NCLEX PRACTICE EXAM 05

Answer the 20 item exam
and get your scores below!

1. The client's chest tube is having removed. Which of the following actions is most appropriate in caring for a person who undergoes this procedure?

A. assist the client to assume a prone position
B. medicate the client for pain half hour prior to removal
C. encourage deep breathing during removal
D. empty the collection chambers before removal


2. The nurse is caring for a client with cystic fibrosis. Which of the following nursing diagnoses would most likely take highest priority?

A. Activity intolerance
B. Anxiety
C. Risk for ineffective airway clearance
D. Risk for fluid volume deficit


3. The client has a lung abscess. Which nursing intervention should be included in the plan to increase the client's level of comfort?

A. encourage activity prior to meals
B. offer frequent oral hygiene
C. provide easy to eat milk products
D. restrict fluid intake


4. The nurse is assessing the laboratory values of a male client being evaluated for GI bleeding. Which laboratory value, if present, would be most suggestive of hemorrhage?

A. RBC = 5 million/mm3
B. hematocrit = 35%
C. Potassium = 4 mg/L
D. Sodium = 140 mg/L


5. The nurse administers an anticholinergic drug to a client scheduled for an endoscopy. What effect should be expected from this medication?

A. sedation
B. increased peristalsis
C. muscle relaxation
D. decreased secretion


6. Metoclopramide is prescribed for an individual with GERD. The nurse is explaining the action of this drug. Which statement most accurately describes the action of the drug?

A. it decreases the time food and fluids are in the stomach
B. it acts as an antacid to reduce gastric acidity
C. it helps to promote movement in the esophagus
D. it has a local anesthetic effect on the lower esophagus and stomach


7. The nurse is teaching a family member how to position a client who is to receive tube feedings in the home. Which instruction is most appropriate?

A. place the client in a left side- lying position
B. elevate head of the bed slightly
C. encourage the client to sit out of bed in a chair
D. allow the client to assume a position of comfort


8. A client who has to have an accumulation of gas and fluid removed from the gastrointestinal tract is connected to intermittent suction. If there were no drainage from the suction, which of the following actions should the nurse take?

A. discontinue the suction
B. increase the amount of suction
C. obtain orders to irrigate the tube
D. advance the tube down the GI tract


9. What measure should the nurse employ to ensure that a client receiving TPN does not develop osmotic diuresis as a complication?

A. monitor the flow rate carefully
B. administer the solution slowly
C. protect the solution from light
D. keep the infusion at room temperature


10. When caring for a client with TPN, which action by the nurse has the potential to cause serious adverse effects in the client?

A. abruptly discontinuing TPN at any time
B. administering the TPN solution via an infusion pump
C. applying an antibiotic ointment to the insertion site
D. maintaining the normal flow rate when the infusion is behind schedule


11. The nurse is recording data from a man newly admitted to the hospital. Which notation, if made by the nurse, is most consistent with the presence of a duodenal ulcer?

A. food causes pain
B. the client complains of spitting blood
C. pain may awaken the client in the middle of the night
D. certain types of food increase distress


12. A client is admitted with a history of fatigue and melena and tentatively diagnosed to have duodenal ulcer. The nurse administers alternating doses of calcium carbonate and magnesium oxide. Which finding best indicates that this drug regimen has been successful?

A. absent nasogastric tube drainage
B. increase gastric pH
C. mild diarrhea
D. decreased abdominal rigidity


13. The severely damaged liver cannot produce the important plasma protein, albumin. Identify the clinical problem that would be expected in a client with a low albumin level.

A. abnormal bleeding
B. polyuria
C. edema
D. weight loss


14. The nurse is assessing a client with gallbladder disease. Which of these findings, if present in the client's history, is commonly found in individuals with gallbladder disease?

A. she complains of her skin being very itchy
B. she is 30 pounds overweight for her height
C. she has had several nosebleeds
D. she feels tired all the time


15. The nurse is participating in a screening program. The nurse should NOT have a high index of suspicion for diabetes mellitus for which individual.

A. an obese 43 year old woman
B. a man complaining of thirst and weight loss
C. a young woman who has had two babies weighing 10 pounds each
D. an adolescent whose grandmother has type I diabetes


16. The nurse is evaluating a young man with diabetes. The client reports a number of symptoms. Which symptom is considered a cardinal sign of diabetes?

A. overwhelming fatigue
B. excessive thirst
C. recurrent blurred vision
D. gradual weight loss


17. A client complains of headache and tells the nurse she feels weak. She is also diaphoretic. The client has been a diabetic for 20 years. The client tells the nurse, "I've been managing my diabetes for a long time; please let me lie down. What is the most appropriate nursing action?

A. assist the client to bed
B. insist that the client eat a snack
C. page the physician
D. start an IV line


18. The nurse assessing the client with hypothyroidism should assign the highest priority to the assessment of which laboratory value?

A. serum calcium levels
B. serum cholesterol levels
C. serum potassium levels
D. urine specific gravity


19. A client has hyperthyroidism. He is admitted to the hospital for the emergency treatment of thyroid storm (thyrotoxicosis). What symptoms should the nurse plan to address?

A. fluid overload
B. hypothermia
C. respiratory distress
D. tachycardia


20. A client is returning to the surgical ward after undergoing a subtotal thyroidectomy. What emergency equipment should the nurse have available at the bedside for this client?

A. an ECG monitor
B. a defibrillator
C. an intra-aortic balloon pump
D. a tracheostomy unit









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Correct answers:

from: Philippine Nurse