1|Page
NCLEX NGN RN (WITH ALL QUESTIONS FORMART)
NEWEST ACTUAL VERIFIED EXAM ALL 150
QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES|| ALREADY GRADED A+||NEWEST
EXAM!!!
A nurse developing a plan of care for a client with a spinal
cord injury includes measures to prevent autonomic
dysreflexia (hyperreflexia). Which intervention does the
nurse incorporate into the plan to prevent this
complication?
a. Keeping the fan running in the client's room
b. Keeping the linens wrinkle free under the client
c. Limiting bladder catheterization to once every 12 hours
d. Avoiding the administration of enemas and rectal
suppositories - Answer-B
The most frequent cause of autonomic dysreflexias are a
distended bladder and impacted feces. Other causes
include stimulation of the skin by tactile, thermal, or painful
stimuli. The nurse renders care in such a way as to
minimize these risks.
A nurse provides home care instructions to a client who
has been fitted with a halo device to treat a cervical
,2|Page
fracture. Which statement by the client indicates the need
for further teaching?
a. I need to get more fluids and fiber into my diet
b. I should cut my food into small pieces before I eat
c. I need to put powder under the vest twice a day to
prevent sweating
d. I have to check the pin sites everyday and watch for
signs of infection - Answer-C
Cleanse the skin under the wool liner each day to prevent
rashes and soars.
A nurse is caring for a client with increased intracranial
pressure. In which position should the nurse maintain the
client?
a. Supine with the head extended
b. Side lying with the neck flexed
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees - Answer-D
Proper positioning promotes venous drainage from the
cranium to minimize ICP.
,3|Page
A client with a basilar skull fracture has clear fluid leaking
from the ears. The nurse should take which action first?
a. Asses the clear fluid for protein
b. Check the clear fluid for glucose
c. Place cotton calls or dry gauze loosely in the ears
d. Use an otoscope to assess the tympanic membrane for
rupture - Answer-B
CSF contains glucose not protein.
A nurse is caring for a client who has just undergone
cardioversion. Which intervention is the nurse's priority
after this procedure.
a. Administer oxygen
b. Monitoring the BP
c. Administering antidysrhythmic medications
d. Monitoring the client's LOC - Answer-A
ABC's of nursing. All other choices are correct, but not
priority.
A nurse is assigned to care for a client with chronic renal
failure who is undergoing hemodialysis through an internal
AV fistula in the RA. Which intervention should the nurse
implement in caring for the client? SATA
, 4|Page
a. Assessing the radial pulse in the right extremity
b. Using the LA ti take BP readings
c. Drawing pre-dialysis blood specimens from the LA
d. Assessing the area over the AV fistula for a bruit and
three each shift
e. Placing a pressure dressing over the site after each
dialysis treatment
f. Administering IV fluids through the venous site of the AV
fistula as needed - Answer-A, B, C, D
A nurse is evaluating outcomes for a client with Guillain-
Barre syndrome. Which outcome does the nurse
recognize as optimal respiratory outcomes for the client?
a. Normal deep tendon reflexes
b. Improved skeletal muscle tone
c. Absences of paresthesias in the lower extremities
d. Clear sound in the lower lung fields bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg - Answer-D, E
A nurse of the telemetry unit is caring for a client who has
had a MI and is now attached to a cardiac monitor. The
nurse is monitoring the client's cardiac rhythm and nots
NCLEX NGN RN (WITH ALL QUESTIONS FORMART)
NEWEST ACTUAL VERIFIED EXAM ALL 150
QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES|| ALREADY GRADED A+||NEWEST
EXAM!!!
A nurse developing a plan of care for a client with a spinal
cord injury includes measures to prevent autonomic
dysreflexia (hyperreflexia). Which intervention does the
nurse incorporate into the plan to prevent this
complication?
a. Keeping the fan running in the client's room
b. Keeping the linens wrinkle free under the client
c. Limiting bladder catheterization to once every 12 hours
d. Avoiding the administration of enemas and rectal
suppositories - Answer-B
The most frequent cause of autonomic dysreflexias are a
distended bladder and impacted feces. Other causes
include stimulation of the skin by tactile, thermal, or painful
stimuli. The nurse renders care in such a way as to
minimize these risks.
A nurse provides home care instructions to a client who
has been fitted with a halo device to treat a cervical
,2|Page
fracture. Which statement by the client indicates the need
for further teaching?
a. I need to get more fluids and fiber into my diet
b. I should cut my food into small pieces before I eat
c. I need to put powder under the vest twice a day to
prevent sweating
d. I have to check the pin sites everyday and watch for
signs of infection - Answer-C
Cleanse the skin under the wool liner each day to prevent
rashes and soars.
A nurse is caring for a client with increased intracranial
pressure. In which position should the nurse maintain the
client?
a. Supine with the head extended
b. Side lying with the neck flexed
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees - Answer-D
Proper positioning promotes venous drainage from the
cranium to minimize ICP.
,3|Page
A client with a basilar skull fracture has clear fluid leaking
from the ears. The nurse should take which action first?
a. Asses the clear fluid for protein
b. Check the clear fluid for glucose
c. Place cotton calls or dry gauze loosely in the ears
d. Use an otoscope to assess the tympanic membrane for
rupture - Answer-B
CSF contains glucose not protein.
A nurse is caring for a client who has just undergone
cardioversion. Which intervention is the nurse's priority
after this procedure.
a. Administer oxygen
b. Monitoring the BP
c. Administering antidysrhythmic medications
d. Monitoring the client's LOC - Answer-A
ABC's of nursing. All other choices are correct, but not
priority.
A nurse is assigned to care for a client with chronic renal
failure who is undergoing hemodialysis through an internal
AV fistula in the RA. Which intervention should the nurse
implement in caring for the client? SATA
, 4|Page
a. Assessing the radial pulse in the right extremity
b. Using the LA ti take BP readings
c. Drawing pre-dialysis blood specimens from the LA
d. Assessing the area over the AV fistula for a bruit and
three each shift
e. Placing a pressure dressing over the site after each
dialysis treatment
f. Administering IV fluids through the venous site of the AV
fistula as needed - Answer-A, B, C, D
A nurse is evaluating outcomes for a client with Guillain-
Barre syndrome. Which outcome does the nurse
recognize as optimal respiratory outcomes for the client?
a. Normal deep tendon reflexes
b. Improved skeletal muscle tone
c. Absences of paresthesias in the lower extremities
d. Clear sound in the lower lung fields bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg - Answer-D, E
A nurse of the telemetry unit is caring for a client who has
had a MI and is now attached to a cardiac monitor. The
nurse is monitoring the client's cardiac rhythm and nots
