100 Neuron NCLEX Nursing Examination Questions with Verified Answers Latest Update 2024-As, Exams of Nursing

Download 100 Neuron NCLEX Nursing Examination Questions with Verified Answers Latest Update 2024-As and more Exams Nursing in PDF only on Docsity! 100 Neuron NCLEX Nursing Examination Q uestions with Verified Answers Latest Update 2024- Assured Success 1. An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? • Reposition the client to avoid neck flexion • Administer 1 g Mannitol IV as ordered • Increase the ventilator’s respiratory rate to 20 breaths/minute • Administer 100 mg of pentobarbital IV as ordered. 2. A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? 1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. 2. Rapid Dilantin administration can cause cardiac arrhythmias. • Dilantin should be mixed in dextrose in water before administration. • A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? • Bloody drainage from the ears 2. Frequent swallowing • Guaiac-positive stools • Hematuria 6. After a hypophysectomy, vasopressin is given IM for which of the following reasons? • To treat growth failure • To prevent syndrome of inappropriate antidiuretic hormone (SIADH) • To reduce cerebral edema and lower intracranial pressure • To replace antidiuretic hormone (ADH) normally secreted by the pituitary. 7. A client comes into the ER after hitting his head in an MVA. He’s alert and oriented. Which of the following nursing interventions should be done first? • Assess full ROM to determine extent of injuries • Call for an immediate chest x-ray • Immobilize the client’s head and neck • Open the airway with the head-tilt-chin-lift maneuver 8. A client with a C6 spinal injury would most likely have which of the following symptoms? • Aphasia • Hemiparesis • Paraplegia a 4. Tetraple gia 9. . A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? • Autonomic dysreflexia • Hypervolemia • Neurogenic shock 12. The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? • Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. • Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. • Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. • Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure. 13. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: • A positive Brudzinski’s sign • A negative Kernig’s sign • Absence of nuchal rigidity • A Glascow Coma Scale score of 15 14. A client is arousing from a coma and keeps saying, “Just stop the pain.” The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to: 17. When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? • Bladde r infectio n • Middle ear infection • Fractured clavicle • Septic arthritis 18. The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply. 1.Head tilt 2.Vomiting 3.Polydipsia 4.Lethargy 5. Increased appetite 6. Increased pulse 1,2,4 19. A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? 1. Cloudy CSF, decreased protein, and decreased glucose 2. Cloudy CSF, elevated protein, and decreased glucose 3.Clear CSF, elevated protein, and decreased glucose 4.Clear CSF, decreased pressure, and elevated protein cal deficit • Pulse ox readings • The client’s feelings about the injury 23. A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? • Absent corneal reflex • Decerebrate posturing • Movement of only the right or left half of the body • The need for mechanical ventilation 24. A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? • Decreased urine output or oliguria • Hypertension and bradycardia • Respiratory depression • Symptoms of shock 25. A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the following instructions should be given? • “Clean the meatus from back to front.” • “Measure the quantity of urine.” • “Gently rotate the catheter during removal.” • “Clean the meatus with soap and water.” 26. An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? • “Watch him for keyhole pupil the next 24 hours.” • “Expect profuse vomiting for 24 hours after the injury.” • “Wake him every hour and assess his orientation to person, time, and place.” • “Notify the physician immediately if he has a headache.” 27. Which neurotransmitter is responsible for many of collection of blood between the skull and dura mater. Which type of head injury does this finding suggest? • Subdural hematoma • Subarachnoid hemorrhage • Epidural hematoma • Contusion 30. After falling 20’, a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect? • Quadriplegia with gross arm movement and diaphragmatic breathing • Quadriplegia and loss of respiratory function • Paraplegia with intercostal muscle loss • Loss of bowel and bladder control 31. A 20-year-old client who fell approximately 30’ is unresponsive and breathless. A cervical spine injury is suspected. How should the first- responder open the client’s airway for rescue breathing? • By inserting a nasopharyngeal airway • By inserting a oropharyngeal airway • By performing a jaw- thrust maneuver • Manito (Osmitrol) 34. The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with: • Skull fracture • Concussion • Subdu ral hemato ma • Epidur al hemato ma 35. The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for: •A flattened abdomen •Hamates positive nasogastric tube drainage •Hyperactive bowel sounds •A history of diarrhea 36. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? • Strict adherence to a bowel retraining program • Limiting bladder catheterization to once every 12 hours • Keeping the linen wrinkle-free under the client • Preventing unnecessary pressure on the lower limbs 37. The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? • Monitoring vital signs before and during position changes • Using vasopressor medications as prescribed • Moving the client quickly as one unit • Applying Teds or compression stockings. 38. The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: • Keeping the client on a stretcher • Loosen tight clothing on the client • Administer an antihypertensive medication 2,4,1,3,5 41. A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? • Unequal pupil size • Decreasing systolic blood pressure • Tachycardia • Decreasing body temperature 42. Which of the following respiratory patterns indicate increasing ICP in the brain stem? • Slow, irregular respirations • Rapid, shallow respirations • Asymmetric chest expansion • Nasal flaring 43. Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? • Give the client a warming blanket • Administer low-dose barbiturate • Encourage the client to hyperventilate • Restrict fluids • Supination of arms, dorsiflexion of feet • Back arched; rigid extension of all four extremities. 47. A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate? • Count the rate to be sure the ventilations are deep enough to be sufficient • Call the physician while another nurse checks the vital signs and ascertains the patient’s Glasgow Coma score. • Call the physician to adjust the ventilator settings. • Check deep tendon reflexes to determine the best motor response 48. In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? • Keeping the client flat on one side or the other • Elevating the head of the bed to 30 degrees • Log rolling or turning as a unit when turning • Keeping the head in neutral position 49. A client has been pronounced brain dead. Which findings would the nurse assess? Check all that apply. • Decerebrate posturing • Dilated nonreactive pupils • Deep tendon reflexes • Absent corneal reflex 2,3,4 50. A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clinic seizures. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising? • Document the onset time, nature of seizure activity, and postictal behaviors for all seizures. • Administer phenytoin (Dilantin) 200 mg PO daily. • Teach patient about the need for good oral hygiene. (Xylocaine) D. Furosemide (Lasix) 53. After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He’s unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? A.Give him a barbiturate. B.Place him on mechanical ventilation. C.Perform a lumbar puncture . D.Elevate the head of his bed. 54. When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report: A.Light flashes and floaters in front of the eye. B.A recent driving accident while changing lanes. C.Headaches, nausea, and redness of the eyes. D.Frequent episodes of double vision. 55. Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis? A. Imbalanced nutrition: Less than body requirements B. Ineffective airway clearance C. Impaired urinary elimination D. Risk for injury A. In 30 to 45 seconds B. In 10 to 15 minutes C. In 30 to 45 minutes D. In 1 to 2 hours 59. A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client’s therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification? A.Parasympathomimetic agent B.Sympatholytic agent C.Adrenergic blocker D. Cholinergic blocker 60. Emergency medical technicians transport a 27-year- old iron worker to the emergency department. They tell the nurse, “He fell from a two- story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag.” Which intervention by the nurse has the highest priority? A.Assessing the left leg B.Assessing the pupils C.Placing the client in Trendelenburg’s position D.Assessing level of consciousness 61. An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes, and then take him to the emergency department of a nearby hospital, where he receives emergency care for the corneal injury. The physician prescribes dexamethasone (Maxine Ophthalmic Suspension), two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate (Neosporin Ophthalmic), A. Instilling one drop of pilocarpine 0.25% into both eyes daily. B. Instilling one drop of pilocarpine 0.25% into both eyes four times daily. C. Instilling one drop of pilocarpine 0.25% into the right eye daily. D. Instilling one drop of pilocarpine 0.25% into the left eye four times daily. 64. A female client who’s paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? A.The client leaves the side rails down. B.The client uses a mirror to inspect the skin. C.The client repositions only after being reminded to do so. D.The client hangs the left arm over the side of the wheelchair. 65. A male client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client’s feet make a half circle. To document the client’s gait, the nurse should use which term? A.Ataxic B.Dystro phy ice C. Helicopte r D. Steppage 66. A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client? C.Vertigo, pain, and hearing impairment. D.Vertigo, blurred vision, and fever. 69. A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? A. “Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours.” B. “Try to ambulate independently after about 24 hours.” C. “Shampoo your hair every day for ten (10) days to help prevent ear infection.” D. “Don’t fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days.” 70. Nurse Marty is monitoring a client for adverse reactions To dantrolene (Atrium). Which adverse reaction is most common? A.Excessive tearing B.Urine retention C. Muscl e weakness D. Slurred speech 71. The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction? A.Tachycardia B. Increased salivation C.Hypotension D.Apnea 72. A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client’s care, the nurse should assign the highest priority to which nursing diagnosis? A. Impaired physical mobility B. Ineffective 75. While reviewing a client’s chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition? A.The client may be less sensitive to the effects of a neuromuscular blocking agent. B.Succinylcholine shouldn’t be used; pancuronium may be used in a lower dosage. C.Pancuronium shouldn’t be used; succinylcholine may be used in a lower dosage. D.Pancuronium and succinylcholine both require cautious administration. 76. A male client is color blind. The nurse understands that this client has a problem with: A.Rods. B.Cones . C.Lens. D.Aqueous humor. 77. A female client who was trapped inside a car for hours after a head- on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? A.Diencephalon determine when the client is ready for a liquid diet, the nurse assesses the client’s swallowing ability once each shift. This assessment evaluates: A.Cranial nerves I and II. B.Cranial nerves III and V. C.Cranial nerves VI and VIII. D. Cranial nerves IX and X. 81. A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? 1.Vomiting continues 2. Intracranial pressure (ICP) is increased 3.The client needs mechanical ventilation 4.Blood is anticipated in the cerebrospinal fluid (CSF) 82. A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? 1.To reduce intraocular pressure 2.To prevent acute tubular necrosis 3.To promote osmotic diuresis to decrease ICP 4.To draw water into the vascular system to increase blood pressure 83. A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? 1.Urin e output increases 2.Pupils are 8 mm and nonreactive 3.Systolic blood pressure remains at 150 mm Hg 4.BUN and creatinine levels return to normal 84. Which of the following values is considered normal for ICP? 1.0 to 15 mm Hg 2.25 mm Hg 3.35 to 45 Tempor al 88. While cooking, your client couldn’t feel the temperature of a hot oven. Which lobe could be dysfunctional? 1.Frontal 2.Occip ut al 3. Parietal 4. Temporal 89. The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client’s peripheral response to pain? •Sternal rub •Pressure on the orbital rim • Squeezing the sternocleidomastoid muscle • Nai l bed pressure 90. . A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? • Evaluate urine specific gravity • Anticipate treatment for renal failure • Provide emollients to the skin to prevent breakdown • Slow down the IV fluids and notify the physician 94. Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? 1. Insert an indwelling urinary catheter to straight drainage 2. Schedule intermittent catheterization every 2 to 4 hours • Perform a straight catheterization every 8 hours while awake • Perform Crede’s maneuver to the lower abdomen before the client voids. 95. A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? • Laceration of the middle meningeal artery • Rupture of the carotid artery • Thromboembolism from a carotid artery • Venous bleeding from the arachnoid space 96. A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? •Position the client flat in bed •Check the fluid for dextrose with a dipstick •Suction the nose to maintain airway patency • Insert nasal and ear packing with sterile gauze 97 . When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? • An interval when the client’s speech is garbled • An interval when the client is alert but can’t recall recent events • An interval when the client is oriented but then becomes somnolent • An interval when the client has a “warning” symptom, such as an odor or visual disturbance. 98. Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? • A client with a brain injury