NCLEX-RN Practice Set

*The client diagnosed with chronic lymphocytic leukemia (CLL) is scheduled for a bone marrow aspiration and biopsy. The client says, "I am frightened. I have never had this test before, and I don't know what to expect." Which statements will the nurse include when responding to the client's concerns? (SATA) a. We will move you to the operating room where the test is always performed b. the bone in front of your chest will be used for the biopsy specimen c. A tight pressure dressing will be placed over the test site after the procedure. d. You will not feel any discomfort as the local anesthetic is injected e. There is a risk of bleeding, so we will monitor the site frequently

"A tight pressure dressing will be placed over the test site after the procedure." "You will not feel any discomfort as the local anesthetic is injected."

The nurse speaks with a client and the spouse who have been undergoing family counseling. The client's spouse states, "You never take any responsibility for the messes you always cause!" Which response by the nurse is best? a. why do you say that? b. blaming is not effective c. lets focus only on the positives d. when is the last time you two had a vacation

"Blaming is not effective."

*The nurse provides care for a client who is diagnosed with depression and anxiety. The client states, "I feel overwhelmed because I'm the only caregiver for my two children." Which response by the nurse is best?

"Do you participate in any religious or spiritual activities?"

*The home care nurse instructs a client diagnosed with multiple sclerosis. The client states, "I have poor concentration and difficulty pronouncing words." The nurse notes that the client's speech is slow and slurred. Which client statement indicates to the nurse that further teaching is necessary?

"During a conversation, I will carefully build up to my most important points."

The nurse discusses the client's plan of care with the student nurse. The student nurse states, "I know the client is from another country, but the client could at least look at me when I'm talking. That is so rude." Which response by the nurse is best?

"Eye contact may be a sign of arrogance in the client's country."

*A client who is diagnosed with end-stage kidney disease is prescribed hemodialysis treatments 3 times a week. After two weeks of treatment, the client states, "I have a HA when the dialysis finishes. Is this normal?" Which is the most appropriate response by the nurse? a. "I have seen this in a lot of clients. don't worry too much about it." b. "headaches may occur at the beginning of treatment and should improve over time." c. "have you experienced any headache similar to these in the past?" d. "Why are you so worried about this?"

"Headaches may occur at the beginning of treatment & should improve over time."

*The nurse provides care for an older adult client who is diagnosed with a fractured ulna. The client reports falling frequently. Which client statements require that the nurse collect more information? (SATA)

"I keep my bedroom pitch black at night." "My sister gave me her cane before she died." "I have my vision checked every 3 years." "I prefer for my pants to fit loosely around my waist."

*The nurse provides medication instruction to a client who is prescribed 50 mcg/hour dose of transdermal fentanyl every 3 days. Which statement made by the client indicates understanding of the instructions?

"I should avoid placing a heating pad over the medication patch."

The nurse admits a client to the postpartum unit and provides instruction about the postpartum process. The nurse determines that teaching is effective if the client makes which statement?

"I will call for assistance the first time I want to get out of bed."

The nurse provides care for a client diagnosed with acquired immune deficiency syndrome (AIDS). The nurse performs discharge teaching with the client. The nurse determines teaching is effective if the client makes which statements? (Select all that apply.)

"I will contact the health care provider if my bed sheets become drenched with perspiration." "I will not go to the fall festival."

*The nurse provides care for a young adult client requiring an emergent appendectomy. The HCP explains to the client the risks and benefits of the procedure. However, the client refuses to sign the informed consent. The client states, "No one is removing any organs from my body because it is against my religious beliefs. I'm leaving!" The client's mother insists the client receive the operation. Which response does the nurse make to the client?

"It is your decision to refuse medical treatment."

The nurse assesses clients for potential spousal abuse. The nurse is most concerned if a client makes which statement?

"It's my fault because I push my spouse's buttons."

The HCP prescribes metoclopramide 2 mg/kg IV to be given to a client 30 minutes before the client receives cisplatin. The client asks the nurse why metoclopramide is being given. Which response will nurse give to client?

"Metoclopramide prevents or reduces the side effects caused by cisplatin."

At a rehabilitation center for clients with spinal cord injuries (SCIs), the nurse conducts an orientation session for a group of unlicensed assistive personnel (UAP). Which statement is most important for the nurse to include?

"Obtain client's permission before touching client."

*The community health nurse conducts a program for suicide prevention at a high school. The nurse discusses high-risk groups for suicide. The nurse determines that further teaching is necessary if students from the group make which statement? a. adolescents are at risk to commit suicide b. depressed people are at risk to commit suicide c. history of previous suicide attempts put people at risk d. people grieving a loss for 9 months are at risk

"People grieving a loss for 9 months are at risk."

*The nurse receives a phone call from a client's adult child who states, "I just got here to see my elderly parent, and I think heat stroke has occurred. I think the air conditioning is not working and the house is very hot." The adult child reports that the parent is confused, very thirsty, nauseated, and in pain. Which is the most appropriate statement for the nurse to make? a. if perspiration is present, heat stroke has not occured b. Give your parent cool fluids to drink immediately c. What medications does your parent take daily? d. Remove any excess clothing immediately.

"Remove any excess clothing immediately."

The nurse assesses a client diagnosed with Ménière disease. The client states, "I take my prescribed meds regularly, but I continue to have episodes of vertigo." Which response by the nurse is most important?

"Tell me about your diet."

*The LPN/LVN reporting to the nurse says, "You may want to see the client recently diagnosed with pancreatic cancer. I am not sure how well things are going." The nurse enters the room and finds the client sitting quietly, looking out the window. As the nurse approaches client, the client does not look at the nurse. Which is the most appropriate response by the nurse?

"Tell me what you know about your diagnosis and the treatment you will receive."

A client is admitted to the ED. The family reports the client had a sudden onset of left-sided facial droop and slurred speech at home. The nurse observes left-sided muscle weakness. Which is the most important question for the nurse to ask?

"When did you notice the onset of your parent's symptoms?"

The nurse makes client assignments on the medical surgical unit. The nurse assigns an LPN/LVN to a client diagnosed with localized herpes zoster. The LPN/LVN tells the nurse, "I have never had chickenpox." Which response by the nurse is most appropriate? a. use standard precautions when providing care for the client b. you will be fine because the client is on airborne precautions c. your client assignment will be changed d. why are you concerned about providing care for the client

"Your client assignment will be changed."

The nurse meets with the parent of an adolescent male who presents for an annual health maintenance visit. The parent voices concern that the child has recently become clumsy and uncoordinated. Which response by the nurse is correct? a. your son might have ADHD b. I'll talk with the HCP about assessing for motor dysfunction c. your son's clumsiness is expected at this age d. this may be an early sign of depression

"Your son's clumsiness is expected at this age."

*A pediatric client is diagnosed with pneumonia and prescribed ampicillin 50 mg/kg oral suspension every 6 hours. The child weighs 18 lb (8.181818 kg). The ampicillin is available in 125 mg/5 mL. How many mL will the nurse administer for each dose? (Round to nearest whole #)

16 mL

The nurse provides care for the client diagnosed with a hypertensive emergency. The client is prescribed sodium nitroprusside 0.3 mcg/kg/min. The client weighs 176 lb (80 kg). The concentration of the sodium nitroprusside is 50 mg/250 mL. What rate will the nurse set for the per hour amount on the micro infusion pump? (Record your answer rounding at the end of the calculation using one decimal place.)

7.2 mL/hr

The nurse in the ED assesses a client diagnosed with tonic-clonic epilepsy. The client's spouse states that the client has been taking phenytoin as prescribed, but has not been feeling well lately. Which client observation most concerns the nurse? a. reddish-brown urine, and the client reports constipation. b. acne, hurtuism, and gingival hyperplasia c. ataxia, slurred speech, and nystagmus d. the left arm is in a sling and the client walks with a limp.

Ataxia, slurred speech, & nystagmus

*The nurse performs triage in the ED. An unemancipated adolescent minor requests to be treated. The registration clerk states the adolescent requires guardian consent for treatment. Which action should the nurse take next?

Ask the unemancipated minor about the medical reason for seeking treatment.

*The HCP prescribes an increase in the parenteral nutrition (PN) infusion rate from 50 mL/hour to 100 mL/hour. The PN is infusing through a PICC device. Which is the priority action for the nurse? a. assess hourly urine b. evaluate total serum protein level c. assess vital signs (VS) every 4 hours d. Evaluate aspartate aminotransferase (AST) test

Assess hourly urine.

The nurse provides care for a client diagnosed with diastolic HF. The nurse observes the recent onset of the A-fib. Which is the most appropriate action for the nurse to take? a. administer digoxin 0.25 mg IV b. instruct the client to take a deep breath and hold it c. assess level of consciousness and orientation d. auscultate posterior chest

Assess level of consciousness & orientation.

A client is brought to the ED by friends reporting a dry mouth, frequent urination, extreme thirst, and no fluid intake for the last 8H. The friends report the client may not have taken insulin during the last couple of days. The nurse reviews prescriptions from the HCP. Which prescription does the nurse implement first? a. administer 30 mEq potassium chloride orally b. begin regular insulin at 0.1 U/kg/hr c. obtain a 12 lead EKG d. begin infusion of 0.9% NaCl at 1L/hr

Begin infusion of 0.9 % NaCl at 1 L per hour.

The nurse provides care to a client who has a chest tube and pleural drainage system placed for the treatment of a right-sided pneumothorax. The suction control chamber is set at 20 cm and tubing is attached to the wall suction. Which finding will the nurse expect to observe after the insertion of the chest tube? a. bubbling in the water-seal chamber b. serosanguinous drainage in the collection chamber c. Fluctuations in the suction control catheter during coughing d. one cm sterile water in the water-seal chamber

Bubbling in the water-seal chamber.

*The nurse provides care for pregnant and postpartum clients. Which client does the nurse see first? a. client at 6 weeks gestation, reporting that the LPN/LVN could not obtain fetal heart tones with a Doptone b. Client at 5 days postpartum, reporting bright red bloody discharge c. Client at 22 weeks gestation, reporting feeling fetal movement four times in the last hour d. client at 2 days postpartum, reporting urinary incontinence

Client at 5 days postpartum, reporting bright red, bloody discharge.

*The nurse reviews the medical record of a client who is confused. The client has soft wrist and ankle restraints in place. The nurse determines care is effective if which actions are documented? (Select all that apply.) a. restraints secured tightly to the kin b. client placed in room next to nursing station c. restraints attached to side rails on client's bed d. informed conset for the restraints has been obtained from client's spouse e. client alert and oriented x3 f. client placed in prone position

Client placed in room next to the nursing station, Informed consent for the restraints obtained from the client's spouse.

The nurse evaluates client care assignments made by the student nurse. The nurse will intervene if the LPN/LVN is scheduled to care for which client? a. Client who received methylprednisolone for lumbar radiculopathy b. Client who received racemic epinephrine for croup. c. Client who received ketorolac for pleurisy d. Client who received tamsulosin for benign prostatic hyperplasia

Client who received racemic epinephrine for croup.

The telemetry nurse is notified that the unit is receiving a new admission from the medical surgical unit. Which client currently on the telemetry unit should the nurse suggest be sent to the medical surgical unit? a. client with a magnesium level of 1.6 mEq/L b. client scheduled for a cardiac cath tomorrow c. client with digoxin lvl of 2.4 ng/mL d. client who reported chest discomfort during cardiac stress test

Client with magnesium level 1.6 mg/dL

The nurse provides care for a hospitalized older adult client who has a BMI of 16.1. Which is the priority action by the nurse?

Confer with a dietitian.

The nurse provides care for an adolescent client reporting arm pain after a fall. The nurse notes bruising in multiple stages of healing. The nurse accesses client's medical record and notes the client was treated twice last month for reported back pain after two separate falls. The client was treated two months ago for a perforated eardrum. Which action by nurse is priority?

Contact social services.

When assessing the incision of a client 2 days postoperatively, the nurse notes a shiny pink area with underlying bowel visible. Which action does the nurse implement?

Cover area w/ sterile gauze soaked in normal saline.

*The nurse provides care for the client immediately after arrival in the ED. Emergency personnel report that the client was involved in a head-on collision with immediate loss of consciousness. Which is the first action taken by the nurse? a. determine glasglow coma scale (GCS) score b. assess bilateral blood pressure c. check bilateral pupillary responses to light d. determine oxygen saturation levels

Determine oxygen saturation levels.

The nurse completes documentation for a client & realizes the entry has been placed in the wrong client's medical record. Which action by nurse is most appropriate? a. complete an incident report and place a copy in the client's medical record b. Draw a single line through each line of the incorrect entry and write a new note explaining what occurred c. Use correction fluid d. copy the note into the correct client's record and indicate that it was erroneously put in the wrong client's record

Draw a single line through each line of the incorrect entry and write a new note explaining what occurred.

Upon assessment of a client admitted for dehydration, the nurse observes that the client appears restless and reports difficulty breathing. Upon auscultation of the client's lungs, the nurse notes bilateral basilar crackles. Which actions will the nurse take first? a. place the client on 2 L of oxygen by nasal cannula and auscultate the lungs b. Elevate the head of the bed and stop the IV infusion c. Decrease the IV flow rate and administer furosemide as prescribed d. Stop the IV infusion and notify the HCP

Elevate the HOB & stop the IV infusion.

The client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which assessment findings for this client? (SATA) a. hypotension b. low back pain c. wet breath sounds d. fever e. urticaria f. severe shortness of breath

Hypotension, Low back pain, Fever

The nurse provides care for a client who underwent a vagotomy with antrectomy to treat a duodenal ulcer. Postoperatively, the client develops dumping syndrome. Which client statement indicates to the nurse that further teaching is necessary? a. I am able to eat a roll or bread at dinner b. I usually eat smaller meals, about 6 per day c. I need to recline after meals to help with digestion d. I should avoid drinking fluids with my meals

I am able to eat a roll or bread at dinner

The nurse supervisor is informed that three serious safety events occurred last month between 0730 & 0800. The last serious safety event occurred because the oncoming nursing shift did not know a client was receiving an IV insulin drip. Which is the priority action for the nurse supervisor to take?

Implement mandatory bedside reporting.

The nurse observes the unlicensed assistive personnel (UAP) obtain a capillary glucose sample. Which is the best location for obtaining a blood glucose sample?

Lateral aspect of finger; end of finger is not recommended d/t less blood flow & more nerve fibers.

*The nurse works on medical surgical unit. The nurse-to-client ratio is 1:10. Which action does nurse take first? a. document the situation in writing b. refuse the client assignment c. delegate tasks to the LPN/LVN d. notify the nursing supervisor

Notify the nursing supervisor.

The family member of a client diagnosed with a pneumothorax states, "I think something is wrong with that drainage device. It just got very noisy." The nurse observes that bubbling in the underwater seal is continuous compared to several hours ago. Which action does the nurse take first? a. clamp the chest tube at the insertion site b. add sterile water to the underwater seal chamber c. notify the health care provider d. observe the connections of the drainage system

Observe the connections of the drainage system.

*The nurse reviews the medical record of a client recently diagnosed with Guillain-Barré syndrome. The client has flaccid paralysis of both legs, a history of coronary artery bypass surgery 3 weeks ago, and a 20-year history of HTN and hypercholesterolemia. The client was also recently diagnosed with type 2 DM. The nurse prepares to apply anti-embolism stockings to both legs. Which priority action does nurse implement?

Palpate bilateral pedal pulse strength.

The nurse provides care to a client who is diagnosed with a stroke and is admitted to a rehab center. The client has left-sided pronator drift and decreased dorsiflexion strength of the left extremity. The nurse notes the client bumps into the left wall when ambulating with a walker. The client leans to the left when sitting in a chair or wheelchair. Which is the most appropriate action for the nurse to take?

Position the client so the right side faces the door of the room.

The nurse determines that a client's tracheostomy requires suctioning. Which action does nurse take first?

Preoxygenate the client.

The client approaches the triage desk in ED & reports exposure to chemicals after a truck overturned. The client has powder and unknown liquid substances on the clothing. The client is diaphoretic & reports difficulty breathing. Which action does nurse take first?

Put on appropriate protective gear.

A client returns to the recovery area after a colonoscopy procedure. Intravenous midazolam was administered during the procedure. The procedure was completed at 1115. The recovery room nurse reviews the sedation chart below. Based on this information, which is the most appropriate action for the nurse to take? a. recheck bp in 15 minutes b. administer ondansetron 4 mg IV c. obtain a 12-lead ECG d. assist the client to get dressed

Recheck BP in 15 minutes

A client diagnosed with malnutrition is prescribed continuous enteral feedings through a newly placed gastrostomy tube. Which actions will the nurse include in the client's plan of care? (SATA) a. cover the insertion site with an adhesive bandage b. add 7 hours of feeing to the bag at a time c. rotate the gastrostomy tube 360 degrees once daily d. Auscultate for a whoosh of air through the gastrostomy tube e. check for slight in-and-out movement of the gastrostomy tube

Rotate the gastrostomy tube 360 degrees once daily Check for slight in-and-out movement of the gastrostomy tube.

The terminally ill client reports to the nurse that a DNR prescription has been initiated. The client is concerned that family members do not accept this wish. Which is the best action made by the nurse?

Schedule a meeting with the client and family.

During a urinary bladder catheter insertion, with a size 16 French catheter on an older adult male, the nurse feels increased resistance. Which is the most appropriate action for the nurse to take? a. withdraw the catheter and apply more lubricant b. instruct the client to take a deep breath and bear down c. Stop the insertion and instruct the client to take deep breaths. d. withdraw the catheter and notify the health care provider

Stop insertion & instruct client to take deep breaths.

*The nurse provides care for a client who is prescribed assist-control mechanical ventilation with PEEP of 5 cm H 2O. Which actions will the nurse include in the client's plan of care? (SATA) a. strict handwashing before suctioning b. brushing teeth every 12 hours c. elevating the head of bed 20 degrees d. administering pantoprazole 40 mg IV daily e. changing positions every 2 hours

Strict hand washing before suctioning Administering pantoprazole 40 mg intravenous daily Changing client position every 2 hours.

The nurse is supervising four unlicensed assistive personnel (UAP). The nurse will immediately intervene and provide assistance if which scope of practice violation is observed?

The UAP restarts a client's IV fluids.

The nurse preceptor observes the novice nurse obtain blood through a peripherally inserted central catheter. Which observation requires an intervention by the nurse preceptor? a. the nurse discards 1 ml of blood prior to obtaining the blood sample b. the nurse uses a 10ml syringe to flush through the port of the catheter c. the nurse applies clean gloves prior to beginning the procedure d. the nurse uses the push-pause technique to flush the catheter

The nurse discards 1 mL of blood prior to obtaining the blood sample.

The nurse instructs a student nurse about the correct way to set up a sterile field. The nurse determines that teaching is effective if which action is observed?

The student nurse sets up the sterile field above waist level.

The nurse reviews the medical record of a client diagnosed with acute kidney injury. It is most important for the nurse to review which lab value? a. fasting blood glucose b. serum uric acid c. serum protein d. urine specific gravity

Urine specific gravity.

The nurse in the ED prepares to administer morphine sulfate to a client. Which action does nurse take first?

Verify the client's name and date of birth.

*A client diagnosed with rheumatoid arthritis (RA) is prescribed 50 mg etanercept subcutaneous weekly. The client reports joint swelling, symmetrical joint pain, and deformities of both hands. Which finding does the nurse report to the HCP?

White cell count 14,000/mm 3 (14 x 10 9/L).