NCLEX Practice Exam 39 (10 Questions)
All questions are shown, but the results will only be given after you’ve finished the quiz. You are given 1 minute per question, a total of 10 minutes in this quiz.
- 1.
A patient arrives at the emergency department complaining of midsternal chest pain. Which of the following nursing action should take priority?
- A.
A complete history with emphasis on preceding events.
- B.
An electrocardiogram.
- C.
Careful assessment of vital signs.
- D.
Chest exam with auscultation.
Correct Answer
C. Careful assessment of vital signs.Explanation
The priority nursing action for a patient arriving at the ED in distress is always assessment of vital signs. This indicates the extent of physical compromise and provides a baseline by which to plan further assessment and treatment. A thorough medical history. including onset of symptoms. will be necessary and it is likely that an electrocardiogram will be performed as well. but these are not the first priority. Similarly. chest exam with auscultation may offer useful information after vital signs are assessed.Rate this question:
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- 2.
A patient has been hospitalized with pneumonia and is about to be discharged. A nurse provides discharge instructions to a patient and his family. Which misunderstanding by the family indicates the need for more detailed information?
- A.
The patient may resume normal home activities as tolerated but should avoid physical exertion and get adequate rest.
- B.
The patient should resume a normal diet with emphasis on nutritious. healthy foods.
- C.
The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved.
- D.
The patient should continue use of the incentive spirometer to keep airways open and free of secretions.
Correct Answer
C. The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved.Explanation
It is always critical that patients being discharged from the hospital take prescribed medications as instructed. In the case of antibiotics. a full course must be completed even after symptoms have resolved to prevent incomplete eradication of the organism and recurrence of infection. The patient should resume normal activities as tolerated. as well as a nutritious diet. Continued use of the incentive spirometer after discharge will speed recovery and improve lung function.Rate this question:
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- 3.
A nurse is caring for an elderly Vietnamese patient in the terminal stages of lung cancer. Many family members are in the room around the clock performing unusual rituals and bringing ethnic foods. Which of the following actions should the nurse take?
- A.
Restrict visiting hours and ask the family to limit visitors to two at a time.
- B.
Notify visitors with a sign on the door that the patient is limited to clear fluids only with no solid food allowed.
- C.
If possible. keep the other bed in the room unassigned to provide privacy and comfort to the family.
- D.
Contact the physician to report the unusual rituals and activities.
Correct Answer
C. If possible. keep the other bed in the room unassigned to provide privacy and comfort to the family.Explanation
When a family member is dying. it is most helpful for nursing staff to provide a culturally sensitive environment to the degree possible within the hospital routine. In the Vietnamese culture. it is important that the dying be surrounded by loved ones and not left alone. Traditional rituals and foods are thought to ease the transition to the next life. When possible. allowing the family privacy for this traditional behavior is best for them and the patient. Answers A. B. and D are incorrect because they create unnecessary conflict with the patient and family.Rate this question:
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- 4.
The charge nurse on the cardiac unit is planning assignments for the day. Which of the following is the most appropriate assignment for the float nurse that has been reassigned from labor and delivery?
- A.
A one-week postoperative coronary bypass patient. who is being evaluated for placement of a pacemaker prior to discharge.
- B.
A suspected myocardial infarction patient on telemetry. just admitted from the Emergency Department and scheduled for an angiogram.
- C.
A patient with unstable angina being closely monitored for pain and medication titration.
- D.
A postoperative valve replacement patient who was recently admitted to the unit because all surgical beds were filled.
Correct Answer
A. A one-week postoperative coronary bypass patient. who is being evaluated for placement of a pacemaker prior to discharge.Explanation
The charge nurse planning assignments must consider the skills of the staff and the needs of the patients. The labor and delivery nurse who is not experienced with the needs of cardiac patients should be assigned to those with the least acute needs. The patient who is one-week post-operative and nearing discharge is likely to require routine care. A new patient admitted with suspected MI and scheduled for angiography would require continuous assessment as well as coordination of care that is best carried out by experienced staff. The unstable patient requires staff that can immediately identify symptoms and respond appropriately. A postoperative patient also requires close monitoring and cardiac experience.Rate this question:
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- 5.
A newly diagnosed 8-year-old child with type I diabetes mellitus and his mother are receiving diabetes education prior to discharge. The physician has prescribed Glucagon for emergency use. The mother asks the purpose of this medication. Which of the following statements by the nurse is correct?
- A.
Glucagon enhances the effect of insulin in case the blood sugar remains high one hour after injection.
- B.
Glucagon treats hypoglycemia resulting from insulin overdose.
- C.
Glucagon treats lipoatrophy from insulin injections.
- D.
Glucagon prolongs the effect of insulin. allowing fewer injections.
Correct Answer
B. Glucagon treats hypoglycemia resulting from insulin overdose.Explanation
Glucagon is given to treat insulin overdose in an unresponsive patient. Following Glucagon administration. the patient should respond within 15-20 minutes at which time oral carbohydrates should be given. Glucagon reverses rather than enhances or prolongs the effects of insulin. Lipoatrophy refers to the effect of repeated insulin injections on subcutaneous fat.Rate this question:
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- 6.
An infant with congestive heart failure is receiving diuretic therapy at home. Which of the following symptoms would indicate that the dosage may need to be increased?
- A.
Sudden weight gain.
- B.
Decreased blood pressure.
- C.
Slow. shallow breathing.
- D.
Bradycardia.
Correct Answer
A. Sudden weight gain.Explanation
Weight gain is an early symptom of congestive heart failure due to accumulation of fluid. When diuretic therapy is inadequate. one would expect an increase in blood pressure. tachypnea. and tachycardia to result.Rate this question:
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- 7.
A patient taking Dilantin (phenytoin) for a seizure disorder is experiencing breakthrough seizures. A blood sample is taken to determine the serum drug level. Which of the following would indicate a sub-therapeutic level?
- A.
15 mcg/mL.
- B.
4 mcg/mL.
- C.
10 mcg/dL.
- D.
5 mcg/dL.
Correct Answer
B. 4 mcg/mL.Explanation
The therapeutic serum level for Dilantin is 10 – 20 mcg/mL. A level of 4 mcg/mL is subtherapeutic and may be caused by patient non-compliance or increased metabolism of the drug. A level of 15 mcg/mL is therapeutic. Choices C and D are expressed in mcg/dL. which is the incorrect unit of measurement.Rate this question:
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- 8.
A patient arrives at the emergency department complaining of back pain. He reports taking at least 3 acetaminophen tablets every three hours for the past week without relief. Which of the following symptoms suggests acetaminophen toxicity?
- A.
Tinnitus.
- B.
Diarrhea.
- C.
Hypertension.
- D.
Hepatic damage.
Correct Answer
D. Hepatic damage.Explanation
Acetaminophen in even moderately large doses can cause serious liver damage that may result in death. Immediate evaluation of liver function is indicated with consideration of N-acetylcysteine administration as an antidote. Tinnitus is associated with aspirin overdose. not acetaminophen. Diarrhea and hypertension are not associated with acetaminophen.Rate this question:
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- 9.
A nurse is caring for a cancer patient receiving subcutaneous morphine sulfate for pain. Which of the following nursing actions is most important in the care of this patient?
- A.
Monitor urine output.
- B.
Monitor respiratory rate.
- C.
Monitor heart rate.
- D.
Monitor temperature.
Correct Answer
B. Monitor respiratory rate.Explanation
Morphine sulfate can suppress respiration and respiratory reflexes. such as cough. Patients should be monitored regularly for these effects to avoid respiratory compromise. Morphine sulfate does not significantly affect urine output. heart rate. or body temperature.Rate this question:
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- 10.
A patient arrives at the emergency department with severe lower leg pain after a fall in a touch football game. Following routine triage. which of the following is the appropriate next step in assessment and treatment?
- A.
Apply heat to the painful area.
- B.
Apply an elastic bandage to the leg.
- C.
X-ray the leg.
- D.
Give pain medication.
Correct Answer
C. X-ray the leg.Explanation
Following triage. an x-ray should be performed to rule out fracture. Ice. not heat. should be applied to a recent sports injury. An elastic bandage may be applied and pain medication given once fracture has been excluded.Rate this question:
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Aug 22, 2023Quiz Edited by
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Jul 14, 2017Quiz Created by
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