NCLEX PRACTICE TEST
after listening to the parents reports and seeing the following pediatric clients, the nurse
knows that which clent demonstrates signs of abuse that may need reporting
1. 1 year old with dyspnea, drooling, and a swollen tongue after eating part of houseplant
2. 2 year old who is crying and has large foregead hemotoma after falling out of a chair
3. 3 year old with second degree burns afte rpulling hot tea off table
4. 5 yr old whose xray recelas 2 humerus fractures after falling from tree - CORRECT
ANSWER -4. 5 year old whose x ray reveal humurus fractures
rationale: the nurse should be aware of signs of abuse including repeated injuries in caried
stages of healing, shaken baby syndrome,
The nurse on an inpatient mental health unit is caring for a client with paranoid delusions
who is refusing to eat. The client states that all the food and drinks have been poisoned.
Which intervention by the nurse is appropriate?
1.
Contact the client's family and ask them to bring prepared food from home
2.
Inform the client that tube feedings will be initiated if the client refuses to eat
3.
Offer to taste the client's food and drinks while the client observes
4.
,Provide the client food in unopened single-serving packages - CORRECT ANSWER -4.
provide the client food in unopened single serving packages
rationale: nursees caring for clients who have paranoid delusions must work to build a
trusting realtionship.
The nurse caring for a male client prepares to insert an indwelling urinary catheter. The
nurse assesses for allergies, explains the procedure to the client, and asks unlicensed
assistive personnel to perform perineal care while equipment is gathered. Place in order the
steps the nurse should take when inserting the urinary catheter. - CORRECT ANSWER -hand
hygiene
apply sterile gloves and place drape down
use non dominant hand to grasp penis
use dominat hand to clean
use dominant hand to insert
advance catheter and inflate balloon
A client is in cardiac arrest, and resuscitation efforts are in progress when the client's spouse
arrives. The client's spouse insists on coming into the room. How should the nurse respond?
1.Allow the spouse into the room and provide a chair
2.
Call the chaplain to sit with the spouse outside the room
3.
Have the unit secretary escort the spouse to the waiting room
,4.
Tell the spouse that the resuscitation is too graphic to be witnessed - CORRECT ANSWER -1.
allow the spouse into the room and provide a chair
The nurse is caring for a client with a central venous catheter (CVC) who reports feeling
nauseated and chilled. The nurse notes that the CVC insertion site is red and inflamed and
that the client has a temperature of 102 F (38.8 C). Which new prescription from the health
care provider should the nurse implement first?
1.Administer ondansetron 4 mg IV push PRN for nausea or vomiting
2.
Document the occurrence and notify the hospital's epidemiology team
3.
Initiate the first dose of IV piperacillin/tazobactam via a new peripheral IV
4.
Obtain blood cultures and discontinue the central venous catheter - CORRECT ANSWER -4.
obtain blood cultures and discontinue the CVS
rationale: when caring for client with signs of Central line infection the nurse should obtain
blood clutlresnd remove the device before beginning antibiotic therapy
The nurse cares for a client with a terminal disease who has an advance directive supporting
a do not resuscitate (DNR) code status. The client stops breathing and loses a pulse. The
client's adult child states, "I changed my mind. Do whatever you can to save him!" Which
intervention is most appropriate at this time?
1.Call for help to initiate cardiopulmonary resuscitation
2.
Call the health care provider to confirm the DNR status
3.
Explain the client's wishes to the client's child
, 4.
Offer to call the hospital chaplain to provide support - CORRECT ANSWER -3. explain the
wishes to the clients child
The clinic nurse is assessing a client who is being treated for depression and suicidal
ideation. Which client statement best indicates that the client is not currently at risk for
suicide?
1.
"I lost my imipramine prescription. Could I have a refill?"
2.
"I plan to attend my granddaughter's graduation next month."
3.
"I seem to have a lot more energy since I started therapy."
4.
"I will sign a 'no-suicide' contract at today's appointment." - CORRECT ANSWER -2. I plan to
aattend my granddaughters graduation next month
The charge nurse is responsible for making room assignments for multiple clients. Which
pair of client assignments to a shared room is appropriate?
1.
Client with blood loss anemia and client with intractable diarrhea [11%]
2.
Client with gastroenteritis and client with chemotherapy-induced nausea and vomiting [6%]
3.
Client who had a bowel resection 1 day ago and client with asthma exacerbation [80%]
4.
Client who had a total hip arthroplasty 2 days ago and client with influenza [1%] - CORRECT
ANSWER -3. client who had a bowel resection 1 day ago and client with asthma
exacerbation
after listening to the parents reports and seeing the following pediatric clients, the nurse
knows that which clent demonstrates signs of abuse that may need reporting
1. 1 year old with dyspnea, drooling, and a swollen tongue after eating part of houseplant
2. 2 year old who is crying and has large foregead hemotoma after falling out of a chair
3. 3 year old with second degree burns afte rpulling hot tea off table
4. 5 yr old whose xray recelas 2 humerus fractures after falling from tree - CORRECT
ANSWER -4. 5 year old whose x ray reveal humurus fractures
rationale: the nurse should be aware of signs of abuse including repeated injuries in caried
stages of healing, shaken baby syndrome,
The nurse on an inpatient mental health unit is caring for a client with paranoid delusions
who is refusing to eat. The client states that all the food and drinks have been poisoned.
Which intervention by the nurse is appropriate?
1.
Contact the client's family and ask them to bring prepared food from home
2.
Inform the client that tube feedings will be initiated if the client refuses to eat
3.
Offer to taste the client's food and drinks while the client observes
4.
,Provide the client food in unopened single-serving packages - CORRECT ANSWER -4.
provide the client food in unopened single serving packages
rationale: nursees caring for clients who have paranoid delusions must work to build a
trusting realtionship.
The nurse caring for a male client prepares to insert an indwelling urinary catheter. The
nurse assesses for allergies, explains the procedure to the client, and asks unlicensed
assistive personnel to perform perineal care while equipment is gathered. Place in order the
steps the nurse should take when inserting the urinary catheter. - CORRECT ANSWER -hand
hygiene
apply sterile gloves and place drape down
use non dominant hand to grasp penis
use dominat hand to clean
use dominant hand to insert
advance catheter and inflate balloon
A client is in cardiac arrest, and resuscitation efforts are in progress when the client's spouse
arrives. The client's spouse insists on coming into the room. How should the nurse respond?
1.Allow the spouse into the room and provide a chair
2.
Call the chaplain to sit with the spouse outside the room
3.
Have the unit secretary escort the spouse to the waiting room
,4.
Tell the spouse that the resuscitation is too graphic to be witnessed - CORRECT ANSWER -1.
allow the spouse into the room and provide a chair
The nurse is caring for a client with a central venous catheter (CVC) who reports feeling
nauseated and chilled. The nurse notes that the CVC insertion site is red and inflamed and
that the client has a temperature of 102 F (38.8 C). Which new prescription from the health
care provider should the nurse implement first?
1.Administer ondansetron 4 mg IV push PRN for nausea or vomiting
2.
Document the occurrence and notify the hospital's epidemiology team
3.
Initiate the first dose of IV piperacillin/tazobactam via a new peripheral IV
4.
Obtain blood cultures and discontinue the central venous catheter - CORRECT ANSWER -4.
obtain blood cultures and discontinue the CVS
rationale: when caring for client with signs of Central line infection the nurse should obtain
blood clutlresnd remove the device before beginning antibiotic therapy
The nurse cares for a client with a terminal disease who has an advance directive supporting
a do not resuscitate (DNR) code status. The client stops breathing and loses a pulse. The
client's adult child states, "I changed my mind. Do whatever you can to save him!" Which
intervention is most appropriate at this time?
1.Call for help to initiate cardiopulmonary resuscitation
2.
Call the health care provider to confirm the DNR status
3.
Explain the client's wishes to the client's child
, 4.
Offer to call the hospital chaplain to provide support - CORRECT ANSWER -3. explain the
wishes to the clients child
The clinic nurse is assessing a client who is being treated for depression and suicidal
ideation. Which client statement best indicates that the client is not currently at risk for
suicide?
1.
"I lost my imipramine prescription. Could I have a refill?"
2.
"I plan to attend my granddaughter's graduation next month."
3.
"I seem to have a lot more energy since I started therapy."
4.
"I will sign a 'no-suicide' contract at today's appointment." - CORRECT ANSWER -2. I plan to
aattend my granddaughters graduation next month
The charge nurse is responsible for making room assignments for multiple clients. Which
pair of client assignments to a shared room is appropriate?
1.
Client with blood loss anemia and client with intractable diarrhea [11%]
2.
Client with gastroenteritis and client with chemotherapy-induced nausea and vomiting [6%]
3.
Client who had a bowel resection 1 day ago and client with asthma exacerbation [80%]
4.
Client who had a total hip arthroplasty 2 days ago and client with influenza [1%] - CORRECT
ANSWER -3. client who had a bowel resection 1 day ago and client with asthma
exacerbation
