NCLEX RN Practice Test (ALL PASSING
LEVEL Qs)
nurse does ED triage. unemancipated minor requests treatment.
registration
states clerk guardian's consent for treatment. which is the nurse's
they need
-next action?
triage after guardian consent
obtained
- ask minor about medical reason for seeking
treatment
- request HCP perform medical screening
exam
- notify nursing supervisor Correct answers ask the minor about the medical
reason for
seeking treatment (wrong,
picked d)
rationale: unemancipated minors may consent to medical treatment if they
have
medical specific
conditions- pregnancy/STI/substance abuse/mental health, not
appropriate
nurse to notifyfor nursing supervisor before assessing situation and
determining
consent is whether
required
nurse makes med surg unit assignments. LPN assigned to client with
localized
zoster. LPNherpes
tells nurse "i have never had chickenpox" which response by
nurse is most
appropriat
e?
- use standard precautions when caring for
-thisyouptwill be fine, airborne precautions
needed
- your client assignment will be
changed
- why are you concerned about providing care for this pt? Correct answers
your client will be changed (wrong,
assignment
picked a)
rationale: localized herpes zoster is shingles, if you care for pt with herpes
zosterget
could youchickenpox from
them
caring for pregnant and postpartum pts. which client does the
-nurse
6wkssee 1st?
gestation, LPN can't get fetal heart tones with
doptone
- 5 days postpartum, bright red bloody
discharge
- 22 wks gestation, feels fetal movement 4times
-per
2 days
hour postpartum, has urinary incontinence Correct answers 5 days
postpartum
reporting pt red, blood discharge
bright
(correct)
rationale: bloody discharge (rubra lochia) should only last 1-3 days - need
to monitor
amount and color in addition to vital signs, fetal heart tones can't be
heardless
wks, until 8-12
than 3 fetal movements in 1 hour could indicate fetal
issue, urinaryis normal during postpartum- teach
incontinence
kegels
, pt has CLL is scheduled for bone marrow aspiration and biopsy. pt says, "i'm
frightened
i haven't had this test before and i don't know what to expect" which
statements
nruse include will
when responding to pt's concerns?
SATA
- we will move you to operating room where test is always
performed
- bone in the front of the chest will be used for
biopsy
- a tight pressure dressing will be placed over test site after
procedure
- you will not feel any discomfort as the local anesthetic is
injected
- risk of bleeding present, so will monitor test site frequently Correct
answers tight
pressure dressing placed over testing site after procedure & there is a risk
of bleeding,
so we will monitor the test site
frequently
rationale: bone marrow aspiration/biopsy can be done in pt room or a
treatment
not room
OR, don't use sternum for biopsy, pressure dressing helps with
bleeding,
sting/discomfort during biopsy, can cause
bleeding
nurse speaks with pt and spouse who have been undergoing family
counseling.
spouse states pt's
" you never take any responsibility for the messes you
alwaysresponse
which cause" by nurse is
best?
- why do you say
that?
- blaming is not
effective
- let's focus only on
positives
- when is the last time you two had a vacation Correct answers blaming
isn't effective
(wrong, picked
c)
rationale: don't ask why, telling them blaming isn't effective helps keep
focus on"only"
people, both isn't a good
word
pt diagnosed with malnutrition has continuous enteral feedings through
newly placedtube. which actions will nurse include in plan of
gastrostomy
-care?
coverSATA
insertion site with adhesive
- add 8 hours of feeding to bag at a
bandage
time
- rotate gastrostomy tube 360 degrees
-once daily for whoosh of air through
auscultate
-gastrostomy
check for slighttubein and out movement of gastrostomy tube Correct
answers rotate
gastrostomy tube 360 degrees once daily & check for slight in and out
movement of
gastrostomy
tube
rationale: insertion site should be covered with sterile bandage to reduce
infection
until stomariskis healed, only 4 hours of enteral feeding added to bag at a
time to reduce
bacterial contamination, rotate 360 degrees daily to reduce risk of skin
irritation anddon't insert air for gastrostomy rube assessment, slight in/out
breakdown,
indicates
isn't tube in wall of
embedded
stomach
nurse asses pt for potential spousal abuse. nurse is most concerned if pt
makes which
statemen
t?
- it's my fault because I push my spouses
buttons
LEVEL Qs)
nurse does ED triage. unemancipated minor requests treatment.
registration
states clerk guardian's consent for treatment. which is the nurse's
they need
-next action?
triage after guardian consent
obtained
- ask minor about medical reason for seeking
treatment
- request HCP perform medical screening
exam
- notify nursing supervisor Correct answers ask the minor about the medical
reason for
seeking treatment (wrong,
picked d)
rationale: unemancipated minors may consent to medical treatment if they
have
medical specific
conditions- pregnancy/STI/substance abuse/mental health, not
appropriate
nurse to notifyfor nursing supervisor before assessing situation and
determining
consent is whether
required
nurse makes med surg unit assignments. LPN assigned to client with
localized
zoster. LPNherpes
tells nurse "i have never had chickenpox" which response by
nurse is most
appropriat
e?
- use standard precautions when caring for
-thisyouptwill be fine, airborne precautions
needed
- your client assignment will be
changed
- why are you concerned about providing care for this pt? Correct answers
your client will be changed (wrong,
assignment
picked a)
rationale: localized herpes zoster is shingles, if you care for pt with herpes
zosterget
could youchickenpox from
them
caring for pregnant and postpartum pts. which client does the
-nurse
6wkssee 1st?
gestation, LPN can't get fetal heart tones with
doptone
- 5 days postpartum, bright red bloody
discharge
- 22 wks gestation, feels fetal movement 4times
-per
2 days
hour postpartum, has urinary incontinence Correct answers 5 days
postpartum
reporting pt red, blood discharge
bright
(correct)
rationale: bloody discharge (rubra lochia) should only last 1-3 days - need
to monitor
amount and color in addition to vital signs, fetal heart tones can't be
heardless
wks, until 8-12
than 3 fetal movements in 1 hour could indicate fetal
issue, urinaryis normal during postpartum- teach
incontinence
kegels
, pt has CLL is scheduled for bone marrow aspiration and biopsy. pt says, "i'm
frightened
i haven't had this test before and i don't know what to expect" which
statements
nruse include will
when responding to pt's concerns?
SATA
- we will move you to operating room where test is always
performed
- bone in the front of the chest will be used for
biopsy
- a tight pressure dressing will be placed over test site after
procedure
- you will not feel any discomfort as the local anesthetic is
injected
- risk of bleeding present, so will monitor test site frequently Correct
answers tight
pressure dressing placed over testing site after procedure & there is a risk
of bleeding,
so we will monitor the test site
frequently
rationale: bone marrow aspiration/biopsy can be done in pt room or a
treatment
not room
OR, don't use sternum for biopsy, pressure dressing helps with
bleeding,
sting/discomfort during biopsy, can cause
bleeding
nurse speaks with pt and spouse who have been undergoing family
counseling.
spouse states pt's
" you never take any responsibility for the messes you
alwaysresponse
which cause" by nurse is
best?
- why do you say
that?
- blaming is not
effective
- let's focus only on
positives
- when is the last time you two had a vacation Correct answers blaming
isn't effective
(wrong, picked
c)
rationale: don't ask why, telling them blaming isn't effective helps keep
focus on"only"
people, both isn't a good
word
pt diagnosed with malnutrition has continuous enteral feedings through
newly placedtube. which actions will nurse include in plan of
gastrostomy
-care?
coverSATA
insertion site with adhesive
- add 8 hours of feeding to bag at a
bandage
time
- rotate gastrostomy tube 360 degrees
-once daily for whoosh of air through
auscultate
-gastrostomy
check for slighttubein and out movement of gastrostomy tube Correct
answers rotate
gastrostomy tube 360 degrees once daily & check for slight in and out
movement of
gastrostomy
tube
rationale: insertion site should be covered with sterile bandage to reduce
infection
until stomariskis healed, only 4 hours of enteral feeding added to bag at a
time to reduce
bacterial contamination, rotate 360 degrees daily to reduce risk of skin
irritation anddon't insert air for gastrostomy rube assessment, slight in/out
breakdown,
indicates
isn't tube in wall of
embedded
stomach
nurse asses pt for potential spousal abuse. nurse is most concerned if pt
makes which
statemen
t?
- it's my fault because I push my spouses
buttons
