NCLEX RN 2023/2024 EXAM WITH 200 QUESTIONS
AND CORRECT ANSWERS WITH RATIONALES/
GRADED A+
NO.1 A depressed client is seen at the mental health center for follow-up
after an attempted suicide 1 week ago. She has taken phenelzine sulfate
(Nardil), a monoamine oxidase (MAO) inhibitor, for 7 straight days. She
states that she is not feeling any better. The nurse explains that the drug
must accumulate to an effective level before symptoms are totally
relieved. Symptom relief is expected to occur within: - Answer--2-4
weeks months months B Explanation:
NO.2 Cystic fibrosis is transmitted as an autosomal recessive trait. This
means that - Answer--Both parents must be carriers for a child to have
the disease
Delusion - Answer--NO.3 A 24-year-old client presents to the
emergency department protesting "I am God. The nurse identifies this as
a
Haloperidol (Haldol) - Answer--acute episodes of mania, lithium is
effective in 1-2 weeks, but it may take up to 4 weeks, or even a few
months treat symptoms fully. Sometimes an antipsychotic agent is
prescribed the first few days or weeks of an acute episode to manage
severe behavioral excitement and acute psychotic symptoms. In addition
to the lithium, which one of the following medications might the
physician prescribe?
,Release restraints every 2 hours for client to exercise. - Answer--NO.5 A
violent client remains in restraints for several hours. Which of the
following interventions is most appropriate while he is in restraints?
Observe for headaches, dizziness, and anorexia - Answer--NO.6 The
pediatrician has diagnosed tinea capitis in an 8-year-old girl and has
placed her on oral griseofulvin. The nurse should emphasize which of
these instructions to the mother and/or child?
Decrease ammonia formation - Answer--n.7 A client with cirrhosis of
the liver becomes comatose and is started on neomycin 300 mg q6h
nasogastric tube. The rationale for this therapy is to:
Observe for evidence of bleeding. - Answer--NO.8 A 5-year-old has just
had a tonsillectomy and adenoidectomy. Which of these nursing
measures should be included in the postoperative care?
Decreased absent pedal pulse in the left leg - Answer--NO.9 An 80-year-
old male client with a history of arteriosclerosis is experiencing severe
pain in his left leg that started approximately 20 minutes ago. When
performing the admission assessment, the nurse would expect to observe
which of the following:
Hematocrit 60% - Answer--NO.10 A 16-month-old infant is being
prepared for tetralogy of Fallot repair. In the nursing assessment, which
lab value should elicit further assessment and requires notification of
physician? 7.39
Walk him as he paces. - Answer--NO.11 A male client is experiencing
extreme distress. He begins to pace up and down the corridor. What
nursing intervention is appropriate when communicating with the pacing
client?
Walk with him as he paces. - Answer--NO.11 A male client is
experiencing extreme distress. He begins to pace up and down the
,corridor. What nursing intervention is appropriate when communicating
with the pacing client?
Locate the position of the placenta and fetus - Answer--NO.12 Prior to
an amniocentesis, a fetal ultrasound is done in order to
February 27 - Answer--NO.13 A 25-year-old client believes she may be
pregnant with her first child. She schedules an obstetric examination
with the nurse practitioner to determine the status of her possible
pregnancy. Her last menstrual period began May 20, and her estimated
date of confinement using Nagele's rule is:
Gestational diabetes mellitus - Answer--NO.14 A client is now pregnant
for the second time. Her first child weighed 4536 g at delivery. The
client's glucose tolerance test shows elevated blood sugar levels.
Because she only shows signs of diabetes when she is pregnant, she is
classified as having:
Vitamin C - Answer--NO.16 The nurse is assisting a 4th-day
postoperative cholecystectomy client in planning her meals for
tomorrow's menu. Which vitamin is the most essential in promoting
tissue healing?
Allowing him to do as much for himself as he is able, including learning
to do pin-site care under supervision - Answer--NO.17 A 10-year-old
client with a pin in the right femur is immobilized in traction. He is
exhibiting behavioral changes including restlessness, difficulty with
problem solving, inability to concentrate on activities, and monotony.
Which of the following nursing implementations would be most
effective in helping him cope with immobility?
First trimester - Answer--NO.18 In client teaching, the nurse should
emphasize that fetal damage occurs more frequently with ingestion of
drugs during:
, High Fowler - Answer--NO.19 On admission, the client has signs and
symptoms of pulmonary edema. The nurse places the client in the most
appropriate position for a client in pulmonary edema, which is:
Respiratory obstruction - Answer--NO.20 A client has returned to the
unit from the recovery room after having a thyroidectomy. The nurse
knows that a major complication after a thyroidectomy is:
Mother calls infant by name. - Answer--NO.2 The nurse should facilitate
bonding during the postpartum period. What should the nurse expect to
observe in the taking-hold phase?
Respect the client's family's wishes. - Answer--NO.22 A female client
has just died. Her family is requesting that all nursing staff leave the
room. The family's religious leader has arrived and is ready to conduct a
ceremony for the deceased in the room, requesting that only family
members be present. The nurse assigned to the client should perform the
appropriate nursing action, which might include:
Wear a patch over one eye - Answer--NO.23 A woman diagnosed with
multiple sclerosis is disturbed with diplopia. The nurse will teach her to
Level of consciousness - Answer--NO.24 One of the most reliable
assessment tools for adequacy of fluid resuscitation in burned children
is:
Urine output - Answer--NO.25 Which one of the following is considered
a reliable indicator for assessing the adequacy of fluid resuscitation in a
3-year-old child who suffered partial- and fullthickness burns to 25% of
her body?
Headache and facial flushing - Answer--NO.26 A client with a diagnosis
of C-4 injury has been stabilized and is ready for discharge. Because this
client is at risk for autonomic dysreflexia, he and his family should be
instructed to assess for and report:
AND CORRECT ANSWERS WITH RATIONALES/
GRADED A+
NO.1 A depressed client is seen at the mental health center for follow-up
after an attempted suicide 1 week ago. She has taken phenelzine sulfate
(Nardil), a monoamine oxidase (MAO) inhibitor, for 7 straight days. She
states that she is not feeling any better. The nurse explains that the drug
must accumulate to an effective level before symptoms are totally
relieved. Symptom relief is expected to occur within: - Answer--2-4
weeks months months B Explanation:
NO.2 Cystic fibrosis is transmitted as an autosomal recessive trait. This
means that - Answer--Both parents must be carriers for a child to have
the disease
Delusion - Answer--NO.3 A 24-year-old client presents to the
emergency department protesting "I am God. The nurse identifies this as
a
Haloperidol (Haldol) - Answer--acute episodes of mania, lithium is
effective in 1-2 weeks, but it may take up to 4 weeks, or even a few
months treat symptoms fully. Sometimes an antipsychotic agent is
prescribed the first few days or weeks of an acute episode to manage
severe behavioral excitement and acute psychotic symptoms. In addition
to the lithium, which one of the following medications might the
physician prescribe?
,Release restraints every 2 hours for client to exercise. - Answer--NO.5 A
violent client remains in restraints for several hours. Which of the
following interventions is most appropriate while he is in restraints?
Observe for headaches, dizziness, and anorexia - Answer--NO.6 The
pediatrician has diagnosed tinea capitis in an 8-year-old girl and has
placed her on oral griseofulvin. The nurse should emphasize which of
these instructions to the mother and/or child?
Decrease ammonia formation - Answer--n.7 A client with cirrhosis of
the liver becomes comatose and is started on neomycin 300 mg q6h
nasogastric tube. The rationale for this therapy is to:
Observe for evidence of bleeding. - Answer--NO.8 A 5-year-old has just
had a tonsillectomy and adenoidectomy. Which of these nursing
measures should be included in the postoperative care?
Decreased absent pedal pulse in the left leg - Answer--NO.9 An 80-year-
old male client with a history of arteriosclerosis is experiencing severe
pain in his left leg that started approximately 20 minutes ago. When
performing the admission assessment, the nurse would expect to observe
which of the following:
Hematocrit 60% - Answer--NO.10 A 16-month-old infant is being
prepared for tetralogy of Fallot repair. In the nursing assessment, which
lab value should elicit further assessment and requires notification of
physician? 7.39
Walk him as he paces. - Answer--NO.11 A male client is experiencing
extreme distress. He begins to pace up and down the corridor. What
nursing intervention is appropriate when communicating with the pacing
client?
Walk with him as he paces. - Answer--NO.11 A male client is
experiencing extreme distress. He begins to pace up and down the
,corridor. What nursing intervention is appropriate when communicating
with the pacing client?
Locate the position of the placenta and fetus - Answer--NO.12 Prior to
an amniocentesis, a fetal ultrasound is done in order to
February 27 - Answer--NO.13 A 25-year-old client believes she may be
pregnant with her first child. She schedules an obstetric examination
with the nurse practitioner to determine the status of her possible
pregnancy. Her last menstrual period began May 20, and her estimated
date of confinement using Nagele's rule is:
Gestational diabetes mellitus - Answer--NO.14 A client is now pregnant
for the second time. Her first child weighed 4536 g at delivery. The
client's glucose tolerance test shows elevated blood sugar levels.
Because she only shows signs of diabetes when she is pregnant, she is
classified as having:
Vitamin C - Answer--NO.16 The nurse is assisting a 4th-day
postoperative cholecystectomy client in planning her meals for
tomorrow's menu. Which vitamin is the most essential in promoting
tissue healing?
Allowing him to do as much for himself as he is able, including learning
to do pin-site care under supervision - Answer--NO.17 A 10-year-old
client with a pin in the right femur is immobilized in traction. He is
exhibiting behavioral changes including restlessness, difficulty with
problem solving, inability to concentrate on activities, and monotony.
Which of the following nursing implementations would be most
effective in helping him cope with immobility?
First trimester - Answer--NO.18 In client teaching, the nurse should
emphasize that fetal damage occurs more frequently with ingestion of
drugs during:
, High Fowler - Answer--NO.19 On admission, the client has signs and
symptoms of pulmonary edema. The nurse places the client in the most
appropriate position for a client in pulmonary edema, which is:
Respiratory obstruction - Answer--NO.20 A client has returned to the
unit from the recovery room after having a thyroidectomy. The nurse
knows that a major complication after a thyroidectomy is:
Mother calls infant by name. - Answer--NO.2 The nurse should facilitate
bonding during the postpartum period. What should the nurse expect to
observe in the taking-hold phase?
Respect the client's family's wishes. - Answer--NO.22 A female client
has just died. Her family is requesting that all nursing staff leave the
room. The family's religious leader has arrived and is ready to conduct a
ceremony for the deceased in the room, requesting that only family
members be present. The nurse assigned to the client should perform the
appropriate nursing action, which might include:
Wear a patch over one eye - Answer--NO.23 A woman diagnosed with
multiple sclerosis is disturbed with diplopia. The nurse will teach her to
Level of consciousness - Answer--NO.24 One of the most reliable
assessment tools for adequacy of fluid resuscitation in burned children
is:
Urine output - Answer--NO.25 Which one of the following is considered
a reliable indicator for assessing the adequacy of fluid resuscitation in a
3-year-old child who suffered partial- and fullthickness burns to 25% of
her body?
Headache and facial flushing - Answer--NO.26 A client with a diagnosis
of C-4 injury has been stabilized and is ready for discharge. Because this
client is at risk for autonomic dysreflexia, he and his family should be
instructed to assess for and report:
