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Quiz Session - Attempts With Random Questions

NCLEX-PN Exam Questions

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21.

You are expecting a new admission, a 3-year-old who has experienced two febrile seizures in the last 24 hours. In preparing for the patient's admission, what is the most important action?

  • Pad the rails of the bed

  • Bring in a cot so that the parents can room in

  • Order age-appropriate meals

  • Notify the lab to draw stat blood work

Correct answer: Pad the rails of the bed

Precautions to prevent injury/promote safety should be foremost - pad the side rails to prevent injury should the patient have another seizure. Stat blood work cannot be collected until the patient has arrived. Bringing in a cot and ordering meals are not a priority.

22.

Which type of soft injury is correctly and accurately paired with its pathophysiological description?

  • Contusion: Bleeding into the soft tissue

  • Strain: Abnormal muscle stretching

  • Abrasion: Abnormal stretching of the skin

  • Sprain: Abnormal muscle stretching

Correct answer: Contusion: Bleeding into the soft tissue

All of the choices include soft tissue injuries. A contusion, also called a bruise, occurs when trauma has led to bleeding into the soft tissue. A strain is a small tear of the muscle that is often referred to as a pulled muscle. An abrasion is the rubbing of the skin surface. A sprain is abnormal ligament stretching.

23.

Your patient is scheduled to undergo a radical mastectomy due to breast cancer. You are teaching the patient the recommended post-op exercises. The client asks you why the exercises are necessary during healing and states that she is afraid the exercises will be painful. What is the correct rationale for performing arm exercises after a mastectomy?

  • "The exercises help you to regain the use of your arm, which will be affected by the surgery, and also prevent your shoulder from becoming stiff and painful."

  • "Arm exercises will eliminate postoperative swelling at the incision site."

  • "Arm exercises increase circulation in the breast and promote healing."

  • "The performance of arm exercises actually prevents postoperative pain."

Correct answer: Arm exercises help to prevent the shoulder from becoming stiff and help patients regain the full use of their arm following mastectomy.

These exercises will not reduce swelling at the incision site, nor are they performed to improve circulation in the breast. Arm exercises will not reduce postoperative discomfort.

24.

Care for the patient with active tuberculosis involves wearing a:

  • Respirator mask

  • Disposable gown

  • Surgical mask

  • "Space" suit

Correct answer: Respirator mask

To prevent the droplet spread of tuberculosis, health care workers must don an appropriately fitting respirator mask. Surgical masks do not provide an appropriate seal to prevent the transmission of droplets, and therefore are not recommended in the care of a patient with active tuberculosis. Hospitals and health care organizations often conduct fit testing for tuberculosis respirator masks to determine the appropriate size mask for each employee.

25.

The nurse is reviewing a list of patients assigned to her for the day. Which of the following patients is/are at high risk for third-spacing? 

Select all that apply.

  • The patient with renal disease

  • The septic patient

  • The patient with Crohn's disease

  • The patient with a history of alcohol abuse

  • The patient with diabetes mellitus

Any disease or injury that destroys tissues or reduces protein intake can lead to protein loss and third-spacing. 

The trapped extracellular fluid that has shifted into the interstitial space (in an actual or potential body space) represents a volume loss and is thus unavailable (useless) for normal physiological processes. Fluid may be trapped in the pericardial, pleural, peritoneal, or joint cavities, in the bowel or the abdomen, or within soft tissues after trauma or burns. 

Risk factors include kidney or liver disease, major trauma or burns, sepsis, major surgery, cancers, malabsorption syndrome or malnutrition, alcoholism, and advanced age.

26.

What are the three dimensions of health and wellness?

  • Agent, host, and environment

  • Primary, secondary, and tertiary prevention

  • Age, gender, and ethnicity

  • Pollution, genetics, and age

Correct answer: Agent, host, and environment

The three dimensions of health and wellness are the agent, the host, and the environment, all of which interact to promote health or lead to illness. The agent is a biological, psychological, social, chemical, or mechanical factor that impacts health. The host is a person or group that is susceptible to a particular illness or disease because of risk factors like lifestyle choices, age and genetics. The environmental dimension consists of all factors in the environment that impact health, including air pollution, infectious agents, toxins, and chemicals.

27.

A patient has been admitted to the emergency department with a compound fracture of the tibia after a car accident. Which of the following interventions should the nurse implement immediately? 

Select all that apply.

  • Splint the extremity

  • Cover the wound with a sterile dressing

  • Check the neurovascular status of the extremity

  • Assist the patient to perform RICE (rest, ice compression, and elevation) of the affected extremity

  • Apply skin traction preoperatively

A compound (open) fracture occurs when bone is exposed to air through a break in the skin, and soft tissue injury and infection are common. Immediate interventions include covering the wound with a sterile dressing and immobilizing the affected extremity with a splint or cast. Check the neurovascular status of the extremity and prepare the patient for reduction, fixation, traction, and casting to allow proper healing of the bone. 

Skeletal and skin traction may be applied postoperatively (skin traction is applied preoperatively with a fractured hip to reduce fracture, immobilize the bone, and help with muscle spasms). Management of a sprain (not a fracture) involves RICE, to reduce swelling and provide joint support.

28.

You are caring for a child who has a temperature of 104 degrees. The child suddenly begins to rhythmically convulse. What is the first thing you should do?

  • Ensure the child's safety

  • Administer an antipyretic medication as ordered

  • Gently restrain the child's movement

  • Call the doctor

Correct answer: Ensure the child's safety

Seizures place clients, both children and adults, at risk for injuries, some of which can be life threatening. The first priority is safety. Later, when the child is out of danger, you should call the doctor and administer antipyretic medications as ordered. Client movement should be protected but not restrained during seizures or convulsions.

29.

Onset of menarche is most often between which age range?

  • 11 and 14 years

  • 15 and 18 years

  • 10 and 12 years

  • 12 and 19 years

Correct answer: 11 and 14 years

Onset of menarche, or menstruation, most often occurs between the ages of 11 and 14 years. Within this adolescent stage, the individual begins separation from the family and develops an interest in intimate relationships. The adolescent should be educated about healthy lifestyle practices, including safe sex.

30.

The therapeutic level for lithium is:

  • 1 to 1.5 mEq/L

  • 1.5 to 2 mEq/L

  • 1.5 to 3 mEq/L

  • 1 to 2 mEq/L

Correct answer: 1 to 1.5 mEq/L

Lithium is an antimanic drug that is used to treat mania and prevent recurrent manic episodes in the patient with bipolar disorder. Serum lithium levels need to be monitored throughout treatment with the drug, to ensure it is at a therapeutic level. The therapeutic level for lithium is considered between 1 and 1.5 mEq/L.

31.

You enter a patient's room for the purpose of inserting a Foley catheter. The patient states that he was not aware that he was to have a catheter inserted and states that he has not been having difficulty voiding. You should:

  • Check the doctor's orders to ensure that you have the right patient

  • Assume that the physician knows what he is doing and insert the catheter

  • Chart that the patient refuses the recommended treatment

  • Leave it for the next shift

Correct answer: Check the doctor's orders to ensure that you have the right patient

If a patient questions a medication or procedure, particularly if the medication or procedure does not make sense to you in the context of the patient's condition or diagnosis, you should verify the order. Never assume that all orders are appropriate--it is your duty to question any orders that do not make sense.

32.

Immediately after an amniotomy has been performed, the nurse should first assess which of the following?

  • The fetal heart rate pattern

  • Bladder distension

  • Cervical dilation

  • The maternal blood pressure

Correct answer: The fetal heart rate pattern

The FHR is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. Bladder distension or maternal blood pressure would not be the first thing to check after the amniotomy.

33.

Your patient has a broken leg. You are teaching them about proper positioning of crutches. Choose the incorrect statement:

  • "Your elbows should be straight when you use the handgrips."

  • "The handgrips should be even with the top of your hipline."

  • "The crutches should reach to 1 to 1 1/2 inches below your armpits when you are standing upright."

  • "You should be using your hands, rather than your armpits, to absorb your weight."

Correct answer: "Your elbows should be straight when you use the handgrips."

Elbows should be slightly bent when using the handgrips. All other statements are correct.

34.

Your patient was admitted with multiple trauma from a severe automobile accident that flipped his car over an embankment. This morning, the patient's blood pressure was 138/65; now it is 158/27. What life-threatening disorder would you most suspect?

  • Increased intracranial pressure

  • Cardiac tamponade

  • Endocarditis

  • Pneumothorax

Correct answer: Increased intracranial pressure

Increased intracranial pressure is suspected when there is a widening pulse pressure, particularly when the client has suffered trauma and a possible head injury. This patient's pulse pressure has widened.

35.

You are caring for a patient who has just had a spinal tap, or lumbar puncture, to rule out meningitis. When the cerebrospinal fluid is analyzed, it reveals that the glucose is low. What does this analysis suggest?

  • The presence of meningitis

  • The absence of meningitis

  • The presence of hypoglycemia

  • A closed head injury

Correct answer: The presence of meningitis

The analysis of the cerebrospinal fluid among patients with meningitis will reveal low glucose levels, increased protein, and an increased white blood cell count.

36.

A positive Babinski reflex in an infant occurs when:

  • The sole of the infant's foot is stroked on the outside from the heel to the toe and the infant's toes fan out and curl while the foot twists in

  • The sole of the infant's foot is stroked on the inside from the toe to the heel and the infant's toes fan out and curl while the foot twists in

  • The sole of the infant's foot is stroked on the inside from the heel to the toe and the infant's toes fan out and curl while the foot twists in

  • The sole of the infant's foot is stroked on the outside from the toe to the heel and the infant's toes fan out and curl while the foot twists in

Correct answer: The sole of the infant's foot is stroked on the outside from the heel to the toe and the infant's toes fan out and curl while the foot twists in

A reflex is an automatic, involuntary response to a stimulus--meaning the person has no control over this response. The Babinski reflex is present in full-term infants from the time of birth through their first year of life. It consists of stroking the sole on the outside of the infant's foot from the heel to the toe--with a positive reflex occurring when the toes fan out and curl while the foot twists inward.

37.

The nurse is assessing a patient with abdominal pain, who underwent abdominal surgery three months prior. The nurse understands which of the following findings may be an early indication of bowel obstruction?

  • Hyperactive bowel sounds

  • Hypoactive bowel sounds

  • Absent bowel sounds

  • None of these

Correct answer: Hyperactive bowel sounds

Bowel obstruction occurs when normal flow of gastrointestinal contents is blocked or disrupted. Physical exam findings differ in early versus late bowel obstruction. In early bowel obstruction, hyperactive bowel sounds are heard on auscultation.

In late bowel obstruction, hypoactive bowel sounds are auscultated. Abdominal distension and pain are almost always present as well.

38.

Proper documentation within a patient's medical chart includes all of the following except:

  • Whiting out any mistakes or errors

  • Signing your name and credentials at the end of a note

  • Noting the date and time of each entry

  • Avoiding "do not use" abbreviations

Correct answer: Whiting out any mistakes or errors

Documentation within a patient's medical chart must be clear and concise. It should include the author's signature and credentials and each entry should have a date and time. The note should be free of any "do not use" abbreviations, as defined by The Joint Commission.

39.

Risk factors for pneumonia include all of the following except:

  • Coronary artery disease

  • AIDS

  • Steroid use

  • Advanced age

Correct answer: Coronary artery disease

There are a number of identifiable risk factors for developing pneumonia. The elderly and infants are the two age groups with the highest risk for developing the disease. Additionally, patients with a compromised immune system are at risk for pneumonia--those with HIV/AIDS, patients who have received a transplant and are on anti-rejection medications, and patients who take steroids on a chronic basis. Coronary artery disease alone is not a factor that would predispose one for pneumonia.

40.

You are in the cafeteria eating lunch. A visitor walking toward you suddenly collapses. You should:

  • Check for responsiveness

  • Open the airway and give 2 breaths

  • Begin chest compressions

  • Check for a pulse

Correct answer: Check for responsiveness

A victim who suddenly collapses should be treated as follows: check for responsiveness, call for help (call a code), provide 30 chest compressions, open the airway and give 2 breaths, then resume chest compressions.

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