NCLEX QUESTIONS
ANSWER
There is no bed available in the med-surg floor,
but there’s bed available at the pediatric unit,
which patient are you going to transfer?
1.
Post op breast CA patient
2. COPD client
3. Fracture of femur
4. TURP post op
3. Fracture of femur.
Rationales for answer:
1. Post op breast CA patient – chemo
involved, being around kids, complicated cre
2. COPD client – high risk for infection
4. TURP patient – CBI required,
complicated
Question #2
A patient is having ongoing hemodialysis. Which
medication is contraindicated?
1.
Amphojel
2.
Maalox
3.
Milk of Magnesia
4.
Magnesium Hydroxide
Question #3
Your patient has an allergy to pollen. Which of the
following advice should you give?
1. Do your gardening in the morning
2. Do your gardening late in the afternoon
3. Take a walk on the beach instead of hiking in
the woods
4. Focus your attention on dried flowers instead
Question #4
1.
Amphojel.
Amphogel contains phosphorous which is
contraindicated with kidney failure.
Magnesium is also, but less so than
phosphorous. This is a very icky question.
4. Focus attention on dried flowers instead
All other choices contain possible exposure
to allergens and pollen
A patient is on peritoneal dialysis. Which of the
following would cause you alarm 1 hour after
procedure?
1.
Frank, bloody drainage
2.
Light brown drainage
3.
No drainage
4.
Clear, yellow drainage
Question #5
1. Frank, bloody drainage. Any time you
have bloody return from CAPD, you have a
danger signal.
Which of the following signs would indicate that
a patient with esophageal varices is deteriorating?
1.
Pt complains of frequent swallowing
2.
Pt’s skin is cool and clammy
3.
An increase in body temperature
4.
The pt has abdominal distension
4. Pt has abdominal distension.
Esophageal varices develop in esophagus,
primarily in rectum and abdomen.
1.
Frequent swallowing is with
laryngectomy
2.
Cool & clammy is cardiac
3.
Increased body temp could signify
infection
Question #6
A pt has an aortic abdominal aneurysm. He is
complaining of a constant back ache. What would
you do?
1. Give pt a pillow to put between his legs and
tell him to lay on his side.
2. Give pt analgesic
3. Call MD immediately
4. Teach breathing exercises for pain
Question #7
Your patient has Meniere’s disease. Which of the
following would you teach?
1. Pt should eat high fiber diet
2. Pt should eat low protein, high carbs diet
3. Pt will not have to worry about tinnitus
4. Pt needs to have hearing tested
1
3. Call MD immediately. Back pain is an
indication of bleed. AAA may have ruptured.
None of the other options are valid
4.
Pt needs to have hearing tested.
Unilateral sensorineural hearing loss may be
present S&SX of Meniere’s disease include
tinnitus, nausea, vomiting and vertigo. All
diets should be high in calories but low in
carbs and fiber.
NCLEX QUESTIONS
ANSWER
Question #8
Your patient is scheduled for a liver biopsy.
Which of the following would be most important?
A.
PT results
B.
NPO 2 hours before
C.
Bedrest 6 hours after procedure
D. Low residue diet 24 hours before
Question #9
The patient should lean forward at the cane
B. The hand piece should allow for 30 degrees
of flexion at the elbow
C. The patient should put all of his weight on
the cane
D. The cane should be perfectly straight.
Question #10
Eggs
B.
Green leafy vegetables
C.
Fish
B. Should allow 30 degrees of flexion at
elbow.
If cane is too straight, the client won’t be
able to support all his weight and may injure
his back. The cane should extend from the
greater trochanter to the floor with a 20-30
degree flexion at elbow.
Answer
B. Green leafy vegetables. Eggs are high
in iron, fish is good source of protein and
oleic acid, cheese is good source of calcium
and tyramine.
Which of the following foods are highest in
Vitamin K?
A.
Bleeding is a major complication of liver
biopsy. Knowing PT may indicate whether
test is performed or not.
Answer
Which of the following would be the correct
position for a patient who is walking with a cane?
A.
A. PT results.
D. Cheese
Question #11
•You have a patient with Glaucoma and who had a
trabaeculotomy. You tell if post discharge teaching
was effective if he states which of the following?
–A. My eyesight will improve when I take my eye
drops for 6 months
–B. I should take my eye drops continually
–C. I should rub my eyes vigorously after
administration
–D. I should use my eye drops only if I have
symptoms
Question #12
•When teaching a patient about crutch walking,
which of the following gets first priority?
•A. Advance both crutches simultaneously
•B. Advance unaffectedleg first
•C. Place weight on arms and hands when using
crutch
•D. Advance affected leg first
Question #13
•You are caring for a burn patient with a serum
potassium of 4. Which of the following medications
would you question?
•A.
Morphine
•B. Demerol
•C. Potassium
•D. Tylenol
2
B. Eye drops should not be stopped
•A. Implies that pt can stop drops after 6
months •C. Never rub eyes vigorously after
administration •D. Implies only use drops if
have symptoms
•C. Place weight on arms & hands when
using crutch
st
•A. This is also correct, but is not 1
priority
•B. Always advance crutches first
•D. If advance affected leg first, will be
placing weight on that leg. Not a principle of
crutch walking.
•C. Potassium. Serum K is 4 which is WNL.
Also, with burn patients, you will see an
increase in K due to crushing injury. •All
other choices are OK because they are
analgesics though Tylenol may seem to be
too little.
NCLEX QUESTIONS
ANSWER
Question #14
•
nd
•A client is admitted to the hospital with deep 2
degree burns of the thighs, chest and arms
covering 40% of total BSA. As a result of the fluid
shift that initially follows such burns, the nurse
would expect which finding in the client?
Question #15
•A client who has undergone AKA has been in
wheelchair for 3 hours. The nurse assists him to
bed, placing him in the prone position. Why is this
position most appropriate?
–A. It decreases edema of the stump
–B. It strengthens the abdominal muscles
–C. It extends the affected hip joint
–D. It prevents pressure ulcer formation
Question #16
•Your patient has just undergone a liver biopsy.
Which nursing intervention would be of highest
priority.
•A. Measuring urine output
•B. Monitoring VS
•C. Checking CVP readings
•D. Checking heart rate
Question #17
The nurse is assessing a pt with COPD. Which of
the following findings would he expect to find?
a.An increase in abdominal girth
b.An increase in anterio-posterior diameter
c.A decrease in urine output
d.A decrease in respiratory rate
Question #18
•A patient who is bedridden for 2 wks has the
following lab values: pH 7.37, PO2 90, PCO2 40,
HCO3 25, with hypoalbuminemia and
hypocalcemia. Which of the following measures
require priority?
a.Offer foods rich in protein
b.Provide PROM
c.Give 3 servings of milk a day
d.Turn pt side to side q2h
Question #19
•Your patient has active tuberculosis. Which of
the following measures should you take to prevent
the spread of infection?
a.Wear a mask when going into patient’s room
b.Wear gown & gloves when giving care to pt
c.Advise relatives of pt to wear gown when visiting
pt
d.Close pt’s door always and minimize personnel
going into room
3
•A. Increased urine output
•B. Increased weight
•C. Decreased pulse rate
•D. Decreased cardiac output
D. Decreased Cardiac output
•A. Urine output will be decreaased due to
fluid shift and hypovolemia
•B. Loss of fluids will contribute to weight
loss not weight gain
•C. Pulse rate will be elevated due to
hypovolemia and body attempting to
compensate
•C. It extends the affected hip joint
• None of the other three choices apply at
all.
•B. Monitoring VS. A complication of liver
biopsy is hemorrhage and pneumo-thorax.
VS is good monitor. •A & C are not
appropriate – no change in urine output. Pt
will not have CVP •D. Checking heart rate
will be done, but choice B includes choice D.
b.An increase in A-P diameter. COPD
patients have barrel chests
Pt will not have increase in abdominal girth,
actually are cachectic. Urine output will not
be affected. Respiratory rate will be
increased due to SOB and DOE.
d.Turn pt side to side q2h. Focus of
question is that pt is bedridden. Most
important is prevent decubitus formation.
All other choices are just to distract you.
They are good, but not of priority.
a.Wear mask when going to pt’s room. TB is
airborne by droplets. Pt is on respiratory
isolation.
B and c do not apply.
D is too isolating
NCLEX QUESTIONS
ANSWER
Question #20
•A client with spinal cord injury has autonomic
dysreflexia. Which action should the nurse take
first?
•A. Call the doctor
•B. Place the pt in reverse trendelenberg
•C. Administer a sedative on a standing order
•D. Check the pt for fecal impaction
D. Check for fecal impaction. Autonomic
dysreflexia in spinal cord injuries are caused
by a stimulus – full bladder or fecal
impaction can cause it.
#21
When inserting an NG tube, in order to further
advance the tube, in what position should the
patient be placed.
A.
Right side lying
B.
Left side lying
C.
Sim’s
D. High Fowlers
#22
What nursing instruction would be most
important to give to patient on Zyloprim?
A.
Lots of rest
B.
Increase fluid intake
C.
Eat lots of fresh fruits
D. Eat lots of cheese
#23
Which of the following professions is at greatest
risk of developing Hepatitis A?
A.
An office worker
B.
A cashier at a supermarket
C.
A cook in a restaurant
D. A teacher
#24
Which of the following patients is most at risk for
developing a CVA?
A.
An HIV patient
B.
A patient with bronchitis
C.
A Patient with sickle cell anemia
D. An amputee
#25
Your patient is placed on a low Tyramine diet.
Which of the following foods should he avoid?
A.
Salmon
B.
Hamburger
C.
Aged cheese
D. Apples
#26
Which of the following age groups should the
nurse assess first?
A.
an 8 year old with diabetes mellitus
B. A 30 year old with prostate cancer
C.
A 24 year old with cervical cancer
D. A 40 year old with sickle cell crisis
#27
A patient with diabetes mellitus is having a
headache. What should you do?
A.
Give a glass of orange juice.
B.
Take a prn blood glucose test
C.
Tell the patient the headache will go away
D. Give the patient her prn Aspirin
D. High Fowlers is best position for NG
tube insertion. Right side-lying is good for
reducing dumping syndrome, left side-lying
is good for advancing intestinal tubes. Sims
is good for enemas.
4
B.
Increase fluid intake
Zyloprim (Allopurinol) is anti-gout
medication. Must be taken with 10-12 eight
ounce glasses of water per day. May be
given with or immediately after meals or
milk.
C.
A cook in a restaurant.
This person has exposure to raw meat.
Hepatitis A is transmitted via the fecal-oral
route, or through raw, contaminated foods.
C. A pt with sickle cell anemia.
Clinical manifestations of sickle cell
anemia include micro and macro infarcts.
Micro-infarcts cause painful crisis; Macroinfarcts cause organ damage.
C.
Aged cheese.
Aged cheese is loaded with tyramine.
D. A 40 year old with sickle cell crisis.
They are trying to fool you here. It isn’t the
age group that is important, it is the disease
and what is happening to the patient.
NO ANSW
NCLEX QUESTIONS
ANSWER
#28
Your client went into labor at 3:15 am. When
did the first stage of labor end?
A.
Full dilation and effacement @ 11:45 am
B.
Delivery of baby at 1 pm
C.
Delivery of placenta at 1:30 pm
D. 9 cm dilation at 10:00 am
Your client is getting Tofranil (Imipramine).
Which of the following nursing interventions would
be considered?
A.Give medications at night
B.Give medications with meals
C.Give medications on an empty stomach
D.
Give medications with milk
#30
What comment made by a patient’s family
member with Alzheimer’s would require further
follow-up? A.
“It makes me angry that my
father will never get better”
B.
“It must be hard for him to deal with this.”
C.
“Sometimes I feel as though I can’t go on.”
D. “Let’s stay with him until morning.”
#31
What would be the most appropriate nursing
action for a confused or demented patient at
night?
A.
Redirect pt whenever he/she enters
another patient’s room
B.
Stay with patient
C.
Reassure patient prn
D. Leave night light on in sleeping area to
promote familiarity
#32
As a home health nurse, which of the following
would you send to the doctor first?
–A. A patient with abdominal pain
–B. A patient with epigastric pain and discomfort
–C. A patient with a headache and flushed face
–D. A patient with a temperature of 102
#33
A child has swallowed a corrosive substance.
What should the mother do immediately?
–A. Give syrup of ipecac immediately
–B. Give the child a glass of milk
–C. Take the child to the nearest ER
–D. Call poison control to obtain correct
instruction as to what to do
#34
You are caring for a patient who is post
laminectomy. Which of the following positions
should you place him in?
A. Flat with HOB to 30 degrees
B. Flat with legs slightly elevated
C. Upright after 6 hours
D. High Fowlers to decrease ICP
5
A. Full dilation and effacement at 11:45
am. Stage 1 goes from beginning of labor
until full dilation and effacement. Stage 2 is
up until delivery of baby, Stage 3 is until
delivery of placenta. Stage 4 is 1-4 hours
after delivery.
A.
Give medications at night.
Tofranil is used to treat depression and
nocturnal enuresis in children >6 YO. SE
include drowsiness, fatigue, dry mouth,
blurred vision, delayed micturition, postural
hypotension.
Answer
C.
“Sometimes I feel as though I can’t
go on.”
D. Leave night light on to promote
familiarity None of the other answers are
too practical, they are labor intensive. You
always want to develop a plan that permits
the patient to participate in his/her own care.
a.Abdominal pain is always top priority in
normal triage.
D. Call poison control. They will have you
read label of substance and give you
directions as to what to do. Do not give
ipecac with corrosive substance. If it burned
on the way down, it will burn on the way up.
A. Flat with HOB to 30 degrees.
This is the recommended position post
laminectomy. Also known as semi-fowlers
NCLEX QUESTIONS
ANSWER
#35
Which of the following patients should be
assigned to nurse who is floated to you from the
maternity unit?
A. A patient with a blood glucose of 575
B. A fresh post-op mastectomy
C. A pt with cervical cancer
D. A post-op hysterectomy
#36
Which of the following statements would indicate
to you that teaching was effective? When the pt
states…
–A. I will walk for 30 minutes every day
–B. I will not engage in sexual activity
–C. I will increase the amount of sodium in my
diet
–D. I will drive home on discharge from the
hospital
#37
You are in charge and must assign patients to an
RN and a CNA. Which of the following would you
assign to the RN first?
A.
Administering drugs as prescribed
B. Giving discharge instructions to newly
diagnosed IDDM
C. Changing a 4 day postop abdominal dressing
D. AM care for allocated patients
#38
There has been a major disaster. To which of
the following should the triage nurse give first
priority?
A.
Pt with chest pain with 130/80, HR 90
B.
2 YO with head laceration
C.
Man with fractured rib
D. Person with cut over eye
#39
wYour patient has just had a trans-sphenoidal
hypophysectomy. Which of the following would
you assess?
A. Urine output and concentration
B. Blood pressure
C. Respirations
D. Heart rate
#40
w A Hindu patient is dying. Which of the following
would you expect to see as part of the death and
dying rituals of that religion?
–A. Placing of rice in the mouth
–B. 24 hour family vigil with chanting
–C. Telling of jokes at bedside
–D. Refusal of care
6
LDRP nurses are used caring for pts with
vaginal bleeds and/or post op C-sections.
Hysterectomies can be either trans-vaginal
or by C-section.
Answer
A. I will walk for 30 minutes every day.
A. Administering drugs as prescribed.
Remember 5 rights include RIGHT TIME.
Both b and c can wait. D can be
completed by CNA.
D. Person with cut over eye. Remember
in disaster situation, you treat least injured
first. Theory is you treat the least injured so
they can help you treat others.
The correct answer is A. Remember where
the sphenoid is!! It lies in the Tella Surtica
where the pituitary lies. Remember the
hormones that the pituitary secretes – one of
them is ADH. DI is a major complication of
any blunt head trauma or surgery involving
the pituitary. BP, RR, HR are considerations
if brainstem, especially medulla oblongata is
involved.
This is a tough one to answer. The best
answer is B. In ancient Hindu practices, the
lighting of candles and the positioning of the
body is also very important. However,
lately, death and dying practices have been
modified. Choice A is Asian, Choice C is
Irish, Choice D is Christian Science – but
then they would not even be in the hospital.