Comprehensive NCLEX-RN| Exam #4: 75 Questions and
Correct Answers/ Rationale (2022 update)
65. Question
Category: Reduction of Risk Potential
Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the
neck stoma, the nurse should include which instruction?
A. “Keep the stoma uncovered.”
B. “Keep the stoma dry.”
C. “Have a family member perform stoma care initially until you get used to the procedure.”
D. “Keep the stoma moist.”
Correct Answer: D. “Keep the stoma moist.”
The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of
petroleum jelly around the edges, because a dry stoma may become i rritated.
66. Question
Category: Physiological Adaptation
A 37-year-old client with uterine cancer asks the nurse, “Which is the most common type of cancer in
women?” The nurse replies that it’s breast cancer. Which type of cancer causes the most deaths in
women?
A. Breast cancer
B. Lung cancer
C. Brain cancer
D. Colon and rectal cancer
Correct Answer: B. Lung cancer
Lung cancer is the most deadly type of cancer in both women and men.
,67. Question
Category: Physiological Adaptation
Antonio with lung cancer develops Horner’s syndrome when the tumor invades the ribs and affects the
sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should
note:
A. Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
B. Chest pain, dyspnea, cough, weight loss, and fever.
C. Arm and shoulder pain and atrophy of arm and hand muscles, both on the affected side.
D. Hoarseness and dysphagia.
Correct Answer: A. Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
Horner’s syndrome, which occurs when a lung tumor invades the ribs and affects the sympathetic nerve
ganglia, is characterized by miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face .
68. Question
Category: Reduction of Risk Potential
Vic asks the nurse what PSA is. The nurse should reply that it stands for:
A. Prostate-specific antigen, which is used to screen for prostate cancer.
B. Protein serum antigen, which is used to determine protein levels.
C. Pneumococcal strep antigen, which is a bacteria that causes pneumonia.
D. Papanicolaou-specific antigen, which is used to screen for cervical cancer.
Correct Answer: A. Prostate-specific antigen, which is used to screen for prostate cancer.
PSA stands for prostate-specific antigen, which is used to screen for prostate cancer.
69. Question
Category: Reduction of Risk Potential
,What is the most important postoperative instruction that nurse Kate must give a client who has just
returned from the operating room after receiving a subarachnoid block?
A. “Avoid drinking liquids until the gag reflex returns.”
B. “Avoid eating milk products for 24 hours.”
C. “Notify a nurse if you experience blood in your urine.”
D. “Remain supine for the time specified by the physician.”
Correct Answer: D. “Remain supine for the time specified by the physician.”
The nurse should instruct the client to remain supine for the time specified by the physician.
70. Question
Category: Reduction of Risk Potential
A male client suspected of having colorectal cancer will require which diagnostic study to confirm the
diagnosis?
A. Stool Hematest
B. Carcinoembryonic antigen (CEA)
C. Sigmoidoscopy
D. Abdominal computed tomography (CT) scan
Correct Answer: C. Sigmoidoscopy
Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of
all colorectal cancers.
71. Question
Category: Physiological Adaptation
During a breast examination, which finding most strongly suggests that the Luz has breast cancer?
A. Slight asymmetry of the breasts
B. A fixed nodular mass with dimpling of the overlying skin
C. Bloody discharge from the nipple
,D. Multiple firm, round, freely movable masses that change with the menstrual cycle
Correct Answer: B. A fixed nodular mass with dimpling of the overlying skin
A fixed nodular mass with dimpling of the overlying skin is common during the late stages of breast
cancer.
72. Question
Category: Physiological Adaptation
A female client with cancer is being evaluated for possible metastasis. Which of the following is one of
the most common metastasis sites for cancer cells?
A. Liver
B. Colon
C. Reproductive tract
D. White blood cells (WBCs)
Correct Answer: A. Liver
The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung,
bone, and brain.
73. Question
Category: Reduction of Risk Potential
Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal
cord lesion. During the MRI scan, which of the following would pose a threat to the client?
A. The client lies still
B. The client asks questions
C. The client hears thumping sounds
D. The client wears a watch and wedding band
Correct Answer: D. The client wears a watch and wedding band
During an MRI, the client should wear no metal objects, such as jewelry, because the strong magnetic
field can pull on them, causing injury to the client and (if they fly off) to others.
,74. Question
Category: Health Promotion and Maintenance
Nurse Cecile is teaching a female client about preventing osteoporosis. Which of the following teaching
points is correct?
A. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss.
B. To avoid fractures, the client should avoid strenuous exercise.
C. The recommended daily allowance of calcium may be found in a wide variety of foods
D. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.
Correct Answer: C. The recommended daily allowance of calcium may be found in a wide variety of
foods.
Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg
per day. It’s often, though not always, possible to get the recommended daily requirement in the foods
we eat.
75. Question
Category: Reduction of Risk Potential
Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings for contraindications
for this procedure. Which finding is a contraindication?
A. Joint pain
B. Joint deformity
C. Joint flexion of less than 50%
D. Joint stiffness
Correct Answer: C. Joint flexion of less than 50%
Arthroscopy is contraindicated in clients with joint flexion of less than 50% because of technical
problems in inserting the instrument into the joint to see it clearly. Other contraindications for this
procedure include skin and wound infections.
,1. Question
Category: Management of Care
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.
A. Assist the patient to reposition every 2 hours.
B. Reapply pneumatic compression boots.
C. Remind the patient to perform active ROM.
D. Check extremities for redness and edema.
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.
2. Question
Category: Management of Care
The patient who had a stroke needs to be fed. What instruction should you give to the nursing assis tant
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.
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.
3. Question
Category: Physiological Adaptation
, 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.
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.
4. Question
Category: Management of Care
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.
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.
5. Question
Category: Management of Care
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.
Correct Answers/ Rationale (2022 update)
65. Question
Category: Reduction of Risk Potential
Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the
neck stoma, the nurse should include which instruction?
A. “Keep the stoma uncovered.”
B. “Keep the stoma dry.”
C. “Have a family member perform stoma care initially until you get used to the procedure.”
D. “Keep the stoma moist.”
Correct Answer: D. “Keep the stoma moist.”
The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of
petroleum jelly around the edges, because a dry stoma may become i rritated.
66. Question
Category: Physiological Adaptation
A 37-year-old client with uterine cancer asks the nurse, “Which is the most common type of cancer in
women?” The nurse replies that it’s breast cancer. Which type of cancer causes the most deaths in
women?
A. Breast cancer
B. Lung cancer
C. Brain cancer
D. Colon and rectal cancer
Correct Answer: B. Lung cancer
Lung cancer is the most deadly type of cancer in both women and men.
,67. Question
Category: Physiological Adaptation
Antonio with lung cancer develops Horner’s syndrome when the tumor invades the ribs and affects the
sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should
note:
A. Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
B. Chest pain, dyspnea, cough, weight loss, and fever.
C. Arm and shoulder pain and atrophy of arm and hand muscles, both on the affected side.
D. Hoarseness and dysphagia.
Correct Answer: A. Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
Horner’s syndrome, which occurs when a lung tumor invades the ribs and affects the sympathetic nerve
ganglia, is characterized by miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face .
68. Question
Category: Reduction of Risk Potential
Vic asks the nurse what PSA is. The nurse should reply that it stands for:
A. Prostate-specific antigen, which is used to screen for prostate cancer.
B. Protein serum antigen, which is used to determine protein levels.
C. Pneumococcal strep antigen, which is a bacteria that causes pneumonia.
D. Papanicolaou-specific antigen, which is used to screen for cervical cancer.
Correct Answer: A. Prostate-specific antigen, which is used to screen for prostate cancer.
PSA stands for prostate-specific antigen, which is used to screen for prostate cancer.
69. Question
Category: Reduction of Risk Potential
,What is the most important postoperative instruction that nurse Kate must give a client who has just
returned from the operating room after receiving a subarachnoid block?
A. “Avoid drinking liquids until the gag reflex returns.”
B. “Avoid eating milk products for 24 hours.”
C. “Notify a nurse if you experience blood in your urine.”
D. “Remain supine for the time specified by the physician.”
Correct Answer: D. “Remain supine for the time specified by the physician.”
The nurse should instruct the client to remain supine for the time specified by the physician.
70. Question
Category: Reduction of Risk Potential
A male client suspected of having colorectal cancer will require which diagnostic study to confirm the
diagnosis?
A. Stool Hematest
B. Carcinoembryonic antigen (CEA)
C. Sigmoidoscopy
D. Abdominal computed tomography (CT) scan
Correct Answer: C. Sigmoidoscopy
Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of
all colorectal cancers.
71. Question
Category: Physiological Adaptation
During a breast examination, which finding most strongly suggests that the Luz has breast cancer?
A. Slight asymmetry of the breasts
B. A fixed nodular mass with dimpling of the overlying skin
C. Bloody discharge from the nipple
,D. Multiple firm, round, freely movable masses that change with the menstrual cycle
Correct Answer: B. A fixed nodular mass with dimpling of the overlying skin
A fixed nodular mass with dimpling of the overlying skin is common during the late stages of breast
cancer.
72. Question
Category: Physiological Adaptation
A female client with cancer is being evaluated for possible metastasis. Which of the following is one of
the most common metastasis sites for cancer cells?
A. Liver
B. Colon
C. Reproductive tract
D. White blood cells (WBCs)
Correct Answer: A. Liver
The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung,
bone, and brain.
73. Question
Category: Reduction of Risk Potential
Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal
cord lesion. During the MRI scan, which of the following would pose a threat to the client?
A. The client lies still
B. The client asks questions
C. The client hears thumping sounds
D. The client wears a watch and wedding band
Correct Answer: D. The client wears a watch and wedding band
During an MRI, the client should wear no metal objects, such as jewelry, because the strong magnetic
field can pull on them, causing injury to the client and (if they fly off) to others.
,74. Question
Category: Health Promotion and Maintenance
Nurse Cecile is teaching a female client about preventing osteoporosis. Which of the following teaching
points is correct?
A. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss.
B. To avoid fractures, the client should avoid strenuous exercise.
C. The recommended daily allowance of calcium may be found in a wide variety of foods
D. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.
Correct Answer: C. The recommended daily allowance of calcium may be found in a wide variety of
foods.
Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg
per day. It’s often, though not always, possible to get the recommended daily requirement in the foods
we eat.
75. Question
Category: Reduction of Risk Potential
Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings for contraindications
for this procedure. Which finding is a contraindication?
A. Joint pain
B. Joint deformity
C. Joint flexion of less than 50%
D. Joint stiffness
Correct Answer: C. Joint flexion of less than 50%
Arthroscopy is contraindicated in clients with joint flexion of less than 50% because of technical
problems in inserting the instrument into the joint to see it clearly. Other contraindications for this
procedure include skin and wound infections.
,1. Question
Category: Management of Care
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.
A. Assist the patient to reposition every 2 hours.
B. Reapply pneumatic compression boots.
C. Remind the patient to perform active ROM.
D. Check extremities for redness and edema.
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.
2. Question
Category: Management of Care
The patient who had a stroke needs to be fed. What instruction should you give to the nursing assis tant
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.
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.
3. Question
Category: Physiological Adaptation
, 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.
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.
4. Question
Category: Management of Care
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.
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.
5. Question
Category: Management of Care
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.
