Free NCLEX Practice Tests 107th Edition

Free NCLEX Practice Tests 107th Edition

1. A nurse is caring for a client with a cerebral aneurysm who is on aneurysm precautions and is monitoring the client for signs of aneurysm rupture. The nurse understands that an early sign of rupture is which of the following?

A. Widened pulse pressure
B. Slowing of pupil response
C. Motor weakness
D. A decline in the level of consciousness

Answer: D. A decline in the level of consciousness

Rationale: Rupture of a cerebral aneurysm usually results in increased intracranial pressure (ICP). The first sign of pressure is a change in the level of consciousness due to compression of the reticular formation in the brain. This change in level of consciousness can be as subtle as drowsiness or restlessness. Because centers that control blood pressure are located lower in the brainstem than those that control consciousness, change in pulse pressure is a later sign. Options 2 and 3 are not early signs of increased ICP. These signs may occur later if the increased ICP has led to neurological damage.

Test-Taking Strategy: Note the key word early. Remember that changes in level of consciousness are the first indication of increased ICP. Review the clinical manifestations associated with increased ICP if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Neurological
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 382-384.

2. A client has just returned from the radiology department following an upper gastrointestinal (GI) series. The nurse reviews the physician’s orders expecting to note which of the following needed for routine postprocedure care?

A. Intravenous (IV) fluids
B. A bland diet
C. An antiemetic
D. A laxative

Answer: A. Intravenous (IV) fluids

Rationale: Barium sulfate, which is used as contrast material during an upper GI series, is a constipating material. If it is not eliminated from the GI tract, it can cause obstruction. Therefore laxatives or cathartics are administered as part of routine postprocedure care. Options 1, 2, and 3 are not components of postprocedure care following an upper GI series.

Test-Taking Strategy: Focus on the diagnostic procedure. Recalling that barium sulfate is administered during this test will direct you to option D. Review postprocedure care following an upper GI series if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Adult Health/Gastrointestinal
Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 1109.

3. A nurse reviews the nursing care plan developed by a nursing student caring for a client who is receiving continuous tube feedings via a nasogastric (NG) tube. The nurse intervenes if the student documented which intervention in the plan?

A. Check the residual every 4 hours
B. Check for placement before administering medications through the tube
C. Check for placement every 4 hours
D. Keep the feeding bag filled with at least 100 mL of feeding continuously so that it does not run dry

Answer: A. Intravenous (IV) fluids

Rationale: The placement of an NG feeding tube is checked at least every 4 hours for residual during administration of continuous tube feedings. Placement is also checked before each bolus with intermittent feedings and before the administration of medications through the tube. The bag and tubing are completely changed every 24 hours or per agency protocol. The hanging bag should be rinsed before new formula is added to it. An excess amount of feeding should not be allowed to sit in the feeding bag because of the potential for the growth of bacteria.

Test-Taking Strategy: Note the key word intervenes in the question. This word indicates a false response question and that you need to select the incorrect intervention. Visualize the procedure for continuous tube feedings to assist in answering the question. Eliminate options 1, 2, and 3 because they are similar. Review care to the client with a nasogastric feeding tube if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 477.

4. A nurse is preparing to assist a physician with the insertion of a chest tube. The nurse anticipates that which of the following supplies will be required for the chest tube insertion site?

A. Sterile 4 x 4 gauze pad
B. Sterile Kerlix dressing
C. Petrolatum (Vaseline) gauze
D. Povidone-iodine gauze

Answer: C. Petrolatum (Vaseline) gauze

Rationale: The first layer of the chest tube dressing is petrolatum (Vaseline) gauze, which allows for an occlusive seal at the chest tube insertion site. Additional layers of gauze cover this layer, and the dressing is secured with a strong adhesive tape or Elastoplast tape. Povidone-iodine may be used to clean the insertion site before insertion of the chest tube. Sterile dressings will be used to cover the Vaseline gauze.

Test-Taking Strategy: The key word in this question is required. To answer this question correctly, recall that it is imperative to have an occlusive seal at the site and know which dressing material will provide that seal. Option 3 is the only dressing that will provide that occlusive seal. Review the procedure for inserting a chest tube if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Adult Health/Respiratory
Reference: Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, p. 397.

Read also:

• NCLEX Practice Tests 106th Edition
• NCLEX Practice Tests & Sample Questions 105th Edition
• NCLEX Questions of the Daily 104th Edition

Thank you for your attention with reading our article Free NCLEX Practice Tests 107th Edition (Adult Health/Respiratory/Neurological/Gastrointestinal/Leadership/Management). Thanks for your participation, like and share if this is usefull.

Share this post