NCLEX REVIEW QUESTIONS
Fall 2010 Set 3
(Answers follow all questions)
Fundamentals of Nursing
1. A nurse sees smoke coming from a client’s hospital room. When entering the
room, the nurse notes that the client is standing on the far side of the room.
Which action should be taken by the nurse immediately?
A. Find the nearest fire alarm box
B. Tell the client to drop and roll on the floor
C. Grab a blanket to smother the fire
D. Obtain water to douse the clothes
Maternal-Child Health
2. Which physiological cervical changes associated with pregnancy should a
nurse expect to find during a physical assessment of a pregnant woman?
Select all that apply.
A. Formation of mucous plug
B. Chadwick’s sign
C. Presence of colostrum
D. Goodell’s sign
E. Cullen’s sign
Pediatrics
3. A nurse is asked to provide education for a 15-year-old who requires surgical
treatment for scoliosis. Which should be an appropriate explanation for the
adolescent? “The goal of surgery is to”:
A. Allow you to be taller
B. Prevent pain
C. Prevent problems with breathing
D. Allow clothes to fit you better
Neurological Disorders (Adult)
4. A nurse should plan for which measure to treat an elderly client with normal
pressure hydrocephalus (NPH)?
A. Carotid endarterectomy
B. Ventriculoperitoneal shunt
C. Lumbar drain
D. Anticonvulsant medications
Musculoskeletal/Integumentary Disorders (Adult)
5. A nurse receives an order to administer cyclobenzaprine (Flexeril) 30 mg
orally three times daily to a client hospitalized with acute cervical neck pain.
The pharmacy has supplied 10-mg tablets. Which action by the nurse is best?
A. Administer three 10-mg tablets with food
B. Call the physician to question the order
C. Observe the client for drowsiness after administration
D. Administer morphine sulfate intravenously for immediate pain control
Oncological/Immune Disorders (Adult)
6. Following a shift report on an oncology unit, a nurse determines that which
client should be assessed first?
A. A client with breast cancer who has an order for ondansetron (Zofran) 8
mg intravenously (IV) 30 minutes prior to chemotherapy
B. A client just admitted with a temperature of 101 degrees F (38.3
degrees C), diaphoresis, and an absolute neutrophil count of 98/mm3
C. A client with breast cancer who is scheduled for external beam
radiation in 15 minutes
D. A client with stomatitis associated with tonsilar cancer who receives
gastrostomy tube feedings
Cardiovascular Disorders (Adult)
7. A client is discovered to have a popliteal aneurysm. Because of the aneurysm,
a nurse should closely monitor the client for:
A. thoracic outlet syndrome
B. ischemia in the lower limb
C. pulmonary embolism
D. Raynaud’s phenomenon
Respiratory Disorders (Adult)
8. Following a thoracotomy to remove a lung tumor, a nurse is preparing a client
to be discharged to home. Which are appropriate teaching points for the
client? Select all that apply.
A. Avoid lifting greater than 20 pounds
B. Build up exercise endurance
C. Continue to build endurance even when dyspneic
D. Expect return to normal activity level and strength within 1 month
E. Make time for frequent rest periods with activity
Endocrine Disorders (Adult)
9. A nurse is teaching a client experiencing hypoparathyroidism resulting from a
lack of parathyroid hormone (PTH) about foods to consume. Which should be
included on a list of appropriate foods for a client experiencing
hypoparathyroidism?
A. Dark green vegetables, soybeans, and tofu
B. Spinach, strawberries, and yogurt
C. Whole grain bread, milk, and liver
D. Rhubarb, yellow vegetables, and fish
GI/GU Disorders (Adult)
10. A nurse is assessing a client with a diagnosed inguinal hernia at a scheduled
clinic visit. The nurse suspects that the client’s hernia may be strangulated
when which finding is noted on assessment?
A. Shortness of breath
B. Intense abdominal pain
C. Constipation
D. Hyperactive bowel sound
Sensory Disorders (Adult)
11. A nurse reports to a health care provider that a client has decreased peripheral
vision. An ophthalmologist consult is ordered and the client is diagnosed with
chronic open-angle glaucoma. The client cries when told the diagnosis. A
nurse identifies the following nursing diagnoses. In which priority order
should the nurse plan to address the nursing diagnoses?
A. Deficient knowledge related to glaucoma causes and treatment
B. Anxiety related to fear of vision loss and changes in quality of life
C. Sensory/perceptual alterations (visual) related to decreased peripheral
vision
D. Dressing and grooming self-care deficit related to visual impairment
Psychiatric and Mental Health (Adult)
12. A nurse is conducting an admission interview with a client who is under the
influence of cocaine. The nurse interprets that which finding is attributable to
the client being under the influence of cocaine at the time of the interview?
A. Underreporting the amount of cocaine used on a regular basis
B. Decreased blood pressure and heart rate
C. Hypersensitivity in response to personal questions
D. Lack of attention to the interview process
ANSWERS
1. B: Rolling on the ground will smother the flames and put the fire out. The client is
priority. Those responding can locate and activate the alarm box. Smothering the fire is
the next action. Finding and obtaining water is too time-consuming and the fire will
continue to burn.
2. A, B, D: Cervical changes associated with pregnancy include the formation of the
mucous plug, softening of the cervix (Goodell’s sign), and a bluish-purple discoloration
of the cervix (Chadwick’s sign).
3. C: Surgery for scoliosis is to prevent future problems with breathing and to improve
any current problems with breathing.
4. B: NPH is a reversible neurological condition in older adults. The clients have mild
dementia, bladder and bowel incontinence, and a specific hypokinetic gait disorder. The
clients have dilated ventricles in the brain despite normal cerebrospinal pressure. NPH is
treated with a procedure that involves removal of excess cerebral spinal fluid (CSF): the
placement of a shunt in a lateral ventricle of the brain that drains into the peritoneal
cavity. Symptoms improve with removal of CSF.
5. B: Cyclobenzaprine is a centrally acting skeletal muscle relaxant. The total daily dose
should not exceed 60 mg.
6. B: The newly admitted client should be assessed first because the client is neutropenic,
showing signs of infection, and microorganisms from other clients would be less likely to
be transmitted to the client if seen first. The client should be placed on neutropenic
precautions. The client is at risk for severe sepsis if the absolute neutrophils count is less
than 100/mm3.
7. B: A popliteal aneurysm (located in the space behind the knee) may cause ischemia in
the leg distal to the aneurysm due to thrombus forming inside the aneurysm and potential
emboli.
8. A, B, E: With discharge after thoracotomy, the client should be instructed to avoid
lifting more than 20 pounds until healing is complete. The client should work up to an
appropriate exercise level and take rest periods during activity.
9. A: Hypoparathyroidism from lack of PTH produces chronic hypocalcemia. Foods
consumed should be high in calcium.
10. B: When a hernia is irreducible and intestinal flow and blood supply are obstructed,
the hernia is strangulated. Lack of blood supply causes severe pain in the strangulated
area.
11. C, B, A, D: Implementing environmental precautions to accommodate loss of
peripheral vision should be the first priority to protect the client from injury. Next,
alleviate the client’s anxiety by increasing the client’s knowledge of the disease process
and the use of medication to delay vision loss. Finally, assist the client in learning selfcare adjustments needed because of the vision loss.
12. C: Cocaine intoxication usually causes changes in sociability, hypervigilance,
interpersonal sensitivity, and anxiety.
Reference
Ohman, K. (2010). Davis’s Q&A for the NCLEX-RN Examination. Philadelphia, PA: F.A. Davis
Company.