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COMPREHENSIVE REVIEW OF THE NCLEX RN

EXAMINATION
QUESTIONS AND ANSWERS with RATIONALE

1. The nurse is assessing the child with a suspected
diagnosis of appendicitis. In assessing the intensity
and progression of the pain, the nurse palpates the
child at McBurneys point. In performing this
assessment, the nurse knows that McBurneys point
is located midway between the
1. Right anterior inferior iliac crest and the
umbilicus.
2. Left anterior superior iliac crest and the
umbilicus.
3. Right anterior superior iliac crest and the
umbilicus.
4. Left anterior superior iliac crest and the
umbilicus.


2. The nurse is caring for a client with a burn injury
to the lower legs. Nitrofurazone (furacin) is
prescribed to be applied to the sites of injury. The
nurse documents which of the following in the plan
of care as the appropriate method to apply this
medication?
1. Apply saline soaked dressings over the
medication.
2. Apply 1-inch film directly to the burn sites.
3. Apply
116
-inch film directly to the burn sites.

4. Apply
1/2
-inch film directly to the burn sites
after cleansing the wounds.


3. A client suspected of having an abdominal tumor
is scheduled for a computerized tomography scan
with dye injection. The nurse tells the client that
1. The test may be painful.
2. The dye injected may cause a warm flushing
sensation.
3. Fluids will be restricted following the test.
4. The test takes about 2 hours.








4. The nurse is caring for a client whose magnesium
level is 3.5 mg/dL. Which assessment sign/symptom
would the nurse most likely expect to note in the
client based on this magnesium level?
1. Tetany
2. Twitches
3. Positive trousseaus sign
4. Loss of deep tendon reflex


5. The nurse is caring for a client with a diagnosis of
hyperthyroidism. Laboratory studies are performed,
and the serum calcium level is 12 mg/dL. Which
medication would the nurse anticipate to be
prescribed for the client?
1. Calcium gluconate
2. Calcium chloride
3. Calcitonin (Calcimar)
4. Large doses of vitamin D


6. The nurse prepares to administer sodium
polystyrene sulfonate (Kayexalate) to the client.
Before administering the medication, the nurse
reviews the action of the medication and
understands that it releases
1. Bicarbonate in exchange primarily for sodium
ions.
2. Sodium ions in exchange primarily for
bicarbonate ions.
3. Sodium ions in exchange primarily for
potassium ions.
4. Potassium ions in exchange primarily for
sodium ions.


7. Which of the following clients is least likely at risk
for the development of third spacing?
1. The client with cirrhosis
2. The client with diabetes mellitus.
3. The clent with liver failure
4. The client with renal failure


8. The nurse is preparing to care for a client
following a gastroscopy procedure. The nurse
includes which most appropriate component in the
nursing care plan?
1. Place the client in supine position to provide
comfort.
2. Monitor the clients vital signs every hour for 4
hours.
3. Provide saline gargles immediately on return to
the unit to aid in comfort.
4. Check the gag reflex by using a tongue
depressor to stroke the back of clients throat.


9. Intravenous Ringers lactate solution is prescribed
for the postoperative client. The nursing instructor
asks the nursing student who is caring for the client
about the tonicity of the prescribed intravenous
solution. The nursing student responds correctly by
stating that this solution is
1. Isotonic.
2. Normotonic.
3. Hypotonic.
4. Hypertonic.


10. The nurse reviews the arterial blood gas results
of a client with Guillain-Barre syndrome. The pH is
7.35 and the PCO
2
is 50mmHg. The nurse interprets
that this client is experiencing which acid-base
imbalance?
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis


11. The client is admitted 24 hours following an
aspirin overdose. The nurse assesses this client for
which signs and symptoms indicating the acid-base
disturbance that can occur in the client?
1. Bradycardia and Hyperactivity
2. Restlessness, confusion and a positive
trousseaus sign
3. Headache, nausea, vomiting and diarrhea
4. Bradypnea, dizziness and paresthesias


12. The adult client with hepatic encephalopathy has
a serum ammonia level of 95 mcg/dL and receives
treatment with lactulose (Chronulac). The nurse
would evaluate that the client had the best and most
realistic response, if the serum ammonia level
changed to which of the following after medication
administration?
1. 80mcg/dL
2. 60mcg/dL
3. 10mcg/dL
4. 5mcg/Dl


13. The client who suffered a crush injury to the leg
has a highly positive urine myoglobin level. The
nurse assesses this particular client carefully for
signs of
1. Cerebrovascular accident
2. Acute tubular necrosis
3. Respiratory failure
4. Myocardial infarction


14. The adult male client admitted to the hospital
with shock has received fluid volume replacement .
The nurse evaluates that the client has had adequate
fluid resuscitation if the clients repeat hematocrit
level has decreased to which of the following values
in the normal range?
1. 56%
2. 48%
3. 39%
4. 34%


15. The nurse is formulating a plan of care for a
client receiving enteral feedings. Which nursing
diagnosis is of highest priority for this client?
1. Imbalanced Nutrition, Less Than Body
Requirements.
2. Risk for aspiration
3. Risk for Deficient Fluid Volume
4. Diarrhea


16. A Client who has gastrostomy tube for feeding
refuses to participate in the plan of care, will not
make eye contact, and does not speak to the family
or visitors. The nurse assesses that this client is using
which type of coping mechanism?
1. Self-control
2. Problem-solving
3. Accepting responsibility
4. Distancing


17. The nurse conducting a weight loss program
prepares to monitor a clients weight loss. What
method would assess the effectiveness of weight
loss most accurately?
1. Daily weights
2. Serum protein levels
3. Calorie counts
4. Daily intake and output


18. The clinic nurse is monitoring a client with
anorexia nervosa. Which statement if made by a
client would indicate to the nurse that treatment has
been effective?
1. I no longer have a weight problem.
2. I dont want to starve myself anymore.
3. Ill eat until I dont feel hungry.
4. My friends and I went out to lunch today.


19. The nurse is teaching the postgastrectomy client
about measures to prevent dumping syndrome.
Which statement by the client indicates a need for
further teaching?
1. I need to lie down after eating.
2. I need to drink liquids with meals.
3. I need to eat small meals six times daily.
4. I need to avoid concentrated sweets.


20. A client has been diagnosed with pernicious
anemia. In planning care for the client, the nurse
anticipates that the client will be treated with
1. Thiamine
2. Iron
3. Vitamin B
12

4. Folic acid


21. An older postoperative client has been tolerating
a full liquid diet, and the nurse plans to advance the
diet to solid food as prescribed. Which assessment is
most important for the nurse to make before
advancing the diet to solids?
1. Food preferences
2. Cultural preferences
3. Preference of bowel sounds
4. Ability to chew


22. The client with diabetes mellitus has been
instructed in the dietary exchange system. The client
ask the nurse if bacon is allowed in the diet. Which
nursing response is most appropriate?
1. Bacon is much too high in fat.
2. Bacon is not allowed.
3. One strip of bacon may be eaten if you
eliminate one teaspoon of butter.
4. Bacon may be eaten if you eliminate one
meat item from your diet.


23. The client with heart disease is provided
instructions regarding a low-fat diet. The nurse
determines that the client understands the diet if
the client states that the food item to avoid is
1. Apples.
2. Oranges.
3. Avocado.
4. Cherries.


24. A client with liver cancer who is receiving
chemotherapy tells the nurse that some foods on
the meal tray taste bitter. The nurse would try to
limit which food that is most likely to cause this taste
for the client?
1. Beef
2. Potatoes
3. Custard
4. Cantaloupe


25. A nursing student is caring for a client who has
been admitted to the hospital with malnutrition. The
student is reviewing the results of the various
laboratory tests performed on the client with the
nursing instructor. Which statement if made by the
nursing student indicates an understanding of the
interpretation of the results?
1. An elevated creatinine level indicates
respiratory problems.
2. A normal hemoglobin level indicates that iron
and protein intake is sufficient.
3. An elevated albumin level indicates a definite
dehydration.
4. A normal red blood cell level indicates
adequate vitamin B
6
intake


26. The nurse notes that the infant with diagnosis of
hydrocephalus has a head that is heavier than the
average infant. The nurse determines that special
safety precautions are needed when moving the
infant. Which statement would the nurse include in
the discharge teaching with the parents to reflect
this safety need?
1. When picking up your infant, support the
infants neck and head with the open palm of your
hand.
2. Feed your infant in a side-lying position.
3. Place a helmet on your infant when your in
bed.
4. Hyperextand your infants head with a rolled
blanket under the neck area.


27. The nurse is performing an admission
assessment on a child with a seizure disorder. The
nurse is interviewing the childs parents to
determine their adjustment to caring for their child
who has a chronic illness. Which statement if made
by the parents would indicate a need for further
teaching?
1. Our child is involved in a swim program with
neighbors and friends.
2. Our child sleeps in our bedroom at night.
3. Our babysitter just completed
cardiopulmonary resuscitation training.
4. We worry about injuries when our child has a
seizure.


28. The nurse is reviewing the results of a serum
level drawn from a child who is receiving
carbamazepine(Tegretol) for the control of seizures.
The results indicate a level of 10 mcg/mL. The nurse
analyzes the results and anticipates that the
physician will prescribe.
1. An increase of the dose of the medication.
2. A decrease of the dose of the medication.
3. Discontinuation of the medication.
4. Continuation of the presently prescribed
dosage.


29. The nursing student is asked to describe the
corpus of the uterus. Which of the following
responses, if made by the student, indicates an
understanding of the anatomy of the uterus?
1. The corpus is the lower portion of the uterus.
2. The corpus is the upper part of the uterus.
3. The corpus is the area where the cervix meet
the external os.
4. The corpus is the area when the vagina meets
the uterus.


30. The nurse instruct the client with diabetes
mellitus about blood glucose monitoring and
monitoring for signs of hypoglycemia. The nurse
informs the client that hypoglycemia is a blood
glucose level of less than
1. 120 mg/dL.
2. 110 mg/dL.
3. 90 mg/dL.
4. 60 mg/dL.
31. The client newly diagnosed with diabetes
mellitus is instructed by the physician to obtain
glucagon for emergency home use. The client asks
the home care nurse about the purpose of the
medication. The nurse instructs the client that the
purpose of the medication is to treat
1. Hypoglycemia from insulin overdose.
2. Hyperglycemia from insufficient insulin.
3. Lipoatrophy from insulin injections.
4. Lipohypertrophy from inadequate insulin
absorption.


32. The nurse is providing care to a Cuban American
client who is terminally ill. Numerous family
members are present most of the time, and many of
the family members are emotional. The most
appropriate action is to
1. Restrict the numbers of family members
visiting at one time.
2. Inform the family that emotional outbursts are
to be avoided.
3. Request permission to move the client to a
private room and allow the family members to visit.
4. Contact the physician to speak to the family
regarding their behaviors.


33. The nurse is instructing a postpartum client with
endometritis about preventing the spread of
infection to the newborn infant. The nurse would tell
the client that
1. Hands should be washed thoroughly before
holding the infant.
2. The newborn infant will not be allowed in the
mothers room at all.
3. There is no danger of the newborn contracting
the disease.
4. Visitors are not allowed to hold the baby.


34. A client presents to the emergency department
with upper gastrointestinal bleeding and is in
moderate distress. In planning care, which nursing
action would be the first priority for this client?
1. Thorough investigation of precipitating events

2. Insertion of a nasogastric tube and hematest of
emesis
3. Complete abdominal examination
4. Assessment of vital signs.


35. The nurse is caring for a client with possible
cholelithiasis who is being prepared for an
intravenous cholangiogram, and the nurse teaches
the client about the procedure. Which client
statement indicates that the client understands the
purpose of this test?
1. They are going to look at my gallbladder and
ducts.
2. This procedure will drain my gallbladder.
3. My gallbladder will be irrigated.
4. They will put medication in my gallbladder.


36. The nurse provides instructions to a
malnourished client regarding iron supplementation
during pregnancy. Which statement if made by the
client would indicate an understanding of the
instructions?
1. The iron is best absorbed if taken with orange
juice.
2. Meat does not provide iron and should be
avoided.
3. Iron supplements will give me diarrhea.
4. My body has all the iron it needs, and I dont
need to take supplements.


37. The nurse has give discharge instructions to the
client who has underwent vain ligation and stripping
early in the day. The nurse evaluates that the client
understands activity and positioning limitations if
the client states that it is most appropriate to
1. Lie down with the legs elevated and avoid
sitting.
2. Cross the legs at the ankle only, but not at the
knee.
3. Sit in the chair 3 times a day for 3 hours at a
time.
4. Walk upright for as much as possible each day.
38. Octreotide acetate (Sandostatin) is prescribed for
the client with acromegaly. The nurse monitors the
client, knowing that which side effect is associated
with the administration of this medication?
1. Constipation
2. Polyuria
3. Abdominal pain
4. Hypotension


39. Levothyroxine (Synthroid) is prescribed for a
client diagnosed with hypothyroidism. The nurse
reviews the clients records and notes that the client
presently is taking warfarin (Caumadin). The nurse
contacts the physician, anticipating that the
physician will prescribe which of the following?
1. An increased dosage of warfarin.
2. A decreased dosage of warfarin.
3. An increased dosage of levothyroxine.
4. A decreased dosage of levothyroxine.


40. The nurse is teaching the client with emphysema
about positions that help breathing during dyspneic
episodes. The nurse instruct the client to avoid
which of the following positions, which will
aggravate breathing?
1. Sitting up with the elbows resting on the knees
2. Standing and leaning against the wall
3. Lying on the back in low Fowlers position
4. Sitting up and leaning on a table


41. The client is about to undergo a lumbar
puncture. The nurse describes to the client that
which of the following positions will be used during
the procedure?
1. Side-lying with the legs pulled up
2.
3.
4.