NURSING NCLEX RN EXAM QUESTIONS WITH BEST RATED ANSWERS LATEST UPDATE GUARANTEED SUCCESS A, Exams of Nursing

Download NURSING NCLEX RN EXAM QUESTIONS WITH BEST RATED ANSWERS LATEST UPDATE GUARANTEED SUCCESS A and more Exams Nursing in PDF only on Docsity! NURSING NCLEX RN EXAM QUESTIONS WITH BEST RATED ANSWERS LATEST UPDATE GUARANTEED SUCCESS A+ 1. Which of the following clients is at a higher risk of developing oral health problems? a. A pregnant client b. A client with diabetes c. A client receiving chemotherapy d. Both b and c 2. Which nursing intervention is most appropriate to reduce environmental stimuli that may cause discomfort for a client? a. Loosen pressure dressings on wounds b. Use assistance to pull a client up in bed c. Check temperature of water used in a sponge bath d. Position the client prone 3. A client has developed a vitamin C deficiency. Which of the following symptoms might the nurse most likely see with this condition? a. Cracks at the corners of the mouth b. Altered mental status c. Bleeding gums and loose teeth d. Anorexia and diarrhea Page 1 of 72 4. Which of the following interventions should a nurse perform for a female client who is incontinent with impaired skin integrity? a. Turn the client at least every 8 hours b. Apply lotion to the skin before a bath Page 2 of 72 8. A client is taking a walk down the hallway when she suddenly realizes that she needs to use the restroom. Although she tries to make it to the bathroom on time, she is incontinent of urine before reaching the toilet. What type of incontinence does this situation represent? a. Reflex incontinence b. Urge incontinence c. Total incontinence d. Functional incontinence 9. Which of the following is an example of a positive effect of exercise on a client? a. Decreased basal metabolic rate b. Decreased venous return c. Decreased work of breathing d. Decreased gastric motility 10. You have taken the vital signs for your patient. They are normal for the patient. What should you do next? a. Report the vital signs to the doctor b. Write the vital signs on a scrap paper c. Call the family members d. Document them on the graphic VS form 11. Penny Thornton has had a stroke, or CVA. She is having difficulty eating on her own. Soon, she will be getting some assistive devices for eating meals. Page 5 of 72 Which healthcare worker will be getting Penny these assistive devices? a. A physical therapist b. A speech therapist Page 6 of 72 c. A social worker d. An occupational therapist 12. Which of the following is an example of emotional abuse? a. A slap to the person's hand b. Threatening the person c. Ignoring and isolating a person d. Leaving a patient soiled for hours 13. Which of the following is an example of emotional neglect? a. A slap to the person's hand b. Threatening the person c. Ignoring and isolating a person d. Leaving a patient soiled for hours 14. The duodenum: a. is the third section of the small intestine, which leads immediately to the colon. b. is the section of the stomach where the gall bladder delivers bile. c. is the section of the small intestine where the pancreas delivers insulin. d. None of the above. 15. The nurse is performing discharge teaching for Mrs. S after cardiac angioplasty. Her husband is present for the teaching. While explaining the prescription for antiplatelet medication to use at home, Mrs. S's husband states, "I Page 7 of 72 to provide care or education to the client? a. A nurse offers educational materials to a client that are written at an 8th grade reading level b. A Vietnamese woman wants to use steaming in addition to her prescription antibiotics Page 10 of 72 c. A nurse uses pantomime to explain a procedure to a deaf client d. A Native American client requests a healing ritual before he will consider surgery 19. Which of the following is an example of low health literacy skills? a. A nurse's aide cannot calculate the correct IV rate for Ringer's lactate b. A client cannot read an admission form to sign it c. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine d. A client does not understand the treatment for his cholecystectomy 20. A 39-year old woman presents for treatment of excessive vaginal bleeding after giving birth to twins one week ago. Which nursing diagnosis is most appropriate in this situation? a. Knowledge Deficit related to post-partum blood loss b. Self-Care Deficit related to post-partum neglect c. Fluid Volume Deficit related to post-partum hemorrhage d. Body Image Disturbance related to body changes after delivery 21. Mr. K is admitted to the orthopedic unit one morning in preparation for a total knee replacement to start in two hours. Which of the following is a priority topic to instruct this client on admission? a. The approximate length of the surgery b. The type of anticoagulants that will be prescribed c. The time of the next meal of solid food Page 11 of 72 d. The length of time until the client can return to work Page 12 of 72 c. A nursing assistant calls for help when a client falls out of bed d. A client developed a sacral pressure ulcer when he was not turned in bed for over four hours 26. Which situation might require an occupational health nurse consult? a. A nurse is injured from using incorrect body mechanics to lift a client b. A nurse receives a subpoena to testify in court about a client's case c. A client who has been injured in a diving accident needs assistance with planning rehabilitation and surgery d. A nursing unit is implementing a new electronic health record system 27. Which of the following is the most appropriate example of anticipatory guidance for a 16- year old who has been hospitalized for an ankle fracture? a. Changes associated with puberty b. Driving and staying safe c. The health hazards of smoking d. Social media influences 28. Which action represents the evaluation stage of the plan of care? a. The nurse assigns a nursing diagnosis of Impaired Skin Integrity related to diminished skin circulation b. The nurse assesses the client's vital signs and asks about symptoms c. The nurse determines that the client is not meeting his set outcomes and makes revisions d. The nurse discusses the client's health history Page 15 of 72 29. Which of the following screening tools have been found to have a high diagnostic accuracy for screening for intimate partner violence? Page 16 of 72 a. Hurt, Insult, Threaten and Scream (HITS) b. Humiliation, Afraid, Rape, and Kick (HARK) c. Slapped, Threatened and Thrown (STaT) d. All the above 30. What is the relationship between HIPPA and technological advances? a. Technology helps to foster HIPPA confidentiality. b. Computers help us to share information with others. c. Computer screens are not visible to others in the area. d. Technology places us at risk for HIPPA violations. 31. Which technological advance is MOST likely to place you at risk for HIPPA violations? a. Social media b. Word processing programs c. Spreadsheets d. Clouds and SOEs 32. A patient is having a colposcopy procedure performed. How should the patient be instructed to prepare for the procedure? a. NPO for 8-12 hours before the procedure. b. D/C all HTN Rx for two days prior to the procedure. c. Take three Dulcolax tablets and two containers of Miralax the day before to Page 17 of 72 b. Stop the assistant and question the consent c. Notify the nurse manager d. Notify the research department Page 20 of 72 36. Monica is a 28-year-old nurse who had been admitted to the hospital after a near-drowning in which she suffered cardiac arrest and hypoxic encephalopathy. She has been stabilized and has a tracheostomy to room air. She has been on the general floor for several weeks, is in a persistent vegetative state, and has a very poor prognosis for any improvement in her neurological status. Monica had previously signed a living will, which indicated that she did not wish to receive enteral feedings to be kept alive if she had a terminal condition or was in a persistent vegetative state from other causes. Her parents have decided to move her to the hospice unit and have given permission for removal of her feeding tube. The patient care technician who has been caring for Monica is very distressed over this decision and feels that the parents are "killing" her. What would be an appropriate initial response? a. This will relieve the burden for her parents." b. Her parents have a right to make decisions for their child." c. Monica has stated her wishes and they should be honored." d. The ethics committee should be consulted." 37. Jack is a 2-month-old with a diagnosis of spinal muscular atrophy (SMA) type I. He has been admitted to the hospital for progressive respiratory difficulty. His parents have been informed that if he is not placed on ventilatory support, he will continue to decompensate and die of respiratory failure. Jack's physician discusses the poor prognosis of Jack's condition, and tells the parents that he will not be able to be removed from ventilatory support once it is initiated, due to his progressive neurological disease. After much discussion, the parents have decided to decline ventilatory support, agree to a do not resuscitate (DNR) order, and request hospice care for Jack. Another parent heard them discussing Jack's situation in the waiting room and says she could never do that to her baby. What is the most appropriate response to this parent? a. You never know what you'll do until you're in that situation." b. I can't discuss another patient's situation." c. They have been through too much already." Page 21 of 72 d. You can contact administration with your concerns." 38. You have noticed that the last several patients you have cared for have had questionable blood pressure readings from their arterial lines. When checked against cuff pressures, a discrepancy has been noted, and further investigation has revealed faulty transducers. This is not the first product issue with this company. What positive step could you take to help resolve this situation? Page 22 of 72 c. Contact a home health agency to provide care d. Provide a pamphlet with detailed instructions 42. What is a key principle of patient teaching that must take place to ensure patient safety? a. Family members should be present b. Teaching must be documented c. Understanding must be confirmed d. Teaching should be provided by multiple staff members 43. A client with adrenal insufficiency has a potassium level of 7.2 mEq/L. Which of the following signs or symptoms might the client exhibit with this result? a. Peaked T waves on the ECG b. Muscle spasms c. Constipation d. A prominent U wave on the ECG 44. A client is having difficulties reading an educational pamphlet. He cannot find his glasses. In order to read the words, he must hold the pamphlet at arm's length, which allows him to read the information. Which vision deficit does this client most likely suffer from? a. Cataracts b. Glaucoma c. Astigmatism Page 25 of 72 d. Presbyopia 45. A nurse is caring for Mrs. T, a client with expressive aphasia. During a bath, she begins to gesture wildly and point toward the bath water, yet is unable to say anything. Which response from the nurse is most appropriate? Page 26 of 72 a. Is something wrong with the bath water?" b. Just calm down, we'll finish your bath soon." c. Are you trying to tell me something?" d. Shall I turn on the television?" 46. A nurse is assisting a client with shampooing his hair while he is still in bed. While helping the client, the nurse raises the bed to approximately the level of her waist. What is the rationale for this action? a. To prevent shampoo from getting into the client's eyes b. To allow excess water to run off the edge of the bed c. To decrease strain on the nurse's back d. To prevent the client's hair from developing tangles 47. Which of the following signs or symptoms indicates a possible nutritional deficiency? a. Subcutaneous fat at the waist and abdomen b. Presence of papillae on the surface of the tongue c. Straight arms and legs d. Pale conjunctiva 48. A nurse is preparing to insert a small-bore nasogastric feeding tube for a client's enteral feedings. In which method does the nurse measure the correct length of the tube? a. From the tip of the nose to the xiphoid process Page 27 of 72 d. Remove the collection chamber and connect the tubing to a new device 52. A nurse is caring for a client with a broken femur who is in a traction splint in bed. All of the following interventions are part of care of this client EXCEPT: Page 30 of 72 a. Palpating the temperature of both feet b. Evaluating pulses bilaterally c. Turning the client to a side-lying position d. Relieving heel pressure by placing a pillow under the foot 53. A client is preparing to undergo a cystoscopy for stones. Which of the following statements indicates that the client understands the procedure? a. I better drink a lot of fluid now because I won't be able to after the test." b. I will probably see a little blood when I urinate." c. I will be able to go home after 3 days in the hospital." d. I won't need any pain medicine; this probably will not hurt." 54. Which of the following conditions may warrant a serum creatinine level? a. Rhabdomyolysis b. Digitalis toxicity c. Glomerulonephritis d. All answers are correct 55. Which nursing intervention is most appropriate to maintain the patency of a client's nasogastric tube? a. Maintain constant connection to low-intermittent suction b. Irrigate the tube as per physician order c. Suction the mouth and nose every shift d. Perform a daily fecal occult blood sample Page 31 of 72 56. A nurse is caring for a client who is having blood tests and who has an elevated lymphocyte level. Based on knowledge of cellular components, the nurse knows that these cells: a. Contain histamine and provide protection during allergic reactions b. Are involved in phagocytosis c. Provide protection and immunity against foreign substances d. Carry hemoglobin and oxygen to body tissues 57. Mrs. F has been diagnosed with hyperparathyroidism. Which of the following complications is Mrs. F at highest risk of developing? a. Hyponatremia b. Hypocalcemia c. Hypermagnesemia d. Hypercalcemia 58. Elderly patients are more prone to dehydration than younger people because the elderly . a. drink more coffee and tea b. have more stomach mucus production c. have more saliva d. have less sense of thirst 59. You are turning your patient in bed and you see that this confused and lethargic patient had loose car keys and lipstick in the bed and had been lying on Page 32 of 72 and does not have a pulse. After calling for help, what is the next action of the nurse? a. Administer 2 ventilations Page 35 of 72 b. Perform a head-tilt, chin lift to open the airway c. Begin chest compressions d. Perform a jaw thrust to open the airway 64. A nurse is caring for a client with severe mitral regurgitation and decreased cardiac output. The nurse assesses the client for mental status changes. What is the rationale for this intervention? a. Decreased cardiac output can cause hypoxia to the brain b. Mental status changes may be a side effect of the client's medication c. Mitral regurgitation is a complication associated with some neurological disorders d. The client may be confused about his diagnosis 65. A client is undergoing radiation therapy for treatment of thyroid cancer. Following the radiation, the client develops xerostomia. Which of the following best describes this condition? a. Cracks in the corners of the mouth b. Peeling skin from the tongue and gums c. Increased dental caries d. Dry mouth 66. A nurse is providing information for a woman who is 36 weeks' pregnant and who has hepatitis B. Which of the following statements from the client indicates understanding of this condition? Page 36 of 72 a. Now I know I will need a cesarean section." b. My baby will need two shots soon after his birth." c. I will not be able to breastfeed." d. My baby's father does not need testing; I know I am the one with hepatitis." Page 37 of 72 a. He should be started on antiretroviral therapy as ordered b. He is no longer just HIV-positive, he most likely has AIDS c. He should be tested for other illnesses, such as anemia d. Both b and c 71. All of the following are complications associated with hypothermia during the perioperative period EXCEPT: a. Decreased blood urea nitrogen levels b. Cardiac arrhythmias c. Decreased immunity d. Increased oxygen needs 72. A nurse is caring for a client who had a bone marrow transplant two weeks ago. Which of the following is most likely to cause an infection during this time period? a. Cytomegalovirus b. Varicella zoster virus c. Herpes simplex virus d. Hepatitis B virus 73. When reading a lab report, you notice that a patient's sample is described as having anisocytosis. Which of the following most accurately describes the patient's condition? a. The patient has an abnormal condition of skin cells. b. The patient's red blood cells vary in size. Page 40 of 72 c. The patient has a high level of fat cells and is obese. d. The patient's cells are indicative of necrosis. Page 41 of 72 74. A patient with Bell's Palsy would have which of the following complaints? a. Paralysis of the right or left arm b. Malfunction of a certain cranial nerve c. A sub-condition of Cerebral Palsy d. A side effect of a stroke 75. A pathologic condition described as, "Increased intraocular pressure of the eye," is: a. Detached Retina b. Fovea Centralis c. Presbyopia d. Glaucoma 76. A physician believes that a patient may be experiencing pancreatitis. Which of the following tests would be best to diagnose this condition? a. CK and Troponin b. BUN and Creatinine c. Amylase and Lipase d. HDL and LDL Cholesterol Levels 77. Which of the following is an example of client handling equipment? a. Wheelchair b. Height-adjustable bed Page 42 of 72 The edges of the incision are approximated. What is the next action of the nurse? a. Assist the client to shower as ordered and monitor the site for further changes b. Instruct the client to lie prone to allow the site to dry Page 45 of 72 c. Place antibiotic ointment and a sterile dressing over the site d. Notify the physician for an antibiotic order 82. A nurse is preparing to administer a dose of platelets to a client. Which of the following actions must the nurse perform before giving the platelets? a. Start an IV of ½ Normal Saline to administer with the platelets b. Ensure the container with the platelets is intact and not damaged c. Verify the client's name and address d. Check the client's chart to ensure he is not taking any antibiotics 83. Which of the following is an example of an environmental hazard that may put the nurse at risk of injury? a. Loud noise from the hospital maintenance system b. Airborne powder that contains latex c. Chemicals containing ethylene oxide d. All of the above e. Both b and c only 84. MSDS sheets: a. Contain the ordering information for each piece of equipment in the office. b. Are required by OSHA to be accessible to all employees of the office. c. Can be used to treat patients who have been injured in equipment accidents. d. None of the above. Page 46 of 72 85. The most virulent blood borne pathogen is: (Choose the BEST answer.) Page 47 of 72 a. WBC b. QRS c. XYZ d. ABC 90. A term that refers to a comprehensive set of thoughts or images of oneself is called: a. Global self b. Core self-concept c. Personal identity d. Ideal self 91. Which of the following interventions is most appropriate when supporting the psychosocial needs of a client who is experiencing negative side effects associated with chemotherapy? a. Read the client's discharge instructions well in advance of dismissal b. Provide medications to reduce nausea and vomiting c. Give simple instructions about self-care while in the hospital d. Determine the levels of support from significant others 92. Which of the following interventions is most appropriate when working with the family of a client who is being treated for substance abuse? a. Advocate for the client before the family b. Provide referrals for community resources and support groups Page 50 of 72 c. Take the side of the family before the client d. Both b and c Page 51 of 72 93. A term used to describe members of the same group based on physiological characteristics, such as skin color or body structure is known as: a. Ethnicity b. Culture c. Race d. Minority 94. Which of the following is an example of non-reversible dementia? a. Pick's disease b. Syphilis c. Encephalopathy d. Hyperthyroidism 95. Which is a true statement regarding stress related disorders? a. Stress related disorders are only caused by stress b. Symptoms of stress related disorders would not exist if the client was not experiencing stress c. Stress related disorders are also called psychophysiologic disorders d. None of the above 96. Which of the following nursing outcomes is most appropriate during the crisis stage of caring for a victim of domestic violence? a. The client will verbalize community resources from which to seek shelter Page 52 of 72 a. only enough information so they can comply with care Page 55 of 72 b. ALL of their health related information c. small amounts of information so they do not get nervous d. moderate amounts of information unless they are old 101. Your patient ate an 8 ounce cup of Italian ice. How much will you record on the patient's Intake and Output form in terms of this patient's fluid intake? a. 240 cc b. 120 cc c. 8 cc d. 0 cc because Italian ice is not a fluid. 102. You are getting the patient ready to eat. The patient is on complete bed rest. You will put the head of the bed up at degrees or more. a. 10 b. 15 c. 20 d. 30 103. Cheryl M. has a serious swallowing disorder. She has asked you for a glass of water. The doctor has ordered honey thickness fluids for her. Water is not a honey thickness fluid. It is much thinner. What should you do? a. Tell the resident that she cannot have water. b. Give her applesauce instead of the water. c. Tell Cheryl that she is NPO until midnight. Page 56 of 72 d. Thicken the water and give it to her. Page 57 of 72 d. Trochanter 108. The Atlas and the Axis: a. are found in the vertebrae. b. can be described as being cervical. c. are the first two bones that form the column for the spine on the superior aspect. d. All of the above. 109. The body system that functions to maintain fluid balance, support immunity and contains the spleen is the: a. Lymphatic System b. Digestive System c. Urinary System d. Reproductive System 110. Of the following, which often triggers an episode of violence or aggression by the patient with a psychiatric diagnosis that may involve violent behavior? a. Obtaining a history b. Asking for input into care c. Enforcing rules d. Taking a walk 111. Which of the following medications would NOT be an appropriate prn Page 60 of 72 medication for use during an episode of aggression or violence for the patient with a psychiatric diagnosis? a. Olanzapine Page 61 of 72 b. Meperidine c. Ziprasidone d. Haloperidol 112. Which of the following is an appropriate tension-reduction intervention for the patient who may be escalating toward aggressive behavior? a. Asking to speak to someone b. Asking to be alone c. Listening to music d. All of the above 113. Causes which contribute to delirium are often remembered as an acronym of the same name. What cause does the E in DELIRIUM represent? a. EEG b. EKG c. Electrolytes d. Echocardiogram 114. A nurse is preparing to administer a rectal suppository to a client. After applying gloves, checking the client's identification band, and closing the door, what is the next step of the nurse? a. Assist the client to lie in the Trendelenburg position b. Unwrap the suppository and lubricate the end c. Remove gloves and wash hands Page 62 of 72 route? a. The drug may be absorbed too rapidly Page 65 of 72 b. The drug may have a bad taste c. The drug is more expensive to use d. Both a and b 119. One tablespoon of medication is equal to how many milliliters of fluid? a. 5 ml b. 15 ml c. 30 ml d. 60 ml 120. A nurse asks her coworker to administer Mr. J's 12pm medication because she is running behind. Which of the following information must the nurse verify with Mr. J before giving him his medication? a. His name and address b. His name and hospital identification number c. His name and room number d. His name and diagnosis 121. Which of the following is more likely to occur with aging as a complication of medication administration? a. Increased renal function b. Increased gastrointestinal absorption c. Increased visual acuity d. Increased ratio of fat compared to lean body mass Page 66 of 72 122. Which of the following interventions should the nurse consider when giving an oral medication to a child? Page 67 of 72 126. Which of the following is an example of a fine motor skill? a. Jumping on a trampoline b. Brushing hair c. Standing on one foot d. Climbing a ladder 127. A child is being discharged to home with a diagnosis of ringworm. Discharge instructions should include the information that: a. The infection is caused by a worm and cannot be passed from person to person. b. The infection is caused by a virus and can be passed from person to person. c. The infection is caused by a bacteria and cannot be passed from person to person. d. The infection is caused by a fungus and can be passed from person to person. 128. Physical bullying, among school aged children, threatens which of Maslow's needs? a. Physical needs b. Love and belonging needs c. Safety needs d. All of the above 129. Your patient has had a very full and rewarding life. She has had a lot of success in her personal and professional life. She has achieved all of her goals and she has maximized her potential. This patient can be best described as a Page 70 of 72 person who has achieved Maslow's . a. self actualization b. exploration c. closeness Page 71 of 72 d. protection ANSWER A: This person has moved along Maslow's hierarchy and is now 130. At the end of life, many people have a fear of . a. insects b. rejection c. acceptance d. being alone Page 72 of 72