NURS NCLEX 1111 EXAM QUESTIONS,ANSWERS WITH
RATIONALE
The nurse is working in the emergency room when a client arrives with severe burns
of the left arm, hands, face, and neck. Which action should receive priority?
A. Starting an IV
B. Applying oxygen
C. Obtaining blood gases
D. Medicating the client for pain
Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen,
so applying oxygen is the priority. The next action should be to start an IV and medicate for
pain, making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the
doctor.
The nurse is visiting a home health client with osteoporosis. The client has a
new prescription for alendronate (Fosamax). Which instruction should be given to the
client?
A. Rest in bed after taking the medication for at least 30 minutes
B. Avoid rapid movements after taking the medication
C. Take the medication with water only
D. Allow at least 1 hour between taking the medicine and taking other medications
Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen,
so applying oxygen is the priority. The next action should be to start an IV and medicate for
pain, making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the
doctor.
The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs.
Which equipment should be kept at the bedside?
A. A pair of forceps
,NURS NCLEX 1111 EXAM QUESTIONS,ANSWERS WITH
RATIONALE
B. A torque wrench
C. A pair of wire cutters
D. A screwdriver
Answer B: A torque wrench is kept at the bedside to tighten and loosen the screws of crutchfield
tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of
forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus,
are incorrect.
An infant weighs 7 pounds at birth. The expected weight by 1 year should
be:
A. 10 pounds
B. 12 pounds
C. 18 pounds
D. 21 pounds
Answer D: A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth
weight. Answers A, B, and C therefore are incorrect.
A client is admitted with a Ewing’s sarcoma. Which symptoms would be expected due
to this tumor’s location?
A. Hemiplegia
B. Aphasia
C. Nausea
D. Bone pain
Answer D: Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers
A, B, and C are not specific to this type of cancer and are incorrect.
,NURS NCLEX 1111 EXAM QUESTIONS,ANSWERS WITH
RATIONALE
The nurse is caring for a client with epilepsy who is being treated with carbamazepine
(Tegretol). Which laboratory value might indicate a serious side effect of this drug?
A. Uric acid of 5mg/dL
B. Hematocrit of 33%
C. WBC 2,000 per cubic millimeter
D. Platelets 150,000 per cubic millimeter
Answer C: Tegretol can suppress the bone marrow and decrease the white blood cell count; thus,
a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and
D are within normal limits, and answer B is a lower limit of normal; therefore, answers A, B,
and D are incorrect.
A 6-month-old client is admitted with possible intussuception. Which question during the
nursing history is least helpful in obtaining information regarding this diagnosis?
A. “Tell me about his pain.”
B. “What does his vomit look like?”
C. “Describe his usual diet.”
D. “Have you noticed changes in his abdominal size?”
Answer C: The least-helpful questions are those describing his usual diet. A, B, and D are useful
in determining the extent of disease process and, thus, are incorrect.
The nurse is assisting a client with diverticulosis to select appropriate foods. Which
food should be avoided?
A. Bran
B. Fresh peaches
C. Cucumber salad
D. Yeast rolls
, NURS NCLEX 1111 EXAM QUESTIONS,ANSWERS WITH
RATIONALE
Answer C: The client with diverticulitis should avoid foods with seeds. The foods in answers A,
B, and D are allowed; in fact, bran cereal and fruit will help prevent constipation.
A client has rectal cancer and is scheduled for an abdominal perineal resection. What
should be the priority nursing care during the post-op period?
A. Teaching how to irrigate the illeostomy
B. Stopping electrolyte loss in the incisional area
C. Encouraging a high-fiber diet
D. Facilitating perineal wound drainage
Answer D: The client with a perineal resection will have a perineal incision. Drains will be used
to facilitate wound drainage. This will help prevent infection of the surgical site. The client will
not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not
focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not
ordered at this time.
The nurse is performing discharge teaching on a client with diverticulitis who has been
placed on a low-roughage diet. Which food would have to be eliminated from this client’s
diet?
A. Roasted chicken
B. Noodles
C. Cooked broccoli
D. Custard
Answer C: The client with diverticulitis should avoid eating foods that are
gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as
those listed in answers A, B, and D are allowed.
RATIONALE
The nurse is working in the emergency room when a client arrives with severe burns
of the left arm, hands, face, and neck. Which action should receive priority?
A. Starting an IV
B. Applying oxygen
C. Obtaining blood gases
D. Medicating the client for pain
Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen,
so applying oxygen is the priority. The next action should be to start an IV and medicate for
pain, making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the
doctor.
The nurse is visiting a home health client with osteoporosis. The client has a
new prescription for alendronate (Fosamax). Which instruction should be given to the
client?
A. Rest in bed after taking the medication for at least 30 minutes
B. Avoid rapid movements after taking the medication
C. Take the medication with water only
D. Allow at least 1 hour between taking the medicine and taking other medications
Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen,
so applying oxygen is the priority. The next action should be to start an IV and medicate for
pain, making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the
doctor.
The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs.
Which equipment should be kept at the bedside?
A. A pair of forceps
,NURS NCLEX 1111 EXAM QUESTIONS,ANSWERS WITH
RATIONALE
B. A torque wrench
C. A pair of wire cutters
D. A screwdriver
Answer B: A torque wrench is kept at the bedside to tighten and loosen the screws of crutchfield
tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of
forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus,
are incorrect.
An infant weighs 7 pounds at birth. The expected weight by 1 year should
be:
A. 10 pounds
B. 12 pounds
C. 18 pounds
D. 21 pounds
Answer D: A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth
weight. Answers A, B, and C therefore are incorrect.
A client is admitted with a Ewing’s sarcoma. Which symptoms would be expected due
to this tumor’s location?
A. Hemiplegia
B. Aphasia
C. Nausea
D. Bone pain
Answer D: Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers
A, B, and C are not specific to this type of cancer and are incorrect.
,NURS NCLEX 1111 EXAM QUESTIONS,ANSWERS WITH
RATIONALE
The nurse is caring for a client with epilepsy who is being treated with carbamazepine
(Tegretol). Which laboratory value might indicate a serious side effect of this drug?
A. Uric acid of 5mg/dL
B. Hematocrit of 33%
C. WBC 2,000 per cubic millimeter
D. Platelets 150,000 per cubic millimeter
Answer C: Tegretol can suppress the bone marrow and decrease the white blood cell count; thus,
a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and
D are within normal limits, and answer B is a lower limit of normal; therefore, answers A, B,
and D are incorrect.
A 6-month-old client is admitted with possible intussuception. Which question during the
nursing history is least helpful in obtaining information regarding this diagnosis?
A. “Tell me about his pain.”
B. “What does his vomit look like?”
C. “Describe his usual diet.”
D. “Have you noticed changes in his abdominal size?”
Answer C: The least-helpful questions are those describing his usual diet. A, B, and D are useful
in determining the extent of disease process and, thus, are incorrect.
The nurse is assisting a client with diverticulosis to select appropriate foods. Which
food should be avoided?
A. Bran
B. Fresh peaches
C. Cucumber salad
D. Yeast rolls
, NURS NCLEX 1111 EXAM QUESTIONS,ANSWERS WITH
RATIONALE
Answer C: The client with diverticulitis should avoid foods with seeds. The foods in answers A,
B, and D are allowed; in fact, bran cereal and fruit will help prevent constipation.
A client has rectal cancer and is scheduled for an abdominal perineal resection. What
should be the priority nursing care during the post-op period?
A. Teaching how to irrigate the illeostomy
B. Stopping electrolyte loss in the incisional area
C. Encouraging a high-fiber diet
D. Facilitating perineal wound drainage
Answer D: The client with a perineal resection will have a perineal incision. Drains will be used
to facilitate wound drainage. This will help prevent infection of the surgical site. The client will
not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not
focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not
ordered at this time.
The nurse is performing discharge teaching on a client with diverticulitis who has been
placed on a low-roughage diet. Which food would have to be eliminated from this client’s
diet?
A. Roasted chicken
B. Noodles
C. Cooked broccoli
D. Custard
Answer C: The client with diverticulitis should avoid eating foods that are
gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as
those listed in answers A, B, and D are allowed.
