NCLEX RN ACTUAL EXAM TEST
BANK QUESTIONS AND ANSWERS
Necessary for proper blood clotting. Insufficient platelets may exhibit frank
bleeding or oozing of blood from puncture sites, wounds, & mucous membranes. -
ANSWER -Platelets
Order of priority is to rescue patient in immediate danger. Next activate fire alarm.
Close all doors & fire extinguished. - ANSWER -Fire event
Transmitted by droplet infection. Precautions include private room or cohort client
& use of standard precaution mask. - ANSWER -Meningococcal pneumonia
Best results sitting head of bed elevated 45 to 90 degrees. Semi-Fowler's or high
Fowler's position. Mouthpiece should be covered completely & tightly while
inhales slowly, with constant flow through unit. Breath should be held for 5
seconds before exhaling slowly. - ANSWER -Incentive spirometer
Placed in left Sims position so enema solution can flow by gravity in natural
direction of colon. - ANSWER -Cleansing enema
Preconventional stage, morals are thought to be motivated by punishment &
reward. - ANSWER -Kohlberg's theory of moral development
Should not try anticipate newborn infant needs but allow newborn infant to signal
needs. If newborn infant is not allowed to signal a need, newborn will not learn
how to control environment. Delayed or prolonged response to newborn infant's
signal would inhibit development trust & lead to mistrust of others - ANSWER -
Erikson's psychosocial development theory
Child has the ability to think abstractly and logically. - ANSWER -Formal
operations stage of Piaget's cognitive developmental theory
Child begins to understand the environment. - ANSWER -Paiget's sensorimotor
stage
Child is able to classify, order, and sort facts. - ANSWER -Paiget's concrete
operational stage
,Child learns to think in terms of past, present, & future. - ANSWER -Paiget's
preoperational stage
20 to 40 breaths/minute - ANSWER -Normal respiratory rate in a 12-month-old
90 to 130 beats/minute - ANSWER -Normal apical heart rate in a 12-month-old
90/56 mm Hg - ANSWER -Average blood pressure in a 12-month-old
Diamond-shaped & located on top of head. Soft & flat in normal infant, & it
normally closes by 12- 18 months of age - ANSWER -Anterior fontane
Decreased lean body mass & age-associated decreased glomerular filtration rate. -
ANSWER -older client is at risk for medication toxicity because
Stand feet together & arms at sides, close eyes & hold position; normally client
can maintain posture & balance. Positive Romberg's sign is a vestibular
neurological sign found when client exhibits loss balance when closing eyes. -
ANSWER -Romberg's test
Rhythmic respirations with periods of apnea. Periods apnea followed by deep
rapid breathing - ANSWER -Cheyne-Stokes respirations
Physical obstruction to transmission of sound waves - ANSWER -Conductive
hearing loss
occurs as result pathological process in inner ear, defect in 8th cranial nerve, or
defect of sensory fibers that lead to cerebral cortex. - ANSWER -Sensorineural
hearing loss
Abnormal heart sound & described as gentle, blowing, swooshing sound. -
ANSWER -Heart murmur
Described as a scratchy, leathery heart sound. - ANSWER -Pericardial friction rub
Tests the six cardinal positions of gaze - ANSWER -Assess for muscle weakness
in eyes
Visual acuity & cranial nerve II (optic). - ANSWER -Snellen eye chart
, Close eyes & then lightly touching areas of face & testing corneal reflexes assess
cranial nerve V (trigeminal). - ANSWER -Testing sensory function
tested insupine position. Flexes head (gently moves head to chest) & there should
be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign
is observed if passively flexes hip & knee in response to neck flexion & reports
pain in vertebral column. - ANSWER -Positive Brudzinski's sign
Blood leaves embryo through two umbilical arteries. Oxygenated, blood returned
by one umbilical vein. Arteries carry deoxygenated blood & waste products from
fetus, umbilical vein carries oxygenated blood & provides oxygen & nutrients to
fetus. - ANSWER -Fetal circulation
Connects umbilical vein to inferior vena cava - ANSWER -Ductus venosus
Is temporary opening between right & left atria. - ANSWER -Foramen ovale
Joins the aorta & pulmonary artery - ANSWER -Ductus arteriosus
Uterine enlargement, Hegar's sign , Goodell's sign , Chadwick's sign, ballottement,
Braxton Hicks contractions, & positive pregnancy test for presence of HCG. -
ANSWER -Probable signs of pregnancy
Fetal heart rate detected by electronic device (Doppler transducer), active fetal
movements palpable by examiner, & outline fetus by radiography or
ultrasonography. - ANSWER -Positive signs of pregnancy
*Pregnancy avoided for 1-3 months. *Vaccine administered subcutaneous
route.*Exposure immunosuppressed individuals avoided. *Hypersensitivity
reaction can occur if client has allergy to eggs. - ANSWER -Rubella virus vaccine
Postpartum
Three classic signs are hypertension, generalized edema, & proteinuria. -
ANSWER -Classic signs of preeclampsia
Can trigger disseminated intravascular coagulation (DIC). Evidence of bleeding,
such as in gums, petechiae, & purpura should be reported to HCP if noted on
assessment. - ANSWER -Severe preeclampsia
, Considered a risk factor for disseminated intravascular coagulation (DIC). -
ANSWER -Dead fetus syndrome
Isoniazid plus rifampin (Rifadin) will be required for 9 months. - ANSWER -
Pregnant client tuberculosis is suspected; sputum culture obtained & identifies
Mycobacterium tuberculosis
When the cervix is dilated completely & ends with birth of the neonate. -
ANSWER -Second Stage of Labor begins
Occur if umbilical cord becomes compressed, reducing blood flow between
placenta & the fetus. - ANSWER -Variable decelerations
Result from pressure on fetal head during a contraction. - ANSWER -Early
decelerations
Fetal heart rate assessed immediately after amniotomy to detect any changes that
may indicate cord compression or prolapse. Minimal vaginal examinations would
be done because of risk of infection. - ANSWER -Assessment finding following an
amniotomy should be conducted first
Acute abdominal pain present. Uterine tenderness with abruption, especially
central abruption & trapped blood behind placenta. Abdomen feels hard/boardlike
on palpation as blood penetrates myometrium & causes uterine irritability.
Premature separation placenta from uterine wall after 20th week gestation, before
fetus delivered. Associated conditions; hypertension, smoking, alcohol/ cocaine
abuse. Overdistention uterus; multiple gestation, polyhydramnios. In addition,
short umbilical cord, physical trauma, increased maternal age & parity are risk
factors. Painful vaginal bleeding, abdominal pain, & back pain identify
signs/symptoms of abruptio placentae. - ANSWER -Abruptio placentae
Symptoms increase in fundal height, hard board-like abdomen, persistent
abdominal pain, late decelerations in fetal heart rate, or decreasing baseline
variability. - ANSWER -Concealed bleeding Prenatal
Improperly implanted placenta lower uterine segment. Manual pelvic exam
contraindicated vaginal bleeding apparent until diagnosis made & placenta previa
ruled out. Digital exam cervix can lead to hemorrhage. Diagnosis by ultrasound.
Hemoglobin/Hematocrit level monitored, external electronic fetal heart rate
monitoring initiated; crucial evaluating status fetus, risk for severe hypoxia. Soft
BANK QUESTIONS AND ANSWERS
Necessary for proper blood clotting. Insufficient platelets may exhibit frank
bleeding or oozing of blood from puncture sites, wounds, & mucous membranes. -
ANSWER -Platelets
Order of priority is to rescue patient in immediate danger. Next activate fire alarm.
Close all doors & fire extinguished. - ANSWER -Fire event
Transmitted by droplet infection. Precautions include private room or cohort client
& use of standard precaution mask. - ANSWER -Meningococcal pneumonia
Best results sitting head of bed elevated 45 to 90 degrees. Semi-Fowler's or high
Fowler's position. Mouthpiece should be covered completely & tightly while
inhales slowly, with constant flow through unit. Breath should be held for 5
seconds before exhaling slowly. - ANSWER -Incentive spirometer
Placed in left Sims position so enema solution can flow by gravity in natural
direction of colon. - ANSWER -Cleansing enema
Preconventional stage, morals are thought to be motivated by punishment &
reward. - ANSWER -Kohlberg's theory of moral development
Should not try anticipate newborn infant needs but allow newborn infant to signal
needs. If newborn infant is not allowed to signal a need, newborn will not learn
how to control environment. Delayed or prolonged response to newborn infant's
signal would inhibit development trust & lead to mistrust of others - ANSWER -
Erikson's psychosocial development theory
Child has the ability to think abstractly and logically. - ANSWER -Formal
operations stage of Piaget's cognitive developmental theory
Child begins to understand the environment. - ANSWER -Paiget's sensorimotor
stage
Child is able to classify, order, and sort facts. - ANSWER -Paiget's concrete
operational stage
,Child learns to think in terms of past, present, & future. - ANSWER -Paiget's
preoperational stage
20 to 40 breaths/minute - ANSWER -Normal respiratory rate in a 12-month-old
90 to 130 beats/minute - ANSWER -Normal apical heart rate in a 12-month-old
90/56 mm Hg - ANSWER -Average blood pressure in a 12-month-old
Diamond-shaped & located on top of head. Soft & flat in normal infant, & it
normally closes by 12- 18 months of age - ANSWER -Anterior fontane
Decreased lean body mass & age-associated decreased glomerular filtration rate. -
ANSWER -older client is at risk for medication toxicity because
Stand feet together & arms at sides, close eyes & hold position; normally client
can maintain posture & balance. Positive Romberg's sign is a vestibular
neurological sign found when client exhibits loss balance when closing eyes. -
ANSWER -Romberg's test
Rhythmic respirations with periods of apnea. Periods apnea followed by deep
rapid breathing - ANSWER -Cheyne-Stokes respirations
Physical obstruction to transmission of sound waves - ANSWER -Conductive
hearing loss
occurs as result pathological process in inner ear, defect in 8th cranial nerve, or
defect of sensory fibers that lead to cerebral cortex. - ANSWER -Sensorineural
hearing loss
Abnormal heart sound & described as gentle, blowing, swooshing sound. -
ANSWER -Heart murmur
Described as a scratchy, leathery heart sound. - ANSWER -Pericardial friction rub
Tests the six cardinal positions of gaze - ANSWER -Assess for muscle weakness
in eyes
Visual acuity & cranial nerve II (optic). - ANSWER -Snellen eye chart
, Close eyes & then lightly touching areas of face & testing corneal reflexes assess
cranial nerve V (trigeminal). - ANSWER -Testing sensory function
tested insupine position. Flexes head (gently moves head to chest) & there should
be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign
is observed if passively flexes hip & knee in response to neck flexion & reports
pain in vertebral column. - ANSWER -Positive Brudzinski's sign
Blood leaves embryo through two umbilical arteries. Oxygenated, blood returned
by one umbilical vein. Arteries carry deoxygenated blood & waste products from
fetus, umbilical vein carries oxygenated blood & provides oxygen & nutrients to
fetus. - ANSWER -Fetal circulation
Connects umbilical vein to inferior vena cava - ANSWER -Ductus venosus
Is temporary opening between right & left atria. - ANSWER -Foramen ovale
Joins the aorta & pulmonary artery - ANSWER -Ductus arteriosus
Uterine enlargement, Hegar's sign , Goodell's sign , Chadwick's sign, ballottement,
Braxton Hicks contractions, & positive pregnancy test for presence of HCG. -
ANSWER -Probable signs of pregnancy
Fetal heart rate detected by electronic device (Doppler transducer), active fetal
movements palpable by examiner, & outline fetus by radiography or
ultrasonography. - ANSWER -Positive signs of pregnancy
*Pregnancy avoided for 1-3 months. *Vaccine administered subcutaneous
route.*Exposure immunosuppressed individuals avoided. *Hypersensitivity
reaction can occur if client has allergy to eggs. - ANSWER -Rubella virus vaccine
Postpartum
Three classic signs are hypertension, generalized edema, & proteinuria. -
ANSWER -Classic signs of preeclampsia
Can trigger disseminated intravascular coagulation (DIC). Evidence of bleeding,
such as in gums, petechiae, & purpura should be reported to HCP if noted on
assessment. - ANSWER -Severe preeclampsia
, Considered a risk factor for disseminated intravascular coagulation (DIC). -
ANSWER -Dead fetus syndrome
Isoniazid plus rifampin (Rifadin) will be required for 9 months. - ANSWER -
Pregnant client tuberculosis is suspected; sputum culture obtained & identifies
Mycobacterium tuberculosis
When the cervix is dilated completely & ends with birth of the neonate. -
ANSWER -Second Stage of Labor begins
Occur if umbilical cord becomes compressed, reducing blood flow between
placenta & the fetus. - ANSWER -Variable decelerations
Result from pressure on fetal head during a contraction. - ANSWER -Early
decelerations
Fetal heart rate assessed immediately after amniotomy to detect any changes that
may indicate cord compression or prolapse. Minimal vaginal examinations would
be done because of risk of infection. - ANSWER -Assessment finding following an
amniotomy should be conducted first
Acute abdominal pain present. Uterine tenderness with abruption, especially
central abruption & trapped blood behind placenta. Abdomen feels hard/boardlike
on palpation as blood penetrates myometrium & causes uterine irritability.
Premature separation placenta from uterine wall after 20th week gestation, before
fetus delivered. Associated conditions; hypertension, smoking, alcohol/ cocaine
abuse. Overdistention uterus; multiple gestation, polyhydramnios. In addition,
short umbilical cord, physical trauma, increased maternal age & parity are risk
factors. Painful vaginal bleeding, abdominal pain, & back pain identify
signs/symptoms of abruptio placentae. - ANSWER -Abruptio placentae
Symptoms increase in fundal height, hard board-like abdomen, persistent
abdominal pain, late decelerations in fetal heart rate, or decreasing baseline
variability. - ANSWER -Concealed bleeding Prenatal
Improperly implanted placenta lower uterine segment. Manual pelvic exam
contraindicated vaginal bleeding apparent until diagnosis made & placenta previa
ruled out. Digital exam cervix can lead to hemorrhage. Diagnosis by ultrasound.
Hemoglobin/Hematocrit level monitored, external electronic fetal heart rate
monitoring initiated; crucial evaluating status fetus, risk for severe hypoxia. Soft
