NCLEX PRACTICE EXAM WITH COMPLETE QUESTIONS AND ANSWERS
GUARANTEED SUCCESS 2022 UPDATE
1. The nurse know that which statement by the mother indicates that Leave the order for the oncoming staff to follow-up
the mother understands safety precautions with her four month-old Contact the charge nurse for an interpretation
infant and her 4 year-old child? Ask the pharmacy for assistance in the interpretation
A) "I strap the infant car seat on the front seat to face backwards."
Call the provider for clarification
"I place my infant in the middle of the living room floor on a Review Information: The correct answer is D: Call the provider for clarification
B) blanket to play with my 4 year old while I make supper in the Relying on anyone else''s interpretation is very risky. When in doubt, check it out
kitchen." with the person who wrote the illegible order. Order entry systems help to
"My sleeping baby lies so cute in the crib with the little buttocks minimize this problem.
C)
stuck up in the air while the four year old naps on the sofa."
"I have the 4 year-old hold and help feed the four month-old a 7. An adult client is found to be unresponsive on morning rounds. After checking
D)
bottle in the kitchen while I make supper." for responsiveness and calling for help, the next action that should be taken by
Review Information: The correct answer is D: "I have the four the nurse is to:
year-old hold and help feed the four month-old a bottle in the kitchen A) check the cartoid pulse
while I make supper." The infant seat is to be placed on the rear seat. B) deliver 5 abdominal thrusts
Small children and infants are not to be left unsupervised. Infants are C) give 2 rescue breaths
to be placed on their "back when they go back" to sleep or are lying in
D) open the client's airway
a crib. A 4 year-old could assist with the care of an infant with proper
Review Information: The correct answer is D: open the client''s airway
supervision. This enhances bonding with the infant and the
According to the ABCs of CPR the first step in rescuing an unresponsive victim
developmental needs of the preschooler to "help" and not feel left out.
after checking responsiveness and calling for help is to open the victims airway.
2. Upon completing the admission documents, the nurse learns that The airway must be opened appropriately before the need for rescue breaths cane
the 87 year-old client does not have an advance directive. What action determined. The pulse is assessed, after breathing is evaluated. The need for
should the nurse take? abdominal thrusts is determined by inability to achieve chest rise when ventilation
is attempted.
A) Record the information on the chart
B) Give information about advance directives 8. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse
C) Assume that this client wishes a full code discovers that 800 ml has been infused after 4 hours. What is the priority
D) Refer this issue to the unit secretary nursing action?
Review Information: The correct answer is B: Give information A) Ask the client if there are any breathing problems
about advance directives B) Have the client void as much as possible
For each admission, nurses should request a copy of the current C) Check the vital signs
advance directive. If there is none, the nurse must offer information
D) Ausculate the lungs
about what an advance directive implies. It is then the client’s choice Review Information: The correct answer is D: Ausculate the lungs
to sign it. In option 1 just recording the information is not sufficient. All of the options would be part of the evaluation for the effects of the large
In option 3 the nurse should not assume that the client has been amount of fluid in a short period of time. However the worst result is heart failure
informed of choices for emergency care. In option 4 this represents an with lung congestion so the auscultation of the lungs is the priority action. The
inappropriate delegation approach. sequence of actions would be 4 1 3 2.
3. A nurse administers the influenza vaccine to a client in a clinic.
9. Following change-of-shift report on an orthopedic unit, which client should the
Within 15 minutes after the immunization was given, the client
nurse see first?
complains of itchy and watery eyes, increased anxiety, and difficulty
breathing. The nurse expects that the first action in the sequence of 16 year-old who had an open reduction of a fractured wrist 10 hours
care for this client will be to ago
A) Maintain the airway 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
B) Administer epinephrine 1:1000 as ordered 72 year-old recovering from surgery after a hip replacement 2 hours
C) Monitor for hypotension with shock ago
D) Administer diphenhydramine as ordered 75 year-old who is in skin traction prior to planned hip pinning surgery.
Review Information: The correct answer is B: Administer Review Information: The correct answer is C: 72 year-old recovering from
epinephrine 1:1000 as ordered .All the answers are correct given the surgery after a hip replacement 2 hours ago
circumstances. The correct sequence of care is to administer the Look for the client who is in the least stable condition. The client who returned
epinephrine, then maintain airway. In the early stages of anaphylaxis, from surgery 2 hours ago is at risk for hemorrhage and should be seen first. The
when the patient has not lost consciousness and is normatensive, 16 year-old should be seen next because it is still the first post-op day. The 75
administering the epinephrine and then applying the oxygen, watching year-old in skin traction should be seen next. The client who can safely be seen
for hypotension and shock are later responses. The prevention of a last is the 20 year-old who is 2 weeks post-injury.
severe crisis is maintained by using diphenhydramine.
10. A nurse observes a family member administer a rectal suppository by having
4. Which of these children at the site of a disaster at a child day care the client lie on the left side for the administration. The family member pushed
center would the triage nurse put in the "treat last" category? the suppository until the finger went up to the second knuckle. After 10 minutes
the client was told by the family member to turn to the right side and the client
did this. What is the appropriate comment for the nurse to make?
Why don’t we now have the client turn back to the left side.
That was done correctly. Did you have any problems with the
insertion?
Let’s check to see if the suppository is in far enough.
Did you feel any stool in the intestinal tract?
,An infant with intermittent buldging anterior fontonel between crying
episodes
NCLEX PRACTICE EXAM WITH COMPLETE QUESTIONS AND ANSWERS
A toddler with severe deep abrasions over 98% of the body
A preschooler with 1 lower leg fracture and the other leg with an upper
leg fracture GUARANTEED SUCCESS 2022 UPDATE
A school-age child with singed eyebrows and hair on the arms
Review Information: The correct answer is B: A toddler with severe
deep abrasions over 98% of the body .This child has the least chance Review Information: The correct answer is B: That was done correctly. Did you
of survival. Severe deep abrasions are to be thought of as second and have any problems with the insertion?
third degree burns. The child has great risk of shock and infection Left side-lying position is the optimal position for the client receiving rectal
combined. medications. Due to the position of the descending colon, left side-lying allows the
medication to be inserted and move along the natural curve of the intestine and
5. When admitting a client to an acute care facility, an identification facilitates retention of the medication. After a short time it will not hurt the client
bracelet is sent up with the admission form. In the event these do not to turn in any manner. The suppository should be somewhat melted after 10 to 15
match, the nurse’s best action is to minutes. The other responses are incorrect since no data is in the stem to support
such comments.
change whichever item is incorrect to the correct information
use the bracelet and admission form until a replacement is supplied 11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA)
notify the admissions office and wait to apply the bracelet has died. Which type of precautions is the appropriate type to use when
make a corrected identification bracelet for the client performing postmortem care?
Review Information: The correct answer is C: notify the admissions A) airborne precautions
office and wait to apply the bracelet B) droplet precautions
The Admissions Office has the responsibility to verify the client’s C) contact precautions
identity and keep all the records in the system consistent. Making the
D) compromised host precautions
changes puts the client at risk for misidentification. Using an incorrect
identification bracelet is unsafe. Making a new bracelet on the unit is Review Information: The correct answer is C: contact precautions
not appropriate. The resistant bacteria remain alive for up to 3 days post death. Therefore, contact
precautions must still be implemented. Also label the body so that the funeral
6. The nurse is having difficulty reading the health care provider's home staff can protect themselves as well. Gown and gloves are required.
written order that was written right before the shift change.
Whataction should be taken? 12. The nurse is reviewing with a client how to collect a clean catch urine
specimen. Which sequence is appropriate teaching?
A) Void a little, clean the meatus, then collect specimen
B) clean the meatus, begin voiding, then catch urine stream
C) Clean the meatus, then urinate into container
D) Void continuously and catch some of the urine
Review Information: The correct answer is B: clean the meatus, begin voiding, then
catch urine stream
A clean catch urine is difficult to obtain and requires clear directions. Instructing the
client to carefully clean the meatus, then void naturallywith a steady stream prevents
surface bacteria from contaminating the urine specimen. As starting and stopping
flow can be difficult, once the client begins voiding it''s best to just slip the container
into the stream. Other responses are not correct technique.
13. The provider orders Lanoxin (digoxin) 0.125 mg po and furosomide 40 mg
every day. Which of these foods would the nursereinforce for the client to eat at
least daily?
A) spaghetti
B) watermelon
C) chicken
D) tomatoes
Review Information: The correct answer is B: watermelon Watermelon is high in
potassium and will replace any potassium lostby the diuretic. The other foods are not
high in potassium.
14. A nurse is stuck in the hand by an exposed needle. Whatimmediate
action should the nurse take?
A) Look up the policy on needle sticks
B) Contact employee health services
C) Immediately wash the hands with vigor
D) Notify the supervisor and risk management
,NCLEX PRACTICE EXAM WITH COMPLETE QUESTIONS AND ANSWERS
GUARANTEED SUCCESS 2022 UPDATE
An elderly client who had a myocardial infarction a week ago - history and physical assessment?
UAP A)
ReviewIncreased temperature
Information: Theand lethargy
correct answer is A: An admission at the change ofshifts with
The care for a new admissions should be performed by an RN. B) Restlessness and increased mucus production
Since the client was admitted at the change of shifts, the C) Increased sleeping and listlessness
stability of the client would not have been established. The D) Diarrhea and poor skin turgor
charge nurse should take this client. The PN could monitorthe IV Review Information: The correct answer is B: Restlessness and increased
fluids in option C. Tasks that do not require independent judgment mucus production
should be delegated. The nurse may delegate the care for a This infant could be experiencing gastroesophageal reflux, or could be allergic to
stable client to a UAP. the formula. Restlessness, irritability and increased mucus production can develop
if an allergy is present. Soy based formula is often recommended.
19. A mother brings her 3 month-old into the clinic, complaining
that the child seems to be spitting up all the time and has a lot of 20. As the nurse takes a history of a 3 year-old with neuroblastoma, what
gas. The nurse expects to findwhich of the following on the initial comments by the parents require follow-up and are consistent with the diagnosis?
A) "The child has been listless and has lost weight."
B) "The urine is dark yellow and small in amounts."
Review
C) Information:
"Clothes The correct
are becoming tighter acrossanswer is C: "Clothes are becoming tighter
her abdomen."
across
D) "Weher abdomen."
notice muscle weakness and some unsteadiness."
One of the most common signs of neuroblastoma is increased abdominal girth.
Review Information: The correct answer is C: Immediately wash
The parents'' report that clothing is tight is significant, and should be followed by
the hands with vigor
additional assessments.
The immediate action of vigorously washing will help remove possible
contamination. Then the sequence would then be options 4, 1, 2.
21. A 16 year-old enters the emergency department. The triage nurse identifies
that this teenager is legally married and signs the consent form for treatment.
15. As the nurse observes the student nurse during the administration
What would be the appropriate action by the nurse?
of a narcotic analgesic IM injection, the nurse notes that the student
begins to give the medication without first aspirating. What should the Ask the teenager to wait until a parent or legal guardian can be
nurse do? contacted
A) Ask the student: "What did you forget to do?” Withhold treatment until telephone consent can be obtained from the
partner
B) Stop. Tell me why aspiration is needed.
Refer the teenager to a community pediatric hospital emergency
C) Loudly state: “You forgot to aspirate.”
department
Walk up and whisper in the student’s ear “Stop. Aspirate. Then
D) Proceed with the triage process in the same manner as any adult client
inject.”
Review Information: The correct answer is D: Proceed with the triage process
Review Information: The correct answer is D: Walk up and whisper
in the same manner as any adult client
in the student’s ear “Stop. Aspirate. Then inject.”
Minors may become known as an "emancipated minor" through marriage,
This action is a direct threat to the client if the medication enters into
pregnancy, high school graduation, independent living or service in the military.
the blood stream instead of the muscle. The purpose of aspiration
Therefore, this client, who is married, has the legal capacity of an adult.
with IM injections is to prevent the injection of the drug directly into
the blood stream. Option 4 protects the client and is the most
22. A newly admitted elderly client is severely dehydrated. When planning care for
professional.
this client, which task is appropriate to assign to an unlicensed assistive personnel
(UAP)?
16. A client with Guillain Barre is in a nonresponsive state, yet vital
signs are stable and breathing is independent. What should the nurse Converse with the client to determine if the mucuous membranes are
document to most accurately describe the client's condition? impaired
A) Comatose, breathing unlabored Report hourly outputs of less than 30 ml/hr
B) Glascow Coma Scale 8, respirations regular Monitor client's ability for movement in the bed
C) Appears to be sleeping, vital signs stable Check skin turgor every 4 hours
D) Glascow Coma Scale 13, no ventilator required Review Information: The correct answer is B: Report output of less than 30
ml/hr
Review Information: The correct answer is B: Glascow Coma Scale
When directing a UAP, the nurse must communicate clearly about each delegated
8, respirations regular
task with specific instructions on what must be reported. Because the RN is
The Glascow Coma Scale provides a standard reference for assessing
responsible for all care-related decisions, only implementation tasks should be
or monitoring level of consciousness. Any score less than 13 indicates
assigned because they do not require independent judgment.
a neurological impairment. Using the term comatose provides too
much room for interpretation and is not very precise.
23. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic
fever. Which statement by the parent would cause the nurse to suspect an
17. A client enters the emergency department unconscious via
association with this disease?
ambulance from the client’s work place. What document should be
given priority to guide the direction of care for this client? Our child had chickenpox 6 months ago.
Strep throat went through all the children at the day care last month.
Both ears were infected over 3 months age.
Last week both feet had a fungal skin infection.
, NCLEX PRACTICE EXAM WITH COMPLETE QUESTIONS AND ANSWERS
The statement of client rights and the client self determination act
GUARANTEED SUCCESS 2022 UPDATE
Orders written by the health care provider
A notarized original of advance directives brought in by the partner
The clinical pathway protocol of the agency and the emergency
department
Review Information: The correct answer is C: A notarized originalof advance directives brought in by the partner
This document specifies the client''s wishes.
18. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Whichassignment should be
questioned by the nurse manager?
Review Information: The correct answer is B: Strep throat went through all the children at the day care last month.
An admission at the change of shifts with atrial fibrillation and heart
Evidence supports a strong relationship between infection with Group A streptococci and subsequent rheumatic fever (usually within 2 to 6 weeks).
failure - PN
Therefore, the history of playmates recovering from strep throat would indicatethat the child diagnosed with rheumatic fever most likely also had strep throat.
Client who had
Sometimes, a major
such stroke 6has
an infection days
no ago - PNsymptoms.
clinical nursing student
A child with burns who has packed cells and albumin IV running -
charge nurseassigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the
24. A nurse
nurseshould be to
Discuss the feeling of reluctance with an objective peer or supervisor
Limit contacts with the client to avoid reinforcement of the
manipulative behavior
Confront the client about the negative effects of behaviors on other 30. Which statement best describes time management strategies applied to the
clients and staff role of a nurse manager?
Develop a behavior modification plan that will promote more functional A) Schedule staff efficiently to cover the needs on the managed unit
behavior B) Assume a fair share of direct client care as a role model
Review Information: The correct answer is A: Discuss the feeling C) Set daily goals with a prioritization of the work
of reluctance with an objective peer or supervisor Delegate tasks to reduce work load associated with direct care and
The nurse who experiences stress in the therapeutic relationship can D)
meetings
gain objectivity through supervision. The nurse must attempt to Review Information: The correct answer is C: Set daily goals with a
discover attitudes and feelings in the self that influence the nurse- prioritization of the work
client relationship. Time management strategies include setting goals and prioritization . This is
similar to time management of direct care for clients
25. A client is being treated for paranoid schizophrenia. When the
client became loud and boisterous, the nurse immediately placed him 31. The pediatric clinic nurse examines a toddler with a tentative diagnosis of
in seclusion as a precautionary measure. The client willingly complied. neuroblastoma. Findings observed by the nurse that is associated with this
The nurse’s action problem include which of these?
A) May result in charges of unlawful seclusion and restraint A) Lymphedema and nerve palsy
B) Leaves the nurse vulnerable for charges of assault and battery B) Hearing loss and ataxia
C) Was appropriate in view of the client’s history of violence C) Headaches and vomiting
D) Was necessary to maintain the therapeutic milieu of the unit D) Abdominal mass and weakness
Review Information: The correct answer is A: May result in Review Information: The correct answer is D: Abdominal mass and weakness
charges of unlawful seclusion and restraint Clinical manifestations of neuroblastoma include an irregular abdominal mass that
Seclusion should only be used when there is an immediate threat of crosses the midline, weakness, pallor, anorexia, weight loss and irritability.
violence or threatening behavior to the staff, the other clients, or the
client upon himself. 32. A 15 year-old client has been placed in a Milwaukee Brace. Which statement
from the adolescent indicates the need for additional teaching?
26. A client has been admitted to the Coronary Care Unit with a A) "I will only have to wear this for 6 months."
myocardial infarction. Which nursing diagnosis should have priority?
B) "I should inspect my skin daily."
A) Pain related to ischemia
C) "The brace will be worn day and night."
B) Risk for altered elimination: constipation
D) "I can take it off when I shower."
C) Risk for complication: dysrhythmias
Review Information: The correct answer is A: "I will only have to wear this for
D) Anxiety related to pain 6 months."
Review Information: The correct answer is A: Pain related to The brace must be worn long-term, during periods of growth, usually for 1 to 2
ischemia years. It is used to correct curvature of the spine.
Pain is related to ischemia, and relief of pain will decrease myocardial
oxygen demands, reduce blood pressure and heart rate and relieve 33. The nurse manager has been using a decentralized block scheduling plan to
anxiety. Pain also stimulates the sympathetic nervous system and staff the nursing unit. However, staff have asked for many changes and
increased preload, further increasing myocardial demands. exceptions to the schedule over the past few months. The manager considers self-
scheduling knowing that this method will
27. The provisions of the law for the Americans with Disabilities Act A) Improve the quality of care
require nurse managers to
B) Decrease staff turnover
A) Maintain an environment free from associated hazards
C) Minimize the amount of overtime payouts
B) Provide reasonable accommodations for disabled individuals
D) Improve team morale
C) Make all necessary accommodations for disabled individuals A) "I have problems with diarrhea."
D) Consider both mental and physical disabilities B) "I have difficulty falling asleep."
Review Information: The correct answer is B: Provide reasonable C) "I have diminished sexual function."
accommodations for disabled individuals D) "I often feel jittery."
The law is designed to permit persons with disabilities access to job Review Information: The correct answer is C: "I have diminished sexual function."
opportunities. Employers must evaluate an applicant’s ability to Inderal, beta-blocking agent used in hypertension, prohibits the release of
perform the job and not discriminate on the basis of a disability. epinephrine into the cells; this may result in hypotensionwhich results in decreased
Employers also must make "reasonable accommodations." libido and impotence.
28. A 42 year-old male client refuses to take propranolol hydrochloride 29. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4
(Inderal) as prescribed. Which client statement s from the assessment hours ago. Which statement from the mother indicates that teaching has been
data is likely to explain his noncompliance? inadequate?
GUARANTEED SUCCESS 2022 UPDATE
1. The nurse know that which statement by the mother indicates that Leave the order for the oncoming staff to follow-up
the mother understands safety precautions with her four month-old Contact the charge nurse for an interpretation
infant and her 4 year-old child? Ask the pharmacy for assistance in the interpretation
A) "I strap the infant car seat on the front seat to face backwards."
Call the provider for clarification
"I place my infant in the middle of the living room floor on a Review Information: The correct answer is D: Call the provider for clarification
B) blanket to play with my 4 year old while I make supper in the Relying on anyone else''s interpretation is very risky. When in doubt, check it out
kitchen." with the person who wrote the illegible order. Order entry systems help to
"My sleeping baby lies so cute in the crib with the little buttocks minimize this problem.
C)
stuck up in the air while the four year old naps on the sofa."
"I have the 4 year-old hold and help feed the four month-old a 7. An adult client is found to be unresponsive on morning rounds. After checking
D)
bottle in the kitchen while I make supper." for responsiveness and calling for help, the next action that should be taken by
Review Information: The correct answer is D: "I have the four the nurse is to:
year-old hold and help feed the four month-old a bottle in the kitchen A) check the cartoid pulse
while I make supper." The infant seat is to be placed on the rear seat. B) deliver 5 abdominal thrusts
Small children and infants are not to be left unsupervised. Infants are C) give 2 rescue breaths
to be placed on their "back when they go back" to sleep or are lying in
D) open the client's airway
a crib. A 4 year-old could assist with the care of an infant with proper
Review Information: The correct answer is D: open the client''s airway
supervision. This enhances bonding with the infant and the
According to the ABCs of CPR the first step in rescuing an unresponsive victim
developmental needs of the preschooler to "help" and not feel left out.
after checking responsiveness and calling for help is to open the victims airway.
2. Upon completing the admission documents, the nurse learns that The airway must be opened appropriately before the need for rescue breaths cane
the 87 year-old client does not have an advance directive. What action determined. The pulse is assessed, after breathing is evaluated. The need for
should the nurse take? abdominal thrusts is determined by inability to achieve chest rise when ventilation
is attempted.
A) Record the information on the chart
B) Give information about advance directives 8. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse
C) Assume that this client wishes a full code discovers that 800 ml has been infused after 4 hours. What is the priority
D) Refer this issue to the unit secretary nursing action?
Review Information: The correct answer is B: Give information A) Ask the client if there are any breathing problems
about advance directives B) Have the client void as much as possible
For each admission, nurses should request a copy of the current C) Check the vital signs
advance directive. If there is none, the nurse must offer information
D) Ausculate the lungs
about what an advance directive implies. It is then the client’s choice Review Information: The correct answer is D: Ausculate the lungs
to sign it. In option 1 just recording the information is not sufficient. All of the options would be part of the evaluation for the effects of the large
In option 3 the nurse should not assume that the client has been amount of fluid in a short period of time. However the worst result is heart failure
informed of choices for emergency care. In option 4 this represents an with lung congestion so the auscultation of the lungs is the priority action. The
inappropriate delegation approach. sequence of actions would be 4 1 3 2.
3. A nurse administers the influenza vaccine to a client in a clinic.
9. Following change-of-shift report on an orthopedic unit, which client should the
Within 15 minutes after the immunization was given, the client
nurse see first?
complains of itchy and watery eyes, increased anxiety, and difficulty
breathing. The nurse expects that the first action in the sequence of 16 year-old who had an open reduction of a fractured wrist 10 hours
care for this client will be to ago
A) Maintain the airway 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
B) Administer epinephrine 1:1000 as ordered 72 year-old recovering from surgery after a hip replacement 2 hours
C) Monitor for hypotension with shock ago
D) Administer diphenhydramine as ordered 75 year-old who is in skin traction prior to planned hip pinning surgery.
Review Information: The correct answer is B: Administer Review Information: The correct answer is C: 72 year-old recovering from
epinephrine 1:1000 as ordered .All the answers are correct given the surgery after a hip replacement 2 hours ago
circumstances. The correct sequence of care is to administer the Look for the client who is in the least stable condition. The client who returned
epinephrine, then maintain airway. In the early stages of anaphylaxis, from surgery 2 hours ago is at risk for hemorrhage and should be seen first. The
when the patient has not lost consciousness and is normatensive, 16 year-old should be seen next because it is still the first post-op day. The 75
administering the epinephrine and then applying the oxygen, watching year-old in skin traction should be seen next. The client who can safely be seen
for hypotension and shock are later responses. The prevention of a last is the 20 year-old who is 2 weeks post-injury.
severe crisis is maintained by using diphenhydramine.
10. A nurse observes a family member administer a rectal suppository by having
4. Which of these children at the site of a disaster at a child day care the client lie on the left side for the administration. The family member pushed
center would the triage nurse put in the "treat last" category? the suppository until the finger went up to the second knuckle. After 10 minutes
the client was told by the family member to turn to the right side and the client
did this. What is the appropriate comment for the nurse to make?
Why don’t we now have the client turn back to the left side.
That was done correctly. Did you have any problems with the
insertion?
Let’s check to see if the suppository is in far enough.
Did you feel any stool in the intestinal tract?
,An infant with intermittent buldging anterior fontonel between crying
episodes
NCLEX PRACTICE EXAM WITH COMPLETE QUESTIONS AND ANSWERS
A toddler with severe deep abrasions over 98% of the body
A preschooler with 1 lower leg fracture and the other leg with an upper
leg fracture GUARANTEED SUCCESS 2022 UPDATE
A school-age child with singed eyebrows and hair on the arms
Review Information: The correct answer is B: A toddler with severe
deep abrasions over 98% of the body .This child has the least chance Review Information: The correct answer is B: That was done correctly. Did you
of survival. Severe deep abrasions are to be thought of as second and have any problems with the insertion?
third degree burns. The child has great risk of shock and infection Left side-lying position is the optimal position for the client receiving rectal
combined. medications. Due to the position of the descending colon, left side-lying allows the
medication to be inserted and move along the natural curve of the intestine and
5. When admitting a client to an acute care facility, an identification facilitates retention of the medication. After a short time it will not hurt the client
bracelet is sent up with the admission form. In the event these do not to turn in any manner. The suppository should be somewhat melted after 10 to 15
match, the nurse’s best action is to minutes. The other responses are incorrect since no data is in the stem to support
such comments.
change whichever item is incorrect to the correct information
use the bracelet and admission form until a replacement is supplied 11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA)
notify the admissions office and wait to apply the bracelet has died. Which type of precautions is the appropriate type to use when
make a corrected identification bracelet for the client performing postmortem care?
Review Information: The correct answer is C: notify the admissions A) airborne precautions
office and wait to apply the bracelet B) droplet precautions
The Admissions Office has the responsibility to verify the client’s C) contact precautions
identity and keep all the records in the system consistent. Making the
D) compromised host precautions
changes puts the client at risk for misidentification. Using an incorrect
identification bracelet is unsafe. Making a new bracelet on the unit is Review Information: The correct answer is C: contact precautions
not appropriate. The resistant bacteria remain alive for up to 3 days post death. Therefore, contact
precautions must still be implemented. Also label the body so that the funeral
6. The nurse is having difficulty reading the health care provider's home staff can protect themselves as well. Gown and gloves are required.
written order that was written right before the shift change.
Whataction should be taken? 12. The nurse is reviewing with a client how to collect a clean catch urine
specimen. Which sequence is appropriate teaching?
A) Void a little, clean the meatus, then collect specimen
B) clean the meatus, begin voiding, then catch urine stream
C) Clean the meatus, then urinate into container
D) Void continuously and catch some of the urine
Review Information: The correct answer is B: clean the meatus, begin voiding, then
catch urine stream
A clean catch urine is difficult to obtain and requires clear directions. Instructing the
client to carefully clean the meatus, then void naturallywith a steady stream prevents
surface bacteria from contaminating the urine specimen. As starting and stopping
flow can be difficult, once the client begins voiding it''s best to just slip the container
into the stream. Other responses are not correct technique.
13. The provider orders Lanoxin (digoxin) 0.125 mg po and furosomide 40 mg
every day. Which of these foods would the nursereinforce for the client to eat at
least daily?
A) spaghetti
B) watermelon
C) chicken
D) tomatoes
Review Information: The correct answer is B: watermelon Watermelon is high in
potassium and will replace any potassium lostby the diuretic. The other foods are not
high in potassium.
14. A nurse is stuck in the hand by an exposed needle. Whatimmediate
action should the nurse take?
A) Look up the policy on needle sticks
B) Contact employee health services
C) Immediately wash the hands with vigor
D) Notify the supervisor and risk management
,NCLEX PRACTICE EXAM WITH COMPLETE QUESTIONS AND ANSWERS
GUARANTEED SUCCESS 2022 UPDATE
An elderly client who had a myocardial infarction a week ago - history and physical assessment?
UAP A)
ReviewIncreased temperature
Information: Theand lethargy
correct answer is A: An admission at the change ofshifts with
The care for a new admissions should be performed by an RN. B) Restlessness and increased mucus production
Since the client was admitted at the change of shifts, the C) Increased sleeping and listlessness
stability of the client would not have been established. The D) Diarrhea and poor skin turgor
charge nurse should take this client. The PN could monitorthe IV Review Information: The correct answer is B: Restlessness and increased
fluids in option C. Tasks that do not require independent judgment mucus production
should be delegated. The nurse may delegate the care for a This infant could be experiencing gastroesophageal reflux, or could be allergic to
stable client to a UAP. the formula. Restlessness, irritability and increased mucus production can develop
if an allergy is present. Soy based formula is often recommended.
19. A mother brings her 3 month-old into the clinic, complaining
that the child seems to be spitting up all the time and has a lot of 20. As the nurse takes a history of a 3 year-old with neuroblastoma, what
gas. The nurse expects to findwhich of the following on the initial comments by the parents require follow-up and are consistent with the diagnosis?
A) "The child has been listless and has lost weight."
B) "The urine is dark yellow and small in amounts."
Review
C) Information:
"Clothes The correct
are becoming tighter acrossanswer is C: "Clothes are becoming tighter
her abdomen."
across
D) "Weher abdomen."
notice muscle weakness and some unsteadiness."
One of the most common signs of neuroblastoma is increased abdominal girth.
Review Information: The correct answer is C: Immediately wash
The parents'' report that clothing is tight is significant, and should be followed by
the hands with vigor
additional assessments.
The immediate action of vigorously washing will help remove possible
contamination. Then the sequence would then be options 4, 1, 2.
21. A 16 year-old enters the emergency department. The triage nurse identifies
that this teenager is legally married and signs the consent form for treatment.
15. As the nurse observes the student nurse during the administration
What would be the appropriate action by the nurse?
of a narcotic analgesic IM injection, the nurse notes that the student
begins to give the medication without first aspirating. What should the Ask the teenager to wait until a parent or legal guardian can be
nurse do? contacted
A) Ask the student: "What did you forget to do?” Withhold treatment until telephone consent can be obtained from the
partner
B) Stop. Tell me why aspiration is needed.
Refer the teenager to a community pediatric hospital emergency
C) Loudly state: “You forgot to aspirate.”
department
Walk up and whisper in the student’s ear “Stop. Aspirate. Then
D) Proceed with the triage process in the same manner as any adult client
inject.”
Review Information: The correct answer is D: Proceed with the triage process
Review Information: The correct answer is D: Walk up and whisper
in the same manner as any adult client
in the student’s ear “Stop. Aspirate. Then inject.”
Minors may become known as an "emancipated minor" through marriage,
This action is a direct threat to the client if the medication enters into
pregnancy, high school graduation, independent living or service in the military.
the blood stream instead of the muscle. The purpose of aspiration
Therefore, this client, who is married, has the legal capacity of an adult.
with IM injections is to prevent the injection of the drug directly into
the blood stream. Option 4 protects the client and is the most
22. A newly admitted elderly client is severely dehydrated. When planning care for
professional.
this client, which task is appropriate to assign to an unlicensed assistive personnel
(UAP)?
16. A client with Guillain Barre is in a nonresponsive state, yet vital
signs are stable and breathing is independent. What should the nurse Converse with the client to determine if the mucuous membranes are
document to most accurately describe the client's condition? impaired
A) Comatose, breathing unlabored Report hourly outputs of less than 30 ml/hr
B) Glascow Coma Scale 8, respirations regular Monitor client's ability for movement in the bed
C) Appears to be sleeping, vital signs stable Check skin turgor every 4 hours
D) Glascow Coma Scale 13, no ventilator required Review Information: The correct answer is B: Report output of less than 30
ml/hr
Review Information: The correct answer is B: Glascow Coma Scale
When directing a UAP, the nurse must communicate clearly about each delegated
8, respirations regular
task with specific instructions on what must be reported. Because the RN is
The Glascow Coma Scale provides a standard reference for assessing
responsible for all care-related decisions, only implementation tasks should be
or monitoring level of consciousness. Any score less than 13 indicates
assigned because they do not require independent judgment.
a neurological impairment. Using the term comatose provides too
much room for interpretation and is not very precise.
23. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic
fever. Which statement by the parent would cause the nurse to suspect an
17. A client enters the emergency department unconscious via
association with this disease?
ambulance from the client’s work place. What document should be
given priority to guide the direction of care for this client? Our child had chickenpox 6 months ago.
Strep throat went through all the children at the day care last month.
Both ears were infected over 3 months age.
Last week both feet had a fungal skin infection.
, NCLEX PRACTICE EXAM WITH COMPLETE QUESTIONS AND ANSWERS
The statement of client rights and the client self determination act
GUARANTEED SUCCESS 2022 UPDATE
Orders written by the health care provider
A notarized original of advance directives brought in by the partner
The clinical pathway protocol of the agency and the emergency
department
Review Information: The correct answer is C: A notarized originalof advance directives brought in by the partner
This document specifies the client''s wishes.
18. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Whichassignment should be
questioned by the nurse manager?
Review Information: The correct answer is B: Strep throat went through all the children at the day care last month.
An admission at the change of shifts with atrial fibrillation and heart
Evidence supports a strong relationship between infection with Group A streptococci and subsequent rheumatic fever (usually within 2 to 6 weeks).
failure - PN
Therefore, the history of playmates recovering from strep throat would indicatethat the child diagnosed with rheumatic fever most likely also had strep throat.
Client who had
Sometimes, a major
such stroke 6has
an infection days
no ago - PNsymptoms.
clinical nursing student
A child with burns who has packed cells and albumin IV running -
charge nurseassigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the
24. A nurse
nurseshould be to
Discuss the feeling of reluctance with an objective peer or supervisor
Limit contacts with the client to avoid reinforcement of the
manipulative behavior
Confront the client about the negative effects of behaviors on other 30. Which statement best describes time management strategies applied to the
clients and staff role of a nurse manager?
Develop a behavior modification plan that will promote more functional A) Schedule staff efficiently to cover the needs on the managed unit
behavior B) Assume a fair share of direct client care as a role model
Review Information: The correct answer is A: Discuss the feeling C) Set daily goals with a prioritization of the work
of reluctance with an objective peer or supervisor Delegate tasks to reduce work load associated with direct care and
The nurse who experiences stress in the therapeutic relationship can D)
meetings
gain objectivity through supervision. The nurse must attempt to Review Information: The correct answer is C: Set daily goals with a
discover attitudes and feelings in the self that influence the nurse- prioritization of the work
client relationship. Time management strategies include setting goals and prioritization . This is
similar to time management of direct care for clients
25. A client is being treated for paranoid schizophrenia. When the
client became loud and boisterous, the nurse immediately placed him 31. The pediatric clinic nurse examines a toddler with a tentative diagnosis of
in seclusion as a precautionary measure. The client willingly complied. neuroblastoma. Findings observed by the nurse that is associated with this
The nurse’s action problem include which of these?
A) May result in charges of unlawful seclusion and restraint A) Lymphedema and nerve palsy
B) Leaves the nurse vulnerable for charges of assault and battery B) Hearing loss and ataxia
C) Was appropriate in view of the client’s history of violence C) Headaches and vomiting
D) Was necessary to maintain the therapeutic milieu of the unit D) Abdominal mass and weakness
Review Information: The correct answer is A: May result in Review Information: The correct answer is D: Abdominal mass and weakness
charges of unlawful seclusion and restraint Clinical manifestations of neuroblastoma include an irregular abdominal mass that
Seclusion should only be used when there is an immediate threat of crosses the midline, weakness, pallor, anorexia, weight loss and irritability.
violence or threatening behavior to the staff, the other clients, or the
client upon himself. 32. A 15 year-old client has been placed in a Milwaukee Brace. Which statement
from the adolescent indicates the need for additional teaching?
26. A client has been admitted to the Coronary Care Unit with a A) "I will only have to wear this for 6 months."
myocardial infarction. Which nursing diagnosis should have priority?
B) "I should inspect my skin daily."
A) Pain related to ischemia
C) "The brace will be worn day and night."
B) Risk for altered elimination: constipation
D) "I can take it off when I shower."
C) Risk for complication: dysrhythmias
Review Information: The correct answer is A: "I will only have to wear this for
D) Anxiety related to pain 6 months."
Review Information: The correct answer is A: Pain related to The brace must be worn long-term, during periods of growth, usually for 1 to 2
ischemia years. It is used to correct curvature of the spine.
Pain is related to ischemia, and relief of pain will decrease myocardial
oxygen demands, reduce blood pressure and heart rate and relieve 33. The nurse manager has been using a decentralized block scheduling plan to
anxiety. Pain also stimulates the sympathetic nervous system and staff the nursing unit. However, staff have asked for many changes and
increased preload, further increasing myocardial demands. exceptions to the schedule over the past few months. The manager considers self-
scheduling knowing that this method will
27. The provisions of the law for the Americans with Disabilities Act A) Improve the quality of care
require nurse managers to
B) Decrease staff turnover
A) Maintain an environment free from associated hazards
C) Minimize the amount of overtime payouts
B) Provide reasonable accommodations for disabled individuals
D) Improve team morale
C) Make all necessary accommodations for disabled individuals A) "I have problems with diarrhea."
D) Consider both mental and physical disabilities B) "I have difficulty falling asleep."
Review Information: The correct answer is B: Provide reasonable C) "I have diminished sexual function."
accommodations for disabled individuals D) "I often feel jittery."
The law is designed to permit persons with disabilities access to job Review Information: The correct answer is C: "I have diminished sexual function."
opportunities. Employers must evaluate an applicant’s ability to Inderal, beta-blocking agent used in hypertension, prohibits the release of
perform the job and not discriminate on the basis of a disability. epinephrine into the cells; this may result in hypotensionwhich results in decreased
Employers also must make "reasonable accommodations." libido and impotence.
28. A 42 year-old male client refuses to take propranolol hydrochloride 29. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4
(Inderal) as prescribed. Which client statement s from the assessment hours ago. Which statement from the mother indicates that teaching has been
data is likely to explain his noncompliance? inadequate?
