NCLEX-RN Practice Test

As clients age, their sense of taste may diminish, reducing the joy that comes with eating. A nurse can promote the sense of taste for a client by encouraging him to chew his food thoroughly while eating. This results in longer contact of food with the taste buds and a greater chance of tasting the food.

All of the answers are correct. A high-protein, low-fat diet is appropriate for patients with GERD as following this diet helps prevent symptoms of acid reflux. A high-fat diet may delay gastric emptying leading to more acid reflux. Remaining upright will help keep pressure off of the esophageal sphincter and allow the muscle to work appropriately. Limiting the intake of acid-stimulating food and drink will also prevent heartburn by calming the esophageal lining and preventing the esophageal sphincter from weakening.

When prioritizing needs of clients, the nurse must begin with the unstable client or manage conditions that affect airway, breathing, or circulation first. The client with COPD has a condition that affects breathing and is exhibiting decreased oxygen saturation levels; therefore, this client should be the first priority.

Nurses must typically work as part of a larger interdisciplinary team that involves collaboration with other professionals. In order to fulfill the client's needs, communication between disciplines should remain respectful, with clear directions about each discipline's responsibilities. Communication between all parties minimizes confusion about the client's care.

The physician has the responsibility of discussing a procedure, risks/benefits, and alternatives to the procedure; the nurse is unable to do this. Additionally, choice A is incorrect as a patient has the right to withdraw consent at any time, even after signing the consent form.

Swelling of the lower limbs, known as edema, is due to a buildup of fluid from an impaired circulatory system and is a common side effect of Congestive Heart Failure.
 
It would not be appropriate to discourage fruits and vegetables, as they are part of a heart healthy diet and should be encouraged. Patients with heart failure are usually put on a water regimen of around 1-2 L of fluid total per day. This is due to the increased pressure on the heart to process fluids and may cause worsening edema. Patients with heart failure need to be careful with the amount of vigorous exercise activities they undertake. Heart rate should be monitored closely to prevent overexertion.

The case manager is the most appropriate healthcare team member to report this kind of statement to, especially around discharge. An assessment may need to take place regarding the living and financial situation of the patient. The doctor and director of nursing would most likely refer the nurse back to the case manager, so it would be appropriate for the nurse to report this statement to the case manager first.

A patient with loss of limb may be experiencing Disturbed Body Image. The nurse should be sensitive to the patient's emotional and mental acceptance of the loss and incorporate therapeutic communication as the patient allows. Acceptance may take time and the patient should not be pressured into looking at the limb.
The patient may be experiencing Altered Sleep Patterns related to the surgery, however the patient refusing to look at the limb indicates Disturbed Body Image. The patient remembers the limb is there and is refusing to look at it, therefore Impaired Memory does not appear to be the issue. The patient does not appear to have any issues communicating with the nurse, so the patient is more likely experiencing Disturbed Body Image related to the loss of the limb rather than Impaired Social Interaction.

Consent to disclosure is implied in the transfer from one health provider to another for Continuity of Care under HIPAA laws as long as the facility members receiving the Patient Health Information, or PHI, are directly involved in the care of the patient. Consent must be in writing from the patient to allow the family members to see the patient's medical record or receive information from care providers. Updates on the patient's status should only be given with consent from the patient. This includes all family members, even a spouse. Under HIPAA laws, only staff operating in the direct care of the patient are allowed access to a patient's medical records.

The certified nursing assistant is not authorized to instruct patients on post-operative care or wound care. This should never be delegated. It is within the certified nursing assistant's scope of practice to perform the other interventions.

A patient with Bacterial Pneumonia may spread the disease through droplets from coughing or sneezing. Droplet precautions would be appropriate. A mask is required to prevent inhalation of droplets containing bacteria.
 
Flowers can be allowed to be brought into the patient room as this should not worsen the patient's condition, unless the patient has an allergy. Proper sanitization measures are acceptable when handling utensils used by a patient on Droplet precautions. Visitors can be allowed provided a mask is worn within the room of a patient who may be coughing.

A patient with Bacterial Pneumonia may spread the disease through droplets from coughing or sneezing. Droplet precautions would be appropriate. A mask is required to prevent inhalation of droplets containing bacteria. Flowers are allowed into the patient room as this should not worsen the patient's condition, unless the patient has an allergy. Proper sanitization measures are acceptable when handling utensils used by a patient on Droplet precautions. Visitors can be allowed, provided a mask is worn within the room of a patient who may be coughing.

Client handling equipment is designed to reduce the stress and workload on nurses who must assist, turn, or lift clients. This equipment decreases the risk of injuries associated with improper lifting. A height-adjustable bed raises the client up to a proper working height for the nurse who must provide assistance.

A room marked with Enteric Contact Precautions indicates that normal alcohol-based hand sanitizer will not remove the bacteria present in the room. Handwashing with soap and water should be used instead of hand sanitizer.
A mask is not indicated with Enteric Contact Precautions. The CNA should dispose of gloves inside the room to contain the bacteria within the room, then hands should be washed with water and soap.

Nasal flaring and retractions indicate that the newborn is working hard to breathe. The other choices are normal findings in the newborn; acrocyanosis and circumoral cyanosis are common in the first day of life, and normal respiratory rate in a newborn is 30-60 breaths per minute.

The correct statement by the nurse is that the patient should wear closed toe shoes when ambulating. Patients with Diabetes are at high risk for impaired sensation in their lower extremities and may develop wounds that are difficult to heal.
Patients with Diabetes should be encouraged to eat more fruits and vegetables as part of a healthy blood-sugar regulating diet. Increasing physical activity is another way the patient with Diabetes can regulate blood sugar levels. If the Diabetic patient is checking blood sugars, the levels would normally be checked prior to meals, typically to determine a dose of insulin.

The patient should notify the physician if edema starts developing in the lower extremities. This indicates more pressure on the heart and can cause complications. Patients with Congestive Heart Failure need to have a limited fluid intake, typically around 2 L per day to prevent fluid overloading. The patient should be aware this includes all types of fluids, not just water. Weight gain of 3-5 lbs in one day should be reported to the physician as this is a significant weight increase and may indicate fluid retention. The patient's medications may need to be adjusted. The patient complaining of difficulty breathing at night is experiencing pulmonary edema, a condition in which fluid builds up into the lungs. This symptom should be reported to the physician immediately.

160 is considered an abnormal value for the 1-hour screening glucose. The correct follow-up is to complete the 3-hour test as this test is diagnostic for gestational diabetes.

The distended abdomen and absent bowel sounds indicate an ileus, which is a common complication after bowel surgery. Pink incision edges and borborygmi are normal findings. Pain is expected after a surgery, and while significant pain is of concern, a pain level of 4 out of 10 is expected.

When suctioning the endotracheal tube of an adult client, the nurse should set the suction apparatus at a level no higher than 150 mmHg, with a preferable level between 100 and 120 mmHg. Suction pressure that is too high can contribute to the client's hypoxia. Alternatively, too low of suction pressure may not clear adequate amounts of secretions.

Diagnostic peritoneal lavage is contraindicated in clients who are morbidly obese because excess body fat makes finding essential landmarks for this procedure difficult. Additionally, the equipment used for the procedure may not be large enough to accommodate an obese person. Finally, morbid obesity puts excess strain on the cardiovascular and respiratory systems, such that anesthetic agents used during the procedure could cause further complications.

The patient is at risk for all the listed conditions related to decreased mobility. Pressure ulcers form as the skin layers break down between the chair or bed surface and bone. This may happen due to the patient remaining in one position too long. This patient may be at risk for pressure ulcers to his sacrum or areas where his leg meets the foot rest. Patients have been shown to be higher risk for Deep Vein Thrombosis with decreased mobility. The patient should ambulate multiple times a day to lower his risk for DVT. Constipation is another common side effect of decreased mobility as the GI system slows.

A patient may be instructed to not eat any solid foods up to 24 hours prior to a colonoscopy, however clear liquids are typically allowed until midnight prior to the procedure up to a couple hours prior to the procedure. The nurse will need to verify the orders given by the physician.

Putting a pillow under the patient's head is an acceptable way to prevent injury to the patient until the seizure has completed.
 
Putting restraints on the patient may cause further injury to the patient and will not prevent the muscles from moving. Putting a tongue blade in the patient's mouth may cause injury to the oral cavity and may cause the patient to choke. It is more appropriate to put the patient on the side as this may help to prevent aspiration as well as prevent injury to the head.

A, B, and C are all complications of prolonged mobility. Prolonged mobility also decreases appetite.

When assessing for signs of developing pressure ulcers in a client with dark skin, decreased circulation may not always be readily apparent. For instance, blanching, the red undertones seen in light-skinned clients, will not always be present. Instead, the skin of an early pressure ulcer may develop a purple or bluish color.

A suspension is a type of medicine that combines medication particles with a liquid solution. When not administered, medication particles within the suspension may settle to the bottom, requiring the nurse to shake the solution to mix. Suspensions are typically given as oral solutions.

Progesterone is a hormone that is produced by the ovaries in women. Progesterone affects the tissue of the endometrium by developing the lining of the uterus in support of embryo implantation. In pregnant women, progesterone nourishes the uterine lining and limits uterine contractions to prevent miscarriage.

Vitamin K acts to reverse the blood-thinning effects of warfarin. Calcium gluconate is the antidote to magnesium toxicity, insulin can help reverse hyperkalemia, and protamine sulfate reverses unfractionated heparin overdose.

Using an Incentive Spirometer will increase lung capacity, opening the bronchioles, and allowing for better oxygenation throughout the body.
Using an Incentive Spirometer gently exercises the lungs and will encourage the patient to take long and deep breaths instead of short and shallow breaths which are common following surgery. Maintaining adequately expanded lungs and allow better oxygenation through the blood stream will improve recovery times, allowing for the patient to start ambulating sooner as well as encourage proper healing to the surgical site. Incentive Spirometry use prevents pneumonia be keeping bronchioles open and clear, minimizing the sustainable environment for pneumonia to develop.

Pudendal nerve blocks use medication, like lidocaine, to numb the area between the vagina and rectum. Additionally, it is usually used in the second stage of labor (once a patient is 10cm dilated and pushing). It is the only option that is considered a pharmacologic intervention. The other options are nonpharmacologic in nature. Per the question, the patient declines pharmacologic intervention.

Warfarin is a common medication given long-term in the management of Atrial Fibrillation to prevent the development of blood clot, or thromboses, that can cause blockages in the heart or lungs.
Heparin, while used to prevent thrombosis in Atrial Fibrillation, is not usually administered long-term as it is an IV or Sub-cutaneous injection. Furosemide is given as a diuretic in decreasing fluid retention. It is normally given to patients with Congestive Heart Failure. Albuterol is typically a drug that is inhaled in the treatment of Chronic Obstructive Pulmonary Medication or Asthma as a rescue medication. It is contraindicated in Atrial Fibrillation.

The correct answer is 34.
First, 200 lb is 90.7 kg.
Multiply the 5 mcg/min by 90.7 kg to get 453.5 mcg/min.
Multiply the 453.5 mcg/min x 60 min to get 27210 mcg/hr.
Multiply 27210 mcg/hr x 1 mg/1000 mcg to get 27.21 mg/hr.
Multiply 27.21 mg/hr x 500 ml/400 mg to get the answer of 34 ml/hr.

325 mg x 2 pills is equal to a total of 650 mg. Therefore, the patient should receive a maximum of 2 pills every 6 hours. It is important to verify the dosage of certain medications, such as Tylenol, to prevent overdosing a patient within a 24-hour period.

The correct answer is c.
First convert 143 lbs to 65 kg.
Multiple 65 kg x 2 mg/kg to get 130 mg q 8 hours.
Multiple 130 mg x 50ml/100mg to get 65 ml q 8 hrs.

Interventions for a client who is suffering from a fever include increasing the client's volume of fluid and providing oxygen. A fever increases the body's metabolism, causing the client to breathe at a faster rate and increasing the work of the heart. The client is at risk of fluid loss due to increased respiration and sweating. The increased work of the heart requires more oxygen to maintain perfusion to the tissues.

While the restraint should have some slack, they should NOT be tied to the side rails. Instead, a quick-release knot should be used and tied in an area where the patient cannot reach.

A patient with hyperthyroidism will present with the opposites of the listed symptoms. Too much thyroxine is produced, causing the body's metabolism to rise. This leads to an intolerance to heat, a decrease in weight gain, increased bowel movements, a rapid heart rate, and warm, clammy skin.

Hypovolemia indicates low fluid volume within the body. Dizziness spells would be one symptom of hypovolemia due to the decreased pressure in the brain.
 
Urine would be dark colored, not light colored, as the urine contains more byproducts and the kidneys process less fluid. An increased pulse rate would indicate hypovolemia as the heart works harder to spread the limited amount of fluid volume throughout the body. A patient would have dry mucus membranes as fluid is directed towards more vital body organs.

First, we look at the pH. The normal pH range is 7.35-7.45. Acidosis is present when the pH is below 7.35. Thus, we can eliminate the alkalosis answers. The HCO3 is also low (normal is 22-26) as is the PaCO2 (normal is 35-45). Both values point to metabolic acidosis.

The first action should be to stop the transfusion immediately once the patient complains of any unusual symptoms. The patient is reporting symptoms of a transfusion reaction therefore the transfusion should be stopped to prevent the patient from worsening. The provider should be notified immediately after stopping the transfusion. Vital signs should be taken as quickly as possible or as instructed by the provider after the transfusion has been stopped and the physician has been notified.
A code should be called if the patient becomes unresponsive. A rapid response could be called if the patient is at risk of destabilizing.

Understaffing of nursing personnel may be an organizational risk associated with workplace violence for nurses. Understaffing involves too few nurses on duty, which may not be enough to meet client needs at the time or may result in longer delays for provision of care. Greater amounts of activity and diminished numbers of nurses to provide care may result in aggression, violence, or anger from clients or families directed toward staff.

At 2 years old child, a patient should have reached certain developmental milestones. The child will be developing their vocabulary and in addition to knowing almost 300 words, will be developing 2-4 sentences. The child may start using one hand to complete tasks and favoring one hand over the other. The child may start running, as well as walking and standing on tiptoes. A child who is lagging in performing these milestones may be at risk for developmental delay and further assessment is indicated.

Using therapeutic communication, the nurse should question the patient about the possibility of abuse. It is appropriate to talk with the patient when the spouse is out of the room as the patient may be fearful and not answer questions honestly if the spouse is in the room.
 
It is not appropriate to question the patient when spouse is in the same room. It is not appropriate to approach the spouse with suspicion of abuse as this could cause further damage to the patient and make it more difficult for the patient to leave the abuser. The patient is not required to speak to the police. It is up to the patient to determine if they want to speak to the police, though the nurse can encourage the patient.

It is most appropriate to notify the doctor that the patient is rethinking about receiving the surgery. The doctor will need to discuss their options again and reinforce to the patient that surgery is required or not.
 
It is not appropriate for the spouse to explain the procedure to the patient. This should be done by medical staff. The patient may have questions that can only be answered by the doctor, therefore the doctor should be notified. The nurse may not be able to explain the procedure appropriately and may cause the patient to distrust the medical staff, therefore the doctor should be notified as they may need to receive consent a second time.

Non-pharmacological methods should be used prior to pharmacological methods. Haldol is normally given to patients experiencing severe anxiety or agitation and should be used as a last resort.
A patient may benefit from the nurse sitting with them and providing calm conversation over the anxiety-causing issue. Deep-breathing is well-known calming technique used to calm the nervous system and can help in cases of anxiety or panic attacks. Progressive Muscle Relaxation can be used to encourage the patient into a more relaxed state. The nurse can assist the patient to lay on the bed and provide instructions to the patient in a slow calm voice. Progressive Muscle Relaxation would be helpful for mild anxiety.

A communal family is a group classified as a non-traditional family. In this situation, adults who are not related may live and work with other adults and their children all together in a household. The communal family may share expenses, food, and childcare in the same way as a traditional family.

Rationalization occurs when a person tries to avoid taking responsibility for their behavior, choosing instead to blame someone or something else. Regression is defined as going backward to a previous developmental stage, usually because it makes a person feel safe. Dissociation deals with a temporary shift in consciousness (such as disconnecting oneself from one's feelings), usually as a reaction to significant stress or trauma. Substitution is when a person substitutes an easier goal or desire for an original goal or desire which proves unreachable.

When preparing to talk with a client about a difficult subject, the nurse can provide an environment that is private and that offers minimal distractions. This gives the client an opportunity to open up about personal feelings without being interrupted, and may provide more open communication between the nurse and client.

When assessing a client's personal identity, the nurse should focus on questions that determine how the client feels about himself. This may mean asking questions that help him identify his personal strengths and weaknesses, as well as how he thinks others see him.

The client is at risk for a cerebral vascular accident (CVA). The client has a recent diagnosis of atrial fibrillation, which increases the risk of a stroke. In atrial fibrillation, the blood flow becomes turbulent from the quivering atria, which does not pump the blood as efficiently to the ventricles. The turbulent blood flow can result in clot formation, which then can travel to the brain and lodge in smaller vessels.
There is no indication that the client is at risk for a hypertensive crisis. Although hypertension can be a common comorbidity with other cardiovascular diseases, the client's history of atrial fibrillation alone does not increase the risk for a hypertensive crisis. However, it is a significant risk factor for stroke.
Although it does appear that the client is presenting with difficulty speaking and neurological symptoms there is no indication that this client has an increased chance of developing seizure-like activity. There is no history of epilepsy, and seizures are not a complication of atrial fibrillation.
Peripheral vascular disease (PVD) is not a complication of the client diagnosed with atrial fibrillation. PVD develops over a long period of time and is usually due to vessel damage from uncontrolled hypertension, not from atrial fibrillation.

The nurse must first perform a neurological examination if the client has a change in neurological status, such as difficulty with speech. This assessment is important to collect valuable additional data to determine the subsequent appropriate intervention and relay critical information to other interdisciplinary team members.
Answer B is incorrect. The nurse does contact the healthcare provider. First, however, the nurse must perform a neurological assessment and collect additional data. Additional findings can assist with a diagnosis and appropriate interventions.
Answer C is incorrect. The nurse does not need to assist the client back into bed for a neurological exam. The client might have further neurological deficits that can interfere with mobility, and the nurse might need additional assistance before getting the client back into bed. For safety purposes, the nurse first performs a neurological assessment to evaluate if there are any additional neurological findings before determining if it is safe to ambulate the client.
Answer D is incorrect. The nurse should plan to check the client's glucose. Hypoglycemia can interfere with the client's level of consciousness and ability to speak and can result in seizure activity, as well as death. However, the nurse must collect more data before initiating interventions.

It is important to determine the client's last known "normal" time. The current guidelines for thrombolytic therapy include if the symptom onset began 4.5 hours prior. When a client starts experiencing stroke-like symptoms such as hemiparesis, difficulty with speech, and a facial droop, the nurse must determine when the client was last seen without the neurological symptoms to determine if the client is a candidate for thrombolytic therapy. Since this client is in the hospital, the nurse can look back on prior documentation and ask other staff and family members when the client was last seen without the symptoms.
Answer A is incorrect. Determining the last time the client had anything to eat or drink is an appropriate action by the nurse. However, the most important additional data after a client begins to experience stroke-like symptoms is when the client was last seen without the symptoms. This information is necessary to determine if the client can receive thrombolytic, which breaks up the clot and provides perfusion to the brain. If the client is not a candidate for this intervention, they might be a candidate for other interventions, such as an embolectomy. During this procedure, they remove the clot from the brain while the client is under sedative medications. Knowing the last time the client ate and drank is helpful in case the client experiences any nausea or vomiting from the suspected stroke or medications for aspiration prevention.
Answer C is incorrect. Determining the last time the client received any narcotics is not a priority after the neurological findings. The nurse recognizes these assessment findings are consistent with a stroke, not a side effect of narcotic medication. Narcotic medication does not cause hemiparesis or a facial droop.
Answer D is incorrect. The amount of time the client had slept the night previously is irrelevant in relation to the client's neurological changes and symptoms. Fatigue commonly occurs in the hospital setting due to common interruptions in sleep. However, the nurse knows the neurological findings are common signs and symptoms of a stroke, not fatigue.

The nurse should be concerned when the client mentions they have a headache. The nurse knows an adverse effect of thrombolytic medications can be bleeding. Therefore, the nurse monitors the client for bleeding, including bleeding in the brain. Signs and symptoms to monitor for are nausea, vomiting and headaches. If these occur, stopping the infusion and notifying the healthcare provider is essential.

The client correctly understands proper stroke education when stating they will take warfarin as prescribed. Clients with atrial fibrillation who experienced a stroke should be discharged on an anticoagulant such as warfarin to prevent further clots from forming.
Answer C is incorrect. There is no way to predict when another stroke will take place, and the client who has had a stroke or TIA in the past is at risk for it to occur again. Families should be taught about the signs and symptoms of a stroke before discharge to identify the symptoms and seek treatment quickly. The pneumonic F.A.S.T. can be used for teaching. The pneumonic stands for face, arm weakness, speech or language difficulty, and time to call 911. This helps family remember classic signs and symptoms of a stroke and the importance of seeking help.