NCLEX PRACTICE EXAM 04

Answer the 20 item exam
and get your scores below!

1. The nurse should encourage clients with intermittent claudication to:

A. give up smoking
B. decrease physical activity, especially walking
C. increase calcium intake
D. restrict caffeine intake


2. A client is to undergo a bone marrow aspiration. When teaching the client about this procedure, the nurse should explain that it is used to:

A. identify blood abnormalities
B. determine long term prognosis
C. assess for presence of infection
D. determine the RBC indices


3. Following the client�s bone marrow aspiration, which of the following nursing intervention should be instituted?

A. apply firm pressure to the area until bleeding stops
B. provide a warm, moist compress to the site
C. encourage the client to assume a supine position
D. place an occlusive dressing on the area for 24 hours


4. Which of the following laboratory test results would be most helpful to the nurse in the assessment of a client with a bleeding disorder?

A. red blood cell count
B. platelet count
C. hematocrit
D. differential count


5. While performing an admission assessment on a severely anemic client, the nurse would expect to find a history of:

A. blurred vision
B. increased appetite
C. cardiac palpitations
D. warm flushing sensations


6. The nurse is explaining the diagnosis of pernicious anemia to the client, which of the following is accurate concerning the disease?

A. shortness of breath often occurs
B. the risk for dehydration is increased
C. it is caused by a deficiency of intrinsic factor
D. there is no treatment for this disorder


7. The nurse is caring for a client with Aplastic anemia. Which of the following nursing diagnoses would have priority in the care of this client?

A. Potential for infection due to decreased leukocyte count
B. Impaired gas exchanged due to low RBC count
C. Potential for impairment of skin integrity due to poor nutritional status
D. Alteration in bowel elimination: constipation due to iron overload


8. Emphysema destroys alveolar walls. The physiological effect that the nurse expects from this damage is:

A. a decrease level of carbon dioxide in the body
B. a decrease in the amount of oxygen diffusing into the blood
C. severe constriction of the segmental and subsegmental bronchi
D. an accumulation of excess fluid in the lungs


9. The nurse received a report that the client has hypercapnia. What respiratory disorder will the nurse expect to note?

A. excessive respiratory secretions
B. inability to take a deep breath
C. increased respiratory rate
D. retention of carbon dioxide


10. The nurse is caring for a client who is having difficulty of breathing. The muscles between the ribs retract with inspiratory effort. The nurse noted that the client is having retraction of which muscles?

A. articular
B. bronchoesophageal
C. intercostal
D. latissimus dorsi


11. A client has a chronic productive cough and is being treated for emphysema. What physical assessment findings are most consistent with this patient�s history?

A. barrel chest
B. lordosis
C. pectus excavatum
D. whispered pectoriloquy


12. The nurse is caring for an adult who has congenital pulmonary disorder that has resulted in a decrease in the production of surfactant. What effect is most consistent with this deficiency?

A. alveolar hypertrophy
B. sleep apnea
C. stiff lungs
D. ventilator dependence


13. The nurse hears a high, hollow drum-like sound when percussing the chest of the client with a large pneumothorax. How should this sound be noted on documentation

A. dullness
B. flatness
C. resonance
D. tympany


14. The nurse percusses an area of dullness on the anterior chest at the level of the 10th right rib of the client who has been diagnosed for many years with COPD. The most appropriate interpretation of this finding is the percussion note was elicited over:

A. a pneumothorax
B. an area of pneumonia
C. liver tissue
D. a pleural effusion


15. The nurse is assessing the PaO2 of a client with asthma. This blood gas result will best assist the nurse to obtain information of what nature?

A. the effectiveness of ventilation
B. the degree of dyspnea
C. the degree of hypoxia
D. the status of tissue oxygenation


16. To prevent the leaking of blood into surrounding tissue following the blood extraction for ABG determination, the nurse should implement which nursing measure:

A. apply ice to the puncture site
B. maintain manual compression over the puncture site for five minutes
C. place bandage over a sterile cotton swab over the puncture site for at least one minute
D. elevate the limb on several pillows


17. The client is an asthmatic and in acute respiratory distress. The nurse auscultates the lungs and notes no inspiratory wheezing. What should this finding suggest to the nurse?

A. airway constriction requiring intensive interventions
B. an appropriate reaction to the medications used in the management of client
C. the need to assess the client further for signs of a pleural effusion
D. overuse of the intercostals muscles resulting in poor exchange


18. Which nursing intervention is most appropriate for a 76 year old client with COPD who has the nursing diagnosis of airway clearance ineffective related to excessive secretions and ineffective coughing?

A. encourage breathing using a panting pattern
B. have the client sit in a low Fowler�s position
C. instruct the client to drink at least eight glasses of water a day
D. discourage pursed-lip breathing


19. A client is hospitalized with pneumonia. The nurse has made the nursing diagnosis, breathing pattern, ineffective related to tachypnea secondary to chest pain. The nurse administers analgesia as prescribed. What additional assessment is needed following medication administration?

A. auscultation of the chest
B. ECG
C. evaluation of pupillary reaction
D. testing of muscle strength


20. Intermittent bubbling is noted in the water seal chamber of a client who has a chest tube in place due to a pneumothorax. Which action of the nurse is most appropriate based on this observation?

A. clamp the chest tube
B. encourage respiratory exercises
C. change the drainage unit
D. place a Vaseline gauze around the chest tube

Score = Correct answers: from: Philippine Nurse