Actual NCLEX-RN Exam: All Questions & Verified Answers per ATI
Marking Scheme | 100% Pass Guarantee | Actual Exam, Comprehensive
Study Guide & Practice Test
1. 1. Question A patient with Parkinson’s disease has a nursing diagnosis of Impaired Physical Mobility related
to neuromuscular impairment. You observe a nursing assistant performing all of these actions. For which
action must you intervene?
o A. The NA assists the patient to ambulate to the bathroom and back to bed.
o B. The NA reminds the patient not to look at his feet when he is walking. o C. The NA
performs the patient’s complete bath and oral care. o D. The NA sets up the patient’s
tray and encourages the patient to feed himself.
Correct Answer: C. The NA performs the patient’s complete bath and
oral care.
The nursing assistant should assist the patient with morning care as
needed, but the goal is to keep this patient as independent and mobile as
possible.
o Option A: Assisting the patient to ambulate prevents
incidences of fall and injury.
o Option B: Reminding the patient not to look at his feet
while walking maintains the client’s independence while
keeping him safe.
o Option D: Encouraging the patient to feed himself is an
appropriate goal of maintaining independence.
The nurse is preparing to discharge a patient with chronic low back pain. Which statement by the patient
indicates that additional teaching is necessary?
o A. “I will avoid exercise because the pain gets worse.” o B. ―I will use heat or
ice to help control the pain.‖ o C. ―I will not wear high-heeled shoes at home or
work.‖
o D. ―I will purchase a firm mattress to replace my old one.‖
, • 2. Question
Correct Answer: A. “I will avoid exercise because the pain gets worse.”
Exercises are used to strengthen the back, relieve pressure on compressed nerves and protect the back from
re-injury. Doing exercises to strengthen the lower back can help alleviate and prevent lower back pain. It can
also strengthen the core, leg, and arm muscles. According to researchers, exercise also increases blood flow
to the lower back area, which may reduce stiffness and speed up the healing process.
o Option B: Ice and heat application are appropriate interventions for back pain.
Applying ice or a reusable gel pack constricts blood vessels and reduces swelling
around the injury. This is particularly useful for conditions, like a sprained ankle, that
cause significant swelling. Heat has the opposite effect, increasing blood flow to the
area. This relaxes muscle fibers, which can help when the client experiences spasms
or stiffness.
o Option C: People with chronic back pain should avoid wearing high-heeled shoes at
all times. The normal s- curve of the spine acts as a cushion or spring, reducing stress
on the vertebrae. When wearing high heels, the shape of the spine is altered and the
client doesn’t get that same shock absorption as she walks, which, over time, can lead
to uneven wear on the cartilage discs, joints and ligaments of the back.
o Option D: A firm mattress prevents lower back pain. Sleeping
on a mattress that is too firm can cause aches and pains on
pressure points. A medium-firm mattress may be more
comfortable because it allows the shoulder and hips to sink
in slightly. Patients who want a firmer mattress for back
support can get one with thicker padding for greater
comfort.
• 3. Question
A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a
short time ago.
Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute),
diaphoresis, and flushing of the face and neck. What action should you take first?
o A. Administer the ordered acetaminophen (Tylenol). o B. Check the
Foley tubing for kinks or obstruction. o C. Adjust the temperature in the
patient’s room. o D. Notify the physician about the change in status.
Correct Answer: B. Check the Foley tubing for kinks or obstruction.
These signs and symptoms are characteristic of autonomic dysreflexia,
a neurologic emergency that must be promptly treated to prevent a
,hypertensive stroke. The cause of this syndrome is noxious stimuli,
most often a distended bladder or constipation, so checking for poor
catheter drainage, bladder distention, or fecal impaction is the first
action that should be taken.
o Option C: Adjusting the room temperature may be helpful,
since too cool a temperature in the room may contribute
to the problem. o Option A: Tylenol will not decrease the
autonomic dysreflexia that is causing the patient’s
headache.
o Option D: Notification of the physician may be necessary if
nursing actions do not resolve symptoms.
Which patient should you, as charge nurse, assign to a new graduate RN who is orienting to the neurologic
unit?
o A. A 28-year-old newly admitted patient with spinal cord injury.
o B. A 67-year-old patient with stroke 3 days ago and left-sided weakness.
o C. An 85-year-old dementia patient to be transferred to long-term care today.
o D. A 54-year-old patient with Parkinson’s who needs assistance with bathing.
Correct Answer: B. A 67-year-old patient with stroke 3 days ago and left-sided weakness.
The new graduate RN who is oriented to the unit should be assigned stable, non-complex patients, such as the
patient with stroke.
o Option A: The newly admitted SCI should be assigned to experienced nurses. Most
cases of SCI take place when trauma breaks and squeezes the vertebrae, or the bones
of the back. This, in turn, damages the axons—the long nerve cell ―wires‖ that pass
through vertebrae, carrying signals between the brain and the rest of the body. The
axons might be crushed or completely severed by this damage. Someone with injury
to only a few axons might be able to recover completely from their injury. On the other
hand, a person with damage to all axons will most likely be paralyzed in the areas
below the injury.
o Option C: A patient for transfer should be assigned to a nurse who has experience in
the process of transferring patients. o Option D: The patient with Parkinson’s disease
needs assistance with bathing, which is best delegated to the nursing assistant.
, • 4. Question
A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment?
o A. Determine the level at which the patient has intact sensation. o B. Assess the level at
which the patient has retained mobility. o C. Check blood pressure and pulse for signs of
spinal shock.
o D. Monitor respiratory effort and oxygen saturation level.
Correct Answer: D. Monitor respiratory effort and oxygen saturation level.
The first priority for the patient with an SCI is assessing respiratory patterns and ensuring an adequate airway.
The patient with a high cervical injury is at risk for respiratory compromise because the spinal nerves (C3 –
5) innervate the phrenic nerve, which controls the diaphragm. o Option A: Determining this data can be
done after addressing the concerns on the respiratory status of the patient. o Option B: This data can be
assessed after monitoring the respiratory effort and oxygen saturation level of the patient.
o Option C: Vital signs checking is also necessary, but not as high priority. Vital signs can be
quite abnormal following SCI. In addition to the usual causes in trauma such as pain, bleeding,
and distress, this can be due to loss of autonomic control, which occurs particularly in cervical
or high thoracic injuries. The autonomic nervous system controls our HR, BP temperature,
etc. Autonomic instability is most acute in the first few days to weeks of the injury.
Marking Scheme | 100% Pass Guarantee | Actual Exam, Comprehensive
Study Guide & Practice Test
1. 1. Question A patient with Parkinson’s disease has a nursing diagnosis of Impaired Physical Mobility related
to neuromuscular impairment. You observe a nursing assistant performing all of these actions. For which
action must you intervene?
o A. The NA assists the patient to ambulate to the bathroom and back to bed.
o B. The NA reminds the patient not to look at his feet when he is walking. o C. The NA
performs the patient’s complete bath and oral care. o D. The NA sets up the patient’s
tray and encourages the patient to feed himself.
Correct Answer: C. The NA performs the patient’s complete bath and
oral care.
The nursing assistant should assist the patient with morning care as
needed, but the goal is to keep this patient as independent and mobile as
possible.
o Option A: Assisting the patient to ambulate prevents
incidences of fall and injury.
o Option B: Reminding the patient not to look at his feet
while walking maintains the client’s independence while
keeping him safe.
o Option D: Encouraging the patient to feed himself is an
appropriate goal of maintaining independence.
The nurse is preparing to discharge a patient with chronic low back pain. Which statement by the patient
indicates that additional teaching is necessary?
o A. “I will avoid exercise because the pain gets worse.” o B. ―I will use heat or
ice to help control the pain.‖ o C. ―I will not wear high-heeled shoes at home or
work.‖
o D. ―I will purchase a firm mattress to replace my old one.‖
, • 2. Question
Correct Answer: A. “I will avoid exercise because the pain gets worse.”
Exercises are used to strengthen the back, relieve pressure on compressed nerves and protect the back from
re-injury. Doing exercises to strengthen the lower back can help alleviate and prevent lower back pain. It can
also strengthen the core, leg, and arm muscles. According to researchers, exercise also increases blood flow
to the lower back area, which may reduce stiffness and speed up the healing process.
o Option B: Ice and heat application are appropriate interventions for back pain.
Applying ice or a reusable gel pack constricts blood vessels and reduces swelling
around the injury. This is particularly useful for conditions, like a sprained ankle, that
cause significant swelling. Heat has the opposite effect, increasing blood flow to the
area. This relaxes muscle fibers, which can help when the client experiences spasms
or stiffness.
o Option C: People with chronic back pain should avoid wearing high-heeled shoes at
all times. The normal s- curve of the spine acts as a cushion or spring, reducing stress
on the vertebrae. When wearing high heels, the shape of the spine is altered and the
client doesn’t get that same shock absorption as she walks, which, over time, can lead
to uneven wear on the cartilage discs, joints and ligaments of the back.
o Option D: A firm mattress prevents lower back pain. Sleeping
on a mattress that is too firm can cause aches and pains on
pressure points. A medium-firm mattress may be more
comfortable because it allows the shoulder and hips to sink
in slightly. Patients who want a firmer mattress for back
support can get one with thicker padding for greater
comfort.
• 3. Question
A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a
short time ago.
Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute),
diaphoresis, and flushing of the face and neck. What action should you take first?
o A. Administer the ordered acetaminophen (Tylenol). o B. Check the
Foley tubing for kinks or obstruction. o C. Adjust the temperature in the
patient’s room. o D. Notify the physician about the change in status.
Correct Answer: B. Check the Foley tubing for kinks or obstruction.
These signs and symptoms are characteristic of autonomic dysreflexia,
a neurologic emergency that must be promptly treated to prevent a
,hypertensive stroke. The cause of this syndrome is noxious stimuli,
most often a distended bladder or constipation, so checking for poor
catheter drainage, bladder distention, or fecal impaction is the first
action that should be taken.
o Option C: Adjusting the room temperature may be helpful,
since too cool a temperature in the room may contribute
to the problem. o Option A: Tylenol will not decrease the
autonomic dysreflexia that is causing the patient’s
headache.
o Option D: Notification of the physician may be necessary if
nursing actions do not resolve symptoms.
Which patient should you, as charge nurse, assign to a new graduate RN who is orienting to the neurologic
unit?
o A. A 28-year-old newly admitted patient with spinal cord injury.
o B. A 67-year-old patient with stroke 3 days ago and left-sided weakness.
o C. An 85-year-old dementia patient to be transferred to long-term care today.
o D. A 54-year-old patient with Parkinson’s who needs assistance with bathing.
Correct Answer: B. A 67-year-old patient with stroke 3 days ago and left-sided weakness.
The new graduate RN who is oriented to the unit should be assigned stable, non-complex patients, such as the
patient with stroke.
o Option A: The newly admitted SCI should be assigned to experienced nurses. Most
cases of SCI take place when trauma breaks and squeezes the vertebrae, or the bones
of the back. This, in turn, damages the axons—the long nerve cell ―wires‖ that pass
through vertebrae, carrying signals between the brain and the rest of the body. The
axons might be crushed or completely severed by this damage. Someone with injury
to only a few axons might be able to recover completely from their injury. On the other
hand, a person with damage to all axons will most likely be paralyzed in the areas
below the injury.
o Option C: A patient for transfer should be assigned to a nurse who has experience in
the process of transferring patients. o Option D: The patient with Parkinson’s disease
needs assistance with bathing, which is best delegated to the nursing assistant.
, • 4. Question
A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment?
o A. Determine the level at which the patient has intact sensation. o B. Assess the level at
which the patient has retained mobility. o C. Check blood pressure and pulse for signs of
spinal shock.
o D. Monitor respiratory effort and oxygen saturation level.
Correct Answer: D. Monitor respiratory effort and oxygen saturation level.
The first priority for the patient with an SCI is assessing respiratory patterns and ensuring an adequate airway.
The patient with a high cervical injury is at risk for respiratory compromise because the spinal nerves (C3 –
5) innervate the phrenic nerve, which controls the diaphragm. o Option A: Determining this data can be
done after addressing the concerns on the respiratory status of the patient. o Option B: This data can be
assessed after monitoring the respiratory effort and oxygen saturation level of the patient.
o Option C: Vital signs checking is also necessary, but not as high priority. Vital signs can be
quite abnormal following SCI. In addition to the usual causes in trauma such as pain, bleeding,
and distress, this can be due to loss of autonomic control, which occurs particularly in cervical
or high thoracic injuries. The autonomic nervous system controls our HR, BP temperature,
etc. Autonomic instability is most acute in the first few days to weeks of the injury.
