NCSBN NCLEX EXAM QUESTIONS
AND CORRECT DETAILED
ANSWERS WITH RATIONALE
LATEST UPDATE THIS YEAR
A nurse is talking to parents about the
side effects of routine immunizations.
Which finding should the nurse
reinforce about calling the health care
provider if it occurs within 24 to 48
hours after a routine immunization?
1Localized tenderness at the injection
site
2Tympanic temperature of 104 F (40 C)
3Some irritability and fussiness
1
,4Swelling at the injection site - correct
answer=✔✔2
A 28-year-old is transferred to the
emergency department (ED) via
ambulance with a traumatic head
injury. The client is awake and reports
having a headache and some amnesia.
What are the priority nursing
interventions for this client? (Select all
that apply.) - correct answer=✔✔Correct
Response
Assess vital signs and neurological
function
Assess the airway
Prepare for CT imaging of the head
Assess the wound for presence of
drainage or bruising on the head
2
,A client exhibits many delusional
thoughts. As the nurse assists the
client to prepare for breakfast, the
client comments, "Don't waste good
food on me. I'm dying from this disease
I have." Which response by the nurse
would be the best?
1"None of the laboratory reports show
that you have any physical disease."
2"Try to eat a little bit. Breakfast is the
most important meal of the day."
3"I know you believe that you have an
incurable disease."
4"What has your primary health care
provider told you?" - correct
answer=✔✔3
The family member tells an admitting
nurse that the client values the
practice of Chinese medicine. The
3
, nurse must understand that for this
family and client a priority goal should
take which focus?
1Achieve harmony
2Respect life in old age
3Maintain energy balance
4Restore yin and yang - correct
answer=✔✔4
The nurse is reinforcing dietary
instructions to the parents of a child
diagnosed with cystic fibrosis. The
nurse will emphasize which of the
following characteristics of this diet?
1A gluten-free diet, avoiding foods that
contain wheat, rye and barley
2Balanced, high calorie diet with extra
fat, salt, protein and calcium
4
AND CORRECT DETAILED
ANSWERS WITH RATIONALE
LATEST UPDATE THIS YEAR
A nurse is talking to parents about the
side effects of routine immunizations.
Which finding should the nurse
reinforce about calling the health care
provider if it occurs within 24 to 48
hours after a routine immunization?
1Localized tenderness at the injection
site
2Tympanic temperature of 104 F (40 C)
3Some irritability and fussiness
1
,4Swelling at the injection site - correct
answer=✔✔2
A 28-year-old is transferred to the
emergency department (ED) via
ambulance with a traumatic head
injury. The client is awake and reports
having a headache and some amnesia.
What are the priority nursing
interventions for this client? (Select all
that apply.) - correct answer=✔✔Correct
Response
Assess vital signs and neurological
function
Assess the airway
Prepare for CT imaging of the head
Assess the wound for presence of
drainage or bruising on the head
2
,A client exhibits many delusional
thoughts. As the nurse assists the
client to prepare for breakfast, the
client comments, "Don't waste good
food on me. I'm dying from this disease
I have." Which response by the nurse
would be the best?
1"None of the laboratory reports show
that you have any physical disease."
2"Try to eat a little bit. Breakfast is the
most important meal of the day."
3"I know you believe that you have an
incurable disease."
4"What has your primary health care
provider told you?" - correct
answer=✔✔3
The family member tells an admitting
nurse that the client values the
practice of Chinese medicine. The
3
, nurse must understand that for this
family and client a priority goal should
take which focus?
1Achieve harmony
2Respect life in old age
3Maintain energy balance
4Restore yin and yang - correct
answer=✔✔4
The nurse is reinforcing dietary
instructions to the parents of a child
diagnosed with cystic fibrosis. The
nurse will emphasize which of the
following characteristics of this diet?
1A gluten-free diet, avoiding foods that
contain wheat, rye and barley
2Balanced, high calorie diet with extra
fat, salt, protein and calcium
4
