Read Online NCLEX-RN Test Practice Test Questions Exam Dumps
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NCLEX-RN exam is a critical test for any aspiring registered nurse in the United States. It is administered by the National Council of State Boards of Nursing (NCSBN) and is designed to test the competency and readiness of individuals who wish to practice as registered nurses. The test is computerized and adaptive, meaning that the difficulty of the questions increases or decreases based on the candidate's responses.
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NEW QUESTION # 315
Which of the following nursing orders should be included in the plan of care for a client with hepatitis C?
- A. The nurse should administer an alcohol backrub at bedtime.
- B. The nurse should use universal precautions when obtaining blood samples.
- C. Total bed rest should be maintained until the client is asymptomatic.
- D. The client should be instructed to maintain a low semi-Fowler position when eating meals.
Answer: B
Explanation:
Section: Questions Set A
Explanation:
(A) The source of infection with hepatitis C is contaminated blood products. (B) Modified bed rest should be maintained while the client is symptomatic. Routine activities can be slowly resumed once the client is asymptomatic. (C) Nausea and vomiting occur frequently with hepatitis
C. A high Fowler position may decrease the tendency to vomit. (D) The buildup of bilirubin in the client's skin may cause pruritus. Alcohol is a drying agent.
NEW QUESTION # 316
The mother of a preschooler reports to the nurse that he frequently tells lies. The admission assessment of the child indicates possible child abuse. The nurse knows that his:
- A. Lying is normal behavior for a preschool child who is learning to separate fantasy from reality.
- B. Mother is lying to protect herself.
- C. Behavior is not normal, and a child psychiatrist should be consulted.
- D. Behavior indicates a developmental delay, because preschoolers should be able to tell right from wrong.
Answer: A
Explanation:
Explanation
(A) Because preschoolers often tell "stories" as they learn to differentiate fantasy from reality, the child's behavior is normal. (B) The nurse has no reason to believe the child's mother is lying, because children of his age often tell lies. (C) The child's lying is actually "storytelling" as he learns to separate fantasy from reality, a normal developmental task for his age group. (D) The child's behavior is consistent with his age and does not indicate a developmental delay.
NEW QUESTION # 317
An 82-year-old former restaurant owner walks to the nursing station and states, "I have to go. The restaurant opens at 11 am." Which response by the nurse is the most appropriate?
- A. "You are in the hospital now. Calm down."
- B. "It is snowing outside. The restaurant is closed."
- C. "Go back to your room. You do not own a restaurant."
- D. "You once owned a restaurant. Tell me about it."
Answer: D
Explanation:
(A)
This response cuts off communication with the client. It does not address her feelings.
(B)
Reality orientation frequently does not work alone. Feelings must be addressed. Telling a client to calm down is frequently ineffective. (C) Reminiscence is used here to reorient and recall past pleasant events. Talking about the restaurant will allay anxiety. (D) This response may confirm to the client that she indeed does still own a restaurant, buying into her confusion. Her feelings and anxiety require nursing intervention.
NEW QUESTION # 318
A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch. She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question:
- A. "Have you had any lesions of the affected leg that have been difficult to heal?"
- B. "Do you experience swelling at the end of the day in the affected and unaffected leg?"
- C. "Do your muscle spasms occur following rest, walking, or exercising?"
- D. "Would you describe the intensity, duration, and symptoms associated with your pain?"
Answer: C
Explanation:
Section: Questions Set D
Explanation:
(A) Describing pain is an important aspect of the assessment; however, assessing activity preceding muscle spasms is equally important. (B) Edema may occur with peripheral vascular disease, but it is not of particular importance in assessing intermittent claudication. (C) Lesions may be present with peripheral vascular disease, but they are not an indication of intermittent claudication. (D) With intermittent claudication, muscle spasms occur intermittently, mainly with walking and after exercising. Rest may relieve muscle spasms.
NEW QUESTION # 319
A client is admitted to the hospital with diabetic ketoacidosis.
The emergency room nurse should anticipate the administration of:
- A. Humulin R
- B. Humulin L
- C. Humulin N
- D. Humulin U
Answer: A
Explanation:
Explanation
(A) Intermediate-acting insulin is not indicated in an emergency. (B) Regular insulin is rapid acting and indicated in an emergency situation. (C) Long-acting insulin is not indicated in an emergency situation. (D) Intermediate-acting insulin is not indicated in an emergency situation.
NEW QUESTION # 320
A 28-year-old woman was admitted to the hospital for a thyroidectomy. Postoperatively she is taken to the postanesthesia care unit for several hours. In preparing for the client's return to her room, which nursing measure best demonstrates the nurse's thorough understanding of possible postthyroidectomy complications?
- A. A tracheostomy set, O2, and suction are available at the bedside.
- B. The nurse should instruct the client as soon as possible on alternative means of communication.
- C. Dressings are placed at the bedside for dressing changes, which are to be done every 2 hours to best detect postoperative bleeding.
- D. Narcotics are readily available and administered when the client returns to her room to prevent excruciating pain.
Answer: A
Explanation:
Section: Questions Set D
Explanation:
(A) Dressing changes are done as necessary for bleeding. However, frequently, post-thyroidectomy bleeding may not be visible on the dressing, but blood may drain down the back of the neck by gravity. (B) Narcotics are administered for acute pain as necessary. They are not necessarily given on return of the client to her room.
(C) The most serious postthyroidectomy complication is ineffective airway and breathing pattern related to tracheal compression and edema. A tracheostomy set, O2, and suction should be available at bedside for at least the first 24 hours postoperatively. (D) Impaired verbal communication may occur due to laryngeal edema or nerve damage, but most commonly, it occurs due to endotracheal intubation. The client is usually able to communicate but is hoarse.
NEW QUESTION # 321
Prior to an amniocentesis, a fetal ultrasound is done in order to:
- A. Evaluate the amount of amniotic fluid
- B. Ensure that the fetus is mature enough to perform the amniocentesis
- C. Evaluate fetal lung maturity
- D. Locate the position of the placenta and fetus
Answer: D
Explanation:
Explanation
(A) Amniocentesis can be performed to assess for lung maturity. Fetal ultrasound can be used for gestational dating, although it does not separately determine lung maturity. (B) Ultrasound can evaluate amniotic fluid volume, which may be used to determine congenital anomalies. (C) Amniocentesis involves removal of amniotic fluid for evaluation. The needle, inserted through the abdomen, is guided by ultrasound to avoid needle injuries, and the test evaluates the position of the placenta and the fetus. (D) Amniocentesis can be performed as early as the 15th-17th week of pregnancy.
NEW QUESTION # 322
A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation, intubated, and receives mechanical ventilation. When performing suctioning, the nurse should:
- A. Suction for a maximum of 30 seconds
- B. Hyperoxygenate before and after suctioning
- C. Maintain clean technique during suctioning
- D. Suction for a maximum of 20 seconds
Answer: B
Explanation:
Explanation
(A) The maximum time for suctioning is 10-15 seconds. (B) Supplemental O2should be administered before and after suctioning to reduce hypoxia. (C) The maximum time for suctioning is 10-15 seconds. (D) Strict sterile technique should be used during suctioning.
NEW QUESTION # 323
A 6-year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix. His mother tells the nurse that he is becoming more restless and is anxious. Assessment findings indicate that the child has atelectasis. Appropriate nursing actions would include:
- A. Remaining with the child and keeping as calm and quiet as possible
- B. Administering analgesics as ordered
- C. Allowing the child to remain in the position of comfort, preferably semi-or high-Fowler position
- D. Having the child turn, cough, and deep breathe every 1-2 hours
Answer: D
Explanation:
Explanation
(A) Allowing the client to remain in the position of comfort will not resolve the atelectasis. This position, if left unchanged, over time may actually increase the atelectasis. (B) Analgesics will not resolve the atelectasis and may contribute to it if proper nursing actions are not taken to help resolve the atelectasis. (C) Having the client turn, cough, and deep breathe every 1-2 hours will aid in resolving the atelectasis. Surgery clients are at risk for postoperative respiratory complications because pulmonary function is reduced as a result of anesthesia and surgery. (D) Remaining with the client and keeping him calm and quiet will not affect the client's anxiety, restlessness, or help to resolve the atelectasis. The cause (atelectasis) needs to be treated, not the symptoms (anxiety and restlessness).
NEW QUESTION # 324
Prior to an amniocentesis, a fetal ultrasound is done in order to:
- A. Evaluate the amount of amniotic fluid
- B. Ensure that the fetus is mature enough to perform the amniocentesis
- C. Evaluate fetal lung maturity
- D. Locate the position of the placenta and fetus
Answer: D
Explanation:
Section: Questions Set D
Explanation:
(A) Amniocentesis can be performed to assess for lung maturity. Fetal ultrasound can be used for gestational dating, although it does not separately determine lung maturity. (B) Ultrasound can evaluate amniotic fluid volume, which may be used to determine congenital anomalies. (C) Amniocentesis involves removal of amniotic fluid for evaluation. The needle, inserted through the abdomen, is guided by ultrasound to avoid needle injuries, and the test evaluates the position of the placenta and the fetus. (D) Amniocentesis can be performed as early as the 15th-17th week of pregnancy.
NEW QUESTION # 325
While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding?
- A. Document in the nurse's notes and notify the physician after redressing the site.
- B. Clean the site well and redress.
- C. Begin a peripheral IV.
- D. Discontinue the central line.
Answer: A
Explanation:
Explanation
(A) The nurse may never discontinue a central line without a physician's order. (B) The nurse may never initiate a peripheral IV without a physician's order except in an emergency situation. (C) The nurse should always document findings and alert the physician to the findings as well. The physician may then initiate a new central line and order the current central line to be discontinued. (D) Besides cleaning and redressing, the nurse should always document the findings.
NEW QUESTION # 326
A 22-year-old client presents with a diagnosis of antisocial personality disorder and a history of using drugs, writing numerous checks with insufficient funds, and stealing. He appears charming and intelligent, and the other clients are impressed and want to be liked by him. The greatest problem that may arise from this situation is that:
- A. He will become delusional and hallucinate as a result of the excess attention given to him by peers
- B. He will manipulate the other clients for his own benefit
- C. He will cause the other clients to become psychotic
- D. He may exhibit self-mutilative behavior
Answer: B
Explanation:
Explanation
(A) This answer is correct. Persons with antisocial personality disorder typically are very manipulative. (B) This answer is incorrect. The client's behavior cannot cause another person to become psychotic. (C) This answer is incorrect. Psychosis is not a symptom of antisocial personality. One of the criteria for diagnosis of this disorder is that no psychosis be present. In addition, the client would love the attention. (D) This answer is incorrect. Self-mutilative behavior is characteristic of the borderline personality disorder.
NEW QUESTION # 327
A 30-year-old female client is receiving antineoplastic chemotherapy. Which of the following symptoms should especially concern the nurse when caring for her?
- A. Respiratory rate of 16 breaths/min
- B. A sore throat
- C. Complaints of muscle aches
- D. Pulse rate of 80 bpm
Answer: B
Explanation:
Section: Questions Set E
Explanation:
(A) A respiratory rate of 16 breaths/min is normal and is not a cause for alarm. (B) A pulse rate of 80 bpm is normal and is not a cause for alarm. (C) Complaints of muscle aches are unrelated to her receiving chemotherapy. There may be other causes related to her hospital stay or the disease process. (D) A sore throat is an indication of a possible infection. A client receiving chemotherapy is at risk of neutropenia. An infection in the presence of neutropenia can result in a life-threatening situation.
NEW QUESTION # 328
A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest?
- A. Various large colored blocks to teach visual discrimination
- B. A mobile to improve hand-eye coordination
- C. A pull toy to encourage locomotion
- D. A large toy with movable parts to improve pincer grasp
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Increased locomotive skills make push-pull toys appropriate for the energetic toddler. (B) Infants progress from reflex activity through simple repetitive behaviors to imitative behavior. Hand-eye coordination forms the foundation of other movements. (C) At age 8 months, infants begin to have pincer grasp. Toys that help infants develop the pincer grasp are recommended for this age group. (D) Various large colored blocks are suggested toys for infants 6-12 months of age to help visual stimulation.
NEW QUESTION # 329
After an infant is delivered by cesarean delivery and placed on the warmer, the RN dries and assesses the infant. At 1 and 5 minutes after birth, the RN does the Apgar scoring of the infant. The RN knows that because this infant was delivered by cesarean section, he is at increased risk for having which one of the following:
- A. Respiratory distress syndrome
- B. Seizures
- C. Cold stress
- D. Cyanosis
Answer: A
Explanation:
(A) The infant is placed on the warmer and dried after birth. Cold stress occurs when the infant is not dried and kept warm. (B) The fact that this infant was born by cesarean delivery does not place him at a greater risk for cyanosis than an infant delivered vaginally. Cyanosis occurs when infants cannot oxygenate their blood after the umbilical cord is severed. (C) Infants born by cesarean delivery are at a higher risk for developing respiratory distress syndrome because these infants do not pass through the pelvis, where the chest is compressed and fluid is able to escape from the lungs. (D) Cesarean-delivered infants are not at greater risk for seizures than infants delivered vaginally.
NEW QUESTION # 330
A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?
- A. Significant head lag when raised to a sitting position
- B. Holding the head to one side and pointing the chin toward the other side
- C. Hyperextension of the neck with evidence of pain on flexion
- D. Holding the head erect and in the midline when in a vertical position
Answer: A
Explanation:
Explanation
(A) This position is indicative of a possible meningeal irritation or infection such as meningitis. (B) This position is seen most frequently in infants who have had an injury to the sternocleidomastoid muscle. (C) Most infants aged 4 months and older are able to maintain this position. (D) Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.
NEW QUESTION # 331
A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:
- A. Confronting the client, letting her know the consequences for getting angry and disrupting the unit
- B. Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet area
- C. Placing her in seclusion until the behavior is under control
- D. Walking up to the client and touching her on the arm to get her attention
Answer: B
Explanation:
Explanation
(A) Threatening a client with punitive action is violating a client's rights and could escalate the client's anger.
(B) Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. (C) Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance from staff. (D) Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry.
NEW QUESTION # 332
A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy:
- A. Listen attentively and participate in in-depth discussions about food, because these actions may encourage her to eat.
- B. Distract the client during meals to get her to eat because she must take in sufficient amounts to keep from starving.
- C. Do frequent room checks to be sure that the client is not hiding food or throwing it away.
- D. Establish a structured environment with routine tasks and activities. Also, serve meals at the same time each day.
Answer: D
Explanation:
Explanation
(A) Anorexia nervosa clients feel out of control. Providing a structured environment offers safety and comfort and can help them to develop internal control, thus reducing their need to control by self-starvation. (B) Distraction does not focus on the client's need for control. (C) Doing frequent room checks reinforces feelings of powerlessness and the need to continue with the dysfunctional behavior. (D) Participating in long discussions about food does not make the client want to eat, but rather this strategy allows her to indulge in her preoccupation and to continue with the dysfunctional behavior.
NEW QUESTION # 333
A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:
- A. Circulatory overload
- B. Febrile transfusion reaction
- C. Hemolytic transfusion reaction
- D. Allergic transfusion reaction
Answer: D
Explanation:
(A) A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. (B) Fever, chills, and headaches are indicative of a febrile transfusion reaction. (C) Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. (D) Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.
NEW QUESTION # 334
In the client with a diagnosis of coronary artery disease, the nurse would anticipate the complication of bradycardia with occlusion of which coronary artery?
- A. Left main coronary artery
- B. Left anterior descending coronary artery
- C. Circumflex coronary artery
- D. Right coronary artery
Answer: D
Explanation:
(A) Sinus bradycardia and atrioventricular (AV) heart block are usually a result of right coronary artery occlusion. The right coronary artery perfuses the sinoatrial and AV nodes in mostindividuals. (B) Occlusion of the left main coronary artery causes bundle branch blocks and premature ventricular contractions. (C) Occlusion of the circumflex artery does not cause bradycardia. (D) Sinus tachycardia occurs primarily with left anterior descending coronary artery occlusion because this form of occlusion impairs left ventricular function.
NEW QUESTION # 335
A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, "This is too much trouble. I would rather just have a Foley.'' An appropriate response for the RN teaching him would be:
- A. "OK. I'll ask your physician if we can replace the Foley.''
- B. "I know. It is a lot to learn. In the long run, though, you will be able to reduce infections if you do an intermittent catheterization program.''
- C. "You need to learn this because your doctor ordered it.''
- D. "It is not too much trouble. This is the best way to manage urination.''
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) This response acknowledges the client's feelings, gives him factual information, and acknowledges that the final decision is his. (B) This response is judgmental and discourages the client from expressing his feelings about the procedure. (C) Catheterization is a procedure thattakes time to learn, but which, for the spinal cord-injured client, can significantly reduce the incidence of urinary tract infections. A young client with a T-4 injury has the hand function to learn this procedure fairly easily. (D) The final decision about bladder elimination management ultimately rests with the client and not the physician.
NEW QUESTION # 336
A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?
- A. Alteration in sensation secondary to third-degree burn
- B. Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity
- C. Alteration in comfort secondary to alteration in skin integrity
- D. Fluid volume deficit secondary to alteration in skin integrity
Answer: B
Explanation:
Section: Questions Set D
Explanation:
(A) Fluid deficit is a high priority not only during the first 8 hours postburn, but also during the first 36 hours postburn. (B) Alteration in comfort is a high priority during the entire length of the client's hospitalization and on discharge. (C) Alteration in sensation is a high priority during the first 48-72 hours postburn. Lack of sensation may be indicative of lack of circulation. (D) Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client's airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.
NEW QUESTION # 337
Three hours postoperatively, a 27-year-old client complains of right leg pain after knee reduction. The first action by the nurse will be to:
- A. Assess vital signs
- B. Remind the client that he has a client-controlled analgesic pump, and reinstruct him on its use
- C. Elevate the extremity
- D. Perform a lower extremity neurovascular check
Answer: D
Explanation:
Explanation
(A) Vital signs may be altered if there is acute pain or complications related to bleeding or swelling, but they should not be assessed before checking the affected extremity. (B) The extremity will be elevated if ordered by the doctor. (C) Assessment of the postoperative area is important to determine if bleeding, swelling, or decreased circulation is occurring. (D) Reinforcement of teaching on use of the client-controlled analgesic pump is important, but not the first action.
NEW QUESTION # 338
A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:
- A. Impaired communication
- B. Impaired social interaction
- C. Altered thought processes
- D. Sensory-perceptual alterations
Answer: D
Explanation:
Explanation
(A) Impaired communication refers to decreased ability or inability to use or understand language in an interaction. (B) In sensory-perceptual alterations an individual has distorted, impaired, or exaggerated responses to incoming stimuli (i.e., a hallucination, which is a false sensory perception that is not associated with real external stimuli). (C) An altered thought processes problem statement is used when an individual experiences a disruption in cognitive operations and activities (i.e., delusions, loose associations, ideas of reference). (D) In impaired social interaction, the individual participates too little or too much in social interactions.
NEW QUESTION # 339
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