NCLEX-RN Practice Quiz Test Bank #4 (75
Questions)
1. 1. Question
Which action(s) should you delegate to the experienced nursing assistant when caring for a patient with
a thrombotic stroke with residual left-sided weakness? Select all that apply.
o A. Assist the patient to reposition every 2 hours.
o B. Reapply pneumatic compression boots.
o C. Remind the patient to perform active ROM.
o D. Check extremities for redness and edema.
Incorrect
Correct Answer: A, B, & C.
The experienced nursing assistant would know how to reposition the patient and how to reapply
compression boots and would remind the patient to perform activities he has been taught to perform.
Option D: Assessing for redness and swelling (signs of deep venous thrombosis {DVT})
requires additional education and is still appropriate to the professional nurse.
2. 2. Question
The patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant
who will feed the patient?
A. Position the patient sitting up in bed before you feed her.
B. Check the patient’s gag and swallowing reflexes.
C. Feed the patient quickly because there are three more waiting.
D. Suction the patient’s secretions between bites of food.
Incorrect
Correct Answer: A. Position the patient sitting up in bed before you feed her.
Positioning the patient in a sitting position decreases the risk of aspiration.
Option B: The nursing assistant is not trained to assess gag or swallowing reflexes.
Option C: The patient should not be rushed during feeding.
, Option D: A patient who needs to be suctioned between bites of food is not handling
secretions and is at risk for aspiration. This patient should be assessed further before
feeding.
3. 3. Question
You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patient
complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Which
collaborative intervention must be accomplished first?
A. Administer codeine 15 mg orally for the patient’s headache.
B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.
C. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever.
D. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure.
Incorrect
Correct Answer: B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.
Untreated bacterial meningitis has a mortality rate approaching 100%, so rapid antibiotic treatment is
essential.
Option A: Pain medications may be given after treating the infection that is most
probably causing it.
Option C: Acetaminophen should be given to decrease the fever after administering the
antibiotics first.
Option D: Furosemide will help reduce CNS stimulation and irritation and should be
implemented as soon as possible.
4. 4. Question
You are mentoring a student nurse in the intensive care unit (ICU) while caring for a patient with
meningococcal meningitis. Which action by the student requires that you intervene immediately?
A. The student enters the room without putting on a mask and gown.
B. The student instructs the family that visits are restricted to 10 minutes.
C. The student gives the patient a warm blanket when he says he feels cold.
D. The student checks the patient’s pupil response to light every 30 minutes.
Incorrect
Correct Answer: A. The student enters the room without putting on a mask and gown.
,Meningococcal meningitis is spread through contact with respiratory secretions so use of a mask and
gown is required to prevent the spread of the infection to staff members or other patients. The other
actions may not be appropriate but they do not require intervention as rapidly.
Option B: The presence of a family member at the bedside may decrease patient
confusion and agitation.
Option C: Patients with hyperthermia frequently complain of feeling chilled, but
warming the patient is not an appropriate intervention.
Option D: Checking the pupil response to light is appropriate, but it is not needed every
30 minutes and is uncomfortable for a patient with photophobia. Focus: Prioritization
5. 5. Question
A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new-
onset generalized tonic-clonic seizures. Which nursing activities included in the patient’s care will be
best to delegate to an LPN/LVN whom you are supervising? Select all that apply.
A. Document the onset time, nature of seizure activity, and postictal behaviors for
all seizures.
B. Administer phenytoin (Dilantin) 200 mg PO daily.
C. Teach the patient about the need for good oral hygiene.
D. Develop a discharge plan, including physician visits and referral to the Epilepsy
Foundation.
E. Gather information about the seizure activity
Incorrect
Correct Answer: B & E
Administration of medications that are not a high risk is included in LPN education and scope of practice.
Collection of data about the seizure activity may be accomplished by an LPN/LVN who observes initial
seizure activity. An LPN/LVN would know to call the supervising RN immediately if a patient started to
seize.
Option A: Documentation is a nursing responsibility.
Option C: Patient education must be accomplished by the registered nurse because it is
within their scope of practice.
Option D: Planning of care is a complex activity that requires RN level education and
scope of practice.
6. 6. Question
, While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these
nursing actions will you implement first if the patient has a seizure?
A. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute.
B. Administer lorazepam (Ativan) 1 mg IV.
C. Turn the patient to the side and protect the airway.
D. Assess level of consciousness during and immediately after the seizure.
Incorrect
Correct Answer: C. Turn the patient to the side and protect the airway.
The priority action during a generalized tonic-clonic seizure is to protect the airway.
Option B: Administration of lorazepam should be the next action since it will act rapidly
to control the seizure.
Option A: Although oxygen may be useful during the postictal phase, the hypoxemia
during tonic-clonic seizures is caused by apnea.
Option D: Checking the level of consciousness is not appropriate during the seizure,
because generalized tonic-clonic seizures are associated with a loss of consciousness.
7. 7. Question
A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the
outpatient clinic. Which information obtained during his chart review and assessment will be of greatest
concern?
A. The gums appear enlarged and inflamed.
B. The white blood cell count is 2300/mm3.
C. Patient occasionally forgets to take the phenytoin until after lunch.
D. Patient wants to renew his driver’s license next month.
Incorrect
Correct Answer: B. The white blood cell count is 2300/mm3.
Leukopenia is a serious adverse effect of phenytoin and would require discontinuation of the
medication.
Option A: Inflammation of the gums should be reported to the physician, but it does not
require immediate attention.
Questions)
1. 1. Question
Which action(s) should you delegate to the experienced nursing assistant when caring for a patient with
a thrombotic stroke with residual left-sided weakness? Select all that apply.
o A. Assist the patient to reposition every 2 hours.
o B. Reapply pneumatic compression boots.
o C. Remind the patient to perform active ROM.
o D. Check extremities for redness and edema.
Incorrect
Correct Answer: A, B, & C.
The experienced nursing assistant would know how to reposition the patient and how to reapply
compression boots and would remind the patient to perform activities he has been taught to perform.
Option D: Assessing for redness and swelling (signs of deep venous thrombosis {DVT})
requires additional education and is still appropriate to the professional nurse.
2. 2. Question
The patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant
who will feed the patient?
A. Position the patient sitting up in bed before you feed her.
B. Check the patient’s gag and swallowing reflexes.
C. Feed the patient quickly because there are three more waiting.
D. Suction the patient’s secretions between bites of food.
Incorrect
Correct Answer: A. Position the patient sitting up in bed before you feed her.
Positioning the patient in a sitting position decreases the risk of aspiration.
Option B: The nursing assistant is not trained to assess gag or swallowing reflexes.
Option C: The patient should not be rushed during feeding.
, Option D: A patient who needs to be suctioned between bites of food is not handling
secretions and is at risk for aspiration. This patient should be assessed further before
feeding.
3. 3. Question
You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patient
complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Which
collaborative intervention must be accomplished first?
A. Administer codeine 15 mg orally for the patient’s headache.
B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.
C. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever.
D. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure.
Incorrect
Correct Answer: B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.
Untreated bacterial meningitis has a mortality rate approaching 100%, so rapid antibiotic treatment is
essential.
Option A: Pain medications may be given after treating the infection that is most
probably causing it.
Option C: Acetaminophen should be given to decrease the fever after administering the
antibiotics first.
Option D: Furosemide will help reduce CNS stimulation and irritation and should be
implemented as soon as possible.
4. 4. Question
You are mentoring a student nurse in the intensive care unit (ICU) while caring for a patient with
meningococcal meningitis. Which action by the student requires that you intervene immediately?
A. The student enters the room without putting on a mask and gown.
B. The student instructs the family that visits are restricted to 10 minutes.
C. The student gives the patient a warm blanket when he says he feels cold.
D. The student checks the patient’s pupil response to light every 30 minutes.
Incorrect
Correct Answer: A. The student enters the room without putting on a mask and gown.
,Meningococcal meningitis is spread through contact with respiratory secretions so use of a mask and
gown is required to prevent the spread of the infection to staff members or other patients. The other
actions may not be appropriate but they do not require intervention as rapidly.
Option B: The presence of a family member at the bedside may decrease patient
confusion and agitation.
Option C: Patients with hyperthermia frequently complain of feeling chilled, but
warming the patient is not an appropriate intervention.
Option D: Checking the pupil response to light is appropriate, but it is not needed every
30 minutes and is uncomfortable for a patient with photophobia. Focus: Prioritization
5. 5. Question
A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new-
onset generalized tonic-clonic seizures. Which nursing activities included in the patient’s care will be
best to delegate to an LPN/LVN whom you are supervising? Select all that apply.
A. Document the onset time, nature of seizure activity, and postictal behaviors for
all seizures.
B. Administer phenytoin (Dilantin) 200 mg PO daily.
C. Teach the patient about the need for good oral hygiene.
D. Develop a discharge plan, including physician visits and referral to the Epilepsy
Foundation.
E. Gather information about the seizure activity
Incorrect
Correct Answer: B & E
Administration of medications that are not a high risk is included in LPN education and scope of practice.
Collection of data about the seizure activity may be accomplished by an LPN/LVN who observes initial
seizure activity. An LPN/LVN would know to call the supervising RN immediately if a patient started to
seize.
Option A: Documentation is a nursing responsibility.
Option C: Patient education must be accomplished by the registered nurse because it is
within their scope of practice.
Option D: Planning of care is a complex activity that requires RN level education and
scope of practice.
6. 6. Question
, While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these
nursing actions will you implement first if the patient has a seizure?
A. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute.
B. Administer lorazepam (Ativan) 1 mg IV.
C. Turn the patient to the side and protect the airway.
D. Assess level of consciousness during and immediately after the seizure.
Incorrect
Correct Answer: C. Turn the patient to the side and protect the airway.
The priority action during a generalized tonic-clonic seizure is to protect the airway.
Option B: Administration of lorazepam should be the next action since it will act rapidly
to control the seizure.
Option A: Although oxygen may be useful during the postictal phase, the hypoxemia
during tonic-clonic seizures is caused by apnea.
Option D: Checking the level of consciousness is not appropriate during the seizure,
because generalized tonic-clonic seizures are associated with a loss of consciousness.
7. 7. Question
A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the
outpatient clinic. Which information obtained during his chart review and assessment will be of greatest
concern?
A. The gums appear enlarged and inflamed.
B. The white blood cell count is 2300/mm3.
C. Patient occasionally forgets to take the phenytoin until after lunch.
D. Patient wants to renew his driver’s license next month.
Incorrect
Correct Answer: B. The white blood cell count is 2300/mm3.
Leukopenia is a serious adverse effect of phenytoin and would require discontinuation of the
medication.
Option A: Inflammation of the gums should be reported to the physician, but it does not
require immediate attention.
