NCLEX Practice Questions
A triage nurse has these four (4) clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first? A. A 2-month-old infant with a history of rolling off the bed and has bulging fontanelle with crying B. A teenager who got a singed beard while camping C. An elderly client with complaints of frequent liquid brown colored stools D. A middle-aged client with intermittent pain behind the right scapula
b This client is in the greatest danger with a potential of respiratory distress. Any client with singed facial hair has been exposed to heat or fire in close range that could have caused serious damage to the interior of the lungs. Note that the interior lining of the lungs has no nerve fibers so the client will not be aware of swelling.
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should A. Place a call to the client's health care provider for instructions B. Send him to the emergency room for evaluation C. Reassure the client's wife that the symptoms are transient D. Instruct the client's wife to call the doctor if his symptoms become worse
b This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client's best interest.
The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq potassium chloride in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued? A. Narrowed QRS complex B. Shortened "PR" interval C. Tall peaked "T" waves D. Prominent "U" waves
c A tall peaked T wave is a sign of hyperkalemia. The healthcare provider should be notified regarding discontinuing the medication.
When teaching a client with coronary artery disease about nutrition, the nurse should emphasize: A. Eating three (3) balanced meals a day B. Adding complex carbohydrates C. Avoiding very heavy meals D. Limiting sodium to 7 g per day
c Eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease. Too much plaque may accumulate in the arteries and block the delivery of blood and oxygen in major organs of the body.
A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time? A. Positive sweat test B. Bulky greasy stools C. Moist, productive cough D. Meconium ileus
c Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings.
A nurse prepares to care for a 4-year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body? A. All striated muscles B. The cerebellum C. The kidneys D. The leg bones
a Rhabdomyosarcoma is the most common children's soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. Symptoms of rhabdomyosarcoma include if the cancer is in the head or neck area: sudden bulging or swelling of the eyes, conjunctival chemosis, and headache. It can also affect the urinary or reproductive system. Its common site of metastasis is the lung.
The nurse is performing a neurological assessment on a client post right cerebrovascular accident. Which finding, if observed by the nurse, would warrant immediate attention? A. Decrease in the level of consciousness B. Loss of bladder control C. Altered sensation to stimuli D. Emotional lability
a A further decrease in the level of consciousness may indicate an increase in intracranial pressure leading to inadequate oxygenation of the brain. A decrease in LOC may also reveal the presence of a transient ischemic attack which may warn of impending thrombotic CVA.
A 25-year-old male client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: a. Should be taken in the morning b. May decrease the client's energy level c. Must be stored in a dark container d. Will decrease the client's heart rate
a Levothyroxine (Synthroid) has a side effect of insomnia. Taking it in the morning could prevent interfering with the client's sleeping pattern.
A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? A. A middle-aged client who says "I took too many diet pills" and "my heart feels like it is racing out of my chest." B. A young adult who says "I hear songs from heaven. I need money for beer. I quit drinking two (2) days ago for my family. Why are my arms and legs jerking?" C. An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 11 D. An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room.
c Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. This client exhibits opioid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future.
In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school-age child for evaluation? a. polyphagia b. dehydration c. bedwetting d. weight loss
c One of the first symptoms of type 1 diabetes in children is bedwetting. Bedwetting in a school-age child is readily detected by the parents.
A 15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45 minutes ago is rushed to the emergency department. Which of these orders should the nurse do first? a. gastric lavage b. administer acetylcysteine (Mucomyst) orally c. start an IV dextrose 5% and 0.33% normal saline to keep the vein open d. have the pt drink activated charcoal mixed with water
a Acetaminophen overdose is extremely toxic to the liver causing hepatotoxicity. Early symptoms of hepatic damage include nausea, vomiting, abdominal pain, and diarrhea. If not treated immediately, hepatic necrosis occurs and may lead to death. Removing as much of the drug as possible is the first step in treatment for acetaminophen overdose, this is best done through gastric lavage. Gastric lavage (irrigation) and aspiration consist of flushing the stomach with fluids and then aspirating the fluid back out. This procedure is done in life-threatening cases such as acetaminophen toxicity and only if less than one (1) hour has occurred after ingestion.
The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is: A. Verify correct placement of the tube B. Check that the feeding solution matches the dietary order C. Aspirate abdominal contents to determine the amount of last feeding remaining in stomach D. Ensure that feeding solution is at room temperature
a Proper placement of the tube prevents aspiration and entrance of food content into the lungs. The definitive way to ascertain the position of the nasogastric tube is through visualization by an x-ray. Another method is to aspirate stomach contents and check its pH (usually pH 1 to 5). Aspirated stomach content can also be tested for bilirubin to confirm it is placed in the stomach.
The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission? a. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago. b. A young adult with diabetes mellitus Type 2 for over ten (10) years and admitted with antibiotic-induced diarrhea 24 hours ago. c. An elderly client with a history of hypertension, hypercholesterolemia, and lupus, and was admitted with Stevens-Johnson syndrome that morning. d. An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago.
a The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.
At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states "My blood pressure is usually much lower." The nurse should tell the client to: a. Go get a blood pressure check within the next 15 minutes b. Check blood pressure again in two (2) months c. See the healthcare provider immediately d. Visit the health care provider within one (1) week for a BP check
a The blood pressure reading is moderately high with the need to have it rechecked after a few minutes to verify. The client states it is 'usually much lower.' Thus a concern exists for complications such as stroke.
Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? a. angina at rest b. thrombus formation c. dizziness d. falling BP
b A thrombus formation may prevent blood from flowing normally through the circulatory system, which may become an embolism, and block the flow of blood towards major organs in the body.
A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? a. trichomoniasis b. chlamydia c. staphylococcus d. Streptococcus
b Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease. Chlamydial bacteria could travel up toward the vagina or cervix into the reproductive organs.
The nurse is giving discharge teaching to a client seven (7) days post-myocardial infarction. He asks the nurse why he must wait six (6) weeks before having sexual intercourse. What is the best response by the nurse to this question? A. "You need to regain your strength before attempting such exertion." B. "When you can climb 2 flights of stairs without problems, it is generally safe." C. "Have a glass of wine to relax you, then you can try to have sex."
b There is a risk of cardiac rupture at the point of the myocardial infarction for about six (6) weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by healthcare providers.
While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs? A. "I want to protect my child from any falls." B. "I will set limits on exploring the house." C. "I understand the need to use those new skills." D. "I intend to keep control over our child."
c Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment and develop autonomy.
A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is: a. maintain fluid/electrolyte balance b. control nausea c. manage pain d. prevent UTI
c Managing pain is always a priority because it ultimately improves the quality of life. The cornerstone of ureteral colic management is analgesia, which can be achieved most expediently with parenteral narcotics or nonsteroidal anti-inflammatory drugs (NSAIDs).
During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to: A. Increase fluids that are high in protein B. Restrict fluids C. Force fluids and reassess blood pressure D. Limit fluids to non-caffeine beverages
c Orthostatic hypotension, a decrease in systolic blood pressure of more than 15 mmHg, and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicate volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.
Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for morphine drip is not working? A. The client complains of discomfort at the IV insertion site B. The client states "I just can't get relief from my pain." C. The level of the drug is 100 ml at 8 AM and is 80 ml at noon D. The level of the drug is 100 ml at 8 AM and is 50 ml at noon
c The minimal dose of 10 mL per hour which would be 40 mL given in a four (4) hour period. Only 60 mL should be left at noon. The pump is not functioning when more than expected medicine is left in the container.
The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to: A. Achieve harmony B. Maintain a balance of energy C. Respect life D. Restore yin and yang
d For followers of Chinese medicine, health is maintained through the balance between the forces of yin and yang. Traditional Chinese medicine is a medical system that began being developed in China about 5000 years ago, which makes it the oldest continuous medical system on the planet.
What would the nurse expect to see while assessing the growth of children during their school-age years? a. decreasing amounts of body fat and muscle mass b. little change in body appearance from year to year c. progressive height increase of 4 in each year d. yearly weight gain of about 5.5 lbs per year
d School-age children gain about 5.5 pounds each year and increase about 2 inches in height. Between ages 2 to 10 years, a child will grow at a steady pace.
Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiography test? A. Client must be NPO before the examination B. Enema to be administered prior to the examination C. Medicate client with furosemide 20 mg IV 30 minutes prior to the examination D. No special orders are necessary for this examination
d There are no special orders for this procedure, however, the client must be instructed of the general rule during radiography tests: remove any clothing, jewelry, or objects that may interfere with the test.
A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling, and suprasternal retractions. What should the nurse do first? a. Prepare the child for X-ray of upper airways b. Examine the child's throat c. Collect a sputum specimen d. Notify the healthcare provider of the child's status
d These findings suggest a medical emergency and may be due to epiglottitis. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate care.
