NCLEX SAMPLE EXAM 1.

. Which therapy should not be implemented for the patient with hemorrhagic complications from oral anticoagulants? A. Volume replacement B. Whole blood C. Fresh frozen plasma D. Protomine sulfate 2. A 4-year-old boy is admitted because of a sudden high fever. His mother noted that he has been generally weak and dyspenic and has had generalized pain and recurrent infections. He is found to have an elevated white blood cell (WBC) count and anemic, as well as being thrombocytopenic and tachycardic. A diagnosis of acute lymphocytic leukemia is made. A common complication in the acute phase of leukemia is: A. Thrombocytosis B. Polycythemia vera C. Gram-negative septicemia D. Seizures 3. The most appropriate basis for discontinuing life-support in a comoatose patient without any hope of meaningful recovery is: A. An agreement reached by the health team and family B. Two flat electroencephalograms C. State law regarding discontinuing life-support D. Physician's order of "no code" 4. Under what circumstances, if any, may a nurse use force against a patient? A. Under no circumstances B. To bring an emotionally distraught patient back to his senses C. To asses an unconscious patient's level of reaction to physical stimuli. D. In self-defense, but only if the nurse has reasonable grounds to believe that she is being, or is about to be attacked. 5. If a nurse is floated to a unit where she has no experience and, as a result, commits an act of negligence, who is legally liable? A. The hospital B. The nurse C. The nurse and the hospital D. The supervisor who floated the nurse

6. A 22-year-old woman who has a recent history of an upper respiratory tract infection is seen in the emergency department (ED). She complains of hoarsness that has lasted 3 days, along with pain on speaking, nasal congestion, and dysphagia. Assessment findings reveal a purulent nasal disharge, erythematous posterior oropharynx, and a temperature of 101o F (38o C) These assesment findings indicate what condition? A. Acute laryngitis B. Chronic laryngitis C. Laryngeal carcinoma D. Vocal cord polyps 7. An 18-year-old man, who was sleeping awoke suddenly with complaints of "something moving" in his ear, comes to the ED. On physical examination a large, live cockroach is noted in his external auditory canal. The nurse would anticipate the initial treatment to be: A. Removing the insect with forceps B. Spraying lidocaine (Xylocaine) 10% in the auditory canal C. Irrigating the ear with warm water D. Instilling warm mineral oil in the ear 8. A 65-year-old man with a known history os chronic obstructive pulmonary disease (COPD) and laryngeal carcinoma is seen in the ED. Is currently undergoing radiation therapy and presents symptoms of acute respiratory distress. Assessment reveals inspiratory stridor, dyspnea, increasing apprehension, and facial flushing. Immediate action should include: A. Arterial blood gas evacuation (ABGs) and 100% oxygen via mask B. Tracheotomy C. Intubation D. Chest X-ray 9. A 40-year-old man is brought to the ED after being mugged. Blood is coming from his left ear, and the physician diagnoses a ruptured tympanic membrane. The initial treatment for this patient should include: A. Remove clots and pack canal B. Administer antibacterial otic drops C. Administer ampicillin (Amcill) 500mg P.O t.i.d. D. Administer tetanus toxoid 10. A 26-year-old man was involved in an automobile accident. Approximately 20 minutes elapsed between the time of the accident and the arrival of the paramedics. He sustained

severe abdominal injuries as well as multiple fractures. When he arrives in the emergency department (ED), his vital signs are as follows: Blood Pressure: 80/50 mm Hg Heart Rate: 120 beats/minute Respiratory Rate: 30 breaths/minute Which of the following nursing actions is inappropriate during the initial stabilization of this patient? A. Administering oxygen therapy B. Applying medical antishock trousers (MAST) C. Placing the patient in the Trendelenburg (head-down) position D. Infusing lactated Ringer's solution via large-bore IV line 11. Which of the following statement regarding MAST suits is false? A. It is a single-unit suit with three compartments B. Each compartment may be pressurized and deflated individually or in combination C. When inflated, it achieves pressures ranging from 0 to 160 mm Hg D. Once optimal pressure is achieved, automatic release valves prevent further pressure increases 12. A patient arrives in the emergency department (ED) with an ice pick protruding from his left lower abdominal quadrant. An appropriate nursing action is to: A. Immediately remove the object and apply firm pressure to the wound B. Leave the object in place until the patient is in the operating room (OR) C. Establish two large-bore intravenous (IV) line and then remove the object D. Obtain an abdominal X-ray and then remove the object 13. Which type of penetrating injury would a gunshot wound at the sixth intercostal space be? A. Chest B. Abdominal C. Thoracoabdominal D. Pelvic 14. Pancreatitis occurs as a complication of perforated duodenal ulcer when: A. Serum amylase is elevated to dangerous levels B. A perforation erodes into the pancreas C. The patient has a high alcohol intake D. The pancreatic duct is obstructed
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Review your answers All results below display your answer, the correct answer, and the reasoning behind the correct answer. Question 1 The correct answer is D. Protomine sulfate Rationale: Protein sulfate neutralizes the effect of parenteral anticoagulant heparin and is used to treat heparin overdose. Therapy for hemorrhagic complications from oral anticoagulants includes volume replacement, clotting factor replacement, vitamin K administration, and infusions of fresh frozen plasma and whole blood. Vitamin K acts as a pharmacologic antagonist to oral anticoagulants and may be given orally or parenterally. Question 2 The correct answer is C. Gram-negative septicemia Rationale: The major causes of death in acute leukemia are infection and bleeding from anemia, and thrombocytopenia. Infection is commonly caused by gram-negative sepsis. Fequent cultures are necessary, and treatment with appropriate antibiotics is required. The patient may require placement in a protection environment. Seizures are rare. Question 3 The correct answer is A. An agreement reached by the health team and family Rationale: An agreement reached by the health team and the family is the most appropriate basis for discontinuing life-support in a comatose patient without any hope of meaningful recovery. This decision has legal, ethical, and psychological implications and can never truly be decided by legal or procedural methods. Coming to an informed decision after careful consideration of the facts prepares the family for death, reduces needless suffering and cost, diminishes the ambiguity surrounding verbal "no code" orders, and decreases the risk of legal action. Such a decision should then be carefully documented in the patient's chart and made known to everyone concerned. Question 4 The correct answer is D. In self-defense, but only if the nurse has reasonable grounds to believe that she is being, or is about to be attacked. Rationale: A nurse may legally use force against a patient in self-defense, but only is the nurse has reasonable grounds to believe that she is being, or is about to be attacked. Everyone, including nurses, has the legal right to protect himself and well as the right to work in a safe environment. When dealing with combative patients and at risk for harm, nurses have the right to defend themselves, as long as the defense is reasonable and only to the extent necessary to defend themselves. Moreover, the selfdefense must not continue when the apparent danger has passed and the patient is no longer combative. Question 5 The correct answer is C. The nurse and the hospital Rationale: If a nurse is floated to a unit where she has no experience and, as a result commits an act of negligence, the nurse and the hospital are both legally liable. This situation is unfortunately a "catch 22" for the nurse. She is responsible to act as any reasonable nurse would in similar situations of nursing care and prevent injury to the patient. However, she may lose her job if she refuses to be floated to an unfamiliar unit. The best advice to the nurse in such situation is to inform the supervisor that she is unfamiliar with the unit being floated to and request that the assignment be adjusted to accommodate the floated nurse. For example, the nurse could perform only those functions she feels comfortable with while more expert nurses perform the more technically difficult skills. The hospital also is liable as they are responsible for providing competent care, especially to critically ill patients, or during an emergency. Question 6 The correct answer is A. Acute laryngitis Rationale: A patient ith a recent history of an upper respiratory tract infection, hoarsness, fever, and erythematous oropharynx has acute laryngitis. Patients with vocal cord polyps have hoarsness but no upper respiratory tract infection, wheras those with laryngeal cancer may have hoarsness and

difficulty breathing only if the leasion is large. Layngeal cancer usually occurs in older men with a long history of smoking and alcohol abuse. Question 7 The correct answer is B. Spraying lidocaine (Xylocaine) 10% in the auditory canal Rationale: Recent studies reveal that insects may be removed form the ear by spraying a topical neurostimulant, such as lidocaine, into the external auditory canal. If this is unavailable, the insect should be immobilized and drowned in mineral oil, then removed with minute forceps. Irrigation with water may cause the insect's body to swell or may push the insect closer to the tympanic membrane. Question 8 The correct answer is C. Intubation Rationale: Immediate establishment of airway is required, and intubation is appropriate. Patients undergoing radiation therapy to the head and neck are subject to complications, including edema of the upper airway, severe dryness of the oral cavity, and burns of the skin. Tracteotomy should not be performed in a patient with laryngeal cancer, because this may lead to stomal carcinoma by direct extension. Question 9 The correct answer is A. Remove clots and pack canal Rationale: When a patient has a ruptured tympanic membrane and basal skull fracture has been ruled out, bleeding from the ear may e controlled by evacuating the clot and packing the ear canal. The packing may be removed when bleeding has stopped. Tympanic membrane rupture does not require antibiotics; a healthy exposed middle ear mucosa is especially vulnerable to ototoxicity from ear drops. The tympanic membrane should heal in 1 to 2 weeks. Question 10 The correct answer is C. Placing the patient in the Trendelenburg (head-down) position Rationale: The initial management of a patient in shock involves provisions for airway and ventilation; maintenance of blood volume, pressure, and circulation; and maintenance of cellular oxygen consumption. Specific measures would include oxygen therapy and administration of IV fluid, preferably lactated Ringer's solution via large-bore IV line. A MAST suit can also be used in patients with lower-extremity or abdominal injuries who have signs and symptoms of hypovolemic shock. This will autotransfuse approximately 1,000ml of blood, reduce blood loss by application of direct pressure, and immobilize injuries of the lower extremities. The patient in shock should be flat with only the legs elevated. The Trendelenburg position, one favored, has been abandoned because it allows the diaphram to migrate upward, thus compromising ventilation. Also, this position may cause a reflex inhibition of the pressoreceptor activity, thereby decreasing sympathetic stimulation and further compromising arterial blood presure. Question 11 The correct answer is C. When inflated, it achieves pressures ranging from 0 to 160 mm Hg Rationale: MAST is a single-unit suit with three compartments; an abdominal compartment and two individual lower-etremity compartments. It may achieve pressures ranging from 0 to 104 mm Hg. Each of the three compartments may be pressurized and deflated individually or in combination. Once a pressure of 104 mm Hg is achieved, automatic release, or pop-off, valves prevent further pressure increases. Question 12 The correct answer is B. Leave the object in place until the patient is in the operating room (OR) Rationale: Impaled objects should never be removed until the patient is in the OR, where hemorrhage can be surgically controlled once the object is removed. Question 13 The correct answer is C. Thoracoabdominal Rationale: The diaphram, which separates the chest from the abdomen, rises to the level of the sixth intercostal space on respiratory exhalation. Therefore, this injury is considered a thoracoabdominal once, because the bullet may enter both the abdomen and the chest.

Question 14 The correct answer is B. A perforation erodes into the pancreas Rationale: Perforation of a duodenal ulcer with ensuring peritonitis erodes the wall of the pancreas, causing pancreatitis. Click below for additional information: NCSBN | CGFNS | CA Board R.N. | CA Board V.N. | BCIS

Nursing Board Exam Review Question in MSN Part 1/10

1. Mrs. Chua a 78 year old client is admitted with the diagnosis of mild chronic heart failure. The
nurse expects to hear when listening to clients lungs indicative of chronic heart failure would be: a. b. c. d. 2. Stridor Crackles Wheezes Friction Rubs

Patrick who is hospitalized following a myocardial infarction asks the nurse why he is taking morphine. The nurse explains that morphine: a. b. c. d. Decrease anxiety and restlessness Prevents shock and relieves pain Dilates coronary blood vessels Helps prevent fibrillation of the heart

3.

Which of the following should the nurse teach the client about the signs of digitalis toxicity? a. b. c. d. Increased appetite Elevated blood pressure Skin rash over the chest and back Visual disturbances such as seeing yellow spots

4.

Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help: a. b. c. Retard rapid drug absorption Excrete excessive fluids accumulated at night Prevents sleeps disturbances during night

d. 5.

Prevention of electrolyte imbalance

What would be the primary goal of therapy for a client with pulmonary edema and heart failure? a. b. c. d. Enhance comfort Increase cardiac output Improve respiratory status Peripheral edema deceased

6.

Nurse Linda is caring for a client with head injury and monitoring the client with decerebrate posturing. Which of the following is the characteristic of this type of posturing? a. b. c. d. Upper extremity flexion with lower extremity flexion Upper extremity flexion with lower extremity extension Extension of the extremities after a stimulus Flexion of the extremities after the stimulus

7.

A female client is taking Cascara Sagrada. Nurse betty informs the client that the following maybe experienced as side effects of this medication: a. b. c. d. GI bleeding Peptic ulcer disease Abdominal cramps Partial bowel obstruction

8.

Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial infarction. Which of the following is the most essential nursing action? a. b. c. d. Monitoring urine output frequently Monitoring blood pressure every 4 hours Obtaining serum potassium levels daily Obtaining infusion pump for the medication

9.

During the second day of hospitalization of the client after a myocardial infarction. Which of the following is an expected outcome? a. b. c. d. Able to perform self-care activities without pain Severe chest pain Can recognize the risk factors of myocardial infarction Can participate in cardiac rehabilitation walking program

10. A 68 year old client is diagnosed with a right - sided brain attack and is admitted to the hospital. In caring for this client, the nurse should plan to; a. b. c. d. Application of elastic stockings to prevent flaccid by muscle Use hand roll and extend the left upper extremity on a pillow to prevent contractions Use a bed cradle to prevent dorsiflexion of feet Do passive range of motion exercise

Answers and Rationale 1. Answer:B Rationale: Left sided heart failure causes fluid accumulation in the capillary network of the lung. Fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration. 2. Answer:B Rationale: Morphine is a central nervous system depressant used to relieve the pain associated myocardial infarction, it also decrease apprehension and prevents cardiogenic shock. 3. Answer:D Rationale: Seeing yellow spots and colored visions are common symptoms of digitalis toxicity 4. Answer:C Rationale: When diuretics are taken in the morning, client will void frequently during daytime and will not need to void frequently at night 5. Answer:B Rationale: The primary goal of therapy for the client with pulmonary edema or heart failure is increasing cardiac output. Pulmonary edema is an acute medical emergency requiring immediate intervention 6. Answer:C Rationale: Decerebrate posturing is the extension of extremities after a stimulus, which may occur with upper brain stem injury 7. Answer:C Rationale: The most frequent side effects of Cascara Sagrada (Laxative) is abdominal cramps and nausea. 8. Answer:D Rationale: Administration of Intravenous Nitroglycerin infusion requires pump for accurate control of medication. 9. Answer:A

Rationale: By the 2nsd day of hospitalization after suffering a Myocardial infarction, clients are able to perform care without chest pain 10. Answer:B Rationale: The left side of the body will be affected in a right-sided brain attack.