NCLEX RN ACTUAL COMPREHENSIVE ANSWERS
AND QUESTIONS SET A+
✔✔The nurse in a pediatric outpatient care facility has received telephone messages
from parents of clients who were previously seen at the facility. The nurse should first
telephone the parent of a client who has
1.acute otitis media and reports insomnia after taking prescribed amoxicillin 6 hours ago
2.a fracture of the left tibia and has placed a crayon in the cast
3.a colostomy and reports skin irritation around the stoma
4.epilepsy and has pink, frothy sputum - ✔✔4.epilepsy and has pink, frothy sputum
✔✔The nurse is caring for a client born 6 hours ago and observes the finding depicted
below. Which of the following actions should the nurse take in response to this finding?
1.Notify the primary health care provider of the findings.
2.Continue to perform routine newborn care.
3.Administer oxygen therapy prescribed p.r.n.
4.Prepare the client for phototherapy. - ✔✔3.Administer oxygen therapy prescribed
p.r.n.
✔✔The nurse has attended a staff development conference about advance directives.
Which of the following information should the nurse understand pertains to advance
directives? Select all that apply.
1.living will
2.organ donation
3.implied consent
4.do not resuscitate (DNR) prescriptions
5.power of attorney for health care - ✔✔1,2,3,4
✔✔The nurse is reinforcing teaching with a client who has iron-deficiency anemia.
Which of the following information should the nurse reinforce? Select all that apply.
1."Continue to take your prescribed iron supplement after your symptoms resolve."
,2."Consult with a genetic counselor to establish inheritance patterns."
3."Alternate periods of activity and rest throughout the day."
4."Increase your dietary intake of foods such as legumes.""
5."Take the prescribed iron supplement with a glass of milk if you experience gastric
upset." - ✔✔5."Take the prescribed iron supplement with a glass of milk if you
experience gastric upset."
✔✔The nurse is contributing to the plan of care for a client who has a nasogastric (NG)
tube for feeding. Which of the following interventions should the nurse recommend
including in the client's plan of care?
1.Raise the head of the client's bed 15 degrees.
2.Apply sterile gloves to irrigate the client's NG tube.
3.Use pH paper to measure the pH of the client's aspirate.
4.Encourage the client to cough while removing the NG tube. - ✔✔2.Apply sterile gloves
to irrigate the client's NG tube.
✔✔The nurse has received the following information about assigned clients. The nurse
should first check the client
1.who has right-sided heart failure and is reporting frequent urination
2.with active pulmonary tuberculosis (TB) who is reporting expectorating blood-tinged
mucus
3.who has a fractured femur and received a dose of pain medication intramuscularly 1
hour ago and is reporting that the pain has not been relieved
4.with benign prostatic hyperplasia (BPH) who is reporting having no bowel movement
for the past 3 days and is requesting a dose of a prescribed laxative - ✔✔3.who has a
fractured femur and received a dose of pain medication intramuscularly 1 hour ago and
is reporting that the pain has not been relieved
✔✔The nurse is caring for a client who has a prescription to remove a nasogastric (NG)
tube. Which of the following actions should the nurse take?
1.Withdraw the tube steadily while the client takes shallow breaths.
2.Have the client hyperextend the neck before withdrawing the tube.
3.Withdraw the tube quickly while the client holds a deep breath.
4.Have the client flex the neck before withdrawing the tube. - ✔✔3.Withdraw the tube
quickly while the client holds a deep breath.
✔✔The nurse is caring for a client with a panic disorder. Which of the following findings
would the nurse expect to observe?
1.dry skin
2.chest pain
3.decreased pulse
4.delusional thinking - ✔✔2.chest pain
✔✔The nurse is caring for a client who has mycoplasma pneumonia. Which of the
following infection control precautions should the nurse implement?
, 1.Wear a surgical mask when checking the client's breath sounds.
2.Place the client in a private room with monitored negative air pressure.
3.Place a stethoscope in the client's room to be used with that client only.
4.Remind visitors to put on a protective gown before entering the client's room. -
✔✔1.Wear a surgical mask when checking the client's breath sounds
✔✔The nurse is caring for a client who has been diagnosed with a hookworm
infestation. The client's parent asks, "How can I prevent my other children from getting
hookworm?" Which of the following would be an appropriate response for the nurse to
make?
1."Cook all meats thoroughly."
2."Have your pets treated for worms."
3."Encourage your children to wear shoes when outside."
4."Wash all clothing in hot water." - ✔✔3."Encourage your children to wear shoes when
outside."
✔✔The charge nurse in a long-term care facility has been advised that the following
clients will be admitted during the shift. The charge nurse should assign the only
available private room to the client with
1.scabies
2.salmonellosis
3.hepatitis B (HBV)
4.cytomegalovirus (CMV) - ✔✔1.scabies
✔✔The nurse is reinforcing teaching with the parents of a 10-year-old client with a
seizure disorder about ketogenic diet therapy. The nurse should reinforce that a
ketogenic diet includes foods that are
1.high in fat, contain adequate protein and are low in carbohydrates
2.low in fat, high in sodium and high in protein
3.high in fat, low in protein and contain caffeine
4.low in fat, low in sodium and are lactose-free - ✔✔1.high in fat, contain adequate
protein and are low in carbohydrates
✔✔The nurse is collecting data from a client with sickle cell anemia. Which of the
following statements by the client would be essential to follow up?
1."I usually drink 4 L of water or juice daily."
2."I am scheduled to receive the influenza vaccine."
3."I may need to receive a prescribed anti-infective if I develop a fever."
4."I have been applying cold packs daily to help relieve the pain in my knees." - ✔✔4."I
have been applying cold packs daily to help relieve the pain in my knees."
✔✔The nurse is preparing a client for emergency surgery to repair a depressed skull
fracture. Which of the following actions would be essential for the nurse to take?
1.determining the time that the client last ate
2.showing the client a picture of the postoperative wound drainage system
AND QUESTIONS SET A+
✔✔The nurse in a pediatric outpatient care facility has received telephone messages
from parents of clients who were previously seen at the facility. The nurse should first
telephone the parent of a client who has
1.acute otitis media and reports insomnia after taking prescribed amoxicillin 6 hours ago
2.a fracture of the left tibia and has placed a crayon in the cast
3.a colostomy and reports skin irritation around the stoma
4.epilepsy and has pink, frothy sputum - ✔✔4.epilepsy and has pink, frothy sputum
✔✔The nurse is caring for a client born 6 hours ago and observes the finding depicted
below. Which of the following actions should the nurse take in response to this finding?
1.Notify the primary health care provider of the findings.
2.Continue to perform routine newborn care.
3.Administer oxygen therapy prescribed p.r.n.
4.Prepare the client for phototherapy. - ✔✔3.Administer oxygen therapy prescribed
p.r.n.
✔✔The nurse has attended a staff development conference about advance directives.
Which of the following information should the nurse understand pertains to advance
directives? Select all that apply.
1.living will
2.organ donation
3.implied consent
4.do not resuscitate (DNR) prescriptions
5.power of attorney for health care - ✔✔1,2,3,4
✔✔The nurse is reinforcing teaching with a client who has iron-deficiency anemia.
Which of the following information should the nurse reinforce? Select all that apply.
1."Continue to take your prescribed iron supplement after your symptoms resolve."
,2."Consult with a genetic counselor to establish inheritance patterns."
3."Alternate periods of activity and rest throughout the day."
4."Increase your dietary intake of foods such as legumes.""
5."Take the prescribed iron supplement with a glass of milk if you experience gastric
upset." - ✔✔5."Take the prescribed iron supplement with a glass of milk if you
experience gastric upset."
✔✔The nurse is contributing to the plan of care for a client who has a nasogastric (NG)
tube for feeding. Which of the following interventions should the nurse recommend
including in the client's plan of care?
1.Raise the head of the client's bed 15 degrees.
2.Apply sterile gloves to irrigate the client's NG tube.
3.Use pH paper to measure the pH of the client's aspirate.
4.Encourage the client to cough while removing the NG tube. - ✔✔2.Apply sterile gloves
to irrigate the client's NG tube.
✔✔The nurse has received the following information about assigned clients. The nurse
should first check the client
1.who has right-sided heart failure and is reporting frequent urination
2.with active pulmonary tuberculosis (TB) who is reporting expectorating blood-tinged
mucus
3.who has a fractured femur and received a dose of pain medication intramuscularly 1
hour ago and is reporting that the pain has not been relieved
4.with benign prostatic hyperplasia (BPH) who is reporting having no bowel movement
for the past 3 days and is requesting a dose of a prescribed laxative - ✔✔3.who has a
fractured femur and received a dose of pain medication intramuscularly 1 hour ago and
is reporting that the pain has not been relieved
✔✔The nurse is caring for a client who has a prescription to remove a nasogastric (NG)
tube. Which of the following actions should the nurse take?
1.Withdraw the tube steadily while the client takes shallow breaths.
2.Have the client hyperextend the neck before withdrawing the tube.
3.Withdraw the tube quickly while the client holds a deep breath.
4.Have the client flex the neck before withdrawing the tube. - ✔✔3.Withdraw the tube
quickly while the client holds a deep breath.
✔✔The nurse is caring for a client with a panic disorder. Which of the following findings
would the nurse expect to observe?
1.dry skin
2.chest pain
3.decreased pulse
4.delusional thinking - ✔✔2.chest pain
✔✔The nurse is caring for a client who has mycoplasma pneumonia. Which of the
following infection control precautions should the nurse implement?
, 1.Wear a surgical mask when checking the client's breath sounds.
2.Place the client in a private room with monitored negative air pressure.
3.Place a stethoscope in the client's room to be used with that client only.
4.Remind visitors to put on a protective gown before entering the client's room. -
✔✔1.Wear a surgical mask when checking the client's breath sounds
✔✔The nurse is caring for a client who has been diagnosed with a hookworm
infestation. The client's parent asks, "How can I prevent my other children from getting
hookworm?" Which of the following would be an appropriate response for the nurse to
make?
1."Cook all meats thoroughly."
2."Have your pets treated for worms."
3."Encourage your children to wear shoes when outside."
4."Wash all clothing in hot water." - ✔✔3."Encourage your children to wear shoes when
outside."
✔✔The charge nurse in a long-term care facility has been advised that the following
clients will be admitted during the shift. The charge nurse should assign the only
available private room to the client with
1.scabies
2.salmonellosis
3.hepatitis B (HBV)
4.cytomegalovirus (CMV) - ✔✔1.scabies
✔✔The nurse is reinforcing teaching with the parents of a 10-year-old client with a
seizure disorder about ketogenic diet therapy. The nurse should reinforce that a
ketogenic diet includes foods that are
1.high in fat, contain adequate protein and are low in carbohydrates
2.low in fat, high in sodium and high in protein
3.high in fat, low in protein and contain caffeine
4.low in fat, low in sodium and are lactose-free - ✔✔1.high in fat, contain adequate
protein and are low in carbohydrates
✔✔The nurse is collecting data from a client with sickle cell anemia. Which of the
following statements by the client would be essential to follow up?
1."I usually drink 4 L of water or juice daily."
2."I am scheduled to receive the influenza vaccine."
3."I may need to receive a prescribed anti-infective if I develop a fever."
4."I have been applying cold packs daily to help relieve the pain in my knees." - ✔✔4."I
have been applying cold packs daily to help relieve the pain in my knees."
✔✔The nurse is preparing a client for emergency surgery to repair a depressed skull
fracture. Which of the following actions would be essential for the nurse to take?
1.determining the time that the client last ate
2.showing the client a picture of the postoperative wound drainage system
