Nursing NCLEX RN EXAM QUESTIONS WITH BEST RATED ANSWERS LATEST UPDATE GUARANTEED SUCCESS A, Exams of Nursing

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NCLEX RN EXAM QUESTIONS WITH BEST RATED

ANSWERS LATEST UPDATE GUARANTEED

SUCCESS A+

1. Which of the following clients is at a higher risk of developing oral health problems? a. A pregnant client b. A client with diabetes c. A client receiving chemotherapy d. Both b and c
2. Which nursing intervention is most appropriate to reduce environmental stimuli that may cause discomfort for a client? a. Loosen pressure dressings on wounds b. Use assistance to pull a client up in bed c. Check temperature of water used in a sponge bath d. Position the client prone
3. A client has developed a vitamin C deficiency. Which of the following symptoms might the nurse most likely see with this condition? a. Cracks at the corners of the mouth b. Altered mental status c. Bleeding gums and loose teeth d. Anorexia and diarrhea

4. Which of the following interventions should a nurse perform for a female client who is incontinent with impaired skin integrity? a. Turn the client at least every 8 hours b. Apply lotion to the skin before a bath

c. Provide perineal care after the client uses the bathroom d. Bathe the client every 3 days

5. A nurse is caring for a client who died approximately one hour ago. The nurse notes that the client's temperature has decreased in the last hour since his death. Which of the following processes explains this phenomenon? a. Rigor mortis b. Postmortem decomposition c. Algor mortis d. Livor mortis
6. A nurse is calculating a client's intake and output. During the last shift, the client has had ½ cup of gelatin, a skinless chicken breast, 1 cup of green beans, and 300 cc of water. The client has urinated 250 cc and has had 2 bowel movements. What is this client's intake and output for this shift? a. 420 cc intake, 250 cc output b. 300 cc intake, 250 cc output c. 550 cc intake, 550 cc output d. 300 cc intake, 550 cc output
7. A nurse is caring for a client with ariboflavinosis. Which of the following foods should the nurse serve this client? a. Citrus fruits b. Milk

c. Fish d. Potatoes

8. A client is taking a walk down the hallway when she suddenly realizes that she needs to use the restroom. Although she tries to make it to the bathroom on time, she is incontinent of urine before reaching the toilet. What type of incontinence does this situation represent? a. Reflex incontinence b. Urge incontinence c. Total incontinence d. Functional incontinence
9. Which of the following is an example of a positive effect of exercise on a client? a. Decreased basal metabolic rate b. Decreased venous return c. Decreased work of breathing d. Decreased gastric motility
10. You have taken the vital signs for your patient. They are normal for the patient. What should you do next? a. Report the vital signs to the doctor b. Write the vital signs on a scrap paper c. Call the family members d. Document them on the graphic VS form
11. Penny Thornton has had a stroke, or CVA. She is having difficulty eating on her own. Soon, she will be getting some assistive devices for eating meals.

Which healthcare worker will be getting Penny these assistive devices? a. A physical therapist b. A speech therapist

c. A social worker d. An occupational therapist

12. Which of the following is an example of emotional abuse? a. A slap to the person's hand b. Threatening the person c. Ignoring and isolating a person d. Leaving a patient soiled for hours
13. Which of the following is an example of emotional neglect? a. A slap to the person's hand b. Threatening the person c. Ignoring and isolating a person d. Leaving a patient soiled for hours
14. The duodenum: a. is the third section of the small intestine, which leads immediately to the colon. b. is the section of the stomach where the gall bladder delivers bile. c. is the section of the small intestine where the pancreas delivers insulin. d. None of the above.
15. The nurse is performing discharge teaching for Mrs. S after cardiac angioplasty. Her husband is present for the teaching. While explaining the prescription for antiplatelet medication to use at home, Mrs. S's husband states, "I

don't think I can afford to refill that medication." What is the most appropriate response of the nurse? a. Don't worry, your insurance will cover it."

b. I'll ask the physician if he can prescribe a medication that is more affordable." c. You should apply for Medicare to see if they can help you." d. This medication is essential for her care and should be given priority over all others that she is taking."

16. The discharge planning team is discussing plans for the dismissal of a 16- year old admitted for complications associated with asthma. The client's mother has not participated in any of the discharge planning process, but has stated that she wants to be involved. Which of the following reasons might prohibit this mother from participating in discharge planning? a. The client is an emancipated minor b. The mother has to work and is unavailable c. The client has a job and a driver's license d. The mother does not speak English
17. A nurse enters a client's room and finds her lying on the floor near the bathroom door. As the nurse provides assistance, the client states, "I thought I could get up on my own." What information must the nurse document in this situation? a. A statement explaining the condition the client was found in, quoting the client's words about the situation b. An explanation of how the fall happened and when the physician was notified c. An account of the conditions of the room that contributed to the client's fall d. A description of the client's condition and the reasons why she should have had assistance to the bathroom
18. Which of the following may be a cultural barrier that impacts a nurse's ability

to provide care or education to the client? a. A nurse offers educational materials to a client that are written at an 8th grade reading level b. A Vietnamese woman wants to use steaming in addition to her prescription antibiotics

c. A nurse uses pantomime to explain a procedure to a deaf client d. A Native American client requests a healing ritual before he will consider surgery

19. Which of the following is an example of low health literacy skills? a. A nurse's aide cannot calculate the correct IV rate for Ringer's lactate b. A client cannot read an admission form to sign it c. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine d. A client does not understand the treatment for his cholecystectomy
20. A 39-year old woman presents for treatment of excessive vaginal bleeding after giving birth to twins one week ago. Which nursing diagnosis is most appropriate in this situation? a. Knowledge Deficit related to post-partum blood loss b. Self-Care Deficit related to post-partum neglect c. Fluid Volume Deficit related to post-partum hemorrhage d. Body Image Disturbance related to body changes after delivery
21. Mr. K is admitted to the orthopedic unit one morning in preparation for a total knee replacement to start in two hours. Which of the following is a priority topic to instruct this client on admission? a. The approximate length of the surgery b. The type of anticoagulants that will be prescribed c. The time of the next meal of solid food

d. The length of time until the client can return to work

22. Which of the following is an example of the intervention phase of the individualized nursing care plan for a client who receives a colostomy after a bowel resection? a. Taking a health history and performing a physical exam prior to the procedure b. Instructing the client about how to care for his colostomy stoma c. Developing goals that state the client will ambulate three times a day d. Determining that the client may need more support at home after dismissal
23. Which method best describes the use of evidence-based practice? a. Reading and analyzing research reports to see how they can be implemented into nursing practice b. Collecting data to determine how efficiently nursing practice is contributing to quality care c. Monitoring unit practices to determine compliance with Joint Commission standards d. Using the most effective, current, and applicable information available to guide nursing care for the best of the clients.
24. A public health nurse discovers that many of the children in the neighborhood where she works are developing lead toxicity. She implements a program to screen for lead exposures among clients in the community. This is an example of: a. Social justice b. Policy resources c. Autonomy

d. Moral justification

25. Which of the following is an example of whistle blowing? a. A nurse contacts administration about a colleague who takes supplies to use for a mission trip b. A client sues a nurse because she failed to call the physician about his wound infection

c. A nursing assistant calls for help when a client falls out of bed d. A client developed a sacral pressure ulcer when he was not turned in bed for over four hours

26. Which situation might require an occupational health nurse consult? a. A nurse is injured from using incorrect body mechanics to lift a client b. A nurse receives a subpoena to testify in court about a client's case c. A client who has been injured in a diving accident needs assistance with planning rehabilitation and surgery d. A nursing unit is implementing a new electronic health record system
27. Which of the following is the most appropriate example of anticipatory guidance for a 16- year old who has been hospitalized for an ankle fracture? a. Changes associated with puberty b. Driving and staying safe c. The health hazards of smoking d. Social media influences
28. Which action represents the evaluation stage of the plan of care? a. The nurse assigns a nursing diagnosis of Impaired Skin Integrity related to diminished skin circulation b. The nurse assesses the client's vital signs and asks about symptoms c. The nurse determines that the client is not meeting his set outcomes and makes revisions d. The nurse discusses the client's health history

29. Which of the following screening tools have been found to have a high diagnostic accuracy for screening for intimate partner violence?

a. Hurt, Insult, Threaten and Scream (HITS) b. Humiliation, Afraid, Rape, and Kick (HARK) c. Slapped, Threatened and Thrown (STaT) d. All the above

30. What is the relationship between HIPPA and technological advances? a. Technology helps to foster HIPPA confidentiality. b. Computers help us to share information with others. c. Computer screens are not visible to others in the area. d. Technology places us at risk for HIPPA violations.
31. Which technological advance is MOST likely to place you at risk for HIPPA violations? a. Social media b. Word processing programs c. Spreadsheets d. Clouds and SOEs
32. A patient is having a colposcopy procedure performed. How should the patient be instructed to prepare for the procedure? a. NPO for 8-12 hours before the procedure. b. D/C all HTN Rx for two days prior to the procedure. c. Take three Dulcolax tablets and two containers of Miralax the day before to

clear out the lower GI system. d. None of the above prep is necessary for this type of procedure.

33. A physician is explaining a procedure to a patient that may cure her recurring Staph infection. The doctor explains how the procedure is done, what to expect, the odds of the procedure curing the infection, and possible side effects and risks. The physician is: a. Preparing the patient to give informed consent. b. Protecting HIPAA by listing all of the steps of the procedure with the risks involved. c. Not required to inform the patient of any alternative therapies. d. None of the above.
34. Teresa is an 84-year-old with stage 4 ovarian cancer who has been admitted for a bowel obstruction. She recently stated that she has decided that she doesn't want any further aggressive care and is requesting to be placed under hospice care. Her husband and daughter are supportive of her decision. She spoke with her oncologist about it, and he stated that he did not agree, and wrote orders on her chart for chemotherapy. What would be the best first response to this situation? a. Give the patient a list of other oncologists b. Tell the family to report the doctor to the state quality board c. Notify the doctor that the patient refuses the chemotherapy d. Give the patient hospice information
35. Upon entering an elderly patient's room, you find a research assistant with a clipboard, obtaining consent to participate in a new study. After signing the form, the patient begins to ask questions about the study. The assistant smiles and says, "Don't worry about all that, we'll take good care of you. Now enjoy the chocolate I brought." What should your first response be? a. Ignore the patient's questions

b. Stop the assistant and question the consent c. Notify the nurse manager d. Notify the research department

36. Monica is a 28-year-old nurse who had been admitted to the hospital after a near-drowning in which she suffered cardiac arrest and hypoxic encephalopathy. She has been stabilized and has a tracheostomy to room air. She has been on the general floor for several weeks, is in a persistent vegetative state, and has a very poor prognosis for any improvement in her neurological status. Monica had previously signed a living will, which indicated that she did not wish to receive enteral feedings to be kept alive if she had a terminal condition or was in a persistent vegetative state from other causes. Her parents have decided to move her to the hospice unit and have given permission for removal of her feeding tube. The patient care technician who has been caring for Monica is very distressed over this decision and feels that the parents are "killing" her. What would be an appropriate initial response? a. This will relieve the burden for her parents." b. Her parents have a right to make decisions for their child." c. Monica has stated her wishes and they should be honored." d. The ethics committee should be consulted."
37. Jack is a 2-month-old with a diagnosis of spinal muscular atrophy (SMA) type I. He has been admitted to the hospital for progressive respiratory difficulty. His parents have been informed that if he is not placed on ventilatory support, he will continue to decompensate and die of respiratory failure. Jack's physician discusses the poor prognosis of Jack's condition, and tells the parents that he will not be able to be removed from ventilatory support once it is initiated, due to his progressive neurological disease. After much discussion, the parents have decided to decline ventilatory support, agree to a do not resuscitate (DNR) order, and request hospice care for Jack. Another parent heard them discussing Jack's situation in the waiting room and says she could never do that to her baby. What is the most appropriate response to this parent? a. You never know what you'll do until you're in that situation." b. I can't discuss another patient's situation." c. They have been through too much already."

d. You can contact administration with your concerns."

38. You have noticed that the last several patients you have cared for have had questionable blood pressure readings from their arterial lines. When checked against cuff pressures, a discrepancy has been noted, and further investigation has revealed faulty transducers. This is not the first product issue with this company. What positive step could you take to help resolve this situation?

a. Use the old stock from a previous company b. Verify the cuff pressures every hour to ensure accuracy c. Notify the risk manager d. Form a peer workgroup to evaluate new products

39. The family of a patient who is receiving therapeutic hypothermia states they do not understand why the patient is being kept so cold. What objective information can you provide to help address their concerns? a. Let them talk to another patient who has had the same therapy b. Provide research-based information about therapeutic hypothermia c. Connect them with the nurse manager d. Call the physician and ask him to talk to the family
40. A family member is complaining that the lights are too dim in the middle of the night when she comes in to visit her husband. What is the most objective response? a. Patients sleep better with the lights dimmed." b. The nightshift nurses prefer to work with less light." c. It's time for him to sleep, and you should, too." d. There's a reason we do that. Let me share a research study with you."
41. You are attempting to teach the wife of a Greek patient how to administer his gastrostomy tube feedings once he returns home. She smiles and nods through your explanations, but when you ask her for a return demonstration, she looks confused and shakes her head. Her daughter enters the room and states that she does not speak English. What would be most helpful in this situation?

a. Teach the daughter instead b. Teach both and ask the daughter to translate for you

c. Contact a home health agency to provide care d. Provide a pamphlet with detailed instructions

42. What is a key principle of patient teaching that must take place to ensure patient safety? a. Family members should be present b. Teaching must be documented c. Understanding must be confirmed d. Teaching should be provided by multiple staff members
43. A client with adrenal insufficiency has a potassium level of 7.2 mEq/L. Which of the following signs or symptoms might the client exhibit with this result? a. Peaked T waves on the ECG b. Muscle spasms c. Constipation d. A prominent U wave on the ECG
44. A client is having difficulties reading an educational pamphlet. He cannot find his glasses. In order to read the words, he must hold the pamphlet at arm's length, which allows him to read the information. Which vision deficit does this client most likely suffer from? a. Cataracts b. Glaucoma c. Astigmatism