UWorld NCLEX-RN TEST 1 QUESTIONS AND ANSWERS ALL CORRECT
A nurse in the intensive care unit is caring for a client in the immediate postoperative period following
abdominal surgery. The nurse receives several prescriptions. Which prescription should the nurse
initiate first? Click on the exhibit button for additional information. Correct Answer: Normal saline 2 L
via rapid IV bolus.
A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How
should the nurse respond? Correct Answer: Refer employee to the employee health provider.
The school nurse assesses an 8-year-old with a history of asthma. The nurse notes mild wheezing and
coughing. Which action should the nurse perform first? Correct Answer: Assess the client's peak
expiratory flow.
A client comes to the community mental health clinic seeking treatment for severe anxiety associated
with a recent job promotion that requires a 30-minute commute via train. The nurse recognizes that this
client most likely suffers from which psychological disorder? Correct Answer: Agoraphobia
A client who is diagnosed with breast cancer asks the nurse, "Am I going to die?" Which statement by
the nurse promotes a therapeutic relationship? Correct Answer: "People with cancer experience fear of
dying; tell me about your concerns."
The nurse is reinforcing education to the caregivers of a 9-year-old client diagnosed with scarlet fever.
The client has a history of type 1 diabetes mellitus. Which statement by the caregivers indicates that
further teaching is needed? Correct Answer: "We will not administer insulin if our child is unable to
eat."
A client is diagnosed with right-sided Bell's palsy. What instructions should the nurse give this client for
care at home? Select all that apply. Correct Answer: 1. Apply a patch to the right eye at night.
3. Chew on the left side.
4. Maintain meticulous oral hygiene.
- Bell's palsy is an inflammation of the cranial nerve VII (facial) that causes motor and sensory
alterations. Clients are usually managed as outpatients, with corticosteroids to reduce inflammation,
and taught eye/oral care. In Bell's palsy, the eyelids do not close properly. This may result in eye dryness
and risk of corneal abrasions. However, weakness of teh lower eyelid may cause excessive tearing due to
overflow in some clients. Facial muscle weakness results in poor chewing and food retention.
The spouse brings a client to the emergency department due to erratic behavior and expressions of
despair. The emergency department is extremely busy with many clients. When the triage nurse asks if
the client feels suicidal now, the client shrugs the shoulders. What initial action should the triage nurse
take? Correct Answer: Place the client in an inside hallway with one-on-one observation.
The orthopedic health care provider instructs a client with a fractured femur, who has been non-weight
bearing for the past 5 weeks, to progress to full weight bearing on the right leg. which advanced crutch
gait that most closely resembles normal walking should the office nurse teach the client? Correct
Answer: 4-point gait
, - there are 5 crutch gaits: 2-, 3-, 4-point, swing-to, and swing-through
`A nurse administers an intramuscular (IM) injection using the Z-track method technique. Place the steps
in chronological order. All options must be used. Correct Answer: 4. Pull the skin 1-1 1/2" (2.5-3.5 cm)
laterally and away from the injection site.
3. Hold the skin taut with non-dominant hand and insert needle at a 90-degree angle.
2. Inject medication slowly with dominant hand while maintaining traction
6. Wait 10 seconds after injecting the medication and withdraw the needle.
Release the hold on the skin, allowing the layers to slide back to their original position.
1. Apply gentle pressure at the injection site but do not massage.
The clinic nurse is teaching a client about levothyroxine, which the health care provider has prescribed
for newly diagnosed hypothyroidism. Which statement made by the client indicates that further
teaching is needed? Correct Answer: "If this makes my stomach upset, I will take it with an antacid."
- will impair the absorption of levothyroxine (Synthroid). -- Antacids, calcium and iron preparations.
- should take levothyroxine on an empty stomach, preferably in the morning, separately from other
medications
The nurse is reviewing laboratory results for several prenatal clients. Which finding is most important to
report to the health care provider? Correct Answer: Client at 24 weeks gestation with hemoglobin of 9
g/dL (90 g/L) and hematocrit of 29%
- during the second half of pregnancy, the fetus beings to store iron, depleting maternal stores.
Hemoglobin <11 g/dL in the first or third trimester or <10.5 g/dL in the second trimester is considered
low.
A client with obesity has just started taking orlistat. Which statement by the client indicates a need for
further teaching? Correct Answer: "I have started taking a daily multivitamin with my dinner-time dose
of medication."
- Orlistat is a lipase inhibitor that prevents the breakdown and absorption of fats from the intestine -
interferes with fat-soluble vitamin uptake
The nurse on the medical-surgical unit receives report on assigned clients. Which client warrants
immediate attention? Correct Answer: Client with epigastric pain after endoscopic retrograde
cholangiopancreatography.
- Perforation or irritation of these areas during the procedure can cause acute pancreatitis, a potentially
life-threatening complication after an ERCP: s/s - acute epigastric or left upper quadrant pain, often
radiating to the back, and a rapid rise in pancreatic enzymes (amylase. lipase)
The home health care nurse reviews the laboratory results for 4 clients. Which laboratory value is most
important for the nurse to report to the health care provider? Correct Answer: Client with rheumatoid
arthritis taking adalimumab has a WBC count of 14,000/mm3
Which emergency department client would be allowed to leave against medical advice after the risks are
discussed with the primary health care provider? Correct Answer: Client with coffee-ground emesis
from chronic use of high-dose aspirin.
- Issues that can make a client ineligible to leave AMA include danger to self or others, lack of
consciousness, altered consciousness, mental illness, being under chemical influence, or a court
decision. Parents may not refuse life-, limb-, or organ- saving treatment on behalf of their minor child for
A nurse in the intensive care unit is caring for a client in the immediate postoperative period following
abdominal surgery. The nurse receives several prescriptions. Which prescription should the nurse
initiate first? Click on the exhibit button for additional information. Correct Answer: Normal saline 2 L
via rapid IV bolus.
A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How
should the nurse respond? Correct Answer: Refer employee to the employee health provider.
The school nurse assesses an 8-year-old with a history of asthma. The nurse notes mild wheezing and
coughing. Which action should the nurse perform first? Correct Answer: Assess the client's peak
expiratory flow.
A client comes to the community mental health clinic seeking treatment for severe anxiety associated
with a recent job promotion that requires a 30-minute commute via train. The nurse recognizes that this
client most likely suffers from which psychological disorder? Correct Answer: Agoraphobia
A client who is diagnosed with breast cancer asks the nurse, "Am I going to die?" Which statement by
the nurse promotes a therapeutic relationship? Correct Answer: "People with cancer experience fear of
dying; tell me about your concerns."
The nurse is reinforcing education to the caregivers of a 9-year-old client diagnosed with scarlet fever.
The client has a history of type 1 diabetes mellitus. Which statement by the caregivers indicates that
further teaching is needed? Correct Answer: "We will not administer insulin if our child is unable to
eat."
A client is diagnosed with right-sided Bell's palsy. What instructions should the nurse give this client for
care at home? Select all that apply. Correct Answer: 1. Apply a patch to the right eye at night.
3. Chew on the left side.
4. Maintain meticulous oral hygiene.
- Bell's palsy is an inflammation of the cranial nerve VII (facial) that causes motor and sensory
alterations. Clients are usually managed as outpatients, with corticosteroids to reduce inflammation,
and taught eye/oral care. In Bell's palsy, the eyelids do not close properly. This may result in eye dryness
and risk of corneal abrasions. However, weakness of teh lower eyelid may cause excessive tearing due to
overflow in some clients. Facial muscle weakness results in poor chewing and food retention.
The spouse brings a client to the emergency department due to erratic behavior and expressions of
despair. The emergency department is extremely busy with many clients. When the triage nurse asks if
the client feels suicidal now, the client shrugs the shoulders. What initial action should the triage nurse
take? Correct Answer: Place the client in an inside hallway with one-on-one observation.
The orthopedic health care provider instructs a client with a fractured femur, who has been non-weight
bearing for the past 5 weeks, to progress to full weight bearing on the right leg. which advanced crutch
gait that most closely resembles normal walking should the office nurse teach the client? Correct
Answer: 4-point gait
, - there are 5 crutch gaits: 2-, 3-, 4-point, swing-to, and swing-through
`A nurse administers an intramuscular (IM) injection using the Z-track method technique. Place the steps
in chronological order. All options must be used. Correct Answer: 4. Pull the skin 1-1 1/2" (2.5-3.5 cm)
laterally and away from the injection site.
3. Hold the skin taut with non-dominant hand and insert needle at a 90-degree angle.
2. Inject medication slowly with dominant hand while maintaining traction
6. Wait 10 seconds after injecting the medication and withdraw the needle.
Release the hold on the skin, allowing the layers to slide back to their original position.
1. Apply gentle pressure at the injection site but do not massage.
The clinic nurse is teaching a client about levothyroxine, which the health care provider has prescribed
for newly diagnosed hypothyroidism. Which statement made by the client indicates that further
teaching is needed? Correct Answer: "If this makes my stomach upset, I will take it with an antacid."
- will impair the absorption of levothyroxine (Synthroid). -- Antacids, calcium and iron preparations.
- should take levothyroxine on an empty stomach, preferably in the morning, separately from other
medications
The nurse is reviewing laboratory results for several prenatal clients. Which finding is most important to
report to the health care provider? Correct Answer: Client at 24 weeks gestation with hemoglobin of 9
g/dL (90 g/L) and hematocrit of 29%
- during the second half of pregnancy, the fetus beings to store iron, depleting maternal stores.
Hemoglobin <11 g/dL in the first or third trimester or <10.5 g/dL in the second trimester is considered
low.
A client with obesity has just started taking orlistat. Which statement by the client indicates a need for
further teaching? Correct Answer: "I have started taking a daily multivitamin with my dinner-time dose
of medication."
- Orlistat is a lipase inhibitor that prevents the breakdown and absorption of fats from the intestine -
interferes with fat-soluble vitamin uptake
The nurse on the medical-surgical unit receives report on assigned clients. Which client warrants
immediate attention? Correct Answer: Client with epigastric pain after endoscopic retrograde
cholangiopancreatography.
- Perforation or irritation of these areas during the procedure can cause acute pancreatitis, a potentially
life-threatening complication after an ERCP: s/s - acute epigastric or left upper quadrant pain, often
radiating to the back, and a rapid rise in pancreatic enzymes (amylase. lipase)
The home health care nurse reviews the laboratory results for 4 clients. Which laboratory value is most
important for the nurse to report to the health care provider? Correct Answer: Client with rheumatoid
arthritis taking adalimumab has a WBC count of 14,000/mm3
Which emergency department client would be allowed to leave against medical advice after the risks are
discussed with the primary health care provider? Correct Answer: Client with coffee-ground emesis
from chronic use of high-dose aspirin.
- Issues that can make a client ineligible to leave AMA include danger to self or others, lack of
consciousness, altered consciousness, mental illness, being under chemical influence, or a court
decision. Parents may not refuse life-, limb-, or organ- saving treatment on behalf of their minor child for
