Nclex Exam Questions with Answers Correctly Verified Updates, Exams of Nursing

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Nclex Exam Questions with Answers Correctly Verified

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1. The nurse is preparing the postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement? A. Establish a rapport with the client to decrease embarrassment of assessing site. B. Encourage the client to lie in the lithotomy position twice a day. C. Milk the tube inserted during surgery to allow the passage of flatus. D. Digitally dilate the rectal sphincter to express old blood.
2. The client has recently been diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms? A. Instruct the client to avoid drinking fluids with meals. B. Explain the need to decrease intake of flatus- forming foods. C. Teach the client how to perform gentle perianal care. D. Encourage the client to see a psychologist.
3. The client is admitted into the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright-red blood at home. Which interventions should the nurse implement? List in order of priority. A. Assess the client’s vital signs. B. Insert a nasogastric tube. C. Begin iced saline lavage. D. Start an IV with an 18-gauge needle.

E. Type and crossmatch for a blood transfusion. F. Ans (priority order): 1,4, 5, 2, and 3

4. The nurse is teaching a community class to people with Type 2 diabetes mellitus. Which explanation would explain the development of Type 2 diabetes? A. The islet cells in the pancreas stop producing insulin. B. The client eats too many foods that are high in sugar. C. The pituitary gland does not produce vasopressin. D. The cells become resistant to the circulating insulin.
5. The nurse is teaching the client diagnosed with Type 2 diabetes mellitus about diet. Which diet selection indicates the client understands the teaching? A. A submarine sandwich, potato chips, and diet cola. B. Four (4) slices of a supreme thin-crust pizza and milk. C. Smoked turkey sandwich, celery sticks, and unsweetened tea. D. A roast beef sandwich, fried onion rings, and a cola. Which laboratory data indicate the client’s pancreatitis is improving? E. The amylase and lipase serum levels are decreased. F. The white blood cell count (WBC. is decreased. G. The conjugated and unconjugated bilirubin levels are decreased. H. The blood urea nitrogen (BUN) serum level is decreased.

6. The client diagnosed with acute pancreatitis has developed a pseudocyst that ruptures. Which procedure should the nurse anticipate the HCP ordering? A. Paracentesis. B. Chest tube insertion C. Lumbar puncture. D. Biopsy of the pancreas.
7. Which signs/symptoms would the nurse expect to find in the client diagnosed with an insulinoma? A. Nervousness, jitteriness, and diaphoresis. B. Flushed skin, dry mouth, and tented skin turgor. C. Polyuria, polydipsia, and polyphagia. D. Hypertension, tachycardia, and feeling hot. 8.. Which risk factor would the nurse expect to find in the client diagnosed with pancreatic cancer? A. Chewing tobacco. B. Low-fat diet. C. Chronic alcoholism. D. Exposure to industrial chemicals.
8. The nurse is aware that epinephrine and norepinephrine are secreted by which endocrine gland? A. The pancreas. B. The adrenal cortex. C. The adrenal medulla. D. The anterior pituitary gland.

10. Which question should the nurse ask when assessing the client for an endocrine dysfunction? A. “Have you noticed any pain in your legs when walking?” B. Have you had any unexplained weight loss?” C. “Have you noticed any change in your bowel movements?” D. “Have you experienced any joint pain or discomfort?”
11. Which nursing instruction should the nurse discuss with the client who is receiving glucocorticoids for Addison’s disease? A. Discuss the importance of tapering medications when discontinuing medication. B. Explain that the dose will need to be decreased during times of stress or infection. C. Instruct the client to take medication on an empty stomach with a glass of water. D. Encourage the client to wear a Medic Alert bracelet and carry a card in the wallet.
12. The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client? A. Deep tendon reflexes. B. Arterial blood gases. C. Skin turgor. D. Capillary refill time.
13. Which endocrine disorder would the nurse assess for in the client who has a closed head injury with increased intracranial pressure?

A. Pheochromocytoma. B. Diabetes insipidus. C. Hashimoto’s disease. D. Gynecomastia.

14. The nurse has been assigned to train the unlicensed nursing assistant about prioritizing care. Which client should the nurse instruct the unlicensed nursing assistant to see first? A. The client who needs both sequential compression devices removed. B. The elderly woman who needs assistance ambulating to the bathroom. C. The surgical client who needs help changing the gown after bathing. D. The male client who needs the intravenous fluid discontinued.
15. The nurse is caring for the client recovering from a percutaneous renal biopsy. Which data indicate that the client is complying with client teaching? A. The client lies flat in the supine position for 12 hours. B. The client continues oral fluids restriction while on bed rest. C. The client’s family changed the dressing on return to the room. D. The family activates the patient-controlled analgesia pump.
16. Which intervention should the nurse implement for the client who has had an ileal conduit?

A. Pouch the stoma with a one (1)-inch margin around the stoma. B. Refer the client to the United Ostomy Association for discharge teaching. C. Report to the health-care provider any decrease in urinary output. D. Monitor the stoma for signs and symptoms of infection every shift.

17. The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care? Select all that apply. A. Monitor vital signs every two (2) hours until stable. B. Measure the client’s oral intake and urinary output daily. C. Administer mouth care every eight (8) hours. D. Weigh the client in the same clothing at the same time daily. E. Assess skin turgor and mucous membranes every shift.
18. Which outcome should the nurse identify for the client diagnosed with fluid volume excess? A. The client will void a minimum of 30 mL per hour. B. The client will have elastic skin turgor. C. The client will have no adventitious breath sounds. D. The client will have a serum creatinine of 1.4 mg/dL.
19. The nurse is caring for a client diagnosed with rule out nephrotic syndrome. Which intervention should be included in the plan of care? A. Monitor the urine for bright-red bleeding.

B. Evaluate the calorie count of the 500-mg protein diet. C. Assess the client’s sacrum for dependent edema. D. Monitor for a high serum albumin level.

20. The nurse is preparing a teaching care plan for the client diagnosed with nephritic syndrome. Which intervention should the nurse include? A. Discontinue the use of steroid therapy immediately if symptoms develop. B. Take diuretics as needed to treat the dependent edema in ankles. C. Increase the intake of dietary sodium every day to decrease fluid retention. D. Report any decrease in daily weight during treatment to the HCP.
21. Which intervention would be the most important for the nurse to implement for the client with a left nephrectomy? A. Assess the intravenous fluids for rate and volume. B. Change surgical dressing every day at the same time. C. Monitor the client’s medication levels daily. D. Monitor the percentage of each meal eaten.
22. The client has failed to conceive after many attempts over a three (3)-year time period and asks the nurse, “I have tried everything. What should I do now?” Which statement is the nurse’s best response? A. “By ‘everything’ do you mean you have consulted an infertility specialist?”

B. “You have tried everything. This must be hard for you. Would you like to talk?” C. “You should get on an adoption list because it can take a long time.” D. “You need to relax and not try so hard. It is your nerves preventing conception.”

23. The nurse writes a problem of “potential for complications related to ovarian hyperstimulation” for a client who is taking clomiphene (ClomiD., an ovarian stimulant. Which intervention should be included in the plan of care? A. Instruct the client to delay intercourse until menses. B. Schedule the client for frequent pelvic sonograms. C. Explain that the infusion therapy will take 21 days. D. Discuss that this may cause an ectopic pregnancy.
24. The HCP care provider orders cultures of the urethral urine, bladder urine, and prostatic fluid. Which instructions would the nurse teach to achieve the first two (2) specimens? A. Collect the first 15 mL in one jar and then the next 50 mL in another. B. Collect three (3) early-morning, clean voided urine specimens. C. Collect the specimens after the HCP massages the prostate. D. Collect a routine urine specimen for analysis.
25. The nurse writes a client problem of “anxiety related to potential sexual dysfunction” for a client diagnosed with cancer of the prostate. Which intervention should the nurse implement?

A. Tell the client to discuss his fears with the HCP. B. Talk to the wife about the client’s concerns. C. Inform the client that sexual functioning will not be altered. D. Provide a private area for the client to discuss his concerns.

26. The male client is considering a vasectomy for birth control. Which information should the nurse teach the client? A. Instruct the client to use hot packs to relieve scrotal edema after the surgery. B. Tell the client to wear loose-fitting boxer underwear after the surgery. C. Explain that initially an alternate form of birth control will be required. D. Discuss that potency will be diminished about 20% after a vasectomy.
27. he 45-year-old male client has had a circumcision secondary to phimosis. Which intervention should the nurse include in the plan of care? A. Teach how to care for the glans to prevent recurrence of the phimosis. B. Assess for pain on a scale of one (1) to ten (10). C. Perform wet to dry dressing changes daily. D. Instruct client to perform a monthly penis check for cancer.
28. Which vaccination would the nurse recommend to the postpubertal male to preventorchitis?

A. Yearly flu injections. B. Herpes varicella inoculations. C. Mumps vaccination. D. Rubella injections.

29. The nurse is instructing a group of workers at an industrial plant regarding the transmission of sexually transmitted diseases (STDs). Which information should be included in the presentation? A. The same behaviors that cause one STD could lead to another. B. Once clients have had an STD, they develop immunity to it. C. An infection with syphilis protects the client from being infected with HIV. D. Herpes simplex I is a totally different disease from herpes simplex II.
30. When caring for a client with a spica cast for a hip injury, what intervention should the nurse include in the plan of care? A. Assess client’s popliteal pulses every shift. B. Elevate the leg on pillows and apply ice packs. C. Teach the client how to ambulate with a tripod walker. D. Assess the client for distention and vomiting.
31. When preparing the client in a short leg cast for discharge, which data indicate that the client needs further teaching?

A. “I need to keep my leg elevated on two pillows for the first 24 hours.” B. “I should apply ice packs for one (1) hour and remove them for one (1) hour.” C. “I need to contact the health-care provider if I have any numbness or pale toenails.” D. “I can put a coat hanger down the cast to scratch gently if I have severe itching.”

32. Which psychosocial client problem would be most likely in a client with an external fixator device? A. Ineffective coping. B. Alteration in body image. C. Grieving. D. Social isolation.
33. A client recovering from a total hip replacement has developed a deep vein thrombosis. The health-care provider has ordered a continuous infusion of heparin, an anticoagulant, to infuse at 1200 units per hour. The bag comes with 20,000 unit of heparin in 500 mL of 0.9% normal saline. At what rate should the nurse set the pump? A. ANS: 30ml B. When conducting rounds at change of shift, the nurse assesses the client with a fractured humerus. Which data would warrant immediate intervention by the nurse?
34. Capillary refill time of that arm is less than three (3) seconds.
35. Pain relieved by the patient-controlled anesthesia machine.

36. Edema under the dressing that caused the nails to be white.

37. Warm and dry skin on the fingers distally to the elastic bandage.
38. The client with a right open fractured elbow has a long arm cast and is complaining of unrelenting severe pain and feeling as if the fingers are asleep. Which complication should the nurse suspect that the client is experiencing? A. Fat embolism. B. Compartment syndrome. C. Pressure ulcer under cast. D. Surgical incision infection.