NCLEX Preparation

Presented by: Dr.Hamza Dr.Nejib

• 1. The nurse is caring for the client with increased intracranial pressure. The
nurse would note which trend in vital signs if the intracranial pressure is
rising?

1. Increasing temperature, increasing pulse, increasing respirations,

decreasing blood pressure
2. Increasing temperature, decreasing pulse, decreasing respirations,
decreasing blood pressure
3. Decreasing temperature, decreasing pulse, increasing respirations,
decreasing blood pressure
4. Decreasing temperature, increasing pulse, decreasing respirations,
increasing blood pressure
2. The nurse has established a goal to maintain intracranial pressure
(ICP) within the normal range for a client who had a craniotomy 12
hours ago. What should the nurse do? Select all that apply.

1. Encourage the client to cough to expectorate secretions.

2. Elevate the head of the bed 15 - 20 degrees.
3. Contact the HCP if ICP is >15 mmHg.
4. Monitor neurologic status using the Glasgow Coma Scale.
5. Stimulate the client with active range-of-motion exercises.
• 3. What should the nurse do first when a client with a head injury
begins to have clear drainage from the nose?

1. Compress the nares

2. Tilt the head back
3. Collect the drainage
4. Administer an antihistamine for postnasal drip
4. A client has clear fluid leaking from the nose following a basilar skull
fracture. Which finding would alert the nurse that cerebrospinal fluid is
present?

1. Fluid is clear and tests negative for glucose.

2. Fluid is grossly blood in appearance and has a pH of 6
3. Fluid clumps together on the dressing and had a pH of 7
Fluid separates into concentric rings and tests positive for glucose.
• 5. The nurse is assigned to care for a client with complete right-sided
hemiparesis from a stroke. Which characteristics are associated with this
condition? Select all that apply.

1. The client is aphasic.

2. The client has weakness on the right side of the body.
3. The client has complete bilateral paralysis of the arms and legs.
4. The client has weakness on the right side of the face and tongue.
5. The client has lost the ability to move the right arm but is able to walk
independently
6. The client has lost the ability to ambulate independently, but is able to
feed and bathe himself or herself without assistance.
• 6. The nurse has instructed the family of a client with stroke who has
homonymous hemianopsia about measures to help the client
overcome the deficit. Which statement suggests that the family
understand the measures to use when caring for the client?

1. We need to discourage him from wearing eyeglasses.

2. We need to place objects in his impaired field of vision.
3. We need to approach him from the impaired field of vision.
4. We need to remind him to turn his head to scan the lost visual field.
7. The nurse sees a client walking in the hallway who begins to have a
seizure. What should the nurse do in order of priority from first to last?
All options must be used.
1. Maintain a patent airway.
2. Record the seizure activity observed.
3. Ease the client to the floor.
4. Obtain vital signs.
• 8. The nurse is instituting seizure precautions for a client who is being
admitted from the emergency department. Which measures should
the nurse include in planning for the client's safety? Select all that
apply.

1. Padding the side rails of the bed.

2. Placing an airway at the bedside.
3. Placing the bed in the high position
4. Putting a padded tongue blade at the head of the bed
5. Placing oxygen and suction equipment at the bedside
6. Flushing the intravenous catheter to ensure that the site is patent.
• 9. The nurse is caring for a client who has undergone a craniotomy
and has a supratentorial incision. The nurse should place the client in
which position postoperatively?

1. Head of bed flat, head and neck midline.

2. Head of bed flat, head turned to the nonoperative side
3. Head of bed elevated 30 to 45 degrees, head and neck midline
4. Head of bed elevated 30 to 45 degrees, head turned to the
operative side
• 10. A nurse is evaluating an acutely ill client with suspected
meningitis. The nurse should take what action first?

1. Check for Kernig's and Brudzinski's signs

2. Establish IV access
3. Place the client on droplet precautions
4. Prepare the client for lumbar puncture
• 11. Four children are brought to the emergency department. Which
child should be assessed first?

1. A 13-month-old who ingested an unknown quantity of children's

multivitamins
2. A 15-month-old with a fever of 100.5 F (38.1 C) after being
vaccinated
3. A 3-year-old with a forehead laceration and colorless nasal drainage
4. A 4-year-old with enlarged tonsillar lymph nodes who is crying in
pain
• 12. A client comes to the emergency department with diplopia and
recent onset of nausea. Which statement by the client would indicate
to the nurse that this is an emergency?

1. "I am very tired, and it's hard for me to keep my eyes open."
2. "I don't feel good, and I want to be seen."
3. "I have not taken my blood pressure medicine in over a week."
4. "I have the worst headache I've ever had in my life."
• 13. A client comes to the emergency department with diplopia and
recent onset of nausea. Which statement by the client would indicate
to the nurse that this is an emergency?

1. "I am very tired, and it's hard for me to keep my eyes open."
2. "I don't feel good, and I want to be seen."
3. "I have not taken my blood pressure medicine in over a week."
4. "I have the worst headache I've ever had in my life."
• 14. The clinic nurse educator is developing a teaching plan for the following 6
clients. The nurse should instruct which client to avoid the Valsalva maneuver
when defecating? Select all that apply.

1. 22-year-old man with a head injury sustained during a college football game
2. 30-year-old woman recently hospitalized for reconstructive augmentation
mammoplasty
3. 56-year-old man 2 weeks post myocardial infarction
4. 68-year-old woman recently diagnosed with pancreatic cancer
5. 74-year-old man with portal hypertension related to alcohol-induced
cirrhosis
6. 82-year-old woman 1 week post cataract surgery
• 15. A client is admitted to the hospital for severe headaches. The
client has a history of increased intracranial pressure (ICP), which has
required lumbar punctures to relieve the pressure by draining
cerebrospinal fluid. The client suddenly vomits and states, "That's
weird, I didn't even feel nauseated." Which action by the nurse is the
most appropriate?

1. Document the amount of emesis

2. Lower the head of the bed
3. Notify the health care provider (HCP)
4. Offer anti-nausea medication
• 16. The nurse is caring for a client after a motor vehicle accident. The
client's injuries include 2 fractured ribs and a concussion. The nurse
notes which of the following as expected neurological changes for the
client with a concussion? Select all that apply.

1. Asymmetrical pupillary constriction

2. Brief loss of consciousness
3. Headache
4. Loss of vision
5. Retrograde amnesia
• 17. An adult client with altered mental status and fever has suspected
bacterial meningitis with sepsis. Blood pressure is 80/60 mm Hg.
Which prescribed intervention should the nurse implement first?

1. Administer IV antibiotics
2. Infuse bolus of IV normal saline
3. Prepare to assist with lumbar puncture
4. Transport client for head CT scan
• 18. A client with a brain tumor is admitted for surgery. The health care
provider prescribes levetiracetam. The client asks why. What is the
nurse's response?

1. "It destroys tumor cells and helps shrink the tumor."

2. "It prevents seizure development."
3. "It prevents blood clots in legs."
4. "It reduces swelling around the tumor."
• 19. A highly intoxicated client was brought to the emergency
department after found lying on the sidewalk. On admission, the
client is awake with a pulse of 70/min and blood pressure of 160/80
mm Hg. An hour later, the client is lethargic, pulse is 48/min, and
blood pressure is 200/80 mm Hg. Which action does the nurse
anticipate taking next?

1. Administer atropine for bradycardia

2. Administer nifedipine for hypertension
3. Have CT scan performed to rule out an intracranial bleed
4. Perform hourly neurologic checks with Glasgow coma scale (GCS
• 20. The nurse receives report for 4 clients in the emergency
department. Which client should be seen first?

1. 30-year-old with a spinal cord injury at L3 sustained in a motor cycle

accident who reports lower abdominal pain and difficulty urinating
2. 33-year-old with a seizure disorder admitted with phenytoin toxicity
who reports slurred speech and unsteady gait
3. 65-year-old with suspected brain tumor waiting to be admitted for
biopsy who reports throbbing headache and had emesis of 250 mL
4. 70-year-old with atrial fibrillation and a closed-head injury waiting
for brain imaging who reports a headache and had emesis of 200 mL
• 21. The school nurse assesses an 8-year-old with a history of asthma.
The nurse notes mild wheezing and coughing. Which action should
the nurse perform first?
1. Start steroid
2. Start B2 agonist like Albuterol
3. Continue monitoring
4. Assess the client's peak expiratory flow.
• 22. A client is diagnosed with right-sided Bell's palsy. What
instructions should the nurse give this client for care at home? Select
all that apply.
• 1. Apply a patch to the right eye at night.
• 2. Tilt the head back
• 3. Chew on the left side.
• 4. Maintain meticulous oral hygiene.
• 23. `A nurse administers an intramuscular (IM) injection using the Z-track method
technique. Place the steps in chronological order. All options must be used.
• 1. Apply gentle pressure at the injection site but do not massage
• 2. Inject medication slowly with dominant hand while maintaining traction
• 3. Hold the skin taut with non-dominant hand and insert needle at a 90-degree
angle
• 4. Pull the skin 1-1 1/2" (2.5-3.5 cm) laterally and away from the injection site.
• 5. Wait 10 seconds after injecting the medication and withdraw the needle.
Release the hold on the skin, allowing the layers to slide back to their original
position.
.
24. he clinic nurse is teaching a client about levothyroxine, which the health
care provider has prescribed for newly diagnosed hypothyroidism. Which
statement made by the client indicates that further teaching is needed?
A. Should take levothyroxine on an empty stomach
B. Should take preferably in the Morining, separately from other medications
C. Should not take with my Iron sulphate that is prescribed for my Anemia
D. If this makes my stomach upset, I will take it with an antacid.
.
-,
• 25. The nurse on the medical-surgical unit receives report on assigned
clients. Which client warrants immediate attention?
1. Client with mild epigastric pain who is diagnosed with PUD
2. Client 2nd post op day with WBC count of 12,000
3. Client with headache after receiving Nitroglycerin
4. Client with epigastric pain after endoscopic retrograde
cholangiopancreatography
• 26. A client admitted 3 days ago with upper gastrointestinal bleeding
underwent an endoscopic procedure to stop the bleeding. The client
is started on a clear liquid diet today. Which foods are appropriate for
the nurse to offer the client. Select all that apply
1. Apple juice
2. Hamburger
3. Chicken broth
4. Spicy spageti
5. 5. Unsweetened tea
• 27. The nurse is caring for a postoperative client who has D5W/0.45%
normal saline with 10 mEq potassium chloride infusing through a
peripheral IV catheter. What are appropriate reasons for the nurse to
change the site? Select all that apply.
• 1. Area around the insertion site feels cool to the touch
• 2. patient complaing to be discharged
• 3. Edema is observed on the dependent side of the involved arm
• 4. Stable patient with cardiac monitoring
• 5. Serous fluid leaks from the site despite secure connections
• 28. An infant is born with a cleft palate. Which actions will promote
oral intake until the defect can be repaired. Select all that apply
• 1. Feeding in an Tripod position
• 2. Burping the infant often.
• 3. Feeding in an upright position
• 5. Using a specialty bottle or nipple
• 29. A home health nurse is managing care for an adolescent client
with cystic fibrosis. Which of the following potential complications
should the nurse consider when developing a nursing care plan?
Select all that apply.
• 1. Chronic hypoxemia
• 2. Frequent Seizure
• 3. Frequent respiratory infections
• 4. Urinary incontenance
• 5. Vitamin deficiencies
30. The home health nurse assesses a child and suspects that the child
is being abused. Which of the following questions are appropriate for
the nurse to ask the caregiver? Select all that apply.
1. "How would you describe your child's usual behavior at home?“
3. "What forms of discipline do you use with your child?"
4. "When you are stressed, what coping mechanisms do you use?"
5. "Who watches your child when you are at work?
31. The most recent laboratory results for a 12-month-old who is HIV-
positive show a CD4 lymphocyte count of 500/mm3 and a CD4
lymphocyte percentage of 10%. The nurse anticipates administering
which immunizations? Select all that apply
1. Haemophilus influenzae type b (Hib)
2. Hepatitis A (Hep A)
3. Immunoglobulin
4. Pneumococcal conjugate vaccine (PCV)
• 32. The nurse provides teaching for the parents of a 6 year old client
diagnosed with nocturnal enuresis. Which of the following
instructions will the nurse include? Select all that apply.
• 1. Don’t Wake the child at a specified time each night to void
• 2. Encourage the child to help change soiled pajamas and linens.
• 3. Prepare a calendar with the child for logging wet and dry nights.
• 4. Allow him to drink water night time
• 5. Wake the child at a specified time each night to void.
• 33. Which assessment findings would the nurse most likely expect to
find in a male infant born at 28 weeks gestation? Select all that apply.
• 1. Abundant lanugo on shoulders and back.
• 2. with normal respiratory rate
• 3. Flat areolae without palpable breast buds
• 4. Smooth, pink skin with visible veins.
• 34. A nurse is evaluating the fetal monitoring strip of a laboring
primigravida at 38 weeks gestation who is receiving an oxytocin infusion
and has external monitors and an intrauterine pressure catheter in place.
Which of the following interventions should the nurse implement?
• 1. administer supplemental oxygen by mask.
• 2. Initiate an IV bolus of 0.9% saline
• 3. administer steroid
• 4. administer methyldopa
• 5. Stop the oxytocin infusion
• 35. A client with a hip fracture is placed in Buck traction. Which
activities are appropriate for the nurse to include in the client's plan
of care? Select all that apply
• 1. Assess for skin breakdown of the limb in traction.
2. Ensure adequate pain relief
3. Keep the limb in a neutral position
4. Perform frequent neurovascular checks on the limb in traction.
• 36. The nurse educates a 30-year-old client who is being evaluated for
hyperthyroidism with a radioactive iodine uptake (RAIU) test. Which
instructions should the nurse include in the teaching plan? Select all
that apply.
• 1. "A pregnancy test must be obtained prior to RAIU test
administration."
2. "All jewelry or metal around the neck area should be removed
before the RAIU test."
3. "Antithyroid medications should be held for 5-7 days before the
RAIU test.
• 37. The nurse is evaluating a parent's understanding of home care
management for a 2-week-old client after initial cast placement for
treatment of congenital clubfoot. Which of the following statements
by the parent indicated a correct understanding? Select all that apply.
1.” I will keep him NPO”
2. "I will check my baby's toes several times a day to ensure that they
are pin
4. "My baby will need to have a new cast applied weekly for 5-8
weeks."
5. "When I bathe or diaper my baby, I will be sure to keep the cast dry."
• 1/ The nurse is assessing a 70yrs old client with a long history of type-
2 DM, for sudden, severe nausea, diaphoresis, dizziness and fatigue in
the ED. Which hospital protocol would be the most appropriate to
follow initially?
• A/ Food poisoning
• B/ Influenza
• C/ Myocardial Infraction
• D/ Stroke
• 2. A registered nurse is making pre-procedure phone call to client
scheduled for cardiac pharmacological nuclear stress testing the
following day. Which instructions should the nurse give the clients?
• A/ Decaffeinated coffee or tea can be consumed
• B/ Do not consume caffeine for 24 hr before the test
• C/ Do not smoke on the day of the test
• D/ Do not take beta blocker on the day of the test
• E/ Take diabetic medications as usual before the test
• 3. A client comes to the ED with severe dyspnea and cough. Vital signs
are Temp. 99.2F (37.3 C), BP 108/70mmHg, HR 88/min, & RR 24/min.
The client has a history of COPD and chronic HF. Which diagnostic test
will be most useful to the nurse determining if this is an exacerbation
of the heart failure?
• A/ ABGs
• B/BNP
• C/CK-MB
• D/ chest x-ray
• 4. The nurse in the outpatient clinic is reviewing phone messages.
Which client should the nurse call back first?
• A/ client post kidney transplant who reports white spots in the oral
cavity
• B/ client with a history of mitral valve regurgitation who report fatigue
• C/ client with erythema and purulent drainage at the site of a spider
bite
• Client with hypertension who reports cold and nasal congestion
• 5. Which assessment finding would the nurse expect to find in a client
with severe aortic stenosis?
• A/ Bounding peripheral pulse
• B/ Diastolic murmur
• C/ Loud second heart sounds
• D/ Syncope on exertion
• 6. A 70yr old female client with type 2 DM comes to the ED with
diaphoresis, generalized weakness, nausea, and epigastric burning
pain. Which intervention should the nurse implement first?
• A/ Administer 2 mg morphine IV
• B/ Assess finger stick blood glucose
• C/ Draw blood for basic metabolic panel
• D/ obtain a 12-lead electrocardiogram
• 7. Which interventions should the nurse include when caring for a
client who has had endovascular repair of an abdominal aortic
aneurysm?
• A/ assess abdominal incision every 4 hrs
• B/ check for bleeding at groin puncture site
• C/ measure chest tube drainage
• D/ monitor fluid intake and urine output
• E/ palpate and monitor peripheral pulses
• 8. The nurse is preparing to perform cardioversion in a client in
supraventricular tachycardia that has been unresponsive to drug
therapy. The client has become hemodynamically unstable. Which
step is most important in performing cardioversion?
• A/ charge the defibrillator
• B/ push the synchronize button
• C/ sedate the client
• D/ select energy level