NCLEX/RN/NCLEX RN TEST BANK
ACTUAL EXAM TESTS QUESTION
AND ANSWERS WITH
RATIONALES 2025
1. Acute glomerulonephritis
Activity limited, most children because of fatigue, voluntarily restrict
their activities during active phase of disease. Catheterization may
cause infection. Child should be allowed to express feelings with play.
Visitors limited to allow for adequate rest.
2. Bladder exstrophy
Bladder exposed & external to body through a defect in lower
abdominal wall . Highest priority impaired tissue integrity related to
exposed bladder mucosa.
3. Succimer (Chemet)
Medication treat lead poisoning. Renal function (BUN & creatinine)
is monitored closely during administration chelation therapy because
excreted via kidneys.
4. Gastroschisis
Bowel herniates through defect abdominal wall to right of umbilical
cord. No membrane covering exposed bowel. Surgical repair done as
soon as possible because risk infection in unprotected bowel. Highest
risk immediately after delivery is infection
5. Ribavirin (Virazole)
Antiviral respiratory medication used mainly for hospitalized children
with severe RSV. Administration via hood, face mask, or oxygen tent.
6. Focused assessment
Involves history & physical exam limited to specific problem, client
complaint & most often used in walk-in clinic or ED
7. Sexually abused child
Assessment finding include difficulty walking/sitting; torn, stained,
bloody underclothing; pain, swelling, itching of genitals; & bruises,
bleeding, lacerations in genital or anal area.
,8. Simple partial seizures
Consist twitching of extremity, face, or neck, or sensation of
twitching or numbness in extremity or face or neck
9. Myoclonic seizure
Brief random contractions of muscle group that can occur on one or
both sides of body.
10. Absence seizures
Brief episodes altered awareness or momentary LOC. No muscle
activity occurs except eyelid fluttering or twitching. Blank facial
expression. Seizures last only 5 to 10 seconds, but may occur one
after another several times a day
11. Older client has an increased tendency to experience constipation
Decreased stomach-emptying time & lowered basal metabolic rate
cause constipation. Adequate dietary fiber aid bowel function. Dietary
fiber increases fecal weight & water content & accelerates transit
fecal mass through GI tract. Retention of water by fiber has ability
soften stools & promote regularity. Fluid intake & exercise facilitate
bowel elimination.
12. woman with preeclampsia is receiving magnesium sulfate
Magnesium sulfate is anticonvulsant, goal of care directed preventing
eclampsia (seizures).
13. Respiratory distress syndrome diagnosed, surfactant replacement
therapy prescribed. Route used to administer this medication?
Surfactant replacement exogenous surfactant preparation instilled into
lungs through endotracheal tube.
14. The Moro reflex
Place newborn flat surface. Striking surface or making loud, abrupt
noise startle newborn. Assumes sharp extension & abduction of arms
with thumbs & forefingers in a C position; followed by flexion &
adduction to an "embrace" position (legs follow a similar pattern).
Moro reflex present at birth & absent by 6 months age if neurological
maturation is not delayed. Persistent response lasting more than 6
months may indicate a neurological abnormality.
15. Traumatic uterine rupture
Excessive fundal pressure, forceps delivery, violent bearing-down
efforts, tumultuous labor, & shoulder dystocia can place at risk
,16. Schultz presentation
Expulsion placenta with fetal side presenting first.
17. Effleurage
Type cutaneous stimulation involving light stroking abdomen used
before transition promote relaxation & relieve mild to moderate pain.
Effleurage also provides tactile stimulation to fetus. Massaging
abdomen during contractions, using both hands in circular motion.
18. If progresses from preeclampsia to eclampsia, nurse should take
which first action?
Clear & maintain open airway. first action during seizure (eclampsia)
is to ensure patent airway
19. Identifying food highest in folic acid.
Leafy green vegetables are rich in folate (folic acid)
20. Nonstress test
Monitoring only; fetus is not challenged or stressed by uterine
contractions. Ultrasound transducer records fetal heart activity
secured over abdomen, Fetal heart activity & movements are recorded.
21. Client esophageal varices needs Sengstaken-Blakemore tube inserted
Pair of scissors must be kept at bedside at all times.
22. Postoperative assessment activities monitoring
Every 15 minutes first hour, every 30 minutes 2 hours, every hour 4
hours, & then every 4 hours as needed
23. Corticosteroid therapy
Can cause calcium & potassium depletion, sodium retention, &
glucose intolerance. Elevate blood glucose levels. Monitor Blood
glucose levels.
24. Enteral nutrition
Require normal digestive capabilities of GI tract. May cause
aspiration pneumonia from regurgitation of formula into lungs. Given
room temperature avoid problems with diarrhea. Caloric value most
standard enteral feeding formula 1 to 2 cal/mL.
25. NG tube feedings
, Possible complications: diarrhea, lactose intolerance, dumping
syndrome, excess fluid volume. Aspiration pneumonia, caused by
regurgitation formula contents into respiratory tract. Head of bed
elevated 30 degrees at all times help prevent this complication. May
be left in place from weeks to months depending on type of tube
inserted.
26. Ambulate with cane
Kept on strong side body. Assisting weakened leg, so weakened leg
moves with cane, or right after it, ambulating or going down stairs.
Height cane even with greater trochanter. Allows elbow held
approximately 15 to 30 degrees of flexion. Flexion necessary allow
client to push off without bending over when ambulating.
27. Apgar scoring for a newborn immediately after birth
Scores 0-10. Five criteria used measure infant adaptation.
Heart rate: absent=0; less 100 =1; greater 100= 2
Respiratory effort: absent = 0; slow or irregular weak cry = 1; good,
crying lustily = 2.
Muscle tone: limp/hypotonic = 0; some extremity flexion = 1; active,
moving, & well flexed = 2.
Irritability/reflexe (measured bulb suction): no response=0; grimace
=1; cough, sneeze, vigorous cry = 2. Color:cyanotic/pale = 0;
acrocyanotic, cyanosis extremities = 1; pink =2. Newborn infant
Apgar score 5-7 often require resuscitative intervention. Scores less 5
indicate newborn infant having difficulty adjusting extrauterine life
and requires more vigorous resuscitation.
28. Normal Newborn Respiratory rate
30 to 60 breaths per minute.
29. Methylergonovine (Methergine)
Oxytocic agent used prevent/control postpartum hemorrhage by
contracting uterus. Causes constant uterine contractions & may cause
BP to elevate. Assessment before administering is obtaining baseline
blood pressure. BP also monitored during administration of
medication.
30. Butorphanol tartrate (Stadol)
Opioid analgesic provides systemic pain relief during labor
31. Cryosurgery with laser therapy
ACTUAL EXAM TESTS QUESTION
AND ANSWERS WITH
RATIONALES 2025
1. Acute glomerulonephritis
Activity limited, most children because of fatigue, voluntarily restrict
their activities during active phase of disease. Catheterization may
cause infection. Child should be allowed to express feelings with play.
Visitors limited to allow for adequate rest.
2. Bladder exstrophy
Bladder exposed & external to body through a defect in lower
abdominal wall . Highest priority impaired tissue integrity related to
exposed bladder mucosa.
3. Succimer (Chemet)
Medication treat lead poisoning. Renal function (BUN & creatinine)
is monitored closely during administration chelation therapy because
excreted via kidneys.
4. Gastroschisis
Bowel herniates through defect abdominal wall to right of umbilical
cord. No membrane covering exposed bowel. Surgical repair done as
soon as possible because risk infection in unprotected bowel. Highest
risk immediately after delivery is infection
5. Ribavirin (Virazole)
Antiviral respiratory medication used mainly for hospitalized children
with severe RSV. Administration via hood, face mask, or oxygen tent.
6. Focused assessment
Involves history & physical exam limited to specific problem, client
complaint & most often used in walk-in clinic or ED
7. Sexually abused child
Assessment finding include difficulty walking/sitting; torn, stained,
bloody underclothing; pain, swelling, itching of genitals; & bruises,
bleeding, lacerations in genital or anal area.
,8. Simple partial seizures
Consist twitching of extremity, face, or neck, or sensation of
twitching or numbness in extremity or face or neck
9. Myoclonic seizure
Brief random contractions of muscle group that can occur on one or
both sides of body.
10. Absence seizures
Brief episodes altered awareness or momentary LOC. No muscle
activity occurs except eyelid fluttering or twitching. Blank facial
expression. Seizures last only 5 to 10 seconds, but may occur one
after another several times a day
11. Older client has an increased tendency to experience constipation
Decreased stomach-emptying time & lowered basal metabolic rate
cause constipation. Adequate dietary fiber aid bowel function. Dietary
fiber increases fecal weight & water content & accelerates transit
fecal mass through GI tract. Retention of water by fiber has ability
soften stools & promote regularity. Fluid intake & exercise facilitate
bowel elimination.
12. woman with preeclampsia is receiving magnesium sulfate
Magnesium sulfate is anticonvulsant, goal of care directed preventing
eclampsia (seizures).
13. Respiratory distress syndrome diagnosed, surfactant replacement
therapy prescribed. Route used to administer this medication?
Surfactant replacement exogenous surfactant preparation instilled into
lungs through endotracheal tube.
14. The Moro reflex
Place newborn flat surface. Striking surface or making loud, abrupt
noise startle newborn. Assumes sharp extension & abduction of arms
with thumbs & forefingers in a C position; followed by flexion &
adduction to an "embrace" position (legs follow a similar pattern).
Moro reflex present at birth & absent by 6 months age if neurological
maturation is not delayed. Persistent response lasting more than 6
months may indicate a neurological abnormality.
15. Traumatic uterine rupture
Excessive fundal pressure, forceps delivery, violent bearing-down
efforts, tumultuous labor, & shoulder dystocia can place at risk
,16. Schultz presentation
Expulsion placenta with fetal side presenting first.
17. Effleurage
Type cutaneous stimulation involving light stroking abdomen used
before transition promote relaxation & relieve mild to moderate pain.
Effleurage also provides tactile stimulation to fetus. Massaging
abdomen during contractions, using both hands in circular motion.
18. If progresses from preeclampsia to eclampsia, nurse should take
which first action?
Clear & maintain open airway. first action during seizure (eclampsia)
is to ensure patent airway
19. Identifying food highest in folic acid.
Leafy green vegetables are rich in folate (folic acid)
20. Nonstress test
Monitoring only; fetus is not challenged or stressed by uterine
contractions. Ultrasound transducer records fetal heart activity
secured over abdomen, Fetal heart activity & movements are recorded.
21. Client esophageal varices needs Sengstaken-Blakemore tube inserted
Pair of scissors must be kept at bedside at all times.
22. Postoperative assessment activities monitoring
Every 15 minutes first hour, every 30 minutes 2 hours, every hour 4
hours, & then every 4 hours as needed
23. Corticosteroid therapy
Can cause calcium & potassium depletion, sodium retention, &
glucose intolerance. Elevate blood glucose levels. Monitor Blood
glucose levels.
24. Enteral nutrition
Require normal digestive capabilities of GI tract. May cause
aspiration pneumonia from regurgitation of formula into lungs. Given
room temperature avoid problems with diarrhea. Caloric value most
standard enteral feeding formula 1 to 2 cal/mL.
25. NG tube feedings
, Possible complications: diarrhea, lactose intolerance, dumping
syndrome, excess fluid volume. Aspiration pneumonia, caused by
regurgitation formula contents into respiratory tract. Head of bed
elevated 30 degrees at all times help prevent this complication. May
be left in place from weeks to months depending on type of tube
inserted.
26. Ambulate with cane
Kept on strong side body. Assisting weakened leg, so weakened leg
moves with cane, or right after it, ambulating or going down stairs.
Height cane even with greater trochanter. Allows elbow held
approximately 15 to 30 degrees of flexion. Flexion necessary allow
client to push off without bending over when ambulating.
27. Apgar scoring for a newborn immediately after birth
Scores 0-10. Five criteria used measure infant adaptation.
Heart rate: absent=0; less 100 =1; greater 100= 2
Respiratory effort: absent = 0; slow or irregular weak cry = 1; good,
crying lustily = 2.
Muscle tone: limp/hypotonic = 0; some extremity flexion = 1; active,
moving, & well flexed = 2.
Irritability/reflexe (measured bulb suction): no response=0; grimace
=1; cough, sneeze, vigorous cry = 2. Color:cyanotic/pale = 0;
acrocyanotic, cyanosis extremities = 1; pink =2. Newborn infant
Apgar score 5-7 often require resuscitative intervention. Scores less 5
indicate newborn infant having difficulty adjusting extrauterine life
and requires more vigorous resuscitation.
28. Normal Newborn Respiratory rate
30 to 60 breaths per minute.
29. Methylergonovine (Methergine)
Oxytocic agent used prevent/control postpartum hemorrhage by
contracting uterus. Causes constant uterine contractions & may cause
BP to elevate. Assessment before administering is obtaining baseline
blood pressure. BP also monitored during administration of
medication.
30. Butorphanol tartrate (Stadol)
Opioid analgesic provides systemic pain relief during labor
31. Cryosurgery with laser therapy
