NCLEX-PN Test Prep Questions and Answers with Explanations, Exams of Nursing

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2020/2021 NCLEX-PN Test Prep

1. A papular lesion is noted on the perineum of the laboring client. Which initial action is most appropriate? A. Document the finding B. Report the finding to the doctor C. Prepare the client for a C-section D. Continue primary care as prescribed Answer B: Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding, so answer A is incorrect. The physician must make the decision to perform a C-section, making answer C incorrect. It is not enough to continue primary care, so answer D is incorrect.
2. A client with a diagnosis of human papillomavirus (HPV) is at risk for which of the following? A. Lymphoma B. Cervical and vaginal cancer C. Leukemia D. Systemic lupus Answer B: The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned in answers A, C, and D, so those are incorrect.
3. The client seen in the family planning clinic tells the nurse that she has a painful lesion on the perineum. The nurse is aware that the most likely source of the lesion is:

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2020/2021 NCLEX-PN Test Prep A. Syphilis B. Herpes C. Candidiasis D. Condylomata Answer B: A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. In answer C, candidiasis is a yeast infection and does not present with a lesion, but it is exhibited by a white, cheesy discharge. Condylomata lesions are painless warts, so answer D is incorrect.

4. A client visiting a family planning clinic is suspected of having an STI. The most diagnostic test for treponema pallidum is: A. Venereal Disease Research Lab (VDRL) B. Rapid plasma reagin (RPR) C. Florescent treponemal antibody (FTA) D. Thayer-Martin culture (TMC) Answer C: FTA is the only answer choice for treponema pallidum. Answers A and B are incorrect because VDRL and RPR are screening tests for syphilis but are not conclusive of the disease; they only indicate exposure to the disease. The Thayer-Martin culture is a test for gonorrhea, so answer D is incorrect.
5. Which laboratory finding is associated with HELLP syndrome in the obstetric client? A. Elevated blood glucose B. Elevated platelet count C. Elevated creatinine clearance D. Elevated hepatic enzymes

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2020/2021 NCLEX-PN Test Prep Answer D: The criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet count. In answer A, an elevated blood glucose level is not associated with HELLP. Platelets are decreased in HELLP syndrome, not

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2020/2021 NCLEX-PN Test Prep elevated, as stated in answer B. The creatinine levels are elevated in renal disease and are not associated with HELLP syndrome, as stated in answer C.

6. The nurse is assessing the deep tendon reflexes of the client with hypomagnesemia. Which method is used to elicit the biceps reflex? A. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer. B. The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow. C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer. D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist. Answer A: The answer can only be A because the other methods elicit different reflexes. Answer B elicits the triceps reflex, answer C elicits the patella reflex, and answer D elicits the radial nerve.
7. Which medication should be used with caution in the obstetric client with diabetes? A. Magnesium sulfate B. Brethine C. Stadol D. Ancef Answer B: Brethine is used cautiously because it raises the blood glucose levels. Answers A, C, and D are all medications that are commonly used in the diabetic client, so there is no need to question the order for these medications.

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EXAM 1

2020/2021 NCLEX-PN Test Prep

8. A multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1. The nurse’s assessment of this data is: A. The infant is at low risk for congenital anomalies.

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2020/2021 NCLEX-PN Test Prep B. The infant is at high risk for intrauterine growth retardation. C. The infant is at high risk for respiratory distress syndrome. D. The infant is at high risk for birth trauma. Answer C: When the L/S ratio reaches 2:1, the lungs are considered to be mature. The infant will most likely be small for gestational age and will not be at risk for birth trauma, so answer B is incorrect. The L/S ratio does not indicate congenital anomalies, as stated in answer A, and the infant is not at risk for intrauterine growth retardation, as stated in answer D.

9. Which observation in the newborn of a mother who is alcohol dependent would require immediate nursing intervention? A. Crying B. Wakefulness C. Jitteriness D. Yawning Answer C: Jitteriness is a sign of seizure in the neonate. Answers A, B, and D are incorrect because crying, wakefulness, and yawning are expected in the newborn.
10. The nurse caring for a client receiving magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is: A. Decreased urinary output B. Hypersomnolence C. Absence of knee jerk reflex D. Decreased respiratory rate Answer B: The client is expected to become sleepy, have hot flashes, and

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2020/2021 NCLEX-PN Test Prep experience lethargy. A decreasing urinary output, absence of the knee jerk reflex, and decreased respirations are signs of toxicity and are not expected side effects of magnesium sulfate. Therefore, answers A, C, and D are incorrect.

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EXAM 1

2020/2021 NCLEX-PN Test Prep

11. The 57 - year-old male client has elected to have epidural anesthesia as the anesthetic during a hernia repair. If the client experiences hypotension, the nurse would: A. Place him in the Trendelenburg position B. Obtain an order for Benedryl C. Administer oxygen per nasal cannula D. Speed the IV infusion of normal saline Answer D: If the client experiences hypotension after an injection of epidural anesthetic, the nurse should turn him to the left side if possible, apply oxygen by mask, and speed the IV infusion. Epinephrine, not Benedryl, in answer B, should be kept for emergency administration. A is incorrect because placing the client in Trendelenburg position (head down) will allow the anesthesia to move up above the respiratory center, thereby decreasing the diaphragm’s ability to move up and down, ventilating the client. Answer C is incorrect because the oxygen should be applied by mask, not cannula.
12. A client has cancer of the pancreas. The nurse should be most concerned with which nursing diagnosis? A. Alteration in nutrition B. Alteration in bowel elimination C. Alteration in skin integrity D. Ineffective individual coping Answer A: Cancer of the pancreas frequently leads to severe nausea and vomiting. Answers B, C, and D are incorrect because although they are a concern to the client, they are not the priority nursing diagnosis.
13. The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?

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2020/2021 NCLEX-PN Test Prep A. Inspection of the abdomen for enlargement B. Bimanual palpation for hepatomegaly C. Daily measurement of abdominal girth D. Assessment for a fluid wave

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2020/2021 NCLEX-PN Test Prep Answer C: Measuring the girth daily with a paper tape measure and marking the area that is measured is the most objective method of estimating ascites. Inspection, in answer A, and checking for fluid waves, in answer D, are more subjective and not correct. Palpation of the liver will not tell the amount of ascites, so answer B is incorrect.

14. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis? A. Alteration in cerebral tissue perfusion B. Fluid volume deficit C. Ineffective airway clearance D. Alteration in sensory perception Answer B: The vital signs indicate hypovolemic shock, so checking for fluid volume deficit is the appropriate action. Answers A, C, and D do not indicate cerebral tissue perfusion, airway clearance, or sensory perception alterations, and are incorrect.
15. Which information obtained from the visit to a client with hemophilia would cause the most concern? The client: A. Likes to play football B. Drinks several carbonated drinks per day C. Has two sisters with sickle cell tract D. Is taking acetaminophen to control pain Answer A: The client with hemophilia is likely to experience bleeding episodes if he participates in contact sports. Drinking several carbonated drinks per day, as in answer B, has no bearing on the hemophiliac’s

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2020/2021 NCLEX-PN Test Prep condition. Having two sisters with sickle cell, as in answer C, is not information that would cause concern. Taking acetaminophen for pain, as in answer D, is an accepted practice and does not cause concern.

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2020/2021 NCLEX-PN Test Prep

16. The nurse on oncology is caring for a client with a white blood count of 800, a platelet count of 150,000, and a red blood cell count of 250,000. During evening visitation, a visitor is noted to be coughing and sneezing. What action should the nurse take? A. Ask the visitor to wash his hands B. Document the visitor’s condition in the chart C. Ask the visitor to leave and not return until the client’s white blood cell count is 1, D. Provide the visitor with a mask and gown Answer D: The client with neutropenia should not have visitors with any type of infection, so the best action by the nurse is to give the visitor a mask and a gown. Asking the visitor to wash his hands is good but will not help prevent the infection from spreading by droplets; therefore, answer A is incorrect. Answer B is incorrect because documenting the visitor’s condition is not enough action for the nurse to take. Answer C is incorrect because asking the visitor to leave and not return until the client’s white blood cell count is 1,000 is an insuffient intervention. The normal WBC is 5,000– 10,000, so a WBC of 1,000 is not high enough to prevent the client from contracting infections.
17. The nurse is caring for the client admitted after trauma to the neck in an automobile accident. The client suddenly becomes unresponsive and pale, with a BP of 60 systolic. The initial nurse’s action should be to: A. Place the client in Trendelenburg position B. Increase the infusion of normal saline C. Administer atropine IM D. Obtain a crash cart Answer B: For some clients with trauma to the neck, the answer would be A;

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2020/2021 NCLEX-PN Test Prep however, in this situation, it is incorrect because lowering the head of the bed could further interfere with the airway. Increasing the infusion and placing the client in supine position is better. If atropine is administered to the client, it should be given IV, not IM, and there is no need for this action at present, as stated in answer C. Answer D is not necessary at this time.

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2020/2021 NCLEX-PN Test Prep

18. Immediately following the removal of a chest tube, the nurse would: A. Order a chest x-ray B. Take the blood pressure C. Cover the insertion site with a Vaseline gauze D. Ask the client to perform the Valsalva maneuver Answer C: When a chest tube is removed, the hole should be immediately covered with a Vaseline gauze to prevent air from rushing into the chest and causing the lung to collapse. The doctor, not the nurse, will order a chest xray; therefore, answer A is incorrect. Taking the BP in answer B is good but is not the priority action. Answer D is incorrect because the Valsalva maneuver is done during removal of the tube, not afterward.
19. A client being treated with sodium warfarin has an INR of 9.0. Which intervention would be most important to include in the nursing care plan? A. Assess for signs of abnormal bleeding B. Anticipate an increase in the dosage C. Instruct the client regarding the drug therapy D. Increase the frequency of neurological assessments Answer A: The normal international normalizing ratio (INR) is 2–3. A 9 might indicate spontaneous bleeding. Answer B is an incorrect action at this time. Answer C is incorrect because just instructing the client regarding his medication is not enough. Answer D is incorrect because increasing the frequency of neurological assessment will not prevent bleeding caused by the prolonged INR.
20. Which snack selection by a client with osteoporosis indicates that the client understands the dietary management of the disease? A. A glass of orange juice

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2020/2021 NCLEX-PN Test Prep B. A blueberry muffin C. A cup of yogurt D. A banana

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2020/2021 NCLEX-PN Test Prep Answer C: The food with the most calcium is the yogurt. The others are good choices, but not as good as the yogurt, which has approximately 400mg of calcium. Therefore, answers A, B, and D are incorrect.

21. The elderly client with hypomagnesemia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of magnesium sulfate? A. The nurse places a sign over the bed not to check blood pressures in the left arm. B. The nurse places a padded tongue blade at the bedside. C. The nurse measures the urinary output hourly. D. The nurse darkens the room. Answer C: The client receiving magnesium sulfate should have a Foley catheter in place, and the hourly intake and output should be checked because a sign of toxicity to magnesium sulfate is oliguria. There is no need to refrain from checking the blood pressure in the left arm, as stated in answer A. A padded tongue blade should be kept in the room at the bedside, just in case of a seizure, but this is not related to the magnesium sulfate infusion, so this makes answer B incorrect. Answer D is incorrect because just darkening the room will not prevent toxicity, although it might help with the headache associated with preeclampsia.
22. The nurse is caring for a 10-year-old client scheduled for surgery. The client’s mother tells the nurse that her religion forbids blood transfusions. What nursing action is most appropriate? A. Document the mother’s statement in the chart B. Encourage the mother to reconsider C. Explain the consequences of no treatment D. Notify the physician of the mother’s refusal

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2020/2021 NCLEX-PN Test Prep Answer D: If the client’s mother refuses to sign for the child’s treatment, the doctor should be notified. Because the client is a minor, the court might order treatment. Answer A is incorrect because simply documenting the statement

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2020/2021 NCLEX-PN Test Prep is not enough. Answer B is incorrect because it is not the nurse’s responsibility to try to persuade the mother to allow the blood transfusion. Answer C is incorrect because the consequences of the denial of a blood transfusion are not known.

23. A client is admitted to the unit 3 hours after an injury with second-degree burns to the face, neck, and head. The nurse would be most concerned with the client developing which of the following? A. Hypovolemia B. Laryngeal edema C. Hypernatremia D. Hyperkalemia Answer B: The nurse should be most concerned with laryngeal edema because of the area of burn. The next priority should be answer A, hypovolemia. Hypernatremia and hyperkalemia, as stated in answers C and D, are incorrect because the client will most likely experience hyponatremia and hypokalemia.
24. The nurse is evaluating nutritional outcomes for an elderly client with anorexia. Which data best indicates that the plan of care is effective? A. The client selects a balanced diet from the menu. B. The client’s hematocrit improves. C. The client’s tissue turgor improves. D. The client gains weight. Answer D: The client with anorexia shows the most improvement by weight gain. Selecting a balanced diet, as in answer A, is of little use if the client does not eat the diet. The hematocrit in answer B is incorrect because although it might improve by several means, such as blood transfusion, it does not indicate improvement in the anorexic condition. The tissue turgor

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2020/2021 NCLEX-PN Test Prep indicates fluid stasis, not improvement of anorexia; therefore, answer C is incorrect.

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2020/2021 NCLEX-PN Test Prep

25. The client is admitted following repair of a fractured femur with cast application. Which nursing assessment should be reported to the doctor? A. Pain B. Warm toes C. Pedal pulses rapid D. Paresthesia of the toes Answer D: Paresthesia, in answer D, is not normal and might indicate compartment syndrome. At this time, pain beneath the cast is normal, so answer A is incorrect. The client’s toes should be warm to the touch and pulses should be present. Because answers B and C are normal findings, these answers are incorrect.
26. Which would be an expected finding during injection of dye with a cardiac catheterization? A. Cold extremity distant to the injection site B. Warmth in the extremity C. Extreme chest pain D. Itching in the extremities Answer B: It is normal for the client to have a warm sensation when dye is injected. Answer A is incorrect because the client should not have a cold extremity. This indicates peripheral vascular disease. Answer C is incorrect because extreme chest pain can be related to a myocardial infarction. The pain is not normal. Answer D is incorrect because itching is a sign of an allergic reaction. Also, the itching will most likely be on the chest and skin folds.
27. Which action by the healthcare worker indicates a need for further teaching?

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2020/2021 NCLEX-PN Test Prep A. The nursing assistant wears gloves while giving the client a bath. B. The nurse wears goggles while drawing blood from the client. C. The doctor washes his hands before examining the client. D. The nurse wears gloves to take the client’s vital signs.

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2020/2021 NCLEX-PN Test Prep Answer D: It is not necessary to wear gloves to take the vital signs of the client under normal circumstances. If the client has active infection with methicillin-resistant staphylococcus aureus, gloves should be worn. The other answer choices indicate knowledge of infection control by the actions, so answers A, B, and C are incorrect.

28. The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective? A. The client loses consciousness. B. The client vomits. C. The client’s ECG indicates tachycardia. D. The client has a grand mal seizure. Answer D: During ECT, the client will have a grand mal seizure. This indicates completion of the electroconvulsive therapy. Answer A is incorrect because clients are frequently given medication that will cause drowsiness or sleep. Answer B is incorrect because vomiting is not a sign that the ECT has been effective. Answer C is incorrect because tachycardia might be present, but it is not a sign that the ECT has been effective.
29. A 5 - year-old is being tested for pinworms. To collect a specimen for assessment of pinworms, the nurse should teach the mother to: A. Examine the perianal area with a flashlight 2 – 3 hours after the child is asleep and to collect any eggs on a clear tape B. Scrape the skin with a piece of cardboard and bring it to the clinic C. Obtain a stool specimen in the afternoon D. Bring a hair sample to the clinic for evaluation Answer A: Infection with pinworms begins when the eggs are ingested or

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2020/2021 NCLEX-PN Test Prep inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2 – 3 hours after the child is asleep.

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2020/2021 NCLEX-PN Test Prep Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. There is no need to scrape the skin, as stated in answer B. Collecting a stool specimen in the afternoon will probably not reveal the eggs because the worms often are not detected during the day; therefore, answer C is incorrect. Answer D is incorrect because eggs are not located in the hair.

30. Which instruction should be given regarding the medication used to treat enterobiasis (pinworms)? A. Treatment is not recommended for children less than 10 years of age. B. The entire family should be treated. C. Medication therapy will continue for 1 year. D. Intravenous antibiotic therapy will be ordered. Answer B: Erterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated to ensure that no eggs remain. The family should then be tested again in 2 weeks to ensure that no eggs remain. Answer A is incorrect because children less than 10 can be treated with Vermox. Answer C is incorrect because a single treatment is usually sufficient. Answer D is incorrect because there is no need for IV antibiotics for the client with pinworms.
31. Which client should be assigned to the pregnant licensed practical nurse? A. The client who just returned after receiving linear accelerator radiation therapy for lung cancer B. The client with a radium implant for cervical cancer C. The client who has just been administered soluble brachytherapy for thyroid cancer D. The client who has returned from placement of iridium seeds for prostate cancer

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2020/2021 NCLEX-PN Test Prep Answer A: The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy in answer A travels to the radium department for therapy; thus, the radiation stays in the department. The client himself is not radioactive. The client in answer B