NCLEX QUESTIONS

Question 1

A nurse is caring for a child with celiac disease. How would the nurse evaluate the effectiveness of nutritional therapy?

Answer 1

Monitor the appearance, size, and number of stools.

Question 2

A client makes a routine visit to the prenatal clinic. Although the client is 14 weeks pregnant, the size of her uterus approximates an 18- to 20-week pregnancy. The physician diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal:

Answer 2

In a client with gestational trophoblastic disease, an ultrasound performed after the third month shows grapelike clusters of transparent vesicles rather than a fetus.

Question 3

A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?

Answer 3

“OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints.”

Question 4

During a visit to the prenatal clinic, a pregnant client at 32 weeks’ gestation has heartburn. The client needs further instruction when they say they must do what to manage heartburn?

Answer 4

Consume liquids only between meals.

Question 5

A nurse is performing a respiratory assessment on a 5-year-old child diagnosed with pneumonia. Which assessment finding should be reported to the health care provider immediately?

Answer 5

moderate intercostal retractions

Question 6

A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client’s chart, as shown above.

At 1030, the client has sharp mid-chest pain after having a bowel movement. What should the nurse do first?

Answer 6

Assess the client’s vital signs.

The blood pressure and heart rate will provide useful information in assessing for hypovolemic shock.

Question 7

Which nursing diagnosis takes highest priority for a client with hyperthyroidism?

Answer 7

Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism.

Question 8

A client has a traumatic injury to the leg and has a blood loss of about 15%. Which finding is most concerning for this client?

Answer 8

systolic blood pressure less than 90 mm Hg

Question 9

What assessment findings in a 1-day-old neonate should the nurse expect when preparing to implement phototherapy? Select all that apply.

Answer 9

yellow skin
yellow mucous membranes
icteric sclera

Question 10

A young adult has been diagnosed with hypertrophic cardiomyopathy. The nurse should further assess the client for which complication?

Answer 10

Fatigue and shortness of breath

Common symptoms of cardiomyopathy are fatigue, low tolerance to activity related to the low ejection fraction, and shortness of breath

Question 11

While the nurse is caring for a neonate at 32 weeks’ gestation in an isolette with continuous oxygen administration, the neonate’s parent asks why the baby’s oxygen is humidified. What should the nurse should tell the parent?

Answer 11

“Oxygen is drying to the mucous membranes unless it is humidified.”

Question 12

The nurse is assessing a client who has aplastic anemia. Which finding indicates the client has physiologic changes as a result of the disease?

Answer 12

bleeding tendencies

Question 13

After gathering all necessary equipment and setting up the supplies, what should be the first step in performing endotracheal (ET) or tracheal suctioning in an infant?

Answer 13

Provide extra oxygen by using a ventilator or through manual bagging.

Question 14

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?

Answer 14

purpura and petechiae

A hepatic disorder, such as cirrhosis, may disrupt the liver’s normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae

Question 15

Following a modified radical mastectomy, a client has an incisional drainage tube attached to Hemovac suction. The nurse determines that the suction is effective when what occurs?

Answer 15

Accumulated serum and blood in the operative area are removed.
A drainage tube is placed in the wound after a modified radical mastectomy to help remove accumulated blood and fluid in the area.

Question 16

The nurse is assessing a client with a cervical injury for autonomic dysreflexia. Which assessment should the nurse make?

Answer 16

sudden, severe hypertension

Question 17

Twelve hours after cardiac surgery, the nurse assesses a 3-year-old who weighs 33 lb (15 kg). The nurse should notify the surgeon about which clinical finding?

Answer 17

alterations in levels of consciousness

Clinical signs of low cardiac output and poor tissue perfusion include pale, cool extremities, cyanosis or mottled skin, delayed capillary refill, weak, thready pulses, oliguria, and alterations in level of consciousness. An adequate urine output for a child over 1 year should be 1 mL/kg per hour. Therefore, 60 mL/4 hr is satisfactory.

Question 18

A school-age child with glomerulonephritis reports a headache and blurred vision. What immediate action should the nurse take?

Answer 18

Obtain the child’s blood pressure.

Question 19

The nurse enters a client’s room and finds the client slumped over in a chair. What actions would the nurse take? Place the steps in the correct order from first to last. All options must be used.

Answer 19

Establish unresponsiveness.

Confirm there are no respirations.

Call for the resuscitation team.

Place the client on a firm surface.

Deliver 30 chest compressions at a rate of 100 per minute.

Have a second person deliver 2 rescue breaths for each 30 compressions.

Question 20

A 32-year-old multigravida client returns to the clinic for a routine prenatal visit at 36 weeks’ gestation. The assessments during this visit include blood pressure, 140/90 mm Hg; pulse, 80 beats/min; and respiratory rate, 16 breaths/min. What further information should the nurse obtain to determine if this client is becoming preeclamptic?

Answer 20

proteinuria
The two major defining characteristics of preeclampsia are blood pressure elevation of 140/90 mm Hg or greater and proteinuria

Question 21

A nurse in the telemetry unit is caring for a client with diagnosis of postoperative coronary artery bypass graft (CABG) surgery from 2 days ago. On assessment, the nurse notes a paradoxical pulse of 88. Which surgical complication would the nurse suspect?

Answer 21

pericardial tamponade

A paradoxical pulse (a palpable decrease in pulse amplitude on quiet inspiration) signals pericardial tamponade, a complication of CABG surgery.

Question 22

The nurse is caring for an alert 2-month-old child and assesses a sunken fontanelle. Which action would be most appropriate for the nurse to take based on the assessment?

Answer 22

Monitor fluid intake and output.

A sunken fontanelle in an alert child would most commonly suggest a concern with dehydration.

Question 23

After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the medical-surgical unit. Postoperatively, how should the nurse position the client?

Answer 23

with the leg on the affected side abducted

The nurse must keep the leg on the affected side abducted at all times after hip surgery to prevent accidental dislodgment of the affected hip joint. Placing a pillow or an A-frame between the legs helps maintain abduction and reminds the client not to cross the legs.

Question 24

The nurse is planning care for a client who is in cardiogenic shock following a myocardial infarction. What is the most important goal of nursing care for this client?

Answer 24

Improve cardiac output.

Question 25

The nurse is assessing a client with superficial thrombophlebitis in the greater saphenous vein of the left leg. The client has “aching” in the leg. Which finding indicates the nurse should contact the health care provider (HCP) to request a prescription to improve the client’s comfort?

Answer 25

red, warm, palpable linear cord along the vein that is painful on palpation

Question 26

A client requires long-term ventilator therapy. The client has a tracheostomy in place and requires frequent suctioning. Which technique should the nurse use?

Answer 26

intermittent suction while withdrawing the catheter

Question 27

A client has severe arterial occlusive disease and gangrene of the left great toe. Which finding is expected?

Answer 27

loss of hair on the lower leg

Question 28

A client is admitted to the emergency department with severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. What is the nurse’s primary goal at this time?

Answer 28

Prepare the client for emergency surgery.

Question 29

A client who had a left thoracoscopy sustained an injury secondary to the surgery position. The nurse should assess the client for which sign?

Answer 29

tingling in the arm

Question 30

A client is placed on hypocalcemia precautions after removal of the parathyroid gland for cancer. The nurse should observe the client for which symptoms? Select all that apply.

Answer 30

numbness
tingling
muscle twitching and spasms

Question 31

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate’s urinary meatus appears to be located on the ventral surface of the penis. The nurse notifies the healthcare provider because the nurse suspects which disorder?

Answer 31

hypospadias
The condition in which the urinary meatus is located on the ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants. Circumcision is delayed until the condition is corrected surgically, usually between 6 and 12 months of age

Question 32

While the nurse is caring for a neonate born at 32 weeks’ gestation, which finding would most suggest the infant is developing necrotizing enterocolitis (NEC)?

Answer 32

abdominal distention

Question 33

To evaluate a client’s atrial depolarization, the nurse observes which part of the electrocardiogram waveform?

Answer 33

P wave

Question 34

The nurse teaches the mother of a toddler who has had cleft palate repair that her child is at risk for developing which problem in the future?

Answer 34

a speech defect

Question 35

A client who has had an above-the-knee amputation develops a dime-sized bright red spot on the dressing after 45 minutes in the postanesthesia recovery unit. What should the nurse do first?

Answer 35

Draw a mark around the site.

Question 36

A client receiving continuous mandatory ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. What should the nurse do?

Answer 36

Notify the health care provider (HCP) of the client’s breathing pattern.

Question 37

A female client is currently receiving radiation therapy to the chest wall for recurrent breast cancer. They have pain while swallowing and burning and tightness in their chest. The nurse should further assess the client for indications of which health problem?

Answer 37

esophagitis

Difficulty in swallowing, pain, and tightness in the chest are signs of esophagitis, which is a common complication of radiation therapy on the chest wall.

Question 38

A nurse is performing discharge teaching with a client who has an implantable cardioverter defibrillator (ICD) placed. Which client statement indicates effective teaching?

Answer 38

“I’ll keep a log of each time my ICD discharges.”

Question 39

A nurse is caring for a child with intussusception. Which of the following is an expected client outcome related to the nursing diagnosis Acute pain related to cramping, which might be made for this child?

Answer 39

The child exhibits no manifestations of discomfort.

Question 40

A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see?

Answer 40

hypercalcemia

Question 41

Twenty-four hours after birth, a neonate has not passed meconium. The infant’s abdomen is firm with hypoactive bowel sounds. The nurse anticipates the healthcare provider will diagnose which condition?

Answer 41

Hirschsprung’s disease

Question 42

When the nurse is preparing the room for admission of a multigravida client at 36 weeks’ gestation diagnosed with severe preeclampsia, which item is most important for the nurse to obtain?

Answer 42

padding for the side rails
A client with severe preeclampsia may develop eclampsia, which is characterized by seizures

Question 43

A nurse determines that a client has 20/40 vision. Which action by the nurse is most appropriate?

Answer 43

Refer the client to a healthcare provider for possible corrective lenses

Question 44

An adolescent, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention is appropriate?

Answer 44

providing small, frequent meals

Question 45

The nurse is caring for a client in labor. The nurse notes variable decelerations on the fetal monitor strip. What is the nurse’s priority intervention?

Answer 45

repositioning the client to the other side

Variable decelerations are caused by umbilical cord compression. These can occur with or without a contraction. Positioning the client on her side would provide optimal oxygenation to the fetus.

Question 46

Bone resorption is a possible complication of Cushing disease. To help the client prevent this complication, the nurse should make which recommendation to the client?

Answer 46

Maintain a regular program of weight-bearing exercise.

Question 47

The nurse assesses a client with diverticulitis and suspects peritonitis when which of the following symptoms is noted?

Answer 47

rigid abdominal wall

Question 48

What intervention should the nurse implement when caring for a 4-year-old child who has just had a lumbar puncture?

Answer 48

Encourage the parents to hold the child.

Question 49

The nurse is assessing a client who had epidural anesthesia 4 hours ago. What should the nurse assess first?

Answer 49

bladder distention
The last area to regain sensation is the perineal area, and the nurse should check the client for a distended bladder.

Question 50

Which finding will the nurse assess in a client diagnosed with peritonitis?

Answer 50

Abdominal wall rigidity is a common manifestation of peritonitis.

Bowel sounds may or may not be present in peritonitis. A positive Cullen’s sign is a manifestation of acute pancreatitis, and Battle’s sign is a manifestation of skull fractures.

Question 51

The nurse places inflatable compression sleeves on the legs of a client undergoing a cesarean birth under a regional anesthetic. When does the nurse tell the client that the sleeves will be removed?

Answer 51

when the client resumes ambulating

Question 52

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?

Answer 52

platelet count, prothrombin time, and partial thromboplastin time

Question 53

What is an expected assessment finding when caring for a client with a percutaneous feeding tube?

Answer 53

Dark pink stoma without drainage
A normal stoma should appear dark pink to red in color and should have no drainage or scant crusty drainage around the feeding tube.

Question 54

A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the health care provider (HCP) if there is a rapid increase in which vital sign?

Answer 54

Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy.

Question 55

A client is taking clozapine and complains of a sore throat. This symptom may be an indication of which adverse reaction?

Answer 55

The complaint of a sore throat may indicate an infection caused by agranulocytosis, a depletion of white blood cells.

Question 56

The nurse is preparing to clean around a client’s G-tube that was placed 1 week ago and change the gauze dressing. Based on the type of procedure, what type of precautions are needed?

Answer 56

Clean procedure, universal precautions

Question 57

A client with a genitourinary problem is being examined in the emergency department. When palpating the client’s kidneys, the nurse should keep in mind which anatomic fact?

Answer 57

The left kidney usually is slightly higher than the right one.

Question 58

The health care provider prescribes a maternal blood test for alpha-fetoprotein for a nulligravid client at 16 weeks’ gestation. When developing the teaching plan, the nurse bases the explanations on the understanding that this test is used to detect which condition?

Answer 58

neural tube defects

Question 59

A client at 39 weeks’ gestation comes to the labor and delivery suite. The client states the membranes ruptured 12 hours ago. What priority assessment will the nurse perform?

Answer 59

Assess fetal heart rate (FHR).

Question 60

After a head injury, a client experiences enuresis, polydipsia, and weight loss. Based on these findings, the nurse should monitor closely for signs and symptoms of

Answer 60

hypokalemia

Question 62

The nurse takes the blood pressure of a preschool child. To determine if the blood pressure is normal, the nurse compares the results with percentiles for systolic and diastolic blood pressure. What other information does the nurse need to graph the blood pressure? Select all that apply.

Answer 62

Age
Sex
Height

Question 63

An older adult is having abdominal surgery. The nurse should assess the client for which postoperative concern related to normal changes in the integumentary system of an older adult?

Answer 63

decreased healing

Question 64

A nurse assesses the client’s pulse as weak and thready in both lower extremities. How would the nurse best document this finding?

Answer 64

pulse amplitude +1 bilateral lower extremities

Question 65

After the nurse explains to a primiparous client the causes of her neonate’s cranial molding, which statement by the client indicates the need for further instruction?

Answer 65

“Brain damage may occur if the molding does not resolve quickly.”

Question 66

Which statement by a parent indicates the best understanding of why raisins should be limited as a snack food in toddlers?

Answer 66

“Raisins can increase tooth decay.”

Question 67

A client who has just returned from a monthly visit home is admitted with an extremely prolonged bleeding time. The nurse observes the client to project a powerful odor of garlic on the breath, person, and clothing. What is the most important factor for the nurse to assess?

Answer 67

the client’s dietary habits

Question 68

A child, age 4, is brought to the clinic for a routine examination. When observing the tympanic membrane, the nurse identifies which color as normal?

Answer 68

pinkish gray

Question 69

The nurse is teaching a group of clients about the risk for varicose veins. Which client is at risk for varicose veins?

Answer 69

a client who has had thrombophlebitis

Question 70

A primiparous client expresses concern to the nurse about why their neonate’s eyes are crossed. Which information would the nurse include when teaching the parent about neonatal strabismus?

Answer 70

Neonates commonly lack eye muscle coordination.

Question 71

The nurse is teaching a client who had a lobectomy for lung cancer and the client’s partner how to promote comfort and optimal respiratory expansion during sexual intimacy. What can the nurse suggest the couple do?

Answer 71

Raise the affected partner’s head and upper torso on pillows.

Question 72

A preschool-age child refuses to take ordered medication. Which nursing strategy is most appropriate?

Answer 72

showing trust in the child’s ability to cooperate even with an unpleasant procedure

Question 73

The nurse performs wellness checks in the pediatric clinic. Which child would the nurse assess as demonstrating behaviors that need further evaluation?

Answer 73

2-year-old who is indifferent to other children and adults and is mute

Question 74

During a health-teaching session, a pregnant client asks the nurse how soon the fertilized ovum becomes implanted in the endometrium. Which answer should the nurse supply?

Answer 74

7 days after fertilization

Question 75

When the nurse is teaching a group of parents about common childhood problems, a parent asks, “Why are children more likely to develop ear infections than adults are?” The nurse bases the response to this question on the understanding that the key anatomic difference between adults and children is due to which structure?

Answer 75

eustachian tubes

Question 76

The nurse determines the parents’ compliance with treatment for their infant who has otitis media. Which behavior would indicate that the parents are adhering to the treatment plan?

Answer 76

holding the child upright when feeding with a bottle

Question 77

A client seeks medical care for severe sunburn. Which teaching should the nurse provide to reduce the client’s risk of skin damage from sun exposure?

Answer 77

Apply sunscreen even on overcast days.”

Question 78

When planning a class for primigravid clients about the common physiologic changes of pregnancy, the nurse should include which information in the teaching plan?

Answer 78

Cardiac output increases by 25% to 50% during pregnancy.

Question 79

Which component of a client’s medical record is the major source of subjective data about the client’s health status?

Answer 79

health history

Question 80

The mother of a toddler asks the nurse what she should do with her toddler when he has a temper tantrum. Which suggestion would be most appropriate?

Answer 80

Leave the toddler alone during the tantrum as long as he is safe.

Question 81

A client is concerned that her 2-day-old, breast-feeding neonate isn’t getting enough to eat. The nurse should teach the client that breast-feeding is effective if:

Answer 81

he neonate latches onto the areola and swallows audibly.

Question 82

Which of the following actions is correct when the student nurse assesses the fontanels of a 6-week-old infant?

Answer 82

palpating the fontanels gently while the infant sits on the parent’s lap

Question 83

A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. The client has a history of previous cesarean birth because of fetal distress. When the client is 4 cm dilated, they receive nalbuphine intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain to the client that the decreased variability is most likely caused by which factor?

Answer 83

effects of analgesic medication

Question 84

The nurse is caring for a client about to receive the first chemotherapy transfusion. When planning how to conduct the teaching session, what action would assist the nurse in determining the client’s learning preferences?

Answer 84

asking the client which is preferred–brochure, video, or podcast