These questions are one of the NCLEX prep samples for Physiological Adaptation. This post has a 15 set of questions with the accompanying answers and rationale located at the bottom. If you want to answer all of our NCLEX questions interactively then be one of our member today. Click here to join. It’s Free.
1. A homeless individual is brought to the Emergency Room after having been out in subfreezing temperatures for three to four days. The toes of the patient’s right foot appear hard and cold with mottling, and are unresponsive to touch. Which of the following would NOT be included in the initial management of this patient by the Emergency Room nurse:
a. Rewarm the extremity with controlled and rapid rewarming until the injured part flushes
b. Wrap the affected extremity in a blanket and apply moist heat
c. Place sterile gauze between the affected digits
d. Elevate the affected extremity
2. An elderly client has sustained an intertrochanteric fracture of the hip and has just returned from surgery where a nailplate was inserted for internal fixation. The client has been instructed that she should not flex her hip. The best explanation of why this movement would be harmful is
a. Displacement can occur with flexion.
b. The soft tissue around the site will be damaged.
c. It will be very painful for the client.
d. It will pull the hip out of alignment.
3. Following a Vasectomy, a patient notices discoloration of the scrotal area and becomes alarmed. In responding to the patient’s concern the nurse should:
a. Explain to the patient that this is a normal finding and usually responds to warm sitz baths
b. Note this is an abnormal finding and notify M.D. to see the patient
c. Know that this is not a likely occurrence, and is probably in the patient’s imagination
d. Note that this is an indication of adequate blood flow to the area, and no intervention is necessary.
4. Following abdominal surgery, a client complaining of “gas pains” will have a rectal tube inserted. The client should be positioned on his
a. Left side, semi-Fowler’s.
b. Right side, semi-Fowler’s.
c. Left side, recumbent.
d. Left side, Sims’.
5. A 21-year-old male has a confirmed diagnosis of a brain tumor. Following surgery for a tumor near the hypothalamus, the nursing assessment should include observing for
a. Inability to perceive sound.
c. Inability to regulate body temperature.
d. Visual disturbances.
6. After falling down the basement steps in his house, a client is brought to the emergency room. His physician confirms that his leg is fractured. Following application of a leg cast, the nurse will first check the client’s toes for
b. Change in color.
d. Increase in temperature.
7. During the neonatal assessment, the nurse notes the baby has a cephalohematoma. Which type of delivery would be most likely to have caused this?
c. Vacuum extraction
8. A client is admitted following an automobile accident in which he sustained a contusion. The nurse knows that the significance of a contusion is that
a. Laceration of the brain may occur.
b. Loss of consciousness may be transient.
c. It is reversible.
d. Amnesia will occur.
9. A patient presents to the Rheumatology Clinic where a diagnosis of Rheumatoid Arthritis is made. Which of the following would NOT be an assessment finding by the nurse:
a. Presence of Heberden’s Nodes
b. Warm, tender, painful joints
c. Serum RF, and elevated ESR
d. Pt. c/o increased pain and stiffness in the morning
10. A client has sustained multiple injuries and fractures in a motor vehicle accident (MVA). During which period would the nurse be most vigilant in assessing for the development of a fat embolism?
a. 72 to 96 hours after the MVA.
b. During the first week after the MVA.
c. During the first 24 to 48 hours after the MVA.
d. During the second week after the MVA.
11. During a well baby check up, the nurse would expect the mother of a 7 month old to report that the baby:
a. Walks while holding on to things
b. Sits alone for brief periods
c. Pulls himself to a standing position in the crib
d. Just began to hold his head erect while sitting with support
12. Peritoneal reaction to acute pancreatitis results in a shift of fluid from the vascular space into the peritoneal cavity. If this occurs, the nurse would evaluate for
a. Decreased serum albumin.
d. Abdominal pain.
13. A woman was admitted to the Labor Room in the active phase of labor. Which of the following assessment findings would confirm that she is in the active phase of labor?
a. Cervical dilation of 3cm, contractions lasting for 45-50 seconds with a frequency of 20 minutes apart
b. Cervical dilation of 4cm, contractions lasting for 60 sec. with a frequency of 10 minutes apart
c. Cervical dilation of 8cm, contractions lasting for 50 seconds with a frequency of 3 minutes apart
d. Cervical dilation of 6cm, contractions lasting for 45 seconds with a frequency of 3 minutes apart
14. A client admitted to a surgical unit for possible bleeding in the cerebrum has vital signs taken every hour to monitor the neurological status. Which of the following neurological checks will give the nurse the best information about the extent of bleeding?
a. Pupillary checks.
b. Deep tendon reflexes.
c. Spinal tap.
d. Evaluation of extrapyramidal motor system.
15. A woman who is 31 weeks pregnant is having contractions that are 5 minutes apart. She has not ruptured membranes. Which of the following interventions should be started first?
a. Give IV fluids
b. Give Ritodrine (Yutopar) to cause uterine muscle relaxation
c. Place her on a fetal monitor
d. Place her in a left lateral recumbent position