NCLEX-PN Practice Exam #10 -> answers with explanation
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Practice Tests: NCLEX-PN Practice Exam #10 - 50 questions
All 50 questions are randomized each time you take the test, and do not appear in the same order here.
1. A patient asks a nurse the following question. Exposure to TB can be identified best with which of the following procedures? Which of the following tests is the most definitive of TB?
- Chest x-ray
- Mantoux test
- Breath sounds examination
- Sputum culture for gram-negative bacteria
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2. A nurse at outpatient clinic is returning phone calls that have been made to the clinic. Which of the following calls should have the highest priority for medical intervention?
- A home health patient reports, "I am starting to have breakdown of my heels."
- A patient that received an upper extremity cast yesterday reports, "I can't feel my fingers in my right hand today."
- A young female reports," I think I sprained my ankle about 2 weeks ago."
- A middle-aged patient reports," My knee is still hurting from the TKR."
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3. The most effective way to perform hand hygiene is.
- washing hands after gloves are removed post patient care
- using hand sanitizer and rubbing hands together for 30 seconds
- either washing your hands for 30 seconds in warm, soapy water or using hand sanitizer if hands are not visibly soiled
- holding hands down after washing to prevent water from rolling down your arm while drying
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4. A nurse is in the operating room where x-rays are being taken during the procedure. What is the best way to use this equipment safely?
- Ensure the equipment being used to take x-rays has sterile drapes and covers on it to prevent contamination of the sterile field.
- Have a lead apron and thyroid shield on when being exposed to active radiation, such as x-rays.
- Make sure the patient does not have any metal in their body which could cause the machine to malfunction.
- Ensure the time out has been done prior to any x-ray imaging being taken.
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5. A 55-year-old female asks a nurse the following, "Which mineral/vitamin is the most important to prevent progression of osteoporosis." The nurse should state:
- Potassium
- Magnesium
- Calcium
- Vitamin B12
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6. Which patient is at greatest risk for papilledema?
- An elderly patient with cataracts and macular degeneration.
- A male patient with hypothyroidism.
- A male patient with hyperthyroidism.
- An adolescent with a closed head injury.
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7. A nurse is assessing an 18-year-old female who has recently suffered a TBI. The nurse notes a slower pulse and impaired respiration. The nurse should report these findings immediately to the physician, due to the possibility the patient is experiencing conditions.
- increased intracranial pressure
- increased function of cranial nerve X
- sympathetic response to activity
- meningitis
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8. A gunshot wound victim has been brought to your unit. He has chosen to be marked as confidential due to safety concerns. Which of these actions would be inappropriate for you to do as the nurse?
- Tell the patient's mother he is okay when she calls to ask about him being on the unit.
- Keep the patient's name/information out of public areas such as the nurses' station.
- Remove the patient from confidential status when he asks to be removed.
- Deny that the patient is on the unit when visitors come or call.
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9. A nurse is assessing a patient that has undergone a recent CABG. The nurse notices a mole with irregular edges with a bluish color. The nurse should:
- recommend a dermatological consult to the MD
- note the location of the mole and contact the physician via the telephone
- note the location of the mole and follow-up with the attending physician via the medical record and phone call
- remove the mole with a sharp's debridement technique, following charge nurse approval
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10. A 15-year-old high school wrestler has been taking diuretics to lose weight to compete in a lower weight class. Which of the following medical tests is most like to be given?
- Lab values of Potassium and Sodium
- Lab values of glucose and hemoglobin
- ECG
- CT scan
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11. A nurse is working in a patient's room who is positive for C. Diff (Clostridium difficile). What is the best action for the nurse to take?
- Don a mask, gown, and gloves when working with this patient.
- Wear gloves and gown during patient care.
- Wear gloves when having any physical contact with the patient.
- Wear gloves and a mask when cleaning the patient.
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12. A patient is currently having a petit mal seizure in the clinic on the floor. Which of the following criteria has the highest priority in this situation?
- Provide a safe environment free of obstructions in the immediate area
- Call a code
- Contact the patient's physician
- Prevent excessive movement of the extremities
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13. A central venous pressure reading of 11cm H20 of an IV of normal saline is determined by the nurse caring for the patient. The patient has a diagnosis of pericarditis. Which of the following is the most applicable?
- The patient has a condition of hypovolemia.
- Not enough fluid has been given to the patient.
- Pericarditis may cause pressures greater than 10cm H2O with testing of CVP.
- The patient may have a condition of arteriosclerosis.
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14. A 64-year-old male who has been diagnosed with COPD, and CHF exhibits an increase in total body weight of 10 lbs. over the last few days. The nurse should:
- contact the patient's physician immediately
- check the intake and output on the patient's flow sheet
- encourage the patient to ambulate to reduce lower extremity edema
- check the patient's vitals every 2 hours
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15. The family carries out its health care functions in which of the following ways?
- Family provides very little preventive health care to its members at home.
- Family provides sick care to its members.
- Family pays for most health services.
- Family decides when and where to hospitalize its members.
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16. As you are working you suspect that another licensed practical nurse is verbally and physically abusing a patient. What is the first thing that you will do?
- Nothing because you are not certain that it is occurring.
- Nothing because you only suspect the abuse.
- Call the police or the security department.
- Report your suspicions to the charge nurse.
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17. A nurse gave medications to the wrong client. She stated the client responded to the name called. What is the nurse's appropriate documentation?
- Note in medication records the drug given
- The client was not hurt, no need for documentation
- Note the client's orientation
- Completely fill out an incident report
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18. A 24-year-old man has been admitted to the hospital due to work-related back injury. The patient's wife would like to see the patient's chart. The nurse should:
- provide the chart to the patient's wife following verbal approval by the patient
- provide the chart to the patient's wife after consulting with the patient's physician
- get written approval from the patient prior to providing the wife with chart information and call the MD about the patient's request
- tell the patient' wife, a copy of the patient's medical record is on-file with medical records
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19. A high school nurse observes a 14-year-old female rubbing her scalp excessively in the gym. The most appropriate course of action for the nurse to do is:
- Request a private evaluation of the female's scalp from her parents.
- Contact the female's parents about the observations.
- Observe the hairline and scalp for possible signs of lice.
- Contact the student's physician.
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20. New parents ask their newborn's neonatal nurse about safety tips for their home with their new baby. Which statement by the nurse is most appropriate?
- "Have a blanket and a bumper in the crib for warmth and injury prevention."
- "Keep all stuffed animals, pillows, blankets, bumpers, etc. out of the crib."
- "Mattresses should be tight-fitting and crib bars should have at least 3 inches of space between each bar."
- "Do not smoke in the baby's room. Other rooms are okay as long as the baby isn't in them."
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21. In which of the following scenarios a violation of a patient's confidentiality occurs if two nurses are discussing client information?
- With a physical therapist treating the patient.
- With a social worker planning for discharge.
- With another nurse on duty to plan for break time.
- In the hallway outside the patient's room.
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22. Which preventive measure can be employed to decrease the risk of compartment syndrome?
- The administration of a potassium sparing diuretic for heart failure.
- A bivalve cast for a skeletal fracture.
- A cerebral diuretic to decease intracranial pressure after a head injury.
- A chest tube to restore normal intrathoracic pressure after a pneumothorax.
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23. A nurse working in a pediatric clinic and observes the following situations. Which of the following may indicate a delayed child to the nurse?
- A 12-month old that does not "cruise".
- A 8-month old that can sit upright unsupported.
- A 6-month old that is rolling prone to supine.
- A 3-month old that does not roll supine to prone.
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24. A nurse has just started on the 7PM surgical unit shift. Which of the following patients should the nurse check on first?
- A 75-year-old female who is scheduled for an EGD in 10 hours.
- A 34-year-old male who is complaining of low back pain following back surgery and has an onset of urinary incontinence in the last hour.
- A 21-year-old male who had a lower extremity BKA yesterday, following a MVA and has phantom pain.
- A 27-year-old female who has received 1.5 units of RBC's. via transfusion the previous day.
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25. Which of these scenarios would be incorrect when practicing aseptic technique?
- Apply sterile gloves by touching the inside only when applying both gloves.
- If anything on the sterile field is contaminated, dispose of everything and start over.
- Do not touch the sterile field unless only touching 1 inch or less of the edges.
- Open sterile supplies or instrument away from your body to make sure contamination does not occur.
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26. A nurse is caring for an elderly patient and realizes she made an error by administering an antibiotic at the drip rate ordered for normal saline. What is the most appropriate action?
- Tell the patient that a medication error occurred and about the potential side effects.
- File an incident report giving objective data about what happened.
- Do nothing. There are no serious risks or side effects to this type of medication error.
- Tell the charge nurse the medication error occurred and that it was due to the previous nurse mislabeling the IV tubing from the antibiotic and normal saline bags.
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27. When working after the occurrence of a natural disaster, the LPN uses a color coding system for triaging patients. Which of these would be an accurate example of this?
- A black sticker is placed on a patient whose injuries prove to be fatal.
- Red is placed on a patient who is losing a lot of blood due to massive trauma.
- Green is placed on a patient with an occluded airway and difficulty breathing.
- Yellow is placed on a patient who is stable and can wait the longest to be treated.
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28. A 64-year-old Alzheimer's patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure?
- Secure the restraints to the bed rails on all extremities.
- Notify the physician that restraints have been placed properly.
- Communicate with the patient and family the need for restraints.
- Position the head of the bed at a 45-degree angle.
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29. Medical records indicate a patient has developed a condition of respiratory alkalosis. Which of the following clinical signs would not apply to a condition of respiratory alkalosis?
- Muscle tetany
- Syncope
- Numbness
- Anxiety
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30. Which of these patients could most safely share a room?
- a 30-year-old patient positive for the flu and a 75-year-old patient positive for MRSA infection
- a patient positive for C. Difficile and an elderly patient who is suspected to have a C. Difficile infection
- a 28-year-old male with blood-tinged sputum and night sweats and an 18-year-old male with the flu
- an elderly woman with Hepatitis A and a 50-year-old woman with the measles
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31. During which phase of the nursing process does data get collected and validated with the patient and/or family members by the nurse?
- The implementation phase.
- The assessment phase.
- The evaluation phase.
- The planning phase.
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32. A client is going to have an endoscopy performed. Which of the following is not a probable reason for an endoscopy procedure?
- Aspiration noted on honey thick diet.
- Pain with a bowel movement
- Pain felt in the left upper quadrant
- Right shoulder pain
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33. A night shift nurse has a patient who is confused and withdrawing from alcohol. He is currently in 4 point restraints after attempting to attack one of the nurses. What is the most appropriate action for the nurse to take during his shift?
- Release the leg restraints to give the patient a break and see if combative behavior has gotten better.
- Have the attending physician discontinue the restraints to give the patient a chance to behave more appropriately.
- Assess the patient's skin integrity around the restraints hourly.
- Ensure the physician has renewed the order for restraints, as this should be done every 12 hours.
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34. Which of the following lab values would indicate symptomatic AIDS in the medical chart? (T4 cell count per deciliter)
- Greater than 1000 cells per deciliter.
- Less than 500 cells per deciliter.
- Greater than 2000 cells per deciliter.
- Less than 200 cells per deciliter.
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35. A patient is scheduled for electro-convulsive therapy treatment scheduled in the morning. What must the evening nurse do to provide the client ECT treatment possible?
- Patient signs an informed consent form.
- Patient is given morning medications.
- Patient gets a good night's sleep.
- Patient has a good breakfast.
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36. A nurse is assessing a patient's right lower extremity. The extremity is warm to touch, red and swollen. The patient is also running a low fever. Which of the following conditions would be the most likely cause of the patient's condition?
- Herpes
- Scleroderma
- Dermatitis
- Cellulitis
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37. A nurse working a surgical unit, notices a patient is experiencing SOB, calf pain, and warmth over the posterior calf. Which of the following medical conditions may indicate all of these?
- Patient may have a DVT.
- Patient may be exhibiting signs of dermatitis.
- Patient may be in the late phases of CHF.
- Patient may be experiencing anxiety after surgery.
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38. A nurse working in a pediatric clinic observes bruises on the body of a four-year-old boy. The parents report the boy fell riding his bike. The bruises are located on his posterior chest wall and gluteal region. The nurse should:
- suggest a script for counseling for the family to the doctor on duty
- recommend a warm bath for the boy to decrease healing time
- notify the case manager in the clinic about possible child abuse concerns
- recommend ROM to the patient's spine to decrease healing time
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39. Which of the following is not considered one of the five rights of medication administration?
- client
- drug
- dose
- routine
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40. The nurse is educating adult patients on safety and injury prevention. Which statement would be inaccurate?
- "Using your safety belt when driving or riding the car prevents injury in the event of an accident."
- "Working fire extinguishers and smoke alarms are extremely important to have in the home."
- "Having taken a gun safety class to learn the basics and following those guidelines decreases the chances of injury."
- "Use condoms when implementing birth control."
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41. A nurse doing a home health visit consults with a male patient that has a diagnosis of CAD and COPD. The patient is currently taking Ventolin, Azmacort, Aspirin, and Theophylline. The patient complains of upset stomach, nausea and feeling uncomfortable. The nurse should:
- Contact the patient's physician immediately
- Recommend the patient position himself in right sidelying.
- Recommend the patient schedule a doctor's visit the next day.
- Recommend a hold on the drug-Azmacort
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42. A patient comes into the Emergency Department with symptoms of chest tightness, difficulty breathing, blood tinged purulent sputum, and night sweats. What is the best action for the nurse to take?
- Review admission criteria, cohort patient with a patient positive for the flu, and draw blood for full work up blood panel.
- Get the patient in a negative air pressure room and alert the attending of active tuberculosis
- Arrange for a chest x-ray and private room, then wait for results.
- Implement airborne precautions, arrange for a chest x-ray of the patient, and get the patient to negative air pressure, private room.
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43. A nurse has been instructed to place an IV line in a patient that has active TB and HIV. Which of the following safety equipment should wear the nurse?
- Sterile gloves, mask, and goggles
- Surgical cap, gloves, mask, and proper shoe wear
- Double gloves, gown, and mask
- Goggles, mask, gloves, and gown
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44. A nurse taking a patient's history realizes the patient is complaining of SOB and weakness in the lower extremities. The patient has a history of hyperlipidemia, and hypertension. Which of the following may be occurring?
- The patient is developing CHF.
- The patient may be having a Ml.
- The patient may be developing COPD.
- The patient may be having an onset of PVD.
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45. A thirty-seven-year-old female in room 307 has a diagnosis of acquired immune deficiency syndrome (AIDS). Which of the following situations requires nurse intervention?
- A certified nursing assistant states, "The patient in 307 is not wearing gloves shaving her legs."
- A nursing assistant at the nursing station states, "The patient in 307 has a respiratory rate of 16."
- A nursing student in the cafeteria states, "Dr. Jones told the patient in room 307 that she was going to die."
- A certified nursing assistant states, "Dr. Jones hasn't made rounds this morning."
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46. The most common cause of injury from a house fire is:
- explosion
- falls from second-story windows
- thermal damage to skin and body surfaces
- inhalation injury
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47. A nurse is returning phone calls in a pediatric clinic. Which of the following reports most requires the nurse's immediate attention and phone call?
- A 8-year-old boy has been vomiting and appears to have slower movements and has a history of an atrio-ventricular shunt placement.
- A 10-year-old girl feels a dull pain in her abdomen after doing sit-ups in gym class.
- A 7-year-old boy has been having a low fever and headache for the past 3 days that has history of an anterior knee wound.
- A 7-year-old girl that had a cast on her right ankle is complaining of itching.
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48. A nurse has been assigned a patient who has recently been diagnosed with Guillain-Barre' Syndrome. Which of the following statements is the most applicable when discussing the impairments with Guillain-Barre' Syndrome with the patient?
- Guillain-Barre' Syndrome gets better after 5 years in almost all cases.
- Guillain-Barre' Syndrome causes limited sensation in the abdominal region.
- Guillain-Barre' Syndrome causes muscle weakness in the legs.
- Guillain-Barre' Syndrome does not effect breathing in severe cases.
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49. Which statement would be the most accurate in safety education for injury prevention in the home of elderly adults?
- Use the handrail when going up and down the stairs, ensure robes or pants are held up if flowy, and wear comfortable, non-skid footwear.
- Use solid chairs without armrests, remove anything in walkways, and use cordless phones.
- Have raised toilet seats, ensure all throw rugs have gripping material on the floor side, and use grab bars in the shower/bathroom.
- Remove all throw rugs, remove furniture from all pathways, and wear comfortable, non-skid footwear.
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50. When caring for a patient with known IV drug use, which statement should the nurse discuss to highlight the risk factors of this behavior?
- The use of these drugs can increase the risk of contracting diseases due to immunosuppression.
- The risk of contracting and/or spreading blood borne pathogens such as HIV, which can progress to AIDS, is a huge risk factor with this activity.
- Drug use can lead to unsafe sex practices, increasing the risk of the transmission of sexually transmitted diseases.
- IV drug use can lead to skin infections at the injection sites and poor health.
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