NCLEX Practice Test 2

31. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these? 

A)	Lymphedema and nerve palsy
B)	Hearing loss and ataxia
C)	Headaches and vomiting
D)	Abdominal mass and weakness

Review Information: The correct answer is D: Abdominal mass and weakness

Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline, weakness, pallor, anorexia, weight loss and irritability. 

 32. A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching?

A)	"I will only have to wear this for 6 months."
B)	"I should inspect my skin daily."
C)	"The brace will be worn day and night."
D)	"I can take it off when I shower."

Review Information: The correct answer is A: "I will only have to wear this for 6 months."

The brace must be worn long-term, during periods of growth, usually for 1 to 2 years. It is used to correct curvature of the spine. 

33. The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this method will

A)	Improve the quality of care
B)	Decrease staff turnover
C)	Minimize the amount of overtime payouts
D)	Improve team morale

Review Information: The correct answer is D: Improve team morale

Nurses are more satisfied when opportunites exist for autonomy and control. The nurse manager becomes the facilitator of scheduling rather than the decision-maker of the schedule when self-scheduling exists. 

34. A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?

A)	Diffuse expiratory wheezing
B)	Loose, productive cough
C)	No relief from inhalant
D)	Fever and chills

Review Information: The correct answer is A: Diffuse expiratory wheezing

In asthma, the airways are narrowed - creating difficulty getting air in and a wheezing sound. 

 35. The nurse manager hears a health care provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the health care provider's complaints. The nurse manager's next action should be to

Walk up to the health care provider and quietly state: "Stop this unacceptable behavior."

Allow the staff nurse to handle this situation without interference

Notify the of the other administrative persons of a breech of professional conduct

Request an immediate private meeting with the health care provider and staff nurse

Review Information: The correct answer is D: Request an immediate private meeting with the health care provider and staff nurse

Assertive communication respects the needs of all parties to express themselves, but not at the expense of others. The nurse manager needs first to protect clients and other staff from this display and come to the assistance of the nurse employee. 

36. A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states “I demand to be released now!” The appropriate action is for the nurse to

A)	You cannot be released because you are still suicidal.
B)	You can be released only if you sign a no suicide contract.
C)	Let’s discuss your decision to leave and then we can prepare you for discharge.
D)	You have a right to sign out as soon as we get an order from the health care provider's discharge order.

Review Information: The correct answer is C: Let’s discuss your decision to leave and then we can prepare you for discharge.

Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing the decision initially allows an opportunity for other interventions. 

37. A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition?

A)	Dyspnea
B)	Heart murmur
C)	Macular rash
D)	Hemorrhage

Review Information: The correct answer is B: Heart murmur

Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. These emboli produce symptoms of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli. Furthermore, the vegetations may travel to various organs such as spleen, kidney, coronary artery, brain and lungs and obstruct blood flow. 

 38. A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to

A)	Stabilize thermoregulation
B)	Maintain alveolar surface tension
C)	Begin normal pulmonary blood flow
D)	Regulate intracardiac pressure

Review Information: The correct answer is B: Maintain alveolar surface tension

Respiratory distress syndrome is primarily a disease related to the developmental delay in lung maturation. Although many factors may lead to the development of the problem, the central factor is the lack of a normally functioning surfactant system in the alveolar sac from immaturity in lung development since the infant is premature. 

39. An 18 year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's priority assessment should be

A)	Response to stimuli
B)	Bladder control
C)	Respiratory function
D)	Muscle weakness

Review Information: The correct answer is C: Respiratory function

Spinal injury at the C-2 level results in quadriplegia. While the client will experience all of the problems identified, respiratory assessment is a priority.  

40. The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care?

A)	Hourly urine output
B)	White blood count
C)	Blood glucose every 4 hours
D)	Temperature every 2 hours

Review Information: The correct answer is A: Hourly urine output

Clients who have had an episode of decreased glomerular perfusion are at risk for pre-renal failure. This is caused by any abnormal decline in kidney perfusion that reduces glomerular perfusion. Pre-renal failure occurs when the effective arterial blood volume falls. Examples of this phenomena include a drop in circulating blood volume as in a cardiac arrest state or in low cardiac perfusion states such as congestive heart failure associated with a cardiomyopathy. Close observation of hourly urinary output is necessary for early detection of this condition.