Nclex Test 02

NCLEX-RN Practice Quiz Test Bank #2 (75
Questions)
NCLEXRN-02-001
Question Tag: confusion
Question Category: Physiological Integrity, Reduction of Risk Potential
A 28-year-old male has been found wandering around in a confusing pattern. The male is
sweaty and pale. Which of the following tests is most likely to be performed first?
 A. Blood sugar check

 B. CT scan
 C. Blood cultures
 D. Arterial blood gases
Correct Answer: A. Blood sugar check
With a history of diabetes, the first response should be to check blood sugar levels.
Option B: Performing CT scan at this stage of assessment is unnecessary. A


computerized tomography (CT) scan combines a series of X-ray images taken
from different angles around the body and uses computer processing to
create cross-sectional images (slices) of the bones, blood vessels and soft
tissues inside the body. CT scan images provide more-detailed information
than plain X-rays do.
 Option C: A blood culture test helps the doctor figure out if the client has a
kind of infection that is in the bloodstream and can affect the entire body.
Doctors call this a systemic infection. The test checks a sample of the blood for
bacteria or yeast that might be causing the infection.
 Option D: An arterial blood gas (ABG) test measures oxygen and carbon
dioxide levels in the blood. It also measures the body’s acid-base (pH) level,
which is usually in balance when healthy.
NCLEXRN-02-002
Question Tag: toilet training

Question Category: Health Promotion and Maintenance
A mother is inquiring about her child’s ability to potty train. Which of the following factors
is the most important aspect of toilet training?
 A. The age of the child

 B. The child’s ability to understand instruction.
C. The overall mental and physical abilities of the child.
 D. Frequent attempts with positive reinforcement.
Correct Answer: C. The overall mental and physical abilities of the child.
Age is not the greatest factor in potty training. The overall mental and physical abilities of
the child are the most important factor.
Option A: Readiness for toilet training varies with every age of the child.

 Option B: A child who can follow simple instructions may start toilet training.
However, it is not considered as the most important factor.
 Option D: Positive reinforcement is a great tool for toilet training, yet, it may
not be the most important one.
NCLEXRN-02-003
Question Tag: poisoning
Question Category: Safety and infection Control
A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child
drank for 20 minutes. Which of the following is the most important instruction the nurse
can give the parent?
A. This too shall pass.

 B. Take the child immediately to the ER
 C. Contact the Poison Control Center quickly
 D. Give the child syrup of ipecac
Correct Answer: C. Contact the Poison Control Center quickly.
The poison control center will have an exact plan of action for this child.
Option A: Ingestion of a chemical is an emergency and should not be


delayed.
 Option B: Taking the client to the ER may be correct, however, they will still
have to contact the Poison Control Center.
 Option D: It should not be given to someone who swallowed chemicals that
cause burns on contact or medicines that can cause seizures very quickly. It
can be dangerous to people with some types of medical problems. When such
poisoning victims got Ipecac anyway, they developed serious complications or
even died.
NCLEXRN-02-004
Question Tag: vitamin K
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy
A nurse is administering a shot of Vitamin K to a 30 day-old infant. Which of the following
target areas is the most appropriate?
 A. Gluteus maximus
 B. Gluteus minimus
 C. Vastus lateralis
 D. Vastus medialis
Correct Answer: C. Vastus lateralis.
Medications are injected into the bulkiest part of the vastus lateralis thigh muscle, which is
the junction of the upper and middle thirds of this muscle.
Option A: Intramuscular injections given at the dorsogluteal and ventrogluteal


sites are intended for the gluteus maximus and gluteus medius muscles,
respectively. However, little research has confirmed the reliability of these sites
for the presence and thickness of the target and other muscles, and
subcutaneous fat.
 Option B: Never give an IM injection in the gluteal muscles to avoid the risk of
sciatica nerve damage.
 Option D: The vastus medialis muscle is a part of the quadriceps muscle
group, located on the front of the thigh.
NCLEXRN-02-005
Question Tag: toddler, language

Question Category: Safe and Effective Care Environment, Safety and Infection Control
A nurse has just started her rounds delivering medication. A new patient on her rounds is a
4-year-old boy who is non-verbal. This child does not have any identification on. What
should the nurse do?
 A. Contact the provider

 B. Ask the child to write their name on paper
 C. Ask a coworker about the identification of the child
 D. Ask the father who is in the room the child’s name
Correct Answer: D. Ask the father who is in the room the child’s name.
In this case, you can determine the name of the child by the father’s statement. You should
not withhold the medication from the child after identification.
 Option A: Contacting the provider is unnecessary and may take time. A

pediatric patient must have folks with them inside the room, so asking the
child’s folks would be the most appropriate intervention.
Option B: The child may have not yet developed his writing abilities. Some

children are able to write their names at age 4, but some typically developing
children still aren’t ready until well into age.
 Option C: Asking a coworker would be inappropriate and against patient’s
confidentiality.
NCLEXRN-02-006
Question Tag: hyperparathyroidism
A patient is admitted to the hospital with a diagnosis of primary hyperparathyroidism. A

nurse checking the patient’s lab results would expect which of the following changes in
laboratory findings?
 A. Elevated serum calcium

 B. Low serum parathyroid hormone (PTH)
 C. Elevated serum vitamin D
 D. Low urine calcium
Correct Answer: A. Elevated serum calcium.
The parathyroid glands regulate the calcium level in the blood. In hyperparathyroidism, the

serum calcium level will be elevated. The chronic excessive resorption of calcium from bone
caused by excessive parathyroid hormone can result in osteopenia.
Option B: Parathyroid hormone levels may be high or normal but not low. The

main effects of parathyroid hormone are to increase the concentration of
plasma calcium by increasing the release of calcium and phosphate from bone
matrix, increasing calcium reabsorption by the kidney, and increasing renal
production of 1,25-dihydroxyvitamin D-3 (calcitriol), which increases intestinal
absorption of calcium.
 Option C: The body will lower the level of vitamin D in an attempt to lower
calcium. Vitamin D levels should be measured in the evaluation of primary
hyperparathyroidism. Vitamin D deficiency (a 25-hydroxyvitamin D level of less
than 20 ng per milliliter) can cause secondary hyperparathyroidism, and
repletion of vitamin D deficiency can help to reduce parathyroid hormone
levels.
 Option D: Urine calcium may be elevated, with calcium spilling over from
elevated serum levels. This may cause renal stones. In addition, the chronically
increased excretion of calcium in the urine can predispose to the formation of
renal stones.
NCLEXRN-02-007
Question Tag: Addison’s disease

A patient with Addison’s disease asks a nurse for nutrition and diet advice. Which of the
following diet modifications is not recommended?
 A. A diet high in grains

 B. A diet with adequate caloric intake
 C. A high protein diet
 D. A restricted sodium diet
Correct Answer: D. A restricted sodium diet.
A patient with Addison’s disease requires normal dietary sodium to prevent excess fluid
loss. Patients should eat an unrestricted diet. Those with primary adrenal insufficiency
(Addison disease) should have ample access to salt because of the salt wasting that occurs
if their condition is untreated. Infants with primary adrenal insufficiency often need 2-4 g of
sodium chloride per day.
Option A: A well-balanced diet is the best way to keep the body healthy and

to regulate sugar levels. Doctors recommend balancing protein, healthy fats,
and high-quality, nutrient-dense carbohydrates.
 Option B: High-calorie comfort food reduces symptoms of neuroglycopenia
in Addison patients, suggesting that Addison’s disease is associated with a
deficit in cerebral energy supply that can partly be alleviated by intake of
palatable food.
 Option C: Healthy fats and high-quality proteins slow the blood sugar
rollercoaster and promote stable blood sugar levels throughout the day.
NCLEXRN-02-008
Question Tag: diabetes mellitus, cholecystectomy

Question Category: Physiological Integrity, Physiological Adaptation
A patient with a history of diabetes mellitus is on the second postoperative day following
cholecystectomy. She has complained of nausea and isn’t able to eat solid foods. The nurse
enters the room to find the patient confused and shaky. Which of the following is
the most likely explanation for the patient’s symptoms?
 A. Anesthesia reaction
 B. Hyperglycemia
 C. Hypoglycemia
 D. Diabetic ketoacidosis
Correct Answer: C. Hypoglycemia
A postoperative diabetic patient who is unable to eat is likely to be suffering from

hypoglycemia. Confusion and shakiness are common symptoms. Reduction in cerebral
glucose availability (ie, neuroglycopenia) can manifest as confusion, difficulty with
concentration, irritability, hallucinations, focal impairments (eg, hemiplegia), and,
eventually, coma and death.
Option A: An anesthesia reaction would not occur on the second


postoperative day. The adrenergic symptoms often precede the
neuroglycopenic symptoms and, thus, provide an early warning system for the
patient. Studies have shown that the primary stimulus for the release of
catecholamines is the absolute level of plasma glucose; the rate of decrease of
glucose is less important.
 Option B: Neuropathy affects up to 50% of patients with type 1 DM, but
symptomatic neuropathy is typically a late development, developing after
many years of chronic prolonged hyperglycemia. Peripheral neuropathy
presents as numbness and tingling in both hands and feet, in a glove-and-
stocking pattern; it is bilateral, symmetric, and ascending.
 Option D: Symptoms of hyperglycemia associated with diabetic ketoacidosis
may include thirst, polyuria, polydipsia, and nocturia.
NCLEXRN-02-009
Question Tag: fiberoptic colonoscopy
A nurse assigned to the emergency department evaluates a patient who underwent

fiberoptic colonoscopy 18 hours previously. The patient reports increasing abdominal pain,
fever, and chills. Which of the following conditions poses the most immediate concern?
 A. Bowel perforation
 B. Viral Gastroenteritis
 C. Colon cancer
 D. Diverticulitis
Correct Answer: A. Bowel perforation.
Bowel perforation is the most serious complication of fiberoptic colonoscopy. Important

signs include progressive abdominal pain, fever, chills, and tachycardia, which indicate
advancing peritonitis. One of the most serious complications of colonoscopy is endoscopic
perforation of the colon, which has been reported as between 0.03% and 0.7%. Although
colonoscopic perforation (CP) occurs rarely, it can be associated with high mortality and
morbidity rates.
 Option B: Viral gastroenteritis is a known cause of nausea, vomiting, diarrhea,

anorexia, weight loss, and dehydration. Isolated cases can occur, but viral
gastroenteritis more commonly occurs in outbreaks within close communities
such as daycare centers, nursing facilities, and cruise ships. Many different
viruses can lead to symptomatology, though in routine clinical practice the
true causative virus is generally not identified.
Option C: If the patient is age 50 or older and at average risk of colon cancer

— he has no colon cancer risk factors other than age — the doctor may
recommend a colonoscopy every 10 years or sometimes sooner to screen for
colon cancer. Colonoscopy is one option for colon cancer screening.
 Option D: Diverticulitis may cause pain, fever, and chills, but is far less serious
than perforation and peritonitis.
NCLEXRN-02-010
Question Tag: liver biopsy, coagulation

A patient is admitted to the same-day surgery unit for a liver biopsy. Which of the
following laboratory tests assesses coagulation? Select all that apply.
 A. Partial thromboplastin time

 B. Prothrombin time
 C. Platelet count
 D. Hemoglobin
Correct Answer: A, B, and C.
Prothrombin time, partial thromboplastin time, and platelet count are all included in
coagulation studies.
 Option A: The partial thromboplastin time (PTT; also known as activated

partial thromboplastin time (aPTT)) is a screening test that helps evaluate a
person’s ability to appropriately form blood clots. It measures the number of
seconds it takes for a clot to form in a sample of blood after substances
(reagents) are added.
 Option B: Prothrombin time (PT) is a blood test that measures how long it
takes blood to clot. A prothrombin time test can be used to check for bleeding
problems. PT is also used to check whether medicine to prevent blood clots is
working.
 Option C: Platelets, also called thrombocytes, are tiny fragments of cells that
are essential for normal blood clotting. They are formed from very large cells
called megakaryocytes in the bone marrow and are released into the blood to
circulate. The platelet count is a test that determines the number of platelets
in a sample of blood.
 Option D: The hemoglobin level, though important information prior to an
invasive procedure like liver biopsy, does not assess coagulation.
NCLEXRN-02-011
Question Tag: hepatitis A
A nurse is assessing a clinic patient with a diagnosis of hepatitis A. Which of the following
is the most likely route of transmission?
 A. Sexual contact with an infected partner

 B. Contaminated food
 C. Blood transfusion
 D. Illegal drug use
Correct Answer: B. Contaminated food.
Hepatitis A is the only type that is transmitted by the fecal-oral route through
contaminated food. HAV is a single-stranded, positive-sense, linear RNA enterovirus of the
Picornaviridae family. In humans, viral replication depends on hepatocyte uptake and
synthesis, and assembly occurs exclusively in the liver cells. Virus acquisition results almost
exclusively from ingestion (eg, fecal-oral transmission)
Option A: Hepatitis B infection, caused by the hepatitis B virus (HBV), is


commonly transmitted via body fluids such as blood, semen, and vaginal
secretions. [1] Consequently, sexual contact, accidental needle sticks or sharing
of needles, blood transfusions, and organ transplantation are routes for HBV
infection.
 Option C: Before widespread screening of the blood supply in 1992, hepatitis
C was also spread through blood transfusions and organ transplants. Now, the
risk of transmission to recipients of blood or blood products is extremely low.
 Option D: Today, most people become infected with hepatitis B, C, or D by
sharing needles, syringes, or any other equipment used to prepare and inject
drugs.
NCLEXRN-02-012
Question Tag: leukemia, blood transfusion

A leukemia patient has a relative who wants to donate blood for transfusion. Which of the
following donor medical conditions would prevent this?
 A. A history of hepatitis C five years previously

 B. Cholecystitis requiring cholecystectomy one year previously
 C. Asymptomatic diverticulosis
 D. Crohn’s disease in remission
Correct Answer: A. A history of hepatitis C five years previously
Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing
inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion
due to the high risk of infection in the recipient.
Option B: Cholecystitis is the inflammation of the gallbladder. This condition


does not transmit through bodily fluids.
 Option C: Diverticulosis is when pockets called diverticula form in the wall of
the digestive tract. The inner layer of the intestine pushes through weak spots
in the outer lining. This pressure makes them bulge out, making little pouches.
 Option D: Crohn’s disease is an inflammatory bowel disease. It causes
inflammation of the digestive tract. This disease does not transmit through the
blood.
NCLEXRN-02-013
Question Tag: acute gastritis

A physician has diagnosed acute gastritis in a clinic patient. Which of the following
medications would be contraindicated for this patient?
A. Naproxen sodium (Naprosyn)

 B. Calcium carbonate
 C. Clarithromycin (Biaxin)
 D. Furosemide (Lasix)
Correct Answer: A. Naproxen sodium (Naprosyn).
Naproxen sodium is a nonsteroidal anti-inflammatory drug that can cause inflammation of

the upper GI tract. For this reason, it is contraindicated in a patient with gastritis. Naproxen
is used to relieve pain from various conditions such as headache, muscle aches, tendonitis,
dental pain, and menstrual cramps. It also reduces pain, swelling, and joint stiffness caused
by arthritis, bursitis, and gout attacks.
 Option B: Calcium carbonate is used as an antacid for the relief of indigestion

and is not contraindicated. Calcium carbonate is a dietary supplement used
when the amount of calcium taken in the diet is not enough. Calcium is
needed by the body for healthy bones, muscles, nervous system, and heart.
Calcium carbonate also is used as an antacid to relieve heartburn, acid
indigestion, and upset stomach. It is available with or without a prescription.
 Option C: Clarithromycin is an antibacterial often used for the treatment of
Helicobacter pylori in gastritis. Clarithromycin is used to treat certain bacterial
infections, such as pneumonia (a lung infection), bronchitis (infection of the
tubes leading to the lungs), and infections of the ears, sinuses, skin, and throat.
It also is used to treat and prevent disseminated Mycobacterium avium
complex (MAC) infection [a type of lung infection that often affects people
with human immunodeficiency virus (HIV)]. It is used in combination with
other medications to eliminate H. pylori, a bacterium that causes ulcers.
Clarithromycin is in a class of medications called macrolide antibiotics. It works
by stopping the growth of bacteria.
 Option D: Furosemide is a loop diuretic and is not contraindicated in a patient
with gastritis. Furosemide is used alone or in combination with other
medications to treat high blood pressure. Furosemide is used to treat edema
(fluid retention; excess fluid held in body tissues) caused by various medical
problems, including heart, kidney, and liver disease. Furosemide is in a class of
medications called diuretics (‘water pills’). It works by causing the kidneys to
get rid of unneeded water and salt from the body into the urine.
NCLEXRN-02-014
Question Tag: cholecystitis
The nurse is conducting nutrition counseling for a patient with cholecystitis. Which of the
following information is important to communicate?
 A. The patient must maintain a low-calorie diet

 B. The patient must maintain a high protein/low carbohydrate diet.
 C. The patient should limit sweets and sugary drinks.
 D. The patient should limit fatty foods.
Correct Answer: D. The patient should limit fatty foods.
Cholecystitis, inflammation of the gallbladder, is most commonly caused by the presence

of gallstones, which may block bile (necessary for fat absorption) from entering the
intestines. Patients should decrease dietary fat by limiting foods like fatty meats, fried
foods, and creamy desserts to avoid irritation of the gallbladder.
Option A: The patient may maintain a moderate to high calorie diet, as a very

low-calorie diet may increase the risk for gallstones that predisposes to
cholecystitis .
 Option B: Both animal fat and animal protein may contribute to the formation
of gallstones. Vitamin C, which is abundant in plants and absent from meat
affects the rate-limiting step in the catabolism of cholesterol to bile acids and
is inversely related to the risk of gallstones and cholecystitis.Individuals
consuming the most refined carbohydrates have a 60% greater risk for
developing gallstones, compared with those who consumed the least.
 Option C: Replacing sugary drinks with drinks high in fiber would reduce the
risk of gallbladder stones by 15%.
NCLEXRN-02-015
Question Tag: myocardial infarction, pulmonary edema
A patient admitted to the hospital with myocardial infarction develops severe pulmonary
edema. Which of the following symptoms should the nurse expect the patient to exhibit?
 A. Slow, deep respirations

 B. Stridor
 C. Bradycardia
 D. Air hunger
Correct Answer: D. Air hunger.
Patients with pulmonary edema experience air hunger, anxiety, and agitation. Symptoms
may also include coughing up blood or bloody froth; difficulty breathing when lying down
(orthopnea); feeling of “air hunger” or “drowning” (this feeling is called “paroxysmal
nocturnal dyspnea” if it causes you to wake up 1 to 2 hours after falling asleep and struggle
to catch your breath).
Option A: Physical findings in patients with pulmonary edema are notable for

tachypnea and tachycardia. Patients may be sitting upright, they may
demonstrate air hunger, and they may become agitated and confused.
Patients usually appear anxious and diaphoretic.
 Option B: Auscultation of the lungs usually reveals fine, crepitant rales, but
rhonchi or wheezes may also be present. Rales are usually heard at the bases
first; as the condition worsens, they progress to the apices.
 Option C: Cardiovascular findings are usually notable for S3, accentuation of
the pulmonic component of S2, and jugular venous distention. Auscultation of
murmurs can help in the diagnosis of acute valvular disorders manifesting with
pulmonary edema.
NCLEXRN-02-016
Question Tag: cardioverter-defibrillator
A nurse caring for several patients in the cardiac unit is told that one is scheduled for
implantation of an automatic internal cardioverter-defibrillator. Which of the following
patients is most likely to have this procedure?
 A. A patient admitted for myocardial infarction without cardiac muscle

damage.
 B. A postoperative coronary bypass patient, recovering on schedule.
 C. A patient with a history of ventricular tachycardia and syncopal episodes.
 D. A patient with a history of atrial tachycardia and fatigue.
Correct Answer: C. A patient with a history of ventricular tachycardia and syncopal
episodes.
An automatic internal cardioverter-defibrillator delivers an electric shock to the heart to

terminate episodes of ventricular tachycardia and ventricular fibrillation. This is necessary
for a patient with significant ventricular symptoms, such as tachycardia resulting in
syncope.
Option A: A patient with myocardial infarction that resolved with no


permanent cardiac damage would not be a candidate.
 Option B: A patient recovering well from coronary bypass would not need the
device.
 Option D: Atrial tachycardia is less serious and is treated conservatively with
medication and cardioversion as a last resort.
NCLEXRN-02-017
Question Tag: MRI, lung cancer

A patient is scheduled for a magnetic resonance imaging (MRI) scan for suspected lung
cancer. Which of the following is a contraindication to the study for this patient?
 A. The patient is allergic to shellfish.

 B. The patient has a pacemaker.
 C. The patient suffers from claustrophobia.
 D. The patient takes antipsychotic medication.
Correct Answer: B. The patient has a pacemaker.
The implanted pacemaker will interfere with the magnetic fields of the MRI scanner and
may be deactivated by them. Patients with cardiac implantable electronic devices or CIED
are at risk for inappropriate device therapy, device heating/movement, and arrhythmia
during MRI. These patients must be scheduled in a CIED blocked slot or scheduled with
electrophysiology nurse or technician support. But nowadays MRI conditional cardiac
implantable electronic devices are widely available.
 Option A: Shellfish/iodine allergy is not a contraindication because the

contrast used in MRI scanning is not iodine-based. MRI contrast agents are
gadolinium chelates with different stability, viscosity, and osmolality.
Gadolinium is a relatively very safe contrast; however, it rarely might cause
allergic reactions in patients.
 Options C: Open MRI scanners and anti-anxiety medications are available for
patients with claustrophobia. Claustrophobic patients might refuse to
complete the MRI scan and need sedation. These patients need to be well
informed about the MRI scan procedure. The recommendation is that a
physician has a discussion with them about the details in advance. Using
Larger and opener MRI systems might be helpful in claustrophobic patients.
 Option D: Psychiatric medication is not a contraindication to MRI scanning.
MRI helps in high-resolution investigations of soft tissues without the use of
ionizing radiation. This safe modality currently becomes the imaging
technique of choice for diagnosing musculoskeletal, neurologic, and
cardiovascular disease. However, there are restrictions and contraindications
caused by MRI magnetic fields, machine structure, and gadolinium contrast
agents.
NCLEXRN-02-018
Question Tag: pulmonary embolism

A nurse calls a physician with the concern that a patient has developed a pulmonary
embolism. Which of the following symptoms has the nurse most likely observed?
 A. The patient is somnolent with decreased response to the family.

 B. The patient suddenly complains of chest pain and shortness of breath.
 C. The patient has developed a wet cough and the nurse hears crackles on
auscultation of the lungs.
 D. The patient has a fever, chills, and loss of appetite.
Correct Answer: B. The patient suddenly complains of chest pain and shortness of
breath.
Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and
severe anxiety. The physician should be notified immediately. Clinical signs and symptoms
for pulmonary embolism are nonspecific; therefore, patients suspected of having
pulmonary embolism—because of unexplained dyspnea, tachypnea, or chest pain or the
presence of risk factors for pulmonary embolism—must undergo diagnostic tests until the
diagnosis is ascertained or eliminated or an alternative diagnosis is confirmed.
Option A: The patient may present atypical symptoms based on risk factors,

such as delirium or decreasing level of consciousness.
 Option B: The diagnosis of pulmonary embolism should be sought actively in
patients with respiratory symptoms unexplained by an alternative diagnosis;
symptoms may include productive cough and wheezing.
 Option D: A patient with fever, chills, and loss of appetite may be developing
pneumonia. Fever of less than 39°C (102.2ºF) may be present in 14% of
patients; however, temperature higher than 39.5°C (103.1º) F is not from
pulmonary embolism.
NCLEXRN-02-019
Question Tag: abdominal aortic aneurysm
A patient comes to the emergency department with abdominal pain. Work-up reveals the
presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions
should the nurse expect?
 A. The patient will be admitted to the medicine unit for observation and
medication.
 B. The patient will be admitted to the day surgery unit for sclerotherapy.
 C. The patient will be admitted to the surgical unit and resection will be
scheduled.
 D. The patient will be discharged home to follow-up with his cardiologist in 24
hours.
Correct Answer: C. The patient will be admitted to the surgical unit and resection will
be scheduled.
A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture and should
be resected as soon as possible. No other appropriate treatment options currently exist.
Option A: Admitting the patient for observation will be a delay and may result

in the rupture of the aneurysm. Immediate surgery is the only recommended
management.
 Option B: Sclerotherapy, in which a solution is injected into a vein, causing it
to collapse, scar, and fade, remains the primary treatment for small-vessel
varicose disease of the lower extremities.
 Option D: The patient should not be discharged because the abdominal
aneurysm may rupture at any time and place the patient’s life at risk.
NCLEXRN-02-020
Question Tag: leukemia, chemotherapy, platelet count

A patient with leukemia is receiving chemotherapy that is known to depress bone marrow.
A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the
following actions related specifically to the platelet count should be included in the nursing
care plan?
 A. Monitor for fever every 4 hours.

 B. Require visitors to wear respiratory masks and protective clothing.
 C. Consider transfusion of packed red blood cells.
 D. Check for signs of bleeding, including examination of urine and stool for
blood.
Correct Answer: D. Check for signs of bleeding, including examination of urine and
stool for blood.
A platelet count of 25,000/microliter is severely thrombocytopenic and should prompt the

initiation of bleeding precautions, including monitoring urine and stool for evidence of
bleeding.
Option A: According to three retrospective case reviews of childhood


leukemia (in which 75% to 100% of the cases were acute lymphoblastic
leukemia), common presenting signs and symptoms include fever (17% to
77%), lethargy (12% to 39%), and bleeding (10% to
45%).
 Option B: Requiring protective clothing is indicated to prevent infection if
white blood cells are decreased. Protective garments consisting of gloves,
chemotherapy gowns, eye protection e.g.; goggles, N95 respirator, and shoe
covers will be worn according to the task being performed with a
Chemotherapy/Biotherapy agent or excreta of a patient who has received a
Chemotherapy/Biotherapy agent within the last 48 hours.
 Option C: Transfusion of red cells is indicated for severe anemia. Blood
transfusions represent one of the most important forms of supportive care for
patients with leukaemia. Cancer is the major cause of transfusion. One third of
transfused patients have a malignant disease, with acute leukaemia being the
malignancy in a large part of them.
NCLEXRN-02-021
Question Tag: increased intracranial pressure

A nurse in the emergency department is observing a 4-year-old child for signs of increased
intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the
following signs or symptoms would be cause for concern?
A. Bulging anterior fontanel


 B. Repeated vomiting
 C. Signs of sleepiness at 10 PM
 D. Inability to read short words from a distance of 18 inches
Correct Answer: B. Repeated vomiting.
Increased pressure caused by bleeding or swelling within the skull can damage delicate
brain tissue and may become life-threatening. Repeated vomiting can be an early sign of
pressure as the vomiting center within the medulla is stimulated.
 Option A: The anterior fontanel is closed in a 4-year-old child. The average

closure time of the anterior fontanelle ranges from 13 to 24 months. Infants of
African descent statically have larger fontanelles that range from 1.4 to 4.7 cm,
and in terms of sex, the fontanelles of male infants will closer sooner
compared to female infants.
 Option C: Evidence of sleepiness at 10 PM is normal for a four-year-old.
Young toddlers have a sleep schedule supplemented by two naps a day.
Toddler sleep problems are compounded by separation anxiety and a fear of
missing out, which translates to stalling techniques and stubbornness at
bedtime.
 Option D: The average 4-year-old child cannot read yet, so this too is normal.
At 4, many children just aren’t ready to sit still and focus on a book for long.
Others may learn the mechanics of reading but aren’t cognitively ready to
comprehend the words.
NCLEXRN-02-022
Question Tag: rubeola
A nonimmunized child appears at the clinic with a visible rash. Which of the following
observations indicates the child may have rubeola (measles)?
 A. Small blue-white spots are visible on the oral mucosa.

 B. The rash begins on the trunk and spreads outward.
 C. There is low-grade fever.
 D. The lesions have a “teardrop-on-a-rose-petal” appearance.
Correct Answer: A. Small blue-white spots are visible on the oral mucosa.
Koplik’s spots are small blue-white spots visible on the oral mucosa and are characteristic
of measles infection. Near the end of the prodrome, Koplik spots (ie, bluish-gray specks or
“grains of sand” on a red base) appear on the buccal mucosa opposite the second molars.
The Koplik spots generally are first seen 1-2 days before the appearance of the rash and
last until 2 days after the rash appears. This enanthem begins to slough as the rash
appears. Although this is the pathognomonic enanthem of measles, its absence does not
exclude the diagnosis.
 Option B: The body rash typically begins on the face and travels downward.
Blanching, erythematous macules and papules begin on the face at the
hairline, on the sides of the neck, and behind the ears (see the images below).
Within 48 hours, they coalesce into patches and plaques that spread
cephalocaudally to the trunk and extremities, including the palms and soles,
while beginning to regress cephalocaudally, starting from the head and neck.
Lesion density is greatest above the shoulders, where macular lesions may
coalesce. The eruption may also be petechial or ecchymotic in nature.
 Option C: High fever (may spike to more than 104°F) is often present. The first
sign of measles is usually a high fever (often >104 o F [40o C]) that typically lasts
4-7 days. This prodromal phase is marked by malaise, fever, anorexia, and the
classic triad of conjunctivitis (see the image below), cough, and coryza (the “3
Cs”).
 Option D: “Teardrop on a rose petal” refers to the lesions found in varicella
(chickenpox). The characteristic chicken pox vesicle, surrounded by an
erythematous halo, is described as a dewdrop on a rose petal
NCLEXRN-02-023
Question Tag: scarlet fever

Question Category: Physiological Adaptation
A child is seen in the emergency department for scarlet fever. Which of the following
descriptions of scarlet fever is not correct?
 A. Scarlet fever is caused by infection with group A Streptococcus bacteria.

 B. “Strawberry tongue” is a characteristic sign.
 C. Petechiae occur on the soft palate.
 D. The pharynx is red and swollen.
Correct Answer: C. Petechiae occur on the soft palate.
Petechiae on the soft palate are characteristic of rubella infection.
Option A: Bacteria called group A Streptococcus or group A strep cause


scarlet fever. The bacteria sometimes make a poison (toxin), which causes a
rash- the “scarlet” of scarlet fever. As the name “scarlet fever” implies, an
erythematous eruption is associated with a febrile illness. The circulating toxin,
produced by GABHS and often referred to as erythemogenic or erythrogenic
toxin, causes the pathognomonic rash as a consequence of local production of
inflammatory mediators and alteration of the cutaneous cytokine milieu. This
results in a sparse inflammatory response and dilatation of blood vessels,
leading to the characteristic scarlet color of the rash.
 Option B: The tongue may have a “strawberry”-like (red and bumpy)
appearance, which is a characteristic sign of scarlet fever. On day 1 or 2, the
tongue is heavily coated with a white membrane through which edematous
red papillae protrude (classic appearance of white strawberry tongue). By day
4 or 5, the white membrane sloughs off, revealing a shiny red tongue with
prominent papillae (red strawberry tongue). Red, edematous,
exudative tonsils are typically observed if the infection originates in this area.
 Option D: The throat and tonsils may be very red and sore with scarlet fever,
and swallowing may be painful. The mucous membranes usually are bright
red, and scattered petechiae and small red papular lesions on the soft palate
are often present.
NCLEXRN-02-024
Question Tag: allergic reaction, diphenhydramine
A child weighing 30 kg arrives at the clinic with diffuse itching as the result of an allergic
reaction to an insect bite. Diphenhydramine (Benadryl) 25 mg 3 times a day is prescribed.
The correct pediatric dose is 5 mg/kg/day. Which of the following best describes the
prescribed drug dose?
 A. It is the correct dose

 B. The dose is too low
 C. The dose is too high
 D. The dose should be increased or decreased, depending on the symptoms
Correct Answer: B. The dose is too low.
This child weighs 30 kg, and the pediatric dose of diphenhydramine is 5 mg/kg/day (5 X 30
= 150/day). Therefore, the correct dose is 150 mg/day. Divided into 3 doses per day, the
child should receive 50 mg 3 times a day rather than 25 mg 3 times a day. Dosage should
not be titrated based on symptoms without consulting a physician.
Option A: Diphenhydramine is used to relieve red, irritated, itchy, watery eyes;


sneezing; and runny nose caused by hay fever, allergies, or the common cold.
Diphenhydramine is also used to relieve coughs caused by minor throat or
airway irritation.
 Option C: Diphenhydramine comes as a tablet, a rapidly disintegrating
(dissolving) tablet, a capsule, a liquid-filled capsule, a dissolving strip, powder,
and a liquid to take by mouth. When diphenhydramine is used for the relief of
allergies, cold, and cough symptoms, it is usually taken every 4 to 6 hours.
 Option D: Before you give a diphenhydramine product to a child, check the
package label to find out how much medication the child should receive. Give
the dose that matches the child’s age on the chart. Ask the child’s doctor if
you don’t know how much medication to give the child.
NCLEXRN-02-025
Question Tag: undescended testis

The mother of a 2-month-old infant brings the child to the clinic for a well-baby check. She
is concerned because she feels only one testis in the scrotal sac. Which of the following
statements about the undescended testis is the most accurate?
 A. Normally, the testes are descended by birth.

 B. The infant will likely require surgical intervention.
 C. The infant probably has only one testis.
 D. Normally, the testes descend by one year of age.
Correct Answer: D. Normally, the testes descend by one year of age.
Normally, the testes descend by one year of age. In young infants, it is common for the
testes to retract into the inguinal canal when the environment is cold or the cremasteric
reflex is stimulated. The exam should be done in a warm room with warm hands. It is most
likely that both testes are present and will descend by a year. If not, a full assessment will
determine the appropriate treatment.
Option A: The testes usually descend by one year of age. Most of the time, a

boy’s testicles descend by the time he is 9 months old. Undescended testicles
are common in infants who are born early. The problem occurs less in full-
term infants.
 Option B: Surgical intervention is unnecessary; the testes descend by one year
of age. The testicles will descend normally at puberty and surgery is not
needed. Testicles that do not naturally descend into the scrotum are
considered abnormal. An undescended testicle is more likely to develop
cancer, even if it is brought into the scrotum with surgery. Cancer is also more
likely in the other testicle.
 Option C: In young infants, it is common for the testes to retract into the
inguinal canal when the environment is cold or the cremasteric reflex is
stimulated.
NCLEXRN-02-026
Question Tag: Wilms tumor
A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the
following statements most accurately describes this stage?
 A. The tumor is less than 3 cm. in size and requires no chemotherapy.

 B. The tumor did not extend beyond the kidney and was completely resected.
 C. The tumor extended beyond the kidney but was completely resected.
 D. The tumor has spread into the abdominal cavity and cannot be resected.
Correct Answer: C. The tumor extended beyond the kidney but was completely
resected.
The staging of Wilms tumor is confirmed at surgery as follows: Stage I, the tumor is limited
to the kidney and completely resected; stage II, the tumor extends beyond the kidney but
is completely resected; stage III, residual non hematogenous tumor is confined to the
abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the
abdomen; and stage V, bilateral renal involvement is present at diagnosis.
 Option A: The mass is solid at presentation and usually >10 cm.

Option B: This option describes stage 1, wherein the tumor is limited to the

kidney and completely resected.
 Option D: In stage IV, hematogenous metastasis has occurred with spread
beyond the abdomen.
NCLEXRN-02-027
Question Tag: acute glomerulonephritis

A teen patient is admitted to the hospital by his physician who suspects a diagnosis of
acute glomerulonephritis. Which of the following findings is consistent with this
diagnosis? Select all that apply.
 A. Urine specific gravity of 1.040.

 B. Urine output of 350 ml in 24 hours.
 C. Brown (“tea-colored”) urine.
 D. Generalized edema.
Correct Answer: A, B, & C
Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria

as well as dark “tea-colored” urine caused by large amounts of red blood cells.
Option A: The urine is dark. Its specific gravity is greater than 1.020. RBCs and

RBC casts are present.
 Option B: Functional changes include proteinuria, hematuria, reduction in GFR
(ie, oliguria or anuria), and active urine sediment with RBCs and RBC casts. The
decreased GFR and avid distal nephron salt and water retention result in
expansion of intravascular volume, edema, and, frequently, systemic
hypertension.
 Option C: This is a universal finding, even if it is microscopic. Gross hematuria
is reported in 30% of pediatric patients, often manifesting as smoky-, coffee-,
or cola-colored urine.
 Option D: There is periorbital edema, but generalized edema is seen
in nephrotic syndrome, not acute glomerulonephritis. Most often, the patient
is a boy, aged 2-14 years, who suddenly develops puffiness of the eyelids and
facial edema in the setting of a poststreptococcal infection.
NCLEXRN-02-028

Which of the following conditions most commonly causes acute glomerulonephritis?
 A. A congenital condition leading to renal dysfunction.

B. Prior infection with group A Streptococcus within the past 10-14 days.
 C. Viral infection of the glomeruli.
 D. Nephrotic syndrome.
Correct Answer: B. Prior infection with group A Streptococcus within the past 10-14
days.
Acute glomerulonephritis is most commonly caused by the immune response to a prior

upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs
about 10-14 days after the infection, resulting in scant, dark urine and retention of body
fluid. Periorbital edema and hypertension are common signs at diagnosis.
Option A: No congenital condition predisposes to glomerulonephritis.


Noninfectious causes of acute GN may be divided into primary renal diseases,
systemic diseases, and miscellaneous conditions or agents.
 Option C: Viruses may cause acute glomerulonephritis but rarely.
Cytomegalovirus (CMV), coxsackievirus, Epstein-Barr virus (EBV), hepatitis B
virus (HBV), rubella, rickettsiae (as in scrub typhus), parvovirus B19, and mumps
virus are accepted as viral causes only if it can be documented that a recent
group A beta-hemolytic streptococcal infection did not occur. Acute GN has
been documented as a rare complication of hepatitis A.
 Option D: Nephrotic syndrome does not cause acute glomerulonephritis.
PSGN usually develops 1-3 weeks after acute infection with specific
nephritogenic strains of group A beta-hemolytic streptococcus. The incidence
of GN is approximately 5-10% in persons with pharyngitis and 25% in those
with skin infections.
NCLEXRN-02-029
Question Tag: hydrocele
An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The
scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the
following actions is the physician likely to recommend?
A. Massaging the groin area twice a day until the fluid is gone.
 B. Referral to a surgeon for repair.
 C. No treatment is necessary; the fluid is reabsorbing normally.
 D. Keeping the infant in a flat, supine position until the fluid is gone.
Correct Answer: C. No treatment is necessary; the fluid is reabsorbing normally.
A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis.
Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases,
the fluid reabsorbs within the first few months of life and no treatment is necessary.
Option A: A hydrocele can develop before birth. Normally, the testicles

descend from the developing baby’s abdominal cavity into the scrotum. A sac
accompanies each testicle, allowing fluid to surround the testicles. Usually,
each sac closes and the fluid is absorbed. Sometimes, the fluid remains after
the sac closes (noncommunicating hydrocele). The fluid is usually absorbed
gradually within the first year of life. But occasionally, the sac remains open
(communicating hydrocele). The sac can change size or if the scrotal sac is
compressed, fluid can flow back into the abdomen. Communicating
hydroceles are often associated with inguinal hernia.
 Option B: A hydrocele that doesn’t disappear on its own might need to be
surgically removed, typically as an outpatient procedure. The surgery to
remove a hydrocele (hydrocelectomy) can be done under general or regional
anesthesia. An incision is made in the scrotum or lower abdomen to remove
the hydrocele. If a hydrocele is found during surgery to repair an inguinal
hernia, the surgeon might remove the hydrocele even if it’s causing no
discomfort.
 Option D: A baby’s hydrocele typically disappears on its own. But if the baby’s
hydrocele doesn’t disappear after a year or if it enlarges, ask the child’s doctor
to examine the hydrocele again.
NCLEXRN-02-030
Question Tag: peripheral vascular disease

A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains
of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which
of the following is the most likely explanation for these symptoms?
 A. Inadequate tissue perfusion leading to nerve damage.

 B. Fluid overload leading to compression of nerve tissue.
 C. Sensation distortion due to psychiatric disturbance.
 D. Inflammation of the skin on the hands and feet.
Correct Answer: A. Inadequate tissue perfusion leading to nerve damage.
Patients with the peripheral vascular disease often sustain nerve damage as a result of
inadequate tissue perfusion. Ischemic rest pain is more worrisome; it refers to pain in the
extremity that is due to a combination of PVD and inadequate perfusion. Ischemic rest pain
often is exacerbated by poor cardiac output. The condition is often partially or fully relieved
by placing the extremity in a dependent position, so that perfusion is enhanced by the
effects of gravity.
 Option B: Fluid overload is not characteristic of PVD. Assess the heart for
murmurs or other abnormalities. Investigate all peripheral vessels, including
carotid, abdominal, and femoral, for pulse quality and bruit. Note that the
dorsalis pedis artery is absent in 5-8% of normal subjects, but the posterior
tibial artery usually is present. Both pulses are absent in only about 0.5% of
patients. Exercise may cause the obliteration of these pulses.
 Option C: There is nothing to indicate a psychiatric disturbance in the patient.
 Option D: Skin changes in PVD are secondary to decreased tissue perfusion
rather than primary inflammation. The skin may have an atrophic, shiny
appearance and may demonstrate trophic changes, including alopecia; dry,
scaly, or erythematous skin; chronic pigmentation changes; and brittle nails.
NCLEXRN-02-031
Question Tag: atherosclerosis
Question Category: Health Promotion
A patient in the cardiac unit is concerned about the risk factors associated with
atherosclerosis. Which of the following are hereditary risk factors for developing
atherosclerosis?
A. Family history of heart disease

 B. Overweight
 C. Smoking.
 D. Age.
Correct Answer: A. Family history of heart disease.
A family history of heart disease is an inherited risk factor that is not subject to lifestyle
change. Having a first-degree relative with heart disease has been shown to significantly
increase risk.
Option B: Overweight is a risk factor that is subject to lifestyle change and can

reduce risk significantly. The terms “overweight” and “obesity” refer to body
weight that’s greater than what is considered healthy for a certain height.
 Option C: Smoking can damage and tighten blood vessels, raise cholesterol
levels, and raise blood pressure. Smoking also doesn’t allow enough oxygen to
reach the body’s tissues.
 Option D: Advancing age increases the risk of atherosclerosis but is not a
hereditary factor. As one gets older, the risk for atherosclerosis increases.
Genetic or lifestyle factors cause plaque to build up in the arteries as one ages.
By the time one is middle-aged or older, enough plaque has built up to cause
signs or symptoms. In men, the risk increases after age 45. In women, the risk
increases after age 55.
NCLEXRN-02-032
Question Tag: peripheral vascular disease, claudication

Claudication is a well-known effect of peripheral vascular disease. Which of the following
facts about claudication is correct? Select all that apply:
 A. It results when oxygen demand is greater than oxygen supply.

 B. It is characterized by pain that often occurs during rest.
 C. It is a result of tissue hypoxia.
 D. It is characterized by cramping and weakness.
 E. It always affects the upper extremities.
Correct Answer: A, C, and D.
Claudication describes the pain experienced by a patient with a peripheral vascular disease
when oxygen demand in the leg muscles exceeds the oxygen supply. The tissue becomes
hypoxic, causing cramping, weakness, and discomfort.
Option A: Claudication refers to muscle pain due to lack of oxygen that’s


triggered by activity and relieved by rest.
 Option B: This most often occurs during activity when demand increases in
muscle tissue.
 Option C: The condition is also called intermittent claudication because the
pain usually isn’t constant. It begins during exercise and ends with rest. As
claudication worsens, however, the pain may occur during rest.
 Option D: Claudication is pain caused by too little blood flow to muscles
during exercise. Most often this pain occurs in the legs after walking at a
certain pace and for a certain amount of time — depending on the severity of
the condition.
 Option E: Pain in the shoulders, biceps, and forearms may occur, but less
often.
NCLEXRN-02-033
Question Tag: peripheral vascular disease

A nurse is providing discharge information to a patient with peripheral vascular disease.

Which of the following information should be included in instructions?
 A. Walk barefoot whenever possible.

 B. Use a heating pad to keep feet warm.
 C. Avoid crossing the legs.
 D. Use antibacterial ointment to treat skin lesions at risk of infection.
Correct Answer: C. Avoid crossing the legs.
Patients with peripheral vascular disease should avoid crossing the legs because this can
impede blood flow. PVD, also known as arteriosclerosis obliterans, is primarily the result of
atherosclerosis. The atheroma consists of a core of cholesterol joined to proteins with a
fibrous intravascular covering. The atherosclerotic process may gradually progress to
complete occlusion of medium-sized and large arteries. The disease typically is segmental,
with significant variation from patient to patient.
Option A: Walking barefoot is not advised, as foot protection is important to


avoid trauma that may lead to serious infection.
 Option B: Heating pads can cause injury, which can also increase the risk of
infection.
 Option D: Skin lesions at risk for infection should be examined and treated by
a physician.
NCLEXRN-02-034
Question Tag: vasospastic disorder, Raynaud’s disease

A patient who has been diagnosed with vasospastic disorder (Raynaud’s disease)
complains of cold and stiffness in the fingers. Which of the following descriptions
is most likely to fit the patient?
 A. An adolescent male
 B. An elderly woman
 C. A young woman
 D. An elderly man
Correct Answer: C. young woman.
Raynaud’s disease is most common in young women and is frequently associated with
rheumatologic disorders, such as lupus and rheumatoid arthritis. Vasospasm of the arteries
reduces blood flow to the fingers and toes. In people who have Raynaud’s, the disorder
usually affects the fingers. In about 40 percent of people who have Raynaud’s, it affects the
toes. Rarely, the disorder affects the nose, ears, nipples, and lips.
 Option A: Primary Raynaud’s usually develops before the age of 30. In primary
Raynaud’s (also called Raynaud’s disease), the cause isn’t known. Primary
Raynaud’s are more common and tend to be less severe than secondary
Raynaud’s.
 Option B: Secondary Raynaud’s usually develop after the age of 30. Secondary
Raynaud’s is caused by an underlying disease, condition, or other factor. This
type of Raynaud’s is often called Raynaud’s phenomenon.
 Option D: Although anyone can develop the condition, Raynaud’s disease
often begins between the ages 15 to 30, but it mostly affects women. If one
has primary or secondary Raynaud’s, cold temperatures or stress can trigger
“Raynaud’s attacks.” During an attack, little or no blood flows to affected body
parts.
NCLEXRN-02-035
Question Tag: pregnancy, chest pain
A 23-year-old patient in the 27th week of pregnancy has been hospitalized on

complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by
chest pain. Which of the following conditions is the most likely cause of her symptoms?
 A. Myocardial infarction due to a history of atherosclerosis.

 B. Pulmonary embolism due to deep vein thrombosis (DVT).
 C. Anxiety attacks due to worries about her baby’s health.
 D. Congestive heart failure due to fluid overload.
Correct Answer: B. Pulmonary embolism due to deep vein thrombosis (DVT).
In a hospitalized patient on prolonged bed rest, the most likely cause of sudden onset
shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged
inactivity both increase the risk of clot formation in the deep veins of the legs. These clots
can then break loose and travel to the lungs.
Option A: Atherosclerosis is the disease primarily responsible for most acute


coronary syndrome (ACS) cases. Approximately 90% of myocardial infarctions
(MIs) result from an acute thrombus that obstructs an atherosclerotic coronary
artery. Plaque rupture and erosion are considered to be the major triggers for
coronary thrombosis. Following plaque erosion or rupture, platelet activation
and aggregation, coagulation pathway activation, and endothelial
vasoconstriction occur, leading to coronary thrombosis and occlusion.
 Option C: There is no reason to suspect an anxiety disorder in this patient.
Though anxiety is a possible cause of her symptoms, the seriousness of
pulmonary embolism demands that it be considered first.
 Option D: According to 2017 American Heart Association (AHA) data, heart
failure affects an estimated 6.5 million Americans aged 20 years and
older. [31] With improved survival of patients with acute myocardial infarction
and with a population that continues to age, heart failure will continue to
increase in prominence as a major health problem in the United States.
NCLEXRN-02-036
Question Tag: thrombolytic therapy, stroke

Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the
following is a significant complication associated with thrombolytic therapy?
 A. Air embolus.
 B. Cerebral hemorrhage.
 C. Expansion of the clot.
 D. Resolution of the clot.
Correct Answer: B. Cerebral hemorrhage.
Cerebral hemorrhage is a significant risk when treating a stroke victim with thrombolytic
therapy intended to dissolve a suspected clot. The success of the treatment demands that
it be instituted as soon as possible, often before the cause of stroke has been determined.
Option A: Air embolism is not a concern. Thrombosis is an important part of


the normal hemostatic response that limits hemorrhage caused by
microscopic or macroscopic vascular injury. Physiologic thrombosis is
counterbalanced by intrinsic antithrombotic properties and fibrinolysis. Under
normal conditions, a thrombus is confined to the immediate area of injury and
does not obstruct flow to critical areas, unless the blood vessel lumen is
already diminished, as it is in atherosclerosis.
 Option C: Both hemostasis and thrombosis depend on the coagulation
cascade, vascular wall integrity, and platelet response. Several cellular factors
are responsible for thrombus formation. When a vascular insult occurs, an
immediate local cellular response takes place. Platelets migrate to the area of
injury, where they secrete several cellular factors and mediators. These
mediators promote clot formation.
 Option D: Thrombolytic therapy does not lead to the expansion of the clot,
but to resolution, which is the intended effect.
NCLEXRN-02-037
Question Tag: infant, head position

An infant is brought to the clinic by his mother, who has noticed that he holds his head in
an unusual position and always faces to one side. Which of the following is the most likely
explanation?
 A. Torticollis, with shortening of the sternocleidomastoid muscle.

 B. Craniosynostosis, with premature closure of the cranial sutures.
 C. Plagiocephaly, with flattening of one side of the head.
 D. Hydrocephalus, with increased head size.
Correct Answer: A. Torticollis, with shortening of the sternocleidomastoid muscle.
In torticollis, the sternocleidomastoid muscle is contracted, limiting the range of motion of

the neck and causing the chin to point to the opposing side.
 Option B: In craniosynostosis one of the cranial sutures, often the sagittal,
closes prematurely, causing the head to grow in an abnormal shape.
Option C: Plagiocephaly refers to the flattening of one side of the head,

caused by the infant being placed supine in the same position over time.
 Option D: Hydrocephalus is caused by a build-up of cerebrospinal fluid in the
brain resulting in large head size.
NCLEXRN-02-038
Question Tag: Addison’s disease

An adolescent brings a physician’s note to school stating that he is not to participate in

sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements
about the disease is correct?
 A. The condition was caused by the student’s competitive swimming schedule.

 B. The student will most likely require surgical intervention.
 C. The student experiences pain in the inferior aspect of the knee.
 D. The student is trying to avoid participation in physical education.
Correct Answer: C. The student experiences pain in the inferior aspect of the knee.
Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the

infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain
and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly
caused by activities that require repeated use of the quadriceps, including track and soccer.
Option A: Swimming is not a likely cause. OSD is a traction phenomenon


resulting from repetitive quadriceps contraction through the patellar tendon at
its insertion upon the skeletally immature tibial tubercle. This occurs in
preadolescence during a time when the tibial tubercle is susceptible to strain.
The pain associated will be localized to the tibial tubercle and occasionally the
patellar tendon itself.
 Option B: The condition is usually self-limited, responding to ice, rest, and
analgesics. OSD is a self-limiting condition. In a study by Krause et al, 90% of
patients treated with conservative care were relieved of all of their symptoms
approximately 1 year after onset of symptoms. [3] After skeletal maturity,
patients may continue to have problems kneeling. This typically is due to
tenderness over an unfused tibial tubercle ossicle or a bursa that may require
resection.
 Option D: Continued participation will worsen the condition and the
symptoms. The onset of OSD is usually gradual, with patients commonly
complaining of pain in the tibial tubercle and/or patellar tendon region after
repetitive activities. Typically, running or jumping activities that significantly
stress the patellar tendon insertion upon the tibial tubercle aggravate the
patient’s symptoms.
NCLEXRN-02-039
Question Tag: assessment
The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging
freely. Which of the following assessments is the nurse most likely conducting?
 A. Spinal flexibility
 B. Leg length disparity
 C. Hypostatic blood pressure
 D. Scoliosis
Correct Answer: D. Scoliosis.
A check for scoliosis, a lateral deviation of the spine, is an important part of the routine
adolescent exam. It is assessed by having the teen bend at the waist with arms dangling,
while observing for lateral curvature and uneven rib level. Scoliosis is more common in
female adolescents.
Options A: The ability to move the spine through its full range of motion,

both forward and backward, is called spinal flexibility. However, it is not
included in routine adolescent exams.
 Options B: Leg length discrepancy or disparity is a condition in which the
paired lower extremity limbs have a noticeably unequal length.
 Option C: Hypostatic or orthostatic blood pressure is a form of low blood
pressure that happens when one is sitting or stands up suddenly.
NCLEXRN-02-040
Question Tag: child abuse

Question Category: Psychosocial Integrity
A clinic nurse interviews a parent who is suspected of abusing her child. Which of the
following characteristics is the nurse least likely to find in an abusing parent?
 A. Low self-esteem
 B. Unemployment
 C. Self-blame for the injury to the child
 D. Single status
Correct Answer: C. Self-blame for the injury to the child.
The profile of a parent at risk of abusive behavior includes a tendency to blame the child or
others for the injury sustained. Abusers typically blame others, especially their partners, for
the mistakes in their lives. This is related to hypersensitivity, but they are not necessarily
alike. This occurs because most abusive people don’t hold themselves as being
accountable for the actions they commit. Instead, they’ll try to shift the blame to the
person that they have abused and somehow say they “deserved it” or that they were forced
into a corner.
Option A: Basically, domestic violence offenders always feel the need to be in


control of their victims. The less in control an offender feels, the more they
want to hurt others.
 Option B: One study suggests that unemployment can cause an increase in
child neglect because parents have more limited access to the resources
required to provide for a child’s basic needs, such as clothing, food and
medical care.
 Option D: A “favorite” of abusers is to isolate their partners from family or
friends. This type of isolation is often very common and often represents the
first step in an abusive relationship. The abusive partner will attempt to set up
an “us versus them” attitude and will begin isolating family members. This can
work through the abuser’s use of jealousy, controlling behavior or veiled
concern.
NCLEXRN-02-041
Question Tag: juvenile idiopathic arthritis

Question Category: Physiological Integrity,
A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has
just been diagnosed with juvenile idiopathic arthritis. Which of the following statements
about the disease is most accurate?
 A. The child has a poor chance of recovery without joint deformity.

 B. Most children progress to adult rheumatoid arthritis.
 C. Nonsteroidal anti-inflammatory drugs are the first choice in treatment.
 D. Physical activity should be minimized.
Correct Answer: C. Nonsteroidal anti-inflammatory drugs are the first choice in
treatment.
Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile
idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4
weeks for the therapeutic anti-inflammatory effects to be realized.
 Options A: Advances in treatment over the last 20 years—especially the

introduction of early use of intra-articular steroids, methotrexate, and biologic
medications—have dramatically improved the prognosis for children with
arthritis. Almost all children with JIA lead productive lives. However, many
patients, particularly those with polyarticular disease, may have problems with
active disease throughout adulthood, with sustained remission attained in a
minority of patients.
Option B: Children with systemic-onset disease tend to either respond

completely to medical therapy or develop a severe polyarticular course that
tends to be refractory to medical treatment, with disease persisting into
adulthood.
 Option D: Physical activity is an integral part of therapy. Encourage patients to
be as active as possible. Bed rest is not a part of the treatment. In fact, the
more active the patient, the better the long-term prognosis. Children may
experience increased pain during routine physical activities. As a result, these
children must be allowed to self-limit their activities, particularly during
physical education classes. A consistent physical therapy program, with
attention to stretching exercises, pain modalities, joint protection, and home
exercises, can help ensure that patients are as active as possible.
NCLEXRN-02-042
Question Tag: osteomyelitis
A child is admitted to the hospital several days after stepping on a sharp object that
punctured her athletic shoe and entered the flesh of her foot. The physician is concerned
about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions
is done immediately before the antibiotic is started?
 A. The admission orders are written.

 B. A blood culture is drawn.
 C. A complete blood count with differential is drawn.
 D. The parents arrive.
Correct Answer: B. A blood culture is drawn.
Antibiotics must be started after the blood culture is drawn, as they may interfere with the
identification of the causative organism.
Option A: Making sure that the physician’s orders for antibiotics are written,

instead of admitting orders, should be done.
 Option C: The blood count will reveal the presence of infection but does not
help identify an organism or guide antibiotic treatment.
 Option D: Parental presence is important for the adjustment of the child but
not for the administration of medication.
NCLEXRN-02-043
Question Tag: swelling, leg injury

A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the
emergency department documents swelling of the lower affected leg. Which of the
following does the nurse suspect is the cause of the child’s symptoms?
 A. Possible fracture of the tibia.

 B. Bruising of the gastrocnemius muscle.
 C. Possible fracture of the radius.
 D. No anatomic injury, the child wants his mother to carry him.
Correct Answer: A. Possible fracture of the tibia.
The child’s refusal to walk, combined with swelling of the limb is suspicious for fracture.
Option B: Toddlers will often continue to walk on a muscle that is bruised or


strained.
 Option C: The radius is found in the lower arm and is not relevant to this
question.
 Option D: Toddlers rarely feign injury to be carried, and swelling indicates a
physical injury.
NCLEXRN-02-044
Question Tag: cerebral palsy

A toddler has recently been diagnosed with cerebral palsy. Which of the following
information should the nurse provide to the parents? Select all that apply.
 A. Regular developmental screening is important to avoid secondary

developmental delays.
 B. Cerebral palsy is caused by injury to the upper motor neurons and results in
motor dysfunction, as well as possible ocular and speech difficulties.
 C. Developmental milestones may be slightly delayed but usually will require
no additional intervention.
 D. Parent support groups are helpful for sharing strategies and managing
health care issues.
 E. Therapies and surgical interventions can cure cerebral palsy.
Correct Answer: A, B, and D.
Delayed developmental milestones are characteristic of cerebral palsy, so regular screening

and intervention is essential. Because of injury to upper motor neurons, children may have
ocular and speech difficulties. Parent support groups help families to share and cope.
Physical therapy and other interventions can minimize the extent of the delay in
developmental milestones.
Option A: During developmental screening a short test is given to see if the

child has specific developmental delays, such as motor or movement delays. If
the results of the screening test are cause for concern, then the doctor will
make referrals for developmental and medical evaluations.
 Option B: Cerebral palsy (CP) is a group of disorders that affect a person’s
ability to move and maintain balance and posture. CP is the most common
motor disability in childhood. Cerebral means having to do with the
brain. Palsy means weakness or problems with using the muscles. CP is caused
by abnormal brain development or damage to the developing brain that
affects a person’s ability to control his or her muscles.
 Option C: Delayed developmental milestones definitely need interventions
and constant follow ups. Developmental monitoring (also called surveillance)
means tracking a child’s growth and development over time. If any concerns
about the child’s development are raised during monitoring, then a
developmental screening test should be given as soon as possible.
 Option D: Both early intervention and school-aged services are available
through a special education law—the Individuals with Disabilities Education
Act (IDEA). Part C of IDEA deals with early intervention services (birth through
36 months of age), while Part B applies to services for school-aged children (3
through 21 years of age). Even if the child has not been diagnosed with CP, he
or she may be eligible for IDEA services.
 Option E: Cerebral palsy has no cure, but treatment can improve the lives of
those who have the condition. After a CP diagnosis is made, a team of health
professionals works with the child and family to develop a plan to help the
child reach his or her full potential. Common treatments include medicines;
surgery; braces; and physical, occupational, and speech therapy. No single
treatment is the best one for all children with CP. Before deciding on a
treatment plan, it is important to talk with the child’s doctor to understand all
the risks and benefits.
NCLEXRN-02-045
Question Tag: Duchenne’s muscular dystrophy

A child has recently been diagnosed with Duchenne muscular dystrophy (DMD). The
parents are receiving genetic counseling prior to planning another pregnancy. Which of the
following statements includes the most accurate information?
 A. Duchenne’s is an X-linked recessive disorder, so daughters have a 50%

chance of being carriers and sons a 50% chance of developing the disease.
 B. Duchenne’s is an X-linked recessive disorder, so both daughters and sons
have a 50% chance of developing the disease.
 C. Each child has a 1 in 4 (25%) chance of developing the disorder.
 D. Sons only have a 1 in 4 (25%) chance of developing the disorder.
Correct Answer: A. Duchenne’s is an X-linked recessive disorder, so daughters have a
50% chance of being carriers and sons a 50% chance of developing the disease.
The recessive Duchenne gene is located on one of the two X chromosomes of a female
carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a 50%
chance of a son being affected. Daughters are not affected, but 50% are carriers because
they inherit one copy of the defective gene from the mother. The other X chromosome
comes from the father, who cannot be a carrier.
Option B: DMD carriers are females who have a normal dystrophin gene on

one X chromosome and an abnormal dystrophin gene on the other X
chromosome. Most carriers of DMD do not themselves have signs and
symptoms of the disease, but a minority do.
 Option C: Advances in molecular biology techniques illuminate the genetic
basis underlying all MD: defects in the genetic code for dystrophin, a 427-kd
skeletal muscle protein (Dp427). These defects result in the various
manifestations commonly associated with MD, such as weakness and
pseudohypertrophy.
 Option D: Minor variations notwithstanding, all types of MD have in common
progressive muscle weakness that tends to occur in a proximal-to-distal
direction, though there are some rare distal myopathies that cause
predominantly distal weakness. The decreasing muscle strength in those who
are affected may compromise the patient’s ambulation potential and,
eventually, cardiopulmonary function.
NCLEXRN-02-046
Question Tag: percutaneous transluminal coronary angioplasty
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The

nurse knows that a PTCA is the
 A. Surgical repair of a diseased coronary artery.

 B. Placement of an automatic internal cardiac defibrillator.
 C. Procedure that compresses plaque against the wall of the diseased coronary
artery to improve blood flow.
 D. Non-invasive radiographic examination of the heart.
Correct Answer: C. Procedure that compresses plaque against the wall of the diseased
coronary artery to improve blood flow
PTCA is performed to improve coronary artery blood flow in a diseased artery. It is

performed during a cardiac catheterization. Aorta coronary bypass graft is the surgical
procedure to repair a diseased coronary artery.
Option A: Coronary artery bypass grafting is the surgical repair of a diseased

coronary artery.
 Option B: Angioplasty does not involve the placement of an internal cardiac
defibrillator. An internal cardiac defibrillator is needed if the client has
ventricular tachycardia or ventricular fibrillation because they detect and stop
abnormal heartbeats or arrhythmias.
 Option D: PTCA is not a radiographic examination of the heart.
NCLEXRN-02-047
Question Tag: hypothyroidism
A newborn has been diagnosed with hypothyroidism. In discussing the condition and
treatment with the family, the nurse should emphasize:
 A. They can expect the child will be mentally retarded.

 B. Administration of thyroid hormone will prevent problems.
 C. This rare problem is always hereditary.
 D. Physical growth/development will be delayed.
Correct Answer: B. Administration of thyroid hormone will prevent problems.
Early identification and continued treatment with hormone replacement correct this
condition.
 Option A: Mental retardation can be prevented with early detection and

treatment. Neurologic sequelae, characterized by spasticity, tremor, and
hyperactive deep tendon reflexes, are found frequently in severe cretinism, but
not in mild cretinism or acquired hypothyroidism. The severity of neurologic
sequelae parallels mental retardation. Early therapy apparently prevents, in
part, these sequelae.
 Option C: Congenital hypothyroidism is caused by iodine deficiency and is
occasionally exacerbated by naturally occurring goitrogens. In the majority of
patients, CH is caused by an abnormal development of the thyroid gland
(thyroid dysgenesis) that is a sporadic disorder and accounts for 85% of cases
and the remaining 15% of cases are caused by dyshormonogenesis. The
clinical features of congenital hypothyroidism are so subtle that many
newborn infants remain undiagnosed at birth and delayed diagnosis leads to
the most severe outcome of CH, mental retardation, emphasizing the
importance of neonatal screening.
 Option D: The growth and development of an infant with congenital
hypothyroidism can be normal if it is detected and treated early. In overt
hypothyroidism, the severe impairment of linear growth leads to dwarfism,
which is characterised by limbs that are disproportionately short compared
with the trunk. Even in subclinical hypothyroidism, a condition of mild thyroid
failure, growth velocity in children is suboptimal.
NCLEXRN-02-048
Question Tag: mental illness
A priority goal of involuntary hospitalization of the severely mentally ill client is
A. Re-orientation to reality

 B. Elimination of symptoms
 C. Protection from harm to self or others
 D. Return to independent functioning
Correct Answer: C. Protection from self-harm and harm to others.
Involuntary hospitalization may be required for persons considered dangerous to self or

others or for individuals who are considered gravely disabled.
Option A: Mentally ill clients should be kept safe first before reorienting them

back to reality. In keeping with emergent mental health public policy and
nursing professional ethics, the articulated aims of deinstitutionalization
included returning individuals to home communities to restore freedom and
autonomy, and reducing or eliminating nursing practices grounded in
punishment that were being societally reconceptualized as harmful.
 Option B: Gradual elimination of the symptoms is not the primary goal in the
hospitalization of a mentally ill client. There are two important concepts about
psychological treatment. First, although it is called “psychological” treatment,
the ultimate effect of these treatments is to bring some changes in the very
delicate change in the structure and function of neurons by changing the way
a person habitually thinks and behaves. They also promote the healing of the
brain by reducing the stress experienced by the patients in daily life. In
psychological treatment, all treatment effects come from the effort to take
new behaviour and adopt new ways of thinking.
 Option D: The client should be kept safe from himself and others first before
he can return to independent functioning. The measurement of functional
capacity in mental illness is an important recent development. Determination
of functional capacity may serve as a surrogate marker for real-world
functioning, thereby aiding clinicians in making important treatment
determinations.
NCLEXRN-02-049
Question Tag: suppression
A 19-year-old client is paralyzed in a car accident. Which statement used by the client
would indicate to the nurse that the client was using the mechanism of “suppression”?
 A. “I don’t remember anything about what happened to me.”

 B. “I’d rather not talk about it right now.”
 C. “It’s the other entire guy’s fault! He was going too fast.”
 D. “My mother is heartbroken about this.”
Correct Answer: A. “I don’t remember anything about what happened to me.”
Suppression is willfully putting an unacceptable thought or feeling out of one’s mind. A

deliberate exclusion “voluntary forgetting” is generally used to protect one’s own self-
esteem.
Option B: Denial is a defense mechanism proposed by Anna Freud which


involves a refusal to accept reality, thus blocking external events from
awareness. If a situation is just too much to handle, the person may respond
by refusing to perceive it or by denying that it exists.
 Option C: This statement refers to projection, which is when an individual
attributes her negative self-concept onto others.
 Option D: This statement refers to the identification, which is when the client
identifies herself with an image that she sees is ideal to our ego.
NCLEXRN-02-050
Question Tag: premature rupture of membranes
The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates
that the membranes were ruptured for 36 hours prior to delivery. What are
the priority nursing diagnoses at this time?
 A. Altered tissue perfusion

 B. Risk for fluid volume deficit
 C. High risk for hemorrhage
 D. Risk for infection
Correct Answer: D. Risk for infection
Membranes ruptured over 24 hours prior to birth greatly increases the risk of infection to
both mother and the newborn. Rupture of membranes results from a variety of factors that
ultimately lead to accelerated membrane weakening. This is caused by an increase in local
cytokines, an imbalance in the interaction between matrix metalloproteinases and tissue
inhibitors of matrix metalloproteinases, increased collagenase and protease activity, and
other factors that can cause increased intrauterine pressure.
 Option A: There should be little or no alteration in perfusion after premature

rupture of the membranes. Decreased tissue perfusion can be temporary, with
few or minimal consequences to the health of the patient, or it can be more
acute or protracted, with potentially destructive effects on the patient. When
diminished tissue perfusion becomes chronic, it can result in tissue or organ
damage or death.
 Option B: There may be a risk for deficient fluid volume, but it is not a priority.
Fluid volume deficit (FVD) or hypovolemia is a state or condition where the
fluid output exceeds the fluid intake. It occurs when the body loses both water
and electrolytes from the ECF in similar proportions. Common sources of fluid
loss are the gastrointestinal tract, polyuria, and increased perspiration.
 Option C: Hemorrhage is not a great risk in premature rupture of membranes.
One of the complications of PROM is intraventricular hemorrhage. This is
because blood vessels in the brain of premature infants are not fully
developed, and are therefore weaker than that of term babies. Research shows
that intraventricular hemorrhages (IVH) or brain bleeds are significantly
reduced by steroid treatment, without an increase in either maternal or
neonatal infection.
NCLEXRN-02-051
Question Tag: hip spica cast
A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the
nurse should:
 A. Expose the cast to air and turn the child frequently.

 B. Use a heat lamp to reduce the drying time.
 C. Handle the cast with the abductor bar.
 D. Turn the child as little as possible.
Correct Answer: A. Expose the cast to air and turn the child frequently
The child should be turned every 2 hours, with the surface exposed to the air. Casts and
splints hold the bones in place while they heal. They also reduce pain, swelling, and muscle
spasm.
Option B: Heat lamps may cause burns in the skin inside the cast. Inspect the

skin around the cast. If the skin becomes red or raw around the cast, contact a
doctor.
 Option C: Do not handle the cast until it is dry because it might still break. It
takes about one hour for fiberglass, and two to three days for plaster to
become hard enough to walk on. Some physicians will give a “cast shoe” to
wear over a walking cast. The cast shoe will help protect the bottom of the
cast.
 Option D: Turning the child would ensure equal drying of the cast at all sides.
Keep the cast dry. If the cast becomes wet, it can hurt the child’s skin. Do not
try to dry cast with something warm (i.e., a blow dryer) this may cause burns.
NCLEXRN-02-052
Question Tag: intravenous pyelogram
A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for
this test, the nurse would:
 A. Instruct the client to maintain a regular diet the day prior to the
examination.
 B. Restrict the client’s fluid intake 4 hours prior to the examination.
 C. Administer a laxative to the client the evening before the examination.
 D. Inform the client that only 1 x-ray of his abdomen is necessary.
Correct Answer: C. Administer a laxative to the client the evening before the
examination
Bowel prep is important because it will allow greater visualization of the bladder and
ureters. Intravenous pyelogram (IVP) is an x-ray exam that uses an injection of contrast
material to evaluate the kidneys, ureters, and bladder and help diagnose blood in the urine
or pain in the side or lower back. An IVP may provide enough information to allow the
doctor to treat with medication and avoid surgery.
Option A: Eating and drinking the night before the exam should be avoided.

 Option B: Restriction of fluids on the night before the exam should be
emphasized.
 Option D: An intravenous pyelogram is an x-ray of the kidneys, ureters, and
urinary bladder that uses iodinated contrast material injected into veins.
NCLEXRN-02-053

Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the
parent’s remark: “We just don’t know how he caught the disease!” The nurse’s response is
based on an understanding that:
 A. AGN is a streptococcal infection that involves the kidney tubules.

 B. The disease is easily transmissible in schools and camps.
 C. The illness is usually associated with chronic respiratory infections.
 D. It is not “caught” but is a response to a previous B-hemolytic strep infection.
Correct Answer: D. It is not “caught” but is a response to a previous B-hemolytic
strep infection.
AGN is generally accepted as an immune-complex disease in relation to an antecedent

streptococcal infection of 4 to 6 weeks prior and is considered as a noninfectious renal
disease.
Option A: Acute glomerulonephritis comprises a specific set of renal diseases


in which an immunologic mechanism triggers inflammation and proliferation
of glomerular tissue that can result in damage to the basement membrane,
mesangium, or capillary endothelium.
 Option B: The disease is most commonly caused by Streptococcus species.
Glomerulonephritis may develop a week or two after recovery from a strep
throat infection or, rarely, a skin infection (impetigo). To fight the infection, the
body produces extra antibodies that can eventually settle in the glomeruli,
causing inflammation.
 Option C: Acute glomerulonephritis is usually associated with staphylococcal
infection. Infections with other types of bacteria, such as staphylococcus and
pneumococcus, viral infections, such as chickenpox, and parasitic infections,
such as malaria, can also result in acute glomerulonephritis. Acute
glomerulonephritis that results from any of these infections is called
postinfectious glomerulonephritis.
NCLEXRN-02-054
Question Tag: diarrhea, vomiting
The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3-day history of diarrhea,
occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5%
dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr.
Which finding should be reported to the healthcare provider immediately?
 A. 3 episodes of vomiting in 1 hour.

 B. Periodic crying and irritability.
 C. Vigorous sucking on a pacifier.
 D. No measurable voiding in 4 hours.
Correct Answer: D. No measurable voiding in 4 hours.
The concern is possible hyperkalemia, which could occur with continued potassium
administration and a decrease in urinary output since potassium is excreted via the kidneys.
Successful management of acute hyperkalemia involves protecting the heart from
arrhythmias with the administration of calcium, shifting potassium (K+) into the cells, and
enhancing the elimination of K+ from the body.
Option A: Episodes of vomiting should be reported, but it is not the priority


and is currently being managed with intravenous infusions. Once clinically
significant dehydration is present, effective and safe strategies for rehydration
are required. Additionally, following rehydration there may be a risk of
recurrence of dehydration and appropriate fluid management may reduce the
likelihood of that event.
 Option B: Crying and irritability is a normal reaction of an infant who is unwell.
 Option C: Vigorous sucking is a good sign in an infant who has episodes of
vomiting.
NCLEXRN-02-055
Question Tag: vaginal delivery
While caring for the client during the first hour after delivery, the nurse determines that the
uterus is boggy and there is vaginal bleeding. What should be the nurse’s first action?
 A. Check vital signs.

 B. Massage the fundus.
 C. Offer a bedpan.
 D. Check for perineal lacerations.
Correct Answer: B. Massage the fundus
The nurse’s first action should be to massage the fundus until it is firm as uterine atony is
the primary cause of bleeding in the first hour after delivery. Approximately 3% to 5% of
obstetric patients will experience postpartum hemorrhage. Annually, these preventable
events are the cause of one-fourth of maternal deaths worldwide and 12% of maternal
deaths in the United States.
 Option A: Vital signs should be checked after vaginal delivery, but in this
situation, the nurse should prioritize prevention of bleeding. 20%
of postpartum hemorrhage occurs in women with no risk factors, so physicians
must be prepared to manage this condition at every delivery
Option C: The client’s fundus should be massaged first to prevent uterine

atony and hemorrhage. Uterine atony is the most common cause of
postpartum hemorrhage. Brisk blood flow after delivery of the placenta
unresponsive to transabdominal massage should prompt immediate action
including bimanual compression of the uterus and use of uterotonic
medications. Massage is performed by placing one hand in the vagina and
pushing against the body of the uterus while the other hand compresses the
fundus from above through the abdominal wall
 Option D: Perineal lacerations may be present but it is not a primary concern
during uterine atony. Lacerations and hematomas due to birth trauma can
cause significant blood loss that can be lessened by hemostasis and timely
repair. Episiotomy increases the risk of blood loss and anal sphincter tears; this
procedure should be avoided unless urgent delivery is necessary and the
perineum is thought to be a limiting factor.
NCLEXRN-02-056
Question Tag: developmental dysplasia
The nurse is assessing an infant with developmental dysplasia of the hip. Which finding
would the nurse anticipate?
 A. Unequal leg length

 B. Limited adduction
 C. Diminished femoral pulses
 D. Symmetrical gluteal folds
Correct Answer: A. Unequal leg length
Shortening of a leg is a sign of developmental dysplasia of the hip. The hip is a “ball-and-
socket” joint. In a normal hip, the ball at the upper end of the thigh bone (femur) fits firmly
into the socket, which is part of the large pelvis bone. In babies and children with
developmental dysplasia (dislocation) of the hip (DDH), the hip joint has not formed
normally. The ball is loose in the socket and may be easy to dislocate.
 Option B: Limited adduction is not a sign of developmental dysplasia. In all

cases of DDH, the socket (acetabulum) is shallow, meaning that the ball of the
thigh bone (femur) cannot firmly fit into the socket. Sometimes, the ligaments
that help to hold the joint in place are stretched. The degree of hip looseness,
or instability, varies among children with DDH.
 Option C: Femoral pulses in a client with developmental dysplasia of the hip
are normal.
 Option D: Asymmetric gluteal folds with uneven gluteal creases are associated
with developmental hip dysplasia.
NCLEXRN-02-057
Question Tag: Valsalva maneuver, acute myocardial infarction
To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction,

the nurse would:
 A. Assist the client to use the bedside commode.

 B. Administer stool softeners every day as ordered.
 C. Administer antidysrhythmics prn as ordered.
 D. Maintain the client on strict bed rest.
Correct Answer: B. Administer stool softeners every day as ordered.
Administering stool softeners every day will prevent straining on defecation which causes
the Valsalva maneuver. If constipation occurs then laxatives would be necessary to prevent
straining. If straining on defecation produced the Valsalva maneuver and rhythm
disturbances resulted then antidysrhythmics would be appropriate.
Option A: A bedside commode for a client with acute MI should be provided,

but it does not prevent Valsalva maneuver alone.
 Option C: Antidysrhythmics do not prevent Valsalva maneuver.
Antidysrhythmic agents, which are also known as antiarrhythmic agents, are a
broad category of medications that help ameliorate the spectrum of cardiac
arrhythmias to maintain normal rhythm and conduction in the heart.
 Option D: A client with acute MI can be given bathroom privileges with
assistance.
NCLEXRN-02-058
Question Tag: psychiatric unit
Question Category: Safe and Effective Care Environment, Management of Care
On admission to the psychiatric unit, the client is trembling and appears fearful. The
nurse’s initial response should be to:
 A. Give the client orientation materials and review the unit rules and
regulations.
 B. Introduce him/her and accompany the client to the client’s room.
 C. Take the client to the day room and introduce her to the other clients.
 D. Ask the nursing assistant to get the client’s vital signs and complete the
admission search.
Correct Answer: B. Introduce him/herself and accompany the client to the client’s
room.
Anxiety is triggered by change that threatens the individual’s sense of security. In response
to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to
a calmer, more secure/safe setting.
Option A: The client is still confused and fearful. Orientation should be


postponed until he is calm. They can deliver effective, safe care by assessing
risk and building a rapport with the patient during the admission process;
utilizing crisis prevention strategies, including appropriate medication
administration, environmental, psychobiological, counseling, and health
teaching interventions; and employing conflict resolution techniques.
 Option C: The client should be taken to a calm environment with less stimuli
so he could feel safe and become calmer.
 Option D: Taking the client’s vital signs while he is still fearful would further
aggravate his feelings of insecurity and fear. Utilizing the nursing process, the
nurse can provide effective therapeutic interventions to promote safety for
both the patient and the nurse.
NCLEXRN-02-059
Question Tag: glaucoma
During the admission assessment on a client with chronic bilateral glaucoma, which
statement by the client would the nurse anticipate since it is associated with this problem?
 A. “I have constant blurred vision.”

 B. “I can’t see on my left side.”
 C. “I have to turn my head to see my room.”
 D. “I have specks floating in my eyes.”
Correct Answer: C. “I have to turn my head to see my room.”
Intraocular pressure becomes elevated which slowly produces a progressive loss of the
peripheral visual field in the affected eye along with rainbow halos around lights.
Intraocular pressure becomes elevated from the microscopic obstruction of the trabecular
meshwork. If left untreated or undetected blindness results in the affected eye.
 Option A: Central vision is one of the most common signs of glaucoma. The
fluid inside the eye, called aqueous humor, usually flows out of the eye
through a mesh-like channel. If this channel gets blocked, the liquid builds up.
Sometimes, experts don’t know what causes this blockage. But it can be
inherited, meaning it’s passed from parents to children.
Option B: The peripheral field of vision is most often lost in a client with

glaucoma. The increased pressure in the eye, called intraocular pressure, can
damage the optic nerve, which sends images to the brain. If the damage
worsens, glaucoma can cause permanent vision loss or even total blindness
within a few years.
 Option D: Patchy blind spots in the peripheral or central vision of both eyes is
a symptom of open-angle glaucoma. It is caused by the drainage channels in
the eye becoming gradually clogged over time.
NCLEXRN-02-060
Question Tag: asthma
A client with asthma has low pitched wheezes present in the final half of exhalation. One
hour later the client has high pitched wheezes extending throughout exhalation. This
change in assessment indicates to the nurse that the client:
 A. Has increased airway obstruction.

 B. Has improved airway obstruction.
 C. Needs to be suctioned.
 D. Exhibits hyperventilation.
Correct Answer: A. Has increased airway obstruction.
The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has
increased or worsened. With no evidence of secretions no support exists to indicate the
need for suctioning.
 Option B: Improvement in airway obstruction should decrease the presence of

wheezes. Wheezing most often is caused by an obstruction (blockage) or
narrowing of the small bronchial tubes in the chest. It can also be caused by
an obstruction in the larger airways or vocal cords. The tone of the wheeze can
vary depending on which part of the respiratory system is blocked or
narrowed.
 Option C: There is no indication for suctioning. Suctioning is used to obtain
mucus and other fluids (secretions) and cells from the windpipe (trachea) and
large airways (bronchi) and is typically used in people who are on mechanical
ventilation or have problems with nerves or muscles that make coughing less
effective for bringing up secretions.
 Option D: Hyperventilation does not produce high pitched wheezes that
extend throughout exhalation. The lowered carbon dioxide levels in the blood
can cause squeezing of the airways, which then results in wheezing.
Hyperventilation syndrome may cause the following chest symptoms like chest
pains or tenderness, shortness of breath, and wheezing.
NCLEXRN-02-061
Question Tag: domestic abuse
Which behavioral characteristic describes the domestic abuser?
 A. Alcoholic
 B. Overconfident
 C. High tolerance for frustrations
 D. Low self-esteem
Correct Answer: D. Low self-esteem
Batterers are usually physically or psychologically abused as children or have had

experiences of parental violence. Batterers are also manipulative, have a low self-esteem,
and have a great need to exercise control or power-over partners.
Option A: Being an alcoholic predisposes an individual to be a domestic


abuser. To be perfectly clear, alcohol and alcoholism are never a sole trigger
for, or cause of, domestic abuse. Rather, they are compounding factors that
could eventually trigger intimate partner abuse in a violent individual.
 Option B: Most domestic abusers have low self-confidence or self-esteem.
Basically, domestic violence offenders always feel the need to be in control of
their victims. The less in control an offender feels, the more they want to hurt
others.
 Option C: Domestic abusers often vent out their frustrations on their partners
or children. Domestic abuse, often referred to as domestic violence or intimate
partner violence (IPV), is a pattern of behavior or behaviors used by one
partner to maintain power and control over another partner that they are in a
relationship with. Anyone, regardless of race, gender, sexual orientation,
religion or age, can be a victim or perpetrator of domestic abuse. Abuse can
be physical, sexual, emotional, mental, social and financial.
NCLEXRN-02-062
Question Tag: long leg cast
The nurse is caring for a client with a long leg cast. During discharge teaching about
appropriate exercises for the affected extremity, the nurse should recommend:
 A. Isometric
 B. Range of motion
C. Aerobic
 D. Isotonic
Correct Answer: A. Isometric
The nurse should instruct the client on isometric exercises for the muscles of the casted
extremity, i.e., instruct the client to alternately contract and relax muscles without moving
the affected part.
Option B: Active range of motion exercises should accompany isometric


exercises for every joint that is not immobilized at regular and frequent
intervals.
 Option C: Aerobic exercise is any type of cardiovascular conditioning and is
inappropriate for a client who has a leg cast.
 Option D: Isotonic exercise is one method of muscular exercise and it is not
recommended for a client who has leg cast.
NCLEXRN-02-063
Question Tag: pregnancy
A client is in her third month of her first pregnancy. During the interview, she tells the nurse
that she has several sex partners and is unsure of the identity of the baby’s father. Which of
the following nursing interventions is a priority?
A. Counsel the woman to consent to HIV screening.

 B. Perform tests for sexually transmitted diseases.
 C. Discuss her high risk for cervical cancer.
 D. Refer the client to a family planning clinic.
Correct Answer: A. Counsel the woman to consent to HIV screening
The client’s behavior places her at high risk for HIV. Testing is the first step. If the woman is
HIV positive, the earlier treatment begins, the better the outcome.
 Option B: Before performing the tests, the client should be informed first and
she must give her consent. Separate written consent for HIV testing is not
recommended. General informed consent for medical care that notifies the
patient that an HIV test will be performed unless the patient declines (opt-out
screening) should be considered sufficient to encompass informed consent for
HIV testing.
 Option C: Discussion about the risks can come after determining if the client
is HIV positive or not. Increased HIV vulnerability is often associated with legal
and social factors, which increases exposure to risk situations and creates
barriers to accessing effective, quality and affordable HIV prevention, testing
and treatment services.
 Option D: Family planning could come after the HIV screening has results. For
women with HIV who want to become pregnant, use of antiretroviral
prophylaxis during pregnancy can reduce mother-to-child transmission of HIV.
Afterwards, family planning services that promote healthy timing and spacing
of pregnancies are important to reduce the risk of adverse pregnancy
outcomes such as low birth weight, preterm birth, and infant mortality.
NCLEXRN-02-064
Question Tag: toddler
A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this
child enters the hospital room for the first time, the toddler runs to the mother, clings to
her, and begins to cry. What would be the initial action by the nurse?
 A. Arrange to change client care assignments.

 B. Explain that this behavior is expected.
 C. Discuss the appropriate use of “time-out”.
 D. Explain that the child needs extra attention.
Correct Answer: B. Explain that this behavior is expected.
During normal development, fear of strangers becomes prominent beginning around age
6-8 months. Such behaviors include clinging to parents, crying, and turning away from the
stranger. These fears/behaviors extend into the toddler period and may persist into
preschool.
Option A: Changing client assignments is unnecessary. The nurse may wait for

the child to calm down.
 Option C: Time outs are usually not appropriate for a toddler, especially if she
is in a new environment.
 Option D: The behavior shown by the toddler is normal and she does not
need any additional attention.
NCLEXRN-02-065
Question Tag: toddler, separation anxiety
While planning care for a 2-year-old hospitalized child, which situation would the nurse
expect to most likely affect the behavior?
 A. Strange bed and surroundings.
 B. Separation from parents.
 C. Presence of other toddlers.
 D. Unfamiliar toys and games.
Correct Answer: B. Separation from parents
Separation anxiety is most evident from 6 months to 30 months of age. It is the greatest
stress imposed on a toddler by hospitalization. If separation is avoided, young children
have a tremendous capacity to withstand other stress.
Option A: Most children, even school-aged children, are fearful of a strange


bed and new surroundings.
 Option C: The presence of other toddlers might help the client calm down
and adjust with the environment.
 Option D: Unfamiliar toys and games would least likely affect the toddler’s
behavior.
NCLEXRN-02-066
Question Tag: cognitive development
While explaining an illness to a 10-year-old, what should the nurse keep in mind about
cognitive development at this age?
 A. They are able to make simple associations of ideas.

 B. They are able to think logically in organizing facts.
 C. Interpretation of events originates from their own perspective.
 D. Conclusions are based on previous experiences.
Correct Answer: B. They are able to think logically in organizing facts.
The child in the concrete operational stage, according to Piaget, is capable of mature
thought when allowed to manipulate and organize objects.
 Option A: Option A describes the preoperational stage. During this stage,

young children can think about things symbolically. The preoperational stage
is the second stage in Piaget’s theory of cognitive development. This stage
begins around age 2, as children start to talk, and lasts until approximately age
7. 1 During this stage, children begin to engage in symbolic play and learn to
manipulate symbols.
 Option C: In the formal operational stage, people develop the ability to think
about abstract concepts, and logically test hypotheses.
 Option D: Option D describes the formal operational stage. The formal
operational stage begins at approximately age twelve and lasts into
adulthood. As adolescents enter this stage, they gain the ability to think in an
abstract manner by manipulating ideas in their head, without any dependence
on concrete manipulation.
NCLEXRN-02-067
Question Tag: depression
The nurse has just admitted a client with severe depression. From which focus should the
nurse identify a priority nursing diagnosis?
 A. Nutrition
 B. Elimination
 C. Activity
 D. Safety
Correct Answer: D. Safety
Safety is a priority of care for the depressed client. Precautions to prevent suicide must be a

part of the plan. Depression can be effectively treated in primary care settings using an
evidence-based collaborative approach in which primary care providers are systematically
supported by mental health providers in caring for a caseload of patients.
Option A: The client’s nutritional plan can be discussed after his safety has

been ensured. Researchers found that a healthy diet (the Mediterranean diet
as an example) was associated with a significantly lower risk of developing
depressive symptoms.
 Option B: Elimination should also be part of the nursing care plan, but this is
not the priority. Any psychosocial disturbances can impact on nervous system
neuroplasticity and this, in turn, will adversely affect downstream systems
including the GIT.
 Option C: Activities for a depressed client should be structured and
introduced gradually. Teach visualization as a tool to “bring them back down
to their bodies” and out of the constant cycle of negative thoughts. Clients
learn methods such as the “tree meditation,” in which they imagine themselves
as a tree that is growing from the ground and sprouting branches.
NCLEXRN-02-068
Question Tag: school-age
Which playroom activities should the nurse organize for a small group of 7-year-old
hospitalized children?
 A. Sports and games with rules.
 B. Finger paints and water play.
 C. “Dress-up” clothes and props.
 D. Chess and television programs
Correct Answer: A. Sports and games with rules
The purpose of play for the 7-year-old is cooperation. Rules are very important. Logical
reasoning and social skills are developed through play.
Option B: Finger paints and water play are appropriate play for toddlers. Most

toddlers do parallel play. When a child plays alongside or near others but
does not play with them this stage is referred to as parallel play.
 Option C: Dress-up and props are recommended for preschool. When a child
plays together with others and has interest in both the activity and other
children involved in playing they are participating in cooperative play.
 Option D: Chess is recommended for school-age to adolescent stage. During
the school-age years, you’ll see a change in your child. He or she will move
from playing alone to having multiple friends and social groups.
NCLEXRN-02-069
Question Tag: congestive heart failure
A client is discharged following hospitalization for congestive heart failure. The nurse
teaching the family suggests they encourage the client to rest frequently in which of the
following positions?
 A. High Fowler’s
 B. Supine
 C. Left lateral
 D. Low Fowler’s
Correct Answer: A. High Fowler’s
Sitting in a chair or resting in a bed in a high Fowler”s position decreases the cardiac
workload and facilitates breathing.
Option B: Lying flat or in a supine position would be difficult for the client and

may induce increased cardiac workload.
 Option C: Left lateral position may increase the client’s cardiac workload.
 Option D: Low Fowler’s may not be sufficient enough to support the client’s
cardiac workload.
NCLEXRN-02-070
Question Tag: burns
The nurse is caring for a 10-year-old on admission to the burn unit. One assessment
parameter that will indicate that the child has adequate fluid replacement is:
 A. Urinary output of 30 ml per hour

 B. No complaints of thirst
 C. Increased hematocrit
 D. Good skin turgor around burn
Correct Answer: A. Urinary output of 30 ml per hour
For a child of this age, this is adequate output, yet does not suggest overload. Disruption
of sodium-ATPase activity presumably causes an intracellular sodium shift which
contributes to hypovolemia and cellular edema. Heat injury also initiates the release of
inflammatory and vasoactive mediators. These mediators are responsible for local
vasoconstriction, systemic vasodilation, and increased transcapillary permeability. Increase
in transcapillary permeability results in a rapid transfer of water, inorganic solutes, and
plasma proteins between the intravascular and interstitial spaces.
Option B: Relying on the client’s thirst would not create accurate results. The

steady intravascular fluid loss due to these sequences of events requires
sustained replacement of intravascular volume in order to prevent end-organ
hypoperfusion and ischemia.
 Option C: An increase in hematocrit suggests vascular space fluid losses.
Reduced cardiac output is a hallmark in this early post-injury phase. The
reduction in cardiac output is the combined result of decreased plasma
volume, increased afterload and decreased cardiac contractility, induced by
circulating mediators.
 Option D: A good skin turgor is not an accurate indicator of adequate fluid
replacement. The goal of fluid management in major burn injuries is to
maintain the tissue perfusion in the early phase of burn shock, in which
hypovolemia finally occurs due to steady fluid extravasation from the
intravascular compartment.
NCLEXRN-02-071
Question Tag: migraine
What is the priority nursing diagnosis for a patient experiencing a migraine headache?
 A. Acute pain related to biologic and chemical factors

 B. Anxiety related to change in or threat to health status
 C. Hopelessness related to deteriorating physiological condition
 D. Risk for Side effects related to medical therapy
Correct Answer: A. Acute pain related to biologic and chemical factors
The priority for interdisciplinary care for the patient experiencing a migraine headache is
pain management.
Option B: Anxiety is a correct diagnosis, but it is not the priority. Tension


headaches are common for people that struggle with severe anxiety or anxiety
disorders. Tension headaches can be described as a heavy head, migraine,
head pressure, or feeling like there is a tight band wrapped around their head.
These headaches are due to a tightening of the neck and scalp muscles.
 Option C: Hopelessness should be addressed as part of the nursing care plan,
but it does not require urgency. Hopelessness can result when someone is
going through difficult times or unpleasant experiences. A person may feel
overwhelmed, trapped, or insecure, or may have a lot of self-doubts due to
multiple stresses and losses. He or she might think that challenges are
unconquerable or that there are no solutions to the problems and may not be
able to mobilize the energy needed to act on his or her own behalf.
 Option D: The risk for side effects is accurate, but it is not as urgent as the
issue of pain, which is often incapacitating. Focus: Prioritization
NCLEXRN-02-072
Question Tag: migraine
You are creating a teaching plan for a patient with newly diagnosed migraine headaches.
Which key items should be included in the teaching plan? Select all that apply.
 A. Avoid foods that contain tyramine, such as alcohol and aged cheese.
 B. Avoid drugs such as Tagamet, nitroglycerin and Nifedipine.
 C. Abortive therapy is aimed at eliminating the pain during the aura.
 D. A potential side effect of medications is rebound headache.
 E. Complementary therapies such as relaxation may be helpful.
 F. Continue taking estrogen as prescribed by your physician.
Correct Answer: A, B, C, D, & E.
The client should be counseled on the food and drugs that are allowed. He should also be
educated about the side effects of the medications given. Methods of distraction from pain
should also be included in the teaching plan.
Option A: One explanation is that it causes nerve cells in the brain to release

the chemical norepinephrine. Having higher levels of tyramine in the system
— along with an unusual level of brain chemicals — can cause changes in the
brain that lead to headaches.
 Option B: Oral contraceptives and vasodilators, such as nitroglycerin, can
aggravate migraines. Dilation of cerebral arteries causes the commonly
reported side effect of migraine type headache.
 Option C: Abortive therapy should be used as early as possible in the course
of a migraine. Combination analgesics containing aspirin, caffeine, and
acetaminophen are an effective first-line abortive treatment for migraine.
Ibuprofen at standard doses is effective for acute migraine treatment.
 Option D: Medication overuse headaches or rebound headaches are caused
by regular, long-term use of medication to treat headaches, such as migraines.
Pain relievers offer relief for occasional headaches. But if one takes them more
than a couple of days a week, they may trigger medication overuse headaches.
 Option E: Complementary therapies are add-on therapies meant to be used
along with traditional treatment, according to the National Center for
Complementary and Integrative Health (NCCIH). Massage, spinal
manipulation, and acupuncture are examples of complementary therapies that
may be beneficial for people with migraines.
 Option F: Medications such as estrogen supplements may actually trigger a
migraine headache attack. Fluctuations in estrogen, such as before or during
menstrual periods, pregnancy and menopause, seem to trigger headaches in
many women.
NCLEXRN-02-073
Question Tag: seizure
The patient with migraine headaches has a seizure. After the seizure, which action can you
delegate to the nursing assistant?
 A. Document the seizure

 B. Perform neurologic checks
 C. Take the patient’s vital signs
 D. Restrain the patient for protection
Correct Answer: C. Take the patient’s vital signs.
Taking vital signs is within the education and scope of practice for a nursing assistant.
 Option A: Documentation is one of the nursing responsibilities.

 Option B: The nurse should perform neurologic checks.
Option D: Patients with seizures should not be restrained; however, the nurse

may guide the patient’s movements as necessary. Focus:
Delegation/supervision
NCLEXRN-02-074
Question Tag: seizure disorder
You are preparing to admit a patient with a seizure disorder. Which of the following actions
can you delegate to LPN/LVN?
 A. Complete admission assessment.

 B. Set up oxygen and suction equipment.
 C. Place a padded tongue blade at the bedside.
 D. Pad the side rails before the patient arrives.
Correct Answer: B. Set up oxygen and suction equipment.
The LPN/LVN can set up the equipment for oxygen and suctioning.
Option A: The RN should perform the complete initial assessment.


 Option C: Tongue blades should not be at the bedside and should never be
inserted into the patient’s mouth after a seizure begins.
 Option D: Padded side rails are controversial in terms of whether they actually
provide safety and may embarrass the patient and family.
NCLEXRN-02-075
Question Tag: epilepsy
A nursing student is teaching a patient and family about epilepsy prior to the patient’s
discharge. For which statement should you intervene?
 A. “You should avoid consumption of all forms of alcohol.”

 B. “Wear your medical alert bracelet at all times.”
 C. “Protect your loved one’s airway during a seizure.”
 D. “It’s OK to take over-the-counter medications.”
Correct Answer: D. “It’s OK to take over-the-counter medications.”
A patient with a seizure disorder should not take over-the-counter medications without
consulting with the physician first.
 Option A: Alcohol is not allowed for patients with seizure because it increases
the risk of another episode.
 Option B: A medical alert bracelet bears the message that the wearer has an
important medical condition that might require immediate attention.
 Option C: One of the priorities during seizure is to prevent obstruction of the
airway by turning the client into a side-lying position to allow drainage to flow.

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NCLEX-RN Practice Quiz Test Bank #2 (75

 A. Blood sugar check

Option B: Performing CT scan at this stage of assessment is unnecessary. A

Question Tag: toilet training

 A. The age of the child

A. This too shall pass.

Option A: Ingestion of a chemical is an emergency and should not be

Option A: Intramuscular injections given at the dorsogluteal and ventrogluteal

Question Tag: toddler, language

 A. Contact the provider

 Option A: Contacting the provider is unnecessary and may take time. A

A patient is admitted to the hospital with a diagnosis of primary hyperparathyroidism. A

 A. Elevated serum calcium

The parathyroid glands regulate the calcium level in the blood. In hyperparathyroidism, the

Question Tag: Addison’s disease

 A. A diet high in grains

Question Tag: diabetes mellitus, cholecystectomy

A postoperative diabetic patient who is unable to eat is likely to be suffering from

Option A: An anesthesia reaction would not occur on the second

A nurse assigned to the emergency department evaluates a patient who underwent

Bowel perforation is the most serious complication of fiberoptic colonoscopy. Important

 Option B: Viral gastroenteritis is a known cause of nausea, vomiting, diarrhea,

Question Tag: liver biopsy, coagulation

 A. Partial thromboplastin time

 Option A: The partial thromboplastin time (PTT; also known as activated

 A. Sexual contact with an infected partner

Option A: Hepatitis B infection, caused by the hepatitis B virus (HBV), is

Question Tag: leukemia, blood transfusion

 A. A history of hepatitis C five years previously

Option B: Cholecystitis is the inflammation of the gallbladder. This condition

Question Tag: acute gastritis

A. Naproxen sodium (Naprosyn)

Naproxen sodium is a nonsteroidal anti-inflammatory drug that can cause inflammation of

 Option B: Calcium carbonate is used as an antacid for the relief of indigestion

 A. The patient must maintain a low-calorie diet

Cholecystitis, inflammation of the gallbladder, is most commonly caused by the presence

 A. Slow, deep respirations

 A. A patient admitted for myocardial infarction without cardiac muscle

An automatic internal cardioverter-defibrillator delivers an electric shock to the heart to

Option A: A patient with myocardial infarction that resolved with no

Question Tag: MRI, lung cancer

 A. The patient is allergic to shellfish.

 Option A: Shellfish/iodine allergy is not a contraindication because the

Question Tag: pulmonary embolism

 A. The patient is somnolent with decreased response to the family.

Question Tag: leukemia, chemotherapy, platelet count

 A. Monitor for fever every 4 hours.

A platelet count of 25,000/microliter is severely thrombocytopenic and should prompt the

Option A: According to three retrospective case reviews of childhood

Question Tag: increased intracranial pressure

A. Bulging anterior fontanel

 Option A: The anterior fontanel is closed in a 4-year-old child. The average

 A. Small blue-white spots are visible on the oral mucosa.

Question Tag: scarlet fever

 A. Scarlet fever is caused by infection with group A Streptococcus bacteria.

Petechiae on the soft palate are characteristic of rubella infection.

Option A: Bacteria called group A Streptococcus or group A strep cause

 A. It is the correct dose

Option A: Diphenhydramine is used to relieve red, irritated, itchy, watery eyes;

Question Tag: undescended testis

 A. Normally, the testes are descended by birth.

 A. The tumor is less than 3 cm. in size and requires no chemotherapy.

 Option A: The mass is solid at presentation and usually >10 cm.