NCLEX RN Example Test Questions with Answers and Rationale 2

Health Promotion and Maintenance

1. An 18-year-old woman comes to the physician’s office for a routine prenatal checkup at 34 weeks gestation. Abdominal palpation reveals the fetal position as right occipital anterior (ROA). At which of the following sites would the nurse expect to find the fetal heart tone?

(A) Below the umbilicus, on the mother’s left side.
(B) Below the umbilicus, on the mother’s right side.
(C) Above the umbilicus, on the mother’s left side.
(D) Above the umbilicus, on the mother’s right side.

2. The nurse in an outpatient clinic is supervising student nurses administering influenza vaccinations. The nurse should question the administration of the vaccine to which of the following clients?

(A) A 45-year-old male who is allergic to shellfish.
(B) A 60-year-old female who says she has a sore throat.
(C) A 66-year-old female who lives in a group home.
(D) A 70-year-old female with congestive heart failure.

3. The nurse performs a home visit on a client who delivered two days ago. The client states that she is bottle-feeding her infant. The nurse notes white, curd-like patches on the newborn’s oral mucous membranes. The nurse should take which of the following actions?

(A) Determine the baby’s blood glucose level.
(B) Suggest that the newborn’s formula be changed.
(C) Remind the caretaker not to let the infant sleep with the bottle.
(D) Explain that the newborn will need to receive some medication.

4. A two-month-old infant is brought to the pediatrician’s office for a well-baby visit. During the examination, congenital subluxation of the left hip is suspected. The nurse knows that symptoms of congenital hip dislocation include

(A) lengthening of the limb on the affected side.
(B) deformities of the foot and ankle.
(C) asymmetry of the gluteal and thigh folds.
(D) plantar flexion of the foot.

5. The nurse teaches a 20-year-old primigravida how to measure the frequency of uterine contractions. The nurse should explain to the patient that the frequency of uterine contractions is determined

(A) from the beginning of one contraction to the end of the next contraction.
(B) from the beginning of one contraction to the end of the same contraction.
(C) by the strength of the contraction at its peak.
(D) by the number of contractions that occur within a given period of time.

ANSWERS AND RATIONALE

1. The answer is B.

Question: The fetus is ROA. Where should the nurse listen for the FHT?

Strategy: Picture the situation described. It may be helpful for you to draw this out so that you can imagine where the heartbeat would be found.

Needed Info: Describing fetal position: practice of defining position of baby relative to mother’s pelvis. The point of maximum intensity (PMI) of the fetus: point on the mother’s abdomen where the FHT is the loudest, usually over the fetal back. Divide the mother’s pelvis into 4 parts or quadrants: right and left anterior, which is the front, and right and left posterior, which is the back. Abbreviated: R and L for right and left, and A and P for anterior and posterior. The head, particularly the occiput, is the most common presenting part, and is abbreviated O. LOA is most common fetal position and FHT heard on left side. In a vertex presentation, FHT is heard below the umbilicus. In a breech presentation, FHT is heard above the umbilicus.

(A) Below the umbilicus, on the mother’s left side — found on right not left side
(B) Below the umbilicus, on the mother’s right side — CORRECT: occiput and back are pressing against right side of mother’s abdomen; FHT would be heard below umbilicus on right side
(C) Above the umbilicus, on the mother’s left side — found in breech presentation
(D) Above the umbilicus, on the mother’s right side — found in breech presentation

2. The correct answer is B.

Question: What is a contraindication to receiving flu vaccine?

Strategy: Think about what each answer choice means.

Needed Info: Influenza vaccine: given yearly, preferably Oct.-Nov.; recommended for people age 65 or older; people under 65 with heart disease, lung disease, diabetes, immuno-suppression, chronic care facility residents.

(A) A 45-year-old male who is allergic to shellfish — allergy to eggs is a contraindication
(B) A 60-year-old female who says she has a sore throat — CORRECT: vaccine deferred in presence of acute respiratory disease
(C) A 66-year-old female who lives in a group home — vaccine deferred only if patient has an active immunization
(D) A 70-year-old female with congestive heart failure — no contraindication

3. The correct answer is D.

Question: What is the treatment for thrush?

Strategy: Determine the outcome of each answer choice.

Needed Info: Thrush (oral candidiasis): white plaque on oral mucous membranes, gums, or tongue; treatment includes good handwashing, nystatin (Mycostatin).

(A) Determine the baby’s blood glucose level — thrush in newborns caused by poor handwashing or exposure to an infected vagina during birth
(B) Suggest that the newborn’s formula be changed — not related to thrush
(C) Remind the caretaker not to let the infant sleep with the bottle — not related to thrush
(D) Explain that the newborn will need to receive some medication — CORRECT: thrush most often treated with nystatin (Mycostatin)

4. The correct answer is C.

Question: What will you see with congenital hip dislocation?

Strategy: Form a mental image of the deformity.

Needed Info: Subluxation: most common type of congenital hip dislocation. Head of femur remains in contact with acetabulum but is partially displaced. Diagnosed in infant less than 4 weeks old S/S: unlevel gluteal folds, limited abduction of hip, shortened femur affected side, Ortolani’s sign (click). Treatment: abduction splint, hip spica cast, Bryant’s traction, open reduction.

(A) lengthening of the limb on the affected side — inaccurate
(B) deformities of the foot and ankle — inaccurate
(C) asymmetry of the gluteal and thigh folds — CORRECT: restricted movement on affected side
(D) plantar flexion of the foot — seen with clubfoot

5. The correct answer is D.

Question: How do you determine the frequency of uterine contractions?

Needed Info: There must be at least 3 contractions to establish frequency.

(A) from the beginning of one contraction to the end of the next contraction — not accurate
(B) from the beginning of one contraction to the end of the same contraction — defines duration
(C) by the strength of the contraction at its peak — describes intensity
(D) by the number of contractions that occur within a given period of time — CORRECT

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