NCLEX QUESTIONS
Spring 2010 Set 1
(Answers follow all questions)
Fundamentals of Nursing
1. A nurse is preparing to care for a client who has returned to the nursing unit
following cardiac catheterization performed through the femoral artery. The nurse
plans to allow which client position or activity following the procedure?
A. Bed rest in high Fowler’s position
B. Bed rest with bathroom privileges only
C. Bed rest with head elevation at 60 degrees
D. Bed rest with head elevation no greater than 30 degrees
Maternity
2. A nurse is monitoring a client in labor. The nurse suspects umbilical cord
compression if which of the following is noted on the external monitor tracing
during a contraction?
A. Late decelerations
B. Early decelerations
C. Short-term variability
D. Variable decelerations
Pediatrics
3. A 1-year-old child with hypospadias is scheduled for surgery to correct this
condition. The nurse prepares a nursing care plan for this child and understands
that this surgery is taking place at a time when:
A. Fears of separation are great.
B. Sibling rivalry will cause regression to occur.
C. Concern over size and function of the penis is present.
D. Embarrassment about voiding irregularities is common.
Neurological Disorders (Adult)
4. The nurse is assessing the motor function of an unconscious client. The nurse
would plan to use which of the following to test the client’s peripheral response to
pain?
A. Sternal rub
B. Nail bed pressure
C. Pressure on the orbital rim
D. Squeezing of the sternocleidomastoid muscle
Musculoskeletal/Integumentary Disorders (Adult)
5. The nurse is caring for a client who had an above-knee amputation 2 days ago.
The residual limb was wrapped with an elastic compression bandage, which has
come off. The nurse immediately:
A. Calls the physician
B. Applies ice to the site
C. Rewraps the stump with an elastic compression bandage
D. Applies a dry sterile dressing and elevates it on one pillow
Oncological/ Immune Disorders (Adult)
6. As part of chemotherapy education, the nurse teaches a female client about the
risk for bleeding and self-care during the period of the greatest bone marrow
suppression (the nadir). The nurse understands that further teaching is needed
when the client states:
A. “I should avoid blowing my nose.”
B. “I may need a platelet transfusion if my platelet count is too low.”
C. “I’m going to take aspirin for my headache as soon as I get home.”
D. “I will count the number of pads and tampons I use when menstruating.”
Cardiovascular Disorders (Adult)
7. A nurse is evaluating the condition of a client after pericardiocentesis is
performed to treat cardiac tamponade. Which of the following observations would
indicate that the procedure was unsuccessful?
A. Rising blood pressure
B. Clearly audible heart sounds
C. Client expressions of relief
D. Rising central venous pressure
Respiratory Disorders (Adult)
8. A client has begun therapy with theophylline (Theo-24). A nurse plans to teach
the client to limit the intake of which of the following while taking this
medication?
A. Coffee, cola, and chocolate
B. Oysters, lobster, and shrimp
C. Melons, oranges, and pineapple
D. Cottage cheese, cream cheese, and dairy creamers
Endocrine Disorders (Adult)
9. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in an
emergency room. Which finding would a nurse expect to note as confirming this
diagnosis?
A. Comatose state
B. Decreased urine output
C. Increased respirations and an increase in pH
D. Elevated blood glucose level and low plasma bicarbonate level
GI/GU Disorders (Adult)
10. A client diagnosed with polycystic kidney disease has been taught about the
treatment plan for this disease. The nurse determines that the client needs
additional teaching if the client states that the treatment plan includes:
A. Genetic counseling
B. Sodium restriction
C. Increased water intake
D. Antihypertensive medications
Sensory Disorders (Adult)
11. The nurse is caring for a client following craniotomy for removal of an acoustic
neuroma. Assessment of which of the following cranial nerves would identify a
complication specifically associated with this surgery?
A. Cranial nerve I, olfactory
B. Cranial nerve IV, trochlear
C. Cranial nerve III, oculomotor
D. Cranial nerve VII, facial nerve
Psychiatric and Mental Health (Adult)
12. The client is admitted to a mental health unit for treatment of psychotic behavior.
The client is at the locked exit door and is shouting, “Let me out! There’s nothing
wrong with me. I don’t belong here.” The nurse analyzes this behavior as:
A. Denial
B. Projection
C. Regression
D. Rationalization
Answers
1. B: After cardiac catheterization, the extremity into which the catheter was inserted
is kept straight for 4-6 hours. If the femoral artery was used, bed rest is enforced
for 3-4 hours (or as prescribed by the physician). The client may turn from side to
side. The affected leg is kept straight and the head is elevated no more than 30
degrees until hemostasis is adequately achieved.
2. D: Variable decelerations occur if the umbilical cord becomes compressed, thus
reducing blood flow between the placenta and the fetus. Early decelerations result
from pressure on the fetal head during a contraction. Late decelerations are an
ominous pattern in labor because they suggest uteroplacental insufficiency during
a contraction. Short-term variability refers to the beat-to-beat range in the fetal
heart rate.
3. A: At the age of 1 year, a child’s fears of separation are great because the child is
facing the developmental task of trusting others. Options 3 and 4 might be issues
if the child were older. No data in the question allow one to determine that
siblings exist.
4. B: Motor testing in the unconscious client can be done only by testing response to
painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral
responses to pain are tested using sternal rub, placing upward pressure on the
orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
5. C: If the client with an amputation has a cast or elastic compression bandage that
slips off, the nurse must wrap the stump immediately with another elastic
compression bandage. Otherwise, excessive edema will form rapidly, which could
cause a significant delay in rehabilitation. If the client has a cast that slipped off,
the nurse would have to call the physician so that a new one could be applied.
Elevation on one pillow is not going to impede the development of edema greatly
once compression is released. Ice would be of limited value in controlling edema
from this cause. If the physician were called, the order likely would be to reapply
the compression dressing.
6. C: During the period of greatest bone marrow suppression (the nadir), the platelet
count may be low, less than 20,000 cells/mm3. Option 3 describes an incorrect
statement by the client. Aspirin and nonsteroidal anti-inflammatory drugs and
products that contain aspirin should be avoided because of their antiplatelet
activity; thus, further teaching is needed. Options 1, 2 and 4 are correct statements
by the client to prevent and monitor bleeding.
7. D: Following pericardiocentesis, a rise in blood pressure and a fall in central
venous pressure are expected. The client usually expresses immediate relief. Heart
sounds are no longer muffled or distant.
8. A: Theophylline (Theo-24) is a methylxanthine bronchodilator. The nurse teaches
the client to limit the intake of xanthine-containing foods while taking this
medication. These foods include coffee, cola, and chocolate.
9. D: In DKA, the arterial pH is lower than 7.35, plasma bicarbonate is lower than
15 mEq/L, the blood glucose level is higher than 250 mg/dL, and ketones are
present in the blood and urine. The client would be experiencing polyuria, and
Kussmaul’s respirations would be present. A comatose state may occur if DKA is
not treated, but coma would not confirm the diagnosis.
10. B: Individuals with polycystic kidney disease seem to waste rather than retain
sodium. Thus, they need increased sodium and water intake. Aggressive control
of hypertension is essential. Genetic counseling is advisable because of the
hereditary nature of the disease.
11. D: Treatment for acoustic neuroma is surgical removal via a craniotomy. Extreme
care is taken to preserve remaining hearing and preserve the function of the facial
nerve. Acoustic neuromas rarely recur following surgical removal.
12. A: Denial is refusal to admit to a painful reality, which is treated as if it does not
exist. In projection, a person unconsciously rejects emotionally unacceptable
features and attributes them to other persons, objects, or situations. In regression,
the client returns to an earlier, more comforting, although less mature, way of
behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or
feelings by developing acceptable explanations that satisfy the teller and the
listener.
References
Silvestri, L.A. (2008). Comprehensive Review for the NCLEX-RN Examination (4th edition). St Louis,
MO: Saunders.