COMPREHENSIVE NCLEX-RN PRACTICE QUESTIONS SET 1 (75 QUESTIONS)
1. Question
While assessing a one-month-old infant, which of the findings
warrants further investigation by the nurse? Select all that
apply.
o A. Abdominal respirations
o B. Irregular breathing rate
o C. Inspiratory grunt
o D. Increased heart rate with crying
o E. Nasal flaring
o F. Cyanosis
o G. Asymmetric chest movement
Incorrect
Correct Answers: C, E, F, & G
Option C. Grunting occurs when an infant attempts to
maintain an adequate functional residual capacity in
the face of poorly compliant lungs by partial glottic
closure. As the infant prolongs the expiratory phase
against this partially closed glottis, there is a
prolonged and increased residual volume that
maintains the airway opening and also an audible
expiratory sound.
Option E: Nasal flaring occurs when the nostrils widen
while breathing and is a sign of troubled breathing or
respiratory distress.
Option F: Cyanosis refers to the bluish discoloration
of the skin and indicates a decrease in oxygen
attached to the red blood cells in the bloodstream.
Option G: Asymmetric chest movement occurs when
the abnormal side of the lungs expands less and lags
, behind the normal side. This indicates respiratory
distress.
Option A: Abdominal respiration is normal among
infants and young children. Since their intercostal
muscles are not yet fully developed, they use their
abdominal muscles much more to pull the diaphragm
down for breathing.
Option B: Newborns can have irregular breathing
patterns ranging from 30 to 60 breaths per minute
with short periods of apnea (15 seconds).
Option D: An increase in heart rate is normal for an
infant during activity (including crying). Fluctuations in
heart rate follow the changes in the newborn’s
behavioral state – crying, movement, or wakefulness
corresponds to an increase in heart rate.
2. 2. Question
A nurse is to administer meperidine hydrochloride (Demerol) 100
mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine
hydrochloride (Phenergan) 50 mg IM to a preoperative client. List
the order in which the nurse must carry out the following
actions prior to the administration of preoperative
medications.
View Answers:
Raise the side rails on the bed
Instruct the client to remain in bed
Place the call bell within reach
Have the client empty bladder
Incorrect
Correct order is shown above.
5. Have the client empty the bladder. The first step
in the process is to have the client void prior to
administering the pre-operative medication. If the
client does not have a catheter, it is important to
empty the bladder before receiving preoperative
medications to prevent bladder injury (especially in
pelvic surgeries). Else, a straight catheter or an
, indwelling catheter may be ordered to ensure the
bladder is empty.
6. Instruct the client to remain in bed. Preoperative
medications can cause drowsiness and
lightheadedness which may put the client at risk for
injury.
7. Raise the side rails on the bed. Raising the side
rails on the bed helps prevent accidental falls and
injury when the client decides to get out of the bed
without assistance.
8. Place the call bell within reach. Call bells should
always be within the reach of a client.
3. 3. Question
A 32-year-old pregnant woman comes to the clinic for her
prenatal visit. The nurse gathers data about her obstetric history,
which includes 3-year-old twins at home and a miscarriage 10
years ago at 12 weeks gestation. How would the nurse accurately
document this information? Fill in the blanks.
o Answer: Gravida (3) para (1)
Incorrect
Correct Answer: Gravida 3 para 1
Gravida is the number of confirmed pregnancies and each
pregnancy is only counted one time, even if the pregnancy was a
multiple gestation (i.e., twins, triplets). Para (parity) indicates the
total number of pregnancies that have reached viability (20
weeks) regardless of whether the infants were born alive. Thus,
for this woman, she is now pregnant, had 2 prior pregnancies,
and 1 viable birth (twins).
4. 4. Question
Which individual is at the greatest risk for developing
hypertension?
o A. 45-year-old African-American attorney
o B. 60-year-old Asian-American shop owner
o C. 40-year-old Caucasian nurse
, o D. 55-year-old Hispanic teacher
Incorrect
Correct Answer: A: 45-year-old African American attorney
Option A: African-Americans develop high blood
pressure at younger ages than other groups in the US.
Researchers have uncovered that African-Americans
respond differently to hypertensive drugs than other
groups of people. They are also found out to be more
sensitive to salt, which increases the risk of
developing hypertension.
Option B: The incidence of hypertension in Asian-
Americans does not appear to be significantly higher
than the general population, according to limited US
data.
Option C: The racial disparity in hypertension and
hypertension-related outcomes has been recognized
for decades with African-Americans with greater risks
than Caucasians.
Option D: Hypertension prevalence rates in Hispanics
may vary by gender and country of origin. Hispanic
Americans overall have relatively low levels of
hypertension, despite elevated levels of diabetes and
obesity.
5. 5. Question
A 15-year-old female who ingested 15 tablets of maximum
strength acetaminophen 45 minutes ago is rushed to the
emergency department. Which of these orders should the nurse
do first?
A. Gastric lavage
B. Administer acetylcysteine (Mucomyst) orally
C. Start an IV Dextrose 5% with 0.33% normal saline to
keep the vein open
D. Have the patient drink activated charcoal mixed with
water
1. Question
While assessing a one-month-old infant, which of the findings
warrants further investigation by the nurse? Select all that
apply.
o A. Abdominal respirations
o B. Irregular breathing rate
o C. Inspiratory grunt
o D. Increased heart rate with crying
o E. Nasal flaring
o F. Cyanosis
o G. Asymmetric chest movement
Incorrect
Correct Answers: C, E, F, & G
Option C. Grunting occurs when an infant attempts to
maintain an adequate functional residual capacity in
the face of poorly compliant lungs by partial glottic
closure. As the infant prolongs the expiratory phase
against this partially closed glottis, there is a
prolonged and increased residual volume that
maintains the airway opening and also an audible
expiratory sound.
Option E: Nasal flaring occurs when the nostrils widen
while breathing and is a sign of troubled breathing or
respiratory distress.
Option F: Cyanosis refers to the bluish discoloration
of the skin and indicates a decrease in oxygen
attached to the red blood cells in the bloodstream.
Option G: Asymmetric chest movement occurs when
the abnormal side of the lungs expands less and lags
, behind the normal side. This indicates respiratory
distress.
Option A: Abdominal respiration is normal among
infants and young children. Since their intercostal
muscles are not yet fully developed, they use their
abdominal muscles much more to pull the diaphragm
down for breathing.
Option B: Newborns can have irregular breathing
patterns ranging from 30 to 60 breaths per minute
with short periods of apnea (15 seconds).
Option D: An increase in heart rate is normal for an
infant during activity (including crying). Fluctuations in
heart rate follow the changes in the newborn’s
behavioral state – crying, movement, or wakefulness
corresponds to an increase in heart rate.
2. 2. Question
A nurse is to administer meperidine hydrochloride (Demerol) 100
mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine
hydrochloride (Phenergan) 50 mg IM to a preoperative client. List
the order in which the nurse must carry out the following
actions prior to the administration of preoperative
medications.
View Answers:
Raise the side rails on the bed
Instruct the client to remain in bed
Place the call bell within reach
Have the client empty bladder
Incorrect
Correct order is shown above.
5. Have the client empty the bladder. The first step
in the process is to have the client void prior to
administering the pre-operative medication. If the
client does not have a catheter, it is important to
empty the bladder before receiving preoperative
medications to prevent bladder injury (especially in
pelvic surgeries). Else, a straight catheter or an
, indwelling catheter may be ordered to ensure the
bladder is empty.
6. Instruct the client to remain in bed. Preoperative
medications can cause drowsiness and
lightheadedness which may put the client at risk for
injury.
7. Raise the side rails on the bed. Raising the side
rails on the bed helps prevent accidental falls and
injury when the client decides to get out of the bed
without assistance.
8. Place the call bell within reach. Call bells should
always be within the reach of a client.
3. 3. Question
A 32-year-old pregnant woman comes to the clinic for her
prenatal visit. The nurse gathers data about her obstetric history,
which includes 3-year-old twins at home and a miscarriage 10
years ago at 12 weeks gestation. How would the nurse accurately
document this information? Fill in the blanks.
o Answer: Gravida (3) para (1)
Incorrect
Correct Answer: Gravida 3 para 1
Gravida is the number of confirmed pregnancies and each
pregnancy is only counted one time, even if the pregnancy was a
multiple gestation (i.e., twins, triplets). Para (parity) indicates the
total number of pregnancies that have reached viability (20
weeks) regardless of whether the infants were born alive. Thus,
for this woman, she is now pregnant, had 2 prior pregnancies,
and 1 viable birth (twins).
4. 4. Question
Which individual is at the greatest risk for developing
hypertension?
o A. 45-year-old African-American attorney
o B. 60-year-old Asian-American shop owner
o C. 40-year-old Caucasian nurse
, o D. 55-year-old Hispanic teacher
Incorrect
Correct Answer: A: 45-year-old African American attorney
Option A: African-Americans develop high blood
pressure at younger ages than other groups in the US.
Researchers have uncovered that African-Americans
respond differently to hypertensive drugs than other
groups of people. They are also found out to be more
sensitive to salt, which increases the risk of
developing hypertension.
Option B: The incidence of hypertension in Asian-
Americans does not appear to be significantly higher
than the general population, according to limited US
data.
Option C: The racial disparity in hypertension and
hypertension-related outcomes has been recognized
for decades with African-Americans with greater risks
than Caucasians.
Option D: Hypertension prevalence rates in Hispanics
may vary by gender and country of origin. Hispanic
Americans overall have relatively low levels of
hypertension, despite elevated levels of diabetes and
obesity.
5. 5. Question
A 15-year-old female who ingested 15 tablets of maximum
strength acetaminophen 45 minutes ago is rushed to the
emergency department. Which of these orders should the nurse
do first?
A. Gastric lavage
B. Administer acetylcysteine (Mucomyst) orally
C. Start an IV Dextrose 5% with 0.33% normal saline to
keep the vein open
D. Have the patient drink activated charcoal mixed with
water
