NUR 114
EXAM 2
NCLEX Style Questions w/
Rationales & Test Taking Strategies
Jefferson State Community College
This Document Description:
❖ This document contains NCLEX-style Exam
questions tailored to the NUR 114 course at
Jefferson State Community College.
❖ It covers core topics assessed in the course
and reflects the actual exam format and question style.
❖ Each question is followed by a correct answer, rationale, and
test-taking strategy to support exam preparation.
,The nurse is monitoring a child for bleeding after surgery for removal of
a brain tumor. The nurse checks the head dressing for the presence of
blood and notes a colorless drainage on the back of the dressing. Which
action would the nurse perform immediately?
1. Notify the surgeon.
2. Reinforce the dressing.
3. Document the findings and continue to monitor.
4. Circle the area of drainage and continue to monitor.
Answer: 1
Rationale: Colorless drainage on the dressing in a child after craniotomy
indicates the presence of cerebrospinal fluid and needs to be reported to the
surgeon immediately. Options 2, 3, and 4 are not the immediate nursing action
because they do not address the need for immediate intervention to prevent
complications.
Test-Taking Strategy: Note the strategic word, immediately. Eliminate options
3 and 4 because they are comparable or alike and delay necessary
intervention. Also, note the words colorless drainage. This would alert you
quickly to the possibil- ity of the presence of cerebrospinal fluid and direct you
to the correct option.
A child undergoes surgical removal of a brain tumor. During the
postoperative period, the nurse notes that the child is restless, the pulse
rate is elevated, and the blood pressure has decreased significantly from
the baseline value. The nurse suspects that the child is in shock. Which is
the most appropriate nursing action?
1. Notify the surgeon.
2. Place the child in a supine position.
3. Place the child in Trendelenburg's position.
4. Increase the flow rate of the intravenous fluids.
Answer: 1
Rationale: In the event of shock, the surgeon is notified immediately. After
craniotomy, a child is never placed in the supine or Trendelenburg’s position
,because either position could increase intracranial pressure (ICP) and the risk
of bleeding. The head of the bed needs to be elevated. Increasing intravenous
fluids can cause an increase in ICP.
Test-Taking Strategy: Focus on the subject, care for the child following
craniotomy, and note the strategic words, most appropriate. Eliminate options
2 and 3 because these positions could increase ICP. Eliminate option 4 because
increasing the flow rate could also increase ICP. In addition, the nurse would
not increase intravenous fluids without a surgeon’s prescription.
The parent of a 4-year-old child tells the pediatric nurse that the child's
abdomen seems to be swollen. During further assessment, the parent
tells the nurse that the child is eating well and that the activity level of
the child is unchanged. The nurse, suspecting the possibility of Wilms'
tumor, would plan to avoid which during the physical assessment?
1. Palpating the abdomen for a mass
2. Assessing the urine for the presence of hematuria
3. Monitoring the temperature for the presence of fever
4. Monitoring the blood pressure for the presence of hypertension
Answer: 1
Rationale: Wilms’ tumor is the most common intraabdominal and kidney
tumor of childhood. If Wilms’ tumor is suspected, the tumor mass would not
be palpated by the nurse. Excessive manipulation can cause seeding of the
tumor and spread of the cancerous cells. Hematuria, fever, and hypertension
are clinical manifestations associated with Wilms’ tumor.
Test-Taking Strategy: Focus on the subject, the action to avoid. Knowledge that
this tumor is an intra-abdominal and kidney tumor will assist in eliminating
options 2 and 4 because of the relationship of these options to renal function.
Next, thinking about the effect of palpating the tumor will direct you to the
correct answer from the remaining options.
The nurse provides a teaching session to the nursing staff regarding
osteosarcoma. Which statement by a member of the nursing staff
indicates a need for further instruction?
, 1. "The femur is the most common site of this sarcoma."
2. "The child does not experience pain at the primary tumor site."
3. "Limping, if a weight-bearing limb is affected, is a clinical
manifestation."
4. "The symptoms of the disease in the early stage are almost always
attributed to normal growing pains."
Answer: 2
Rationale: Osteosarcoma is the most common bone cancer in children. Cancer
usually is found in the metaphysis of long bones, especially in the lower
extremities, with most tumors occurring in the femur. Osteosarcoma is
manifested clinically by progressive, insidious, and intermittent pain at the
tumor site. By the time these children receive medical attention, they
may be in considerable pain from the tumor. Options 1, 3, and 4 are accurate
regarding osteosarcoma.
Test-Taking Strategy: Note the strategic words, need for further instruction.
These words indicate a negative event query and ask you to select an option
that is an incorrect statement. Knowledge that osteosarcoma is a malignant
tumor of the bone will direct you to the correct option.
The nurse analyzes the laboratory values of a child with leukemia who is
receiving chemotherapy. The nurse notes that the platelet count is
19,500 mm3 (19.5 × 109/L). On the basis of this laboratory result, which
intervention would the nurse include in the plan of care?
1. Initiate bleeding precautions.
2. Monitor closely for signs of infection.
3. Monitor the temperature every 4 hours.
4. Initiate protective isolation precautions.
Answer: 1
Rationale: Leukemia is a malignant increase in the number of leukocytes,
usually at an immature stage, in the bone marrow. It affects the bone marrow,
causing anemia from decreased erythrocytes, infection from neutropenia, and
bleeding from decreased platelet production (thrombocytopenia). If a child
EXAM 2
NCLEX Style Questions w/
Rationales & Test Taking Strategies
Jefferson State Community College
This Document Description:
❖ This document contains NCLEX-style Exam
questions tailored to the NUR 114 course at
Jefferson State Community College.
❖ It covers core topics assessed in the course
and reflects the actual exam format and question style.
❖ Each question is followed by a correct answer, rationale, and
test-taking strategy to support exam preparation.
,The nurse is monitoring a child for bleeding after surgery for removal of
a brain tumor. The nurse checks the head dressing for the presence of
blood and notes a colorless drainage on the back of the dressing. Which
action would the nurse perform immediately?
1. Notify the surgeon.
2. Reinforce the dressing.
3. Document the findings and continue to monitor.
4. Circle the area of drainage and continue to monitor.
Answer: 1
Rationale: Colorless drainage on the dressing in a child after craniotomy
indicates the presence of cerebrospinal fluid and needs to be reported to the
surgeon immediately. Options 2, 3, and 4 are not the immediate nursing action
because they do not address the need for immediate intervention to prevent
complications.
Test-Taking Strategy: Note the strategic word, immediately. Eliminate options
3 and 4 because they are comparable or alike and delay necessary
intervention. Also, note the words colorless drainage. This would alert you
quickly to the possibil- ity of the presence of cerebrospinal fluid and direct you
to the correct option.
A child undergoes surgical removal of a brain tumor. During the
postoperative period, the nurse notes that the child is restless, the pulse
rate is elevated, and the blood pressure has decreased significantly from
the baseline value. The nurse suspects that the child is in shock. Which is
the most appropriate nursing action?
1. Notify the surgeon.
2. Place the child in a supine position.
3. Place the child in Trendelenburg's position.
4. Increase the flow rate of the intravenous fluids.
Answer: 1
Rationale: In the event of shock, the surgeon is notified immediately. After
craniotomy, a child is never placed in the supine or Trendelenburg’s position
,because either position could increase intracranial pressure (ICP) and the risk
of bleeding. The head of the bed needs to be elevated. Increasing intravenous
fluids can cause an increase in ICP.
Test-Taking Strategy: Focus on the subject, care for the child following
craniotomy, and note the strategic words, most appropriate. Eliminate options
2 and 3 because these positions could increase ICP. Eliminate option 4 because
increasing the flow rate could also increase ICP. In addition, the nurse would
not increase intravenous fluids without a surgeon’s prescription.
The parent of a 4-year-old child tells the pediatric nurse that the child's
abdomen seems to be swollen. During further assessment, the parent
tells the nurse that the child is eating well and that the activity level of
the child is unchanged. The nurse, suspecting the possibility of Wilms'
tumor, would plan to avoid which during the physical assessment?
1. Palpating the abdomen for a mass
2. Assessing the urine for the presence of hematuria
3. Monitoring the temperature for the presence of fever
4. Monitoring the blood pressure for the presence of hypertension
Answer: 1
Rationale: Wilms’ tumor is the most common intraabdominal and kidney
tumor of childhood. If Wilms’ tumor is suspected, the tumor mass would not
be palpated by the nurse. Excessive manipulation can cause seeding of the
tumor and spread of the cancerous cells. Hematuria, fever, and hypertension
are clinical manifestations associated with Wilms’ tumor.
Test-Taking Strategy: Focus on the subject, the action to avoid. Knowledge that
this tumor is an intra-abdominal and kidney tumor will assist in eliminating
options 2 and 4 because of the relationship of these options to renal function.
Next, thinking about the effect of palpating the tumor will direct you to the
correct answer from the remaining options.
The nurse provides a teaching session to the nursing staff regarding
osteosarcoma. Which statement by a member of the nursing staff
indicates a need for further instruction?
, 1. "The femur is the most common site of this sarcoma."
2. "The child does not experience pain at the primary tumor site."
3. "Limping, if a weight-bearing limb is affected, is a clinical
manifestation."
4. "The symptoms of the disease in the early stage are almost always
attributed to normal growing pains."
Answer: 2
Rationale: Osteosarcoma is the most common bone cancer in children. Cancer
usually is found in the metaphysis of long bones, especially in the lower
extremities, with most tumors occurring in the femur. Osteosarcoma is
manifested clinically by progressive, insidious, and intermittent pain at the
tumor site. By the time these children receive medical attention, they
may be in considerable pain from the tumor. Options 1, 3, and 4 are accurate
regarding osteosarcoma.
Test-Taking Strategy: Note the strategic words, need for further instruction.
These words indicate a negative event query and ask you to select an option
that is an incorrect statement. Knowledge that osteosarcoma is a malignant
tumor of the bone will direct you to the correct option.
The nurse analyzes the laboratory values of a child with leukemia who is
receiving chemotherapy. The nurse notes that the platelet count is
19,500 mm3 (19.5 × 109/L). On the basis of this laboratory result, which
intervention would the nurse include in the plan of care?
1. Initiate bleeding precautions.
2. Monitor closely for signs of infection.
3. Monitor the temperature every 4 hours.
4. Initiate protective isolation precautions.
Answer: 1
Rationale: Leukemia is a malignant increase in the number of leukocytes,
usually at an immature stage, in the bone marrow. It affects the bone marrow,
causing anemia from decreased erythrocytes, infection from neutropenia, and
bleeding from decreased platelet production (thrombocytopenia). If a child
