This is part 3 of the NCLEX review questions that can serve as a reviewer for nurses planning to take the NCLEX examination. This is another multiple-choice type of questions consisting of 25-items that tests your knowledge on the basic topics in nursing such as Medical-Surgical, Fundamentals of Nursing and Pediatric Nursing.
1. The client is receiving cryotheraphy for repair of a detached retina. Which of the following symptoms should the nurse EXPECT the client to have?
b. Severe eye pain
c. Sudden blindness
d. Bright flashes of light
2. The client with a detached retina asked the nurse what may have contributed to its development. Which of the following demonstrates that the nurse understands the predisposing factors of retinal detachment?
b. Cranial tumors
3. The nurse is creating a teaching plan on Meniere’s disease. The nurse will include the following important information:
a. A labyrinthectomy is the preferred treatment for relieving symptoms and restoring hearing.
b. During an acute attack, the client’s room should be brightly lit and the side rails must be raised to provide safety.
c. Turning the head rapidly will provide comfort when the client is suffering from acute attacks and vertigo.
d. This disease is managed well by giving diuretics to the client and maintaining the client in a low-sodium diet.
4. The client is diagnosed with Bell’s Palsy. The nurse knows that the medical condition:
a. Is a unilateral inflammation of the 9th cranial nerve.
b. Is a consequence of stroke or transient ischemic attack.
c. Will present as spastic paralysis of the client’s facial muscles.
d. Is due to a lower motor neuron lesion to the 7th cranial nerve.
5. The client fell off a cliff and sustained head trauma. Fortunately, the client has no spinal cord injury. The following nursing interventions are correct measures EXCEPT:
a. Place the client in supine position.
b. Keep the head in neutral position.
c. Avoid neck and hip flexion.
d. All are correct nursing interventions.
6. The client presented with complaints of bruises in the arms and elbow after a vehicular accident. CT scan reveals a contusion in the upper left portion of the head. What is the first nursing action?
a. Continue administering the pain medication.
b. Ask if the client is feeling lethargic.
c. Increase the Intravenous Fluid flow rate.
d. Call the significant others for a stand-by assistance.
7. The client presented with complaint of blurry vision. The nurse assesses the client and noted a hole in the retina. The assessment findings that are consistent with the client’s condition are:
a. Light flashes and black spots or floaters
b. Decreased vision and abnormal color perception
c. Diminished accommodation and increased intraocular pressure
d. Presence of Scotomas and drusen in the fundus
8. The client is scheduled for cholecystectomy due to the presence of multiple gallstones. The nurse is taking the client’s past medical history and associated risk factors. Which of the following is a relevant risk factor for the development of gallstones?
a. Family history of Diabetes
b. High waist circumference
c. Enzyme deficiency
d. Medication intake
9. The client has an ongoing infection. Serum test revealed an increased concentration of IgM in the plasma. The increase of IgM (immunoglobulin M) means that the infection is:
a. Related to an allergic reaction
b. Parasitic in nature
c. In the acute phase
d. Chronic in duration
10. The nurse is assessing a client with a hematologic disorder. Which of the following nursing assessments is relevant to hematologic conditions?
a. Twin pregnancy
b. Early onset of menarche
c. Severe vomiting and diarrhea
d. Duodenum surgery
11. The client presented with complaints of sudden onset of chest pain which is described as sharp and continuous. The pain is reportedly increasing especially during inhalation and friction rub is positive. Which of the following is an appropriate nursing action?
a. Administer nitroglycerin.
b. Prepare for test tube insertion.
c. Assist client in sitting position leaning slightly forward.
d. Call the physician.
12. The client had just undergone intra-aortic balloon pump (IABP) counterpulsation to reduce the workload of ventricles and improve coronary perfusion. Which is an important nursing action when the catheter is in place ?
a. Maintain adequate hydration of the client.
b. If bleeding occurs, notify the physician.
c. Encourage active ROM exercises for the unaffected side of the body every 4 hours after the catheter is removed.
d. Inform the client not to sit upright, flex hip or bend knee.
Fundamentals of Nursing
13. The client with chest trauma after a vehicular accident has undergone subsequent intubation. The nurse is monitoring the client who is attached to a mechanical ventilator and is aware that high pressure alarms are caused by the following EXCEPT: (Select All That Apply)
a. Increased amount of secretions in the airway or a mucous plugs
b. Pneumothorax occurs
c. Decrease in lung pressure due to a change in lung or patient condition
d. Artificial airway is displaced
e. Leak in ventilator circuit
f. Client is anxious
14. The client is connected to an intact chest tube drainage system. The nurse discusses with the client the need to call the physician immediately for which of the following conditions:
a. Difficulty breathing
b. Continuous bubbling in the water seal chamber
c. Fluctuation of fluid in the water seal chamber
d. Presence of fluid in the chest tube
15. The nurse is preparing to suction the client with tracheostomy. Which of the following are appropriate nursing actions when suctioning an artificial airway? (Select All That Apply)
a. Explain to the client that sensations of shortness of breath and coughing are not normal.
b. Check suction source, occlude the suction source and adjust the dial between 80 to 120 mmHg.
c. Preoxygenate the client with 100% oxygen for 30 seconds with at least two hyperinflations.
d. While applying suction, quickly insert the suction catheter until resistance is met.
e. Use intermittent suction and a twirling motion of the catheter during withdrawal.
f. Never suction longer than 40 to 60 seconds.
16. As part of the physical assessment, the nurse is to percuss the client’s chest wall to assess pulmonary resonance. The nurse understands that there are 5 percussion notes. Which of the following indicates that the nurse correctly identified the following notes? (Select All That Apply)
a. Resonance is low pitch, moderate to loud intensity, hollow and has long duration.
b. Hyperresonance is higher than resonance in pitch, very loud intensity, booming and longer than resonance in duration.
c. Flatness is low pitch, loud intensity, extremely dull, and short duration.
d. Dullness is low pitch, medium intensity, thud-like and moderate duration.
e. Tymphany is high pitch, loud intensity, musical or drum like and short duration.
f. Dullness is the characteristic of the normal lung tissue.
17. The client verbalized feelings of frustration about abnormal blood pressure and subsequent intake of medications. The nurse tells the client: “You are frustrated and upset…” The comment of the nurse is reflective of which interview technique?
a. Reflective question
b. Open-ended question
c. Closed question
d. Clarifying question
18. The nurse on duty is gathering data from the client. Which phase in the nursing process involves problem identification and analysis of objective and subjective data?
19. The nurse conducted initial assessment to the client and noted a compromised airway. The nurse performed a head tilt-chin lift maneuver as an immediate measure for a patent airway. The nurse should be aware that the head tilt-chin lift maneuver is contraindicated in what condition?
a. Laryngeal trauma
b. Facial trauma
20. The client with multiple stab wounds and is at risk for hemorrhagic shock is rushed to the emergency department. In this situation, it is best that the nurse check blood circulation through the:
a. Radial pulse
b. Brachial pulse
c. Popliteal pulse
d. Carotid pulse
21. The client presented with complaints of tachypnea, dilated pupils, mild confusion, fatigue, and ash-like skin color. The following are immediate nursing interventions for heat exhaustion in the emergency department EXCEPT:
a. Intravenous rehydration with normal saline
b. Removal of client’s constrictive clothing
c. Placing the client in a cool area
d. Oral fluid and electrolyte replacement
22. The nurse is caring for the newborn with a Hemolytic Disease. Which of the following assessment is manifested in this disease? Select all that apply.
a. Jaundice within 24 hours appears after birth.
b. Increased WBC count in CBC result.
c. The newborn’s serum bilirubin level elevates rapidly.
d. There is a positive Coombs test result.
e. There is a decreased hematocrit level.
f. The newborn manifest cyanosis when crying.
23. The nurse is caring for the pediatric client. Upon reviewing the chart, the nurse noted that the client’s age is 7 months. Which of the following growth and development milestones is normal for this age? Select all that apply.
a. The infant can sit for a short period of time.
b. The infant can grasp a toy with a hand.
c. The infant can stand erectly with support.
d. The infant can vocalize 1 or 2 words.
e. The infant can crawl well at this age.
f. The 7 month old infant can bring hands together.
24. A mother of a 12 month old asks about the recommended toys for her child. The nurse knows that the age-appropriate toys for a 1-year old are (Select all that apply):
a. Foot-to-floor ride-on toys
b. Cradle gym
c. Push and Pull toys
d. Books with large pictures
e. Building blocks
25. The nurse is assessing a healthy term neonate post spontaneous delivery. Which of the following parameters are normal? Select all that apply.
a. The newborn’s head circumference is 37 cm.
b. An APGAR score of 8, 5 minutes after birth
c. The anterior fontanel moderately bulges when the infant is crying.
d. Presence of tiny, white, pinpoint papules on the nose and cheeks.
e. Bluish gray pigmentation found over the buttocks area.
f. Apical rate of 132 bpm upon auscultation
26. Assessing the neonate includes the different fontanels. Which of the following statements is TRUE about the anterior fontanel? Select all that apply.
a. The anterior fontanel is diamond in shape and measures approximately 2.5-4cm.
b. The anterior fontanel closes between 8-12 weeks of the newborn’s life.
c. The anterior fontanel is not easily palpated.
d. Sustained bulging of the fontanel indicates increased intracranial pressure.
e. Anterior fontanel is triangular and measures 0.5-1cm.
f. Depression of the anterior fontanel indicates dehydration.