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nclex practice testPHYSIOLOGICAL INTEGRITY QUESTIONS

  1. Which assignment should not be performed by a licensed practical nurse (LPN)? 
  1. Discontinue a nasogastric tube
  2. Start a blood transfusion
  3. Insert a Foley catheter
  4. Obtain a sputum specimen
  1. You are the nurse caring for an infant that was admitted from the delivery room.  Which finding should you report?
  1. absent femoral pulses
  2. acrocyanosis
  3. halequin sign
  4. acyanosis
  1. A 71-yr-old male client is recovering from a stroke and exhibits signs of unilateral neglect.  Which of the following supports this suspicion? 
  1. The client is unable to distinguish between two tactile stimuli presented simultaneously
  2. The client is unable to carry out cognitive and motor activity at the same time
  3. The client is observed shaving only one side of his face
  4. The client is unable to complete range of vision assessment without turning his head side to side.
  1. A child with an ankle sprain is being discharged from the emergency room. To promote tissue healing and relieve discomfort, the nurse instructs the parents to: 
  1. Apply cold compress to the affected area
  2. Keep the extremity in a dependent position
  3. Apply a hot compress to the affected area
  4. Restrict activity until there is no swelling to the affected area
  1. Which of the following statements made by a mother of an-eight-month-old infant would concern the nurse? My baby: 
  1. Cries all day at the sitter’s
  2. Is teething and therefore running a fever
  3. Doesn’t pay much attention to loud noises
  4. Throws both arms forward when held
  1. A 12-year-old client has a PICC line inserted for home IV therapy. To confirm proper PICC line placement, which of the following should the nurse anticipate doing immediately following insertion? 
  1. Aspirating for venous blood return
  2. Auscultating the site for a bruit
  3. Taking the child for a chest x-ray
  4. Measuring the catheter’s external length

7. You are performing discharge teaching for a ten-year-old client who has been diagnosed with sickle cell anemia. Which of the following  interventions is it important to stress to the child and the family? 

  1. Increase fluid intake
  2. Increase fat intake
  3. Closely monitor bowel movements
  4. Serve leafy green vegetable daily
  1. A 2-yr-old child with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To get the most pertinent information about the child’s symptoms, the nurse should ask his mother: 
  1. Does your child’s ear hurt?
  2. Does your child have any hearing problems?
  3. Does your child tug at either ear?
  4. “Does anyone in your family have hearing problems?
  1. A nine-month-old infant with acquired immunodeficiency syndrome (AIDS) is admitted with pneumonia. In addition to the antibiotics he will be receiving via IV, Dr. Williams orders the following for the infant. Which of these orders should the nurse question?
  1. Vital signs with rectal temperature every four hours
  2. Flush the intravenous saline lock after meds and p.r.n.
  3. Check oxygen saturation (oximetry) every shift and p.r.n.
  4. Obtain a CBC (complete blood cell count) with differential
  1. Nurses are mandatory reporters of any suspected child abuse. The most important observation by the nurse that can be used as a basis for reporting suspected abuse is: 
  1. Inconsistency between the history and the injury
  2. Visible bruises on the child
  3. A caregiver brings the child to the clinic instead of a parent
  4. The child is crying inconsolably while being held by the parent
  1. Nurse Lyndall knows which of the following is an inappropriate statement regarding preterm infant’s need for large amounts of fluids? The preterm infant: 
  1. Is unable to concentrate urine
  2. Has a large body water content
  3. Requires extra essential amino acids
  4. Has large amounts of evaporation of body water
  1. A 4-month-old is brought to the clinic for a wellness checkup. Which immunizations should the infant receive? 
  1. Diphtheria, tetanus toxoids, and acellular pertussis (DTaP), inactivated polio virus (IPV), rotavirus, and measles-mumps-rubella (MMR)
  2. Haemophilus influenzae type B (Hib), rotavirus, DTaP, and IPV
  3. DTaP, IPV, Hib, and hepatitis B
  4. DTaP, hepatitis B, Hib, and varicella
  1. The father of a 4-year-old child tells the nurse that his child is a very poor eater. What is the best recommendation for helping to increase the child’s nutritional intake? 
  1. Allow the child to feed herself
  2. Use specially designed dishes for children — for example, a plate with the child’s favorite cartoon character
  3. Only serve the child’s favorite foods
  4. Allow the child to eat at a small table and chair by herself
  1. A 13-year-old client with asthma is instructed in the use of a peak flow meter to assist with home management of the disease. The nurse knows that the purpose of the peak flow meter is to enable the client to: 
  1. Detect airway obstruction before the onset of manifestations
  2. Take deep breaths every one to two hours
  3. Accurately adjust the delivery rate of oxygen
  4. Breathe deeper when using metered dose inhalers
  1. What is the minimal apical pulse the nurse should obtain prior to administering digoxin (Lanoxin) to a hospitalized five-year-old?

a. 60

b. 70

c. 100

d. 120

  1. A child with asthma is brought to the emergency room with audible wheezing and difficulty breathing. The initial action by the nurse is to: 
  1. Give epinephrine intramuscularly
  2. Place the child in a mist tent
  3. Administer aminophylline intravenously
  4. Provide oxygen via mask
  1. A 6-month-old infant is brought to the clinic for a well-baby visit. The mother reports that the infant weighed 7 lbs. at birth. Based on the nurse’s knowledge of infant weight gain, which current weight would be within the normal range for this infant? 
  1. 14 lbs.
  2. 21 lbs.
  3. 10.5 lbs.
  4. 17.5 lbs.
  1. Nurse Susan is concerned that another nurse’s relationship with the members of a family and their ill preschooler may be inappropriate. Which of the following behaviors would be most worrisome and should be brought to the attention of the nurse-manager? 
  1. The nurse keeps communication channels open among herself, the family, physicians, and other health care providers
  2. The nurse attempts to influence the family’s decisions by presenting her own thoughts and opinions
  3. The nurse works with the family members to find ways to decrease their dependence on health care providers
  4. The nurse has developed teaching skills to instruct the family members so they can accomplish tasks independently
  1. A child in shock has been brought to the clinic The initial nursing action to promote ventilation for the child is to:
  1. Establish an airway
  2. Assess the respiratory rate
  3. Obtain arterial blood gases (ABGs)
  4. Monitor the blood pressure
  1. Nurse Thomas knows that children who receive diphtheria, tetanus, and pertussis (DPT) injections on a regular basis have obtained which of the following: 
  1. Naturally acquired active immunity
  2. Artificially acquired active immunity
  3. Naturally acquired passive immunity
  4. Artificially acquired passive immunity
  1. Nurse Grace understands that a toddler should begin to scribble spontaneously with a crayon at what age? 
  1. Twelve months
  2. Eighteen months
  3. Twenty-four months
  4. Twenty-eight months
  1. Intraosseous drug administration is typically used when a child is: 
  1. under age 3
  2. over age 3
  3. critically ill and under age 3
  4. critically ill and over age 3
  1. The nurse becomes concerned when observing a two-year-old girl admitted to the hospital, because the child: 
  1. Is not yet potty trained
  2. Replies no to every question
  3. Cannot share toys
  4. Recognizes four to six words
  1. Which of these actions, would best relieve a toddler’s anxiety if his parents must leave the hospital while he is hospitalized? 
  1. Ask the parents to leave one of their possessions with the toddler
  2. Place the toddler in a room with a two-year-old
  3. Place the toddler in a room near the nurses’ station
  4. Have a hospital volunteer visit the toddler
  1. A pediatric patient is found to have a mildly elevated serum lead level.  The nurse knows to instruct the parents in the need to provide the child with a diet that is: 
  1. High in iron
  2. Low in calcium
  3. High in fat
  4. Low in fiber

ANSWERS

  1. The correct answer is B. The LPN cannot start a blood transfusion; this assignment requires a registered nurse. Answers A, C, and D are all duties that a LPN can perform, and are therefore incorrect.
  2. The correct answer is A. Absent femoral pulses indicate coarctation of the aorta. This defect causes strong bounding pulses and elevated blood pressure in the upper body, and low blood pressure in the lower extremities. Answers B, C, and D are incorrect because they are normal findings in the newborn.
  3. The correct answer is C. The client with unilateral neglect will neglect one side of the body. Answers A, B, and D are not associated with unilateral neglect.
  4. The correct answer is A. Cold minimizes swelling and erythema to the affected area. However, cold compresses should not be applied continuously for more than 30 minutes.
  5. The correct answer is B. The process of teething is a normal physiological development and does not cause an elevation in body temperature. If an infant has a fever, there is an infectious process occurring in the body.
  6. The correct answer is C. A chest x-ray will confirm that the PICC line is properly situated in the superior vena cava.
  7. The correct answer is A. Due to the viscosity of the blood cells as they change shape during a crisis, the child needs to increase fluid intake to help prevent dehydration.
  8. The correct answer is C. Although all of the options are appropriate questions to ask when assessing a young child’s ear problems, questions about the child’s behavior are most useful because a young child usually can’t describe symptoms accurately.
  9. The correct answer A. This question asks you to identify a physician’s order that would be inappropriate for this client. Rectal temperatures should never be done on any client who is immuno-compromised. This order would require clarification.
  10. The correct answer is A. A lack of consistency indicates inappropriate injuries for the given history. When the history does not match the injury, other causes such as abuse should be suspected.
  11. The correct answer is C. Preterm infants do not require extra essential amino acids. Due to the immaturity of preterm infants, they have difficulty metabolizing protein. Therefore, increased protein intake can cause increased essential amino acids.
  12. The correct answer is C. DTaP, IPV, Hib, and hepatitis B are administered at ages 2 and 4 months.
  13. The correct answer is A. The best recommendation is to allow the child to feed herself because the child’s stage of development is the preschool period of initiative. It’s important to offer new foods and choices, not just serve her favorite foods. Using a small table and chair would enhance the primary recommendation
  14. The correct answer is A. The peak flow meter is used by clients with asthma to monitor airway resistance to air flow. If a patient knows his own personal norm or what is his best effort, he can recognize changes from the norm and increase the use of prophylactic measures. If the change from the norm is severe, the client will recognize the need to notify his physician or seek emergency care.
  15. The correct answer is B. A five-year-old needs to have an apical pulse rate of at least a 70 before digoxin can be administered. This medication slows the heart rate, and the normal heart rate of a five-year-old is between 70 and 100 beats per minute.
  16. The correct answer is A. The drug most frequently prescribed is epinephrine. Epinephrine provides rapid bronchodilation that will increase the diameter of the airways and increase the flow of air through the bronchi.
  17. The correct answer is A. Birth weight typically doubles by age 6 months and triples by age 12 months. Therefore, an infant who weighed 7 lbs. at birth should weigh 14 lbs. at age 6 months.
  18. The correct answer is B. When a nurse attempts to influence a family’s decision with her own opinions and values, the situation becomes one of over-involvement on the nurse’s part and a nontherapeutic relationship.
  19. The correct answer is A. Establishing an airway is always the initial priority. The airway must be maintained for adequate ventilation.
  20. The correct answer is B. Vaccines offer artificially acquired active immunity. A small amount of a microorganism is injected into the host to cause the host to form antibodies for a disease.
  21. The correct answer is B. At eighteen months of age, fine motor skills should be developed well enough to allow the toddler to begin to hold a crayon and scribble. If an eighteen-month-old cannot scribble, further developmental assessment is needed.
  22. The correct answer is C. In an emergency, intraosseous drug administration is typically used when a child is critically ill and under age 3.
  23. The correct answer is D. A two-year-old should have a 300 word vocabulary. A four to six word vocabulary could indicate a health issue such as hearing loss.
  24. The correct answer is A. When family members are unable to stay at the hospital, the toddler will probably feel frightened and alone and may feel abandoned. If the parents leave something that belongs to them, the toddler will feel more secure.
  25. The correct answer is A. Diets low in iron and calcium and high in fat have been shown to increase lead absorption in children exposed to a high-lead environment. Iron deficiency is especially problematic in these children. The diet should be also be high in iron because many children with lead poisoning are anemic because lead is extremely toxic to the biosynthesis of hemoglobin.

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