NCLEX Sample Test on Physiological Adaptation

1. Dyspnea associated with congestive heart failure is primarily due to

a. Accumulation of fluid in the interstitial spaces and alveoli of the lungs.
b. Compression of lungs by the dilated heart.
c. Blockage of a pulmonary artery by an embolus.
d. Blockage of bronchi by mucous secretions.

2. A 24-year-old client is admitted to the hospital following an automobile accident. She was brought in unconscious with the following vital signs: BP 130/76, P 100, R 16, T 988F. The nurse observes bleeding from the client’s nose. Which of the following interventions will assist in determining the presence of cerebrospinal fluid?

a. Suctioning the nose gently with a bulb syringe and sending specimen to the laboratory.
b. Inserting sterile packing into the nares and removing in 24 hours.
c. Obtaining a culture of the specimen using sterile swabs and sending to the laboratory.
d. Allowing the drainage to drip on a sterile gauze and observing for a halo or ring around the blood.

3. A 28-year-old male client is admitted to the hospital for a suspected brain tumor. While assessing this client, the nurse would keep in mind that the most reliable index of cerebral status is

a. Pupil response.
b. Deep tendon reflexes.
c. Level of consciousness.
d. Muscle strength.

4. A client has outpatient surgery on his knee and has just been admitted to the ED with the following symptoms: marked shortness of breath, tachycardia, chest pain and severe anxiety. The nurse will recognize that these symptoms must be reported immediately to the physician. The next intervention will be to prepare to administer

a. Oxygen.
b. Coumadin.
c. Urokinase.
d. Heparin.

5. A client was in an automobile accident, and sustained a head injury. Following admission to the hospital, a diagnosis of increasing intracranial pressure was made. The nursing intervention appropriate in the care of this client is to

a. Teach controlled coughing and deep breathing.
b. Elevate the head 15 to 30 degrees.
c. Provide a quiet and brightly lit environment.
d. Encourage the intake of clear fluids.

6. A client has been admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The complication that the nurse will constantly observe for is

a. Congestive heart failure.
b. Systemic emboli.
c. Fever.
d. Presence of a heart murmur.

7. The nurse is counseling a client with the diagnosis of glaucoma. She explains that if left untreated, this condition leads to

a. Blindness.
b. Myopia.
c. Uveitis.
d. Retrolental fibroplasia.

8. A client with a history of cholecystitis is now being admitted to the hospital for possible surgical intervention. The orders include NPO, IV therapy, and bedrest. In addition to assessing for nausea, vomiting and anorexia, the nurse should observe for pain

a. In the right lower quadrant.
b. Radiating to the left shoulder.
c. After ingesting food.
d. In the right upper quadrant.

9. Auscultation of a client’s lungs reveals rales (crackles) in the left posterior base. The nursing intervention is to

a. Inspect the client’s ankles and sacrum for the presence of edema.
b. Repeat auscultation after asking the client to deep breath and cough.
c. Instruct the client to limit fluid intake to less than 2000 mL/day.
d. Place the client on bedrest in a semi-Fowler’s position.

10. An employee at the local factory comes to the nurse’s office with a large furuncle (boil) on his left upper arm. He has come to the office with this same complaint over the past 6 months. In addition to specific care for the boil itself, the nursing intervention should include

a. Calling in all employees and checking them for furuncles.
b. Doing nothing else, as furuncles are not related to any other disease process.
c. Encouraging the client to see his family physician as recurrent boils may be a sign of underlying disease.
d. Advising the client to bathe more regularly.

11. Certain physiological changes will result from the treatment for myxedema. The symptoms that may indicate adverse changes in the body that the nurse should observe for are

a. Weight loss, nervousness, and insomnia.
b. Increased pulse and cardiac output.
c. Hyperglycemia.
d. Increased respiratory excursion.

12. When the nurse is completing an assessment of a burned client, second-degree burns would appear as

a. Full-thickness with extension to underlying muscle and bone.
b. Partial-thickness with involvement of epidermis and dermis, showing edema and vesicles.
c. Full-thickness with dry, waxy, or leathery appearance without vesicles.
d. Partial-thickness with erythema and often edema, but no vesicles.

13. A client is admitted to the trauma unit with a suspected arterial bleed in his head following an injury. He is experiencing periods of confusion and lucidity. As the nurse assesses his status, she will further assess for

a. Increased intracranial pressure.
b. Epidural hematoma.
c. Subdural hematoma.
d. Increased blood pressure.

14. Following abdominal surgery, which of the following clinical manifestations will be indicative of negative nitrogen balance?

a. Diarrhea.
b. Poor skin turgor from dehydration.
c. Pale color to skin.
d. Edema or ascites of the abdomen and flank.

15. A client has a bile duct obstruction and is jaundiced. Which intervention will be most effective in controlling the itching associated with his jaundice?

a. Maintain the client’s room temperature at 72 to 75°F.
b. Use alcohol for back rubs.
c. Provide tepid water for bathing.
d. Keep the client’s nails clean and short.

NCLEX Sample Test on Physiological Adaptation [ANSWERS & RATIONALE]

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