NCLEX Practice Test 3

The registered nurse is part of a team that includes two LPNs (Licensed Practical Nurses) and a UAP (Unlicensed Assistive Personnel). Which of the following patients would be most appropriate for an LPN?

The nurse working on the diabetic specialty unit cares for four patients. A nursing assistant reports that each of the patients requires the nurse’s attention. Which of the following patients, if described as detailed below by the nursing assistant, should be seen FIRST?

The nursing team on the medical/surgical unit consists of an RN, two LPNs, and a nursing assistant. Which of the following clients should be assigned to the nursing assistant?

A local congressman is admitted to the psychiatric unit with a diagnosis of major depression with intent to self-harm. A nurse who works in the pediatric unit asks the psychiatric nurse why the patient has been admitted. Which of the following responses by the nurse is BEST?

The nurse works on a medical/surgical unit. She asks a UAP (unlicensed assistive personnel) to ambulate a client recovering from a hysterectomy. Two hours later, the patient rings her call bell and asks to be walked, claiming that she has not seen the UAP this shift. The nurse finds the UAP talking on her cell phone in the break room. Which of the following actions should the nurse take NEXT?

The charge nurse works with two LPNs (licensed practical nurses) and one UAP (unlicensed assistive personnel). Which of the following assignments, if selected for the UAP, would be considered appropriate?

A student nurse is giving a child with suspected otitis media an ear examination. Which of the following actions, if taken by the student nurse, would require correction?

The charge nurse is supervising the nursing care administered on a busy medical/surgical unit. Which of the following situations, if noticed, would require immediate intervention?

The RN (registered nurse) supervises nursing care administered at a nursing home. A patient is ordered by the doctor to receive a tonometry exam. The RN calls to schedule the appointment with the ophthalmologist’s office and receives four different appointment times. Which of the following times would be BEST for this patient’s exam?

The LPN (licensed practical nurse) observes nursing care administered by a UAP (unlicensed assistive personnel). Which of the following actions, if noted by the LPN, would require further teaching?

Which of the following tasks can be delegated to a UAP (unlicensed assistive personnel)?

The charge nurse is making patient assignments and assigns the LPN to a patient who had a chest tube inserted 3 hours ago. Which of the following is correct?

Which of the following should be included in performance evaluations of nursing staff?

Performing a procedure on a client in the absence of an informed consent can lead to which of the following charges?

The licensed practical nurse may NOT assume the primary care for which of the following patients?

A patient diagnosed with SIADH is ordered by the physician to receive 3% NaCl 500mL at a rate of 60mL/hr. Which of the following actions, if taken by the nurse, is most important in regard to patient safety?

The herpes zoster virus requires a nurse to follow ________ precautions at all times.

When evaluating the growth and development of a 6 month-old infant, a nurse expects the infant to be able to perform which of the following actions?

The client with an undisplaced midshaft fracture of the left tibia was placed in a long leg cast after experiencing a car accident. Overnight the client returned to the emergency department and is now complaining of unrelenting severe pain and feeling as if the toes are asleep. When the cast is removed and the patient still complains of severe pain, the nurse suspects that the client is experiencing which of the following conditions?

A 4-year-old child is seen in the emergency department with rashes mostly found on his torso. The nurse obtained a medical history from the mother and she said her child had fever before the rashes appeared. Other symptoms include loss of appetite and he began coughing and complains of a sore throat. With these objective data at hand, the nurse suspects that the child is having?

The nurse is correctly implementing the prescribed transmission-based precaution when she does the following:

During report, the previous nurse emphasized that one of the newly admitted patients is on seizure precautions. The incoming nurse is correct when she performs which of the following actions to the client?

The doctor orders a 24-hour ambulatory electrocardiography using a Holter monitor to a client with frequent fainting spells. To prevent electrical interference with the Holter monitor, the nurse should instruct the client to avoid which of the following?

A licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the LPN to intervene?

What is the primary responsibility of the nurse and radiology staff when assisting a client with multiple myeloma who is ordered to receive a bone scan and a chest x-ray?

A mother calls the outpatient health clinic and asks the nurse a few questions about how to care for her newborn. Which of the following statements, if made by the patient to the nurse, are correct?

SELECT ALL THAT APPLY:

The nurse works in an outpatient sexual health clinic. A patient asks the nurse what the absolute method is to prevent pregnancy. The nurse knows that the absolute method is

A five-month-old boy is brought to the doctor’s office by his mother for a well-child visit. Which of the following, if observed by the nurse, would reflect a developmental delay?

A student nurse interns at an outpatient health center. Which of the following responsibilities of the student nurse are considered tertiary prevention strategies?

SELECT ALL THAT APPLY:

The nurse screens patients for colon cancer. Which information, if indicated in the patient’s chart, is considered a risk factor for colorectal cancer?

SELECT ALL THAT APPLY:

A client receives a PPD test. He returns to the clinic 24 hours later and shows the inoculated arm, which has no induration or redness. Which of the following statements, if made by the nurse, is a CORRECT interpretation of the results?

A patient with postpartum depression is scheduled for discharge today. Which of the following statements by the patient would indicate the postpartum depression has RESOLVED?

A patient has just been told by the physician that she has stage III uterine cancer. The patient says to the nurse, “I don’t know what to do. How do I tell my husband?” and begins to cry. Which of the following responses by the nurse is the MOST therapeutic?

The mother of a two-year-old and a four-year-old becomes frustrated and asks the nurse for advice on how to handle time-out situations for her children. Which of the following guidelines, if given by the nurse, is CORRECT?

A nurse is teaching a primipara patient how to correctly breastfeed her infant for the first time. The patient states, “Why is this so hard? I feel like a bad mother already!” Which of the following responses is best?

The nurse cares for a patient whose baby was born with unexpected spina bifida. Which of the following statements is MOST therapeutic to say to the parents?

In a mental health facility, clients are allowed to eat together in the dining room to promote social interaction. The nurse is caring for a manic client in the seclusion room, and it is time for lunch. Which of the following actions should the nurse take?

A client who has sustained damage to the bladder is being prepared for diagnostic tests. The client asks, “If I have my bladder removed, how will I ever be able to urinate?” The most therapeutic answer by the nurse is?

The nurse reviews dietary teaching for a client diagnosed with cholecystitis. The nurse determines that teaching is effective if the client states which of the following meals?

A teenager is discharged to home wearing halo vest traction after a car accident. What guidelines should the nurse give to the parent that are BEST for her care?

SELECT ALL THAT APPLY:

A 4-year-old client is admitted for eye surgery. The nurse is performing the correct action in preparing the child for the procedure when she:

A patient has been on bedrest for a week after a fractured left hip. Which of the following symptoms, if noted in the patient, would be considered signs of complications due to immobility?

SELECT ALL THAT APPLY:

A newly admitted client is about to receive a radiation treatment later in the day. In preparing the room, the nurse should plan to post this sign outside the client’s room:

The bed of a patient who has an indwelling urinary catheter (Foley) is found wet with urine. After determining that the catheter is patent, the nurse should:

A patient with gout wants to know what meal choice she should order from the cafeteria for dinner. The nurse helps her to select which of the following dinners?

The nurse screens patients for colon cancer. Which information, if indicated in the patient’s chart, is considered a risk factor for colorectal cancer?

SELECT ALL THAT APPLY:

The nurse cares for a patient on the medical/surgical unit. The patient rings the call bell and exclaims, “My urine has been orange today! What medication is doing this to me?” Which of the following medications, if noted in the patient’s chart, would explain this side effect?

SELECT ALL THAT APPLY:

The nurse correctly administers the PPD to a client when she:

A client receiving Zyprexa (olanzapine) will most likely have another prescription of which medications?

The nurse works in a NICU (neonatal intensive care unit). The doctor orders Digoxin 6 mcg/kg/day IV in two divided doses to be given to one of the nurse’s patients. The patient weighs 7 pounds. Calculate the amount, in mcg, the nurse will give per dose.

A patient has been taking a heavy aspirin regimen for the past two months. Which side effects, if noted by the patient, are directly related to overdose of aspirin?

SELECT ALL THAT APPLY:

The physician prescribes alprazolam (Xanax) 0.25 mg p.o. TID for a client with anxiety and physical symptoms related to work pressures. The nurse should assess the client for the most common adverse effect of this drug, which is?

A 40 year-old client who is receiving a MAOI is going home on a weekend pass. Considering the drug, the nurse plans to instruct the client to avoid?

SELECT ALL THAT APPLY:

Which of the following statements is true regarding the responsibility of the Licensed Practical Nurse when it comes to IV therapy? The LPN may:

The nurse is administering an unpleasant-tasting liquid medication to a 2-year-old child. Which intervention should the nurse implement?

A patient is sent home on prescribed Nitroglycerin, to be taken as needed for angina. Which of the following instructions, if stated by the patient to the nurse, would require further teaching?

SELECT ALL THAT APPLY:

A patient with SCI (spinal cord injury) rings the call bell for the nurse and complains of a headache and nasal stuffiness. The patient asks for Advil and nasal spray. The nurse knows that the next correct action is to:

A nurse performs a home care visit to a patient performing peritoneal dialysis at home and observes the procedure. Which of the following actions by the patient would be considered incorrect?

The nurse knows that the care plan for a patient with a pheochromocytoma will involve which of the following?

Which of the following is a finding that the nurse will be able to assess in a client with a pleural effusion?

SELECT ALL THAT APPLY:

A patient has just returned from a hypophysectomy and complains of “mucus” dripping from her nose. What action does the nurse take next?

A nurse cares for patients in the emergency department of a large hospital. One of the nurse’s patients has acute right-sided abdominal pain and is suspected of having appendicitis. Which of the following, if overheard by the nurse, would prompt immediate intervention?

The nurse cares for patients on a medical/surgical unit. One of the nurse’s patients has just returned from a surgery to place a colostomy. The patient looks panicked and says to the nurse, “Should it look like that?!” The nurse responds:

A patient with AIDS comes to the clinic and tells the nurse he thinks he was exposed to tuberculosis a month ago. The nurse knows that the results of a PPD will be considered positive if induration measures at least:

A diabetic patient suddenly becomes confused and diaphoretic. Which of the following actions should the nurse take FIRST?

A patient post-Biliroth II asks the nurse how to prevent dumping syndrome. Which advice, given by the nurse to the patient, would be considered correct?

A patient comes into the ER complaining of chest pain and shortness of breath. What action does the nurse perform FIRST?

The nurse collects a urine sample from a patient with urolithiasis. The nurse knows that urolithiasis is the presence of _____ stuck in the genitourinary system.

The home care nurse visits a patient two days after cataract extraction and implant. Which of the following statements, if made by the patient, requires further teaching?

A client with jaundice is experiencing pruritus. Which nursing intervention would be included in the care plan for the client?

The patient below has just been admitted to the ER following a motor vehicle accident. Describe the positioning of this patient with the most specific term.

Spironolactone (Aldactone) is prescribed for a client with chronic cirrhosis and ascites. The nurse should monitor the client for which of the following medication-related side effects?

A 16-year-old client was brought to the emergency department after a vehicular accident. The client’s blood pressure is 105/58 mmHg, and further physical assessment reveals a ruptured spleen. With all this information, the nurse should assess the client for an early sign of decreased arterial pressure, such as?

A male patient has the following lab values: Arterial HCO3 of 25, Hemoglobin of 15.5, Phosphate of 1.5, Calcium of 8.0, TSH of 2.9. Which of the above is a critical result and must be reported to the physician immediately?

A nurse is assisting the physician with a lumbar puncture on a patient suspected of having meningitis. During the procedure, the nurse notes the patient is experiencing cold, clammy skin, tachypnea, and an increased pulse rate. The nurse should: