FINAL NCLEX QUESTIONS

FINAL NCLEX QUESTIONS

AND ANSWERS

• A nurse identifies that a client on a prolonged bed rest may be developing a pressure ulcer.

Which color over the bony prominence supports this conclusion?

• Red
• Blue
• Black
• Yellow
• Which is an example of a response to a physiological physiological stressor? SELECT ALL

THAT APPLY

• A sunburn after being outside all day
• Diarrhea after eating contaminated food
• Shortness of breath while walking up a hill
• A rapid heart rate during a final examination
• Excess fluid volume as a result of renal disease
• Why does turning a patient every 2 hours prevent pressure ulcers from developing?
• Promotes muscle contractions, increasing the basal metabolic rate of the body
• Relieves weight on the capillaries, allowing oxygen to reach peripheral blood cells
• Keeps the extremities dependent, permitting blood flow to the distal cells by gravity
• Drops the organs in the abdominal cavity by gravity, relieving pressure against the

diaphragm

• Which condition places a client at the highest risk for developing infection?
• Implantation of a prosthetic device
• Burns over more than 20% of the body
• Presence of an indwelling urinary catheter
• More than 2 puncture sites from a laparoscopic surgery
• Which does the nurse determine is a specific line of defense against infection?
• Mucous membrane of the respiratory system
• Urinary tract environment
• Integumentary system
• Immune response
• A nurse is concerned about a client’s ability to withstand exposure to pathogens. Which blood

component should the nurse monitor?

• Platelets
• Hemoglobin
• Neutrophils
• Erythrocytes

• An 83 year-old-woman fell at home and was diagnosed with a traumatic left femur fracture.

She is alert and oriented and is able to make her own medical decisions. Which assessment is priority given her injuries and utilizes patient safety?

• Abdominal assessment
• Neuro vascular checks every hour
• Skin assessment

• Mobility assessment
• The patient has learned that she will need surgery and will be going to the operating room in

a few hours. Given her age and history, the order set states the nurse is to reposition the patient every two hours. Which should be included in the nurse’s explanation and education to the patient?

• Turning every two hours will prevent a pressure injury
• Turning every two hours will alleviate gas
• Turning every two hours will promote blood flow of the fractured leg
• Turning every two hours will enhance nutrition
• The patient has finished with her procedure and received an intramedullary rod placement of

the left femur. Which nursing intervention can the nurse apply to prevent post-operative complications in the clinical setting?

• Initiating fluid replacement orders
• Eating as soon as possible after surgery
• Utilizing an incentive spirometer
• Turning the patient every two hours
• The patient has completed the surgery without acute complications at this time and is moved

to the post anesthesia care unit (PACU). Which nursing intervention is necessary to apply to the patient’s care during her temporary stay on this specific unit?

• Monitoring urinary output
• Assessing cognition status
• Assessing draining from the surgical site
• Suctioning any mucous from the patient’s airway
• After the patient has arrived at the post anesthesia care unit (PACU), what is the most

important information that the nurse should conclude about the patient?

• Type and extent of the surgery
• Medications that were delivered in surgery
• The name and phone number of the patient’s spouse
• Anxiety level pre and post procedure
• The patient has been transferred out of the post anesthesia care unit (PACU) and has been

assigned a room on the surgical progressive care unit. Which is most important for the nurse to utilize while positioning this patient post-operatively?

• Ensure the head of the bed is greater than 30 degrees
• Performing a log roll during linen changes
• Prevent pressure on bony prominences
• Avoid any friction or shear while turning the patient
• The patient has started to develop pleuritic chest pain, tachypnea, and tachycardia. According

to these findings, the nurse can identify this being which post-operative complication?

• Infection
• Pulmonary Emboli
• Anxiety
• Myocardial Infarction
• The nurse is suspecting the patient is suffering from the post-operative complication

pulmonary embolism. Which nursing action should the nurse apply first before notifying the doctor?

• Apply oxygen via nasal cannula

• Place the bed in the lowest position
• Make the patient strict NPO
• Ensure the head of the bed is 30 degrees

• The nurse is explaining pertinent education to the patient about pulmonary embolism. The

nurse states that death from an acute pulmonary embolism commonly occurs within one hour of the onset of symptoms and it is necessary to begin treatment as soon as possible. Is this statement True or False?

• True
• False

• Which diagnostic procedures are utilized in identifying an acute pulmonary embolism?

Select all that apply.

• Cat scan of the chest
• Pulmonary angiogram
• CBC/BMP lab work
• Chest radiograph
• Electrocardiogram

• A client’s stool specimen is positive for clostridium-difficle. Which isolation precautions

should the nurse institute for this client?

• Droplet
• Contact
• Reverse
• Airborne

• Which should the nurse do to interrupts the transmission link in the chain of infection?
• Wash the hands before providing care to the patients
• Position a commode next to the clients bed
• Provide education about a balanced diet
• Change a dressing when it is soiled
• Which stage pressure ulcer requires the nurse to measure the extent of undermining?
• Stage 0
• Stage I
• Stage II
• Stage III
• A nurse is caring for a client with impaired mobility. Which position contributes most to the

formation of hip flexion contractures?

• Low-fowler
• Orthopneic
• Supine
• Sims
• A client is diagnosed with a stage IV pressure ulcer with eschar. Which medical treatment

should the nurse anticipate the primary health-care provider will prescribe for the client?

• Heath lamp treatment three times a day
• Application of a topical antibiotic

• Cleansing irrigation twice daily
• Debridement of the wound
• A nurse identifies that a client’s pressure ulcer has partial-thickness skin loss involving the

epidermis and dermis. Which stage pressure ulcer should the nurse document have based on the assessment?

• Stage I
• Stage II
• Stage III
• Stage IV
• A nurse places a client in the orthopneic position. Which is the primary reason for the use of

this positioning?

• Facilitates breathing
• Supports hip extension
• Prevents pressure ulcers
• Promotes urinary elimination
• An immobilized bedbound client placed on a 2 hour turning and positioning program. Which

should the nurse explain to the client is the primary reason why this program is important?

• Supports comfort
• Promotes elimination
• Maintains skin integrity
• Facilitates respiratory function
• A nurse is caring for a client with Parkinson’s disease who is experiencing difficulty

swallowing. For which major potential problem associated with dysphagia should the nurse assess the client?

• Anorexia
• Aspiration
• Self-care deficit
• Inadequate intake
• A nurse is caring for a confused client. Which should the nurse do to prevent this client from

falling?

• Encourage the client to use the corridor handrails
• Place the client in a room near the nurses’ station
• Reinforce how to use the call bell
• Maintain close supervision
• A nurse educator is teaching a group of newly hired nursing assistants. Which hospitalized

client should they be taught is at the highest risk for injury?

• School-age child
• Comatose teenager
• Postmenopausal woman
• Confused middle-aged man
• Which is the priority nursing intervention to prevent client problems associated with latex

allergies?

• Use nonlatex gloves
• Identify persons at risk
• Keep a latex-safe supple cart available
• Administer an antihistamine prophylactically