NCLEX PN Practice Test 1

6. The nurse is caring for a client who will undergo surgical repair of a detached retina. Which of the following is the most likely preoperative nursing diagnosis for this client? A. Anxiety related to loss of vision and potential failure to regain vision. B. Deficient knowledge (preoperative and postoperative activities) related to lack of information. C. Acute pain related to tissue injury and decreased circulation to the eye. D. Risk for infection related to the eye injury.

A. Anxiety related to loss of vision and potential failure to regain vision.

13. The nurse is caring for a 44-year-old client diagnosed with hypoparathyroidism. Which electrolyte imbalance is closely associated with hypoparathyroidism? A. Hypocalcemia. B. Hyponatremia. C. Hyperkalemia. D. Hypophosphatemia.

A. Hypocalcemia

14. The nurse is caring for a client diagnosed with end-stage liver disease. The client has completed an advance directive and a do-not-resuscitate (DNR) document and wishes to receive palliative care. Which of the following would correspond to the client's wish for comfort care? A. Positioning frequently to prevent skin breakdown and providing pain management and other comfort measures. B. Carrying out vigorous resuscitation efforts if the client were to stop breathing, but no resuscitation if the heart stops beating. C. Providing intravenous fluids when the client becomes dehydrated. D. Providing total parenteral nutrition (TPN) if the client is not able to eat.

A. Positioning frequently to prevent skin breakdown and providing pain management and other comfort measures.

10. A one-month old infant in the neonatal intensive care unit is dying. The parents request that the nurse administer an opioid analgesic to their infant, who is crying weakly. The infant's heart rate is 68 beats per minute and the respiratory rate is 18 breaths per minute. The infant is on room air and the oxygen saturation is 92%. The nurse's response is based on which of the following principles? A. Providing analgesia during the last days and hours is an ethically-appropriate nursing action. B. Withholding the opioid analgesia during the last days and hours is an ethical duty because administering it would represent assisted suicide. C. Administering analgesia during the last days and hours is the parent's ethical decision. D. Withholding the opioid analgesia is clinically appropriate because it will hasten the infant's death.

A. Providing analgesia during the last days and hours is an ethically-appropriate nursing action.

17. A 12-year-old boy has been receiving aggressive treatment for leukemia for the past year. His condition has continued to deteriorate, and the prognosis is poor. The parents would like to implement a "Do Not Resuscitate" plan but inform the nurse that they cannot bring themselves to discuss it with their child and ask the nurse to discuss it with the child instead. When approaching the subject with the child, the nurse must assess which of the following first? A. What the child knows about the disease and his prognosis. B. How the child would like to handle the plan of care. C. What interventions the child would like in the event of cardiac or respiratory arrest. D. What the child believes about death.

A. What the child knows about the disease and his prognosis.

4. When educating a pregnant client about home safety, which of the following information is appropriate for the nurse to include in the teaching plan? Select all that apply. A. When taking a shower, place a non-skid mat on the floor of the tub or shower. B. Avoid climbing stairs. C. Avoid wearing high heels. D. Use non-slip rugs on the floors.

A. When taking a shower, place a non-skid mat on the floor of the tub or shower. B. Avoid climbing stairs. C. Avoid wearing high heels.

16. The nurse is checking laboratory values on a patient who has crackling rales in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which of the following laboratory values does the nurse expect to be abnormal? A. Potassium. B. B-type natriuretic peptide (BNP). C. C-reactive protein (CRP). D. Platelets.

B. B-type natriuretic peptide (BNP).

7. When assessing a client with glaucoma, a nurse expects which of the following findings? A. Complaints of double vision. B. Complaints of halos around lights. C. Intraocular pressure of 15 mm Hg. D. Soft globe on palpation.

B. Complaints of halos around lights.

20. A nurse is taking the health history of an 85-year-old client. Which of the following physical findings is consistent with normal aging? A. Increase in subcutaneous fat. B. Diminished cough reflex. C. Long-term memory loss. D. Myopia.

B. Diminished cough reflex.

11. While undergoing hemodialysis, the client becomes restless and tells the nurse he has a headache and feels nauseous. Which of the following complications does the nurse suspect? A. Infection. B. Disequilibrium syndrome. C. Air embolus. D. Acute hemolysis.

B. Disequilibrium syndrome.

5. A client had a C5 spinal cord contusion that resulted in quadriplegia. Two days after the injury occurred, the nurse sees his mother crying in the waiting room. The mother asks the nurse whether her son will ever play football again. Which of the following is the best initial response? A. "Given time and motivation, your son can return to normal function." B. "I'm not sure, but I'll call the physician to talk to you right away." C. "What do you know about your son's injury?" D. "Getting upset isn't in you son's best interest."

C. "What do you know about your son's injury?"

15. The nurse is caring for a client receiving warfarin therapy (Coumadin®) following a stroke. The client's PT/INR was completed at 7:00 A.M. prior to the morning meal with an INR reading of 4.0. Which of the following is the nurse's first priority? A. Call the physician to request an increase in the Coumadin® dose. B. Administer a vitamin K injection IM and notify the physician of the results. C. Assess the client for bleeding around the gums or in the stool and notify the physician of the lab results and latest dose of Coumadin®. D. Notify the next shift to hold the daily dose of Coumadin® scheduled for 5:00 pm.

C. Assess the client for bleeding around the gums or in the stool and notify the physician of the lab results and latest dose of Coumadin®.

1. The nurse is caring for a client following an appendectomy. The client reports nausea and complains of surgical site pain at a 6 on a 0 to 10 scale. The client's employer is present in the room and states he is paying for the insurance and wants to know what pain medication has been prescribed by the physician. Which of the following is the appropriate nurse response? A. Answer any questions the employer may have as he pays for the insurance. B. Tell the employer his question is inappropriate and that the information is none of his business. C. Explain to the employer that you cannot release private information and ask the employer to step out while you conduct your assessment of the client. D. Ask the employer to leave and wait until the client returns home to visit.

C. Explain to the employer that you cannot release private information and ask the employer to step out while you conduct your assessment of the client.

2. The nurse is caring for a client with a history of advanced chronic obstructive pulmonary disease (COPD). The client had conventional gallbladder surgery 2 days previously. Which intervention has priority for preventing respiratory complications? A. Incentive spirometry every 4 hours. B. Coughing and deep breathing four times daily. C. Getting the client out of bed 4 times daily as ordered by the physician. D. Giving oxygen at 4 L/minute according to the physician's order.

C. Getting the client out of bed 4 times daily as ordered by the physician

8. A client had a Caesarean delivery and is postpartum day 1. She asks for pain medication when the nurse enters the room to do her shift assessment. The client states that her pain level is an 8 on a scale of 1 to 10. What should be the nurse's priority of care? A. Give the pain medication and return in an hour for further assessment to allow time for the medication to work. B. Complete the postpartum assessment and then give the client pain medication. C. Give the pain medication first, do a quick assessment while administering the medication to ensure the pain is not caused by a complication, and return for the full assessment after the client's pain has subsided. D. Instruct the patient to do relaxation exercises to relieve her discomfort.

C. Give the pain medication first, do a quick assessment while administering the medication to ensure the pain is not caused by a complication, and return for the full assessment after the client's pain has subsided.

12. An elderly couple is speaking to the nurse about their ambivalence related to sending the client, their adult, dual-diagnosed (bipolar and drug addict) son, into residential placement. They tell the nurse that neither keeping their son at home nor sending him to a facility is a satisfactory solution for them. What information should the nurse keep in mind when discussing this dilemma with the family? Select all that apply. A. Implement what is best for the couple. B. Suggest another psychiatric evaluation for the son. C. Look for all potential options for care. D. Review the client's treatment history. E. Consult legal authorities for information.

C. Look for all potential options for care. D. Review the client's treatment history.

19. The nurse is reviewing self-care measures for a client with peripheral vascular disease. Which of the following statements indicates proper self-care measures? A. "I like to soak my feet in the hot tub everyday." B. "I walk to the mailbox in my bare feet." C. "I stopped smoking and only use chewing tobacco." D. "I have my wife examine the soles of my feet each day."

D. "I have my wife examine the soles of my feet each day."

9. The nurse is preparing to teach a client about the effects of isoniazid (INH). Which information is important for the client to understand? A. Isoniazid should be taken on an empty stomach. B. Prolonged use of isoniazid produces poorly concentrated urine. C. Taking aluminum hydroxide (Maalox)® with isoniazid minimizes gastrointestinal upset. D. Drinking alcohol daily can increase the incidence of drug-induced hepatitis.

D. Drinking alcohol daily can increase the incidence of drug-induced hepatitis

18. The nurse is advising a client with a colostomy. The client reports problems with flatus. Which of the following foods should the nurse recommend? A. High fiber foods, such as bran. B. Cruciferous vegetables, such as cabbage, broccoli, and kale. C. Carbonated beverages. D. Yogurt.

D. Yogurt.