NCLEX NCLEX-RN
NCLEX RN VERSIONS 1-12 EXAM QUESTIONS
& ANSWERS GUARANTEED 100 % CORRECT
QUESTION 1
The child with iron poisoning is given IV deforoxamine mesylate (Desferal). Following administration, the
child suffers hypotension, facial flushing, and urticari A. The initial nursing intervention would be to:
A. Discontinue the IV
B. Stop the medication, and begin a normal saline infusion
C. Take all vital signs, and report to the physician
D. Assess urinary output, and if it is 30 mL an hour, maintain current treatment
Answer: B
Explanation:
(A) The IV line should not be discontinued because other IV medications will be needed.
(B) Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction
and could go into shock if the medication is not stopped. The line should be kept opened for other
medication. (C) Taking vital signs and reporting to the physician is not an adequate intervention because the
IV medication continues to flow. (D) Assessing urinary output and, if it is 30 mL an hour, maintaining
current treatment is an inappropriate intervention owing to the child’s obvious allergic reaction.
QUESTION 2
Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above 100
Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry
Color: Body pink, blue extremities
A. 7
B. 10
C. 8
D. 9
Answer: A Explanation:
(A) Seven out of a possible perfect score of 10 is correct. Two points are given for heart rate above 100; 1 point
is given for slow, irregular respiratory effort; 1 point is given for some flex- ion of extremities in assessing
muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed for color
when the body is pink with blue extremities (acrocyanosis). (B) For a perfect Apgar score of
10, the infant would have a heart rate over 100 but would also have a good cry, active motion, and be completely
pink.
, NCLEX NCLEX-RN
(C) For an Apgar score of 8 the respiratory rate, muscle tone, or color would need to fall into the 2-point rather
than the 1-point category. (D) For this infant to receive an Apgar score of 9, four of the areas evaluated would
need ratings of 2 points and one area, a rating of 1 point.
QUESTION 3
A client has been diagnosed as being preeclamptic. The physician orders magnesium sulfate. Magnesium sulfate
(MgSO4) is used in the management of preeclampsia for:
A. Prevention of seizures
B. Prevention of uterine contractions
C. Sedation
D. Fetal lung protection
Answer: A Explanation:
(A) MgSO4 is classified as an anticonvulsant drug. In preeclampsia management, MgSO4 is used for
prevention of seizures. (B) MgSO4 has been used to inhibit hyperactive labor, but results are questionable. (C)
Negative side effects such as respiratory depression should not be confused with generalized sedation. (D)
MgSO4 does not affect lung maturity. The infant should be assessed for neuromuscular and respiratory
depression.
QUESTION 4
In the client with a diagnosis of coronary artery disease, the nurse would anticipate the complication of
bradycardia with occlusion of which coronary artery?
A. Right coronary artery
B. Left main coronary artery
C. Circumflex coronary artery
D. Left anterior descending coronary artery
Answer: A Explanation:
(A) Sinus bradycardia and atrioventricular (AV) heart block are usually a result of right coronary artery
occlusion. The right coronary artery perfuses the sinoatrial and AV nodes in mostindividuals. (B) Occlusion of
the left main coronary artery causes bundle branch blocks and premature ventricular contractions. (C) Occlusion
of the circumflex artery does not cause bradycardi
A. (D) Sinus tachycardia occurs primarily with left anterior descending coronary artery occlusion because this
form of occlusion impairs left ventricular function.
QUESTION 5
When the nurse is evaluating lab data for a client 18–24 hours after a major thermal burn, the expected
physiological changes would include which of the following?
A. Elevated serum sodium
B. Elevated serum calcium
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C. Elevated serum protein
D. Elevated hematocrit
Answer: D
Explanation:
(A) Sodium enters the edema fluid in the burned area, lowering the sodium content of the vascular fluid.
Hyponatremia may continue for days to several weeks because of sodium loss to edema, sodium shifting into the
cells, and later, diuresis. (B) Hypocalcemia occurs because of calcium loss to edema fluid at the burned site
(third space fluid). (C) Protein loss occurs at the burn site owing to increased capillary permeability. Serum
protein levels remain low until healing occurs. (D) Hematocrit level is elevated owing to hemoconcentration
from hypovolemi
A. Anemia is present in the postburn stage owing to blood loss and hemolysis, but it cannot be assessed until the
client is adequately hydrated.
QUESTION 6
What is the most effective method to identify early breast cancer lumps?
A. Mammograms every 3 years
B. Yearly checkups performed by physician
C. Ultrasounds every 3 years
D. Monthly breast self-examination
Answer: D Explanation:
(A) Mammograms are less effective than breast self-examination for the diagnosis of abnormalities in younger
women, who have denser breast tissue. They are more effective forwomen older than 40. (B) Up to 15% of early-
stage breast cancers are detected by physical examination; however, 95% are detected by women doing breast
self-examination. (C) Ultrasound is used primarily to determine the location of cysts and to distinguish cysts
from solid masses. (D) Monthly breast self-examination has been shown to be the most effective method for
early detection of breast cancer. Approximately 95% of lumps are detected by women themselves.
QUESTION 7
A client with a C-3–4 fracture has just arrived in the emergency room. The primary nursing intervention is:
A. Stabilization of the cervical spine
B. Airway assessment and stabilization
C. Confirmation of spinal cord injury
D. Normalization of intravascular volume
Answer: B Explanation:
(A) If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also
protects the cervical spine. (B) Primary intervention is protection of the airway and adequate ventilation. (C, D)
All other interventions are secondary to adequate ventilation.
, NCLEX NCLEX-RN
QUESTION 8
To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the
following responses with administration?
A. Stinging, burning when placed under the tongue
B. Temporary blurring of vision
C. Generalized urticaria with prolonged use
D. Urinary frequency
Answer: A Explanation:
(A) Stinging or burning when nitroglycerin is placed under the tongue is to be expected. This effect indicates
that the medication is potent and effective for use. Failure to have this response means that the client needs to
get a new bottle of nitroglycerin. (B, C, D) The other responses are not expected in this situation and are not
even side effects.
QUESTION 9
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
A. Maintaining seizure precautions
B. Restricting fluid intake
C. Increasing sensory stimuli
D. Applying ankle and wrist restraints
Answer: A Explanation:
(A) These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. (B) Fluid
intake should be increased to prevent dehydration. (C) Environmental stimuli should be decreased to prevent
precipitation of seizures. (D) Application of restraints may cause the client to increase his or her physical activity
and may eventually lead to exhaustion.
QUESTION 10
The day following his admission, the nurse sits down by a male client on the sofa in the dayroom. He was
admitted for depression and thoughts of suicide. He looks at the nurse and says, “My life is so bad no one can
do anything to help me.” The most helpful initial response by the nurse would be:
A. “It concerns me that you feel so badly when you have so many positive things in your life.”
B. “It will take a few weeks for you to feel better, so you need to be patient.”
C. “You are telling me that you are feeling hopeless at this point?”
D. “Let’s play cards with some of the other clients to get your mind off your problems for now.”
Answer: C Explanation:
(A) This response does not acknowledge the client’s feelings and may increase his feelings of guilt. (B) This
response denotes false reassurance. (C) This response acknowledges the client’s feelings and invites a response.
(D) This response changes the subject and does not allow the client to talk about his feelings.
NCLEX RN VERSIONS 1-12 EXAM QUESTIONS
& ANSWERS GUARANTEED 100 % CORRECT
QUESTION 1
The child with iron poisoning is given IV deforoxamine mesylate (Desferal). Following administration, the
child suffers hypotension, facial flushing, and urticari A. The initial nursing intervention would be to:
A. Discontinue the IV
B. Stop the medication, and begin a normal saline infusion
C. Take all vital signs, and report to the physician
D. Assess urinary output, and if it is 30 mL an hour, maintain current treatment
Answer: B
Explanation:
(A) The IV line should not be discontinued because other IV medications will be needed.
(B) Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction
and could go into shock if the medication is not stopped. The line should be kept opened for other
medication. (C) Taking vital signs and reporting to the physician is not an adequate intervention because the
IV medication continues to flow. (D) Assessing urinary output and, if it is 30 mL an hour, maintaining
current treatment is an inappropriate intervention owing to the child’s obvious allergic reaction.
QUESTION 2
Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above 100
Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry
Color: Body pink, blue extremities
A. 7
B. 10
C. 8
D. 9
Answer: A Explanation:
(A) Seven out of a possible perfect score of 10 is correct. Two points are given for heart rate above 100; 1 point
is given for slow, irregular respiratory effort; 1 point is given for some flex- ion of extremities in assessing
muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed for color
when the body is pink with blue extremities (acrocyanosis). (B) For a perfect Apgar score of
10, the infant would have a heart rate over 100 but would also have a good cry, active motion, and be completely
pink.
, NCLEX NCLEX-RN
(C) For an Apgar score of 8 the respiratory rate, muscle tone, or color would need to fall into the 2-point rather
than the 1-point category. (D) For this infant to receive an Apgar score of 9, four of the areas evaluated would
need ratings of 2 points and one area, a rating of 1 point.
QUESTION 3
A client has been diagnosed as being preeclamptic. The physician orders magnesium sulfate. Magnesium sulfate
(MgSO4) is used in the management of preeclampsia for:
A. Prevention of seizures
B. Prevention of uterine contractions
C. Sedation
D. Fetal lung protection
Answer: A Explanation:
(A) MgSO4 is classified as an anticonvulsant drug. In preeclampsia management, MgSO4 is used for
prevention of seizures. (B) MgSO4 has been used to inhibit hyperactive labor, but results are questionable. (C)
Negative side effects such as respiratory depression should not be confused with generalized sedation. (D)
MgSO4 does not affect lung maturity. The infant should be assessed for neuromuscular and respiratory
depression.
QUESTION 4
In the client with a diagnosis of coronary artery disease, the nurse would anticipate the complication of
bradycardia with occlusion of which coronary artery?
A. Right coronary artery
B. Left main coronary artery
C. Circumflex coronary artery
D. Left anterior descending coronary artery
Answer: A Explanation:
(A) Sinus bradycardia and atrioventricular (AV) heart block are usually a result of right coronary artery
occlusion. The right coronary artery perfuses the sinoatrial and AV nodes in mostindividuals. (B) Occlusion of
the left main coronary artery causes bundle branch blocks and premature ventricular contractions. (C) Occlusion
of the circumflex artery does not cause bradycardi
A. (D) Sinus tachycardia occurs primarily with left anterior descending coronary artery occlusion because this
form of occlusion impairs left ventricular function.
QUESTION 5
When the nurse is evaluating lab data for a client 18–24 hours after a major thermal burn, the expected
physiological changes would include which of the following?
A. Elevated serum sodium
B. Elevated serum calcium
, NCLEX NCLEX-RN
C. Elevated serum protein
D. Elevated hematocrit
Answer: D
Explanation:
(A) Sodium enters the edema fluid in the burned area, lowering the sodium content of the vascular fluid.
Hyponatremia may continue for days to several weeks because of sodium loss to edema, sodium shifting into the
cells, and later, diuresis. (B) Hypocalcemia occurs because of calcium loss to edema fluid at the burned site
(third space fluid). (C) Protein loss occurs at the burn site owing to increased capillary permeability. Serum
protein levels remain low until healing occurs. (D) Hematocrit level is elevated owing to hemoconcentration
from hypovolemi
A. Anemia is present in the postburn stage owing to blood loss and hemolysis, but it cannot be assessed until the
client is adequately hydrated.
QUESTION 6
What is the most effective method to identify early breast cancer lumps?
A. Mammograms every 3 years
B. Yearly checkups performed by physician
C. Ultrasounds every 3 years
D. Monthly breast self-examination
Answer: D Explanation:
(A) Mammograms are less effective than breast self-examination for the diagnosis of abnormalities in younger
women, who have denser breast tissue. They are more effective forwomen older than 40. (B) Up to 15% of early-
stage breast cancers are detected by physical examination; however, 95% are detected by women doing breast
self-examination. (C) Ultrasound is used primarily to determine the location of cysts and to distinguish cysts
from solid masses. (D) Monthly breast self-examination has been shown to be the most effective method for
early detection of breast cancer. Approximately 95% of lumps are detected by women themselves.
QUESTION 7
A client with a C-3–4 fracture has just arrived in the emergency room. The primary nursing intervention is:
A. Stabilization of the cervical spine
B. Airway assessment and stabilization
C. Confirmation of spinal cord injury
D. Normalization of intravascular volume
Answer: B Explanation:
(A) If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also
protects the cervical spine. (B) Primary intervention is protection of the airway and adequate ventilation. (C, D)
All other interventions are secondary to adequate ventilation.
, NCLEX NCLEX-RN
QUESTION 8
To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the
following responses with administration?
A. Stinging, burning when placed under the tongue
B. Temporary blurring of vision
C. Generalized urticaria with prolonged use
D. Urinary frequency
Answer: A Explanation:
(A) Stinging or burning when nitroglycerin is placed under the tongue is to be expected. This effect indicates
that the medication is potent and effective for use. Failure to have this response means that the client needs to
get a new bottle of nitroglycerin. (B, C, D) The other responses are not expected in this situation and are not
even side effects.
QUESTION 9
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
A. Maintaining seizure precautions
B. Restricting fluid intake
C. Increasing sensory stimuli
D. Applying ankle and wrist restraints
Answer: A Explanation:
(A) These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. (B) Fluid
intake should be increased to prevent dehydration. (C) Environmental stimuli should be decreased to prevent
precipitation of seizures. (D) Application of restraints may cause the client to increase his or her physical activity
and may eventually lead to exhaustion.
QUESTION 10
The day following his admission, the nurse sits down by a male client on the sofa in the dayroom. He was
admitted for depression and thoughts of suicide. He looks at the nurse and says, “My life is so bad no one can
do anything to help me.” The most helpful initial response by the nurse would be:
A. “It concerns me that you feel so badly when you have so many positive things in your life.”
B. “It will take a few weeks for you to feel better, so you need to be patient.”
C. “You are telling me that you are feeling hopeless at this point?”
D. “Let’s play cards with some of the other clients to get your mind off your problems for now.”
Answer: C Explanation:
(A) This response does not acknowledge the client’s feelings and may increase his feelings of guilt. (B) This
response denotes false reassurance. (C) This response acknowledges the client’s feelings and invites a response.
(D) This response changes the subject and does not allow the client to talk about his feelings.
