“NCLEX Question Trainer Test 3 with Explanations |
Comprehensive Practice Exam with Verified Answers & Detailed
Rationales”
6. Which of the following statements, if made by the nurse, is accurate about the exercise program
required for a patient with rheumatoid arthritis?
1. “If you are having a ‘bad’ day, postpone your exercises until the next day.”
2. “Passive exercises are better for you than active exercises.”
3. “When inflammation is severe, decrease the number of repetitions of the exercise.”
4. “You can substitute your normal household tasks for your exercises to provide variety.”
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) consistency is important to maintain joint mobility
(2) active exercises are better than passive or active-assistive exercises
(3) correct–should reduce when patient experiences more pain
(4) should do exercises that have been prescribed for patient
NURSING TUTOR 2
,7. The nurse is assessing a client with severe bilateral peripheral edema. Which of the following is the
BEST way for the nurse to determine the degree of edema in a limb, and the client’s response to
treatment?
1. Measure both limbs with the tape measure and compare.
2. Depress the skin and rank the degree of pitting.
3. Describe the swelling in the affected area.
4. Pinch the skin and note how quickly it returns to normal.
Strategy: Think about each answer choice.
(1) is not the best way to evaluate for peripheral edema
(2) correct–severity of edema is characterized by grading it 1+ (2-mm pitting) to 4+ (8-mm pitting)
(3) not as objective
(4) is used for evaluating hydration
8. A six-month-old infant has had all of the required immunizations. The nurse knows this would
include which of the following?
1. Two doses of diphtheria, tetanus, and pertussis vaccine.
2. Measles, mumps, and rubella vaccines.
3. A booster dose of the trivalent oral polio vaccine.
4. Chickenpox and smallpox vaccines.
Strategy: Think about each answer choice.
(1) correct–first dose of the DPT may be given at two months, the second is given around four
months
(2) MMR is given at 15 months
(3) polio is given at two and four months and again at 12 to 18 months
(4) smallpox vaccine is no longer recommended
9. The nurse should include which of the following in a teaching plan for a client receiving tetracycline?
1. Take the medication with milk or antacids to decrease GI problems.
2. The medication should always be taken with meals.
3. Use a maximum-protection sunscreen when outdoors.
4. Crackers and juice will help decrease gastric irritation.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) tetracycline should never be taken with milk or antacids as these inhibit the medication’s action
(2) should take with full glass of water at least one hour before or two hours after meals
(3) correct–because of problems related to photosensitivity, sunscreen, wide-brimmed hats, and
long sleeves should be worn when client is at risk for sun exposure
(4) should take with full glass of water at least one hour before or two hours after meals
,10. An elderly alcoholic client has been receiving a long-acting benzodiazepine (Librium) for two days for
symptom management and reduction. The client states: “Get those bugs off of me and clean them
out of here.” The nurse knows the client is exhibiting symptoms of
1. a reaction to the sedative medication.
2. a worsening course of the withdrawal syndrome.
3. an exacerbation of the schizophrenia process.
4. the process of aging and the effects of delirium.
Strategy: Think about each answer choice.
(1) client has been medicated with benzodiazepines and did not experience untoward reactions
(2) correct–client has most probably progressed to another level of abstinence withdrawal from
polypharmacy chemical dependence; characteristic symptoms include tremors, increased heart
rate, and fever, as well as psychological problems of confusion, delusions, and hallucinations
(3) schizophrenic client usually experiences an episode of auditory hallucinations, not visual or
tactile hallucinations
(4) combination effect of the normal aging process and dementia could precipitate a similar
reaction; however, the normal aging process does not produce delirium, but rather dementia
11. A client is admitted for a series of tests to verify the diagnosis of Cushing’s syndrome. Which of the
following assessment findings, if observed by the nurse, would support this diagnosis?
1. Buffalo hump, hyperglycemia, and hypernatremia.
2. Nervousness, tachycardia, and intolerance to heat.
3. Lethargy, weight gain, and intolerance to cold.
4. Irritability, moon face, and dry skin.
Strategy: Think about each answer choice and how it relates to Cushing’s syndrome.
(1) correct–Cushing’s syndrome is characteristic of these assessments, as are weight gain, moon
face, purple striae, osteoporosis, mood swings, and high susceptibility to infections
(2) symptoms of hyperthyroidism
(3) symptoms of hypothyroidism (myxedema)
(4) symptoms of hypoparathyroidism
12. The nurse is caring for a patient several days after an above-knee amputation (AKA). Which of the
following symptoms would be characteristic of an infected stump wound?
1. The patient is anxious and restless.
2. There is a small amount of dark drainage on the dressing.
3. The patient complains of persistent pain at the operative site.
4. The skin is cool above the operative site.
Strategy: Determine how each answer choice relates to an infected wound.
(1) may be due to changes in body image or pain
(2) expected, not indicative of an infection
(3) correct–pain is characteristic of inflammation and infection
(4) warm skin above site would indicate infection
NURSING TUTOR 2
, 13. Which of the following statements, if made by a client to the nurse, would indicate that the client is
using the defense mechanism of conversion?
1. “I love my family with all my heart even though they don’t love me.”
2. “I was unable to take my final exams because I was unable to write.”
3. “I don’t believe I have diabetes. I feel perfectly fine.”
4. “If my wife was a better housekeeper I wouldn’t have such a problem.”
Strategy: Think about each answer choice.
(1) indicates reaction formation
(2) correct–client has converted his anxiety over school performance into a physical symptom that
interferes with his ability to perform
(3) indicates denial
(4) indicates projection
14. Which observation indicates to the nurse that the client needs further teaching before he can
administer his own insulin?
1. The client draws up his regular insulin first, then the NPH.
2. The client gently rotates the insulin bottle before withdrawing the dose.
3. The client rotates injection sites following the guide on his printed diagram.
4. The client administers the insulin while it is still cold from the refrigerator.
Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) when mixing regular insulin with other types of insulin, the client should draw up the clear
(regular) before the cloudy (NPH)
(2) bottle of insulin should never be vigorously shaken, but rather gently mixed
(3) imperative to rotate injection sites to avoid tissue irritation/infection and ensure proper
absorption
(4) correct–insulin should be administered at room temperature, temperature extremes should be
avoided
15. A client has orders for cefoxitin (Mefoxin) 2 g IV piggyback in 100 cc 5% dextrose in water. The
primary IV is 5% dextrose in lactated Ringer’s and is infusing by gravity. It is MOST important for the
nurse to take which of the following actions?
1. Administer the medication slowly, at 25-25 cc/h.
2. Change the primary IV solution.
3. Hang the piggyback infusion bag higher than the primary infusion bag.
4. Obtain an infusion pump prior to administration.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) antibiotic should be administered within one hour
(2) unnecessary for safe infusion
(3) correct–when using a gravity drip, piggyback fluid level needs to be higher than primary
infusion
(4) unnecessary for safe infusion
Comprehensive Practice Exam with Verified Answers & Detailed
Rationales”
6. Which of the following statements, if made by the nurse, is accurate about the exercise program
required for a patient with rheumatoid arthritis?
1. “If you are having a ‘bad’ day, postpone your exercises until the next day.”
2. “Passive exercises are better for you than active exercises.”
3. “When inflammation is severe, decrease the number of repetitions of the exercise.”
4. “You can substitute your normal household tasks for your exercises to provide variety.”
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) consistency is important to maintain joint mobility
(2) active exercises are better than passive or active-assistive exercises
(3) correct–should reduce when patient experiences more pain
(4) should do exercises that have been prescribed for patient
NURSING TUTOR 2
,7. The nurse is assessing a client with severe bilateral peripheral edema. Which of the following is the
BEST way for the nurse to determine the degree of edema in a limb, and the client’s response to
treatment?
1. Measure both limbs with the tape measure and compare.
2. Depress the skin and rank the degree of pitting.
3. Describe the swelling in the affected area.
4. Pinch the skin and note how quickly it returns to normal.
Strategy: Think about each answer choice.
(1) is not the best way to evaluate for peripheral edema
(2) correct–severity of edema is characterized by grading it 1+ (2-mm pitting) to 4+ (8-mm pitting)
(3) not as objective
(4) is used for evaluating hydration
8. A six-month-old infant has had all of the required immunizations. The nurse knows this would
include which of the following?
1. Two doses of diphtheria, tetanus, and pertussis vaccine.
2. Measles, mumps, and rubella vaccines.
3. A booster dose of the trivalent oral polio vaccine.
4. Chickenpox and smallpox vaccines.
Strategy: Think about each answer choice.
(1) correct–first dose of the DPT may be given at two months, the second is given around four
months
(2) MMR is given at 15 months
(3) polio is given at two and four months and again at 12 to 18 months
(4) smallpox vaccine is no longer recommended
9. The nurse should include which of the following in a teaching plan for a client receiving tetracycline?
1. Take the medication with milk or antacids to decrease GI problems.
2. The medication should always be taken with meals.
3. Use a maximum-protection sunscreen when outdoors.
4. Crackers and juice will help decrease gastric irritation.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) tetracycline should never be taken with milk or antacids as these inhibit the medication’s action
(2) should take with full glass of water at least one hour before or two hours after meals
(3) correct–because of problems related to photosensitivity, sunscreen, wide-brimmed hats, and
long sleeves should be worn when client is at risk for sun exposure
(4) should take with full glass of water at least one hour before or two hours after meals
,10. An elderly alcoholic client has been receiving a long-acting benzodiazepine (Librium) for two days for
symptom management and reduction. The client states: “Get those bugs off of me and clean them
out of here.” The nurse knows the client is exhibiting symptoms of
1. a reaction to the sedative medication.
2. a worsening course of the withdrawal syndrome.
3. an exacerbation of the schizophrenia process.
4. the process of aging and the effects of delirium.
Strategy: Think about each answer choice.
(1) client has been medicated with benzodiazepines and did not experience untoward reactions
(2) correct–client has most probably progressed to another level of abstinence withdrawal from
polypharmacy chemical dependence; characteristic symptoms include tremors, increased heart
rate, and fever, as well as psychological problems of confusion, delusions, and hallucinations
(3) schizophrenic client usually experiences an episode of auditory hallucinations, not visual or
tactile hallucinations
(4) combination effect of the normal aging process and dementia could precipitate a similar
reaction; however, the normal aging process does not produce delirium, but rather dementia
11. A client is admitted for a series of tests to verify the diagnosis of Cushing’s syndrome. Which of the
following assessment findings, if observed by the nurse, would support this diagnosis?
1. Buffalo hump, hyperglycemia, and hypernatremia.
2. Nervousness, tachycardia, and intolerance to heat.
3. Lethargy, weight gain, and intolerance to cold.
4. Irritability, moon face, and dry skin.
Strategy: Think about each answer choice and how it relates to Cushing’s syndrome.
(1) correct–Cushing’s syndrome is characteristic of these assessments, as are weight gain, moon
face, purple striae, osteoporosis, mood swings, and high susceptibility to infections
(2) symptoms of hyperthyroidism
(3) symptoms of hypothyroidism (myxedema)
(4) symptoms of hypoparathyroidism
12. The nurse is caring for a patient several days after an above-knee amputation (AKA). Which of the
following symptoms would be characteristic of an infected stump wound?
1. The patient is anxious and restless.
2. There is a small amount of dark drainage on the dressing.
3. The patient complains of persistent pain at the operative site.
4. The skin is cool above the operative site.
Strategy: Determine how each answer choice relates to an infected wound.
(1) may be due to changes in body image or pain
(2) expected, not indicative of an infection
(3) correct–pain is characteristic of inflammation and infection
(4) warm skin above site would indicate infection
NURSING TUTOR 2
, 13. Which of the following statements, if made by a client to the nurse, would indicate that the client is
using the defense mechanism of conversion?
1. “I love my family with all my heart even though they don’t love me.”
2. “I was unable to take my final exams because I was unable to write.”
3. “I don’t believe I have diabetes. I feel perfectly fine.”
4. “If my wife was a better housekeeper I wouldn’t have such a problem.”
Strategy: Think about each answer choice.
(1) indicates reaction formation
(2) correct–client has converted his anxiety over school performance into a physical symptom that
interferes with his ability to perform
(3) indicates denial
(4) indicates projection
14. Which observation indicates to the nurse that the client needs further teaching before he can
administer his own insulin?
1. The client draws up his regular insulin first, then the NPH.
2. The client gently rotates the insulin bottle before withdrawing the dose.
3. The client rotates injection sites following the guide on his printed diagram.
4. The client administers the insulin while it is still cold from the refrigerator.
Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) when mixing regular insulin with other types of insulin, the client should draw up the clear
(regular) before the cloudy (NPH)
(2) bottle of insulin should never be vigorously shaken, but rather gently mixed
(3) imperative to rotate injection sites to avoid tissue irritation/infection and ensure proper
absorption
(4) correct–insulin should be administered at room temperature, temperature extremes should be
avoided
15. A client has orders for cefoxitin (Mefoxin) 2 g IV piggyback in 100 cc 5% dextrose in water. The
primary IV is 5% dextrose in lactated Ringer’s and is infusing by gravity. It is MOST important for the
nurse to take which of the following actions?
1. Administer the medication slowly, at 25-25 cc/h.
2. Change the primary IV solution.
3. Hang the piggyback infusion bag higher than the primary infusion bag.
4. Obtain an infusion pump prior to administration.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) antibiotic should be administered within one hour
(2) unnecessary for safe infusion
(3) correct–when using a gravity drip, piggyback fluid level needs to be higher than primary
infusion
(4) unnecessary for safe infusion
