NCSBN NCLEX PRACTICE EXAM
Questions 76-90 and Answers
1.An 18 month-old weighing 22 pounds is admitted to the pediatric unit with
a diagnosis of dehydration. A replacement bolus of normal saline at 20
mL/kg is ordered to be administered intravenously over 40 minutes.
In mL/hour, what will be the setting for the IV delivery system?
ANS 300
Using ratio proportion;First, convert 22 pounds to kilograms (22/2.2) =
10 kg20 mL/kg = 20 x 10 kg = 200 mL200 mL/40 minutes = x mL/60
minutes (in an hour)200 x 60 = 12000/40 = 300 mL/hrUsing
dimensional analysis;20 mL/kg x 1 kg/2.2 lb x 22 lb x 60 min/hr x 1/40
min = 300 mL/hr
2.The mother of a 2 month-old baby calls a pediatrician's nurse two days
after the first DTaP, inactivated polio vaccine (IPV), Hepatitis B and
Haemophilus influenzae type B (HIB) immunizations. She reports that the
baby feels very warm, cries inconsolably for as long as three hours, and has
had several shaking spells. Which immunization would the nurse expect to
be primarily responsible with these findings?
A. DTaP
B. IPV
C. Hepatitis B
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,D. HIB
ANS A
DTaP immunization is a vaccine that protects against diptheria, tetanus
and pertus- sis (whooping cough). The majority of reactions described in
this question occur with the administration of the DTaP vaccination.
Contraindications to giving repeat DTaP immunizations include the
occurrence of severe side effects after a previous dose, as well as signs
of encephalopathy within seven days of the immunization.
3.A client diagnosed with angina has been instructed about the use of
sub- lingual nitroglycerin. Which statement made by the client is incorrect
and indicates a need for further teaching?
A. "I'll call the health care provider if pain continues after three tablets
five minutes apart."
B. "I will rest briefly right after taking one tablet."
C. "I understand that the medication should be kept in the dark bottle."
D. "I can swallow two or three tablets at once if I have severe pain."
ANS D Clients must understand that just one sublingual tablet should
be taken at a time and placed under the tongue. After rest and a five-
minute interval, a second and then eventually a third tablet may be
necessary.
4.The nurse is working with victims of domestic abuse. The nurse
should understand which of these factors is a reason why domestic
violence or emotional abuse remains extensively undetected?
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104
,A. The expenses due to police and court costs are prohibitive
B. Little knowledge is known about batterers and battering relationships
C. There are typically many series of minor, vague complaints
D. Few people who have been battered seek medical care
ANS C
Signs of domestic violence or emotional abuse may not be clearly
manifested and include many series of a minor complaints such as
headache, abdominal pain, insomnia, back pain and dizziness. These
may be covert indications of violence or abuse that go undetected.
These complaints may be vague and reflect ambivalence about the
disclosure of any violence or abuse.
5.The nurse is obtaining an aerobic wound culture from a client with stage
two pressure injury. The nurse first removes a gauze dressing and
observes a moderate amount of purulent drainage on the dressing and then
the nurse performs hand hygiene. What is the next correct step in the
procedure?
A. Swab the gauze dressing that was removed from the wound
B. Irrigate the wound with normal saline
C. Obtain a culture by rotating a sterile swab in the open wound
D. Remove wound exudate from the wound edges with a cotton tip applicator
ANS B
After removing the dressing and performing hand hygiene, the wound
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, needs to be irrigated to remove surface pathogens before the nurse can
obtain a wound culture. Cultures are not obtained from wound exudate
on the dressing or wounds that have not been irrigated since the
exudate may be contaminated with normal skin flora.
6.The nurse is caring for a client who is experiencing frightening hallucina-
tions that are markedly increased at night. The client's partner asks to stay a
few hours beyond the visiting time, in the client's private room. What would
be the best response by the nurse?
A. "Yes, staying with the client and orienting the client to the
surroundings may decrease any anxiety."
B. "No, your presence may cause the client to become more anxious."
C. "No, it would be best if you brought the client some reading material
that the client could read at night."
D. "Yes, would you like to spend the night when the client's behavior
indicates that the client is or will be frightened?"
ANS A
Encouragement of a family member or a close friend to stay with the
client in a quiet surrounding cannot only help increase orientation, but
can also minimize confusion
and anxiety. The visitor could also report to the nurse any unusual
findings of the client. This would be the most supportive approach for
this client.
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104
Questions 76-90 and Answers
1.An 18 month-old weighing 22 pounds is admitted to the pediatric unit with
a diagnosis of dehydration. A replacement bolus of normal saline at 20
mL/kg is ordered to be administered intravenously over 40 minutes.
In mL/hour, what will be the setting for the IV delivery system?
ANS 300
Using ratio proportion;First, convert 22 pounds to kilograms (22/2.2) =
10 kg20 mL/kg = 20 x 10 kg = 200 mL200 mL/40 minutes = x mL/60
minutes (in an hour)200 x 60 = 12000/40 = 300 mL/hrUsing
dimensional analysis;20 mL/kg x 1 kg/2.2 lb x 22 lb x 60 min/hr x 1/40
min = 300 mL/hr
2.The mother of a 2 month-old baby calls a pediatrician's nurse two days
after the first DTaP, inactivated polio vaccine (IPV), Hepatitis B and
Haemophilus influenzae type B (HIB) immunizations. She reports that the
baby feels very warm, cries inconsolably for as long as three hours, and has
had several shaking spells. Which immunization would the nurse expect to
be primarily responsible with these findings?
A. DTaP
B. IPV
C. Hepatitis B
1/
104
,D. HIB
ANS A
DTaP immunization is a vaccine that protects against diptheria, tetanus
and pertus- sis (whooping cough). The majority of reactions described in
this question occur with the administration of the DTaP vaccination.
Contraindications to giving repeat DTaP immunizations include the
occurrence of severe side effects after a previous dose, as well as signs
of encephalopathy within seven days of the immunization.
3.A client diagnosed with angina has been instructed about the use of
sub- lingual nitroglycerin. Which statement made by the client is incorrect
and indicates a need for further teaching?
A. "I'll call the health care provider if pain continues after three tablets
five minutes apart."
B. "I will rest briefly right after taking one tablet."
C. "I understand that the medication should be kept in the dark bottle."
D. "I can swallow two or three tablets at once if I have severe pain."
ANS D Clients must understand that just one sublingual tablet should
be taken at a time and placed under the tongue. After rest and a five-
minute interval, a second and then eventually a third tablet may be
necessary.
4.The nurse is working with victims of domestic abuse. The nurse
should understand which of these factors is a reason why domestic
violence or emotional abuse remains extensively undetected?
2/
104
,A. The expenses due to police and court costs are prohibitive
B. Little knowledge is known about batterers and battering relationships
C. There are typically many series of minor, vague complaints
D. Few people who have been battered seek medical care
ANS C
Signs of domestic violence or emotional abuse may not be clearly
manifested and include many series of a minor complaints such as
headache, abdominal pain, insomnia, back pain and dizziness. These
may be covert indications of violence or abuse that go undetected.
These complaints may be vague and reflect ambivalence about the
disclosure of any violence or abuse.
5.The nurse is obtaining an aerobic wound culture from a client with stage
two pressure injury. The nurse first removes a gauze dressing and
observes a moderate amount of purulent drainage on the dressing and then
the nurse performs hand hygiene. What is the next correct step in the
procedure?
A. Swab the gauze dressing that was removed from the wound
B. Irrigate the wound with normal saline
C. Obtain a culture by rotating a sterile swab in the open wound
D. Remove wound exudate from the wound edges with a cotton tip applicator
ANS B
After removing the dressing and performing hand hygiene, the wound
3/
104
, needs to be irrigated to remove surface pathogens before the nurse can
obtain a wound culture. Cultures are not obtained from wound exudate
on the dressing or wounds that have not been irrigated since the
exudate may be contaminated with normal skin flora.
6.The nurse is caring for a client who is experiencing frightening hallucina-
tions that are markedly increased at night. The client's partner asks to stay a
few hours beyond the visiting time, in the client's private room. What would
be the best response by the nurse?
A. "Yes, staying with the client and orienting the client to the
surroundings may decrease any anxiety."
B. "No, your presence may cause the client to become more anxious."
C. "No, it would be best if you brought the client some reading material
that the client could read at night."
D. "Yes, would you like to spend the night when the client's behavior
indicates that the client is or will be frightened?"
ANS A
Encouragement of a family member or a close friend to stay with the
client in a quiet surrounding cannot only help increase orientation, but
can also minimize confusion
and anxiety. The visitor could also report to the nurse any unusual
findings of the client. This would be the most supportive approach for
this client.
4/
104
