NCLEX Practice Questions — Set 5
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 comes to an emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse should first ask the client if:
Show answer and rationale
Correct answer: C. There had been recent trauma to the bladder or lower abdomen.
pain and blood in the urine without a fever would be more consistent with a blow or trauma to the abdomen or bladder.
A client with diabetes has a blood sugar of 300 mg/dL and an Na+ of 133. What nursing intervention is indicated to manage the sodium with this client?
Show answer and rationale
Correct answer: B. Monitor Na+ return to normal with lowering of blood sugar.
as blood sugar rises, serum osmolarity increases and the pituitary secretes antidiuretic hormone. This causes the kidneys to retain free water, diluting down serum sodium. Direct treatment of the hyponatremia is not needed.
The nursing priorities for the care of a client with acute glomerulonephritis are: Select all that apply.
Show answer and rationale
Correct answer: A. Maintaining strict I&O.
acute glomerulonephritis (AGN) decreases glomerular function. Fluid is restricted during the edematous phase. There is a risk of renal failure as a result of the inflammation ("itis").
A nurse is caring for a client with a left hemisphere stroke. The appropriate nursing actions for this client are: Select all that apply.
Show answer and rationale
Correct answer: B. Place food and the television on the left side of the bedside table.
loss of half of the visual field (hemianopsia) will be on the same side as the paralyzed side. The left visual field will be intact.
A nurse notes that a client, who experienced a head injury 24 hours ago has returned to the emergency department with slurred speech and is disoriented to time and place. The first nursing action should be to:
Show answer and rationale
Correct answer: B. Report the change to the physician.
a medical or surgical intervention is needed for an apparent increase in intracranial pressure.
Which assessment finding should indicate to a nurse that a client has progression of intermittent claudication?
Show answer and rationale
Correct answer: B. The distance a client can walk before leg pain starts.
intermittent claudication occurs with peripheral vascular disease and inadequate blood flow to the tissues. As the disease progresses, the pain will occur sooner.
Which assessment findings should alert a nurse to early alcohol withdrawal in a client 2 days after surgery? Select all that apply.
Show answer and rationale
Correct answer: D. Diaphoresis.
the client will experience autonomic overactivity causing tachycardia, dilated pupils, and profuse perspiration. Answer 5 is correct because the autonomic overactivity will cause tachycardia. Answer 6 is correct because the pupils will be dilated from the autonomic overactivity.
An older adult attending a community health fair asks about receiving the necessary vaccines for the swine flu. The nurse tells the client that, to prevent the spread of swine flu, the client should receive:
Show answer and rationale
Correct answer: B. The seasonal and novel H1N1 vaccines the same day.
the older adult, while less susceptible to the swine flu than younger clients, should receive both vaccines particularly if they also have pre-existing chronic conditions. The vaccines can be taken the same day.
A client, who had been playing golf in 110°F outside temperature, is admitted to an emergency department with hyperthermia. A nursing assessment would reveal: Select all that apply.
Show answer and rationale
Correct answer: A. Absence of sweating.
sweating decreases as heat exhaustion progresses to heat stroke.
A nurse should recognize the signs of deep vein thrombosis (DVT) if a client reports: Select all that apply.
Show answer and rationale
Correct answer: C. Sudden swelling of one leg with dependent edema.
a clot in a leg vein will affect venous return and cause swelling and edema.
What nursing action is appropriate if a client has a K+ of 8 mEq/L?
Show answer and rationale
Correct answer: C. Give insulin, glucose, calcium, and/or bicarbonate STAT, as ordered.
this is dangerously high potassium. Glucose, insulin, and bicarbonate help move the potassium intracellularly. Calcium helps protect the heart from hyperkalemia-induced arrhythmias.
Which client has the greatest need for K+ replacement?
Show answer and rationale
Correct answer: A. A client with cardiac disease who is about to receive furosemide with a K+ of 3.5.
clients with cardiac disease are vulnerable to arrhythmia when serum potassium is low. Furosemide will cause potassium loss. It is important to replace potassium before the furosemide is given.
A nurse knows that the choice of a topical antimicrobial for a client with burns is most influenced by:
Show answer and rationale
Correct answer: A. The presence and extent of eschar formation.
since eschar is devitalized tissue, the topical agent must be able to penetrate eschar and not be systemically toxic.
Which condition should a community health nurse report to the health department?
Show answer and rationale
Correct answer: A. Confirmation of acid-fast bacilli.
TB is a bacterial infectious disease that is communicable to others and is associated with significant mortality and morbidity
Which client can be safely discharged to make room for clients suffering from a salmonella outbreak from a local food chain?
Show answer and rationale
Correct answer: D. A 61-year-old with osteoarthritis who lives in a nursing home.
the older adult client has a chronic problem and would be supervised in the longterm care facility.
What should a nurse monitor first when caring for a client who is undergoing treatment for pheochromocytoma?
Show answer and rationale
Correct answer: B. Blood pressure.
treatment initially is directed at reducing the marked elevation of blood pressure quickly.
Which aspect of care is most important for a client with diabetic neuropathy?
Show answer and rationale
Correct answer: A. Teach the client to inspect the feet using a mirror.
neuropathies reduce the sensation (pain) in the client’s feet. Consequently, the client is unaware of injuries or trauma to the feet that could lead to ulceration and cellulitis, which are more difficult to treat in the person who has diabetes.
A client with diabetic ketoacidosis has been treated with an insulin drip for the past 3 hours. For which imbalance is this client at greatest risk?
Show answer and rationale
Correct answer: D. Hypokalemia.
rehydration and the administration of insulin will cause the potassium to move back into the cells, resulting in a potentially even lower K+ level. Potassium replacement begins when the K+ level drops to normal to prevent hypokalemia.
Which symptom would a nurse most likely observe in a client with cholecystitis?
Show answer and rationale
Correct answer: A. Nausea after a high-fat meal.
biliary colic is common in cholecystitis and is associated with nausea and vomiting several hours after a heavy, high-fat meal.
If a client’s bowel sounds are absent, a nurse should listen for at least:
Show answer and rationale
Correct answer: B. 3 minutes.
to determine if bowel sounds are absent, the nurse must listen for a minimum of 3 minutes and for as long as 5 minutes.
What should be the first nursing action if an NG tube is not draining?
Show answer and rationale
Correct answer: A. Determine tube placement.
the lack of drainage may mean the tube is no longer in the correct location.
A nurse would know that a client was experiencing chronic renal failure (CRF) if which signs or symptoms were present?
Show answer and rationale
Correct answer: C. Pruritus and anemia.
the irritating toxins are accumulating and result in skin irritation. Anemia results from the inadequate erythropoietin production.
A client has returned to the unit from surgery after having an arteriovenous (A-V) fistula created in the left arm. The client’s teaching should include: Select all that apply.
Show answer and rationale
Correct answer: A. Squeezing a ball to increase vessel size.
exercise increases the vessel size to better accommodate the large-bore needles used in hemodialysis.
After a cystectomy and construction of an ileal conduit, which complication should a nurse instruct a client to take special precautions to prevent?
Show answer and rationale
Correct answer: C. Pyelonephritis.
an ileal conduit is a urinary diversion that allows direct access of organisms to the kidneys. Proper management of the appliance, good skin care, proper hand hygiene, and adequate fluids will reduce the chance of developing an infection.
A nurse should teach a client with a Kock pouch urinary diversion to prevent urinary tract infection by:
Show answer and rationale
Correct answer: A. Maintaining a daily fluid intake of 2 liters.
adequate fluids will maintain the urine output and optimal renal function.
A client who is scheduled for surgery to correct a retinal detachment should be positioned:
Show answer and rationale
Correct answer: B. Upright with face down.
detachments or tears are toward the back of the eye. A gas bubble is frequently used to flatten the retina (pneumatic retinopexy), and the client must be positioned to make the bubble float into position.
A client has been admitted with mild symptoms of novel H1N1. Which family member is at greatest risk for developing the infection?
Show answer and rationale
Correct answer: D. The 13-year-old son with asthma.
the risk increases in a young person with a chronic condition. Ages 6 months to 24 years were effected more often than healthy older adults.
Which respiratory change would a nurse see most often in a client with increased intracranial pressure?
Show answer and rationale
Correct answer: C. Slow, irregular respirations.
increased intracranial pressure (ICP) presses on the structures of the brain, causing irregularities such as Cheyne-Stokes respirations.
Leakage of spinal fluid is a potential neurosurgical complication. How should a nurse assess for this complication?
Show answer and rationale
Correct answer: D. Test all nasal and ear drainage for glucose.
spinal fluid contains glucose. The RN should also look for the "halo" sign of blood drainage with a yellow ring of spinal fluid. In addition, nose and ears should be kept clean to reduce the chance of infection.
A client is admitted to an ICU with a possible brain attack (stroke). Assessment findings consistent with a brain attack include: Select all that apply.
Show answer and rationale
Correct answer: C. Pronator drift.
pronator drift reflects ischemic consequences of a stroke.
Which is the most common treatment for a client in addisonian crisis?
Show answer and rationale
Correct answer: C. IV normal saline and glucocorticoids.
immediate treatment is directed toward reversing circulatory shock of addisonian crisis. Replacement of sodium and the missing steroid hormones is critical.
When a client is on chemotherapy, for which manifestations of bone marrow depression should a nurse continuously assess?
Show answer and rationale
Correct answer: C. Ecchymosis, weakness, and fatigue.
myelosuppression decreases WBCs, RBCs, and platelets. The anemia reduces oxygencarrying capacity, leading to fatigue and weakness. The reduced platelets increases bruising and bleeding tendencies.
A client is admitted to a hospital in the terminal stage of illness. At this time, a nurse, who is planning end-of-life care, should recognize that the client is most likely to fear:
Show answer and rationale
Correct answer: A. Dying alone and in pain.
the client who is terminally ill most often wishes to be pain-free and to know that someone will be there in the end.
A complication of Buck’s extension traction would be noted by a nurse if:
Show answer and rationale
Correct answer: C. Toes of affected leg became dusky in color.
Buck’s is skin traction to the lower leg. Circulatory disturbances and skin abrasions are the most important nursing concerns.
Due to the extent of a client’s fracture, a hip prosthesis is inserted. A nurse knows that the most serious complication of implant surgery is:
Show answer and rationale
Correct answer: B. Infection.
there is always a risk of osteomyelitis (bone infection) with orthopedic surgery
A client returns from an operating room. The client’s IV is running at 150 mL/hr; pulse is 90 and full; respirations are moist and wheezy. A nurse’s initial action should be to:
Show answer and rationale
Correct answer: A. Slow down the IV and call the physician.
the assessment may indicate volume overload. Slowing the IV rate keeps the IV access open while waiting for further orders.
During the first 24 hours after an above-the-knee amputation for vascular disease, nursing priority for stump care would be:
Show answer and rationale
Correct answer: C. Elevating to reduce edema.
reducing edema will promote healing and prevent complications.
What are the emergency nursing actions for a client with a head injury due to a fall from a third-floor roof?
Show answer and rationale
Correct answer: C. Stabilize C-spine, assess airway, and assess respirations.
before assessing the CABs (compression, airway, and breathing) in this client, it is important to prevent further injury to the spinal cord.
As a nurse is assisting a client out of bed, which objective sign should indicate to the RN that the client is experiencing hypotension?
Show answer and rationale
Correct answer: D. Pulse rate increases 20 beats per minute.
an increase in pulse would be an attempt by the body to increase the BP.
Which group is considered high risk for acquiring the human immunodeficiency virus (HIV)?
Show answer and rationale
Correct answer: D. Men who are 65 plus years of age.
older men tend to not use condoms and do not consider themselves to be at risk for HIV.
Victims of a disastrous earthquake have been transported to an emergency department. Which victim should the nurse assess first?
Show answer and rationale
Correct answer: C. A victim with second-degree burns on 25% of the body.
this client will likely survive the injury with pain medication and fluids.
A client with a tracheotomy just pulled out the tracheal tube. Which action by a RN is correct?
Show answer and rationale
Correct answer: D. Get a hemostat to open the tracheotomy, and then try to reinsert the tube.
keeping the airway open is most important. Concern for contamination of the tube can be addressed after a patent airway is established.
A client with COPD is scheduled for abdominal surgery. Arterial blood gases before surgery were: pH 7.36, PCO2 54, PO2 70. After surgery the ABGs were pH 7.35, PCO2 60, PO2 65 on 2 L of O2. Which action should a nurse take?
Show answer and rationale
Correct answer: B. Have the client cough and deep breathe.
atelectasis is likely as a result of general anesthesia. The client also appears to be hypoventilating most likely because of abdominal pain. The client should be medicated for pain before coughing and deep breathing.
Which symptom(s) would be expected if a pacemaker suddenly malfunctioned?
Show answer and rationale
Correct answer: A. Shortness of breath, dizziness.
ventricular function would be affected, causing signs of heart failure and inadequate perfusion.
What signs will a nurse observe in a client who is experiencing right-sided heart failure? Select all that apply.
Show answer and rationale
Correct answer: A. Bilateral ankle edema.
the heart is unable to handle the venous return, and it will back up into the venous system, causing the ankle edema.
When assessing a client for signs of early septic shock, a nurse should observe for:
Show answer and rationale
Correct answer: C. Warm, flushed skin.
there is an increase in the body temperature, and vasodilation would occur.
An indicator of a worsening hypovolemic shock related to GI bleeding would be:
Show answer and rationale
Correct answer: A. Increasingly rapid, thready pulse.
the heart would attempt to increase cardiac output by increasing the pulse rate as the volume continued to decrease.
A 50-year-old client is being seen in the outpatient clinic with complaints of a fever, cough, muscle soreness, and fatigue. The nurse would be concerned that the client had novel H1N1 flu if the complaints included: Select all that apply.
Show answer and rationale
Correct answer: C. Persistent cough.
there is frequently a worsening of a cough that may have appeared to be improving.
A client’s vital signs are: BP 80/60 mm Hg, P 120, R 30, T 100.4°F. A nurse should know that these findings most likely indicate:
Show answer and rationale
Correct answer: B. Hypovolemic shock from fluid volume deficits.
the hypotension and tachycardia are classic signs of hypovolemic shock.
A nurse should expect that a client with a severe loss of potassium (hypokalemia) from diarrhea will have:
Show answer and rationale
Correct answer: A. Muscle weakness, cramps, cardiac irritability.
potassium affects normal muscle function.
Which finding should indicate to a nurse that a client has recovered from respiratory acidosis?
Show answer and rationale
Correct answer: D. Increasing respiratory rate.
the respiratory rate would increase as respiratory function improved. Respiratory acidosis occurs from slow and inadequate ventilation.
The goal of care for a client with liver failure is to lower the blood ammonia level. Which actions would prevent increased ammonia? Select all that apply.
Show answer and rationale
Correct answer: C. Prevent gastrointestinal bleeding.
ammonia is a by-product of protein breakdown by the intestinal flora. Blood is a source of protein.
If a bowel obstruction occurs from inflammatory bowel disease at the transverse colon, a nurse will initially hear bowel sounds that are:
Show answer and rationale
Correct answer: C. Increased RLQ; decreased LLQ.
initially peristalsis will increase in the ascending colon (right lower quadrant [RLQ]) in an attempt to clear the blockage. There will be no peristalsis distal to the obstruction.
Identify the appropriate actions in the prevention of thrombophlebitis in a client on bedrest. Select all that apply.
Show answer and rationale
Correct answer: B. Encourage exercises that dorsiflex and plantar flex the ankle.
these exercises prevent venous pooling.
Which nursing actions should be completed before a physician performs a thoracentesis? Select all that apply.
Show answer and rationale
Correct answer: A. Assessing the client for any allergy to local anesthetics.
a local anesthetic will be used to minimize pain to the puncture site.
A nurse should evaluate the effects of coumadin, used in the treatment of deep vein thrombosis, by looking at the results of which laboratory tests?
Show answer and rationale
Correct answer: D. Prothrombin time (PT).
the PT is the specific test to determine the effectiveness of Coumadin therapy.
Which client should be the first priority for a telephone advice RN? A client who reports:
Show answer and rationale
Correct answer: A. Ankle swelling and shortness of breath.
these are signs and symptoms associated with heart failure.
To promote maximum ventilation in a client who is postoperative, a nurse should:
Show answer and rationale
Correct answer: A. Maintain placement of airway until the client is awake.
until fully awake, the tongue may obstruct the airway. Keeping the airway in place until the client pushes it out prevents obstruction.
A nurse gets a report that a client will be admitted with an ejection fraction of 58%. Which history and physical finding should the nurse anticipate?
Show answer and rationale
Correct answer: D. Inspiratory wheezing in upper lobes, bilaterally.
bilateral adventitious sounds are heard early in left-sided failure. The ejection fraction is below the normal for a health heart (60% to 70%).
Management of a BUN of 71 and a creatinine of 2.7 in a client with diabetic ketoacidosis (DKA) is correctly accomplished with:
Show answer and rationale
Correct answer: C. Rehydration.
severe dehydration is often seen in DKA. This can decrease renal perfusion and cause buildup of BUN and creatinine. First, the client needs rehydration to correct prerenal failure. Then, an assessment can be made of renal function (which can be decreased in diabetes).
A nurse notes that a client has a total bilirubin of 1.0 mg/dL. The nurse should:
Show answer and rationale
Correct answer: C. Record this normal finding.
total bilirubin comes from normal turnover of RBCs in the body. Excess destruction or inability of the liver to process waste products may cause an increase in bilirubin, which may turn the client’s skin yellow. This is a normal total bilirubin.
Ten hours after beginning an insulin drip on a client with diabetic ketoacidosis, the following laboratory results are returned: Na+ 130, K+ 4.4, Cl- 100, bicarb 15, BUN 60, creatinine 2.5, glucose 100. Which action should a nurse take?
Show answer and rationale
Correct answer: D. Continue the insulin.
this client is still acidotic, which means the cells are burning fats and releasing ketones. (Anion gap is 130 – 100 – 15 = 15, which is high; bicarbonate is low at 15). Insulin is still required. With blood sugar at 100, you will also need to give sugar.
A client is admitted with diabetic ketoacidosis (DKA). Five months ago, the hemoglobin A1c (HgbA1c) was 9.4%; currently it is 10.3%. Based on this information, a nurse should:
Show answer and rationale
Correct answer: B. Provide diabetic teaching.
the A1c gives a number that reflects the average blood sugar over the last 3 months. Clients with diabetes are told to try to keep the A1c less than 7% (sometimes less than 6.5%). This high level, which is getting worse, means that the client needs better management of the diabetes. Client teaching is the correct way to help a client manage this chronic disease.
Seizure precautions should be applied to clients who have:
Show answer and rationale
Correct answer: D. A serum sodium of less than 125 mg/dL.
hyponatremia can precipitate seizures.
Which techniques are effective in communicating with a client who has complete loss of vision? Select all that apply.
Show answer and rationale
Correct answer: B. Face the client when talking.
the client hears better when spoken to directly.
A client with mild hypertension asks a nurse for suggestions to control blood pressure. What should a nurse recommend?
Show answer and rationale
Correct answer: D. Follow a regular exercise program.
exercise in the absence of weight reduction is a significant factor in reducing blood pressure.
A nurse is checking a client’s third cranial nerve. How should physical assessment be performed?
Show answer and rationale
Correct answer: B. Check pupillary reaction using a penlight.
the normal response of the pupil to light is constriction, if CN III is normal.
A nurse should assess for hypercalcemia by checking a client for:
Show answer and rationale
Correct answer: D. Deep tendon reflex.
hypercalcemia reduces neuromuscular excitability, resulting in muscle weakness and hyporeflexia.
The mother of a 2-year-old child is concerned her child may have novel H1N1. The nurse tells the mother that she should immediately report:
Show answer and rationale
Correct answer: A. Lack of alertness.
a change in alertness or responsiveness is an emergency warning sign in children and needs urgent attention.
Which nursing intervention should a nurse complete first for a client experiencing addisonian crisis?
Show answer and rationale
Correct answer: B. IV administration of fluid, glucose, and electrolytes.
the client is at risk for shock.
A nurse knows that the serum sodium level of a client with a head trauma should be above 140 to:
Show answer and rationale
Correct answer: B. Prevent cerebral edema.
osmolarity is largely determined by serum sodium. If the sodium level is low, water will move from the bloodstream into the cells. The client is already at risk for cerebral edema because of the injury. The swelling could result in a dangerous increase in intracerebral pressure.
A client is admitted with diabetic ketoacidosis. A nurse’s first priority should be to give:
Show answer and rationale
Correct answer: A. IV normal saline.
clients who are admitted with high blood sugar levels are very dehydrated and need IV normal saline. High blood sugar levels dehydrate cells, spilling sugar in the kidneys and causing obligate water loss.
A client with diabetic ketoacidosis (DKA) has been receiving IV insulin for 6 hours. Laboratory findings are: Na+ 131, K+ 3.7, Cl- 102, HCO3 22, and glucose 170. Which action should a nurse take?
Show answer and rationale
Correct answer: B. Expect the insulin drip to be discontinued.
the anion gap is closed and the glucose is close to normal. The client can be switched to subcutaneous insulin and the insulin drip discontinued. An anion gap occurs in metabolic acidosis when there is an excessive accumulation of fixed acid. Anion gap is determined by the balance between the anions (Na+ and K+ ) and the cations (Cl- and HCO3 – ).
A client, who is malnourished, is admitted with a serum calcium of 7.5. A nurse should:
Show answer and rationale
Correct answer: D. Check the serum albumin lab result.
most calcium is bound to plasma proteins such as albumin. As long as the physiologically important portion (the ionized, nonbound calcium) is normal, low total calcium does not need to be treated.
Following a thyroidectomy, a nurse assesses for complications related to damage or removal of the parathyroid. The nurse should assess for:
Show answer and rationale
Correct answer: C. Numbness around the mouth.
the parathyroid is responsible for calcium absorption. Numbness around the mouth is an early sign of hypocalcemia.
A 19-year-old victim of trauma is admitted to an emergency department with a blood pressure of 80/50 mm Hg, and a heart rate of 130 bpm. Which action should a nurse take first?
Show answer and rationale
Correct answer: C. Give 1 liter NS IV as fast as possible.
this client is in shock and requires rapid volume infusion with IV normal saline (NS).
A client with CHF has: 2+ pedal edema, jugular venous distention (JVD), bilateral basilar crackles, urine output of 1.2 L/24 hr, blood pressure of 145/88 mm Hg, Na+ of 129. A nurse should plan to:
Show answer and rationale
Correct answer: C. Restrict fluids.
generally low serum sodium results from excessive water intake or retention. This client has adequate fluid levels. Fluid restriction will help treat the hyponatremia.
A client is scheduled for outpatient bariatric surgery. Deep vein thrombosis (DVT) is best prevented by:
Show answer and rationale
Correct answer: A. Early ambulation.
early ambulation is the most effective way to reduce the risk of DVT.
Following general anesthesia for a hip replacement, an elderly client’s vital signs are: P 80, R 14, blood pressure 110/78 mm Hg; O2 Sat 100% on 40% mask; pain 2/10. The client is shivering and complains of being cold. The first nursing priority should be to:
Show answer and rationale
Correct answer: B. Apply warm blankets.
shivering increases oxygen consumption. Hypothermia associated with the perioperative period may cause arrhythmia, clotting problems, and impaired wound healing.
Which finding is consistent with a client developing fluid overload?
Show answer and rationale
Correct answer: C. Oxygen saturation less than 92% on 40% O2 via facemask.
excess fluid in the lung is decreasing oxygen transfer into the tissues.
What is the best nursing action to prevent pressure sores during a long surgical procedure?
Show answer and rationale
Correct answer: A. Pad bony prominences before surgery begins.
padding is very important before surgery begins. During surgery, the client will be immobilized on a hard surface.
A client with diabetes and hypertension has returned from surgery. Which nursing intervention will most likely reduce the risk of wound infection?
Show answer and rationale
Correct answer: C. Monitor blood sugar and keep it under 200 postoperatively.
an elevated blood sugar (over 200) is associated with an increased risk of infection and poor wound healing.
A client asks a nurse what to expect with a condition of uncomplicated gallstones. The best response would be:
Show answer and rationale
Correct answer: B. "Most clients do not notice any effects."
gallstones are asymptomatic in over 80% of clients.
A nurse is caring for a 32-year-old client who is 1 day post-gastric bypass. Vital signs are: T 37.9�C, P 100, R 18, BP 130/80 mm Hg, pain 2/10, O2 Sat 92% on room air. The nurse should first:
Show answer and rationale
Correct answer: C. Have the client use the incentive spirometer.
low-grade fever on postoperative day 1 is almost always an indication of atelectasis. This low O2 saturation supports this. Have the client take deep breaths on the incentive spirometer to open up the alveoli.
One day after surgery for intestinal resection, a client has no bowel sounds. Which action should a nurse take?
Show answer and rationale
Correct answer: B. Record this expected finding.
paralytic ileus is expected after major abdominal surgery. The absence should be recorded in the medical record.
A client with gallstones asks a nurse what might have caused the condition. The nurse knows the risk of developing this condition is greater in:
Show answer and rationale
Correct answer: D. Significant recent weight loss.
rapid weight loss is a risk factor for gallstones due to bile that becomes supersaturated with cholesterol. Also, frequent changes in weight increases the risk.
A client is in a rehabilitation unit 2 weeks after a right middle cerebral artery infarct. Which is the best activity plan?
Show answer and rationale
Correct answer: C. The client should know how to get up from the right side of the bed.
a stroke in the right brain would cause paralysis or weakness on the left side. Getting out of bed is easiest on the strong side.
A client with a vertebrobasilar stroke is being managed for dysphagia. Which intervention will be most helpful?
Show answer and rationale
Correct answer: D. Provide nutrition through a feeding tube.
dysphagia refers to difficulty swallowing. Nutrition may need to be provided through a feeding tube to prevent aspiration.
Which intervention will be most helpful to a client with aphasia?
Show answer and rationale
Correct answer: C. Encourage use of gestures in communication.
in aphasia, clients have difficulty understanding and/or using language. Nonverbal communication strategies may help this.
The nursing assistant asks the nurse if a N95 respirator should be worn when caring for the client with H1N1. The correct response by the nurse is:
Show answer and rationale
Correct answer: C. The N95 is usually reserved if treatment produces an aerosol spray of sputum.
the N95 is recommended when treatment may produce the potential of sputum spray, such as intubation or suctioning. Only a medicalsurgical mask is necessary when entering the client room. Some hospitals may provide all direct-care providers with facemasks or respirators.
The nurse should ensure that a healthy 89-year-old client admitted to a skilled nursing facility has received which vaccinations? Select all that apply.
Show answer and rationale
Correct answer: B. Pneumococcal.
pneumococcus is an important cause of pneumonia in the elderly. Clients who were vaccinated more than 5 years previously or who were under 65 years old when they received the vaccination should receive a booster.
An elderly client has a noncemented total hip joint placed. Postoperative activity for this client should include:
Show answer and rationale
Correct answer: A. Touch-down weight-bearing starting first postoperative day.
early mobilization improves healing and reduces complications resulting from immobility. Because the joint is not cemented, surgeons often request less than full weight-bearing for initial mobilization.
A client with Alzheimer’s disease has superficial skin breakdown related to functional incontinence. The correct nursing intervention includes:
Show answer and rationale
Correct answer: B. Assisting to the toilet and protecting bed with pads.
in functional incontinence, as in Alzheimer’s disease, the client is usually unable to perform self-care because of alteration in mental status. Assisting the client to use a toilet and cleaning after any incontinence are appropriate.
An elderly client, who has had a stroke, is receiving fullstrength tube feedings of 75 mL/hr, and an IV of D5 1 /2NS at 50 mL/hr. The Na+ level is 150. Which action should be taken by a nurse?
Show answer and rationale
Correct answer: B. Tap water should be given through the feeding tube.
hypernatremia can result from the solute load in tube feedings. Additionally, the IV contains normal saline, which could be removed. The client needs free water to dilute the sodium level down. The enteral route is appropriate for this delivery.
An elderly client with kidney disease is admitted with dementia. The laboratory values are: Ca++ at 7 mg/dL, PO4 at 7 mg/dL, albumin at 2 gm, creatinine at 8 mg/dL. The laboratory findings indicate:
Show answer and rationale
Correct answer: A. Elevated phosphates from kidney failure.
the kidneys normally excrete phosphate, which is usually maintained at a level of 2.5 to 4.5 mg/dL in adults (up to 6 mg/dL in infants and children). A low total calcium in the presence of low albumin is expected in kidney failure. Physiologically important nonbound calcium is likely to be normal so that seizure risk is not elevated.
An elderly client continues to have fecal incontinence with 6 to 7 small brown liquid stools each day. The client eats a soft diet and does not receive any stool softeners or laxatives. The client’s primary form of activity is sitting in the wheelchair for 2 hours twice a day. What is the correct explanation for the frequent diarrhea stools?
Show answer and rationale
Correct answer: B. Fecal impaction.
the client is at risk to develop fecal impaction secondary to constipation. Pressure on the colonic mucosa causes seepage of liquid stool around the area of impaction.
An elderly client has a suspected medical diagnosis of cataracts. Which symptom is consistent with this finding?
Show answer and rationale
Correct answer: C. Objects are distorted and blurry.
the opacity and cloudiness of the lens cause blurry and dimmer vision.
What is the most appropriate footwear that a nurse should recommend to a client with Parkinson’s disease?
Show answer and rationale
Correct answer: B. Slip-on rubber soles.
the client will be able to maintain a level of independence with a slip-on shoe. The rubber soles will lessen the risk of falls.
What are normal changes associated with aging? Select all that apply.
Show answer and rationale
Correct answer: C. Decreased salivation.
medications and some diseases common in the older adult affect salivation in 30% of clients.
An RN makes a home visit to a client who is 62 years old, and finds that the client is not responding to verbal stimuli and has no pulse or respirations, and the skin is cool to touch. The nurse’s first action should be to:
Show answer and rationale
Correct answer: B. Call emergency response (911).
the emergency response system needs to be activated before beginning CPR so that support services can arrive as quickly as possible.
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.
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