NCLEX Admission Tests NCLEX NCLEX-PN Questions & Answers

• Question 31:

  As you are administering penicillin intravenously, you determine that the patient becomes hypotensive and with a bounding, rapid pulse rate.

  What is the first thing that you would do?

  A. Decrease the rate of the intravenous medication flow.

  B. Increase the rate of the intravenous medication flow.

  C. Call the doctor.

  D. Stop the intravenous flow.

  Correct Answer: D

  This patient is experiencing the signs and symptoms of anaphylactic shock which is a severe life

  threatening allergic response that is often associated with a penicillin allergy or hypersensitivity.

  The first thing you should do is stop the intravenous flow and respond to this medical emergency which

  can lead to death.

  After this you should call the doctor about this episode and inform the doctor of the patient's current

  medical status.

• Question 32:

  The doctor has ordered 20 cc an hour of normal saline intravenously for your pediatric patient. You will be using a pediatric intravenous tubing that delivers 60 cc per drop.

  How many drops per minute will you administer using this pediatric intravenous set?

  A. 30 drops per minute

  B. 25 drops per minute

  C. 20 drops per minute

  D. 22 drops per minute

  Correct Answer: C

  You would adjust the intravenous fluid rate to deliver 20 drops of the normal saline every minute.

• Question 33:

  A cavity containing pus surrounded by inflamed tissue is __________.

  A. cellulitis

  B. an abscess

  C. extravasation

  D. an adhesion

  Correct Answer: B

  A cavity containing pus surrounded by inflamed tissue is an abscess. An abscess is typically formed as a

  result of suppuration in a localized infection.

  Cellulitis is an infection of the skin characterized by heat, pain, erythema, and edema.

  Extravasation is the passage, or escape of blood, serum, or lymph fluids into the tissues.

  A band of scar tissue that binds together two surfaces that are typically separated is an adhesion.

• Question 34:

  During which stage of anesthesia is a patient most likely to experience involuntary motor activity?

  A. Stage I

  B. Stage II

  C. Stage III

  D. Stage VI

  Correct Answer: B

  Stage II, commonly referred to as the excitement stage, is the stage of anesthesia when the patient is most

  likely to experience involuntary motor activity period; at this time, auditory and physical stimuli must be

  avoided to reduce the risk of increased tachycardia during this stage.

  Stage I is the administration phase, Stage III is the surgical phase, and Stage IV is the cessation phase.

• Question 35:

  The doctor has ordered 1,000 cc of intravenous fluid every 8 hours. You will be using intravenous tubing that delivers 20 cc/drop.

  At what rate will you adjust the intravenous fluid flow?

  _____ gtts per minute.

  A. 38 gtts/min

  B. 42 gtts/min

  C. 50 gtts/min

  D. 40 gtts/min

  Correct Answer: B

• Question 36:

  Select the stage of shock that is accurately paired with its characteristic.

  A. The initial stage of shock: Hyperventilation occurs and the blood pH rises.

  B. The compensatory stage of shock: Hypoxia occurs and lactic acid rises.

  C. The progressive stage of shock: Histamine is released; fluid and proteins leak into surrounding tissues and the blood thickens.

  D. The refractory stage of shock: Potassium ions leak out, sodium ions build up and metabolic acidosis increases.

  Correct Answer: C

  During the progressive stage of shock, histamine is released, fluid and proteins leak into surrounding

  tissues and the blood thickens. The initial stage of shock is marked with hypoxia and an increase in lactic

  acid; the compensatory stage of shock is characterized with hyperventilation and rises in the blood pH.

  The progressive stage of shock is also characterized with the leakage of potassium ions, the buildup of

  sodium ions and increasingly more severe metabolic acidosis.

  The refractory, or final, stage of shock becomes irreversible.

• Question 37:

  An episiotomy is __________.

  A. a surgical incision of the perineum to prevent tearing during delivery

  B. releasing the red plug from the cervix just before crowning occurs

  C. an incision in the abdomen with which the baby can be delivered through

  D. the severance of the umbilical cord between mother and child

  Correct Answer: A

  An episiotomy is a surgical incision of the perineum and the posterior vaginal wall to quickly enlarge the

  opening for the baby to pass through; this incision prevents tearing during a vaginal delivery.

  The releasing of the red plug is known as the bloody show.

  The baby delivered through an incision in the abdomen is a Caesarian delivery.

  Umbilical severance or cutting and clamping of the cord both apply to the procedure of separating mother

  and child after childbirth.

• Question 38:

  Which of the following is best for a client who has difficulty swallowing and chokes frequently?

  A. A liquid diet.

  B. Tilting the head back when swallowing.

  C. Tucking the chin in when swallowing.

  D. Following each bite with a drink of water.

  Correct Answer: C

  The client should tuck the chin when swallowing rather than tilting the head back. Thin fluids and liquids,

  like water, are thickened prior to drinking to prevent chocking.

  Tilting the head back is dangerous.

• Question 39:

  Which type of burn leads to the greatest degree of pain?

  A. A first degree burn

  B. A second degree burn

  C. A third degree burn

  D. A fourth degree burn

  Correct Answer: B

  Although the first degree burn can cause pain, it is the second degree burn that is the most painful of all. There is a lack of pain with third and fourth degree burns because these burns have destroyed pain sensory nerves.

• Question 40:

  Sutures and staples are typically removed following surgery within __________.

  A. 7 to 10 days if healing is considered adequate

  B. 10 to 14 days if healing is considered adequate

  C. 7 to 10 days if no further dressings are needed

  D. 10 to 14 days if no further dressings are needed

  Correct Answer: A

  Sutures and staples can be removed within 7 to 10 days if healing has been sufficient and while this removal tends to reduce the amount of dressing supplies needed after removal, a light dressing may still be necessary.