NCLEX Practice Test for Physiological Adaptation 2023 (40 Questions with Explained Answers)

welcome to the 2023 NCLEX physiological adaptation practice test this test will have 40 questions with explained answers that will help you prepare for the test be sure to resuscitate the like button by turning it white question one the nurse is monitoring a five-year-old for increased intracranial pressure after the child fell from his tree house which of the following should be reported to the MD immediately a coughing B inability to say a forward phrase C the child says I see two of everything D excessive laughing the correct answer is C the child says I see two of everything it is not uncommon for a patient with increased ICP to experience diplopia double vision the child stating that he is seeing two of everything would indicate that he is experiencing double vision and the MD needs to be notified promptly question two the nurse is caring for a patient that is six hours post-surgery with a Jackson Pratt drain the nurse knows that the proper way to create suction is to a ensure that the drain is inflated and closed B compress the drain and ensure it is closed C fold the drain in half and ensure it is closed D ensure the drain is below the insertion site and closed the correct answer is B compress the drain and ensure it is closed for constant suction the collecting bulb should constantly be compressed pushing in the bottom end shouldn't be used to collapse the bulb since it doesn't provide suction when the bulb is filled with fluid or stop sucking it has to be emptied question three you're caring for a patient who is six hours post-surgery after a terp transurethral resection of the prostate the nurse notices that there is bright red blood in the Foley drainage tubing what is the correct intervention by the nurse a notify the MD immediately B increase the irrigation fluids connected to the Foley catheter C place the patient in a Trendelenburg position D gently massage the patient's bladder the correct answer is B increase the irrigation fluids connected to the Foley catheter post-opter patients are usually receiving irrigation of normal saline via irrigation tubing that is set up to flow through the bladder and into the Foley catheter bag it is a gravity system in which the nurse uses a roller clamp to increase or decrease the flow based on what color the urine fluid is coming out of the Foley tubing the goal of irrigation is to keep the outflow a light pink color to avoid clotting in this instance the nurse is seeing bright red blood and should increase the flow of the irrigation question four the nurses educating a patient who is receiving radiation therapy which of the following is most important to educate the patient on increasing in their diet a vitamin B12 B water C protein D vitamin D the correct answer is B water radiation therapy may cause a patient to become quickly dehydrated patients should be educated about dehydration and how to combat it as well as extremely dry skin question five which of the following is most important to educate a patient on when receiving chemotherapy and radiation therapy a take excessive precautions when you will be exposed to the sun b be sure to stay at least 12 feet from others to avoid becoming sick C be sure to check your BP daily D be sure to increase vitamin K in your diet the correct answer is a take excessive precautions when you will be exposed to the sun chemotherapy and radiation therapy cause photosensitivity in patients patients should be educated to take excessive precautions when they will be exposed to the sun question six a mother in the transitional stage of Labor begins having late decelerations causing the fetus's heart rate to drop what is the best intervention for the nurse to perform a have the patient lay on her left side B have the patient get on her hands and knees C place the patient in a trend position D have the patient lay on her right side the correct answer is a have the patient lay on her left side when a mother is experiencing late decelerations there is likely a compressed umbilical cord having the mother lay on her left side can decrease pressure on the umbilical cord thus providing oxygen to the fetus question seven a patient who has just undergone a mastectomy is being discharged home from the hospital after a five-day stay She was recently widowed when her husband's plane crashed overseas what is the most important thing for the nurse to ensure to set the patient up for a successful recovery at home a support system B wound care dressings C discharge paperwork explaining when to perform her wound care D follow-up appointment in six weeks with the surgeon the correct answer is a support system this patient has just lost her husband and gone through a surgery that can cause her great emotional and mental distress while it is important to provide the patient with the other options for this patient a support system is key question 8 a nurse is assessing a patient's Foley catheter drain tube the patient has previously had yellow clear urine the nurse noticed that there is heavy sediment in the patient's urine what can the nurse most likely expect to do once notifying the doctor a obtain a urinalysis with culture and sensitivity B flush the catheter with normal saline C change out the Foley catheter D start the patient on antibiotics the correct answer is a obtain a urinalysis with culture and sensitivity this patient has previously been having yellow clear urine sediment is often a sign of infection the doctor May order for the nurse to flush the catheter if the sediment becomes thick however obtaining a culture and sensitivity is the nurse's priority changing the Foley catheter out only puts the patient at a higher risk of infection unless the patient is running a fever The Physician will not likely order an antibiotic question 9 a 16-week pregnant mother being seen in her OB gyn's office is a gravita one mother who explains to the doctor that she is worried because she has not yet felt her baby move what education is likely to be provided to the patient a this is normal some first-time mothers do not feel their baby move until 18 to 20 weeks B the doctor needs to perform an ultrasound to ensure the baby is okay C the mother needs to have some IV fluids with glucose administered D the infant's heart rate must be assessed immediately the correct answer is a this is normal some first-time mothers do not feel their baby move until 18 to 20 weeks it is normal for a first-time mother to not feel her baby kick up to 20 weeks or longer this is often due to an anterior placenta on the front wall of the uterus the fetus has a cushion between them and the mother's abdomen so the mother may not feel the kicks until the fetus is larger question 10 a patient is being seen in his pcp's office due to pain and redness in his left calf the site is hot and edematous what is the most likely intervention to be performed for this patient a the calf will be drained with a large bore needle B the calf will be wrapped tightly to decrease the swelling C an ice pack will be placed on the calf D the patient will have an ultrasound of his leg the correct answer is D the patient will have an ultrasound of his leg this patient is likely experiencing a blood clot in his left leg he will need a stat ultrasound and is likely to start on blood thinners immediately an extremity that is red swollen painful and hot should never be wrapped tightly this can cause the clot to move and become an embolus question 11 a nurse is assisting a physician at the patient's bedside with inserting a chest tube what is the most important intervention by the nurse a keep a sterile field B May make sure the patient is comfortable C make sure the patient is still D have all supplies ready when the physician arrives the correct answer is a keep a sterile field the central line is a type of IV that will be inserted and its tip rests in the patient's heart this means that it must be a sterile procedure the nurse's concern should be maintaining a sterile field while ensuring the patient is comfortable and still is correct this patient is at a very high risk for infection so the sterile field should be kept typically a second nurse would be ensuring that the patient is comfortable and still question 12 a patient has just had a thoracentesis performed at the bedside which of the following is most important for the nurse to do a assess RR and sao2 B watch for drainage on the sterile dressing placed over the insertion site C have the patient lie supine for one hour post procedure D treat the patient for any pain they may have the correct answer is a assess RR and sao2 the plural space which surrounds the lungs can be sampled via a procedure known as thoracentesis Pleural fluid is a fluid that often only occurs as a thin layer in the space between the lungs and the chest wall the procedure involves a long needle that drains the lungs the patient is at risk for a pneumothorax the RR and sao2 should be monitored closely after the procedure is done a sterile dressing should be placed over the insertion site the patient is not required to lay supine after the procedure the nurse may give pain medication as prescribed but this is not the priority question 13 a patient who is three hours post-procedure from a bronchoscopy the patient suddenly states that he has chest pain and is showing signs of shortness of breath which of the following does the nurse suspect a pneumonia B pneumothorax C myocardial infarction D stroke the correct answer is B pneumothorax a bronchoscopy can cause trauma to the lungs causing a pneumothorax The Telltale sign in this scenario is that the patient is suddenly experiencing chest pain and SOB during this procedure question 14 a nurse is about to assist the physician in a lumbar puncture for a patient with suspected bacterial meningitis the nurse knows that the patient should be placed in which position a lateral decubitus B prone C Sims D trendelenberg the correct answer is a lateral decubitus in order to perform a lumbar puncture The Physician will have the patient in a lateral decubitus fetal position knees to chest the patient may assume this position by sitting with knees to chest as well question 15 an infant with hyperbilirubinemia has orders for phototherapy under the Billy light what is the most important education to provide to the parents a the infant must wear eye protection while under the light B the infant must take at least four ounces of milk per feeding C report any yellow stools immediately D the infant must have lotion rubbed on their skin twice daily the correct answer is a the infant must wear eye protection while under the light the Billy light phototherapy can cause eye damage to an infant the infant must have protective eyewear on at all times when they are under the light a newborn may not accept four oz of milk per feed yellow stools are normal in a newborn it is not imperative that the infant have lotion rubbed on them twice daily although the light can dry out their skin question 16 a patient in the ICU is on a ventilator following a diagnosis of covid-19 the patient has copious amounts of secretions in the lungs and must be suctioned often which of the following is the most important thing for the nurse to remember a suctioning too deep may cause bradycardia B the nurse must administer normal saline before suctioning C the respiratory therapist must be at the bedside before the nurse can suction the patient D ensure the patient is in a supine position before suctioning the correct answer is a suctioning too deep may cause bradycardia in line suctioning on the ventilator stimulates the vagus nerve and may cause significant bradycardia this usually happens if the suction catheter is too deep it is not imperative to administer normal saline before suctioning it can however Aid in suctioning when the patient has thicker secretions the nurse is able to perform inline suctioning the patient does not have to be in a Supine position to suction question 17 a nurse is educating a patient on his diet to support optimal wound healing the patient asks the nurse what he can eat for lunch which of the following would be the best lunch option a baked chicken breast small side salad with Romaine lettuce with strawberry vinaigrette orange slices and a glass of unsweet tea BBQ pork sandwich on wheat bread baked potato fries and unsweet tea c chicken salad baked lays strawberries and Diet Coke D pot roast with potatoes and carrots with a side of vitamin D milk the correct answer is a baked chicken breast small side salad with Romaine lettuce with strawberry vinaigrette orange slices and a glass of unsweet tea wound healing is promoted by high levels of protein and vitamin C and low levels of glucose option A has a high level of protein chicken and vitamin C strawberry and orange and low glucose unsweet tea the other options provide less protein more carbs sugar and little to no vitamin C question 18 a patient who is three days post-surgery from a knee replacement was discharged from the hospital yesterday today he woke up with symptoms of a cold and states that he does not feel well which of the following are most important to report to the surgeon a a temperature of 100.8 B pain at the surgical site C small amount of brown Blood on the surgical dressing D stiffness in the knee the correct answer is a a temperature of 100.8 the patient is three days post-op from a knee replacement surgery the biggest concern is a fever due to the high risk for infection it is normal for a patient who has undergone knee replacement surgery to a experience pain at the surgical site Brown Blood on the dressing is normal the knee will be stiff as it heals most patients require physical therapy as they heal question 19. which of the following is most important when a nurse is providing peritoneal dialysis for a patient in kidney failure a give the patient a sedative for relaxation B weigh the patient C review allergies D ask the patient when the last time they urinated was the correct answer is B weigh the patient a patient on dialysis should be weighed before and after dialysis this helps the nurse document how much fluid is pulled off of the patient a patient on dialysis is not typically given a sedative the patient's allergies should be reviewed however this is not priority with this procedure patients on dialysis usually do not urinate or when they do it's very little this information is not imperative to perform dialysis question 20. the nurse is performing deep suctioning on a patient with pneumonia what is most important for the nurse to remember a have the patient hold their breath B perform suctioning during insertion of the suction catheter for 20 seconds C be sure to wipe the suction catheter with 70 alcohol before inserting D perform suctioning during withdrawal of the catheter the correct answer is D performs suctioning during withdrawal of the catheter when deep suctioning a patient the nurse should keep the catheter sterile should insert the catheter and suction as the suction catheter is withdrawn keeping it under 15 seconds to avoid trauma to the airway it is not necessary for the patient to hold their breath wiping the suction catheter with an alcohol pad would break sterility question 21 which of the following is not a phase of seizures a ictal b post-dictal c prodromal D preactyl the correct answer is D preetectal the phases of a seizure are prodromal early ictal Aura ictal and post-dictal prodromal means the time before the seizure early ictal the oraphase ictal the time from the beginning of symptoms to the end of the seizure post-dictal the period of time after the seizure question 22 the nurse is assisting a patient with pneumonia with postural drainage which position will the nurse place the patient in a Sims b trendlinburg c supine with arms at side with pillow underneath D left side with arms above head with pillow under neck the correct answer is C supine with arms at side with pillow underneath postural drainage usually entails a patient lying in a Supine position with their arms at the side with a pillow under their knees Sims position is usually used for administering enemas trendelenberg is an upside down position often used in patients with GI bleeds question 23 the nurse is teaching a patient with covid-19 to use an incentive spirometer the nurse instructs the patient to a inhale as deeply as possible and exhale into the spirometer and note the highest level the indicator reaches B blow into the spirometer three times and note the highest level the indicator reaches C suck on the spirometer every five minutes for one hour to break up secretions D exhale as deeply as possible and inhale into the spirometer and note the highest level the indicator reaches the correct answer is D exhale as deeply as possible and inhale into the spirometer and note the highest level the indicator reaches the proper way to use an incentive spirometer is to Exhale as deeply as possible and inhale into the spirometer and note the highest level the indicator reaches the physician will provide the patient with a goal but a typical goal is 500 ml The Physician will also provide orders to how often the patient should use the incentive spirometer question 24 which of the following patients should the nurse not perform respiratory percussion on due to it being contraindicated a a patient on a ventilator b a patient with an artificial Airway such as a tracheostomy C A post-op patient with painful incisions d a patient with a pulmonary embolism the correct answer is d a patient with a pulmonary embolism it is contraindicated to perform respiratory percussion on a patient with a pulmonary embolism this is due to the high risk of the emboli moving and causing further damage the other options are not contraindications of respiratory discussion question 25 which of the following should the nurse anticipate administering to a post-op patient who requires respiratory percussion a a sedative for relaxation B pain medication C oxygen D antitussive the correct answer is B pain medication it is normal for a patient who has had surgery to be in pain that pain makes the patient not want to breathe deep or walk sometimes respiratory percussion can be very painful for some patients especially after surgery if the nurse administers pain medication the patient is more likely to tolerate respiratory percussion question 26 which of the following is the proper way for the nurse to perform proper respiratory percussion a use the first two fingers index and middle fingers to lightly tap in the intercostal spaces over the lungs b cup hands to trap air between the nurse's hand and the patient's thorax in an alternating rhythmic pattern over the lungs C use the first two fingers index and middle fingers of the non-dominant hand while tapping the fingers with the dominant hand at a rate of 60 to 100 per minute at the bottom lobes of the lungs D use the pads of the four fingers on both hands to rhythmically tap the patient's thorax in an alternating rhythmic pattern the correct answer is b cup hands to trap air between the nurse's hand and the patient's thorax in an alternating rhythmic pattern over the lungs the proper way to perform respiratory percussion is to cup the hands to trap air between the nurse's hand and the patient's thorax in an alternating rhythmic pattern over the lungs this should be done at a rate of 100 to 480 times slash Min electronic options are used for the higher rates question 27 which of the following medications May a nurse anticipate administering to a patient with increased intracranial pressure following an MVA a salicylic acid B Warfarin C Mannitol D Methotrexate the correct answer is C Mannitol patients with increased intracranial pressure often require osmotic laxatives like Mannitol salicylic acid is aspirin and is not needed Warfarin will not help with ICP Methotrexate is an immunosuppressant used to treat conditions such as rheumatoid arthritis question 28 a patient in the ICU that was involved in an MVA yesterday is experiencing taking from the ear which of the following is indicative of the Halo sign in this patient a dark brown drainage B sanguineous fluid C pink to Red stain with a circle of clear fluid around it d a dark brown stain with a circle of yellow fluid around it the correct answer is C pink to Red stain with a circle of clear fluid around it a classic Halo sign is a pink slash red stain with a circle Halo of clear fluid around it this is seen often when a patient is leaking CSF cerebrospinal fluid due to head trauma question 29 a patient who is post-op from a kbg two days ago with a pain level 4 over 10 has a blood pressure of 95 over 60. all BP meds were held after surgery for this patient the nurse knows that this is a sign of what a post-op trauma B pressure around the incision site C infection D sedation the correct answer is C infection this patient had a surgery on his heart two days ago and is at a very high risk for infection following surgery the patient is experiencing a blood pressure of 95 over 60. this is a sign of sepsis and should be reported to the MD immediately question 30 in which of the following patients would an external ventricular drain be contraindicated in a a five-year-old child with meningitis b a 37 year old post-op a brain tumor removal c a 65 year old on Warfarin due to DVT blood clots d a two-week-old with complex hydrocephalus the correct answer is c a 65 year old on Warfarin due to DVT blood clots an external ventricular drain should not be placed when a patient is at a high risk for bleeding the patient on Warfarin would be at a high risk for a brain bleed if an EVD was placed question 31 a patient has a potassium level of seven what intervention is the nurse's first priority a place the patient on a continuous cardiothoracic monitor B tell the patient he can no longer have bananas or greens C prepare an IV bolus of nacal D give Lasix per MD order the correct answer is a place the patient on a continuous cardiothoracic monitor the patient has a high level of potassium that may cause lethal heart rhythms the patient should be placed on continuous cardiac monitoring immediately withholding dietary potassium from the patient will not reduce the potassium giving the patient an ACL will not reduce the potassium giving furosemide is correct but the first priority is obtaining a baseline cardiac Rhythm on a monitor question 32 which of the following is a patient with Addison's disease most at risk for a hyperkalemia B hypercalcemia C hyponatremia D hypernatremia the correct answer is a hyperkalemia the patient with Addison's disease is at high risk for hyperkalemia as hypoaldosteronism is the principal mediator of hyperkalemia in Addison's illness a lack of aldosterone would cause potassium retention due to its inability to eliminate potassium in the urine question 33 what symptoms might a nurse see in a patient with a potassium level of 6.5 a tachycardia b hypotonia c bradycardia D inverted T waves the correct answer is C bradycardia bradycardia is a side effect of a high potassium level on a cardiac monitor the patient may exhibit peaked T waves question 34 a patient taking potassium chloride syrup Q 12 hours has a morning potassium lab of 5.5 which of the following is the proper nursing intervention a give the syrup and tell the patient to not eat bananas today B give the syrup and recheck the potassium in the morning C hold the syrup and notify the doctor D hold the syrup and check a BMP in one hour the correct answer is C hold the syrup and notify the doctor the patient has a high potassium although slightly high potassium has a major effect on the heart and has a small therapeutic window the nurse should hold the potassium syrup and notify the doctor question 35 a patient with hypokalemia is at a high risk of digoxin toxicity when on which of the following medications a Mannitol b chlorothiazide c spironolactone D bumetanide the correct answer is D bumetanide bumetonide bumex is a loop diuretic that may cause hypokalemia when taking Digoxin with potassium depleting drugs the patient is at a high risk for digoxin toxicity in the blood signs of digoxin toxicity include confusion vomiting and vision changes the other options listed are all diuretics but not specifically Loop Diuretics that deplete potassium question 36 a patient in the ICU has a potassium level of 2.5 which of the following interventions can the nurse anticipate for this patient a IV push potassium B potassium chloride syrup C potassium chloride tablets d IV potassium infusion the correct answer is D IV potassium infusion this patient has a critically low potassium so it should be replaced the quickest way possible which is intravenously IV potassium should never be given via IV push the best option is an IV potassium infusion question 37 which of the following May a nurse anticipate in a patient with hypervolemia a crackles in the lungs b t tinted skin on the hands see dry eyes with no tears while crying D wheezing upon expiration the correct answer is a crackles in the lungs hypervolemia means fluid overload it may result in crackles in the lungs wet lungs options B and C are symptoms of dehydration hypovolemia wheezing upon expiration happens when the airway is obstructed or narrowed like with asthma question 38 a patient with a sodium level of 120 can be expected to have the following symptoms except a seizures B lethargy C irritability D headache the correct answer is D headache this patient is experiencing hyponatremia or low sodium levels having a headache is a symptom of hyponatremia the other options are symptoms of hypernatremia or high sodium levels question 39 a patient with a calcium level of the fifth of may be expected to have the following symptoms except a seizures b parkinsonism c circumoral numbness D bone pain the correct answer is D bone pain a calcium level of 5 indicates hypocalcemia hypocalcemia may cause seizures parkinsonism and circumoral numbness numbness around the mouth bone pain is not a symptom of hypocalcemia question 40 an infant with dehydration can be expected to have which of the following clinical manifestations a acrocyanosis b sunken fontanelle C enlarged head circumference D contractures of the hands the correct answer is B sunken fontanelle an infant with dehydration will have a sunken fontanelle on the other hand an infant with hypervolemia may have a bulging fontanelle acrocyanosis means blue hands and feet which does not have any relationship to dehydration dehydration does not cause an enlarged head circumference or contractures thank you for watching this video we hope hope you enjoyed it click the first link in the description to take the free NCLEX practice test also check out these videos that can help you with your future studies don't forget to resuscitate the like button and subscribe to our Channel and please share this video with your fellow nursing friends

Channel: All Healthcare Careers

Views: 13,478

Keywords: Physiological Adaptation questions, Physiological Adaptation nclex questions, nclex Physiological Adaptation questions, Physiological Adaptation nclex rn questions, Physiological Adaptation nclex rn, Physiological Adaptation nclex practice test answers, Physiological Adaptation nclex practice test answer key

Id: 3xN8yuJlvrs

Length: 30min 3sec (1803 seconds)

Published: Sat Jun 17 2023