NCLEX NGN 2024 ACTUAL EXAM ALL 180 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+
A registered nurse is assigned to care for a service user with chronic renal failure who is undergoing
hemodialysis through an internal AV fistula in the RA. Which intervention should the registered nurse
implement in caring for the service user? SATA
a. Assessing the radial pulse in the right extremity
b. Using the LA ti take BP readings
c. Drawing pre-dialysis blood specimens from the LA
d. Assessing the area over the AV fistula for a bruit and three each shift
e. Placing a pressure dressing over the site after each dialysis treatment
f. Administering IV fluids through the venous site of the AV fistula as needed - answer-A, B, C, D
A registered nurse is evaluating outcomes for a service user with Guillain-Barre syndrome. Which
outcome does the registered nurse recognize as optimal respiratory outcomes for the service user?
a. Normal deep tendon reflexes
b. Improved skeletal muscle tone
c. Absences of paresthesias in the lower extremities
d. Clear sound in the lower lung fields bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg - answer-D, E
A registered nurse of the telemetry unit is caring for a service user who has had a MI and is now
attached to a cardiac monitor. The registered nurse is monitoring the service user's cardiac rhythm and
nots ventricular fibrillation. Which nursing intervention should the registered nurse take first?
a. Calling the rapid response team
b. Preparing the service user for cardioversion
c. Asking the service user to bear down and cough
d. Preparing to administer diltiazem - answer-A
The pattern of ventricular fibrillation is identified and can be a result after a service user with an MI. VF
makes the service user feel faint, then loses consciousness and becomes pulseless and apneic (BP and
heart
,sounds absent). Treatment is to terminate VF and covert it into a rhythm via defibrillation-> call a rapid
and initiate CPR. Cardioversion is used for ventricular or supraventricular tachydysrhythmias.
A registered nurse developing a plan of care for a service user with a spinal cord injury includes
measures to prevent autonomic dysreflexia (hyperreflexia). Which intervention does the registered
nurse incorporate into the plan to prevent this complication?
a. Keeping the fan running in the service user's room
b. Keeping the linens wrinkle free under the service user
c. Limiting bladder catheterization to once every 12 hours
d. Avoiding the administration of enemas and rectal suppositories - answer-B
The most frequent cause of autonomic dysreflexias are a distended bladder and impacted feces. Other
causes include stimulation of the skin by tactile, thermal, or painful stimuli. The registered nurse
renders care in such a way as to minimize these risks.
A registered nurse provides home care instructions to a service user who has been fitted with a halo
device to treat a cervical fracture. Which statement by the service user indicates the need for further
teaching?
a. I need to get more fluids and fiber into my diet
b. I should cut my food into small pieces before I eat
c. I need to put powder under the vest twice a day to prevent sweating
d. I have to check the pin sites everyday and watch for signs of infection - answer-C
Cleanse the skin under the wool liner each day to prevent rashes and soars.
A registered nurse is caring for a service user with increased intracranial pressure. In which position
should the registered nurse maintain the service user?
a. Supine with the head extended
b. Side lying with the neck flexed
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees - answer-D
Proper positioning promotes venous drainage from the cranium to minimize ICP.
A service user with a basilar skull fracture has clear fluid leaking from the ears. The registered nurse
should take which action first?
, a. Asses the clear fluid for protein
b. Check the clear fluid for glucose
c. Place cotton calls or dry gauze loosely in the ears
d. Use an otoscope to assess the tympanic membrane for rupture - answer-B
CSF contains glucose not protein.
A registered nurse is caring for a service user who has just undergone cardioversion. Which
intervention is the registered nurse's priority after this procedure.
a. Administer oxygen
b. Monitoring the BP
c. Administering antidysrhythmic medications
d. Monitoring the service user's LOC - answer-A
ABC's of nursing. All other choices are correct, but not priority.
A service user with diabetes mellitus who is scheduled to have blood drawn for determination of the
glycosylated hemoglobin (HbA1c) level asks the registered nurse why the test is necessary if he is
performing blood glucose monitoring at home. Which is the best response for the registered nurse to
provide?
a. Detect diabetic complications
b. Assess long-term glycemic control
c. Determine whether the service user is at risk for hypoglycemia
d Determine whether the prescribed insulin dosage is correct - answer-B
A registered nurse caring for a service user with acquired immunodeficiency syndrome is monitoring
the service user for signs of complications. Which of the following would cause the registered nurse to
suspect infection with Pneumocystis jirovec? SATA
a. Diarrhea
b. Tachypnea
c. Pedal edema
d. Intermittent fever
e. Dyspnea with ambulating
AND CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+
A registered nurse is assigned to care for a service user with chronic renal failure who is undergoing
hemodialysis through an internal AV fistula in the RA. Which intervention should the registered nurse
implement in caring for the service user? SATA
a. Assessing the radial pulse in the right extremity
b. Using the LA ti take BP readings
c. Drawing pre-dialysis blood specimens from the LA
d. Assessing the area over the AV fistula for a bruit and three each shift
e. Placing a pressure dressing over the site after each dialysis treatment
f. Administering IV fluids through the venous site of the AV fistula as needed - answer-A, B, C, D
A registered nurse is evaluating outcomes for a service user with Guillain-Barre syndrome. Which
outcome does the registered nurse recognize as optimal respiratory outcomes for the service user?
a. Normal deep tendon reflexes
b. Improved skeletal muscle tone
c. Absences of paresthesias in the lower extremities
d. Clear sound in the lower lung fields bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg - answer-D, E
A registered nurse of the telemetry unit is caring for a service user who has had a MI and is now
attached to a cardiac monitor. The registered nurse is monitoring the service user's cardiac rhythm and
nots ventricular fibrillation. Which nursing intervention should the registered nurse take first?
a. Calling the rapid response team
b. Preparing the service user for cardioversion
c. Asking the service user to bear down and cough
d. Preparing to administer diltiazem - answer-A
The pattern of ventricular fibrillation is identified and can be a result after a service user with an MI. VF
makes the service user feel faint, then loses consciousness and becomes pulseless and apneic (BP and
heart
,sounds absent). Treatment is to terminate VF and covert it into a rhythm via defibrillation-> call a rapid
and initiate CPR. Cardioversion is used for ventricular or supraventricular tachydysrhythmias.
A registered nurse developing a plan of care for a service user with a spinal cord injury includes
measures to prevent autonomic dysreflexia (hyperreflexia). Which intervention does the registered
nurse incorporate into the plan to prevent this complication?
a. Keeping the fan running in the service user's room
b. Keeping the linens wrinkle free under the service user
c. Limiting bladder catheterization to once every 12 hours
d. Avoiding the administration of enemas and rectal suppositories - answer-B
The most frequent cause of autonomic dysreflexias are a distended bladder and impacted feces. Other
causes include stimulation of the skin by tactile, thermal, or painful stimuli. The registered nurse
renders care in such a way as to minimize these risks.
A registered nurse provides home care instructions to a service user who has been fitted with a halo
device to treat a cervical fracture. Which statement by the service user indicates the need for further
teaching?
a. I need to get more fluids and fiber into my diet
b. I should cut my food into small pieces before I eat
c. I need to put powder under the vest twice a day to prevent sweating
d. I have to check the pin sites everyday and watch for signs of infection - answer-C
Cleanse the skin under the wool liner each day to prevent rashes and soars.
A registered nurse is caring for a service user with increased intracranial pressure. In which position
should the registered nurse maintain the service user?
a. Supine with the head extended
b. Side lying with the neck flexed
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees - answer-D
Proper positioning promotes venous drainage from the cranium to minimize ICP.
A service user with a basilar skull fracture has clear fluid leaking from the ears. The registered nurse
should take which action first?
, a. Asses the clear fluid for protein
b. Check the clear fluid for glucose
c. Place cotton calls or dry gauze loosely in the ears
d. Use an otoscope to assess the tympanic membrane for rupture - answer-B
CSF contains glucose not protein.
A registered nurse is caring for a service user who has just undergone cardioversion. Which
intervention is the registered nurse's priority after this procedure.
a. Administer oxygen
b. Monitoring the BP
c. Administering antidysrhythmic medications
d. Monitoring the service user's LOC - answer-A
ABC's of nursing. All other choices are correct, but not priority.
A service user with diabetes mellitus who is scheduled to have blood drawn for determination of the
glycosylated hemoglobin (HbA1c) level asks the registered nurse why the test is necessary if he is
performing blood glucose monitoring at home. Which is the best response for the registered nurse to
provide?
a. Detect diabetic complications
b. Assess long-term glycemic control
c. Determine whether the service user is at risk for hypoglycemia
d Determine whether the prescribed insulin dosage is correct - answer-B
A registered nurse caring for a service user with acquired immunodeficiency syndrome is monitoring
the service user for signs of complications. Which of the following would cause the registered nurse to
suspect infection with Pneumocystis jirovec? SATA
a. Diarrhea
b. Tachypnea
c. Pedal edema
d. Intermittent fever
e. Dyspnea with ambulating
