This chapter provides an example NCLEX-RN exam with detailed explanations of each answer to help you practice.
Editor's Note: You may also be interested in newer versions of this book and related titles:
A 43-year-old African-American man is admitted with sickle cell disease. The nurse plans to check the lower extremity blood flow every 2 hours. Which of the following outcome criteria would the nurse use?
Body temperature of 99°F or less
Toes moved in active range of motion
The sensation is reported when the soles of the feet are touched.
Capillary refill of < 3 seconds
A 30-year-old Haitian man is brought to the emergency room with sickle cell disease. What is the best position for this client?
Lateral position with knees bent
Tall hunter with bent knees
Semi-Fowler with legs stretched out on bed
A 25-year-old man is hospitalized with sickle cell disease. Which of the following interventions would be the highest priority for this client?
Hourly blood pressure measurement with mechanical cuff
Encourage fluid intake of at least 200 ml per hour.
High Fowler Stance with Raised Knee Lock
Administer Tylenol as directed
Which of the following foods would the nurse recommend for the patient with sickle cell disease?
A newly admitted client has a sickle cell crisis. The nurse plans care based on the client's assessment. The client complains of severe pain in his feet and hands. Pulse oximetry is 92. Which of the following would be done first? Assume there are orders for each intervention.
set room temperature
Administer a bolus of intravenous fluids
oh it starts2
Giving meperidine (Demerol) 75 mg IV was
The nurse refers a client with iron deficiency anemia. Which of the following meal plans would the nurse expect the client to select?
Roastbeef, Jell-O Salad, Green Beans and Peach Cobbler
Chicken salad sandwich, coleslaw, french fries, ice cream
Egg salad on wheat bread, carrot sticks, lettuce, raisin cake
Pork ribs, potato cream, corn and coconut cake
Patients with sickle cell disease are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
Family vacation in the Rocky Mountains
Join the local men's club on a snow ski trip
Traveling by plane for business trips
A bus ride to the Natural History Museum
The nurse performs an admission examination of a client with vitamin B12 deficiency. Which of the following items would the nurse include in the physical examination?
palpate the spleen
take blood pressure
Check for petechiae on the feet.
examine the language
An African-American woman enters the ambulance. The doctor suspects vitamin B12 deficiency anemia. Since jaundice is often a clinical manifestation of this type of anemia, what part of the body would be the best indicator?
The nurse performs a physical examination on a patient with anemia. Which of the following clinical manifestations would be most indicative of anemia?
28 shallow breathing
Weight gain of 10 kilos in 6 months.
The nurse teaches the patient with polycythemia vera about preventing complications from the disease. Which of the following customer statements indicates the need for additional training?
"I will drink 500 ml of fluids or less every day."
"I'll wear elastic stockings when I'm up."
"I'll use an electric razor to shave."
"I'll eat foods that are low in iron."
A 33-year-old man is being evaluated for possible acute leukemia. Which of the following questions will the nurse ask as part of the assessment?
The customer collects stamps as a hobby.
The customer has recently lost his postman job.
The client was irradiated as a teenager to treat Hodgkin's disease.
The client's brother had leukemia as a child.
An African-American client is admitted with acute leukemia. The nurse looks for signs and symptoms of bleeding. Where is the best place to test for petechiae?
the soles of the feet
A patient with acute leukemia is admitted to the oncology department. Which of the following questions would be most important to the caregiver?
"Have you noticed a change in your sleeping habits lately?"
"Have you had a respiratory infection in the last 6 months?"
"Have you lost weight lately?"
"Have you noticed changes in your alertness?"
Which of the following diagnoses would be the main nursing diagnosis for the adult patient with acute leukemia?
Oral mucosa, altered in relation to chemotherapy
Risk of injury associated with thrombocytopenia
Fatigue associated with the disease process.
Disrupted family processes related to a life-threatening illness in a family member
A 21-year-old man with Hodgkin's lymphoma is a senior at a local university. He is about to get married and must start a new job after graduation. Which of the following diagnoses would take precedence for this client?
Sexual dysfunction associated with radiotherapy
Anticipatory grief associated with terminal illness
Tissue integrity associated with prolonged bed rest
Fatigue associated with chemotherapy
A client has autoimmune thrombocytopenic purpura. To determine the patient's response to treatment, the nurse checked:
white blood cell count
Partial Prothrombin Zeit (PTT)
The home nurse visits a patient with autoimmune thrombocytopenic purpura (ATP). The client's platelet count is currently 80. It will be very important to educate the client and family about the following:
A client with a pituitary tumor underwent a transphenoidal hypospectomy. Which of the following interventions would be appropriate for this client?
Place the client in the Trendelenburg position for postural drainage.
Encourage coughing and deep breathing every 2 hours.
Elevate the head of the bed 30°
Encourage the Valsalva maneuver to defecate
The client with a history of diabetes insipidus is admitted with polyuria, polydipsia and mental confusion. The priority intervention for this client is:
measure urine output
check vital signs
Promote increased fluid intake.
Weigh the customer
A client with hemophilia has a nosebleed. Which nursing measure is the most appropriate to stop the bleeding?
Placing the client in a sitting position with head tilted
Tightly close the nostrils with gauze to apply pressure to the source of the bleeding
Squeeze the soft underside of the nose for at least 5 minutes.
Apply ice packs to the forehead and neck.
A client underwent a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measure in the immediate postoperative period for the nurse is:
A patient with Addison's disease was admitted with a history of nausea and vomiting within the past 3 days. Client receives intravenous glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse perform?
Blood glucose readings as ordered
Monitored sodium and potassium levels
A client had a total thyroidectomy yesterday. The client complains of tingling in her mouth and fingers and toes. What would the nurses do next?
Get a bumper car
Check calcium levels
Check dressing for drainage.
Assess blood pressure for high blood pressure
A 32-year-old woman, mother of three, is taken to the hospital. He has a heart rate of 52, a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses has the highest priority?
Limited physical mobility associated with reduced stamina
Hypothermia r/t decrease in metabolic rate
Altered thought processes r/t interstitial edema
Decreased cardiac output r/c bradycardia
A client arrives at the clinic with a serum cholesterol of 275 mg/dL and is receiving rosuvastatin (Crestor). What instruction should be given to the customer?
Report muscle weakness to your doctor.
Wait six months for the medicine to take effect.
Take the medicine with fruit juice.
Ask your doctor to do a complete blood count before you start taking this medicine.
Client is hospitalized with hypertensive crisis. Diazoxide (Hyperstat) is ordered. During administration, the caregiver should:
Use an infusion pump
Check blood sugar level
Place the client in the Trendelenburg position
Cover the solution with aluminum foil.
The 6-month-old patient with a ventral septal defect is receiving digitalis to regulate his heart rate. What findings should be reported to the physician?
blood pressure of 126/80
110 mg/dL blood sugar
Heart rate of 60 bpm
Respiratory rate of 30 per minute
A client hospitalized with angina receives a prescription for nitroglycerin. The customer must be instructed:
Replenish your supply every 3 months
Take one every 15 minutes if pain occurs
Leave the medicine in the brown bottle.
Crush the medicine and take it with water.
The customer is informed about low-fat and low-cholesterol foods. Which diet options are the lowest in saturated fat?
pasta with cheese
shrimp with rice
peito de peru
The patient is admitted with left-sided heart failure. When evaluating the patient for edema, the caregiver should check for the following:
The nurse checks the patient's central venous pressure. The caregiver should reset the pressure gauge at the following points:
The doctor prescribes simultaneous administration of lisinopril (Zestril) and furosemide (Lasix) to the patient with hypertension. The nurse must:
order of questions
administer the medication
Please contact the pharmacy
The best way to assess the amount of peripheral edema is:
Daily weighing of customers
measuring the member
Measure inflow and outflow
Check for bites
A patient with vaginal cancer is treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain:
Family overnight stays are against hospital policy.
You don't have to stay because the team is enough.
His wife will rest much better knowing he's home.
The visit is limited to 30 minutes after implant placement.
A nurse attends to a patient who has been hospitalized with a facial stroke. What diet options would be appropriate for the client?
Roast beef sandwich, fries, pickle skewers, iced tea
Pea soup, mashed potato, pudding, milk
Tomato soup, cheese toast, gelatin, coffee
Burgers, Baked Beans, Fruit Cups, Iced Tea
The doctor prescribed Novalog insulin to a patient with diabetes mellitus. Which statement indicates that the client knows when the insulin effect peaks?
"I'll make sure I eat breakfast 10 minutes after I take my insulin shot."
"I'm going to have to have candy or some kind of sugar with me at all times."
"I'll have a snack around three every afternoon."
"I can save my dinner dessert for a bedtime snack."
The nurse teaches a group of new parents basic baby care. The nurse should explain that sponge bath is recommended in the first 2 weeks of life because:
New parents need time to learn how to hold their baby.
The umbilical cord takes time to detach.
Newborn skin is easily traumatized by washing.
The chance of the baby catching a cold outweighs the benefits of the bath.
A patient with leukemia is given trimetrexate. After reviewing the patient's medical history, the doctor prescribes Wellcovorin (leucovorin calcium). The reason for administering leucovorin calcium to a patient receiving trimetrexate is:
Treat iron deficiency anemia caused by chemotherapy drugs
Creates a synergistic effect that reduces treatment time
Increase the number of circulating neutrophils
Reverses drug toxicity and prevents tissue damage.
A 4-month-old boy is taken to the Well-Baby Clinic to be vaccinated. In addition to the DPT and polio vaccines, the baby should receive:
Hepatitis B vaccination
The doctor prescribed Nexium (esomeprazole) for a patient with erosive gastritis. The nurse should administer the medication:
30 minutes before meals
at every meal
In a single dose before bedtime
30 minutes after meals
A client in the psychiatric ward has an out-of-control rage and threatens other clients and staff. What is the most appropriate action for the caregiver to take?
Call security for help and be prepared to calm the customer down.
Tell the customer to calm down and ask if he wants to play cards.
Tell the customer that if he continues with his behavior he will be punished.
Leave the client alone until he calms down.
When the nurse examines the fundus of a client's eye on the first day after birth, she finds that the fundus is fixed, at the level of the navel, and shifted to the right. The next action the caregiver should take is:
Examine the client for bladder distention.
Assess blood pressure for hypotension
Determine if oxytocin was given
Check the expulsion of small blood clots
A client is hospitalized with a temperature of 30°C, complaints of bloody hemoptysis, fatigue, and night sweats. The client's symptoms are consistent with a diagnosis:
Response to antiviral drugs
Superinfection due to low CD4 count
The client is seen at the clinic for migraine treatment. The client receives the drug Imitrex (sumatriptan succinate). Which of the following cases in the client's medical history should be reported to the physician?
Angina de Prinzmetal
The patient with suspected meningitis is admitted to the department. The doctor will do an examination to look for meningeal irritation and inflammation of the spinal nerve roots. A positive Kernig's sign is recorded when the caregiver observes:
Pain when bending the hip and knee
Neck stiffness when the neck is flexed
Pain when turning the head to the left side
Dizziness when changing position
A client with Alzheimer's disease is being assisted in activities of daily living when the caregiver notices that the client is using a toothbrush to brush her hair. The nurse is aware that the client has:
The client with dementia feels confused in the late afternoon and before going to sleep. The nurse is aware that the client is experiencing what is known as:
The confused customer says to the nurse, "I haven't had anything to eat all day. What time do you have breakfast?" The nurse saw the client having breakfast with other clients in the common room 30 minutes before this interview What is the best answer the caregiver can give?
"You know you had breakfast 30 minutes ago."
"I'm sorry they didn't bring you breakfast. I'll let the head nurse know."
"I'm going to get some juice and toast. Do you want anything else?"
"You'll have to wait a bit, lunch will be here soon."
The doctor prescribed Exelon (rivastigmine) for the client with Alzheimer's disease. What side effect is most commonly associated with this medication?
headache(Video) NCLEX Practice Quiz about Maternal and Child Health Nursing
A customer is included in the unit of work and delivery in active work. During the examination, the nurse notices a papular lesion on the perineum. Which first step makes the most sense?
document the discovery
Report the findings to the physician.
Preparing the client for a cesarean section
Continue with basic care as indicated
Which of the following is a patient at risk when diagnosed with HPV?
In the initial consultation, the client reports that she has a perineal lesion. Closer examination reveals a small blister on the vulva that is painful to the touch. The nurse is aware that the most likely source of injury is:
A client at a family planning clinic suspects he has an STD. The best diagnostic test for Treponema pallidum is:
Venereal Disease Research Laboratory (VDRL)
Rapid Plasma Reagin (RPR)
Fluorescent Treponemal Antibody (FTA)
A 15-year-old eldest child was admitted with a suspected diagnosis of HELLP syndrome. What laboratory finding is associated with HELLP syndrome?
high blood sugar
Increased platelet count
Increased creatinine clearance
Elevated liver enzymes
Nurse evaluates deep tendon reflexes in a patient with pre-eclampsia. What method is used to trigger the biceps reflex?
The nurse places the thumb on the muscle attachment in the antecubital space and taps the thumb vigorously with the reflex hammer.
The nurse lets the patient's arm loose with an open hand while tapping the back of the patient's elbow.
The caregiver instructs the client to swing the legs while tapping the area below the kneecap with the blunt side of the reflex hammer.
The nurse instructs the client to place her arms loosely at her sides while the nurse touches the muscle insertion just above the wrist.
A first-born with diabetes is admitted to the labor and delivery unit at 34 weeks of gestation. Which medical prescription should the nurse question?
Magnesium sulfate 4 g (25%) IV
Bretina 10 mcg i.v.
Stadol 1 mg IV booster every 4 hours as needed for pain
Ancef 2 g IVPB every 6 hours
In diabetic multiples, amniocentesis is scheduled at 32 weeks of gestation to determine the L/S ratio and phosphatidylglycerol levels. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse's assessment of these data is:
The child has a low risk of birth defects.
The baby is at high risk of intrauterine growth retardation.
The baby is at high risk of respiratory distress syndrome.
The child is at high risk of birth trauma.
What observation in the newborn of a diabetic mother would require immediate nursing intervention?
The nurse caring for a patient receiving intravenous magnesium sulfate must be alert to the side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
Lack of knee reflex
Decreased respiratory rate
The client opted for an epidural to relieve her labor pains. If the client is hypotensive, the caregiver:
Place them in the Trendelenburg position
Decrease IV infusion rate
Administer oxygen through a nasal cannula.
Increase IV infusion rate
A client has pancreatic cancer. What is the nursing diagnosis that nurses should be most concerned about?
change in diet
Change in intestinal excretion
change in skin integrity
Coping individual ineficaz
The nurse attends to a patient with ascites. What is the best method for determining the early stages of ascites?
Inspect the abdomen for enlargement.
Bimanual palpation for hepatomegaly
Daily measurement of waist circumference.
Evaluation of a liquid wave
The customer goes to the emergency room after a car accident. The nursing assessment results include blood pressure 80/34, pulse 120, and respiration 20. What is the most appropriate priority nursing diagnosis for the patient?
Change in blood flow to brain tissue
fluid volume depletion
Ineffective airway clearance
change in sensory perception
A home nurse visits an 18-year-old boy with osteogenesis imperfecta. What information obtained during the visit would be of most concern? The client:
likes to play football
Drink several carbonated drinks a day.
He has two sisters with sickle cell disease.
Take paracetamol to control the pain.
The nurse at the organ transplant unit sees a client with a white blood cell count of During the evening visit, a visitor brings a basket of fruit. What attitude should the caregiver take?
Allow the customer to keep the fruit.
Place the fruit next to the bed so the client can easily reach it.
Offer to wash the fruit for the customer
Tell family members to take the fruit home.
The nurse is caring for the patient after a laryngectomy when the patient is suddenly unresponsive, pale, and has a systolic blood pressure of 90/40. The caregiver's first action should be:
Place the client in the Trendelenburg position
Increase dextrose infusion in normal saline
Administer atropine intravenously.
Move the ambulance to the side of the bed.
Client, admitted 2 days earlier with pulmonary resection, accidentally removes the chest tube. Which nurse's action indicates understanding of chest drain management?
Request a chest X-ray
reinstall the tube
Cover the insertion site with vaseline gauze.
call the doctor
A patient taking warfarin sodium has a protime of 120 seconds. Which intervention should be most prominently included in the plan of care?
Look for signs of abnormal bleeding
Wait for an increase in Coumadin dosage
Inform the client about drug therapy.
Increase the frequency of neurological exams
Which option would provide the client with more calcium at month 4?
a granola bar
a bran muffin
a cup of yogurt
A glass of fruit juice
The client with pre-eclampsia comes into the department with a prescription for magnesium sulfate. Which caregiver action indicates understanding of the possible side effects of magnesium sulfate?
The nurse places a sign above the bed telling her not to take the pressure in her right arm.
The caregiver places a padded tongue depressor next to the bed.
The nurse inserts a Foley catheter.
The nurse darkens the room.
A 6-year-old patient is admitted to the department with a hemoglobin level of 6 g/dl. The doctor prescribed a transfusion of 2 units of whole blood. Discussing the treatment, the boy's mother tells the nurse that she does not believe in blood transfusions and will not allow her son to be treated. What are the most appropriate maintenance measures?
Ask the mother to leave while the blood transfusion is in progress.
Encourage the mother to reconsider
Explain the consequences without treatment.
Notify the physician of the mother's refusal.
A customer enters the unit 2 hours after an explosion burns his face. Would the nurse be most concerned with which of the following developments does the client develop?
A nurse assesses the nutritional outcomes of an elderly patient with bulimia. What data best demonstrates that the care plan is effective?
The customer chooses a balanced diet from the menu.
The client's hemoglobin and hematocrit improve.
The client's tissue turgidity improves.
The client gains weight.
The client is admitted after repairing a fractured tibia and applying a cast. Which nursing assessment should be reported to the physician?
pain under the cast
Weak and fast pedal pulses
paresthesia two fingers
The client has an arteriogram. During the procedure, the client says to the nurse, "I'm too hot." Which answer would be the best?
"You're having an allergic reaction. I'm going to order some Benadryl."
"That warm sensation is normal when the dye is injected."
"That warm sensation indicates that the clots in the coronary arteries are dissolving."
"I'm going to tell your doctor and ask him to explain why you're feeling hot."
The nurse observes several nurses in attendance. What nursing staff actions indicate the need for additional training?
The nursing assistant wears gloves during the client's bath.
The nurse wears safety glasses when drawing blood from the patient.
The doctor washes his hands before examining the client.
The nurse wears gloves to measure the patient's vital signs.
The client is receiving electroconvulsive therapy to treat major depression. Which of the following statements indicates that the client's ECT was effective?
The client loses consciousness.
The customer vomits.
The client's ECG indicates tachycardia.
The client is having a grand mal seizure.
The 5-year-old boy is being tested for enterobiasis (worms). To collect a sample to test for pinworms, the nurse should teach the mother:
Examine the perianal area with a flashlight 2 to 3 hours after the child falls asleep
Scrape the skin with a piece of cardboard and take it to the clinic.
Get a stool sample in the afternoon.
Bring a hair sample to the clinic for analysis.
The nurse teaches the mother about the treatment of enterobiasis. What guidelines should be given regarding medication?
Treatment is not recommended for children under 10 years of age.
The whole family must be treated.
Drug therapy is continued for 1 year.
Intravenous antibiotic therapy is ordered.
The Registered Nurse does the tasks for the day. Which client should be assigned to the pregnant nurse?
Customer receiving radiation therapy with linear accelerator for lung cancer
The client with a radium implant for cervical cancer
The client who just received soluble brachytherapy for thyroid cancer
The customer who came back after getting iridium seeds for prostate cancer
The nurse plans the room assignments for the day. Which customer should be assigned a private room if there is only one available?
The client with Cushing's disease
The customer with diabetes
The client with acromegaly
The client with myxedema
Nurse caring for a patient in the NICU administers adult digitalis to the 3-pound baby. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse may be responsible for:
What task should the licensed practical nurse not perform?
Foley catheter insertion
nasogastric tube removal
obtaining a sputum sample
start a blood transfusion
The patient returns to the operating room with a blood pressure of 90/50, a pulse of 132, and a respiration of 30. Which caregiver actions should take precedence?
Monitoring of vital signs continues
contact the doctor
Ask the customer how he feels
Ask LPN to continue post-operative care
Which caregiver should be assigned to the postpartum client with preeclampsia?
The newborn with 2 weeks of postpartum experience
Nurse with 3 years of experience in labor and delivery.
Nurse with 10 years of experience in surgery.
The Nurse with 1 year of experience in the NICU
What information should be reported to the State Department of Nursing?
This property does not offer literature in Spanish and English.
The narcotics count has been incorrect on the device for the past 3 days.
The client does not receive a breakdown of his bills and services received during his stay.
The nursing assistant assigned to care for the patient with hepatitis refuses to feed and bathe him.
The nurse is suspected of recording the administration of medication that she did not give. After speaking with the nurse, the duty nurse should:
call the nursing staff
Provide a formal reference
leave the nurse
Accuse the nurse of a mistake
The house nurse plans the day's visits. Which customer should be served first?
The 78-year-old man who had a gastrectomy 3 weeks ago and has a PEG tube
The 5-month-old boy was discharged 1 week ago with pneumonia being treated with amoxicillin liquid suspension
A 50-year-old man with MRSA is being treated with vancomycin through a PICC line
A 30-year-old man with an exacerbation of multiple sclerosis is treated with cortisone through a central venous catheter
The emergency room is flooded with patients injured in a tornado. Which customers can get room in the emergency room during a disaster?
A schizophrenic client with visual and auditory hallucinations and the client with ulcerative colitis
The 6-month pregnant client with abdominal pain and the female client with facial lacerations and a broken arm
A child with fixed and dilated pupils and their parents, and a client with a frontal head injury
The client who arrives with a big stab wound to the abdomen and the client with chest pains
The nurse takes care of a 6-year-old patient who was admitted with a diagnosis of conjunctivitis. Before administering the drops, the caregiver should recognize that it is important to consider the following?
Before instilling the eye drops, the eye should be washed with warm water and any discharge removed.
The child should be allowed to instill his own eye drops.
The mother must be allowed to instill the eye drops.
If the eye is free of redness or swelling, the eye drops should be withheld.
The nurse discusses meal planning with the mother of a 2-year-old. Which of the following statements, when made by a mother, requires the most teaching?
"It's okay to give my son white grape juice for breakfast."
"My son can have a grilled cheese sandwich for lunch."
"We're going camping this weekend and I got her some hot dogs to grill for lunch."
"For a snack, my son can have ice cream."
A 2-year-old boy is brought to the hospital. Which of the following nursing interventions would you expect?
Ask the parent/guardian to leave the room when assessments are taking place.
Ask the parent/guardian to take home the child's favorite blanket, as nothing outside should be brought into the hospital.
Ask the parent/guardian to move in with the child.
If the child cries, tell him it's inappropriate behavior.
What instructions should the customer who fits a behind-the-ear hearing aid receive?
Remove mold and clean every week.
Store the hearing aid in a warm place.
Remove lint from the hearing aid with a toothpick.
Change batteries weekly.
A priority nursing diagnosis for a child admitted for surgery after tonsillectomy is:
body image disorder
Verbal communication deficiency
A client with bacterial pneumonia is admitted to the pediatrics department. What would the nurse expect to be revealed at admission screening?
vomiting and diarrhea
Nurse assists hospitalized patient with epiglottis. Given the possibility of complete airway obstruction, which of the following should the caregiver have available?
intravenous access supplies
Pump for administration of intravenous fluids
A 25-year-old patient with Graves' disease is admitted to the department. What would the nurse expect to be revealed at admission screening?
A nurse gives nutritional advice to the mother of an 8-year-old boy diagnosed with celiac disease. Which of the following foods, if chosen by the mother, would indicate that she understood the dietary instructions?
Ham Sandwich on Wholegrain Toast
spaghetti and meatballs
hamburger with ketchup
A nurse takes care of an 80-year-old man with chronic bronchitis. During morning rounds, the nurse finds an O2Sat 76%. Which of the following actions should the caregiver take first?
notify the doctor
Check the O again2Saturation level in 15 minutes(Video) Fundamentals of Nursing NCLEX Practice Quiz
Apply oxygen through the mask.
Assess the child's pulse
A Gravida III to 0 is admitted to the maternity ward. The doctor performs an amniotomy. What observation should the nurse make after the amniotomy?
Fetal heartbeat 160 bpm
A moderate amount of straw-colored liquid.
A small amount of greenish liquid
A small segment of the umbilical cord
The client is admitted to the unit. A vaginal exam shows that she is 2 cm dilated. Which of the following statements would the nurse expect you to make?
"We have chosen a name for the baby."
"I have to push when I'm in labor."
"I can't concentrate if someone touches me."
"When can I get my epidural?"
The client has a fetal heart rate of 90110 bpm during labor. The first action the caregiver should take is:
replace the monitor
Turn the client over to the left side.
Ask the customer to leave
Prepare the customer for delivery.
When evaluating the effectiveness of i.v. Pitocin For a patient with secondary dystocia, the caregiver should expect:
a painless delivery
progressive cervical dilation
A vaginal examination reveals a superficial pelvic presentation. Which of the following actions should the caregiver take at this time?
Anticipating the need for a cesarean section
Place the fetal heart monitor
Place the client in the genu-pectoral position
do an ultrasound
Vaginal examination shows that the cervix is 4 cm dilated with intact membranes and a fetal heart rate of 160 to 170 bpm. The caregiver decides to use an external fetal monitor. The rationale for this implementation is:
The cervix is closed.
The membranes are still intact.
Fetal heart sounds are within normal limits.
The contractions are intense enough to introduce an internal monitor.
Listed below are all the appropriate nursing diagnoses for a 1 to 0 pregnant woman at the time of delivery. What would be best for the pregnant primate when she ends preterm labor?
Impaired gas exchange associated with hyperventilation
Change in placental perfusion associated with maternal position
Limited physical mobility associated with fetal monitoring devices
Possible fluid volume deficit associated with decreased fluid intake
When the client reaches 8 cm dilation, the caregiver observes the late decelerations on the fetal monitor. Baseline FHR is 165 ± 175 bpm with a variability of 0 ± 2 bpm. What is the most likely explanation for this pattern?
The baby is sleeping.
The umbilical cord is compressed.
There is a vagal reaction.
There is uteroplacental insufficiency.
The caregiver notes variable delays on the fetal monitor strip. The most appropriate first measure would be:
notify your doctor
start an IV
reposition the client
Which of the following is characteristic of a calming fetal heart rate pattern?
A fetal heart rate of 170180 bpm
A reference variability of 2535bpm
Ominous Periodic Changes
FHR acceleration with fetal movements
The reasons for inserting a french catheter every hour for the epidural client are:
The bladder fills faster because of the drugs used for epidural anesthesia.
His state of consciousness is such that he is in a trance state.
The sensation of a full bladder is reduced or lost.
He is embarrassed to ask for the potty so often.
A client at the family planning clinic asks the nurse when she is most likely to become pregnant. The nurse explains that conception is more likely when:
Estrogen levels are low.
Luteinizing hormone is high.
The lining of the uterus is thin.
Progesterone levels are low.
A client tells the nurse that she plans to use rhythmic contraception. The caregiver is aware that the success of the Rhythm Method depends on:
frequency of sexual intercourse
customer temperature range
A diabetic client asks the nurse for advice on contraception. Which contraceptive method is most suitable for the patient with diabetes?
The physician suspects that the client has an ectopic pregnancy. What symptom is consistent with the diagnosis of ectopic pregnancy?
painless vaginal bleeding
Throbbing pain in the upper quadrant
Sudden shooting pain in the lower quadrant
The nurse educates a pregnant client about nutritional needs during pregnancy. Which menu options best meet the dietary needs of the pregnant customer?
Burgers, green beans, fries and iced tea
Roast beef sandwich, french fries, beans and coke
Roasted chicken, fruit cup, potato salad, coleslaw, yogurt and iced tea
Fish rolls, fruit jam and coffee
The client with hyperemesis gravidarum is at risk of developing:
Respiratory alkalosis without dehydration
metabolic acidosis with dehydration
Respiratory acidosis without dehydration
metabolic alkalosis with dehydration
A client tells the doctor that she is 20 weeks pregnant. The most obvious sign of pregnancy is:
Elevated human chorionic gonadotropin
The presence of fetal heart sounds.
Breast augmentation and sensitivity
The nurse takes care of a newborn whose mother is diabetic. The nurse waits for the newborn:
Hypoglycemic, small for gestational age
Hyperglycemic, large for gestational age
Hypoglycemic, large for gestational age
Hyperglycemic, small for gestational age
Which of the following instructions should be included in the nurse's instructions for oral contraceptives?
Weight gain should be reported to the doctor.
An alternative method of contraception is needed when taking antibiotics.
If the client forgets one or more pills, two pills should be taken daily for 1 week.
Changes in menstrual flow should be reported to the doctor.
The nurse talks to a postpartum client about breastfeeding. Breastfeeding is contraindicated in postpartum clients with:
A client is admitted to the maternity ward complaining of vaginal bleeding with very little discomfort. The caregiver's first action should be:
Assess fetal heart sounds
Check for cervical dilation
Check the firmness of the uterus
Get Detailed History
A customer calls the emergency room and says she thinks she is going into labor. The caregiver should tell the client that labor is likely to have started when:
Your contractions are 2 minutes apart.
He has back pain and a bloody discharge.
She suffers from abdominal pain and frequent urination.
Her contractions are every 5 minutes.
The nurse teaches a group of antenatal clients about the effects of cigarette smoke on fetal development. What trait is associated with babies born to mothers who smoked during pregnancy?
low birth weight
Large for gestational age
Premature birth, but suitable size for pregnancy
Delayed growth in weight and length
The doctor has prescribed a RhoGam injection for the postpartum patient whose blood type is A negative but whose baby is O positive. For postpartum prophylaxis, RhoGam should be administered:
Within 72 hours of delivery
In 1 week after delivery
Within 2 weeks after delivery
Within 1 month after delivery
After the doctor performs an amniotomy, the first thing the caregiver should do is assess:
degree of cervical dilation
fetal heart sounds
Client's vital signs
Customer discomfort level.
A customer is added to the unit of work and delivery. The nurse performs a vaginal examination and finds that the client's cervix is 5 cm dilated and 75% obliterated. What stage of labor does the nurse think the client is in?
A newborn with narcotic withdrawal syndrome is admitted to the nursery. Newborn care should include:
Teach the mother to provide tactile stimulation.
Wrap the newborn tightly in a blanket
Placing the newborn in the carrier
Start an early childhood stimulation program
A client decides to get an epidural to ease the discomfort of childbirth. After starting the epidural, the caregiver should prioritize the following:
cervical dilation test
Place the client in a supine position
Checking the client's blood pressure.
Obtaining the fetal heart rate
The nurse is aware that the best way to prevent postoperative wound infection in the surgical patient is:
Administer a prescribed antibiotic
Wash hands for 2 minutes before combing
Use a mask when combing your hair
Ask the client to cover their mouth when they cough
The elderly client is admitted to the emergency room. What symptom is the client most likely to have with a hip fracture?
Absence of pedal impulses
The nurse knows that a 60-year-old client's susceptibility to osteoporosis is likely related to:
lack of exercise
lack of calcium
A 2-year-old boy is brought in to repair a broken femur and place him in Bryant traction. What finding by the caregiver indicates that traction is working correctly?
The baby no longer complains of pain.
The buttocks are 15° from the bed.
The legs are suspended in traction.
The pins are attached to the pulley.
A client with a broken hip was placed in Buck traction. Which statement about balanced skeletal traction is correct? Balanced Skeletal Traction:
Use um pino Steinman
Requires both legs to be secure.
Use fios of Kirschner
It is mainly used to heal broken hips.
Client is admitted for internal fixation of hip fracture with open reduction. Immediately after surgery, the nurse should prioritize the assessment of the following:
Drainage for serum collection (Davol).
What statement by the family member who provides the patient with a percutaneous gastrostomy tube indicates the nurse's understanding of teaching?
"I have to rinse the tube with water after feeding and clamp the tube."
"I have to check the location four times a day."
"I will report any signs of indigestion to the doctor."
"If my dad can't swallow, I stop feeding him and call the clinic."
The nurse examines the patient 2 hours after the operation with a total knee replacement. What information should be given to the doctor?
The bleeding on the bandage is 3 cm in diameter.
The client has a temperature of 6°F.
The client's hematocrit is 26%.
Urine output was 60 in the last 2 hours.
The nurse serves the client with a 5-year plumbing diagnosis. What information in the medical history is likely related to the development of lead sponges?
The client has traveled abroad in the last 6 months.
The client's parents are experienced glass painters.
The builder lives in a house built in 1
The client has several siblings.
A total hip replacement client requires special equipment. What devices would help the client with a total hip replacement with activities of daily living?
high seat dresser
The Kidnapping Sketch
An elderly patient undergoing abdominal surgery is admitted to the department after the operation. Anticipating complications arising from anesthesia and drug administration, the caregiver should:
Administer oxygen through a nasal cannula.
Have Narcan (naloxan) ready
Prepare to administer blood products
Prepare for cardiac resuscitation
Which roommate would be best suited for the 6-year-old boy with a broken femur in Russell's traction?
16 year old woman with scoliosis
12-year-old boy with femur fracture
10 year old boy with sarcoma
6 year old boy with osteomyelitis
A client with osteoarthritis has a prescription for Celebrex (celecoxib). What teachings should be included in the doctrine of exoneration?
Take the medicine with milk.
Report chest pain.
Remain upright for 30 minutes after eating.
Wait 6 weeks for optimal effect.
A plaster cast is applied to a patient with a broken tibia to immobilize the fracture. Which caregiver action indicates understanding of a cast? The nurse:
Hold the plaster with your fingertips.
Dry the mold with a hair dryer.
Wait 24 hours before uploading weight
The teenager in a fiberglass cast asks the nurse if his friends can sign the cast. Which answer would be the best?
"It's okay if your friends sign the cast."
"Since plaster is made of plaster, signing autographs can weaken the plaster."
"If they don't use chalk to sign autographs, that's fine."
"Signing or writing on plaster in any way damages the plaster."
The nurse is assigned to assist the client with a Steinmen needle. During needle care, you find that the LPN uses sterile gloves and cotton swabs to clean the needle. What action should the caregiver take at this time?
Assist the LPN in opening sterile packaging and peroxide
Tell LPN that clean gloves are allowed
Notify the LPN that the RN must take care of the needle
Ask the LPN to clean the weights and pulleys with hydrogen peroxide
A child with scoliosis is placed in a cast. What actions should be taken specifically for Spica plastering?
Check bowel sounds
Assess blood pressure
Check for swelling
The client with a cervical fracture is placed in traction. What type of traction is used when unloading?
Crutchfield caliper pull
A total knee replacement patient will have a CPM (Continuous Passive Motion Device) applied during the post-operative period. Which caregiver statement indicates understanding of the CPM device?
"The use of CPM allows the patient to walk during therapy."
"CPM machine controls should be placed distal to the site."
"If the client complains of pain during therapy, I turn off the device and call the doctor."
"The use of the CPM device will reduce the need for physical therapy after patient discharge."
A client with a broken hip is taught how to use the walker correctly. The caregiver is aware that correct use of the walker is achieved when:
Palms rest lightly on the handles.
Elbows are flexed to 0°
The client goes in front of the walker.
The customer carries the walker
While examining a client who is giving birth, the nurse finds a prolapsed umbilical cord. The nurse must:
try to change the cable
Lay the client on his left side(Video) NCLEX-RN Practice Test 2022 (75 Questions with Explained Answer)
Elevate the client's hips
Cover the umbilical cord with a dry, sterile gauze pad.
The nurse treats a 30-year-old man who was admitted with a stab wound. A chest tube is placed in the emergency room. Which of the following statements explains the main reason for chest tube placement?
The tube allows to compensate for pulmonary expansion.
Chest tubes serve as a method of draining blood and serous fluid and help to re-inflate the lungs.
Chest drains relieve the pain associated with a collapsed lung.
Chest drains support cardiac function by stabilizing lung expansion.
A client who gave birth this morning tells the nurse that she intends to breastfeed her baby. The caregiver recognizes that the success of breastfeeding depends more on:
baby birth weight
maternal breast size
mother's desire to breastfeed
The nurse monitors the progress of a client in labor. What findings should be reported to the doctor immediately?
The presence of scant blood flow.
The presence of green amniotic fluid.
mild uterine contractions
The nurse measures the duration of the client's contractions. Which statement about measuring the duration of contractions is correct?
Duration is measured by the time from the start of one contraction to the start of the next contraction.
Duration is measured by the time from the end of one contraction to the start of the next contraction.
Duration is measured by the time from the beginning of a contraction to the end of the same contraction.
Duration is measured by the time from the peak of a contraction to the end of the same contraction.
The doctor prescribed an intravenous infusion of oxytocin to induce labor. When caring for an obstetric patient receiving intravenous Pitocin, the nurse should monitor:
A client with diabetes arrives at the antenatal clinic at the 28th week of her pregnancy. Which statement about the need for insulin during pregnancy is correct?
Insulin needs moderate as the pregnancy progresses.
Reduced insulin requirements occur during the second trimester.
Elevations in human chorionic gonadotropin decrease the need for insulin.
Fetal development depends on proper insulin regulation.
A patient at the antenatal clinic is diagnosed with a blood pressure of 180/96. The nurse must prioritize:
Provide a peaceful environment.
Obtaining a nutritional history
administration of an analgesic
Assessment of fetal heart sounds
A 42-year-old firstborn is 6 weeks pregnant. Depending on the client's age, your child is at risk for:
A client with a missed abortion at 29 weeks of gestation is hospitalized. The customer will likely be treated with:
Dinoproston (Prostin E.)
A patient with preeclampsia received an infusion of magnesium sulfate for a blood pressure of 160/80; deep tendon reflexes are 1 more and last hour urine output is 100 ml The nurse should:
Continue the magnesium sulfate infusion while monitoring the patient's blood pressure.
Stop the magnesium sulfate infusion and contact your physician.
Decrease infusion rate and turn client to left side
Give intravenous calcium gluconate and continue to monitor blood pressure.
Which nursing statement describes the inheritance pattern of autosomal recessive disorders?
An affected newborn has unaffected parents.
An affected newborn has an affected parent.
Affected parents have a one in four chance of passing on the defective gene.
Affected parents have unaffected children who are carriers.
A 32-year-old pregnant client asks the nurse why her physician recommended serum alpha-fetoprotein. The nurse should explain that the doctor recommended the test:
Because it's a state law.
For detection of cardiovascular defects
because of his age
To detect neurological defects.
A patient with hypothyroidism asks the nurse if she needs to continue taking thyroid medication during her pregnancy. The caregiver's response is based on knowing that:
There is no need to take thyroid medication as the fetal thyroid produces thyroid-stimulating hormone.
Regulating thyroid medication is more difficult as the thyroid gland enlarges during pregnancy.
It is more difficult to maintain thyroid regulation during pregnancy due to a slowdown in metabolism.
Fetal growth will be arrested if thyroid medication is continued during pregnancy.
The nurse is responsible for performing a neonatal assessment of a full-term baby. After 1 minute, the nurse could expect:
An apical pulse of 100
lack of tone
Cyanosis of hands and feet
Jaundice of the skin and sclera
A patient with sickle cell disease is admitted to the labor and delivery unit during the first stage of labor. The caregiver should anticipate the client's need to:
A patient with diabetes has an ultrasound request. Preparing for an ultrasound includes:
Increased fluid intake
limited ability to walk
administration of an enema
Food deprivation for 8 hours.
A baby who weighs 8 kilos at birth, how many kilos should he weigh in 1 year?
A pregnant client with a history of alcohol dependence is scheduled for a stress-free trial. The stress free test:
Determine fetal lung maturity
Measure fetal activity
Shows the effect of contractions on fetal heart rate
Measures the neurological well-being of the fetus
A man born at term has hypospadias. Which statement describes hypospadias?
The urethral opening is absent.
The urethra opens on the dorsal side of the penis.
The penis is shorter than normal.
The urethra opens on the ventral side of the penis.
The working unit includes a Gravida III to II. Vaginal examination shows that the client's cervix is 8 cm dilated and completely obliterated. Currently, the main nursing diagnosis is:
change in pain control
Risk of injury associated with premature birth
Alteration in excretion associated with anesthesia
Possible fluid volume deficit associated with the NPO state
What category of medication is the client with chickenpox likely to order?
A customer comes in with chest pains. Which of the following drug prescriptions should the nurse question?
Which of the following instructions should be included in the classroom for the client with rheumatoid arthritis?
Avoid exercise as it tires the joints.
Take prescription anti-inflammatory medications with meals.
Alternate hot and cold packs on the affected joints.
Avoid weight bearing activities.
A patient with acute pancreatitis has severe abdominal pain. Which of the following commands should the caregiver question?
Meperidine 100 mg IM every 4 hours PRN pain
Mylanta 30cc every 4 hours via NG
Cimetadina 300 mg p.o. q.i.d.
Morphine 8 mg IM every 4 hours PRN pain
The client is hospitalized in the Chemical Dependency Unit with a constant observation order. The nurse knows that the physician has ordered continued observation because:
Hallucinogenic drugs produce stimulant and depressant effects.
Hallucinogenic drugs induce a state of altered perception.
Hallucinogenic drugs produce severe respiratory depression.
Hallucinogenic drugs lead to rapid physical dependence.
A client with a history of barbiturate abuse abruptly stops taking the drug. The caregiver should prioritize the client's assessment of:
depression and suicidal thoughts
tachycardia and diarrhea
muscle cramps and abdominal pain
Tachycardia and euphoric mood
When assessing a client in labor, the nurse finds that the ESFs are strongest in the upper right quadrant. What position is the child most likely to be in?
Representation of the right buttock
Anterior view of the right occiput
Left anterior sacral representation
Left occipital transverse exposure
The main physiological change in the development of asthma is:
bronchiolar inflammation and shortness of breath
Hypersecretion of abnormally viscous mucus
Infectious processes that cause edema of the mucosa.
Spasm of the smooth muscles of the bronchioles.
A manic customer can't finish dinner. To help her maintain proper nutrition, the caregiver should:
Serve high-calorie foods that she can take with her
Stimulate your appetite by ordering your favorite food
Serve small, well-distributed portions.
Allow him to be in the unit's kitchen for extra food whenever he wants
To maintain Bryant traction, the nurse must ensure that the child:
Hips rest on the bed, legs hang at right angles to the bed.
The hips are slightly raised above the bed, and the legs hang at right angles to the bed.
The hips are raised above body level on a pillow, and the legs hang parallel to the bed.
Hips and legs rest on the bed with traction positioned at the foot of the bed
Which caregiver action indicates understanding about herpes zoster?
The nurse covers the wounds with a sterile dressing.
The nurse wears gloves during breastfeeding.
The nurse administers a prescribed antibiotic.
The nurse administers oxygen.
The customer has an order to place a drop on the customer who is receiving vancomycin. The nurse knows that she must contact the laboratory to collect blood:
15 minutes after infusion
30 minutes before infusion
1 hour after infusion
2 hours after infusion
The patient using a diaphragm must be instructed:
Avoid keeping the diaphragm longer than 4 hours
Store the diaphragm in a cool place.
Have Your Diaphragm Resized If You Gain 5 Pounds
Make the diaphragm shrink when you have surgery.
The nurse teaches a puerperal woman who wants to breastfeed her child. Which of the client's statements indicates the need for further instruction?
"I'm wearing a supportive bra."
"I'm pumping milk from my breast."
"I drink four glasses of liquid in 24 hours."
"While I shower, I let the water run down my breasts."
Damage to cranial nerve VII leads to:
Lack of ability to smell.
lack of eye movements
A client is receiving Pyridium (phenazopyridine hydrochloride) for a urinary tract infection. The client should be taught that the drug:
Change the color of your urine.
cause mental confusion
cause changes in taste
Which of the following tests should be done before starting an Accutane prescription?
Check calcium levels
Take a pregnancy test
Monitor the apical pulse
Get a creatinine level
A patient with AIDS takes Zovirax (acyclovir). Which nursing intervention is most critical during acyclovir administration?
Limit customer activity
Promote a high-carbohydrate diet.
Use an incentive spirometer to improve respiratory function
A client is admitted for an MRI. The caregiver should ask the client about:
A hip prosthesis made of titanium.
inability to move the feet
The nurse cares for the patient receiving amphotericin B. What indicates that the patient is toxic to this drug?
skin color changes
Which of the following clients should the caregiver visit first?
The client with diabetes with a blood sugar level of 95 mg/dL
The hypertensive patient maintained with lisinopril
The client with chest pain and a history of angina.
The client with Raynaud's disease
A patient with cystic fibrosis takes pancreatic enzymes. The nurse should administer this medication:
Once a day in the morning
Three times a day with meals.
Once a day before going to bed
Four times a day
Cataracts cause the lens of the eye to become cloudy. Which of the following statements best explains the characteristics of the lens?
The lens controls retinal stimulation.
The lens orchestrates eye movement.
The lens focuses light rays onto the retina.
The lens magnifies small objects.
A patient with glaucoma should have miotic drops instilled in both eyes. The nurse knows that the purpose of the medicine is:
dilate the pupils
Paralyze accommodated muscles.
A customer with a severe corneal ulcer placed an order for Gentamicin gtt. q 4 hours and neomycin 1 gtt q 4 hours. Which of the following schemes should be used when administering the drops?
Wait 5 minutes between the two medications.
Drugs can be used together.
The drugs must be separated by a cycloplegia drug.
Medicines must not be used on the same client.
The colorblind customer will likely have trouble distinguishing which of the following colors.
The client with a pacemaker should learn the following:
Report ankle edema
Check your blood pressure daily
Refrain from using a microwave oven
Monitor your heart rate
The client with enuresis is instructed in bladder training. The caregiver should advise the client to refrain from drinking after:
one thousand and nine hundred
Which of the following dietary instructions should the client with recurrent urinary tract infections receive?
Increase meat consumption.
Avoid citrus fruits.
Perform pericare with hydrogen peroxide.
Drink a glass of cranberry juice every day.
The doctor prescribed NPH insulin for a patient with diabetes mellitus. Which statement indicates that the client knows when the insulin effect peaks?
"I will make sure to eat breakfast within 2 hours of the insulin injection."
"I'm going to have to have candy or some kind of sugar with me at all times."(Video) NCLEX-RN REVIEW PRACTICE TEST 2021 | NCLEX QUESTION AND ANSWER TEST | NCLEX test with rationales
"I'll have a snack around three every afternoon."
"I can save my dinner dessert for a bedtime snack."
A patient with Pneumacystis carini pneumonia is receiving trimetrexate. The reason for administering leucovorin calcium to a patient receiving methotrexate is:
Create a synergy effect.
Increase white blood cell count.
Reverse drug toxicity.
A client tells the nurse that she is allergic to eggs, dogs, rabbits and chicken feathers. What arrangement should the caregiver question?
The doctor prescribed Rantidin (Zantac) to a patient with erosive gastritis. The nurse should administer the medication:
30 minutes before meals
at every meal
In a single dose before bedtime
60 minutes after meals
A temporary colostomy is performed in patients with colon cancer. Is the caregiver aware that the proximal end of a double-barrel colostomy:
It is the opening on the left side of the customer
The opening at the distal end of the client's left side
It is the opening on the right side of the customer
It is the opening on the right distal side
When assessing the postpartum woman, the nurse observes that the fundus is deviated to the right. Based on this finding, the caregiver should:
Ask the customer to cancel
Assess blood pressure for hypotension
Beware of Vaginal Bleeding
The doctor ordered an MRI for a patient with an orthopedic condition. An MRI should not be performed if the client:
The need for oxygen therapy
A story of claustrophobia
a permanent pacemaker
A 6-month-old client is placed on bed rest after hernia repair. Which toy is best for the customer?
colorful crib mobile
handheld electronic games
cars in a plastic container
jigsaw puzzle 30 pieces
The nurse prepares to discharge a client with a long history of polio. The nurse should tell the client that:
A warm bath reduces stiffness and spasticity.
A strenuous exercise program improves muscle strength.
Rest periods should be scheduled throughout the day.
Visual disturbances can be corrected with prescription glasses.
A client in the postpartum ward has a proctoepisotomy. Which medication should the nurse administer?
Bromocriptine sulfate (Parlodel)
A patient with pancreatic cancer receives an infusion of TPN (Total Parenteral Nutrition). The doctor prescribed sliding insulin. The most likely explanation for this order is:
Total parenteral nutrition results in negative nitrogen balance and elevated glucose levels.
Total parenteral nutrition cannot be controlled with oral hypoglycaemia.
Total parenteral nutrition is a high-glucose solution that often raises blood sugar levels.
Total parenteral nutrition leads to other diseases of the pancreas.
A primiparous teenager, at 10 weeks of gestation, visits the antenatal clinic for a first evaluation. To develop a lesson plan, the caregiver must first assess:
Client knowledge of signs of preterm labor.
The client's feelings about the pregnancy.
If the client is using any contraceptive method
The client's thoughts about future children.
An obstetric client is admitted with dehydration. Which IV fluid would be best for the client?
0.45 normal saline solution
1% dextrose in water
5% dextrose in normal saline 0.45
The doctor ordered a thyroid test to confirm the diagnosis. Before the procedure, the nurse must:
Check the client for allergies.
Bole for the client with IV fluid
Tell the customer to go to sleep
Insert a urinary catheter
The doctor prescribed an injection of RhoGam to a patient with negative blood group A. The nurse understands that RhoGam is given to:
Provides immunity to Rh isoenzymes
Prevents the formation of Rh antibodies
Eliminates circulating Rh antibodies
Convert the Rh factor from negative to positive
A nurse attends to a patient admitted to the emergency room after a fall. X-rays show that the client has multiple fractures in the foot. What treatment should the caregiver expect for a fractured foot?
Application of a short inclusive spica mold
Kirschner Wire Deployment Operation
Just a gauze bandage
A client with bladder cancer is treated with iridium seed implants. The nurse's discharge report should include encouraging the client to:
sift your urine
Increase fluid intake.
Indicate the frequency of urination
Avoid sitting for prolonged periods
After a heart transplant, the patient is given drugs to prevent heart rejection. What class of drugs prevents the formation of antibodies against the new organ?
The nurse prepares a client for cataract surgery. The nurse is aware that the procedure is used:
Mydriatics for easy removal
Miotic drugs like Timoptic
A laser to smooth and reshape the lens.
Silicone oil injections into the eyeball.
A client with Alzheimer's disease expects to be admitted to a specialist clinic. What long-term plans would be most therapeutic for the client?
Installation of mirrors in various places in the house.
Put a picture of yourself in the room.
Place simple signs to indicate the location of the bedroom, bathroom, etc.
Rotate healthcare professionals to avoid boredom
A patient with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt tube. The primary purpose of the Jackson-Pratt drain is:
Eliminates the need for dressing changes.
Reduce swelling in the incision.
Provide wound drainage.
Keep the bile duct open
The nurse performs an initial assessment of a Caucasian male newborn who was born at 32 weeks of gestation. The caregiver can expect the following:
The nurse takes care of a client hospitalized with polytrauma. Fractures include the pelvis, femur and ulna. What findings should be reported to the doctor immediately?
A customer is taken to the emergency room by the police. He is combative and yells, "I have to get out of here. They are trying to kill me." Which assessment is closest to this statement?
The client experiences an auditory hallucination.
The client suffers from megalomania.
The client suffers from paranoid delusions.
The customer is drunk.
The nurse prepares the suction of the patient with a tracheostomy. The nurse notices a previously used saline bottle on the patient's bedside table. There is no label showing date or time of first use. The nurse must:
Cap the bottle and use a sterile 4x4 pack for the dressing.
Get a new bottle and label it with the date and time it was first used.
Ask the room secretary when the resolution was requested
Label the existing bottle with the current date and time
A baby's Apgar score is 9 at 5 minutes. The caregiver is aware that the most likely cause for a point deduction is:
The baby is cold.
The baby suffers from bradycardia.
The baby's hands and feet are blue.
The baby is lethargic.
The main reason for rapid and continuous rewarming of the area affected by frostbite is:
Decrease the amount of cellular damage.
promote the movement
Prevent pain and discomfort
A patient who has recently started hemodialysis wants to know how dialysis will replace his kidneys. The nurse's answer is based on the knowledge that hemodialysis works by:
Passage of water through a dialysis membrane
Removal of plasma proteins from the blood.
Lower pH by removing non-volatile acids
Filtering waste through a dialysis membrane
During a home visit, an AIDS patient tells the nurse that he has been exposed to measles. Which caregiver action makes the most sense?
Administer an antibiotic
Contact your doctor to order immunoglobulins
Administer an antiviral
Tell the client to self-isolate for 2 weeks
A hospitalized patient with MRSA (methicillin-resistant Staphylococcus aureus) is given contact protection measures. Which statement is true about precautions for contact-borne infections?
The client must be placed in a negative pressure room.
Infection requires close contact; therefore, the door can remain open.
Transmission is very likely, so the customer must wear a mask at all times.
Infection requires skin-to-skin contact and is prevented by washing hands, gloves, and apron.
A client who comes in with a transfemoral amputation tells the caregiver that his foot hurts and itches. Which caregiver response indicates that he understands phantom pain?
"The pain will pass in a few days."
“The pain is due to alterations in the peripheral nervous system. I'll get you some painkillers."
"The pain is psychological because your foot is gone."
"The pain and itchiness are due to the infection I had before the surgery."
A patient with pancreatic cancer underwent a Whipple procedure. The nurse is aware that during the Whipple procedure the doctor will remove:
Third proximal section of small intestine
stomach and duodenum
esophagus and jejunum
The physician prescribed a low-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:
A client is discharged with a prescription for Coumadin (sodium warfarin). The customer must be instructed:
Have a monthly protime
Eat more fruits and vegetables
drink more fluids
Avoid the crowds
The nurse helps the doctor to remove a central venous catheter. To facilitate removal, the caregiver should instruct the patient:
Perform the Valsalva maneuver while advancing the catheter
Turn your head to the left and hyperextend your neck.
Inhale slowly and deeply as the catheter is withdrawn.
Turn your head to the right while maintaining a sniffing position.
A customer has an order for streptokinase. Before administering medication, the caregiver should examine the patient for the following:
Pineapple and banana allergy
History of streptococcal infections.
Prior therapy with phenytoin
A history of alcohol abuse
The nurse gives discharge classes to the client with leukemia. The client must be instructed to avoid:
Use of oil or cream based soaps.
dental floss between teeth
With an electric shaver
The nurse changes the client's restrictions with a tracheostomy. The safest way to change tracheostomy bands is:
Put on the new tie before removing the old one.
Bring a helper.
Hold the tracheostomy in your non-dominant hand while removing the old tie.
Ask the doctor to sew up the tracheostomy.
The nurse supervises a patient after a lung resection. The chest tube output per hour was 300 mL The nurse should prioritize:
Turn the client over to the left side.
Milk the probe to ensure patency
Delay of intravenous infusion
The child is admitted to the unit due to Tetralogy of Falot. The nurse is waiting for a prescription for which medication?
Nurse trains Ladies Club in breast self-examination. The nurse is aware that most malignant breast tumors occur in Spence's tail. Put an X on Spence's tail on the diagram.
The boy is admitted with a heart abnormality. The nurse knows that the baby with a ventricular septal defect:
gets tired easily
you need more calories
Being more prone to viral infections.
The nurse supervises a client with a history of stillbirths. The nurse understands that an effortless test may be ordered for this client to:
Determine lung maturity
measure fetal activity
Demonstrate the effect of contractions on fetal heart rate
Measuring the well-being of the fetus
The nurse is examining the client who was admitted for labor induction 8 hours ago. The following graph is recorded on the monitor. What action should the caregiver take first?
Tell the customer to push
do a vaginal exam
Turn off the oxytocin infusion
Place the client in a semi-Fowler position
The nurse observes the following on the EKG monitor. The nurse would assess the arrhythmia as follows:
a sinus rhythm
A client with a coagulopathy is advised to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the patient that Lovenox injections:
To be injected into the deltoid muscle
To be injected into the abdomen
After injection, aspirate
Before injecting, remove the air from the syringe.
The nurse is preoperatively ordered to administer Valium (diazepam) 10 mg and Phenergan (promethazine) 25 mg. The correct method of administering these medications is:
Administer the medications together in one syringe.
Administer medication separately.
Administer the Valium, wait 5 minutes, then inject the Phenergan
Question the command because they cannot be given at the same time
A client with frequent UTIs asks the nurse how to prevent recurrence. The caregiver should teach the client:
shower after intercourse
Empty every 3 hours
Have a urine test monthly
After emptying, wipe from back to front.
What task should be assigned to the nursing assistant?
Client accommodation in isolation.
Foley catheter drainage in a patient with preeclampsia
Dementia client diet
Hip Fracture Outpatient Clinic
The client recently returned from a thyroidectomy. Which of the following items should the caregiver have at the bedside?
A tracheostomy kit
A padded tongue sheet
an endotracheal tube
The physician ordered a histoplasmosis test for the elderly client. The caregiver is aware that histoplasmosis is transmitted to humans by:
turtles(Video) NCLEX QUESTIONS AND ANSWERS, Nclex 2022, NCLEX RN Exam | NCLEX HIGH YIELD | NCLEX Review, QBankPro#2
Does 145 questions on NCLEX mean you failed? No, if you answer all 145 questions on the NCLEX, that does not mean you fail. In fact, if you answered 145 questions and each question was progressively more challenging, then that is a good sign that you passed.How do I pass the NCLEX-RN 2022? ›
- Give Yourself Sufficient Time to Prepare. ...
- Familiarize Yourself with the Test Structure. ...
- Learn the Types of Questions. ...
- Take Practice Tests. ...
- Develop Test-Taking Strategies. ...
- Create a Robust Study Plan. ...
- Hone Your Stress Management Skills. ...
- Prepare for Exam Day.
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Dedicated to nursing education, ATI (Assessment Technologies Institute) focuses on the quality of NCLEX review packages it offers. Its Virtual-ATI + BoardVitals program boasts a 99% pass rate for NCLEX-RN takers and 100% for NCLEX-PN.
Practice exams are absolutely the best and most important way to prepare – HOWEVER – simply taking the practice exam questions is only half of the process. It is just as important to: Look up questions that you answered incorrectly.What are signs you failed the NCLEX? ›
- Questions at random difficulty.
- The exam shuts off.
- Lots of easy questions.
- Running out of time before minimum required questions.
- Bad pop-up from the Pearson Vue NCLEX Trick.
- Pearson Vue Quick Results Service says you failed.
- Your name and license number don't appear on the state board.
Yea it can potentially turn off at 75 questions if you've gotten a certain amount wrong. The NCLEX works with an algorithm of questions, asking questions that are harder as you go and bases each question on If you answered the last question correctly.Do you need 50% on NCLEX to pass? ›
How the 2022 NCLEX is Scored. The NCLEX is scored using dichotomous scoring, so you can either pass or fail the exam. Currently, to pass the NCLEX-RN, the standard is 0.00 logits–or answer questions correctly at least 50% of the time.How do I pass NCLEX after failing 3 times? ›
If they fail, they'll need to wait 45 days before retesting. After failing three times, though, they'll need to complete a board-approved remediation program before the next retake. Candidates have six attempts to pass in total.Can I study for NCLEX in 2 weeks? ›
So, you're about to take the NCLEX, don't sweat you are in great hands with UWorld. I gave myself TWO weeks to study and I passed the NCLEX with 75 questions.Does NCLEX get harder the more times you take it? ›
Does NCLEX-RN Get Harder with Every Retake After Failing? Some candidates mistakenly believe that the NCLEX is harder each time. Questions become more challenging with each correct answer you provide on the NCLEX. However, subsequent tests are not easier or more difficult than previous exams.
While it's possible to pass the NCLEX after answering all 145, it's also possible to pass the test with a minimum of 60 questions or any number in between. Keep in mind NCLEX has a time limit of five hours. If you haven't answered enough questions correctly when the clock runs out, you will fail the test.What are the harder questions on the NCLEX? ›
Each category of questions requires an increasing level of critical thinking skills. Analysis, synthesis and evaluation questions would be considered higher-level NCLEX questions. Synthesis questions are based on creating or proposing solutions, such as a plan of care.How many NCLEX practice questions should I do a day? ›
Practice Questions: Set a Goal
We recommend that you complete about 2,800 practice questions before your exam. If you are giving yourself a month to study, that means that you would be doing about 100 NCLEX practice questions per day.
Many people take the NCLEX after prepping with ATI, but pass the NCLEX with 75 questions. The “passing rate” on NCLEX is adaptive, but many state that if you pass at least 50-60% of the questions on ATI test banks, then you will pass the NCLEX.How can I quickly pass NCLEX? ›
- Go to your candidate profile, candidates will need to sign in with their username and password.
- Under "My Account," select "Quick Results"
- If your results are available, you may click on the "Purchase" button. ...
- Fill in the payment information and click Next.
On the NCLEX® examination, test takers will see a minimum of 75 questions and a maximum of 265 (145 maximum due to new COVID-19 policies). The NCLEX® examination is taken through Computer Adaptive Testing (CAT). During the five-hour examination, test takers will be offered two optional breaks.Does the Pearson VUE trick always work? ›
Does the Pearson Vue NCLEX Trick Work? The NCLEX trick is not 100% accurate. Some students have reported getting “a bad pop-up” when they passed and getting “the good pop-up” when they failed.Is it common to fail the NCLEX the first time? ›
From 2016 to 2020, an average of 21,553 NCLEX-RN candidates failed the exam on their first attempt each year. In 2016, more than 24,000 test-takers were unsuccessful. Although that number decreased in 2017 and 2018, first-time failure rates increased in 2019 and 2020 to 20,258 and 23,826, respectively.How do I know if I passed my NCLEX early? ›
Unfortunately, the only way to know for sure if you have passed the NCLEX is to wait for your official results.What is a good passing rate for NCLEX? ›
Practice the NCLEX-RN Exam for Free
The NCLEX pass rate for first-time U.S. educated test-takers in 2021 was 82.48%. But don't fall into the trap of relying on these numbers for your exam success. While they're positive numbers, remember that your ability to pass the NCLEX is in your hands.
The number of internationally-educated NCLEX-RN candidates increased from 7,803 in the first quarter of 2021 to 11,814 in the first quarter of 2022. The passing rate also increased from 32.03% to 38.14%.Which state has the easiest NCLEX exam? ›
- #1 Connecticut. ...
- #2 Montana. ...
- #3 New York. ...
- #4 Northern Mariana Islands. ...
- #5 South Dakota.
How CAT Works?
|NCLEX PN||NCLEX RN|
|Maximum Time||5 hours||6 hours|
The number of questions you answered is an indication of how close you were to the passing standard. Only those candidates whose performance was close to the passing standard had to answer the maximum number of questions (130 for NCLEX-RN and NCLEX-PN).Are quick results for NCLEX accurate? ›
Are NCLEX Quick Results Accurate? The NCLEX Quick Results/Pearson Vue Quick Results are believed to be 100% accurate. However, the quick results are computer-generated and unofficial. Official results are released by the state board of nursing, not the NCLEX Quick Results Service.How many hours a day should I study NCLEX? ›
The amount of time that you choose to schedule in your NCLEX study plan can be highly subjective from person to person — but on average, it is recommended that a nursing student aims to study at least 3-5 hours a day (excluding days off) while they prepare for the exam.What percentage do I need on UWorld to pass NCLEX? ›
Learners with an average QBank score of 56% pass the NCLEX at a 92% rate. While your average UWorld QBank score gives you important information, studying each question's explanation is the most valuable way to spend your time.How long do most people study for NCLEX? ›
Recommended study times may vary depending upon the level of preparation needed and can range anywhere from four to twelve weeks or more. Although this article provides a guide to studying NCLEX in one month, it is highly recommended you allocate more than just four weeks to prepare for your exam.How do you make sure I pass the NCLEX the second time? ›
The best strategy is to review every day and practice NCLEX-style questions again and again. It is far better to set aside some time every day over weeks than to try and cram everything into a few study sessions right before you retest. Set a schedule and stick to it.What does it mean if you get all the questions on NCLEX? ›
If you end up answering the full 145 questions, that is an indication that you're close to the passing standard and the computer is going to keep giving you questions until you've reached the full number of possible questions.
If the last question is below the level of difficulty needed to pass, the candidate fails. If the last question is above the level of difficulty needed to pass, the candidate passes.What is the most questions on NCLEX? ›
Six hours—the maximum time allotted for the NCLEX is 6 hours. Take breaks if you need a time out or need to move around. 75/265—the minimum number of questions you can answer is 75 and a maximum of 265.Can you pass NCLEX with 150 questions? ›
So, a test-taker can pass or fail the NCLEX-RN/PN with 60 questions, 145 questions, or any number in between.Is the NCLEX 145 or 265 questions? ›
The maximum number of items for both the RN and PN exam is 145 rather than 265 and 205. The total test time for both the RN and PN exam will be five hours rather than six and five, respectively.When did NCLEX switch to 145 questions? ›
The typical NCLEX has a maximum of 265 questions. As a result of the COVID-19 pandemic, the length has been altered. The NCLEX in 2022 has 15 pretest questions and a maximum length of 145 questions. You'll also have a total of 5 hours to complete the exam.What are good signs you passed NCLEX? ›
The test begins with easy questions, and as you answer questions correctly, they become more challenging. If you answer a question incorrectly, the next question is easier. When the NCLEX gives increasingly more complicated questions before shutting off, this is one of the good signs you passed NCLEX in 2022.How many questions out of 75 do you have to get right to pass NCLEX? ›
Many people take the NCLEX after prepping with ATI, but pass the NCLEX with 75 questions. The “passing rate” on NCLEX is adaptive, but many state that if you pass at least 50-60% of the questions on ATI test banks, then you will pass the NCLEX.What happens if you fail NCLEX 3 times? ›
If they fail, they'll need to wait 45 days before retesting. After failing three times, though, they'll need to complete a board-approved remediation program before the next retake. Candidates have six attempts to pass in total.How many questions can you miss on the NCLEX and still pass? ›
Failing the test can result from not answering the minimum amount of 60 questions within the allotted time. You can answer the first 59 questions correctly, but you will automatically fail the exam if you don't reach number 60.How soon after NCLEX can I do the trick? ›
While some people try the trick within an hour or so after completing the NCLEX exam, giving yourself a two-to-four-hour post-test window seems to be the best. It is essential to give the system enough time to process your test.
- #1 Connecticut. ...
- #2 Montana. ...
- #3 New York. ...
- #4 Northern Mariana Islands. ...
- #5 South Dakota.
Each category of questions requires an increasing level of critical thinking skills. Analysis, synthesis and evaluation questions would be considered higher-level NCLEX questions. Synthesis questions are based on creating or proposing solutions, such as a plan of care.