NCLEX PN REAL EXAM QUESTIONS AND CORRECT ANSWERS WITH RATIONALES 2024-2025 LATEST UPDATE &, Exams of Nursing

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NCLEX PN REAL EXAM QUESTIONS AND CORRECT

ANSWERS WITH RATIONALES 2024-2025 LATEST

UPDATE &GRADED A+

The charge nurse has received a change-of-shift report on the following clients in labor. The charge nurse should ask a staff member to first see the client in the

1. first stage of labor who has an oral temperature of 99.7° F (37.6° C)
2. first stage of labor whose contractions are occurring every 30 seconds
3. second stage of labor who has respirations of 26
4. second stage of labor whose contractions are lasting for 60 seconds - answer-2. first stage of labor whose contractions are occurring every 30 seconds

Contractions should be no longer than 90 secs and no closer than

2 mins (120 secs) 90 secs is the duration, 2 mins is the frequency.

Rationale:

1. Elevated temp is normal during labor
2. Increased resps are normal during labor "pant-pant-blow" "hee-hee-hoo" breathing pattern
3. Contractions shouldn't be longer than 90 secs, 60 secs is

okay and normal Second stage: 2-3 mins apart, 60-90 secs

long, 10 cm dilated, strong pain

The nurse is observing a staff member caring for a client who has chickenpox.

Which of the following actions by the staff member would require the nurse to intervene?

1. placing the client in a private room with monitored negative air pressure
2. placing a box of disposable face shields outside the client's room
3. placing an alcohol-based hand rub in the client's room for hand hygiene
4. placing a surgical mask on the client during transport out of the client's room - answer-2. placing a box of disposable face shields outside the client's room

disposable face masks are not suitable for airborne precautions

Rationale:

Varicella (chickenpox) is airborne precaution. Private, negative pressure room, universal precautions (hand sanitizer in room) and placing surgical mask on client during transport are all correct interventions for Varicilla.

The nurse is caring for a client who reports feeling faint and is experiencing the cardiac rhythm shown in the electrocardiogram (ECG) strip below.

• BRADYCARDIA (it is more than 5 spaces apart, sinus rhythm)

Which of the following actions would be appropriate for the nurse to take? Select all that apply:

1. Administer the client's prescribed beta blocker.
2. Prepare for transcutaneous pacing.
3. Instruct the client to perform the Valsalva maneuver.
4. Begin chest compressions.
5. Assess the client for angina. - answer-2. transcutaneous pacing

• external pacing that stimulates the ventricles to pump at a set rate

5. Assess the client for angina

• Angina (Chest pain) can be caused by both tachycardia (most common) and bradycardia (rare but can happen). Assessment of angina is appropriate

Rationale:

1. Beta blocker would further decrease HR
2. Valsalva maneuver/Vagal stimulation would further decrease HR. (can be indicated for sinus Tachy)
3. Chest compressions are for cardiac arrest

The nurse is planning care for a client with moderate Alzheimer's disease (AD).

Which of the following interventions should the nurse include in the client's plan of

care?

1. Encourage the client to reminisce about happy memories.
2. Confront the client when inappropriate or agitated behaviors occur.
3. Administer to the client the cholinesterase inhibitor to reverse the course of AD.
4. Provide the client with information about activity choices in the morning so the client can make plans for the day. - answer-1. Encourage the client to reminisce about happy memories.

Its possible for AD patients to retain long-term memories

Rationale:

2. Acknowledge feelings --> Redirect is protocol for Dementia. Don't confront; they can't learn
3. AD is irreversible
4. In moderate AD, dementia has already progressed to where pt needs help with ADLs and planning daily activities. Asking them to plan can frustrate them and cause distress.

STRUCTURED pleasant activities that consider the persons likes and interests are the best.

The nurse is teaching a client how to ambulate using crutches. Which of the following information should the nurse include?

1. "Use your hands and arms to support your body weight."
2. "Wear slippers when ambulating with the crutches in your home."
3. "Maintain the crutches 12 in (30 cm) in front of your feet while standing."
4. "Adjust the hand grips of the crutches so that your elbows are fully extended."

• answer-1. "Use your hands and arms to support your body weight."

True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s: paresis and paresthesias in wrists and hands

Rationales:

2. Fall risk!
3. Should be 6 in. in front and 6 in. lateral
4. Elbows should be bent at 30 degree angle

The nurse has taught a client with multiple sclerosis (MS).

Which of the following statements by the client would indicate a correct understanding of the teaching?

1. "I will complete all of my household chores in the morning when I am well rested."
2. "I have learned how to massage my bladder to help empty my bladder completely."
3. "I will take a hot bath in the evening to help me relax if I have had a stressful day at work."

4. "I should expect the blurred vision to resolve after I have received medications for several weeks." - answer-4. "I should expect the blurred vision to resolve after I have received medications for several weeks."

MS causes nerve damage and can result in optic neuritis (vision loss, burry vision). In most cases it resolves itself in 4-12 weeks, but medication (steroids) can speed up the process and resolve it quicker

Rationale:

1. MS patients should not exert themselves too much at one time. Space out activities and allow time for rest.
2. Urinary retention is primarily treated by medication (bethanochol), and exercises can aid with it but are not the primary treatment
3. Hot temperatures are bad for MS and can worsen symptoms. Your nerves are already fcked up and extra heat can stress your body into overdrive

The nurse has attended a staff education program about caring for clients who are receiving positive pressure mechanical ventilation. Which of the following statements by the nurse would indicate a correct understanding of the teaching?

1. "Clients should avoid range-of-motion (ROM) exercises until weaned from ventilation."
2. "Clients may develop stress ulcers and gastrointestinal bleeding."
3. "Clients will be chemically paralyzed to improve oxygenation."
4. "Clients will experience diuresis and polyuria." - answer-2. "Clients may develop stress ulcers and gastrointestinal bleeding."

Rationale: Postive Pressure Ventilation may cause stress ulcers and GI bleeding because

The charge nurse must transfer a female client from the medical-surgical unit to the maternity unit to make a bed available. It would be most appropriate for the

nurse to transfer the client who is

1. 28 years old, had a right mastectomy and has a closed-wound drainage system
2. 49 years old, has diabetes mellitus (type 2) and has begun receiving insulin
3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours
4. 70 years old, has a fractured left tibia and had an external fixation device applied 48 hours ago - answer-3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours

The nurse has been made aware of the following client situations. The nurse should first assess the client with:

1. heart failure who has a productive cough and is anxious
2. regional enteritis (Crohn's disease) who is reporting cramping abdominal pain and diarrhea
3. idiopathic thrombocytopenic purpura (ITP) who has petechiae on the trunk and is reporting heavy menses
4. chronic obstructive pulmonary disease (COPD) who has dyspnea with exertion and is using accessory muscles to breathe - answer-1. heart failure who has a productive cough and is anxious

Productive cough (pink frothy sputum) indicates pulmonary edema, anxiety might be caused by decreased perfusion

The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks would be appropriate for the nurse to assign to UAP?

1. assisting a client with atrial fibrillation to shower
2. checking the ability of a client to swallow water after a transesophageal echocardiogram (TEE)
3. observing while a client with dysphagia begins a thickened liquid diet
4. transporting a client with respiratory distress to the radiology department for a chest radiograph - answer-1. assisting a client with atrial fibrillation to shower

UAP can perform hygiene

Rationale:

Only nurses can assess. Transporting a client in respiratory arrest is not safe to delegate to a UAP

The nurse has taken a nutritional history from parents of clients. It would be a priority for the nurse to follow up with the

1. 5-month-old client whose only source of nutrition is 5 formula feedings daily
2. 7-month-old client who eats several crackers as finger food
3. 9-month-old client whose typical daily diet includes 10 bottles of 2% milk, 1 cup of apple juice, and 3 servings of infant cereal
   4. 1-year-old client whose typical food intake includes 4 breast-feedings and 3 servings of cooked vegetables, pears, or sliced cheese - answer-3. 9-month-old client whose typical daily diet includes 10 bottles of 2% milk, 1 cup of apple juice, and 3 servings of infant cereal

Rationale: Cows milk should be introduced at 12 months old. It doesn't provide the necessary nutrients and baby can develop iron deficiency

The nurse is planning a staff education program about client privacy. Which of the following scenarios should the nurse include as an example of a violation of client privacy?

1. discussing with an unlicensed assistive personnel (UAP) that the UAP's assigned client will require a smaller condom catheter
   2. sharing the client's blood alcohol level (BAL) test result with the police officer who brought the client to the emergency department (ED)
2. responding to the call light of the client who is assigned to another nurse and needs assistance in the bathroom
3. allowing a nursing student who has been assigned to the client to review the client's medical record - answer-2. sharing the client's blood alcohol level (BAL) test result with the police officer who brought the client to the emergency department (ED)

Rationale: PHI is permitted to be disclosed to police when PHI is needed to apprehend the perpetrator of a violent crime, suspect, or fugitive.

The nurse has become aware of the following client situations. The nurse should first assess the client

1. who had a right pneumonectomy 24 hours ago and is in the high-Fowler's position while lying on the right side
2. with chronic obstructive pulmonary disease (COPD) who is using pursed-lip breathing and reporting hemoptysis
3. who had a wedge resection of the left lung 24 hours ago and is sitting in the high- Fowler's position

4. with heart failure who has a productive cough and is restless - answer-4. with heart failure who has a productive cough and is restless

Productive cough (pink frothy sputum) is indicative of pulmonary edema which is life-threatening. T(x) would be to improve cardiac output by placing client in high fowlers, O2, mechanical ventilation, meds

The nurse is caring for a 3-year-old client with a cerebral concussion who is being observed overnight in the pediatric unit. Which of the following observations would be most significant for the nurse to report to the oncoming shift?

1. The client has a blood pressure of 94/58 mm Hg and an apical pulse of 90.

2. The client is sleeping but is easily aroused.
3. The client's pupils are equal and reactive to light.
4. The client has an axillary temperature of 99.0° F (37.2° C) and respirations of 24.

• answer-2. The client is sleeping but is easily aroused.

Important to keep checking for decline in M/S with concussions, even when sleeping.

The nurse in the same-day surgical center has received a change-of-shift report on the following clients. The nurse should first see the client who had

1. closed reduction of a fractured tibia with cast application 1 hour ago and is reporting that the casted leg feels hot
2. extraction of a cataract lens 2 hours ago and is reporting nausea
   3. an arthroscopy of the right knee 3 hours ago and is reporting knee pain rated as 4 on a scale of 0 (no pain) to 10 (severe pain)
3. a laparoscopic cholecystectomy 4 hours ago and is reporting right shoulder pain - answer-1. closed reduction of a fractured tibia with cast application 1 hour ago and is reporting that the casted leg feels hot

Pain, tightness, hot feeling can indicate that the cast is on too tight

Rationale:

2. Normal to feel nauseous after coming off of anesthesia
3. Knee pain is expected after knee surgery
4. Right shoulder pain is common in laparoscopic cholecystectomy due to gas left in abdomen after the procedure. Will resolve on its own

The nurse is planning care for a client with multiple sclerosis (MS) who has ataxia. Which of the following interventions should the nurse include in the client's plan of care?

1. Add thickener to thin liquids for the client.
2. Obtain a referral to a physical therapist for the client.
3. Face the client directly when speaking with the client.
4. Provide a board with pictures to help the client communicate needs. - answer-2. Obtain a referral to a physical therapist for the client.

Ataxia is lack of muscle control in arms and legs leading to lack of balance, coordination, and walking. PT is the area of referral for this type of issue.

Rationale:

1. thick liquids for dysphagia
2. Always indicated
3. Can be a tool for patients with expressive aphasia

The home-health nurse is assigned to visit the following clients who live within 3 miles (4.8 km) of one another. The nurse should first visit the client with

1. breast cancer who had a mastectomy 2 days ago and has had 25 mL of drainage from the closed- wound drainage system in the past 12 hours
2. lung cancer who received a dose of chemotherapy 2 weeks ago and has a temperature of 101.1° F (38.4° C)
3. chronic obstructive pulmonary disease (COPD) who is reporting expectorating large amounts of thick, yellow mucus
4. diabetes mellitus (type 1) who had a right below-the-knee amputation (BKA) and is reporting having right toe pain - answer-1. breast cancer who had a mastectomy 2 days ago and has had 25 mL of drainage from the closed-wound drainage system in the past 12 hours

This is really little blood in 12 hours for a surgery that was only 2 days ago. Nurse should assess for obstruction of the drainage system which could be life- threatening if not resolved.

The nurse has become aware of the following client situations. The nurse should first assess the client

1. who had a total abdominal hysterectomy (TAH) 1 day ago and is unable to void 7 hours after the indwelling urethral catheter was removed
2. who had a total knee replacement 24 hours ago, is restless, and has a petechial

rash on the chest

3. with bacterial pneumonia who has bronchial breath sounds auscultated between the scapulae and a temperature of 103.3° F (39.6° C)
4. with hepatic cirrhosis who has an elevated aspartate aminotransferase (AST) level and respirations of 24 - answer-2. who had a total knee replacement 24 hours ago, is restless, and has a petechial rash on the chest

petechial rash — sign of DIC or fat embolus

The nurse is planning care for a pediatric client being admitted with pertussis. Which of the following interventions should the nurse include in the client's plan of care?

1. Keep the client NPO.
2. Place a dehumidifier in the client's room.
3. Encourage the client to ambulate frequently.
4. Implement droplet precautions. - answer-4. Implement droplet precautions.

The nurse has attended a staff education program about infection control precautions. It would indicate a correct understanding of the teaching if the nurse is observed

1. wearing a particulate respirator mask (N95) when entering the room of a client with Haemophilus influenzae pneumonia
   2. placing a client with streptococcal pneumonia in a room with a client who has respiratory syncytial virus (RSV)
2. wearing a protective gown when entering the room of a client with Escherichia coli who is incontinent
3. placing a client with pediculosis capitis (head lice) in a room with a client who has scabies - answer-3. wearing a protective gown when entering the room of a client with Escherichia coli who is incontinent

E. Coli is contact precautions; wear gown whenever coming in contact with bodily fluids which is highly likely with an incontinent patient

Rationale:

1. H. flu is droplet precautions
2. Strep is droplet and RSV is contact
3. They will infect each other, they need private rooms

The nurse is assessing an older adult client who is scheduled for discharge and is at risk for falls. Which of the following are extrinsic risk factors for falling? Select all that apply.

1. uneven stairs
2. throw rugs
3. hemiparesis
4. dim lighting

5. confusion - answer-uneven stairs, throw rugs, dim lighting

Hemiparesis and confusion are intrinsic risk factors

The nurse is caring for a 3-year-old client with impetigo.

Which of the following infection control precautions should the nurse implement? Select all that apply.

1. Wear a surgical mask when bathing the client.
2. Wear a protective gown when changing the client's bed linens.
3. Keep the door to the client's room closed.
4. Place a box of clean gloves outside the client's door.
5. Place a surgical mask on the client during transport to other departments. - answer-2. Wear a protective gown when changing the client's bed linens.
6. Place a box of clean gloves outside the client's door.

Rationale: Impetigo is a highly infectious skin disease spread by direct contact. Contact precautions include gown and gloves. Private closed door and surgical masks are appropriate for airborne and not necessary for contact

The nurse is evaluating a staff member's care of a client with active pulmonary tuberculosis (TB). Which of the following actions by the staff member would indicate to the nurse an understanding of the principles of infection control for tuberculosis isolation?

1. instructing visitors to wash their hands before entering the client's room
2. putting on a mask, gown, and gloves before entering the client's room
3. placing tissues and a trash receptacle within the client's reach

4. asking the client to put on a clean mask each time someone enters the room - answer-3. placing tissues and a trash receptacle within the client's reach

Important to not leave tissues laying around and to put them in a leak proof bag in the trash.

The nurse in the pediatric unit is preparing to admit a client with rubeola (measles). The nurse should assign the client to a

1. private room at the end of the hallway

2. private room with monitored negative air pressure
3. room with a client who has chickenpox
4. room with a client who has atopic dermatitis (eczema) - answer-2. private room with monitored negative air pressure

Measles is airborne (MTV) and requires a private room with negative air pressure

The charge nurse is observing the following client situations. It would require intervention if a

1. client with hepatitis B (HBV) is eating food brought into the facility by a visitor
2. visitor is sitting on the side of the bed of a client with acute pancreatitis
3. staff member is entering the room of a client with Haemophilus influenzae meningitis wearing a protective gown and gloves
4. family member of a client with mycoplasma pneumonia leaves the door to the client's room open - answer-1. client with hepatitis B (HBV) is eating food brought into the facility by a visitor

HBV is spread through contact with body fluids including saliva, so it is important to intervene if the patient is eating and possibly sharing food with another person.

The nurse is reviewing the orders of a client who has acute kidney injury. Which of the following orders should the nurse clarify?

1. computed tomography (CT) scan of the abdomen with intravenous contrast media
2. urine specimen for urinalysis
3. blood specimen for arterial blood gas (ABG)
4. referral to registered dietitian for parenteral nutrition evaluation - answer-1. computed tomography (CT) scan of the abdomen with intravenous contrast

media

CTs use iodinated contrast which is harmful to the kidneys and therefore contraindicated in a client with AKI

The nurse is planning a staff education program about caring for clients with restraints. Which of the following information should the nurse include?

1. "Restraints should be removed once during a shift to perform passive range-of-motion (ROM) exercises for the client."
2. "Restraints should be secured to the side rails of the client's bed for quick release."

3. "Restraints require an order from the primary health care provider."
4. "Restraints may be used p.r.n. for clients who are confused." - answer-3. "Restraints require an order from the primary health care provider."

Rationale:

1. Restraints are removed every 2 HOURS for ROM exercises, toileting, and fluids. Assess every 15 mins for the first hour and then every 30 minutes
2. Restraints should be secured to the bed, not side rails
3. Restraints are never PRN

The nurse is caring for a client with active pulmonary tuberculosis (TB). Which of the following should the nurse include in the client's plan of care?

1. placing the client in a private room with the door open
2. putting a surgical mask on the client during transport to the radiology department
3. instructing the primary caregivers to wear surgical masks when caring for the client
4. instituting the standards for droplet precautions while caring for the client

• answer-2. putting a surgical mask on the client during transport to the radiology department

X- Ray to confirm active TB d(x)

Rationale:

1. Door should be

closed 3.

4. Airborne precautions

The home-health nurse is teaching the parents of a 4-year-old client with impetigo. Which of the following information should the nurse include?

1. "Put a surgical mask on your child when around siblings."
2. "Cleanse the lesions with a povidone-iodine solution daily."
3. "Apply petroleum jelly to the lesions daily."
4. "Instruct your child not to use the same towels as siblings." - answer-4. "Instruct your child not to use the same towels as siblings."

Impetigo is highly contagious through contact. Towels can easily spread the infection

Rationale:

1. It is contact precautions; surgical mask would be for airborne

The nurse has attended a staff education program about bioterrorism. Which of the following statements by the nurse would require follow-up?

1. "Botulism is transmitted by ingestion of contaminated canned foods."
2. "Hemorrhagic fever is spread by direct contact with blood or body fluids."
3. "Anthrax is spread through direct contact with the bacteria and its spores."
4. "Bubonic plague is transmitted from person to person via airborne droplets."

• answer-4. "Bubonic plague is transmitted from person to person via airborne droplets."

It is spread through flea bites and contact with infected skin

Rationale:

1. Botulism is transmitted by foods. ex: babies getting Botulism from honey
2. Infectious diseases that affect clotting and is spread by blood or body fluids
3. Anthrax: Contact

The nurse observes a coworker who is assessing a client's thoracic expansion.

Which of the following would indicate that the coworker is using the correct assessment technique?

1. percussion from the apex of the scapula downward on each side
2. placement of the hands flat on the back with the thumbs at the level of the tenth ribs pointing to the spine, then asking the client to inhale