NCLEX RN EXAM 2024-ACTUAL EXAM
WITH 100+...T DETAILED ANSWERS WITH
RATIONALES, Exams of Nursing
The nurse has taught a client with diabetes mellitus (type 2) about foot care.
Which of the following statements by the client would indicate a correct
understanding of the teaching? Select all that apply.
1. "I will check my shoes for foreign objects prior to putting them on."
2. "I should use a large, coarse file to remove dry skin from a bunion."
3. "I will apply a petroleum-based ointment between my toes after bathing."
4. "I should avoid crossing my legs to prevent decreased circulation to my feet."
5. "I should wear new shoes for a few hours for several days until they fit well."
<<<answer>>>1, 4, 5
Rationale:
1. Diabetics are at risk for feet injuries
4. Diabetics have poor perfusion and peripheral neuropathy so this makes sense
5. Always wear good fitting shoes and never walk barefoot.
2. Do not use files on feet you can injure yourself
3. Do NOT apply lotion between the toes because it can cause maceration and
skin breakdown. Dry carefully between toes
,The nurse is teaching a client who is scheduled for a total hip arthroplasty via a
posterior approach. Which of the following information should the nurse include?
Select all that apply.
1. "The type of prosthesis used is based on the muscle strength and joint function
of your upper extremities."
2. "Do not bend the affected hip more than 90 degrees after surgery."
3. "Skin preparation and cleansing is mandatory before surgery."
4. "Use an elevated toilet seat for at least 6 weeks after surgery."
5. "You can resume sexual intercourse after surgery if your partner is in a
dependent position." <<<answer>>>2,3,4
Posterior Approach Precautions:
Do not bend the hip more than 90 degrees
Do not cross legs or feet
Do not roll or lie on the unoperated side for the first 6 weeks
Do not twist the upper body when standing
Sleep on the back for the first 6 weeks
The patient may benefit from a shower chair or elevated seat for home use
Avoid bathing for 8 to 12 weeks (flexed and bent down in the tub)
The nurse is caring for a client who is receiving an intravenous infusion via a
peripheral venous access device (VAD). The client reports sharp pain at the VAD
site. The nurse notes the intravenous fluid is infusing more slowly than prescribed.
The nurse should recognize that the client is most likely experiencing
,1. venous spasm
2. nerve damage
3. septicemia
4. hematoma <<<answer>>>1. venous spasm
S/S include sharp pain and slowing of infusion
Rationale: Hematoma main s/s are redness, warmth and swelling. Sharp pain is
not a characteristic of hematomas, which are relatively harmful
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?
WITH 100+...T DETAILED ANSWERS WITH
RATIONALES, Exams of Nursing
The nurse has taught a client with diabetes mellitus (type 2) about foot care.
Which of the following statements by the client would indicate a correct
understanding of the teaching? Select all that apply.
1. "I will check my shoes for foreign objects prior to putting them on."
2. "I should use a large, coarse file to remove dry skin from a bunion."
3. "I will apply a petroleum-based ointment between my toes after bathing."
4. "I should avoid crossing my legs to prevent decreased circulation to my feet."
5. "I should wear new shoes for a few hours for several days until they fit well."
<<<answer>>>1, 4, 5
Rationale:
1. Diabetics are at risk for feet injuries
4. Diabetics have poor perfusion and peripheral neuropathy so this makes sense
5. Always wear good fitting shoes and never walk barefoot.
2. Do not use files on feet you can injure yourself
3. Do NOT apply lotion between the toes because it can cause maceration and
skin breakdown. Dry carefully between toes
,The nurse is teaching a client who is scheduled for a total hip arthroplasty via a
posterior approach. Which of the following information should the nurse include?
Select all that apply.
1. "The type of prosthesis used is based on the muscle strength and joint function
of your upper extremities."
2. "Do not bend the affected hip more than 90 degrees after surgery."
3. "Skin preparation and cleansing is mandatory before surgery."
4. "Use an elevated toilet seat for at least 6 weeks after surgery."
5. "You can resume sexual intercourse after surgery if your partner is in a
dependent position." <<<answer>>>2,3,4
Posterior Approach Precautions:
Do not bend the hip more than 90 degrees
Do not cross legs or feet
Do not roll or lie on the unoperated side for the first 6 weeks
Do not twist the upper body when standing
Sleep on the back for the first 6 weeks
The patient may benefit from a shower chair or elevated seat for home use
Avoid bathing for 8 to 12 weeks (flexed and bent down in the tub)
The nurse is caring for a client who is receiving an intravenous infusion via a
peripheral venous access device (VAD). The client reports sharp pain at the VAD
site. The nurse notes the intravenous fluid is infusing more slowly than prescribed.
The nurse should recognize that the client is most likely experiencing
,1. venous spasm
2. nerve damage
3. septicemia
4. hematoma <<<answer>>>1. venous spasm
S/S include sharp pain and slowing of infusion
Rationale: Hematoma main s/s are redness, warmth and swelling. Sharp pain is
not a characteristic of hematomas, which are relatively harmful
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?
