NCLEX Comprehensive Exam Part 5

1. An obese 36-year-old multigravid client at 12 weeks’ gestation has a history of chronic hypertension. She was treated with methyldopa (Aldomet) before becoming pregnant. When counseling the client about diet during pregnancy, the nurse realizes that the client needs additional instruction when she states which of the following?

A. “I need to reduce my caloric intake to 1,200 calories a day.”
B. “A regular diet is recommended during pregnancy.”
C. “I should eat more frequent meals if I get heartburn.”
D. “I need to consume more fluids and fiber each day.”

2. The physician has ordered a chemotherapy drug to be administered to a client every day for the next week. The client is on an adult medical–surgical floor but the nurse assigned to the client has not been trained to handle chemotherapy agents. What is the nurse’s most appropriate response?

A. Send the client to the oncology floor for administration of the medication.
B. Ask a nurse from the oncology floor to come to the client and administer the medication.
C. Ask another nurse to help mix the chemotherapy agent.
D. Ask the pharmacy to mix the chemotherapy agent and administer it.

3. Which of the following nursing diagnoses would the nurse identify as a priority after surgical repair of a cleft lip?

A. Pain.
B. Risk for Infection.
C. Impaired Physical Mobility.
D. Impaired Parenting.

4. Which of the following would be an appropriate outcome for a client with rheumatoid arthritis? The client will

A. manage joint pain and fatigue to perform activities of daily living.
B. maintain full range-of-motion (ROM) in joints.
C. prevent the development of further pain and joint deformity
D. take anti-inflammatory medications as indicated by the presence of disease symptoms.

5. A client’s burn wounds are being cleaned twice a day in a hydrotherapy tub. Which of the following interventions should be included in the plan of care before a hydrotherapy treatment is initiated?

A. Limit food and fluids 45 minutes before therapy to prevent nausea and vomiting.
B. Increase the intravenous flow rate to offset fluids lost through the therapy.
C. Apply a topical antibiotic cream to burns to prevent infection.
D. Administer pain medication 30 minutes before therapy to help manage pain.

6. A health care provider has been exposed to hepatitis B through a needlestick. Which of the following drugs would the nurse anticipate administering as postexposure prophylaxis?

A. Hepatitis B immune globulin.
B. Interferon.
C. Hepatitis B surface antigen.
D. Amphotericin B.

7. When performing an otoscopic examination of the tympanic membrane of a 2-year-old child, the nurse would pull the pinna in which of the following directions?

A. Down and back.
B. Down and slightly forward.
C. Up and back.
D. Up and forward.

8. Which of the following findings would the nurse most likely note in the client who is in the compensatory stage of shock?

A. Decreased urinary output.
B. Significant hypotension.
C. Tachycardia.
D. Mental confusion.

9. A client has been prescribed hydrochlorothiazide (HydroDIURIL) for treatment of heart failure. For which of the following symptoms should the nurse monitor the client?

A. Urinary retention.
B. Muscle weakness.
C. Confusion.
D. Diaphoresis.

10. The son of a client with Alzheimer’s disease excitedly tells the nurse, “Mom was singing one of her favorite old songs. I think she’s getting her memory back!” Which of the following responses by the nurse is most appropriate?

A. “She still has long-term memory, but her short-term memory will not return.”
B. “I’m so happy to hear that. Maybe she is getting better.”
C. “Don’t get your hopes up. This is only a temporary improvement.”
D. “I’m glad she can sing even if she can’t talk to you.”

11. The nurse collects a urine specimen from a client for a culture and sensitivity analysis. Which of the following is the correct care of the specimen?

A. Promptly send the specimen to the laboratory.
B. Send the specimen with the next pickup.
C. Send the specimen the next time a nursing assistant is available.
D. Store the specimen in the refrigerator until it can be sent to the laboratory.

12. A 16-year-old client is in the emergency department for treatment of minor injuries from a car accident. A crisis nurse is with her because she became hysterical and was saying, “It’s my fault. My Mom is going to kill me. I don’t even have a way home.” Which of the following would be the nurse’s initial intervention?

A. “Hold her hands and say, “Slow down. Take a deep breath.”
B. “Calm down. The police can take you home.”
C. “Put a hand on her shoulder and say, ‘It wasn’t your fault.”‘
D. “Your mother is not going to kill you. Stop worrying.”

13. The nurse is developing a community health education program about STDs. Which information about women who acquire gonorrhea should be included?

A. Women are more reluctant than men to seek medical treatment.
B. Gonorrhea is not easily transmitted to women who are menopausal.
C. Women with gonorrhea are usually asymptomatic.
D. Gonorrhea is usually a mild disease for women.

14. A client has his leg immobilized in a long leg cast. Which of the following assessments would indicate the early beginning of circulatory impairment?

A. Inability to move toes.
B. Cyanosis of toes.
C. Complaints of cast tightness.
D. Tingling of toes.

15. While feeding a term neonate at 2 hours of age, the nurse observes that the neonate has a drooping appearance on the left side of the face. The nurse notifies the physician based on the understanding that this is associated with which of the following?

A. Craniotabes.
B. Meningitis.
C. Facial nerve damage.
D. Skull fracture.

16. A client tells the nurse that she has had sexual contact with someone whom she suspects has genital herpes. Which of the following instructions should the nurse give the client in response to this information?

A. Anticipate lesions within 25 to 30 days.
B. Continue sexual activity unless lesions are present.
C. Report any difficulty urinating.
D. Force fluids to prevent lesions from forming.

17. The nurse is assigned to a client with irreversible shock. The nurse realizes that the negative outcomes of irreversible shock include severe hypoperfusion to all vital organs and failure of vital functions. Therefore, the nurse will monitor the client for

A. increased alertness.
B. circulatory collapse.
C. hypertension.
D. diuresis.

18. The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client’s vital signs, the nurse notes an apical pulse of 150 bpm, a respiration rate of 46 breaths/minute and a blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse’s first course of action?

A. Notify the physician.
B. Administer a sedative.
C. Try to elicit a positive Homan’s sign.
D. Increase the flow rate of intravenous fluids.

19. The charge nurse should give a new graduate nurse who made an insulin medication error the following advice:

A. “Trust your judgment; don’t listen to your client.”
B. “Compare the insulin doses that other clients are receiving.”
C. “Large doses must always be double-checked.”
D. “Use ‘U’ as an abbreviation for ‘Unit.”‘

20. A client who has Ménière’s disease is trying to cope with the chronic tinnitus that she is experiencing. Which of the following interventions would be most appropriate for the nurse to suggest for coping with the tinnitus?

A. Maintain a quiet environment.
B. Play background music.
C. Avoid caffeine and nicotine.
D. Take a mild sedative.

(ANSWERS & RATIONALE) NCLEX Comprehensive Exam Part 5