NCLEX Practice Questions — Set 12
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
The client is getting out of bed, becomes very anxious, and has a feeling of impending doom. The nurse reports these findings to Ms. Gail. Which intervention should Ms. Gail tell the nurse to implement first after placing the client in the high-Fowler’s position?
Show answer and rationale
Correct answer: B. Administer oxygen via nasal cannula.
The client needs oxygen to help perfuse the lungs, heart, and body; therefore, this is the first intervention Ms. Gail should tell the nurse to implement.
The client with a right-sided chest tube is complaining of pain rated 6 on a pain scale of 1 to 10. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Assess the client’s respiratory status and chest tube insertion site.
The nurse must first determine whether the pain is expected for the client’s condition or whether the client is experiencing a complication requiring nursing or medical intervention. This is the nurse’s first intervention.
Ms. Gail is discussing the care of a client with a right-sided chest tube secondary to a pneumothorax with a graduate nurse. Which interventions should Ms. Gail discuss with the graduate nurse? Select all that apply.
Show answer and rationale
Correct answer: C. Place the client in the high-Fowler’s position.
The client should be in a high-Fowler’s position to facilitate lung expansion.
Ms. Gail is making client assignments. Which client should Ms. Gail assign to the LPN?
Show answer and rationale
Correct answer: A. The client who is scheduled for a bronchoscopy to R/O lung cancer.
A client scheduled for a bronchoscopy is stable and should be assigned to the LPN. This client is the most stable and least critical.
The nurse is caring for clients on a medical unit. Which task should the nurse implement first?
Show answer and rationale
Correct answer: A. Assess the male client who called the desk to say he is nauseated and just vomited.
This client has experienced a physiological problem and the nurse must assess the client and the emesis to decide on possible interventions.
The nurse is preparing a client diagnosed with peptic ulcer disease for a barium study of the stomach and esophagus. Which nursing intervention is the priority for this client?
Show answer and rationale
Correct answer: A. Tell the client not to eat or drink anything prior to the procedure.
The test is a barium study of the upper GI system and requires the client’s upper GI system to be empty. This client should be made NPO at least 8 to 10 hours before the test.
Which client warrants immediate intervention from the nurse on the medical unit?
Show answer and rationale
Correct answer: A. The client with Crohn’s disease who has right lower abdominal pain and diarrhea.
The client with Crohn’s disease should be asymptomatic, so pain and diarrhea warrant intervention by the nurse. Pain could indicate a complication.
The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP?
Show answer and rationale
Correct answer: A. Instruct the UAP to feed the 69-year-old client who is experiencing dysphagia.
The nurse should not delegate to the UAP feeding a client who is not stable and at risk for complications during feeding, as a result of dysphagia. This requires judgment that the UAP is not expected to possess.
Which behavior by the unlicensed assistive personnel (UAP) requires immediate intervention by the nurse?
Show answer and rationale
Correct answer: B. The UAP placed the client with a continuous feeding tube in the supine position.
A client with a continuous feeding tube should be in the Fowler’s or high-Fowler’s position to prevent aspiration pneumonia. This action requires immediate intervention by the nurse.
The charge nurse is transcribing HCP orders for a client scheduled for a barium enema. In addition to the radiology department, which department of the hospital should be notified of the procedure?
Show answer and rationale
Correct answer: B. The dietary department.
The client must be NPO for 8 to 10 hours before the procedure. Therefore, the dietary department should be notified to hold the meal trays.
The charge nurse is making assignments on a medical unit. Which client should the nurse assign to the graduate nurse?
Show answer and rationale
Correct answer: A. The client scheduled for an esophagogastroduodenoscopy in the morning.
This client is being prepared for a test in the morning and is the least acute of the clients listed. The new graduate should be assigned to this client.
Which client should the nurse assess first after receiving the p.m. shift assessment?
Show answer and rationale
Correct answer: B. The client with abdominal pain who has an 8-hour urinary output of 150 mL/hr.
The client has a urinary output of less than 30 mL/hr; therefore, this client may be going into renal failure and should be assessed first.
The nurse is planning the care of a client diagnosed with acute gastroenteritis. Which nursing problem is priority?
Show answer and rationale
Correct answer: D. Fluid and electrolyte imbalance.
Fluid and electrolyte imbalance can cause cardiac dysrhythmias. This is the priority problem.
The nurse is preparing to administer morning medications to clients on a medical unit. Which medication should the nurse administer first?
Show answer and rationale
Correct answer: A. Sucralfate (Carafate), a mucosal barrier agent, to a client diagnosed with ulcer disease.
A mucosal barrier agent must be administered before the client eats in order for the medication to coat the gastric mucosa. This medication should be administered first.
The nurse has received the morning shift report on a surgical unit in a community hospital. Which client should the nurse assess first?
Show answer and rationale
Correct answer: C. The client who is 1 day postoperative for abdominal surgery and has a rigid, hard abdomen.
A hard, rigid abdomen indicates peritonitis, which is a life-threatening emergency. This client should be assessed first.
The charge nurse is reviewing the morning laboratory results. Which data should the charge nurse report to the HCP via telephone?
Show answer and rationale
Correct answer: D. The client who is 4 hours postoperative for gastric lap banding with a white blood cell (WBC) count of 15,000 mm.
Because a client undergoing an elective procedure such as a gastric lap banding is usually healthy prior to the surgery, an elevated postoperative WBC count-which this client has-may indicate infection and, therefore, requires notifying the HCP.
The nurse is preparing clients for surgery. Which client has the greatest potential for experiencing complications?
Show answer and rationale
Correct answer: D. The client scheduled for an open cholecystectomy who smokes two packs of cigarettes per day.
The location of the incision for a cholecystectomy, the general anesthesia needed, and a heavy smoking history make this client high risk for pulmonary complications.
The nurse is performing ostomy care for a client who had an abdominal-peritoneal resection with a permanent sigmoid colostomy. Rank the following interventions in order of priority.
Show answer and rationale
Correct answer: C. Monitor the drainage in the ostomy drainage bag.
The nurse must first assess the drainage in the bag for color, consistency, and amount.
The nurse is transcribing the HCP’s orders for a client who is scheduled for an emergency appendectomy and is being transferred from the emergency department (ED) to the surgical unit. Which order should the nurse implement first?
Show answer and rationale
Correct answer: C. Obtain the client’s informed consent.
The nurse must first obtain the operative permit, or determine whether it has been signed by the client, prior to implementing any other orders.
The client 1 day postoperative abdominal surgery has an evisceration of the wound. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Place sterile normal saline gauze on the eviscerated area.
Evisceration is the removal of viscera (internal organs, especially those in the abdominal cavity). If the bowels protrude from the abdominal incision, the nurse must apply sterile normal saline gauze and then notify the client’s surgeon.
The medical-surgical nurse has just received the a.m. shift report. Which client should the nurse assess first?
Show answer and rationale
Correct answer: B. The client who is 6 hours postoperative and has an abdominal wound dehiscence.
Wound dehiscence is the premature "bursting" open of a wound along surgical suture, and is an emergency that would require the nurse to assess this client first.
The client is being prepared for a colonoscopy in the day surgery center. The charge nurse observes the primary nurse instructing the unlicensed assistive personnel (UAP) to assist the client to the bathroom. Which action should the charge nurse implement?
Show answer and rationale
Correct answer: D. Take no action because this is appropriate delegation.
The primary nurse’s instruction to the UAP to assist the client to the bathroom is an appropriate delegation that ensures the safety of the client. It requires no action by the charge nurse.
The nurse is caring for clients on a surgical unit. Which client should the nurse assess first?
Show answer and rationale
Correct answer: B. The client who is 8 hours postoperative for splenectomy and who is complaining of abdominal pain, rating it as a 9 on a pain scale of 1 to 10.
Pain is priority because the nurse must determine if this is expected postoperative pain or a complication of the surgery. This client should be assessed first.
The unlicensed assistive personnel (UAP) tells the nurse angrily, "You are the worst nurse I have ever worked with and I really hate working with you." Which action should the nurse implement first?
Show answer and rationale
Correct answer: B. Don’t respond to the comment and appraise the situation.
The nurse should first appraise the situation and not do anything. This is the pivotal point at which the nurse can return the anger or reappraise the situation. The most important action to take is to empathize with the UAP and to try to find out the provocation for the behavior.
The client is admitted to the critical care unit after a motor vehicle accident. The client asks the nurse, "Do you know if the person in the other car is all right?" The nurse knows the person died. Which statement supports the ethical principle of veracity?
Show answer and rationale
Correct answer: D. "I am sorry to have to tell you, but the person died."
This statement supports the ethical principle of veracity, which is the duty to tell the truth. This statement will probably further upset the client and cause psychological distress, which may hinder the recovery period.
The client admitted to the critical care unit tells the nurse, "I have an advance directive (AD) and I do not want to have cardiopulmonary resuscitation (CPR)." Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: C. Inform the healthcare provider of the client’s request as soon as possible.
The nurse should first inform the HCP so the order can be written in the client’s chart. The HCP must write the do not resuscitate (DNR) order before the client’s wishes can be honored.
The client is diagnosed with esophageal bleeding. Which of the following assessment data warrants immediate intervention by the nurse?
Show answer and rationale
Correct answer: B. The client’s vital signs are T 99, AP 114, RR 18, B/P 88/60.
The client’s apical pulse (AP) is above normal and the B/P is low, which are signs of hypovolemic shock, which warrants immediate intervention by the nurse.
Which task should the nurse in the long-term care facility delegate to the unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: D. Assist the resident up in a wheelchair for meals.
Getting a resident up in a wheelchair for meals is an appropriate delegation to an unlicensed assistive personnel (UAP). This task does not require nursing judgment.
Which behavior by the unlicensed assistive personnel (UAP) warrants intervention by the long-term care nurse?
Show answer and rationale
Correct answer: C. The UAP is giving the client with a gastrostomy tube a glass of water.
The client with a gastrostomy tube cannot eat or drink oral fluids; therefore, this behavior warrants intervention by the nurse.
The nurse is preparing to teach the male client how to irrigate his sigmoid colostomy. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Ask the client whether he has any questions.
The client cannot learn if he has any questions or concerns. Therefore, the first intervention is to ask the client whether he has any questions. The nurse must allay any of the client’s concerns or fears before beginning to teach the client.
The LPN tells the nurse the client diagnosed with liver failure is getting more confused. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: C. Assess the client’s neurological status.
The nurse should first assess the client’s neurological status to determine the status of the client.
The nurse is changing the client’s colostomy bag. Which interventions should the nurse implement? Rank in the order of priority.
Show answer and rationale
Correct answer: A. Don non-sterile gloves.
The nurse should first put on non-sterile gloves, due to body fluid contamination.
Which task is most appropriate for the home healthcare nurse to delegate to the unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: A. Tell the UAP to wash and dry the client’s hair.
The UAP can wash and dry the client’s hair, as this is the least invasive task, so this would be the most appropriate task for the nurse to delegate to the UAP.
Which behavior by the UAP warrants intervention by the home health (HH) nurse? The client tells the HH nurse the UAP:
Show answer and rationale
Correct answer: A. Picked up the client’s prescriptions from the pharmacy.
The UAP should not take money from the client to pick up prescriptions and the UAP is not responsible for doing errands for the client. If money is missing or medications are missing, this could result in a difficult situation. The home health (HH) nurse should tell the UAP not to do this type of activity for the client.
The female client, diagnosed with diverticulosis, called the home healthcare agency and told the nurse, "I am having really bad pain in my left lower stomach and I think I have a fever." Which action should the nurse take?
Show answer and rationale
Correct answer: C. Tell the client to have someone drive them to the emergency room.
The nurse must have knowledge of disease processes. The client is verbalizing signs of acute diverticulitis, which requires the client to be NPO and prescribed antibiotics. The client needs to receive immediate medical attention.
The client with a sigmoid colostomy has an excoriated area around the stoma that has not improved for more than 2 weeks. Which intervention is most appropriate for the home health nurse (HH) to implement?
Show answer and rationale
Correct answer: B. Refer the client to the wound care nurse.
According to the NCLEX-RN� test blueprint under management of care, the nurse should be knowledgeable of referrals. The wound care nurse is trained to care for clients with colostomy and is knowledgeable in treating complications.
The client, who is terminally ill, tells the nurse, "I just want to live to see my grandson graduate in 2 months." Which stage of grief is the client experiencing?
Show answer and rationale
Correct answer: C. Bargaining.
Bargaining: "I’ll do anything for a few more years." The third stage involves the hope that the individual can somehow postpone or delay death. The client’s comments indicate bargaining.
The nurse is discussing end-of-life care (EOL) with the client diagnosed with pancreatic cancer. Which statements are the goals for end-of-life care? Select all that apply.
Show answer and rationale
Correct answer: D. To provide comfort and supportive care during the dying process.
This is a goal for EOL care.
The male Mexican American client, who is terminally ill, refuses hospice services because he says it is "giving up" and he is not going to die. Which is the most appropriate action by the nurse?
Show answer and rationale
Correct answer: C. Discuss the philosophy and services of palliative care with the client.
Mexican American families are close-knit communities and often prefer to care for their own family members; therefore, they would not seek hospice or palliative care. The nurse should attempt to help the client understand the philosophy, the benefits, and the help hospice can give the client and family.
The nurse is discussing end-of-life issues with a client. The nurse is explaining about a document used for listing the person the client will allow to make healthcare decisions should he or she become unable to make informed decisions for him- or herself. Which document is the nurse discussing with the client?
Show answer and rationale
Correct answer: C. Durable power of attorney for healthcare.
The nurse is specifically describing the term "durable power of attorney for healthcare." It is a document included in an advance directive.
The significant other of a client diagnosed with liver cancer and who is dying asks the nurse, "What is bereavement counseling?" Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: D. "It provides support to you and your family in the transition to a life without your loved one."
This is the definition of bereavement counseling.
The nurse is working in a digestive disease disorder clinic. Which nursing action is an example of evidence-based practice (EBP)?
Show answer and rationale
Correct answer: A. Educate a client based on current published information.
Evidence-based practice is the conscientious use of current best evidence in making decisions about nursing care. Using the "evidence," or research, to teach a client is evidence-based practice.
The charge nurse notices a nurse recapping a needle in a client’s room. Which action should the charge nurse take first?
Show answer and rationale
Correct answer: B. Quietly ask the nurse to step into the hall.
The charge nurse should not reprimand the nurse in front of the client or client’s family. The charge nurse should ask the nurse to step into the hall, where the client cannot hear.
The administrative supervisor is staffing the hospital’s medical-surgical units during an ice storm and has received many calls from staff members who are unable to get to the hospital. Which action should the supervisor implement first?
Show answer and rationale
Correct answer: A. Notify the on-duty staff to stay.
The first action for the administrative supervisor is to make sure the clients receive care. The supervisor cannot allow the on-duty staff to leave until replacement staff members have been arranged.
The staff nurse is working with a colleague who begins to act erratically and is loud and argumentative. Which action should be taken by the nurse?
Show answer and rationale
Correct answer: B. Ask the supervisor to come to the unit.
The actions of the colleague indicate possible drug or alcohol impairment. The staff nurse is not in a position of authority to require the potentially impaired nurse to submit to a drug test. The administrative supervisor should assess the situation and initiate the appropriate follow-up. The nurse must make sure an impaired nurse is not allowed to care for clients.
The charge nurse is making assignments on a medical-surgical unit. Which client should be assigned to the most experienced nurse?
Show answer and rationale
Correct answer: D. The client diagnosed with gastroesophageal reflux disease who has bilateral wheezes.
This client is exhibiting symptoms of asthma, a complication of GERD; therefore, the client should be assigned to the most experienced nurse.
The client is experiencing severe diarrhea and a serum potassium level of 3.3 mEq/L. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: A. Place the client on cardiac telemetry.
The client is at high risk for cardiac dysrhythmias, due to hypokalemia. The nurse should first assess the cardiac status, then implement other interventions. Remember Maslow’s Hierarchy of Needs.
The unlicensed assistive personnel (UAP) notifies the charge nurse that the male client is angry with the care he is receiving and is packing to leave the hospital. Which intervention should the charge nurse implement first?
Show answer and rationale
Correct answer: D. Discuss the problem with the client.
This is the first action for the charge nurse. The client is preparing to leave, and a delay in going to the client’s room could result in the client leaving before the situation can be resolved.
The client tells the nurse in the bariatric clinic, "I have tried to lose weight on just about every diet out there but nothing works." Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: A. "Which diets and modifications have you tried?"
This is an assessment question and should be asked to determine what the client has attempted has been unsuccessful.
The client 2 days postoperative from a laparoscopic cholecystectomy tells the office nurse, "My right shoulder hurts so bad I can’t stand it." Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: D. "This is a result of the carbon dioxide gas used in surgery."
During a laparoscopic cholecystectomy, carbon dioxide is instilled into the client’s abdomen. Postoperatively, the gas migrates to the shoulder by gravity and causes shoulder pain.
The nurse is caring for a client who is hemorrhaging from a duodenal ulcer. Which collaborative interventions should the nurse implement? Select all that apply.
Show answer and rationale
Correct answer: D. Prepare to administer a Sengstaken-Blakemore tube.
The HCP must order the insertion of a Sengstaken-Blakemore tube, so this is a collaborative nursing intervention.
The nurse is caring for a client diagnosed with peptic ulcer disease. Which assessment data would cause the client to require an immediate intervention by the nurse?
Show answer and rationale
Correct answer: B. The client has coffee ground emesis.
Coffee ground emesis indicates bleeding and old blood, and warrants intervention by the nurse. Further assessment is needed to determine if the client is hypovolemic and the HCP should be notified.
The nurse is caring for a client 1 day postoperative sigmoid resection. There is a large amount of bright red blood on the dressing. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: C. Assess the client’s apical pulse and blood pressure.
The nurse should first determine if the client is hypovolemic prior to taking any other action. This will determine the nurse’s next action.
The unlicensed assistive personnel (UAP) tells the nurse a female client, who had a laparoscopic cholecystectomy, is complaining of abdominal pain. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Assess the client to rule out any postoperative surgical complications.
The first part of the nursing process is assessment. The nurse must first assess the client’s pain to determine if the pain indicates a complication requiring medical intervention, or if this is routine postoperative pain, which is expected.
The male client is 30 minutes post-procedure liver biopsy. Which action by the unlicensed assistive personnel (UAP) requires the nurse to intervene?
Show answer and rationale
Correct answer: C. The UAP turned the client on the left side.
Direct pressure is applied to the site and then the client is placed on the right side to maintain site pressure for at least 2 hours. Turning the client to the left side warrants intervention by the nurse so the client will not hemorrhage.
The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice and is scratching the upper extremities. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Place mittens on both hands of the client.
Mittens will help prevent the client from scratching the skin and causing skin breakdown, which is priority for the client with liver failure. The client has decreased Vitamin K, which will lead to bleeding. The client is also immunosuppressed, which will lead to infection.
The client with hepatitis asks the nurse, "Is there any herb I can take to help my liver get better?" Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: D. "Milk thistle is a powerful oxidant and promotes liver cell growth."
Milk thistle has an active ingredient, silymarin, which has been used to treat liver disease for more than 2,000 years. It is a powerful oxidant and promotes liver cell growth. This response gives the client factual information.
Which task would be most appropriate for the nurse on the GI unit to delegate to the unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: B. Tell the UAP to empty the client’s colostomy bag.
The UAP can empty feces from a colostomy bag; this is not changing the colostomy bag, just emptying the feces.
The client is diagnosed with gastroenteritis. Which laboratory data warrants immediate intervention by the nurse?
Show answer and rationale
Correct answer: A. A serum sodium level of 152 mEq/L.
The normal serum sodium level is 135-145 mEq/L; this sodium level is elevated, indicating the client is dehydrated, which warrants intervention by the nurse.
Which nursing problem is the highest priority for the client diagnosed with gastroenteritis from staphylococcal food poisoning?
Show answer and rationale
Correct answer: C. Fluid and electrolyte imbalance.
Fluid and electrolyte imbalance is priority because of the potential for metabolic acidosis and hypokalemia, which are both life threatening, especially in the elderly.
The nurse has received the a.m. shift report. Which client should the nurse assess first?
Show answer and rationale
Correct answer: C. The client with peptic ulcer disease who is complaining of acute epigastric pain.
Pain should be assessed, even if it is expected for the client’s diagnosis, if the other clients are stable.
The client who has had abdominal surgery is complaining of pain and tells the nurse, "I felt something pop in my stomach." Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Assess the client’s surgical wound site.
Assessing the surgical incision is the first intervention because this may indicate the client has wound dehiscence.
The client who is 2 days postoperative abdominal surgery has a hemovac drainage tube. Which assessment data indicates the Jackson-Pratt (JP) is functioning appropriately?
Show answer and rationale
Correct answer: C. The hemovac has suction and is compressed.
The hemovac should be sunken in or depressed, indicating that suction is being applied, which indicates the hemovac is functioning appropriately.
The nurse is caring for the following clients on a surgical unit. Which client should the nurse assess first?
Show answer and rationale
Correct answer: C. The client with an emergency appendectomy who was transferred from PACU.
This client was just transferred from the Post Anesthesia Care Unit (PACU); therefore, the nurse should assess this client first to perform a baseline assessment and ensure the client is stable.
The client who is morbidly obese is 8 hours postoperative gastric bypass surgery. Which nursing intervention is of the greatest priority?
Show answer and rationale
Correct answer: C. Instruct the client to use the incentive spirometer.
The client that is morbidly obese will have a large abdomen that prevents the lungs from expanding, and predisposes the client to respiratory complications. Having the client use an incentive spirometer will help prevent respiratory complications.
The charge nurse has completed report. Which client should be seen first?
Show answer and rationale
Correct answer: B. The client with intractable vomiting who has tented skin turgor and dry mucous membranes.
This client has signs of dehydration, which is not expected when a client is vomiting. The client should remain hydrated even when the client is vomiting.
Ms. Kathy is making assignments. Which client should be assigned to the graduate nurse who has been on the unit for 1 month?
Show answer and rationale
Correct answer: D. The client diagnosed with lower esophageal dysfunction who is complaining of pyrosis.
Pyrosis is heartburn and is expected in a client diagnosed with GERD. The new graduate can care for this client and administer an antacid.
The client diagnosed with inflammatory bowel disease has a serum potassium level of 4.4 mEq/L. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Continue to monitor the client.
The client’s potassium level is within normal limits, so the nurse should continue to monitor the client. The normal level is 3.5 to 5.5 mEq/L.
The client has been admitted to the hospital with hemorrhaging from a duodenal ulcer. Which independent interventions should Ms. Kathy instruct the primary nurse to implement? Select all that apply.
Show answer and rationale
Correct answer: D. Complete the admission assessment.
An admission assessment is an independent intervention that the nurse should implement.
Ms. Kathy is discharging a client with a new sigmoid colostomy. Which statement made by the client indicates to Ms. Kathy the client needs more teaching?
Show answer and rationale
Correct answer: D. "I will irrigate my colostomy every week with 750 mL of tap water."
A sigmoid colostomy must be irrigated daily, so the client will have a bowel movement daily. This statement indicates the client needs more teaching.
The client is admitted to the medical unit with a diagnosis of acute diverticulitis. Which order should Ms. Kathy clarify with the healthcare provider?
Show answer and rationale
Correct answer: D. Schedule the client for a sigmoidoscopy.
Ms. Kathy should question a sigmoidoscopy. Invasive tests are not completed during an acute exacerbation of diverticulosis.
Ms. Kathy observes the unlicensed assistive personnel (UAP) turning the client who has just had a liver biopsy to the supine position. Which action should Ms. Kathy implement first?
Show answer and rationale
Correct answer: B. Instruct the UAP to place the client on the right side.
The client should be placed on the right side, same side as liver, to prevent hemorrhaging after the liver biopsy.
One of the primary nurses tells Ms. Kathy she stuck herself in the finger with a "used" needle and cleaned the site with soap and water. Which intervention should Ms. Kathy implement first?
Show answer and rationale
Correct answer: A. Complete an adverse occurrence report.
Ms. Kathy must first have the nurse complete the adverse occurrence report, so there is written documentation concerning the situation. Then Ms. Kathy should notify the infection control nurse, who will arrange for post-exposure prophylaxis and then determine if the client has hepatitis.
Which nursing task is most appropriate for Ms. Kathy to delegate to the unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: C. Assist the client with pruritis to the bathroom for a shower and a.m. care.
The client with pruritis (itching) is stable and the unlicensed assistive personnel (UAP) can assist with showering and a.m. care; therefore, this task can be delegated by Ms. Kathy.
Ms. Kathy is making rounds on the unit. Which client should Ms. Kathy assess first?
Show answer and rationale
Correct answer: B. The client who is 1 day post-op abdominal surgery with a hard, rigid abdomen and elevated temperature.
A hard, rigid abdomen and elevated temperature is indicative of peritonitis, which is an acute postoperative complication of abdominal surgery and requires immediate intervention. Ms. Kathy should assess this client first.
The nurse is caring for the following clients on a medical unit. Which client should the nurse assess first?
Show answer and rationale
Correct answer: C. The client with benign prostatic hypertrophy who has blood oozing from the intravenous site.
The nurse would not expect the client with BPH to have oozing blood from the intravenous site. This may indicate disseminated intravascular coagulation (DIC), which is a potentially life-threatening complication and requires immediate intervention.
The nurse is inserting an indwelling catheter into a male elderly client. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: A. Determine if the client has any betadine allergies.
Betadine is included in the indwelling catheter kit; so another form of cleaning agent must be used when inserting the catheter. Therefore, this is the first intervention.
The nurse is preparing to administer intravenous narcotic medication to the client who has renal calculi and is complaining of pain rated as 8 on 1 to 10 pain scale. The client’s vital signs are stable. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Determine if the client’s intravenous site is patent.
Ensuring the site is patent is the first intervention because even if it is the correct client, the medication should not be administered if the IV site is infiltrated.
The nurse is administering medications to clients on a surgical unit. Which medication should the nurse administer first?
Show answer and rationale
Correct answer: C. The narcotic analgesic morphine IV infusion to the client who is 8 hours postoperative and is complaining of pain, rating it as a 7 on a 1 to 10 pain scale.
The client who is in pain is priority. None of the other clients have a life-threatening condition. Pain is considered the fifth vital sign.
The nurse and unlicensed assistive personnel (UAP) are caring for clients on a surgical unit. Which action by the UAP warrants immediate intervention?
Show answer and rationale
Correct answer: D. The UAP assists a client who received an IV narcotic analgesic 30 minutes ago to ambulate in the hall.
The client who received a narcotic analgesic 30 minutes ago is at risk for falling because of the effects of the medication; therefore, the UAP should not ambulate this client. The nurse should intervene.
The charge nurse is making shift assignments to the surgical staff, which consists of two nurses, two licensed practical nurses (LPNs), and two unlicensed assistive personnel (UAP). Which assignment would be most appropriate for the charge nurse to make?
Show answer and rationale
Correct answer: D. Assign the LPN to change the client’s ileal conduit bag.
It is within an LPN’s scope of practice to change an ileal conduit drainage bag; therefore, this would be the most appropriate assignment for the LPN.
The charge nurse is making assignments in the day surgery center. Which client should be assigned to the most experienced nurse?
Show answer and rationale
Correct answer: D. The 24-year-old client who had a circumcision and is being prepared for discharge.
The most experienced nurse should be assigned to the client who requires teaching prior to being discharged. Postoperative complications can occur, so the client must be knowledgeable of when to call the healthcare provider and how to take care of the surgical site.
The nurse is completing the admission assessment on the client scheduled for cystectomy with creation of an ileal conduit. The client tells the nurse, "I am taking saw palmetto for my enlarged prostate." Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: A. Consult with the pharmacist to determine any potential drug interactions.
According to the NSCBN NCLEX-RN� test plan, collaboration with interdisciplinary team members is part of the management of care. The nurse should first consult with the pharmacist to determine whether the client is taking any medications that could interact with the saw palmetto.
The client scheduled for a D&C is upset because the HCP told her she has syphilis. The client asks the nurse, "This is so embarrassing. Do you have to tell anyone about this?" Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: D. "This must be reported to the Public Health Department and your sexual partners."
HIPAA does not apply in some situations, including the reporting of sexually transmitted diseases to the Public Health Department. The Public Health Department will attempt to notify any sexual partners the client reports.
The nurse is caring for clients on the renal unit. Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: A. Instruct the UAP to calculate the clients’ urinary intake and output.
The unlicensed assistive personnel (UAP) can calculate intake and output for clients. The UAP cannot evaluate the numbers to determine if the treatment is effective, but the UAP can obtain the numbers.
The nurse is caring for clients on a renal unit and making assignments for the day shift. Which client should the nurse assess first?
Show answer and rationale
Correct answer: A. The client diagnosed with nephrolithiasis who has hematuria and is complaining of pain, rating it as a 9 on 1 to a 10 pain scale.
Nephrolithiasis, kidney stones, is characterized by pain and hematuria, but the nurse must assess the pain to determine whether a complication has occurred or it is the expected routine pain. Pain is the common priority of these four clients.
Which action by the licensed practical nurse (LPN) requires intervention by the critical care charge nurse?
Show answer and rationale
Correct answer: C. The LPN has the trough drawn after hanging the aminoglycoside.
The trough should be drawn before the aminoglycoside, vancomycin, antibiotic is hung. This requires intervention by the critical care charge nurse.
The unlicensed assistive personnel (UAP) reports to the nurse the client’s urine output has bright red blood. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Assess the client’s urine specimen and complete a renal assessment.
The nurse must first assess the UAP’s findings and the client before taking any further action.
The charge nurse is making client assignments. Which client should the nurse assign to the graduate nurse who has just finished orientation?
Show answer and rationale
Correct answer: B. The client with a cystectomy who had a creation of an ileal conduit.
Although cystectomy is a major surgical procedure, it has a predictable course, and no complications were identified. After removing the bladder, the client must have an ileal conduit. This is expected with this type of surgery, and the new graduate nurse could be assigned of this client.
The charge nurse on the renal unit is notified of a bus accident with multiple injuries and clients are being brought to the emergency department (ED). The hospital is implementing the disaster policy. Which action should the nurse take first?
Show answer and rationale
Correct answer: A. Assess the staffing to determine which staff could be sent to ED.
Most disaster policies require one nurse to be sent immediately from each area; therefore, this intervention should be implemented first. The charge nurse must determine which staff nurse would be most helpful in the ED without compromising the staffing in the ICU.
The 18-year-old client diagnosed with renal trauma is admitted to the critical care unit after a serious motor vehicle accident resulting from driving under the influence. The mother comes to the unit and starts yelling at her son about "driving drunk." Which action should the nurse implement?
Show answer and rationale
Correct answer: C. Escort the mother to a private area and talk to her.
The nurse should remove the mother from the room and allow her to ventilate her feelings about the accident her son sustained while he was under the influence.
The nurse is caring for an 84-year-old male client diagnosed with benign prostatic hypertrophy. The client has undergone a transurethral resection of the prostate (TURP) and is complaining of bladder spasms. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: A. Assess the client’s three-way urinary catheter for patency.
The three-way indwelling catheter is placed during surgery to keep blood clots from remaining in the bladder and causing bladder spasms and increasing bleeding. The nurse should first assess the drainage system to make sure that it has not become obstructed with a clot.
The nurse is caring for clients on a surgical unit. Which client should the nurse assess first after shift report?
Show answer and rationale
Correct answer: D. The client with acute pyelonephritis who has nausea/vomiting and is dehydrated.
The client with acute pyelonephritis, an inflammation of the renal parenchyma and collecting system, is not expected to get dehydrated; therefore, this client should be assessed first.
The 78-year-old client with Alport syndrome asks the clinic nurse, "What should I do so I won’t get sick this winter?" Which priority statement is the nurse’s best response?
Show answer and rationale
Correct answer: A. "It is recommended you get a flu vaccine yearly."
The yearly flu shot is the best way to help prevent getting sick during the winter months, since the flu can cause serious illness, and even death, in the elderly. Alport syndrome is also known as chronic hereditary nephritis.
The elderly female client tells the nurse, "I have vaginal dryness and it hurts when my husband and I make love." Which priority intervention should the nurse discuss with the client?
Show answer and rationale
Correct answer: A. Recommend the client use a vaginal lubricant prior to intercourse.
Vaginal lubricant will help with the vaginal dryness and help decrease pain during sexual intercourse.
The elderly female client diagnosed with osteoporosis is prescribed the bisphosphonate medication alendronate (Fosamax). Which intervention is priority when administering this medication?
Show answer and rationale
Correct answer: B. Have the client remain upright for 30 minutes after administering the medication.
Fosamax should be administered on an empty stomach with a full glass of water to promote absorption of the medication. The client should remain upright for at least 30 minutes to prevent regurgitation into the esophagus and esophageal erosion.
Which nursing task should the nurse on the renal unit assign to the licensed practical nurse (LPN)?
Show answer and rationale
Correct answer: A. Insert an indwelling urinary catheter before surgery.
The LPN is qualified to perform a sterile procedure, such as inserting an indwelling catheter before surgery. This is an appropriate assignment.
The nurse on a medical unit has just received the evening shift report. Which client should the nurse assess first?
Show answer and rationale
Correct answer: C. The client with renal vein thrombosis who has a heparin drip infusion and a PTT of 92.
The therapeutic PTT level should be 1.5 to 2 times the normal PTT of 39 seconds. The therapeutic levels of heparin are 58 and 78. With a PTT of 92, the client is at risk for bleeding, and the heparin drip should be held. The nurse should assess this client first.
The nurse is preparing to administer medications. Which medication should the nurse administer first?
Show answer and rationale
Correct answer: A. Acetaminophen (Tylenol), an analgesic, due in 5 minutes.
Tylenol is administered for mildto-moderate pain. By the time the nurse obtains the medication and performs all of the steps to administer a medication correctly, it will be time for the client to receive the Tylenol. This medication should be administered first.
Which intervention should the nurse implement first when assisting a client with a flaccid bladder to urinate?
Show answer and rationale
Correct answer: D. Perform the Cred�’s maneuver on the client.
Cred�’s maneuver is a method used for expressing urine by pressing the hand on the bladder, especially a paralyzed bladder. It is a non-invasive procedure and should be implemented first prior to catheterization, which is an invasive procedure.
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
Everything on this site tagged NCLEX lives in the NCLEX category.
Sources