“NCLEX Question Trainer Test 4 with Explanations |
Verified Questions, Correct Answers & Detailed Rationales
for Exam Success”
6. A mother brings her two-year-old boy to the pediatrician’s office. Which of the following symptoms
would suggest to the nurse that the child has strabismus?
1. When the child draws, he places his head close to the table.
2. The child rubs his eyes frequently.
3. The child closes one eye to see a poster on the wall.
4. The child is unable to see objects in the periphery of his visual field.
Strategy: Think about each answer choice.
(1) suggestive of refractive error, myopia (nearsightedness), able to see objects at close range
(2) suggestive of refractive error
(3) correct–visual axes are not parallel so the brain receives two images
(4) suggestive of cataracts or problem with peripheral vision
7. A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug,
the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which
of the following nursing actions is MOST appropriate?
1. Allow the client to sleep undisturbed.
2. Administer oxygen via facemask or nasal prongs.
3. Administer naloxone (Narcan).
4. Place epinephrine 1:1,000 at the bedside.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) should be given Narcan for low respiratory rate
(2) problem is low respirations, this may be administered after medication
(3) correct–IV naloxone (Narcan) should be given to reverse respiratory depression; respiratory rate
of 8 is too low and necessitates a nursing action
(4) unnecessary
,8. The school nurse is teaching a group of preschool mothers about poison prevention in the home.
Which of the following statements, if made by a mother to the nurse, indicates that further teaching
is necessary?
1. “I should have a bottle of Ipecac for each of my children.”
2. “I should induce vomiting if my child swallows lighter fluid.”
3. “Giving my child water or milk may help dilute the poison.”
4. “Proper storage is the key to poison prevention in the home.”
Strategy: “Further teaching is necessary” indicates an incorrect statement.
(1) Ipecac is available in 30 cc vials, advise parents to have available full doses for each child,
doses range from 10 to 30 cc
(2) correct–vomiting contraindicated when child ingests hydrocarbons due to danger of aspiration
(3) small amounts of water or milk may dilute toxins
(4) store in locked cabinets
9. The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST
appropriate for the nurse to take which of the following actions?
1. Take the client to the dining room with 1:1 supervision.
2. Inform the client he may go to the dining room when he controls his behavior.
3. Hold the meal until the client is able to come out of seclusion.
4. Serve the meal to the client in the seclusion room.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) should remain in the seclusion room
(2) should have meal at regular time
(3) should have meal at regular time
(4) correct–should eat at regular time; remain in the seclusion room for client’s safety
10. Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns
to 50% of his body?
1. Counseling regarding problems of body image.
2. Maintain airborne precautions.
3. Maintain aseptic technique during procedures.
4. Encourage peers to visit on a regular basis.
Strategy: Think “Maslow.”
(1) psychosocial, not highest priority
(2) physical, use standard precautions
(3) correct–safety is a priority for the client who is at high risk for infection
(4) psychosocial, important for an adolescent, but is not highest priority
,11. The home health care nurse is caring for a 30-year-old woman with type I diabetes mellitus. The
client has been maintained on a regimen of NPH and regular insulin and a 1,800-calorie diabetic
diet with normal blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past
two days were 205 mg/dL and 233 mg/dL. The nurse expects the physician to
1. reduce the client’s diet to 1,500 calorie ADA.
2. order 3 additional units of NPH insulin at 10 PM.
3. order an additional 10 units of regular insulin at 8 PM.
4. eliminate the client’s bedtime snack.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) diet should not be reduced
(2) correct–dawn phenomena, treatment is to adjust evening diet, bedtime snack, insulin dose,
and exercise to prevent early morning hyperglycemia
(3) peaks in 4–6 hours, would not prevent dawn phenomena
(4) would adjust snack, not eliminate it
12. After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck,
a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal
response to noxious stimuli. Which of the following assessments, if observed by the nurse three
hours after admission, should be reported to the physician?
1. The client has slight edema of the eyelids.
2. There is clear fluid draining from the client’s right ear.
3. There is some bleeding from the child’s lacerations.
4. The client withdraws in response to painful stimuli.
Strategy: Think about how each answer choice relates to a head injury.
(1) not priority
(2) correct–indicates a rupture of meninges and presents a potential complication of meningitis
(3) not priority
(4) is not a change in assessment
13. A psychiatric nurse is assigned to conduct an admission nursing history on a new client. The
admission should include which of the following?
1. The nurse’s opinion regarding the mental and emotional status of the client.
2. Data addressing the client’s emotional state.
3. Data that address a biopsychosocial approach, including a family system assessment.
4. Specific data detailing the client’s mental status.
Strategy: Think about each answer choice.
(1) depends on opinions that are not based on a complete assessment
(2) limits the degree of information that is obtained from the client
(3) correct–complete nursing history includes biopsychosocial data; client’s psychosocial and
physical status are evaluated along with an assessment of the client’s family system and social
support network; evaluation of the client’s cognitive ability is important during the physiological
status assessment
(4) is necessary information about mental status, but is also an incomplete assessment
, 14. Prochlorperazine maleate (Compazine) 10 mg IM has been ordered for a client. The client is also to
receive Stadol 2 mg IM. Before administering these medications, the nurse should
1. obtain respirations and temperature.
2. dilute with 9 ml of NS.
3. draw the medications in separate syringes.
4. verify the route of administration.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) should monitor blood pressure and heart rate for orthostatic hypotension; respiration and
temperature are not as high a priority
(2) inappropriate
(3) correct–Compazine should be considered incompatible in a syringe with all other medications
(4) unnecessary
15. The nurse is caring for clients in the student health center. A client confides to the nurse that the
client’s boyfriend informed her that he tested positive for hepatitis B. Which of the following
responses by the nurse is BEST?
1. “That must have been a real shock to you.”
2. “You should be tested for hepatitis B.”
3. “You’ll receive the hepatitis B immune globulin (HBIG).”
4. “Have you had unprotected sex with your boyfriend?”
Strategy: Answers are a mix of assessments and implementations. Does this situation require
assessment? Yes. Is there an appropriate assessment? Yes.
(1) nurse is interjecting own feelings
(2) will require testing, not best response initially
(3) implementation, receive HBIG for postexposure prophylaxis; may also receive HBV vaccine
(4) correct–assessment, transmitted through parenteral drug abuse and sexual contact; determine
exposure before implementing
16. A young adult patient constantly seeks attention from the nurses, stomping away from the nurses’
station and pouting when her requests are refused. Which of the following responses by the nurse
is MOST appropriate?
1. Have the patient establish trust with one staff person with whom therapeutic interventions
should occur.
2. Give the patient unsolicited attention when she is not exhibiting the unacceptable behaviors.
3. Ignore the patient when she exhibits attention-seeking behavior.
4. Rotate the staff so the patient will learn to relate to more than one nurse.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) staff should use a consistent undivided approach
(2) correct–reward nonseeking attention behaviors by giving the patient unsolicited attention
(3) remain nonjudgmental, carry out limit-setting
(4) staff should use a consistent undivided approach
Verified Questions, Correct Answers & Detailed Rationales
for Exam Success”
6. A mother brings her two-year-old boy to the pediatrician’s office. Which of the following symptoms
would suggest to the nurse that the child has strabismus?
1. When the child draws, he places his head close to the table.
2. The child rubs his eyes frequently.
3. The child closes one eye to see a poster on the wall.
4. The child is unable to see objects in the periphery of his visual field.
Strategy: Think about each answer choice.
(1) suggestive of refractive error, myopia (nearsightedness), able to see objects at close range
(2) suggestive of refractive error
(3) correct–visual axes are not parallel so the brain receives two images
(4) suggestive of cataracts or problem with peripheral vision
7. A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug,
the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which
of the following nursing actions is MOST appropriate?
1. Allow the client to sleep undisturbed.
2. Administer oxygen via facemask or nasal prongs.
3. Administer naloxone (Narcan).
4. Place epinephrine 1:1,000 at the bedside.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) should be given Narcan for low respiratory rate
(2) problem is low respirations, this may be administered after medication
(3) correct–IV naloxone (Narcan) should be given to reverse respiratory depression; respiratory rate
of 8 is too low and necessitates a nursing action
(4) unnecessary
,8. The school nurse is teaching a group of preschool mothers about poison prevention in the home.
Which of the following statements, if made by a mother to the nurse, indicates that further teaching
is necessary?
1. “I should have a bottle of Ipecac for each of my children.”
2. “I should induce vomiting if my child swallows lighter fluid.”
3. “Giving my child water or milk may help dilute the poison.”
4. “Proper storage is the key to poison prevention in the home.”
Strategy: “Further teaching is necessary” indicates an incorrect statement.
(1) Ipecac is available in 30 cc vials, advise parents to have available full doses for each child,
doses range from 10 to 30 cc
(2) correct–vomiting contraindicated when child ingests hydrocarbons due to danger of aspiration
(3) small amounts of water or milk may dilute toxins
(4) store in locked cabinets
9. The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST
appropriate for the nurse to take which of the following actions?
1. Take the client to the dining room with 1:1 supervision.
2. Inform the client he may go to the dining room when he controls his behavior.
3. Hold the meal until the client is able to come out of seclusion.
4. Serve the meal to the client in the seclusion room.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) should remain in the seclusion room
(2) should have meal at regular time
(3) should have meal at regular time
(4) correct–should eat at regular time; remain in the seclusion room for client’s safety
10. Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns
to 50% of his body?
1. Counseling regarding problems of body image.
2. Maintain airborne precautions.
3. Maintain aseptic technique during procedures.
4. Encourage peers to visit on a regular basis.
Strategy: Think “Maslow.”
(1) psychosocial, not highest priority
(2) physical, use standard precautions
(3) correct–safety is a priority for the client who is at high risk for infection
(4) psychosocial, important for an adolescent, but is not highest priority
,11. The home health care nurse is caring for a 30-year-old woman with type I diabetes mellitus. The
client has been maintained on a regimen of NPH and regular insulin and a 1,800-calorie diabetic
diet with normal blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past
two days were 205 mg/dL and 233 mg/dL. The nurse expects the physician to
1. reduce the client’s diet to 1,500 calorie ADA.
2. order 3 additional units of NPH insulin at 10 PM.
3. order an additional 10 units of regular insulin at 8 PM.
4. eliminate the client’s bedtime snack.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) diet should not be reduced
(2) correct–dawn phenomena, treatment is to adjust evening diet, bedtime snack, insulin dose,
and exercise to prevent early morning hyperglycemia
(3) peaks in 4–6 hours, would not prevent dawn phenomena
(4) would adjust snack, not eliminate it
12. After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck,
a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal
response to noxious stimuli. Which of the following assessments, if observed by the nurse three
hours after admission, should be reported to the physician?
1. The client has slight edema of the eyelids.
2. There is clear fluid draining from the client’s right ear.
3. There is some bleeding from the child’s lacerations.
4. The client withdraws in response to painful stimuli.
Strategy: Think about how each answer choice relates to a head injury.
(1) not priority
(2) correct–indicates a rupture of meninges and presents a potential complication of meningitis
(3) not priority
(4) is not a change in assessment
13. A psychiatric nurse is assigned to conduct an admission nursing history on a new client. The
admission should include which of the following?
1. The nurse’s opinion regarding the mental and emotional status of the client.
2. Data addressing the client’s emotional state.
3. Data that address a biopsychosocial approach, including a family system assessment.
4. Specific data detailing the client’s mental status.
Strategy: Think about each answer choice.
(1) depends on opinions that are not based on a complete assessment
(2) limits the degree of information that is obtained from the client
(3) correct–complete nursing history includes biopsychosocial data; client’s psychosocial and
physical status are evaluated along with an assessment of the client’s family system and social
support network; evaluation of the client’s cognitive ability is important during the physiological
status assessment
(4) is necessary information about mental status, but is also an incomplete assessment
, 14. Prochlorperazine maleate (Compazine) 10 mg IM has been ordered for a client. The client is also to
receive Stadol 2 mg IM. Before administering these medications, the nurse should
1. obtain respirations and temperature.
2. dilute with 9 ml of NS.
3. draw the medications in separate syringes.
4. verify the route of administration.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) should monitor blood pressure and heart rate for orthostatic hypotension; respiration and
temperature are not as high a priority
(2) inappropriate
(3) correct–Compazine should be considered incompatible in a syringe with all other medications
(4) unnecessary
15. The nurse is caring for clients in the student health center. A client confides to the nurse that the
client’s boyfriend informed her that he tested positive for hepatitis B. Which of the following
responses by the nurse is BEST?
1. “That must have been a real shock to you.”
2. “You should be tested for hepatitis B.”
3. “You’ll receive the hepatitis B immune globulin (HBIG).”
4. “Have you had unprotected sex with your boyfriend?”
Strategy: Answers are a mix of assessments and implementations. Does this situation require
assessment? Yes. Is there an appropriate assessment? Yes.
(1) nurse is interjecting own feelings
(2) will require testing, not best response initially
(3) implementation, receive HBIG for postexposure prophylaxis; may also receive HBV vaccine
(4) correct–assessment, transmitted through parenteral drug abuse and sexual contact; determine
exposure before implementing
16. A young adult patient constantly seeks attention from the nurses, stomping away from the nurses’
station and pouting when her requests are refused. Which of the following responses by the nurse
is MOST appropriate?
1. Have the patient establish trust with one staff person with whom therapeutic interventions
should occur.
2. Give the patient unsolicited attention when she is not exhibiting the unacceptable behaviors.
3. Ignore the patient when she exhibits attention-seeking behavior.
4. Rotate the staff so the patient will learn to relate to more than one nurse.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) staff should use a consistent undivided approach
(2) correct–reward nonseeking attention behaviors by giving the patient unsolicited attention
(3) remain nonjudgmental, carry out limit-setting
(4) staff should use a consistent undivided approach
