NCLEX Practice Exam for Physiological Adaptation

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1. An adult with chronic renal failure is receiving peritoneal dialysis. His acid-base balance and electrolyte levels are now within normal limits. His hemoglobin is 9.2 and his hematocrit is 30. The most likely cause of his anemia is:

  1. hemodilution secondary to fluid retention.
  2. eating insufficient protein due to taste changes that occur with dialysis.
  3. failure of his kidneys to produce the hormone necessary to stimulate bone marrow to produce red blood cells.
  4. hemolysis of red blood cells as they move past the membrane containing the dialysis solution.

2. An adult client has a comminuted fracture of the ulnar bone. He asks the nurse what type of fracture this is. The nurse’s response is based on which of these understandings?

  1. The ulnar bone has been crushed and broken in several places.
  2. The two ends of the fractured ulnar bone are pulled apart and separated from each other.
  3. The ulnar bone has been broken in two and one end of the bone broke through the skin.
  4. Only one side of the ulnar bone is broken.

3. The nurse is assessing a client admitted in ketoacidosis. The nurse can expect the client’s skin to be:

  1. clammy.
  2. flushed.
  3. diaphoretic.
  4. silky.

4. A child has been brought to the emergency room with an asthma attack. What signs and symptoms would the nurse expect to see?

  1. A prolonged inspiratory time and a short expiratory time.
  2. Frequent productive coughing of clear, frothy, thin mucus progressing to thick, tenacious mucus heard only on auscultation.
  3. Hypoinflation of the alveoli with resulting poor gas exchange from increasingly shallow inspirations.
  4. Swelling of the bronchial mucosa, with wheezes starting on expiration and spreading to continuous.

5. The nurse is assisting a child with congestive heart failure. Which of the following would the child be least likely to manifest?

  1. Weakness and fatigue.
  2. Dyspnea.
  3. Tachycardia.
  4. Oliguria.

6. A child who is two years and six months old has had one bout of nephrosis (nephrotic syndrome). His mother suspected a recurrence when she observed swelling around his eyes. The nurse helps to confirm this condition by recognizing what additional symptom?

  1. Blood pressure of 140/90.
  2. Marked proteinuria.
  3. Cola-colored urine.
  4. A history of positive streptococcal infection.

7. The nurse is caring for a client with cirrhosis of the liver who has developed esophageal varices. The nurse understands that the best explanation for development of esophageal varices is which of the following?

  1. Chronic low serum protein levels result in inadequate tissue repair, allowing the esophageal wall to weaken.
  2. The enlarged liver presses on the diaphragm, which in turn presses on the esophageal wall, causing collapse of blood vessels into the esophageal lumen.
  3. Increased portal pressure causes some of the blood that normally circulates through the liver to be shunted to the esophageal vessels, increasing their pressure and causing varicosities.
  4. The enlarged liver displaces the esophagus toward the left, tearing the muscle layer of the esophageal blood vessels, which allows small aneurysms to form along the lower esophageal vessels.

8. A client has a closed head injury. Vital signs are T 103°F rectally; pulse 100; respirations 24; B.P. 110/84. Hourly urine output is 200 ml/hr. What is the best understanding of the cause of these findings?

  1. Damage to the hypothalamus resulting in decreased hormone production.
  2. Movement of fluid from the tissue into the intravascular space, resulting from sepsis.
  3. An increase in antidiuretic hormone (ADH) as a result of injury to the hypothalamus.
  4. Fluid shifts from the tissue into the intravascular space due to administration of normal saline used during fluid resuscitation.

9. One of the most important pulmonary treatments in cystic fibrosis is:

  1. inhaled beta agonists.
  2. inhaled corticosteroids.
  3. chest physiotherapy.
  4. oral enzymes.

10. The RN is caring for a patient with a chest tube after a right upper lobectomy. On the day of surgery, the RN notes bubbling in the water-seal chamber. What is this, and what should the RN do?

  1. air leak, expected finding
  2. air leak, notify physician
  3. suction control, expected finding
  4. suction control, decrease wall suction

11. The RN has finished teaching a patient about treatment of GERD. The RN knows the patient has understood the teaching if she states:

  1. “I should eat a small bedtime snack each night.”
  2.  “I should lie flat in bed.”
  3. “I can have red wine with dinner.”
  4. “I should eat six small meals daily.”

12. The nurse is caring for a 73-year-old patient with chronic pain being treated with opioids. One complication to be monitored for is:

  1. constipation.
  2. diarrhea.
  3. anorexia.
  4. heartburn.

13. Which order can be associated with the prevention of atelectasis and pneumonia in a client with amyotrophic lateral sclerosis?

  1. Active and passive range of motion exercises twice a day
  2. Every 4 hours incentive spirometer
  3. Chest physiotherapy twice a day
  4. Repositioning every 2 hours around the clock

14. A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?

  1. Until the health care provider has determined that your ejaculate doesn’t contain sperm, continue to use another form of contraception.
  2. This procedure doesn’t impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate.
  3. Involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days.
  4. The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.

15. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal

  1. S3 ventricular gallop
  2. Apical click
  3. Systolic murmur
  4. Split S2

16. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the
client’s pulse and respirations, what should be the function of the second nurse?

  1. Relieve the nurse performing CPR
  2. Go get the code cart
  3. Participate with the compressions or breathing
  4. Validate the client’s advanced directive

17. The nurse is caring for a client with uncontrolled hypertension. Which findings require priority nursing action?

  1. Lower extremity pitting edema
  2. Rales
  3. Jugular vein distension
  4. Weakness in left arm

18. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse’s priority should be

  1. Cover the areas with dry sterile dressings
  2. Assess for dyspnea or stridor
  3. Initiate intravenous therapy
  4. Administer pain medication

19. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant?

  1. Hemoglobin level of 12 g/dI
  2. Pale mucosa of the eyelids and lips
  3. Hypoactivity
  4. A heart rate between 140 to 160

20. A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time?

  1. What are you taking for pain and does it provide total relief?
  2. What does the skin on the testicles look and feel like?
  3. Do you have any questions about your care?
  4. Did you know a consequence of epididymitis is infertility?
Answers and Rationales
  1. Answer C. Hemodilution can produce a drop in hematocrit. However, if the cause of the decrease in hematocrit were fluid retention, one would expect to find corresponding decreases in serum sodium. If the dialysis has corrected the electrolyte balance, it is unlikely that the client would retain sufficient fluid to cause this drop in hematocrit. Hemodilution does not usually produce such a drop in hemoglobin. The cause of anemia in persons with chronic renal failure is lack of erythropoietin. Erythropoietin produced by the kidneys is necessary to stimulate the bone marrow to produce red blood cells. In chronic renal failure this hormone is not produced. Hemolysis does not occur with peritoneal dialysis because red blood cells do not move outside the client’s own blood vessels, so there are no mechanical forces to harm them.
  2. Answer A. A comminuted fracture usually results from a crush injury and results in fractured and crushed bones. The bone is broken in several places. A displaced bone occurs when the two ends of the fractured bone are pulled apart and separated from each other. A compound or open fracture occurs when the bone has been broken in two and one end of the bone breaks through the skin. A greenstick or incomplete fracture is when only one side of the bone is broken. A greenstick fracture happens in children whose bones are still soft.
  3. Answer B. Cool, clammy skin is seen in hypoglycemia. Ketoacidosis causes dehydration that results in flushed, dry skin. Diaphoresis is seen in hypoglycemia. Silky skin is not seen in ketoacidosis.
  4. Answer D. Bronchi normally expand and lengthen during inspiration and shorten during expiration. Asthma causes spasm of the smooth muscles in the bronchi and bronchioles, resulting in an even tighter airway on exhalation and prolonged exhalation. Inspirations increase in rate in an effort to relieve hypoxia. At the beginning of the attack, the cough is nonproductive and results from bronchial edema. Then the mucus becomes profuse and rattly, with a cough producing frothy, clear sputum. Gas trapping is the central feature of asthma. It is caused by allowing more air to enter alveoli than can escape from them through the narrowed airways. Gas trapping also causes an increased depth and rate of respirations. The wheeze starts during the expiratory phase because of the extreme narrowing of the bronchus on exhalation. As obstruction increases, wheezes become more high pitched and continuous.
  5. Answer D. Weakness and fatigue are common in congestive heart failure. Dyspnea is common in congestive heart failure. Tachycardia is common in congestive heart failure. Oliguria is not usually seen in congestive heart failure. Diuretics are a mainstay treatment in congestive heart failure. The nurse would expect urine output. Weakness, fatigue, dyspnea, and tachycardia are clinical manifestations of congestive heart failure.
  6. Answer B. Blood pressure is generally not elevated in nephrotic syndrome except in a child with severe renal insufficiency. A normal blood pressure in a two-and-a-half-year-old should be between 80 and 85 systolic and 50 and 60 diastolic. In nephrotic syndrome (nephrosis) plasma proteins are excreted in the urine due to an abnormal permeability of the glomerular basement membrane of the kidney to protein molecules, particularly albumin. The cause of nephrosis is unknown. The average age of onset is two and a half years and it is more common in boys than girls. Dark urine is not seen in nephrotic syndrome. A history of a streptococcal infection is associated with glomerulonephritis.
  7. Answer C. While low serum albumin is common with liver disease, it does not weaken the existing structures of the body. Weakness of the esophageal wall is not the problem. Since the esophageal vessels lie close to the surface, under the mucous membranes, the esophageal wall does not support them at the inner surface. The liver is located to the right of the esophagus. When it enlarges, it is more likely to compromise expansion of the right lung than to affect the esophagus. The fibrosed liver obstructs flow through portal vessels, which normally receive all blood circulating from the gastrointestinal tract. The increased pressure in portal vessels shunts some of the blood into the lower pressure veins around the lower esophagus. Since these veins are not designed to handle the high-pressure portal blood flow, they develop varicosities, which often rupture and bleed. Enlargement of the liver does not displace the esophagus.
  8. Answer A. Injury to the hypothalamus usually leads to decreased secretion of antidiuretic hormone (ADH), which is manifested by large amounts of very dilute urine output. The hypothalamus also controls temperature. Injury causes a very high temperature. Sepsis is unlikely with a closed head injury. The assessments are classic for hypothalamus injury. Injury to the hypothalamus usually leads to decreased secretion of antidiuretic hormone (ADH), which is manifested by large amounts of very dilute urine output. The hypothalamus also controls temperature. Injury causes a very high temperature. Normal saline is isotonic and would not cause these fluid shifts.
  9. Answer C. The major pulmonary problem with CF is thick tenacious secretions. CPT moves the secretions from the small airways to the large where they can be coughed out. Options a and b are used but are secondary to option c; the oral enzymes that CF patients take are for digestion, not pulmonary reasons.
  10. Answer A. Until the lung incision seals, there will be air leaking from it, which will be collected and drained by the chest tube; option b would be correct if the air leak had stopped and later reappeared; the suction control chamber is separate from the water seal chamber in a typical chest drainage device.
  11. Answer D. Smaller more frequent meals help decrease reflux. The patient shouldn’t eat within 3 hours of bedtime; her head should be elevated-either put bed up on 6-inch blocks or use a wedge; alcohol is contraindicated-it relaxes the GE sphincter and increases reflux.
  12. Answer A. Opioids slow transit through the GI tract; older patients and those being treated chronically are at increased risk. Opioids slow not speed transit through the GI tract; patients with chronic pain often lack appetite from their pain and will eat better when it is relieved; nausea, not heartburn is often seen in the upper GI tract with opioid usage.
  13. Answer C. These clients have a potential for an inability to have voluntary and involuntary muscle movement or activity. Thus, options a and b are inadequate with this problem in mind. Option d is not specific for prevention of complications associated with the lung.
  14. Answer A. Until the health care provider has determined that your ejaculate doesn”t contain sperm, continue to use another form of contraception. All of these options are correct information. The most important point to reinforce is the need to take additional actions for birth control.
  15. Answer A. S3 ventricular gallop An S3 ventricular gallop is caused by blood flowing rapidly into a distended non-compliant ventricle. Most common with congestive heart failure.
  16. Answer C. Once CPR is started, it is to be continued using the approved technique until such time as a provider pronounces the client dead or the client becomes stable. American Heart Association studies have shown that the 2 person technique is most effective in sustaining the client. It is not appropriate to relieve the first nurse or to leave the room for equipment. The client’s advanced directives should have been filed on admission and choices known prior to starting CPR.
  17. Answer D. In a client with hypertension, weakness in the extremities is a sign of cerebral involvement with the potential for cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining 3 choices indicate mild fluid overload and are not medical emergencies.
  18. Answer: B. Due to the location of the burns, the client is at risk for developing upper airway edema and subsequent respiratory distress.
  19. Answer B. In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with mild to severe tachycardia.
  20. Answer B. All of the questions should be asked. However, the one about the problem is the most important to start with at this time.