NCLEX EXAM PREVIEW EXAM NEW LATEST VERSION WITH
ALL 175 QUESTIONS FROM ACTUAL EXAM WITH ANSWERS
AND RATIONALE
The nurse is teaching a client how to ambulate using crutches. Which of the following information
should the nurse include?
1. "Use your hands and arms to support your body weight."
2. "Wear slippers when ambulating with the crutches in your home."
3. "Maintain the crutches 12 in (30 cm) in front of your feet while standing."
4. "Adjust the hand grips of the crutches so that your elbows are fully extended." - CORRECT
ANSWERS-1. "Use your hands and arms to support your body weight."
True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s: paresis and paresthesias in
wrists and hands
Rationales:
2. Fall risk!
3. Should be 6 in. in front and 6 in. lateral
4. Elbows should be bent at 30 degree angle
The nurse has taught a client with multiple sclerosis (MS).
Which of the following statements by the client would indicate a correct understanding of the teaching?
1. "I will complete all of my household chores in the morning when I am well rested."
2. "I have learned how to massage my bladder to help empty my bladder completely."
3. "I will take a hot bath in the evening to help me relax if I have had a stressful day at work."
4. "I should expect the blurred vision to resolve after I have received medications for several weeks." -
CORRECT ANSWERS-4. "I should expect the blurred vision to resolve after I have received
medications for several weeks."
MS causes nerve damage and can result in optic neuritis (vision loss, burry vision). In most cases it
resolves itself in 4-12 weeks, but medication (steroids) can speed up the process and resolve it quicker
Rationale:
,1. MS patients should not exert themselves too much at one time. Space out activities and allow time for
rest.
2. Urinary retention is primarily treated by medication (bethanochol), and exercises can aid with it but
are not the primary treatment
3. Hot temperatures are bad for MS and can worsen symptoms. Your nerves are already fcked up and
extra heat can stress your body into overdrive
The nurse has attended a staff education program about caring for clients who are receiving positive
pressure mechanical ventilation. Which of the following statements by the nurse would indicate a
correct understanding of the teaching?
1. "Clients should avoid range-of-motion (ROM) exercises until weaned from ventilation."
2. "Clients may develop stress ulcers and gastrointestinal bleeding."
3. "Clients will be chemically paralyzed to improve oxygenation."
4. "Clients will experience diuresis and polyuria." - CORRECT ANSWERS-2. "Clients may
develop stress ulcers and gastrointestinal bleeding."
Rationale: Postive Pressure Ventilation may cause stress ulcers and GI bleeding because
The charge nurse must transfer a female client from the medical-surgical unit to the maternity unit to
make a bed available. It would be most appropriate for the nurse to transfer the client who is
1. 28 years old, had a right mastectomy and has a closed-wound drainage system
2. 49 years old, has diabetes mellitus (type 2) and has begun receiving insulin
3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours
4. 70 years old, has a fractured left tibia and had an external fixation device applied 48 hours ago -
CORRECT ANSWERS-3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours
The nurse has been made aware of the following client situations. The nurse should first assess the client
with:
1. heart failure who has a productive cough and is anxious
2. regional enteritis (Crohn's disease) who is reporting cramping abdominal pain and diarrhea
3. idiopathic thrombocytopenic purpura (ITP) who has petechiae on the trunk and is reporting heavy
menses
,4. chronic obstructive pulmonary disease (COPD) who has dyspnea with exertion and is using accessory
muscles to breathe - CORRECT ANSWERS-1. heart failure who has a productive cough and is
anxious
Productive cough (pink frothy sputum) indicates pulmonary edema, anxiety might be caused by
decreased perfusion
The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the
following tasks would be appropriate for the nurse to assign to UAP?
1. assisting a client with atrial fibrillation to shower
2. checking the ability of a client to swallow water after a transesophageal echocardiogram (TEE)
3. observing while a client with dysphagia begins a thickened liquid diet
4. transporting a client with respiratory distress to the radiology department for a chest radiograph -
CORRECT ANSWERS-1. assisting a client with atrial fibrillation to shower
UAP can perform hygiene
Rationale:
Only nurses can assess. Transporting a client in respiratory arrest is not safe to delegate to a UAP
The nurse has taken a nutritional history from parents of clients. It would be a priority for the nurse to
follow up with the
1. 5-month-old client whose only source of nutrition is 5 formula feedings daily
2. 7-month-old client who eats several crackers as finger food
3. 9-month-old client whose typical daily diet includes 10 bottles of 2% milk, 1 cup of apple juice, and 3
servings of infant cereal
4. 1-year-old client whose typical food intake includes 4 breast-feedings and 3 servings of cooked
vegetables, pears, or sliced cheese - CORRECT ANSWERS-3. 9-month-old client whose typical
daily diet includes 10 bottles of 2% milk, 1 cup of apple juice, and 3 servings of infant cereal
Rationale: Cows milk should be introduced at 12 months old. It doesn't provide the necessary nutrients
and baby can develop iron deficiency
, The nurse is planning a staff education program about client privacy. Which of the following scenarios
should the nurse include as an example of a violation of client privacy?
1. discussing with an unlicensed assistive personnel (UAP) that the UAP's assigned client will require a
smaller condom catheter
2. sharing the client's blood alcohol level (BAL) test result with the police officer who brought the client
to the emergency department (ED)
3. responding to the call light of the client who is assigned to another nurse and needs assistance in the
bathroom
4. allowing a nursing student who has been assigned to the client to review the client's medical record -
CORRECT ANSWERS-2. sharing the client's blood alcohol level (BAL) test result with the police
officer who brought the client to the emergency department (ED)
Rationale: PHI is permitted to be disclosed to police when PHI is needed to apprehend the perpetrator of
a violent crime, suspect, or fugitive.
The nurse has become aware of the following client situations. The nurse should first assess the client
1. who had a right pneumonectomy 24 hours ago and is in the high-Fowler's position while lying on the
right side
2. with chronic obstructive pulmonary disease (COPD) who is using pursed-lip breathing and reporting
hemoptysis
3. who had a wedge resection of the left lung 24 hours ago and is sitting in the high-Fowler's position
4. with heart failure who has a productive cough and is restless - CORRECT ANSWERS-4. with
heart failure who has a productive cough and is restless
Productive cough (pink frothy sputum) is indicative of pulmonary edema which is life-threatening. T(x)
would be to improve cardiac output by placing client in high fowlers, O2, mechanical ventilation, meds
The nurse is caring for a 3-year-old client with a cerebral concussion who is being observed overnight in
the pediatric unit. Which of the following observations would be most significant for the nurse to report
to the oncoming shift?
1. The client has a blood pressure of 94/58 mm Hg and an apical pulse of 90.
2. The client is sleeping but is easily aroused.
3. The client's pupils are equal and reactive to light.
4. The client has an axillary temperature of 99.0° F (37.2° C) and respirations of 24. - CORRECT
ANSWERS-2. The client is sleeping but is easily aroused.
ALL 175 QUESTIONS FROM ACTUAL EXAM WITH ANSWERS
AND RATIONALE
The nurse is teaching a client how to ambulate using crutches. Which of the following information
should the nurse include?
1. "Use your hands and arms to support your body weight."
2. "Wear slippers when ambulating with the crutches in your home."
3. "Maintain the crutches 12 in (30 cm) in front of your feet while standing."
4. "Adjust the hand grips of the crutches so that your elbows are fully extended." - CORRECT
ANSWERS-1. "Use your hands and arms to support your body weight."
True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s: paresis and paresthesias in
wrists and hands
Rationales:
2. Fall risk!
3. Should be 6 in. in front and 6 in. lateral
4. Elbows should be bent at 30 degree angle
The nurse has taught a client with multiple sclerosis (MS).
Which of the following statements by the client would indicate a correct understanding of the teaching?
1. "I will complete all of my household chores in the morning when I am well rested."
2. "I have learned how to massage my bladder to help empty my bladder completely."
3. "I will take a hot bath in the evening to help me relax if I have had a stressful day at work."
4. "I should expect the blurred vision to resolve after I have received medications for several weeks." -
CORRECT ANSWERS-4. "I should expect the blurred vision to resolve after I have received
medications for several weeks."
MS causes nerve damage and can result in optic neuritis (vision loss, burry vision). In most cases it
resolves itself in 4-12 weeks, but medication (steroids) can speed up the process and resolve it quicker
Rationale:
,1. MS patients should not exert themselves too much at one time. Space out activities and allow time for
rest.
2. Urinary retention is primarily treated by medication (bethanochol), and exercises can aid with it but
are not the primary treatment
3. Hot temperatures are bad for MS and can worsen symptoms. Your nerves are already fcked up and
extra heat can stress your body into overdrive
The nurse has attended a staff education program about caring for clients who are receiving positive
pressure mechanical ventilation. Which of the following statements by the nurse would indicate a
correct understanding of the teaching?
1. "Clients should avoid range-of-motion (ROM) exercises until weaned from ventilation."
2. "Clients may develop stress ulcers and gastrointestinal bleeding."
3. "Clients will be chemically paralyzed to improve oxygenation."
4. "Clients will experience diuresis and polyuria." - CORRECT ANSWERS-2. "Clients may
develop stress ulcers and gastrointestinal bleeding."
Rationale: Postive Pressure Ventilation may cause stress ulcers and GI bleeding because
The charge nurse must transfer a female client from the medical-surgical unit to the maternity unit to
make a bed available. It would be most appropriate for the nurse to transfer the client who is
1. 28 years old, had a right mastectomy and has a closed-wound drainage system
2. 49 years old, has diabetes mellitus (type 2) and has begun receiving insulin
3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours
4. 70 years old, has a fractured left tibia and had an external fixation device applied 48 hours ago -
CORRECT ANSWERS-3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours
The nurse has been made aware of the following client situations. The nurse should first assess the client
with:
1. heart failure who has a productive cough and is anxious
2. regional enteritis (Crohn's disease) who is reporting cramping abdominal pain and diarrhea
3. idiopathic thrombocytopenic purpura (ITP) who has petechiae on the trunk and is reporting heavy
menses
,4. chronic obstructive pulmonary disease (COPD) who has dyspnea with exertion and is using accessory
muscles to breathe - CORRECT ANSWERS-1. heart failure who has a productive cough and is
anxious
Productive cough (pink frothy sputum) indicates pulmonary edema, anxiety might be caused by
decreased perfusion
The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the
following tasks would be appropriate for the nurse to assign to UAP?
1. assisting a client with atrial fibrillation to shower
2. checking the ability of a client to swallow water after a transesophageal echocardiogram (TEE)
3. observing while a client with dysphagia begins a thickened liquid diet
4. transporting a client with respiratory distress to the radiology department for a chest radiograph -
CORRECT ANSWERS-1. assisting a client with atrial fibrillation to shower
UAP can perform hygiene
Rationale:
Only nurses can assess. Transporting a client in respiratory arrest is not safe to delegate to a UAP
The nurse has taken a nutritional history from parents of clients. It would be a priority for the nurse to
follow up with the
1. 5-month-old client whose only source of nutrition is 5 formula feedings daily
2. 7-month-old client who eats several crackers as finger food
3. 9-month-old client whose typical daily diet includes 10 bottles of 2% milk, 1 cup of apple juice, and 3
servings of infant cereal
4. 1-year-old client whose typical food intake includes 4 breast-feedings and 3 servings of cooked
vegetables, pears, or sliced cheese - CORRECT ANSWERS-3. 9-month-old client whose typical
daily diet includes 10 bottles of 2% milk, 1 cup of apple juice, and 3 servings of infant cereal
Rationale: Cows milk should be introduced at 12 months old. It doesn't provide the necessary nutrients
and baby can develop iron deficiency
, The nurse is planning a staff education program about client privacy. Which of the following scenarios
should the nurse include as an example of a violation of client privacy?
1. discussing with an unlicensed assistive personnel (UAP) that the UAP's assigned client will require a
smaller condom catheter
2. sharing the client's blood alcohol level (BAL) test result with the police officer who brought the client
to the emergency department (ED)
3. responding to the call light of the client who is assigned to another nurse and needs assistance in the
bathroom
4. allowing a nursing student who has been assigned to the client to review the client's medical record -
CORRECT ANSWERS-2. sharing the client's blood alcohol level (BAL) test result with the police
officer who brought the client to the emergency department (ED)
Rationale: PHI is permitted to be disclosed to police when PHI is needed to apprehend the perpetrator of
a violent crime, suspect, or fugitive.
The nurse has become aware of the following client situations. The nurse should first assess the client
1. who had a right pneumonectomy 24 hours ago and is in the high-Fowler's position while lying on the
right side
2. with chronic obstructive pulmonary disease (COPD) who is using pursed-lip breathing and reporting
hemoptysis
3. who had a wedge resection of the left lung 24 hours ago and is sitting in the high-Fowler's position
4. with heart failure who has a productive cough and is restless - CORRECT ANSWERS-4. with
heart failure who has a productive cough and is restless
Productive cough (pink frothy sputum) is indicative of pulmonary edema which is life-threatening. T(x)
would be to improve cardiac output by placing client in high fowlers, O2, mechanical ventilation, meds
The nurse is caring for a 3-year-old client with a cerebral concussion who is being observed overnight in
the pediatric unit. Which of the following observations would be most significant for the nurse to report
to the oncoming shift?
1. The client has a blood pressure of 94/58 mm Hg and an apical pulse of 90.
2. The client is sleeping but is easily aroused.
3. The client's pupils are equal and reactive to light.
4. The client has an axillary temperature of 99.0° F (37.2° C) and respirations of 24. - CORRECT
ANSWERS-2. The client is sleeping but is easily aroused.
