NCLEX-RN 100 Practice Questions
- 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.
To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented.
- B.
The client will be unable to maintain any oral intake as long as the tracheotomy is in place.
- C.
Nutritional and/or gastric feedings will not be attempted for approximately 3 weeks to decrease the incidence of aspiration.
- D.
Because the client is dependent on the ventilator, nutritional intake will be delayed.
- 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.
Dexamethasone suppression test.
- B.
Thyroid studies.
- C.
Drug toxicology screen.
- D.
Trendelenburg test.
- 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.
Client posturing.
- B.
Glasgow coma scale.
- C.
Client thinking pattern.
- D.
Occurrence of hallucinations.
- 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.
The client has edema of the lower extremities.
- B.
Physical exam of the client reveals the presence of lanugo.
- C.
The client has ulcerated mucous membranes of the mouth.
- D.
The client has dry, yellowish color of the skin.
- 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.
Evaluate the urine output.
- B.
Obtain the client’s weight.
- C.
Determine the patency of the IV line.
- D.
Measure pulmonary artery pressures.
- 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.
The nursing assistant answers the phone while wearing gloves.
- B.
The nursing assistant log rolls the patient to provide back care.
- C.
The nursing assistant places an incontinent pad under the patient.
- D.
The nursing assistant positions the patient on the left side, head elevated.
- 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.
Sore throat, fever, increased fatigue, vomiting, diarrhea.
- B.
Dry mouth, nasal stuffiness, weight gain.
- C.
Rapid heartbeat, frequent headaches, yellowing of eyes or skin.
- D.
Weakness, staggering gait, tremor, feeling of drunkenness.
- 8.The nurse receives report from the previous shift. Which of the following patients should the nurse see FIRST?
- A.
A patient post coronary artery bypass graft (CABG) having the atrioventricular (AV) wires removed later in the day.
- B.
A patient with type 1 diabetes scheduled for a cardiac catheterization later today.
- C.
A patient 1 day postoperative with an epidural catheter in place.
- D.
A patient diagnosed with cardiomyopathy being evaluated for a heart transplant.
- 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.
Check the radial pulses bilaterally and compare.
- B.
Evaluate the skin temperature and tissue turgor in the area.
- C.
Assess sensation of each foot while the child closes her eyes.
- D.
Apply baby powder to decrease skin irritation under the cast.
- 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.
Perform a straight catheterization.
- B.
Offer the client the bedpan.
- C.
Put the baby to breast.
- D.
Massage the uterine fundus.
- 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.
A small amount of white mucus is aspirated from the NG tube.
- B.
The contents aspirated from the NG tube have a pH of 3.
- C.
No bubbles are seen when the nurse inverts the NG tube in water.
- D.
The client says he can feel the NG tube in the back of his throat.
- 12.The nurse cares for a client after right cataract surgery. The nurse should intervene if which of the following is observed?
- A.
Client is in the supine position.
- B.
The head of the bed is elevated 30 degrees.
- C.
The client is lying on the right side.
- D.
An eye shield is over the right eye.
- 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.
Risk for constipation related to immobilization.
- B.
Risk for impaired skin integrity related to immobilization and secretions.
- C.
Risk for wound infection related to involuntary bowel secretions.
- D.
Risk for fluid volume excess related to secretions.
- 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.
Promote ventilation and prevent respiratory acidosis.
- B.
Increase oxygenation and removal of secretions.
- C.
Increase pH and facilitate balance of bicarbonate.
- D.
Prevent respiratory alkalosis by increasing oxygenation.
- 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.
Death is punishment for his/her actions.
- B.
Death is inevitable and irreversible.
- C.
Death is temporary and gradual.
- D.
Death as a concept based on past experience.
- 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.
"It is best to buy new shoes in the morning."
- B.
"Have each foot measured every time you buy new shoes."
- C.
"Buy shoes a half-size larger than your foot size so the fit is roomy."
- D.
"Buy vinyl shoes because they won’t lose their shape easily."
- 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.
Hypovolemia.
- B.
Hypoglycemia.
- C.
Hyperglycemia.
- D.
Cold stress.
- 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.
Petal the edges of the cast to prevent irritation.
- B.
Elevate the client’s left arm on two pillows.
- C.
Apply cool, humidified air to dry the cast.
- D.
Ask the client to move the fingers to maintain mobility.
- 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.
Direct the LPN/LVN to obtain the child’s vital signs.
- B.
Ask the mother if the child’s sutures are still intact.
- C.
Tell the nursing assistant to take the child for a walk.
- D.
Check to see when the child last received pain medication.
- 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.
High protein, high fat, and high calories.
- B.
High protein, low fat, and high calories.
- C.
Low protein, low fat, and low carbohydrate.
- D.
High protein, high fat, and low carbohydrate.
- 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.
these tests are valuable screening tests for prostatic cancer.
- B.
the level of PSA is decreased in clients with renal stones.
- C.
the tests reflect the level of renal involvement in acid-base problems.
- D.
the level of PSA is elevated in clients in early-stage renal failure.
- 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.
Apply warm soaks to the infiltration site, start a new IV, and continue IV medications.
- B.
Wait 2 hours, reassess the client, and restart the IV if the client has wheezing or labored breathing.
- C.
Restart the IV and continue the previous medication schedule.
- D.
Call the physician and recommend that the IV medications be changed to PO.
- 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.
Provide adequate hygiene and nutrition.
- B.
Decrease environmental stimuli.
- C.
Slowly involve the client in unit activities.
- D.
Administer and monitor sedative and mood-stabilizing medications.
- 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.
"I have been having difficulty with my hearing."
- B.
"I lose my balance easily."
- C.
"I can't tell the difference between a sweet and sour taste."
- D.
"It is not easy for me to remember names and faces."
- 25.Nursing management prior to an intravenous pyelogram (IVP) would include which of the following?
- A.
A fat-free meal the evening before the examination and radiopaque tablets at bedtime.
- B.
Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter.
- C.
Cleansing enemas the evening before to provide for adequate visualization of the urinary tract.
- D.
Explaining the importance of following directions regarding voiding during the test.
Questions: 10 | Attempts: 61554 | Last updated: Mar 22, 2022
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