NCLEX-RN
Free 180
Questions
and Answers
with
Rationale
, NCLEX-RN Free 180 Questions and Answers with Rationale
1. An emergency department (ED) nurse working triage has assessed four clients. Which
client should receive the highest priority?
1. Alert client who fell on the side walk. Skin warm and dry to the touch, with a three
inch laceration on the right knee continuously oozing dark red liquid.
2. Elderly client who moans when the nurse asks, "Can you hear me?" Respirations
even/non labored. Skin slightly cool to touch with pale nailbeds.
3. A client who "passed out" but regained consciousness when feet were elevated. Awake
and confused, with warm and dry skin.
4. An alert, responsive client who reports severe abdominal and shoulder pain that began
two hours after eating at a local fast food restaurant. Skin is warm and dry
Correct answer: 2. Elderly client who moans when the nurse asks, "Can you hear me?"
Respirations even/nonlabored. Skin slightly cool to touch with pale nailbeds.
2. This client is responding to verbal stimuli by moaning and has an open airway; but any
client with an altered level of consciousness is at risk for airway obstruction. The skin
assessment indicates a circulation problem.
Which task should the nurse perform first?
1. Suctioning the tracheostomy.
2. Changing a colostomy bag that is leaking.
3. Performing an admission assessment on a client.
4. Administering pain medication to a postoperative client. 1.
Correct: The tracheostomy tube must be suctioned to keep the client's airway open. Suctioning
the tracheostomy should take priority. Remember, airway first.
3. The six bed Labor and Delivery area is full when the Emergency Department nurse calls
for a bed for a woman reporting low back pain, pelvic pressure and increased vaginal
discharge at 36 weeks gestation. Which would be the most appropriate action for the
charge nurse?
1. Transfer a G4P4 who delivered full-term twins one hour ago to the
antepartum/postpartum floor.
2. Transfer a G3 P3 who delivered an 8 lb. newborn three hours ago to the
antepartum/postpartum floor.
3. Transfer an 8 hour postpartum G1P1 on Magnesium Sulfate for eclampsia from the
LDR unit to the ante/postpartum unit.
4. Request that the new client be admitted to the antepartum/postpartum floor.
Transfer a G3 P3 who delivered an 8 lb. newborn three hours ago to the
antepartum/postpartum floor.
,-The client and newborn are not in any present distress. Also the delivery occurred 3 hours ago.
This client would not be a risk and could be cared for on the antepartum/postpartum floor.
4. Post cataract removal a client reports nausea and severe pain in the operative eye. Which
nursing intervention takes priority?
1. Administer morphine and ondansetron.
2. Reposition client to non-operative side.
3. Massage the canthus to unblock the lacrimal duct.
4. Notify the primary healthcare provider.
Severe pain with nausea indicates an increase in intraocular pressure and needs to be
reported at once. Eye damage can result if not resolved quickly. The primary healthcare
provider may prescribe medications or take the client back to surgery.
5. Which statement by a student nurse indicates to the nurse educator that teaching
regarding witnessing consent signatures has been successful?
-Signing as a witness implies that the witness has observed the client personally signing
the consent form with no coercion.
-The witness does not have to be an RN.
-A witness is required to be over the age of 18.
A client has been on the mental health unit for three days and is requesting to leave
against medical advice (AMA).
6. It has been determined that the client is not suicidal. What should the nurse do?
1. Inform the primary healthcare provider that the client wishes to leave. Protocols on the
unit must be followed when someone is requesting to leave AMA. The first step is to call
the primary healthcare provider about the client's desire to leave AMA.
Make arrangements for a commitment hearing, as soon as possible only if the client is not
a threat or potential threat to self or others, the client may leave
unlicensed assistive personnel (UAP) cant do invasive tasks like removing catheters or
obtaining sterile specimens from indwelling catheter
7. Which nursing action is likely to improve client satisfaction and demonstrate acts of
beneficence?
1. Allowing clients to make their own decisions about care
2. Answering all questions posed by client in an honest manner
3. Reporting faulty equipment to the proper departments
4. Sitting at the bedside and listening to an elderly client Sitting at the bedside and listening to
an elderly client
, -Sitting and listening demonstrates kindness and compassion that are consistent with the ethical
term "beneficence." Beneficence is taking positive action to help others and a desire to do good
which is the core principle of client advocacy.
Autonomy is the ethical principle illustrated here by supporting independent decision making
with clients.
Fidelity is the ethical principle illustrated here and refers to the concept of keeping a
commitment. It is based upon the virtue of caring.
Reporting faulty equipment is an act to promote... -nonmaleficence or to do no harm. This is
the core of nursing ethics.
8. A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral
vascular accident who will need assistive devices upon discharge. Which devices should
the case manager include for this client?
1. Dinner plate food guards
2. Transfer belt
3. Raised toilet seat
4. Long handled shoe horn
5. Wide grip eating utensils
6. Button closures on clothes 1., 2., 3., 4., & 5.
Correct: The goal is to promote self-care by the client as much as possible. The case
manager should evaluate the need for assistive devices to help with eating, bathing,
dressing, and ambulating. The dinner plate food guard will prevent food from being
pushed off the plate. The transfer belt will provide safety for the client to get into a chair
or back in bed. A raised toilet seat makes it easier for the client to sit on the toilet without
falling. The long-handled shoe horn allows the client to put on shoes without assistance.
Wide grip utensils accommodate a weak grip.
6. Incorrect: It is hard for someone with hemiplegia to use buttons. Velcro fasteners are
best.
hemiplegia= paralysis of one side of the body.
9. The nurse determines that a client does not have an advance directive. The daughter is
designated to make healthcare decisions in the event that the client becomes incapacitated
or unable to make informed decisions. Which nursing actions are appropriate for this
client?
* 1. Document the client's statement in the client's own words.
2. Provide information on advance directives to the client.
3. Inform the client that personnel are available to assist with completing an advance
directive.*
4. Avoid inquiring about a client's advance directive as this could cause the client anxiety
and concern.
5. Ask the daughter if she agrees with her mother's decision.
Free 180
Questions
and Answers
with
Rationale
, NCLEX-RN Free 180 Questions and Answers with Rationale
1. An emergency department (ED) nurse working triage has assessed four clients. Which
client should receive the highest priority?
1. Alert client who fell on the side walk. Skin warm and dry to the touch, with a three
inch laceration on the right knee continuously oozing dark red liquid.
2. Elderly client who moans when the nurse asks, "Can you hear me?" Respirations
even/non labored. Skin slightly cool to touch with pale nailbeds.
3. A client who "passed out" but regained consciousness when feet were elevated. Awake
and confused, with warm and dry skin.
4. An alert, responsive client who reports severe abdominal and shoulder pain that began
two hours after eating at a local fast food restaurant. Skin is warm and dry
Correct answer: 2. Elderly client who moans when the nurse asks, "Can you hear me?"
Respirations even/nonlabored. Skin slightly cool to touch with pale nailbeds.
2. This client is responding to verbal stimuli by moaning and has an open airway; but any
client with an altered level of consciousness is at risk for airway obstruction. The skin
assessment indicates a circulation problem.
Which task should the nurse perform first?
1. Suctioning the tracheostomy.
2. Changing a colostomy bag that is leaking.
3. Performing an admission assessment on a client.
4. Administering pain medication to a postoperative client. 1.
Correct: The tracheostomy tube must be suctioned to keep the client's airway open. Suctioning
the tracheostomy should take priority. Remember, airway first.
3. The six bed Labor and Delivery area is full when the Emergency Department nurse calls
for a bed for a woman reporting low back pain, pelvic pressure and increased vaginal
discharge at 36 weeks gestation. Which would be the most appropriate action for the
charge nurse?
1. Transfer a G4P4 who delivered full-term twins one hour ago to the
antepartum/postpartum floor.
2. Transfer a G3 P3 who delivered an 8 lb. newborn three hours ago to the
antepartum/postpartum floor.
3. Transfer an 8 hour postpartum G1P1 on Magnesium Sulfate for eclampsia from the
LDR unit to the ante/postpartum unit.
4. Request that the new client be admitted to the antepartum/postpartum floor.
Transfer a G3 P3 who delivered an 8 lb. newborn three hours ago to the
antepartum/postpartum floor.
,-The client and newborn are not in any present distress. Also the delivery occurred 3 hours ago.
This client would not be a risk and could be cared for on the antepartum/postpartum floor.
4. Post cataract removal a client reports nausea and severe pain in the operative eye. Which
nursing intervention takes priority?
1. Administer morphine and ondansetron.
2. Reposition client to non-operative side.
3. Massage the canthus to unblock the lacrimal duct.
4. Notify the primary healthcare provider.
Severe pain with nausea indicates an increase in intraocular pressure and needs to be
reported at once. Eye damage can result if not resolved quickly. The primary healthcare
provider may prescribe medications or take the client back to surgery.
5. Which statement by a student nurse indicates to the nurse educator that teaching
regarding witnessing consent signatures has been successful?
-Signing as a witness implies that the witness has observed the client personally signing
the consent form with no coercion.
-The witness does not have to be an RN.
-A witness is required to be over the age of 18.
A client has been on the mental health unit for three days and is requesting to leave
against medical advice (AMA).
6. It has been determined that the client is not suicidal. What should the nurse do?
1. Inform the primary healthcare provider that the client wishes to leave. Protocols on the
unit must be followed when someone is requesting to leave AMA. The first step is to call
the primary healthcare provider about the client's desire to leave AMA.
Make arrangements for a commitment hearing, as soon as possible only if the client is not
a threat or potential threat to self or others, the client may leave
unlicensed assistive personnel (UAP) cant do invasive tasks like removing catheters or
obtaining sterile specimens from indwelling catheter
7. Which nursing action is likely to improve client satisfaction and demonstrate acts of
beneficence?
1. Allowing clients to make their own decisions about care
2. Answering all questions posed by client in an honest manner
3. Reporting faulty equipment to the proper departments
4. Sitting at the bedside and listening to an elderly client Sitting at the bedside and listening to
an elderly client
, -Sitting and listening demonstrates kindness and compassion that are consistent with the ethical
term "beneficence." Beneficence is taking positive action to help others and a desire to do good
which is the core principle of client advocacy.
Autonomy is the ethical principle illustrated here by supporting independent decision making
with clients.
Fidelity is the ethical principle illustrated here and refers to the concept of keeping a
commitment. It is based upon the virtue of caring.
Reporting faulty equipment is an act to promote... -nonmaleficence or to do no harm. This is
the core of nursing ethics.
8. A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral
vascular accident who will need assistive devices upon discharge. Which devices should
the case manager include for this client?
1. Dinner plate food guards
2. Transfer belt
3. Raised toilet seat
4. Long handled shoe horn
5. Wide grip eating utensils
6. Button closures on clothes 1., 2., 3., 4., & 5.
Correct: The goal is to promote self-care by the client as much as possible. The case
manager should evaluate the need for assistive devices to help with eating, bathing,
dressing, and ambulating. The dinner plate food guard will prevent food from being
pushed off the plate. The transfer belt will provide safety for the client to get into a chair
or back in bed. A raised toilet seat makes it easier for the client to sit on the toilet without
falling. The long-handled shoe horn allows the client to put on shoes without assistance.
Wide grip utensils accommodate a weak grip.
6. Incorrect: It is hard for someone with hemiplegia to use buttons. Velcro fasteners are
best.
hemiplegia= paralysis of one side of the body.
9. The nurse determines that a client does not have an advance directive. The daughter is
designated to make healthcare decisions in the event that the client becomes incapacitated
or unable to make informed decisions. Which nursing actions are appropriate for this
client?
* 1. Document the client's statement in the client's own words.
2. Provide information on advance directives to the client.
3. Inform the client that personnel are available to assist with completing an advance
directive.*
4. Avoid inquiring about a client's advance directive as this could cause the client anxiety
and concern.
5. Ask the daughter if she agrees with her mother's decision.
