New Year Special Limited Time 70% Discount Offer - Ends in 0d 00h 00m 00s - Coupon code: cramtick70

NCLEX-RN National Council Licensure Examination(NCLEX-RN) Questions and Answers

Questions 4

Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality. When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy is:

Options:

A.

70 mg/dL and 120 mg/dL

B.

100 mg/dL and 200 mg/dL

C.

40 mg/dL and 130 mg/dL

D.

90 mg/dL and 200 mg/dL

Buy Now
Questions 5

Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to 25% of her body?

Options:

A.

Urine output

B.

Edema

C.

Hypertension

D.

Bulging fontanelle

Buy Now
Questions 6

A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate?

Options:

A.

Put in a nasogastric tube and lavage the child’s stomach.

B.

Monitor muscular status.

C.

Teach mother poison prevention techniques.

D.

Place child on respiratory assistance.

Buy Now
Questions 7

A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?

Options:

A.

“Keep breathing with your abdominal muscles as long as you can.”

B.

“Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breathe about 16–20 times a minute with shallow chest breaths.”

C.

“Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles.”

D.

“If a woman in labor listens to her body and takes rapid, deep breaths, she will be able to deal with her contractions quite well.”

Buy Now
Questions 8

A complication for which the nurse should be alert following a liver biopsy is:

Options:

A.

Hepatic coma

B.

Jaundice

C.

Ascites

D.

Shock

Buy Now
Questions 9

The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 1–2 minutes; strong, large amount of “bloody show.” The most appropriate nursing goal for this client would be:

Options:

A.

Maintain client’s privacy.

B.

Assist with assessment procedures.

C.

Provide strategies to maintain client control.

D.

Enlist additional caregiver support to ensure client’s safety.

Buy Now
Questions 10

Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome?

Options:

A.

Eating three large meals a day

B.

Drinking small amounts of liquids with meals

C.

Taking a long walk after meals

D.

Eating a low-carbohydrate diet

Buy Now
Questions 11

A diagnosis of hepatitis C is confirmed by a male client’s physician. The nurse should be knowledgeable of the differences between hepatitis A, B, and C. Which of the following are characteristics of hepatitis C?

Options:

A.

The potential for chronic liver disease is minimal.

B.

The onset of symptoms is abrupt.

C.

The incubation period is 2–26 weeks.

D.

There is an effective vaccine for hepatitis B, but not for hepatitis C.

Buy Now
Questions 12

A dose of theophylline may need to be altered if a client with COPD:

Options:

A.

Is allergic to morphine

B.

Has a history of arthritis

C.

Operates machinery

D.

Is concurrently on cimetidine for ulcers

Buy Now
Questions 13

Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug?

Options:

A.

Limit fluids to 500 mL/day.

B.

Administer 2 hours before meals.

C.

Observe for skin rash and diarrhea.

D.

Monitor blood pressure, pulse.

Buy Now
Questions 14

When a client with pancreatitis is discharged, the nurse needs to teach him how to prevent another occurrence of acute pancreatitis. Which of the following statements would indicate he has an understanding of his disease?

Options:

A.

“I will not eat any raw or uncooked vegetables.”

B.

“I will limit my alcohol to one cocktail per day.”

C.

“I will look into attending Alcoholics Anonymous meetings.”

D.

“I will report any changes in bowel movements to my doctor.”

Buy Now
Questions 15

One of the medications that is prescribed for a male client is furosemide (Lasix) 80 mg bid. To reduce his risk of falls, the nurse would teach him to take this medication:

Options:

A.

On arising and no later than 6 PM

B.

At evenly spaced intervals, such as 8 AM and 8 PM

C.

With at least one glass of water per pill

D.

With breakfast and at bedtime

Buy Now
Questions 16

A 56-year-old psychiatric inpatient has had recurring episodes of depression and chronic low self-esteem. She feels that her family does not want her around, experiences a sense of helplessness, and has a negative view of herself. To assist the client in focusing on her strengths and positive traits, a strategy used by the nurse would be to:

Options:

A.

Tell the client to attend all structured activities on the unit

B.

Encourage or direct client to attend activities that offer simple methods to attain success

C.

Increase the client’s self-esteem by asking that she make all decisions regarding attendance in group activities

D.

Not allow any dependent behaviors by the client because she must learn independence and will have to ask for any assistance from staff

Buy Now
Questions 17

Which of the following signs might indicate a complication during the labor process with vertex presentation?

Options:

A.

Fetal tachycardia to 170 bpm during a contraction

B.

Nausea and vomiting at 8–10 cm dilation

C.

Contraction lasting 60 seconds

D.

Appearance of dark-colored amniotic fluid

Buy Now
Questions 18

The family member of a child scheduled for heart surgery states, “I just don’t understand this open-heart or closed-heart business. I’m so confused! Can you help me understand it?” The nurse explains that patent ductus arteriosus repair is:

Options:

A.

Open-heart surgery. The child will be placed on a heart-lung machine while the surgery is being performed.

B.

Closed-heart surgery. It does not require that the child be placed on the heart-lung machine while the surgery is being performed.

C.

A pediatric version of the coronary artery bypass graft surgery performed on adults. It is an open-heart surgery.

D.

A pediatric version of percutaneous transluminal coronary angioplasty performed on adults. It is a closed-heart surgery.

Buy Now
Questions 19

The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include:

Options:

A.

Ordering a full liquid diet for her

B.

Ordering five small meals for her

C.

Ordering a mechanical soft diet for her

D.

Ordering a puréed diet for her

Buy Now
Questions 20

A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:

Options:

A.

Placing her in seclusion until the behavior is under control

B.

Walking up to the client and touching her on the arm to get her attention

C.

Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet area

D.

Confronting the client, letting her know the consequences for getting angry and disrupting the unit

Buy Now
Questions 21

A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, “Oh dear, I feel like I have to urinate again!” Which of the following is the most appropriate initial nursing response?

Options:

A.

Assure her that this is most likely the result of bladder spasms.

B.

Check the collection bag and tubing to verify that the catheter is draining properly.

C.

Instruct her to do Kegel exercises to diminish the urge to void.

D.

Ask her if she has felt this way before.

Buy Now
Questions 22

The parents of a 9-year-old child with acute lymphocytic leukemia expressed concern about his alopecia from cranial irradiation. The nurse explains that:

Options:

A.

Alopecia is an unavoidable side effect.

B.

There are several wig makers for children.

C.

Most children select a favorite hat to protect their heads.

D.

His hair will grow back in a few months.

Buy Now
Questions 23

A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be more comfortable if the nurse:

Options:

A.

Dims the lights in her room

B.

Encourages her to breathe slowly and deeply

C.

Offers sips of warm liquids

D.

Places a large, soft pillow under her head

Buy Now
Questions 24

An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observe which of the following:

Options:

A.

Both lower extremities warm to touch with 2_pedal pulses

B.

Both lower extremities cyanotic when placed in a dependent position

C.

Decreased or absent pedal pulse in the left leg

D.

The left leg warmer to touch than the right leg

Buy Now
Questions 25

A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused. In accordance with the law, the nurse must:

Options:

A.

Tell the physician her concerns

B.

Report her suspicions to the authorities

C.

Talk to the child’s father

D.

Confront the child’s mother

Buy Now
Questions 26

The nurse notes multiple bruises on the arms and legs of a newly admitted client with lupus. The client states, “I get them whenever I bump into anything.” The nurse would expect to note a decrease in which of the following laboratory tests?

Options:

A.

Number of platelets

B.

WBC count

C.

Hemoglobin level

D.

Number of lymphocytes

Buy Now
Questions 27

The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the client?

Options:

A.

“Do you take aspirin on a regular basis?”

B.

“Do you drink alcohol on a regular basis?”

C.

“Do you eat red meat?”

D.

“Have your stools been normal?”

Buy Now
Questions 28

The initial focus when providing nursing care for a child with rheumatic fever during the acute phase of the illness should be to:

Options:

A.

Maintain contact with her parents

B.

Provide for physical and psychological rest

C.

Provide a nutritious diet

D.

Maintain her interest in school

Buy Now
Questions 29

During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by:

Options:

A.

Putting all joints through full range-of-motion twice daily

B.

Massaging the joints briskly with lotion or liniment after bath

C.

Immobilizing the joints in functional position using splints, rolls, and pillows

D.

Applying warm water bottle or heating pads over involved joints

Buy Now
Questions 30

When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. This behavior is most indicative of:

Options:

A.

Pericarditis

B.

Anxiety

C.

Congestive heart failure

D.

Angina

Buy Now
Questions 31

Which of the following findings would be abnormal in a postpartal woman?

Options:

A.

Chills shortly after delivery

B.

Pulse rate of 60 bpm in morning on first postdelivery day

C.

Urinary output of 3000 mL on the second day after delivery

D.

An oral temperature of 101F (38.3C) on the third day after delivery

Buy Now
Questions 32

The nurse is in the hallway and one of the visitors faints. The nurse should:

Options:

A.

Sit the victim up and lightly slap his face

B.

Elevate the victim’s legs

C.

Apply a cool cloth to the victim’s neck and forehead until he recovers

D.

Sit the victim up and place the head between the knees

Buy Now
Questions 33

One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, “It’s really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers.” The nurse’s best response would be:

Options:

A.

“That might be a problem. Tell me more about them.”

B.

“Risk factors can often be controlled by self-responsibility.”

C.

“It sounds like you’re intellectualizing your drinking problem.”

D.

“Your grandfather and father were both alcoholics?”

Buy Now
Questions 34

A client was prescribed a major tranquilizer 2 months ago. One month ago she was placed on benztropine (Cogentin). What would indicate that benztropine therapy is effective?

Options:

A.

Smooth, coordinated voluntary movement

B.

Tremors

C.

Rigidity

D.

Muscle weakness

Buy Now
Questions 35

A 33-year-old client is diagnosed with bipolar disorder, acute phase. This is her first psychiatric hospitalization, and she is being evaluated for treatment with lithium. Which of the following diagnostic tests are essential prior to the initiation of lithium therapy with this client?

Options:

A.

Hematocrit, hemoglobin, and white blood cell (WBC) count

B.

Blood urea nitrogen, electrolytes, and creatinine

C.

Glucose, glucose tolerance test, and random blood sugar

D.

X-rays, electroencephalogram, and electrocardiogram(ECG)

Buy Now
Questions 36

A 47-year-old male client is admitted for colon surgery. Intravenous antibiotics are begun 2 hours prior to surgery. He has no known infection. The rationale for giving antibiotics prior to surgery is to:

Options:

A.

Provide cathartic action within the colon

B.

Reduce the risk of wound infection from anaerobic bacteria

C.

Relieve the client’s concern regarding possible infection

D.

Reduce the risk of intraoperative fever

Buy Now
Questions 37

A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, “I know that alcohol is a problem for some people, but I can stop whenever I want to. I’m never sick or miss work, and no one can complain about me.” During the initial assessment, the best response by the nurse would be:

Options:

A.

“The fact is you are an alcoholic or you wouldn’t be here.”

B.

“I understand it took strength to admit yourself to the unit, and I will do my part to help you to stay alcohol- free.”

C.

“If you can stop drinking when you want to, why don’t you stop?”

D.

“It’s good that you can stop drinking when you want to.”

Buy Now
Questions 38

Nursing assessment of early evidence of septic shock in children at risk includes:

Options:

A.

Fever, tachycardia, and tachypnea

B.

Respiratory distress, cold skin, and pale extremities

C.

Elevated blood pressure, hyperventilation, and thready pulses

D.

Normal pulses, hypotension, and oliguria

Buy Now
Questions 39

A 3-year-old female client is brought into the pediatric clinic because she limps. She has not been to the clinic since she was 9 months old. The nurse practitioner describes the limp as a “Trendelenburg gait.” This gait is characteristic of:

Options:

A.

Scoliosis

B.

Dislocated hip

C.

Fractured femur

D.

Fractured pelvis

Buy Now
Questions 40

The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival stimulation. When tooth-brushing is contraindicated, the next most effective cleansing and gingival stimulation technique would be:

Options:

A.

Using a water pik

B.

Rinsing with water

C.

Rinsing with hydrogen peroxide

D.

Rinsing with baking soda

Buy Now
Questions 41

A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of:

Options:

A.

Potassium-rich foods

B.

Tryptophan

C.

Tyramine

D.

Saturated fats

Buy Now
Questions 42

One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:

Options:

A.

Blood pressure

B.

Level of consciousness

C.

Skin turgor

D.

Fluid intake

Buy Now
Questions 43

A 1000-mL dose of lactated Ringer’s solution is to be infused in 8 hours. The drop factor for the tubing is 10 gtt/mL. How many drops per minute should the nurse administer?

Options:

A.

125 gtt/min

B.

48 gtt/min

C.

20 gtt/min

D.

21 gtt/min

Buy Now
Questions 44

The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, when compared to an adult, include:

Options:

A.

Fewer alveoli, slower respiratory rate

B.

Diaphragmatic breathing, larger volume of air

C.

Larger number of alveoli, diaphragmatic breathing

D.

Rounded shape of chest, smaller volume of air

Buy Now
Questions 45

An elective saline abortion has been performed on a 3- week primigravida. Following the procedure, the nurse should be alert for which early side effect?

Options:

A.

Water satiety

B.

Thirst

C.

Edema

D.

Diabetes insipidus

Buy Now
Questions 46

A 24-year-old client presents to the emergency department protesting “I am God.” The nurse identifies this as a:

Options:

A.

Delusion

B.

Illusion

C.

Hallucination

D.

Conversion

Buy Now
Questions 47

An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?

Options:

A.

Apply ice packs to both legs.

B.

Begin débridement by removing all charred clothing from wound.

C.

Apply Silvadene cream (silver sulfadiazine).

D.

Immerse both legs in cool water.

Buy Now
Questions 48

A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:

Options:

A.

Fourth stage of labor

B.

Third stage of labor

C.

Transition stage of labor

D.

Second stage of labor

Buy Now
Questions 49

A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?

Options:

A.

Bulging fontanelles

B.

Seizure

C.

Headache

D.

Ataxia

Buy Now
Questions 50

A 16-year-old client reports a weight loss of 20% of her previous weight. She has a history of food binges followed by self-induced vomiting (purging). The nurse should suspect a diagnosis of:

Options:

A.

Anorexia nervosa

B.

Anorexia hysteria

C.

Bulimia

D.

Conversion reaction

Buy Now
Questions 51

The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?

Options:

A.

Mother is concerned about her recovery.

B.

Mother calls infant by name.

C.

Mother lightly touches infant.

D.

Mother is concerned about her weight gain.

Buy Now
Questions 52

A young boy tells the nurse, “I don’t like my Dad to kiss or hug my Mom. I love my Mom and want to marry her.” The nurse recognizes this stage of growth and development as:

Options:

A.

Electra complex

B.

Oedipus complex

C.

Superego

D.

Ego

Buy Now
Questions 53

A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the laboring woman during transition are:

Options:

A.

Frustration, vague in communication

B.

Seriousness, some difficulty following directions

C.

Calmness, follows directions easily

D.

Excitement, openness to instructions

Buy Now
Questions 54

A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse’s first action should be to:

Options:

A.

Call the physician

B.

Assess her vital signs

C.

Give the prescribed oxytocic drug

D.

Massage her fundus

Buy Now
Questions 55

A newborn is admitted to the newborn nursery with tremors, apnea periods, and poor sucking reflex. The nurse should suspect:

Options:

A.

Central nervous system damage

B.

Hypoglycemia

C.

Hyperglycemia

D.

These are normal newborn responses to extrauterine life

Buy Now
Questions 56

A nurse is performing a vaginal exam on a client in active

labor. An important landmark to assess during labor

and delivery are the ischial spines because:

Options:

A.

Ischial spines are the narrowest diameter of the pelvis

B.

Ischial spines are the widest diameter of the pelvis

C.

They represent the inlet of birth canal

D.

They measure pelvic floor

Buy Now
Questions 57

A client’s physician has prescribed theophylline (Theo- Dur) to help control the bronchospasm associated with the client’s COPD. Instructions that should be given to the client include:

Options:

A.

“Call your physician if you develop palpitations, dizziness, or restlessness.’’

B.

“Cigarette smoking may significantly increase the risk for theophylline toxicity.’’

C.

“Take this medication on an empty stomach.’’

D.

“Do not take your medicine if your pulse is less than 60 beats per minute.’’

Buy Now
Questions 58

The nurse instructs a client on the difference between true labor and false labor. The nurse explains, “In true labor:

Options:

A.

Uterine contractions will weaken with walking.”

B.

Uterine contractions will strengthen with walking.”

C.

The cervix does not dilate.”

D.

The fetus does not descend.”

Buy Now
Questions 59

A mother who is breast-feeding her newborn asks the RN, “How can I express milk from my breasts manually?” The RN tells her that the correct method for manual milk expression includes using the thumb and the index finger to:

Options:

A.

Alternately compress and release each nipple

B.

Roll the nipple and gently pull the nipple forward

C.

Slide the thumb and index finger forward from the outer border of the areola toward the end of the nipple

D.

Compress and release each breast at the outer border of the areola

Buy Now
Questions 60

A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, “The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he’s going to cut out my heart.” The nurse’s best response is:

Options:

A.

“I know you’re feeling frightened right now, but I want you to know that I don’t see anyone in the corner.”

B.

“You’ll probably see strange things for a while until the PCP wears off.”

C.

“Try to sleep. When you wake up, the devil will be gone.”

D.

“You’re probably feeling guilty because you used illegal drugs tonight.”

Buy Now
Questions 61

While the nurse is taking a male client’s blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:

Options:

A.

Politely tells the client, “Keep your hands off ”

B.

Ignores the remarks and hopes he will not try it again

C.

Confronts the remarks but attempts not to reject the client

D.

Leaves the room in order to compose herself

Buy Now
Questions 62

A client’s membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?

Options:

A.

Assess quantity of fluid.

B.

Assess color and odor of fluid.

C.

Document on fetal monitor strip and chart.

D.

Assess fetal heart rate (FHR).

Buy Now
Questions 63

A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?

Options:

A.

Give fluids if the client requests them.

B.

Assess skin integrity and circulation of extremities before applying restraints and as they are removed.

C.

Measure vital signs at least every 4 hours.

D.

Release restraints every 2 hours for client to exercise.

Buy Now
Questions 64

A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:

Options:

A.

Crying

B.

Falling asleep

C.

Rolling from his back to his tummy

D.

Sucking his thumb

Buy Now
Questions 65

A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?

Options:

A.

State nursing practice act

B.

AWHONN Standards for the Nursing Care of Women and Newborns

C.

American Nurses’ Association Standards of Maternal- Child Health Nursing

D.

International Council of Nurses’ Code

Buy Now
Questions 66

A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6, and 7 on the left and developed a left pneumothorax. Assessment findings include:

Options:

A.

Crackles and paradoxical chest wall movement

B.

Decreased breath sounds on the left and chest pain with movement

C.

Rhonchi and frothy sputum

D.

Wheezing and dry cough

Buy Now
Questions 67

A 44-year-old female client is receiving external radiation to her scapula for metastasis of breast cancer.

Teaching related to skin care for the client would include which of the following?

Options:

A.

Teach her to completely clean the skin to remove all ointments and markings after each treatment.

B.

Teach her to cover broken skin in the treated area with a medicated ointment.

C.

Encourage her to wear a tight-fitting vest to support her scapula.

D.

Encourage her to avoid direct sunlight on the area being treated.

Buy Now
Questions 68

A female client at 36 weeks’ gestation is experiencing preterm labor. Her physician has prescribed two doses of betamethasone 12 mg IM q24h. The nurse explains that she is receiving this drug to:

Options:

A.

Treat fetal respiratory distress syndrome

B.

Prevent uterine infection

C.

Promote fetal lung maturation

D.

Increase uteroplacental circulation

Buy Now
Questions 69

A male client has been hospitalized with congestive heart failure. Medical management of heart failure focuses on improving myocardial contractility. This can be achieved by administering:

Options:

A.

Digoxin (Lanoxin) 0.25 mg po every day

B.

Furosemide (Lasix) 40 mg po every morning

C.

O22 L/min via nasal cannula

D.

Nitroglycerin (Nitrol) 1 inch topically every 4 hours

Buy Now
Questions 70

A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5’4” and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:

Options:

A.

Obtain an accurate weight

B.

Search the client’s purse for pills

C.

Assess vital signs

D.

Assign her to a room with someone her own age

Buy Now
Questions 71

A 2-year-old child is recovering from surgery. Considering growth and development according to Erikson, the nurse identifies which of the following play activities as most appropriate?

Options:

A.

Assembling a puzzle with large pieces

B.

Being taken for a wheelchair ride

C.

Listening to a story about the Muppets

D.

Watching Sesame Street on television

Buy Now
Questions 72

The physician of a client diagnosed with alcoholism orders neomycin 0.5 g q6h to prevent hepatic coma. Neomycin decreases serum ammonia levels by:

Options:

A.

Decreasing nitrogen-forming bacteria in the intestines

B.

Acidifying colon contents by causing ammonia retention in the colon

C.

Decreasing the uptake of vitamin D, thereby drawing more water into the colon

D.

Irritating the bowel and promoting evacuation of stool

Buy Now
Questions 73

Two weeks after a client’s admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following conditions, if present, would be a contraindication for ECT?

Options:

A.

Brain tumor or other space-occupying lesion

B.

History of mitral valve prolapse

C.

Surgically repaired herniated lumbar disk

D.

History of frequent urinary tract infections

Buy Now
Questions 74

A male client receives 10 U of regular human insulin SC at 9:00 AM. The nurse would expect peak action from this injection to occur at:

Options:

A.

9:30 AM

B.

10:30 AM

C.

12 noon

D.

4:00 PM

Buy Now
Questions 75

A 24-year-old woman who is gravida 1 reports, “I can’t take iron pills because they make me sick.” She continues, “My bowels aren’t moving either.” In counseling her based on these complaints, the nurse’s most appropriate response would be, “It would be beneficial for you to eat . . .

Options:

A.

prunes.”

B.

green leafy vegetables.”

C.

red meat.”

D.

eggs.”

Buy Now
Questions 76

In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4 toxicity?

Options:

A.

A 31 patellar tendon reflex

B.

Respirations of 12 breaths/min

C.

Urine output of 40 mL/hr

D.

A 21 proteinuria value

Buy Now
Questions 77

A female client is concerned that she is in a “high-risk” group for the development of acquired immunodeficiency syndrome (AIDS). She wants to know about the advisability of donating blood. Which of the following responses is correct?

Options:

A.

“Individuals who donate blood are at risk of getting the AIDS virus. You should not donate.”

B.

“It’s OK for you to donate because the blood bank has a test that is 100% effective.”

C.

“You should not donate since it takes time to develop antibodies to the AIDS virus. If you donate blood before you develop the antibody, you could pass it on in the blood.”

D.

“It is not a good idea for you to donate. If you have AIDS, the information is made public and could destroy your personal life.”

Buy Now
Questions 78

A female client comes for her second prenatal visit. The nurse-midwife tells her, “Your blood tests reveal that you do not show immunity to the German measles.” Which notation will the nurse include in her plan of care for the client? “Will need . . .

Options:

A.

Rh-immune globulin at the next visit”

B.

Rh-immune globulin within 3 days of delivery”

C.

Rubella vaccine at the next visit”

D.

Rubella vaccine after delivery on the day of discharge”

Buy Now
Questions 79

A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination?

Options:

A.

Auditory

B.

Gustatory

C.

Olfactory

D.

Visceral

Buy Now
Questions 80

One of the most dramatic and serious complications associated with bacterial meningitis is Waterhouse- Friderichsen syndrome, which is:

Options:

A.

Peripheral circulatory collapse

B.

Syndrome of inappropriate antiduretic hormone

C.

Cerebral edema resulting in hydrocephalus

D.

Auditory nerve damage resulting in permanent hearing loss

Buy Now
Questions 81

The nurse would need to monitor the serum glucose levels of a client receiving which of the following medications, owing to its effects on glycogenolysis and insulin release?

Options:

A.

Norepinephrine (Levophed)

B.

Dobutamine (Dobutrex)

C.

Propranolol (Inderal)

D.

Epinephrine (Adrenalin)

Buy Now
Questions 82

A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?

Options:

A.

“I did not get the raise because my boss does not like me.”

B.

“I felt a lump in my breast 2 weeks ago. I put off getting it checked until after my sister’s wedding.”

C.

“My son died 3 years ago. I still cannot bring myself to clean out his room.”

D.

“My husband told me this morning that he wants a divorce. I am upset, but I cannot discuss the matter with him until after my company’s board meeting today.”

Buy Now
Questions 83

A parent told the public health nurse that her 6-year-old son has been taking tetracycline for a chronic skin condition. The parent asked if this could cause any problems for the child. What should the nurse explain to the parent?

Options:

A.

Giving tetracycline to a child younger than 8 years may cause permanent staining of his teeth.

B.

If you give tetracycline with milk, it may be absorbed readily.

C.

The medication should be given to adults, not children.

D.

Secondary infections of chronic skin disorders do not respond to antibiotics.

Buy Now
Questions 84

A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:

Options:

A.

Explain that he will be kept NPO for 24 hours before the exam

B.

Practice with him so he will be able to hold his breath for 1 minute

C.

Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver

D.

Explain that his vital signs will be checked frequently after the test

Buy Now
Questions 85

A chronic alcoholic client’s condition deteriorates, and he begins to exhibit signs of hepatic coma. Which of the following is an early sign of impending hepatic coma?

Options:

A.

Hiccups

B.

Anorexia

C.

Mental confusion

D.

Fetor hepaticus

Buy Now
Questions 86

A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her third attempt in 2 years. The highest priority intervention at this time is to:

Options:

A.

Assess level of consciousness

B.

Assess suicide potential

C.

Observe for sedation and hypotension

D.

Orient to her room and unit rules

Buy Now
Questions 87

The healthcare team determines that an elderly client has had progressive changes in memory over the last 2 years that have interfered with her personal, social, or occupational functioning. Her memory, learning, attention, and judgment have all been affected in some way. These symptoms describe which of the following conditions?

Options:

A.

Dementia

B.

Parkinsonism

C.

Delirium

D.

Mania

Buy Now
Questions 88

Assessment of a client reveals a 30% loss of preillness weight, lanugo, and cessation of menses for 3 months. Her vital signs are BP 90/50, P 96 bpm, respirations 30, and temperature 97 οF. She admits to the nurse that she has induced vomiting 3 times this morning, but she had to continue exercising to lose “just 5 more lb.” Her symptoms are consistent with:

Options:

A.

Pregnancy

B.

Bulimia

C.

Gastritis

D.

Anorexia nervosa

Buy Now
Questions 89

A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2-week period. Her husband asks, “Isn’t that a lot?” The nurse’s best response is:

Options:

A.

“Yes, that does seem like a lot.”

B.

“You’ll have to talk to the doctor about that. The physician knows what’s best for the client.”

C.

“Six to 10 treatments are common. Are you concerned about permanent effects?”

D.

“Don’t worry. Some clients have lots more than that.”

Buy Now
Questions 90

A 14-year-old boy fell off his bike while “popping a wheelie” on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of headache during the first 24 hours of his hospitalization, the nurse would:

Options:

A.

Ask the physician to order a sedative

B.

Have the client describe his headache every 15 minutes

C.

Increase his fluid intake to 3000 mL/24 hr

D.

Offer diversionary activities

Buy Now
Questions 91

Blood work reveals the following lab values for a client who has been diagnosed with anorexia nervosa: hemoglobin 9.6 g/dL, hemocrit 27%, potassium 2.7 mEq/L, sodium 126 mEq/L. The greatest danger to her at this time is:

Options:

A.

Hypoglycemia from low-carbohydrate intake

B.

Possible cardiac dysrhythmias secondary to hypokalemia

C.

Dehydration from vomiting

D.

Anoxia secondary to anemia

Buy Now
Questions 92

Following a fracture of the left femur, a client develops symptoms of osteomyelitis. During the acute phase of osteomyelitis, nursing care is directed toward:

Options:

A.

Moving or turning the client’s left leg carefully to minimize pain and discomfort

B.

Allowing the client out of bed only in a wheelchair or gurney to minimize weight bearing on the left leg

C.

Providing the client with a high-protein, high-fiber diet to promote healing

D.

Instituting physical therapy to ensure restoration of optimal functioning of the leg

Buy Now
Questions 93

A client is diagnosed with diabetic ketoacidosis. The nurse should be prepared to administer which of the following IV solutions?

Options:

A.

D5in normal saline

B.

D5W

C.

0.9 normal saline

D.

D5in lactated Ringer’s

Buy Now
Questions 94

A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?

Options:

A.

Serosanguinous

B.

Purulent

C.

Sanguinous

D.

Catarrhal

Buy Now
Questions 95

A mother called the physician’s office to ask if it would help relieve her small daughter’s abdominal pain if she gave an enema and placed a heating pad on the abdomen. Her daughter has a fever and has vomited twice.

The nurse’s response is based on the knowledge that:

Options:

A.

The symptoms could easily have been caused by constipation, which an enema would relieve

B.

Heat would help to relax the abdominal muscles and relieve her pain

C.

Both heat and enemas stimulate intestinal motility and could increase the risk of perforation

D.

Complaints of stomach ache are common in young children and are generally best ignored

Buy Now
Questions 96

A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states:

Options:

A.

“I know I will need special swallowing training after my surgery.”

B.

“The quality of my voice will be excellent after surgery.”

C.

“I will have very little difficulty swallowing after surgery.”

D.

“I may also have to have a radical neck dissection done.”

Buy Now
Questions 97

One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The client’s level is 1.3 mEq/L. The nurse recognizes that this level is considered to be:

Options:

A.

Within therapeutic range

B.

Below therapeutic range

C.

Above therapeutic range

D.

At a level of toxic poisoning

Buy Now
Questions 98

A neonate was admitted to the hospital with projectile vomiting. According to the parents, the baby had experienced vomiting episodes after feeding for the last 2 days. A medical diagnosis of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor, sunken eyeballs, dry skin, and weight loss. Identify the number-one priority nursing diagnosis.

Options:

A.

Fluid volume deficit

B.

Altered nutrition

C.

Altered bowel elimination

D.

Anxiety

Buy Now
Questions 99

An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:

Options:

A.

A tension pneumothorax

B.

An asthma attack

C.

Pneumonia

D.

Pulmonary embolus

Buy Now
Questions 100

A 34-year-old client who is gravida 1, para 0 has a history of infertility and conceived this pregnancy while taking fertility drugs. She is at 32 weeks’ gestation and is carrying triplets. She is complaining of low back pain and a feeling of pelvic pressure. Her cervical exam reveals a long, closed cervix. The nurse notes that the client is experiencing mild uterine contractions every 7–8 minutes after the nurse has placed her on the fetal monitor. Her condition should indicate that:

Options:

A.

Her cervix shows she will likely deliver soon

B.

The nurse should not be alarmed because mild uterine activity is common at 32 weeks’ gestation

C.

She may be in preterm labor because this is more common with multiple pregnancies

D.

She most likely has a urinary tract infection (UTI) because this is common with pregnancy

Buy Now
Questions 101

A client is placed on lithium therapy for her manicdepressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above:

Options:

A.

1.0 mEq/L

B.

2.2 mEq/L

C.

0.03 mEq/L

D.

1.5 mEq/L

Buy Now
Questions 102

A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:

Options:

A.

A left hemothorax

B.

A right hemothorax

C.

Intubation of the right mainstem bronchus

D.

An inadequate mechanical ventilator

Buy Now
Questions 103

A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular

accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?

Options:

A.

Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness

B.

Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood flow

C.

Potential for injury related to impaired mobility and seizures

D.

Impaired verbal communication related to aphasia

Buy Now
Questions 104

The physician prescribes a medical regimen of isoniazid, rifampin, and vitamin B6 for a tuberculosis client. The nurse instructs the client that B6 is given because it:

Options:

A.

Increases activity of isoniazid

B.

Increases activity of rifampin

C.

Improves nutritional status

D.

Reduces peripheral neuropathy

Buy Now
Questions 105

A 22-year-old client who is being seen in the clinic for a possible asthma attack stops wheezing suddenly as the nurse is doing a lung assessment. Which one of the following nursing interventions is most important?

Options:

A.

Place the client in a supine position.

B.

Draw a blood sample for arterial blood gases.

C.

Start O2 at 4 L/min.

D.

Establish a patent airway.

Buy Now
Questions 106

The nurse is caring for a client who has diabetes insipidus. The nurse would describe this client’s urine

output pattern as:

Options:

A.

Anuria

B.

Oliguria

C.

Dysuria

D.

Polyuria

Buy Now
Questions 107

A client takes warfarin (Coumadin) 15 mg po daily. To evaluate the medication’s effectiveness, the nurse should monitor the:

Options:

A.

prothrombin time (PT)

B.

partial thromboplastin time (PTT)

C.

PTT-C

D.

Fibrin split products

Buy Now
Questions 108

Following her surgery, a 5-year-old child will return to the pediatric unit with a long-arm cast. She experienced a supracondylar fracture of the humerus near the elbow. Which nursing action is most essential during the first

24 hours after surgery and cast application?

Options:

A.

Mobilization of the child

B.

Discharge teaching

C.

Pain management

D.

Assessment of neurovascular status

Buy Now
Questions 109

A 32-year-old female client is being treated for Guillain- Barré syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?

Options:

A.

Complaints of a headache

B.

Loss of superficial and deep tendon reflexes

C.

Complaints of shortness of breath

D.

Facial paralysis

Buy Now
Questions 110

An obstructing stone in the renal pelvis or upper ureter causes:

Options:

A.

Radiating pain into the urethra with labia pain experienced in females or testicular pain in males

B.

Urinary frequency and dysuria

C.

Severe flank and abdominal pain with nausea, vomiting, diaphoresis, and pallor

D.

Dull, aching, back pain

Buy Now
Questions 111

A female client is anticipating a visit with her parents over the Thanksgiving holidays. She has recently begun experiencing periods of extreme shortness of breath, which her physician has labeled as panic attacks. Which of the following statements by the nurse would enhance therapeutic communication?

Options:

A.

“Why do you feel this way?”

B.

“Tell me about your dislike for your parents.”

C.

“Don’t worry, everything will be all right on your visit with your parents.”

D.

“Perhaps you and I can discover what produces your anxiety.”

Buy Now
Questions 112

Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?

Options:

A.

She uses the bulb syringe to help clear her baby’s nose when milk is regurgitated.

B.

She places her infant on her right side after feeding her.

C.

She props the bottle in the crib to feed her baby,which allows her to write birth announcements and feed her baby at the same time.

D.

She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.

Buy Now
Questions 113

A female client plans to bottle-feed her newborn. Her physician has ordered bromocriptine (Parlodel) to suppress lactation. Which of the following instructions about bromocriptine should be given by the nurse?

Options:

A.

Bromocriptine stimulates the production of prolactin.

B.

Hypertension is a primary side effect.

C.

Bromocriptine is generally taken for 5 days.

D.

Her blood pressure must be stable before starting bromocriptine.

Buy Now
Questions 114

After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered. Which statement shows that the client will properly care for her son’s circumcision?

Options:

A.

“I’ll make sure I soak the gauze with warm water first, before I take it off each time.”

B.

“I’ll make sure that I report any drainage around where they operated.”

C.

“I’ll apply alcohol to the area daily to clean it and prevent any infection.”

D.

“I’ll keep a close watch on it for a day or two.”

Buy Now
Questions 115

A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24 hours postoperatively, the nurse would be concerned if the client:

Options:

A.

Cries easily and says she is having abdominal pain

B.

Develops a temperature of 102_F

C.

Has no bowel sounds

D.

Has a urine output of 200 mL for 4 hours

Buy Now
Questions 116

A 32-year-old male client is a marketing representative. His job requires him to have a tremendous amount of energy during the day. He frequently uses cocaine to sustain his energy level. Lately he has increased his use of cocaine and even experimented with crack cocaine. Realizing he can no longer continue this destructive behavior, he is seeking treatment for cocaine addiction. In planning nursing care for the client’s inpatient stay, which expected outcome is most appropriate?

Options:

A.

He will attend four consecutive group educational sessions on substance abuse.

B.

He will name activities that he would most likely be involved in posttreatment.

C.

He will meet with his family in counseling sessions and discuss his feelings.

D.

He will be able to deal with his feelings through participation in group therapy sessions.

Buy Now
Questions 117

An infant weighing 15 lb has just been treated for severe diarrhea in the hospital. Discharge instructions by the nurse will include maintenance fluid requirements for the pediatric client. Which of the following values best indicates the nurse’s understanding of normal fluid requirements for this infant?

Options:

A.

240 mL/day

B.

680 mL/day

C.

330 mL/day

D.

960 mL/day

Buy Now
Questions 118

A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client’s self-esteem by:

Options:

A.

Adhering to a strict schedule of diet, exercise, and wound care

B.

Allowing him to go to physical therapy for whirlpool treatment when other clients were not in physical therapy

C.

Following a standardized plan of care for burn clients formulated by a world-renowned burn center

D.

Allowing him to plan, assist in, and perform his own care whenever possible

Buy Now
Questions 119

A male client is being treated in the burn unit for thirddegree burns on his head, neck, and upper chest received in the last 24 hours. The nurse is evaluating the effectiveness of fluid resuscitation. Which of the following indicates effective fluid balance?

Options:

A.

His weight increases from 165 to 175 lb.

B.

His urine output is equal to his total fluid intake.

C.

His urine output has been>35 mL/hr for the past 12 hours.

D.

His blood pressure is 94/62.

Buy Now
Questions 120

A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:

Options:

A.

10 weeks

B.

16 weeks

C.

20 weeks

D.

30 weeks

Buy Now
Questions 121

A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks’ postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is:

Options:

A.

Autonomic dysreflexia

B.

Bradycardia

C.

Central cord syndrome

D.

Spinal shock

Buy Now
Questions 122

A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her daughter is very concerned about increasing her nutrition. The nurse helps the daughter devise a plan of care for her mother. The plan of care should include which of the following interventions to promote nutrition?

Options:

A.

Offer her oral hygiene before and after meals.

B.

Encourage her to consume milk products.

C.

Encourage her to engage in an activity before a meal to stimulate her appetite.

D.

Restrict her fluid intake to three glasses of water a day.

Buy Now
Questions 123

A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?

Options:

A.

Pain in his legs when he walks

B.

Thirst, weight loss, and polyuria

C.

Drowsiness and lethargy after his activities

D.

Weight gain, edema in his lower extremities, and shortness of breath

Buy Now
Questions 124

Which of the following ECG changes would be seen as a positive myocardial stress test response?

Options:

A.

Hyperacute T wave

B.

Prolongation of the PR interval

C.

ST-segment depression

D.

Pathological Q wave

Buy Now
Questions 125

To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following?

Options:

A.

Positive inotropic therapy

B.

Negative chronotropic therapy

C.

Increase in balance of myocardial O2 supply and demand

D.

Afterload reduction therapy

Buy Now
Questions 126

Dietary planning is an essential part of the diabetic client’s regimen. The American Diabetes Association recommends which of the following caloric guidelines for daily meal planning?

Options:

A.

50% complex carbohydrate, 20%–25% protein, 20%–25% fat

B.

45% complex carbohydrate, 25%–30% protein, 30%–35% fat

C.

70% complex carbohydrate, 20%–30% protein, 10%–20% fat

D.

60% complex carbohydrate, 12%–15% protein, 20%–25% fat

Buy Now
Questions 127

A long-term goal for the nurse in planning care for a depressed, suicidal client would be to:

Options:

A.

Provide him with a safe and structured environment.

B.

Assist him to develop more effective coping mechanisms.

C.

Have him sign a “no-suicide” contract.

D.

Isolate him from stressful situations that may precipitate a depressive episode.

Buy Now
Questions 128

When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take?

Options:

A.

Continue monitoring because this is a normal occurrence.

B.

Turn client on right side.

C.

Decrease IV fluids.

D.

Report to physician or midwife.

Buy Now
Questions 129

The predominant purpose of the first Apgar scoring of a newborn is to:

Options:

A.

Determine gross abnormal motor function

B.

Obtain a baseline for comparison with the infant’s future adaptation to the environment

C.

Evaluate the infant’s vital functions

D.

Determine the extent of congenital malformations

Buy Now
Exam Code: NCLEX-RN
Exam Name: National Council Licensure Examination(NCLEX-RN)
Last Update: Dec 27, 2024
Questions: 862
NCLEX-RN pdf

NCLEX-RN PDF

$25.5  $84.99
NCLEX-RN Engine

NCLEX-RN Testing Engine

$30  $99.99
NCLEX-RN PDF + Engine

NCLEX-RN PDF + Testing Engine

$40.5  $134.99