NCLEX exam 2020

 

1.          A 52- year- old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 lbs. Her vital signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8 degrees Celsius, and oxygen saturation of 94%. She is receiving oxygen at 2L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy.

A.          Temperature: 37 degrees Celsius

B.          Radial pulse: 112

C.          Respiratory Rate: 24

D.          Oxygen Saturation: 96%

E.          Blood pressure: 134/ 78

2.          The licensed practical nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first?

A.          84- year old man recently admitted with pneumonia, RR 28, SPO2 89%

B.          54-year- old woman admitted after surgery for fractured arm, BP 160/86 mm Hg, HR 72.

C.          63- year-old man with venous ulcers from diabetes, temperature 37.3 degrees Celsius, HR 84

D.          77- year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62

3.          A 55-year-old female patient was in a motor vehicle accident and is admitted to a surgical unit after repairs of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. Which sites do you instruct the nursing assistant to use for obtaining the patient’s blood pressure and temperature?

A.          Right antecubital and tympanic

B.          Right popliteal and rectal

C.          Left antecubital and oral

D.          Left popliteal and temporal artery

4.          The nurse observes a nursing student taking a blood pressure (BP) on a patient. The nurse notes that the student very slowly deflates the cuff in an attempt to hear the sounds. The patient’s BP range over the past 24 hour is 132/64 to 126/72 mm Hg. Which of the following BP readings made by the student is most likely caused by an incorrect technique?

A.          96/ 40

B.          110/66

C.          130/90

D.          156/82

5.          As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail. And she asks you why her nail polish had to be removed. What is the best response?

A.          Nail polish attracts microorganisms and contaminates the finger sensor.

B.          Nail polish increases oxygen saturation.

C.          Nail polish interferes with sensor function.

D.          Nail polish creates excessive heat in sensor probe.

6.          A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical records indicates tympanic temperatures of 38.7 degrees Celsius (0400), 36.6 degrees Celsius (0800),  36.9 degrees Celsius (1200), 37.6 degrees Celsius (1600) and 38.3 degrees Celsius (2000). How would you describe this pattern of temperature of measurements?

A.          Usual range of the circadian rhythm measurements

B.          Sustained fever pattern

C.          Intermittent fever pattern

D.          Resolving fever pattern

7.          A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a slow but regular radial pulse of 44. What is your priority intervention?

A.          Request that the nursing assistant repeat the pulse check

B.          Call for a stat electrocardiogram (ECG)

C.          Assess the patient’s apical pulse and evidence of a pulse deficit

D.          Prepare to administer cardiac- stimulating medications

8.          Which patient is at risk for tachycardia?

A.          A healthy basketball player during warmup exercises

B.          A patient admitted with hypothermia

C.          A patient with a fever of 39.4 degrees Celsius

D.          A 90 year old male taking bet blockers 

9.          Which of the following patients are at most risk for tachypnea? (Select all that apply)

A.          Patient admitted with four rib fractures

B.          Woman who is 9 months’ pregnant

C.          Adult who has consumed alcoholic beverages

D.          Adolescent waking from sleep

E.          Three-pack-per-day smoker with pneumonia

10.        Which number marks the location where you would auscultate the point og maximal impulse (PMI)?

A.          1

B.          2

C.          3

D.          4

E.          5

F.           6

11.        A patient has been admitted for a cerebrovascular accident (stroke). She cannot mover her right arm, and she has a right-sided facial droop. She is able to eat with her dentures in place and swallow safely. The nursing assistant personnel (NAP) reports to you that the patient will not keep the oral thermometer probe in her mouth. What direction do you provide to the NAP?

A.          Direct the NAP to hold the thermometer in place with her gloved hand

B.          Direct the NAP to switch thermometer probe to the left sublingual pocket

C.          Direct the NAP to obtain a right tympanic temperature

D.          Direct the NAP to use a temporal artery thermometer from right to left

12.        The nursing assistive personnel (NAP) reports to you that the blood pressure (BP) of the patient in question 11 is 140/76 on the left arm and 128/72 on the right arm. Which action do you take on the basis of this information? (Select all that apply).

 

A.          Notify the health care provider immediately

B.          Repeat the measurements on both arms using a stethoscope

C.          Ask the patient if she has taken her blood pressure medications recently

D.          Obtain blood pressure measurements on lower extremities

E.          Verify that the correct cuff size was used during the measurements

F.           Review the patients’ record’s for her baseline vital signs

G.          Compare right and left radial pulses for strength

13.        The nursing assistive personnel (NAP) informs you that the electronic blood pressure machine on the patient  who has recently returned from surgery following removal of her gallbladder is flashing a blood pressure of 65/46 and alarming. Place your care activities in priority order.

A.          Press the start button of the electronic blood pressure machine to obtain a new reading

B.          Obtain a manual blood pressure with a stethoscope

C.          Check the patient’s pulse distal to the blood pressure cuff.

D.          Assess the patient’s mental status

E.          Remind the patient not to bend her arm with the blood pressure cuff

D, A, C, B, E

14.        A healthy adult patient tells the nurse that he obtained his blood pressure on “one of those quick machines in the mall” and was alarmed that it was 152/72 when his normal value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/67. What would account for the blood pressure of 152/92? (Select all that apply)

A.          Cuff too small

B.          Arm position above heart level

C.          Slow inflation of the cuff by the machine

D.          Patient did not remove his long sleeve shirt

E.          Insufficient time between measurements

15.        A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant reports his admitting vital signs to the nurse. Which measurements should the nurse reassess? (Select all that apply)

A.          Right arm BP: 118/72

B.          Radial pulse rate: 72 and irregular

C.          Temporal Temperature: 37.4 degrees Celsius

D.          Respiratory rate: 28

E.          Oxygen saturation: 98%

 

Potter, P.A., Perry, A. G., Hall, A., & Stockert, P.A. (2017). Fundamentals of nursing. Ninth edition. St. Louis, MO.: Mosby Elsevier pages 530-531

 

16.        What is the most effective way to control transmission of infection?

A.          Isolation precautions

B.          Identifying the infectious agent

C.          Hand hygiene practices

D.          Vaccinations

17.        A patient who has been isolated for Clostridium difficile (C.diff) asks you to explain what he should know about this organism. What is the most appropriate information to include in patient teaching?

SELECT ALL THAT APPLY.

A. The organism is usually transmitted through the fecal oral route.

B. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer.

C. Everyone coming into the room must be wearing a gown and gloves.

D. While the patient is in contact precautions, he cannot leave the room.

E. C diff dies quickly outside the body.

18.        Your assigned patient has a leg ulcer that has a dressing on it. During your assessment you find that the dressing is saturated with purulent drainage. Which action would be best on your part?

A. Reinforce dressing with a clean, dry dressing and call the health care provider.

B. Remove wet dressing and apply new dressing using sterile procedure.

C. Put on gloves before removing the old dressing; then obtain a wound culture.

D. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing.

19.        A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Which type of isolation precaution is most appropriate for this patient?

A. Reverse isolation

B. Droplet precautions

C. Standard precautions

D. Contact precautions

20.        A family member is providing care to a loved one who has an infected leg wound. What would you instruct the family member to do after providing care and handling contaminated equipment or organic material?

A. Wear gloves before eating or handling food.

B. Place any soiled materials into a bag and double bag it.

C. Have the family member check with the health care provider about need for immunization.

D. Perform hand hygiene after care and/or handling contaminated equipment or material.

21.        A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention?

A. Provide a dark, quiet room to calm the patient.

B. Reduce the level of precautions to keep the patient from becoming angry.

C. Explain the reasons for isolation procedures and provide meaningful stimulation.

D. Limit family and other caregiver visits to reduce the risk of spreading the infection.

22.        When should a nurse wear a mask? (Select all that apply).

A The patient's dental hygiene is poor.

B The nurse is assisting with an aerosolizing respiratory procedure such as suctioning.

C The patient has acquired immunodeficiency syndrome (AIDS) and a congested cough.

D The patient is in droplet precautions.

E The nurse is assisting a health care provider in the insertion of a central line catheter.

23.        Which type of personal protective equipment are staff required to wear when caring for a pediatric patient who is placed into airborne precautions for confirmed chicken pox/herpes zoster? (Select all that apply.)

A Disposable gown

B N 95 respirator mask

C Face shield or goggles

D Surgical mask

E Gloves

24.        The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing health care-acquired infections? (Select all that apply.)

A Teaching correct hand washing to assigned patients

B Using correct procedures in starting and caring for an intravenous infusion

C Providing perineal care to a patient with an indwelling urinary catheter

D Isolating a patient who has just been diagnosed as having tuberculosis

E Decreasing a patient's environmental stimuli to decrease nausea

25.        Which of the following actions by the nurse comply with core principles of surgical asepsis? (Select all that apply.)

A Set up sterile field before patient and other staff come to the operating suite.

B Keep the sterile field in view at all times.

C Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated.

D Only health care personnel within the sterile field must wear personal protective equipment.

E The sterile gown must be put on before the surgical scrub is performed.

26.        A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? (Select all that apply.)

A It allows migration of organisms into the bladder.

B The insertion procedure is not done under sterile conditions.

C It obstructs the normal flushing action of urine flow.

D It keeps an incontinent patient's skin dry.

E The outer surface of the catheter is not considered sterile.

27.        What is the correct order of steps for removal of protective barriers after leaving an isolation room?

1. Remove gloves.

2. Perform hand hygiene.

3. Remove eyewear or goggles.

4. Untie top and then bottom mask strings and remove from face.

5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side.

1,3,5,4,2

28.        What does it mean when a patient is diagnosed with a multidrug-resistant organism in his or her surgical wound? (Select all that apply.)

A There is more than one organism in the wound that is causing the infection.

B The antibiotics the patient has received are not strong enough to kill the organism.

C The patient will need more than one type of antibiotic to kill the organism.

D The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively.

E There are no longer any antibiotic options available to treat the patient's infection.

29.        A patient's surgical wound has become swollen, red, and tender. You note that the patient has a new fever, purulent wound drainage, and leukocytosis. Which interventions would be appropriate and in what order?

1. Notify the health care provider of the patient's status.

2. Reassure the patient and recheck the wound later.

3. Support the patient's fluid and nutritional needs.

4. Use aseptic technique to change the dressing.

4,2,1,3

30.        Which of these statements are true regarding disinfection and cleaning? (Select all that apply.)

A Proper cleaning requires mechanical removal of all soil from an object or area.

B General environmental cleaning is an example of medical asepsis.

C When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound.

D Cleaning in a direction from the least to the most contaminated area helps reduce infections.

E Disinfecting and sterilizing medical devices and equipment involve the same procedures.

 

Potter, P.A., Perry, A. G., Hall, A., & Stockert, P.A. (2017). Fundamentals of nursing. Ninth edition. St. Louis, MO.: Mosby Elsevier pages 483-484

 

31.        What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? (Select all that apply).

A. Prone position

B. Sims' position

C. Semi-Fowler's position with head to side

D. Trendelenburg position

E. Supine position

32.        The student nurse is teaching a family member the importance of foot care for his or her mother, who has diabetes. Which safety precautions are important for the family member to know to prevent infection? (Select all that apply).

A. Cut nails frequently.

B. Assess skin for redness, abrasions, and open areas daily.

C. Soak feet in water at least 10 minutes before nail care.

D. Apply lotion to feet daily.

E. Clean between toes after bathing.

33.        A nurse uses long firm, strokes distal to proximal while bathing a patient's legs because:

A. It promotes venous circulations.

B. It covers a larger area of the leg.

C. It completes care in a timely fashion.

D. It prevents blood clots in legs.

34.        Integrity of the oral mucosa depends on salivary secretion. Which of the following factors impairs salivary secretion? (Select all that apply).

A. Use of cough drops

B. Immunosuppression

C. Radiation therapy

D. Dehydration

E. Presence of oral airway

35.        A nurse is assigned to care for the following patients. Which of the patients is most at risk for developing skin problems and thus requiring thorough bathing and skin care?

A. A 44-year-old female who has had removal of a breast lesion and is having her menstrual period.

B. A 56-year-old male patient who is homeless and admitted to the emergency department with malnutrition and dehydration and who has an intravenous line.

C. A 60-year-old female who experienced a stroke with right-sided paralysis and has an orthopedic brace applied to the left leg.

D. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool.

36.        When you are assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should you perform before the procedure? (Select all that apply).

A. Oxygen saturation

B. Heart rate

C. Respirations

D. Gag reflex

E. Response to painful stimulus

37.        A nurse is listening to a student provide instruction to a patient who is having difficulty with activities needed to care for soft contact lenses. Which of the following statements by the nursing student might require some correction by the nurse?

A. Use tap water to clean soft lenses.

B. Follow recommendations of lens manufacturer when inserting the lenses.

C. Keep lenses moist or wet when not worn.

D. Use fresh solution daily when storing and disinfecting lenses.

 

38.        The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care: (Select all that apply).

A. Use antimicrobial toothpaste.

B. Brush teeth 4 times a day.

C. Use 0.12% chlorhexidine gluconate (CHG) oral rinses.

D. Use a soft toothbrush for oral care.

E. Avoid cleaning the gums and tongue.

39.        While planning morning care, which of the following patients would have the highest priority to receive his or her bath first?

A. A patient who just returned to the nursing unit from a diagnostic test.

B. A patient who prefers a bath in the evening when his wife visits and can help him.

C. A patient who is experiencing frequent incontinent diarrheal stools and urine.

D. A patient who has been awake all night because of pain 8/10.

40.        An 88-year-old patient comes to the medical clinic regularly. During a recent visit the nurse noticed that the patient had lost 10 lbs in 6 weeks without being on a special diet. The patient tells the nurse that he has had trouble chewing his food. Which of the following factors are normal aging changes that can affect an older adult's oral health? (Select all that apply).

A. Dentures do not always fit properly.

B. Most older adults have an increase in saliva secretions.

C. With aging the periodontal membrane becomes tighter and painful.

D. Many older adults are edentulous, and remaining teeth are often decayed.

E. The teeth of elderly patients are more sensitive to hot and cold.

41.        A patient with a malignant brain tumor requires oral care. The patient's level of consciousness has declined, with the patient only being able to respond to voice commands. Place the following steps in the correct order for administration of oral care.

A. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway.

B. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up to 30 degrees.

C. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first.

D. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity.

E. Remove partial plate or dentures if present.

F. Gently brush tongue but avoid stimulating gag reflex.

B,E,A,C,F, and D

42.        The nurse delegates needed hygiene care for an elderly stroke patient. Which intervention would be appropriate for the nursing assistive personnel to accomplish during the bath?

A. Checking distal pulses.

B. Providing range-of-motion (ROM) exercises to extremities.

C. Determining type of treatment for stage 1 pressure ulcer.

D. Changing the dressing over an intravenous site.

 

43.        The nurse observes an adult Middle Eastern patient attempting to bathe himself with only his left hand. The nurse recognizes that this behavior likely relates to:

A. Obsessive compulsive behavior.

B. Personal preferences.

C. The patient's cultural norm.

D. Controlling behaviors.

44.        When a nurse delegates hygiene care for a male patient to a nursing assistive personnel, the NAP must use an electric razor to shave the patient with the following diagnosis:

A. Congestive heart failure.

B. Pneumonia.

C. Arthritis.

D. Thrombocytopenia.

45.        A patient receiving chemotherapy experiences stomatitis. The nurse advises the patient to use:

A. Community mouthwash.

B. Alcohol-based mouth rinse.

C. Normal saline rinse.

D. Firm toothbrush.

 

Potter, P.A., Perry, A. G., Hall, A., & Stockert, P.A. (2017). Fundamentals of nursing. Ninth edition. St. Louis, MO.: Mosby Elsevier pages 868-869

 

46.        Two patient deaths have occurred on a medical unit in the last month. The staff notices that everyone feels pressured and team members are getting into more arguments. As a nurse on the unit, what will best help you manage this stress?

A. Keep a journal

B. Participate in a unit meeting to discuss feelings about the patient deaths

C. Ask the nurse manager to assign you to less difficult patients

D. Review the policy and procedure manual on proper care of patients after death

47.        A nurse has seen many cancer patients struggle with pain management because they are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping patients focus on their values and beliefs about pain control, a nurse can best make clinical decisions. This is an example of:

A. Creativity.

B. Fairness.

C. Clinical reasoning.

D. Applying ethical criteria.

48.        A nurse prepares to insert a Foley catheter. The procedure manual calls for the patient to lie in the dorsal recumbent position. The patient complains of having back pain when lying on her back. Despite this, the nurse positions the patient supine with knees flexed as the manual recommends and begins to insert the catheter. This is an example of:

A. Accuracy.

B. Reflection.

C. Risk taking.

D. Basic critical thinking.

49.        A nurse is preparing medications for a patient. The nurse checks the name of the medication on the label with the name of the medication on the doctor's order. At the bedside the nurse checks the patient's name against the medication order as well. The nurse is following which critical thinking attitude:

A. Responsible

B. Complete

C. Accurate

D. Broad

50.        By using known criteria in conducting an assessment such as reviewing with a patient the typical characteristics of pain, a nurse is demonstrating which critical thinking attitude?

A. Curiosity

B. Adequacy

C. Discipline

D. Thinking independently