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NCLEX Practice Exam 11 (20 Questions)
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NCLEX Practice Exam 11 (20 Questions)
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1. A mother complains to the clinic nurse that her 2 ½-year-old son is not yet toilet trained. She is particularly concerned that, although he reliably uses the potty seat for bowel movements, he isn’t able to hold his urine for long periods. Which of the following statements by the nurse is correct?
A. The child should have been trained by age 2 and may have a psychological problem that is responsible for his “accidents.”
B. Bladder control is usually achieved before bowel control, and the child should be required to sit on the potty seat until he passes urine.
C. Bowel control is usually achieved before bladder control, and the average age for completion of toilet training varies widely from 24 to 36 months.
D. The child should be told “no” each time he wets so that he learns the behavior is unacceptable.
2. The mother of a 14-month-old child reports to the nurse that her child will not fall asleep at night without a bottle of milk in the crib and often wakes during the night asking for another. Which of the following instructions by the nurse is correct?
A. Allow the child to have the bottle at bedtime, but withhold the one later in the night.
B. Put juice in the bottle instead of milk.
C. Give only a bottle of water at bedtime.
D. Do not allow bottles in the crib.
3. Which of the following actions is NOT appropriate in the care of a 2-month-old infant?
A. Place the infant on her back for naps and bedtime.
B. Allow the infant to cry for 5 minutes before responding if she wakes during the night as she may fall back asleep.
C. Talk to the infant frequently and make eye contact to encourage language development.
D. Wait until at least 4 months to add infant cereals and strained fruits to the diet.
4. An older patient asks a nurse to recommend strategies to prevent constipation. Which of the following suggestions would be helpful? Note: More than one answer may be correct.
A. Get moderate exercise for at least 30 minutes each day.
B. Drink 6-8 glasses of water each day.
C. Eat a diet high in fiber.
D. Take a mild laxative if you don’t have a bowel movement every day.
5. A child is admitted to the hospital with suspected rheumatic fever. Which of the following observations is NOT confirming of the diagnosis?
A. A reddened rash visible over the trunk and extremities.
B. A history of sore throat that was self-limited in the past month.
C. A negative antistreptolysin O titer.
D. An unexplained fever.
6. A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea. Which of the following actions is the first the nurse should perform?
7. A clinic patient has recently been prescribed nitroglycerin for treatment of angina. He calls the nurse complaining of frequent headaches. Which of the following responses to the patient is correct?
A. “Stop taking the nitroglycerin and see if the headaches improve.”
B. “Go to the emergency department to be checked because nitroglycerin can cause bleeding in the brain.”
C. “Headaches are a frequent side effect of nitroglycerine because it causes vasodilation.”
D. “The headaches are unlikely to be related to the nitroglycerin, so you should see your doctor for further investigation.”
8. A patient received surgery and chemotherapy for colon cancer, completing therapy 3 months previously, and she is now in remission. At a follow-up appointment, she complains of fatigue following activity and difficulty with concentration at her weekly bridge games. Which of the following explanations could account for her symptoms?
9. A clinic patient has a hemoglobin concentration of 10.8 g/dL and reports sticking to a strict vegetarian diet. Which of the follow nutritional advice is appropriate?
A. The diet is providing adequate sources of iron and requires no changes.
B. The patient should add meat to her diet; a vegetarian diet is not advised.
C. The patient should use iron cookware to prepare foods, such as dark green, leafy vegetables and legumes, which are high in iron.
D. A cup of coffee or tea should be added to every meal.
10. A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment of severe anemia. Which of the following is the most accurate statement?
A. Transfusion reaction is most likely immediately after the infusion is completed.
B. PRBCs are best infused slowly through a 20g. IV catheter.
C. PRBCs should be flushed with a 5% dextrose solution.
D. A nurse should remain in the room during the first 15 minutes of infusion.
11. Emergency department triage is an important nursing function. A nurse working the evening shift is presented with four patients at the same time. Which of the following patients should be assigned the highest priority?
A. A patient with low-grade fever, headache, and myalgias for the past 72 hours.
B. A patient who is unable to bear weight on the left foot, with swelling and bruising following a running accident.
C. A patient with abdominal and chest pain following a large, spicy meal.
D. A child with a one-inch bleeding laceration on the chin but otherwise well after falling while jumping on his bed.
12. A patient is admitted to the hospital with a calcium level of 6.0 mg/dL. Which of the following symptoms would you NOT expect to see in this patient?
A. Numbness in hands and feet.
B. Muscle cramping.
C. Hypoactive bowel sounds.
D. Positive Chvostek’s sign.
13. A nurse cares for a patient who has a nasogastric tube attached to low suction because of a suspected bowel obstruction. Which of the following arterial blood gas results might be expected in this patient?
A. pH 7.52, PCO2 54 mmHg.
B. pH 7.42, PCO2 40 mmHg.
C. pH 7.25, PCO2 25 mmHg.
D. pH 7.38, PCO2 36 mmHg.
14. A patient is admitted to the hospital for routine elective surgery. Included in the list of current medications is Coumadin (warfarin) at a high dose. Concerned about the possible effects of the drug, particularly in a patient scheduled for surgery, the nurse anticipates which of the following actions?
A. Draw a blood sample for prothrombin (PT) and international normalized ratio (INR) level.
B. Administer vitamin K.
C. Draw a blood sample for type and crossmatch and request blood from the blood bank.
D. Cancel the surgery after the patient reports stopping the Coumadin one week previously.
15. The follow lab results are received for a patient. Which of the following results are abnormal? Note: More than one answer may be correct.
A. Hemoglobin 10.4 g/dL.
B. Total cholesterol 340 mg/dL.
C. Total serum protein 7.0 g/dL.
D. Glycosylated hemoglobin A1C 5.4%.
16. A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?
A. The child has a poor chance of recovery without joint deformity.
B. Most children progress to adult rheumatoid arthritis.
C. Nonsteroidal anti-inflammatory drugs are the first choice in treatment.
D. Physical activity should be minimized.
17. A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?
A. The admission orders are written.
B. A blood culture is drawn.
C. A complete blood count with differential is drawn.
D. The parents arrive.
18. A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child’s symptoms?
19. A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Note: More than one answer may be correct.
A. Regular developmental screening is important to avoid secondary developmental delays.
B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties.
C. Developmental milestones may be slightly delayed but usually will require no additional intervention.
D. Parent support groups are helpful for sharing strategies and managing health care issues.
20. A child has recently been diagnosed with Duchenne’s muscular dystrophy. The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information?
A. Duchenne’s is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease.
B. Duchenne’s is an X-linked recessive disorder, so both daughters and sons have a 50% chance of developing the disease.
C. Each child has a 1 in 4 (25%) chance of developing the disorder.
D. Sons only have a 1 in 4 (25%) chance of developing the disorder.
Answers and Rationale
1. Answer: C. Bowel control is usually achieved before bladder control, and the average age for completion of toilet training varies widely from 24 to 36 months.
Toddlers typically learn bowel control before bladder control, with boys often taking longer to complete toilet training than girls. Many children are not trained until 36 months and this should not cause concern. Later training is rarely caused by psychological factors and is much more commonly related to individual developmental maturity. Reprimanding the child will not speed the process and may be confusing.
2. Answer: C. Give only a bottle of water at bedtime.
Babies and toddlers should not fall asleep with bottles containing liquid other than plain water due to the risk of dental decay. Sugars in milk or juice remain in the mouth during sleep and cause caries, even in teeth that have not yet erupted. When water is substituted for milk or juice, babies will often lose interest in the bottle at night.
3. Answer: B. Allow the infant to cry for 5 minutes before responding if she wakes during the night as she may fall back asleep.
Infants under 6 months may not be able to sleep for long periods because their stomachs are too small to hold adequate nourishment to take them through the night. After 6 months, it may be helpful to let babies put themselves back to sleep after waking during the night, but not prior to 6 months. Infants should always be placed on their backs to sleep. Research has shown a dramatic decrease in sudden infant death syndrome (SIDS) with back sleeping. Eye contact and verbal engagement with infants are important to language development. The best diet for infants under 4 months of age is breast milk or infant formula.
4. Answers: A, B, and C
A daily bowel movement is not necessary if the patient is comfortable and the bowels move regularly. Moderate exercise, such as walking, encourages bowel health, as does generous water intake. A diet high in fiber is also helpful. Laxatives should be used as a last resort and should not be taken regularly. Over time, laxatives can desensitize the bowel and worsen constipation.
5. Answer: C. A negative antistreptolysin O titer.
Rheumatic fever is caused by an untreated group A B hemolytic Streptococcus infection in the previous 2-6 weeks, confirmed by a positive antistreptolysin O titer. Rheumatic fever is characterized by a red rash over the trunk and extremities as well as fever and other symptoms.
6. Answer: D. Check blood pressure.
A patient with congestive heart failure and dyspnea may have pulmonary edema, which can cause severe hypertension. Therefore, taking the patient’s blood pressure should be the first action. Lying flat on the exam table would likely worsen the dyspnea, and the patient may not tolerate it. Blood draws for chemistry and ABG will be required, but not prior to the blood pressure assessment.
7. Answer: C. “Headaches are a frequent side effect of nitroglycerine because it causes vasodilation.”
Nitroglycerin is a potent vasodilator and often produces unwanted effects such as headache, dizziness, and hypotension. Patients should be counseled, and the dose titrated, to minimize these effects. In spite of the side effects, nitroglycerine is effective at reducing myocardial oxygen consumption and increasing blood flow. The patient should not stop the medication. Nitroglycerine does not cause bleeding in the brain.
8. Answer: A. The symptoms may be the result of anemia caused by chemotherapy.
Three months after surgery and chemotherapy the patient is likely to be feeling the after-effects, which often includes anemia because of bone-marrow suppression. There is no evidence that the patient is immunosuppressed, and fatigue is not a typical symptom of immunosuppression. The information given does not indicate that depression or dehydration is a cause of her symptoms.
9. Answer: C. The patient should use iron cookware to prepare foods, such as dark green, leafy vegetables and legumes, which are high in iron.
Normal hemoglobin values range from 11.5-15.0. This vegetarian patient is mildly anemic. When food is prepared in iron cookware its iron content is increased. In addition, dark green leafy vegetables, such as spinach and kale, and legumes are high in iron. Mild anemia does not require that animal sources of iron be added to the diet. Many non-animal sources are available. Coffee and tea increase gastrointestinal activity and inhibit absorption of iron.
10. Answer: D. A nurse should remain in the room during the first 15 minutes of infusion.
Transfusion reaction is most likely during the first 15 minutes of infusion, and a nurse should be present during this period. PRBCs should be infused through a 19g or larger IV catheter to avoid slow flow, which can cause clotting. PRBCs must be flushed with 0.45% normal saline solution. Other intravenous solutions will hemolyze the cells.
11. Answer: C. A patient with abdominal and chest pain following a large, spicy meal.
Emergency triage involves quick patient assessment to prioritize the need for further evaluation and care. Patients with trauma, chest pain, respiratory distress, or acute neurological changes are always classified number one priority. Though the patient with chest pain presented in the question recently ate a spicy meal and may be suffering from heartburn, he also may be having an acute myocardial infarction and require urgent attention. The patient with fever, headache and muscle aches (classic flu symptoms) should be classified as non-urgent. The patient with the foot injury may have sustained a sprain or fracture, and the limb should be x-rayed as soon as is practical, but the damage is unlikely to worsen if there is a delay. The child’s chin laceration may need to be sutured but is also non-urgent.
12. Answer: C. Hypoactive bowel sounds.
Normal serum calcium is 8.5 – 10 mg/dL. The patient is hypocalcemic. Increased gastric motility, resulting in hyperactive (not hypoactive) bowel sounds, abdominal cramping and diarrhea is an indication of hypocalcemia. Numbness in hands and feet and muscle cramps are also signs of hypocalcemia. Positive Chvostek’s sign refers to the sustained twitching of facial muscles following tapping in the area of the cheekbone and is a hallmark of hypocalcemia.
13. Answer: A. pH 7.52, PCO2 54 mmHg.
A patient on nasogastric suction is at risk of metabolic alkalosis as a result of loss of hydrochloric acid in gastric fluid. Of the answers given, only answer A (pH 7.52, PCO2 54 mm Hg) represents alkalosis. Answer B is a normal blood gas. Answer C represents respiratory acidosis. Answer D is borderline normal with slightly low PCO2.
14. Answer: A. Draw a blood sample for prothrombin (PT) and international normalized ratio (INR) level.
The effect of Coumadin is to inhibit clotting. The next step is to check the PT and INR to determine the patient’s anticoagulation status and risk of bleeding. Vitamin K is an antidote to Coumadin and may be used in a patient who is at imminent risk of dangerous bleeding. Preparation for transfusion, as described in option C, is only indicated in the case of significant blood loss. If lab results indicate an anticoagulation level that would place the patient at risk of excessive bleeding, the surgeon may choose to delay surgery and discontinue the medication.
15. Answer: A and B
Normal hemoglobin in adults is 12 – 16 g/dL. Total cholesterol levels of 200 mg/dL or below are considered normal. Total serum protein of 7.0-g/dL and glycosylated hemoglobin A1c of 5.4% are both normal levels.
16. Answer: C. Nonsteroidal anti-inflammatory drugs are the first choice in treatment.
Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. Half of children with the disorder recover without joint deformity, and about a third will continue with symptoms into adulthood. Physical activity is an integral part of therapy.
17. Answer: B. A blood culture is drawn.
Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. Parental presence is important for the adjustment of the child but not for the administration of medication.
18. Answer: A. Possible fracture of the tibia.
The child’s refusal to walk, combined with swelling of the limb is suspicious for fracture. Toddlers will often continue to walk on a muscle that is bruised or strained. The radius is found in the lower arm and is not relevant to this question. Toddlers rarely feign injury to be carried, and swelling indicates a physical injury.
19. Answers: A, B and D.
Delayed developmental milestones are characteristic of cerebral palsy, so regular screening and intervention is essential. Because of injury to upper motor neurons, children may have ocular and speech difficulties. Parent support groups help families to share and cope. Physical therapy and other interventions can minimize the extent of the delay in developmental milestones.
20. Answer: A. Duchenne’s is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease.
The recessive Duchenne gene is located on one of the two X chromosomes of a female carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a 50% chance of a son being affected. Daughters are not affected, but 50% are carriers because they inherit one copy of the defective gene from the mother. The other X chromosome comes from the father, who cannot be a carrier.
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