NCLEX-PN TEST-BANK (200 QUESTIONS WITH
ANSWERS AND EXPLANATIONS) 2024 UPDATE.
• The nurse is caring for a client scheduled for removal of a pituitary
tumor using the transsphenoidal approach. The nurse should be particularly
alert for:
• Nasal congestion
• Abdominal tenderness
• Muscle tetany
• Oliguria
Answer A: Removal of the pituitary gland is usually done by a transsphenoidal
approach, through the nose. Nasal congestion further interferes with the
airway. Answers B, C, and D are not correct because they are not directly
associated with the pituitary gland.
• A client with cancer is admitted to the oncology unit. Stat lab values
reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets
178,000. The nurse evaluates that the client is experiencing which of the
following?
• Hypernatremia
• Hypokalemia
• Myelosuppression
• Leukocytosis
Answer B: Hypokalemia is evident from the lab values listed. The other
laboratory findings are within normal limits, making answers A, C, and D
incorrect.
• A 24-year-old female client is scheduled for surgery in the morning.
Which of the following is the primary responsibility of the nurse?
,• Taking the vital signs
• Obtaining the permit
• Explaining the procedure
• Checking the lab work
Answer A: The primary responsibility of the nurse is to take the vital signs
before any surgery. The actions in answers B, C, and D are the responsibility of
the doctor and, therefore, are incorrect for this question.
• 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?
• Starting an IV
• Applying oxygen
• Obtaining blood gases
• 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?
• Rest in bed after taking the medication for at least 30 minutes
• Avoid rapid movements after taking the medication
• Take the medication with water only
• 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 pair of forceps
• A torque wrench
• A pair of wire cutters
• 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:
• 10 pounds
• 12 pounds
• 18 pounds
• 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?
• Hemiplegia
• Aphasia
, • Nausea
• 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.
• 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?
• Uric acid of 5mg/dL
• Hematocrit of 33%
• WBC 2,000 per cubic millimeter
• 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?
• “Tell me about his pain.”
• “What does his vomit look like?”
• “Describe his usual diet.”
• “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.
ANSWERS AND EXPLANATIONS) 2024 UPDATE.
• The nurse is caring for a client scheduled for removal of a pituitary
tumor using the transsphenoidal approach. The nurse should be particularly
alert for:
• Nasal congestion
• Abdominal tenderness
• Muscle tetany
• Oliguria
Answer A: Removal of the pituitary gland is usually done by a transsphenoidal
approach, through the nose. Nasal congestion further interferes with the
airway. Answers B, C, and D are not correct because they are not directly
associated with the pituitary gland.
• A client with cancer is admitted to the oncology unit. Stat lab values
reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets
178,000. The nurse evaluates that the client is experiencing which of the
following?
• Hypernatremia
• Hypokalemia
• Myelosuppression
• Leukocytosis
Answer B: Hypokalemia is evident from the lab values listed. The other
laboratory findings are within normal limits, making answers A, C, and D
incorrect.
• A 24-year-old female client is scheduled for surgery in the morning.
Which of the following is the primary responsibility of the nurse?
,• Taking the vital signs
• Obtaining the permit
• Explaining the procedure
• Checking the lab work
Answer A: The primary responsibility of the nurse is to take the vital signs
before any surgery. The actions in answers B, C, and D are the responsibility of
the doctor and, therefore, are incorrect for this question.
• 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?
• Starting an IV
• Applying oxygen
• Obtaining blood gases
• 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?
• Rest in bed after taking the medication for at least 30 minutes
• Avoid rapid movements after taking the medication
• Take the medication with water only
• 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 pair of forceps
• A torque wrench
• A pair of wire cutters
• 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:
• 10 pounds
• 12 pounds
• 18 pounds
• 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?
• Hemiplegia
• Aphasia
, • Nausea
• 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.
• 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?
• Uric acid of 5mg/dL
• Hematocrit of 33%
• WBC 2,000 per cubic millimeter
• 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?
• “Tell me about his pain.”
• “What does his vomit look like?”
• “Describe his usual diet.”
• “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.
