NURS 101 NCLEX Practice Exam 5 (45 Items) - UPDATED | NURS101 NCLEX Practice Exam 5 (45 Items) - Answers and Explanations {A Grade}

NCLEX Practice Exam 5 (45 Items) Question 1 A nurse is administering IV furosemide to a patient admitted with congestive heart failure. After the infusion, which of the following symptoms is NOT expected? Increased urinary output. Decreased edema. Decreased pain. Decreased blood pressure. Question 1 Explanation: Furosemide, a loop diuretic, does not alter pain. Option A: Furosemide acts on the kidneys to increase urinary output. Option B: Fluid may move from the periphery, decreasing edema. Option D: Fluid load is reduced, lowering blood pressure. Question 2 There are a number of risk factors associated with coronary artery disease. Which of the following is a modifiable risk factor? Obesity. Heredity. Gender. Age. Question 2 Explanation: Obesity is an important risk factor for coronary artery disease that can be modified by improved diet and weight loss. Options B, C, and D: Family history of coronary artery disease, male gender, and advancing age increase risk but cannot be modified. Question 3 Tissue plasminogen activator (t-PA) is considered for treatment of a patient who arrives in the emergency department following onset of symptoms of myocardial infarction. Which of the following is a contraindication for treatment with t-PA? Worsening chest pain that began earlier in the evening. History of cerebral hemorrhage. History of prior myocardial infarction. Hypertension. Question 3 Explanation: A history of cerebral hemorrhage is a contraindication to tPA because it may increase the risk of bleeding. TPA acts by dissolving the clot blocking the coronary artery and works best when administered within 6 hours of onset of symptoms. Option C: Prior MI is not a contraindication to tPA. Option D: Patients receiving tPA should be observed for changes in blood pressure, as tPA may cause hypotension. Question 4 Following myocardial infarction, a hospitalized patient is encouraged to practice frequent leg exercises and ambulate in the hallway as directed by his physician. Which of the following choices reflects the purpose of exercise for this patient? Increases fitness and prevents future heart attacks. Prevents bedsores. Prevents DVT (deep vein thrombosis). Prevent constipations. Question 4 Explanation: Exercise is important for all hospitalized patients to prevent deep vein thrombosis. Muscular contraction promotes venous return and prevents hemostasis in the lower extremities. Options A, B, and D: This exercise is not sufficiently vigorous to increase physical fitness, nor is it intended to prevent bedsores or constipation. Question 5 A patient arrives in the emergency department with symptoms of myocardial infarction, progressing to cardiogenic shock. Which of the following symptoms should the nurse expect the patient to exhibit with cardiogenic shock? Hypertension. Bradycardia. Bounding pulse. Confusion. Question 5 Explanation: Cardiogenic shock severely impairs the pumping function of the heart muscle, causing diminished blood flow to the organs of the body. This results in diminished brain function and confusion, as well as hypotension, tachycardia, and weak pulse. Cardiogenic shock is a serious complication of myocardial infarction with a high mortality rate. - - - - - -- - - - - - - - - - - - - - - - - - -- - Question 43 A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement? Glucometer readings as ordered Intake/output measurements Sodium and potassium levels monitored Daily weights Question 43 Explanation: IV glucocorticoids raise the glucose levels and often require coverage with insulin. Options B, C, and D: Intake/output measurements is not necessary at this time, sodium and potassium levels would be monitored when the client is receiving mineralocorticoids, and daily weights is unnecessary. Question 44 A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses’ next action be? Obtain a crash cart Check the calcium level Assess the dressing for drainage Assess the blood pressure for hypertension Question 44 Explanation: The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling is due to low calcium levels. Option A: The crash cart would be needed in respiratory distress but would not be the next action to take. Options C and D: Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage. Question 45 A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority? Impaired physical mobility related to decreased endurance Hypothermia r/t decreased metabolic rate Disturbed thought processes r/t interstitial edema Decreased cardiac output r/t bradycardia Question 45 Explanation: The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices; therefore, answers A, B, and C are incorrect.