NCLEX- Practice Test 1

The health care provider (HCP) prescribes a warm moist compress for an adult client with deep muscle pain. What is the average temperature for a warm compress applied to an adult?

120 Degrees F (49 Degrees C)

The unlicensed assistive personnel (UAP) informs the nurse that a client's blood pressure is 166/92. The nurse instructs the UAP to recheck the reading. How long should the UAP wait before retaking the blood pressure?

2 minutes

A client with a diagnosis of congestive heart failure (CHF) is on strict intake and output (I&O) with a daily weight. When the nurse records the 24-hour I&O, the client's intake was 2200 mL, with an output of 1200 mL. What will the next daily weight likely be?

2.2 lb gain.

The health care provider (HCP) prescribes strict intake and output (I&O) for a client with end stage renal disease. When the nurse provides 6 ounces of ice chips to the client, how will the nurse record the liquid volume?

3 ounces

As part of a pre-operative prep, the LPN/LVN is administering a cleansing enema to an adult client. After positioning the client on their left side and lubricating the tip of the rectal tube, how far should the nurse insert the rectal tube?

3-4 inches (7.5-10 cm)

The LPN/LVN is monitoring a client who has just returned from surgery. The health care provider (HCP) should be notified when the hourly urine drops BELOW which of the following volumes?

30 mL

The nurse is preparing to transfer a client with a recent cerebrovascular accident (CVA) from their bed to a wheelchair. The client has left-sided hemiplegia. What is the proper position for the wheelchair to ensure a safe transfer?

Parallel to the bed on the client's right side.

An LPN/LVN is administering an enema solution to a client. The client tells the nurse that they feel pain and cramping in their abdomen. What is the nurse's BEST action?

Pause for 1 minute, then restart slower.

When the nurse encourages a client to cough following abdominal surgery, the client tells the nurse, "I can't. It hurts too much." Which nursing intervention will be MOST helpful for the client?

Place a small pillow over the incision while coughing.

An adult client with a fractured right tibia is placed in a leg cast. The health care provider (HCP) prescribes axilla crutches for use at home. The client tells the nurse there are stairs at home and wants to learn how to go down the stairs using the crutches. When reinforcing instructions about proper technique to descend stairs, what is the client's FIRST step?

Place both crutches on the first step.

A client undergoing chemotherapy tells the nurse that they have constant nausea and would like to learn more about complementary therapy. Which of the following therapies can be safe and helpful for this client?

Acupuncture

Following surgery, a client is placed on a "diet as tolerated" food plan. Which of the following is BEST for the client's first post-operative meal?

Clear liquid

Following a stroke with left-sided weakness, a client is also diagnosed with hemianopia. Which intervention is BEST to accommodate the client's condition?

Approach the client from the unaffected side.

A hospice nurse is caring for a client with cancer. The client has acute bone pain related to metastases. The BEST way to assess the client's level of pain is to

Ask the client to rate their pain on a scale from 1-10.

The LPN/LVN is caring for a pediatric client in a spica cast. All of the following are true EXCEPT

Assist the client to ambulate several times a day.

A client diagnosed with Crohn's disease has a new colostomy. When assessing the client's stoma, which of these would alert the nurse that the stoma has retracted?

Concave and bowl shape.

A client calls the clinic to report the presence of loose stools. Which question should the nurse ask FIRST?

Could you describe the number and appearance of your stools?

When providing postmortem care for a client who will be an eye donor, which action is MOST appropriate to prepare for the donation?

Cover the eyes with saline-soaked pads and place the client in a low Fowler's position.

A client hospitalized with primary biliary cirrhosis complains of severe itching (pruritis). Which of the following nursing interventions is MOST helpful for the client?

Cut the client's fingernails.

Before administering an intermittent feeding by an enteral tube, the nurse measures the gastric residual volume (GRV). What is the CORRECT reason for this nursing action?

Evaluate the absorption of the previous feeding.

Before a nurse implements a bladder retraining program for an incontinent client, what is the FIRST action that the nurse should take?

Gather data on the clients volding pattern.

After their 12-year-old child is prescribed a brace for their scoliosis, the nurse reinforces instructions for the parents. Which statement by the mother indicates a need for more education?

I'll put lotion on their skin before they put on the brace.

An LPN/LVN working at a long-term care facility is observing a new client. Which of the following signs indicates that the client may have a vitamin B2 (riboflavin) deficiency?

Mouth sores

A client with a diagnosis of multiple sclerosis is learning to walk with a cane. Which of the following instructions regarding safety is CORRECT?

Move the cane at the same time as the weak side.

A 54-year-old client with chronic kidney disease (CKD) tells the LPN/LVN that they love to have dessert after dinner. Knowing that CKD requires fluid restriction, which is the BEST dessert for the nurse to recommend?

Angel food cake.

A client newly diagnosed with glomerulonephritis is starting a low-sodium diet. Which of the following meals is the BEST choice?

Baked chicken breast with a salad.

The LPN/LVN is demonstrating to a new unlicensed assistive personnel (UAP) how to apply antiembolism stockings. When is the CORRECT time to apply the stockings?

Before getting out of bed in the morning.

A client receiving chemotherapy has a poor appetite, so a liquid nutritional supplement is recommended. What is the BEST time for the client to drink the supplement?

Between breakfast and lunch.

A pediatric client with a diagnosis of leukemia is experiencing nausea and vomiting from chemotherapy. Which of the following food will be BEST in providing adequate nutrition at this time?

Cold foods with no smell.

A pregnant friend of the nurse confesses that she has a limited income and can't afford to eat meat very often. What food can the nurse recommend?

Dried beans

During their annual physical examination, a client tells the nurse that they have dry, hard stools every 3 days. Which of the following will be MOST helpful in improving the client's bowel movements?

Drink at least 4 glasses of liquid a day.

A client with Stage III lung cancer reports that they have nausea and loss of appetite caused by the chemotherapy. Which is the BEST recommendation to promote adequate nutrition?

Eat small meals throughout the day.

During the admission process, a client tells the nurse that they are lacto-vegetarian. The nurse knows that this means the client cannot eat

Eggs

Following abdominal surgery, a client tells the nurse that they can't follow post-op instructions on coughing because of pain at the incision site. Which of the following is the BEST way to help reduce the client's discomfort?

Hold a pillow on the incision while coughing.

The nurse is assisting a client with bladder training in order to manage their urinary incontinence. What should the nurse recommend as the FIRST step with their bladder training?

Keep a long of how often the client urinates.

A new client at the long-term care facility has experienced a recent loss of vision tells the nurse that they are bored. Which activity is BEST for the nurse to suggest?

Listening to audiobooks.

A school-age child is recovering from the stomach flu (gastroenteritis) with vomiting and diarrhea. After tolerating clear liquids, which food is BEST for the next meal?

Mashed potatoes

The nurse delivers a meal tray to a client of Orthodox Jewish faith. The tray contains a cheeseburger with lettuce and tomato, French fries, a fruit salad, and a vanilla milkshake. What is the nurse's BEST action?

Remove the tray and order a new meal.

The health care provider (HCP) prescribed a rectal tube for a post-operative client to relieve abdominal distention due to flatus. Following insertion, the nurse notes that the client's abdomen remains distended after 30 minutes. What should the nurse do NEXT?

Remove the tube and reinsert it in 2-3 hours.

The nurse delivers a meal tray to a client of Muslim faith. The tray has ham, a green salad with tomatoes, rice, corn, a roll and butter. Hot tea is the beverage. What is the nurse's BEST action?

Request a different meal tray.

For a client with a surgical wound, which of the following meals will BEST promote healing?

Roast chicken, broccoli, cantaloupe, and a glass of milk.

The nurse on a Memory Care Unite notices that a client with a diagnosis of Alzheimer's disease is not getting adequate nutrition. What is the BEST way to stimulate the client's appetite?

Serve the cliant's favorite foods.

Following a traumatic back injury and extensive rehabilitation, a client is being discharged to home. The client still requires a wheelchair, because they are unable to bear full weight on their legs. Which of the following will be BEST `for transfer from wheelchair to bed and toilet?

Sliding board

A client receiving chemotherapy is experiencing stomatitis. What should the nurse offer the client?

Warm saline rinses four times each day.

A 65-year-old calls the clinic to report they are experiencing severe left lumbar pain. After diagnostic testing, the client learns they have kidney stones in the left kidney. Initial treatment is provided and the client is instructed on dietary changes. An increase in which of the following will be MOST helpful in preventing a recurrence?

Water