NCLEX Practice Questions

The nurse is caring for a client with Clostridium difficile colitis. Which of the following infection control measures by the nurse are appropriate? Select all that apply. 1. applies sterile gloves before performing client care 2. ensures surgical mask are worn by staff while in clients room 3. request that the client be assigned to single-room 4. uses alcohol-based sanitizers for hand hygiene 5. wears single-use, disposable gown during cares

3 and 5

The nurse provides care for clients in the intensive care unit (ICU). A client diagnosed with a head injury requires admission, but there are no empty beds. Which client does the nurse anticipate as being the most stable for a transfer to the step-down neurological unit? 1. A client diagnosed with bacterial meningitis and who has a Glasgow Coma Scale of 7. 2. A client 1 day postoperative after a transsphenoidal craniotomy with a possible cerebrospinal leak. 3. A client diagnosed with a frontal lobe stroke 4 days ago and who is exhibiting confusion. 4. A client with a head injury and who is having seizures.

3. A client diagnosed with a frontal lobe stroke 4 days ago and who is exhibiting confusion. After 4 days, the risk of this client having a second stroke is significantly reduced. Therefore, the focus of care is rehabilitation. This client can be transferred.

A nurse cares for a patient who has a nasogastric tube attached to low suction because of a suspected bowel obstruction. Which of the following arterial blood gas results might be expected in this patient? A. pH 7.52, PCO2 54 mm Hg. B. pH 7.42, PCO2 40 mm Hg. C. pH 7.25, PCO2 25 mm Hg. D. pH 7.38, PCO2 36 mm Hg.

A A patient on nasogastric suction is at risk of metabolic alkalosis as a result of loss of hydrochloric acid in gastric fluid. Of the answers given, only answer A (pH 7.52, PCO2 54 mm Hg) represents alkalosis. Answer B is a normal blood gas. Answer C represents respiratory acidosis. Answer D is borderline normal with slightly low PCO2.

The charge nurse on the cardiac unit is planning assignments for the day. Which of the following is the most appropriate assignment for the float nurse that has been reassigned from labor and delivery? A. A one-week postoperative coronary bypass patient, who is being evaluated for placement of a pacemaker prior to discharge. B. A suspected myocardial infarction patient on telemetry, just admitted from the Emergency Department and scheduled for an angiogram. C. A patient with unstable angina being closely monitored for pain and medication titration. D. A post-operative valve replacement patient who was recently admitted to the unit because all surgical beds were filled.

A The charge nurse planning assignments must consider the skills of the staff and the needs of the patients. The labor and delivery nurse who is not experienced with the needs of cardiac patients should be assigned to those with the least acute needs. The patient who is one-week post-operative and nearing discharge is likely to require routine care. A new patient admitted with suspected MI and scheduled for angiography would require continuous assessment as well as coordination of care that is best carried out by experienced staff. The unstable patient requires staff that can immediately identify symptoms and respond appropriately. A post-operative patient also requires close monitoring and cardiac experience.

A patient in labor and delivery has just received an amniotomy. Which of the following are correct? A. Frequent checks for cervical dilation will be needed after the procedure. B. Contractions may rapidly become stronger and closer together after the procedure. C. The FHR (fetal heart rate) will be followed closely after the procedure due to the possibility of cord compression. D. The procedure is usually painless and is followed by a gush of amniotic fluid.

B, C, and D Uterine contractions typically become stronger and occur more closely together following amniotomy. The FHR is assessed immediately after the procedure and followed closely to detect changes that may indicate cord compression. The procedure itself is painless and results in the quick expulsion of amniotic fluid. Following amniotomy, cervical checks are minimized because of the risk of infection

A patient is admitted to the hospital with a calcium level of 6.0 mg/dL. Which of the following symptoms would you NOT expect to see in this patient? A. Numbness in hands and feet. B. Muscle cramping. C. Hypoactive bowel sounds. D. Positive Chvostek's sign.

C Normal serum calcium is 8.5 - 10 mg/dL. The patient is hypocalcemic. Increased gastric motility, resulting in hyperactive (not hypoactive) bowel sounds, abdominal cramping and diarrhea is an indication of hypocalcemia. Numbness in hands and feet and muscle cramps are also signs of hypocalcemia. Positive Chvostek's sign refers to the sustained twitching of facial muscles following tapping in the area of the cheekbone and is a hallmark of hypocalcemia.

The nurse performs an initial abdominal assessment on a patient newly admitted for abdominal pain. The nurse hears what she describes as "clicks and gurgles in all four quadrants" as well as "swishing or buzzing sound heard in one or two quadrants." Which of the following statements is correct? A. The frequency and intensity of bowel sounds varies depending on the phase of digestion. B. In the presence of intestinal obstruction, bowel sounds will be louder and higher pitched. C. A swishing or buzzing sound may represent the turbulent blood flow of a bruit and is not normal. D. All of the above.

D All of the statements are true. The gurgles and clicks described in the question represent normal bowel sounds, which vary with the phase of digestion. Intestinal obstruction causes the sounds to intensify as the normal flow is blocked by the obstruction. The swishing and buzzing sound of turbulent blood flow may be heard in the abdomen in the presence of abdominal aortic aneurism, for example, and should always be considered abnormal.

A nurse is counseling the mother of a newborn infant with hyperbilirubinemia. Which of the following instructions by the nurse is NOT correct? A. Continue to breastfeed frequently, at least every 2-4 hours. B. Follow up with the infant's physician within 72 hours of discharge for a recheck of the serum bilirubin and exam. C. Watch for signs of dehydration, including decreased urinary output and changes in skin turgor. D. Keep the baby quiet and swaddled, and place the bassinet in a dimly lit area.

D An infant discharged home with hyperbilirubinemia (newborn jaundice) should be placed in a sunny rather than dimly lit area with skin exposed to help process the bilirubin. Frequent feedings will help to metabolize the bilirubin. A recheck of the serum bilirubin and a physical exam within 72 hours will confirm that the level is falling and the infant is thriving and is well hydrated. Signs of dehydration, including decreased urine output and skin changes, indicate inadequate fluid intake and will worsen the hyperbilirubinemia.

A hospitalized patient has received transfusions of 2 units of blood over the past few hours. A nurse enters the room to find the patient sitting up in bed, dyspneic and uncomfortable. On assessment, crackles are heard in the bases of both lungs, probably indicating that the patient is experiencing a complication of transfusion. Which of the following complications is most likely the cause of the patient's symptoms? A. Febrile non-hemolytic reaction. B. Allergic transfusion reaction. C. Acute hemolytic reaction. D. Fluid overload.

D Fluid overload occurs when then the fluid volume infused over a short period is too great for the vascular system, causing fluid leak into the lungs. Symptoms include dyspnea, rapid respirations, and discomfort as in the patient described. Febrile non-hemolytic reaction results in fever. Symptoms of allergic transfusion reaction would include flushing, itching, and a generalized rash. Acute hemolytic reaction may occur when a patient receives blood that is incompatible with his blood type. It is the most serious adverse transfusion reaction and can cause shock and death.

The nurse is caring for a client with acute pericarditis. Which clinical finding would require immediate intervention by the nurse? 1. reposts of chest pain that is worse with deep inspiration 2. distant heart tones and jugular venous distension 3. ECG shows ST segment elevations in all leads 4. pericardial friction rub auscultated at the left sternal border

The nurse is caring for a client with acute pericarditis. Which clinical finding would require immediate intervention by the nurse? 1. reposts of chest pain that is worse with deep inspiration 2. distant heart tones and jugular venous distension 3. ECG shows ST segment elevations in all leads 4. pericardial friction rub auscultated at the left sternal border