NCLEX-RN Practice Exam #10 In Text Mode: All questions and answers are given for reading and answering at your own pace.
Question 1. The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply.
A). To place an eye shield on the surgical eye at bedtime.
B). To take acetaminophen (Tylenol) for minor eye discomfort.
C). That episodes of sudden severe pain in the eye is expected.
D). To avoid activities that require bending over.
E). To contact the surgeon if a decrease in visual acuity occurs.
F). To contact the surgeon if eye scratchiness occurs.
Question 1 Answer: A). To place an eye shield on the surgical eye at bedtime. AND B). To take acetaminophen (Tylenol) for minor eye discomfort. AND D). To avoid activities that require bending over. AND E). To contact the surgeon if a decrease in visual acuity occurs.
Question 1 Explanation: After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.
Question 2. The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:
Question 2 Answer: A). Malpractice.
Question 2 Explanation: The nurse could be charged with malpractice, which is failing to perform, or performing an act that causes harm to the client. Giving the infant an overdose falls into this category. Negligence , Tort , and Assault are incorrect because they apply to other wrongful acts. Negligence is failing to perform care for the client; a tort is a wrongful act committed on the client or their belongings; and assault is a violent physical or verbal attack.
Question 3. A nurse is collecting data on a client with severe preeclampsia. Choose the findings that would be noted in severe preeclampsia. Select all that apply.
B). Muscle cramps.
C). Proteinuria 3+.
E). Blood pressure 168/116 mm Hg.
Question 3 Answer: C). Proteinuria 3+. AND D). Oliguria. AND E). Blood pressure 168/116 mm Hg.
Question 3 Explanation: Severe preeclampsia is characterized by blood pressure higher than 160/110 mm Hg, proteinuria 3+ or higher, and oliguria. Seizures (convulsions) are present in eclampsia and are not a characteristic of severe preeclampsia. Muscle cramps and contractions are not findings noted in severe preeclampsia, although the client is monitored for these occurrences.
Question 4. The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority?
A). Continuing to monitor the vital signs.
B). Asking the client how he feels.
C). Contacting the physician.
D). Asking the LPN to continue the post-op care.
Question 4 Answer: C). Contacting the physician.
Question 4 Explanation: The vital signs are abnormal and should be reported immediately. Continuing to monitor the vital signs can result in deterioration of the client’s condition. Asking the client how he feels will only provide subjective data, and LPN is not the best nurse to assign because this client is unstable.
Question 5. A nurse is monitoring a client with Graves’ disease for signs of thyrotoxicosis (thyroid storm). Which of the following signs and symptoms, if noted in the client, will alert the nurse to the presence of this crisis? Select all that apply.
Question 5 Answer: A). Fever. AND B). Agitation. AND E). Sweating.
Question 5 Explanation: Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body’s tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.
Question 6. The home health nurse is planning for the day’s visits. Which client should be seen first?
A). he 50-year-old with MRSA being treated with Vancomycin via a PICC line.
B). The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension.
C). The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube.
D). The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter.
Question 6 Answer: D). The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter.
Question 6 Explanation: The client at highest risk for complications is the client with multiple sclerosis who is being treated with cortisone via the central line. The others are more stable. MRSA is methicillin-resistant staphylococcus aureus. Vancomycin is the drug of choice and is given at scheduled times to maintain blood levels of the drug. The clients in other answer choices of the question are more stable and can be seen later.
Question 7. Which assignment should not be performed by the licensed practical nurse?
A). Inserting a Foley catheter.
B). Discontinuing a nasogastric tube.
C). Obtaining a sputum specimen.
D). Starting a blood transfusion.
Question 7 Answer: D). Starting a blood transfusion.
Question 7 Explanation: The licensed practical nurse should not be assigned to begin a blood transfusion. The licensed practical nurse can insert a Foley catheter, discontinue a nasogastric tube, and collect sputum specimen.
Question 8. The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:
A). File a formal reprimand.
B). Terminate the nurse.
C). Call the Board of Nursing.
D). Charge the nurse with a tort.
Question 8 Answer: A). File a formal reprimand.
Question 8 Explanation: The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but these are not the first actions requested in the stem. A tort is a wrongful act to the client or his belongings and is not indicated in this instance.
Question 9. The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?
A). A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury.
B). A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis.
C). The client who arrives with a large puncture wound to the abdomen and the client with chest pain.
D). The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm.
Question 9 Answer: D). The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm.
Question 9 Explanation: The pregnant client and the client with a broken arm and facial lacerations are the best choices for placing in the same room. The clients in other choices answers of the question need to be placed in separate rooms due to the serious natures of their injuries.
Question 10. A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?
A). Ask the parent/guardian to take the child’s favorite blanket home because anything from the outside should not be brought into the hospital..
B). Ask the parent/guardian to room-in with the child..
C). Ask the parent/guardian to leave the room when assessments are being performed..
D). If the child is screaming, tell him this is inappropriate behavior..
Question 10 Answer: B). Ask the parent/guardian to room-in with the child..
Question 10 Explanation: The nurse should encourage rooming-in to promote parent-child attachment. It is okay for the parents to be in the room for assessment of the child. Allowing the child to have items that are familiar to him is allowed and encourage. If the child is screaming, telling him this is inappropriate behavior is not part of the nurse’s responsibilities.
Question 11. Which information should be reported to the state Board of Nursing?
A). The client fails to receive an itemized account of his bills and services received during his hospital stay..
B). The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath..
C). The facility fails to provide literature in both Spanish and English..
D). The narcotic count has been incorrect on the unit for the past 3 days..
Question 11 Answer: D). The narcotic count has been incorrect on the unit for the past 3 days..
Question 11 Explanation: The Joint Commission on Accreditation of Hospitals will probably be interested in the problems if facility fails to provide literature in both Spanish and English. and if the client fails to receive an itemized account of his bills and services received during his hospital stay. The failure of the nursing assistant to care for the client with hepatitis might result in termination, but is not of interest to the Joint Commission.
Question 12. The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?
A). Cheese omelet.
B). Ham sandwich on whole-wheat toast.
C). Spaghetti and meatballs.
D). Hamburger with ketchup.
Question 12 Answer: A). Cheese omelet.
Question 12 Explanation: The child with celiac disease should be on a gluten-free diet. Ham sandwich on whole-wheat toast, Spaghetti and meatballs , and Hamburger with ketchup all contain gluten, while answer Cheese omelet gives the only choice of foods that does not contain gluten.
Question 13. A nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply .
A). Pneumonia client.
B). Asthma client.
C). Severely anxious client.
D). Diabetic mellitus client.
E). Malnourished client.
F). Renal failure client.
Question 13 Answer: D). Diabetic mellitus client. AND E). Malnourished client. AND F). Renal failure client.
Question 13 Explanation: Diabetes mellitus, malnutrition, and renal failure lead to metabolic acidosis because of the increasing acids in the body. Severe anxiousness , pneumonia and asthma are respiratory problems, not metabolic, and result in either respiratory acidosis or respiratory alkalosis.
Question 14. The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first?
A). Assess the child’s pulse.
B). Apply oxygen by mask.
C). Notify the physician.
D). Recheck the O2 saturation level in 15 minutes.
Question 14 Answer: B). Apply oxygen by mask.
Question 14 Explanation: Remember the ABCs (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the pulse, oxygen should be applied to increase the oxygen saturation. The normal oxygen saturation for a child is 92%–100%.
Question 15. The nurse is caring for a client admitted with epiglottis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?
A). Intravenous access supplies.
B). Intravenous fluid administration pump.
C). Supplemental oxygen.
D). A tracheostomy set.
Question 15 Answer: D). A tracheostomy set.
Question 15 Explanation: For a child with epiglottis and the possibility of complete obstruction of the airway, emergency tracheostomy equipment should always be kept at the bedside. Intravenous supplies, fluid, and oxygen will not treat an obstruction.
Question 16. A nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Choose the instructions that the nurse places on the list.Select all that apply.
A). The test will take between 45 minutes and 2 hours..
B). Cola is acceptable to drink on the day of the test..
C). Tea and coffee are restricted on the day of the test..
D). A nothing-by-mouth (NPO) status is required on the day of the test..
E). The hair should be washed the evening before the test..
F). All medications need to be withheld on the day of the test..
Question 16 Answer: A). The test will take between 45 minutes and 2 hours.. AND C). Tea and coffee are restricted on the day of the test.. AND E). The hair should be washed the evening before the test..
Question 16 Explanation: Pre-procedure instructions include informing the client that the procedure is painless. The procedure requires no dietary restrictions other than avoidance of cola, tea, and coffee on the morning of the test. These products have a stimulating effect and should be avoided. The hair should be washed the evening before the test, and gels, hairsprays, and lotion should be avoided. The client is informed that the test will take 45 minutes to 2 hours and that medications are usually not withheld before the test.
Question 17. Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?
A). Clean the lint from the hearing aid with a toothpick..
B). Store the hearing aid in a warm place..
C). Remove the mold and clean every week..
D). Change the batteries weekly..
Question 17 Answer: B). Store the hearing aid in a warm place..
Question 17 Explanation: The hearing aid should be stored in a warm, dry place. It should be cleaned daily but should not be moldy, so removing the mold and clean every week is incorrect. A toothpick is inappropriate to use to clean the aid; the toothpick might break off in the hearing aide. Changing the batteries weekly, is not necessary.
Question 18. A 25-year-old client with Grave’s disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal?
B). Weight gain.
C). Decreased appetite.
Question 18 Answer: D). Exophthalmos.
Question 18 Explanation: Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss.
Question 19. The client is having an arteriogram. During the procedure, the client tells the nurse, “I’m feeing really hot.” Which response would be best?
A). “You are having an allergic reaction. I will get an order for Benadryl.”.
B). “I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing.”.
C). “That feeling of warmth is normal when the dye is injected.”.
D). “That feeling of warmth indicates that the clots in the coronary vessels are dissolving.”.
Question 19 Answer: C). “That feeling of warmth is normal when the dye is injected.”.
Question 19 Explanation: It is normal for the client to have a warm sensation when dye is injected. Other choices in the question indicates that the nurse believes that the hot feeling is abnormal, so they are incorrect.
Question 20. The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
A). The client with acromegaly.
B). The client with Cushing’s disease.
C). The client with diabetes.
D). The client with myxedema.
Question 20 Answer: B). The client with Cushing’s disease.
Question 20 Explanation: The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immune suppressed. In client with diabetes, the client poses no risk to other clients. The client with acromegaly has an increase in growth hormone and poses no risk to himself or others. The client with myxedema has hyperthyroidism or myxedema and poses no risk to others or himself.
Question 21. A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:
A). Body image disturbance.
B). Risk for aspiration.
D). Impaired verbal communication.
Question 21 Answer: B). Risk for aspiration.
Question 21 Explanation: Always remember your ABCs (airway, breathing, circulation) when selecting an answer. Although answers impaired verbal communication and pain might be appropriate for this child, answer risk for aspiration should have the highest priority. Body image disturbance does not apply for a child who has undergone a tonsillectomy.
Question 22. The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:
A). Bring a hair sample to the clinic for evaluation.
B). Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep.
C). Scrape the skin with a piece of cardboard and bring it to the clinic.
D). Obtain a stool specimen in the afternoon.
Question 22 Answer: B). Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep.
Question 22 Explanation: Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. There is no need to scrap the skin, collect a stool specimen, or bring a sample of hair.
Question 23. A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
B). High fever.
C). Vomiting and diarrhea.
D). Nonproductive cough.
Question 23 Answer: B). High fever.
Question 23 Explanation: If the child has bacterial pneumonia, a high fever is usually present. Bacterial pneumonia usually presents with a productive cough, not a nonproductive cough, making nonproductive cough incorrect. Rhinitis is often seen with viral pneumonia, and vomiting and diarrhea are usually not seen with pneumonia, so rhinitis , vomiting and diarrhea are incorrect.
Question 24. The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?
A). Intravenous antibiotic therapy will be ordered.
B). The entire family should be treated.
C). Treatment is not recommended for children less than 10 years of age.
D). Medication therapy will continue for 1 year.
Question 24 Answer: B). The entire family should be treated.
Question 24 Explanation: Erterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated to ensure that no eggs remain. Because a single treatment is usually sufficient, there is usually good compliance. The family should then be tested again in 2 weeks to ensure that no eggs remain.
Question 25. The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
A). The client who has just been administered soluble brachytherapy for thyroid cancer.
B). The client receiving linear accelerator radiation therapy for lung cancer.
C). The client who returned from placement of iridium seeds for prostate cancer.
D). The client with a radium implant for cervical cancer.
Question 25 Answer: B). The client receiving linear accelerator radiation therapy for lung cancer.
Question 25 Explanation: The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy travels to the radium department for therapy. The radiation stays in the department, so the client is not radioactive. The client in other answer choices pose a risk to the pregnant nurse. These clients are radioactive in very small doses, especially upon returning from the procedures. For approximately 72 hours, the clients should dispose of urine and feces in special containers and use plastic spoons and forks
Question 26. The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction?
A). “For a snack, my child can have ice cream.”.
B). “My child can have a grilled cheese sandwich for lunch.”.
C). “It is okay to give my child white grape juice for breakfast.”.
D). “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.”.
Question 26 Answer: D). “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.”.
Question 26 Explanation: Remember the ABCs (airway, breathing, circulation) when answering this question. The statement, “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.” is correct because a hotdog is the size and shape of the child’s trachea and poses a risk of aspiration. The rest of the choices in the question are incorrect because white grape juice, a grilled cheese sandwich, and ice cream do not pose a risk of aspiration for a child.
Question 27. The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective?
A). The client has a grand mal seizure.
B). The client vomits..
C). The client’s ECG indicates tachycardia.
D). The client loses consciousness.
Question 27 Answer: A). The client has a grand mal seizure.
Question 27 Explanation: During ECT, the client will have a grand mal seize. This indicates completion of the electroconvulsive therapy.
Question 28. Which nurse should be assigned to care for the postpartal client with preeclampsia?
A). The RN with 3 years of experience in labor and delivery.
B). The RN with 1 year of experience in the neonatal intensive care unit.
C). The RN with 10 years of experience in surgery.
D). The RN with 2 weeks of experience in postpartum.
Question 28 Answer: A). The RN with 3 years of experience in labor and delivery.
Question 28 Explanation: The nurse with 3 years of experience in labor and delivery knows the most about possible complications involving preeclampsia. The RN with 2 weeks of experience in postpartum is a new nurse to the unit, and the RN with 10 years of experience in surgery and RN with 1 year of experience in the neonatal intensive care unit have no experience with the postpartum client.
Question 29. The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following?
A). The child should be allowed to instill his own eyedrops..
B). The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops..
C). The mother should be allowed to instill the eyedrops..
D). If the eye is clear from any redness or edema, the eyedrops should be held..
Question 29 Answer: B). The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops..
Question 29 Explanation: Before instilling eyedrops, the nurse should cleanse the area with water. A 6-year-old child is not developmentally ready to instill his own eyedrops. Although the mother of the child can instill the eyedrops, the area must be cleansed before administration. Although the eye might appear to be clear, the nurse should instill the eyedrops, as ordered.
Question 30. The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?
A). The nurse wears gloves to take the client’s vital signs..
B). The doctor washes his hands before examining the client..
C). The nurse wears goggles while drawing blood from the client..
D). The nursing assistant wears gloves while giving the client a bath..
Question 30 Answer: A). The nurse wears gloves to take the client’s vital signs..
Question 30 Explanation: It is not necessary to wear gloves to take the vital signs of the client. If the client has active infection with methicillin-resistant staphylococcus aureus, gloves should be worn. The healthcare workers in other answer choices indicate knowledge of infection control by their actions.