VATI GREENLIGHT EXAM PREP 206 NCLEX-
STYLE PRACTICE QUESTIONS WITH 100%
CORRECT ANSWERS AND DETAILED
RATIONALES
1. A nurse is reinforcing teaching with an adolescent who has a new
prescription for cefazolin. For which of the following findings should
the nurse instruct the adolescent to monitor and report to the
provider?
A Nausea
B Headache
C Depression
D Dry mouth
Rationale: Cefazolin (cephalosporin antibiotic) can cause central
nervous system side effects including depression, confusion, and
agitation. These should be reported to the provider.
2. A nurse is caring for a client who has just been diagnosed with type
2 diabetes mellitus. Which of the following laboratory values should
the nurse expect?
A Fasting blood glucose 70 mg/dL
B HbA1c 8.5%
C Random blood glucose 110 mg/dL
,D Urine ketones 4+
Rationale: HbA1c reflects average blood glucose over 2-3 months. A
value of 8.5% indicates poor glycemic control (normal <5.7%, diabetic
≥6.5%).
3. A nurse is caring for a school-age child who has epistaxis. Which of
the following actions should the nurse take?
A Apply pressure at the bridge of the child's nose
B Apply pressure to the nostrils while the child leans forward
C Tilt the child's head backward
D Insert gauze packing into both nostrils
Rationale: For epistaxis, apply direct pressure to the nostrils (not the
bridge) while the child leans forward to prevent blood from draining
into the throat.
4. A nurse is reinforcing teaching with a group of expectant parents
regarding the proper use of a car seat. Which of the following
statements by a parent indicates an understanding of the teaching?
A "I can place a rolled blanket behind my newborn's back."
B "I can place a rolled towel on each side of my newborn's head until
he can hold his head up"
C "I should place the car seat forward-facing from birth."
D "I should put the retainer clip at my newborn's belly button level."
Rationale: Rolled towels or blankets provide head support for
newborns. The car seat should be rear-facing until age 2, retainer clip at
armpit level.
5. A nurse is preparing to administer a blood transfusion to a client.
Which of the following actions should the nurse take first?
A Obtain a signed consent form
,B Prime the tubing with lactated Ringer's solution
C Verify the client's identity using two identifiers
D Check vital signs 15 minutes after starting the transfusion
Rationale: The first step is verifying client identity with two identifiers
(name, date of birth, medical record number) to prevent transfusion
errors.
6. A nurse working in an inpatient mental health facility is assisting
with the plan of care for a client who has anorexia nervosa. Which of
the following should the nurse recommend to include in the plan of
care?
A Rotate staff members daily
B Maintain continuity of staff members
C Allow the client to choose all mealtimes
D Weigh the client once per week
Rationale: Consistent staff assignments build trust and therapeutic
rapport, which is essential for clients with anorexia nervosa.
7. A nurse is assisting with an admission interview for a client who has
schizophrenia. He tells the nurse that he is receiving special audible
messages from the Central Intelligence Agency that no one else is able
to hear. The nurse should identify that the client is having which of the
following alterations in perception?
A Delusion
B Hallucination
C Illusion
D Neologism
Rationale: Hallucinations are sensory perceptions that occur without an
external stimulus. Auditory hallucinations are most common in
schizophrenia.
, 8. A nurse is caring for a client who is 2 hours postoperative following
a thyroidectomy. Which of the following findings should the nurse
report to the provider immediately?
A Pain rated 4 on a scale of 0 to 10
B Stridor on inspiration
C Hoarse voice
D Temperature 37.5°C (99.5°F)
Rationale: Stridor indicates airway obstruction from laryngeal edema or
hematoma, a life-threatening emergency after thyroidectomy.
9. A nurse is reinforcing teaching with a postpartum client about
bathing her newborn. Which of the following statements should the
nurse include?
A "Submerge your newborn completely in warm water."
B "Wash your newborn's head under a stream of running water."
C "Use soap directly on the umbilical cord stump."
D "Bathe your newborn immediately after a feeding."
Rationale: Washing the head under running water prevents soap from
running into the eyes. Sponge baths are recommended until the cord
falls off.
10. A nurse is caring for a client who has heart failure and reports
difficulty limiting sodium in his diet. Which of the following
recommendations should the nurse provide?
A Use canned vegetables instead of fresh
B Add salt during cooking rather than at the table
C Replace bottled salad dressing with homemade vinegar and oil
dressing
D Season foods with garlic salt instead of table salt
STYLE PRACTICE QUESTIONS WITH 100%
CORRECT ANSWERS AND DETAILED
RATIONALES
1. A nurse is reinforcing teaching with an adolescent who has a new
prescription for cefazolin. For which of the following findings should
the nurse instruct the adolescent to monitor and report to the
provider?
A Nausea
B Headache
C Depression
D Dry mouth
Rationale: Cefazolin (cephalosporin antibiotic) can cause central
nervous system side effects including depression, confusion, and
agitation. These should be reported to the provider.
2. A nurse is caring for a client who has just been diagnosed with type
2 diabetes mellitus. Which of the following laboratory values should
the nurse expect?
A Fasting blood glucose 70 mg/dL
B HbA1c 8.5%
C Random blood glucose 110 mg/dL
,D Urine ketones 4+
Rationale: HbA1c reflects average blood glucose over 2-3 months. A
value of 8.5% indicates poor glycemic control (normal <5.7%, diabetic
≥6.5%).
3. A nurse is caring for a school-age child who has epistaxis. Which of
the following actions should the nurse take?
A Apply pressure at the bridge of the child's nose
B Apply pressure to the nostrils while the child leans forward
C Tilt the child's head backward
D Insert gauze packing into both nostrils
Rationale: For epistaxis, apply direct pressure to the nostrils (not the
bridge) while the child leans forward to prevent blood from draining
into the throat.
4. A nurse is reinforcing teaching with a group of expectant parents
regarding the proper use of a car seat. Which of the following
statements by a parent indicates an understanding of the teaching?
A "I can place a rolled blanket behind my newborn's back."
B "I can place a rolled towel on each side of my newborn's head until
he can hold his head up"
C "I should place the car seat forward-facing from birth."
D "I should put the retainer clip at my newborn's belly button level."
Rationale: Rolled towels or blankets provide head support for
newborns. The car seat should be rear-facing until age 2, retainer clip at
armpit level.
5. A nurse is preparing to administer a blood transfusion to a client.
Which of the following actions should the nurse take first?
A Obtain a signed consent form
,B Prime the tubing with lactated Ringer's solution
C Verify the client's identity using two identifiers
D Check vital signs 15 minutes after starting the transfusion
Rationale: The first step is verifying client identity with two identifiers
(name, date of birth, medical record number) to prevent transfusion
errors.
6. A nurse working in an inpatient mental health facility is assisting
with the plan of care for a client who has anorexia nervosa. Which of
the following should the nurse recommend to include in the plan of
care?
A Rotate staff members daily
B Maintain continuity of staff members
C Allow the client to choose all mealtimes
D Weigh the client once per week
Rationale: Consistent staff assignments build trust and therapeutic
rapport, which is essential for clients with anorexia nervosa.
7. A nurse is assisting with an admission interview for a client who has
schizophrenia. He tells the nurse that he is receiving special audible
messages from the Central Intelligence Agency that no one else is able
to hear. The nurse should identify that the client is having which of the
following alterations in perception?
A Delusion
B Hallucination
C Illusion
D Neologism
Rationale: Hallucinations are sensory perceptions that occur without an
external stimulus. Auditory hallucinations are most common in
schizophrenia.
, 8. A nurse is caring for a client who is 2 hours postoperative following
a thyroidectomy. Which of the following findings should the nurse
report to the provider immediately?
A Pain rated 4 on a scale of 0 to 10
B Stridor on inspiration
C Hoarse voice
D Temperature 37.5°C (99.5°F)
Rationale: Stridor indicates airway obstruction from laryngeal edema or
hematoma, a life-threatening emergency after thyroidectomy.
9. A nurse is reinforcing teaching with a postpartum client about
bathing her newborn. Which of the following statements should the
nurse include?
A "Submerge your newborn completely in warm water."
B "Wash your newborn's head under a stream of running water."
C "Use soap directly on the umbilical cord stump."
D "Bathe your newborn immediately after a feeding."
Rationale: Washing the head under running water prevents soap from
running into the eyes. Sponge baths are recommended until the cord
falls off.
10. A nurse is caring for a client who has heart failure and reports
difficulty limiting sodium in his diet. Which of the following
recommendations should the nurse provide?
A Use canned vegetables instead of fresh
B Add salt during cooking rather than at the table
C Replace bottled salad dressing with homemade vinegar and oil
dressing
D Season foods with garlic salt instead of table salt
