NCLEX PRACTICE EXAM 02

Answer the 20 item exam
and get your scores below!

1. The nurse notes that the client with head trauma has clear fluid draining from his nose. Which of the following actions by the nurse is most appropriate initially?

A. notify the physician immediately
B. test the fluid for glucose
C. send a specimen of the fluid for culture
D. encourage the client to blow his nose often to promote drainage


2. The nurse performing a neurological assessment on a client in a coma. In order to assess motor response, the nurse should ask the client to:
A. grasp the nurse�s finger
B. cough and deep breathe
C. wiggle his toes
D. repeat a phrase


3. Following intracranial surgery, the nurse should observe the client for signs of increased ICP which include:

A. increased urinary output
B. bradycardia
C. fever
D. change in level of consciousness


4. Henry is a 13 yr old who has been diagnosed as having epilepsy. A positive sign that Henry is taking his Dilantin properly is:

A. hair growth on his upper lip
B. absence of seizures
C. lowered Hgb and Hct
D. drowsiness


5. The nurse understands that Doll�s eyes reflex is present if the patient�s eyes:

A. move in the same direction in which his head is turned
B. move in the direction opposite to which his head is turned
C. remain midline when the head is turned
D. move to the medial aspect of the orbit when his head is turned


6. What should the nurse include in the plan of care for a newly admitted client with an infratentorial craniotomy for a brain tumor?

A. keep HOB elevated 30 -45 degree and a large pillow under the client� head and shoulder
B. keep the head flat with a small pillow under the nape of the neck
C. assess vital signs and pupils every four hours
D. flex neck every two hours to prevent stiffness


7. A 74 yr. old widow client is hospitalized for cataract surgery. During his interview, he repeatedly talks about how his wishes when he was as strong and energetic as when he was younger. In planning care for this client, the nurse should include which of the following?

A. use of the intervention reminiscence
B. confrontation of the client about being so grim
C. changing the topic whenever he brings it up
D. incorportation of a humorous view of the normal loss of strength


8. A client reports gradual painless blurring of vision. On assessment, the nurse notes a cloudy opague lens, the nurse suspects the client has:

A. glaucoma
B. cataracts
C. retinal detachment
D. diabetic retinopathy


9. Which of the following risk factors would the nurse assess for in a client with glaucoma?

A. family history of increased intraocular pressure, and age of 45 -65
B. history of diabetes and age greater than 50
C. female gender, cigarette smoking, age greater than 65
D. myopia, history of diabetes, and sudden severe physical exertion


10. A nurse is admitting a client who reports vision loss; to determine if a client has glaucoma or a detached retina, the nurse understands that a client with glaucoma will report:


A. seeing floating spots
A. seeing floating spots
B. eye pain
C. seeing flashing lights
D. sudden loss of vision


11. The nurse is teaching a post-op stapedectomy client, what should be included in the teaching?

A. work can be resumed the next day
B. gently sneeze or cough with the mouth closed
C. blow the nose gently one side at a time
D. resume exercise in one week


12. What is the priority nursing diagnosis for a client with very loud overpowering ringing in his ears, fluctuating hearing loss on the right side with severe vertigo accompanied by nausea & vomiting and a feeling of fullness in the right ear?

A. knowledge deficit related to the disease process
B. anxiety
C. impaired physical mobility
D. pain


13. An adult patient who is in pain is on long term aspirin therapy and experiencing tinnitus, the nurse best interprets this to mean:

A. the Aspirin is working correctly
B. the client ingested more medicine that was recommended
C. the client has an upper GI bleed
D. the is experiencing a mild overdosage


14. An adult is receiving a nonsteroidal anti-inflammatory drug. Which of the following would the nurse observe if the client is experiencing no side-effects?

A. the client is somnolent and hard to arouse
B. the client is having dark, tarry stools
C. there is no complaint of nausea or vomiting
D. the pain is still a 6 on a scale of 1 to 10


15. An adult is to receive an intramuscular injection of Morphine for post op pain. Which of the following is necessary for the nurse to assess prior to giving a narcotic analgesic?

A. the client�s level of alertness and respiratory rate
B. the last time the client ate or drank
C. the client�s bowel habits and last bowel movement
D. the client�s history of addiction


16. The nurse has explained the use of neostigmine methylsulfate (Prostigmin) to a client with Myasthenia Gravis. Which comment by the client indicates the need for further instruction?

A. I need to take the medication regularly even when I feel strong
B. I should take the medication once daily at bedtime
C. if I take too much medication, I can become weak and have breathing problems
D. I may have difficulty swallowing my saliva if I take too much medication


17. A 36 yr. old female reports double vision, visual loss, weakness, numbness of the hands, fatigue, tremors, and incontinence. On assessment, the nurse notes nystagmus, scanning speech, ataxia, and muscular weakness. Based on these findings, the nurse suspects the client has:

A. Parkinson�s disease
B. Myasthenia gravis
C. Amyotrophic lateral sclerosis
D. Multiple sclerosis


18. A client with Parkinson�s disease is receiving combination therapy with Levodopa and Carbidopa. Which of the following manifestations indicates to the nurse that an adverse drug reaction is occurring?

A. involuntary head movement
B. bradykinesia
C. shuffling gait
D. depression


19. The nurse is teaching a client the potential complications of osteoporosis. Which of the following conditions are related to this disorder?

A. fractures of the hip, wrist, & spine
B. fractures of the femur, ankle, and clavicle
C. acute MI, CVA, and acute renal failure
D. hyperparathyroidism, hypothyroidism, & osteomyelitis


20. The nurse is counseling a client with osteoporosis; which of the following foods should the nurse instruct the client to avoid consuming in large amount:

A. carbonated beverages, citrus fruits, and foods high in simple carbohydrates
B. foods high in protein, salt, & caffeine
C. foods high in fat, sodium, and nitrates
D. fatty meats & organ meats







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Correct answers:

from: Philippine Nurse