NCLEX-RN Practice Exam #15 In Text Mode: All questions and answers are given for reading and answering at your own pace.
Question 1. A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?
A). Weight gain of 5 pounds.
B). Decreased appetite.
C). Edema of the ankles.
D). Gastric irritability.
Question 1 Answer: B). Decreased appetite.
Question 1 Explanation: Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias.
Question 2. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to
A). visit the health care provider within 1 week for a BP check.
B). go get a blood pressure check within the next 48 to 72 hours.
C). see the health care provider immediately.
D). check blood pressure again in 2 months.
Question 2 Answer: B). go get a blood pressure check within the next 48 to 72 hours.
Question 2 Explanation: The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke. However immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.
Question 3. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is
A). Manage pain.
B). Prevent urinary tract infection.
C). Maintain fluid and electrolyte balance.
D). Control nausea.
Question 3 Answer: A). Manage pain.
Question 3 Explanation: The immediate goal of therapy is to alleviate the client’s pain.
Question 4. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission?
A). An elderly client with a history of hypertension, hypercholesterolemia and lupus, and was admitted with Stevens-Johnson syndrome that morning.
B). An adolescent with a positive HIV test and admitted for acute cellulitus of the lower leg 48 hours ago.
C). A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago.
D). A young adult with diabetes mellitus Type 2 for over 10 years and admitted with antibiotic induced diarrhea 24 hours ago.
Question 4 Answer: C). A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago.
Question 4 Explanation: The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.
Question 5. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?
A). falling blood pressure.
B). thrombus formation.
D). angina at rest.
Question 5 Answer: B). thrombus formation.
Question 5 Explanation: Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure.
Question 6. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation?
A). Bed wetting.
C). Weight loss.
Question 6 Answer: A). Bed wetting.
Question 6 Explanation: In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents.
Question 7. The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
A). Apply dressing using sterile technique.
B). Initiate limb compression therapy.
C). Begin proteolytic debridement.
D). Improve the client’s nutrition status.
Question 7 Answer: D). Improve the client’s nutrition status.
Question 7 Explanation: The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other answers are correct, but without proper nutrition, the other interventions would be of little help.
Question 8. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response?
A). Electrical energy fields.
B). Spinal column manipulation.
C). Exercise of joints.
D). Mind-body balance.
Question 8 Answer: B). Spinal column manipulation.
Question 8 Explanation: The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation.
Question 9. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first?
A). Acetylcysteine (mucomyst) for age per pharmacy.
B). Activated charcoal per pharmacy.
C). Start an IV Dextrose 5% with 0.33% normal saline to keep vein open.
D). Gastric lavage PRN.
Question 9 Answer: D). Gastric lavage PRN.
Question 9 Explanation: Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids.
Question 10. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?
A). Tall peaked T waves.
B). Narrowed QRS complex.
C). Shortened “PR” interval.
D). Prominent “U” waves.
Question 10 Answer: A). Tall peaked T waves.
Question 10 Explanation: A tall peaked T wave is a sign of hyperkalemia. The health care provider should be notified regarding discontinuing the medication.
Question 11. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is
A). Aspirate abdominal contents to determine the amount of last feeding remaining in stomach.
B). Ensure that feeding solution is at room temperature.
C). Check that the feeding solution matches the dietary order.
D). Verify correct placement of the tube.
Question 11 Answer: D). Verify correct placement of the tube.
Question 11 Explanation: Proper placement of the tube prevents aspiration.
Question 12. A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure:
A). Left heart function.
B). Right heart function.
C). Carotid artery function.
D). Renal tubule function.
Question 12 Answer: A). Left heart function.
Question 12 Explanation: The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. The pressure readings are inferred from pressure measurements obtained on the right side of the circulation. Right-sided heart function is assessed through the evaluation of the central venous pressures (CVP).
Question 13. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to:
A). Increase fluids that are high in protein.
B). Force fluids and reassess blood pressure.
C). Limit fluids to non-caffeine beverages.
D). Restrict fluids.
Question 13 Answer: B). Force fluids and reassess blood pressure.
Question 13 Explanation: Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.
Question 14. A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time?
A). Positive sweat test.
B). Meconium ileus.
C). Bulky greasy stools.
D). Moist, productive cough.
Question 14 Answer: D). Moist, productive cough.
Question 14 Explanation: Moist, productive cough is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.
Question 15. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should:
A). Place a call to the client’s health care provider for instructions.
B). Instruct the client’s wife to call the doctor if his symptoms become worse.
C). Send him to the emergency room for evaluation.
D). Reassure the client’s wife that the symptoms are transient.
Question 15 Answer: C). Send him to the emergency room for evaluation.
Question 15 Explanation: This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client’s best interest.
Question 16. Which individual is at greatest risk for developing hypertension?
A). 60 year-old Asian American shop owner.
B). 55 year-old Hisapanic teacher.
C). 40 year-old Caucasian nurse.
D). 45 year-old African American attorney.
Question 16 Answer: D). 45 year-old African American attorney.
Question 16 Explanation: The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.
Question 17. The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention?
A). Altered sensation to stimuli.
B). Decrease in level of consciousness.
C). Loss of bladder control.
D). Emotional ability.
Question 17 Answer: B). Decrease in level of consciousness.
Question 17 Explanation: A further decrease in the level of consciousness would be indicative of a further progression of the CVA.
Question 18. A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which:
A). Increase the heart rate.
B). May be competitive.
C). Lead to dehydration.
D). Are considered aerobic.
Question 18 Answer: C). Lead to dehydration.
Question 18 Explanation: The client must take in adequate fluids before and during exercise periods.
Question 19. A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?
A). Gravida 3 para 1.
B). Gravida 2 para 1.
C). Gravida 3 para 2.
D). Gravida 4 para 2.
Question 19 Answer: A). Gravida 3 para 1.
Question 19 Explanation: Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).
Question 20. A nurse enters a client’s room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is:
A). Start a peripheral IV.
B). Initiate closed-chest massage.
C). Establish an airway.
D). Obtain the crash cart.
Question 20 Answer: C). Establish an airway.
Question 20 Explanation: Establishing an airway is always the primary objective in a cardiopulmonary arrest.
Question 21. A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?
A). The cerebellum.
B). The leg bones.
C). The kidneys.
D). All striated muscles.
Question 21 Answer: D). All striated muscles.
Question 21 Explanation: Rhabdomyosarcoma is the most common children”s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word and is “myo” which typically means muscle.
Question 22. When teaching a client with coronary artery disease about nutrition, the nurse should emphasize:
A). Eating 3 balanced meals a day.
B). Avoiding very heavy meals.
C). Limiting sodium to 7 gms per day.
D). Adding complex carbohydrates.
Question 22 Answer: B). Avoiding very heavy meals.
Question 22 Explanation: Eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease.
Question 23. What would the nurse expect to see while assessing the growth of children during their school age years?
A). Decreasing amounts of body fat and muscle mass.
B). Little change in body appearance from year to year.
C). Yearly weight gain of about 5.5 pounds per year.
D). Progressive height increase of 4 inches each year.
Question 23 Answer: C). Yearly weight gain of about 5.5 pounds per year.
Question 23 Explanation: School age children gain about 5.5 pounds each year and increase about 2 inches in height.
Question 24. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?
Question 24 Answer: B). Chlamydia.
Question 24 Explanation: Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.
Question 25. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?
A). Respiratory rate 16.
B). Heart rate 76.
C). Urine output 50 ml/hour.
D). Blood pressure 94/60.
Question 25 Answer: D). Blood pressure 94/60.
Question 25 Explanation: Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100; systolic B/P over 100) in order to safely administer both medications.
Question 26. During the evaluation of the quality of home care for a client with Alzheimer’s disease, the priority for the nurse is to reinforce which statement by a family member?
A). The medication is not a problem to have it taken 3 times a day..
B). We go to a group discussion every week at our community center..
C). At least 2 full meals a day is eaten..
D). We have safety bars installed in the bathroom and have 24 hour alarms on the doors..
Question 26 Answer: D). We have safety bars installed in the bathroom and have 24 hour alarms on the doors..
Question 26 Explanation: Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are correct statements. However, safety is most important to reinforce.
Question 27. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child’s developmental needs?
A). “I will set limits on exploring the house.”.
B). “I intend to keep control over our child.”.
C). “I understand the need to use those new skills.”.
D). “I want to protect my child from any falls.”.
Question 27 Answer: C). “I understand the need to use those new skills.”.
Question 27 Explanation: Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.
Question 28. A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?
A). Examine the child’s throat.
B). Collect a sputum specimen.
C). Prepare the child for x-ray of upper airways.
D). Notify the healthcare provider of the child’s status.
Question 28 Answer: D). Notify the healthcare provider of the child’s status.
Question 28 Explanation: These findings suggest a medical emergency and may be due to epiglottises. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.
Question 29. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question?
A). “If you can maintain an active walking program, you will have less risk.”.
B). “Have a glass of wine to relax you, then you can try to have sex.”.
C). “You need to regain your strength before attempting such exertion.”.
D). “When you can climb 2 flights of stairs without problems, it is generally safe.”.
Question 29 Answer: D). “When you can climb 2 flights of stairs without problems, it is generally safe.”.
Question 29 Explanation: There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.
Question 30. The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to:
A). Depletion of subcutaneous fat.
B). Low blood sugar levels.
C). Progressive placental insufficiency.
D). Excessive fetal weight.
Question 30 Answer: C). Progressive placental insufficiency.
Question 30 Explanation: The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia.
Question 31. The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to
A). Achieve harmony.
B). Maintain a balance of energy.
C). Respect life.
D). Restore yin and yang.
Question 31 Answer: D). Restore yin and yang.
Question 31 Explanation: For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang.
Question 32. A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?
A). A middle aged client with intermittent pain behind the right scapula.
B). A teenager who got a singed beard while camping.
C). An elderly client with complaints of frequent liquid brown colored stools.
D). A 2 month old infant with a history of rolling off the bed and has bulging fontanels with crying.
Question 32 Answer: B). A teenager who got a singed beard while camping.
Question 32 Explanation: A client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.
Question 33. Which of these statements best describes the characteristic of an effective reward-feedback system?
A). Staff are given feedback in equal amounts over time.
B). Specific feedback is given as close to the event as possible.
C). Positive statements are to precede a negative statement.
D). Performance goals should be higher than what is attainable.
Question 33 Answer: B). Specific feedback is given as close to the event as possible.
Question 33 Explanation: Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if the standards are clearly understood.
Question 34. A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:
A). Should be taken in the morning.
B). Will decrease the client’s heart rate.
C). Must be stored in a dark container.
D). May decrease the client’s energy level.
Question 34 Answer: A). Should be taken in the morning.
Question 34 Explanation: Thyroid supplement should be taken in the morning to minimize the side effects of insomnia
Question 35. The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurse’s immediate attention?
A). “It seems that the pain medication is not working as well today.”.
B). I have bad muscle spasms in my lower leg of the affected extremity..
C). “I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.”.
D). “I have to use the bedpan to pass my water at least every 1 to 2 hours.”.
Question 35 Answer: C). “I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.”.
Question 35 Explanation: The nurse would be concerned about all of these comments. However the most life threatening is answer choice “I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.”. Clients who have had hip or knee surgery are at greatest risk for development of post operative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Answer choice “I have to use the bedpan to pass my water at least every 1 to 2 hours.” may indicate a urinary tract infection. answer choice “It seems that the pain medication is not working as well today.” requires further investigation and is not life threatening.
Question 36. A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?
A). Raise the side rails on the bed.
B). Have the client empty bladder.
C). Place the call bell within reach.
D). Instruct the client to remain in bedv.
Question 36 Answer: B). Have the client empty bladder.
Question 36 Explanation: The first step in the process is to have the client void prior to administering the pre-operative medication.
Question 37. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
A). An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 10.
B). A middle-aged client who says “I took too many diet pills” and “my heart feels like it is racing out of my chest.”.
C). An elderly client who reports having taken a “large crack hit” 10 minutes prior to walking into the emergency room.
D). A young adult who says “I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?”.
Question 37 Answer: A). An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 10.
Question 37 Explanation: Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 10 exhibits opoid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future.
Question 38. While assessing a 1 month-old infant, which finding should the nurse report immediately?
A). Abdominal respirations.
B). Inspiratory grunt.
C). Increased heart rate with crying.
D). Irregular breathing rate.
Question 38 Answer: B). Inspiratory grunt.
Question 38 Explanation: Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant.
Question 39. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working?
A). The client states “I just can’t get relief from my pain.”.
B). The level of the drug is 100 ml at 8 AM and is 50 ml at noon.
C). The level of drug is 100 ml at 8 AM and is 80 ml at noon.
D). The client complains of discomfort at the IV insertion site.
Question 39 Answer: C). The level of drug is 100 ml at 8 AM and is 80 ml at noon.
Question 39 Explanation: The minimal dose of 10 ml per hour which would be 40 ml given in a 4 hour period. Only 60 ml should be left at noon. The pump is not functioning when more than expected medicine is left in the container.
Question 40. Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test?
A). No special orders are necessary for this examination.
B). Client must be NPO before the examination.
C). Enema to be administered prior to the examination.
D). Medicate client with Lasix 20 mg IV 30 minutes prior to the examination.
Question 40 Answer: A). No special orders are necessary for this examination.
Question 40 Explanation: No special preparation is necessary for this examination.