NCLEX Admission Tests NCLEX NCLEX-PN Questions & Answers

• Question 41:

  The protrusion of an internal organ through a wound or surgical incision is referred to as __________.

  A. serosanguineous

  B. dehiscence

  C. evisceration

  D. exuded

  Correct Answer: C

  Evisceration, or the protrusion of an organ through a wound, most often occurs in the abdominal wall.

  Serosanguineous describes the thin, red exudate produced by a surgical wound and dehiscence is the

  separation of a surgical incision.

  Exuded is another name for discharged in reference to the exudate.

• Question 42:

  Select the stage of a pressure ulcer that is accurately pair with its characteristics.

  A. Stage I: Only slight blanching when pressure is applied to the skin.

  B. Stage II: The epidermis and part of the dermis is damaged or lost.

  C. Stage III: The wound has slough and eschar.

  D. Stage IV: The loss of skin usually exposes some fat.

  Correct Answer: B

  A Stage I pressure ulcer remains intact and the skin doesn't briefly lighten or blanch when touched.

  A Stage II pressure ulcer damages the epidermis and part of the dermis.

  A Stage III pressure ulcer is a deep wound that can expose some fat; and

  a Stage IV pressure ulcer exposes bone, muscle and tendons. It is also characterized with slough and

  eschar.

• Question 43:

  Your patient has been diagnosed with orchiditis.

  What information about this disorder should you inform the patient about?

  A. This disorder often occurs as the result of a streptococcus.

  B. This disorder can be symptomatically treated with ice.

  C. This disorder can be symptomatically treated with heat.

  D. This disorder is typically treated with surgery.

  Correct Answer: B

  The pain associated with orchiditis, an inflammation of the testicles, is symptomatically treated with the application of ice, not heat, to the groin area. It is not treated with surgery. This infection most often occurs as the result of mumps, the paramyxovirus and some sexually transmitted diseases, not streptococcus.

• Question 44:

  You are caring for a patient with multiple-trauma.

  Of all of these injuries and conditions, it the most serious?

  A. a deviated trachea

  B. gross deformity of a lower extremity

  C. hematuria

  D. decreased bowel sounds

  Correct Answer: A

  A deviated trachea is a serious life threatening condition.

  A deviated trachea is a symptom of tension pneumothorax which can be life threatening.

  All of the other symptoms will need to be addressed and treated, however, it is the deviated trachea that is

  the most severe and of the greatest priority.

• Question 45:

  Your long term care patient has chronic pain and at this point in time the patient needs increasing dosages to adequately control this pain.

  What is this patient most likely to be affected with?

  A. Drug addiction

  B. Drug interactions

  C. Drug side effects

  D. Drug tolerance

  Correct Answer: D

  Patients with chronic pain are often affected with drug tolerance. Drug tolerance occurs when the patient needs increasing dosages of analgesic medications to adequately control their pain in order to produce the same effect that was produced when the drug was originally begun. Drug addiction, on the other hand, is a constant and compulsive need for a drug even when the use of the drug causes harm to the person. Addiction can occur with or without physical dependence. The need for increasing dosages is not the result of medication side effects or food/drug or drug/drug interactions.

• Question 46:

  Which of the following is the best worded expected outcome?

  A. "The nurse will provide for adequate hydration"

  B. "The nurse will insure that the patient is safe"

  C. "The patient will cough and deep breath every two hours"

  D. "The patient will value health"

  Correct Answer: C

  "The patient will cough and deep breath every two hours" is the best worded expected patient outcome.

  This outcome or goal is specific, measurable, achievable, realistic, within a specified timeframe, trackable

  and it should be agreed to by the patient.

  All expected outcomes are worded in terms of what the patient, not the nurse, will do and it should also be

  specific and measurable. "The patient will value health" is not measurable.

• Question 47:

  What intervention is the best to relieve constipation during pregnancy?

  A. Increasing the consumption of fruits and vegetables.

  B. Taking a mild over-the-counter laxative.

  C. Lying flat on back when sleeping.

  D. Reduction of iron intake by half or more.

  Correct Answer: A

  Dietary roughage (or fiber) with sufficient fluids and exercise may help relieve constipation.

  Over-the-counter medications should be avoided during pregnancy.

  The supine position can place additional pressure on the aorta and vena cava, leading to vena cava

  syndrome.

  A reduction of iron supplements during pregnancy may reduce hemoglobin production and result in a less

  than an effective immune system.

• Question 48:

  The patient should be sitting when deep breathing and coughing because this position __________.

  A. is physically more comfortable for the patient

  B. helps the patient to support their incision with a pillow

  C. loosens respiratory secretions

  D. allows the patient to observe their area and relax

  Correct Answer: B

  The patient should be sitting when deep breathing and coughing because this position allows the patient to be better able to splint the incision with a pillow which provides abdominal support during coughing. It also allows the lungs to more fully expand because the diaphragm drops. The most comfortable position for the patient is the supine position; however, this position does not permit the lungs to fully expand. There is no association or correlation between loosening respiratory secretions or relaxation with this sitting position.

• Question 49:

  The recommended daily caloric intake for sedentary older men, active adult women and children is __________.

  A. 2400 calories

  B. 1600 calories

  C. 2800 calories

  D. 2000 calories

  Correct Answer: D

  Sedentary older men, active adult women and children should all have 6 ounces of grains, 21/2 cups of vegetables, 2 cups of fruits, and 3 cups of milk to help make up their 2000 calorie requirement. Sedentary adolescents require 2400 calories, sedentary women and children require 1600 calories and active adolescents need 2800 calories daily.

• Question 50:

  A nurse is teaching a client about self-administration of Haldol 15 mg po hs. For which side effects must the client seek medical attention?

  A. SOB and fatigue

  B. restlessness and muscle spasms

  C. dry mouth

  D. diarrhea

  Correct Answer: B

  Muscle spasms and restlessness are side effects of Haldol.