Nursing Now Today’s Issues Tomorrows Trends 7th Edition by Joseph T. Catalano – Test Bank

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INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS

 

Nursing Now Today’s Issues Tomorrows Trends 7th Edition by Joseph T. Catalano – Test Bank

 

Sample  Questions

 

Chapter 5: The Evolution of Licensure, Certification, and Nursing Organizations

 

MULTIPLE CHOICE

 

  1. What measure can nurses use to establish a nurse support network?
A) Insist that all nurses follow the same path to success.
B) Avoid criticizing each other in public.
C) Set very high standards for care.
D) Advocate for a multi-entry level education system.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. What is the primary goal for establishing licensure of nurses?
A) Guarantee high-quality nurses.
B) Increase tax revenues for the state.
C) Set a minimum level of competency to protect the public.
D) Maintain high numbers of nurses in the profession.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. Identify the basic requirement found in a mandatory nurse practice act.
A) Nurses must be employed under the general supervision of a licensed physician.
B) Nurses must be currently licensed in the state where they wish to practice nursing.
C) Nurses must graduate from a school accredited by a national nursing organization.
D) Nurses must be enrolled at least yearly in courses approved by the state to meet requirements for continuing education.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Analysis | Integrated Process: Problem Identification | Client Need: Safe and Effective Care Environment

 

  1. What is the primary form of RN licensure currently used in the United States?
A) Optional
B) Compulsory
C) Customary
D) Traditional

 

 

ANS:  B                    PTS:   1                    DIF:    Easy

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Comprehension | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. In relationship to a profession, what is the primary purpose of professional organizations?
A) Collect dues and fund research.
B) Monitor professional practice and discipline incompetent practitioners.
C) Fund political actions groups.
D) Establish standards for maintaining high-quality practice in the profession.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Integrity

 

  1. Which term is used to identify the listing of names of individuals on an official roster when they have met certain pre-established criteria?
A) Certification
B) Licensure
C) Registration
D) Practitioner

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Application | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. Identify the primary function of permissive licensure.
A) Protects only the title “Registered Nurse”
B) Allows anyone to use the title “Registered Nurse”
C) Used by states to maintain quality and control over nurses
D) Allows institutions to use foreign nurses as RNs

 

 

ANS:  A                    PTS:   1                    DIF:    Hard

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Evaluation | Integrated Process: Evaluation | Client Need: Physiological Integrity

 

  1. Select the most serious problem encountered when institutional licensure is used.
A) The standards are too difficult for most nurses to meet.
B) It makes moving from one institution to another more difficult.
C) Many qualified individuals are excluded from the profession.
D) There are no external controls to determine a minimum level of ability.

 

 

ANS:  D                    PTS:   1                    DIF:    Hard

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. What type of credentialing indicates that an individual has achieved a high level of expertise and knowledge in an area of practice?
A) Licensure
B) Certification
C) Professionalism
D) Registration

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Synthesis | Integrated Process: Problem Identification | Client Need: Safe and Effective Care Environment

 

  1. Identify the primary purpose of the National League for Nursing.
A) Establish standards of practice to ensure high-quality care.
B) Maintain and improve the standards of nursing education.
C) Increase the political power of nurses to influence legislation.
D) Prevent unqualified nurses from practicing in hospitals.

 

 

ANS:  B                    PTS:   1                    DIF:    Easy

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. Identify a primary goal of the American Nurses Association.
A) Promote the professional growth and development of all nurses.
B) Maintain and improve the standards of nursing education.
C) Limit access to health-care services to individuals in need.
D) Control the independence of practice by nurses to those with BS degrees.

 

 

ANS:  A                    PTS:   1                    DIF:    Easy

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. Which group composes the primary membership in the American Nurses Association?
A) Schools of nursing
B) Health-care facilities such as hospitals
C) Individual nurses
D) State nursing organizations

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. Identify a key service provided by the American Nurses Association.
A) Accrediting schools of nursing
B) Improving the standards for higher education in nursing
C) Improving health and nursing care throughout the world
D) Testing and certifying advanced practice nurses

 

 

ANS:  D                    PTS:   1                    DIF:    Easy

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Comprehension | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. What is the primary goal of the National Student Nurses Organization?
A) Changing curricula in schools of nursing to allow more students to graduate
B) Eliminating poor and unprofessional nursing professors from schools of nursing
C) Maintaining high standards of education in schools of nursing
D) Keeping unqualified students from entering the profession

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Synthesis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. What is the most significant benefit to a student who belongs to the National Student Nurses Association?
A) Receiving the official publication, Imprint, along with the membership
B) Experiencing firsthand the operation, activities, and professionalism of a national organization
C) Obtaining one of the many large cash scholarships available through the organization
D) Joining an elite group that has a great deal of power and a wide range of control over other students

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Synthesis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. Identify the primary advantage that grassroots organizations have over large, well-established organizations.
A) Members are very passionate about only one or two issues.
B) The organization is usually well funded from local sources.
C) Membership is drawn from a diverse, more representative population.
D) The organization deals with issues that have national significance.

 

 

ANS:  A                    PTS:   1                    DIF:    Hard

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Analysis | Integrated Process: Problem Identification | Client Need: Safe and Effective Care Environment

 

  1. Why is it important to determine if the goals and purposes of a specialty organization are at odds with the goals and purposes of the American Nurses Association?
A) Divergent goals produce better dialog between groups of nurses to improve both the quality and the options for care.
B) Nurses will have a choice between several distinct options and can make more informed decisions about which organization to belong to.
C) Legislators can become easily confused if they receive conflicting information from several different groups of nurses.
D) The health-care system has become so complex that only a wide range of options for the provision of health care can successfully be used.

 

 

ANS:  C                    PTS:   1                    DIF:    Hard

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Synthesis | Integrated Process: Problem Identification | Client Need: Safe and Effective Care Environment

 

COMPLETION

 

  1. Fill in the blanks with the correct word(s) to complete the following statement:

One of the most important factors in recent changes that have occurred in the health-care system is demands by __________ __________ for higher quality care.

 

ANS:  health-care; consumers

 

PTS:   1                    DIF:    Medium

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. Fill in the blanks with the correct word(s) to complete the following statement:

The primary driving force in the history of the development of licensure for nurses was _____________ _____________ of nursing care and protection of the public.

 

ANS:  inconsistent; quality

 

PTS:   1                    DIF:    Hard

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Synthesis | Integrated Process: Problem Identification | Client Need: Safe and Effective Care Environment

 

MULTIPLE RESPONSE

 

  1. Select all of the items characteristics of the New York State Licensure Bill of 1904.
A) Required hospitals to accept nursing students for training
B) Required nursing schools to be registered with the state board of regents
C) Formulated rules for the examination of nurses
D) Established the minimum length of basic nursing programs at 1 year
E) Established a State Board of Nursing

 

 

ANS:  B, C, E           PTS:   1                    DIF:    Hard

TOP:   The Evolution of Licensure, Certification, and Nursing Organizations

KEY:  Cognitive Domain: Analysis | Integrated Process: Implementation | Client Need: Safe and Effective Care Environment

Chapter 6: Ethics in Nursing

 

MULTIPLE CHOICE

 

  1. What is best described as the concepts, ideals, behaviors, and significant themes that give meaning to a person’s life?
A) Morals
B) Values
C) Laws
D) Ethics

 

 

ANS:  B                    PTS:   1                    DIF:    Easy               TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Comprehension | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. What are rules of conduct that protect the social fabric?
A) Morals
B) Values
C) Laws
D) Ethics

 

 

ANS:  C                    PTS:   1                    DIF:    Easy               TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Comprehension | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. What term is best defined as standards of right and wrong that often are based on religious beliefs?
A) Morals
B) Values
C) Laws
D) Ethics

 

 

ANS:  A                    PTS:   1                    DIF:    Easy               TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Comprehension | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. Identify the term defined as systems of valued behaviors and beliefs.
A) Morals
B) Values
C) Laws
D) Ethics

 

 

ANS:  D                    PTS:   1                    DIF:    Easy               TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Comprehension | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. As nurses achieve increased professional autonomy, what must they also accept?
A) Legal immunity
B) Decrease in workload
C) Ethical accountability
D) Ethical freedom

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. What is the primary function of an ethical code?
A) A framework for decision-making
B) A collection of static rules
C) A group of legally binding values
D) The “ball and chain” of the profession

 

 

ANS:  A                    PTS:   1                    DIF:    Medium         TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Application | Integrated Process: Evaluation | Client Need: Safe and Effective Care Environment

 

  1. Identify the system of ethical decision-making that has as its focus a concern for efficiency and utility.
A) Deontological
B) Jurisdictional
C) Teleological
D) Theological

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. Provision number 1 of the 2001 Code of Ethics for Nurses states: “The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health-care problems.” On which ethical principle is this statement primarily based?
A) The right to privacy
B) Distributive justice
C) Client autonomy
D) Nurse veracity

 

 

ANS:  B                    PTS:   1                    DIF:    Hard               TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. Identify the statement that most accurately compares the ethical code for nurses with the law.
A) If a law is not broken, then the nurse is following the ethical code.
B) If the ethical code and the law have a discrepancy, it is always better to follow the law.
C) The ethical code encompasses all the pertinent laws.
D) If the ethical code is violated, a law is also violated.

 

 

ANS:  C                    PTS:   1                    DIF:    Hard               TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Synthesis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. Provision number 6 of the 2001 Code of Ethics for Nurses states: “The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.” On which ethical principle is this statement primarily based?
A) Veracity
B) Autonomy
C) Accountability
D) Beneficence

 

 

ANS:  C                    PTS:   1                    DIF:    Hard               TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. Identify the name of the system of ethical decision-making that is based on the “greatest good” principle.
A) Egoism
B) Utilitarianism
C) Deontological
D) Jurisdictional

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. Identify the system of ethical decision-making that is based on the discovery and confirmation of a set of morals or rules that govern the ethical dilemma.
A) Deontological
B) Jurisdictional
C) Teleological
D) Theological

 

 

ANS:  A                    PTS:   1                    DIF:    Medium         TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. What is the ethical principle that requires that the primary goal of health care and nursing is to do good for others?
A) Autonomy
B) Fidelity
C) Beneficence
D) Veracity

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. What is the best definition of the ethical principle of nonmaleficence?
A) Health-care workers avoiding harm to clients
B) Telling the truth to clients in all matters
C) Being faithful to commitments made to clients
D) The right of self-determination of clients

 

 

ANS:  A                    PTS:   1                    DIF:    Easy               TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Comprehension | Integrated Process: Problem Identification | Client Need: Safe and Effective Care Environment

 

  1. Identify the term used when an ethical situation arises in which there is a choice between two equally unfavorable alternatives.
A) A tort
B) Ethical antagonism
C) Contraindication
D) Ethical dilemma

 

 

ANS:  D                    PTS:   1                    DIF:    Medium         TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. What is the first step in the ethical decision-making process?
A) Consider the alternatives.
B) Collect, analyze, and interpret the data.
C) Consider the consequences of the actions.
D) Make a decision.

 

 

ANS:  B                    PTS:   1                    DIF:    Easy               TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Knowledge | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. Identify the outcome that best demonstrates a critical care nurse’s successful application of the ethical principle of nonmaleficence to the care of a client who has experienced a cerebrovascular accident.
A) The client is aware of his or her diagnosis despite attempts of the family to withhold that information.
B) The client is beginning to be able to use simple words to express his or her needs.
C) The family has been taught the necessary skills to care for the client at home with the supervision of a home health-care nurse.
D) There is no evidence of skin breakdown on bony pressure points, and the client’s shoulder and hip on the affected side remain intact.

 

 

ANS:  D                    PTS:   1                    DIF:    Hard               TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Evaluation | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the best method for a nurse to acknowledge a client’s autonomy.
A) Follow only the instructions of the client’s family.
B) Know and understand the state’s laws that address living wills.
C) Use the ethical principle of best interest when making decisions about the client’s care needs.
D) Incorporate the ethical principle of paternalism into all client care activities.

 

 

ANS:  B                    PTS:   1                    DIF:    Hard               TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

COMPLETION

 

  1. Arrange the steps of the ethical decision-making process in their correct order. (Enter the letter of each step in the proper sequence; do not use commas or spaces.)
  2. A) Consider the choices of action.
  3. B) Act on the decision.
  4. C) Collect, analyze, and interpret data.
  5. D) Analyze the advantages of each action.
  6. E) State the dilemma.

 

ANS:  CEADB

 

PTS:   1                    DIF:    Medium         TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. Fill in the blanks with the correct word(s) to complete the following statement:

Over time, popular acceptance of _______________ rights can give them force of _______________ rights.

 

ANS:  ethical; legal

 

PTS:   1                    DIF:    Medium         TOP:   Ethics in Nursing

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

Chapter 9: NCLEX: What You Need to Know

 

MULTIPLE CHOICE

 

  1. What statement is most accurate about the NCLEX-CAT, RN?
A) It is a certification examination taken by all nurses.
B) It is too difficult for most new graduates to pass the first time.
C) It is unnecessary in states where institutional licensure is the rule.
D) It is required of all nurses for licensure.

 

 

ANS:  D                    PTS:   1                    DIF:    Easy

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Comprehension | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. How is the nursing process treated by the NCLEX-CAT, RN?
A) It is a five-step process that involves assessment, analysis, planning, implementation, and evaluation.
B) It is a four-step process that involves assessment, planning, implementation, and evaluation.
C) It is unimportant, and no questions are asked about it.
D) It is the most important part of the examination.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. Identify the question stem that best indicates that an “Evaluation” category question is being asked.
A) Which of these actions should the nurse perform first?
B) You know your teaching concerning colostomy care was successful if the client makes which statement?
C) Identify the data that are most important to obtain for a client with cardiac disease.
D) Which nursing diagnosis has the highest priority?

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Evaluation | Client Need: Safe and Effective Care Environment

 

  1. Identify the question stem that best indicates that an “Assessment” category question is being asked.
A) Which action should the nurse perform first?
B) You know your teaching concerning colostomy care was successful if the client makes which statement?
C) Identify the data that are most important to obtain for a client with cardiac disease.
D) Which nursing diagnosis has the highest priority?

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Problem Identification | Client Need: Safe and Effective Care Environment

 

  1. Which question stem best indicates that an “Analysis” category question is being asked?
A) Which action should the nurse perform first?
B) You know your teaching concerning colostomy care was successful if the client makes which statement?
C) Identify the data that are most important to obtain for a client with cardiac disease.
D) Which nursing diagnosis has the highest priority?

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Analysis | Client Need: Safe and Effective Care Environment

 

  1. Which question stem best indicates that an “Implementation” category question is being asked?
A) Which action should the nurse perform first?
B) You know your teaching concerning colostomy care was successful if the client makes which statement?
C) Identify the data that are most important to obtain for a client with cardiac disease.
D) Which nursing diagnosis has the highest priority?

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. In which health needs categories of the NCLEX-CAT, RN examination would the student find questions about a pregnant woman?
A) Safe and effective care environment
B) Psychosocial needs
C) Health promotion and maintenance needs
D) Physiological needs

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Problem Identification | Client Need: Health Promotion and Maintenance

 

  1. A question stem asks: “A client admitted with BUN of 64 and a creatinine of 6 would require which nursing actions first?” What cognitive level does this question stem indicate?
A) Level 1, recall question
B) Level 2, analysis question
C) Level 3, synthesis question
D) Level 4, advanced question

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Problem Identification | Client Need: Physiological Integrity

 

  1. What is the maximum number of questions that a graduate may answer on the NCLEX-RN, CAT?
A) 60
B) 75
C) 265
D) 355

 

 

ANS:  B                    PTS:   1                    DIF:    Easy

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Memory | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. In the abbreviation NCLEX-CAT, RN, what does CAT stand for?
A) Computerized assistive testing
B) Complex assessment technique
C) Computerized assessment testing
D) Computerized adaptive testing

 

 

ANS:  D                    PTS:   1                    DIF:    Easy

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Comprehension | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. Which statement made by a student after a class on the NCLEX-CAT, RN test indicates that the student has a good understanding of the examination?
A) “Partial credit is given for close answers.”
B) “The sequence of questions is determined by the difficulty level.”
C) “High levels of computer skills are needed to successfully complete the test.”
D) “The graduate is allowed to go back and change the answers of questions answered previously on the examination.”

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Problem Identification | Client Need: Safe and Effective Care Environment

 

  1. Identify the correct procedure that a graduate who fails the NCLEX-CAT, RN must follow.
A) Wait 45 days before retaking the examination.
B) Retake only the portion of the examination that was failed.
C) Repeat an approved “refresher” course before taking the examination a second time.
D) Retake the examination immediately.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Comprehension | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. What is an important factor to remember for graduates who decide to use group study as a means of preparing for the NCLEX-CAT, RN examination?
A) A group of at least 15 students is needed for optimal study.
B) Make sure that study sessions are at least 3 hours long for the most efficient use of time.
C) Have each group member prepare a section of the topic for study during that session.
D) Bring large quantities of chips, candy, pizza, and soda to the session to maintain energy levels.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. Which test-taking tip is most important to remember when taking a multiple-choice examination such as the NCLEX-CAT, RN?
A) Read each question four times so that related information can be remembered.
B) To save time, select the first answer that is correct.
C) Ignore negative words in the question stem because they confuse the issue.
D) Avoid reading into the question information that is not included in the client situation.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. Which word found in a question stem would make the question negative?
A) First
B) Atypical
C) Highest priority
D) Appropriate

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Problem Identification | Client Need: Safe and Effective Care Environment

 

  1. While taking the NCLEX-CAT, RN examination, a graduate encounters a question about a disease process that had not been covered in any class in nursing school. Which strategy would be best for the graduate to use in answering this question?
A) Look for an unfamiliar answer and select it because it probably relates to the unknown disease process.
B) Select answer A and move on to the next question.
C) Try to remember a question earlier in the examination that dealt with a similar situation and apply that information to the current question.
D) Select the answer that appears logical and involves general nursing care.

 

 

ANS:  D                    PTS:   1                    DIF:    Easy

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. The mother of four children brings her 6-year-old girl to the public health well-child clinic because the child has “scratched herself raw.” The public health nurse diagnoses the child as having scabies and gives the mother appropriate medication for the child’s treatment. Select the most appropriate instructions by the nurse to the mother of these four children.
A) Avoid sharing towels and linens with the infected child.
B) Treat the other children immediately.
C) Treat the other children only if symptoms develop because the medication has many side effects.
D) Wash the family’s hair in strong detergent shampoo.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. A 28-year-old woman is diagnosed with systemic lupus erythematosus. Select the discharge instructions by the nurse that best help prevent exacerbation of the disease.
A) Avoid using birth control pills and stay out of bright sun.
B) Make sure to take your penicillin and sulfa antibiotics as prescribed.
C) Avoid foods that are high in potassium or protein.
D) Once you go into remission, you can stop taking your prednisone.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Evaluation | Integrated Process: Evaluation | Client Need: Safe and Effective Care Environment

 

  1. Identify the action that the nurse should take first when a 12-year-old boy who is sitting in a chair begins to have a tonic-clonic seizure.
A) Restrain the child to prevent injury to his arms and legs.
B) Pad the environment around the chair.
C) Quickly insert an oral airway in his mouth to keep the airway patent.
D) Move him to a flat surface and position him on his side.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Select the discharge instruction to a client diagnosed with multiple sclerosis that most reduces the risk potential for complications.
A) Take cool baths or showers only.
B) Midday naps will interfere with your ability to sleep at night.
C) Avoid high-fiber foods such as fresh fruits and vegetables.
D) Limit your fluid intake to 1,000 mL a day to prevent incontinence.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. After a third episode of cystitis, a client asks the nurse what she can do to prevent another infection. The nurse recommends that the client follow an acid-ash diet and avoid which of the following foods?
A) Cranberry and orange juice
B) Milk and apples
C) Coffee and tea
D) Prune juice and plums

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Problem Identification | Client Need: Physiological Integrity

 

  1. Identify the instructions by the nurse that best help prevent complications from renal disease in a client who is being prepared for hemodialysis due to end-stage renal disease secondary to polycystic kidney disease.
A) Make sure you drink 2 to 3 liters each day to prevent cramps.
B) Increase your intake of fresh fruits such as bananas and oranges.
C) Limit your sodium intake and avoid using a salt substitute.
D) Eat 3 to 5 ounces of meat at each meal to prevent catabolism.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the action by the public health nurse that best reduces the risk for infection of a man who now has a positive purified protein derivative (PPD) and whose wife was recently diagnosed with active pulmonary tuberculosis.
A) Obtain a list of names of other persons his wife has come into contact with.
B) Instruct the man that he has to remain in isolation for 1 week.
C) Begin a 6- to 12-month course of treatment with rifampin (Rifadin).
D) Re-administer the PPD because it may be a false positive.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. After a stab wound to the chest, a client develops a pneumothorax and has a chest tube inserted in the emergency room (ER) that is connected to a self-contained underwater-seal drainage system (pleur-evac). Select the action the ER nurse should take first when she notices that the second chamber has stopped bubbling.
A) Remove any blockages from the drainage tube.
B) Tape all connections to eliminate leaks in the system.
C) Change out the drainage system because the first one is obviously defective.
D) Increase the suction to 120 mm Hg negative pressure.

 

 

ANS:  A                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Choose the position that the nurse should place a client in to best relieve the midsternal chest pain caused by pericarditis secondary to a viral infection.
A) Head elevated 30 to 40 degrees
B) Flat in bed in the supine position
C) Trendelenburg’s to help promote drainage of the excessive pericardial fluid
D) Sitting up 90 degrees and leaning forward

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the nursing intervention that has the highest priority for a client who is experiencing hemiparesis secondary to an intercerebral blood clot (stroke).
A) Position the client on the affected side.
B) Encourage the client to perform active range of motion exercises every 4 hours.
C) Place hand rolls in the hands to prevent contractures.
D) Keep the head of the bed flat to prevent dizziness.

 

 

ANS:  A                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Planning | Client Need: Physiological Integrity

 

  1. Select the action by the nurse that best helps promote the adaptation of a client in Addisonian crisis.
A) Assign the client to a private room.
B) Cover the client with one or two extra blankets to keep him or her warm.
C) Ambulate the client four times per day to maintain exercise tolerance.
D) Encourage the client to take a shower instead of a bed bath.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the initial action that the nurse should take to treat an acute episode of diabetic ketoacidosis in a client with type 1 insulin-dependent diabetes mellitus.
A) Administer 50 units of regular insulin IV.
B) Start an IV of 0.45 percent normal saline at 150 mL per hour.
C) Administer 2 amps of sodium bicarbonate.
D) Ask the client if he or she has taken his insulin that morning.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Planning | Client Need: Physiological Integrity

 

  1. Identify the statement made by the nurse during the discharge instructions to a client with a hiatal hernia that best aids in the prevention of gastrointestinal discomfort.
A) “You may eat three large meals a day but limit carbohydrate intake.”
B) “If you lie down right after you eat, the food will digest more thoroughly.”
C) “Try to eat six bland small meals per day that are high in fiber.”
D) “Drinking two to three glasses of water with each meal will prevent reflux.”

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. A client is admitted to the medical-surgical unit with acute pancreatitis secondary to a viral infection. Select the action by the nurse that is most important in promoting healing of the pancreas.
A) Place the client in the prone position to increase comfort.
B) Maintain the client in a strict NPO status.
C) Decrease the IV intake to prevent cardiac overload.
D) Administer prescribed IV antibiotics on schedule.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Select the action that the nurse should take after finding a firm nodule during a scrotal examination of a 32-year-old man.
A) Notify the client’s urologist.
B) Perform a rectal examination for abnormalities of the prostate gland.
C) Prepare the client for a follow-up ultrasound to confirm the diagnosis.
D) Use a flashlight to transilluminate the scrotum.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Problem Identification | Client Need: Physiological Integrity

 

  1. A client receives an autograph of skin from his abdomen to his right arm after suffering a third-degree burn from a campfire. Select the instructions by the nurse that best ensure that the newly grafted skin is not rejected.
A) Decrease your protein intake to 60 grams per day.
B) Increase your fluid intake to 2 to 3 liters per day.
C) Avoid going outside for 2 weeks after you are discharged from the hospital.
D) Keep your right arm in a sling with minimal range of motion for 2 weeks.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the action by the nurse that would promote the optimal effectiveness of Bryant’s traction for a 3-year-old child in the pediatric unit who sustained a fractured femur in a fall from his front porch.
A) Maintain the hips at a 90-degree angle to the body.
B) Allow the parents to remain with the child as much as possible.
C) Place a sheep-skin pad under the child to prevent skin breakdown.
D) Make sure the traction weights were resting against the side of the crib to reduce the excessive pull on the bones.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the activity instructions given by the nurse at the time of discharge to a client with acute hepatitis A that best promote the client’s recovery.
A) Except for going to the bathroom, you should stay in bed.
B) Start walking short distances as soon as you feel strong enough.
C) Active, isometric-type exercises performed four times a day will help prevent muscle atrophy.
D) You may work at your computer for no more than 4 hours per day.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Select the most effective action a nurse can take to protect a client who has been recently diagnosed with thrombocytopenia.
A) Have the client use a wheelchair whenever the client must leave the room.
B) Increase the client’s fluid intake to 3 liters per day to prevent a urinary tract infection.
C) When giving IM injections, use the smallest needle possible to administer the medication.
D) Limit visits to immediate family only for 10 minutes per hour.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Physiological Integrity

 

  1. Select the position that is best for the nurse to keep a client who received a head injury in a sports accident and has his neck stabilized in a neck collar.
A) Flat in the supine position
B) Trendelenburg’s position
C) Low Fowler’s position with the head elevated 30 degrees
D) Side-lying position with the legs flexed slightly

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the nursing action that is most appropriate when the nurse assesses a small amount of clear, watery fluid oozing from the nose of a client who received a blow to the head in a barroom fight.
A) Encourage the client to blow his nose to clear the sinuses.
B) Use a dip-stick to test the drainage for glucose.
C) Keep the client’s head flat.
D) Ask the client about with what type of object he was struck.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. A 32-year-old woman who has a fractured T7 following an automobile accident develops urinary retention. The physician orders intermittent catheterizations every 6 hours, and the nurse obtains between 600 and 830 mL of urine each time. Select the most appropriate nursing action for this client.
A) Notify the physician and obtain an order for a Foley catheter.
B) Restrict the client’s fluid intake to 500 mL per shift.
C) Obtain an order to catheterize the client every 3 to 4 hours.
D) Continue catheterizing the client per the physician’s order.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the action by the nurse caring for a client who has just returned from extracorporeal shock wave lithotripsy that best promotes the client’s physiological adaptation.
A) Increase fluid intake to 2 to 3 liters per day.
B) Evaluate vital signs every 2 hours.
C) Use an antimicrobial ointment and sterile dressing on the incision site.
D) Report any blood in the urine to the physician immediately.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Evaluation | Integrated Process: Planning | Client Need: Physiological Integrity

 

  1. The pulse oximeter connected to a client with viral pneumonia, but who has no other underlying respiratory disease, has had readings between 79 and 88 percent for the last half hour. Identify the type of oxygen delivery system that is most effective for the nurse to initiate when the client complains of shortness of breath.
A) Nonrebreather mask
B) Nasal cannula
C) Rebreather mask
D) High-humidity face tent

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Select the nursing action that takes highest priority in the care of a client with a chest tube connected to a closed underwater-seal drainage system.
A) Strip or milk the chest and drainage tube every 2 hours.
B) Make sure there is continuous bubbling in the underwater-seal chamber.
C) Record the amount of drainage in the drainage collection chambers every 8 hours.
D) Hang the drainage collection system at chest level to promote optimal function.

 

 

ANS:  C                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the client the triage nurse would send first for treatment after a severe motor vehicle accident that involves four clients who are brought to the ER for treatment.
A) A 23-year-old third-trimester pregnant woman who is having contractions
B) A 42-year-old man who has a crushed cranium and no blood pressure or pulse
C) A 61-year-old woman having gurgling respirations secondary to a maxillofacial injury
D) An 8-year-old boy with lower extremity paralysis secondary to a lumbar spinal cord injury

 

 

ANS:  C                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Evaluation | Client Need: Safe and Effective Care Environment

 

  1. Select the action that the clinic nurse should take first when an adult client with a severe sunburn of the chest, back, face, and legs is seen in the clinic.
A) Begin an IV of D5/0.45NS to run at 150 mL per hour.
B) Give the client a prescribed pain medication.
C) Apply a prescribed antimicrobial ointment to the burn areas to prevent infection.
D) Discuss with the client the risks of developing skin cancer related to repeated sun exposure.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Select the action by the nurse that best helps reduce intracranial pressure in a client who sustained a head injury after a diving accident.
A) Use a manual respirator (Ambu bag) to hyperventilate the client.
B) Have the client breathe slowly into a paper bag.
C) Administer 1 amp of sodium bicarbonate IV slowly.
D) Maintain the client in a supine position.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify how the nurse can best assess the blood pressure of a client who develops lymphedema in both arms after a bilateral mastectomy.
A) Take the blood pressure in the arm, but alternate arms each time it is taken.
B) Take the blood pressure in the thigh using a thigh cuff.
C) Assess the client’s capillary refill and extremities for color, warmth, and sensation.
D) Use an arm cuff for consistency, but take the blood pressure in the thigh area.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Select the teaching point the nurse should include in the discharge instructions for a client with asthma about the mode of action of the home medication cromolyn sodium (Intal).
A) Produces bronchodilation
B) Reduces the production of mucus
C) Liquefies and thins thick mucus secretions so they can be coughed out
D) Blocks the release of bronchoconstrictors from the mast cells

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Planning | Client Need: Physiological Integrity

 

  1. Identify the initial action by the ER nurse that is most appropriate for a 42-year-old woman diagnosed with a mood disturbance disorder who overdosed on amitriptyline (Elavil).
A) Induce vomiting by administering 30 mL of syrup of Ipecac.
B) Initiate an IV of normal saline at 200 mL per hour.
C) Lavage the stomach with a #14 nasogastric tube to prevent trauma.
D) Administer activated charcoal 50 g every 4 hours for 24 hours.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

  1. Select the action by the nurse that is most appropriate for a 32-year-old woman diagnosed with Sjögren’s syndrome.
A) Select a diet for the client with foods high in potassium, such as oranges and bananas.
B) Use a moisturizing emollient on the client’s skin after a shower.
C) Instruct the client to take a multivitamin plus iron each day when discharged.
D) Maintain the client’s bed so that the head is elevated 30 to 45 degrees.

 

 

ANS:  B                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. During her first month postpartum, a woman who is breastfeeding her baby develops unilateral mastitis. Select the statement by the nurse that demonstrates an appropriate use of the therapeutic communication technique called self-disclosure.
A) “I remember the discomfort I had after my first child and how quickly it went away after I started taking antibiotics.”
B) “You seem to be very anxious about the condition. Tell me how you think it will affect your ability to breastfeed.”
C) “This is a common and relatively minor problem, and you should be better in 2 to 4 days.”
D) “The infection is not your fault. The organism probably came from the respiratory tract of your baby.”

 

 

ANS:  A                    PTS:   1                    DIF:    Easy

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. Identify the nursing action that best prevents the introduction of air into a subclavian IV when the nurse is changing the tubing on the IV solution.
A) Keep the head of the bed elevated 45 degrees.
B) Have the client turn his head away from the insertion site.
C) Encourage the client to do the Valsalva’s maneuver during the procedure.
D) Make sure the tubing on the old IV is turned off before changing.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. Select the action the nurse should take first when a client becomes short of breath, pale, diaphoretic, and complains of localized chest pain after a new bottle of total parenteral nutrition (TPN) has been hung.
A) Bring the code cart into the room and prepare for cardiopulmonary resuscitation.
B) Place the bed in Trendelenburg’s position and turn the client on the left side.
C) Keep the head and body flat and elevate the legs.
D) Notify the physician that the client is having an myocardial infarction.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the initial action by the nurse that is most appropriate for a 10-year-old boy who is seen in the ER with a partially detached retina on the left side of the left eye after sustaining a head injury during a baseball game.
A) Cover both eyes with a soft eye patch.
B) Position the client on the right side with his head slightly elevated.
C) Irrigate the left eye with a gentile stream of normal saline.
D) Position the client on the left side with his head flat.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Select the communication technique that is most appropriate for the nurse to use when working with a client who has both eyes patched.
A) Speak loudly and clearly so the client can understand better.
B) Identify himself or herself each time the nurse enters the client’s room.
C) Enter and leave the room quietly so as not to startle the client.
D) Touch the client only when absolutely necessary.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the discharge instructions by the nurse for a client diagnosed with Addison’s disease that most accurately describes how the client should take fludrocortisone acetate and hydrocortisone at home.
A) Take two-thirds of the dose when you wake in the morning and the remaining one-third late in the afternoon.
B) Take the hydrocortisone in the morning with breakfast and the fludrocortisone in the afternoon on an empty stomach.
C) Take both medications before you go to bed at night.
D) Take both medications when you wake up in the morning.

 

 

ANS:  A                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Evaluation | Integrated Process: Evaluation | Client Need: Physiological Integrity

 

  1. Select the position that is most appropriate for a client who just returned from a myelogram in which a water-soluble contrast medium (metrizamide) was used.
A) Trendelenburg’s
B) Prone
C) Supine/flat
D) Head elevated 45 degrees

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. Choose the nursing action that is most appropriate for the collection of a stool specimen from a 3-year-old child who has had diarrhea for the past 4 days.
A) Use a preservative solution after the specimen is obtained.
B) Store the specimen in the refrigerator until it can be taken to the laboratory.
C) Place the specimen in a sterile container.
D) Collect an entire stool.

 

 

ANS:  C                    PTS:   1                    DIF:    Easy

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. Identify the intervention by the nurse that is most appropriate in caring for a client with a recent diagnosis of acute pancreatitis.
A) Administer a prescribed leave it in prn pain medication.
B) Reduce the IV rate to 50 mL per hour to prevent fluid overload.
C) Encourage the client to increase intake of protein to promote healing.
D) Position the client with the head elevated 45 degrees.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. A post–C-section client who had the procedure under an inhalation anesthetic begins to experience severe shivering in the recovery room. In addition to covering the client with extra blankets, select another appropriate action to be taken by the nurse.
A) Raise the temperature of the room by increasing the thermostat.
B) Call the surgeon and notify of the deterioration in the client’s condition.
C) Apply the prescribed oxygen by face tent.
D) Decrease the IV rate to reduce the amount of cold fluid entering the client’s cardiovascular system.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. A client with pancreatitis complains of abdominal pain. If the physician has prescribed all of the following medications prn for pain for this client, identify the one the nurse should give.
A) Morphine sulfate, 5 to 10 mg IV
B) Propoxyphene HCL (Darvon), 65 mg PO
C) Meperidine (Demerol), 25 to 50 mg IV
D) Acetaminophen (Tylenol), 650 mg PO

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Choose the dietary recommendations that are most appropriate for the nurse to make to a client who was diagnosed with hypoparathyroidism.
A) Increase your intake of vitamin D and calcium.
B) Increase your intake of potassium and iron.
C) Decrease your intake of calcium and phosphate.
D) Increase your intake of folic acid and decrease your intake of sodium.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. Select the instructions by the nurse to a postoperative client who had a transsphenoidal hypophysectomy that best promote his recovery.
A) If you have any ringing in your ears, let me know right away.
B) Please keep your head flat for the first 12 hours after surgery.
C) Do not blow your nose, cough, or sneeze for the first 48 hours after surgery.
D) You must increase your fluid intake to 2 liters of fluid per day.

 

 

ANS:  C                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. Identify the dietary instructions by the nurse that are most appropriate for a client who has a positive Trousseau’s sign.
A) Decrease your intake of calcium and phosphate.
B) Increase your intake of potassium and iron.
C) Increase your intake of vitamin D and calcium.
D) Increase your intake of folic acid and decrease your intake of sodium.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Problem Identification | Client Need: Physiological Integrity

 

  1. Identify the action by the nurse that is most important in providing care for a client who has a Fiberglas cast on her right arm.
A) Cover the cast with a pillowcase to keep the arm warm.
B) Keep a cast cutter at the bed side.
C) Assess the fingers of the right hand for movement and sensation every 2 hours.
D) Elevate the cast 45 degrees for the first 48 hours.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. A 30-month-old boy with acute bronchitis and respiratory distress is admitted to the pediatric unit for croup (mist) tent treatment. Choose the intervention by the nurse that is developmentally most appropriate when the child refuses to stay in the tent.
A) Take away his favorite toy until he decides to remain in the tent.
B) Tell him a story about how a little boy died because he did not stay in the tent.
C) Medicate him with a sedative to reduce anxiety and calm him.
D) Instruct his mother to play a board game with him while sitting in the tent.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. A 44-year-old woman who is diagnosed with paranoid personality disorder is seen in the clinic for treatment. Select the intervention by the nurse that best achieves the goal of promoting consensual validation of reality.
A) Challenge her delusional perceptions by joking in a nonthreatening way about how unrealistic they are.
B) Use reality reinforcement and avoid arguing with the client about her perceptions.
C) Use distraction when the client begins to expound about her perceptions.
D) Administer a prescribed prn antianxiety medication 1 hour before attempting to council with the client.

 

 

ANS:  B                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Planning | Client Need: Physiological Integrity

 

  1. Select the instructions given by the nurse to a group of senior citizens attending a class on aging at a senior center that best addresses the normal age-related changes in vision.
A) You may have problems seeing blue or black objects against a yellow wall.
B) Your central vision is poorer, so you may not see objects in front of you.
C) Try to avoid driving at night due to decreased night vision.
D) It is not unusual to see rainbows or halos around artificial lights.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Evaluation | Client Need: Health Promotion and Maintenance

 

  1. Choose the most therapeutic response by the nurse to a new mother who verbalizes uncertainty about her ability to breastfeed her new baby boy.
A) Breastfeeding a baby is best. Bottle feeding is only a poor substitute for women who can’t produce enough milk.
B) Let’s try the breastfeeding first and see how you do. I’ll be right here to help you with the process.
C) We can give him a bottle until your milk comes in and you feel more sure about your ability to breastfeed.
D) If you don’t make up your mind right away, we’ll be forced to bottle feed him.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. Identify the intervention by the nurse that is most appropriate when providing care for a client who has just returned to the surgical unit with a below-the-knee amputation.
A) Keeping the stump elevated for the first 24 hours
B) Removing and reapplying the pressure dressing every 2 hours to prevent necrosis
C) Keeping the client on complete bedrest for the first 48 hours
D) Treating the phantom limb pain by applying a warm compress to the stump

 

 

ANS:  A                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Physiological Integrity

 

  1. Select the intervention that the nurse places highest priority on when caring for an adult client with severe impetigo.
A) Using a circular motion to apply prescribed topical antibiotic ointment
B) Covering the client’s hands with gauze or mitts to prevent scratching
C) Administering prescribed systemic antibiotics
D) Giving the client two tepid baths, one in the a.m. and one in the p.m.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. A 23-year-old woman with partial and full thickness burns over 28 percent of her body is being treated with the “open method” of burn treatment. Select the nursing action that best helps prevent discomfort caused by air currents over the burn areas.
A) Keeping her well sedated
B) Adding humidity to the room air
C) Supporting her upper linens on a bed cradle
D) Keeping the doors and windows tightly closed in her room

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Evaluation | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the nursing action that is most appropriate for the nurse to take when caring for a newborn who has tremors and a high-pitched cry and is diaphoretic.
A) Obtain urine for drug screen for cocaine.
B) Perform a finger stick blood sugar.
C) Cover the infant’s head with a cap.
D) Give the infant 1 ounce of sterile water.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. Identify the teaching point the nurse should include in the discharge plan for a renal transplant client about the risks of infection postoperatively.
A) If you develop fever, chills, joint pain, or headache, contact the physician immediately.
B) You can stop taking your tacrolimus (Prograf) if you start to feel sick or if you are very tired.
C) You will never be able to go to church or go any place where there are crowds of people.
D) You should avoid going to the dentist or the gynecologist for at least a year after your surgery.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. Select the action by the nurse that has the highest priority in the care of several clients who are receiving postoperative pain management by epidural analgesia on the surgical unit.
A) Change the IV tubing with each bag of medication.
B) Keep the head of bed elevated 30 degrees to prevent hypotension.
C) Monitor peripheral pulses every 2 hours.
D) Assess for movement and sensation of the feet and legs each shift.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. For the past three exchanges, a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) has retained between 250 and 400 mL with each exchange. He has no urine output and has not moved his bowels in 3 days. The returned CAPD fluid is clear. Select the most appropriate action by the nurse at this time.
A) Increase the glucose concentration of the fluid to pull off more fluid.
B) Cap the catheter and notify the physician.
C) Evaluate the patient for possible constipation.
D) Skip the next exchange and allow the fluid to drain.

 

 

ANS:  C                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the best measure the nurse can take to limit the complications of a client who is developing compartment syndrome after a splint is applied to a fractured ankle.
A) Remove the splint, clothing, socks, and other external sources of pressure.
B) Assess the pulses and skin color every 2 hours.
C) Make sure the ankle is below the level of the heart.
D) Apply ace bandages to the foot to decrease the swelling.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. A client in chronic renal failure asks the nurse, “Why must I drink this awful-tasting Kayexalate 4 times a day?” Which of the following explanations by the nurse would be most appropriate?
A) “If you do not drink it, we’ll have to give it as an enema.”
B) “It will help lower your potassium level by exchanging sodium ions for potassium ions in your intestines.”
C) “It will help increase your urine output by stimulating your kidneys and promoting the movement of water into the tubule system.”
D) “It will prevent infections by decreasing the bacteria in your intestinal tract.”

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Select the action by the nurse in the obstetric clinic that is most appropriate in preparing a client at 18 weeks’ gestation for an amniocentesis.
A) Encourage her to void just before the procedure.
B) Post all blood work on the chart.
C) Give her a prescribed sedative medication 1 hour before the procedure.
D) Have her drink two glasses of water to make sure her bladder is full.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Implementation | Client Need: Health Promotion and Maintenance

 

  1. Identify the nursing action that takes the highest priority in the care of a 2-year-old boy in the edematous phase of nephrotic syndrome.
A) Increase fluid intake to 1,000 mL per day.
B) Encourage the child to play actively for 10 minutes each hour.
C) Clean and powder the skin folds every 2 hours.
D) Monitor intake and output every 24 hours.

 

 

ANS:  C                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Planning | Client Need: Physiological Integrity

 

  1. Choose the nursing intervention that is most appropriate in providing care to a 28-year-old mother of two children who is in the terminal stages of ovarian cancer but is still able to communicate.
A) Instruct her in the benefits and risks of new experimental cancer treatments.
B) Give her as much opportunity as possible for control over her care.
C) Allow her to verbalize her regrets and shortcomings of her life.
D) Limit the number of visits by her children to two per day.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the additional changes in the ventilator settings the nurse needs to make when changing a ventilator client from full-control mode to assist/control mode.
A) Increase in the sensitivity setting
B) Decrease in the FIO2
C) Increase in the FIO2
D) Decrease in the sensitivity setting

 

 

ANS:  A                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the action the nurse should take first when the low tidal volume alarm on a positive pressure, volume-cycled ventilator begins and continues to sound.
A) Check for water buildup in the ventilator tubing.
B) Disconnect the oxygen supply to the ventilator.
C) Check for separation of the ventilator tube from the endotracheal tube.
D) Encourage the client to cough to remove excessive secretions.

 

 

ANS:  C                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Evaluation | Integrated Process: Problem Identification | Client Need: Physiological Integrity

 

  1. A 78-year-old client who experiences angina after even minimal activity is treated with medications. Identify the medication mode of action that the nurse would give to best decrease myocardial oxygen consumption and reduce chest pain.
A) Increase preload.
B) Reduce afterload.
C) Reduce preload.
D) Increase contractility.

 

 

ANS:  B                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Evaluation | Client Need: Physiological Integrity

 

  1. Select the nursing action that takes highest priority in providing care for a client diagnosed with an organic brain syndrome.
A) Place the client in a group of clients to maintain his social skills.
B) Order foods for the client that are attractive and tasty to maintain nutritional status.
C) Provide a safe environment to prevent injury.
D) Encourage as much self-care as possible to maintain independence.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

  1. Identify the nursing action that is most appropriate for a client who is diagnosed with injury to cranial nerves IX and X after a blow to the head.
A) Use enemas to maintain normal bowel function.
B) Maintain the client in an NPO status.
C) Cover both of the client’s eyes with soft eye patches to prevent corneal abrasions.
D) Keep the head of bed flat for 24 hours after admission.

 

 

ANS:  B                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Evaluation | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Select the instruction given by the nurse to a group of senior citizens attending a class on aging at a senior center that best addresses the normal age-related changes in the skin.
A) Avoid using emollients because of the increased elasticity of your skin.
B) Because of the increase in the activity of the sweat glands, you will have to take more baths and use deodorant more often.
C) Even minor cuts will require special attention because of slower healing.
D) As you age, your fingernails and toenails grow more quickly and require more frequent cutting to prevent ingrown nails.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Evaluation | Client Need: Health Promotion and Maintenance

 

  1. Choose the action the nurse should take to elicit the oculocephalic response in a motor vehicle accident victim who is unconscious.
A) Use a wisp of cotton to stimulate the cornea.
B) Hold the eyelids open while turning the client’s head.
C) Squirt ice water into the client’s ear canal.
D) Hold both eyelids open and shine a bright light into the eyes.

 

 

ANS:  B                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Comprehension | Integrated Process: Problem Identification | Client Need: Physiological Integrity

 

  1. Identify the action the nurse takes to best prevent contractures in a client with second- and third-degree burns of the legs.
A) Hyperextend the client’s legs by elevating them on two pillows.
B) Apply ace bandages to the entire leg.
C) Have the client perform active range of motion exercises every hour.
D) Apply knee splints.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. A 37-year-old woman has an internal radioactive implant placed for the treatment of uterine cancer. Select the action the nurse should take first when she finds the implant in the bed linens during routine care.
A) Quickly leave the room and call for help.
B) Use plastic forceps to replace the implant after donning a lead apron.
C) Place the implant in a lead-lined container with a pair of long-handled forceps.
D) Tell the client how to re-insert the implant.

 

 

ANS:  C                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. Identify the action by the nurse that would best promote a positive therapeutic community milieu when several clients in the psychiatric inpatient unit ask the unit manager if she could extend the visiting hours until 9 p.m.
A) Explain that she cannot make that decision, and it must be referred to the administrator.
B) Ask the clients to offer their suggestion during individual therapy sessions.
C) Suggest that the clients elect two members of their group as representatives to speak for the whole group.
D) Encourage the clients to bring their concerns to the next community meeting.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

  1. Select the teaching point the community health nurse should emphasize as a clue to possible attempted suicide when conducting a parenting class about suicidal ideation in school-aged children.
A) Poor grades in school
B) Children giving away favorite CDs or toys
C) Insisting that smoking cigarettes is “cool”
D) Becoming more aggressive with classmates

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Psychosocial Integrity

 

  1. Choose the action by the nurse that takes highest priority in the treatment of a child with sickle cell anemia.
A) Maintain hydration at two times the normal intake.
B) Assist the child in range of motion exercises to increase joint mobility.
C) Medicate frequently with analgesics to reduce pain.
D) Initiate and maintain reverse isolation.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the statement made by a client that would indicate to the nurse that additional teaching was required for a client who was scheduled for a lumbar puncture.
A) “This procedure will be done in my room.”
B) “I can get up and go to the bathroom within 1 hour after the procedure.”
C) “My body will replace the fluid taken by the physician within 12 hours.”
D) “I have to sign a special procedures permit before the procedure can be done.”

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Evaluation | Client Need: Safe and Effective Care Environment

 

  1. Which finding on the admission assessment would make the nurse question the order for a cerebral angiogram for the client?
A) Intermittent memory loss and dizziness for 2 months.
B) History of hypertension controlled with angiotensin-converting enzyme inhibitor.
C) Presence of a permanent pacemaker implanted 6 months ago.
D) Client breaks out in hives when eating shrimp or clams.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Assessment | Client Need: Physiological Integrity

 

  1. After a client is connected to a heart monitor in the ER, the nurse notes an elevated ST segment on the electrocardiogram strip. What nursing action would have the highest priority for this client?
A) Assess the vital signs and the degree and location of any chest pain.
B) Administer a stat dose of sublingual nitroglycerine spray to dilate the coronary arteries.
C) Notify the physician of the client’s dire condition.
D) Place the client in the prone position to reduce the workload of the heart.

 

 

ANS:  A                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. After reviewing the laboratory results for the clients to which the nurse is assigned, select the client the nurse should assess first.
A) 53-year-old man with a CPKMB of 3 percnet
B) 33-year-old man with a cTnT2 of 0.8 ng/mL
C) 48-year-old woman with a LDH1 of 25 percent
D) 64-year-old woman with a triglyceride level of 175 mg/dL

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Assessment | Client Need: Safe and Effective Care Environment

 

  1. During the 0700 beginning of the shift assessment, the nurse finds a male client who was diagnosed with type 1 diabetes mellitus to be difficult to arouse. Per unit protocol, arterial blood gases and a blood glucose are performed. The results show pH 7.01, PO2 92, PCO2 36, HCO3 9, blood glucose 873. What action should the nurse take first?
A) Administer the client’s 0800 dose of NPH insulin immediately.
B) Notify the physician and the house supervisor of the client’s condition.
C) Begin an IV with 0.5 percent normal saline and prepare sodium bicarbonate for administration.
D) Attempt to arouse the client and determine what he ate the previous evening to raise his blood glucose.

 

 

ANS:  C                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. While reviewing the laboratory results for a client, the RN notes that pulmonary function test values are as follows: residual volume 1,800 mL, vital capacity 2,300 mL, and tidal volume 275 mL. Identify the nursing action included in the care plan developed by the LPN that the RN would change.
A) Increase fluid intake to 3,500 mL per day.
B) Position the client in the high-Fowler’s position.
C) Contact the dietitian to arrange for a six-feeding, small-portion diet.
D) Increase the oxygen flow rate to 10 L/min by rebreather mask for shortness of breath.

 

 

ANS:  D                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Which postbronchoscopy assessment observed by the nurse in a 54-year-old woman would require immediate intervention?
A) Coughing up a moderate amount of dark, blood-tinged mucus
B) Negative gag reflex 15 minutes postprocedure
C) Presence of a stridor in the upper airway
D) Difficulty to arouse with initial disorientation

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Evaluation | Integrated Process: Evaluation | Client Need: Safe and Effective Care Environment

 

  1. In reviewing the chart of a 15-year-old client who suffered a head trauma in a sports accident, the nurse notes a serum potassium of 2.8 mEq/L and a serum sodium of 122 mEq/L. What addition to the nursing care plan would be most appropriate for the nurse to make based on this information?
A) Strict intake and output (I & O) each shift
B) Passive range of motion exercises each shift
C) Six-feeding, small-portion diet
D) Assessment of flank region every 12 hours for kidney tenderness

 

 

ANS:  A                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Planning | Client Need: Physiological Integrity

 

  1. Identify the additional assessment the nurse should make when the serum uric acid level of a 64-year-old man is 12.8 mg/dL.
A) Glasgow coma scale each shift
B) Heart sounds every 4 hours for murmurs and clicks
C) Flank region every 12 hours for kidney tenderness
D) Joints for tenderness and swelling

 

 

ANS:  D                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Assessment | Client Need: Physiological Integrity

 

  1. During a prenatal visit, the nurse is teaching a pregnant client about sources of complete protein. Identify the food with the highest amount of this nutrient.
A) Two boiled eggs
B) 1 cup whole-grain cereal
C) 1 cup red beans
D) One fried chicken leg

 

 

ANS:  A                    PTS:   1                    DIF:    Easy

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Comprehension | Integrated Process: Planning | Client Need: Health Promotion and Maintenance

 

  1. Which nursing action is most important in the care of a client who is receiving 300 mL of Isocal by nasogastric feeding tube every 4 hours?
A) Keep the head of bed elevated 35 to 45 degrees at all times.
B) Check the tube for placement prior to each feeding.
C) Obtain daily weights and accurate I & O to monitor status.
D) Monitor the client for dumping syndrome.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Select the nursing action that would best help reduce the cramping experience by a client who was receiving intermittent feedings though a gastric tube (percutaneous endoscopic gastrostomy tube).
A) Warm the feeding to near body temperature prior to administration.
B) Elevate the client’s head to 35 to 45 degrees during feedings.
C) Encourage the client to suck on a hard candy 5 to 10 minutes prior to the feeding.
D) Assess the tube for placement prior to each feeding.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. The nurse notes that the primary health-care provider has prescribed that the TPN that a client had been receiving for the past 10 days be discontinued and changed to 0.9 percent normal saline. Which action would be most appropriate for the nurse to take?
A) Stop the TPN and change the solution to 0.9 percent normal saline as soon as it was available.
B) Allow the remaining TPN to infuse until the bag was empty and then change the solution to 0.9 percent normal saline.
C) Gradually reduce the rate of the TPN over the next 4 to 6 hours, then change the solution to 0.9 percent normal saline.
D) Question the primary health-care provider about the change because the solution is inappropriate.

 

 

ANS:  C                    PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. A client receiving TPN through a central line reports chest discomfort and mild dyspnea. The nurse notes a churning sound over the Point of Maximal Impulse and tachycardia. Which action should the nurse take first?
A) Replace the tubing and the TPN solution immediately.
B) Clamp the central catheter and place the client on the left side with the head lower than the body.
C) Start oxygen by mask to reduce the hypoxia and notify the primary health-care provider immediately.
D) Assess the client for cough and cyanosis while evaluating the central catheter site for signs of infection.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. A one-day postoperative client has both morphine sulfate and meperidine (Demerol) prescribed for pain. Upon which assessment would the nurse decide to give the meperidine rather than the morphine sulfate?
A) Pain has increased from a 2/10 to a 6/10
B) BP 90/58, pulse 62 bpm
C) Temperature 99.2°F, respirations 10/min
D) Awake, alert, and oriented ´3

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Safe and Effective Care Environment

 

  1. Which statement by a nurse working with a client who is suffering from paranoid delusions and who is not very talkative would block therapeutic communication?
A) “You seem to be more suspicious of the other clients today.”
B) “I feel you have made progress by speaking about your fears”.
C) “I know just how you feel. I often see the head nurse waiting for me to make a mistake.”
D) “You mentioned that you see them looking through the window. Please tell me more about that.”

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

  1. Identify the statement made by a psychiatric clinical nurse specialist to a client with anorexia nervosa that best demonstrates the use of cognitive therapy.
A) “You seem to feel much better about yourself when you eat something.”
B) “Being thin doesn’t seem to solve your problems, since you’re thin now and still unhappy.”
C) “It must be difficult to talk about private matters with someone you just met.”
D) “What are your feelings about not eating the food that you prepare?”

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Evaluation | Integrated Process: Evaluation | Client Need: Psychosocial Integrity

 

  1. A client is being treated for depression with phenelzine (Nardil). Which statement by the client indicates that the goal for the client to understand the potential side effects of the antidepressant has been achieved?
A) “I should wear sturdy and supportive shoes when I’m outside”
B) “My legs should be elevated when I’m sitting.”
C) “I must avoid eating at Chinese restaurants.”
D) “Colognes and perfumed soaps can cause allergic reactions.”

 

 

ANS:  C                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

  1. A client with severe anxiety is being treated with lorazepam (Ativan) and outpatient therapy. Which statement indicates that the client requires additional discharge instructions for this medication?
A) “If I become drowsy or have blurred vision, I need to stop the medication immediately.”
B) “This medication can be habit forming, so I should take it only as directed.”
C) “I need to add foods such as fresh fruits and grain to my diet.”
D) “If I get a cold I should check with my primary health-care provider before taking cold medicines.”

 

 

ANS:  A                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Synthesis | Integrated Process: Evaluation | Client Need: Psychosocial Integrity

 

  1. Identify the assessment found by a nurse on a client who is admitted with a possible accidental overdose of imipramine (Tofranil) that would require the most immediate intervention.
A) Depressed deep tendon reflexes and Glasgow Coma Scale rating of 9
B) Sinus tachycardia of 128 with a QRS complex of 0.14 second
C) Ecchymotic areas on arms and a hematocrit of 33 percent
D) Distended abdomen and decreased bowel sounds

 

 

ANS:  B                    PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Assessment | Client Need: Safe and Effective Care Environment

 

  1. Based on accepted standards of care for documentation, identify the element that the nurse should avoid placing in the client’s medical record.
A) Blank spaces between the lines for late entries
B) Date and time on all entries
C) Observation about the client’s behaviors
D) Direct quotes from the family

 

 

ANS:  A                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. An otherwise healthy 40-year-old woman who is brought into the emergency room (ER) with an overdose is declared brain dead and evaluated for organ donation. On her driver’s license, the “Organ Donor” box is checked and there is a legal witness signature present. Identify the action to be taken next by the ER nurse.
A) Prepare the body for transfer to the operating room for organ removal.
B) Order appropriate tests for tissue typing.
C) Attempt to notify the client’s family and ask their permission for donation.
D) Pack the body in ice to lower metabolism and prevent deterioration of the organs.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. A psychiatric nurse employed in a busy outpatient psychiatric clinic notes that the foreign-born psychiatrist who covers the clinic in the afternoons regularly bills clients for 60-minute sessions that only last 30 to 40 minutes. Under the Federal False Claims Act, select what the nurse must report concerning the physician.
A) Upcoding
B) Overbilling
C) False representation of services
D) Medicare fraud

 

 

ANS:  A                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. The hospital administration has just notified all the unit managers that the care delivery model is to be changed from team nursing to modular nursing because of budget restraints. Identify the action by the unit managers that is essential to the successful implementation of the modular nursing care model.
A) Hire nurses who are self-directed and concerned with consistency of care.
B) Obtain the cooperation and input from respiratory therapy, radiology, dietary, and laboratory departments and other support services.
C) Develop total quality management studies to determine risk areas.
D) Initiate a training program for ancillary health workers, such as nurse aides and orderlies.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. An HIV-positive client with Pneumocystis carinii pneumonia (PCP) is confused and keeps removing the IV piggy back (IVPB) needle during the administration of his trimethoprim-sulfamethoxazole (Bactrim). Select the instructions by the charge registered nurse to the licensed practical nurse administering medications that would best rectify this situation.
A) Give the client his prn sedative a half hour before the IVPB medication.
B) Assign one of the certified nursing assistants to stay with the client during the medication administration.
C) During the 30 minutes the medication infuses, place the client in bilateral wrist restraints.
D) Call the physician and request the medication by mouth.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. After her first week on a busy medical surgical unit, the new charge nurse notes that the individual nurses are highly competent but seem to be unable to function productively as a team. Select the action by the charge nurse that would best facilitate team building among the staff.
A) Provide an opportunity for the nurses to express feelings and emotions.
B) Hire more staff to reduce stress and fatigue from understaffing.
C) Allow the staff more input into important policy decision-making.
D) Give the staff more time to adjust to the change in charge nurses.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. The nurses on the 7 a.m. to 3 p.m. shift have been complaining to the head nurse that the nurses on the 9 p.m. to 7 a.m. shift have not been doing the ordered client daily weights, and the physicians are very upset when they make their early morning rounds. Identify the initial action the head nurse should take to resolve this conflict.
A) Post a stern memo that reminds the night shift nurses to do the daily weights.
B) Review the daily weight flow sheet.
C) Change the time for daily weights to the late morning.
D) Hold a meeting with the physicians to discuss their attitudes.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. Select the statement by a unit manager to the vice president of nursing during a budget meeting that would be most effective in decreasing the staffing ratio on her unit from one nurse for every nine clients to one nurse for every seven clients. “This proposed change will:
A) have a positive effect on the usage of institutional resources.”
B) better meet current national standards of practice.”
C) help with the recruitment of new nurses to the facility.”
D) improve the quality of care for the clients on the unit.”

 

 

ANS:  D                    PTS:   1                    DIF:    Hard               TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Judgment | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. A particularly vocal staff nurse on a busy obstetrical unit has been complaining to the other nurses about the unit manager’s preferential treatment of the night shift nurses. Select the action the unit manager should take to resolve this problem that best demonstrates the use of the assertive approach to conflict resolution.
A) Note that the vocal staff nurse is not intelligent enough to understand the situation and disregard her comments as worthless.
B) Arrange for the transfer of the staff nurse to the night shift.
C) Set up a time and place for a one-on-one meeting with the staff nurse.
D) Wait until there is an opportunity to use the incident to confront the staff nurse in front of her colleagues.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. The oxygen saturation on a client with acute infective bronchitis drops to 84 percent, and he develops severe dyspnea. There is a standing order for a handheld nebulizer (HHN) treatment prn for shortness of breath, and respiratory therapy is designated to give all respiratory treatments in the facility. When the nurse calls the respiratory therapist, he states that he has several more treatments to give but he should be there in 10 or 15 minutes. Select the action by the nurse that would be most appropriate at this time.
A) Increase the flow rate of the client’s oxygen until the respiratory therapist can arrive.
B) Call the respiratory therapist back and insist that he come immediately.
C) Give the HHN treatment himself or herself.
D) Give the client a prescribed leave it in prn sedative to reduce anxiety.

 

 

ANS:  C                    PTS:   1                    DIF:    Hard               TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Judgment | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. A client infected with hepatitis C becomes confused, pulls out his IV catheter, and bleeds profusely on the bed rail and floor. Select the instructions by the nurse to the housekeeper that would best prevent the spread of the infection.
A) Clean the area with 70 percent alcohol.
B) Mop the floor with a strong ammonia solution.
C) Let the blood dry first before cleaning to limit the spread of the infection.
D) Wipe all contaminated surfaces with a 5 percent chlorine bleach solution.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. An 8-year-old girl is brought by her mother to the outpatient clinic with complaints of abdominal cramping and greenish diarrhea. A diagnosis of shigellosis is made after a stool culture. Identify the discharge instruction by the nurse that best explains the requirement for enteric precautions at home.
A) Enteric precautions only have to be maintained until the diarrhea stops.
B) The child must remain on enteric precautions until she has three stool cultures negative for shigella.
C) After the child has been taking the antibiotics for 48 hours, you can stop the enteric precautions.
D) The child must remain on enteric precautions for 30 days or until her viral titer is normal.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. Select the instructions given by the nurse to a preoperative client going for a hiatal hernia repair about the use of an incentive spirometer that best describes its use postoperatively.
A) If you use it as prescribed, you won’t need a nasogastric (NG) tube.
B) You will not need as much postoperative pain medication if used every 2 hours.
C) Using it every 2 hours will help increase your respiratory effectiveness.
D) You will be able to begin eating much sooner if you use it every 4 hours.

 

 

ANS:  C                    PTS:   1                    DIF:    Hard               TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Judgment | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. Select the instructions by the nurse that would best prevent postoperative complications in a client who has just undergone a stapedectomy for a bone conduction hearing loss.
A) Leave the mouth open when sneezing.
B) Use a soft, cotton-tipped applicator to clean the blood and drainage from the affected ear to prevent infection.
C) Bend over very slowly during the first 48 hours postoperative.
D) Keep the head of bed flat for the first 24 hours.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. Identify the position in which an adult client in the recovery room should be placed when he or she complains of a sore throat and is lethargic after a tonsillectomy.
A) Side-lying
B) High Fowler’s
C) Trendelenburg’s
D) Batrachian

 

 

ANS:  A                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Judgment | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. After eye surgery, a client is alert, oriented, and has eye patches over both of his eyes. Select the action by the nurse that would have the highest priority in preventing injury to this client.
A) Keep the client restrained to prevent him from falling out of bed.
B) Walk the client around the room so he knows where the obstacles are located.
C) Make sure the bed is in the low position with the side rails down so that the client can exit the bed more easily.
D) Show the client how to use the call bell signal and place it within easy reach.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. After a bicycle accident that caused a fractured tibia, a client has a fiberglass cast applied and is discharged to home with crutches. Select the instructions by the nurse about climbing stairs with crutches that would best prevent an additional injury.
A) Place the unaffected leg on the first step, then move the crutches and injured leg up to the step together.
B) Move the injured leg to the first step, then place the crutches and uninjured leg on the step together.
C) Place the injured leg and the crutch on the opposite side on the first step, then move the injured leg and the other crutch up to the step.
D) Place both crutches on the first step together, then swing through both legs to the next step.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Safe and Effective Care Environment

 

  1. During a well-child visit to the clinic, the nurse notes that a 4-month-old girl is alert, responsive, and has a positive Moro reflex. Identify the statement by the nurse to the mother about the child’s growth and development that is most appropriate.
A) “Your child is developing normally, so bring her back in 1 month for a checkup.”
B) “There appears to be a neurological delay in your child’s development. We will need to refer her to a pediatrician.”
C) “Your child needs more stimulation at home. Play lively music when she is in her crib.”
D) “Your child has a severe developmental delay due to lack of proper care. I’m going to have to report you to social services.”

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Judgment | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. The parents of a 10-year-old boy ask the nurse about his acting-out behavior. Select the behavior(s) that best identifies when a child this age requires professional help.
A) Peer relationships are affected.
B) Family relationships are affected.
C) Multiple aspects of the child’s life are affected.
D) The child’s grades in school show a decline.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. A 15-year-old girl is brought by her mother to the pediatric clinic because she has not yet started her menstrual cycles and shows minimal physical development typical of puberty. When the diagnosis of delayed puberty is made, the girl begins to cry, stating, “Everybody at school makes fun of me because I’m so flat.” Select the response by the nurse that best addresses the girl’s concerns.
A) “Don’t worry. This a very common problem and you will soon catch up with your classmates.”
B) “You are a very beautiful girl just the way you are. You’ll probably get zits when you start your development.”
C) “If you keep busy in band and sports, you won’t worry so much about how you look.”
D) “Let’s see if we can figure out what type of clothes you can wear that won’t accent your lack of physical development so much.”

 

 

ANS:  D                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. A 42-year-old man comes to the outpatient clinic with complaints of joint swelling in his knees and pain in his feet. Select the type of arthritis that is most common in men in the 30 to 50 age range.
A) Gouty arthritis
B) Rheumatoid arthritis
C) Osteoarthritis
D) Septic arthritis

 

 

ANS:  A                    PTS:   1                    DIF:    Hard               TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Problem Identification | Client Need: Health Promotion and Maintenance

 

  1. During her routine annual physical examination, a 48-year-old woman tells the nurse that she worries about her health all the time, spends 8 to 10 hours at the health center every week, and has spent a larger than usual amount of money on cosmetics over the past 6 months. Select the most appropriate response by the nurse to this client.
A) “Your concerns and actions are normal because you are trying to maintain your health and youth.”
B) “How are you doing at your work? Did you get that promotion you wanted?”
C) “Is your husband still helping with the household chores? Support systems are very important.”
D) “You seem very healthy. You should avoid excessive exercise because it can cause more damage in the long run.”

 

 

ANS:  B                    PTS:   1                    DIF:    Hard               TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. A 72-year-old woman is injured in a fall down a flight of steps at home and is placed on bedrest in the hospital. Select the intervention(s) by the nurse for this client that best prevent the complications of immobility.
A) Limiting the fluid intake to 200 mL per shift to prevent dependent edema.
B) Giving the client a full bed bath and feeding her all meals to reduce potential injury to fragile bones.
C) Massaging bony prominences and turning the client every 2 hours.
D) Ambulating the client to the bathroom instead of using the bedpan.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. During a “Health Promotion” class at a senior citizen center, one of the elderly attendees asks the nurse teaching the class, “I know older persons fall frequently. What types of fractures are most common in people in our age group?” Select the type of fracture the elderly most often experience.
A) Pelvis
B) Lumbar spine
C) Hand and wrist
D) Tibia

 

 

ANS:  A                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Assessment | Client Need: Safe and Effective Care Environment

 

  1. While climbing over a barbed wire fence, a 22-year-old man received a deep laceration on his arm and hand. After washing and dressing the laceration with an antibiotic ointment, the emergency department nurse notes that the client has had all his immunizations, with his last tetanus at age 18 for another injury. Select the action that should be taken by the nurse at this time.
A) Instruct the client on care of the laceration at home.
B) Give a tetanus toxoid injection.
C) Order a serum tetanus titer test.
D) Advise the client to get another tetanus immunization in 2 years.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application |Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. A couple who has been unable to conceive seeks counseling from the nurse in a family planning clinic. In discussing solutions to the couples’ difficulties, identify what information the nurse should emphasize.
A) Care for health problems not related to pregnancy
B) Data supporting the incidences of pregnancy in their age and ethnic groups
C) How the couple can better improve their communication skills
D) New positions and techniques to use during intercourse

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. At the family planning clinic, a 19-year-old woman who has recently become HIV positive is given counseling by the clinic nurse. Identify the instructions by the nurse that are most effective in preventing the transmission of HIV during sexual intercourse.
A) You can have unprotected sex if both you and your partner(s) are HIV positive.
B) The use of contraceptive measures, such as birth control pills and hormone injections, will limit the spread of the virus.
C) The only way to prevent the transmission of HIV is to have an intrauterine device placed.
D) Using a latex condom with a potent spermicide during intercourse is one of the best ways to prevent the spread of HIV.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. A 24-year-old woman comes to the family planning clinic with dysuria, purulent vaginal drainage, and perineal pruritus and has a positive culture for a sexually transmitted disease (STD). Identify the STD that the nurse is required to report to the public health department.
A) Genital herpes
B) Vaginal warts
C) Gonorrhea
D) Chlamydia

 

 

ANS:  C                    PTS:   1                    DIF:    Hard               TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Identification | Client Need: Health Promotion and Maintenance

 

  1. Select the instructions given by the nurse that are most accurate for a woman who is HIV positive and 3 months pregnant who comes to the prenatal clinic for care.
A) You will need a C-section to prevent the transmission of the virus to your baby.
B) There is a good chance that your baby will not be infected with the virus if you take your medications.
C) In a large percentage of the cases, the virus is transmitted through the placenta.
D) Your baby will be very ill from the HIV infection when it is born.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. During the assessment of a 35-week gestation client admitted to the obstetrics unit in active labor, the nurse notes the following: estimated fetal weight less than 2,500 grams; membranes ruptured 12 hours ago; blood type AB negative; positive rubella titer; positive vaginal culture for Group B streptococcus; current vital signs: T 99.2°F, P 104, R 26, BP 128/88. Identify the most appropriate action by the nurse at this time.
A) Administer a measles, mumps, and rubella vaccine.
B) Call the on-call pediatrician to warn him about a premature infant delivery.
C) Order a type and crossmatch for two units of blood.
D) Administer an ordered IV antibiotic.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Judgment | Integrated Process: Problem Identification | Client Need: Health Promotion and Maintenance

 

  1. Select the instruction by the nurse that is most helpful in relieving the pain from an episiotomy in a 1-day postpartum client.
A) Increase fluid intake to 2,000 mL per day.
B) Keep the head of bed elevated 45 degrees.
C) Apply an ice pack to her perineum.
D) Use a sitz bath twice a day.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. Select the recommendation given by a nurse to a group of clients at a cancer prevention seminar that is most effective in reducing the risk for colon cancer in persons who have a family history of the illness.
A) Avoiding obesity and losing weight reduces the incidence of colon cancer.
B) Limit or stop smoking because it places a person at a high risk for colon cancer.
C) There is a direct link between using saccharin-containing products and colon cancer, so avoid using the sweetener.
D) Limit alcohol intake to one glass of wine per day.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. The nurse in an outpatient clinic notes that a client with a persistent nagging cough has come in for treatment after hearing about the seven signs of cancer on the TV show Dr. Oz. Identify the statement by the nurse that best reinforces this client’s understanding of the warning signs of cancer.
A) All the signs have to be present to detect cancer.
B) Other signs to look for include indigestion, difficulty swallowing, and changes in the size or shape of a mole.
C) If you develop persistent nausea, skin rash, or acute pain, you are at high risk for having a cancer.
D) The warning signs you hear about are just to scare people who do not schedule regular appointments into visiting the physician.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. While evaluating a postcolon cancer surgery client who has a new colostomy, the nurse notes that the client is in the denial stage of the grieving process. Select the response by the nurse that best facilitates the client’s progression through the grieving process.
A) Interpret the denial for the client and point out it is part of the grieving process.
B) Confront the client’s denial as an unrealistic response.
C) Support the client in his denial.
D) Accept the denial as one of the stages in the grieving process.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. Identify the nursing action that best prevents autonomic dysreflexia in a client with a spinal cord injury.
A) Giving the client his prn dose of oxazepam (Serax) before the muscle spasms begin
B) Maintaining the patency of the Foley catheter
C) Keeping the client in the sitting position as much as possible
D) Monitoring the client’s electrolyte levels

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Synthesis | Integrated Process: Problem Identification | Client Need: Psychosocial Integrity

 

  1. Using crisis intervention theory in the care of a 26-year-old woman who was raped 1 week ago, select the intervention by the nurse that best achieves successful treatment.
A) Preventing rape trauma syndrome
B) Helping the woman grow to a higher level of functioning
C) Referring the woman to a rape victims’ group therapy session
D) Restoring the woman to her prerape level of functioning

 

 

ANS:  D                    PTS:   1                    DIF:    Hard               TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

  1. A 22-year-old man is recovering from injuries obtained in an automobile accident in which he was the driver and his 20-year-old girlfriend was killed. His parents have requested that information about the girl’s death be withheld from the client, including restricting visitors and phone calls. While bringing the client a leave-it prn pain medication, the nurse notices that the local television lead news story is about the accident. Select the best action by the nurse in response to this situation.
A) Talk loudly to the client so that he will not be able to hear the news.
B) Turn the TV off stating that the pain medication will work better with less environmental stimuli.
C) Leave the TV on and then answer any questions the client has.
D) “Accidentally” change the channel while raising the head of the bed.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

  1. A 32-year-old man who is HIV positive and in the later stages of AIDS is hospitalized for treatment of PCP. While the nurse is administering the IV medication, the client begins to cry and states, “None of my friends and relatives visit or call me anymore because of this disease.” Select the response by the nurse that best promotes a positive self-concept for this client.
A) “I’ll talk with your physician and arrange a consultation with a psychologist so you can deal with these negative feelings.”
B) “You seem very down today. Let’s talk about what’s going on.”
C) “I’m sure they want to visit and call, but may be afraid they’ll say the wrong thing. I can call them for you.”
D) “It sure seems that if they don’t call or visit, they are not really friends to begin with. Just forget about them.”

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

  1. A 34-year-old mother of three young children who works as an administrative assistant at a university comes to the crisis center due to the inability to sleep, increasing disorganization at her job, and feelings of guilt about her ability to care for her children and house. She tells the nurse that her husband used to help with the children and house a lot, but because of a recent job promotion and additional work hours required, he can no longer do this. The client feels that they cannot afford a full-time housekeeper and has become overwhelmed and depressed over the condition of her house. Select the therapeutic technique to be used by the nurse that best helps this client deal with her altered role performance.
A) Environmental modification
B) Anticipatory guidance
C) Confrontation
D) Cognitive restoration

 

 

ANS:  A                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

  1. A 48-year-old woman had become increasingly depressed since her youngest son left for college 4 months ago. She has been a stay-at-home mother who has focused most of her time and energy on her children and now has little to do. Identify the response by the nurse that best helps the client deal with the spiritual aspects of her concerns.
A) “You need to find other outlets for your energy, such as helping at the church soup kitchen.”
B) “What is it that sustains you when all else fails? You need to rely on yourself for your happiness.”
C) “You need to focus your anger away from yourself onto a harmless third party.”
D) “Once you begin to take antidepressants, you will feel better in about a week.”

 

 

ANS:  B                    PTS:   1                    DIF:    Hard               TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

  1. A 5-foot, 5-inch tall, 15-year-old girl who weighs 88 lb is admitted to the hospital with a diagnosis of anorexia nervosa. After the second day in the hospital, the child gains 1 lb. Select the nurse’s response to the weight gain that most enhances the child’s recovery.
A) “Now that little amount of weight didn’t kill you!”
B) “If you follow your diet plan and the goals we established, you will be back to normal in no time.”
C) “It must be scary for you to think that you gained that much weight.”
D) “Your family and I are very happy and pleased about your weight gain.”

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Comprehension | Integrated Process: Intervention | Client Need: Health Promotion and Maintenance

 

  1. A 22-year-old man who is diagnosed with obsessive-compulsive disorder (OCD) that includes a compulsion to check all faucets to make sure they do not drip is hospitalized when he is no longer able to function at home or work due to his behavior. In the psychiatric unit, his actions consume a major part of his waking hours, and often he misses meals and other scheduled activities. Identify the intervention by the nurse that is most likely to precipitate a panic attack in this client.
A) Asking the client about his repressed feelings after he completes his ritual
B) Requiring the client to participate in scheduled meal times even if his rituals are not complete
C) Pointing out to the client that his actions are meaningless
D) Using thought stopping and aversion therapy to block the ritualistic actions

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

  1. Identify the initial intervention by the nurse that is most effective in treating a 23-year-old woman who is diagnosed with a dependent personality disorder.
A) Encouraging the client to make more decisions, starting with simple ones like what to select from a menu
B) Teaching the client about the nature of the disorder and what the usual treatments are for it
C) Placing the client in a group therapy session with other clients who have dependent personality disorder
D) Working with the client to identify and express feelings of anger

 

 

ANS:  D                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

  1. A client with an antisocial personality disorder is caught shoplifting and as part of his probation agreement is required to spend 1 month at a psychiatric facility for treatment. Select the intervention by the nurse that has the highest probability of success in treating this disorder.
A) Using daily one-on-one sessions with the nurse
B) Placing the client in group peer therapy with strong external controls
C) Initiating treatment with antianxiety medications
D) Quickly placing the client in isolation when he acts out

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

  1. Identify the intervention by the nurse that would be most therapeutic for a client diagnosed with schizophrenia who has delusions about extraterrestrial spacecraft invading the earth.
A) Use distraction to reduce the client’s focus on the delusions.
B) Ask the client to talk about the delusion and his feelings when he is having it.
C) Agree with the delusion to prevent angering the client.
D) Point out the absurdity of the delusion and refocus in reality.

 

 

ANS:  A                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Judgment | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

  1. Identify the action by the nurse that is most appropriate when caring for a client hospitalized with chronic schizophrenia who has been taking clozapine (Clozaril) for the past 2 weeks.
A) Limit the client’s fluid intake to 500 mL per day.
B) Check the client’s white blood cell count and differential every week.
C) Obtain a serum cholesterol every month.
D) Make sure the client spends at least 30 minutes outside each day in the sun.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

  1. Identify the intervention by the nurse that best maintains a safe hospital environment for a client diagnosed with Korsakoff’s syndrome who is hospitalized because of several falls due to an unsteady gate.
A) Reinforcing activity restrictions by repeating instructions frequently
B) Placing the client in a quiet, nonstimulating room away from the busy nurses’ station
C) Providing assistance as needed, including walker or cane, when the client ambulates
D) Limiting the client’s visitors to immediate family only

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

  1. Choose the instructions to an elderly woman with osteoarthritis that best help her maintain normal activities of daily living (ADLs) and complete her usual household chores.
A) Try to complete all your chores before lunch because the pain and soreness is less serious in the morning.
B) If you rest in the morning and afternoon, you will be able to complete your chores in the evening with less discomfort.
C) Make sure you do warm-up and stretching exercises before you do your chores to maximize your agility.
D) Do your chores at a pace that is comfortable for you, resting frequently after periods of activity.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the intervention by the nurse that has the highest priority when assisting with ADLs for a client diagnosed with multiple myeloma.
A) Keep the client on oxygen by nasal cannula at all times.
B) Use great care in transferring the client from bed to chair to prevent bone injury.
C) Allow the client to rest for 10 minutes before and after each activity.
D) Encourage the client to be as independent as possible.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Select the recommendation by the nurse that is most helpful in restoring a normal sleep pattern to a 58-year-old man who has chronic insomnia.
A) A regular waking time in the morning will help re-establish your circadian sleep cycle.
B) Using an occasional sleeping pill will be of some benefit.
C) A light snack before bed will help encourage sleep.
D) I am going to refer you to a sleep specialist for further evaluation.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the best response by the nurse to a physician’s prescription for temazepam (Restoril) 15 mg PO, prn for a hospitalized client.
A) Question the order because the dose is too large.
B) Give it as ordered when the client is restless.
C) Schedule the medication for half strength.
D) Question the order because the dose is too small.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Judgment | Integrated Process: Problem Identification | Client Need: Physiological Integrity

 

  1. Identify the dietary teaching by the nurse that best promotes the comfort of a client in the late stages of cirrhosis who has ascites.
A) You must increase your daily fluid intake to 3 liters per day to avoid dehydration.
B) Your protein intake should be between 100 and 120 grams per day.
C) Keep your sodium intake to 1 to 2 grams per day.
D) Extra fats in your diet are necessary to maintain your energy levels.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Comprehension | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the diet change recommendation by the nurse that best helps reduce the cramping experienced by a client who is diagnosed with chronic renal failure and has severe abdominal and leg cramping during hemodialysis treatments.
A) You need to increase your fluid intake between treatments to 4 liters per day.
B) Restrict your potassium intake to 80 mEq per meal.
C) Your fluid intake should not exceed 1 liter per 24 hours.
D) Low biological quality protein foods will help reduce muscle spasms.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. A 14-year-old girl is admitted to the ER with a suspected overdose of an unknown drug. Arterial blood gasses are drawn with the following results: pH 7.31, PO2 88, PCO2 59, HCO3 22. Identify the initial action to be taken by the nurse.
A) Insert a large gage NG tube for gastric lavage.
B) Insert a Foley catheter and obtain a urine for drug screen.
C) Use a manual ventilator (Ambu bag) to assist with ventilation.
D) Attach the client to a cardiac monitor and watch for dysrhythmia.

 

 

ANS:  C                    PTS:   1                    DIF:    Hard               TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Select the statement by the nurse that is most accurate when instructing a client with a newly formed permanent colostomy on how to use the irrigation set to prevent constipation.
A) “Make sure the irrigation bag is above the level of your head for best results.”
B) “Insert the lubricated catheter 2 to 4 inches into the stoma.”
C) “Dilate the stoma prior to beginning the procedure by using one finger.”
D) “Use cold water to best stimulate colon peristalsis.”

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the instructions about the care of the urinary system the nurse should give to a 44-year-old hospitalized woman who has an indwelling urinary catheter and IV who insists on going to the smoking room for a cigarette every few hours.
A) Place the drainage bag on the floor when you are sitting to prevent pulling on the catheter.
B) Clamp the catheter before you leave and unclamp it when you return.
C) Loop the drainage tubing around the IV pole to keep it in place.
D) Hang the drainage bag on the pole at a level to keep it below your bladder at all times.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Problem Identification | Client Need: Physiological Integrity

 

  1. Identify the action the nurse should take when he notes that a client who is receiving captopril (Capoten) for congestive heart failure has developed hyperkalemia.
A) Give the next dose with a full 240 mL glass of water.
B) Hold the next dose and notify the physician.
C) Increase the client’s intake of fresh fruits and vegetables.
D) Reduce the dose by half and give both a.m. and p.m.

 

 

ANS:  B                    PTS:   1                    DIF:    Hard               TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Judgment | Integrated Process: Evaluation | Client Need: Physiological Integrity

 

  1. A 73-year-old man receives hydralazine (Apresoline) 20 mg PO at 0800. When the nurse checks his blood pressure at 0900, she obtains a reading of 72/44 mm Hg. The client has been taking this same dose of medication for 3 years. The nurse finds all of the following data in the client’s chart. Identify the finding that is most significant for producing the client’s current blood pressure.
A) Pedal pulses 1 + and weak
B) 24-hour fluid intake 1,000 mL ´3 days
C) Serum potassium 3.3 mEq/L
D) Apical pulse 150 bpm, slightly irregular

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Select the medication that the ER nurse should give to an unconscious client experiencing a severe hypoglycemic reaction.
A) Hydrocortisone
B) D50W
C) Sodium bicarbonate
D) Glucagon

 

 

ANS:  D                    PTS:   1                    DIF:    Hard               TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Prior to discharge, a client diagnosed with a gastric ulcer is given prescriptions for cimetidine (Tagamet) and aluminum-magnesium complex (Riopan). Identify the instructions that the nurse should emphasize to the client about these two medications.
A) To achieve maximum effectiveness, take them at the same time.
B) Take the Riopan with meals and the Tagamet on an empty stomach.
C) Make sure to take the medications with a full 8-ounce glass of orange juice.
D) The Tagamet can be taken with meals; then wait 1 to 2 hours to take the Riopan.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Select the response by the nurse to a 22-year-old woman that best answers her question on why she must take two antibiotics, ceftriaxone (Rocephin) and doxycycline (Vivox), for a gonorrhea infection.
A) These two antibiotics taken together lessen the side effects of each other.
B) Many people who have gonorrhea also have a Chlamydia infection, and these two medications will eliminate both.
C) The medications potentiate each other and are stronger together than separately.
D) The course of treatment can be shortened to 5 days when two antibiotics are used.

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Select the discharge instructions by the nurse to a client diagnosed with pruritus that most increase the effectiveness of a prescribed emollient.
A) Apply the medication at night before you go to bed.
B) To keep it in contact with the skin longer, wrap the area with a gauze dressing after applying the cream.
C) Apply the cream immediately after a bath or shower.
D) To protect your skin from the drying effects of hot water, apply the cream just before you take a bath or shower.

 

 

ANS:  C                    PTS:   1                    DIF:    Easy               TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the statement by the public health nurse that most accurately describes treatment with immune globulin for the wife and two children of a client who was diagnosed with hepatitis A.
A) One injection provides immunity for life.
B) If the family has not been in close contact with the client, they do not need the medication.
C) The medication conveys active immunity.
D) If administered more than 2 weeks after exposure, it may not be effective.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Select the best time for the nurse to administer a prn dose of morphine sulfate, 5 mg IV, to a client who is experiencing leg pain after an open reduction for a fractured femur.
A) When the pain is in the moderate to severe range
B) When the pain first starts, before it becomes severe
C) No more than every 6 hours to prevent morphine addiction
D) Regularly every 4 hours

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Comprehension | Integrated Process: Problem Identification | Client Need: Physiological Integrity

 

  1. A client with a urinary tract infection is given a prescription for sulfamethoxazole (Gantanol), 1 gram by mouth three times a day. Choose the common side effects that can be expected after 3 days.
A) Diarrhea and gastrointestinal bloating
B) Anxiety and inability to concentrate
C) Drowsiness and dizziness
D) Headache and hyperactivity

 

 

ANS:  A                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the teaching point that has the highest priority when the nurse is instructing a client about the home use of respiratory medications for treatment of his emphysema.
A) If you stop taking expectorants suddenly, there will be a rebound effect.
B) Avoid driving your car for 2 hours after using the nasal decongestant.
C) Never use glass, stainless steel, or plastic when taking mucolytics.
D) Be sure to use water either orally or inhaled with mucous secretions to decrease the amount of the secretions.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Synthesis | Integrated Process: Problem Identification | Client Need: Physiological Integrity

 

  1. A client with a history of prolapsed mitral valve complains to the ER nurse that he is having palpitations (pounding heart) even at rest. Identify the discharge instructions by the nurse that are most effective in reducing future episodes of this symptoms.
A) Make sure you eat foods high in potassium, like oranges and bananas.
B) You will need to increase your fluid intake to 2 to 3 liters per day.
C) Avoid beverages that contain caffeine, like coffee and colas.
D) Limit your activity as much as possible.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Evaluation | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. A client with myeloid metaplasia is experiencing joint pain, guaiac-positive stools, and a platelet count of 31,000 per mm3. If a prn dose of meperidine (Demerol) is ordered by all of the following routes, choose the route the nurse should avoid using to give the medication.
A) Intramuscular
B) Intravenous
C) Oral
D) Subcutaneous

 

 

ANS:  A                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the discharge instructions by the nurse that best help prevent potential complications related to the pacemaker for a 65-year-old man who received an implanted ventricular demand pacemaker for treatment of a complete atrioventricular block secondary to an anterior myocardial infarction.
A) Avoid all activities that require raising your arms over your head.
B) When a microwave oven is in use, stay out of the room.
C) You will not be able to fly because the airport metal detectors will disrupt the pacemaker function.
D) Avoid using a cellular phone.

 

 

ANS:  D                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the instructions by the nurse in charge of a diabetic clinic about exercises that are most effective in maintaining the cardiovascular system integrity of a newly diagnosed diabetic client.
A) You should avoid all isometric exercises because they place too much demand on your heart.
B) You should exercise at least five to seven times a week for best effect.
C) Exercising at least three times a week will help meet the goals of weight and blood sugar maintenance.
D) Only vigorous aerobic exercises for an hour at a time will help you maintain your blood pressure and heart rate.

 

 

ANS:  C                    PTS:   1                    DIF:    Hard               TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the nutrient that the nurse should increase in the diet of a client who is 3 days postoperative after a thyroidectomy and is experiencing muscle twitching and tremors.
A) Potassium
B) Calcium
C) Magnesium
D) Iodine

 

 

ANS:  B                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Problem Identification | Client Need: Physiological Integrity

 

  1. A client’s throat was sprayed with a topical local anesthetic prior to a bronchoscopy. Select the action that the nurse should take when the client returns from the procedure and has an absent gag reflex.
A) Use an oral airway to maintain a patent airway.
B) Place the client in the side-lying position to facilitate respirations.
C) Hold the breakfast tray and all fluids.
D) Position the client in a low Fowler’s position.

 

 

ANS:  C                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the instructions by the nurse to a client with a history of pancreatitis that best aid in the prevention of discomfort associated with diet.
A) Drink 2 liters of fluid at each meal and eat a high-fat diet.
B) Avoid caffeine beverages and eat a low-fat diet.
C) You need to keep your energy levels up by eating a high-carbohydrate and high-fat diet.
D) A high-sodium, high-protein diet best prevents abdominal discomfort.

 

 

ANS:  B                    PTS:   1                    DIF:    Easy               TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Synthesis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. Identify the action by the nurse in the care of a client with cervical cancer who has a vaginal applicator of radioactive material in place that poses the highest risk potential for a radiation hazard.
A) Giving the client a complete bed bath each morning
B) Maintaining the client on strict bedrest
C) Checking the applicator for placement every 4 hours
D) Elevating the head of bed 30 degrees for meals

 

 

ANS:  A                    PTS:   1                    DIF:    Medium         TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Application | Integrated Process: Problem Identification | Client Need: Physiological Integrity

 

  1. Select the instructions by the clinic nurse that are most effective in preventing back injury for a client with chronic low back pain.
A) Stand close to a heavy object before attempting to lift it.
B) Use your arms to lift objects to prevent back strain.
C) A narrow base of stance is most effective for lifting.
D) Make sure to bend at the waist when lifting objects more than 30 lb.

 

 

ANS:  A                    PTS:   1                    DIF:    Easy               TOP:   Bonus NCLEX Questions

KEY:  Cognitive Domain: Analysis | Integrated Process: Problem Identification | Client Need: Psychosocial Integrity

 

SHORT ANSWER

 

  1. An adult client with Hodgkin’s disease who weighs 168 lb is to receive vincristine (Oncovin), 25 mcg/kg IV. Calculate the correct medication dosage and type the answer in the box.

 

 

ANS:

1,900 mcg

 

PTS:   1                    DIF:    Medium         TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. A client is to receive a heparin drip at 800 units per hour. The medication is mixed heparin 20,000 units in 500 mL of D5W. At what rate should the nurse set the volumetric pump?

 

 

ANS:

20 mL/hr

 

PTS:   1                    DIF:    Hard              TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Intervention | Client Need: Physiological Integrity

 

  1. While performing a physical examination during a well-child check on a 6-month-old infant, the nurse hears a loud machinery murmur. Identify the area on the child’s chest where this abnormal heart sound can best be heard. (Place cursor on correct area and click.)

 

ANS:

Second intercostals space on the left sternal border

 

PTS:   1                    DIF:    Medium         TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Assessment | Client Need: Health Promotion and Maintenance

 

COMPLETION

 

  1. Fill in the blanks with the correct word(s) to complete the following statement:

A client who is to receive external radiation therapy asks the nurse why the cancer cells in his body are so harmful. The nurse responds that a characteristic found in all cancer cells, called _________________, allows the cells to reproduce in a different manner that is harmful to the healthy body tissues.

 

ANS:  anaplasia

 

PTS:   1                    DIF:    Medium         TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Psychosocial Integrity

 

  1. Fill in the blanks with the correct word(s) to complete the following statement:

A client with lung cancer has a lobectomy of the left lung and is returned to the recovery room with a chest tube connected to a closed, underwater-seal drainage system. The nurse observes that the system is functioning correctly when he or she notes that the pressure in the suction control chamber of the systems remains at _____________ pressure.

 

ANS:  20 cm of water

 

PTS:   1                    DIF:    Hard              TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Planning | Client Need: Physiological Integrity| Client Need: Physiological Adaptation

 

  1. Identify the proper sequence for the steps the nurse should follow in changing the dressing on an incision that is closed with surgical staples. (Enter the letter of each step in the proper sequence; do not use commas or spaces.)
  2. A) Apply antiseptic ointment to the suture line.
  3. B) Cleanse the area around the incision with an appropriate cleansing solution.
  4. C) Explain the procedure to the client.
  5. D) Teach the client how to minimize stress on the incision line.
  6. E) Note characteristics of any drainage.
  7. F) Remove the old dressing using clean technique.
  8. G) Apply the new dressing using sterile technique.

 

ANS:  EDAGCBF

 

PTS:   1                    DIF:    Hard              TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Intervention | Client Need: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. Hospice care is often used for the treatment of terminally ill clients with cancer. Identify the basic characteristics found in hospice programs. (Select all that apply.)
A) Control of client symptoms and relief of pain
B) Treatment of the client as a separate entity from the family to reduce grief
C) Services provided on the ability to pay
D) Use of trained volunteers to augment staff services
E) Bereavement follow-up
F) Care provided in the home independent of physicians

 

 

ANS:  A, D, E           PTS:   1                    DIF:    Medium

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Planning | Client Need: Physiological Integrity

 

  1. Identify the primary complications for which the nurse should monitor clients who have had a subtotal thyroidectomy for treatment of hyperthyroidism. (Select all that apply.)
A) Vomiting
B) Airway obstruction
C) Thrombocytopenia
D) Hidden bleeding
E) Hypothyroidism
F) Hypocalcemia

 

 

ANS:  B, D, E, F       PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Assessment | Client Need: Health Promotion and Maintenance

 

  1. A client with colon cancer has surgery with a colostomy. Which assessments indicate to the nurse that the client is developing postoperative complications? (Select all that apply.)
A) Urine output greater than 30 mL/hr
B) Dusky appearance of the stoma
C) Stoma protrusion from the skin
D) Small amount of blood-tinged liquid stool in colostomy bag
E) Edema of the stoma during the first 24 hours postoperative
F) Sharp abdominal pain

 

 

ANS:  B, C, F           PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Analysis | Integrated Process: Evaluation | Client Need: Health Promotion and Maintenance

 

  1. A client who had a kidney transplant experiences myelosuppression as one of the side effects of the antirejection medication. Select the points the nurse should include in the client’s home discharge plan. (Select all that apply.)
A) Avoid people who have recently received attenuated vaccines.
B) Use ibuprofen (Motrin) or acetaminophen (Tylenol) every 4 hours for pain.
C) Wash your hands frequently.
D) Clean the cat-litter box daily.
E) Avoid going to the shopping mall.
F) Gargle with a mouthwash for a sore throat because it is an expected side effect.

 

 

ANS:  A, C, E           PTS:   1                    DIF:    Hard

TOP:   NCLEX: What You Need to Know

KEY:  Cognitive Domain: Application | Integrated Process: Planning | Client Need: Safe and Effective Care Environment