NCLEX-PN TEST-BANK (200 QUESTIONS WITH
100% CORRECT ANSWERS AND EXPLANATION)
1. The Nurse Is Caring For A Client Scheduled For Removal Of A Pituitary Tumor
Using The Transsphenoidal Approach. The Nurse Should Be Particularly Alert For:
A. Nasal Congestion
B. Abdominal Tenderness
C. Muscle Tetany
D. Oliguria
Answer A: Removal Of The Pituitary Gland Is Usually Done By A Transsphenoidal Approach,
Through The Nose. Nasal Congestion Further Interferes With The Airway. Answers B, C, And D
Are Not Correct Because They Are Not Directly Associated With The Pituitary Gland.
2. A Client With Cancer Is Admitted To The Oncology Unit. Stat Lab Values Reveal
Hgb 12.6, Wbc 6500, K+ 1.9, Uric Acid 7.0, Na+ 136, And Platelets 178,000. The Nurse
Evaluates That The Client Is Experiencing Which Of The Following?
A. Hypernatremia
B. Hypokalemia
C. Myelosuppression
D. Leukocytosis
Answer B: Hypokalemia Is Evident From The Lab Values Listed. The Other Laboratory
Findings Are Within Normal Limits, Making Answers A, C, And D Incorrect.
3. A 24-Year-Old Female Client Is Scheduled For Surgery In The Morning. Which Of
The Following Is The Primary Responsibility Of The Nurse?
A. Taking The Vital Signs
B. Obtaining The Permit
C. Explaining The Procedure
D. Checking The Lab Work
Answer A: The Primary Responsibility Of The Nurse Is To Take The Vital Signs Before Any
Surgery. The Actions In Answers B, C, And D Are The Responsibility Of The Doctor And,
Therefore, Are Incorrect For This Question.
,4. The Nurse Is Working In The Emergency Room When A Client Arrives With
Severe Burns Of The Left Arm, Hands, Face, And Neck. Which Action Should Receive
Priority?
A. Starting An Iv
B. Applying Oxygen
C. Obtaining Blood Gases
D. Medicating The Client For Pain
Answer B: The Client With Burns To The Neck Needs Airway Assessment And Supplemental
Oxygen, So Applying Oxygen Is The Priority. The Next Action Should Be To Start An Iv And
Medicate For Pain, Making Answers A And C Incorrect. Answer D, Obtaining Blood Gases, Is
Ordered By The Doctor.
5. The Nurse Is Visiting A Home Health Client With Osteoporosis. The Client Has A
New Prescription For Alendronate (Fosamax). Which Instruction Should Be Given To The
Client?
A. Rest In Bed After Taking The Medication For At Least 30 Minutes
B. Avoid Rapid Movements After Taking The Medication
C. Take The Medication With Water Only
D. Allow At Least 1 Hour Between Taking The Medicine And Taking Other Medications
Answer B: The Client With Burns To The Neck Needs Airway Assessment And Supplemental
Oxygen, So Applying Oxygen Is The Priority. The Next Action Should Be To Start An Iv And
Medicate For Pain, Making Answers A And C Incorrect. Answer D, Obtaining Blood Gases, Is
Ordered By The Doctor.
6. The Nurse Is Making Initial Rounds On A Client With A C5 Fracture And
Crutchfield Tongs. Which Equipment Should Be Kept At The Bedside?
A. A Pair Of Forceps
B. A Torque Wrench
C. A Pair Of Wire Cutters
D. A Screwdriver
Answer B: A Torque Wrench Is Kept At The Bedside To Tighten And Loosen The Screws Of
Crutchfield Tongs. This Wrench Controls The Amount Of Pressure That Is Placed On The
Screws. A Pair Of Forceps, Wire Cutters, And A Screwdriver, In Answers A, C, And D, Would
Not Be Used And, Thus, Are Incorrect.
,7. An Infant Weighs 7 Pounds At Birth. The Expected Weight By 1 Year Should Be:
A. 10 Pounds
B. 12 Pounds
C. 18 Pounds
D. 21 Pounds
Answer D: A Birth Weight Of 7 Pounds Would Indicate 21 Pounds In 1 Year, Or Triple His
Birth Weight. Answers A, B, And C Therefore Are Incorrect.
8. A Client Is Admitted With A Ewing’s Sarcoma. Which Symptoms Would Be
Expected Due To This Tumor’s Location?
A. Hemiplegia
B. Aphasia
C. Nausea
D. Bone Pain
Answer D: Sarcoma Is A Type Of Bone Cancer; Therefore, Bone Pain Would Be Expected.
Answers A, B, And C Are Not Specific To This Type Of Cancer And Are Incorrect.
9. The Nurse Is Caring For A Client With Epilepsy Who Is Being Treated With
Carbamazepine (Tegretol). Which Laboratory Value Might Indicate A Serious Side Effect
Of This Drug?
A. Uric Acid Of 5mg/Dl
B. Hematocrit Of 33%
C. Wbc 2,000 Per Cubic Millimeter
D. Platelets 150,000 Per Cubic Millimeter
Answer C: Tegretol Can Suppress The Bone Marrow And Decrease The White Blood Cell
Count; Thus, A Lab Value Of Wbc 2,000 Per Cubic Millimeter Indicates Side Effects Of The
Drug. Answers A And D Are Within Normal Limits, And Answer B Is A Lower Limit Of
Normal; Therefore, Answers A, B, And D Are Incorrect.
10. A 6-Month-Old Client Is Admitted With Possible Intussuception. Which Question
During The Nursing History Is Least Helpful In Obtaining Information Regarding This
Diagnosis?
A. “Tell Me About His Pain.”
, B. “What Does His Vomit Look Like?”
C. “Describe His Usual Diet.”
D. “Have You Noticed Changes In His Abdominal Size?”
Answer C: The Least-Helpful Questions Are Those Describing His Usual Diet. A, B, And D Are
Useful In Determining The Extent Of Disease Process And, Thus, Are Incorrect.
11. The Nurse Is Assisting A Client With Diverticulosis To Select Appropriate Foods.
Which Food Should Be Avoided?
A. Bran
B. Fresh Peaches
C. Cucumber Salad
D. Yeast Rolls
Answer C: The Client With Diverticulitis Should Avoid Foods With Seeds. The Foods In
Answers A, B, And D Are Allowed; In Fact, Bran Cereal And Fruit Will Help Prevent
Constipation.
12. A Client Has Rectal Cancer And Is Scheduled For An Abdominal Perineal
Resection. What Should Be The Priority Nursing Care During The Post-Op Period?
A. Teaching How To Irrigate The Illeostomy
B. Stopping Electrolyte Loss In The Incisional Area
C. Encouraging A High-Fiber Diet
D. Facilitating Perineal Wound Drainage
Answer D: The Client With A Perineal Resection Will Have A Perineal Incision. Drains Will Be
Used To Facilitate Wound Drainage. This Will Help Prevent Infection Of The Surgical Site. The
Client Will Not Have An Illeostomy, As In Answer A; He Will Have Some Electrolyte Loss, But
Treatment Is Not Focused On Preventing The Loss, So Answer B Is Incorrect. A High-Fiber
Diet, In Answer C, Is Not Ordered At This Time.
13. The Nurse Is Performing Discharge Teaching On A Client With Diverticulitis Who
Has Been Placed On A Low-Roughage Diet. Which Food Would Have To Be Eliminated
From This Client’s Diet?
A. Roasted Chicken
B. Noodles
C. Cooked Broccoli
D. Custard
Answer C: The Client With Diverticulitis Should Avoid Eating Foods That Are
100% CORRECT ANSWERS AND EXPLANATION)
1. The Nurse Is Caring For A Client Scheduled For Removal Of A Pituitary Tumor
Using The Transsphenoidal Approach. The Nurse Should Be Particularly Alert For:
A. Nasal Congestion
B. Abdominal Tenderness
C. Muscle Tetany
D. Oliguria
Answer A: Removal Of The Pituitary Gland Is Usually Done By A Transsphenoidal Approach,
Through The Nose. Nasal Congestion Further Interferes With The Airway. Answers B, C, And D
Are Not Correct Because They Are Not Directly Associated With The Pituitary Gland.
2. A Client With Cancer Is Admitted To The Oncology Unit. Stat Lab Values Reveal
Hgb 12.6, Wbc 6500, K+ 1.9, Uric Acid 7.0, Na+ 136, And Platelets 178,000. The Nurse
Evaluates That The Client Is Experiencing Which Of The Following?
A. Hypernatremia
B. Hypokalemia
C. Myelosuppression
D. Leukocytosis
Answer B: Hypokalemia Is Evident From The Lab Values Listed. The Other Laboratory
Findings Are Within Normal Limits, Making Answers A, C, And D Incorrect.
3. A 24-Year-Old Female Client Is Scheduled For Surgery In The Morning. Which Of
The Following Is The Primary Responsibility Of The Nurse?
A. Taking The Vital Signs
B. Obtaining The Permit
C. Explaining The Procedure
D. Checking The Lab Work
Answer A: The Primary Responsibility Of The Nurse Is To Take The Vital Signs Before Any
Surgery. The Actions In Answers B, C, And D Are The Responsibility Of The Doctor And,
Therefore, Are Incorrect For This Question.
,4. The Nurse Is Working In The Emergency Room When A Client Arrives With
Severe Burns Of The Left Arm, Hands, Face, And Neck. Which Action Should Receive
Priority?
A. Starting An Iv
B. Applying Oxygen
C. Obtaining Blood Gases
D. Medicating The Client For Pain
Answer B: The Client With Burns To The Neck Needs Airway Assessment And Supplemental
Oxygen, So Applying Oxygen Is The Priority. The Next Action Should Be To Start An Iv And
Medicate For Pain, Making Answers A And C Incorrect. Answer D, Obtaining Blood Gases, Is
Ordered By The Doctor.
5. The Nurse Is Visiting A Home Health Client With Osteoporosis. The Client Has A
New Prescription For Alendronate (Fosamax). Which Instruction Should Be Given To The
Client?
A. Rest In Bed After Taking The Medication For At Least 30 Minutes
B. Avoid Rapid Movements After Taking The Medication
C. Take The Medication With Water Only
D. Allow At Least 1 Hour Between Taking The Medicine And Taking Other Medications
Answer B: The Client With Burns To The Neck Needs Airway Assessment And Supplemental
Oxygen, So Applying Oxygen Is The Priority. The Next Action Should Be To Start An Iv And
Medicate For Pain, Making Answers A And C Incorrect. Answer D, Obtaining Blood Gases, Is
Ordered By The Doctor.
6. The Nurse Is Making Initial Rounds On A Client With A C5 Fracture And
Crutchfield Tongs. Which Equipment Should Be Kept At The Bedside?
A. A Pair Of Forceps
B. A Torque Wrench
C. A Pair Of Wire Cutters
D. A Screwdriver
Answer B: A Torque Wrench Is Kept At The Bedside To Tighten And Loosen The Screws Of
Crutchfield Tongs. This Wrench Controls The Amount Of Pressure That Is Placed On The
Screws. A Pair Of Forceps, Wire Cutters, And A Screwdriver, In Answers A, C, And D, Would
Not Be Used And, Thus, Are Incorrect.
,7. An Infant Weighs 7 Pounds At Birth. The Expected Weight By 1 Year Should Be:
A. 10 Pounds
B. 12 Pounds
C. 18 Pounds
D. 21 Pounds
Answer D: A Birth Weight Of 7 Pounds Would Indicate 21 Pounds In 1 Year, Or Triple His
Birth Weight. Answers A, B, And C Therefore Are Incorrect.
8. A Client Is Admitted With A Ewing’s Sarcoma. Which Symptoms Would Be
Expected Due To This Tumor’s Location?
A. Hemiplegia
B. Aphasia
C. Nausea
D. Bone Pain
Answer D: Sarcoma Is A Type Of Bone Cancer; Therefore, Bone Pain Would Be Expected.
Answers A, B, And C Are Not Specific To This Type Of Cancer And Are Incorrect.
9. The Nurse Is Caring For A Client With Epilepsy Who Is Being Treated With
Carbamazepine (Tegretol). Which Laboratory Value Might Indicate A Serious Side Effect
Of This Drug?
A. Uric Acid Of 5mg/Dl
B. Hematocrit Of 33%
C. Wbc 2,000 Per Cubic Millimeter
D. Platelets 150,000 Per Cubic Millimeter
Answer C: Tegretol Can Suppress The Bone Marrow And Decrease The White Blood Cell
Count; Thus, A Lab Value Of Wbc 2,000 Per Cubic Millimeter Indicates Side Effects Of The
Drug. Answers A And D Are Within Normal Limits, And Answer B Is A Lower Limit Of
Normal; Therefore, Answers A, B, And D Are Incorrect.
10. A 6-Month-Old Client Is Admitted With Possible Intussuception. Which Question
During The Nursing History Is Least Helpful In Obtaining Information Regarding This
Diagnosis?
A. “Tell Me About His Pain.”
, B. “What Does His Vomit Look Like?”
C. “Describe His Usual Diet.”
D. “Have You Noticed Changes In His Abdominal Size?”
Answer C: The Least-Helpful Questions Are Those Describing His Usual Diet. A, B, And D Are
Useful In Determining The Extent Of Disease Process And, Thus, Are Incorrect.
11. The Nurse Is Assisting A Client With Diverticulosis To Select Appropriate Foods.
Which Food Should Be Avoided?
A. Bran
B. Fresh Peaches
C. Cucumber Salad
D. Yeast Rolls
Answer C: The Client With Diverticulitis Should Avoid Foods With Seeds. The Foods In
Answers A, B, And D Are Allowed; In Fact, Bran Cereal And Fruit Will Help Prevent
Constipation.
12. A Client Has Rectal Cancer And Is Scheduled For An Abdominal Perineal
Resection. What Should Be The Priority Nursing Care During The Post-Op Period?
A. Teaching How To Irrigate The Illeostomy
B. Stopping Electrolyte Loss In The Incisional Area
C. Encouraging A High-Fiber Diet
D. Facilitating Perineal Wound Drainage
Answer D: The Client With A Perineal Resection Will Have A Perineal Incision. Drains Will Be
Used To Facilitate Wound Drainage. This Will Help Prevent Infection Of The Surgical Site. The
Client Will Not Have An Illeostomy, As In Answer A; He Will Have Some Electrolyte Loss, But
Treatment Is Not Focused On Preventing The Loss, So Answer B Is Incorrect. A High-Fiber
Diet, In Answer C, Is Not Ordered At This Time.
13. The Nurse Is Performing Discharge Teaching On A Client With Diverticulitis Who
Has Been Placed On A Low-Roughage Diet. Which Food Would Have To Be Eliminated
From This Client’s Diet?
A. Roasted Chicken
B. Noodles
C. Cooked Broccoli
D. Custard
Answer C: The Client With Diverticulitis Should Avoid Eating Foods That Are
