STAFF NURSE EXAM MODEL QUESTION PAPER PDF 08 WITH ANSWER
Sources - NCLEX-RN Practice Question Answer
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Total No. of Questions – 50
Q. 1 The nurse is caring for a client post-op femoral popliteal bypass graft. Which post-operative assessment finding would require immediate physician notification?
A. Edema of the extremity and pain at the incision site
B. A temperature of 99.6°F and redness of the incision
C. Serous drainage noted at the surgical area
D. A loss of posterior tibial and dorsalis pedis pulses
Q. 2. A client admitted with gastroenteritis and a potassium level of 2.9mEq/dL has been placed on telemetry. Which ECG finding would the nurse expect to find due to the client’s potassium results?
A. A depressed ST segment
B. An elevated T wave
C. An absent P wave
D. A flattened QRS
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Q. 3 A client is experiencing acute abdominal pain. Which abdominal assess-ment sequence is appropriate for the nurse to use for examination of the abdomen?
A. Inspect, palpate, auscultate, percuss
B. Inspect, auscultate, palpate, percuss
C. Auscultate, inspect, palpate, percuss
D. Percuss, palpate, auscultate, inspect
Q. 4. The nurse is to administer a cleansing enema to a client scheduled for colon surgery. Which client position would be appropriate?
A. Prone
B. Supine
C. Left Sim’s
D. Dorsal recumbent
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Q. 5. The nurse is caring for a client following a crushing injury to the chest. Which finding would be most indicative of a tension pneumothorax?
A. Frothy hemoptysis
B. Trachea shift toward the unaffected side of the chest
C. Subcutaneous emphysema noted at the anterior chest
D. Opening chest wound with a whistle sound emitting from the area
Q. 6. The nurse receives a report from the paramedic on four trauma victims. Which client would need to be treated first? A client with:
A. Lower rib fractures and a stable chest wall
B. Bruising on the anterior chest wall and a possible pulmonary contusion
C. Gun shot wound with open pneumothorax unstabilized
D. Dyspnea, stabilized with intubation and manual resuscitator
Q. 7. The nurse is discharging a client with asthma who has a prescription for zafirlukast (Accolate). Which comment by the client would indicate a need for further teaching?
A. I should take this medication with meals.
B. I need to report flulike symptoms to my doctor.
C. My doctor might order liver tests while I’m on this drug.
D. If I’m already having an asthma attack, this drug will not stop it.
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Q. 8 A client is 4 hours post-op left carotid endarterectomy. Which assess-ment finding would cause the nurse the most concern?
A. Temperature 99.4°F, heart rate 110, respiratory rate 24
B. Drowsiness, urinary output of 50mL the past hour, 1cm blood drainage noted on surgical dressing
C. BP 120/60, lethargic, right-sided weakness
D. Alert and oriented, BP 168/96, heart rate 70
Q. 9. The RN is making assignments on a 12-bed unit. Staff consists of one RN and two certified nursing assistants. Which client should be self-assigned?
A. A client receiving decadron for emphysema
B. A client with chest trauma and a new onset of hemoptysis
C. A client with rib fractures and an O2 saturation of 93%
D. A client 2 days post-operative lung surgery with a pulse oximetry of 92%
Q. 10. The nurse caring for a client after a suspected CVA recognizes which nursing diagnosis as the priority?
A. Impaired communication
B. Sensory perceptual alteration
C. Alteration in cerebral tissue perfusion
D. Impaired mobility
Q. 11. A client is being discharged on Coumadin after hospitalization for a deep vein thrombosis. The nurse recognizes that which food would be restricted while the client is on this medication?
A. Lettuce
B. Apples
C. Potatoes
D. Macaroni
Q.12. Which assessment finding in a client with COPD indicates to the nurse that the respiratory problem is chronic?
A. Wheezing on exhalation
B. Productive cough
C. Clubbing of fingers
D. Cyanosis
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Q. 13 A client who has just undergone a laparoscopic cholecystectomy com-plains of ―free air pain.‖ What would be your best action?
A. Ambulate the client
B. Instruct the client to breathe deeply and cough
C. Maintain the client on bed rest with his legs elevated
D. Insert an NG tube to low wall suction
14. The RN is planning client assignments. Which is the least appropriate task for the nursing assistant?
A. Assisting a COPD client admitted 2 days ago to get up in the chair
B. Feeding a client with bronchitis who is paralyzed on the right side
C. Accompanying a discharged emphysema client to the transportation area
D. Assessing an emphysema client complaining of difficulty breathing
15. When providing care for a client with pancreatitis, the nurse would anticipate which of the following orders?
A. Force fluids to 3,000mL/24 hours
B. Insert a nasogastric tube and connect it to low intermittent suction
C. Place the client in reverse Trendelenburg position
D. Place the client in enteric isolation
16. The nurse is performing a neurological assessment on a client admitted with TIAs. Assessment findings reveal an absence of the gag reflex. The nurse suspects injury to:
A. XII (hypoglossal)
B. X (vagus)
C. IX (glossopharyngeal)
D. VII (facial)
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17. The nurse arrives at a motorcycle accident and finds the client unresponsive, apneic, and pulseless. After calling for a spectator to help, what would be the nurse’s next action?
A. Ventilate with a mouth-to-mask device
B. Begin chest compressions
C. Administer a precordial thump
D. Open the airway
Q. 18 A client with gallstones and obstructive jaundice is experiencing severe itching. The physician has prescribed cholestyramine .The client asks, -How does this drug work?‖ What is the nurse’s best response?
A. It blocks histamine, reducing the allergic response.
B. It inhibits the enzyme responsible for bile excretion.
C. It decreases the amount of bile in the gallbladder.
D. It binds with bile acids and is excreted in bowel movements with stool.
Q. 19. A client with inflammatory bowel disease (IBD) requires an illeostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma?
A. Perform massage of the stoma three times a day
B. Include high-fiber foods in the diet, especially nuts
C. Limit fluid intake to prevent loose stools
D. Cleanse the peristomal skin meticulously
Q. 20. Diphenoxylate hydrochloride and atropine sulfate (Lomotil) is prescribed for the client with ulcerative colitis. The nurse realizes that the medication is having a therapeutic effect when the following is noted:
A. There is an absence of peristalsis.
B. The number of diarrhea stools decreases.
C. Cramping in the abdomen has increased.
D. Abdominal girth size increases.
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Q. 21. A nurse is assisting the physician with chest tube removal. To remove the chest tube, the client is instructed to:
A. Take a deep breath, exhale, and bear down
B. Hold the breath for 2 minutes and exhale slowly
C. Exhale upon actual removal of the tube
D. Continually breathe deeply in and out during removal
Q. 22. A client with advanced Alzheimer’s disease has been prescribed haloperidol. What clinical manifestation suggests that the client is experiencing side effects from this medication?
A. Cough
B. Tremors
C. Diarrhea
D. Pitting edema
Q. 23 A student in a cardiac unit is performing auscultation of a client’s heart. The nurse recognizes that the student is performing pulmonic auscultation correctly when the stethoscope is placed:
A. Between the apex and the sternum
B. At the fifth intercostal space at the left midclavicular line
C. At the second intercostal space, left of the sternum
D. At the manubrium
Q. 24 A client with Alzheimer’s disease has been prescribed donepezil. Which information should the nurse include in the teaching plan for a client on Aricept?
A. Take the medication with meals.
B. The medicine can cause dizziness, so rise slowly.
C. If a dose is skipped, take two the next time.
D. The pill can cause an increase in heart rate.
Q. 25 A client who had major abdominal surgery is having delayed healing of the wound. Which laboratory test result would most closely correlate with this problem?
A. Decreased albumin
B. Decreased creatinine
C. Increased calcium
D. Increased sodium
Q. 26 A client is admitted to the medical-surgical unit with a report of severe hematemesis. The nurse should give priority to:-
A. Performing an assessment
B. Obtaining a blood permit
C. Initiating an IV with a large-bore needle
D. Inserting an NG tube
Q. 27 The nurse caring for a client with a suspected peptic ulcer recognizes which exam as the one most reliable in diagnosing the disease?
A. Upper-gastrointestinal x-ray
B. Gastric analysis
C. Endoscopy
D. Barium studies
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Q.28 On the second post-operative day after a subtotal thyroidectomy, the client tells the nurse, I feel numbness and my face is twitching. What is the nurse’s best initial action?
A. Offer mouth care
B. Loosen the neck dressing
C. Notify the physician
D. Document the finding as the only action
Q. 29. A client with adult respiratory distress syndrome has been placed on mechanical ventilation with PEEP. Which finding would indicate to the nurse that the client is experiencing the undesirable effect of an increase in airway and chest pressure?
A. A PO2 of 88
B. Rales on auscultation
C. Blood pressure decrease to 90/48 from 120/70
D. A decrease in spontaneous respiration
Q. 30. A nurse is teaching a group of teenagers the correct technique for applying a condom. Which point would the nurse include in the teaching plan?
A. The condom can be reused one time.
B. Unroll the condom all the way over the erect penis.
C. Apply petroleum jelly to reduce irritation.
D. Place water in the tip of the condom before use.
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Q. 31. The nurse recognizes which of the following as the priority nursing diagnosis for the client in thyroid crisis?
A. Risk for ineffective breathing pattern
B. Risk for imbalanced body temperature
C. Risk for decreased cerebral tissue perfusion
D. Activity intolerance
Q. 32. The nurse in the ER has received report of four clients en route to the emergency department. Which client should the nurse see first? A client with:
A. Third-degree burns to the face and neck area, with singed nasal hairs
B. Second-degree burns to each leg and thigh area, who is alert and oriented
C. A chemical burn that has been removed and liberally flushed before admission
D. An electrical burn entering and leaving on the same side of the body
Q. 33 A client with epilepsy has a vagal nerve stimulator in place. Which would indicate that the device is working properly?
A. The client’s voice changes when the stimulator is operating.
B. Hiccups occur with each stimulation.
C. The client can feel vibrations in the area of the vagal nerve stimulator when operational.
D. The client’s radial pulse obliterates when the stimulator is activated.
Q. 34. Which of the following clients has the highest risk for pulmonary complications after surgery?
A. A 24-year-old with open reduction internal fixation of
the ulnar
B. A 45-year-old with an open cholecystectomy
C. A 36-year-old after a hysterectomy
D. A 50-year-old after a lumbar laminectomy
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Q. 35. What clinical manifestation is most indicative of possible carbon monoxide poisoning?
A. Pulse oximetry reading of 80%
B. Expiratory stridor and nasal flaring
C. Cherry red color to the mucous membranes
D. Presence of carbonaceous particles in the sputum
Q. 36. A client is admitted with a ruptured spleen following a four-wheeler accident. In preparation for surgery, the nurse suspects that the client is in the compensatory stage of shock because of which clinical manifestation?
A. Blood pressure 120/70, confusion, heart rate 120
B. Crackles on chest auscultation, mottled skin, lethargy
C. Skin color jaundice, urine output less than 30mL the past hour, heart rate 170
D. Rapid shallow respirations, unconscious, petechiae anterior chest
Q. 37 A client is post-operative laryngectomy for cancer of the larynx. Which nursing diagnosis would be the priority for this client?
A. Disturbed body image related to major changes in the structure and function of the larynx
B. Ineffective airway clearance related to excess mucus in air-way, due to surgical procedure
C. Imbalanced nutrition less than body requirement related to the inability to have food intake, due to dysphagia
D. Impaired verbal communication related to inability to talk, due to removal of larynx
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Q. 38. A client arrives in the emergency room with severe burns of the hands, right arm, face, and neck. The nurse needs to start an IV. Which site would be most suitable for this client?
A. Top of client’s right hand
B. Left antecubital fossa
C. Top of either foot
D. Left forearm
Q. 39. Which clinical manifestation during the actual bone marrow transplantation alerts you to the possibility of an adverse reaction?
A. Fever
B. Red urine
C. Hypertension
D. Shortness of breath
Q. 40. The nurse is assessing the integumentary system of a dark-skinned individual. Which area would be the most likely to show a skin cancer lesion?
A. Chest
B. Arms
C. Face
D. Palms
Q. 41 A client with a gastrointestinal bleed has an NG tube to low continuous wall suction. Which technique is the correct procedure for the nurse to utilize when assessing bowel sounds?
A. Insert 10mL of air in the NG tube and listen over the abdomen with a stethoscope
B. Clamp the tube while listening to the abdomen with a stethoscope
C. Irrigate the tube with 30mL of NS while auscultating the abdomen
D. Turn the suction on high and auscultate over the naval area
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Q. 42. A burn client’s care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?
A. Wound culture results that show minimal bacteria
B. Cloudy, foul-smelling urine output
C. White blood cell count of 14,000
D. Temperature of 101°F
Q. 43. The nurse is discharging a client with a prescription of eyedrops. Which observation by the nurse would indicate a need for further client teaching?
A. Shaking of the suspension to mix the medication
B. Administering a second eyedrop medication immediately after the first one was instilled
C. Washing the hands before and after the administration of the drops
D. Holding the lower lid down without pressing the eyeball to instill the drops
Q. 44. The nurse is caring for a client with pneumonia who is allergic to penicillin. Which antibiotic is safest to administer to this client?
A. Cefazolin
B. Amoxicillin
C. Erythromycin
D. Ceftriaxone
Q. 45. The nurse notes the following laboratory test results on a 24-hour post-burn client. Which abnormality should be reported to the physician immediately?
A. Potassium 7.5mEq/L
B. Sodium 131mEq/L
C. Arterial pH 7.34
D. Hematocrit 52%
Q. 46 The nurse is observing a student nurse administering ear drops to a 2-year-old. Which observation by the nurse would indicate correct technique?
A. Holds the child’s head up and extended
B. Places the head in chin-tuck position
C. Pulls the pinna down and back
D. Irrigates the ear before administering medication
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Q. 47. The nurse is caring for a client after a burn. Which assessment finding best indicates that the client’s respiratory efforts are currently adequate?
A. The client is able to talk.
B. The client is alert and oriented.
C. The client’s O2 saturation is 97%.
D. The client’s chest movements are uninhibited.
Q. 48. The nurse caring for a client in shock recognizes that the glomerular filtration rate of the kidneys will fail if the client’s mean arterial pressure falls below:
A. 140
B. 120
C. 100
D. 80
Q. 49. The nurse is caring for a child with a diagnosis of possible hydrocephalus. Which assessment data on the admission history would be the most objective?
A. Anorexia
B. Vomiting
C. Head measurement
D. Temperature
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Q. 50. Which type of leukemia is more common in older adults?
A. Acute myelocytic leukemia
B. Acute lymphocytic leukemia
C. Chronic lymphocytic leukemia
D. Chronic granulocytic leukemia
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