2022/2023 NCLEX-PN Test Prep Exam
3(THREE)
Questions and Answers with Explanations
1. A papular lesion is noted on the perineum of the laboring client. Which
initial action is most appropriate? A. Document the finding
B. Report the finding to the doctor
C. Prepare the client for a C-section
D. Continue primary care as prescribed
Answer B: Any lesion should be reported to the doctor. This can indicate a
herpes lesion. Clients with open lesions related to herpes are delivered by
Cesarean section because there is a possibility of transmission of the
infection to the fetus with direct contact to lesions. It is not enough to
document the finding, so answer A is incorrect. The physician must make the
decision to perform a C-section, making answer C incorrect. It is not enough
to continue primary care, so answer D is incorrect.
2. A client with a diagnosis of human papillomavirus (HPV) is at risk for
which of the following?
A. Lymphoma
B. Cervical and vaginal cancer
C. Leukemia
D. Systemic lupus
Answer B: The client with HPV is at higher risk for cervical and vaginal
cancer related to this STI. She is not at higher risk for the other cancers
mentioned in answers A, C, and D, so those are incorrect.
3. The client seen in the family planning clinic tells the nurse that she has a
painful lesion on the perineum. The nurse is aware that the most likely source
of the lesion is:
A. Syphilis
B. Herpes
C. Candidiasis
D. Condylomata
Answer B: A lesion that is painful is most likely a herpetic lesion. A chancre
lesion associated with syphilis is not painful, so answer A is incorrect. In
answer C, candidiasis is a yeast infection and does not present with a lesion,
but it is exhibited by a white, cheesy discharge. Condylomata lesions are
painless warts, so answer D is incorrect.
4. A client visiting a family planning clinic is suspected of having an STI.
The most diagnostic test for treponema pallidum is:
A. Venereal Disease Research Lab (VDRL)
B. Rapid plasma reagin (RPR)
C. Florescent treponemal antibody (FTA)
D. Thayer-Martin culture (TMC)
Answer C: FTA is the only answer choice for treponema pallidum. Answers A
and B are incorrect because VDRL and RPR are screening tests for syphilis
but are not conclusive of the disease; they only indicate exposure to the
disease. The Thayer-Martin culture is a test for gonorrhea, so answer D is
incorrect.
5. Which laboratory finding is associated with HELLP syndrome in the
obstetric client? A. Elevated blood glucose
B. Elevated platelet count
C. Elevated creatinine clearance
D. Elevated hepatic enzymes
Answer D: The criteria for HELLP is hemolysis, elevated liver enzymes, and
low platelet count. In answer A, an elevated blood glucose level is not
associated with HELLP. Platelets are decreased in HELLP syndrome, not
elevated, as stated in answer B. The creatinine levels are elevated in renal
disease and are not associated with HELLP syndrome, as stated in answer
C.
6. The nurse is assessing the deep tendon reflexes of the client with
hypomagnesemia. Which method is used to elicit the biceps reflex?
A. The nurse places her thumb on the muscle inset in the antecubital
space and taps the thumb briskly with the reflex hammer.
B. The nurse loosely suspends the client’s arm in an open hand while
tapping the back of the client’s elbow.
C. The nurse instructs the client to dangle her legs as the nurse strikes the
area below the patella with the blunt side of the reflex hammer.
D. The nurse instructs the client to place her arms loosely at her side as
the nurse strikes the muscle insert just above the wrist.
Answer A: The answer can only be A because the other methods elicit
different reflexes. Answer B elicits the triceps reflex, answer C elicits the
patella reflex, and answer D elicits the radial nerve.
7. Which medication should be used with caution in the obstetric client with
diabetes?
A. Magnesium sulfate
B. Brethine
C. Stadol
D. Ancef
Answer B: Brethine is used cautiously because it raises the blood glucose
levels. Answers A, C, and D are all medications that are commonly used in
the diabetic client, so there is no need to question the order for these
medications.
8. A multigravida is scheduled for an amniocentesis at 32 weeks gestation to
determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1.
The nurse’s assessment of this data is:
A. The infant is at low risk for congenital anomalies.
B. The infant is at high risk for intrauterine growth retardation.
C. The infant is at high risk for respiratory distress syndrome. D. The infant is
at high risk for birth trauma.
Answer C: When the L/S ratio reaches 2:1, the lungs are considered to be
mature. The infant will most likely be small for gestational age and will not
be at risk for birth trauma, so answer B is incorrect. The L/S ratio does not
indicate congenital anomalies, as stated in answer A, and the infant is not at
risk for intrauterine growth retardation, as stated in answer D.
9. Which observation in the newborn of a mother who is alcohol dependent
would require immediate nursing intervention?
A. Crying
B. Wakefulness
C. Jitteriness
D. Yawning
Answer C: Jitteriness is a sign of seizure in the neonate. Answers A, B, and D
are incorrect because crying, wakefulness, and yawning are expected in the
newborn.
10. The nurse caring for a client receiving magnesium sulfate must closely
observe for side effects associated with drug therapy. An expected side effect
of magnesium sulfate is:
A. Decreased urinary output
B. Hypersomnolence
C. Absence of knee jerk reflex
D. Decreased respiratory rate
Answer B: The client is expected to become sleepy, have hot flashes, and
experience lethargy. A decreasing urinary output, absence of the knee jerk
reflex, and decreased respirations are signs of toxicity and are not expected
side effects of magnesium sulfate. Therefore, answers A, C, and D are
incorrect.
11. The 57-year-old male client has elected to have epidural anesthesia as the
anesthetic during a hernia repair. If the client experiences hypotension, the
nurse would:
A. Place him in the Trendelenburg position
B. Obtain an order for Benedryl
C. Administer oxygen per nasal cannula
D. Speed the IV infusion of normal saline
Answer D: If the client experiences hypotension after an injection of epidural
anesthetic, the nurse should turn him to the left side if possible, apply oxygen
by mask, and speed the IV infusion. Epinephrine, not Benedryl, in answer B,
should be kept for emergency administration. A is incorrect because placing
the client in Trendelenburg position (head down) will allow the anesthesia to
move up above the respiratory center, thereby decreasing the diaphragm’s
ability to move up and down, ventilating the client. Answer C is incorrect
because the oxygen should be applied by mask, not cannula.
12. A client has cancer of the pancreas. The nurse should be most concerned
with which nursing diagnosis? A. Alteration in nutrition
B. Alteration in bowel elimination
C. Alteration in skin integrity
D. Ineffective individual coping
Answer A: Cancer of the pancreas frequently leads to severe nausea and
vomiting. Answers B, C, and D are incorrect because although they are a
concern to the client, they are not the priority nursing diagnosis.
13. The nurse is caring for a client with ascites. Which is the best method to
use for determining early ascites?
A. Inspection of the abdomen for enlargement
B. Bimanual palpation for hepatomegaly
C. Daily measurement of abdominal girth
D. Assessment for a fluid wave
Answer C: Measuring the girth daily with a paper tape measure and marking
the area that is measured is the most objective method of estimating ascites.
Inspection, in answer A, and checking for fluid waves, in answer D, are more
subjective and not correct. Palpation of the liver will not tell the amount of
ascites, so answer B is incorrect.
14. The client arrives in the emergency department after a motor vehicle
accident. Nursing assessment findings include BP 80/34, pulse rate 120, and
respirations 20. Which is the client’s most appropriate priority nursing
diagnosis?
A. Alteration in cerebral tissue perfusion
B. Fluid volume deficit
C. Ineffective airway clearance
D. Alteration in sensory perception
Answer B: The vital signs indicate hypovolemic shock, so checking for fluid
volume deficit is the appropriate action. Answers A, C, and D do not indicate
cerebral tissue perfusion, airway clearance, or sensory perception alterations,
and are incorrect.
15. Which information obtained from the visit to a client with hemophilia
would cause the most concern? The client:
A. Likes to play football
B. Drinks several carbonated drinks per day
C. Has two sisters with sickle cell tract
D. Is taking acetaminophen to control pain
Answer A: The client with hemophilia is likely to experience bleeding
episodes if he participates in contact sports. Drinking several carbonated
drinks per day, as in answer B, has no bearing on the hemophiliac’s
condition. Having two sisters with sickle cell, as in answer C, is not
information that would cause concern. Taking acetaminophen for pain, as in
answer D, is an accepted practice and does not cause concern.
16. The nurse on oncology is caring for a client with a white blood count of
800, a platelet count of 150,000, and a red blood cell count of 250,000.
During evening visitation, a visitor is noted to be coughing and sneezing.
What action should the nurse take?
A. Ask the visitor to wash his hands
B. Document the visitor’s condition in the chart
C. Ask the visitor to leave and not return until the client’s white blood cell
count is 1,000
D. Provide the visitor with a mask and gown
Answer D: The client with neutropenia should not have visitors with any
type of infection, so the best action by the nurse is to give the visitor a mask
and a gown. Asking the visitor to wash his hands is good but will not help
prevent the infection from spreading by droplets; therefore, answer A is
incorrect. Answer B is incorrect because documenting the visitor’s condition
is not enough action for the nurse to take. Answer C is incorrect because
asking the visitor to leave and not return until the client’s white blood cell
count is 1,000 is an insuffient intervention. The normal WBC is 5,000–
10,000, so a WBC of 1,000 is not high enough to prevent the client from
contracting infections.
17. The nurse is caring for the client admitted after trauma to the neck in an
automobile accident. The client suddenly becomes unresponsive and pale,
with a BP of 60 systolic. The initial nurse’s action should be to:
A. Place the client in Trendelenburg position
B. Increase the infusion of normal saline
C. Administer atropine IM
D. Obtain a crash cart
Answer B: For some clients with trauma to the neck, the answer would be A;
however, in this situation, it is incorrect because lowering the head of the bed
could further interfere with the airway. Increasing the infusion and placing
the client in supine position is better. If atropine is administered to the client,
it should be given IV, not IM, and there is no need for this action at present, as
stated in answer C. Answer D is not necessary at this time.
18. Immediately following the removal of a chest tube, the nurse would:
A. Order a chest x-ray
B. Take the blood pressure
C. Cover the insertion site with a Vaseline gauze
D. Ask the client to perform the Valsalva maneuver
Answer C: When a chest tube is removed, the hole should be immediately covered with a Vaseline
gauze to prevent air from rushing into the chest and causing the lung to collapse. The doctor, not
the nurse, will order a chest xray; therefore, answer A is incorrect. Taking the BP in answer B is
good but is not the priority action. Answer D is incorrect because the Valsalva maneuver is done
during removal of the tube, not afterward.
19. A client being treated with sodium warfarin has an INR of 9.0. Which
intervention would be most important to include in the nursing care plan?
A. Assess for signs of abnormal bleeding
B. Anticipate an increase in the dosage
C. Instruct the client regarding the drug therapy
D. Increase the frequency of neurological assessments
Answer A: The normal international normalizing ratio (INR) is 2–3. A 9
might indicate spontaneous bleeding. Answer B is an incorrect action at this
time. Answer C is incorrect because just instructing the client regarding his
medication is not enough. Answer D is incorrect because increasing the
frequency of neurological assessment will not prevent bleeding caused by the
prolonged INR.
20. Which snack selection by a client with osteoporosis indicates that the
client understands the dietary management of the disease?
A. A glass of orange juice
B. A blueberry muffin
C. A cup of yogurt
D. A banana
Answer C: The food with the most calcium is the yogurt. The others are good
choices, but not as good as the yogurt, which has approximately 400mg of
calcium. Therefore, answers A, B, and D are incorrect.
21. The elderly client with hypomagnesemia is admitted to the unit with an
order for magnesium sulfate. Which action by the nurse indicates
understanding of magnesium sulfate?
A. The nurse places a sign over the bed not to check blood pressures in the
left arm.
B. The nurse places a padded tongue blade at the bedside.
C. The nurse measures the urinary output hourly. D. The nurse darkens the
room.
Answer C: The client receiving magnesium sulfate should have a Foley
catheter in place, and the hourly intake and output should be checked
because a sign of toxicity to magnesium sulfate is oliguria. There is no need to
refrain from checking the blood pressure in the left arm, as stated in answer
A. A padded tongue blade should be kept in the room at the bedside, just in
case of a seizure, but this is not related to the magnesium sulfate infusion, so
this makes answer B incorrect. Answer D is incorrect because just darkening
the room will not prevent toxicity, although it might help with the headache
associated with preeclampsia.
22. The nurse is caring for a 10-year-old client scheduled for surgery. The
client’s mother tells the nurse that her religion forbids bloo
Version | 2022 |
Category | NCLEX(both rn and pn) |
Included files | |
Authors | qwivy.com |
Pages | 41 |
Tags | 2022/2023 NCLEX-PN Test Prep Exam 3(THREE) Questions and Answers with Explanations. |
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