Nclex-rn Practice 100 Questions

100 Questions  I  By Kvmtoolsdotcom on September 18, 2012
NCLEX-RN Practice 100 Questions

  
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1.  A client has a total laryngectomy with a permanent tracheostomy. The nurse plans nutritional intake for the next 3 days. Which of the following is necessary for the nurse to consider regarding the client’s nutrition?
A.
B.
C.
D.
2.  The nurse cares for a client who presents with confusion, mood lability, impaired communication, and lethargy. The nurse should question which of the following orders?
A.
B.
C.
D.
3.  For a client with a neurologic disorder, which of the following nursing assessments is MOST helpful in determining subtle changes in the client’s level of consciousness?
A.
B.
C.
D.
4.  The nurse conducts a physical examination of a client suspected to have bulimia. Which of the following observations by the nurse MOST likely indicates bulimia?
A.
B.
C.
D.
5.  The nurse prepares a dopamine (Intropin) infusion on a client. Before beginning the infusion the nurse should take which of the following actions?
A.
B.
C.
D.
6.  The nurse assists a nursing assistant in providing a bed bath to a comatose patient with incontinence. The nurse should intervene if which of the following actions is noted?
A.
B.
C.
D.
7.  The nurse instructs a client who is receiving imipramine (Tofranil). It is MOST important for the nurse to instruct the client to immediately report which of the following?
A.
B.
C.
D.
8.  The nurse receives report from the previous shift. Which of the following patients should the nurse see FIRST?
A.
B.
C.
D.
9.  A child has a closed transverse fracture of the right ulna. Which of the following actions, if performed by the nurse before the application of a cast, is MOST important?
A.
B.
C.
D.
10.  The nurse cares for a multipara client who delivered a female infant 1 hour ago. The nurse observes that the client’s breasts are soft; the uterus is boggy to the right of the midline and 2 cm below the umbilicus; moderate lochia rubra. It is MOST important for the nurse to take which of the following actions?
A.
B.
C.
D.
11.  The nurse checks for placement of a nasogastric (NG) tube prior to initiating a tube feeding for a client. Which of the following results indicates to the nurse that the tube feeding can begin?
A.
B.
C.
D.
12.  The nurse cares for a client after right cataract surgery. The nurse should intervene if which of the following is observed?
A.
B.
C.
D.
13.  A young adult immobilized for trauma to the spinal cord has periods of diaphoresis, a draining abdominal wound, and diarrhea. On the basis of the nursing assessment, which of the following is the MOST important nursing diagnosis?
A.
B.
C.
D.
14.  The nurse cares for a client one day after a thoracotomy. Nursing actions listed on the care plan include turn, cough, and deep breathe q 2 h. The nurse understands that the purpose of this nursing action includes which of the following?
A.
B.
C.
D.
15.  The mother of a 7-year-old child is dying. The nurse anticipates the child will have which of the following concepts of death?
A.
B.
C.
D.
16.  A client with newly diagnosed type 1 diabetes says to the nurse, "I know that I have to take good care of my feet. When I buy new shoes, is there anything special I should do?" Which of the following responses by the nurse is BEST?
A.
B.
C.
D.
17.  A neonate weighing 7 lb 4 oz with Apgar scores of 7 and 8 at 1 and 5 minutes, respectively, is admitted to the nursery. Because the infant’s mother is diagnosed with a type 1 diabetes, the nurse knows the infant is at GREATEST risk for developing which of the following?
A.
B.
C.
D.
18.  The nurse in the outpatient clinic assists with the application of a cast to the left arm of a pre-school-aged child. After the cast is applied, the nurse should take which of the following actions?
A.
B.
C.
D.
19.  The nurse cares for patients on the pediatric unit. The mother of a 2-year-old who is one day postoperative tells the nurse, "My child is so restless and overactive." The nurse should take which of the following actions?
A.
B.
C.
D.
20.  The nurse plans a diet for a child diagnosed with cystic fibrosis (CF). Which of the following dietary requirements should be considered by the nurse?
A.
B.
C.
D.
21.  A male client is admitted with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase test are to be done. The nurse knows that
A.
B.
C.
D.
22.  A client with clear lung sounds and unlabored breathing receives aminophylline IV. Which of the following is the MOST appropriate nursing action if the client’s IV infiltrates?
A.
B.
C.
D.
23.  A client diagnosed with bipolar disorder is in a manic phase with combative behavior. Which of the following is the INITIAL priority nursing action?
A.
B.
C.
D.
24.  A client is admitted to the neurosurgery unit for the removal of a cerebellar tumor. The nurse expects the patient to make which of the following statements about symptoms?
A.
B.
C.
D.
25.  Nursing management prior to an intravenous pyelogram (IVP) would include which of the following?
A.
B.
C.
D.
26.  A client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The client, diagnosed with a spinal cord injury at the level of C4, is tearful, constantly complains of discomfort, and requests to be suctioned. The nurse understands that the client’s attention-seeking behaviors may be due to which of the following?
A.
B.
C.
D.
27.  A client is scheduled for electromyography (EMG). What should the nurse tell the client about the procedure?
A.
B.
C.
D.
28.  The nurse is aware that Rh immune globulin (RhoGAM) is administered to prevent complications in which of the following situations?
A.
B.
C.
D.
29.  The nurse in the outpatient clinic instructs a client diagnosed with right-sided weakness to walk down stairs using a cane. What behavior, if demonstrated by the client, indicates to the nurse that teaching is successful?
A.
B.
C.
D.
30.  The nurse makes patient assignments on the obstetrics unit. Which of the following patients should the nurse assign to an RN who has been reassigned to the obstetrics unit from outpatient surgery?
A.
B.
C.
D.
31.  A 2-day-old infant in the newborn nursery does not appear interested in taking formula from the mother or the nurse. An appropriate nursing diagnosis is high risk for
A.
B.
C.
D.
32.  The nurse cares for clients in the medical clinic. A nursing assessment of a client with a hiatal hernia is MOST likely to reveal which of the following?
A.
B.
C.
D.
33.  The MOST appropriate nursing action before administering captopril (Capoten) is to check the client’s
A.
B.
C.
D.
34.  An older client diagnosed with pneumonia is admitted to the medical/surgical unit. The nurse should place the patient in a room with which of the following patients?
A.
B.
C.
D.
35.  An elderly man diagnosed with chronic schizophrenia is followed in a partial hospitalization program. The client has been on long-term antipsychotic medication and recently developed symptoms of tardive dyskinesia. The nurse’s documentation should include which of the following?
A.
B.
C.
D.
36.  The nurse obtains a client’s temperature of 103°F(39.4°C). The nurse knows body compensatory mechanisms include which of the following?
A.
B.
C.
D.
37.  A client is admitted with irritable bowel syndrome. The nurse anticipates that the client’s history will reflect which of the following?
A.
B.
C.
D.
38.  The nurse cares for a client who has had an above-knee amputation (AKA) with an immediate prosthetic fitting. It is MOST important for the nurse to take which of the following actions?
A.
B.
C.
D.
39.  A patient is admitted to the hospital for a hypoglossectomy with lymph node dissection. The patient’s preoperative care includes frequent oral hygiene with hydrogen peroxide. The nurse knows the purpose of this treatment includes which of the following?
A.
B.
C.
D.
40.  The school nurse observes a group of preschool children in the playroom. The nurse recognizes which of the following activities as appropriate behavior for a 5-year-old boy?
A.
B.
C.
D.
41.  Which of the following statements, if made by the nurse, is accurate about the exercise program required for a patient with rheumatoid arthritis?
A.
B.
C.
D.
42.  The nurse assesses a client with severe bilateral peripheral edema. Which of the following is the BEST way for the nurse to determine the degree of edema in a limb?
A.
B.
C.
D.
43.  A 6-month-old infant has had all of the required immunizations. The nurse knows that this would include which of the following?
A.
B.
C.
D.
44.  The nurse should include which of the following in a teaching plan for a client receiving tetracycline?
A.
B.
C.
D.
45.  An elderly alcoholic client receives a long-acting benzodiazepine (Librium) for 2 days for symptom management and reduction. The client states, "Get those bugs off of me and clean them out of here." The nurse knows the client is exhibiting symptoms of which of the following?
A.
B.
C.
D.
46.  A client is admitted for a series of tests to verify the diagnosis of Cushing syndrome. Which of the following assessment findings, if observed by the nurse, support this diagnosis? Select all that apply.
A.
B.
C.
D.
E.
F.
47.  The nurse cares for a patient several days after an above-knee amputation (AKA). Which of the following symptoms are characteristic of an infected residual limb wound?
A.
B.
C.
D.
48.  Which of the following statements, if made by a client to the nurse, indicates that the client is using the defense mechanism of conversion?
A.
B.
C.
D.
49.  Which observation indicates to the nurse that the client needs further teaching before self-administering insulin?
A.
B.
C.
D.
50.  A client has orders for cefoxitin (Mefoxin) 2 g IV piggyback in 100 ml 5% dextrose in water. The primary IV is 5% dextrose in lactated Ringer’s and is infusing by gravity. It is MOST important for the nurse to take which of the following actions?
A.
B.
C.
D.
51.  The nurse supervises care given to clients on a medical/surgical unit. The nurse should intervene if which of the following is observed?
A.
B.
C.
D.
52.  The nurse recognizes that the client diagnosed with an obsessive-compulsive ritual is attempting to achieve which of the following?
A.
B.
C.
D.
53.  An infant is admitted with vomiting and diarrhea. The infant’s anterior fontanelle is depressed and temperature is 103.2°F (39.5°C). Which of the following nursing actions is MOST appropriate?
A.
B.
C.
D.
54.  The nurse anticipates which of the following when assessing a client with a diagnosis of a ruptured lumbar disc?
A.
B.
C.
D.
55.  A client has been taking propranolol (Inderal) 40 mg BID and furosemide (Lasix) 40 mg daily for several months. Two weeks ago, the physician added verapamil (Calan) 80 mg TID to the client’s medication regimen. The client returns to the outpatient clinic for evaluation. It is MOST important for the nurse to assess for which of the following?
A.
B.
C.
D.
56.  A client has a three-way Foley catheter following a transurethral resection. The nurse should rapidly infuse the irrigating solutions if which of the following is observed?
A.
B.
C.
D.
57.  The nurse cares for clients on a psychiatric unit and is suddenly faced with multiple issues. Which of the following situations require the nurse’s IMMEDIATE attention?
A.
B.
C.
D.
58.  The nurse cares for an elderly client who is receiving IV fluids of 0.9% NaCl at 125 mL/h into the left arm. During a routine assessment, the nurse finds that the client has distended neck veins, shortness of breath, and crackles in both lung bases. Which of the following actions should the nurse take FIRST?
A.
B.
C.
D.
59.  The nurse knows that which of the following symptoms is supportive of a diagnosis of Guillain-Barré syndrome?
A.
B.
C.
D.
60.  A patient is treated in the telemetry unit for cardiac disease. The patient receives propranolol hydrochloride (Inderal) 20 mg PO at 9 A.M. When the nurse enters the room to give the medication to the patient, the nurse finds the patient wheezing with a nonproductive cough and shortness of breath. INITIALLY, the nurse should take which of the following actions?
A.
B.
C.
D.
61.  A client in a psychiatric facility describes seeing snakes on the walls of the room. Which of the following is an accurate nursing diagnosis?
A.
B.
C.
D.
62.  The nurse reviews client assignments on a medical/surgical unit. The nurse determines that the assignment is appropriate if the nursing assistant is caring for which of the following clients?
A.
B.
C.
D.
63.  The nurse teaches nutrition classes at the community center. Which of the following foods should the nurse encourage a low-income client to eat to satisfy essential protein needs?
A.
B.
C.
D.
64.  The nurse observes the fetal heart monitor for a client in active labor. The fetal heart tracing shows early fetal decelerations. The nurse is aware that this is
A.
B.
C.
D.
65.  A client is scheduled for a myelogram at the outpatient clinic. The physician’s office nurse reinforces the physician’s explanation of the procedure. Which of the following statements, if made by the nurse, correctly describes a myelogram?
A.
B.
C.
D.
66.  The nurse caring for a client on suicide precautions makes the following observations: the client is verbalizing other options besides suicide, appears to be responding to antidepressant medication, is sleeping and eating better, and has indicated a willingness to interact more with family members. Based on these data, which of the following nursing actions is MOST appropriate?
A.
B.
C.
D.
67.  The nurse obtains a history from the father of a 6-year-old boy with a history of epilepsy who was admitted with uncontrolled seizures. It is MOST important for the nurse to ask which of the following questions?
A.
B.
C.
D.
68.  The nurse teaches a health class at the local library to a group of senior citizens. Which of the following behaviors should the nurse emphasize to facilitate regular bowel elimination?
A.
B.
C.
D.
69.  The physician orders morphine sulfate 8 mg IM q 3 to 4 h for pain PRN. In which of the following situations should the nurse consider withholding the medication until further assessment is completed?
A.
B.
C.
D.
70.  The nurse observes a student nurse caring for a client. In addition to following standard precautions, the student nurse is wearing a gown and gloves. The nurse determines care is appropriate if the student nurse performs which of the following activities?
A.
B.
C.
D.
71.  A client is diagnosed with obsessive-compulsive disorder manifested by the compulsion of hand-washing. The nurse knows that which of the following BEST describes the client’s need for the repetitive acts of hand-washing?
A.
B.
C.
D.
72.  The nurse cares for an elderly client who has just had a prosthetic hip implant. The nurse should position the client in which of the following positions?
A.
B.
C.
D.
73.  A mother brings her 10-year-old and 3-year-old daughters to the pediatrician’s office because the younger girl complains of dysuria. The physician orders a catheterization to obtain a urine specimen. The nurse should take which of the following actions?
A.
B.
C.
D.
74.  A patient is returned to the unit after surgery with a cuffed tracheostomy tube in place. The nurse knows that the purpose of the cuff on the tracheostomy tube includes which of the following?
A.
B.
C.
D.
75.  The nurse cares for a client after an electroconvulsive therapy (ECT) treatment. The nurse should report which observation to the client’s physician?
A.
B.
C.
D.
76.  A mother brings her 9-month-old infant to the pediatrician’s office with complaints of a fever of 102.2°F (39°C) and frequent vomiting. The nurse expects which of the following reflexes to still be present?
A.
B.
C.
D.
77.  A client with an irregular pulse rate of 81 and a potassium level of 3.0 mEq/L has digoxin (Lanoxin) ordered. Which of the following actions, if taken by the nurse, is BEST?
A.
B.
C.
D.
78.  The nurse assesses a client’s neurosensory cerebellar functioning. Which of the following assessment techniques is correct?
A.
B.
C.
D.
79.  The nurse cares for an elderly adult client with multi-infarct dementia. Which of the following actions, if taken by the nurse, is BEST?
A.
B.
C.
D.
80.  A teenager diagnosed with anorexia nervosa is admitted to the hospital. In planning to care for the client, the nurse would expect the client to
A.
B.
C.
D.
81.  The nurse cares for a client admitted with a diagnosis of acute hypoparathyroidism. It is MOST important for the nurse to have which of the following items available?
A.
B.
C.
D.
82.  An adult woman has missed her menstrual period. The client’s last menstrual period began May 8 and ended May 12. The nurse determines that the client’s EDC (estimated date of confinement) is which of the following?
A.
B.
C.
D.
83.  The nurse checks the incision of a patient 48 hours after surgery for a hernia repair. Which of the following findings indicates a possible complication?
A.
B.
C.
D.
84.  The nurse knows that which of these plans is MOST successful in caring for a client with dementia?
A.
B.
C.
D.
85.  A client has partial-thickness and full-thickness burns over 75% of his body. The nurse is MOST concerned if which of the following is observed?
A.
B.
C.
D.
86.  The nurse observes a client who is taking phenelzine (Nardil) eat another client’s lunch. After a few minutes, the client complains of headache, nausea, and rapid heartbeat, and begins to vomit. The nurse anticipates administering which of the following medications?
A.
B.
C.
D.
87.  The nurse receives report from the previous shift. Which of the following clients should the nurse see FIRST?
A.
B.
C.
D.
88.  The nurse cares for a client who is receiving a tube feeding around the clock. Which of the following nursing actions is MOST appropriate?
A.
B.
C.
D.
89.  A 25-year-old primigravida diagnosed with type 1 diabetes mellitus reviews the insulin regimen with the nurse. The nurse explains to the client that her insulin needs will change in which of the following ways?
A.
B.
C.
D.
90.  A client asks what the difference is between a gastric ulcer and a duodenal ulcer. The nurse’s response should be based on which of the following statements?
A.
B.
C.
D.
91.  An 8-year-old has been receiving chemotherapy for 6 months. During her nursing care she asks, "Am I going to die?" Which of the following responses by the nurse is BEST?
A.
B.
C.
D.
92.  An 11-year-old boy falls off his bicycle and sustains a minor head injury, which is treated at the outpatient clinic. The nurse instructs the boy’s mother about his care at home. The nurse determines that further teaching is necessary if the mother makes which of the following statements?
A.
B.
C.
D.
93.  The nurse cares for patients on the psychiatric unit. An extremely angry patient with bipolar illness tells the nurse he just learned his wife has filed for divorce and he needs to use the phone. Which of the following responses by the nurse is MOST appropriate?
A.
B.
C.
D.
94.  The nurse cares for a child who is in Buck’s traction. During the neurovascular assessment, the nurse notes that the foot of the uninjured leg feels warmer to touch than that of the broken leg. The nurse should take which of the following actions?
A.
B.
C.
D.
95.  A 4 lb 10 oz baby boy is delivered at 32 weeks’ gestation. The infant is admitted to the neonatal intensive care unit and placed in an incubator. The infant has mottling of the skin and acrocyanosis with irregular respirations of 60. The nurse should recognize that these findings indicate which of the following?
A.
B.
C.
D.
96.  A client is admitted for regulation of insulin dosage. The client takes 15 units of Humulin N insulin at 8 A.M. every day. At 4 P.M., which of the following nursing observations indicates a complication from the insulin?
A.
B.
C.
D.