NCLEX Practice Test (Online Questions Answers) Set : 1

A nurse is caring for a client who sustained a chemical burn in his right eye. She’s preparing to irrigate the eye with sterile normal saline solution. Which steps are appropriate when performing the procedure? Select all that apply.

A client is transferred from a recovery room to a surgical unit after undergoing a pyelolithotomy with placement of a nephrostomy tube. Which nursing action is least likely to benefit the client at this time?

A nurse is preparing to leave a contact isolation room. Place the following steps in ascending chronological order as to how protective wear should be removed. Use all the options.

A client with a diagnosis of acute myocardial infarction has new orders for aspirin 75 mg PO daily, lisinopril (Zestril®) 10 mg PO daily, furosemide (Lasix®) 10 mg PO daily, and potassium chloride (K-Dur®) 20 mEq PO bid. The nurse reviewing the serum laboratory report for the client notes a potassium level of 4.2 mEq/L, creatinine level of 2.3 mg/dL, and platelets of 250 K/μL. Based on the results of the laboratory values, the nurse should plan to consult the physician before administering the:

A client is ordered to receive a sodium phosphate enema for relief of constipation. Proper administration of the enema includes which steps? Select all that apply

Which actions should be taken by a nurse when caring for a client who is experiencing dyspnea due to heart failure and chronic obstructive pulmonary disease (COPD)? SELECT ALL THAT APPLY

A nurse is completing the intake and output record for a client who was restarted on his regular diet after being on nothing-by-mouth status for laboratory studies. The client has had the following intake and output during the shift:

Intake: 4 oz of cranberry juice, 1 ⁄2 cup of oatmeal, 2 slices of toast, 8 oz of black decaffeinated coffee, tuna fish sandwich,
1 ⁄2 cup of fruit-flavored gelatin, 1 cup of cream of mushroom soup, 6 oz. of 1% milk, 16 oz of water

Output: 1,300 ml of urine

How many milliliters should the nurse document as the client’s intake?

A physician orders a glucose tolerance test for a client with a suspected diagnosis of diabetes mellitus. The order reads, “Administer glucose 1.0 g/kg for the glucose tolerance test.” The client weights 154 pounds. To give the correct dosage, the nurse should administer ______ grams of glucose.

A hospitalized client asks the nurse for “something for pain.” What information is most important for the nurse to gather before administering the medication? Select all that apply.

After receiving an order from a health-care provider to complete a tracheostomy cleaning, a nurse explains the procedure to a client, washes hands, prepares the equipment, opens and sets up the supplies, and performs tracheostomy suctioning. After the suctioning, the nurse uses the gloved hand, which has been kept sterile, to unlock the inner cannula, places the inner cannula in the hydrogen peroxide solution, removes the gloves, and rewashes. Which actions should be taken by the nurse to safely complete the tracheostomy cleaning? Prioritize the nurse’s actions by placing the remaining steps in the correct sequence.

A postoperative client has an abdominal incision. While getting out of bed, the client reports feeling a “pulling” sensation in his abdominal wound. The nurse assesses the client’s wound and finds that it has separated and the abdominal organs are protruding. Which nursing interventions are most appropriate at this time? Select all that apply.

While performing a physical assessment on a client with a longterm history of tobacco use, a nurse notes changes in the client’s fingers (see illustration).

The nurse should best document this assessment finding as:

A nurse puts on gloves to perform a fecal occult blood test using a Hemoccult slide. Place these steps in ascending chronological order. Use all the options.

A nurse is planning care for a client who is to receive a radiation treatment later in the day. In preparing the client’s room, which
sign should the nurse plan to post outside the client’s room?

Enter the correct number in the box.

A client suffers a broken leg as a result of a car accident and is taken to the emergency department. A plaster cast is applied. Before discharge, the nurse provides the client with instructions regarding cast care. Which instructions are most appropriate? Select all that apply

An unresponsive client is admitted to an emergency room. The client’s cardiac rhythm is extremely irregular with no measurable heart rate, no P waves, and no QRS complexes. A nurse leading the resuscitation team should direct the team to perform which action first?

A nurse reports to employee health services for an injury to the hand from a needle stick. The needle was used on a client who is known to be HIV positive. Which interventions should be taken by the occupational health nurse in employee health services? (select all that apply)

A nurse is caring for a client with a hiatal hernia. The client complains of abdominal and sternal pain after eating. The pain makes it difficult for the client to sleep. Which instructions should the nurse stress when teaching this client? Select all that apply.

When communicating with a normally developed 2-year-old about to undergo a diagnostic test, the nurse would expect the child to communicate:

A registered nurse is orienting a new nurse. Together, they are caring for a group of clients diagnosed with enlarged prostates and each is scheduled for a radical prostatectomy. The registered nurse tells the new nurse that one client is likely to need additional support due to the client’s high risk for prostate cancer. To which client is the registered nurse most likely referring?

A nurse investigates the smell of smoke in the hallway of a long-term care unit. She enters a client’s room and finds the wastebasket is on fire. The nurse takes immediate action. Place the nurse’s actions in proper ascending chronological order.Use all the options.

A nurse is caring for a client who’s disoriented to time, place, and person and is attempting to get out of bed and pull out an I.V. line that’s supplying hydration and antibiotics. The client has a vest restraint and bilateral soft wrist restraints. Which actions by the nurse would be appropriate? Select all that apply.

A client has just been diagnosed with terminal cancer and is being transferred to home hospice care. The client’s daughter tells the nurse, “I don’t know what to say to my mother if she asks me if she’s going to die.” Which responses by the nurse would be appropriate? Select all that apply.

A nurse is calculating the amount of urine output at the end of an 8-hour shift for a client who has a continuous bladder irrigation after a transurethral resection of the prostate (TURP). The nurse emptied the urinary drainage bag twice during the shift. The first time there was 900 mL and the second time there was 1,000 mL. The amount of irrigation hung at the beginning of the shift was 3,000 mL, and there is 1,600 mL left at the end of the shift. The nurse should record that the client had _____ mL of urine output over the 8-hour period. Fill in the blank.

A nurse is administering promethazine (Phenergan®) to a postoperative client. In evaluating the effectiveness of the medication, which finding should the nurse anticipate?

The spouse of a client discharged following a transurethral prostatectomy (TURP) calls a clinic because the client continues to have pink-tinged urine 2 days after the procedure. Which response by the nurse is most appropriate?

While providing care to a 26-year-old married female, a nurse notes multiple ecchymotic areas on her arms and trunk. The color of the ecchymotic areas ranges from blue to purple to yellow. When asked by the nurse how she got these bruises, the client responds, “Oh, I tripped.” How should the nurse respond? Select all that apply

A nurse is caring for a client who’s terminally ill. Place the symptoms of the five stages of death and dying described by Elisabeth Kübler-Ross in ascending chronological order. Use all the options

Which nursing diagnosis is the highest priority for the client experiencing heart failure?

A nurse is caring for a hospitalized 10-year-old client who has chest contusions from a motor vehicle accident. The client is on room air and is being monitored by a pulse oximeter. When the nurse enters the room, the pulse oximeter monitor is alarming and is showing an oxygen saturation of 84%. The nurse should immediately:

A client is admitted with a tentative diagnosis of hepatitis. A nurse determines which client statement would be consistent with the diagnosis?

A 26-year-old client with chronic renal failure was recently told by his physician that he’s a poor candidate for a transplant because of chronic uncontrolled hypertension and diabetes mellitus. Now, the client tells the nurse, “I want to go off dialysis. I’d rather not live than be on this treatment for the rest of my life.” Which responses by the nurse are appropriate? Select all that apply

A nurse is collecting data on a newly admitted client. When filling out the family assessment, who should the nurse consider to be a part of the client’s family? Select all that apply

A client is admitted with vancomycin-resistant enterococci (VRE) in a leg wound. The wound is draining although dressings are covering the wound. To prevent the spread of the VRE, which is a nurse’s best plan of action?

A nurse is caring for a client whose cultural background is different from her own. Which actions are appropriate for the nurse? Select all that apply.

A nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client? Select all that apply.

A nurse is evaluating teaching for a client who has diabetes and is beginning insulin therapy using an insulin pen. Which behavior should best indicate to a nurse that teaching about the insulin therapy was effective?

A 5-year-old child who is brought to an emergency room is experiencing dyspnea and swelling of the lips and tongue. Audible wheezes, rhinitis, and stridor are also present, and the child is very anxious. Based on these assessment findings, a nurse should first

Every client admitted to the hospital must receive information about advance directives. Which statements are true about advance directives? Select all that apply

A nurse is assessing an elderly postoperative client who is exhibiting signs of delirium. The nurse observes that the client is
convinced that it is 1954 and is complaining about “the bugs in this hotel.” The nurse’s priority intervention should be to:

A nurse is working with the family of a client who has Alzheimer’s disease. The nurse notes that the client’s spouse is too exhausted to continue providing care all alone. The adult children live too far away to provide relief on a weekly basis. Which nursing interventions would be helpful? Select all that apply

Two hours after initiating total parenteral nutrition (TPN), a nurse assesses a client and notes diuresis and decreased blood pressure. The nurse recognizes that these signs may indicate that the:

A client has just had total hip replacement surgery. The physician orders heparin 8,000 units to be administered subcutaneously. The label on the heparin vial reads: heparin 10,000 units/ml. How many milliliters of heparin should the nurse draw up in the syringe to administer the correct dose?

After laparoscopic cholecystectomy, a client complains of pain and nausea. The nurse is preparing meperidine hydrochloride (Demerol) 75 mg and promethazine hydrochloride (Phenergan) 12.5 mg to be administered I.M. in the same syringe. If the label on the Demerol reads 50 mg/ml and the label on the Phenergan reads 25 mg/ml, how many milliliters should the nurse have in the syringe after the correct doses are drawn up?

A nurse is teaching day-care providers caring for young children about infectious disease transmission. About which most common sources for disease transmission should the nurse teach the day-care providers?

. A nurse is reinforcing a teaching plan with a client who’s prescribed enalapril maleate (Vasotec) for treatment of hypertension. Which instructions would the nurse expect to see included in the teaching plan? Select all that apply

A client is newly admitted with a diagnosis of left-sided heart failure. On assessment of the client, which findings should a nurse expect?

A nurse is administering ampicillin (Polycillin) 125 mg I.M. every 6 hours to a 10-kg child with a respiratory tract infection. The drug label reads, “The recommended dosage for a client weighing less than 40 kg is 25 to 50 mg/kg/day I.M. or I.V. in equally divided doses at 6- to 8-hour intervals.” The drug concentration is 125 mg/5 ml. Which nursing interventions are appropriate at this time? Select all that apply.

A nurse is using the Z-track method of I.M. injection to administer iron dextran to a client with iron deficiency anemia. Which techniques should the nurse use to give this injection? Select all that apply

The nurse is preparing to administer regular insulin 4 units to a client with type 1 diabetes mellitus. Which equipment does the nurse need to perform the injection? Select all that apply.