NCLEX Questions

Question 1

A client suffering from a narcotic overdose is seen in the Emergency Department. The client is confused, with warm flushed skin, head ache, and weakness. Vital signs noted are T 98.9 / HR 128 / R 24 / and BP 130 / 86. A blood gas analysis is as follows: pH 7.33, PaCO2 53, PaO2 72, HCO3 24. The client is:

Answer 1

Respiratory acidosis

Question 2

A 42 y/o male client has the following lab values: pH 7.55, HCO3 22, and PaCO2 30. What should the nurse do?

Answer 2

Encourage the client to slow down his breathing

Question 3

A nurse in the emergency department admits a male client who has experienced severe frostbite to his hands and toes after becoming lost on a ski hill. The nurse recognizes that which of the following phenomena has contributed to his tissue damage?

Answer 3

Decreased blood flow has induced hypoxia to the cells

Question 4

A nurse is teaching a group of older adults about the value of including foods containing antioxidants in their diet. Which of the following statements best captures the rationale underlying the nurse’s advice?

Answer 4

Antioxidants inhibit the actions of reactive oxygen species

Question 5

A male patient’s X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from:

Answer 5

Increased pulmonary capillary permeability

Question 6

A client was admitted to the hospital 24 hours ago after sustaining blunt chest trauma. The nurse monitors for which earliest clinical manifestation of acute respiratory distress syndrome (ARDS)?

Answer 6

Increased respiratory rate from 18 to 30 breaths per minute.

Question 7

A client has been excessively vomiting for several days. Why would the patient experience HYPOkalemia?

Answer 7

Potassium excreted through the vomitus

Question 8

Stimulation of the facial nerve via the masseter muscle causes twitching of the nose and lips in HYPOcalcemia is known as:

Answer 8

Chvostek’s sign

Question 9

A 32-year-old client with a history of sickle cell anemia is admitted to the hospital during a sickle cell crisis. The physician orders all of these interventions. Which order will you implement first?

Answer 9

d) Administer oxygen at an Fi02 of 100% per non-rebreather mask

Question 10

When the nurse is implementing bleeding precautions for a patient with thrombocytopenia, the following should be included (SELECT ALL THAT APPLY):

Answer 10

a) The use of an electric razor
b) Discontinuation of aspirin
c) Limitation of needle sticks

Question 11

A client was admitted to the hospital 24 hours ago after sustaining blunt chest trauma. The nurse monitors for which EARLIEST clinical manifestation or acute respiratory distress syndrome (ARDS)?

Answer 11

Increase respiratory rate from 18 to 30 breathes per min

Question 12

A male patients’s Xray result reveals bilateral white outs indicating ARDS (adult respiratory distress syndrome) This syndrome results from:

Answer 12

Increase pulmonary capillary permeability

Question 13

The nurse admits a patient to the ED with new onset of slurred speech and right-sided weakness. What is the priority nursing action?

Answer 13

Determine the time of symptom onset

Question 14

A client has signs of increased ICP. Which of the following is anearlyindicator of deterioration in the client’s condition?

Answer 14

Decrease in LOC (level of consciousness)

Question 15

A diagnosis of pneumonia is typically achieved by which of the following diagnostic test?

Answer 15

Chest x-ray

Question 16

The nurse is evaluating the tuberculin skin test (TST) for a patient who has a diagnosis of human immunodeficiency virus (HIV). The skin test is positive if the area of induration is at least __ mm?

Answer 16

5

Question 17

The physician orders a urine culture on your patient with a urinary tract infection. In addition, the patient is ordered to start IV antibiotics. How will you proceed with following this order?

Answer 17

First, collect the urine culture, and then hang the antibiotic.

Question 18

You’re providing discharge teaching to a female patient on how to prevent urinary tract infections. Which statement is INCORRECT?

Answer 18

“Use scented sanitary napkins or tampons during menstruation.”

Question 19

A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?

Answer 19

Laceration of the middle meningeal artery

Question 20

An awake, alert patient arrives at the ED following a fall down a flight of stairs. The physician suspects a basilar skull fracture. Which assessment findings should the nurse anticipate?

Answer 20

Rhinorrhea and raccoon eyes

Question 21

An 11 year-old boy with skin lesions on his trunk characteristic of ringworm has been brought to the health care provider. Which aspect of the clinician’s assessment relates most directly to the suspected diagnosis?

Answer 21

Potential contact with the fungus from pets or other children

Question 22

A 13 year-old girl has presented to a clinic with her mother explaining that she had an oval-shaped red patch on her chest a week ago, but that more of the lesions are now appearing on her back. On examination, the lesions on her back are in a “Christmas tree” pattern. What is the girl’s most likely diagnosis?

Answer 22

Pityriasis rosea

Question 23

Clinical manifestations related to pneumothorax include all of the following except:

Answer 23

Acrocyanosis

Question 24

The following are types of pneumothoraces except:

Answer 24

Direct

Question 25

A 55 year old male patient is admitted with a massive GI bleed. The patient is at risk for what type of acute kidney injury?

Answer 25

Pre-renal

Question 26

A patient with AKI has a urinary output of 350 mL/day. In addition, morning labs showed an increased BUN and creatinine level along with potassium level of 6 mEq/L. What type of diet ordered by the physician is most appropriate for this patient?

Answer 26

Low-protein, low-potassium, low phosphorus and low-sodium

Question 27

A client develops left-sided heart failure. An appropriate nursing diagnosis is?

Answer 27

Ineffective airway clearance

Question 28

A client develops right sided heart failure. Which of the following s/s would the nurse expect to find?

Answer 28

Edematous legs and ankles

Question 29

A 7-year-old boy has been diagnosed with juvenile idiopathic arthritis (JIA), and his parents are anxious to know how his health problem will affect his short-term and longer-term future. What can his health care provider most accurately tell the family?

Answer 29

“With appropriate use of anti-inflammatory drugs along with lifestyle modifications, your son stands a good chance of leading a normal life.”

Question 30

The nurse is teaching a class about the joints commonly affected by osteoarthritis​ (OA). Which joints should the nurse​ include?

Answer 30

Hands, knees, and hips

Question 31

A nurse is providing a program for older men in a senior community center about measures that can be taken to reduce the risk for prostate cancer. Which of the following would the nurse include in the program?

Answer 31

Decrease red meat and fat intake

Question 32

To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about:

Answer 32

Occurrence of a weak urinary stream

Question 33

A 60-year-old man has been diagnosed with renal calculi after repeated episodes of excruciating flank pain in recent weeks. The man states that, “I don’t know how this could happen to me, since I’m so careful about eating a healthy diet.” What is the most appropriate response to the man’s statement?

Answer 33

“What you eat can influence your risk of stone formation, but many other factors like your gender and your activity level are involved.”

Question 34

Which of the following pain descriptions would lead the nurse to suspect the client is experiencing renal/ureteral colic?

Answer 34

Excruciating pain in the flank and upper outer quadrant of the abdomen that radiates to the bladder area

Question 35

The nurse is caring for a client with pheochromocytoma. Which of the following must be included in planning the nursing care for this client ?

Answer 35

Monitor blood pressure frequently, assessing for hypertension

Question 36

Which of the following nursing implications is most important in a client being medicated for Addison’s disease?

Answer 36

Instruct the client to never abruptly discontinue the medication

Question 37

The nurse is evaluating the respiratory outcomes for the client with Guillain-Barré syndrome. The nurse would evaluate that which of the following is the least optimal outcome for the client?

Answer 37

Adventitious breath sounds

Question 38

The client has been diagnosed to have ALS (amyotrophic lateral sclerosis). Which of the following manifestations characterize the disease? (Select all that apply)

Answer 38

Muscle weakness
Muscle atrophy
Fatigue
Respiratory difficulty

Question 39

The nurse concludes that a client has understood teaching about menopause when the client states:

Answer 39

“I know I have begun menopause and it will take awhile to finish.”

Question 40

Signs and symptoms of andropause include all of the following except:

Answer 40

Decrease in intellectual capacity

Question 41

A child with CHD experiences hypercyanotic tet spells. The nurse would place the child in which position for relief?

Answer 41

Knee-to-chest

Question 42

The client is diagnosed with cancer of the head of the pancreas. When assessing the patient, which signs and symptoms would the nurse expect to find?

Answer 42

Clay-colored stools and dark urine

Question 43

What is an expected assessment finding in a child with coarctation of the aorta?

Answer 43

Disparity in blood pressure between the upper and lower extremities

Question 44

The nurse is caring for patients in an outpatient clinic. Which information should the teach regarding recommendations for early detection of colon cancer?

Answer 44

At age 50, a colonoscopy, then once at least every 10 years

Question 45

Mr. Gonzalez has been diagnosed with bone cancer. You know this type of cancer is classified as:

Answer 45

Sarcoma

Question 46

Which of the following are the two main symptoms of osteosarcomas?

Answer 46

Pain and swelling

Question 47

What is usually the first clinical manifestation of breast cancer?

Answer 47

Painless lump

Question 48

What are the current guidelines for breast cancer screening?

Answer 48

Yearly mammograms starting at age 40

Question 49

Which of the following symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm?

Answer 49

Lower back pain

Question 50

A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure?

Answer 50

Pedal pulses

Question 51

The client diagnosed with lung cancer has been told that the cancer has metastasized to the brain. Which intervention should the nurse implement?

Answer 51

Discuss implementing an advance directive

Question 52

The nurse is taking the social history of a client diagnosed with lung cancer. Which information is significant for this disease?

Answer 52

Has smoked 2 packs of cigarettes/day for 20 years

Question 53

A nurse calls a physician with the concern that a patient has developed a pulmonary embolism. Which of the following symptoms has the nurse most likely observed?

Answer 53

The patient suddenly complains of chest pain and shortness of breath

Question 54

A nurse is caring for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before the procedure. The nurse would inspect the surgical site most closely for signs of:

Answer 54

Bleeding and infection