Download Test for all specialty in nursing

Test for all specialty in nursing
FILL IN THE BLANKS
Fill in the blank spaces with the correct word or phrase to complete each statement.
1. The three most basic causes of cell injury are
a.
b.
c.
2. The five classic signs of infection are
a.
b.
c.
d.
e.
3. The two major components of the inflammatory response are
a.
b.
4. The three types of exudates are
a.
b.
c.
5. The four components of the healing process are
a.
b.
c.
d.
6. Collagen fibers in scar tissue are weak for days.
7. The four most common sites of nosocomial infection are
a.
b.
c.
d.
8. Cancers arising in tissues derived from mesoderm such as muscles, bones, or connective
tissue are called
.
9. The two distinct processes involved in carcinogenesis are
a.
b.
10. Another name for the contractile force of the heart is .
1058 PART II: Content Review
TRUE & FALSE QUESTIONS
Mark each of the following statements True or False. Correct all false statements in the space
provided.
1. Calcification occurs only in necrotic tissue.
2. Chronic inflammation progressively destroys tissue and results in loss of function
and scarring.
3. Once regeneration occurs, function is restored to damaged organs.
4. If a child cuts his hand on a piece of broken glass and has eight sutures to close the
wound, healing will occur by second intention.
5. To facilitate healing of a wound across the middle knuckle of the index finger, the
joint needs to be immobilized.
6. Signs of systemic infection include swollen lymph nodes, fever, and elevated ESR.
7. Total length of the cell cycle is the same for all cells; what differs is the length of time
spent in each phase.
8. A characteristic of a benign tumor is that it is composed of cells that resemble the
tissue of origin.
9. Malignant tumors cause systemic symptoms such as altered taste and weight loss.
10. The initial effect of an increase in heart rate is a decrease in cardiac output.
MATCHING QUESTIONS
Match the following:
1. Adhesions a. Type of nosocomial infection, which is the direct result of a diagnostic or
therapeutic procedure
2. Hypertrophy b. Angioneogenesis
3. Serous exudates c. Ability of a microorganism to produce infection
4. Dehiscence d. Enlargement of cells and organs as a result of increased demand
5. Apoptosis e. Number of cells increased through cell division in response to demand
6. Contracture f. Fluid in blisters of a mild sunburn
7. Suppurative exudate g. Microorganism that causes infection only in a susceptible person
TF
TF
TF
TF
TF
TF
TF
TF
TF
TF
CHAPTER 33 Physiological Integrity 1059
8. Necrosis h. Tissue death
9. Granuloma i. Process by which strains of microorganisms become resident flora in an area
of the body
10. Keloid j. Tissue is disordered and cells vary in size and shape
11. Hyperplasia k. Shrinking of cells and organs as a result of decreased demand
12. Phagocytosis l. Lack of organ development
13. Revascularization m. Exaggerated contraction of maturing collagen, mostly affecting large
wounds
which results in distortion and limited mobility
14. Colonization n. Joining of serous membranes which normally move freely against each other
due to organization of inflammatory exudates. Risk is greatest with trauma to
abdominal organs, heart, and lungs
15. Atrophy o. Breaking open of a healing wound usually a result of pressure on the wound
16. Opportunistic p. Irregular masses of scar tissue protruding from the skin that result from
pathogen overproduction of collagen
17. Iatrogenic infection q. Decreased number of cells as a result of self-destruction
18. Virulence r. Round masses of transformed macrophages surrounded by lymphocytes and
fibroblasts
19. Aplastic s. Shortening of a muscle or scar tissue causing distortion or deformity
20. Dysplasia t. Ingestion of particles by cells
u. Material that passes through vessels into adjacent tissues in inflammation
(continued)
APPLICATION QUESTIONS
1. Of which process is gangrene an example?
a. Coagulation necrosis
b. Liquefaction necrosis
c. Autolysis
d. Phagocytosis
2. Which is the primary factor that determines the time
interval that can elapse between removal of an organ
from a donor and its transplantation into a recipient?
a. Time an organ can survive ischemia
b. Ability of the organ to withstand temperature change
c. Amount of DNA present in the organ’s cells
d. Number of organelles in the organ’s cells
3. Which factors can initiate an inflammatory response?
(Select all that apply.)
a. Heat or cold
b. Trauma
c. Infection
d. Antigen–antibody-complex deposition
e. Complement activation
1060 PART II: Content Review
4. What type of diet should be encouraged for a client
having radiation through an abdominal port who
complains of nausea and vomiting? (Select all that
apply.)
a. High-protein
b. High-carbohydrate
c. High-fat
d. High-residue
e. High-calorie
f. Low-protein
g. Low-calorie
h. Low-carbohydrate
i. Low-residue
j. Low-fat
5. When caring for a client having radiation therapy the
nurse receives a report that the client’s laboratory values
are normal and there are no signs of anemia,
infection, or bleeding. Which conclusion should the
nurse draw from this information?
a. Radiation has not yet reached a therapeutic level.
b. The client is free of side effects of radiation.
c. Nutritional status is normal.
d. Bone-marrow suppression is not a problem.
6. The father of a 9-month-old boy just diagnosed with
a primary immune deficiency says to the nurse “I
don’t understand it. Why did my son seem healthy
until he was 6-months old and then start getting all
these infections?” On which fact should the nurse’s
response be based?
a. Under 6-months of age, most babies do not show
signs of active infection.
b. It takes about 6 months for babies to be exposed
to enough pathogens for infection to readily occur.
c. Until about 6 months, babies are protected from
infection by immunity from their mothers.
d. Before 6 months, babies are only susceptible to
bacterial infections.
7. When assessing skin of a client having external radiation
therapy, which fact should the nurse keep in
mind?
a. Skin damage is preceded by changes in oral
mucous membranes.
b. Most skin changes occur 4–8 weeks after the start
of radiation.
c. Skin areas with poor blood flow are at greatest risk
for injury.
d. Intertriginous areas are at particular risk for skin
reactions.
8. How should the care of a client undergoing brachytherapy
be assigned?
a. To male nurses whenever possible
b. On a rotating basis among nonpregnant nursing
staff
c. Consistently to the same nurses
d. Never to a nurse with a history of cancer
9. A client having radiation therapy asks the nurse if his
blood cells are going to be affected. Which fact
should form the basis of the nurse’s answer?
a. Bone marrow and therefore blood cells is affected
with almost all ports of radiation.
b. If radiation is delivered to the hip or leg, no effect
should occur.
c. It depends on whether or not medications are
being taken that sensitize blood cells to radiation.
d. Speed and volume of blood to tissues of the port
will determine the effect.
10. Which direction should be given to a client with a
platelet count of 45,000 mm3, a WBC count of
1250/mm3, and an RBC count of 4.8 million/mm3?
a. Cook vegetables well.
b. Use an electric razor.
c. Rest at regular intervals.
d. Increase vitamin B12 intake.
11. A client having chemotherapy for breast cancer
reports a temperature of 101.4 F. How should the
nurse interpret this fact?
a. Sign of infection, which needs to be reported right
away
b. Side effect of chemotherapy, not requiring intervention
c. Sign of infection, which needs monitoring and
reporting if it persists for 48 hours
d. Indicator of dehydration requiring client teaching
regarding fluid intake
12. A client who had a dose of chemotherapy at 8 a.m.
calls the clinic at 2:30 p.m. complaining of nausea
and vomiting despite having taken the prescribed
medication. She asks how much worse the nausea
and vomiting is going to get. On which fact should
the nurse’s answer be based?
a. Nausea and vomiting is totally unpredictable.
b. Nausea and vomiting typically peak in the first
12 hours.
c. Nausea and vomiting will ease on going to bed.
d. Vomiting should cease in about 36 hours but nausea
may persist for 7–10 days.
CHAPTER 33 Physiological Integrity 1061
13. For which type of toxicity would the nurse plan to
monitor a client who is being treated with cisplatin?
a. Neurotoxicity
b. Cardiotoxicity
c. Nephrotoxicity
d. Hepatotoxicity
14. Which class of chemotherapy drugs is most likely to
affect fertility?
a. Alkylating agents
b. Antimetabolytes
c. Cytotoxic antibiotics
d. Mitotic inhibitors
15. Which information could be correctly included in
the teaching plan for a client receiving chemotherapy?
a. Scalp hair may be lost but body hair is unaffected.
b. Hair loss usually occurs 6–8 weeks after chemotherapy
starts.
c. Regrowth usually starts 1–2 months after chemotherapy
is completed.
d. Hair regrowth can be expected to take 24–36
months.
16. Which comment about measuring pulmonary artery
wedge pressure indicates a correct understanding of
at least one aspect of the procedure?
a. The pressure-monitoring system must be calibrated
at least every 12 hours.
b. Normal mean pressure is 15 mmHg.
c. The balloon must be completely deflated after
each pressure measurement is obtained.
d. The catheter is passed through the right heart and
into the right pulmonary artery.
17. Which statement is an appropriate practice guideline
when CVP is being monitored?
a. A pressure greater than 6 mmHg must be reported
immediately.
b. A CVP of greater than 10 mmHg indicates the
need for immediate fluid.
c. Overall trend is more important than any individual
measure.
d. A CVP of 1–3 mmHg requires immediate intervention
to prevent pulmonary edema.
18. Which statement made by a client receiving radiation
therapy indicates a need for further teaching?
a. “Today is my last treatment so by next week I will
know if I am going to have any side effects from
the radiation.”
b. “I’m tired of having blood drawn but I know I
need it to check my bone marrow.”
c. “I need to check my skin for redness, especially in
the skin folds.”
d. “I’m awfully fatigued all the time but I understand
it is expected.”
19. When caring for a client with a Swan–Ganz catheter,
for which complications would the nurse monitor?
(Select all that apply.)
a. Heart failure
b. Thromboembolism
c. Hypervolemia
d. Cardiac dysrhythmia
e. Infection
20. A client who has received a biopsy report indicating
dysplasia asks the nurse if this means she has cancer.
Which is the most appropriate response?
a. “Yes, it is cancer but an early form that is usually
treatable.”
b. “It may be cancer. More tests have to be done and
you will know in about 5 days.”
c. “No, it is not cancer but the tissue is abnormal and
sometimes it becomes cancerous.”
d. “No, it is not cancer and it doesn’t turn into cancer.”
21. Which complication must the nurse be alert for when
caring for a client on intra-arterial blood pressure
monitoring?
a. Ventricular tachycardia
b. Myocardial infarct
c. Pulmonary artery rupture
d. Hemorrhage
Think Smart/Test Smart
This question is looking for a correct statement
because it asks which statement shows that
the person making it correctly understands
some aspect of the procedure. Thus, three
distractors are going to be incorrect statements
about the procedure and one is going
to be correct and will be the answer.
(continued)
1062 PART II: Content Review
22. The spouse of a client who is to have intra-arterial
blood pressure monitoring initiated, tells the nurse
he heard someone say that an Allen test would be
done and asks what it is for. Which fact should form
the basis of the nurse’s response?
a. To make sure there is collateral circulation sufficient
to keep tissue supplied with oxygenated blood.
b. To check for abnormal clotting because of the risk
of thromboembolism.
c. To check if the volume of bloodflow is sufficient to
provide an accurate measurement.
d. To determine if the artery has a diameter great
enough to allow passage of the catheter.
23. When measuring CVP, which is the reference point or
the zero point of the manometer or the transducer?
a. Fourth intercostal space at the left midclavicular
line
b. Fourth intercostal space at the left sternal border
c. Sixth intercostal space at the right sternal border
d. Sixth intercostal space at the left midclavicular line
ANSWERS FOR FILL IN THE BLANKS
Fill in the blank spaces with the correct word or phrase to complete each statement.
1. The three most basic causes of cell injury are
a. deficiency
b. intoxication/poisoning
c. trauma/physical injury
2. The five classic signs of infection are
a. redness
b. heat
c. pain
d. swelling
e. loss of function
3. The two major components of the inflammatory response are
a. vascular
b. cellular
24. A client having a Swan–Ganz catheter inserted asks
how the MD will know when it is in the right place.
What is the most accurate reply to the client’s question?
a. A chest X-ray shows the position.
b. It is inserted under fluoroscopy so it can be seen
on a television screen.
c. The pressure in the artery changes depending on
where the catheter is located.
d. The distance from the point of entry to the heart is
measured and the catheter is marked off in centimeters.
25. When preparing a client for insertion of a pulmonary
artery catheter, the nurse’s explanation of the procedure
could include information based on which fact?
a. Procedure is usually done in an operating room or
treatment room.
b. EKG is monitored continuously during insertion.
c. Insertion is basically a risk-free procedure.
d. Light, general anesthesia is used for client comfort.
ANSWERS & RATIONALES
CHAPTER 33 Physiological Integrity 1063
4. The three types of exudates are
a. serous
b. purulent/suppurative
c. hemorrhagic
5. The four components of the healing process are
a. regeneration
b. repair
c. revascularization
d. reepithelialization
6. Collagen fibers in scar tissue are very weak for 6–8 days.
7. The four most common sites of nosocomial infection are
a. urinary tract
b. respiratory tract
c. bloodstream
d. wounds
8. Cancers arising in tissues derived from mesoderm such as muscles, bones, or connective
tissue are called sarcomas.
9. The two distinct processes involved in carcinogenesis are
a. initiation
b. promotion
10. Another name for the contractile force of the heart is inotropy.
TRUE & FALSE ANSWERS
Mark each of the following statements True or False. Correct all false statements in the space
provided.
1. Calcification occurs only in necrotic tissue. False
Deposits of calcium can occur in normal tissues as a result of marked hypercalcemia.
2. Chronic inflammation progressively destroys tissue and results in loss of function and scarring.
True
3. Once regeneration occurs, function is restored to damaged organs. False
Function is restored if the stroma is undamaged; if stroma is damaged then regeneration may be
disorganized and some degree
of functional loss results.
4. If a child cuts his hand on a piece of broken glass and has eight sutures to close the wound,
healing will occur by second
intention. False
Healing is by first intention when the edges of the wound are approximated; it is second
intention when the wound is not closed
but is left to granulate in.
5. To facilitate healing of a wound across the middle knuckle of the index finger, the joint needs
to be immobilized.
True
6. Signs of systemic infection include swollen lymph nodes, fever, and elevated ESR. True
(continued)
1064 PART II: Content Review
MATCHING ANSWERS
Match the following:
1. Adhesions a. Type of nosocomial infection, which is the direct result of a diagnostic or
therapeutic procedure
2. Hypertrophy b. Angioneogenesis
3. Serous exudates c. Ability of a microorganism to produce infection
4. Dehiscence d. Enlargement of cells and organs as a result of increased demand
5. Apoptosis e. Number of cells increased through cell division in response to demand
6. Contracture f. Fluid in blisters of a mild sunburn
7. Exudate g. Microorganism that causes infection only in a susceptible person
8. Necrosis h. Tissue death
9. Granuloma i. Process by which strains of microorganisms become resident flora in an area of
the body
10. Keloid j. Tissue is disordered and cells vary in size and shape
11. Hyperplasia k. Shrinking of cells and organs as a result of decreased demand
12. Phagocytosis l. Lack of organ development
13. Revascularization m. Exaggerated contraction of maturing collagen, mostly affecting large
wounds
which results in distortion and limited mobility
14. Colonization n. Joining of serous membranes which normally move freely against each other
due to organization of inflammatory exudates. Risk is greatest with trauma to
abdominal organs, heart, and lungs
i
b
t
e
p
r
h
u
s
q
o
f
d
n
7. Total length of the cell cycle is the same for all cells; what differs is the length of time spent in
each phase. False
Total length of cell cycle varies with the type of cell ranging from 1 hour to 100 hours with the
difference a result of time spent
in G0 and G1.
8. A characteristic of a benign tumor is that it is composed of cells that resemble the tissue of
origin. True
9. Malignant tumors cause systemic symptoms such as altered taste and weight loss. True
10. The initial effect of an increase in heart rate is a decrease in cardiac output. False
The initial effect is an increase in heart rate because cardiac output equals heart rate x stroke
volume. When the heart rate
reaches 180 bpm and is sustained there is less time for the ventricle to fill with blood so the
stroke volume starts to decrease and
ultimately the cardiac output decreases even though the rate is high.
CHAPTER 33 Physiological Integrity 1065
15. Atrophy o. Breaking open of a healing wound usually a result of pressure on the wound
16. Opportunistic p. Irregular masses of scar tissue protruding from the skin that result from
pathogen overproduction of collagen
17. Iatrogenic infection q. Decreased number of cells as a result of self-destruction
18. Virulence r. Round masses of transformed macrophages surrounded by lymphocytes and
fibroblasts
19. Aplastic s. Shortening of a muscle or scar tissue causing distortion or deformity
20. Dysplasia t. Ingestion of particles by cells
u. Material that passes through vessels into adjacent tissues in inflammation
j
l
c
a
g
k
APPLICATION ANSWERS
1. Of which process is gangrene an example?
a. Coagulation necrosis
b. Liquefaction necrosis
c. Autolysis
d. Phagocytosis
Rationale
Correct answer: a.
Gangrene is an example of coagulation necrosis and is
characterized by initial appearance of a firm area with the
structure of normal tissue even though cells are dead;
subsequently, the area is broken down and cleared by
phagocytes. Gangrene is common when cells die due to
anoxia or toxic injury except in the brain.
Liquefaction necrosis is characterized by an initial liquid
area of dead cells. It is seen in death of nervous-system
cells due to anoxia and in death of cells associated with
bacterial infections.
2. Which is the primary factor that determines the time
interval that can elapse between removal of an organ
from a donor and its transplantation into a recipient?
a. Time an organ can survive ischemia
b. Ability of the organ to withstand temperature
change
c. Amount of DNA present in the organ’s cells
d. Number of organelles in the organ’s cells
Rationale
Correct answer: a.
Oxygen, which is essential to cell survival, is brought to
the tissues by the blood. Once an organ is removed from
the donor its cells no longer have a source of oxygenated
blood until it is implanted in the recipient. Different types
of cells/tissues can withstand ischemia for different
lengths of time. Hence, how long the organ can survive
until implanted depends on this ability of the cells to
withstand ischemia.
3. Which factors can initiate an inflammatory response?
(Select all that apply.)
a. Heat or cold
b. Trauma
c. Infection
d. Antigen–antibody-complex deposition
e. Complement activation
Rationale
Correct answers: a, b, c, and d.
Inflammation is a nonspecific response that occurs when
there is damage to skin or mucous membranes, which serve
as the body’s first line of defense against infection. Anything
that can damage these tissues can cause inflammation.
Thus, factors such as prolonged exposure to the sun, surgery,
exposure to irritating chemicals, and accidental cuts
and scrapes are all initiators of the inflammatory response.
The inflammatory response is nonspecific because it occurs
as a result of many different kinds of damage and is the
same regardless of the specific initiating factor.
(continued)
1066 PART II: Content Review
4. What type of diet should be encouraged for a client
having radiation through an abdominal port who complains
of nausea and vomiting? (Select all that apply.)
a. High-protein
b. High-carbohydrate
c. High-fat
d. High-residue
e. High-calorie
f. Low-protein
g. Low-calorie
h. Low-carbohydrate
i. Low-residue
j. Low-fat
Rationale
Correct answers: a, b, and e.
Clients having radiation therapy need a high-protein,
high-carbohydrate, and high-calorie diet. Radiation
causes tissue damage so extra protein is needed for tissue
repair. Carbohydrates and calories are needed to provide
the energy for tissue repair and to combat the fatigue
associated with radiation therapy. Fat is high in calories
but is harder to digest; neither a low-fat nor a high-fat diet
is recommended. Amount of residue is unrelated.
5. When caring for a client having radiation therapy the
nurse receives a report that the client’s laboratory values
are normal and there are no signs of anemia,
infection, or bleeding. Which conclusion should the
nurse draw from this information?
a. Radiation has not yet reached a therapeutic level.
b. The client is free of side effects of radiation.
c. Nutritional status is normal.
d. Bone-marrow suppression is not a problem.
Rationale
Correct answer: d.
Some effect on bone marrow occurs with almost all radiation
therapy regardless of port. Bone-marrow suppression
becomes a significant problem when RBC and WBC
counts and platelet count drop below critical levels. This
drop is seen in laboratory values and can result in the
development of anemia, infection, or bleeding. Therefore,
normal laboratory values and the absence of signs/symptoms
of anemia, infection, and bleeding indicate that
bone-marrow suppression is not a problem at this time.
6. The father of a 9-month-old boy just diagnosed with
a primary immune deficiency says to the nurse “I
don’t understand it. Why did my son seem healthy
until he was 6-months old and then start getting all
these infections?” On which fact should the nurse’s
response be based?
a. Under 6 months of age, most babies do not show
signs of active infection.
b. It takes about 6 months for babies to be exposed
to enough pathogens for infection to readily
occur.
c. Until about 6 months, babies are protected from
infection by immunity from their mothers.
d. Before 6 months, babies are only susceptible to
bacterial infections.
Rationale
Correct answer: c.
In utero, fetuses are protected against infection by passive
immunity received from the mother via the placenta. This
passive protection against pathogens that the mother has
immunity to lasts for approximately 6 months at which
time the infant becomes dependent on his or her own
immune system for protection against infection. Therefore,
it is not until the passive immunity has “worn off” that
immunodeficiency in the infant manifests itself in chronic
or recurrent infections. Infants develop signs of infection.
Infection can occur at any time; it can even be present at
birth. The cause of infection can be any type of microorganism.
7. When assessing skin of a client having external radiation
therapy, which fact should the nurse keep in
mind?
a. Skin damage is preceded by changes in oral
mucous membranes.
b. Most skin changes occur 4–8 weeks after the start
of radiation.
c. Skin areas with poor blood flow are at greatest risk
for injury.
d. Intertriginous areas are at particular risk for skin
reactions.
Rationale
Correct answer: d.
Skin fold areas are at particular risk for developing a reaction
to radiation therapy.
It is important to keep these areas clean, dry, and free of
irritation to help decrease the risk. Changes in oral
mucous membranes do not always occur with radiation
therapy; it depends on the port. This is different from
chemotherapy, which is administered systemically. Acute
skin reactions consist of erythema which increases over
2–3 weeks and then either fades or progresses to dry or
moist desquamation.
Areas of poor bloodflow are less well-oxygenated and
hypoxic tissues are resistant to radiation not at greater
risk for injury.
CHAPTER 33 Physiological Integrity 1067
8. How should the care of a client undergoing brachytherapy
be assigned?
a. To male nurses whenever possible
b. On a rotating basis among nonpregnant nursing
staff
c. Consistently to the same nurses
d. Never to a nurse with a history of cancer
Rationale
Correct answer: b.
To limit exposure to specific individuals, care of clients
undergoing brachytherapy should be rotated among staff
members with the exception of those who are pregnant
because of the risk of damage to the developing fetus.
Male gender or cancer history are not considered influencing
factors. Assigning the same nurses would support
consistency and efficiency of care but these benefits do
not outweigh the risk of exposure.
9. A client having radiation therapy asks the nurse if his
blood cells are going to be affected. Which fact
should form the basis of the nurse’s answer?
a. Bone marrow and therefore blood cells are affected
with almost all ports of radiation.
b. If radiation is delivered to the hip or leg, no effect
should occur.
c. It depends on whether or not medications are
being taken that sensitize blood cells to radiation.
d. Speed and volume of blood to tissues of the port
will determine the effect.
Rationale
Correct answer: a.
Radiation therapy exerts its greatest effect on well-oxygenated,
actively dividing cells. As a result, bone-marrow
cells are almost always affected. The hip and long bones of
the leg contain large amounts of bone marrow so effects on
the blood from radiation to these areas do occur. The effect
on the blood occurs because the active cells in the bone
marrow are affected, not because of any sensitizing drug.
10. Which direction should be given to a client with a
platelet count of 45,000 mm3, a WBC count of
1250/mm3, and an RBC count of 4.8 million/mm3?
a. Cook vegetables well.
b. Use an electric razor.
c. Rest at regular intervals.
d. Increase vitamin B12 intake.
Rationale
Correct answer: b.
A platelet count of 45,000 mm3 is significantly below the
normal of 150,000–400,000/mm3 and so the client is at risk
for bleeding. A basic bleeding precaution is to use an electric
razor to avoid cutting the skin. The WBC and RBC
counts are within normal range so do not require precautions.
Cooking vegetables well is a direction given to neutropenic
clients. Rest at regular intervals is needed by clients
with anemia and other sources of fatigue. Increased vitamin
B12 intake is needed by clients with pernicious anemia.
11. A client having chemotherapy for breast cancer
reports a temperature of 101.4 F. How should the
nurse interpret this fact?
a. Sign of infection, which needs to be reported right
away
b. Side effect of chemotherapy, not requiring intervention
c. Sign of infection, which needs monitoring and
reporting if it persists for 48 hours
d. Indicator of dehydration requiring client teaching
regarding fluid intake
Rationale
Correct answer: a.
Any temperature over 101 F is considered a sign of infection
and needs to be reported right away. Clients having
radiation therapy are immunosuppressed because of the
effect of the radiation on the bone marrow and so infection
poses a particular risk for this population.
12. A client who had a dose of chemotherapy at 8 a.m.
calls the clinic at 2:30 p.m. complaining of nausea
and vomiting despite having taken the prescribed
medication. She asks how much worse the nausea
and vomiting is going to get. On which fact should
the nurse’s answer be based?
a. Nausea and vomiting is totally unpredictable.
b. Nausea and vomiting typically peak in the first 12
hours.
c. Nausea and vomiting will ease on going to bed.
d. Vomiting should cease in about 36 hours but nausea
may persist for 7–10 days.
Rationale
Correct answer: b.
Nausea and vomiting typically peak in the first 12 hours
so in this case the nausea and vomiting should begin to
subside after 8 p.m. The degree of nausea and vomiting
can vary from person to person and with different types
of chemotherapy but broad patterns are evident; it is not
totally unpredictable. Going to bed does not ease nausea
and vomiting and its absolute duration is not known.
13. For which type of toxicity would the nurse plan to
monitor a client who is being treated with cisplatin?
a. Neurotoxicity
b. Cardiotoxicity
c. Nephrotoxicity
d. Hepatotoxicity
(continued)
1068 PART II: Content Review
Rationale
Correct answer: c.
Cisplatin is associated with nephrotoxicity and as a result,
the nurse must monitor for signs of renal tubule damage.
Intake and output must be monitored. The client must be
well-hydrated before administration of cisplatin and
encouraged to maintain a fluid intake of 2–3 l daily for
the duration of therapy. Cisplatin can also cause ototoxicity
(deafness) and should be monitored for tinnitus.
14. Which class of chemotherapy drugs is most likely to
affect fertility?
a. Alkylating agents
b. Antimetabolytes
c. Cytotoxic antibiotics
d. Mitotic inhibitors
Rationale
Correct answer: a.
Alkylating agents are the type of chemotherapeutic agents
that most commonly affect the ovaries and testes resulting
in changes in fertility. Amenorrhea is common in young
females and induced menopause common in older
females. Decreased sperm production as well as sperm
and semen abnormalities occur in men. In some cases, fertility
returns after treatment but this varies with the age of
the client and the specific drug and dose of drug received.
15. Which information could be correctly included in the
teaching plan for a client receiving chemotherapy?
a. Scalp hair may be lost but body hair is unaffected.
b. Hair loss usually occurs 6–8 weeks after
chemotherapy starts.
c. Regrowth usually starts 1–2 months after
chemotherapy is completed.
d. Hair regrowth can be expected to take 24–36
months.
Rationale
Correct answer: c.
Regrowth of hair usually starts 1–2 months after
chemotherapy is completed. Both scalp and body hair
may be lost and loss usually starts 2–3 weeks after treatment
starts. Regrowth takes about a year.
16. Which comment about measuring pulmonary artery
wedge pressure indicates a correct understanding of
at least one aspect of the procedure?
a. The pressure-monitoring system must be calibrated
at least every 12 hours.
b. Normal mean pressure is 15 mmHg.
c. The balloon must be completely deflated after
each pressure measurement is obtained.
d. The catheter is passed through the right heart and
into the right pulmonary artery.
Rationale
Correct answer: c.
The balloon must be completely deflated after each
pressure measurement is obtained. This is correct. The
other statements are incorrect because calibration
should be checked before each reading; normal mean
pressure is 10 mmHg not 15; and the catheter passes
through the left ventricle into the left pulmonary artery
because it provides a measure of left ventricle end diastolic
pressure, which is increased in left ventricular failure
and pericardial tamponade and decreased in hypovolemia.
17. Which statement is an appropriate practice guideline
when CVP is being monitored?
a. A pressure greater than 6 mmHg must be reported
immediately.
b. A CVP of greater than 10 mmHg indicates the
need for immediate fluid.
c. Overall trend is more important than any individual
measure.
d. A CVP of 1–3 mmHg requires immediate intervention
to prevent pulmonary edema.
Rationale
Correct answer: c.
Trend in CVP change is more significant than any individual
measurement. Normal range of CVP is 0–8 mmHg
or 5–10 cm H2O depending on equipment used; so, a
pressure of 6 mmHg is within normal range and would
not need to be reported immediately. A CVP 10 mmHg is
the upper limit of normal and does not indicate need for
immediate fluid; elevated CVP is associated with hypervolemia
not hypovolemia. Risk of pulmonary edema is
indicated by an elevated CVP.
Think Smart/Test Smart
This question is looking for a correct statement
because it asks which statement shows that
the person making it correctly understands
some aspect of the procedure. Thus, three
distractors are going to be incorrect statements
about the procedure and one is going
to be correct and will be the answer.
CHAPTER 33 Physiological Integrity 1069
18. Which statement made by a client receiving radiation
therapy indicates a need for further teaching?
a. “Today is my last treatment so by next week I will
know if I am going to have any side effects from
the radiation.”
b. “I’m tired of having blood drawn but I know I
need it to check my bone marrow.”
c. “I need to check my skin for redness, especially in
the skin folds.”
d. “I’m awfully fatigued all the time but I understand
it is expected.”
Rationale
Correct answer: a.
There are late as well as immediate effects of radiation
therapy. Late effects are due to blood vessel or connective
tissue damage and occur months or years after therapy.
Examples of late effects include skin atrophy, fibrosis or
ulceration, pulmonary fibrosis, and cataracts.
19. When caring for a client with a Swan–Ganz catheter,
for which complications would the nurse monitor?
(Select all that apply.)
a. Heart failure
b. Thromboembolism
c. Hypervolemia
d. Cardiac dysrhythmia
e. Infection
Rationale
Correct answers: b, d, and e.
Thromboembolism, cardiac dysrhythmia, and infection
are risks associated with a Swan–Ganz catheter.
Thromboembolism is a risk because the catheter is a foreign
object in the circulatory system that interferes with
bloodflow. Cardiac dysrhythmia is a risk because the
catheter is threaded through the heart. Infection is a risk
because the catheter enters through the skin and thus
provides a potential source of entry for bacteria into normally
sterile areas of the body.
20. A client who has received a biopsy report indicating
dysplasia asks the nurse if this means she has cancer.
Which is the most appropriate response?
a. “Yes, it is cancer but an early form that is usually
treatable.”
b. “It may be cancer. More tests have to be done and
you will know in about 5 days.”
c. “No, it is not cancer but the tissue is abnormal and
sometimes it becomes cancerous.”
d. “No, it is not cancer and it doesn’t turn into cancer.”
Rationale
Correct answer: c.
Dysplastic tissue is characterized by disorder and cells
that vary in size and shape. It results from severe and prolonged
irritation and often precedes neoplasia. Some
forms are known as precancerous lesions.
21. Which complication must the nurse be alert for when
caring for a client on intra-arterial blood pressure
monitoring?
a. Ventricular tachycardia
b. Myocardial infarct
c. Pulmonary artery rupture
d. Hemorrhage
Rationale
Correct answer: d.
Hemorrhage is a potential complication because the
catheter is inserted directly into a pulsating artery. Other
complications are infection, air embolism, and throboembolism.
The arterial line called an art line or A line does
not pass through the heart so dysrhythmias are not a
major risk nor do they enter or affect the pulmonary
artery so pulmonary artery rupture is not a concern.
Occurrence of MI is unrelated.
22. The spouse of a client who is to have intra-arterial
blood pressure monitoring initiated, tells the nurse
he heard someone say that an Allen test would be
done and asks what it is for. Which fact should form
the basis of the nurse’s response?
a. To make sure there is collateral circulation sufficient
to keep tissue supplied with oxygenated
blood.
b. To check for abnormal clotting because of the risk
of thromboembolism.
c. To check if the volume of bloodflow is sufficient to
provide an accurate measurement.
d. To determine if the artery has a diameter great
enough to allow passage of the catheter.
Rationale
Correct answer: a.
An Allen test is done to ascertain that inserting a catheter
into one of the large arteries of an extremity will not result
in a decrease in oxygenated blood to the part such that
tissue damage occurs. When performing the Allen test on
an upper extremity, both the radial and ulna arteries are
compressed until the pulses are obliterated while the
client is making a fist. The client is then asked to open the
fist and pressure is released on one of the arteries and the
palm is observed for flushing. This procedure is then
repeated for the other artery.
(continued)
1070 PART II: Content Review
23. When measuring CVP, which is the reference point or
the zero point of the manometer or the transducer?
a. Fourth intercostal space at the left midclavicular
line
b. Fourth intercostal space at the left sternal border
c. Sixth intercostal space at the right sternal border
d. Sixth intercostal space at the left midclavicular
line
Rationale
Correct answer: a.
The reference level for the transducer is the right atrium,
whose filling pressure is measured by CVP. The right
atrium is located below the fourth intercostal space at the
left midclavicular line.
24. A client having a Swan–Ganz catheter inserted asks
how the MD will know when it is in the right place.
What is the most accurate reply to the client’s question?
a. A chest X-ray shows the position.
b. It is inserted under fluoroscopy so it can be seen
on a television screen.
c. The pressure in the artery changes depending on
where the catheter is located.
d. The distance from the point of entry to the heart is
measured and the catheter is marked off in centimeters.
Rationale
Correct answer: a.
A chest X-ray is done to confirm the position of a Swan–
Ganz catheter once it is inserted. It is inserted usually as a
bedside procedure; it is not done under fluoroscopy.
Pressure in the arterial system does change in different
locations but this is not how placement is confirmed nor
is it confirmed by the length of catheter inserted. No IV
fluid is run into a central line until placement is confirmed
by X-ray.
25. When preparing a client for insertion of a pulmonary
artery catheter, the nurse’s explanation of the procedure
could include information based on which fact?
a. Procedure is usually done in an operating room or
treatment room.
b. EKG is monitored continuously during insertion.
c. Insertion is basically a risk-free procedure.
d. Light, general anesthesia is used for client comfort.
Rationale
Correct answer: b.
EKG is monitored continuously due to the risk of the
catheter triggering a dysrhythmia as it passes through the
right ventricle. The procedure is typically done at the
bedside and general anesthesia is not needed. However,
the procedure is not without risk. Air embolism, thromboembolism,
pulmonary artery rupture or infarct, dysrhythmia,
and infection can all occur.
Part III
TAKING
THE TEST
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1073
Practice Test for
NCLEX-RN®
CHAPTER 34
HEALTH PROMOTION AND
MAINTENANCE
Human Sexuality
Counsel client/family/significant others on sexuality issues
1. A client who has experienced a myocardial infarction
is being discharged from the hospital. The client questions
when he can resume sexual activity with his
spouse. The nurse’s best response is:
A. sex is no longer possible after your surgery.
B. you must avoid foreplay but sex is acceptable as
long as it is of a short duration.
C. sex can be resumed when you can climb stairs
without becoming short of breath.
D. masturbation is the only allowable form of sexual
expression after the surgery.
The answer is C. Sex can be resumed when the client can climb
two flights of stairs without becoming short of breath or the
client can walk more than 2 miles without shortness of breath.
A is incorrect—Sex is possible after a myocardial infarction.
B is incorrect—Foreplay is encouraged to slowly
prepare the body for the changes in heart rate and respiratory
rate that accompany sex. D is incorrect—Masturbation
is acceptable after a myocardial infarction but it is not the
only form of sexual expression allowed.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Disaster Planning
Identify nursing roles in disaster planning
2. What is the most important nursing role in disaster
planning?
A. Knowing the policy for disasters in the facility.
B. Maintaining contact with community resources.
C. Making a list of the most frequent contacts in the
hospital.
D. Attending meetings that discuss the potential for
disasters in the community.
The answer is A. Knowing the policy for disasters in the facility
is the most important role for the nurse. This allows the
nurse to function within the policies of the hospital, which
aids in maintaining patient and staff safety.
B is incorrect—Maintaining contact with community
resources will benefit the nurse in a disaster situation, but is
not the most important role. C is incorrect—Making a list of
frequent contacts is helpful but not the most important nursing
role. D is incorrect—Attending meetings on the disasters
that can occur in the community will not prepare the nurse
for how to handle the disaster in the facility.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Medical and Surgical Asepsis
Evaluate whether aseptic technique is performed correctly
3. A nurse is working with a physician on the insertion of
a central line. What action performed by the physician
requires the nurse to stop the procedure due to a
breach in asepsis?
A. The kit is opened toward the physician last.
B. The physician drops his or her gloved hands below
the level of the chest.
C. The physician touches two sterile hands together.
D. The physician turns his or her back to the sterile field.
The answer is D. A person who is working in a sterile field
should not turn his or her back to the sterile field or it is considered
contaminated.
A is incorrect—A sterile kit is opened toward the outside
first and toward the individual last to avoid contamination
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1074 PART III: Taking the Test
of the sterile contents. B is incorrect—The sterile field is
from the chest to below the level of the sterile field. C is
incorrect—A person wearing sterile gloves is allowed to
touch two sterile gloved hands together without causing
contamination to the field.
HEALTH PROMOTION AND
MAINTENANCE
Developmental Stages and Transitions
Identify expected physical, cognitive, psychosocial, and
moral stages of development
4. Which verbal complaint during the assessment of a
55-year-old female client is considered abnormal and
requires further investigation?
A. Absence of menstrual cycle
B. Thinning of hair
C. Periods of sweating and feeling warm
D. Lumps in axilla area
The answer is D. Lumps in the axilla area could be lymph
nodes, which could be a sign of cancer and needs further
attention.
A is incorrect—The loss of menses is normal at the age
of 55. B is incorrect—The thinning of hair is secondary to a
drop in estrogen levels and is considered normal in the 55year-old woman. C is incorrect—Periods of sweating and
feeling warm are a response to the body’s hormonal changes.
PSYCHOSOCIAL INTEGRITY
Coping Mechanisms
Assess client response to illness (rationalization, hopefulness,
anger)
5. A client receives a diagnosis of cancer after a biopsy of
a suspicious lymph node. The client states, “You must
have made a mistake, I want a second opinion.” Which
stage of grief is the client experiencing?
A. Denial
B. Anger
C. Bargaining
D. Despair
The answer is A. The client is denying that the diagnosis is
correct and desires a second opinion. This is a normal
response and the client should be allowed to work through
it with support from staff.
B is incorrect—The client is not yet angry but may
encounter this response as time progresses. The client who is
angry will blame others or himself as to why the health crisis
occurred. C is incorrect—The client will begin to bargain with
God or others whom he or she feels holds the key to healing.
D is incorrect—The client will exhibit signs of depression in
despair and will become disorganized with daily activities.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Elimination
Perform irrigations
6. A nurse is performing continuous bladder irrigation at
1 L/h. Which assessment is the priority?
A. The amount of fluid being returned.
B. The size of the indwelling catheter.
C. The client’s knowledge level of the procedure.
D. The percentage of formalin ordered for irrigation.
The answer is A. The amount of fluid being returned is priority
since a decrease in output without a decrease in the input
may indicate clot formation or catheter malfunction and
needs to be addressed immediately.
B is incorrect—The size of the catheter is important but
not priority in bladder irrigation. C is incorrect—The client
should have his knowledge level assessed prior to the beginning
of the procedure. D is incorrect—Formalin is used in
the operating room under anesthesia due to the pain it
causes and the need to prevent ureteral reflux.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Standard/Transmission-Based/Other Precautions
Educate client/family/staff on infection control measures
7. A nurse is discharging a client who has been undergoing
chemotherapy. When discussing at home care, the
priority instruction should be to:
A. avoid public places.
B. include fresh fruits and vegetables in your diet.
C. limit visitors in the home.
D. wash your hands often.
The answer is D. Hand washing is the number one method of
preventing infection and should be taught to all clients who
are immunosuppressed.
A is incorrect—While avoiding public places is important
and should be taught, it is not the priority teaching. B is
incorrect—While fresh fruits and vegetables will aid in
including vitamin C and other essential nutrients in the diet,
this is not the priority. C is incorrect—Limiting visitors is
important but not the priority.
CHAPTER 34 Practice Test for NCLEX-RN® 1075
HEALTH PROMOTION AND
MAINTENANCE
Self-Care
Assess and intervene in client performance of instrumental
activities of daily living
8. When planning the care of a client with rheumatoid
arthritis, which plan would be best to assist with activities
of daily living?
A. Teach the client methods of energy conservation.
B. Provide the client with a shower chair.
C. Encourage family members to take over challenging
activities.
D. Provide the client with large handled instruments
for eating.
The answer is A. The client should learn which activities are
the most tiresome and limit the activities to conserve energy.
The client with rheumatoid arthritis needs rest to limit
increased inflammation in joints.
B is incorrect—The client can benefit with a shower
chair but it is not the best plan to assist with activities of daily
living. C is incorrect—The client needs to be able to perform
the activities of daily living and delegate the activities that he
or she is unable to perform. The nurse should not encourage
family members to take over these activities. D is incorrect—
The client does need instruments for eating but it is not the
best plan to assist with activities of daily living.
PSYCHOSOCIAL INTEGRITY
Sensory/Perceptual Alterations
Evaluate client with altered ability to communicate effectively
and intervene to promote successful adaptation
9. A client has undergone a total laryngectomy due to
cancer. The nurse should plan on assisting the client
with communicating by:
A. providing an interpreter.
B. providing a sheet explaining sign language.
C. providing a tablet and pencil.
D. talking to the client’s face, accentuating words
through lip movement.
The answer is C. The client should be given a tablet and pencil
for communication postop.
A is incorrect—An interpreter is not needed unless the
client does not speak English. B is incorrect—The client
should be allowed to communicate through the written
word unless he requests a sheet about sign language. D is
incorrect—The client should not be expected to read lips to
communicate with the nurse due to the possibility of miscommunication.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Potential for Complications of Diagnostic
Tests/Treatments/Procedures
Apply knowledge of nursing procedures and psychomotor
skills when caring for a client with potential for complications
10. A client is 24 hours postop from gastric bypass surgery.
Which of the following nursing actions is best in preventing
thrombus formation?
A. The application of sequential compression devices.
B. Ambulating the client.
C. Administering salicylate (Aspirin).
D. Massaging of lower extremities.
The answer is B. The best method of preventing thrombus
formation is ambulation. This will prevent a deep vein
thrombosis as well as a pulmonary embolism.
A is incorrect—Sequential compression devices are beneficial
in preventing thrombus formation but the best
method is ambulation. C is incorrect—Aspirin is known for
decreasing platelet aggregation and reduction in inflammation.
It is not the best method of prevention of thrombus formation.
D is incorrect—Massaging extremities is not appropriate
in the postop client. Massaging of extremities may
dislodge clots that have formed.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Monitoring Conscious Sedation
Assist with preparing client for conscious sedation
11. Prior to administering conscious sedation the nurse
must first:
A. verify informed consent.
B. perform ABGs.
C. assess vital signs.
D. place high-flow oxygen on the client.
The answer is A. Prior to initiating conscious sedation, the
nurse must ensure informed consent has been obtained and
is on the chart.
B is incorrect—ABGs are not performed on a client
before conscious sedation. C is incorrect—Vital signs are
taken prior to medication administration but the first action
is to verify consent has been obtained. D is incorrect—The
client is not routinely placed on high-flow oxygen prior to
conscious sedation. The client has a loss of protective reflexes
but will breathe and the assessment of the client’s oxygen saturation
should occur.
1076 PART III: Taking the Test
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-Specific Assessment
Perform focused assessment or reassessment
12. A client presents to the ED complaining of acute low
back pain, which is unrelieved with over the counter
pain medications. The client is pacing the room,
diaphoretic and grimacing. Which assessment data is
most indicative of renal calculi?
A. Hematuria
B. Hypertension
C. Vomiting
D. Groin pain
The answer is A. A client with renal calculi will have hematuria
or numerous red blood cells in the urine upon examination.
B is incorrect—Hypertension is not an indicative sign of
renal calculi. Hypertension is common in a client who is experiencing
severe pain. C is incorrect—While the client with
renal calculi may experience vomiting, this is a side effect of
the pain and not an indicative sign. D is incorrect—Some
clients experience pain in the groin with renal calculi while
some only experience unilateral flank pain making this not an
indicative sign.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Vital Signs
Apply knowledge needed to perform related nursing procedures
and psychomotor skills when assessing vital
signs
13. The nurse will plan to avoid performing which nursing
actions on the left arm of a client with an arteriovenous
fistula?
A. Blood pressure monitoring
B. Oxygen saturation monitoring
C. Blood glucose monitoring
D. Assessment of capillary refill
The answer is A. A client with a arteriovenous fistula for
hemodialysis should not have a blood pressure taken in
that area to prevent damage and thrombosis formation
inside the fistula.
B is incorrect—Oxygen saturation monitoring is acceptable
in the site where a fistula is placed. C is incorrect—
Blood glucose monitoring is appropriate in the affected arm
as long as dialysis is not in progress. D is incorrect—
Assessment of capillary refill is possible and safe for the
client with an arteriovenous fistula.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Hemodynamics
Identify cardiac rhythm strip abnormalities
14. What is the most appropriate action for a rapidly occurring
wide QRS complex with no discernable p-waves?
A. Shock the client with 200 J
B. Perform chest compressions
C. Administer oxygen
D. Take a manual blood pressure
The answer is C. The client has a rhythm known as ventricular
tachycardia and needs to have oxygen applied to meet the
standards of ABC.
A is incorrect—The client will not require a shock of the
rhythm. B is incorrect—Chest compressions should not be initiated
until it is determined if a pulse is present. D is incorrect—
A blood pressure is measured after a pulse is obtained.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Hemodynamics
Identify cardiac rhythm strip abnormalities
15. The nurse is assessing his or her patients at the beginning
of the shift. One of the client’s exhibits a rhythm
that displays p waves occurring regularly, a p–r interval
of 0.20 and a QRS complex for every p wave measuring
0.12 with a rate of 70 and the t wave is
upright. The nurse would document this rhythm as:
A. normal sinus rhythm
B. sinus bradycardia
C. first-degree AV block
D. second-degree AV block type I
The answer is A. The rhythm is regular since the rate is regular
with a p–r interval and QRS complex measures within
normal limits and the rate is above 60 and below 100.
B is incorrect—The rhythm is not below 60 beats per
minute. . C is incorrect—The p–r interval is not elongated making
this a normal sinus rhythm. D is incorrect—The relationship
between the p wave and the QRS is consistently occurring.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
Perform emergency care procedures
16. When responding to a code in the hospital, the nurse
finds a client who is being bagged with high flow
oxygen by a fellow nurse. The client is pulseless and
CHAPTER 34 Practice Test for NCLEX-RN® 1077
CPR was begun less than 1 minute ago; there is no
doctor on scene. Which action is next?
A. Reassess for a pulse
B. Attach the echocardiogram electrodes to the client
C. Begin a fluid bolus of normal saline
D. Ask another nurse for a history of the client
The answer is B. If CPR is in progress, the staff that arrives on
scene should attach the electrodes to the client to prevent
interruption of CPR.
A is incorrect—Reassessment for a pulse occurs after
two full minutes of CPR. C is incorrect—Normal saline
boluses must be ordered by the physician in the event the
client has a history of heart failure. D is incorrect—A history
regarding the client can occur after the electrodes are
attached and the physician takes over the code.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
Provide postoperative care
17. A client is in the recovery room following a carotid
endarterectomy. Place the following assessments in priority
order
___ neurological status
___ signs of hemorrhage
___ intracranial pressure
___ blood pressure
The nurse’s first priority is to assess the area for signs of hemorrhaging.
This is most important since hemorrhage indicates
that the brain is not receiving much needed oxygen and a
stroke could occur as a result. Blood loss will affect the blood
pressure and could cause the client to rapidly deteriorate.
The second priority is the client’s blood pressure. This is
important since fluctuations are common during the first 24
hours postprocedure. The blood pressure should be monitored
for hypertensive emergencies and hypotension, which
will lead to poor perfusion of vital organs. The client’s neurological
status is the third assessment to monitor for changes
consistent with a stroke. The last assessment is the intracranial
pressure. The first three assessments will help identify if
there is an increase in the intracranial pressure.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Error Prevention
Ensure proper identification of client when providing care
18. Which of the following is the best method of identifying
an infant before providing care?
A. Verify the information on the armband with the chart.
B. Ask the mom if the armband information is correct.
C. Ask the client if the information on the armband is
correct.
D. Ask the previous nurse the client’s name and date of
birth.
The answer is B. Verifying the information on the armband
with the mom will ensure that the correct armband was
placed on the correct client before treatment is rendered.
A is incorrect—While verifying the chart against the
band does demonstrate that the order for the client matches
the client’s armband, it does not ensure that the correct client
is wearing the correct armband. Not verifying the information
with a family member could still lead to a treatment
error. C is incorrect—An infant will not be able to speak and
so this is not an appropriate method. D is incorrect—Each
nurse providing care should verify the correct client each
time that care is provided during a shift.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Ethical Practices
Intervene to promote ethical practice
19. A client returns from surgery with a diagnosis of cancer.
The physician informs the staff to avoid telling
the client the diagnosis. Upon awakening the client
asks if he has cancer. Which response by the nurse is
best?
A. I will call the physician and have him speak with
you.
B. I do not know the results of the test.
C. You need to ask your family if they know the results.
D. The surgeon found what he feels is cancer; he will
speak with you later.
The answer is A. Calling the physician is the best answer to
this ethical dilemma. The physician is responsible for informing
the client of the diagnosis; questions will be asked that
the nurse may not be able to answer. By calling the physician,
the nurse is not compromising fidelity and/or veracity.
B is incorrect—This is a violation of veracity, which is
the principle that a nurse will not knowingly lie to a client.
C is incorrect—The family is not responsible for informing a
client of the results of a surgery performed. Informing a family
member may fall into a HIPPA violation if the client does
not want the family to know the results. D is incorrect—
Informing the client of the diagnosis is a violation of fidelity.
Fidelity is when a health care provider must maintain a professional
loyalty to those in the profession, which in this case
is the physician.
1078 PART III: Taking the Test
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Advocacy
Act as a client advocate
20. A client presents to the emergency department complaining
of pain. The physician refuses to prescribe narcotic
pain medication after stating the client is drug seeking.
Which action by the nurse would be most appropriate?
A. Report the physician to nursing administration for
unethical behavior.
B. Ask the physician why he or she believes the client
is drug seeking.
C. Discuss with the physician the client’s chief complaint
and ask if another type of pain reliever can be
ordered.
D. Go to the charge nurse, tell her of the physician’s
actions and ask if another physician can assess the
client.
The answer is C. The nurse is responsible for acting as a client
advocate. If the nurse feels that the physician is not addressing
the client’s pain due to a fear of narcotic addiction, the
nurse is responsible for discussing alternative methods of
pain relief with the physician.
A is incorrect—It does not address the needs of
the client. B is incorrect—It only questions the physician
and does not allow for a solution to the client’s needs. D is
incorrect—It does not address the issue that is with the
physician and is not cost-effective to have another physician
see the client.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Confidentiality/Information Security
Maintain client confidentiality/privacy
21. You are working in an intensive care unit when an
individual approaches you to ask about the unresponsive
client in the bed you are assigned to. Before
giving out information regarding the client you
should first:
A. verify that the individual is a family member by asking
for the name of the client.
B. ask the individual about his or her relationship to
the client.
C. ask the individual what is the personal identification
number for the client.
D. ask to see a driver’s license and compare it to the
information listed on the chart as the next of kin.
The answer is C. According to HIPPA laws, a person requesting
information on a client must present the personal identification
number before information can be distributed. In
this case, the client is unresponsive; therefore, the nurse
must ensure that a HIPPA violation does not occur.
A is incorrect—Knowing the name of the individual
does not authorize information to be distributed. B is incorrect—
Regardless of the relationship of the individual to the
client, information cannot be distributed without the PIN. D
is incorrect—It does not follow the policy for identification
and distribution of medical information.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Referrals
Assess the need to refer clients for assistance with actual
or potential problems
22. While developing the clinical pathway of four clients,
which client will need a referral to speech therapy
based on the nurse’s assessment?
A. A client who experienced a fractured hip.
B. A client who underwent a laryngectomy.
C. A client who underwent a cholecystectomy.
D. A client who was admitted for congestive heart failure.
The answer is B. A client who underwent a laryngectomy
may require therapy to regain voice function or consume
food.
A is incorrect—A client with a fractured hip will not
require speech therapy. C is incorrect—A client who underwent
a cholecystectomy will not require speech therapy. D is
incorrect—A client with congestive heart failure will not
require speech therapy.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Safe Use of Equipment
Remove malfunctioning equipment from client care area
and report the problem to appropriate personnel
23. While performing a morning check on the crash cart
and defibrillator, the nurse notices the defibrillator
does not charge and discharge as expected. Which
action by the nurse is most appropriate?
A. Place a repair tag on the equipment for biomedical
services to pick up.
B. Notify the charge nurse and page biomedical services
to check the equipment.
CHAPTER 34 Practice Test for NCLEX-RN® 1079
C. Notify the house supervisor and request a temporary
cart and defibrillator.
D. Ask the nursing assistant to take the cart to the
biomedical department and ask for an immediate
repair.
The answer is C. If a defibrillator is found to be nonfunctioning,
then the nursing supervisor needs to replace the equipment
immediately to cover the area in the event a code occurs.
A is incorrect—Placing a tag on the equipment does not
resolve the problem, which leaves the clients on the floor
vulnerable if cardiac arrest occurs. B is incorrect—Paging
biomedical services is not a resolution to the need for a new
defibrillator. D is incorrect—Although asking for an immediate
repair is possible, it may not be repaired. The need to
replace the defibrillator is immediate and a replacement is
needed while repairs are being completed.
HEALTH PROMOTION AND
MAINTENANCE
Health Screening
Perform targeted screening exams
24. A school nurse should schedule which type of screening
exam for all 12-year-olds enrolled in the school?
A. Scoliosis
B. Diabetes
C. Hypertension
D. Hearing
The answer is A. Scoliosis screening occurs when a child
reaches the age of puberty and should be conducted in the
school setting with referrals made as needed.
B is incorrect—Diabetes is not a screening exam that
needs to be performed in the school setting. C is incorrect—
Hypertension screenings are not needed in the school setting.
D is incorrect—Hearing exams are performed before school
and if a child complains of difficulty hearing in class.
PSYCHOSOCIAL INTEGRITY
End-of-Life Care
Assist client/family/significant others in resolution of
end-of-life issues
25. During the initial meeting with a client who has been
referred for palliative care for a terminal illness, what is
the primary nursing goal?
A. To determine the client’s religious preference.
B. To determine the client’s goals for the care to be
provided.
C. To form a trusting relationship with the client.
D. To form a list of support systems that the client can use.
The answer is C. The primary goal of the nurse during the
first encounter with a client who is in need of palliative care
is to form a trusting relationship. The trusting relationship is
the bridge to begin planning care that will focus on the level
of care he or she desires and to ensure that the end of life is
met with the client having a sense of control.
A is incorrect—The client’s religious preference is
important but is not the goal of the initial meeting. B is
incorrect—The nurse will determine the client’s goals for
care after a trusting relationship has been formed with the
client. D is incorrect—A list of support systems for the client
will be formed after an analysis is performed of the client’s
goals, current financial situation, family members, physical
abilities, religious preferences, and psychosocial status.
PSYCHOSOCIAL INTEGRITY
Unexpected Body Image Changes
Assess client/family/significant other’s reactions to a
change in body image
26. Which statement made by a client indicates that
acceptance of a new colostomy has not occurred?
A. “My husband will never want to be intimate with
me again.”
B. “I will experiment with various pouches to see
which one controls odor the best.”
C. “I plan on beginning elimination training for my
colostomy as soon as the doctor says it is okay.”
D. “I will teach my spouse how to work with the
colostomy in the event I ever need assistance.”
The answer is A. The client is feeling despair that her spouse
will not accept the changes she has undergone and will not
desire her in a way he once did. She has not accepted the
colostomy and assumes her spouse has not either.
B is incorrect—The client has accepted the colostomy
and is ready to work with it so that it fits into her life. C is
incorrect—The client has accepted the colostomy and is
open to working with it to fit her needs. D is incorrect—The
client has accepted the colostomy and is ready to teach others
how to work with it as she does.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Nutrition and Oral Hydration
Monitor client’s hydration status
27. Which of the following is the best indicator of a negative
hydration status in a client who weighed 200
pounds on admission and has been vomiting for 3
days after being diagnosed with diabetic ketoacidosis?
A. Daily weight of 170 pounds on day 3.
B. Serum glucose 100 mg/dL.
1080 PART III: Taking the Test
C. Ketones negative in urine.
D. Potassium level 4.0 mEq/L.
The answer is A. The client who is dehydrated will have a
decrease in daily weights. This is a reflection of a negative
fluid volume status.
B is incorrect—The serum glucose will rise in a client
who is dehydrated due to insulin deficiency and glycogen
breakdown to glucose of which cannot be eliminated by the
body. C is incorrect—Ketones are positive due to free-floating
fatty acids. The ketones are not eliminated due to low
urine output and fluid volume deficit leading to ketones
being in the urine. D is incorrect—As the client vomits and
the potassium leaves the cell and goes to circulation, the
level will rise; 4.0 mEq/L is considered a normal potassium
level and therefore is an incorrect response.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Central Venous Access Devices
Access implanted venous access devices
28. A client has a medi-port for chemotherapy administration.
The nurse has an order to access the medi-port
for a blood draw and the administration of normal
saline at 125mL/hr. The nurse will plan on obtaining
which of the following to access the device?
A. A 20-gauge 1.5-inch Huber needle
B. A 20-gauge 1.5-inch jelco
C. A butterfly needle
D. A needleless syringe system
The answer is A. A Huber needle is required to access a mediport
system so that damage will not occur to the structure of
the system.
B is incorrect—A jelco is not the correct needle to access
a medi-port. The use of a jelco would damage the implanted
device and possibly the client. C is incorrect—A butterfly
needle is small and used for lab collection only. It does not
contain a catheter for fluid administration. D is incorrect—A
needle is required to access the medi-port. A needleless system
can be used after the medi-port is accessed by the
appropriate needle.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Total Parenteral Nutrition
Administer/maintain/discontinue total parenteral nutrition
29. Which site is the best for administering total parenteral
nutrition to a client whose feeding contains greater
than 10% glucose?
A. PEG tube
B. NG tube
C. Peripheral site
D. Central catheter site
The answer is D. The preferred site for the administration of
parenteral nutrition is to use a central catheter site to prevent
damage to the peripheral areas.
A is incorrect—Parenteral nutrition is administered
intravenously not in a PEG tube site; tube feedings are
reserved for PEG tube sites. B is incorrect—TPN is an intravenous
form of feeding a client and an NG tube goes directly
to the stomach, which requires tube feeding solutions. D is
incorrect—Placing a high concentration of glucose in a
peripheral site will irritate the vein and can cause damage to
the client’s surrounding tissues. TPN with greater than 10%
glucose should use a central site.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Alterations in Body Systems
Monitor client output for changes from baseline
30. The client’s output trend from a chest tube drainage
system is as follows:
0700 1500 2200
Day 1 600 mL 750 mL 648 mL
Day 2 500 mL 425 mL 400 mL
Day 3 400 mL 380 mL 400 mL
Day 4 500 mL 600 mL 700 mL
Based on the data trended, which initial action by the
nurse would be best?
A. Report the trend to the physician.
B. Continue to monitor the client’s drainage.
C. Review the chart to see what the acceptable parameters
are.
D. Increase the suction on the chest tube.
The answer is C. On day 4 the output is similar to day 1, the
nurse should verify with the chart what parameters are
acceptable before consulting the physician.
A is incorrect—Before calling the physician, the nurse
should verify the parameters with the chart to see what the
physician considers acceptable. B is incorrect—Continuing
to monitor the client comes after ensuring that the output
is within expected limits. D is incorrect—The suction
should never be increased unless a physician writes an
order.
CHAPTER 34 Practice Test for NCLEX-RN® 1081
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Fluid and Electrolyte Imbalances
Identify signs and symptoms of client fluid and/or electrolyte
imbalance
31. A client’s serum calcium level is 7 mg/dL. What would
be the clinical manifestations of for this laboratory
result?
A. Abdominal cramps
B. Depressed DTRs and dysrhythmias
C. Lethargy and weakness
D. Numbness and tingling in the extremities
The answer is D. Normal serum calcium range is 8.5–10.5
mg/dL and so the client has hypocalcemia. Symptoms of
hypocalcemia include numbness and tingling in the extremities,
carpopedal spasm, and ultimately tetany.
A, B, and C are incorrect—Lethargy and weakness as
well as depressed deep tendon reflexes, anorexia, nausea,
vomiting, constipation and dysrhythmias are symptoms of
hypercalcemia. Abdominal cramping occurs with hyponatremia.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications and Side Effects
Implement procedures to counteract adverse effects of
medications and parental therapy
32. A client who takes digoxin (Lanoxin) at home has presented
with a digoxin level of 4 ng/mL and a heart rate
of 38. What is the priority nursing action?
A. Set up the client for external pacing.
B. Administer Atropine 1 mg IV.
C. Administer Digibind 228 mg IV.
D. Assess the client for visual changes and nausea/
vomiting.
The answer is C. The therapeutic digoxin level is 0.5–2
ng/mL. The client who has digitalis toxicity will require a
dose of Digibind, which binds to the digoxin in the serum
and removes it from the circulating system.
A is incorrect—The client does not need external pacing
for digoxin toxicity. B is incorrect—While Atropine will raise
the heart rate, it will not remove digoxin from the serum,
which is the cause of the bradycardia. D is incorrect—The
client may have visual changes and nausea/vomiting but the
priority nursing action is to remove the digoxin from the system.
The nurse understands the client is has digoxin toxicity
by the level in the serum and the client’s heart rate.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Radiation Therapy
Implement interventions to address side/adverse effects
of radiation therapy
33. What is the priority of care in a client that is undergoing
external radiation therapy?
A. Washing the markings off of the face.
B. Maintaining a 6-ft distance.
C. Grouping client care to minimize exposure to the
radiation.
D. Assessing the skin for burned areas.
The answer is D. The client should be assessed for areas that
are burned so that treatment can occur to prevent further
damage to the skin and underlying tissues. Fluid volume status
should also be addressed due to the body’s response to
the burn.
A is incorrect—The markings placed on the body for radiation
therapy should not be removed to ensure that alignment
of the radiation can occur with preciseness. B is incorrect—
Only with internal radiation should a distance be kept from the
patient. C is incorrect—Grouping client care to minimize
exposure to radiation is not necessary with external radiation.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
Apply knowledge of nursing procedures and psychomotor
skills when caring for a client experiencing a medical
emergency
34. A client presents to the emergency department after
being involved in a vehicular accident. The client has
obvious facial fractures and a head injury. The nurse
should refrain from:
A. placing a nasogastric tube.
B. inserting a urinary catheter.
C. cleaning the blood from the face.
D. bagging the client with a bag valve mask and high
flow oxygen.
The answer is A. With obvious facial fractures, the client
should not receive a nasogastric tube through the nose.
B is incorrect—A urinary catheter is safe as long as
there is not any blood at the meatus. C is incorrect—The
nurse should clean blood from the face to see what injuries
are present. D is incorrect—The client can be bagged with
BVM until an artificial airway is placed by the physician.
1082 PART III: Taking the Test
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Standard/Transmission-Based/Other Precautions
Understand communicable disease and the modes of
organism transmission
35. A client is admitted with active tuberculosis. Which
form of isolation should the client be placed on?
A. Contact
B. Droplet
C. Airborne
D. Standard
The answer is C. Airborne isolation includes particles transmitted
by droplet or airborne particles. By placing the client
on airborne isolation, the client receives a room with negative
airflow; mask are worn by staff while in the patient room
and by the patient if out of the room for test.
A is incorrect—Contact isolation is for pathogens that
are transmitted through direct or indirect contact with the
client or items the client may have touched. B is incorrect—
Droplet transmission is when the client coughs or the
mucous membranes of the client are touched. Droplet transmission
does not mean the client will need negative air pressure
in his or her room since the particles are not suspended
in the air as they are with airborne. D is incorrect—Standard
is used for blood or body fluid pathogen transmission.
HEALTH PROMOTION AND
MAINTENANCE
Family Systems
Assess impact of change on family system
36. Which statement made by a parent would indicate a
need for immediate evaluation and counseling after
the birth of the fifth child?
A. “I just don’t know how I will pay for college for all
of the children.”
B. “I have thoughts of throwing the baby in a dumpster.”
C. “The four oldest siblings argue constantly over the
remote.”
D. “I wish I made more money so my family would be
happier.”
The answer is B. The parent making the statement of the
desire to throw the baby in the dumpster is indicative of a
need for counseling. The parent could be experiencing
depression or psychosis that needs intervention.
A is incorrect—Wondering how a parent will pay for
college is a normal concern and does not pose an immediate
threat to the parent or children. C is incorrect—A sibling
arguing with another is normal and does not pose a threat to
the children or parent. D is incorrect—A parent wishing he
or she made more money is normal and does not pose an
immediate threat.
HEALTH PROMOTION AND
MAINTENANCE
Lifestyle Choices
Assess client lifestyle choices
37. Which statement made by a parent indicates that a
child may need to be evaluated every year by a health
care provider?
A. “My children are home schooled to avoid societal
influences.”
B. “I allow my children to attend private schools only.”
C. “We encourage our children to take a multivitamin
at bedtime every night.”
D. “We don’t allow our children to go outside alone.”
The answer is A. The parents in this situation have chosen to
teach the children at home to avoid societal influences. The
children need a yearly screening to note for developmental
delays and issues associated with a lack of social interaction
with other children. The children are also at risk for being
victims of abuse by not having outside observers to notice
signs or symptoms of abuse leading for the need of the parents
to participate in a yearly evaluation of the children by a
health care professional.
B is incorrect—The parents have chosen to place their
children in private schools, which still allows for health
screenings by the school nurse and evaluations for signs of
abuse. C is incorrect—Taking a multivitamin is not a reason
for yearly visits to the physician. D is incorrect—By not
allowing children to go outside alone, the children are being
protected from external dangers; furthermore, this is not a
reason for yearly visits by a health care provider.
PSYCHOSOCIAL INTEGRITY
Chemical and Other Dependencies
Assess client for drug-/alcohol-related dependencies,
withdrawal, or toxicities
38. A client presents with a history of illegal use of prescription
narcotics. Which assessment data is the earliest
sign of withdrawal?
A. BP 90/60, HR 100
B. Anxiety, irritability
C. Insomnia, diarrhea
D. Nausea, vomiting
CHAPTER 34 Practice Test for NCLEX-RN® 1083
The answer is B. Anxiety and irritability is one of the first
signs of opioid withdrawal with salivation, diaphoresis, and
other symptoms following.
A is incorrect—The client presents with hypertension
and tachycardia with an opioid withdrawal. C is incorrect—
Insomnia does occur with opioid withdrawal but later in the
cycle. Diarrhea is usually not seen as the client has a decrease
in motility due to the opioid. D is incorrect—Nausea and
vomiting occur late in the withdrawal process.
PSYCHOSOCIAL INTEGRITY
Grief and Loss
Assist client/family/significant others in coping with suffering
grief, loss, dying, and bereavement
39. A client is nearing the end of his life. To assist the family
to cope, the nurse should suggest that the family:
A. tell the client good-bye.
B. leave the client to die in peace.
C. become visibly upset to expel all emotions.
D. contact a local psychiatrist to discuss what has
occurred.
The answer is A. The family will gain closure through telling
the client good-bye. Gaining closure will help the family
through the grieving and bereavement process.
B is incorrect—When the family leaves the client, they
carry the fact that their family member died alone and this
can harm the grieving process. C is incorrect—A family
should respond to death in their own way; therefore, encouraging
the family to become visibly upset is inappropriate. D is
incorrect—The family should be provided with a list of support
services to assist with grieving but a family should not be
instructed to contact a psychiatrist by the nurse.
PSYCHOSOCIAL INTEGRITY
Stress Management
Implement measures to reduce environmental stressors
40. A client is being weaned from a patient controlled
analgesic pump (PCA pump). Which nursing intervention
would be best to assist in the control of pain?
A. Provide small chatter in the background.
B. Play classical music in the background.
C. Darken the room and close the door.
D. Teach the client to only call for pain meds when
pain is a 10/10.
The answer is C. Dimming the lights and closing the client’s door
will lessen environmental stressors, which can precipitate pain.
A is incorrect—Chatter can be perceived as an added
stress to the client. B is incorrect—While music in the background
can assist in pain control, the client may find classical
music annoying and not helpful. The client should be
allowed his or her favorite music, if desired, during the
period weaning. D is incorrect—The client should learn to
call for pain medication before the pain is a 10/10 or pain
management becomes more difficult.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Nutrition and Oral Hydration
Monitor client hydration status
41. Based on the postsurgical client’s 24-hour intake and
output documentation, which data should be reported
to the physician?
Day 1 Day 2 Day 3 Day 4
Intake Output Intake Output Intake Output Intake Output
A 2000 1000 1500 1250 1325 1300 1250 1300
B 2000 900 1800 1100 1750 1000 1500 1000
C 2000 1700 1700 1625 1575 1400 1300 1275
D 2000 1500 1500 1300 1400 1300 1425 1400
The answer is B. The client is not maintaining an appropriate
fluid balance after surgery as expected and the chances of electrolyte
imbalances and pulmonary edema are high. The physician
should be notified so that pharmacological interventions
can occur and a fluid restriction can be ordered.
A, C, and D represent a normal ratio of fluid intake to
fluid lost and does not require notification of the physician.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Blood and Blood Products
Check the client for appropriate venous access for red
blood cell/blood product administration
42. Prior to administering a blood product, the nurse must
ensure which of the following is present?
A. A patent intravenous line
B. Y-Site tubing
C. An intravenous pump
D. A 20 gauge or large intravenous line
The answer is D. A client must have a 20 gauge or larger intravenous
line before blood products can be administered. If
this is not present, a new IV must be initiated.
A is incorrect—While a patent line is important, the size
of the line is the most important item a nurse must ensure is
present before blood is administered. A 22-gauge line may be
patent, but it is not sufficient for blood administration and a
1084 PART III: Taking the Test
new site IV must be initiated. B is incorrect—Y-site tubing is
important but not as important as the correct size intravenous
line. C is incorrect—Blood should be administered on a
pump, but it is not as important to ensure a pump is present
as it is to ensure the proper size intravenous line is present.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Review pertinent data prior to medication administration
43. Prior to administration, a client starting an increased
dose of clonidine (Catapress) should be assessed for
which of the following
A. Orthostatic hypotension
B. Tachycardia
C. Hyperglycemia
D. Oliguria
The answer is A. A client who starts an increased dose of
Catapress will experience orthostatic hypotension and so
assessment for preexisting orthostatic hypotension is important
and the physician can be notified for further orders.
B is incorrect—An adverse effect of Catapress is bradycardia
not tachycardia and is not a contraindication to administering
the medication. C is incorrect—Hyperglycemia is not
a side effect of Catapress and is not a contraindication to
administering the drug. D is incorrect—There is no contraindication
to administering Catapress if oliguria is present.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Total Parenteral Nutrition
Monitor client for side/adverse effects of TPN
44. For a client that is receiving total parenteral nutrition
(TPN), which assessment data would be most indicative
of infection within 48 hours of initiation of therapy?
A. Confusion
B. Diaphoresis
C. Heart rate 120
D. Temperature of 101_Fahrenheit.
The answer is D. Fever in an afebrile patient is indicative of
sepsis in a client that is receiving TPN.
A is incorrect—Confusion is common in the first 24–48
hours of initiation of TPN. This is due to the shift of electrolytes
from the plasma to the cell. B is incorrect—
Diaphoresis is common with hypoglycemia associated with
TPN. C is incorrect—While tachycardia accompanies a fever,
it is not the most indicative sign of infection in the client.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic
Tests/Treatments/Procedures
Intervene to manage potential circulatory complications
45. Which finding in a client who has undergone repair of
a radial fracture 12 hours ago would require immediate
notification of the orthopedic surgeon?
A. Pain at the incision site
B. Edema of the affected arm
C. Pain with passive movement of the fingers
D. Fever
The answer is C. The client has compartment syndrome and
one of the indicative signs is pain with passive movement of
the fingers. This requires the physician to be notified immediately
so that intervention can occur.
A is incorrect—Pain is common after a surgical repair of
a fractured arm. B is incorrect—Edema is common after surgical
repair due to the body’s response to the injury and the
beginning of repair. D is incorrect—Fever is a sign of infection
and should be reported but it does not require the nurse
to notify the orthopedic surgeon immediately.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-Specific Assessment
Perform a risk assessment
46. A home health nurse is performing an admission assessment
on a client who has been discharged from the hospital.
Which finding on the risk for falls assessment
must be resolved prior to the nurse leaving the home?
A. Carpet in the home
B. Throw rugs over hardwood floors
C. Shower/tub combo with shower curtain
D. Steps leading into the home
The answer is B. Throw rugs over hardwood floors are a
common problem in homes of older clients and is an area
where clients may fall. The nurse should remove the throw
rugs prior to leaving the home and explain to the client her
rationale.
A is incorrect—Carpet is not a falls risk. C is incorrect—
While a tub/shower combo is not ideal and the client can fall
getting into or out of the tub, the nurse cannot fix this before
leaving and should request items that would assist the client
to continue using the shower. D is incorrect—Although
steps leading into the home present a fall risk, the nurse cannot
modify these.
CHAPTER 34 Practice Test for NCLEX-RN® 1085
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
Evaluate achievement of client treatment goals
47. A client with a history of COPD complains of
increased shortness of breath and has wheezing noted
upon auscultation. The client is administered a nebulizer
treatment of Albuterol and Atrovent. Which evaluation
would indicate a therapeutic response to this
treatment?
A. Increase in wheezing upon auscultation
B. Pink frothy sputum
C. Decrease in shortness of breath
D. Decrease in heart rate
The answer is C. The client is complaining of shortness of
breath, and therefore, a decrease would be considered a
therapeutic response to the treatment.
A is incorrect—An increase in wheezing upon auscultation
is not considered a therapeutic response to the breathing
treatment. B is incorrect—Pink frothy sputum is indicative
of pulmonary edema and is not a therapeutic response
to the treatment. D is incorrect—A decrease in the heart rate
is not a therapeutic response and indicates a complication
since Albuterol and Atrovent are known to increase the
client’s heart rate.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
Apply knowledge of pathophysiology when caring for a
client experiencing a medical emergency
48. A client presents to the emergency department after being
ejected from an all terrain vehicle. The client received an
opioid analgesic in route for control of pain associated
with a lower leg injury. Which assessment data is most
indicative of early increased intracranial pressure?
A. Irritability
B. Hypotension
C. Pupils 2 mm
D. Decreased respiratory rate
The answer is A. Irritability is the most indicative sign of
increased intracranial pressure due to the changes the oxygen
the brain receives due to compressed vessels. The
absence of oxygen places the brain in a state of hypoxia,
which causes irritability to occur.
B is incorrect—Hypertension is a sign of increased
intracranial pressure due to the excited fibers, which control
vasoconstriction. C is incorrect—Pupil dilation occurs due
to increased intracranial pressure but in this case the pupils
are constricted due to the administration of an opioid analgesic
in the field. D is incorrect—Initially, the respiratory
rate will be increased due to the body’s response to hypoxia,
as a late sign it will decrease.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Radiation Therapy
Apply knowledge of pathophysiology when discussing
radiation therapy with client/family/significant others
49. A nurse is teaching a client about care of a wound after
surgery, which will also be the site of radiation treatments.
Discharge instructions should include:
___ How to care for the surgical site.
___ Signs and symptoms of delayed wound healing.
___ How often to report to outpatient for a treatment.
___ Signs and symptoms of anaphylactic reaction to
radiation.
___ Signs of radiation toxicity.
___ Foods to avoid during therapy.
The discharge instructions should include how to care for
the surgical site and the signs and symptoms of delayed
wound healing since difficulties in wound healing are common
in the client undergoing radiation therapy. Reporting
to outpatient is important so that treatments stay on the
scheduled path for the greatest benefits. Radiation toxicity
is common and the signs and symptoms should be discussed
with the client so that the individual can seek medical
attention as needed. Foods to avoid are taught about
due to the possibility of oral ulcerations and sores associated
with radiation therapy.
Anaphylactic reactions are not a risk with radiation therapy.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Blood and Blood Products
Administer blood products and evaluate the client response
50. A nurse has an order to administer packed red blood
cells to a client. Prior to administration, the nurse
should (check all that apply):
___ obtain consent
___ gather IV tubing with a filter
___ gather D5 1⁄2 NS
___ prime the line with fluid
___ check the blood with either an RN or LPN
1086 PART III: Taking the Test
___ warm the blood to 100_F
___ assess the site for patency
Before administering blood, the nurse should obtain consent
for blood administration, gather IV tubing ensuring a filter
for blood administration is present, prime the line with
fluid, and assess the site for patency.
The nurse should not use D5 1⁄2 NS for blood administration.
Only NS can be used for blood administration and only
an RN can check blood with another RN. The blood should
not be warmed unless orders are present to warm the blood to
a specific temperature for rapid infusion. Warming of the
blood will cause it to clot and can promote bacterial growth.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Reporting of Incident/Event/Irregular
Occurrence/Variance
Report error/event/occurrence per protocol
51. A nurse walks into a room after the bathroom call light
is sounded and finds a client lying on the floor. The
client states that he became dizzy and lost his balance
after using the bathroom. Which documentation of the
fall is most appropriate?
A. “Client fell after standing-up from the toilet.”
B. “Client fell due to lowering in blood pressure upon
standing.”
C. “Client found lying in floor, states ‘I became dizzy
and lost my balance after using the bathroom’.”
D. “Client experienced a vagal response and fell after
using the bathroom.”
The answer is C. The nurse should only document what she
saw and what the client told her. Documentation other than
what was stated and visualized is falsifying a document.
A is incorrect—This is a nursing assumption and is not
legal. B is incorrect—This is not reporting what was seen or
what the client told the nurse; therefore, it is inappropriate
charting. D is incorrect—This is assuming the client experienced
a vagal response and is not appropriate charting.
HEALTH PROMOTION AND
MAINTENANCE
Ante-/Intra-/Postpartum and Newborn Care
Calculate expected delivery date
52. A client has her pregnancy confirmed by the nurse in a
physician’s office. The client wishes to know her
expected date of delivery and the first day of her last
menstrual period was July 4th. The nurse calculates
the delivery date as:
A. April 10th
B. April 11th
C. April 1st
D. April 4th
The answer is B. The client’s expected date of delivery is
April 11th. This is calculated by subtracting 3 months from
the month the client had her last menstrual period and
adding 7 days to the date of the last menstrual period.
A, C, and D are incorrect using this method.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-Specific Assessment
Perform focused assessment or reassessment
53. List in order from first to fourth the assessment technique
used for a client who is complaining of abdominal
pain.
A. Inspection
B. Palpation
C. Auscultation
D. Percussion
Inspection is the first step for an assessment of the gastrointestinal
system. The second step is auscultation so that
sounds can be heard since manipulation of the abdominal
wall may alter sounds. The third step is to percuss for tympani
or dullness and the last step is to palpate the abdomen
for pain, tenderness, or other abnormalities.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Laboratory Values
Obtain specimens other than blood for diagnostic testing
54. A nurse has an order for a wound culture to be taken
via aspiration; prior to aspirating the wound bed, the
nurse should:
A. massage the wound bed.
B. irrigate the wound bed with normal saline.
C. clean the wound bed edges with normal saline.
D. dry exudate from the wound bed with sterile gauze.
The answer is B. The wound bed should be irrigated first with
normal saline to remove exudate, which allows for fresh exudate
from the wound bed to surface.
A is incorrect—The wound is massaged after the old
exudate and saline irrigant is removed from the wound bed.
CHAPTER 34 Practice Test for NCLEX-RN® 1087
C is incorrect—Wound edges are not required to be cleaned
when aspirating for a culture. D is incorrect—Exudate is
removed from the wound bed with sterile gauze after saline
irrigant is placed in the wound.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Continuity of Care
Perform procedures necessary for admitting,
transferring, or discharging a client
55. Prior to transferring a client from the medical surgical
floor to the intensive care unit, the nurse should first:
A. obtain a signed consent from the client for transfer.
B. notify the nurse manager.
C. obtain an accepting physician.
D. phone a report to the nurse in the ICU who will
receive the client.
The answer is D. The nurse must transfer care of the client to
another nurse and this is performed in a patient report.
A is incorrect—A client does not need to sign consent if
a transfer is within the same facility. B is incorrect—A nurse
manager is not needed in a transfer as long as there is a
physician order and a bed is available in the receiving unit.
C is incorrect—The client’s primary physician is responsible
for following the client within the facility, and if a transfer of
care to another physician is required, it is the responsibility
of the physician to obtain an accepting physician.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Staff Education
Assess purpose of staff education activities
56. A nurse understands that the primary rationale behind
attending an in-service for newly acquired unit specific
equipment is to:
A. aid in medicaid reimbursement for the hospital.
B. gain continuing education credits for licensure.
C. meet JCAHO requirements for staff education of
hospital equipment.
D. maintain patient safety by understanding the proper
use of hospital equipment.
The answer is D. The nurse possesses the responsibility to
remain current on all equipment that is used in a specific
area of employment so he or she can assist in maintaining
patient safety. Being unfamiliar with equipment can lead to
litigation if he or she is negligent and causes client harm.
A is incorrect—Medicaid does not require nurses to
attend in-services before reimbursement for client care is
awarded. B is incorrect—While gaining continuing education
credits are possible with some in-services, those that
deal specifically with equipment use are not governed by the
licensure board therefore are not applicable for continuing
education credits. C is incorrect—JCAHO requires that staff
is educated regarding equipment used in the facility but the
primary purpose of attending an in-service on equipment
use is to maintain patient safety.
HEALTH PROMOTION AND
MAINTENANCE
Aging Process
Provide care that meets the special needs of the preschool
client ages 1 month to 4 years
57. When performing a routine assessment on a 1-year-old
client, which data should be collected first?
A. Rectal temperature
B. Heart rate
C. Respirations
D. Blood pressure
The answer is C. Respirations should be counted first before
the client becomes upset with the assessment process.
Changes in respiratory rate will often occur before other
signs and symptoms are present in a child.
A is incorrect—The rectal temperature should be performed
last since it will upset the child. B is incorrect—The
heart rate should be assessed after the respiratory rate since
it requires a stethoscope and will alter the respiratory rate if
the client becomes upset. D is incorrect—The blood pressure
is not performed on the 1-year-old client unless there is
a cause of concern such as altered level of consciousness,
depressed or bulging fontanels, or signs and symptoms of
dehydration. In this scenario, the assessment is routine.
HEALTH PROMOTION AND
MAINTENANCE
Health and Wellness
Evaluate client/family/significant other understanding of
health promotion behaviors/activities
58. A client in the doctor’s office for a routine check-up
demonstrates an understanding of health promotion
behaviors and activities when he says that he will:
(check all that apply)
___ walk at least twice a week.
___ avoid excessive caffeine.
1088 PART III: Taking the Test
___ cut down to one pack of cigarettes a day.
___ eat a vegetable at every meal.
___ take medication exactly as prescribed.
___ have blood pressure checked regularly.
The client voicing that he will walk at least twice a week,
avoid excessive caffeine, eat a vegetable at every meal, take
medication as prescribed and have blood pressure monitored
frequently demonstrates an understanding of health
promotion behaviors and activities.
The client stating he will cut down to one pack of cigarettes
a day shows he does not realize the necessity of quitting
smoking to improve health and further education is needed.
PSYCHOSOCIAL INTEGRITY
Abuse/Neglect
Identify risk factors for domestic, child and/or elder
abuse/neglect, and sexual abuse
59. Which clients are at a high risk for sexual abuse?
(Select all that apply.)
___ An 8-year-old boy who lives with both parents.
___ A 6-year-old girl living in foster care.
___ A 21-year-old female living in a college dorm.
___ An 88-year-old client living in a nursing home.
___ An 18-year-old male living in an apartment in a
new town.
The answers are the 6-year-old girl living in foster care and the
21-year-old female living in a college dorm. Females are at a
higher risk for sexual abuse than any other group. Sexual
abuse for this group can consist of molestation of the 6-yearold
girl or rape of either the 6- or 21-year-old.
Incorrect—The 8-year-old is at a low risk because he is
male and lives with both parents making it a stable environment.
The 88-year-old client living in a nursing home is at a
low risk of being sexually abused due to age and facility. An
18-year-old male is at a low risk of being sexually abused
even though he lives in a new town.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Identify signs and symptoms of impaired cognition
60. A client’s family is concerned about recent changes in
their family member’s behavior and is afraid that he is
developing Alzheimer’s disease. Which signs and
symptoms reported by the family is associated with
Alzheimer’s disease? (Check all that apply.)
___ Memory loss
___ Seizures
___ Syncope
___ Personality changes
___ Anorexia
___ Poor judgment
The answers are memory loss, personality changes, anorexia, and
poor judgment. All of these are signs and/or symptoms of
Alzheimer’s disease and require reporting to the physician
for follow up.
Seizures is incorrect—they are not associated with the
disease. Syncope is not associated with Alzheimer’s unless a
pre- or coexisting cardiac problem exists.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Complementary and Alternative Therapies
Evaluate client/family/significant other outcomes of
alternative and/or complementary therapy practices
61. A cancer client has been attending yoga to aid in relaxation
and mind healing. Which evaluation would indicate
a therapeutic response to this alternative therapy?
A. The client claims to be “cancer free.”
B. The client has decided death will occur and is ready
to “pass on.”
C. The client states she has found inner strength and
has accepted the diagnosis.
D. The client has decided to stop treatment and allow
the body to heal itself.
The answer is C. The cancer patient will often turn to alternative
therapies to assist in the treatment process. Yoga has
proven to be a method of relaxation and allows for reflection
and finding peace within one’s self. The client who has a successful
response to yoga will find the peace within and learn
how to relax and channel thoughts until peace is achieved.
A is incorrect—The client has a false sense of being cancer
free and this has proven to be a negative result of an alternative
therapy. B is incorrect—The client has made the decision
that the end will occur and this can leave the client with
a negative outlook on the future and impede healing. D is
incorrect—The client has a false assurance of the reality of
yoga and the expectations of ones self. The client needs counseling
on the benefits of yoga and the expected outcomes.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications and Side Effects
Assess client for actual or potential side effects and
adverse effects of medications
62. A client is being discharged home with a prescription for
warfarin (Coumadin). Discharge instructions include:
A. avoid Tylenol while taking Coumadin.
B. avoid ginseng while taking Coumadin.
CHAPTER 34 Practice Test for NCLEX-RN® 1089
C. avoid clopidogrel (Plavix) while taking Coumadin.
D. avoid clonidine (Catapress) while taking Coumadin.
The answer is B. A client who takes Coumadin should avoid
taking herbal supplements that contain ginseng due to the
risk of increased risk of blood thinning beyond desired effects.
A is incorrect—Tylenol is acceptable to take while on
Coumadin therapy unless hepatic function is impaired. C is
incorrect—Plavix is a common drug used to prevent platelet
aggregation and is compatible for use with Coumadin therapy.
D is incorrect—Catapress is commonly used for hypertension
and is compatible with Coumadin therapy.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Pharmacological Interactions
Provide client/family/significant others with information
on known pharmacological interactions of medication
prescriptions
63. A client is prescribed theophylline (Theo-24) for
COPD. Discharge instructions should include the
interaction of which of the following:
A. Nicotine transdermal patches
B. fosinopril (Monopril)
C. Advair Diskus 250/50
D. clopidogrel (Plavix)
The answer is A. Nicotine is contraindicated with the use of
theophylline because of the stimulant effects and may cause
tachycardia.
B is incorrect—Monopril is an ACE inhibitor and does
not carry any interactions with theophylline. C is incorrect—
Advair is a nonsteroidal bronchodilator and is safe to be used
concurrently with theophylline. D is incorrect—Plavix is a
platelet aggregate and is safe to be used with theophylline.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Vital Signs
Intervene when client vital signs are abnormal
64. The vital signs on a client are as follows:
• B/P 178/120
• P 112
• R 28
• O2Sat 98%
• T 99.0
The client is complaining of a headache and blurred
vision. Which medication from the client’s MAR should
the nurse administer?
A. Metoprolol (Toprol XL) 100 mg p.o.
B. Clonidine (Catapress) 0.3 mg p.o.
C. Metoprolol (Lopressor) 5 mg IV
D. Tylenol 650 mg p.o.
The answer is C. The client meets criteria for a hypertensive
crisis. Lopressor is to be given intravenously. This is the best
drug to give from the client’s MAR. Lopressor will lower the
blood pressure and heart rate.
A is incorrect—The Toprol XL will also lower blood
pressure and heart rate, but it is taken by mouth and will take
30 minutes to act. In hypertensive emergency, intravenous
antihypertensives are given followed by oral dosing. B is
incorrect—The client has an increased heart rate as well as
increased blood pressure, the drug of choice would be an
antihypertensive agent that will work on both areas. The
Catapress is used for hypertensive emergencies but it does
not have a labeled use for lowering the heart rate and the oral
dose will take longer to show results. D is incorrect—The
client does have a low-grade fever and a headache, but the
headache will resolve with a resolution in the blood pressure.
PSYCHOSOCIAL INTEGRITY
Abuse/Neglect
Assess client risk for abuse/neglect
65. Which client is at the highest risk for neglect?
A. Infant of a 30-year-old woman who is single.
B. Infant of a 14-year-old girl who lives with her parents.
C. 95-year-old client living in an assisted living facility.
D. 79-year-old client living at home with her 41-yearold
daughter.
The answer is B. Statistically, a child of a teenager is at the highest
risk for neglect. The mother and father live with the
teenager but in most situations, the teenager is still responsible
for the care of the infant. A teenager generally does not
have the coping skills and knowledge to care for an infant.
A is incorrect—The mother is an adult and the infant is
less likely to be neglected. C is incorrect—A client in an
assisted living facility is able to provide care with some assistance
by other personnel lessening the chances of neglect. D
is incorrect—The client living with her daughter is at a low
risk with the daughter still young enough to provide adequate
care.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
Perform peritoneal dialysis
66. A nurse is performing peritoneal dialysis and instills 2 L
of dialysate into the peritoneal cavity. After 30 minutes
has elapsed, the client returns only 1 L of solution. The
nurse should:
1090 PART III: Taking the Test
A. have the client roll from side to side.
B. gather a syringe and pull fluid from the peritoneal
cavity.
C. apply warm compresses to the abdomen.
D. stop the process and call the physician.
The answer is A. The client should move from side to side in
the bed so that drainage can occur.
B is incorrect—A syringe should not be used to pull
dialysate from the cavity. C is incorrect—Warm compresses
on the abdomen will not help removing the solution from
the peritoneal cavity. D is incorrect—The physician should
not be notified unless moving the client is unsuccessful in
removing the fluid.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Review pertinent data prior to medication administration
67. A client has vancomycin (Vancocin) ordered every 12
hours. The client has one IV access and it currently has
dopamine (Intropin) infusing to maintain blood pressure.
Prior to the administration of the vancomycin
(Vancocin) the nurse should:
A. obtain another IV access.
B. check for patency of the existing IV site.
C. discontinue the Dopamine.
D. check for compatibility ofDopamineandVancomycin.
The answer is D. Before obtaining another IV site, the nurse
should check for compatibility of the Dopamine and the
Vancomycin. If compatibility is not assured, then another IV
site should be obtained.
A is incorrect—The nurse should check for compatibility
first. B is incorrect—The patency of the IV line should be
unquestionable if a medication is infusing in it currently. C is
incorrect—Dopamine cannot be discontinued for the length
of time it will take for Vancomycin to infuse.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Teach client about managing illness
68. A client is being discharged after receiving the diagnosis
of human immunodeficiency virus (HIV). Priority
teaching at the time of discharge is:
A. how to prevent the spread of infection to others.
B. when to take medications.
C. what foods to avoid.
D. when to follow up with physician.
The answer is A. Preventing the spread of the disease is the
most important fact to teach the client prior to discharge
from the hospital. This is most important with a new diagnosis
of HIV.
B is incorrect—Although when to take medications is
important, the nurse should first ensure that the client knows
how to prevent the spread. C is incorrect—With a new diagnosis
there are not any food restrictions. D is incorrect—
When to follow up with the physician is important but not the
most important fact to teach to the client before discharge.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Client Rights
Recognize the client’s right to refuse treatment/procedures
69. A client who is scheduled to undergo chemotherapy
today states, “I do not wish to undergo my treatment
today.” Which action by the nurse is most appropriate?
A. Discuss with the client the need to follow the prescribed
treatment regime.
B. Ask the client as to what has occurred to make him
or her not want today’s treatment.
C. Notify the physician that the client has refused a
treatment.
D. Notify the chemotherapy nurse that the client has
refused today’s treatment.
The answer is B. The nurse needs to recognize that the client
has the right to refuse treatment but he or she should also
determine what has occurred to make the client refuse treatment
so that an intervention can occur if needed.
A is incorrect—It discounts the client’s feelings. C and D
are incorrect—Although they recognize the client has
refused treatment neither choice addresses the client and his
or her current state of mind.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Information Technology
Use information technology to enhance the care provided
to a client
70. A 14-year-old client has been diagnosed with diabetes and
needs diabetes education at the time of discharge. Which
method of instruction would be best for this client?
A. A book that discusses diabetes, including how to
administer medications.
B. Interactive computer software that discusses diabetes
management.
CHAPTER 34 Practice Test for NCLEX-RN® 1091
C. A diabetes educator discussing diabetes management
in a group environment.
D. A pamphlet that contains pictures on diabetes management.
The answer is B. A teenage would benefit most from computer
software since teenagers are accustomed to a computer
and learn best when they can interact with the information
being given.
A is incorrect—A teenager is less likely to read a book discussing
diabetes and thus leading to incomplete information. C
is incorrect—Because of the nature of the illness and the psychological
changes that a teenager goes through, a teenager
often will not participate in a group discussion about diabetes
management and therefore will not learn. D is incorrect—A
pamphlet is not best for a teenager since they are active learners.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Home Safety
Educate client/family on home safety issues
71. Which of the following should be included in the discharge
teaching for a family who is in the pediatrician’s
office for a 2-year-old well baby check-up?
A. Cover all outlets in the home.
B. Place pots and pans on the front of the stove while
cooking.
C. Avoid leaving the child for more than 1 minute
while in the tub.
D. Remove all pets while the child is in the home.
The answer is A. A 2-year-old child is ambulatory and possess
the motor skills to place objects in the electrical outlets which
could potentially cause an electrical shock. The parents need to
cover all outlets to prevent this from occurring.
B is incorrect—The parents should not place pots and
pans on the front of the stove. They should be placed on the
back. C is incorrect—A child should never be left alone in
the tub. D is incorrect—Pets are not required to be removed
from the home unless the child has an allergy to pets or other
risks are associated.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Emergency Response Plan
Implement emergency response plans
72. A nurse would expect the internal disaster plan to be
enacted if which event occurs?
A. Plane crash
B. Infant abduction
C. Fire in a client’s room
D. Explosion at a local plant
The answer is C. A fire in a client’s room is an internal disaster
and the plan should be enacted by administrative staff.
A is incorrect—A plane crash is an external disaster and
requires an external disaster plan to be enacted. B is incorrect—
An infant abduction carries a separate plan of action
by the hospital and is not considered an internal disaster. D
is incorrect—An explosion at a local plant is an external disaster
and requires the external disaster plan to be enacted.
HEALTH PROMOTION AND
MAINTENANCE
Expected Body Image Changes
Assess occurrence of expected body image changes
73. A client is in the hospital after experiencing a burn to
the face. Which statement made by the client demonstrates
an acceptance of the change in her appearance?
A. “I will make sure to avoid going outside during the
day.”
B. “I am ready to look into the mirror.”
C. “I can put a scarf over my face so no one will
notice.”
D. “Going to a salon is worthless; a new hairstyle won’t
fix my deformity.”
The answer is B. This statement made by the client demonstrates
an acceptance of the changes that occurred as a result
of the burn. The client is ready to see her face after the event,
which is the first step to healing.
A is incorrect—This demonstrates that the client continues
to have a disturbed body image. C is incorrect—
Wearing a scarf is a sign that the client has not accepted the
changes that have occurred. D is incorrect—The client continues
with a disturbed body image and has yet to accept the
changes that have occurred. The client needs continued support
and counseling.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Reporting of Incident/Event/Irregular
Occurrence/Variance
Identify need/situation where reporting of incident/
event/irregular occurrence/variance is appropriate
74. The nurse should fill out an incident report for which
occurrence?
1092 PART III: Taking the Test
A. A client is found lying on the floor of his room.
B. An “as needed” medication is given for a complaint
of pain.
C. Calling a physician for an illegible order.
D. A medication is held due to a decreased blood pressure.
The answer is A. A client found lying in the floor is considered
an unexpected event and requires an incident report to
be completed.
B is incorrect—A medication given for the complaint of
pain is an expected occurrence and an incident report is not
needed. C is incorrect—Calling a physician for an illegible
order is preventing an error and does not require an incident
report. D is incorrect—Holding a medication due to a low
blood pressure is a valid nursing judgment and does not
require an incident report.
PSYCHOSOCIAL INTEGRITY
Crisis Intervention
Assess the need for, initiate, and maintain suicide precautions
75. A client presents to the emergency department and
states that he wants to kill himself. Which action by
the nurse is the priority?
A. Removal of client’s clothing.
B. Placement of client in room with camera.
C. Search of client for weapons.
D. Pad the side rails of the bed.
The answer is B. The first action by the nurse is to place the
client in a room with a camera. The client will need to be
monitored at all times and this is the best method.
A is incorrect—The client will need to remove clothing
that could be used to assist with a suicide but this needs to be
done in a room with a camera so that the staff can make sure
the client is not harming self while alone. C is incorrect—The
client’s clothing will be searched for a weapon upon removal
and the search of clothing is performed by security staff. D is
incorrect—The side rails do not need to be padded for a suicidal
client. The padding of side rails is reserved for the client
experiencing seizures.
PSYCHOSOCIAL INTEGRITY
Therapeutic Communications
Use therapeutic communication techniques to provide
support to client and/or family
76. A pediatric client is scheduled for a bone marrow
biopsy. The mother begins to sob stating, “I am a horrible
mother for letting this happen to my little girl.”
The nurse’s best response is:
A. to leave the mother alone to cry.
B. to ask “Is there anyone I can call for you?”
C. to call the physician and request a sedative for the
mother.
D. to state “You are not responsible for your child
being ill; you have placed your child in the best
environment for what she needs.”
The answer is D. The mother needs hope for the situation at
hand and needs to be reminded that this is not her fault and
that she is doing what is best for her child.
A is incorrect—Leaving the mom will only worsen the
situation. B is incorrect—The mother needs support at the
moment. Calling other family is helpful but does not address
the current situation. C is incorrect—The physician will not
be able to prescribe a sedative for the mother. The mother
must be of sound mind to make decisions for her child if
needed and a sedative would impair her mental state.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Personal Hygiene
Assist the client in the performance of activities of daily
living
77. Which of the following should a nurse perform every
day to ensure the client’s activities of daily living have
been met?
A. Set the client in a chair with the supplies needed to
bathe.
B. Administer medications on time.
C. Place a consult for occupational therapy.
D. Perform wound care.
The answer is A. The client needs to bathe every day, and to
assist the client the nurse should set him or her in a chair
and allow time for bathing.
B is incorrect—Administering meds is not ensuring that
activities of daily living have been met. C is incorrect—
Placing the consult does not ensure that activities of daily
living have been met. D is incorrect—Wound care is not part
of the client’s activities of daily living.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Expected Effects/Outcomes
Evaluate and document client response to medication
78. Which of the following is a sign that IV ondansetron
(Zofran) was therapeutic?
A. The client has a bowel movement within 6 hours.
B. The client no longer complains of a headache.
CHAPTER 34 Practice Test for NCLEX-RN® 1093
C. The client’s abdominal pain is relieved.
D. The client no longer complains of nausea.
The answer is D. Zofran is an antiemetic and is used for nausea
and vomiting associated with chemotherapy and surgery.
A is incorrect—Zofran, as with all antiemetics, has the
tendency to cause constipation. B is incorrect—Zofran does
not contain any pain-relieving properties. C is incorrect—
Zofran does not contain any pain-relieving properties.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Diagnostic Tests
Evaluate the results of diagnostic testing and intervene
as needed
79. The technician reports to the nurse that the client has
2 mm ST segment elevation in lead II and III on a 12lead electrocardiogram. What is the priority nursing
intervention?
A. Assess the client
B. Repeat the test
C. Administer Oxygen 2L NC
D. Phone the physician
The answer is A. When a nurse is presented with a suspicious
test result, the nurse must first assess the patient for signs and
symptoms of distress, as in this case, a suspected myocardial
infarction. This allows the nurse to intervene as needed.
B is incorrect—The test may be repeated after an assessment
of the client. C is incorrect—The nurse must first assess
the client before performing any nursing action. D is incorrect—
The physician is phoned after the nurse assesses the
client and any actions are taken that are deemed necessary.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-Specific Assessment
Identify factors that result in delayed wound healing
80. A nurse is assessing four of her assigned clients. Which
client is at the highest risk for delayed wound healing?
A. 18-year-old admitted after right knee arthroscopy.
B. 34-year-old diabetic admitted for hernia repair.
C. 64-year-old with peripheral vascular disease that
underwent a toe amputation.
D. 78-year-old with congestive heart failure admitted
for a thoracentesis.
The answer is C. The 64-year-old client with peripheral vascular
disease is at the highest risk for delayed wound healing.
The client has vascular deficiency already as evidenced by
the toe amputation. The body’s ability to transport oxygenrich
blood and nutrients to the area is compromised and the
client is likely to have difficulty healing from the procedure
due to the already compromised state.
A is incorrect—The 18-year-old is not likely to have
difficulty healing from the procedure. B is incorrect—While
34-year-old diabetic client will have difficulty with wound
healing, the 64-year-old client with peripheral vascular disease
is at the highest risk due to evidence of an already compromised
system. D is incorrect—The 78-year-old client with
congestive heart failure has a cardiac pump problem and will
have decreased blood supply; although, for this question, C is
the best answer.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic Procedures
Educate client and family about home management of care
81. A client is being discharged with a CPAP machine for a
diagnosis of sleep apnea. Which of the following
should be included in the discharge instructions?
A. Clean the face mask with bleach solution.
B. Stop using the machine if noise precipitates insomnia.
C. Place the mask securely on the face.
D. Redness to the face where the mask is placed is normal.
The answer is C. The mask should fit securely on the face to
prevent air leaking around the mask and causing eye irritation
and maintain desired outcome.
A is incorrect—The bleach solution will harm the
client’s skin; the mask should be cleaned with vinegar and
water solution. B is incorrect—The CPAP should be worn
as directed by the physician and if the noise is causing
insomnia, the physician should be notified. D is incorrect—
Redness to the face may indicate an allergic reaction
to the mask and should be reported to the physician.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
Perform or assist with dressing change
82. A nurse has an order to perform central line care.
Which action by the nurse will be best in removing
bacteria from the catheter insertion site?
A. Allowing the chlora-prep to dry on the site.
B. Scrubbing the insertion site for 2 minutes with
chlora-prep.
1094 PART III: Taking the Test
C. Wearing a mask during the procedure.
D. Placing a medicated disk (bio-patch) around the
insertion site.
The answer is B. Scrubbing the site with chlora-prep will be
best nursing action in removing bacteria from the site of the
catheter and prevent infection.
A is incorrect—The chlora-prep can dry on the site after
it is scrubbed. C is incorrect—Wearing a mask is beneficial
in preventing the introduction of new bacteria, but is not the
best action when removing bacteria from the catheter insertion
site. D is incorrect—Placing a bio-patch on the site will
prevent growth of bacteria but it is not the best action in
removing bacteria from the site.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Fluid and Electrolytes
Implement interventions to restore client fluid and/or
electrolyte balance
83. A client has a magnesium level of 1.4 mg/dL. The
nurse administers magnesium oxide at 1300 and
will plan on ordering a redraw of the magnesium
level at:
A. 1500
B. 1600
C. 1700
D. 2100
The answer is C. Magnesium has an onset of action in 3
hours of administration. The blood redraw is performed in
4 hours from administration to see if a desired response
occurred.
A and B are incorrect—These time frames are not long
enough from administration to onset for levels to increase. D
is incorrect—This time frame is too long from the time of
administration to know if desired outcomes occurred.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Hemodynamics
Apply knowledge of pathophysiology to interventions in
response to the client’s abnormal hemodynamics
84. Which client will not exhibit the expected assessment
findings in response to septic shock?
A. A client with a previous myocardial infarction.
B. A client who is taking a beta blocker for hypertension.
C. A client who performs peritoneal dialysis.
D. A client with diabetes.
The answer is B. A client taking a beta blocker will not exhibit
the heart rate change associated with septic shock and the
blood pressures will remain at a lower level.
A is incorrect—A client with a myocardial infarction
will exhibit the anticipated response. C is incorrect—A
client who performs peritoneal dialysis will have the findings
expected with septic shock. D is incorrect—While the client
with diabetes will have an alteration such as an increase in
blood pressure, the individual will exhibit the findings associated
with septic shock.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
Provide emergency care for wound disruption
85. List in order the steps the nurse will take if faced with
a wound dehiscence
___ Notify the physician
___ Cover the wound with sterile saline soaked gauze
___ Lay the client in low Fowlers and bend the client’s
knees
___ Instruct the client to splint the abdomen if needing
to cough
The client should first lie down initially to prevent further
strain on the incision site. Next, the nurse applies saline
soaked sterile gauze to the area to keep the area moist. The
nurse should then instruct the client on splinting during
coughing in the event he or she needs to cough while the
physician is being notified.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Unexpected Response to Therapies
Assess client for unexpected adverse response to therapy
86. A client is on the ventilator due to a diagnosis of acute
respiratory distress syndrome (ARDS). Which assessment
finding is most indicative of a complication?
A. Diminished breath sounds on auscultation
B. Deviation of the trachea
C. Weight gain
D. Decreased urine output
The answer is B. A deviated trachea is indicative of a tension
pneumothorax associated with noncompliant lungs (as with
ARDS) being ventilated at a higher pressure than the lung can
tolerate. This requires immediate intervention by the physician.
A is incorrect—Diminished breath sounds are common
in the client with ARDS due to decrease lung compliance
CHAPTER 34 Practice Test for NCLEX-RN® 1095
and collapsed alveoli. C is incorrect—While weight gain
may occur in ARDS, it is not the most indicative sign of a
complication. D is incorrect—Although decreased urinary
output is a problem and needs to be addressed, it is not the
most indicative sign of a complication.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic
Tests/Treatments/Procedures
Implement measures to manage/prevent/lessen possible
complications of the client condition and/or procedure
87. A client with a history of congestive heart failure
who has gained 3 pounds in 1 day should be placed
on:
A. 1800 calorie ADA diet
B. calorie count
C. fluid restriction
D. potassium restriction
The answer is C. The client who has gained more than 2
pounds in 1 day and has a history of congestive heart failure
should be placed on a fluid restriction to keep the client
from exacerbating his or her condition.
A is incorrect—The 1800 calorie ADA diet is for a diabetic
and will not be beneficial in this situation of volume
overload. B is incorrect—The client should not count calories
but count liquid intake in volume. D is incorrect—A
potassium restriction is not needed unless lab values indicate
a high potassium level.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Administer oxygen therapy and evaluate response
88. A nurse is assessing the vital signs of a client and notices
that the oxygen level is 91% on room air. The client complains
of a headache and wheezing is noted upon auscultation.
Which nursing intervention would be best?
A. Ask the client to sit in high Fowlers.
B. Ask the client to cough and reassess.
C. Apply 2 L of oxygen per nasal cannula.
D. Offer a pain medication for the headache.
The answer is C. The client has a low oxygen saturation level,
is wheezing, and has a headache. The headache could be
attributed to the low oxygen saturation level and so the nurse
should place oxygen on the client to see if symptoms improve.
The wheezing should be addressed with a bronchodilator.
A is incorrect—Making the client sit in high Fowlers will
not resolve the situation of a low oxygen level. B is incorrect—
Asking the client to cough is used when rhonchi is auscultated;
wheezing is due to a narrowing of the airway. D is incorrect—
Pain medication will worsen the oxygen saturation level.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Medical Surgical Asepsis
Assess client environment area for sources of infection
89. In the room of a client who has sustained a burn,
which of the following would be the greatest potential
source of infection?
A. Fresh flowers
B. Fresh fruit
C. Helium filled latex balloons
D. Staff
The answer is D. Staff is the greatest source of infection for
clients with a burn. For this reason, isolation is ordered for
most clients who have sustained a burn.
A is incorrect—Fresh flowers produce toxins as they die;
they are also a source of infection and should be limited in the
rooms of client’s with a burn. B is incorrect—Fresh fruit that is
to be eaten is safe in the room of a client as long as it has not
begun to rot. C is incorrect—Helium filled latex balloons are
safe as long as the client does not have a latex allergy.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Informed Consent
Ensure that client has given informed consent for treatment
90. A client is scheduled for a colonoscopy to be performed
this morning. Prior to preparing the client for
the procedure, the nurse must first:
A. ensure that the client has an advance directive in
the chart.
B. assess the client’s level of understanding about the
procedure.
C. verify that consent for the procedure has been
signed by the client.
D. verify that the client has not eaten since midnight.
The answer is C. Prior to preparing the client for the procedure,
the nurse must ensure a signed consent is on the chart.
The signing of the consent is the responsibility of the physician
who will be performing the surgical procedure.
1096 PART III: Taking the Test
A is incorrect—An advanced directive is desired but not
essential in the chart of a client who is going for a
colonoscopy. B is incorrect—The client’s level of understanding
regarding the procedure is required prior to consent
being signed. The signed consent establishes that the client
understands the procedure that the physician will perform. D
is incorrect—Verification that the client has remained NPO is
less of a priority than verification that consent is on the chart
prior to prepping the client for the procedure.
HEALTH PROMOTION AND
MAINTENANCE
Ante/Intra/Postpartum and Newborn Care
Assess client for symptoms of postpartum complications
91. Which assessment data would be most indicative of a
uterine infection in the postpartum client who underwent
a vaginal delivery?
A. Dark brown discharge from the vagina.
B. Pain at the site of the episiotomy.
C. Cramping in the lower abdomen.
D. Foul smelling vaginal discharge.
The answer is D. Foul smelling discharge is indicative of an
infection in the postpartum client and requires intervention.
A is incorrect—Dark brown discharge is old blood that
is being expelled through the vagina and is normal. B is
incorrect—Pain at the site of the episiotomy is normal until
healed. C is incorrect—Cramping in the lower abdomen
occurs as the uterus returns to its pre-pregnancy state.
HEALTH PROMOTION AND
MAINTENANCE
Principles of Teaching/Learning
Assess readiness to learn, learning preferences, and
barriers to learning
92. Which evaluation would be most indicative of readiness
to begin self-wound care?
A. The client does not wish to see the wound.
B. The client no longer needs pain medication before
wound care.
C. The client watches the nurse perform care of the
wound.
D. The client begins to ask questions about the care of
the wound.
The answer is D. When the client begins to ask questions
about the care of the wound he or she has taken an interest
in the procedure, which demonstrates a readiness to learn.
A is incorrect—If the client is unwilling to visualize the
wound then he or she is not ready to care for the wound. B is
incorrect—The client may no longer require pain medication
before wound care but that does not show a readiness to learn
how to care for the wound. C is incorrect—The client may
begin to watch the care of the wound prior to being ready to
take over the care. Watching the wound care is the first step
but is not most indicative of a readiness to begin self-care.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Mobility/Immobility
Maintain client skin integrity
93. Which of the following is the best method for preventing
skin breakdown in an immobile client?
A. Use of an alternating mattress.
B. Turning every 2 hours.
C. Keeping wrinkles out of sheets.
D. Elevating heels off of the bed.
The answer is B. The best method of preventing skin breakdown
is to turn the client every 2 hours.
A is incorrect—Even though a client uses an alternating
mattress, a staff member must still turn the client every 2
hours. C is incorrect—The client will benefit from removal of
wrinkles that may be in the sheets but it is not the best method
of preventing skin breakdown. D is incorrect—While elevating
the feet will prevent shearing, it is not the best method of
preventing skin breakdown for an immobile client.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Blood and Blood Products
Identify the client according to facility/agency policy
prior to administration of red blood cells/blood products
94. Which of the following is the first action a nurse must
take prior to initiating blood administration?
A. Check the chart for the physician’s order.
B. Ask the client to sign consent for blood.
C. Order a type and cross from the lab.
D. Check the chart for the hematocrit and hemoglobin
level.
The answer is C. Prior to blood administration, the nurse must
be sure an order is on the chart signed by the physician.
Without an order, the nurse cannot proceed with the process.
B is incorrect—The client should not sign consent unless
an order is present on the chart. For the options given, ensuring
an order is on the chart is the best answer. C is incorrect—
The physician must write an order for a type and cross to be
performed on the client. D is incorrect—After a physician’s
order is received, the nurse is responsible for checking the
client’s level before having a consent signed by the client.
CHAPTER 34 Practice Test for NCLEX-RN® 1097
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Pharmacological Pain Management
Evaluate and document client use and response to pain
medications
95. The assessment of a client complaining of pain is documented
as:
• RR 24
• BP 140/90
• HR 100
• grimacing, guarding
Demerol 50 mg IM was administered 30 minutes
prior to the pain reassessment. Which findings would
best indicate a therapeutic response to the medication?
A. RR 20
B. HR 95
C. BP 138/88
D. Patient resting with eyes closed
The answer is D. The client is resting now, which shows a resolution
from the grimacing and guarding the client was
demonstrating before pharmacological intervention.
A is incorrect—The respiratory rate is not the best indicator
of pain resolution. B is incorrect—The heart rate has
only decreased by 5 bpm, which is not a significant indicator
of pain relief. C is incorrect—The blood pressure has not
decreased enough to demonstrate pain relief and is not the
best indicator of pain relief.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Hemodynamics
Identify cardiac rhythm strip abnormalities
96. The nurse attaches an unresponsive client to the monitor.
What is the rhythm the nurse sees on the monitor?
A. Asystole
B. Ventricular fibrillation
C. Ventricular tachycardia
D. Torsades De Pointes
The answer is B. The rhythm is ventricular fibrillation. There
are irregular ventricular contractions due to the absence of
depolarization in the heart.
A is incorrect—With asystole, there is an absence of
impulses to cause ventricular contractions. C is incorrect—
Ventricular tachycardia exist with an increased and irregular ventricular
rate. D is incorrect—Torsades De Pointes is due to prolonged
repolarization and will progress to VF if left untreated.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
Apply knowledge of pathophysiology when caring for a
client experiencing a medical emergency
97. A client is brought to the emergency department after
working outdoors. The temperature is 99_F with a heat
index of 102. The nurses assess for which of the following
knowing it is the most indicative sign of a heat stroke?
A. Agitation, confusion
B. Nausea, headache
C. Shedding of clothes, unable to move
D. Syncope, neck stiffness
The answer is A. Agitation and confusion are the first signs
of a heat stroke due to the body’s response to the vasoconstriction
and subsequent cerebral hypoxia associated with
the body attempting to conserve fluid loss from sweating.
B is incorrect—Nausea and headache are common with
heat exhaustion. C is incorrect—The shedding of clothes
and inability to move is found with hypothermia. D is incorrect—
Syncope and neck stiffness are not associated with
heat stroke, but are associated with meningitis.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic
Tests/Treatments/Procedures
Implement measures to manage/prevent/lessen possible
complications of client condition and/or procedure
98. A client is being admitted to the floor from the emergency
department with possible seizures. Before the
client arrives to the floor, the nurse should plan on:
1098 PART III: Taking the Test
A. padding the rails of the bed.
B. placing a bed alarm on the bed.
C. placing restraints at the bed side.
D. placing the crash cart at the bedside.
The answer is A. The rails of the bed should be padded to
prevent injury if the client has a seizure while in the bed.
B is incorrect—Placing a bed alarm on the bed will not be
beneficial in protecting the client if he or she has a seizure. C is
incorrect—Restraints are not used on a client who might have
a seizure. D is incorrect—There is no need for the crash cart to
be at the bedside for a client with possible seizures.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
Counsel/teach client, family, or significant others about
managing client health problems
99. The nurse is teaching the client and the family regarding
peritoneal dialysis, which will be performed at
home. The priority discharge instruction is:
A. signs and symptoms of peritoneal infection.
B. how to care for and clean the catheter.
C. how to take a blood pressure and heart rate.
D. how long the procedure should take.
The answer is B. How to care for and clean the catheter is priority
teaching for the client. Prevention of infection is a high priority
for clients who are performing peritoneal dialysis at home.
A is incorrect—Signs and symptoms of peritoneal infection
are important and the client should be taught to report
these to the physician. C is incorrect—How to take a blood
pressure and heart rate is important but not necessary before
every at-home treatment unless the client has complaints. D
is incorrect—How long a procedure should take is important
but it is better to teach the client about how to measure input
to output to know that the treatment was successful.
PSYCHOSOCIAL INTEGRITY
Family Dynamics
Assist client/family/significant others to integrate new
members into family structure
100. A mother states that her 3-year-old potty trained child
has begun to urinate in his pants after the new baby
was brought home from the hospital. Which response
by the nurse is best?
A. “Children often regress when new members are
introduced; continue to remind him to go to the
rest room every hour.”
B. “Punish him before this becomes a pattern.”
C. “Children often regress at this age; it is normal and
will improve with time.”
D. “Talk to your child about what is occurring and
then show him he is still important by spending an
hour of one-on-one time with him every day while
someone watches the baby.”
The answer is D. The most important thing is to let the parents
know it is okay to talk about what is occurring with
their child and assist the family with a plan to help the child
feel loved and still an important member of the family.
A is incorrect—This does explain to the family what is
occurring but reminding the child to go to the restroom does
not show the child that he or she is still a valuable member of
the family. B is incorrect—Regression is a normal response to
a new family member and punishment does not validate normalcy.
C is incorrect—This will not resolve without intervention
by the parents. Waiting for change to occur without
action by the parents will only lead to more problems.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Laboratory Values
Provide client with information about the purpose and
procedure of prescribed laboratory tests
101. A client presents to the ED with chest pain. The nurse
draws blood during the initiation of an intravenous
line for a triponin and CPK. The client asks what this
test is for. The best response by the nurse is:
A. “the triponin looks for a heart attack.”
B. “the triponin will verify what the EKG shows.”
C. “the triponin is the cardiac marker test that shows
cardiac injury.”
D. “the triponin shows muscle damage.”
The answer is C. The triponin is the only test that is explicitly for
cardiac muscle ischemia making this the correct option.
A is incorrect—Although the client can have muscle
ischemia from lack of blood supply, it is not the only indicator
of a heart attack. B is incorrect—While the EKG and the
triponin are used as indicators of muscle ischemia, this test
is not used to verify another test. D is incorrect—The
triponin is specifically a cardiac marker test. The CPK is the
test that shows muscle damage.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Dosage Calculation
Perform calculations needed for medication administration
102. A client has ordered Cardizem 250 mg in 250 mL to
run at 10 mg/h. To deliver the ordered dose, the infusion
pump should be set at:
A. 8 mL/h
B. 10 mL/h
CHAPTER 34 Practice Test for NCLEX-RN® 1099
C. 5 mL/h
D. 1 mL/h
The answer is B. The concentration of drug is a 1:1 ratio. The
infusion pump should be set to 10 mL/h.
A, C, and D are incorrect—These choices would be
under dosing the client.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Assistive Devices
Assess client for actual/potential difficulty with communication
and speech/vision/hearing problems
103. Which of the following drugs requires regular hearing
exams with prolonged use?
A. Streptomycin
B. Ciprofloxacin (Cipro)
C. Hydromorphone (Dilaudid)
D. Isoniazid (INH)
The answer is A. The client who receives an aminoglycoside
such as streptomycin requires auditory exams routinely to
assess for hearing loss due to the drugs ototoxic affects.
B is incorrect—Cipro does not require routine exams of
any sensory functions. C is incorrect—Dilaudid causes CNS
depression, which leads to changes in respiratory rate and
blood pressure and does not require routine auditory exams.
D is incorrect—INH requires routine liver enzyme studies
due to the possibility of liver toxicity with use.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Resource Management
Plan safe, cost-effective care for the client
104. Which action by the nurse would be the safest and
most cost-effective when administering daily medications?
A. Administer all morning meds at the same time
regardless of time scheduled.
B. Date and time all IV tubing on piggybacks and continuous
infusions.
C. Use only one medicine cup per client when administering
meds in a 24-hour period.
D. Use Betadine versus alcohol swabs when cleaning
sites for injections.
The answer is B. Dating and timing all tubing for intravenous
medications and fluids eliminates the need to change tubing
each shift. Tubing is acceptable for continuous use 24 hours
after being attached to a bag and the client.
A is incorrect—Medications are scheduled by the pharmacy
and should be followed. Administering medications
as scheduled can prevent poor absorption and alterations
in the client’s physiologic status. C is incorrect—Using one
medicine cup per day is unsanitary and should be avoided.
D is incorrect—Betadine can damage the cells of the skin;
using Betadine is not recommended for routine injections.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Advance Directives
Provide client or family with information
about advance directives
105. While admitting a client to the unit, the nurse asks the
client if he or she has a living will. The client questions
the nurse as to what a living will is. The nurse’s best
response is:
A. “A living will lets the family know your wishes if
you go into cardiac arrest.”
B. “A living will is a legal document that explains your
wishes for health care depending on the severity of
your illness.”
C. “A living will is a written order by the physician.”
D. “A living will allows you to name someone to make
decisions for you.”
The answer is B. A living will is an advance directive that
states the wishes of a client in the event he or she is critically
or terminally ill.
A is incorrect—A living will states more than the wishes
of a client if he or she is in cardiac arrest. A living will not only
informs the family of the client’s wishes but also the health
care team. C is incorrect—“Do not resuscitate” is the order
written by the physician and placed in the chart after the
wishes are made known by the client in an advance directive.
D is incorrect—A living will does not allow the client to name
an individual to make decisions for him or her, a durable
power of attorney allows an appointed individual to make
decisions for the client anytime he or she is unable to do so.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Collaborate with Interdisciplinary Team
Identify significant information to report to other disciplines
106. A nurse enters a client’s room to administer ferrous sulfate
324 mg. When the nurse checks the MAR against
the medication, he or she notices that the dosage on
1100 PART III: Taking the Test
the package indicates ferrous sulfate 300 mg. Which
action would be the most appropriate?
A. Notify the pharmacist of the dosage error and
request the correct dosage.
B. Administer the medication since milligrams to be
administered is lower than the ordered dose making
it safe.
C. Hold the medication until the physician can be
notified.
D. Ask the nurse who cared for the client yesterday
what he or she administered to the client.
The answer is A. The nurse should phone the pharmacist first
to request the correct dosage for the client before it is administered.
B is incorrect—Administering a medication that is under
or over the ordered dose is a medication error unless an order
is written for the dose being administered. C is incorrect—
The pharmacy is responsible for dispensing medication and
needs to be notified of the error. D is incorrect—The nurse
should take responsibility for today and clarify the dosage
with the pharmacy.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Legal Rights and Responsibilities
Report unsafe practice of health care personnel to internal/
external entities
107. A nurse walks by the room of a client and sees a
licensed practical nurse beginning the administration
of blood. Which action by the nurse would be most
appropriate?
A. Confront the licensed practical nurse as to what is
occurring.
B. Check the chart of the client to see if blood was
ordered.
C. Report what was seen to the charge nurse.
D. Phone the board of nursing to report unsafe practice.
The answer is C. If a nurse suspects unsafe practice, it is
imperative he or she follows the chain of command and
report the nurse to the charge nurse. The charge nurse is
responsible for confronting the nurse and continuing to
report the nurse through the chain of command to the
appropriate individuals.
A is incorrect—It is policy of most institutions to report
unsafe practice to the nurse in charge of the unit. B is incorrect—
Regardless of the order, it is not in the scope of practice
of an LPN to administer blood. D is incorrect—The
nursing administration is responsible for reporting a nurse
for unsafe practice.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Supervision
Evaluate effectiveness of staff member’s time management
skills
108. Which assessment by the charge nurse is most indicative
that a staff member is demonstrating difficulty
with time management of daily assignments?
A. Performing 3 minute assessments on all clients.
B. Being unable to leave the unit by the end of shift.
C. Administering medications as scheduled.
D. Not meeting the standards of client care during the
shift.
The answer is D. Not meeting the standards of care is a sign that a
nurse has difficulty with time management. Nurses are required
to multitask to complete all assignments but meeting the standards
of care is essential and should never be compromised.
A is incorrect—A 3-minute assessment is acceptable on
a client that is not a new admission. It addresses the systemspecific
assessment and an overview of all other systems. B is
incorrect—Being unable to leave the unit when the day is
complete is not the highest indicator that a nurse has poor
time management skills. Not meeting the standards of care
ranks higher. C is incorrect—Administering medications on
time demonstrates that a nurse does have the correct priorities
for time management.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Security Plan
Participate in maintaining the institution’s security plan
109. The hospitals policy regarding infant abductions is
below:
Hospital Policy Regarding Infant Abductions: Code Pink
1. If an infant is found to be missing or is reported missing
by staff, phone the hospital operator immediately and a
code pink will be called over the intercom system.
2. All staff should stand by elevators, doors leading to
the outside, and stairwells in their department.
3. Anyone carrying a large bag, backpack, wearing a
heavy coat or appears to be pregnant should be followed
and a description of the person should be noted.
4. Phone security and follow the person.
5. Avoid confronting the individual, wait on security.
CHAPTER 34 Practice Test for NCLEX-RN® 1101
A nurse is working in a hospital and as she is exiting the
elevator on the main floor a code pink is called over the
intercom. Which action by the nurse is most appropriate?
A. Stand outside the elevator until an all clear is called.
B. Return to the assigned floor to stand outside the
stairwell.
C. Leave the elevator and go to a stairwell and stand.
D. Begin stopping all staff and visitors and ask them to
open bags and coats.
The answer is A. If a code pink is called, according to the policy
the staff is to stand by any port of exit. In this case, the
nurse should stand outside of the elevator so that it is
attended during a possible abduction.
B is incorrect—Returning to the assigned floor does not
follow the policy and leaves the elevator as a possible exit site
for the abductor. C is incorrect—The elevator is a portal of exit
as is the stairwell and so the one the staff member is at should
be manned. D is incorrect—According to the policy, staff
should not confront anyone suspected of being the abductor,
but follow the possible abductor and phone security.
HEALTH PROMOTION AND
MAINTENANCE
Health Promotion Programs
Instruct client on ways to promote health
110. A male should be instructed on using which method
when performing a routine testicular self-examination?
A. Perform before taking a shower.
B. Perform every 3 months.
C. Roll the testicle between the thumb and fingers.
D. Pinch the epididymis until sensation is loss in the
penis and release.
The answer is C. The client should be instructed to roll the testicle
between the thumb and fingers to monitor for abnormalities.
A is incorrect—The test should be performed after taking a
shower so that the scrotum is relaxed. B is incorrect—Self-exams
should be performed every month to monitor for changes so
they can be caught early. D is incorrect—The epididymis should
not be pinched due to the potential for damage to the structure.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Handling Hazardous and Infectious Materials
Identify biohazardous, flammable, and infectious materials
111. Which of the following should be placed in a biohazardous
bag?
A. Foley urine bag of a client with CHF.
B. Used intravenous medication bag of a client suffering
from dehydration.
C. Soiled diaper of a client with Clostridium difficile.
D. Syringe used to flush a central line.
The answer is C. Clostridium difficile is highly contagious and
the stool of this client should be placed in a biohazardous
bag for proper disposal.
A is incorrect—A client’s Foley bag should be emptied
in the toilet prior to throwing the bag in the trash can which
removes waste into the appropriate facility. B is incorrect—A
used intravenous bag can be thrown into the trash can in a
client’s room as long as a name is not on the bag. If a name is
on the bag, the label should be removed and the bag can be
placed in the trash receptacle. D is incorrect—A syringe used
to flush a central line should be placed in a sharps receptacle
and not into a biohazardous bag.
PSYCHOSOCIAL INTEGRITY
Mental Health Concepts
Explore why the client is refusing/not following the
treatment plan (e.g., nonadherence)
112. A client with end stage renal disease (ESRD) tells the
transporter that he is not going down for his dialysis
treatment today. The nurse should
A. tell the client that it is okay and he can go tomorrow.
B. notify the physician.
C. ask the client if he is frustrated with the process of
dialysis.
D. tell the client he will need to sign an “Against
Medical Advice” form.
The answer is C. The most common reason for nonadherence to
treatment regimens is a frustration with the procedure and the
aspects of the disease process. Acknowledging that the client
may be unhappy with the demands of the disease and the loss
of control over life will help the nurse and client devise a plan to
meet the treatment regimen that benefits both parties.
A is incorrect—The client needs to go to dialysis every
scheduled day, telling him it is okay to miss a treatment will
enable him to refuse every treatment and does not determine
why he refused. B is incorrect—Notifying the physician does
not explore why the client refused today’s treatment. D is
incorrect—Having the client to sign an AMA form does not
explore why the client refused today’s treatment.
PSYCHOSOCIAL INTEGRITY
Support Systems
Promote independence of client/family/significant others
113. Which of the following would promote independence
in the client who recently underwent a below-the-knee
amputation?
1102 PART III: Taking the Test
A. Teach range of motion exercises.
B. Provide the client with a wheelchair.
C. Instruct the client on proper wound care.
D. Provide analgesics for pain relief.
The answer is B. The client has the disability of limited mobility
after an amputation. Providing the client with a wheelchair
will enable him or her to move around in the environment
and continue with independent activities.
A is incorrect—While a range of motion exercises prevent
contractures and prepare the stump for prosthesis, it is
not the best method of promoting independence initially. C
is incorrect—Instructing the client on wound care promotes
readiness to care for self, but does not promote independence
overall. D is incorrect—Analgesics do not promote
independence for the client.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Palliative/Comfort Care
Assess client’s symptoms related to end of life
114. Which of the following would a nurse find in her
assessment of a client that is nearing the end of life?
(Check all that apply.)
___ Decrease in time spent sleeping
___ Loss of appetite
___ Alteration in mental status
___ Generalized weakness
___ Periods of apnea
___ Seizures
The answers are loss of appetite, alteration in mental status, generalized
weakness, and periods of apnea. These are consistent with the
findings a nurse might see in his or her assessment of someone
nearing the end of life. The loss of appetite is due to the decrease
in metabolism that the body undergoes at death. Generalized
weakness and an alteration in mental status is due to the
changes in metabolism as well. Periods of apnea occur and are
called Cheyne-Stokes; panting respirations will accompany the
periods of apnea in some cases.
Incorrect answers are decrease in time spent sleeping
and seizures. The client will often have an increase in time
sleeping and seizures are uncommon.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Review pertinent data prior to medication administration
115. The morning assessment of a client reveals this data:
• BP 90/60
• HR 110
• RR 20
• Temp 98.9
The nurse should hold which of the following drugs:
A. levothyroxine (Synthroid)
B. carvedilol (Coreg)
C. gabapentin (Neurontin)
D. pioglitazone (Actos)
The answer is A. The nurse should hold the dose of
Levothroid if the client has a resting pulse of greater than
100 bpm. This is a sign of hyperthyroidism and a dose will
only compound the problem.
B is incorrect—While the blood pressure is borderline,
it is within normal limits. Coreg is a beta blocker and is
needed to lower the heart rate. C is incorrect—Neurontin is
a drug used for nerve pain and there are no contraindications
to administration based on vital signs. D is incorrect—
Actos is used to serum glucose levels and does not carry a
contraindication based on vital signs.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Total Parenteral Nutrition
Provide client/family/significant others with information
on TPN
116. A family is taking a client home that will be receiving
total parenteral nutrition (TPN). The family should be
instructed on:
A. how to perform glucose monitoring.
B. how to change the intravenous dressing every
24 hours.
C. how to dilute the TPN solution.
D. how to turn off the infusion pump.
The answer is A. The client receiving total parenteral nutrition
requires frequent monitoring of glucose levels. The client’s
family will need to learn how to assess the client’s glucose level
and what action to take depending on the outcome.
B is incorrect—The dressing is changed every 48–72
hours unless contamination is suspected. Changing more
often than needed is not cost-effective and opens the site to
the possibility of contamination. C is incorrect—The TPN
solution should not be diluted. The solution should be
administered in its prepared form. D is incorrect—The infusion
should never be stopped or changed abruptly to allow
time for the body to change its metabolic needs.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Alterations in Body Systems
Identify client potential for aspiration
117. Which client is at the highest risk for aspiration pneumonia?
CHAPTER 34 Practice Test for NCLEX-RN® 1103
A. A client who has a nasogastric tube to low suction
and an endotracheal tube in place.
B. A client who has a PEG tube feeding and is lying at
20 degrees
C. A client who has recently undergone surgery and is
eating clear liquid diet.
D. A client who has returned from esophageal dilatation
and is ready for discharge.
The answer is B. A client who has a PEG tube should not
lie below 30 degrees to prevent aspiration of gastric contents.
A is incorrect—A client with an endotracheal tube has a
protected airway and aspiration is not a worry. C is incorrect—
A client on a clear liquid diet has an intact gag reflex
and aspiration is a low risk. D is incorrect—A client who has
undergone an esophageal dilatation and is ready for discharge
is at a low risk for aspiration.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications from Surgical
Procedures and Health Alterations
Apply knowledge of pathophysiology to monitoring for
complications
118. A client has returned to the floor following a transverse
loop colostomy. Which assessment finding would be
indicative of a complication?
A. Hypoactive bowel sounds
B. A dusky color to the stoma
C. Liquid stool measuring 900 mL
D. Scant bleeding at the stoma site
The answer is B. A dusky colored stoma reveals that necrosis is
occurring to the bowel that has been brought to the surface.
The physician needs to be notified of this finding.
A is incorrect—Hypoactive bowel sounds are expected
following a colostomy and are no cause for concern postoperatively.
C is incorrect—Liquid stool is a normal finding following
a colostomy. The bowel will need time to begin reabsorbing
water from the GI track before stool will be more
formed. D is incorrect—Scant bleeding is normal following a
colostomy and is due to a rich blood supply from the GI track.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-Specific Assessment
Assess client for signs of hypoglycemia or hyperglycemia
119. A nurse is performing the morning assessment on a
client that has a diagnosis of diabetes mellitus controlled
by diet. Which assessment finding requires
notification of the physician?
A. Urine output of 1000 cc in 2 hours
B. BP 140/90
C. Heart rate 100
D. Temp 99.9_F
The answer is A. Polyuria is indicative of hyperglycemia and
requires the physician to be notified so that orders can be
written for fluid replacement and insulin administration if
needed.
B is incorrect—This is borderline hypertension, but
does not require notification of the physician. A reassessment
of the blood pressure should occur. C is incorrect—
Mild tachycardia is not a reason to consult the physician.
The tachycardia may be secondary to the polyuria and may
resolve when the condition improves. D is incorrect—This is
a mildly elevated temperature and does not require notification
of the physician.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic Procedures
Provide pre- and/or postoperative education
120. Prior to a client undergoing a pinning of the right hip,
the client should be instructed on:
A. how to use the client controlled analgesic pump.
B. when he can expect to eat a meal.
C. how soon after surgery discharge is possible.
D. how to care for the surgical wound.
The answer is A. The client should be instructed on how to
use the client controlled analgesic pump prior to surgery to
ensure understanding has occurred.
B is incorrect—When the client can eat is not something
the nurse must prepare the client for prior to a
surgical procedure. C is incorrect—Discharge is based
on the individual’s progress and the physician is
responsible for writing the order and discussing a time
frame for discharge with the client. D is incorrect—
How to care for the wound occurs after the surgery
when the client feels he or she is ready to take over the
care.
PSYCHOSOCIAL INTEGRITY
Family Dynamics
Assess parental techniques related to discipline
121. A school nurse is evaluating families during an open
house at a school. Which assessment indicates
1104 PART III: Taking the Test
abnormal discipline techniques and requires intervention?
A. A mother telling her child she will place her in
“time out” once they are at home.
B. A mother yelling at her child to “behave” during a
walk down the hall.
C. A mother stating “When we get home, I will beat
you with a belt.”
D. A mother stating “You need to learn to control your
behavior or you will go straight to bed when we are
home.”
The answer is C. The mother is threatening the child with
physical harm, which is a sign of abuse and should be acted
on by the school nurse. Not reporting abuse or suspected
abuse places the child in danger.
A is incorrect. Placing a child in “time out” is an appropriate
method of discipline. B is incorrect—Asking a child to
“behave” is a normal form of parental discipline. D is incorrect—
Threatening a child with going to bed does not place
the child in physical harm and is an appropriate form of
parental discipline.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Radiation Therapy
Implement interventions to address side/adverse effects
of radiation therapy
122. A client has experienced mucositis while undergoing
radiation therapy. Which nursing action will be best to
assist the client’s nutritional intake?
A. Offer the client foods with enhanced taste.
B. Offering a commercially prepared mouth rinse.
C. Offer the client bland, soft foods such as puddings,
shake.
D. Administer oral antibiotics to the client to swish
daily.
The answer is C. The client should avoid spicy or hard foods
if mucositis occurs. By offering the client foods that are
bland and soft, he or she will be more likely to continue eating
and maintain a nutritional intake sufficient for the body’s
needs.
A is incorrect—Offering foods with enhanced taste is
equivalent to offering foods with spices. These foods may
irritate or worsen the condition. B is incorrect—Most
mouthwashes contain alcohol, which can worsen the
mucositis. The client should rinse with water and hydrogen
peroxide. D is incorrect—Oral antibiotics will not be beneficial
in assisting the client with his or her nutritional intake
when mucositis is present.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Hemodynamics
Connect and maintain pacing devices
123. Place an X where the nurse will place the pads for pacing
on a client who is in a third-degree heart block
with a rate of 38.
The pads should be placed on the anterior chest wall and the
back for external, noninvasive transcutaneous pacing.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-Specific Assessment
Perform focused assessment or reassessment
124. A client is admitted for pneumonia. Which assessment
finding is most indicative of a potential complication?
A. Skin that appears dry
B. Clear sputum
C. Asymmetric fremitus
D. Bronchiovesicular breath sounds
The answer is C. Asymmetric fremitus is a significant finding.
Fremitus is the vibration felt upon palpation in pneumonia.
If this is asymmetrical, it means that the side with fremitus
may have a tumor or the side without fremitus may be
indicative of a pneumothorax. Decreased fremitus occurs
when there is excess air in the lung space.
A is incorrect—Skin can appear dry and still be considered
normal. B is incorrect—Clear sputum is a normal finding.
D is incorrect—Bronchiovesicular breath sounds are the
normal sounds heard upon auscultation of the lung fields.
HEALTH PROMOTION AND
MAINTENANCE
Immunizations
Identify precautions and contraindications to immunizations
125. The MMR (measles, mumps, rubella) vaccine should
be held if the client has a history of
CHAPTER 34 Practice Test for NCLEX-RN® 1105
A. anaphylactic reaction to eggs.
B. HIV.
C. rotavirus.
D. tuberculosis.
The answer is A. A client with a history of an anaphylactic
reaction to eggs should not receive the MMR vaccine.
B is incorrect—A history of HIV is not a contraindication
to the MMR vaccine. C is incorrect—The rotavirus is
not a contraindication to receiving the MMR vaccine. D is
incorrect—A client with tuberculosis or a positive PPD skin
test can still receive the MMR vaccine.
HEALTH PROMOTION AND
MAINTENANCE
Disease Prevention
Inform client/family/significant others of actions to
maintain health and prevent disease
126. While preparing a client for discharge, which of the
following should be included in the discharge instructions
for a client who received stents during a heart
catheterization?
A. Eat foods high in fat
B. Exercise daily
C. Limit fruits and vegetables
D. Increase intake of garlic
The answer is B. A client with new stents should exercise
daily to maintain proper blood flow and improve overall
health.
A is incorrect—Eating foods high in fat should be
avoided after stent placement to prevent occlusion due to
plague accumulation. C is incorrect—A client who has
undergone stents needs a diet of fruits and vegetables for
heart health. D is incorrect—Garlic should be avoided and
may interact with postprocedure prescription medications
administered at home.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Case Management
Plan individualized care for client based on need
127. A client is being discharged from the hospital after
experiencing a myocardial infarction. The client
desires to have home health care scheduled to make
biweekly visits. Which finding in the discharge
needs assessment indicates that home health care
will not be beneficial?
A. The client does not have a home telephone.
B. The client does not have a wheelchair ramp to get
into the home.
C. The client is unable to drive.
D. The client does not have family in town to check on
him daily.
The answer is A. If the client does not have a home telephone,
he or she will not have the ability to call 911 for an emergency
or a method for the home health care agency to contact
the client, which is a requirement for admission into
home health care services.
B is incorrect—The question does not state that there is
a need for a wheelchair ramp. C is incorrect—In order for a
client to receive home health care, he or she is considered
homebound and the inability to drive is irrelevant. D is
incorrect—Not having family in town does not indicate that
home health care will not be beneficial.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Consultation
Initiate consultations
128. Which of the following clients would benefit from the
social services department consultation for help with
prescription medications? (Check all that apply.)
___ A disabled veteran who uses the veterans’ hospital
facilities.
___ A homeless client with HIV.
___ A elderly client who has Medicare.
___ A child who does not have health insurance.
___ A client who is employed but is without health
insurance.
___ A teenager who is currently enrolled on his parents’
health insurance.
The homeless client, the child, and the client who is
employed all are without health insurance and would benefit
from social services for assistance with payment for prescription
medications. These clients are the best choice for
the answer since they are without any governmental or private
assistance.
The veterans’ hospital will assist the client who is a
veteran, Medicare has prescription cards that are dependent
upon the need of the client, and the teenager who is on
his parent’s health insurance will have coverage for medications.
1106 PART III: Taking the Test
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Ergonomic Principles
Review necessary modifications with client to reduce
stress on specific muscle or skeletal groups
129. An elderly client is going home after hip replacement
surgery. Which discharge instructions are most appropriate
for this client?
A. Turn kneecap toward body while standing still to
maintain balance.
B. Avoid crossing legs while sitting in a chair.
C. Keep the operative leg behind you when bending.
D. Use a long handled grabber to reach.
E. Avoid using an elevated toilet seat.
F. Keep a pillow between legs while sleeping.
The answers are B, C, D, and F. These activities will allow the
client to avoid flexion greater than 90 degrees, adduction of
the hip and internal rotation of the hip, which can cause the
prosthesis to become dislocated.
A and E are incorrect answers—The client should not
cause adduction by placing the kneecap inward toward the
operative side to maintain balance. If balance is in question,
an alternative assistive device should be used. Avoiding an
elevated toilet seat is incorrect since it is recommended that
clients use an elevated toilet seat to ease with standing and
help to avoid dislocation of the prosthesis while standing
and sitting.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Nonpharmacological Comfort Interventions
Provide therapies for comfort and treatment of inflammation
and swelling
130. A client has undergone repair of a fractured femur. Which
nonpharmacological therapy is best for reducing swelling?
A. Application of heat.
B. Application of compression bandages.
C. Elevation of affected leg.
D. Acupuncture therapy.
The answer is C. Elevation of the leg will decrease swelling
and subsequent pain in the leg.
A is incorrect—Heat is used to reduce muscle spasms
and not for the reduction of swelling. Ice is used for the
reduction of swelling. B is incorrect—Compression bandages
are used to prevent deep vein thrombosis and do not
provide relief from swelling. D is incorrect—Acupuncture
therapy is an alternative therapy for pain relief but does not
aid in the reduction of swelling.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications and Side Effects
Identify symptoms/evidence of an allergic reaction
131. A client has an order for an intravenous injection of
sodium ferric gluconate complex (Ferrlecit). Which
nursing action would be best in monitoring for allergic
reaction to the medication?
A. Administer the dose in twice the recommended
time frame.
B. Perform an iron reaction scan prior to administration.
C. Administer 10 gtts/min for a 10 minute test dose.
D. Assess the client for allergy to eggs and wheat.
The answer is C. A test dose of 10 drops/minute for 10 minutes
is best to monitor for allergic reaction to the iron-containing
product.
A is incorrect—Administering a dose faster than the recommended
time frame is not safe nursing practice and can
lead to undesired effects. B is incorrect—There is no such
scan as an iron reaction scan. D is incorrect—While a client
taking iron supplements should avoid using eggs or whole
grain breads an hour after the administration of iron-containing
medications, there is no evidence of a correlation
between these items and reactions to iron medications.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Establishing Priorities
Assess/triage client(s) to prioritize the order of care delivery
132. Which client should be assessed first upon receiving
report?
A. A 70-year-old postop client with hip replacement
who has a new onset of A-fib.
B. A 54-year-old client admitted 2 hours ago with
chest pain, which is relieved by ketorlac (Toradol)
while in the ED.
C. A 69-year-old client scheduled for discharge today
after being treated for a pulmonary embolism.
D. A 75-year-old client admitted 2 days ago for a
myocardial infarction who has been transferred
from CCU during the night shift.
The answer is A. The client who has a rhythm change is a priority
to assess for symptoms associated with atrial fibrillation,
CHAPTER 34 Practice Test for NCLEX-RN® 1107
such as shortness of breath and/or chest pain. This client is
already at a high risk for thrombosis due to the nature of the
surgical procedure.
B is incorrect—A client whose pain was relieved by an
antiinflammatory is lower priority than option A. C is incorrect—
A client who is scheduled to be discharged receives
the last assessment of all four. This client is considered stable
if discharge was ordered by the physician. D is incorrect—A
client who is transferred from CCU is considered stable and
requires assessment after the client described in option A.
HEALTH PROMOTION AND
MAINTENANCE
Growth and Development
Compare client psychosocial/behavioral/physical development
to norm for age/developmental stage of client
133. Which of the following is an abnormal finding in the
growth and development assessment of a 6-month-old
client?
A. Imitates sounds
B. Bears weight on hands while prone
C. Holds bottle
D. Pulls self to standing position
The answer is D. A child does not pull self to standing position
until the ninth month. A 6-month-old child will bear
most of weight if held in standing position by an adult.
A is incorrect—A 6-month-old child will babble sounds
such as ma and hi. B is incorrect—A child of this age can
bear weight on hands while prone and will lift chest and
upper abdomen. C is incorrect—A child of this age can hold
a bottle without assistance.
PSYCHOSOCIAL INTEGRITY
Behavioral Interventions
Orient client to reality
134. A client presents to the emergency department stating
that he is an FBI agent and is there to secure the building.
Which technique will be best in caring for this client?
A. Following with the story and allow the client to
continue with the delusion.
B. Medicate the client till sedation occurs.
C. Tell the client that he is in a hospital and he does
not work for the FBI.
D. Ask the client if he has used drugs in the last 24 hours.
The answer is C. The client needs to be oriented to reality to
begin the process of treating the delusion.
A is incorrect—The nurse should not follow with the
story, this only feeds the delusion and does not allow for
interventions to begin. B is incorrect—The client does not
need sedation until an assessment can be performed to see if
the client is a danger to self or others and what other manifestations
are associated with the current delusion. D is
incorrect—The client is delusional and will not be able to
tell the nurse what occurred in the last 24 hours.
Psychosocial Integrity
Situational Role Changes
Evaluate whether client/family/significant others have
successfully adapted to situational role changes
135. Which statement made by a client’s wife indicates that
she has not accepted her husband’s acute condition?
A. “I will call a gardener to take over the yard until my
husband recovers.”
B. “I know my husband will recover faster than
expected and be ready to go back to work.”
C. “I will look into how we can modify our schedule so
someone can always be by his side in the hospital.”
D. “I have planned on having someone at home to help
me when we are discharged.”
The answer is B. The wife has not accepted her husband’s illness
and the change in her role in the family as the support
person and the caregiver.
A is incorrect—The wife realizes her husband is ill and
will not be able to continue strenuous labor at the home. C
is incorrect—The wife understands her role change as the
caregiver and is ready to change as needed. D is incorrect—
The wife understands her husband’s illness and the need to
gather support personnel to assist where needed.
PSYCHOSOCIAL INTEGRITY
Therapeutic Environment
Make client room assignments that promote the therapeutic
milieu
136. When planning to provide a therapeutic environment
for a client, the appropriate room assignment for a
client who has recently been diagnosed with breast
cancer is
A. a room with a client who has renal cell carcinoma.
B. a room with a client who has bone cancer.
C. a room with a client who recently underwent a mastectomy.
D. a room with a client who is scheduled for a lobectomy.
The answer is C. The client who has been diagnosed with
breast cancer will be able to relate to the client who has undergone
a mastectomy providing for a therapeutic environment.
A is incorrect—The client who has renal cell carcinoma
is not a therapeutic choice for the client since the cancers
1108 PART III: Taking the Test
differ and the treatments will differ as well. B is incorrect—
The client with bone cancer is in chronic pain; therefore,
sharing a room with a client is not a therapeutic environment
for either. D is incorrect—A client who is undergoing
a lobectomy is not a therapeutic choice for the client who
has breast cancer due to the difference in the type of cancer
and the treatments.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Administer and document medications given by common
routes
137. Which of the following forms of insulin can be given
intravenously?
A. Novolin 70/30
B. Novalog
C. Lantus
D. Novolin-R
The answer is D. Regular insulin is a short-acting insulin and
is the only insulin approved to be given intravenously.
A is incorrect—Novolin 70/30 is a combination of 70%
NPH and 30% regular insulin and therefore contains a short
and intermediate acting form of insulin and is only
approved to be administered subcutaneously. B is incorrect—
Novalog is a rapid-acting insulin and is only administered
subcutaneously. C is incorrect—Lantus is a long-acting
insulin and is not approved to be given intravenously,
only subcutaneously.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Laboratory Values
Know laboratory values for ABGs, BUN, cholesterol, glucose,
hematocrit, hemoglobin, hemoglobin A1C, platelets,
potassium, RBC, sodium, urine-specific gravity, and WBC
138. The respiratory therapist draws ABGs and shows them
to the nurse. Which state is the client currently in
based on the values:
• pH: 7.39
• CO2: 40
• HCO3: 23
• PaO2: 90
A. Metabolic acidosis
B. Respiratory acidosis
C. Respiratory alkalosis
D. Homeostasis
The answer is D. The client’s values are within normal limits and
the client has compensated and is a state of homeostasis.
A is incorrect—For a client to be in a state of metabolic
acidosis the pH less than 7.35 and the HCO3 less than 22. B
is incorrect—The client would need a pH less than 7.34 and
a CO2 greater than 45 to be in a state of respiratory acidosis.
C is incorrect—The client would need a pH greater than
7.45 and CO2 less than 45.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic
Tests/Treatments/Procedures
Intervene to manage potential circulatory complications
139. A client is found lying on the floor after a fall out of the
bed. On assessment, the left foot appears shorter than
the right and externally rotated. Palpation of the
affected leg reveals a cold extremity with no palpable
pulse at the doralis pedis or the posterior tibial. What
is the priority nursing action?
A. Palpate for a popiteal pulse
B. Call the physician
C. Try to realign the injured leg
D. Elevate the injured leg and reassess
The answer is B. When an injury has caused disruption of the
neurovascular system to the point that pulses are lost, the
physician must be notified immediately so that action can be
taken to prevent the tissue in the affected extremity from
becoming necrotic.
A is incorrect—Palpating for a popiteal pulse would show
whether the injury was severe enough to cause vascular compromise.
Regardless if a pulse is present or not at the popiteal
site, the area distal is without adequate blood supply and the
physician needs to be notified immediately. C is incorrect—
An injured leg should not be realigned by the nurse to prevent
further injury. D is incorrect—The leg should not be elevated
to prevent further injury to the vascular system.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
Monitor and maintain the client on a ventilator
140. A client is placed on the ventilator and has positive
end-expiratory pressure (PEEP) added. Which assessment
data will be most indicative of a potential complication?
A. Tachycardia
B. Wheezes
CHAPTER 34 Practice Test for NCLEX-RN® 1109
C. Hypotension
D. Hypertension
The answer is C. Hypotension is a sign of a complication.
Hypotension can be related to a decreased venous return or
a pneumothorax. Assessments should follow that determine
the cause of hypotension.
A is incorrect—Tachycardia is due to the body’s
response to the illness and is not necessarily indicative of a
complication. B is incorrect—Wheezing is due to bronchial
constriction and is common with intubation. D is incorrect—
Hypertension is due to the physiological response to
the stress the client is under.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Fluid and Electrolytes
Implement interventions to restore client fluid and/or
electrolyte balance
141. A client has a sodium level of 153. The nurse consults the
physician and is given orders for dietary restrictions. The
nurse should instruct the client to avoid which foods?
A. Cheese
B. Squash
C. Tomatoes
D. Apples
The answer is A. Cheese is considered to be high in sodium
and should be restricted for the client who has a high
sodium level.
B, C, and D are incorrect—These items are fresh foods
and are not considered to be high in sodium.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Hemodynamics
Assess the client for decreased cardiac output
142. A client with congestive heart failure has been coughing
up pink frothy sputum and exhibiting shortness of
breath. The client’s assessment 1 hour ago revealed:
• BP 80/40
• HR 90
• rhonchi upon auscultation
• oxygen saturation 90%
• normal sinus rhythm
Which assessment finding shows a worsening in the
client’s condition and a decrease in the client’s cardiac
output?
A. Premature ventricular contractions
B. HR 99
C. Wheezing upon auscultation
D. Oxygen saturation of 89%
The answer is A. Premature ventricular contractions are a
direct result of cardiac muscle hypoxia, which is secondary to
the pulmonary edema. PVCs do not allow for the diffusion of
gasses to occur across the alveolar capillary membrane. All of
this is directly proportional to the decrease in the cardiac
output, which has caused blood to back up into the lungs.
B is incorrect—The heart rate change is due to the body
trying to compensate for the state of hypoxia that exist by
pumping faster in an attempt to supply dying cells with oxygen.
C is incorrect—Wheezing does not indicate a worsening in the
cardiac output. D is incorrect—The hypoxia is still present and
is not the best indicator of a worsening in the client’s condition.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
Monitor and maintain a client on the ventilator
143. A client on the ventilator becomes agitated and restless.
Which action by the nurse is best?
A. Check the cuff pressure on the tube.
B. Remove the ventilator and bag the patient.
C. Assess for breath sounds.
D. Restrain the client to prevent tube dislodgement.
The answer is C. The client should be assessed for breath
sounds to see if ventilation is occurring. Agitation is often
due to hypoxia and lack of adequate ventilation would be
seen with absent breath sounds.
A is incorrect—Checking the cuff pressure will not
assist in determining the source of agitation. B is incorrect—
Bagging the client will not be beneficial if the tube is not in
the lungs. D is incorrect—Restraining the client will prevent
tube dislodgement but it is not the best method to determine
the cause of the agitation.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Unexpected Response to Therapies
Assess the client for unexpected adverse response to
therapy
144. Which of the following are preventable adverse outcomes
to the placement of a urinary catheter?
___ Infection
___ Urethral damage
1110 PART III: Taking the Test
___ Ureter damage
___ necrosis of the meatus
___ Vaginal tearing
A client who has an indwelling urinary catheter may develop
infection from nonmaintenance of sterile technique, urethral
damage if the balloon is placed in the urethra, and necrosis
of the meatus due to shearing of the catheter on the meatus.
All these are preventable by appropriate nursing actions
such as maintenance of sterile technique and meticulous
perineal care, ensuring the balloon is in the bladder before
inflation, and applying a lubricant to the meatus to lessen
shearing.
Ureter damage should not occur since the tube does go
above the structure of the bladder. Vaginal tearing should
not occur since the catheter is placed in the bladder and not
the vaginal area.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Identify signs and symptoms of impaired cognition
145. An elderly client is brought to the emergency department
after being found trying to enter a home. The
paramedics state that the client says she is 25 years
old and lives in the home. The client is barefoot and
has feces- and urine-stained clothes. The first nursing
action is to:
A. provide the client with a change of clothes.
B. assess the client for bruising/injuries.
C. reassure the client that she is safe and in a hospital.
D. ask the client her name and date of birth.
The answer is C. The client should be assured that she is safe
and of her location. Then the physical assessment can continue.
A is incorrect—The client can undergo a change of
clothes after trust is formed. B is incorrect—The client’s physical
exam will show any bruising or injuries after the client is
assured of her safety. D is incorrect—The client will not give
the correct date of birth due to her current confused state.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Vital Signs
Evaluate invasive monitoring data
146. A client has a ventriculostomy after suffering a traumatic
brain injury. The monitor is measuring the
intracranial pressure at 30 mm Hg. Which nursing
action is best for this client?
A. Raise the head of bed to 30 degrees.
B. Assess the client for peripheral edema.
C. Dim the lights and place the bed at 15 degrees.
D. Suction the client.
The answer is C. The client should have minimal stimuli and
the bed should not be at a height that will cause increased
pressure. This will help to lower the intracranial pressure
and prevent it from rising.
A is incorrect—Raising the bed to semi Fowlers will
cause the pressure to rise. B is incorrect—The client has
increased pressure in the cranial vault. Assessment for
peripheral is not a priority action for this situation. D is
incorrect—Suctioning the client will increase the pressure,
which can lead to ischemia of the brain.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Informed Consent
Identify appropriate person to provide informed consent
for client
147. An unidentified client is brought to the emergency
department after being found on the side of the road
with multiple stab wounds and an obvious head
injury. After a series of radiological test, it is found
that the client has a lacerated liver, brain injury, and
needs immediate surgery. Which of the following
would be best in obtaining consent for the surgical
procedure?
A. The client should be placed in state custody and
consent obtained from the appropriate personnel.
B. The physician should consider this implied consent
and should follow the hospital policy for the
situation.
C. The nurse should sign consent for the client as the
client advocate.
D. The facility should wait to see if the client wakes up
to give consent.
The answer is B. The hospital policy should be followed in
this situation. In implied consent, the law recognizes that
client in need of life saving measures will be provided with
those measures unless documents can be provided that
states otherwise. In this situation, the client is unidentified
and needs surgery to save his life.
A is incorrect—To place a client in state custody, the
state must go through a judge. In this case, there is not
enough time for that to occur and this action would place
the client’s life in jeopardy. C is incorrect—The nurse cannot
sign consent for a client. D is incorrect—The client may not
CHAPTER 34 Practice Test for NCLEX-RN® 1111
wake up to give consent and while waiting on this to occur,
the client’s condition could decline.
HEALTH PROMOTION AND
MAINTENANCE
Health Screening
Perform health history/health and risk assessment
148. When performing the health history of a pediatric
client in for a well baby visit, the nurse should determine
if which of the following is present?
___ Immunizations are up to date
___ Smoking in the home
___ History of cardiac disorders
___ History of Asthma
___ Eating habits
___ Toileting concerns
The nurse should assess for immunizations, smoking in the
home, eating habits, and any toileting concerns to understand
if the client is receiving the care needed and if there are
concerns that may not be verbalized by the mom without a
direct question.
A history of cardiac disorders or asthma should be questioned
on a routine visit only if assessment findings indicate
a concern.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
Perform emergency care procedures
149. A client is found in the room holding his hands to his
throat and his lips are turning blue. Which action by
the nurse is most appropriate?
A. Lying the client on the floor and administering
abdominal thrust.
B. Ask the client to cough.
C. Placing both fists around the abdomen above the
umbilicus and administering abdominal thrust.
D. Attempting a blind finger sweep.
The answer is C. The nurse should perform the Heimlich
maneuver. The client is demonstrating the universal sign for
choking and is obviously lacking oxygen.
A is incorrect—The client should not be lowered to the
floor unless he or she is unconscious. B is incorrect—The
client will not be able to cough at this point. D is incorrect—
A blind finger sweep is not recommended since it can push
the food further into the throat.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Expected Effects/Outcomes
Notify primary health care provider of side effects,
adverse effects, and contraindications of medications
and parenteral therapy
150. A client is taking digoxin (Lanoxin) for atrial fibrillation
and cardiomegally. Which assessment finding
requires the nurse to notify the physician of a potential
adverse effect?
A. Abdominal pain and nausea
B. Rhythm change to normal sinus rhythm
C. Heart rate of 62
D. Weight gain of 1⁄2 pound
The answer is A. Abdominal pain and nausea are the first
signs of digoxin toxicity in the elderly and should be
reported so that the physician can order a digoxin level
desired.
B is incorrect—A rhythm change is not an adverse
effect. The client continues to need the digoxin to treat the
cardiomegally. C is incorrect—The heart rate is within normal
limits for the drug to be administered. D is incorrect—A
1/2 pound weight gain is not an adverse effect. Monitoring of
I&O should continue.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Interpret client data that needs to be reported immediately
151. Which of the following should be reported to the
physician immediately?
A. Monitor showing a sinus rhythm with a premature
ventricular contractions (PVC) occurring every 10th
beat.
B. Sodium level 130 mEq/L.
C. Potassium level of 5.9 mEq/L.
D. Oxygen saturation level of 90% on room air.
The answer is C. The nurse should phone the physician to
receive orders for treatment of the high potassium level,
which can cause cardiac arrhythmias if untreated.
A is incorrect—This is considered sinus rhythm with
occasional PVCs and is considered a normal finding. B is
incorrect—This sodium level is lower than the normal range
of 135–145 mEq/L, but is not low enough to bear reporting
to the physician immediately. Lower than 127 mEq/L is considered
critical. D is incorrect—The oxygen saturation level
1112 PART III: Taking the Test
should not be reported unless it remains low after oxygen is
applied. This finding requires a nursing intervention before
phoning the physician.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic
Tests/Treatments/Procedures
Assess the client for an abnormal response following a
diagnostic test/procedure
152. A client has just undergone a computerized tomography
(CT) of the abdomen with oral contrast. Which assessment
finding is indicative of an abnormal response to
the exam?
A. Feeling of fullness in the abdomen
B. Redness of the face, generalized itching
C. Increase in urination
D. Nausea, diarrhea
The answer is B. The client who has undergone a CT of
abdomen has been exposed to oral contrast. Those who are
allergic to oral contrast will experience redness to the face,
generalized itching, and other signs of a systemic reaction.
This requires intervention by a physician order.
A is incorrect—Feeling of fullness is common after a CT
where oral contrast was used. C is incorrect—The client will
have an increase in urination following the ingestion of oral
contrast for a CT. D is incorrect—The oral contrast contains
a laxative and it is common for the client to become nauseated
and experience diarrhea until the contrast has been
passed through the system.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Unexpected Response to Therapies
Assess the client for unexpected adverse response to
therapy
153. After placing a nasogastric tube into the right nare of a
client, which assessment finding is indicative of an
adverse response to this therapy?
A. Epistaxis
B. Vomiting
C. Feeling of fullness in the throat
D. Sore throat
The answer is A. Epistaxis is an adverse response to the placement
of a nasogastric tube and measures should be implemented
to stop the bleeding.
B is incorrect—The nasogastric tube will cause the
client to vomit due to the irritation of the gag reflex. C is
incorrect—The client will feel fullness in the throat until the
body becomes accustomed to the tube. D is incorrect—A
sore throat is common after a nasogastric tube is placed due
to the irritation during insertion.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Radiation Therapy
Assess the client for signs and symptoms of adverse
effects of radiation therapy
154. Which assessment finding requires immediate nursing
intervention in a client who is receiving radiation therapy
for esophageal cancer?
A. Alopecia
B. Skin ulceration
C. Hearing loss
D. Difficult swallowing
The answer is D. The nurse should take action regarding the
client’s difficulty swallowing. If there is damage to the esophagus
then subsequent damage to the trachea could be occurring,
which will compromise the client’s airway.
A is incorrect—Alopecia is the loss of hair and is
inevitable for the client undergoing radiation therapy. B is
incorrect—Skin ulcerations are common with radiation
therapy and require wound care to prevent infection. C is
incorrect—Hearing loss is common with radiation to the
neck and while precautions can be taken to lessen the
effects, damage will likely occur.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Infectious Disease
Evaluate client response to treatment for an infectious
disease
155. Which evaluation would indicate a therapeutic response
to treatment for tuberculosis?
A. A negative sputum culture after 3 months of therapy.
B. Absence of symptoms.
C. Decrease in cavities on an x-ray.
D. Completion of medication therapy.
The answer is A. If cultures convert to negative within 3
months of therapy, the treatment is considered a success.
B is incorrect—Symptoms may disappear even if the bacteria
are active. C is incorrect—Cavities on the x-ray are not a
CHAPTER 34 Practice Test for NCLEX-RN® 1113
determinant for a therapeutic response to treatment. D is incorrect—
Completion of medicinal therapy is not a therapeutic
response to the treatment since the bacteria can still be active.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Hemodynamics
Monitor and maintain arterial lines
156. A nurse is assessing the arterial line via an intra-arterial
catheter in a client in the ICU. Which assessment finding
is most indicative of a potential complication?
A. Cool extremities bilaterally
B. Low blood pressure reading
C. Capillary refill
2 seconds on affected arm
D. Low mean arterial pressure
The answer is C. The capillary refill of less than 2 seconds is a
sign that a thrombus may have formed and blood flow via the
ulnar artery and the microcirculation is compromised.
A is incorrect—Cool extremities bilaterally are not the
most indicative finding in a potential complication. B is
incorrect—A low blood pressure reading is not a sign of a
complication since the arterial line is used for monitoring
the client’s blood pressure. D is incorrect—A low mean
arterial pressure is a direct reflection of the client’s blood
pressure and does not indicate a complication with the
line itself.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
Provide suctioning via endotracheal or tracheostomy
tube
157. Prior to suctioning a client who has an endotracheal
tube, the nurse must first:
A. hyperoxygenate the client.
B. place saline in the endotracheal tube.
C. ask the client to cough.
D. deflate the cuff on the endotracheal tube.
The answer is A. Prior to suctioning a client with an artificial
airway such as an endotracheal tube, the nurse must provide
adequate oxygen to the client.
B is incorrect—While placing saline down the tube may
loosen secretions, it is not what the nurse must first do prior
to suctioning the client. C is incorrect—A client with an
endotracheal tube should not cough to prevent tube dislodgement.
D is incorrect—The endotracheal tube cuff is
only deflated when moving of the tube is necessary.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic Procedures
Monitor effective functioning of therapeutic devices
158. When performing an assessment on a client with a
chest tube and an attached drainage system, which
assessment finding is indicative of a complication?
A. Continuous bubbling in the suction chamber.
B. Yellow fluid accumulating in the drainage chamber.
C. Suction in the off position.
D. Vigorous bubbling in the water seal chamber.
The answer is D. Vigorous bubbling in the water seal chamber is
indicative of a leak. The nurse must determine where the leak is
and fix the problem before the lung is compromised.
A is incorrect—The suction chamber should have continuous
bubbling if suction is connected. B is incorrect—
Yellow fluid is serous and is normal with a chest tube
drainage system. C is incorrect—Suction may or may not be
connected to the drainage system depending on the client
needs based on the physician’s assessment.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Concepts of Management
Supervise care provided by others
159. A member of the nursing team approaches you to
complain that an unlicensed assistive personnel is not
performing accuchecks on patients as assigned. Which
action is most appropriate?
A. Confront the unlicensed assistive personnel about
the neglect in her role.
B. Ask the nurse why he or she could not perform the
accucheck on the patient.
C. Ask the unlicensed assistive personnel if there is something
preventing her from completing her assignment.
D. Report the unlicensed assistive personnel to the nurse
manager of the unit for a verbal reprimand.
The answer is C. Asking the unlicensed assistive personnel if
there is something preventing her from completing her
assignment gives the individual an opportunity to verbalize
what is occurring that has delayed client care and follows the
chain of conflict resolution.
A is incorrect—Confronting an individual will cause
increased tension and does not resolve the conflict. B is
incorrect—The licensed personnel is being asked to perform
the duty of an unlicensed personnel therefore negating the
1114 PART III: Taking the Test
delegation of duty. D is incorrect—This response does not
follow the chain of conflict resolution and does not provide
the unlicensed assistive personnel the opportunity to explain
her actions.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Delegation
Ensure appropriate education, skills, and experience of
personnel performing delegated task
160. Match the appropriate personnel to the task that is
within the scope of practice. (Choices may be used
more than once.)
___ Insert a Foley catheter.
___ Perform an admission assessment.
___ Perform postprocedure vital signs.
___ Administer one unit of packed red blood cells.
___ Perform a morning assessment.
A. Registered Nurse
B. Licensed Practical Nurse
C. Unlicensed Nursing Assistant
B Insert a Foley catheter: It is within the scope of practice for
a LPN to insert an indwelling catheter.
A Perform an admission assessment: Only a registered
nurse can perform an admission assessment.
C Perform postprocedure vital signs: It is within the scope of
practice for unlicensed personnel to perform postprocedure
vital signs as long as a licensed personnel is reviewing the data
obtained and the unlicensed personnel has gone through the
verification process in conjunction with the rules of the hospital.
A Administer one unit of packed red blood cells: Only a registered
nurse can administer blood products.
B Perform a morning assessment: A LPN can perform a
morning assessment on a client who has undergone an
assessment by a RN upon admission to the area.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Performance Improvement (Quality Improvement)
Define performance improvement/assurance activities
161. Which of the following is an example of quality assurance
that meets the standards of JCAHO?
A. Gathering a second opinion before administering as
needed pain medications.
B. Use of clinical pathways by all health care team
members.
C. Avoid admitting clients that have chronic conditions.
D. Performing tests that are covered by insurance and
avoiding those that are not.
The answer is B. The use of clinical pathways has replaced
nursing care plans. Clinical pathways enable the staff to monitor
for a progression of prescribed client care among all health
care disciplines, which is a component of quality assurance.
A is incorrect—A client should receive pain medication
based on his or her rating on the pain scale. Gathering a second
opinion before medication is administered delays care
and is not cost-effective and does not meet the standards. C
is incorrect—Clients with chronic conditions may need to
be admitted making this not an effective method of quality
assurance. D is incorrect—Avoiding tests that are not covered
by insurance may lessen overall cost, but is not meeting
the standards of care a client deserves.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Accident Prevention
Identify deficits that may impede client safety
162. Which finding in an admission assessment is most
indicative of a potential falls risk?
A. Hearing deficit
B. Numbness in the left foot
C. Confusion
D. Unsteady gait
The answer is D. A client with an unsteady gait is at the highest
risk for a fall due to an inability to correct a potential fall
or brace during a fall.
A is incorrect—A loss of hearing is not the highest risk.
A client who cannot hear can still maintain a steady gait
while ambulating in a room. B is incorrect—Numbness in
one foot does not place the client at the highest risk for falls
risk, often a client will compensate with the normal extremity.
C is incorrect—A confused client can possess a steady
gait therefore not placing this client at the highest risk.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Injury Prevention
Question prescriptions for treatments that may contribute
to an accident or injury
163. Which discharge prescription should be questioned for
a client who has peripheral neuropathy due to diabetes?
CHAPTER 34 Practice Test for NCLEX-RN® 1115
A. A prescription for shoes to be purchased at a health
care supply store.
B. A prescription to follow up with diabetic services
for routine foot care.
C. A prescription for a heating pad to be used on the
lower extremities twice a day.
D. A prescription for TED hose to be used on the lower
extremities unless bathing.
The answer is C. An order for a heating pad should be questioned
because a client with diabetic neuropathy should not
use a heating pad since he or she will be unable to feel if
burning to the skin is occurring. A is incorrect—A prescription
for shoes at a health care supply store is appropriate for
the diabetic client. B is incorrect—The client with peripheral
neuropathy due to diabetes should follow up with diabetic
services for routine foot care such as nail cutting and inspections
for ulcerations. D is incorrect—TED hose are useful to
prevent deep vein thrombosis and swelling that may occur
with peripheral neuropathy and diabetes.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Use of Restraints/Safety Devices
Monitor client responses to restraints
164. Which assessment is priority for a client who is being
placed in restraints due to confusion and agitation?
A. Toiletry needs
B. Hydrations needs
C. Circulation in restrained extremities
D. Client’s knowledge of restraint purpose
The answer is C. Monitoring the extremities for adequate circulation
is most important to prevent damage to underlying
structures. Assessments of the area where the restraint is placed
should be performed every 2 hours or per hospital policy.
A is incorrect—Toiletry needs are important while a client
is in restraints but this is not the priority assessment. B is incorrect—
Hydration needs are assessed every 2 hours but this is
not the priority. D is incorrect—A client who is confused and
agitated will not understand why he or she is being restrained.
HEALTH PROMOTION AND
MAINTENANCE
Family Planning
Assess client need/desire for contraception
165. Which statement made by a client indicates a need for
counseling regarding contraceptive devices?
A. “I plan on abstaining from sex until I am married.”
B. “My boyfriend and I use condoms for protection.”
C. “I have been having sex, but my boyfriend pulls out.”
D. “It is against my religion to use birth control.”
The answer is C. The client is using the withdrawal method,
which is has a high failure rate. The client needs information
regarding contraceptive devices to prevent pregnancy.
A is incorrect—The client does not have a plan to participate
in sexual activity. The client should be reminded to contact
her health care provider if her intentions change. B is incorrect—
The client currently has a form of contraception in use. D
is incorrect—The client is citing a religious restriction on the
use of birth control; therefore, counseling is not needed.
HEALTH PROMOTION AND
MAINTENANCE
High-Risk Behaviors
Assist client/family/significant others to identify behaviors/
risks that may impact health
166. A client is being discharged after an admission for a
sodium of 127 and recent weight loss. The family voices
a concern that the client may be suffering from anorexia.
At the time of discharge, the family will be instructed to
monitor the client for which sign of the disorder?
A. Increase in menstrual cycles per month.
B. Pushing food around plate without taking bites.
C. Lack of desire to exercise.
D. Heat intolerance.
The answer is B. The client with anorexia nervosa will push
food around on the plate and put bites of food to the face
without eating the bite.
A is incorrect—A client with anorexia nervosa will experience
amenorrhea due to loss of weight. C is incorrect—In
anorexia nervosa, a client will exercise excessively and may
not attend events/school to exercise. D is incorrect—With
anorexia nervosa the client is intolerant of cold.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Choose physical assessment equipment and technique
appropriate for the client
167. Which equipment will be most important when performing
the physical assessment of a client with a deep
vein thrombosis (DVT) of the left leg?
A. Tape measure
B. Doppler
1116 PART III: Taking the Test
C. Tongue depressor
D. Penlight
The answer is B. When a client has a DVT, a Doppler is needed
to assess for pulses in the affected extremity to ensure blood flow
is occurring in the extremity at one of two pedal pulse areas.
A is incorrect—A tape measure is used to document the
size of the leg compared to the unaffected leg, but it is not as
important as the Doppler, which will assess for adequate
blood flow to the affected foot. C is incorrect—A tongue
depressor is not needed when assessing the client who has a
DVT. D is incorrect—A penlight is needed to assess papillary
response when performing a physical assessment, but is not
the most important piece of equipment for this client.
PSYCHOSOCIAL INTEGRITY
Cultural Diversity
Incorporate client cultural practice and beliefs when
planning and providing care
168. A client of Asian descent has been admitted to the surgical
floor. Which of the following should the nurse
consider when building the client care map for pain
management?
A. Consult an acupuncturist.
B. Offer a narcotic every 4 hours.
C. Offer daily medications only in the morning.
D. Have a rabbi visit the client daily for prayer.
The answer is A. The Asian American culture uses acupuncture
as a form of oriental medicine, which is based on an
energy system that when used balances the yin and yang and
promotes balance in the life and thus pain relief.
B is incorrect—This Asian American culture uses narcotics
as a last form of pain relief, and the primary form of
pain relief is acupuncture and herbs. C is incorrect—The
Asian American culture does not have a preference on when
medications are offered making this a nonjustified choice. D
is incorrect—The Asian American culture uses a temple
healer for religious needs and this is not a significant choice
for care mapping of pain management.
PSYCHOSOCIAL INTEGRITY
Religious and Spiritual Influences on Health
Assess and plan interventions that meet client emotional
and spiritual needs
169. A client who practises Catholicism will be undergoing
a hip repair. Which nursing plan will be best to prevent
tension between the patient and nurse and meet
hospital policies and procedures?
A. Allow the client to wear his medicine bundle into
the operating room.
B. Remove the client’s traditional headpiece before
leaving for the operating room.
C. Inform the client that you will take his rosary and
give it to his wife.
D. Inform the client that all spiritual pieces need to be
surrendered to security until after surgery.
The answer is C. The nurse should take the client’s rosary and
allow a trusted family member to hold it while he is in surgery.
A rosary is sacred to the catholic religion and the nurse
must treat is respectfully.
A is incorrect—Medicine bundles are worn by Native
Americans. B is incorrect—Traditional headpieces are worn
by Islamic Muslim women and they are not to be removed in
public leaving the patient to remove it once in the holding room
and giving it to a family member. D is incorrect—Spiritual
pieces are not surrendered to security unless the client requests.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Elimination
Insert/remove nasogastric, urethral catheter, or other tubes
170. A nurse is inserting a nasogastric tube when resistance
is met. The nurse should:
A. continue to push the tube into the nose.
B. ask the client to swallow.
C. pull out the tube and try the other side.
D. check for correct placement with 30 cc of air.
The answer is C. If resistance is met during the insertion of a
nasogastric tube, the nurse should remove the tube and try
the other nostril to prevent damage to the nasal mucosa and
internal structures.
A is incorrect—The nurse should avoid continuing to
push the tube into the nose to prevent injury. B is incorrect—
Asking the client to swallow will not prevent injury to
the client. D is incorrect—The tube has met resistance and
when it is inserted in the stomach, this does not occur;
therefore, checking for placement is invalid.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Nutrition and Oral Hydration
Assess client’s ability to eat
171. A client has returned from having a procedure that
required conscious sedation. Prior to offering food the
nurse should:
A. assess for the return of the gag reflex.
B. administer morning medications missed due to
NPO status.
C. order a warm tray for the client.
CHAPTER 34 Practice Test for NCLEX-RN® 1117
D. view the chart to see the time the last dose of a medication
was given for sedation.
The answer is A. Prior to offering food, the client should be evaluated
to see if the gag reflex has returned.Without a gag reflex,
the client should not eat due to the potential for aspiration.
B is incorrect—The client may need to eat before being
offered meds. The client must also have an intact gag reflex
before meds can be offered. C is incorrect—The client will need
a warm tray but only after the client has been assessed to see if
eating can occur without the risk of aspiration. D is incorrect—
Regardless of the last dose of medication, the nurse is responsible
for assessing to see if the gag reflex is intact before offering food.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Rest and Sleep
Schedule client care activities to promote adequate rest
172. A burn client is recovering and needs periods of rest to
aid in healing. Which plan would be best to promote
rest periods for the client?
A. Group activities such as physical assessment, bath,
linen change, and morning meds together.
B. Administer a sleeping aid every night from the “as
needed” medication list.
C. Schedule the client to go to occupational therapy
and physical therapy consecutively.
D. Place a sign on the door to limit visitors.
The answer is A. The best method for promoting rest is to
group client care so that there are periods of time for the
client to rest without interruption.
B is incorrect—The client may not need a sleeping aid at
night when activities can be altered to assist with rest during
the day. C is incorrect—Sending the client to both areas for
therapy consecutively will place the client at a disadvantage.
A client who has experienced a burn will need to rest
between sessions due to an increased use of energy for healing.
The client will not benefit from therapy sessions if he or
she is too tired to participate. D is incorrect—Placing a sign
on the door will help to warn visitors that the client is resting
but it is not the best method of promoting rest.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Blood and Blood Products
Administer blood products and evaluate client responses
173. A client who is experiencing an acute hemolytic transfusion
reaction will exhibit what symptom?
A. Hypertension
B. Back pain
C. Bradycardia
D. Hyperglycemia
The answer is B. The symptoms of an acute hemolytic transfusion
reaction are due to the breakdown of the red cell antibodies
and cell destruction, which manifest as pain and an
increase in body temperature.
A is incorrect—Hypotension occurs with an acute
hemolytic transfusion reaction. C is incorrect—Tachycardia
is common with an acute hemolytic transfusion reaction due
to the body’s response to the stress, increase in temperature,
and hypotension. D is incorrect—Hyperglycemia does not
occur in a hemolytic reaction.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Pharmacological Agents/Actions
Identify a contraindication to the administration of a
prescribed or over-the-counter medication to a client
174. During an admission assessment a client states an allergy
to Motrin. Which drug order should be questioned?
A. ketorlac (Toradol) 60 mg IM every 8 hours _2 doses
for pain.
B. Tylenol 650 mg p.o. every 4 hours as need for pain.
C. Morphine 2–4 mg IV every 4 hours as needed for pain.
D. orphenadrine (Norflex) 100 mg p.o. BID prn pain.
The answer is A. Toradol is an antiinflammatory and is in the
same classification as Motrin. A cross sensitivity may exist so
it is best to avoid using Toradol for client’s with an allergy.
B is incorrect—Tylenol is a non-opioid analgesic and
Motrin is a nonsteroidal antiinflammatory. There is no evidence
of cross sensitivity leaving this to be a safe drug for
mild pain relief. C is incorrect—Morpine is an opioid analgesic
and does not fall into the same category as Motrin. D is
incorrect—Norflex is a muscle relaxant and is not contraindicated
in the client with an allergy to Motrin.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
Provide wound care
175. A nurse caring for a client with a burn has an order to
apply a silver sulfadiazine (Silvadene) dressing to the
area. Which plan would be best to prevent infection of
the wound during cleaning?
A. Avoid applying Silvadene to areas that are not burned.
B. Cleaning the area with Betadine.
C. Using an irrigation system for cleaning.
D. Wearing a mask, gown, and sterile gloves during care.
1118 PART III: Taking the Test
The answer is D. The nurse’s goal for wound care is to prevent
infection and promote revitalization of the tissue. The nurse
should place a barrier between her and the client to prevent
infection.
A is incorrect—Applying Silvadene to areas that are not
burned will cause redness to the surrounding skin. B is
incorrect—Betadine is avoided in burns since it can cause
damage to the cells and will dry out the tissue. C is incorrect—
While an irrigation system is best for removal of debris
found in the wound bed, it is not the best plan for preventing
infection.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Expected Effects/Outcomes
Use clinical decision making/critical thinking when
addressing expected effects/outcomes of medications
176. A client is complaining of tightness in her throat and
arm pain. The nurse assesses the client and administers
nitroglycerine 0.4 mg sublingual. After 4 minutes,
the client claims no relief was felt. The nurse should:
A. administer another dose and reassess in 5 minutes.
B. check the client’s blood pressure.
C. administer Maalox from the “as needed” order list.
D. notify the physician.
The answer is B. The client has no relief from the initial dose
of nitroglycerine but with its potent vasodilatation, the nurse
should assess the client’s blood pressure before administering
the second dose. If hypotension exist, the next dose
should be held and other actions taken.
A is incorrect—The client’s blood pressure should be
assessed after every dose of nitroglycerine to assess for
hypotension. C is incorrect—The nurse could attempt the
use of Maalox to see if relief occurs but the blood pressure
should be assessed prior to the administration of any other
medications. D is incorrect—The physician should be notified
after the nurse exhausts the protocol.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
Evaluate and document client response to emergency
interventions
177. A client in respiratory distress is intubated by the
physician. Which evaluation by the nurse best indicates
the intubation was successful?
A. Decrease in anxiety
B. Lowering of blood pressure
C. Increase in heart rate
D. Bilateral breath sounds
The answer is D. Bilateral breath sounds are the best indicator
of a successful intubation.
A is incorrect—While anxiety is an indicator of hypoxia,
the resolution of anxiety is not the best indicator of a successful
intubation. B is incorrect—Lowering of a client’s
blood pressure is not an indicator of a successful intubation.
C is incorrect—An increase in the heart rate is not an indicator
of a successful intubation.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Diagnostic Tests
Perform an electrocardiogram test
178. Place a client in lead II using a 5-lead monitor.
An “X” should be placed at:
RA (white lead) is placed below the right clavicle where the
arm and torso meet. The LA is placed below the left clavicle
where the arm and torso meet. The LL is red and is placed on
lower abdomen where the leg and torso meet. The RL is
placed at the lower right abdomen and the C lead is placed
at the fourth intercostal space, right sternal border.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic
Tests/Treatments/Procedures
Monitor client for signs of bleeding
179. A client has recently undergone a cardiac catheterization.
Which assessment is the best to monitor for postprocedure
bleeding?
A. Assessing the insertion site.
B. Assessing the area directly posterior to the insertion
site.
C. Assessment of vital signs.
D. Assessment of neurological status.
The answer is A. Assessment of the insertion site is best when
monitoring for postoperative bleeding. This site will be the
first source of clot dislodgement and hemorrhage.
CHAPTER 34 Practice Test for NCLEX-RN® 1119
B is incorrect—The area posterior to the insertion site is
secondary on the areas to assess for bleeding. This is usually
noted if vital signs change. C is incorrect—Although vital
signs are an appropriate assessment for the procedure that
was performed, the first area to be assessed is the insertion
site. D is incorrect—The neurological status will not be the
best assessment for postprocedure bleeding.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Vital Signs
Apply knowledge needed to perform related nursing procedures
and psychomotor skills when assessing vital signs
180. A nurse takes the blood pressure with an electronic
blood pressure machine and receives a reading of
80/54. A review of the chart indicates this is uncharacteristic
of the client’s usual reading. The nurse should
perform which action next?
A. Retake the blood pressure using the electronic
machine.
B. Auscultate the blood pressure using a manual cuff.
C. Phone the physician for orders.
D. Leave the client and reassess in 30 minutes.
The answer is B. The nurse should assess the blood pressure
using a manual cuff and stethoscope prior to taking any further
action.
A is incorrect—The machine could be reading inappropriately.
The nurse should perform option B. C is incorrect—
The physician should not be notified until a manual pressure
is taken. D is incorrect—The client should not be left for 30
minutes.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Fluid and Electrolytes
Apply knowledge of pathophysiology when caring for
client with fluid and electrolyte imbalances
181. A nurse is assigned to four clients. Which client is at an
increased risk for developing fluid volume deficit?
A. A client who is in renal failure.
B. A client receiving normal saline at 125 mL/h.
C. A client who has an NG tube to low continuous
suction.
D. A client who has diarrhea related to Clostridium difficile.
The answer is D. The client with Clostridium difficile is at an
increased risk for fluid volume deficit due to the loss of fluid
via the GI tract.
A is incorrect—The client in renal failure is at an
increased risk of fluid volume excess. B is incorrect—The
client receiving normal saline is at a risk for fluid volume
excess. C is incorrect—A client with an NG tube to low suction
is not at as high a risk as the client with diarrhea.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Perform gastric lavage
182. A nurse has an order to perform a gastric lavage on a
client who has overdosed on Tylenol. After the lavage
tube is inserted in the nose, the nurse should:
A. place tap water in the stomach and begin pulling
out gastric contents.
B. verify placement of the tube in the stomach using
60 cc of air.
C. tape to tube in place.
D. verify placement of the tube in the stomach using
30 cc of normal saline.
The answer is B. Prior to instilling anything in the stomach
of a client who is undergoing gastric lavage, the nurse must
make sure the tube is in the correct place by auscultation
for air.
A is incorrect—While tap water can be used for lavage
where the tap water will be pulled from the stomach, the
nurse must assure the tube is in the stomach prior to performing
the lavage. C is incorrect—The tube should not be
taped in place until placement is verified. D is incorrect—
Verification of the placement should be performed using air
and not normal saline.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Fluid and Electrolyte Imbalances
Apply knowledge of pathophysiology when caring for
client with fluid and electrolyte imbalances
183. A client is in a state of respiratory acidosis. The nurse
understands that which of the following is a potential
cause of the current acidotic state?
A. Morphine (M.S. Contin)
B. Vomiting
C. Diarrhea
D. Over the counter antacids
The answer is A. Morphine will place a client in a state of respiratory
acidosis by lowering the respiratory drive, which
causes the client to retain carbon dioxide.
1120 PART III: Taking the Test
B is incorrect—Vomiting will place a client in a state of
metabolic alkalosis due to the loss of acid through the GI
track. C is incorrect—Diarrhea will place the client in a state
of metabolic acidosis by removing the bicarbonate from the
GI track. D is incorrect—Antacids cause a build up on bicarbonate
and will place the client in a state of alkalosis.
HEALTH PROMOTION AND
MAINTENANCE
Ante/Intra/Postpartum and Newborn Care
Provide newborn care
184. An 8-pound infant is delivered via vaginal delivery.
After the cord is cut and handed to the nurse, the
nurse should first assess the baby’s:
A. respiratory effort
B. Apgar score
C. vital signs
D. blood sugar
The answer is A. The respiratory effort should be assessed and
assisted as needed.
B is incorrect—The Apgar score is second in the assessment.
C is incorrect—Vital signs are assessed after the respiratory
effort and Apgar score. D is incorrect—Unless
mom was a diabetic, the baby does not require a blood
sugar check.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Concepts of Management
Apply principles of conflict resolution as needed when
working with health care staff
185. Two staff nurses on the nursing unit disagree on how to
involve a client’s family in the client’s care. Nurse A feels
that only the husband needs to be included in the planning
of the client’s care as he will be the primary care giver
when she is discharged home. Nurse B feels that both her
husband and her son need to be involved as they are
both very close to the client and both will have a role in
her care once she is discharged. As the nurse leader you
must decide how you will manage the conflict.
A. Ignore the situation: if it isn’t acknowledged it will
go away.
B. Do nothing and allow the two staff nurses to work
out a mutually agreed upon decision.
C. Make a decision for the staff nurses, as it is not
appropriate for the client to be in the middle of the
conflict.
D. Sit down with the two staff nurses and allow them to
express their points of view, encouraging both to consider
the positive and negative aspects of their views.
The answer is D. By sitting with both nurses, each has a
chance to consider the other’s opinion. This will help the
nurses to settle conflicts in the future.
Ignoring the situation and doing nothing will not
resolve the problem. Decisions made by the authority will
not resolve future problems and may lead to resentment on
the nurses’ part.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
Provide postoperative care
186. A client has been brought to the floor by the PACU
nurse after having a cholecystectomy. When performing
the postop assessment, which finding would be
most indicative of a complication?
A. Nausea, vomiting
B. Abdominal pain
C. Shoulder pain
D. Rigid abdomen
The answer is D. A rigid abdomen is a sign of internal bleeding
and requires immediate intervention.
A is incorrect—Nausea and vomiting are common
after abdominal surgery and are not a complication. B is
incorrect—Pain is common after surgery and is not a complication
unless other symptoms of hemorrhage are present.
C is incorrect—Shoulder pain is due to the gas that is
placed in the abdomen for the surgeon to see the organs
inside the abdominal cavity.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic
Tests/Treatments/Procedures
Position client to prevent complication following tests/
treatments/procedures
187. A client who has undergone a spinal tap should be
placed in what position after the procedure?
A. Prone
B. Supine
C. Semi-Fowlers
D. Side lying
The answer is B. A client who has undergone a spinal tap should
be placed in the supine position for 2 hours after the procedure.
CHAPTER 34 Practice Test for NCLEX-RN® 1121
A is incorrect—The client should not be placed prone
after the procedure to prevent airway compromise. C is
incorrect—The client should remain supine. Semi-Fowlers
would likely place pressure on the insertion site and cause
bleeding. D is incorrect—While the client may be placed in
the side-lying position during the procedure, after the procedure
the client should be supine. Side-lying carries the
possibility of placing pressure onto the insertion site.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Fluid and Electrolytes
Identify signs and symptoms of client fluid and/or electrolyte
imbalance
188. A nurse will expect which assessment findings when
caring for a client with a potassium level of 2.9?
A. Irregular pulse
B. Orthostatic hypertension
C. Seizures
D. Deep tendon hyperreflexia
The answer is A. An irregular pulse is found in the client with
a low potassium level due to the effects on cardiac muscle
activity.
B is incorrect—Hypokalemia will cause orthostatic
hypotension not hypertension. C is incorrect—There are
alterations in neuromuscular excitability leading to muscle
weakness and flaccidness. D is incorrect—Hyporeflexia is
common in hypokalemia due to alterations in neuromuscular
excitability.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
Monitor wounds for signs and symptoms of infection
189. A nurse is caring for a surgical wound which is 3 days
old. Which assessment data is most indicative of a
wound infection?
A. Increased white blood cell count
B. Separated wound edges
C. Purulent drainage
D. Edema at the site
The answer is C. Purulent drainage is an indication of a
wound infection due to the body’s response to the bacteria
that has invaded the wound.
A is incorrect—While an elevated white blood cell count
is indicative of the activation of the body’s immune response
system, it does not mean the source of infection is the wound
itself. B is incorrect—Wound edges may separate without
infection being present. A client can strain and dislodge
sutures or sutures can be dislodged if enough stress is placed
on the operative area. D is incorrect—Edema is expected initially
due to the body’s response to invasion of skin integrity.
PSYCHOSOCIAL INTEGRITY
Abuse/Neglect
Provide a safe environment for an abused/neglected client
190. A client presents to the emergency department after
her husband physically assaulted her during a fight.
She states she feels as though he will come to the hospital
to find her and she does not want to see him.
Which nursing intervention will be best to protect this
client from her husband?
A. Notify security
B. Place the client as “confidential”
C. Notify the police department of the assault
D. Place the client in a room separate from the emergency
department
The answer is B. Placing the client as confidential places a
restriction on employees of the hospital so they cannot tell
any visitors that the client is at the hospital. This is best since
the husband may try to search for his spouse and/or lie to
security about who he is.
A is incorrect—Notifying security is not the best intervention
for this client as evidenced by the rationale provided
for answer A. C is incorrect—While the police should be notified
on all assaults, it is not the best choice for protecting the
client at the hospital. D is incorrect—Placing the client away
from the emergency department is not an appropriate choice.
If the client is away from the department, she is too far for the
nurse to monitor and the husband may be able to find her.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
Remove sutures or staples
191. An order has been written to remove the staples,
which were placed in a client’s left hip during surgery.
Prior to removing the staples, the nurse should first:
A. assess the site for infection.
B. determine the number of staples from the operative
note.
C. soak the site with normal saline.
D. clean the site with hydrogen peroxide.
The answer is B. Prior to removing sutures from a wound, the
nurse needs to determine how many staples were placed
1122 PART III: Taking the Test
during surgery to make sure the same number of staples is
removed as were placed.
A is incorrect—Assessing the site is part of the process
but not the first step. C is incorrect—The site is soaked if
excess dry blood is around the area or the staples are embedded
into the wound bed but this is not the first step. D is
incorrect—Hydrogen peroxide can be used as needed if the
wound has dried exudate or the staples are embedded in the
skin, but this is not the first step.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Infectious Disease
Recognize signs and symptoms of infectious diseases
192. A client presents to the emergency department complaining
of cough, fever, and night sweats. Which
nursing intervention would have the highest priority?
A. Provide the client with a sputum cup.
B. Place a mask on the client.
C. Move the client to a private room in the treatment bay.
D. Provide the client with a tissue to cover the mouth
when he or she coughs.
The answer is B. The client exhibits signs of tuberculosis and
should be placed on isolation via a mask until he or she can
be placed in a room in the treatment bay to prevent spread
to those in the surrounding area.
A is incorrect—The client can be given a sputum cup
after isolation measures are taken to protect those in the
area. C is incorrect—The client does need to be moved after
begin given a mask to wear. D is incorrect—The client
should wear a mask or airway coverage at all times versus
only when coughing.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-Specific Assessment
Perform focused assessment or reassessment
193. A nurse is assisting a physician with the intubation of
a client. Which assessment is the priority after the
intubation is complete?
A. Oxygen saturation level
B. Heart rate
C. Breath sounds bilaterally
D. Rise and fall of the chest
The answer is C. The breath sounds are the priority for a
client who has just been intubated. If breath sounds are present,
then the intubation was successful and the lungs are
being ventilated.
A is incorrect—The oxygen saturation level is not the
best indicator of successful intubation immediately after the
procedure is complete. The oxygen level will improve as the
lungs are ventilated and diffusion of gases occurs. B is incorrect—
While the heart rate is important, the first assessment
after intubation should be breath sounds in both lungs. The
heart rate will respond to the physiological status of the
body. Initially, the heart rate will be high while the heart is
trying to pump blood to meet the oxygen needs of the body.
It will return to a more normal state as oxygen rich blood is
available. D is incorrect—The rise and fall of the chest is
important, but the nurse must hear breath sounds bilaterally
to ensure the intubation was successful and the lungs are
being ventilated.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Hemodynamics
Identify cardiac rhythm strip abnormalities
194. A client on the unit was complaining of chest pain
when he became unresponsive. The nurse attaches the
monitor and sees the following rhythm. Which action
by the nurse is most important?
A. Begin chest compressions
B. Palpate for a pulse
C. Check to see if the leads are attached properly
D. Assess for breathing
The answer is D. The first step in CPR is to assess for breathlessness
and begin rescue breathing for the client. If breathing
is present, assess for lead placement; if the client is not
breathing, begin CPR.
A is incorrect—Chest compressions begin after airway,
breathing, and pulses are assessed. B is incorrect—Palpation
CHAPTER 34 Practice Test for NCLEX-RN® 1123
for pulses occurs after airway and breathing are assessed. C
is incorrect—Lead placement is assessed after airway and
breathing is assessed.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Teach client about managing illness
195. A client with a diagnosis of chronic obstructive pulmonary
disease (COPD) is being discharged from the
hospital. Which of the following is appropriate patient
teaching before discharge?
A. “Make sure to use a humidifier in your room while
you sleep.”
B. “Apply powder to all crevices to prevent yeast while
taking oral steroids.”
C. “Turn the oxygen up to no more than 6 L if you are
short of breath.”
D. “Use your inhalers every day as directed even if
symptoms are not present.”
The answer is D. The client needs to use the inhalers every
day regardless of symptoms to keep condition controlled
and lessen the frequency of exacerbations.
A is incorrect—A humidifier is not necessary in the
room of a client with COPD and can be a source of infection.
B is incorrect—Powder can be an irritant to the client with
COPD and cause an exacerbation of the disease. C is incorrect—
The client with COPD should not use oxygen at
greater than 2 L per nasal cannula.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Hemodynamics
Monitor and maintain arterial lines
196. A nurse is working with a client who has an arterial
line for direct blood pressure monitoring. What is the
first action the nurse should take when performing an
assessment of the system?
A. Ensure the transducer is at the phlebostatic axis.
B. Zero out the system.
C. Flush the system with normal saline.
D. Administer a bolus of normal saline into the line.
The answer is A. The transducer should be placed at the phlebostatic
axis, which is at the junction of the fourth intercostal
space and the midchest area. If the transducer is
placed above the axis, the monitor will give a low reading; if
it is too low, the reading will be high.
B is incorrect—The transducer must be at the phlebostatic
axis before zeroing occurs. C is incorrect—The system
allows for blood draws but does not allow for fluid infusion.
D is incorrect—The system has a Heparin solution which is
used to keep the area from clotting; with that known other
fluids such as normal saline are not to be instilled into the
line as a flush or bolus.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Expected Effects/Outcomes
Use clinical decision making/critical thinking when
addressing expected effects/outcomes of medications
197. A nurse is reviewing a client’s chart and notices the
potassium level is 6.0; the nurse plans on administering
which drug from protocol?
A. Sodium polystyrene sulfonate (Kayexalate) 30
grams retention enema _ 1 dose.
B. 1 L normal saline with 20 mEq potassium chloride
IV over 2 hours.
C. Normal saline 1 L IV over 10 hours.
D. phosphate/biphosphate (Phospho-Soda) 48 grams
by mouth _ 1 dose.
The answer is A. Kayexalate binds with the potassium and
removes it from the body via the GI track. This drug carries
less of a risk of hypovolemia than other preparations.
B is incorrect—This is adding potassium to the client,
which will potentiate the problem. C is incorrect—Normal
saline will not remove the potassium. Attempting to flush
the system with normal saline places the client at risk for
fluid overload. D is incorrect—Phospho-Soda inhibits
absorption of fluids and electrolytes in the small intestine
through an increase in peristalsis. This drug can potentially
place a client in a state of hypovolemia and is not preferred
for potassium reduction.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Vital Signs
Evaluate invasive monitoring data
198. A nurse is caring for a client who has a pulmonary
artery catheter. Which assessment finding should be
reported to the physician immediately?
1124 PART III: Taking the Test
A. Increase in capillary wedge pressure to 15 mm Hg.
B. Central venous pressure of 2 mm Hg.
C. Right ventricular pressure of 20 mm Hg systolic.
D. Cardiac output of 4 L/min.
The answer is A. The normal wedge pressure is from 8 to 12
mmHg and anything above that indicates increased pressures
in the left side of the heart, which are indicative of left
sided heart failure and should be reported to the physician
immediately.
B is incorrect—The normal central venous pressure is
2–6 mm Hg and indicates the volume status of the client.
This reading will rise with volume overload. C is incorrect—
The normal right ventricular pressure is 20–30 mm Hg and
indicates the right ventricular function and volume. D is
incorrect—The normal cardiac output is 4–8 L/min and is
found by multiplying the stroke volume by the heart rate.
This value is a direct reflection of the adequacy of cardiac
function.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
Identify client status based on pathophysiology
199. The nurse has received report on a client who has just
been admitted for an acute myocardial infarction. The
nurse’s assessment findings are:
• BP 90/66
• HR 100
• RR 16
• skin cool to touch
• A&O _ 3 with mild anxiety
• Urine output 40 mL/h
The nurse understands that this assessment data is
indicative of:
A. class I cardiogenic shock
B. class I hypovolemic shock
C. class II septic shock
D. class II neurogenic shock
The answer is A. In mild cardiogenic shock, the body
responds to hypoperfusion by the heart through the activation
of the Renin-Angiotensin system, which causes vasoconstriction.
The heart rate increases to meet the demand of
the body and the blood pressure is within normal limits during
compensation. The antidiuretic hormone is secreted in
response and urine output is decreased due to an increased
resistance in the vascular system. Respirations will increase
to provide oxygen to the critical organs. The cool skin is the
response of the body shunting blood to the critical organs
and the anxiety is due to the body’s response to the shock
and developing metabolic acidosis.
PHYSIOLOGICAL INTEGRITY
Elimination
Insert/remove nasogastric, urethral catheter, or other tubes
200. List in order the steps a nurse would follow prior to
inserting a nasogastric tube:
___ Idenfy the client
___ Explain the procedure to the client
___ Wash hands
___ Gather supplies
___ Measure for tube placement
___ Assess the client
___ Turn suction to desired level
___ Sit client in high Fowlers
The nurse should first identify the client and then explain
the procedure to gather a verbal acceptance. At that point, a
system-specific assessment should be performed to ensure
the client has no underlying complications that need immediate
attention. Next the nurse gathers his or her supplies,
washes hands, and then measures for tube placement. The
suction is then set for the ordered level and finally the client
is placed in high Fowlers.
MANAGEMENT OF CARE
Safety and Infection Control
Error Prevention
Verify appropriateness and/or accuracy of a treatment
order
201. A client who has been in a car wreck resulting in head
trauma and chest contusion is complaining of headache,
chest pain radiating down his left arm, and difficulty
breathing. The nurse receives the following orders from
the physician. Which of the orders would the nurse
question?
A. Start an IV at a keep open rate.
B. Raise the head of the bed 45 degrees.
C. Start oxygen at 4 L per minute as ordered.
D. Medicate with Nitrostat (Nitroglycerine) sublingual
every 5 minutes _ 3 for chest pain
The answer is D. Nitroglycerine is a vasodilator and may
increase intracranial pressure.
The other actions would all be inappropriate.
CHAPTER 34 Practice Test for NCLEX-RN® 1125
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
202. Which cranial nerve is being tested when the nurse
asks the client to shrug his/her shoulders and resist
pressure to put them down?
A. One (olfactory)
B. Eleven (spinal accessory)
C. Five (trigeminal)
D. Seven (facial)
The answer is B. Cranial nerve eleven (spinal accessory) is
tested by asking the client to shrug the shoulders and resist
pressure to put them down because this cranial nerve controls
muscular strength of the trapezius and sternocleidomastoid
muscles.
A is incorrect—Cranial nerve one (olfactory nerve) is
responsible for the sense of smell. It is tested by occluding
each of the client’s nostrils one at a time, holding a
substance such as coffee or vanilla with a familiar aroma
under the other nostril, and asking the client to identify
the smell. The test is repeated with a different aromatic
substance to determine if the client can differentiate
smells.
C is incorrect—Cranial nerve five (trigeminal nerve)
has both motor and sensory components. It is responsible
for sensation in the face, scalp, oral and nasal mucous membranes,
and the cornea and allows chewing movements of
the jaw. Its three-part sensory division is tested by touching
the forehead, cheek, and chin on each side with a wisp of
cotton and asking the client whose eyes are closed to identify
the type of touch and its location. Next the cornea of
each eye is lightly touched with a wisp of cotton brought in
from the side and the eye observed for the normal blink
response. The motor function of cranial nerve five is tested
by asking the client to clench the teeth and keep them
clenched while the examiner pushes down on the chin to
try and separate the jaws.
D is incorrect—Cranial nerve seven (facial nerve) is
responsible for taste on the front two thirds of the tongue
and for movement of the face including the ability to close
the eyes and move the lips for speech. To test taste, an
applicator dipped in a sugar, salt, or lemon solution is
placed on the tongue and the client is asked what is tasted.
Motor function of cranial nerve seven is tested by asking
the client to smile, frown, grimace, show the upper and
lower teeth, keep the eyes closed while the examiner tries
to open them and puff out the cheeks. The examiner
observes for symmetry and movement and presses the
puffed out cheeks in to check if air is expelled equally
from both sides.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Evaluate appropriateness/accuracy of medication order
for client
203. A client is admitted with a diagnosis of cholecystitis.
One of the admitting orders is for morphine PRN for
pain. Why would the nurse question this order?
A. Morphine is constipating.
B. Morphine can cause nausea and vomiting.
C. Morphine promotes biliary stone formation.
D. Morphine causes spasm of the bile ducts.
The answer is D. Morphine is contraindicated for clients with
cholecystitis because of the risk of precipitating duct spasm.
A, B, and C are incorrect—Morphine, which is an opioid,
does cause constipation and also can cause nausea and
vomiting but these are not the reason it is not used for clients
with cholecystitis. Morphine is not documented as a factor
in the formation of biliary stones.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
204. Which would be a normal finding when percussing
the left 10th intercostal space at the anterior axillary
line?
A. Tympany over the gastric air bubble
B. Dullness over the spleen
C. Resonance over the lungs
D. Flatness over bone
The answer is B. Dullness over the spleen.
A, C, and D are incorrect. At the tenth intercostal space
one is percussing over the spleen not over the gastric air
bubble, lungs, or bone.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Diagnostic Tests
Obtain specimens other than blood for diagnostic testing
205. A diabetic client is admitted with a foul smelling,
draining leg wound and a wound culture is ordered.
When should the nurse plan to obtain the culture?
A. Before any antiinfectives are administered.
1126 PART III: Taking the Test
B. When the blood sugar is within normal range.
C. Within 12 hours of a dose of a broad spectrum
antibiotic.
D. After 48 hours of antimicrobial therapy
The answer is A. The culture needs to be obtained before any
antiinfectives are given because antiinfectives will alter the
microbial population. Blood sugar is unrelated to the timing
of the culture.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Elimination
206. The nurse is planning care for a client who requires
a Sarita lift or the assistance of two people for transfer
or ambulation. Which likely would be the best
time to schedule having the client taken to the bathroom?
A. On awakening in the morning.
B. After breakfast.
C. Following mid-morning medications.
D. At bedtime after a warm drink.
The answer is B. The gastrocolic reflex is most active after
breakfast so this is the time that the client is most likely to
have a bowel movement. It is important to utilize the reflex
because the client is somewhat immobilized and therefore
prone to constipation. Warm fluids can stimulate the reflex
but it is still most active in the morning.
PSYCHOSOCIAL INTEGRITY
Behavioral Interventions
Assess client appearance, mood, and psychomotor behavior
and identify/respond to inappropriate/abnormal behavior
207. Which is an appropriate nursing intervention for a
newly admitted client diagnosed with schizophrenia?
A. Avoid offering choices to the client.
B. Use touch to calm and reassure the client.
C. Keep explanations of care and activities to a minimum.
D. Spend time with the client even if there is no
response.
The answer is D. The nurse should spend time with the client
even if the client cannot respond. Being with the client is an
indication of caring and is a form of human interaction.
Initially, the client should not be offered choices; with treatment
the client is gradually assisted in making decisions.
Maintenance of ego boundaries is important when caring for
the schizophrenic client and touching the client should be
avoided. Explanations are an important part of the care of
the schizophrenic client and everything that is being done
should be explained to help create trust.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Teach client about managing illness
208. Which instruction would the nurse give when teaching
a client pursed lip breathing?
A. Take a slow breath in through your mouth.
B. Breathe out through your mouth puffing out your
cheeks.
C. Use your abdominal muscles to help exhale as deeply
as possible.
D. Use this breathing technique before any strenuous
activity.
The answer is C. Abdominal muscles should be used to
help force as much air out as possible during each exhalation.
All other instructions are incorrect. When teaching
pursed lip breathing the client is instructed to
breathe in through the nose with the mouth closed and
then to purse the lips as if to whistle and exhale slowly
(exhalation should be double the time of inspiration)
through the mouth without puffing the cheeks using the
abdominal muscles to maximize exhalation of air. Pursed
lip breathing should be used during not before physical
activity.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness management
209. Which statement made by a client with cirrhosis indicates
the need for further clarification on self-care?
A. “I will not get any injections unless my doctor
specifically approves.”
B. “I will use an electric razor.”
C. “I will take two acetaminophen tabs every 4 hours if
I have pain.”
D. “I will avoid exposure to people with colds or other
infections.”
The answer is C. Acetaminophen is hepatotoxic and contraindicated
in cirrhosis so if the client says that he or she is
going to take acetaminophen then further instruction is selfcare
is required.
A, B, and D are incorrect—Avoiding unnecessary injections
and using an electric razor are appropriate because of the
CHAPTER 34 Practice Test for NCLEX-RN® 1127
risk of bleeding due to impaired clotting. Avoiding exposure to
infection is appropriate because of decreased immune function.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
210. When assessing the heart, the nurse palpates for heaves
over the tricuspid area which would be an abnormal
finding. Which lettered block on the accompanying
diagram marks the location where the nurse would
place the ball of the hand to palpate over the tricuspid
area. Write the letter of the block on the line provided.
The answer is D.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Use the six “rights” when administering client medications
211. A client’s order for pain medication reads “Codeine 15
sc q4h PRN for pain.” Which aspect of this order
should the nurse question?
A. Frequency
B. Route
C. Dose
D. None
The answer is C. The dose is incomplete and therefore needs
to be questioned. No unit of dosage is specified and the
nurse cannot assume mg or any other unit was intended.
Route and frequency are specified. This is an as needed
order and the reason for the need is also specified as
required.
ab
c
d
e
First thoracic
First
lumbar
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
212. When assessing the knee, which types of motion must
be present to a normal degree for the nurse to document
full range of motion? (Mark all that apply.)
___ A. Supination
___ B. Flexion
___ C. Pronation
___ D. Hyperextension
___ E. Internal rotation
___ F. External rotation
___ G. Abduction
___ H. Adduction
The answers are B, D, E, and F. Normal range of motion in the
knee is flexion, hyperextension, and internal and external
rotation. Normal flexion is the ability to fully bend the knee
so the calf touches the thigh. Hyperextension is the ability to
extend the knee beyond the normal point of extension.
Internal rotation is the ability to rotate the knee and lower
leg toward the midline. External rotation is the ability to
rotate the knee and lower leg laterally.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Fluid and Electrolyte Imbalances
Evaluate the client response to interventions to correct
fluid and electrolyte imbalance
213. Which assessment finding indicates that a young adult
client admitted with dehydration has been successfully
rehydrated?
A. Urine output of 40 Ml/h.
B. Skin “tents” when pinched.
C. Urine-specific gravity of 1.031.
D. Apical pulse of 120 and blood pressure of 90/40.
The answer is A. Urinary output of 40 mL/h or more indicates
adequate hydration and glomerular filtration rate.
B is incorrect—Tenting of the skin is indicative of
dehydration, although care must be taken particularly
with the elderly to check for tenting in areas such as
around the top of the sternum because tenting can occur
when the skin of the forearm or hand is pinched due to
normal age changes and therefore does not always indicate
dehydration. C is incorrect—Urine-specific gravity of
1.031 is indicative of concentrated urine, which would be
seen when hydration is inadequate. D is incorrect—An
1128 PART III: Taking the Test
apical pulse of 120 is abnormally rapid and a blood pressure
of 90/40 is low. These findings are consistent with
dehydration.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
214. When assessing the heart, the nurse auscultates for
abnormal heart sounds over the mitral area. Which lettered
block on the accompanying diagram marks the
location where the nurse would place the diaphragm
of the stethoscope to auscultate the mitral area? Write
the Letter of the block on the line provided.
The answer is E.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Apply knowledge of client pathophysiology to illness
management
215. When assessing a client with cholecystitis, a report of
which type of pain would the nurse interpret as consistent
with the diagnosis?
A. Dull, aching upper right abdominal pain.
B. Sharp, crampy periumbilical pain.
C. Sharp pain in the back under the shoulder blade.
D. Dull upper abdominal and right shoulder pain.
The answer is C. Cholecystitis causes right upper quadrant
pain referred to the back under the shoulder blade.
A is incorrect—Liver cancer causes dull, aching pain in
the right abdomen. B is incorrect—Crampy, sharp periuma
b
c
d
e
First thoracic
First
lumbar
bilical pain is characteristic of a variety of intestinal disorders
including food poisoning. D is incorrect—An enlarged
spleen can press on the diaphragm and stimulate the phrenic
nerve resulting in referred shoulder pain but this is pain on
the left side not the right.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
216. When assessing a client’s hands, the nurse notes clubbing
of the fingers. The nurse recognizes that clubbing
is a sign of:
A. respiratory disease
B. cardiomegaly
C. diabetes
D. rheumatoid arthritis
The answer is A. Clubbing of the fingers occurs secondary to
low oxygen tension leading to an increased hemoglobin and
hematocrit. The other answers are incorrect.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Expected Effects/Outcomes
Use clinical decision making/critical thinking when
addressing expected effects/outcomes of medications
217. Which is the priority assessment when caring for a
client taking a calcium channel blocker medication?
A. Weight
B. Breathing
C. Blood pressure
D. Urinary output
The answer is C. Calcium channel blockers cause coronary
and peripheral vasodilation, which can lead to drop in blood
pressure. There are no effects on weight, breathing, or urinary
output requiring priority assessment.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
218. Which lung sound if auscultated over point E in the
diagram would be evaluated by the nurse as a normal
assessment finding?
CHAPTER 34 Practice Test for NCLEX-RN® 1129
A. Bronchovesicular
B. Crackle
C. Gurgle
D. Sibilant
E. Tracheal
F. Vesicular
G. Wheeze
The answer is A. Bronchovesicular sounds are normally heard
over the areas where the right and left bronchi branch.
Anteriorly this is at the first and second intercostal spaces
and posteriorly between the scapulae so this includes point
B. Bronchovesicular sounds are of medium intensity and
pitch with the inspiratory and expiratory phases equal.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Implement interventions to manage the client recovering
from an illness
219. Which intervention would be inappropriate in the
emergent care of a client with a dislocation?
A. Putting joint through passive range of motion
B. Splinting the joint in the dislocated position
C. Applying ice to the joint
D. Providing tactile stimulation distal to the affected joint
Option A is the inappropriate intervention. The joint is not
moved through a ROM; so this option is incorrect.
Other interventions are correct actions—The joint
would be splinted in the dislocated position until controlled
reduction is possible. Cold is applied initially to reduce
swelling. Tactile stimulation distal to the affected joint serves
no purpose.
ab
c
de
fg
First thoracic
First
lumbar
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Establishing Priorities
Assess/triage the client to prioritize the order of care
delivery
220. The nurse is planning care for a client newly admitted
for rectal bleeding. What is the priority order in which
the nurse should plan to carry out the following nursing
care activities? (Arrange the options in priority
order. All options must be used.)
A. Start an intravenous.
B. Observe the client’s level of anxiety.
C. Continue to monitor the client for rectal bleeding.
D. Teach the client self-care in preparation for the discharge.
E. Assess the client’s skin, blood pressure, heart rate,
and urine output.
F. Teach the client about the upcoming diagnostic
tests that the doctor has ordered over the next couple
of days.
Correct order of priorities: E, A, B, C, F, and D. Physical needs
precede psychological needs. Client teaching would be the
last priority in this situation.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic Tests/
Treatments/Procedures
Implement measures to manage/prevent/lessen possible
complications of client condition and/or procedure
221. When caring for a client with a long intestinal tube
attached to suction, the nurse would ensure that the
suction does not exceed how many mmHg? (Record
your answer using a whole number.)
The answer is 25. Suction higher than 25 mmHg can damage
the intestinal mucosa.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
222. The nurse asks a client what the client would do if she/he
found a stamped and addressed envelope on the street.
1130 PART III: Taking the Test
The client says she/he would put it in a mailbox.
What conclusion should the nurse draw from this
exchange?
A. Judgment is intact
B. Short-term memory is intact
C. Mathematical abilities are intact
D. Abstract thinking is intact
The answer is A. Judgment is intact. This scenario requires
the patient to exercise judgment before reacting.
B, C, and D are incorrect—The question and answer
exchange does not address short-term memory, mathematical
ability, or abstract thinking.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Educate the client/family about medications
223. A 19-year-old college student is diagnosed with a strep
throat and penicillin is prescribed. Which question
should the nurse ask the girl when giving her the prescription?
A. Do you drink milk?
B. Are you allergic to shellfish?
C. Do you take birth control pills?
D. Have you ever had vaginitis?
The answer is C. Penicillin can interfere with the action of
oral contraceptives so if they are being used for birth control,
the client needs to be advised to use an additional method
while taking the medication. The other questions are not relevant
to taking penicillin.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-Specific Assessment
Perform focused assessment or reassessment
224. When monitoring abdominal girth, which guideline
should the nurse follow?
A. Measure at the same time each day.
B. Measure before breakfast each morning.
C. Have the client empty the bladder before measuring.
D. Measure at the same location each time.
The answer is D. In order for the measurements to be comparable
and therefore provide accurate information on the
development of ascites, the girth of the abdomen must be
measured at the same location each time. Usually the umbilicus
is the location of choice but records of the measurements
need to specify the location.
A, B, and C are incorrect—Time of day, breakfast, or a
full bladder do not have the same potential for affecting the
measurement as does location of the measurement on the
abdomen.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications and Side Effects
Assess the client for actual or potential side effects and
adverse effects of medications
225. A client comes to the clinic complaining of unexplained
black and blue areas and red tinged urine.
Which type of medication is it most important to find
out if the client is taking?
A. Urinary antiseptic
B. Systemic glucocorticoid
C. Antianemic
D. Anticoagulant
The answer is D. Unexplained black and blue areas and
hematuria are signs of bleeding associated with excessive
doses of anticoagulants. Because of the potential harmful
effects of abnormal bleeding, checking for use of anticoagulants
is the most important.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
226. When assessing the hip, which types of motion must
be present to a normal degree for the nurse to document
full range of motion? (Mark all that apply.)
___ A. Supination
___ B. Flexion
___ C. Pronation
___ D. Extension
___ E. Internal rotation
___ F. External rotation
___ G. Abduction
___ H. Adduction
The answers are B, D, E, F, G, and H. The hip is a ball and
socket joint as is the shoulder and this type of joint provides
for the most movement. Types of movement possible are
flexion, extension, adduction (movement toward the midCHAPTER
34 Practice Test for NCLEX-RN® 1131
line of the body), abduction (movement away from the midline
of the body), and internal and external rotation.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
227. Which are risk factors for cancer of the liver? Mark all
that apply.
A. ___ Hepatitis A
B. ___ Cirrhosis
C. ___ History of gastric cancer
D. ___ Alcohol abuse
E. ___ Portal hypertension
F. ___ Exposure to environmental toxins
G. ___ Smoking
H. ___ Hepatitis C
The answers are B, D, F, G and H. Cirrhosis, alcohol abuse,
exposure to chemicals and toxins, smoking, and hepatitis C
are identified as risk factors for liver cancer. Liver cancer
occurs more often among males and heredity seems to play
a role in its occurrence.
A, C, and E are incorrect—Hepatitis A and a history of
gastric cancer are unrelated to the development of liver cancer.
Portal hypertension occurs with cirrhosis and can
accompany liver cancer and other diseases. It is a result of
rather than a cause of liver cancer.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Diagnostic Tests
Evaluate the results of diagnostic testing and intervene
as needed
228. Which results of a CBC (complete blood count) with
differential should the nurse interpret as indicating the
client has a viral infection?
A. WBC 8,500; lymphocytes 45%
B. WBC 25,000; band neutrophils 20%
C. WBC 15,000; segmented neutrophils 50%
D. WBC 20,000; segmented neutrophils 58%
The answer is A. With a viral infection the WBC is normal
with elevated lymphocytes.
B is incorrect—This indicates a severe bacterial infection
because the total white blood cell count is above normal
and the band neutrophils are elevated because the body
is trying to fight the infection so quickly that the neutrophils
are being released into the circulation before they
are mature cells. C is incorrect—This indicates a bacterial
infection, but not a severe one because the WBC count is
above normal but the segs are normal. D is incorrect—This
again indicates a bacterial infection, but not a severe one
because although the WBC count is elevated, the segs are
still within normal limits.
HEALTH PROMOTION AND
MAINTENANCE
Immunizations
Assess the client/family/significant other knowledge of
immunization schedules
229. Which statement made by a client at an immunization
clinic indicates an understanding about the hepatitis B
vaccine?
A. “I have to come back in six months to a year for the
booster dose.”
B. “I won’t have maximum protection until after the
third dose of the vaccine.”
C. “I’ll be able to eat shellfish without worry once I get
all these injections.”
D. “I regret I won’t be able to give blood anymore after
I get these injections.”
The answer is B. Three doses of vaccine are needed for maximum
protection.
A is incorrect—It is hepatitis A vaccine that requires a
booster dose in 6–12 months after the initial dose is given.
C is incorrect—Hepatitis A, not hepatitis B, can be contracted
from eating contaminated shellfish. D is incorrect—
Receiving hepatitis B vaccine does not prevent blood
donation.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Apply knowledge of pathophysiology to illness management
230. Which would be an expected finding when assessing a
client with gout?
A. Rash over the nose and cheeks.
B. Joint stiffness for 1–2 hours on arising.
C. Reddened edematous joints.
D. Intolerance of vegetable protein.
The answer is C. Reddened erythematous joints are signs of gout.
A is incorrect—Rash over the nose and cheeks is a symptom
of SLE. B is incorrect—Joint stiffness for more than 1
hour on arising in the morning is characteristic of rheumatoid
1132 PART III: Taking the Test
arthritis. D is incorrect—Intolerance to vegetable program is
unrelated to a musculoskeletal disorder.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Review pertinent data prior to medication administration
231. Because of the risk of a toxic drug reaction, monitoring
laboratory reports for hypokalemia would be a
part of the plan of care for a client receiving which
medication?
A. Hydrodiuril
B. Motrin
C. Lovastatin
D. Digoxin
The answer is D. Hypokalemia can precipitate a toxic reaction
to digoxin.
A, B, and C are incorrect—Hypokalemia does not precipitate
a toxic reaction to Hydrodiuril, Motrin, or Lovastatin.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
232. In which group of clients would the nurse expect to
find a positive plantar reflex with an up going first toe
and the others fanning out?
A. The elderly
B. Adolescents
C. Infants
D. School aged children
The answer is C. Infants. The plantar or Babinski reflex in
infants is positive, i.e., first toe goes up and toes fan.
A, B, and D are incorrect—In all other age groups, the
first toe curls and the rest of the toes move downward.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Educate the client/families about medication
233. Which instruction should the nurse give to an elderly
patient about the proper storage of medications?
A. Keep medications in their original containers.
B. Store in a bathroom cabinet out of the reach of children
C. Keep in a brightly lit area to better read labels.
D. Avoid storing in dry, cool locations.
The answer is A. Medications should always be kept in their
original, properly labeled containers to decrease the risk of
taking the wrong drug, or of taking the right drug but in the
wrong amount, by the wrong route, or at the wrong time.
B is incorrect—Medications should be stored out of the
reach of children but not in the bathroom cabinet where
exposure to moisture can occur. C is incorrect—Drugs
should be stored out of the light and away from heat and so
a dark, cool location is needed. D is incorrect—It is important
to pour pills from their containers in good lighting so
that labels can be read accurately but bottles of medication
should not be stored in bright light.
PSYCHOSOCIAL INTEGRITY
Behavioral Interventions
Assess client appearance, mood, and psychomotor
behavior and identify/respond to inappropriate/abnormal
behavior
234. Which is a priority goal for a client with borderline
personality disorder?
A. Acceptance of group therapy.
B. Elimination of bizarre fantasies.
C. Development of social relationships
D. Decrease of actual and intended self-destructive
behavior
The answer is D. Clients with borderline personality disorder
make recurrent threats or gestures of self mutilation
or suicide or actually attempt to mutilate or kill
themselves. As a result a priority nursing intervention is
to support efforts to decrease the actual behaviors as
well as the client’s intent to perform them. Group therapy
can assist the client with borderline personality disorder
in developing awareness of how one’s behavior
affects others.
PHYSIOLOGIC INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic
Tests/Treatments/Procedures
Implement measures to manage/prevent/lessen possible
complications of the client condition and/or procedure
235. When caring for a client with pancreatitis, the nurse
monitors the nasogastric tube attached to suction for
proper functioning. It is important that proper functioning
be maintained:
CHAPTER 34 Practice Test for NCLEX-RN® 1133
A. To prevent backup of secretions to the liver.
B. To protect the intestine from gastric secretions.
C. To allow for monitoring of gastric pH.
D. To protect the gastric lining from pancreatic enzymes.
The answer is B. The N/G tube serves to remove acidic gastric
contents so these do not enter and damage the intestine.
This is a risk because alkaline pancreatic secretions are not
available to neutralize them.
A, C, and D are incorrect—Gastric secretions do not
back up to the liver, gastric pH is not measured as part of the
management of pancreatitis, and pancreatic enzymes back
flowing to the stomach is not a problem.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
236. When assessing the elbow, which types of motion
must be present to a normal degree for the nurse to
document full range of motion? (Mark all that apply.)
___ A. Supination
___ B. Flexion
___ C. Pronation
___ D. Extension
___ E. Rotation
___ F. Tilting
The answers are A, B, C, and D. As a hinge joint the basic movement
possible in the elbow is flexion and extension. In addition
checking ROM of the elbow joint includes pronation and
supination. To assess pronation the nurse asks the client to
hold each arm straight out and turn the palm upward toward
the ceiling. To assess supination, the arms are held out straight
and the palms turned downward toward the floor.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Administer and document medications given by common
routes
237. What instruction would be most effective in helping a
client relax the rectal sphincter in preparation for
administration of a rectal suppository?
A. “Turn on your left side and flex your knees.”
B. “Bear down as though for a bowel movement.”
C. “Take a deep breath exhaling through the mouth.”
D. “Think of something that you find soothing.”
The answer is C. Taking a deep breath and exhaling through
the mouth helps relax the rectal sphincter. Turning on the
left side and flexing the knees is a desirable position for inserting
the suppository. Bearing down as though for a bowel
movement would act to eject the suppository. Thinking of
something soothing may help the client relax but is not specific
to the rectal sphincter.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Diagnostic Tests
Evaluate the results of diagnostic testing and intervene
as needed
238. A nurse is reading a PPD test that he or she administered
to a healthy 50-year-old grade school teacher. Which of
the following measurements would the nurse interpret
as a “positive” reading for this individual?
A. 10 mm of erythema
B. 5 mm of induration
C. 10 mm of induration
D. 15 mm of induration
The answer is C. With the exception of the immunocompromised,
clients with risk factors such as teachers, health care
workers, and people living in crowded areas, 10 mm and
above of induration is considered positive.
A is incorrect—Erythema is not considered as positive.
B is incorrect—5 mm of induration is positive if the person
is immunocompromised. D is incorrect—15 mm of induration
is positive for persons with no known risk factors.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Apply knowledge of pathophysiology to illness management
239. Which would be an expected finding when assessing a
client with lupus erythematosis?
A. Rash over the nose and cheeks.
B. Joint stiffness for 1–2 hours on arising.
C. Reddened edematous joints.
D. Intolerance to milk sugar.
The answer is A. Rash over the nose and cheeks is a symptom
of SLE, which is an autoimmune disease.
B is incorrect—Joint stiffness for more than 1 hour on
arising in the morning is characteristic of rheumatoid arthritis.
C is incorrect—Reddened erythematous joints are a sign
of gout. Intolerance to milk sugar or lactose intolerance is
unrelated to lupus erythematosis.
1134 PART III: Taking the Test
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
240. When assessing the ankle, which types of motion must
be present to a normal degree for the nurse to document
full range of motion? (Mark all that apply.)
___ A. Supination
___ B. Dorsiflexion
___ C. Pronation
___ D. Hyperextension
___ E. Eversion
___ F. Plantar flexion
___ G. Abduction
___ H. Adduction
___ I. Inversion
The answers are B, E, F, G, H, and I. Movements that are part of
the normal range of motion for the ankles are dorsiflexion
(foot bent upward with toes pointing at head), plantar flexion
(foot pointed downward, abduction, adduction, and eversion
(movement of the sole of the foot outward), and inversion
(movement of the sole of the foot inward. Supination and
pronation are movements of the elbow. Hyperextension is a
movement of the shoulder, elbow, and knee.
PHYSIOLOGICAL INTEGRITY
Reduction in Risk Potential
Vital Signs
Apply knowledge needed to perform related nursing procedures
and psychomotor skills when assessing vital signs
241. When delegating blood pressure measurement to an
unlicensed assistant, the nurse cautions that correct
technique must be used to avoid obtaining false low
pressures. Which is one of the directions the nurse
would give to prevent a false low pressure reading?
A. Take the blood pressure on an extremity positioned
below heart level.
B. Use a cuff whose width is 40% of the diameter of
the extremity.
C. Wrap the cuff loosely around the extremity.
D. Apply the cuff unevenly to the extremity.
The answer is B. The width of the cuff should be 40% of the
diameter of the arm; use of a cuff that is too wide can cause
false low blood pressure readings and use of a cuff that is too
narrow can result in false high readings.
A is incorrect—Taking the blood pressure on an extremity
positioned below heart level can result in a false low reading;
it does not prevent it. The extremity needs to be supported
and at heart level. C is incorrect—Wrapping the cuff
too loosely on the extremity results in a false high reading
not a false low reading. D is incorrect— If the cuff is wrapped
unevenly around the extremity, the result can be a false high,
not a false low, pressure reading.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
242. When assessing the heart, the nurse auscultates for both
aortic and pulmonic murmurs over Erb’s point. Which
lettered block on the accompanying diagram marks the
location where the nurse would place the diaphragm of
the stethoscope to auscultate over Erb’s point? Write the
letter of the block on the line provided.
The answer is C.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Diagnostic Tests
Perform diagnostic testing
243. When instructing a client on obtaining a stool specimen
for an FOBT, the nurse tells the client not to take
aspirin or NSAIDs for how many days prior to collecting
the specimen?
Record your answer using a whole number.
The answer is 2 days. FOBT is a screening test for colon cancer,
a sign of which is occult blood in the stool. Aspirin and
NSAIDS can cause GI irritation and bleeding and thus can
result in a positive FOBT.
ab
c
d
e
First thoracic
First
lumbar
CHAPTER 34 Practice Test for NCLEX-RN® 1135
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Administer and document medications given by parenteral
routes
244. In which situation would the nurse need to administer
an injection using Z-track technique?
A. The client is malnourished with muscle wasting.
B. The medication is thick and requires a large gauge
needle.
C. The medication is very irritating.
D. The client’s platelet count is 200,000 or more.
The answer is C. The Z-track method is designed to prevent
backflow of medication through the needle track and into
the surrounding tissues. It is used when medications are
very irritating and can cause tissue damage.
A, B, and D are incorrect—Administration using a Z-track
technique is not determined by the size of the client, the thickness
of the medication, or the client’s platelet count.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
245. Which lung sound if auscultated over point F in the
diagram would be evaluated by the nurse as a normal
assessment finding?
A. Bronchovesicular
B. Crackle
C. Gurgle
D. Sibilant
ab
c
de
fg
First thoracic
First
lumbar
E. Tracheal
F. Vesicular
G. Wheeze
The answer is F. Vesicular sounds are normally heard over alveolar
lung tissue, which is the majority of both lungs including
point B. Vesicular sounds are soft in intensity and low in pitch.
The inspiratory phase is longer than the expiratory phase.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Laboratory Values
Provide the client with information about the purpose
and procedure of prescribed laboratory tests
246. A client receives a report that his PSA level is 9 ng/mL
and asks the nurse what this means. The nurse will
base the response on the knowledge that:
A. This result is within normal range and no follow up
is required.
B. This result is below the normal range and repeat
testing is needed.
C. This result is slightly elevated and may reflect problems
such as urinary tract infection and benign prostatic
hypertrophy as well as prostate cancer; follow
up is needed.
D. This result is above normal and indicative of prostate
cancer; treatment is needed.
The answer is C. The normal PSA is less than 4 ng/mL but
can be elevated into the hundreds with metastatic prostate
cancer. Elevations can occur as a result of BPH, cirrhosis,
prostatitis, urinary tract infection, and urinary retention.
False elevated levels can occur after urinary catheterization,
cystoscopy, transrectal ultrasound, or prostate biopsy.
PHYSIOLOGIC INTEGRITY
Reduction of Risk Potential
Laboratory Values
Recognizes deviations from normal
247. A pregnant woman is seen in the prenatal clinic. The
following lab values are received during this visit.
Which lab value requires further investigation?
A. Positive HCG
B. High alpha fetoprotein
C. Low hemoglobin and hematocrit
D. Urine negative for protein and glucose
The answer is B. High alpha fetoprotein is seen in conjunction
with fetal abnormalities, such as spina bifida and Down’s
syndrome and should be investigated further.
1136 PART III: Taking the Test
A is incorrect—Positive HCG means she is pregnant. C is
incorrect—During pregnancy, the volume portion of blood
increases at a faster rate than the cellular portion producing a
pseudoanemia. D is incorrect—Negative urine protein and
glucose is normal.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Diagnostic Tests
Evaluate the results of diagnostic testing and intervene
as needed
248. Because of the risk of spontaneous bleeding, the
nurse would institute bleeding precautions for a
client whose laboratory report documents a platelet
count below ___ /mm3. Record your answer using a
whole number.
The answer is 20,000. Spontaneous bleeding can occur with a
platelet count of less than 20,000/mm3. Therefore bleeding
precautions are required:
• Test all urine and stool for blood.
• No rectal treatments (temperatures, suppositories,
enemas, etc.).
• No IM injections.
• Put firm pressure on all venipuncture sites for 5
minutes and on arterial puncture sites for 10
minutes.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Teach the client about managing illness
249. Which topic would be included in the teaching plan
for a client with gout?
A. Need to decrease dietary intake of foods high in
purine.
B. Importance of restricting caffeine in the daily diet.
C. Necessity of limiting fluid intake.
D. Benefits of decreasing intake of dairy products.
The answer is A. Clients with gout need to limit intake of high
purine foods such as scallops, sadines, gravies, and cream
sauces.
B is incorrect—Caffeine does not need to be restricted.
C is incorrect—Fluid intake should be increased to aid
renal filtration of uric acid from the blood; it should not be
restricted. D is incorrect—Dairy products do not have to be
decreased.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
250. Which lung sound if auscultated over point D in the
diagram would be evaluated by the nurse as a normal
assessment finding?
A. Bronchovesicular
B. Crackle
C. Gurgle
D. Sibilant
E. Tracheal
F. Vesicular
G. Wheeze
The answer is A. Bronchovesicular sounds are normally heard
over the areas where the right and left bronchi branch.
Anteriorly this is at the first and second intercostal spaces
and posteriorly between the scapulae so this includes point
B. Bronchovesicular sounds are of medium intensity and
pitch with the inspiratory and expiratory phases equal.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications and Side Effects
Assess the client for actual or potential side effects and
adverse effects of medications
251. When caring for a client on antibiotic therapy, monitoring
for which type of common complication is an
important component of the plan of care?
A. Electrolyte imbalance
B. Suprainfection
ab
c
de
fg
First thoracic
First
lumbar
CHAPTER 34 Practice Test for NCLEX-RN® 1137
C. Liver failure
D. Abnormal bleeding
The answer is B. Suprainfection is a common complication of
antibiotic therapy because as organisms susceptible to the prescribed
antibiotic are eliminated, other nonsusceptible organisms
can overgrow. This results in a second infection caused
by an organism different from the one causing the infection for
which the antibiotic was prescribed. Common examples of
suprainfection are monilial vaginal infections and diarrhea.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Delegation
Utilize five “rights” of delegations (right task, right circumstances,
right person, right direction or communication,
and right supervision or feedback)
252. When delegating blood pressure measurement to an
unlicensed assistant, the nurse cautions that correct
technique must be used to avoid obtaining false high
blood pressures. Which errors in technique should be
identified as the potential causes of false high blood
pressures? Mark all that apply.
A. ___ Use of an unsupported limb to take the blood
pressure
B. ___ Use of a cuff that is too wide.
C. ___ Immediate reinflation of the cuff
D. ___ Too rapid deflation of the cuff
E. ___ Uneven application of the cuff
The answers are A, C, and E. Taking the blood pressure on
an unsupported extremity, reinflation of the cuff without
waiting 1–2 minutes, and applying the cuff unevenly to the
arm all can cause a false high blood pressure.
B and D are incorrect—Use of a cuff that is too wide or
deflating the cuff too rapidly can cause false low blood pressures.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications and Side Effects
Educate client/family about medications
253. Which statement made by a client who has been given
instructions on taking NSAIDs for joint pain indicates
the need for further teaching?
A. “I have to take these pills with food and a full glass
of liquid.”
B. “I can’t have beer or other alcoholic drinks while
taking these pills.”
C. “I need to be on the alert for any signs of abnormal
bleeding.”
D. “I can take other over the counter drugs with these as
long as I don’t take more than the prescribed dose.”
The answer is D. NSAIDS cannot be mixed with any over the
counter drugs; safe use of other drugs varies with what they
are and how they work. NSAIDS should not be mixed with
any other NSAIDS. This statement indicates that the client has
not understood all the information necessary for safe use of
the prescribed NSAID. Therefore the client is in need of further
teaching. Other responses are correct. NSAIDS should be
taken with food and a full glass of fluid because of their irritating
effects on the gastric mucosa; alcoholic beverages also
should be avoided. Because aspirin and ibuprofen, which are
classic examples of the two types of NSAIDS (a salicylate
and a prostaglandin synthetase inhibitor respectively) affect
platelet function and can cause GI bleeding, a client needs to
observe for and report any signs of bleeding.
PHYSIOLOGIC INTEGRITY
Reduction of Risk Potential
Laboratory Values
Recognizes deviations from normal
254. A child is admitted to the hospital with a diagnosis of
“rule out meningitis.” A spinal tap is performed in the
emergency room. It will take 24–48 hours before a culture
is grown. Which finding in the spinal fluid indicates
a probable bacterial meningitis?
A. Elevated protein
B. Decreased glucose
C. Elevated WBC count
D. Cloudy in appearance
The answer is B. The bacteria feed on the glucose lowering
that level.
A, C, and D are incorrect—Elevated protein is usually
indicative of a slowing or obstruction of the CSF, and elevated
WBCs and cloudy appearance are seen in both types of
meningitis.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Choose physical assessment equipment and technique
appropriate for the client
255. When assessing deep tendon reflexes, when does the
nurse use the pointed end of the reflex hammer? Mark
all that apply. The nurse uses the pointed end of the
reflex hammer to check
1138 PART III: Taking the Test
A. ___ brachioradialis reflex
B. ___ biceps reflex
C. ___ triceps reflex
D. ___ patellar reflex
E. ___ Achilles reflex
F. ___ cremasteric reflex
The answers are A, B, and C. The brachioradialis reflex located
in the forearm above the radial styloid process of the wrist,
the biceps reflex located in front of the elbow, and the triceps
reflex located just above the elbow on the back of the arm are
all checked using the pointed end of the reflex hammer.
D, E, and F are incorrect—The patellar and Achilles
reflexes located at the front of the knee and the back of the
heel respectively are tested using the broad end of the reflex
hammer. The cremasteric reflex is a superficial reflex, which
causes elevation of one side of the testicle in response to
stroking the thigh on that side. The handle of the reflex hammer
is used to stroke the thigh.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Laboratory Values
Provide the client with information about the purpose
and procedure of prescribed laboratory tests
256. Which instruction should the nurse give to a client
who is to be scheduled for blood work, which includes
measures of cholesterol?
A. Do not drink alcohol for at least 24 hours before the
test.
B. Fast for 8 hours before the test.
C. Drink at least 4 large glasses of water the evening
before the test.
D. Avoid fatty foods for 2 days before the test.
The answer is A. Alcohol should be avoided before the test.
B, C, and D are incorrect—Fasting is necessary for 9–12
hours before the test. There is no requirement regarding
fluid intake or avoidance of fatty foods.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic
Tests/Treatments/Procedures
Apply knowledge of nursing procedures and psychomotor
skills when caring for a client with potential for
complications
257. A 72-year-old client is scheduled for a CT scan with
contrast media. Prior to the test, the nurse checks to
ascertain that which laboratory tests have been
done?
Mark all that apply.
A. ___ Urinalysis
B. ___ Fasting blood sugar
C. ___ BUN
D. ___ Aspartate aminotransferase (AST)
E. ___ Alanine aminotransferase (ALT)
F. ___ Creatinine
The answers are C and F. BUN and creatinine are tests of kidney
function. Because contrast media is excreted through the kidneys,
clients undergoing CT scans using contrast media need
adequate kidney function. Because older clients are at risk for
decreased renal function, those over age 60 have BUN and
creatinine assessed prior to a test using contrast media.
Abnormal urinalysis, blood sugar (FBS), or liver function
tests (AST, ALT) do not typically prevent a patient from
having a CT scan.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Teach client about managing illness
258. Which instructions should be given to the client with
gout?
(Mark all that apply.)
A. “Do not drink red wine or other alcohol.”
B. “Drink a lot of nonalcoholic fluids.”
C. “Decrease intake of foods high in purine.”
D. “Increase intake of foods high in calcium.”
E. “Reduce intake of salt.”
The answers are A, B, and C. Clients with gout need to limit
intake of high purine foods such as scallops, sadines, gravies,
and cream sauces. Alcohol especially red wine should be
avoided. Fluid intake should be increased to aid renal filtration
of uric acid from the blood.
D and E are incorrect—Calcium does not need to be
increased and salt does not need to be restricted.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Provide client and family with information about acute
and chronic mental illness
259. The nurse is speaking to a group of family members of
clients with Alzheimer’s disease. Which behaviors
would the nurse identify as characteristic of Stage 2
Alzheimer’s disease?
CHAPTER 34 Practice Test for NCLEX-RN® 1139
A. Progressive impairment primarily of short term
memory
B. Difficulties with house keeping and cooking
C. Agitated movements and speech
D. Confabulation
E. Expressions of concern over loss of mental capacity
The answers are A, B, and D. Stage 2 of Alzheimer’s disease is the
stage of confusion. In this stage there is a progressive loss of
memory with short term memory being most impaired. There
is difficulty with the Instrumental Activities of Daily Living
including house cleaning and cooking. Confabulation and
stereotyped speech word usage occurs to cover up for memory
loss. Agitation is a characteristic of stage 3 Alzheimer’s disease
which is ambulatory dementia. Expressions or awareness of
the problem and concerns over mental abilities occur in Stage
1 which is the Stage of forgetfulness.
PHYSIOLOGIC INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic Tests/
Treatments/Procedures
Implement measures to manage/prevent/lessen possible
complications of client condition and/or procedure
260. When preparing to care for a client returning from
surgery after a left lower extremity amputation, which
piece of equipment is most critical to obtain for the
bedside?
A. Traction set up
B. Alternating pressure mattress
C. Tourniquet
D. Wire cutters
The answer is C. If hemorrhage occurs, a tourniquet must be
immediately applied and therefore is kept at the bedside.
A is incorrect—Traction is used for a variety of orthopedic
conditions including fractures and low back pain. B is
incorrect—An alternating pressure mattress is used to prevent
or manage skin breakdown. D is incorrect—Wire cutters
are needed at the bedside of clients who have wired jaws.
HEALTH PROMOTION AND
MAINTENANCE
Ante-/Intra-/Postpartum and Newborn Care
Provide newborn care
261. A newborn is admitted to the newborn nursery. Initial
assessment findings are axillary, temperature 97_F, pulse
128, and respirations 33. Based on these findings, the
nurse would delay which normal admission activity?
A. Bath newborn and shampoo hair.
B. Complete a head to toe assessment.
C. Feed the infant 1 ounce or less of glucose water.
D. Place in an overbed warmer for easy observation.
The answer is A. Bathing a newborn with a low temperature
will further lower the infant’s temperature and put the
infant in cold stress. All other responses are correct.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Nutrition and Oral Hydration
Evaluate and monitor client height and weight
262. A 2-month-old infant was admitted for poor weight
gain and frequent vomiting. The child is diagnosed
with gastroesophageal reflux. Nursing interventions
are implemented to reduce the vomiting. The nurse
will know the interventions have been successful
when:
A. urine output increases.
B. the infant is discharged home.
C. the child shows daily weight gain.
D. the mother says she is comfortable feeding her infant.
The answer is C. Weight gain is the best indication that sufficient
food is being retained.
A is incorrect—Urine output may or may not increase.
B is incorrect—Discharge home does not indicate the problem
is totally solved. D is incorrect—This is a physical problem
for the child, not the mother.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
Promote client wound healing
263. A client has been admitted to the hospital unit for stasis
venous ulcers. Nursing care for this client would
include:
A. doing Burger-Allen exercises.
B. providing bedrest with legs in a dependent position.
C. placing a foot board on the bed.
D. placing the client in a high fowlers position.
The answer is C. This keeps pressure off of the ulcer.
A is incorrect—Burger-Allen Exercises are done for
Buerger’s disease. B is incorrect—Keeping legs in a dependent
position increases edema. D is incorrect—High Fowlers position
increases pressure and kinking on the vascular system.
1140 PART III: Taking the Test
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
264. Which lung sound if auscultated over point G in the
diagram would be evaluated by the nurse as a normal
assessment finding?
A. Bronchovesicular
B. Crackle
C. Gurgle
D. Sibilant
E. Tracheal
F. Vesicular
G. Wheeze
The answer is F. Vesicular sounds are normally heard over alveolar
lung tissue, which is the majority of both lungs including
point B. Vesicular sounds are soft in intensity and low in pitch.
The inspiratory phase is longer than the expiratory phase.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Expected effects/outcomes
265. Which class of drug is given to prevent heart failure in
the first 24 hours after a myocardial infarction (MI)?
A. Calcium channel blocker
B. ACE inhibitor
C. Beta blocker
D. Digitalis derivative
The answer is B. Ace inhibitors prevent conversion of
angiotensin I to angiotensin II.
ab
c
de
fg
First thoracic
First
lumbar
A is incorrect—Calcium channel blockers cause coronary
and peripheral vasoconstriction. C is incorrect—Beta blockers
reduce heart rate and contractility. D is incorrect—Digitalis
slows the heart and increases the force of contraction.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications and Side Effects
Implement procedures to counteract adverse effects of
medications and parenteral therapy
266. A client who is in the cardiac care unit complains of
mediastinal chest pain, dyspnea, and anxiety. The nurse
gives the client a nitroglycerine tablet sublingual. The
client now complains of being dizzy. Which of the following
nursing interventions should the nurse do first?
A. Get a 12 lead ECG.
B. Raise the side rails on the bed.
C. Open the D5W IV to 100 cc per hour.
D. Take the client’s vital sign including pulse oximetry.
The answer is B. Safety is the priority.
Option C would not be correct because it is not an isotonic
solution and would not help to maintain circulating
volume. Option A would be done but would not be the priority.
Option D is not indicated as a priority.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Pharmacological Agents/Actions
Use clinical decision making/critical thinking when
addressing actions of prescribed pharmacological agents
on clients
267. A client with atrial fibrillation is receiving warfarin
(Coumadin) 5 mg each day. His INR today is 1.8.
What is the expected decision regarding change in
medication dosage?
A. His INR is too low. His warfarin dose needs to be
increased.
B. His INR is too high. His warfarin dose needs to be
decreased.
C. His INR is too high. His warfarin dose needs to be
increased.
D. His INR is within desired range. No change is warfarin
dose is needed.
The answer is A. Target INR for clients with afib is 2.0–3.0.
This client’s INR is below this range so it would be expected
that the dose of warfarin would be increased.
CHAPTER 34 Practice Test for NCLEX-RN® 1141
B and C are incorrect—The client’s INR is not too low or
high. D is incorrect—The INR is not within desired range.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Ergonomic Principles
Use ergonomic principles when providing care
268. While assisting a client to perform activities of daily living,
how can the nurse best enhance his/her balance?
A. By spreading his/her feet a comfortable distance.
B. By stretching the thoracic cavity by taking deep
breaths.
C. By performing the activity(ies) to the level the client
can tolerate without experiencing adverse effects.
D. By exerting pressure against a solid object.
The answer is A. By spreading his/her feet a comfortable distance.
Balance is achieved when there is a low center of gravity
over a wide stable base of support.
B, C, and D are incorrect—Stretching the thorax will
have no effect on balance; maintaining equilibrium
responds to various head movements. Activity tolerance is
performed to the level the individual can tolerate the activity,
but this does not impact the nurse’s balance. Isometric
exercises involves exerting pressure against a solid object.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Plan nursing care based on assessment findings
269. A 4-year-old child was diagnosed with hydrocephaly
shortly after birth and had a ventricular-peritoneal
shunt inserted. The child has started vomiting and
complaining of headaches in the morning but is well
the rest of the day. Which problem would the nurse
suspect?
A. Meningitis
B. Gastroenteritis
C. Malfunctioning shunt
D. The development of a brain tumor
The answer is C. The symptoms are those of increased
intracranial pressure. Early morning vomiting and headaches
are common. While the child is asleep at night, blood
increases the intracranial contents causing symptoms.
The other responses would not be early morning only
symptoms.
PHYSIOLOGIC INTEGRITY
Reduction of Risk Potential
Potential for Complications from Surgical
Procedures and Health Alterations
Apply knowledge of pathophysiology to monitoring for
complications
270. Your patient is an 80-year-old female who is 4 hours
postoperative from a right total hip replacement and is
experiencing urinary retention. What is the most likely
cause of this problem?
A. Decreased renal blood flow
B. Decreased bladder muscle tone
C. Urethral edema
D. Benign prostatic hypertrophy.
The answer is B. Decreased bladder tone will result in urinary
retention.
A is incorrect—Decreased renal blood flow is incorrect
because this would result in decreased production of urine
(anuria or oliguria) not urinary retention, which refers to the
inability to empty urine from the bladder. C is incorrect—
Urethral edema is unlikely because the surgery does not
involve manipulation of the urethra or any adjacent tissues.
D is incorrect—Benign prostatic hypertrophy is incorrect
because the patient is female.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
271. Which lung sound if auscultated over point C in the
diagram would be evaluated by the nurse as a normal
assessment finding?
ab
c
de
fg
First thoracic
First
lumbar
1142 PART III: Taking the Test
A. Bronchovesicular
B. Crackle
C. Gurgle
D. Sibilant
E. Tracheal
F. Vesicular
G. Wheeze
The answer is E. Tracheal sounds are normally heard over the
trachea, which lies below point B. Tracheal sounds are very
loud and high pitched rather like the sound made by blowing
through the cardboard tube found at the center of a roll
of paper towels. The expiratory phase is longer than the
inspiratory phase.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Implement interventions to manage the client recovering
from an illness
272. Which interventions would appropriately be included
in the care plan of a client experiencing an acute
episode of rheumatoid arthritis? (Mark all that apply.)
A. ___ Keep affected joints splinted for rest.
B. ___ Apply ice packs to affected joints.
C. ___ Maintain affected joints in a neutral, functional
position.
D. ___ Assist the client to weight bear on affected
joints for at least 15 minutes tid.
E. ___ Use heat to relieve pain.
The answers are A, B, and C. Ice helps reduce inflammation
and relieve pain during acute episodes; heat is used to relax
muscles and relieve pain at other times. During acute
episodes affected joints are splinted for rest, are not exercised,
are used to bear weight nor placed in a hyperextended
position.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
273. A client is receiving vancomycin intravenously when
the nurse notices the client’s neck and face becoming
red. The immediate response by the nurse should be to:
A. notify the physician
B. stop the infusion
C. administer benadryl
D. do nothing since this is a common reaction to
vancomycin
The answer is B. The nurse would stop the infusion, then notify
the physician who would order Benadryl. Once Benadryl has
been administered and the flushing disappears, the antibiotic
can be restarted, but at a slower rate. This reaction is
called Red Man’s syndrome and can be fatal if appropriate
interventions do not occur.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Indentify Pharmacological interactions
Educate the client/family about medications
274. Instructions given to a client taking which medication
would include the need to keep the amount of green
leafy vegetables eaten steady from day to day?
A. Heparin
B. Warfarin sodium
C. Lovastatin
D. Digoxin
The answer is B.Warfarin sodium exerts its anticoagulant effect
through interference with the use of vitamin K for clotting.
Green leafy vegetables are a major dietary source of vitamin K.
If a person varies the amounts of green leafy vegetables in the
diet significantly, the dosage of warfarin will be incorrect—
either too much or too little depending on whether the client
has increased or decreased intake of the green leafy vegetables.
For correct dosage of warfarin amounts of vitamin K need to
be stable and so dietary intake needs to be stable.
A, C, and D are incorrect—Green leafy vegetables do
not impact the effect of heparin, lovastatin, or digoxin.
PSYCHOSOCIAL INTEGRITY
Behavioral Interventions
Assess client appearance, mood, and psychomotor
behavior and identify/respond to inappropriate/abnormal
behavior.
275. Which is a priority nursing intervention for a client
with borderline personality disorder?
A. Encourage acceptance of intensive therapy.
B. Eliminate bizarre fantasies.
C. Facilitate social relationships
D. Promote verbalization of feelings about self.
The answer is D. Promoting verbalization of feelings about
self is important in an attempt to gain insight for clients
with borderline personality disorder. These clients have a
poor and unstable self image and sense of self. They have
overwhelming feelings of aloneness, emptiness and rage
which is often manifested as self abusive behavior such as
head banging, skin scratching, substance abuse, and suiCHAPTER
34 Practice Test for NCLEX-RN® 1143
cide gestures and attempts. Relationships are typically
unstable.
Clients with borderline personality disorder are dependent
and needy and tend to seek help readily. Bizarre fantasies
are not a prominent component of this disorder and facilitation
of social relationships is not a priority need.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Pharmacological Agents/Actions
Identify a contradiction to the administration of a prescribed
or over-the-counter preparation to the client
276. You are reviewing the medications taken by a client who is
going to be scheduled for surgery. You note that one baby
aspirin is taken each day. When asked if the medications
listed are all that he takes, the client says “Oh, I also take
two garlic pills because I heard garlic was good for me.”
What should the nurse instruct the patient to do?
A. Continue to take all of your medication including
the garlic pill.
B. Discontinue taking the garlic pill and continue all
other medication.
C. Discontinue taking the baby aspirin and continue
all other medication.
D. Discontinue taking both the baby aspirin and garlic
pill now
The answer is D. Both the garlic pill and aspirin inhibit
platelet aggregation and prolong bleeding.
A, B, and C are incorrect because the client is only told
to stop either taking the garlic or aspirin.
HEALTH PROMOTION AND
MAINTENANCE
Growth and Development
Assist client/family to identify/participate in activities
fitting his/her age, preference, physical capacity, and
psychosocial/behavior/physical development
277. The parents bring their 2-month-old to the clinic for a
well baby check-up. The mother asks how they should
start the baby on solid foods. Which information
should be included in the nurse’s response?
A. It is too early to start solid foods.
B. Rice cereal will be the first food added to the diet.
C. Start with baby desserts as the baby will not spit
that out.
D. The solids can be put in the bottle with the milk in
the beginning.
The answer is B.
A is incorrect—The parents did not ask when to start solids
but how to start solids. C is incorrect—Desserts are not necessary
and promote a “sweet tooth.” D is incorrect—If the infant
should need to take medication, it will be from a spoon and this
new skill will not be learned if the solids are put in the bottle.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Instruct the client on medication self-administration
procedures
278. Which client statement indicates understanding of the
correct use of nitroglycerine paste?
A. “I will decide on a convenient site for the medicine
and use it consistently.”
B. “I will make sure I have medicine on 24 hours per
day.”
C. “I will wipe the skin with alcohol before I put the
paste on.”
D. “I will make sure to keep enough paste on hand
because it is dangerous to just stop it.”
The answer is D. Use of nitroglycerine paste is tapered off at
the direction of the prescriber; it is not abruptly stopped.
A is incorrect—Sites need to be rotated to avoid skin
irritation. B is incorrect—The medication is not used 24
hours per day; there needs to be a period each day when the
medication is not used. This is typically 8 hours out of every
24. C is incorrect—Skin should not be shaved nor should
alcohol be applied prior to application of the paste because
of irritation and possible breaks in the skin, which allows for
increased absorption of medication.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
279. Which cranial nerve is being tested when the nurse
asks the client to smile, frown, grimace, show the
upper and lower teeth, keep the eyes closed while the
examiner tries to open them and puff out the cheeks?
A. One (olfactory)
B. Five (trigeminal)
C. Seven (facial)
D. Eleven (spinal accessory)
The answer is C. Cranial nerve seven (facial nerve) is responsible
for taste on the front two thirds of the tongue and for
movement of the face including the ability to close the eyes
and move the lips for speech. Motor function of cranial
1144 PART III: Taking the Test
nerve seven is tested by asking the client to smile, frown, grimace,
show the upper and lower teeth, keep the eyes closed,
while the examiner tries to open them and puff out the
cheeks. The examiner observes for symmetry and movement
and presses the puffed out cheeks in to check if air is
expelled equally from both sides. To test taste, an applicator
dipped in a sugar, salt, or lemon solution is placed on the
tongue and the client is asked what is tasted.
A is incorrect—Cranial nerve one (olfactory nerve) is
responsible for the sense of smell. It is tested by occluding
each of the client’s nostrils one at a time, holding a substance
such as coffee or vanilla with a familiar aroma under the
other nostril, and asking the client to identify the smell. The
test is repeated with a different aromatic substance to determine
if the client can differentiate smells.
B is incorrect—Cranial nerve five (trigeminal nerve) has
both motor and sensory components. It is responsible for sensation
in the face, scalp, oral and nasal mucous membranes,
and the cornea and allows chewing movements of the jaw. Its
three-part sensory division is tested by touching the forehead,
cheek, and chin on each side with a wisp of cotton and asking
the client whose eyes are closed to identify the type of touch
and its location. Next the cornea of each is lightly touched
with a wisp of cotton brought in from the side and the eye
observed for the normal blink response. The motor function
of cranial nerve five is tested by asking the client to clench the
teeth and keep them clenched while the examiner pushes
down on the chin to try and separate the jaws.
D is incorrect—Cranial nerve eleven (spinal accessory)
is tested by asking the client to shrug the shoulders and
resist pressure to put them down because this cranial nerve
controls muscular strength of the trapezius and sternocleidomastoid
muscles.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Infectious Disease
Recognize signs and symptoms of infectious diseases
280. The nurse is assessing an infant in the newborn nursery.
Which finding requires intervention?
A. Milia on the nose
B. Breasts are heavily engorged.
C. Erythema toxicum on the trunk
D. White adherent patches on the tongue
The answer is D. White patches are a sign of a candida infection
called thrush. This must be reported to the physician so
that a fungicide can be ordered.
A, B, and C are normal findings. Milia are white epidermal
cysts that disappear on their own. Breast engorgement is
normal and due to maternal hormones. Erythema toxicum
or newborn rash is common and requires no intervention.
PHYSIOLOGICAL INTEGRITY
Reduction in Risk Potential
Laboratory Values
Recognize deviations from normal for values of WBC
281. How should the nurse interpret a laboratory report of
“WBC 15,000; segmented neutrophils 50%”?
A. Severe bacterial infection
B. Low- to moderate-grade bacterial infection
C. Viral infection
D. No infection
The answer is B. WBC count is elevated but segs are normal.
This indicates nonsevere bacterial infection. Severe infection
is indicated by an elevated WBC with elevated band neutrophils.
Viral infection is indicated by a normal WBC and
elevated lymphocytes. No infection is indicated by a normal
WBC with normal segs.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
282. The nurse checks radial deviation as a part of the range
of motion assessment of which joint (s) ?
A. Cervical spine
B. Elbow
C. Wrist
D. Ankle
The answer is C. Radial deviation occurs at the wrist and
allows the hand to be pointed toward the side with the
thumb and the radial artery. Other movements of the
wrist are ulnar deviation in which the hand is pointed
toward the side with the fifth or little finger and the ulnar
artery.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Infectious Diseases
Apply knowledge of client pathophysiology when managing
infectious disease
283. Which assessment findings would the nurse expect
when caring for a client in the preicteric phase of hepatitis?
Mark all that apply.
A. ___ Anorexia
B. ___ Scleral jaundice
CHAPTER 34 Practice Test for NCLEX-RN® 1145
C. ___ Fatigue
D. ___ Liver tenderness
E. ___ Headache
F. ___ Weight loss
G. ___ Vomiting
The answers are A, C, and E. Anorexia, headache, and fatigue
are symptoms of the preicteric phase of hepatitis. Any jaundice,
liver tenderness and weight loss are characteristic of
the icteric phase. In the posticteric phase, the client begins to
improve and anorexia lessens and jaundice begins to disappear.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Diagnostic Tests
Evaluate the results of diagnostic testing and intervene
as needed
284. The nurse would interpret a PaO2 value of less than
how many mmHg as indicating hypoxemia? Record
your answer using a whole number.
The answer is 70.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Teach the client about managing illness
285. Which statement made by a client who has a fractured
hip indicates the need for additional teaching about
required activity restrictions?
A. “I can’t fully extend my leg at the hip for one month.”
B. “I won’t be able to cross my knees for up to 8 weeks.”
C. “I can’t put weight on the affected leg until my doctor
says to.”
D. “I can flex my hip but not more than 90 degrees for
up to 2 months.
The answer is A. There is no restriction on extending the leg
so if the client says she is not allowed to fully extend her leg
for a month it means that she has misunderstood her selfcare
instructions.
B is incorrect—Adduction past the midline must be
avoided for up to 2 months so the knees cannot be crossed
for 2 months. C is incorrect—Weight bearing is restricted
and doctor’s orders regarding extent of restriction need to be
followed. D is incorrect—Hip flexion of more than 90
degrees must be avoided for up to 2 months.
HEALTH PROMOTION AND
MAINTENANCE
Growth and Development
Identify and report deviations from expected growth and
development
286. When assessing the anterior fontanel, the nurse would
interpret it as an abnormal finding requiring follow up
if it was not closed in a child of which age?
A. Six months
B. Nine months
C. One year
D. Two years
The answer is D. It would be an abnormal finding if the anterior
fontanel was not closed by age 2 years. The posterior
fontanel is smaller and closes earlier.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Use the six “rights” when administering client medications
287. A 0.7-mL oral dose of liquid medication is ordered for
an infant. In which device should the nurse measure
the dose for administration?
A. 2 mL syringe
B. Tuberculin syringe
C. Infant teaspoon
D. Medicine cup
The answer is B. A tuberculin syringe allows accurate measurement
of tenths of millimeters and so a dose of seven
tenths of a milliliter can be obtained.
A, C, and D are incorrect—A 2-mL syringe is marked off
in two tenths of a milliliter increments and so seven tenths
cannot be accurately measured and for an infant very small
extra amounts of drug have the potential to cause serious
effects. Neither an infant teaspoon nor a medicine cup allow
accurate measurement of tenths of millimeters.
PHYSIOLOGIC INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic Tests/
Treatments/Procedures
Implement measures to manage/prevent/lessen possible
complications of client condition and/or procedure
288. Which postoperative exercise is best used to prevent
deep vein thrombosis in postoperative clients?
1146 PART III: Taking the Test
A. Deep knee bends
B. Straight leg lifts
C. Side leg lifts
D. Forward lunges
The answer is B. Straight leg lifts exercise the muscle similar
to walking to maintain normal blood flow to and from the
lower extremity.
A, C, and D are incorrect. These exercises cannot normally
be performed immediately following surgical procedures and
require movement that may not be appropriate for all clients.
SAFE AND EFFECTIVE ENVIRONMENT
Management of Care
Establishing Priorities
Assess/triage the client to prioritize the order of care
delivery
289. The nurse obtains the following vital signs on a client
who has just been admitted to the unit. BP 162/84,
pulse 100 and irregular, respirations 16, and pulse
oximetry 88%. Which would be the immediate nursing
intervention?
A. Place the client on cardiac telemetry.
B. Call the physician to report the vital signs.
C. Start a saline lock for IV medication access.
D. Start oxygen at 2–4 L per minute per nasal cannula
per protocol.
The answer is D. The client’s oxygen level is very low. All
other interventions would be done later.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Teach the client about managing illness
290. Which statement made by the mother of a child with
muscular dystrophy indicates a need for further teaching
about the disease?
A. “I cannot believe that my son inherited this terrible
disease.”
B. “I’m going to try to see that my son has the best life
possible even though it will be short.”
C. “If intellectual impairment was not always a part of
the disease, it would be easier to deal with.”
D. “It will be very hard watching as the muscle wasting
and loss of function occur.”
Option C indicates a misunderstanding. Intellectual impairment
occurs with a few forms of MD but not with all so the
mother believing that intellectual impairment is always a
part of the disease indicates a misunderstanding and therefore
further teaching is needed.
The other statements are correct—Muscular dystrophy
is an inherited disorder, with a shortened life expectancy.
Muscle wasting, weakness, and loss of function are characteristic
of muscular dystrophy.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
291. When assessing the temporomandibular joint, where
does the nurse palpate as the client is asked to clench
the teeth and move the jaw?
A. In front of the ear
B. Behind the mastoid process
C. Just beneath the occipital lymph nodes
D. Over the insertion of the sternocleidomastoid muscle
The answer is A. The nurse palpates in front of the ear as the
client clenches his/her teeth and moves the jaw. The temporomandibular
joint is the junction of the temporal and mandibular
bones in front of each ear and allows movement of the jaw.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Illness Management
Interpret client data that needs to be reported immediately
292. Which symptom reported in the health history of a 45year-old man should be interpreted by the nurse as
requiring immediate follow-up evaluation for possible
upper GI bleeding?
A. Black, tarry stools
B. Loose, frothy stool
C. Flat, ribbon-shaped stool
D. Mahogany colored, formed stool
The answer is A. Black, tarry stools are indicative of blood
from the upper GI tract, which has been in the GI tract long
enough to be completely digested.
B is incorrect—Loose, frothy stool is indicative of high
fat content and is associated with malabsorptive disorders. C
is incorrect—Flat, ribbon shaped stool is consistent with a
tumor, which alters the shape of the left colon and prevents
formation and passage of normally formed stool. D is incorrect—
Mahogany colored stool is a symptom of right-sided
cancer of the colon. It results from the mixing of blood from
the tumor with the stool and its exposure to digestive tract
secretions as it progresses through the remaining colon.
CHAPTER 34 Practice Test for NCLEX-RN® 1147
PHYSIOLOGICAL INTEGRITY
Reduction in Risk Potential
Vital Signs
Assess vital signs
293. A client is assessed for orthostatic hypotension with
blood pressure and pulse taken lying and standing after
3 minutes in the supine position and then after standing
for 1 minute. Which sets of blood pressure measurements
is indicative of orthostatic hypotension? Mark all
that apply.
A. Supine 188/92; standing 164/78
B. Supine 148/84; standing 116/52
C. Supine 132/84; standing 102/50
D. Supine 114/72; standing 90/56
The answers are B and C. A drop of 30 mm Hg or more is
indicative of orthostatic hypotension.
PHYSIOLOGIC INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic Tests/
Treatments/Procedures
Implement measures to manage/prevent/lessen possible
complications of client condition and/or procedure
294. Which direction given to a postoperative client will
best promote comfort during coughing and deep
breathing?
A. Listen to music
B. Practice imagery
C. Watch TV during the exercise
D. Splint the incision with a pillow
The answer is D. Splinting the incisional area prevents stress
on the injured area and thereby reduces pain associated with
coughing and deep breathing.
A, B, and C are incorrect—Listening to music, practising
imagery, and watching TV are good distractors but do
not address the actual prevention/limitation of pain that
occurs with deep breathing and a forceful cough.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
295. What is being assessed when the client is approached
from the back and the nurse puts his or her hands on
either side of the trachea pushing one side medially
while asking the patient to swallow?
A. Patency of the trachea
B. Size and regularity of the thyroid gland
C. Size and movement of the pineal body
D. Elasticity of the cricoid cartilage
The answer is B. The size and regularity of the thyroid gland.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Administer and document medications given by common
routes
296. When using an oral syringe to administer medications,
where should the tip of the syringe be placed?
A. Between the cheek and the gums half way back in
the mouth.
B. In the hollow of the mouth under the tongue.
C. One third of the way back on top of the tongue.
D. In the lower back corner of the mouth.
The answer is A. Placing the medication between the cheek and
the gums half way back in the mouth helps prevent choking,
medication running out of the mouth, or medication being
spit out of the mouth. In the other locations these problems
are more likely.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Teach the client about managing illness
297. Which statement made by a client indicates a need for
further teaching about systemic lupus erythematosis?
A. Exposure to sunlight can exacerbate the disease.
B. Exacerbations are most likely to occur in the spring
and summer.
C. Pulmonary function tests are needed annually
because of frequent lung involvement.
D. Blood pressure needs monitoring because of the
risk of hypertension.
Option C indicates a need for further teaching. Pleuritis can be
a symptom of the disease, but monitoring with annual pulmonary
function tests is not part of the medical routine.
The client stating that pulmonary function tests are needed
annually is incorrect and therefore indicates that self-care
instructions have been misunderstood and more teaching
is needed.
The other statements regarding the disease are correct—
Sunlight can exacerbate the disease and exacerbations occur
1148 PART III: Taking the Test
most often in the spring or summer. Clients with systemic
lupus erythematosis are at risk for hypertension and therefore
blood pressure monitoring is needed.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic
Tests/Treatments/Procedures
Implement measures to manage/prevent/lessen possible
complications of the client condition and/or procedure
298. The charge nurse is observing another nurse who is
inserting a nasogastric tube in a preterm infant. The
charge nurse observes the following activities. Which
action would the charge nurse correct?
The nurse
A. checks placement by aspirating stomach contents.
B. lubricates the tip of the tube with a water-soluble
lubricant.
C. measures the length to be inserted from the tip of
the nose to the ear to the sternum.
D. checks placement by inserting 5 mL air while listening
over the stomach for the gurgle.
The answer is D. 5 mL of air would be an extremely large
amount for the size of the infant. This volume is not necessary
to check placement; 1 mL or less will provide adequate
air for testing. All other activities are correct.
PHYSIOLOGICAL INTEGRITY
Reduction in Risk Potential
Laboratory Values
Recognize deviations from normal for values of WBC
299. Which results of a CBC (complete blood count) with
differential should the nurse interpret as indicating the
client has a severe bacterial infection?
A. WBC 8,500; lymphocytes 45%
B. WBC 15,000; segmented neutrophils 50%
C. WBC 25,000; band neutrophils 20%
D. WBC 20,000; segmented neutrophils 58%
The answer is C. With a severe bacterial infection, the total
white blood cell count would be above normal. Band neutrophils
would be elevated because the body is trying to
quickly fight the infection; in fact, so quickly that the neutrophils
are being released into the circulation before they
are mature cells.
A is incorrect—The WBC count is normal with elevated
lymphocytes, indicating viral infection. B is incorrect—WBC
count is above normal but segs are normal, thus indicating
the infection is not severe. D is incorrect—Although the
WBC count is elevated, the segs are still within normal limits,
again indicating the infection is not severe.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
300. The nurse checks inversion as a part of the range of
motion assessment of which joint(s)?
A. Lumbar spine
B. Knee
C. wrist
D. ankle
The answer is D. Movements that are part of the normal range
of motion for the ankles are dorsiflexion (foot bent upward
with toes pointing at head), plantar flexion (foot pointed
downward, abduction, adduction, and eversion (movement
of the sole of the foot outward) and inversion (movement of
the sole of the foot inward)). Flexion, hyperextension,
abduction, and adduction are movements of the knee.
Movements at the wrist are flexion, extension, radial deviation,
and ulnar deviation.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Nutrition and Oral Hydration
Evaluate impact of disease/illness on nutritional status
of the client
301. What symptom reported in the health history of a
underweight teenager indicates the need for careful
assessment of nutritional status?
A. Black, tarry stools
B. Loose, frothy stool
C. Flat, ribbon-shaped stool
D. Mahogany colored, formed stool
The answer is B. Loose, frothy stool is indicative of steatorrhea
or fat in the stool. Large amounts of fat are expelled in
the stool as a result of a variety of malabsorption syndromes.
Therefore a report of this symptom would cause the nurse to
carefully assess for other signs of malnutrition.
A is incorrect—Black, tarry stools are indicative of
blood from the upper GI tract, which has been in the GI tract
long enough to be completely digested. C is incorrect—Flat,
ribbon shaped stool is consistent with a tumor, which alters
the shape of the left colon and prevents formation and pasCHAPTER
34 Practice Test for NCLEX-RN® 1149
sage of normally formed stool. D is incorrect—Mahogany
colored stool is a symptom of right-sided cancer of the
colon. It results from the mixing of blood from the tumor
with the stool and its exposure to digestive tract secretions as
it progresses through the remaining colon.
PSYCHOSOCIAL INTEGRITY
Family Dynamics
Assess parental techniques related to discipline
302. The mother of a preschool child tells the child, “If you
don’t behave, I’ll have the nurse give you a shot.” The
best nurse’s response would be to:
A. ignore the comment as it is obviously not true.
B. reply, “Oh yes, you better be good while you are
here.”
C. wait until the mother leaves the room and then tell
the child that this was incorrect.
D. reply, “Oh, no, I only give shots when the doctor
thinks it will make you better.”
The answer is D. This response provides the child with information
about the nursing function and will reduce fear of
the nurses.
A is incorrect—Ignoring the comment does not resolve
any problem. B is incorrect—provides incorrect information.
C is incorrect—would not help the mother to understand
that her comment will make the child afraid of
nurses.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Instruct the client on medication self-administration
procedures
303. Which instruction should the nurse give a client for
whom a vaginal cream has been prescribed?
A. Lie on your left side for about 5 minutes.
B. Remain supine with hips elevated for 5–10 minutes.
C. Remove excess medication with soap and water in
15 minutes.
D. Urinate and wipe front to back in 15–30 minutes.
The answer is B. Remaining supine with hips elevated for 5–10
minutes keeps the medication in place in the vagina where it is
needed to exert its effect. If the client stands up immediately,
the medication can slide down and out of the vagina.
A, C, and D are incorrect—Clients should lie on the left
side following a rectal treatment such as an enema.
Instructions regarding washing or urinating are not critical
to the self-administration of the medication.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Expected effects/outcomes
304. Which medication is given preoperatively to decrease
gastric and pharyngeal secretions?
A. Glycopyrrolate (Robinul)
B. Pentobarbitol sodium
C. Hydroxyzine hydrochloride (Vistaril)
D. Lorazepam (Ativan)
The answer is A.
B, C, and D are incorrect— Pentobarbitol sodium is used
as an induction agent for anesthesia, hydroxyzine hydrochloride
is used to decrease anxiety, and lorazepam is used to provide
sedation and impair memory of the perioperative events.
HEALTH PROMOTION AND
MAINTENANCE
Developmental Stages and Transitions
Provide education on age-specific growth and development
to clients and family
305. An 11-year-old girl is upset. She states her friends are
buying bras and their breasts are much larger than
hers. She is worried because only one of her breasts is
developing and asks the school nurse what is wrong
with her. How should the nurse respond? (Mark all
that apply.)
___ A. Suggest an appointment with an endocrinologist
___ B. Explain that development is unique to each
individual
___ C. Suggest she watch her progress by looking at
the Tanner stages of development
___ D. Reassure that asymmetrical development is not
unusual
___ E. Ask her to return weekly so her progress can be
monitored
The answers are B, C, and D. Explaining that development is
unique to each individual, suggesting she use the Tanner
stages of development to watch her progress, and reassuring
that asymmetrical development is not unusual are all appropriate
responses.
A and E are incorrect—There is no information given to
suggest an endocrine consult is needed and asking her to
return for weekly monitoring is unnecessary and communicates
the idea of a problem.
1150 PART III: Taking the Test
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Review pertinent data prior to medication administration
306. For which of the following medications should a
patient undergo therapeutic drug monitoring?
A. Penicillin (antibiotic)
B. Propranolol (beta-blocker)
C. Furosemide (diuretic)
D. Lithium (mood stabilizer)
The answer is D. There is a narrow margin of safety between
therapeutic drug effect and drug toxicity with lithium.
A, B, and C are incorrect—There is a wide margin of
safety with penicillin, propranolol, and furosemide and so
therapeutic drug monitoring is not needed.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Implement interventions to manage the client recovering
from an illness
307. Which intervention is inappropriate as part of the
emergent treatment of a simple long bone fracture?
A. Application of cold
B. Elevating the limb
C. Splinting above and below the fracture
D. Application of a pressure bandage
Option D is the inappropriate intervention. A pressure bandage
would not be used for a simple fracture.
Other interventions are correct actions—Cold is applied
immediately and the limb is elevated not lowered to limit
edema. Above and below the fracture is stabilized to prevent
movement of the bone segments and further damage.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
308. The nurse checks adduction as a part of the range of
motion assessment of which joints? Mark all that apply.
A. ___ Lumbar spine
B. ___ Knee
C. ___ Wrist
D. ___ Ankle
E. ___ Finger
F. ___ Toe
G. ___ Shoulder
H. ___ Elbow
The answers are D, E, F, and G. The ankle, fingers, toes, and
shoulders can all be adducted and abducted. Adduction is
movement toward the midline of the body and abduction is
away from the midline. When the ankle is adducted, the foot
is turned inward toward the other foot; when the ankle is
abducted, the foot is turned out to the side away from the other
foot. When fingers and toes are adducted they are brought
close together; when they are abducted, they are spread apart.
When the shoulder is adducted the arm is brought across the
body to the opposite side; when abducted the arm is extended
out to the side away from the body. Remember ad means to or
toward: you send a letter to an address. Ab means away from
as when a student is absent or away from class.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Instruct the client on medication self-administration
procedures
309. Which client statement indicates understanding of the
procedure for using a steroid inhaler?
A. “I will rinse my mouth out with water after using
the inhaler.”
B. “I will take 5 to 6 slow deep breaths after each puff
on the inhaler.”
C. “I will use my bronchodilator immediately after my
steroid inhaler.”
D. “I will blow my nose forcefully after I finish with the
inhaler.”
The answer is A. Steroid residual in the mouth can lead to
Candida overgrowth and infection. Rinsing the mouth out
with water after using the inhaler removes residual steroid
and can prevent this problem.
B is incorrect—Deep breaths do not have to be taken after
using the inhaler. C is incorrect—Bronchodilator inhalers are
always used first to open the lung passages so that other medications
such as the steroids can get deep into the lung for maximum
effect. D is incorrect— Blowing the nose forcefully has
no role in the use of a steroid inhaler.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Medical and Surgical Asepsis
Use appropriate supplies to maintain asepsis
310. When getting a drainage set for an indwelling catheter,
the nurse notices that the bag containing the set is not
CHAPTER 34 Practice Test for NCLEX-RN® 1151
entirely sealed at one end. Which is the appropriate
action for the nurse to take?
A. Use it but notify purchasing about the condition of
the bag.
B. Dispose of it and get another.
C. Use it only if the drainage system appears untouched.
D. Check with the nurse manager on agency policy.
The answer is B. If the protective packaging is not sealed
then the equipment is not sterile and it cannot be used.
This applies regardless of its appearance. Notifying purchasing
or whomever is responsible for equipment can
help with quality control. It is not necessary to check on
agency policy regarding its use because use of contaminated
sterile items places the client at risk for infection and
so the decision to not use falls within the scope of ethical,
professional decision making of the individual nurse.
PSYCHOSOCIAL INTEGRITY
Behavioral Interventions
Assess client appearance, mood, and psychomotor behavior
and identify/respond to inappropriate/abnormal behavior
311. Which is an appropriate nursing intervention for a
client diagnosed with schizophrenia?
A. Maintain a slightly higher level of environmental
stimuli than usual.
B. Prevent the client from lapsing into periods of
silence of longer than 5 minutes.
C. Tell the client if you do not understand what is
being communicated.
D. Be warm with a show of positive emotion when
interacting with the client.
The answer is C. The nurse should tell the client in a simple,
direct manner that he or she is not being understood.
Excessive environmental stimuli should be avoided; stimuli
should not be increased. Clients may be silent and the nurse
should accept this and sit with the client even during periods
of silence if necessary. The client should be approached
in a neutral manner as it is less threatening to the client than
an overly warm approach.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Illness Management
Interpret client data that needs to be reported immediately
312. What symptom reported in the health history of a 64year-old man should be interpreted by the nurse as
requiring immediate follow-up evaluation for possible
left colon cancer?
A. Black, tarry stools
B. Loose, frothy stool
C. Flat, ribbon-shaped stool
D. Mahogany colored, formed stool
The answer is C. Flat, ribbon shaped stool is consistent with
a tumor, which alters the shape of the left colon and prevents
formation and passage of normally formed stool.
A is incorrect—Black, tarry stools are indicative of
blood from the upper GI tract, which has been in the GI tract
long enough to be completely digested. B is incorrect—
Loose, frothy stool is indicative of steatorrhea or fat in the
stool. Large amounts of fat are expelled in the stool as a
result of a variety of malabsorption syndromes. D is incorrect—
Mahogany colored stool is a symptom of right-sided
cancer of the colon. It results from the mixing of blood from
the tumor with the stool and its exposure to digestive tract
secretions as it progresses through the remaining colon.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
313. When assessing the heart, the nurse palpates for pulsation
over the aortic area which would be an abnormal
finding. Which lettered block on the accompanying
diagram marks the location where the nurse would
place his or her finger tips to palpate over the aortic
area. Write the letter of the block on the line provided.
The answer is A.
PHYSIOLOGIC INTEGRITY
Reduction of Risk Potential
Therapeutic Procedures
Assess client response to recovery from local, regional,
or general anesthesia
314. An elderly postoperative client has a history of chronic
obstructive pulmonary disease. Based on this history,
ab
c
d
e
First thoracic
First
lumbar
1152 PART III: Taking the Test
the nurse is especially concerned with monitoring the
client for which problem?
A. Aspiration
B. Delirium
C. Decreased gas exchange
D. Positioning difficulty
The answer is C. Decreased gas exchange is a particular risk
with a history of COPD.
A is incorrect—Aspiration would be associated with the age
related changes of the gastrointestinal system. B is incorrect—
Delirium is associated with the age-related changes of the neurological
system. D is incorrect—Positioning difficulty is associated
with age related changes of the musculoskseletal system.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Choose physical assessment equipment and technique
appropriate for the client
315. Which criterion should the nurse use when selecting
the proper size cuff to use when assessing the blood
pressure of an 8-month-old infant?
The cuff will
A. say infant on the cuff
B. wrap around the arm twice
C. cover 1⁄4 of the upper extremity.
D. cover 80% of the length of the extremity section
The answer is D. The cuff should cover 80% of the extremity section,
if the upper arm is the site, the cuff should cover 80% of the
distance from the elbow to the acromian process. Another way to
determine size is the bladder should cover 40% of the circumference
of the extremity. All other responses are incorrect.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Apply knowledge of client pathophysiology to illness
management
316. When assessing a client in the emergency room, which
finding should be interpreted as a major indicator of
acute pancreatitis?
A. Positive Cullen’s sign.
B. Postprandial elevated serum amylase.
C. Decreased pancreatic secretion with secretin stimulation.
D. Midepigastric pain worsened by fasting.
The answer is A. A positive Cullen’s sign (cyanosis of the
periumbilical skin due to subcutaneous intraperitoneal hemorrhage)
is symptomatic of acute disease. Reduced volume
of pancreatic secretions on a secretin stimulation test is the
most diagnostic measure of chronic disease. Elevated serum
amylase is found with both acute and chronic disease. LUQ
pain radiating to the back, not mid epigastric pain, is characteristic
of acute disease.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Nutrition and Oral Hydration
Provide/maintain special diets based on the client diagnosis/
nutritional needs and cultural considerations
317. Which is the basic type of diet that the nurse would
obtain for a client with celiac disease?
A. Fat free
B. Gluten free
C. Lactose free
D. Low sodium
The answer is B. Clients with celiac disease are unable to
break down gluten, which is a protein. These clients are
treated with a gluten-free diet. This diet excludes products
containing wheat, rye, oats and barley since these grains
contain gluten.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
318. When assessing the heart, the nurse palpates for thrills
over the pulmonic area which would be an abnormal
finding. Which lettered block on the accompanying
diagram marks the location where the nurse would
place the ball of the hand to palpate over the pulmonic
area. Write the Letter of the block on the line provided.
The answer is B.
ab
c
d
e
First thoracic
First
lumbar
CHAPTER 34 Practice Test for NCLEX-RN® 1153
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Pharmacological Agents and Actions
Apply knowledge of pathophysiology when addressing
the pharmacological agents/actions of client prescriptions
319. During discharge teaching, a client asks the nurse how
the prescribed antacids relieve heart burn. The nurse’s
response should be based on the knowledge that
antacids work by
A. decreasing the secretion of gastric acid.
B. coating the stomach lining.
C. thickening the mucus secreted by the stomach wall.
D. neutralizing the acid present in the stomach.
The answer is D. Antacids are alkaline and they relieve heartburn
by neutralizing the acid in the stomach.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Pharmacological Agents/Actions
Identify a contraindication to the administration of a
prescribed or over-the-counter medication to the client
320. On admission to the emergency room, a client with a
traumatic lower extremity amputation is given an opioid
for pain. Which herbal medication if taken by the
client prior to the accident will prolong the sedative
effects of the opioid?
A. Echinacea augustifolia
B. Hypericum perforatum (St. John’s Wort)
C. Piper methysticum (Kava-kava)
D. Valeriana officinalis (Valerian)
The answer is B. Hypericum perforatum (St. John’s Wort) prolongs
the sedative effects of opioids. It also prolongs the
sedative effects of anesthesia.
A, C, and D are incorrect—Echinacea augustifolia
increases the effectiveness of corticosteroids. Piper methysticum
(Kava-kava) potentiates central nervous system
depressants, anesthetics, and corticosteroids. Valerian only
prolongs the sedative effects of anesthesia.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-Specific Assessment
Assess client for abnormal neurological status
321. The nurse is assessing for diminished deep tendon
reflexes in a client with increasing intracranial pressure.
Which location on the accompanying diagram
would the nurse strike with the reflex hammer to
check the biceps reflex?
___ A _______
___ B _______
___ C _______
___ D _______
The answer is A. To check the biceps reflex, the examiner’s
thumb is placed over the biceps tendon located in the
antecubital space. The thumb is struck with the pointed
end of the reflex hammer. The forearm should flex in
response.
Location B denotes the triceps reflex; location C denotes
the patellar or knee jerk reflex; location D denotes the
Achilles reflex.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
322. Which cranial nerve is the nurse assessing when the
client’s gag reflex is checked?
A. Five (trigeminal)
B. Six (abducens)
C. Nine (glossopharyngeal)
D. Twelve (hypoglossal)
The answer is C. The glossopharyngeal nerve is responsible
for the pharyngeal gag reflex as well as for movement of the
phonation muscles of the pharynx. It is also responsible for
taste on the posterior third of the tongue and sensation from
the ear drum and ear canal. The gag reflex is tested by touching
the posterior pharyngeal wall with a tongue blade and
observing for gagging.
A is incorrect—Cranial nerve five (trigeminal nerve) has
both motor and sensory components. It is responsible for sensation
in the face, scalp, oral and nasal mucous membranes,
and the cornea and allows chewing movements of the jaw. Its
three-part sensory division is tested by touching the forehead,
cheek, and chin on each side with a wisp of cotton and asking
the client whose eyes are closed to identify the type of touch
b
a
c
c
d
1154 PART III: Taking the Test
and its location. Next the cornea of each is lightly touched
with a wisp of cotton brought in from the side and the eye
observed for the normal blink response. The motor function
of cranial nerve five is tested by asking the client to clench the
teeth and keep them clenched while the examiner pushes
down on the chin to try and separate the jaws.
B is incorrect—Cranial nerve six (abducens nerve) is
responsible for lateral eye movement.
D is incorrect—Cranial nerve twelve (hypoglossal
nerve) is responsible for tongue movement. It is tested by
asking the client to stick out the tongue and later having the
client say “late date night.”
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications from Surgical
Procedures and Health Alterations
Apply knowledge of pathophysiology to monitoring for
complications
323. After a difficult delivery, a newborn develops a large
cephalohematoma. The nurse will monitor this infant for:
A. infection
B. brain damage
C. hyperbilirubinemia
D. congestive heart failure
The answer is C. Cephalohematoma is bleeding into the periosteum
of the bone. When blood escapes the vascular system, it
is broken down. When red blood cells are broken down,
bilirubin is released. The immature liver is unable to handle
large amounts of bilirubin and jaundice is the result. The
nurse will need to monitor the child so early interventions can
be instituted to prevent complications from high levels of
bilirubin in the blood.
A, B, and D are incorrect—The hematoma is on the
outside of the skull and will cause no brain damage. There
is no risk of infection or congestive heart failure from this
condition.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-specific assessments
324. Which assessment finding should the nurse interpret
as abnormal when admitting an infant to the newborn
nursery?
A. Pulse 142
B. Respirations 38
C. Head circumference: 29 cm
D. Chest circumference: 34 cm
The answer is C. Head circumference should exceed the chest
circumference and could indicate microcephaly. The other
assessment findings are normal.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
325. When assessing the scrotum of a 64-year-old client,
what would be a normal difference as compared to the
scrotum of a 24-year-old client?
The scrotum of the 64-year-old would be
A. longer
B. more pendulous
C. less flexible
D. more firm
The answer is B. The scrotum becomes more pendulous
with age. It does not become longer, less flexible, or more
firm.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-Specific Assessment
Assess client for abnormal neurological status
326. The nurse is assessing for diminished deep tendon
reflexes in a client with hypothyroidism. Which location
on the accompanying diagram would the nurse
strike with the reflex hammer to check the triceps
reflex?
___ A _______
___ B _______
___ C _______
___ D _______
The answer is B. To check the triceps reflex, the client’s arm is
positioned with the elbow bent and the arm and the forearm
and hand relaxed and down. The triceps tendon located just
above the elbow on the back of the arm is struck with the
b
a
c
c
d
CHAPTER 34 Practice Test for NCLEX-RN® 1155
pointed end of the reflex hammer. The forearm should
extend in response.
Location A denotes the biceps reflex; location C denotes
the patellar or knee jerk reflex; location D denotes the
Achilles reflex.
PHYSIOLOGIC INTEGRITY
Reduction of Risk Potential
Therapeutic Procedures
Assess client response to recovery from local, regional,
or general anesthesia
327. Which of the following is a common postoperative
cause of airway obstruction?
A. Difficult intubation
B. Facial edema
C. PO2 greater than 60 mmHg
D. Tongue blocking the airway
The answer is D. The tongue blocking the airway is a risk in the
postoperative client who has had general anesthesia.
A is incorrect—Difficult intubation is not a common
cause of airway obstruction in postoperative clients; it is most
often associated with age-related respiratory system changes
in the elderly. B is incorrect—Facial edema does not necessarily
cause a blocked airway. C is incorrect—A PO2 greater than
60 mmHg is not associated with respiratory difficulty.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic Procedures
Educate the client and family about treatments and procedures
328. A client having surgery for glaucoma asks the nurse how
the doctor will know if the surgery is successful. Which
would be an appropriate response for the nurse to make?
A. IOP will decrease.
B. Ability to read small print will improve.
C Pupil will remain permanently dilated.
D. Peripheral vision will increase.
The answer is A. The reason surgery is done for glaucoma is to
lower intraocular pressure because increased IOP causes progressive
loss of vision. Surgery is done when medication is ineffective.
B is incorrect—Damage done by increased IOP is permanent
therefore ability to read will not improve. C is incorrect—
The pupil is not affected by the surgery so contraction
and dilation occur normally. D is incorrect—Glaucoma causes
loss of peripheral vision before loss of central vision and this
loss is irreversible.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
329. Which lung sound is auscultated over point A in the
diagram would be evaluated by the nurse as a normal
assessment finding?
A. Bronchovesicular
B. Crackle
C. Gurgle
D. Sibilant
E. Tracheal
F. Vesicular
G. Wheeze
The answer is F. Vesicular sounds are normally heard over
alveolar lung tissue, which is the majority of both lungs
including point A. Vesicular sounds are soft in intensity
and low in pitch. The inspiratory phase is longer than the
expiratory phase.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in body systems
330. Six hours after birth, an infant is found to have an axillary
temperature of 97_F. The child is placed in an
overbed warmer. When the nurse tells the mother that
the infant will not be able to leave the nursery at the
next feeding, the mother asks why this low temperature
is a concern. The nurse explains that low body
temperature in the newborn can cause which effects?
(Select all that apply.)
ab
c
de
fg
First thoracic
First
lumbar
1156 PART III: Taking the Test
A. Hypoglycemia
B. Metabolic acidosis
C. Respiratory distress
D. Hyperbilirubinemia
E. Caput Succedaneum
The answers are A, B, C, and D. Heat loss causes the body to try
to produce heat which causes the respiratory rate to rise and
can lead to respiratory distress. Metabolic acidosis occurs
from the anaerobic burning of fats for energy. Hypoglycemia
occurs because the body has burned the glucose to produce
heat. All of the stress taxes the liver which is unable to convert
the indirect bilirubin to direct bilirubin causing hyperbilirubinemia.
Caput is a swelling of the presenting part and not
related to cold stress.
PSYCHOSOCIAL INTEGRITY
Behavioral Interventions
Assess client appearance, mood and psychomotor behavior
and identify/respond to inappropriate/abnormal
behavior
331. Which is a priority nursing intervention for a client
with narcissistic personality disorder?
A. Encourage acceptance of intensive therapy.
B. Eliminate bizarre fantasies.
C. Minimize potential for self harm.
D. Promote verbalization of feelings about self.
The answer is D. Clients with narcissistic personality disorder
are self-centered, independent, not easily intimidated, quite
aggressive individuals who lack the ability to be empathetic
and hence have difficulties with establishing and maintaining
interpersonal relationships. They put forth a sense of
grandiosity but underneath have low self esteem, and feel
insecure and inadequate. These clients need to be helped to
view themselves differently and verbalization of feelings about
self is a first step toward this goal. Other responses do not
apply to the client with a narcissistic personality disorder.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
332. A child is being discharged 18 hours after a tonsillectomy
and adenoidectomy. Discharge instructions for
the parents would include:
A. Give the child aspirin for pain
B. Use a straw to encourage drinking
C. Offer a soft diet without spicy or acidic foods.
D. Encourage the child to clear throat and cough frequently
to remove secretions
The answer is C. A soft diet is maintained to prevent injury to
the surgical area.
A, B, and D are incorrect—Aspirin would increase
bleeding and would not be desirable. Drinking through a
straw and throat clearing increases pressure and could dislodge
a forming clot and cause hemorrhage.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
333. Which direction would the nurse give to a client when
assessing function of cranial nerve twelve (hypoglossal)?
A. “Holding your head straight, move only your eyes
to look first to the right and then to the left.”
B. “Clench your jaw as tightly shut as you can.”
C. “Stick out your tongue.”
D. “Raise your eyebrows.”
The answer is C. Cranial nerve twelve (hypoglossal nerve) is
responsible for tongue movement. It is tested by asking the
client to stick out the tongue and later having the client say
“late date night.”
A, B, and D are incorrect—Cranial nerve six (abducens)
is responsible for lateral eye movement. Clenching the teeth
and keeping the jaw shut while the examiner pushes down
on the chin to try and separate the jaws is a test of cranial
nerve five (trigeminal nerve). Raising eyebrows along with
smiling, frowning, and showing the upper and lower teeth
are tests of the motor division of cranial nerve seven (facial
nerve).
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
334. The nurse would assess a client’s short-term memory
by asking the client:
A. his/her birth date
B. to count backwards from 100 to 7
C. to repeat the phrase “no ifs ands or buts”
D. about current events
The answer is D. Asking about current events assesses shortterm
memory.
CHAPTER 34 Practice Test for NCLEX-RN® 1157
A is incorrect—Asking about birth date assesses longterm
memory. B is incorrect—asking the client to count
backwards from 100 by 7s assesses mathematical calculation.
C is incorrect—Asking the client to repeat the phrase
“no ifs ands or buts” assesses speech.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness management
335. When teaching a type II diabetic client about preventing
hypoglycemic episodes, which information is
appropriate for the nurse to include?
A. Delaying a meal for as little as 15 minutes can significantly
increase the risk of hypoglycemia.
B. With the onset of menses, insulin requirement may
decrease.
C. Prolonged exercise can precipitate a hypoglycemic
episode.
D. Five grams of CHO raise blood sugar about
30 mg/dL.
The answer is B.With the onset of menses progesterone drops
and this may cause a decrease in the need for insulin and so
the risk of hypoglycemia is increased.
A, C, and D are incorrect—Delaying a meal for more
than a half hour increases the risk of hypoglycemia. Exercise
is associated with a drop in blood glucose levels in clients
with type I diabetes. Prolonged exercise in these clients can
cause increased rate of glucose uptake and use by cells for
several hours after the exercise is complete. Thus blood glucose
needs to be monitored and CHO supplements taken
during exercise. Five grams of CHO raise blood sugar about
20 mg/dL not 30 mg/dL.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Ergonomic Principles
Use ergonomic principles when providing care
336. The nurse considers which of the following aspects
when performing a client’s activity and exercise assessment.
Select all that apply:
A. ___ body alignment and posture
B. ___ routine exercised patterns
C. ___ the body’s response to activity and exercise
D. ___ impact of activity and exercise on overall health
The answers are A, B, C, and D. All four aspects are components
that necessary to consider to determine a correct nursing diagnosis.
Assessment of activity tolerance, physical fitness, body
alignment, and mobility are defining characteristics necessary
to make a nursing diagnosis.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Dosage Calculations
Perform calculations needed for medication administration
337. The drug book states that a therapeutic dose for a
medication is 50–75 mg per kg of body weight per day.
The child weighs 33 pounds and is to receive the medication
4 times a day. What would be the maximum
amount of drug the child should receive per dose?
Record your answer is a whole number carried out to
two decimal places. _____ mg per dose
Answer: 281.25 mg per dose; 33 pounds divided by 2.2
pounds per kilogram _ 15 (the child’s weight in kilograms);
15 times 75 _ 1125 mg per day divided by 4 doses equals
281.25 mg.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-Specific Assessment
Assess client for abnormal neurological status
338. The nurse is assessing for hyperreflexia in a client with
preeclampsia. Which location on the accompanying
diagram would the nurse strike with the reflex hammer
to check the patellar reflex?
___ A _______
___ B _______
___ C _______
___ D _______
The answer is C. To check the patellar reflex, the client
sits with legs dangling. The patellar tendon located just
below the patella on the front of the knee is struck
b
a
c
c
d
1158 PART III: Taking the Test
with the wide end of the reflex hammer. The lower leg
should extend in response. If the client cannot dangle,
the knee may be supported by the examiner’s nondominant
hand in a flexed position while the reflex is checked.
Location A denotes the biceps reflex; location B denotes
the triceps reflex; location D denotes the Achilles reflex.
HEALTH PROMOTION AND
MAINTENANCE
Health Promotion Programs
Plan and/or, Participate in the Education of Individuals
in the Community
Provide the client information about health screening tests
339. A 24-year-old unmarried woman has never had a
mammogram. The client states that she has heard that
the exam is painful and she is afraid to have one. The
nurse’s response should be:
A. “Why don’t you have the test once and if it is too
painful don’t do it again?”
B. “No, the mammogram is not painful. Whoever told
you this was lying to you.”
C. “Yes, it is uncomfortable but it only lasts a few seconds.
And the test is so important.”
D. “Since you are not married, it is okay to delay the
test until you become sexually active.”
The answer is C. Honesty is important when responding to
the client. This response will assist the client in seeking
health promotion activities.
A is incorrect as if she decides it was too uncomfortable,
the nurse has given permission to not follow national guidelines.
B and D are incorrect information.
MANAGEMENT OF CARE
Safety and Infection Control
Standard/Transmission-Based/Other Precautions
Apply knowledge of the client pathophysiology to interventions
related to standard/transmission based/other
precautions
340. A child is being treated for bacterial meningitis. Nursing
interventions would include:
A. forcing fluids.
B. positioning in Trendelenburg position.
C. maintaining a brightly lit room to observe for seizures.
D. maintaining respiratory isolation for 24–48 hours
after antibiotics are started.
The answer is D. Although the organism may be a common
one (H. influenzae or pneumococci), other children on the
unit must be protected from the infection. Isolation is
maintained for at least 24 hours after antibiotics are
started.
A is incorrect—Forcing fluids would not be advisable as
cerebral edema is a concern. B is incorrect—The child
should be positioned in semi-Fowler’s position for comfort.
C is incorrect—The child has photophobia; so a brightly lit
room would not be appropriate.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-Specific Assessment
Perform focused assessment or reassessment
341. Which is a step in the assessment of jugular venous
pressure?
A. Assist the client to a right side lying position.
B. Raise the head of the bed 10–15 degrees.
C. Shine a light across the client’s neck.
D. Measure the horizontal distance from the sternal
angle to the meniscus of the internal jugular vein.
The answer is C. A light is shone tangentally across the client’s
neck to highlight the pulsations of the jugular vein. All other
steps listed are incorrect. The client is placed in a supine
position. The head of the bed is raised 30–45 degrees. The
meniscus which is the highest point at which the pulsation
of the internal jugular vein can be seen is identified. The
sternal angle is located and a centimeter ruler is used to
measure the vertical distance from the sternal angle to the
meniscus. The number of centimeters, normally not more
than 4, equals the jugular venous pressure.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Parenteral/intravenous therapies
342. A client’s parenteral antibiotic therapy has been completed.
The physician writes orders to discontinue to
IV line and discharge the client home. Which is a step
the nurse will take when discontinuing the intravenous
line?
A. Leave the IV site open to the air.
B. Use sterile gloves for catheter removal.
C. Remove the catheter and apply an occlusive dressing.
D. Use alcohol to prevent infection of the site during
removal.
The answer is C. An occlusive dressing is recommended following
catheter removal. The site should not be left open to
the air. Clean gloves, not sterile gloves, are necessary for
CHAPTER 34 Practice Test for NCLEX-RN® 1159
nurse protection. Alcohol will increase the bleeding at the
site. A dry sterile dressing will be applied to the site.
PHYSIOLOGICAL INTEGRITY
Reduction in Risk Potential
Vital Signs
Assess vital signs
343. A client is assessed for orthostatic hypotension with
blood pressure and pulse taken lying and standing after
3 minutes in the supine position and then after standing
for 1 minute. Which sets of pulse rates is indicative
of orthostatic hypotension? Mark all that apply.
A. Supine 96 beats per minute; standing 54 beats per
minute
B. Supine 88 beats per minute; standing 62 beats per
minute
C. Supine 84 beats per minute; standing 70 beats per
minute
D. Supine 80 beats per minute; standing 50 beats per
minute
The answer is A. A drop of 40 beats per minute or more in
pulse rate is indicative of orthostatic hypotension.
HEALTH PROMOTION AND
MAINTENANCE
Health Promotion Programs
Instruct the client on ways to promote health
344. A female client is being taught self-breast exam. Which
information should the nurse include in the instructions?
A. The nipple area should be avoided in palpating the
breast.
B. Breast exams are best performed immediately prior
to menses.
C. Self-breast exams are performed in the upright and
supine positions.
D. Should a lump be found, make an appointment for
a professional examination if it hasn’t disappeared
in a month.
The answer is C. Supine and upright positions are used while
palpating the breast.
A is incorrect—The entire breast including the nipple
region should be palpated. B is incorrect—The best time for
self-breast exam is immediately after their menstrual period
as the hormonal influence will be at the minimal. D is incorrect—
If a lump is found, a medical appointment should be
made immediately.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Applies knowledge of intravenous therapy to the care of
client
345. A child is admitted to the hospital with gastroenteritis.
The physician orders D51/4 NS with 20 mEq KCL
per 1000 ml to be administered at a rate of 50 ml per
hour. The appropriate nursing action for this order
would be to
A. delay adding the KCL until the child has voided.
B. ask why the physician didn’t include other electrolytes.
C. question the physician why a hypertonic solution
was ordered.
D. monitor the child for fluid volume overload because
of the fast rate.
The answer is A. Potassium would not be added until the
child has voided. Hyperkalemia would occur if kidney function
was impaired resulting in cardiac dysfunction.
The other responses are incorrect. Fluid replacement is
the main concern in gastroenteritis, the fluid is hypotonic
and the rate is not excessive.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Mobility/Immobility
Apply knowledge of nursing procedures and psychomotor
skills when providing care to clients with immobility
346. Mr. Clark, a 77-year-old, was admitted with a CVA 3
days ago. This is the first time you have been assigned
to care for the gentleman. You carry out an assessment
of Mr. Clark’s mobility level and ability to participate in
activities of daily living. You identify a nursing diagnosis
of Impaired Mobility related to Hemiplegia and
Weakness. Select all the nursing interventions that
would be appropriate for the nursing diagnosis.
A. ___ Change Mr. Clark’s position every 2 hours,
maintaining sound body alignment.
B. ___ Use appropriate supportive devices to assist in
maintaining correct positioning.
C. ___ Teach client and his family correct positioning.
D. ___ Prepare Mr. Clark for bed based on his usual
bedtime patterns prior to the stroke.
The answers are A, B, and C. Correct positioning prevents contractures
and maintains proper body alignment; support
devices aid in maintaining correct body alignment; teaching
involves the family in Mr. Clark’s care from the beginning.
1160 PART III: Taking the Test
D is incorrect—Bedtime patterns are not related to
nursing diagnosis of impaired mobility.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Ergonomic Principles
Use ergonomic principles when providing care
347. Identify the position depicted in the picture.
A. Sims’ position
B. Supine position
C. Prone position
D. Fowlers position
The answer is C. In the prone position, the client has her/his
head turned to the side when lying on the abdomen. The
shoulders, head, and neck are in an erect position, the arms
are in alignment with the shoulder girdle, the hips are
extended.
A is incorrect—Sims’ position is a position halfway
between the lateral and prone positions where the lower arm
is placed behind the client and the upper arm is flexed; both
legs are flexed in front of the client. B is incorrect—Supine
position is a position in which the client lies on his/her back
with head and shoulders slightly elevated on a pillow. D is
incorrect—Fowlers position is a semisitting position with
the head of the bed elevated 45–60_.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness management
348. When teaching a client with type I diabetes, which factors
would the nurse identify as increasing the risk of
hypoglycemic episodes? Mark all that apply.
A. ___ End of menses
B. ___ Change in injection site
C. ___ Use of a new bottle of insulin
D. ___ Delaying a meal for 30 minutes
The answers are B, C, and D. Some individuals experience
hypoglycemia as a result of an increased rate of absorption of
insulin when the site of injection is changed. Hypoglycemia
can occur when a new bottle of insulin is used if the old bottle
had lost some of its potency. Delaying a meal for more
than 30 minutes can also result in hypoglycemia because of
deficient food intake.
Onset of menses with the associated drop in progesterone
can increase the risk of hypoglycemia; the end of
menses does not.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
Uses assessment findings to plan nursing care
349. A nurse is working in the labor and delivery unit. The
nurse assesses all the laboring clients and notes that
one has a small baby in breech position, one has a large
baby who is engaged, one has an average sized infant
in a transverse lie, and the last has an average sized
infant with a floating head. Which client will the nurse
definitely have to prepare for a cesarean delivery?
The client with the
A. small baby in breech position
B. large baby who is engaged
C. average sized infant in transverse lie
D. average sized infant with a floating head
The answer is C. A transverse lie is a shoulder presentation
and cannot be delivered in this position. All of the other
infants could be delivered vaginally.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
350. Which parameters would the nurse assess as part of a
complete neurological assessment? (Mark all that
apply.)
___ A. Deep tendon reflexes
___ B. Shape of the head
___ C. Cranial nerves
___ D. Sensory perception
___ E. Coordination
___ F. Skin
___ G. Heart
The answers are A, C, D, and E. The other areas are not part of
the neurological examination.
CHAPTER 34 Practice Test for NCLEX-RN® 1161
PHYSIOLOGICAL INTEGRITY
Reduction risk potential
Provide Pre- or Postoperative Education
351. A 4-year-old child has just returned from surgery for a
tonsillectomy. Instructions that the nurse should give
the parents would include:
A. encourage the child to cough frequently.
B. have the child drink through a straw to promote
hydration.
C. aviod red liquids in the postoperative period.
D. aspirin is available for pain relief.
The answer is C. Red liquids are avoided to prevent confusion
over bleeding in vomitus or stool.
A is incorrect—Coughing can cause the loss of a clot,
leading to hemorrhage. B is incorrect—Drinking through a
straw may cause the loss of the clot and lead to hemorrhage.
D is incorrect—Aspirin inhibits clotting.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Nutrition and oral hydration
352. A postpartum woman comes to the lactation clinic
2 weeks after birth. The woman states that she doesn’t
seem to produce enough milk for her infant. Which
statement by the woman indicates a possible source of
the lactation problem?
A. “My breasts are not the least bit sore.”
B. “I am always hungry and just eat and eat.”
C. “I make sure I drink 500 ml of fluid every day.”
D. “The baby latches on and nurses for 20 minutes on
each breast every 2 to 3 hours.”
The answer is C. A minimal fluid intake is 1000 ml a day.
Most breast feeding moms exceed this fluid intake as thirst is
common.
A, B, and D are incorrect—The fact that the breasts are
not sore is a positive finding. A breast feeding mother needs
to increase her caloric intake by about 500 calories per day,
which this woman seems to be doing. The infant is nursing
for sufficient time.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Hemodynamics
353. A woman has delivered an infant by cesarean section.
Which factors place this woman at risk for thromboembolic
disease? (Select all that apply.)
A. Due to the surgical procedure, the client will be less
active.
B. The platelet count is elevated as the body prepared
for delivery.
C. The pregnant woman’s blood volume decreases in
later pregnancy.
D. Venous stasis in the lower extremities is common in
late pregnancy.
E. The fetus produces platelets which cross the placenta
into the maternal circulation.
The answers are A, B, and D. Stasis of blood due to pressure
of the term uterus and elevated platelet count in late pregnancy
places all postpartum women at risk for thrombus.
The cesarean client has the added burden of decreased
mobility. The pregnant woman’s blood volume increases not
decreases. The fetal blood components do not readily cross
the placenta.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
354. Which lung sound if auscultated over point B in the
diagram would be evaluated by the nurse as a normal
assessment finding?
A. Bronchovesicular
B. Crackle
C. Gurgle
D. Sibilant
E. Tracheal
F. Vesicular
G. Wheeze
ab
c
de
fg
First thoracic
First
lumbar
1162 PART III: Taking the Test
The answer is F. Vesicular sounds are normally heard over alveolar
lung tissue, which is the majority of both lungs including
point B. Vesicular sounds are soft in intensity and low in pitch.
The inspiratory phase is longer than the expiratory phase.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical emergencies
355. While being fed, a newly admitted infant with tetralogy
of Fallot suddenly becomes very cyanotic and
shows severe cardiac distress. Physician orders have
not been written. Which action should the nurse take?
A. Administer oxygen
B. Administer morphine sulfate
C. Place the child in knee chest position
D. Place the child in high fowler’s position
The answer is C. The child is displaying a “Tet” or hypercyanotic
spell. Placing the child in knee chest reduces the blood
return from the lower extremities and allows better recovery
of the heart. High Fowler’s position does not as effectively
trap blood in the lower extremities and decrease venous
return to the heart. The other responses are not appropriate
as independent nursing actions.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Choose physical assessment equipment and technique
appropriate for the client
356. When assessing deep tendon reflexes, when does the
nurse use the wide end of the reflex hammer? Mark all
that apply.
The nurse uses the wide end of the reflex hammer to
check
A. ___ brachioradialis reflex
B. ___ biceps reflex
C. ___ triceps reflex
D. ___ patellar reflex
E. ___ Achilles reflex
F. ___ cremasteric reflex
The answers are D and E. The patellar and Achilles reflexes
located at the front of the knee and the back of the heel
respectively are tested using the broad end of the reflex
hammer.
A, B, C, and F are incorrect—The brachioradialis reflex
located in the forearm above the radial styloid process of the
wrist, the biceps reflex located in front of the elbow, and the
triceps reflex located just above the elbow on the back of the
arm are all checked using the pointed end of the reflex hammer.
The cremasteric reflex is a superficial reflex, which
causes elevation of one side of the testicle in response to
stroking the thigh on that side. The handle of the reflex hammer
is used to stroke the thigh.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Standard/Transmission-Based/Other Precautions
Apply principles of infection control
357. Which type of precautions would be used when caring
for a client with hepatitis A?
A. Standard precautions
B. Airborne precautions
C. Droplet precautions
D. Contact precautions
The answer is A. Standard precautions are used to decrease
the risk of transmission from bloodborne pathogens and
moist body substances. Moist body substances include
blood, urine, feces, sputum, saliva, wound drainage, and all
aspirated fluids. Because hepatitis A is spread by the fecal
oral route, standard precautions are appropriate.
B is incorrect—Airborne precautions are used when the
mode of spread of an organism is by small particle droplets
borne on air currents. Airborne precautions require a private
room with negative airflow and adequate filtration; those entering
the room wear a mask and if the client leaves the room, a
mask is worn. C is incorrect—Droplet precautions are used
when the mechanism of transmission is by large droplets spread
by coughing, sneezing, or talking. Droplet precautions require a
private room or a room shared with someone infected with the
same organism. Those entering the room and coming within 3
feet of the client need to wear a mask and the client wears a
mask if taken out of the room. D is incorrect—Contact precautions
are used when organisms causing serious disease are easily
transmitted through direct contact. Contact precautions
require a private room or a room shared with someone infected
with the same organism. Gloves are worn at all times and gowns
and protective barriers are used if direct contact is required.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Nutrition and oral hydration
358. A young female adult client is admitted for anorexia
nervosa. The client’s weight has reached a precarious
level and hospitalization was deemed necessary for the
CHAPTER 34 Practice Test for NCLEX-RN® 1163
client’s physical well being. Which is the priority nursing
intervention?
A. Obtaining daily weights
B. Referring for psychological counseling
C. Administering total parenteral nutrition
D. Reinforcing a positive body image
The answer is C. Because the client’s weight loss has reached
a critical level, it is important that nutritional support be
begun immediately. The other interventions are not the priority
interventions.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Provide client and family with information about acute
and chronic mental illness
359. The daughter of a woman who has just been admitted
to an Alzheimer’s care unit because of stage 3 symptoms
of ambulatory dementia, asks the nurse what
changes she should expect in her mother as the disease
continues to progress. The nurse explains that stage 4
is endstage disease and identifies which symptoms that
the client will likely manifest?
A. Does not recognize family members
B. Does not walk
C. Engages in minimal purposeful activity
D. May yell or scream spontaneously
E. Is incontinent
F. Does not recognize self in the mirror
The answers are A, B, C, D, E, and F. Endstage Alzheimer’s
Disease is characterized by inability to recognize family
members, inability to recognize self in a mirror, incontinence
and possibly seizures, inability to walk, little purposeful
activity, spontaneous yelling or screaming often interspersed
in periods of muteness, forgetting how to eat, swallow or
chew, weight loss, and problems associated with immobility
such as pressure ulcers, contractures, UTIs, and pneumonia.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Laboratory values
360. A child is admitted to the pediatric unit with acute
glomerulonephritis. The unit secretary receives a
phoned lab report from the laboratory. Which result
should the nurse question?
A. Urine protein 3_
B. Urine RBCs 4_
C. Urine color: Smokey gray
D. Urine-specific gravity 1.003
The answer is D. Protein and RBCs are expected findings in
the urine. The urine will be very concentrated. All of these
facts will cause the urine-specific gravity to be high, not low.
The color is smoky gray or “cola” colored.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Educate the client/family about medications
361. A pregnant woman has been found to be very anemic.
Because she can’t take pills, liquid iron supplements
have been ordered. Which direction would the nurse
give the client about taking the liquid iron preparation?
A. Take the iron with milk
B. Drink the iron through a straw
C. Take the iron on an empty stomach
D. Take the iron at the same time every day
The answer is B. Iron stains the teeth so should be taken in a
manner to bypass the teeth.
A is incorrect—Milk will prevent iron absorption—iron
should be taken with juice for the best absorption. C is
incorrect—Iron can be irritating to the stomach. D is incorrect—
It doesn’t matter what time of day the iron is taken.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform a comprehensive health assessment
362. What is the nurse assessing when, with the client’s eyes
closed, the nurse traces the number 3 on the palm of
the client’s hand with a capped pen and asks the client
to identify what was traced?
A. Two-point discrimination
B. Stereognosis
C. Graphesthesia
D. Light touch
The answer is C. This is the procedure for assessing graphesthesia.
Two-point discrimination involves touching the skin
simultaneously with two sterile needles at closer and
closer distances to each other until the client perceives
only one touch. Stereognosis is asking the client to identify
a familiar object such as a key when it is placed in the
client’s hand with the client’s eyes closed. Light touch is
tested by stroking an area of the client’s skin with a wisp of
cotton.
1164 PART III: Taking the Test
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
363. An infant’s crib is placed next to the window allowing the
infant to lose heat to a cooler solid surface not in contact
with the infant’s skin. This type of heat loss is termed
A. radiation
B. convection
C. conduction
D. evaporation
The answer is A. This type of heat loss occurs by radiation.
Convection is the loss of heat into the cooler room temperature.
Conduction is the loss of body heat to a solid surface in
direct contact with the body. Evaporation is the loss of heat
when moisture on the skin is converted to a vapor.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Ergonomic Principles
Use ergonomic principles when providing care
364. Which activity requires an individual carrying out the
activity to use the most energy:
A. Rolling
B. Pivoting
C. Lifting
D. Turning
The answer is C. Lifting a person or object requires going
against the force of gravity.
A, B, and D are incorrect—Rolling, pivoting, and turning
a client use a limited amount of energy compared to lifting a
client. Moving an object along a level surface requires less
energy than moving an object against the force of gravity.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for alterations in body systems
365. The client has pulse oximetry ordered to monitor oxygen
saturation. The nurse applies the monitoring
probe to the right index finger and receives a reading
of 91%. The nurse should
A. notify the physician.
B. encourage the client to take a deep breath.
C. check the oxygen level on each of the other fingers.
D. check the monitor site for skin breakdown from the
probe.
The answer is A. The test is used to titrate levels of oxygen.
This value is low. Taking a single deep breath will not resolve
the problem. There is no reason to check the oxygen level of
the other fingers, this is not a test of circulation to the hands.
Although the probe uses heat to read the oxygen level, skin
breakdown is not common in adults.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Choose physical assessment equipment and technique
appropriate for the client
366. Which equipment does the nurse need to perform a
Rinne test on a client?
A. Reflex hammer
B. Pneumatic otoscope
C. Tuning fork
D. Snellen chart
The answer is C. The Rinne test utilizes a tuning fork to compare
bone conduction and air conduction of sound. The
base of a lightly vibrating tuning fork is placed on the mastoid
process and the client is directed to state when the tone
is no longer heard. When the client reports no longer hearing
the tone the tuning fork is moved so the tines are in front
of the opening to the suditory canal. The client is asked if
sound is heard and if so to report when it stops. Normally,
the client hears the sound for as long as the sound was heard
with the base of the tuning fork on the mastoid bone. This
means that air conduction is normally twice as long as bone
conduction. If air conduction is found to be equal to or
shorter than bone conduction, the client has a conductive
hearing loss. If air conduction is longer, but not twice as long
as bone conduction, sensorineural hearing loss is indicated.
A is incorrect—A reflex hammer is used to check
reflexes. B is incorrect—A pneumatic otoscope is used to
check for motion of the tympanic membrane. D is incorrect—
A Snellen chart is used to test distance vision.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-Specific Assessment
Assess the client for abnormal neurological status
367. The nurse is assessing for diminished deep tendon
reflexes in a client with increasing intracranial pressure.
Which location on the accompanying diagram
CHAPTER 34 Practice Test for NCLEX-RN® 1165
would the nurse strike with the reflex hammer to
check the achilles reflex?
___ A _______
___ B _______
___ C _______
___ D _______
The answer is D. To check the Achilles reflex, the knee is
flexed, the foot is dorsiflexed and held by the examiner, and
the leg is externally rotated to allow easy access to the back
of the heel. The Achilles tendon is struck with the wide end
of the reflex hammer. The examiner should feel plantar flexion
in the foot in response.
Location A denotes the biceps reflex; location B denotes
the triceps reflex; location C denotes the patellar reflex.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Pharmacological interactions
368. A client with known heart disease is being treated with
digoxin and lasix. The client is admitted to the hospital
for lethargy and shortness of breath. The admission labs
show a potassium level of 2.9. The nurse would suspect
A. renal failure
B. digoxin toxicity
C. a respiratory infection.
D. decreased chloride levels
The answer is B. Low potassium levels can result from Lasix
administration but would increase the action of the digoxin
causing digoxin toxicity. The other responses are incorrect.
HEALTH PROMOTION AND
MAINTENANCE
Growth and Development
Identify and report deviations from expected growth and
development
369. When assessing a 5-month-old child, which finding
would the nurse interpret as representing normal
growth and development?
b
a
c
c
d
A. Presence of the tonic neck reflex
B. Presence of the crawling reflex
C. Presence of the dance reflex
D. Presence of the rooting reflex
The answer is A. The tonic neck reflex disappears between
4 and 6 months of age and so if it was still present at 5 months
it would not be interpreted as an abnormal finding.
B, C, and D are incorrect—The crawling and dance
reflexes disappear between 1 and 2 months of age. The rooting
and sucking reflexes disappear at 3–4 months of age.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Laboratory values
370. An adult client with SIADH is on restricted fluids to
return serum sodium to normal. A serum sodium level
within which range would indicate that this client
management goal was achieved?
A. 105–115 mEq/L
B. 118–125 mEq/L
C. 135–145 mEq/L
D. 148–158 mEq/L
The answer is C. The normal range of serum sodium is
135–145 mEq/L. Below 135 mEq/L is hyponatremia and
above 145 mEq/L is hypernatremia. With SIADH serum
sodium level is low as a result of dilution by retained fluid
because of the inappropriate secretion of antidiuretic hormone
which prevents diuresis.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Ergonomic Principles
Use ergonomic principles when providing care
371. When moving a client from the bed to a stretcher the
nurse needs to consider utilizing a:
A. draw or pull sheet
B. pillow
C. footboard
D. trapeze bar
The answer is A. A draw or pull sheet will provide friction
which will lead to less force needed to move the client.
Pillows are used in positioning clients. Footboards are
used to prevent foot drop. Trapeze bar is used when the
client can assist in pulling him/herself up in bed.
1166 PART III: Taking the Test
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
372. A newborn is being admitted to the newborn nursery.
The father has accompanied the infant to the nursery.
During the admission process, the nurse prepares to
administer vitamin K intramuscularly. The father asks
why his baby needs the vitamin K. Which response by
the nurse would be most appropriate?
A. “We give this to all babies born by cesarean section.”
B. “Babies can’t take fruits and juices which are the
main source of vitamin K in the diet.”
C. “Your baby will not have anything by mouth for the
next 12 hours so he will be unable to get any vitamin
K from his diet.”
D. “Newborns have sterile intestines. You and I get
vitamin K from bacteria that live in our intestines.”
The answer is D. The main source of vitamin K is from the
intestinal flora and from the ingestion of fats.
A is incorrect because it is also given to infants born by
vaginal delivery. Vitamin K is found in fats, not fruits. The
infant will not be NPO.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
373. A premature male infant is admitted to the high risk
nursery. On the admission assessment, the nurse notes
there are no testes in the scrotum. In relation to this
finding, the nurse would
A. document the finding.
B. monitor urine output.
C. prepare the parents for immediate orchiopexy.
D. evaluate the child for low set ears.
The answer is A. Undescended testes are a common finding in
the preterm infant and do not warrant further investigation
at this time. Orchiopexy may be scheduled prior to the child
starting school, but the testes may descend on their own. Low
set ears are associated with renal abnormalities. Undescended
testes are a sign of immaturity not renal abnormalities.
PSYCHOSOCIAL INTEGRITY
Therapeutic Communications
Develop and maintain therapeutic relationships with client/
family/significant others
374. Upon return from a group meeting a client is visibly upset.
When the nurse notes this fact and asks if the client would
like to talk about it, the client replies “I’ll tell you what
happened but you can’t tell anyone I told you.” Which is
the most appropriate response for the nurse to make?
A. “I will respect your confidentiality.”
B. “I cannot make that promise.”
C. “As long as it doesn’t involve another client, I won’t
say anything.”
D. “I won’t write it in your record but I may need to tell
someone.”
The answer is B. “I cannot make that promise.” This is the
appropriate response because promising to keep information
secret may be appropriate in a social relationship but is inappropriate
in a therapeutic relationship. It is also an honest,
direct answer to the client.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications from Surgical
Procedures and Health Alterations
Applies knowledge of pathophysiology to selected
assessment findings
375. A client is known to have hyperthyroidism with symptoms
including recent weight loss, diarrhea and mild
exophthalmos. The client is seen in the emergency room
with a high temperature, tachycardia and hypertension.
Tremors are noted in the hands. Which problem should
the nurse suspect based on these assessment findings?
A. Goiter
B. Urinary tract infection
C. Thyrotoxic Crisis (thyroid storm)
D. Overdose of Synthroid (Levothyroxine sodium)
The answer is C. Thyroid storm is the sudden oversecretion of
thyroid hormone and can be life threatening. Goiter is an
enlargement of the thyroid gland secondary to decreased
thyroid production. A urinary tract infection would cause
hyperthermia but not the other symptoms. The client with
hyperthyroidism would not be on medication for hypothyroidism
(Synthroid).
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Expected effects/outcomes
376. A newly diagnosed asthma client calls the clinic nurse
to ask which medication is taken routinely to prevent
an asthma attack. Which medication is the one that
would be taken prophylactically?
A. Cromolyn sodium (Intal)
B. Inhalant glucocorticoids such as flunisolide (Aerobid)
CHAPTER 34 Practice Test for NCLEX-RN® 1167
C. Short-acting bronchodilator such as albuterol
(Preventil)
D. Long-acting bronchodilator such as salmeterol
(Serevent)
The answer is A. Cromolyn sodium is a mast cell stabilizer
and is used to prevent an asthmatic attack.
Glucocorticoids are anti-inflammatories used to reduce
inflammation and airway constriction. Oral glucocorticoids
may be administered for severe asthmatics as a prophylactic,
the accumulated side effects are very problematic. Short-acting
bronchodilators would be used prn for exercise induced
asthma. Long-acting bronchodilators are used to obtain control
of asthmatic attacks.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform a comprehensive health assessment
377. What would you ask the client to do as you assess respiratory
excursion?
A. “Take two or three rapid breaths.”
B. “Say 99.”
C. “Take a deep breath.”
D. “Cough.”
The answer is C. Respiratory excursion refers to the symmetry
and degree of chest expansion upon taking a deep breath.
Posteriorly excursion is measured by placing the palms of the
hands with fingers spread wide and thumbs facing each other
on either side of the spinal column with a skinfold pushed up
between them. The client is then asked to exhale and then to
take a deep breath and hold it. The examiner notes the
amount of increased distance between his or her thumbs
when the deep breath is taken. This increase in distance represents
the amount of chest expansion or excursion. Normally
the thumbs will separate by 1 1⁄4 to 2 inches.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
Perform emergency care procedures
378. A 59-year-old male was admitted to your unit following
removal of a tumor on the sigmoid colon with a
diverting colostomy. On the third postoperative day,
the client’s wife asks that you look at the dressing
because it is all wet. Upon removal of the dressing you
observe bowel protruding out of the abdomen through
a dehisced incision. What is the priority nursing
action?
A. Notify the surgeon
B. Reassure the client that he will be fine
C. Apply sterile, normal saline soaked gauze to the
bowel and cover with a second sterile dressing
D. Gently push the bowel back into the abdominal
cavity and apply an abdominal binder
The answer is C. Sterile gauze soaked with normal saline
should be applied to the bowel to prevent drying and then
covered with a secondary sterile dressing to prevent contamination.
A is incorrect—The nurse’s priority action is to preserve
the bowel; then the surgeon is notified. B is incorrect—
Although the nurse does want to assure the client that this
problem will be corrected immediately, it is not the priority
action. D is incorrect—Pushing loops of bowel back into the
abdominal cavity could result in injury to the bowel.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse effects/contraindications
379. A known drug addict arrived in the labor unit at 8 cm
dilated. The client managed the contractions and the
infant was delivered within 1 hour of the mother’s
admission. For which conditions would the infant be
monitored? (Select all that apply.)
A. ___ Hyperbilirubinemia
B. ___ Congenital anomalies
C. ___ Narcotic depression immediately after birth
D. ___ Narcotic withdrawal within a few hours of delivery
The answers are B, C, and D. Many drug abusers will wait to the
last minute to arrive at the labor unit and will have used recreational
drugs immediately before admission. Therefore, the
infant could be depressed at birth but then will develop withdrawal
within a short period of time. Congenital anomalies are
associated with some recreational drugs. The infant will probably
not have problems with hyperbilirubinemia as the narcotic
exposure in utero seems to mature the liver and infants
born to substance abuses seem to have fewer problems with
bilirubin than other infants.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Ergonomic Principles
Use ergonomic principles when providing care
380. A client needs help in transferring from his bed to a chair.
He is 6 feet 2 inches tall, weighs approximately 250 lbs,
1168 PART III: Taking the Test
has weakness on his left side, and has been on prolonged
bed rest. Which factors should the nurse consider prior
to implementing the transfer? Select all that apply.
A. ___ Determine the need for assistance from other
personnel
B. ___ Determine the client’s activity tolerance
C. ___ Assess muscle strength in the client’s legs and
upper arms
D. ___ Assess the amount of instruction the nurse will
need to provide the client’s
The answers are A, B, C, and D. Clients require various levels
of assistance; the nurse needs to recognize her/his strengths
and limitations; a safe transfer is the first priority.
Determining a client’s activity tolerance will aid in determining
the client’s ability to assist in the transfer. Clients that
have been immobile for a period of time may have decreased
muscle strength, tone, and mass. This will effect his/her ability
to bear weight and raise the body. By explaining the transfer
procedure the client will be involved and maybe able to
help in the transfer.
HEALTH PROMOTION AND
MAINTENANCE
Growth and Development
Identify and report deviations from expected growth and
development
381. When assessing a 6-month-old child, which finding
should the nurse interpret as a sign of possible developmental
delay?
The child
A. is not attempting to pull up to a standing position.
B. does not turn toward a person who is speaking.
C. does not imitate speech.
D. does not respond to infant games like peek-a-boo.
The answer is B. At 6 months of age an infant should turn
toward a person who is speaking. If the infant does not do this,
the possibility of developmental delay or other disability exists.
A, C, and D are incorrect—At 1 year a child should have
begun to pull up to a standing position; begun to imitate a
variety of speech sounds; and begun to respond to games
like peek-a-boo and pat-a-cake.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in body system
382. A pregnant woman at 39 weeks gestation tells the
nurse “I started feeling like I can breathe better two
days ago, but now I noticed I have to void a lot.”
How should the nurse would suspect interpret this
information?
A. Lightening has most likely occurred.
B. Quickening has occurred.
C. Labor has begun.
D. A urinary tract infection has developed.
The answers is A. As the uterus descends into the pelvis in
preparation for labor, the client will be able to breathe easier
but will now have pressure on the bladder causing urinary
frequency.
Quickening is feeling fetal movement. The client gives
no indication of contractions although the body is preparing
for labor. A urinary tract infection would cause frequent urination
but not easier breathing.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse effects/contraindications and side effects
383. An 80-year-old man comes to the clinic complaining
of erectile dysfunction. Which question is most important
for the nurse to ask?
A. How often do you usually have intercourse?
B. What medications do you take?
C. When was the last time you had your prostate
examined?
D. Do you have any problems urinating?
The answer is B. As clients age, the likelihood that they take
medications increases. Many of the medications taken by the
older population have erectile dysfunction as a side effect,
including antihypertensives. In many cases the problem can
be eliminated by changing the medication. The other questions,
although they might be asked, do not most directly
impact the problem.
PSYCHOSOCIAL INTEGRITY
Behavioral Interventions
Assist client with achieving and maintaining self-control
of behavior
384. Which statement accurately describes a “no suicide”
contract?
A. The contract provides a boundary.
B. The contract takes the responsibility for control
away from the client.
C. The contract serves to reinforce to the client that life
is valuable.
D. The contract must be written to be effective.
CHAPTER 34 Practice Test for NCLEX-RN® 1169
The answer is A. A “no suicide” contract is a way of providing
boundaries. Contracts help place control in the domain
of the client; they don’t remove control. Contracts assure
the client that someone is concerned enough about them to
provide boundaries but do not directly reinforce that life is
valuable. Verbal “no suicide” contracts have been proven
effective.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Nutrition and oral hydration
385. The husband of an elderly client tells the clinic nurse
that the doctor has diagnosed his wife who has been
increasingly confused, with anemia caused by a vitamin
deficiency. The husband asks which vitamin
could be causing the problem. Which vitamin deficiency
would the nurse suspect is the cause of the
problem?
A. A
B. B12
C. C
D. D
The answer is B. Vitamin B12 deficiency is associated with
anemia and mental confusion. This vitamin deficiency is
common in the elderly. The other vitamins are not associated
with these symptoms.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in body systems
386. A client was diagnosed with a hiatal hernia. Discharge
teaching was provided and the client was discharged
home. The client returns to clinic a week later to
complain that the symptoms have not improved.
The nurse questions the client on activities and notes
that the client eats small frequent feedings; eats at
least one hour before going to bed; has switched
from coffee to tea to reduce caffeine ingestion; and
has begun a smoking cessation program with moderate
success.
Which activity should the nurse counsel the client to
change?
A. Eats small frequent feedings.
B. Eats at least one hour before going to bed.
C. Has switched from coffee to tea to reduce caffeine
ingestion.
D. Has begun a smoking cessation program with moderate
success.
The answer is C. Both coffee and tea are to be avoided as they
increase stomach acidity. All the other activities are appropriate
for a client with a hiatal hernia.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Ergonomic Principles
Use ergonomic principles when providing care
387. Prior to discharge, a client still experiencing some
weakness on his left side has axillary crutches ordered
for him. Which is the correct crutch gait for the nurse
to teach this client?
A. four-point gait
B. three-point gait
C. two-point gait
D. swing through gait
The answer is B. The three-point gait requires the weight to
be borne on both crutches and then on the uninvolved leg or
side. Since this client still has some left sided weakness this
would be the gait of choice.
The four-point gait requires weight bearing on both legs.
The two-point gait requires at least partial weight bearing on
each foot. The swing through gait is used by an individual
wearing braces which assist in supporting the person’s weight.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
388. An obese 34-year-old black man with a high stress job is
seen for primary hypertension. His diet is high in fried
foods and sodium. The client asks why he developed
this problem. Which are the risk factors for hypertension
that this man has? (Select all that apply.)
A. ___ Age
B. ___ Race
C. ___ Obesity
D. ___ Fat Intake
E. ___ High Stress
F. ___ Sodium Intake
The answers are B, C, E, and F. Hypertension is more common
in blacks. Obesity and high sodium intake have been
associated with high blood pressure. Stress is associated
with hypertension. This gentleman is young, the risk of
hypertension increases with age. Although fat intake is
related to obesity, fat intake alone has not been associated
with hypertension.
1170 PART III: Taking the Test
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Alteration in Body Systems
Compare current client data with baseline client data
389. A 63-year-old female, with a history of lymphoma
treated with chemotherapy, is admitted for repair of a
fractured right tibia. Postoperatively her white blood
cell count is 4 mm3 and temperature is 98.6_F. She is
complaining of not feeling well and being chilled.
Which is the priority nursing action?
A. Compare the postoperative lab value and temperature
to the preoperative data.
B. Ask the client what her WBC and temperature has
been in the past.
C. Notify the physician of the change.
D. Do nothing, these are normal values.
The answer is A. With a known history of cancer treated with
chemotherapy the client has a low white blood cell count and
a value close to normal is indicative of an infection.
B is incorrect—The client may not know what their lab
values or temperatures typically have been. C is incorrect—
The answer does not provide information that should be
shared with the physician. D is incorrect—Doing nothing
may result in a negative event for the patient.
HEALTH PROMOTION AND
MAINTENANCE
Developmental Stages and Transitions
Identify expected physical, cognitive, psychosocial and
moral stages of development
390. The nurse is observing a 9-month-old infant to see how
the child is developing cognitively. Which behavior
indicates object permanence has developed?
The infant
A. has found his hands
B. reaches for a toy out of his reach
C. cries when mother leaves the room
D. puts a block into his mouth while playing
The answer is C. A child who cries when mother leaves the
room is aware that mother exists outside his vision so object
permanence has developed. None of the other activities indicate
the child is aware of objects when not in his or her vision.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Pharmacological agents/actions
391. The nurse caring for a client on digoxin checks the
client’s electrolyte reports because of the risk of toxicity
precipitated by hypokalemia. To avoid this risk, the
client’s serum potassium level should be equal to or
above how many milliequivalents per liter?
Write your answer as a whole number carried to one
decimal place. __________ mEq/L.
The answer is 3.5 mEq/L. The normal range of serum potassium
is 3.5-5.0 mEq/L.
PSYCHOSOCIAL INTEGRITY
Behavioral Interventions
Assess client appearance, mood and psychomotor behavior
and identify/respond to inappropriate/abnormal behavior
392. Which is a priority goal for a client with obsessive
compulsive personality disorder?
A. Acceptance of group therapy.
B. Elimination of bizarre fantasies.
C. Development of social relationships
D. Decrease of maladaptive behaviors
The answer is D. Clients with obsessive compulsive personality
disorder are rigid and preoccupied with issues of control
and power. They fear losing control and utilize different maladaptive
behaviors in an effort to control anxiety. Primary
goals of therapy are to reduce anxiety, improve self esteem
and understand and decrease maladaptive behaviors.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Nutrition and oral hydration
393. The physician instructs a client to eat a low residue
diet. Which foods would the nurse instruct the client
to reduce or avoid? (Select all that apply.)
A. ___ Eggs
B. ___ Bananas
C. ___ Strong cheeses
D. ___ Lean tender meats
E. ___ Whole grain cereals
F. ___ Dried beans and beans
The answers are C, E, and F. These foods contain significant
residue. The other foods are considered low residue.
HEALTH PROMOTION AND
MAINTENANCE
Health Screening
Apply knowledge of pathophysiology to health screening
394. A 68-year-old client participating in a community
skin screening tells the nurse about a raised “spot” on
CHAPTER 34 Practice Test for NCLEX-RN® 1171
his upper, outer arm, which has enlarged and changed
color. Inspection discloses an irregular border and
variegated color. What is the priority nursing
response?
A. Caution the client to avoid sun exposure.
B. Advise the client to see a dermatologist as soon as
possible.
C. Suggest use of a topical OTC antibiotic ointment to
prevent infection.
D. Instruct to wash with a mild soap and avoid irritation.
The answer is B. See a dermatologist as soon as possible. A
skin lesion that has an irregular border, inconsistent color,
and is enlarging may be a serious condition such as
melanoma. It is wise for the patient to see a specialist
soon.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication administration
395. A 10-year-old child is diagnosed in the pediatric clinic
with conjunctivitis (pink eye) and an antibiotic eye
ointment is ordered. Which instruction is appropriate
for the nurse to give the mother in regard to the
administration of the eye ointment?
A. Place the ointment directly on the pupil
B. Have the child apply the ointment by himself
C. Ask the child to close his eyes and spread the ointment
on the lids
D. Pull the lower lid down and place the ointment into
this “sack”
The answer is D. The lower lid is pulled down to form a
sack and the ointment is spread into the sack from
the inner corner to the outer corner.
The ointment should not be placed directly on the
pupil. The child will be unable to instill the ointment by
himself. The ointment should be placed into the subconjunctival
sac not on the outer lids.
HEALTH PROMOTION AND
MAINTENANCE
Growth and Development
Identify and report deviations from expected growth and
development
396. When assessing a 12-month-old child, observation of
which behavior is indicative of normal developmental
progression?
A. Feeds self with a spoon
B. Smiles and babbles
C. Says two or three words such as mama, dada, and
bye bye.
D. Arches the back and raises the head when lying on
abdomen.
The answer is C. Saying two or three words is a developmental
milestone that should be achieved by 1 year of
age.
A is incorrect—Feeding self with a spoon is not expected
until 18 months. B is incorrect—Smiling and babbling
should be present by 6 months of age and so is not an
indicator of normal development at the 1-year level. D is
incorrect—Arching the back and raising the head when
lying prone also is expected by the age of 6 months.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Blood and blood products
397. A client is to receive a transfusion of packed cells. Prior
to administering the unit, which steps will the nurse
take? (Select all that apply.)
A. ___ Take vital signs
B. ___ Start an IV of D5W
C. ___ Check that the blood types match
D. ___ Check the client’s arm band for match to the
unit of blood
E. ___ Double check the client’s name and packed
cells unit for match
The answers are A, C, D, and E. All are correct except B. The
IV should be started with normal saline. Dextrose in the line
will cause the cells to clot.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Standard/Transmission-Based/Other Precautions
Apply principles of infection control
398. Which type of precautions would be used when caring
for a client with hepatitis B?
A. Standard precautions
B. Airborne precautions
C. Droplet precautions
D. Contact precautions
The answer is A. Standard precautions are used to decrease
the risk of transmission from bloodborne pathogens and
moist body substances. Moist body substances include
blood, urine, feces, sputum, saliva, wound drainage, and all
aspirated fluids. Because hepatitis B is spread by blood and
blood products, standard precautions are appropriate.
1172 PART III: Taking the Test
B is incorrect—Airborne precautions are used when the
mode of spread of an organism is by small particle droplets
borne on air currents. Airborne precautions require a private
room with negative airflow and adequate filtration; those
entering the room wear a mask and if the client leaves the
room, a mask is worn. C is incorrect—Droplet precautions are
used when the mechanism of transmission is by large droplets
spread by coughing, sneezing, or talking. Droplet precautions
require a private room or a room shared with someone
infected with the same organism. Those entering the room
and coming within 3 feet of the client need to wear a mask and
the client wears a mask if taken out of the room. D is incorrect—
Contact precautions are used when organisms causing
serious disease are easily transmitted through direct contact.
Contact precautions require a private room or a room shared
with someone infected with the same organism. Gloves are
worn at all times and gowns and protective barriers are used if
direct contact is required.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Administers parenteral medication in a safe and effective
manner
399. The physician has ordered a medication to be given by
IV push method. Which is an appropriate nursing
action?
A. Refuse to push the medication.
B. Push the medication over 1 full minute.
C. Push the medication over 5 full minutes.
D. Determine the rate of infusion for this particular
medication.
The answer is D. Each medication has an individual rate of
infusion allowed for IV bolusing (pushing).
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
400. During the third trimester of her pregnancy, a client
develops mild PIH (pregnancy induced hypertension).
Which instruction would be included in the teaching
planned for this client?
A. Avoid all sodium containing foods.
B. Rest in bed during the mid-afternoon.
C. When recumbent, always lay in the supine position.
D. Notify the physician at the next prenatal visit if
headaches or visual disturbances occur.
The answer is B. Rest is beneficial to reduce hypertension.
Rest should be in the lateral position to prevent vena cava
syndrome.
Sodium is a necessary nutrient so eliminating all sodium
would be incorrect. If headaches or visual disturbances
occur, the physician should be notified immediately as they
may indicate worsening of the client’s condition.
HEALTH PROMOTION AND
MAINTENANCE
Growth and Development
Identify and report deviations from expected growth and
development
401. When assessing a 3-month-old infant, which finding
indicates the need for further evaluation?
A. Infant reacts to sudden noise.
B. Infant does not vocalize sounds.
C. Infant does not reach for toys.
D. Infant raises head without arching the back when in
a prone position.
The answer is B. By 3 months of age, an infant should be
vocalizing sounds and so the absence of this behavior indicates
possible developmental delay or other disability and
requires further evaluation.
A, C, and D are incorrect—It is normal for a 3-monthold
infant to react to sudden noises and so no further investigation
is required. Infants are not expected to reach for toys
as a developmental marker until 6 months of age. It is normal
for a 3-month-old to raise the head without arching the
back when in a prone position; arching of the back is not
expected until 6 months of age.
PHYSIOLOGICAL INTEGRITY
System Specific Assessment
Perform Focused Assessment or Reassessment
(Respiratory)
Identify alterations
402. A client has COPD and a barrel chest. Which finding
would the nurse expect when assessing the chest?
A. Paradoxical chest movement
B. Presence of a friction rub
C. Decreased respiratory excursion
D. Absent breath sounds
The answer is C. Respiratory excursion is decreased in the
client with emphysema because a barrel chest develops as a
result of air trapping in the alveoli and the accompanying
lung hyperinflation and flattening of the diaphragm.
CHAPTER 34 Practice Test for NCLEX-RN® 1173
A, B, and D are incorrect—Paradoxical chest movement
exists when an unaffected area of the chest wall rises on
inspiration and the affected area falls and the reverse occurs
during expiration. This is seen with flail chest not with
emphysema. Friction rubs are associated with pleural inflammation
secondary to problems such as pleuritis, tuberculosis,
and pneumonia.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Laboratory values
403. A client has blood drawn for an electrolyte profile. The
venipuncture was difficult and the blood aspiration
was slow. The findings included the following: sodium
150 mEq/L, potassium 6.1 mEq/L, chloride 101 mEq/L,
and CO2 25 mEq/L. Which conclusion could the nurse
draw from this information?
A. The client is doing well as all values are normal.
B. The sodium is low so the client may have heat stroke.
C. The CO2 is elevated so there may be a respiratory
problem.
D. The potassium is high, the specimen may have been
hemolyzed.
The answer is D. The potassium is very high but all other values
are normal. Because of the problems with the blood
draw, the specimen could have been hemolyzed. Hemolysis
results in the release of intracellular potassium and hence
can cause hyperkalemia in the specimen. All other values are
within normal limits.
HEALTH PROMOTION AND
MAINTENANCE
Provide education on age specific growth and development
to the client and families
404. A toddler is shopping with mother. The toddler grabs
a toy off the shelf. When mother replaces the toy on
the shelf, the toddler cries and falls on the floor. Which
is the best response by the mother?
A. Buy him the toy
B. Spank his hands and tell him no
C. Explain to the child why he can’t have the toy.
D. Remove the child from the area and divert attention
to something else
The answer is D. The child is expressing his frustration. The
goal of the parent is to allow the child to regain control without
a loss of self-esteem. Removing and distracting him will
allow him to regain self control.
Buying him the toy will not help him learn to deal with
frustrations. Spanking his hand does not help with selfesteem.
The child doesn’t have the vocabulary for long
explanations and frustration will continue as long as the
desired object is in sight.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Ergonomic Principles
Use ergonomic principles when providing care
405. The nurse is reinforcing the correct way for a client to
descend stairs using crutches. In which order would the
nurse instruct the client to proceed with the listed steps?
A. Places crutches on the next stair, transfers weight to
the crutches, moves affected side (leg) forward
B. Moves unaffected side (leg) forward
C. Transfers body weight to the unaffected side (leg)
The answer is C, then A, and then B. The client transfers body
weight to the unaffected side (leg) then places the crutches
on the next stair. Next the client transfers weight to the
crutches and moves the affected side (leg) forward. Finally
the client moves unaffected side (leg) forward.
This order enables balance to be maintained and allows
the client to more safely go down the stairs.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse effects/contraindications and side effects
406. A client is receiving a chemotherapy agent that is
known to be irritating to the bladder wall. Which
nursing action would best reduce irritation?
A. Encourage the client to drink milk
B. Restrict fluids to decrease urine volume
C. Administer the once daily drug at bedtime
D. Have the client void every two hours while awake
The answer is D. Having the client void frequently reduces
the time the medication sits in the bladder. The nurse would
also force fluids to dilute the medication and on once daily
meds, give it early in the morning so the client can void frequently.
Milk would have no effect on bladder irritation.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Recognize signs and symptoms of impaired cognition
407. A client with schizophrenia says “raining turkeys” to
himself and to others as he walks around the unit and
1174 PART III: Taking the Test
performs various activities. Which would be a correct
label for the nurse to use when documenting this
behavior?
A. word salad
B. clang association
C. neologism
D. verbigeration
The answer is D. Verbigeration is the purposeless repetition
of words or phrases. Word salad refers to the meaningless
connection of words and phrases. Clang association
refers to repeating words and phrases which sound
alike but are otherwise unconnected. A neologism is a
new word coined by the client and with meaning only to
the client.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Total parenteral nutrition
408. A client has an order for total parenteral nutrition to
run at 95 ml/hour. The TPN is infusing into a central
line. While transferring the client to a stretcher to go to
x-ray, the central line is accidentally pulled out. Which
is the immediate nursing action?
A. Give the client sugar laced orange juice by mouth.
B. Start a peripheral line with D5W running at 95
ml/hour.
C. Start a peripheral line and administer the TPN at 95
ml/hour.
D. Notify the physician and wait for the central line to
be restarted.
The answer is B. The client’s body is accustomed to receiving
a strong sugar solution at that rate so sudden stopping
would cause hypoglycemia. TPN cannot be given by peripheral
line. Sugar laced orange juice would not meet the need
for continuous glucose infusion until the central line could
be replaced.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic procedures
409. A client has been severely burned in a house fire and
admitted to the burn unit. After emergency stabilization,
one of the primary nursing goals is to prevent
contractures. Which nursing intervention supports
achievement of this goal?
A. Administration of albumin
B. Promoting the intake of protein foods.
C. Application of splints to immobilize body parts
D. Treating the burns with the open method and not
wrapping the burned injury.
The answer is C. Whereas all of the interventions may be used
in the treatment of burns, the one intervention associated
with prevention of contractions is the application of splints.
In addition to splinting, ROM exercises are important in
maintaining joint function.
HEALTH PROMOTION AND
MAINTENANCE
Immunizations
410. An infant received her first immunization on schedule
but is now past due for both the second and third
immunization of the series. The nurse should
A. give the infant the second and third immunization
during this visit.
B. start the immunizations over, giving the infant the
first of the series.
C. give the second immunization and schedule the
infant for a return visit for the third immunization.
D. give a double dose of the second immunization and
then give the third immunization one month later.
The answer is C. Although there is an abnormal space
between the first and second immunization, the nurse
will give the second and schedule the third immunization
for later. There is no need to restart the immunization.
Two immunizations should not be given at the same
time.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
411. A teenager is admitted to the hospital with a diagnosis
of osteomyelitis. An IV is started for administration of
parenteral antibiotics. The teenager complains about
hospitalization and asks the nurse: “Why can’t I just be
given some pills to take like my friend that had the
abscess?” The nurse’s response would be based on the
knowledge that osteomyelitis:
A. Lacks an effective oral antibiotic.
B. Can cause pathologic fractures so the child must be
hospitalized.
C. Is caused by a different organism than the one that
causes abscesses.
D. Requires parenteral antibiotics to reach bone levels
of the drug high enough to be effective.
CHAPTER 34 Practice Test for NCLEX-RN® 1175
The answer is D. Blood supply to the bones is less than to the
skin. Parenteral antibiotics provide the best blood levels. The
organism may or may not be the same as the other child had.
Although pathologic fractures can occur from osteomyelitis,
bedrest prevents the fracture not hospitalization.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
412. A child has a tonsillectomy. On return to the floor, the
child is positioned prone until fully awake. Instructions
given to the parents should include: (Select all that apply.)
A. Avoid red liquids
B. Use a straw to make drinking easier
C. Cold liquids like popsicles will feel good.
D. Give milk and non-acidic liquids to soothe the throat
E. As soon as the child wakes up, start the child drinking
The answers are A, C, and E. Red liquids could be confused
with blood in vomitus or stool. Cold liquids will reduce pain
and promote blood clotting. Pushing orals fluids will keep
the throat moist and reduce discomfort. A straw requires
suction which could dislodge the clot that has formed in the
throat. Milk thickens secretions requiring more throat clearing
which is discouraged.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
413. A client with polycystic kidney disease needs a kidney
transplant. Which action will the physician take prior
to another family member being considered as a suitable
donor?
A. Discuss with the client feelings about the donor.
B. Instruct the client to take over the counter drugs for
pain
C. Screen the family member for evidence of polycystic
kidney disease
D. Stop dialysis treatment so that the client’s kidney
function can be adequately evaluated
The answer is C. Polycystic kidney disease is inherited as an
autosomal dominant disorder. Any family member should
be screened for kidney disease before consideration as a
donor. Until a donor is found, there is no need to discus the
client’s feelings about the donor. Medications are avoided
because of the injury to the kidneys. If the client was on dialysis,
the kidney function is known so stopping would be
unnecessary and unhealthy.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Safe Use of Equipment
Ensure appropriate and safe use of equipment in performing
client care procedures and treatments
414. Which are safety measures that the nurse needs to
keep in mind when transporting a client in a wheelchair?
Select all that apply.
A. Lock the wheels before the client transfers from bed
to wheelchair
B. Push the wheelchair in a forward direction when
getting on an elevator
C. Be sure the footplates are in the down/lower position
as the client gets into the wheelchair
D. Position the client well back in the seat
The answers are A and D. The wheelchair’s wheels always
need to be locked before transferring a client into the wheelchair
to prevent the wheelchair from moving and the client
falling. Ensuring the client is sitting fully in the wheelchair
will prevent the wheelchair from being off balance and possibly
tipping forward.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Pharmacological agents/actions
415. Due to an allergy to cats, a client has had several allergy
attacks after visiting a family member. The physician
has prescribed an antihistamine to reduce the symptoms.
The client asks the nurse when would be the best
time to take the antihistamine. The nurse’s response is
based on the knowledge that antihistamines
A. transfer the allergic response to a mast cell.
B. destroy the allergen that caused the symptoms
C. block histamine from attaching to receptor sites.
D. destroy histamine, the cause of allergic symptoms.
The answer is C. Antihistamines compete with histamine for the
receptor sites. Once histamine is attached to the receptor site,
an anti-histamine will not work. The best time to take the antihistamine
would be before going to the house with cats.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic procedures
416. Due to injuries in a car accident, a client has a tracheostomy.
Which is a step in providing tracheostomy care?
1176 PART III: Taking the Test
A. Put on clean gloves in preparation for the procedure.
B. Advance the suction catheter while applying suction.
C. Insert the suction catheter as deep into the airway
as possible and begin suctioning.
D. Rotate the suction catheter while applying intermittent
suction during withdrawal.
The answer is D. Rotating the catheter cleans all surfaces of
the trach. Intermittent suction prevents the client from
becoming hypoxic. The procedure is sterile so sterile gloves
are worn. Suction is never applied while inserting the
catheter. The suction catheter is inserted fully and then withdrawn
slightly before suctioning begins.
HEALTH PROMOTION AND
MAINTENANCE
Human Sexuality
417. A woman is talking to her best friend who is a nurse.
The woman knows that she does not carry the gene for
sickle cell anemia. She tells the nurse she is going to
marry a man who has the disease. She asks whether
her future children will be affected with sickle cell anemia.
The nurse’s best response would be
A. no, but they will all be carriers for the disease.
B. one in four of your children will have the disease
C. none of your children will have the disease but 50%
will be carriers.
D. there is no way to determine the possible outcome
for your future children.
The answer is A. Sickle cell anemia is an autosomal recessive
disorder, which means the child must receive an affected
gene from each parent. Since she does not carry the affected
gene, none of the children will be affected. However, since
the both of the husband’s genes are affected, the children will
all receive one copy of the affected gene meaning they will be
carriers. The other responses are incorrect.
PHYSIOLOGICAL INTEGRITY
Reduction in Risk Potential
Potential for complications of diagnostic tests/treatments/
procedures
418. An infant was diagnosed with hydrocephalus shortly
after birth and a ventriculo-peritoneal shunt was
inserted. Three years later, the child is readmitted to
the hospital with a malfunctioning shunt. Which
assessment findings would the nurse interpret as
expected based on the problem?
A. Vomiting and headache
B. Temperature and bradycardia
C. Abdominal pain and electrolyte imbalance
D. Bulging fontanels and increasing head circumference
The answer is A. Early symptoms of a malfunctioning shunt
(and of hydrocephalus) are vomiting and headache, especially
in the early morning. A younger child might have
bulging fontanels and increasing head circumferences but
this child is over 3 and fontanels should have closed.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for alteration in body systems
419. There are several clients currently in the burn unit
with extensive burns. Which client would be at greatest
risk for infection in the burn?
The client who:
A. has skin grafts completely covering all burn surfaces.
B. is being discharged home with follow-up physical
therapy.
C. is being treated with the open method (no dressings)
of burn treatment.
D. is being treated with the closed method (dressings
covering) of burn treatment.
The answer is C. The client whose burns are open to the air
would be most likely to develop an infection. Dressed burns
and grafted burns have coverings which will reduce the likelihood
of infection. The client who is being discharged for
follow-up physical therapy has burns that are well on the
way to healing.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform a comprehensive health assessment
420. Which question should the nurse ask the parent of a
7-month-old infant to obtain the most meaningful
information about the child’s development?
A. Can she sit up by herself?
B. Does she make cooing sounds?
C. Does she turn over?
D. Can she transfer a spoon hand to hand?
The answer is A. By seven months, the infant should be able
to sit without support. The other options are appropriate for
younger children.
CHAPTER 34 Practice Test for NCLEX-RN® 1177
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication administration
421. A 10-month-old infant needs an immunization. Which
is the best site for the intramuscular injection?
A. Deltoid
B. Gluteal
C. Dorsogluteal
D. Vastus lateralis
The answer is D. This muscle is the best choice until the child
is walking well.
The deltoid is never used on young children. The
gluteal and dorsagluteal both refer to the same site and
should not be used in children under 2.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Injury Prevention
Protect the client from injury
422. After admission to the hospital unit, a 5-year-old child
is diagnosed with a brain tumor involving the cerebellum.
While providing care in the preoperative period,
which would be the primary nursing intervention?
A. Protect the child from falls
B. Monitor the child for seizures
C. Measure the head circumference daily
D. Maintain the child’s temperature within the normal
range
The answer is A. Pathology in the cerebellum leads to ataxia
which places the child at risk for falls.
B, C, and D are incorrect—Seizures are a late symptom
in brain tumors so would not be expected here. The child’s
sutures have closed at 5 years of age so head circumference
will not change. The temperature is not likely to be affected.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic procedures
423. An elderly client is going to have a feeding tube permanently
placed. The physician is debating placing a
PEG gastrostomy tube or a jejunostomy tube. Which
fact about the client suggests that a jejunostomy tube is
the best option?
A. The client’s caloric needs are high.
B. The client has a tendency to vomit.
C. The client’s family will be caring for the feeding tube.
D. The client is mentally confused and may pull on a
tube.
The answer is B. Vomiting would decrease with a jejunostomy
tube as the feeding will be placed in the duodenum rather
than in the stomach. The other statements would have no
bearing on the decision.
HEALTH PROMOTION AND
MAINTENANCE
Self-Care
424. A client has recently been diagnosed with a mild
case of emphysema and has been instructed in self
care at home. On a return visit to the clinic, the
client makes the following statements. Which
statement indicates the need for further client education?
A. “I quit the gym since I shouldn’t exercise.”
B. “I told my family they could no longer smoke in my
house.”
C. “I have increased the water I drink by two extra
glasses per day.”
D. “I had a room air conditioner put into my home so
that I can stay indoors when the pollution level is
high.”
The answer is A. Moderate exercise can be beneficial to help
keep the airways open and clean. All other statements were
correct information and do not indicate need for further
intervention.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Laboratory values
425. A nurse is working with several pediatric renal clients.
The nurse notes similarities between the labs of the
pediatric clients with nephrotic syndrome and those
with acute glomerulonephritis. Which lab findings
would be similar?
A. Urine positive for protein
B. Serum albumin decreased
C. Elevated serum triglyceride levels
D. Urine positive for red blood cells.
The answer is A. In nephrotic syndrome, albumin is lost while
in acute glomerulonephritis, red blood cells are lost in the
urine. Both are proteins and would give a positive proteinuria
level. In nephrotic syndrome, the serum albumin is
1178 PART III: Taking the Test
decreased and serum triglyceride levels are elevated. RBCs
are in the urine for acute glomerulonephtirits.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Nutrition and oral hydration
426. A child is found to be allergic to milk. To ensure adequate
calcium intake, which foods would the nurse
recommend be included in the child’s diet?
A. Coffee and tea
B. Pork and ground beef
C. Fruits such as apples and pears
D. Green leafy vegetables such as collard greens and
spinach
The answer is D. Greens and spinach are good sources of calcium.
The other foods are not sources of calcium.
HEALTH PROMOTION AND
MAINTENANCE
Growth and Development
427. Many high schools organize programs to discourage
teenagers from driving drunk, e.g., a fatal car accident
involving popular students is staged in a place where
students will see it. On which developmental fact is
the effectiveness of these programs postulated?
Teenagers
A. view death as a result of an accident.
B. view death as a temporary separation.
C. think death only occurs to the elderly and the sick.
D. recognize that death is universal but usually do not
see themselves as susceptible.
The answer is D. Teenagers can conceptionally view death as
an adult does, but often do not think it can happen to them
or their friends. These programs help them to understand
the reality that driving and drinking can be fatal to everyone.
The other views of death are those of younger children.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication administration
428. Which is a step in the procedure for applying a transdermal
patch for medication administration?
A. Wear sterile gloves when handling the patch.
B. Apply the patch to clean, dry, and un-inflamed skin.
C. Wipe the skin with alcohol and Betadine before
applying the patch.
D. Rub the patch firmly after application to insure
solid contact with skin.
The answer is B. Applying to clean dry and un-inflamed skin
provides the best medication absorption.
Clean gloves should be worn, not sterile. The alcohol
and Betadine are not used because they could affect medication
absorption. Always follow manufacturer recommendations
for application including rubbing the patch after application.
PHYSIOLOGICAL INTEGRITY
Reduction in Risk Potential
Diagnostic tests
429. A client admitted for a workup to rule out multiple
sclerosis has an evoked response test. The client asks
what this test will evaluate. Which is the correct reply?
The test will evaluate:
A. radiation uptake by the brain.
B. the size of the brain for atrophy.
C. the amount of protein in the cerebrospinal fluid.
D. the length of time it takes for the nerve cell to conduct
an impulse.
The answer is D. The evoked response test stimulates one
nerve and evaluates how long it takes that message to travel
to the brain. The stimuli can be visual, auditory or
somatosensory. Radiation uptake would be a scan, a CT will
evaluate atrophy of the brain. The amount of protein in the
CSF is evaluated by a lumbar puncture.
PSYCHOSOCIAL INTEGRITY
Grief and Loss
430. A terminally ill client tells the nurse “If I can only live
to see my grandchild born.” The nurse recognizes this
is an example of
A. disbelief
B. bargaining
C. depression
D. acceptance
The answer is B. Bargaining is the “If this, then that” response.
The disbelief response is “No, not me” and doctor shopping
looking for a more acceptable diagnosis. In depression,
the client accepts that death is inevitable and is saddened
about all that they are losing. Acceptance is when the client
is at peace with the terminal illness.
CHAPTER 34 Practice Test for NCLEX-RN® 1179
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications of diagnostic test/treatments/
procedures
431. A client with a history of severe allergic reactions, is to
be allergy tested. Which type of allergy test requires
the most careful monitoring for a severe reaction?
A. A RAST test
B. Skin patch testing
C. An eosinophil count
D. Intracutaneous skin testing
The answer is D. This test provides the risk of the greatest
exposure to potential allergens. Skin patch testing also
involves exposure to potential allergens, but since the allergen
is not injected, there is less risk of a systemic reaction.
RAST test and eosinophil counts involve no risk of an allergic
reaction.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness management
432. A client develops Bell’s Palsy affecting the right side of
their face. Which would be an important nursing
intervention?
A. Instill artificial tears into the right eye.
B. Reinforce that appearance doesn’t matter.
C. Provide a clear liquid diet to prevent choking.
D. Apply skin care products to the right side of the face
from scalp to jaw line.
The answer is A. Because of the palsy, the client will be unable
to blink on the right side. This will cause the right eye to dry
out so artificial tears will keep the eye moist and promote
comfort. Telling someone appearance doesn’t matter doesn’t
affect how the client feels about appearance. Chewing and
swallowing are only minimally affected so clear liquids are
not appropriate. The skin on the affected side remains intact
so skin care products are not required.
HEALTH PROMOTION AND
MAINTENANCE
Self-Care
433. A diabetic client is being taught foot care. Which information
will the nurse include in the teaching? (Select
all that apply.)
A. ___ Do not wear sandals or open toed shoes
B. ___ Rubber/plastic shoes are best for your feet.
C. ___ Use a mirror to inspect the soles and back of
the foot daily
D. ___ Buy your shoes in the late afternoon when your
feet are their largest.
E. ___ Cut your toenails first thing in the morning
when they are the softest.
The answers are A, C, and D. Sandals and open toed shoes
increase the risk of injury to the feet. A mirror will allow the
inspection of hard to see areas. Your feet are their largest in
late afternoon, so that is the best time to shop for shoes.
Natural fibers should as leather and canvas allow perspiration
to escape and are better than rubber and plastic.
Toenails should be cut after a bath when they are the softest.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness management
434. A client is seen in the emergency room for severe pain
secondary to renal calculi. Following the administration
of pain medication, the client is sent home and
instructed to filter all urine for stones. Which other
instructions will the nurse give the client? (Select all
that apply.)
A. ___ Limit milk intake
B. ___ Rest in the lateral sims position
C. ___ Void every two hours while awake
D. ___ Increase intake of meat, eggs and cranberries
E. ___ Increase fluid intake to 2 to 3 liters of fluid per day.
The answers are A, D, and E. In some clients, milk intake
increases the calcium levels which are a component of some
renal calculi. In addition, milk increases the alkalinity of the
urine which can be a factor contributing to renal calculi.
Meat, eggs, and cranberries produce acidic urine which
reduces renal calculi. Fluid intake will help to reduce calculi.
Resting in the lateral Sim’s position and voiding every two
hours will not reduce renal calculi.
PHYSIOLOGICAL INTEGRITY
Reduction in Risk Potential
Therapeutic procedures
435. A client with nutritional deficiencies has a jejunostomy
tube placed for enteral feedings. The physician orders
the client to receive 2400 ml of feeding per day. Which
is an appropriate nursing action?
A. Divide the feeding into 3 parts and feed at meal times.
B. Feed the client an equal amount every two hours
around the clock.
1180 PART III: Taking the Test
C. Place the feeding on a pump and feed continuously
around the clock.
D. Divide the feeding into 6 feedings and feed every 4
hours around the clock.
The answer is C. Jejunostomy feedings should be continuous.
Gastrostomy feedings can be bolused.
PSYCHOSOCIAL INTEGRITY
Mental Health Concepts
436. A client has been ordered by the court into a facility
which specializes in the treatment of substance
abuse. Group meetings are an integral part of the
program. On the third day of treatment, the client
says “I am not going to group this morning.” In
responding to the client, which fact must the nurse
consider?
A. The client may be required to be in the facility but
he has the right to informed consent in regard to
participation in treatment.
B. The client can be physically escorted to the meeting
room but cannot be made to enter.
C. The client can be coerced into attending the meeting
as long as no physical force is used.
D. The client can elect not to attend 20% of treatment
activities without any repercussions.
The answer is A. Because a client is involuntarily admitted to
a facility does not mean that his right to informed choice is
forfeited.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse effects/contraindications/side effects
437. The client has been on antibiotics for 10 days. When
talking to the clinic nurse, the client mentions that
diarrhea has become bothersome. Which would be an
appropriate action for the nurse to suggest?
A. Decrease water intake
B. Add yogurt to the diet.
C. Increase milk in the diet.
D. Inform the physician at the next clinic visit
The answer is B. Antibiotics eliminate the normal flora
of the intestines. Decreasing water intake will worsen
the problem with dehydration. Adding yogurt to the diet
will help replace the normal flora. Milk would not benefit
the client. Putting off intervening until the next clinic
visit is not appropriate.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Parenteral/intravenous therapies
438. A client is receiving erythromycin by peripheral IV. On
the third dose, the client complains of pain at the IV
insertion site. The nurse checks the insertion site but
the site is benign. Which action is appropriate for the
nurse take to decrease the risk of phlebitis?
A. Give the infusion faster to reduce vein exposure.
B. Give the medication orally instead of intravenously.
C. Give the client the pain medication that has been
ordered prn.
D. Call the pharmacist and ask for the medication to
be diluted.
The answer is D. Diluting the concentration of the drug will
reduce the irritation to the vein. The other responses will not
improve the developing phlebitis.
HEALTH PROMOTION AND
MAINTENANCE
Family Planning
439. A woman has just delivered her fourth baby in 5 years.
She states she doesn’t want to become pregnant again
immediately. Which is the birth control option that
would offer the best protection for this client in the
first 6 weeks post partum?
A. Diaphragm
B. Breast feeding
C. Intrauterine device (IUD)
D. Natural family planning (Rhythm)
The answer is C. An IUD may be inserted soon after childbirth
as it does not affect involution. A diaphragm needs to
be fitted to the cervix. During involution, the cervical shape
could change thus altering the fit of the diaphragm so it no
longer provides protection. Breast feeding is not a method
of contraception. Natural family planning can be used, but
since many women ovulate before menstruation returns, it
may not be successful in the immediate postpartal period.
PSYCHOSOCIAL INTEGRITY
Coping Mechanisms
440. A toddler has been hospitalized for several days. The
mother visits irregularly. Although the toddler cried a
lot at first, the child now seems to have settled in and
is happy and playful. Which type of reaction is the
child displaying?
CHAPTER 34 Practice Test for NCLEX-RN® 1181
A. Despair
B. Denial
C. Protest
D. Bargaining
The answer is B. Protest, despair, and denial are the three
stages of toddler hospitalization reaction. Denial is a symptom
of a severe psychological reaction. In despair, the child
mourns the loss of the mother. In protest, the toddler is
angry, and screams and kicks. Bargaining is not a component
of toddler hospitalization reaction.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness management
441. A child is admitted with marked edema and frothy
urine. Lab tests showed proteinuria and decreased
serum albumin and globulin. Which is an appropriate
diet for this child?
A. Low protein, high calorie
B. High protein, no added salt
C. High calorie, low sodium
D. High protein, low calorie
The answer is B. Nephrotic syndrome is the idiopathic loss of
protein in the urine. With the loss of protein, there is a loss of
osmotic pressure and fluid escapes from the vessels into the
tissues. Replacement of protein is key to reducing edema.
Sodium promotes fluid retention, however low sodium diets
are not tasty. In children, low sodium diets are avoided if possible
so no added salt would be the right choice.
HEALTH PROMOTION AND
MAINTENANCE
Growth and Development
442. The mother tells the nurse that her older children have
been trading money with her 3-year-old. The older children
offer the toddler their pennies for her dimes. The
nurse recognizes that the toddler has not developed:
A. Egocentrism
B. Conservation
C. Object permanence
D. Cognitive dysfunction
The answer is B. Conservation is the ability to deal with a
number of different aspects at the same time. At this time,
the toddler can only see that the penny is bigger than the
dime and cannot understand that the dime has more value.
This is a skill learned in the school-age period. Egocentrism
is the inability to put themselves in others’ place. Object
permanence is the realization that objects exist even when
the child cannot see the object.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Laboratory Test
Calculates an absolute neutrophil count
443. A client has a white blood cell count of 6000/mm3.
The differential reports 47% of these are neutrophils
(segs) and 5% are bands. What is the absolute neutrophil
count?
A. 2520
B. 2820
C. 3120
D. 3420
The answer is C. ANC _ segs _ bands _ white blood cell
count. .47 _ .05 _ .52 _ 6000 _ 3120.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Diagnostic tests
444. A pregnant woman at term comes to the labor unit saying
her membranes have ruptured. Which characteristic
of the client’s vaginal secretions would confirm that
the membranes had ruptured? The vaginal secretions:
A. Are positive for glucose
B. Contain red blood cells
C. Turn nitrazine paper a reddish orange
D. Appear fern like under the microscope when dried
on a slide.
The answer is D. Amniotic fluid present in the vagina indicates
the membranes have ruptured. When dried amniotic
fluid is examined under a microscope, a crystalline fern pattern
may be observed.
When vaginal secretions are tested with nitrazine paper,
the color change would be blue green if the membranes have
ruptured as amniotic fluid is alkaline. The presence of glucose
gives no indication of the status of the membranes. Red blood
cells would be positive even before the membranes ruptures.
PSYCHOSOCIAL INTEGRITY
Therapeutic Communications
Use therapeutic communication techniques to provide
support to the client and/or family
445. A client is scheduled for a surgical procedure under
local anesthesia. Which is an appropriate nursing
1182 PART III: Taking the Test
intervention when preparing the client for the surgery?
A. Reassure the client that a nurse will stay with him.
B. Explain to the client what will be felt, seen, and
heard.
C. Tell the client not to worry as the physician has
done it many times before.
D. Explain what the nurse and the surgeon will be
doing during the procedure.
The answer is B. Preparations for any procedure should be in
terms of what the client will feel, see and hear.
Choice A does not prepare the patient for what will happen.
C is not a reassurance. D explains the procedures in terms
of what happens to the nurse and doctor, not the client.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness management
446. A client is suspected of having renal calculi. Which is
the classic assessment finding indicative of this problem?
A. Oliguria
B. RBCs in the urine
C. Frothy appearing urine
D. Acute severe flank pain on one side
The answer is D. Pain is the chief symptom although blood may
be noted especially in bladder calculi. The volume of urine
does not change so oliguria is not a symptom. Frothy appearing
urine is seen in the individual with albumin in the urine.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse effects/contraindications
447. An elderly client returned from surgery this am. Since
surgery, the client has become increasingly confused. The
nurse reviews the client chart and notes the following:
• The biopsy from surgery was positive for cancer.
• The wound dressing had a small amount of
serosanguineous drainage.
• An NG tube to suction was in place during the first
6 hours post surgery.
• Meperidine HCL (Demerol) has been given every 4
hours for pain.
Which of these findings could account for the increasing
mental confusion?
A. The biopsy from surgery was positive for cancer.
B. The wound dressing had a small amount of serosanquinous
drainage.
C. An NG tube to suction was in place during the first
6 hours postsurgery.
D. Meperidine HCL (Demerol) has been given every 4
hours for pain.
The answer is D. Meperidine is broken down in the body and
releases by-products that are difficult for the elderly client to
excrete. These by-products build up in the body with
repeated doses causing mental confusion. None of the other
findings would be associated with mental confusion.
HEALTH PROMOTION AND
MAINTENANCE
Ante-/Intra-/Postpartum and
Newborn Care
448. When admitted for labor, the client had been excited
and talkative. Now, two hours later, the client appears
serious and does not participate in “chit-chat.” How
should the nurse interpret this behavior?
The client is:
A. worn out from laboring.
B. in the active phase of labor.
C. dissatisfied with the nursing care.
D. displaying concern for the fetus’ well-being.
The answer is B. Clients in early (latent) labor are excited and
talkative. As they proceed into active labor, their demeanor
becomes serious and they are less talkative. There is no evidence
that any other of the statements are true.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Instructs the client on measures to promote health
449. A client is admitted for pneumonia. The nurse
instructs the client to change positions every two
hours. The client asks the nurse why this is important.
The nurse explains that turning:
A. prevents Actelectasis of the lungs.
B. promotes drainage from the lung lobes by gravity.
C. changes the portion of the lung that is splinted by
the bed.
D. keeps uninvolved portions of the lungs from
becoming infected.
The answer is C. The bed splints the chest and limits the ability
of the lung to expand. Turning changes the portion of the
lung that is splinted promoting better oxygenation. The
other responses are incorrect.
CHAPTER 34 Practice Test for NCLEX-RN® 1183
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness management
450. A child has just been diagnosed with asthma. The
nurse has taught the mother how to “allergy proof” the
home. Which statement by the parent indicates a need
for additional teaching?
A. “I will remove all stuffed toys from my child’s bedroom.”
B. “Out of season clothes will be stored away from my
child’s room.”
C. “I will enclose my child’s mattress and box springs
with plastic coverings.”
D. “I will put wall-to-wall carpeting in my child’s room
to reduce exposure to chemicals.”
The answer is D. Wall to wall carpeting will hold dust and
increase allergy exposure. A better option is hard wood
floors which can be mopped on a daily basis. The other
options are correct.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Infectious disease
451. The client has been diagnosed with syphilis and begins
treatment with intramuscular penicillin G. Within 24
hours of this first injection, the client returns to the
clinic complaining of joint pain and fever. On assessment,
the nurse notes tachycardia and hypotension.
How should the nurse interpret these signs and
symptoms?
A. A worsening of the syphilis
B. An allergic reaction to the penicillin
C. Cellular debris from the destruction of the spirochetes.
D. Anxiety due to the diagnosis of a sexually transmitted
disease
The answer is C. The symptoms describe Jarisch-Herxheimer
reaction, indication that a large amount of spirochetes have
been killed by the penicillin. The client would be treated
symptomatically; the penicillin would not be stopped.
Symptoms will abate in another 12 hours.
HEALTH PROMOTION AND
MAINTENANCE
Growth and Development
452. During a well child visit, a mother tells the nurse she
will be bringing her toddler to a play group for the first
time and asks what the child’s reaction is likely to be.
As part of her response, which type of play does the
nurse describe as characteristic of toddlers?
A. Solitary
B. Cooperatively with several toddlers
C. Interactively in groups of no more than 3
D. Beside another toddler but not with the other toddler
The answer is C. Parallel play in which a toddler plays beside
but not with another toddler is the type of play characteristic
of the age group. Infants play alone, called solitary play.
Cooperative play is organized and seen in older children.
Toddlers do not interact with other children well because of
their egocentricity.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness management
453. A child is admitted to the hospital for Kwashiorkor,
protein malnourishment. Which physical finding
would be expected on the admission assessment?
A. Eczema
B. Edematous
C. Height below normal range
D. Weight below normal range
The answer is B. Protein provides the osmotic property of the
blood and without protein, liquid escapes into the tissues.
The child may be overweight if there were adequate carbohydrates
in the diet.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Laboratory values
454. An adult client is scheduled for a tonsillectomy. Several
labs are ordered pre-operatively. Which lab test is most
significant prior to this surgery?
A. CBC
B. PTT
C. Urinalysis
D. WBC with differential
The answer is B. The surgery includes a significant risk for
hemorrhage; so the client’s ability to clot should be
carefully evaluated prior to the surgical procedure. CBC is
important but not the most important. Urinalysis is usually
not significant. WBC with differential probably would be
ordered as tonsillectomies are not done when there is infection
present.
1184 PART III: Taking the Test
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Infectious diseases
455. Several members of a family have been diagnosed with
pinworms. In addition to treating the family with medications,
which is an important instruction for the
nurse to give the family?
A. Cook all meats well.
B. Never go barefoot outside
C. Wash all vegetables before eating
D. Wash all clothes and bed linens in hot soapy water.
The answer is D. Pinworms are spread from person to person
and have no dirt cycle. The primary source of contamination
is the clothing. Cooking meats reduces the risk tapeworms.
Walking barefoot can lead to hookworm. Washing all vegetables
reduces the risk of roundworms.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
456. What is the nurse assessing when with the client’s eyes
closed, the nurse moves the client’s toes up or down
one by one and asks the client to say in which direction
each was moved?
A. Two-point discrimination
B. Stereognosis
C. Position sense
D. Light touch
The answer is C. This procedure is a test of position sense.
A, B, and D are incorrect—Two-point discrimination
involves touching the skin simultaneously with two sterile needles
at closer and closer distances to each other until the client
perceives only one touch. Stereognosis is asking the client to
identify a familiar object such as a key when it is placed in the
client’s hand with the client’s eyes closed. Light touch is tested
by stroking an area of the client’s skin with a wisp of cotton.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Administer and document medications given by common
routes
457. A 2-year-old client with otitis media is to receive ear
drops. To properly administer the ear drops, the nurse
pulls the pinna:
A. Up and back
B. Up and forward
C. Down and back
D. Down and forward
The answer is C. The pinna of the ear is pulled down and
back for children under three and up and back for children
over three.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
458. A 1-week-old infant has surgery to repair a cleft lip.
Which is the priority concern when the child returns
from the recovery room?
A. Feeding method
B. Maintaining airway
C. Preventing scarring of the lip
D. Preventing incisional infection
The answer is B. Immediately after surgery, the concern is airway.
Because of surgery to the nares and the fact that newborns
are obligant nasal breathers, swelling could occlude
the nares. Feeding method will be a concern because sucking
will interfere with the integrity of the suture line.
Preventing scarring and infection are also concerns but not
immediately on return to the floor.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Standard/transmission-based/other precautions
459. A client with cancer is being treated with chemotherapy.
The client becomes neutropenic. To prevent infection,
the nurse implements the following: (select all that apply)
A. Place the client in contact isolation
B. Eliminate fresh flowers from the client’s room
C. Serve the client only cooked fruits and vegetables
D. Use a soft toothbrush to prevent the gums from
bleeding
E. Allow only close family members (spouses and children)
to visit
The answers are B and C. Fresh flowers may spread mold.
Only cooked vegetables and fruits are allowed to be sure all
organisms have been destroyed.
A, D, and E are incorrect—The client will be in protective
isolation, not contact. Bleeding gums is thrombocytopenia.
Visitors are acceptable as long as they are not
CHAPTER 34 Practice Test for NCLEX-RN® 1185
sick. The client will avoid crowds and children who might
be infected.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic procedures
460. Following an automobile accident, the client is admitted
to the hospital unit with a fractured femur. The
client is placed in skeletal traction. Which is an appropriate
nursing action?
A. Restrict fluid
B. Turn side to side every two hours
C. Perform Range of Motion exercises on the affected hip
D. Give sterile pin care using Betadine and sterile dressing
The answer is D. Skeletal traction involves a pin being
inserted through the bone as a component of the traction.
Since there is a loss of skin integrity at the site of the bone
pinning, this site is at risk for infection. Therefore, pin care
is an important part of the nursing care.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Parenteral/intravenous therapies
461. The nurse is attempting to start a peripheral intravenous
infusion line on a client with small veins. The
nurse has made one attempt without success. The
nurse states the veins aren’t palpable with gloves on.
Which action should the nurse take?
A. Start the IV line without gloves.
B. Wear a glove on the dominant hand only.
C. Wear two gloves that the pointer finger of one glove
has been removed for palpation
D. Locate the vein without gloves and mark the site
then put on gloves
The answer is D. For all procedures where blood exposure
could occur, gloves are required. Removal of one finger has
the same consequence as removing the whole glove and is
not acceptable.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
462. The nurse is doing a complete physical assessment on
a young child. Which is the most appropriate order of
assessment for the nurse to use?
A. Heart and lungs sounds first
B. Percussion before auscultation
C. Organized in a head to toe manner
D. Invasive procedures first to get them over.
The answer is A. Listen to heart and lungs sounds first. Once
an infant starts crying, it will be more difficult to hear these.
Auscultation is before percussion. Organized is appropriate
but because of the child’s developmental stage, it is not
head to toe. Invasive should be performed last as children
tend to be less cooperative after invasive procedures.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic procedures
463. A baby has been diagnosed with developmental dysplasia
of the hips and a Pavlik harness is applied. The
Pavlik harness is a type of splint that abducts and
flexes the hips while still allowing leg movement. The
harness can be removed and reapplied by the parents.
Instructions to include for the family caring for an
infant in this type of harness would include:
A. increase fluid intake to promote urine output.
B. keep the harness on the child at least 23 hours a day.
C. take the harness off at night if the baby is uncomfortable.
D. the baby will need a high protein diet to allow hip
repair.
The answer is B. When harnesses and splints can be applied
and removed by the parents, there is a tendency for parents
to remove them if the child complains.
C will result in insufficient treatment. A is not appropriate
as this condition is not related to urinary function. D is
incorrect as this is not a protein deficiency.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Recognize signs of acute and chronic mental illness
464. A man brings his mother to the clinic and says she
has been diagnosed with Alzheimer’s disease but her
behavior has changed drastically and he is concerned
about what has happened. On obtaining the history,
the nurse learns the client had been disoriented in terms
of time and place, had loss of memory, and had difficulty
with banking, housecleaning and other activities
of daily living but has now become agitated and combative;
doesn’t bathe or groom; and rarely speaks.
Which conclusion does the nurse draw from this information?
A. The client has entered stage 2 of Alzheimer’s disease.
B. The client has passed from stage 2 to stage 3 of
Alzheimer’s disease.
1186 PART III: Taking the Test
C. The client has endstage disease.
D. The client has a secondary disease process going on.
The answer is B. The client’s past symptoms of disorientation,
memory loss and difficulty with instrumental activities of
daily living are all characteristic of stage 2 Alzheimer’s disease.
The client’s new symptoms of agitation, combativeness,
lack of bathing and grooming, and rarely speaking are all
symptoms of stage 3 Alzheimer’s disease.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness management
465. During the initial assessment process, a client tells the
nurse that he is lactose intolerant. When the nurse
questions the client about the lactose intolerance, the
nurse would expect the client to describe symptoms
including (select all that apply).
A. ___ Rashes
B. ___ Flatus
C. ___ Constipation
D. ___ Black furry tongue
E. ___ Abdominal cramping
The answers are B and E. In addition to these symptoms, the
other major symptom is diarrhea which can be explosive.
Rashes are associated with allergic responses, not lactose
intolerance. Black furry tongue is usually do to the overgrowth
of organisms not susceptible to antibiotics and not
associated with lactose intolerance.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications
Implement procedures to counteract adverse effects of
medications and parenteral therapy
466. A cancer client is receiving chemotherapy known to
cause stomatitis. Which nursing action would be
appropriate in an effort to reduce or prevent the development
of stomatitis?
A. Ask the physician for a prophylactic antibiotic
B. Provide a firm toothbrush to enhance oral cleaning
C. Encourage the use of mouthwash containing alcohol
D. Instruct the client to rinse their mouth with water
every two hours
The answer is D. Research has shown that simply rinsing the
mouth with water on a frequent basis can reduce stomatitis in
chemotherapy clients. A firm toothbrush could damage the
oral mucous membranes. Alcohol is drying and would damage
the mucous membranes. Antibiotics would be inappropriate.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Standard/Transmission-Based/Other Precautions
Apply principles of infection control
467. Which type of precautions would be used when caring
for a client with C. difficile?
A. Standard precautions
B. Airborne precautions
C. Droplet precautions
D. Contact precautions
The answer is D. Contact precautions are used when organisms
causing serious disease are easily transmitted through
direct contact. This includes all multidrug resistant strains of
organisms such as C. difficile, shigella, and impetigo. Contact
precautions require a private room or a room shared with
someone infected with the same organism. Gloves are worn
at all times and gowns and protective barriers are used if
direct contact is required.
A is incorrect—Standard precautions are used to decrease
the risk of transmission from bloodborne pathogens and
moist body substances. Moist body substances include blood,
urine, feces, sputum, saliva, wound drainage, and all aspirated
fluids. B is incorrect—Airborne precautions are used when
the mode of spread of an organism is by small particle droplets
borne on air currents. Airborne precautions require a private
room with negative airflow and adequate filtration; those
entering the room wear a mask and if the client leaves the
room, a mask is worn. C is incorrect—Droplet precautions are
used when the mechanism of transmission is by large droplets
spread by coughing, sneezing, or talking. Droplet precautions
require a private room or a room shared with someone
infected with the same organism. Those entering the room
and coming within 3 feet of the client need to wear a mask and
the client wears a mask if taken out of the room.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Apply knowledge of client pathophysiology to illness
management
468. A client presents to the emergency room in sickle cell
crisis. The priority nursing intervention for this client
to break the sickling cycle would be to:
A. administer oxygen as ordered.
B. teach sources of iron and folic acid in the diet.
C. draw blood for a hemoglobin and hematocrit value.
D. explain to the client the need to seek treatment as
soon as a crisis begins.
CHAPTER 34 Practice Test for NCLEX-RN® 1187
The answer is A. The crisis is caused by a decrease in oxygen
in the blood. Activities designed to reduce sickling would
include administration of oxygen, fluids including intravenous
fluids, promoting rest and providing pain relief.
All other activities would be inappropriate to break the
sickling cycle.
HEALTH PROMOTION AND
MAINTENANCE
Ante-/Intra-/Postpartum and Newborn Care
469. A pregnant woman is in early labor. After performing
Leopold’s maneuvers, the nurse determines that the
infant is probably a right occiput posterior presentation.
Where would the nurse check fetal heart tones?
A. Through the mother’s back.
B. At the umbilicus on the left side.
C. Below the umbilicus on the right side.
D. Above the umbilicus on the right side.
The answer is C. The infant would be a vertex presentation on
the right side making the fetal heart tones heard best below
the umbilicus on the right. FHTs are never assessed through
the maternal back. FHTs heard at the umbilicus are due to a
transverse lie. Breech presentations put the FHTs above the
umbilicus.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk potential
Diagnostic tests
470. The client’s history indicates several allergic diseases
including eczema and asthma as a child and hay fever as
an adult. Which laboratory findings support this history?
A. Moderate anemia
B. Elevated eosinophil count
C. Elevated C reactive protein
D. Alkaline Phosphatase decreased
The answer is B. Eosinophils are a type of WBC and are elevated
in persons with allergies and worm infestations. The
other responses are not related to allergic reactions.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapy
Medication Administration
Educate client/family about medications
471. A client was admitted to the burn unit after suffering
extensive partial and full thickness burns in a house
fire. At 24 hours postadmission, the physician orders
albumin for the client. The family asks why the client
is receiving albumin. The nurse’s response would be
based on the knowledge that albumin is a:
A. blood product that will help restore circulating RBCs.
B. hypertonic solution that will help restore plasma
volume.
C. source of clotting factors that will control wound
bleeding.
D. source of antibodies to help the client fight infection
secondary to the loss of skin.
The answer is B. Following a burn injury, the blood vessels
become permeable and fluid and protein is lost into the tissues.
Administering a hypertonic solution will cause the
fluid to return from the tissues and maintain circulating volume.
Although albumin is a blood product, it does not contain
red blood cells. Wound bleeding is not a problem this
late in the injury. Albumin is not given to fight infection.
PSYCHOSOCIAL INTEGRITY
Behavioral Interventions
Assess client appearance, mood, and psychomotor behavior
and identify/respond to inappropriate/abnormal behavior
472. Which is a priority nursing intervention for a client
with paranoid personality disorder?
A. Encourage acceptance of intensive therapy.
B. Eliminate bizarre fantasies.
C. Promote social relationships
D. Minimize potential for aggression
The answer is D. Clients with a paranoid personality disorder is
suspicious and hypervigilant with irritable, agitated moods.
They can interpret all behavior as threatening and react in an
aggressive manner. Therefore minimizing the potential for
aggressive behavior is a priority nursing intervention. Clients
with paranoid personality disorders are not good candidates for
intensive therapy, especially group therapy, because it can
heighten their suspiciousness and escalate the risk of aggressive
response. Promotion of social relationships is a priority intervention
for clients with schizoid personality disorder. Bizarre
fantasies are characteristic of schizotypal personality disorder.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk potential
Laboratory values
473. A preterm infant has significant respiratory distress
due to the immaturity of the lungs. When arterial
blood gases results are received, the nurse would
expect to see which abnormality?
A. Respiratory alkalosis
1188 PART III: Taking the Test
B. The pH is lower than normal
C. The oxygen saturation is 94%
D. The carbon dioxide pressure (PCO2) is normal.
The answer is B. A lower pH is acidosis and an infant breathing
poorly would have respiratory acidosis. An oxygen saturation
of 94% is normal. The carbon dioxide pressure would
not be normal.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic procedures
474. A client had polio as a child and now wears a leg brace.
A pressure sore has formed under the leg brace.
Instructions for this client should include:
A. wear the brace only 6 hours per day.
B. do not wear the brace until the skin has healed.
C. apply a dressing over the sore to protect it from the
brace.
D. cover the wound with petroleum prior to putting
on the brace.
The answer is B. The brace should not be worn until the sore is
healed as the brace is the most likely cause of the injury.
Wearing the brace 6 hours a day will further damage the
skin. A dressing under a brace that is already rubbing on the
skin will only make the pressure sore worse. Petroleum will
not protect this wound if the brace is worn.
PSYCHOSOCIAL INTEGRITY
Therapeutic Communications
Uses therapeutic communications skills in providing
care to the client
475. A 36-year-old woman has had a hysterectomy for
fibroid disease. Prior to surgery, the woman stated her
family was complete and she would be glad to not
have to deal with her periods anymore. Two days after
surgery, the nurse finds the woman crying. Which
would be an appropriate response by the nurse?
A. “I know what you are going through, I was upset
after my hysterectomy too.”
B. “You shouldn’t cry. Just think, no more periods, no
more cramps, no more birth control.”
C. “I know that you thought you wouldn’t be sad
about the hysterectomy but it still bothers you,
doesn’t it?”
D. “Other clients have told me that they were surprised
about their feelings of loss even though they
didn’t want more children. Is that what you are
feeling?”
The answer is D. This statement allows the client to recognize
her feelings are common and seeks verification on the cause
of the sadness.
A is incorrect—Usually it is best to avoid personal experiences
when talking to clients about their feelings. Option B
denies the validity of the client’s sadness. Option C seeks
clarification but does not let the client know that her feelings
are common.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Total Parenteral Nutrition
Provide client/family/significant others with information
on TPN
476. When the family notices that the Total Parenteral
Nutrition the surgical client is receiving contains
insulin, they question the nurse about why insulin has
been added to the bag. The nurse explains that the
client:
A. is a diabetic and needs the exogenous insulin.
B. is underweight and the insulin will help with
weight gain.
C. is a pseudodiabetic due to the sugar content of the
solution.
D. needs the insulin because of ileus secondary to the
surgical procedure.
The answer is C. TPN has a very high sugar content which
stresses the client’s pancreas. There is no evidence the client
is diabetic or is underweight. Ileus does not affect the pancreas.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform comprehensive health assessment
477. Which cranial nerve is the nurse assessing when the
nurse the client’s blink reflex is checked?
A. One (olfactory)
B. Five (trigeminal)
C. Seven (facial)
D. Eleven (spinal accessory)
The answer is B. The motor component of cranial nerve five
(trigeminal nerve) controls the blink reflex, which is tested
by bringing a wisp of cotton in from the side to touch the
cornea of each eye.
A is incorrect—Cranial nerve one (olfactory nerve) is
responsible for the sense of smell. It is tested by occluding
CHAPTER 34 Practice Test for NCLEX-RN® 1189
each of the client’s nostrils one at a time, holding a substance
such as coffee or vanilla with a familiar aroma under the
other nostril, and asking the client to identify the smell. The
test is repeated with a different aromatic substance to determine
if the client can differentiate smells.
C is incorrect—Cranial nerve seven (facial nerve) is
responsible for taste on the front two thirds of the tongue
and for movement of the face including the ability to close
the eyes and move the lips for speech. Motor function of
cranial nerve seven is tested by asking the client to smile,
frown, grimace, show the upper and lower teeth, keep the
eyes closed, while the examiner tries to open them and
puff out the cheeks. The examiner observes for symmetry
and movement and presses the puffed out cheeks in to
check if air is expelled equally from both sides. To test
taste, an applicator dipped in a sugar, salt, or lemon solution
is placed on the tongue and the client is asked what is
tasted.
D is incorrect—Cranial nerve eleven (spinal accessory)
is tested by asking the client to shrug the shoulders and
resist pressure to put them down because this cranial nerve
controls muscular strength of the trapezius and sternocleidomastoid
muscles.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
478. A client has been admitted with a possible bowel
obstruction. The nurse completes a head to toe
assessment. Which finding should the nurse interpret
as inconsistent with a bowel obstruction?
A. Vital signs normal
B. Vomitus has a fecal odor
C. Complains of colicky pain
D. Loud rumbling bowel sounds
The answer is D. Bowel sounds in early obstruction are
often high pitched and tinkling above the obstruction.
Bowel sounds will be absent in late obstruction. Vital signs
may remain within the normal range in early obstruction and
progress to shock as the obstruction continues. The pain is
often colicky and the vomitus may have a fecal odor.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic procedures
479. A client’s care giver is performing tracheostomy care.
Which action by the care giver would the nurse correct?
The care giver
A. Used half strength hydrogen peroxide to clean the
inner cannula.
B. Held the tracheostomy tube in place while changing
the ties.
C. Rinsed the inner cannula with sterile normal saline
after cleaning.
D. Used commercial tracheostomy dressing material to
eliminate the need for cutting gauze
The answer is C. To prevent accidental decannulation, the
soiled ties are not removed until the new ties have been put
in place. Half strength hydrogen peroxide is used to clean
the inner cannula and sterile saline is used to rinse it.
Commercial tracheostomy dressings may be used for ease of
application if desired.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Standard/transmission-based/other precautions
480. A pregnant woman at term has an outbreak of genital
herpes. She asks the nurse how this will affect her labor
and delivery. Which response would be correct?
A. “You will probably have a cesarean delivery.”
B. “The baby will require antibiotics after delivery.”
C. “You will be placed on antibiotics when you go into
labor.”
D. “You will need antibiotics in the postpartum period
to prevent a uterine infection.”
The answer is A.With an outbreak of genital herpes, the baby
is usually delivered by cesarean section to decrease the infant
exposure. Herpes is a virus; so antibiotics will not be effective
against this organism.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for alteration in body systems
481. A child has been diagnosed with Wilms Tumor. Prior to
surgery, a sign is placed over the child’s bed that states:
“Do Not Palpate Abdomen.” The mother asks why that
sign was placed over the bed. The nurse’s response will
be based on the knowledge that palpating the abdomen:
A. would be painful for the child.
B. can increase the child’s anxiety.
C. may affect the blood supply to the kidney.
D. could release cancer cells that will migrate to other
areas.
1190 PART III: Taking the Test
The answer is D.Wilms Tumor is encapsulated until relatively
late in the disease. Palpating the abdomen may cause a seeding
of tumor cells to other tissues by way of the blood and
should be avoided except as absolutely necessary for diagnosis.
Palpating the abdomen is not usually painful and should
not cause anxiety. The blood supply to the kidney will not be
affected except through cancer cell seeding.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Fluid and Electrolyte Imbalances
Identify signs and symptoms of client fluid and/or electrolyte
balance
482. A child is admitted to the hospital unit for gastroenteritis
and dehydration. Which laboratory values does
the nurse interpret as indicative of dehydration? Select
all that apply.
A. ___ Elevated WBC
B. ___ Elevated Hemoglobin
C. ___ Elevated Hematocrit
D. ___ Decreased urine-specific gravity.
E. ___ Elevated lymphocytes in the WBC differential
The answers are B and C. Both hemoglobin and hematocrit
are comparisons of solids to liquids. If the amount of solids
stays constant but the volume decreases, the Hgb and Hct
would be elevated. Elevated WBC indicates infection, while
the elevated lymphocytes indicate a viral infection. A
decreased urine-specific gravity would be a more dilute
urine and not associated with dehydration.
HEALTH PROMOTION AND
MAINTENANCE
Ante-/Intra-/Postpartum and Newborn Care
483. A client is 12 weeks pregnant. During her regular prenatal
visit, the following findings are noted:
• Leukorrhea is present
• Complains of urinary frequency
• Uterus is lower in the pelvis than 12 weeks gestation
• Has symptoms of PIH (pregnancy induce hypertension)
Which finding is suggestive of a hydatiform mole?
A. Leukorrhea is present
B. Complains of urinary frequency
C. Uterus is lower in the pelvis than 12 weeks gestation
D. Has symptoms of PIH (pregnancy induced hypertension)
The answer is D. PIH is rare in the first trimester except in the
case of a hydatiform mole. Urinary frequency and leucorrhoea
are normal in pregnancy. In molar pregnancies, the
uterus is larger than anticipated.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
484. A client has been diagnosed with pre-invasive cervical
cancer. When assessing the client, what type of symptomology
would the nurse expect?
A. Pain
B. Anorexia
C. Bleeding
D. None
The answer is D. There are usually no symptoms of preinvasive
cervical cancer.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse effects/contraindications and side effects implement
procedures to counteract adverse effects of medications
and parenteral therapy
485. A toddler is seen in the emergency room after taking a
number of codeine tablets belonging to a grandparent.
Which antidote does the nurse expect the child to receive?
A. Glucagon
B. Naloxone
C. Vitamin K
D. Sodium Bicarbonate
The answer is B. Naloxone (narcan) is an antidote for narcotics
such as codeine.
The other answers are incorrect.
SAFE AND EFFECTIVE
ENVIRONMENT
Management of Care
Establishing Priorities
Apply knowledge of pathophysiology when establishing
priorities for interventions with multiple clients
486. A nurse on the postpartum unit receives report on his
or her assigned clients. Which client should the nurse
assess first?
A. Primipara with problems breastfeeding.
B. Fresh delivery complaining of severe perineal pain.
CHAPTER 34 Practice Test for NCLEX-RN® 1191
C. Multipara, 48 hours postpartum, with elevated blood
pressure.
D. Client who received spinal anesthesia for delivery
and is complaining of a headache.
The answer is B. The severe perineal pain could be a labial
hematoma. The other clients present no immediate concern.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Applies knowledge of bloodborne pathogens to the care
of the client
487. A nurse has been diagnosed with hepatitis C. The
source of the hepatitis C is not known. Which factor
may have contributed to the nurse becoming infected?
A. Having a tattoo
B. Used oral street drugs during the teen years.
C. Failure to complete the Hepatitis Vaccine Series
D. Frequently eats vegetables straight from the garden
The answer is A. There is a major concern that tattoos may be
a source of the hepatitis C if the tattoo artist does not use
new or properly sterilized needles.
Oral drugs would not be a source of hepatitis C,
injectibles would be. The hepatitis vaccine series protects
against hepatitis B. It offers no protection for hepatitis C.
Hepatitis C is a bloodborne pathogen. Hepatitis A comes
from contaminated food and water.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Total parenteral nutrition
488. A client is receiving total parenteral nutrition. In
recognition of a common complication of TPN, the
nurse will monitor the client for:
A. Dehydration
B. Renal failure
C. Cerebral edema
D. Pulmonary hypertension
The answer is A. TPN is a hypertonic solution which can lead to
diuresis. The other complications are not associated with TPN.
PSYCHOSOCIAL INTEGRITY
Behavioral Interventions
Assess client appearance, mood and psychomotor behavior
and identify/respond to inappropriate/abnormal behavior
489. Which behaviors exhibited by a client alert the nurse
to the need to take measures to protect self and others
against an aggressive outburst? Mark all that apply.
A. ___ fist clenching
B. ___ finger snapping
C. ___ foot tapping
D. ___ pacing
E. ___ shouting
F. ___ glaring
The answers are A, D, E, and F. Fist clenching, pacing, shouting,
glaring along with jaw clenching are all common signs
of markedly increased agitation and indicate that the risk of
aggressive behavior is real and immediate. Foot tapping and
finger snapping often occur unrelated to risk of aggression
and if related generally indicate a lower level of agitation.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Palliative/Comfort Care
Assess, intervene, and educate client/family/significant
others about pain management
490. A client had a vulvectomy yesterday. On initial assessment,
the nurse notes the client is dosing while sitting
up in bed in Fowler’s position. When she awakens, the
client states she is uncomfortable. Which is the priority
nursing action?
A. Call the physician
B. Change the client’s position to Semi-Fowler’s.
C. Give more pain medication
D. Explain it is normal to be uncomfortable after a surgical
procedure
The answer is B. Lowering the head of the bed will reduce the
pressure and tension on the incision and reduce the client’s
pain.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptability
Illness Management
Apply knowledge of client pathology to illness management
491. A newborn has been transferred to the pediatric hospital
from the birth hospital with a large myleomeningocele.
On admission to the pediatric hospital, in which
position will the nurse place the infant?
A. Prone
B. Supine
C. In semi-Fowler’s
D. In trendelenburg
The answer is A. The myleomeningocele is extremely fragile
prior to surgical removal. The infant is positioned prone to
1192 PART III: Taking the Test
prevent pressure on the sac. The other responses are
incorrect.
HEALTH PROMOTION AND
MAINTENANCE
Ante-/Intra-/Postpartum and Newborn Care
492. The home economics class in a high school has a class
on pregnancy as part of the family life curriculum. A
nurse has been asked to present information about
pregnancy to the class. The nurse tells the students
that smoking during pregnancy can have a negative
effect on the fetus. The nurse explains that mothers
who smoke often give birth to:
A. diabetic infants.
B. low birth weight infants.
C. large for gestational age babies.
D. infants who grow up to be smokers.
The answer is B. Miscarriages, preterm birth, and low birth
rate babies are associated with smoking during pregnancy. It
is not associated with diabetic infants or large for gestational
age babies. Seeing a parent smoke can be a influencing factor
in the children smoking but the mother smoking during
pregnancy does not encourage smoking by the infant when
he or she grows up.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
493. An 18-month-old child has returned from cleft palate
repair. The postoperative physician’s orders include full
liquid diet. Which would be the best feeding method
for this child?
A. Cup
B. Straw
C. Spoon
D. Baby bottle
The answer is C. Anything that can be made into a liquid
could be fed to the child. Drinking from a cup will prevent
injury to the palate. Nothing rigid should be allowed in the
mouth that could damage the palate repair. Sucking on a
bottle or straw would also be inappropriate.
PSYCHOSOCIAL INTEGRITY
Coping Mechanisms
494. When the new baby comes home from the hospital,
the older sibling, a toddler, begins wetting himself.
The mother calls the clinic nurse to ask what is happening
as the toddler was toilet trained over a year
ago. Which is the most likely explanation for this
problem? The client:
A. May need more oral fluids.
B. Has a urinary tract infection.
C. Has regressed due to the stress of the new baby.
D. Is mad at the mother for bringing home a new baby.
The answer is C. Regression is common when a child is psychologically
stressed. There is no evidence of a need for
increased fluids or a urinary tract infection. Even a toddler
that is excited about a new sibling will feel stress when the
family dynamics change.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Teach client about managing illness
495. Which statement made by a client with COPD after
being taught about the use of pursed lip breathing
indicates the need for additional instruction?
A. “I will make sure to puff my cheeks out when I
breathe out through my mouth.”
B. “I will set my lips for breathing out like I am going
to whistle.”
C. “Breathing out should take me twice as long as
breathing in.”
D. “I will never hold my breath when trying to lift
something heavy.”
The answer is A. Exhalation should be slow through pursed
lips taking care not to let the checks puff out. All other
statements accurately reflect instructions related to pursed
lip breathing. Lips are set as if to whistle. Exhalation
should be twice as long as inhalation. Pursed lip breathing
should be used during any strenuous physical activity and
the client should inhale before exerting and exhale during
the activity. The breath should never be held.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Teach client about managing illness
496. The nurse has completed client teaching on activities to
reduce the recurrence of kidney stones. Which statement
by a client indicates the need for additional teaching?
A. “I need to increase my intake of dried fruits and
milk products.”
CHAPTER 34 Practice Test for NCLEX-RN® 1193
B. “I should increase my intake of liquids to at least
2–3 liters per day.”
C. “It is important that I drink extra water at bedtime
to keep my urine dilute during the night.”
D. “Cranberries, eggs and meats may help acidify my
urine to reduce my kidney stones.”
The answer is A. Dried fruits and milk products are high in
calcium which is often associated with renal calculi so
should be avoided. This statement indicates the need for
additional teaching. Fluid intake, especially at night and
acidifying the urine are all associated with reduced episodes
of renal calculi.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
497. Four days postoperatively, a client is noted to have
thick yellow drainage on the operative dressing. The
nurse would document this drainage as:
A. serous
B. purulent
C. sanguineous
D. serosanguineous
The answer is B. This drainage is purulent containing dead
organisms and white blood cells. Serous is clear and watery;
sanguineous is bloody; serosanguineous is pale, more watery
but blood streaked.
HEALTH PROMOTION AND
MAINTENANCE
Self-Care
498. Following a automobile accident, a client is treated for
a head injury in the emergency room. After 12 hours of
observation, the client is discharged. Which information
should be given to the client/family in preparation
for discharge?
A. Narcotic analgesics may be taken for headache
B. Memory of the car accident should return within
the next 12 hours.
C. Vomiting may be a symptom of worsening neurologic
status
D. The physician should be notified if the client is
sleepy but easily aroused.
The answer is C. Vomiting could be a symptom of increased
intracranial pressure. Narcotics would be avoided as they
may mask increasing neurologic symptoms. Amnesia is common
for the events surrounding the head injury. As long as
the client is easily arousal, sleepiness is not a concern.
PHYSIOLOGICAL INTEGRITY
Reduction in Risk Potential
Vital signs
499. When delegating blood pressure measurement to an
unlicensed assistant, the nurse cautions that correct
technique must be used to avoid obtaining falsely high
pressures. Which is one of the directions the nurse
would give to prevent a falsely high pressure reading?
A. Take the blood pressure on an extremity positioned
below heart level.
B. Use a cuff whose width is at least 60% of the diameter
of the extremity.
C. If you have to inflate the cuff a second time, be sure
to wait 1–2 minutes.
D. Apply the cuff loosely to the extremity.
The answer is C. Reinflating the cuff without a 1–2 minutes
interval between inflations can result in a falsely high blood
pressure reading. Therefore waiting the 1–2 minutes
between inflations helps prevent a falsely high reading.
Taking the blood pressure on an extremity positioned
below heart level can result in a falsely low reading; the
extremity needs to be supported and at heart level. The
width of the cuff should be 40% of the diameter of the arm
so a cuff that is at least 60% the diameter is too wide. Use
of a cuff that is too wide can cause a falsely low blood pressure
reading not a falsely high one. If the cuff is wrapped
too loosely around the extremity the result can be a falsely
high pressure reading so loose wrapping does not prevent
a falsely high reading.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Total parenteral nutrition
500. A client is receiving TPN. The bag of TPN arrives on
the hospital unit with an ampule of multi-vitamins for
the nurse to add. A new staff nurse asks why the pharmacy
didn’t add the vitamins before sending the bag to
the floor. The experienced nurse will explain that:
A. The client may be allergic to the vitamins.
B. The vitamins are infused in the first 100 ml of the
TPN bag.
C. The physician may change the order and leave out
the vitamins.
D. Vitamins must be infused within 24 hours of being
added to the bag.
1194 PART III: Taking the Test
The answer is D. The vitamins are stable only for 24 hours
after being added to the TPN bag. The other responses are
incorrect.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Standard/Transmission-Based/Other Precautions
Apply principles of infection control
501. Which type of precautions would be used when caring
for a client with tuberculosis?
A. Standard precautions
B. Airborne precautions
C. Droplet precautions
D. Contact precautions
The answer is B. Airborne precautions are used when the
mode of spread of an organism is by small particle droplets
borne on air currents and tuberculosis is spread by this
route. Airborne precautions require a private room with
negative airflow and adequate filtration; those entering the
room wear a mask and if the client leaves the room, a mask
is worn.
A is incorrect—Standard precautions are used to decrease
the risk of transmission from bloodborne pathogens and
moist body substances. Moist body substances include
blood, urine, feces, sputum, saliva, wound drainage, and all
aspirated fluids. C is incorrect—Droplet precautions are
used when the mechanism of transmission is by large
droplets spread by coughing, sneezing, or talking. Droplet
precautions require a private room or a room shared with
someone infected with the same organism. Those entering
the room and coming within 3 feet of the client need to wear
a mask and the client wears a mask if taken out of the room.
D is incorrect—Contact precautions are used when organisms
causing serious disease are easily transmitted through
direct contact. Contact precautions require a private room or
a room shared with someone infected with the same organism.
Gloves are worn at all times and gowns and protective
barriers are used if direct contact is required.
PHYSIOLOGICAL INTEGRITY
Reduction in Risk Potential
Vital signs
502. A decrease in blood pressure of ____ mm Hg or more
between the pressure taken after the client has been
supine for 3 minutes and the pressure taken after the
client arises and stands for a minute is indicative of
orthostatic hypotension.
Answer is 30 mm Hg.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic procedures
503. A wet to dry dressing has been ordered for an ulcer on
the leg. Which is a step in the correct procedure for
changing the dressing?
A. Remove the soiled dressing dry.
B. Apply the new dressing that has been wet with tap
water.
C. Moisten the soiled dressing with sterile water prior
to removal.
D. Moisten the soiled dressing with normal saline
prior to removal.
The answer is A. A wet to dry dressing starts with sterile
dressing wet with sterile water, sterile saline, or other prescribed
liquid, placed over the wound and allowed to dry.
Once dry, the soiled dressing is removed, taking with the
dressing the adherent debris.
HEALTH PROMOTION AND
MAINTENANCE
Ante-/Intra-/Postpartum and Newborn Care
504. A newborn is admitted to the nursery with a history of
maternal diabetes that was poorly controlled during
the pregnancy. The newborn’s admission weight is
over 9 pounds. The initial blood glucose level is within
normal limits. Which is the priority nursing intervention
for this infant?
A. Initiate formula feedings.
B. Encourage parental bonding.
C. Avoid blood draws which could contribute to anemia
D. Monitor the temperature because the infant is
macrosomic.
The answer is A. Although the infant’s blood glucose is normal
now, the levels are expected to drop in the next two to three
hours. Feeding protein foods (formula) will maintain blood
glucose better than glucose water.
B, C, and D are incorrect—Parenteral bonding is not
the priority intervention. Blood draws will be necessary to
monitor glucose levels. The infant’s temperature will need
to be monitored but it is not the priority.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
505. The evening nurse is assessing a client who had a
modified mastectomy earlier that morning. Which is a
CHAPTER 34 Practice Test for NCLEX-RN® 1195
fact that must be considered when planning nursing
care?
A. The client will be depressed and asking for medication
frequently
B. Blood pressures should not be performed on the
arm of the operative side
C. The client will need to hold off doing arm exercises
for 10 days
D. The client should not elevate involved extremity
The answer is B. Blood pressures should not be performed
on the arm on the operative side to prevent venous congestion
in the affected extremity. The other responses are
incorrect.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Recognize signs and symptoms of impaired cognition
506. A client with schizophrenia says “cat tree swim
house sick jump pretty” when the nurse asks how he
is feeling this morning. Which would be a correct
label for the nurse to use when documenting this
communication?
A. word salad
B. clang association
C. neologism
D. verbigeration
The answer is A. Word salad refers to the meaningless connection
of words and phrases. Clang association refers to
repeating words and phrases which sound alike but are
otherwise unconnected. A neologism is a new word
coined by the client and with meaning only to the client.
Verbigeration is the purposeless repetition of words or
phrases.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Expected Effects/Outcomes
Evaluate and document client response to medication
507. A client on the burn unit is receiving IV albumin.
Which parameter will the nurse monitor to determine
the effectiveness of this treatment?
A. Weight
B. Pain
C. Wound healing
D. Hematocrit
The answer is A. With a burn injury, the integrity of the vessels
is lost and fluid escapes into the tissues. Albumin is a
hypertonic solution which draws fluids from the tissues to
the plasma from where the kidneys can excrete it. Weight
loss indicates fluid loss in this manner.
Albumin will not affect pain sensation. Albumin contains
antibodies but does not promote wound healing
directly and is not the reason for administering it. Albumin
contains no red blood cells.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Teach client about managing illness
508. The nurse is working with the parents of a child newly
diagnosed with hemophilia. Which topics should be
included in teaching about home care of the child?
A. Providing extra iron in the child’s diet
B. Oral administration of the missing factor
C. Avoiding sports activities as the child grows
D. Avoiding the use of aspirin for temperature elevations
The answer is D. Use of aspirin would decrease the clotting
ability of the child’s blood. The child does not need extra
iron as the child is able to produce ample red blood cells.
Factor is administered intravenously. The child would not
avoid all sports. The nurse would provide guidance about
sporting activities that would not put the child at risk for
injury.
HEALTH PROMOTION AND
MAINTENANCE
Immunizations
509. A child is in for a routine immunization. The child has
recently received the following medications:
• insulin
• antibiotic
• antihistamine
• immunoglobulins (IVIG)
Which would interfere with the effectiveness of the
vaccination?
A. insulin
B. antibiotic
C. antihistamine
D. immunoglobulins (IVIG)
The answer is D. Immunoglobulins are antibodies. An immunization
is a antigen designed to stimulate immunoglobulin
production. If the immunoglobulins are already present, the
antigen will be destroyed before antibodies are produced. The
other responses would not have a significant effect on
vaccination.
1196 PART III: Taking the Test
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Mobility/immobility
Maintain client skin integrity
510. At what inetrval should an elderly client be instructed
to change position when up in her wheelchair during
the day?
A. Two (2) hours
B. One (1) hour
C. Thirty (30) minutes
D. Fifteen (15) minutes
The answer is A. Frequent shifts of body weight are needed
to maintain circulation and decrease the risk of a pressure
ulcer. Repositioning is required every 2 hours.
A, B, and C are incorrect because more frequent body
shifts while in a chair have been shown to be ineffective.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in body systems
511. A client has had a cesarean section. The client complains
of postoperative discomfort due to abdominal distention.
Which suggestion would reduce the client’s discomfort?
A. Walk to promote peristalsis
B. Chew ice to facilitate peristalsis
C. Lay flat in bed as much as possible
D. Drink through a straw instead of sipping from a cup.
The answer is A. Walking promotes peristalsis. Drinking
through a straw and chewing ice increases the amount of air the
client swallows increasing the abdominal distention. Laying
flat is not an appropriate intervention for abdominal distention.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Blood and blood products
512. A hospitalized client receives a transfusion of whole
blood. The client suddenly develops chest pain, fever
and chills. The nurse suspects a hemolytic transfusion
reaction. Which is the priority nursing intervention?
A. Notify the physician.
B. Flush the line with D5NS.
C. Stop the infusion and maintain the IV line with normal
saline.
D. Give the client the Benadryl (diphenhydramine)
available as a prn order.
The answer is C. Hemolytic transfusion reactions are caused
by a reaction from antibodies in the recipient blood reacting
to the donor’s blood protein. This can lead to serious consequences
and may be fatal. Stopping the infusion is critical to
reduce the source of the reaction. It is essential that the IV
line be kept open for emergency access. The physician needs
to be notified but it is not the priority action. Flushing the
line with dextrose will cause the blood to clot. This is not an
allergic reaction so Benadryl will not resolve the problem.
HEALTH PROMOTION AND
MAINTENANCE
Ante-/Intra-/Postpartum and Newborn Care
513. A pregnant woman, whom the nurse notes has lordosis,
asks why she has had bad back pain. Which factor
explains the development of the lordosis and back
pain and should serve as the basis of the nurse’s
response to the client’s question?
A. Maternal hormones
B. The shifting center of gravity
C. The loosening of the pelvic structure.
D. Stasis of blood in the lower extremities
The answer is B. With the weight of the fetus shifting the center
of gravity, the pregnant woman will develop lordosis and
back pain.
Maternal hormones are present but not the cause of the
back pain. The loosening pelvic structures affect the pregnant
woman’s balance and walk, not back pain. The pressure
of the uterus will cause stasis of blood in the lower extremities
but not back pain.
PHYSIOLOGICAL INTEGRITY
Physiologic Adaptation
Illness Management
Teach client about managing illness
514. Which actions might the nurse discuss with a client
with multiple sclerosis who has recently had a number
of exacerbations of the disease? (Select all that apply.)
A. Joining a support group
B. Avoiding the use of hot tubs.
C. Preventing pregnancy
D. Limiting fluid intake to 1250 ml per day
E. Requesting a job transfer to a less stressful situation
The answers are A, B, and E. Support groups help support
emotional coping mechanisms. The MS client is encouraged
to avoid heat and cold situations as they have been implicated
in exacerbations. A job transfer may allow the client to
CHAPTER 34 Practice Test for NCLEX-RN® 1197
continue working. Pregnancy in general does not seem to
affect the overall outcome of MS. Fluid intake is important to
maintain body function and should not be limited.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Teach client about managing illness
515. A client with thrombocytopenia, secondary to
leukemia, has developed epistaxis. Which instruction
should the nurse give the client?
A. Lie supine with the neck extended
B. Sit upright, leaning slightly forward and apply heat.
C. Blow the nose and then put lateral pressure on the
nose
D. Hold the nose while bending forward at the waist
The answer is D. This response provides pressure to halt the
bleeding while preventing the blood from draining into the
lungs. The other answers are incorrect. A would promote
blood entering the respiratory system. Heat would increase
bleeding. Blowing the nose will remove any clots which have
formed and should be discouraged.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Recognize signs and symptoms of acute and chronic
mental illness
516. Which type of personality disorder does the nurse suspect
when the client’s history indicates an apparent
lack of concern with others’ opinions, a “loner”, unfocused
lifestyle without close friends, and a cold, aloof
persona?
A. paranoid
B. schizoid
C. antisocial
D. borderline
The answer is B. Clients with schizoid personality disorder
are detached from social relationships and demonstrate little
emotional expression with other people. There appears to be
no pleasure derived from interaction with other people.
These individuals prefer solitary activities and can perform
well when left alone.
Clients with paranoid personality disorder are suspicious
of others believing that others are trying to exploit,
deceive or harm them. They question the loyalty and trustworthiness
of others; read hidden meanings into events; and
bear grudges.
Clients with antisocial personality disorder are impulsive,
risk takers who do not learn from experience, exploit
others and ignore their rights; and lack guilt, honesty, fidelity
and loyalty.
Clients with borderline personality disorder have a
poor and unstable self image; are unable to maintain stable
relationships; fear abandonment; engage in impulsive activities
that are damaging to self such as substance abuse,
binge eating and reckless sexual activity; repeatedly threaten
or engage in self mutilating or suicidal behavior; experience
a chronic sense of emptiness; and manifest inappropriate,
intense, uncontrolled anger.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Total Parenteral Nutrition
Monitor client for side/adverse effects of TPN
517. A client is receiving Total Parenteral Nutrition (TPN).
Which is a common complication of TPN for which
the nurse must monitor?
A. Phlebitis
B. Hypoglycemia
C. Electrolyte Imbalance
D. Fluid Volume Deficiency
The answer isD. The hypertonic fluid draws water from the tissues
and can lead to fluid volume deficit. Hyperglycemia may
be a problem, not hypoglycemia. The physician writes TPN
orders based on the client’s electrolyte balance TPN is always
administered by central line so phlebitis would be a minimal
risk.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic
Tests/Treatments/Procedures
Intervene to prevent potential neurological complications
518. A client has been casted for a fractured radius. The cast
extends from the hand to above the elbow. The client
complains of constant pain under the cast. The nurse
completes a neurovascular check and notes swelling of
the hand and loss of sensation to the little finger.
Which is the priority nursing intervention?
A. Elevate the arm
B. Notify the physician
C. Administer pain medication
D. Reassure the client that these are common findings.
1198 PART III: Taking the Test
The answer is B. The client is demonstrating diminished
circulation secondary to the cast which can lead to compartment
syndrome. The cast may need bivalving. Elevating
the arm is appropriate to reduce swelling but it is not the
priority action at this time. Pain management may be
appropriate but not the priority. These sensations are not
normal but symptoms of compartment syndrome from a
cast that is too tight.
PSYCHOSOCIAL INTEGRITY
Cultural Diversity
519. An ultra-orthodox Jewish client is 1 day postpartum. It
is the Sabbath for this client. The client calls to the
nurse and asks help in changing her peripad. The
client asks the nurse to open the pad’s packaging for
her as this is considered work in her culture and not
allowed on the Sabbath. Which is an appropriate nursing
response?
A. Ask the client if a family member couldn’t open the
package for her.
B. Open several pads and leave them covered so that
the client can use them as needed.
C. Assign a male nurse to the client as she wouldn’t ask
him to open her peri packages.
D. Tell the client that opening a peri pad package is not
work and encourage her to do it for herself.
The answer is B. By opening several packages and leaving
them within her reach, she will be able to perform self care
without deviating from her religious beliefs.
The client’s family would probably be of the same culture
and therefore would not be willing to perform this task.
A male nurse would make the ultraorthodox Jewish woman
uncomfortable and not be culturally sensitive. Telling the
client that this is not work does not consider her beliefs and
feelings at all.
HEALTH PROMOTION AND
MAINTENANCE
Immunizations
520. The clinic is running short of RSV Immune Globulin (the
immunization for respiratory syncytival virus). Which
child should have priority in receiving the vaccine?
A. The 8-year-old with cystic fibrosis.
B. The teenager who is sexually active.
C. The 5-year-old with failure to thrive.
D. The 6-month-old premie with a history of bronchial
pulmonary dysplasia.
The answer is D. RSV is primarily a disease of infancy so preference
would be given to children under 2 years of age.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Implement procedures to counteract adverse effects of
medications
521. A client with leukemia is scheduled to get chemotherapy
which includes vincristine. Which nursing action
is appropriate?
A. Insert the intravenous line in a vein in a joint area.
B. Ensure that the intravenous is administered per pump.
C. Administer the medication in a free flowing intravenous
line.
D. Always use an intravenous line that has been in
place for several days.
The answer is C. Because it is so irritating to tissues, it is critical
that extravasation of vincristine into tissue be prevented.
A free flowing line means that the line is most
likely in the vein. A pump will continue to pump IV fluids
even after the line has extraversated. A fresh line is best to
ensure its integrity and the joint areas should be avoided.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Rest and sleep
522. A client informs the nurse that he is “unable to fall
asleep at night and tends to walk around until he gets
sleepy.” Which suggestion can the nurse make to help
the client to develop better sleep habits?
A. Have an alcoholic drink prior to bedtime
B. Exercise when unable to sleep
C. Increase fluid intake prior to bedtime to maintain
hydration
D. Avoid stressful situations prior to bedtime
E. Wear loose clothing to bed
F. Avoid caffeinated beverages before bedtime
The answers are D, E, and F. Stress will deter the client from
falling asleep so avoiding stressful situations prior to bedtime
will promote sleep. Wearing loose clothing to bed and avoiding
caffeinated beverages before bedtime will also facilitate sleep.
Alcohol, exercise, and increasing fluid intake before bed
all interfere with sleep.
HEALTH PROMOTION AND
MAINTENANCE
Ante-/Intra-/Postpartum and Newborn Care
523. Which comment made by a teenager who is attending
a health class on pregnancy indicates the need for clarification
of information?
CHAPTER 34 Practice Test for NCLEX-RN® 1199
A. “I didn’t realize that smoking during pregnancy
could cause a miscarriage.”
B. “I didn’t realize that smoking during pregnancy
could cause the baby to have high blood pressure
as an adult.”
C. “I didn’t realize that smoking during pregnancy
could result in a large baby and a difficult birth.”
D. “I didn’t realize that smoking during pregnancy is
associated with asthma as the child grows older.
The answer is A. Miscarriages, preterm birth and low birth
weight babies are associated with smoking during pregnancy.
It is not known to be associated with adult hypertension
nor with childhood asthma.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Teach client about managing illness
524. Following a long history of vomiting, a child is diagnosed
with GERD, Gastric esophageal reflux disease.
Instructions are given to the parents for conservative
management to reduce the reflux. Following the parent
teaching, the nurse will recognize the need for
additional information when the parent states:
A. “I will keep my child’s weight at the recommended
levels.”
B. “My child should avoid caffeine, and spicy foods to
reduce reflux.”
C. “I will lay my child down in bed after meals to allow
time for digestion.”
D. “I will see that my child receives the antacid that his
physician prescribed for him.”
The answer is C. The child should not be placed flat in bed
following feedings but should be maintained in a semi to
high fowler’s position to promote formula retention.
Overweight children are more prone to GERD. Caffeine,
chocolate and spicy foods seems to weaken the esophageal
pressure and increase the reflux. The physician may order an
H2 antagonist, a proton pump inhibitor or other drugs to
promote stomach emptying.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Assistive Devices
Evaluate correct use of assistive devices by staff/client/
family
525. A client is recovering from a broken tibia and is walking
on wooden crutches. Which observed client
behavior requires nursing intervention?
A. The client props his foot up while sitting.
B. The cast is visibly dirty.
C. While standing, the client rests his body weight on
the top of the crutches.
D. The client uses a swing through motion when walking
with the crutches.
The answer is C. Resting the arm pits on the top of the
crutches could damage nerves and circulation. A visibly
dirty cast can be covered with adhesive tape for better
appearances but this is not the priority intervention. It is
appropriate to elevate the foot while sitting. A swing
through motion is often used to prevent weight bearing on
the casted leg.
HEALTH PROMOTION AND
MAINTENANCE
Ante-/Intra-/Postpartum and Newborn Care
Provides safe nursing care to the pregnant client
526. A pregnant woman has developed diabetes during the
pregnancy. After several attempts to control the diabetes
with diet alone, the physician plans to place the woman
on insulin. The woman asks the nurse why she can’t take
the “oral” insulins like her grandpa. The nurse’s response
is based on the knowledge that oral hypoglycemics:
A. May cross the placenta and be teratogenic
B. Contain too little insulin and would require multiple
pills.
C. Will affect the fetal pancreas leading to infantile diabetes.
D. Contain too much insulin and would be dangerous
to the fetus.
The answer is A. The full effect of the oral hypoglycemics on
the fetus is not yet known. The oral hypoglycemics are not
insulin but stimulate insulin production.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-Specific Assessment
Perform focused assessment or reassessment
527. A newborn is suspected of having hydrocephalus. For
which symptoms would the nursery nurse monitor the
child? (Select all that apply.)
A. Sunset eyes
B. Depressed fontanels
C. Thin scalp and sparse hair
D. Increasing head circumference
E. Head circumference equal to chest circumference
1200 PART III: Taking the Test
The answers are A, C, and D. The fontanels would be bulging,
not depressed. The head circumference is larger than the
chest circumference at birth in normal children. In this
child, the difference would be even greater.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Recognize signs and symptoms of acute and chronic
mental illness
528. When assessing a client newly admitted with a diagnosis
of active phase schizophrenia, which are negative
symptoms of schizophrenia which the nurse might
find?
Mark all that apply.
A. ___ disorganized speech
B. ___ flat affect
C. ___ alogia
D. ___ impaired attention
E. ___ bizarre behavior
F. ___ avolition
The answers are B, C, D, and F. Flat affect, alogia, attention
impairment, avolition along with anhedonia are all negative
symptoms of schizophrenia.
Disorganized speech and bizarre or disorganized behavior
are positive symptoms of schizophrenia.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications and
Side Effects
Implement procedures to counteract adverse effects of
medications and parenteral therapy
529. A client is receiving Vancomycin HCL for an infection.
Shortly after the nurse starts the intravenous infusion,
the client appears flushed and complains of feeling
hot. The nurse should:
A. slow the infusion.
B. stop the infusion and call the physician.
C. speed up the infusion as it seems to be making the
client nervous.
D. recognize the client is having a drug interaction.
The answer is B. The client is showing symptoms of red man
syndrome. The flushing is caused by a release of histamine
causing vasodilatation. If untreated, the problem could be
fatal. The physician will usually order Benadryl and order
the vancomycin to be restarted at a slower rate.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
Understand general principles of pathophysiology
530. The nurse is reviewing the laboratory report of a
client who underwent a bone marrow biopsy. The
finding that would most strongly support a diagnosis
of acute leukemia is the existence of a large number
of immature:
A. nucleated red blood cells
B. thrombocytes
C. reticulocytes
D. leukocytes
The answer is D. Leukocytes are immature WHCs.
Thrombocytes are immature platelets and reticulocytes and
nucleated red blood cells are immature red blood cells.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Standard/Transmission Based/Other Precautions
Provides care to the child with an infectious disease
531. A child has been diagnosed with tubercule (tuberculosis)
meningitis and is admitted to the hospital. The child
should be placed on:
A. contact isolation.
B. droplet isolation.
C. respiratory isolation.
D. standard precautions.
The answer is D. These children are not considered contagious.
Active, untreated respiratory tuberculosis is spread by
droplets. The CDC recommends these individuals be placed
in a negative flow (airflow) room with caregivers wearing
masks and gowns.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
532. The nurse is performing a physical examination of a
client’s abdomen. In what order should the assessment
be performed?
A. Inspection, palpation, auscultation
B. Palpation, auscultation, inspection
C. Inspection, auscultation, palpation
D. Auscultation, inspection, palpation
CHAPTER 34 Practice Test for NCLEX-RN® 1201
The answer is C. Inspection is always the first step. Palpation
is always performed last because palpation of the abdomen
may interfere with bowel sounds and could cause pain.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic
Tests/Treatments/Procedures
Provide nursing care that identifies potential complications
533. A client has been admitted to the hospital for a gastrointestinal
procedure. The physician orders the following:
• NPO at midnight
• Clear liquids except those that are red
• Multiple tap water enemas until clear
• One dose of an oral antibiotic the morning of the
procedure.
Which order should the nurse question?
A. NPO at midnight
B. Clear liquids except those that are red
C. Multiple tap water enemas until clear
D. One dose of an oral antibiotic the morning of the
procedure.
The answer is C. Multiple tap water enemas can lead to water
intoxication. NPO at midnight is a common order preceding
a treatment. Prophylactic antibiotics may be ordered. Clear
liquids will maintain the cleanliness of the bowel—reds are
avoided as it cannot be differentiated from blood in stool or
vomitus.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
534. Two clients are comparing symptoms while waiting in
the endocrine clinic. One client has been diagnosed
with diabetes insipidus while the other client has diabetes
mellitus. The clients note that they have many
similar symptoms. Which symptom would differentiate
the two disorders?
A. Polyuria
B. Polydipsia
C. Polyphagia
D. Nocturnal voidings
The answer is C. Both clients will have excessive urination and
thirst. Nighttime voiding would be common. Polyphagia,
excessive hunger, would only be seen in the client with diabetes
mellitus.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Injury prevention
535. An elderly client is admitted to the hospital unit. On
admission, the family tells the nurse that the client has
fallen several times recently. The nurse evaluates the
client and finds the client alert and without symptoms
of ataxia. Which is an appropriate nursing action?
A. Place the client on fall precautions
B. Ask physical therapy to evaluate the client.
C. Not place the client of fall precautions
D. Question the family about what they did for the falls.
The answer is A. The nurse has been warned and therefore
has a heightened legal liability to protect this client. The
other responses are inappropriate.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Teach client about managing illness
536. A client has been diagnosed with fibrocystic breast disease.
Which information should be included in the self
care teaching for this client?
A. Occasional nipple discharge is normal.
B. If breast pain is not relieved after menses begins,
the client should see her primary care provider.
C. Breast pain due to inflammation and root stimulation
begins before the luteal phase of the menstrual
cycle.
D. Diuretics are never used to relieve symptoms of
fibrocystic breast disease.
The answer is B. If breast pain is not relieved after menses
begins, the client should see her primary health care
provider as inflammation and nerve root stimulation begin
at 4–7 days into the luteal phase of the menstrual cycle and
end with the beginning of menses.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Vital Signs
Apply knowledge needed to perform related nursing procedures
and psychomotor skills when assessing vital signs
537. A nursing assistant reports to a staff nurse that the
neonate assigned to her care is crying and has axillary
1202 PART III: Taking the Test
temperature of 90_F. Which is the appropriate action
on the part of the staff nurse?
A. Call a code
B. Notify the physician
C. Retake the temperature
D. Place the infant in a warming unit
The answer is C. A temperature of 90 axillary is not compatible
with life. When infants cry they also tend to wave their arms
around which can interfere with obtaining an accurate axillary
temperature. The temperature should be retaken.
PSYCHOSOCIAL INTEGRITY
Chemical and Other Dependencies
Assess client for drug/alcohol related dependencies,
withdrawal, or toxicities
538. A client comes to the clinic saying he is withdrawing
from heroin and needs help. Which assessment findings
would support the client’s statement?
A. Vomiting and decreased respirations
B. confusion and ataxia
C. muscle twitching and dilated pupils
D. impaired memory and seizure activity
The answer is C. Symptoms of withdrawal from heroin include
muscle twitching and dilated pupils along with yawning, rhinorrhea,
lacrimation, abdominal cramps, diaphoresis, irritability,
restlessness, anxiety, agitation, sleep disturbance, body
aches, muscle cramps, “goose flesh” sensations of hot or cold,
nausea, diarrhea, anorexia, fever, hypertension, tachycardia,
tachypnea, dysphoria, and craving.
Confusion, impaired memory and seizure activity occurs
with withdrawal from alcohol, sedatives/hypnotics, and anxiolytic
drugs. Vomiting and ataxia are associated with withdrawal
from alcohol, sedatives/hypnotics, and anxiolytic
drugs. Respirations are increased with withdrawal from alcohol,
opiates, and sedatives/hypnotics, and anxiolytics.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Blood and Blood Products
Administer blood products and evaluate client response
539. A client is to receive a blood transfusion. When will
the nurse plan to take vital signs? (Select all that apply.)
A. Prior to starting the transfusion.
B. Every 15 minutes during the first hour of the transfusion.
C. Fifteen minutes after the transfusion is completed
D. At least twice during the transfusion.
The answers are A, B, and C. Changes in vital signs are early
indications of reactions to the blood. Therefore baseline
vital signs should be taken prior to starting the transfusion.
Subsequently vital signs should be taken every 15
minutes during the first hour, periodically during the rest
of the transfusion and then upon completion of the transfusion.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Use the six “rights” when administering client medications
540. The nurse is administering Cyanocobalamin (vitamin
B12) to a client with pernicious anemia, secondary to a
gastrectomy. Which route should the nurse use to
most effectively administer the vitamin?
A. topical route
B. enteral route
C. parenteral route
D. transdermal route
The answer is C. Cyanocobalamin is administered IM or SC.
The other routes are incorrect.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Delegation
Assure appropriate education, skills, and experience of
personnel performing delegated task
541. There are three clients on the unit who are receiving
chemotherapy. Which type of assignment of care is
appropriate?
A. Care divided among two newly hired and one experienced
registered nurses
B. Care divided among three experienced registered
nurses
C. Care assigned to an experienced Licensed Practice
Nurse
D. Care assigned to a chemotherapy certified pregnant
nurse
The answer is B. Chemotherapy administration should be
divided among a number of nurses rather than assigning all
chemotherapy to one nurse to decrease the cytotoxic
chemical exposure. Chemotherapy certified nurse would
be the best option, but because the nurse is pregnant, she
CHAPTER 34 Practice Test for NCLEX-RN® 1203
should protect her fetus by avoiding all exposure possible.
The nurse administering chemotherapy does not have to be
certified.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Elimination
Assess and intervene with a client who has an alteration
in elimination
542. Which intervention would be included in the plan of care
for a client who is post operative from pelvic surgery?
A. Administer stool softeners to prevent constipation
B. Teach a low fat diet.
C. Limit fluid intake to reduce bladder filling.
D. Encourage pelvic tilt exercises.
The answer is A. Constipation will cause straining which will
cause discomfort and pressure on the suture lines. There is
no rationale for a low fat diet. Fluid intake is important to
reduce urinary stasis. Pelvic tilt exercises are not appropriate
at this time.
PSYCHOSOCIAL INTEGRITY
Family Dynamics
Assist the family in crisis and under stress to adapt and
change
543. An elderly woman was diagnosed with Alzheimer’s
disease several years ago. Her confusion is increasing.
During AM care, the woman tells the nurse about
something that happened to her years ago. The husband,
who overheard, immediately corrects the
woman and explains the correct information to the
nurse. The nurse would talk to the husband in private
to encourage him to:
A. continue to correct her stories to help her stay in
touch with reality.
B. discourage his wife from talking so that listeners
will not be confused.
C. allow her to tell stories as she remembers them to
reduce risk of agitation.
D. ignore all of the woman’s rantings as everyone is
aware of her confusion.
The answer is C. Clients with Alzheimer’s are aware of their
confusion and try to mask their loss of memory. That is why
they spend so much time talking about the past. Eventually
the past memories also become confused. Repeated corrections
will increase the woman’s agitation and may affect her
self-esteem. In addition, it will not keep the woman in touch
with reality. Discouraging the woman from talking will further
isolate the woman from the world as will ignoring her.
HEALTH PROMOTION AND
MAINTENANCE
Ante-/Intra-/Postpartum and Newborn Care
544. During the later part of her pregnancy, a woman was
treated for pregnancy-induced hypertension. The
woman delivered a healthy infant 6 hours ago. Why is
close monitoring of this client during the first two
postpartum days an important nursing action?
The client
A. will have problems bonding to her infant.
B. could have heart damage from the hypertension.
C. is at high risk for renal failure in the postpartal period.
D. may become eclamptic for up to 48 hours after
delivery.
The answer is D. Eclampsia or seizures could occur for up to
48 hours after delivery. The other responses are not correct.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse effects/contraindications/side effects
545. A woman is getting married and asks for birth control
pills. Which assessment finding suggests that “the pill”
may not be the best choice of birth control for this
client because of the associated risk of heart disease?
The client
A. is a heavy smoker.
B. is 22 years old.
C. had an abortion as a teenager.
D. has a sexually transmitted disease.
The answer is A. Smokers on oral contraceptives are significantly
more at risk for the development of heart disease. This
risk increases with age. The other findings are not significant
risk factors.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
Perform emergency care procedures
546. A client receives a dose of penicillin and has an anaphylactic
reaction. Which is the priority nursing intervention
for this client?
1204 PART III: Taking the Test
A. Monitoring vital signs
B. Maintaining a patent airway
C. Assessing for adequate circulating blood volume
D. Treating symptoms of vascular overload
The answer is B. Maintaining a paten airway is essential for
the maintenance of tissue oxygenation. Monitoring vital
signs and assessing for adequate circulating blood volume
are both assessments and will not provide any relief to the
client. The client will have circulatory collapse.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Error Prevention
Verify appropriateness and/or accuracy of a treatment
order
547. A newborn with a diaphragmatic hernia and respiratory
distress is admitted to the pediatric unit. The
admitting physician writes the following orders:
• Position in semi- to high Fowlers
• Position on affected side.
• Diet for age.
• NG tube to suction
Which order should the nurse question in the preoperative
period?
A. Position in semi- to high Fowlers
B. Position on affected side.
C. Diet for age.
D. NG tube to suction
The answer is C. Feeding the infant would increase the contents
in the GI tract. Since bowel material is in the chest,
this would increase the contents of the chest further compressing
the unaffected lung. Semi to high Fowlers would
use gravity to decrease the contents of the chest which
would help respirations. Position on the affected side so
the unaffected lung has full expansion ability. NG tube to
suction is used to decompress the gastric contents and is
appropriate.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Expected Effects/Outcomes
Evaluate and document client response to medication
548. A client is admitted with third degree burns. On the
second day post burn, the physician orders the client
to receive albumin. The nurse will know that the treatment
was successful when the client:
A. loses weight
B. feels less pain
C. doesn’t develop a burn infection
D. has an increased hemoglobin and hematocrit
The answer is A.With a burn injury, the integrity of the vessels
is lost and fluid escapes into the tissues. Albumin is a hypertonic
solution which draws fluids from the tissues to the
plasma from where it can be excreted by the kidneys. Weight
loss indicates fluid loss in this manner. Albumin will not
affect pain sensation. Although albumin does contain antibodies,
this is not the reason for administering it. Albumin
contains no red blood cells.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Diagnostic Tests
Apply knowledge of related nursing procedures and psychomotor
skills when caring for clients undergoing diagnostic
testing
549. A woman 9 months pregnant is admitted for a NonStress Test. How will the nurse position the woman?
A. Prone
B. Supine
C. With legs elevated
D. With right hip tilted with a pad.
The answer is D. The client is positioned with a pad used to
slightly elevate the right hip. This position will prevent vena
cava syndrome, a side effect of lying supine. When in the
supine position, the pregnant uterus lies on the inferior vena
cava reducing blood flow to the heart. The other options are
incorrect.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Expected Effects/Outcomes
Use clinical decision making/critical thinking when
addressing expected Effects/Outcomes of medications
550. A client is receiving levothyroxine (Synthroid) for
hypothyroidism. Occurrence of which symptom would
cause the nurse to suspect the dosage is too high?
A. Weight gain
B. Hypotension
C. Diarrhea
D. Round the clock sleepiness.
The answer is C. Symptoms of overdose would be those of
hyperthyroidism. All the listed symptoms are those of
hypothyroidism except for diarrhea.
CHAPTER 34 Practice Test for NCLEX-RN® 1205
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Standard/Transmission-Based/Other Precautions
Apply principles of infection control
551. Which type of precautions would be used when caring
for a client with H. influenzae?
A. Standard precautions
B. Airborne precautions
C. Droplet precautions
D. Contact precautions
The answer is C. Droplet precautions are used when the
mechanism of transmission is by large droplets spread by
coughing, sneezing, or talking. This is the mechanism of
spread of H. influenzae.
A is incorrect—Standard precautions are used to
decrease the risk of transmission from bloodborne
pathogens and moist body substances. Moist body substances
include blood, urine, feces, sputum, saliva, wound
drainage, and all aspirated fluids. B is incorrect—Airborne
precautions are used when the mode of spread of an organism
is by small particle droplets borne on air currents.
Airborne precautions require a private room with negative
airflow and adequate filtration; those entering the room
wear a mask and if the client leaves the room, a mask is
worn. D is incorrect—Droplet precautions require a private
room or a room shared with someone infected with the
same organism. Those entering the room and coming
within 3 feet of the client need to wear a mask and the
client wears a mask if taken out of the room. Contact precautions
are used when organisms causing serious disease
are easily transmitted through direct contact. Contact precautions
require a private room or a room shared with
someone infected with the same organism. Gloves are worn
at all times and gowns and protective barriers are used if
direct contact is required.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Assess client for alterations in mood, judgment, cognition,
and reasoning as evidence of psychopathology
552. Which type of personality disorder presents a challenge
to treatment because it is characterized by a
charming manner often used to manipulate staff into
agreeing with or granting client demands?
A. dependent
B. histrionic
C. antisocial
D. narcissistic
The answer is C. Clients with antisocial personality disorder
are typically intelligent, charming, manipulative and with
outstanding verbal and nonverbal communication skills. As a
result, staff must be on guard against being inadvertently
manipulated by these clients and must consistently set firm
limits to avoid reinforcing the clients maladaptive behaviors.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Pharmacological interactions
553. Which assessment findings would the home care nurse
interpret as increasing a new client’s risk for problems
related to polypharmacy? (Select all that apply.)
A. Uses several practitioners
B. Currently being treated for several chronic conditions
C. Has switched health care providers frequently
D. Has a history of cataracts
E. Currently is on an antibiotic for an acute UTI
The answers are A, B, and C. Using several physicians, and
switching physicians both can lead to multiple conflicting
prescriptions. Multiple chronic conditions will be treated
with numerous medications. History of cataracts is not a significant
factor in polypharmacy. Short term use of antibiotic
for UTI is not a problem.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Error prevention
554. A client is admitted with a draining wound. MRSA is suspected
as the causative agent. The physician writes the following
orders. Which order should the nurse question?
A. Diet as tolerated
B. Contact isolation
C. D5
1⁄4 NS at keep vein open
D. Procaine Penicillin G 150,000 units every 4 hours IV
The answer is D. Procaine is an additive that is to slow the
absorption of the medication from the muscle. Procaine is
never administered intravenously. The intravenous form of
penicillin is Aqueous penicillin.
PHYSIOLOGICAL INTEGRITY
Physiologic Adaptation
Pathophysiology
Identify client status based on pathophysiology
555. An infant in the newborn nursery has been cyanotic
since birth. Which type of congenital problem could
account for the cyanosis?
1206 PART III: Taking the Test
A. A left to right shunt
B. A right to left shunt
C. Congestive heart failure
D. Red blood cell deficiency
The answer is B. A right to left shunt is a cyanotic heart
defect. A left to right shunt is acyanotic. The presence of
cyanosis does not provide any information about congestive
heart failure. A child with inadequate red blood cells would
be hypoxic but not cyanotic as cyanosis is unoxygenated
hemoglobin.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Perform a comprehensive health assessment
556. What is the nurse assessing when, with the client’s eyes
closed, the nurse places a key in the client’s hand and
asks the client to identify what it is?
A. Two-point discrimination
B. Stereognosis
C. Position sense
D. Light touch
The answer is B. Stereognosis is asking the client to identify a
familiar object such as a key when it is placed in the client’s
hand with the client’s eyes closed.
A, C, and D are incorrect—Two-point discrimination
involves touching the skin simultaneously with two sterile
needles at closer and closer distances to each other until the
client perceives only one touch. Position sense is tested by
moving the client’s toes up or down one by one and asking
the client, whose eyes are closed, to say in which direction
each was moved. Light touch is tested by stroking an area of
the client’s skin with a wisp of cotton.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic
Tests/Treatments/Procedures
Educate client and family about home management of care
557. The nurse is preparing a client with a full leg cast for
discharge. Discharge instructions on cast care have
been provided. Which statement by the client indicates
the need for more information?
A. “I will not get my cast wet.”
B. “I will contact my physician immediately if the cast
breaks.”
C. “Keeping my toes still will reduce my pain.”
D. “I should put nothing into the cast.”
The answer is C. The client would be encouraged to wiggle
his toes. All other responses would be correct responses by
the client.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Central Venous Access Devices
Provide care for a client with a central venous access
device
558. A client is admitted to the hospital unit with a PICC
that was placed at another facility. Although the client
has documentation indicating the PICC has been x-ray
verified, there is no information about whether the
catheter is valved or non-valved. Which is an appropriate
nursing action?
A. Flush the line with normal saline only.
B. Do not flush the line.
C. Ask the client what other nurses have done with the
line.
D. Flush the line with heparin flush solution per hospital
protocol.
The answer isD. Flushing the line with heparin flush solution
will not harm a valved catheter but failure to flush with
heparin in a non-valved line will result in occlusion of the
line.
HEALTH PROMOTION AND
MAINTENANCE
Ante-/Intra-/Postpartum and Newborn Care
559. A client with known cardiac disease becomes pregnant.
The nurses monitor the woman throughout her
pregnancy. At what point during her pregnancy is the
client at greatest risk of developing congestive heart
failure?
A. First trimester
B. 20 weeks gestation
C. As the woman approaches 30–32 weeks gestation
D. As she goes into labor
The answer is C. The blood volume and workload for the
heart reaches its maximum at 30–32 weeks. If the pregnant
cardiac client makes it beyond this point, she will probably
complete the pregnancy.
CHAPTER 34 Practice Test for NCLEX-RN® 1207
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Establishing Priorities
Assess/triage clients to prioritize the order of care delivery
560. The nurse is working in the emergency room. On what
basis should the nurse determine the order that clients
in the reception room should be seen?
A. Triage
B. Time of arrival
C. Comprehensive assessment
D. Age
The answer is A. Triage identifies the clients who need medical
attention first. Order of arrival is not appropriate
because it does not address immediacy of need for care.
Comprehensive assessment takes substantial time and slows
the organization of client interventions. Age is not appropriate
because by itself it does not determine the severity of
a problem or the immediacy of the need for care.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Educate client/family about medications
561. A client with sickle cell anemia has been treated with
several blood transfusions. Now deferoxamine (Desferal)
has been ordered and the client asks the nurse the purpose
of this medication. Which is the correct answer for
the nurse to give?
The medication will:
A. prevent the RBCs from sickling
B. remove excessive iron from the body
C. improve the longevity of the red blood cells.
D. increase the oxygen carrying capacity of the blood.
The answer is B. When repeated blood transfusions are given,
the RBCs will eventually be broken down. The body retains
the iron from these donated cells leading to iron toxicity. All
other responses are incorrect.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
Perform emergency care procedures
562. A nurse stops at the scene of a car accident and provides
first aid to the victim who has a neck injury. Which is the
most appropriate way to open the airway of this victim?
A. jaw-thrust
B. head lift
C. neck thrust
D. neck tilt.
The answer is A. A jaw thrust will prevent damage to the spinal
cord that could occur with other methods of opening the airway.
HEALTH PROMOTION AND
MAINTENANCE
Growth and Development
563. A 3-year-old child is scheduled for surgery. The nurse
is explaining the procedure to the child. Which is the
most appropriate statement for the nurse to make
about the anesthesia?
“The doctor will give you some special medicine that:
A. “Will help you take a nap.”
B. “Will put you to sleep.”
C. “Make you unconscious.”
D. “Mommy wants you to have.”
The answer is A. Children may be familiar with animals
which have been “put to sleep” and never returned.
Unconscious is a word that would not be in their vocabulary
Telling the child that mommy wants them to take the
medicine does not explain what will happen.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Teach client about managing illness
564. Which statement made by a client with Multiple
Sclerosis indicates that the nurse needs to clarify self
care instructions with the client?
A. “When I am tired, I lay down and rest.”
B. “When I feel stressed, I get in the hot tub.”
C. “I try to avoid conflicts with my husband.”
D. “I’m thinking of changing jobs to reduce stress.”
The answer is B. Heat increases the risk of exacerbations in
Multiple Sclerosis so hot tubs should be avoided. All the
other statements will promote wellness in the client.
HEALTH PROMOTION AND
MAINTENANCE
Immunizations
565. While administering the hepatitis vaccine to a group of
medical students, the nurse is asked: “Is this going to
1208 PART III: Taking the Test
produce active or passive immunity?” Which is the
correct response?
A. This is passive immunity because I am giving you
the vaccine.
B. This is passive immunity because this shot contains
the antibodies.
C. This is active immunity because you did not get it
from your mother.
D. This is active immunity because your body must
respond to the vaccine.
The answer is D. Most vaccinations contain toxins or attenuated
organisms. Your body views the vaccine as an antigen and produces
antibodies against it. That is what makes it active.
A, B, and C are incorrect—Vaccination produces active
immunity. Antibodies received from the mother provides
passive immunity.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Implement interventions to manage client recovering
from an illness
566. A client is experiencing severe respiratory distress. The
nurse would perform which of the following activities
to promote gas exchange? Select all that apply
A. Sit the client up in bed
B. Support both arms on a pillow
C. Encourage the client to drink clear liquids
D. Keep the room temperature somewhat warmer than
usual
The answers are A and B. Sitting the client up in bed with both
arms supported on pillows allows for better lung expansion
by reducing pressure from abdominal contents and removing
the weight of the arms from the chest. The client would
not be encouraged to drink because the severe respiratory
distress could cause aspiration. Keeping the room warm
would raise the client’s basal metabolism rate increasing the
body’s requirement for oxygen and should be avoided. The
room should be kept cool.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Blood and blood products
567. An immunocompromised client is to receive a blood
transfusion for anemia. Which type of blood product
would the nurse expect the physician to order?
A. Platelets
B. Whole blood
C. Filtered packed cells
D. Irradiated packed cells
The answer is C. An immunocompromised client is at risk for
graft versus host disease. Irradiated packed blood cells will
reduce this risk. Whole blood is rarely administered as
packed cells provide the needed cells without the volume.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Standard/Transmission-Based/Other Precautions
Understand communicable diseases and the modes of
organism transmission
568. A college student has been admitted to the hospital
unit with a diagnosis of meningococcal meningitis.
The client should be placed in:
A. droplet isolation
B. airborne isolation
C. protective isolation
D. no isolation as universal precautions is sufficient
The answer is A. Meningococcal meningitis is spread by droplets
and is the only meningitis form that is readily transmitted to
others. Droplet transmission involves contact with a large particle
in the conjunctivae or mucous membranes of the nose or
mouth. Transmission by large particle requires close contact
whereas airborne can be transmitted through the air. Protective
isolation protects the client from others and is not appropriate.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Palliative/comfort Care
Assess client for nonverbal signs of pain/discomfort
569. A client is seen in the emergency room following a fall
at home. The client is known to have late stage
Alzheimer’s disease. A fractured hip is diagnosed and
surgery is scheduled for the next morning. When
asked, the client denies pain. Which symptoms would
cause the nurse to suspect the client is in pain?
A. Client yells for her long deceased husband
B. Client’s hands finger the sheets continuously.
C. Blood pressure is elevated from admission findings
D. Client reaches for the nurse’s hand when the nurse
approaches the client.
The answer is C. Elevation in blood pressure may indicate an
increase in pain.
Clients with Alzheimer’s disease often call for individuals
from their past, finger sheets, and other material and want
physical contact.
CHAPTER 34 Practice Test for NCLEX-RN® 1209
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
570. A newborn has been diagnosed with osteogenesis
imperfecta. Which assessment findings would the
nurse expect? Select all that apply.
A. Blue sclera
B. Simian crease
C. Hyperbilirubinemia
D. Multiple fractures apparent at birth
E. Cephalohematoma developed within hours of birth
The answers are A and D. Blue sclerae and multiple fractures
at birth are signs of osteogenesis imperfecta. Simian crease is
a soft neurologic sign associated with Down’s syndrome.
Hyperbilirubinemia is not a symptom of osteogenesis imperfecta
although it could result from bleeding injuries secondary
to the broken bones. Cephalohematoma is not a symptom
of osteogenesis imperfecta.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Diagnostic tests
571. Which is the most important question to ask a 36year-old woman prior to having a bone scan?
A. Do you have an allergy to seafood?
B. Did you have anything to eat or drink after midnight?
C. Are you claustrophobic?
D. Are you pregnant?
The answer is D. With a bone scan, there is a risk of radiation
exposure to the fetus.
A is incorrect—this question is asked of any client
receiving an isotope. B is incorrect—the client does not have
to be NPO for this diagnostic test. C is incorrect—not all CT
or MRI machines are full enclosures.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
572. A 68-year-old female is admitted with a chief complaint
of low back pain. Spinal x-ray indicates that the
client has intervertebral disc disease. When asked by
the client’s family, the nurse would explain the etiology
of this disease as:
A. caused by weakening of the bone due to loss of calcium
from the bone.
B. the degeneration of the spine due to dehydration of
the intervertebral discs.
C. caused by inflammation of the joints and surrounding
tissues.
D. the displacement and loss of contact of articulating
surfaces.
The answer is B.
A is incorrect—Weakening of bone due to loss of calcium
occurs with osteoporosis. C is incorrect—Inflammation of
joints and surrounding tissue occurs with arthritis. D is incorrect—
Displacement and loss of contact of articulating surfaces
occurs with dislocation of a joint.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Confidentiality/Information Security
Maintain client confidentiality/privacy
573. The nurse is working on the pediatric unit when a call
is received from a school teacher asking about the condition
of one of her students who is hospitalized on the
unit. The nurse should:
A. give only general information about the child.
B. encourage the teacher to contact the child’s parents.
C. transfer the call to the hospital administrator.
D. answer her questions if the nurse can verify that the
person on the phone is the child’s teacher.
The answer is B. No information can be given to the teacher.
Only the guardians may receive information about the
child.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications and Side Effects
Assess client for actual or potential side effects and
adverse effects of medications
574. Gentamicin is known to be nephrotoxic. The nurse
administering gentamicin should independently evaluate
the client’s:
A. BUN
B. Urinary output
C. Fluid intake
D. Creatinine clearance
The answer is B. Urinary output provides information about
renal functioning. BUN and Creatinine clearance also evaluate
1210 PART III: Taking the Test
renal functioning but require a physician’s order so may not
be available for monitoring.
HEALTH PROMOTION AND
MAINTENANCE
Ante-/Intra-/Postpartum and Newborn Care
Identifies deviations from normal in the newborn
575. After a difficult vaginal delivery, a newborn is admitted
to the newborn nursery. During the assessment, it is
noted that the baby’s moro reflex does not include the
right arm. Which problem would the nurse suspect?
A. Brain damage
B. Fractured radius
C. Erb Duchenne palsy
D. Cephalohematoma
The answer is C. Erb Duchenne Palsy usually is due to pulling
the head away from the shoulder. The palsy, which may be
permanent, prevents movement of the shoulder and upper
arm. There is no evidence of brain damage. A fractured radius
would not affect shoulder movement. Cephalohematoma is
bleeding into the periosteum of the skull bone.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Central Venous Access Devices
Provide care for client with a central venous access device
576. A client’s PICC line will not flush. The nurse is unable
to aspirate blood from the line. Which is an appropriate
nursing action to restore patency?
A. Instill heparin into the line
B. Increase the pump pressure setting
C. Use increased pressure to flush the line with saline.
D. Contact the physician for orders for Activase
(alteplase)
The answer is D. Activase is a thrombolytic which breaks down
clots. Heparin prevents the formation of clots, it does not break
down clots. Increased pressure may cause the clotted line to
release an embolus into the client’s circulation. Increasing the
pump’s pressure setting would not cause the clot to disintegrate.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
577. A client has developed a pulmonary embolism. Which
factors predispose a client to this problem? (Select all
that apply.)
A. Bradycardia
B. Hypertension
C. Hypercoagulability
D. Fluid volume overload
E. Venous stasis in the lower extremities
The answers are C and E. Hypercoagulability and venous stasis
in the lower extremities predispose to development of a
pulmonary embolism. The other options are unrelated to
pulmonary embolism.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Apply knowledge of pathophysiology to illness management
578. A client is admitted to the hospital unit with a diagnosis
of hemophilia A. The nurse reviews the client’s lab
report. Which lab result should the nurse interpret as
unexpected and requiring further investigation?
A. Low platelet count
B. Low factor VIII values
C. Prolonged bleeding time
D. Prolonged partial thromboplastin time
The answer is A. The client with hemophilia A has insufficient
levels of factor VIII which is a component of the clotting cascade.
The platelet counts are normal. The other laboratory
values would be prolonged due to the inadequacy of the
clotting cascade.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Home safety
579. A client is brought to the emergency room for acute
lead poisoning. When determining the source of the
lead poisoning, the nurse will question the client
about which topic?
A. Eating lead pencils
B. Recent house painting
C. Using homemade pottery or ceramic dishes.
D. Eating unwashed vegetables from the garden.
The answer is C. Poorly fired pottery and ceramics may
be improperly glazed allowing the lead to leak out of
the clay. Lead pencils are made of carbon. Paint is now
CHAPTER 34 Practice Test for NCLEX-RN® 1211
lead free. Unwashed vegetables do not contribute a risk
of lead.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic
Tests/Treatments/Procedures
Provide nursing care that includes interventions designed
to reduce post procedure complications
580. A client has returned to the cardiac unit following a
cardiac catheterization performed through the left
femoral artery. Which item is an appropriate part of
the nursing care plan for this client?
A. Out of bed as soon as awake from anesthesia
B. Neurovascular check to the insertion site times two
C. Pressure dressing and immobility for the insertion site
D. Range of motion exercises to the left leg every two
hours.
The answer is C. The site is kept immobile for up to 24 hours
after cardiac catheterization to reduce the risk of a severe arterial
bleed. Range of motion exercises would be contraindicated.
The client would be on bedrest. Neurovascular checks
should be performed at least hourly for the first 24 hours due
to the risk of thrombosis.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Fluid and Electrolyte Imbalances
Identify signs and symptoms of client fluid and/or electrolyte
imbalance
581. A client with multiple myeloma is beginning
chemotherapy. The client’s serum calcium level is 15
mg/dl. For which clinical manifestations related to this
laboratory finding would the nurse assess?
A. Abdominal cramps
B. Confusion and anxiety
C. Lethargy and weakness
D. Muscle twitching
The answer is C. Normal serum calcium range is 8.5– 10.5
mg/dL so the client has hypercalcemia. Symptoms of hypercalcemia
include lethargy and weakness as well as depressed
deep tendon reflexes, anorexia, nausea, vomiting, constipation
and dysrhythmias.
A, B, and D are incorrect—Abdominal cramping occurs
with hyponatremia; confusion and anxiety occur with
hypocalcemia; muscle twitching occurs with hyponatremia.
HEALTH PROMOTION AND
MAINTENANCE
Ante-/Intra-/Postpartum and Newborn Care
582. The nurse is working on the postpartum unit and is
assigned to four clients. Which of the four clients is
most likely to suffer afterbirth pain based on their
obstetrical history?
A. Mother of twins
B. Bottle feeding mother.
C. Multipara with a premature infant
D. Primipara with an average for gestational age infant
The answer is A. Factors which increase afterbirth pain
include overdistended uterus such as in twins or large
infants, breast feeding, and multiparas.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic Procedures
Provide pre- and/or postoperative education
583. A client with a recent below the knee amputation of the
left lower extremity is admitted to the rehabilitation unit
and will be fitted with a prosthesis. Which is the priority
self care instruction to be given to the client?
A. Keep a diary of time and type of activity related to
the use of the prosthesis.
B. Assess skin integrity of the stump daily.
C. Apply cold compresses to the residual extremity bid.
D. Take analgesics if needed for phantom pain.
The answer is B. Preserving the integrity of the skin over the residual
extremity is critical to use of the prosthesis and resumption
of mobility. Thus the client is instructed to assess the skin at least
daily so any problem is identified and treated early.
A is incorrect—a diary related to the use of the prosthesis
is not a standard recommendation. C is incorrect—application
of cold is not a standard part of residual extremity care.
D is incorrect—although self-administration of analgesic may
be required secondary to phantom limb pain it is not considered
a priority in client education at this time.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
584. A client arrives in the emergency room with a chief
complaint of new onset stiff neck and muscle aches. A
physical exam reveals erythema migrans on the right
1212 PART III: Taking the Test
upper arm. Which is the most likely cause of the
client’s signs and symptoms?
A. Gout
B. Lyme disease
C. Lupus erythematosis
D. Polymyositis
The answer is B. Lyme disease, caused by the spirochete
Borrelia burgdorferi carried and transmitted by ticks, is characterized
by erythema migrans or the “bull’s eye” rash. Other
symptoms of Stage I disease are muscle and joint pain and
stiffness. Symptoms of gout are acute pain and inflammation
of one or more small joints. Lupus erythematosis can affect
virtually every body system. It can cause joint inflammation
and myositis. It also can cause a rash but the rash is the dry,
scaly, raised “butterfly” rash typically involving the cheeks
and bridge of the nose resulting in the butterfly shape. The
rash is not a bull’s eye rash. Polymyositis is an inflammation
of striated muscle causing symmetrical weakness and atrophy.
It is not characterized by erythema migrans.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Management of Care
Principles of Management
Supervise care provided by others
585. The charge nurse is observing a newly hired nurse measure
jugular venous pressure. Which action on the part of
the new nurse requires correction by the charge nurse?
The newly hired nurse
A. positions the client supine.
B. raises the head of the bed 30–45 degrees.
C. shines a light tangentally across the client’s neck.
D. measures the vertical distance from the manubrium
to the meniscus of the internal jugular vein.
The answer is D. The distance is measured vertically is from
the sternal angle (angle of Louis) to the meniscus of the
internal jugular vein. This distance which is measured in
centimeters equals the jugular venous pressure which usually
does not exceed 4 cm.
PSYCHOSOCIAL INTEGRITY
Chemical and Other Dependencies
Assess client for drug/alcohol related dependencies,
withdrawal, or toxicities
586. When examining a two and a half year old, which
assessment findings would the nurse interpret as consistent
with fetal alcohol syndrome?
A. ___ strabismus
B. ___ Irritability
C. ___ Absence of teeth
D. ___ Hyperactivity
E. ___ Developmental delay
The answers are A, B, D, and E. Abnormalities associated with
fetal alcohol syndrome which would be evident on assessing
a two and one half year child include strabismus, myopia,
irritability, hyperactivity, poor attention span, developmental
delay and growth deficiency. Teeth are malformed not
absent. Once in school, poor school performance is characteristic.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Mobility/immobility
587. You are caring for a 40-year-old male who is on complete
bed rest following a traumatic injury to his
pelvis. The data collected during your morning assessment
include elevated oral temperature (100°F),
diminished lung sounds in right lower lobe and oxygen
saturation of 90% on room air. The most likely
cause of these findings:
A. hypostatic pneumonia
B. atelectasis
C. bronchitis
D. asthma
The answer is A. immobility results in respiratory complications
which include pooling of respiratory secretions.
B is incorrect—atelectasis is a collapse of a single lobe or
an entire lung. C is incorrect—bronchitis is the acute inflammation
of airway passages. D is incorrect—asthma is not
caused by immobility.
HEALTH PROMOTION AND
MAINTENANCE
Developmental Stages and Transitions
Modify approaches to care in accordance with client’s
developmental stage
588. An 11-year-old boy is admitted to the hospital unit
following a bicycle accident. A fractured femur is
diagnosed and the child is placed in traction. The
best room assignment for this child would be a
room:
A. with other boys of the same age as roommates.
B. near the nurse’s station so the child can be closely
supervised.
CHAPTER 34 Practice Test for NCLEX-RN® 1213
C. away from other children so that the child can rest
adequately.
D. with an alert adult roommate who can respond to
the child’s needs.
The answer is A. Boys of this age are usually active. This child
has restricted activity and will be easily bored. The child will
enjoy the company of the other children.
This child’s condition is not a high risk condition so any
room location on the unit would be acceptable. It is not the
job of other clients to care for a client who is immobilized so
option D would be incorrect.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse effects/contraindications
589. Which statement made by the parent of a 15-year-old
girl receiving doxorubicin (Adriamycin) to treat
leukemia indicates that information regarding side
effects of the medication was understood?
A. “My daughter is lucky that the major side effects of
her medication are headache and drowsiness; they
could be a lot worse.”
B. “It will be hard to see my daughter confused and
hallucinating from the medication but at least these
side effects won’t last forever.”
C. “I hope my daughter’s heart isn’t damaged from this
medication; she is already going through so much
that would just be awful for her.”
D. “I worry about the effect of the medication on my
daughter’s kidneys but the important thing is to
cure the cancer then we will deal with the rest.”
The answer is C. heart damage is one of several side effects
of doxorubicin (Adriamycin) so this statement indicates
the client’s parent understands this fact.
Answer A is incorrect—headache and drowsiness are side
effects of methotrexate. Answer B is incorrect—hallucinations
and confusion are side effects of ifsoamide (Ifex). Answer D
is incorrect—kidney damage is a side effect of carboplatin
(Paraplatin).
PHYSIOLOGICAL INTEGRITY
Reduction of Risk
Potential for complications of diagnostic Tests/Treatments/
Procedures
590. A client is admitted for an arthrogram of the right
knee. Which is the most important information to
obtain as part of the admission history?
A. Allergies to iodine, seafood, or local anesthetic
B. Current pain level to right knee
C. Previous experience with arthrogram
D. Time of last meal or fluid intake
The answer is A. it is important to know if the client has any
of these allergies because a radiopaque dye, administered IV,
is given to visualize the joint.
B and C are incorrect—Although collecting information
related to pain and previous experience with an arthrogram
should be included, it is not the most important information.
D is incorrect—The client does not have to be NPO
prior to this diagnostic test.
PSYCHOSOCIAL INTEGRITY
Therapeutic Communication
Use therapeutic communication techniques to provide
support to client and/or family
591. A woman has recently been diagnosed with a terminal
illness. Although her physical condition is stable at
this time, the client seems depressed. Which approach
by the nurse would be most effective in encouraging
the client to talk about her feelings?
A. “You seem down today.”
B. “Why are you feeling so depressed?”
C. “What can I do to make you feel better?”
D. “Would you like to talk to the hospital chaplain?”
The answer is A. The nurse has made a statement of his or her
perceptions. The client can agree or deny these perceptions.
The client is never asked to explain feelings so asking
why is a incorrect response. In option C, the nurse offers his
or her self but this does not get at the client’s feelings. Option
D limits the conversation and is a way for the nurse to get
out of an uncomfortable situation.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Pharmacological agents/actions
592. A client is admitted to the hospital with a diagnosis
of disseminated intravascular coagulation (DIC).
The physician orders the client treated with
heparin. A family member asks why heparin is
being given to the client who is bleeding internally.
The nurse’s response is based on the knowledge that
heparin:
A. increases the production of clotting factors.
B. preserves the platelets to prevent the client from
bleeding out.
1214 PART III: Taking the Test
C. activates the clot disintegration process which
breaks up the clots that have formed.
D. promotes neutralization of thrombin and prevents
the conversion of fibrinogen to fibrin.
The answer isD. This action blocks the coagulation cascade at
the common pathway and stops the intravascular coagulation
disorder. The other responses do not accurately
describe the effect of heparin.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Educate client/family about medications
593. A client is being placed on long-term corticosteroid
therapy. Which information should be included as part
of the client’s discharge teaching?
A. Drink lots of water daily
B. Do not stop the medication suddenly
C. The medication may cause weight loss
D. It is critical not to not smoke while on corticosteroid
therapy
The answer is B. Corticosteroids depress the body’s natural
production of corticosteroids. Sudden stopping of the
medication could be fatal. The other responses are not
correct.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Fluid and Electrolyte Imbalances
594. In caring for a client with a serum calcium level of 15
mg/dl, which instruction would be given to the
client?
A. Increase the amount of calcium rich foods eaten
each day
B. Incorporate fiber into the daily diet to decrease constipation
C. Avoid foods high in sodium content
D. Limit fluid intake of water
The answer is B. Normal serum calcium range is 8.5– 10.5
mg/dl so the client has hypercalcemia. Hypercalcemia can
cause constipation.
A, C, and D are incorrect—Increasing calcium food
consumption is indicated for hypocalcemia; a decrease in
sodium intake is appropriate for hypernatremia; free water
intake is indicated with hyponatremia.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Standard/Transmission-Based/Other Precautions
Educate client/family/staff on infection control measures
595. A client goes to a clinic requesting to be tested for
Acquired Immunodeficiency Syndrome (AIDS). The
test was positive. Instructions to avoid spreading the
infection will include:
A. Avoid sharing toothbrushes and razors
B. Do not share a bathroom with other individuals
C. Keep your dishes seperate
D. Keep fresh flowers and plants out of the home to
reduce the accumulation of mold.
The answer is A. Body fluids can be spread by sharing toothbrushes
and razors. Sharing a bathroom is acceptable. Others
do not need to wear gloves during casual contact with the client.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Educate client/family about medications
596. A client with sickle cell anemia has been treated
with several blood transfusions. Now Deferoxamine
(Desferal) has been ordered and the client asks the
nurse the purpose of this medication. Which is the
correct answer for the nurse to give?
The medication will:
A. prevent the RBCs from sickling.
B. remove excessive iron from the body.
C. improve the longevity of the red blood cells.
D. increase the oxygen carrying capacity of the
blood.
The answer is B. When repeated blood transfusions are given,
the RBCs will eventually be broken down. The body retains
the iron from these donated cells leading to iron toxicity. All
other responses are incorrect.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
Provide postoperative care
597. A client has a cesarean section and delivers a healthy
infant. Which of the following interventions are useful
CHAPTER 34 Practice Test for NCLEX-RN® 1215
in preventing pulmonary embolism in the postoperative
mother?
A. Low salt diet and exercise
B. Compression stockings and leg exercises
C. Daily aspirin and daily breathing exercises
D. Low fat diet and rehabilitation therapy
The answer is B. Pulmonary emboli would result from thrombus
formation. The pregnant woman is at greater risk for the development
of thrombus. All surgical clients would also have this
risk while bed ridden. Compression stockings and leg exercises
would be most effective in preventing circulatory stasis.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Assess client for alterations in mood, judgment, cognition,
and reasoning as evidence of psychopathology
598. Nurses working with a client with which type of personality
disorder must be particularly alert for splitting
behavior?
A. Antisocial
B. Borderline
C. Narcissistic
D. Histrionic
The answer is B. Splitting is an unconscious mechanism characteristic
of the client with an borderline personality disorder.
The client is unable to accept imperfections in others
and sees people as all good or all bad with the result that
persons are set up against one another. For example, nurses
may be good if they say only positive things to the client;
nurses are bad if they provide negative feedback even when
appropriate. Splitting is a coping behavior.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Mobility/immobility
Provide nursing care that incorporates knowledge of the
risks associated with immobility
599. A client has been bed ridden for several months due to
the effects of Alzheimer’s Disease. For which musculoskeletal
problem is the client at risk?
A. Deep vein thrombosis
B. Osteoporosis
C. Avascular necrosis of hip
D. Embolism
The answer is B. prolonged bed rest result in loss of calcium
leading to osteoporosis.
A is incorrect—this is a complication of the vascular system
due to bed rest. C is incorrect—avascular necrosis is due
to trauma and/or chronic steroid use. D is incorrect—an
embolism is a cardiovascular complication from long term
bed rest.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
600. An elderly client develops disuse osteoporosis. The
client’s adult son asks why his parent has this disease.
The nurse would explain that disuse osteoporosis
occurs because of:
A. a decrease in calcium intake.
B. contractures to the lower extremities.
C. lack of stress to weight-bearing activity.
D. stiff and painful joints of the extremities.
The answer is C. calcium loss in the bones occurs due to lack
of weight-bearing activity to the bones.
A is incorrect—a decrease in calcium content does not
directly have an impact on disuse osteoporosis. B is incorrect—
contractures of lower extremities can be the result of
immobility. D is incorrect—immobility will eventually result
in stiff and sore joints.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
601. A 13-month-old child is to receive an oral medication.
The child starts crying as soon as the nurse enters the
room with the medication despite the fact that his
mother is telling him a story. After checking the child’s
identification bracelet, how should the nurse proceed
with administering the medication?
A. Blow gently across his face with a soft whistling
sound to stop the crying.
B. Allow the mother to administer the medication.
C. Delay giving the medication until the child is
calmer.
D. Hold the child on his or her lap in a semi-Fowler’s
position.
The answer is B. After the nurse checks the bracelet, the
mother can be allowed to administer the medication
while the nurse watches. The nurse would not blow
across the child’s face; microorganisms can be spread in
this way. Medication must be given in a timely fashion to
1216 PART III: Taking the Test
be effective. The child would be held upright to prevent
choking.
HEALTH PROMOTION AND
MAINTENANCE
Developmental Stages and Transitions
Assist the client to achieve an appropriate outcome
602. A mother asks the nurse when she should begin toilet
training her toddler. Which is an appropriate response
for the nurse to give?
An indication that a child is ready to begin toilet training
is that the child
A. pulls on the diaper when it is wet.
B. has a BM at the same time every day.
C. doesn’t want to lay down for diaper changes.
D. hides behind the living room chair when having a
BM
The answer is D. This indicates the child is aware that he is
about to have a BM, a necessary step in toilet training. A
indicates the child is aware that he has eliminated, but does
not show anticipation of the event. Having a BM at the same
time every day makes toilet training easier for mother, but
does not indicate readiness. Toddlers are so busy they often
complain about the need to have diapers changed. It doesn’t
indicate readiness.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Use clinical decision making/critical thinking when calculating
dosages
603. What is the maximum daily dose of acetaminophen in
mg/Kg of body weight that can safely be given to
children? Record your answer in a whole number.
_____ mg/Kg.
The answer is 90 mg/Kg. The maximum daily dose for adults
is 4 gm.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapy
Expected effects/outcomes
604. The nurse is comparing laboratory results on admission
with laboratory results following treatment of a client
with DIC. Which change in laboratory values from
admission indicates a positive response to therapy?
A. Decrease in platelet count
B. Increase in fibrinogen level
C. D-dimer assay increase
D. Decreased bleeding time
The answer is B. Heparin is used in the treatment of DIC. If
therapy is effective, the heparin should stop the process of
intravascular coagulation thereby allowing the fibrinogen
level in the blood to increase. Platelet count would increase
not decrease with effective therapy. D-dimer assay is a global
marker of coagulation activation measuring a fibrin degradation
product. Clotting time, not bleeding time, is a reliable
indicator of effective therapy for DIC.
PSYCHOSOCIAL INTEGRITY
Therapeutic Communications
Use therapeutic communication techniques to provide
support to client and/or family
605. A woman has given birth to a preterm infant. The
infant is doing well in the high risk nursery. The
woman states to the nurse: “I am so worried about my
baby.” The best response by the nurse would be:
A. “You’re worried about your baby?”
B. “Don’t be worried, your baby is doing fine.”
C. “God will take care of your baby if it is meant to be.”
D. “Babies born at the gestation of your baby usually
do very well.’
The answer is A. It is reflective and encourages the mother to
provide more information. The other responses are not therapeutic.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Parenteral/Intravenous Therapy
Monitor and maintain infusion site(s) and rate(s)
606. The nurse is scheduled to administer 500 mg of ampicillin
IV by secondary line. The drug is to be infused
over 20 minutes. The ampicillin is in a 50 ml baggie of
D5W. The IV drop factor for this IV is 15. How many
drops per minute should the nurse regulate the IV to
infuse at over the required 20 minutes?
A. 20 gtts/min
B. 30 gtts/min
C. 40 gtts/min
D. 60 gtts/min
CHAPTER 34 Practice Test for NCLEX-RN® 1217
The answer is B. 50 ml in 20 minutes or 21⁄2 ml per minute.
Each ml contains 12 drops so 12 times 21⁄2 _ 30 gtts/min.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical emergencies
607. When performing the Heimlich maneuver on a pregnant
or markedly obese client, the nurse should position
her hands in which area? Mark the spot with the
letter “X”.
Correct response:
X
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Fluid and Electrolyte Imbalances
Identify signs and symptoms of client fluid and/or electrolyte
imbalance
608. A child has been admitted to the pediatric unit with
gastroenteritis. Which laboratory finding indicates the
child is dehydrated?
A. Elevated reticulocyte count
B. Elevated white blood cell counts
C. Decreased urine-specific gravity
D. Elevated hemoglobin and hematocrit
The answer is D. Since both hemoglobin and hematocrit are comparisons
of solids to liquids, dehydration causes an increase in
these values. The other responses do not indicate dehydration.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Choose physical assessment equipment and technique
appropriate for client
609. A client is transferred from the operating room to the
postpartum unit following a cesarean section for fetal
distress. When the nurse performs the postpartum
assessment, the client complains of pain and asks the
nurse not to palpate the fundus. Which is the appropriate
nursing action?
A. Ask a more experienced nurse to palpate the fundus.
B. Palpate the fundus anyway while avoiding the incision
area.
C. Avoid palpating the fundus as long as the vital signs
are stable.
D. Explain the need for fundal palpation and then palpate
the fundus from the side.
The answer is D. Fundal palpation is essential for the wellbeing
of the client. Contraction of the fundus occludes open
blood vessels and prevents excessive bleeding from the site
of placental implantation. The client will be more cooperative
if the client understands the rationale.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for alterations in body systems
610. An 84-year-old female is brought to the E.R. presenting
with confusion, restlessness and altered mental status.
Which nursing action is appropriate?
1218 PART III: Taking the Test
A. Ask the client about the medications she is currently
taking.
B. Give electrolyte replacing fluids.
C. Refer the client for a psychiatric evaluation.
D. Prepare for a physical exam including a chest x-ray,
EKG, UA, and CBC.
The answer is D. Changes in mental status such as confusion
and restlessness are typical signs of acute illness in older
adults requiring physical exam and lab work to r/o UTI, MI,
pneumonia.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Mobility/immobility
611. An elderly client has been hospitalized for two weeks
and develops the beginning of a pressure ulcer on the
coccyx. The nurse recognizes that pressure ulcers in
older adults are considered:
A. primary changes
B. secondary changes
C. normal changes
D. expected changes when hospitalized
The answer is B. Primary, normal, and expected changes are
the same thing and pressure ulcers are not a normal sign,
rather a pathological one.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Accident Prevention
Identify and facilitate correct use of infant and child
safety seats
612. The nurse is teaching a prenatal class on child safety.
Where would the nurse instruct the expectant mothers
to put their baby’s car seat?
A. Front passenger seat
B. Middle of the back seat
C. Back seat behind the driver
D. Back seat behind the passenger
The answer is B. The middle of the back seat is the safest place
for the infant car seat.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
613. A client had a left total knee replacement two days ago
and is now having dyspnea and appears to be very
apprehensive. Pulse rate is 110 and she is diaphoretic.
Which problem does the nurse suspect?
A. Infection
B. Pneumonia
C. Fat embolus
D. Anaphylaxis
The answer is C. These are symptoms of a fat embolus which
is a risk when the marrow cavities of long bones are opened
due to accidental trauma or surgery.
A is incorrect—the symptoms listed are not indicators of
infection, B is incorrect—Data collected does not include temperature.
D is incorrect—information provided does not
include drug history.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Recognize signs and symptoms of impaired cognition
614. A client with schizophrenia says “skipping, whipping,
tripping” over and over during his waking hours.
Which would be a correct label for the nurse to use
when documenting this communication?
A. word salad
B. clang association
C. neologism
D. echolalia
The answer is B. Clang association. Clang association refers to
repeating words and phrases which sound alike but are otherwise
unconnected. Word salad refers to the meaningless
connection of words and phrases. A neologism is a new
word coined by the client and with meaning only to the
client. Echolalia is the repetition of words or phrases heard
from another person.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapy
Pharmacological interactions
615. A client is on anticoagulant therapy following a pulmonary
embolism. During the first visit to the client’s
CHAPTER 34 Practice Test for NCLEX-RN® 1219
home, the home health nurse asks the client to take
out all the medications that he has on hand. Which
medication is a cause for concern when taken by a
client on an anticoagulant?
A. Ferrous sulfate (Iron)
B. Acetylsalicylic acid (Aspirin)
C. Isoniazid (INH)
D. Phenytoin (Dilantin)
The answer is B. Aspirin can potentiate the effects of anticoagulants.
Ferrous sulfate does not affect anticoagulants; it is
used for RBC production. INH is an antitubercular product
and does not affect clotting time. Phenytoin is an antiseizure
med and does not affecting clotting time.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Central Venous Access Devices
Access implanted venous access devices
616. While visiting the area from another state, a client presents
to the emergency room with severe pain secondary
to a kidney stone. The physician orders an IV line
started with 125 ml per hour of D5 1⁄4 NS and morphine
for pain. The client shows the nurse his chest where he
states he has a Subcutaneous venous port and asks the
nurse to start the IV there. Prior to starting an IV line in
this port, the nurse would need to verify that the:
A. Brand of subcutaneous port.
B. Medications can be given by central line.
C. Port internal tip lies in the superior vena cava.
D. Intravenous fluids can be administered by central line.
The answer is C. Prior to administering anything through a
central line, the location of the internal tip must be verified.
Since this client is not known in the area, the tip location can
be verified by x-ray if the client does not have a card documenting
this information. Any medication and intravenous
fluids that can be administered by peripheral line can be
administered in a central line.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Standard/Transmission Based/Other Precautions
Evaluate infection control precautions implemented by
staff members
617. A client is on contact isolation due to a MSRA abscess.
The charge nurse observes all of the following nursing
activities. Which nursing activity fails to safely protect
others from the client?
The nurse:
A. washes hands after removing gloves.
B. does not wear gloves when changing the bed.
C. does not wear a gown when checking the IV
level.
D. covers the client with a sheet when being transported
to x-ray.
The answer is B. The abscess could have drained onto the bedding.
The nurse does not need to wear a gown unless contact
with items in the room is expected. Hands should always be
washed or disinfected after removing gloves. Covering the
client with a sheet when out of the room will reduce exposure
to others.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
618. The nurse is assessing an elderly client and notes the
following findings. Which assessment findings would
the nurse identify as a normal signs of aging? Mark all
that apply.
A. Increase in diastolic blood pressure
B. Reduced lens elasticity
C. Reduced vital capacity
D. Decreased force of myocardial contraction
The answers are B, C, and D. Decreases in lens elasticity, vital
capacity and force of myocardial contraction all occur normally
with aging. Mild increase in systolic BP also occurs,
however an increase in diastolic BP is pathological and
requires monitoring.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications
Provide nursing care that incorporates knowledge of
adverse effects of selected pharmaceutical agents
619. A client presents to the emergency department, dehydrated
and with metabolic acidosis. An overdose of
which drug can result in these problems?
A. Digitalis
B. Aspirin
C. Insulin
D. Acetaminophen
1220 PART III: Taking the Test
The answer is B. Aspirin toxicity causes hyperventilation leading
to respiratory alkalosis which leads to metabolic acidosis
and dehydration. In digitalis toxicity, the major symptoms
would be bradycardia. Insulin overdose would lead to hypoglycemia.
Acetaminophen toxicity would result in symptoms
of liver damage including AST and ALT elevations.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Standard/Transmission-Based/Other Precautions
Apply principles of infection control
620. The charge nurse is orienting a new nurse to the
mother baby unit. The charge nurse explains that
gloves should be worn (select all that apply):
A. when changing diapers.
B. for the initial newborn bath.
C. when changing the bag of IV fluids.
D. while performing initial assessment on a newborn.
E. when assisting the new mother to the bathroom for
the first time after delivery.
The answers are A, B, D, and E. The nurse would be at risk for
exposure to bloodborne pathogens during all these events.
Newborns are covered with amniotic fluid and blood.
Diaper changes might expose the nurse to body fluids. The
first time the mother is out of bed, a large amount of blood
usually escapes from the vagina. Combine that with the fact
that many new mothers become weak or faint when first
up, gloves at this time provide protection for the nurse.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Central Venous Access Devices
Provide care for a client with a central venous access
device
621. A client has had a PICC line for 2 weeks which is being
used for intermittent infusion of an antibiotic. Between
uses, the PICC line is heparinized and locked. The
nurse is ready to administer the PM dose of antibiotic.
The nurse flushes the line which flushes easily, but is
unable to aspirate blood. The nurse should:
A. administer the medication as planned.
B. ask for x-ray verification of the PICC placement.
C. discontinue this PICC line and insert a new PICC line.
D. hold the dose until the physician sees the client in
the AM.
The answer is A. PICC lines have a very small lumen and
blood aspiration is often not possible after several weeks of
use. The easy flush with no other complaints usually indicates
that the PICC is intact. X-ray verification is used whenever
the location of the tip is in question. Only specially
trained nurses can insert PICC lines. Holding the dose until
the next day would allow the client’s blood level to drop and
could allow the organism to become resistant.
PSYCHOSOCIAL INTEGRITY
Family Dynamics
Assist client/family/significant others to integrate new
members into family structure
622. A young teenage girl has just given birth to a baby girl.
She has decided to keep her baby. The nurses are concerned
about bonding between mother and infant. To
promote bonding, the nurse will:
A. tell the mother her baby is beautiful.
B. delay eye prophylaxis immediately after birth.
C. leave the mother and baby alone to get acquainted.
D. keep the lights in the room on bright so the mother
can see her infant clearly.
The answer is B. Bonding is supported when the mother looks
at her infant and the infant looks back. Delaying eye prophylaxis
and lowering the lights in the room will promote
the infant looking back.
The mother may be afraid to be alone with her infant.
Telling the mother the baby is beautiful is not the best intervention
to promote bonding.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Total Parenteral Nutrition
Provide client/family/significant others with information
on TPN
623. A 4-year-old child with cystic fibrosis has difficulty
maintaining adequate nutrition and has had a subcutaneous
venous port surgically implanted for home
administration of total parenteral nutrition. The child
receives the TPN for 8 hours each night and is disconnected
from the IV line during the day. The home
health nurse teaches the mother to:
A. Calculate the drip rate since a pump will not be
needed.
B. Check the child’s blood glucose every two hours
during the night.
C. Limit the child’s intake during the day so the child
will not become obese.
CHAPTER 34 Practice Test for NCLEX-RN® 1221
D. Start the TPN slow and taper up to the desired rate
each night and then taper off each morning.
The answer is D. TPN is always tapered on and tapered off.
Sudden onset will cause hyperglycemia, sudden stopping
will cause hypoglycemia. An electronic infusion pump is
always used with TPN. It is not necessary to check the child’s
glucose as often as every two hours. Limiting the child’s daily
intake would be inappropriate as the child is malnourished.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
624. A 67-year-old female is returning to the medical clinic
for a follow-up visit due to complaints of back pain,
frequent fevers and weight loss. CBC and serum chemistry
disclosed high serum calcium and protein levels
and low levels of hemoglobin, red blood cells,
platelets, and white blood cells. With which problem
are these signs and symptoms consistent?
A. Anemia
B. Arthritis
C. Multiple myeloma
D. Systemic lupus erythematosis
The answer is C. Multiple myeloma is correct.
A is incorrect—there is only a decrease in hemoglobin
and hematocrit with anemia. B is incorrect—these tests
would not be performed to diagnose arthritis. D is incorrect—
these tests are not performed to diagnose lupus erythematosis.
HEALTH PROMOTION AND
MAINTENANCE
Principles of Teaching/Learning
Assess readiness to learn, learning preferences, and
barriers to learning
625. A nurse is preparing to teach a newly diagnosed diabetic
about the disease. Which is the initial step the
nurse should take?
A. Identify the client’s willingness to learn.
B. Find out what the client knows about the disease.
C. Determine the client’s level of formal education.
D. Select written material available for the client’s use.
The answer is B. The initial step is always to begin where
the client is. All other responses may be helpful, but initially
determining the client’s current knowledge is most
important.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-Specific Assessment
Perform focused assessment
626. The nurse is checking Homan’s sign on a client suspected
of having a venous thrombosis. Which action
should the nurse take?
A. Flex the client’s hip and the knee
B. Flex the client’s hip while extending the knee
C. Ask the client to point the toes while bending the
knee
D. Push the client’s foot forward toward the knee while
maintaining the knee in extension
The answer isD. A positive Homan’s sign is calf pain on dorsiflexing
the foot while maintaining the knee in extension. If
Homan’s is positive, a venous thrombosis is suspected. The
other responses do not describe the appropriate technique to
assess for Homan’s sign.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic Procedures
Use precautions to prevent further injury when moving a
client with a musculoskeletal position
627. A client has had spinal surgery and the physician has
ordered the client to be “log-rolled.” To be log rolled,
the nurse will:
A. have the client turn slowly and stiffly.
B. use a draw sheet to maintain body alignment.
C. only position the client prone or supine to prevent
spinal trauma.
D. ask for assistance from another nurse to maintain
the body alignment.
The answer is D. Log rolling will require two nurses or more
to maintain alignment of the spine and prevent trauma. The
other actions are not the correct methods for log-rolling.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Recognize signs of acute and chronic mental illness
628. The nurse would expect to encounter withdrawal and
odd eccentric behaviors when caring for a group of
clients with which cluster of personality disorders?
A. Paranoid, schizoid, schizotypal
B. Antisocial, borderline, histrionic, narcissistic
1222 PART III: Taking the Test
C. Avoidant, dependent, obsessive-compulsive
D. Passive-aggressive, masochistic
The answer is A. Withdrawal and odd, eccentric behaviors
are characteristic of clients with paranoid, schizoid, and
schizotypal personality disorder. Attention seeking and
erratic behaviors are characteristic of clients with antisocial,
borderline, histrionic and narcissistic personality disorders.
Clients with avoidant, dependent or obsessive compulsive
personality disorder are attempting to avoid or
minimize anxiety or fear.
Clients with passive-aggressive or masochistic personality
disorder are covertly aggressive against self or others.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in body systems
629. A woman is admitted to the emergency room with
bleeding from a stab wound in the right chest area.
Which assessment findings would the nurse interpret
as indicating the initial phase of hypovolemic shock?
Mark all that apply.
A. Increased hematocrit
B. Narrowed pulse pressure
C. Elevated heart rate
D. Oxygen saturation of less than 80%
E. Increased rate and depth of respiration
F. Absent superficial peripheral pulses
G. Slowed capillary refill
The answers are B, C, and G. Pulse pressure narrows because
in the initial stage of hypovolemic shock the body attempts to
compensate for the blood loss through vasoconstriction
which decreases the size of the vascular bed. Vasoconstriction
increases the diastolic blood pressure but not the systolic,
thus the pulse pressure is decreased or narrowed before the
systolic pressure drops from loss of volume. Heart rate also
increases as part of the compensatory effort. The increased
heart rate is an attempt to maintain cardiac output despite the
fact that stroke volume is decreased. Capillary refill or the
time taken for color to return to the nail bed after being
pressed until it blanches is slow or even absent in shock.
Hematocrit and hemoglobin are decreased in shock
caused by hemorrhage; they are increased in other types of
hypovolemic shock. Oxygen saturation of less than 80% is
not a sign of initial shock; it is a sign of later progressive
shock. Increased respiratory rate is a sign of initial shock but
depth does not increase until shock has progressed to the
point that lactic acidosis is present. Superficial peripheral
pulses may be difficult to locate and easily obliterated in initial
shock but absent superficial peripheral pulses are a sign
of later shock.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic Procedures
Provide preoperative care
630. A child is scheduled for surgery. Which are nursing
actions to be carried out prior to surgery? (Select all
that apply.)
A. Check the child for loose teeth.
B. Remove finger nail polish from fingers and toes.
C. Have appropriate lab reports available on the chart.
D. Verify that the parents have signed an informed
consent.
E. Check that the child has been NPO for a specified
period of time.
The answers are A, B, C, D, and E. All responses are correct
and should be included in the presurgery routine.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body System
631. A 44-year-old client is admitted to the emergency
department with burns to the neck and face received
from an explosion while working on a gas pipeline.
During the nurse’s initial assessment, highest priority
should be given to:
A. Noting signs of increased intracranial pressure (ICP)
B. Monitoring hourly intake and output
C. Assessing changes in circumference of the neck
D. Replacing fluid loss since based on weight
The answer is C. Assessing circumference of the neck will
identify increases in girth and potential restriction of the airway
from edema. ICP not pertinent in the absence of head
injury and would not replace maintenance of a patent airway
as a priority. Monitoring I&O is important but not the initial
priority. Replacing fluid is essential in burn therapy but not
a priority over airway.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Standard/Transmission-Based/Other Precautions
Apply principles of infection control
632. Which precaution measures would be instituted when
a client has a Mycoplasma pneumoniae infection?
(Mark all that apply.)
CHAPTER 34 Practice Test for NCLEX-RN® 1223
A. ___ Client is placed in a private, negative airflow
pressure room.
B. ___ Client is placed in a private room or with other
clients with infection caused by the same organism.
C. ___ Use mask at all times while in the client’s
room.
D. ___ Use mask when working within 3 feet of the
client
E. ___ Use gown and protective barriers when giving
direct care.
F. ___ Mask on client if transported out of room.
G. ___ Use gloves at all times when caring for
clients.
H. ___ Use gloves when there is risk of exposure to
blood or body fluids.
The answers are B, D, F, and H. Mycoplasma pneumoniae is
spread by droplet transmission. Transmission-based precautions
for droplet transmission require a private room
or a room shared with someone infected with the same
organism. Those entering the room and coming within 3
feet of the client need to wear a mask and the client wears
a mask if taken out of the room. Standard precautions,
which involve wearing gloves whenever there is the risk
of touching something wet that comes from the body surface
or a body cavity, i.e., when there is the risk of contact
with blood or body fluids, are used at all times for all
clients.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
Perform emergency care procedures
633. A client comes into the Emergency Room with a heavily
bleeding thigh wound. Which is the priority nursing
action?
A. Start oxygen
B. Put pressure on the wound
C. Establish an IV line
D. Determine the cause of the wound
The answer is B. The first priority is to put pressure on the
wound to stop the bleeding and prevent further blood loss
which can lead to hypovolemic shock. Oxygen is given to aid
maintenance of tissue oxygenation. An IV line is established
for fluid replacement and the cause of the wound would be
determined as a guide to management. However none of
these is the first priority.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Dosage calculations
634. Using the Parkland formula (4 ml of lactated ringer’s
solution/% TBSA burn/kg body weight/24 hours), the
nurse would calculate fluid replacement for a 70-kg
client with a 50% TBSA burn over 24 hours as
A. 1400 ml
B. 14,000 ml
C. 6720 ml
D. 700 ml
The answer is B. 14,000 ml is the correct number. 4 _ 50 _
200 ml/kg. Client weighs 70 kilograms so 70 _ 200 _
14000 ml.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Informed Consent
Ensure that client has given informed consent for treatment
635. The physician has ordered IVIG (intravenous
immunoglobulins) to be administered to a client on a
monthly basis. Prior to starting this therapy, the nurse
would make certain that the client:
A. is aware of the importance of being NPO the morning
of the infusion.
B. has signed an informed consent for a blood product.
C. understands that once started, the therapy cannot
be stopped.
D. recognizes that he or she will be contagious for 2
days after receiving the IVIG product.
The answer isB. IVIG are antibodies removed from the blood of
blood donors. One dose of IVIG can contain antibodies from
60,000 individuals. All other statements are not correct.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Educate client and family about medications
636. Due to a severe asthma attack, a client has been on corticosteroids
for more than 2 weeks. Which information
should the nurse give the client about when the
time comes to stop the medication?
1224 PART III: Taking the Test
A. Fluid intake will need to be limited.
B. The dose of medication will be tapered down
slowly.
C. Extra calcium will be needed for a week to ten days.
D. Vitamin supplements will be needed to prevent
bone loss.
The answer is B. Corticosteroids suppress the body’s own production
of corticosteroids by the adrenal gland. Sudden
stopping of the medication could be fatal. The other
responses are incorrect.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Recognize signs and symptoms of acute and chronic
mental illness
637. Which symptoms would the nurse expect to find
when assessing a client in the prodromal stage of
schizophrenia?
A. social isolation and withdrawal
B. impaired role function
C. Speech aberration
D. peculiar beliefs
E. markedly odd behavior
The answers are A, B, C, D, and E. Social isolation withdrawal,
impaired role function, speech aberration, peculiar
beliefs, and markedly odd behavior are all symptoms that
can occur in the prodromal phase of schizophrenia. Speech
disturbance may be manifested as vague or circumstantial
speech, over elaborate speech, or poverty of speech and
content. Other prodromal symptoms include unusual perceptual
experience and marked lack of initiative, interests
and energy. At least two of these symptoms persisting continuously
for six months must occur for the diagnosis of
prodromal schizophrenia to be made.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptations
Fluid and electrolyte imbalances
638. A client arrives in the emergency department after having
been burned with hot oil over the upper entire
anterior chest and right leg. When the client is being
triaged, which is the most important question for the
nurse to ask?
A. “What time did the burn occur?”
B. “Have you had any pain meds since the burn?”
C. “How did you stop the burning process?”
D. “What caused this burn initially?”
The answer is A. The time the burn occurred will determine the
amount of fluid replacement.
The other questions may be asked but none is more
important than the time of the burn because fluid replacement
is of critical importance and none of the other questions
provide information needed to determine it. Pain
assessment is important but fluid replacement is priority.
Knowing how the burning process was stopped is not critical
in fluid replacement. Option D is important but not
priority.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
639. A visitor falls to the floor in front of the nursing station.
Which assessment findings are indicative of sudden
cardiac death?
A. Fixed, dilated pupils
B. Absent respirations
C. Absent pulses
D. Absent blood pressure
E. Loss of consciousness
The answers are B, C, D, and E. Absence of respirations,
pulses and blood pressure along with loss of consciousness
are signs of full cardiac arrest. Pupils become fixed but not
necessarily dilated.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Use of Restraints/Safety Devices
Comply with federal/state/institutional policy regarding
the use of client restraints and/or safety devices
640. A 2-year-old child has had a cleft palate repair. Elbow
restraints have been placed on the child’s arms to prevent
the child from damaging the suture line. How
does the nurse manage the restraints?
The nurse
A. never removes the restraints.
B. removes both restraints at the same time every 2
hours.
C. removes the restraints one at a time when providing
range of motion.
CHAPTER 34 Practice Test for NCLEX-RN® 1225
D. removes the restraints only when there is another
adult present to prevent suture damage.
The answer is C. The restraints are removed every two hours,
one at a time. At that time the underlying skin is evaluated
and range of motion exercises are provided.
A is incorrect as the restraints need to be removed periodically.
B is incorrect as the restraints would be removed
one at a time. D is incorrect as the nurse does not need
another adult to remove the restraints.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
Counsel/teach client/family/significant others about managing
client health problem
641. A 3-month-old infant has been diagnosed as being
at risk for sudden infant death and apnea monitors
are being used in the home. Parent teaching will
include:
A. infant CPR.
B. heimlich maneuver for infancy.
C. postural drainage techniques.
D. use of portable oxygen.
The answer is A. Unless the parents know infant CPR, they
will be unable to respond if their child has an apneic period.
The other responses are incorrect.
HEALTH PROMOTION AND
MAINTENANCE
Growth and Development
642. A newborn infant has been diagnosed with Down’s
syndrome. The parents have been informed that the
child will have mental retardation. The parents ask the
nurse what they can expect of their child’s development.
The best response by the nurse would include
the information that their child will:
A. develop in an undeterminable pattern.
B. never develop basic skills due to the mental retardation.
C. develop in the same pattern as other children but at
a slower rate.
D. will follow the same developmental time frame as
other children but will stop developing before the
other children.
The answer is C. Mentally retarded children develop in the
same order as other children—they will learn to sit before
they stand, stand before they walk, etc. The other answers
are incorrect.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Teach client about managing illness
643. A child has been diagnosed with scabies. In addition to
washing the child with the prescribed medication, the
nurse would instruct the mother to:
A. wash all bed linens in hot soapy water.
B. wash all fruits and vegetables before use.
C. have the family’s dog checked for evidence of infestation.
D. discard all of the child’s clothing and replace with
new clothing.
The answer is A. All bed linens and clothing should be
washed in hot soapy water to kill the itch mites. This itch
mite is not acquired from food sources. The dog does not
transmit the itch mite to humans. It is not necessary to discard
all clothing.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical emergencies
644. An industrial nurse responds to an emergency in the
plant where a worker is burned. Which is the correct
sequence of nursing actions?
A. Eliminate the source of the burn, ensure airway
patency, observe for and treat associated injuries,
treat burn shock.
B. Eliminate the source of the burn, ensue airway
patency, cool the burn wound, apply topical antibiotic
cream.
C. Ensure airway patency, insert a nasogastric tube,
insert a bladder catheter, stare IV fluid infusion.
D. Treat burn shock, ensure airway patency, start IV
antibiotics and put the client in reverse isolation.
The answer is A. The appropriate sequence of nursing actions
for clients with major burn injuries is to eliminate the source
of the burn, ensure airway patency, assess for and treat associated
injuries, and treat burn shock. Options B, C, and D
may be appropriate during care of such a client, but
response (A) represents the correct sequence for initial
assessment.
1226 PART III: Taking the Test
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
645. Why are clients who have had back surgery, such as a
laminectomy or spinal fusion, turned by log rolling?
A. Guard against wound dehiscence
B. Prevent excess pressure on the operative site
C. Maintain body alignment
D. Protect against skin breakdown
The answer is C. In log rolling, the client is turned all at once
with the back as straight as possible. This maintains proper
body alignment and avoids disruption of the surgical site.
Other answers are incorrect.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Confidentiality/Information Security
Maintain client confidentiality/privacy
646. The nurse is working in the emergency department
when a call is received from a police officer asking
about the condition of one his colleagues who has
been injured while on duty. Which is an appropriate
nursing action?
A. Give only general information about the client.
B. Encourage the officer to contact a member of the
client’s family.
C. Transfer the call to the hospital administrator.
D. Answer his questions once the identity of the officer
is confirmed.
The answer is B. Sharing of a client’s health information is
governed by the HIPPA regulations. No information can be
given to a friend or coworker. Referring the officer to a family
member does not guarantee that this person has or will
share information but does not violate the privacy requirements.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
647. Your client has an external fixator to the right lower
extremity to stabilize an open fracture of the tibia and
fibia with extensive soft tissue damage. The client is
complaining of a tingling sensation in the foot. Which
is the priority nursing action in response to the client’s
new complaint?
A. Administer pain medication
B. Assess pain level using a pain scale
C. Notify physician of client’s status
D. Perform neurovascular assessment
The answer is D. Prior to any of the other interventions, the
nurse will need to do a full assessment of the status of the
leg. The physician will need the additional information to
determine the appropriate medical intervention.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness management
648. A client suffered blunt trauma to the chest in a motor
vehicle accident (MVA) and is later diagnosed with
adult respiratory distress syndrome (ARDS). The nurse
is formulating a plan of care for this client and knows
that the nursing goal with the highest priority should
relate to which area?
A. Improving nutritional status and decreasing protein
wasting
B. Administering diuretics and antibiotics to combat
infection
C. Maintaining oxygenation and eliminating underlying
cause of ARDS
D. Monitoring the client’s blood pressure and PaCO2
levels
The answer is C. Airway and oxygenation are always the
first priority. Maintaining oxygenation takes the priority
over monitoring blood pressure and ensuring good
nutrition.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Recognize signs of acute and chronic mental illness
649. The nurse would expect to encounter attention
seeking and erratic behaviors when caring for a
group of clients with which cluster of personality
disorders?
A. Paranoid, schizoid, schizotypal
B. Antisocial, borderline, histrionic, narcissistic
C. Avoidant, dependent, obsessive-compulsive
D. Passive-aggressive, masochistic
CHAPTER 34 Practice Test for NCLEX-RN® 1227
The answer is B. Attention seeking and erratic behaviors are
characteristic of clients with antisocial, borderline, histrionic
and narcissistic personality disorders. Withdrawal and odd,
eccentric behaviors are characteristic of clients with paranoid,
schizoid, and schizotypal personality disorder. Clients
with avoidant, dependent or obsessive compulsive personality
disorder are attempting to avoid or minimize anxiety
or fear.
Clients with passive-aggressive or masochistic personality
disorder are covertly aggressive against self or
others.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness management
650. The nurse is caring for a client with ARDS. To reduce
oxygen consumption in this client, the nurse should
provide
A. ample time for rest and relaxation
B. 100% oxygen per nasal cannula
C. increased daily caloric intake
D. 21% oxygen per mask as needed
The answer is A. It is the only response that considers and
reduces oxygen consumption.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
651. A suicidal client has ingested a large amount of an
unknown poison. The client has no signs of injury to
the mouth but is difficult to arouse. Which would be
the appropriate intervention for this client?
A. Administer syrup of ipecac immediately
B. Initiate gastric lavage after assessment
C. Give milk or water orally to dilute gastric content
D. Call the poison control center for an antidote
The answer is B. Gastric lavage would be instituted to remove
the poison. Gastric lavage would not be used if signs of
injury from a corrosive poison are present because the lavage
tube might perforate the burned esophagus. Syrup of ipecac
should not be given to induce vomiting with a difficult to
arouse client because of the risk of aspiration. Giving oral
fluids also is contraindicated because of the risk of aspiration.
Since the poison is unknown, calling the Poison control
center for an antidote is not possible.
HEALTH PROMOTION AND
MAINTENANCE
Developmental Stages and Transitions
Identify expected physical, cognitive, psychosocial, and
moral stages of development
652. The nurse is observing a group of preschoolers in a
day care. The nurse recognizes that the child who is
showing signs of a developing conscience is the child
who:
A. tattles on a classmate.
B. stays close to the teacher.
C. ignores other children’s toys.
D. carries a security object with them at all times.
The answer is A. When a child is developing a sense of conscience,
they often tattle because of their recognition of right
and incorrect in others. None of the other behaviors are
related to the development of conscience.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness Management
Apply knowledge of pathophysiology to illness management
653. A newborn was diagnosed with osteogenesis imperfecta.
When handling the infant, the nurse would:
A. wear gloves to prevent contamination.
B. maintain the infant in semi-fowler’s position.
C. restrain the infant to prevent trauma to the bones.
D. use the palms of the hands to handle the infant’s
extremities.
The answer is D. Children with osteogenesis imperfecta have
fragile bones and must be handled by the palms of the
hands. None of the other responses are appropriate for this
child.
HEALTH PROMOTION AND
MAINTENANCE
Growth and Development
654. Which of the following principles of growth and
development is being addressed when the nurse
explains to the parent that the infant will develop control
of the head before control of the torso and legs?
A. Cephalocaudal
B. Proximodistal
1228 PART III: Taking the Test
C. Mass to specific
D. Simple to complex
The answer is A. Cephalocaudal means head to tail and refers
to the fact that development occurs from the head downward.
Normal development simultaneously occurs from
midline to periphery which is proximodistal. Mass to specific
refers to differentiation. Simple to complex refers
to operations in which simple precedes complex ones and is
similar to mass to specific.
PSYCHOSOCIAL INTEGRITY
Therapeutic Communications
655. A 78-year-old male in the late stages of Alzheimer’s disease
is in an extended care facility. He complains to the
nurse that he is tired and his neck is sore from working
in the field all day. Which of the following is the
best response from the nurse?
A. “You know you don’t work in the field anymore”
B. “What type of motion caused the soreness”
C. “You’re 78-years-old, You’ve been here all day with
me, you haven’t worked in the field in years”
D. “Would you like me to rub your neck and apply a
warm compress?”
The answer is D. Validating the client’s reality is the most
appropriate intervention for later stages of Alzheimer’s disease.
He is not a candidate for reality orientation. The nurse
is responding to what she can help with, his sore neck. The
other answers are confrontational and close off communication.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
656. A client is transported to the emergency department
following multiple traumatic fractures from a motor
vehicle accident. Which assessment findings would be
a priority for the nurse to report to the physician 6
hours after a spica body cast has been applied?
A. Pedal pulses are equal but weak.
B. The lower extremities are cool to touch.
C. The client is complaining of itch under the cast.
D. The client complains of pain with respirations
The answer is D. Pain with respirations could mean restricted
lung expansion and compartment syndrome. This is the priority
because it involves airway and oxygenation.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Palliative/comfort care
657. The client in the burn unit is complaining of severe
pain in the first 24 hours following the burn injury.
Which of the following is the usual method of dealing
with pain during this period?
A. Liquid narcotics are given via the NG (nasogastric)
tube as needed.
B. Narcotics are administered via the intramuscular
route into non-burned tissue.
C. Intravenous narcotic agents are administered for
pain as needed.
D. No medications are given during this period
because of respiratory depression.
The answer is C. The client will have IV access as a component
of the resuscitation process. Intravenous administration
allows for quick results of the narcotic. Narcotics administered
through the NG or IM route would be slower in providing
relief. Although respiratory depression would be
monitored, narcotic pain relief would still be given.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
658. A client is seen in the emergency room following an
industrial accident involving chemical burns. The
nurse recognizes that the severity of a chemical burn
depends on which factors?
A. The mechanisms of action.
B. Penetrating strength and concentration.
C. The amount and duration of exposure.
D. The age of the client
E. The occupation of the client
The answers are A, B, C, and D. Factors related to the chemical
itself, type of chemical, concentration, amount and duration
of exposure, all affect the severity of the burn. The age
of the skin affects how easily it is injured as well as healing
ability. Age affects general condition of client. The occupation
will have no effect.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Recognize signs and symptoms of acute and chronic
mental illness
659. When assessing a client newly admitted with a diagnosis
of active phase schizophrenia, which are positive
CHAPTER 34 Practice Test for NCLEX-RN® 1229
symptoms at least one of which the nurse would
expect to find?
Mark all that apply.
A. ___ disorganized speech
B. ___ flat affect
C. ___ delusion
D. ___ impaired attention
E. ___ bizarre behavior
F. ___ hallucination
The answers are A, C, E, and F. The positive signs of active
phase schizophrenia are delusion, hallucination, disorganized
speech, and bizarre or disorganized behavior. At least
one of these positive signs must be present for at least one
month for a diagnosis of active phase schizophrenia to be
made. Flat affect and impaired attention are negative symptoms
of schizophrenia.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
660. A client with burns on the face and neck is at risk for
airway obstruction. Which of the following would be
most indicative of a potential airway obstruction?
A. Singed nasal hairs
B. Neck and face pain
C. PaO2 of 80 mm Hg
D. Coughing up large amounts of thick, white sputum
The answer is A. Singed nasal hairs indicate the client
breathed in hot gases. This can lead to edema of the oral
mucus membranes. Pain in these areas does not indicate airway
problems. PaOx of 80 is low normal. Thick white sputum
would not indicate airway burns.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
661. A client with a suspected pulmonary embolus is
admitted to a medical unit from the emergency department.
The client complains of shortness of breath and
severe chest pain. Which other signs and symptoms
would support the diagnosis of pulmonary embolism?
A. Low grade fever
B. Productive white sputum
C. 2 degree AV block
D. Frothy sputum
E. Tachycardia
F. Blood-tinged sputum
The answers are A, E, and F. Chest pain and dyspnea are cardinal
signs and symptoms of pulmonary embolism. Clients may also
have a low grade fever, tachycardia which is a compensatory
mechanism for decreased oxygen supply, and blood tinged
sputum. Productive white sputum is not suggestive of pulmonary
embolism. Frothy sputum would indicate pulmonary
edema.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Nutrition and oral hydration
662. An older gentleman reports that he has needed to use
more salt than usual to make his food taste good. He
asks the nurse what this could mean. The nurse’s
response should be based on the knowledge that
A. the number of taste buds decreases with age.
B. older persons need more sodium to ensure good
kidney function.
C. increased sodium is needed to compensate for lost
fluids.
D. the client may be confused due to his advancing
age.
The answer is A. The taste buds begin to atrophy at age 40
and after age 60 there is an insensitivity to taste qualities.
There are also studies that indicate that there are changes in
the salt threshold in some elderly individuals. The other
options are incorrect.
HEALTH PROMOTION AND
MAINTENANCE
Developmental Stages and Transitions
Identify common developmental patterns of a pediatric
client
663. When observing a two year old in the hospital playroom,
which type of play would the nurse interpret as
representative of normal development?
A. Solitary
B. Parallel
C. Associative
D. Dramatic
The answer is B. Solitary play is seen in the infant, associative
play is seen in a preschooler. A school age child may demonstrate
dramatic play.
1230 PART III: Taking the Test
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical emergencies
664. The client is admitted to the emergency room with
massive bleeding and a gunshot wound to the chest in
severe respiratory distress. Which nursing action has
the highest priority when managing the emergency?
A. Establish and maintain an open airway
B. Start cardiopulmonary resuscitation
C. Initiate oxygen therapy via nasal cannula
D. Apply pressure to wound to control bleeding
The answer is A. Establish airway is the correct response.
Without a patent airway, all other measures are not critical.
CPR is not appropriate since the client is not pulseless.
Oxygen therapy via nasal cannula is not appropriate for
severe respiratory distress. Applying pressure to the wound
to control bleeding is critical but does not take priority over
establishing and maintaining an airway.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
665. A client is being discharged home on anticoagulant
therapy. Which instructions should the nurse include
as part of discharge teaching? (Select all that apply.)
A. ___ Avoid use of aspirin containing drugs while
receiving Coumadin.
B. ___ Do not keep fresh flowers in the home.
C. ___ Report dark, tarry stools to primary health care
provider.
D. ___ Avoid brushing teeth to prevent bleeding gums.
E. ___ Avoid inactivity for prolonged periods of sitting
with legs crossed.
F. ___ Change positions frequently while traveling;
walk occasionally; exercise legs and ankles.
G. ___ Continue anticoagulants for length of time
ordered.
The answers are A, C, and G. Aspirin has an anticoagulant effect
and as a result enhances the effect of Coumadin. Therefore it is
contraindicated for clients taking Coumadin. Dark tarry stools
need to be reported because bleeding is an adverse effect of
anticoagulation and bleeding in the upper GI tract can present
as dark, tarry stools as a result of the presence of blood which
has been exposed to digestive secretions. It is important that
clients for whom anticoagulants are prescribed follow the
directions for taking the medications precisely; this includes
taking the medication for the length of time ordered. Fresh
flowers are not contraindicated for clients on Coumadin; they
are contraindicated for clients who are immunocompromised.
Brushing the teeth should be done regularly, not avoided.
However, a soft bristled toothbrush should be used. Moving
and avoiding inactivity are instructions that would be given to
clients at risk for venous thrombosis.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Laboratory values
666. A client suffered deep partial-thickness and full-thickness
burns over 40% of his body approximately 12
hours ago. Urine output is 22 ml/hour and the hematocrit
is 50%. ABG values show pH, 7.32; paO2, 95 mm
Hg; PaCo2, 35 mm Hg; and HCO3-, 18 mEq/L. Based
on this data, which conclusion can the nurse draw
about the client’s status?
The client
A. is hypovolemic from fluid shift and has metabolic
acidosis.
B. is in the early stages of heart failure caused by over
hydration.
C. is adequately hydrated, but in acute renal failure
and respiratory acidosis
D. has developed a polycythemia as the body attempts to
compensate for metabolic acidosis and renal failure.
The answer is A. During the first 24 hours after a burn injury,
fluid is lost from the intravascular space into the tissues
causing hemoconcentration and diminished urine output.
There is no indication of over hydration. The client does
not show symptoms of respiratory alkalosis. The condition is
hemoconcentration not polycythemia.
PSYCHOSOCIAL INTEGRITY
Chemical and Other Dependencies
Assess client for drug/alcohol related dependencies,
withdrawal, or toxicities
667. When examining a neonate on admission to the newborn
nursery, which assessment findings would the
nurse interpret as consistent with fetal alcohol syndrome?
Mark all that apply.
A. ___ Elongated palpebral fissures
B. ___ Strawberry hemangioma
C. ___ Thick upper lip
D. ___ Cleft palate
E. ___ Congenital hip dislocation
The answers are B, D, and E. Malformations associated with
fetal alcohol syndrome which would be evident in the neonate
include strawberry hemangioma, low set posteriorly rotated
CHAPTER 34 Practice Test for NCLEX-RN® 1231
ears, cleft lip/cleft palate, pointy chin, thin upper lip, short
palpebral fissures, microcephaly, joint dysfunction including
congenital hip dislocation, abnormal palmar creases, thoracic
cage abnormalities, atrial and ventricular septal defects.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for alterations in body systems
668. The client is admitted to the emergency room for acetaminophen
overdose. The nurse should prepare to
A. place an intravenous catheter and administer
1000cc D5W intravenously.
B. induce gastric emptying by inserting a nasogastric
tube for lavage.
C. give syrup of ipecac and follow with activated charcoal.
D. insert a Foley catheter and start diuresis immediately.
The answer is C. Removal of the poison by inducing vomiting
followed by preventing absorption is standard treatment for
a non-caustic poisoning. Gavage would be unnecessary as a
way to remove the poison. The other two options have nothing
to do with poison removal.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Choose physical assessment equipment and technique
appropriate for the client
669. When examining a 3-year-old, which part of the health
assessment should be done first?
A. Abdominal palpation
B. Otoscopic examination
C. Oral examination
D. Chest auscultation
The answer is D. Chest auscultation is the least intrusive part
of the physical examination and should be done first to provide
time for the child to adjust somewhat to being examined
and to delay upsetting the child.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
670. An 18-year-old client is brought to the emergency
room for a hornet sting. Which symptoms suggest that
the client is having an anaphylactic reaction?
A. rhinorrhea
B. wheezing
C. local edema
D. urticaria
E. angioedema
F. generalized pruritus
The answers are A, B, D, E, and F. Signs of anaphylaxis which
is a hypersensitivity reaction, typically begin with feelings of
apprehension and impending doom. Generalized pruritus,
urticaria, and sometimes swelling of the eyes, lips, and
tongue (angioedema) follow. Respiratory congestion, rhinorrhea,
wheezing and dyspnea occur as a result of bronchoconstriction,
mucosal edema and production of excess
mucus. Laryngeal edema is associated with hoarseness and
stridor. Full blown shock may ensue.
PSYCHOSOCIAL INTEGRITY
Therapeutic Environment
671. A new mother of a 1-month-old infant is concerned
that she is spoiling the baby “because she carries her
around the house in an infant sling against her chest.”
The nurse’s best response would be:
A. “You should not carry her in the sling except when
you are going out and need to take her.”
B. “She should spend at least half of her waking time
on a firm surface by herself.”
C. “Spoiling an infant is difficult; cuddling and holding
are essential for normal development.”
D. “Carrying an infant in a sling is not advised because of
potential problems with development of the spine.”
The answer is C. Cuddling and holding along with meeting
other basic needs builds trust and is essential for normal
growth and development. The child can be carried in the infant
sling at home as well as when the mother goes out. There is no
set time the infant should be alone and on a flat surface. Use of
a sling has not been shown to cause problems with the spine.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic
Tests/Treatments/Procedures
Provide nursing care in a safe and effective manner
672. The nurse would question an order for a mydriatic
medication to be administered to a client with which
disorder?
A. Narrow angle glaucoma
B. Drug overdose
1232 PART III: Taking the Test
C. Blunt force head injury
D. Suspected spinal cord injury
The answer is A. A mydriatic medication dilates the pupils.
Pupil dilation is contraindicated with narrow angle glaucoma
so an order for a mydriatic would be questioned
because of its ability to cause harm. Pupil dilation does not
have the potential for injury in relationship to the other
disorders.
HEALTH PROMOTION AND
MAINTENANCE
Expected Body Image Changes
673. During the routine well check up of an 18 month old,
the mother asks the nurse about her son’s protruding
abdomen. Which fact should form the basis of the
nurse’s response?
A. The abdomen protrudes as a result of increased
food intake at this age
B. Underdeveloped abdominal muscles are the reason
for the protruding abdomen.
C. A protruding abdomen indicates a possible abnormal
curvature of the spine.
D. A protruding abdomen is uncommon in toddlers
and requires further assessment.
The answer is B. Undeveloped abdominal musculature gives
the toddler the characteristic protruding abdomen.
A is incorrect because during toddlerhood food intake
decreases. C is incorrect because, although it’s normal, it
doesn’t provide the answer to the mother’s question. D is
incorrect as protruding abdomen is common in toddlers.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for alterations in body systems
674. The client with which problem would be at greatest
risk for developing a pulmonary artery thrombosis?
A. Fluid volume overload
B. Ventricular fibrillation
C. Increased cardiac output
D. Polycythemia
The answer is D. Polycythemia predisposes to stasis of blood
as a result of increased viscosity secondary to the increased
numbers of red blood cells. None of the other problems predispose
to thrombosis.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic
Tests/Treatments/Procedures
675. A client presents to the emergency department with a
foreign object in the eye. Which action should the
nurse take?
A. Remove the object after an x-ray is taken.
B. Remove the object after notifying the ophthalmologist.
C. Leave the object untouched while awaiting the ophthalmologist..
D. Flush the eye with saline to dislodge the object.
The answer is C. The nurse would make no attempt to
remove the foreign body until the client has been examined
by an ophthalmologist.
HEALTH PROMOTION AND
MAINTENANCE
Techniques of Physical Assessment
Choose physical assessment equipment and technique
appropriate for the client
676. The nurse is admitting a 2-year-old child to the hospital
unit for a minor surgical procedure. When examining
the child, which approach is most appropriate?
A. Have the parent wait in the next room
B. Have the toddler sit on the parent’s lap
C. Allow the child to remain clothed.
D. Keep equipment to be used out of sight
The answer is B. The child will be more cooperative if his
or her parent holds the toddler on lap for the exam.
Separating the child from the parent will most likely
increase the child’s distress and there is no reason to do so.
It is not possible to perform an effective physical examination
with clothing in place. The child should not only see
but be allowed to handle equipment to decrease fear and
anxiety.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Recognize signs of acute and chronic mental illness
677. The nurse would expect to encounter clients who are
covertly aggressive against self or others when working
with a group diagnosed with which types of personality
disorder?
CHAPTER 34 Practice Test for NCLEX-RN® 1233
A. Paranoid, schizoid, schizotypal
B. Antisocial, borderline, histrionic, narcissistic
C. Avoidant, dependent, obsessive-compulsive
D. Passive-aggressive, masochistic
The answer is D. Clients with passive-aggressive or masochistic
personality disorder are covertly aggressive against self
or others. Withdrawal and odd, eccentric behaviors are
characteristic of clients with paranoid, schizoid, and schizotypal
personality disorder. Attention seeking and erratic
behaviors are characteristic of clients with antisocial, borderline,
histrionic and narcissistic personality disorders.
Clients with avoidant, dependent or obsessive compulsive
personality disorder are attempting to avoid or minimize
anxiety or fear.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse effects/contraindications
678. Which statement made by a client taking methotrexate
for rheumatoid arthritis indicates that information
regarding side effects of the medication was understood?
A. “It’s too bad medications have to have side effects
but I guess I can deal with headache and nausea.”
B. “I don’t know how my husband will cope if I
become confused and hallucinate from this medication.”
C. “I already have a heart murmur; I am afraid that this
medication will make it worse and I will end up
needing heart surgery.”
D. “I know this medication is very likely to cause
kidney damage but the symptoms of the rheumatoid
arthritis are so bad that I have to take it anyway.”
The answer is A. Side effects of methotrexate include
headache and nausea and this statement indicates the client
understands that fact. Heart damage is one of several side
effects of doxorubicin (Adriamycin). Hallucinations and
confusion are side effects of ifsoamide (Ifex). Kidney damage
is a side effect of carboplatin (Paraplatin).
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
679. While being helped out of bed to a chair, a client
who is two days postoperative from abdominal surgery
starts to cough forcefully and the surgical
wound eviscerates. What is the priority nursing
intervention?
A. Cover the wound with a moist sterile dressing
B. Start intravenous fluids and antibiotics
C. Apply an abdominal binder
D. Notify the physician.
The answer is A. The wound should be covered with a moist
sterile dressing. Moisture prevents the wound from drying
out and becoming necrotic prior to surgery. Wound evisceration
is a surgical emergency and while one nurse is with the
client and covering the wound, a second should be notifying
the surgeon. If a client is at known risk for evisceration, sterile
dressing and sterile saline should be available in the
client’s room. Intravenous fluids and antibiotics will be part
of the client’s care but are not the immediate priority.
Abdominal binders are not appropriate and could cause
damage to wound.
HEALTH PROMOTION AND
MAINTENANCE
Developmental Stages and Transitions
680. A toddler is hospitalized for medical treatment. When
the mother leaves, the child screams and cries for his
mother. He refuses to be comforted and will not eat
while mother is not present. The nurse interprets the
child’s behavior as indicative of which stage of toddler
hospitalization reaction?
A. Protest
B. Despair
C. Detachment
D. Regression
The answer is A. Protest is a stage of anger at the separation
from the parent. Despair is mourning the loss of the parent.
The child would no longer display anger but would be saddened
by the loss. Detachment is a stage where the toddler
appears to be the “good client”—appears happy with the
parent present.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in body systems
681. The client is diagnosed with a life-threatening condition
characterized by inadequate blood flow to the tissues
and cells of the body to meet metabolic demands.
Nursing care should focus on:
A. restoring circulating volume
B. maintaining adequate IV access
1234 PART III: Taking the Test
C. monitoring intake and output
D. weighing daily
E. observing for fluid overload
The answers are A and B. These activities are designed to
restore circulation while observing for complications of
nursing interventions.
Responses C, D and E are assessment tools to evaluate
the success of the interventions.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Rest and sleep
682. Which information should the nurse include when
teaching the parent of an 8-year-old child about bedtime
schedules?
A. The child’s need for sleep is greater now than in
adolescence.
B. Minimum requirement for optimal growth and
development is 10 hours of sleep a night.
C. The child is often unaware of his own fatigue level.
D. Nightmares and night tremors are common in this
age group.
The answer is C. School-age children are often unaware of
their own fatigue level. If allowed to stay awake they will be
tired the next day.
Because of slowed growth rate, during the school-age
period less sleep, not more, is required than in adolescence.
Eight-year-old children do not require a minimum of 10
hours of sleep. Nightmares and night terrors are common in
the preschool period.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication administration
683. A client is requiring resuscitation secondary to a respiratory
arrest. During the code, epinephrine is
ordered. The most effective route of administration
would be:
A. Intravenously
B. Endotracheally
C. Intradermally
D. Subcutaneously
The answer is B. The quickest and most effective route would
be via endotracheal tube.
The IV route is slower but effective. Subcutaneous or
intradermal administration is inappropriate.
HEALTH PROMOTION AND
MAINTENANCE
Developmental Stages and Transitions
684. The nurse is discussing readiness for toileting with a
child’s parents. Which factor would the nurse identify
as a contraindication to beginning toilet training at this
time?
A. The toddler wakes up dry from a nap
B. The toddler stays dry for up to 3 hours
C. The toddler wants to have a soiled diaper changed
promptly.
D. The toddler has a toilet adjacent to his bedroom in
the family’s brand new home.
The answer is D. Moving is a stressful and toilet training
should not be initiated during stressful period.
Choices A, B, and C are all signs of readiness for toilet
training.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in body systems
685. A child is admitted to the emergency room with multiple
blunt trauma to the chest, and crushing wounds to
the abdomen, and legs. Which are the priority nursing
assessments?
A. Level of consciousness and pupil size
B. Abdominal contusions and other wounds
C. Pain, respiratory rate, and blood pressure
D. Quality of respirations and presence of pulses
The answer is D. These are top priorities in trauma management;
basic life functions must be maintained or reestablished.
Level of consciousness and pupil size are part of the
assessment for head injury. Assessment for head injury and
assessment for abdominal injury and pain follow appraisal of
airway, breathing, and circulation.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse effects/contraindications
686. Which instructions would the nurse give to a client
starting on Pentoxifylline (Trental)? Mark all that
apply.
A. ___ Take on an empty stomach
B. ___ Report any unusual bleeding or bruising
CHAPTER 34 Practice Test for NCLEX-RN® 1235
C. ___ There may be toxic drug effects if taken with
Theophylline
D. ___ Drug reduces red blood cell aggregation
The answers are B, C, and D. Pentoxifylline (Trental) should be
taken with food to decrease GI symptoms. Information in all
other answers should be included in client teaching regarding
self administration of Pentoxifylline (Trental).
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Standard/Transmission-Based/Other Precautions
Apply principles of infection control
687. Which precaution measures would be instituted when
a client has tuberculosis? (Mark all that apply.)
A. ___ Client is placed in a private, negative airflow
pressure room.
B. ___ Client is placed in a private room or with other
clients with infection caused by the same
organism.
C. ___ Use mask at all times while in the client’s
room.
D. ___ Use mask when working within 3 feet of the
client.
E. ___ Use gown and protective barriers when giving
direct care.
F. ___ Mask on client if transported out of room.
G. ___ Use gloves at all times when caring for clients.
H. ___ Use gloves when there is risk of exposure to
blood or body fluids.
The answers are A, C, F, and H. Tuberculosis is spread in small
particle droplets by airborne transmission. Airborne precautions
require a private room with negative airflow and
adequate filtration; those entering the room wear a mask
and if the client leaves the room, a mask is worn. Standard
precautions, which involve wearing gloves whenever there
is the risk of touching something wet that comes from the
body surface or a body cavity, i.e., when there is the risk of
contact with blood or body fluids, are used at all times for
all clients.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alteration in body systems
688. A client is admitted to the emergency room with a
diagnosis of acute respiratory distress syndrome.
Which assessment findings would the nurse expect?
A. A systolic blood pressure greater than 170
B. Tenacious thick greenish yellow sputum
C. An altered level of consciousness
D. Slow abdominal breathing
The answer is C. Cognition and level of consciousness are
reduced secondary to cerebral hypoxia which accompanies
ARDS. Blood pressure may be reduced. Sputum is not tenacious,
but may be frothy if pulmonary edema is present.
Breathing will be rapid and shallow not slow and abdominal.
HEALTH PROMOTION AND
MAINTENANCE
Growth and Development
689. After administering an IM injection to 3-year-old child
the nurse puts an adhesive bandage on the site. The
reason for applying the bandage is based on the fact
that:
A. the child will “pick” at the injection site.
B. the bandage will relieve pain at the site.
C. the preschool child is afraid his “insides will fall
out” and the bandage prevents “insides from leaking.”
D. the bandage will remind the nurses that the child
has received an injection recently.
The answer is C. Preschoolers want a bandage on any scrape
or bruise to prevent their insides from leaking out. Most
children will not pick at the site, bandages do not relieve
pain, and nurses should not need a reminder that a child has
received an injection.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness management
690. Which type of delivery system would the nurse use
when administering oxygen to a client who has experienced
a cardiac arrest?
A. A nasal cannula at l liter per minute.
B. A 100% non-rebreather mask.
C. A 28% venti-mask
D. A face mask at 4 liters per minute
The answer is B. A non-rebreather mask provides the highest
concentration of oxygen available. All other choices would
provide insufficient oxygen. With a simple face mask, the
flow rate must be at least 5 liters per minute to flush the
mask of carbon dioxide.
1236 PART III: Taking the Test
PSYCHOSOCIAL INTEGRITY
Family Dynamics
Assist client/family/significant others to integrate new
members into family structure
691. A very young teenager has just given birth to a healthy
infant. The nurse is concerned about bonding. To promote
bonding, the nurse would:
A. Encourage early parent–infant interaction and close
body contact.
B. Allow mother infant interaction only when a nurse
can be present.
C. Require the new mother to breastfeed the infant.
D. Tell the new mother how bright and alert her baby is.
The answer is A. Studies have shown that immediately after
birth is the best time for maternal infant bonding.
B, C, and D are incorrect because maternal-child contact
would not be limited; the mother has the right to choose
to breast feed or not; telling the mother her baby is bright
and alert does not promote bonding.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
692. A client with disseminated intravascular coagulation
has a severe reaction to a unit of packed cells and
develops a humoral immunity. The nurse knows that
humoral immunity:
A. Is produced by T-cell activity
B. Involves immunoglobulins
C. Occurs only in anaphylactic reactions
D. Involves the thymus
The answer is B. Humoral immunity is mediated by B lymphocytes
and is involved in an anaphylactic reaction. A is
incorrect as it is B cell activity. Humoral immunity can also
involve immunocomplex hypersensitivities. The thymus is
not involved.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
693. Which symptoms occurring in a 4-week-old male infant
are consistent with a diagnosis of pyloric stenosis?
A. Metabolic alkalosis
B. Uninterested in feeding
C. Vomiting bile stained fluid.
D. 2 ounce weight loss over last 3 days.
E. Peristalsis observed over the abdomen.
The answers are A, D, and E. A and D are related to the vomiting
that occurs. Peristalsis may be visible on the abdomen
as the stomach tries to push formula past the obstruction.
The infant will be hungry, vomiting will not be bile
stained.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
694. A client has been admitted to the hospital unit for stasis
venous ulcers. Which nursing intervention would
be included in the plan of care?
A. Performing Burger-Allen Exercises
B. Providing bedrest with legs in a dependent position
C. Placing a foot board on the bed
D. Placing the client in a high fowler’s position
The answer is C. Use of a footboard keeps pressure off of the
ulcer. Burger-Allen Exercises are done for Buerger’s disease.
Keeping legs in a dependent position increases edema. High
Fowler’s position increases pressure and kinking on the vascular
system.
PSYCHOSOCIAL INTEGRITY
Sensory/Perceptual Alterations
Assess needs of clients with altered sensory perception
695. When planning care for a client with hallucinations,
the nurse would consider that the client is most likely
to harm self or others in which stage of the hallucinatory
process?
A. comforting
B. condemning
C. threatening
D. controlling
The answer is D. Controlling. There are four stages in the hallucinatory
process. In stage 1, the hallucination is familiar
and comforting and anxiety level is mild. In stage 2, the hallucination
is condemning; it is accusing and makes the person
feel guilty and isolated. In stage 3, the hallucination is
threatening and begins to rule all different aspects of behavior.
In the fourth or controlling stage, anxiety has increased
to the panic level and the individual is unable to control
behavior. It is in this stage that the risk of harm to self or others
is greatest.
CHAPTER 34 Practice Test for NCLEX-RN® 1237
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
696. A maternity client is seen for her regular checkup at 20
weeks gestation. On assessment, the nurse notes that
the uterus is at the level of the xiphoid process. The
nurse would suspect:
A. Oligohydramnios
B. Multiple Gestation
C. Intrauterine growth retardation
D. Fetal demise
The answer is B. At 20 weeks gestation, the fundus should be
at the level of the umbilicus. This finding indicates the fundus
is above the expected location. The only response that would
cause the fundus to be higher than normal is B. All other conditions
would lead to a fundus below the expected level.
HEALTH PROMOTION AND
MAINTENANCE
Developmental Stages and Transitions
697. The parent of a 3-year-old child tells the nurse that she is
worried because the child has irrational fears. “My child
is afraid to go to bed, afraid of the neighbor’s gentle
Golden Retriever, every day there’s a new fear” Which of
the following is the best response from the nurse?
A. “Preschool children have the most fears; try a night
light to help going to bed and know that being afraid
of large dogs is very common in this age group.”
B. “Your child should be growing out of these irrational
fears by now, let’s get her involved in some
play and see what seems to be going on.”
C. “Don’t make too much of it; just be patient; this
phase will pass soon”
D. “Going to bed is often a problem, let her fall asleep
in your bed and then carry her back to her bed
when she is sleeping”
The answer is A. The preschool years are the time when children
have the most fears. Option A reassures the mother
her child’s behavior is normal and it gives the mother information
that will help her deal with the child’s fear.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
698. A 4-month-old infant puts a toy in their mouth and
begins to choke. Which is the appropriate nursing action?
A. Position infant head down and provide back blows.
B. Elevate the infant’s head and provide back blows.
C. Position the fist below the navel, then using both
fists perform four abdominal thrusts.
D. Place one fist on the sternum and perform chest
thrusts.
The answer is A. The infant is positioned head down and
back blows are given. Back blows are used on the conscious
infant. Trendelenburg position is used to assist with foreign
body removal. The other responses are incorrect.
HEALTH PROMOTION AND
MAINTENANCE
Developmental Stages and Transitions
699. Which suggestion could the school nurse make to the
parents of a 10-year-old child who want to promote
their child’s psychosocial development?
A. Encourage the child to start a collection of model
cars, baseball cards, or other similar items.
B. Meet the needs of the child in a consistent manner.
C. Avoid disciplining the child during this difficult
period.
D. Reinforce that the child is a good person even if
behavior is bad.
According to Erikson, the school age child’s task is to
develop industry vs. inferiority. A child’s sense of industry is
enhanced by building a collection. Being consistent helps
meet the needs of the infant. Informing the child that he is a
good person even if his behavior is bad is appropriate for a
toddler. All children need discipline as they are uncomfortable
when there are no rules.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
700. While providing nursing care, the client has a respiratory
arrest. Which are the priority interventions for the
resuscitation of this client?
A. Intubating with an endotracheal tube
B. Starting 100% oxygen
C. Drawing serial arterial blood gases
D. Checking the Glasgow coma scale
E. Monitoring oxygen saturation level
The answers are A and B. Both of these actions would promote
oxygenation.
1238 PART III: Taking the Test
C and D are assessment measures that would be done but
they are not the priority. Response E is unrelated to a respiratory
arrest.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
701. A client returns to the hospital unit following an
appendectomy. Which finding on the postoperative
admission assessment should be reported to the physician
immediately?
A. Oral temperature 99_F
B. Pulse 98 and thready
C. Complaints of nausea
D. Absent bowel sounds
The answer is B. A pulse of 98 and thready is suggestive of
hemorrhage. Oral temperature may be slightly elevated as a
result of the procedure. Nausea is common in the post operative
period. Absent bowel sounds are common in the
immediate post operative period.
HEALTH PROMOTION AND
MAINTENANCE
Aging Process
702. An 89-year-old man came to the clinic for his annual
checkup. Which finding related to pulmonary function
would the nurse expect?
A. An increase in functional alveoli
B. A reduction of residual volume
C. A decrease in vital capacity
D. Blood gases that show mild acidosis
The answer is C. A decrease in vital capacity because loss of
elastic forces in the lung lead to an increase in residual volume,
and a decrease in vital capacity.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications of diagnostic tests/treatments/
procedures
703. A client in the emergency department is intubated and
connected to a mechanical ventilator. She becomes
extremely anxious, and the pressure alarm sounds with
each inspiration. Which is the priority nursing intervention?
A. Increase the tidal volume
B. Increase the oxygen concentration
C. Disconnect the ventilator and manually ventilate
the client using a ventilator bag for a few breaths.
D. Administer the prescribed diazepam or morphine
sulfate as needed.
The answer is C. This allows the nurse to assess for a mucus
plug which would occlude the ET tube causing the increased
pressure alarm. The other interventions would be inappropriate.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Hemodynamics
704. The nurse is teaching self care to a client who has been
diagnosed with Raynaud’s disease. Which instruction best
meets the goal of maintaining optimal tissue perfusion?
A. Inspect skin daily for breakdown
B. Alleviate factors that increase pain
C. Wear mittens when going out into the cold
D. Elevate extremities when color changes occur due
to vasoconstriction
The answer is C. Keeping the hand warm enhances vasodilation
and tissue perfusion. Inspection of the skin is important
to prevent complications but does not enhance vasodilation.
Alleviating factors that increase pain promotes comfort and
may help prevent further decreases in tissue perfusion but
does not optimize it. Elevating extremities decreases circulation
to the extremity.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Recognize signs and symptoms of impaired cognition
705. The nurse says to a schizophrenic client “Swallow your
pills, John.” The client responds by saying “Swallow
your pills John; swallow your pills John; swallow your
pills John; swallow your pills John” Which would be a
correct label for the nurse to use when documenting
this communication?
A. word salad
B. clang association
C. neologism
D. echolalia
The answer is D. Echolalia. Echolalia is the repetition of
words or phrases heard from another person. Word salad
refers to the meaningless connection of words and phrases.
Clang association refers to repeating words and phrases
which sound alike but are otherwise unconnected. A neologism
is a new word coined by the client and with meaning
only to the client.
CHAPTER 34 Practice Test for NCLEX-RN® 1239
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
706. A teenager has been admitted to the hospital unit with
a diagnosis of appendicitis. While awaiting the start of
surgery, it becomes apparent that the appendix has
ruptured. At this time, in what position will the nurse
maintain the client?
A. Prone
B. High Fowlers
C. Left side-lying
D. Trendelenburg
The answer is B. High Fowlers position utilizes gravity to collect
the infectious material in one area of the abdomen
reducing the extent of peritonitis. The other responses
would not be correct.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
707. A client is admitted to the emergency room with a
blood pressure of 72/42 mm HG and a diagnosis of
septic shock. Which assessment finding would best
confirm this diagnosis?
A. Hot, dry skin with poor skin turgor
B. ABG analysis revealing metabolic alkalosis
C. Temperature of 105_F (40.6_C) and a pulse rate of
122 beats/minute
D. Urine output of 30 ml/hour and central venous
pressure of 8 cmH2O
The answer is C. Septic shock is related to the presence of
endotoxins or exotoxins released from bacteria. Symptoms
include fever, tachycardia, increased respiratory rate and
shock and coma. The other responses are not related to septic
shock.
HEALTH PROMOTION AND
MAINTENANCE
Developmental Stages and Transitions
Identify expected physical, cognitive, psychosocial, and
moral stages of development
708. When planning care for a 4-year-old, the nurse considers
the fact that the child does not yet comprehend
which concepts?
A. Alternative points of view
B. Conservation
C. Reversibility
D. Object permanence
The answers are A, B, and C. A 4-year-old child is egocentric
and doesn’t understand another’s view yet. Conservation,
which is permanence of mass and volume, is not comprehended
nor is the concept of reversibility i.e. if 2 _ 3 _ 5,
then 5 _ 3 _ 2. Object permanence is mastered and understood
in toddlerhood.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Hemodynamics
709. A client is experiencing septic shock and the attending
physician wants to titrate medications to be regulated
so that a mean arterial pressure (MAP) between 75 and
85 mmHg is maintained. When evaluating the response
of the drug, which of the blood pressure readings meet
the goal?
A. 135/90
B. 125/80
C. 115/70
D. 110/60
The answer is C. The formula for mean arterial pressure
(MAP) is SBP _2 DBP divided by 3. The blood pressure with
mean arterial pressure between 75 and 85 is 115/70 (MAP),
(115 _ 70 _ 70 _ 255/3 _ 85) is 85.
A, B, and C are incorrect.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness management
710. A 24-year-old post partum client is transferred to the
ICU after developing disseminated intravascular coagulation
(DIC). The nurse develops a care plan in collaboration
with the physician knowing that the care of a
client with a bleeding(clotting disorder usually includes:
A. Monitoring core body temperature
B. Initiating heparin therapy
C. Administering blood
D. Restricting dairy products in the diet
The answer is B. Heparin is given because the abnormal clotting
that occurs with DIC uses up available clotting factor. Heparin
inhibits clotting and therefore allows clotting factor to be
replenished. Monitoring core body temperature is not a priority
with DIC. Blood is not administered because the problem is
clotting, not bleeding. Dairy products are unrelated to DIC.
1240 PART III: Taking the Test
HEALTH PROMOTION AND
MAINTENANCE
Aging Process
711. Which finding when reviewing the record of an elderly
client would the nurse interpret as a normal occurrence
with aging?
A. Very concentrated urine
B. Microscopic hematuria
C. Occasional urinary incontinence
D. Decreased glomerular filtration rate
The answer is D. Changes in the renal tubules cause a dramatic
decrease in the glomerular filtration rate. Hematuria,
either microscopic or gross, is always abnormal. Incontinence
is also abnormal.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness management
712. After diagnosis of diverticulitis, a client has been
taught about the appropriate dietary changes. Which
statements by the client indicate that teaching was successful?
A. “I will eat a low-fiber diet.”
B. “Milk will increase my episodes of diverticulitis.”
C. “Whole grains are better for me than refined
grains.”
D. “Starches, fruits and vegetables will increase my flatus
and diarrhea.”
The answers are B and C. A diet to prevent constipation is recommended.
Milk can be constipating so it can contribute to
increase episodes of diverticulitis. Whole grains are better
than refined grains because they provide more fiber. Option
A is incorrect because a high fiber not a low fiber diet is
needed to prevent constipation. Starches, fruits and vegetables
are good sources of fiber so they decrease not increase
symptoms.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complications of Diagnostic Tests/
Treatments/Procedures
713. A 20-year-old male suffered a broken jaw in an automobile
accident. The jaw has been wired shut. The
nurse will ensure that which of the following equipment
will be available at the client’s bedside for
safety?
A. Call light
B. Wire cutters
C. Clear liquids
D. Paper and pencil
The answer is B. If the client should vomit, he could choke
and aspirate. Wire cutters would need to be immediately
available. The call light is appropriate for all clients. Clear
liquids would not be a safety feature. Paper and pencil may
aid communication but are not emergency supplies.
PSYCHOSOCIAL INTEGRITY
Chemical and Other Dependencies
Provide symptom management for clients experiencing
withdrawal or toxicity
714. When planning care for a client withdrawing from
cocaine, which is a critical nursing intervention?
A. Monitor for seizures
B. Protect from self harm
C. Orient to time and place
D. Monitor for hypotension
The answer is D. Protect from self harm. The client withdrawing
from cocaine or another central nervous stimulant
experiences severe dysphoria, anxiety, disturbed sleep and is
at significant risk for suicide. Hence a priority nursing intervention
is to prevent self harm. Seizures and confusion can
occur with withdrawal from alcohol, sedatives/hypnotics,
and anxiolytic drugs. Hypertension, not hypotension is a
risk with cocaine withdrawal.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical emergencies
715. A client is brought into the emergency department
complaining of severe back pain. He is diaphoretic,
pale, tachycardic, and has absent pedal pulses. Which
is the immediate nursing intervention?
A. Start an IV with a 16 gauge catheter
B. Get a stat back x-ray
C. Prepare the client for insertion of hemodynamic
monitoring
D. Get a 12 lead ECG
The answer is A. The client is showing signs of shock and
needs immediate vascular access. The other interventions
could be done later.
CHAPTER 34 Practice Test for NCLEX-RN® 1241
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
716. A 2-week-old infant has returned from surgery for
repair of a unilateral cleft lip. The nurse instructs the
mother to comfort the baby when the baby becomes
upset and starts to cry. The mother asks why it is
important that the baby not cry. The nurse’s response
would be based on the knowledge that crying:
A. puts strain on the suture line.
B. may prevent the infant from developing trust.
C. causes the infant to swallow air and may cause
vomiting.
D. simulates coughing in the post operative infant.
The answer is A. A crying infant will open the mouth wide putting
strain on the sutures in the upper lip. Although meeting
the infant’s needs in a timely fashion is important in the development
of trust, it is not the correct response in this situation.
Crying does cause the infant to swallow air, but that is not the
primary reason for comforting the child. Crying stimulates
coughing but is not appropriate for this child.
PSYCHOSOCIAL INTEGRITY
Coping Mechanisms
717. A 15-year-old boy was admitted to the pediatric unit
following an injury to his leg. When told that the complicated
fracture would require surgical repair and prevent
a return to the football team for an unknown
extended period of time, the boy throws an apple from
the lunch tray at the nurse. Which type of coping
behavior is the teenager exhibiting?
A. Reaction formation
B. Projection
C. Denial
D. Displacement
The answer is D. Displacement is shifting focus from an undesired
object or feeling to a more acceptable object or feeling.
Reaction formation is acting opposite to how one feels.
Projection occurs when one attributes ones own unacceptable
feelings to another. In denial one ignores unacceptable realities.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Diagnostic tests
718. A client is suspected of having osteoporosis. Which test
will provide the best information regarding this problem?
A. Serum calcium
B. X-ray of pelvis
C. CT scan of spine
D. DEXA scan
The answer is D. Dual energy x-ray absorptiometry
(DEXA) measures bone mineral density. It allows detection
of early osteoporotic changes in the wrist, spine
and/or hip. It is the best diagnostic tool available for
osteoporosis. There are no laboratory tests that definitively
diagnose primary osteoporosis. Serum calcium is
one of a battery of laboratory tests used to rule out secondary
osteoporosis or other metabolic disease. X-rays
and CT scans do not provide an accurate picture of the
mineral content in bone that denotes bone density and do
not detect early bone changes.
HEALTH PROMOTION AND
MAINTENANCE
Aging Process
719. Which assessment finding on a 78-year-old woman
most likely reflects age-related decreased blood vessel
elasticity and increased peripheral resistance?
A. An irregular peripheral pulse
B. An increase in blood pressure
C. Night time confusion
D. Wide QRS complexes on the ECG
The answer is B. Thickening of the blood vessels and less distensible
arteries and veins cause impeded blood flow and
increased vascular resistance, leading to hypertension.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication administration
720. The nurse is pushing IV medications during a “code
blue.” Which is a critical step in the procedure?
A. Check the orders with the chart
B. Inspect the IV site for infiltration
C. Evaluate the peripheral pulses
D. Flush the line with dextrose between drugs
The answer is B. Inspecting the IV site for infiltration is critical
because medication will not be effective if administered
into the tissue rather than the blood stream. Orders are usually
verbal during a code situation. Pulses are generally
absent if in a code blue situation. Lines should be flushed
with sodium chloride.
1242 PART III: Taking the Test
PSYCHOSOCIAL INTEGRITY
Therapeutic Communications
Develop and maintain therapeutic relationships with
client/family/significant others
721. Which is an appropriate guideline for the nurse to utilize
when communicating with an adolescent?
A. Reassure that what he or she is going through is
understood.
B. Invite the parents to be present when talking with
the adolescent.
C. Ask meaning of expressions if not clearly understood
as a result of teen culture.
D. Share with the parents information received in their
absence.
The answer is C. Understanding the meaning of the adolescent’s
expression will aid in understanding the communication
and display interest in the adolescent’s point of view.
A is incorrect as this statement will discourage further
comments. B is incorrect as the adolescent may not be willing
to talk in front of his parents. The child will feel betrayed
if the nurse reports the conversation to the parents.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Laboratory values
722. A child is admitted to the hospital unit with a diagnosis
of pyloric stenosis, On admission, the nurse would
expect to see which electrolyte imbalance?
A. Hypokalemia
B. Hypernatremia
C. Hyperchloremia
D. Hypomagnesemia
The answer is A. Potassium is lost by vomiting. All other
responses are incorrect.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Expected effects/outcomes
723. A client is being treated for Gastroesophageal Reflux
Disease (GERD). When the nurse administers famotidine
(Pepcid) to the client, the client asks how this
medication will help. The nurse’s reply will be based
on the knowledge that the medication will:
A. Decrease gastric acidity reducing irritation to the
esophagus.
B. Relax the lower esophageal sphincter (LES) preventing
further reflux.
C. Increase intraabdominal pressure to maintain positive
pressure in the esophagus.
D. Decrease the intra-gastric pressure putting less
strain on the lower esophageal sphincter (LES).
The answer is A. Symptoms of the disease are due to the regurgitation
of stomach acids into the esophagus. By reducing the
acidity of stomach contents, symptoms will be reduced.
The other responses are incorrect. The activity described
in B and C would increase the symptoms.
HEALTH PROMOTION AND
MAINTENANCE
Disease Prevention
724. Working on a geriatric unit, the nurse knows that the
bed bound hospitalized older adult is at risk for pressure
ulcers. Which factors seen in the unit’s clients
would increase the risk for pressure ulcers?
A. Diminished sensory perception
B. Dry fragile skin
C. Decreased mobility
D. Indwelling urinary catheter
E. Decreased appetite since hospitalization
F. Nursing assessment every shift
The answers are A, B, C, and E. Dry fragile skin increases the
risk for skin breakdown. Diminished sensory perception
diminishes the amount of normal shifting and movement, not
allowing for the relief of pressure, increasing the risk for skin
breakdown. This is true with decreased mobility as well.
Incontinence, not an indwelling catheter would increase the
risk of pressure ulcers. Nursing assessment and interventions
including a turning and positioning schedule, bed
bath and massage, ROM exercises, and providing appetizing
nutritious foods with adequate protein that the client likes,
is key to the prevention of pressure ulcers.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body System
725. In preparing a discharge teaching plan for a client diagnosed
with thrombophlebitis and being treated with
warfarin, which instructions would the nurse include?
A. Eat a diet high in fiber and leafy green vegetables
B. Start a progressive exercise program
C. Drink at least eight glasses of fluid daily
D. Do not use oral contraceptives
CHAPTER 34 Practice Test for NCLEX-RN® 1243
The answers are B, C, and D. The instruction to eat a diet high
in leafy green vegetables would not be included because
green leafy vegetables contain vitamin K, which can affect
the needed dose of warfarin. All other instructions are
appropriate and would be included in discharge plan.
PSYCHOSOCIAL INTEGRITY
Psychopathology
Recognize signs of acute and chronic mental illness
726. The nurse would expect to encounter clients who are
attempting to avoid or minimize anxiety or fear when
working with a group diagnosed with which types of
personality disorder?
A. Paranoid, schizoid, schizotypal
B. Antisocial, borderline, histrionic, narcissistic
C. Avoidant, dependent, obsessive-compulsive
D. Passive-aggressive, masochistic
The answer is C. Clients with avoidant, dependent or
obsessive compulsive personality disorder are attempting
to avoid or minimize anxiety or fear. Withdrawal and
odd, eccentric behaviors are characteristic of clients with
paranoid, schizoid, and schizotypal personality disorder.
Attention seeking and erratic behaviors are characteristic of
clients with antisocial, borderline, histrionic and narcissistic
personality disorders. Clients with passive-aggressive or
masochistic personality disorder are covertly aggressive
against self or others.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
727. The nurse is caring for a client with Alzheimer’s disease
(AD), the most common form of dementia in older
adults. Which factors are associated with AD? Select all
that apply:
A. Acute onset
B. Impaired memory
C. Confusion
D. Difficulties with language
E. Reversible organic disorder
F. Amyloid plaques
The answers are B, C, D, and F. AD is a progressive, irreversible,
organic disorder, characterized by confusion, disorientation,
impaired memory and cognition. Personality
changes are seen, and in later stages eventual dependency
for all ADLs and IADLs. Amyloid plaques and neurofibrillary
tangles are found in the brains of AD clients.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Pharmacological agents/actions
728. A child has been admitted to the hospital unit for gastroenteritis.
The child has been having diarrhea for 3 days
and is moderately severely dehydrated. The stool cultures
indicate a rotovirus as the cause of the diarrhea. The
mother questions the nurse why her child isn’t on antibiotics
like the other children on the unit with GE. The
nurse’s response would be based on the knowledge that:
A. antibiotics will make the diarrhea worse.
B. the diarrhea has probably already run its course.
C. antibiotics are not used for rotovirus gastroenteritis.
D. the child is too dehydrated for antibiotics to be
effective.
The answer is C. Antibiotics are used to treat bacterial infections
not viral. Diarrhea is often a side effect of antibiotics but is not
the correct response here. The other responses are incorrect.
HEALTH PROMOTION AND
MAINTENANCE
Developmental Stages and Transitions
Recognize behaviors associated with psychosocial development
729. Which of the following behaviors indicates a 3 month
old infant is developing a sense of trust?
A. Eats and sleeps well
B. Makes cooing noises
C. Has developed object permanence
D. Clings to mother and cries when she is not present
The answer is A. A sense of trust indicates trust in the world
around them that basic needs will be met. Cooing noises
occur because a child can hear himself. Object permanence
is a component of Piaget’s theory and not related to trust versus
mistrust. Clinging to the mother occurs after object permanence
develops in a much older infant.
PSYCHOSOCIAL INTEGRITY
Therapeutic Communications
Develop and maintain therapeutic relationships with
client/family/significant others
730. A toddler is hospitalized for minor surgery. The parents
are unable to stay with the child. The child reacts
to the separation with a saddened expression, refusal
to eat and continues to cry for momma. How should
the nurse respond?
1244 PART III: Taking the Test
A. Encourage the child to forget mom and dad.
B. Hold the child and tell him mommy loves him and
will come back.
C. Ignore his cries as they do not represent physical
discomfort.
D. Avoid mentioning parents while holding and comforting
the child.
The answer is B. This is the despair phase of toddler hospitalization
reaction. The appropriate response is for the
nurse to provide physical comfort and reinforce that the
parents will return. The child’s psychological needs can not
be ignored. The child needs the parents for healthy development.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic procedures
731. After an infant has a barium enema reduction of
intussception, the nurse will know the reduction was
successful when the infant:
A. smiles at mother.
B. passes a solid stool.
C. falls asleep without medications.
D. takes his regular amount of formula.
The answer is B. In addition to pain, the symptoms of intussception
include passing a “currant jelly” stool followed by
intestinal obstruction. Passing a solid stool would indicate
the obstruction has cleared. The other responses do not
address the pathology.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
732. A 22-year-old man has accidentally ingested about
200 ml of a lye-based liquid drain cleaner. Which
treatment should the nurse be prepared to administer
when the client arrives at the emergency department?
A. A cathartic to promote elimination of the poisonous
substance
B. 30 ml of ipecac syrup followed by 240 ml of water
to induce vomiting
C. 150 ml of milk or water to dilute the ingested substance
D. 75 g of activated charcoal to absorb the ingested
chemical
The answer is C. The goal is to dilute the lye based product
because it is caustic and tissue burn can result from contact
with the agent. Diluting the product decreases the burn.
Vomiting is contraindicated because the caustic product
would come into contact with tissues of the esophagus,
throat and mouth a second time and do more damage.
Absorption of the chemical into the body is not the immediate
concern so activated charcoal is not used.
HEALTH PROMOTION AND
MAINTENANCE
Health and Wellness
733. A home health nurse sees many elderly clients and is
concerned about their nutritional status. The nurse
recognizes that the following factors contribute to the
risk of malnutrition in older adults:
A. Gastrointestinal changes including diminished
saliva, decreased gastric acid and digestive enzyme
secretions
B. Chronic illness
C. Poor dentition
D. Inadequate financial resources
E. Decline in functional ability
F. Moving to an Assisted Living Facility
The answers are A, B, C, D, and E. Poor dentition, GI
changes, and chronic illness result in inadequate intake,
poor ingestion and digestion of food. The older adult may
believe that limited resources will prevent them from purchasing
nutritional foods and eat junk food instead. The
nurse needs to educate regarding affordable nutritional
foods and work as case manager and arrange for food
stamps. Functional ability is the extent to which one is able
to perform Activities of Daily Living (ADLs) & Instrumental
Activities of Daily Living (IADLs). Decline in ADLs includes
the ability to prepare meals; a decline in IADLs includes the
ability to go food shopping. With functional limitations, the
nurse as case manager can arrange for meals on wheels.
Assisted living provides balanced meals that promotes good
nutrition.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Use the “six rights” when administering client medications
734. A dose of intravenous acyclovir should be administered
over what period of time? Record your answer as
a whole number of minutes in the space provided.
___________minutes
CHAPTER 34 Practice Test for NCLEX-RN® 1245
Answer is 60 minutes.
Acyclovir is nephrotoxic. It is excreted primarily by
glomerular filtration and tubular secretion. To decrease the
risk of nephrotoxicity, the client must be well hydrated; the
drug must be administered over a period of 60 minutes; and
urinary output must be measured for two hours after the
infusion. Output of less than 500 mL of urine per gram of
acyclovir must be reported immediately.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic Procedures
735. The nurse preparing a client for a cardiac catheterization
and revascularization should include which
information in the pre-op teaching.
A. The client will be asleep during the procedure
B. The client may experience a hot flash as the dye is
injected
C. There may be a sand bag placed over the cannulated
site following the procedure
D. The client will be on fluid restrictions until the gag
reflex returns
E. The client may experience chest pain when the balloon
is inflated
F. The client will experience a headache as the dye is
injected
The answers are B, C, and E. The client is generally awake
during the procedure and fluid intake is encouraged in order
to assist the kidneys with excretion of the dye. Generally a
client may experience a metallic taste in the mouth or a hot
flash when the dye is injected.
PSYCHOSOCIAL INTEGRITY
Coping Mechanisms
Assess client response to illness
736. An 8-year-old child is hospitalized and undergoing
diagnostic testing. Her parents can spend very little
time with her because of the demands of work and
four younger children at home. Nonetheless the child
appears calm, does not complain, and seems unperturbed
by all the stress. How would the nurse interpret
this behavior?
A. The child is mature for her age and is dealing well
with hospitalization.
B. A child of this age is not invested in health or family
matters; peers are the concern and she will be
receiving a lot of attention from them.
C. The child is employing reaction formation which is
a primary defense mechanism for her age.
D. The child is coping by regressing.
The answer is C. The primary defense mechanism at this stage
is reaction formation, which is acting brave, when really being
quite frightened.
A, B, and D are incorrect—The child is interested in
peers, but the rest of the comments are not true. Regression is
seen in younger children and the symptoms of this child are
not those of regression but are typical in reaction formation.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse effects/contraindications
737. The client is receiving Heparin IV at 1200 units/hour
as part of the treatment regime for pulmonary embolism.
The nurse notes that the urine has become bright red
in color. The nurse would prepare to administer which
of the following medications?
A. Protamine Sulfate
B. Aquamephyton (vitamin K)
C. Warfarin (Coumadin)
D. Acetylcysteine (Mucomyst)
The answer is A. The antidote for Heparin is protamine sulfate.
Bright red urine suggests hematuria which is a potential
adverse effect of anticoagulation. Aquamephyton is the antidote
for Coumadin overdose and Acetylcysteine is the antidote
for acetaminophen poisoning.
HEALTH PROMOTION AND
MAINTENANCE
Developmental Stages and Transitions
Incorporate knowledge of theories of development in
planning care for the client
738. A chronically ill adolescent has been hospitalized frequently
for extended periods of time. Because of the
severity of the illness and as a result of the hospitalization,
the adolescent has been unable to develop a sense of
who he is or what he will become. According to Erikson,
these deficiencies will result in which of the following:
A. role diffusion
B. inferiority
C. isolation
D. stagnation
The answer is A. The adolescent is working on developing a
sense of identity. Other answers are for other stages.
1246 PART III: Taking the Test
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse effects/contraindications and side effects
739. A client who is in the Cardiac Care Unit complains of
mediastinal chest pain, dyspnea, and anxiety. The
nurse gives the client a nitroglycerine tablet sublingual.
The client now complains of being dizzy. Which
is the priority nursing intervention?
A. Get a 12 lead ECG
B. Raise the side rails on the bed
C. Open the D5W IV to 100 cc per hour
D. Take vital signs including pulse oximetry
The answer is B. Safety is the priority.
C would not be correct because it is not an isotonic solution
and would not help to maintain circulating volume. A would be
done but would not be the priority. D is not the priority.
HEALTH PROMOTION AND
MAINTENANCE
Aging Process
740. Which of the following would the nurse identify as normative
signs of aging, as opposed to pathologic signs?
A. Increase in diastolic blood pressure
B. Decrease in glomerular filtration rate
C. Reduced lens elasticity
D. Reduced vital capacity
E. Dulled sense of taste
F. Pressure ulcers
The answers are B, C, D, and E. A mild increase in systolic BP
is expected, however an increase in diastolic BP is pathological.
Normative changes in renal tubules cause a dramatic
decrease in glomerular filtration rate. There is a normal
decrease in lens elasticity. A normative decrease in chest wall
compliance and atrophy of respiratory muscles contributes to
reduced vital capacity. There is a normative dulled sense of
taste, touch, and pain. Pressure ulcers are a pathological sign.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
741. Which is an indication of a successful outcome for a
client who is recovering from an abdominal aortic
aneurysm repair?
A. Capillary refill of the toes _5 seconds
B. Pulse Oximetry of the foot _ 88%
C. BP diastolic _ 80 mm Hg.
D. Urine output _ 15 cc per hour
The answer is C. Diastolic blood pressure of 80 mm Hg.. High
BP puts pressure on the surgical site. Capillary refill should
be _3 seconds. Pulse oximetry should be _95%. Urine output
should be _30 cc per hour.
PSYCHOSOCIAL INTEGRITY
Behavioral Interventions
Assist client with achieving and maintaining self-control
of behavior
742. Which statement made by the parent of a suicidal
client indicates the need for further explanation
about a “no suicide” contract?
A. The contract provides a boundary.
B. The contract gives the client responsibility for control.
C. These contract serve to reinforce to the client that
life is valuable.
D. Verbal as well as written contracts have been shown
to be effective.
The answer is C. No suicide contracts do not directly reinforce
that life is valuable. Therefore this is an incorrect statement
and indicates that the parent needs further explanation.
All other statements about a no suicide contract are correct.
A “no suicide” contract is a way of providing boundaries.
Contracts help place control in the domian of the client. Both
verbal and written “no suicide” contracts have proven effective.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
743. Which symptoms identified during the assessment of a
4-week-old male infant are consistent with the diagnosis
of pyloric stenosis?
A. Metabolic alkalosis
B. Lack of interest in feeding
C. Vomiting bile stained fluid.
D. 2 ounce weight loss over last 3 days.
E. Peristalsis observed over the abdomen.
The answers are A, D, and E. Metabolic alkalosis, weight loss,
and visible peristalsis are signs of pyloric obstruction.
Metabolic alkalosis and weight loss result from vomiting that
occurs with pyloric stenosis. A and D are related to the vomiting
that occurs. Peristalsis may be visible on the abdomen as
the stomach tries to push formula past the obstruction. The
infant will be hungry, vomiting will not be bile stained.
CHAPTER 34 Practice Test for NCLEX-RN® 1247
HEALTH PROMOTION AND
MAINTENANCE
Aging Process
744. When doing an intake assessment on the older adult,
which factor should the nurse consider?
The older adult
A. responds with increased emotion to questions
related to family history.
B. often has diminished auditory acuity and may
impede communication.
C. is uncomfortable with the physical assessment
because of multiple physical changes.
D. has an increased response to pain requiring extreme
caution with the physical assessment.
The answer is B. Diminished auditory acuity is common and
communication is affected. Response to pain is decreased.
Other responses are incorrect.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Nutrition and oral hydration
745. A two week old infant has had several periods of apnea.
After work-up, the physician diagnoses the infant with
GERD and instructs the nurse to teach the mother feeding
techniques to diminish reflux. The nurse will teach
the mother to:
A. avoid burping the baby to discourage reflux.
B. keep the infant in an upright position after feeding.
C. rock the baby during the feeding to keep him calm.
D. place the baby prone after feeding to prevent aspiration
if reflux occurs.
The answer is B. Upright position uses gravity to assist in formula
retention. Burping would be more frequent in the
GERD infant. Rocking will mix air with the formula making
vomiting more likely. Prone position would put pressure on
the abdomen and may increase vomiting.
HEALTH PROMOTION AND
MAINTENANCE
Aging Process
746. The nurse knows the older adult has an increased risk
for drug toxicity. Which of the following contributing
factors increase the risk for drug toxicity?
A. Impaired renal function
B. Decrease in blood flow to the kidneys
C. Polypharmacy
D. Urinary incontinence
E. Possibility of multiple chronic conditions requiring
medications
F. Using many physicians and lack of communication
between physicians
The answers are A, B, C, E, and F. The decline in renal function
in the older adult results in inefficient excretion of active
drug, allowing toxic levels of drug to accumulate, placing
the older adult at risk for drug toxicity. Polypharmacy is the
concurrent use of many drugs, which is common in older
adults as a result of: increased number of chronic conditions,
using many physicians, changing physicians frequently,
using more than one pharmacy, lack of information about
over the counter medications, and assumption that once a
drug is started it must be finished.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Instruct client on medication self-administration procedures
747. Which information/instruction would the nurse include
when teaching the mother of child diagnosed with ADD
about the proper use of the prescribed stimulant medication?
A. Take the medication before a meal.
B. If a dose is missed, take it as soon as remembered.
C. Expect heavy sweating and heat intolerance as side
effects of the medication.
D. Follow up visits for lab tests or other monitoring are
needed.
The answer is D. Follow up visits are critical so that the effects
of the prescribed medication can be monitored. Monitoring
may include laboratory studies, vital sign checks or EKGs.
Stimulant medications should be taken after eating to avoid
problems with appetite or indigestion. If a dose is missed, it
is not “made up”, the next dose is simply taken as scheduled.
Side effects of stimulant medications are anorexia, nausea and
vomiting, insomnia, tachycardia and chest pain, headache, and
irritability, nervousness or confusion.
PSYCHOSOCIAL INTEGRITY
Behavioral Interventions
Assess client appearance, mood, and psychomotor behavior
and identify/respond to inappropriate/abnormal behavior
748. An elderly client in an extended care facility hollers
from her bed “Nurse, help me. They are throwing
1248 PART III: Taking the Test
dishes at me.” Which is the best response on the part
of the nurse?
A. “What kind of dishes is someone throwing at
you?”
B. “Have a drink of water and by then it will be
over.”
C. “I don’t see anyone throwing dishes but it must
be scary for you; you are safe here.”
D. “Why do you think anyone would want to throw
dishes at you? You have never hurt anyone have
you?
The answer is C. This response is empathetic; acknowledges
the client’s feeling; and offers reassurance. Responses A and
D encourage the client to get more involved and add detail
to the delusion and this is not therapeutic. Response B
makes light of the client’s experience and has an element of
false reassurance.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications of diagnostic tests/treatments/
procedures
749. A client has just had an arthroscopy of the right knee
for diagnostic evaluation of chronic knee pain. Which
assessment finding has the highest priority for being
reported to the surgeon?
A. Report of pain is 7 out of 10 on pain scale
B. Strength of right pedal pulse is decreased.
C. Capillary refill time is 3 seconds..
D. Pain is unrelieved by application of ice.
The answer is B. The decrease in pedal pulse could be indicative
of obstruction to arterial flow to the foot.
A, C, and D are not correct because pain immediately
following the arthroscopy is expected. Capillary refill time of
three seconds is normal and indicates good blood flow
through the capillaries. In older individuals, up to 5 seconds
is considered normal.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
750. A 35-year old man is brought to the emergency department
by EMS personnel after he was found sitting in
the car in an enclosed garage with the motor running.
He is unresponsive and hypotensive, and his skin is
bright red. Which intervention would have the greatest
priority?
A. Administration of oxygen
B. Placing the client in a prone position.
C. Administration of Narcan
D. Initiating CPR.
The answer is A. Being found in an enclosed space in a car
with its motor running with symptoms of bright red skin
and unresponsiveness is indicative of carbon monoxide poisoning.
The immediate intervention is to remove the client
from exposure to carbon monoxide and administer oxygen.
Oxygenation is always the first priority. Placing the client in
a prone position is inappropriate. Narcan is an opiate antagonist;
it is not used in the treatment of carbon monoxide poisoning.
The client does not need CPR because his heart is
beating if he is hypotensive.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Unexpected response to therapies
751. The nurse is performing post operative assessments on
a client who has had a femoral artery revascularization.
Which is the most critical finding?
A. A quarter sized area of bright red drainage on the
dressing
B. An apical pulse of 100 beats per minute
C. Complaint of numbness of the toes on the operative leg
D. An ankle-brachial index (ABI) of 1.0
The answer is C. Numbness is a symptom of arterial occlusion
therefore it is the most critical finding as it can result in
death of tissue. A quarter size area of bright red drainage on
the dressing is not immediately critical; the nurse would circle
the area and observe for continued bleeding. The apical
pulse of 9 and the ABI pf 1.0 are both within normal range.
PSYCHOSOCIAL INTEGRITY
Abuse/Neglect
752. The home care nurse is providing an in-service on
elder abuse to the home health aides that will be going
out in the field. Which should be identified as potential
signs of abuse? (Select all that apply.)
A. Bruises in various stages of healing
B. Malnutrition and dehydration
C. Poor personal hygiene, disheveled unkempt
appearance
D. Burns and broken bones
The answers are A, B, C, and D. All responses are possible
signs of abuse.
CHAPTER 34 Practice Test for NCLEX-RN® 1249
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
753. A nurse is a guest on a health related radio show. A listener
calls in and asks what is the most common symptom
of esophageal cancer. Which is the correct reply?
A. Projectile vomiting.
B. Progressive indigestion.
C. Progressive dysphagia.
D. Hoarseness progressing to loss of voice.
The answer is C. Progressive dysphagia is the most common
symptom of esophageal cancer. It is insidious in onset and
often the client simply eliminates foods from the diet which
are difficult to swallow and so remains unaware of the problem
until suddenly realizing that only liquids can be swallowed.
Projectile vomiting is associated with increased intracranial
pressure, not with cancer. Progressive indigestion is associated
with GERD and hiatal hernia. Hoarseness and ultimately
voice loss is associated with laryngeal cancer.
HEALTH PROMOTION AND
MAINTENANCE
High Risk Behaviors
754. When teaching about accidental injury to adolescents,
what does the nurse identify as the most common
cause of injury?
Answer: Motor vehicle accidents.
The adolescent is prone to Motor Vehicle Accidents due
to reckless driving and speeding to show off, driving under
the influence of drugs or alcohol (doing drugs and alcohol to
be part of the gang), and failure to use seatbelts because it
isn’t ‘cool’.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Laboratory values
755. The nurse is reviewing laboratory findings for a
client who has Congestive Heart Failure. Which laboratory
value should be reported to the physician
immediately?
A. Cholesterol level of 240 mg/dl
B. Digoxin level of 2.5ng/ml
C. Troponin 1 level of 0.30 ng/ml
D. Triglyceride level of 160 md/dl
The answer is B. Normal digoxin level is 2ng/ml and 2.5
ng/ml is a toxic level. Cholesterol level is slightly high but
not critical. Troponin 1 level is normal. Triglyceride level is
borderline high but not critical.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Home safety
756. The home care nurse is concerned with reducing the
risk of falling for an 86-year-old client. Which statement
represents the most appropriate approach to the
problem?
A. “I understand that you are concerned about
finances, however adequate non glare lighting is
very important to keep you safe. Can I speak to
your son about trying the new florescent bulbs that
are much less expensive to use.”
B. “This house is not safe, it has years of accumulated
clutter. Why don’t you consider selling the house
and move to a nursing home, where you will be safe
and well fed.”
C. “The old rug in the dining room under the table will
have to go, it’s worn out anyway.”
D. “Never leave your room, when you are home alone,
sit in the lounge chair or stay in bed, I’ll set up a bed
side commode for you.”
The answer is A. When reading questions on communication
listen to the tone of the response, abrupt, impolite, overly
paternalistic responses can be eliminated. Responses with
absolute terms such as all or never can be eliminated. Option
A offers not only information needed but helps discover
options within the client’s means.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
757. A nurse is speaking to a community group on the early
detection of cancer. A member of the audience asks
what is a symptom of cancer of the larynx. Which is
the correct response for the nurse to give?
A. Projectile vomiting.
B. Progressive indigestion.
C. Progressive dysphagia.
D. Hoarseness progressing to loss of voice.
The answer is D. Hoarseness and ultimately voice loss is associated
with laryngeal cancer.
1250 PART III: Taking the Test
Projectile vomiting is associated with increased intracranial
pressure, not with cancer. Progressive indigestion is
associated with GERD and hiatal hernia. Progressive dysphagia
is the most common symptom of esophageal cancer.
HEALTH PROMOTION AND
MAINTENANCE
Health Screening
Perform targeted screening examination
758. The nurse is performing health screening at the local
junior high school for scoliosis. Which test should the
nurse perform?
A. Ask the child to stand on one foot to see if the pelvis
shifts down.
B. Have the child bend at the waist to see if there is a
difference between the sides.
C. Have the child twist at the waist from side to side to
see if there is pain with the motion.
D. Ask the child to stretch toward the ceiling first with
the left, then with the right side to see if one hand
reaches higher.
The answer is B. This test is called the Adam’s Forward Bend
Test. Children with scoliosis will have a prominence on one
side or the other. The other responses are not tests for scoliosis.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic Procedures
759. A registered nurse and an LPN are working as a team
to provide care for a group of clients. Which action by
the LPN requires the RN to intervene?
A. The LPN raises the knee gatch on the bed of a client
who has an intraaortic balloon pump in order to
relieve pressure on the client’s back.
B. The LPN prepares to administer Lasix (furosimide)
to a client whose potassium level is 4.2 mEq/L
C. The LPN returns a client to bed after the client’s
heart rate increases from 72 to 96 beats per minute
while ambulating in the hall
D. The LPN brings breakfast to a client who is scheduled
for an echocardiogram later in the morning.
The answer is A. The knee gatch should not be raised because
it could cause the balloon catheter to be kinked off. All other
actions are appropriate and do not require corrective intervention
by the RN.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
760. Which disorder places the client at risk for tissue necrosis
and breakdown of bone structure with decalcification?
A. Osteoarthritis
B. Osteomyelitis
C. Osteoporosis
D. Osteogenesis
The answer is B.
A is incorrect—osteoarthritis or degenerative joint disease.
C is incorrect—osteoporosis is a loss of bone density. D is incorrect—
osteogenesis refers to the formation of bone in the body.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
761. A 5-year-old child has just returned from a tonsillectomy.
The child’s mother is at the bedside and caring
for her child. Which observation made by the nurse
while taking vital signs, requires nursing intervention?
A. The child is lying supine.
B. An ice collar is lying on the child’s neck.
C. The mother is offering the child ice chips from a
spoon.
D. The child is drooling and the mother is wiping the
child’s mouth with a wash rag.
The answer is A. The child should not be in a supine position
because of the risk of aspirating blood if the surgical wound
should ooze. Nursing intervention is required to reposition the
child in a side lying position and to explain to the mother the
importance of maintaining the child in this position. None of
the other options indicate the need for nursing intervention.
HEALTH PROMOTION AND
MAINTENANCE
Aging Process
762. Many body systems manifest deteriorative changes to a
greater or lesser degree with aging. The expected, normal
signs of aging are called —— changes.
Answer: Primary.
Primary changes are the expected normal changes associated
with aging. An example of a primary change is
CHAPTER 34 Practice Test for NCLEX-RN® 1251
decreased elasticity of the skin. Pathological or disease
related changes are referred to as secondary changes.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse effects/contraindications
763. A client has rheumatoid arthritis and is receiving
hydroxychloroquine (Plaquenil). Which instruction
should be given to the client prior to discharge home?
A. Take this medication on an empty stomach.
B. Expect your urine to be greenish-yellow in color
while taking this medication.
C. Report a weight gain of more than 5 lbs. to your
physician.
D. Notify your physician if you experience any
changes in vision.
The answer is D. because hydroxychloroquine can produce over
time changes in vision due to ocular toxicity or retinopathy.
These manifest as episodes of misty or foggy vision, “disappearing
words” when reading, light flashes before the eyes, or
seeing only half of the visual field. Hydroxychloroquine can be
taken with meals to minimize gastrointestinal side effects.
Hydroxychloroquine may discolor urine red or brown not
green. Weight gain is not related to use of hydroxychloroquine.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Diagnostic tests
764. The CCU nurse notices that a client’s T wave has
become inverted. Which is the priority nursing intervention?
A. Give the client nitroglycerine sublingual, 1 tablet every
5 minutes three times
B. Start oxygen at 2–4 liters per minute via nasal cannula
C. Check for T wave elevation in the V1 lead
D. Check the client and verify lead placement
The answer is D. The leads may have gotten moved. It is priority
to always check your client to verify that monitoring
data is correct.
HEALTH PROMOTION AND
MAINTENANCE
Health Screening
765. You are assessing an infant brought to the pediatric
clinic. Which assessment finding would indicate that
follow up is needed because of possible developmental
dysplasia of the hip?
A. Outward turning of both legs
B. Limited range of motion in the hip joint
C. Crying and other signs of pain on flexing the hips
D. Asymmetrical thigh and buttock skin creases
The answer is D. Asymmetrical thigh and buttock skin creases
are an obvious sign of developmental dysplasia of the hip.
A is incorrect—there is no outward turning of the legs. B
is incorrect—there is no limited range of motion in the hip. C
is incorrect—developmental hip dysplasia is not painful.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
Identify client status based upon pathophysiology
766. Which interpretation should the nurse assign to
assessment findings of delayed capillary refill, cyanosis
and clubbing?
A. Arterial oxygen levels are chronically low.
B. Carbon dioxide levels in the blood are elevated.
C. Compensatory polycythemia has developed.
D. Vital capacity has progressively decreased over time.
The answer is A. Delayed capillary refill, cyanosis and clubbing
are signs of chronically decreased arterial oxygen levels.
Elevated carbon dioxide levels (hypercarbia) is not always
associated with hypoxemia and does not cause these signs.
Polycythemia is an increase in red blood cells which does occur
as a compensatory effort in clients with chronic hypoxemia; it
does not cause the signs. Changes in vital capacity which is the
amount of gas that can be expired after a maximum inspiration
do not cause delayed capillary refill, cyanosis or clubbing.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
767. On assessing a client who has had coronary artery
bypass grafting the nurse finds: T 100.2_F; pulse 110
beats per minute; BP 96/60 mm Hg; Respirations 20
per minute; distended neck veins; muffled heart sounds.
Based on this assessment data, which is the priority
nursing action?
A. Increase frequency of client monitoring.
B. Ask the client about pain.
C. Report findings immediately to the physician
D. Call the lab to draw blood cultures
1252 PART III: Taking the Test
The answer is C. The client is displaying signs and symptoms
of cardiac tamponade which is a medical emergency.
Increased monitoring will occur but calling the physician is
the priority. Pain may cause tachycardia but it wouldn’t
cause JVD. Lab cultures are usually not done until the temperature
is 102_F or above.
PSYCHOSOCIAL INTEGRITY
Chemical and Other Dependencies
768. A client in a methadone program, is admitted with a
broken pelvis following an automobile accident.
Which fact should be considered when planning care
for this client?
A. The client is likely to be euphoric at intervals.
B. Methadone should continue to be given while the
client is in the hospital.
C. The client will not need pain medication if he is
receiving methadone.
D. If methadone is stopped, delusions or hallucinations
may ensue.
The answer is B. Methadone maintenance should be continued
while the client is in the hospital if at all possible.
Methadone does not cause euphoria so if it is continued,
the client will not have intervals of euphoria. Methadone
does not adequately relieve acute pain so it will not eliminate
the need for pain medication; it can be used with success
in the management of chronic pain. Delusions and
hallucinations are not symptoms of withdrawal from
methadone and other opiates; delusions and hallucinations
are associated with withdrawal from alcohol, sedatives/
hypnotics, and anxiolytics.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse effects/contraindications
769. Which is the most common side effect of salicylates
and NSAIDs used in the management of the
pain and swelling associated with rheumatoid
arthritis?
A. Anorexia
B. Dizziness
C. Gastrointestinal distress
D. Weight loss
The answer is C. Long term use can result in irritation of the
stomach lining.
Answers A, B, and D are incorrect because they are side
effects for different classes of medication.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
770. The nurse is providing discharge instructions for a
client who has been diagnosed with stable angina and
has a prescription for nitroglycerine sublingual tablets.
Which statement by the client indicates that further
teaching is needed?
A. “I should keep my pills in the original container.”
B. “I need to replace my pills every month.”
C. “I should go to the hospital if the pain is not
relieved after taking a nitroglycerine.”
D. “I should stop all activity and rest when having
chest pain.”
The answer is B. Pills should be replaced every 3–6 months.
A, C, and D are all correct.
HEALTH PROMOTION AND
MAINTENANCE
Developmental Stages and Transitions
771. According to Piaget’s theory of cognitive development
which of the following cognitive developmental skills
are mastered between the ages of 7 and 11 (school-age
years)?
A. Concrete thought
B. Conservation
C. Complex classification
D. Abstract thinking
E. Sees another’s point of view
The answers are A, B, C, and E. The stage of concrete operations
is between 7 and 11 years of age. Thought becomes
logical, concrete, and based on tasks in the here and now.
The school-age child masters conservation and complex
classification and is also starting to understand that other’s
have a different point of view form their own. Abstract
thinking and reflecting on theoretical matters begins in the
preadolescent years.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
772. The nurse on the hospital unit receives a call from
admitting stating a client with a question of an intestinal
obstruction is being admitted. In preparing for
CHAPTER 34 Practice Test for NCLEX-RN® 1253
the arrival of the client, the nurse will gather equipment
for:
A. Gastric lavage
B. Morphine drip
C. Gastric decompression
D. Soap suds enema
The answer is C. The client will be NPO in preparation for
surgery and a NG tube will be inserted for gastric decompression.
There is no reason to lavage the stomach.
Morphine and other opioids are generally withheld until
after the diagnosis is established. Soap suds enema are contraindicated.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Establishing priorities
773. Which client being treated in the emergency room
requires the most immediate intervention?
A. A client whose initial assessment disclosed elevated
T waves and a serum potassium level of 6.1.
B. A client whose x-ray showed a fractured radius.
C. A client with a stab wound to the thigh covered
with a bloody gauze pad.
D. A woman who is 30 weeks pregnant with abdominal
pain.
The answer is A. An elevated T wave is suggestive of a cardiac
problem and the potassium is dangerously elevated. Thus
this client is in a potentially life threatening situation and
requires rapid intervention. All of the other clients are in
need of treatment for significant problems but none are in
immediate danger.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-specific assessment
774. Which assessment findings would the nurse expect
when examining a client with chronic low arterial oxygen
levels? Mark all that apply.
A. ___ cyanosis
B. ___ skin tenting
C. ___ positive Cullen’s sign
D. ___ delayed capillary refill
E. ___ clubbing
F. ___ muffled heart sounds
The answers are A, D, and E. Delayed capillary refill, cyanosis
and clubbing are signs of chronically decreased arterial oxygen
levels. Skin tenting is an indicator of dehydration. A
positive Cullen’s sign is bluish discoloration around the
umbilicus and is indicative of bleeding into the peritoneal
cavity. Muffled heart sounds are not a sign of chronic low
arterial oxygen levels.
HEALTH PROMOTION AND
MAINTENANCE
Ante-/Intra-/Postpartum and Newborn Care
775. The nurse is doing the neurologic assessment of the
newborn infant. Which would be normal findings?
A. ___ Sucking in response to touching infant’s lips;
strong and coordinated
B. ___ Blinking in response to light or touch
C. ___ Gag in response to stimulation of the posterior
pharynx by food or tube
D. ___ Asymmetrical sporadic movement of the
extremities
E. ___ Extremities extended when prone
F. ___ Minimal head lag when pulled to a sitting position
The answers are A, B, and C. Sucking, blinking, and gag
reflexes are present at birth. Sucking reflex disappears at 3–4
months, blinking and gag reflexes persist for life.
Movements are symmetrical, sporadic and involve all
extremities. Extremities are flexed and knees are flexed
under abdomen in the newborn. The neonate has minimal
head control therefore there is significant head lag when
pulled to a sitting position.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Fluid and electrolyte imbalance
776. A client has a CVP reading of 12mmHg. Which physical
assessment finding is consistent with this measurement?
A. Increased JVD
B. 1_ peripheral pulses
C. Tachycardia
D. Crackles in the lung bases
The answer is A. Increased JVD is an indication of volume
overload. Tachycardia, not bradycardia, is the physiologic
response to decreased cardiac output. Crackles in the lung
bases are indicative of pulmonary overload.
1254 PART III: Taking the Test
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for complications from surgical procedures and
health alterations
777. The nurse teaches new parents about nutrition for the
first year of life. What information does the nurse
include in her teaching plan?
A. Breast milk is a complete and healthful diet for first
6 months of life.
B. Commercially prepared fortified infant formula is a
good alternative if breast feeding is not desirable or
feasible.
C. No additional fluids are needed for first 4–6
months with breast or formula fed infant.
D. In the second 6 months skim or regular cow’s milk
may be used depending on infant’s weight pattern.
E. Solid foods are started with cereals at 2 months,
and then fruits, vegetables and meats are gradually
introduced over next 4 months.
F. Honey is not given for the first year because it is a
source of botulism.
The answers are A, B, C, and F. Breast feeding and fortified
commercially prepared infant formulas are the best and only
sources of nutrition appropriate for the first 6 months of life
and continue to be the primary source of nutrition in the
second six months of life as well. Cows’ milk, skim or regular,
and imitation milks are not acceptable during the first
year, as they are difficult to digest and lack the nutrients
needed for growth. Solid foods are generally introduced at 5
to 6 months starting with cereals and progressing and gradually
progressing to fruits, vegetables and meats. Honey is
not given in the first year as it is associated with botulism.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Medical Emergencies
778. While shopping the nurse observes a school age child
put something in his mouth and immediately begins
coughing. Which would be an appropriate initial action
for the nurse to take?
A. Ask the child if he is choking.
B. Place the child in reverse Trendelenburg position.
C. Perform the Heimlich maneuver.
D. Check pulse and respirations.
The answer is A. Asking for a response is a method of determining
if the airway is obstructed and immediate emergency
intervention is needed. If a person can speak the airway is
not obstructed. Reverse Trendelburg position in which the
client is supine with feet lower than the head would serve no
purpose. A Heimlich maneuver is performed if a foreign
body is occluding the upper airway. Checking pulse and respirations
serves no purpose in the immediate situation.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Fluid and electrolyte imbalance
779. A client has a CVP reading of 12mm Hg. Which physician
order for fluids would the nurse question?
A. 5% Dextrose and Normal Saline IV at 100 cc hr
B. Oral fluid restrictions of 1500 cc per 24 hours
C. Normal Saline at 20 cc hr.
D. Nitroglycerine IV drip at 5 mcg per minute
The answer is A. D5NS is a hypertonic IV solution and would
pull more fluid into the vascular system which is already
overloaded. Fluid restrictions would help decrease fluid
overload. Normal Saline at 20 cc/hr would only keep the
vein open and would not add to overload. Nitroglycerine
would cause vasodilation and decrease circulating volume.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Establishing priorities
780. The nurse has just received report on assigned clients.
Which client should the nurse see first?
A. A 23-year-old admitted two hours ago with a gunshot
wound; 3 cm area of dark drainage noted on
the dressing.
B. A 38-year-old with a collapsed lung due to an accident;
no drainage noted in the previous 3 hours.
C. A 47-year-old who had a stab wound to the
abdomen one day ago; client complains of chills
and fever.
D. A 34-year-old with a mastectomy two days ago; 15
cc of serosanguineous fluid noted in the Hemovac
drain. Complaining of pain in axilla.
The answer is C. Because the client is at risk for internal
bleeding, infection, or peritonitis. This client should be
assessed for further symptoms of infection.
The client in option A would not be first because there is
apparently no active bleeding as indicated by the small
amount of drainage on the dressing. The client in option B has
no more than the expected amount and color of drainage. The
client in option D has no unexpected signs or symptoms.
CHAPTER 34 Practice Test for NCLEX-RN® 1255
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
781. Which problem associated with Hirschsprung’s
Disease in a newborn is the most critical?
A. Respiratory distress.
B. Abdominal distention.
C. Vomits several feedings.
D. Failure to pass meconium by 48 hours of life.
The answer is A. Respiratory distress can occur with
Hirschsprung’s disease as a result of abdominal distention.
Because respiratory distress can be immediately life threatening
it is the most critical problem associated with the disease.
All of the other responses are symptoms of
Hirschsprung’s Disease but none are immediately life
threatening.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Disaster planning
782. As a nurse manager at the area medical center you
have been asked to participate as a member of the team
to develop the community’s disaster preparedness
plan. As you begin to think through the steps of a
sound plan you identify the following key phases in a
disaster management program:
A. Preparedness, mitigation, response, recovery, and
evaluation
B. Planning, organizing, leading, controlling
C. Assessment, analyzes planning, implementation,
evaluation
D. Prevention, warning, rehabilitation, reconstruction
The answer is A. There are five basic phases to a disaster management
program, there may be some overlapping between the
phases but each phase has a specific component relating to
disaster management.
B lists the four concepts of the management process, C lists
the components of the nursing process, and D is a listing of
terms that are not related to each other.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Alterations in Body Systems
Evaluate achievement of client treatment goals
783. How would the nurse best evaluate the effectiveness of
a client’s oxygen therapy?
Monitor change in
A. Hematocrit
B. Hemoglobin
C. Arterial blood gases
D. Pulmonary function tests
The answer is C. Oxygen is used to treat hypoxemia and
hypoxia. The best measure of its effectiveness in reversing
these conditions is ABG analysis.
PHYSIOLOGICAL INTEGRITY
Therapeutic Communications
Use therapeutic communication techniques to provide
support to client and/or family
784. A client standing in the doorway to his room,
screams at the nurse as she comes down the hall
“How long am I supposed to wait for someone to
straighten my bed? Do you know how much this
room is costing me per day? I want my bed fixed
and I want it done now.” How should the nurse
respond?
A. Say “I don’t think you need your bed straightened
this minute. . .”
B. Place a hand on the client’s arm and lead him to a
chair in his room.
C. Ask the client if he really thinks this type of behavior
will help him feel better.
D. Acknowledge the distress and obtain more information
about what the pateint needs.
The answers is D. Acknowledging a person’s distress is therapeutic.
Dismissing a person’s feelings is nontherapeutic and
interferes with establishing an effective nurse–client relationship.
Obtaining more information about the situation allows
for discussion of a solution.
A is incorrect—Disagreeing/arguing with the angry
client can lead to escalation of angry behavior. B is incorrect—
Touching an angry client or entering the client’s personal
space can also escalate anger. C is incorrect— it is
patronizing and this type of response increases anger.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Hemodynamics
785. A client has a pulmonary artery pressure catheter inserted
for hemodynamic monitoring. The client’s cardiac output
reading is 2 liters per minute. Which physical assessment
finding is consistent with this measurement?
A. Increased JVD
B. 1_ peripheral pulses
C. Bradycardia
D. Crackles in the lung bases
1256 PART III: Taking the Test
The answer is B. 1_ peripheral pulses. The normal CO is 4–7
liters per minute so the client would display signs and symptoms
of decreased cardiac output. Increased JVD is an indication
of volume overload. Tachycardia, not bradycardia, is the
physiologic response to decreased cardiac output. Crackles in
the lung bases are indicative of pulmonary overload.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Fluid and electrolyte imbalances
786. A 4-week-old infant boy has been admitted to the pediatric
unit with a diagnosis of “rule out pyloric stenosis.”
For signs of which electrolyte imbalance would the
nurse monitor the infant?
A. Hypokalemia
B. Hypernatremia
C. Metabolic acidosis
D. Respiratory alkalosis
The answer is A. Vomiting causes the loss of potassium, hence
hypokalemia would occur as well as metabolic alkalosis
from the loss of stomach acids.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse effects/contraindications
787. A physician writes the following orders for a client
being evaluated for a possible bowel obstruction.
Which order would the nurse question?
A. Intake and Output
B. NG tube to suction
C. IV, D51/4 NS at 125 ml/hr
D. Morphine q 3 hours prn pain
The answer is D. Morphine suppresses peristalsis and would
increase the bowel obstruction. Morphine and other opioid
analgesics are usually withheld during the diagnostic period
because of the effect on peristalsis and also because they can
cause vomiting. Vomiting can complicate the diagnosis and
determination of the plan of care because vomiting is also a sign
of worsening bowel obstruction and of N/G tube obstruction.
HEALTH PROMOTION AND
MAINTENANCE
Ante-/Intra-/Postpartum and Newborn Care
788. The nurse is assessing a newborn. A sudden noise
causes the newborn infant to extend and then flex the
arms and fingers. The nurse would document this as a
positive:
A. Moro reflex
B. Gag reflex
C. Babinski reflex
D. Tonic neck reflex
The answer is A. The Moro reflex occurs in response to a sudden
noise or movement. The infant extends arms and legs
and then flexes them. The infant’s hands form a C with the
thumb and fingers.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Alterations in Body Systems
Evaluate achievement of client treatment goals
789. Which would be an expected effect of resistive breathing
training in a client with COPD?
A. Energy conservation
B. Increased oxygen saturation
C. Decreased hypercarbia
D. Increased respiratory muscle strength
The answer is D. Resistive breathing training is used for clients
with exercise induced dyspnea and may be done as part of a
pulmonary rehabilitation program. In resistive breathing the
client breathes against a set resistance with the goal of developing
strength and endurance in the respiratory muscles. The
goal of resistive breathing is not energy conservation,
increased oxygen saturation, or decreased hypercarbia.
PSYCHOSOCIAL INTEGRITY
Therapeutic Communications
Use therapeutic communication techniques to provide
support to client and/or family
790. The daughter of a nursing home client comes to the
nurse’s station and shouts angrily “My mother’s condition
is a disgrace–this place should be closed down
and you all should lose your licenses.” How should the
nurse respond?
A. Say “I was just into your mother and there is nothing
disgraceful about her condition.”
B. Place a hand on the daughter’s arm and lead her to
a chair.
C. Ask the daughter if she really thinks this is a proper
way for an adult to behave.
D. Acknowledge the distress and obtain more information
about the problem.
The answer is D. Acknowledging a person’s distress is
therapeutic; dismissing a person’s feelings is non-theraCHAPTER
34 Practice Test for NCLEX-RN® 1257
peutic and interferes with establishing an effective nurseclient
relationship. Determining the immediate trigger of
the daughter’s anger allows the possibility of addressing
the problem and opening the door to discussion of underlying
issues.
Response A is inappropriate because it disagrees/argues
with the angry daughter and this can lead to escalation of
angry behavior. Similarly response B is incorrect because
touching an angry client or entering the client’s personal
space can also escalate anger.
Response C is incorrect because it is patronizing and
this type of response increases anger.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
791. The parents of a child with Tetralogy of Fallot are very
upset by the cyanotic “tet” spells and asks the nurse
what causes them. Which fact should be the basis of
the nurse’s response?
A. The aorta carries mixed deoxygenated and oxygenated
blood into the systemic circulation.
B. Low hemoglobin and circulating iron levels of the
newborn cause low oxygen saturation.
C. A left to right shunt increases blood return to the
lungs.
D. Increased heart rate causes a ventilation/perfusion
mismatch when the child becomes stressed.
The answer is A. Increased right ventricular pressure creates
right to left shunt. The hemoglobin and iron levels
are not one of the factors associated with Tetralogy of
Fallot. A left to right shunt involves an acyanotic defects.
Ventilation/perfusion mismatch occurs in pulmonary
embolisms.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Expected effects/outcomes
792. The CCU nurse admits a client from ER who has been
diagnosed with an evolving MI and has received
thrombolytic therapy with T-PA, tissue plasminogen
activator, and heparin. Which is an expected client
outcome?
A. ST elevation of 2 mm in two chest leads
B. PTT level of 1.5–2.5 times the control
C. An INR value of 2–3
D. A cardiac ejection fraction of 30%
The answer is B. PTT level of 1.5–2.5 times the control is the
therapeutic range during heparin therapy. ST elevation is an
indication of cardiac tissue injury. INR is for warfarin
(Coumadin) therapy. Normal cardiac ejection fraction is
60% or higher.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Legal rights and responsibilities
793. A nurse is explaining to a client that she has the right
to be treated in a certain manner, receive adequate
information, and have her confidentiality maintained
while hospitalized. The client asks what gives her
these rights. Which document should the nurse refer
to in responding to the client’s question?
A. Client Constitution
B. Client Bill of Rights
C. Client Medical Record
D. Client Self-Determination Act
The answer is B. The Client Bill of Rights is a document published
by the American Hospital Association to promote the
rights of hospitalized clients.
Client Constitutions is not a document but is a form of
law–constitutional law. The Medical Record is the record of
the hospitalization includes medical tests, procedures and
nursing documentation. The Client Self-Determination Act is
a legal act that requires every competent adult be informed in
writing upon admission to a health care institution about the
client’s rights to accept or refuse treatment.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Therapeutic Procedures
Provide nursing care of surgical clients
794. A client has just returned from surgery for colorectal
cancer. In assessing the client, the nurse notes that the
perineal dressing is soaked with bright red drainage.
Which action should the nurse take?
A. Reinforce the existing dressing.
B. Change the dressing using sterile technique.
C. Apply a pressure dressing using clean technique.
D. Cover the existing dressing with waterproof material.
The answer is A. The first dressing following surgery is
changed by the surgeon. The nurse would reinforce the
dressing. If the drainage continues, the nurse would notify
the surgeon. The other responses are incorrect.
1258 PART III: Taking the Test
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness management
795. The mother of an 8-week-old infant is telling the pediatric
nurse that her baby has colic and cries all the
time. The mother is visibly tired and frustrated. In
helping the mother to cope with an infant with colic,
the nurse can remind the mother that colic usually disappears
by the age of:
A. 3 months
B. 6 months
C. 9 months
D. 12 months
The answer is A. Colic is a short-term complaint and the
infant usually outgrows it by 3 months of age.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Pharmacological Agents/Actions
Use clinical decision making/critical thinking when
addressing actions of prescribed pharmacological agents
on clients
796. A client receiving chemotherapy for cancer also has
epoetin alfa prescribed. The client’s spouse asks what
the epoetin alfa will do for the client. The nurse’s
response is based on the knowledge that the therapeutic
goal of therapy with epoetin alfa for clients receiving
chemotherapy for cancer is to:
A. Potentiate the chemotherapy drugs
B. Decrease the need for transfusions.
C. Bolster immune system activity
D. Protect against renal damage
The answer is B. Epoetin alfa is used to treat chemotherapy
induced anemia and reduce the need for transfusions in
clients with cancer who will receive chemotherapy for two
months or more. It does not potentiate chemotherapeutic
drugs. Like endogenous erythropoietin, It stimulates the production
of red blood cells not immune system cells. Epoetin
alfa is used to treat the anemia associated with chronic renal
failure; it does not protect against kidney damage.
HEALTH PROMOTION AND
MAINTENANCE
Disease Prevention
797. The nurse teaches new parents about infant dentition
and care of the teeth.
Which of the following will the nurse include in the
teaching plan?
A. Beginning signs of tooth eruption are not seen
before 10–11 months
B. A frozen teething ring may be used to reduce
inflammation and relieve discomfort
C. Prevent dental carries by avoiding having infant fall
asleep with bottle
D. Fluoride should not be supplemented in the first year
E. Infant Tylenol may be given with practitioners
approval, for teething pain disrupting sleep and
feeding
F. Teeth may be cleaned with damp cloth
The answers are B, C, E, and F. Beginning signs of tooth eruption
are commonly seen by 5 or 6 months. In areas where
water supply is not adequately fluorinated, supplemental
fluoride begins at around 6 months. A frozen teething ring is
used to reduce inflammation and manage pain. Infant
Tylenol may be used for severe pain disrupting function with
practitioners order. Teeth may be cleaned with a damp cloth.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Instruct client on medication self-administration procedures
798. The nurse is giving a client instructions on the use of
an inhaled beta 2 agonist for mild symptoms associated
with emphysema and chronic bronchitis. The
nurse cautions that the maximum number of puffs to
be taken in 24 hours is how many?
A. 12–16
B. 8–12
C. 6–10
D. 4–8
The answer is B. For mild symptoms 1–2 puffs of a beta 2
agonist can be taken every 2 to 6 hours PRN not to exceed 8
to 12 puffs in any 24 hour period.
HEALTH PROMOTION AND
MAINTENANCE
Health and Wellness
799. The nurse is teaching parents of toddlers about nutritional
needs, food preferences and expected appetite
patterns. Which information would the nurse include
in the teaching plan?
A. ___ Do not overwhelm the toddler with large portions.
B. ___ Serve stews with meat and vegetables in one
bowl to maximize nutrition with minimal fuss.
CHAPTER 34 Practice Test for NCLEX-RN® 1259
C. ___ It is important to encourage eating because
growth is increasing and appetite is decreasing.
D. ___ Toddlers are very concerned with the plate or
cup used.
E. ___ Serve foods that are new and interesting to the
toddler as often as possible.
F. ___ Substitute cow’s milk if meat isn’t eaten.
The answers are A and D. Toddlers are easily overwhelmed by
large portions. Toddler’s prefer single foods and often refuse
mixtures such as stews. The toddler will even refuse foods
that are touching each other. In toddlerhood growth slows,
and appetite is diminished, with periods of physiologic
anorexia. The toddler has a favorite cup, spoon, dish, and
will often refuse a well-liked food because it’s not served in
the favorite dish. Repeat a set of nutritious foods often so
they will be recognized by the toddler, and better received.
Cow’s milk is a poor source of iron and interferes with iron
absorption leading to iron deficiency anemia if not curtailed.
SAFE AND EFFECTIVE CARE
ENVIRONMENTS
Safety and Infection Control
Standard/Transmission-Based/Other Precautions
Apply principles of infection control
800. Which precaution measures would be instituted when
a client has shigella? Mark all that apply.
A. ___ Client is placed in a private, negative airflow
pressure room.
B. ___ Client is placed in a private room or with other
clients with infection caused by the same
organism.
C. ___ Use mask at all times while in the client’s room.
D. ___ Use mask when working within 3 feet of the client.
E. ___ Use gown and protective barriers when giving
direct care.
F. ___ Mask on client if transported out of room.
G. ___ Use gloves at all times when caring for clients.
H. ___ Use gloves when there is risk of exposure to
blood or body fluids.
The answers are B, E, and G. Shigella is a serious disease that is
easily transmitted through direct contact. Contact precautions
require a private room or a room shared with someone
infected with the same organism. Gloves are worn at all times
and gowns and protective barriers are used if direct contact is
required. Since gloves are worn at all times, the requirements
of standard precautions, which involve wearing gloves whenever
there is the risk of touching something wet that comes
from the body surface or a body cavity, i.e., when there is the
risk of contact with blood or body fluids, are met.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
801. A client who has Rheumatic Fever is being admitted to
your floor. Admitting has assigned the client to share a
room with a client who is a fresh post-operative client.
As the charge nurse, you would
A. arrange for the new client to be reassigned to a private
room.
B. ask that the new client be assigned to a room with a
non-surgical client.
C. admit the client to the room assigned.
D. move the postoperative client to a room with
another postoperative client.
The answer is C. The client can be admitted to the room
assigned because rheumatic fever is an autoimmune
response to a streptococcal infection and is not contagious.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Laboratory values
802. A client is admitted for hemorrhagic gastritis of prolonged
standing. The nurse reviews the lab results on
this client. Which lab result would the nurse question?
A. Hematocrit 29
B. Hemoglobin 9.9
C. Guaiac negative
D. Reticulocyte count elevated
The answer is C. Guaiac evaluates blood in the stool which
should be positive. The client with hemorrhagic gastritis
would likely be anemic from chronic bleeding so low hemoglobin
and hematocrit would be expected. An elevated reticulocyte
count is the body’s attempt to replace lost blood cells.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications and Side Effects
Implement procedures to counteract adverse effects of
medications and parenteral therapy
803. Guarding against suicide is a priority nursing intervention
for which client?
A client who is withdrawing from
A. Methylphenidate (Ritalin)
B. Alprazolam (Xanax)
1260 PART III: Taking the Test
C. Propoxyphene (Darvon)
D. Butabarbital (Butisol)
The answer is A. Methylphenidate (Ritalin) is a central nervous
system stimulant and like other CNS stimulants such as cocaine
and the amphetamines, clients who are withdrawing from it are
severely dysphoric, anxious and at risk for suicide. Suicide is
not a withdrawal effect of any of the other drug options.
HEALTH PROMOTION AND
MAINTENANCE
Growth and Development
804. When teaching new mothers about play and stimulation
for the first 6 months, which of the following toys
would be recommended?
A. Unbreakable mirror in a soft black and white frame
B. Large brightly colored balloon
C. 5" doll with removable clothing and shoes
D. Push-pull toy
E. Soft cuddly stuffed toy
F. Musical Mobile
The answers are A, E, and F. Balloons are a choking hazard. Pushpull
toys will be useful later on when the child can manipulate
the toy. With a 5’ doll the removable shoes and possibly other
accessories are too small and therefore a choking hazard.
Mirrors, toys with contrasting colors, musical mobiles and soft
stuffed toys are appropriate for the first 6 months.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Instruct client on medication self-administration procedures
805. Which directions should be given to a patient taking
Fosamax?
Mark all that apply.
A. ___ Take with a full glass of water
B. ___ Take at bedtime
C. ___ Take on an empty stomach
D. ___ Avoid fatty foods.
E. ___ Avoid heavy lifting
F. ___ Do not lie down until after eating once the pill is
taken.
G. ___ Do not eat for 30 minutes
The answers are A, C, F, and G. Fosamax should be swallowed,
not chewed or sucked, with a full glass of water on an empty
stomach after getting up for the day. After taking Fosamax, the
client should not eat, drink, or take another medication for at
least 30 minutes. Clients should not lie down once the pill is
taken until 30 minutes has passed and they have eaten.
Fosamax should not be taken at bed time or before getting up
for a day. If a dose is missed, a tablet should be taken the morning
after the client remembers and then the usual dosage schedule
followed. Two tablets should not be taken on the same day.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Disaster planning
806. During a disaster the director of the command post
sends a nurse to the emergency department to assist in
triaging causality victims as they arrive. Which is the
priority concern of this nurse?
A. Meet the needs of the largest number of victims
B. Provide care to the most seriously injured
C. Record names of victims as they arrive
D. Place victims in zones according to their color
coded tags
The answer is A. Triage is the process of prioritizing which clients
are to be treated first during a disaster. Triage is based on making
decisions that will do the greatest good for the greatest
number. Treating the most seriously injured is describing
“daily triage.” The victim is expected to arrive at the hospital
with a tag already filled out. Victims are evaluated and a color
coded tag is applied for easy identification of the victims status.
PSYCHOSOCIAL INTEGRITY
Behavioral Interventions
Assess client appearance, mood, and psychomotor behavior
and identify/respond to inappropriate/abnormal behavior
807. A client with delusions says to the nurse “The aliens
are after me because they think I am going to take over
their planet.” Which is the most appropriate response
for the nurse to make?
A. “I don’t know anything about aliens. Do you feel
afraid that people are trying to harm you?”
B. “Why would the aliens think you are going to take
over their planet?”
C. “You are a good person; no one wants to kill you.”
D. “What makes you think the aliens want to kill you?”
The answer is A. This is an empathetic response that
acknowledges the client’s feeling.
Responses B and D encourage the client to get more
involved and add detail to the delusion and this is not therapeutic.
Response C has an element of false reassurance and
cliche as well as disagreement with the client’s delusion.
Disagreeing can result in a defensive reaction with the client
sticking even more firmly to the delusion.
CHAPTER 34 Practice Test for NCLEX-RN® 1261
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Illness management
808. After being diagnosed with diverticulitis, a client has
been taught about the appropriate dietary changes.
The nurse recognizes that additional teaching is
needed when the client states:
A. “I will follow a high-fiber diet.”
B. “Milk will decrease my episodes of diverticulitis.”
C. “Whole grains are better for me than refined grains.”
D. “Fruits and vegetables are good for me but not nuts
and seeds.”
The answer is B. A diet to prevent constipation is recommended.
Milk can be constipating. A high fiber diet helps to prevent constipation.
Whole grains are a good source of fiber. Fruits and
vegetables are good sources of fiber but nuts and seeds should
be avoided because of the risk of them getting trapped in a
diverticulum and serving as a source of inflammation.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Pathophysiology
809. A client has recently been diagnosed with cancer of the
tongue. Client teaching about oral cancer has been
completed. Which comment by the client indicates the
need for additional client teaching?
A. “My type of cancer metastasizes quickly because of
the rich lymph and blood supply in the area.”
B. “Like me, most clients don’t have early symptoms of
tongue cancer.”
C. “The doctor may need to do a neck resection to get
to the lymph nodes there.”
D. “I never thought that smoking would get me, but
they tell me that studies show a direct link between
smoking and cancer of the tongue.”
The answer is D. Smoking has been linked to all oral cancers
except that of the tongue. All other responses are correct.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort
Elimination
810. The nurse is teaching a group of pregnant clients about
hemorrhoid prevention. Which risk factors would the
nurse identify?
A. Constipation
B. Straining on elimination
C. Sitting for prolonged periods
D. Excessive roughage in the diet.
E. Standing for prolonged periods
The answers are A, B, C, and E. Constipation and straining on
elimination increases the pressure in the rectal area.
Maintaining one position for an extended period will cause
stasis of circulation. Roughage is encouraged to prevent constipation
so is not a risk factor for hemorrhoids.
HEALTH PROMOTION AND
MAINTENANCE
Growth and Development
811. The nurse teaches parents about fears in the preschool
years. Which information does the nurse include in the
teaching plan?
A. Past fears of the toddlerhood years are gradually
disappearing
B. The preschool child is no longer bothered by imagined
fears; fears are more realistic
C. The preschool child is no longer afraid to go to bed
as in the toddler years
D. The preschool child finds large dogs and other animals
frightening
E. The preschool child is afraid of mutilation and pain
F. Playing out fears with dolls that helped in toddlerhood
is not effective for the pre-schooler.
The answers are D and E. The preschool child experiences a
greater number of real and imagined fears than in any other
time of childhood. The child is afraid of the dark, being
alone at bedtime, large dogs, ghosts, thunderstorms, pain,
and mutilation. Playing out fears with dolls is useful in alleviating
fears as well as desensitization.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Medication Administration
Instruct client on medication self-administration procedures
812. What is the primary reason why the nurse teaches a
client to wear a glove or finger cot when applying topical
acyclovir to a herpetic lesion?
A. Prevent suprainfection
B. Prevent autoinoculation
C. Prevent overdose from excess absorption
D. Prevent unnecessary staining of the skin
The answer is B. Herpes can spread by autoinoculation.
Wearing a glove to apply medication to the lesions helps
1262 PART III: Taking the Test
prevent this. Even when wearing a glove or finger cot,
clients must also be taught the importance of hand washing
before and after each application of medication. Use
of a barrier also helps prevent possible bacterial contamination
and suprainfection but is not the primary reason
for teaching the use of a barrier rather than just hand
washing alone.
PSYCHOSOCIAL INTEGRITY
Therapeutic Communications
Use therapeutic communication techniques to provide
support to client and/or family
813. The nurse asks a client with Alzheimer’s Disease
“Do you want some orange juice?” The client
responds “Wha. . . .”. What should be the nurse’s
response?
A. “Do you want a glass of orange juice?”
B. “Are you thirsty–do you want some juice?”
C. “Have a nice cold glass of juice; it will taste good.”
D. “Do you want some orange juice?”
The answer is D. “Do you want some orange juice?” This is
the same question the nurse asked first. When communicating
with a client with Alzheimer’s disease one guideline to be
followed is repeat questions if needed but do not rephrase
them because this would only further confuse the client.
Other guidelines for communicating with the client with
Alzheimer’s disease are: use simple words and short sentences;
ask only one question at a time; give only one direction
at a time; speak slowly and clearly.
HEALTH PROMOTION AND
MAINTENANCE
Developmental Stages and Transitions
814. The nurse teaches new parents about gross motor and
fine motor development of the infant. What can the
mother expect by 6 months?
A. Head lag at 6 months
B. Can usually roll from prone to supine and supine to
prone
C. Can transfer cube from one hand to the other
hand
D. Can pull self to stand
E. Crude pincer grasp
F. Palmer grasp with fingers encircling object
The answers are B, C, and F. Head lag at 6 months is an ominous
sign and should be reported for follow up. The 6 month
old can roll from the prone to supine and supine to prone
position. With the new practice of placing infants on their
backs for sleep, as opposed to the abdomen, because of SIDs,
there is a noted delay in many infants in rolling from
abdomen to back, but by 6 months infants have accomplished
this task. The 6-month-old has a palmer grasp and is
beginning to transfer a cube from one hand to the other. The
infant pulls himself to stand, and develops a crude pincer
grasp at 9 months.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Monitoring conscious sedation
815. The nurse is caring for a client who has received conscious
sedation for elective cardioversion. Following
the procedure the arterial blood gas results are as follows:
pH 7.32; PaO2 95mm Hg; PaCO2 62 mm Hg;
HCO3 19 meq/L; O2 Sat 95%. Based on these values
which action would the nurse take?
A. Chart the values and continue assessing the client
B. Start supplemental oxygen at 2 liter per minute via
nasal cannula
C. Have the client perform deep breathing exercises
D. Have the client breathe into a paper bag
The answer is C. Deep breathing exercises will help the client
blow off carbon dioxide and bring down the PaCO2 level.
A is incorrect because the blood gas results are showing
respiratory acidosis.
O2 is not needed because the Os 2 level is within the
normal range. Breathing into a paper bag is used when the
client is experiencing respiratory alkalosis.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Management of Care
Establishing priorities
816. The nurse assigned to a client being admitted for rectal
bleeding, must establish priorities of care. In which
order would the nurse carry out the following care
activities?
A. Start an intravenous
B. Observe the client’s level of anxiety
C. Continue to monitor the client for rectal bleeding
D. Teach the client self care in preparation for her discharge
E. Assess the client’s skin, blood pressure, heart rate,
and urine output
F. Teach the client about the diagnostic tests ordered
during the next 48 hours
CHAPTER 34 Practice Test for NCLEX-RN® 1263
Record your answer by placing the letter of each activity in
proper sequence in the space provided.
Correct order of priorities: E, A, B, C, F, D. Physical needs
precede psychological needs. Client teaching would be the
last priority in this situation.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
817. A 3-week-old infant has been diagnosed with
Hirschsprung’s Disease and has just returned from surgery
with a double barreled colostomy. The mother
cries when she sees the colostomy stoma and says: “My
poor baby, to have to go through life with that thing on
his abdomen.” The nurse’s response would be based
on the knowledge that
A. colostomy care is not as difficult as it may seem.
B. the colostomy will not be permanent.
C. the child will never have known anything but the
colostomy.
D. colostomy stomas are hidden easily under clothing.
The answer is B. A double barreled colostomy indicates the
intention to reconnect the bowel at a later time so the mother’s
misconception needs to be addressed. All the other options
are inappropriate as the basis of the nurse’s response because
the colostomy is not going to be permanent. Colostomy care
during infancy is relatively simple as the child would not be
continent anyway. Stomas can be hidden under clothing. The
child would eventually know that he or she is different.
HEALTH PROMOTION AND
MAINTENANCE
Developmental Stages and Transitions
818. The nurse is planning a class to promote effective parenting
of toddlers. Which topics should the nurse plan
to discuss?
A. Negativism
B. Ritualism
C. Egocentrism
D. Temper Tantrums
E. Possessiveness
F. Altruism
The answers are A, B, C, D, and E. These are all topics pertinent
to toddler behavior. Negativism refers to strongly expressed
emotions: ‘no’. Ritualism is seen as the toddler having a favorite
doll, favorite blanket and various rituals of behavior, especially
at bedtime. Egocentrism refers to the fact that the toddlers can
not comprehend that others think differently than they do.
Temper Tantrums which are characteristic of toddlers are
attention seeking and best dealt with by ignoring them.
Possessiveness indicates the toddler’s beginning awareness of
ownership, as shown by the use of the word “mine.” Altruism
is not a characteristic of toddlerhood.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications and Side Effects
Assess client for actual or potential side effects and
adverse effects of medications
819. Which is the priority factor for the nurse to assess
when a client is receiving IV acyclovir?
A. mental status
B. cardiac rhythm
C. urinary output
D. temperature
The answer is C. Monitoring urinary output is critical when acyclovir
is given systemically because it is excreted primarily by
glomerular filtration and tubular secretion and therefore can be
nephrotoxic. To decrease the risk of nephrotoxicity, the client
must be well hydrated; the drug must be administered over a
period of 60 minutes; and urinary output must be measured for
2 hours after the infusion. Output of less than 500 mL of urine
per gram of acyclovir must be reported immediately.
Confusion and hallucinations along with tremors and
seizures are some of the serious adverse reactions to systemic
acyclovir but they are uncommon. Cardiac rhythm is unaffected.
Temperature may be monitored because of existing
infection but not directly because of the acyclovir; it does not
present an immediate threat so does not take priority over
monitoring urinary output.
SAFE AND EFFECTIVE
ENVIRONMENT
Management of Care
Establishing priorities
820. Vital signs on a client who has just been admitted to
the unit are: BP 162/84, Pulse 100 and irregular,
Respirations 16, and Pulse Oximetry 88%. Which
would be the immediate nursing intervention?
A. Place the client on cardiac telemetry
B. Call the physician to report the vital signs
C. Start a saline lock for IV medication access
D. Start oxygen at 2–4 liters per minute per nasal cannula
per protocol
1264 PART III: Taking the Test
The answer is D. The client’s oxygen level is very low. All
other interventions would be done later.
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies
Evaluate appropriateness/accuracy of medication order
for client
821. A nurse would question an order for misoprostol to
prevent gastric ulcers for which client?
A. A client allergic to shellfish
B. A pregnant client
C. A client taking warfarin sodium
D. A client with a history of hepatitis
The answer is B. Misoprostol is a synthetic form of
prostaglandin E which is used to prevent NSAID-induced
gastric ulcers in high risk clients. It is a pregnancy category
X drug because of its abortifacient action and therefore the
order would be questioned if the client is pregnant. Before
beginning treatment with misoprostol women of childbearing
age must have a negative serum pregnancy test within
two weeks of start of treatment which should be on day 2 or
3 or menses. They must also be warned both orally and in
writing that the drug causes uterine contractions and miscarriage
and be able and willing to use an effective form of
contraception.
HEALTH PROMOTION AND
MAINTENANCE
Health Promotion Programs
822. The nurse teaches new parents about nutrition for the
first year of life. What information does the nurse
include in her teaching plan?
A. Breast milk is a complete and healthful diet for the
first 6 months of life.
B. Commercially prepared fortified infant formula is a
good alternative if breast feeding is not desirable or
feasible.
C. No additional fluids are needed for the first 4–6
months when the infant is breast or formula fed.
D. In second 6 months skim or regular cow’s milk used
depending on infant’s weight pattern.
E. Solid foods starting with cereals at 2 months, and
gradually introducing fruits, vegetables and meats
over next 4 months.
F. Honey is not given for the first year because it is a
source of botulism.
The answers are A, B, C, and F. Breast feeding and fortified
commercially prepared infant formulas are the best and
only sources of nutrition appropriate for the first 6
months of life and continues to be the primary source of
nutrition in the second 6 months of life as well. Cows’
milk, skim or regular, and imitation milks are not
acceptable during the first year, as they are difficult to
digest and lack the nutrients needed for growth. Solid
foods are generally introduced at 5–6 months starting
with cereals with gradual introduction of fruits, vegetables
and meats. Honey is not given in the first year as it
is associated with botulism.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Hemodynamics
823. The nurse is caring for a client when the cardiac monitor
shows that cardiac pattern has changed from a normal
sinus rhythm. QRSs are now widened and bizarre at a
rate of 160 beats per minute. The client begins complaining
of being dizzy. Which is the nurse’s immediate action?
A. Call a code
B. Administer a precordial thump
C. Give Lidocaine 50–100 mG. IV push
D. Assess the client’s vital signs
The answer is D. The nurse needs to assess the client to determine
cardiac perfusion and to be sure of what the monitor is
showing. The nurse would not call a code because the client
has not arrested. Precordial thump is only used with a witnessed
arrest. Lidocaine would be the drug of choice if the
client were in a sustained Ventricular Tachycardia and was
symptomatic.
SAFE AND EFFECTIVE CARE
ENVIRONMENT
Safety and Infection Control
Handling hazardous and infectious materials
824. The nurse is serving on a safety committee which is
currently examining policies regarding the proper handling
and storage of dangerous chemicals. Which
guidelines would the nurse expect the policies to
address?
A. ___ Label the containers containing materials
B. ___ Maintain an inventory list of the materials
C. ___ Keep older products in the front, newer products
in the back
D. ___ Store chemicals on open shelves
E. ___ Segregate chemicals alphabetically
CHAPTER 34 Practice Test for NCLEX-RN® 1265
The answers are A, B, and C. Containers containing hazardous
chemicals need to be clearly labeled with the full chemical
name. Current hazard waste inventory list is required to be
maintained. Older chemicals need to be used before newer
products.
Chemicals stored on open shelves could be accidentally
knocked off the shelf. Chemicals also need to be
stored based on compatibility and not necessarily alphabetically.
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation
Alterations in Body Systems
825. A client has a permanent colostomy for colon cancer.
The client is struggling to learn colostomy care. In
frustration, the client throws the equipment and says,
“It’s not worth it. I might as well be dead.” Which
interpretation of this behavior should be the basis of
the nurse’s initial response to the client?
A. The client has not developed an adult level of self
control.
B. The client does not want to learn.
C. The approach to teaching is incorrect for this client.
D. The client is having difficulty coping.
The answer is D. The most likely interpretation of this behavior
and the one that should serve as the basis of the nurse’s
first response is that the client is displaying signs of inadequate
coping with his life threatening disease and the need
for a colostomy. It is possible that the client is lacking in self
control or doesn’t want to learn but these are not as likely as
difficulty coping given the client’s health problems. It is also
possible that the approach to teaching is not ideal for this
client and this may need to be addressed but it is not the
most likely cause of the behavior.
HEALTH PROMOTION AND
MAINTENANCE
Growth and Development
826. The nurse at a day care is observing pre-school children
at play. Which types of play observed would the
nurse evaluate as normal for a preschooler?
A. Playing house and doing housekeeping chores.
B. Jumping, running or climbing
C. Riding a tricycle
D. Having an “imaginary playmate”
E. Playing dress up
The answers are A, B, C, D, and E. Imitative, imaginary and
dramatic play are characteristic of the pre-school period.
Playing house, dress up, and housekeeping chores are examples
of imitative, imaginary and dramatic play. Imaginary
playmates are a normal healthy and useful part of the
preschoolers play. Parents can even set a place setting for a
“friend,” but can not allow the child to avoid responsibility
by blaming “friend” for mess.
Activities for motor development should also be
encouraged including: running, jumping, climbing and
tricycle riding. Reading or watching an educational video
are examples of mutual activities that can be enjoyed with
a parent.
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
System-specific assessment
827. To calculate central venous pressure from the jugular
venous pressure, how many centimeters are added to
the JVP? Record your answer as a whole number in the
space provided.
The answer is 4 cm. Four centimeters are added to the
jugular venous pressure to obtain the central venous
pressure.
PSYCHOSOCIAL INTEGRITY
Behavioral Interventions
Assess client appearance, mood, and psychomotor behavior
and identify/respond to inappropriate/abnormal behavior
828. What is the most important reason for monitoring a
client with a borderline personality disorder and
depression for a sudden change in mood?
A. Mood change can be the first indication that therapeutic
gains are being made.
B. Mood change can indicate a need for change in
medication.
C. Mood change can herald a decision to commit suicide.
D. Mood change can signal the appropriate time to
introduce group therapy.
The answer is C. A mood change can indicate a decision to
commit suicide. Client safety is always the priority hence
this is the most important reason for monitoring mood.
Change in mood may indicate any of the other options
but they are not the priority over protecting the client’s
life.
1266 PART III: Taking the Test
PHYSIOLOGICAL INTEGRITY
Reduction of Risk Potential
Potential for Complication of Diagnostic
Tests/Treatments/Procedures
829. Following eye surgery, the client is told by the physician
that care must be taken to avoid elevating intraocular
pressure. Which activities would the nurse identify as
those the client needs to avoid? Mark all that apply.
A. ___ Blowing the nose
B. ___ Straining at stool
C. ___ Wearing a tight collar
D. ___ Bending over at the waist
E. ___ Coughing
F. ___ Keeping the head down
The answers are all A, B, C, D, E, and F. All of these activities
increase pressure within the eyeball as does sneezing, vomiting
and sexual intercourse.