NCLEX-PN PRACTICE QUESTIONS AND ANSWERS 2022

NCLEX-PN PRACTICE QUESTIONS AND ANSWERS 2022

• The nurse is caring for a client scheduled for removal of the pituitary gland. The nurse

should be particularly alert for:

❍ A. Nasal congestion ❍ B. Abdominal tenderness ❍ C. Muscle tetany ❍ D. Oliguria

Rationale:

Removal of the pituitary gland is usually done by a transsphenoidal approach, through the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are not correct because they are not directly associated with the pituitary gland.

• A 24-year-old female client is scheduled for surgery in the morning. Which of the

following is the primary responsibility of the nurse?

❍ A. Taking the vital signs ❍ B. Obtaining the permit ❍ C. Explaining the procedure ❍ D. Checking the lab work

• Answer A is correct.

Rationale:

The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question.

• The nurse is making initial rounds on a client with a C5 fracture and Crutchfield

tongs. Which equipment should be kept at the bedside?

❍ A. A pair of forceps ❍ B. A torque wrench ❍ C. A pair of wire cutters ❍ D. A screwdriver

Rationale:

A torque wrench is kept at the bedside to tighten and loosen the screws of Crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are incorrect.

• A client is admitted with a Ewing's sarcoma. Which symptoms would be expected due

to this tumor's location?

❍ A. Hemiplegia ❍ B. Aphasia ❍ C. Nausea ❍ D. Bone pain

Rationale:

Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers A, B, and C are not specific to this type of cancer and are incorrect.

• The nurse is caring for a client with epilepsy who is being treated with carbamazepine

(Tegretol). Which laboratory value might indicate a serious side effect of this drug?

❍ A. Uric acid of 5mg/dL ❍ B. Hematocrit of 33% ❍ C. WBC 2,000 per cubic millimeter ❍ D. Platelets 150,000 per cubic millimeter - Answer C is correct.

Rationale:

Tegretol can suppress the bone marrow and decrease the white blood cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and D are within normal limits, and answer B is a lower limit of normal; therefore answers A, B, and D are incorrect.

• A 6-month-old client is admitted with possible intussusception. Which question

during the nursing history is least helpful in obtaining information regarding this diagnosis?

❍ A. "Tell me about his pain." ❍ B. "What does his vomit look like?" ❍ C. "Describe his usual diet." ❍ D. "Have you noticed changes in his abdominal size?"

Rationale:

The least-helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process and, thus, are incorrect.

• A client has rectal cancer and is scheduled for an abdominal perineal resection. What

should be the priority nursing care during the post-op period?

❍ A. Teaching how to irrigate the ileostomy ❍ B. Stopping electrolyte loss in the incisional area

❍ C. Encouraging a high-fiber diet ❍ D. Facilitating perineal wound drainage

Rationale:

The client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an ileostomy, as in answer A; he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not ordered at this time.

The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis?

❍ A. Foul breath ❍ B. Dysphagia ❍ C. Diarrhea ❍ D. Chronic hiccups

Rationale:

Diarrhea is not common in clients with mouth and throat cancer. All the findings in answers A, B, and D are expected findings.

Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should

chart this finding as:

❍ A. A cephalohematoma ❍ B. Molding ❍ C. Subdural hematoma ❍ D. Caput succedaneum

Rationale:

A swelling over the right parietal area is a cephalohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line because it is outside the cranium but beneath the periosteum. Answer B, molding, is overlapping of the bones of the cranium and, thus, incorrect. In answer C, a subdural hematoma, or intracranial bleeding, is ominous and can be seen only on a CAT scan or x-ray. A caput succedaneum, in answer D, crosses the suture line and is edema.

A client in the cardiac step-down unit requires suctioning for excess mucous secretions.The nurse should be most careful to monitor the client for which dysrhythmia during this procedure?

❍ A. Bradycardia

❍ B. Tachycardia ❍ C. Premature ventricular beats ❍ D. Heart block

Rationale:

Suctioning can cause a vagal response and bradycardia. Answer B is unlikely and, therefore, not most important, although it can occur. Answers C and D can occur as well, but they are less likely.

The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?

❍ A. Assessment of the client's level of anxiety ❍ B. Evaluation of the client's exercise tolerance ❍ C. Identification of peripheral pulses ❍ D. Assessment of bowel sounds and activity

Rationale:

The assessment that is most crucial to the client is the identification of peripheral pulses because the aorta is clamped during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities. Answer A is of lesser concern, answer B is not advised at this time, and answer D is of lesser concern than answer A.

A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session?

❍ A. "You will be sitting for the examination procedure." ❍ B. "Portions of the procedure will cause pain or discomfort." ❍ C. "You will be given some medication to anesthetize the area." ❍ D. "You will not be able to drink fluids for 24 hours before the study."

Rationale:

Portions of the exam are painful, especially when the sample is being withdrawn, so this should be included in the session with the client. Answer A is incorrect because the client will be positioned prone, not in a sitting position, for the exam. Anesthesia is not commonly given before this test, making answer C incorrect. Answer D is incorrect because the client can eat and drink following the test.

The nurse is caring for a client with a malignancy. The classification of the primary

tumor is Tis. The nurse should plan care for a tumor:

❍ A. That cannot be assessed ❍ B. That is in situ