2020/2021 NCLEX-PN V5 Practice Exam 2 Questions and Answers with Explanations (STUDY MODE)

  1. Which post-operative assessment finding on a client with a femoral popliteal graft of the right leg would require immediate charge nurse notification? A. Edema of the right extremity and pain at the incision site B. A temperature of 99.6°F and redness of the incision C. Serous drainage noted at the surgical area D. A loss of posterior tibial and dorsalis pedis pulses on the right leg Answer D: A loss of pulses could indicate an occlusion in the graft, requiring surgical intervention. Answers A and C are expected post-operative occurrences with this surgical procedure, which makes them incorrect. Answer B is not classified as hyperthermia, so it is incorrect. 2. The nurse is caring for a client with nausea and vomiting. Laboratory results reveal a potassium level of 2.9mEq. Which ECG finding would the nurse expect to find due to the client’s potassium results? A. Depressed ST segments B. Elevated T waves C. Absent P waves D. Flattened QRSs Answer A: ECG changes associated with hypokalemia are peaked P waves, flat T waves, depressed ST segments, and prominent U waves. Answers B, C, and D are not associated with low potassium levels, so they are incorrect. 3. The nurse is preparing a patient for surgery on the lower abdomen. Which position would the nurse most likely place the client in for surgery on this area? A. Lithotomy B. Sims C. Prone D. Trendelenburg Answer D: The Trendelenburg position is used for surgeries on the lower abdomen and pelvis. This position helps to displace intestines into the upper abdomen and out of the surgical area. Answer A is reserved for vaginal, perineal, and some rectal surgeries. Answer B is used for renal surgery, and answer C is used for back surgery and some rectal surgeries. 4. The physician has prescribed a cleansing enema to a client scheduled for colon surgery. The nurse would place the client: A. Prone B. Supine C. Left Sims D. Dorsal recumbent Answer C: The left Sims position is the best position to use in this case because it follows the natural direction of the colon. Answer A places the client on the abdomen, and answers B and D position the client on the back, so they are all incorrect. 5. The nurse is caring for a client with chest trauma. Which finding would be most indicative of a tension pneumothorax? A. Frothy hemoptysis B. Trachea shift toward unaffected side of the chest C. Subcutaneous emphysema noted anterior chest D. Opening chest wound with a whistle sound emitting from the area Answer B: Trachea shift differentiates this clinical manifestation as a tension pneumothorax. When a person has a tension pneumothorax, air enters but cannot escape, causing a pressure build-up and a shifting of the great vessels, the heart, and the trachea to the unaffected side. Answer A correlates with a pulmonary contusion, so it is incorrect. Answers C and D are associated with a pneumothorax. This makes them nonspecific for tension pneumothorax and, thus, incorrect. 6. The nurse is reviewing a history on a new admission for surgery in the morning. Which long-term medication in the client’s history would be most important to report to the physician? A. Prednisone B. Lisinopril (Zestril) C. Docusate (Colace) D. Calcium carbonate (Oscal D) Answer A: Abrupt withdrawal of steroids can lead to collapse of the cardiovascular system; therefore, the physician should be notified for drug coverage. The medications in answers B, C, and D would not be as important as the maintenance of the steroids. Answer B is an ace-inhibitor used as an antihypertensive. Answer C is a stool softener, and answer D is a calcium and vitamin agent; thus, all are incorrect. 7. The nurse is explaining about the drug zafirlukast (Accolate) to a client with asthma. Which comment by the client would indicate ineffective teaching? A. “I should take this medication with meals.” B. “I need to report flulike symptoms to my doctor.” C. “My doctor might order liver tests while I’m on this drug.” D. “If I’m already having an asthma attack, this drug will not stop it.” Answer A: Accolate should be taken 1 hour before or 2 hours after eating to prevent slow absorption of the drug caused by taking it with meals; therefore, this statement is incorrect and requires further teaching by the nurse. Answers B, C, and D are all true statements regarding this drug and are correct statements made by the client. 8. A client is 4 hours post-operative left brain cerebral aneurysm clipping. Which assessment finding would cause the nurse the most concern? A. Temperature 99.4°F, heart rate 110, respiratory rate 24 B. Drowsiness, urinary output of 50mL in the past hour, 1cm blood drainage noted on surgical dressing C. BP 120/60, lethargic, right-sided weakness D. Alert and oriented, BP 168/96, heart rate 70 Answer C: The assessment finding that causes the most concern is the finding that could indicate a possible stroke. The right-sided weakness would mean there is a loss of muscular functioning on the side opposite the surgical procedure. Answers A, B, and D might indicate a need for reassessments but not a cause for immediate concern or intervention, so they are incorrect. 9. A client with pancreatic cancer has just been given a negative prognosis by the oncologist. The nurse hears the client state, “I don’t believe the doctor, and I think he has me confused with another patient.” This is an example of which of Kubler-Ross’ stages of dying? A. Denial B. Anger C. Depression D. Bargaining Answer A: Kubler Ross identified five stages of dying as the ways that people cope with death: denial, anger, bargaining, depression, and acceptance. Answer A is the first stage of denial that can be used as a buffer and a way to adapt. Other examples of statements made by the client in this stage are “This can’t be true” and “I want another opinion.” When dealing with these clients, the nurse needs to use open-ended statements, such as “Tell me more.” Answers B, C, and D are a few of the other stages of dying and, thus, are incorrect. 10. The nurse is discussing staff assignments. Which client assignment should be given to the nurse’s assistant? A. Emergency exploratory laparotomy with a colon resection the previous shift B. Client with a stroke scheduled for discharge to rehabilitation C. A client with terminal cancer in severe pain D. New admission with diverticulitis Answer B: The client with the stroke is the most stable client of the ones listed. The client in answer A would need extensive assessment. Answer C involves a client with a need for psychosocial support and nursing interventions. The client in answer D is a new admission with an infected diverticulum and would be less stable, with more unknowns. 11. A client is being discharged on warfarin (Coumadin) after hospitalization for atrial fibrillation. The nurse recognizes that which of the following foods would be restricted while the client is on this medication? A. Cabbage B. Apples C. Potatoes D. Macaroni Answer A: Vitamin K would decrease the effects of Coumadin; therefore the client should be taught to restrict green, leafy vegetables, such as broccoli, cabbage, turnip greens, and lettuce. Answers B, C, and D are food choices that are low in vitamin K, so they are incorrect. 12. Which assessment finding in a client with emphysema indicates to the nurse that the respiratory problem is chronic? A. Wheezing on exhalation B. Productive cough C. Clubbing of fingers D. Cyanosis Answer C: The clinical manifestation of clubbing of the fingers takes time. This indicates that the condition is chronic and not acute, making answer C the correct answer. Answers A, B, and D are all nonspecific for chronicity, so they are incorrect. 13. A client who has just undergone a laparoscopic tubal ligation complains of “free air pain.” What would be the nurse’s best action? A. Ambulate the client B. Instruct the client to breathe deeply and cough C. Maintain the client on bed rest with her legs elevated D. Insert an NG tube to low wall suction Answer A: Ambulating the client should help to pass the air. The air is used during the surgical procedure to assist in performance of the surgery. Answers B and C would not help, so they are incorrect. Answer D is not necessary or appropriate at this time. 14. The nurse is planning shift duties. Which is the least appropriate task for the nursing assistant? A. Assisting a COPD client admitted 2 days ago to get up in the chair B. Feeding a client with bronchitis who has an old paralysis on the right side C. Accompanying a discharged emphysema client to the transportation area D. Assessing an emphysema client complaining of difficulty breathing Answer D: Assessment is not within the role of a nurse’s assistant, which makes this the least appropriate of the tasks listed. Answers A, B, and C are all appropriate tasks for an assistant, so they are incorrect. 15. Which nursing order would the nurse anticipate for a client with pancreatitis? A. Force fluids to 3,000mL/24 hours B. Insert a nasogastric tube and connect it to low intermittent suction C. Place the client in reverse Trendelenburg position D. Place the client in enteric isolation Answer B: An NG is inserted to decrease the secretion of pancreatic juices and assist in pain relief. Answer A is incorrect because these clients are held NPO. Clients are placed in semi-Fowler’s position, which makes answer C incorrect. Answer D is not appropriate because the wastes are not contaminated. 16. Assessment findings for the client admitted with a stroke reveal an absence of the gag reflex. The nurse suspects injury to which cranial nerve? A. XII (hypoglossal) B. X (vagus) C. IX (glossopharyngeal) D. VII (facial) Answer B: To test for vagus nerve problems, the nurse uses a tongue blade and depresses the back of the throat to elicit a gag reflex. Other ways to test for damage to the vagus nerve are by having the client say “Ah” while observing for uniform rising of the uvula and the soft palate. The absence of this reflex could indicate damage to the X cranial nerve. Answers A, C, and D are not tested in this manner, so they are incorrect. 17. The nurse at a clinic is present when the healthcare provider (HCP) notifies a client of the diagnosis of rheumatoid arthritis. What medication does the nurse anticipate the provider prescribing? A. Hydrocodone/acetaminophen (Loritab) B. Meloxicam (Mobic) C. Hydromorphone hydrochloride (Dilaudid) D. Alprazolam (Xanax) Answer B: Mobic has anti-inflammatory effects and is useful for arthritis. Answers A and C are opiods and can cause dependency. They are not effective for arthritis. Answer D is an anti-anxiety agent not given for arthritis. 18. A client with gallstones and obstructive jaundice is experiencing severe itching. The physician has prescribed cholestyramine (Questran). The client asks, “How does this drug work?” What is the nurse’s best response? A. “It blocks histamine, reducing the allergic response.” B. “It inhibits the enzyme responsible for bile excretion.” C. “It decreases the amount of bile in the gallbladder.” D. “It binds with bile acids and is excreted in bowel movements with stool.” Answer D: Questran works by binding the bile acids in the GI tract and eliminating them, decreasing the itching associated with jaundice. Answers A, B, and C are not how Questran works to decrease itching. 19. A client with ulcerative colitis requires an illeostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma? A. Perform massage of the stoma three times a day B. Include high-fiber foods, especially nuts, in the diet C. Limit fluid intake to prevent loose stools D. Cleanse the peristomal skin meticulously Answer D: Careful cleansing is necessary to prevent skin breakdown and skin irritation. Answer A is not an intervention used for illeostomies. Clients should avoid high fiber and gas-producing foods, as in answer B. Answer C is incorrect because these clients are not on fluid restriction. 20. Diphenoxylate hydrochloride and atropine sulfate (Lomotil) is prescribed for the client with ulcerative colitis. The nurse realizes that the medication is having a therapeutic effect when which of the following is noted? A. There is an absence of peristalasis. B. The number of diarrhea stools decreases. C. Cramping in the abdomen has increased. D. Abdominal girth size increases. Answer B: Lomotil’s desired effect is to decrease GI motility and the number of diarrhea stools. Answers A and D do not occur with the use of Lomotil. The drug should decrease cramping instead of increasing it, as in answer C.