These questions are one of the NCLEX prep samples for Reduction of Risk Potential. 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 client’s laboratory results are returned and the hemoglobin is 10 g/dL and the hematocrit is 30 percent. The highest-priority nursing goal should be to
a. Encourage mobility.
b. Promote skin integrity.
c. Prevent constipation.
d. Conserve the client’s energy.
2. The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. This specimen is then
a. Placed in a separate container and later added to the collection.
b. Saved as part of the 24-hour collection.
c. Tested, then discarded.
d. Discarded, then the collection begins.
3. The main complication following a nephrostomy that the nurse must assess for is
a. Contamination of the site.
b. Difficulty in restoring fluid and electrolyte balance.
c. Cardiopulmonary involvement following the procedure.
d. Bleeding from the nephrostomy site.
4. You are assigned to work in the Endocrine Clinic. A teenage patient with Type I Diabetes comes for monthly evaluation. Her serum glucose is 175mg/dl and the Glycosylated Hgb is 25%. Based on these lab values, which of the following determinations can the nurse make about the patient’s control of her diabetes?
a. That it is in good control
b. That it is being poorly controlled and further evaluation is warranted
c. Serum Glucose is within an acceptable range. Glycosylated Hgb is not significant
d. That lab values likely reflect the fact that teenagers usually do not comply with diet at all times, and therefore control is unlikely
5. A client has a demand pacemaker inserted. The nurse knows that which of the following is true concerning such:
a. It is unaffected by spontaneous heart beat
b. Only fires when heart rate falls below pre-set minimum rate
c. Uses a sending and pacing electrode in the atria
d. It is always a temporary modality to provide electrical stimuli to the heart
6. A client with a history of Polycystic Kidney Disease is admitted to the Renal Unit for evaluation for dialysis. Which of the following lab values would be MOST significant in determining renal function?
a. Creatinine 8.7 mg/dl
b. BUN 90 mg/dl
c. Serum K+ 7.0 MEq/l
d. Uric Acid 7.5
7. A patient has a Salem Sump Tube. When the nurse goes to irrigate the tube she notices that the gastric drainage is dark brown. Which of the following is the FIRST intervention the nurse should take upon noticing this?
a. Check the pH of the gastric contents
b. Perform a Hemoccult Test on the contents
c. Irrigate the tube and then check the returns
d. Remove the tube from suction
8. A patient is being monitored for signs of increased intracranial pressure. An Intraventricular catheter has been placed. Which of the following would indicate normal intracranial pressure?
a. An ICP of less than 20mmHg and CPP of 10mmHG
b. An ICP of 30mmHg and a CPP of 20mmHg
c. An ICP of more than 20mmHg and a CPP of 30mmHg
d. An ICP of less than 20mg and a CPP of 60mmHg or more
9. On a first prenatal visit, a woman has an alphafetoprotein test. The nurse is going to explain the reason for this test. The nurse would be sure to include:
a. The test detects Down’s Syndrome
b. The test detects congenital heart defects
c. The test detects neural tube defects
d. The test detects the baby’s sex
10. The nurse has just admitted a 4 month old infant to the Recovery Room after a repair of a cleft lip. In transferring the infant from the stretcher to the bed, the nurse would position the infant in the following position:
b. Prone with the head turned to the right
c. Supine with head of bed elevated 30 degrees
d. Prone with head elevated slightly
11. You are assigned to care for a patient with a Below the Knee Amputation (BKA). Among the patient’s orders is one which states that the patient should be placed in the prone position twice daily. The nurse knows that the reason for this is:
a. Changing the patient’s position will help to prevent skin breakdown
b. To observe the stump for signs of infection
c. To assist the patient in doing ROM (Range of Motion) exercises
d. To stretch the flexor muscles and prevent flexion contractures
12. A woman delivered a set of twins 2 hours ago via C-Section and is now in the Recovery Room. The following fundal assessment findings would be expected:
a. Fundus at umbilicus, hard and midline
b. Fundus 1-2 finger breadths above umbilicus, hard and midline
c. Fundus 1-2 finger breadths below umbilicus, hard and midline
d. Fundus would not be assessed because of the C-Section
13. The nurse is assessing a patient who is on a fetal monitor. On the last tracing, 2 late decelerations have occurred. The nurse is aware that late decelerations are:
a. Not worrisome and indicate head compression
b. Not worrisome and indicate cord compression
c. Worrisome and indicate uteroplacental insufficiency
d. Worrisome and indicate head compression
14. The nurse is caring for a 9 month old in Bryant’s Traction. When the nurse enters the room she observes that the baby is in the crib with the buttocks elevated slightly off the bed and the hips are flexed at a 90 degree angle. The appropriate nursing action to take would be to:
a. Call the Orthopedic Department to adjust the traction
b. Reposition the patient to the correct position
c. Chart the observation
d. Loosen the traction so that the buttocks rest on the bed
15. You are assisting a physician in removing a chest tube from a patient. Which of the following will the patient be asked to do when the physician is ready to remove the tube?
a. Exhale and hold breath, or bear down
b. Inhale and hold breath, or bear down
c. Breathe normally
d. Inhale and cough