Exam Cram NCLEX-PN PRACTICE QUESTIONS 100 QUESTIONS WITH 100% VERIFIED ANSWERS, Exams of Nursing

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1. the nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. the nurse should be particularly alert to: A. Nasal congestion B. Abdominal Tenderness C. Muscle Tetany D. Oliguria 2. A client with cancer is a, admitted to the oncology unit. Stat lab values revel A. Nasal congestion why? removal of the pituitary gland is usually done by transspher- noidal approach through the nose. Nasal congestion further interferes with the airway. B. Hypokalemia Hgb 12.6, WBC 6500, K+1.9, uric acid 7.0, why? Na+136, and platelets 178,000. The nurse Hypokalemia is evident from the evaluates that the client is experiencing which of the following? A. Hypernatremia B. Hypokalemia C. Myelosuppression D. Leukocytosis 3. A 24 year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse? A. taking the vital signs B. obtaining the permit C. explaining the procedure D. Checking the lab work 4. The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. which action should receive prior- ity? A. starting an IV?

lab values listed. The other labo- ratory findings are within normal limits. making answers A,C and D incorrect A. taking the vital signs why? the primary responisblity of the nurse is to take the vital signs before any surgery. answers B,C and D are the re- sponsibility of the doctor. B. Applying oxygen why? the client with burns to the neck needs airway assessments and supplemental oxygen, so apply- ing oxygen is priority. the next

B. Applying oxygen C.Obtaining blood gas D. Medicating the client foe pain action should be to start an IV and medicate for pain.

5. The nurse is visiting a home health client C. Take medication with water with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instructions should be given to the client A. rest in bed after taking the medication for at least 30 mins B. Avoid rapid movements after taking the medication C. Take medication with water only D. Allow at least 1 hour between taking the medicine and taking other medica- tions 6. The nurse is making initial rounds on a client with a C5 fracture and crutch- field thongs. Which equipment should be kept at the bedside? A. A pair of forceps B. A torque wrench C. A pair or wire cutters D. A screwdriver 7. An infant weighs 7 pounds at birth. The excpectd weight by 1 year should be: A. 10 pounds B.12 pounds C. 18 pounds D. 21 pounds only why ? Fosmax should be taken with water only. The client should also remain upright for at least 30 mins after taking the medication. B. A torque wrench why? A tourque wrench is kept at the bedside to tighten and loosen the screws of crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. D. 21 pounds

why? A birth weight of 7 pounds would indicate 21 pounds in 1 year or triple the his birth weight.

8. A client is admitted with a Ewing's sacro- D. Bone Pain ma. which symptoms would be expected

due to this tumor's location? A. Hemiplegia B. Aphasia C. Nausea D. Bone Pain

9. The nurse is caring for a client with epilepsy who is being treated with car- bamazepine (Tegretol). Which labatory value might be a indicate a serious side effect of this drug? A. Uric acid of 5mg/dL B. Hematoccrit of 33% C. WBC 2,000 per cubic millimeter why? Sacroma is a type of bone can- cer, therefor, bone pain would be expected C. WBC 2,000 per cubic millime- ter why? Tegratol can suppress the bone marrow and decrease the white blood cells count; thus, a lab val- ue of WBC 2,000 per cubic mil- D. Platelets 150,000 per cubic millimeter limeter indicates side effects of the drug. 10. A 6-month-old client is admitted with possible intussuception. Which ques- tion during the nursing history is least helpful in obtaining information regard- ing this diagnosis? A. "tell me about the pain" B."what does his vomit look like?" C." Describe his usual diet." D. " have you noticed changes in his adominal size?" 11. The nurse is assisting a client with di- verticulosis to select appropiate foods. Which food should be avoided? A. Bran B. Fresh Peaches C. Cucumber salad D.Yeast Rolls

C." Describe his usual diet." why? The least-helpful questions are those describing his usual diet. A, B, and D are useful in de- termining the extent of disease process and thus, are incorrect C. Cucumber salad why? the client with diverticulitis should avoid foods with seeds.

12. A client has rectal cancer and is sched- uled for an abdominal perineal resec- tion. What should be the priority nursing care during the post-op period? A. Teaching how to irrigate the illeosto- my B. Stopping electrolytes loss in the inci- sional area C. Encouraging a high fiber diet D. Facilitating perineal wound drainage 13. The nurse is performing discharge teaching on a client with diverticulitis who has been placed on low-roughage diet. Which food would have to be elimi- nated from this client's diet? A. Roasted Chicken B. Noodles C. Cooked Broccoli D. Custard 14. The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best ex- planation of the weight loss is: A. The baby is dehydrated due to polyuria. B. The baby is hypoglycemic due to glu- cose.

D. Facilitating perineal wound drainage why? the client with a perineal resec- tion will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illestomy. as in answer A he will have some electrolyte loss, but treatment is not focused on pre- venting the loss, so answer B is incorrect A high fiber diet in answer C is not ordered at this time. C. Cooked Broccoli why? the client with diverticulitis should avoid eating foods that are gas forming and that in- crease abdominal discomfort, such as cooked broccoli. D. The baby can lose up to 10% of weight due to meconium still, loss of extraceullar fluid, and ini- tiation of breast-feeding. why? After birth, meconium stool, loss of extracellular fluid, and initia-

C. The baby is allergic to the formula the mother is giving him. D. The baby can lose up to 10% of weight due to meconium still, loss of extracellu- ar fluid, and initiation of breast-feeding.

15. The nurse if caring for a client with laryn- geal cancer. Which finding ascertained in the health history would not be com- mon for this diagnosis? A. Foul breath B. Dysphagia C. Diarrhea D. Chronic hiccups 16. A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included? A. Closed chest drainage B. A tracheostomy C. A mediastinal tube D. Percussion vibration and drainage 17. Six hours after birth, the infant is found to have an areas of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as: A. A cephalohematoma B. Molding C. Subdural hematoma D. Caput succedaneum tion of breastfeeding cause the infant to lose body mass. There is no evidence to indicate dehy- dration, hypoglycemia, or allergy to the infant formula C. Diarrhea why? Diarrhea is not common in clients with mouth and throat cancer A. A closed chest drainage why? The client with a lung resec- tion will have chest tubes and a drainage-collection device. He probably will not have a tra- cheoostomy or mediastinal tube, and he will not have an or- der for percussion, vibration, or drainage. A. A cephalohematoma why?

The swelling over the right pari- etal area is a cephalohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line

18. The nurse is assisting the RN with dis- charge instructions for a client with an implantable defibrillator. What dis- charge instruction is essential? A. "You cannot eat food prepared in a microwave." B. "You should avoid moving the should on the side of the pacemaker site for 6 weeks." C. "You should use your cellphone on your right side." D. "You will not be able to fly on a com- mercial airliner with the defibrillator in place." 19. A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure? A. Bradycardia B. Tachycardia C. Premature ventricular beats D. Heart block 20. The nurse is caring for a client sched- uled for a surgical repair of a sacular abdominal aortic aneurysm. Which as- sessment is most crucial during the pre- operative period? A. Assessment of the client's level of anxiety. B. Evaluation of the client's exercise tol-

because it's outside the cranium but beneath the periosteum. C. "You should use your cell- phone on your right side." why? The client with an internal de- fibrilliator should learn to use any battery operated machinery on the opposite side. He should also take his pulse rate and re- port dizziness or fainting. A. Bradycardia why? Suctioning can cause a vagal re- sponse and bradycardia. C. Identification of peripheral pulses why? The assessment that is most crucial to the client is identifi- cation of peripheral pulses be- cause aorta is clammed during

erance C. Identification of peripheral pulses. D. Assessment of bowel sounds and ac- tivity.

21. A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session? A. "You will be sitting for the examina- tion procedure." B. "Portions of the procedure will cause pain or discomfort." C. "You will be given some medication to anesthetize the area." D. "you will not be able to drink fluids for 24 hours before the study." 22. The nurse is performing an assessment on a client with possible pernicious ane- mia. Which data would support this diag- nosis? A. A weight loss of 10 pounds in 2 weeks. B. Complaints of numbness and tingling in the extremities. C. A red, beefy tongue. D. A hemoglobin level of 12.0 gm/dL 23. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: A. Trendelenburg position B. Ice to the entire extremity surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower ex- tremities. B. "Portions of the procedure will cause pain or discomfort." why? Portions of the exam are painful especially when the sample is being withdrawn so this should be included in the session with the client. C. A red, beefy tongue why? A red, beefy tongue is charac- teristic of a client with pernicious anemia. C. Bucks traction why?

The client with a fractured femur will be placed in Bucks traction

C. Bucks traction D. An abduction pillow

24. A client with caner is to undergo an in- travenous pyelogram. The nurse should: A. Force fluids 24 hours before the pro- cedure. B. Ask the client to void immediately be- fore the study. C. Hold medication that affects the cen- tral nervous system for 12 hours pre- and post-test. D. Cover the client's reproductive or- gans with an x-ray shield. 25. The nurse is caring for a client with a malignancy. The classification of the pri- mary tumor is Tis. The nurse should plan care for a tumor: A. That cannot be assessed B. That is in situ C. With increasing lymph node involve- ment D. With distant mestastasis 26. A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nurs- ing action is most appropriate? A. Reinsert the protruding organ and cover with 4x4s B. Cover the wound with a sterile 4x4 and ABD dressing C. Cover the wound with a sterile saline-soaked dressing to realign the leg and decrease spasms and pain. B. Ask the client to void immedi- ately before the study. why? The client having an intravenous pyelogram will have orders for laxatives of enemas so asking the client to void before the test is in order. A full bladder or bowel can obscure the visualization of the kidney, ureters, and urethra. B.That is in situ. why? Cancer in situ means that the cancer is still localized in the pri- mary site. Cancer is graded in terms of tumor, grade, node, in- volvement, and mestatasis. C. Cover the wound with a sterile saline-soaked dressing. why? If the client eviscerates, the ab- dominal content should

be cov- ered with a sterile saline-soaked dressing.

D. Apply an abdominal binder and man- ual pressure to the wound

27. The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery? A. Hearing aid B. Contact lenses C. Wedding ring D. Artificial eye 28. The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible compli- cations. Which is the most appropriate action? A. Call the surgeon and ask him or her to see the client to clarify the information B. Explain the procedure and complica- tions to the client C. Check in the physician's progress notes to see if understanding has been documented. D. Check with the client's family to see if they understand the procedure fully 29. When assessing a client for risk of hy- perphosphatemia, which piece of infor- mation is most important for the nurse to obtain? A. A history of radiation treatment in the

B. Contact lenses why? It is most important to remove the contact lenses because leav- ing them in can lead to corneal drying, particularly with contact lenses that are not extended wear lenses. A. Call the surgeon and ask him or her to see the client to clarify the information why? It is the responsibility of the physician to explain and clarify the procedure to the client. A. A history of radiation treat- ment in the neck region why? Previous radiation to the neck

neck region B. A history of recent orthopedic surgery C. A history of minimal physical activity D. A history of the client's food intake

30. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170 meq/L. What be- havioral changes would be common for this client? A. Anger B. Mania C. Depression D. Pyschosis 31. The nurse is obtaining a history of an 80 year old client. Which statement made by the client might indicate a possible fluid and electrolyte imbalance? A. "My skin is always so dry." B. "I often use laxatives for constipa- tion." C. "I have always liked to drink ice tea." D. "I sometimes have a problem with dribbling urine." 32. A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal griev- ing? A. "My sister still has episodes of cry- ing and it's been 3 months since daddy died." B. "Sally seems to have forgotten the bad things that daddy did in his life-

might have damaged parathy- roid glands, which are located on the thyroid gland and inter- fered with calcium and phospho- rus regulation. B. Mania why? The client with serum sodium of 170 meq/L has hypernatrimia and might exhibit manic behvior. B. "I often use laxatives for con- stipation." why? Frequent use of laxatives can lead to diarrhea and electrolyte loss. D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened at all." why? Abnormal grieving is exhibited by a lack of feeling sad; if the client's sister appears not to grieve, it might be abnor-

time." C. "She really had a hard time after dad- dy's funeral. She said that she had a sense of longing." D. "Sally has not been sad at all by dad- dy's death. She acts like nothing has happened."

33. The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough? A. Mask B. Gown C. Gloves D. Shoe covers 34. The nurse is caring for a client with a diagnosis of Hepatitis who is experienc- ing pruritis. Which would be the most appropriate nursing intervention? A. Suggest that the client take warm showers b.i.d. B. Add baby oil to the client's bath water C. Apply powder to the client's skin D. Suggest a hot water rinse after bathing. 35. A client with pancreatitis has been trans- ferred to the intensive care unit. Which order would the nurse anticipate? A. Blood pressure every 15 minutes B. Insertion of a levine tube C. Cardiac monitoring D. Dressing changes 2x per day

mal grieving. This family member might be suppressing feelings of grief. A. Mask why? If the nurse is exposed to the client with a cough, the best item to wear is a mask. If the answer had included a mask, gloves, and a gown, all would be appro- priate. B. Add baby oil to the client's bath water why? Oil can be applied to help with the dry skin and to decrease itching, so adding baby oil to bath water is soothing to the skin. B. Insertion of a levine tube why? The client with pancreatitis fre- quently has nausea and vomit- ing. Lavage is often used to de- compress the stomach and rest

36. The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are uti- lized on this client because: A. The client is at risk for evisceration B. The client will require frequent dress- ing changes C. The straps provide support for drains that are inserted into the incision D. No sutures or clips are used to secure the incision. 37. The physician has order that the client's medication be administered intrathecal- ly. The nurse is aware that the med- ications will be administered by which method? A. Intravenously B. Rectally C. Intramuscularly D. Into the cerebrospinal fluid 38. Which client can be best assigned to the newely licensed to the Practical Nurse? A. The client receiving chemotherapy B. The client post-coronary bypass C. The client with a TURP D. The client with diverticulitis

the bowel, so the insertion of a levine tube should be anticipat- ed. B. The client will require frequent dressing changes why? Montgomery straps are used to secure dressing that require frequent dressing changes be- cause the client with a cho- lescystectomy usually has a large amount of drainage on the dressing. Montgomery straps are also used for clients who are allergic to several types of tape. D. Into the cerebrospinal fluid why? Intrathecal medications are administered into the cere- brospinal fluid. This method of administering medications is re- served for the client with metas- tases, the client with chronic pain, or the client with cere- brospinal infections. D. The client with diverticulitis why? The best client to assign to the newly licensed nurse is the most

39. The nurse notes the patient care assis- tant looking through the personal items of the client with cancer. Which action should be taken by the RN? A. Notify the police department as a rob- bery B. Report this behavior to the charge nurse C. Monitor the situation and note whether any items are missing D. Ignore the situation until items are reported missing 40. The nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should: A. Change the nursing assistant's as- signment B. Explore the interaction with the nurs- ing assistant C. Discuss the matter with the client's family D. Initiate a group session with the nurs- ing assistant. 41. A home health nurse is planning for her daily visits. Which client should the home health nurse visit first? A. A client with AIDS being treated with Foscarnet B. A client with a fractured femur in a long leg cast C. A client with a laryngeal cancer with stable client; in this case, it's the client with diverticulitis. B. Report the behavior to the charge nurse why? The best action at this time is to report the incident to the charge nurse. Further action might be needed, but it should be deter- mined by the charge nurse. B. Explore the interaction with the nursing assistant why? The best action for the nurse to take is to explore the interaction with the nursing assistant. This will allow for clarification of the situation. C. A client with a laryngeal can- cer with a laryngetomy why?