SAMPLE NCLEX QUESTIONS WWW.CHOOSINGNURSING.

NET 1
1. A home health nurse is doing an admissions assessment, part of which includes
the risk for falls. Which of the following is the most important factor to consider
when assessing this risk?

a. how often the patient is ambulatory inside his home

b. whether the patient experiences orthostatic hypotension
c. proper lighting in each room of the home
d. if the patient has been diagnosed with diabetes mellitus

2. Your patient had a complete hysterectomy yesterday. When you enter her
room, she is sitting on the side of the bed. Her skin is cold and pale; she does
not respond to verbal stimulation and slowly responds to tactile stimulation.
What is the first thing you should do?

a. assess vital signs

b. call for a crash cart because the patient appears to be near collapse
c. help the patient back to bed
d. administer oxygen at 3L per nasal cannula

3. A 20 year old patient has been being treated for second and third-degree
burns over 30% of his body. Part of the discharge planning education includes
wound care instructions. Which statement made by the patient would lead the
nurse to feel that he is ready to be discharged and begin home care?

a. “I need to keep my wound covered in the wound bandage 24 hrs a day.”

b. “If any healed areas break open, I should cover them with a sterile
dressing and notify the doctor’s office right away.”
c. “If I have a temperature, I can take Tylenol every 4 hours.”
d. “I can take sponge baths, but not tub baths because tub baths have
unsterile water.”

4. A nurse teaching health safety to new employees who work dietary, instructs
the new employees on the importance of proper handwashing after toileting to
prevent:

a. the spread of acquired immune deficiency syndrome (AIDS)

b. the spread of hepatitis C
c. the spread of leukemia
d. the spread of hepatitis A

SAMPLE NCLEX QUESTIONS WWW.CHOOSINGNURSING.NET 2

5. You are the charge nurse on your unit. Today you are evaluating the unit’s
infection control procedures. Which of the following indicates the need for
further education of staff?

a. The nurse aide is not wearing gloves when feeding an elderly client.
b. A client with active tuberculosis is asked to wear a mask when he leaves
his room to go to another department for testing.
c. A nurse’s aide with open lesions on her hands double gloves prior to
giving direct client care.
d. The nurse puts on a mask, a gown, and gloves before entering the room of
a client on strict isolation.

6. A 5 year old patient is brought in to the emergency room with rashes found
mostly on his abdomen. The mother reports that the child has had a cough and
sore throat and has displayed a decrease in appetite. Based on the symptoms
reported, the nurse suspects that the child may have:

a. pneumonia
b. strep throat
c. chicken pox
d. measles

7. You are the RN on the evening shift and are preparing to delegate care of a
client who is in upper extremity restraints to a nurse assistant on your team.
Which of the following would you instruct the nurse assistant to report to you
immediately?

a. The patient insists she is hungry and wants a snack

b. any signs of redness under the restraint
c. the patient cursing her because she does not want to have restraints
d. the patient had two bowel movements during this shift

8. As the hospital’s education nurse, you are responsible for educating staff on
the prevention of the transmission of HIV. Which of the following would
indicate to you that the staff has a clear understanding of universal
precautions?

a. a pregnant nurse states she cannot care for an HIV positive patient due to
the risk of the virus being transmitted to her unborn child

SAMPLE NCLEX QUESTIONS WWW.CHOOSINGNURSING.NET 3

 b. nursing assistants change gloves between feeding patients
c. a nurse assistant dons personal protective equipment before assisting the
charge nurse who is suctioning a tracheostomy
d. the lab supervisor wears gloves while recapping the needle after drawing
blood from a patient

9. When practicing transmission-based precautions, the nurse is correct to do

which of the following:

a. wear a mask when providing care for the patient

b. use a disposable thermometer each time she checks the patient’s
temperature
c. use biohazard bags with zip closures when sending specimens to the lab
d. instruct the patient’s visitors on the proper way to apply a face mask

10. While receiving report as you are coming on to the evening shift, the nurse
giving report notifies you that Mr. Jenkins, a new patient who will be in your
care, has a recent history of seizure disorder. Which of the following is an
appropriate action as his primary nurse?

a. assign a nurse assistant to observe the patient during his evening meal to
prevent choking
b. remove all pillows from the patient’s bed to prevent suffocation if he
begins to seize
c. instruct all staff providing care to the patient to make sure the patient’s
bed is kept in the lowest position at all times
d. move the call light away from the bed so that the patient does not get
tangled in the cord if he begins to have a seizure

11. Mr. Smith is being discharged from the hospital and will be required to change
the dressing on his injured leg daily. The dressing is to be sterile. Mr. Smith is to
irrigate the wound with normal saline, pat dry with sterile 4 x 4s and apply
sterile 4 x 4s covered with an abdominal pad. Which statement by Mr. Smith
indicates that he requires further instruction regarding the proper technique for
his wound care?

a. If I am unsure whether any of the material is sterile, I should discard it at once.

b. I need to put on my sterile gloves and then open the normal saline and
pour it onto the 4 x 4s to soak them.

SAMPLE NCLEX QUESTIONS WWW.CHOOSINGNURSING.NET 4

 c. If a 4 x 4 appears soiled, I should throw it away, even if I just took it out of
the sterile package.
d. I should check the expiration date of all products used to do my wound care.

12. With regard to patient safety, which is the most appropriate

assessment/instruction for the nurse to perform following a myelogram?

a. check for bilateral popliteal bruising

b. remind the patient that lying on his right side is restricted until the
physician clears him
c. assess for proper neurological function
d. keep the patient’s feet elevated for the first two hours following the
procedure

13. When educating a new LPN on safety measures regarding a patient with
hemiplegia, the following statement indicates that the nurse requires further
instruction:

a. “Paralysis can be frustrating, and I will be sure to encourage any effort my

patient makes in attempting independent care.”
b. “Difficulty swallowing is common with patients with hemiplegia.”
c. “Passive range of motion is very important in helping decrease muscle
atrophy in a paralyzed patient.”
d. “When helping my patient reposition in the bed, I need to place my hand
under the affected arm for assistance.”

14. A patient is ordered to have a CT scan with contrast. What is the first step the
nurse should take to ensure patient safety?

a. encourage fluids after the procedure

b. obtain a copy of the patient’s power of attorney
c. check the patient’s chart for allergies
d. keep the patient’s call light within reach at all times

SAMPLE NCLEX QUESTIONS WWW.CHOOSINGNURSING.NET 5

15. A bladder scan on your patient who has reported inability to void reveals
approximately 2000mL of urine in the bladder. The nurse understands that
which of the following is important when preparing to perform catheterization?

a. allow the patient to attempt to void after 300 mL of urine has been drained
b. instruct the patient on the importance of proper hydration
c. teach the patient’s spouse how to perform catheterization in the event this
happens again
d. clamp the catheter tubing after each 500 mL is drained and wait five
minutes before opening the clamp again

Answers:

1. C: Proper lighting is essential in the prevention of falls, especially in the elderly

who may already experience impaired vision.

2. C: Help the patient back to bed. AFTER the patient is assisted back to bed,
oxygen at 2L per minute can be initiated and vital signs checked.

3. B: If any healed area opens again, the doctor should be immediately notified.
The patient should report fever immediately, as this could be a sign of infection
and he should be assessed. Administering Tylenol every 4 hours may relieve
the fever, but not resolve the cause of the fever.

4. D: Hepatitis A is transmitted through contaminated food or water, often by the

hands of infected people who do not practice good handwashing after
toileting.

5. C: Healthcare workers with open wounds or lesions should not provide direct
care to patients until the wounds are completely healed.

SAMPLE NCLEX QUESTIONS WWW.CHOOSINGNURSING.NET 6

6. C: Chickenpox (varicella) often presents with a low-grade temperature,
decreased appetite, cough and sore throat prior to the breakout of blisters on
the skin. With the history provided by the mother regarding the previous days,
the symptoms are indicative of the chickenpox virus.

7. B: Any redness under the restraints should be reported immediately as this

may indicate that the restraints have been applied too tightly which could lead
to compromised circulation of the affected area.

8. C: HIV is transmitted by exposure to blood or body fluids. The application of

personal protective equipment prior to any procedure during which exposure is
possible helps reduce the risk of spread of the virus.

9. C: When lab specimens are placed in appropriate containers and then

transported in biohazard bags with zip closures, it reduces the risk of exposure
to infectious disease.

10. C: Keeping the patient’s bed in the lowest position prevents the risk of injury by
falls related to seizures.

11. B: Mr. Smith does not need to put on sterile gloves before opening the normal
saline. The normal saline cap is not sterile; therefore, if he puts the sterile
gloves on prior to opening the bottle, he will contaminate his gloves.

12. C: Assess for appropriate neurological response

13. D: Placing an arm under the affected shoulder could cause displacement, esp
since the patient is unable to feel and report any pain or discomfort. A draw
sheet should be used to turn or reposition the patient.

14. C: Although encouraging fluids to flush the kidneys is important; checking the
patient’s charts for allergies is the first priority.

15. D: Clamping the tubing after every 500 mL and waiting five minutes allows the
bladder to “rest” and thus helps to prevent bladder spasms.

SAMPLE NCLEX QUESTIONS WWW.CHOOSINGNURSING.NET 7

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SAMPLE NCLEX QUESTIONS WWW.CHOOSINGNURSING.NET 8