NCLEX Practice Exam 2 / 11 Question and Answers

NCLEX Practice Exam Question and
Answers


 When performing a head-to-toe assessment, the
nurse has difficulty hearing the client's heart sounds.
What should the nurse do to better auscultate the S1
and S2 heart sounds?

 Ask the client to lean forward in a sitting position
 2.
 Have the client inhale deeply and hold the breath
 3.
 Instruct the client to raise the left arm over the head
 4.
 Use the bell of the stethoscope instead of the
diaphragm ---100%Correct Answers--- 1.


 Client with active gastrointestinal bleeding receiving a
blood transfusion
 4.
 Client with diabetes requiring blood glucose checks
and subcutaneous mealtime insulin
 5.
 Client with paroxysmal atrial fibrillation requiring
scheduled oral diltiazem ---100%Correct Answers---
1, 4, 5

, A medical-surgical nurse with no critical care
experience has been assigned to float to the intensive
care unit for the shift. Which clients would be
appropriate for the charge nurse to assign to this
nurse? Select all that apply.
 1.
 Client 3 days postoperative from a femoral-popliteal
bypass graft
 2.
 Client in restraints to prevent self-extubation of an
endotracheal tube
 3.
 Client receiving a continuous IV norepinephrine
infusion for septic shock
 4.
 Client with acute stroke receiving tissue plasminogen
activator
 5.
 Client with diabetic ketoacidosis receiving insulin
before meals ---100%Correct Answers--- 1, 5

 The nurse suspects that a client with cirrhosis is
developing hepatic encephalopathy based on which
assessment findings? Select all that apply.
 1.
 Breath has musty, sweet odor
 2.
 Excessively sleepy
 3.
 Flapping tremors when arms and hands are extended
 4.

, Had 2 soft bowel movements in 24 hours
 5.
 Pinpoint pupils ---100%Correct Answers--- 1, 2, 3




 The nurse on a medical-surgical unit prepares
scheduled daily medications for a client and places
them in a pill cup. After receiving the pill cup, the
client states, "I take a whole tablet of metoprolol at
home. Why did you cut this one in half?" What is the
best response by the nurse?
 1.
 "Do you know how many milligrams of metoprolol you
normally take at home every day?"
 2.
 "Show me which pill you're talking about so I can
verify your prescriptions again."
 3.
 "This is the same dose you received the past 3 days
in the hospital, so we know it's safe to take."
 4.
 "Your health care provider has prescribed a half-dose
of metoprolol while you're in the hospital." ---
100%Correct Answers--- 2.

 The nurse assesses a client who is intubated and
mechanically ventilated after a cerebrovascular

, accident. Which assessment finding is most important
for the nurse to report to the health care provider?
 1.
 Flaccid right hand and arm
 2.
 Impaired gag reflex when suctioning
 3.
 Presence of urinary incontinence
 4.
 Rigid flexion of arms at the elbows ---100%Correct
Answers--- 4.

 The nurse is preparing to discharge a client 4 days
after colostomy placement. Which of the following
findings are concerning and require further
investigation? Select all that apply.
 1.
 Areas of excoriation are noted on the skin
surrounding the stoma.
 2.
 No bowel sounds are present and the client reports
nausea.
 3.
 The client states, "I will call home health to come
empty the pouch."
 4.


 A nurse coworker is called into work from home to
help care for an influx of clients being admitted after a
bus accident. While assisting the coworker prepare