NCLEX-RN Practice Set and Lab Values 2022/2023
Correct: 3
1. A client is admitted to the emergency de-
Rationale: Time is of the
partment (ED). The family reports the client
essence when providing
had a sudden onset of left-sided facial droop
care to a client who expe-
and slurred speech at home. The nurse ob-
riences ischemic stroke, as
serves left-sided muscle weakness. Which is
thrombolytic therapy is only
the most important question for the nurse to
effective for 4.5 to 6 hours
ask?
from onset of sx. This is the
1. "What over-the-counter medications does priority assessment ques-
your parent take?" tion as thrombolytic thera-
2. "What was your parent doing when the py can restore circulation
symptoms began?" for this client.
3. "When did you notice the onset of your
2:A hemorrhagic stroke
parent's symptoms?"
may be precipitated by
4. "Does your parent have a history of high
strenous activity. This
blood pressure?"
question is important to
differentiate whether the
client is experiencing a
hemorrhagic or ischemic
stroke but not the priority.
4: HTN or high blood pres-
sure is a common risk fac-
tor for all types of stroke. Al-
though this is an appropri-
ate assessment question,
it does not address the
here and now.
Correct: 3
2. The nurse meets with the parent of an adoles-
Rationale: Adolescent
cent male who presents for an annual health
males experience a rapid
maintenance visit. The parent voices concern
rate of physical growth,
that the child has recently become clumsy
which can cause clumsi-
and uncoordinated. Which response by the
, NCLEX-RN Practice Set and Lab Values 2022/2023
nurse is correct? ness and a lack of co-
ordination. This statement
1. "Your son might have attention deficit hy- is accurate and addresses
peractivity disorder." the parent's concern.
2. "I'll talk with the health care provider about
assessing for subtle motor dysfunction." 1,4: This is a false state-
3. "Your son's clumsiness is expected at this ment about clumsiness
age." and lack of coordination
4. "This may be an early sign of depression." in adolescent males, as
these manifestations are
not associated with at-
tention deficit hyperactiv-
ity disorder (ADHD) nor
depression. Therefore, this
response by the the nurse
is not correct.
2: Inappropriate for the
nurse tos uggest to HCP
the need to assess for sub-
tle motor dysfunction.
3. *The client diagnosed with chronic lympho- Correct: 3,4
cytic leukemia (CLL) is scheduled for a bone Rationale: A bone marrow
marrow aspiration and biopsy. The client biopsy can cause bleed-
says, "I am frightened. I have never had this ing and a pressure dress-
test before, and I don't know what to expect." ing is applied to reduce the
Which statements will the nurse include when risk of bleeding. Therefore,
responding to the client's concerns? (Select both are accurate and ap-
all that apply.) propriate for the nurse t o
include in teaching.
1. "We will move you to the operating room
where the test is always performed." 1: BMA/biopsy may be
2. "The bone in the front of your chest will be done in a client room or
used for the biopsy specimen." treatment room. OR is not
3. "A tight pressure dressing will be placed required.
over the test site after the procedure."
4. "You will not feel any discomfort as the 2: Sternum may be used for
local anesthetic is injected." BMA but not enough mar-
, NCLEX-RN Practice Set and Lab Values 2022/2023
5. "There is a risk of bleeding, so we will row available for biopsy.
monitor the test site frequently."
4: Client will feel some
stinging and discomfort
during bone marrow biop-
sy. This is false reassur-
ance.
4. *The LPN/LVN reporting to the nurse says, Correct: 2
"You may want to see the client recently diag- Rationale: MOST imp't to
nosed with pancreatic cancer. I am not sure determine client's percep-
how well things are going." The nurse enters tion of the health problem.
the room and finds the client sitting quiet- Open-ended statement.
ly, looking out the window. As the nurse ap-
proaches the client, the client does not look Strategy: need to address
at the nurse. Which is the most appropriate the problem and better to
response by the nurse? ask open-ended questions.
It is more imp't to deal with
1. "Sleep problems are common during times the here and now.
of stress. Have you had difficulty sleeping?"
2. "Tell me what you know about your diag-
nosis and the treatment you will receive."
3. "How would you describe your overall
health status up to this time of your life?"
4. "How have you handled any health prob-
lems you experienced in the past?"
5. *The nurse provides care for the client imme- Correct: 4
diately after arrival in the emergency depart- Rationale: When prioritiz-
ment (ED). Emergency personnel report that ing care for a client,
the client was involved in a head-on collision nurse uses the ABC's (air-
with immediate loss of consciousness. Which way, breathing, circulation).
is the first action taken by the nurse? Oxygen saturation levels
allow the nurse to monitor
, NCLEX-RN Practice Set and Lab Values 2022/2023
1. Determine Glasgow Coma Scale (GCS) the client's airway (priority).
score.
2. Assess bilateral blood pressure. 1: GCS is used to assess
3. Check bilateral pupillary response to light. ABC and neuro status for
4. Determine oxygen saturation levels. clients c head trauma. It is
appropriate but too broad
and will take longer.
2: Assessing BP is monitor-
ing for circulation. Howev-
er, airway is priority and in-
creases in arterial CO2 will
increase ICP.
3: Nurse assesses neuro
status (eg. PERRLA) after
ABC.
6. At a rehabilitation center for clients with Correct: 2
spinal cord injuries (SCIs), the nurse con- Rationale: This statement
ducts an orientation session for a group of provides the UAP c info
unlicensed assistive personnel (UAP). Which needed to provide care for
statement is most important for the nurse to a client c SCI. Therefore,
include? this isa priority when del-
egating tasks to the UAP
1. "The clients may appear angry at times." who provides client care.
2. "Obtain the client's permission before
touching the client." 1,3,4: MAY be true but
3. "Most clients arrive believing they will walk does not provide info re-
out of here." garding care for SCI pa-
4. "Personnel in this environment often need tients.
counseling."
7. *The home care nurse instructs a client diag- Correct: 3
nosed with multiple sclerosis (MS). The client Rationale: Verbal commu-
states, "I have poor concentration and diffi- nication often causes fa-
culty pronouncing words." The nurse notes tigue for MS clients. There-
that the client's speech is slow and slurred. fore, client is taught to
Which client statement indicates to the nurse make important points first
Correct: 3
1. A client is admitted to the emergency de-
Rationale: Time is of the
partment (ED). The family reports the client
essence when providing
had a sudden onset of left-sided facial droop
care to a client who expe-
and slurred speech at home. The nurse ob-
riences ischemic stroke, as
serves left-sided muscle weakness. Which is
thrombolytic therapy is only
the most important question for the nurse to
effective for 4.5 to 6 hours
ask?
from onset of sx. This is the
1. "What over-the-counter medications does priority assessment ques-
your parent take?" tion as thrombolytic thera-
2. "What was your parent doing when the py can restore circulation
symptoms began?" for this client.
3. "When did you notice the onset of your
2:A hemorrhagic stroke
parent's symptoms?"
may be precipitated by
4. "Does your parent have a history of high
strenous activity. This
blood pressure?"
question is important to
differentiate whether the
client is experiencing a
hemorrhagic or ischemic
stroke but not the priority.
4: HTN or high blood pres-
sure is a common risk fac-
tor for all types of stroke. Al-
though this is an appropri-
ate assessment question,
it does not address the
here and now.
Correct: 3
2. The nurse meets with the parent of an adoles-
Rationale: Adolescent
cent male who presents for an annual health
males experience a rapid
maintenance visit. The parent voices concern
rate of physical growth,
that the child has recently become clumsy
which can cause clumsi-
and uncoordinated. Which response by the
, NCLEX-RN Practice Set and Lab Values 2022/2023
nurse is correct? ness and a lack of co-
ordination. This statement
1. "Your son might have attention deficit hy- is accurate and addresses
peractivity disorder." the parent's concern.
2. "I'll talk with the health care provider about
assessing for subtle motor dysfunction." 1,4: This is a false state-
3. "Your son's clumsiness is expected at this ment about clumsiness
age." and lack of coordination
4. "This may be an early sign of depression." in adolescent males, as
these manifestations are
not associated with at-
tention deficit hyperactiv-
ity disorder (ADHD) nor
depression. Therefore, this
response by the the nurse
is not correct.
2: Inappropriate for the
nurse tos uggest to HCP
the need to assess for sub-
tle motor dysfunction.
3. *The client diagnosed with chronic lympho- Correct: 3,4
cytic leukemia (CLL) is scheduled for a bone Rationale: A bone marrow
marrow aspiration and biopsy. The client biopsy can cause bleed-
says, "I am frightened. I have never had this ing and a pressure dress-
test before, and I don't know what to expect." ing is applied to reduce the
Which statements will the nurse include when risk of bleeding. Therefore,
responding to the client's concerns? (Select both are accurate and ap-
all that apply.) propriate for the nurse t o
include in teaching.
1. "We will move you to the operating room
where the test is always performed." 1: BMA/biopsy may be
2. "The bone in the front of your chest will be done in a client room or
used for the biopsy specimen." treatment room. OR is not
3. "A tight pressure dressing will be placed required.
over the test site after the procedure."
4. "You will not feel any discomfort as the 2: Sternum may be used for
local anesthetic is injected." BMA but not enough mar-
, NCLEX-RN Practice Set and Lab Values 2022/2023
5. "There is a risk of bleeding, so we will row available for biopsy.
monitor the test site frequently."
4: Client will feel some
stinging and discomfort
during bone marrow biop-
sy. This is false reassur-
ance.
4. *The LPN/LVN reporting to the nurse says, Correct: 2
"You may want to see the client recently diag- Rationale: MOST imp't to
nosed with pancreatic cancer. I am not sure determine client's percep-
how well things are going." The nurse enters tion of the health problem.
the room and finds the client sitting quiet- Open-ended statement.
ly, looking out the window. As the nurse ap-
proaches the client, the client does not look Strategy: need to address
at the nurse. Which is the most appropriate the problem and better to
response by the nurse? ask open-ended questions.
It is more imp't to deal with
1. "Sleep problems are common during times the here and now.
of stress. Have you had difficulty sleeping?"
2. "Tell me what you know about your diag-
nosis and the treatment you will receive."
3. "How would you describe your overall
health status up to this time of your life?"
4. "How have you handled any health prob-
lems you experienced in the past?"
5. *The nurse provides care for the client imme- Correct: 4
diately after arrival in the emergency depart- Rationale: When prioritiz-
ment (ED). Emergency personnel report that ing care for a client,
the client was involved in a head-on collision nurse uses the ABC's (air-
with immediate loss of consciousness. Which way, breathing, circulation).
is the first action taken by the nurse? Oxygen saturation levels
allow the nurse to monitor
, NCLEX-RN Practice Set and Lab Values 2022/2023
1. Determine Glasgow Coma Scale (GCS) the client's airway (priority).
score.
2. Assess bilateral blood pressure. 1: GCS is used to assess
3. Check bilateral pupillary response to light. ABC and neuro status for
4. Determine oxygen saturation levels. clients c head trauma. It is
appropriate but too broad
and will take longer.
2: Assessing BP is monitor-
ing for circulation. Howev-
er, airway is priority and in-
creases in arterial CO2 will
increase ICP.
3: Nurse assesses neuro
status (eg. PERRLA) after
ABC.
6. At a rehabilitation center for clients with Correct: 2
spinal cord injuries (SCIs), the nurse con- Rationale: This statement
ducts an orientation session for a group of provides the UAP c info
unlicensed assistive personnel (UAP). Which needed to provide care for
statement is most important for the nurse to a client c SCI. Therefore,
include? this isa priority when del-
egating tasks to the UAP
1. "The clients may appear angry at times." who provides client care.
2. "Obtain the client's permission before
touching the client." 1,3,4: MAY be true but
3. "Most clients arrive believing they will walk does not provide info re-
out of here." garding care for SCI pa-
4. "Personnel in this environment often need tients.
counseling."
7. *The home care nurse instructs a client diag- Correct: 3
nosed with multiple sclerosis (MS). The client Rationale: Verbal commu-
states, "I have poor concentration and diffi- nication often causes fa-
culty pronouncing words." The nurse notes tigue for MS clients. There-
that the client's speech is slow and slurred. fore, client is taught to
Which client statement indicates to the nurse make important points first
