NCLEX Practice Questions RN 3/7

1. Of the following positions, which one facilitates maximum air exchange?

2. The nurse is providing education for a client who has just been prescribed a transcutaneous electrical nerve stimulation (TENS) unit for relief of chronic back pain. Which of the following instructions to the client is correct?

3. A father brings his 6-month-old son and 3-year-old daughter for their routine check-ups. What is the nurse’s best strategy?

4. The nurse is teaching parents to instill eye drops for their 4-month-old daughter. The parents tell the nurse that she shuts her eyes tightly to avoid the drops. Which instruction by the nurse is most appropriate?

5. The home health nurse notices that a client with a diagnosis of multiple sclerosis is recently having difficulty chewing and swallowing. What is the appropriate diet for this client?

6. The nurse is providing postmortem care for a client who was being treated for Staphylococcus aureus. Which transmission-based precautions are indicated?

7. Contraindications for administering an enema include all of the following EXCEPT

8. Which lab value indicates hypokalemia?

9. After your patient dies, the patient’s family gathers at the bedside and asks you to step out while their clergy performs a religious rite for the deceased. As the patient’s nurse, what is your most appropriate course of action?

10. A nurse is caring for a client whose heel has a pressure ulcer covered with intact hard, dry, black tissue. Which is the appropriate dressing for this client?

11. The palliative care nurse is caring for a client with advanced multiple myeloma. Which intervention is MOST appropriate?

12. Despite frequent turning and skin assessment, occasional urinary incontinence has caused a bedridden resident to develop a reddened and tender area on the coccyx. The resident weighs 192 pounds. Which pressure-relieving device should be used for the client?

13. What is the smallest gauge intravenous catheter that can be used to administer blood?

14. Before administering a scheduled 300 mL enteral feeding bolus to a comatose adult client, the nurse aspirates 100 mL of gastric residual volume. Which nursing action is MOST appropriate?

15. A patient diagnosed with Crohn’s disease has a new colostomy. When assessing the patient’s stoma, which of these would alert the healthcare provider that the stoma has retracted?

16. To measure an adult client’s apical heart rate, where does the nurse place the stethoscope?

17. A patient with a total hip replacement requires certain equipment for recovery. Which of the following will assist the patient with activities of daily living (ADL)?

18. After emptying a Jackson-Pratt drainage bulb, how does the nurse reestablish negative pressure in the system?

19. A patient receiving chemotherapy is experiencing stomatitis. Which of the following should the healthcare provider offer the patient?

20. A nurse working at a community health fair is administering intramuscular injections of influenza vaccine. Which injection technique will avoid leakage into subcutaneous tissue?

The healthcare provider is preparing a patient for a total colectomy and the placement of an ileostomy. The patient asks where the stoma will be located. The healthcare provider identifies which of the following areas as the correct stoma site?

22. During assessment, the home health nurse learns that the client has a fecal impaction. Before proceeding to manually remove the stool, what is the nurse’s PRIORITY?

23. Which of the following is the proper procedure for cleaning and storing dentures as part of a client’s HS oral care?

24. The nurse is educating the parents of a young child with a recent diagnosis of cystic fibrosis. The nurse tells the parents that the child will be at risk for which vitamin deficiencies?

25. A 10-year-old boy is admitted to the pediatric unit with a diagnosis of viral meningitis. He is experiencing a severe headache, a stiff neck, vomiting, photophobia, and drowsiness. The nurse can make him more comfortable by

26. The nurse prepares a 5-year-old girl for a pre-operative IV insertion. Which statement is most appropriate to reduce the child’s anxiety?

27. The parent of a child with a short leg fiberglass cast phones the clinic because the child complains of constant itching inside the cast. Which intervention is appropriate for the nurse to suggest?

28. The purpose of a splint is to

29. When taking the blood pressure of a client who is seated, which position must the client change so that the nurse can get an accurate measurement?

30. The nurse is planning care for a client with status-post CVA and limited mobility. The client is scheduled for occupational therapy at 10:00 a.m. and physical therapy at 2:00 p.m. What times are most appropriate for nursing care?

31. When instructing a patient with Addison’s disease about nutrition, the healthcare provider should NOT recommend which of the following dietary modifications?

32. When a patient’s nasogastric (NG) tube stops draining, what is the nurse’s first action?

33. A patient with a diagnosis of lung cancer is receiving chemotherapy. The patient reports nausea and loss of appetite, resulting in decreased food intake. What should the healthcare provider recommend to the patient to promote adequate nutrition?

34. Which meal best promotes healing for a patient recovering from a burn injury?

35. A client has a pressure ulcer on the sacrum. While assessing it, the nurse observes that it has partial thickness, loss of dermis, and a red-pink wound bed. Which stage will the nurse assign this pressure ulcer?

36. A client with chronic renal failure (CRF) is learning to perform peritoneal dialysis at home. The nurse instructs the client to warm the dialyzing solution to 37 degrees Celsius so that it will

37. A client comes to the clinic, complaining of severe gastrointestinal distress. Which abdominal physical assessment step does the nurse do first?

The Wong-Baker FACES Pain Rating Scale can be used by all of the following EXCEPT

39. A client with end-stage renal disease has opted for an arteriovenous (AV) fistula for long-term treatment with hemodialysis. Following the surgical creation of the AV fistula, when will the client be able to use it for hemodialysis?

40. The nurse teaching a 14-year-old client about her cervico-thoracolumbosacral orthosis (CTLSO) brace. Which statement by the client would indicate a lack of understanding about the brace?

41. A pregnant client comes to the prenatal clinic for her first visit. The nurse notes that this is the client’s third pregnancy. Four years ago, she delivered a healthy boy at 38 weeks, and two years ago, she delivered a healthy girl at 35 weeks. Using the gravida/para system to record the client’s obstetrical history, the nurse will document

42. The nurse is instructing a client with a new sigmoid colostomy about caring for the colostomy. The nurse explains that to best regulate the bowel, the client should perform colostomy irrigation at the same time every day. What is the optimal time for doing this?

43. The pediatric nurse receives a 1-year-old child with a hip spica cast application to treat hip dysplasia. Which of the following nursing actions should be implemented for the child?

44. The nurse in the prenatal clinic is teaching a client who is a vegetarian how to avoid iron-deficiency anemia during her pregnancy. Which food choice by the client indicates a need for further instruction?

45. The post-anesthesia care unit (PACU) provides a report to the pediatric nurse on a 15-month-old who has had repair of a congenital hip deformity. What type of traction does the nurse anticipate will be used for the child?

46. The nurse is educating a client with cardiac disease who is taking furosemide and digoxin about eating foods rich in potassium. The client states, “I know I need potassium, but I get tired of eating bananas.” The nurse then suggests choosing any of the following foods EXCEPT

47. A client in the Emergency Department is experiencing the “fight-or-flight” response, a sympathetic nervous system reaction. Which of the following will the nurse expect to observe?

48. The nurse is educating a client with hypovolemia related to dehydration. Which statement by the client indicates a need for further instruction?

49. An unconscious trauma patient is admitted to the ICU. The health care provider (HCP) prescribes enteral feedings via the nasogastric (NG) tube. Before the nurse administers a formula feeding, which finding by the nurse requires IMMEDIATE action?

50. One of the nurse’s patients has a nasogastric (NG) tube for tube feedings and medications. Which nursing action is appropriate when caring for this patient?

51. Following delivery of a stillborn infant, a mother is transferred to a room in the postpartum unit. When the nurse enters the room to take vital signs and check the mother’s uterus, the mother says, “Get out and leave me alone. It’s people like you who let my baby die!” Which is the nurse’s most therapeutic response?

52. A client with a severe ankle sprain will be using crutches. Which of the following indicates that the crutches have been fitted correctly?

53. The nurse calculates the 1-minute Apgar score for a neonate with the following: 1. Respiratory effort: slow; 2. heart rate: 120 bpm; 3. muscle tone: some flexion of extremities; 4. reflex irritability: vigorous; 5. skin color: body pink, blue extremities. What score does the nurse assign?

54. A 32-year-old female with no significant history comes to the clinic for a routine check-up. Where is the most appropriate spot to measure this client’s pulse?

55. While providing pre-operative education to a client, the nurse explains that the client will return from surgery with a sequential compression device (SCD). Which of the following statements by the nurse would be most correct?

56. When preparing a client for the removal of the nasogastric (NG) tube, which instruction to the client is correct?

57. A pediatric patient has been admitted to the unit with a diagnosis of right lower lobe (RLL) pneumonia. When auscultating the RLL, which sound should the nurse expect to hear?

58. When providing postmortem care for a patient who will be an eye donor, which action is most appropriate?

59. Which skin care instruction is correct for a male client receiving head and neck radiation therapy?

60. The tool that predicts the risk of developing a hospital- or facility-acquired pressure ulcer or injury is called the

61. A resident at the assisted living center pushes his tray onto the floor and shouts at the nurse, “This food is terrible! I can’t stand this another minute!” What is the nurse’s best response?

62. A client with a nasogastric (NG) tube complains that his nasal passage is irritated. Which action by the nurse is most appropriate?

63. A newborn is diagnosed with tracheoesophageal fistula (TEF) shortly after birth. Which finding will be MOST important for the nurse to report to the Health Care Provider (HCP)?

64. A client with a diagnosis of congestive heart failure (CHF) is placed on strict intake and output (I&O). The unlicensed assistive personnel (UAP) records the client’s intake at lunch as 8 oz. of black coffee, 6 oz. of orange juice, 4 oz. of lime jello, and 4 oz. of vanilla pudding. What is the client’s intake?

65. A primigravida client comes to the prenatal clinic after missing three periods. After her pregnancy has been confirmed, the client tells the nurse that her last period started on June 10. Using Naegele’s Rule, what is the client’s estimated date of delivery (EDD)?

66. A child with a new diagnosis of celiac disease is being discharged. The nurse provides education to the parents, including appropriate nutrition for their child. The nurse will instruct the parents to follow a

67. The nurse is educating a client with primary adrenal insufficiency (Addison’s disease) on diet and nutrition changes needed to manage the client’s disease. Which statement by the client would indicate that the nurse’s instructions have been effective?

68. When the nurse enters a patient’s room to administer insulin, the patient is in an awkward position in her bed. What should the nurse do FIRST?

69. The nurse is instructing a client with a new ileostomy on when to empty their pouch. Which of the following instructions is correct?

70. The nurse is providing wound care for a client with a Stage III pressure ulcer. Which of the following signs indicates that the wound is healing?

71. In a neurological assessment, what does “PERLA” stand for?

72. The nurse is providing discharge instructions to parents of a 3-year-old who was hospitalized for severe croup. In the event of a future croup attack, what non-pharmacological intervention can the parents do at home?

73. When transferring a client from the bed to a wheelchair, what is the FIRST action?

74. During an initial client assessment, which of the following techniques will the nurse use to gather subjective data?

75. A client with diabetes insipidus has urine output described as

76. After a client was diagnosed with gastroesophageal reflux disease (GERD), the nurse educates the client about diet. Which of the following foods should the client avoid?

77. A client who sustained a fractured femur in a construction accident is admitted to the orthopedic unit directly from surgery. The client is in skeletal traction. Which nursing action is the PRIORITY?

78. During a routine check-up, a client asks the nurse to suggest a breakfast that can help prevent constipation. Which of the following would be the best food choices?

79. The nurse does an admit for a client with a diagnosis of pleural effusion. When doing a respiratory assessment of this client, the nurse will determine if the client has

80. A client has a nephrostomy tube. When the nurse assists the client to ambulate, which is the best way to keep the tube safe?

81. When the nurse enters a client’s room, the client states, “I asked that aide girl for a cup of tea 10 minutes ago. She’s ignoring me!” What is the nurse’s BEST response?

82. A male client with a diagnosis of paranoid schizophrenia is admitted to the inpatient mental health unit. The client tells the nurse that he hears God telling him that he is a sinner and must punish himself. Which is the nurse’s most appropriate response?

83. As part of the administration of a Mini-Mental Status Exam (MMSE), the healthcare provider asks the patient to copy a simple geometric shape. This part of the exam tests which of the following mental functions?

84. A patient has been diagnosed with agoraphobia. Which of the following would the healthcare provider identify as a characteristic of this disorder?

85. Before touching a crying client to offer comfort, the nurse should consider

86. A patient diagnosed with obsessive-compulsive disorder (OCD) continually carries a toothbrush and will brush and floss up to fifty times each day. The healthcare provider understands that the patient’s behavior is an attempt to

87. A psychiatric client tells the nurse that he hears voices telling him he must leave the hospital and kill his family. The nurse’s best response is

88. A parent brings a 3-year-old to the Emergency Department for a dislocated shoulder. The parent reports that the child fell down the stairs. Which of the following behaviors should raise suspicions that the child may have been abused?

89. A patient diagnosed with delirium sees the intravenous (IV) tubing and believes it to be a snake. How should the healthcare provider document this behavior?

90. A patient who was diagnosed with bipolar disorder is prescribed lithium carbonate (Lithobid). When teaching the patient about the medication, the healthcare provider should be sure to mention which of the following statements?

91. As the oncology nurse prepares to administer chemotherapy to a client with newly diagnosed cancer, the client says, “Everyone who gets cancer dies. I don’t know why we’re bothering with this.” What is the nurse’s best response?

92. As the Emergency Department nurse completes a rape kit and care for a client, the client appears calm and quiet. When the nurse asks how she feels, the client replies, “I’m fine, thanks.” What is the likely cause of the client’s behavior?

93. A patient is receiving care after being diagnosed with generalized anxiety disorder (GAD). Which of these statements made by the patient would indicate to the healthcare provider that the patient is beginning to show signs of improvement?

94. A client with chronic kidney disease (CKD) learns that her condition has progressed and she now requires hemodialysis. She becomes angry and tells the nurse, “My life is ruined. Nothing will ever be the same.” The nurse understands that the client’s statement is related to

95. A client with bipolar disorder, manic phase, says to the nurse, “Hey, beautiful! You’re sure looking pretty today.” Which is the nurse’s best response?

96. A newly admitted patient’s medication orders include donepezil hydrochloride (Aricept). The nurse knows that this medication is prescribed for which of the following?

97. When assessing a patient with severe depression, which of the following would the healthcare provider identify as a cognitive alteration?

98. A patient diagnosed with major depressive disorder is admitted for inpatient care. Which of the following is the primary goal during the admission assessment?

99. The nurse approaches a client with a diagnosis of depression, but the client says,
“Leave me alone. Go find someone else to talk to.” Which is the nurse’s best response?

100. The children of a patient diagnosed with Alzheimer’s disease (AD) tell the healthcare provider, “Our mother seems better during the day, but she gets very confused and agitated in the late afternoon and evenings.” How should the healthcare provider document the patient’s behavior?