NCLEX Practice Exam 1 (40 Questions)
Which individual is at greatest risk for developing hypertension?
45 year-old African American attorney
60-year-old Asian American shop owner
40-year-old Caucasian nurse
55-year-old Hispanic teacher
Question 1 Explanation:
The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.
A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first?
Gastric lavage PRN
Acetylcysteine (mucomyst) for age per pharmacy
Start an IV Dextrose 5% with 0.33% normal saline to keep vein open
Activated charcoal per pharmacy
Question 2 Explanation:
Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids.
Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?
angina at rest
falling blood pressure
Question 3 Explanation:
Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure.
A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is:
Maintain fluid and electrolyte balance
Prevent urinary tract infection
Question 4 Explanation:
The immediate goal of therapy is to alleviate the client’s pain.
What would the nurse expect to see while assessing the growth of children during their school age years?
Decreasing amounts of body fat and muscle mass
Little change in body appearance from year to year
Progressive height increase of 4 inches each year
Yearly weight gain of about 5.5 pounds per year
Question 5 Explanation:
School age children gain about 5.5 pounds each year and increase about 2 inches in height.
At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states “My blood pressure is usually much lower.” The nurse should tell the client to
go get a blood pressure check within the next 48 to 72 hours
check blood pressure again in two (2) months
see the health care provider immediately
visit the health care provider within 1 week for a BP check
Question 6 Explanation:
The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke. However, immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.
The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission?
A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago.
A young adult with diabetes mellitus Type 2 for over ten (10) years and admitted with antibiotic-induced diarrhea 24 hours ago.
An elderly client with a history of hypertension, hypercholesterolemia, and lupus, and was admitted with Stevens-Johnson syndrome that morning.
An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago
Question 7 Explanation:
The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.
A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:
Should be taken in the morning
May decrease the client’s energy level
Must be stored in a dark container
Will decrease the client’s heart rate
Question 8 Explanation:
Thyroid supplement should be taken in the morning to minimize the side effects of insomnia
A 3-year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?
Prepare the child for x-ray of upper airways
Examine the child’s throat
Collect a sputum specimen
Notify the healthcare provider of the child’s status
Question 9 Explanation:
These findings suggest a medical emergency and may be due to epiglottises. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.
In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation?
Question 10 Explanation:
In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents.
A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?
Question 11 Explanation:
Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.
An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
A middle-aged client who says “I took too many diet pills” and “my heart feels like it is racing out of my chest.”
A young adult who says “I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?”
An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 10.
An elderly client who reports having taken a “large crack hit” 10 minutes prior to walking into the emergency room
Question 12 Explanation:
Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opoid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future.
When teaching a client with coronary artery disease about nutrition, the nurse should emphasize
Eating three (3) balanced meals a day
Adding complex carbohydrates
Avoiding very heavy meals
Limiting sodium to 7 gms per day
Question 13 Explanation:
Eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease.
Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working?
The client complains of discomfort at the IV insertion site
The client states “I just can’t get relief from my pain.”
The level of drug is 100 mL at 8 AM and is 80 mL at noon
The level of the drug is 100 mL at 8 AM and is 50 mL at noon
Question 14 Explanation:
The minimal dose of 10 mL per hour which would be 40 mL given in a four (4) hour period. Only 60 mL should be left at noon. The pump is not functioning when more than expected medicine is left in the container.
The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response?
Electrical energy fields
Spinal column manipulation
Exercise of joints
Question 15 Explanation:
The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation.
The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention?
Decrease in level of consciousness
Loss of bladder control
Altered sensation to stimuli
Question 16 Explanation:
A further decrease in the level of consciousness would be indicative of a further progression of the CVA.
A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time?
Positive sweat test
Bulky greasy stools
Moist, productive cough
Question 17 Explanation:
Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts, and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should
Place a call to the client’s health care provider for instructions
Send him to the emergency room for evaluation
Reassure the client’s wife that the symptoms are transient
Instruct the client’s wife to call the doctor if his symptoms become worse
Question 18 Explanation:
This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client’s best interest.
Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test?
Client must be NPO before the examination
Enema to be administered prior to the examination
Medicate client with Lasix 20 mg IV 30 minutes prior to the examination
No special orders are necessary for this examination
Question 19 Explanation:
No special preparation is necessary for this examination.
The nurse is giving discharge teaching to a client seven (7) days post myocardial infarction. He asks the nurse why he must wait six (6) weeks before having sexual intercourse. What is the best response by the nurse to this question?
“You need to regain your strength before attempting such exertion.”
“When you can climb 2 flights of stairs without problems, it is generally safe.”
“Have a glass of wine to relax you, then you can try to have sex.”
“If you can maintain an active walking program, you will have less risk.”
Question 20 Explanation:
There is a risk of cardiac rupture at the point of the myocardial infarction for about six (6) weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.
A triage nurse has these four (4) clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?
A 2-month old infant with a history of rolling off the bed and has bulging fontanels with crying
A teenager who got a singed beard while camping
An elderly client with complaints of frequent liquid brown colored stools
A middle-aged client with intermittent pain behind the right scapula
Question 21 Explanation:
This client is in the greatest danger with a potential of respiratory distress. Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.
While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child’s developmental needs?
“I want to protect my child from any falls.”
“I will set limits on exploring the house.”
“I understand the need to use those new skills.”
“I intend to keep control over our child.”
Question 22 Explanation:
Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.
The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is
Verify correct placement of the tube
Check that the feeding solution matches the dietary order
Aspirate abdominal contents to determine the amount of last feeding remaining in stomach
Ensure that feeding solution is at room temperature
Question 23 Explanation:
Proper placement of the tube prevents aspiration.
The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?
Narrowed QRS complex
Shortened “PR” interval
Tall peaked T waves
Prominent “U” waves
Question 24 Explanation:
A tall peaked T wave is a sign of hyperkalemia. The health care provider should be notified regarding discontinuing the medication.
A nurse prepares to care for a 4-year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?
All striated muscles
The leg bones
Question 25 Explanation:
Rhabdomyosarcoma is the most common children's soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word and is “myo” which typically means muscle.
The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to
Maintain a balance of energy
Restore yin and yang
Question 26 Explanation:
For followers of Chinese medicine, health is maintained through the balance between the forces of yin and yang.
During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mmHg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to
Increase fluids that are high in protein
Force fluids and reassess blood pressure
Limit fluids to non-caffeine beverages
Question 27 Explanation:
Postural hypotension, a decrease in systolic blood pressure of more than 15 mmHg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicate volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.
The nurse prepares the client for insertion of a pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about:
Left ventricular functioning
Question 28 Explanation:
The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated.
A nurse enters a client’s room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is
Start a peripheral IV
Initiate high-quality chest compressions
Establish an airway
Obtain the crash cart
Question 29 Explanation:
As per new guidelines, the American Heart Association recommends beginning CPR with chest compression (rather than checking for the airway first). Start CPR with 30 chest compressions before checking the airway and giving rescue breaths. Starting with chest compressions first applies to adults, children, and infants needing CPR, but not newborns. CPR can keep oxygenated blood flowing to the brain and other vital organs until more definitive medical treatment can restore a normal heart rhythm.
A client is receiving digoxin (Lanoxin) 0.25 mg daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?
Blood pressure 94/60
Heart rate 76
Urine output 50 ml/hour
Respiratory rate 16
Question 30 Explanation:
Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100; systolic B/P over 100) in order to safely administer both medications.
While assessing a 1-month-old infant, which finding should the nurse report immediately?
Irregular breathing rate
Increased heart rate with crying
Question 31 Explanation:
Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant.
The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to
Excessive fetal weight
Low blood sugar levels
Depletion of subcutaneous fat
Progressive placental insufficiency
Question 32 Explanation:
The placenta functions less efficiently as the pregnancy continues beyond 42 weeks. Immediate and long-term effects may be related to hypoxia.
The nurse is caring for a client who had a total hip replacement four (4) days ago. Which assessment requires the nurse’s immediate attention?
I have bad muscle spasms in my lower leg of the affected extremity.
“I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.”
“I have to use the bedpan to pass my water at least every 1 to 2 hours.”
“It seems that the pain medication is not working as well today.”
Question 33 Explanation:
The nurse would be concerned about all of these comments. However, the most life threatening is option B. Clients who have had hip or knee surgery are at greatest risk for development of post operative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Option C may indicate a urinary tract infection. And option D requires further investigation and is not life threatening.
A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?
Weight gain of 5 pounds
Edema of the ankles
Question 34 Explanation:
Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias.
A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?
Gravida 4 para 2
Gravida 2 para 1
Gravida 3 para 1
Gravida 3 para 2
Question 35 Explanation:
Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).
The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
Apply dressing using sterile technique
Improve the client’s nutritional status
Initiate limb compression therapy
Begin proteolytic debridement
Question 36 Explanation:
The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other answers are correct, but without proper nutrition, the other interventions would be of little help.
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?
Raise the side rails on the bed
Place the call bell within reach
Instruct the client to remain in bed
Have the client empty bladder
Question 37 Explanation:
The first step in the process is to have the client void prior to administering the pre-operative medication. The other actions follow this initial step in this sequence: D, C, A, and B.
Which of these statements best describes the characteristic of an effective reward-feedback system?
Specific feedback is given as close to the event as possible
Staff is given feedback in equal amounts over time
Positive statements are to precede a negative statement
Performance goals should be higher than what is attainable
Question 38 Explanation:
Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if the standards are clearly understood.
A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which
Increase the heart rate
Lead to dehydration
Are considered aerobic
May be competitive
Question 39 Explanation:
The client must take in adequate fluids before and during exercise periods.
During the evaluation of the quality of home care for a client with Alzheimer’s disease, the priority for the nurse is to reinforce which statement by a family member?
At least two (2) full meals a day is eaten.
We go to a group discussion every week at our community center
We have safety bars installed in the bathroom and have 24-hour alarms on the doors.
The medication is not a problem to have it taken three (3) times a day.
Question 40 Explanation:
Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are correct statements. However, safety is most important to reinforce.