NCLEX PEDS EXAM ACTUAL EXAM 2024 | ALL
QUESTIONS AND CORRECT AND CORRECT
ANSWERS WITH RATIONALES | GRADED A+ |
VERIFIED VERSION
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:
Phenytoin (Dilantin) - ANSWER NO.27 A client states to his nurse that I was told
by the doctor not to take one of my drugs because it seems to have caused
decreasing blood cells. Based on this information, which drug might the nurse expect
to be discontinued?
Administer the morning lithium dose as scheduled - ANSWER NO.28 A client has
been taking lithium 300 mg po bid for the past two weeks. This morning her lithium
level was 1 mEq/L. The nurse should:
Maintaining an adequate level of hydration - ANSWER NO.29 The primary focus
of nursing interventions for the child experiencing sickle cell crisis is aimed toward:
You've been feeling sad and alone for some time now? - ANSWER NO.30 Three
weeks following discharge, male client is readmitted to the psychiatric unit for
depression. His wife stated that he had threatened to kill himself with a handgun. As
the nurse admits him to the unit, he says, "I wish I were dead because I am
worthless to everyone; I guess I am just no good." Which response by the nurse is
most appropriate at this time?
QUESTIONS AND CORRECT AND CORRECT
ANSWERS WITH RATIONALES | GRADED A+ |
VERIFIED VERSION
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:
Phenytoin (Dilantin) - ANSWER NO.27 A client states to his nurse that I was told
by the doctor not to take one of my drugs because it seems to have caused
decreasing blood cells. Based on this information, which drug might the nurse expect
to be discontinued?
Administer the morning lithium dose as scheduled - ANSWER NO.28 A client has
been taking lithium 300 mg po bid for the past two weeks. This morning her lithium
level was 1 mEq/L. The nurse should:
Maintaining an adequate level of hydration - ANSWER NO.29 The primary focus
of nursing interventions for the child experiencing sickle cell crisis is aimed toward:
You've been feeling sad and alone for some time now? - ANSWER NO.30 Three
weeks following discharge, male client is readmitted to the psychiatric unit for
depression. His wife stated that he had threatened to kill himself with a handgun. As
the nurse admits him to the unit, he says, "I wish I were dead because I am
worthless to everyone; I guess I am just no good." Which response by the nurse is
most appropriate at this time?
