NCLEX-RN Exam Free Review By NCLEX Masters

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Questions and Answers
  • 1. 

    The nurse would anticipate that an eight month-old would be able to  do one or more of the following:

    • A.

      Say two words

    • B.

      Pull up to stand

    • C.

      Sit without support

    • D.

      Use a spoon

    Correct Answer
    C. Sit without support
    Explanation
    The correct answer is C: Sit without support. The age at which the normal child develops the ability to sit steadily without support is from seven to eight months.

    Rate this question:

  • 2. 

    A client states, "People think I'm no good, you know what I mean?" Which nursing response would be most therapeutic for this client?

    • A.

      "People often take their own feelings of inadequacy out on others."

    • B.

      "Let's identify a few people who like you."

    • C.

      "I'm not sure what you mean. Tell me a bit more about that."

    • D.

      Lets' explore what you may have done to create this impression on people

    Correct Answer
    C. "I'm not sure what you mean. Tell me a bit more about that."
    Explanation
    The correct answer is C: "I'm not sure what you mean. Tell me a bit more about that.". Therapeutic communication technique that elicits more information is delivered in an open non-judgmental fashion.

    Rate this question:

  • 3. 

    A client states, "People think I'm no good, you know what I mean?" Which nursing response would be most therapeutic for this client?

    • A.

      "People often take their own feelings of inadequacy out on others."

    • B.

      "Let's identify a few people who like you."

    • C.

      "I'm not sure what you mean. Tell me a bit more about that."

    • D.

      Lets' explore what you may have done to create this impression on people

    Correct Answer
    C. "I'm not sure what you mean. Tell me a bit more about that."
    Explanation
    The correct answer is C: "I'm not sure what you mean. Tell me a bit more about that.". Therapeutic communication technique that elicits more information is delivered in an open non-judgmental fashion.

    Rate this question:

  • 4. 

    A client calls the evening health clinic to state "I know I have a severely low sugar since the Lantus insulin was given three hours ago and it peaks in two hours." What should be the nurse's initial response to the client?

    • A.

      What else do you know about this type of insulin?.

    • B.

      What are you feeling at this moment?

    • C.

      Have you eaten anything today?

    • D.

      Are you taking any other insulin or medication?

    Correct Answer
    B. What are you feeling at this moment?
    Explanation
    B is the most correct action by the nurse; determining what the patient may be feeling at the moment help the RN assessing the patient current state.

    Rate this question:

  • 5. 

    A client calls the evening health clinic to state "I know I have a severely low sugar since the Lantus insulin was given three hours ago and it peaks in two hours." What should be the nurse's initial response to the client?

    • A.

      What else do you know about this type of insulin?.

    • B.

      What are you feeling at this moment?

    • C.

      Have you eaten anything today?

    • D.

      Are you taking any other insulin or medication?

    Correct Answer
    B. What are you feeling at this moment?
    Explanation
    B is the most correct action by the nurse; determining what the patient may be feeling at the moment help the RN assessing the patient current state.

    Rate this question:

  • 6. 

    A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove her dentures prior to leaving the unit for the operating room. The most appropriate intervention by the nurse is:

    • A.

      Explain to the client that the dentures must come out as they may get lost or broken in the operating room

    • B.

      Ask the client if there are second thoughts about the procedure

    • C.

      Ask the client if it would be preferred to remove the dentures in the waiting room and give them to a familiy member

    • D.

      Ask the client if it would be preferred to remove the dentures in the operating room receiving area

    Correct Answer
    D. Ask the client if it would be preferred to remove the dentures in the operating room receiving area
    Explanation
    The correct answer is D: Ask the client if it would be preferred to remove the dentures in the operating room receiving area. Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client''s sense of self-esteem and self-concept. Additionally,reduces any self harmingo to the patint's. moth/tonge, etc

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  • 7. 

    The mother of a two year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The best response of the nurse would be to:    

    • A.

      Request for the mother to remain with the child at all times

    • B.

      Request for the mother to remain with the child at all times

    • C.

      Help the mother understand that this is a normal response to hospitalization

    • D.

      Suggest that the mother "sneak out" of the child's room when the child is asleep

    Correct Answer
    C. Help the mother understand that this is a normal response to hospitalization
    Explanation
    The best answer is C; helping the mother understand the child behavior is normal ressures her and help her deal with the child crying.

    Rate this question:

  • 8. 

    Which of these actions best describes the application of time management strategies for the role of the PN charge nurse?

    • A.

      Schedule staff efficiently to cover client needs

    • B.

      Take a fair share of the assigned clients as a role model

    • C.

      Set daily goals to prioritize the workload of self and others

    • D.

      Delegate tasks to reduce workload within the team

    Correct Answer
    C. Set daily goals to prioritize the workload of self and others
    Explanation
    The correct answer is C: Set daily goals to prioritize the workload of self and others. Time management strategies must include setting priorities and meeting goals on a daily and long-term basis

    Rate this question:

  • 9. 

    Which of these actions best describes the application of time management strategies for the role of the PN charge nurse?

    • A.

      Schedule staff efficiently to cover client needs

    • B.

      Take a fair share of the assigned clients as a role model

    • C.

      Set daily goals to prioritize the workload of self and others

    • D.

      Delegate tasks to reduce workload within the team

    Correct Answer
    C. Set daily goals to prioritize the workload of self and others
    Explanation
    The correct answer is C: Set daily goals to prioritize the workload of self and others. Time management strategies must include setting priorities and meeting goals on a daily and long-term basis

    Rate this question:

  • 10. 

    A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts "You think you're so perfect and pure and good." The appropriate response for the nurse is:  

    • A.

      "That explains why you've been starring at me."

    • B.

      "You seem to be in a bad mood."

    • C.

      "Perfect? I don't quite understand."

    • D.

      "You are angry right now."

    Correct Answer
    D. "You are angry right now."
    Explanation
    The correct answer is D: "You are angry right now.". The nurse recognizes the underlying emotion with matter of fact attitude.

    Rate this question:

  • 11. 

    A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts "You think you're so perfect and pure and good." The appropriate response for the nurse is:  

    • A.

      "That explains why you've been starring at me."

    • B.

      "You seem to be in a bad mood."

    • C.

      "Perfect? I don't quite understand."

    • D.

      "You are angry right now."

    Correct Answer
    D. "You are angry right now."
    Explanation
    The correct answer is D: "You are angry right now.". The nurse recognizes the underlying emotion with matter of fact attitude.

    Rate this question:

  • 12. 

    The health care provider order reads "aspirate nasogastric feeding (NG) tube every four hours and check pH of aspirate". The pH of the aspirate is 10. Which action should the nurse take?

    • A.

      Hold the tube feeding and notify the provider

    • B.

      Administer the tube feeding as scheduled

    • C.

      Irrigate the tube with cola diet soda.

    • D.

      Apply intermittent suction to the feeding tube

    Correct Answer
    A. Hold the tube feeding and notify the provider
    Explanation
    The correct answer is A: Hold the tube feeding and notify the provider. A pH of less than four indicates that the tube is appropriately placed in the stomach, a highly acidic environment. A higher than 4 or more alkaline pH indicates intestinal placement which is incorrect.

    Rate this question:

  • 13. 

    The nurse is reviewing a handout on infant feeding to be distributed to families visiting the clinic. Which information should be included in the teaching materials?  

    • A.

      Solid foods are introduced one at a time beginning with cereal

    • B.

      Finely ground meat should be started early to provide iron

    • C.

      Egg white is added early to increase protein intake

    • D.

      Solid foods should be mixed with formula in a bottle

    Correct Answer
    A. Solid foods are introduced one at a time beginning with cereal
    Explanation
    The correct answer is A: Solid foods are introduced one at a time beginning with cereal. Between four and six months, solid foods should be added one at a time to detect allergies or intolerance. If the infant is able to tolerate the food, another may be added in a week. Iron fortified cereal is the recommended first food.

    Rate this question:

  • 14. 

    The nurse is reviewing a handout on infant feeding to be distributed to families visiting the clinic. Which information should be included in the teaching materials?  

    • A.

      Solid foods are introduced one at a time beginning with cereal

    • B.

      Finely ground meat should be started early to provide iron

    • C.

      Egg white is added early to increase protein intake

    • D.

      Solid foods should be mixed with formula in a bottle

    Correct Answer
    A. Solid foods are introduced one at a time beginning with cereal
    Explanation
    The correct answer is A: Solid foods are introduced one at a time beginning with cereal. Between four and six months, solid foods should be added one at a time to detect allergies or intolerance. If the infant is able to tolerate the food, another may be added in a week. Iron fortified cereal is the recommended first food.

    Rate this question:

  • 15. 

    A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my companion will never come near me." The nurse's best response would be "Are you:

    • A.

      Questioning the depth of your relationship?"

    • B.

      Concerned that you will be rejected?"

    • C.

      wondering about the effect on your sexual relations?"

    • D.

      Worried that the surgery will change you?"

    Correct Answer
    D. Worried that the surgery will change you?"
    Explanation
    The correct answer is D: worried that the surgery will change you?". This is a response that encourages further discussion without focusing on an area that the nurse feels is a problem.

    Rate this question:

  • 16. 

    A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my companion will never come near me." The nurse's best response would be "Are you:

    • A.

      Questioning the depth of your relationship?"

    • B.

      Concerned that you will be rejected?"

    • C.

      wondering about the effect on your sexual relations?"

    • D.

      Worried that the surgery will change you?"

    Correct Answer
    D. Worried that the surgery will change you?"
    Explanation
    The correct answer is D: worried that the surgery will change you?". This is a response that encourages further discussion without focusing on an area that the nurse feels is a problem.

    Rate this question:

  • 17. 

    A client was just taken off the ventilator following surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client?

    • A.

      Allow the client to melt ice chips in the mouth

    • B.

      Provide mints to freshen the breath

    • C.

      Perform frequent oral care with a toothsponge

    • D.

      Swab the mouth with glycerin swabs

    Correct Answer
    C. Perform frequent oral care with a toothsponge
    Explanation
    The correct answer is C: Perform frequent oral care with a toothsponge. Frequent cleansing and stimulation of the mucous membrane is important for a client with a nasogastric tube to prevent development of lesions and to promote comfort. Ice chips or mints could be contraindicated, and do not stimulate the tissue. Glycerin swabs do not cleanse since they only moisturize.

    Rate this question:

  • 18. 

    A client was just taken off the ventilator following surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client?

    • A.

      Allow the client to melt ice chips in the mouth

    • B.

      Provide mints to freshen the breath

    • C.

      Perform frequent oral care with a toothsponge

    • D.

      Swab the mouth with glycerin swabs

    Correct Answer
    C. Perform frequent oral care with a toothsponge
    Explanation
    The correct answer is C: Perform frequent oral care with a toothsponge. Frequent cleansing and stimulation of the mucous membrane is important for a client with a nasogastric tube to prevent development of lesions and to promote comfort. Ice chips or mints could be contraindicated, and do not stimulate the tissue. Glycerin swabs do not cleanse since they only moisturize.

    Rate this question:

  • 19. 

    The parents of a four year-old hospitalized child tell the nurse they will leave for a time and return at 6 PM. When the child asks when the parents will come again, the nurse can best respond by saying:

    • A.

      "They will be back right after supper."

    • B.

      "In about two hours, you will see them."

    • C.

      "After you play awhile, they will be here."

    • D.

      D) "When the clock hands are on six and twelve."

    Correct Answer
    A. "They will be back right after supper."
    Explanation
    The correct answer is A: "They will be back right after supper.". Time is not completely understood by a four year-old. The child interprets time with his own frame of reference. Thus, it is best to explain time in relationship to routine events such as a meal.

    Rate this question:

  • 20. 

    The parents of a four year-old hospitalized child tell the nurse they will leave for a time and return at 6 PM. When the child asks when the parents will come again, the nurse can best respond by saying:

    • A.

      "They will be back right after supper."

    • B.

      "In about two hours, you will see them."

    • C.

      "After you play awhile, they will be here."

    • D.

      D) "When the clock hands are on six and twelve."

    Correct Answer
    A. "They will be back right after supper."
    Explanation
    The correct answer is A: "They will be back right after supper.". Time is not completely understood by a four year-old. The child interprets time with his own frame of reference. Thus, it is best to explain time in relationship to routine events such as a meal.

    Rate this question:

  • 21. 

    The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. The nurse should be sure to include which information?

    • A.

      Complete the entire course of the medication for an effective cure

    • B.

      Begin treatment with acyclovir at the onset of findings of recurrence

    • C.

      Stop treatment if she thinks she may be pregnant to prevent birth defects

    • D.

      Continue to take prophylactic doses for at least five years after the diagnosis

    Correct Answer
    B. Begin treatment with acyclovir at the onset of findings of recurrence
    Explanation
    The correct answer is B: Begin treatment with acyclovir at the onset of findings of recurrence. When the client is aware of early findings, such as pain, itching or tingling, treatment is very effective.

    Rate this question:

  • 22. 

    The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. The nurse should be sure to include which information?

    • A.

      Complete the entire course of the medication for an effective cure

    • B.

      Begin treatment with acyclovir at the onset of findings of recurrence

    • C.

      Stop treatment if she thinks she may be pregnant to prevent birth defects

    • D.

      Continue to take prophylactic doses for at least five years after the diagnosis

    Correct Answer
    B. Begin treatment with acyclovir at the onset of findings of recurrence
    Explanation
    The correct answer is B: Begin treatment with acyclovir at the onset of findings of recurrence. When the client is aware of early findings, such as pain, itching or tingling, treatment is very effective.

    Rate this question:

  • 23. 

    A client is admitted to the emergency room following an acute asthma attack. Which of the following findings would be most important to report?

    • A.

      Diffuse, inspiratory wheezing

    • B.

      Loose, productive cough

    • C.

      Lengthened expiratory phase

    • D.

      Expiratory wheezing

    Correct Answer
    A. Diffuse, inspiratory wheezing
    Explanation
    The correct answer is A: Diffuse, inspiratory wheezing. In asthma, the airways are narrowed - creating difficulty getting air in which produces a wheezing sound. Note that all of the findings are associated with an acute asthma attack. Inspiratory wheezing indicates a potential for airwary closure. Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information.

    Rate this question:

  • 24. 

    A client is admitted to the emergency room following an acute asthma attack. Which of the following findings would be most important to report?

    • A.

      Diffuse, inspiratory wheezing

    • B.

      Loose, productive cough

    • C.

      Lengthened expiratory phase

    • D.

      Expiratory wheezing

    Correct Answer
    A. Diffuse, inspiratory wheezing
    Explanation
    The correct answer is A: Diffuse, inspiratory wheezing. In asthma, the airways are narrowed - creating difficulty getting air in which produces a wheezing sound. Note that all of the findings are associated with an acute asthma attack. Inspiratory wheezing indicates a potential for airwary closure. Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information.

    Rate this question:

  • 25. 

    In the last 48 hours of life, a hospice client may complain of dry mouth from a poor fluid intake. The nurse should only offer to moisten the mouth because:

    • A.

      The client can aspirate on thin liquids

    • B.

      Increased hydration can prolong discomfort

    • C.

      renal function cannot handle the extra fluids

    • D.

      The venous system cannot accommodate fluids.

    Correct Answer
    B. Increased hydration can prolong discomfort
    Explanation
    The correct answer is B: increased hydration can prolong discomfort. Increased hydration can make the dying process more uncomfortable and prolonged. In option 1 aspiration is likely only if the gag reflex is reduced or the client is comatose. There is no evidence that renal shutdown has occurred without more information.

    Rate this question:

  • 26. 

    In the last 48 hours of life, a hospice client may complain of dry mouth from a poor fluid intake. The nurse should only offer to moisten the mouth because:

    • A.

      The client can aspirate on thin liquids

    • B.

      Increased hydration can prolong discomfort

    • C.

      renal function cannot handle the extra fluids

    • D.

      The venous system cannot accommodate fluids.

    Correct Answer
    B. Increased hydration can prolong discomfort
    Explanation
    The correct answer is B: increased hydration can prolong discomfort. Increased hydration can make the dying process more uncomfortable and prolonged. In option 1 aspiration is likely only if the gag reflex is reduced or the client is comatose. There is no evidence that renal shutdown has occurred without more information.

    Rate this question:

  • 27. 

    A child, injured on the school playground, appears to have a fractured leg. The first action the school nurse should take is

    • A.

      Call for emergency transport to the hospital

    • B.

      Immobilize the limb and joints above and below the injury

    • C.

      Assess the child and the extent of the injury

    • D.

      Apply cold compresses to the injured area

    Correct Answer
    C. Assess the child and the extent of the injury
    Explanation
    The correct answer is C: Assess the child and the extent of the injury. When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis).
    Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

    Rate this question:

  • 28. 

    A child, injured on the school playground, appears to have a fractured leg. The first action the school nurse should take is

    • A.

      Call for emergency transport to the hospital

    • B.

      Immobilize the limb and joints above and below the injury

    • C.

      Assess the child and the extent of the injury

    • D.

      Apply cold compresses to the injured area

    Correct Answer
    C. Assess the child and the extent of the injury
    Explanation
    The correct answer is C: Assess the child and the extent of the injury. When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis).
    Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

    Rate this question:

  • 29. 

    An important goal in the development of a therapeutic inpatient milieu is providing a A) businesslike atmosphere where clients can work on individual goals forum in which clients deB) group cide on unit rules, regulations, and policies

    • A.

      businesslike atmosphere where clients can work on individual goals

    • B.

      Group forum in which clients decide on unit rules, regulations, and policies

    • C.

      Testing ground for new patterns of behavior for which the client takes responsibility

    • D.

      Discouragment for expressions of anger because they can be disruptive to other clients

    Correct Answer
    C. Testing ground for new patterns of behavior for which the client takes responsibility
    Explanation
    The correct answer is C: testing ground for new patterns of behavior for which the client takes responsibility. A therapeutic milieu is purposeful and planned to provide safety and a testing ground for new patterns of behavior. Refer to Psych Nursing for additional information.Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

    Rate this question:

  • 30. 

    An important goal in the development of a therapeutic inpatient milieu is providing a A) businesslike atmosphere where clients can work on individual goals forum in which clients deB) group cide on unit rules, regulations, and policies

    • A.

      businesslike atmosphere where clients can work on individual goals

    • B.

      Group forum in which clients decide on unit rules, regulations, and policies

    • C.

      Testing ground for new patterns of behavior for which the client takes responsibility

    • D.

      Discouragment for expressions of anger because they can be disruptive to other clients

    Correct Answer
    C. Testing ground for new patterns of behavior for which the client takes responsibility
    Explanation
    The correct answer is C: testing ground for new patterns of behavior for which the client takes responsibility. A therapeutic milieu is purposeful and planned to provide safety and a testing ground for new patterns of behavior. Refer to Psych Nursing for additional information.Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

    Rate this question:

  • 31. 

    The nurse is collecting data on a client with a stage 2 skin ulcer. Which treatment is considered most effective to promote healing?

    • A.

      Covering the wound with a dry dressing

    • B.

      Using hydrogen peroxide soaks

    • C.

      Leaving the area open to dry

    • D.

      Applying a transparent film cover

    Correct Answer
    D. Applying a transparent film cover
    Explanation
    The correct answer is D: Applying a transparent film cover. For this type of ulcer, the most effective treatment is a transparent cover.Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

    Rate this question:

  • 32. 

    The nurse is collecting data on a client with a stage 2 skin ulcer. Which treatment is considered most effective to promote healing?

    • A.

      Covering the wound with a dry dressing

    • B.

      Using hydrogen peroxide soaks

    • C.

      Leaving the area open to dry

    • D.

      Applying a transparent film cover

    Correct Answer
    D. Applying a transparent film cover
    Explanation
    The correct answer is D: Applying a transparent film cover. For this type of ulcer, the most effective treatment is a transparent cover.Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

    Rate this question:

  • 33. 

    The nurse is caring for a four year-old two hours after tonsillectomy and adenoidectomy. Which observation must be reported immediately?

    • A.

      Vomiting of dark brown emesis

    • B.

      Complaints of throat pain

    • C.

      Apical heart rate of 110

    • D.

      Increased restlessness

    Correct Answer
    D. Increased restlessness
    Explanation
    The correct answer is D: Increased restlessness. Restlessness and increased respiratory and heart rates are often early signs of hemorrhage.

    Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

    Rate this question:

  • 34. 

    The nurse is caring for a four year-old two hours after tonsillectomy and adenoidectomy. Which observation must be reported immediately?

    • A.

      Vomiting of dark brown emesis

    • B.

      Complaints of throat pain

    • C.

      Apical heart rate of 110

    • D.

      Increased restlessness

    Correct Answer
    D. Increased restlessness
    Explanation
    The correct answer is D: Increased restlessness. Restlessness and increased respiratory and heart rates are often early signs of hemorrhage.

    Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

    Rate this question:

  • 35. 

    The nurse is assisting with a pre-kindergarten physical on a five year-old. The last MMR vaccine will be administered. Allergy to which item might be a contraindication to giving the vaccine?

    • A.

      Chocolate

    • B.

      Peanut butter

    • C.

      Eggs

    • D.

      Strawberries

    Correct Answer
    C. Eggs
    Explanation
    The correct answer is C: Eggs. The MMR antigens are derived from embryonic chicken eggs. Individuals with anaphylactic reactions to eggs, neomycin, or gelatin should not receive this vaccine.


    Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

    Rate this question:

  • 36. 

    A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking the lips alternately with grinding of the teeth. The nurse assesses this as

    • A.

      Dystonia

    • B.

      Akathesia

    • C.

      Brady dysknesia

    • D.

      Tardive dyskinesia

    Correct Answer
    D. Tardive dyskinesia
    Explanation
    Tardive dyskinesia is a neurological syndrome caused by the long-term use of neuroleptic drugs. Neuroleptic drugs are generally prescribed for psychiatric disorders, as well as for some gastrointestinal and neurological disorders. Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements. Features of the disorder may include grimacing, tongue protrusion, lip smacking, puckering and pursing, and rapid eye blinking. Rapid movements of the arms, legs, and trunk may also occur. Involuntary movements of the fingers may appear as though the patient is playing an invisible guitar or piano.
    Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

    Rate this question:

  • 37. 

    A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking the lips alternately with grinding of the teeth. The nurse assesses this as

    • A.

      Dystonia

    • B.

      Akathesia

    • C.

      Brady dysknesia

    • D.

      Tardive dyskinesia

    Correct Answer
    D. Tardive dyskinesia
    Explanation
    Tardive dyskinesia is a neurological syndrome caused by the long-term use of neuroleptic drugs. Neuroleptic drugs are generally prescribed for psychiatric disorders, as well as for some gastrointestinal and neurological disorders. Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements. Features of the disorder may include grimacing, tongue protrusion, lip smacking, puckering and pursing, and rapid eye blinking. Rapid movements of the arms, legs, and trunk may also occur. Involuntary movements of the fingers may appear as though the patient is playing an invisible guitar or piano.
    Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

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  • 38. 

    A 14 month-old child ingested half a bottle of aspirin tablets. Which finding would the nurse expect to see in the child?

    • A.

      Hypothermia

    • B.

      Dysopnea

    • C.

      Dizziness

    • D.

      Epistaxis

    Correct Answer
    D. Epistaxis
    Explanation
    Blood thinners such as Coumadin or aspirin may cause or worsen nosebleeds Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

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  • 39. 

    A 14 month-old child ingested half a bottle of aspirin tablets. Which finding would the nurse expect to see in the child?

    • A.

      Hypothermia

    • B.

      Dysopnea

    • C.

      Dizziness

    • D.

      Epistaxis

    Correct Answer
    D. Epistaxis
    Explanation
    Blood thinners such as Coumadin or aspirin may cause or worsen nosebleeds Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

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  • 40. 

    The nurse is reinforcing instructions for a client with asthma. Which item should be stressed for the client to monitor on a daily basis?

    • A.

      Respiratory rate

    • B.

      Peak air flow volumes

    • C.

      Pulse oximetry

    • D.

      Skin color

    Correct Answer
    B. Peak air flow volumes
    Explanation
    The correct answer is B: Peak air flow volumes. The peak airflow volume decreases about 24 hours before clinical findings of acute asthma attacks. Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

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  • 41. 

    The nurse is reinforcing instructions for a client with asthma. Which item should be stressed for the client to monitor on a daily basis?

    • A.

      Respiratory rate

    • B.

      Peak air flow volumes

    • C.

      Pulse oximetry

    • D.

      Skin color

    Correct Answer
    B. Peak air flow volumes
    Explanation
    The correct answer is B: Peak air flow volumes. The peak airflow volume decreases about 24 hours before clinical findings of acute asthma attacks. Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

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  • 42. 

    A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to

    • A.

      Have the client identify coping methods

    • B.

      Get the description of the location and intensity of the pain

    • C.

      Accept the client's report of pain

    • D.

      Determine the client's status of pain

    Correct Answer
    C. Accept the client's report of pain
    Explanation
    The correct answer is C: accept the client's report of pain. Although the information above is correct, the first and most important piece of information in this client's pain assessment is what the client is telling you about the pain --"the client's report". The correct answer is C: accept the client's report of pain. Although the information above is correct, the first and most important piece of information in this client's pain assessment is what the client is telling you about the pain --"the client's report". Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

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  • 43. 

    A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to

    • A.

      Have the client identify coping methods

    • B.

      Get the description of the location and intensity of the pain

    • C.

      Accept the client's report of pain

    • D.

      Determine the client's status of pain

    Correct Answer
    C. Accept the client's report of pain
    Explanation
    The correct answer is C: accept the client's report of pain. Although the information above is correct, the first and most important piece of information in this client's pain assessment is what the client is telling you about the pain --"the client's report". The correct answer is C: accept the client's report of pain. Although the information above is correct, the first and most important piece of information in this client's pain assessment is what the client is telling you about the pain --"the client's report". Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

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  • 44. 

    The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?

    • A.

      Repeatedly checking that the door is locked

    • B.

      Verbalized suspicions about thefts

    • C.

      Preference for consistent care givers

    • D.

      Repetitive, involuntary movements

    Correct Answer
    A. Repeatedly checking that the door is locked
    Explanation
    The correct answer is A: Repeatedly checking that the door is locked. Behaviors that are repeated are symptomatic of obsessive-compulsive disorders. These behaviors often interfere with normal function and employment and are based in anxiety.

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  • 45. 

    The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?

    • A.

      Repeatedly checking that the door is locked

    • B.

      Verbalized suspicions about thefts

    • C.

      Preference for consistent care givers

    • D.

      Repetitive, involuntary movements

    Correct Answer
    A. Repeatedly checking that the door is locked
    Explanation
    The correct answer is A: Repeatedly checking that the door is locked. Behaviors that are repeated are symptomatic of obsessive-compulsive disorders. These behaviors often interfere with normal function and employment and are based in anxiety.

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  • 46. 

    Which one of these tasks could be assigned to the certified nursing assistant (cna)? 

    • A.

      Feeding a client who has difficulty swallowing after a stroke

    • B.

      Giving enemas until clear to a middle-aged man scheduled for a colonoscopy

    • C.

      Performing a post-op dressing change

    • D.

      Assisting a client with colostomy care 24 hours after surgery

    Correct Answer
    B. Giving enemas until clear to a middle-aged man scheduled for a colonoscopy
    Explanation
    The correct answer is B: Giving enemas until clear to a middle-aged man scheduled for a colonoscopy. The certified nursing assistant can be assigned tasks which have predictable outcomes.

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  • 47. 

    Which one of these tasks could be assigned to the certified nursing assistant (cna)? 

    • A.

      Feeding a client who has difficulty swallowing after a stroke

    • B.

      Giving enemas until clear to a middle-aged man scheduled for a colonoscopy

    • C.

      Performing a post-op dressing change

    • D.

      Assisting a client with colostomy care 24 hours after surgery

    Correct Answer
    B. Giving enemas until clear to a middle-aged man scheduled for a colonoscopy
    Explanation
    The correct answer is B: Giving enemas until clear to a middle-aged man scheduled for a colonoscopy. The certified nursing assistant can be assigned tasks which have predictable outcomes.

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  • 48. 

    A client refuses to take the medication prescribed because the client prefers to take an herbal preparation. What is the first action the nurse should take?

    • A.

      Report the behavior to the charge nurse

    • B.

      Talk with the client to find out about the preferred herbal preparation

    • C.

      Contact the client's health care provider about the refusal

    • D.

      Explain the importance of the medication to the client

    Correct Answer
    B. Talk with the client to find out about the preferred herbal preparation
    Explanation
    Explain the importance of the medication to the client
    Explain the importance of the medication to the client and obtain addtional information regarding the medication preferred by the patient.

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  • 49. 

    A client refuses to take the medication prescribed because the client prefers to take an herbal preparation. What is the first action the nurse should take?

    • A.

      Report the behavior to the charge nurse

    • B.

      Talk with the client to find out about the preferred herbal preparation

    • C.

      Contact the client's health care provider about the refusal

    • D.

      Explain the importance of the medication to the client

    Correct Answer
    B. Talk with the client to find out about the preferred herbal preparation
    Explanation
    Explain the importance of the medication to the client
    Explain the importance of the medication to the client and obtain addtional information regarding the medication preferred by the patient.

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  • 50. 

    Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?

    • A.

      "Have the client sit on the side of the bed before starting to walk in the room."

    • B.

      "If the client is dizzy on standing, ask the client to take some deep breaths."

    • C.

      "Assist the client to the bathroom at least twice."

    • D.

      "After you assist the client to the chair, let me know if any complaints of abnormal feelings by the client."

    Correct Answer
    A. "Have the client sit on the side of the bed before starting to walk in the room."
    Explanation
    The correct answer is A: "Have the client sit on the side of the bed before starting to walk in the room.". Give clear information to the UAP about what is expected for client safety. The rule of specific delegation of outcomes applies in this case.

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Quiz Review Timeline +

Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Mar 21, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • May 03, 2009
    Quiz Created by
    Rneducator
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