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NCLEX-RN EXAM| NCLEX EXAM PREVIEW
WITH RATIONALES NEW EXAM QUESTIONS
WITH CORRECT ANSWERS
The nurse is evaluating a staff member's care of a client with active pulmonary tuberculosis
(TB). Which of the following actions by the staff member would indicate to the nurse an
understanding of the principles of infection control for tuberculosis isolation?
1. instructing visitors to wash their hands before entering the client's room
2. putting on a mask, gown, and gloves before entering the client's room
3. placing tissues and a trash receptacle within the client's reach
4. asking the client to put on a clean mask each time someone enters the room --
ANSWER--
3. placing tissues and a trash receptacle within the client's reach
Important to not leave tissues laying around and to put them in a leak proof bag in the trash.
The nurse in the pediatric unit is preparing to admit a client with rubeola (measles). The nurse
should assign the client to a
1. private room at the end of the hallway
2. private room with monitored negative air pressure
3. room with a client who has chickenpox
4. room with a client who has atopic dermatitis (eczema) -- ANSWER--2. private room
with monitored negative air pressure
Measles is airborne (MTV) and requires a private room with negative air pressure
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The charge nurse is observing the following client situations. It would require intervention if
a
1. client with hepatitis B (HBV) is eating food brought into the facility by a visitor
2. visitor is sitting on the side of the bed of a client with acute pancreatitis
3. staff member is entering the room of a client with Haemophilus influenzae meningitis
wearing a protective gown and gloves
4. family member of a client with mycoplasma pneumonia leaves the door to the client's
room open -- ANSWER--1. client with hepatitis B (HBV) is eating food brought into the
facility by a visitor
HBV is spread through contact with body fluids including saliva, so it is important to
intervene if the patient is eating and possibly sharing food with another person.
The nurse has become aware of the following client situations. The nurse should first assess
the client
1. who had a right pneumonectomy 24 hours ago and is in the high-Fowler's position
while lying on the right side
2. with chronic obstructive pulmonary disease (COPD) who is using pursed-lip
breathing and reporting hemoptysis
3. who had a wedge resection of the left lung 24 hours ago and is sitting in the high-
Fowler's position
4. with heart failure who has a productive cough and is restless -- ANSWER--4. with
heart failure who has a productive cough and is restless
Productive cough (pink frothy sputum) is indicative of pulmonary edema which is
lifethreatening. T(x) would be to improve cardiac output by placing client in high fowlers,
O2, mechanical ventilation, meds
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The nurse is caring for a 3-year-old client with a cerebral concussion who is being observed
overnight in the pediatric unit. Which of the following observations would be most
significant for the nurse to report to the oncoming shift?
1. The client has a blood pressure of 94/58 mm Hg and an apical pulse of 90.
2. The client is sleeping but is easily aroused.
3. The client's pupils are equal and reactive to light.
4. The client has an axillary temperature of 99.0° F (37.2° C) and respirations of 24. --
ANSWER--2. The client is sleeping but is easily aroused.
Important to keep checking for decline in M/S with concussions, even when sleeping.
The nurse in the same-day surgical center has received a change-of-shift report on the
following clients. The nurse should first see the client who had
1. closed reduction of a fractured tibia with cast application 1 hour ago and is reporting
that the casted leg feels hot
2. extraction of a cataract lens 2 hours ago and is reporting nausea
3. an arthroscopy of the right knee 3 hours ago and is reporting knee pain rated as 4 on a
scale of 0 (no pain) to 10 (severe pain)
4. a laparoscopic cholecystectomy 4 hours ago and is reporting right shoulder pain --
ANSWER--1. closed reduction of a fractured tibia with cast application 1 hour ago and is
reporting that the casted leg feels hot
Pain, tightness, hot feeling can indicate that the cast is on too tight
Rationale:
2. Normal to feel nauseous after coming off of anesthesia
3. Knee pain is expected after knee surgery
4. Right shoulder pain is common in laparoscopic cholecystectomy due to gas left in
abdomen after the procedure. Will resolve on its own
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The nurse is planning care for a client with multiple sclerosis (MS) who has ataxia. Which of
the following interventions should the nurse include in the client's plan of care?
1. Add thickener to thin liquids for the client.
2. Obtain a referral to a physical therapist for the client.
3. Face the client directly when speaking with the client.
4. Provide a board with pictures to help the client communicate needs. -- ANSWER--2.
Obtain a referral to a physical therapist for the client.
Ataxia is lack of muscle control in arms and legs leading to lack of balance, coordination, and
walking. PT is the area of referral for this type of issue.
Rationale:
1. thick liquids for dysphagia
3. Always indicated
4. Can be a tool for patients with expressive aphasia
The nurse is teaching a client how to ambulate using crutches. Which of the following
information should the nurse include?
1. "Use your hands and arms to support your body weight."
2. "Wear slippers when ambulating with the crutches in your home."
3. "Maintain the crutches 12 in (30 cm) in front of your feet while standing."
4. "Adjust the hand grips of the crutches so that your elbows are fully extended." --
ANSWER--1. "Use your hands and arms to support your body weight."
True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s: paresis and
paresthesias in wrists and hands
NCLEX-RN EXAM| NCLEX EXAM PREVIEW
WITH RATIONALES NEW EXAM QUESTIONS
WITH CORRECT ANSWERS
The nurse is evaluating a staff member's care of a client with active pulmonary tuberculosis
(TB). Which of the following actions by the staff member would indicate to the nurse an
understanding of the principles of infection control for tuberculosis isolation?
1. instructing visitors to wash their hands before entering the client's room
2. putting on a mask, gown, and gloves before entering the client's room
3. placing tissues and a trash receptacle within the client's reach
4. asking the client to put on a clean mask each time someone enters the room --
ANSWER--
3. placing tissues and a trash receptacle within the client's reach
Important to not leave tissues laying around and to put them in a leak proof bag in the trash.
The nurse in the pediatric unit is preparing to admit a client with rubeola (measles). The nurse
should assign the client to a
1. private room at the end of the hallway
2. private room with monitored negative air pressure
3. room with a client who has chickenpox
4. room with a client who has atopic dermatitis (eczema) -- ANSWER--2. private room
with monitored negative air pressure
Measles is airborne (MTV) and requires a private room with negative air pressure
, Page 2 of 78
The charge nurse is observing the following client situations. It would require intervention if
a
1. client with hepatitis B (HBV) is eating food brought into the facility by a visitor
2. visitor is sitting on the side of the bed of a client with acute pancreatitis
3. staff member is entering the room of a client with Haemophilus influenzae meningitis
wearing a protective gown and gloves
4. family member of a client with mycoplasma pneumonia leaves the door to the client's
room open -- ANSWER--1. client with hepatitis B (HBV) is eating food brought into the
facility by a visitor
HBV is spread through contact with body fluids including saliva, so it is important to
intervene if the patient is eating and possibly sharing food with another person.
The nurse has become aware of the following client situations. The nurse should first assess
the client
1. who had a right pneumonectomy 24 hours ago and is in the high-Fowler's position
while lying on the right side
2. with chronic obstructive pulmonary disease (COPD) who is using pursed-lip
breathing and reporting hemoptysis
3. who had a wedge resection of the left lung 24 hours ago and is sitting in the high-
Fowler's position
4. with heart failure who has a productive cough and is restless -- ANSWER--4. with
heart failure who has a productive cough and is restless
Productive cough (pink frothy sputum) is indicative of pulmonary edema which is
lifethreatening. T(x) would be to improve cardiac output by placing client in high fowlers,
O2, mechanical ventilation, meds
, Page 3 of 78
The nurse is caring for a 3-year-old client with a cerebral concussion who is being observed
overnight in the pediatric unit. Which of the following observations would be most
significant for the nurse to report to the oncoming shift?
1. The client has a blood pressure of 94/58 mm Hg and an apical pulse of 90.
2. The client is sleeping but is easily aroused.
3. The client's pupils are equal and reactive to light.
4. The client has an axillary temperature of 99.0° F (37.2° C) and respirations of 24. --
ANSWER--2. The client is sleeping but is easily aroused.
Important to keep checking for decline in M/S with concussions, even when sleeping.
The nurse in the same-day surgical center has received a change-of-shift report on the
following clients. The nurse should first see the client who had
1. closed reduction of a fractured tibia with cast application 1 hour ago and is reporting
that the casted leg feels hot
2. extraction of a cataract lens 2 hours ago and is reporting nausea
3. an arthroscopy of the right knee 3 hours ago and is reporting knee pain rated as 4 on a
scale of 0 (no pain) to 10 (severe pain)
4. a laparoscopic cholecystectomy 4 hours ago and is reporting right shoulder pain --
ANSWER--1. closed reduction of a fractured tibia with cast application 1 hour ago and is
reporting that the casted leg feels hot
Pain, tightness, hot feeling can indicate that the cast is on too tight
Rationale:
2. Normal to feel nauseous after coming off of anesthesia
3. Knee pain is expected after knee surgery
4. Right shoulder pain is common in laparoscopic cholecystectomy due to gas left in
abdomen after the procedure. Will resolve on its own
, Page 4 of 78
The nurse is planning care for a client with multiple sclerosis (MS) who has ataxia. Which of
the following interventions should the nurse include in the client's plan of care?
1. Add thickener to thin liquids for the client.
2. Obtain a referral to a physical therapist for the client.
3. Face the client directly when speaking with the client.
4. Provide a board with pictures to help the client communicate needs. -- ANSWER--2.
Obtain a referral to a physical therapist for the client.
Ataxia is lack of muscle control in arms and legs leading to lack of balance, coordination, and
walking. PT is the area of referral for this type of issue.
Rationale:
1. thick liquids for dysphagia
3. Always indicated
4. Can be a tool for patients with expressive aphasia
The nurse is teaching a client how to ambulate using crutches. Which of the following
information should the nurse include?
1. "Use your hands and arms to support your body weight."
2. "Wear slippers when ambulating with the crutches in your home."
3. "Maintain the crutches 12 in (30 cm) in front of your feet while standing."
4. "Adjust the hand grips of the crutches so that your elbows are fully extended." --
ANSWER--1. "Use your hands and arms to support your body weight."
True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s: paresis and
paresthesias in wrists and hands
