BPH NCLEX ACTUAL EXAMS TEST PAPER
QUESTIONS AND ANSWERS SURE A+
✔✔The nurse has reinforced discharge teaching with the parent of a newborn. Which of
the following statements by the parent would require follow-up?
1."I will leave my baby's diaper off when possible if the diaper area starts to become
red."
2."I will secure my baby in a rear-facing infant seat in the front seat of the car since
there is an airbag there."
3."I should give my baby a pacifier at bedtime to reduce the risk for sudden infant death
syndrome (SIDS)."
4."I should squeeze the bulb syringe before inserting it into my baby's mouth when I
suction excess secretions." - ✔✔3."I should give my baby a pacifier at bedtime to
reduce the risk for sudden infant death syndrome (SIDS)."
✔✔The nurse is caring for a client with pediculosis. Which of the following infection
control precautions should the nurse implement?
1.Place a thermometer in the client's room to be used with that client only.
2.Wear a surgical mask when assisting the client to bathe.
3.Keep the door to the client's room closed.
4.Remove the gloves after leaving the client's room. - ✔✔1.Place a thermometer in the
client's room to be used with that client only.
,✔✔The charge nurse in a long-term care facility has completed client care assignments
for unlicensed assistive personnel (UAP). Which of the following statements by the
charge nurse would provide the best directions to a UAP regarding the assignment?
1."Record your assigned clients' vital signs before you take a mid-morning break."
2."Weigh your assigned clients before breakfast with the scale used 1 day ago."
3."Help the clients who eat their meals in the dining room with breakfast."
4."Measure your assigned clients' intake and output regularly." - ✔✔2."Weigh your
assigned clients before breakfast with the scale used 1 day ago."
✔✔The nurse in a long-term care facility is making client care assignments for
unlicensed assistive personnel (UAP). Which of the following statements by the nurse
would provide UAP with the best directions for the assignment?
1."Clients who are able to ambulate should be assisted to ambulate after meals."
2."Notify me if any client develops an abnormal temperature."
3."Check the meal trays distributed to clients with diabetes mellitus (type 1)."
4."Obtain vital signs first for the client with hypertension and report the results to me." -
✔✔1."Clients who are able to ambulate should be assisted to ambulate after meals."
✔✔The nurse in an outpatient facility has collected the following data regarding the
clients' concerns. The nurse should place in a private room first the client with
1.a productive cough with night sweats
2.diabetes mellitus (type 1) with tingling in both feet
3.red eyes with moderate tearing
4.emphysema with clubbing of the fingernails - ✔✔1.a productive cough with night
sweats
✔✔The nurse is caring for a client who has just been told their cancer has
metastasized. The nurse enters the room and observes the client crying. Which of the
following responses would be appropriate for the nurse to make first?
1."You seem upset. May I sit with you for awhile?"
2."I can telephone a family member to come and stay with you."
3."Do you have a spiritual advisor that you would like me to notify?"
4."I will give you some time alone and will come back soon." - ✔✔2."I can telephone a
family member to come and stay with you."
✔✔The nurse is caring for a client with disseminated intravascular coagulation (DIC).
Which of the following statements by the client would be essential to follow up?
1."I prefer to receive my medication subcutaneously rather than intramuscularly."
2."I have been taking 1 aspirin every day since I had a myocardial infarction (MI) 1 year
ago."
3."I held pressure on the puncture site for 5 minutes after the nurse drew blood from my
arm."
, 4."I have avoided blowing my nose today because I have had 2 episodes of epistaxis." -
✔✔2."I have been taking 1 aspirin every day since I had a myocardial infarction (MI) 1
year ago."
✔✔The nurse is caring for a client who has just returned from the radiology department
after having an upper gastrointestinal (UGI) series. Which of the following actions
should the nurse take first?
1.Administer the prescribed enema.
2.Give the prescribed multiple vitamin that was withheld prior to the procedure.
3.Determine whether follow-up x-rays are to be taken.
4.Verify the preliminary test results. - ✔✔4.Verify the preliminary test results.
✔✔The nurse is talking with a client who has schizophrenia. The client states, "I just
returned from Mars." Which of the following responses would be appropriate for the
nurse to make?
1."I need to tell you that you cannot talk about silly things here."
2."Why do you think you made that trip?"
3."How does it feel to be back?"
4."I am here to listen to your concerns." - ✔✔4."I am here to listen to your concerns."
✔✔The nurse is assisting to admit a client with active pulmonary tuberculosis (TB).
Which of the following actions should the nurse take prior to the client's arrival?
1.Assign the client to room with a client who has pertussis if a private room is not
available.
2.Have a particulate respirator mask available for client transport.
3.Have particulate respirator masks available for staff who care for the client.
4.Post a sign outside the room restricting pregnant women from entering the room. -
✔✔3.Have particulate respirator masks available for staff who care for the client.
✔✔The nurse is collecting data from an 85-year-old male client. Which of the following
statements would be essential to follow up?
1."I find that it takes longer to do tasks such as balancing my checkbook."
2."I feel some stomach discomfort after eating a large meal."
3."I have awakened from sleep because of shortness of breath."
4."I have a problem starting a strong stream of urine." - ✔✔3."I have awakened from
sleep because of shortness of breath."
✔✔The nurse is observing a coworker suctioning a client with a tracheostomy. The
nurse should intervene if the coworker
1.applies suction as the catheter is being withdrawn
2.wears a face shield throughout the procedure
QUESTIONS AND ANSWERS SURE A+
✔✔The nurse has reinforced discharge teaching with the parent of a newborn. Which of
the following statements by the parent would require follow-up?
1."I will leave my baby's diaper off when possible if the diaper area starts to become
red."
2."I will secure my baby in a rear-facing infant seat in the front seat of the car since
there is an airbag there."
3."I should give my baby a pacifier at bedtime to reduce the risk for sudden infant death
syndrome (SIDS)."
4."I should squeeze the bulb syringe before inserting it into my baby's mouth when I
suction excess secretions." - ✔✔3."I should give my baby a pacifier at bedtime to
reduce the risk for sudden infant death syndrome (SIDS)."
✔✔The nurse is caring for a client with pediculosis. Which of the following infection
control precautions should the nurse implement?
1.Place a thermometer in the client's room to be used with that client only.
2.Wear a surgical mask when assisting the client to bathe.
3.Keep the door to the client's room closed.
4.Remove the gloves after leaving the client's room. - ✔✔1.Place a thermometer in the
client's room to be used with that client only.
,✔✔The charge nurse in a long-term care facility has completed client care assignments
for unlicensed assistive personnel (UAP). Which of the following statements by the
charge nurse would provide the best directions to a UAP regarding the assignment?
1."Record your assigned clients' vital signs before you take a mid-morning break."
2."Weigh your assigned clients before breakfast with the scale used 1 day ago."
3."Help the clients who eat their meals in the dining room with breakfast."
4."Measure your assigned clients' intake and output regularly." - ✔✔2."Weigh your
assigned clients before breakfast with the scale used 1 day ago."
✔✔The nurse in a long-term care facility is making client care assignments for
unlicensed assistive personnel (UAP). Which of the following statements by the nurse
would provide UAP with the best directions for the assignment?
1."Clients who are able to ambulate should be assisted to ambulate after meals."
2."Notify me if any client develops an abnormal temperature."
3."Check the meal trays distributed to clients with diabetes mellitus (type 1)."
4."Obtain vital signs first for the client with hypertension and report the results to me." -
✔✔1."Clients who are able to ambulate should be assisted to ambulate after meals."
✔✔The nurse in an outpatient facility has collected the following data regarding the
clients' concerns. The nurse should place in a private room first the client with
1.a productive cough with night sweats
2.diabetes mellitus (type 1) with tingling in both feet
3.red eyes with moderate tearing
4.emphysema with clubbing of the fingernails - ✔✔1.a productive cough with night
sweats
✔✔The nurse is caring for a client who has just been told their cancer has
metastasized. The nurse enters the room and observes the client crying. Which of the
following responses would be appropriate for the nurse to make first?
1."You seem upset. May I sit with you for awhile?"
2."I can telephone a family member to come and stay with you."
3."Do you have a spiritual advisor that you would like me to notify?"
4."I will give you some time alone and will come back soon." - ✔✔2."I can telephone a
family member to come and stay with you."
✔✔The nurse is caring for a client with disseminated intravascular coagulation (DIC).
Which of the following statements by the client would be essential to follow up?
1."I prefer to receive my medication subcutaneously rather than intramuscularly."
2."I have been taking 1 aspirin every day since I had a myocardial infarction (MI) 1 year
ago."
3."I held pressure on the puncture site for 5 minutes after the nurse drew blood from my
arm."
, 4."I have avoided blowing my nose today because I have had 2 episodes of epistaxis." -
✔✔2."I have been taking 1 aspirin every day since I had a myocardial infarction (MI) 1
year ago."
✔✔The nurse is caring for a client who has just returned from the radiology department
after having an upper gastrointestinal (UGI) series. Which of the following actions
should the nurse take first?
1.Administer the prescribed enema.
2.Give the prescribed multiple vitamin that was withheld prior to the procedure.
3.Determine whether follow-up x-rays are to be taken.
4.Verify the preliminary test results. - ✔✔4.Verify the preliminary test results.
✔✔The nurse is talking with a client who has schizophrenia. The client states, "I just
returned from Mars." Which of the following responses would be appropriate for the
nurse to make?
1."I need to tell you that you cannot talk about silly things here."
2."Why do you think you made that trip?"
3."How does it feel to be back?"
4."I am here to listen to your concerns." - ✔✔4."I am here to listen to your concerns."
✔✔The nurse is assisting to admit a client with active pulmonary tuberculosis (TB).
Which of the following actions should the nurse take prior to the client's arrival?
1.Assign the client to room with a client who has pertussis if a private room is not
available.
2.Have a particulate respirator mask available for client transport.
3.Have particulate respirator masks available for staff who care for the client.
4.Post a sign outside the room restricting pregnant women from entering the room. -
✔✔3.Have particulate respirator masks available for staff who care for the client.
✔✔The nurse is collecting data from an 85-year-old male client. Which of the following
statements would be essential to follow up?
1."I find that it takes longer to do tasks such as balancing my checkbook."
2."I feel some stomach discomfort after eating a large meal."
3."I have awakened from sleep because of shortness of breath."
4."I have a problem starting a strong stream of urine." - ✔✔3."I have awakened from
sleep because of shortness of breath."
✔✔The nurse is observing a coworker suctioning a client with a tracheostomy. The
nurse should intervene if the coworker
1.applies suction as the catheter is being withdrawn
2.wears a face shield throughout the procedure
