Kaplan Nclex Exam 4 - injury with suspected subdural hematoma. Althou...

1 Kaplan Nclex Exam 4

• A young adult who was in a motorcycle accident is brought to the emergency room with a closed head

injury with suspected subdural hematoma. Although the client complains of a severe headache, he is alert and answers questions appropriately. The nurse would question which of the following orders?

• “Promethazine (Phenergan) 25 mg IM 3 h.”
• “Morphine sulfate 10 mg IM q3-4h.”
• “Docusate sodium (Colace) 50 mg PO bid.”
• “Ranitidine (Zantac) 50 mg IVPB q12h.”
• The nurse has just returned to the desk and has four phone messages to return. Which of the following

messages should the nurse return FIRST?

• A woman in her first trimester of pregnancy complaining of heartburn.
• A man complaining of heartburn that radiates to his jaw.
• A woman complaining of hot flashes and difficulty sleeping.
• A boy complaining of knee pain after playing basketball.
• A patient is admitted to the surgical unit with a diagnosis of rule out intestinal obstruction. The nurse is

preparing to insert a Salem sump NG tube as ordered. In which of the following positions would it be BEST for the nurse to place this patient during the procedure?

• Head of bed elevated 30°–45°.
• Head of bed elevated 60°–90°.
• Side-lying with head elevated 15°.
• Lying flat with head turned to the left side.
• The nurse is monitoring the fluid status of a 63-year-old woman receiving IV fluids following surgery.

Which of the following symptoms would suggest to the nurse that the patient has fluid volume overload?

• Temperature 101°F (38.3°C), BP 96/60, pulse 96 and thready.
• Cool skin, respiratory crackles, pulse 86 and bounding.
• Complaints of a headache, abdominal pain, and lethargy.
• Urinary output 700 cc/24 h, CVP of 5, and nystagmus.
• A woman has been recently diagnosed with systemic lupus and shares with the nurse, “I am thinking

about getting pregnant, but I don’t know how I will be able to tolerate a pregnancy since I have lupus.” Which of the following responses by the nurse is BEST?

• “Most women find that they feel better when they are pregnant.”
• “How long have you been in remission?”
• “Women with lupus frequently have slightly longer gestations.”
• “It is best to become pregnant within the first six months of diagnosis.”
• The multidisciplinary team decides to implement behavior modification with a client. Which of the

following nursing actions is of primary importance during this time?

• Confirm that all staff members understand and comply with the treatment plan.
• Establish mutually agreed upon, realistic goals.
• Ensure that the potent reinforcers (rewards) are important to the client.
• Establish a fixed interval schedule for reinforcement.
• A client received six units of regular insulin three hours ago. The nurse would be MOST concerned if

which of the following was observed?

• Kussmaul respirations and diaphoresis.
• Anorexia and lethargy.
• Diaphoresis and trembling.
• Headache and polyuria.

Kaplan Nclex Exam 4

2

• The nursing assistant reports to the nurse that a client who is one-day postoperative after an

angioplasty is refusing to eat and states, “I just don’t feel good.” Which of the following actions, if taken by the nurse, is BEST?

• The nurse talks with the client about how he is feeling.
• The nurse instructs the nursing assistant to sit with the client while he eats.
• The nurse contacts the physician to obtain an order for an antacid.
• The nurse evaluates the most recent vital signs recorded in the chart.
• The nurse prepares a 25-year-old woman for a cesarean section. The patient says she had major

surgery several years ago and asks if she will receive a similar “shot” before surgery. The nurse’s response should be based on an understanding that the preoperative medication given before a cesarean section

• contains a lower overall dosage of medication than is given before general surgery.
• contains reduced amounts of sedatives and hypnotics than are given before general surgery.
• contains reduced amounts of narcotics than are given before general surgery.
• contains medications similar in type and dosages to those given before general surgery.
• The nurse is caring for an 11-year-old patient being treated for a fractured right femur with balanced

suspension traction with a Thomas splint and Pearson attachment. The nurse notes that the patient’s left leg is externally rotated. The nurse should

• place a trochanter roll on the outer aspect of the thigh.
• perform resistive range of motion of the left leg.
• adduct and internally rotate the left leg.
• instruct the patient to maintain the left leg in a neutral position.
• The nurse is preparing a five-year-old child for surgery. The nurse notes that the child’s parents are

divorced and have joint legal custody. The informed consent for surgery has been signed by the mother.Which of the following actions by the nurse is BEST?

• Notify the physician.
• Inform surgery.
• Contact the father to obtain consent.
• Continue the child’s preoperative preparation.
• The nurse is caring for clients on the neurology unit. What would be the MOST appropriate action for

the nurse to take after noting that a client suddenly developed a fixed and dilated pupil?

• Reassess in five minutes.
• Check the client’s visual acuity.
• Lower the head of the client’s bed.
• Contact the physician.
• A mother brings her two-year-old boy to the pediatrician’s office. Which of the following symptoms

would suggest to the nurse that the child has strabismus?

• When the child draws, he places his head close to the table.
• The child rubs his eyes frequently.
• The child closes one eye to see a poster on the wall.
• The child is unable to see objects in the periphery of his visual field.
• A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug,

the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate?

• Allow the client to sleep undisturbed.
• Administer oxygen via facemask or nasal prongs.
• Administer naloxone (Narcan).

4. Place epinephrine 1:1,000 at the bedside.

Kaplan Nclex Exam 4

3

• The school nurse is teaching a group of preschool mothers about poison prevention in the home.

Which of the following statements, if made by a mother to the nurse, indicates that further teaching is necessary?

• “I should have a bottle of Ipecac for each of my children.”
• “I should induce vomiting if my child swallows lighter fluid.”
• “Giving my child water or milk may help dilute the poison.”
• “Proper storage is the key to poison prevention in the home.”
• The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST

appropriate for the nurse to take which of the following actions?

1. Take the client to the dining room with 1:1 supervision.

• Inform the client he may go to the dining room when he controls his behavior.
• Hold the meal until the client is able to come out of seclusion.
• Serve the meal to the client in the seclusion room.
• Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to

50% of his body?

• Counseling regarding problems of body image.
• Maintain airborne precautions.
• Maintain aseptic technique during procedures.
• Encourage peers to visit on a regular basis.
• The home health care nurse is caring for a 30-year-old woman with type I diabetes mellitus. The client

has been maintained on a regimen of NPH and regular insulin and a 1,800-calorie diabetic diet with normal blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past two days were 205 mg/dL and 233 mg/dL. The nurse expects the physician to

• reduce the client’s diet to 1,500 calorie ADA.
• order 3 additional units of NPH insulin at 10 PM .
• order an additional 10 units of regular insulin at 8 PM .
• eliminate the client’s bedtime snack.
• After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a

five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician?

• The client has slight edema of the eyelids.
• There is clear fluid draining from the client’s right ear.
• There is some bleeding from the child’s lacerations.
• The client withdraws in response to painful stimuli.
• A psychiatric nurse is assigned to conduct an admission nursing history on a new client. The

admission should include which of the following?

• The nurse’s opinion regarding the mental and emotional status of the client.
• Data addressing the client’s emotional state.
• Data that address a biopsychosocial approach, including a family system assessment.
• Specific data detailing the client’s mental status.
• Prochlorperazine maleate (Compazine) 10 mg IM has been ordered for a client. The client is also to

receive Stadol 2 mg IM. Before administering these medications, the nurse should

• obtain respirations and temperature.
• dilute with 9 ml of NS.
• draw the medications in separate syringes.
• verify the route of administration.

Kaplan Nclex Exam 4

4

• The nurse is caring for clients in the student health center. A client confides to the nurse that the

client’s boyfriend informed her that he tested positive for hepatitis B. Which of the following responses by the nurse is BEST?

• “That must have been a real shock to you.”
• “You should be tested for hepatitis B.”
• “You’ll receive the hepatitis B immune globulin (HBIG).”
• “Have you had unprotected sex with your boyfriend?”
• A young adult patient constantly seeks attention from the nurses, stomping away from the nurses’

station and pouting when her requests are refused. Which of the following responses by the nurse is MOST appropriate?

• Have the patient establish trust with one staff person with whom therapeutic interventions should occur.
• Give the patient unsolicited attention when she is not exhibiting the unacceptable behaviors.
• Ignore the patient when she exhibits attention-seeking behavior.
• Rotate the staff so the patient will learn to relate to more than one nurse.
• After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client

becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?

• Irrigate the nasogastric tube with distilled water.
• Aspirate the gastric contents with a syringe.
• Administer an antiemetic medicine.
• Insert a new nasogastric tube.
• A 38-year-old woman, mother of two, has a mastectomy for breast cancer. When she returns to the

physician’s office a month later for a routine check-up, the nurse asks the client how she has been. Which of the following responses, if made by the client to the nurse, indicates that the client is experiencing a normal reaction to the surgery?

• “I have been helping my family deal with their feelings about the surgery.”
• “I have been having difficulty coping with the surgery and cry frequently.”
• “I have been unable to leave the house or talk to my friends about the surgery.”
• “I am doing just great since the surgery and have gone back to work at my job.”
• The nurse is caring for clients in outpatient surgery. The mother of a four-year-old asks the nurse how

to prepare her daughter for eye surgery. Which of the following statements by the nurse is BEST?

• “Draw a picture of the eye to explain what will happen.”
• “Tell your daughter that the procedure will take one hour.”
• “Use dolls or puppets to explain how to get ready for surgery.”
• “Read an age-appropriate illustrated book about eye surgery to your daughter.”
• A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following

findings, if assessed by the nurse, would indicate a possible complication?

• The client’s urine test is positive for glucose and acetone.
• The client has 1+ pedal edema in both feet at the end of the day.
• The client complains of an increase in vaginal discharge.
• The client says she feels pressure against her diaphragm when the baby moves.
• A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and

vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient’s nutritional status has improved after 4 days?

• The patient eats most of the food served to her.
• The patient has gained 1 pound since admission.
• The patient’s albumin level is 4.0mg/dL.
• The patient’s hemoglobin is 8.5g/dL.

Kaplan Nclex Exam 4