NCLEX DEC FILE 2
1. Potential Which individual is at greatest risk for developing
hypertension?
A. 45-year-old African-American attorney
2. A 15-year-old female who ingested 15 tablets of maximum strength
acetaminophen 45 minutes ago is rushed to the emergency department.
Which of these orders should the nurse do first?
A. Gastric lavage
3. Which complication of cardiac catheterization should the nurse monitor for in the
initial 24 hours after the procedure?
B. Thrombus formation
4. A client is admitted to the emergency room with renal calculi and is
complaining of moderate to severe flank pain and nausea. The client’s
temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this
client is:
C.Manage pain
5. What would the nurse expect to see while assessing the growth of children
during their school age years?
D.Yearly weight gain of about 5.5 pounds per year
6. At a community health fair, the blood pressure of a 62-year-old client is
160/96 mmHg. The client states “My blood pressure is usually much lower.”
The nurse should tell the client to:
A. Go get a blood pressure check within the next 15 minutes
7. The hospital has sounded the call for a disaster drill on the evening shift.
Which of these clients would the nurse put first on the list to be discharged in
order to make a room available for a new admission?
A. A middle-aged client with a history of being ventilator dependent for over
Seven (7) years and admitted with bacterial pneumonia five days ago.
8. A 25-year-old male client has been newly diagnosed with hypothyroidism and
will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the
teaching plan, the nurse emphasizes that this medication:
A. Should be taken in the morning
9. A 3-year-old child was brought to the pediatric clinic after the sudden onset of
findings that include irritability, thick muffled voice, croaking on inspiration,
hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal
retractions. What should the nurse do first?
,D.Notify the healthcare provider of the child’s status
10. In children suspected to have a diagnosis of diabetes, which one of the
following complaints would be most likely to prompt parents to take their
school-age child for evaluation?
C.Bedwetting
11. A client comes to the clinic for treatment of recurrent pelvic inflammatory
disease. The nurse recognizes that this condition most frequently follows
which type of infection?
B.Chlamydia
12. A registered nurse who usually works in a spinal rehabilitation unit is floated to
the emergency department. Which of these clients should the charge nurse
assign to this RN?
C.An adolescent who has been on pain medications terminal cancer
with an initial assessment finding pupils and a relaxed respiratory rate of
11,
13. When teaching a client with coronary artery disease about nutrition, the nurse
should emphasize:
C.Avoiding very heavy meals
14. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per
hour plus PRN for pain breakthrough for morphine drip is not working?
C.The level of drug is 100 ml at 8 AM and is 80 ml at noon
15. The nurse is speaking at a community meeting about personal responsibility
for health promotion. A participant asks about chiropractic treatment for
illnesses. What should be the focus of the nurse’s response?
B.Spinal column manipulation
16. The nurse is performing a neurological assessment on a client post right
cerebrovascular accident. Which finding, if observed by the nurse, would
warrant immediate attention ?
A. Decrease in level of consciousness
17. A child who has recently been diagnosed with cystic fibrosis is in a pediatric
clinic where a nurse is performing an assessment. Which later finding of this
disease would the nurse not expect to see at this time?
C.Moist, productive cough
18. The home health nurse visits a male client to provide wound care and finds the
client lethargic and confused. His wife states he fell down the stairs two (2)
hours ago. The nurse should
, B.Send him to the emergency room for evaluation
19. Which of the following should the nurse implement to prepare a client for a KUB
(Kidney, Ureter, Bladder) radiography test?
D.No special orders are necessary for this examination
20. The nurse is giving discharge teaching to a client seven (7) days post myocardial
infarction. He asks the nurse why he must wait six (6) weeks before having
sexual intercourse. What is the best response by the nurse to this question?
B.“When you can climb 2 flights of stairs without problems, it is generally
safe.”
21. A triage nurse has these four (4) clients arrive in the emergency
department within 15 minutes. Which client should the triage nurse send
back to be seen first?
B.A teenager who got a singed beard while camping
22. While planning care for a toddler, the nurse teaches the parents about the
expected developmental changes for this age. Which statement by the
mother shows that she understands the child’s developmental needs?
C.“I understand the need to use those new skills.”
23. A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal,
full- term girl and is now progressing toward the establishment of successful lactation. To remove the
babyfrom her breast, she should be instructed to:
A. Insert a clean finger into the baby’s mouth beside the nipple
24. A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus
to beboggy, high, and deviated to the right. The most appropriate nursing action is to:
A. Have the client void and then re-evaluate the fundus
25. A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been
pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second
pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using
the GTPAL system to record her obstetrical history, the nurse should record:
C. 3-1-1-0-2
26. A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been
pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second
pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using
the gravida and para system to record the client’s obstetrical history, the nurse should record:
A. Gravida 3 para 2
1. Potential Which individual is at greatest risk for developing
hypertension?
A. 45-year-old African-American attorney
2. A 15-year-old female who ingested 15 tablets of maximum strength
acetaminophen 45 minutes ago is rushed to the emergency department.
Which of these orders should the nurse do first?
A. Gastric lavage
3. Which complication of cardiac catheterization should the nurse monitor for in the
initial 24 hours after the procedure?
B. Thrombus formation
4. A client is admitted to the emergency room with renal calculi and is
complaining of moderate to severe flank pain and nausea. The client’s
temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this
client is:
C.Manage pain
5. What would the nurse expect to see while assessing the growth of children
during their school age years?
D.Yearly weight gain of about 5.5 pounds per year
6. At a community health fair, the blood pressure of a 62-year-old client is
160/96 mmHg. The client states “My blood pressure is usually much lower.”
The nurse should tell the client to:
A. Go get a blood pressure check within the next 15 minutes
7. The hospital has sounded the call for a disaster drill on the evening shift.
Which of these clients would the nurse put first on the list to be discharged in
order to make a room available for a new admission?
A. A middle-aged client with a history of being ventilator dependent for over
Seven (7) years and admitted with bacterial pneumonia five days ago.
8. A 25-year-old male client has been newly diagnosed with hypothyroidism and
will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the
teaching plan, the nurse emphasizes that this medication:
A. Should be taken in the morning
9. A 3-year-old child was brought to the pediatric clinic after the sudden onset of
findings that include irritability, thick muffled voice, croaking on inspiration,
hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal
retractions. What should the nurse do first?
,D.Notify the healthcare provider of the child’s status
10. In children suspected to have a diagnosis of diabetes, which one of the
following complaints would be most likely to prompt parents to take their
school-age child for evaluation?
C.Bedwetting
11. A client comes to the clinic for treatment of recurrent pelvic inflammatory
disease. The nurse recognizes that this condition most frequently follows
which type of infection?
B.Chlamydia
12. A registered nurse who usually works in a spinal rehabilitation unit is floated to
the emergency department. Which of these clients should the charge nurse
assign to this RN?
C.An adolescent who has been on pain medications terminal cancer
with an initial assessment finding pupils and a relaxed respiratory rate of
11,
13. When teaching a client with coronary artery disease about nutrition, the nurse
should emphasize:
C.Avoiding very heavy meals
14. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per
hour plus PRN for pain breakthrough for morphine drip is not working?
C.The level of drug is 100 ml at 8 AM and is 80 ml at noon
15. The nurse is speaking at a community meeting about personal responsibility
for health promotion. A participant asks about chiropractic treatment for
illnesses. What should be the focus of the nurse’s response?
B.Spinal column manipulation
16. The nurse is performing a neurological assessment on a client post right
cerebrovascular accident. Which finding, if observed by the nurse, would
warrant immediate attention ?
A. Decrease in level of consciousness
17. A child who has recently been diagnosed with cystic fibrosis is in a pediatric
clinic where a nurse is performing an assessment. Which later finding of this
disease would the nurse not expect to see at this time?
C.Moist, productive cough
18. The home health nurse visits a male client to provide wound care and finds the
client lethargic and confused. His wife states he fell down the stairs two (2)
hours ago. The nurse should
, B.Send him to the emergency room for evaluation
19. Which of the following should the nurse implement to prepare a client for a KUB
(Kidney, Ureter, Bladder) radiography test?
D.No special orders are necessary for this examination
20. The nurse is giving discharge teaching to a client seven (7) days post myocardial
infarction. He asks the nurse why he must wait six (6) weeks before having
sexual intercourse. What is the best response by the nurse to this question?
B.“When you can climb 2 flights of stairs without problems, it is generally
safe.”
21. A triage nurse has these four (4) clients arrive in the emergency
department within 15 minutes. Which client should the triage nurse send
back to be seen first?
B.A teenager who got a singed beard while camping
22. While planning care for a toddler, the nurse teaches the parents about the
expected developmental changes for this age. Which statement by the
mother shows that she understands the child’s developmental needs?
C.“I understand the need to use those new skills.”
23. A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal,
full- term girl and is now progressing toward the establishment of successful lactation. To remove the
babyfrom her breast, she should be instructed to:
A. Insert a clean finger into the baby’s mouth beside the nipple
24. A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus
to beboggy, high, and deviated to the right. The most appropriate nursing action is to:
A. Have the client void and then re-evaluate the fundus
25. A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been
pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second
pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using
the GTPAL system to record her obstetrical history, the nurse should record:
C. 3-1-1-0-2
26. A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been
pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second
pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using
the gravida and para system to record the client’s obstetrical history, the nurse should record:
A. Gravida 3 para 2
