NCLEX-PN Assessment Questions

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client?

1. "Have you talked to your family about this?" 2. "Everyone feels this way when they are depressed." 3. "You will feel better once your medication begins to work." 4. "You sound very upset. Are you thinking of hurting yourself?"

The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then performs which action?

1. Checks the vital signs 2.Begins fundal massage 3. Encourages ambulation 4. Encourages the client to drink fluids

The licensed practical nurse is considering leaving the nursing profession after caring for multiple clients who have been diagnosed with conditions that have poor outcomes. Which measures would most likely assist the nurse in relieving this distress? Select all that apply.

1. Decrease opportunities for multidisciplinary rounds. 2. Share the frustrations at unit multidisciplinary meetings. 3. Tell stories about the experiences with other professionals. 4. Participate in continuing education that is restricted to nurses. 5. Engage in ethics discussions with both nurses and other health care practitioners.

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the dwell time for the dialysis at the prescribed time because of risk for which complication?

1. Infection 2. Fluid overload 3. Hyperglycemia 4. Disequilibrium syndrome

The nurse reviews the laboratory values on a child with leukemia receiving chemotherapy. The nurse notes that the platelet count is 19,000/mm3. Based on this laboratory result, which action should the nurse include in the plan of care?

1. Protective isolation precautions 2. Using a soft toothbrush for mouth care 3. Monitoring closely for signs of infection 4. Monitoring the temperature every 4 hours

A nursing instructor asks a nursing student to describe accountability. Which statement by the student indicates an inaccurate description of accountability?

1. "Accountability can be delegated." 2. "It carries legal implications for task performance." 3. "One must answer for the care that one asks others to complete." 4. "It refers to the process of answering or being responsible for what occurs."

A client with cancer has received a course of chemotherapy with fluorouracil (Adrucil). The nurse should plan to reinforce which instructions?

1. "Visit a flu clinic to receive a yearly flu vaccine." 2. "Do not get any immunizations without health care provider approval." 3. "Use alcohol in moderation as a means of coping with the disease process." 4. "Use aspirin (acetylsalicylic acid, ASA) as the medication of choice for headache."

The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. The appropriate nursing intervention is which?

1. Ask direct questions to encourage talking. 2. Leave the client alone and intermittently check on him. 3. Sit beside the client in silence and verbalize occasional open-ended questions. 4. Take the client into the dayroom with other clients so they can help watch him.

Pilocarpine hydrochloride (Isopto Carpine) is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity?

1. Atropine sulfate 2. Timolol maleate (Timoptic) 3. Metipranolol (OptiPranolol) 4. Carteolol hydrochloride (Ocupress)

A client is at risk for complications of heart failure. Which is the nurse's priority for early detection of the most likely cause of complications with this client?

1. Checking vital signs 2. Reviewing serum electrolytes 3. Evaluating total body fluid 4. Monitoring electrocardiogram

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium?

1. Milk 2. Butter 3. Spinach 4. Collard greens

The licensed practical nurse (LPN) is assisting in the admission of a child with suspected sickle cell crisis because of which signs/symptoms noted in this client? Select all that apply.

1. Swollen knee joint 2. Temperature, 97.3° F 3. Pulse,120 beats per minute 4. Peripheral oxygen level of 89% 5. Pain rated as a 6 on a scale of 1 to 10

A client diagnosed with depression is starting therapy with imipramine hydrochloride (Tofranil). The nurse is concerned that the client will not comply with the medication regimen. To encourage the client to continue taking the medication, the nurse tells the client that it is normal not to feel beneficial effects of the medication for which amount of time?

1. 3 to 5 days 2. 5 to 7 days 3. 1 to 2 weeks 4. 2 to 3 weeks

The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further teaching?

1. "I need to use proper hand-washing techniques." 2. "I need to take my child's rectal temperature daily." 3. "I need to inspect my child's skin daily for redness." 4. "I need to inspect my child's mouth daily for lesions."

The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made?

1. "I will use a straw for drinking." 2. "I will drive only during the daytime." 3. "I will use caution because the device alters balance." 4. "I will wash the skin daily under the lamb's-wool liner of the vest."

The nurse has admitted a client to the clinical nursing unit following a right mastectomy. The nurse plans to place the right arm in which position?

1. Level with the right atrium 2. Dependent to the right atrium 3. Elevated above shoulder level 4. Elevated on one or two pillows

The nurse is reinforcing dietary instructions to a client diagnosed with acute glomerulonephritis. The nurse determines that the client understands the information presented if the client states the intention to do which action?

1. Limit protein intake. 2. Increase intake of high-fiber foods. 3. Limit intake of magnesium-rich foods. 4. Increase intake of potassium-rich foods.

A licensed practical nurse (LPN) assisting a registered nurse in the cardiac care unit (CCU) prepares to admit a client with a diagnosis of myocardial infarction (MI). The LPN should be certain to have which item(s) readily available on the unit when the client arrives by stretcher?

1. Trapeze bar 2. Bedside commode 3. Electrocardiogram machine 4. Oxygen cannula and flowmeter

The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse should tell the client that fetal circulation consists of which?

1. Two umbilical veins and one umbilical artery 2. Two umbilical arteries and one umbilical vein 3. Arteries that carry oxygenated blood to the fetus 4. Veins that carry deoxygenated blood to the fetus

The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? Select all that apply.

1. Apply disposable gloves. 2. Place the client in the right Sims' position. 3. Lubricate the enema tube and insert it approximately 4 inches. 4. Clamp the tubing if the client expresses discomfort during the procedure. 5. Hang the container containing the enema solution 24 inches above the client's anus. 6. Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C).

The client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed?

1. Echocardiography 2. Electrocardiography 3. Cervical radiography 4. Pulmonary function studies

The nurse is preparing a 2-year-old child with suspected nephrotic syndrome for a renal biopsy to confirm the diagnosis. The mother asks the nurse, "Will my child ever look thin again?" The nurse should respond by giving which statement?

1. "Do you feel guilty about your child's weight gain?" 2. "In most cases, medication and diet will control fluid retention." ** 3. "Wearing loose-fitting clothing should help conceal the extra weight." 4. "When children are little, it's expected that they'll look a little chubby."

A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions?

1. "I am considering cutting my workload." 2. "I need to cut down on cigarette smoking."* 3. "I am so relieved that my heart is repaired." 4."I need to adhere to my dietary restrictions."

The nurse is caring for a client in preterm labor who is receiving terbutaline sulfate to stop uterine activity. During this medication therapy, the nurse implements nursing interventions to monitor which specific body organs that can be affected by this medication?

1. Heart and lungs 2.Kidneys and lungs 3. Heart and kidneys 4. Lungs and gastrointestinal tract

The nurse is collecting initial data on a newborn in the delivery room. Which observation should the nurse expect to note when examining the umbilical cord of the newborn?

1. One artery and one vein 2. Two arteries and one vein ** 3. Two veins and one artery 4. Two arteries and two

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit?

1. The client with cirrhosis 2. The client with a colostomy 3. The client with heart failure (HF) 4. The client with decreased kidney function

A child is brought to the emergency department, and a fracture of the left lower arm is suspected. The mother states that the child was rollerblading and attempted to break a fall with an outstretched arm. The child receives diagnostic x-rays, from which it has been determined that a fracture is present. A plaster of Paris cast is applied to the arm, and the nurse reinforces instructions to the mother regarding cast care at home. Which instructions should the nurse provide to the mother?

1. "The cast should be dry in about 6 hours." 2. "The cast is water resistant, so the child is able to take a bath or a shower." 3. "The cast needs to be kept dry because, when wet, it will begin to disintegrate." * 4. "The cast will not mold to the body and should heal the fracture in no time at all."

The nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Based on this information, which determination does the nurse make regarding consent?

1. An informed consent does not need to be obtained. 2. The health care provider will obtain the informed consent. 3. An informed consent should be obtained from the family. 4. An informed consent needs to be obtained from the client. *

The nurse is preparing to administer an injection of regular insulin. The vial of the regular insulin has been refrigerated. On inspection of the vial, the nurse finds that the medication is frozen. Which action should the nurse take?

1. Discard the insulin and obtain another vial. 2. Wait for the insulin to thaw at room temperature. 3. Check the temperature settings of the refrigerator. 4. Rotate the vial between the hands until the medication becomes liquid.

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply.

1. Discourage reminiscing. 2. Make the decisions for the family. 3. Encourage expression of feelings, concerns, and fears. 4. Explain everything that is happening to all family members. 5. Touch and hold the client's or family member's hand if appropriate. 6. Be honest and let the client and family know that they will not be abandoned by the nurse.

A client is taking large doses of acetylsalicylic acid (aspirin) for rheumatoid arthritis. The nurse tells the client to report which signs and symptoms of ototoxicity?

1. Dizziness, tinnitus, purpura 2. GI bleeding, ecchymosis, tinnitus 3. Tinnitus, hearing loss, dizziness, ataxia 4. Gastrointestinal (GI) upset, hematuria, dizziness

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period was October 20, 2016. Using Nägele's rule, the nurse determines the estimated date of birth is which?

1. July 12, 2017 2. July 27, 2017* 3. August 12, 2017 4. August 27, 2017

A client with human immunodeficiency virus is taking nevirapine (Viramune). The nurse should monitor for which side/adverse effects of the medication? Select all that apply.

1. Rash 2. Hepatotoxicity 3. Hyperglycemia 4. Peripheral neuropathy 5. Reduced bone mineral density

The nurse caring for a child with nephrotic syndrome reviews the medication record. The nurse notes that prazosin hydrochloride (Minipress) is prescribed for the child. The nurse determines that this medication has been prescribed to achieve which result?

1. Reduce proteinuria. 2. Control hypertension. 3. Decrease inflammation. 4. Suppress the autoimmune response.

The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS) who has Pneumocystis jiroveci pneumonia. In planning infection control for this client which should be the appropriate form of isolation to use to prevent the spread of infection to others?

1. Strict isolation 2. Enteric precautions 3. Contact precautions 4. Blood and body fluid precautions

The nurse is assigned to care for a child with a compound (open) fracture of the arm that occurred as a result of a fall. The nurse plans care knowing that this type of fracture involves which specific characteristic?

1. The entire bone fractured straight across 2. A greater risk of infection than a simple fracture 3. The bone being fractured but not producing a break in the skin 4. One side of the bone being broken and the other side being bent

A client who has undergone cataract removal without an intraocular lens implant is visibly upset because his vision is still blurry. Which action should the nurse perform to provide realistic reassurance to this client?

1. Explain that vision will improve with adjustment to aphakic lenses. 2. Reassure the client that bright color contrasts in the environment will help. 3. Tell the client that there are many resources available for those with impaired vision. 4.Determine whether the client knows any other people who have experienced blindness.

The nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. Which statement most accurately describes Kawasaki disease?

1. It is an acquired cell-mediated immunodeficiency disorder. 2. It is a chronic multisystem autoimmune disease characterized by the inflammation of connective tissue. 3. It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause. 4. It is an inflammatory autoimmune disease that affects the connective tissue of the heart, joints, and subcutaneous tissues.

The nurse is caring for a client with placenta previa who is at high risk for infection and hemorrhage. The nurse plans care based on which information related to the condition?

1. It will cause increased uterine contractions postdelivery. 2. Increased vaginal secretions will prevent the site from healing properly. 3. Fewer muscle fibers in the lower segment of the uterus will result in poor contractions. 4. Sexual intercourse before 6 weeks postpartum will significantly increase the risk for infection.

The nurse is employed at a drug abusers' residential treatment center. The nurse is preparing for the arrival of a new client and prepares to explain to the client that the emphasis of the center is on group and social interaction and that rules and expectations are mediated by peer pressure. The most likely focus of therapy of this residential center is which?

1. Milieu therapy 2. Aversion conditioning 3. Systematic desensitization 4. Cognitive behavioral therapy

A client who has terminal cancer has been experiencing a significant increase in pain. However, today the client is no longer complaining of pain but is quiet and isolative. Which types of therapeutic communication should the nurse employ? Select all that apply.

1. Sit by client's bed holding his or her hand. 2. Reminisce with the client and sharing a humorous story that the client enjoys. 3. The nurse asks: "What can I do, that might make you feel more comfortable today?" 4. The nurse states: "Just think; you will soon be in a better place where you will not be in pain." 5. The nurse asks: "I noticed you grimacing earlier when I walked in your room. Are you in pain?" 6. The nurse states: "It must be very frustrating to be in pain and not be able to get complete relief from your pain."

The registered nurse has written an outcome statement of "Client will feel less anxious by the end of session" for a client with generalized anxiety disorder. Which interventions should the licensed practical nurse use to assist this client in meeting this goal? Select all that apply.

1. Stay with the client. 2. Give detailed directions to the client. 3. Administer anxiolytics medications if prescribed. 4. Ensure the client is in an environment with little stimuli. 5. Refrain from speaking until the client's anxiety is decreased.

A 1-year-old child is seen in the health care provider's office with complaints of an elevated temperature that began the previous evening. When gathering subjective data from the mother, the nurse notices that which sign/symptom would most likely indicate the child has acute otitis media?

1. The child is crying and irritable. 2. The temperature is 40° C (104° F). 3. The child is pulling at her ear and rolling her head from side to side. 4. The mother states the child had purulent discharge from the ear last night.

The nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia (VT), followed by ventricular fibrillation (VF). The client suddenly loses consciousness. Which intervention should the nurse do first?

1. Go to the nurse's station quickly and call a code. 2. Run to get a defibrillator from an adjacent nursing unit. 3. Call for help and initiate cardiopulmonary resuscitation (CPR). 4. Start oxygen by cannula at 10 L/minute and lower the head of the bed.

A client with end stage kidney disease (ESKD) undergoes a surgical procedure to create an arteriovenous fistula for hemodialysis in the upper extremity. The nurse should take which actions when the client returns from surgery? Select all that apply.

1. Monitor pain and administer analgesics. 2. Monitor bleeding and swelling at the site. 3. Monitor for circulation above the fistula site. 4. Measure the blood pressure in the arm every hour. 5. Check for audible bruit and palpable thrill at the fistula site.

The nursing student is asked to describe the correct steps for performing adult cardiopulmonary resuscitation (CPR). Arrange the steps of adult CPR in the order of priority. Drag and drop the options into the correct order.

1. Determine unconsciousness by shaking the client and asking, "Are you OK?" 2. Open the client's airway. 3. Perform chest compressions. 4. Initiate breathing.

A pregnant client is newly diagnosed as having gestational diabetes. She cries during the interview and keeps repeating, "What have I done to cause this? If I could only live my life over." Which client problem should initially direct nursing care at this time?

1. The client is blaming herself. 2. The client is experiencing fetal distress. 3. The client is concerned about her appearance. 4. The client lacks knowledge regarding diabetes treatment.

The nursing student demonstrates understanding of the pathophysiology of reflex tachycardia in the client taking an antihypertensive medication by making which statement?

1. "Tachycardia results from the suppression of the influx of ionized calcium into the vessel wall." 2. "Fluid is retained by the kidneys in an attempt to increase blood volume, resulting in tachycardia." 3. "Renin, secreted by the kidney in response to lowered blood pressure, increases epinephrine secretion and stimulation of the sinoatrial node." 4. "When blood pressure begins to decrease, the heart responds with tachycardia as a compensatory mechanism to raise the blood pressure."

The nurse is reviewing a health care provider's prescriptions for a client with newly diagnosed, untreated hypothyroidism. Which medication prescribed for the client should the nurse question and verify?

1. Morphine sulfate 2. Atenolol (Tenormin) 3. Docusate sodium (Colace) 4. Levothyroxine (Synthroid)

The nurse is assigned to care for a child with a spica cast. Which action should be avoided when caring for the child?

1. Observing for nonverbal signs of pain 2. Using pillows to elevate the head and shoulders 3. Checking neurovascular status of the extremities 4. Placing the child on a stretcher and bringing the child to the playroom

The nurse determines that a student in a basic cardiac life support (BCLS) course correctly performs cardiopulmonary resuscitation (CPR) on an infant when the nurse observes which rate of chest compressions delivered to the infant mannequin?

1. 50 times per minute 2. 80 times per minute 3. 100 times per minute 4. 160 times per minute

When caring for a 3-year-old child, the nurse should provide which toy for the child?

1. A puzzle 2. A wagon 3. A golf set 4. A farm set

The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of HF?

1. Pallor 2. Cough 3. Tachycardia 4. Slow and shallow breathing

Oxybutynin chloride (Ditropan XL) is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication?

1. Pallor 2. Drowsiness 3. Bradycardia 4. Restlessness

The nurse is assigned to assist in preparing a woman who is gravida VI for delivery. In planning care for this client, the nurse places which item(s) at the client's bedside?

Code cart 2. Suction machine 3. Nasogastric tube 4. Intravenous (IV) supplies

The nurse in the psychiatric unit is reviewing the records of the clients admitted to the nursing unit. A client with a history of violent behavior approaches the nurse and demands immediate discharge from the hospital. The nurse notes that the client was voluntarily admitted to the psychiatric unit. Which is the appropriate nursing action?

1. Allow the client to leave. 2. Attempt to persuade the client to stay. 3. Call security to assist in restraining the client. 4. Tell the client that the health care provider will be contacted regarding discharge.

The nurse is assigned to care for a client with a diagnosis of toxoplasmosis. The health care provider has prescribed sulfasalazine (Azulfidine). The nurse preparing to administer the medication understands that this medication is in which drug category?

1. Antibiotic 2. Sulfonamide 3. Opioid analgesic 4. Nonsteroidal anti-inflammatory

A cervical radiation implant is placed in the client for treatment of cervical cancer. Which activity would the nurse most likely expect to note in the health care provider's prescriptions?

1. Bed rest 2. Out of bed in a chair 3. Ambulate to the bathroom 4. Out of bed and up to the bedside commode

The nurse is reading the results of a Mantoux tuberculin skin test on a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. Which interpretation should the nurse make of these results?

1. Positive 2. Negative 3. Uncertain 4. Borderline

A client receiving an anxiolytic medication complains that he feels very "faint" when he tries to get out of bed in the morning. The nurse explains to the client that which is a side effect of this type of medication?

1. Postural hypotension 2. Cardiac dysrhythmias 3. Psychosomatic symptoms 4. Respiratory insufficiency

The nurse is assigned to care for a client following a cataract extraction. The nurse plans to place the client in which position?

1. Prone 2. Supine 3. On the operative side 4. On the nonoperative side

The nurse is caring for a client following the application of a plaster cast because of a fractured left radius. The nurse monitors the neurovascular status of the client's casted extremity for which reason?

1. The skin under the cast is at high risk for infection. 2. Compartment syndrome may lead to irreversible nerve and muscle tissue injury. 3. Alterations in the neurovascular status of the fingers may be early signs of fat embolism. 4. The client is at high risk of neurovascular compromise until the cast is completely dry.

The nurse is assigned to care for a client with a diagnosis of detached retina. Which finding would indicate that bleeding has occurred as a result of retinal detachment?

1. Total loss of vision 2. A reddened conjunctiva 3. A sudden sharp pain in the eye 4. Complaints of a burst of black spots or floaters

A client with recurrent constipation has begun using psyllium (Metamucil). The nurse tells this client that this medication should be taken in which manner?

1. With any hot beverage 2. With any cold beverage 3. With any type of gelatin 4. With a full glass of liquid, followed by a second glass of liquid

Penicillin V potassium 250 mg orally every 8 hours is prescribed for a child with a respiratory infection. The medication label reads: Penicillin, 125 mg per 5 mL. The nurse has determined that the dosage prescribed is a safe dose for the child. How many milliliters (mL) will the nurse administer to the child per dose? Fill in the blank.

mL

Alendronate (Fosamax) is prescribed for a client with osteoporosis. The nurse should reinforce instructing the client taking this medication to do which?

Take the medication at bedtime. 2. Take the medication in the morning with breakfast. 3. Lie down for 30 minutes after taking the medication. 4. Take the medication with a full glass of water after rising in the morning.