NCLEX Practice Test 103

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1. A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?

1. Document the finding

2. Report the finding to the doctor

3. Prepare the client for a C-section

4. Continue primary care as prescribed

2. A client with a diagnosis of HPV is at risk for which of the following?

1. Hodgkin's lymphoma

2. Cervical cancer

3. Multiple myeloma

4. Ovarian cancer

3. During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:

1. Syphilis

2. Herpes

3. Gonorrhea

4. Condylomata

4. A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:

1. Venereal Disease Research Lab (VDRL)

2. Rapid plasma reagin (RPR)

3. Florescent treponemal antibody (FTA)

4. Thayer-Martin culture (TMC)

5. A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?

1. Elevated blood glucose

2. Elevated platelet count

3. Elevated creatinine clearance

4. Elevated hepatic enzymes

6. The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?

1. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.

2. The nurse loosely suspends the client's arm in an open hand while tapping the back of the client's elbow.

3. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.

4. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.

7. A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor's order should the nurse question?

1. Magnesium sulfate 4gm (25%) IV

2. Brethine 10mcg IV

3. Stadol 1mg IV push every 4 hours as needed prn for pain

4. Ancef 2gm IVPB every 6 hours

8. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse's assessment of this data is:

1. The infant is at low risk for congenital anomalies.

2. The infant is at high risk for intrauterine growth retardation.

3. The infant is at high risk for respiratory distress syndrome.

4. The infant is at high risk for birth trauma.

9. Which observation in the newborn of a diabetic mother would require immediate nursing intervention?

1. Crying

2. Wakefulness

3. Jitteriness

4. Yawning

10. The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:

1. Decreased urinary output

2. Hypersomnolence

3. Absence of knee jerk reflex

4. Decreased respiratory rate

11. The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:

1. Place her in Trendelenburg position

2. Decrease the rate of IV infusion

3. Administer oxygen per nasal cannula

4. Increase the rate of the IV infusion

12. A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?

1. Alteration in nutrition

2. Alteration in bowel elimination

3. Alteration in skin integrity

4. Ineffective individual coping

13. The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?

1. Inspection of the abdomen for enlargement

2. Bimanual palpation for hepatomegaly

3. Daily measurement of abdominal girth

4. Assessment for a fluid wave

14. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client's most appropriate priority nursing diagnosis?

1. Alteration in cerebral tissue perfusion

2. Fluid volume deficit

3. Ineffective airway clearance

4. Alteration in sensory perception

15. The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:

1. Likes to play football

2. Drinks several carbonated drinks per day

3. Has two sisters with sickle cell tract

4. Is taking acetaminophen to control pain

16. The nurse working the organ transplant unit is caring for a client with a white blood cell count of During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?

1. Allow the client to keep the fruit

2. Place the fruit next to the bed for easy access by the client

3. Offer to wash the fruit for the client

4. Tell the family members to take the fruit home

17. The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40 systolic. The initial nurse's action should be to:

1. Place the client in Trendelenburg position

2. Increase the infusion of Dextrose in normal saline

3. Administer atropine intravenously

4. Move the emergency cart to the bedside

18. The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?

1. Order a chest x-ray

2. Reinsert the tube

3. Cover the insertion site with a Vaseline gauze

4. Call the doctor

19. A client being treated with sodium warfarin has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?

1. Assess for signs of abnormal bleeding

2. Anticipate an increase in the Coumadin dosage

3. Instruct the client regarding the drug therapy

4. Increase the frequency of neurological assessments

20. Which selection would provide the most calcium for the client who is 4 months pregnant?

1. A granola bar

2. A bran muffin

3. A cup of yogurt

4. A glass of fruit juice

21. The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of the possible side effects of magnesium sulfate?

1. The nurse places a sign over the bed not to check blood pressure in the right arm.

2. The nurse places a padded tongue blade at the bedside.

3. The nurse inserts a Foley catheter.

4. The nurse darkens the room.

22. A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The physician has written an order to transfuse 2 units of whole blood. When discussing the treatment, the child's mother tells the nurse that she does not believe in having blood transfusions and that she will not allow her child to have the treatment. What nursing action is most appropriate?

1. Ask the mother to leave while the blood transfusion is in progress

2. Encourage the mother to reconsider

3. Explain the consequences without treatment

4. Notify the physician of the mother's refusal

23. A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?

1. Hypovolemia

2. Laryngeal edema

3. Hypernatremia

4. Hyperkalemia

24. The nurse is evaluating nutritional outcomes for an elderly client with bulimia. Which data best indicates that the plan of care is effective?

1. The client selects a balanced diet from the menu.

2. The client's hemoglobin and hematocrit improve.

3. The client's tissue turgor improves.

4. The client gains weight.

25. The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?

1. Pain beneath the cast

2. Warm toes

3. Pedal pulses weak and rapid

4. Paresthesia of the toes