NCLEX PRACTICE EXAM QUESTIONS

NCLEX PRACTICE EXAM QUESTIONS

The nurse on the surgical floor is receiving a hand-off report from the previous shift. Which of the following clients should the nurse see first?

• A client admitted 3 hours ago with a gunshot wound; 1.5 cm area of dark

drainage on the dressing.

• A client who had a mastectomy 2 days ago; 23 mL of serosanguinous fluid in

the wound drain.

• A client with a collapsed lung due to an accident; no chest drainage noted in

the previous 8 hours.

• A client who had an abdominal-perineal resection 3 days ago; client now

reports chills.The correct answer is 4. A client admitted 3 hours ago with a gunshot wound; 1.5 cm area of dark drainage on the dressing— does not indicate acute bleeding; small amount of blood. A client who had a mastectomy 2 days ago; 23 mL of serosanguinous fluid in the wound drain— expected outcome. A client with a collapsed lung due to an accident; no chest drainage noted in the previous 8 hours— air (not drainage) is expected with a pneumothorax. A client who had an abdominal-perineal resection 3 days ago; client now reports chills— CORRECT: at risk for peritonitis; should be assessed for further symptoms of infection.

A nursing team consists of an RN, an LPN/LVN, and an unlicensed assistive personnel (UAP). The nurse should assign which of the following clients to the

LPN/LVN?

• A client with a diabetic ulcer that requires a dressing change.
• A client diagnosed with cancer who is reporting bone pain.
• A client with terminal cancer being transferred to hospice home care.
• A client with a fracture

The correct answer is number 1. A client with a diabetic ulcer that requires a dressing change— CORRECT: stable client with an expected outcome. A client with cancer who is reporting bone pain— requires assessment; RN is the appropriate caregiver. A client with terminal cancer being transferred to hospice home care— requires nursing judgment; RN is the appropriate caregiver. A client with a fracture of the right leg who asks to use the urinal— standard, unchanging procedure; assign to the UAP.

When reviewing their knowledge of the stages of infections, the nurse knows that which period precedes the first symptoms of the infection?

• Entry of pathogen
• Colonization of organism
• Incubation period
• Convalescent period

C is correct: The incubation period is the point in time where the organism has already invaded the person's body through a portal of entry, is multiplying, and is getting ready to manifest the first symptoms of infection. The colonization occurs right after entry into 1 / 4

the body where the organism takes up residence in the host and prepares to multiply.The convalescent period is when the person is recovering from the illness.The nurse is caring for a client who recently underwent radiation therapy to his abdomen. Based on the location of the radiation, the nurse expects which of the following side effects?

• Diarrhea
• Fatigue
• Trembling
• Muscle aches

A is correct: Based on the abdominal location of the radiation therapy, it is likely that the patient will experience gastrointestinal symptoms, including diarrhea, nausea, and vomiting, as a side effect. Fatigue, trembling, and muscle aches are possible with radiation therapy but not specific to the organs of the abdomen.

A patient with a Swan-Ganz catheter in the ICU is being assessed by the nurse for the first time during the shift. The nurse notices which number on the hemodynamic profile is abnormal and needs further investigating?

a. Mean arterial pressure: 75 mmHg

b. Cardiac output: 2L/min

c. Central venous pressure: 5 mmHg

d. Pulmonary capillary wedge pressure: 6 mmHg

B is correct: The patient's cardiac output is very low, suggesting a possible bleed or hypotensive crisis. Normal cardiac output falls between 4 and 8 L/min. All the other values listed are within normal range. Normal mean arterial pressure is between 70 and 100 mmHg. Normal central venous pressure is between 2 and 6 mmHg. Normal pulmonary capillary wedge pressure is between 4 and 12 mmHg.

The hospitalized client with heart failure is receiving dobutamine intravenously.Which of the following responsibilities is most appropriate for the RN to delegate to an experienced nurse aide?

1.Teaching the client about the reasons for remaining on bedrest.

2.Taking the client's vital signs every hour, and reporting them to the RN.

3.Turning off the infusion pump if the client becomes hypotensive.

4.Notifying the physician that the client's urine output is less than 30 ml/hr.

• The scope of practice for a nurse aide, no matter how experienced, does not include

medication management. Turning off the infusion pump would also entail stopping the dobutamine, and altering the medication administration. This is not an appropriate task for the RN to delegate. Teaching about the need for bedrest involves explaining the intervention (bedrest), the specifics of the client's condition, and how the intervention supports healing. This is beyond the knowledge base of the nurse aide. Finally, the decreased urine output is only part of the assessment data that the physician will need to interpret the client's status. The RN will need to collect and report more assessment data, and the RN may receive orders in response to the physician's interpretation of the data.

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The nurse is notifying the physician of the client's change in status, using the SBAR format. What is the correct order of the following nurse's statements?

• "I suggest the client be transferred to the ICU, and I would like you to come

evaluate the patient."

• "The client is deteriorating, and I'm afraid the client is going to arrest."
• "I am calling about [client name and location]. Vital signs are BP=100/50,

P=120, RR=30, T=100.4 degrees F (38 degrees Celsius)"

• "The client is becoming confused and agitated. The skin is pale, mottled, and

diaphoretic. The client is very dyspneic with an oxygen saturation of 85%, despite placing a nonrebreather mask."

A, B, C, D

B, C, A, D

D, B, A, C

C, D, B, A

The correct answer is 4.Rationale:Identifying the client, and reporting the vital signs describes the situation and what is happening at the present time. (Statement C). This represents the S of SBAR.The additional information related to the client's confusion, skin condition, respiratory status, and the intervention of the nonrebreather mask describes the background of what happened, leading up to the situation. (Statement D).It is the B of SBAR.The nurse's statement that the client is deteriorating, and the concern for cardiopulmonary arrest, is the nurse's assessment of the problem.(Statement B). It is the A of SBAR.The nurse's statement that the client should be transferred to the ICU is the recommendation for correcting the problem. (Statement A).It is the R of SBAR.

The nurse is wearing PPE (personal protective equipment). Place the steps to removing the PPE in the correct sequence.

• Remove gown
• Remove gloves and perform hand hygiene.
• Remove mask
• Remove eye protection.
• Perform hand hygiene.

(B,D,A,C,E) The gloves harbor the largest number of microorganisms from the client, and should be removed first. The nurse's hands may come in contact with the microorganisms while removing gloves, so hand hygiene should now be performed. The protective eyewear is no longer needed, and may be removed prior to any other action.The gown should now be removed, just prior to exiting the room. The mask is the last item of PPE to be removed, and should be removed at the doorway of the client's room.Once out of the room, perform hand hygiene because the hands may have come into contact with microorganisms in the process of removing the PPE.

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The hospitalized client has a history of weekly moderate alcohol use. Which symptoms, assessed by the nurse, indicate that the client may be experiencing alcohol withdrawal? Select ALL that apply.

• Agitation
• Hypotension
• Tachycardia
• Hallucinations
• Tongue Tremor

1,2,4,5

Alcohol withdrawal is a very dangerous event. It leads to increased activity of post- synaptic N-methyl-D-aspartate (NMDA) receptors in the brain, resulting in agitation.Option 1 is a correct response. Alcohol withdrawal leads to elevated blood pressure, not hypotension, so option 2 is incorrect. Alcohol withdrawal, as noted above, leads to increased NMDA receptors in the brain, leading to tachycardia, hallucinations, and tongue tremor.Test-taking tip: Think about increased activity in the brain as a mechanism in all but one of the possible responses.

As the nurse is receiving reports on her patients for the day, she knows that which patient will take top priority in being assessed and treated?

• 33-year-old female who is nauseous and needs an antiemetic administered
• 49-year-old female who is scheduled for a cardiac catheterization and needs to

sign the informed consent

• 55-year-old male who is being discharged later today and has a question about

his care at home

• 78-year-old male who is complaining of shortness of breath

D is correct: The nurse will see the patient who is complaining of shortness of breath first. Airway, breathing, and circulation are always the highest priority for the nurse to address, as they can quickly become life-threatening situations. Maintaining proper respiration is a vital function to the patient's well-being, and stabilization is necessary immediately. The woman who is nauseous and needs antiemetics such as Zofran is the second priority, as she is actively ill and there is something the nurse can do to help her symptoms. The nurse's third priority will be the patient who needs to sign the informed consent. The nurse needs to ensure she gets that signed before the patient leaves the floor, although there are nurses in the cardiac catheterization lab who can obtain the consent if need be. The patient who has a question about discharge is the last priority, as there is no immediate threat to his health and the doctor will need to see the patient before he is discharged anyway.

A client has just had a catheter placed in their chest for the purpose of total parenteral nutrition (TPN) administration. The chest x-ray shows that the catheter has slipped and caused a leakage of air into the pleural space. What is this condition called?

• Pneumothorax
• Hemothorax
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