NCLEX Questions

The nurse is assigned to care for a client with the diagnosis of schizophrenia. The client tells the nurse, "I am having trouble tuning out the voices." What is the nurse's best response to this statement?

1. "There is nothing to help with this problem." 2. "You might hum when the voices are so troublesome." 3. "You should ask your primary healthcare provider to increase your medication." 4. "Wear earplugs to block out the voices." 2

Which nursing action takes priority once a term infant has delivered vaginally?

1. Apply identification bands 2. Apply eye ointment 3. Dry the baby 4. Obtain footprints 3

Which postpartum client should the nurse assign to a private room?

1. Has antibodies for Hepatitis C. 2. Is rubella non-immune. 3. Is rubella immune. 4. Has lupus antibodies. 1

The nurse is caring for a burn client 48 hours after the burn occurred. What would be the nurse's priority assessment?

1. Measure the abdominal girth. 2. Administer pain medication. 3. Auscultate the lungs every 2 hours. 4. Inspect the burn for infection. 3

A client diagnosed with Alzheimer's disease becomes agitated and combative when the nurse approaches to perform a shift assessment. What would be the most appropriate first action for the nurse to take?

1. Obtain assistance to restrain the client. 2. Talk quietly to the client. 3. Administer haloperidol. 4. Leave until the family can calm the client down. 2

A 13 year old, found unresponsive in the park, is brought into the emergency department. The nurse sees a medical alert bracelet stating "Diabetic", and notes a fruity smell to the breath. There are no family members available to obtain consent for treatment and an attempt to call them has been unsuccessful. What action should the nurse take?

1. Obtain consent from the social worker on duty in the emergency department. 2. Begin treatment by inserting two large bore IVs of normal saline. 3. Give Glucagon IM and the wait for the arrival of a parent to consent to further treatment. 4. Withhold treatment until a parent arrives at the emergency department. 2

Which referral would the nurse anticipate that the primary healthcare provider would make for a client who has difficulty eating using regular utensils?

1. Occupational therapist 2. Physical therapist 3. Rehabilitation nurse 4. Registered Dietitian 1

A term primipara is admitted in active labor and with rupture of membranes. Her last vaginal exam one hour ago revealed that she was dilated to 6 centimeters, 100% effaced, and at -1 station. The client calls out "My belly really hurts. I feel like I have to have a bowel movement!" Which action should the nurse perform first?

1. Offer her a bedpan. 2. Call the primary healthcare provider. 3. Prepare for epidural administration. 4. Perform a sterile vaginal exam. 4

Which action should the nurse recommend to parents so that their home will be safer for a toddler?

1. Place the child in the center of an adult-sized bed when napping. 2. Buckle the child into the high chair if parents leave the room during a meal. 3. Anchor top-heavy furniture or fish tanks so that they cannot be pulled over. 4. Allow the toddler to explore stairs in the home if supervised. 3

What term should the nurse use to document that a woman is pregnant for the first time?

1. Primigravida 2. Multigravida 3. Primipara 4. Multipara 1

A primipara at 36 weeks gestation is seen in the OB/GYN clinic. Which sign/symptom should the nurse immediately report to the primary healthcare provider?

1. Puffy hands and face 2. Reports indigestion 3. Pedal edema 4. Trace proteinurea 1

A nine year old child with attention deficit hyperactivity disorder (ADHD) is being admitted to the pediatric unit. Who should the charge nurse assign this client to room with?`

1. Ten year old with Crohn's disease. 2. Eight year old with a history of seizures. 3. Six year old admitted with asthma. 4. Seven year old with a urinary tract infection. 4

A palliative care client is suffering from persistent diarrhea. What foods should the nurse suggest?

Select All 1. Applesauce 2. Rice 3. Bananas 4. Tea 5. Yogurt 1,2,3

Who often performs the responsibilities of a case manager?

Select All 1. Physical therapist 2. Social worker 3. Dietitian nutritionist 4. Nurse 5. Unlicensed assistive personnel 2,4

An LPN/VN is reinforcing instructions for the spouse of a home care client recently diagnosed with Alzheimer's Disease. The LPN/VN acknowledges that previous teaching was successful when the spouse makes what statement?

1. "Activities that provide stimulation will help to reorient my spouse". 2. "With medications and therapy, my spouse will begin to improve". 3. "Keeping the rooms dark and quiet will be calming for my spouse". 4. "As the disease progresses, I need to review safety issues at home". 4

Which action by a nurse would indicate that this nurse is following standard precautions?

1. Clean gloves while performing a heel stick on an infant. 2. Sterile gloves to empty a indwelling urinary catheter bag. 3. Shoe covers when entering the room of a client with influenza. 4. Clean gloves while inserting a urinary catheter. 1

The home health nurse is assessing the home environment for threats to the safety of the toddler who lives in the home. Which observations should be included in this assessment?

Select All 1. Do stairs have guard gates? 2. Are safety covers on electrical outlet plugs? 3. Is the swimming pool inaccessible to the toddler? 4. Are cleaning supplies located out of the toddler's reach? 5. Are stairs brightly lit? 1,2,3,4

A client is seen in the clinic expressing feelings of hopelessness and despair after losing his wife two months ago. He tells the nurse, "I think I am ready to go meet her. Please don't tell anyone." How should the nurse respond?

1. "I can see that you miss your wife very much." 2. "Tell me about your wife." 3. "I will keep your secret if you promise me you won't do anything until we talk again." 4. "I can't keep a secret like that. Are you planning to harm yourself?" 4

The driver of a motor vehicle was driving while intoxicated with a friend in the passenger seat. Both clients are admitted to the Intensive Care Unit. The nurse is caring for the driver of the vehicle who states, "I'm so scared. What if the car accident is my fault and my friend dies?" What is the most appropriate response from the nurse?

1. "I wouldn't worry about that; everything will be all right." 2. "You are worried that you may be responsible for your friend's condition?" 3. "How come you were drinking and driving?" 4. "Let's not talk about that right now." 2

A client has been admitted voluntarily to the psychiatric unit. During the admitting interview, the client confides to the nurse that they have a lethal plan for committing suicide. At the end of the interview the client asks the nurse, "How long will I have to stay here?" What should the nurse say to this client?

1. "Let's discuss this after the health team has assessed you." 2. "Since you signed papers to be admitted, you cannot leave until the primary healthcare provider discharges you." 3. "A lawyer will have to make that decision." 4. "You can leave when you are no longer suicidal." 1

A clinic nurse completed teaching the parents of a 9 month old baby how to prevent otitis media infections in their baby. Which statement by the parents indicates to the nurse that further teaching is necessary?

1. "Our baby should sit up for feedings." 2. "It is fine to prop up a juice bottle for our baby to drink at night." 3. "Since our baby has ear tubes, ear plugs should be worn when swimming." 4. "We need to keep our baby away from people who are smoking." 2

What should the nurse tell a 68 year old client who states that they have started experiencing tremors?

1. "This is nothing to worry about and is common with aging." 2. "You should increase your intake of potassium." 3. "We need to let your primary health care provider know because it may indicate a problem." 4. "Have someone check your blood pressure the next time you experience tremors." 3

The nurse is planning an activity for the client who has a diagnosis of paranoid schizophrenia. Which activity would be most appropriate for the client?

1. A game of Scrabble with peers 2. A group game of basketball. 3. An individual art project. 4. A card game with the nurse. 3

A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). Which of the following RNs should not be assigned to this baby?

1. A nurse just back from maternity leave. 2. A nurse who is 10 weeks pregnant. 3. A nurse who is breastfeeding her 4 month old. 4. A nurse who is on hormone replacement therapy. 2

The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. In order to reorganize staffing, the nurse manager should initiate which action first?

1. Announce the new changes at the monthly staff meeting. 2. Ask for any staff objections to rearranging work hours. 3. Invite staff to contribute ideas on scheduling changes. 4. Explain administration is demanding a decreased overtime. 3

A 16 year old female student is escorted to the school nurse after fainting in gym class. The student tells the nurse, "I just got weak from running." Upon examination, the nurse notes poor skin turgor, dry mucous membranes, and erosion of tooth enamel from her front teeth. Height is 5'4" (162.56 cm) and weight is 110 lbs (50 kg). The student reports muscle pain in the legs. Based on this data, what should the nurse suspect?

1. Anorexia Nervosa 2. Bulimia Nervosa 3. Obesity 4. Physical violence 2

A school nurse is caring for a child who fell on the playground. Upon examination of the child, the nurse notes multiple bruises in various stages of healing. What is the nurse's initial intervention?

1. Ask the parents who hit the child on the back. 2. Notify the child's primary healthcare provider. 3. Contact the Department of Health and Human Services. 4. Document the findings and observe the child over the next week. 3

The nurse is assessing a pregnant client returning for her first, one month check-up. The client has normal vital signs, blood count, and urinalysis, but has gained 6 pounds (2.7 kg). What is the most important assessment at this time?

1. Blood glucose level 2. Ankles for edema 3. Twenty-four hour diet recall 4. Confirmation of last menstrual period 3

The nurse has been caring for a client who is experiencing new onset of constipation. Which goal is most appropriate for a client reporting constipation?

1. Client will have one bowel movement each day. 2. Client will no longer experience constipation. 3. Client will return to his normal bowel elimination habits. 4. Client will have more frequent bowel movements. 3

The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which observation would indicate the need to slow the irrigation?

1. Clots in urine 2. Bladder pressure 3. Clear urine 4. Bladder spasms 3

A 70 year-old client reports not sleeping well at night, having trouble staying asleep, and awakening about 4:00 a.m. What should the nurse teach the client about sleep patterns in the elderly?

1. Don't worry about a few hours of lost sleep. 2. Elders need as much sleep as younger adults. 3. Caffeine and some medications may interfere with sleep. 4. Elders sleep more than younger adults. 3

A client in active labor has an epidural catheter inserted for management of pain. Which finding should the nurse report to the primary health care provider?

1. Early decelerations 2. Fetal heart rate (FHR) 160/min 3. Blood pressure 90/62 4. Temperature of 99.6° F (37.5° C). 3

A client scheduled for a bronchoscopy and possible lung biopsy tells the nurse, "I don't know what a bronchoscopy is." Which nursing intervention should the nurse implement?

1. Explain the bronchoscopy procedure to the client and inform the client of the risks, benefits, and treatment alternatives. 2. Immediately inform the primary healthcare provider that the client requests additional information about the bronchoscopy procedure. 3. Give the client an information pamphlet on the bronchoscopy procedure, and tell the client to sign the consent after reading the pamphlet. 4. Instruct the client to sign the informed consent form. The primary healthcare provider will answer any additional questions right before the procedure is performed. 2

The client with obsessive-compulsive disorder (OCD) asks the nurse for help with a repetitive behavior. What is the most likely origin of this behavior?

1. Fear 2. Depression 3. Delusions 4. Anxiety 4

The nurse is admitting an 8 month old infant to the pediatric unit. For what major developmental stressor in this infant should the nurse plan interventions?

1. Fear of unknown 2. Loss of daily routine 3. Body image disturbance 4. Separation anxiety 4

A client is sedated. His wife asks the nurse about her husband's test results. The client does not have a healthcare proxy or durable power of attorney executed at this time. How should the nurse respond in compliance with HIPAA (Health Insurance Portability and Accountability Act) regulations regarding the confidentiality of the sedated client's health information?

1. I can't give you those results. You should ask his primary healthcare provider the next time that he comes in to examine your husband. 2. Those test results are confidential, but since you are his wife I can give them to you. Let me look them up in the computer system. 3. The health information of all clients is confidential and is protected by law. Those test results cannot be released without the consent of the client in order to protect the client's right to choose who receives health information. 4. Your husband is only lightly sedated. I can wake him up and ask him if it is all right to release these test results to you. 3

A client diagnosed with pancreatic cancer is being discharged home to live with an adult child. What action should the nurse take to promote continuity of care?

1. Identify community services available for the client and family. 2. Refer client for hospice care. 3. Advise family that client would benefit more from nursing home placement. 4. Make arrangements for around the clock home health aides. 1

A community health nurse is assessing a migrant farmer who raises chickens. The nurse notes the client has developed a cough, fever, dyspnea, and hemoptysis. What infection should the nurse suspect?

1. Lyme disease 2. Toxoplasmosis 3. Tuberculosis 4. Histoplasmosis 4

When preparing to administer the client a dose of intravenous (IV) antibiotics, the nurse notes that the IV pump cord is frayed with wiring visible. What priority action should the nurse take?

1. Notify maintenance to come and check the pump immediately. 2. Continue to use the IV pump and fill out an equipment maintenance request. 3. Obtain a replacement pump. 4. Tag the equipment for maintenance. 3

A client with diabetes is hospitalized for debridement of a non-healing foot ulcer. Following the procedure, the nurse notes that the client has become confused and combative. The family expresses concern with the behavioral changes and requests that the client be restrained in bed. What is the nurse's priority action?

1. Notify the primary healthcare provider. 2. Apply a vest restraint as requested by family. 3. Move client to a room near the nurse's desk. 4. Obtain a finger-stick blood glucose level. 4

A client with a terminal illness, asks the nurse about palliative care. What would be the nurse's best response?

1. Palliative care is a holistic way of finding a cure for a serious illness. 2. Palliative care begins when the client has 3 months or less to live. 3. Palliative care, will require you to change to a palliative care healthcare provider. 4. Palliative care prevents and treats symptoms and side effects of disease and treatments. 4

A client asks the nurse, "How is relaxation therapy going to help reduce my stress?" What would be the nurse's best response?

1. Relaxation therapy leads to more awareness of potential stressors 2. Relaxation therapy reduces stress by releasing small doses of epinephrine into the body. 3. Stress can be eliminated from your life when you use this therapy. 4. Relaxation therapy can counteract the flight or fight response. 4

A 6 year old admitted from the emergency department (ED) with a fractured tibia is scheduled for surgery in the morning. All of the private rooms are full so the child must be admitted to a semi-private room. What room assignment is appropriate for the nurse to make for this client?

1. Rooming with an 8 year old in sickle cell crisis. 2. Rooming with a 2 year old admitted with bacteremia. 3. Rooming with a 3 year old with pneumonia. 4. Rooming with a 4 year old with gastroenteritis. 1

A client was admitted to the medical unit after an acute stroke. Which nursing activity can the registered nurse delegate to the LPN/VN?

1. Screen client for contraindications for tissue plasminogen activator (tPA) therapy. 2. Place seizure precaution equipment in client's room. 3. Perform passive range of motion (ROM) exercises. 4. Administer enoxaparin 1 mg/kg subcutaneously every 12 hours. 4

A client is admitted to a chemical dependency unit for addiction treatment. Which of the client's belongings should the nurse remove from the client's room?

1. Shampoo and conditioner 2. Mouthwash and hand sanitizer 3. Toothpaste and dental floss 4. Lotion and foot powder 2

The home health nurse is concerned about the safety of the client who lives alone in a poorly maintained home. The nurse convenes the interdisciplinary team to discuss the situation. Which action should occur first?

1. Share the assessment findings with the interdisciplinary team. 2. Suggest that the social worker visit the client in the home. 3. Ask the primary healthcare provider about possible nursing home placement. 4. Suggest a "meals on wheels" solution to nutrition. 1

In the office for a yearly physical examination, a 30-year-old client reports that the client and husband used to be very happy before the children were born. Now the client is struggling with the current situation. What should the nurse understand about this situation?

1. The client is probably having an extramarital affair. 2. The developmental task at this stage is adjusting to the needs of more than two family members. 3. A relative or close friend should be consulted for help so the client can pursue activities outside the home. 4. The client should be referred to a psychotherapist for evaluation and care. 2

A nurse wants to find out a better way to perform oral care on unresponsive clients. What is the best first action for the nurse to take in order to achieve this goal?

1. Try different methods of oral care on unresponsive clients to see what works best. 2. Discuss the issue with the leader of the "best practices" committee. 3. Read all the current literature related to oral care on unresponsive clients. 4. Ask the primary healthcare provider to suggest the best oral care procedure. 2

For a client with a major burn, which evaluation criterion identified by the nurse best indicates that fluid resuscitation has been effective during the first 24 hours of care?

1. Urine output of 860 mL / 24 hours. 2. Increase in weight from preburn weight. 3. Heart rate of 122 beats per minute 4. Central venous pressure of 18 mm 1

A Hispanic client is considering treatment options for cancer. The client says that she needs to discuss the options with her sons before she makes her final decision. What should the nurse say to the client?

1. You are wanting your sons to assist you in deciding about treatment options. 2. It is really your decision about which option you choose. 3. I will be happy to discuss this issue with you. 4. This shows that you are proud of your sons. 1

A client asks, "I would like to view my medical records." Which response made by the nurse is most appropriate?

1. You will first need to contact your primary healthcare provider. 2. You may view your electronic health records on a weekly basis. 3. You have the right to view the medical records that pertain to your care. 4. You want to view your medical records? 3

A healthy newborn has just been delivered and placed in the care of the nursery nurse. What nursing actions should the nursery nurse initiate?

1.Assess newborn's airway/breathing 2. Bulb suction excesive mucus 3. Assess newborn's heart rate 4. Place ID bands on mom and newborn 5. Administer sterile ophthalmic ointment containing 0.5% erythromycin

The RN, LPN, and unlicensed assistive personnel (UAP) are providing care for clients on the nursing unit. Which tasks could be completed only by the RN?

Select All 1. Administration of routine medications. 2. Dressing changes. 3. Assessment of newly admitted clients. 4. Calling the primary healthcare provider about lab results. 5. Teaching the diabetic client foot care. 3,5

The nurse is teaching comfort measures to a postpartum client with an episiotomy and external hemorrhoids? Which teaching points should the nurse include?

Select All 1. Apply ice to perineum for first 12 hours. 2. Take sitz baths at temperature of 42-44°C (107.60° 111.2°F). 3. Use witch hazel compresses on rectal areas for hemorrhoids. 4. Take ibuprofen for pain. 5. Apply topical anesthetics to perineal area. 6. Avoid sexual intercourse until episiotomy has healed. 1,3,4,5,6

A 3-year-old child refuses to take a prescribed medication. Which statements by the mother, regarding the child's refusal, indicate to the nurse that parental education is needed?

Select All 1. "My child is trying to make me angry". 2. "I feel like such a bad mother when my child acts this way". 3. "I promise my child a reward for taking medicine". 4. "I am unfazed by my child's actions". 5. "My child doesn't have to take medicine if he doesn't want to". 1,2,5

Which interventions should the nurse include for a client with sickle cell crisis who is experiencing pain?

Select All 1. Apply cold compresses to affected joints. 2. Massage affected areas gently. 3. Support and elevate swollen joints. 4. Monitor pain level by looking for BP, respiratory, and heart rate elevation. 5. Place client on Nothing By Mouth (NPO) status. 6. Administer Normal Saline (NS) at 125 mL/hour. 2,3,4,6

Which manifestations, if noted in a pregnant client, would the nurse need to report to the primary healthcare provider?

Select All 1. Calf muscle irritability 2. Facial edema 3. Pressure on the bladder 4. Blurry vision 5. Hemoglobin of 11 mg/dL 6. Epigastric pain 1,2,4,6

What actions should a nurse take to provide continuity of care when discharging a client diagnosed with hemiparesis to a long-term care facility for rehabilitation?

Select All 1. Document current functional status assessment 2. Notify the primary healthcare provider of transfer completion. 3. Transfer essential medical record to the receiving facility. 4. Phone report to the receiving nurse. 5. Send a day's worth of medications with the client to the receiving facility. 1,2,3,4

A nurse is monitoring a newly hired unlicensed assistive personnel (UAP) perform a bed bath on a client needing total care. Which action by the UAP would require further teaching?

Select All 1. Lowers side rails on both sides of bed. 2. Washes eyes with mild soap and water from the inner to outer canthus. 3. Makes certain bath water temperature is between 110-115°F (43-46°C). 4. Uses long, firm strokes to wash from wrist to shoulder of each arm. 5. Performs a back massage after completing the bath. 1,2

The nurse is developing a teaching plan covering emergency responses to smallpox. This presentation will be used with newly hired hospital employees. What information is essential for the presentation?

Select All 1. People may be exposed to smallpox but not get the disease. 2. People may contract the disease by handling contaminated clothing or bedding. 3. Smallpox is fatal is about 50% of cases. 4. Smallpox victims are contagious for two weeks. 5. Smallpox victims are isolated from others. 1,2,5