NCLEX PN COMPREHENSIVE 2023 FORM C
ACTUAL EXAM CONTAINS 160 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+
NCLEX PN COMPREHENSIVE FORM C
The nurse is collecting data on a client with a diagnosis of right-sided heart failure.
The nurse should expect to note which specific characteristic of this condition?
- Dyspnea
- Hacking cough
- Dependent edema
- Crackles on lung auscultation
- Dependent edema
Rationale:
Right-sided heart failure is characterized by signs of systemic congestion that
occur as a result of right ventricular failure, fluid retention, and pressure buildup in
the venous system. Edema develops in the lower legs and ascends to the thighs and
abdominal wall. Other characteristics include jugular (neck vein) congestion,
enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands
and fingers, polyuria at night, and weight gain. Left-sided heart failure produces
pulmonary signs. These include dyspnea, crackles on lung auscultation, and a
hacking cough.
The nurse is checking the neurovascular status of a client who returned to the
surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The
affected leg is warm, and the nurse notes redness and edema. The pedal pulse is
palpable and unchanged from admission. The nurse interprets that the
neurovascular status is which?
- Moderately impaired, and the surgeon should be called
- Normal, caused by increased blood flow through the leg
- Slightly deteriorating, and should be monitored for another hour
- Adequate from an arterial approach, but venous complications are arising
- Normal, caused by increased blood flow through the leg
Rationale:
An expected outcome of surgery is warmth, redness, and edema in the surgical
extremity caused by increased blood flow. Options 1, 3, and 4 are incorrect.
A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the
health care provider is going to perform carotid massage. The nurse responds that
this procedure may stimulate which? - Vagus nerve to slow the heart rate
- Vagus nerve to increase the heart rate
- Diaphragmatic nerve to slow the heart rate
- Diaphragmatic nerve to increase the heart rate
- Vagus nerve to slow the heart rate
Rationale:
Carotid sinus massage is one maneuver used for vagal stimulation to decrease a
rapid heart rate and possibly terminate a tachydysrhythmia. The other maneuvers
are the Valsalva maneuver of inducing the gag reflex and asking the client to strain
or bear down. Medication therapy is often needed as an adjunct to keep the rate
down or maintain the normal rhythm.
A client is admitted to the hospital with possible rheumatic endocarditis. The nurse
should check for a history of which type of infection? - Viral infection
- Yeast infection
- Streptococcal infection
- Staphylococcal infection
- Streptococcal infection
Rationale:
Rheumatic endocarditis, also called rheumatic carditis, is a major indicator of
rheumatic fever, which is a complication of infection with group A β-hemolytic
streptococcal infections. It is frequently triggered by streptococcal pharyngitis.
Options 1, 2, and 4 are incorrect.
A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The
nurse notes that the client’s toes are mottled, and cool and the client verbalizes
some numbness and tingling of the foot. Which interpretation should the nurse
make of these findings?
- The boot has not yet dried.
- The boot is controlling leg edema.
- The boot is impairing venous return.
- The boot has been applied too tightly.
- The boot has been applied too tightly.
Rationale:
An Unna boot that is applied too tightly can cause signs of arterial occlusion. The
nurse assesses the circulation in the foot and teaches the client to do the same. The
other options are incorrect interpretations.
A client with angina complains that the anginal pain is prolonged and severe and
occurs at the same time each day, most often in the morning. On further data
collection, the nurse notes that the pain occurs in the absence of precipitating
factors. How should the nurse best describe this type of anginal pain? - Stable angina
- Variant angina
- Unstable angina
- Nonanginal pain
NCLEX PN COMPREHENSIVE 2023 FORM B
ACTUAL EXAM CONTAINS 160 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+
NCLEX PN COMPREHENSIVE FORM B
The nurse is assisting with caring for a client who is receiving a unit of packed red
blood cells (PRBCs). The nurse would tell the client that it is most important to
report which signs immediately?
- Sore throat or earache
- Chills, itching, or rash
- Unusual sleepiness or fatigue
- Mild discomfort at the catheter site – ANSWER- 2. Chills, itching, or rash
The nurse is helping perform a focused data collection process on a client who is
complaining of symptoms of a cold, a cough, and lung congestion. Which would
the nurse include for this type of data collection? Select all that apply. - Listening to lung sounds
- Obtaining the client’s temperature
- Checking the strength of peripheral pulses
- Obtaining information about the client’s respirations
- Performing a musculoskeletal and neurological examination
- Asking the client about a family history of any illness or disease – ANSWER- 1.
Listening to lung sounds - Obtaining the client’s temperature
- Obtaining information about the client’s respirations
The nurse is reviewing the client’s health record and notes that the client elicited a
positive Romberg sign. Based on this finding, the nurse would institute which
interventions? Select all that apply. - Collect data to determine factors for fall risk.
- Close the blinds and turn off the overhead light.
- Instruct the client to ask for assistance when getting up to walk.
- Teach the client to lift legs high while walking, as if walking over planks.
- Ensure the client is upright when eating and swallows twice after each bite. –
ANSWER- 1. Collect data to determine factors for fall risk. - Instruct the client to ask for assistance when getting up to walk.
The nurse learns in report that a client is exhibiting Cheyne-Stokes respirations.
Based on this data, which action is most appropriate for the nurse to take initially? - Listen to the client’s heart sounds.
- Determine whether the client has a pulse deficit.
- Instruct the client to use an incentive spirometer.
- Determine the client’s ability to follow verbal commands. – ANSWER- 4.
Determine the client’s ability to follow verbal commands.
The nurse notes documentation that a client has conductive hearing loss. The nurse
plans care knowing that this kind of hearing loss can be caused by which
circumstances? Select all that apply.
- A defect in the cochlea
- Acute otitis media with effusion
- A defect in the 8th cranial nerve
- A defect in the sensory fibers that lead to the cerebral cortex
- A physical obstruction to the transmission of sound waves – ANSWER- 2. Acute
otitis media with effusion - A physical obstruction to the transmission of sound waves
The nurse is preparing to assist the primary health care provider to test the
extraocular movements in a client and muscle weakness in the eyes. The nurse
anticipates that which physical assessment technique will be done? - Testing using the Ishihara chart
- Testing using a Snellen eye chart
- Testing the corneal light reflexes
- Testing the six cardinal positions of gaze – ANSWER- 4. Testing the six cardinal
positions of gaze
The nurse is reinforcing instructions for a client on how to perform a testicular
self-examination (TSE). Which instructions would the nurse include? Select all
that apply. - Perform TSE after a shower or bath.
- Perform TSE after emptying the bladder.
- Perform TSE on the same day each month.
- Observe for urethral discharge after performing TSE.
- Perform TSE by rolling each testicle between the thumb and fingers. –
ANSWER- 1. Perform TSE after a shower or bath. - Perform TSE on the same day each month.
- Perform TSE by rolling each testicle between the thumb and fingers.
The nurse notes the physical assessment findings for a client with a diagnosis of
possible meningitis. Which findings would the nurse expect to observe because of
meningeal irritation? Select all that apply. - Pupils are unequal and react slowly to light.
- The client reports stiffness and soreness in the neck area.
- The client reports pain in the vertebral column and passively flexes the hip and
knee in response to neck flexion. - The client flexes a leg at the hip and knee and reports pain in the vertebral
column when the leg is extended. - The client’s upper arms are flexed and held tightly to the sides of the body, and
the legs are extended and internally rotated. – ANSWER- 2. The client reports
stiffness and soreness in the neck area. - The client reports pain in the vertebral column and passively flexes the hip and
knee in response to neck flexion. - The client flexes a leg at the hip and knee and reports pain in the vertebral
column when the leg is extended.
The nurse is caring for a client with a health care associated infection caused by
methicillin-resistant Staphylococcus aureus. Contact precautions are prescribed for
the client. The nurse prepares to irrigate the wound and apply a new dressing.
Which protective interventions would the nurse use to perform this procedure?
Select all that apply.
NCLEX PN COMPREHENSIVE 2023 FORM A
ACTUAL EXAM CONTAINS 160 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+
The nurse is preparing to administer a continuous tube feeding to a client with a
nasogastric tube. The primary health care provider has prescribed an amount of
100 mL/hr. The tube feeding setup is an open system, a bag that has formula added
at intervals. How much formula would the nurse plan to add to fill the feeding bag?
- 400 mL of formula
- 600 mL of formula
- 800 mL of formula
4.Enough formula to last for 8 hours – ANSWER- 1. 400 mL of formula.
The nurse is preparing to administer eardrops to an infant. How would the nurse
administer the eardrops? - Pull up and back on the ear, and direct the solution onto the eardrum.
- Pull down and back on the ear, and direct the solution onto the eardrum.
- Pull down and back on the ear, and direct the solution toward the wall of the
canal. - Pull up and back on the ear lobe, and direct the solution toward the wall of the
canal. – ANSWER- 3. Pull down and back on the ear, and direct the solution
toward the wall of the canal.
The nurse prepares to take a blood pressure (BP) on a school-age child. Where
would the nurse place the blood pressure cuff to obtain an accurate measurement?
- One-half the distance between the antecubital fossa and the shoulder
- One-third the distance between the antecubital fossa and the shoulder
- Two-thirds the distance between the antecubital fossa and the shoulder
- One-quarter the distance between the antecubital fossa and the shoulder –
ANSWER- 3. Two-thirds the distance between the antecubital fossa and the
shoulder
A primary health care provider is planning to administer a skeletal muscle relaxant
to a client with a spinal cord injury. The medication is going to be administered
intrathecally. Which medication would the nurse expect to be prescribed and
administered by this route?
1.Baclofen
2.Chlorzoxazone
3.Dantrolene sodium
4.Cyclobenzaprine hydrochloride – ANSWER- 1. Baclofen
The nurse is developing a nutritional plan for an assigned client. Which is the most
critical piece of data to collect before formulating the plan?
1.A dietary diary
2.Food preferences
3.The presence of food allergies
4.Medical history of conditions related to nutritional deficits – ANSWER- 3. The
presence of food allergies.
The licensed practical nurse employed in the ambulatory clinic is assisting the
registered nurse in preparing to administer a dose of intravenous immune globulin
(IVIG). The licensed practical nurse would ensure that which medication is readily
available before the medication is administered?
- Epinephrine
- Phytonadione
- Acetylcysteine
- Protamine sulfate – ANSWER- 1. Epinephrine
The nurse has just been told by the primary health care provider that a prescription
has been written to administer a heparin injection to a client every 12 hours. The
nurse anticipates using which technique to administer the medication?
1.Z-track
2.Using a 20-gauge needle
3.Intramuscular using a 1-inch needle
4.Subcutaneous using the abdomen – ANSWER- 4.Subcutaneous using the
abdomen
A client is to receive medication via patient-controlled analgesia (PCA), and the
nursing instructor asks the nursing student caring for the client to describe the use
of the PCA. The instructor determines there is a need for further teaching about the
PCA when the student makes which statement? - “The PCA gives the client greater control over analgesic administration.”
- “Asking the client to rate pain is unnecessary when the client has a PCA.”
- “PCA delivers predetermined amounts of analgesia within preset intervals.”
- “A continuous intravenous (IV) solution is needed to keep the vein open
between analgesia infusions.” – ANSWER- 2. “Asking the client to rate pain is
unnecessary when the client has a PCA.”
The nurse is caring for a client with a diagnosis of chronic kidney disease who is
receiving dialysis. Epoetin alfa has been prescribed for the client. How would the
nurse prepare to administer the medication? - The subcutaneous route
- Shaking the vial before drawing up the medication
- Obtaining the medication from the medication freezer
- Mixing the medication with 0.1 mL of heparin before administration to prevent
clotting – ANSWER- 1. The subcutaneous route.
The nurse is administering a medication intramuscularly to an assigned client. The
nurse would include which actions in administering the medication? Select all that
apply. - Massage the site after injection.
- Use a Z-track method for administration.
- Wear sterile gloves to administer the medication.
- Hold the syringe as if it is a dart to insert the needle.
- Select an appropriate injection site such as the ventral gluteus.
- Cleanse the injection site using a back-and-forth motion with an antiseptic pad. –
ANSWER- 2. Use a Z-track method for administration. - Hold the syringe as if it is a dart to insert the needle.
- Select an appropriate injection site such as the ventral gluteus.
NCLEX PN COMPREHENSIVE 2023 FORM A, B
AND C ACTUAL EXAM (3 LATEST VERSIONS)
CONTAINS 460 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+
NCLEX PN COMPREHENSIVE FORM A
The nurse is preparing to administer a continuous tube feeding to a client with a
nasogastric tube. The primary health care provider has prescribed an amount of
100 mL/hr. The tube feeding setup is an open system, a bag that has formula added
at intervals. How much formula would the nurse plan to add to fill the feeding bag?
- 400 mL of formula
- 600 mL of formula
- 800 mL of formula
4.Enough formula to last for 8 hours – ANSWER- 1. 400 mL of formula.
The nurse is preparing to administer eardrops to an infant. How would the nurse
administer the eardrops? - Pull up and back on the ear, and direct the solution onto the eardrum.
- Pull down and back on the ear, and direct the solution onto the eardrum.
- Pull down and back on the ear, and direct the solution toward the wall of the
canal. - Pull up and back on the ear lobe, and direct the solution toward the wall of the
canal. – ANSWER- 3. Pull down and back on the ear, and direct the solution
toward the wall of the canal.
The nurse prepares to take a blood pressure (BP) on a school-age child. Where
would the nurse place the blood pressure cuff to obtain an accurate measurement? - One-half the distance between the antecubital fossa and the shoulder
- One-third the distance between the antecubital fossa and the shoulder
- Two-thirds the distance between the antecubital fossa and the shoulder
- One-quarter the distance between the antecubital fossa and the shoulder –
ANSWER- 3. Two-thirds the distance between the antecubital fossa and the
shoulder
A primary health care provider is planning to administer a skeletal muscle relaxant
to a client with a spinal cord injury. The medication is going to be administered
intrathecally. Which medication would the nurse expect to be prescribed and
administered by this route?
1.Baclofen
2.Chlorzoxazone
3.Dantrolene sodium
4.Cyclobenzaprine hydrochloride – ANSWER- 1. Baclofen
The nurse is developing a nutritional plan for an assigned client. Which is the most
critical piece of data to collect before formulating the plan?
1.A dietary diary
2.Food preferences
3.The presence of food allergies
4.Medical history of conditions related to nutritional deficits – ANSWER- 3. The
presence of food allergies.
The licensed practical nurse employed in the ambulatory clinic is assisting the
registered nurse in preparing to administer a dose of intravenous immune globulin
(IVIG). The licensed practical nurse would ensure that which medication is readily
available before the medication is administered?
- Epinephrine
- Phytonadione
- Acetylcysteine
- Protamine sulfate – ANSWER- 1. Epinephrine
The nurse has just been told by the primary health care provider that a prescription
has been written to administer a heparin injection to a client every 12 hours. The
nurse anticipates using which technique to administer the medication?
1.Z-track
2.Using a 20-gauge needle
3.Intramuscular using a 1-inch needle
4.Subcutaneous using the abdomen – ANSWER- 4.Subcutaneous using the
abdomen
A client is to receive medication via patient-controlled analgesia (PCA), and the
nursing instructor asks the nursing student caring for the client to describe the use
of the PCA. The instructor determines there is a need for further teaching about the
PCA when the student makes which statement? - “The PCA gives the client greater control over analgesic administration.”
- “Asking the client to rate pain is unnecessary when the client has a PCA.”
- “PCA delivers predetermined amounts of analgesia within preset intervals.”
- “A continuous intravenous (IV) solution is needed to keep the vein open
between analgesia infusions.” – ANSWER- 2. “Asking the client to rate pain is
unnecessary when the client has a PCA.”
The nurse is caring for a client with a diagnosis of chronic kidney disease who is
receiving dialysis. Epoetin alfa has been prescribed for the client. How would the
nurse prepare to administer the medication? - The subcutaneous route
- Shaking the vial before drawing up the medication
- Obtaining the medication from the medication freezer
- Mixing the medication with 0.1 mL of heparin before administration to prevent
clotting – ANSWER- 1. The subcutaneous route.
The nurse is administering a medication intramuscularly to an assigned client. The
nurse would include which actions in administering the medication? Select all that
apply. - Massage the site after injection.
- Use a Z-track method for administration.
- Wear sterile gloves to administer the medication.
- Hold the syringe as if it is a dart to insert the needle.
- Select an appropriate injection site such as the ventral gluteus.