NCLEX Practice Exam: 2024 Edition, Exams of Nursing

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NCLEX Practice Exam with questions and verified answers

1. A nurse is teaching a client about type 2 diabetes mellitus. What information would reduce a client's risk of developing this disease? "Maintain weight within normal limits for your body size and muscle mass." Explanation: The most important factor predisposing to the development of type 2 diabetes mellitus is obesity. Insulin resistance increases with obesity. Cigarette smoking is not a predisposing factor, but it is a risk factor that increases complications of diabetes mellitus. A high-protein diet does not prevent diabetes mellitus, but it may contribute to hyperlipidemia. Hypertension is not a predisposing factor, but it is a risk factor for developing complications of diabetes mellitus.
2. What should the nurse teach a client receiving vitamin D therapy for hypoparathyroidism? Vitamin D is taken to increase absorption of calcium. Explanation: A client with hypoparathyroidism has a decreased serum calcium level. Variable doses of vitamin D preparations enhance the absorption of calcium from the gastrointestinal tract. This does not cure the client's hypoparathyroidism. Vitamins A, C, and E are not involved with this process. Vitamin D therapy will not assist in stabilizing potassium.
3. A minister approaches a nurse caring for a client who is a member of the minister's congregation. The minister inquires as to whether the member has been made aware of his/her diagnosis. Which of the following would be the best response by the nurse?

"I understand your concern, but have you asked the client?" Explanation: The nurse must maintain confidentiality. The minister may mean well but is trying to gather information that is confidential. The nurse should acknowledge the minister's concern and then suggest asking the client about the reason for hospitalization. This allows the client to share with the minister whatever information the client wants to disclose. The other options are not correct because they do not protect the client's privacy. Telling the minister that it is not his/her business is not a decision the nurse should be making without discussing the situation with the client.

4. A client experienced a right frontal stroke that left him with short-term memory loss and lack of impulse control. The nurse caring for the client on the previous shift identified him at high risk for falls. While making rounds to begin the shift, a nurse notices the client lying on the floor. The nurse assesses the client and notes no injuries. How should the nurse follow up this incident? Notify the physician, then document the location of the fall, physician notification, any injury, necessary follow-up, and any changes in the care plan needed as a result of the fall. Explanation: The nurse should notify the physician, then document the facts related to the fall, such as the location of the fall, physician notification, injury if any, necessary follow-up, and any changes in the care plan that occurred as a result of the fall. The nurse shouldn't include any information that places blame on other health care members. The fall must be reported even if the client doesn't suffer an injury.
5. A client seeks medical attention for dyspnea, chest pain, syncope, fatigue, and palpitations. A thorough physical examination reveals an apical systolic thrill and heave, along with a fourth heart sound (S4) and a systolic murmur. Diagnostic tests reveal that the client has hypertrophic cardiomyopathy (HCM). Which nursing diagnosis may be appropriate? Decreased cardiac output

Explanation: Decreased cardiac output is an appropriate nursing diagnosis for a client with HCM because the hypertrophied cardiac muscle decreases the effectiveness of the heart's contraction, decreasing cardiac output. Heart failure may complicate HCM, causing fluid volume excess; therefore, the nursing diagnosis of Risk for deficient fluid volume isn't applicable. Ineffective thermoregulation and Risk for peripheral neurovascular dysfunction are inappropriate because HCM doesn't cause these problems.

6. On admission to the psychiatric unit, a client with major depression reports that a family member is physically abusive and requests that the nurse not release any personal information to anyone. When the allegedly abusive family member calls the unit and demands information about the client's treatment, what is the nurse's best response? "To protect clients' confidentiality, I can't give any information, including whether your relative is receiving treatment here." Explanation: The client has the right to confidential treatment, and the nurse has a duty to protect his confidentiality. Stating that to protect clients' confidentiality no information will be given is a diplomatic response. Although simply telling the caller that information can't be released protects the client's confidentiality, this response isn't as diplomatic as the first response. Stating that the client isn't accepting phone calls or that the client didn't sign an information form with the caller's name on it divulges the client's whereabouts and status, violating confidentiality.
7. A health care provider is legally and ethically required to disclose certain information. Which confidential information should the nurse disclose? A taxi driver's diagnosis of an uncontrolled seizure disorder to his licensing agency Explanation:

The health care provider may lawfully disclose confidential information about a client when the welfare of others is at stake. The health care provider is required to inform the Department of Motor Vehicles that the taxi driver has an uncontrolled seizure disorder because it's in the best interest of the public's and client's safety. Confidentiality of HIV testing is required. Disclosing a client's cancer diagnosis to a significant other or pregnancy to a legally separated partner do not affect the welfare of person.

8. The nurse is inspecting the client's abdomen (see the accompanying image). The nurse should document that the client's abdomen: is flat and symmetrical. Explanation: The client's abdomen is flat and without abnormalities. There is no aortic pulsation (motion is client's breathing). There is no hernia; the umbilicus is normal. There are no markings or lines (striae) on this client's abdomen.
9. When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent: contractures. Explanation: Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory infections. Nursing care should be directed toward the goal of preventing these complications. Ascites, fluid overload, and dry mouth are not associated with multiple sclerosis.

10. A nurse is teaching an elderly client about developing good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required? "I need to use laxatives regularly to prevent constipation." Explanation: The client requires more teaching if he states that he'll use laxatives regularly to prevent constipation. The nurse should teach this client to gradually eliminate the use of laxatives because using laxatives to promote regular bowel movements may have the opposite effect. A high-fiber diet, ample amounts of fluids, and regular exercise promote good bowel health.
11. A client with newly diagnosed chronic obstructive pulmonary disease (COPD) comes to the clinic for a routine examination. The nurse teaches the client strategies for preventing airway irritation and infection. Which statement by the client best indicates that teaching was successful? "I should avoid using powders." Explanation: There are many considerations when a client is diagnosed with COPD. A client with COPD should avoid exposure to powders, dust, and smoke from cigarettes, pipes, and cigars. The client should stay away from crowds should avoid aerosol sprays as a precaution. The client should also obtain immunizations against pneumococcal pneumonia as well as influenza. A combination of measures is needed to maintain the client's highest level of respiratory function.
12. A 15-year-old client is 4 cm dilated and 100% effaced and is in active labor with her first baby. The nurse contacts the physician to communicate the findings of fetal heart rate decelerations, thick meconium in the amniotic fluid, and low fetal scalp pH results. What is the most appropriate nursing action at this time? Prepare the client for an assisted or cesarean birth.

Explanation: Fetal heart decelerations, thick meconium, and low fetal scalp pH indicate severe fetal distress. Because the client is a primigravida and in early labor at 4 cm cervical dilatation, it is unlikely that the baby will tolerate further labor and a vaginal birth. It is prudent for the nurse to begin preparing the client for an assisted or operative birth. While changing maternal position and increasing oxygen availability may enhance placental perfusion and fetal oxygenation, these interventions do not meet the immediate fetal needs. There are no implications that a social worker needs to be involved in the care provided at this particular stage.

13. A client is expecting her second child in 6 months. During the psychosocial assessment, she says to the nurse, "I've been through this before. Why are you asking me these questions?" What is the nurse's best response? "Each pregnancy has a unique psychosocial meaning." Explanation: With each pregnancy, a woman explores a new aspect of the mother role and must reformulate her self- image as a pregnant woman and a mother. The other options don't address the client's feelings. No evidence suggests that a second pregnancy requires more adjustment. Couvade symptoms occur in the father, not the mother.
14. A client is admitted with a diagnosis of diabetic ketoacidosis. An insulin drip is initiated with 50 units of insulin in 100 ml of normal saline solution administered via an infusion pump set at 10 ml/hour. The nurse determines that the client is receiving how many units of insulin each hour? Record your answer using a whole number. 5 Explanation:

To determine the number of insulin units the client is receiving per hour, the nurse must first determine the number of units in each milliliter of fluid (50 units ÷ 100 ml = 0.5 units/ml). Next, multiply the units per milliliter by the rate of milliliters per hour (0.5 units × 10 ml/hr = 5 units).

15. A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by: showing the location of the obstruction and the collateral circulation. Explanation: An arteriogram involves injecting a radiopaque contrast agent directly into the vascular system to visualize the vessels. It usually involves computed tomographic scanning. The velocity of the blood flow can be estimated by duplex ultrasound. The client's ankle-brachial index is determined, and then the client is requested to walk. The normal response is little or no drop in ankle systolic pressure after exercise.
16. The nurse is preparing a teaching plan about increased exercise for a female client who is receiving long-term corticosteroid therapy. What type of exercise is most appropriate for this client? walking Explanation: The best exercise for females who are on long-term corticosteroid therapy is a low-impact, weightbearing exercise such as walking or weight lifting. Floor exercises do not provide for the weightbearing. Stretching is appropriate but does not offer sufficient weightbearing. Running provides for weightbearing but is hard on the joints and may cause bleeding.

17. A nurse administers albuterol, as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? Respiratory rate of 22 breaths/minute Explanation: In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.
18. A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel has positioned the oxygen mask as shown. The nurse is assessing the neonate and determines that the mask: is appropriate for the neonate. Explanation: The correct size covers the nose but not the eyes.The mask is too large if it covers the neonate's eyes. Masks that are too small may pinch the nose. Masks should fit snugly against the cheeks and chin. It is not necessary to cover the mask with a soft cloth. If the mask fits snugly, it will not be as likely to rub the skin.
19. A nurse is caring for a client with end-stage heart failure who is awaiting a heart transplant. The client tells the nurse that he thinks he's going to die before a donor heart is found. He also tells the nurse that he hasn't been attending a church but wants to talk with a priest. What action should the nurse take? Contact the clergy member who is assigned to the transplant team.

Explanation: Each multidisciplinary transplant team has a clergy person assigned. The nurse should contact that person and request that he visit the client. It isn't appropriate for the nurse to ask her priest to see the client. Telling the client that he has nothing to worry about because donors are typically found offers false reassurance. Telling the client that it doesn't matter if he attends a church invalidates the client's concern.

20. A nurse is providing instruction to a 38-year-old male client undergoing treatment for anxiety and insomnia. The practitioner has prescribed lorazepam 1 mg/po/tid. The nurse determines that teaching has been effective when the client states: "I'll avoid coffee." Explanation: Lorazepam is a benzodiazepine used to treat various forms of anxiety and insomnia. Caffeine is contraindicated because it is a stimulant and increases anxiety. A client taking lorazepam should avoid alcoholic beverages. Clients taking certain antipsychotic medications should avoid sunlight. Salt intake has no effect on lorazepam.
21. In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment? Health habits, family relationships, affect, and thought patterns Explanation: A psychosocial assessment involves assessment of health habits, family relationships, emotional responses, and thought patterns. These areas are important to assess to determine how the client is coping with illness. It is also important to identify the support systems of the client. Each of the other choices includes physical assessment factors, not just psychosocial factors.

22. A client with type I diabetes mellitus is scheduled to have surgery. The client has been nothing- by-mouth (NPO) since midnight. In the morning, the nurse notices the client's daily insulin has not been prescribed. Which action should the nurse do first? Obtain the client's blood glucose at the bedside. Explanation: The nurse should contact the health care provider and clarify whether the client's usual insulin dose should be given before surgery; having the blood glucose level is objective information that the health care provider may need to know before making a final decision as to the insulin dosage. The nurse should not assume that the usual insulin dose is to be given. It is not appropriate for the nurse to defer decision making on this issue until after surgery.
23. A day-shift nurse on the pediatric neurologic unit has just received a report from the previous shift. Which infant should the nurse assess first? A restless infant with a high-pitched cry who was transferred from the intensive care unit (ICU) the previous evening Explanation: An infant's restlessness and high-pitched cry can indicate increased intracranial pressure (ICP). Because the infant was transferred from the ICU the previous night, assessing for increased ICP should be a nursing priority. The infant with a pulse of 140-160 bpm exhibits normal parameters. Although the nurse must assess a low-grade fever on the third postoperative day, this stable infant isn't the priority at this time. Decreased respirations are indicative of increased intracranial pressure, but this infant's respirations of 38 breaths per minute would not be a priority concern.
24. During the immediate postpartum period, the nurse is caring for a primipara who gave birth to a postterm neonate after an oxytocin induction. When developing the client's plan of care, which problem should the nurse expect to assess for frequently?

uterine atony Uterine atony is more common in clients who have received oxytocin during labor because the uterine muscle becomes fatigued and does not contract effectively to compress the vessels at the placental site. Respiratory depression, not typically associated with oxytocin induction, may occur with narcotic overdose or excessive magnesium sulfate administration. Increased pulse rate and hypertension are not typically associated with oxytocin induction during labor.

25. When preparing discharge instructions for a client after an abdominal hysterectomy, the nurse should first: assess the client's available social supports. Explanation: Assessment is the first step in planning client education. Assessing social support resources is a key aspect of discharge planning that begins when the client is admitted to the hospital. It is imperative to know what assistance and support the client has at home. Assessment includes obtaining data about any family or home responsibilities the client is concerned with during the recovery period. It is within the scope of nursing practice to provide discharge instructions. A social worker is not needed at this time. The nurse should assess the client's needs before determining whether using a video or reading instructions to the client is appropriate.
26. A nurse is caring for a client that received a colostomy 2 days ago. Which is the priority intervention? Assess the drainage from the stoma. Explanation:

Assessing the stoma is important because of the potential for surgical site infection. Teaching on irrigation and dietary planning should be performed before discharge. The client should be encouraged to look at the stoma, but this is not the priority.

27. A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution? I. V. tubing with a volume-control chamber Explanation: Because infants have a small circulating blood volume, inadvertent administration of extra I.V. fluid can cause fluid volume excess. To prevent this from occurring, I.V. tubing with a volume-control chamber should always be used for infants and children to closely regulate the amount of fluid infused. The volume-control chamber should be filled only with enough I.V. fluid for the next two 2 hours. A microdrip chamber that allows for 60 drops/ml (as opposed to a macrodrip chamber, which allows for 10 to 20 drops/ml, depending on the manufacturer) should be used to infuse the smaller amounts of I.V. fluids an infant needs. A filter is typically used only for the administration of total parenteral nutrition and certain blood products. Standard I.V. tubing for adults should be avoided for infants because of the inability to closely regulate the amount of fluid infused.
28. A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation? Measles Explanation: Measles warrants airborne isolation, which aims to prevent transmission of disease by airborne nuclei droplets. Other infections necessitating respiratory isolation include varicella and tuberculosis. The mumps call for droplet isolation; impetigo, contact isolation; and cholera, enteric isolation.

29. The nurse observes a family member of a client who is on contact precautions enter and exit the client's room without performing hand hygiene. What is the nurse's most appropriate action? Offer to show family members how to perform hand hygiene using soap and water or alcohol rub. Explanation: The nurse should address the family member's oversight and promote infection control, but in a way that is nonconfrontational. Offering to show the family members how to perform hand hygiene achieves these goals. Moving signage may not result in a behavior change. Speaking about hospital-acquired infections may not result in improved hand hygiene.
30. A healthy client comes to the clinic for a routine examination. When auscultating his lower lung lobes, the nurse should expect to hear which type of breath sound? Vesicular Explanation: Vesicular breath sounds are soft, low-pitched sounds normally heard over the lower lobes of the lung. They're prolonged on inhalation and shortened on exhalation. Bronchial breath sounds are loud, high- pitched sounds normally heard next to the trachea; discontinuous, they're loudest during expiration. Tracheal breath sounds are harsh, discontinuous sounds heard over the trachea during inhalation or exhalation. Bronchovesicular breath sounds are medium-pitched, continuous sounds that occur during inhalation or exhalation. They're best heard over the upper third of the sternum and between the scapulae.
31. The nurse advises a client recovering from a myocardial infarction to decrease fat and sodium intake. Which foods should the nurse instruct the client to avoid? Select all that apply. -Pepperoni pizza -Bacon

-Cheese -Soft drinks Explanation: Foods high in sodium include cheese, processed meats such as pepperoni and bacon, and soft drinks. Bacon and cheese also have a high fat content.

32. During the evening shift on the day of a client's bowel resection surgery, the nasogastric (NG) tube drains 500 mL of green-brown fluid. The nurse should: record the amount of drainage on the client's chart. Explanation: Because peristalsis has not been reestablished, this amount of gastric drainage would be expected. The green-brown color would also be expected. The appropriate nursing action is to chart the amount and color of output and continue monitoring the client. There is no need to notify the health care provider or to provide additional IV fluids. A patent NG tube does not require irrigation.
33. The nurse is instructing a client about skin care while receiving radiation therapy to the chest. What should the nurse instruct the client to do? Wash the area with tepid water and mild soap. Explanation:

Clients receiving radiation experience dryness or redness in the area of the radiation. The nurse instructs the client to wash the area with soap and water and keep the area dry. The client does not apply lotion, shave, or cover the area.

34. Which night clothes would the nurse recommend for an infant with atopic dermatitis? one-piece cotton pajamas with long sleeves Explanation: Atopic dermatitis results in pruritus. The infant's skin should be covered as completely as possible to keep him from scratching himself. Cotton is the preferred material because it allows the skin to breathe and moisture to evaporate.A short-sleeved shirt would be inappropriate because the infant could scratch the uncovered arms, exacerbating the condition. Flannel may be too warm, causing the child to perspire, which will aggravate the condition. Because atopic dermatitis is commonly associated with allergies, wool garments should be avoided.
35. A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse. The client's morning ammonia level is 110 mcg/dl. The nurse should suspect which situation? The client's hepatic function is decreasing. Explanation: The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings are not indicative of reduced renal filtration.

36. A client who is very depressed exhibits psychomotor retardation, a flat affect, and apathy. The nurse observes the client to be in need of grooming and hygiene. Which nursing action is most appropriate? stating to the client that it is time for him to take a shower Explanation: The client with depression is preoccupied, has decreased energy, and cannot make decisions, even simple ones. Therefore, the nurse presents the situation, "It is time for a shower," and assists the client with personal hygiene to preserve his dignity and self-esteem. Explaining the importance of good hygiene to the client is inappropriate because the client may know the benefits of hygiene but is too fatigued and preoccupied to pay attention to self-care. Asking the client if he is ready for a shower is not helpful because the client with depression commonly cannot make even simple decisions. This action also reinforces the client's feeling about not caring about showering. Waiting for the family to visit to help with the client's hygiene is inappropriate and irresponsible on the part of the nurse. The nurse is responsible for making basic decisions for the client until the client can make decisions for himself.
37. A client with type 1 diabetes mellitus is conscious but confused, weak, diaphoretic, and is having heart palpitations. What is the nurse's priority action? Provide 15 to 20 grams of a fast-acting oral carbohydrate Explanation: The client is exhibiting signs of hypoglycemia. Since the client is conscious, the first intervention is to give a fast-acting oral carbohydrate, such as orange juice, hard candy, or honey. If the client becomes unconscious, the nurse would administer IM or subQ glucagon or dextrose 50% IV if access is available. Administering insulin wouldn't be appropriate because the client is experiencing hypoglycemia.
38. A client tells the nurse about having numbness from the back of the left buttock to the dorsum of the foot and big toe. The client is scheduled to undergo a laminectomy, and the operative consent form states "a left lumbar laminectomy of L3-L4." What should the nurse do next?

Call the surgeon. Explanation: Based on the client's comments, the nurse should call the surgeon to verify the location of the surgery. The client's comments indicate radiculopathy of L4-L5, but the informed consent form states L3-L4. Radiculopathy of L3-L4 involves pain radiating from the back to the buttocks to the posterior thigh to the inner calf. The nurse must act as a client advocate and not ask the client to sign the consent until the correct procedure is identified and confirmed on the consent. The nurse has no legal authority or responsibility to change the consent. The history is a source of information, but when the client is coherent and the history is contradictory, the health care provider (HCP) should be contacted to clarify the situation. Ultimately, it is the surgeon's responsibility to identify the site of surgery specified on the surgical consent form.

39. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status? Weighing the client daily at the same time each day Explanation: Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.
40. A client at 28 weeks gestation is admitted to the maternity unit in preterm labor. The client asks the nurse if there is anything that can be done to stop the preterm labor. Which one of the following is the most appropriate response from the nurse? "A cerclage may be performed depending on the competency of your cervix."

Explanation: A cerclage is a surgical procedure where a stitch is placed by the physician in the cervix to prevent a spontaneous abortion or premature birth. The physician would have to determine the competency of the cervix, cervical dilation, and placement of the amniotic sac to determine whether the procedure is an option to stop progression of the birth. This is a potential option for the family. A 28-week fetus is considered viable and responding about confirming the viability of the fetus is not therapeutic at this time. Coordinating other family members to come into the hospital for support is an important response, but not the first response from the nurse.