Kaplan Nclex Exam 1 - nurse return FIRST? 1. A mother reports that th...

Kaplan Nclex Exam 1

• The nurse is caring for clients in the outpatient clinic. Which of the following messages should the

nurse return FIRST?

• A mother reports that the umbilical cord of her five-day-old infant is dry and hard to the touch.
• A mother reports that the “soft spot” on the head of her four-day-old infant feels slightly elevated when

the baby sleeps.

• A mother reports that the circumcision of her 3-day-old infant is covered with yellowish exudate.
• A father reports that he bumped the crib of his two-day-old infant and she violently extended her

extremities and returned to them their previous position.

• The parents of a child with hemophilia want to know the cause of the disease. Which of the following

would be the BEST response by the nurse?

• “The father transmits the gene to his son.”
• “Both the mother and the father carry a recessive trait.”
• “The mother transmits the gene to her son.”
• “There is a 50% chance that the mother will pass the trait to each of her daughters.”
• A six-month-old is brought to the clinic for a well-baby check-up. During the exam, the nurse should

expect to assess which of the following?

• A pincer grasp.
• Sitting with support.
• Tripling of the birth weight.
• Presence of the posterior fontanelle.
• A 48-year-old man with an endotracheal tube needs suctioning. Which of the following statements is an

accurate description of how the nurse should perform the procedure?

• Insert the suction catheter four inches into the tube. Apply suction for 30 seconds, using a twirling

motion as the catheter is withdrawn.

• Hyperoxygenate the client and then insert the suction catheter into the tube. Suction while you remove

the catheter using a back and forth motion.

• Explain the procedure to the patient. Insert the catheter while gently applying suction, and withdraw

using a twisting motion.

• Insert the suction catheter until resistance is met, then withdraw it slightly. Apply suction intermittently

as the catheter is withdrawn.

• A 47-year-old woman comes to the outpatient psychiatric clinic for treatment of a fear of heights. The

nurse knows that phobias involve

• projection and displacement.
• sublimation and internalization.
• rationalization and intellectualization.
• reaction formation and symbolization.
• The prenatal client at eight-weeks gestation has a positive VDRL. In preparing the teaching plan, which

of the following would be MOST appropriate for the nurse to include?

• The importance of not taking any medications so as not to damage the fetus.

Kaplan Nclex Exam 1

• Instructing the client on the importance of taking the penicillin for the prescribed time.
• Instructing the client to refrain from sexual activity.
• Maintaining the confidentiality of sexual partners or contacts.
• An elderly client who has been recently immobilized is ordered to begin passive range-of-motion (ROM)

exercises. What should the nurse understand about ROM before initiating this order?

• Passive range-of-motion exercises increase muscle strength.
• A full range of motion must be completed for the elderly client.
• Exercises should be completed to the point of discomfort.
• A sufficient range of motion assists the elderly to carry out activities of daily living (ADLs).
• A 65-year-old man is scheduled for a colon resection this morning. Last night he had polyethylene

glycolelectrolyte solution (GoLytely) and a soapsuds enema. This morning he passes a medium amount of soft, brown stool. The nurse should know that this

• indicates that the bowel preparation is incomplete.
• is evidence that the patient ate something after midnight.
• is an expected finding before this type of surgery.
• is the last stool that was left in the colon.
• The nurse cares for a newborn infant with fetal alcohol syndrome. The nurse would expect to see which

of the following physical characteristics?

• An infant that is large for gestational age (LGA) with craniofacial abnormalities and hydrocephalus.
• An infant with a small head circumference, low birth weight, and undeveloped cheekbones.
• An infant with a small head circumference, low birth weight, and excessive rooting and sucking

behaviors.

• An infant with a normal head circumference, low birth weight, and respiratory distress syndrome.
• The physician orders hydromorphone hydrochloride (Dilaudid) 15 mg IM for a 56-year-old woman.

Side effects of this medication that the nurse should observe the patient for include

• photosensitivity and constipation.
• hypotension and respiratory depression.
• tardive dyskinesia and diplopia.
• dry mouth and tinnitus.
• The outpatient clinic nurse is caring for a 66-year-old woman with insulin-dependent diabetes mellitus

(IDDM). Because the client is unwilling to perform blood glucose monitoring, she tests her urine for sugar and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because

• the renal threshold for glucose is elevated in the elderly.
• blood glucose monitoring is easier and less costly for clients to perform.
• urine testing for glucose provides false-positive readings.
• determination of the color on a reagent strip varies from person to person.
• At 32-weeks gestation, a client has an order for an ultrasound. The client indicates an understanding

of this procedure if she makes which of the following statements to the nurse?Kaplan Nclex Exam 1

• “The results will inform us of the gestational age.”
• “This test will evaluate the baby’s lungs.”
• “The test will show us if there is any problem in the spinal cord.”
• “Early problems with the baby’s blood can be identified with this test.”
• A child has pediculosis capitis (head lice) and is being treated with 1% gamma benzene hexachloride

(Kwell) shampoo. The nurse should explain to the child’s parents that

• treatment should be continued every other day for 1 week.
• clothing and personal belongings require normal cleansing with soap and water.
• application of the shampoo is repeated in 7 to 10 days.
• one treatment with Kwell kills both lice and nits.
• The nurse is supervising an LPN/LVN who is administering an enema to a patient. During the

administration, it is MOST important for the LPN/LVN to take which of the following actions?

• Place the solution 20 inches above the anus.
• Adjust the temperature of the solution.
• Insert the tube six inches.
• Position the patient left side-lying (Sim’s) with knee flexed.
• An 18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB). During the

initial assessment, the nurse should expect to find which of the following early symptoms?

• Kussmaul respirations and bradycardia.
• Elevated temperature and slow respiratory rate.
• Expiratory wheezing and substernal retractions.
• Inspiratory stridor and restlessness.
• A client has been receiving chlorpromazine hydrochloride (Thorazine). When the nurse checks on the

patient, the patient is restless, unable to sit still, and complains of insomnia and fine tremors of her hands.The nurse knows that these symptoms are

• a side effect of the medication that she will tolerate better as time passes.
• the reason she is receiving this medication.
• extrapyramidal side effects resulting from this medication.
• an indication that the dosage of the medication needs to be increased.
• The nurse is caring for a client with a tracheostomy. An appropriate nursing diagnosis for this client is
• impaired verbal communication related to absence of speaking ability.
• ineffective airway clearance related to increased tracheobronchial secretions.
• risk for impaired skin integrity related to tracheostomy incision.

4. alteration in comfort: pain related to tracheostomy.

• Which of the following types of foods should the nurse encourage in the diet of a client with

hypoparathyroidism?Kaplan Nclex Exam 1

• High in phosphorus.
• High in calcium.
• Low in sodium.
• Low in potassium.
• A 20-year-old woman arrives at the hospital in active labor. The admitting nurse attaches an internal

fetal monitor. The nurse knows the MOST important reason for the fetal monitor is

• to evaluate the progress of the client’s labor.
• to assess the strength and duration of the client’s contractions.
• to monitor the oxygen status of the fetus during labor.
• to decide if an oxytocin drip is necessary.
• A mentally retarded client is to be discharged home on warfarin sodium (Coumadin), 5 mg each day.

To maintain client safety, which of the following would be an appropriate FIRST nursing action?

• Instruct a significant other about the medication regimen.
• Evaluate client comprehension of the medication administration.
• Prepackage the medication to encourage correct administration.
• Encourage a return demonstration of medication self-administration.
• A client, gravida 2 para 1, is admitted with hypertension and complains that her wedding band is tight.

The nurse should expect to assess which of the following with early pre-eclampsia?

• Blurred vision and proteinuria. 2. Epigastric pain and headache.
• Facial swelling and proteinuria. 4. Polyuria and hypertonic reflexes.
• The nurse is caring for clients in a drug rehabilitation facility. Which of the following complications of IV

drug abuse is the nurse MOST likely to observe?

• Jaundice. 2. Rash.
• Bruising. 4. Cellulitis.
• The client is admitted with cerebrovascular accident (CVA) and has facial paralysis. Nursing care

should be planned to prevent which of the following complications?

• Inability to talk.
• Inability to swallow caused by loss of the gag reflex.
• Inability to open the affected eye.
• Corneal abrasion.
• A client is ordered to take aspirin gr. X, PO. The drug label reads: “Aspirin 325 mg per tablet.” Which

of the following actions should the nurse take?

• Request that the pharmacy send a correctly labeled medication.
• Notify the doctor regarding the dosage.
• Give one tablet.
• Give two tablets.

Kaplan Nclex Exam 1