NCLEX- RN Practice Exam 13

1. The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?

1. The tube will allow for equalization of the lung expansion.
2. Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs.
3. Chest tubes relieve pain associated with a collapsed lung.
4. Chest tubes assist with cardiac function by stabilizing lung expansion.

2. A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the:

1. Mother’s educational level
2. Infant’s birth weight
3. Size of the mother’s breast
4. Mother’s desire to breastfeed

3. The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?

1. The presence of scant bloody discharge
2. Frequent urination
3.  The presence of green-tinged amniotic fluid
4. Moderate uterine contractions

4. The nurse is measuring the duration of the client’s contractions. Which statement is true regarding the measurement of the duration of contractions?

1. Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction.
2. Duration is measured by timing from the end of one contraction to the beginning of the next contraction.
3. Duration is measured by timing from the beginning of one contraction to the end of the same contraction.
4. Duration is measured by timing from the peak of one contraction to the end of the same contraction.

5. The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:

1. Maternal hypoglycemia
2. Fetal bradycardia
3. Maternal hyperreflexia
4. Fetal movement

6. A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?

1. Insulin requirements moderate as the pregnancy progresses.
2. A decreased need for insulin occurs during the second trimester.
3. Elevations in human chorionic gonadotrophin decrease the need for insulin.
4. Fetal development depends on adequate insulin regulation.

7. A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:

1. Providing a calm environment
2. Obtaining a diet history
3. Administering an analgesic
4. Assessing fetal heart tones

8. A primigravida, age 42, is 6 weeks pregnant. Based on the client’s age, her infant is at risk for:

1. Down syndrome
2. Respiratory distress syndrome
3. Turner’s syndrome
4. Pathological jaundice

9. A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:

1. Magnesium sulfate
2. Calcium gluconate
3. Dinoprostone (Prostin E.)
4. Bromocrystine (Pardel)

10. A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100mL. The nurse should:

1. Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure
2. Stop the infusion of magnesium sulfate and contact the physician
3. Slow the infusion rate and turn the client on her left side
4. Administer calcium gluconate IV push and continue to monitor the blood pressure

11. Which statement made by the nurse describes the inheritance pattern of autosomal recessive disorders?

1. An affected newborn has unaffected parents.
2. An affected newborn has one affected parent.
3. Affected parents have a one in four chance of passing on the defective gene.
4. Affected parents have unaffected children who are carriers.

12. A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:

1. Because it is a state law
2. To detect cardiovascular defects
3. Because of her age
4. To detect neurological defects

13. A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse’s response is based on the knowledge that:

1. There is no need to take thyroid medication because the fetus’s thyroid produces a thyroid-stimulating hormone.
2. Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy.
3. It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism.
4. Fetal growth is arrested if thyroid medication is continued during pregnancy.

14. The nurse is responsible for performing a neonatal assessment on a full-term infant. At 1 minute, the nurse could expect to find:

1. An apical pulse of 100
2. An absence of tonus
3. Cyanosis of the feet and hands
4. Jaundice of the skin and sclera

15. A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client’s need for:

1. Supplemental oxygen
2. Fluid restriction
3. Blood transfusion
4. Delivery by Caesarean section

16. A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes:

1. Increasing fluid intake
2. Limiting ambulation
3. Administering an enema
4. Withholding food for 8 hours

17. An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year?

1. 14 pounds
2. 16 pounds
3. 18 pounds
4. 24 pounds

18. A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test:

1. Determines the lung maturity of the fetus
2. Measures the activity of the fetus
3. Shows the effect of contractions on the fetal heart rate
4. Measures the neurological well-being of the fetus

19. A full-term male has hypospadias. Which statement describes hypospadias?

1. The urethral opening is absent.
2. The urethra opens on the dorsal side of the penis.
3. The penis is shorter than usual.
4. The urethra opens on the ventral side of the penis.

20. A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8cm dilated, with complete effacement. The priority nursing diagnosis at this time is:

1. Alteration in coping related to pain
2. Potential for injury related to precipitate delivery
3. Alteration in elimination related to anesthesia
4. Potential for fluid volume deficit related to NPO status

21. The client with varicella will most likely have an order for which category of medication?

1. Antibiotics
2. Antipyretics
3. Antivirals
4. Anticoagulants

22. A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question?

1. Nitroglycerin
2. Ampicillin
3. Propranolol
4. Verapamil

23. Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?

1.  Avoid exercise because it fatigues the joints.
2.  Take prescribed anti-inflammatory medications with meals.
3.  Alternate hot and cold packs to affected joints.
4.  Avoid weight-bearing activity.

24. A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should be questioned by the nurse?

1. Meperidine 100mg IM q 4 hours PRN pain
2. Mylanta 30 ccs q 4 hours via NG
3. Cimetadine 300mg PO q.i.d.
4. Morphine 8mg IM q 4 hours PRN pain

25. The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:

1. Hallucinogenic drugs create both stimulant and depressant effects.
2. Hallucinogenic drugs induce a state of altered perception.
3. Hallucinogenic drugs produce severe respiratory depression.
4. Hallucinogenic drugs induce rapid physical dependence

26. A nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Choose the instructions that would be included on the list. Select all that apply.

1. Use the fingertips to lift the cast while it is drying.
2. Keep small toys and sharp objects away from the cast.
3. Use a padded ruler or another padded object to scratch the skin under the cast if it itches.
4. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold.
5. Contact the health care provider if the child complains of numbness or tingling in the extremity.
6. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling.

27. The nurse would anticipate the use of which medications in the treatment of the client with heart failure? Select all that apply.

1. Diuretics
2. Anticoagulants
3. Anticholinergics
4. Cardiac glycosides
5. Phosphodiesterase (PDE) inhibitors
6. Angiotensin-converting enzyme (ACE) inhibitors

28. Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply.

1. A premature infant
2. A 101-year-old man
3. A client on renal dialysis
4.  A client with diabetes mellitus
5. A 29-year-old woman with pneumonia
6. A client with congestive heart failure

29. When the nurse is collecting data from the older adult, which of the following findings would be considered normal physiological changes? Select all that apply.

1. Increased heart rate
2. Decline in visual acuity
3. Decreased respiratory rate
4. Decline in long-term memory
5. Increased susceptibility to urinary tract infections
6. Increased incidence of awakening after sleep onset

30. Which data indicates to the nurse that a client may be experiencing ineffective coping?

1. Constantly neglects personal grooming
2. Visits her husband’s grave once a month
3. Visits the senior citizens’ center once a month
4. Frequently looks at snapshots of her husband and family

Answers and Rationales