NCLEX Pre exam Questions
1. Client is being discharged with a prescription for enoxaparin. What will the nurse document to
address that medication teaching occurred? Select all that apply.
-The client's response to teaching
- The client knows the time for the next dose
- The client can select a site for injection
- The client knows adverse effects such as bleeding, bloody or black stools.
Explanation:
The nurse has a legal duty to do teaching with the client including reporting adverse effects such as
bleeding, bloody or black stools. The nurse will document client's ability to select site for injection and
the client's response to teaching as well as confirming the next scheduled dose with client. The client's
ability to pay for the medication is not part of the teaching obligation.
2. The nurse is educating a woman with type 2 diabetes from France who speaks English as a
second language. What behavior(s) alerts the nurse to a possible lack of communication of the
educational material? Select all that apply.
- asking questions about shopping
-laughing at some of the brochures
- looking away from the speaker
Explanation:
Some of the behaviors which indicate that the client is not understanding the nurse's teaching are:
asking inappropriate questions to change the subject, laughing to disguise embarrassment, and looking
away from the speaker. Taking notes and writing down medical terms are positive behaviors indicating
that the client is engaged in learning.
, 3. A client in the postanesthesia care unit with a left below-the-knee amputation has pain in the
left big toe. What should the nurse do first?
Give the client the prescribed opioid analgesic.
Explanation:
The nurse's first action should be to administer the prescribed opioid analgesic to the client because this
phenomenon is phantom sensation and interventions should be provided to relieve it. Pain relief is the
priority. Phantom sensation is a real sensation. It is incorrect and inappropriate to tell a client that it is
impossible to feel the pain. Although it does relieve the client's apprehensions to be told that phantom
sensations are a real phenomenon, the client needs prompt treatment to relieve the pain sensation.
Usually phantom sensation will go away. However, showing the client that the toes are not there does
nothing to provide the client with relief.
4. An infant is diagnosed with a congenital hip dislocation. On assessment, the nurse expects to
note:
Ortolani's sign
Explanation:
In a child with a congenital hip dislocation, assessment typically reveals Ortolani's sign, asymmetrical
thigh and gluteal folds, limited hip abduction, femoral shortening, and Trendelenburg's sign.
5. A client with colon cancer is having a barium enema. The nurse should instruct the client to take
which type of medication after the procedure is completed?
laxative
Explanation:
, After a barium enema, a laxative is ordinarily prescribed. This is done to promote elimination of the
barium. Retained barium predisposes the client to constipation and fecal impaction. Anticholinergic
drugs decrease gastrointestinal motility. Antacids decrease gastric acid secretion. Demulcents soothe
mucous membranes of the gastrointestinal tract and are used to treat diarrhea.
6. A 1-month-old infant in the neonatal intensive care unit is dying. His parents request that a
nurse give the infant an opioid analgesic. The infant's heart rate is 68 beats/minute and his
respiratory rate is 18 breaths/minute. He is on room air; oxygen saturation is 92%. The nurse's
response to the parents' request should be based on the fact that:
providing an analgesic during the last days and hours is an ethically appropriate nursing action.
Explanation:
The nurse's action should be based on the fact that all clients, regardless of age, have the right to die
with dignity and to be free of pain. Assisted suicide requires some action on the part of the client, which
isn't possible in the case a 1-month-old infant. The parent's decision doesn't eliminate the nurse's
ethical obligation to the infant and to the nursing profession. Withholding the opioid analgesic isn't
appropriate because it isn't known that administering the drug would hasten death in this case.
7. The client asks the nurse if surgery is needed to correct a hiatal hernia. Which reply by the nurse
would be most accurate?
"Hiatal hernia symptoms can usually be successfully managed with diet modifications, medications, and
lifestyle changes."
Explanation:
Most clients can be treated successfully with a combination of diet restrictions, medications, weight
control, and lifestyle modifications. Surgery to correct a hiatal hernia, which commonly produces
complications, is performed only when medical therapy fails to control the symptoms.
1. Client is being discharged with a prescription for enoxaparin. What will the nurse document to
address that medication teaching occurred? Select all that apply.
-The client's response to teaching
- The client knows the time for the next dose
- The client can select a site for injection
- The client knows adverse effects such as bleeding, bloody or black stools.
Explanation:
The nurse has a legal duty to do teaching with the client including reporting adverse effects such as
bleeding, bloody or black stools. The nurse will document client's ability to select site for injection and
the client's response to teaching as well as confirming the next scheduled dose with client. The client's
ability to pay for the medication is not part of the teaching obligation.
2. The nurse is educating a woman with type 2 diabetes from France who speaks English as a
second language. What behavior(s) alerts the nurse to a possible lack of communication of the
educational material? Select all that apply.
- asking questions about shopping
-laughing at some of the brochures
- looking away from the speaker
Explanation:
Some of the behaviors which indicate that the client is not understanding the nurse's teaching are:
asking inappropriate questions to change the subject, laughing to disguise embarrassment, and looking
away from the speaker. Taking notes and writing down medical terms are positive behaviors indicating
that the client is engaged in learning.
, 3. A client in the postanesthesia care unit with a left below-the-knee amputation has pain in the
left big toe. What should the nurse do first?
Give the client the prescribed opioid analgesic.
Explanation:
The nurse's first action should be to administer the prescribed opioid analgesic to the client because this
phenomenon is phantom sensation and interventions should be provided to relieve it. Pain relief is the
priority. Phantom sensation is a real sensation. It is incorrect and inappropriate to tell a client that it is
impossible to feel the pain. Although it does relieve the client's apprehensions to be told that phantom
sensations are a real phenomenon, the client needs prompt treatment to relieve the pain sensation.
Usually phantom sensation will go away. However, showing the client that the toes are not there does
nothing to provide the client with relief.
4. An infant is diagnosed with a congenital hip dislocation. On assessment, the nurse expects to
note:
Ortolani's sign
Explanation:
In a child with a congenital hip dislocation, assessment typically reveals Ortolani's sign, asymmetrical
thigh and gluteal folds, limited hip abduction, femoral shortening, and Trendelenburg's sign.
5. A client with colon cancer is having a barium enema. The nurse should instruct the client to take
which type of medication after the procedure is completed?
laxative
Explanation:
, After a barium enema, a laxative is ordinarily prescribed. This is done to promote elimination of the
barium. Retained barium predisposes the client to constipation and fecal impaction. Anticholinergic
drugs decrease gastrointestinal motility. Antacids decrease gastric acid secretion. Demulcents soothe
mucous membranes of the gastrointestinal tract and are used to treat diarrhea.
6. A 1-month-old infant in the neonatal intensive care unit is dying. His parents request that a
nurse give the infant an opioid analgesic. The infant's heart rate is 68 beats/minute and his
respiratory rate is 18 breaths/minute. He is on room air; oxygen saturation is 92%. The nurse's
response to the parents' request should be based on the fact that:
providing an analgesic during the last days and hours is an ethically appropriate nursing action.
Explanation:
The nurse's action should be based on the fact that all clients, regardless of age, have the right to die
with dignity and to be free of pain. Assisted suicide requires some action on the part of the client, which
isn't possible in the case a 1-month-old infant. The parent's decision doesn't eliminate the nurse's
ethical obligation to the infant and to the nursing profession. Withholding the opioid analgesic isn't
appropriate because it isn't known that administering the drug would hasten death in this case.
7. The client asks the nurse if surgery is needed to correct a hiatal hernia. Which reply by the nurse
would be most accurate?
"Hiatal hernia symptoms can usually be successfully managed with diet modifications, medications, and
lifestyle changes."
Explanation:
Most clients can be treated successfully with a combination of diet restrictions, medications, weight
control, and lifestyle modifications. Surgery to correct a hiatal hernia, which commonly produces
complications, is performed only when medical therapy fails to control the symptoms.
