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NCLEX TIPS: ( NCLEX questions and some pointers )

(…some questions have incomplete choices….just refer to your Saunders for some of the topics mentioned……)

1) BILI-BLANKET DO’S AND DON’TS One method of phototherapy in the hospital or at home is a fiber-optic blanket (bili-blanket). It consists of a fiber-optic pad (A), a cable connector (B), and a light generating box (C). Use of the bili-blanket is simple and safe as long as the directions for use are followed.

DO make sure the light source box is on a flat, non-absorbent surface. Do not place on carpet or sit on the crib mattress. DO make sure as much of the infant’s skin is in direct contact with the light pad. Diapers should be worn. DO have the disposable cover as the ONLY material between the light-emitting side of the pad and infant’s skin. Clothing may be worn over the pad. DO leave the light pad on when holding or feeding your baby. DO turn off light when bathing your infant. DO change the disposable cover if it becomes soiled. DO use a 3-prong plug for safety. DO set the intensity knob on the light box to the highest setting.

DON’T use the light-emitting pad without a disposable cover. DON’T directly expose your baby’s eyes to the covered light pad. DON’T sit anything on top of the light source box or the fiber optic cable ***they asked how to properly pull out the electric cord

2) In Sengstaken Blakemore tube, there are two balloons, one in the stomach and one in the esophageal part, a pair of scissors is kept near the patient at all times in case balloons migrate superiorly and cause respiratory obstruction in non-intubated patients. The whole tube can be cut and removed.


What are the usual virus used for bioterrorism. (select all that applies.)



Question on LOW ALARM SOUND -- means what?




HIGH ALRAM SOUND-- pt needs suctioning


About Clostridium Difficile, how to control infection, isolation precaution( use disposable stethoscope is the answer)


C/I in coumadin but at the same time needed to be avoided by a pt. Getting constipated, for fear of bleeding.


Select all that applies: topic was about :



Compound fracture of left radius position after long cast is applied

11) CVA ® weakness with receptive aphasia instructions on tooth brushing

12) Lyme’s disease ( types of travelers at risk)

13) Heart failure with HPN. What to question. Select all that apply (medications)

14) Management for thrombocytopenia


Pls read on the ffg:

PPD is now TST-tuberculin skin testing captopril duramorph zafirlukast vardenafil (like viagra) zelnorm for irritable bowel disease Le Veen shunt digoxin toxicity


Rocky mountain dse- type of clothing

17) Thallium scan health teaching

18) Ileostomy care…


Care…….Colostomy care

19) Tranylcypromine SO4 (Parnate) MAO foods to avoid

20) Mother feeding a month old child with GERD. What to question

21) Child with Hyperbilirubinemia. Parent teaching

22) 14 y.o. pregnant mother. Caloric requirement

23) Postmature infant

24) Obsessive Compulsive disorder indicates that the teaching is effective

25) Chest PT- when to perform

26) BPH on Proscar. Adverse effect

27) Father asks what is the action of Vit K to the newborn

28) Incentive spirometer correct usage

29) Nitroglycerin spray (Nitrolingual)

30) Diversional activity for an 8 y.o. child

31) Child with chickenpox has severe itching and ------. How to prevent secondary infection?

32) Bacterial meningitis room

33) Sterile techniques are done only by nurses…





abdominal aortic aneurysm= s/s and positioning

35) pls read about aging process… a lot of questions re: elderly

36) cerebral palsy- feeding technique

37) clept lip/palate- type of nipples

38) diverticulitis/diverticulosis

39) Pls. check the word “assent”…means: to agree to something or express agreement…. research from Encarta. This was encountered for the 3 rd time now.

40) RSV…Contact precaution, not respiratory precaution

41) Rubella vaccine…not recommended to pt. undergoing infertility test

42) Flu vaccine….don’t give it to pts w/ allergy to eggs

43) Clozaril… need for blood exam

44) Pls. read on post management of the ffg: HIP replacement, Below the knee amputation and Above the knee amputation

45) Level of fundus 20 hrs after…. At the umbilicus

46) ) hernia- type of repair, post op care

47) Utilize blood and body fluids precaution which is STANDARD (Formerly known as universal)

1. Hand hygiene

2. Gloves when in contact with blood and body fluids

3. Goggles if splashes are likely to happen

4. Gowning if soiling is likely

5. the use of 1 mouth barrier for cpr

6. never recap used needles and sharps, place them in a biohazard container

7. the use of needleless system

8. in cases of needle sticks/ prick…. wash the area, report, assessment of the nurse's blood and patient plus possible prophylaxis


Who needs vitamin B and who needs vitamin C?

For a patient with alcoholism, they will have an increase need for vitamin B; think of B and Bottle.

"Smoking has a C in cigarettes."

In a client that smokes, they will have an increase need for vitamin C. Think of C for cigarettes, and associate it with smoking).


In shock the blood pressure goes down and the pulse goes up to compensate for loss of circulation.

HINT: Remember that in increased ICP, this is the exact opposite: BP goes up and pulse rate goes down.

Opposite of increased ICP in BP and Pulse.


- use to treat mild to moderate depression, anxiety disorders, hysteria, menstruation, contusions, myalgia and insomnia.

- has demonstrated antibiotic effects, increasing wound and burn healing

- works by stimulating multiple receptors.

50) All about MRSA…NCLEX’s favorite ( delegation, prioritization, precaution, management and room assignments )



ultiple or prolonged antibiotic therapy


esistance to pennicilin, erhthromycin and tetracycline


kin open lesions and open wounds


gressive procedures and invasive indwelling catheters


A void monotherapy to prevent emergence of additional drug resistance

B odily secretions must be properly handled

C ontact precaution (eyes, hands, body)

D rug of choice VANCOMYCIN

E quipment, instruments (stethoscope) should only be used by the patient (esp with

extensive infections)

F ingernalis must be kept short

G GGG gloves, gowns and goggles (if splashes are likely to happen)

H andwashing or hand hygiene (first line of prevention)

I solation (cohorting-same organism but should be 3 feet separation)

What is MRSA? The acronym MRSA stands for methicillin-resistant Staphylococcus aureus.

Common clinical manifestations:

1. Folliculitis - infection of a hair follicle.

2. Carbuncle - deep seated pyogenic (pus-producing) infection of the skin and

subcutaneous tissue.

3. Impetigo - a contagious superficial pyoderma (any pyogenic infection of the skin)

often caused in conjunction with Streptococcus pyogenes

4. Mastitis (inflammation of the breast) - occurs in 1 - 3% of nursing mothers.

5. Wound infections.

6. Osteomyelitis - bone infection.

7. Food poisoning - usually occurs 2 - 6 hours after ingestion of food containing high

concentration of carbohydrates such as custard filled bakery, potato salads and ice cream.


Toxic shock syndrome - a severe illness characterized by a sudden onset of high fever,

profuse watery diarrhea, myalgia, followed by hypotension and, in severe cases shock. Typically occurring in young women ages 15 - 25 using tampons. Starts abruptly during menses.

9. Scalded skin syndrome - most commonly in children and neonates. Starts abruptly with

perioral (around the mouth) erythema, sunburn-like rash rapidly turning bright red

spreading to bullae (large vesicle appearing as a circumscribed area) in 2-3 days and desquamating (peeling) within 5 days.

10. Septicemia/endocarditis - associated with age extremes, cardiovascular disease,

diabetes, and heroin addicts.

11. Pneumonia - rare event with S. aureus unless preceded with influenza pneumonia or


12. Neonatal skin lesions - sometimes occurring in hospital nurseries. Often attributed to

hospital staff members (poor hand washing practices) or vaginally colonized mothers.

Incubation period The incubation period (the time period that the organism gains entry into a patient until the appearance of the first sign(s) of symptom(s) or infection) for S. aureus infection is variable and indefinite. Occurs commonly around 4 - 10 days.

Reservoir Common reservoir for Staphylococcus aureus including MRSA is primarily humans. Other animals are rarely involved

Mode of transmission Since Staphylococcus aureus colonizes the anterior nares, auto-infection) is responsible for many infections that occur in a health-care and community setting. Patients with purulent drainage that can not be contained are the most common source of possible epidemic spread. Airborne transmission is rare. Fomite (inanimate objects) is also rare. Health-care workers can contribute to the spread of S. aureus if they do not perform common hygienic behavior (i.e., washing of hands, wearing gloves)

Risk factors that should increase the level of suspicion for MRSA:

History of MRSA infection or colonization

History in the past year of:




Admission to a long term care facility (nursing home, skilled nursing, or hospice)


Dialysis and end-stage renal disease


Diabetes mellitus




Permanent indwelling catheters or medical devices that pass through the skin into the


o Injection drug use

• High prevalence of MRSA in local community or patient population (as indicated by

results of local antimicrobial susceptibility testing, clinical experience and surveillance data)

Recent and/or frequent antibiotic use

Close contact with someone known to be infected or colonized with MRSA

Recurrent skin disease

Crowded living conditions (e.g., homeless shelters)


Infection among sports participants who have:


Skin-to-skin contact


Pre-existing skin damage


Shared clothing and/or equipment

Certain populations (e.g., Pacific Islanders, Alaskans Natives, Native Americans)

Outbreaks of MRSA have been reported among men who have sex with men

Also consider MRSA in patients with SSTI and poor response to b-lactam antibiotics

Information for patients with S. aureus infection (including MRSA) and their caregivers6 Patients with S. aureus infections including MRSA, their family members and close contacts should be thoroughly counseled about measures to prevent spread of infection. Drainage from S. aureus infections, wound dressings and other materials contaminated with wound drainage are highly infectious.

Infection control messages for patients to prevent transmission of S. aureus SSTI, including MRSA include:

1. Keep wounds and lesions covered with clean, dry bandages. This is especially

important when drainage is present.

2. Wash hands with soap and warm water or alcohol-based hand rub after touching

infected skin and bandages. Put disposable waste (e.g., dressings, bandages) in a separate trash bag and close the bag tightly before throwing it out with the regular garbage.

3. Advise family members, other close contacts to wash their hands frequently with soap

and warm water, especially if they change your bandages or touch the infected area or anything that might have come in contact with the infected area.

4. Consider using clean, disposable, non sterile gloves to change bandages.

5. Do not share personal items (e.g., towels, washcloths, razors, clothing, or uniforms) or

other items that may have been contaminated by wound drainage.

6. Disinfect all non-clothing (and non-disposable) items that come in contact with the

wound or wound drainage with a solution of one tablespoon of household bleach mixed in one quart of water (must be prepared fresh each day) or a store-bought, household



Wash soiled linens and clothes with hot water and laundry detergent. Drying clothes in


hot dryer, rather than air-drying, may also help kill bacteria in clothes.


Wash utensils and dishes in the usual manner with soap and hot water or using a

standard home dishwasher.

9. Avoid participating in contact sports or other skin-to-skin contact until the infection

has healed. 10. Be sure to tell any healthcare providers who treat you that you have a MRSA, a “resistant staph infection.”

Infection control practices

Handwashing Personnel should wash their hands after contact with patients regardless if gloves are worn. The use of an antimicrobial soap remains controversial. This measure is based on the assumption that soaps that contain antimicrobial agents will remove MRSA from the skin more effectively than standard soap. There is little convincing evidence that this practice is necessary, and its cost-effectiveness has not been established. It is not what you wa Masks The use of masks for caring for a patient with MRSA pneumonia is based on the assumption that S. aureus can be spread by droplet transmission (similar to tuberculosis). There is little evidence to support that S. aureus creates this type of aerosol. Masks are not generally recommended for this type of patient or burn patients. Housekeeping practices Use common housekeeping practices for environmental cleaning (facility's procedures) of a room containing a MRSA infected patient. Common disinfectants such as quaternary ammonium compounds can use for general cleaning. Phenolics or hypochlorite solutions are unnecessary. Laundry and personnel clothing of infected MRSA patients There is absolutely no need to wash any linens or clothing separately containing suppurative material from an infected MRSA patient. The normal processing of linen, i.e., temperature of water, detergents, sours (to reduce the alkali pH to a slightly acid condition in order to match human skin's pH), rinsing and drying will eliminate this organism from such materials. Dietary dishes There is absolutely no need to use disposal dishes for someone who is infected with MRSA. The normal processing of dishes will eliminate this organism. Common-use equipment Patients who require whirlpools and foot baths should not be denied this service because they have an infection caused by MRSA. There is no need to delay this service until the end of the day or week to allow other patients to use these types of equipment first. Follow the procedures for cleaning as recommended by the manufacturer. You can place an infected MRSA patient any time during the day in common-use equipment regardless of the number of uninfected patients schedule to use them. Microbiological cultures Under no circumstance should a healthcare facility submit routine environmental cultures to determine if MRSA is in the area. Unless epidemiological data strongly suggests that such items were responsible for spread, environmental cultures should be discouraged.

Patient placement

To isolate a patient who is infected with MRSA the following criteria should be used:

Can the infection be contained with proper dressing? Is the hygiene of the patient questionable? Does the patient have mental competence? Can the patient comply with appropriate hand washing procedures?

Can the staff comply with Standard Precautions? Room placement

If a private room can not be obtained for isolation and a potential roommate is required

for placement, the following criteria should be used:

Does the potential roommate have any of the following? Open wounds [ ] tracheotomy [ ] NG tube [ ] G-tube [ ] Indwelling Foley catheter [ ]

IV sites [ ]

If the answer to any of the above is yes [x], this is not a potential roommate. If there is an already known colonized or infected patient, then cohorting would be the most logical procedure.

Isolation systems Contact isolation (private room) is the preferred method of containment for a patient who is infected with MRSA. This is based on the assumption that the drainage can not be contained and the hygiene of the patient is suspect. MRSA carriers There is absolutely no need to work restrict staff members who carry MRSA in their nares or other sites unless they have skin lesions or hygiene is suspect. Decolonization Sometimes a patient has recurrent infections caused by MRSA. The physician should be knowledgeable in the combination therapy that is required if decolonization is going to be attempted. It is important to note here that decolonization does not always work. The patient is being subjected to more antibiotics which could cause other factors such as elimination of indigenous flora (giving rise to Clostridium difficile pseudomembraneous colitis) or development of more resistant organisms. Summation MRSA is a contact organism. Standard precautions (formerly known as Universal Precautions) when followed, should control the spread of this organism. It is important that all members of healthcare facilities be in-serviced on the epidemiology of Staphylococcus aureus as well as other organisms such as vancomycin-resistant Enterococcus sp. that are endemic to an institution. This document that you have just read should be placed on all nursing stations so that the epidemiology on MRSA is fully understood.

51) Prioritization…

Some questions will have all assessment or all implementation as

answers. In this case, you'll have to go with the *BEST* answer. How to come-up with that is by process of elimination. Read each answer

will the outcome be?" "Is this a true




question is based on a circulation problem & you see a resp & a

circulation choice among the four answers

the circulatory answer because it fits with the stem of the question/situation (use your common sense or *critical thinking* skills

a prudent nurse do this or not?" When

you see a question that suggests "further teaching is necessary" or a senario wherein you, the RN know an UAP or a LPN is performing

here). Ask yourself


throw it out. "Does it follow the ABCs?" When following

statement?" If it is

& ask yourself




consider that answer response













by all means pick


something inappropriately, then you'll be looking for an answer with a "negative" or "wrong" statement. Read each answer & ask




a true statement?"






throw that



As far as delegation, Kaplan stresses that the RN is ultimately responsible for all tasks delegated. In reality LPNs can be given a lot of tasks that require assessment/gathering, planning, & evaluating


do ANY assessing, planning, evaluation, OR initial teaching. That is

entirely the role of the RN on that exam! Also, LPNs can only be given patients that are hemodynamically *STABLE*. They can't be given any patients that require constant monitoring for evaluation purposes. LPNs are only allowed to implement written orders from MDs/APNs & follow instructions given to them by the RNs in charge to cover their patients. As far as the UAPs (unlicensed assistive

can only be given the most basic of psychomotor

loads of information


in terms of the NCLEX-RN


loads of information BUT in terms of the NCLEX-RN they personnel) they nursing tasks like taking



nursing tasks like taking vital signs on stable patients ADLs & ambulating patients for therapy & again

planning and evaluation


assisting with





Therapists are *ALWAYS* available to the NCLEX-RN staff nsg!


NOT PASS THE BUCK TO THEM* !!! You have to assume that there are standing….if not written orders for your


answer choice where "call the physician", "contact a supervisor from another dept", "refer grieving families to the Chaplain", for example, before you've exhausted everything that YOU as the RN can do for

the patient

everything was done for the patient, i.e. O2 was started, the patient

was repositioned, high vent alarms & you've disconnect the patient &

started bagging

You may be asked questions on


have to know the normal values & what's expected when they're abnormal & know where to go from there. The only other time that you will "pass the buck" is when an UAP or a LPN observed something wrong with another RN's patient. You are not suppose to

what to do for a patient based on their ABGs or common labs

pick those answers. If though, you read that

is a *perfect world*. If you see in your

Another thing dept/personnel






These people are multiple & fruitful



remember this

are multiple & fruitful remember this remember this don't then & only then do you contact
are multiple & fruitful remember this remember this don't then & only then do you contact



& only then do you contact the physician,


supervisor, Resp Therapist

assess that patient since you don't know that patient's base vitals & situation. Only then would you inform either that RN or contact your


Questions that suggest a UAP of 12 years or a LPN of 20 years observes a new grad RN do something that they know (or feel) isn't right. What do you do? Confront said nurse, observed said nurse in

supervisor (staying within your chain of command)


their duties, or ask the reporting personnel to elaborate on how they come to feel this way. Unless what the UAP/LPN seen is


concerns further.

you as the RN would ask that personnel to explain their


--- just lifted this advice, hope this helps

52) Which of the following places a client to the development of ovarian cancer? SELECT ALL THAT APPLY:




Genetic predisposition


White women


Regular menses


Asian Women

F. More frequent between 11 to 19 years of age

Correct Answer: A, B, C

Risk factors for the development of Ovarian Cancer are as follows

Think of the acronym OVARIAN:

Ovarian dysfunction Vaginal use of talcum powder Alcohol Race - White women & family history Infertility Age - Peak=5th decade of life Nulliparity

53) Situation: an electrician is fixing a light bulb & you are assisting him with ecart in front of you closed & locked, a JCAHO inspector is around, your back on him, &

calls you what's the first thing to do

a) greet him

b)shake hands c)ignore him

d)turn your back & acknowledge him. ans: C - IGNORE HIM, you must never leave the ecart out of your sight, when there is someone like the electrician fixing it in front of you, just ignore the inspector

54) After immediate post operative hysterctomy patient to observe (or) Nursing care includes

a) Observe vaginal bleeding

b) Urine output

c) Vital signs

55) Which statement best describes the effects of immobility in children?

A) Immobility prevents the progression of language and fine motor development

B) Immobility in children has similar physical effects to those found in adults

C) Children are more susceptible to the effects of immobility than are adults

D) Children are likely to have prolonged immobility with subsequent complications

The correct answer is B:

Care of the immobile child includes efforts to prevent complications of muscle atrophy, contractures, skin breakdown, decrease metabolism and bone demineralization. Secondary alterations also occur in the cardiovascular, respiratory and renal systems. Similar effects and alterations occur in adults.

56) Which of the following sports can be safely recommended for patients with Hemophilia?

Horseback riding, Outdoor rock climbing, golf, or racquetball. The correct answer is: GOLF

Safe and can be recommended for most people with hemophilia. Recommended sports in which most individuals with hemophilia can participate safely: *aquatic/water exercises *archery *elliptical machine *frisbee *golf *hiking *tai chi(martial arts) *sailing *snorkeling *stationary bike *swimming*walking

57) Following change-of-shift report on an orthopedic unit, which client should the nurse see first?

A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago

B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident

C) 72 year-old recovering from surgery after a hip replacement 2 hours ago

D) 75 year-old who is in skin traction prior to planned hip pinning surgery.

The answer is C because it is the least stable among the four choices. Patients undergoing such surgery are at high risk of fat embolism especially during the first 72 hours. She may be at risk of fat embolism.

58) A client arrives in the emergency room ff. an eye injury from a chemical solution. The nurse would do which of the ff. first?

1. Test the eye pH with litmus paper.

2. Irrigate the eye.

3. Cover the eye with sterile saline solution and contact the physician.

4. Place a pressure dressing on the eye until the physician arrives.

59) Which nursing intervention will be most effective in helping a withdrawn client to develop relationship skills?

A) Offer the client frequent opportunities to interact with 1 person

B) Provide the client with frequent opportunities to interact with other clients

C) Assist the client to analyze the meaning of the withdrawn behavior

D) Discuss with the client the focus that other clients have similar problems

The correct answer is A: Offer the client frequent opportunities to interact with 1 person. The withdrawn client is uncomfortable in social interaction. The nurse- client relationship is a corrective relationship in which the client learns both tolerance and skills for relationships.

60) When planning care for client with small bowel obstruction, what should the nurse consider as her primary goal?

a. report of pain relief.

b. maintenance of body weight

c. maintenance of fluid balance

d. reestablishment of bowel pattern

Answer is C, maintenance of fluid balance. The primary action of the small intestines is absorption of nutrients. Pain is a physiologic symptom. What varies among individual, is the tolerance to pain. All human beings have the same threshold to pain, meaning the amount of stimulus to evoke pain is the same. However, the tolerance varies. That's the reason why some may tend to bear it without taking meds, like what Filipinos are known for.

61) A nurse suffers a needle stick while treating an AIDS patient. What should the nurse do?

A) Talk to a counselor.

B) Start AZT treatment.

C) Make an appointment with a social worker.


you have four chioces right? and one of it contains all the all the answer a.assess heart rate b.ssess Pulse rate c.heck temperature d. assess vital signs

Vital signs - it contains all of them

Choose an option which is:

*more inclusive

like an "umbrella"

* more benefits for the patient

* drugs with lesser side effect

* or sometimes, (educated guess) the longest option in the exam

63) During Disaster drill, which of the ff. Pts should you discharge to empty one bed?

a. pt. with glas. coma scale of 3

b. pt with head trauma and injury to C4 level

c. pt with CAD with bp of 189/98 and RR of 28

d. pt w/ ESRD with BUN 20, potassium of 5.5

64) As the RN responsible for a client in isolation, which can be delegated to the practical nurse (PN)?

A.)Reinforcement of isolation precautions

B) Assessment of the client's attitude about infection control

C) Evaluation of staffs' compliance with control measures

D) Observation of the client's total environment for risks

65) While examining a new mother, she asks you about PKU. Which of the following statements about PKU is true?

A)The effects of PKU cannot be reversed with the correct treatment.

B) PKU does not cause mental problems.

C) The lab values of PKU cannot be determined by a Guthrie test.

D) The urine shows low levels of phenylpyruvic acid.

* PKU causes permanent damage

66) A thirty-year old blind patient has been admitted to your ward. Which of the following is your primary responsibility as charge nurse?


Inform your supervisor.


Communicate your patient's needs to others.


Create a secure environment for the patient.


Contact a specialist.

67) A woman who is trying to get pregnant asks a nurse how she can increase her intake of folic acid. Which of the following foods contains the highest concentrations?




Dairy products.


Green vegetables.


White meat

68) A father asks you when he should begin his child's potty training. Which of the following is true:

A) A child should begin potty training as soon as s/he is 3 years old.

B) The most important aspect of potty training is giving praise.

C) The child must be able to understand instruction before toilet training can


D) The most important aspect of potty training is the child's mental and physical


69) A parent calls your floor after discovering that her child drank washing up liquid half an hour before. Which of the following should the nurse tell the parent?

A) Call the Poison Control Center.

B) Force the child to drink milk.

C) Bring the child to the ER as quickly as possible.

D) Not to worry, the child will be fine.

70) A nurse who is assigned to the emergency department needs to understand that gastric lavage is a priority in which situation?

A) An infant who has been identified as suffering from botulism

B) A toddler who has eaten a number of ibuprofen tablets

C) A preschooler who has swallowed powdered plant food

71) A child, age 8, is immobilized with a hip spica cast. To minimize the child's feelings of isolation, the nurse should:

A. let the child visit the playroom daily.

B. sit with the child for an hour in the room.

C. place a telephone in the child's room.

D. arrange a visit by a cooperative child from the same unit.

Rationale: School-age children need peer interaction and thrive on peer approval and acceptance. Allowing the child to visit the playroom daily provides a non threatening atmosphere for peer interaction and helps the child feel less isolated. Sitting with the child for an hour wouldn't foster the necessary peer interaction. Placing a telephone in the child's room would allow the child to communicate with family and friends but could reinforce feelings of isolation. Having another child visit would be appropriate only if the child is of the same age-group.

72) Cor pulmonale as a s/e of left sided failure. s/s to expect

a. Crackles, frothy sputum

b. Distended neck veins, bipedal edema

c. Pulmonary edema

COR PULMONALE is failure of the right side of the heart caused by prolonged high blood pressure in the pulmonary artery and right ventricle of the heart.


Any condition that leads to prolonged high blood pressure in the arteries or veins of the lungs (called pulmonary hypertension) will be poorly tolerated by the R ventricle of the heart. When this R ventricle fails to properly pump against these abnormally high pressures, this is called cor pulmonale.

Symptoms - 6'S

S/S of right sided heart failure Shortness of breath Symptoms of underlying disorders (wheezing, coughing) Swelling of the feet or ankles Skin-cyanosis Sounds-Abnormal heart sounds

Diagnostic Test

Echocardiogram (heart ultrasound) Chest X-ray CAT scan of the chest Pulmonary function tests Swan-Ganz catheterization V/Q scan Measurement of blood oxygen by arterial blood gas (ABG) Lung biopsy (rarely performed) Blood antibody tests Blood test for brain natriuretic peptide (BNP) -- a new blood test to detect heart



A dminister O2

B edrest

C alcium channel blockers

D iuretic, diet low in salt

E noxaparin, heparin or coumadin (anticoagulants)

F requent follow-up

G iving supplemental oxygen

H eart/lung transplant

I nstruct to avoid triggering factors (smoking)

73) What to check before giving KCl?

The answer is urine output. Or Assess renal function Creatinine Level


Check K+ level. Never ever push KCL IV as bolus or your patient will immediately have a cardiac arrythmia. It is incorporated with NSS and given at a set rate. KCL can burn skin and veins in large doses. Doses are adjusted based on patients age and physical stability. After giving, monitor the heart rythmn.

Remember in NCLEX "No pee No K" it means always check urine output before giving K

74) A client is admitted with increased ascites related to cirrhosis. Which nursing diagnosis should receive top priority?

A. Fatigue

B. Excessive fluid volume

C. Ineffective breathing pattern

D. Imbalanced nutrition: Less than body requirements

No indication in the question to support that pt. has actual problem with

breathing, the client is high risk for this problem, so this option is wrong., and no indication in the question to support fatigue , so eliminate.




all are potential problems. Ascites is the acumulation of fluids, so

75) Incorrect statement regarding hiatal hernia

a. maintain fowler’s position after eating

b. avoid eating before going to sleep

c. place binder to prevent heartburn

76) Which one should need further teaching to parents whose child is on apnea monitor:

a. The leads are removed whenever the baby takes a bath

b. The leads are located just below the nipple line

c. The monitor is attached to an extension cord and mounted near the wall

d. The monitor is in the kitchen area where most of the family members take their meals

The key words are NEEDING FURTHER TEACHING. This means you select the answer (among the options) that is WRONG or the most wrong for a child on an apnea monitor.

a.) The leads are removed whenever the baby takes a bath - This is proper/correct care so it is does not require further teaching.

b.) The leads are located just below the nipple line - This is the correct placement, so the parents do not require further teaching.

c.) The monitor is attached to an extension cord and mounted near the wall - BEST ANSWER. It is considered a safety hazard (fire) to use extension cords (household extension cords) with medical equipment. In addition, cords along the floor are a hazard for tripping and falling. Because of the safety issue (remember NCLEX is asking about SAFE and EFFECTIVE care) the parents need further teaching if they were to do this.

d.) The monitor is in the kitchen area where most of the family members take their meals.- This audio monitor should be place where it can be heard. The child is monitored directly, but there is an audio monitor/alarm that would sound if the child has an apneic episode. This is correct procedure, so no further teaching is required.

77) Which of these clients would the nurse recommend keeping in the hospital during an internal disaster at that facility?

A) An adolescent diagnosed with sepsis 7 days ago and whose vital signs are maintained within low normal limits.

B) A middle-aged woman known to have had an uncomplicated myocardial infarction 4 days ago

C) An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis

D) A young adult in the second day of treatment for an overdose of acetometaphen

C…. is the only unstable one, and this condition exacebates, high risk for electrolyte imbalance

78) A client had an accident with brow laceration and fractured of the jaw. Suturing of the laceration and maxillary pinning was done. Which of the following action of the nurse is appropriate? The answerkeep wire cutter at bedside

79) Food processing…

A) frozen food can be defrost for up to six hours

B) Frozen food which has been defrost can be return back to fridge

C) Cook perishable food should cover and cool

D) Frozen food should be defrost by using hot water

Food processing…

A) frozen food can be defrost for up to six hours

frozen food out of the freezer for this length of time will accomplish the goal of defrosting the item, but at the same time harmful bacteria can replicate and the end result is the person can become sick when they ingest the item. Therefore this is an inappropriate and unsafe method of defrosting frozen food.


the best answer. Leaving

B) Frozen food which has been defrosted can be return back to fridge

best answer. Frozen food that has been defrosted must be cooked first before refrigerating it in order to kill harmful bacteria.

NOT the


Cook perishable food should be covered and cooled


the available choices, this is least likely to promote the growth of bacteria/microorganisms that can cause a food borne illness.

D) Frozen food should be defrosted by using hot water

Using this method of defrosting facilitates bacterial growth.

NOT the best answer.

Source of the information supporting the best answer: USDA (United States Department of Argiculture)

80) A client with diabetes mellitus (type I). NPH insulin given at 8:00 am- When do you expect the effect?


A) at noon

B) late afternoon

C) early afternoon

D) early evening

What is the priority for a hypertensive client on CAPTOPRIL( capoten)


encourage to take medicine with meals


discuss need for potassium supplement


If client misses a dose, take 2 doses at next scheduled time


Instruct client to take drug one hour before meals


- captopril taken on empty stomach at least 1- 2hrs before meal not to decrease


82) A client with anxiety is manifesting nervousness. What herbal drug is prescribed?

a.) saw palmetto b.) ma huang c.) kava kava* d.) gingko biloba

saw palmetto - used for txt of BPH gingko bilboa - for memory

kava kava - The effect on the nerve centres is at first stimulating, then depressing.

It can also be used as local anaesthetic it relieves pain and has an aphrodisiac

effect; it has also an antiseptic effect on the urine Ma huang - is also known as Ephedra. It causes appetite suppression and increases metabolic rate. It can also lead to hypertension, nervousness, insomnia,

palpitations, hyperglycemia, and anxiety.



b) with mrsa patient

c) with copd pt


84) The sterile technique is broke when

a) The sterile field and supplies are wet

b) Clean the area peripheral to center

The sterile field and supplies are wet - there are wet areas/items which are sterile (suture, alcohol swab etc). *Clean the area peripheral to center - General Principle applies to aseptic technique "inner to outer".

85) Mother called a nurse from home stating that her child having chicken


follow up?


of the following statements by the mother needs immediate

a. father of the child with liver failure

b. sibling with anemia

c. child just had tonsillectomy

d. child has intermittent low grade fever

a.) Father of the child with liver failure - BEST ANSWER. Rationale: VZIG (varicella immune globulin) should be administered as soon as possible, but no later than 96 hours after exposure to chickenpox. Varicella can seriously affect the liver and this patient, is not only immunocompromised but they already have liver disease. Therefore their varicella immune status needs to be determined ASAP so that appropriate treatment can be started. FYI, the revised adult immunization guidelines call for patients with chronic liver disease (including alcohol induced liver disease) to receive varicella immunization, if they are not immune to the disease.

b.) Sibling with anemia - Not the best answer (see above rationale). Also, "anemia" without a qualifying adjective (i.e. aplastic, sickle cell, etc.) implies deficient number of red blood cells and decreased oxygen carrying capacity. The problem the child would evidence would be related to oxygenation. They are in fact more susceptible to infection, but their WBCs aren't affected. The patient in response A, is at greater risk.

c.) Child just had tonsillectomy-Not the best answer. Remember in priority questions you have to make a determination as to who is sickest, or who needs care first. You would in fact be concerned about this patient, but in response A you have a limited period of time to treat and prevent further disease or death. Response A, will die without proper care and treatment. Response C isn't "as critical". There are infection control issues with this answer, i.e. child had ENT surgical procedure during period of communicability and this infection is spread via droplet route, so hospital notification would have to occur.

d.) Child has intermittent low grade fever-This is anticipated associated symptom. Parents would be instructed to avoid aspirin products to prevent Reye's syndrome from occurring.

86) Who will u see first:

a.) black and blue at the lumbo sacral area b.) shiny white pearls at the fountain in the gums c.) red spots at the trunk that blanches when pressed d.) irregular blue and red spots at the buccal membrane

a.) black and blue at the lumbo sacral area Mongolian spot common in Asian NB b.) shiny white pearls at the fountain in the gums commonly found in NB which generally shed in a few weeks time

c.) red spots at the trunk that blanches when pressed. may be due to viral infection such as Herpes wherein rashes starts at the trunk (rashes blanches when pressed while a rash that doesn’t blanch when pressed it may be a petechiae or purpura)

d.) irregular blue and red spots at the buccal membrane – Koplik’s spot seen commonly with patients with measles is described as small, grain-of-sand sized, irregular, bright red spots with blue-white centres, occurring on the inside of the cheek (buccal mucosa)

Subcutaneous emphysema occurs when air enters the tissue under the skin covering the chest wall or neck. This can happen due to stabbing, gun shot wounds, other penetrations, or blunt trauma it can often be seen as a smooth bulging of the skin. When a health care provider feels the skin (palpates), it produces an unusual crackling sensation as the gas is pushed through the tissue.

I think its C….double check this pls

87) During NGT insertion what should be avoided

a.) normal saline b.) sterile water c) mineral oil

88.) The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first 2 weeks of life because:


New parents need time to learn how to hold the baby.


The umbilical cord needs time to separate.


Newborn skin is easily traumatized by washing.


The chance of chilling the baby outweighs the benefits of bathing.


Answer B is correct. The umbilical cord needs time to dry and fall off before putting the infant in the tub. Although answers A, C, and D might

be important,

they are not the primary answer to the question.

In aging patient is tidal volume capacity increase or decrease?

1. There is no change in total lung capacity/tidal lung capacity (the total volume

of air receives in each breathe), however residual volume and functional residual capacity increase.

2. High fat diet is correlated to stomach cancer and some kinds of cancers

90) A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?


Body temperature of 99°F or less


Toes moved in active range of motion


Sensation reported when soles of feet are touched


Capillary refill of < 3 seconds

Answer D is correct. It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill

would indicate a change in circulation. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, answers A, B, and C are incorrect.

91) A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?

a) Side-lying with knees flexed

b) Knee-chest

c) High Fowler's with knees flexed

d) Semi-Fowler's with legs extended on the bed

Answer D is correct. Placing the client in semi-Fowler’s position provides the best oxygenation for this client. Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client. Therefore, answers A, B, and C are incorrect.

92) A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?

a) Taking hourly blood pressures with mechanical cuff

b) Encouraging fluid intake of at least 200mL per hour

c) Position in high Fowler's with knee gatch raised

d) Administering Tylenol as ordered

Answer B is correct. It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Answer A is incorrect because a mechanical cuff places too much pressure on the arm. Answer C is incorrect because raising the knee gatch impedes circulation. Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis.

93) Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

a) Peaches

b) Cottage cheese

c) Popsicle

d) Lima beans

Answer C is correct. Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. The foods in answers A, B, and D do not aid in hydration and are, therefore, incorrect.

94) A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention.


Adjust the room temperature


Give a bolus of IV fluids


Start O2


Administer meperidine (Demerol) 75mg IV push

Answer C is correct. The most prominent clinical manifestation of sickle cell crisis is pain. However, the pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over pain relief. Answer A is incorrect because although a warm environment reduces pain and minimizes sickling, it would not be a priority. Answer B is incorrect because although hydration is important, it would not require a bolus. Answer D is incorrect because Demerol is acidifying to the blood and increases sickling.

95) The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?


Roast beef, gelatin salad, green beans, and peach pie


Chicken salad sandwich, coleslaw, French fries, ice cream


Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie


Pork chop, creamed potatoes, corn, and coconut cake

Answer C is correct. Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not; therefore, answers A, B, and D are incorrect

96) Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?


A family vacation in the Rocky Mountains


Chaperoning the local boys club on a snow-skiing trip


Traveling by airplane for business trips


A bus trip to the Museum of Natural History

Answer D is correct. Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided; therefore, answers A, B, and C are incorrect.

97) The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment?


Palpate the spleen


Take the blood pressure


Examine the feet for petechiae


Examine the tongue

Answer D is correct. The tongue is smooth and beefy red in the client with vitamin B12 deficiency, so examining the tongue should be included in the physical assessment. Bleeding, splenomegaly, and blood pressure changes do not occur, making answers A, B, and C incorrect.

98) An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator?


Conjunctiva of the eye


Soles of the feet


Roof of the mouth



Answer C is correct. The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a yellowish hue; thus, answer A is incorrect. The soles of the feet can be yellow if they are calloused, making answer B incorrect; the shins would be an area of darker pigment, so answer D is incorrect.

99) The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?


BP 146/88


Respirations 28 shallow


Weight gain of 10 pounds in 6 months


Pink complexion

Answer B is correct. When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath, as indicated in answer B. The client with anemia is often pale in color, has weight loss, and may be hypotensive. Answers A, C, and D are within normal and, therefore, are incorrect.

100) The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?


"I will drink 500mL of fluid or less each day."


"I will wear support hose when I am up."

c) "I will use an electric razor for shaving."

d) "I will eat foods low in iron."

Answer A is correct. The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Answers B, C, and D are incorrect because they all contribute to the prevention of complications. Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation.

101) A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment?


The client collects stamps as a hobby.


The client recently lost his job as a postal worker.


The client had radiation for treatment of Hodgkin's disease as a teenager.


The client's brother had leukemia as a child.

Answer C is correct. Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia, but not the ones in these answers; therefore, answers A and B are incorrect. Answer D is incorrect because the incidence of leukemia is higher in twins than in siblings.

102) An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site in examining for the presence of petechiae?


The abdomen


The thorax


The earlobes


The soles of the feet

Answer D is correct. Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petichiae. Answers A, B, and C are incorrect because the skin might be too

dark to make an assessment.

103) A client with acute leukemia is admitted at the oncology unit. Which of the following would be most important for the nurse to inquire?


"Have you noticed a change in sleeping habits recently?"


"Have you had a respiratory infection in the last 6 months?"


"Have you lost weight recently?"


"Have you noticed changes in your alertness?"

Answer B is correct. The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations; therefore, answers A, C, and D are incorrect.

104) Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?


Oral mucous membrane, altered related to chemotherapy


Risk for injury related to thrombocytopenia


Fatigue related to the disease process


Interrupted family processes related to life-threatening illness of a family member

Answer B is correct. The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses in answers A, C, and D, which are incorrect.

105) A 21-year-old male with Hodgkin's lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?


Sexual dysfunction related to radiation therapy


Anticipatory grieving related to terminal illness


Tissue integrity related to prolonged bed rest


Fatigue related to chemotherapy

Answer A is correct. Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the

client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Answers B, C, and

D are incorrect because they are of lesser priority.

106) A client has autoimmune thrombocytopenic purpura. To determine the client's response to treatment, the nurse would monitor:

a) Platelet count

b) White blood cell count

c) Potassium levels

d) Partial prothrombin time (PTT)

Answer A is correct. Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct answer. White cell counts, potassium levels, and PTT are not affected in ATP; thus, answers B, C, and D are incorrect.

107) The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80, It will be most important to teach the client and family about:


Bleeding precautions


Prevention of falls


Oxygen therapy


Conservation of energy

Answer A is correct. The normal platelet count is 120,000400, Bleeding occurs

in clients with low platelets. The priority is to prevent and minimize bleeding.

Oxygenation in answer C is important, but platelets do not carry oxygen. Answers

B and D are of lesser priority and are incorrect in this instance.

108) A client with a pituitary tumor has had a transphenoidal hyposphectomy. Which of the following interventions would be appropriate for this client?

a) Place the client in Trendelenburg position for postural drainage

b) Encourage coughing and deep breathing every 2 hours

c) Elevate the head of the bed 30°

d) Encourage the Valsalva maneuver for bowel movements

Answer C is correct. Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. Answers A, B, and D are incorrect because

Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure.

109) The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:


Measure the urinary output


Check the vital signs


Encourage increased fluid intake


Weigh the client

Answer B is correct. The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Measuring the urinary output is important, but the stem already says that the client has polyuria, so answer A is incorrect. Encouraging fluid intake will not correct the problem, making answer C incorrect. Answer D is incorrect because weighing the client is not necessary at this time.

110) A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?


Place the client in a sitting position with the head hyperextended


Pack the nares tightly with gauze to apply pressure to the source of bleeding


Pinch the soft lower part of the nose for a minimum of 5 minutes


Apply ice packs to the forehead and back of the neck

Answer C is correct. The client should be positioned upright and leaning forward, to prevent aspiration of blood. Answers A, B, and D are incorrect because direct pressure to the nose stops the bleeding, and ice packs should be applied directly to the nose as well. If a pack is necessary, the nares are loosely packed.

111) A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate post-operative period for the nurse to take is:

a) Blood pressure

b) Temperature

c) Output

d) Specific gravity

Answer A is correct. Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of infection, decreased output would be a clinical manifestation but

would take longer to occur than blood pressure changes, and specific gravity changes occur with other disorders; therefore, answers B, C, and D are incorrect.

112) A client with Addison's disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu- Medrol). Which of the following interventions would the nurse implement?

a) Glucometer readings as ordered

b) Intake/output measurements

c) Sodium and potassium levels monitored

d) Daily weights

Answer A is correct. IV glucocorticoids raise the glucose levels and often require coverage with insulin. Answer B is not necessary at this time, sodium and potassium levels would be monitored when the client is receiving mineral corticoids, and daily weights is unnecessary; therefore, answers B, C, and D are incorrect.

113) A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses' next action be?

a) Obtain a crash cart

b) Check the calcium level

c) Assess the dressing for drainage

d) Assess the blood pressure for hypertension

Answer B is correct. The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling is due to low calcium levels. The crash cart would be needed in respiratory distress but would not be the next action to take; thus, answer A is incorrect. Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage, so answers C and D are incorrect.

114) A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

a) Impaired physical mobility related to decreased endurance

b) Hypothermia r/t decreased metabolic rate

c) Disturbed thought processes r/t interstitial edema

Answer D is correct. The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices; therefore, answers A, B, and C are incorrect.

115) The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client?

a) Report muscle weakness to the physician.

b) Allow six months for the drug to take effect.

c) Take the medication with fruit juice.

d) Ask the doctor to perform a complete blood count before starting the


Answer A is correct. The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyositis. The medication takes effect within 1 month of beginning therapy, so answer B is incorrect. The medication should be taken with water because fruit juice, particularly grapefruit, can decrease the effectiveness, making answer C incorrect. Liver function studies should be checked before beginning the medication, not after the fact, making answer D incorrect.

116) The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:

a) Utilize an infusion pump

b) Check the blood glucose level

c) Place the client in Trendelenburg position

d) Cover the solution with foil

Answer B is correct. Hyperstat is given IV push for hypertensive crises, but it often causes hyperglycemia. The glucose level will drop rapidly when stopped. Answer A is incorrect because the hyperstat is given by IV push. The client should be placed in dorsal recumbent position, not a Trendelenburg position, as stated in answer C. Answer D is incorrect because the medication does not have to be covered with foil.

117) The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?

a) Blood pressure of 126/80

b) Blood glucose of 110mg/dL

c) Heart rate of 60bpm

Answer C is correct. A heart rate of 60 in the baby should be reported immediately. The dose should be held if the heart rate is below 100bpm. The blood glucose, blood pressure, and respirations are within normal limits; thus answers A, B, and D are incorrect.

118) The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:

a) Replenish his supply every 3 months

b) Take one every 15 minutes if pain occurs

c) Leave the medication in the brown bottle

d) Crush the medication and take with water

Answer C is correct. Nitroglycerine should be kept in a brown bottle (or even a special air- and water-tight, solid or plated silver or gold container) because of its instability and tendency to become less potent when exposed to air, light, or water. The supply should be replenished every 6 months, not 3 months, and one tablet should be taken every 5 minutes until pain subsides, so answers A and B are incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, as stated in answer D.

119) The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?

a) Macaroni and cheese

b) Shrimp with rice

c) Turkey breast

d) Spaghetti

Answer C is correct. Turkey contains the least amount of fats and cholesterol. Liver, eggs, beef, cream sauces, shrimp, cheese, and chocolate should be avoided by the client; thus, answers A, B, and D are incorrect. The client should bake meat rather than frying to avoid adding fat to the meat during cooking.

120) The client is admitted with left-sided congestive heart failure. In assessing the clien for edema, the nurse should check the:

a) Feet

b) Neck

c) Hands

Answer B is correct. The jugular veins in the neck should be assessed for distension. The other parts of the body will be edematous in right-sided congestive heart failure, not left-sided; thus, answers A, C, and D are incorrect.

121) The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:


Phlebostatic axis




Erb's point


Tail of Spence

Answer A is correct. The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the correct placement of the manometer. The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line, so answer B is incorrect. Erb’s point is the point at which you can hear the valves close simultaneously, making answer C incorrect. The Tail of Spence (the upper outer quadrant) is the area where most breast cancers are located and has nothing to do with placement of a manometer; thus, answer D is incorrect.

122) The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:


Question the order


Administer the medications


Administer separately


Contact the pharmacy

Answer B is correct. Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension. Answers A, C, and D are incorrect because the order is accurate. There is no need to question the order, administer the medication separately, or contact the pharmacy.

123) The best method of evaluating the amount of peripheral edema is:


Weighing the client daily


Measuring the extremity


Measuring the intake and output

d) Checking for pitting

Answer B is correct. The best indicator of peripheral edema is measuring the extremity. A paper tape measure should be used rather than one of plastic or cloth, and the area should be marked with a pen, providing the most objective

assessment. Answer A is incorrect because weighing the client will not indicate peripheral edema. Answer C is incorrect because checking the intake and output will not indicate peripheral edema. Answer D is incorrect because checking for pitting edema is less reliable than measuring with a paper tape measure.

124) A client with vaginal cancer is being treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that:


Overnight stays by family members is against hospital policy.


There is no need for him to stay because staffing is adequate.


His wife will rest much better knowing that he is at home.


Visitation is limited to 30 minutes when the implant is in place.

Answer D is correct. Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important. Answers A, B, and C are not empathetic and do not address the question; therefore, they are incorrect.

125) The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?


"I will make sure I eat breakfast within 10 minutes of taking my insulin."


"I will need to carry candy or some form of sugar with me all the time."


"I will eat a snack around three o'clock each afternoon."


"I can save my dessert from supper for a bedtime snack."

Answer A is correct. Novalog insulin onsets very quickly, so food should be available within 1015 minutes of taking the insulin. Answer B does not address a particular type of insulin, so it is incorrect. NPH insulin peaks in 812 hours, so a snack should be eaten at the expected peak time. It may not be 3 p.m. as stated in answer C. Answer D is incorrect because there is no need to save the dessert until bedtime.

126)A client with leukemia is receiving Trimetrexate. After reviewing the client's chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:


Treat iron-deficiency anemia caused by chemotherapeutic agents


Create a synergistic effect that shortens treatment time


Increase the number of circulating neutrophils


Reverse drug toxicity and prevent tissue damage

Answer D is correct. Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid derivative. Answers A, B, and C are incorrect because Leucovorin does not treat iron deficiency, increase neutrophils, or have a synergistic effect.

127)A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:


Hib titer


Mumps vaccine


Hepatitis B vaccine



Answer A is correct. The Hemophilus influenza vaccine is given at 4 months with the polio vaccine. Answers B, C, and D are incorrect because these vaccines are given later in life.

128)The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:


30 minutes before meals


With each meal


In a single dose at bedtime


30 minutes after meals

Answer B is correct. Proton pump inhibitors such as Nexium and Protonix should be taken with meals, for optimal effect. Histamine-blocking agents such as Zantac should be taken 30 minutes before meals, so answer A is incorrect. Tagamet can be taken in a single dose at bedtime, making answer C incorrect. Answer D does not treat the problem adequately and, therefore, is incorrect.

129) A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?


Call security for assistance and prepare to sedate the client.


Tell the client to calm down and ask him if he would like to play cards.


Tell the client that if he continues his behavior he will be punished.


Leave the client alone until he calms down.

Answer A is correct. If the client is a threat to the staff and to other clients the nurse should call for help and prepare to administer a medication such as Haldol to sedate him. Answer B is incorrect because simply telling the client to calm down will not work. Answer C is incorrect because telling the client that if he continues he will be punished is a threat and may further anger him. Answer D is incorrect because if the client is left alone he might harm himself.

130) When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:

a) Check the client for bladder distention

b) Assess the blood pressure for hypotension

c) Determine whether an oxytocic drug was given

d) Check for the expulsion of small clots

Answer A is correct. If the fundus of the client is displaced to the side, this might indicate a full bladder. The next action by the nurse should be to check for bladder distention and catheterize, if necessary. The answers in B, C, and D are actions that relate to postpartal hemorrhage.

131)A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are consistent with a diagnosis of:

a) Pneumonia

b) Reaction to antiviral medication

c) Tuberculosis

d) Superinfection due to low CD4 count

Answer C is correct. A low-grade temperature, blood-tinged sputum, fatigue, and night sweats are symptoms consistent with tuberculosis. If the answer in A had said pneumocystis pneumonia, answer A would have been consistent with the symptoms given in the stem, but just saying pneumonia isn’t specific enough to diagnose the problem. Answers B and D are not directly related to the stem.

132)The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client's history should be reported to the doctor?

a) Diabetes

b) Prinzmetal's angina

c) Cancer

d) Cluster headaches

Answer B is correct. If the client has a history of Prinzmetal’s angina, he should not be prescribed triptan preparations because they cause vasoconstriction and coronary spasms. There is no contraindication for taking triptan drugs in clients with diabetes, cancer, or cluster headaches making answers A, C, and D incorrect.

133)The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig's sign is charted if the nurse notes:

a) Pain on flexion of the hip and knee

b) Nuchal rigidity on flexion of the neck

c) Pain when the head is turned to the left side

d) Dizziness when changing positions

Answer A is correct. Kernig’s sign is positive if pain occurs on flexion of the hip and knee. The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest so answer B is incorrect. Answers C and D might be present but are not related to Kernig’s sign.

134)The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:

a) Agnosia

b) Apraxia

c) Anomia

d) Aphasia

Answer B is correct. Apraxia is the inability to use objects appropriately. Agnosia is loss of sensory comprehension, anomia is the inability to find words, and aphasia is the inability to speak or understand so answers A, C, and D are incorrect.

135)The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is



a) Chronic fatigue syndrome


Normal aging





Answer C is correct. Increased confusion at night is known as "sundowning" syndrome. This increased confusion occurs when the sun begins to set and continues during the night. Answer A is incorrect because fatigue is not necessarily present. Increased confusion at night is not part of normal aging;

therefore, answer B is incorrect. A delusion is a firm, fixed belief; therefore,

answer D is


136)The client with confusion says to the nurse, "I haven't had anything to eat all day long. When are they going to bring breakfast?" The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?


"You know you had breakfast 30 minutes ago."


"I am so sorry that they didn't get you breakfast. I'll report it to the charge nurse."


"I'll get you some juice and toast. Would you like something else?"


"You will have to wait a while; lunch will be here in a little while."

Answer D is correct. Nausea and gastrointestinal upset are very common in clients taking acetlcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity, dizziness, unsteadiness, and clumsiness. The client might already be experiencing urinary incontinence or headaches, but they are not necessarily associated; and the client with Alzheimer’s disease is already confused. Therefore, answers A, B, and C are incorrect.

137)The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?

a) Roast beef sandwich, potato chips, pickle spear, iced tea

b) Split pea soup, mashed potatoes, pudding, milk

c) Tomato soup, cheese toast, Jello, coffee

d) Hamburger, baked beans, fruit cup, iced tea

138)A woman is going to have a mammography, which will you be most concerned about and need to report?

a.) powders and lotions used under the armpit. b.) a permanent pacemaker.

Typically in NCLEX priority questions all responses are actions that should be taken in the situation described in the question. The test-taker is asked which is the most important. Therefore it would seem that reporting the pacemaker is a higher priority. In addition this question had asked which needs to be reported. NCLEX is evaluating the test-taker's knowledge about what can be handled/addressed by the nurse. The powder and lotions should be removed completely by either the nurse or the client before the mammogram (the question indicated the time frame was before the procedure). This is part of safe and effective care for clients in this situation. Once these products are removed they are no longer a concern.

In the end the NCLEX test takers have to make up their own mind, which is the best answer. These questions help those studying for the exam to consider the underlying rationale for the best answer.

139)Rationale for giving the ffg.

1. D5LR to patients with Dengue Fever?

2. D5.3NaCl to patients with CRF

The reason for giving D5LR in DF is that it serves as alternative fluid if plasma expander is not yet available. It expands intravascular space to prevent vascular collapse so as to prevent shock. D5 0.3 Nacl is given in pts with CRF to prevent hyperkalemia. Remember this fluid has no K+ and you would not place ur pt into congestion that is why it is given.

140) What to check before giving Epoetin Alfa?

Check for epilepsy or a history of seizures. Epoetin alfa may cause seizures. Be careful if you drive or do anything that requires to be awake and alert.


Low protein diet to reduce ammonia production. However, dietary counseling is important, as too little protein in the diet can contribute to malnutrition. Lactulose

may be given to prevent intestinal bacteria from creating ammonia, and as a laxative to evacuate blood from the intestines. Neomycin may also be used to reduce ammonia production by intestinal bacteria

142) When to give Atacid with Tagamet

a.) Antacid given 1 hour after tagamet b.) Antacid is given with Tagamet c.) Antacid given 1 hour before Tagamet d.) Antacid given 30 min before Tagamet

143) A corner of a room is on fire, what to do first?

a.) evacuate the residents b.) put out the fire c.) activate the alarm d.) put the oxygen off

144) Patient with rhematoid arthritis, what to prioritize?

a.) Give anti inflammatory drug before exercising? b.) Exercise immidiately upon waking up c.) warm compress the hand before exercising the wrist


Medical surgical is full first


to move patient to OB ward

a.)13y/o with rheumatic fever b.) 23 y/o with pyelonephritis c.) 45 y/o with SLE (lupus) d.) 33 y/o with PCP


patient to move

146) The mother of a 6 month old states that she has started her infant on 2% milk . Which of the following would be the nurse's best response?

a.)"Your baby will probably be fine with this milk" b.)"The baby should be switched to whole milk" c.)"You need to keep the infant on formula" d.) "You need to switch to formula right now"

147) TB pt understands that he can reduce the risk of spreading his disease if he states?

a.) i wont sleep in same room w/ my wife for 1-2 months b.) i will stay away from pregnant women and children c.) i will use plastic utensil when i eat

148) Allergic to sulfa would not to take?

a.) ma huang b.) Echinacea

149) Client with allergy to sudafed


of the statements is correct?

a.) i will take valerian b.) i will take ma huang c.) i will take echinacea for acute viral inf. d.) i will take black cohosh



151) Alzheimer's patient, incontinent of urine during the night times. The nursing care includes

a) Offers bed pan every 2 hours

b) Limit fluids during evening times

c) Foley's catheter

152) A young patient most likely to get lead poisoning if?

a. he is drinking from a ceramic pitcher.

b. father refurnishes old furniture at their home

153) A client is receiving O2 via nasal cannula.when providing nursing,which or the following intervention would be appropriate

a) determine that adequate mist is supplied

b) inspect the nares and ears 4 skin breakdown

c) lubricate the tips of cannula b4 insertion

d) maintain sterile techniqueto when handling cannula

154) A mother tells the nurse that she wants her 4 year old to stop sucking her thumb. When developing the teaching plan for this mother, which of the following would the nurse expect to suggest?

a.) Apply a special medicine that tastes terrible on the thumb b.) Get the child to agree to stop the thumb sucking c.) Remind the child every time the mother sees the thumb in her mouth d.) Put the child in "time-out" every time the mother observes thumb sucking

155) A nurse is coming back from her lunch break. Which of the ff patients shld she assess first?

a.).A pt. that has dissociative personality disorder and goes into the room of an anxious pt's room b.). Bipolar pt. that is singing loudly in the activity room. c.). Deppressed pt. lying on the floor on fetal position. d.) Delirium pt. pacing up and down the hall, admiring the painting on the wall


Risk Factor of colorectal cancer

a.) female b.) High fiber diet c.) Bowel inflamatery disease d.) Irritable bowel syndrome

157) The nursing team consist of RN who has been practicing for 6 mos.,LPN/LVN been practicing for 15 years and a nursing assistant who has been practicing for 5 years.The RN should care for which of the following client?

a.) a client 1 day post op after internal fixation of fractured femur b.) a patient receiving diltiazem and dilantin c.) a client who is to recieve 2 packed cells prior to an upper endoscopy procedure

d.) a client who was admitted yesterday with exhaustion and diagnosis of acute bipolar disorder

158) What to do first b4 crutch walking?

give pain

medication first.

take bp lying down & sitting down or

159) If you are a Community health nurse w/c one to see first…. 26 y.o with scheduled terbutaline inhalation or 45 y.o. who needs lithium refill


Patient diagnosed with myocardial infarction has lots of crushing chest

pain, what should nurse do first?


give morphineÂ


administer O2


check vital signs

d. start an IV

161) A nurse in the psychiatric ward is making rounds. Which of the below patient should receive his/her medication FIRST.

a) a patient who is scheduled to have her anxiety med.

b) a patient who just returned from her group therapy and is to receive her

anxiety med.

c) a patient with bi-polar who is wringing her hands and pacing down the


d) a patient with depression who has not spoken to staff for several days

162)A 2 year old year old with a suspected diagnosis of hearing impairment. Which of the following action by the child contribute to the diagnosis?

A) Child talking few words

B) Child plays alone with other children around

C) Gesture and pointing what he wants


Check all that apply what would you expect to see in the aging process:

a.)shortness of breath

b.) dry skin c.)loss of vision d.)thin nails e.)long memory loss

164) Early sign of acute otitis media

a.) hearing loss b.) rolling of head from side to side c.) purulent ear discharge d.) ?

165) Appendicitis what to report to the M.D

a. pain at periumbilical area

b. abdominal distention

c. pain unrelieved by meds

166)Food to question in Diverticulosis

a. fats

b. carbohydrates

c. fiber

d. amino acid

167) Which of the ff is an incorrect statement made by the student nurse about infection control?

a.) hand washing is the single most effective way of preventing the spread of infection. b.) autoclaving kills all pathogenic microorganisms including spores. c.) autoclaved items is considered sterile until 6mos only. d.) the skin can never be sterile.

168) Home O2 therapy. Client need further teaching when she state that

a. change my cotton blanket to wool

b. If I experienced a dry mucous membrane, I will put water in the humidifier

c. Telling the family members not to smoke

169) While a client is being prepared for discharge, the nasogastric (NG) feeding tube becomes clogged. To remedy this problem and teach the client's family how to deal with it at home, what should the nurse do?

a) Irrigate the tube with cola.

b) Advance the tube into the intestine.

c) Apply intermittent suction to the tube.

d) Withdraw the obstruction with a 30-ml syringe.

170) A pt. has cor pulmonale as a s/e of left sided heart failure, What are the expected s/s

a) Crackles,frothy sputum

b) Distended neck vein,bi-pedal edema

c) Pulmonary edema

d) Anxiety

171) Which of the ff pt. would the nurse see first

a.) a child with vomiting 4x b.) a child who had abdominal pain few hours said"my pain is gone" c.) a child with cough

172)The pt with injury


of the ff is a correct statement

a.)injury at C2 level,can move independently a.) C4 can eat alone b.) T3 can walk alone c.) T6 dress independently

173) Prioritize:

a.) Patient call out (to go to the bathroom) b.) Angry relative about incorrect food tray being left with diabetic mother c.) Patient calls out bleeding d.) Doctor on the phone

174) The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's disease. Which side effect is most often associated with this drug?

a) Urinary incontinence

b) Headaches

c) Confusion

d) Nausea

175) A pt. on heparin infusion, he told the nurse that "his gums bleed when brushing the teeth", the should do first?

a) notify doctor.

b) stop the infusion.

c) do ptt test

d) give protamine sulfate

Goodluck and Godbless to all!!!!!!!!!!

//compiled by VMH


------------------NCLEX tips from Sir Darius------------------

NCLEX 2005

32. You have an 80 year old client, what would be a normal aging process?


problem with light accommodation


increase sensation to pain


tingling or sensation at tip of extremities

33. You have a 45 year old who had a Salpingo-oophorectomy hysterectomy. What would patient say to let you know they understood teaching?

a. I will have to take estrogen for life.

b. I will take estrogen until I am 65.

c. I will take estrogen when I have.

34. A patient on a detox unit went home and upon return told the nurse that he snorted cocaine this weekend. What should the nurse do?

a. You should not be seen in the hall

b. You will be ask to leave the program

c. Monitor the vital signs

d. What triggered this drug use over the weekend.

35. As a community health nurse, you have 4 patients with ESRD or hospice and the

caregivers are supposed to call and report to the nurse everyday. Which patient to see first?

a. a patient who had a new IV line started yesterday evening.

36. A patient on chemotherapy skin is red and irritated. What could possible cause this?


frequent bathing daily


applying an abrasive ointment


drying with a soft cloth


A group of patients on radiation therapy. Which one would be cause for intervention?

a. a patient who has prostate cancer with radium seed implants with a 4 year old on his lap

b. a client on external radiation talking to a pregnant woman

38. A client with anorexia. What would be of concern?

a. amenorrhea for 2 months

b. weakness for two weeks

c. hair loss

d. enamel

NCLEX 2005


1. 58 year old woman, what is the most significant in this age?

(a) Kyphosis

Normal aging in the mouth decrease taste in food

(b) Presbycussis



1. What should be a concern to the nurse when Lactulose is ordered?

(a) Pt who has not had bowel movement 3 days ago


Pt who has not eaten for a day




Action of tagamet in Cystitis


Action of Parlodel


What to do when administering heparin?


Pull back on syringe


Massage area after administration


Wait to see if hematoma will form Cancer


Highest risk for colon cancer


History of Inflammatory Bowel Disease and Colostomy


Pt with rectal polyps


Pt who smoke



What should you delegate to a nurses aide


ambulate a pt with lobectomy 1 hour ago


flush the BGT


A nurse have a group of pts, which one can she assign to the CNA?


A pt. with PCP who needs a bath


A pt. who needs dressing change for a decubitus


A pt. who had surgery and needs ambulation

Psychiatric Nursing What should concern to the nurse


child who remains quiet during venipuncture


toddler who falls occasionally when




1. Domestic violence, main reason for staying with abusive spouse

2. Study chemotherapy drug (methotrexate) i.e bone marrow depression

3. Depression

4. Schizophrenic patient, how does the nurse know that group therapy is working come on time for session

5. Post traumatic Stress Syndrome, s & s insomnia and anxious

6. OCD, ritualistic behavior has started and Pt has a phone call, what should the nurse tell the caller call back

7. Delirium tremens, why is shadow in the environment contraindicated

8. The nurse is talking to the spouse of a pt who’s husband had a prostatectomy when the spouse said “ we will not be intimate anymore”. The nurse will say

A) What does intimate mean to you?

B) Can you tell me more about your relationship?

C) There is difficulty getting an erection after this surgery

9. Husband had an MI. Wife says I don’t know what I would do if I lose him he is my best friend. Nurse’s response

A.) It’s nice that you can to your husband B.) What makes you think he is going to die? C.) Would you like for me to call a family member to stay with you?

A) What higher being or something

B) What is your religion?

C) Would you like to inform your spiritual adviser about your hospitalization?

11.Pt in labor came in with bruise on neck and arm. What would the nurse do?

A) Ask pt about bruise on neck and arm B) Try to find out about pts delivery plan

12.A nurse suspects that co-worker is drinking on the job. What should the nurse do?

A) Confront the co-worker about the drinking

B) Watch and report to the supervisor

C) Sit and wait until they have proof

D) Do you need help with pt. care?

13) A parent is terminally ill. How do adult children show that they are coping effectively?

A) We are planning how we are going to organize care for parent

B) We already began to accept the lost by grieving and crying

C) We reminisce with mom about the good time.

14) The nurse is having a staff meeting to discuss safety for an Alzheimers pt.

A) Encourage staff client to reorient client

B) Place food trays on client in chair

C) Apply a restraint

D) Put alarm on exit doors

15) An Alzheimers client is at home but has the tendency to keep going out side. What should he do?

A) Put sensors on doors

B) Have the family security guard check client

C) When the days are nice go outside with the client for a walks ??

16) The nurse is talking to a group of adults who were raped in childhood. How would she know that they are developing high self-esteem?

A) I will be going back to college to get a degree

B) They say that I am attractive

C) I go out dates regularly

D) I feel good in familiar environment


1. Hepatic Encephalopathy need to restrict

(a) protein

(b) K

(c) carbohydrates

2.Child with Tylenol poisoning, what do you assess right upper quadrant pain and jaundice

Feedback from another candidate:

- Pt who just had an ileostomy 2 days ago, states she is going for vacation, what will the nurse say it is too soon but you can still travel with an ileostomy

- Ulcerative colitis and Crohn’s disease

- Sengstaken Blakemore tube

- Stool in ulcerative colitis

- Colostomy irrigation, solution for initial irrigation


1. Most indicator of Amyotrophic Lateral Sclerosis


unilateral weakness


abnormal involuntary movement


paralysis from legs to up


Parkinsons disease serves small bites of food


Cranial Nerve III


Myasthenia Gravis, appropriate nursing diagnosis


Spinal Cord Injury, purpose pt ask why he is being taken for surgery



Most indicator of Septic Shock


Hypertension and increase leukocytes count


Hypotension and decrease urinary output


1. Ventilator low pressure alarm sounds


suction the pt


check whether the tube is disconnected


the pt is fighting the ventilator


Child with inspiratory stridor, what do you assess ask the mother if they were remodeling the house few days ago

Feedback from Another Candidate:

A pt is on mechanical ventilator, when the machine starts beeping, who does the nurse checks first machine or the pt.

3. PPD test positive for AFB, what will you teach the pt

4. Breath sounds

5. Chest tube, has bubbling in the suction bottle, what does it tells the nurse

6. Why soft diet in emphysema

7. How to conduct a pulmonary assessment?

A) Place hand around sternum with thumbs touching and feel when diaphgram rises

B) Listen to pt. making sound

C) have pt. breathe in and out listen with a stethoscope



Hemodialysis pt was the following situation, which one should you attend first



blood oozing continuously through AV shunt


respiration is 32



Lower UTI


drainage with pus (b) hesitancy in urination



Home technique for catheterization clean technique


Kidney transplant, what would alert the nurse


abdominal tenderness

(b) burning sensation during urination

(c) 1.8

kg weight gain since transplant a week ago


After kidney transplant, pt has urine 1200 cc /day - is it normal or abnormal

6. Glomerulonephritis and Nephrotic syndrome

7. You have a pt with an Ileal Conduit. How would you know that teaching was effective?

A) For several weeks my urine will be cloudy

B) I will hook up my bag to a drainage system at night

C) I can’t wait for my bag to be ¾ full to empty it


1. Hip replacement, type of exercise

(a) full ROM


(b) Quadriceps setting exercise (d) adduction and abduction

(c) Internal and external


1. Pt with hypoglycemia, orage juice was given, what do you give next

(a)a bottle of cola (b) a bolus of candy (c) peanut butter

2. Pancreatitis, which one should concern the nurse

(a) increase serum amylase

Feedback from another Candidate:

(b) upper right quadrant pain

3. Continuous subcutaneous infusion of Insulin, what are you going to teach patient

4. A diabetic pt has no control over his blood sugar, during assessment what will you ask

the pt use of prednisone

5. Differencce between type I and Type II Diabetes Melitus

6. Hyperglycemia in DM, what should the nurse do first


Urine testing in DM, collection of urine specimen



PMS, effective teaching


Limit intake of chocolate


Maintain complex carbohydrates


Limit caffeine and tea

Feedback from another Candidate 11/01

2. After an elective abortion of 10 weeks, what is the nursing priority?

3. First phase of labor

4. Use of pitocin

5. Difference between true and false signs of labor

6. Rhogam, criteria

7. Late deceleration

8. PID, s & s severe lower abdominal pain/ purulent vaginal discharge

9. Premenstrual syndrome

10. Toxemia of pregnancy

11. Purpose of forceps delivery

12. Relief of hypertension in pregnancy

13. Magnesium sulfate, criteria prior to administration

14. Why BSE is done 7 days after menstruation


The nurse is talking to a group of pregnant mothers and she would like to discuss about sex during pregnancy. What would the nurse say?


Sex during pregnancy will cause harm to the fetus


In the second trimester the woman has no interst in sex


If the couple had a good sex life before the pregnancy there should not be any change in their sex life


It is likely that the couple will experience some change in their sex life



Physical competence of 2month old child


Purpose of putting newborn


Cystic Fibrosis, effectiveness of therapy clear lung sound


Mother refuse immunization for her child find out her reason


Cross-eye in newborn, explanation by the nurse -


Aspirin poisoning, what should the nurse do first


Mother of a 10 month infant complained about the baby getting up during the night and disturbing other family members. How can the nurse help her to get the child to sleep?


Leave a bottle of water in the crib


Let child cry longer before checking on child


Enroll child in infant exercise program


A mother comes to the clinic with a 4 month old and a set of 18 month old twins. The 4 month old has a diaper rash and is in the stroller and the only time he gets out of the stroller is for a check in the examination table. One twin is eating chocolate covered peanut candy sitting quietly in the chair, while the mom is attending to the other twin who is being examined. What is a good thing for the nurse to teach about?






Dental caries


Mother complains of being frustrated trying to teach her child toilet training, so she asks the nurse for help. What should the nurse tell her?


Put a diaper on the child at night




Let mom know that child will let her know when he is ready

A) 37 inches

B) 56 inches

C) Tie shoe lace


The nurse is assessing a group of infants.What should be cause for concern?

A) negative moro tonic neck reflex

B) A 5 mnth. old with negative palmar grasp


A pt has Bells Palsy. What will pt say to let you know he understands the disease?

A) I heard its related to a stroke

B) I heard that some people have a complete recovery

C) Constant lacrimation TRIAGE


You are a nurse working a emergency room and you have these pt.s. Who would you see first

A) 17 yr. old with amputated toe and 2 nd degree burn

B) 7 yr old with a fractured femur or tibia and crying

C) 70 yr old with chest contusion and restless


You have these pts and they are roommates, which one of these room assignments would you question?

A) A 6 month old with RSV and a 5 month old with RSV

B) Hemophiliac in a private room

C) A pt with Bronchiolitis and a pt with a fracture


A 2 day old infant is asleep and needs to be assessed. What should the nurse do first

A)Take an axillary temp.

B) Measure the head circumference

C) Listen to the bowel sound


Client admitted with DKA. What order to carry out first?

A) Etablished or initiate blood glucose level

B) Check BUN result

C) Administer 0.9 normal saline

D) Insert catheter


You are going out on home visits to see 4 pt’s who live within 3 miles of each other.

Which one will you see first?

A) A pt who had abdominal surgery and needs abdominal packing and dressing


B) A pt who is on IV antibiotics that is due within an hour


1. Characteristic of 2 nd degree burn waxy white and pain

2. Why increase fluids in burn

3. Precipitant factor to SCC


Glaucoma, early s & s



A child who is about to take OPV, what is contraindicated


signs and symptoms of cold


taking steroid therapy




use separate utensils (b) use chlorox to wash drainage spill


Wound precaution gown and gloves


Nurse doing health promotion to stop/modify risky behavior. Who needs to modify their behavior?


A pt with vaginal wart and multiple sexual partners


A pt whose sister had a breast cancer


An electrician who has prostate cancer


Which one require incident report a patient with brochoscopy eat food served

Physical Assessment Auscultation of the Chest

(a) use the diaphragm (b) use the bell

Difference of chest pain in MI and pulmonary embolism

You need to assess the abdomen.Which one do you carry out first?

a) abdominal girth

b) ascultate

c) palpate

d) percuss

1) What would be a cause for concern? a) capilliary refill 4 6 seconds


1. purpose of hospice care- for terminally ill pt so that they can die with dignity


1. Renal failure, the patient will have

a. hyperkalemia

b. hypokalemia

2. Glomerulonephritis, what will you intervene?

a. hypertension

b. hypotension

3. Urinary Tract Infection, signs and symptoms

a. penile discharge with pus

4. Discharge teaching for TURP?

* Perineal exercise

b. hesitancy on urination

5. Hemodialysis patient has the following situations, which one do you attend first?


blood oozing continuously through AV shunt


respiration is 32

6. Lower UTI

a. drainage with pus

b. hesistancy on urination

7.Kidney transplant, what would alert the nurse


abdominal tenderness


burning sensation during urination


1.8 kg weight gain since transplant a week ago

8. After kidney transplant, patient has urine 1200 cc/day. Is it normal or



1. View of death by preschooler?

* Prolonged sleep

2. Study newborn reflexes

* I had two questions

3. When would you intervene as RN?

* a 10 month old baby can’t transfer a toy from hand to hand

4. Baby born to cocaine mother, signs and symptoms

5. Toy for 2 month old

6. A question about formula for a 5 month old baby * do not mix cereal in it

7. Sickle cell crisis, nursing intervention

* narcotic and hydration

8. Hypospadias, what can the nurse observe when patient urinate?

9. Study cleft lip and cleft palate

* type of feeding device

10. Why Vitamin K given to newborn?

11. Meningococcal meningitis, universal precautions

12. Physical competence of 2 month old child

13. Purpose of putting newborn in warmer

14. Cross eye in newborn explanation by the nurse

15. Aspirin poisoning, what should the nurse do first

16. A child with esophageal fistula

a. projectile vomiting

b. potential for aspiration

rocking horse


1. Leukemia is hospitalized, safety question remove fresh plants from the bedside



COPD patient understanding of illness


I will use separate bathroom


I will cover my nose and mouth when coughing



Tenormin, side effect


Oncovin, side effect


Theophylline, toxic effect


bradycardia and vomiting


Tagamet and Maalox, how to administer


give together


give both after meals


give 1 hour apart



Milieu therapy, for manic patient


quiet, non-stimulating with neutral pale colors


Food for manic patient


cookies, carrot stick, raisin


Manic patient disturbing the group, what should you do?


Post ECT, nursing intervention



Community health nurse, which patient to see first

a. patient w/ leg pain

b. give insulin with blood glucose at 250

2. Signs and symptoms of pacemaker failure



Purpose of incentive spirometer


Care of the patient with chest tube


Thoracentesis, position


How to collect 24 hour urine specimen


Foley catheter insertion, procedure



Ileostomy, how do you know that patient is coping well


Risk for cancer of the stomach



Aplastic anemia, nursing diagnosis high risk for infection



Cervical injury, common complication autonomic dysreflexia


1. Study hypothyroidism and hyperthyroidism


1. Who is at risk for Hepatitis B?

a. hemodialysis patient

b. restaurant worker

c. office worker


1. When to give rubella, pregnant woman is concern of receiving it give after birth before discharge


1. Treatment for decubitus ulcer


1. A schizophrenic pt. In a day room with other pts. Is yelling loudly and staring at the wall what will the psyche nurse say?


Tell pt. That yelling in the day room is inappropriate to stop.


Stay outside the day room and watch the pt. Yell until he stops


Take the other pts. Out of the day room


Tell the pt. If he does not stop yelling he will be reprimanded

2. A bipolar pt. with manic is due to get haldol but the pt. told the nurse he is refusing to take the medicine. What action by the head nurse is appropriate and aware that the medicating nurse got 4 people to hold the pt. down so she can give the med. to the patient.


Tell the med. nurse that her action is inappropriate


Make sure that the other pts. Are not around the pt. during the procedure.


Tell the nurse that the pt. can refuse the med.

3. Pt. with Personality and behavioral problem. How will you know pt. is making progress

a. Pt. who calls relatives home several times a day and ask them to visit

b. Pt. who witnesses a pt. fighting and walks away

4. You are orienting a group of nurses to a mental unit, what do is appropriate as you begin your orientation?


Tell the nurses the prevalence of mental disorders in the community


Tell the nurses the number of admissions to the unit


Let the nurses tell you their feelings toward the mentally ill

5. A mother delivered a baby with cleft lip, she says, “I can’t believe this, what a mesh.” What response is best first?


Your child is so beautiful hair and clear eyes, & the md should see you soon


Don’t worry, the lip will be taken care of


I know you are upset but this can be taken care of before the child is 1 year old.


avoid all friends & sleeping more than usual


always go out with friends and taking drugs

7. Read anorexia nervosa

8. Very quiet during IV insertion

a. abused child

8. Milieu therapy for manic pt.

a. quiet, non stimulating with neutral pale colors

9. Food for manic pt.

a. cookies, carrot stick, raisin

10. Manic pt disturbing the group, what should you do?

11. Post ECT, nursing intervention


1. Pt. with Cholecystitis that is caused by calcium oxalate which diet is good


Fiber and grain


Chicken and potatoes


Tofu and ?

2. Pt. with esophageal varices signs of rupture of the varices


Upper gastrointestinal bleeding





3. What question would you ask a patient with Crohn’s disease or ulcerative colitis?


How many times do you move your bowel?


Do you have pain when you move your bowel?


Do you eat foods high in fiber?

4. Which statements indicate pt’s understanding of ileal conduit


I may need no colostomy bag


My urine may be cloudy for weeks.

5. Effect of pancreatic enzyme

a. decrease diarrhea

b. increase appetite

c. decrease steatorrhea

6. Paracentesis

a. Frequently check BP

b. Encourage to cough

7. Ileostomy, how do you know that pt is coping well


1. Diabetic pt shows understanding

a. “I will not use moisturizer on my feet”

2. Pancreatitis, which one need to be reported to the md stat?

a. Increase amylase

b. LUQ pain

c. Sensorineural changes

3. Hyperthyroidism:

a. Insomia and restlessness


1. A community health nurse is teaching a group of pts. about coronary artery disease. Which of the following is true.


African-American male have more CAD than caucasian male


People with high density lipoprotein is at risk for CAD

2. Which of the following is not a contraindication of pace maker?


Do not go near a microwave


Don’t take showers but take bath

3. A pt’s relative was talking to you about prevention of CAD. What is an appropriate answer to give initially?

a. Increased high lipids


Exercise by walking


Change your attitude of eating food high in selenium

4. MRI, pt understands the procedure


I will put myself NPO


An earplug will be put on my ears in order not to hear the noise

5. Cardiac cath, what should concern the nurse?

a. capillary refill 4 seconds

6. S & s of pacemaker failure


1. Intravenous pylogram


Are you allergic to eggs


Do you have any reactions after a procedure


1. A perimenopausal woman suffers from hot flashes what is the best nursing intervention

a. High protein food

2. A pt on magnesium sulfate, effectiveness


a reflex of +2


having convulsion

3. Exercise for a patient with incontinence

a. Kegel exercise

4. Active phase of labor, type of breathing :

a. breath through paper bag

5. Pt in labor on continuous epidural anesthesia, what to check?





6. During labor, umbilical cord was visible at the vagina, what should the nurse do?


push it back with gloved hand


notify the doctor


put pt on knee chest position & check FHR


early decelerations


late decelerations


variable decelerations

8. A pt after delivery with uterus shifted to the right


call the doctor


massage the fundus with open hands


ask pt to void

9. Position for a woman in active labor






Left lateral

10. Papsmear, class I, what does it mean?


1. External radiation therapy, the area develop skin redness & scaly, need further teaching when pt:


cover with gauze


expose to air & keep dry


bath with water


apply mentholiptus oil to affected area

2. Internal radiation therapy, understood the teaching


My visitors should wear protective leads


I will tell my relatives to stay only for 30 minutes

3. Leukemia is hospitalized, safety question

a. remove fresh plants from the bedside.


1. A pt. with autonomic dysflexia a. Has a very high BP or High pulse

2. Head injury what is a sign that pt. is deteriorating




Doll eye reflex



3. A pt. on coma for 3 days, pt is improving


able to hold your hand


able to turn his head when talking about him


Left hemianopsia, nursing action


approach him from the left side


let pt get up from the left side


let pt see an object with his left eye

5. Parkinson’s disease for discharge, what teaching


chew small bite food placed on both sides of the mouth


place pt in sitting position with hip slightly lean forward infront.

6. Myasthenia gravis teaching:

a. rest before eating

7. Epilepsy, a question on safety issue

a. Pt. can swim under adult supervision


1. Which baby should you see first?


A baby whose lower extremities are pink and upper part of the body is pale


A baby with a red rubbery nodule with a rough surface on the chest


A baby whose pulse oximeter is 91%

2. Which pt. are you going to see first


Pt. with stiff neck


Pt. with fractured bone protruding out

3. Which pt. to see first

a. Pt. with RBC of 100,000

4. Who would you see first?


a pt. with temp. 38.6 ˚F


a pt. with pH 7.25 and PCO2 56.

5. Who would you see first?


WBC 12,000


Platelet 69,000


Hb 12-14 gm

6. Who would you see first?


75 year old with heart beat of 110


75 year old with slow reaction

7. What would you intervene?

a. a pt on coumadin with prolonged PT

b. a pt coming to ER c/o of abdominal pain


a pt with severe abdominal pain at the lower quadrant

8. Following pts are taking medications, which pt to see first?

a. Clonazepam with dizziness

b. Valium with headache

c. Lithium carbonate with contraceptive pills


1. A new admitted pt. is told that he is HIV+ what information will the nurse give to help decrease the pt’s stress level.


How do you usually deal with stress


I will bring another HIV+ pt. to talk to you


This information will be confidential

2. Aside from universal precaution, what do you do to a pt with VRE?


wear a mask


wear a mask & glove




close the door

3. What shows a positive result in a TB pt?

a. 10 mm erythema

b. 10 mm induration on the skin

4. Chlostridium deficil precaution


private room


gown, gloves & mask

5. Clostridium deficile

6. Which one will prevent spread of infection in a day care center?

a. Immunizations for staffs for Hepatitis A

b. Changing the diaper changer top cover every 2 hours

c. Sending soiled clothing home in plastic bag.

7. S & s of measles:


1. A pt’s spouse complains to the nurse that her husband stay awake in the night wandering around in the house. What assessment should the nurse make


Ask about the pt’s wake resting time


If the drink red wine before bedtime


If he has problem with alcohol

2. A pt. who is admitted in the hospital. The nurse should be aware that all teaching starts

a. The day of discharge



The day of admission


When the pt. is getting better


Which pt. to discharge home to make room for new admission



Pt. with hernio 24 hours ago


Mastectomy 24 hours with drainage


Pt. diagnosed with DKA 48 hours ago


A woman had hip surgery, what would you intervene



pt. trying to get out of bed


pt bending at the waist


Pt. with mastitis, shows understanding



“I will not breastfeed my child”


“I will breastfeed on the healthy breast”


“I will empty my breast”


Understanding of a pt on coumadin



“I will not take my multivitamin tablet”


“I will take green leafy vegetables”


Nurse’s aide is always angry with a pt for soiling her diaper all the time. What would the nurse say to the aide?


a. What time do you spend with the pt?

b. Let’s sit down & talk about this pt.