Cris Nclex
Comprehensive Resource To Help You Ace 2026-2027
Exams Includes Frequently Tested Questions With
ELABORATED 100% Correct COMPLETE SOLUTIONS
Guaranteed Pass First Attempt!! Current Update!!
1. The nurse teaches a client about how to care for an ileostomy. Which comment,
if made by the client to the nurse, indicates further teaching is needed?
1. "The skin around the stoma should be cleaned with warm water and
thoroughly dried."
2. "The appliance should fit snugly around the ileostomy opening."
3. "I should take polyethylene glycol (MiraLax) with a large glass of water."
4. "I will continue to take a daily multi-vitamin." - 1) Implementation: outcome
desired; standard of care for ileostomy
2) Implementation: outcome desired; ileostomy drainage is liquid and very
alkaline; great risk of skin irritation
3) CORRECT - Implementation: outcome not desired; osmotic laxative and is
contraindicated; avoid enteric-coated or capsule medication, which may not be
absorbed through GI tract
4) Implementation: outcome desired; inform healthcare provider and pharmacist
about ileostomy
,2. The nurse cares for a client diagnosed with chronic bronchitis and peripheral
vascular disease. The nurse expects to assess which of these breath sounds?
1. Continuous, high-pitched musical sounds heard on expiration.
2. Soft, high-pitched interrupted sounds heard on inspiration.
3. Deep, low-pitched rumbling sounds are heard mainly on expiration.
4. Harsh, grating sounds heard best during inspiration. - 1) Assessment: outcome
not expected; sibilant wheezes, heard with asthma, caused by narrow bronchioles
2) Assessment: outcome not expected; crackles, heard with pneumonia and CHF,
caused by fluid in the alveoli
3) CORRECT - Assessment: outcome expected; sonorous wheezes or rhonchi,
caused by mucus in the airways; excessive mucous production is primary symptom
4) Assessment: outcome not expected; pericardial friction rub, caused by inflamed
pleura or pericarditis
3. The nurse prepares to administer gentamicin (Garamycin) to the 65-year-old
client. Which is the MOST important action for the nurse to take prior to
administration of the medication?
1. Request a daily hemoglobin and hematocrit test.
2. Monitor the serum BUN and creatinine.
3. Request a highly-sensitive C-reactive protein (hs-CRP) test.
4. Monitor the erythrocyte sedimentation rate (ESR). - 1) Assessment: outcome
not priority; may cause anemia, but not usually seen
2) CORRECT - Assessment: outcome priority; nephrotoxic; will see proteinuria,
oliguria, hematuria, thirst, increased BUN, decreased creatine clearance
,3) Assessment: outcome not priority; will be increased in inflammation and
rheumatoid arthritis
4) Assessment: outcome not priority; will be increased with any inflammatory
process
4. The nurse cares for the client in the labor unit. During the transitional phase of
labor, the umbilical cord becomes prolapsed. It is MOST important for the nurse to
take which action?
1. Place the client on her back with thighs flexed on her abdomen.
2. Place the client on her left side with legs flexed.
3. Place the client supine with the head of the bed elevated 30°.
4. Place the client supine with the foot of the bed elevated. - 1) Implementation:
outcome not desired; lithotomy position; will not decrease pressure on umbilical
cord
2) Implementation: outcome not desired; position used to remove weight of fetus
from vena cava to prevent maternal hypotension; will not help with prolapsed
cord
3) Implementation: outcome not desired; would aggravate prolapsed cord
pressure
4) CORRECT - Implementation: outcome desired; Trendelenburg or knee chest
position desired to decrease pressure on umbilical cord
5. The nurse cares for the client diagnosed with lung cancer. The family states that
the client has become confused and that urinary output has decreased during the
previous 24 hours. Which finding MOST concerns the nurse?
1. 2+ pitting pretibial edema.
, 2. Sodium 128 mEq/L.
3. Weight gain of 2 kg in 24 hours.
4. Urine specific gravity 1.008. - 1) Assessment: outcome desired but not priority;
edema not seen with SIADH even though water is retained; needs to be
monitored
2) CORRECT - Assessment: outcome desired and priority; normal sodium range is
135-145 mEq/L, dilutional hyponatremia due to SIADH; client is neurologically
depressed with increased risk of seizures
3) Asssessment: outcome desired but not priority; indicates fluid retention, not as
important as hyponatremia; important to watch trends in weight
4) Assessment: outcome not desired; 1.008 indicates that urine is very dilute; with
SIADH, urine will have high concentration and specific gravity due to excess ADH
secretion
6. The home care nurse cares for a client who is diagnosed with hypertension and
mild depression. The client's daughter states that her mother has been falling
frequently. WWhich response by the nurse is BEST?
1. "Let's get your mother a walker."
2. "Do you think it's time to put your mother in a nursing home?"
3. "When does your mother fall?"
4. "Does your mother seem to be more confused lately?" - 1) Implementation:
outcome not desired; need to assess first
2) Assessment: outcome not priority; "yes/no" question; doesn't help determine
the problem
Comprehensive Resource To Help You Ace 2026-2027
Exams Includes Frequently Tested Questions With
ELABORATED 100% Correct COMPLETE SOLUTIONS
Guaranteed Pass First Attempt!! Current Update!!
1. The nurse teaches a client about how to care for an ileostomy. Which comment,
if made by the client to the nurse, indicates further teaching is needed?
1. "The skin around the stoma should be cleaned with warm water and
thoroughly dried."
2. "The appliance should fit snugly around the ileostomy opening."
3. "I should take polyethylene glycol (MiraLax) with a large glass of water."
4. "I will continue to take a daily multi-vitamin." - 1) Implementation: outcome
desired; standard of care for ileostomy
2) Implementation: outcome desired; ileostomy drainage is liquid and very
alkaline; great risk of skin irritation
3) CORRECT - Implementation: outcome not desired; osmotic laxative and is
contraindicated; avoid enteric-coated or capsule medication, which may not be
absorbed through GI tract
4) Implementation: outcome desired; inform healthcare provider and pharmacist
about ileostomy
,2. The nurse cares for a client diagnosed with chronic bronchitis and peripheral
vascular disease. The nurse expects to assess which of these breath sounds?
1. Continuous, high-pitched musical sounds heard on expiration.
2. Soft, high-pitched interrupted sounds heard on inspiration.
3. Deep, low-pitched rumbling sounds are heard mainly on expiration.
4. Harsh, grating sounds heard best during inspiration. - 1) Assessment: outcome
not expected; sibilant wheezes, heard with asthma, caused by narrow bronchioles
2) Assessment: outcome not expected; crackles, heard with pneumonia and CHF,
caused by fluid in the alveoli
3) CORRECT - Assessment: outcome expected; sonorous wheezes or rhonchi,
caused by mucus in the airways; excessive mucous production is primary symptom
4) Assessment: outcome not expected; pericardial friction rub, caused by inflamed
pleura or pericarditis
3. The nurse prepares to administer gentamicin (Garamycin) to the 65-year-old
client. Which is the MOST important action for the nurse to take prior to
administration of the medication?
1. Request a daily hemoglobin and hematocrit test.
2. Monitor the serum BUN and creatinine.
3. Request a highly-sensitive C-reactive protein (hs-CRP) test.
4. Monitor the erythrocyte sedimentation rate (ESR). - 1) Assessment: outcome
not priority; may cause anemia, but not usually seen
2) CORRECT - Assessment: outcome priority; nephrotoxic; will see proteinuria,
oliguria, hematuria, thirst, increased BUN, decreased creatine clearance
,3) Assessment: outcome not priority; will be increased in inflammation and
rheumatoid arthritis
4) Assessment: outcome not priority; will be increased with any inflammatory
process
4. The nurse cares for the client in the labor unit. During the transitional phase of
labor, the umbilical cord becomes prolapsed. It is MOST important for the nurse to
take which action?
1. Place the client on her back with thighs flexed on her abdomen.
2. Place the client on her left side with legs flexed.
3. Place the client supine with the head of the bed elevated 30°.
4. Place the client supine with the foot of the bed elevated. - 1) Implementation:
outcome not desired; lithotomy position; will not decrease pressure on umbilical
cord
2) Implementation: outcome not desired; position used to remove weight of fetus
from vena cava to prevent maternal hypotension; will not help with prolapsed
cord
3) Implementation: outcome not desired; would aggravate prolapsed cord
pressure
4) CORRECT - Implementation: outcome desired; Trendelenburg or knee chest
position desired to decrease pressure on umbilical cord
5. The nurse cares for the client diagnosed with lung cancer. The family states that
the client has become confused and that urinary output has decreased during the
previous 24 hours. Which finding MOST concerns the nurse?
1. 2+ pitting pretibial edema.
, 2. Sodium 128 mEq/L.
3. Weight gain of 2 kg in 24 hours.
4. Urine specific gravity 1.008. - 1) Assessment: outcome desired but not priority;
edema not seen with SIADH even though water is retained; needs to be
monitored
2) CORRECT - Assessment: outcome desired and priority; normal sodium range is
135-145 mEq/L, dilutional hyponatremia due to SIADH; client is neurologically
depressed with increased risk of seizures
3) Asssessment: outcome desired but not priority; indicates fluid retention, not as
important as hyponatremia; important to watch trends in weight
4) Assessment: outcome not desired; 1.008 indicates that urine is very dilute; with
SIADH, urine will have high concentration and specific gravity due to excess ADH
secretion
6. The home care nurse cares for a client who is diagnosed with hypertension and
mild depression. The client's daughter states that her mother has been falling
frequently. WWhich response by the nurse is BEST?
1. "Let's get your mother a walker."
2. "Do you think it's time to put your mother in a nursing home?"
3. "When does your mother fall?"
4. "Does your mother seem to be more confused lately?" - 1) Implementation:
outcome not desired; need to assess first
2) Assessment: outcome not priority; "yes/no" question; doesn't help determine
the problem
