NCLEX RN ASSESSMENT 2025 WITH QUESTIONS AND 100%
CORRECT ANSWERS GRADED A+
A client in a hospice program has increasing pain, and the nurse is
collaborating with the client to make a pain management plan. Which
plan will be most effective for the client?
administering doses of analgesic when pain is a "5" on a scale of 1 to 10.
providing enough analgesia to keep the client semi-somnolent
allowing an analgesia-free period so that the client can carry out daily
hygienic activities.
administering pain medications over a 24-hour period VERIFIED
ANSWER The desired outcome for management of pain is that the
client's or family's subjective report of pain is acceptable and
documented using a pain scale; the goal is that behavioral and
physiologic indicators of pain are absent around the clock. The nurse
and client/family should develop a systematic approach to pain
management using information gathered from history and a hierarchy of
pain measurement. Pain should be assessed at frequent intervals. The
client should not wait to receive medication until the pain is midpoint on
the pain scale, nor should the client receive so much pain medication
that he or she is not alert. Continuous pain relief is the goal, not just
during particular periods during the day.
The nurse is instructing a client who has had an ileostomy about the diet
following surgery. The nurse should tell the client:
"Limit your fluids to 1,000 mL/day."
"Chew your food thoroughly."
"There is no need to monitor your diet."
,"Six small meals a day will prevent abdominal distention." VERIFIED
ANSWER The client is instructed to chew food well to aid digestion and
prevent obstruction.The client should maintain an adequate fluid
intake.The client is usually placed on a regular diet but is encouraged to
eat high-fiber, high-cellulose foods (e.g., nuts, popcorn, corn, peas,
tomatoes) with caution; these foods may swell in the intestine and cause
an obstruction.Eating six small meals a day is not necessary.
A client with a history of posttraumatic stress is panting and breathing
heavily while shouting out some strange words. The nurse reviews the
nursing assessment and understands that the client is practicing a form of
relaxation called power breathing. The best action for the nurse to take is
to:
monitor the client for respiratory difficulties.
contact the health care provider for a psychiatric consult.
allow privacy, but check on the client frequently.
arrange for a sitter so the client is not left alone. VERIFIED ANSWER
The nurse should acknowledge that the client is performing self-care for
anxiety symptoms. The most respectful action is to allow privacy but to
check on the client frequently. The client is likely chanting or reciting a
mantra. There is no indication that the client is experiencing respiratory
conflict. The client does not need a sitter or a psychiatric consult.
Which action should be included in the nursing care for a client with
cervical cancer who has an internal radium implant in place?
Offer the bedpan every 2 hours.
Provide perineal care twice daily.
Check the position of the applicator hourly.
,Offer a low-residue diet. VERIFIED ANSWER Bowel movements can
be difficult with the radium applicator in place. The purpose of the low-
residue diet is to decrease bowel movements. The bowel is cleaned
before therapy, and the woman is maintained on a low-residue diet
during treatment to prevent bowel distention and defecation. To prevent
dislodgment of the applicator, the client is maintained on strict bed rest
and allowed only to turn from side to side. Perineal care is omitted
during radium implant therapy, although any vaginal discharge should be
reported to the health care provider (HCP). It is rare for the applicator to
extrude, so this does not need to be checked every hour.
A breastfeeding mother who is experiencing breast engorgement asks the
nurse if there is anything she can do to get relief. What is the best
intervention for the nurse to implement?
applying ice
applying a breast binder
teaching how to express the breasts
administering bromocriptine VERIFIED ANSWER Teaching the client
how to express her breasts will facilitate let-down, and provide
temporary relief. Ice can promote comfort by decreasing blood flow,
numbing, and discouraging further let-down of milk. It is not
recommended because it also causes the rebound reaction of more let-
down once the ice is removed. Breast binders are not effective in
relieving the discomforts of engorgement. Bromocriptine is no longer
recommended for lactation suppression.
A client is being discharged with nasal packing in place. What should
the nurse instruct the client to do?
Perform frequent mouth care.
, Use normal saline nose drops daily.
Sneeze and cough with mouth closed.
Gargle every 4 hours with salt water. VERIFIED ANSWER Frequent
mouth care is important to provide comfort and encourage eating. Mouth
care promotes moist mucous membranes. Nose drops cannot be used
with nasal packing in place. When sneezing and coughing, the client
should do so with the mouth open to decrease the chance of dislodging
the packing. Gargling should not be attempted with packing in place.
A breastfeeding postpartum client experiencing breast engorgement tells
the nurse that she has applied cabbage leaves to decrease her breast
discomfort. What is the nurse's best response?
"Using cabbage leaves to relieve engorgement is considered a folk
remedy."
"I'm concerned that the cabbage leaves may harm your nursing baby."
"I need to notify your health care provider immediately that you're using
cabbage leaves."
"Let me know if you get relief using the cabbage leaves." VERIFIED
ANSWER Holistic nursing honors the client's preference for safe,
alternative, and complementary practices. Cabbage leaves tucked into
the bra is an alternative practice that may relieve pain and swelling from
engorgement in some clients. Saying that using cabbage is a folk remedy
does not address the safety or efficacy of the practice. There are no
known safety risks to using cabbage as a treatment for engorgement. The
nurse should document the client's use of cabbage leaves to treat the
engorgement in the medical record, but there is no risk that warrants
immediate notification of the health care provider.
CORRECT ANSWERS GRADED A+
A client in a hospice program has increasing pain, and the nurse is
collaborating with the client to make a pain management plan. Which
plan will be most effective for the client?
administering doses of analgesic when pain is a "5" on a scale of 1 to 10.
providing enough analgesia to keep the client semi-somnolent
allowing an analgesia-free period so that the client can carry out daily
hygienic activities.
administering pain medications over a 24-hour period VERIFIED
ANSWER The desired outcome for management of pain is that the
client's or family's subjective report of pain is acceptable and
documented using a pain scale; the goal is that behavioral and
physiologic indicators of pain are absent around the clock. The nurse
and client/family should develop a systematic approach to pain
management using information gathered from history and a hierarchy of
pain measurement. Pain should be assessed at frequent intervals. The
client should not wait to receive medication until the pain is midpoint on
the pain scale, nor should the client receive so much pain medication
that he or she is not alert. Continuous pain relief is the goal, not just
during particular periods during the day.
The nurse is instructing a client who has had an ileostomy about the diet
following surgery. The nurse should tell the client:
"Limit your fluids to 1,000 mL/day."
"Chew your food thoroughly."
"There is no need to monitor your diet."
,"Six small meals a day will prevent abdominal distention." VERIFIED
ANSWER The client is instructed to chew food well to aid digestion and
prevent obstruction.The client should maintain an adequate fluid
intake.The client is usually placed on a regular diet but is encouraged to
eat high-fiber, high-cellulose foods (e.g., nuts, popcorn, corn, peas,
tomatoes) with caution; these foods may swell in the intestine and cause
an obstruction.Eating six small meals a day is not necessary.
A client with a history of posttraumatic stress is panting and breathing
heavily while shouting out some strange words. The nurse reviews the
nursing assessment and understands that the client is practicing a form of
relaxation called power breathing. The best action for the nurse to take is
to:
monitor the client for respiratory difficulties.
contact the health care provider for a psychiatric consult.
allow privacy, but check on the client frequently.
arrange for a sitter so the client is not left alone. VERIFIED ANSWER
The nurse should acknowledge that the client is performing self-care for
anxiety symptoms. The most respectful action is to allow privacy but to
check on the client frequently. The client is likely chanting or reciting a
mantra. There is no indication that the client is experiencing respiratory
conflict. The client does not need a sitter or a psychiatric consult.
Which action should be included in the nursing care for a client with
cervical cancer who has an internal radium implant in place?
Offer the bedpan every 2 hours.
Provide perineal care twice daily.
Check the position of the applicator hourly.
,Offer a low-residue diet. VERIFIED ANSWER Bowel movements can
be difficult with the radium applicator in place. The purpose of the low-
residue diet is to decrease bowel movements. The bowel is cleaned
before therapy, and the woman is maintained on a low-residue diet
during treatment to prevent bowel distention and defecation. To prevent
dislodgment of the applicator, the client is maintained on strict bed rest
and allowed only to turn from side to side. Perineal care is omitted
during radium implant therapy, although any vaginal discharge should be
reported to the health care provider (HCP). It is rare for the applicator to
extrude, so this does not need to be checked every hour.
A breastfeeding mother who is experiencing breast engorgement asks the
nurse if there is anything she can do to get relief. What is the best
intervention for the nurse to implement?
applying ice
applying a breast binder
teaching how to express the breasts
administering bromocriptine VERIFIED ANSWER Teaching the client
how to express her breasts will facilitate let-down, and provide
temporary relief. Ice can promote comfort by decreasing blood flow,
numbing, and discouraging further let-down of milk. It is not
recommended because it also causes the rebound reaction of more let-
down once the ice is removed. Breast binders are not effective in
relieving the discomforts of engorgement. Bromocriptine is no longer
recommended for lactation suppression.
A client is being discharged with nasal packing in place. What should
the nurse instruct the client to do?
Perform frequent mouth care.
, Use normal saline nose drops daily.
Sneeze and cough with mouth closed.
Gargle every 4 hours with salt water. VERIFIED ANSWER Frequent
mouth care is important to provide comfort and encourage eating. Mouth
care promotes moist mucous membranes. Nose drops cannot be used
with nasal packing in place. When sneezing and coughing, the client
should do so with the mouth open to decrease the chance of dislodging
the packing. Gargling should not be attempted with packing in place.
A breastfeeding postpartum client experiencing breast engorgement tells
the nurse that she has applied cabbage leaves to decrease her breast
discomfort. What is the nurse's best response?
"Using cabbage leaves to relieve engorgement is considered a folk
remedy."
"I'm concerned that the cabbage leaves may harm your nursing baby."
"I need to notify your health care provider immediately that you're using
cabbage leaves."
"Let me know if you get relief using the cabbage leaves." VERIFIED
ANSWER Holistic nursing honors the client's preference for safe,
alternative, and complementary practices. Cabbage leaves tucked into
the bra is an alternative practice that may relieve pain and swelling from
engorgement in some clients. Saying that using cabbage is a folk remedy
does not address the safety or efficacy of the practice. There are no
known safety risks to using cabbage as a treatment for engorgement. The
nurse should document the client's use of cabbage leaves to treat the
engorgement in the medical record, but there is no risk that warrants
immediate notification of the health care provider.
