NCLEX Comprehensive Exam Part 2
1. A multigravida client visiting the prenatal clinic at 16 weeks’ gestation exhibits facial swelling, a brownish vaginal discharge, and fundal height of 22 cm. The client’s blood pressure is 160/90 mm Hg and her pulse is 80 bpm. The nurse interprets these findings as suggestive of which of the following?
a. Placenta previa.
b. Fetal anemia.
c. Multifetal pregnancy.
d. Gestational trophoblastic disease.
2. Which of the following responses would be most helpful for a client who is euphoric, intrusive, and interrupts other clients engaged in conversations to the point where they get up and leave or walk away?
a. “When you interrupt others, they leave the area.”
b. You are being rude and uncaring.”
c. “You should remember to use your manners.”
d. “You know better than to interrupt someone.”
3. The nurse coordinates with the laboratory staff to have the gentamicin trough serum level drawn. At what time should the blood be drawn in relation to the administration of the intravenous dose of gentamicin sulfate (Garamycin)?
a. 2 hours before the administration of the next intravenous dose.
b. 3 hours before the administration of the next intravenous dose.
c. 4 hours before the administration of the next intravenous dose.
d. Just before the administration of the next intravenous dose.
4. Older adults with known cardiovascular disease must balance which of the following measures for optimum health?
a. Diet, exercise, and medication.
b. Stress, hypertension, and pain.
c. Mental health, diet, and stress.
d. Social events, diet, and smoking.
5. A 4-year-old is brought to the emergency department with sudden onset of a temperature of 103°F (39.5°C), sore throat, and refusal to drink. The child will not lie down and prefers to lean forward while sitting up. Which of the following would the nurse do next?
a. Give 600 mg acetaminophen (Tylenol) per rectum as ordered.
b. Inspect the child’s throat for redness and swelling.
c. Have an appropriate-sized tracheostomy tube readily available.
d. Obtain a specimen for a throat culture.
6. Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, which of the following would the nurse do next?
a. Hold the lithium and obtain a stat lithium level to determine therapeutic effectiveness.
b. Continue the lithium and immediately notify the physician about the assessment findings.
c. Continue the lithium and reassure the client that these temporary side effects will subside.
d. Hold the lithium and monitor the client for signs and symptoms of increasing toxicity.
7. A client asks the nurse how long she will have to take her medicine for hypothyroidism. The nurse’s response is based on the knowledge that
a. lifelong daily medicine is necessary.
b. the medication is expensive, and the dose can be reduced in a few months.
c. the medication can be gradually withdrawn in 1 to 2 years.
d. the medication can be discontinued after the client’s thyroid-stimulating hormone (TSH) level is normal.
8. Assessment of which of the following clients would lead the nurse to expect the physician to order an adjustment in lithium dosage?
a. A client who continues work as a computer programmer.
b. A client who attends college classes.
c. A client who is now able to care for his or her children.
d. A client who is beginning training for a tennis team.
9. A client admitted with a gastric ulcer has been vomiting bright red blood. His hemoglobin is 5.11 g/dL, and his blood pressure is 100/50 mm Hg. The client and the family state that their religious beliefs do not support the use of blood products and refuse blood transfusions as a treatment for the bleeding. The nurse would expect that the next step in the treatment plan would be to
a. discontinue all measures.
b. notify the hospital attorney.
c. attempt to stabilize the client through the use of fluid replacement.
d. give enough blood to keep the client from dying.
10. The parents of a child with cystic fibrosis express concern about how the disease was transmitted to their child. The nurse would explain that
a. a disease carrier also has the disease.
b. two parents who are carriers may produce a child who has the disease.
c. a disease carrier and an affected person will never have children with the disease.
d. a disease carrier and an affected person will have a child with the disease.
11. A client with angina shows the nurse her nitroglycerin (Nitrostat) that she is carrying in a plastic bag in her pocket. The nurse instructs the client that nitroglycerin should be kept
a. in the refrigerator.
b. in a cool, moist place.
c. in a dark container to shield from light.
d. in a plastic bag where it is readily available
12. The nurse caring for client on the telemetry unit is able to determine that the client is in sinus bradycardia by recognizing which characteristics? Select all that apply.
a. P wave present.
b. Ventricular rate of 50 beats per minute (bpm).
c. Atrial rate of 120 bpm.
d. PR interval ranging from 0.12 to 0.20.
13. When teaching a client with bipolar disorder, mania, who has started to take valproic acid (Depakene) about possible side effects of this medication, the nurse would include which of the following in the teaching plan?
a. Increased urination.
b. Slowed thinking.
d. Weight loss.
14. An infant is born with facial abnormalities, growth retardation, mental retardation, and vision abnormalities. These abnormalities are probably caused by maternal
a. alcohol consumption
b. vitamin B6 deficiency.
c. vitamin A deficiency.
d. folic acid deficiency.
15. Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used in the treatment of musculoskeletal conditions. It is important for the nurse to remind the client to
a. take NSAIDs at least three times per day.
b. exercise the joints at least 1 hour after taking the medication.
c. take antacids 1 hour after taking NSAIDs.
d. take NSAIDs with food.
16. The nurse would suspect that the client taking disulfiram (Antabuse) therapy has ingested alcohol when the client exhibits which of the following symptoms?
a. Sore throat and muscle aches.
b. Nausea and flushing of the face and neck.
c. Fever and muscle soreness.
d. Bradycardia and vertigo.
17. The nurse holds the gauze pledget against an intramuscular injection site while removing the needle from the muscle. This technique helps to
a. seal off the track left by the needle in the tissue.
b. speed the spread of the medication in the tissue.
c. avoid the discomfort of the needle pulling on the skin.
d. prevent organisms from entering the body through the skin puncture.
18. A client whose condition remains stable after a myocardial infarction gradually increases his activity. Which the following conditions should the nurse assess to determine whether the activity is appropriate for the client?
d. Weight loss
19. When a client with alcohol dependency begins to talk about not having a problem with alcohol, the nurse would use which of the following approaches?
a. Questioning the client about how much alcohol she drinks.
b. Confronting the client with the fact that she was intoxicated 2 days ago
c. Pointing out how alcohol has gotten her into trouble.
d. Listening to what the client states and then asking her how she plans to stay sober.
20. Which of the following correctly describes Medicaid?
a. A program designed to assist ill, low-income older adults.
b. A federal insurance program for pregnant women.
c. A joint federal–state program for low-income persons.
d. A program administered by health maintenance organizations.
ANSWERS and RATIONALE for NCLEX Comprehensive Exam Part 2 coming soon…