NCLEX QUESTION TRAINER EXPLANATIONS
TEST 3
1. A client has a total laryngectomy with a permanent tracheostomy. The nurse is planning
nutritional intake for the next three days. Which of the following would be necessary for the
nurse to consider regarding the client’s nutrition?
1. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube
feedings may be implemented.
2. The client will be unable to maintain any PO intake as long as he has a tracheotomy in
place.
3. Nutritional and/or gastric feedings will not be attempted for approximately three weeks to
decrease the incidence of aspiration.
4. Since the client is dependent on the ventilator, nutritional intake will be delayed.
Strategy: Think about each answer choice.
(1) correct–tube feedings frequently started as the initial nutritional intake; prevents trauma to
suture area
(2) although the client has permanent tracheotomy, will be able to eat normally after area has
healed
(3) nutritional intake will begin when bowel sounds return and client can tolerate intake
(4) client is not dependent on ventilator
2. The nurse is caring for a client who presents with confusion, mood lability, impaired
communication, and lethargy. The nurse should question which of the following orders?
1. Dexamethasone suppression test.
2. Thyroid studies.
3. Drug toxicology screen.
4. Trendelenburg test.
Strategy: Think about each test.
(1) may be ordered to determine the presence of major depression
(2) may be ordered to check for an endocrine cause for the symptoms before the diagnosis of
dementia is made
(3) may be ordered to see if the client’s symptoms are caused by excessive use of medications
or alcohol
(4) correct–test is used with a client who may have varicose veins, no relationship to the
symptoms described in this situation
,3. For a client with a neurological disorder, which of the following nursing assessments will be
MOST helpful in determining subtle changes in the client’s level of consciousness?
1. Client posturing.
2. Glasgow coma scale.
3. Client thinking pattern.
4. Occurrence of hallucinations.
Strategy: Think about each answer choice.
(1) indicates increased intracranial pressure
(2) correct–Glasgow coma scale score best evaluates changes in a client’s level of
consciousness by evaluating eye-opening, motor, and verbal responses
(3) more appropriate for the psychiatric client
(4) more appropriate for the psychiatric client
4. The nurse is conducting a physical examination of a client suspected to have bulimia. Which
of the following observations by the nurse would MOST likely indicate bulimia?
1. The client has edema of the lower extremities.
2. Physical exam of the client reveals the presence of lanugo.
3. The client has ulcerated mucous membranes of the mouth.
4. The client has dry, yellowish color of the skin.
Strategy: Determine the cause of each symptom. Does it relate to bulimia?
(1) common with anorexia
(2) seen with anorexia
(3) correct–due to frequent vomiting
(4) bulimics are normal in appearance
5. The nurse is preparing to begin a dopamine (Intropin) infusion on a client. Before beginning
the infusion the nurse should
1. evaluate the urine output.
2. obtain the client’s weight.
3. determine the patency of the IV line.
4. measure pulmonary artery pressures.
Strategy: Determine how each answer choice relates to dopamine.
(1) not a critical assessment at this time
(2) contains correct information, but is not a priority
(3) correct–if extravasation occurs, there is sloughing of the surrounding skin and tissue; patent
IV line is essential to prevent serious side effects
(4) not a critical assessment at this time
6. The nurse is assisting a nursing assistant provide a bed bath to a comatose patient who is
incontinent. The nurse should intervene if which of the following actions is noted?
, 1. The nurse assistant answers the phone while wearing gloves.
2. The nursing assistant log rolls the patient to provide back care.
3. The nursing assistant places an incontinence pad under the patient.
4. The nursing assistant positions the patient on the left side, head elevated.
Strategy: “Nurse should intervene” indicates that you are looking for an incorrect action.
(1) correct–contaminated gloves should be removed before answering the phone
(2) correct way to roll a patient to maintain proper alignment
(3) appropriate to use incontinence pad for this patient
(4) appropriate position to prevent aspiration and protect the airway
7. A client is going to be taking imipramine (Tofranil) at home following discharge. The nurse
should instruct the client to report which of the following immediately to the nurse?
1. Sore throat, fever, increased fatigue, vomiting, diarrhea.
2. Dry mouth, nasal stuffiness, weight gain.
3. Rapid heartbeat, frequent headaches, yellowing of eyes or skin.
4. Weakness, staggering gait, tremor, feeling of drunkenness.
Strategy: Think about each answer choice.
(1) correct–possible side effects of Tofranil, a tricyclic antidepressant medication, which can be
resolved by altering the dosage or changing the medication
(2) describes side effects of antidepressants, which client can learn to manage at home without
changing the medication
(3) describes side effects of a different category of medications
(4) describes side effects of a different category of medications
8. The nurse has just received report from the previous shift. Which of the following patients
should the nurse see FIRST?
1. A patient who had coronary artery bypass graft (CABG) and will have the atrioventricular
(AV) wires removed later in the day.
2. A patient with type I diabetes who is scheduled for a cardiac catheterization later today.
3. A patient who is one-day postoperative and has an epidural catheter in place.
4. A cardiac patient who is being evaluated for a heart transplant.
Strategy: Determine which patient is the least stable.
(1) although the patient requires a high level of nursing care, no indication that the patient is
unstable
(2) patient requires preoperative assessment and teaching, no indication that the patient is
unstable
(3) correct–epidural used for pain relief, monitor for urinary incontinence, hypotension,
respiratory depression, and nausea and vomiting
(4) requires monitoring but patient with epidural takes priority
, 9. An 8-year-old girl has a closed transverse fracture of her right ulna. Which of the following
actions, if performed by the nurse before the application of a cast, is MOST important?
1. Check the radial pulses bilaterally and compare.
2. Evaluate the skin temperature and tissue turgor in the area.
3. Assess sensation of each foot while the girl closes her eyes.
4. Apply baby powder to decrease skin irritation under the cast.
Strategy: Answers are a mix of assessments and implementations. Does this situation require
assessment? Yes.
(1) correct–assess neurovascular status, check pain, pallor, paralysis, paresthesia,
pulselessness
(2) assessment, temperature indicates decreased circulation, but is subjective and not most
important
(3) assessment, upper (not lower) extremity fracture
(4) implementation, should not be done because it would increase skin irritation
10. The nurse is caring for a multipara client who delivered a female infant one hour ago. The
nurseobserves that the client’s breasts are soft; the uterus is boggy, to the right of the midline,
and 2 cm below the umbilicus; moderate lochia rubra. It is MOST important for the nurse to
take which of the following actions?
1. Perform a straight catheterization.
2. Offer the client the bedpan.
3. Put the baby to breast.
4. Massage the uterine fundus.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is
it desired?
(1) encourage the client to void before catheterizing
(2) correct–boggy uterus deviated to right indicates full bladder, encourage client to void
(3) will increase uterine tone, but the problem is a full bladder
(4) findings indicate a full bladder
11. The nurse checks for placement of a nasogastric (NG) tube before beginning a tube feeding
for aclient. Which of the following results would indicate to the nurse that the tube feeding can
begin?
1. A small amount of white mucus is aspirated from the NG tube.
2. The pH of the contents removed from the NG tube is 3.
3. No bubbles are seen when the nurse inverts the NG tube in water.
4. The client says he can feel the NG tube in the back of his throat.
Strategy: Determine how the answers relate to a tube feeding.
(1) mucus may be from lungs
TEST 3
1. A client has a total laryngectomy with a permanent tracheostomy. The nurse is planning
nutritional intake for the next three days. Which of the following would be necessary for the
nurse to consider regarding the client’s nutrition?
1. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube
feedings may be implemented.
2. The client will be unable to maintain any PO intake as long as he has a tracheotomy in
place.
3. Nutritional and/or gastric feedings will not be attempted for approximately three weeks to
decrease the incidence of aspiration.
4. Since the client is dependent on the ventilator, nutritional intake will be delayed.
Strategy: Think about each answer choice.
(1) correct–tube feedings frequently started as the initial nutritional intake; prevents trauma to
suture area
(2) although the client has permanent tracheotomy, will be able to eat normally after area has
healed
(3) nutritional intake will begin when bowel sounds return and client can tolerate intake
(4) client is not dependent on ventilator
2. The nurse is caring for a client who presents with confusion, mood lability, impaired
communication, and lethargy. The nurse should question which of the following orders?
1. Dexamethasone suppression test.
2. Thyroid studies.
3. Drug toxicology screen.
4. Trendelenburg test.
Strategy: Think about each test.
(1) may be ordered to determine the presence of major depression
(2) may be ordered to check for an endocrine cause for the symptoms before the diagnosis of
dementia is made
(3) may be ordered to see if the client’s symptoms are caused by excessive use of medications
or alcohol
(4) correct–test is used with a client who may have varicose veins, no relationship to the
symptoms described in this situation
,3. For a client with a neurological disorder, which of the following nursing assessments will be
MOST helpful in determining subtle changes in the client’s level of consciousness?
1. Client posturing.
2. Glasgow coma scale.
3. Client thinking pattern.
4. Occurrence of hallucinations.
Strategy: Think about each answer choice.
(1) indicates increased intracranial pressure
(2) correct–Glasgow coma scale score best evaluates changes in a client’s level of
consciousness by evaluating eye-opening, motor, and verbal responses
(3) more appropriate for the psychiatric client
(4) more appropriate for the psychiatric client
4. The nurse is conducting a physical examination of a client suspected to have bulimia. Which
of the following observations by the nurse would MOST likely indicate bulimia?
1. The client has edema of the lower extremities.
2. Physical exam of the client reveals the presence of lanugo.
3. The client has ulcerated mucous membranes of the mouth.
4. The client has dry, yellowish color of the skin.
Strategy: Determine the cause of each symptom. Does it relate to bulimia?
(1) common with anorexia
(2) seen with anorexia
(3) correct–due to frequent vomiting
(4) bulimics are normal in appearance
5. The nurse is preparing to begin a dopamine (Intropin) infusion on a client. Before beginning
the infusion the nurse should
1. evaluate the urine output.
2. obtain the client’s weight.
3. determine the patency of the IV line.
4. measure pulmonary artery pressures.
Strategy: Determine how each answer choice relates to dopamine.
(1) not a critical assessment at this time
(2) contains correct information, but is not a priority
(3) correct–if extravasation occurs, there is sloughing of the surrounding skin and tissue; patent
IV line is essential to prevent serious side effects
(4) not a critical assessment at this time
6. The nurse is assisting a nursing assistant provide a bed bath to a comatose patient who is
incontinent. The nurse should intervene if which of the following actions is noted?
, 1. The nurse assistant answers the phone while wearing gloves.
2. The nursing assistant log rolls the patient to provide back care.
3. The nursing assistant places an incontinence pad under the patient.
4. The nursing assistant positions the patient on the left side, head elevated.
Strategy: “Nurse should intervene” indicates that you are looking for an incorrect action.
(1) correct–contaminated gloves should be removed before answering the phone
(2) correct way to roll a patient to maintain proper alignment
(3) appropriate to use incontinence pad for this patient
(4) appropriate position to prevent aspiration and protect the airway
7. A client is going to be taking imipramine (Tofranil) at home following discharge. The nurse
should instruct the client to report which of the following immediately to the nurse?
1. Sore throat, fever, increased fatigue, vomiting, diarrhea.
2. Dry mouth, nasal stuffiness, weight gain.
3. Rapid heartbeat, frequent headaches, yellowing of eyes or skin.
4. Weakness, staggering gait, tremor, feeling of drunkenness.
Strategy: Think about each answer choice.
(1) correct–possible side effects of Tofranil, a tricyclic antidepressant medication, which can be
resolved by altering the dosage or changing the medication
(2) describes side effects of antidepressants, which client can learn to manage at home without
changing the medication
(3) describes side effects of a different category of medications
(4) describes side effects of a different category of medications
8. The nurse has just received report from the previous shift. Which of the following patients
should the nurse see FIRST?
1. A patient who had coronary artery bypass graft (CABG) and will have the atrioventricular
(AV) wires removed later in the day.
2. A patient with type I diabetes who is scheduled for a cardiac catheterization later today.
3. A patient who is one-day postoperative and has an epidural catheter in place.
4. A cardiac patient who is being evaluated for a heart transplant.
Strategy: Determine which patient is the least stable.
(1) although the patient requires a high level of nursing care, no indication that the patient is
unstable
(2) patient requires preoperative assessment and teaching, no indication that the patient is
unstable
(3) correct–epidural used for pain relief, monitor for urinary incontinence, hypotension,
respiratory depression, and nausea and vomiting
(4) requires monitoring but patient with epidural takes priority
, 9. An 8-year-old girl has a closed transverse fracture of her right ulna. Which of the following
actions, if performed by the nurse before the application of a cast, is MOST important?
1. Check the radial pulses bilaterally and compare.
2. Evaluate the skin temperature and tissue turgor in the area.
3. Assess sensation of each foot while the girl closes her eyes.
4. Apply baby powder to decrease skin irritation under the cast.
Strategy: Answers are a mix of assessments and implementations. Does this situation require
assessment? Yes.
(1) correct–assess neurovascular status, check pain, pallor, paralysis, paresthesia,
pulselessness
(2) assessment, temperature indicates decreased circulation, but is subjective and not most
important
(3) assessment, upper (not lower) extremity fracture
(4) implementation, should not be done because it would increase skin irritation
10. The nurse is caring for a multipara client who delivered a female infant one hour ago. The
nurseobserves that the client’s breasts are soft; the uterus is boggy, to the right of the midline,
and 2 cm below the umbilicus; moderate lochia rubra. It is MOST important for the nurse to
take which of the following actions?
1. Perform a straight catheterization.
2. Offer the client the bedpan.
3. Put the baby to breast.
4. Massage the uterine fundus.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is
it desired?
(1) encourage the client to void before catheterizing
(2) correct–boggy uterus deviated to right indicates full bladder, encourage client to void
(3) will increase uterine tone, but the problem is a full bladder
(4) findings indicate a full bladder
11. The nurse checks for placement of a nasogastric (NG) tube before beginning a tube feeding
for aclient. Which of the following results would indicate to the nurse that the tube feeding can
begin?
1. A small amount of white mucus is aspirated from the NG tube.
2. The pH of the contents removed from the NG tube is 3.
3. No bubbles are seen when the nurse inverts the NG tube in water.
4. The client says he can feel the NG tube in the back of his throat.
Strategy: Determine how the answers relate to a tube feeding.
(1) mucus may be from lungs
