Nclex Nursing Practice Quiz 30 Item Answer and Rationale

NCLEX (National Council Licensure Examination) is an examination for the licensing of nurses in the United States and Canada.

NCLEX (National Council Licensure Examination) is an examination for the licensing of nurses in the United States. There are two types, the NCLEX-RN and the NCLEX-PN. The NCLEX exam is taken after an individual graduates from a school of nursing, in order to receive his or her nursing license. A nursing license gives an individual the permission to practice nursing, granted by the state he or she has met the requirements for NCLEX-PN and NCLEX RN.

Question #1: George who has undergone thoracic surgery has chest tube connected to a water-seal drainage system attached to suction. Presence of excessive bubbling is identified in water-seal chamber, the nurse should…

Option 2: Excessive bubbling indicates an air leak which must be eliminated to permit lung expansion.

Question #2: Nurse Liza is assigned to care for a client who has returned to the nursing unit after left nephrectomy. Nurse Liza’s highest priority would be…

Option 1: After nephrectomy, it is necessary to measure urine output hourly. This is done to assess the effectiveness of the remaining kidney also to detect renal failure early.

Question #3: A female client is experiencing painful and rigid abdomen and is diagnosed with perforated peptic ulcer. A surgery has been scheduled and a nasogastric tube is inserted. The nurse should place the client before surgery in

Option 3: Semi-fowlers position will localize the spilled stomach contents in the lower part of the abdominal cavity.

Question #4: A client who has undergone a cholecystectomy asks the nurse whether there are any dietary restrictions that must be followed. Nurse Hilary would recognize that the dietary teaching was well understood when the client tells a family member that:

Option 4: It may take 4 to 6 months to eat anything, but most people can eat anything they want.

Question #5: Dr. Marquez tells a client that an increased intake of foods that are rich in Vitamin E and beta-carotene are important for healthier skin. The nurse teaches the client that excellent food sources of both of these substances are:

Option 4: Beta-carotene and Vitamin E are antioxidants which help to inhibit oxidation. Vitamin E is found in the following foods: wheat germ, corn, nuts, seeds, olives, spinach, asparagus and other green leafy vegetables. Food sources of beta-carotene include dark green vegetables, carrots, mangoes and tomatoes.

Question #6: Which nursing intervention ensures adequate ventilating exchange after surgery?

Option 3: Positioning the client laterally with the neck extended does not obstruct the airway so that drainage of secretions and oxygen and carbon dioxide exchange can occur.

Question #7: In reducing the risk of endocarditis, good dental care is an important measure. To promote good dental care in client with mitral stenosis in teaching plan should include proper use of…

Option 3: The use of electronic toothbrush, irrigation device or dental floss may cause bleeding of gums, allowing bacteria to enter and increasing the risk of endocarditis.

Question #8: Which of the following compilations should the nurse carefully monitors a client with acute pancreatitis?

Option 4: A client with acute pancreatitis is prone to complications associated with respiratory system.

Question #9: Nurse Joan is assigned to come for client who has just undergone eye surgery. Nurse Joan plans to teach the client activities that are permitted during the postoperative period. Which of the following is best recommended for the client?

Option 3: Watching TV is permissible because the eye does not need to move rapidly with this activity, and it does not increase intraocular pressure.

Question #10: John suddenly experiences a seizure, and Nurse Gina notice that John exhibits uncontrollable jerking movements. Nurse Gina documents that John experienced which type of seizure?

Option 3: Myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single or multiple muscle group.

Question #11: Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help

Option 3: When diuretics are taken in the morning, client will void frequently during daytime and will not need to void frequently at night.

Question #12: Kris with a history of chronic infection of the urinary system complains of urinary frequency and burning sensation. To figure out whether the current problem is of renal origin, the nurse should assess whether the client has discomfort or pain in the…

Option 4: Discomfort or pain is a problem that originates in the kidney. It is felt at the costovertebral angle on the affected side.

Question #13: Kate who has undergone mitral valve replacement suddenly experiences continuous bleeding from the surgical incision during postoperative period. Which of the following pharmaceutical agents should Nurse Aiza prepare to administer to Kate?

Option 1: Protamine Sulfate is used to prevent continuous bleeding in client who has undergone open heart surgery.

Question #14: A client has Gastroesophageal Reflux Disease (GERD). The nurse should teach the client that after every meals, the client should

Option 1: Gravity speeds up digestion and prevents reflux of stomach contents into the esophagus.

Question #15: Which of the following should the nurse teach the client about the signs of digitalis toxicity?

Option 4: Seeing yellow spots and colored vision are common symptoms of digitalis toxicity.

Question #16: Patrick who is hospitalized following a myocardial infarction asks the nurse why he is taking morphine. The nurse explains that morphine

Option 2: Morphine is a central nervous system depressant used to relieve the pain associated with myocardial infarction, it also decreases apprehension and prevents cardiogenic shock.

Question #17: Marco who was diagnosed with brain tumor was scheduled for craniotomy. In preventing the development of cerebral edema after surgery, the nurse should expect the use of:

Option 3: Glucocorticoids (steroids) are used for their anti-inflammatory action, which decreases the development of edema.  

Question #18: Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel should:

Option 1: The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume.

Question #19: Nurse Maureen knows that the positive diagnosis of HIV infection is made based on which of the following:

Option 4: These tests confirm the presence of HIV antibodies that occur in response to the presence of the human immunodeficiency virus (HIV).

Question #20: Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure recognizes an adequate amount of high-biologic-value protein when the food the client selected from the menu was:

Option 4: One cup of cottage cheese contains approximately 225 calories, 27 g of protein, 9 g of fat, 30 mg cholesterol, and 6 g of carbohydrate. Proteins of high biologic value (HBV) contain optimal levels of amino acids essential for life.

Question #21: A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant assessment would be:

Option 2: This indicates that the bladder is distended with urine, therefore palpable.

Question #22: A client has undergone with penile implant. After 24 hrs of surgery, the client’s scrotum was edematous and painful. The nurse should:

Option C: Elevation increases lymphatic drainage, reducing edema and pain.

Question #23: Nurse Hazel receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?

Option 2: Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred.

Question #24: Nurse Maureen would expect a client with mitral stenosis would demonstrate symptoms associated with congestion in the:

Option 2: When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle because there is no valve to prevent backward flow into the pulmonary vein, the pulmonary circulation is under pressure.

Question #25: A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be:

Option 4: Managing hypertension is the priority for the client with hypertension. Clients with hypertension frequently do not experience pain, deficient volume, or impaired skin integrity. It is the asymptomatic nature of hypertension that makes it so difficult to treat.

Question #26: Nurse Hazel teaches the client with angina about common expected side effects of nitroglycerin including:

Option 3: Because of its widespread vasodilating effects, nitroglycerin often produces side effects such as headache, hypotension, and dizziness.

Question #27: The following are lipid abnormalities. Which of the following is a risk factor for the development of atherosclerosis and PVD?

Option 1: An increase in LDL cholesterol concentration has been documented at risk factor for the development of atherosclerosis. LDL cholesterol is not broken down into the liver but is deposited into the wall of the blood vessels.

Question #28: Which of the following represents a significant risk immediately after surgery for repair of aortic aneurysm?

Option 4: There is a potential alteration in renal perfusion manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during the surgery.

Question #29: Nurse Josie should instruct the client to eat which of the following foods to obtain the best supply of Vitamin B12?

Option 4: Good source of vitamin B12 are dairy products and meats.

Question #30: Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the following physiologic functions?

Option 4: Aplastic anemia decreases the bone marrow production of RBC’s, white blood cells, and platelets. The client is at risk for bruising and bleeding tendencies.

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