NCLEX Practice Tests 106th Edition
NCLEX Practice Tests 106th Edition
1. A nurse is observing a client with chronic obstructive pulmonary disease (COPD) performing the pursed-lip breathing technique. Which observation by the nurse would indicate accurate performance of this breathing technique?
A. The client’s inhalation is twice as long as exhalation
B. The client loosens the abdominal muscles while breathing out
C. The client’s exhalation is twice as long as inhalation
D. The client inhales with pursed lips and exhales with the mouth open wide
2. A nurse is caring for a client who is receiving lithium carbonate (lithium) for the treatment of bipolar disorder and monitors the client for signs of lithium toxicity. Which sign would alert the nurse to the potential for toxicity?
A. Constipation
B. Headaches
C. Vomiting
D. Increased urination
3. A nurse is assisting in performing a prenatal examination on a client in the third trimester of pregnancy. The primary health care provider performs Leopold’s maneuvers on the client. The nurse understands that the fourth maneuver will assess for which of the following?
A. Fetal lie and presentation
B. Fetal descent
C. Strength of uterine contractions
D. Placenta previa
Rationale: Fetal descent is determined with the fourth maneuver. The first maneuver is to determine the contents of the fundus (either fetal head or breech) and thereby the fetal lie. Leopold’s maneuvers should not be performed during a contraction. Placenta previa is diagnosed by ultrasonography and not by palpation.
Test-Taking Strategy: Use the process of elimination. Options 3 and 4 can be eliminated first because they are unrelated to this assessment technique. To select between the remaining options, you must be familiar with these maneuvers. Review Leopold’s maneuvers if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Antepartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 106-107.
4. A nurse is monitoring a client with a spinal cord injury who is experiencing spinal shock. Which of the following will provide the nurse with the best information about recovery from the spinal shock?
A. Blood pressure
B. Pulse rate
C. Reflexes
D. Temperature
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