NCLEX-RN EXAM 2020
1. Which of the following signs or symptoms indicates a possible nutritional deficiency?
Pale conjunctiva
2. A nurse is preparing to insert a small-bore nasogastric feeding tube for a client's enteral
feedings. In which method does the nurse measure the correct length of the tube?
From the tip of the nose to the earlobe to the xiphoid process
3. In which of the following ways can a nurse promote sleep for a client who is
experiencing insomnia?
Give the client a pair of socks to wear if his feet become cold
4. A client is complaining of pain that starts in the shoulder and travels down the length of
his arm. This type of pain is referred to as:
Radiating pain
5. A client with an enlarged prostate is having trouble starting his flow of urine when using
the bathroom. Another name for this condition is:
Hesitancy
6. A nurse is preparing to irrigate a client's colostomy. Which of the following situations is
a contraindication for this type of irrigation?
The client has diverticulitis
,7. The nurse hears a client calling out for help, hurries down the hallway to the client's
room, and finds the client lying on the floor. The nurse performs an assessment, assists
the client back to bed, notifies the health care provider of the incident, and completes an
incident report. Which statement should the nurse document on the incident report?
The client was found lying on the floor.
8. A client is brought to the emergency department by emergency medical services (EMS)
after being hit by a car. The name of the client is unknown, and the client has sustained a
severe head injury and multiple fractures and is unconscious. An emergency craniotomy
is required. Regarding informed consent for the surgical procedure, which is the best
action?
Transport the victim to the operating room for surgery.
9. Which of the following statements best describes substance P?
Substance P is found in the dorsal horn of the spinal column
10. The primary purpose of a patient care meeting or conference is to determine which of the
following?
How the healthcare team can best meet the patient's needs.
11. Who should be members of a patient care conference?
ALL members of the healthcare team and the patient/resident.
12. The nurse has just assisted a client back to bed after a fall. The nurse and health care
provider have assessed the client and have determined that the client is not injured. After
completing the incident report, the nurse should implement which action next?
Reassess the client.
13. The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for
the day because the ICU is understaffed and needs additional nurses to care for the
clients. The nurse has never worked in the ICU. The nurse should take which best action?
, Clarify with the team leader to make a safe ICU client assignment.
14. The nurse who works on the night shift enters the medication room and finds a co-worker
with a tourniquet wrapped around the upper arm. The co- worker is about to insert a
needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is
the most appropriate action by the nurse?
Call the nursing supervisor.
15. A hospitalized client tells the nurse that an instructional directive is being prepared and
that the lawyer will be bringing the document to the hospital today for witness signatures.
The client asks the nurse for assistance in obtaining a witness to the will. Which is the
most appropriate response to the client?
"I will call the nursing supervisor to seek assistance regarding your
request."
16. The nurse has made an error in a narrative documentation of an assessment finding on a
client and obtains the client's record to correct the error. The nurse should take which
actions to correct the error? Select all that apply.
i. Document the correct information and end with the nurse's signature and
title.
ii. Draw 1 line through the error, initialing and dating it.
17. Who is legally able to make decisions for the patient or resident during a patient care
conference when the patient is not mentally able to make decisions on their own?
Only the health care proxy
18. Which of the following is an example of physical abuse?
A slap to the person's hand
19. Which of the following is an example of emotional abuse?
Threatening the person
1. Which of the following signs or symptoms indicates a possible nutritional deficiency?
Pale conjunctiva
2. A nurse is preparing to insert a small-bore nasogastric feeding tube for a client's enteral
feedings. In which method does the nurse measure the correct length of the tube?
From the tip of the nose to the earlobe to the xiphoid process
3. In which of the following ways can a nurse promote sleep for a client who is
experiencing insomnia?
Give the client a pair of socks to wear if his feet become cold
4. A client is complaining of pain that starts in the shoulder and travels down the length of
his arm. This type of pain is referred to as:
Radiating pain
5. A client with an enlarged prostate is having trouble starting his flow of urine when using
the bathroom. Another name for this condition is:
Hesitancy
6. A nurse is preparing to irrigate a client's colostomy. Which of the following situations is
a contraindication for this type of irrigation?
The client has diverticulitis
,7. The nurse hears a client calling out for help, hurries down the hallway to the client's
room, and finds the client lying on the floor. The nurse performs an assessment, assists
the client back to bed, notifies the health care provider of the incident, and completes an
incident report. Which statement should the nurse document on the incident report?
The client was found lying on the floor.
8. A client is brought to the emergency department by emergency medical services (EMS)
after being hit by a car. The name of the client is unknown, and the client has sustained a
severe head injury and multiple fractures and is unconscious. An emergency craniotomy
is required. Regarding informed consent for the surgical procedure, which is the best
action?
Transport the victim to the operating room for surgery.
9. Which of the following statements best describes substance P?
Substance P is found in the dorsal horn of the spinal column
10. The primary purpose of a patient care meeting or conference is to determine which of the
following?
How the healthcare team can best meet the patient's needs.
11. Who should be members of a patient care conference?
ALL members of the healthcare team and the patient/resident.
12. The nurse has just assisted a client back to bed after a fall. The nurse and health care
provider have assessed the client and have determined that the client is not injured. After
completing the incident report, the nurse should implement which action next?
Reassess the client.
13. The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for
the day because the ICU is understaffed and needs additional nurses to care for the
clients. The nurse has never worked in the ICU. The nurse should take which best action?
, Clarify with the team leader to make a safe ICU client assignment.
14. The nurse who works on the night shift enters the medication room and finds a co-worker
with a tourniquet wrapped around the upper arm. The co- worker is about to insert a
needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is
the most appropriate action by the nurse?
Call the nursing supervisor.
15. A hospitalized client tells the nurse that an instructional directive is being prepared and
that the lawyer will be bringing the document to the hospital today for witness signatures.
The client asks the nurse for assistance in obtaining a witness to the will. Which is the
most appropriate response to the client?
"I will call the nursing supervisor to seek assistance regarding your
request."
16. The nurse has made an error in a narrative documentation of an assessment finding on a
client and obtains the client's record to correct the error. The nurse should take which
actions to correct the error? Select all that apply.
i. Document the correct information and end with the nurse's signature and
title.
ii. Draw 1 line through the error, initialing and dating it.
17. Who is legally able to make decisions for the patient or resident during a patient care
conference when the patient is not mentally able to make decisions on their own?
Only the health care proxy
18. Which of the following is an example of physical abuse?
A slap to the person's hand
19. Which of the following is an example of emotional abuse?
Threatening the person
