1
NCLEX RN
NCLEX-RN
TEST PREP
QUESTIONS AND ANSWERS WITH
EXPLANATIONS
P a g e 1 | 419
, 2
NCLEX
RNTEST PREPQUESTIONS AND
ANSWERS WITH
EXPLANATIONS
IT COVERS:
1. BASIC NURSING CARE-171
2. MANAGEMENT AND PRACTICE DIRECTIVES-
115
3. PREVENTING RISKS AND COMPLICATIONS-81
4. CARING FOR ACUTE OR CHRONIC
C.ONDITIONS-97
5. SAFETY -68
6. MENTAL HEALTH -49
7. PHARMACOLOGY 114
8. GROWTH AND DEVELOPMENT-66
BASIC NURSING CARE (STUDY MODE)
1.
In which of the following ways can the nurse promote the sense of taste for
an older adult?
a. Mix foods together on the dinner tray
b. Avoid cologne, air fresheners, or room deodorizers
P a g e 2 | 419
, 3
c. Encourage the client to chew food thoroughly
d. Discourage the use of salt or seasonings with prepared food
ANSWER C: As clients age, their sense of taste may diminish, reducing the
P a g e 3 | 419
, 4
joy that comes with eating. A nurse can promote the sense of taste for a client
by encouraging him to chew his food thoroughly while eating. This results in
longer contact of food with the taste buds and a greater chance of tasting the
food.
2.
Which of the following is classified as a prerenal condition that affects
urinary elimination?
a. Nephrotoxic medications
b. Pericardial tamponade
c. Neurogenic bladder
d. Polycystic kidney disease
P a g e 4 | 419
, 5
ANSWER B: A prerenal condition is that which causes reduced urinary
elimination due to a diminished blood flow to the kidneys. A condition such
as cardiac tamponade affects the heart's ability to pump adequate amounts of
blood, thereby reducing blood flow to vital organs throughout the body,
including the kidneys.
3.
A nurse is assessing an African American client for risks of a pressure ulcer.
Which of the following best describes what the nurse might find with an early
pressure ulcer in this client?
a. Skin has a purple/bluish color
b. Capillary refill is 1 second
c. Skin appears blanched at the pressure site
d. Tenting appears when checking skin turgor
ANSWER A: When assessing for signs of developing pressure ulcers in a
client with dark skin, decreased circulation may not always be readily
apparent. For instance, blanching, the red undertones seen in light-skinned
clients, will not always be present. Instead, the skin of an early pressure ulcer
may develop a purple or bluish color.
4.
A term used to refer to generalized wasting of body tissues and malnutrition
is called:
a. Entropion
b. Confabulation
c. Induration
d. Cachexia
P a g e 5 | 419
, 6
ANSWER D: Cachexia is a term used to describe the generalized wasting of
body tissues, ill health, and malnutrition that is associated with some chronic
diseases. Cachexia involves a loss of fat tissue to protect the bones and joints.
Clients with cachexia are at risk of pressure ulcers in addition to
complications associated with malnutrition and poor health.
5.
Which of the following clients is at a higher risk of developing oral health
problems?
a. A pregnant client
b. A client with diabetes
c. A client receiving chemotherapy
d. Both b and c
ANSWER D: Some clients are at higher risk of developing oral health
problems due to changes in the mouth associated with certain diseases, or an
inability to provide proper self care and oral hygiene. Diabetic clients may be
more likely to develop periodontal disease, gingivitis, or mouth dryness.
Clients receiving chemotherapy may have mouth ulcers or gingivitis, leading
to further pain and infection.
6.
Which nursing intervention is most appropriate to reduce environmental
stimuli that may cause discomfort for a client?
a. Loosen pressure dressings on wounds
b. Use assistance to pull a client up in bed
c. Check temperature of water used in a sponge bath
P a g e 6 | 419
, 7
d. Position the client prone
ANSWER C: A nurse can reduce environmental stimuli that can cause
discomfort for a client through several interventions. When giving a sponge
bath, the nurse can check the temperature of the bath water to ensure it is not
too hot to avoid burns, nor too cold, to avoid causing discomfort. Other
measures the nurse can perform include lifting clients rather than pulling
them up in bed, changing wet dressings, and providing proper positioning
while in bed.
7.
A client has developed a vitamin C deficiency. Which of the following
symptoms might the nurse most likely see with this condition?
a. Cracks at the corners of the mouth
b. Altered mental status
c. Bleeding gums and loose teeth
d. Anorexia and diarrhea
ANSWER C: A client with a severe vitamin C deficiency has a condition
called scurvy. Clients with scurvy are most likely to develop bleeding gums,
loose teeth, poor wound healing, and easy bruising.
8.
Which of the following interventions should a nurse perform for a female
client who is incontinent with impaired skin integrity?
a. Turn the client at least every 8 hours
b. Apply lotion to the skin before a bath
P a g e 7 | 419
, 8
c. Provide perineal care after the client uses the bathroom
d. Bathe the client every 3 days
ANSWER C: A nurse can help protect the skin integrity of some clients,
especially female clients who are incontinent, by performing cares that keep
the skin clean and dry. Providing perineal care after the client uses the
bathroom promotes good skin integrity by removing excess secretions that
could cause odor and infection.
9.
A client has fallen asleep in his bed in the hospital. His heart rate is 65 bpm,
his muscles are relaxed, and he is difficult to arouse. Which stage of the sleep
cycle is this client experiencing?
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4
ANSWER C: A client in stage 3 of the sleep cycle has moved into deeper
stages of sleep and is more difficult to arouse. The client may have relaxed
muscles, a decrease in vital signs, and may lie very still. Stage 3 of sleep is a
type of non-REM sleep in which the client progresses toward REM sleep and
vivid dreams.
10.
A nurse is assisting a client who uses an intraaural hearing aid. Once the aid
has been placed in the ear, it begins to whistle. What is the next action of the
nurse?
P a g e 8 | 419
, 9
a. Try to reposition the hearing aid
b. Change the batteries
c. Remove the device and have it cleaned
d. Notify the physician that the hearing aid is not working
ANSWER A: An intraaural hearing aid, sometimes called an in-the-ear
hearing aid, is one that is placed in the ear canal. When positioning the
hearing aid, a whistling sound indicates it may be positioned improperly. If
whistling sounds begin after placement, the nurse should try to reposition the
hearing aid.
11.
A nurse is preparing to irrigate a client's indwelling catheter through a closed,
intermittent system. Which of the following steps must the nurse take as part
of this process?
a. Use sterile solution from the refrigerator
b. Position the client in the prone position
c. Clamp the catheter at the level above the injection port
d. Inject sterile solution through the injection port into the catheter
ANSWER D: When performing a closed intermittent system of catheter
irrigation, the nurse should draw up sterile solution that has been at room
temperature using sterile technique. The client should be positioned for easy
access to the catheter site and to assess the abdomen during the procedure.
After clamping the tubing below the level of the injection port and cleansing
the site, the nurse injects fluid into the port, which travels up the catheter to
irrigate the tubing and the bladder.
P a g e 9 | 419
, 10
12.
Which of the following is a negative outcome associated with impaired
mobility?
a. Increased amounts of calcium are absorbed from circulation
b. A drop in blood pressure occurs when rising from a sitting to a
standing position
c. The amount of mucous in the bronchi and lungs decreases
d. The vessel walls of the circulatory system thicken
ANSWER B: A client with impaired mobility may develop many changes in
body systems that put him at risk of further illness or injury. Orthostatic
hypotension occurs when blood pressure drops more than 25 mmHg systolic
or 10 mmHg diastolic upon rising from a sitting or lying position to standing.
Orthostatic hypotension may develop in the client with impaired mobility
when blood circulates more slowly or pools in the distal extremities.
13.
A nurse is caring for a client who died approximately one hour ago. The
nurse notes that the client's temperature has decreased in the last hour since
his death. Which of the following processes explains this phenomenon?
a. Rigor mortis
b. Postmortem decomposition
c. Algor mortis
d. Livor mortis
ANSWER C: Algor mortis occurs after death when the body's circulation
stops and the client's temperature begins to fall. The client's temperature will
drop by approximately 1.8 degrees per hour until it reaches room
P a g e 10 | 419
NCLEX RN
NCLEX-RN
TEST PREP
QUESTIONS AND ANSWERS WITH
EXPLANATIONS
P a g e 1 | 419
, 2
NCLEX
RNTEST PREPQUESTIONS AND
ANSWERS WITH
EXPLANATIONS
IT COVERS:
1. BASIC NURSING CARE-171
2. MANAGEMENT AND PRACTICE DIRECTIVES-
115
3. PREVENTING RISKS AND COMPLICATIONS-81
4. CARING FOR ACUTE OR CHRONIC
C.ONDITIONS-97
5. SAFETY -68
6. MENTAL HEALTH -49
7. PHARMACOLOGY 114
8. GROWTH AND DEVELOPMENT-66
BASIC NURSING CARE (STUDY MODE)
1.
In which of the following ways can the nurse promote the sense of taste for
an older adult?
a. Mix foods together on the dinner tray
b. Avoid cologne, air fresheners, or room deodorizers
P a g e 2 | 419
, 3
c. Encourage the client to chew food thoroughly
d. Discourage the use of salt or seasonings with prepared food
ANSWER C: As clients age, their sense of taste may diminish, reducing the
P a g e 3 | 419
, 4
joy that comes with eating. A nurse can promote the sense of taste for a client
by encouraging him to chew his food thoroughly while eating. This results in
longer contact of food with the taste buds and a greater chance of tasting the
food.
2.
Which of the following is classified as a prerenal condition that affects
urinary elimination?
a. Nephrotoxic medications
b. Pericardial tamponade
c. Neurogenic bladder
d. Polycystic kidney disease
P a g e 4 | 419
, 5
ANSWER B: A prerenal condition is that which causes reduced urinary
elimination due to a diminished blood flow to the kidneys. A condition such
as cardiac tamponade affects the heart's ability to pump adequate amounts of
blood, thereby reducing blood flow to vital organs throughout the body,
including the kidneys.
3.
A nurse is assessing an African American client for risks of a pressure ulcer.
Which of the following best describes what the nurse might find with an early
pressure ulcer in this client?
a. Skin has a purple/bluish color
b. Capillary refill is 1 second
c. Skin appears blanched at the pressure site
d. Tenting appears when checking skin turgor
ANSWER A: When assessing for signs of developing pressure ulcers in a
client with dark skin, decreased circulation may not always be readily
apparent. For instance, blanching, the red undertones seen in light-skinned
clients, will not always be present. Instead, the skin of an early pressure ulcer
may develop a purple or bluish color.
4.
A term used to refer to generalized wasting of body tissues and malnutrition
is called:
a. Entropion
b. Confabulation
c. Induration
d. Cachexia
P a g e 5 | 419
, 6
ANSWER D: Cachexia is a term used to describe the generalized wasting of
body tissues, ill health, and malnutrition that is associated with some chronic
diseases. Cachexia involves a loss of fat tissue to protect the bones and joints.
Clients with cachexia are at risk of pressure ulcers in addition to
complications associated with malnutrition and poor health.
5.
Which of the following clients is at a higher risk of developing oral health
problems?
a. A pregnant client
b. A client with diabetes
c. A client receiving chemotherapy
d. Both b and c
ANSWER D: Some clients are at higher risk of developing oral health
problems due to changes in the mouth associated with certain diseases, or an
inability to provide proper self care and oral hygiene. Diabetic clients may be
more likely to develop periodontal disease, gingivitis, or mouth dryness.
Clients receiving chemotherapy may have mouth ulcers or gingivitis, leading
to further pain and infection.
6.
Which nursing intervention is most appropriate to reduce environmental
stimuli that may cause discomfort for a client?
a. Loosen pressure dressings on wounds
b. Use assistance to pull a client up in bed
c. Check temperature of water used in a sponge bath
P a g e 6 | 419
, 7
d. Position the client prone
ANSWER C: A nurse can reduce environmental stimuli that can cause
discomfort for a client through several interventions. When giving a sponge
bath, the nurse can check the temperature of the bath water to ensure it is not
too hot to avoid burns, nor too cold, to avoid causing discomfort. Other
measures the nurse can perform include lifting clients rather than pulling
them up in bed, changing wet dressings, and providing proper positioning
while in bed.
7.
A client has developed a vitamin C deficiency. Which of the following
symptoms might the nurse most likely see with this condition?
a. Cracks at the corners of the mouth
b. Altered mental status
c. Bleeding gums and loose teeth
d. Anorexia and diarrhea
ANSWER C: A client with a severe vitamin C deficiency has a condition
called scurvy. Clients with scurvy are most likely to develop bleeding gums,
loose teeth, poor wound healing, and easy bruising.
8.
Which of the following interventions should a nurse perform for a female
client who is incontinent with impaired skin integrity?
a. Turn the client at least every 8 hours
b. Apply lotion to the skin before a bath
P a g e 7 | 419
, 8
c. Provide perineal care after the client uses the bathroom
d. Bathe the client every 3 days
ANSWER C: A nurse can help protect the skin integrity of some clients,
especially female clients who are incontinent, by performing cares that keep
the skin clean and dry. Providing perineal care after the client uses the
bathroom promotes good skin integrity by removing excess secretions that
could cause odor and infection.
9.
A client has fallen asleep in his bed in the hospital. His heart rate is 65 bpm,
his muscles are relaxed, and he is difficult to arouse. Which stage of the sleep
cycle is this client experiencing?
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4
ANSWER C: A client in stage 3 of the sleep cycle has moved into deeper
stages of sleep and is more difficult to arouse. The client may have relaxed
muscles, a decrease in vital signs, and may lie very still. Stage 3 of sleep is a
type of non-REM sleep in which the client progresses toward REM sleep and
vivid dreams.
10.
A nurse is assisting a client who uses an intraaural hearing aid. Once the aid
has been placed in the ear, it begins to whistle. What is the next action of the
nurse?
P a g e 8 | 419
, 9
a. Try to reposition the hearing aid
b. Change the batteries
c. Remove the device and have it cleaned
d. Notify the physician that the hearing aid is not working
ANSWER A: An intraaural hearing aid, sometimes called an in-the-ear
hearing aid, is one that is placed in the ear canal. When positioning the
hearing aid, a whistling sound indicates it may be positioned improperly. If
whistling sounds begin after placement, the nurse should try to reposition the
hearing aid.
11.
A nurse is preparing to irrigate a client's indwelling catheter through a closed,
intermittent system. Which of the following steps must the nurse take as part
of this process?
a. Use sterile solution from the refrigerator
b. Position the client in the prone position
c. Clamp the catheter at the level above the injection port
d. Inject sterile solution through the injection port into the catheter
ANSWER D: When performing a closed intermittent system of catheter
irrigation, the nurse should draw up sterile solution that has been at room
temperature using sterile technique. The client should be positioned for easy
access to the catheter site and to assess the abdomen during the procedure.
After clamping the tubing below the level of the injection port and cleansing
the site, the nurse injects fluid into the port, which travels up the catheter to
irrigate the tubing and the bladder.
P a g e 9 | 419
, 10
12.
Which of the following is a negative outcome associated with impaired
mobility?
a. Increased amounts of calcium are absorbed from circulation
b. A drop in blood pressure occurs when rising from a sitting to a
standing position
c. The amount of mucous in the bronchi and lungs decreases
d. The vessel walls of the circulatory system thicken
ANSWER B: A client with impaired mobility may develop many changes in
body systems that put him at risk of further illness or injury. Orthostatic
hypotension occurs when blood pressure drops more than 25 mmHg systolic
or 10 mmHg diastolic upon rising from a sitting or lying position to standing.
Orthostatic hypotension may develop in the client with impaired mobility
when blood circulates more slowly or pools in the distal extremities.
13.
A nurse is caring for a client who died approximately one hour ago. The
nurse notes that the client's temperature has decreased in the last hour since
his death. Which of the following processes explains this phenomenon?
a. Rigor mortis
b. Postmortem decomposition
c. Algor mortis
d. Livor mortis
ANSWER C: Algor mortis occurs after death when the body's circulation
stops and the client's temperature begins to fall. The client's temperature will
drop by approximately 1.8 degrees per hour until it reaches room
P a g e 10 | 419
