RN NCLEX Set 3 - Free Nurse Test Bank

Are you ready to pass your final nursing exam? Test your knowledge with this free nurse test bank on 10 questions and answers. Answers are provided at the end of the questions.

Question 1

After an abdominal perineal resection, the patient has returned from the operating room. The nurse is evaluating the client's perineal wound and observes serosanguineous leakage from the incision. What kind of nursing intervention is most suited?

A. Clamp the surgical drain.

B. Change the dressing as prescribed.

C. Notify the surgeon.

D. Remove and replace the perineal packing.

Question 2

The nurse is going over a client's medical history who has bladder cancer. Which of the following is the most typical sign or symptom of this kind of cancer that the nurse expects to be documented?

A. Dysuria

B. Hematuria

C. Urgency on urination

D. Frequency of urination

Question 3

A client is diagnosed as having an intestinal tumor. For which problems of this kind of tumor should the nurse keep an eye on the patient?

Select all that apply.

A. Flatulence

B. Peritonitis

C. Hemorrhage

D. Fistula formation

E. Bowel perforation

F. Lactose intolerance

Question 4

After a mastectomy, the client is being cared for by the nurse. Which

nursing action would help keep the injured arm from becoming lymphedematous?

A. Placing cool compresses on the affected arm

B. Elevating the affected arm on a pillow above heart level

C. Avoiding arm exercises in the immediate postoperative period

D. Maintaining an intravenous site below the antecubital area on the affected side

Question 5

Given that the dosage of chemotherapy is often determined by the patient's total body surface area (BSA), which examination must the nurse complete before starting chemotherapy?

A. Measure the client's abdominal girth.

B. Calculate the client's body mass index.

C. Measure the client's current weight and height.

D. Ask the client about his or her weight and height.

Question 6

A client who has just received a type 1 diabetes diagnosis is given instructions by the nurse. When the patient says which sentence, the nurse knows that the patient accurately understands the steps to prevent diabetic ketoacidosis?

A. "I will stop taking my insulin if I'm too sick to eat."

B. "I will decrease my insulin dose during times of illness."

C. "I will adjust my insulin dose according to the level of glucose in my urine."

D. "I will notify my primary health care provider (PHCP) if my blood glucose level is higher than 250 mmol/L."

Question 7

A myxedema coma diagnosis is made and the patient is admitted to the emergency room. Which task should the nurse get ready to perform first?

A. Warm the client.

B. Maintain a patent airway.

C. Administer thyroid hormone.

D. Administer fluid replacement.

Question 8

A patient with acromegaly who underwent transsphenoidal hypophysectomy and is recuperating in the intensive care unit is being observed by the nurse. Which results should raise a nurse's concern about a potential postoperative complication? Select all that apply.

A. Anxiety

B. Leukocytosis

C. Chvostek's sign

D. Urinary output of 800 mL/hrE. Clear drainage on nasal dripper pad

Question 9

A patient who had a thyroidectomy has just been admitted to the nursing unit. For this client, which assessment is the most important?

A. Hoarseness

B. Hypocalcemia

C. Audible stridor

D. Edema at the surgical site

Question 10

A client who is having an acute bout of cholecystitis is being assessed by the nurse. Which of these clinical signs and symptoms is consistent with this diagnosis?

Select all that apply.

A. Fever

B. Positive Cullen's sign

C. Complaints of indigestion

D. Palpable mass in the left upper quadrant

E. Pain in the upper right quadrant after a fatty meal

F. Vague lower right quadrant abdominal discomfort

Answer Key

Question 1 Answer - B

Rationale: It is normal to expect extensive serosanguineous leakage from the perineal incision right after surgery. As a result, the nurse needs to apply the new dressing as directed. Clamping a surgical drain will result in an accumulation of drainage within the tissue, thus avoid doing so. At this point, the surgeon does not need to be informed by the nurse. As directed, packing and drains are gradually removed over the course of five to seven days. The perineal packing should not be taken out by the nurse.

Question 2 Answer - B

Rationale: Hemateuria is the most prevalent indication in patients with bladder cancer. The patient may also exhibit irritative voiding symptoms, which are frequently linked to carcinoma in situ. These symptoms include urgency, frequency, and dysuria. Additional signs and symptoms of a bladder infection include urgency, frequent urination, and dysuria.

Question 3 Answers - B,C,D,E

Rationale: Bowel perforation, which can cause bleeding and peritonitis, is one of the complications associated with intestinal tumors. Bowel blockage and the development of fistulas are further problems. While it can happen, flatulence and lactose intolerance are not complications of an intestinal tumor.

Question 4 Answer - B

Rationale: The arm should be raised above the level of the heart after a mastectomy. Easy arm workouts ought to be promoted. Injections, IV lines, blood draws, and blood pressure checks should not be done on the afflicted arm. It is not advised to use cool compresses to stop lymphedema from developing.

Question 5 Answer - C

Rationale: Chemotherapy dosage is often determined by calculating the total body surface area (BSA), which necessitates the client's precise height and weight at the time of medicine administration. It is possible to determine an accurate BSA and dosage by asking the customer about their height and weight, although this could cause to errors. Finding the abdominal circumference and calculating the body mass index will not yield the necessary information.

Question 6 Answer - D

Rationale: A client with type 1 diabetes mellitus is more likely to experience diabetic ketoacidosis when unwell because of decreased caloric intake and hyperglycemia linked to the stress response. The diabetic client must monitor their blood glucose levels as part of sick day management, and they must tell the PHCP if their level exceeds 250 mg/dL (13.9 mmol/L). One should never stop taking insulin.

Question 7 Answer - B

Rationale: An uncommon yet dangerous condition called myxedema coma is brought on by a chronically low thyroid output. Acute sickness, abrupt discontinuation of thyroid medication, anesthesia and surgery, hypothermia, and the use of sedatives and opioid analgesics can all cause comas. Keeping the airway open is the first nursing intervention in a myxedema coma. After giving the patient oxygen, it is important to replace lost fluids, keep them warm, check their vital signs, and give them thyroid hormones intravenously.

Question 8 Answers - B, D, E

Rationale: Growth hormone is secreted in excess in Acromegaly, which is typically brought on by a benign tumor on the anterior pituitary gland. The tumor is surgically removed as part of treatment; a sublingual transsphenoidal total or partial hypophysectomy is frequently used. A gum-line incision on the inner upper lip is used in the sublingual transsphenoidal technique to soften the tissue. One kind of brain surgery is transsphenoidal surgery, and the main risk factor is infection. An increased white count, or leukocytosis, may be a sign of illness. One potential side effect of transsphenoidal hypophysectomy is diabetes insipidus.

Question 9 Answer - C

Rationale: The thyroid gland, which is situated in the front neck, is removed during a thyroidectomy. Airway status must be closely monitored since any edema at the surgical site may result in respiratory difficulty. The airway needs to be monitored first in nursing, even if the nurse should be keeping an eye on all of the alternatives.

Question 10 Answers - A, C, E

Rationale: The patient may have severe pain in the right upper quadrant that spreads to the right shoulder or scapula during an acute bout of cholecystitis, or they may have epigastric pain following a fatty or large meal. Along with symptoms of indigestion, belching, gas, nausea, and vomiting, a fever and indicators of dehydration would also be anticipated. Due of their inconsistency with the gallbladder's anatomical placement, options 4 and 6 are wrong. The second option, Cullen's sign, is linked to pancreatitis.

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