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NCLEX Practice Questions for Nursing Students, Exams of Nursing

A collection of nclex-style practice questions designed to test nursing knowledge and critical thinking skills. The questions cover a range of nursing topics, including patient care, medication administration, and ethical considerations. Each question is followed by a detailed explanation of the correct answer, providing valuable insights into the rationale behind the chosen response. This resource is ideal for nursing students preparing for the nclex-rn or nclex-pn exams.

Typology: Exams

2024/2025

Available from 01/10/2025

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NCSBN NCLEX QUESTIONS WITH 100% CORRECT

SOLUTIONS 2025 UPDATED GRADED A+

A LPN complains to the charge nurse that an unlicensed assistive person (UAP) consistently leaves the work area untidy and does not restock supplies. What is the best initial response by the charge nurse? 1Write down potential solutions to the problems today by shift's end 2Add this concern to the agenda of the next unit meeting 3Assure the staff nurse that the complaint will be investigated 4Explore for further identification about the nature of the problem - Solution 4 Explore for further identification about the nature of the problem The nurse assists with the reinforcement of information about breast self- examination to a group of college students. A female student asks when to perform the monthly exam. The appropriate reply by the nurse should include which statement? 1"Ovulation, or midcycle is the best time to detect changes." 2"Do the exam at the same time every month." 3"Right after the period, when your breasts are less tender." 4"The first of every month, because it will be easiest to remember." - Solution 3 The nurse is caring for a 75 year-old client with type 2 diabetes mellitus. The client should be instructed to contact the outpatient clinic immediately if which findings are present? 1An open wound on the heel with minimal discomfort 2Occasional hiccups and sneezing 3Sustained insomnia and daytime fatigue 4Persistent dryness and itching of the perineal area - Solution 1An open wound on the heel with minimal discomfort- A pregnant woman has been advised to alter her diet during pregnancy by increasing the intake of protein and vitamin C to meet the needs of the growing fetus. Which diet choice would best meet the woman's needs?

  1. 1 cup of macaroni, three-fourths cup of peas, glass whole milk, medium pear
  2. Scrambled egg, hash browned potatoes, one-half glass of buttermilk, large nectarine
  1. 3 oz. chicken, one-half cup of corn, lettuce salad, small banana
  2. Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries - Solution 4. Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries - A nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness should the nurse recognize as being associated with an increased the risk for the development of Reye's syndrome?
  3. Varicella
  4. Meningitis
  5. Hepatitis
  6. Rubeola - Solution 1. Varicella - A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The nurse comments to a colleague: "I wonder if he has any idea how ridiculous he looks - he's a grown man!" The nurse's comment is an example of what type of attitude?
  7. Prejudice
  8. Ethnocentrism
  9. Discrimination
  10. Stereotyping - Solution 1. Prejudice- A nursing student asks the licensed practical nurse (LPN) to explain the forces that drive health care reform. When responding to the student's question, what information should the nurse emphasize?
  11. Increased competition between health care insurers
  12. Increase in health care spending that's growing faster than the economy
  13. Increase in the population who have health insurance
  14. Increase in spending for end-of-life treatment - Solution 2 A child is admitted to the unit with the suspected diagnosis of pertussis (whooping cough). What is the priority nursing intervention for this child?
  15. Maintain hydration and encourage fluids
  16. Implement droplet precautions
  17. Monitor respiratory rate and oxygen saturation
  18. Anti- infective therapy - Solution 2 A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago.

Which finding at this time should be reported to the registered nurse (RN) charge nurse? 1Complaints for the feeling of pulling on the urinary catheter 2Light, pink to clear urine 3Occasional suprapubic cramping 4Minimal drainage into the urinary collection bag - Solution 4Minimal drainage into the urinary collection bag A nurse is caring for a woman two hours after a vaginal delivery. Documentation indicates that the membranes ruptured 36 hours prior to delivery. Which of these nursing diagnoses should the nurse expect the charge nurse to list as a priority at this time? 1Risk for fluid volume deficit 2Risk for excessive bleeding 3Risk for infection - 4Altered tissue perfusion - Solution 3 A 14 month-old child ingests a half a bottle of baby aspirin (81 mg) tablets. Which finding should a nurse expect to see in the child? 1Hypothermia 2Nausea and vomiting 3Hypoventilation 4Bradycardia - Solution 2 A school nurse monitors a child with a history of tonic-clonic seizures. The school nurse should inform teachers that if the child falls to the floor and experiences a seizure while in the classroom, which of the following would be the most important action to take during the seizure? 1Place the hands or a folded blanket under the head of the child 2Provide privacy as much as possible to minimize frightening the other children 3Move any chairs or desks at least three feet away from the child 4Note the sequence of movements with the time lapse of the event - Solution 1Place the hands or a folded blanket under the head of the child - A client is admitted with diagnosis of a right upper lobe infiltrate and to rule out active tuberculosis (TB). Which type of precautions will be needed for this client? 1Droplet 2Contact

3Standard 4Airborne - Solution 4 A client has had a positive reaction to purified protein derivative (PPD). Which statement made by the client suggests the client understands the teaching by the registered nurse (RN)? 1"I have active tuberculosis." 2"I have been exposed to mycobacterium tuberculosis." 3"I have never been infected with mycobacterium tuberculosis." 4"I have never had tuberculosis." - Solution 2 A nurse is caring for a client with pneumococcal pneumonia. Which breath sounds would the nurse expect to disappear as the client responds to the antibiotic treatment? 1Wheezes 2Friction rubs 3Rhonchi 4Diminished sounds - Solution 3 A young adult seeks treatment in an outpatient mental health center. The client tells a nurse, "I am a government official and spies are following me." Upon further questioning, the client reveals that warnings must be heeded to prevent nuclear war. What is the initial therapeutic approach that the nurse should use? 1Listen quietly without comment 2Ask for further information on the spies 3Confront the client about the delusions 4Contact security for potential safety concerns - Solution 1Listen quietly without comment - Lactulose has been prescribed for a client with advanced liver disease. Which finding should the nurse use to evaluate the effectiveness of this treatment? 1Less jaundice 2Increased appetite 3Decreased lethargy 4Less edema - Solution 3

The LPN is unsure about an assignment by the charge nurse to hang an intravenous (IV) infusion that contains potassium. What resource should the LPN check first to determine if LPNs can administer IV medications? 1Employer policy and procedures manuals 2Nursing faculty from a local nursing program 3The nurse practice act of the state in which the practice takes place 4American Nurses Association (ANA) professional standards - Solution 3 The nurse is assisting with the delivery of a newborn infant. What is the priority nursing intervention for a normal newborn immediately after delivery? 1Dry off infant with a warm blanket or towel 2Apply identification bracelets 3Assign the one-minute APGAR score 4Obtain vital signs - Solution 1Dry off infant with a warm blanket or towel - The registered nurse is teaching a childbirth education class about postpartum depression. Which statement, made by a class member, indicates that more teaching is needed? 1"I will make an effort to talk with someone about my feelings if I start to feel overwhelmed." 2"It's common for women with postpartum depression to have delusions about the infant." 3"Women with postpartum depression have feelings of guilt and worthlessness." 4"I may experience postpartum depression up to a year after delivery." - Solution 2 The nurse is reinforcing information about the side effects of fluoxetine to a client. Which group of findings should be included? 1Diarrhea, dry mouth, weight loss, reduced libido 2Tachycardia, blurred vision, hypotension, anorexia 3Orthostatic hypotension, vertigo, reactions to tyramine, nausea 4Photosensitivity, seizures, edema, hyperglycemia - Solution 1Diarrhea, dry mouth, weight loss, reduced libido A client has a diagnosis of heart failure. Which intervention is most important for the nurse to implement prior to the administration of digoxin? 1Use the pulse reading from the electronic blood pressure device 2Take a radial pulse, counting for a full 60 seconds

3Check for a pulse deficit at least twice with another nurse 4Assess the apical pulse, counting for a full 60 seconds - Solution 4Assess the apical pulse, counting for a full 60 seconds - A client diagnosed with bipolar disorder refuses to take the prescribed medication. Which is the most therapeutic response by a nurse to the client's refusal of the medication? 1"You need to take your medicine. This is how you get better." 2"What is it about the medicine that you don't like?" 3"I can see that you are uncomfortable right now; let's talk about it tomorrow." 4"If you refuse your medicine, tell me how do you think you will get better?"

  • Solution 2 A parent expresses frustration and anger about the toddler constantly saying "no" and refusing to follow directions. The nurse should help the parent understand that this behavior meets which developmental need? 1Self-esteem 2Initiative 3Independence 4Trust - Solution 3 The LPN is assisting the RN to provide care for a client diagnosed with a traumatic brain injury. Using the Glasgow Coma Scale, when the client does not obey verbal commands to move, which technique will the RN use to evaluate motor function? 1Squeeze the trapezius muscle firmly 2Lift the client's arm and observe for pronation and drift 3Apply finger tip pressure for 10 seconds 4Rub the sternum with the knuckles - Solution 1Squeeze the trapezius muscle firmly - A newborn has hyperbilirubinemia and is being treated with a biliblanket. Which intervention is indicated during this therapy? 1Discontinue breastfeeding during treatment 2Rotate the neonate to treat all of his/her skin 3Restrict holding the newborn during treatment 4Provide more frequent feedings - Solution 4Provide more frequent feedings-

A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts, "You think you're so perfect, pure and good." How should the nurse respond? 1"You seem to be in a bad mood." 2"Perfect? I don't quite understand." 3"You sound angry right now." 4"That explains why you've been staring at me." - Solution 3 The client with coronary artery disease has a prescription for nitroglycerin transdermal patches. What is the best reason the client should not wear a patch for more than 12 to 14 hours each day? 1It can cause severe headaches 2It may no longer work as well 3It will cause profound hypotensive effects 4it will irritate the skin - Solution 2 A hospitalized infant is receiving gentamicin. Which nursing intervention should receive priority in the plan of care? 1Compare daily infant weights 2Monitor the infant's urine output 3Ensure appropriate fluid intake 4Maintain accurate intake and output - Solution 2 A newborn is diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize which point? 1They can expect the child will be mentally retarded 2Administration of a thyroid hormone will prevent problems 3This rare condition is hereditary 4Physical growth and development will be delayed - Solution 2 A child is admitted to the hospital for emergency surgery. The child's parent reports several allergies. Which of these allergies should all the operative health care personnel be notified about? 1Perfumed soap 2Shellfish 3Balloons 4Mold - Solution 3 A practical nurse (PN) team member identifies that the fundus is boggy for a woman who is gravida 4 para 4 and is two hours after a spontaneous

vaginal delivery. The fundus is displaced slightly above and to the right of the umbilicus. What should be the initial nursing action? 1Assist the woman to empty her bladder 2Monitor the pulse and blood pressure 3Call the registered nurse (RN) immediately 4Check lochia for color and amount - Solution 1Assist the woman to empty her bladder - The nurse is planning the therapeutic milieu and the various activity groups for a client. What is the primary goal for the nurse to consider? 1Diminish destructive behavior through peer pressure 2Plan strict schedules with defined expectations 3Punish inappropriate behavior as it occurs 4Achieve a client's therapeutic goals - Solution 4Achieve a client's therapeutic goals - A client tells a nurse, "I have something very important to tell you if you promise not to tell anyone." Which statement by the nurse would be the most appropriate response? 1"That depends on what you tell me." 2"I must report everything to the treatment team." 3"All right, I promise." 4"I can't make such a promise." - Solution 4"I can't make such a promise."

A client is discharged with a prescription for warfarin. A nurse recognizes that additional teaching is needed if the client makes which incorrect comment? 1"I know I must avoid crowds." 2"I will report any bruises or bleeding." 3"I plan to use an electric razor for shaving." 4"I will keep all laboratory appointments." - Solution 1"I know I must avoid crowds." - The nurse discovers an unresponsive client and determines there is no pulse. This nurse then activates the code notification button to alert all personnel about the code and begins chest compressions. What is the function of the second nurse on the scene? 1Validate the client's advance directive

2Participate with the compressions or breathing as requested by the first nurse 3Bring the code cart - 4Relieve the first nurse on the scene and continue single person CPR - Solution 3 The nurse and client are discussing the client's progress toward understanding the client's behavioral responses to stressful events. This is typical of which phase in the therapeutic relationship? 1Termination 2Working - 3Orientation 4Pre-interaction - Solution 2 The nurse is collecting data on a group of clients in a long-term health care facility. Which client is at a highest risk for the development of pressure ulcers? 1Ambulatory client who had three incontinent diarrhea stools in the past 24 hours 2Ambulatory older adult diagnosed with type 2 diabetes for the past 20 years 3Obese client who uses a wheelchair throughout the facility 4Malnourished older adult client who is on bed rest - Solution 4 A client diagnosed with head trauma is in a non-responsive state. Vital signs are stable and breathing is regular and spontaneous. What should the nurse document to accurately describe the client's status? 1Glasgow Coma Scale 13, no ventilator required 2Glasgow Coma Scale 8, respirations regular - 3Appears to be sleeping, vital signs stable 4Comatose, breathing unlabored; is resting - Solution 2 A client with heart failure is newly referred to a home health care agency. The nurse determines that the client has not been following the prescribed diet. It would be most appropriate for the nurse to take which action at this time? 1Notify the health care provider of the client's failure to follow the prescribed diet 2Make a referral to Meal-on-Wheels for delivery of one meal three times a week

3Discuss the diet with the client to learn the reasons for not following the diet - 4Recommend a release from home health care related to noncompliance - Solution 3 A client has chronic renal failure and is being treated at home. During weekly home visits, which factor is the most accurate indicator of fluid balance? 1Trends in daily weights - 2Skin turgor over at least two areas of the body 3Changes in mucous membrane moistness 4Difference between intake and output - Solution 1Trends in daily weights

The client is receiving a thrombolytic agent to open a clot-occluded coronary artery following a myocardial infarction. Which finding would be the greatest concern and should be immediately reported to the registered nurse? 1Hematemesis - 2Pink-tinged saliva 3Serosanguinous drainage from the IV site 4Slight rust-colored urine - Solution 1Hematemesis - The nurse is caring for a postoperative client following a closed reduction of distal tibia and mid-femur fractures. The client has a long leg plaster cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 F (39.4 C). What should be the first action by the nurse? 1Check the distal circulation of the casted extremity 2Obtain the pulse oximetry reading 3Measure the client's blood pressure in the supine and Fowler's positions 4Check the orientation to time, place and person - Solution 2 The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is the priority action by the nurse to accurately assess correct placement of the G-tube? 1Listen for active bowel sounds in all four quadrants 2Measure the pH of stomach content aspirate 3Auscultate the abdomen while instilling 10 mL of air into the G-tube

4Measure the length of tubing from the insertion site each shift - Solution 1Listen for active bowel sounds in all four quadrants 2Measure the pH of stomach content aspirate - 3Auscultate the abdomen while instilling 10 mL of air int1Listen for active bowel sounds in all four quadrants 2Measure the pH of stomach content aspirate - 3Auscultate the abdomen while instilling 10 mL of air into the G-tube 4Measure the length of tubing from the insertion site each shifto the G-tube 4Measure the length of tubing from the insertion site each shift The client is diagnosed with infective endocarditis of the tricuspid valve. Which finding suggests a complication of this condition? 1Pronounced wheezes 2Pain on deep inspiration 3Sudden back pain 4Sudden dyspnea - Solution 4 A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). What should the nurse understand about the purpose of this procedure? 1The surgical repair of a diseased coronary artery 2An noninvasive radiographic examination of the heart 3A process to compress arterial plaque to improve blood flow 4The placement of an automatic internal cardiac defibrillator - Solution 3 A 2 day-old infant born with spina bifida and meningomyocele is recovering after an initial surgery. As the nurse accompanies the grandparents for their first visit since the child's birth, which of these responses might the nurse expect from the grandparents? 1Anger 2Disbelief 3Depression 4Frustration - Solution 2 The ICU nurse works in a rural hospital that has a remote electronic ICU monitoring system (eICU.) What is one of the best reasons for having access to an eICU? 1An ICU nurse and intensivist remotely monitor ICU clients around the clock 2An ICU nurse is on-call to solution questions when needed

3Clients can ask the intensivist for a second opinion 4Less staff is needed on site when a remote eICU is available - Solution 1 A child has severe burns to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse should care for this client with the knowledge that the most important reason for such a diet is to achieve which result? 1Provide a well-balanced nutritional intake 2Promote healing and strengthen the immune system 3Spare protein catabolism to meet metabolic and healing needs 4 stimulate increased peristalsis and nutrient absorption - Solution 3 A nurse is reinforcing information about the administration of an albuterol inhaler to an adult diagnosed with asthma. What should be the priority comment made by the nurse? 1"Use this medication at bedtime to promote rest." 2"Notify the health care provider if your canister lasts only two weeks." 3"Inhale this medication after other asthma sprays." 4"Discontinue the inhaler if you are dizzy." - Solution 2 An 80 year-old client is hospitalized for a chronic condition. The client informs family members that a living will has been prepared and the client wants no life-prolonging measures performed. The client's condition deteriorates and the client becomes unresponsive. Which of the following nursing actions is most appropriate? 1Notify the attending physician 2Consult the charge nurse and prepare to transfer the client to an intensive care unit 3Call the rapid response team 4Contact the family member indicated in the admission forms - Solution 1 The nurse is caring for a client who has just been admitted to the inpatient mental health unit with severe depression. Which concern should be a priority of care? 1Safety 2Elimination 3Rest 4Nutrition - Solution 1

A nurse is discussing with a client the precautions with warfarin. The nurse should tell the client to avoid foods with excessive amounts of what substance? 1Iron 2Calcium 3Vitamin E 4Vitamin K - Solution 4 The nurse has established a therapeutic relationship with a client. Which observation would indicate that the nurse-client relationship has passed from the orienting phase to the working phase? 1The client revitalizes a relationship with the family to help in coping with a child's death 2The client recognizes feelings and expresses them appropriately 3The client expresses a desire to be mothered and pampered 4The client recognizes regression as a part of a defense mechanism - Solution 2 During the working phase, problems are identified and the client is able to focus on unpleasant feelings and express them appropriately. During the working phase, problems are identified and the client is able to focus on unpleasant feelings and express them appropriately. - Solution An advance health care directive is also known as a living will. It is a legal document in which a person specifies his or her wishes concerning medical treatments at the end-of-life, when s/he is unable to make those decisions. Advance care planning involves sharing personal values and wishes with loved ones and selecting someone, (called a medical power of attorney or health care proxy) who will eventually make medical decisions on the client's behalf A nurse is talking to a group of parents about how to reduce risks in the home. What is the most important factor for the nurse to consider during the discussion? 1Proximity to emergency services 2Number of children in the home 3Knowledge level of the parents 4Age of children in the home - Solution 4

When reviewing the medication lithium with a client, the client asks, "How long will it take before I can feel the effects of the medication?" Which response by the nurse is the best? 1"About two weeks" 2"One month" 3"Immediately" 4"Several days" - Solution 1 A client has completed a renal biopsy. Which nursing intervention is appropriate after a renal biopsy? 1Ambulate the client within four hours after procedure 2Change the dressing when it becomes saturated 3Monitor vital signs using post-op protocols 4Maintain client on NPO status for 24 hours - Solution 3 The nurse is caring for a client who is one-day postoperative with a T-tube following a cholecystectomy. What color would the nurse expect the drainage from the client's T-tube to be? 1Dark brown 2Green 3Yellowish-brown 4Orange - Solution 3 A newly admitted client reports taking phenytoin for several months. Which of the following assessments should the nurse be sure to include in the admission report? (Select all that apply.) - Solution Serious adverse outcomes of antiseizure medications such as phenytoin (Dilantin) are unsteady gait, slurred speech, extreme fatigue, blurred vision or feelings of suicide. Increased hunger (not anorexia), increased thirst or increased urination are additional serious side effects. The nurse is giving a morning bath to a client who has a colostomy. While giving the bath, the nurse should reinforce that the collection pouch should be emptied at what time? 1Prior to going to sleep at night 2After each fecal elimination 3At the same time each day 4When it is one-third to one-half full - Solution 4

A client is scheduled to have blood drawn for serum cholesterol and triglycerides tomorrow morning. What information should the nurse reinforce to the client about the test? 1"Be sure to eat a fat-free diet until the test, and drink lots of water." 2"Stay at the laboratory so that two blood samples can be drawn an hour apart." 3"Do not eat or drink anything but water for 12 hours before the blood test." 4"Have the blood drawn within two hours of eating breakfast." - Solution 3 The nurse is caring for a hospitalized adolescent. The nurse recognizes that which of these concerns will be the greatest for a hospitalized adolescent? 1Restricted physical activity 2Separation from family 3Altered body image 4Unrelieved pain - Solution 3 In checking a postpartum client, the nurse palpates a firm fundus. However, the nurse also observes a constant trickle of bright red blood from the vaginal opening. What should the nurse suspect? 1Retained placenta 2Clotting disorder 3Vaginal lacerations 4Uterine atony - Solution 3 A client diagnosed with gout is admitted with severe pain, swelling and redness in the proximal toe joint of the right foot. The nurse should anticipate that the plan of care would include which focus? 1High-protein diet 2Fluid intake of at least 3000 mL/day 3Acetaminophen for inflammation 4Hot compresses to affected joints - Solution 2 A 6 year-old child is hospitalized with findings of moderate edema, gross hematuria and mild hypertension associated with the diagnosis of acute glomerulonephritis (AGN). Which nursing intervention would be appropriate for this client? 1Weigh the child twice per shift 2Relieve boredom through physical activity 3Institute seizure precautions

4Encourage the child to eat protein-rich foods - Solution 3 A mother asks about expected motor skills for her 3 year-old child. Which activity should the nurse discuss as normal at this age? 1Riding a tricycle 2Tying shoelaces 3Jumping rope 4Playing hopscotch - Solution 1 The nurse is assessing a client who has been treated long-term with glucocorticoid therapy. Which finding might the nurse expect? 1Jaundice 2Peripheral edema 3Buffalo hump 4Increased muscle mass - Solution 3 A client diagnosed with autism begins to eat with both hands. The nurse can best handle the behavior by using which approach? 1Commenting "I believe you know better than to eat with your hands." 2Removing the food and stating "You can't have any more food until you use the spoon." 3Jokingly stating "Well, I guess fingers sometimes work better than spoons." 4Placing the spoon in the client's hand and stating "Use the spoon to eat your food." - Solution 4 The client is diagnosed with heart failure and oral digoxin is prescribed. What is the priority nursing assessment for this medication? 1Monitor serum electrolytes and creatinine 2Measure apical pulse prior to administration 3Maintain accurate intake and output ratios 4Monitor blood pressure every 4 hours - Solution 2 A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What should be the next action of the nurse? 1Arrange to change client-care assignments 2Discuss with the parent the appropriate use of "time-out" 3Explain to the mother that the child needs extra attention

4Explain to the parent that this behavior is expected - Solution 4 The mother of a hospitalized 2 year-old child asks a nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The best advice by the nurse would include which approach? 1Explain that this behavior will stop with in a few days 2Suggest that the mother "sneak out" of the child's room when the child is asleep 3Request for the mother to remain with the child at all times 4Help the mother understand that this is a normal response to hospitalization - Solution 4 A client has a percutaneous endoscopic gastrostomy (PEG) tube that is used to administer feedings and medications. Which nursing action is best to ensure patency of the tube? 1Encouraging the client to cough to relieve abdominal bloating prior to or following a feeding 2Adequately flushing the tube with water before and after use 3Completely crushing all medications prior to administration 4Squeezing the tube to dislodge obstructions - Solution 2 A nurse is observing an 8 month-old client. Which behavior would the nurse anticipate the infant to be able to display? 1Pull up to stand 2Use a spoon 3Say two words 4Sit without support - Solution 4 A client is admitted with newly diagnosed hypothyroidism. A nurse would expect the client to exhibit which finding until the client achieves a euthyroid state with therapy? 1Heat intolerance 2Diarrhea 3Tachycardia 4Lethargy - Solution 4 The licensed practical nurse is caring for a client with advanced cirrhosis of the liver. Which finding should receive immediate follow-up by the charge nurse? 1Jaundice

2Anorexia 3Hematemesis 4Ascites - Solution 3 A nurse discusses the healthy use of both conscious and unconscious defense mechanisms with a group of clients. An appropriate goal for these clients would be to use these mechanisms for which purpose? 1Foster independence with better communication 2Protect the ego and diminish anxiety 3Eliminate anxiety and apprehension 4Avoid conflict and unpleasant consequences - Solution 2 A 3 year-old child is brought to the health clinic. The grandmother reports that the child is always "scratching his bottom" and is "extremely irritable." Based on this information, which health issue would the nurse assess for initially? 1Pinworm 2Scabies 3Ringworm 4Allergies - Solution 1 The nurse is caring for a client diagnosed with acute angina. The client reports substernal chest pain, diaphoresis and nausea. What should be the first action by the nurse? 1Administer PRN pain medication as ordered 2Determine the origin of the pain 3Draw blood for for troponin/CK and CBC per standing orders 4Order ECG per standing orders - Solution 1 The client is diagnosed with Parkinson's disease (PD) and takes more than one hour to dress for scheduled therapies. Based on this finding, what is the most appropriate nursing intervention? 1Allow the client the time needed to dress 2Encourage the client to dress more quickly 3Ask family members to dress the client 4Demonstrate methods on how to dress more quickly - Solution 1 A pregnant client asks the nurse about the scheduled blood test for alpha- fetoprotein (AFP). The nurse's explanation should include which of these comments?

1"It tells us how far along your pregnancy is." 2"It can help identify potential neurological defects." 3"The results help determine if the baby is growing normally." 4"The placental exchange of oxygen is measured." - Solution 2 A client is diagnosed with a severe mental illness. What is the priority goal of involuntary hospitalization? 1Protection from harm to self and others 2Return to independent functioning 3Elimination of negative findings 4Reorientation to reality - Solution 1 A pregnant woman in the third trimester reports having severe heartburn. What action should a nurse remind the client to take? 1Drink small amounts of liquids frequently 2Eat the evening meal within two hours of going to sleep 3Sleep with head propped on several pillows 4Take a proton pump inhibitor either before or after eating - Solution 3 A practical nurse (PN) is observing an 8 month-old infant in the clinic waiting room. Which activity should be reported to the registered nurse (RN)? 1Lifts head from the prone position 2Rolls from abdomen to back 3Falls forward when sitting 4Responds to parents' voices - Solution 3 A nurse is monitoring the client's initial postoperative condition after a total thyroidectomy. Which findings should the nurse expect as complications and report immediately to the registered nurse (RN)? 1Paresthesia and muscle cramping 2Mild dysphagia and hoarseness 3Headache and nausea 4Irritability and insomnia - Solution 1 An 18 year-old client is admitted to intensive care from the emergency department after a diving accident. The injury to the spinal cord is suspected to be at the level of the second cervical vertebrae (C-2). When collecting data, which issue should be the priority focus? 1Muscle weakness

2Respiratory function 3Bladder control 4Peripheral sensation - Solution 2 There's a new order to apply one-inch of nitroglycerin paste to the client's chest every 12 hours, but the medication is not in the automatic medication dispensing system's drawer for this client. What should the nurse do next? 1Use another client's nitroglycerin paste until pharmacy sends a tube for this client 2Substitute an equivalent amount of nitroglycerin sublingual spray from the crash cart 3Call the pharmacy to send up a tube of nitroglycerin paste 4Call the prescriber and ask to substitute a different formulation of nitroglycerin - Solution 3 A nurse is caring for a child being discharged after a tonsillectomy. Which instruction is appropriate for the nurse to reinforce with the parents? 1Report a persistent cough to the health care provider 2The child can return to school in four days 3Administer chewable medication for pain 4The child may gargle as necessary for discomfort - Solution 1 An 80 year-old client is scheduled for a cardioversion. The nurse is reviewing the client's medication administration records for the previous 24 hours. Which medication would prompt the nurse to notify the health care provider? 1Diltiazem (Cardizem) 2Digoxin (Lanoxin) 3Nitroglycerine ointment 4Metoprolol tartrate (Toprol XL) - Solution 2 A nurse has reinforced teaching for a client who is being discharged after an arterial revascularization of the right lower extremity. Which statement made by the client is incorrect and requires further discussion with the nurse? 1"Smoking will decrease the circulation to my leg" 2"Coughing and deep breathing are important for a few weeks." 3"I will put my right leg through a full range of motion." 4"I might feel a throbbing pain in my right leg." - Solution 3

The nurse is assisting in the application of a plaster cast for a client with a broken arm. Which action is a priority? 1The cast material should be dipped several times into warm water 2The cast should be uncovered until it dries 3The casted extremity should be placed on a supporting surface 4The wet cast should be handled with the palms of hands for 48 to 72 hours - Solution 4 The client undergoes a gastrectomy. Several hours after surgery, the nasogastric (NG) tube stops draining. What action does the LPN anticipate the RN will take first? 1Reposition the tube 2Increase the amount of suction 3Gently irrigate the tube with sterile normal saline 4Notify the surgeon - Solution 3 A 12 year-old child, admitted with a broken arm, is waiting for a scheduled surgery. The nurse finds the child crying and unwilling to talk. What would be the most appropriate initial response by the nurse? 1Reassure the child that the surgery will go fine with no problems 2Provide privacy with encouragement to work through feelings 3Distract the child with a choice of activities to do while waiting for surgery 4Make arrangements for friends to visit as soon as possible - Solution 2 A nurse is caring for a client with a sigmoid colostomy. The client requests assistance in removing the flatus from a one-piece drainable ostomy pouch. Which intervention should the nurse use? 1Pierce the plastic at the top of the ostomy pouch with a pin to vent the flatus 2Pull the adhesive seal around the ostomy pouch to allow the flatus to escape 3Open the bottom of the pouch to allow the flatus to be expelled 4Assist the client to ambulate to reduce the flatus in the pouch - Solution 3 A client returns from the operating room after a right orchiectomy. What is the priority nursing intervention during the immediate postoperative period? 1Manage postoperative pain 2Maintain fluid and electrolyte balance 3Control bladder spasms with PRN medication 4Ambulate the client within a few hours after surgery - Solution 1

The nurse enters the room of a postpartum mother and observes the baby lying at the edge of the bed while the mother sits in a chair. The mother states, "This is not my baby, and I do not want it." How should the nurse respond? 1"What a beautiful baby! The baby's eyes are just like yours." 2"This is a common occurrence after birth. Let's talk about how to accept the baby." 3"You seem upset, tell me about how you are feeling"? 4"Many women have postpartum blues and need some time to love the baby." - Solution 3 The client calls the clinic nurse and reports nausea, headache and fatigue. The client also reports seeing yellow halos around lights. What is the best response by the nurse? 1"Do your eyes appear bloodshot and is there any itching?" 2"Tell me about your prescription for digoxin. Are you still taking the medication?" 3"Call back in a week and schedule an appointment if your symptoms don't improve." 4"Is there anyone else at home who has the same symptoms?" - Solution 2 A client is admitted to the mental health inpatient unit with a diagnosis of major depression after a suicide attempt. In addition to expressions of sadness and hopelessness, the nurse anticipates observing which characteristics? 1Meticulous attention to hygiene, grooming 2Anxiety, hostility 3Psychomotor retardation, agitation 4Guilt, indecisiveness - Solution 3 A nurse is assigned to care for a 10 month-old infant with the new diagnosis of anemia. Which of these findings should the nurse anticipate? 1Behavior consistent with hyperactivity 2Slow heart rate when sleeping 3Pale mucosa inside the mouth 4High hemoglobin level - Solution 3

The nurse is assisting a withdrawn client to begin to develop relationship skills. Which nursing intervention should be most effective? 1Assist the client to analyze the meaning of behaviors 2Remind the client frequently to interact with other clients 3Offer the client frequent opportunities to interact with the nurse 4Initiate client interactions with one or two other clients - Solution 3 A female client admitted for a breast biopsy says tearfully to a nurse, "If this turns out to be cancer and I have to have my breast removed, my partner will never come near me." What would be the most appropriate response to this statement? 1"Are you questioning the depth of your relationship?" 2"Why are you concerned that you will be rejected?" 3"You sound worried that the surgery might change your relationship with your partner." 4"I'm sure your companion will understand." - Solution 3 The client is diagnosed with asthma. What information should the nurse reinforce that the client should monitor on a daily basis? 1Peak air flow volume 2Respiratory rate 3Pulse oximetry 4Skin color - Solution 1 The client underwent a total hip arthroplasty 48 hours ago. The client has been up in a chair and is prescribed physical therapy twice daily. What type of nursing care is needed for this client? (Select all that apply.) - Solution Two days after surgery, the client will be walking in the hallway. When in bed, the client should continue to perform leg exercises and use a pillow or foam wedge between his or her legs (to keep the legs abducted.) The drain is usually removed the second day after surgery; there should be little-to-no drainage on the second post-op day. A nurse is providing home care for a client diagnosed with chronic heart failure and episodes of pulmonary edema. Which nursing diagnosis should the nurse expect as a priority in the plan of care? 1Activity intolerance related to an imbalance of oxygen supply and demand 2Imbalanced nutrition related to poor appetite 3Risk for impaired skin integrity related to dependent edema 4Constipation related to reduced activity level - Solution 1

The nurse has been reinforcing information about cardiac risks to adult clients when they visit the hypertension clinic. What would be the best way to determine if learning has occurred? 1Performance on written tests 2Completion of a mailed survey 3Responses to verbal questions 4Reported behavioral changes - Solution 4 The client undergoes a laparoscopic removal of the appendix. Which postoperative instructions will the nurse reinforce? (Select all that apply.) - Solution may cause shoulder discomfort postoperatively. Clients should keep the dressings clean and dry for 48 hours before they can shower, but no tub baths for a few weeks. If "skin glue" is used over the incision(s), the client should not try to scrub it off because it will wear off on its own. Clients may resume normal activities as soon as they are able but no heavy lifting or aerobic exercise for about 2 weeks. If they do not have a BM after 2-3 days, clients can take 2 tablespoons of MOM several times a day until they have a BM. Diet can be advanced as tolerated but it's best to stick to non- greasy, non-spicy foods for a few days. The nurse is caring for a postoperative client. What is the priority nursing intervention the nurse will reinforce for preventing atelectasis? 1Turn, cough and breathe deeply 2Ambulate client within 12 hours 3Maintain adequate hydration 4Splint incision when moving or coughing - Solution 1 A nurse is working with parents to plan home care for a toddler with a heart problem. What should be the priority nursing intervention on the plan of care? 1Assist the parents to plan quiet play activities with the toddler at home 2Stress to the parents that they will need relief care givers 3Instruct the parents for them and the toddler to avoid contact with persons with infection 4Encourage the parents to enroll in child cardiopulmonary resuscitation (CPR) class - Solution 4

A client becomes acutely short of breath with an SpO2 (oxygen saturation) of 82%. Which oxygen delivery system should the nurse apply that would provide the highest concentrations of oxygen to the client? 1Simple face mask 2Partial rebreather mask 3Venturi mask 4Non-rebreather mask - Solution 4 A nurse gathers data related to delayed gross motor development in a 3 year-old client. Which observation by the nurse should confirm this finding? 1Cannot ride a bicycle 2Cannot catch a ball 3Cannot skip on alternate feet 4Cannot stand on one foot - Solution 4 A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes lost when outside of the home. Which statement would provide the best reality orientation for this client? 1"Hello. My name is Elaine Jones and I am your nurse for today." 2"Good morning. You're in the hospital. I am your nurse Elaine Jones." 3"How are you today? Remember, you're in the hospital. I will be your nurse all day. My name is Elaine Jones." 4"Good morning. I am Elaine Jones, your nurse. Do you remember where you are?" - Solution 2 A client is diagnosed with a Salmonella infection. What is a primary nursing intervention to be taken to minimize the transmission of disease from this client? 1Double glove when in contact with feces or emesis 2Wash hands thoroughly before and after any client contact 3Wear gloves when disposing of contaminated linens 4Use gloves when in contact with body secretions - Solution 2 A 6 month-old infant is being treated for developmental hip dysplasia and has been placed in a hip spica plaster cast. Which discharge information is important for the nurse to reinforce with the parents? 1Turn the baby every two hours using the abduction stabilizer bar 2Check frequently for swelling in the baby's feet 3Gently rub the skin with a cotton swab to relieve itching