NCLEX PRACTICE EXAM 01

Answer the 20 item exam
and get your scores below!

1. An adult male is in the post-anesthesia care unit (PACU) following a hemicolectomy. While in the PACU, the nurse will monitor his vital signs:

A. continuously
B. every 5 minutes
C. every 15 minutes
D. on a PRN basis


2. In this patient who underwent general anesthesia, one of the signs that may indicate that artificial airway should be removed is:

A. gagging
B. restlessness
C. an increase in pain
D. clear lungs on auscultation


3. An adult is 6 days post abdominal surgery. Which sign alerts the nurse to wound evisceration?
A. acute bleeding
B. pink serous drainage
C. purple drainage
D. severe pain


4. An adult client�s wound has eviscerated; the nurse assesses his respiratory status because:

A. dehiscence elevates the diaphragm
B. coughing increases the risk of evisceration
C. respiratory arrest commonly accompanies wound dehiscence
D. splinting the wound will compromise respiratory status


5. A major advantage of regional anesthesia is that the client:

A. retains all reflexes
B. remains conscious
C. has retroactive amnesia
D. is in the OR for a short period of time


6. A client is scheduled for an emergency appendectomy; which of the following preoperative laboratory valued would require intervention prior to surgery?

A. hemoglobin 13.5 g/dL
B. serum potassium 3.0 mEq/L
C. partial thromboplastin time (PTT) 25 sec
D. serum sodium 140 mEq/L

7. During preoperative assessment, the nurse finds that the client has an irregular pulses, pedal edema, and cyanotic nail beds. These symptoms indicate an alteration in:

A. pulmonary function
B. renal function
C. cardiovascular function
D. liver function


8. During preop interview, which of the following statements made by the client would alert the nurse to an increased risk during surgery?

A. I rarely eat red meat, it usually makes me feel bloated
B. I do take a large assortment of vitamins daily
C. I experience headaches almost daily, but I only need to take a couple of aspirin to get relief
D. I am a reformed smoker, I haven not had a cigarette in 10 years


9. Which assessment methodology is likely to provide the most useful information related to a person�s teaching/learning needs preoperatively?

A. asking the person what he or she wants to know
B. conducting a purposeful interview
C. encouraging the person to share aspects of his or her daily routine
D. examining old records


10. Which nursing action would best help to prevent thrombophlebitis in a postop client?

A. massaging the client�s leg
B. assisting the client to sit up in bed after surgery
C. maintaining the legs in an elevated position
D. reminding the client to exercise her legs and feet


11. A client (high school student) who has a history of seizures reports a recent inability to concentrate and mood swings, which of the following actions is appropriate for the nurse to take?

A. explain to the client that this is a normal progression of seizures
B. speak to the client�s physician regarding a change in medications
C. assess the client for changer in motor or sensory function
D. recommend a decrease in the client�s physical activity


12. The nurse observed a client�s gait as short, accelerating steps, shuffling, forward-leaning posture, and difficulty in starting and stopping. The nurse would identify this gait as:

A. ataxic
B. parkinsonian
C. dystrophic
D. festinating


13. A patient with CVA is showing slightly dilated pupils. This can be explained by non-conduction of the:

A. Cranial nerve II
B. Cranial nerve III
C. Cranial nerve VII
D. Cranial nerve XII


14. Intact, functioning Cranial nerves give information about the:

A. cerebellum
B. brain stem
C. cerebrum
D. spinal cord


15. An adult has been in a motor vehicle accident, has 4 inch laceration on forehead that is bleeding profusely. Her left ankle is splinted and with BP-100/60, PR-110 RR-16. What is the first action of the nurse?

A. start of IV line
B. place a foley catheter
C. get an ECG
D. check her neurologic status


16. An adult is brought in by ambulance after a motor vehicle accident. He is unconscious, on a backboard with his neck immobilized. He is bleeding profusely from a large gash on his right thigh. What is the first action the nurse should take?

A. stop the bleeding
B. check his airway
C. take his vital signs
D. find out what happened from the eyewitness


17. While assessing the CVA client, the nurse gently scrapes the sole of his foot with a blunt-pointed object. The nurse notes plantar flexion of the toes and records this response as:

A. a present Babinski�s reflex
B. a present ankle jerk reflex
C. an absent Babinski�s reflex
D. an absent patellar reflex


18. The client is comatose following brain surgery, which of the following actions would be contraindicated in his care?

A. raising the head of his bed
B. pharyngeal suctioning
C. nasal suctioning
D. tooth brushing


19. A patient in a coma is scheduled for a lumbar puncture. The CSF obtained is cloudy in appearance. This finding most likely indicates:

A. infection
B. increased ICP
C. meningeal irritation
D. a normal finding


20. The patient is admitted to the hospital with right sided hemiplegia as a result of a stroke. The nurse should position the client:

A. on her right side as much as possible
B. on her left side with brief periods on her back and right side
C. upright as long as tolerated
D. supine with a pillow under her knees

Score = Correct answers: from: Philippine Nurse