shown after you have selected an answer. No time limit for this
exam. NCLEX Practice Exam 19 (50 Questions)
Question 1
Wrong
The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node
syndrome) should be based on the high risk for development of which problem?
A
Chronic vessel plaque
formation B
Pulmonary embolism
Occlusions at the vessel bifurcations
Coronary artery
aneurysms Question 1
Explanation:
Option D: Kawasaki Disease involves all the small and medium-sized blood vessels. There is
progressive inflammation of the small vessels which progresses to the medium-sized muscular
arteries, potentially damaging the walls and leading to coronary artery aneurysms.
Question 2
Wrong
A nurse has just received a medication order which is not legible. Which statement best reflects
assertive communication?
A
“I cannot give this medication as it is written. I have no idea of what you mean.”
“Would you please clarify what you have written so I am sure I am reading it correctly?”
C
“I am having difficulty reading your handwriting. It would save me time if you would be more careful.”
,“Please print in the future so I do not have to spend extra time attempting to read your writing.”
Question 2 Explanation:
Option B: Assertive communication respects the rights and responsibilities of both parties. This
statement is an honest expression of concern for safe practice and a request for clarification without
self- depreciation. It reflects the right of the professional to give and receive information.
Question 3
Wrong
The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell
the parents to best respond to this behavior?
Reprimand the child and give a 15-minute “time
out” B
Maintain a permissive attitude for this behavior
Use patience and a sense of humor to deal with this behavior
D
Assert authority over the child through limit
setting Question 3 Explanation:
Option C: The nurse should help the parents see the negativism as a normal growth of autonomy in the
toddler. They can best handle the negative toddler by using patience and humor.
Question 4
Correct
An ambulatory client reports edema during the day in his feet and an ankle that disappears while
sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
A
“Have you had a recent heart attack?”
,“Do you become short of breath during your normal daily activities?”
C
“How many pillows do you use at night to sleep comfortably?”
D
“Do you smoke?”
Question 4 Explanation:
Option B: These are the symptoms of right-sided heart failure, which causes increased pressure in the
systemic venous system. To equalize this pressure, the fluid shifts into the interstitial spaces causing
edema. Because of gravity, the lower extremities are first affected in an ambulatory patient. This
question would elicit information to confirm the nursing diagnosis of activity intolerance and fluid
volume excess both associated with right-sided heart failure.
Question 5
Wrong
The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which
of the following actions would be most appropriate?
Fluid restriction 1000cc per
day B
Ambulate in hallway 4 times a day
Administer analgesic therapy as
ordered D
Encourage increased caloric
intake Question 5 Explanation:
Option C: The main general objectives in the treatment of a sickle cell crisis is bed rest, hydration,
electrolyte replacement, analgesics for pain, blood replacement and antibiotics to treat any existing
infection.
Question 6
Correct
While working with an obese adolescent, it is important for the nurse to recognize that obesity in
adolescents is most often associated with what other behavior?
, A
Sexual promiscuity
Poor body
image C
Dropping out of school
D
Drug experimentation
Question 6 Explanation:
Option B: As the adolescent gains weight, there is a lessening sense of self-esteem and poor body image.
Question 7
Wrong
A nurse and client are talking about the client’s progress toward understanding his behavior under
stress. This is typical of which phase in the therapeutic relationship?
Pre-interaction
B
Orientation
Working
D
Termination
Question 7 Explanation:
Option C: During the working phase, alternative behaviors and techniques are explored. The nurse and
the client discuss the meaning behind the behavior.
Question 8
Correct
exam. NCLEX Practice Exam 19 (50 Questions)
Question 1
Wrong
The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node
syndrome) should be based on the high risk for development of which problem?
A
Chronic vessel plaque
formation B
Pulmonary embolism
Occlusions at the vessel bifurcations
Coronary artery
aneurysms Question 1
Explanation:
Option D: Kawasaki Disease involves all the small and medium-sized blood vessels. There is
progressive inflammation of the small vessels which progresses to the medium-sized muscular
arteries, potentially damaging the walls and leading to coronary artery aneurysms.
Question 2
Wrong
A nurse has just received a medication order which is not legible. Which statement best reflects
assertive communication?
A
“I cannot give this medication as it is written. I have no idea of what you mean.”
“Would you please clarify what you have written so I am sure I am reading it correctly?”
C
“I am having difficulty reading your handwriting. It would save me time if you would be more careful.”
,“Please print in the future so I do not have to spend extra time attempting to read your writing.”
Question 2 Explanation:
Option B: Assertive communication respects the rights and responsibilities of both parties. This
statement is an honest expression of concern for safe practice and a request for clarification without
self- depreciation. It reflects the right of the professional to give and receive information.
Question 3
Wrong
The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell
the parents to best respond to this behavior?
Reprimand the child and give a 15-minute “time
out” B
Maintain a permissive attitude for this behavior
Use patience and a sense of humor to deal with this behavior
D
Assert authority over the child through limit
setting Question 3 Explanation:
Option C: The nurse should help the parents see the negativism as a normal growth of autonomy in the
toddler. They can best handle the negative toddler by using patience and humor.
Question 4
Correct
An ambulatory client reports edema during the day in his feet and an ankle that disappears while
sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
A
“Have you had a recent heart attack?”
,“Do you become short of breath during your normal daily activities?”
C
“How many pillows do you use at night to sleep comfortably?”
D
“Do you smoke?”
Question 4 Explanation:
Option B: These are the symptoms of right-sided heart failure, which causes increased pressure in the
systemic venous system. To equalize this pressure, the fluid shifts into the interstitial spaces causing
edema. Because of gravity, the lower extremities are first affected in an ambulatory patient. This
question would elicit information to confirm the nursing diagnosis of activity intolerance and fluid
volume excess both associated with right-sided heart failure.
Question 5
Wrong
The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which
of the following actions would be most appropriate?
Fluid restriction 1000cc per
day B
Ambulate in hallway 4 times a day
Administer analgesic therapy as
ordered D
Encourage increased caloric
intake Question 5 Explanation:
Option C: The main general objectives in the treatment of a sickle cell crisis is bed rest, hydration,
electrolyte replacement, analgesics for pain, blood replacement and antibiotics to treat any existing
infection.
Question 6
Correct
While working with an obese adolescent, it is important for the nurse to recognize that obesity in
adolescents is most often associated with what other behavior?
, A
Sexual promiscuity
Poor body
image C
Dropping out of school
D
Drug experimentation
Question 6 Explanation:
Option B: As the adolescent gains weight, there is a lessening sense of self-esteem and poor body image.
Question 7
Wrong
A nurse and client are talking about the client’s progress toward understanding his behavior under
stress. This is typical of which phase in the therapeutic relationship?
Pre-interaction
B
Orientation
Working
D
Termination
Question 7 Explanation:
Option C: During the working phase, alternative behaviors and techniques are explored. The nurse and
the client discuss the meaning behind the behavior.
Question 8
Correct
