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

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............................................................................................................................ NCLEX QUESTION TRAINERNCLEX QUESTION TRAINERTEST 31. A client has a total laryngectomy with a permanent tracheostomy. The nurse plans nutritional intakefor the next 3 days. Which of the following is necessary for the nurse to consider regarding the client’snutrition?1.To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedingsmay 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 feedings will not be attempted for approximately 3 weeks to decreasethe 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 suturearea(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 ventilator2. 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.Dexamethasone 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 ofdementia is made(3) may be ordered to see if the client’s symptoms are caused by excessive use of medications oralcohol(4)correct—test is used with a client who may have varicose veins, no relationship to the symptomsdescribed in this situation3. For a client with a neurologic disorder, which of the following nursing assessments is MOST helpfulin determining subtle changes in the client’s level of consciousness?1.Client posturing.2.Glasgow coma scale.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 consciousnessby evaluating eye-opening, motor, and verbal responses(3) more appropriate for the psychiatric client(4) more appropriate for the psychiatric client4. The nurse conducts a physical examination of a client suspected to have bulimia. Which of thefollowing 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 TRAINERStrategy: 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 appearance5. The nurse prepares a dopamine (Intropin) infusion on a client. Before beginning the infusion thenurse 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 line.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 IVline is essential to prevent serious side effects(4) not a critical assessment at this time6. The nurse assists a nursing assistant in providing a bed bath to a comatose patient withincontinence. 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 incontinent 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 airway7. The nurse instructs a client who is receiving imipramine (Tofranil). It is MOST important for thenurse 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 gain.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 beresolved by altering the dosage or changing the medication(2) describes side effects of antidepressants, which client can learn to manage at home withoutchanging the medication(3) not side effects of Tofranil(4) not side effects of Tofranil8. The nurse receives report from the previous shift. Which of the following patients should the nursesee FIRST?1.A patient post coronary artery bypass graft (CABG) having the atrioventricular (AV) wiresremoved 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, respiratorydepression, and nausea and vomiting(4) requires monitoring but patient with epidural takes priority9. A child has a closed transverse fracture of the right ulna. Which of the following actions, ifperformed 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 requireassessment? 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 irritation10. The nurse cares for a multipara client who delivered a female infant 1 hour ago. The nurseobserves that the client’s breasts are soft; the uterus is boggy to the right of the midline and 2 cmbelow the umbilicus; moderate lochia rubra. It is MOST important for the nurse to take which of thefollowing actions?1.Perform a straight catheterization.2.Offer the client the bedpan.3.Put the baby to breast.4.Massage the uterine fundus.

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............................................................................................................................ NCLEX QUESTION TRAINERStrategy: All answers are implementations. Determine the outcome of each answer choice. Is itdesired?(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 bladder11. The nurse checks for placement of a nasogastric (NG) tube prior to initiating a tube feeding for aclient. 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 tube 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 indication12. The nurse cares for a client after right cataract surgery. The nurse should intervene if which of thefollowing 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 thebed(4) shield is appropriate13. A young adult immobilized for trauma to the spinal cord has periods of diaphoresis, a drainingabdominal wound, and diarrhea. On the basis of the nursing assessment, which of the following is theMOST 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 involuntary 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 secretions14. The nurse cares for a client one day after a thoracotomy. Nursing actions listed on the care planinclude turn, cough, and deep breathe q 2 h. The nurse understands that the purpose of this nursingaction includes which of the following?1.Promote ventilation and prevent respiratory acidosis.2.Increase oxygenation 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 TRAINERStrategy: Think about each answer choice.(1)correct—primary purpose of this nursing measure is to improve and/or maintain good gasexchange, 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 measure15. The mother of a 7-year-old child is dying. The nurse anticipates the child will have which of thefollowing concepts of death?1.Death is punishment for his/her actions.2.Death is inevitable 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 understandthat death is irreversible(3) is a preschool child’s concept of death(4) is an adolescent’s concept of death16. A client with newly diagnosed type 1 diabetes says to the nurse, "I know that I have to take goodcare of my feet. When I buy new shoes, is there anything special I should do?" Which of the followingresponses 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 newshoes."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 TRAINERStrategy: All answers are implementations. Determine the outcome of each answer choice. Is itdesired?(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, havemeasurements 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 andaggravate fungal infections17. A neonate weighing 7 lb 4 oz with Apgar scores of 7 and 8 at 1 and 5 minutes, respectively, isadmitted to the nursery. Because the infant’s mother is diagnosed with a type 1 diabetes, the nurseknows 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 duringpregnancy; 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; infantneeds to maintain normal body temperature while producing minimal amount of heat generated frommetabolic processes; not expected with diabetic mother18. 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 TRAINER3.Apply cool, humidified air to dry the cast.4.Ask the client to move the fingers 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 andflattening of cast(3) would delay drying of cast(4) maintaining mobility of fingers not most important after application of cast19. The nurse cares for patients on the pediatric unit. The mother of a 2-year-old who is one daypostoperative tells the nurse, "My child is so restless and overactive." The nurse should take which ofthe following actions?1.Direct the LPN/LVN to obtain the child’s vital signs.2.Ask the mother if the child’s sutures arestill 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 requirevalidation? 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, clenchingteeth, rocking, and aggressive behavior may also be observed20. The nurse plans a diet for a child diagnosed with cystic fibrosis (CF). Which of the followingdietary requirements should be considered by the nurse?1.High protein, high fat, and high calories.

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............................................................................................................................ NCLEX QUESTION TRAINER2.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 proteinand calories; fat is decreased because it may interfere with absorption of other nutrients(3) not adequate for this child(4) contains high fat21. A male client is admitted with urinary tract problems. A prostate-specific antigen (PSA) and acidphosphatase test are to be done. The nurse knows that1.these tests are valuable screening tests for prostatic cancer.2.the level of PSA is decreased in clients with renal stones.3.thetests 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 mustbe drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSAvalue(2) inaccurate information about a PSA(3) inaccurate information about a PSA(4) inaccurate information about a PSA22. A client with clear lung sounds and unlabored breathing receives aminophylline IV. Which of thefollowing is the MOST appropriate nursing action if the client’s IV infiltrates?

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............................................................................................................................ NCLEX QUESTION TRAINER1.Apply warm soaks to the infiltration site, start a new IV, and continue IV medications.2.Wait 2 hours, reassess the client, and restart the IV if the client has wheezing or laboredbreathing.3.Restart the IV and continue the previous medication schedule.4.Call the physician and recommend that the IVmedications 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 medicationsrecommended23. A client diagnosed with bipolar disorder is in a manic phase with combative behavior. Which of thefollowing is the INITIAL priority nursing action?1.Provide adequate hygiene and nutrition.2.Decrease environmental stimuli.3.Slowly involve the client in unit activities.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/milieusafety are an initial priority(2) decreasing environmental stimulation is an additional strategy that, when utilized in conjunctionwith psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasingenvironmental 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 psychopharmacologicintervention with both sedative medications and mood-stabilizing agents

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............................................................................................................................ NCLEX QUESTION TRAINER24. A client is admitted to the neurosurgery unit for the removal of a cerebellar tumor. The nurseexpects 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."Itis 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 dysfunction25. Nursing management prior to an intravenous pyelogram (IVP) would include which of thefollowing?1.A fat-free meal the evening before the examination and radiopaque tablets 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 following directions regarding voiding during the test.Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is itdesired?(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 eveningbefore an IVP are usually ordered(4) there are few directions the client needs to follow during the test

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............................................................................................................................ NCLEX QUESTION TRAINER26. A client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. Theclient, diagnosed with a spinal cord injury at the level of C4, is tearful, constantly complains ofdiscomfort, and requests to be suctioned. The nurse understands that the client’s attention-seekingbehaviors 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 spinalcord injury; fosters increased dependency needs that are real due to his injury; is trying to determinewho is consistent and trustworthy for meeting his significant physical needs(3) is not accurate for situation(4) is not accurate for situation27. A client is scheduled for electromyography (EMG). What should the nurse tell the client about theprocedure?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 allowed to eat 4 to 6 hours before the procedure."Strategy: All answers are implementations. Determine the outcome of each answer choice. Is itdesired?(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 system28. The nurse is aware that Rh immune globulin (RhoGAM) is administered to prevent complicationsin 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 thebaby is Rh-negative.4.The mother is Rh-positive, the baby is Rh-negative, and there is a history of one incompletepregnancy.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 thebaby 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 inthe incomplete pregnancy29. The nurse in the outpatient clinic instructs a client diagnosed with right-sided weakness to walkdown stairs using a cane. What behavior, if demonstrated by the client, indicates to the nurse thatteaching 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 right 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 itdesired?(1) to go down stairs, advance weak leg and cane first; to go up stairs, advance strong leg, then weakleg and cane

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