NCLEX Practice Questions — Set 7
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 35-year-old man has been experiencing low back pain for 2 days with no relief from ibuprofen 400 mg 4 times daily. His pain is 7 on a scale of 1 to 10. An opioid is prescribed by a physician for pain. A nurse should know that the most important barrier to the use of opioids for pain is:
Show answer and rationale
Correct answer: A. Physicians’ concern about drug abuse.
physicians often undermedicate clients because of fear that the client is abusing a narcotic opioid.
A nurse enters a client’s room to administer an IV medication and finds that the IV site is swollen, cool, and pale. The client reports discomfort at the insertion site. The nurse recognizes that this may be:
Show answer and rationale
Correct answer: B. Infiltration.
it is the only one that fits all four symptoms.
Medications are absorbed differently with aging. A nurse should expect the dosage for an older adult to be:
Show answer and rationale
Correct answer: C. Reduced to prevent excessive systemic levels.
changes in kidney and/or liver function will affect excretion of drugs. The chance of toxicity increases.
A client is scheduled for an inguinal herniorrhaphy in the morning and wants to know when to take the blood pressure pill before surgery. The best response by a nurse would be:
Show answer and rationale
Correct answer: B. "You will probably take your medicine with a small amount of water in the morning as usual."
antihypertensive medications may still be given because the procedure is usually done by using local, spinal, or epidural anesthesia.
A client, who is newly diagnosed with tuberculosis, is being seen in a clinic. Current treatment includes isoniazid (INH) and rifampin (Rifadia). During the assessment, the client states that there has been blood in the urine since starting treatment. The best response by a nurse would be:
Show answer and rationale
Correct answer: A. "One of your medications changes the color of body fluids."
rifampin changes tears, sweat, saliva, and urine to an orange-red color. This is an expected effect.
A child is hospitalized for moderate respiratory distress caused by asthma. A physician orders a corticosteroid. A nurse knows that the main rationale for this medication is to:
Show answer and rationale
Correct answer: C. Reduce inflammation.
corticosteroids are used in the treatment of acute asthma exacerbation to reduce inflammation of the airways.
A child with gastroenteritis is admitted to a pediatric unit. The child is severely dehydrated and anuric. After the child receives a fluid bolus, a physician orders continuous IV fluids. Which IV fluid order should a nurse question?
Show answer and rationale
Correct answer: C. 0.45% NaCl with KCl 20 mmol/L.
the nurse should question an order to administer an IV solution containing potassium to a child who is anuric. Potassium should not be added to a child’s IV until kidney function is established by the return of urine output.
A nurse admits a preschooler with sickle cell anemia. Which medications should the nurse expect that the child has been receiving at home? Select all that apply.
Show answer and rationale
Correct answer: B. Penicillin.
children with sickle cell anemia frequently take prophylactic antibiotics because of an increased risk for infection.
A client, who is gravida 4, para 3 at 28 weeks’ gestation, is dilated 2 cm. A physician has prescribed nifedipine to treat her preterm labor. For which common maternal side effect of the medication should a nurse assess?
Show answer and rationale
Correct answer: A. Hypotension.
nifedipine is a calcium channel blocker, more commonly used to treat high blood pressure and heart disease. Nifedipine blocks the passage of calcium into certain tissues, relaxing the uterine muscles and smooth muscles of blood vessels throughout the body. Use of nifedipine for the treatment of preterm labor is an unlabeled use of the drug. Hypotension is a side effect of nifedipine.
A client, who is gravida 2, para 0 at 31 weeks’ gestation, has been hospitalized for 5 days on oral terbutaline. A physician discharges the client with a prescription for terbutaline 5 mg PO q4h. When giving discharge instructions, which instruction should a nurse include?
Show answer and rationale
Correct answer: C. "Call your physician if your heart rate is higher than 120 before you take your terbutaline."
terbutaline is considered to be working at a therapeutic level when a woman’s resting heart rate is between 90 and 105 beats per minute. If the heart rate is higher than 120, the physician should be notified before taking the terbutaline.
A client, who is gravida 1, para 0, is at 39 weeks’ gestation. She has an uncomplicated prenatal history. Her recent cervical examination reveals that she is 4 to 5 cm dilated, 100% effaced, and at a +1 station. She is asking for an epidural for labor pain control. Which order should a nurse anticipate to prevent hypotension in this client?
Show answer and rationale
Correct answer: A. Administer a 500- to 2,000-mL bolus of IV fluid.
administering a fluid bolus before beginning the epidural can prevent hypotension that is associated with anesthesia administration.
A client, who is a 17-year-old gravida 1, para 0, is at 35 weeks’ gestation with a blood pressure of 164/116 mm Hg on her left side, 4+ deep tendon reflexes, and 3+ proteinuria. Her physician orders a 4-gram loading dose of magnesium sulfate over 30 minutes, followed by 2 gm/hr. After administration of the bolus, the client complains of chest heaviness. A nurse assesses the client’s deep tendon reflexes, which are now absent. The nurse should anticipate that the physician will most likely order:
Show answer and rationale
Correct answer: C. Calcium gluconate.
this client most likely is experiencing magnesium toxicity. Calcium gluconate is the antidote for magnesium overdose.
A client, who is a 44-year-old gravida 2, para 1, is at 18 weeks’ gestation with consistent blood pressures ranging from 130 to 140/80 to 90 mm Hg during her last two prenatal visits. She has no proteinuria or hyperreflexia. Which medication should a nurse anticipate being prescribed for this client?
Show answer and rationale
Correct answer: C. Aldomet.
this client is in the second trimester of pregnancy and has a history of high blood pressure during the pregnancy, an indicator of chronic hypertension. Aldomet is an antihypertensive drug that is safe during pregnancy, and is commonly used for chronic hypertension during pregnancy.
A client, who is gravida 6, para 5 and in the fourth stage of labor, receives an injection of carboprost (Hemabate) 250 mcg IM. The nurse knows that the expected outcomes of this medication are: Select all that apply.
Show answer and rationale
Correct answer: A. Increased myometrial contractions.
the major action of Hemabate is to increase uterine (myometrial) contractions and decrease uterine bleeding.
A client, who is gravida 3, para 1, is being induced for pregnancy-induced hypertension using IV oxytocin. Under which circumstances should a nurse discontinue infusion of oxytocin? Select all that apply.
Show answer and rationale
Correct answer: B. Contractions every 3 minutes, lasting 90 seconds each.
contractions that occur every 3 minutes, lasting 90 seconds, do not allow adequate resting time for the uterus, and the oxytocin should be discontinued.
The nursing instructor questions a nursing student about an analgesic that may be ordered for a child with otitis media who is complaining of mild ear pain. Which medication should the nursing student correctly expect to be ordered?
Show answer and rationale
Correct answer: B. Ibuprofen.
ibuprofen has a longer duration of action (about 6 hours) than acetaminophen (about 4 hours), which is a distinct advantage for nighttime comfort or when a child is resistant to taking medication. Selecting ibuprofen would require giving fewer doses to the child.
An adolescent who has attention deficit-hyperactivity disorder (ADHD) complies with taking the prescribed once-a-day medication. The adolescent’s academic classes (e.g., math, science, etc.) should be scheduled by the school nurse for the:
Show answer and rationale
Correct answer: A. Morning.
the adolescent’s schedule should be arranged so that academic subjects (e.g., math, science, etc.) are taught in the morning when the adolescent is experiencing the effect of the morning dose of medication. This will allow the adolescent to focus more readily on difficult content, and to avoid sleep disturbances.
A client, who is an 18-year-old primigravida with gestational diabetes, is admitted to a labor and delivery unit at 34 weeks’ gestation in preterm labor. Which physician’s order for this client should a nurse question?
Show answer and rationale
Correct answer: C. Brethine 10 mcg IV.
the correct dosage and route for Brethine is 0.25 mg SQ. Both the dosage and route are wrong for this drug.
A client, who is gravida 1, para 0, delivers an infant at 39 weeks’ gestation. The client’s blood type is O negative and the baby is O positive. A physician orders an injection of Rho(D) immune globulin. To provide adequate postpartum prophylaxis, when should a nurse administer Rho(D) immune globulin?
Show answer and rationale
Correct answer: D. Within 72 hours of delivery.
Rho(D) immune globulin needs to be administered before 72 hours after delivery to be effective.
A client is discharged on a 2-gm sodium-restricted diet. Which menu choice would indicate the client understands the restriction?
Show answer and rationale
Correct answer: A. Turkey breast Divan, rice pilaf, iced tea.
turkey and rice are lowest in sodium. The sauce used on the turkey Divan can be made with a low-sodium soup.
A client with Parkinson’s disease will likely have the greatest difficulty swallowing:
Show answer and rationale
Correct answer: D. Apple juice.
any thin liquid or food increases the chance of aspiration.
Which statement by a client with hypokalemia indicates a need for further teaching by a nurse?
Show answer and rationale
Correct answer: D. "I will eat more bran."
bran has fiber but little potassium for a client with low potassium.
A nurse should determine that a client understands the dietary restrictions with a low-cholesterol diet if the client selects a larger portion of:
Show answer and rationale
Correct answer: B. Brown rice.
50% to 60% of the calories should come from a carbohydrate source such as brown rice.
A nurse instructs a client to eat a low-iodine diet before a thyroid study. A client should be told to avoid:
Show answer and rationale
Correct answer: B. Shellfish.
shellfish are high in iodine. Also, some brands of table salt should be avoided.
A client would demonstrate awareness of dietary influences in the prevention of dumping syndrome if the intake were adjusted by: Select all that apply.
Show answer and rationale
Correct answer: C. Increasing fats as tolerated.
dietary fat does not contribute to dumping syndrome like carbohydrates do.
In preparation for surgery, a client is placed on a lowresidue diet. In discussing the kinds of foods that will be allowed, a nurse should list:
Show answer and rationale
Correct answer: B. Ground lean beef, soft-boiled eggs.
residue is produced by high-fiber foods. Lean beef, well cooked, and eggs are not good sources of fiber. Low residue reduces the amount of stool in the large bowel.
In Meniere’s disease, the diet is modified as a part of the treatment plan. Which diet is most appropriate?
Show answer and rationale
Correct answer: A. Low sodium.
fluid retention is thought to aggravate the symptoms of Meniere’s disease. Foods high in sodium contribute to fluid retention.
The results of a client’s complete blood count are: RBC 3.2 million/mm3, Hgb 10 gm/dL, Hct 29%, and mean corpuscular hemoglobin (MCH) 25 pg/cell. Which foods should the nurse recommend to the client? Select all that apply.
Show answer and rationale
Correct answer: A. Peas.
the client’s red blood cell (RBC), hemoglobin (Hgb), and hematocrit (Hct) levels are low and indicate iron-deficiency anemia, and legumes are a good source of iron.
A client is admitted with a diagnosis of brain attack (stroke). A physician orders a diet as tolerated. Before feeding the client, a nurse should first:
Show answer and rationale
Correct answer: B. Evaluate the client’s swallow reflex.
the client may be at risk for aspiration if the ability to swallow has been affected.
A client is admitted to a hospital for pneumonia and it is discovered that the client also has a stage II pressure ulcer. When planning a diet for this client, what foods should a nurse encourage the client to eat?
Show answer and rationale
Correct answer: D. Lean meats and low-fat milk.
proteins help to repair and build cells.
A 16-year-old client, who is gravida 1, para 0, is attending a class on pregnancy and nutrition. Which menu selection should a nurse recommend that would best meet the nutritional needs of the client who is pregnant?
Show answer and rationale
Correct answer: C. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and herbal tea.
this menu has a variety of lean protein, carbohydrates, fruits, vegetables, and dairy. While the choices within the categories are not ideal, it is the most balanced of the options.
A client, who is 23 years old, gravida 3, para 1, has a hemoglobin of 9 gm/dL. She has been prescribed an exogenous iron supplement, but tells a nurse that she cannot take pills. Which food should the nurse recommend that is high in iron?
Show answer and rationale
Correct answer: D. Dried apricots.
dried apricots are a good source of iron, require no cooking, and are palatable for a young mother.
A neonatal nurse is caring for a newborn who is breastfeeding. How many kilocalories are present in an ounce of maternal breast milk?
Show answer and rationale
Correct answer: A. 20 kcal/ounce.
maternal breast milk contains 20 kilocalories per ounce.
A child is diagnosed with cystic fibrosis. Which food(s) should the child avoid? Select all that apply.
Show answer and rationale
Correct answer: B. Low-fat yogurt.
the child with cystic fibrosis should avoid low-fat foods and eat foods that are high in calories instead, such as full-fat yogurt.
What would be allowed in the diet of a client with peptic ulcer disease (PUD)?
Show answer and rationale
Correct answer: C. Tomato juice.
although tomato juice may be acidic, it does not increase acid production. The guideline for the diet with PUD is to avoid foods that increase symptoms, and these vary from client to client.
Sodium intake is recommended to be no more than 2,400 mg each day. Which client is most at risk for stroke and heart attack with a higher than recommended Na+ intake?
Show answer and rationale
Correct answer: A. A client who is overweight.
high sodium intake increases the risk of cardiovascular disease and death in clients who are obese.
Which food would be restricted in a low-sodium diet?
Show answer and rationale
Correct answer: C. Whole milk.
whole milk has 120 mg of sodium per 8 oz.
A client is attending an informational session for invitro fertilization. The client asks a nurse, "What foods can I eat to increase my intake of folic acid?" The nurse suggests that the best source of folic acid is:
Show answer and rationale
Correct answer: B. Green vegetables and liver.
green vegetables and liver are rich sources of folic acid, an essential nutrient to prevent neural tube defects in the developing fetus.
A 40-year-old client at 9 weeks’ gestation presents to an obstetric clinic complaining of nausea and vomiting every morning when she awakens. Which intervention should a nurse recommend for this client?
Show answer and rationale
Correct answer: B. Eat dry, unsalted crackers before getting out of bed.
eating a small amount of easily digested carbohydrate can help decrease nausea and vomiting. To avoid having an empty stomach, the crackers should be eaten before getting out of bed.
A nurse prepares to give maternal breast milk to an infant via a bottle. Which steps should the nurse take when preparing and administering breast milk? Select all that apply and place in priority order.
Show answer and rationale
Correct answer: B. Review the diet orders.
the first step is to confirm the diet order.
A client, who has not been eating or drinking, is admitted to a hospital. Which sign of dehydration should a nurse expect?
Show answer and rationale
Correct answer: C. Tachycardia.
the body is trying to compensate for the fluid loss by stimulating the heart rate to increase cardiac output and perfusion.
A client, who is 24 years old and has gestational diabetes, is getting instructions about her diet. A nurse knows that her teaching has been successful when the client correctly identifies that she should avoid: Select all that apply.
Show answer and rationale
Correct answer: C. White rice.
white rice has a high glycemic index and results in a rapid increase in the client’s blood sugar, and it should be avoided.
A client, who is a 17-year-old gravida 2, para 1, practices a strict vegetarian diet. She has been prescribed an iron supplement during her second trimester of pregnancy. To promote better absorption, a nurse should instruct the client to take the iron supplement with which beverage?
Show answer and rationale
Correct answer: B. Orange juice.
orange juice is high in vitamin C, which can increase the absorption of iron and is needed for the production of hemoglobin.
A client is attending a class on prenatal nutrition. The client asks why vitamin C is important during pregnancy. A nurse’s best response would be:
Show answer and rationale
Correct answer: A. Vitamin C is needed to promote collagen formation.
vitamin C is important in the synthesis of collagen, which is the main structural component of the skin as well as many other body tissues. Vitamin C also works as a powerful antioxidant, aids in the absorption of iron, is critical in fighting off infections, helps alleviate allergic reactions, and aids in wound healing. Vitamin C helps the fetus grow and builds strong bones and teeth.
A nurse assesses a school-age child who asks questions and can associate subjects with concepts. In which stage of development is this child?
Show answer and rationale
Correct answer: A. Intuitive.
the school-age child in the intuitive stage asks questions, uses symbols, and can associate subjects with concepts.
A nurse observes a client on a locked mental health unit who is manifesting behaviors consistent with the mastery of Maslow’s level of safety and security. Which behavior is this client most likely exhibiting?
Show answer and rationale
Correct answer: B. Responding to limit setting and requesting anxiolytics.
safety and security are evident when the client feels safe with structure and avoids harm.
An adult client, who is petitioning for release from a legal hold on a mental health unit, demonstrates care and consideration for other clients, complies with unit rules, and attends regular group meetings. According to Maslow, what level(s) has the client mastered? Select all that apply.
Show answer and rationale
Correct answer: B. Safety and security.
the client is meeting basic physiological needs.
An adolescent client, admitted for depression due to peer pressures and substance use, is unable to contract for safety. A nurse should recognize that this client is in Erikson’s developmental stage of:
Show answer and rationale
Correct answer: A. Identity vs. role diffusion.
the adolescent develops intense concern over peer influences and is at risk for developing role diffusion (e.g., acting out with substance abuse).
A client is on lithium for management of bipolar disorder. Which signs and symptoms should indicate to a nurse that the client is at risk for severe toxicity?
Show answer and rationale
Correct answer: C. Lethargy and motor weakness.
motor weakness and lethargy are early signs of toxicity.
A client’s spouse reveals ongoing infidelity in their relationship. A nurse identifies that this client is at increased risk for:
Show answer and rationale
Correct answer: D. Injury.
if sexual encounters were unprotected, this may place the client at risk for sexually transmitted infections, which could lead to injury, permanent dysfunction, and possible infection-related problems.
A nurse assesses an adolescent client in a psychiatric emergency department for suicidal ideation. The client’s parents are preoccupied with divorce proceedings. Which problem should the nurse suspect that this client is experiencing?
Show answer and rationale
Correct answer: C. Adjustment disorder related to parental separation.
this is a typical disorder experienced by adolescents whose parents are experiencing marital problems; suicidal ideation is short-lived and usually related to separation or divorce.
Clients who are dependent on alcohol and experience withdrawal are at risk for physical problems. Which independent nursing actions should be conducted during the detoxification phase when caring for this client? Select all that apply.
Show answer and rationale
Correct answer: D. Assess vital signs every 4 hours and as needed.
the client may experience increases in vital signs (e.g., pulse and blood pressure).
The client is prescribed risperidone (Risperdal) at discharge for treatment of bipolar disorder. A nurse should recognize that more teaching is needed when the client states:
Show answer and rationale
Correct answer: C. "I will have my liver panel drawn every month."
it is not routine for the client using risperidone (Risperdal) to have liver function tests performed.
A client, who has had several verbal outbursts and is pacing around a psychiatric unit, is at risk for assaultive behavior. Which verbal response by a nurse is most appropriate?
Show answer and rationale
Correct answer: C. "Please take a time-out in your room."
at the client’s increasing level of anxiety, the client can only understand simple, short phrases.
A client, who is severely depressed, is unable to contract for safety. Which nurse would be most appropriate to care for this client?
Show answer and rationale
Correct answer: B. An RN with 3 years’ experience in a psychiatric/ mental health unit who has been on leave for 2 months.
the nurse is experienced in working with clients who are at risk for self-harm.
A client on a medical-surgical unit is recovering from a suicide attempt and is now stable and anticipating discharge to an outpatient program. Which staff nurse is most appropriate to assign to this client?
Show answer and rationale
Correct answer: B. The LPN/LVN with 5 years’ experience, supervised by an experienced nurse.
this client is stable.
A nurse is conducting a health program regarding grief at a local community center. Considering the concepts related to loss, which client is most likely to experience an unsuccessful grief response?
Show answer and rationale
Correct answer: D. The young child experiencing the sudden death of a parent.
a young child who has experienced a sudden loss has more risk factors than other age groups.
A nurse is caring for a client who is diagnosed with psychogenic diabetes insipidus. Which laboratory value is most indicative of this condition?
Show answer and rationale
Correct answer: A. Serum Na of 300 mEq/L.
serum sodium is elevated with diabetes insipidus.
A client’s family reports clinical manifestations of hyperactivity, delusions of grandeur, impaired judgment, and inability to sit still during a meal. Which diagnosis should a nurse suspect?
Show answer and rationale
Correct answer: D. Mania.
these are typical signs of mania distinguished by the delusions of grandeur.
A nurse’s priority related to clients who are experiencing clinical manifestations of borderline personality disorder should be to:
Show answer and rationale
Correct answer: D. Set limits when the client exhibits threats of selfdamaging behaviors.
the client who is borderline may demonstrate a need for attention and break unit-based rules (e.g., hiding contraband), which could lead to behaviors that are dangerous (e.g., self-mutilation). The nurse reinforces expected behaviors through setting limits.
A client was recently diagnosed with depression related to loss of a spouse. The client describes thinking constantly about the relationship and dreams of reconciliation even though the spouse is deceased. A nurse should document this as:
Show answer and rationale
Correct answer: B. Fantasy.
the client is "dreaming" and experiencing the ego defense mechanism of fantasy to cope with the anxiety associated with the loss of a spouse. Fantasy is a break from reality.
A client is 1 day postoperative for a stereotactic brain procedure for relief of compulsive behavior. For which complication should a nurse observe this client?
Show answer and rationale
Correct answer: D. Altered level of consciousness.
a client who has stereotactic brain surgery has had an invasive neurosurgical procedure that places the client at risk for increased intracranial pressure, exhibited by a decreasing level of consciousness.
An adolescent client is diagnosed with anorexia nervosa and discloses an incestuous relationship. Which is a nurse’s most therapeutic response?
Show answer and rationale
Correct answer: C. "Can you tell me how you feel about what happened?"
the nurse is using a therapeutic approach by encouraging expression of feelings.
A registered nurse (RN) can best demonstrate empathy by:
Show answer and rationale
Correct answer: C. Conveying genuine understanding of the client’s problems.
the intent is for the client to feel that the nurse understands the client’s experiences and conveys this back to the client.
In attempting to reduce acting-out behaviors by a child in a pediatric psychiatric unit, a brief therapeutic hold is implemented. An RN knows that a therapeutic hold means:
Show answer and rationale
Correct answer: D. Physically holding a child, up to 30 minutes, to assist the child to calm down.
as this is a desired and recognized therapeutic pediatric hold. The nurse implements this type of hold when a client is acting out and in danger of hurting self or others. The therapeutic hold is brief-no longer than 30 minutes- and is used specifically to calm down a child who is out of control.
A psychiatric nurse is assigned to care for multiple clients. Which client should the nurse assess first?
Show answer and rationale
Correct answer: B. The client with hallucinations, who has increased blood pressure and heart rate.
this client has a risk of cardiovascular problems and may need medical attention.
In evaluating a client’s understanding of divalproex sodium (Depakote) during discharge teaching, a nurse should identify that the client requires additional teaching if the client states:
Show answer and rationale
Correct answer: C. "I will need to get my complete blood count tested frequently."
the client will need liver function tests, not a complete blood count, due to Depakote use and the potential to cause liver damage.
Which actions should a nurse include when developing a care plan for a client with problems associated with body image disturbance? Select all that apply.
Show answer and rationale
Correct answer: A. Support the client with a realistic appraisal of the situation.
the nurse should plan to support the client by encouraging the client to apply a practical problem-solving approach. Answer 3 is correct because the nurse should explore the client’s strengths and resources to assist the client to explore his or her own positive assets and seek help from others to focus on positive coping strategies.
Considering the development of egocentrism, which clients are most likely to experience egocentrism? Select all that apply.
Show answer and rationale
Correct answer: B. The adolescent with addiction to weight loss products.
the adolescent experiences a surge in egocentrism (e.g., self-focus on meeting own needs). The adolescent is overly concerned with the self-image and the presentation of self to others.
A nurse is required to provide limit setting on a pediatric mental health unit. What are the most important concepts related to limit setting? Select all that apply.
Show answer and rationale
Correct answer: C. Provide unit information to clients upon admission.
giving information regarding unit rules and expected behavior informs the client that structure and adherence to standards is enforced and defiance will result in consequences (e.g., withholding a privilege).
A client with antisocial personality disorder has been acting very manipulative. Which actions by a nurse will help to reduce the manipulative behaviors? Select all that apply.
Show answer and rationale
Correct answer: A. Develop a list of realistic goals with the client.
the client works with the nurse to develop goals that are realistic and attainable, aimed at improving selfesteem and redirecting the use of manipulation.
A client was admitted yesterday with a diagnosis of acute traumatic stress disorder. What should a nurse expect this client’s assessment to reveal? Select all that apply.
Show answer and rationale
Correct answer: A. Flashbacks.
the client experiencing acute traumatic stress disorder will have flashbacks (e.g., repetitive intrusive images) of the traumatic event.
Which clinical manifestations should a nurse recognize as being related to the "negative" symptoms associated with a schizophrenic client? Select all that apply.
Show answer and rationale
Correct answer: C. Brief, empty responses.
the client with negative symptoms has diminished functions systematically (e.g., withdrawn, mute, and psychomotor retardation) and a flattened or inappropriate affect.
A client, who is manic, is at risk for nutritional deficits. Which nutritional products should the nurse encourage this client to select? Select all that apply.
Show answer and rationale
Correct answer: C. Protein booster shake.
this is a high-calorie supplement that is easy for the client who is manic to consume in a short period of time.
The parent of the client with attention deficit-hyperactivity disorder (ADHD) is receiving discharge teaching for methylphenidate (Ritalin). A nurse evaluates that the parent is in need of additional teaching when the parent states: Select all that apply.
Show answer and rationale
Correct answer: C. "I must give my child the medication 30 minutes before meals."
methylphenidate (Ritalin) is a stimulant and has an appetite suppression effect. It is best to administer the medication after meals to avoid problems with decreased appetite.
A clinical nurse specialist describes behavior modification techniques to a group of new graduates. Which therapies should the clinical nurse specialist include in this description? Select all that apply.
Show answer and rationale
Correct answer: D. Desensitization.
desensitization involves a behavior change. Desensitization, with repeated exposure to provoking stimuli, reduces the client’s anxiety and undesirable behaviors (e.g., severe or panic level anxiety).
A client, who abuses alcohol, is at risk for injury during the detoxification phase of alcohol withdrawal. Which physician order for this client should the nurse question?
Show answer and rationale
Correct answer: A. Apply soft wrist restraints as needed.
it is inappropriate for the physician to order restraints as needed for any client.
A client is responding with hostility to staff and other clients. A nurse’s priority diagnosis for this client should be:
Show answer and rationale
Correct answer: B. Risk for violence.
a client who is full of intense anger and rage may pose a safety issue for others.
When caring for a client who has been raped, which action should a nurse take first?
Show answer and rationale
Correct answer: D. Acknowledge client’s anxiety and fear.
it may be difficult for the client to process any information the nurse will be giving until anxiety is reduced and the client’s feelings are acknowledged.
A primary prevention measure that should be implemented by a nurse when working with clients who are at risk for elder abuse is:
Show answer and rationale
Correct answer: D. Referring caregivers to community resources.
of the problems associated with role strain, stress, and taxed coping behaviors; the caregiver needs support (e.g., through individual or group therapy, education, and respite) to prevent elder abuse.
A nurse suspects that a client may be experiencing anorexia nervosa. Which statement by the client’s family supports the nurse’s suspicion?
Show answer and rationale
Correct answer: A. "She plans the meals and counts calories."
clients with anorexia nervosa tend to obsess about food, meals, and calories.
A long-term care client, diagnosed with Alzheimer’s disease, is having difficulties with changes in daily routine and attempts to call family members at all hours and is no longer able to walk unassisted. Which problem should a nurse document as priority?
Show answer and rationale
Correct answer: D. Relocation stress syndrome.
the client is having difficulties with separation from the usual support system, is experiencing physical problems, and cannot cope with changes in routine.
A client, who has abused alcohol for 20 years, is admitted to a rehabilitation unit. Which laboratory values should a nurse expect to find?
Show answer and rationale
Correct answer: C. Increased LDH and amylase and decreased albumin.
these are common laboratory values for liver impairment when someone is a long-term abuser of alcohol.
Which nursing assessments should indicate to a nurse that a newly admitted client is in amphetamine withdrawal?
Show answer and rationale
Correct answer: D. Depression, lack of energy, and somnolence.
lack of energy, and somnolence are signs of withdrawal from amphetamines. The body responds to the sudden lack of amphetamine with symptoms similar to depression.
A client whispers, "The spiders are coming out of the vents; we need to move." Which response by a nurse demonstrates the therapeutic technique of focusing on reality?
Show answer and rationale
Correct answer: A. "That’s strange. I don’t see any spiders."
the nurse is expressing doubt about an unreal perception.
Oxygen therapy is ordered to assist the client with breathing. Which principle should guide a nurse in managing the delivery of oxygen to an elderly client with emphysema?
Show answer and rationale
Correct answer: D. O2 should be low (2-3 L) since the stimulus to breathe is the low PO2.
the client with emphysema (COPD) will stop breathing if O2 is set too high.
If fluctuation (tidaling) in the water-seal compartment of a closed chest drainage system has stopped, a nurse should:
Show answer and rationale
Correct answer: A. Ask the client to cough and deep breathe.
this will change the intrapleural pressure and reestablish suctioning.
Which nursing measures are aspects of proper tracheostomy care? Select all that apply.
Show answer and rationale
Correct answer: C. Securing the twill tape ties on the side of the neck.
positioning the ties on the side of the neck makes it easier and safer to change.
Which nursing actions are appropriate following a liver biopsy? Select all that apply.
Show answer and rationale
Correct answer: C. Immediately assist client to turn on right side.
right-side positioning exerts pressure on the liver and reduces the chance for bleeding.
What should alert a nurse to a possible problem with a client who is on a mechanical ventilator?
Show answer and rationale
Correct answer: B. A client is using accessory muscles while on the ventilator.
use of accessory muscles indicates the client has to work to breathe.
A client is scheduled for an ultrasound to rule out bile duct obstruction. What preparation is required for an ultrasound test?
Show answer and rationale
Correct answer: A. Explanation about the procedure.
all procedures should be explained prior to being done on a client.
A nurse is assessing a client who had an esophagogastroduodenoscopy. The first priority for the nurse should be:
Show answer and rationale
Correct answer: B. Monitoring for return of the gag reflex.
to pass the scope down through the esophagus, the gag reflex is suppressed by spraying an anesthetic on the back of the throat. After the procedure, nothing should be taken orally until the gag reflex has returned.
Gallstones can be diagnosed and sometimes removed by endoscopic retrograde cholangiopancreatography (ERCP). Preparation of a client scheduled for this procedure should include:
Show answer and rationale
Correct answer: A. Receiving sedative but not general anesthesia.
a sedative is given for this procedure, which does not require general anesthesia. ERCP permits direct visualization of structures and requires multiple position changes.
A client will return to the floor from the postanesthesia care unit (PACU) following a laparoscopic cholecystectomy when:
Show answer and rationale
Correct answer: D. The client is awake with stable vital signs.
in the PACU, the client recovers from anesthesia. This surgery will have been done using general anesthesia, so the client should be awake. Vital signs are typically measured every 15 minutes, so after about an hour, stability can be determined and the client discharged to an area with less frequent monitoring.
Discharge teaching for the client following a laparoscopic cholecystectomy includes:
Show answer and rationale
Correct answer: B. Take a shower but do not soak in the bathtub.
while it is important to keep the skin clean, soaking in a tub can soften the skin closure and allow microbes to enter the wound. It is better to suggest that the client take a shower rather than a bath.
A client with cystic fibrosis is to receive chest physiotherapy. When should a nurse plan to give this treatment?
Show answer and rationale
Correct answer: B. One hour before lunch.
chest physiotherapy includes postural drainage and chest percussion and vibration. A full stomach would interfere with the effectiveness of the treatment, and vomiting and aspiration could occur.
A nurse is preparing a client for an elective electrical cardioversion. What should be included in this client’s teaching?
Show answer and rationale
Correct answer: C. Analgesia and sedation are given before the procedure.
the client will receive moderate IV sedation as well as an analgesic medication before the procedure.
A client is scheduled for a cholecystogram. In preparation for the test, a nurse should ask the client about allergies to: Select all that apply.
Show answer and rationale
Correct answer: D. Clams.
clams are a shellfish and an allergy to shellfish would increase the risk that the client would have an allergic reaction to the dye used during the test.
A client has a T-tube inserted in the surgical wound following a cholecystectomy. The most important nursing function in managing this tube is:
Show answer and rationale
Correct answer: C. Preventing the tube from kinking.
a T-tube is used when there has been exploration of the common bile duct, which results in swelling. The tube prevents blockage to the flow of bile, and patency of the tube is important to the client’s recovery.
A client reports pain in the right shoulder following a laparoscopic cholecystectomy. A nurse explains that the pain is related to:
Show answer and rationale
Correct answer: D. Migration of the gas used to insufflate the abdomen during the procedure.
right shoulder pain is normal following the laparoscopy. The client should know this before the procedure is done. A heating pad applied for 15 to 20 minutes every hour helps.
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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