NCLEX-PN Practice Questions, Answers and Rationales, Exams of Nursing

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NCLEX-PN PRACTICE QUESTIONS, ANSWERS

and RATIONALES

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 - Correct answer A. Nasal congestion why? removal of the pituitary gland is usually done by transsphernoidal approach through the nose. Nasal congestion further interferes with the airway. A client with cancer is a, admitted to the oncology unit. Stat lab values revel Hgb 12.6, WBC 6500, K+1.9, uric acid 7.0, Na+136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following? A. Hypernatremia B. Hypokalemia C. Myelosuppression D. Leukocytosis - Correct answer B. Hypokalemia why?

Hypokalemia is evident from the lab values listed. The other laboratory findings are within normal limits. making answers A,C and D incorrect 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 - Correct answer 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 responsibility of the doctor. 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 priority? A. starting an IV? B. Applying oxygen C.Obtaining blood gas D. Medicating the client foe pain - Correct answer B. Applying oxygen why? the client with burns to the neck needs airway assessments and supplemental oxygen, so applying oxygen is priority. the next action should be to start an IV and medicate for pain.

The nurse is visiting a home health client 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 medications - Correct answer C. Take medication with water only why? Fosmax should be taken with water only. The client should also remain upright for at least 30 mins after taking the medication. The nurse is making initial rounds on a client with a C5 fracture and crutchfield 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 - Correct answer 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. 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 - Correct answer D. 21 pounds why? A birth weight of 7 pounds would indicate 21 pounds in 1 year or triple the his birth weight. A client is admitted with a Ewing's sacroma. which symptoms would be expected due to this tumor's location? A. Hemiplegia B. Aphasia C. Nausea D. Bone Pain - Correct answer D. Bone Pain why? Sacroma is a type of bone cancer, therefor, bone pain would be expected 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 - Correct answer C. WBC 2,000 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?" - Correct answer 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 - Correct answer 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?

A. Teaching how to irrigate the illeostomy B. Stopping electrolytes loss in the incisional area C. Encouraging a high fiber diet D. Facilitating perineal wound drainage - Correct answer D. Facilitating perineal wound drainage why? the client with a perineal resection 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 preventing the loss, so answer B is incorrect A high fiber diet in answer C is not ordered at this time. 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 eliminated from this client's diet? A. Roasted Chicken B. Noodles C. Cooked Broccoli D. Custard - Correct answer C. Cooked Broccoli 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. - Correct answer 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 - Correct answer 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 - Correct answer A. A closed chest drainage why? The client with a lung resection will have chest tubes and a drainage-collection device. He probably will not have a tracheoostomy or mediastinal tube, and he will not have an order for percussion, vibration, or drainage. 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 - Correct answer A. A cephalohematoma why? The swelling over the right parietal area is a cephalohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line because it's outside the cranium but beneath the periosteum. The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge 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 commercial airliner with the defibrillator in place." - Correct answer 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 - Correct answer 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. - Correct answer 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. "You will be sitting for the examination 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." - Correct answer 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. The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis? 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 - Correct answer C. A red, beefy tongue why?

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 - Correct answer 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. - Correct answer 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 - Correct answer 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. A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing 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 D. Apply an abdominal binder and manual pressure to the wound

• Correct answer C. Cover the wound with a sterile saline- soaked dressing. why? If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked dressing. 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 - Correct answer B. Contact lenses why? It is most important to remove the contact lenses because leaving them in can lead to corneal drying, particularly with contact lenses that are not extended wear lenses. 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 complications. 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 complications 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 - Correct answer 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. When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain? A. A history of radiation treatment in the 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 - Correct answer A. A history of radiation treatment in the neck region why? Previous radiation to the neck might have damaged parathyroid glands, which are located on the thyroid gland and interfered with calcium and phosphorus regulation. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170 meq/L. What behavioral changes would be common for this client? A. Anger B. Mania C. Depression D. Pyschosis - Correct answer B. Mania why? The client with serum sodium of 170 meq/L has hypernatrimia and might exhibit manic behvior. 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 constipation." C. "I have always liked to drink ice tea." D. "I sometimes have a problem with dribbling urine." - Correct answer B. "I often use laxatives for constipation." why?

Frequent use of laxatives can lead to diarrhea and electrolyte loss. A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal grieving? A. "My sister still has episodes of crying and it's been 3 months since daddy died." B. "Sally seems to have forgotten the bad things that daddy did in his lifetime." C. "She really had a hard time after daddy's funeral. She said that she had a sense of longing." D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened." - Correct answer 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 abnormal grieving. This family member might be suppressing feelings of grief. 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 - Correct answer 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 appropriate. The nurse is caring for a client with a diagnosis of Hepatitis who is experiencing 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. - Correct answer 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. A client with pancreatitis has been transferred 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 - Correct answer B. Insertion of a levine tube why? The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a levine tube should be anticipated.

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 utilized on this client because: A. The client is at risk for evisceration B. The client will require frequent dressing 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. - Correct answer B. The client will require frequent dressing changes why? Montgomery straps are used to secure dressing that require frequent dressing changes because the client with a cholescystectomy 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. The physician has order that the client's medication be administered intrathecally. The nurse is aware that the medications will be administered by which method? A. Intravenously B. Rectally C. Intramuscularly D. Into the cerebrospinal fluid - Correct answer D. Into the cerebrospinal fluid why? Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client with metastases, the client with chronic pain, or the client with cerebrospinal infections.

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 - Correct answer D. The client with diverticulitis why? The best client to assign to the newly licensed nurse is the most stable client; in this case, it's the client with diverticulitis. The nurse notes the patient care assistant 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 robbery 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 - Correct answer 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 determined by the charge nurse. The nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should: A. Change the nursing assistant's assignment

B. Explore the interaction with the nursing assistant C. Discuss the matter with the client's family D. Initiate a group session with the nursing assistant. - Correct answer 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. 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 a laryngetomy D. A client with diabetic ulcers to the left foot - Correct answer C. A client with a laryngeal cancer with a laryngetomy why? The client with laryngeal cancer has a potential airway alteration and should be seen first. The nurse is assigned to care from infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin? A. Increase the infant's fluid intake B. Maintain the infant's body temp at 98.6 F C. Minimize tactile stimulation D. Decrease caloric intake - Correct answer A. Increase the infant's fluid intake

why? Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temp is important but will not assist in eliminating bilirubin. The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority? A.Maintain the client's systolic blood pressure at 70 mm/Hg or greater B. Maintain the client's urinary output greater than 300 cc/hr C. Maintain the client's body temp of greater than 33 F rectal D. Maintain the client's hematocrit less than 30% - Correct answer A. Maintain the client's systolic blood pressure at 70 mm/Hg or greater why? When the cadaver client is being prepared to donate and organ, the systolic blood pressure should be maintained at 70 mm/Hg or greater to ensure a blood supply to the donor organ. Which action by the novice nurse indicates need for further teaching? A. A nurse fails to wear gloves to remove a dressing B. The nurse applies the oxygen saturation monitor to the earlobe C. The nurse elevates the head of the bed to check blood pressure D. The nurse places the extremity to a dependent position to acquire a peripheral blood sample - Correct answer A. A nurse fails to wear gloves to remove a dressing

why? The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction The nurse is preparing the client for a mammogram. To prepare the client for a mammogram, the nurse should tell the client: A. Restrict her fat intake for one week before the test B. To omit creams, powders, or deodorants before the exam C. The mammography replaces the need for self breast exams D. That mammography requires higher does of radiation than an x-ray. - Correct answer B. To omit creams, powders, or deodorants before the exam. why? The client having the mammogram should be instructed to omit deodorants or powders beforehand because powders and deodorants can be interpreted as abnormal. Which of the following roommates would be best for the client with gastric resection? A. A client with Chron's disease B. A client with pneuomia C. A client with gastritis D. A client with phlebitis - Correct answer D. A client with phlebitis why?

The most suitable roommate for the client with gastric resection is the client with phlebitis because phlebitis is an inflammation of the blood vessel and is not infectious. The licensed practical nurse is working with a RN and a patient care assistant. Which of the following clients should be cared for by the RN? A. A client two days post-appendectomy B. A client one week post-thyroidectomy C. A client 3 days post- splenectomy D. A client 2 days post- thoracotomy - Correct answer D. A client 2 days post-thoracotomy why? The most critical client should be assigned to the RN; in this case, that is the client 2 days post-thoracotomy. The LPN is observing a graduate nurse as she assess the central venous pressure. Which observation indicates that the graduate needs further teaching? A. The graduate places the client in a supine position to read the manometer B. The graduate turns the stopcock to the off position from the IV fluid to the client C. The graduate instructs the client to perform the Valsalva manuever during the CVP reading D. The graduate notes the level at the top of the meniscus - Correct answer C. The Graduate instructs the client to perform the Valsalva manuever during the CVP reading. why?

The client should breathe normally during a central venous pressure monitor reading. Which of the following roommates would be most suitable for the client with myasthenia gravis? A. A client with hypothyroidism B. A client with Chron's disease C. A client with pylonephritis D. A client with bronchitis - Correct answer A. A client with hypothyroidism why? The most suitable roommate for the client with myasthenia gravis is the client with hypothyroidism because he is quiet. The nurse employed in the ER is responsible for triage for 4 clients injured in a motor vehicle accident. Which of the following clients should receive priority in care? A. A 10 year old with lacerations to the face B. A 15 year old with sternal bruising C. A 34 year old with fractured femur D. A 50 year old with dislocation of the elbow - Correct answer B. A 15 year old with sternal bruising why? The teenager with sternal bruising might be experiencing airway and oxygenation problems and, thus, should be seen first. The client is receiving peritoneal dialysis. If the dialysis returns cloudy the nurse should"

A. Document the finding B. Send a specimen to the lab C. Strain the urine D. Obtain a complete blood count - Correct answer B. Send a specimen to the lab why? If the dialysate returns cloudy, infection might be present and must be evaluated The client with cirrhosis of the liver is receiving lactulose. The nurse is aware that the ratio for the order of lactulose is : A. To lower the blood glucose level B. To lower the uric acid level C. To lower ammonia level D. To lower the creatinine level - Correct answer C. To lower ammonia level why? Lactulose is administered to the client with cirrhosis to lower ammonia levels. The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client's ability to care for himself. Which statement by the client indicates a need for follow-up after discharge? A."I live by myself." B." I have trouble seeing." C. "I have a cat in the house with me."

D. " I usually drive myself to the doctor." - Correct answer B. "I have trouble seeing" why? A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help. The client is receiving total parenteral nutrition (TPN). Which lab should be evaluated while the client is receiving TPN? A. Hemoglobin B. Creatinine C. Blood glucose D. White blood cell count - Correct answer C. Blood glucose why? When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution that contains large amounts of glucose. The client with a myocardial farction comes to the nurse's station stating that he is ready to go come because there is nothing wrong with him. Which defense mechanism is the client using? A. Rationalization B. Denial C. Projection D. Conversion reaction - Correct answer B. Denial why?