A LPN complains to the charge nurse that an unlicensed assistive person (UAP) consistently leaves the work area untidy and does not restock supplies. What is the best initial response by the charge nurse?
1Write down potential solutions to the problems today by shift’s end
2Add this concern to the agenda of the next unit meeting
3Assure the staff nurse that the complaint will be investigated
4Explore for further identification about the nature of the problem
4 Explore for further identification about the nature of the problem
The nurse assists with the reinforcement of information about breast self-examination to a group of college students. A female student asks when to perform the monthly exam. The appropriate reply by the nurse should include which statement?
1″Ovulation, or midcycle is the best time to detect changes.”
2″Do the exam at the same time every month.”
3″Right after the period, when your breasts are less tender.”
4″The first of every month, because it will be easiest to remember.”
3
The nurse is caring for a 75 year-old client with type 2 diabetes mellitus. The client should be instructed to contact the outpatient clinic immediately if which findings are present?
1An open wound on the heel with minimal discomfort
2Occasional hiccups and sneezing
3Sustained insomnia and daytime fatigue
4Persistent dryness and itching of the perineal area
1An open wound on the heel with minimal discomfort-
A pregnant woman has been advised to alter her diet during pregnancy by increasing the intake of protein and vitamin C to meet the needs of the growing fetus. Which diet choice would best meet the woman’s needs?
- 1 cup of macaroni, three-fourths cup of peas, glass whole milk, medium pear
- Scrambled egg, hash browned potatoes, one-half glass of buttermilk, large nectarine
- 3 oz. chicken, one-half cup of corn, lettuce salad, small banana
- Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries
- Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries –
A nurse is taking a health history from parents of a child admitted with possible Reye’s syndrome. Which recent illness should the nurse recognize as being associated with an increased the risk for the development of Reye’s syndrome?
- Varicella
- Meningitis
- Hepatitis
- Rubeola
- Varicella –
A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The nurse comments to a colleague: “I wonder if he has any idea how ridiculous he looks – he’s a grown man!” The nurse’s comment is an example of what type of attitude?
- Prejudice
- Ethnocentrism
- Discrimination
- Stereotyping
- Prejudice-
A nursing student asks the licensed practical nurse (LPN) to explain the forces that drive health care reform. When responding to the student’s question, what information should the nurse emphasize?
- Increased competition between health care insurers
- Increase in health care spending that’s growing faster than the economy
- Increase in the population who have health insurance
- Increase in spending for end-of-life treatment
2
A child is admitted to the unit with the suspected diagnosis of pertussis (whooping cough). What is the priority nursing intervention for this child?
- Maintain hydration and encourage fluids
- Implement droplet precautions
- Monitor respiratory rate and oxygen saturation
- Anti- infective therapy
2
A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the registered nurse (RN) charge nurse?
1Complaints for the feeling of pulling on the urinary catheter
2Light, pink to clear urine
3Occasional suprapubic cramping
4Minimal drainage into the urinary collection bag
4Minimal drainage into the urinary collection bag
A nurse is caring for a woman two hours after a vaginal delivery. Documentation indicates that the membranes ruptured 36 hours prior to delivery. Which of these nursing diagnoses should the nurse expect the charge nurse to list as a priority at this time?
1Risk for fluid volume deficit
2Risk for excessive bleeding
3Risk for infection –
4Altered tissue perfusion
3
A 14 month-old child ingests a half a bottle of baby aspirin (81 mg) tablets. Which finding should a nurse expect to see in the child?
1Hypothermia
2Nausea and vomiting
3Hypoventilation
4Bradycardia
2
A school nurse monitors a child with a history of tonic-clonic seizures. The school nurse should inform teachers that if the child falls to the floor and experiences a seizure while in the classroom, which of the following would be the most important action to take during the seizure?
1Place the hands or a folded blanket under the head of the child
2Provide privacy as much as possible to minimize frightening the other children
3Move any chairs or desks at least three feet away from the child
4Note the sequence of movements with the time lapse of the event
1Place the hands or a folded blanket under the head of the child –
A client is admitted with diagnosis of a right upper lobe infiltrate and to rule out active tuberculosis (TB). Which type of precautions will be needed for this client?
1Droplet
2Contact
3Standard
4Airborne
4
A client has had a positive reaction to purified protein derivative (PPD). Which statement made by the client suggests the client understands the teaching by the registered nurse (RN)?
1″I have active tuberculosis.”
2″I have been exposed to mycobacterium tuberculosis.”
3″I have never been infected with mycobacterium tuberculosis.”
4″I have never had tuberculosis.”
2
NCSBN NCLEX QUESTIONS AND ANSWERS
A nurse is caring for a client with pneumococcal pneumonia. Which breath sounds would the nurse expect to disappear as the client responds to the antibiotic treatment?
1Wheezes
2Friction rubs
3Rhonchi
4Diminished sounds
3
A young adult seeks treatment in an outpatient mental health center. The client tells a nurse, “I am a government official and spies are following me.” Upon further questioning, the client reveals that warnings must be heeded to prevent nuclear war. What is the initial therapeutic approach that the nurse should use?
1Listen quietly without comment
2Ask for further information on the spies
3Confront the client about the delusions
4Contact security for potential safety concerns
1Listen quietly without comment –
Lactulose has been prescribed for a client with advanced liver disease. Which finding should the nurse use to evaluate the effectiveness of this treatment?
1Less jaundice
2Increased appetite
3Decreased lethargy
4Less edema
3
The LPN is unsure about an assignment by the charge nurse to hang an intravenous (IV) infusion that contains potassium. What resource should the LPN check first to determine if LPNs can administer IV medications?
1Employer policy and procedures manuals
2Nursing faculty from a local nursing program
3The nurse practice act of the state in which the practice takes place
4American Nurses Association (ANA) professional standards
3
The nurse is assisting with the delivery of a newborn infant. What is the priority nursing intervention for a normal newborn immediately after delivery?
1Dry off infant with a warm blanket or towel
2Apply identification bracelets
3Assign the one-minute APGAR score
4Obtain vital signs
1Dry off infant with a warm blanket or towel –
The registered nurse is teaching a childbirth education class about postpartum depression. Which statement, made by a class member, indicates that more teaching is needed?
1″I will make an effort to talk with someone about my feelings if I start to feel overwhelmed.”
2″It’s common for women with postpartum depression to have delusions about the infant.”
3″Women with postpartum depression have feelings of guilt and worthlessness.”
4″I may experience postpartum depression up to a year after delivery.”
2
The nurse is reinforcing information about the side effects of fluoxetine to a client. Which group of findings should be included?
1Diarrhea, dry mouth, weight loss, reduced libido
2Tachycardia, blurred vision, hypotension, anorexia
3Orthostatic hypotension, vertigo, reactions to tyramine, nausea
4Photosensitivity, seizures, edema, hyperglycemia
1Diarrhea, dry mouth, weight loss, reduced libido
A client has a diagnosis of heart failure. Which intervention is most important for the nurse to implement prior to the administration of digoxin?
1Use the pulse reading from the electronic blood pressure device
2Take a radial pulse, counting for a full 60 seconds
3Check for a pulse deficit at least twice with another nurse
4Assess the apical pulse, counting for a full 60 seconds
4Assess the apical pulse, counting for a full 60 seconds –
A client diagnosed with bipolar disorder refuses to take the prescribed medication. Which is the most therapeutic response by a nurse to the client’s refusal of the medication?
1″You need to take your medicine. This is how you get better.”
2″What is it about the medicine that you don’t like?”
3″I can see that you are uncomfortable right now; let’s talk about it tomorrow.”
4″If you refuse your medicine, tell me how do you think you will get better?”
2
A parent expresses frustration and anger about the toddler constantly saying “no” and refusing to follow directions. The nurse should help the parent understand that this behavior meets which developmental need?
1Self-esteem
2Initiative
3Independence
4Trust
3
The LPN is assisting the RN to provide care for a client diagnosed with a traumatic brain injury. Using the Glasgow Coma Scale, when the client does not obey verbal commands to move, which technique will the RN use to evaluate motor function?
1Squeeze the trapezius muscle firmly
2Lift the client’s arm and observe for pronation and drift
3Apply finger tip pressure for 10 seconds
4Rub the sternum with the knuckles
1Squeeze the trapezius muscle firmly –
A newborn has hyperbilirubinemia and is being treated with a biliblanket. Which intervention is indicated during this therapy?
1Discontinue breastfeeding during treatment
2Rotate the neonate to treat all of his/her skin
3Restrict holding the newborn during treatment
4Provide more frequent feedings
4Provide more frequent feedings-
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, pure and good.” How should the nurse respond?
1″You seem to be in a bad mood.”
2″Perfect? I don’t quite understand.”
3″You sound angry right now.”
4″That explains why you’ve been staring at me.”
3
The client with coronary artery disease has a prescription for nitroglycerin transdermal patches. What is the best reason the client should not wear a patch for more than 12 to 14 hours each day?
1It can cause severe headaches
2It may no longer work as well
3It will cause profound hypotensive effects
4it will irritate the skin
2
A hospitalized infant is receiving gentamicin. Which nursing intervention should receive priority in the plan of care?
1Compare daily infant weights
2Monitor the infant’s urine output
3Ensure appropriate fluid intake
4Maintain accurate intake and output
2
A newborn is diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize which point?
1They can expect the child will be mentally retarded
2Administration of a thyroid hormone will prevent problems
3This rare condition is hereditary
4Physical growth and development will be delayed
2
A child is admitted to the hospital for emergency surgery. The child’s parent reports several allergies. Which of these allergies should all the operative health care personnel be notified about?
1Perfumed soap
2Shellfish
3Balloons
4Mold
3
A practical nurse (PN) team member identifies that the fundus is boggy for a woman who is gravida 4 para 4 and is two hours after a spontaneous vaginal delivery. The fundus is displaced slightly above and to the right of the umbilicus. What should be the initial nursing action?
1Assist the woman to empty her bladder
2Monitor the pulse and blood pressure
3Call the registered nurse (RN) immediately
4Check lochia for color and amount
1Assist the woman to empty her bladder –
The nurse is planning the therapeutic milieu and the various activity groups for a client. What is the primary goal for the nurse to consider?
1Diminish destructive behavior through peer pressure
2Plan strict schedules with defined expectations
3Punish inappropriate behavior as it occurs
4Achieve a client’s therapeutic goals
4Achieve a client’s therapeutic goals –
A client tells a nurse, “I have something very important to tell you if you promise not to tell anyone.” Which statement by the nurse would be the most appropriate response?
1″That depends on what you tell me.”
2″I must report everything to the treatment team.”
3″All right, I promise.”
4″I can’t make such a promise.”
4″I can’t make such a promise.” –
A client is discharged with a prescription for warfarin. A nurse recognizes that additional teaching is needed if the client makes which incorrect comment?
1″I know I must avoid crowds.”
2″I will report any bruises or bleeding.”
3″I plan to use an electric razor for shaving.”
4″I will keep all laboratory appointments.”
1″I know I must avoid crowds.” –
The nurse discovers an unresponsive client and determines there is no pulse. This nurse then activates the code notification button to alert all personnel about the code and begins chest compressions. What is the function of the second nurse on the scene?
1Validate the client’s advance directive
2Participate with the compressions or breathing as requested by the first nurse
3Bring the code cart –
4Relieve the first nurse on the scene and continue single person CPR
3
The nurse and client are discussing the client’s progress toward understanding the client’s behavioral responses to stressful events. This is typical of which phase in the therapeutic relationship?
1Termination
2Working –
3Orientation
4Pre-interaction
2
The nurse is collecting data on a group of clients in a long-term health care facility. Which client is at a highest risk for the development of pressure ulcers?
1Ambulatory client who had three incontinent diarrhea stools in the past 24 hours
2Ambulatory older adult diagnosed with type 2 diabetes for the past 20 years
3Obese client who uses a wheelchair throughout the facility
4Malnourished older adult client who is on bed rest
4
A client diagnosed with head trauma is in a non-responsive state. Vital signs are stable and breathing is regular and spontaneous. What should the nurse document to accurately describe the client’s status?
1Glasgow Coma Scale 13, no ventilator required
2Glasgow Coma Scale 8, respirations regular –
3Appears to be sleeping, vital signs stable
4Comatose, breathing unlabored; is resting
2
A client with heart failure is newly referred to a home health care agency. The nurse determines that the client has not been following the prescribed diet. It would be most appropriate for the nurse to take which action at this time?
1Notify the health care provider of the client’s failure to follow the prescribed diet
2Make a referral to Meal-on-Wheels for delivery of one meal three times a week
3Discuss the diet with the client to learn the reasons for not following the diet –
4Recommend a release from home health care related to noncompliance
3
A client has chronic renal failure and is being treated at home. During weekly home visits, which factor is the most accurate indicator of fluid balance?
1Trends in daily weights –
2Skin turgor over at least two areas of the body
3Changes in mucous membrane moistness
4Difference between intake and output
1Trends in daily weights –
The client is receiving a thrombolytic agent to open a clot-occluded coronary artery following a myocardial infarction. Which finding would be the greatest concern and should be immediately reported to the registered nurse?
1Hematemesis –
2Pink-tinged saliva
3Serosanguinous drainage from the IV site
4Slight rust-colored urine
1Hematemesis –
The nurse is caring for a postoperative client following a closed reduction of distal tibia and mid-femur fractures. The client has a long leg plaster cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 F (39.4 C). What should be the first action by the nurse?
1Check the distal circulation of the casted extremity
2Obtain the pulse oximetry reading
3Measure the client’s blood pressure in the supine and Fowler’s positions
4Check the orientation to time, place and person
2
The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is the priority action by the nurse to accurately assess correct placement of the G-tube?
1Listen for active bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate
3Auscultate the abdomen while instilling 10 mL of air into the G-tube
4Measure the length of tubing from the insertion site each shift
1Listen for active bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate –
3Auscultate the abdomen while instilling 10 mL of air int1Listen for active bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate –
3Auscultate the abdomen while instilling 10 mL of air into the G-tube
4Measure the length of tubing from the insertion site each shifto the G-tube
4Measure the length of tubing from the insertion site each shift
The client is diagnosed with infective endocarditis of the tricuspid valve. Which finding suggests a complication of this condition?
1Pronounced wheezes
2Pain on deep inspiration
3Sudden back pain
4Sudden dyspnea
4
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). What should the nurse understand about the purpose of this procedure?
1The surgical repair of a diseased coronary artery
2An noninvasive radiographic examination of the heart
3A process to compress arterial plaque to improve blood flow
4The placement of an automatic internal cardiac defibrillator
3
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