NCLEX-PN TEST-BANK ACTUAL AND
APPROVED 2023/2024 EXAM 204 QUESTIONS
WITH ANSWERS AND DETAILED
EXPLANATIONS.
A 24-year-old female client is scheduled for surgery in the morning. Which of the following is
the primary responsibility of the nurse? - ANSWER>>Taking vital signs
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? - ANSWER>>B. Applying
oxygen
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? - ANSWER>>take
the medication with water only
The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which
equipment should be kept at the bedside? - ANSWER>>torque wrench
An infant weighs 7 pounds at birth. The expected weight by 1 year should be: - ANSWER>>21
pounds
A client is admitted with a Ewing's sarcoma. Which symptoms would be expected due to this
tumor's location? - ANSWER>>Bone pain
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? -
ANSWER>>WBC 2,000 per cubic millimeter
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? -
ANSWER>>"Describe his usual diet."
The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should
be avoided? - ANSWER>>Cucumber salad
,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? - ANSWER>>Facilitating perineal wound
drainage
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? -
ANSWER>>Cooked broccoli
A client arrives in the emergency room with a possible fractured femur. The nurse should
anticipate an order for: - ANSWER>>Buck's traction
A client with cancer is to undergo an intravenous pyelogram. The nurse should: - ANSWER>>Ask
the client to void immediately before the study
The nurse is caring for a client with a malignancy. The classification of the primary tumor is this.
The nurse should plan care for a tumor: - ANSWER>>That is in situ
A client is 2 days post-operative colon resection. After a coughing episode, the client's wound
eviscerates. Which nursing action is most appropriate? - ANSWER>>Cover the wound with a
sterile saline-soaked dressing
The nurse is preparing a client for surgery. Which item is most important to remove before
sending the client to surgery? - ANSWER>>contact lenses
The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm
scheduled for surgery in the morning and finds that the consent form has been signed, but the
client is unclear about the surgery and possible complications. Which is the most appropriate
action? - ANSWER>>Call the surgeon and ask him or her to see the client to clarify the
information
The client with diabetes is preparing for discharge. During discharge teaching, the nurse
assesses the client's ability to care for himself. Which statement made by the client would
indicate a need for follow-up after discharge? - ANSWER>>"I have trouble seeing."
The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while
the client is receiving TPN? - ANSWER>>Blood glucose
, The client with a myocardial infarction comes to the nurse's station stating that he is ready to
go home because there is nothing wrong with him. Which defense mechanism is the client
using? - ANSWER>>Denial
Which laboratory test would be the least effective in making the diagnosis of a myocardial
infarction? - ANSWER>>AST
The licensed practical nurse assigned to the post-partal unit is preparing to administer Rhogam
to a postpartum client. Which woman is not a candidate for RhoGam? - ANSWER>>A gravida IV
para 2 that is Rh negative with an Rh-negative baby
The first exercise that should be performed by the client who had a mastectomy is: -
ANSWER>>Squeezing a ball
The client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication
should be kept available during the test? - ANSWER>>Atropine sulfate
The client is scheduled for a pericentesis. Which instruction should be given to the client before
the exam? - ANSWER>>"You need to empty your bladder before the procedure."
To ensure safety while administering a nitroglycerine patch, the nurse should: -
ANSWER>>Wear gloves
The physician has prescribed tranylcypromine sulfate (Parnate) 10mg bid. The nurse should
teach the client to refrain from eating foods containing tyramine because it may cause: -
ANSWER>>Hypertension
The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the
following statements by the patient's mother indicates to the nurse that the patient is
experiencing a side effect of Dilantin therapy? - ANSWER>>"Her gums look too big for her
teeth."
A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would
indicate a complication of the surgery? - ANSWER>>Constant swallowing
A 6-year-old with cerebral palsy functions at the level of an 18-month- old. Which finding would
support that assessment? - ANSWER>>She pulls a toy behind her.
APPROVED 2023/2024 EXAM 204 QUESTIONS
WITH ANSWERS AND DETAILED
EXPLANATIONS.
A 24-year-old female client is scheduled for surgery in the morning. Which of the following is
the primary responsibility of the nurse? - ANSWER>>Taking vital signs
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? - ANSWER>>B. Applying
oxygen
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? - ANSWER>>take
the medication with water only
The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which
equipment should be kept at the bedside? - ANSWER>>torque wrench
An infant weighs 7 pounds at birth. The expected weight by 1 year should be: - ANSWER>>21
pounds
A client is admitted with a Ewing's sarcoma. Which symptoms would be expected due to this
tumor's location? - ANSWER>>Bone pain
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? -
ANSWER>>WBC 2,000 per cubic millimeter
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? -
ANSWER>>"Describe his usual diet."
The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should
be avoided? - ANSWER>>Cucumber salad
,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? - ANSWER>>Facilitating perineal wound
drainage
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? -
ANSWER>>Cooked broccoli
A client arrives in the emergency room with a possible fractured femur. The nurse should
anticipate an order for: - ANSWER>>Buck's traction
A client with cancer is to undergo an intravenous pyelogram. The nurse should: - ANSWER>>Ask
the client to void immediately before the study
The nurse is caring for a client with a malignancy. The classification of the primary tumor is this.
The nurse should plan care for a tumor: - ANSWER>>That is in situ
A client is 2 days post-operative colon resection. After a coughing episode, the client's wound
eviscerates. Which nursing action is most appropriate? - ANSWER>>Cover the wound with a
sterile saline-soaked dressing
The nurse is preparing a client for surgery. Which item is most important to remove before
sending the client to surgery? - ANSWER>>contact lenses
The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm
scheduled for surgery in the morning and finds that the consent form has been signed, but the
client is unclear about the surgery and possible complications. Which is the most appropriate
action? - ANSWER>>Call the surgeon and ask him or her to see the client to clarify the
information
The client with diabetes is preparing for discharge. During discharge teaching, the nurse
assesses the client's ability to care for himself. Which statement made by the client would
indicate a need for follow-up after discharge? - ANSWER>>"I have trouble seeing."
The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while
the client is receiving TPN? - ANSWER>>Blood glucose
, The client with a myocardial infarction comes to the nurse's station stating that he is ready to
go home because there is nothing wrong with him. Which defense mechanism is the client
using? - ANSWER>>Denial
Which laboratory test would be the least effective in making the diagnosis of a myocardial
infarction? - ANSWER>>AST
The licensed practical nurse assigned to the post-partal unit is preparing to administer Rhogam
to a postpartum client. Which woman is not a candidate for RhoGam? - ANSWER>>A gravida IV
para 2 that is Rh negative with an Rh-negative baby
The first exercise that should be performed by the client who had a mastectomy is: -
ANSWER>>Squeezing a ball
The client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication
should be kept available during the test? - ANSWER>>Atropine sulfate
The client is scheduled for a pericentesis. Which instruction should be given to the client before
the exam? - ANSWER>>"You need to empty your bladder before the procedure."
To ensure safety while administering a nitroglycerine patch, the nurse should: -
ANSWER>>Wear gloves
The physician has prescribed tranylcypromine sulfate (Parnate) 10mg bid. The nurse should
teach the client to refrain from eating foods containing tyramine because it may cause: -
ANSWER>>Hypertension
The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the
following statements by the patient's mother indicates to the nurse that the patient is
experiencing a side effect of Dilantin therapy? - ANSWER>>"Her gums look too big for her
teeth."
A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would
indicate a complication of the surgery? - ANSWER>>Constant swallowing
A 6-year-old with cerebral palsy functions at the level of an 18-month- old. Which finding would
support that assessment? - ANSWER>>She pulls a toy behind her.
