NCLEX QUESTIONS - but there’s bed available at the pediatric unit,

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NCLEX QUESTIONS

ANSWER

There is no bed available in the med-surg floor, but there’s bed available at the pediatric unit, which patient are you going to transfer?

• Post op breast CA patient
• COPD client
• Fracture of femur
• TURP post op

• Fracture of femur.

Rationales for answer:

• Post op breast CA patient – chemo

involved, being around kids, complicated cre

• COPD client – high risk for infection
• TURP patient – CBI required,

complicated

Question #2 A patient is having ongoing hemodialysis. Which medication is contraindicated?

• Amphojel
• Maalox
• Milk of Magnesia
• Magnesium Hydroxide

• Amphojel.

Amphogel contains phosphorous which is contraindicated with kidney failure.Magnesium is also, but less so than phosphorous. This is a very icky question.

Question #3 Your patient has an allergy to pollen. Which of the following advice should you give?

• Do your gardening in the morning
• Do your gardening late in the afternoon
• Take a walk on the beach instead of hiking in

the woods

• Focus your attention on dried flowers instead

• Focus attention on dried flowers instead

All other choices contain possible exposure to allergens and pollen

Question #4 A patient is on peritoneal dialysis. Which of the following would cause you alarm 1 hour after procedure?

• Frank, bloody drainage
• Light brown drainage
• No drainage
• Clear, yellow drainage

• Frank, bloody drainage. Any time you

have bloody return from CAPD, you have a danger signal.

Question #5 Which of the following signs would indicate that a patient with esophageal varices is deteriorating?

• Pt complains of frequent swallowing
• Pt’s skin is cool and clammy
• An increase in body temperature
• The pt has abdominal distension

• Pt has abdominal distension.

Esophageal varices develop in esophagus, primarily in rectum and abdomen.

• Frequent swallowing is with

laryngectomy

• Cool & clammy is cardiac
• Increased body temp could signify

infection Question #6 A pt has an aortic abdominal aneurysm. He is complaining of a constant back ache. What would you do?

• Give pt a pillow to put between his legs and

tell him to lay on his side.

• Give pt analgesic
• Call MD immediately
• Teach breathing exercises for pain

• Call MD immediately. Back pain is an

indication of bleed. AAA may have ruptured.None of the other options are valid

Question #7 Your patient has Meniere’s disease. Which of the following would you teach?

• Pt should eat high fiber diet
• Pt should eat low protein, high carbs diet
• Pt will not have to worry about tinnitus
• Pt needs to have hearing tested
• Pt needs to have hearing tested.

Unilateral sensorineural hearing loss may be present S&SX of Meniere’s disease include tinnitus, nausea, vomiting and vertigo. All diets should be high in calories but low in

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NCLEX QUESTIONS

ANSWER

Question #8 Your patient is scheduled for a liver biopsy.Which of the following would be most important?

• PT results
• NPO 2 hours before
• Bedrest 6 hours after procedure
• Low residue diet 24 hours before
• PT results.

Bleeding is a major complication of liver biopsy. Knowing PT may indicate whether test is performed or not.

Question #9 Which of the following would be the correct position for a patient who is walking with a cane?

• The patient should lean forward at the cane
• The hand piece should allow for 30 degrees

of flexion at the elbow

• The patient should put all of his weight on

the cane

• The cane should be perfectly straight.

Answer

• Should allow 30 degrees of flexion at

elbow.If cane is too straight, the client won’t be able to support all his weight and may injure his back. The cane should extend from the greater trochanter to the floor with a 20-30 degree flexion at elbow.

Question #10 Which of the following foods are highest in Vitamin K?

• Eggs
• Green leafy vegetables
• Fish
• Cheese

Answer

• Green leafy vegetables. Eggs are high

in iron, fish is good source of protein and oleic acid, cheese is good source of calcium and tyramine.

Question #11 •You have a patient with Glaucoma and who had a trabaeculotomy. You tell if post discharge teaching was effective if he states which of the following?–A. My eyesight will improve when I take my eye drops for 6 months –B. I should take my eye drops continually –C. I should rub my eyes vigorously after administration –D. I should use my eye drops only if I have symptoms

• Eye drops should not be stopped

•A. Implies that pt can stop drops after 6 months •C. Never rub eyes vigorously after administration •D. Implies only use drops if have symptoms Question #12 •When teaching a patient about crutch walking, which of the following gets first priority?•A. Advance both crutches simultaneously •B. Advance unaffectedleg first •C. Place weight on arms and hands when using crutch •D. Advance affected leg first •C. Place weight on arms & hands when using crutch •A. This is also correct, but is not 1 st

priority •B. Always advance crutches first •D. If advance affected leg first, will be placing weight on that leg. Not a principle of crutch walking.Question #13 •You are caring for a burn patient with a serum potassium of 4. Which of the following medications would you question?•A. Morphine •B. Demerol •C. Potassium •D. Tylenol

•C. Potassium . Serum K is 4 which is WNL.Also, with burn patients, you will see an increase in K due to crushing injury. •All other choices are OK because they are analgesics though Tylenol may seem to be too little.

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NCLEX QUESTIONS

ANSWER

Question #14 • •A client is admitted to the hospital with deep 2 nd

degree burns of the thighs, chest and arms covering 40% of total BSA. As a result of the fluid shift that initially follows such burns, the nurse would expect which finding in the client?

•A. Increased urine output •B. Increased weight •C. Decreased pulse rate •D. Decreased cardiac output

• Decreased Cardiac output

•A. Urine output will be decreaased due to fluid shift and hypovolemia •B. Loss of fluids will contribute to weight loss not weight gain •C. Pulse rate will be elevated due to hypovolemia and body attempting to compensate Question #15 •A client who has undergone AKA has been in wheelchair for 3 hours. The nurse assists him to bed, placing him in the prone position. Why is this position most appropriate?–A. It decreases edema of the stump –B. It strengthens the abdominal muscles –C. It extends the affected hip joint –D. It prevents pressure ulcer formation

•C. It extends the affected hip joint

• None of the other three choices apply at all.

Question #16 •Your patient has just undergone a liver biopsy.Which nursing intervention would be of highest priority.•A. Measuring urine output •B. Monitoring VS •C. Checking CVP readings •D. Checking heart rate •B. Monitoring VS. A complication of liver biopsy is hemorrhage and pneumo-thorax.VS is good monitor. •A & C are not appropriate – no change in urine output. Pt will not have CVP •D. Checking heart rate will be done, but choice B includes choice D.Question #17 The nurse is assessing a pt with COPD. Which of the following findings would he expect to find?a.An increase in abdominal girth b.An increase in anterio-posterior diameter c.A decrease in urine output d.A decrease in respiratory rate b.An increase in A-P diameter.

COPD patients have barrel chests Pt will not have increase in abdominal girth, actually are cachectic. Urine output will not be affected. Respiratory rate will be increased due to SOB and DOE.

Question #18 •A patient who is bedridden for 2 wks has the

following lab values: pH 7.37, PO2 90, PCO2 40,

HCO3 25, with hypoalbuminemia and hypocalcemia. Which of the following measures require priority?a.Offer foods rich in protein b.Provide PROM c.Give 3 servings of milk a day d.Turn pt side to side q2h d.Turn pt side to side q2h.Focus of question is that pt is bedridden. Most important is prevent decubitus formation.All other choices are just to distract you.They are good, but not of priority.

Question #19 •Your patient has active tuberculosis. Which of the following measures should you take to prevent the spread of infection?a.Wear a mask when going into patient’s room b.Wear gown & gloves when giving care to pt c.Advise relatives of pt to wear gown when visiting pt d.Close pt’s door always and minimize personnel going into room a.Wear mask when going to pt’s room.TB is airborne by droplets. Pt is on respiratory isolation.B and c do not apply.D is too isolating

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NCLEX QUESTIONS

ANSWER

Question #20 •A client with spinal cord injury has autonomic dysreflexia. Which action should the nurse take first?•A. Call the doctor •B. Place the pt in reverse trendelenberg •C. Administer a sedative on a standing order •D. Check the pt for fecal impaction

• Check for fecal impaction.

Autonomic dysreflexia in spinal cord injuries are caused by a stimulus – full bladder or fecal impaction can cause it.#21 When inserting an NG tube, in order to further advance the tube, in what position should the patient be placed.

• Right side lying
• Left side lying
• Sim’s
• High Fowlers
• High Fowlers is best position for NG

tube insertion. Right side-lying is good for reducing dumping syndrome, left side-lying is good for advancing intestinal tubes. Sims is good for enemas.#22 What nursing instruction would be most important to give to patient on Zyloprim?

• Lots of rest
• Increase fluid intake
• Eat lots of fresh fruits
• Eat lots of cheese
• Increase fluid intake

Zyloprim (Allopurinol) is anti-gout medication. Must be taken with 10-12 eight ounce glasses of water per day. May be given with or immediately after meals or milk.#23 Which of the following professions is at greatest risk of developing Hepatitis A?

• An office worker
• A cashier at a supermarket
• A cook in a restaurant
• A teacher
• A cook in a restaurant.

This person has exposure to raw meat.Hepatitis A is transmitted via the fecal-oral route, or through raw, contaminated foods.#24 Which of the following patients is most at risk for developing a CVA?

• An HIV patient
• A patient with bronchitis
• A Patient with sickle cell anemia
• An amputee
• A pt with sickle cell anemia.

Clinical manifestations of sickle cell anemia include micro and macro infarcts.Micro-infarcts cause painful crisis; Macro- infarcts cause organ damage.#25 Your patient is placed on a low Tyramine diet.Which of the following foods should he avoid?

• Salmon
• Hamburger
• Aged cheese
• Apples
• Aged cheese.

Aged cheese is loaded with tyramine.

#26 Which of the following age groups should the nurse assess first?

• an 8 year old with diabetes mellitus
• A 30 year old with prostate cancer
• A 24 year old with cervical cancer
• A 40 year old with sickle cell crisis
• A 40 year old with sickle cell crisis.

They are trying to fool you here. It isn’t the age group that is important, it is the disease and what is happening to the patient.#27 A patient with diabetes mellitus is having a headache. What should you do?

• Give a glass of orange juice.
• Take a prn blood glucose test
• Tell the patient the headache will go away
• Give the patient her prn Aspirin

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