1.

When caring for a client with a post right thoracotomy who has
undergone an upper lobectomy, the nurse focuses on pain
management to promote:
a. Relaxation and sleep
b. Deep breathing and coughing
c. Incisional healing
d. Range of motion exercises
2. A client has a chest tube in place following a left lower lobectomy
inserted after a stab wound to the chest. When repositioning the
client, the nurse notices 200 cc of dark, red fluid flows into the
collection chamber of the chest drain. What is the most appropriate
nursing action?
a. Clamp the chest tube
b. Call the surgeon immediately
c. Prepare for blood transfusion
d. Continue to monitor the rate of drainage
3. The nurse is reviewing laboratory results on a client with acute renal
failure. Which one of the following should be reported immediately?
a. Blood urea nitrogen 50 mg/dl
b. Hemoglobin of 10.3 mg/dl
c. Venous blood pH 7.30
d. Serum potassium 6 mEq/L
4. The nurse is caring for a child immediately after surgical correction
of a ventricular septal defect. Which of the following nursing
assessments should be a priority?
a. Blanch nail beds for color and refill
b. Assess for post operative arrhythmias
c. Auscultate for pulmonary congestion
d. Monitor equality of peripheral pulses

5. A client is diagnosed with a spontaneous pneumothorax

necessitating the insertion of a chest tube. What is the best
explanation for the nurse to provide this client?
a. The tube will drain fluid from your chest.
b. The tube will remove excess air from your chest.
c. The tube controls the amount of air that enters your chest.
d. The tube will seal the hole in your lung.
6. A four year-old has been hospitalized for 24 hours with skeletal
traction for treatment of a fracture of the right femur. The nurse finds
that the child is now crying and the right foot is pale with the absence
of a pulse. What should the nurse do FIRST?
a. Notify the physician
b. Readjust the traction
c. Administer the ordered prn medication
d. Reassess the foot in fifteen minutes
7. A client has a history of chronic obstructive pulmonary
disease (COPD). As the nurse enters the clients room, his oxygen is
running at 6 L/min, his color is flushed and his respirations are 8/min.
What should the nurse do FIRST?
a. Obtain a 12-lead EKG
b. Place client in high Fowlers position
c. Lower the oxygen rate
d. Take baseline vital signs
8. The nurse is assessing a client two hours postoperatively after a
femoral popliteal bypass. The upper leg dressing becomes saturated
with blood. The nurses FIRST action should be to:
a. Wrap the leg with elastic bandages
b. Apply pressure at the bleeding site

c. Reinforce the dressing and elevate the leg

d. Remove the dressings and re-dress the incision
9. The nurse is caring for a client who requires a mechanical ventilator
for breathing. The high pressure alarm goes off on the ventilator. What
is the FIRST action the nurse should perform?
a. Disconnect the client from the ventilator and use a manual
resuscitation bag
b. Perform a quick assessment of the clients condition
c. Call the respiratory therapist for help
d. Press the alarm re-set button on the ventilator
10. The nurse is reviewing laboratory results on a client with acute
renal failure. Which one of the following should be reported
IMMEDIATELY?
a. Blood urea nitrogen 50 mg/dl
b. Hemoglobin of 10.3 mg/dl
c. Venous blood pH 7.30
d. Serum potassium 6 mEq/L
11. A client has a chest tube in place following a left lower lobectomy
done after a stab wound to the chest. When repositioning the client,
the nurse notices 200 cc of dark, red fluid flows into the collection
chamber of the chest drain. What is the MOST appropriate nursing
action?
a. Clamp the chest tube
b. Call the surgeon immediately
c. Prepare for blood transfusion
d. Continue to monitor the rate of drainage
12. When caring for a client with a post right thoracotomy who has
undergone an upper lobectomy, the nurse focuses on pain

management to promote:
a. Relaxation and sleep
b. Coughing and deep breathing
c. Incisional healing
d. Range of motion exercises
13. The priority is postoperative respiratory toilet. This client will
quickly develop profound atelectasis and eventually pneumonia
without adequate gas exchange. This will only be achieved with the
appropriate pain management.
a. Pallor
b. Increased temperature
c. Dyspnea
d. Involuntary muscle spasms
14. The nurse is performing a physical assessment on a client who just
had an endotracheal tube inserted. Which finding would call for
IMMEDIATE action by the nurse?
a. Breath sounds can be heard bilaterally
b. Mist is visible in the T-Piece
c. Pulse oximetery of 88
d. Client is unable to speak
15. A client is receiving external beam radiation to the mediastinum
for treatment of bronchial cancer. Which of the following should take
PRIORITY in planning care?
a. Esophagitis
b. Leukopenia
c. Fatigue
d. Skin irritation
16. A client is diagnosed with a spontaneous pneumothorax

necessitating the insertion of a chest tube. What is the BEST

explanation for the nurse to provide this client?
a. The tube will drain fluid from your chest.
b. The tube will remove excess air from your chest.
c. The tube controls the amount of air that enters your chest.
d. The tube will seal the hole in your lung.
17. The nurse is caring for a child immediately after surgical correction
of a ventricular septal defect. Which of the following nursing
assessments should be a PRIORITY?
a. Blanch nail beds for color and refill
b. Assess for post operative arrhythmias
c. Auscultate for pulmonary congestion
d. Monitor equality of peripheral pulses
18. The MOST effective nursing intervention to prevent atelectasis
from developing in a post operative client is to:
a. Maintain adequate hydration
b. Assist client to turn, cough and deep breathe
c. Ambulate client within 12 hours
d. Splint incision
19. The nurse is preparing a client who will undergo a myelogram.
Which of the following statements by the client indicates a
contraindication for this test?
a. I cant lie in one position for more than thirty minutes.
b. I am allergic to shrimp.
c. I suffer from claustrophobia.
d. I developed a severe headache after a spinal tap.
20. A client has returned from a cardiac catheterization. Which one of
the following assessments would indicate the client is experiencing a

complication from the procedure?

a. Increased blood pressure
b. Increased heart rate
c. Loss of pulse in the extremity
d. Decreased urine output

Answer and Rationale- Reduction of Risk

Potential NCLEX Practice Test
<< Back to Questions
1. Answer B. The priority is postoperative respiratory toilet. This client will quickly
develop profound atelectasis and eventually pneumonia without adequate gas exchange.
This will only be achieved with the appropriate pain management.
2. Answer D. Blood that comes in contact with the pleural space becomes defibrinogenated
and usually will not clot. It is not unusual for blood to collect in the chest and be released
into the chest drain when the client changes position. The dark color of the blood indicates
it is not fresh bleeding inside the chest
3. Answer D. Although all of these findings are abnormal, the elevated potassium is a life
threatening finding and must be reported immediately.
4. Answer B. The atrioventricular bundle (bundle of His), a part of the electrical
conduction system of the heart, extends from the atrioventricular node along each side of
the interventricular septum and then divides into right and left bundle branches. Surgical
repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over
the opening.
5. Answer B. The purpose of the chest tube is to create negative pressure and remove the
air that has accumulated in the pleural space.
6. Answer A. The findings are indicative of circulatory impairment. The physician (or
practitioner) must be notified immediately.
7. Answer C. A low oxygen level acts as a stimulus for respiration. A high concentration of
supplemental oxygen removes the hypoxic drive to breathe, leading to increased
hypoventilation, respiratory decompensation, and the development of or worsening of

respiratory acidosis. Unless corrected, it can lead to the clients death.

8. Answer C. Reinforce the dressing, elevate the extremity to decrease blood flow into the
extremity and thus decrease bleeding, and call the physician immediately. This is an
emergency post surgical situation.
9. Answer B. A number of situations can cause the high pressure alarm to sound. It can be
as simple as the client coughing. A quick assessment of the client will alert the nurse to
whether it is a more serious or complex situation that might then require using a manual
resuscitation bag and calling the respiratory therapist.
10. Answer D. Although all of these findings are abnormal, the elevated potassium is a life
threatening finding and must be reported immediately.
11. Answer D. Blood that comes in contact with the pleural space becomes
defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest
and be released into the chest drain when the client changes position. The dark color of the
blood indicates it is not fresh bleeding inside the chest.
12. Answer B. The priority is postoperative respiratory toilet. This client will quickly
develop profound atelectasis and eventually pneumonia without adequate gas exchange.
This will only be achieved with the appropriate pain management.
13. Answer C. Clients having the insertion of a central venous catheter are at risk for
tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this
complication.
14. Answer C. Pulse oximetry should not be lower than 90.
15. Answer B. Clients develop leukopenia due to the depressant effect of radiation therapy
on bone marrow function. Infection is the most frequent cause of morbidity and death in
clients with cancer.
16. Answer B. The purpose of the chest tube is to create negative pressure and remove the
air that has accumulated in the pleural space.
17. Answer B. The atrioventricular bundle (bundle of His), a part of the electrical
conduction system of the heart, extends from the atrioventricular node along each side of
the interventricular septum and then divides into right and left bundle branches. Surgical
repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over
the opening.
18. Answer B. Deep air excursion by turning, coughing, and deep breathing will expand
the lungs and stimulate surfactant production. The nurse should instruct the client on how
to splint the chest when coughing. Humidification, hydration and nutrition all play a part in

preventing atelectasis following surgery.

19. Answer B. A client undergoing myelography should be questioned carefully about
allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or
seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An
allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used
in the test. An allergic reaction could be as serious as seizures.
20. Answer C. Loss of the pulse in the extremity would indicate impaired circulation.