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NCLEX 2024 PRACTICE
QUESTIONS WITH CORRECTLY
SOLVED AND UPDATED
SOLUTIONS
A nurse is caring for a client who has a depressed skull fracture of the bone that makes up the larger part of the upper and side wall of the cranium. This fracture is located on which of the following bones? a. sphenoid b. occipital c. parietal d. frontal - Correct Answer-Parietal -sphenoid forms part of face -occipital is the back of the skull -frontal is the front of the skull What is the primary dietary alteration for a client who has heart failure? - Correct Answer-Sodium Restriction ex: turkey sandwich with whole-wheat bread
A nurse is caring for a client who has multiple sclerosis and is receiving interferon beta-1a. The nurse should identify that which of the following client statements indicates a potential adverse effect of the medication? a. my body aches all over b. I have abdominal cramping c. my hair seems to be thinning d. it hurts when I urinate - Correct Answer-My body aches all over -adverse effects of interferon beta-1a include flu-like symptoms A nurse is teaching a client with cystic fibrosis about daily chest physiotherapy. Which of the following is the purpose of these treatments? a. to encourage deep breaths b. to mobilize secretions in the airways c. to dilate the bronchioles d. to stimulate the cough reflex - Correct Answer-To mobilize secretions in the airways
- the purpose is to loosen and promote the drainage of secretions from the lungs A nurse is performing a nonstress test (NST) on a client who is at 41 weeks of gestation. The client asks what the purpose of the test is/ Which of the following responses should the nurse provide? a. this test will determine if you are likely to deliver within the next week b. this test will help determine if your baby is healthy c. this test can see how you baby responds when you have contractions d. this test will determine if you're baby's lungs are mature - Correct Answer- This test will help determine if your baby is healthy
- This NST is used as a prenatal fetal assessment, it tracks fetal heart rate patterns expected with fetal movement and can help identify fetal distress A nurse cares for a client receiving chemotherapy. The latest blood work shows: platelet count 18,000/mm WBC count of 5,000/mm
a. obtain sample menus from the dietitian to give to the client b. ask the client to identify the types of food she prefers c. identify the recommended range of the client's blood glucose level d. discuss long-term complications that can result from non-adherence to the dietary plan - Correct Answer-Ask the client to identify the types of food she prefers -Nursing process: assess, diagnosis, planning, implementation and evaluation A nurse is providing dietary teaching to a client who has late-stage chronic kidney disease (CKD). Which of the following nutrients should the nurse instruct the client to increase her diet? a. calcium b. phosphorus c. potassium d. sodium - Correct Answer-Calcium -CKD can cause hypocalcemia due to reduced production of vitamin D which is needed for calcium absorption -Clients with CKD can develop hyperphosphatemia, hyperkalemia and hypernatremia The nurse assesses a client who has new onset atrial fibrillation. The ventricular rate is 145 beats/min. What does the nurse expect to observe? a. head and neck pain b. bilateral lower extremity swelling c. distended jugular veins d. dizziness and dyspnea - Correct Answer-Dizziness and dyspnea -uncontrolled atrial fibrillation can result in acute drop in cardiac output. s/s are dizziness and shortness of breath -bilateral lower swelling = high salt, stay in position too long, heart failure, kidney failure, etc. -distended jugular signs of chronic heart failure, fluid overload, pulmonary hypertension, cardiac tamponade
A nurse is caring for a newborn immediately following delivery. Which of the following actions should the nurse perform first? a. perform a detailed physical assessment b. place the newborn directly on the client's chest c. give the newborn IM vitamin K d. administer erythromycin ophthalmic ointment - Correct Answer-Place the newborn directly on the client's chest A nurse is interviewing a client who is seeking help from intimate partner violence. Which of the following client statements should the nurse identify as an indication that the client is in the tension-building phase of the cycle of violence? a. last night my partner beat me worse than ever before b. it'll be easier just to make my partner mad and get the violence over with c. I believe my partner is remorseful and won't hurt me again d. I only get shoved a little bit, and it was my fault for coming home late - Correct Answer-I only get shoved a little bit, and it was my fault for coming home late -during tension-building phase violence is often minor and the recipient might rationalize it A nurse on an oncology unit is providing discharge teaching to an adolescent female client who received a bone marrow transplant for leukemia. Which of the following pieces of information should the nurse include in the teaching? (select all) a. take your temperature twice each day b. you may return to school if you feel strong enough c. it is important to wear shoes always d. clean your toothbrush weekly with isopropyl alcohol e. avoid using tampons - Correct Answer-a. Take your temperature twice each day c. It is important to wear shoes always e. Avoid using tampons
- avoid infection, patient is extremely immunosuppressed
- compatible tissue and blood types are the most important factors when matching a donor to a recipient A nurse is preparing to administer digoxin to a client. Which of the following findings should the nurse identify as a contraindication to the client receiving this medication? a. blood pressure 180/70 mmHg b. oxygen saturation rate 94% c. heart rate 51/min d. respiratory rate 21/min - Correct Answer-Heart rate 51/min -digoxin slows down the heart rate A nurse is caring for an older adult client who has chronic obstructive pulmonary disease (COPD) with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? a. respiratory alkalosis b. respiratory acidosis c. metabolic alkalosis d. metabolic acidosis - Correct Answer-Respiratory acidosis -common COPD complication occurs because clients are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs A nurse is completing dietary teaching with a client who has heart failure and is prescribed a 2g sodium diet. Which of the following statements by the client indicates an understanding of the teaching? a. I should use salt sparingly while cooking b. I can have yogurt as a dessert c. I should use baking soda when I bake d. I should use canned vegetables instead of frozen - Correct Answer-I can have yogurt as a dessert -yogurt is low in fat and sodium and is a good source of calcium and protein
A nurse is preparing a client who has a brain tumor for computed tomography (CT). Which of the following factors affects the manner in which the nurse will prepare the client for the scan? a. no food or fluids consumed for 4hr b. difficulty recalling recent events c. development of hives when eating shrimp d. paresthesia in both hands - Correct Answer-Development of hives when eating shrimp -allergy to shellfish is a contraindication for the use of contrast media A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following adverse effects? a. diarrhea b. increased serum albumin c. hypoglycemia d. peritonitis - Correct Answer-Peritonitis (when the thin layer of tissue inside abdomen becomes inflamed) -note peritoneal dialysis can cause decreased serum albumin A nurse is teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. Which of the following topics should the nurse include? a. smoking cessation b. benefits of a diet high in cruciferous vegetables c. new types of ostomy appliances d. importance of colonoscopy screening starting at age 50 years old - Correct Answer-Importance of colonoscopy screening starting at age 50 years old -Primary (action that prevents the development of a disease) smoking cessation and benefits of diet in cruciferous vegetables -Secondary (actions that promotes early detection of disease) screening -Tertiary (action that minimizes the effects of long-term disease or disability) ostomy appliances
d. implement restraints and seclusion as needed - Correct Answer-Taper the medication gradually over several weeks -Alprazolam (Xanax) - benzodiazepines = anti anxiety While performing passive range of motion (PROM), the client reports discomfort with an abduction exercise. After stopping the exercise, which action does the nurse take next? a. complete a focused pain assessment b. ask the client if heat or ice to the area is preferred c. offer a dose of PRN analgesia to the client d. report the pain to the healthcare provider - Correct Answer-Complete a focused pain assessment -the nurse should perform an assessment as the next step to guide further actions A client with emphysema is short of breath. The nurse assists the client into which position? a. supine with pillows under the legs b. lying to the left side c. leaning back in a recliner d. sitting upright and leaning forward - Correct Answer-Sitting upright and leaning forward -emphysema is a lung disease that causes breathlessness (usually caused by cigarette smoking, no cure) A nurse is assessing a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction? a. severe hypertension b. low body temperature c. sudden oliguria d. decreased respirations - Correct Answer-Sudden oliguria
-acute intravascular hemolytic reaction causes acute kidney injury resulting in oliguria and hemoglobinuria (blood in urine) A nurse in an emergency department is caring for a 4 year old who has burns to the neck and face following a house fire. Which action should the nurse take first? a. cover the child's wounds with a clean, dry cloth b. establish IV access with a large-bore catheter c. provide reassurance to the child's parents d. determine the child's breathing pattern - Correct Answer-Determine the child's breathing pattern (ABCs) A nurse is caring for an 18 year old adolescent who is up to date on immunizations and is planning to attend college. The nurse should recommend which immunization prior to moving into the dormitory? a. pneumococcal polysaccharide b. meningococcal polysaccharide c. rotavirus d. herpes zoster - Correct Answer-Meningococcal polysaccharide -immunization to prevention meningococcal bacteria (which can cause meningitis and meningococcemia) A nurse is working in a mental health facility is admitting a client with opioid use disorder who is experiencing withdrawal. The nurse should anticipate a prescription for which of the following medications from the provider? a. methylnaltrexone b. methadone c. naloxone d. hydromorphone - Correct Answer-Methadone -opioid medication used for pain management and treatment of withdrawal manifestations in clients with opioid use disorder -Methylnaltrexone = treat opioid-induced constipation
d. warming the irrigation fluid to at least 37 C (98 F) - Correct Answer- Instilling 50 mL of fluid with each irrigation
- should use no more than 5 to 10 mL of irrigating fluid at a time to decrease the chance of stimulating the vestibular nerve of the inner ear A nurse in an emergency department is assessing a school-aged child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider? a. excessively prolonged expiration b. increased diaphoresis c. increased production of frothy sputum d. sudden decrease in wheezing - Correct Answer-Sudden decrease in wheezing
- indicates child is experiencing decreased air movement and A nurse is caring for a child who has glomerulonephritis. Which of the following actions should the nurse take? a. monitor the child's blood pressure twice per day b. maintain the child on bed rest for 3 days c. weigh the child once each day d. increase the child's daily intake of sodium - Correct Answer-Weigh the child once each day (to monitor fluid balance)
- Glomerulonephritis = inflammation and damage to the filtering part of the kidneys (can cause hypertension, should have regular diet with moderate sodium restriction) A nurse is assessing an infant who develops respiratory distress, absence of breath sounds on one side, and deviation of the trachea away from the affected side. Based on these manifestations, which of the following conditions is the infant experiencing? a. tension pneumothorax b. flail chest c. pulmonary contusion
d. fractured rib - Correct Answer-Tension pneumothorax
- the infant may also become cyanotic and show asymmetry of the thorax
- Flail chest = pulling of traumatized rib area inward during inspiration and outward during expiration
- Pulmonary contusion = decreased breath sounds, tachycardia, tachypnea, and blood-tinged secretions
- Fractured rib = pain and ecchymosis (bruise) in area of trauma, swelling and muscle spasms A nurse is providing teaching to a client who has COPD about maintaining proper nutrition. Which of the following statements by the client indicates an understanding of the teaching? a. I will increase my fluid intake when I eat a meal b. I will eat more cold foods at meals rather than hot foods c. I will avoid high-fat foods like butter and gravies d. I will cook my meals instead of eating convenience foods - Correct Answer- I will eat more cold foods at meals rather than hot foods
- cold foods provide a decreased feeling of fullness compared to hot foods (remember we want to increase nutrition) A nurse is providing teaching about baclofen to the guardian of a toddler who has cerebral palsy. Which of the following adverse effects should the nurse include? a. bradycardia b. muscle weakness c. diarrhea d. dry skin - Correct Answer-Muscle weakness
- and dizziness, drowsiness and nausea A nurse is providing teaching to a client who has a new prescription for clozapine. Which of the following statement should the nurse include in the teaching?
- fluid balance is maintained by a variety of regulators: renal and endocrine
- parathyroid glands regulate calcium levels
- prothrombin is a clotting factor produced in the liver A nurse is planning care for a client who has AIDS and has developed stomatitis. Which of the following interventions should the nurse include in the plan of care. a. rinse the mouth with chlorhexidine solution every 2 hr b. limit fluid intake with meals c. provide oral hygiene with a firm-bristled toothbrush after each meal d. avoid salty foods - Correct Answer-Avoid salty foods
- stomatitis is an inflammation of the mucosa of the mouth, usually with ulcerations - spicy and acidic or salty food should be avoided for preventing further irritation A home health nurse is talking with the partner of a client who has dementia. Which of the following statements by the partner indicates that the client is displaying signs of apraxia? a. yesterday, my partner put on a jacket upside down b. my partner has trouble reading the newspaper c. my partner often repeats words d. last week, my partner did not recognize the sound of the alarm clock - Correct Answer-Yesterday, my partner put on a jacket upside down (apraxia - lack of ability to accomplish once known tasks)
- agraphia = decrease ability to read or write
- perseveration - repetition of word or phrase
- agnosia - loss of the ability to recognize objects, this loss can be auditory, visual or tactile A nurse is teaching a client who has type 1 diabetes mellitus about a new subcutaneous insulin infusion pump. Which of the following pieces of information should the nurse include in the teaching? a. plan to use a type of short-duration insulin in the infusion pump
b. replace the infusion pump set every 4 days c. turn off the infusion pump for at least 3 hours each day d. move the infusion pump catheter 1.27 cm (0.5 in) away from the old site - Correct Answer-Plan to use a type of short-duration insulin in the infusion pump
- this subcutaneous insulin infusion pump should be replaced every 1 to 3 days, there should be constant infusion and the catheter infusion site should be moved at least 2.54 cm (1 in) away from old site to maintain tissue integrity A nurse at a pediatric clinic is assessing a 5-month-old infant during a well- child visit. Which of the following findings should the nurse report to the provider? a. head lagging when the infant is pulled from a lying to a sitting position b. absence of startle and crawl reflexes c. inability to pick up a rattle after dropping it d. rolling from back to side - Correct Answer-Head lagging when the infant is pulled from a lying to a sitting position
- at 5 months = infant should have enough head lag
- startle reflex disappears by the age of 4 months
- the crawl reflex disappears around 6 weeks
- at 5 months the infant can follow a dropped object but can't pick it up until 6 months
- at 4 months the infant should be able to roll form back to side A nurse is providing teaching to a client who has constipation. Which of the following instruction should the nurse include? a. use bismuth subsalicylate regularly b. consume a low-fiber diet c. eat yogurt with live cultures d. use bisacodyl suppositories regularly - Correct Answer-Eat yogurt with live cultures
- bismuth subsalicylate (antidiarrheal)
A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child? a. cutting figures from colored paper b. drawing stick figures using crayons c. riding a tricycle d. building towers with blocks - Correct Answer-Building towers with blocks
- 3 year-olds work with scissors
- 4 year-olds draw stick figures
- 3 year-olds ride tricycle. A nurse is teaching a client who is pregnant and has pregestational diabetes about dietary changes. Which of the following statements should the nurse include in the teaching? a. carbohydrates should make up to 55% of your diet b. protein should make up 70% of your diet c. fats should make up 45% of your diet d. fiber should make up 10% of your diet - Correct Answer-Carbohydrates should make up to 55% of your diet
- For client who have pregestational diabetes, intake of simple carbohydrates should be limited. The ideal diet is composed of 55% carbohydrates, 20% protein, 25% fat and less than 10% saturated fat -There is no limit on fiber, fiber should be recommended to clients to decrease constipation which is an often problem in pregnancy The nurse in the emergency room cares for a client who has a traumatic brain injury (TBI). The healthcare provider has prescribed 100 mL of 3% saline to infuse at 45 mL/hr via a central line. What is the purpose of this infusion for this client? a. it is prescribed to reduce the risk of serum sodium imbalances b. this solution will rapidly decrease the vascular and cerebral fluid volume c. this solution will maintain a serum sodium level greater than 160 mmol/L (136-145 mmol/L)
d. it is a hypertonic solution that is used to decrease intracranial pressure (ICP) - Correct Answer-It is a hypertonic solution that is used to decrease intracranial pressure (ICP)
- 3% saline draws fluid out of edematous cerebral tissues because of its higher concentration of sodium and a lower concentration of water than blood
- serum sodium should be 145 mmol/L or less (135-145) A nurse is caring for a client with a pseudomonas infection who has a new prescription for ticarcillin clavulanate. Which of the following data should the nurse collect before administering this medication? a. indications of super infection b. peak and through medication levels c. baseline BUN and creatinine d. history of allergy to aminoglycoside antibiotics - Correct Answer-Baseline BUN and creatinine Ticarcillin-clavulanate is a penicillin antibiotic and is excreted by the kidneys. Therefore renal impairment could result, so checking BUN and creatinine levels are important while giving this medication A nurse is completing the admission history for a client who reports drinking 1 pint of whiskey every day for 6 years. The clients last drink was 10 hr ago. Which of the following medications should the nurse plan to administer upon admission? a. chlordiazepoxide b. disulfiram c. naloxone d. acetaminophen - Correct Answer-Chlordiazepoxide
- benzodiazepines are the most effective medication for alcohol withdrawal
- disulfiram - used to help overcome drinking problems, once detox is accomplished
- naloxone - antidote for opioid overdose
- acetaminophen and alcohol increases the client's risk of liver damage
