NCLEX Practice Test 2

NCLEX Practice Test 2 1.A patient taking Fluoxetine Hcl (Prozac) asks the nurse when the medication will start to work. The patient started this medication two weeks ago. The nurse’s response is CORRECT if she states: a.“Prozac needs three months to work, so you will need to give it more time.” b.“In another two weeks, you should start to feel a difference in your mood.” * (4-6 weeks) c.“It should be another day or two. Then you will feel much better.” d.“Prozac works as soon as you take it and should be working now.” 2.The home health nurse visits a patient with HIV who lives alone in her apartment. Which of the following observations the nurse makes while in the patient’s home is MOST concerning?a.The patient has a bowl of fake fruit on the table.b.The patient has a cat who purrs loudly. * (cat feces contain toxoplasmosis/bacteria dangerous to immunocompromised patients like HIV or pregnant women) c.The dishwasher is broken and the patient complains that she has low water pressure throughout the whole apartment.d.There is an open container of food in the refrigerator.

3.A nurse cares for a patient who cannot turn by using an overhead lift. The nurse knows that which of the following is the MOST important actions to follow in terms of safety?a.Allow the patient to hook themselves up to the sling so that they feel involved in their care.b.When using the lift, raise the patient above the bed before laterally positioning the lift over the intended chair. * c.Ensure the sling is removed from the patient after they are seated in the chair.d.Tell the patient to rock back and forth to propel themselves.

4.The nursing team includes two RNs, one LPN, a nursing assistant, and a nurse reassigned from the postpartum unit. The nurse should consider the assignments appropriate if the reassigned nurse cares for which of the following patients?a.A client diagnosed with a head injury and a Glasgow coma scale of 5.b.A client diagnosed with COPD who displays Cheyne-Stokes respirations.c.A client with a spinal cord injury requiring assistance with meals.d.A client diagnosed with a myocardial infarction complaining of burning on urination. *(most stable patient) 5.The nurse works at an outpatient health center and receives a call from an adolescent girl who was recently prescribed the birth control pill. She describes “an awful leg cramp that turned the skin red.” Which of the following statements, if made by the nurse to the patient, is CORRECT?a.“Do you play any sports where you could have injured yourself?” b.“Has this happened before?” c.“We’ll need you to come into the clinic to be evaluated immediately.” *(A DVT complication of birth control pills) d.“This is a normal side effect with the pill and should go away after the first month.” 6.The nurse cares for a patient with AIDS who has acquired jiroveci pneumonia. Which of the following precautions levels is appropriate for this patient?a.Airborne precautions.b.Contact precautions.c.Standard precautions. *(immunocompromised patient at risk of an opportunistic infection. Anyone with normal immune system function cannot catch this infection).d.Droplet precautions. This study source was downloaded by 100000849631069 from CourseHero.com on 09-05-2022 07:34:25 GMT -05:00

https://www.coursehero.com/file/85345838/NCLEX-Practice1docx/

7.The nurse in the outpatient care clinic cares for a client diagnosed with heart failure. Which of the following orders, if written by the physician, should the nurse question?a.“Administer Lactated Ringers solution IV at a rate of 50mL/hr.” b.“Administer Potassium 40mEq tab once daily PO.” c.“Administer Lasix 40mg twice daily PO.” d.“Administer 0.9% NS solution IV at a rate of 125mL/hr.” *(can put patient in fluid overload) 8.An 8-year-old patient is admitted with a suspected fractured of the ulna. An x-ray is taken, and the nurse

correctly identifies this type of fracture as:

 a.Transverse.b.Greenstick. * c.Complete.d.Open.

9.A nurse cares for a patient with a head injury after a boating accident. The nurse knows that which of the following is an EARLY sign of increased ICP?a.The patient has a severe headache.b.The patient has a seizure.c.The patient does not recognize a close family member. *(LOC) d.The patient vomits twice in an hour.

10.When caring for a patient who experienced a head injury in a car accident, the nurse observes a bruised section behind the patient’s ear. The nurse knows that this type of marking is known as: a.Battle’s sign. *(test back of ear) b.Cohen’s sign. (Doesn’t exist) c.Chvostek’s sign. (Hypocalcemia exam) d.Homan’s sign. (DVT exam) 11.A patient comes into the ER with COPD exacerbation and is having difficulty breathing. What action, if performed by the nurse, would be considered negligence?A.The nurse checks the pulse ox of the patient.B.The nurse raises the head of the bed to Semi-Fowler’s position.C.The nurse gives the patient an 8 oz glass of water.D.The nurse places the patient on 4L of O2. *(too much O2) This study source was downloaded by 100000849631069 from CourseHero.com on 09-05-2022 07:34:25 GMT -05:00

https://www.coursehero.com/file/85345838/NCLEX-Practice1docx/

12.The medical/surgical nurse watches a student nurse prepare a sterile field. Which of the following actions, if performed by the student nurse, requires further instruction?a.The student nurses places the sterile drape, then turns to grab a packaged set of sterile gloves from the table behind her.b.The student nurses’ hands, once in the sterile gloves, do not go above her head or below her waist.c.The student nurse drops the sterile gloves into the sterile field before disposing of the outer packaging.d.The student nurse places an unwrapped sterile 4×4 on the sterile drape.

13.A patient with dementia has been identified as having a high BUN in lab results. Which of the following non- pharmacological actions would be best for the nurse to take?a.Notify the physician that the patient is in kidney failure.b.Place water in front of the patient every hour to encourage oral hydration. * c.Assist the patient to the bathroom every morning.d.Ask the charge nurse how best to solve the problem.

14.The wife of a client with PTSD (post traumatic stress disorder) communicates to the nurse that she is having trouble dealing with her husband’s condition at home. Which of the following suggestions made by the nurse is

CORRECT?

a.“Discourage your husband from exercising, as this will worsen his condition.” b.“Do not touch or speak to your husband during an active flashback. Wait until it is finished to give him support.”* c.“Encourage your husband to avoid regular contact with outside family members.” d.“Keep your cupboards free of high-sugar and high-fat foods.” 15.The nurse in the neurology unit cares for a patient diagnosed with CVA who is ready to go home today. The patient suffers from hemiplegia and dysphagia. Which of the following statements, if made by the patient’s wife, indicates that further teaching is necessary?a.“A peanut butter sandwich and tall, cold glass of milk is Bob’s favorite lunch.” *(peanut butter hard to swallow) b.“We will change our daily schedule to six meals per day, rather than our usual three.” c.“I will always ensure that Bob is finished chewing before I give him another bite of food.” d.“I will have Bob sit up for about twenty minutes before we start eating and for an hour afterward.” 16.You are a nurse on a medical/surgical unit who is caring for a patient with Grave’s Disease. The patient has just returned from a thyroidectomy. Which of the following statements from the patient would require further assessment by the nurse?a.“My throat feels sore and my voice is hoarse.” b.“My lips feel like they are tingling.” *(sign of hypocalcemia. The parathyroid gland may have been removed) c.“I have a headache.” d.“I hope I will be allowed to drink coffee now.” 17.The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided?

SELECT ALL THAT APPLY:

a.Cucumber salad. * b.Yeast rolls.c.Cooked broccoli. * d.Fresh peaches.e.Bran.f.Cabbages. * This study source was downloaded by 100000849631069 from CourseHero.com on 09-05-2022 07:34:25 GMT -05:00

https://www.coursehero.com/file/85345838/NCLEX-Practice1docx/

18.A patient on several medications is being cared for on a medical/surgical unit by the nurse. Which of the following laboratory values, if reported to the nurse, would require follow-up?

SELECT ALL THAT APPLY:

a.Lithium level of 1.3mEq/L.b.Blood sugar of 103 mg/dL.c.Calcium 8.5 mg/dL.d.Digoxin level of 2.4 mEq/L. * e.Potassium level of 5.5 mEq/L. * 19.A charge nurse on the cardiac unit observes a new graduate nurse as she suctions a patient with a tracheostomy.What action, if performed by the graduate nurse, would require intervention from the charge nurse?a.The graduate nurse withdraws the catheter and intermittently applies suction for no longer than nine seconds.b.The graduate nurse hyperoxygenates the client for three minutes before suctioning.c.The graduate nurse withdraws the catheter and intermittently applies suction for no longer than fifteen seconds.*(no longer than 10 seconds for suctioning) d.The graduate nurse elevates the head of the bed to Semi-Fowler’s position before beginning.

20.A patient has been admitted with symptoms of BPH. Which of the following complaints, if observed by the nurse, requires follow-up?a.Nocturia.b.Elevated PSA.c.Hesitancy in urinary flow.d.WBCs in urine. *(No WBC’s, RBC’s, Protein, or Glucose should be in the urine) 21.An older patient is scheduled for hip replacement surgery in twelve hours. As the nurse reviews the health history, she notes that the patient has a history of alcoholism. Which of the following actions should be taken to best care for this patient?a.Alert the physician that further assessment is required.b.Care for the patient here and now despite his history.c.Ask the patient when he had his last drink. *(an alcoholic can go into DT’s delirium tremors after surgery and go into withdrawals) d.Ask the patient for a urine (BAC) blood alcohol content prior to surgery.

22.Which of the following must be performed by an RN and NOT a UAP (unlicensed assistive personnel)?

SELECT ALL THAT APPLY:

a.Ambulation post-op day 1. * b.Ambulation post-op day 5.c.Patient teaching. * d.Activities of daily living.e.Wound care. * 23.A patient has been prescribed the medication spironolactone (aldasterone). When preparing the patient for discharge, the nurse should include which of the following instructions? This study source was downloaded by 100000849631069 from CourseHero.com on 09-05-2022 07:34:25 GMT -05:00

https://www.coursehero.com/file/85345838/NCLEX-Practice1docx/