NCLEX Practice Questions — Set 8
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
Which assessment would be most appropriate for a nurse to make during peritoneal dialysis while the solution is dwelling within the abdomen?
Show answer and rationale
Correct answer: C. Observing respiratory status.
2 to 3 L of fluid is infused into the peritoneum and the fluid may be pressing on the diaphragm.
Radioactive iodine (131I) is administered to a client with hyperthyroidism to:
Show answer and rationale
Correct answer: A. Limit secretion of thyroid hormone by destroying thyroid tissue.
the radioactive iodine destroys the overactive thyroid tissue that is causing hyperthyroidism and produces a hypothyroid state.
A radioactive iodine (131I) treatment has just been completed. Knowing the excretion and effect of 131I, a nurse should:
Show answer and rationale
Correct answer: C. Inform the client that there is little danger of exposing others to radiation.
the dose is so low that there is little chance of exposure to others. Avoiding contact with pregnant women and young children, or close contact, such as kissing or dancing cheek to cheek, is often advised for 2 to 3 days after treatment.
A client with intractable ascites from liver failure has a transjugular intrahepatic portosystemic shunt (TIPS). For which common complication should a nurse assess the client?
Show answer and rationale
Correct answer: A. Change in mental status.
the purpose of the shunt is to reduce portal hypertension. TIPS is a procedure in which a stent carries blood from the portal vein to the hepatic vein. Consequently, toxic substances reach the brain without being detoxified by the liver.
The best nursing action to reduce an allergic response in a client who is latex-sensitive is to:
Show answer and rationale
Correct answer: D. Use cloth, plastic, or vinyl products.
these products avoid exposing a client to something to which he or she is allergic.
A nurse should anticipate that the chest tube for a client recovering from a pneumothorax will be removed when:
Show answer and rationale
Correct answer: D. Water-seal chamber no longer fluctuates with breathing.
the cessation of fluctuation in the water-seal chamber when the chest drainage system is no longer attached to suction is an indication of re-expansion. A chest x-ray would also be indicated.
An RN observes a nursing student collecting a wound culture specimen from a client’s surgical site. The RN determines that the nursing student is using the correct technique when:
Show answer and rationale
Correct answer: C. The wound is swabbed from the center outward.
rolling the swab from the center of the wound to the outside of the wound is the correct technique. Organisms that have colonized the wound directly will be collected by this technique.
A nurse observes a medical student preparing to insert a central venous catheter. The nurse would know that the insertion technique was correct if, after cleansing the site:
Show answer and rationale
Correct answer: A. Insertion occurred after the site dried thoroughly.
the site needs to air-dry totally before catheter insertion.
Maximal barrier precautions prior to insertion of a central venous catheter should include: Select all that apply.
Show answer and rationale
Correct answer: B. Hand hygiene.
hand hygiene (hand washing) is a very important barrier to transmission of microorganism.
The staff nurse is observing the student teaching the client about collecting a 24-hour urine test after discharge. The student understands the collection process if the student’s teaching includes:
Show answer and rationale
Correct answer: C. Need to void, discard the urine, and then start the 24-hour time period.
the 24-hour collection period begins after the client voids and discards the urine. The test measures glomerular filtration of substances such as protein, creatinine, electrolytes, and urinary steroids, which are excreted at different rates, anounts, and times of day. Starting the time after the client voids and discards the urine gives a true picture of filtration during the 24 hours.
A client’s wife tells a nurse that her husband snores loudly when sleeping, then he actually stops breathing. The nurse informs the client’s wife that a physician can order a sleep study and he may need to use:
Show answer and rationale
Correct answer: A. A continuous positive airway pressure (CPAP) device.
CPAP is used to prevent airway collapse associated with obstruction during sleep.
A nurse tells a client that, after total knee replacement surgery, a continuous passive motion (CPM) device will be used. Which statement by the nurse should be included in the client education?
Show answer and rationale
Correct answer: B. The device will generally be applied immediately after surgery and used continuously when in bed.
the device is best applied after surgery and may be used for up to 6 weeks as prescribed.
The spouse of a client who had a transurethral resection of the prostate (TURP) 24 hours ago is upset because the irrigation seems to be increasing the client’s pain. Which is the best response by a nurse?
Show answer and rationale
Correct answer: B. "The rate of the irrigant can be slowed when the drainage is pale pink."
the purpose of the irrigant is to prevent clots. A pale pink would indicate that bleeding is diminishing.
A nurse is concerned that the results of a client’s recent arterial blood gas (ABG) analysis may be inaccurate. Which factors may affect the accuracy of ABG results? Select all that apply.
Show answer and rationale
Correct answer: D. Sample was drawn 15 minutes after suctioning.
blood gases should be drawn at least 20 minutes after suctioning because suctioning removes oxygen.
A client presents to an emergency department complaining of pain on the left side and shortness of breath. Vital signs are: BP 140/80 mm Hg; P 110, and R 44. The client’s ABG results are: pH 7.5, PaCO2 30 mm Hg; and HCO3 22 mEq/L, SaO2 86%, PaO2 64 mm Hg. A nurse should recognize that these symptoms are consistent with:
Show answer and rationale
Correct answer: B. Possible pulmonary embolism.
the ABGs show respiratory alkalosis (pH above 7. 45 and CO2 below 35) and a problem with hypoxemia (O2 Sat below 96%) from rapid respirations. The vital signs and symptoms are consistent with a pulmonary embolism, which interferes with exchange of O2. Client hyperventilates, blowing off CO2.
A client with ascites as a result of hepatitis C is in the emergency department complaining of abdominal discomfort. A paracentesis has been ordered. Nursing actions would include: Select all that apply.
Show answer and rationale
Correct answer: C. Having the client void before the procedure.
emptying the bladder before the procedure will reduce the risk of damage to the bladder when the needle is inserted into the peritoneal cavity to drain the fluid.
Which nursing actions would most likely help prevent the development of ventilator-associated pneumonia (VAP) in a client who is mechanically ventilated? Select all that apply.
Show answer and rationale
Correct answer: C. Oral hygiene every 2 hours.
frequent oral hygiene prevents the pooling of oral secretions, which may lead to aspiration.
Following a cardiac catheterization for recurrent angina, a 76-year-old client with a history of hypertension and type 2 diabetes, has had no urine output since the catheterization 16 hours before. Laboratory results revealed: Na+ 134 mEq/L, Cl- 96 mEq/L, K+ 6.4 mEq/L, BUN 71 mg/dL, and creatinine 4.0 mg/dL. Which factors are most likely contributing to this client’s condition? Select all that apply.
Show answer and rationale
Correct answer: D. Prophylactic tobramycin (Nebcin) given during the procedure.
the client is likely to have decreased renal function because of hypertension and diabetes. Aminoglycoside antibiotics are known to be nephrotoxic.
In which situations would it be appropriate for a critical care nurse to use intra-arterial monitoring access to meet the client’s needs? Select all that apply.
Show answer and rationale
Correct answer: D. To do frequent arterial blood gases for a client in acute respiratory failure.
arterial blood gas sticks are painful. Using the arterial port would be appropriate for clients requiring frequent collection of samples.
Which statements by a client prior to a cardiac catheterization would require a nurse to take further action? Select all that apply.
Show answer and rationale
Correct answer: A. "My kidney doctor has been suggesting I have this done for a year."
the presence of renal dysfunction should be known before a cardiac catheterization, which increases the risk of renal failure from the dye. The nurse needs to be sure whether the history includes possible renal dysfunction.
Following a left pneumonectomy, the optimal position for a client would be:
Show answer and rationale
Correct answer: D. In a high Fowler’s position.
high Fowler’s and turned slightly on the operative side promotes ventilation in the remaining lung.
An RN draws an arterial blood gas sample from a client. The correct action to prevent bleeding at the site is to:
Show answer and rationale
Correct answer: B. Apply direct pressure for 2 minutes.
2 minutes is usually long enough to stop the bleeding.
A client has just returned from having a femoral arteriogram. The first assessment by a nurse should be:
Show answer and rationale
Correct answer: B. Groin area.
there is a higher incidence of bleeding and hematoma formation in the groin, where the procedure was performed, due to high pressure in the femoral artery.
A client has just returned from the operating room following a hip replacement. The most important nursing assessment over the next 8 hours is:
Show answer and rationale
Correct answer: B. Respiratory status.
the client’s respiratory status needs to be monitored closely for the prolonged effects of general anesthesia used during major surgery.
A client, who is 23 years old, gravida 2, para 0, had a miscarriage at 6 weeks’ gestation last year. She presents for her first prenatal appointment at 12 weeks’ gestation. She is having blood drawn for routine prenatal screening. Which laboratory result would indicate a risk to the fetus for erythroblastosis fetalis?
Show answer and rationale
Correct answer: C. Blood type B-, antibody +.
this client has a positive (+) antibody screen indicating antibodies are present. The antibodies formed by a mother can cause erythroblastosis fetalis. Blood and Rh typing and antibody screening can alert the physician to the possible development of this condition.
A client, who is 15 years old, gravida 1, para 0 at 26 weeks of gestation, is admitted to an obstetrics unit with a diagnosis of mild preeclampsia. She has a blood pressure of 138/88 mm Hg and 1+ protein on urine dipstick. Which assessment finding should indicate to a nurse that the client’s condition is getting severe?
Show answer and rationale
Correct answer: B. 3+ urine protein on dipstick.
3+ urine protein on dipstick is a symptom of severe preeclampsia and would indicate that the client’s condition is worsening.
A nurse is performing a postpartum assessment on a client who is gravida 2, para 1 and delivered 6 hours ago by vacuum extraction with a fourth-degree laceration. The nurse notes that the fundus is firm, 2 fingerbreadths above the level of the umbilicus, and displaced to the right. Which action should the nurse take next?
Show answer and rationale
Correct answer: D. Check the client for bladder distention.
the likely reason for the fundus to be higher than expected and deviated to the right is bladder distention. If the bladder is not emptied, a postpartum hemorrhage can occur.
A client, who is 27 years old, gravida 1, para 0, presents to a labor and delivery unit in active labor at 38 weeks’ gestation. During the initial vaginal examination, a nurse notes a papular lesion on her left labia minora. Which action should the nurse take first?
Show answer and rationale
Correct answer: A. Report the finding to the physician.
a papular lesion is consistent with genital herpes and needs to be reported to the physician first before proceeding with any other assessment or treatment.
A client, who is 27 years old, presents to the gynecology clinic for her yearly screening examination. She is diagnosed with human papillomavirus (HPV). A nurse should recognize that this client is at increased risk for developing which illness?
Show answer and rationale
Correct answer: B. Cervical cancer.
HPV has been associated with an increased risk of developing cervical cancer.
A client, who is gravida 3, para 1 at 37 weeks’ gestation, is dilated to 5 cm, 100% effaced, and at a -2 station. A physician performs an amniotomy to augment the progress of labor. After an amniotomy, which should a nurse assess first?
Show answer and rationale
Correct answer: C. Fetal heart tones.
with amniotomy, there is a chance of prolapsed umbilical cord, and that results in fetal bradycardia. Assessing the fetal heart tones is the nurse’s most important action.
A 34-year-old client, who is gravida 1, para 0, comes in for a routine prenatal visit. A physician orders a routine prenatal blood panel. The client asks a nurse why her physician has recommended a multiple marker screen. The nurse should explain that the physician has recommended the test:
Show answer and rationale
Correct answer: A. To screen for spinal cord defects.
the multiple marker screen can screen for certain spinal column defects.
An 18-year-old client, who is gravida 4, para 0, has been treated for sickle cell anemia since age 5. She is admitted to labor and delivery at 37 weeks’ gestation in the latent phase of labor with spontaneous rupture of membranes. Which client need should a nurse anticipate?
Show answer and rationale
Correct answer: A. Supplemental oxygen.
supplemental oxygen is needed to compensate for the decreased oxygen-carrying capacity of sickling cells.
A 34-year-old client, who is gravida 4, para 2, has gestational diabetes that is controlled by diet. At 38 weeks’ gestation, a physician orders an ultrasound for estimated fetal weight and amniotic fluid index. To prepare for the ultrasound, a nurse instructs the client to:
Show answer and rationale
Correct answer: C. Increase fluid intake.
the bladder should be full to lift the uterus and fetus out of the pelvis in order to obtain good measurements.
A 22-year-old client with a history of perinatal substance abuse is scheduled for biweekly nonstress tests. The client asks why she has to come twice a week for nonstress tests. A nurse knows that teaching has been successful when the client states:
Show answer and rationale
Correct answer: A. "The test is to measure the well-being of the baby."
the purpose of a nonstress test is to measure the well-being of the fetus.
During surgery, a client received spinal anesthesia 4 hours ago. The client reports severe incisional pain. BP is 90/70 mm Hg, P is 108, T is 99�F (37.2�C), and R is 30. The skin is pale. The dressing is dry and intact. The most appropriate nursing intervention is to:
Show answer and rationale
Correct answer: A. Medicate the client for pain, as ordered.
the postoperative pain is most likely causing the vital sign changes.
Following insertion of a pacemaker, a nurse should instruct a client to avoid:
Show answer and rationale
Correct answer: A. Contact sports.
contact sports could dislodge the pacing electrodes.
The most common cause of an increase in a hemoglobin (Hgb) value is:
Show answer and rationale
Correct answer: B. Dehydration.
hemoglobin responds to changes in hydration. Dehydration would result in hemoconcentration and elevated hemoglobin.
Which client should the nurse assess first following report?
Show answer and rationale
Correct answer: A. A client with a prothrombin time of 36 seconds.
the normal prothrombin time is 9.5 to 12 seconds. If anticoagulation is desired, the level is usually 11 /2 to 2 times the normal. This value puts the client at serious risk for bleeding.
Following colostomy-reversal surgery, a client refuses to wear the prescribed antiembolic stockings. A prophylactic heparin dose was not given because the order was unclear. Admission BP was 130/80 mm Hg; pulse 106. Morphine was given for pain. The next morning the BP is 88/60 mm Hg and the pulse is 140. Pain level is 5/10. The correct action by a nurse would be:
Show answer and rationale
Correct answer: B. Check pulse oximetry and breath sounds.
this client is at high risk for pulmonary emboli. Assess for additional signs before calling the physician.
Client assessment for pain should include a general history, clinical examination, and a pain history. A nurse knows that the most reliable indication of pain severity is:
Show answer and rationale
Correct answer: B. Client’s self-report.
pain is what the client reports it to be: severe, unrelenting, or relieved. Pain is now considered as the fifth vital sign.
Which change in a vital sign should a nurse note that is specific to neurogenic shock in a client who has a spinal cord injury?
Show answer and rationale
Correct answer: D. Bradycardia.
there is a loss of autonomic nervous system function below the level of injury-pulse decreases, which is unique to spinal cord injury.
A nurse should instruct a client with edema from venous stasis to avoid: Select all that apply.
Show answer and rationale
Correct answer: B. Crossing the legs while sitting.
crossing the legs impedes circulation.
A client’s laboratory results reveal: Hct 52, K+ 5.0, BUN 35, creatinine 1.1. Vital signs are: BP 102/60 mm Hg, P 124, R 20, T 38.7�C, and O2 Sat 96%. A possible explanation of these findings would be:
Show answer and rationale
Correct answer: A. Dehydration from an elevated temperature.
the findings indicate hemoconcentration from dehydration.
A client who has had a stroke begins to exhibit symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). Which laboratory findings should be expected with SIADH? Select all that apply.
Show answer and rationale
Correct answer: B. Increased urine sodium.
in SIADH urine output is decreased, the urine becomes more concentrated and the urine Na+ increases.
A nursing student asks an RN for an example of an arterial blood gas result that demonstrates compensation for acidosis has occurred. The correct pH example would be:
Show answer and rationale
Correct answer: A. pH = 7.36; PaCO2 = 33; HCO3 = 20.
compensation is evident when the pH is within the normal range (7.35 to 7.45) and one of the other components is outside of normal. Both the bicarbonate (normal is 22 to 26) and CO2 (normal: 35 to 45) are below the normal range.
A nurse is caring for a client who had a recent myocardial infarction (MI). During the cardiac assessment, a new murmur is noted. What question should the nurse ask the client first?
Show answer and rationale
Correct answer: A. "Did you recently walk to the bathroom?"
murmurs occur when blood flow through a normal cardiac structure is increased with activity.
A client who has diabetes is admitted to a hospital with a blood glucose of over 500, and states that the diabetic diet and exercise plan has been followed faithfully. The result of the HgbA1c is 10. The best interpretation by a nurse would be:
Show answer and rationale
Correct answer: D. This is very high and the client needs to be honest with the medical team.
a HgbA1c of 5 is a blood sugar of approximately 100. A HgbA1c below 7 is desired. A HgbA1c of 10 reflects lack of glycemic control.
When evaluating the laboratory results of a client who is diabetic, which test should a nurse review for the best indication of compliance with the diabetic regimen?
Show answer and rationale
Correct answer: B. Hemoglobin A1c.
this test gives an average of the client’s blood glucose for the past 90 days rather than just 1 day or one point in time.
A large, red area is noted over a client’s right greater trochanter. To differentiate between simple redness and a Stage I decubitus ulcer, a nurse should:
Show answer and rationale
Correct answer: A. Press on the intact skin to see if it blanches.
the redness of a stage I ulcer does not blanch with pressure, whereas simple redness will blanch.
A nurse prepares to suction the tracheostomy tube of a 15-month-old child. What steps should the nurse take in completing this procedure? Select all that apply.
Show answer and rationale
Correct answer: C. Select vacuum pressure between 60 and 100 mm Hg.
the nurse should select the appropriate amount of suction, which is between 60 and 100 mm Hg. Selecting less suction would not remove secretions and applying greater than 100 mm Hg of suction may cause trauma to the tissues.
A nurse prepares to obtain a blood sample from a preschooler who is hospitalized. Which steps should the nurse take to complete this procedure? Select all that apply.
Show answer and rationale
Correct answer: A. Tell the child what will happen in simple terms.
the child should be informed about the procedure in a way that the child can understand.
A camp nurse is reviewing the intake forms of the schoolage children in attendance. Which children should the nurse recognize as having an increased risk for infection? Select all that apply.
Show answer and rationale
Correct answer: B. Child with sickle cell anemia.
a child with sickle cell anemia has decreased oxygen-carrying capacity of the blood, increasing the risk for infection.
A nurse is performing discharge teaching with the parents of a newborn diagnosed with Down syndrome. Which statements by the parents should indicate to the nurse that teaching has been effective? Select all that apply.
Show answer and rationale
Correct answer: B. "We should pay close attention to any cold-like symptoms."
the child with Down syndrome is at increased risk for respiratory infection.
A child is seen in an emergency department for possible leukemia. Which laboratory values should a nurse expect to be abnormal? Select all that apply.
Show answer and rationale
Correct answer: B. WBC.
leukemia causes a decrease in white blood cells (WBCs).
A Hispanic client, who is gravida 5, para 4, notices small bluish marks with indistinct edges on her newborn’s buttocks and lower back. The most appropriate response by the nurse would be to:
Show answer and rationale
Correct answer: C. Reassure her that it is a normal finding in darker skinned infants.
the mark is a mongolian spot, a normal variant in darker-skinned infants.
During the physical assessment of a client diagnosed with a right tension pneumothorax, a nurse would expect to find: Select all that apply.
Show answer and rationale
Correct answer: C. Point of Maximum Impulse (PMI) shifted further to the left of midline.
thoracic structures, including the heart, would shift to the left.
Following application of a cast to immobilize a closed fracture of the humerus, a client returns to an emergency department. A nurse suspects compartment syndrome when the client reports: Select all that apply.
Show answer and rationale
Correct answer: B. Urine has become dark reddish-brown.
myoglobin is released from the damaged muscle and excreted in the urine, which makes it dark reddishbrown.
A toddler with leukemia is hospitalized for fever and neutropenia. Which physician order should a nurse question?
Show answer and rationale
Correct answer: D. Tylenol PR q4h prn fever.
rectal medications should be avoided since they pose the risk of trauma to the rectum, which could lead to further infection. A toddler should be able to take Tylenol (acetaminophen) elixir for fever.
A neonatal nurse is performing the initial assessment on a neonate. The neonate was delivered by vacuum extraction at 39 weeks’ gestation. Which finding would be considered "normal" for this infant at 1 minute of age?
Show answer and rationale
Correct answer: D. Acrocyanosis.
acrocyanosis is cyanosis of the fingers and toes, and is a normal finding for the first few hours after delivery.
Surgery has been delayed for a client with Graves’ disease. The correct nursing actions while waiting for the operating room to call should be: Select all that apply.
Show answer and rationale
Correct answer: D. Offer mouth care as NPO status may cause oral dryness.
prolonged NPO status will increase dryness of the mouth. Oral care increases client comfort.
A male neonate is delivered by cesarean section at 36 weeks’ gestation. A neonatal nurse is performing a newborn assessment and notes the presence of hypospadias. Which statement to the mother best describes hypospadias?
Show answer and rationale
Correct answer: B. The urethra opens on the ventral side of the penis.
a hypospadias is when the urethra opens on the ventral side of the penis.
A client with benign prostatic hypertrophy (BPH) asks a nurse what can be done to manage the symptoms. The correct response by the nurse would be:
Show answer and rationale
Correct answer: C. "Herbal therapy such as saw palmetto may improve urinary flow."
saw palmetto has been shown to improve urine flow by blocking the ability of dihydrotestosterone (DHT) to stimulate prostate cell growth.
A client, who is gravida 3, para 2, is admitted to labor and delivery. A sterile vaginal examination reveals that the client’s cervix is 9 to 10 cm dilated, 100% effaced, and a +2 station. Which action should the nurse take first?
Show answer and rationale
Correct answer: A. Prepare the client for delivery.
this client is a multipara and is very close to delivery. Preparing the client for delivery is the most important nursing action at this time.
An 18-year-old client is having her first gynecological examination. She asks a nurse about a pill for birth control. Which nursing statement about oral contraceptive agents is correct?
Show answer and rationale
Correct answer: C. Oral contraceptives inhibit ovulation and change the consistency of cervical mucus.
oral contraceptives do inhibit ovulation and change the consistency of cervical mucus. The hormones prevent ovulation and affect the color and consistency of cervical mucus.
During a physical assessment of a client with cardiac tamponade, a nurse should expect to find: Select all that apply.
Show answer and rationale
Correct answer: C. Jugular venous distention (JVD).
increased intracardiac pressure causes impaired filling of the right atrium, resulting in JVD. JVD is one of the three indicators of cardiac tamponade known as Beck’s triad.
A client, who is gravida 1, para 0, is attending a prenatal breastfeeding class. Which statement by the client should indicate to a nurse that additional teaching is needed?
Show answer and rationale
Correct answer: A. "I will follow a strict schedule for breastfeeding, every 3 hours."
babies who are breastfed should be on a demand schedule, feeding an average of 8 to 12 times in a 24-hour period.
Which situation could lead to metabolic acidosis in a client?
Show answer and rationale
Correct answer: C. ASA overdose.
acetylsalicylic acid (ASA) is an acid compound.
A nurse is working with the parents of an infant who has just died of sudden infant death syndrome (SIDS). What interventions by the nurse would be most appropriate? Select all that apply.
Show answer and rationale
Correct answer: A. Place a sign on the child’s room door requesting visitors to first check in at the nurse’s station.
parents should be allowed to grieve in privacy, allowing visitors at their own discretion.
A client, who is a gravida 1, para 0, delivers a 9-pound, 8-ounce baby using vacuum extraction after a 2-hour second stage of labor. The client has a fourth-degree laceration. Which medication should the nurse anticipate administering to this client?
Show answer and rationale
Correct answer: C. Docusate sodium.
having a bowel movement can be painful after a fourthdegree laceration. Docusate sodium is a stool softener that can make the bowel movements less painful.
The client’s arterial blood gases (ABGs) are: pH 7.32; PaCO2 48 mm Hg, and HCO3 25 mEq/L. A nurse should anticipate that an appropriate order for this client will be:
Show answer and rationale
Correct answer: D. Incentive spirometer to be used hourly.
the ABGs show respiratory acidosis (pH below 7.35 and CO2 above 45), which would be decreased with effective deep breathing.
A 14-year-old client, who is gravida 1, para 0 at 11 weeks’ gestation, is at her first prenatal visit. To provide anticipatory guidance for this client, the nurse should assess:
Show answer and rationale
Correct answer: C. The client’s attitude about the pregnancy.
the client’s attitude about the pregnancy is the primary concern during the first trimester. Plans for termination or continuation of the pregnancy should be discussed to provide anticipatory guidance for this client.
A nursing student asks an RN to explain the results of a client’s arterial blood gases. The results are: pH 7.43; PaCO2 30 mm Hg; and HCO3 18 mEq/L. The nurse knows the client’s acid-base status is:
Show answer and rationale
Correct answer: C. Compensated respiratory alkalosis.
the pH is within normal limits, which reflects compensation. The body never overcompensates; therefore, the problem is an alkalosis because the pH is on the alkaline side of 7.4 and the CO2 is low.
A client, who is gravida 4, para 3 at 38 weeks’ gestation, is entering the second stage of labor. Which essential action should a nurse perform at this time?
Show answer and rationale
Correct answer: D. Notify the physician of the client’s vaginal exam.
the second stage of labor is the pushing stage, and a client who is a multipara usually delivers without a long second stage. The nurse should notify the physician of the results of the cervical examination and the need for the physician to come for delivery.
The night before surgery, a client is given pentobarbital sodium (Nembutal) for sleep, with an order to repeat. One hour later the client is still unable to sleep. What should the nurse do next?
Show answer and rationale
Correct answer: C. Explore the client’s feelings about surgery.
given the data, presurgical anxiety is suspected. The client needs an opportunity to talk about concerns related to surgery before further actions (which may mask the anxiety) are taken.
A client, who is gravida 2, para 1, delivered an 8-pound baby 24 hours ago. The client’s blood type is B negative and the fetus is B positive. A physician orders an injection of Rho(D) immune globulin. A nurse understands that the Rho(D) immune globulin should be administered to this client to:
Show answer and rationale
Correct answer: D. Inactivate the fetal Rh antigens.
Rho(D) immune globulin contains anti-Rh antibodies that work by destroying the fetal blood cells in the mother’s blood before her body can react to them, inactivating the fetal antigens.
A client with a history of type 1 diabetes has not been eating or taking insulin for 3 days because of "feeling poorly." The client is confused, respirations are 32, and breath odor is fruity. The serum glucose is 620 mg/dL. A nurse should know that the correct action for this client is:
Show answer and rationale
Correct answer: A. Regular insulin IV 5 units/hr in D5NS per order.
the client needs insulin and fluids to correct the hyperglycemia (serum glucose of 620 mg/dL) and dehydration that occurs with diabetic ketoacidosis (DKA).
A Caucasian, male neonate is delivered at 33 weeks’ gestation due to premature, preterm rupture of membranes and a maternal fever. A nurse is performing an initial assessment of the neonate. The nurse should expect to find the presence of:
Show answer and rationale
Correct answer: C. Vernix caseosa.
vernix caseosa is very apparent in a preterm fetus at 33 weeks’ gestation.
A client has a pressure ulcer that extends into the dermis and subcutaneous tissue. Which stage of pressure ulcer formation should a nurse document?
Show answer and rationale
Correct answer: C. III.
a stage III pressure ulcer extends past the top layer of the skin.
A school nurse is creating a plan to educate teenagers against the use of smokeless tobacco. What informational strategy would be best suited for the target population?
Show answer and rationale
Correct answer: A. Display informational posters that carry images of former users’ faces disfigured by oral cancer.
the posters would demonstrate how smokeless tobacco use can affect an individual’s appearance as well as cause serious health complications. Additionally, the posters would be visible for a sustained period of time.
A neonate is delivered by cesarean section at 39 weeks’ gestation. The neonate has an Apgar score of 9 at 5 minutes. A nurse should be aware that the most likely cause for subtraction of one point is:
Show answer and rationale
Correct answer: A. The neonate has acrocyanosis.
acrocyanosis (blue color of hands and feet in most infants usually for the first few hours after birth) is a normal finding for a neonate at 5 minutes of age. The acrocyanosis would lead to subtracting a point from the Apgar score. An Apgar score of 9 at 5 minutes is normal in a healthy neonate.
A client, who is admitted in hypertensive crisis, has a blood pressure of 246/128 mm Hg. Which findings in the client’s history should a nurse identify as being related to complications of hypertension? Select all that apply.
Show answer and rationale
Correct answer: A. History of brain attack (stroke).
untreated hypertension increases the risk of stroke.
A client, who is gravida 4, para 3, delivered a "fetal demise" last year. A physician orders a contraction stress test (CST) for this client at 38 weeks’ gestation. A nurse is aware that a contraction stress test is ordered for this client to:
Show answer and rationale
Correct answer: D. Check the fetal oxygen reserve.
the test uses a fetal monitor to watch the baby’s response to contractions. A healthy fetus in good condition will tolerate the mild stress caused by contractions without difficulty. However, a fetus who is getting barely enough oxygen may have late decelerations, where the baby’s heart slows down from the stress of the contraction, then recovers back to baseline after a few moments. In this way, a CST is able to check fetal oxygen reserve.
A nurse should determine a client with type 2 diabetes needs additional teaching if which statement is made?
Show answer and rationale
Correct answer: B. "The goal for my HgbA1c is less than 8."
the goal for the HgbA1c is less than 7.0.
A 43-year-old client delivers a neonate with Down syndrome at 37 weeks’ gestation. A nurse performs a routine assessment on the neonate. Which finding should the nurse report immediately to a physician?
Show answer and rationale
Correct answer: A. Cyanosis after feeding.
cyanosis after feeding may be indicative of a heart defect. Since heart defects are common in neonates with Down syndrome, it needs to be reported immediately to the physician.
A 30-year-old client has been trying to conceive for about a year. A physician prescribes clomiphene citrate. A nurse is teaching the client about the drug’s potential side effects. Which statement, if made by the client, would indicate that the teaching was effective?
Show answer and rationale
Correct answer: A. "I have a possibility of having more than one fetus."
clomiphene citrate may result in multiple births (e.g., twins, triplets) due to the stimulation of ovulation, when more than one egg may be released and fertilized.
A client, who is gravida 5, para 4, delivers an 11-pound, 4-ounce neonate at 38 weeks’ gestation. The client has been noncompliant with her insulin administration for gestational diabetes and her blood sugar has been poorly controlled throughout this pregnancy. Which nursing intervention is the most important for the neonate?
Show answer and rationale
Correct answer: A. Check heel stick blood sugar.
checking heel stick blood sugar is the first intervention. Based on the results, further interventions may be necessary. Specific intervention will depend on the blood sugar value.
Over the past 36 hours following open heart surgery, a client has become increasingly restless and agitated, and demands that "the bird" be removed from the room. Which factors are most likely contributing to this client’s mental status? Select all that apply.
Show answer and rationale
Correct answer: A. Administration of norepinephrine (Levophed) IV for low blood pressure.
delirium may be related to the use of vasoactive drugs.
A neonate is born at 39 weeks’ gestation and is exclusively breastfed. Which finding by a nurse is considered "normal" in a neonate of this gestation during the first few days after birth?
Show answer and rationale
Correct answer: C. Weight loss of 5% to 10% from birth weight.
weight loss of 5% to 10% from birth weight is normal for neonates the first few days after birth, not weight gain.
Which side effect(s) from the combination therapy of isoniazid and rifampin should a client report immediately?
Show answer and rationale
Correct answer: D. Dark urine and pale-colored stool.
antifungal agents can cause liver damage, which results in obvious jaundice and the disruption of normal bile flow.
A child is admitted for suspicion of Reye syndrome. A nurse understands that symptoms of Reye syndrome follow a timeline. Which manifestations support the nurse’s suspicion? Select all that apply.
Show answer and rationale
Correct answer: B. Coma.
coma is a late symptom of Reye syndrome.
An emergency department nurse assess a client, who is gravida 2, para 0 at 8 weeks’ gestation, with a history of pelvic inflammatory disease. The nurse suspects a diagnosis of ectopic pregnancy. Which signs or symptoms would be consistent with this diagnosis?
Show answer and rationale
Correct answer: B. Amenorrhea, abdominal pain, and hypotension.
amenorrhea is a possible sign of pregnancy, abdominal pain can be a sign of tubal pregnancy, and hypotension can be a sign of internal bleeding as a result of a ruptured ectopic pregnancy.
Which signs and symptoms are often seen in a person with active tuberculosis?
Show answer and rationale
Correct answer: C. Fatigue, night sweats, low-grade fever.
the presenting symptoms are vague and "flu-like." Initially, they are nagging and less acute.
A home health nurse visits a client 10 days after delivery. The client is breastfeeding her infant. The nurse’s assessment includes pain, redness, and swelling of the client’s left breast. The nurse suspects that the client has developed mastitis. The nurse’s teaching plan for the client with mastitis should include:
Show answer and rationale
Correct answer: A. Taking analgesics for pain relief.
acetaminophen and/or ibuprofen are safe to take while breastfeeding. Unrelieved pain not only decreases the ability to produce milk, but suppresses the body’s ability to fight infection.
A nurse should know that the oxygen flow rate set for clients with emphysema is usually low because:
Show answer and rationale
Correct answer: A. Higher flow rates can depress the hypoxic drive.
clients with emphysema suffer from chronically high CO2 levels, so the normal CO2 stimulus is ineffective. The stimulus is the low O2-a hypoxic drive.
A 23-year-old client has missed two menstrual periods and decides to visit a prenatal clinic to see if she is pregnant. Besides amenorrhea, the client tells a nurse that she has experienced breast tenderness, nausea and vomiting, urinary frequency, and fatigue. The nurse determines that the client has been experiencing symptoms of pregnancy that are classified as:
Show answer and rationale
Correct answer: A. Presumptive.
presumptive signs/ symptoms of pregnancy include: absent menstrual periods (amenorrhea), nausea and/or vomiting ("morning sickness"), unexplained fatigue, the frequent need to urinate, breast tenderness and changes, excessive salivation (ptyalism), skin changes, and a sensation of movement in the abdomen (quickening).
The best indication of dehydration in a client who is 85 years old would be changes in:
Show answer and rationale
Correct answer: B. Urine output.
normal frequency, quantity, and characteristics of urine (specific gravity) would be the best choice. (Daily weight would be a better choice, if included.)
A client, who is gravida 4, para 3, delivered a 7-pound, 3-ounce neonate at 38 weeks’ gestation about 24 hours ago. Upon assessment, where should a nurse expect to palpate the client’s fundus?
Show answer and rationale
Correct answer: A. At the level of the umbilicus.
the fundus would be about the level of the umbilicus 24 hours after delivery. It rises up about 1 cm above the umbilicus about 12 hours after delivery. Then at 24 hours after delivery it is back to the level of the umbilicus, and then decreases about a fingerbreadth per day after delivery.
What should a nurse watch for in a client with autonomic dysreflexia following a cervical spinal cord injury?
Show answer and rationale
Correct answer: C. Severe hypertension.
there is a sudden onset of severe hypertension (300 mm Hg systolic), headache, and diaphoresis from some stimulus such as a distended bladder or fecal impaction.
A client, who is gravida 1, para 0, asks a nurse about how to get back into shape after the birth of her child. The nurse instructs the client about a variety of exercises including Kegel exercises. The client asks about the purpose for the Kegel exercises. Which explanation should the nurse give?
Show answer and rationale
Correct answer: B. To strengthen the perineal muscles.
the goal of Kegel exercises is to improve muscle tone by strengthening the pubococcygeus muscles of the pelvic floor. This helps the muscles to regain the strength they had before childbirth.
A possible complication from a carotid endarterectomy performed for transient ischemic attacks is:
Show answer and rationale
Correct answer: C. Trouble speaking.
the vagus nerve (cranial nerve X) can be damaged during surgical retraction. Other complications include hemorrhage and neurological impairment.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
More NCLEX practice and review
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