NCLEX QUESTIONS 1

Psychosocial Integrity

1. An adolescent male being treated for depression arrives with his family at the Adolescent Day
Treatment Center for an initial therapy meeting with the staff. The nurse explains that one of the
goals of the family meeting is to encourage the adolescent to:

(A) trust the nurse who will solve his problem.

(B) learn to live with anxiety and tension.
(C) accept responsibility for his actions and choices.
(D) use the members of the therapeutic milieu to solve his problems.

2. A 23-year-old-woman comes to the emergency room stating that she had been raped. Which of
the following statements BEST describes the nurse’s responsibility concerning written consent?

(A) The nurse should explain the procedure to the patient and ask her to sign the consent form.
(B) The nurse should verify that the consent form has been signed by the patient and that it is attached to
her chart.
(C) The nurse should tell the physician that the patient agrees to have the examination.
(D) The nurse should verify that the patient or a family member has signed the consent form.

3. The nurse cares for an elderly patient with moderate hearing loss. The nurse should teach the
patient’s family to use which of the following approaches when speaking to the patient?

(A) Raise your voice until the patient is able to hear you.
(B) Face the patient and speak quickly using a high voice.
(C) Face the patient and speak slowly using a slightly lowered voice.
(D) Use facial expressions and speak as you would normally.

4. A 52-year-old man is admitted to a hospital after sustaining a severe head injury in an

automobile accident. When the patient dies, the nurse observes the patient’s wife comforting
other family members. Which of the following interpretations of this behavior is MOST justifiable?

(A) She has already moved through the stages of the grieving process.
(B) She is repressing anger related to her husband’s death.
(C) She is experiencing shock and disbelief related to her husband’s death.
(D) She is demonstrating resolution of her husband’s death.

5. After two weeks of receiving lithium therapy, a patient in the psychiatric unit becomes
depressed. Which of the following evaluations of the patient’s behavior by the nurse would be
MOST accurate?

(A) The treatment plan is not effective; the patient requires a larger dose of lithium.
(B) This is a normal response to lithium therapy; the patient should continue with the current treatment
plan.
(C) This is a normal response to lithium therapy; the patient should be monitored for suicidal behavior.
(D) The treatment plan is not effective; the patient requires an antidepressant.
FOUNDATION OF NURSING NCLEX

Situation: One important legal and safe nursing responsibility is concerned with administration of
medications.

1.    A pediatric client has been diagnosed with conjunctivitis. The nurse is to administer eye drops 4 times
a day. The nurse should administer the medication on to which of the following areas?
a.    Center of the cornea
b.    Sclera by the inner canthus
c.    C. Sclera by the outer canthus
d.    Lower conjunctival sac

2.     While assessing the client’s intravenous (IV) line, the nurse notes that the area is swollen and cool,
causing the client discomfort. The nurse suspects which of the following problems:
a.    Infiltration
b.    Phlebitis
c.    Infection
d.    Air embolism

3.     The client is receiving a 5% dextrose in 0.45% NaCl intravevenously (IV) and report pain at the site,
the nurse assesses the site and notes erythema and edema. What would be the appropriate action for the
nurse to take?
a.    Slow the infusion rate
b.    Discontinue the IV and apply a warm compress to the IV site
c.    Apply antibiotic ointment to the IV site
d.    Gently pull back the IV access device to reposition it within the vein

4.    A patient’s medication order is to take digoxin 0.125 mg p.o. q.i.d. The nurse has on hand Lanoxin
0.25 mg tablet. The best course of action is to:
a.    Dispense 1 ½ tab
b.     Dispense ½ tab
c.     Dispense 2 tablets
d.     Return the medication to the pharmacy

5.    The patient is ordered 2000 ml of Lactated Ringer’s over 12 hours. The drop factor is 15gtts/ml. The
nurse will regulate the IV to how many gtts/min?
a.    28 gtts/min
b.    42 gtts/min
c.    56 gtts/min
d.    14 gtts/min

Situation: The nurse is caring for a group of hospitalized patients.

6.    What should the nurse do first to prevent patient infections?

a.    Provide small bedside bags to dispose of used tissues
b.    Encourage staff to avoid coughing near patients
c.    Administer antibiotics as ordered
d.    Identify patients at risk
7.    The nurse must collect the following specimens. Which specimen collection does not require the use
of surgical aseptic technique?
a.    Stool for ova and parasites
b.    Specimen for a throat culture
c.     Urine from a retention catheter
d.    Exudate from a wound for culture and sensitivity

8.    The nurse identifies that the greatest risk for a wound infection exists for a patient with a:
a.    Surgical creation of a colostomy
b.     First degree burn on the back
c.     Puncture of a foot by a nail
d.     Paper cut on the finger

9.    The nurse understands that the factor that places a patient at the greatest risk for developing an
infection is:
a.    Implantation of a prosthetic device
b.    Presence of an indwelling catheter
c.    Burns more than twenty percent of the body
d.    Multiple puncture sites from laparascopic surgery

10.    The nurse is caring for a patient with high fever secondary septicemia. When the physician orders a
cooling blanket, the nurse understands that it is used to achieved heat loss via:
a.    Radiation
b.    Convection
c.    Conduction
d.    Evaporation

Situation: The nurse is caring for Mrs. Estrada who has recently diagnosed with advanced cancer.

11.    Which statement reflects Kubler-Ross stage of denial in the grief process?
a.    “Why this have to happen to me now?”
b.    “My daughter will live with my sister after I am gone”
c.    “Maybe they mixed up my records with someone else’s”
d.    “How could this happen to me when I quit smoking cigarettes?”

12.     After the physician has informed Mrs. Estrada that her cancer is inoperable and the prognosis is
poor, the patient begins to cry. The nurse should:
a.    Touch the patient’s hand to provide support
b.    Leave the room to give the patient privacy to cry
c.    Telephone the patient’s family to inform them of the diagnosis
d.    Ask the patient how she feels to encourage ventilation of feelings

13.    Mrs. Estrada became withdrawn and depressed. The nursing action that is most therapeutic is:
a.    Assisting the patient to focus on positive thoughts daily
b.    Explaining that the patient still accomplish goals
c.    Accepting the patient’s behavioral adaptation
d.    Offering the patient advice when appropriate
14.    Which is the most appropriate inference made by the nurse when a patient says, “I’m the same age
as my father when he died. Am I going to die of my cancer?” The patient is experiencing:
a.    Grieving associated with perceived impending death
b.    Powerlessness associated with feelings of loss of control
c.    Fear associated with perceived threat to biological integrity
d.    Ineffective coping associated with inadequate psychological resources

15.    Mrs. Estrada is now willing to try new therapies. The nurse identifies that the patient is in what stage
of Kubler-Ross’ stages of grieving?
a.    Denial
b.    Bargaining
c.    Depression
d.    Acceptance

Situation: The nurse should be aware of the legal principles associated with nursing practice.

16.    Licensure of Registered Professional Nurses is required necessarily to protect:

a.    Nurses
b.    Patients
c.    Common law
d.    Health care agencies

17.    A patient falls while getting out of bed unassisted. When completing and Incident Report, the nurse
understands that it main purpose is to:
a.    Ensure that all parties have an opportunity to document what happened
b.    Help establish who is responsible for the incident
c.    Make available data available for quality control analysis
d.    Document the incident on the patient’s chart

18.    The nurse says. “If you do not let me do this dressing change, I will not let you eat dinner with other
residents in the dining room”. This is an example of :
a.    Assault
b.    Battery
c.    Negligence
d.    Malpractice

19.    An anxious patient repeatedly uses the call bell to get the nurse to come to the room. Finally the
nurse says to the patient, “If you keep ringing, there will come a time I won’t answer the bell.”This is an
example of:
a.    Slander
b.    Assault
c.    Battery
d.    Libel

20.    A patient asks the nurse, “What is a Living Will?” the nurse should respond that it is a document
that:
a.    Instructs a physician to withhold/withdraw life-sustaining procedures if death is near
b.    Enables a person to request medication to end life in a humane and dignified manner
c.    Gives consent to perform life-sustaining medical intervention during an emergency
d.    Wills ones organs to help others who need a transplant to sustain life
Situation: As a nurse you must be responsible for the needs of your client.

21.    Ms. R has been medicated for her surgery. The operating room (OR) nurse, when going through the
client’s chart, realizes that the consent form has not been signed. Which of the following is the best action
for the nurse to take?
a.    Assume it is emergency surgery and the consent is implied
b.    Give the consent form and have the client sign it
c.    Tell the physician that the consent form is not signed
d.    Have a family member sign the consent form

22.    Ms. R is a client on your medical-surgical unit. His cousin is a physician and wants to see the chart.
Which of the following is the best response for the nurse to take?
a.    Hand the cousin the client’s chart to review
b.    Ask Ms. R to sign an authorization, and have someone review the chart with the cousin
c.    Call the attending physician and have the doctor speak with his cousin
d.    Tell the cousin that the request cannot be granted

23.    Ms. R has had both wrists restrained because she is agitated and pulls out her IV lines. Which of
the following would the nurse observe if Ms. R is not suffering any ill effects from the restraints? That:
a.    She has difficulty moving her fingers and making a fist
b.    Her skin is reddened where the limits were tied around her wrist
c.    Ms. R’s capillary refill is less than two seconds
d.    The client complains of numbness and tingling in her hand

24.    The nurse is in the hospital’s public cafeteria and hears two nursing assistants talking about Ms. R
in 406. They are using her name and discussing intimate details about her illness. Which of the following
actions is best for the nurse to take?
a.    Go over and tell the nursing assistants that their actions are inappropriate, especially in  public place
b.    Wait and tell the assistants later that they were overheard discussing the client. Otherwise, they
might be embarrassed.
c.    Tell the nursing assistants’ supervisor about the incident. It is the supervisor’s responsibility to
address the issue
d.    Say nothing. It is not the nurse’s job and she is not responsible for the assistants’ actions

25.    A nurse comes up a motor vehicle accident when driving to work. The nurse administers care to the
people involved. Under the Good Samaritan Act, the nurse could be liable:
a.    For nothing, any action is covered
b.    For gross negligence
c.    For not providing the standard care found in the hospital
d.    For not stopping and offering care
MEDICAL SURGICAL NURSING NCLEX QUESTIONS

1. Following surgery, Mario complains of mild incisional pain while performing deep- breathing
and coughing exercises. The nurse’s best response would be:

A. “Pain will become less each day.”

B. “This is a normal reaction after surgery.”
C. “With a pillow, apply pressure against the incision.”
D. “I will give you the pain medication the physician ordered.”

2. The nurse needs to carefully assess the complaint of pain of the elderly because older people

A. are expected to experience chronic pain

B. have a decreased pain threshold
C. experience reduced sensory perception
D. have altered mental function

3. Mary received AtropineSO4 as a pre-medication 30 minutes ago and is now complaining of dry
mouth and her PR is higher, than before the medication was administered. The nurse’s best

A. The patient is having an allergic reaction to the drug.

B. The patient needs a higher dose of this drug
C. This is normal side-effect of AtSO4
D. The patient is anxious about upcoming surgery

4. Ana’s postoperative vital signs are a blood pressure of 80/50 mm Hg, a pulse of 140, and
respirations of 32. Suspecting shock, which of the following orders would the nurse question?

A.Put the client in modified Trendelenberg’s position.

B. Administer oxygen at 100%.
C. Monitor urine output every hour.
D. Administer Demerol 50mg IM q4h

5. Mr. Pablo, diagnosed with Bladder Cancer, is scheduled for a cystectomy with the creation of
an ileal conduit in the morning. He is wringing his hands and pacing the floor when the nurse
enters his room. What is the best approach?

A. "Good evening, Mr. Pablo. Wasn’t it a pleasant day, today?"

B. "Mr, Pablo, you must be so worried, I’ll leave you alone with your thoughts.
C. “Mr. Pablo, you’ll wear out the hospital floors and yourself at this rate."
D. "Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow’s surgery?"

6. After surgery, Gina returns from the Post-anesthesia Care Unit (Recovery Room) with a
nasogastric tube in place following a gall bladder surgery. She continues to complain of nausea.
Which action would the nurse take?

A. Call the physician immediately.

B. Administer the prescribed antiemetic.
C. Check the patency of the nasogastric tube for any obstruction.
D. Change the patient’s position.
7. Mr. Perez is in continuous pain from cancer that has metastasized to the bone. Pain medication
provides little relief and he refuses to move. The nurse should plan to:

A. Reassure him that the nurses will not hurt him

B. Let him perform his own activities of daily living
C. Handle him gently when assisting with required care
D. Complete A.M. care quickly as possible when necessary

8. A client returns from the recovery room at 9AM alert and oriented, with an IV infusing. His pulse
is 82, blood pressure is 120/80, respirations are 20, and all are within normal range. At 10 am and
at 11 am, his vital signs are stable. At noon, however, his pulse rate is 94, blood pressure is
116/74, and respirations are 24. What nursing action is most appropriate?

A. Notify his physician.

B. Take his vital signs again in 15 minutes.
C. Take his vital signs again in an hour.
D. Place the patient in shock position.

9. A 56 year old construction worker is brought to the hospital unconscious after falling from a 2-
story building. When assessing the client, the nurse would be most concerned if the assessment
revealed:

A. Reactive pupils
B. A depressed fontanel
C. Bleeding from ears
D. An elevated temperature

10. Which of the ff. statements by the client to the nurse indicates a risk factor for CAD?

A. “I exercise every other day.”

B. “My father died of Myasthenia Gravis.”
C. “My cholesterol is 180.”
D. “I smoke 1 1/2 packs of cigarettes per day.”

11. Mr. Braga was ordered Digoxin 0.25 mg. OD. Which is poor knowledge regarding this drug?

A. It has positive inotropic and negative chronotropic effects

B. The positive inotropic effect will decrease urine output
C. Toxixity can occur more easily in the presence of hypokalemia, liver and renal problems
D. Do not give the drug if the apical rate is less than 60 beats per minute.

12. Valsalva maneuver can result in bradycardia. Which of the following activities will not
stimulate Valsalva’s maneuver?

A. Use of stool softeners.

B. Enema administration
C. Gagging while toothbrushing.
D. Lifting heavy objects
13. The nurse is teaching the patient regarding his permanent artificial pacemaker. Which
information given by the nurse shows her knowledge deficit about the artificial cardiac
pacemaker?

A. take the pulse rate once a day, in the morning upon awakening
B. may be allowed to use electrical appliances
C. have regular follow up care
D. may engage in contact sports

14. A patient with angina pectoris is being discharged home with nitroglycerine tablets. Which of
the following instructions does the nurse include in the teaching?

A. “When your chest pain begins, lie down, and place one tablet under your tongue. If the pain
continues, take another tablet in 5 minutes.”
B. “Place one tablet under your tongue. If the pain is not relieved in 15 minutes, go to the
hospital.”
C. “Continue your activity, and if the pain does not go away in 10 minutes, begin taking the nitro
tablets one every 5 minutes for 15 minutes, then go lie down.”
D. “Place one Nitroglycerine tablet under the tongue every five minutes for three doses. Go to the
hospital if the pain is unrelieved.

15. A client with chronic heart failure has been placed on a diet restricted to 2000mg. of sodium
per day. The client demonstrates adequate knowledge if behaviors are evident such as not salting
food and avoidance of which food?

A. Whole milk
B. Canned sardines
C. Plain nuts
D. Eggs

16. A student nurse is assigned to a client who has a diagnosis of thrombophlebitis. Which action
by this team member is most appropriate?

A. Apply a heating pad to the involved site.

B. Elevate the client’s legs 90 degrees.
C. Instruct the client about the need for bed rest.
D. Provide active range-of-motion exercises to both legs at least twice every shift.

17. A client receiving heparin sodium asks the nurse how the drug works. Which of the following
points would the nurse include in the explanation to the client?

A. It dissolves existing thrombi.

B. It prevents conversion of factors that are needed in the formation of clots.
C. It inactivates thrombin that forms and dissolves existing thrombi.
D. It interferes with vitamin K absorption.
18. The nurse is conducting an education session for a group of smokers in a “stop smoking”
class. Which finding would the nurse state as a common symptom of lung cancer? :

A. Dyspnea on exertion
B. Foamy, blood-tinged sputum
C. Wheezing sound on inspiration
D. Cough or change in a chronic cough

19. Which is the most relevant knowledge about oxygen administration to a client with COPD?

A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.

B. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
C. Oxygen is administered best using a non-rebreathing mask
D. Blood gases are monitored using a pulse oximeter.

20. When suctioning mucus from a client’s lungs, which nursing action would be least
appropriate?

A. Lubricate the catheter tip with sterile saline before insertion.

B. Use sterile technique with a two-gloved approach
C. Suction until the client indicates to stop or no longer than 20 second
D. Hyperoxygenate the client before and after suctioning

21. Dr. Santos prescribes oral rifampin (Rimactane) and isoniazid (INH) for a client with a positive
Tuberculin skin test. When informing the client of this decision, the nurse knows that the purpose
of this choice of treatment is to

A. Cause less irritation to the gastrointestinal tract

B. Destroy resistant organisms and promote proper blood levels of the drugs
C. Gain a more rapid systemic effect
D. Delay resistance and increase the tuberculostatic effect

22. Mario undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted,
and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care
unit Mario is placed in Fowler’s position on either his right
side or on his back to

A. Reduce incisional pain.

B. Facilitate ventilation of the left lung.
C. Equalize pressure in the pleural space.
D. Increase venous return

23. A client with COPD is being prepared for discharge. The following are relevant instructions to
the client regarding the use of an oral inhaler EXCEPT

A. Breath in and out as fully as possible before placing the mouthpiece inside the mouth.
B. Inhale slowly through the mouth as the canister is pressed down
C. Hold his breath for about 10 seconds before exhaling
D. Slowly breath out through the mouth with pursed lips after inhaling the drug.
24. A client is scheduled for a bronchoscopy. When teaching the client what to expect afterward,
the nurse’s highest priority of information would be

A. Food and fluids will be withheld for at least 2 hours.

B. Warm saline gargles will be done q 2h.
C. Coughing and deep-breathing exercises will be done q2h.
D. Only ice chips and cold liquids will be allowed initially.

25. The nurse enters the room of a client with chronic obstructive pulmonary disease. The client’s
nasal cannula oxygen is running at a rate of 6 L per minute, the skin color is pink, and the
respirations are 9 per minute and shallow. What is the nurse’s best initial action?

A. Take heart rate and blood pressure.

B. Call the physician.
C. Lower the oxygen rate.
D. Position the client in a Fowler’s position.

26. The nurse is preparing her plan of care for her patient diagnosed with pneumonia. Which is the
most appropriate nursing diagnosis for this patient?

A. Fluid volume deficit

B. Decreased tissue perfusion.
C. Impaired gas exchange.
D. Risk for infection

27. A nurse at the weight loss clinic assesses a client who has a large abdomen and a rounded
face. Which additional assessment finding would lead the nurse to suspect that the client has
Cushing’s syndrome rather than obesity?

A. large thighs and upper arms

B. pendulous abdomen and large hips
C. abdominal striae and ankle enlargement
D. posterior neck fat pad and thin extremities

28. Which statement by the client indicates understanding of the possible side effects of
Prednisone therapy?

A. “I should limit my potassium intake because hyperkalemia is a side-effect of this drug.”

B. “I must take this medicine exactly as my doctor ordered it. I shouldn’t skip doses.”
C. “This medicine will protect me from getting any colds or infection.”
D. “My incision will heal much faster because of this drug.”

29. A client, who is suspected of having Pheochromocytoma, complains of sweating, palpitation

and headache. Which assessment is essential for the nurse to make first?

A. Pupil reaction
B. Hand grips
C. Blood pressure
D. Blood glucose
30. The nurse is attending a bridal shower for a friend when another guest, who happens to be a
diabetic, starts to tremble and complains of dizziness. The next best action for the nurse to take is
to:

A. Encourage the guest to eat some baked macaroni

B. Call the guest’s personal physician
C. Offer the guest a cup of coffee
D. Give the guest a glass of orange juice

31. An adult, who is newly diagnosed with Graves disease, asks the nurse, “Why do I need to take
Propanolol (Inderal)?” Based on the nurse’s understanding of the medication and Grave’s
disease, the best response would be:

A. “The medication will limit thyroid hormone secretion.”

B. “The medication limit synthesis of the thyroid hormones.”
C. “The medication will block the cardiovascular symptoms of Grave’s disease.”
D. “The medication will increase the synthesis of thyroid hormones.”

32. During the first 24 hours after thyroid surgery, the nurse should include in her care:

A. Checking the back and sides of the operative dressing

B. Supporting the head during mild range of motion exercise
C. Encouraging the client to ventilate her feelings about the surgery
D. Advising the client that she can resume her normal activities immediately

33. On discharge, the nurse teaches the patient to observe for signs of surgically induced
hypothyroidism. The nurse would know that the patient understands the teaching when she states
she should notify the MD if she develops:

A. Intolerance to heat
B. Dry skin and fatigue
C. Progressive weight gain
D. Insomnia and excitability

34. What is the best reason for the nurse in instructing the client to rotate injection sites for
insulin?

A. Lipodystrophy can result and is extremely painful

B. Poor rotation technique can cause superficial hemorrhaging
C. Lipodystrophic areas can result, causing erratic insulin absorption rates from these
D. Injection sites can never be reused

35. Which of the following would be inappropriate to include in a diabetic teaching plan?

A. Change position hourly to increase circulation

B. Inspect feet and legs daily for any changes
C. Keep legs elevated on 2 pillows while sleeping
D. Keep the insulin not in use in the refrigerator
36. Included in the plan of care for the immediate post-gastroscopy period will be:

A. Maintain NGT to intermittent suction

B. Assess gag reflex prior to administration of fluids
C. Assess for pain and medicate as ordered
D. Measure abdominal girth every 4 hours

37. Which description of pain would be most characteristic of a duodenal ulcer?

A. Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by food intake
B. RUQ pain that increases after meal
C. Sharp pain in the epigastric area that radiates to the right shoulder
D. A sensation of painful pressure in the midsternal area

38. The client underwent Billroth surgery for gastric ulcer. Post-operatively, the drainage from his
NGT is thick and the volume of secretions has dramatically reduced in the last 2 hours and the
client feels like vomiting. The most appropriate nursing action is to:

A. Reposition the NGT by advancing it gently NSS

B. Notify the MD of your findings
C. Irrigate the NGT with 50 cc of sterile
D. Discontinue the low-intermittent suction

39. After Billroth II Surgery, the client developed dumping syndrome. Which of the following
should the nurse exclude in the plan of care?

A. Sit upright for at least 30 minutes after meals

B. Take only sips of H2O between bites of solid food
C. Eat small meals every 2-3 hours
D. Reduce the amount of simple carbohydrate in the diet

40. The laboratory of a male patient with Peptic ulcer revealed an elevated titer of Helicobacter
pylori. Which of the following statements indicate an understanding of this data?

A. Treatment will include Ranitidine and Antibiotics

B. No treatment is necessary at this time
C. This result indicates gastric cancer caused by the organism
D. Surgical treatment is necessary

41. What instructions should the client be given before undergoing a paracentesis?

A. NPO 12 hours before procedure

B. Empty bladder before procedure
C. Strict bed rest following procedure
D. Empty bowel before procedure
42. The husband of a client asks the nurse about the protein-restricted diet ordered because of
advanced liver disease. What statement by the nurse would best explain the purpose of the diet?

A. “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the
digestive system.”
B. “The liver heals better with a high carbohydrates diet rather than protein.”
C. “Most people have too much protein in their diets. The amount of this diet is better for liver
healing.”
D. “Because of portal hyperemesis, the blood flows around the liver and ammonia made from
protein collects in the brain causing hallucinations.”

43. Which of the drug of choice for pain controls the patient with acute pancreatitis?

A. Morphine
B. NSAIDS
C. Meperidine
D. Codeine

44. Immediately after cholecystectomy, the nursing action that should assume the highest priority
is:

A. encouraging the client to take adequate deep breaths by mouth

B. encouraging the client to cough and deep breathe
C. changing the dressing at least BID
D. irrigate the T-tube frequently

45. A Sengstaken-Blakemore tube is inserted in the effort to stop the bleeding esophageal varices
in a patient with complicated liver cirrhosis. Upon insertion of the tube, the client complains of
difficulty of breathing. The first action of the nurse is to:

A. Deflate the esophageal balloon

B. Monitor VS
C. Encourage him to take deep breaths
D. Notify the MD

46. The client presents with severe rectal bleeding, 16 diarrheal stools a day, severe abdominal
pain, tenesmus and dehydration. Because of these symptoms the nurse should be alert for other
problems associated with what disease?

A. Chrons disease
B. Ulcerative colitis
C. Diverticulitis
D. Peritonitis

47. A client is being evaluated for cancer of the colon. In preparing the client for barium enema,
the nurse should:

A. Give laxative the night before and a cleansing enema in the morning before the test
B. Render an oil retention enema and give laxative the night before
C. Instruct the client to swallow 6 radiopaque tablets the evening before the study
D. Place the client on CBR a day before the study
48. The client has a good understanding of the means to reduce the chances of colon cancer
when he states:

A. “I will exercise daily.”

B. “I will include more red meat in my diet.”
C. “I will have an annual chest x-ray.”
D. “I will include more fresh fruits and vegetables in my diet.”

49. Days after abdominal surgery, the client’s wound dehisces. The safest nursing intervention
when this occurs is to

A. Cover the wound with sterile, moist saline dressing

B. Approximate the wound edges with tapes
C. Irrigate the wound with sterile saline
D. Hold the abdominal contents in place with a sterile gloved hand

50. An intravenous pyelogram reveals that Paulo, age 35, has a renal calculus. He is believed to
have a small stone that will pass spontaneously. To increase the chance of the stone passing, the
nurse would instruct the client to force fluids and to

A. Strain all urine.

B. Ambulate.
C. Remain on bed rest.
D. Ask for medications to relax him.
MATERNAL AND CHILD NCLEX QUESTIONS

1. A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of
the following would the nurse be alert?

a. Endometritis

b. Endometriosis

c. Salpingitis

d. Pelvic thrombophlebitis

2. A client at 36 weeks’ gestation is schedule for a routine ultrasound prior to an amniocentesis. After
teaching the client about the purpose for the ultrasound, which of the following client statements
would indicate to the nurse in charge that the client needs further instruction?

a. The ultrasound will help to locate the placenta

b. The ultrasound identifies blood flow through the umbilical cord

c. The test will determine where to insert the needle

d. The ultrasound locates a pool of amniotic fluid

3. While the postpartum client is receiving herapin for thrombophlebitis, which of the following drugs
would the nurse Mica expect to administer if the client develops complications related to heparin
therapy?

a. Calcium gluconate

b. Protamine sulfate

c. Methylegonovine (Methergine)

d. Nitrofurantoin (macrodantin)

4. When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in
charge would expect to do which of the following?

a. Turn the neonate every 6 hours

b. Encourage the mother to discontinue breast-feeding

c. Notify the physician if the skin becomes bronze in color

d. Check the vital signs every 2 to 4 hours

5. A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block
anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the
following locations identified by the client as the area of relief would indicate to the nurse that the
teaching was effective?

a. Back

b. Abdomen

c. Fundus

d. Perineum

6. The nurse is caring for a primigravida at about 2 months and 1 week gestation. After explaining self-
care measures for common discomforts of pregnancy, the nurse determines that the client
understands the instructions when she says:

a. “Nausea and vomiting can be decreased if I eat a few crackers before arising”

b. “If I start to leak colostrum, I should cleanse my nipples with soap and water”

c. “If I have a vaginal discharge, I should wear nylon underwear”

d. “Leg cramps can be alleviated if I put an ice pack on the area”

7. Thirty hours after delivery, the nurse in charge plans discharge teaching for the client about infant care.
By this time, the nurse expects that the phase of postpartal psychological adaptation that the client
would be in would be termed which of the following?

a. Taking in

b. Letting go

c. Taking hold

d. Resolution

8. A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells
the client that the usual treatment for partial placenta previa is which of the following?

a. Activity limited to bed rest

b. Platelet infusion

c. Immediate cesarean delivery

d. Labor induction with oxytocin

9. Nurse Julia plans to instruct the postpartum client about methods to prevent breast engorgement.
Which of the following measures would the nurse include in the teaching plan?

a. Feeding the neonate a maximum of 5 minutes per side on the first day

b. Wearing a supportive brassiere with nipple shields

c. Breast-feeding the neonate at frequent intervals

d. Decreasing fluid intake for the first 24 to 48 hours

10. When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands
opened, and begins to cry. The nurse interprets this reaction as indicative of which of the following
reflexes?

a. Startle reflex

b. Babinski reflex

c. Grasping reflex

d. Tonic neck reflex

11. A primigravida client at 25 weeks’ gestation visits the clinic and tells the nurse that her lower back
aches when she arrives home from work. The nurse should suggest that the client perform:

a. Tailor sitting

b. Leg lifting

c. Shoulder circling

d. Squatting exercises

12. Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red
bleeding on the diaper of a neonate who just had a circumcision?

a. Notify the neonate’s pediatrician immediately

b. Check the diaper and circumcision again in 30 minutes

c. Secure the diaper tightly to apply pressure on the site

d. Apply gently pressure to the site with a sterile gauze pad

13. Which of the following would the nurse Sandra most likely expect to find when assessing a pregnant
client with abruption placenta?

a. Excessive vaginal bleeding

b. Rigid, boardlike abdomen

c. Titanic uterine contractions

d. Premature rupture of membranes

14. While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes
contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following
would be the nurse’s most appropriate action?

a. Note the fetal heart rate patterns

b. Notify the physician immediately

c. Administer oxygen at 6 liters by mask

d. Have the client pant-blow during the contractions

15. A client tells the nurse, “I think my baby likes to hear me talk to him.” When discussing neonates and
stimulation with sound, which of the following would the nurse include as a means to elicit the best
response?

a. High-pitched speech with tonal variations

b. Low-pitched speech with a sameness of tone

c. Cooing sounds rather than words

d. Repeated stimulation with loud sounds

16. A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to
be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in?

a. Active phase

b. Latent phase

c. Expulsive phase

d. Transitional phase
17. A pregnant patient asks the nurse Kate if she can take castor oil for her constipation. How should the
nurse respond?

a. “Yes, it produces no adverse effect.”

b. “No, it can initiate premature uterine contractions.”

c. “No, it can promote sodium retention.”

d. “No, it can lead to increased absorption of fat-soluble vitamins.”

18. A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal bleeding
for the past 8 hours. She has passed several cloth. What is the primary nursing diagnosis for this
patient?

a. Knowledge deficit

b. Fluid volume deficit

c. Anticipatory grieving

d. Pain

19. Immediately after a delivery, the nurse-midwife assesses the neonate’s head for signs of molding.
Which factors determine the type of molding?

a. Fetal body flexion or extension

b. Maternal age, body frame, and weight

c. Maternal and paternal ethnic backgrounds

d. Maternal parity and gravidity

20. For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring
(EFM) device. What must occur before the internal EFM can be applied?

a. The membranes must rupture

b. The fetus must be at 0 station

c. The cervix must be dilated fully

d. The patient must receive anesthesia

21. A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in early
part of the first stage of labor. Her pain is likely to be most intense:

a. Around the pelvic girdle

b. Around the pelvic girdle and in the upper arms

c. Around the pelvic girdle and at the perineum

d. At the perineum

22. A female adult patient is taking a progestin-only oral contraceptive, or minipill. Progestin use may
increase the patient’s risk for:

a. Endometriosis

b. Female hypogonadism

c. Premenstrual syndrome

d. Tubal or ectopic pregnancy

23. A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms?

a. Proteinuria, headaches, vaginal bleeding

b. Headaches, double vision, vaginal bleeding

c. Proteinuria, headaches, double vision

d. Proteinuria, double vision, uterine contractions

24. Because cervical effacement and dilation are not progressing in a patient in labor, Dr. Smith orders
I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patient’s fluid intake and
output closely during oxytocin administration?

a. Oxytoxin causes water intoxication

b. Oxytocin causes excessive thirst

c. Oxytoxin is toxic to the kidneys

d. Oxytoxin has a diuretic effect

25. Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent
hypothermia. What is a common source of radiant heat loss?

a. Low room humidity

b. Cold weight scale

c. Cools incubator walls

d. Cool room temperature

26. After administering bethanechol to a patient with urine retention, the nurse in charge monitors the
patient for adverse effects. Which is most likely to occur?

a. Decreased peristalsis

b. Increase heart rate

c. Dry mucous membranes

d. Nausea and Vomiting

27. The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but
most difficult part of this stage?

a. Active phase

b. Complete phase

c. Latent phase

d. Transitional phase

28. After 3 days of breast-feeding, a postpartal patient reports nipple soreness. To relieve her discomfort,
the nurse should suggest that she:

a. Apply warm compresses to her nipples just before feedings

b. Lubricate her nipples with expressed milk before feeding

c. Dry her nipples with a soft towel after feedings

d. Apply soap directly to her nipples, and then rinse

29. The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should tell
the patient that she can expect to feel the fetus move at which time?

a. Between 10 and 12 weeks’ gestation

b. Between 16 and 20 weeks’ gestation

c. Between 21 and 23 weeks’ gestation

d. Between 24 and 26 weeks’ gestation

30. Normal lochial findings in the first 24 hours post-delivery include:

a. Bright red blood

b. Large clots or tissue fragments

c. A foul odor

d. The complete absence of lochia

31. Accompanied by her husband, a patient seeks admission to the labor and delivery area. The client
states that she is in labor, and says she attended the hospital clinic for prenatal care. Which question
should the nurse ask her first?

a. “Do you have any chronic illness?”

b. “Do you have any allergies?”

c. “What is your expected due date?”

d. “Who will be with you during labor?”

32. A patient is in the second stage of labor. During this stage, how frequently should the nurse in charge
assess her uterine contractions?

a. Every 5 minutes

b. Every 15 minutes

c. Every 30 minutes

d. Every 60 minutes
33. A patient is in last trimester of pregnancy. Nurse Jane should instruct her to notify her primary health
care provider immediately if she notices:

a. Blurred vision

b. Hemorrhoids

c. Increased vaginal mucus

d. Shortness of breath on exertion

34. The nurse in charge is reviewing a patient’s prenatal history. Which finding indicates a genetic risk
factor?

a. The patient is 25 years old

b. The patient has a child with cystic fibrosis

c. The patient was exposed to rubella at 36 weeks’ gestation

d. The patient has a history of preterm labor at 32 weeks’ gestation

35. A adult female patient is using the rhythm (calendar-basal body temperature) method of family
planning. In this method, the unsafe period for sexual intercourse is indicated by;

a. Return preovulatory basal body temperature

b. Basal body temperature increase of 0.1 degrees to 0.2 degrees on the 2 nd or 3rd day of cycle

c. 3 full days of elevated basal body temperature and clear, thin cervical mucus

d. Breast tenderness and mittelschmerz

36. During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement,
making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, the nurse in charge should
instruct the client to push the control button at which time?

a. At the beginning of each fetal movement

b. At the beginning of each contraction

c. After every three fetal movements

d. At the end of fetal movement

37. When evaluating a client’s knowledge of symptoms to report during her pregnancy, which statement
would indicate to the nurse in charge that the client understands the information given to her?

a. “I’ll report increased frequency of urination.”

b. “If I have blurred or double vision, I should call the clinic immediately.”

c. “If I feel tired after resting, I should report it immediately.”

d. “Nausea should be reported immediately.”

38. When assessing a client during her first prenatal visit, the nurse discovers that the client had a
reduction mammoplasty. The mother indicates she wants to breast-feed. What information should the
nurse give to this mother regarding breast-feeding success?

a. “It’s contraindicated for you to breast-feed following this type of surgery.”

b. “I support your commitment; however, you may have to supplement each feeding with
formula.”

c. “You should check with your surgeon to determine whether breast-feeding would be possible.”

d. “You should be able to breast-feed without difficulty.”

39. Following a precipitous delivery, examination of the client’s vagina reveals a fourth-degree laceration.
Which of the following would be contraindicated when caring for this client?

a. Applying cold to limit edema during the first 12 to 24 hours

b. Instructing the client to use two or more peripads to cushion the area

c. Instructing the client on the use of sitz baths if ordered

d. Instructing the client about the importance of perineal (Kegel) exercises

40. A client makes a routine visit to the prenatal clinic. Although she’s 14 weeks pregnant, the size of her
uterus approximates that in an 18- to 20-week pregnancy. Dr. Diaz diagnoses gestational
trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal:

a. an empty gestational sac.

b. grapelike clusters.

c. a severely malformed fetus.

d. an extrauterine pregnancy.
41. After completing a second vaginal examination of a client in labor, the nurse-midwife determines that
the fetus is in the right occiput anterior position and at –1 station. Based on these findings, the nurse-
midwife knows that the fetal presenting part is:

a. 1 cm below the ischial spines.

b. directly in line with the ischial spines.

c. 1 cm above the ischial spines.

d. in no relationship to the ischial spines.

42. Which of the following would be inappropriate to assess in a mother who’s breast-feeding?

a. The attachment of the baby to the breast.

b. The mother’s comfort level with positioning the baby.

c. Audible swallowing.

d. The baby’s lips smacking

43. During a prenatal visit at 4 months gestation, a pregnant client asks whether tests can be done to
identify fetal abnormalities. Between 18 and 40 weeks’ gestation, which procedure is used to detect
fetal anomalies?

a. Amniocentesis.

b. Chorionic villi sampling.

c. Fetoscopy.

d. Ultrasound

44. A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her
fetus. Her BPP score is 8. What does this score indicate?

a. The fetus should be delivered within 24 hours.

b. The client should repeat the test in 24 hours.

c. The fetus isn’t in distress at this time.

d. The client should repeat the test in 1 week.

45. A client who’s 36 weeks pregnant comes to the clinic for a prenatal checkup. To assess the client’s
preparation for parenting, the nurse might ask which question?

a. “Are you planning to have epidural anesthesia?”

b. “Have you begun prenatal classes?”

 c. “What changes have you made at home to get ready for the baby?”

d. “Can you tell me about the meals you typically eat each day?”

46. A client who’s admitted to labor and delivery has the following assessment findings: gravida 2 para 1,
estimated 40 weeks’ gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station.
Which of the following would be the priority at this time?

a. Placing the client in bed to begin fetal monitoring.

b. Preparing for immediate delivery.

c. Checking for ruptured membranes.

d. Providing comfort measures.

47. Nurse Roy is caring for a client in labor. The external fetal monitor shows a pattern of variable
decelerations in fetal heart rate. What should the nurse do first?

a. Change the client’s position.

b. Prepare for emergency cesarean section.

c. Check for placenta previa.

d. Administer oxygen

48. The nurse in charge is caring for a postpartum client who had a vaginal delivery with a midline
episiotomy. Which nursing diagnosis takes priority for this client?

a. Risk for deficient fluid volume related to hemorrhage

b. Risk for infection related to the type of delivery

c. Pain related to the type of incision

49. Which change would the nurse identify as a progressive physiological change in postpartum period?

a. Lactation

b. Lochia

c. Uterine involution

d. Diuresis
50. A 39-year-old at 37 weeks’ gestation is admitted to the hospital with complaints of vaginal bleeding
following the use of cocaine 1 hour earlier. Which complication is most likely causing the client’s
complaint of vaginal bleeding?

a. Placenta previa

b. Abruptio placentae

c. Ectopic pregnancy

d. Spontaneous abortion

51. A client with type 1 diabetes mellitus who’s a multigravida visits the clinic at 27 weeks gestation. The
nurse should instruct the client that for most pregnant women with type 1 diabetes mellitus:

a. Weekly fetal movement counts are made by the mother.

b. Contraction stress testing is performed weekly.

c. Induction of labor is begun at 34 weeks’ gestation.

d. Nonstress testing is performed weekly until 32 weeks’ gestation

52. When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this
drug is given to:

a. Prevent seizures

b. Reduce blood pressure

c. Slow the process of labor

d. Increase dieresis

53. What’s the approximate time that the blastocyst spends traveling to the uterus for implantation?

a. 2 days

b. 7 days

c. 10 days

d. 14 weeks
54. After teaching a pregnant woman who is in labor about the purpose of the episiotomy, which of the
following purposes stated by the client would indicate to the nurse that the teaching was effective?

a. Shortens the second stage of labor

b. Enlarges the pelvic inlet

c. Prevents perineal edema

d. Ensures quick placenta delivery

55. A primigravida client at about 35 weeks gestation in active labor has had no prenatal care and admits
to cocaine use during the pregnancy. Which of the following persons must the nurse notify?

a. Nursing unit manager so appropriate agencies can be notified

b. Head of the hospital’s security department

c. Chaplain in case the fetus dies in utero

d. Physician who will attend the delivery of the infant

56. When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum
period, the nurse in charge should include which of the following?

a. The vaccine prevents a future fetus from developing congenital anomalies

b. Pregnancy should be avoided for 3 months after the immunization

c. The client should avoid contact with children diagnosed with rubella

d. The injection will provide immunity against the 7-day measles.

57. A client with eclampsia begins to experience a seizure. Which of the following would the nurse in
charge do first?

a. Pad the side rails

b. Place a pillow under the left buttock

c. Insert a padded tongue blade into the mouth

d. Maintain a patent airway

58. While caring for a multigravida client in early labor in a birthing center, which of the following foods
would be best if the client requests a snack?

a. Yogurt

b. Cereal with milk

c. Vegetable soup

d. Peanut butter cookies

59. The multigravida mother with a history of rapid labor who us in active labor calls out to the nurse, “The
baby is coming!” which of the following would be the nurse’s first action?

a. Inspect the perineum

b. Time the contractions

c. Auscultate the fetal heart rate

d. Contact the birth attendant

60. While assessing a primipara during the immediate postpartum period, the nurse in charge plans to
use both hands to assess the client’s fundus to:

a. Prevent uterine inversion

b. Promote uterine involution

c. Hasten the puerperium period

d. Determine the size of the fundus