Exam Cram NCLEX-PN PRACTICE
QUESTIONS
A 5 year old is admitted to the unit following a tonsillectomy. Which of the following
would indicate a complication of the surgery?
A. Decreased appetite
B. A low-grade fever
C. Chest congestion
D. Constant swallowing -
A 6 year old with cerebral palsy functions at the level of an 18 month old. Which finding
would support that assessment?
A. She dresses herself
B. She pulls a toy behind her
C. She can build a tower of eight blocks
D. She can copy a horizontal or vertical line. -
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 the pain"
B. "what does his vomit look like?"
C. " Describe his usual diet."
D. " have you noticed changes in his adominal size?" - C." Describe his usual diet."
why?
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
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 - A. taking the vital signs
why?
the primary responisblity of the nurse is to take the vital signs before any surgery.
,answers B,C and D are the responsibility of the doctor.
A 25 year old male is brought to the ER with a piece of metal in his eye. Which action by
the nurse is correct?
A. Use a magnet to remove the object
B. Rinse the eye thoroughly with saline
C. Cover both eyes with paper cups
D. Patch the affected eye only - C. Cover both eyes with paper cups
why?
Covering both eyes prevents consensual movement of the affected eye.
A 70 year old man who is recovering from a stroke exhibits signs of unilateral neglect.
Which behavior is suggested of unilateral neglect?
A. The client is observed by shaving only one side of his face
B. The client is unable to distinguish between two tactile stimuli presented
simultaneously
C. The client is unable to complete a range a vision without turning his head side to side
D. The client is unable to carry out cognitive and motor activity at the same time - A.
The client is observed by shaving only one side of his face
why?
The client with unilateral neglect will neglect one side of the body
A client arrives in the emergency room with a possible fractured femur. The nurse
should anticipate an order for:
A. Trendelenburg position
B. Ice to the entire extremity
C. Bucks traction
D. An abduction pillow - C. Bucks traction
why?
The client with a fractured femur will be placed in Bucks traction to realign the leg and
decrease spasms and pain.
A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks.
Which lab finding indicates that the medication is having the desired effect?
A. Neutrophil count of 60%
B. Basophil count of 0.5%
,C. Monocyte count of 2%
D. Reticlocyte count of 1% - D. Reticlocyte count of 1 %
why?
Cyanocolamine is a B12 medication that is used for pernicious anemia, and a
reticulocyte count of 1% indicates that it is having the desired effect.
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 electrolytes loss in the incisional area
C. Encouraging a high fiber diet
D. Facilitating perineal wound drainage - D. Facilitating perineal wound drainage
why?
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 illestomy. 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.
A client in the cardiac step-down unit requires suctioning for excess mucous secretions.
The nurse should be most careful to monitor the client for which dysrhythmia during this
procedure?
A. Bradycardia
B. Tachycardia
C. Premature ventricular beats
D. Heart block - A. Bradycardia
why?
Suctioning can cause a vagal response and bradycardia.
A client is 2 days post-operative colon resection. After a coughing episode, the client's
wound eviscerates. Which nursing action is most appropriate?
A. Reinsert the protruding organ and cover with 4x4s
B. Cover the wound with a sterile 4x4 and ABD dressing
C. Cover the wound with a sterile saline-soaked dressing
D. Apply an abdominal binder and manual pressure to the wound - C. Cover the wound
with a sterile saline-soaked dressing.
, why?
If the client eviscerates, the abdominal content should be covered with a sterile saline-
soaked dressing.
A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium
of 170 meq/L. What behavioral changes would be common for this client?
A. Anger
B. Mania
C. Depression
D. Pyschosis - B. Mania
why?
The client with serum sodium of 170 meq/L has hypernatrimia and might exhibit manic
behvior.
A client is admitted with a Ewing's sacroma. which symptoms would be expected due to
this tumor's location?
A. Hemiplegia
B. Aphasia
C. Nausea
D. Bone Pain - D. Bone Pain
why?
Sacroma is a type of bone cancer, therefor, bone pain would be expected
A client visits the clinic after the death of a parent. Which statement made by the client's
sister signifies abnormal grieving?
A. "My sister still has episodes of crying and it's been 3 months since daddy died."
B. "Sally seems to have forgotten the bad things that daddy did in his lifetime."
C. "She really had a hard time after daddy's funeral. She said that she had a sense of
longing."
D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened."
- D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened
at all."
why?
Abnormal grieving is exhibited by a lack of feeling sad; if the client's sister appears not
to grieve, it might be abnormal grieving. This family member might be suppressing
feelings of grief.
QUESTIONS
A 5 year old is admitted to the unit following a tonsillectomy. Which of the following
would indicate a complication of the surgery?
A. Decreased appetite
B. A low-grade fever
C. Chest congestion
D. Constant swallowing -
A 6 year old with cerebral palsy functions at the level of an 18 month old. Which finding
would support that assessment?
A. She dresses herself
B. She pulls a toy behind her
C. She can build a tower of eight blocks
D. She can copy a horizontal or vertical line. -
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 the pain"
B. "what does his vomit look like?"
C. " Describe his usual diet."
D. " have you noticed changes in his adominal size?" - C." Describe his usual diet."
why?
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
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 - A. taking the vital signs
why?
the primary responisblity of the nurse is to take the vital signs before any surgery.
,answers B,C and D are the responsibility of the doctor.
A 25 year old male is brought to the ER with a piece of metal in his eye. Which action by
the nurse is correct?
A. Use a magnet to remove the object
B. Rinse the eye thoroughly with saline
C. Cover both eyes with paper cups
D. Patch the affected eye only - C. Cover both eyes with paper cups
why?
Covering both eyes prevents consensual movement of the affected eye.
A 70 year old man who is recovering from a stroke exhibits signs of unilateral neglect.
Which behavior is suggested of unilateral neglect?
A. The client is observed by shaving only one side of his face
B. The client is unable to distinguish between two tactile stimuli presented
simultaneously
C. The client is unable to complete a range a vision without turning his head side to side
D. The client is unable to carry out cognitive and motor activity at the same time - A.
The client is observed by shaving only one side of his face
why?
The client with unilateral neglect will neglect one side of the body
A client arrives in the emergency room with a possible fractured femur. The nurse
should anticipate an order for:
A. Trendelenburg position
B. Ice to the entire extremity
C. Bucks traction
D. An abduction pillow - C. Bucks traction
why?
The client with a fractured femur will be placed in Bucks traction to realign the leg and
decrease spasms and pain.
A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks.
Which lab finding indicates that the medication is having the desired effect?
A. Neutrophil count of 60%
B. Basophil count of 0.5%
,C. Monocyte count of 2%
D. Reticlocyte count of 1% - D. Reticlocyte count of 1 %
why?
Cyanocolamine is a B12 medication that is used for pernicious anemia, and a
reticulocyte count of 1% indicates that it is having the desired effect.
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 electrolytes loss in the incisional area
C. Encouraging a high fiber diet
D. Facilitating perineal wound drainage - D. Facilitating perineal wound drainage
why?
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 illestomy. 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.
A client in the cardiac step-down unit requires suctioning for excess mucous secretions.
The nurse should be most careful to monitor the client for which dysrhythmia during this
procedure?
A. Bradycardia
B. Tachycardia
C. Premature ventricular beats
D. Heart block - A. Bradycardia
why?
Suctioning can cause a vagal response and bradycardia.
A client is 2 days post-operative colon resection. After a coughing episode, the client's
wound eviscerates. Which nursing action is most appropriate?
A. Reinsert the protruding organ and cover with 4x4s
B. Cover the wound with a sterile 4x4 and ABD dressing
C. Cover the wound with a sterile saline-soaked dressing
D. Apply an abdominal binder and manual pressure to the wound - C. Cover the wound
with a sterile saline-soaked dressing.
, why?
If the client eviscerates, the abdominal content should be covered with a sterile saline-
soaked dressing.
A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium
of 170 meq/L. What behavioral changes would be common for this client?
A. Anger
B. Mania
C. Depression
D. Pyschosis - B. Mania
why?
The client with serum sodium of 170 meq/L has hypernatrimia and might exhibit manic
behvior.
A client is admitted with a Ewing's sacroma. which symptoms would be expected due to
this tumor's location?
A. Hemiplegia
B. Aphasia
C. Nausea
D. Bone Pain - D. Bone Pain
why?
Sacroma is a type of bone cancer, therefor, bone pain would be expected
A client visits the clinic after the death of a parent. Which statement made by the client's
sister signifies abnormal grieving?
A. "My sister still has episodes of crying and it's been 3 months since daddy died."
B. "Sally seems to have forgotten the bad things that daddy did in his lifetime."
C. "She really had a hard time after daddy's funeral. She said that she had a sense of
longing."
D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened."
- D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened
at all."
why?
Abnormal grieving is exhibited by a lack of feeling sad; if the client's sister appears not
to grieve, it might be abnormal grieving. This family member might be suppressing
feelings of grief.
