Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detail, Exams of Nursing

Download Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detail and more Exams Nursing in PDF only on Docsity! Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 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? 1. Varicella 2. Meningitis 3. Hepatitis 4. Rubeola - CORRECT ANSWERS 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? 1. Prejudice 2. Ethnocentrism 3. Discrimination 4. Stereotyping - CORRECT ANSWERS 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? 1. Increased competition between health care insurers 2. Increase in health care spending that's growing faster than the economy 3. Increase in the population who have health insurance 4. Increase in spending for end-of-life treatment - CORRECT ANSWERS 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? 1. Maintain hydration and encourage fluids 2. Implement droplet precautions 3. Monitor respiratory rate and oxygen saturation 4. Anti- infective therapy - CORRECT ANSWERS 2 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 1Place the hands or a folded blanket under the head of the child - Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 4Contact security for potential safety concerns - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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." - CORRECT ANSWERS 2 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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?" - CORRECT ANSWERS 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 - CORRECT ANSWERS 3 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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." - CORRECT ANSWERS 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 - CORRECT ANSWERS 2 A hospitalized infant is receiving gentamicin. Which nursing intervention should receive priority in the plan of care? Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 1Trends in daily weights - Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 answer questions when needed 3Clients can ask the intensivist for a second opinion 4Less staff is needed on site when a remote eICU is available - CORRECT ANSWERS 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? Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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.) - CORRECT ANSWERS 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 - CORRECT ANSWERS 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." Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 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." - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 3 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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." - CORRECT ANSWERS 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 - CORRECT ANSWERS 2 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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." - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 4Take a proton pump inhibitor either before or after eating - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 4Call the prescriber and ask to substitute a different formulation of nitroglycerin - CORRECT ANSWERS 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 - CORRECT ANSWERS 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) - CORRECT ANSWERS 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." - CORRECT ANSWERS 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 - CORRECT ANSWERS 4 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 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 - CORRECT ANSWERS 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." - CORRECT ANSWERS 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 - CORRECT ANSWERS 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.) - CORRECT ANSWERS 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 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 3Risk for impaired skin integrity related to dependent edema 4Constipation related to reduced activity level - CORRECT ANSWERS 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 - CORRECT ANSWERS 4 The client undergoes a laparoscopic removal of the appendix. Which postoperative instructions will the nurse reinforce? (Select all that apply.) - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 4 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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?" - CORRECT ANSWERS 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 - CORRECT ANSWERS 2 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 1Makes simple association of ideas 2Bases conclusions on abstract thinking I3nterprets events from own perspective 4Thinks logically to organize facts - CORRECT ANSWERS 4 The nurse calls for help after finding an unresponsive adult client in a hospital room. What action should the nurse take next for the client who has no pulse and is not breathing? 1Open the airway and deliver two breaths followed by 30 compressions 2Provide continuous chest compressions until someone comes with the crash cart 3Provide a cycle of 30 compressions followed by two breaths 4Provide 15 compressions and then pause while someone delivers one "breath" using an ambu bag - CORRECT ANSWERS 3 A nurse is discussing with a group of parents when they can begin teaching their preschool children about injury prevention. Which approach should the nurse reinforce? 1Discuss the consequences of not wearing protective devices 2Protect their preschooler from outside influences 3Set good examples themselves through their actions 4Make sure their preschooler understands all the safety rules - CORRECT ANSWERS 3 The nurse is caring for a postmature infant in the newborn nursery. What factor should the nurse recognize as being the primary reason associated with complications of being post-term? 1Depletion of subcutaneous fat 2Progressive placental insufficiency 3Excessive fetal weight 4Low blood sugar levels - CORRECT ANSWERS 2 The registered nurse (RN) has initiated the administration of an intravenous vesicant chemotherapeutic agent to a client. Which finding during the care by a practical nurse (PN) would require the PN to immediately notify the RN? 1A rash on the client's extremities 2Complaints of pain at the infusion site Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 3Stomatitis lesions in the mouth 4Severe nausea and vomiting - CORRECT ANSWERS 2 A client with testicular cancer has had a unilateral orchiectomy. Prior to discharge the client expresses his fears related to the prognosis. Which statement should be the initial response by a nurse? 1"Self-examination needs to be continued in order to prevent and detect recurrences." 2"Chemotherapy is most likely to be started right away." 3"Adoption may be a consideration if you want children." 4"Testicular cancer has a very high cure rate with early diagnosis and treatment." - CORRECT ANSWERS 4 A nurse is caring for a child who has been recently diagnosed with cystic fibrosis. Which finding should the nurse anticipate? 1Dry, nonproductive cough 2Poor appetite 3Frequent urinary infections 4Ribbon-like stools - CORRECT ANSWERS 1 The nurse is caring for a client who is diagnosed with chronic renal failure with hemodialysis three times per week. The client becomes confused and irritable six hours before the next treatment. Which of these findings might explain the reason for the client's behavior? 1Low potassium level 2Elevated blood urea nitrogen (BUN) 3Low calcium level 4Metabolic alkalosis - CORRECT ANSWERS 2 The client is instructed to collect stool specimens at home using the guaiac test. In addition to explaining how to collect the specimens, the nurse instructs the client to avoid certain substances prior to obtaining the stool specimens. Which of the following substances should the client avoid? (Select all that apply.) - CORRECT ANSWERS a false positive test and should be avoided for at least 3 days before the fecal occult blood test; Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass Fruits and vegetables with high peroxidase activity, such as red radishes, broccoli, and cauliflower should also be avoided several days prior to obtaining specimens. Clients should also limit their intake of vitamin C because too much can lead to a false negative result. A client with a fracture of the radius had a plaster cast applied two days ago. The client calls the clinic to report constant pain and swelling of the fingers since the cast was applied. What should be the next action of a nurse? 1Suggest to elevate the arm higher than heart level 2Ask if numbness is present in the fingers and if the client can move the fingers 3Have the client make an appointment with the surgeon for the next day 4Approve the application of a cool cloth to the fingers of the affected arm - CORRECT ANSWERS 2 The client is seen in the emergency one day after falling in his bathroom at home. The client reports having "a few drinks" prior to the fall. Which finding requires the nurse's immediate attention? 1Bruise behind one ear 2Blurred vision 3Nausea and vomiting 4Headache - CORRECT ANSWERS 1 Diagnosed with heart failure, the client had an implantable cardioverter-defibrillator (ICD) implanted several years ago. The client now has end-stage heart failure and is receiving home hospice care. Which end-of-life care option could have the greatest impact on client comfort? 1Encouraging the client to sit upright in bed 2Confirming advanced directives and plans for resuscitation 3Deactivating the implantable cardioverter-defibrillator (ICD) 4Assisting the client to eat several small meals - CORRECT ANSWERS 3 The client is prescribed alendronate (Fosamax). What information about medication administration should the nurse be sure to reinforce? 1Take on an empty stomach 2Take with milk, two hours after meals 3Take with calcium Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass The nurse is caring for a group of clients when a fire alarm sounds in the hospital cafeteria. What should the nurse do next? 1Close all doors in the area. 2Find the fire extinguisher. 3Remove oxygen devices. 4Begin evacuating the clients. - CORRECT ANSWERS 1 The licensed practical nurse (LPN) is caring for a client with an order that reads, "morphine sulfate 2 mg IV push every 3 to 4 hours as needed for pain." There are no other licensed persons working that shift. Which action should the nurse take? 1Give the medication orally and follow-up with the health care provider. 2Hold the medication and contact the health care provider. 3Administer the prescribed dose as ordered. 4Check with the pharmacist to verify the order. - CORRECT ANSWERS 2 The nurse is providing care for a client who was recently diagnosed with end-stage heart failure. The client does not have advance directives in place. Which of the following statements by the nurse would be appropriate? (Select all that apply.) - CORRECT ANSWERS "Have you thought about what you want done as your disease progresses?" "What does your family know about your condition and prognosis?" "Have you discussed your wishes regarding resuscitation with your health care provider?" A newly licensed nurse is concerned about time management. Which action should be most effective in the initial development of a time management plan? 1Set daily goals with the establishment of priorities 2Complete each task before beginning another activity 3Ask for additional assistance when necessary to complete tasks 4Keep a time log for what was done during the hours worked - CORRECT ANSWERS 4 A home health nurse is providing care for a client. Which client statement should the nurse report immediately to the client's health care provider? 1"When I emptied my urine catheter drainage bag it looked like rusty-colored water." Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 2"I just didn't sleep well the last few nights. I keep having sad thoughts running through my mind." 3"I really don't want home-delivered meals any longer. I am just not hungry." 4"My neighbors just don't visit me anymore since I came home from the hospital." - CORRECT ANSWERS 1 The LPN/VN assists the RN in evaluating the plan of care for clients. What action does the LPN focus on during the evaluation phase? 1Selection of interventions that are measurable and achievable 2Achievement or status of progress related to prior goals 3Identification of any findings of physical and psychosocial stressors 4Establishment of goals to ensure continuity of care - CORRECT ANSWERS 2 A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law? 1Clinical specialty certification by an accredited organization 2Complete and accurate documentation of assessments and interventions 3Sworn statement that health care provider orders were followed 4Above-average performance reviews prepared by nurse manager - CORRECT ANSWERS 2 The nurse is assigned to care for several clients on the day shift. Which client should the nurse see first after receiving shift report? 1The client with asthma who is scheduled for a chest X-ray prior to discharge 2The client with peptic ulcer disease who has been vomiting most of the night 3The client with chronic kidney disease who completed peritoneal dialysis two hours ago 4The client with pancreatitis who reports pain at a level of eight out of 10 - CORRECT ANSWERS 2 The nurse hears a health care provider (HCP) loudly criticizing one of the unlicensed assistive persons (UAP) within the earshot of others. The UAP does not react or respond to the HCP's complaints. What is the best action by the nurse? 1Notify the chief of the medical staff about the HCP's breach of professional conduct. 2Encourage the UAP to directly confront the HCP about the unprofessional behavior. 3Complete an incident report describing the HCP's unprofessional behavior. Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 4Walk up to the HCP and quietly state, "This unacceptable behavior has to stop." - CORRECT ANSWERS 2 Information about case management and the role of the case management nurse is presented during an orientation session for new nurses. Which statement correctly describes an important fact about case management? 1Case management strategies focus mainly on the client's needs after discharge. 2Case management is a collaborative process designed to meet complex client needs. 3Physicians are responsible and accountable for client outcomes. 4The interdisciplinary team makes all the decisions for the client and family. - CORRECT ANSWERS 2 During the management of a client's pain, the nurse should adhere to the code of ethics for nurses. Which of these actions should the nurse consider first when treating the client's pain? 1Cultural sensitivity is fundamental to client-centered pain management. 2Clients have the right to have their pain managed promptly. 3Nurses should not judge a client's pain based on the nurse's values. 4The client's self-report of pain is the most important consideration. - CORRECT ANSWERS 4 A client with a musculoskeletal disorder has been newly fitted with a lower limb orthotic. Which activity can the nurse delegate to the certified nursing assistant (CNA)? 1Provide instruction to the client for ambulation with the orthotic. 2Monitor the client's response to moving with the orthotic. 3Check the client's skin for any redness or irritation from the orthotic. 4Assist with transferring the client from the bed to the chair. - CORRECT ANSWERS 4 Upon completing a review of a 27-year-old client's admission documents, the nurse identifies that the client does not have an advance directives. What action should the nurse take? 1Lecture the client on the importance of having advance directives. 2Inform the charge nurse to offer information about advance directives. 3Advance directives are not appropriate for this client due to the client's age. 4Refer this issue to the client's health care provider. - CORRECT ANSWERS 2 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass The nurse is reviewing information about the health care organization's efforts to improve quality of care. Which of these statements best describes the goal of continuous quality improvement (CQI) in a health care setting? 1Perform actions based on reactive problem solving. 2Create a flow chart of department or staff interactions. 3Conduct chart audits for common error discovery. 4Improve the quality of care in a proactive manner. - CORRECT ANSWERS 4 The client is admitted with a diagnosis of hyperglycemia and poor glycemic control. Which task can the nurse assign to an unlicensed assistive person (UAP)? 1Check sensation in the extremities 2Observe for mental status changes every four hours 3Reinforce findings of hypoglycemia when the client asks 4Measure blood pressure, pulse and respirations - CORRECT ANSWERS 4 When walking past a client's room, the nurse hears an unlicensed assistive person (UAP) talking to another UAP. Which of these statements requires further intervention by the nurse? 1"I'll come back and make the bed after I go to the lab." 2"If we work together we can get all of the client care completed." 3"Since I am late for lunch, would you perform my client's blood glucose test?" 4"This client seems confused, we need to watch the client closely." - CORRECT ANSWERS 3 The nurse has been assigned to four clients. Which client should the nurse see first? 1The client with a history of coronary artery disease (CAD) reporting dyspnea, nausea and unusual discomfort in the upper back 2The client diagnosed with peripheral artery disease (PAD) who reports cramp-like pains in both calf muscles following physical therapy 3The client with a history of heart failure (HF) who reports going to the bathroom "too much" after taking a diuretic 4The client diagnosed with hypertension whose last recorded blood pressure (BP) was 180/90 after returning from the radiology department - CORRECT ANSWERS 1 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass The licensed practical nurse (LPN) is reassigned to work on an acute care unit. Which of these clients would be most appropriate for the LPN to accept? 1A trauma victim with multiple lacerations requiring complex dressings 2An older adult client diagnosed with cystitis who has an indwelling urethral catheter 3A confused client whose family complains about the nursing care given after the client's surgery 4A client, admitted for a possible stroke, with unstable neurological findings - CORRECT ANSWERS 2 A nurse must use an interpreter to collect data from a client. Which action should the nurse take to help communicate with the client? 1Include a family member and direct comments to that person 2Talk to the interpreter in advance and leave the client and interpreter alone for discussion 3Speak directly to the interpreter while asking questions 4Face the client while asking questions as the interpreter translates the information - CORRECT ANSWERS 4 The 4-year-old child is newly diagnosed with hepatitis A. Which instructions should the nurse reinforce with the child's parents? 1Use gentle cleansers to protect jaundiced child's skin from breakdown. 2Child can return to daycare two days after starting antibiotic treatment. 3Keep child on bedrest for several weeks before gradually resuming activity. 4Wash hands thoroughly with soap and warm water after contact with the child. - CORRECT ANSWERS 4 The hepatitis A virus spreads through contaminated food or water, as well as unsanitary conditions in childcare facilities or schools. The infection resolves spontaneously and symptom relief is usually the only treatment. A client has been placed in physical restraints due to aggressive behavior. Which of the following demonstrates that the nurse has appropriately implemented the restraints? (Select all that apply.) - CORRECT ANSWERS To avoid injury, restraints should never be fastened to a moving part of a bed or stretcher. A physical restraint order is never "as needed." An order must be written by a provider for each restraint episode. Documentation must be done every 15 minutes on the restraint flow sheet, which is part of the client's permanent medical record. It is a legal requirement to notify the client's advocate or a relative if requested by the client. Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass The nurse is reinforcing education to a group of parents on how to treat accidental poisoning of children in the home. What information should the nurse include? 1Empty the child's mouth of any poisonous substance still present. 2Give the child a glass of milk to drink to neutralize the poisonous substance. 3Induce vomiting if the child is suspected of swallowing something poisonous. 4Start treatment before calling the Poison Control Center - CORRECT ANSWERS 1 The nurse is stuck in the hand by an exposed needle that was accidentally left in the client's bed. What action should the nurse take first? 1Contact employee or occupational health services. 2Look up the policy and procedure on needlestick injury. 3Immediately wash hands vigorously with soap and warm water. 4Notify the nursing supervisor and complete an incident report. - CORRECT ANSWERS 3 The nurse is reviewing the documentation of a client's care in their electronic health record and realizes that one of the entries was completed on the wrong client. Which of the following actions are appropriate for the nurse to take? - CORRECT ANSWERS Mark the entry as "mistaken entry- wrong patient." Enter the time the error was discovered. The nurse is preparing a client for a colonoscopy and notes that the consent form has not been signed. Which of the following statements by the nurse are appropriate to make to the client? - CORRECT ANSWERS "Please tell me your full name and date of birth." "Do you have any questions about the colonoscopy?" "Describe what the health care provider told you about a colonoscopy." An outpatient client is scheduled to receive an oral solution of radioactive iodine. In order to reduce radiation exposure to others, which information should the nurse reinforce? 1No solid food may be eaten for six hours after ingestion. 2Urine and saliva will be radioactive for 24 hours after ingestion. 3Wash laundry separately and rinse twice in hot water. 4Wait for 48 hours to have grandchildren visit at home. - CORRECT ANSWERS 2 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 4Identify the client's learning needs. - CORRECT ANSWERS 4 During a well-baby visit, the nurse is evaluating developmental milestones for the 7-month-old child. Which of these developmental activities should the child be able to perform? 1Sits without support 2Uses pincer grasp 3Says several words 4Drinks from a cup - CORRECT ANSWERS 1 The age at which a child typically develops the ability to sit steadily without support is around 7 to 8 months. Saying several words, drinking from a cup and using a neat pincer grasp are developmental milestones that most children do not reach until age 11 to 12 months. A client is forgetful and experiencing short-term memory loss. While collecting data about short-term memory loss, which action should the nurse take first? 1Ask the client to state his date of birth. 2Confirm that the client's hearing is intact. 3Observe the client while performing an activity. 4Ask the client to name the current U.S. president. - CORRECT ANSWERS 2 During the physical inspection of a client, the nurse notes a pulsating mass in the client's periumbilical area. Which action should the nurse take next? 1Measure the length of the mass. 2Auscultate the area. 3Palpate the area. 4Percuss the area. - CORRECT ANSWERS 2 A client has a family history of coronary artery disease (CAD). Which of the following findings should be of concern to the nurse? 1Low density lipoprotein (LDL) cholesterol level of 80 mg/dL 2Blood pressure of 154/78 3Serum creatinine of 0.4 mg/dL 4A glycosylated hemoglobin (Hb A1C) level of 4.8% - CORRECT ANSWERS 2 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass Which of the following actions performed by the nurse indicates that additional education on ergonomic principles is needed to reduce the risk of injury? 1Flex the knees and knee close to an object, before lifting it from the floor. 2Use arm and leg strength to assist in repositioning a client in bed. 3Push a bed down the hall, instead of pulling it during transport. 4Bend and twist at the waist when assisting a client in transferring to the chair. - CORRECT ANSWERS 4 A client with a back injury asks the nurse how chiropractic manipulation works. What is the nurse's best response? 1Electrical energy fields 2Spinal column manipulation 3Mind-body balance 4Exercise of joints - CORRECT ANSWERS 2 The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) and a significant family history of coronary artery disease. Which of the following prescriptions by the health care provider would treat a major modifiable risk factor of coronary artery disease? 1Atorvastatin 2Prednisone 3Albuterol 4Fluticasone/salmeterol - CORRECT ANSWERS 1 Atorvastatin is an HMG-CoA reductase inhibitor, more widely known as a statin, and it is a medication used to treat hyperlipidemia. Statins reduce LDL levels, reduce triglycerides and increase HDL levels. Hyperlipidemia is a major modifiable risk factor of coronary artery disease. A 20-year-old male client who has a profuse, purulent urethral discharge with painful urination is seen at a community health clinic. Which information will be most important for the nurse to obtain? 1Sexual orientation 2Recent sexual contacts 3Immunization history Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 4Contraceptive preference - CORRECT ANSWERS 2 The nurse recognizes that which finding indicates a child has attained the developmental stage of concrete operations, according to Piaget? 1The child makes the moral judgment that "stealing is wrong." 2The child explores the environment with the use of sight and movement. 3The child thinks in mental images or word pictures. 4The child reasons that homework is time-consuming but necessary. - CORRECT ANSWERS 1 After the death of a client, the family approaches the nurse and requests that a family member be allowed to perform a ritual bath on the deceased client prior to moving the body. What would be the most appropriate response by the nurse? 1"I will have to check on hospital regulations and policies." 2"These procedures have to be carried out by our staff." 3"Is there anything you need from me to perform the bath?" 4"A ritual bath will have to wait until after postmortem care." - CORRECT ANSWERS 3 A nurse is working to establish a therapeutic relationship with a client. Which action would support the nurse's goal? 1Establish trust and rapport with the client. 2Identify with what the client is feeling. 3Praise the client for appropriate behavior. 4Advise the client on problem-solving techniques. - CORRECT ANSWERS 1 The client diagnosed with paranoid-type schizophrenia is sitting alone, intently staring at and watching other clients and staff members. The client becomes hostile when approached with medication and claims that the medication controls the mind. What type of symptom(s) does the nurse recognize that this client is exhibiting? 1Antisocial behavior 2Negative symptoms 3Positive symptoms 4Inappropriate affect - CORRECT ANSWERS 3 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass A client who is taking duloxetine asks the nurse if the medication treats depression or diabetes. What is the best response from the nurse? 1"Duloxetine is used to treat depression but can also be used to lower blood sugar levels." 2"Duloxetine is used to treat depression but can be used to treat pain that can occur in people with diabetes." 3"Duloxetine is not prescribed for either depression or diabetes." 4"Duloxetine is used to treat diabetes but can also be used to treat depression." - CORRECT ANSWERS 2 Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor (SNRI) that can be used to treat depression but also can be used to treat pain associated with diabetic neuropathy. The nurse is caring for a female client with a body mass index (BMI) of 45. Which conditions should the nurse plan to discuss with the client due to the risks associated with her weight? (Select all that apply.) - CORRECT ANSWERS obstructive sleep apnea gallstones coronary artery disease breast cancer HYPERTHYROIDISM IS NOT ASSOCIATED WITH BEING OVERWEIGHT OR BMI The nurse is caring for a client diagnosed with substance use disorder (SUD). The client states, "I just drink occasionally. I don't know why my wife and the judge think that I need to be in an alcohol treatment program." Which of the following behaviors are consistent with SUD? (Select all that apply.) - CORRECT ANSWERS Prone to act impulsively Insecurity in relationships Craving and inability to abstain from alcohol The nurse is caring for a client who has a history of heavy alcohol use. Which findings would indicate that the client is probably experiencing delirium tremens (DTs)? 1Chest pain, nausea, diaphoresis and tachycardia 2Nausea, vomiting, bloody stools and hypotension 3Headache, blurred vision, garbled speech and hypertension Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 4Excitability, disorientation, tremors and tachycardia - CORRECT ANSWERS 4 A couple that recently immigrated to the United States tells the nurse about their concern that hospital staff is giving their child the "evil eye." What should the nurse communicate to the other personnel who are involved in the care of this family? 1Touch the child after or while looking at the child. 2Avoid touching or looking at the child. 3Look only at the parents and not the child. 4Instruct the parents to remain outside of the room. - CORRECT ANSWERS 1 an "evil eye" is cast by looking at a person without touching them or while the person is unaware. The evil eye is believed to cause misfortune or injury. The spell is broken by touching the child while looking at them or assessing them. The nurse is caring for a client diagnosed with end-stage heart failure (HF). The family members are distressed about the client's impending death. Which action should the nurse take initially? 1Explain the stages of death and dying to the family. 2Recommend an easy-to-read book on grief. 3Ask about the family's religious affiliation and practices. 4Explore the family's past patterns for dealing with death. - CORRECT ANSWERS 4 A nurse is caring for a client who is being treated for major depression. During which time period is the client most likely to be at the highest risk for attempting suicide? 1 1 to 2 weeks after initiating antidepressant medication. 26 to 12 months after discharge from the hospital. 3Around the time of the client's birthday. 4While under one-on-one observation in the hospital. - CORRECT ANSWERS 1 A client diagnosed with schizophrenia first speaks animatedly to another client, with exaggerated clarity of pronunciation. The nurse then observes the client turning abruptly away, mumbling to themselves and speaking to the wall. Which priority goal/outcome should the nurse select for the client's plan of care? 1Client will express feelings appropriately through verbal interactions. 2Client will accurately interpret events and other's behaviors. Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 3Client will engage in meaningful and understandable verbal communication. 4Client will demonstrate improved social relationships. - CORRECT ANSWERS 3 The nurse is working in an inpatient psychiatric setting and understands that touching clients should be limited to a quick handshake for which reason? 1Touching a client, other than a handshake, can set off a violent episode. 2Refraining from touching signals the termination of the nurse-client relationship. 3A handshake allows the use of therapeutic touch while maintaining boundaries. 4A handshake will not be misinterpreted as an invitation to more sexual behavior. - CORRECT ANSWERS 3 The nurse in a behavioral health inpatient unit is observing a female client who has been diagnosed with obsessive-compulsive disorder (OCD). Which behavior should the nurse expect to see with this diagnosis? 1The client is seen washing her hands every 15 minutes. 2The client exhibits repetitive, involuntary movements. 3The client verbalizes suspicions about thefts on the unit. 4The client prefers to interact with female staff members. - CORRECT ANSWERS 1 OCD is characterized by repetitive, unwanted, intrusive thoughts (obsessions) and irrational, excessive urges to perform certain actions (compulsions). The nurse is caring for a client who has an alcohol use disorder (AUD). The client states that the client's dysfunctional family caused the addiction. Which response by the nurse would best help the client accept responsibility for their own behavior? 1"It was your choice to drink, so you need to take responsibility." 2"It is wrong for you to blame your problems on your family." 3"Yes, I can understand that families can be tough to deal with." 4"The lab report showed a high blood alcohol level when you were admitted." - CORRECT ANSWERS 4 A nurse is collecting data on a client believed to be in an abusive relationship. Which client statement is most indicative that this individual is experiencing intimate partner abuse? 1"I must have done something to deserve this." Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 1Instruct the client to tilt their head back while swallowing. 2Position the client in an upright position while they are eating. 3Assist the client to drink through a straw. 4Instruct the client to use sips of water to help wash down food. - CORRECT ANSWERS 2 A client is transferred from the postanesthesia care unit (PACU) to the medical-surgical unit after an appendectomy. Which action should the nurse on the medical-surgical unit perform first? 1Ask the client about pain. 2Orient the client to the unit. 3Review the postoperative orders. 4Take the client's vital signs. - CORRECT ANSWERS 4 The nurse is evaluating the effectiveness of a bowel training program for a client with chronic constipation. Which statements made by the client should the LPN/VN report to the RN for additional teaching? - CORRECT ANSWERS Bowel training programs are designed to return defecation to normal. Fluid intake should be 2.5 to 3 liters per day. The client should increase fiber in their diet, and intake hot drinks just prior to their normal bowel elimination time to facilitate normal bowel function. A suppository treatment should be administered about half an hour before the client's normal bowel elimination time—inserting it just prior to bedtime will disturb the client's sleep pattern. The client should be provided with privacy for about 30 to 40 minutes and should sit on a commode or bedpan whenever they have the urge to defecate. An obese client tells the nurse, "I just started a diet and I am eating no more than 800 calories a day." What information should the nurse reinforce with the client? 1Very low-calorie diets often have severe and irreversible side effects. 2Very low-calorie diets are adequate if balanced with fruits and vegetables. 3Very low-calorie diets are intended for short-term use only. 4Very low-calorie diets are appropriate for long-term weight management. - CORRECT ANSWERS 3 A 2-year-old child is brought to the pediatrician's office by the parents, who report that the child has been having diarrhea for two days. What nutritional information should the nurse provide to the parents? 1Keep the child fasting, give them nothing to eat, and return the next day. 2Give the child only clear liquids and gelatin for 24 hours. Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 3Continue a regular diet and add electrolyte replacement drinks. 4Give the child bananas, apples, rice and toast as tolerated. - CORRECT ANSWERS 3 The nurse is providing care to an older adult client diagnosed with bilateral pneumonia. Which intervention should the nurse implement to best promote the client's comfort? 1Encourage visits from family and friends. 2Keep conversations short. 3Increase the client's oral fluid intake. 4Monitor vital signs frequently. - CORRECT ANSWERS 2 An 82-year-old male client is admitted with benign prostatic hyperplasia (BPH). Which finding by the nurse will require immediate action? 1Severe abdominal pain 2A bladder ultrasound value of 900 mL 3A heart rate of 110 bpm 4A blood pressure of 180/105 - CORRECT ANSWERS 2 The nurse is reviewing the laboratory results for a client diagnosed with dehydration. Which result is most important to communicate to the health care provider? 1Serum creatinine level of 2.8 mg/dL 2Blood glucose level of 146 mg/dL 3Serum potassium level of 5.0 mEq/L 4Serum hemoglobin level of 15.7 g/dL - CORRECT ANSWERS 1 normal range of 0.5 to 1.2 mg/dL in adults. Dehydration can contribute to impaired renal function. A creatinine level of 2.8 mg/dL is significantly elevated and indicative of renal impairment. Therefore, the creatinine value is the most important result The nurse is evaluating a client who has been diagnosed with heart failure (HF) to gauge their understanding of the required diet modifications. Which menu items selected by the client indicate to the nurse that the client understood the teaching? 1Cheeseburger and baked potato chips 2Grilled cheese sandwich with a glass of skim milk Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 3Leftover turkey on a sandwich and fresh pineapple 4Vegetable pizza and ice cream - CORRECT ANSWERS 3 Clients with HF should adhere to a low-sodium diet to prevent fluid volume excess. A sodium- restricted diet should consist of less than 2 grams of sodium per day. (A regular diet should include 4 to 6 grams of sodium per day.) The nurse receives an order to give a client iron by deep injection. What does the nurse understand about the reason for using this method of administration? 1Provides more even distribution of the drug 2Prevents the medication from tissue irritation 3Ensures that the entire dose of medication is given 4Enhances absorption of the medication - CORRECT ANSWERS 2 Deep injection, or Z-track, is a special method of giving medications via the intramuscular route. Use of this technique prevents irritating or staining medications from being tracked through tissue. A client has been taking alprazolam for three days. For which expected effect of the medication should the nurse evaluate the client? 1The client reports feeling less depressed. 2The client reports sleeping through the night. 3The client denies having auditory hallucinations. 4The client denies having suicide ideation. - CORRECT ANSWERS 2 Antianxiety medications or anxiolytics, such as alprazolam, a benzodiazepine, work quickly. They produce sedative effects and reduce anxiety through effects on the limbic system, a neuronal network associated with emotionality. They also promote sleep through effects on cortical areas and on the brain's sleep-wakefulness "clock." At 9 am, the nurse administers 10 units of insulin aspart subcutaneously to a client with a blood sugar of 322 mg/dL. At approximately what time should the nurse expect the insulin to peak? 1At noon 2At 9:30 am 3At 10:00 am 4This insulin does not peak because it acts over 24 hours. - CORRECT ANSWERS 1 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 2Constipation 3Wheezing 4Hyperglycemia - CORRECT ANSWERS 2 A client is prescribed trimethoprim/sulfamethoxazole for recurrent urinary tract infections. Which statement by the nurse about this medication is correct? 1"You can stop the medication after five days." 2"Be sure to take the medication with food." 3"Drink at least eight glasses of water a day." 4"It is safe to take with oral contraceptives." - CORRECT ANSWERS 3 Unlike many other antibiotics, trimethoprim/sulfamethoxazole does not seem to affect hormonal birth control such as the pill, the patch or ring. The hospice nurse is visiting a client diagnosed with end-stage lung cancer and metastases to the bone. What should the nurse keep in mind when planning for effective pain management? 1Relief of pain will be achieved quickly. 2Pain therapy is based on the client's report of pain. 3High doses of opioid analgesics will be required. 4The client will most likely become addicted. - CORRECT ANSWERS 2 The nurse is discharging a client who is at risk for venous thromboembolism (VTE). The client is prescribed enoxaparin. Which instruction should the nurse provide to this client? 1"Notify your health care provider if your stools appear tarry or black." 2"You should massage the injection site for better absorption." 3"An intravenous (IV) catheter will be placed to administer the medication." 4"You must have your partial thromboplastin time (PTT) checked weekly." - CORRECT ANSWERS 1 As with any anticoagulant, enoxaparin carries the risk of bleeding. Clients should be instructed to report the presence of tarry stools, bleeding gums, hematuria, ecchymosis or petechiae to their HCP A client who has been diagnosed with Raynaud's disease and hypertension is prescribed nifedipine. For which side effect should the nurse monitor the client? 1Decreased urine output Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 2Facial flushing 3Cyanosis of the lips 4Increased pain in fingers - CORRECT ANSWERS 2 Nifedipine is a calcium channel blocker (CCB) used in the treatment of Raynaud's disease and hypertension by producing vasodilation. As a result of this vasodilating effect, facial flushing can occur. A postoperative client has a prescription for acetaminophen with codeine for pain relief. The nurse understands which action to be the primary purpose of this drug combination? 1Faster onset of action 2Minimized side effects 3Enhanced pain relief 4Prevents tolerance - CORRECT ANSWERS A client diagnosed with tuberculosis is prescribed rifampin and isoniazid. Which information should the nurse include when reinforcing information about these medications? 1"You may have occasional problems sleeping." 2"You can take the medication with food." 3"You may notice an orange-red color to your urine." 4"You may experience an increase in appetite." - CORRECT ANSWERS 3 The nurse is reinforcing medication interactions with a client who is taking warfarin. Which over-the- counter (OTC) medication should the nurse remind the client to avoid? 1Naproxen 2Diphenhydramine 3Acetaminophen 4Pantoprazole - CORRECT ANSWERS 1 Naproxen can prolong bleeding time and should therefore be avoided by clients who take anticoagulants. Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass The nurse is preparing to administer an antibiotic intramuscularly (IM) to a 2-year-old child. The total volume of the injection is 2 mL. What is the best approach for the nurse to take when administering this medication? 1Call the provider and request a smaller dose. 2Split the medication into two separate injections. 3Substitute an oral form of the medication. 4Inject the medication in the deltoid muscle. - CORRECT ANSWERS 2 The nurse is reinforcing teaching for a client with chronic kidney disease about the prescribed aluminum hydroxide. Which is the best statement by the nurse about this medication? 1"It reduces potassium levels." 2"It increases urine output." 3"It controls stomach acid secretions." 4"It decreases phosphate levels." - CORRECT ANSWERS 4 Phosphates tend to accumulate in the client with chronic kidney disease due to decreased filtration capacity of the kidneys. Antacids that contain aluminum such as aluminum hydroxide (Amphojel) are commonly used to lower phosphate levels. A client has a new prescription for sertraline, a selective serotonin reuptake inhibitor (SSRI) antidepressant. After reviewing the client's medical record, which data is the nurse most concerned about? 1History of an eating disorder 2Current prescription for phenelzine 3History of premenstrual dysphoric disorder 4Current prescription for alprazolam - CORRECT ANSWERS 2 Phenelzine is a monoamine oxidase inhibitor (MAOI) antidepressant. Combining MAOIs with SSRIs and other serotonergic drugs poses a risk of serotonin syndrome. The client is discharged from the hospital with a new prescription for furosemide. During a follow-up visit one week later, the nurse notes the following findings. Which finding is most important to report to the health care provider? 1Increased urine production 2Occasional lightheadedness Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass The nurse is reinforcing teaching about levothyroxine for a client newly-diagnosed with hypothyroidism. Which information should the nurse make sure to reinforce about this medication? 1The medication may decrease the client's energy level. 2The medication will decrease the client's heart rate. 3The medication should be taken in the morning. 4The medication must be stored in a dark container. - CORRECT ANSWERS 3 A thyroid supplement, such as levothyroxine, should be taken on an empty stomach in the morning. Morning dosing minimizes the side effect of insomnia and an empty stomach facilitates absorption. Levothyroxine will cause an increase in the client's energy level and heart rate. A client received hydromorphone orally one hour ago. When the nurse enters the client's room, the client is unresponsive to verbal stimuli and has a respiratory rate of six. Which action should the nurse take next? 1Prepare for endotracheal intubation. 2Administer supplemental oxygen. 3Begin cardiopulmonary resuscitation. 4Prepare to administer naloxone. - CORRECT ANSWERS 4 A client has been prescribed alendronate for osteoporosis. Which of the following statements indicate the client understands how to safely take this medication? (Select all that apply.) - CORRECT ANSWERS Alendronate is a bisphosphonate used to treat osteoporosis. It can cause esophagitis or esophageal ulcers unless precautions are followed. The client must sit upright or stand for at least 30 minutes after taking the medication. The client should take the medication with a full glass of water, at least 30 minutes before eating or drinking anything or taking any other medication. Antacids will interfere with absorption and should not be taken at the same time. The nurse observes a new nurse administering a rectal suppository to a client. Which actions are appropriate for the new nurse to implement? (Select all that apply.) - CORRECT ANSWERS The nurse pushes the suppository in, up to the second knuckle. The nurse applies water-soluble lubricant to the suppository. The nurse places the client on the left side during insertion. Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass After 10 minutes, the nurse turns the client to the right side. A nurse is caring for a client who was recently admitted following an episode of status epilepticus. Which of the following data is most important to collect? 1Level of consciousness (LOC) 2Amount of intravenous fluid infused 3Pulse and blood pressure 4Injuries to the extremities - CORRECT ANSWERS 1 The nurse is preparing a client for an intravenous pyelogram (IVP) test. What information is most important for the nurse to obtain prior to the procedure? 1Time of the client's last meal 2History of allergies 3Amount of urine output 4BUN and creatinine level - CORRECT ANSWERS 2 An older adult client, diagnosed with active pulmonary tuberculosis, has difficulty in coughing up secretions for a sputum specimen. Which nursing intervention would be most helpful for this client? 1Encourage client to ambulate frequently. 2Spray the oropharynx with saline. 3Administer a nebulizer treatment. 4Push fluids for the next eight hours. - CORRECT ANSWERS 3 A client is receiving heparin and warfarin after total hip replacement surgery. Lab results show an international normalized ratio (INR) of 5.5. Which priority action should the nurse take? 1Hold the next dose of warfarin. 2Monitor for bruising or bleeding. 3Notify the health care provider (HCP). 4Administer protamine sulfate. - CORRECT ANSWERS 3 The therapeutic range for INR is 2 to 3, therefore a client with a 5.5 INR is at a high risk for bleeding and the nurse should notify the HCP immediately. Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass A nurse is caring for a 2-year-old child who underwent a tonsillectomy at 8:00 am. At 11:00 am, the child has a temperature of 98.2⁰ F (36.7⁰ C). At 1:00 pm, the child's parent reports to the nurse that the child feels very warm to touch. What should the nurse do first? 1Reassure the parent that this is normal. 2Take the child's temperature. 3Offer the child cold oral fluids. 4Administer prescribed acetaminophen. - CORRECT ANSWERS 2 The nurse is caring for a 60-year-old female client scheduled for abdominal surgery. Which factor in the client's history indicates that the client is at an increased risk for deep vein thrombosis (DVT) in the postoperative period? 1Past hypersensitivity to heparin 2Family history of uterine cancer 3Estrogen replacement therapy for the past three years 4History of acute hepatitis A - CORRECT ANSWERS 3 The estrogen in hormone replacement therapy (and in birth control pills) can increase clotting factors in the blood, increasing the risk for development of a DVT. The nurse is caring for a client receiving mechanical ventilation. The nurse understands which are the possible causes for a high-pressure alarm? (Select all that apply.) - CORRECT ANSWERS Kinked tubing, secretions and/or bronchospasms cause obstruction to airflow from the ventilator, creating high pressure in the ventilator circuit and setting off the high-pressure alarm. The nurse is reviewing the medical record of a client on the medical surgical unit and notes a positive result of the stool for occult blood (OB) test. The nurse recognizes which risk factors for this result? (Select all that apply.) - CORRECT ANSWERS Drugs that can cause GI bleeding include NSAIDs such as ibuprofen and naproxen (Aleve). Corticosteroids can cause gastric irritation, including peptic ulcers that can also lead to GI bleeding. Factors that may cause a false positive result include bleeding gums following a dental procedure and the ingestion of red meats within three days before testing because red meats contain animal hemoglobin. A client is scheduled for a computerized tomography (CT) scan of the abdomen with contrast. What action should the nurse take before sending the client to the imaging department? 1Insert a temporary urinary catheter. Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass The nurse initiates continuous enteral feeding at 8 am at 50 mL/hour for a client with malnutrition. It is now noon. What priority action should the nurse take at this time? 1Flush the feeding tube with 100 mL of water. 2Assess bowel sounds and gastric pH. 3Measure the gastric residual volume. 4Keep head of bed elevated at least 30 degrees. - CORRECT ANSWERS 3 A transesophageal echocardiogram (TEE) is ordered for a client with possible endocarditis. Which action included in the TEE orders should the nurse implement first? 1Place the client on NPO status. 2Administer O2 per nasal cannula. 3Start a peripheral IV line. 4Give midazolam (Versed) 1 mg IV push. - CORRECT ANSWERS 1 A pregnant woman in the third trimester is admitted with a report of painless vaginal bleeding that started several hours ago. The nurse should prepare the client for what procedure? 1Pelvic exam 2Abdominal ultrasound 3Nonstress test 4Caesarean section - CORRECT ANSWERS 2 A client has been taking isoniazid (INH) and rifampin for several months. Which laboratory test should the nurse monitor with this client? 1Creatinine clearance 2Cardiac enzymes 3Liver enzymes 4Sputum culture - CORRECT ANSWERS 3 INH and rifampin are used to treat tuberculosis and both are hepatotoxic. Isoniazid can cause hepatocellular injury Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass A male client underwent a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery six hours ago. He received 1000 mL of intravenous (IV) fluids. Which action should the nurse implement to help this client urinate? 1Have the client drink several glasses of water. 2Insert a urinary catheter. 3Assist the client to stand to void. 4Obtain a bladder ultrasound. - CORRECT ANSWERS 3 The nurse is caring for a client who had a closed reduction of a fractured right wrist, followed by the application of a cast about 12 hours ago. Which finding requires the nurse's immediate attention? 1Serum calcium level of 6.8 mg/dL 2Numbness in the right hand 3Reported pain level of six on a numeric pain scale 4Edema and swelling of the right hand - CORRECT ANSWERS 2 A nurse is caring for a client who had a cholecystectomy with common bile duct exploration and placement of a T-tube 24 hours ago. The nurse observes large amounts of bilious drainage from the T-tube. Which action should the nurse take? 1Administer pain medication. 2Clamp the T-tube for two hours. 3Continue to monitor the drainage. 4Lower the head of the bed. - CORRECT ANSWERS 3 A client is admitted to the hospital with endocarditis. The nurse understands that which risk factors can lead to the development of endocarditis? (Select all that apply.) - CORRECT ANSWERS Oral abscess with tooth extraction History of aortic valve replacement Placement of an arteriovenous fistula for hemodialysis Placement of a central venous access device The nurse is reviewing the chart of a client who was recently diagnosed with coronary artery disease due to atherosclerosis. Which factors most likely contributed to the development of this disease? (Select all that apply.) - CORRECT ANSWERS Mother died of a myocardial infarction Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass Low-density lipoprotein (LDL) level of 149 mg/dL History of diabetes mellitus Used to smoke 40 packs per year until one year ago The target LDL level for a client is less than 100 mg/dL. The nurse is evaluating a client who was admitted for a small bowel obstruction and dehydration. Which observation by the nurse would indicate that the dehydration is improving? 1The client has normoactive bowel sounds. 2The client voided 300 mL of urine in the past two hours. 3The client denies any nausea or vomiting. 4The client reports the passing of flatus. - CORRECT ANSWERS 2 A client is admitted to the telemetry unit with syncope due to sinus bradycardia. Which intervention should the nurse include in the client's plan of care? 1Maintain the client on bedrest. 2Administer a stool softener daily. 3Implement seizure precautions. 4Discuss the client's wishes for organ donation. - CORRECT ANSWERS A client is admitted to the telemetry unit with syncope due to sinus bradycardia. Which intervention should the nurse include in the client's plan of care? 1Maintain the client on bedrest. 2Administer a stool softener daily. 3Implement seizure precautions. 4Discuss the client's wishes for organ donation. - CORRECT ANSWERS 2 To avoid a vasovagal response (i.e., the slowing of the heart rate caused by bearing down when trying to defecate) and the risk for another syncopal episode, it is important to ensure that the client's bowel movements are soft and easily expelled. The client should also be instructed to avoid holding their breath or bearing down (Valsalva maneuver). A client diagnosed with iron deficiency anemia is prescribed ferrous sulfate suspension orally. Which instruction would be most appropriate for the nurse to give to the client regarding this medication? Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass Reinforce teaching on the importance of not walking without shoes on. Assist the client in enrolling in a smoking cessation program. The nurse is caring for a client admitted with sickle cell crisis. Which medication is the drug of choice for pain management with this client? 1Meperidine 2Ibuprofen 3Acetaminophen 4Hydromorphone - CORRECT ANSWERS 4 The nurse is planning care for a client newly diagnosed with essential hypertension. Which interventions should the nurse include in the client's plan of care? (Select all that apply.) - CORRECT ANSWERS Encourage the client to take daily, 30-minute walks. Explain the negative effects of hypertension on Evaluate the client's understanding of a low-sodium diet. Evaluate the client's ability to take their own blood pressure. The nurse is assisting in developing a plan of care for a client who is on complete bedrest due to a spinal cord injury. Which intervention is most important for the nurse to include? 1Apply pneumatic compression devices to both legs. 2Turn and reposition the client every shift. 3Insert an indwelling urinary catheter. 4Administer a daily enema. - CORRECT ANSWERS 1 The nurse is reinforcing teaching for a client who was newly diagnosed with asthma. Clients with asthma should demonstrate understanding of which of the following? (Select all that apply.) - CORRECT ANSWERS Clients must understand the use of medications including quick-relief (rescue) and long-acting (maintenance) therapies. Clients use the peak flow meter to assess effectiveness of Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass medication or breathing status. An acute attack can be a medical emergency and knowing where and how to seek medical care is important. Certain conditions (triggers) can exacerbate an attack and should be avoided. A client is seen at the primary care clinic for allergic rhinitis. Which clinical manifestations should the nurse expect with this diagnosis? (Select all that apply.) - CORRECT ANSWERS Common symptoms of allergic rhinitis are due primarily to the release of immune mediators such as histamine, prostaglandins, eosinophils and cytokines. This leads to sneezing, runny nose with clear discharge, nasal congestion and an increased eosinophil counts. Symptoms may appear similar to a cold. Due to drainage, the client's sense of smell can be altered. The nurse is caring for a client with a dry chest tube drainage system due to a left tension pneumothorax. Two hours ago, the health care provider (HCP) changed the chest tube prescription to water seal only. When entering the client's room, the nurse finds the client to be short of breath, tachypneic and with an oxygen saturation (SpO2) of 84%. On auscultation, the nurse notes absent breath sounds to the left upper lobe. What action should the nurse take first? 1Apply oxygen via nasal cannula 2Document all interventions in the client's medical record 3Notify the appropriate HCP 4Request a chest X-ray - CORRECT ANSWERS 1 The nurse is planning care for a client admitted to the hospital with influenza. Which interventions should the nurse include in the client's plan of care? (Select all that apply.) - CORRECT ANSWERS Antiviral agents, such as oseltamivir, are used to shorten the course and reduce symptoms of the flu. Droplet transmission-based precautions are indicated to prevent the spread of the flu. To avoid further transmission of the illness, visitors with signs/symptoms of a respiratory illness should not be permitted on the unit. It is important to ensure that clients understand how to prevent transmission of infections such as the flu through proper hand hygiene and cough etiquette. A client has been diagnosed with emphysema. Which intervention should the nurse implement when caring for this client? 1Inquire if the client has a power of attorney for health care. 2Reassure the client that the lung damage is usually reversible. 3Schedule a lung cancer screening for the client. 4Assist the client with enrolling in a smoking cessation program. - CORRECT ANSWERS 4 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass A nurse is administering the influenza vaccine in an occupational health clinic. Within 10 minutes of giving the vaccine to a middle-aged adult male, the man reports having itchy and watery eyes, feeling anxious and short of breath. What should the nurse do first? 1Administer SQ epinephrine. 2Maintain the airway. 3Take the client's vital signs. 4Apply oxygen. - CORRECT ANSWERS 1 The nurse is evaluating whether teaching a client with dysphagia about preventing aspiration was effective. Which action by the client indicates that additional teaching is required? 1The client is sitting in a chair during meals. 2The client uses a straw to drink. 3The client tucks in the chin while swallowing. 4The client alternates solids with liquids. - CORRECT ANSWERS 2 The nurse is assisting with discharging a client from the hospital who was admitted for acute exacerbation of chronic obstructive pulmonary disease. Which statement by the client indicates that teaching was effective? 1"I will make sure to get the pneumonia vaccine every October." 2"I will eat foods low in calories and protein." 3"I will switch from regular to electronic cigarettes." 4"I will use my spacer each time I use my inhaler." - CORRECT ANSWERS 4 The home health nurse is reviewing information with a client who is being treated for pulmonary tuberculosis. Which statement by the nurse is correct? 1"You should not leave your home until your cough is completely gone." 2"Your family members should get the tuberculosis vaccine." 3"You can stop the medications once your symptoms have resolved." 4"You should avoid public transportation and crowds in enclosed areas." - CORRECT ANSWERS 4 The nurse is caring for a client newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reviews the client's medical record and notes which risk factors? (Select all that apply.) - Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 1Soft wrist restraints 2An oral airway 3A bedside commode 4Pads to be placed over the bed's side rails - CORRECT ANSWERS 4 The nurse is reinforcing discharge instructions for a client after cataract surgery of the left eye. Which statements by the client indicate an understanding of the instructions? (Select all that apply.) - CORRECT ANSWERS "I will follow the instructions for the eye drops." "I will call the surgeon if the pain is intense." "I will not rub, press on or scratch my eye." The nurse is providing care for a 40-year-old client suspected of having Guillain-Barré syndrome. Which intervention should the nurse plan for? 1Genetic testing of the client's children 2A bone marrow biopsy 3Administration of immunoglobulins 4Implementation of airborne precautions - CORRECT ANSWERS 3 Intravenous immunoglobulins (IV Ig) are used to treat Guillain-Barré in the early phase. They are believed to interfere with antigen presentation and help to modulate the body's immune response. The nurse in the neurology office is reviewing information about levetiracetam with a 30-year-old female client with a history of seizures. Which instruction about the medication should the nurse make sure to include? 1"You might experience irregular menses and intermittent bleeding." 2"Call the office immediately if you feel like hurting or killing yourself." 3"You should stay away from large crowds and sick children." 4"You should avoid becoming pregnant while taking this medication." - CORRECT ANSWERS 2 Levetiracetam is an anti-convulsant medication used to prevent seizures. One of the significant side effects is behavioral changes and suicidal ideations. Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass The nurse is performing a home visit for an older adult client with Alzheimer's disease. Which of the following observations should be a priority for the nurse to address? 1Good lighting in the stairwell 2Throw rugs on the kitchen floor 3Lamps plugged directly into wall outlets 4Handrails in the bathtub - CORRECT ANSWERS 2 The nurse is collecting data from a college student who comes to the health clinic with symptoms of meningitis. The student resides in the school dormitory. What is the priority action the nurse should take? 1Perform a focused neurological assessment. 2Administer acetaminophen for the headache. 3Alert the college's administration and dormitory staff. 4Obtain the client's immunization history. - CORRECT ANSWERS 3 The clinic nurse is following up with a client who was seen a few days ago for trigeminal neuralgia. Which action by the client indicates an understanding of how to manage the condition? 1Takes an analgesic after performing household chores. 2Keeps the environment at a moderate temperature and free from drafts. 3Eats a bowl of hot, steaming soup every day for lunch. 4Performs vigorous brushing of teeth twice per day. - CORRECT ANSWERS 2 Trigeminal neuralgia is a disruption in the cranial nerve and causes sudden, severe, brief stabbing pain. Keeping the environment at a moderate temperature and free from drafts can reduce the risk of triggering an acute attack. The nurse in the long-term care facility is reviewing the plan of care for a client with Parkinson's disease. Which interventions should the nurse make sure to include for this client? (Select all that apply.) - CORRECT ANSWERS Set-up a bladder training program for the client. Encourage participation in speech therapy. Use cognitive strategies to enhance the client's memory. Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass Provide assistance with ambulation. The nurse is reviewing the plan of care for a 30-year-old client newly diagnosed with multiple sclerosis. Which interventions should the nurse include for this client? (Select all that apply.) Instruct the client on how to self-catheterize as needed. Review methods to prevent and treat constipation. Encourage participation in physical and occupational therapy. Encourage participation in vocational rehabilitation. Encourage independence in personal care and bathing. - CORRECT ANSWERS Review methods to prevent and treat constipation. Encourage participation in physical and occupational therapy. Encourage participation in vocational rehabilitation. Encourage independence in personal care and bathing. The nurse is caring for a client who has a history of peptic ulcer disease. The nurse notes the abdomen is rigid and the client complains of severe pain with palpation. What is the priority action by the nurse? 1Record the findings in the client's record. 2Ask the client about dietary habits. 3Notify the health care provider of the findings. 4Review the client's record for NSAID use. - CORRECT ANSWERS 3 Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass "You should only consume clear liquids for the next 12 to 24 hours." "Remember to stop eating any food six hours before you come to the center." "Make sure to drink the entire bowel preparation liquid." A client is being admitted to the hospital with complaints of bloody stools for several days. Which interventions should the nurse expect to be prescribed for this client? (Select all that apply.) - CORRECT ANSWERS Administration of pantoprazole Collection of a stool sample for occult blood testing Discontinuation of all NSAID medications The nurse is reinforcing teaching with a client regarding their diagnosis of hepatic encephalopathy. Which statement by the client indicates that additional teaching is needed? 1"I will brush my teeth with a soft toothbrush to avoid bleeding gums." 2"I will eat enough protein and calories to stay healthy." 3"I will stop taking ibuprofen for my knee and back pain." 4"I will stop taking my lactulose when I have more than one loose stool." - CORRECT ANSWERS 4 The nurse is assisting with meal planning for a client with cholelithiasis. Which food items would be most appropriate for this client? (Select all that apply.) - CORRECT ANSWERS The most common cause of gallbladder disease is from stones that block the biliary ducts. Other causes are due to inflammation, infection, tumors or decreased blood flow due to damaged vessels. Intake of high cholesterol or fatty foods can increase the risk of gallbladder inflammation. To avoid inflammation, the client should follow a low cholesterol, low-fat diet and limit their intake of fried and processed foods such as breakfast cereals, lunch meats and microwavable meals. The nurse is assigned to care for a client with end-stage liver failure and portal hypertension. Which clinical manifestations would the nurse expect to see with these conditions? (Select all that apply.) Diminished pedal pulses Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass Shortness of breath Increased weight gain Increased abdominal girth Elevated serum albumin level - CORRECT ANSWERS Shortness of breath Increased weight gain Increased abdominal girth Which discharge instruction should the nurse make sure to include for a client with chronic pancreatitis? 1"Make sure to eat a low-fat, high-fiber diet." 2"Try to reduce smoking cigarettes to half a pack per day." 3"Limit alcohol intake to one drink a day." 4"Take the prescribed pancreatic enzymes on an empty stomach." - CORRECT ANSWERS 1 The nurse is assisting in developing as plan of care for a postoperative client following a radical left mastectomy. Which nursing problem should be the priority for this client? 1Risk of infection of the surgical site 2Anxiety related to the cancer diagnosis 3Acute pain related to the surgery 4Impaired left arm circulation (lymphedema) - CORRECT ANSWERS 3 The nurse is evaluating a client's understanding of appropriate dietary choices with chronic kidney disease. Which food choices by the client indicate an understanding of the teaching? (Select all that apply.) Fresh apples Baked chicken Unsalted pretzels Slice of cheese Orange juice Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass Baked potato - CORRECT ANSWERS Fresh apples Baked chicken Unsalted pretzels A client with chronic kidney disease (CKD) must limit intake of potassium, sodium, phosphorus and protein. In CKD, the kidneys are unable to adequately excrete these components. Foods low in potassium include: apples, grapes, lettuce and cauliflower. Foods high in potassium include: bananas, oranges, potatoes and spinach. Foods low in phosphorus include: chicken, shrimp, crab and rice. Foods high in phosphorus include: organ meats, salmon, scallops, nuts and cheese. A client comes to the community health clinic with symptoms of gonorrhea. Which intervention should the nurse implement first? 1Discuss the risk of infertility with the client. 2Collect a urethral swab from the client. 3Instruct the client to notify past sexual partners. 4Obtain information about the client's recent sexual encounters. - CORRECT ANSWERS 4 The nurse is assisting with developing a plan of care for a client with benign prostatic hyperplasia. Which nursing interventions should the nurse include for this client? (Select all that apply.) Limit caffeinated and alcoholic beverages. Calculate accurate intake and output. Void every 1 to 2 hours to empty the bladder. Catheterize as needed for post-void residual urine. Monitor for bladder distention. - CORRECT ANSWERS limit caffeine catheterize as needed monitor The nurse is reviewing the medical record of a client admitted with acute kidney injury. Which findings would support this diagnosis? (Select all that apply.) Proteinuria Hypokalemia Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass The nurse in the emergency department is admitting a client with a reduced level of consciousness due to severe hypothyroidism. Which interventions should the nurse implement first? 1Implement warming blankets as indicated. 2Orient the patient to person, time and place. 3Monitor O2 saturation and provide supplemental oxygen. 4Administer propranolol as prescribed. - CORRECT ANSWERS 3 The nurse is caring for a client who has type I diabetes mellitus. Upon entering the room, the nurse notes the client has rapid, deep respirations, and is lethargic and difficult to arouse. What should the nurse do first? 1Check the client's blood sugar. 2Administer glucagon per protocol. 3Review the client's insulin pump settings. 4Review when the last dose of insulin was given. - CORRECT ANSWERS 1 The nurse in the primary health care provider's office is speaking with a 40-year-old male client whose most recent hemoglobin A1C level was 9%. The client states that he is motivated to make lifestyle changes to better manage his disease. What interventions should the nurse recommend for this client? (Select all that apply.) Eliminate all consumption of alcohol. Minimize intake of caffeinated beverages. Schedule an appointment with a registered dietitian. Start a weight loss program until BMI is below 25. Check the blood sugar several times a day, ideally before eating. Engage in regular physical activity, such as walking. - CORRECT ANSWERS Schedule an appointment with a registered dietitian. Start a weight loss program until BMI is below 25. Check the blood sugar several times a day, ideally before eating. Engage in regular physical activity, such as walking. The nurse is reinforcing education for a client with type 2 diabetes mellitus who is being discharged home. Which statement by the client would require clarification from the nurse? Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 1"At home, I should check my blood sugar before meals and at bedtime." 2"It is important to increase my physical activity gradually." 3"I will make sure to have an eye exam every five years." 4"When I administer my insulin, I will rotate injection sites." - CORRECT ANSWERS 3 Eye exams should be performed annually for diabetic clients due to the risk of diabetic retinopathy. The nurse is caring for a client who has suspected Cushing's disease. The nurse should monitor for which potential symptoms? (Select all that apply.) Large fat pads on the back and shoulders History of pathologic fractures Tachycardia and panic attacks Changes in visual acuity Polyuria and polydipsia - CORRECT ANSWERS Large fat pads on the back and shoulders History of pathologic fractures Cushing's disease occurs when there is an excess amount of cortisol. The nurse must understand that glucocorticoids, including cortisol, regulate metabolism and immune function, and play a role in the regulation and distribution of serum calcium levels. Therefore, deposition of fat pads on the back and shoulders, as well as fractures secondary to osteoporosis, are signs and symptoms of Cushing's disease that the nurse should be able to recognize. The nurse is caring for a client who was admitted for hyperglycemic hyperosmolar state (HHS). Which clinical finding would support this diagnosis? 1Blood sugar > 600 mg/dL 2Positive urine ketones 3Deep, rapid breathing pattern 4Serum pH level < 7.35 - CORRECT ANSWERS 1 A client diagnosed with hypoparathyroidism would be most likely to display which of the following symptoms? 1Pruritus 2Flank pain Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass 3Decreased reflexes 4Polydipsia - CORRECT ANSWERS 1 The nurse is caring for a client with diabetes who was admitted for intractable vomiting. The nurse notes that the client's skin is cool to the touch, and the fingerstick blood sugar result is 55 mg/dL. What intervention should the nurse implement first? 1Administer glucagon. 2Recheck the blood sugar in 15 minutes. 3Offer the client a warm blanket. 4Administer an antiemetic. - CORRECT ANSWERS 1 The nurse is reviewing the plan of care for a client with acute adrenocortical insufficiency. Which intervention should be a priority for this client? 1Administration of potassium supplements 2Electrocardiogram monitoring 3Implementation of a low-sodium diet 4Administration of insulin - CORRECT ANSWERS 2 The nurse understands that the prescribed levothyroxine is effective when the client with hypothyroidism makes which statement? 1"I still feel lethargic and fatigued." 2"I have been having daily, formed bowel movements." 3"I have to change my sheets in the morning because I sweat a lot at night." 4"I was reprimanded at work after becoming angry with my boss." - CORRECT ANSWERS 2 The nurse is caring for a client who presents with polyuria, polydipsia and a urine specific gravity of 1.002. The nurse suspects that the client is experiencing diabetes insipidus. Which risk factors would support this diagnosis? (Select all that apply.) Recent neurologic injury Current use of lithium History of recent surgery History of radiation treatment Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass A client has received instructions for the management of osteoarthritis. Which statement by the client would indicate a need for additional teaching? 1"Early surgical intervention is the preferred treatment." 2"Gradual weight loss may help my pain." 3"It is important for me to balance my exercise and rest periods." 4"I will avoid driving after I have taken cyclobenzaprine." - CORRECT ANSWERS 1 The nurse is reviewing the medical record of a client who has been diagnosed with systemic lupus erythematous (SLE). The nurse would expect which findings associated with this disease? (Select all that apply.) Generalized weakness Reports of pain in the hands and knees A recent ten pound weight gain A temperature of 100.6° F (38° C) Polydipsia for the last month A red, raised rash on the face - CORRECT ANSWERS generalized weakness reports of pain temperature of 100.6 red, raised rash A client who has osteoarthritis, affecting both knees, is reporting constant pain at a level of 4 on a 0 to 10 scale. Which nonpharmacological intervention should the nurse implement for this client to help alleviate the pain? 1Position the client with the knee joints in a flexed position. 2Provide opportunity for the client to participate in hydrotherapy. 3Collaborate with physical therapy for paraffin dips to the knees. 4Place the client on strict bedrest with bathroom privileges only. - CORRECT ANSWERS 2 Soaking in a hot bathtub or doing hydrotherapy with physical therapy provides warmth that will decrease pain. The buoyancy of the client's body in water decreases weight on the joints, which will also decrease pain. Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass The nurse in the urgent care clinic is reinforcing teaching for a client who is being discharged with a new cast on the left arm due to a spiral fracture. Which statement indicates that the client correctly understands how to care for the cast? 1"I will avoid using ice the first 24 hours that my cast is on." 2"A moderate amount of daily drainage from my cast is expected." 3"I will notify my health care provider if my hand becomes pale." 4"I should be able to fit three fingers between the cast and my skin." - CORRECT ANSWERS 3 The nurse is assisting in the admission of a 73-year-old client who has a fractured right hip. Which interventions should the nurse include in the client's plan of care? (Select all that apply.) Ask about the client's pain level with every set of vital signs. Perform daily circulation, motion and sensation checks on the client's right leg. Palpate the client's bilateral pedal pulses every four hours. Place the client on continuous pulse oximetry. Reposition the client every hour to prevent skin breakdown. - CORRECT ANSWERS The client with a hip fracture is at risk for impaired perfusion to the affected extremity. Monitoring bilateral pedal pulses allows the nurse to compare the pulse strength in the injured site with that in the non-injured site. A decrease in the injured leg could signal a decrease in circulation that would require immediate intervention. A fat embolism is also a risk with a hip fracture and continuous pulse oximetry would allow the nurse to identify hypoxia quickly which could be associated with a fat embolism. Clients with a hip fracture usually experience great pain and assessing pain with each set of vital signs is key to effective pain management. Circulation, motion and sensation checks should be completed at least every four hours, not daily. The nurse is assisting in the preoperative plan of care for an older adult client who will be undergoing a total hip arthroplasty. To improve the client's postoperative course, which interventions should the nurse plan for? (Select all that apply.) Preoperative pain control with naproxen Instruction on plantar and dorsiflexion exercises Administration of subcutaneous warfarin The use of assistive devices for ambulation Application of sequential compression devices - CORRECT ANSWERS Due to the client's age and the surgical procedure, the client is at risk for a venous thromboembolism. The nurse should include the use of sequential compression devices to decrease venous stasis along with providing instruction on plantar and dorsiflexion exercises. Warfarin is administered orally; it does not come in an injectable form. The client will most likely need assistive devices initially for safe ambulation postoperatively. Ncsbn Nclex Questions And Answers Latest Updated 2024/2025 All Answers 100% Correct Detailed Best Graded A+ For Excellent Pass Preoperatively, the nurse should not use naproxen to control pain because it is a nonsteroidal anti- inflammatory drug (NSAID) and can increase the risk of bleeding during surgery. The nurse is caring for a client who is experiencing an acute gout attack. Which action should the nurse implement? 1Monitor liver enzymes. 2Provide a high-protein diet. 3Restrict sodium intake. 4Administer indomethacin. - CORRECT ANSWERS 4 the nurse should administer a non-steroidal anti-inflammatory medication such as indomethacin to help decrease pain and inflammation. The nurse is reinforcing teaching regarding the use of methotrexate with a female client who has systemic lupus erythematosus. Which statement by the client indicates an understanding of the teaching? 1"I should not use contraception that contains estrogen." 2"I will avoid interacting with people in large crowds." 3"Lab work won't be necessary while I take this medication." 4"I will not take any vitamin that contains folic acid." - CORRECT ANSWERS 2 Methotrexate is an immunosuppressant medication that is used to treat systemic lupus erythematosus (SLE). Due to immunosuppression, clients taking methotrexate should avoid large crowds of people to prevent becoming ill. Methotrexate should be taken with folic acid to decrease gastrointestinal and hepatic toxicity. Clients who are taking this medication should have a complete blood count test done regularly to monitor for decreased white blood cells and platelets, which can indicate bone marrow suppression. Methotrexate is teratogenic, therefore, pregnancy should be avoided while taking this medication. The nurse is caring for a client with osteoporosis who has been prescribed alendronate. When providing care, which intervention would be a priority? 1Notify the health care provider if the client reports jaw pain. 2Monitor the client's serum calcium levels. 3Encourage the client to increase their intake of vitamin D. 4Administer the alendronate 30 to 60 minutes before the client eats. - CORRECT ANSWERS 1