Comprehensive NCLEX-RN| Exam #5: (75 Questions
and Correct Answers/ Rationale (2022 update)
65. Question
Category: Reduction of Risk Potential
A male client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery,
Nurse Oliver notes that the client’s stoma appears dusky. How should the nurse interpret this finding?
A. Blood supply to the stoma has been interrupted.
B. This is a normal finding 1 day after surgery.
C. The ostomy bag should be adjusted.
D. An intestinal obstruction has occurred.
Correct Answer: A. Blood supply to the stoma has been interrupted
An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin,
creating an artificial opening for waste elimination. The stoma should appear cherry red, in dicating
adequate arterial perfusion. A dusky stoma suggests decreased perfusion, which may result from
interruption of the stoma’s blood supply and may lead to tissue damage or necrosis.
66. Question
Category: Physiological Adaptation
Anthony suffers burns on the legs, which nursing intervention helps prevent contractures?
A. Applying knee splints.
B. Elevating the foot of the bed.
C. Hyperextending the client’s palms.
D. Performing shoulder range-of-motion exercises.
Correct Answer: A. Applying knee splints.
Applying knee splints prevents leg contractures by holding the joints in a position of function.
,67. Question
Category: Physiological Adaptation
Nurse Ron is assessing a client admitted with second and third-degree burns on the face, arms, and
chest. Which finding indicates a potential problem?
A. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
B. Urine output of 20 ml/hour.
C. White pulmonary secretions.
D. Rectal temperature of 100.6° F (38° C).
Correct Answer: B. Urine output of 20 ml/hour.
A urine output of less than 40 ml/hour in a client with burns indicates a fluid volume defici t.
68. Question
Category: Basic Care and Comfort
Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To
help the client avoid pressure ulcers, Nurse Celia should:
A. Turn him frequently.
B. Perform passive range-of-motion (ROM) exercises.
C. Reduce the client’s fluid intake.
D. Encourage the client to use a footboard.
Correct Answer: A. Turn him frequently.
The most important intervention to prevent pressure ulcers is frequent position changes, which relieve
pressure on the skin and underlying tissues. If pressure isn’t relieved, capillaries become occluded,
reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation.
69. Question
Category: Pharmacological and Parenteral Therapies
,Nurse Maria plans to administer dexamethasone cream to a female client who has dermatitis over the
anterior chest. How should the nurse apply this topical agent?
A. With a circular motion, to enhance absorption.
B. With an upward motion, to increase blood supply to the affected area.
C. In long, even, outward, and downward strokes in the direction of hair growth.
D. In long, even, outward, and upward strokes in the direction opposite hair growth.
Correct Answer: C. In long, even, outward, and downward strokes in the direction of hair growth
When applying a topical agent, the nurse should begin at the midline and use long, even, outward, and
downward strokes in the direction of hair growth. This application pattern reduces the ris k of follicle
irritation and skin inflammation.
70. Question
Category: Pharmacological and Parenteral Therapies
Nurse Kate is aware that one of the following classes of medication protects the ischemic myocardium
by blocking catecholamines and sympathetic nerve stimulation is:
A. Beta-adrenergic blockers
B. Calcium channel blocker
C. Narcotics
D. Nitrates
Correct Answer: A. Beta-adrenergic blockers
Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to
catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the
risk of another infarction by decreasing myocardial oxygen demand.
71. Question
Category: Reduction of Risk Potential
A male client has jugular distention. In what position should the nurse place the head of the bed to
obtain the most accurate reading of jugular vein distention?
,A. High Fowler’s
B. Raised 10 degrees
C. Raised 30 degrees
D. Supine position
Correct Answer: C. Raised 30 degrees
Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the
sternal angle and the point of highest pulsation with the head of the bed inclined between 15 to 30
degrees.
72. Question
Category: Pharmacological and Parenteral Therapies
The nurse is aware that one of the following classes of medications maximizes cardiac performance in
clients with heart failure by increasing ventricular contractility?
A. Beta-adrenergic blockers
B. Calcium channel blocker
C. Diuretics
D. Inotropic agents
Correct Answer: D. Inotropic agents
Inotropic agents are administered to increase the force of the heart’s contractions, thereby increasing
ventricular contractility and ultimately increasing cardiac output.
73. Question
Category: Physiological Adaptation
A male client has a reduced serum high-density lipoprotein (HDL) level and an elevated low-density
lipoprotein (LDL) level. Which of the following dietary modifications is not appropriate for this client?
A. Fiber intake of 25 to 30 g daily.
B. Less than 30% of calories from fat.
,C. Cholesterol intake of less than 300 mg daily.
D. Less than 10% of calories from saturated fat.
Correct Answer: B. Less than 30% of calories from fat
A client with low serum HDL and high serum LDL levels should get less than 30% of daily calories from
fat.
74. Question
Category: Management of Care
A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with acute
myocardial infarction. Which of the following actions would breach the client’s confidentiality?
A. The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client
to that unit.
B. The CCU nurse notifies the on-call physician about a change in the client’s condition.
C. The emergency department nurse calls up the latest electrocardiogram results to check the client’s
progress.
D. At the client’s request, the CCU nurse updates the client’s wife on his condition.
Correct Answer: C. The emergency department nurse calls up the latest electrocardiogram results to
check the client’s progress
The emergency department nurse is no longer directly involved with the client’s care and thus has no
legal right to information about his present condition.
75. Question
Category: Management of Care
A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from
paramedics who are giving ventilation through an endotracheal (ET) tube that they placed in the client’s
home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart
rate of beats/minute with a palpable pulse. Which of the following actions should the nurse take first?
A. Start an L.V. line and administer amiodarone (Cordarone), 300 mg L.V. over 10 minutes.
B. Check endotracheal tube placement.
,C. Obtain an arterial blood gas (ABG) sample.
D. Administer atropine, 1 mg L.V.
Correct Answer: B. Check endotracheal tube placement.
ET tube placement should be confirmed as soon as the client arrives in the emergency department.
Once the airway is secured, oxygenation and ventilation should be confirmed using an end -tidal carbon
dioxide monitor and pulse oximetry.
1. Question
Category: Physiological Adaptation
Mr. Rodriguez is admitted with severe pain in the knees. Which form of arthritis is characterized by
urate deposits and joint pain, usually in the feet and legs, and occurs primarily in men over age 30?
A. Septic arthritis
B. Traumatic arthritis
C. Intermittent arthritis
D. Gouty arthritis
Correct Answer: D. Gouty arthritis
Gouty arthritis, a metabolic disease, is characterized by urate deposits and pain in the joints, especially
those in the feet and legs. Urate deposits don’t occur in septic or traumatic arthritis.
2. Question
Category: Pharmacological and Parenteral Therapies
A heparin infusion at 1,500 units/hour is ordered for a 64-year-old client with stroke in evolution. The
infusion contains 25,000 units of heparin in 500 ml of saline solution. How many milliliters per hour
should be given?
A. 15 ml/hour
B. 30 ml/hour
C. 45 ml/hour
D. 50 ml/hour
, Correct Answer: B. 30 ml/hour
An infusion prepared with 25,000 units of heparin in 500 ml of saline solution yields 50 units of heparin
per milliliter of solution. The equation is set up as 50 units times X (the unknown quantity) equals 1,500
units/hour, X equals 30 ml/hour.
3. Question
Category: Physiological Adaptation
A 76-year-old male client had a thromboembolic right stroke; his left arm is swollen. Which of the
following conditions may cause swelling after a stroke?
A. Elbow contracture secondary to spasticity.
B. Loss of muscle contraction decreasing venous return.
C. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side.
D. Hypoalbuminemia due to protein escaping from an inflamed glomerulus.
Correct Answer: B. Loss of muscle contraction decreasing venous return
In clients with hemiplegia or hemiparesis, loss of muscle contraction decreases venous return and may
cause swelling of the affected extremity.
4. Question
Category: Physiological Adaptation
Heberden’s nodes are a common sign of osteoarthritis. Which of the following statements i s correct
about this deformity?
A. It appears only in men.
B. It appears on the distal interphalangeal joint.
C. It appears on the proximal interphalangeal joint.
D. It appears on the dorsolateral aspect of the interphalangeal joint.
Correct Answer: B. It appears on the distal interphalangeal joint.
Heberden’s nodes appear on the distal interphalangeal joint on both men and women.
and Correct Answers/ Rationale (2022 update)
65. Question
Category: Reduction of Risk Potential
A male client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery,
Nurse Oliver notes that the client’s stoma appears dusky. How should the nurse interpret this finding?
A. Blood supply to the stoma has been interrupted.
B. This is a normal finding 1 day after surgery.
C. The ostomy bag should be adjusted.
D. An intestinal obstruction has occurred.
Correct Answer: A. Blood supply to the stoma has been interrupted
An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin,
creating an artificial opening for waste elimination. The stoma should appear cherry red, in dicating
adequate arterial perfusion. A dusky stoma suggests decreased perfusion, which may result from
interruption of the stoma’s blood supply and may lead to tissue damage or necrosis.
66. Question
Category: Physiological Adaptation
Anthony suffers burns on the legs, which nursing intervention helps prevent contractures?
A. Applying knee splints.
B. Elevating the foot of the bed.
C. Hyperextending the client’s palms.
D. Performing shoulder range-of-motion exercises.
Correct Answer: A. Applying knee splints.
Applying knee splints prevents leg contractures by holding the joints in a position of function.
,67. Question
Category: Physiological Adaptation
Nurse Ron is assessing a client admitted with second and third-degree burns on the face, arms, and
chest. Which finding indicates a potential problem?
A. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
B. Urine output of 20 ml/hour.
C. White pulmonary secretions.
D. Rectal temperature of 100.6° F (38° C).
Correct Answer: B. Urine output of 20 ml/hour.
A urine output of less than 40 ml/hour in a client with burns indicates a fluid volume defici t.
68. Question
Category: Basic Care and Comfort
Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To
help the client avoid pressure ulcers, Nurse Celia should:
A. Turn him frequently.
B. Perform passive range-of-motion (ROM) exercises.
C. Reduce the client’s fluid intake.
D. Encourage the client to use a footboard.
Correct Answer: A. Turn him frequently.
The most important intervention to prevent pressure ulcers is frequent position changes, which relieve
pressure on the skin and underlying tissues. If pressure isn’t relieved, capillaries become occluded,
reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation.
69. Question
Category: Pharmacological and Parenteral Therapies
,Nurse Maria plans to administer dexamethasone cream to a female client who has dermatitis over the
anterior chest. How should the nurse apply this topical agent?
A. With a circular motion, to enhance absorption.
B. With an upward motion, to increase blood supply to the affected area.
C. In long, even, outward, and downward strokes in the direction of hair growth.
D. In long, even, outward, and upward strokes in the direction opposite hair growth.
Correct Answer: C. In long, even, outward, and downward strokes in the direction of hair growth
When applying a topical agent, the nurse should begin at the midline and use long, even, outward, and
downward strokes in the direction of hair growth. This application pattern reduces the ris k of follicle
irritation and skin inflammation.
70. Question
Category: Pharmacological and Parenteral Therapies
Nurse Kate is aware that one of the following classes of medication protects the ischemic myocardium
by blocking catecholamines and sympathetic nerve stimulation is:
A. Beta-adrenergic blockers
B. Calcium channel blocker
C. Narcotics
D. Nitrates
Correct Answer: A. Beta-adrenergic blockers
Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to
catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the
risk of another infarction by decreasing myocardial oxygen demand.
71. Question
Category: Reduction of Risk Potential
A male client has jugular distention. In what position should the nurse place the head of the bed to
obtain the most accurate reading of jugular vein distention?
,A. High Fowler’s
B. Raised 10 degrees
C. Raised 30 degrees
D. Supine position
Correct Answer: C. Raised 30 degrees
Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the
sternal angle and the point of highest pulsation with the head of the bed inclined between 15 to 30
degrees.
72. Question
Category: Pharmacological and Parenteral Therapies
The nurse is aware that one of the following classes of medications maximizes cardiac performance in
clients with heart failure by increasing ventricular contractility?
A. Beta-adrenergic blockers
B. Calcium channel blocker
C. Diuretics
D. Inotropic agents
Correct Answer: D. Inotropic agents
Inotropic agents are administered to increase the force of the heart’s contractions, thereby increasing
ventricular contractility and ultimately increasing cardiac output.
73. Question
Category: Physiological Adaptation
A male client has a reduced serum high-density lipoprotein (HDL) level and an elevated low-density
lipoprotein (LDL) level. Which of the following dietary modifications is not appropriate for this client?
A. Fiber intake of 25 to 30 g daily.
B. Less than 30% of calories from fat.
,C. Cholesterol intake of less than 300 mg daily.
D. Less than 10% of calories from saturated fat.
Correct Answer: B. Less than 30% of calories from fat
A client with low serum HDL and high serum LDL levels should get less than 30% of daily calories from
fat.
74. Question
Category: Management of Care
A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with acute
myocardial infarction. Which of the following actions would breach the client’s confidentiality?
A. The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client
to that unit.
B. The CCU nurse notifies the on-call physician about a change in the client’s condition.
C. The emergency department nurse calls up the latest electrocardiogram results to check the client’s
progress.
D. At the client’s request, the CCU nurse updates the client’s wife on his condition.
Correct Answer: C. The emergency department nurse calls up the latest electrocardiogram results to
check the client’s progress
The emergency department nurse is no longer directly involved with the client’s care and thus has no
legal right to information about his present condition.
75. Question
Category: Management of Care
A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from
paramedics who are giving ventilation through an endotracheal (ET) tube that they placed in the client’s
home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart
rate of beats/minute with a palpable pulse. Which of the following actions should the nurse take first?
A. Start an L.V. line and administer amiodarone (Cordarone), 300 mg L.V. over 10 minutes.
B. Check endotracheal tube placement.
,C. Obtain an arterial blood gas (ABG) sample.
D. Administer atropine, 1 mg L.V.
Correct Answer: B. Check endotracheal tube placement.
ET tube placement should be confirmed as soon as the client arrives in the emergency department.
Once the airway is secured, oxygenation and ventilation should be confirmed using an end -tidal carbon
dioxide monitor and pulse oximetry.
1. Question
Category: Physiological Adaptation
Mr. Rodriguez is admitted with severe pain in the knees. Which form of arthritis is characterized by
urate deposits and joint pain, usually in the feet and legs, and occurs primarily in men over age 30?
A. Septic arthritis
B. Traumatic arthritis
C. Intermittent arthritis
D. Gouty arthritis
Correct Answer: D. Gouty arthritis
Gouty arthritis, a metabolic disease, is characterized by urate deposits and pain in the joints, especially
those in the feet and legs. Urate deposits don’t occur in septic or traumatic arthritis.
2. Question
Category: Pharmacological and Parenteral Therapies
A heparin infusion at 1,500 units/hour is ordered for a 64-year-old client with stroke in evolution. The
infusion contains 25,000 units of heparin in 500 ml of saline solution. How many milliliters per hour
should be given?
A. 15 ml/hour
B. 30 ml/hour
C. 45 ml/hour
D. 50 ml/hour
, Correct Answer: B. 30 ml/hour
An infusion prepared with 25,000 units of heparin in 500 ml of saline solution yields 50 units of heparin
per milliliter of solution. The equation is set up as 50 units times X (the unknown quantity) equals 1,500
units/hour, X equals 30 ml/hour.
3. Question
Category: Physiological Adaptation
A 76-year-old male client had a thromboembolic right stroke; his left arm is swollen. Which of the
following conditions may cause swelling after a stroke?
A. Elbow contracture secondary to spasticity.
B. Loss of muscle contraction decreasing venous return.
C. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side.
D. Hypoalbuminemia due to protein escaping from an inflamed glomerulus.
Correct Answer: B. Loss of muscle contraction decreasing venous return
In clients with hemiplegia or hemiparesis, loss of muscle contraction decreases venous return and may
cause swelling of the affected extremity.
4. Question
Category: Physiological Adaptation
Heberden’s nodes are a common sign of osteoarthritis. Which of the following statements i s correct
about this deformity?
A. It appears only in men.
B. It appears on the distal interphalangeal joint.
C. It appears on the proximal interphalangeal joint.
D. It appears on the dorsolateral aspect of the interphalangeal joint.
Correct Answer: B. It appears on the distal interphalangeal joint.
Heberden’s nodes appear on the distal interphalangeal joint on both men and women.
