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