TOP 400 NCLEX PRACTICE QUESTIONS

TOP 400 NCLEX PRACTICE QUESTIONS

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1. Purpose of small volume enema: Used to clean the sigmoid and rectum

• How enema function: Causes distention of the bowel and stimulates the defecation reflex
• During enema administration, direct rectal tip of enema

solution container to

: Causes distention of the bowel and stimulates the defecation reflex

• Once the client is in position the nurse visualizes the

anus and is ready to insert the rectal tip. She is doing the procedure correctly when she directs the rectal tip to

the:

: umbilicus

• Principle behind obtaining informed consent before

invasive procedure

: Autonomy

• Autonomy: respect for an individual's right to self-determination and freedom to choose and

implement one's own decision • be sure that all patients have consented to all treatments and procedure • explain procedures to patients properly

• A staff nurse reports to the supervisor that a newly

hired nurse is "falsifying data in the vital signs sheet for the clients assigned to her." What action should the supervisor do FIRST?: Take the client's vital signs and compare with the data recorded by the new nurse

ANSWER: C

• Priority management in patient with restraint : Release every 2 to 4 hours, Assess every 30 minutes or as needed
• The parents understand safety precautions on children

when they state that they:

: Will keep plastic bags and wraps are away from reach of children

ANSWER: C

• Accidental poisoning is an important concern because

poisons cause serious injuries to children and the elderly.As you conduct your safety awareness class for parents, you find that you need to give more detailed instructions

when a parent says "I will:

: induce vomiting if my child swallows kerosene."

• Which of the following are required measures

observed by health care workers when in contact with blood and body fluids?

: Hand hygiene and gloves

• When communicating with Theresa, the nurse assumes

the face to face position to:

: Express availability and desire to communicate

• Communication zone for communication between

nurse and patient

: Personal distance

• While communicating with Theresa you use attentive

listening. This requires that the nurse:

: Pays attention to both the content and feeling tone of the client

• The client complains of pain in the left chest down to

the left shoulder and left jaw. In your documentation for

your nurses' notes, you will record this as:

: Radiating pain

• The changes in Mrs. De Vera's vital signs that you

would expect when she complains of pain are the

following EXCEPT:

: Decrease in temperature

• A client with congestive heart failure is taking

hydrochlorothiazide once a day. While the client is taking the medication, the nurse should encourage the client to

eat which of the following fruits:

: banana

• The nurse is administering a bronchodilator to a client

with severe upper respiratory tract infection. The client is manifesting the desired effect of the bronchodilator

when the nurse assesses which of the following:

: Effortless respiration

• When the nurse conducts physical assessment of the

abdomen, auscultation should precede palpation to:

: Prevent altering the frequency and character of bowel sounds

• Dimming lights of the room as request by the client,

level of Maslow's hierarchy of needs met

: Safety and Security

21. Inadequate nutrition: Emaciated and weak appearance

• Desired effect of the bronchodilator in patient with

severe upper respiratory tract infection

: effortless respiration

• In abdominal assessment, auscultation should

precede palpation to:

: Prevent altering the frequency and character of bowel sounds

24. During palpation: use fingertips

• After giving analgesic, what is the priority : reassess pain level after 30 minutes to 1 hour of giving the drug
• McCaffery's guideline in pain management: "whatever the experiencing person says it is, existing whenever and wherever the

person say it does" has become the prevailing conceptualization of pain for clinicians over the past few decades

• To maintain efficacy of nitroglycerine, store drug

where

: Keep sublingual tablets in amber glass bottle

• Appropriate instruction to patient with Patient-

Controlled Analgesia

: "Push the button when you feel the pain is starting."

29. Possible sign of ruptured appendix: Pain subsides

• An effective intervention to prevent perforation of the

inflamed appendix

: Keep patient on N PO

• Short discrete bubbling sounds over the lower region

of lungs

: crackles

• Continuous, high-pitched, squeaky musical sounds

adventitious breath sound

: wheezing

• Acromegaly, manifestation: Enlarged extremities due to skeletal thickness and macroglossia (large tongue)

34. Transphenoidal hypophysectomy, incision site : under the upper lip

35. What to wear BEFORE scrubbing of hands in OR : head cap, mask, goggles

• Skin preparation in OR, what and how to wear : sterile gloves - open glove technique
• Most painful site of the wrist during venipuncture : inner aspect of the WRIST
• Cause of hypospadias: congenital (occurs during 3rd month of fetal development)
• Surgical operation needed to be postponed for a

child with hypospadias

: Circumcision

• Radioactive iodine uptake determines what : Absorption of the iodine isotope

41. Diet for hypothyroidism: low calorie, high fiber

• Post-thyroidectomy, assessment for possible

laryngeal nerve damage

: Talk with the client and note change in voice

43. Serum calcium level of 5.0 mg/dl, what to do : Assess for signs of tetany

44. Confirmatory diagnosis for hiatal hernia: barium swallow

45. To prevent increase in gastric acid secretion : avoid cigarette smoking

46. Confirmatory test for cholelithiasis: UTZ

• Morphine is contraindicated for cholelithaisis because:: Causes spasm of the Sphincter of Oddi
• Bilateral tubal ligation, ask for informed consent to

whom

: BOTH husband and wife

49. Role of nurse in informed consent: witness

• Characteristic (typology) of RBC in iron deficiency

anemia

: Microcytic and hypochromic

• Vitamin B12 deficiency, S/Sx: Slight jaundice, fatigue, paresthesia, glossitis
• Surgeon came into the OR suite swinging her hands : Oblige the assistant surgeon to scrub again
• How to apply dressing after stitching of incisional site

ANSWER: Put the dressings, remove his gloves to apply the tape

• Processes of absorption of nutrients by SMALL

intestine

: diffusion and active transport

55. Psoriasis: A chronic inflammatory skin disorder, not contagious

• Psoriasis skin lesions: Well demarcated regions of erythematous plaques that shed thick silvery white

flakes

57. Herpes Zoster (shingles), precipitating factor : decrease immune system

58. Shock, position: modified trendelenburg

• 2 characteristics of circulating blood volume in septic

shock

: (1) Vasodilation and (2) Maldistribution of circulating blood volume

60. Water in the water seal bottle to fluctuate: patent chest tube

61. Chest tube is dislodged: Cover insertion site with petroleum gauze

62. sudden increase drainage in chest tube: Assess for signs of hemorrhage

• Corticosteroids use, nursing diagnosis: Ineffective protection (risk for infection)

64. Hypoglycemia, manifestations: Cool, moist skin, Slurred speech, Tremors

65. Hyperresonance, determined by: percussion