NCLEX Practice Questions
The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? A) One to one suicide precautions B) Suicide precautions with 30 minute checks C) Checking the whereabouts of the client every 15 minutes D) Asking the client to report suicidal thoughts immediately
A) One to one suicide precautions
A patient with bipolar disorder is admitted to the unit with acute mania and dehydration. Which prescription does the nurse question? A) Administer zolpidem at bedtime as needed for insomnia B) Continue prescribed home dose of 300mg lithium PO every 8 hours C) Give haloperidol IM for aggressive behavior D) Infuse 500mL normal saline IV bolus over one hour
B) Continue prescribed home dose of 300mg lithium PO every 8 hours
The healthcare provider prescribes fluoxetine to a patient with depression. Which statement by the patient indicates proper understanding of the medication? A) "I can discontinue the medication if my symptoms improve." B) "I need a healthy diet and exercise to control weight gain." C) "If I don't feel better in 1-2 weeks, we can try a new medication." D) "This medication might increase my sexual performance."
B) "I need a healthy diet and exercise to control weight gain."
The nurse reviews the patient's medical record and notes the following PRN medications: acetaminophen, haloperidol, and benztropine. The nurse would administer a dose of benztropine because of which patient behavior? A) Muscle rigidity and shuffling gait B) Nihilistic delusions C) Tangentiality D) Waxy flexibility
A) Muscle rigidity and shuffling gait
Which findings are significant data to gather from a client who has been diagnosed with pneumonia? Select all that apply. A) Quality of breath sounds B) Presence of bowel sounds C) Occurrence of chest pain D) Amount of peripheral edema E) Color of nail beds
A) Quality of breath sounds C) Occurrence of chest pain E) Color of nail beds
A client with acute chest pain is receiving IV morphine sulfate. Which is an expected effect of morphine? Select all that apply. A) Reduces myocardial oxygen consumption B) Promotes reduction in respiratory rate C) Prevents ventricular remodeling D) Reduces blood pressure and heart rate E) Reduces anxiety and fear
A) Reduces myocardial oxygen consumption D) Reduces blood pressure and heart rate E) Reduces anxiety and fear
The nurse is caring for a client who had an open cholecystectomy 24 hours ago. Which set of vital signs indicates that the nurse should contact the healthcare provider? A) Temp 101.8, BP 140/86, HR 94, RR 24 B) Temp 100.7, BP 118/68, HR 84, RR 20 C) Temp 99.5, BP 126/80, HR 58, RR 16 D) Temp 97.5, BP 98/64, HR 98, RR 18
A) Temp 101.8, BP 140/86, HR 94, RR 24
Fluoroquinolones should be discontinued immediately if: A) Tendon pain or inflammation develop B) Nausea, vomiting or diarrhea are experienced C) Dizziness, headache or confusion occur D) Theophylline is prescribed for asthma
A) Tendon pain or inflammation develop
The nurse is caring for a client who recently experienced a myocardial infarction and has been started on clopidogrel. The nurse should develop a teaching plan that includes which points? Select all that apply. A) The client should report unexpected bleeding or bruising that lasts a long time B) The client should take clopidogrel with food C) The client may bruise more easily and may experience bleeding gums D) Clopidogrel works best by preventing platelets from sticking together and forming a clot E) The client should drink a glass a water after the clopidogrel
A) The client should report unexpected bleeding or bruising that last a long time C) The client may bruise more easily and may experience bleeding gums D) Clopidogrel works best by preventing platelets from sticking together and forming a clot
A nurse is assessing a client for dementia. What history findings would the nurse anticipate while talking with the client and family? Select all that apply. A) The progression of symptoms has been slow B) The client admits to feelings of sadness C) The client acts apathetic and pessimistic D) The family cannot determine when the symptoms first appeared E) The client has been exhibiting personality changes F) The client has great difficulty paying attention to others
A) The progression of symptoms has been slow D) The family cannot determine when the symptoms first appeared E) The client has been exhibiting personality changes F) The client has great difficulty paying attention to others
The nurse is evaluating infection control practices performed by a spouse on a loved one who has methicillin-resistant Staphylococcus aureus (MRSA) in a right leg wound. Which actions indicate that the spouse requires further teaching? Select all that apply. A) The spouse places soiled dressing supplies in the kitchen garbage bag B) Clean gloves are used for wound dressing removal C) Sheets with wound drainage are washed in lukewarm water D) Dressing supplies are placed in a clean, dry location E) Routine hang hygiene is preformed before and after care
A) The spouse places soiled dressing supplies in the kitchen garbage bag C) Sheets with wound drainage are washed in lukewarm water
The nurse is caring for a patient receiving gentamicin (Garamycin) intravenously (IV). What statement by the patient would most concern the nurse? "I am experiencing... A) high-pitched ringing in my ears." B) dizziness." C) ear pain." D) tone deafness."
A) high-pitched ringing in my ears."
A nurse is caring for a client displaying extreme mood swings with suicidal tendencies. A provider prescribed lithium and diagnoses the client with bipolar disorder. When teaching the client, which statements, verbalized by the client, indicate a good understanding of the teaching of medication management? Select all that apply: A) "I understand the potential for addiction." B) "I need to watch for signs and symptoms of drug toxicity including blurred vision and ringing in the ears." C) "I will adjust my medication depending on my symptoms." D) "I will need to be on a low-tyramine diet." E) "I will need to consistently monitor blood levels." F) "The therapeutic effect of the medication takes time to occur."
B) "I need to watch for signs and symptoms of drug toxicity including blurred vision and ringing in the ears." E) "I will need to consistently monitor blood levels." F) "The therapeutic effect of the medication takes times to occur."
The nurse in an ambulatory care center is teaching a patient with depression about the appropriate use of bupropion hydrochloride SR. Which statement made by the client indicates a need for further teaching? A) "If I have a sudden change in mood, I should call my physician." B) "If I have trouble swallowing the tablet, I can cut it in half." C) "If I miss a dose, I should not double up the dose to catch up." D) "It may take several weeks before I start to feel better."
B) "If I have trouble swallowing the tablet, I can cut it in half."
The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. A) Open doors to client rooms. B) Move beds away from windows. C) Close window shades and curtains. D) Place blankets over patients who are confined to bed. E) Relocate ambulatory clients from the hallways back into their rooms.
B) Move beds away from windows. C) Close window shades and curtains. D) Place blankets over patients who are confined to bed.
What should the nurse do to prevent catheter-associated urinary tract infection (CAUTI)? Select all that apply: A) Change the catheter daily B) Provide perineal care several times a day C) Minimize length of time catheter is left in D) Encourage the client to drink 3000mL of fluids E) Recommend the healthcare provider prescribe antibiotics
B) Provide perineal care several times a day C) Minimize length of time catheter is left in D) Encourage the client to drink 3000mL of fluids
A client with bacterial pneumonia is to be started on IV antibiotics. Which diagnostic test must be completed before antibiotic therapy begins? A) Urinalysis B) Sputum Culture C) Chest x-ray D) Red blood cell count
B) Sputum Culture
A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. The nurse should tell the client: A) Ulcerative colitis can be cured by the use of steroids B) Steroids are used in severe flare-ups because they can decrease the incidence of bleeding C) Long-term use of steroids will prolong periods of remission D) The side effects of steroids outweigh their benefits to clients with ulcerative clients
B) Steroids are used in severe flare-ups because they can decrease the incidence of bleeding
Because they are broad-spectrum antibiotics, tetracyclines can cause: A) Targeted kill of susceptible microbes B) Superinfections, especially C. difficile and yeast C) Eradication of candida in mouth, pharynx, vagina and bowel D) Stimulate frequent voiding
B) Superinfections, especially C. difficile and yeast
The nurse is working at a sexually transmitted disease (STD) clinic. A patient has been diagnosed with an STD and will be treated with penicillin G. The nurse understands that penicillin G is the drug of choice in the treatment of A) Gonorrhea B) Syphilis C) Genital Herpes D) Chlamydia
B) Syphilis
The nurse assesses the client's stoma during the initial postoperative period. What observation should the nurse report to the healthcare provider? A) The stoma is slightly edematous B) The stoma is dark red to purple C) The stoma is leaking a small amount of blood
B) The stoma is dark red to purple
The parents of a child with cystic fibrosis express concern about how the disease was transmitted to their child. The nurse should explain that: A) A disease carrier also has the disease. B) Two parents who are carriers may produce a child who has the disease. C) A disease carrier and an affected person will never had children with the disease. D) A disease carrier and an affected person will have a child with the disease.
B) Two parents who are carriers may produce a child who has the disease
A patient has been prescribed oral ciprofloxacin (Cipro) for a skin infection. When administering the medication, the nurse will: A) Monitor for a decrease in prothrombin time (PT) if the patient is also taking warfarin (Coumadin) B) Withhold antacids and milk products for 6 hours before or 2 hours after C) Observe for clinical manifestations of renal toxicity D) Assess the skin for phototoxicity reactions
B) Withhold antacids and milk products for 6 hours before or 2 hours after
The nurse is caring for a client with Clostridium difficile colitis. Which of the following infection measures by the nurse are the most appropriate? Select all that apply. A) Applies sterile gloves before performing patient care B) Ensures surgical masks are worn by staff in the clients room C) Requests that the client be assigned to a single client room D) Uses alcohol-based sanitizers for hand hygiene E) Wear a gown during client care
C) Requests that the client be assigned to a single client room E) Wear a gown during client care
The nurse is assessing the leg pain of a patient who has just undergone femoral-popliteal artery bypass grafting. Which question would be most useful in determining whether the patient is experiencing graft occlusion? A) "Can you describe what the pain feels like?" B) "Can you rate this pain on a scale of 1 to 10?" C) "Did you get any relief from the last dose of pain medication?" D) "Can you compare this pain to the pain you felt before surgery?"
D) "Can you compare this pain to the pain you felt before surgery?"
A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that: A) Acetaminophen and ibuprofen can be taken for this common side effect B) Nitroglycerin should be avoided if the client is experiencing this serious side effect C) Taking the nitroglycerin with a few glasses of water will reduce the problem D) The client should lie in a supine position to alleviate the headache
A) Acetaminophen and ibuprofen can be taken for this common side effect
When teaching a group of nursing students about the use of antipsychotic medications, the nurse advises them that certain symptoms can occur within the first few weeks of treatment. Which symptoms are likely to occur? Select all that apply: A) Acute dystonia B) Akathisia C) Tardive dyskinesia D) Neuroleptic malignant syndrome E) Hearing loss
A) Acute dystonia B) Akathisia D) Neuroleptic malignant syndrome
The nurse is caring for a hospitalized patient with a diagnosis of heart failure who suddenly complains of shortness of breath and dyspnea. The nurse should take which immediate action? A) Administer oxygen to the client B) Prepare to administer furosemide C) Elevate the head of the client's bed D) Call the healthcare provider
C) Elevate the head of the client's bed
The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel? A) A client requiring frequent colostomy irrigation B) A client receiving continuous tube feedings C) A client who requires urine specimen collections D) A client with difficulty swallowing food and fluids
C) A client who required urine specimen collections
Erythromycin is an example of a: A) Aminoglycoside B) Cephalosporin C) Antifungal D) Macrolide
D) Macrolide
A client who has had a laparoscopic cholecystectomy has adhesive strips over the puncture sites. When preparing the client for discharge, which statement by the client indicates that the teaching has been successful? Select all that apply. A) I can resume my normal diet when I want. B) I need to avoid driving for about 4 weeks. C) I may experience some pain in my right shoulder. D) I should spend 2 to 3 days in bed before resuming activity. E) I can take a shower 2 days later.
A) I can resume my normal diet when I want C) I may experience some pain in my right shoulder E) I can take a shower 2 days later
A child with meningococcal meningitis is being admitted to the pediatric unit. What should the nurse do first: A) Institute droplet precautions B) Obtain the child's vital signs C) Ask the parent about medication allergies D) Inquire about the health of siblings at home
A) Institute droplet precautions
Eight hours after administering a sulfonamide, the nurse notes that a patient has a temperature of 104, pulse of 112, BP of 104/52, respirations of 20, malaise, and widespread lesions of the skin and mucous membranes. The nurse would be correct to suspect A) Superinfection B) Systemic mycoses C) Stevens-Johnson syndrome D) Red man syndrome
C) Stevens-Johnson syndrome
The nurse is caring for a client admitted with serotonin syndrome after taking citalopram and tramadol. Which assessment findings does the nurse expect to find? A) Absent deep tendon reflexes B) Cold, clammy skin C) Tachycardia D) Muscle clonus E) Restlessness and agitation
C) Tachycardia D) Muscle clonus E) Restlessness and agitation
Renal impairment associated with aminoglycosides is usually ________ while hearing loss is usually ________ A) permanent, temporary B) delayed, permanent C) reversible, permanent D) momentary, brief
C) reversible, permanent
The nurse is assessing a 20 year old patient who started taking paroxetine 3 weeks ago. Which statement by the patient is the most important for the nurse to investigate? A) "I don't have much of an appetite since starting this medication." B) "I have a lot more energy, but I'm feeling just as depressed." C) "I have been feeling dizzy when I walk around at home." D) "I've been having diarrhea a lot lately."
B) "I have a lot more energy, but I'm feeling just as depressed."
The nurse prepares to administer clozapine to a patient with schizophrenia. Which patient statement would require priority investigation before administering the medication? A) "I have gained a few pounds since I started this medication." B) "I have had a sore throat for three days and feel feverish today." C) "I have noticed increased salivation and drooling." D) "I often feel sleepy when I take this medication."
B) "I have had a sore throat for three days and feel feverish today."
A nurse has reinforced discharge instructions to a patient who has undergone a right mastectomy with axillary lymph node dissection. Which statement by the patient indicates a need for further teaching regarding home care measures? A) "I should use a straight razor to shave under my arms" B) " I need to be sure that I don't have blood pressure or blood drawn from my right arm." C) "I should inform all my other health care providers that I have had this procedure." D) "I need to be sure I wear thick hand covers or use thick pot holders when I am cooking or touching hot pans"
A) "I should use a straight razor to shave under my arms."
The nurse is creating assignments for the day and has a Licensed Practical Nurse (LPN) and an Unlicensed Assistive Personnel (UAP) on the nursing team. The nurse most appropriately assigns which client to the LPN? A) A client with a tracheotomy that requires frequent suctioning B) A client who requires collection of urine for a 24 hour period C) A client recovering from pneumonia who requires ambulation every three hours D) A client who requires turning and positioning every two hours and range of motion exercises every two hours.
A) A client with a tracheotomy that requires frequent suctioning
A client is prescribed sertraline, a selective serotonin reuptake inhibitor. Which adverse effects would the nurse review when creating a medication teaching plan? Select all that apply. A) Agitation B) Agranulocytosis C) Sleep disturbance D) Persistent cough E) Dry mouth F) Seizures
A) Agitation C) Sleep disturbance E) Dry mouth
A patient with Bipolar I has been on lithium carbonate for 7 days. Which of the following findings would be the most important to report to the healthcare provider? A) Diarrhea, vomiting and mild tremor B) Dry mouth and mild thirst C) Hyperactivity and auditory hallucinations D) Lithium level of 1.1mEq/L
A) Diarrhea, vomiting and mild tremor
A hospitalized client is started on phenelzine for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply: A) Dried figs B) Salami C) Crackers D) Aged cheese E) Tossed salad F) Oatmeal raisin cookies
C) Crackers E) Tossed salad
A patient is prescribed doxycycline (Vibramycin). If the patient complains of gastric irritation, the nurse should: A) Instruct the patient to take the medication with milk B) Tell the patient to take an antacid with the medication C) Give the patient food such as crackers or toast with the medication D) Have the patient stop the medication immediately and contact the healthcare provider
C) Give the patient food such as crackers or toast with the medication
The nurse is assessing a newborn who was born to a mother who is addicted to opioids. Which findings should the nurse expect to note during the assessment of the newborn? Select all that apply. A) Lethargy B) Sleepiness C) Irritability D) Constant Crying E) Difficult to Comfort F) Cuddles when being held
C) Irritability D) Constant Crying E) Difficult to Comfort
The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which strategies should the nurse include in the teaching plan? Select all that apply. A) Maintaining an upright position while eating B) Restricting the diet to liquids until swallowing improves C) Introducing foods on the unaffected side of the mouth D) Keeping distractions to a minimum E) Cutting food into larger pieces of finger foods
A) Maintaining an upright position while eating C) Introducing foods on the unaffected side of the mouth D) Keeping distractions to a minimum
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply: A) Monitor vital signs B) Provide a safe environment C) Address hallucinations therapeutically D) Provide stimulation in the environment E) Provide reality orientation as appropriate F) Maintain NPO status
A) Monitor vital signs B) Provide a safe environment C) Address hallucinations therapeutically E) Provide reality orientation as appropriate
What is the priority reason why the nurse teaching a patient who is prescribed sulfamethoxazole to take this medication with a full glass of water? A) Decrease the risk of esophageal irritation B) Minimize crystal formation in the urine C) Prevent nausea D) Stimulate frequent voiding
B) Minimize crystal formation in the urine
A patient with generalized anxiety disorder has just received a new prescription for sertraline. The nurse should teach this client about which possible side effect? A) Constipation B) Tachycardia C) Sexual dysfunction D) Weight loss
C) Sexual dysfunction
The nurse is caring for a client with bacterial pneumonia. The effectiveness of the client's oxygen therapy can be best determined by: A) Absence of cyanosis B) Client's respiratory rate C) Arterial blood gas values D) Client's level of consciousness
C) Arterial blood gas values
A pregnant adolescent asks the nurse whether it would be all right to continue to take her prescription for tetracycline to clear up her acne. What response by the nurse provides the best information? A) "Tetracycline is effective in clearing up acne." B) "Tetracycline may cause allergic reactions in pregnant women." C) "Tetracycline will resolve an asymptomatic urinary tract infection." D) "A tetracycline drug could be harmful to the baby's teeth and should be avoided."
D) "A tetracycline drug could be harmful to the baby's teeth and should be avoided."
The nurse is employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and 3 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? A) A client who requires a bed bath B) An older client requiring frequent ambulation C) A client who requires hourly vital sign measurements D) A client requiring abdominal wound irrigations and dressing changes every 3 hours
D) A client required abdominal wound irrigations and dressing changes every 3 hours
A patient who recently was discharged from the hospital and prescribed ciprofloxacin (Cipro) phones the prescriber's office complaining of pain above the heel while walking or stretching. The nurse expects the patient to be instructed to A) Avoid the treadmill and apply ice to area B) Try isometric exercises prior to walking or stretching C) Continue the medication and watch for signs of redness or swelling D) Discontinue the medication and avoid weight bearing on the ankle
D) Discontinue the medication and avoid weight bearing on the ankle
The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu? A) Nuts and milk B) Coffee and tea C) Cheese and fish D) Oranges and dark green leafy vegetables
D) Oranges and dark green leafy vegetables
A primiparous client who is beginning to breast-feed her neonate asks the nurse, "Is it important for my baby to get colostrum?" When instructing the client, the nurse would explain that colostrum provides the neonate with: A) More fat than breast milk B) Vitamin K, which the neonate lacks C) Delayed meconium passage D) Passive immunity from maternal antibodies.
D) Passive immunity from maternal antibodies
A nurse is discharging a patient who is receiving lithium for treatment of bipolar disorder. It is most important for the nurse to provide which instruction to the patient? A) Avoid a high potassium diet B) Exercise regularly and maintain a high fiber diet C) Maintain oral hygiene D) Report excessive urination and increased thirst
D) Report excessive urination and increased thirst
A client admitted to the hospital with peptic ulcer disease tells the nurse about having black, tarry stools. The nurse should: A) Encourage the client to increase fluid intake B) Advise the client to avoid iron-rich foods C) Place the client on contact precautions D) Report the finding to the healthcare provider
D) Report the finding to the healthcare provider
Aminoglycosides are first line drugs: A) For oral therapy of a serious systemic infection B) In patients with a history of hearing impairment associated with loud noise exposure C) Against infections with a mixture of aerobic and anaerobic microbes D) To treat infections with aerobic gram negative bacilli
D) To treat infections with aerobic gram negative bacilli
