Nclex- Rn Exam Preparation VERSION 2 REAL
EXAM Paper with 100% correct answers 2023
Updated Summer qtr
1. Question
The nurse is providing discharge teaching for the client with
leukemia. The client should be told to avoid:
o A. Using oil- or cream-based soaps
o B. Flossing between the teeth
o C. The intake of salt
o D. Using an electric razor
Correct Answer: B. Flossing between the teeth
The client who is immune-suppressed and has bone marrow
suppression should be taught not to floss his teeth because
platelets are decreased.
o Option A: Oil or cream-based soap is allowed for
leukemia patients because these will prevent dry skin,
which predisposes to skin injury.
o Option C: A healthy amount of salt in the patient’s
food is allowed.
o Option D: The use of an electric razor is
recommended because it reduces the risk of injury to
the skin that can cause bleeding.
• 2. Question
The nurse is changing the ties of the client with a tracheostomy.
The safest method of changing the tracheostomy ties is to:
o A. Apply the new tie before removing the old one.
o B. Have a helper present.
, o C. Hold the tracheostomy with the nondominant hand
while removing the old tie.
o D. Ask the doctor to suture the tracheostomy in place.
Correct Answer: A. Apply the new tie before removing the
old one.
Leaving the old ties in place while securing the clean ties
prevents inadvertent dislodging of the tracheostomy tube.
o Option B: Having a helper is good, but the helper
might not prevent the client from coughing out the
tracheotomy.
o Option C: Hold the tracheostomy with the
nondominant hand while removing the old tie is not
the best way to prevent the client from coughing out
the tracheotomy.
o Option D: Asking the doctor to suture the
tracheostomy in place is unnecessary.
• 3. Question
The nurse is monitoring a client following a lung resection. The
hourly output from the chest tube was 300mL. The nurse should
give priority to:
o A. Turning the client to the left side
o B. Milking the tube to ensure patency
o C. Slowing the intravenous infusion
o D. Notifying the physician
Correct Answer: D. Notifying the physician
The output of 300 mL is indicative of hemorrhage and should be
reported immediately.
o Option A: Turning the client to the left side does
nothing to help the client.
o Options B and C: Milking the tube is done only with
an order and will not help in this situation, and slowing
the intravenous infusion is not an appropriate action.
, • 4. Question
The infant is admitted to the unit with tetralogy of fallot. The
nurse would anticipate an order for which medication?
o A. Digoxin
o B. Epinephrine
o C. Aminophylline
o D. Atropine
Correct Answer: A. Digoxin
The infant with Tetralogy of Fallot involves four heart defects: A
large ventricular septal defect (VSD), Pulmonary stenosis, Right
ventricular hypertrophy and, An overriding aorta. He will be
treated with digoxin to slow and strengthen the heart.
o Option B: One of the side effects of epinephrine is the
pounding, fast, or irregular heartbeat, which is
detrimental to a patient with Tetralogy of Fallot.
o Option C: Increased or rapid heart rate is an adverse
effect of aminophylline and should be avoided for a
patient with Tetralogy of Fallot.
o Option D: Atropine prevents or abolishes bradycardia.
• 5. Question
The nurse is educating the lady’s club in a self-breast exam. The
nurse is aware that most malignant breast masses occur in the
Tail of Spence.
On the diagram below, select where the Tail of Spence is.
, o A
o B
o C
o D
Correct Answer: A.
The Tail of Spence is located in the upper outer quadrant of the
breast.
o Option B: Option B is the areola, a dark area of skin
surrounding the nipple.
• 6. Question
The toddler is admitted with a cardiac anomaly. The nurse is
aware that the infant with a ventricular septal defect will:
o A. Tire easily
o B. Grow normally
o C. Need more calories
o D. Be more susceptible to viral infections
EXAM Paper with 100% correct answers 2023
Updated Summer qtr
1. Question
The nurse is providing discharge teaching for the client with
leukemia. The client should be told to avoid:
o A. Using oil- or cream-based soaps
o B. Flossing between the teeth
o C. The intake of salt
o D. Using an electric razor
Correct Answer: B. Flossing between the teeth
The client who is immune-suppressed and has bone marrow
suppression should be taught not to floss his teeth because
platelets are decreased.
o Option A: Oil or cream-based soap is allowed for
leukemia patients because these will prevent dry skin,
which predisposes to skin injury.
o Option C: A healthy amount of salt in the patient’s
food is allowed.
o Option D: The use of an electric razor is
recommended because it reduces the risk of injury to
the skin that can cause bleeding.
• 2. Question
The nurse is changing the ties of the client with a tracheostomy.
The safest method of changing the tracheostomy ties is to:
o A. Apply the new tie before removing the old one.
o B. Have a helper present.
, o C. Hold the tracheostomy with the nondominant hand
while removing the old tie.
o D. Ask the doctor to suture the tracheostomy in place.
Correct Answer: A. Apply the new tie before removing the
old one.
Leaving the old ties in place while securing the clean ties
prevents inadvertent dislodging of the tracheostomy tube.
o Option B: Having a helper is good, but the helper
might not prevent the client from coughing out the
tracheotomy.
o Option C: Hold the tracheostomy with the
nondominant hand while removing the old tie is not
the best way to prevent the client from coughing out
the tracheotomy.
o Option D: Asking the doctor to suture the
tracheostomy in place is unnecessary.
• 3. Question
The nurse is monitoring a client following a lung resection. The
hourly output from the chest tube was 300mL. The nurse should
give priority to:
o A. Turning the client to the left side
o B. Milking the tube to ensure patency
o C. Slowing the intravenous infusion
o D. Notifying the physician
Correct Answer: D. Notifying the physician
The output of 300 mL is indicative of hemorrhage and should be
reported immediately.
o Option A: Turning the client to the left side does
nothing to help the client.
o Options B and C: Milking the tube is done only with
an order and will not help in this situation, and slowing
the intravenous infusion is not an appropriate action.
, • 4. Question
The infant is admitted to the unit with tetralogy of fallot. The
nurse would anticipate an order for which medication?
o A. Digoxin
o B. Epinephrine
o C. Aminophylline
o D. Atropine
Correct Answer: A. Digoxin
The infant with Tetralogy of Fallot involves four heart defects: A
large ventricular septal defect (VSD), Pulmonary stenosis, Right
ventricular hypertrophy and, An overriding aorta. He will be
treated with digoxin to slow and strengthen the heart.
o Option B: One of the side effects of epinephrine is the
pounding, fast, or irregular heartbeat, which is
detrimental to a patient with Tetralogy of Fallot.
o Option C: Increased or rapid heart rate is an adverse
effect of aminophylline and should be avoided for a
patient with Tetralogy of Fallot.
o Option D: Atropine prevents or abolishes bradycardia.
• 5. Question
The nurse is educating the lady’s club in a self-breast exam. The
nurse is aware that most malignant breast masses occur in the
Tail of Spence.
On the diagram below, select where the Tail of Spence is.
, o A
o B
o C
o D
Correct Answer: A.
The Tail of Spence is located in the upper outer quadrant of the
breast.
o Option B: Option B is the areola, a dark area of skin
surrounding the nipple.
• 6. Question
The toddler is admitted with a cardiac anomaly. The nurse is
aware that the infant with a ventricular septal defect will:
o A. Tire easily
o B. Grow normally
o C. Need more calories
o D. Be more susceptible to viral infections
