NCLEX PREP PASSING LEVEL EXAM
PRACTICE QUESTIONS WITH CORRECT
ANSWERS
The client diagnosed with malnutrition is prescribed continuous enteral feedings
through a gastrostomy tube. Which actions will the nurse include in the plan of
care?
Select all that apply.
1. Cover the insertion site with an adhesive bandage.
2. Add 8 hours of feeding to the bag at a time.
3. Rotate the gastrostomy tube 360 degrees once daily.
4. Auscultate for whoosh of air through the gastrostomy tube.
5. Check for slight in-and-out movement of the gastrostomy tube. ---1)
gastrostomy insertion site should be covered with sterile bandage to reduce the
risk of infection
2) only 4 hours of enteral feeding should be added to bag to reduce the risk of
bacterial contamination
pg. 1
,3) CORRECT — should be rotated 360 degrees daily to reduce the risk of skin
irritation and breakdown
4) insertion of air is not recommended for gastrostomy tube placement
assessment; this action would not be placed in the plan of care
5) CORRECT — slight in-and-out movement indicates that the gastrostomy
tube is not embedded in the wall of stomach
The client diagnosed with a stroke is admitted to a rehabilitation center. The
client has left-sided pronator drift and decreased dorsiflexion strength of the left
extremity. The nurse notes the client bumps into the left wall when ambulating
with a walker. The client leans to the left when sitting in a chair or wheelchair.
Which is the most appropriate action for the nurse to take?
1. Place the client's favorite watch on the left wrist.
2. Provide a written list for client to follow during morning care.
3. Instruct the client to choose a dress for the day.
4. Position the client so the right side faces the door of the room. ---1)
psychosocial; client may ignore watch; should be considered because it may
encourage client to look at affected side of body; safety is main concern
2) psychosocial; verbal instructions with short sentences are used; client may
have short attention span
pg. 2
,3) psychosocial; having the client choose a dress is an appropriate
implementation; positioning is the priority
4) CORRECT — physical; has right-sided stroke with left-sided unilateral
neglect syndrome; client cannot see out of left side of both eyes; position client
for best vision so the client is not scared or upset by approaching people
The client is brought to the emergency department by friends. The client reports
a dry mouth, frequent urination, extreme thirst, and no fluid intake for the last 8
hours. The friends report the client may not have taken insulin during the last
couple of days. The nurse reviews orders from the health care provider. Which
order should the nurse implement first?
1. Administer 20 mEq potassium chloride orally.
2. Begin regular insulin at 0.1 units/kg/hour.
3. Obtain a 12-lead electrocardiogram.
4. Begin infusion of 0.9 % NaCl at 1 liter per hour. ---1) implementation,
physical, circulation; mild to moderate hyperkalemia seen during initial phase
of diabetic ketoacidosis; potassium chloride not indicated at this time, but will
be administered later when potassium moves into the cells during insulin
administration
2) implementation, physical, not A, B, or C; eliminate; indicated, but priority is
to restore fluid volume
pg. 3
, 3) assessment, is this needed; no, eliminate; may be indicated to detect
dysrhythmias related to potassium imbalance; not priority
4) CORRECT — implementation, physical, circulation; priority is to replace
fluid volume; during DKA osmotic diuresis occurs and client at significant risk
for fluid volume deficit
A family brings the client to the emergency department. The family reports the
client had a sudden onset of left facial droop and slurred speech at home. The
nurse observes left-sided muscle weakness. Which is the most important
question for the nurse to ask?
1. "What over-the-counter medications does your parent take?"
2. "What was your parent doing when the symptoms began?"
3. "When did you first notice the onset of the symptoms?"
4. "Does your parent have a history of high blood pressure?" ---1) not the most
important question to ask; may be important to determine if any medications
increase the risk of bleeding
2) hemorrhagic stroke may be precipitated by strenuous activity and an increase
in blood pressure
pg. 4
PRACTICE QUESTIONS WITH CORRECT
ANSWERS
The client diagnosed with malnutrition is prescribed continuous enteral feedings
through a gastrostomy tube. Which actions will the nurse include in the plan of
care?
Select all that apply.
1. Cover the insertion site with an adhesive bandage.
2. Add 8 hours of feeding to the bag at a time.
3. Rotate the gastrostomy tube 360 degrees once daily.
4. Auscultate for whoosh of air through the gastrostomy tube.
5. Check for slight in-and-out movement of the gastrostomy tube. ---1)
gastrostomy insertion site should be covered with sterile bandage to reduce the
risk of infection
2) only 4 hours of enteral feeding should be added to bag to reduce the risk of
bacterial contamination
pg. 1
,3) CORRECT — should be rotated 360 degrees daily to reduce the risk of skin
irritation and breakdown
4) insertion of air is not recommended for gastrostomy tube placement
assessment; this action would not be placed in the plan of care
5) CORRECT — slight in-and-out movement indicates that the gastrostomy
tube is not embedded in the wall of stomach
The client diagnosed with a stroke is admitted to a rehabilitation center. The
client has left-sided pronator drift and decreased dorsiflexion strength of the left
extremity. The nurse notes the client bumps into the left wall when ambulating
with a walker. The client leans to the left when sitting in a chair or wheelchair.
Which is the most appropriate action for the nurse to take?
1. Place the client's favorite watch on the left wrist.
2. Provide a written list for client to follow during morning care.
3. Instruct the client to choose a dress for the day.
4. Position the client so the right side faces the door of the room. ---1)
psychosocial; client may ignore watch; should be considered because it may
encourage client to look at affected side of body; safety is main concern
2) psychosocial; verbal instructions with short sentences are used; client may
have short attention span
pg. 2
,3) psychosocial; having the client choose a dress is an appropriate
implementation; positioning is the priority
4) CORRECT — physical; has right-sided stroke with left-sided unilateral
neglect syndrome; client cannot see out of left side of both eyes; position client
for best vision so the client is not scared or upset by approaching people
The client is brought to the emergency department by friends. The client reports
a dry mouth, frequent urination, extreme thirst, and no fluid intake for the last 8
hours. The friends report the client may not have taken insulin during the last
couple of days. The nurse reviews orders from the health care provider. Which
order should the nurse implement first?
1. Administer 20 mEq potassium chloride orally.
2. Begin regular insulin at 0.1 units/kg/hour.
3. Obtain a 12-lead electrocardiogram.
4. Begin infusion of 0.9 % NaCl at 1 liter per hour. ---1) implementation,
physical, circulation; mild to moderate hyperkalemia seen during initial phase
of diabetic ketoacidosis; potassium chloride not indicated at this time, but will
be administered later when potassium moves into the cells during insulin
administration
2) implementation, physical, not A, B, or C; eliminate; indicated, but priority is
to restore fluid volume
pg. 3
, 3) assessment, is this needed; no, eliminate; may be indicated to detect
dysrhythmias related to potassium imbalance; not priority
4) CORRECT — implementation, physical, circulation; priority is to replace
fluid volume; during DKA osmotic diuresis occurs and client at significant risk
for fluid volume deficit
A family brings the client to the emergency department. The family reports the
client had a sudden onset of left facial droop and slurred speech at home. The
nurse observes left-sided muscle weakness. Which is the most important
question for the nurse to ask?
1. "What over-the-counter medications does your parent take?"
2. "What was your parent doing when the symptoms began?"
3. "When did you first notice the onset of the symptoms?"
4. "Does your parent have a history of high blood pressure?" ---1) not the most
important question to ask; may be important to determine if any medications
increase the risk of bleeding
2) hemorrhagic stroke may be precipitated by strenuous activity and an increase
in blood pressure
pg. 4
