NCLEX NGN NEWEST 2024 ACTUAL EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+
The nurse has attended a staff education program about obtaining blood specimens from a central
venous access device (VAD).
Which of the following statements by the nurse would require follow-up?
1. "I will use a 3 mL syringe to flush the catheter port."
2. "The injection cap should be cleansed with antiseptic and allowed to air-dry."
3. "I will aspirate 5 mL of blood and discard the syringe in the biohazard container before obtaining the
specimen."
4. "The infusion should be turned off for at least 1 minute before the specimen is aspirated." - answer-
1. "I will use a 3 mL syringe to flush the catheter port."
A 10 mL flush is appropriate
Obtaining blood specimens from VAD:
Stop IV infusion for at least a minute
Scrub cap for 10-15 secs and allow to air dry
Pull back 5 ml of discard blood and discard in biohazard container
Scrub cap again
Withdraw blood for specimen
Scrub, Flush and Lock
Restart infusion
The nurse has taught about preventing osteoporosis to a 45-year-old client who has had a hysterectomy
and bilateral salpingo-oophorectomy. Which of the following statements by the client would indicate
correct understanding of the teaching?
1. "I will begin to take dancing lessons."
2. "I will get more rest at night."
3. "I will take a multivitamin supplement daily."
4. "I will add more fiber to my diet." - answer-1. "I will begin to take dancing lessons."
,The nurse is preparing to insert a peripheral venous access device (VAD) for a client. Which of the
following actions should the nurse take?
1. Ask the client to open and close the fist multiple times.
2. Tap the client's vein multiple times to promote dilation.
3. Apply the tourniquet 9 to 10 in (22.5 to 25 cm) above the venipuncture site.
4. Palpate for a vein after cleansing the selected site. - answer-1. Ask the client to open and close the
fist multiple times.
The nurse is assessing a newly admitted client who sustained partial-thickness (second-degree) burns to
the anterior thorax in a house fire. Which of the following findings would require immediate follow-up?
1. dizziness and confusion
2. hypoactive bowel sounds and nausea
3. vesicular breath sounds throughout the lung fields
4. pain rated 5 on a scale of 0 (no pain) to 10 (severe pain) - answer-1. dizziness and confusion
Vesicular breath sounds are normal breath sounds
The nurse has taught a client with a hiatal hernia about interventions for the condition. Which of the
following statements by the client would indicate a correct understanding of the teaching?
1. "I will consume 3 regular-sized meals daily."
2. "Wearing an abdominal binder can help relieve symptoms."
3. "I should elevate the head of the bed on 6 in (15 cm) blocks."
4. "Eating foods with a high fat content will increase gastric emptying." - answer-3. "I should elevate
the head of the bed on 6 in (15 cm) blocks."
Speed up passage of food by raising the HOB
Rationale:
4. Eating foods high in carbs, fluids and low in protein speeds up digestion which is indicated for HH. DS
would be the opposite
,The nurse is assessing a client with suspected gout. Which of the following findings would support a
diagnosis of gout? Select all that apply.
1. elevated serum uric acid level
2. a swollen, red joint
3. reports of moderate fatigue
4. distal extremities cool to touch
5. pain associated with movement of the affected extremity
6. intolerance of dairy products - answer-1,2,3,5
4. distal joints are warm to touch
6. low fat milk can decrease occurrence of gout attacks!
The nurse is assessing a client with suspected endometriosis.
Which of the following findings would support a diagnosis of endometriosis?
1. dyspareunia
2. hot flashes
3. weight gain
4. amenorrhea - answer-1. dyspareunia
Pain with intercourse
The nurse is assessing a client with cirrhosis. Which of the following findings would be consistent with a
diagnosis of cirrhosis?
1. steatorrhea
2. deep vein thrombosis (DVT)
3. high fever
4. spontaneous bruising - answer-4. spontaneous bruising
The liver has a role in synthesizing coagulating factors. Damage to the liver impairs coagulation
, Rationale:
1. Steatorrhea indicates a pancreatic problem
The nurse is assessing a male client who has suspected syphilis. Which of the following findings would
support a diagnosis of syphilis?
1. urethritis
2. conjunctivitis
3. chancre lesions
4. penile discharge - answer-3. chancre lesions
The nurse has attended a staff education program about spinal shock following acute spinal cord injury.
Follow-up is required if the nurse states that manifestations of spinal shock include
1. bowel dysfunction
2. bladder dysfunction
3. spastic paralysis below the level of injury
4. loss of sensation below the level of injury - answer-3. spastic paralysis below the level of injury
The nurse is planning care for a client who has an arteriovenous (AV) shunt in the left arm. Which of the
following interventions should the nurse include in the client's plan of care?
1. Instruct the client to protect the AV shunt by tucking the left arm under the body while sleeping.
2. Check for a bruit by palpating the AV shunt.
3. Administer prescribed intravenous fluids through the AV shunt.
4. Avoid obtaining blood pressure measurements in the arm with the AV shunt. - answer-4. Avoid
obtaining blood pressure measurements in the arm with the AV shunt.
Rationale:
1. Sleep on unaffected side
2. You would auscultate for bruit and palpate for trill to verify that the shunt is working 3. No iv
fluids through the shunt, just dialysis
CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+
The nurse has attended a staff education program about obtaining blood specimens from a central
venous access device (VAD).
Which of the following statements by the nurse would require follow-up?
1. "I will use a 3 mL syringe to flush the catheter port."
2. "The injection cap should be cleansed with antiseptic and allowed to air-dry."
3. "I will aspirate 5 mL of blood and discard the syringe in the biohazard container before obtaining the
specimen."
4. "The infusion should be turned off for at least 1 minute before the specimen is aspirated." - answer-
1. "I will use a 3 mL syringe to flush the catheter port."
A 10 mL flush is appropriate
Obtaining blood specimens from VAD:
Stop IV infusion for at least a minute
Scrub cap for 10-15 secs and allow to air dry
Pull back 5 ml of discard blood and discard in biohazard container
Scrub cap again
Withdraw blood for specimen
Scrub, Flush and Lock
Restart infusion
The nurse has taught about preventing osteoporosis to a 45-year-old client who has had a hysterectomy
and bilateral salpingo-oophorectomy. Which of the following statements by the client would indicate
correct understanding of the teaching?
1. "I will begin to take dancing lessons."
2. "I will get more rest at night."
3. "I will take a multivitamin supplement daily."
4. "I will add more fiber to my diet." - answer-1. "I will begin to take dancing lessons."
,The nurse is preparing to insert a peripheral venous access device (VAD) for a client. Which of the
following actions should the nurse take?
1. Ask the client to open and close the fist multiple times.
2. Tap the client's vein multiple times to promote dilation.
3. Apply the tourniquet 9 to 10 in (22.5 to 25 cm) above the venipuncture site.
4. Palpate for a vein after cleansing the selected site. - answer-1. Ask the client to open and close the
fist multiple times.
The nurse is assessing a newly admitted client who sustained partial-thickness (second-degree) burns to
the anterior thorax in a house fire. Which of the following findings would require immediate follow-up?
1. dizziness and confusion
2. hypoactive bowel sounds and nausea
3. vesicular breath sounds throughout the lung fields
4. pain rated 5 on a scale of 0 (no pain) to 10 (severe pain) - answer-1. dizziness and confusion
Vesicular breath sounds are normal breath sounds
The nurse has taught a client with a hiatal hernia about interventions for the condition. Which of the
following statements by the client would indicate a correct understanding of the teaching?
1. "I will consume 3 regular-sized meals daily."
2. "Wearing an abdominal binder can help relieve symptoms."
3. "I should elevate the head of the bed on 6 in (15 cm) blocks."
4. "Eating foods with a high fat content will increase gastric emptying." - answer-3. "I should elevate
the head of the bed on 6 in (15 cm) blocks."
Speed up passage of food by raising the HOB
Rationale:
4. Eating foods high in carbs, fluids and low in protein speeds up digestion which is indicated for HH. DS
would be the opposite
,The nurse is assessing a client with suspected gout. Which of the following findings would support a
diagnosis of gout? Select all that apply.
1. elevated serum uric acid level
2. a swollen, red joint
3. reports of moderate fatigue
4. distal extremities cool to touch
5. pain associated with movement of the affected extremity
6. intolerance of dairy products - answer-1,2,3,5
4. distal joints are warm to touch
6. low fat milk can decrease occurrence of gout attacks!
The nurse is assessing a client with suspected endometriosis.
Which of the following findings would support a diagnosis of endometriosis?
1. dyspareunia
2. hot flashes
3. weight gain
4. amenorrhea - answer-1. dyspareunia
Pain with intercourse
The nurse is assessing a client with cirrhosis. Which of the following findings would be consistent with a
diagnosis of cirrhosis?
1. steatorrhea
2. deep vein thrombosis (DVT)
3. high fever
4. spontaneous bruising - answer-4. spontaneous bruising
The liver has a role in synthesizing coagulating factors. Damage to the liver impairs coagulation
, Rationale:
1. Steatorrhea indicates a pancreatic problem
The nurse is assessing a male client who has suspected syphilis. Which of the following findings would
support a diagnosis of syphilis?
1. urethritis
2. conjunctivitis
3. chancre lesions
4. penile discharge - answer-3. chancre lesions
The nurse has attended a staff education program about spinal shock following acute spinal cord injury.
Follow-up is required if the nurse states that manifestations of spinal shock include
1. bowel dysfunction
2. bladder dysfunction
3. spastic paralysis below the level of injury
4. loss of sensation below the level of injury - answer-3. spastic paralysis below the level of injury
The nurse is planning care for a client who has an arteriovenous (AV) shunt in the left arm. Which of the
following interventions should the nurse include in the client's plan of care?
1. Instruct the client to protect the AV shunt by tucking the left arm under the body while sleeping.
2. Check for a bruit by palpating the AV shunt.
3. Administer prescribed intravenous fluids through the AV shunt.
4. Avoid obtaining blood pressure measurements in the arm with the AV shunt. - answer-4. Avoid
obtaining blood pressure measurements in the arm with the AV shunt.
Rationale:
1. Sleep on unaffected side
2. You would auscultate for bruit and palpate for trill to verify that the shunt is working 3. No iv
fluids through the shunt, just dialysis
