Nclex-Exam practice

Nclex-Exam practice Introduction A 24-item NCLEX style exam all about the ADPIE or the Nursing Process. Topics • Nursing Process Guidelines • Read each question carefully and choose the best answer. • You are given one minute per question. Spend your time wisely! • Answers and rationales are given below. Be sure to read them. • If you need more clarifications, please direct them to the comments section. Questions 1. Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses, a: 1. Plan is developed for nursing care. 2. Physical assessment begins 3. List of priorities is determined. 4. Review of the assessment is conducted with other team members. 2. Planning is a category of nursing behaviors in which: 1. The nurse determines the health care needed for the client. 2. The Physician determines the plan of care for the client. 3. Client-centered goals and expected outcomes are established. 4. The client determines the care needed. 3. Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client’s: 1. Physician 2. Non Emergent, non-life threatening needs 3. Future well-being. 4. Urgency of problems 4. A client centered goal is a specific and measurable behavior or response that reflects a client’s: 1. Desire for specific health care interventions 2. Highest possible level of wellness and independence in function. 3. Physician’s goal for the specific client. 4. Response when compared to another client with a like problem. 5. For clients to participate in goal setting, they should be: 1. Alert and have some degree of independence. 2. Ambulatory and mobile. 3. Able to speak and write. 4. Able to read and write. 6. The nurse writes an expected outcome statement in measurable terms. An example is: 1. Client will have less pain. 2. Client will be pain free. 3. Client will report pain acuity less than 4 on a scale of 0-10. 4. Client will take pain medication every 4 hours around the clock. 7. As goals, outcomes, and interventions are developed, the nurse must: 1. Be in charge of all care and planning for the client. 2. Be aware of and committed to accepted standards of practice from nursing and other disciples. 3. Not change the plan of care for the client. 4. Be in control of all interventions for the client. 8. When establishing realistic goals, the nurse: 1. Bases the goals on the nurse’s personal knowledge. 2. Knows the resources of the health care facility, family, and the client. 3. Must have a client who is physically and emotionally stable. 4. Must have the client’s cooperation. 9. To initiate an intervention the nurse must be competent in three areas, which include: 1. Knowledge, function, and specific skills 2. Experience, advanced education, and skills. 3. Skills, finances, and leadership. 4. Leadership, autonomy, and skills. 10. Collaborative interventions are therapies that require: 1. Physician and nurse interventions. 2. Nurse and client interventions. 3. Client and Physician intervention. 4. Multiple health care professionals. 11. Well formulated, client-centered goals should: 1. Meet immediate client needs. 2. Include preventative health care. 3. Include rehabilitation needs. 4. All of the above. 12. The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free from infection throughout hospitalization. This statement is an example of a (an): 1. Nursing diagnosis 2. Short-term goal 3. Long-term goal 4. Expected outcome 13. The following statements appear on a nursing care plan for a client after a mastectomy: Incision site approximated; absence of drainage or prolonged erythema at incision site; and client remains afebrile. These statements are examples of: 1. Nursing interventions 2. Short-term goals 3. Long-term goals 4. Expected outcomes. 14. The planning step of the nursing process includes which of the following activities? 1. Assessing and diagnosing 2. Evaluating goal achievement. 3. Performing nursing actions and documenting them. 4. Setting goals and selecting interventions. 15. The nursing care plan is: 1. A written guideline for implementation and evaluation. 2. A documentation of client care. 3. A projection of potential alterations in client behaviors 4. A tool to set goals and project outcomes. 16. After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal: 1. Encourage client to implement guided imagery when pain begins. 2. Determine effect of pain intensity on client function. 3. Administer analgesic 30 minutes before physical therapy treatment. 4. Pain intensity reported as a 3 or less during hospital stay. 17. When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including: 1. Apply a cold pack to the tibia. 2. Elevate the leg 5 inches above the heart. 3. Perform range of motion to right leg every 4 hours. 4. Administer aspirin 325 mg every 4 hours as needed. 18. Which of the following nursing interventions are written correctly? (Select all that apply.) 1. Apply continuous passive motion machine during day. 2. Perform neurovascular checks. 3. Elevate head of bed 30 degrees before meals. 4. Change dressing once a shift. 19. A client’s wound is not healing and appears to be worsening with the current treatment. The nurse first considers: 1. Notifying the physician. 2. Calling the wound care nurse 3. Changing the wound care treatment. 4. Consulting with another nurse. 20. When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following: 1. Length of time the current treatment has been in place. 2. The spouse’s reaction to the client’s dressing change. 3. Client’s concern about the current treatment. 4. Physician’s reluctance to change the current treatment plan. 21. The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to: 1. Implement the specialist’s recommendations. 2. Report the recommendations to the primary physician. 3. Clarify the suggestions with the client and family members. 4. Discuss and review advised strategies with CNS. 22. After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first. 1. Constipation 2. Anticipated grieving 3. Ineffective airway clearance 4. Ineffective tissue perfusion. 23. The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis? 1. A client’s family attending a diabetic teaching session. 2. Canceling physical therapy sessions on the weekend. 3. Normal VS and absence of wound infection in a post-op client. 4. A client demonstrating accurate medication administration following teaching. 24. The RN has received her client assignment for the day-shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first? 1. A client who is ambulatory. 2. A client, who has a fever, is diaphoretic and restless. 3. A client scheduled for OT at 1300. 4. A client who just had an appendectomy and has just received pain medication. Answers and Rationale 1. A 2. B 3. D 4. B 5. A 6. C 7. B 8. B 9. A 10. D 11. D 12. B 13. D 14. D 15. A 16. D. This is measurable and objective. 17. B. This does not require a physician’s order. (A & D require an order; C is not appropriate for a fractured tibia) 18. C. It is specific in what to do and when. 19. B. Calling in the wound care nurse as a consultant is appropriate because he or she is a specialist in the area of wound management. Professional and competent nurses recognize limitations and seek appropriate consultation. (a. This might be appropriate after deciding on a plan of action with the wound care nurse specialist. The nurse may need to obtain orders for special wound care products. c. Unless the nurse is knowledgeable in wound management, this could delay wound healing. Also, the current wound management plan could have been ordered by the physician. d. Another nurse most likely will not be knowledgeable about wounds, and the primary nurse would know the history of the wound management plan.) 20. A. This gives the consulting nurse facts that will influence a new plan. (b, c, and d. These are all subjective and emotional issues/conclusions about the current treatment plan and may cause a bias in the decision of a new treatment plan by the nurse consultant.) 21. D. Because the primary nurse requested the consultation, it is important that they communicate and discuss recommendations. The primary nurse can then accept or reject the CNS recommendations. (a. Some of the recommendations may not be appropriate for this client. The primary nurse would know this information. A consultation requires review of the recommendations, but not immediate implementation. b. This would be appropriate after first talking with the CNS about recommended changes in the plan of care and the rationale. Then the primary nurse should call the physician. c. The client and family do not have the knowledge to determine whether new strategies are appropriate or not. Better to wait until the new plan of care is agreed upon by the primary nurse and physician before talking with the client and/or family.) 22. C, D, A, B. 23. B. 24. B. This clients needs are a priority. Introduction An NCLEX practice exam dedicated to Coronary Artery Disease and Hypertension. This exam contains 50 items about the two diseases. Topics • Coronary Artery Disease • Hypertension Guidelines • Read each question carefully and choose the best answer. • You are given one minute per question. Spend your time wisely! • Answers and rationales are given below. Be sure to read them. • If you need more clarifications, please direct them to the comments section. Questions 1. A client is scheduled for a cardiac catheterization using a radiopaque dye. Which of the following assessments is most critical before the procedure? 1. Intake and output 2. Baseline peripheral pulse rates 3. Height and weight 4. Allergy to iodine or shellfish 2. A client with no history of cardiovascular disease comes into the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse to discriminate pain caused by a non-cardiac problem? 1. “Have you ever had this pain before?” 2. “Can you describe the pain to me?” 3. “Does the pain get worse when you breathe in?” 4. “Can you rate the pain on a scale of 1-10, with 10 being the worst?” 3. A client with myocardial infarction has been transferred from a coronary care unit to a general medical unit with cardiac monitoring via telemetry. A nurse plans to allow for which of the following client activities? 1. Strict bed rest for 24 hours after transfer 2. Bathroom privileges and self-care activities 3. Unsupervised hallway ambulation with distances under 200 feet 4. Ad lib activities because the client is monitored. 4. A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. The nurse would plan to do which of the following next? 1. Review the intake and output records for the last 2 days 2. Change the time of diuretic administration from morning to evening 3. Request a sodium restriction of 1 g/day from the physician. 4. Order daily weights starting the following morning. 5. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is to: 1. Check the client status and lead placement 2. Press the recorder button on the electrocardiogram console. 3. Call the physician 4. Call a code blue 6. A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following? 1. Seating the client with arm bared, supported, and at heart level. 2. Measuring the blood pressure after the client has been seated quietly for 5 minutes. 3. Using a cuff with a rubber bladder that encircles at least 80% of the limb. 4. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion. 7. IV heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of the following medications is available on the nursing unit? 1. Vitamin K 2. Aminocaproic acid 3. Potassium chloride 4. Protamine sulfate 8. A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin (Coumadin). The client’s prothrombin time is 20 seconds, with a control of 11 seconds. The nurse assesses that this result is: 1. The same as the client’s own baseline level 2. Lower than the needed therapeutic level 3. Within the therapeutic range 4. Higher than the therapeutic range 9. A client who has been receiving heparin therapy also is started on warfarin. The client asks a nurse why both medications are being administered. In formulating a response, the nurse incorporates the understanding that warfarin: 1. Stimulates the breakdown of specific clotting factors by the liver, and it takes 2-3 days for this to exert an anticoagulant effect. 2. Inhibits synthesis of specific clotting factors in the liver, and it takes 3-4 days for this medication to exert an anticoagulant effect. 3. Stimulates production of the body’s own thrombolytic substances, but it takes 2-4 days for this to begin. 4. Has the same mechanism of action as Heparin, and the crossover time is needed for the serum level of warfarin to be therapeutic. 10. A 60-year-old male client comes into the emergency department with complaints of crushing chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction. Immediate admission orders include oxygen by NC at 4L/minute, blood work, chest x-ray, an ECG, and 2 mg of morphine given intravenously. The nurse should first: 1. Administer the morphine 2. Obtain a 12-lead ECG 3. Obtain the lab work 4. Order the chest x-ray 11. When administered a thrombolytic drug to the client experiencing an MI, the nurse explains to him that the purpose of this drug is to: 1. Help keep him well hydrated 2. Dissolve clots he may have 3. Prevent kidney failure 4. Treat potential cardiac arrhythmias. 12. When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that apply. 1. Reflects electrical impulse beginning at the SA node 2. Indicated electrical impulse beginning at the AV node 3. Reflects atrial muscle depolarization 4. Identifies ventricular muscle depolarization 5. Has duration of normally 0.11 seconds or less. 13. A client has driven himself to the ER. He is 50 years old, has a history of hypertension, and informs the nurse that his father died of a heart attack at 60 years of age. The client is presently complaining of indigestion. The nurse connects him to an ECG monitor and begins administering oxygen at 2 L/minute per NC. The nurse’s next action would be to: 1. Call for the doctor 2. Start an intravenous line 3. Obtain a portable chest radiograph 4. Draw blood for laboratory studies 14. The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following? 1. Cancer 2. Hypertension 3. Liver disease 4. Myocardial infarction 15. When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol hydrochloride: 1. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction. 2. Increases norepinephrine secretion and thus decreases blood pressure and heart rate. 3. Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers blood pressure. 4. Is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II. 16. The most important long-term goal for a client with hypertension would be to: 1. Learn how to avoid stress 2. Explore a job change or early retirement 3. Make a commitment to long-term therapy 4. Control high blood pressure 17. Hypertension is known as the silent killer. This phrase is associated with the fact that hypertension often goes undetected until symptoms of other system failures occur. This may occur in the form of: 1. Cerebrovascular accident 2. Liver disease 3. Myocardial infarction 4. Pulmonary disease 18. During the previous few months, a 56-year-old woman felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she is visiting an invalid friend twice a week and now cannot walk up the second flight of steps to the friend’s apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client deal with this problem? 1. Visit her friend earlier in the day. 2. Rest for at least an hour before climbing the stairs. 3. Take a nitroglycerin tablet before climbing the stairs. 4. Lie down once she reaches the friend’s apartment. 19. Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to her physician? 1. A change in the pattern of her pain 2. Pain during sex 3. Pain during an argument with her husband 4. Pain during or after an activity such as lawn mowing 20. The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to: 1. Open and dilate the blocked coronary arteries 2. Assess the extent of arterial blockage 3. Bypass obstructed vessels 4. Assess the functional adequacy of the valves and heart muscle. 21. As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3mg given sublingually. This drug’s principal effects are produced by: 1. Antispasmodic effect on the pericardium 2. Causing an increased myocardial oxygen demand 3. Vasodilation of peripheral vasculature 4. Improved conductivity in the myocardium 22. The nurse teaches the client with angina about the common expected side effects of nitroglycerin, including: 1. Headache 2. High blood pressure 3. Shortness of breath 4. Stomach cramps