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NCLEX Kaplan Trainer Test 3 Practice Exam with Answers (100 Solved Questions)

NCLEX Kaplan Trainer Test 3 Practice Exam with Answers offers a set of real exam Q&As, helping you hone your skills before test day.

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    ............................................................................................................................ NCLEX QUESTION TRAINER NCLEX QUESTION TRAINER TEST 3 1. A client has a total laryngectomy with a permanent tracheostomy. The nurse plans nutritional intake for the next 3 days. Which of the following is necessary for the nurse to consider regarding the client’s nutrition? 1. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented. 2. The client will be unable to maintain any oral intake as long as the tracheotomy is in place. 3. Nutritional and/or gastric f eedings will not be attempted for approximately 3 weeks to decrease the incidence of aspiration. 4. Because the client is dependent on the ventilator, nutritional intake will be delayed. Strategy: Think about each answer choice. (1) correct —tube feedings frequently started as the initial nutritional intake; prevents trauma to suture area (2) although client has permanent tracheotomy, will be able to eat normally after area has healed (3) nutritional intake will begin when bowel sounds return and client can tolerate intake (4) client is not dependent on ventilator 2. The nurse cares for a client who presents with confusion, mood lability, impaired communication, and lethargy. The nurse should question which of the following orders? 1. Dexamethas one suppression test. 2. Thyroid studies. 3. Drug toxicology screen. 4. Trendelenburg test. Strategy: Think about each test.

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    ............................................................................................................................ NCLEX QUESTION TRAINER (1) may be ordered to determine the presence of major depression (2) may be ordered to check for an endocrine cause for the symptoms before the diagnosis of dementia is made (3) may be ordered to see if the client’s symptoms are caused by excessive use of medications or alcohol (4) correct —test is used with a client who may have varicose veins, no relationship to the symptoms described in this situation 3. For a client with a neurologic disorder, which of the following nursing assessments is MOST helpful in determining subtle changes in the client’s level of consciousness? 1. Client posturing. 2. Glasgow coma sc ale. 3. Client thinking pattern. 4. Occurrence of hallucinations. Strategy: Think about each answer choice. (1) indicates increased intracranial pressure (2) correct —Glasgow coma scale score best evaluates changes in a client’s level of consciousness by evaluating eye-opening, motor, and verbal responses (3) more appropriate for the psychiatric client (4) more appropriate for the psychiatric client 4. The nurse conducts a physical examination of a client suspected to have bulimia. Which of the following observations by the nurse MOST likely indicates bulimia? 1. The client has edema of the lower extremities. 2. Physical exam of the client reveals the presence of lanugo. 3. The client has ulcerated mucous membranes of the mouth. 4. The client has dry, yellowish color of the skin.

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    ............................................................................................................................ NCLEX QUESTION TRAINER Strategy: Determine the cause of each symptom. Does it relate to bulimia? (1) common with anorexia (2) seen with anorexia (3) correct —due to frequent vomiting (4) bulimics are normal in appearance 5. The nurse prepares a dopamine (Intropin) infusion on a client. Before beginning the infusion the nurse should take which of the following actions? 1. Evaluate the urine output. 2. Obtain the client’s weight. 3. Determine the patency of the IV li ne. 4. Measure pulmonary artery pressures. Strategy: Determine how each answer choice relates to dopamine. (1) not a critical assessment at this time (2) contains correct information, but is not a priority (3) correct —if extravasation occurs, there is sloughing of the surrounding skin and tissue; patent IV line is essential to prevent serious side effects (4) not a critical assessment at this time 6. The nurse assists a nursing assistant in providing a bed bath to a comatose patient with incontinence. The nurse should intervene if which of the following actions is noted? 1. The nursing assistant answers the phone while wearing gloves. 2. The nursing assistant log rolls the patient to provide back care. 3. The nursing assistant places an i ncontinent pad under the patient. 4. The nursing assistant positions the patient on the left side, head elevated. Strategy: "Nurse should intervene" indicates that you are looking for an incorrect action.

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    ............................................................................................................................ NCLEX QUESTION TRAINER (1) correct —contaminated gloves should be removed before answering the phone (2) correct way to roll a patient to maintain proper alignment (3) appropriate to use incontinence pad for this patient (4) appropriate position to prevent aspiration and protect the airway 7. The nurse instructs a client who is receiving imipramine (Tofranil). It is MOST important for the nurse to instruct the client to immediately report which of the following? 1. Sore throat, fever, increased fatigue, vomiting, diarrhea. 2. Dry mouth, nasal stuffiness, weight gai n. 3. Rapid heartbeat, frequent headaches, yellowing of eyes or skin. 4. Weakness, staggering gait, tremor, feeling of drunkenness. Strategy: Think about each answer choice. (1) correct —possible side effects of Tofranil, a tricyclic antidepressant medication, which can be resolved by altering the dosage or changing the medication (2) describes side effects of antidepressants, which client can learn to manage at home without changing the medication (3) not side effects of Tofranil (4) not side effects of Tofranil 8. The nurse receives report from the previous shift. Which of the following patients should the nurse see FIRST? 1. A patient post coronary artery bypass graft (CABG) having the atrioventricular (AV) wires removed later in the day. 2. A patient with type 1 diabetes scheduled for a cardiac catheterization later today. 3. A patient 1 day postoperative with an epidural catheter in place. 4. A patient diagnosed with cardiomyopathy being evaluated for a heart transplant. Strategy: Determine which patient is the least stable.

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    ............................................................................................................................ NCLEX QUESTION TRAINER (1) although the patient requires a high level of nursing care, no indication that the patient is unstable (2) patient requires preoperative assessment and teaching, no indication that the patient is unstable (3) correct —epidural used for pain relief, monitor for urinary incontinence, hypotension, respiratory depression, and nausea and vomiting (4) requires monitoring but patient with epidural takes priority 9. A child has a closed transverse fracture of the right ulna. Which of the following actions, if performed by the nurse before the application of a cast, is MOST important? 1. Check the radial pulses bilaterally and compare. 2. Evaluate the skin temperature and tissue turgor in the area. 3. Assess sensation of each foot while the child closes her eyes. 4. Apply baby powder to decrease skin irritation under the cast. Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) correct —assess neurovascular status, check pain, pallor, paralysis, paresthesia, pulselessness (2) assessment; temperature indicates decreased circulation but is subjective and not most important (3) assessment; upper (not lower) extremity fracture (4) implementation; should not be done because it would increase skin irritation 10. The nurse cares for a multipara client who delivered a female infant 1 hour ago. The nurse observes that the client’s breasts are soft; the uterus is boggy to the right of the midline and 2 cm below the umbilicus; moderate lochia rubra. It is MOST important for the nurse to take which of the following actions? 1. Perform a straight catheterization. 2. Offer the client the bedpan. 3. Put the baby to breast. 4. Mass age the uterine fundus.

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    ............................................................................................................................ NCLEX QUESTION TRAINER Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) encourage the client to void before catheterizing (2) correct —boggy uterus deviated to right indicates full bladder, encourage client to void (3) will increase uterine tone, but the problem is a full bladder (4) findings indicate a full bladder 11. The nurse checks for placement of a nasogastric (NG) tube prior to initiating a tube feeding for a client. Which of the following results indicates to the nurse that the tube feeding can begin? 1. A small amount of white mucus is aspirated from the NG tube. 2. The contents aspirated from the NG tube have a pH of 3. 3. No bubbles are seen when the nurse inverts the NG t ube in water. 4. The client says he can feel the NG tube in the back of his throat. Strategy: Determine how the answers relate to a tube feeding. (1) mucus may be from lungs (2) correct —stomach contents are acidic (3) not a safe way to check placement (4) not a reliable indication 12. The nurse cares for a client after right cataract surgery. The nurse should intervene if which of the following is observed? 1. Client is in the supine position. 2. The head of the bed is elevated 30 degrees. 3. The client is lying on the right side. 4. An eye shield is over the right eye. Strategy: "Nurse should intervene" indicates an incorrect action.

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    ............................................................................................................................ NCLEX QUESTION TRAINER (1) appropriate position (2) decreases swelling and pain (3) correct —client should not be positioned with operative side in a dependent position or against the bed (4) shield is appropriate 13. A young adult immobilized for trauma to the spinal cord has periods of diaphoresis, a draining abdominal wound, and diarrhea. On the basis of the nursing assessment, which of the following is the MOST important nursing diagnosis? 1. Risk for constipation related to immobilization. 2. Risk for impaired skin integrity related to immobilization and secretions. 3. Risk for wound infection related to in voluntary bowel secretions. 4. Risk for fluid volume excess related to secretions. Strategy: Think about each answer choice. (1) constipation is not a problem because the client has diarrhea (2) correct —skin is very susceptible to breakdown because of immobility and bodily secretions; needs numerous nursing interventions to prevent this (3) not most important (4) may be risk of fluid volume deficit due to diarrhea and secretions 14. The nurse cares for a client one day after a thoracotomy. Nursing actions listed on the care plan include turn, cough, and deep breathe q 2 h. The nurse understands that the purpose of this nursing action includes which of the following? 1. Promote ventilation and prevent respiratory acidosis. 2. Increase oxygenat ion and removal of secretions. 3. Increase pH and facilitate balance of bicarbonate. 4. Prevent respiratory alkalosis by increasing oxygenation.

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    ............................................................................................................................ NCLEX QUESTION TRAINER Strategy: Think about each answer choice. (1) correct —primary purpose of this nursing measure is to improve and/or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis (2) answer choice #1 is better in that it refers to ventilation rather than oxygenation (3) increasing the pH is not desirable (4) respiratory alkalosis is not prevented by this nursing measure 15. The mother of a 7-year-old child is dying. The nurse anticipates the child will have which of the following concepts of death? 1. Death is punishment for his/her actions. 2. Death is i nevitable and irreversible. 3. Death is temporary and gradual. 4. Death as a concept based on past experience. Strategy: Remember growth and development. (1) correct –7-year-olds see death as a punishment (2) by age of 9, most children begin to develop an adult concept of death and begin to understand that death is irreversible (3) is a preschool child’s concept of death (4) is an adolescent’s concept of death 16. A client with newly diagnosed type 1 diabetes says to the nurse, "I know that I have to take good care of my feet. When I buy new shoes, is there anything special I should do?" Which of the following responses by the nurse is BEST? 1. "It is best to buy new shoes in the morning." 2. "Have each foot measured every time you buy new shoes." 3. "Buy shoes a half - size larger than your foot size so the fit is roomy." 4. "Buy vinyl shoes because they won’t lose their shape easily."

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    ............................................................................................................................ NCLEX QUESTION TRAINER Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should buy shoes in the afternoon when feet are larger than in the morning (2) correct —feet enlarge with age, break in shoes gradually rather than all at one time, have measurements for shoes taken while standing (feet are larger) (3) buy correct shoe size (4) leather shoes recommended because they "breathe," vinyl could cause foot to perspire and aggravate fungal infections 17. A neonate weighing 7 lb 4 oz with Apgar scores of 7 and 8 at 1 and 5 minutes, respectively, is admitted to the nursery. Because the infant’s mother is diagnosed with a type 1 diabetes, the nurse knows the infant is at GREATEST risk for developing which of the following? 1. Hypovolemia. 2. Hypoglycemia. 3. Hyperglycemia. 4. Cold stress. Strategy: Determine the cause of each answer choice. (1) no change in blood volume for infant of diabetic mother (2) correct —fetus produces increased insulin to match mother’s increased glucose level during pregnancy; infant continues to have high insulin output after birth, resulting in hypoglycemia (3) infant would be at risk of hypoglycemia due to increased insulin production (4) thermal receptors in skin are stimulated due to cold environment; increases metabolic rate; infant needs to maintain normal body temperature while producing minimal amount of heat generated from metabolic processes; not expected with diabetic mother 18. The nurse in the outpatient clinic assists with the application of a cast to the left arm of a pre- school-aged child. After the cast is applied, the nurse should take which of the following actions? 1. Petal the edges of the cast to prevent irritation. 2. Elevate the client’s left arm on two pillows.

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    ............................................................................................................................ NCLEX QUESTION TRAINER 3. Apply cool, humidified air to dry the cast. 4. Ask the client to move the fin gers to maintain mobility. Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) done when cast is completely dry, prevents crumbling of plaster into cast (2) correct —minimizes swelling, elevated for first 24 to 48 hours, protects from pressure and flattening of cast (3) would delay drying of cast (4) maintaining mobility of fingers not most important after application of cast 19. The nurse cares for patients on the pediatric unit. The mother of a 2-year-old who is one day postoperative tells the nurse, "My child is so restless and overactive." The nurse should take which of the following actions? 1. Direct the LPN/LVN to obtain the child’s vital signs. 2. Ask the mother if the child’s sutures are still intact. 3. Tell the nursing assistant to take the child for a walk. 4. Check to see when the child last received pain medication. Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? Yes. Determine the best assessment. (1) no indication that there are any problems (2) passing the buck (3) implementation; should first assess (4) correct —young children typically become restless and overactive if in pain; grimacing, clenching teeth, rocking, and aggressive behavior may also be observed 20. The nurse plans a diet for a child diagnosed with cystic fibrosis (CF). Which of the following dietary requirements should be considered by the nurse? 1. High protein, high fat, and high calories.

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    ............................................................................................................................ NCLEX QUESTION TRAINER 2. High protein, low fat, and high calories. 3. Low protein, low fat, and low carbohydrate. 4. High protein, high fat, and low carbohydrate. Strategy: Think about each answer choice. (1) contains high fat (2) correct —impaired intestinal absorption due to cystic fibrosis necessitates a diet higher in protein and calories; fat is decreased because it may interfere with absorption of other nutrients (3) not adequate for this child (4) contains high fat 21. A male client is admitted with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase test are to be done. The nurse knows that 1. these tests are valuable screening tests for prostatic cancer. 2. the level of PSA is decreased in clients with renal stones. 3. the tests reflect the level of renal involvement in acid - base problems. 4. the level of PSA is elevated in clients in early - stage renal failure. Strategy: Think about each answer choice. (1) correct —PSA test has replaced acid phosphatase test in screening for prostatic cancer; test must be drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSA value (2) inaccurate information about a PSA (3) inaccurate information about a PSA (4) inaccurate information about a PSA 22. A client with clear lung sounds and unlabored breathing receives aminophylline IV. Which of the following is the MOST appropriate nursing action if the client’s IV infiltrates?

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    ............................................................................................................................ NCLEX QUESTION TRAINER 1. Apply warm soaks to the infiltration site, start a new IV, and c ontinue IV medications. 2. Wait 2 hours, reassess the client, and restart the IV if the client has wheezing or labored breathing. 3. Restart the IV and continue the previous medication schedule. 4. Call the physician and recommend that the IV medications be changed to PO. Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) continued IV medication may not be necessary based on the current assessment (2) physician should be notified if IV medications are not infusing as scheduled (3) client has improved breathing, so IV medications may not be indicated (4) correct —before a new IV is started on this client, physician should be called and PO medications recommended 23. A client diagnosed with bipolar disorder is in a manic phase with combative behavior. Which of the following is the INITIAL priority nursing action? 1. Provide adequate hygiene and nutrition. 2. Decrease environmental stimuli. 3. Slowly involve the client in unit activi ties. 4. Administer and monitor sedative and mood - stabilizing medications. Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) is very important to ensure adequate hygiene and nutrition, but behavioral control and client/milieu safety are an initial priority (2) decreasing environmental stimulation is an additional strategy that, when utilized in conjunction with psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasing environmental stimulation will not diminish client’s internal sense of agitation and aggression (3) this action is inappropriate at this time (4) correct —is most important to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agents

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    ............................................................................................................................ NCLEX QUESTION TRAINER 24. A client is admitted to the neurosurgery unit for the removal of a cerebellar tumor. The nurse expects the patient to make which of the following statements about symptoms? 1. "I have been having difficulty with my hearing." 2. "I lose my balance easily." 3. "I can't tell the difference between a sweet and sour taste." 4. "It is not easy for me to remember names and faces." Strategy: Remember physiology. (1) temporal lobe contains auditory center, loss of hearing would involve CN VIII acoustic (2) correct —cerebellum maintains balance (3) CN IX, glossopharyngeal responsible for differentiation of taste (4) not specific symptom of cerebellum dysfunction 25. Nursing management prior to an intravenous pyelogram (IVP) would include which of the following? 1. A fat - free meal the evening before the examination and radiopaque ta blets at bedtime. 2. Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter. 3. Cleansing enemas the evening before to provide for adequate visualization of the urinary tract. 4. Explaining the importance of f ollowing directions regarding voiding during the test. Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) fat-free meal is associated with a gallbladder series (2) a retention Foley catheter may be in place, but not for the purpose of dilating the bladder sphincter (3) correct —because of the need to visualize the abdominal area, cleansing enemas the evening before an IVP are usually ordered (4) there are few directions the client needs to follow during the test

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    ............................................................................................................................ NCLEX QUESTION TRAINER 26. A client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The client, diagnosed with a spinal cord injury at the level of C4, is tearful, constantly complains of discomfort, and requests to be suctioned. The nurse understands that the client’s attention-seeking behaviors may be due to which of the following? 1. Anger and frustration. 2. Awareness of vulnerability. 3. Increased social isolation. 4. Increased sensory stimulation. Strategy: Think about each answer choice. (1) is not accurate for situation (2) correct —is experiencing an increased awareness of his physical vulnerability due to his spinal cord injury; fosters increased dependency needs that are real due to his injury; is trying to determine who is consistent and trustworthy for meeting his significant physical needs (3) is not accurate for situation (4) is not accurate for situation 27. A client is scheduled for electromyography (EMG). What should the nurse tell the client about the procedure? 1. "Your hair will be carefully washed prior to the procedure." 2. "This is a noninvasive procedure that takes about 30 minutes." 3. "A sedative will be given to you shortly before the procedure." 4. "You will not be all owed to eat 4 to 6 hours before the procedure." Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) usually performed on the legs (2) correct —electrodes are attached to legs, length of time for impulse transmission is measured (3) may impair test results

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    ............................................................................................................................ NCLEX QUESTION TRAINER (4) procedure does not involve general anesthesia or GI system 28. The nurse is aware that Rh immune globulin (RhoGAM) is administered to prevent complications in which of the following situations? 1. The baby is Rh - negative, the mother is Rh - negative, and the father is Rh - positive. 2. The mother is Rh - negative, the baby is Rh - positive, and there is a negative direct Coombs. 3. The mother is Rh - positive and previously sensitized, and the baby is Rh - negative. 4. The mother is Rh - positive, the baby is Rh - negative, and there is a history of one incomplete pregnancy. Strategy: Think about each answer choice. (1) if both mother and baby are Rh-negative, there is no problem (2) correct —RhoGAM is given to an Rh-negative mother who delivers an Rh-positive baby when the baby has a negative Coombs test (3) medication is not given if the mother has been sensitized by a previous pregnancy (4) there is no incompatibility here, but the mother needs to be evaluated regarding sensitization in the incomplete pregnancy 29. The nurse in the outpatient clinic instructs a client diagnosed with right-sided weakness to walk down stairs using a cane. What behavior, if demonstrated by the client, indicates to the nurse that teaching is successful? 1. The client puts the right leg on the step, then the cane, followed by the left leg. 2. The client leads with the cane, followed by the right leg and then the left leg. 3. The client advances the ri ght leg, followed by the left leg and the cane. 4. The client puts the cane on the step and advances the left leg, followed by the right leg. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) to go down stairs, advance weak leg and cane first; to go up stairs, advance strong leg, then weak leg and cane

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