NCLEX Practice Questions — Set 2
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
A client sustains multiple fractures following a motor vehicle accident. The client is intubated and on a mechanical ventilator. Chest x-ray reveals diffuse bilateral pulmonary infiltrates. The ratio of fractional concentration of inspired oxygen to arterial oxygen concentration (PaO2/FIO2 ratio) is 174, central venous pressure (CVP) is 5 mm Hg, and pulmonary capillary wedge pressure (PCWP) is 10 mm Hg. What interventions would be most appropriate for the client? Select all that apply.
Show answer and rationale
Correct answer: D. Addition of positive end-expiratory pressure (PEEP) to ventilator.
PEEP improves ventilation to the atelectatic alveoli, improving oxygenation.
A client is admitted to labor and delivery with a diagnosis of placental abruption. A nursing priority for this client is to minimize alterations in fetal tissue perfusion. A nurse recognizes that this goal has been met when which finding is noted?
Show answer and rationale
Correct answer: D. Presence of accelerations.
accelerations are an indication of fetal well-being and a well-oxygenated fetus.
Which findings should indicate to a nurse that a traumatic brain injury has resulted in brain death? Select all that apply.
Show answer and rationale
Correct answer: A. No response to the cold caloric test.
the cold caloric test is a test of the oculovestibular reflex, and absence of this reflex indicates severe brainstem injury.
A home health nurse visits a child with hemophilia following a dental extraction. Which medication would the nurse suggest be removed from the family’s bathroom medicine cabinet?
Show answer and rationale
Correct answer: D. Ibuprofen.
while nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are effective in relieving pain caused by the chronic synovitis associated with hemophilia, they inhibit platelet function, which is essential in controlling bleeding episodes.
Following surgery for appendicitis, a client develops peritonitis. Which signs or symptoms should a nurse identify as being consistent with peritonitis? Select all that apply.
Show answer and rationale
Correct answer: C. Shallow respirations.
deep breathing causes pressure on the peritoneum from the diaphragm and pain. Expect to see shallow breathing, which causes minimal pressure on the diaphragm. Answer 2 is correct because peritoneal inflammation causes peritoneal contraction and the classic "boardlike abdomen."
A nurse is preparing to administer intravenous magnesium sulfate to a client diagnosed with preeclampsia. Which action should the nurse take when administering this medication?
Show answer and rationale
Correct answer: B. Discontinue the infusion and notify the physician of a respiratory rate of
a respiratory rate of less than 12 breaths/min can be a result of magnesium toxicity. The nurse should discontinue the infusion and notify the physician.
When would a client with community-acquired pneumonia be clinically stable enough to change from IV antibiotics to oral antibiotics? When the client has a(n):
Show answer and rationale
Correct answer: D. Systolic blood pressure that stays at 90 mm Hg or higher.
a systolic BP of 90 mm Hg or higher signals stability of the client.
An adolescent with hemophilia sustains a bilateral lower extremity injury and is hospitalized. Which selection on the adolescent’s lunch menu indicates the need for further dietary counseling by the nurse?
Show answer and rationale
Correct answer: B. A cheeseburger and coleslaw.
diet is an important consideration in the treatment of hemophilia. Excessive body weight can increase the strain on affected joints, especially the knees, and predispose the adolescent to hemarthrosis. Consequently calories need to be supplied in accordance with energy requirements.
A 44-year-old client has just found out that she is pregnant. The client knows that she is at a higher risk for carrying a fetus with a chromosomal abnormality. Which genetic test for chromosomal abnormalities should a nurse recommend to provide the client with chromosomal results within the first trimester?
Show answer and rationale
Correct answer: D. Chorionic villus sampling (CVS).
chorionic villus sampling (CVS) can be performed as early as about 9 weeks’ gestation, providing information before the end of the first trimester
The parents of a baby boy, who is newly diagnosed with hemophilia, state "This can’t be true! No one in our family has hemophilia." A nurse’s most factual response would be:
Show answer and rationale
Correct answer: B. "Up to one third of all hemophilia cases may be caused by a gene mutation."
it is the response that supplies the parents with the most facts/information. It tells the parents why this disease is present in their infant.
Which is the most important initial nursing action for a client with community-acquired pneumonia?
Show answer and rationale
Correct answer: C. Maintain IV site used for antibiotic therapy.
antibiotic therapy is the most important aspect of treatment. Maintaining IV site patency and integrity is a key role for the RN and for the client’s recovery.
A client, who is a primigravida at 39 weeks’ gestation, is being instructed on when she should come to the hospital. Which instructions should a nurse include? Select all that apply.
Show answer and rationale
Correct answer: C. "Come to the hospital if you are feeling decreased fetal movement."
decreased fetal movement may be an indication of fetal hypoxia, and the fetus should be evaluated using an external fetal monitor.
What type of dressing should a nurse use on a stage I pressure ulcer?
Show answer and rationale
Correct answer: D. None.
no dressing is needed for a stage I pressure ulcer because the skin is intact. Just turn the client frequently and keep pressure off the area.
Which pediatrician’s orders for a newborn boy with a family history of hemophilia should a nurse question?
Show answer and rationale
Correct answer: A. Finger or heel punctures for blood draws only.
venipuncture for blood draws are usually preferred in infants/children with hemophilia. There is usually less bleeding after venipuncture than after finger or heel punctures.
A client, who is a primigravida, delivered a healthy neonate by vacuum-assisted vaginal delivery after 24 hours of labor. A nurse is performing a routine postpartum assessment 12 hours later and finds the following vital signs: blood pressure, 118/76 mm Hg; temperature, 100.8�F; pulse, 102; respirations, 20. Which interventions would be appropriate for this client? Select all that apply.
Show answer and rationale
Correct answer: D. Call the physician.
calling the physician is appropriate when the client’s temperature is above 100.4�F.
Causation is an element that must be demonstrated by the plaintiff in a suit against a nurse for professional malpractice. Under what circumstance will the actions of the nurse be determined to be within a legal causal connection? Select all that apply.
Show answer and rationale
Correct answer: D. If the harm caused was a foreseeable consequence of the nurse’s action.
legal cause includes both harm caused directly by the actions of the nurse and harm caused by others when the actions of the nurse knowingly placed the client at risk of harm.
During change of shift, a day shift nurse states that all of a client’s urine is to be strained. The evening nurse knows that straining is ordered because:
Show answer and rationale
Correct answer: D. The composition of renal calculi needs to be identified.
straining is done to collect a renal stone for analysis of composition.
A 22-year-old client, who is gravida 1, para 0, is attending a routine 38-week prenatal visit. A physician gives the client instructions about when to come to the hospital for evaluation of onset of labor. A nurse evaluates that the client has understood the instructions when she states:
Show answer and rationale
Correct answer: B. "I should go to the hospital when my contractions are 5 minutes apart for an hour."
contractions that are 5 minutes apart and regular for an hour are the signs of normal onset of labor.
A nurse is caring for a client with second-degree burns of both arms. Which care need will be more challenging because of the location of the burn?
Show answer and rationale
Correct answer: C. Reducing potential for contractures and deformity.
burn wound tissue shortens because of flexion of muscles in wound healing. Contractures will need to be prevented with splints or traction.
A nurse prepares to administer N-acetylcysteine (Mucomyst) to a child who ingested a toxic dose of acetaminophen (Tylenol). What equipment will the nurse need to gather in order to administer the medication?
Show answer and rationale
Correct answer: C. A glass of juice.
N-acetylcysteine (Mucomyst) is usually given orally, but is first diluted in fruit juice or soda because of the antidote’s offensive odor ("rotten eggs").
A client, who is gravida 1, para 0 at 35 weeks’ gestation, delivered her infant 1 day ago by cesarean section for breech presentation. The infant was admitted to the nursery for unstable blood sugar. Which action by a nurse would be the most appropriate to promote the attachment process between mother and infant?
Show answer and rationale
Correct answer: C. Take the mother to the nursery and encourage her to participate in his care.
the combination of direct physical contact between mother and baby and participation in the infant’s care helps the mother in recognizing her infant as a distinct individual who is yet a part of her. This process is the beginning of attachment.
A 3-year-old child has ingested some "pink pills" in an unlabeled bottle found on the floor of the garage. In what order should a nurse correctly perform a gastric lavage and administration of activated charcoal?
Show answer and rationale
Correct answer: C. Perform the gastric lavage and then administer the activated charcoal.
the ingested toxin is removed by lavage from the stomach, and then the activated charcoal is instilled to aid in the absorption and removal of any medication left after the gastric lavage is completed. To "lavage" means to wash the stomach and remove the saline when the lavage is completed.
A client asks a nurse how soon after bowel surgery normal bowel function will return. The best response by the nurse would be:
Show answer and rationale
Correct answer: D. "By 72 hours you should start to pass gas."
the bowel should be functioning by 72 hours.
A client is in active labor at 38 weeks’ gestation. She requests an epidural for labor pain. Which actions should a nurse take to prepare for this procedure? Select all that apply.
Show answer and rationale
Correct answer: D. Sit client upright on the side of the bed.
client must be sitting up before beginning the epidural procedure.
A teenager with sickle cell anemia tells a clinic nurse that the school has arranged for a nature hike in the nearby mountains. The teen excitedly shows the nurse a new water bottle that has been purchased just for this trip. Which initial response by the nurse would be most appropriate?
Show answer and rationale
Correct answer: C. "It’s great that you are preparing to hydrate properly on your hike. How else have you planned for the hike?"
the nurse first provides praise for a positive health behavior, then opens up the conversation into a discussion about additional steps that should be taken to promote the child’s health.
A client, who is diabetic, is scheduled for discharge. A nurse should recognize the need for further teaching if the client states:
Show answer and rationale
Correct answer: D. "I had been taking a name brand drug, but the generic brand costs less."
there may be variations in the effects of a name brand versus a generic brand. The physician should be advised.
The lips and oral cavity of a child who ingested a corrosive substance are blistered, peeling, and swollen. The priority action for a nurse in the emergency department is to:
Show answer and rationale
Correct answer: B. Maintain a patent airway.
maintaining a patient airway is always the nurse’s first priority. In the presence of swelling, the loss of a patent airway is both a real possibility and the nurse’s first concern
A client, who is gravida 8, para 7, has saturated three perineal pads with bright red blood during the first hour after delivery. What are appropriate nursing actions for this client? Select all that apply.
Show answer and rationale
Correct answer: B. Administer oxytocin.
administering oxytocin can decrease the bleeding after delivery.
Which types of congenital heart disease are characterized by blood flow from right to left? Select all that apply.
Show answer and rationale
Correct answer: D. Transposition of the great vessels.
right-to-left blood flow is found in transposition of the great vessels.
An older client is scheduled to go home following hospitalization for thrombophlebitis. When a nurse offers the client the daily warfarin tablet, the client refuses the medication. The best response by the nurse would be:
Show answer and rationale
Correct answer: D. "Tell me about your concerns with your medication."
this response attempts to understand the client’s actions.
A client, who is gravida 7, para 6, delivered an infant at 39 weeks’ gestation approximately 14 hours ago. Which assessment finding indicates normal postpartum progression?
Show answer and rationale
Correct answer: A. Firm fundus 1-2 fingerbreadths above the umbilicus and midline with moderate lochia rubra.
fundal height increases to 1 to 2 fingerbreadths above the umbilicus within 12 hours after delivery
A client has not been following the drug regimen for control of gastroesophageal reflux disease (GERD). The best approach by a nurse to improve compliance would be to:
Show answer and rationale
Correct answer: C. Ensure that the client understands the expected outcome from the drug regimen.
giving the client information also gives the client control over the condition.
A nurse is performing health teaching with the parents of a 16-month-old child who has tetralogy of Fallot. Which steps should the nurse advise the parents to take to properly respond to a "tet spell"? Select all that apply.
Show answer and rationale
Correct answer: B. Call EMS.
after taking action to treat the "tet spell," the parents should activate emergency medical services (EMS).
A client, who is 19 years old, gravida 1, para 0, is admitted to labor and delivery at 30 weeks’ gestation. The client reports nausea and vomiting, epigastric pain, and a headache. Her vital signs are temperature: 98.8�F, pulse: 78, respirations: 20, and blood pressure: 170/110 mm Hg. Her laboratory values are as follows: WBC: 4.5, hematocrit: 30, platelets: 88,000, AST: 146, ALT: 120. What other assessments should a nurse perform on this client? Select all that apply.
Show answer and rationale
Correct answer: B. Deep tendon reflexes.
this client has HELLP syndrome, with a decreased hematocrit, elevated liver function tests, and low platelets. Deep tendon reflexes are an essential part of an assessment for a client with HELLP syndrome.
An RN would be judged negligent if which event occurred during client care?
Show answer and rationale
Correct answer: C. Making a medication error resulting in injury.
an action that results in an injury can be judged as negligent.
Which client is most appropriate for an RN to delegate to a CNA?
Show answer and rationale
Correct answer: D. A client who is 8 hours postop thyroidectomy with decreased blood pressure.
the CNA could encourage use of the incentive spirometer and ambulate the client as ordered in a client who is postoperative GI surgery and needs routine help with postoperative self-care (breathing exercises).
Which client would be appropriate for the RN to delegate to the LVN/LPN?
Show answer and rationale
Correct answer: A. A client in liver failure who needs a blood transfusion.
the client’s condition is not going to change suddenly
A client dies in the hospital. The driver’s license indicates that the client wanted to be an organ donor. The family is refusing organ donation. What is the correct action by an RN?
Show answer and rationale
Correct answer: B. Respect the family’s wishes.
the family’s wishes must be followed. If the client had an advance directive, this may not have been an issue.
A client is admitted with an existing advance directive that states "Do Not Resuscitate" (DNR). The client goes into cardiac arrest. How should a nurse respond?
Show answer and rationale
Correct answer: C. Do not resuscitate the client as detailed in the advance directive.
advance directive is an expression of the client’s wishes.
When assessing a client with peripheral neuropathy, which question is most important for a nurse to ask?
Show answer and rationale
Correct answer: C. "Can you feel me touching your feet?"
peripheral neuropathy is a condition caused by nerve damage in the feet, sometimes also in the legs and upper extremities. Clients have either decreased sensation or neuropathic pain from the condition. Clients with this condition need extra assessments and care to protect the affected extremities from injury. They may require seizure or psychiatric drugs to assist with the pain. If a client has diabetes, avoidance of high blood sugar levels is also important.
What isolation precautions are necessary for a client with a history of hepatitis C who is "anti-HCV positive?"
Show answer and rationale
Correct answer: B. Standard precautions.
the presence of antibodies against the hepatitis C virus (HCV) means that the client has had hepatitis C in the past, but is not necessarily still infected. Management of this potential blood-borne infection involves standard precautions.
A charge nurse on a medical-surgical floor observes a certified nursing assistant (CNA) taking care of a client with impaired vascular circulation. What behavior by the aide requires immediate action by the RN?
Show answer and rationale
Correct answer: D. Aide places client’s feet in warm water.
heat is contraindicated since the client has reduced sensation from impaired vascular circulation. Injury may result.
During hospital orientation for new graduates, an instructor covers health-care-associated infections (HAI), formerly referred to as nosocomial infections. Which infections are known to be spread to the client by health-care providers during care? Select all that apply.
Show answer and rationale
Correct answer: B. Clostridium difficile.
poor hand hygiene spreads this infection.
A client in rehabilitation following a brain attack is receiving tube feedings at 75 mL/hr, Na+ is 148, K+ is 4.2, creatinine is 1.2, glucose is 145. What should a nurse ask a physician, as part of the SBAR (Situation, Background, Action, Recommendation) communication?
Show answer and rationale
Correct answer: B. "Do you want to give intermittent tap water through the feeding tube?"
full-strength tube feedings can cause hypernatremia. This is generally managed with enteral electrolyte-free water. Tap water is appropriate directly into the GI system; it does not need to be sterile.
The most effective intervention to help a client quit smoking, that a nurse could suggest, is:
Show answer and rationale
Correct answer: A. Counseling.
the 1-year quit rate for a person completing a group counseling program is 20%. Individual counseling has a small but significant impact on quitting.
When an RN returns from dinner break, which client should be assessed first?
Show answer and rationale
Correct answer: D. 46-year-old, stable, 4 hours after cardiac catheterization.
there is a risk of bleeding at the insertion site and other postcatheterization complications. Stability of vital signs and ECG need to be assessed.
A client with MRSA is transferred to a nursing unit. A charge nurse should place the client in a room with:
Show answer and rationale
Correct answer: D. Another client with MRSA.
all other choices are vulnerable to infection.
Under which circumstance can an RN safely delegate tasks to unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: D. Task competency was verified during orientation.
when delegating, the RN needs to confirm that the UAP has met the task competencies. If delegating to a licensed staff (LPN/LVN), the assignment must be within the scope of practice.
A client is prepared for a bronchoscopic examination. The RN gives an IV sedative. Which activity could be delegated to an LPN/LVN?
Show answer and rationale
Correct answer: C. Checking the client’s blood pressure and pulse.
the client has been given IV sedation. Vital signs (VS) need to be checked after receiving sedation. The LVN/LPN can take the VS, but the RN must assess the findings.
Four clients walked into an ambulatory clinic at the same time. Which client should a nurse assess first?
Show answer and rationale
Correct answer: A. A 35-year-old client complaining of a severe headache, vomiting, and stiff neck.
the classic signs and symptoms of bacterial meningitis in an adult are severe headache and neck stiffness (nuchal rigidity). This is a serious condition because of the proximity to the brain and spinal cord and the possibility of sepsis.
Which client should an RN direct an LPN/LVN to check on first?
Show answer and rationale
Correct answer: B. A client with GI bleeding who was up to use the bedside commode.
it is important to determine if the client is actively bleeding. Since this client is the most unstable, the RN needs to ask the LPN/LVN to check on this client first.
When relocating an older client from a family home to an assisted-living community, the correct action by a nursing case manager is to:
Show answer and rationale
Correct answer: A. Ensure the client’s perceived control with the move to an assisted-living setting.
preserving the client’s control over the decision is important to a successful adjustment.
Following report on four clients, which client should a nurse assess first?
Show answer and rationale
Correct answer: C. A client with possible acute pyelonephritis. Urine output is 25 mL in the past 2 hours.
pyelonephritis is an infectious process that can lead to acute renal failure. If kidney function is inadequate, the client may develop a life-threatening condition, such as hyperkalemia.
Which finding should a nurse report immediately to a physician?
Show answer and rationale
Correct answer: A. Client who has a pulse of 100 and irregular; who was previously 80 and regular.
a change in cardiac status is a priority and potentially life threatening, which requires the nurse to collaborate with the physician on the appropriate action.
An RN delegates the administration of a nasogastric tube feeding to a licensed practical/vocational nurse (LPN/LVN). Which statement about responsibility in this situation is most accurate?
Show answer and rationale
Correct answer: D. The RN is responsible for delegated care.
the RN can never delegate the ultimate responsibility for the client. Before delegating, the RN needs to determine that the LPN/LVN is competent.
Following antibiotic therapy, a client develops bloody diarrhea. A nurse suspects Clostridium difficile, which often occurs when antibiotics disrupt the normal intestinal flora and injure the lumen of the bowel. Control of this infection will include: Select all that apply.
Show answer and rationale
Correct answer: A. Hand hygiene and wearing gloves.
the bacterium can be spread on the hands of health care providers.
After receiving an end-of-shift report on four clients, a nurse plans client care. Which client should the nurse assess first?
Show answer and rationale
Correct answer: A. Client admitted through the emergency department 3 hours ago with acute abdominal pain.
a newly admitted client with abdominal pain is not stable and is first priority. The cause of the pain is unknown and vital signs should be assessed.
Which client should a nurse assess first?
Show answer and rationale
Correct answer: C. Client with pancreatitis complaining of jaw pain, 4 on a scale of 10.
jaw pain is not a typical pain pattern for pancreatitis; therefore, the client needs to be assessed for myocardial ischemia.
Following a major earthquake, clients begin to arrive in an emergency department. Using the disaster triage system, which client should be treated first?
Show answer and rationale
Correct answer: D. Client with an open pneumothorax and severe dyspnea.
a client color-coded red (emergency) is the first priority. This client has a life-threatening problem that needs immediate action.
Which activities could an RN delegate to a certified nursing assistant (CNA)? Select all that apply.
Show answer and rationale
Correct answer: C. Taking routine vital signs.
the activity is technical, and there is no potential for harm to the client. The RN would need to evaluate the findings.
Medicare has enacted a new policy that states that, if a client develops certain conditions while in the hospital, the hospital will not be reimbursed for the care of the client. Which condition does a nurse know that quality care can prevent?
Show answer and rationale
Correct answer: B. Poor blood sugar control.
poor blood sugar control is related to the quality of care received while hospitalized.
To ensure that the hospital is delivering quality care, a nurse participates in collecting data for core measures, which are:
Show answer and rationale
Correct answer: A. Standardized, evidence-based performance measures needed for hospital accreditation.
these measures or standards of care are required by the Joint Commission to ensure that the best practices are being used in the hospital. An example of a core measure is the standard of care for a client admitted with heart failure.
One of the hospital-acquired conditions that Medicare will not pay for is falls. The nursing staff is responsible for fall prevention. The best predictor of the likelihood of a client falling while hospitalized is:
Show answer and rationale
Correct answer: B. A history of falling before admission.
the circumstances of a previous fall can be used to plan specific interventions to prevent a fall.
A client is very agitated and needs to have soft restraints applied. To ensure the safety of the client, the nurse should:
Show answer and rationale
Correct answer: B. Inspect the client’s skin under the restraints every 2 hours.
the tightness of the restraints and the effects on client’s skin must be frequently assessed.
A nurse returns to work after vacation and the clients are all new to the RN. National Patient Safety Goals require that at least two pieces of identification must be used to establish client identity. The best approach to identifying the clients before giving medications would be to:
Show answer and rationale
Correct answer: A. Have the client spell name and give date of birth.
spelling the name and stating birth date would only be possible by the actual client.
To prevent a catheter-associated bloodstream infection, when would hand washing be required? Select all that apply.
Show answer and rationale
Correct answer: C. Before and after palpating around the site.
hand washing is the most important technique to reduce the risk of infections.
An RN observes the hand hygiene routine of a nursing assistant. Additional teaching will be needed if the RN observes that:
Show answer and rationale
Correct answer: C. Hands were rubbed together for 10 seconds.
hands should be vigorously rubbed together for at least 15 seconds, not 10 seconds.
A nurse in an emergency department performs triage of clients in the waiting room. Which child should the nurse send for immediate examination?
Show answer and rationale
Correct answer: C. A 6-month-old infant with a sunken fontanel and history of poor feeding.
the infant’s history and assessment findings are suggestive of moderate to severe dehydration, which should be addressed quickly.
A nurse prepares to admit a child diagnosed with respiratory syncytial virus (RSV). Which infection control measure would be most appropriate for this child?
Show answer and rationale
Correct answer: A. Place child on contact precautions.
RSV is transmitted by contact. The child diagnosed with RSV should be placed on contact precautions (gown, gloves) with strict emphasis on hand washing.
A nurse is caring for an infant with acute gastroenteritis with an estimated 10% weight loss. Which actions should the nurse take when caring for this infant? Select all that apply.
Show answer and rationale
Correct answer: C. Monitor hourly urine output.
the child’s urinary output should be monitored frequently to determine the response to treatment. Answer 6 is correct because, once the nurse is protected, IV fluids should be administered to correct the severe dehydration.
A school nurse receives a call from the parent of a child diagnosed with chickenpox. The parent asks when the child may return to school. What is the best information that the nurse should provide to this parent?
Show answer and rationale
Correct answer: C. Children with chickenpox may return to school once all of the lesions have scabbed over.
the child is not considered contagious once all of the chickenpox (varicella) lesions have crusted.
A nurse is caring for a postoperative client. Which nursing action will prevent infection?
Show answer and rationale
Correct answer: D. Remove dressing to assess wound only during needed dressing changes.
wounds that require dressings should be covered. Frequent removal for wound assessments increases infection risk and reduces optimal presence of healing fluids and substances in wound bed.
A nurse is counseling the parent of a young child with HIV. What information is essential for the nurse to convey during the first meeting?
Show answer and rationale
Correct answer: B. Adherence to antiretroviral therapy is critical for the child’s health.
it is essential that the parent recognize the importance of following through with the medication regimen prescribed by the practitioner. Failure to do so could quickly lead to resistant HIV and opportunistic infection.
A nurse is assigned to care for multiple clients who had surgery 2 days ago. Following the 7 a.m. shift report, which client should the nurse assess first?
Show answer and rationale
Correct answer: A. A 24-year-old, who had a splenectomy at age 18, with a temperature of 38.8�C.
bloodstream infections are of great concern in clients without the normal filter of the spleen. The high temperature indicates this client could be septic and will require immediate care with fluids and antibiotics.
Which nursing action is appropriate in the care of a client admitted with pneumonia who had a right mastectomy 3 years ago?
Show answer and rationale
Correct answer: B. Start an IV on the left forearm.
during breast surgery, lymph nodes are removed to rid the body of spreading cancer. This leaves the distal tissue at risk for swelling and infections. IV catheters, carrying a risk of infection, should be placed in the opposite arm.
A drop of a client’s blood splashes on a nurse’s skin in an area where the nurse had a small, dried scab. The appropriate nursing action is to:
Show answer and rationale
Correct answer: B. Wash the site without disrupting the scab.
washing is the most effective way of removing potentially infectious material. Avoid disrupting the scab, which is providing a microbial barrier.
A nurse has received an end-of-shift report on four clients. Which client should the nurse see first?
Show answer and rationale
Correct answer: C. A client who is a stockbroker, admitted with GERD, with BP of 160/90.
the elevated blood pressure may indicate stress or pain, and further assessment is needed to establish why the blood pressure is elevated.
The parents of a child with sickle cell anemia ask for information about heredity. What information should a nurse provide? Select all that apply.
Show answer and rationale
Correct answer: A. If both parents have sickle cell trait, there is a 25% chance their offspring will have sickle cell anemia.
this is the probability for these parents to have a child with sickle cell anemia.
A client, who is a 19-year-old gravida 2, para 1, delivers a 10-pound neonate by cesarean section after 36 hours of labor and failure to progress. The client has developed abdominal tenderness, a fever of 102.2�F (39�C), and foul-smelling lochia. A nurse should recognize that the most likely reason for the client’s condition is:
Show answer and rationale
Correct answer: B. Endometritis.
the most common reason for postpartum fever is endometritis. Other symptoms include abdominal tenderness and foul-smelling lochia. Postpartum endometritis occurs in 15% to 20% of unscheduled cesarean deliveries after a prolonged labor.
A nurse tells a client that a positive reaction to a tuberculosis (TB) test will be determined by:
Show answer and rationale
Correct answer: B. The size of the induration 48 hours after the test.
the presence of a positive TB test is determined by the size of the induration. Induration of 10 mm or more is a positive reaction.
In making room in a hospital for emergency admission of clients who were in a disaster, which client can be discharged?
Show answer and rationale
Correct answer: D. Client with bronchial asthma with 95% oxygen saturation on room air.
the oxygen saturation is normal. The asthma is being controlled.
In prioritizing care, to which client should a nurse respond first?
Show answer and rationale
Correct answer: D. Client with IV chemotherapy and the infusion pump is alarming.
chemotherapy drugs are toxic and can cause tissue destruction if infiltrated, and maintaining the access port is vital to therapy.
An HIV-positive client with type 1 diabetes gives birth at 28 weeks’ gestation because of severe preeclampsia. She is asking a nurse about breastfeeding her infant in the neonatal intensive care unit. The nurse should explain to the client that that breastfeeding is contraindicated in the client with:
Show answer and rationale
Correct answer: D. Positive HIV.
HIV can be transmitted through breast milk.
In what position should a client in a wheelchair be placed to facilitate a safe transfer to bed, if the client has had a right-sided brain attack (stroke)?
Show answer and rationale
Correct answer: A. Weakened (L) side of the client away from the bed.
with a right-sided brain attack, the client would have left-sided hemiplegia or weakness. The client’s unaffected side should be closest to the bed to facilitate the transfer.
Where should a nurse place the call light for a client with a right-sided brain attack and left homonymous hemianopsia?
Show answer and rationale
Correct answer: D. On the client’s right side.
the client has left visual field blindness. The client will see only from the right side.
A client has a colostomy following surgery for colon cancer. Which assessment finding would require immediate action by a nurse?
Show answer and rationale
Correct answer: B. Complaint of pain with light touch.
since there are no nerves in the mucous membranes, there should be no pain when touching. Pain would possibly indicate a problem internally.
A nurse prepares a hospital room for the pending admission of a 1-week-old infant with hyperbilirubinemia. Which piece of equipment would be best suited for this infant?
Show answer and rationale
Correct answer: A. Isolette.
the infant will likely be receiving phototherapy, which requires the baby to be unclothed. The isolette allows the baby to be in a closed, temperature-regulated environment.
Following report on four clients, the priority intervention for a nurse should be to:
Show answer and rationale
Correct answer: B. Report a K+ level of 5.9 in a client receiving Kayexalate.
the K+ level is above the normal high of 5.5 mEq/L. An elevated K+ can have serious effects on the heart and affect the stability of the client. The physician needs to be called regarding the report so that changes in treatment can be made to manage the elevated K+.
A client, who is gravida 1, para 0, is attending a prenatal visit. She asks about water aerobic exercise class. A nurse gives the client instructions about swimming and bathing during pregnancy. Which client statement indicates that health teaching has not been effective?
Show answer and rationale
Correct answer: C. "I can relax in a hot tub for 30 minutes after swimming."
women who are pregnant should not sit in hot tubs for longer than 10 minutes. Becoming overheated in a hot tub is not recommended during pregnancy. The American College of Obstetricians and Gynecologists (ACOG) also recommends that women who are pregnant should never let their core body temperature rise above 102.2�F. Women who choose to use a hot tub should monitor their temperature to avoid overheating
A client, who is a 28-year-old gravida 4, para 3, presents to labor and delivery with the fetal head crowning. A physician is called for an emergent delivery, but has not yet arrived. After the neonate’s head is delivered, which nursing intervention would be the most appropriate?
Show answer and rationale
Correct answer: B. Check for a nuchal cord.
before delivery of the neonate’s body, it is important to check for a cord around the neonate’s neck. It is the first action after delivery of the head and before the shoulders are delivered.
A family lives in an apartment building built in the 1950s, which has lead pipes. The family cannot afford to move. To prevent exposure to lead through the water, a nurse should instruct the family to:
Show answer and rationale
Correct answer: B. Use cold water from the tap for cooking purposes.
hot water can cause leakage of lead from old pipes. The family should use cold water for drinking, cooking, and preparation of infant formula. Cold water reduces the leakage of lead from old pipes.
What would the appropriate infection control technique be for changing a leg dressing on a client who has Pneumocystis jiroveci (formerly carinii) pneumonia (PCP)?
Show answer and rationale
Correct answer: B. Wash hands after removing gloves.
standard (universal) precautions should be used, and washing hands is the most important technique for preventing disease transmission.
The first nursing concern for a client following bronchoscopy should be to:
Show answer and rationale
Correct answer: B. Check for the return of the gag reflex.
the throat will have been anesthetized to facilitate passage of the tube. If the gag reflex has not returned before food or fluid is given, the client may aspirate.
While a client is getting out of bed, the chest tube catches on the night stand and is pulled out. What should a nurse do first?
Show answer and rationale
Correct answer: D. Hold client’s gown over opening.
the priority is to prevent air from entering the chest cavity with the most occlusive method. (Gloves might be available, but time is critical.)
Which person should be restricted from visiting a client with TB until at least 2 weeks of drug therapy has been completed?
Show answer and rationale
Correct answer: A. The client’s 3-year-old granddaughter.
infants and children under age 5 are susceptible to TB.
Client teaching on how long the medication for TB should be taken would include:
Show answer and rationale
Correct answer: A. Daily for at least 9 months.
total destruction of the infection takes at least 9 months, if not longer.
When a client’s family members come to visit, they would be adhering to respiratory isolation precautions when they:
Show answer and rationale
Correct answer: A. Wash their hands when leaving.
hand washing is the best method for reducing cross-contamination. Gowns and gloves are not always required when entering a client’s room.
Which task should a nurse delegate to a certified nursing assistant (CNA)?
Show answer and rationale
Correct answer: D. Walking with a client who is postoperative.
nursing assistants can walk clients (or feed them, if there is no risk of aspiration). If assessment is required, the task cannot be delegated.
A nurse notices that a client’s signed consent form states "amputation of the right leg," although it is the left leg that is to be amputated. The client has already received preoperative medications. What should the nurse do?
Show answer and rationale
Correct answer: A. Call the MD to reschedule the surgery.
the responsibility for an accurate informed consent is the physician’s. An exception to this answer would be a life-threatening emergency, but there are no data to support another response.
What should be the first nursing actions for a client admitted to an emergency department following an accident?
Show answer and rationale
Correct answer: D. Check respirations, stabilize spine, check circulation.
checking the airway would be a priority, and a neck injury should be suspected.
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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