NCLEX PN 2024 / PN NCLEX EXAM NEWEST ACTUAL
EXAM 120 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
The nurse is planning care for a client with moderate Alzheimer's disease (AD).
Which of the following interventions should the nurse include in the client's plan of care? Select all that
apply.
1. Establish a daily routine for the client.
2. Assist the client to void every 2 hours.
3. Introduce self upon interacting with the client.
4. Display a clock and calendar in the client's room.
5. Keep the client's television on during the day to distract the client. - answer-1, 2, 3, 4
A parent is discussing with the nurse about the behaviors of a 4-year-old child following the death of a
grandparent.
The nurse should understand that the child may be experiencing dysfunctional grieving if the parent
reports that the child
1. conducts mock funerals with stuffed animals
2. refuses to go to sleep at night
3. continues to talk about the grandparent coming to visit
4. asks to play with the grandparent while at the cemetery - answer-2. refuses to go to sleep at night
The nurse has taught a client who has been ordered a low-sodium diet about appropriate food choices.
Which of the following statements by the client would indicate a correct understanding of the teaching?
1. "I will eat steamed, fresh broccoli with herbs and spices for an evening meal."
2. "I will add cottage cheese and other dairy products to my daily diet."
3. "I am glad I can still enjoy eating cereals, such as bran flakes with raisins."
4. "I am glad I can eat lean meats daily because I eat ham sandwiches for an afternoon meal." -
answer-
1. "I will eat steamed, fresh broccoli with herbs and spices for an evening meal."
,Veggies are low sodium and herbs and spices are great substitutes for salt.
The nurse is caring for a client who had a left modified radical mastectomy. The client received discharge
instructions for performing range-of-motion (ROM) exercises on her left arm. Which of the following, if
reported by the client on her return visit to the clinic, would indicate to the nurse that the instructions
have been followed correctly?
1. regular squeezing of a tennis ball in her left hand
2. placing her left palm against a wall and "climbing" the wall with the left fingers
3. carrying light hand weights while walking 1 mile every other day
4. performing isometric exercises with both arms extended - answer-2. placing her left palm against a
wall and "climbing" the wall with the left fingers
The nurse is planning care for a client who has expressive aphasia after a left-sided stroke. Which of the
following statements by the client's spouse would indicate a correct understanding of the client's
communication abilities and interaction needs? Select all that apply.
1. "My spouse's response of 'fine' when asked how the day has been may or may not be what my
spouse meant to communicate."
2. "I can anticipate what my spouse wants to say, so I complete my spouse's sentences to make
communication quicker."
3. "I will purchase a picture board to help my spouse express common needs, thoughts, and
feelings that are difficult to communicate."
4. "My spouse's angry response when we have a conversation makes me hesitant to try further
communication."
5. "I have arranged for my spouse to meet with a speech therapist twice each week to improve
communication skills." - answer-1,3,5
The nurse is caring for a client who is in Buck traction. Which of the following would require immediate
intervention?
1. A pillow is placed under the knee.
2. The foot is 2 in (5 cm) away from the foot plate.
3. The weights attached to the pulley are 6 in (15 cm) from the floor.
4. A pillow is placed under the lower leg with the heel off the bed. - answer-2. The foot is 2 in (5 cm)
away from the foot plate.
,Should be touching the foot plate
The nurse has taught the adult child caregiver of a client with moderate Alzheimer's disease (AD) about
home care. Which of the following statements by the adult child would indicate a correct understanding
of the teaching?
1. "I will only allow my parent to smoke while my parent is outdoors."
2. "I will place a picture on the bathroom door to indicate which room in our home is the bathroom."
3. "I will encourage family members to visit in large groups to keep my parent interested in the
conversation."
4. "I will encourage my parent to take walks in the park when the weather permits to get the exercise
needed." - answer-2. "I will place a picture on the bathroom door to indicate which room in our
home is the bathroom."
4. dangerous, they can get lost
The nurse is teaching a client newly diagnosed with diverticulosis. Which of the following information
should the nurse include?
1. "Limit your daily fluid intake to 2 L to avoid bloating."
2. "You may be prescribed a bulk-forming laxative."
3. "Limit your intake of dairy products such as milk and yogurt."
4. "You should avoid consuming cooked vegetables." - answer-2. "You may be prescribed a bulk-
forming laxative."
No need to restrict fluids and no need to restrict diet. Diet does not cause diverticulitis exacerbations!
The nurse is preparing to administer lorazepam 2 mg, IV, now to a client who is scheduled for surgery in
30 minutes. The nurse is unfamiliar with the dosage for the medication.
Which of the following actions should the nurse take next?
1. Check the medication dosage in a medication reference source.
2. Ask another nurse whether the prescribed dose is a safe dose.
3. Clarify that the dose is correct with the primary health care provider.
, 4. Contact the pharmacist to verify the safe dosage range for the medication. - answer-1. Check the
medication dosage in a medication reference source.
The nurse is caring for a client who is receiving a high dose of a phenothiazine. When evaluating the
client for a life-threatening syndrome related to the medication, it would be a priority for the nurse to
report
1. dry mouth
2. orthostatic hypotension
3. fever
4. photophobia - answer-3. fever
Rationale: Phenothazine side effects include ABCDEFG -- Anticholinergic (dry mouth), blurry vision,
constipation, drowsiness, EPS, Photosensitivity, and agranulocytosis. Fever would be a complication of
agranulocytosis and requires the nurse to report.
The nurse is caring for a client who is receiving a blood transfusion and states, "I feel chilled and am
having back pain." Which of the following actions should the nurse take? Select all that apply.
1. Stop the transfusion.
2. Check the client's vital signs.
3. Notify the client's primary health care provider.
4. Return the blood and infusion tubing to the blood bank.
5. Infuse 5% dextrose in water through the intravenous catheter.
6. Administer a dose of an antiemetic prescribed p.r.n. to the client. - answer-1, 2, 3, 4
Back pain and chills are symptoms of Hemolytic transfusion reaction (wrong blood type). Must stop
infusion, check vital signs, and notify the provider
5. NS to keep the line open, not dextrose in water
The nurse is preparing a staff education program about total parenteral nutrition (TPN). Which of the
following information should the nurse include? Select all that apply.
1. "The TPN intravenous tubing should be changed once a week."
EXAM 120 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
The nurse is planning care for a client with moderate Alzheimer's disease (AD).
Which of the following interventions should the nurse include in the client's plan of care? Select all that
apply.
1. Establish a daily routine for the client.
2. Assist the client to void every 2 hours.
3. Introduce self upon interacting with the client.
4. Display a clock and calendar in the client's room.
5. Keep the client's television on during the day to distract the client. - answer-1, 2, 3, 4
A parent is discussing with the nurse about the behaviors of a 4-year-old child following the death of a
grandparent.
The nurse should understand that the child may be experiencing dysfunctional grieving if the parent
reports that the child
1. conducts mock funerals with stuffed animals
2. refuses to go to sleep at night
3. continues to talk about the grandparent coming to visit
4. asks to play with the grandparent while at the cemetery - answer-2. refuses to go to sleep at night
The nurse has taught a client who has been ordered a low-sodium diet about appropriate food choices.
Which of the following statements by the client would indicate a correct understanding of the teaching?
1. "I will eat steamed, fresh broccoli with herbs and spices for an evening meal."
2. "I will add cottage cheese and other dairy products to my daily diet."
3. "I am glad I can still enjoy eating cereals, such as bran flakes with raisins."
4. "I am glad I can eat lean meats daily because I eat ham sandwiches for an afternoon meal." -
answer-
1. "I will eat steamed, fresh broccoli with herbs and spices for an evening meal."
,Veggies are low sodium and herbs and spices are great substitutes for salt.
The nurse is caring for a client who had a left modified radical mastectomy. The client received discharge
instructions for performing range-of-motion (ROM) exercises on her left arm. Which of the following, if
reported by the client on her return visit to the clinic, would indicate to the nurse that the instructions
have been followed correctly?
1. regular squeezing of a tennis ball in her left hand
2. placing her left palm against a wall and "climbing" the wall with the left fingers
3. carrying light hand weights while walking 1 mile every other day
4. performing isometric exercises with both arms extended - answer-2. placing her left palm against a
wall and "climbing" the wall with the left fingers
The nurse is planning care for a client who has expressive aphasia after a left-sided stroke. Which of the
following statements by the client's spouse would indicate a correct understanding of the client's
communication abilities and interaction needs? Select all that apply.
1. "My spouse's response of 'fine' when asked how the day has been may or may not be what my
spouse meant to communicate."
2. "I can anticipate what my spouse wants to say, so I complete my spouse's sentences to make
communication quicker."
3. "I will purchase a picture board to help my spouse express common needs, thoughts, and
feelings that are difficult to communicate."
4. "My spouse's angry response when we have a conversation makes me hesitant to try further
communication."
5. "I have arranged for my spouse to meet with a speech therapist twice each week to improve
communication skills." - answer-1,3,5
The nurse is caring for a client who is in Buck traction. Which of the following would require immediate
intervention?
1. A pillow is placed under the knee.
2. The foot is 2 in (5 cm) away from the foot plate.
3. The weights attached to the pulley are 6 in (15 cm) from the floor.
4. A pillow is placed under the lower leg with the heel off the bed. - answer-2. The foot is 2 in (5 cm)
away from the foot plate.
,Should be touching the foot plate
The nurse has taught the adult child caregiver of a client with moderate Alzheimer's disease (AD) about
home care. Which of the following statements by the adult child would indicate a correct understanding
of the teaching?
1. "I will only allow my parent to smoke while my parent is outdoors."
2. "I will place a picture on the bathroom door to indicate which room in our home is the bathroom."
3. "I will encourage family members to visit in large groups to keep my parent interested in the
conversation."
4. "I will encourage my parent to take walks in the park when the weather permits to get the exercise
needed." - answer-2. "I will place a picture on the bathroom door to indicate which room in our
home is the bathroom."
4. dangerous, they can get lost
The nurse is teaching a client newly diagnosed with diverticulosis. Which of the following information
should the nurse include?
1. "Limit your daily fluid intake to 2 L to avoid bloating."
2. "You may be prescribed a bulk-forming laxative."
3. "Limit your intake of dairy products such as milk and yogurt."
4. "You should avoid consuming cooked vegetables." - answer-2. "You may be prescribed a bulk-
forming laxative."
No need to restrict fluids and no need to restrict diet. Diet does not cause diverticulitis exacerbations!
The nurse is preparing to administer lorazepam 2 mg, IV, now to a client who is scheduled for surgery in
30 minutes. The nurse is unfamiliar with the dosage for the medication.
Which of the following actions should the nurse take next?
1. Check the medication dosage in a medication reference source.
2. Ask another nurse whether the prescribed dose is a safe dose.
3. Clarify that the dose is correct with the primary health care provider.
, 4. Contact the pharmacist to verify the safe dosage range for the medication. - answer-1. Check the
medication dosage in a medication reference source.
The nurse is caring for a client who is receiving a high dose of a phenothiazine. When evaluating the
client for a life-threatening syndrome related to the medication, it would be a priority for the nurse to
report
1. dry mouth
2. orthostatic hypotension
3. fever
4. photophobia - answer-3. fever
Rationale: Phenothazine side effects include ABCDEFG -- Anticholinergic (dry mouth), blurry vision,
constipation, drowsiness, EPS, Photosensitivity, and agranulocytosis. Fever would be a complication of
agranulocytosis and requires the nurse to report.
The nurse is caring for a client who is receiving a blood transfusion and states, "I feel chilled and am
having back pain." Which of the following actions should the nurse take? Select all that apply.
1. Stop the transfusion.
2. Check the client's vital signs.
3. Notify the client's primary health care provider.
4. Return the blood and infusion tubing to the blood bank.
5. Infuse 5% dextrose in water through the intravenous catheter.
6. Administer a dose of an antiemetic prescribed p.r.n. to the client. - answer-1, 2, 3, 4
Back pain and chills are symptoms of Hemolytic transfusion reaction (wrong blood type). Must stop
infusion, check vital signs, and notify the provider
5. NS to keep the line open, not dextrose in water
The nurse is preparing a staff education program about total parenteral nutrition (TPN). Which of the
following information should the nurse include? Select all that apply.
1. "The TPN intravenous tubing should be changed once a week."
