NCLEX Comprehensive Exam Part 4

1. The nurse recognizes that a client with pain disorder is improving when the client states which of the following?

a. “I need to have a good cry about all the pain I’ve been in and then not dwell on it.”
b. “I need to find another physician who can accurately diagnose my condition.”
c. “The pain medicine that you gave me helps me to relax.”
d. I’m angry with all of the doctors I’ve seen who don’t know what they’re doing.”

2. A client admitted in an acute psychotic state says that she hears “terrible voices in the head” and thinks her neighbor is “out to get her.” Which of the following would be the nurse’s best response?

a. “What has your neighbor been doing that bothers you?”
b. “How long have you been hearing these ‘terrible voices?”‘
c. “We won’t let your neighbor visit, so you’ll be safe.”
d. “What exactly are these ‘terrible voices’ saying to you?”

3. The nurse would assess the client with severe diarrhea for which acid–base imbalance?

a. Respiratory acidosis.
b. Respiratory alkalosis.
c. Metabolic acidosis.
d. Metabolic alkalosis.

4. Which of the following outcome criteria would be appropriate for a client with excess fluid volume?

a. A weight resolution of 10% will occur.
b. Pain will be controlled effectively.
c. Arterial blood gas values will be within normal limits.
d. Serum osmolality value will be within normal limits.

5. A 7-year-old child is admitted to the hospital with the medical diagnosis of acute rheumatic fever. Which of the following laboratory blood findings would confirm that the child probably has had a streptococcal infection?

a. High leukocyte count.
b. Low hemoglobin count.
c. Elevated antibody concentration.
d. Low erythrocyte sedimentation rate.

6. A client is scheduled for hip replacement surgery and is interviewed by the nurse in the preadmission testing unit. The client states that he wishes to receive his own blood for the upcoming surgery. What is the nurse’s most appropriate response?

a. Document the client’s request on the chart.
b. Notify the hematology laboratory.
c. Notify the surgeon’s office.
d. Call the blood bank.

7. A client needs surgery to relieve an intestinal obstruction. The day before the surgery, the nurse receives the following set of orders for the client. Which of the following orders should the nurse question before performing?

a. Tapwater enemas until clear.
b. Out of bed as tolerated.
c. Neomycin sulfate 1 g PO every 4 hours.
d. Betadine scrub to abdomen twice daily.

8. After teaching a client about collecting a stool sample for occult testing, which client statement indicates effective teaching? Select all that apply.

a. “I will avoid eating meat for 1 to 3 days before getting a stool sample.”
b. “I need to eat foods low in fiber a few days prior to collecting the sample.”
c. “I’ll take the sample from different areas of the stool that I have passed.”
d. “I need to send the stool sample to the lab in a covered container right away.”

9. A client who is NPO is constantly asking for a drink. Which of the following would be the most appropriate nursing intervention?

a. Reexplain to the client why she cannot drink.
b. Offer ice chips every hour to decrease thirst.
c. Offer the client frequent oral hygiene care.
d. Divert the client’s attention by turning on the television.

10. A female client is admitted with complaints of fatigue, cold intolerance, weight gain, and muscle weakness. The initial nursing assessment reveals brittle nails, dry hair, constipation, and possible goiter. The client is most likely experiencing signs and symptoms of

a. Cushing’s disease.
b. hypothyroidism.
c. hyperthyroidism.
d. a pituitary tumor.

11. A mother visiting the clinic for a routine visit with her 10-year-old daughter reports that her daughter has an increase in hair growth and breast enlargement. The nurse explains to the mother and daughter that after the symptoms of puberty are noticed, menstruation most typically occurs within which of the following time frames?

a. 6 months.
b. 12 months.
c. 30 months.
d. 36 months.

12. While a mother is feeding her full-term neonate 1 hour after birth, she asks the nurse, “What are these white dots in my baby’s mouth? I tried to wash them out, but they’re still there.” After assessing the neonate’s mouth, the nurse explains that these spots are which of the following?

a. Koplik’s spots.
b. Epstein’s pearls.
c. Precocious teeth.
d. Thrush curds.

13. The nurse would suspect esophageal atresia (EA) and tracheoesophageal fistula (TEF) in a newborn exhibiting which of the following initially? Select all that apply.

a. Copious frothy mucus.
b. Episodes of cyanosis.
c. Several loose stools.
d. Initial weight loss.

14. Which one of the following factors is most important for healing an infected decubitus ulcer?

a. Adequate circulatory status.
b. Scheduled periods of rest.
c. Balanced nutritional diet.
d. Fluid intake of 1,500 mL/day.

15. A client is receiving digoxin (Lanoxin). His pulse range is normally 70 to 76 bpm. After assessing the apical pulse for 1 minute and finding it to be 60 bpm, the nurse should initially

a. call the physician for orders.
b. withhold the digoxin.
c. administer the digoxin.
d. notify the charge nurse

16. While shopping at a local mall, the nurse hears a pregnant client yell “Oh my! The baby’s coming!” After placing the client in a supine position and trying to maintain some privacy, the nurse sees that the neonate’s head is delivering. Which of the following would the nurse do first?

a. Suction the mouth with two fingertips.
b. Check for presence of a cord around the neck.
c. Tell the client to bear down with force.
d. Advise the mother that help is on the way.

17. The nurse is preparing a discharge plan for a 16-year-old who has fractured her femur and ulna. The client asks the nurse how quickly her fractures will heal so she can return to her normal activities. Which of the following responses would be most appropriate for the nurse to make?

a. “The healing of your leg will be delayed because you have had a skeletal traction.”
b. “It will take your arm about 12 weeks to heal completely, but it will take your leg about 24 weeks.”
c. “Because you are young and healthy, your bones should heal in less than 12 weeks.”
d. “You will require long-term rehabilitation and should expect it to take at least 8 months for your bones to heal.”

18. A client with delirium becomes very anxious and says, “I can’t stop what is happening to me. Make it stop, please!” Which of the following would be the nurse’s most appropriate response?

a. “I’ll get you some medicines to help you relax. The more you worry, the worse it will get.”
b. “As soon as we know what’s causing this, we can try to stop it. I’ll get you some medicine to help you relax.”
c. “I wish I could do something to make it stop, but unfortunately I can’t.”
d. “I’ll sit with you until you calm down a little.”

19. After teaching a primigravid client at 10 weeks’ gestation about the recommendations for exercise during pregnancy, which of the following client statements indicates successful teaching?

a. “While pregnant, I should avoid contact sports.”
b. “Even though I’m pregnant, I can learn to ski next month.”
c. “While we are on vacation next month, I can continue to scuba dive.”
d. “Sitting in a hot tub after exercise will help me to relax.”

20. The nurse is caring for a client who has had a myocardial infarction involving a large section of the heart muscle. The nurse anticipates that the client is at risk for

a. cardiogenic shock.
b. hypovolemic shock.
c. neurogenic shock.
d. metabolic shock.

ANSWERS & RATIONALE – NCLEX Comprehensive Exam Part 4

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