warm baths, which relax the muscles, might increase the client’s feeling of weakness and fatigue.
13. Correct answer: B
In the early stages of increased intracranial pressure, the client’s heart and respiratory rates slow down. The result is an increase in systolic pressure with further decrease in heart rate and respiratory rate, and a widening pulse pressure. With head trauma, there may be significant swelling that decreases perfusion, causing hypoxia and hypercapnia, triggering increased blood flow. The increase volume when injury has impaired auto-regulation increases the edema, which in turn increases intracranial pressure, causing further ischemia. If the intracranial pressure is not controlled, the brain may herniate.
14. Correct answer: A
According to HIPAA standards, one cannot give information regarding a child’s care unless permission is granted by the parents/guardian of the child to divulge information. In this case, the guardians may not yet have been identified. It would be inappropriate to give the name of the child, and there is no need for the nurse to contact an attorney. Although not illegal, giving a statement of feelings regarding the situation is not professional. In most hospitals, a public relations officer may be directed to make a public statement.
15. Correct answer: A
Most deaths in children are accidental. Many children are injured or killed each year from accidents related to fire, drowning, motor vehicles, and firearms. Generally, children of this age do not overdose on medications unless they are accidentally given too much medication. Most state laws require that infants remain rear-facing in a car seat until they are at least one year old and weigh 20 pounds, but studies indicate that it is safer to remain rear-facing for the first two years. Children are at a higher risk for injury then adults due to the developmental level of children and their lack of knowing right from wrong and recognizing danger signs.
16. Correct answer: A
Placing the client in high Fowler’s position, such as in a chair, uses gravity to reduce the risk of aspiration. Solids and liquids shouldn’t be offered together because when they’re in the mouth together, the liquids can cause the solids to be swallowed before they’re properly chewed. However, water or other fluid should be sipped after swallowing to clear the throat. Thin liquids should be thickened. Food should be placed on the unaffected side to prevent it from being trapped in the cheek on the affected side. Using smaller utensils to limit bite size and doing muscle-strengthening exercises may reduce dysphagia.
17. Correct answer: D
The use of informed consent allows the client and the nurse to work as partners in the development and accomplishment of treatment goals. Even clients with a history of psychosis have the right to be informed about their treatment risks and benefits. It is not appropriate for the nurse to assume that the client understands information given without obtaining some feedback from the client. A third party is not required to be present unless the client cannot give informed consent. In the case of a minor or legally incompetent client, a legally appointed guardian or parent must give informed consent for treatment.
18. Correct answer: D
Constrictive clothing, especially around the client’s neck, can interfere with oxygenation, so it should be loosened. One should never force anything such as a padded tongue blade into the mouth because it could break teeth or induce vomiting. A client who is having seizures should not be restrained, as it can cause soft-tissue injury and musculoskeletal damage. Instead, any dangerous objects should be removed from around the client. Because a supine position increases the risk of aspiration, the client should be helped into a side-lying position.
19. Correct answer: C
The parent needs assistance in maintaining her child’s diet. The dietitian is a healthcare professional that could speak to the parent regarding the diet of the child. This is within the scope of practice for a nurse. The nurse would not call the local police or social worker on duty. This is not a case of child abuse or neglect. Many toddlers are picky eaters and resist eating and drinking, and small children are less sensitive to feelings of thirst. The nurse would not call the physician to have the child referred to a gastroenterologist, as there is no indication that this is necessary.
20. Correct answer: B
Because this patient is obese and sedated, she is unable to assist with the transfer, so the sliding board transfer is the best method of transfer as it can be done with two to three people. The patient is turned to her side and the sliding board placed to bridge the stretcher and the bed. The nurse can stabilize the side opposite the bed while the other two pull the patient across to the bed with a pull sheet. A carry lift requires 4 people but is not safe for an obese patient. A lift sheet transfer requires at least 4 people, but if the patient is obese up to 7 or 8 people may be needed. The hydraulic lift is not the appropriate equipment to use with a sedated patient because the patient cannot cooperate.
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