3033 Exam 2 NCLEX Questions

Question 1

Assessment of a patient's body temperature in the late afternoon is 37.2C (99F). The nurse assesses this as most likely due to what?
A) A sign of an infection
B) Result of a normal circadian rhythm
C) Hyperpyrexia
D) Due to a warm environment

Answer 1

B) Result of a normal circadian rhythm

Question 2

Which of the following records muscle tone?
A) Electroencephalograph (EEG)
B) Electrocardiograph (ECG)
C) Electrooculograph (EOG)
D) Electromyograph (EMG)

Answer 2

D) Electromyograph (EMG)

Question 3

The nurse observes some involuntary muscle jerking in a sleeping patient. The nurse determines that the patient is most likely in which stage of sleep?
A) Stage I NREM sleep
B) Stage II NREM sleep
C) Stage IV NREM sleep
D) REM sleep

Answer 3

A) Stage 1 NREM sleep

Question 4

The nurse observes a slight increase in a patient’s vital signs while he is sleeping during the night. According the patient’s stage of sleep, the nurse expects which of the following to be true?
A) He is aware of his surroundings at this point.
B) He is in delta sleep at this time.
C) It would be most difficult to awaken him at this time.
D) This is most likely an NREM stage.

Answer 4

C) It would be most difficult to awake him at this time.

Question 5

How many cycles of sleep does a person typically go through each night?
A) 2 or 3
B) 4 or 5
C) 10 to 12
D) 20 to 25

Answer 5

B) 4 or 5

Question 6

The nurse is discussing with an older woman the factors that induce sleep. Which of the following does the nurse teach her?
A) A cup of regular tea may induce sleep.
B) Large quantities of alcohol promote a deep sleep.
C) The amount of REM sleep decreases with age.
D) Physical activity decreases REM and NREM sleep.

Answer 6

C) The amount of REM Sleep decreases with age.

Question 7

A patient falls asleep in the middle of a conversation. The nurse would suspect which disorder?
A) Hypersomnia
B) Narcolepsy
C) Somnambulism
D) Sleep apnea

Answer 7

B) Narcolepsy

Question 8

Which of the following descriptions is true of the diagnosis tool called a sleep diary?
A) It is usually kept for 1 week.
B) It includes a record of daily physical activity.
C) It includes a record of body temperature taken each evening.
D) It reports primarily subjective data about sleep activities.

Answer 8

B) It includes a record of daily physical activity.

Question 9

To help a patient get to sleep, the nurse suggests that he do which of the following?
A) Follow his usual bedtime routine if possible.
B) Drink two or three glasses of water at bedtime.
C) Have a large snack at bedtime.
D) Take a sedative-hypnotic every night at bedtime.

Answer 9

A) Follow his usual bedtime routine if possible.

Question 10

Which of the following is the most common complaint of patients visiting sleep disorder clinics?
A) Hypersomnia
B) Narcolepsy
C) Chronic insomnia
D) Enuresis

Answer 10

C) Chronic insomnia

Question 11

A prolonged patter of REM deprivation may result in which of the following?
A) Symptoms of psychosis
B) Increased episodes of dreaming
C) Decreased sensitivity to pain
D) Increased mental alertness

Answer 11

A) Symptoms of psychosis

Question 12

Active dreaming occurs during what stage of sleep?
A) Stage II NREM sleep
B) Stage III NREM sleep
C) Stage IV NREM sleep
D) REM sleep

Answer 12

D) REM sleep

Question 13

When describing illness as a stressor that can influence sleep during various stages, which example would be most appropriate for the nurse to use?
A) Hypothyroidism can result in a decrease in the amount of certain stages of NREM sleep.
B) A person with heart disease is more likely to have chest pain during NREM sleep.
C) A patient with epilepsy is more likely to have seizures during REM sleep.
D) An increase in gastric secretions in a person with an ulcer will most likely occur during NREM sleep.

Answer 13

A) Hypothyroidism can result in a decrease in the amount of certain stages of NREM sleep.

Question 14

Caffeine is a known stimulant, and its intake should be:
A) Avoided at least 30 minutes before bedtime
B) Combined with milk to counteract its effect
C) Avoided at least 4 to 5 hours before bedtime
D) Encouraged during waking hours to counteract the effects of sleeplessness

Answer 14

C) Avoided at least 4 to 5 hours before bedtime

Question 15

Medications that induce sleep (sedative-hypnotics) may disturb REM or NREM sleep. The nurse should be aware of which of the following considerations?
A) They should be taken with alcohol for increased effect.
B) They usually become ineffective after several weeks.
C) They can usually be given at intervals during the night.
D) They should be combined with daytime amphetamines to counteract hangover effect.

Answer 15

B) They usually become ineffective after several weeks.

Question 16

A patient has a fractured rib and is breathing less often and with less depth because of the pain. The nurse would document this finding using which term?
A) Fremitus
B) Hyperventilation
C) Pleural friction rub
D) Hypoventilation

Answer 16

D) Hypoventilation

Question 17

When auscultating Mr. Chang's breath sounds, the nurse detects a continuous, musical sound heard on expiration. The nurse identifies this sound as which of the following?
A) Crackles
B) Wheezes
C) Bronchial sounds
D) Pleural friction rub

Answer 17

B) Wheezes

Question 18

Air that develops in the pleural space is referred to as:
A) Pneumothorax
B) Pleural effusion
C) Hemothorax
D) Atelectasis

Answer 18

a) Pneumothorax

Question 19

When planning care for a patient with chronic lung disease who is receiving oxygen through a nasal cannula, what does the nurse expect?
A) The oxygen must be humidified
B) The rate will be 2 L/min or less.
C) Arterial blood gases will be drawn every 4 hours to assess flow rate.
D) The rate will be 6 L/min or more.

Answer 19

B) The rate will be 2 L/min or less

Question 20

Which oxygen delivery device would the nurse expect to use to provide the highest concentration of oxygen to a patient who is breathing spontaneously?
A) Partial rebreather mask
B) Nonrebreather mask
C) Simple mask
D) Venturi mask

Answer 20

B) Nonrebreather mask

Question 21

When teaching a patient about pulse oximetry, which statement would the nurse most likely include in the discussion?
A) A range of 95% to 100% is considered normal oxygen saturation.
B) Oximetry measures oxygen saturation of venous blood.
C) Fasting is required for 12 hours before the test.
D) Pulse oximetry is a replacement for arterial blood gas analysis.

Answer 21

A) A range of 95% to 100% is considered normal oxygen saturation.

Question 22

Which action would the nurse include when performing oropharyngeal suctioning on a patient?
A) Use clean technique.
B) Apply suction as the catheter is introduced.
C) Flush the catheter with saline between catheter insertions.
D) Limit suctioning to 25- to 30-second intervals at one time.

Answer 22

C) Flush the catheter with saline between catheter insertions.

Question 23

Effective use of a metered-dose inhaler requires that the patient accomplish which action?
A) Breathe in through the nose.
B) Inhale two sprays with one breath.
C) Hold the breath for 5 to 10 seconds after inspiration.
D) Exhale quickly through an open mouth.

Answer 23

C) Hold the breath for 5 to 10 seconds after inspiration

Question 24

Mr. Parks has chronic obstructive pulmonary disease (COPD). The nurse has taught him that pursed-lip breathing helps him by:
A) Increasing carbon dioxide, which stimulates breathing
B) Prolonging inspiration and shortening expiration.
C) Liquefying his secretions
D) Decreasing the amount of air trapping and resistance.

Answer 24

D) Decrease the amount of air trapping and resistance

Question 25

A patient develops sudden cardiac arrest. It is imperative to begin CPR as soon as possible. What is the critical time that the nurse must keep in mind before irreversible brain damage occurs?
A) 1 to 3 minutes
B) 2 to 4 minutes
C) 4 to 6 minutes
D) 8 to 10 minutes

Answer 25

C) 4 to 6 minutes

Question 26

David White is in the hospital with a medical diagnosis of viral pneumonia. He is receiving oxygen through a simple face mask. The nurse ensures that the mask fits snugly over the patient’s face for which reason?
A) To prevent the mask movement and consequent skin breakdown
B) To help the patient feel secure
C) To maintain carbon dioxide retention
D) To aid in maintaining expected oxygen delivery

Answer 26

D) To aid in maintaining oxygen delivery

Question 27

When suctioning a patient through a tracheostomy tube, the nurse was careful not occlude the Y port when inserting the suction catheter because this would do which of the following?
A) Prevent suctioning from occurring
B) Cause trauma to the tracheal mucosa
C) Break the sterile technique
D) Suction out all the carbon dioxide

Answer 27

B) Cause trauma to the tracheal mucosa

Question 28

What action does the nurse use to follow safe technique when using a portable oxygen cylinder?
A) Checking the amount of oxygen in the cylinder before using it.
B) Using a cylinder for a patient transfer that indicates available oxygen is 500 psi
C) Placing the oxygen cylinder on the stretcher next to the patient
D) Discontinuing oxygen flow by turning cylinder key counterclockwise until tight

Answer 28

A) Checking the amount of oxygen in the cylinder before using it

Question 29

Which of the following assessment should the nurse consider when performing tracheal suctioning? Select all that apply.
A) Close assessment of the patient before, during and after the procedure.
B) Hyperoxygenate the patient before and after suctioning.
C) Limit the application of suction to 20 to 30 seconds.
D) Monitor the patient’s pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve.
E) Using an appropriate suction pressure (80-120 mm Hg).
F) Insert the suction catheter as far as it will go before applying suction. This will help prevent atelectasis related to the use of high negative pressure.

Answer 29

A) Close assessment of the patient before, during and after the procedure
B) Hyperoxygenate the patient before and after suctioning
D) Monitor the patient’s pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve
E) Using an appropriate suction pressure (80-120 mm Hg)

Question 30

Abdominal breathing at 30 to 60 breaths/minute with an irregular pattern of rate and depth would closely describe the breathing patterns of what age group?
A) Aged adult
B) Infant
C) Early childhood
D) Late childhood

Answer 30

B) Infant