Nclex-RN practice test

The nurse is interviewing a client who is being treated for obsessive-compulsive disorder (OCD). Which of the following is the most important question the nurse should ask this client?

1. "Do you find yourself forgetting simple things?"

2. "Do you find it hard to stay on a task?"

3. "Do you have trouble controlling upsetting thoughts?"

4. "Do you experience feelings of panic in a closed area?"

3.

Which of the following actions by the nurse would be considered negligence?

1. Obtaining a Guthrie blood test on a 4-day-old infant

2. Massaging lotion on the abdomen of a 3-year-old diagnosed with Wilms' tumor

3. Instructing a 5-year-old asthmatic to blow on a pinwheel

4. Playing kickball with a 10-year-old with juvenile arthritis (JA)

2.

The nurse on a postpartum unit is preparing 4 clients for discharge. It would be MOST important for the nurse to refer which of the following clients for home care?

1. A 15-year-old primipara who delivered 7-lb. male 2 days ago

2. An 18-year-old multipara who delivered a 9-lb. female by cesarean section 2 days ago

3. A 20-year-old multipara who delivered 1 day ago and is reporting cramping

4. A 22-year-old who delivered by cesarean section and is reporting burning on urination

4.

A client is telling the nurse about his perception of his thought patterns. Which of the following statements by the client would validate the diagnosis of schizophrenia

1. "I can't get the same thoughts out of my head."

2. "I know I sometimes feel on top of the world, then suddenly down."

3. "Sometimes I look up and wonder where I am."

4. "It's clear that this is an alien laboratory and I am in charge"

4.

A nursing team consists of an RN, an LPN/LVN, and an NAP. The nurse should assign which of the following clients to the LPN/LVN?

1. A 72-year-old client with diabetes who requires a dressing change for a stasis ulcer

2. A 42-year-old client with cancer of the bone reporting pain

3. A 55-year-old client with terminal cancer being transferred to hospice home care

4. A 23-year-old client with a fracture of the right leg who asks to use the urinal

1.

To determine the structural relationship of one hospital department with another, the nurse should consult which of the following?

1. Organizational chart

2. Job descriptions

3. Personnel policies

4. Policies and procedures manual

1.

A client reports pain in his right lower extremity. The physician orders codeine60 mg and aspirin grains X PO every 4 hours, as needed for pain. Each codeine tablet contains 15 mg of codeine. Each aspirin tablet contains 325 mg of aspirin. Which of the following should the nurse administer?

1. 2 codeine tablets and 4 aspirin tablets

2. 4 codeine tablets and 3 aspirin tablets

3. 4 codeine tablets and 2 aspirin tablets

4. 3 codeine tablets and 3 aspirin tablets

3.

The nurse is leading an in service about management issues. The nurse would intervene if another nurse made which of the following statements?

(1) "It is my responsibility to ensure that the consent form has been signed and attached to the client's chart prior to surgery."- describes the nurse's responsibility

(2) "It is my responsibility to witness the signature of the client before surgery is performed."

(3) "It is my responsibility to provide a detailed description of the surgery."

(4) "It is my responsibility to answer questions that the client may have prior to surgery."

(3)

A nurse in the outpatient clinic evaluates the Mantoux test of a client whose history indicates that she has been treated during the past year for an AIDS- related infection. The nurse should document that there was a positive reaction if there is an area of induration measuring which of the following?

1. 1 mm

2. 3 mm

3. 5 mm

4. 7 mm

4.

The in the newborn nursery has just received report. Which of the following infants should the nurse see first?

1) A 2-day old infant who is lying quietly alert with a heart rate of 185

2) A 1-day-old infant who is crying and has a bulging anterior fontanel

3) A 12-hour-old infant who is being held, with respirations that are 45 breaths per minute and irregular

4) A 5-hour-old infant who is sleeping and whose hands and feet are blue bilaterally

1)

While inserting a nasogastric tube, the nurse should use which of the following protective measures?

1. Gloves, gown, goggles, and surgical cap

2. Sterile gloves, mask, plastic bags, and gown

3. Gloves, gown, mask, and googles

4. Double gloves, goggles, mask, and surgical cap

3.

The nurse is caring for clients in the outpatient clinic. Which of the following phone calls should the nurse return FIRST?

1. A client with hepatitis A who states, "My arms and legs are itching."

2. A client with a cast on the right leg who states, "I have a funny feeling in my right leg."

3. A client with osteomyelitis of the spine who states, "I am so nauseous that I can't eat."

4. A client with rheumatoid arthritis who states, " I am having trouble sleeping."

2.

The nursing team consists of 1 RN, 2 LPNs/LVNs, and 3 NAPs. The RN should care for which of the following clients?

1. A client with a chest tube who is ambulating in the hall

2. A client with a colostomy who requires assistance with a colostomy irrigation

3. A client with a right-sided cerebrovascular accident (CVA) who requires assistance with bathing

4. A client who is refusing medication to treat cancer of the colon

4.

The home care nurse is visiting a client during the interim phase of hepatitis of unknown etiology. The nurse would be most concerned if the client made which of the following statements?

1. "I must not share eating utensils with my family."

2. "I must use my own bath towel."

3. "I'm glad that my husband and I can continue to have intimate relations."

4. "I must eat small, frequent feedings."

3.

A nurse plans for care of a client with anemia who is reporting weakness. Which of the following tasks should the nurse assign to nursing assistive personnel?

1. Listening to the clients breath sounds

2. Setting up the clients lunch tray

3. Obtaining a diet history

4. Instructing the client on how to balance rest and activity

2.

The nurse is caring for clients on the surgical floor and has just received report from the previous shift. Which of the following clients should the nurse see FIRST?

1. A 35-year-old admitted 3 hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on the dressing

2. A43-year-old who had a mastectomy 2 days ago; 23 mL of serosanguinous fluid noted in the Jackson-Pratt drain

3. A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous 8 hours

4. A 62-year-old who had an abdominal perineal resection 3 days ago; client reports chills

4.

Which of the following actions by the nurse would certainly be considered negligence?

1. Inserting a 16 Fr nasogastric tube and aspirating 15 mL of gastric contents

2. Administering meperidine IM to a client prior to using the incentive spirometer

3. Turning and repositioning a client once every 8 hours post-abdominal surgery

4. Initially administering blood at 5mL per minute for 15 minutes

3.

A 1-day-old newborn diagnosed with intrauterine growth retardation is observed by the nurse to be restless, irritable, and first-sucking, and having a high-pitched, shrill cry. Based on this data, which of the following actions should the nurse take FIRST?

1. Massage the infant's back.

2. Tightly swaddle the infant in a flexed position

3. Schedule feeding times every 3 to 4 hours.

4. Encourage eye contact with the infant during feeding

2.

The nurse visits a neighbor who is at 20 weeks' gestation. The neighbor reports nausea, headache, and blurred vision. The nurse notes that the neighbor appears nervous, is diaphoretic, and is experiencing tremors. It would be MOST important for the nurse to ask which of the following questions?

1. "Are you having menstrual-like cramps?"

2. "When did you last eat or drink?"

3. "Have you been diagnosed with diabetes?"

4. "Have you been lying on the couch?"

2.

The school nurse notes that a first-grade child is scratching her head almost constantly. It would be MOST important for the nurse to take which of the following actions?

1. Discuss basic hygiene with the parents.

2. Instruct the child not to sleep with her dog

3. Inform the parents that they must contact an exterminator.

4. Observe the scalp for small white specks

4.

A suicidal client who was admitted to the psychiatric unit for treatment and observation a week ago suddenly appears cheerful and motivated. The nurse should be aware of which of the following?

1. The client is likely sleeping well because of the medication.

2. The client has made new friends and has a support group.

3. The client may have finalized a suicide plan.

4. The client is responding to treatment and is no longer depressed.

3.

The nurse is caring for clients in the GYN clinic. A client reports an off-white vaginal discharge with a curdlike appearance. The nurse notes the discharge and vulvular erythema. It would be MOST important for the nurse to ask which of the following questions?

1. "Do you douche?"

2. "Are you sexually active?"

3. "What kind of birth control do you use?"

4. "Have you taken any cough medicine?"

3.

The nurse is caring for a client in the prenatal clinic. The nurse notes that the client's chart contains the following information: blood type AB, Rh-negative; serology-negative; indirect Coombs test-negative; fetal paternity-unknown. The nurse should anticipate taking which of the following actions?

1. Administer Rho (D) immune globulin (RhoGAM).

2. Schedule an amniocentesis.

3. Obtain a direct Coombs test.

4. Asses maternal serum for alpha fetoprotein level

1.

The nurse is caring for a women at 37 weeks' gestation. The client was diagnosed with insulin-dependent diabetes Mellitis (IDDM) at age 7. The client states, "I am so thrilled that I will be breastfeeding my baby." Which of the following responses by the nurse is BEST?

1. " you will probably need less insulin while you are breastfeeding."

2. "You will need to initially increase your insulin after the baby is born."

3. "You will be able to take an oral hypoglycemic instead of insulin after the baby is born."

4. "You will probably require the same dose of insulin that you are now taking."

1.

The nurse is caring for a client in a pediatric clinic. The mother of a 14-year-old male privately tells the nurse that she is worried about her son because she unexpectedly walked into his room and discovered him masturbating. Which of the following responses by the nurse would be MOST appropriate?

1. "Tell your son he could go blind doing that."

2. "Masturbation is a normal part of sexual development."

3. "He's really too young to be masturbating."

4. "Why don't you give him more privacy?"

2.

The nurse performs a home visit on a client who delivered 2-days ago. The client states that she is bottle-feeding her infant. The nurse notes white, curdlike patches on the newborn's oral mucous membranes. The nurse should take which of the following actions?

1. Determine the newborn's blood glucose level.

2. Suggest that the newborn's formula be changed.

3. Remind the caregiver not to let the infant sleep with the bottle.

4. Explain that the newborn will need to receive some medication.

4.

The nurse at the birthing facility is caring for a primipara women in labor, who is 4cm dilated and 25% effaced, and whose fetal vertex is at +1. The physician informs the client that an amniotomy is to be performed. The client states, " my friend's baby died when the umbilical cord came out when her water broke. I don't want you to do that to me!" Which of the following responses by the nurse is BEST?

1. "If you are that concerned, you should refuse the procedure."

2. "The procedure will help your labor go faster."

3. "That shouldn't happen to you because the baby's head is engaged."

4. "We will monitor you carefully to prevent cord prolapse."

3.

A primigravid women comes to the clinic for her initial prenatal visit. She is at 32 weeks' gestation and says that she has just moved from out of states. The client says that she has had periodic headaches during her pregnancy, and that she is continually bumping into things. The nurse notes numerous bruises in various stages of healing around the clients breast and abdomen. Vital signs are: BP 120/80, pulse 72, resp 18, and FHT 142. Which of the following responses by the nurse is BEST?

1. "Are you battered by your partner?"

2. "How do you feel about being pregnant?"

3. "Tell me about your headaches."

4. "You May be more clumsy due to your size."

1.

The nurse is teaching a class on natural family planning. Which of the following statements by the client indicates that teaching has been successful?

1. "When I ovulate, my basal body temperature will be elevated for 2 days and then will decrease."

2. "My cervical mucus will be thick cloudy, and sticky when I ovulate."

3. "Because I am regular, I will be fertile about 14 days after the beginning of my period."

4. "When I ovulate, my cervix will feel firm."

3.

The home care nurse plans care for a child in a leg cast for treatment of a fractured right ankle. The nurse enters the following nursing diagnosis on the care plan: skin integrity, risk for impaired. Which of the following actions by the nurse is Best?

1. Teaching the child how to perform isometric exercises of the right leg

2. Teaching the mother to gently massage the child's right foot with emollient cream

3. Instructing the mother to keep the leg cast clean and dry

4. Teaching the mother how to turn and position the child.

1.

The nurse is caring for a client who had a thyroidectomy 12 hours ago for treatment of Graves' disease. The nurse would be MOST concerned if which of the following was observed?

1. The client's blood pressure is 138/82, pulse 84, respirations 16, oral temp 99 degrees Fahrenheit (37.2 degrees Celsius).

2. The client supports his head and neck when turning his head to the right.

3. The client spontaneously flexes his wrist when the blood pressure is obtained.

4. The client is drowsy and reports a sore throat.

3.

A client is admitted who reports severe pain in the right lower quadrant of the abdomen. To assist with pain relief, the nurse should take which of the following actions?

1. Encourage the client to change positions frequently in bed.

2. Massage the right lower quadrant of the abdomen.

3. Apply warmth to the abdomen with a heating pad.

4. Use comfort measures and pillows to position the client

4.

The nurse prepares a client for peritoneal dialysis. Which of the following actions should the nurse take FIRST?

1. Assess for a bruit and thrill.

2. Warm the dialysate solution.

3. Position the client on the left side.

4. Insert a Foley catcher.

2.

The nurse teaches an elderly client with right-sided weakness how to use a cane. Which of the following behaviors by the client indicates that the teaching was effective?

1. The client holds the cane with his right hand, moves the cane forward followed by the right leg, and then moves the left leg.

2. The client holds the cane with his right hand, moves the cane forward followed by his left leg, and then moves the left leg

3. The client holds the cane with his left hand , moves the cane forward followed by the right leg, and then moves the left leg.

4. The client holds the cane with his left hand, moves the cane forward followed by his left leg, and then moves the right leg.

3.

While caring for a client receiving total parenteral nutrition (TPN) through a central line, the nurse notices a small trickle of opaque fluid leaking from around the central line dressing. It is MOST important for the nurse to take which of the following actions?

1. Prepare to change the central line dressing.

2. Verify that the client is on antibiotics.

3. Place the client's head lower than his feet.

4. Secure the Y-port where the lipids are infusing.

3.

A 46-year-old man is admitted to the hospital with a fractured right femur. He is placed in balanced suspension traction with a Thomas splint and Pearson attachment. During the first 48 hr, the nurse should assess the client for which of the following complications?

1. Pulmonary embolism

2. Fat embolism

3. Avascular necrosis

4. Malunion

2.

The nurse is helping an NAP provide a bed bath to a comatose client who is incontinent. The nurse should intervene if which of the following actions is noted?

1. The NAP answers the phone while wearing gloves.

2. The NAP log-rolls the client to provide back care.

3. The NAP places an incontinence diaper under the client

4. The NAP positions the client on the left side, head elevated.

1.

A 70-year-old women is brought to the emergency room for treatment after being found on the floor by her daughter. X-rays reveal a displaced subcapital fracture of the left hip and osteoarthritis. When comparing the leg, the nurse would most likely make which of the following observation?

1. The client's left leg is longer than the right leg and externally rotated.

2. The client's left leg is shorter than the right leg and internally rotated

3. The client's left leg is shorter than the right leg and adducted.

4. The client's left leg is longer than the right leg and is abducted.

1.

The nurse is caring for a client with a cast on the left leg. The nurse would be most concerned if which of the following is observed?

1. Capillary refill time is less than 3 seconds

2. Client reports discomfort and itching

3. Client reports tightness and pain

4. Client's foot is elevated on a pillow

3.

The nurse is discharging a client from an inpatient alcohol treatment unit. Which of the following statements by the client's wife indicates to the nurse that the family is coping adaptively?

1. "My husband will do well as long as I keep him engaged in activities that he likes."

2. "My focus is learning how to live my life."

3. "I am so glad that our problems are behind us."

4. "I'll make sure that the children don't give my husband any problems."

2.

A nurse is caring for a client's in the mental health clinic. A women comes to the clinic reporting insomnia and anorexia. The client tearfully tells the nurse that she was laid off from a job that she had for 15 years. Which of the following responses by the nurse would be most appropriate?

1. "Did your company give you a severance package?"

2. "Focus on the fact that you have a healthy, happy, family."

3. "Tell me what happened."

4. "Losing a job is common nowadays."

3.

A client with a history of alcoholism is brought to the emergency room in an agitated state. He is vomiting and diaphoretic. He says he had his last drink 5 hours ago. The nurse would expect to administer which of the following medications?

1. Chlordiazepoxide hydrochloride

2. Disulfiram

3. Methadone hydrochloride

4. Naloxone hydrochloride

1.

The nurse cares for a client diagnosed with terminal colon cancer. The spouse of the client says, "we have been married for so long. I am not sure how I can go on now." What is the most appropriate response by the nurse?

1 "It sounds like your children will be there to help during your time of grieving."

2. "I know this is difficult. Tell me more about what you are feeling now."

3. "Think about the pain and suffering your spouse has experienced lately."

4. "I will call the hospice nurse to talk to you about this."

2.

The nurse teaches an elderly client how to use a standard aluminum walker. Which of the following behaviors by the client indicates that the nurse's teaching was effective?

1. The client slowly pushes the walker forward 12 inches, then takes small steps forward while leaning on the walker.

2. The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward.

3. The client supports his weight on the walker while advancing it forward, then takes small steps while balancing on the walker.

4. The client slides the walker 18 inches forward, then takes small step while holding onto the walker for balance.

2.

A nurse is supervising a group of elderly clients in a residential home setting. The nurse knows that the elderly are at greater risk of developing sensory deprivation for which of the following reasons?

1. Increased sensitivity to the side effects of medications

2. Decreased visual, auditory, and gustatory abilities

3. Isolation from their families and familiar surroundings

4. Decreased musculoskeletal functions and mobility

2.

After receiving report, the nurse should see which of the following clients FIRST?

1. A 14-year-old client in sickle-cell crisis with an infiltrated IV

2. A 59-year-old client with leukemia who has received half of a packed red blood cell transfusion

3. A 68-year-old client scheduled for a bronchoscopy

4. A 74-year-old client reporting a leaky colostomy

1.

The home care nurse is visiting a client with a diagnosis of hepatitis of unknown etiology. The nurse knows that teaching has been successful if the client make which of the following statements?

1. "I am so sad that I am not able to hold my baby"

2. "I will eat after my family eats."

3. "I will make sure that my children don't use my eating utensils or drinking glasses."

4. "I'm glad that I don't have to get help taking care of my children."

3.

The nurse calculates the IV flow rate for a postoperative client. The client is to receive 3,000mL of Ringer's lactate solution IV to run over 24 hours. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should regulate the client's IV to deliver how many drops per minute?

1. 18

2. 21

3. 35

4. 40

2.

A client with emphysema becomes restless and confused. Which of the following steps should the nurse take next?

1. Encourage the client to perform pursed lip breathing.

2. Check the client's temperature.

3. Asses the client's potassium level.

4. Increase the client's oxygen flow rate to 5 L/mIn.

1.

The nurse is caring for a client 1 day after an abdominal-perineal resection for cancer of the rectum. The nurse should question which of the following orders?

1. Discontinue the nasogastric tube when bowel sounds are heard.

2. Irrigate the colostomy.

3. Place petrolatum gauze over the stoma.

4. Administer meperidine 50 mg IM for pain.

2.

The nurse is caring for a client 4 hours after intracranial surgery. Which of following actions should the nurse take immediately?

1. Turn, cough, and deep-breathe the client.

2. Place the client with the neck flexed and head turned to the side.

3. Perform passive range-of-motion exercises.

4. Move the client to the head of the bed using a turning sheet.

4.

A 6-year-old child with a congenital heart disorder is admitted with congestive heart failure. Digoxin 0.12mg is ordered for the child. The bottle contain 0.05 mg of digoxin in 1 mL of solution. Which of the following amounts should the nurse administer to the child?

1. 1.2 mL

2. 2.4 mL

3. 3.5 mL

4.4.2 mL

2.

The nurse is caring for a client with chest pain in the emergency department. Which of the following laboratory findings would most concern the nurse?

1. Erythrocyte sedimentation rate (ESR): 10 mm/hr

2. Hematocrit (Hct):42%

3. Creatine phosphokinase-MB (CK-MB): 4 ng/mL

4.serum glucose: 100 mg/dL

3.

The nurse is caring for a client with cervical cancer. The nurse notes that the radium implant has become dislodged. Which of the following actions should the nurse take FIRST?

1. Grasp the implant with a sterile hemostat and carefully reinsert it into the client.

2. Wrap the implant in a blanket and place it behind a lead shield.

3. Ensure the implants is picked up with long-handled forceps and placed in a lead container.

4. Obtain a dosimeter reading on the client and report it to the physician

3.

The nurse in a primary care clinic is caring for a 68- year old man. History reveals that per day for 45 years and drinks 2 beers per day. He reports a nonproductive cough, chest discomfort, and displeasure the nurse hears isolated wheezing in the right middle lobe. It would be most important for the nurse to complete which of the following orders?

1. Pulmonary function test

2. Echocardiogram

3. Chest x-ray

4. Sputum culture

3.

The nurse is caring for a client with pernicious anemia. The nurse knows that her teaching has been successful if the client makes which of the following statements?

1. "In order to get better, I will take iron pills."

2. "I am going to attend smoking cessation classes."

3. "I will learn how to perform IM injection."

4. "I will increase my intake of carbohydrates."

3.