NCLEX Practice Tests
A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and next: 1 Bending and then straightening their knees 2 Bending at the waist and then straightening the back 3 Placing one foot in front of the other and then leaning back 4 Placing pressure against the client's axillae and then raising their arms
1 The leg bones and muscles are used for weight bearing and are the strongest in the body. Using the knees for leverage while lifting the client shifts the stress of the transfer to the caregiver's legs. By using the strong muscles of the legs the back is protected from injury. Bending at the waist and then using the back for leverage is how many caregivers and people who must lift heavy objects sustain back injuries. The anatomical structure of the back is equipped only to bear the weight of the upper body. By leaning back, the client's weight is on the caregiver's arms, which are not equipped for heavy weight bearing. The caregiver's arms are not strong enough to lift the client. In the struggle to lift the client, the client and caregiver may be injured.
A nurse arrives for work to find that the medical unit is short-staffed. Nursing administration has called several staffing agencies, but they are unable to send a replacement nurse for three hours. The nursing care coordinator sends a recently oriented patient care assistant to help relieve the burden of care. Which activities should the nurse delegate to the patient care assistant? Select all that apply. 1Making occupied beds 2 Taking routine vital signs 3 Answering clients' call lights 4 Watching a client take oral medications 5 Emptying a closed chest drainage system for intake and output
1, 2, 3 Patient care assistants can make occupied and unoccupied beds. Taking routine vital signs is within the scope of practice of patient care assistants. Answering call lights and meeting clients' basic safety, hygiene, and comfort needs are within the scope of practice of patient care assistants. Watching a client take oral medications is part of procedure for administration of medications, which requires a professional license. Emptying a closed chest drainage system for intake and output is inappropriate; a closed chest drainage system is not emptied for intake and output. Documentation is indicated on the outside of the drainage collection chamber.
A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report? 1 A statement that the nursing staff was not at fault because the client initiated the accident. 2 A listing of facts related to the incident as witnessed by the nurse. 3 The name of the nurse who was responsible for implementing the restraints. 4 The potential reasons why the restraints were not in place at the time of the fall.
2 The nurse filling out an incident or variance report needs to state only the objective facts surrounding the incident, no opinion or speculation. In an incident report fault or blame is subjective and should not be implied. It is not necessary to include names except for those of witnesses. Speculations or opinions as to the reason why the ordered restraints were not on the client are subjective and not appropriate to include in an incident or variance report.
A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client? 1 Arrangements will be made by the client and the client's family. 2 The plan is formulated and implemented early in the client's care. 3 The rehabilitation is minimal and short term because the client will return to former activities. 4 Arrangements will be made for long-term care because the client is no longer capable of self-care.
2 To promote optimism and facilitate smooth functioning, rehabilitation planning should begin on admission to the hospital. The client and family often are unaware of the options available in the health care system; the nurse should be available to provide the necessary information and support. Rehabilitation helps a client adjust to a new lifestyle that must compensate for the paralysis. The goal of rehabilitation is to foster independence wherever the client may live after discharge.
When suctioning a client with a tracheostomy, an important safety measure for the nurse is to: 1 Hyperventilate the client with room air prior to suctioning. 2 Apply suction only as the catheter is being withdrawn. 3 Insert the catheter until the cough reflex is stimulated. 4 Remove the inner cannula before inserting the suction catheter.
2 Use of suction upon withdrawal of a suction catheter reduces unnecessary removal of oxygen. In addition, suction should be applied intermittently during the withdrawal procedure to prevent hypoxia. A sterile catheter is used to prevent infection, and the catheter should only be inserted approximately 1 to 2 cm past the end of the tracheostomy tube to prevent tissue trauma. Hyperventilating a client before suctioning should always be with oxygen, not room air. Inserting the catheter until the cough reflex is stimulated frequently occurs and does help to mobilize secretions but is not a safety measure. Removal of the inner cannula before inserting the suction catheter is not necessary.
A client is admitted voluntarily to a psychiatric unit. Later, the client develops severe pain in the right lower quadrant and is diagnosed as having acute appendicitis. How should the nurse prepare the client for the appendectomy? 1 Have two nurses witness the client signing the operative consent form. 2 Ensure that the health care provider and the psychiatrist sign for the surgery because it is an emergency procedure. 3 Ask the client to sign the operative consent form after the client has been informed of the procedure and required care. 4 Inform the client's next of kin that it will be necessary for one of them to sign the consent form because the client is on a psychiatric unit.
3 Because the client is not certified as incompetent, the right of informed consent is retained. The client can sign the consent, but the client's signature requires only one witness. Because there is no evidence of incompetence, the client should sign the consent.
A client is receiving fresh frozen plasma (FFP). The nurse would expect to see improvement in which condition? 1 Thrombocytopenia 2 Oxygen deficiency 3 Clotting factor deficiency 4 Low hemoglobin
3 FFP is an unconcentrated form of blood plasma containing all of the clotting factors except platelets. It can be used to supplement red blood cells (RBCs) when other blood products are not available or to correct a bleeding problem of unknown cause. Thrombocytopenia is a condition of low platelet count and is not treated with FFP. An oxygen deficiency and low hemoglobin may be improved indirectly with FFP, but it is not a definitive treatment.
A home health nurse on a first visit checks the client's vital signs and obtains a blood sample for an international normalization ratio (INR). After completion of these tasks, the client asks the nurse to straighten the blankets on the bed. What is the nurse's most appropriate response? 1 "I would, but my back hurts today." 2 "Okay. It will be my good deed for the day." 3 "Of course. I want to do whatever I can for you." 4 "I would like to, but it is not in my job description."
3 Helping the client to meet physical needs is within the role of the nurse; arranging blankets on the client's bed is an appropriate intervention. The nurse's comfort needs should not take precedence over the client's needs; the nurse should not assume responsibility for the role of care provider if incapable of providing care. It is not a good deed but fulfills the expected role of the nurse; this response sounds grudgingly compliant. This is within the nurse's job description.
A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to: 1 Promote gluconeogenesis. 2 Produce an anti-inflammatory effect. 3 Promote cell growth and bone union. 4 Decrease pain medication requirements.
3 There is an increased need for protein with any type of body tissue trauma. High protein intake in the client with a fractured bone promotes cell growth and therefore bone union. Intake of a high protein diet during recovery from a bone fracture is not related to gluconeogenesis, inflammation, or pain.
A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? 1 Postural drainage 2 Cupping the chest 3 Nasotracheal suctioning 4 Frequent changes of position
4 Frequent changes of position minimize pooling of respiratory secretions and maximize chest expansion, which aids in the removal of secretions; this helps maintain the airway and is an independent nursing function. Postural drainage and cupping the chest are part of pulmonary therapy that requires a health care provider's prescription. Nasotracheal suctioning will remove secretions once they accumulate in the upper airway, not prevent their accumulation.
While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. This condition is known as: 1 Osteoarthritis 2 Osteoporosis 3 Muscle atrophy 4 Contracture
4 Immobilized clients are at high risk for the development of contractures. Contractures are characterized by permanent shortening of the muscle covering a joint. Osteoarthritis is a disease process of the weight-bearing joints due to wear and tear. Osteoporosis is a metabolic disease process where the bones lose calcium. Muscle atrophy is a wasting and/or decrease in the strength and size of muscles due to a lack of physical activity or a neurological or musculoskeletal disorder.
The nurse providing post-procedure care to a client who had a cardiac catheterization through the femoral artery discovers a large amount of blood under the client's buttocks. After donning gloves, which action should the nurse take first? 1 Apply pressure to the site. 2 Obtain vital signs. 3 Change the client's gown and bed linens. 4 Assess the catheterization site.
4 Observing standard precautions is the first priority when dealing with any body fluid, followed by assessment of the catheterization site as the second priority. This action establishes the source of the blood and determines how much blood has been lost. Once the source of the bleeding is determined the priority goal for this client is to stop the bleeding and ensure stability of the client by monitoring the vital signs. Changing the client's gown and bed linens is not necessary until the bleeding is controlled and the client is stabilized.
A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. The nurse should assign the client to which type of room? 1 Private room 2 Semi-private room 3 Room with windows that can be opened 4 Negative airflow room
4 Tuberculosis is an airborne contagious disease that is best contained in a negative airflow room. Negative airflow rooms are always private. A private room, semiprivate room, and a room with windows that can be opened are not appropriate for the standard of care for a client diagnosed with tuberculosis. Additionally, opening windows would present a possible safety hazard in a client's room.
A physician orders a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site? 1Tubing injection port 2 Distal end of the tubing 3 Urinary drainage bag 4 Catheter insertion site
1 The appropriate site to obtain a urine specimen for a patient with an indwelling catheter is the injection port. The nurse should clean the injection port cap of the catheter drainage tubing with appropriate antiseptic, attach a sterile 5-mL syringe into the port, and aspirate the quantity desired. The nurse should apply a clamp to the drainage tubing, distal to the injection port, not obtain the specimen from this site. Urine in the bedside drainage bag is not an appropriate sample as the urine in the bag may have been there too long; thus a clean sample cannot be obtained from the bag. The client's urine will be contained in the indwelling catheter; there will be no urine at the insertion site.
After several weeks of caring for clients who are in the terminal stage of illness, the nurse becomes aware of feeling depressed when coming to work. What should the nurse do? 1 Talk with other nurses on the unit. 2 Take several personal days off from work. 3 Limit emotional involvement with the clients. 4 Request a transfer to another area of the hospital.
1Talking with nurses who cope with similar issues allows the nurse to share feelings and obtain constructive emotional support. Avoidance may provide an immediate solution, but it works only for a short time. The nurse will eventually have to work through feelings. Limiting emotional involvement with the clients avoids personal feelings about death and dying and is an unacceptable attitude when caring for dying clients. Emotional withdrawal may be perceived by the clients as rejection. Avoidance may provide an immediate solution, but it works only for a short time. The nurse will eventually have to work through feelings.
A client tells the nurse that the client's chest tube is scheduled to be removed soon. Before it is removed, the nurse is aware that: 1 The drainage system will be disconnected from the chest tube. 2 A chest x-ray will be performed to determine lung re-expansion. 3 An arterial blood gas will be obtained to determine oxygenation status. 4 The client will be sedated 30 minutes before the procedure.
2 A chest x-ray should be performed to ensure and to document that the lung is re-expanded and has remained expanded. The drainage system should not be disconnected from the actual chest tube while still in the client because this may cause a pneumothorax to recur. An arterial blood gas may be performed prior to removal but is not necessary. An oxygen saturation reading with a pulse oximeter is usually sufficient to determine oxygenation level. The client may be given pain medication before the procedure but not sedation, as this may decrease the oxygen status.
A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care? 1 Exploring the client's emotional conflict 2 Identifying personal feelings toward this client 3 Planning to discuss this with the client's family 4 Developing a rapport with the client's health care provider
2 Nurses must identify their own feelings and prejudices because these may affect the ability to provide objective, nonjudgmental nursing care. Exploring a client's emotional well-being can be accomplished only after the nurse works through one's own feelings. The focus should be on the client, not the family. Health team members should work together for the benefit of all clients, not just this client.
A client has a platelet count of 49,000/mL. The nurse should instruct the client to avoid which activity? 1 Ambulation 2 Blowing the nose 3 Visiting with children 4 The semi-Fowler's position
2 Patients with thrombocytopenia are at a greater risk of excessive bleeding in response to minimal trauma. The nurse should instruct the patient to avoid blowing their nose as this activity can increase the risk of bleeding. The following activities are not contraindicated with thrombocytopenia: ambulation, visiting with children, and semi-Fowler's position.
A nurse is caring for a client with albuminuria resulting in edema. What pressure change does the nurse determine to be the cause of the edema? 1 Decrease in tissue hydrostatic pressure 2 Increase in plasma hydrostatic pressure 3 Increase in tissue colloid osmotic pressure 4 Decrease in plasma colloid oncotic pressure (COP)
4 Because the plasma COP is the major force drawing fluid from the interstitial spaces back into the capillaries, a drop in COP caused by albuminuria results in edema. Hydrostatic tissue pressure is unaffected by alteration of protein levels; colloidal pressure is affected. Hydrostatic pressure is influenced by the volume of fluid and the diameter of the blood vessel, not directly by the presence of albumin. The osmotic pressure of tissues is unchanged.
The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to: 1 Promote equalization of osmotic pressures. 2 Prevent hypoxia associated with diaphoresis. 3 Promote integrity of intracerebral neurons. 4 Reduce brain metabolism and limit hypoxia.
4 Cooling blankets and antipyretic medications can induce hypothermia thus decreasing brain metabolism. This in turn makes the brain less vulnerable by decreasing the need for oxygen. The integrity of intracerebral neurons and osmotic pressure equalization depend on an adequate supply of oxygen, carbon dioxide, and glucose, and may occur as a result of decreased cerebral metabolism and hypoxia. Diaphoresis does not cause hypoxia. Antipyretic medications may cause diaphoresis as vasodilation occurs.
A day after an explanation of the effects of surgery to create an ileostomy, a 68-year-old male client remarks to the nurse, "It will be difficult for my wife to care for a helpless old man." This comment by the client regarding himself is an example of Erikson's conflict of:1 Initiative versus guilt 2 Integrity versus despair 3 Industry versus inferiority 4 Generativity versus stagnation
2 According to Erikson, poor self-concept and feelings of despair are conflicts manifested in those who are older than 65 years of age. The initiative versus guilt conflict is manifested in early childhood between 3 and 6 years of age. The industry versus inferiority conflict is manifested during the ages from 6 to 11 years. The generatively versus stagnation conflict is manifested during middle adulthood, 45 to 65 years of age.
A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin, decreased hair growth, and thickened toenails. The nurse understands that this may indicate: 1 Venous insufficiency 2 Arterial Insufficiency 3 Phlebitis 4 Lymphedema
2 Clients suffering from arterial insufficiency present with pale colored extremities when elevated and dusky red colored extremities when lowered. Lower extremities may also be cool to touch, pulses may be absent or mild, and skin may be shiny, thin, with decreased hair growth, and thickened nails. Clients suffering from venous insufficiency often have normal colored extremities, normal temperature, normal pulses, marked edema, and brown pigmentation around ankles. Phlebitis is an inflammation of a vein that occurs most often after trauma to the vessel wall, infection, and immobilization. Lymphedema is swelling in one or more extremities that is a direct result from impaired flow of the lymphatic system.
The nurse discovers several palpable elevated masses on a client's arms. Which term most accurately describes the assessment findings? 1 Erosions 2 Macules 3 Papules 4 Vesicles
3 Papules are superficial and elevated up to 0.5 cm. Nodules and tumors are masses similar to papules but are elevated more than 0.5 cm and may infiltrate deeper into tissues. Erosions are characterized as loss of the epidermis layer; macules are nonpalpable, flat changes in skin color less than 1 cm in diameter; and vesicles are usually transparent, filled with serous fluid, and are a blisterlike elevation.
A client with coronary artery disease has a sudden episode of cyanosis and a change in respirations. The nurse starts oxygen administration immediately. Legally, should the nurse have administered the oxygen? 1 The oxygen had not been prescribed and therefore should not have been administered. 2 The symptoms were too vague for the nurse to determine a need for administering oxygen. 3 The nurse's observations were sufficient, and therefore oxygen should have been administered. 4 The health care provider should have been called for a prescription before the nurse administered the oxygen.
3 The Nurse Practice Act states that nurses diagnose and treat human responses to actual or potential health problems. Administration of oxygen in an emergency situation is within the scope of nursing practice. Because the client's clinical manifestations reflected an immediate need for oxygen, postponement of treatment could have resulted in further deterioration of the client's condition.
A nurse receives abnormal results of diagnostic testing. What action should the nurse take first? 1 Inform the client of the results. 2 Ensure that the results are placed in the client's medical record. 3 Notify the client's health care provider of the results. 4 Obtain results of the other lab tests that were performed.
3 The nurse is most ethically and legally accountable for reporting diagnostic testing results to the client's health care provider, whether the results are normal or, more important, abnormal. Informing the client of the results is an incorrect action in this situation. Placing the results in the client's record and obtaining normal values of the results from the lab are acceptable actions for the nurse after notifying the health care provider of the abnormal results.
A client has a "prayer cloth" pinned to the hospital gown. The cloth is soiled from being touched frequently. What should the nurse do when changing the client's gown? 1 Make a new prayer cloth. 2 Discard the soiled prayer cloth. 3 Pin the prayer cloth to the clean gown. 4 Wash the prayer cloth with a detergent.
3 The prayer cloth has religious significance for the client and should be preserved as is. Making a new prayer cloth disregards what the prayer cloth means to the client. The prayer cloth is the property of the client and should not be discarded. Washing the prayer cloth with a detergent disregards what the prayer cloth means to the client; this never should be done without the client's permission.