NCLEX QUESTION TRAINER

NCLEX QUESTION TRAINER

TEST 1

• The nurse is caring for clients in the outpatient clinic. Which of the following messages should the

nurse return FIRST?

• A mother reports that the umbilical cord of her five-day-old infant is dry and hard to the touch.
• A mother reports that the “soft spot” on the head of her four-day-old infant feels slightly elevated

when the baby sleeps.

• A mother reports that the circumcision of her 3-day-old infant is covered with yellowish exudate.
• A father reports that he bumped the crib of his two-day-old infant and she violently extended her

extremities and returned to them their previous position.

• The parents of a child with hemophilia want to know the cause of the disease. Which of the following

would be the BEST response by the nurse?

• “The father transmits the gene to his son.”
• “Both the mother and the father carry a recessive trait.”
• “The mother transmits the gene to her son.”
• “There is a 50% chance that the mother will pass the trait to each of her daughters.”

• A six-month-old is brought to the clinic for a well-baby check-up. During the exam, the nurse should

expect to assess which of the following?

• A pincer grasp.
• Sitting with support.
• Tripling of the birth weight.
• Presence of the posterior fontanelle.

• A 48-year-old man with an endotracheal tube needs suctioning. Which of the following statements is

an accurate description of how the nurse should perform the procedure?

• Insert the suction catheter four inches into the tube. Apply suction for 30 seconds, using a twirling

motion as the catheter is withdrawn.

• Hyperoxygenate the client and then insert the suction catheter into the tube. Suction while you

remove the catheter using a back and forth motion.

• Explain the procedure to the patient. Insert the catheter while gently applying suction, and withdraw

using a twisting motion.

• Insert the suction catheter until resistance is met, then withdraw it slightly. Apply suction

intermittently as the catheter is withdrawn.

• A 47-year-old woman comes to the outpatient psychiatric clinic for treatment of a fear of heights. The

nurse knows that phobias involve

• projection and displacement.
• sublimation and internalization.
• rationalization and intellectualization.
• reaction formation and symbolization.

• The prenatal client at eight-weeks gestation has a positive VDRL. In preparing the teaching plan, which

of the following would be MOST appropriate for the nurse to include?

• The importance of not taking any medications so as not to damage the fetus.
• Instructing the client on the importance of taking the penicillin for the prescribed time.
• Instructing the client to refrain from sexual activity.
• Maintaining the confidentiality of sexual partners or contacts.

• An elderly client who has been recently immobilized is ordered to begin passive range-of-motion

(ROM) exercises. What should the nurse understand about ROM before initiating this order?

• Passive range-of-motion exercises increase muscle strength.
• A full range of motion must be completed for the elderly client

. 3. Exercises should be completed to the point of discomfort.

• A sufficient range of motion assists the elderly to carry out activities of daily living (ADLs).

• A 65-year-old man is scheduled for a colon resection this morning. Last night he had polyethylene

glycolelectrolyte solution (GoLytely) and a soapsuds enema. This morning he passes a medium amount of soft, brown stool. The nurse should know that this

• indicates that the bowel preparation is incomplete.
• is evidence that the patient ate something after midnight.

• is an expected finding before this type of surgery.
• is the last stool that was left in the colon.

• The nurse cares for a newborn infant with fetal alcohol syndrome. The nurse would expect to see

which of the following physical characteristics?

• An infant that is large for gestational age (LGA) with craniofacial abnormalities and hydrocephalus

. 2. An infant with a small head circumference, low birth weight, and undeveloped cheekbones.

• An infant with a small head circumference, low birth weight, and excessive rooting and sucking

behaviors.

• An infant with a normal head circumference, low birth weight, and respiratory distress syndrome.

• The physician orders hydromorphone hydrochloride (Dilaudid) 15 mg IM for a 56-year-old woman.

Side effects of this medication that the nurse should observe the patient for include

• photosensitivity and constipation.
• hypotension and respiratory depression.
• tardive dyskinesia and diplopia.
• dry mouth and tinnitus.

• The outpatient clinic nurse is caring for a 66-year-old woman with insulin-dependent diabetes

mellitus (IDDM). Because the client is unwilling to perform blood glucose monitoring, she tests her urine for sugar and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because

• the renal threshold for glucose is elevated in the elderly.
• blood glucose monitoring is easier and less costly for clients to perform.
• urine testing for glucose provides false-positive readings.
• determination of the color on a reagent strip varies from person to person.

• At 32-weeks gestation, a client has an order for an ultrasound. The client indicates an understanding

of this procedure if she makes which of the following statements to the nurse?

• “The results will inform us of the gestational age.”
• “This test will evaluate the baby’s lungs.”
• “The test will show us if there is any problem in the spinal cord.”
• “Early problems with the baby’s blood can be identified with this test.”

• A child has pediculosis capitis (head lice) and is being treated with 1% gamma benzene hexachloride

(Kwell) shampoo. The nurse should explain to the child’s parents that

• treatment should be continued every other day for 1 week.
• clothing and personal belongings require normal cleansing with soap and water.
• application of the shampoo is repeated in 7 to 10 days.
• one treatment with Kwell kills both lice and nits.

• The nurse is supervising an LPN/LVN who is administering an enema to a patient. During the

administration, it is MOST important for the LPN/LVN to take which of the following actions?

• Place the solution 20 inches above the anus.
• Adjust the temperature of the solution.
• Insert the tube six inches.
• Position the patient left side-lying (Sim’s) with knee flexed.

• An 18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB). During

the initial assessment, the nurse should expect to find which of the following early symptoms?

• Kussmaul respirations and bradycardia.
• Elevated temperature and slow respiratory rate.
• Expiratory wheezing and substernal retractions.
• Inspiratory stridor and restlessness.