Free NCLEX-RN Practice Exam #6 – Nclex Test Prep

Unilateral neglect is characterized by failure to attend to one side of the body or environment, commonly after a stroke affecting the cerebral hemisphere. The client may groom, dress, or eat on only the attended side while behaving as though the neglected side is not present. Therefore, shaving only one side of the face is a classic behavioral clue. The finding is especially important because the client may not recognize the omission without prompting and may require safety measures and cueing during activities of daily living.

Acute leukemia with a low white blood cell count indicates significant immunosuppression and increased susceptibility to infection. In addition to isolation precautions, reducing exposure to contaminated food is important. Sealed, single-serving packages reduce the opportunity for microorganisms or environmental contaminants to enter the food before it is consumed. This is the source-supported intervention for protecting the neutropenic client from avoidable infection exposure.

According to the supplied rationale, representing oneself as a licensed registered nurse before receiving licensure results is fraud because the individual is deliberately presenting a professional status that has not been legally established. Accurate professional identification is a legal and ethical responsibility. The nurse must practice and document within the authority actually granted by the licensing system rather than assuming that completion of an examination makes the person licensed.

A discrepancy involving a controlled medication requires immediate attention and adherence to the institution’s chain of command. The supplied rationale identifies notification of the nursing supervisor as the first action. The supervisor can initiate the appropriate investigation, verify the count and documentation, and determine whether pharmacy or other administrative personnel need to be notified. The Board of Nursing or higher administration may become involved depending on the findings, but they are not the initial step identified by the source.

The supplied rationale identifies the woman recovering from a hysterectomy as the most appropriate client for transfer to the postpartum unit. Staff on a postpartum unit have experience assessing gynecologic/postoperative bleeding and can recognize expected versus concerning amounts of vaginal bleeding. This makes the hysterectomy client a better fit for that unit than clients whose primary needs are medical-surgical or psychiatric.

The supplied rationale identifies the 40-year-old female with a hysterectomy as the best client to transfer to the postpartum unit. The postpartum nurses are familiar with gynecologic and postpartum-type assessment, including monitoring bleeding and recognizing abnormal findings. This makes the hysterectomy client a better fit for the available unit than clients whose primary needs are medical-surgical or psychiatric care.

The fresh peach is the best choice because it is naturally low in sodium compared with the processed or dairy-based alternatives listed. Sodium restriction is used to reduce fluid retention and cardiovascular or renal workload when indicated. Choosing minimally processed foods, such as fresh fruits, is a practical way to reduce dietary sodium.

The client with congestive heart failure who reports nighttime dyspnea should be assessed first because the complaint can indicate worsening cardiopulmonary status and compromised oxygenation. Using nursing prioritization, airway and breathing concerns take precedence over stable chronic conditions. The supplied rationale therefore identifies this client as the priority visit.

Xerostomia means dry mouth, and a saliva substitute directly addresses the problem by providing moisture and improving oral comfort. Cancer treatment can reduce salivary production and make swallowing, speaking, and oral care uncomfortable. The source identifies saliva substitute as the intervention that most directly relieves xerostomia.

The client with Alzheimer’s disease is identified by the supplied rationale as the most stable client and therefore the one appropriate for the nursing assistant for routine supportive care such as feeding and assistance with activities of daily living. Delegation should match the client’s stability and the assistant’s permitted scope. Clients with acute medical problems require nursing assessment and clinical judgment.

Clients with cerebral palsy may have abnormal muscle tone, involuntary movements, and increased energy expenditure during movement. The supplied rationale states that frequent rest periods help relax tense muscles and preserve energy, making reduction of grimacing and writhing movements with relaxation the supported answer. Rest periods can therefore make care and functional activities more manageable and reduce fatigue.

The supplied rationale identifies genital secretions as the specimen for a gonorrhea culture. The infection primarily involves the genitourinary tract, so obtaining an appropriate genital specimen allows the organism to be identified from the affected site. Proper specimen collection and handling are important for accurate diagnostic testing.

The supplied rationale identifies a clear-liquid diet as the initial postoperative diet after hemorrhoidectomy, with progression toward a regular diet as tolerated. Stool softeners are also used to reduce constipation and straining. A high-fiber diet becomes beneficial later, but the source specifically identifies clear liquids as the initial postoperative choice.

A sitz bath provides warm water therapy to the perineal area and can reduce discomfort, promote relaxation, improve local circulation, and support healing after an episiotomy. The supplied rationale specifically identifies sitz baths as the effective intervention two days after delivery. Ice may be useful immediately after delivery, but at this stage the source favors sitz baths.

Pain is subjective, so the client’s own report is the most reliable measure when the client can communicate. Asking the client to rate pain on a numerical scale provides a standardized measure that can be compared over time and after interventions. The supplied rationale identifies the pain rating scale as the best method among these choices.

The supplied rationale identifies compensated respiratory acidosis as the answer and focuses on the relationship between pH, carbon dioxide, and bicarbonate in a respiratory disorder. A near-normal pH on the acidic side together with an elevated bicarbonate is consistent with renal compensation for a respiratory acid-base disturbance. The source’s written rationale contains the phrase ‘compensated metabolic acidosis,’ but the answer key identifies C, compensated respiratory acidosis; the latter terminology matches the respiratory pattern described by the rationale.

The supplied rationale identifies the registered nurse as the staff member among these choices who can legally initiate seclusion, with the physician also able to do so. Seclusion is a restrictive intervention with significant legal, ethical, and safety implications, so it requires appropriately authorized personnel and ongoing monitoring according to facility policy and applicable rules.

The supplied rationale identifies approximately 1700 hours as the administration time for sodium warfarin. The source explains that late-afternoon administration allows bleeding or coagulation-related laboratory monitoring to be obtained in the morning and evaluated in relation to the therapy. Therefore, 1700 is the answer supported by the source.

When a penetrating or embedded foreign object is present in the eye, the nurse should avoid manipulating or attempting to remove the object. The supplied rationale identifies covering both eyes as the first action because it limits eye movement, including consensual movement of the affected eye, and helps prevent additional trauma. The priority is protection of the eye until definitive treatment is provided.

The nurse should wear gloves when applying topical nitroglycerin to prevent unintended absorption through the nurse’s skin. The supplied rationale also emphasizes avoiding actions that increase absorption or damage the skin. Safe application requires an appropriate skin site, avoidance of unnecessary heat or abrasion, and prevention of direct medication exposure to the nurse.

Before paracentesis, the client should empty the bladder to reduce the risk of accidental bladder puncture when the needle enters the abdominal cavity. The supplied rationale identifies this as the appropriate preprocedure instruction. Paracentesis removes fluid from the peritoneal cavity and is generally performed with the client awake and positioned to facilitate access to the abdomen.

Tensilon (edrophonium) is a short-acting acetylcholinesterase inhibitor used in the diagnostic evaluation of myasthenia gravis. Because excessive cholinergic effects can occur, atropine sulfate should be available to counteract severe muscarinic effects or a cholinergic reaction. The supplied rationale identifies atropine as the required medication to keep available.

The supplied rationale identifies squeezing a ball as the first exercise after mastectomy. Gentle hand and arm exercises are introduced progressively to promote circulation, maintain mobility, and reduce stiffness without immediately placing excessive strain on the surgical area. More demanding activities are introduced later as healing progresses.

The supplied rationale identifies the Rh-negative mother who has an Rh-negative baby as the woman who does not require Rho(D) immune globulin. RhoGam is used when an Rh-negative mother is exposed to Rh-positive fetal red blood cells and is intended to prevent maternal sensitization. If the infant is Rh-negative, there is no Rh-positive antigen exposure requiring this prophylaxis according to the source.

The supplied rationale identifies AST as the least effective of these tests for diagnosing myocardial infarction because it is not specific to cardiac muscle injury. Troponin and CK-MB are more cardiac-specific markers, while myoglobin can rise with muscle injury from several causes. Therefore, AST provides the least specific diagnostic information among the listed choices.

The client is demonstrating denial by refusing to acknowledge the reality of the myocardial infarction and insisting that nothing is wrong. Denial can temporarily protect a person from overwhelming emotional distress, but the nurse must still ensure that the client receives appropriate education, safety assessment, and treatment. The supplied rationale specifically identifies denial as the defense mechanism in this situation.

TPN contains a substantial glucose load, so blood glucose must be monitored closely during therapy. Hyperglycemia can occur if the glucose infusion exceeds the client’s ability to metabolize it, while abrupt changes in infusion can also create glucose-management problems. The supplied rationale therefore identifies blood glucose as the laboratory value that should be evaluated during TPN.

Difficulty seeing is the statement that indicates a need for follow-up because adequate vision may be necessary for safely preparing medications, measuring doses, reading labels, identifying equipment, and performing diabetes self-care. The supplied rationale specifically highlights impaired visual acuity as a potential barrier to independently preparing and administering insulin and therefore requiring additional assistance or planning before discharge.

Lactulose is used in clients with cirrhosis to reduce elevated ammonia and thereby help manage hepatic encephalopathy. The supplied rationale identifies lowering the ammonia level as the purpose of the medication. This is important because impaired hepatic function reduces the body’s ability to handle nitrogenous waste, allowing ammonia to accumulate and contribute to neurologic changes.

Cloudy dialysate is abnormal and can indicate peritonitis or another infectious process. The supplied rationale states that the fluid should be evaluated and identifies sending a specimen to the laboratory as the appropriate action. Prompt evaluation is important because peritoneal infection can become serious and can compromise the effectiveness and safety of dialysis.