NCLEX Question Trainer Explanations
Test 5
1. The nurse is preparing a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment.
Which of the following questions is the MOST important for the nurse to ask?
1. “Did you have anything to eat or drink before you came in today?”
2. “Have you had any headaches since your last treatment?”
3. “Who came with you to the hospital today?”
4. “Have you had much memory loss since you began your treatments?”
Strategy: Determine how each answer choice relates to ECT.
(1) correct–client given general anesthesia for ECT; NPO after midnight
(2) not relevant to ECT
(3) not most important
(4) memory loss is an expected outcome
2. A 36-year-old man has a flaccid bladder following a spinal cord injury. The nurse is teaching the
client about dietary changes. Which of the following beverages, if selected by the client, would
indicate to the nurse that teaching was effective?
1. Lemonade.
2. Prune juice.
3. Milk.
4. Orange juice.
Strategy: “Teaching was effective” indicates you are looking for a true statement.
(1) promotes alkaline urine, should also avoid citrus juices, excessive amounts of milk,
carbonated beverages
(2) correct–promotes acidic urine, minimizes risk of urinary tract infection and stone formation,
also use cranberry, tomato juice, bouillon
(3) excessive amounts of milk promotes alkaline urine
(4) promotes alkaline urine, should also avoid citrus juices, excessive amounts of milk and
carbonated beverages
31
,Preparation for the Nursing Licensure Examination
3. The nurse is caring for a client with a long history of alcohol and drug dependence. It would be
MOST important for the nurse to include which of the following as a part of his discharge
planning?
1. Referral to a social service agency for assistance with housing.
2. Referral to an aftercare center in the community.
3. Participation in Alcoholics Anonymous (AA) meetings with a sponsor.
4. A prescription for an antidepressant medication.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) may be of some help, but will not directly provide support necessary to maintain sobriety
(2) may be of some help, but will not directly provide support necessary to maintain sobriety
(3) correct–self-help groups have greatest success rate as a sustained support system in the
community
(4) unnecessary
4. A client has come to the clinic for a hepatitis B vaccine and asks if he has to be re-vaccinated after
his first injection. Which of the following responses by the nurse is BEST?
1. “A booster shot is required yearly.”
2. “Additional injections are given at one and six months.”
3. “Repeat doses are given at two and four months.”
4. “Revaccination is not required.”
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) yearly doses are given for flu shots, not for hepatitis B vaccine
(2) correct–hepatitis B vaccine is repeated at one and six months
(3) schedule for infant immunizations for OPV and DPT
(4) inaccurate
5. The nurse is planning care for a 56-year-old man who returned from surgery for a bowel resection
with an IV of 0.9% NaCl infusing at 100 cc/h into his left wrist. Which of the following actions, if
performed by the nurse, is BEST?
1. Change the IV tubing each time a new IV solution is hung.
2. Cleanse the IV site with an alcohol swab using long strokes.
3. Limit manipulation of the cannula at the IV insertion site.
4. Adjust the drop rate to keep the total volume of IV fluids on schedule.
Strategy: The topic of the question is unstated. Read the answer choices to determine the topic.
“BEST” indicates that this is a priority question. All answers are implementations. Determine the
outcome of each answer choice. Is it desired?
(1) unnecessary, changed every 48–72 hrs
(2) should move swab in a circular motion outward
(3) correct–will prevent dislodgment of needle
(4) should give IV at rate ordered by physician, don’t play “catch-up” with fluids
32
, NCLEX Question Trainer
6. The nurse notes that one of the staff members caring for clients has a watery discharge from the
right eye and the eye appears red. Which of the following actions, if taken by the nurse, is BEST?
1. Send the staff member home.
2. Assess the staff member’s compliance with standard precautions.
3. Assign the staff member only to clients with chronic diseases.
4. Re-assign the staff member to clean the supply closet.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) correct–extreme tearing, redness, foreign body sensation are symptoms of viral conjunctivitis,
highly contagious; infected employees cannot work until symptoms have resolved in 3–7 days
(2) restrict from patient contact and the patient’s environment
(3) restrict from patient contact and the patient’s environment
(4) cannot work
7. The nursing staff is planning to use behavior modification techniques for an elderly woman who
constantly screams. Which of the following nursing assessments is necessary to establish a
successful program?
1. Monitor the client’s ability to complete her activities of daily living (ADL).
2. Assess the client’s levels of pain and correlate it with her response to analgesia.
3. Observe the client’s behavior at regular intervals to obtain baseline information related to her
screaming.
4. Ask the client why she is screaming and document it on her nursing assessment record.
Strategy: Determine what is being assessed in each answer choice and how it relates to
screaming.
(1) important because activities of daily living can contribute to the targeted behavior of
screaming; assessing only the area of ADLs does not provide comprehensive data for
developing a behavior management program
(2) important because activities of pain can contribute to the targeted behavior of screaming;
assessing only the area of pain does not provide comprehensive data for developing a
behavior management program
(3) correct–to design an effective behavior modification program, accurate baseline data must
first be collected about the target behavior in relation to frequency, amount, time, and
precipitating factors
(4) client may be unable to state why she is screaming; asking “why” questions is nontherapeutic
33
, Preparation for the Nursing Licensure Examination
8. The nurse observes a student nurse checking the placement of a nasogastric (NG) tube. Which
of the following actions, if performed by the student nurse, would require an intervention by the
nurse?
1. Places the end of the NG tube in a cup of water and watches for bubble formation.
2. Checks the pH of the contents aspirated from the NG tube.
3. Positions a stethoscope on the upper abdomen and listens as air is introduced into the NG
tube.
4. Uses a large barreled syringe to aspirate for stomach contents.
Strategy: “Require an intervention” indicates that you are looking for an incorrect behavior.
(1) correct–not considered acceptable procedure
(2) gastric contents are acidic
(3) “swoosh” of air indicates proper placement
(4) acceptable action
9. While scheduling the administration of bromocriptine (Parlodel), which nursing action has the
HIGHEST priority?
1. The medication should be taken once a day for six weeks.
2. The medication should be taken with orange juice.
3. The medication should be taken in the morning and at bedtime.
4. The medication should be taken with meals.
Strategy: Answers are implementations. Determine the outcome of each answer. Is it desired?
(1) is taken twice a day for two to three weeks
(2) unnecessary
(3) will cause GI upset unless taken with meals
(4) correct–will decrease GI upset
10. A brace is ordered for a young teen with scoliosis. The nurse knows that teaching has been
effective if the client makes which of the following statements?
1. “I will have my parents put bed-boards on my bed.”
2. “I should decrease my caloric intake.”
3. “I should only take tub baths.”
4. “I can remove the brace for one hour a day.”
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) bed-boards maintain proper vertebral alignment, but can’t correct lateral curvature of
scoliosis
(2) diet should be high-calorie due to age of child and growth requirements; diet doesn’t affect
curvature of the spine
(3) either tub bathing or a shower is permitted
(4) correct–should be worn at all times, except when bathing
34
Test 5
1. The nurse is preparing a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment.
Which of the following questions is the MOST important for the nurse to ask?
1. “Did you have anything to eat or drink before you came in today?”
2. “Have you had any headaches since your last treatment?”
3. “Who came with you to the hospital today?”
4. “Have you had much memory loss since you began your treatments?”
Strategy: Determine how each answer choice relates to ECT.
(1) correct–client given general anesthesia for ECT; NPO after midnight
(2) not relevant to ECT
(3) not most important
(4) memory loss is an expected outcome
2. A 36-year-old man has a flaccid bladder following a spinal cord injury. The nurse is teaching the
client about dietary changes. Which of the following beverages, if selected by the client, would
indicate to the nurse that teaching was effective?
1. Lemonade.
2. Prune juice.
3. Milk.
4. Orange juice.
Strategy: “Teaching was effective” indicates you are looking for a true statement.
(1) promotes alkaline urine, should also avoid citrus juices, excessive amounts of milk,
carbonated beverages
(2) correct–promotes acidic urine, minimizes risk of urinary tract infection and stone formation,
also use cranberry, tomato juice, bouillon
(3) excessive amounts of milk promotes alkaline urine
(4) promotes alkaline urine, should also avoid citrus juices, excessive amounts of milk and
carbonated beverages
31
,Preparation for the Nursing Licensure Examination
3. The nurse is caring for a client with a long history of alcohol and drug dependence. It would be
MOST important for the nurse to include which of the following as a part of his discharge
planning?
1. Referral to a social service agency for assistance with housing.
2. Referral to an aftercare center in the community.
3. Participation in Alcoholics Anonymous (AA) meetings with a sponsor.
4. A prescription for an antidepressant medication.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) may be of some help, but will not directly provide support necessary to maintain sobriety
(2) may be of some help, but will not directly provide support necessary to maintain sobriety
(3) correct–self-help groups have greatest success rate as a sustained support system in the
community
(4) unnecessary
4. A client has come to the clinic for a hepatitis B vaccine and asks if he has to be re-vaccinated after
his first injection. Which of the following responses by the nurse is BEST?
1. “A booster shot is required yearly.”
2. “Additional injections are given at one and six months.”
3. “Repeat doses are given at two and four months.”
4. “Revaccination is not required.”
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) yearly doses are given for flu shots, not for hepatitis B vaccine
(2) correct–hepatitis B vaccine is repeated at one and six months
(3) schedule for infant immunizations for OPV and DPT
(4) inaccurate
5. The nurse is planning care for a 56-year-old man who returned from surgery for a bowel resection
with an IV of 0.9% NaCl infusing at 100 cc/h into his left wrist. Which of the following actions, if
performed by the nurse, is BEST?
1. Change the IV tubing each time a new IV solution is hung.
2. Cleanse the IV site with an alcohol swab using long strokes.
3. Limit manipulation of the cannula at the IV insertion site.
4. Adjust the drop rate to keep the total volume of IV fluids on schedule.
Strategy: The topic of the question is unstated. Read the answer choices to determine the topic.
“BEST” indicates that this is a priority question. All answers are implementations. Determine the
outcome of each answer choice. Is it desired?
(1) unnecessary, changed every 48–72 hrs
(2) should move swab in a circular motion outward
(3) correct–will prevent dislodgment of needle
(4) should give IV at rate ordered by physician, don’t play “catch-up” with fluids
32
, NCLEX Question Trainer
6. The nurse notes that one of the staff members caring for clients has a watery discharge from the
right eye and the eye appears red. Which of the following actions, if taken by the nurse, is BEST?
1. Send the staff member home.
2. Assess the staff member’s compliance with standard precautions.
3. Assign the staff member only to clients with chronic diseases.
4. Re-assign the staff member to clean the supply closet.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) correct–extreme tearing, redness, foreign body sensation are symptoms of viral conjunctivitis,
highly contagious; infected employees cannot work until symptoms have resolved in 3–7 days
(2) restrict from patient contact and the patient’s environment
(3) restrict from patient contact and the patient’s environment
(4) cannot work
7. The nursing staff is planning to use behavior modification techniques for an elderly woman who
constantly screams. Which of the following nursing assessments is necessary to establish a
successful program?
1. Monitor the client’s ability to complete her activities of daily living (ADL).
2. Assess the client’s levels of pain and correlate it with her response to analgesia.
3. Observe the client’s behavior at regular intervals to obtain baseline information related to her
screaming.
4. Ask the client why she is screaming and document it on her nursing assessment record.
Strategy: Determine what is being assessed in each answer choice and how it relates to
screaming.
(1) important because activities of daily living can contribute to the targeted behavior of
screaming; assessing only the area of ADLs does not provide comprehensive data for
developing a behavior management program
(2) important because activities of pain can contribute to the targeted behavior of screaming;
assessing only the area of pain does not provide comprehensive data for developing a
behavior management program
(3) correct–to design an effective behavior modification program, accurate baseline data must
first be collected about the target behavior in relation to frequency, amount, time, and
precipitating factors
(4) client may be unable to state why she is screaming; asking “why” questions is nontherapeutic
33
, Preparation for the Nursing Licensure Examination
8. The nurse observes a student nurse checking the placement of a nasogastric (NG) tube. Which
of the following actions, if performed by the student nurse, would require an intervention by the
nurse?
1. Places the end of the NG tube in a cup of water and watches for bubble formation.
2. Checks the pH of the contents aspirated from the NG tube.
3. Positions a stethoscope on the upper abdomen and listens as air is introduced into the NG
tube.
4. Uses a large barreled syringe to aspirate for stomach contents.
Strategy: “Require an intervention” indicates that you are looking for an incorrect behavior.
(1) correct–not considered acceptable procedure
(2) gastric contents are acidic
(3) “swoosh” of air indicates proper placement
(4) acceptable action
9. While scheduling the administration of bromocriptine (Parlodel), which nursing action has the
HIGHEST priority?
1. The medication should be taken once a day for six weeks.
2. The medication should be taken with orange juice.
3. The medication should be taken in the morning and at bedtime.
4. The medication should be taken with meals.
Strategy: Answers are implementations. Determine the outcome of each answer. Is it desired?
(1) is taken twice a day for two to three weeks
(2) unnecessary
(3) will cause GI upset unless taken with meals
(4) correct–will decrease GI upset
10. A brace is ordered for a young teen with scoliosis. The nurse knows that teaching has been
effective if the client makes which of the following statements?
1. “I will have my parents put bed-boards on my bed.”
2. “I should decrease my caloric intake.”
3. “I should only take tub baths.”
4. “I can remove the brace for one hour a day.”
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) bed-boards maintain proper vertebral alignment, but can’t correct lateral curvature of
scoliosis
(2) diet should be high-calorie due to age of child and growth requirements; diet doesn’t affect
curvature of the spine
(3) either tub bathing or a shower is permitted
(4) correct–should be worn at all times, except when bathing
34
