NCLEX-PN Practice Questions: A Comprehensive Guide for Nursing Students, Exams of Nursing

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103 Exam NCLEX-PN PRACTICE

QUESTIONS

A 25 year old male is brought to the ER with a piece of metal in his eye. Which action by the nurse is correct?

A. Use a magnet to remove the object

B. Rinse the eye thoroughly with saline

C. Cover both eyes with paper cups

D. Patch the affected eye only - ✔ ✔ C. Cover both eyes with

paper cups

why?

Covering both eyes prevents consensual movement of the affected eye.

The physician has order sodium warfrin ( Coumadin) for the client with thrombophlebitis. The order should be entered to administer the medication at:

A. 0900

B. 1200

C. 1700

D. 2100 - ✔ ✔ C. 1700

why?

Sodium warfarin is administered in the late afternoon, at approximately 1700 hours. this allows for accurate bleeding times to be drawn in the morning.

The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion?

A. Secrurity guard

B. RN

C. LPN

D. The nursing assistant - ✔ ✔ B. RN

why?

The RN is the only one of these who can legally put the client in seclusion. The only other healthcare worker who is allowed to initiate seclusion is the doctor.

C. Watch the client's facial expression

D. Ask the client if he is in pain - ✔ ✔ B. Ask the client to rate

his pain from 1-

why?

The best way to evaluate pain levels is to ask the client to rate his pain on a scale.

The nursing is participating in a discharge teaching for the post- partal client. The nurse is aware that an effective means of managing discomfort associated with a episiotomy after discharge is:

A. Promethazine

B. Aspirin

C. Sitz bath

D. Ice bath - ✔ ✔ C. Sitz bath

why?

A sitz bath will help with swelling and improve healing

Which of the following post-op diets are most appropriate for a client who has had a hemorroidectomy?

A. High fiber

B. Low-residue

C. Bland

D. Clear liquids - ✔ ✔ D. Clear liquids

why?

After surgery, the client will be placed o n a clear-liquid diet and progressed to a regular diet. stool softeners will be included in the plan of care, to avoid constipation.

The physician has ordered a culture for the client with suspected Gonorrhea. The nurse should obtain what type of culture?

A. Blood

B. Nasopharyngeal secretions

C. Stool

D. Genital secretions - ✔ ✔ D. Genital secretions

why?

The physician has prescibed tranylcypromine sulfate (Parnate) 10 mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause:

A. Hypertension

B. Hyperthermia

C. Melanoma

D. Urinary retention - ✔ ✔ A. Hypertension

why?

If the client eats foods high in tyramine, he might experience malignant hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sherry, beer, pickled herring, liver, canned figs, raisins, bananas, avocados, chocolate, soy sauce, fava beans, and yeast. These episodes are treated with Regitine, and alpha- adrenergic blocking agent.

The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?

A. "She is very irritable lately."

B. "She sleeps quite a bit of the time."

C. "Her gums look too big for her teeth."

D. "She has gained about 10 pounds in the last 6 months." - ✔

✔

A 5 year old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?

A. Decreased appetite

B. A low-grade fever

C. Chest congestion

D. Constant swallowing - ✔ ✔

A 6 year old with cerebral palsy functions at the level of an 18 month old. Which finding would support that assessment?

A. She dresses herself

B. She pulls a toy behind her

C. She can build a tower of eight blocks

D. She can copy a horizontal or vertical line. - ✔ ✔

An infant weighs 7 pounds at birth. The excpectd weight by 1 year should be:

A. 10 pounds

The nurse is caring for a client with epilepsy who is being treated with carbamazepine (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

D. Platelets 150,000 per cubic millimeter - ✔ ✔ C. WBC 2,

per cubic millimeter

why?

Tegratol can suppress the bone marrow and decrease the white blood cells count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug.

A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding 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?" - ✔ ✔ C."

Describe his usual diet."

why?

The least-helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process and thus, are incorrect

The nurse is assisting a client with diverticulosis to select appropiate foods. Which food should be avoided?

A. Bran

B. Fresh Peaches

C. Cucumber salad

D. Yeast Rolls - ✔ ✔ C. Cucumber salad

why?

the client with diverticulitis should avoid foods with seeds.

A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period?

why?

the client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli.

The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is:

A. The baby is dehydrated due to polyuria.

B. The baby is hypoglycemic due to glucose.

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 extracelluar fluid, and initiation of breast-feeding. - ✔ ✔

D. The baby can lose up to 10% of weight due to meconium still, loss of extraceullar fluid, and initiation of breast-feeding.

why?

After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding cause the infant to lose body mass. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula

The nurse if caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis?

A. Foul breath

B. Dysphagia

C. Diarrhea

D. Chronic hiccups - ✔ ✔ C. Diarrhea

why?

Diarrhea is not common in clients with mouth and throat cancer

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 - ✔ ✔ A. A closed chest drainage

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 commercial airliner with the defibrillator in place." - ✔ ✔ C. "You should use your cellphone

on your right side."

why?

The client with an internal defibrilliator should learn to use any battery operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting.

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 - ✔ ✔ A. Bradycardia

why?

Suctioning can cause a vagal response and bradycardia.

The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?

A. Assessment of the client's level of anxiety.

B. Evaluation of the client's exercise tolerance

C. Identification of peripheral pulses.

D. Assessment of bowel sounds and activity. - ✔ ✔ C. Identification of peripheral pulses

why?

The assessment that is most crucial to the client is identification of peripheral pulses because aorta is clammed during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities.

A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session?

A red, beefy tongue is characteristic of a client with pernicious anemia.

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

C. Bucks traction

D. An abduction pillow - ✔ ✔ C. Bucks traction

why?

The client with a fractured femur will be placed in Bucks traction to realign the leg and decrease spasms and pain.

A client with caner is to undergo an intravenous pyelogram. The nurse should:

A. Force fluids 24 hours before the procedure.

B. Ask the client to void immediately before the study.

C. Hold medication that affects the central nervous system for 12 hours pre- and post-test.

D. Cover the client's reproductive organs with an x-ray shield. - ✔

✔ B. Ask the client to void immediately 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.

The nurse is caring for a client with a malignancy. The classification of the primary 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 involvement

D. With distant mestastasis - ✔ ✔ B. That is in situ.

why?

Cancer in situ means that the cancer is still localized in the primary site. Cancer is graded in terms of tumor, grade, node, involvement, and mestatasis.