NCLEX RN Practice Questions 10 (Exam Mode) By RNpedia.Com

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Questions and Answers
  • 1. 

    The client is having an arteriogram. During the procedure, the client tells the nurse, "I’m feeing really hot." Which response would be best?

    • A.

      "You are having an allergic reaction. I will get an order for Benadryl."

    • B.

      "That feeling of warmth is normal when the dye is injected."

    • C.

      "That feeling of warmth indicates that the clots in the coronary vessels are dissolving."

    • D.

      "I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing."

    Correct Answer
    B. "That feeling of warmth is normal when the dye is injected."
    Explanation
    It is normal for the client to have a warm sensation when dye is injected. Other choices in the question indicates that the nurse believes that the hot feeling is abnormal, so they are incorrect.

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  • 2. 

    The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?

    • A.

      The nursing assistant wears gloves while giving the client a bath.

    • B.

      The nurse wears goggles while drawing blood from the client.

    • C.

      The doctor washes his hands before examining the client.

    • D.

      The nurse wears gloves to take the client’s vital signs.

    Correct Answer
    D. The nurse wears gloves to take the client’s vital signs.
    Explanation
    It is not necessary to wear gloves to take the vital signs of the client. If the client has active infection with methicillin-resistant staphylococcus aureus, gloves should be worn. The healthcare workers in other answer choices indicate knowledge of infection control by their actions.

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  • 3. 

    The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective? 

    • A.

      The client loses consciousness

    • B.

      The client vomits.

    • C.

      The client’s ECG indicates tachycardia

    • D.

      The client has a grand mal seizure

    Correct Answer
    D. The client has a grand mal seizure
    Explanation
    During ECT, the client will have a grand mal seize. This indicates completion of the electroconvulsive therapy.

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  • 4. 

    The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to: 

    • A.

      Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep

    • B.

      Scrape the skin with a piece of cardboard and bring it to the clinic

    • C.

      Obtain a stool specimen in the afternoon

    • D.

      Bring a hair sample to the clinic for evaluation

    Correct Answer
    A. Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep
    Explanation
    Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. There is no need to scrap the skin, collect a stool specimen, or bring a sample of hair.

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  • 5. 

    The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?

    • A.

      Treatment is not recommended for children less than 10 years of age

    • B.

      The entire family should be treated

    • C.

      Medication therapy will continue for 1 year

    • D.

      Intravenous antibiotic therapy will be ordered

    Correct Answer
    B. The entire family should be treated
    Explanation
    Erterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated to ensure that no eggs remain. Because a single treatment is usually sufficient, there is usually good compliance. The family should then be tested again in 2 weeks to ensure that no eggs remain.

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  • 6. 

    The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?

    • A.

      The client receiving linear accelerator radiation therapy for lung cancer

    • B.

      The client with a radium implant for cervical cancer

    • C.

      The client who has just been administered soluble brachytherapy for thyroid cancer

    • D.

      The client who returned from placement of iridium seeds for prostate cancer

    Correct Answer
    A. The client receiving linear accelerator radiation therapy for lung cancer
    Explanation
    The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy travels to the radium department for therapy. The radiation stays in the department, so the client is not radioactive. The client in other answer choices pose a risk to the pregnant nurse. These clients are radioactive in very small doses, especially upon returning from the procedures. For approximately 72 hours, the clients should dispose of urine and feces in special containers and use plastic spoons and forks

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  • 7. 

    The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available? 

    • A.

      The client with Cushing’s disease

    • B.

      The client with diabetes

    • C.

      The client with acromegaly

    • D.

      The client with myxedema

    Correct Answer
    A. The client with Cushing’s disease
    Explanation
    The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immune suppressed. In client with diabetes, the client poses no risk to other clients. The client with acromegaly has an increase in growth hormone and poses no risk to himself or others. The client with myxedema has hyperthyroidism or myxedema and poses no risk to others or himself.

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  • 8. 

    The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with: 

    • A.

      Negligence

    • B.

      Tort

    • C.

      Assault

    • D.

      Malpractice

    Correct Answer
    D. Malpractice
    Explanation
    The nurse could be charged with malpractice, which is failing to perform, or performing an act that causes harm to the client. Giving the infant an overdose falls into this category. Negligence , Tort , and Assault are incorrect because they apply to other wrongful acts. Negligence is failing to perform care for the client; a tort is a wrongful act committed on the client or their belongings; and assault is a violent physical or verbal attack.

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  • 9. 

    Which assignment should not be performed by the licensed practical nurse?

    • A.

      Inserting a Foley catheter

    • B.

      Discontinuing a nasogastric tube

    • C.

      Obtaining a sputum specimen

    • D.

      Starting a blood transfusion

    Correct Answer
    D. Starting a blood transfusion
    Explanation
    The licensed practical nurse should not be assigned to begin a blood transfusion. The licensed practical nurse can insert a Foley catheter, discontinue a nasogastric tube, and collect sputum specimen.

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  • 10. 

    The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority? 

    • A.

      Continuing to monitor the vital signs

    • B.

      Contacting the physician

    • C.

      Asking the client how he feels

    • D.

      Asking the LPN to continue the post-op care

    Correct Answer
    B. Contacting the physician
    Explanation
    The vital signs are abnormal and should be reported immediately. Continuing to monitor the vital signs can result in deterioration of the client’s condition. Asking the client how he feels will only provide subjective data, and LPN is not the best nurse to assign because this client is unstable.

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  • 11. 

    Which nurse should be assigned to care for the postpartal client with preeclampsia? 

    • A.

      The RN with 2 weeks of experience in postpartum

    • B.

      The RN with 3 years of experience in labor and delivery

    • C.

      The RN with 10 years of experience in surgery

    • D.

      The RN with 1 year of experience in the neonatal intensive care unit

    Correct Answer
    B. The RN with 3 years of experience in labor and delivery
    Explanation
    The nurse with 3 years of experience in labor and delivery knows the most about possible complications involving preeclampsia. The RN with 2 weeks of experience in postpartum is a new nurse to the unit, and the RN with 10 years of experience in surgery and RN with 1 year of experience in the neonatal intensive care unit have no experience with the postpartum client.

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  • 12. 

    Which information should be reported to the state Board of Nursing? 

    • A.

      The facility fails to provide literature in both Spanish and English.

    • B.

      The narcotic count has been incorrect on the unit for the past 3 days.

    • C.

      The client fails to receive an itemized account of his bills and services received during his hospital stay.

    • D.

      The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.

    Correct Answer
    B. The narcotic count has been incorrect on the unit for the past 3 days.
    Explanation
    The Joint Commission on Accreditation of Hospitals will probably be interested in the problems if facility fails to provide literature in both Spanish and English. and if the client fails to receive an itemized account of his bills and services received during his hospital stay. The failure of the nursing assistant to care for the client with hepatitis might result in termination, but is not of interest to the Joint Commission.

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  • 13. 

    The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should: 

    • A.

      Call the Board of Nursing

    • B.

      File a formal reprimand

    • C.

      Terminate the nurse

    • D.

      Charge the nurse with a tort

    Correct Answer
    B. File a formal reprimand
    Explanation
    The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but these are not the first actions requested in the stem. A tort is a wrongful act to the client or his belongings and is not indicated in this instance.

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  • 14. 

    The home health nurse is planning for the day’s visits. Which client should be seen first?

    • A.

      The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube

    • B.

      The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension

    • C.

      He 50-year-old with MRSA being treated with Vancomycin via a PICC line

    • D.

      The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter

    Correct Answer
    D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
    Explanation
    The client at highest risk for complications is the client with multiple sclerosis who is being treated with cortisone via the central line. The others are more stable. MRSA is methicillin-resistant staphylococcus aureus. Vancomycin is the drug of choice and is given at scheduled times to maintain blood levels of the drug. The clients in other answer choices of the question are more stable and can be seen later.

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  • 15. 

    The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster? 

    • A.

      A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis

    • B.

      The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm

    • C.

      A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury

    • D.

      The client who arrives with a large puncture wound to the abdomen and the client with chest pain

    Correct Answer
    B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm
    Explanation
    The pregnant client and the client with a broken arm and facial lacerations are the best choices for placing in the same room. The clients in other choices answers of the question need to be placed in separate rooms due to the serious natures of their injuries.

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  • 16. 

    The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following? 

    • A.

      The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops.

    • B.

      The child should be allowed to instill his own eyedrops.

    • C.

      The mother should be allowed to instill the eyedrops.

    • D.

      If the eye is clear from any redness or edema, the eyedrops should be held.

    Correct Answer
    A. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops.
    Explanation
    Before instilling eyedrops, the nurse should cleanse the area with water. A 6-year-old child is not developmentally ready to instill his own eyedrops. Although the mother of the child can instill the eyedrops, the area must be cleansed before administration. Although the eye might appear to be clear, the nurse should instill the eyedrops, as ordered.

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  • 17. 

    The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction? 

    • A.

      "It is okay to give my child white grape juice for breakfast."

    • B.

      "My child can have a grilled cheese sandwich for lunch."

    • C.

      "We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch."

    • D.

      "For a snack, my child can have ice cream."

    Correct Answer
    C. "We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch."
    Explanation
    Remember the ABCs (airway, breathing, circulation) when answering this question. The statement, "We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch." is correct because a hotdog is the size and shape of the child’s trachea and poses a risk of aspiration. The rest of the choices in the question are incorrect because white grape juice, a grilled cheese sandwich, and ice cream do not pose a risk of aspiration for a child.

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  • 18. 

    A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect? 

    • A.

      Ask the parent/guardian to leave the room when assessments are being performed.

    • B.

      Ask the parent/guardian to take the child’s favorite blanket home because anything from the outside should not be brought into the hospital.

    • C.

      Ask the parent/guardian to room-in with the child.

    • D.

      If the child is screaming, tell him this is inappropriate behavior.

    Correct Answer
    C. Ask the parent/guardian to room-in with the child.
    Explanation
    The nurse should encourage rooming-in to promote parent-child attachment. It is okay for the parents to be in the room for assessment of the child. Allowing the child to have items that are familiar to him is allowed and encourage. If the child is screaming, telling him this is inappropriate behavior is not part of the nurse’s responsibilities.

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  • 19. 

    Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid? 

    • A.

      Remove the mold and clean every week.

    • B.

      Store the hearing aid in a warm place.

    • C.

      Clean the lint from the hearing aid with a toothpick.

    • D.

      Change the batteries weekly.

    Correct Answer
    B. Store the hearing aid in a warm place.
    Explanation
    The hearing aid should be stored in a warm, dry place. It should be cleaned daily but should not be moldy, so removing the mold and clean every week is incorrect. A toothpick is inappropriate to use to clean the aid; the toothpick might break off in the hearing aide. Changing the batteries weekly, is not necessary.

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  • 20. 

    A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is: 

    • A.

      Body image disturbance

    • B.

      Impaired verbal communication

    • C.

      Risk for aspiration

    • D.

      Pain

    Correct Answer
    C. Risk for aspiration
    Explanation
    Always remember your ABCs (airway, breathing, circulation) when selecting an answer. Although answers impaired verbal communication and pain might be appropriate for this child, answer risk for aspiration should have the highest priority. Body image disturbance does not apply for a child who has undergone a tonsillectomy.

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  • 21. 

    A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal? 

    • A.

      High fever

    • B.

      Nonproductive cough

    • C.

      Rhinitis

    • D.

      Vomiting and diarrhea

    Correct Answer
    A. High fever
    Explanation
    If the child has bacterial pneumonia, a high fever is usually present. Bacterial pneumonia usually presents with a productive cough, not a nonproductive cough, making nonproductive cough incorrect. Rhinitis is often seen with viral pneumonia, and vomiting and diarrhea are usually not seen with pneumonia, so rhinitis , vomiting and diarrhea are incorrect.

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  • 22. 

    The nurse is caring for a client admitted with epiglottis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?

    • A.

      Intravenous access supplies

    • B.

      A tracheostomy set

    • C.

      Intravenous fluid administration pump

    • D.

      Supplemental oxygen

    Correct Answer
    B. A tracheostomy set
    Explanation
    For a child with epiglottis and the possibility of complete obstruction of the airway, emergency tracheostomy equipment should always be kept at the bedside. Intravenous supplies, fluid, and oxygen will not treat an obstruction.

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  • 23. 

    A 25-year-old client with Grave’s disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal? 

    • A.

      Bradycardia

    • B.

      Decreased appetite

    • C.

      Exophthalmos

    • D.

      Weight gain

    Correct Answer
    C. Exophthalmos
    Explanation
    Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss.

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  • 24. 

    The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions? 

    • A.

      Ham sandwich on whole-wheat toast

    • B.

      Spaghetti and meatballs

    • C.

      Hamburger with ketchup

    • D.

      Cheese omelet

    Correct Answer
    D. Cheese omelet
    Explanation
    The child with celiac disease should be on a gluten-free diet. Ham sandwich on whole-wheat toast, Spaghetti and meatballs , and Hamburger with ketchup all contain gluten, while answer Cheese omelet gives the only choice of foods that does not contain gluten.

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  • 25. 

    The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first?

    • A.

      Notify the physician

    • B.

      Recheck the O2 saturation level in 15 minutes

    • C.

      Apply oxygen by mask

    • D.

      Assess the child’s pulse

    Correct Answer
    C. Apply oxygen by mask
    Explanation
    Remember the ABCs (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the pulse, oxygen should be applied to increase the oxygen saturation. The normal oxygen saturation for a child is 92%–100%.

    Rate this question:

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  • Mar 18, 2023
    Quiz Edited by
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  • Feb 12, 2011
    Quiz Created by
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