.FINAL NCLEX
QUESTIONS AND
ANSWERS
1. A nurse identifies that a client on a prolonged bed rest may be developing a pressure
ulcer. Which color over the bony prominence supports this conclusion?
1. Red
2. Blue
3. Black
4. Yellow
2. Which is an example of a response to a physiological physiological stressor? SELECT
ALL THAT APPLY
1. A sunburn after being outside all day
2. Diarrhea after eating contaminated food
3. Shortness of breath while walking up a hill
4. A rapid heart rate during a final examination
5. Excess fluid volume as a result of renal disease
3. Why does turning a patient every 2 hours prevent pressure ulcers from developing?
1. Promotes muscle contractions, increasing the basal metabolic rate of the body
2. Relieves weight on the capillaries, allowing oxygen to reach peripheral blood cells
3. Keeps the extremities dependent, permitting blood flow to the distal cells by gravity
4. Drops the organs in the abdominal cavity by gravity, relieving pressure against
the diaphragm
4. Which condition places a client at the highest risk for developing infection?
A. Implantation of a prosthetic device
B. Burns over more than 20% of the body
C. Presence of an indwelling urinary catheter
D. More than 2 puncture sites from a laparoscopic surgery
5. Which does the nurse determine is a specific line of defense against infection?
A. Mucous membrane of the respiratory system
B. Urinary tract environment
C. Integumentary
system D. Immune
response
6. A nurse is concerned about a client’s ability to withstand exposure to pathogens. Which
blood component should the nurse monitor?
A. Platelets
B. Hemoglobin
C. Neutrophils
D. Erythrocytes
7. An 83 year-old-woman fell at home and was diagnosed with a traumatic left femur fracture.
She is alert and oriented and is able to make her own medical decisions. Which assessment
is priority given her injuries and utilizes patient safety?
A. Abdominal assessment
B. Neuro vascular checks every hour
C. Skin assessment
, .FINAL NCLEX
QUESTIONS AND
ANSWERS
D. Mobility assessment
8. The patient has learned that she will need surgery and will be going to the operating room in
a few hours. Given her age and history, the order set states the nurse is to reposition the
patient every two hours. Which should be included in the nurse’s explanation and
education to the patient?
A. Turning every two hours will prevent a pressure injury
B. Turning every two hours will alleviate gas
C. Turning every two hours will promote blood flow of the fractured leg
D. Turning every two hours will enhance nutrition
9. The patient has finished with her procedure and received an intramedullary rod placement
of the left femur. Which nursing intervention can the nurse apply to prevent post-operative
complications in the clinical setting?
A. Initiating fluid replacement orders
B. Eating as soon as possible after surgery
C. Utilizing an incentive spirometer
D. Turning the patient every two hours
10. The patient has completed the surgery without acute complications at this time and is moved
to the post anesthesia care unit (PACU). Which nursing intervention is necessary to apply
to the patient’s care during her temporary stay on this specific unit?
A. Monitoring urinary output
B. Assessing cognition status
C. Assessing draining from the surgical site
D. Suctioning any mucous from the patient’s airway
11. After the patient has arrived at the post anesthesia care unit (PACU), what is the
most important information that the nurse should conclude about the patient?
A. Type and extent of the surgery
B. Medications that were delivered in surgery
C. The name and phone number of the patient’s spouse
D. Anxiety level pre and post procedure
12. The patient has been transferred out of the post anesthesia care unit (PACU) and has been
assigned a room on the surgical progressive care unit. Which is most important for the
nurse to utilize while positioning this patient post-operatively?
A. Ensure the head of the bed is greater than 30 degrees
B. Performing a log roll during linen changes
C. Prevent pressure on bony prominences
D. Avoid any friction or shear while turning the patient
13. The patient has started to develop pleuritic chest pain, tachypnea, and tachycardia.
According to these findings, the nurse can identify this being which post-operative
complication?
A. Infection
B. Pulmonary Emboli
C. Anxiety
D. Myocardial Infarction
14. The nurse is suspecting the patient is suffering from the post-operative complication
pulmonary embolism. Which nursing action should the nurse apply first before notifying
the doctor?
QUESTIONS AND
ANSWERS
1. A nurse identifies that a client on a prolonged bed rest may be developing a pressure
ulcer. Which color over the bony prominence supports this conclusion?
1. Red
2. Blue
3. Black
4. Yellow
2. Which is an example of a response to a physiological physiological stressor? SELECT
ALL THAT APPLY
1. A sunburn after being outside all day
2. Diarrhea after eating contaminated food
3. Shortness of breath while walking up a hill
4. A rapid heart rate during a final examination
5. Excess fluid volume as a result of renal disease
3. Why does turning a patient every 2 hours prevent pressure ulcers from developing?
1. Promotes muscle contractions, increasing the basal metabolic rate of the body
2. Relieves weight on the capillaries, allowing oxygen to reach peripheral blood cells
3. Keeps the extremities dependent, permitting blood flow to the distal cells by gravity
4. Drops the organs in the abdominal cavity by gravity, relieving pressure against
the diaphragm
4. Which condition places a client at the highest risk for developing infection?
A. Implantation of a prosthetic device
B. Burns over more than 20% of the body
C. Presence of an indwelling urinary catheter
D. More than 2 puncture sites from a laparoscopic surgery
5. Which does the nurse determine is a specific line of defense against infection?
A. Mucous membrane of the respiratory system
B. Urinary tract environment
C. Integumentary
system D. Immune
response
6. A nurse is concerned about a client’s ability to withstand exposure to pathogens. Which
blood component should the nurse monitor?
A. Platelets
B. Hemoglobin
C. Neutrophils
D. Erythrocytes
7. An 83 year-old-woman fell at home and was diagnosed with a traumatic left femur fracture.
She is alert and oriented and is able to make her own medical decisions. Which assessment
is priority given her injuries and utilizes patient safety?
A. Abdominal assessment
B. Neuro vascular checks every hour
C. Skin assessment
, .FINAL NCLEX
QUESTIONS AND
ANSWERS
D. Mobility assessment
8. The patient has learned that she will need surgery and will be going to the operating room in
a few hours. Given her age and history, the order set states the nurse is to reposition the
patient every two hours. Which should be included in the nurse’s explanation and
education to the patient?
A. Turning every two hours will prevent a pressure injury
B. Turning every two hours will alleviate gas
C. Turning every two hours will promote blood flow of the fractured leg
D. Turning every two hours will enhance nutrition
9. The patient has finished with her procedure and received an intramedullary rod placement
of the left femur. Which nursing intervention can the nurse apply to prevent post-operative
complications in the clinical setting?
A. Initiating fluid replacement orders
B. Eating as soon as possible after surgery
C. Utilizing an incentive spirometer
D. Turning the patient every two hours
10. The patient has completed the surgery without acute complications at this time and is moved
to the post anesthesia care unit (PACU). Which nursing intervention is necessary to apply
to the patient’s care during her temporary stay on this specific unit?
A. Monitoring urinary output
B. Assessing cognition status
C. Assessing draining from the surgical site
D. Suctioning any mucous from the patient’s airway
11. After the patient has arrived at the post anesthesia care unit (PACU), what is the
most important information that the nurse should conclude about the patient?
A. Type and extent of the surgery
B. Medications that were delivered in surgery
C. The name and phone number of the patient’s spouse
D. Anxiety level pre and post procedure
12. The patient has been transferred out of the post anesthesia care unit (PACU) and has been
assigned a room on the surgical progressive care unit. Which is most important for the
nurse to utilize while positioning this patient post-operatively?
A. Ensure the head of the bed is greater than 30 degrees
B. Performing a log roll during linen changes
C. Prevent pressure on bony prominences
D. Avoid any friction or shear while turning the patient
13. The patient has started to develop pleuritic chest pain, tachypnea, and tachycardia.
According to these findings, the nurse can identify this being which post-operative
complication?
A. Infection
B. Pulmonary Emboli
C. Anxiety
D. Myocardial Infarction
14. The nurse is suspecting the patient is suffering from the post-operative complication
pulmonary embolism. Which nursing action should the nurse apply first before notifying
the doctor?
