NCLEX RN REVIEW ACTUAL EXAM
CORRECTLY DETALIED QUESTIONS AND
ANSWERS GRADED A+
A patient who has amyotrophic lateral sclerosis is having frequent episodes of dysphagia. Which of the
following referrals is appropriate for the nurse to make currently?
1. Physical Therapist
2. Speech Pathologist
3. Registered Dietitian
4. Occupational Therapist - ANSWER2. Speech Pathologist
A patient who has chronic progressive dementia exhibits symptoms of malnutrition. Which action is
needed at this time?
1. Notify social services about concern for abuse.
2. Initiate a consult for physical therapy to visit daily.
3. Ask home care services to provide written instructions.
4. Arrange a meeting with the interprofessional team to coordinate care? - ANSWER4. Arrange a meeting
with the interprofessional team to coordinate care?
A nurse should recognize which of the following patients are likely to need rehabilitation services after
hepatization? (SATA)
1. School-age child who is recovering from an appendectomy.
2. patient who had a cesarean delivery for a breech presentation.
3. An adult patient who has left hemiplegia after a stroke.
4. An adult patient who is recovering from Guillain-Barre syndrome.
5. An older adult patient who had a left hip replacement.
,6. An adolescent patient who required hospitalization due to asthma. - ANSWER3. An adult patient who
has left hemiplegia after a stroke.
4. An adult patient who is recovering from Guillain-Barre syndrome.
5. An older adult patient who had a left hip replacement.
A nurse is assigned to a group of patients. Which of the following has an increased risk of aspiration
while eating? (SATA)
1. A patient who has a new diagnosis of gastroesophageal reflux disease.
2. A patient who has admitted with a diagnosis of cerebrovascular accident.
3. A patient who is 4 hr. post-op and received general anesthesia.
4. A patient who is 8 hr. following traumatic laryngeal nerve damage.
5. A patient who continually experiences prolonged coughing episodes. - ANSWER2. A patient who has
admitted with a diagnosis of cerebrovascular accident.
3. A patient who is 4 hr. post op and received general anesthesia.
4. A patient who is 8 hr. following traumatic laryngeal nerve damage.
5. A patient who continually experiences prolonged coughing episodes.
A patient is receiving packed RBCs and becomes tachypneic. The patient's temperature changes from
36.8*C (98.4*F) to 38.4*C (101.2*F). Which of the nursing interventions should the nurse perform first.
1. Give 750 mg acetaminophen orally.
2. Collect blood and urine specimens for analysis.
3. Administer and IV infusion of 0.9% sodium chloride.
4. Stop the infusion and return the blood to the lab. - ANSWER4. Stop the infusion and return the blood
to the lab.
A nurse receives a request from four patients at the same time. Which of the following patients should the
nurse address first? A patient who
1. Needs to void 1 hr. after removal of an indwelling urinary catheter.
2. Reports restlessness and shortness of breath following surgery for a fractured femur.
,3. Asks for a stool softener 2 days following surgery.
4. Demands to take prescribed insulin early the spouse is bringing dinner. - ANSWER2. Reports
restlessness and shortness of breath following surgery for a fractured femur.
After receiving the report, a nurse should plan to access the patients in which priority order?
1. A 9-month-old who is receiving hydration therapy with IV fluids infusion peripherally.
2. A 6-year-old who is receiving continuous chemotherapy via a central venous catheter.
3. A 14-year-old who is awaiting discharge instructions receiving prednisone therapy.
4. An 8-year-old who is 2 days postoperative with an indwelling urinary catheter. - ANSWER1st) 2. A 6-
year-old who is receiving continuous chemotherapy via a central venous catheter.
2nd) 1. A 9-month-old who is receiving hydration therapy with IV fluids infusion peripherally.
3rd) 4. An 8-year-old who is 2 days postoperative with an indwelling urinary catheter.
4th) 3. A 14-year-old who is awaiting discharge instructions receiving prednisone therapy.
A nurse received the report and should plan to see which of the following patient first?
1. A patient at 39 weeks of gestation who is having contractions over 5 min lasting45 to 60 seconds.
2. A patient who is pregnant and has a blood glucose level of 150mg/dl.
3. A patient at 33 weeks of gestation who is receiving magnesium sulfate IV.
4. A patient 1 day postpartum who has changed perineal pads twice in the last 7 hr. - ANSWER3. A
patient at 33 weeks of gestation who is receiving magnesium sulfate IV.
After receiving the report, which of the following patients should the nurse see first?
1. A patient who was admitted with kidney stones and is crying with back pain.
2. A patient who had chest discomfort prior to admission and is now requesting coffee.
3. A patient who is scheduled for surgery and needs the linen changed.
4. A patient who is to receive one unit of packed RBCs today and needs an IV restarted. - ANSWER1. A
patient who was admitted with kidney stones and is crying with back pain.
, The nurse should triage which of the following patients first?
1. Vomiting, photosensitivity, and stiff neck.
2. Elevated temperature, sore throat, and fatigue.
3. A guarded gait and a bruised, edematous ankle.
4. Cloudy urine with painful urination. - ANSWER1. Vomiting, photosensitivity, and stiff neck.
5 Rights of Delegation - ANSWERRight Person
Right Task
Right Circumstance
Right Direction/Communication
Right Supervision/Evaluation
Scope of Practice
RN -
LPN -
UAP - - ANSWERRN - Unstable patients, Assessments, Initiate Care Plans, Initial Teaching, Blood
Productions, IV Fluids and IV Push Medications.
LPN - Stable patients, Gather data, Contribute to Care Plan, Reinforce Teaching, Monitor IVFs and Blood
Transfusions, Administer Piggybacks.
UAP - Stable patients, Obtain Vital Signs, Gather specific date, Hygiene care, Bed making, Feeding,
Positioning, Ambulation.
A nurse is organizing care for four patients, which of the following tasks should the nurse instruct the
UAP to perform?
1. Measure the urine output from a patient who was recently admitted with dehydration.
2. Bathe and shampoo hair for a patient who was just admitted after a motor vehicle crash.
3. Help a patient who is requesting a bedpan after a lumbar puncture.
CORRECTLY DETALIED QUESTIONS AND
ANSWERS GRADED A+
A patient who has amyotrophic lateral sclerosis is having frequent episodes of dysphagia. Which of the
following referrals is appropriate for the nurse to make currently?
1. Physical Therapist
2. Speech Pathologist
3. Registered Dietitian
4. Occupational Therapist - ANSWER2. Speech Pathologist
A patient who has chronic progressive dementia exhibits symptoms of malnutrition. Which action is
needed at this time?
1. Notify social services about concern for abuse.
2. Initiate a consult for physical therapy to visit daily.
3. Ask home care services to provide written instructions.
4. Arrange a meeting with the interprofessional team to coordinate care? - ANSWER4. Arrange a meeting
with the interprofessional team to coordinate care?
A nurse should recognize which of the following patients are likely to need rehabilitation services after
hepatization? (SATA)
1. School-age child who is recovering from an appendectomy.
2. patient who had a cesarean delivery for a breech presentation.
3. An adult patient who has left hemiplegia after a stroke.
4. An adult patient who is recovering from Guillain-Barre syndrome.
5. An older adult patient who had a left hip replacement.
,6. An adolescent patient who required hospitalization due to asthma. - ANSWER3. An adult patient who
has left hemiplegia after a stroke.
4. An adult patient who is recovering from Guillain-Barre syndrome.
5. An older adult patient who had a left hip replacement.
A nurse is assigned to a group of patients. Which of the following has an increased risk of aspiration
while eating? (SATA)
1. A patient who has a new diagnosis of gastroesophageal reflux disease.
2. A patient who has admitted with a diagnosis of cerebrovascular accident.
3. A patient who is 4 hr. post-op and received general anesthesia.
4. A patient who is 8 hr. following traumatic laryngeal nerve damage.
5. A patient who continually experiences prolonged coughing episodes. - ANSWER2. A patient who has
admitted with a diagnosis of cerebrovascular accident.
3. A patient who is 4 hr. post op and received general anesthesia.
4. A patient who is 8 hr. following traumatic laryngeal nerve damage.
5. A patient who continually experiences prolonged coughing episodes.
A patient is receiving packed RBCs and becomes tachypneic. The patient's temperature changes from
36.8*C (98.4*F) to 38.4*C (101.2*F). Which of the nursing interventions should the nurse perform first.
1. Give 750 mg acetaminophen orally.
2. Collect blood and urine specimens for analysis.
3. Administer and IV infusion of 0.9% sodium chloride.
4. Stop the infusion and return the blood to the lab. - ANSWER4. Stop the infusion and return the blood
to the lab.
A nurse receives a request from four patients at the same time. Which of the following patients should the
nurse address first? A patient who
1. Needs to void 1 hr. after removal of an indwelling urinary catheter.
2. Reports restlessness and shortness of breath following surgery for a fractured femur.
,3. Asks for a stool softener 2 days following surgery.
4. Demands to take prescribed insulin early the spouse is bringing dinner. - ANSWER2. Reports
restlessness and shortness of breath following surgery for a fractured femur.
After receiving the report, a nurse should plan to access the patients in which priority order?
1. A 9-month-old who is receiving hydration therapy with IV fluids infusion peripherally.
2. A 6-year-old who is receiving continuous chemotherapy via a central venous catheter.
3. A 14-year-old who is awaiting discharge instructions receiving prednisone therapy.
4. An 8-year-old who is 2 days postoperative with an indwelling urinary catheter. - ANSWER1st) 2. A 6-
year-old who is receiving continuous chemotherapy via a central venous catheter.
2nd) 1. A 9-month-old who is receiving hydration therapy with IV fluids infusion peripherally.
3rd) 4. An 8-year-old who is 2 days postoperative with an indwelling urinary catheter.
4th) 3. A 14-year-old who is awaiting discharge instructions receiving prednisone therapy.
A nurse received the report and should plan to see which of the following patient first?
1. A patient at 39 weeks of gestation who is having contractions over 5 min lasting45 to 60 seconds.
2. A patient who is pregnant and has a blood glucose level of 150mg/dl.
3. A patient at 33 weeks of gestation who is receiving magnesium sulfate IV.
4. A patient 1 day postpartum who has changed perineal pads twice in the last 7 hr. - ANSWER3. A
patient at 33 weeks of gestation who is receiving magnesium sulfate IV.
After receiving the report, which of the following patients should the nurse see first?
1. A patient who was admitted with kidney stones and is crying with back pain.
2. A patient who had chest discomfort prior to admission and is now requesting coffee.
3. A patient who is scheduled for surgery and needs the linen changed.
4. A patient who is to receive one unit of packed RBCs today and needs an IV restarted. - ANSWER1. A
patient who was admitted with kidney stones and is crying with back pain.
, The nurse should triage which of the following patients first?
1. Vomiting, photosensitivity, and stiff neck.
2. Elevated temperature, sore throat, and fatigue.
3. A guarded gait and a bruised, edematous ankle.
4. Cloudy urine with painful urination. - ANSWER1. Vomiting, photosensitivity, and stiff neck.
5 Rights of Delegation - ANSWERRight Person
Right Task
Right Circumstance
Right Direction/Communication
Right Supervision/Evaluation
Scope of Practice
RN -
LPN -
UAP - - ANSWERRN - Unstable patients, Assessments, Initiate Care Plans, Initial Teaching, Blood
Productions, IV Fluids and IV Push Medications.
LPN - Stable patients, Gather data, Contribute to Care Plan, Reinforce Teaching, Monitor IVFs and Blood
Transfusions, Administer Piggybacks.
UAP - Stable patients, Obtain Vital Signs, Gather specific date, Hygiene care, Bed making, Feeding,
Positioning, Ambulation.
A nurse is organizing care for four patients, which of the following tasks should the nurse instruct the
UAP to perform?
1. Measure the urine output from a patient who was recently admitted with dehydration.
2. Bathe and shampoo hair for a patient who was just admitted after a motor vehicle crash.
3. Help a patient who is requesting a bedpan after a lumbar puncture.
