NCLEX Practice Exam 1

NCLEX Practice Exam 1 shown after you have selected an answer. No time limit for this exam. NCLEX Practice Exam 19 (50 Questions) Question 1 Wrong The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem? A Chronic vessel plaque formation B Pulmonary embolism Occlusions at the vessel bifurcations Coronary artery aneurysms Question 1 Explanation: Option D: Kawasaki Disease involves all the small and medium-sized blood vessels. There is progressive inflammation of the small vessels which progresses to the medium-sized muscular arteries, potentially damaging the walls and leading to coronary artery aneurysms. Question 2 Wrong A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? A “I cannot give this medication as it is written. I have no idea of what you mean.” “Would you please clarify what you have written so I am sure I am reading it correctly?” C “I am having difficulty reading your handwriting. It would save me time if you would be more careful.” “Please print in the future so I do not have to spend extra time attempting to read your writing.” Question 2 Explanation: Option B: Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self- depreciation. It reflects the right of the professional to give and receive information. Question 3 Wrong The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior? Reprimand the child and give a 15-minute “time out” B Maintain a permissive attitude for this behavior Use patience and a sense of humor to deal with this behavior D Assert authority over the child through limit setting Question 3 Explanation: Option C: The nurse should help the parents see the negativism as a normal growth of autonomy in the toddler. They can best handle the negative toddler by using patience and humor. Question 4 Correct An ambulatory client reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask? A “Have you had a recent heart attack?” “Do you become short of breath during your normal daily activities?” C “How many pillows do you use at night to sleep comfortably?” D “Do you smoke?” Question 4 Explanation: Option B: These are the symptoms of right-sided heart failure, which causes increased pressure in the systemic venous system. To equalize this pressure, the fluid shifts into the interstitial spaces causing edema. Because of gravity, the lower extremities are first affected in an ambulatory patient. This question would elicit information to confirm the nursing diagnosis of activity intolerance and fluid volume excess both associated with right-sided heart failure. Question 5 Wrong The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the following actions would be most appropriate? Fluid restriction 1000cc per day B Ambulate in hallway 4 times a day Administer analgesic therapy as ordered D Encourage increased caloric intake Question 5 Explanation: Option C: The main general objectives in the treatment of a sickle cell crisis is bed rest, hydration, electrolyte replacement, analgesics for pain, blood replacement and antibiotics to treat any existing infection. Question 6 Correct While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other behavior? A Sexual promiscuity Poor body image C Dropping out of school D Drug experimentation Question 6 Explanation: Option B: As the adolescent gains weight, there is a lessening sense of self-esteem and poor body image. Question 7 Wrong A nurse and client are talking about the client’s progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship? Pre-interaction B Orientation Working D Termination Question 7 Explanation: Option C: During the working phase, alternative behaviors and techniques are explored. The nurse and the client discuss the meaning behind the behavior. Question 8 Correct A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly blue. The appropriate initial action should be to A Begin mouth to mouth resuscitation B Give the child water to help in swallowing Perform 5 abdominal thrusts D Call for the emergency response team Question 8 Explanation: Option C: At this age, the most effective way to clear the airway of food is to perform abdominal thrusts. Question 9 Correct The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse? A “Do not worry. Epilepsy can be treated with medications.” “The seizure may or may not mean your child has epilepsy.” C “Since this was the first convulsion, it may not happen again.” D “Long-term treatment will prevent future seizures.” Question 9 Explanation: Option B: There are many possible causes for a childhood seizure. These include fever, central nervous system conditions, trauma, metabolic alterations and idiopathic (unknown). Question 10 Wrong A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis? A Gestational age assessment suggested growth retardation Meconium was cleared from the airway at delivery C Phototherapy was used to treat Rh incompatibility The infant received mechanical ventilation for 2 weeks Question 10 Explanation: Option D: Bronchopulmonary dysplasia is an iatrogenic disease caused by therapies such as use of positive-pressure ventilation used to treat lung disease. Question 11 Correct Parents of a 6 month-old breastfed baby ask the nurse about increasing the baby’s diet. Which of the following should be added first? Cereal B Eggs C Meat D Juice Question 11 Explanation: Option A: The guidelines of the American Academy of Pediatrics recommend that one new food be introduced at a time, beginning with strained cereal. Question 12 Correct A victim of domestic violence states, “If I were better, I would not have been beaten.” Which feeling best describes what the victim may be experiencing? A Fear B Helplessness Self-blame D Rejection Question 12 Explanation: Option C: Domestic violence victims may be immobilized by a variety of affective responses, one being self-blame. The victim believes that a change in their behavior will cause the abuser to become nonviolent, which is a myth. Question 13 Wrong The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client’s recent memory? “Name the year.” “What season is this?” (pause for answer after each question) B “Subtract 7 from 100 and then subtract 7 from that.” (pause for answer) “Now continue to subtract 7 from the new number.” “I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen.” D “What is this on my wrist?” (point to your watch) Then ask, “What is the purpose of it?” Question 14 Correct Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client? A Venturi mask B Partial rebreather mask Non-rebreather mask D Simple face mask Question 14 Explanation: Option C: The non-rebreather mask has a one-way valve that prevents exhales air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent inhalation of room air but to allow exhalation of air. When a tight seal is achieved around the mask up to 100% of oxygen is available. Question 15 Wrong A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse’s immediate attention? A Capillary refill of fingers on right hand is 3 seconds B Skin warm to touch and normally colored