NURS 120 Exam 1 – Actual NCLEX
Questions & Answers (WCU) 100%
Guarantee Pass
1. A nurse is planning care for a client to prevent postoperative atelectasis.
Which of the following interventions should the nurse include in the plan of
care? (SATA)
A. Encourage use of IS every 2h
B. Instruct client to splint the incision when coughing and deep breathing
C. Reposition every 2h
D. Administer antibiotic therapy
E. Assist with early ambulation
Answer: A, B, C, E
2. A nurse is caring for a client who arrived in the PACU following a total hip
arthroplasty. The client is not responding to verbal stimuli. Which of the
following actions should the nurse perform first?
A. Compare and contrast the peripheral pulses
B. Apply a warm blanket
C. Assess dressings
D. Place the client in a lateral position
Answer: D
3. A nurse is caring for a client who is scheduled for an exploratory
laparotomy. The client's temperature is 102.2°F orally. Which of the following
actions should the nurse take?
A. Inform the surgeon of elevated temp
B. Transfer the client to the preoperative unit
C. Apply ice packs to the groin
,D. Encourage the client to increase intake of clear liquids
Answer: A
4. A nurse is caring for a client who reports nausea and vomiting 2 days
postoperative following hysterectomy. Which of the following actions should
the nurse perform first?
A. Assess bowel sounds
B. Administer antiemetic medication
C. Restart prescribed IV fluids
D. Insert prescribed NG tube
Answer: A
5. A nurse is caring for a female client who manifests indications of
hypovolemia while in the PACU. Which of the following findings requires action
by the nurse? (SATA)
A. Urine output less than 25 mL/hr
B. Hematocrit 48%
C. BUN 24 mg/dL
D. Tenting of skin over the sternum
E. Apical pulse rate 62/min
Answer: A, B, C, D
6. A nurse is providing preoperative teaching to a client who is to have
abdominal surgery. Which of the following statements should the nurse make?
(SATA)
A. "Take your heart medication with a sip of water before surgery."
B. "Splint the abdominal incision with a pillow when coughing and deep
breathing."
C. "Bed rest is recommended for the first 48 hr."
,D. "Antiembolism stockings are applied before surgery."
E. "You may eat solid foods up to 4 hr before surgery."
Answer: A, B, D
7. A nurse is reviewing the health records of several clients in the PACU to
identify risk factors that can lead to postoperative complications. Which of the
following clients are at risk for complications? (SATA)
A. A client who has a WBC of 22,500/uL
B. A client who uses an insulin pump
C. A client who takes warfarin daily
D. A client who has heart failure
E. A client who has a BMI of 26
Answer: A, B, C, D
8. A nurse is verifying informed consent for a client who is having a
paracentesis. Which of the following actions should the nurse take? (SATA)
A. Explain to the client the purpose of having the procedure
B. Inform the client of risks to having the procedure
C. Ensure the client understands information about the procedure
D. Witness the client signing the informed consent form
E. Determine if the client is capable of understanding the reason for the
procedure
Answer: C, D, E
9. A preoperative nurse is caring for a client who is having a colon resection.
Which of the following actions should the nurse take?
A. Encourage the client to void after preoperative medication administration
B. Administer antibiotics 2 hr prior to surgical incision
C. Remove hair using a manual razor
, D. Remove nail polish
Answer: D
10. A charge nurse is discussing critical thinking attitudes with a newly
licensed nurse. Match the following nursing actions with the critical thinking
attitude.
Confidence
Integrity
Humility
Discipline
Curiosity
A. Showing honesty when caring for clients
B. Using a head-to-toe approach to conduct a physical examination on a client
C. Speaking with certainty to a client when instructing them about a new diet
D. Asking questions to obtain more information about a client's problem
E. Identifying limitations of oneself when dealing with a clinical situation
Answer: 1-C, 2-A, 3-E, 4-B, 5-D
11. A charge nurse is discussing critical thinking attitudes with a newly
licensed nurse. Match the following nursing actions with the critical thinking
attitude.
Creativity
Risk-taking
Fairness
Perseverance
Responsibility
A. Caring for a client in a nonjudgmental manner
B. Checking a client's medical record for allergies before administering a
medication
Questions & Answers (WCU) 100%
Guarantee Pass
1. A nurse is planning care for a client to prevent postoperative atelectasis.
Which of the following interventions should the nurse include in the plan of
care? (SATA)
A. Encourage use of IS every 2h
B. Instruct client to splint the incision when coughing and deep breathing
C. Reposition every 2h
D. Administer antibiotic therapy
E. Assist with early ambulation
Answer: A, B, C, E
2. A nurse is caring for a client who arrived in the PACU following a total hip
arthroplasty. The client is not responding to verbal stimuli. Which of the
following actions should the nurse perform first?
A. Compare and contrast the peripheral pulses
B. Apply a warm blanket
C. Assess dressings
D. Place the client in a lateral position
Answer: D
3. A nurse is caring for a client who is scheduled for an exploratory
laparotomy. The client's temperature is 102.2°F orally. Which of the following
actions should the nurse take?
A. Inform the surgeon of elevated temp
B. Transfer the client to the preoperative unit
C. Apply ice packs to the groin
,D. Encourage the client to increase intake of clear liquids
Answer: A
4. A nurse is caring for a client who reports nausea and vomiting 2 days
postoperative following hysterectomy. Which of the following actions should
the nurse perform first?
A. Assess bowel sounds
B. Administer antiemetic medication
C. Restart prescribed IV fluids
D. Insert prescribed NG tube
Answer: A
5. A nurse is caring for a female client who manifests indications of
hypovolemia while in the PACU. Which of the following findings requires action
by the nurse? (SATA)
A. Urine output less than 25 mL/hr
B. Hematocrit 48%
C. BUN 24 mg/dL
D. Tenting of skin over the sternum
E. Apical pulse rate 62/min
Answer: A, B, C, D
6. A nurse is providing preoperative teaching to a client who is to have
abdominal surgery. Which of the following statements should the nurse make?
(SATA)
A. "Take your heart medication with a sip of water before surgery."
B. "Splint the abdominal incision with a pillow when coughing and deep
breathing."
C. "Bed rest is recommended for the first 48 hr."
,D. "Antiembolism stockings are applied before surgery."
E. "You may eat solid foods up to 4 hr before surgery."
Answer: A, B, D
7. A nurse is reviewing the health records of several clients in the PACU to
identify risk factors that can lead to postoperative complications. Which of the
following clients are at risk for complications? (SATA)
A. A client who has a WBC of 22,500/uL
B. A client who uses an insulin pump
C. A client who takes warfarin daily
D. A client who has heart failure
E. A client who has a BMI of 26
Answer: A, B, C, D
8. A nurse is verifying informed consent for a client who is having a
paracentesis. Which of the following actions should the nurse take? (SATA)
A. Explain to the client the purpose of having the procedure
B. Inform the client of risks to having the procedure
C. Ensure the client understands information about the procedure
D. Witness the client signing the informed consent form
E. Determine if the client is capable of understanding the reason for the
procedure
Answer: C, D, E
9. A preoperative nurse is caring for a client who is having a colon resection.
Which of the following actions should the nurse take?
A. Encourage the client to void after preoperative medication administration
B. Administer antibiotics 2 hr prior to surgical incision
C. Remove hair using a manual razor
, D. Remove nail polish
Answer: D
10. A charge nurse is discussing critical thinking attitudes with a newly
licensed nurse. Match the following nursing actions with the critical thinking
attitude.
Confidence
Integrity
Humility
Discipline
Curiosity
A. Showing honesty when caring for clients
B. Using a head-to-toe approach to conduct a physical examination on a client
C. Speaking with certainty to a client when instructing them about a new diet
D. Asking questions to obtain more information about a client's problem
E. Identifying limitations of oneself when dealing with a clinical situation
Answer: 1-C, 2-A, 3-E, 4-B, 5-D
11. A charge nurse is discussing critical thinking attitudes with a newly
licensed nurse. Match the following nursing actions with the critical thinking
attitude.
Creativity
Risk-taking
Fairness
Perseverance
Responsibility
A. Caring for a client in a nonjudgmental manner
B. Checking a client's medical record for allergies before administering a
medication
