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NCLEX STYLE EXAM ALL QUESTIONS AND CORRECT
DETAILED SOLUTIONS LATEST UPDATED VERSION JUST
RELEASED
Question: The nurse provides discharge teaching for a patient who has two fractured ribs from
an automobile accident. Which statement, if made by the patient, would indicate that teaching
has been effective?
a. "I am going to buy a rib binder to wear during the day."
b. "I can take shallow breaths to prevent my chest from hurting."
c. "I should plan on taking the pain pills only at bedtime so I can sleep."
d. "I will use the incentive spirometer every hour or two during the day." - CORRECT
ANSWER✔✔ANS: D
Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This
can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and
taking pain medications only at night are likely to result in atelectasis
Question: The nurse is caring for a patient who has a right-sided chest tube after a right lower
lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel
(UAP)?
a. Document the amount of drainage every eight hours.
b. Obtain samples of drainage for culture from the system.
c. Assess patient pain level associated with the chest tube.
d. Check the water-seal chamber for the correct fluid level. - CORRECT ANSWER✔✔ANS: A
UAP education includes documentation of intake and output. The other actions are within the
scope of practice and education of licensed nursing personnel.
Question: After change-of-shift report, which patient should the nurse assess first?
a. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet
b. 28-year-old with a history of a lung transplant and a temperature of 101° F (38.3° C)
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c. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain
d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion -
CORRECT ANSWER✔✔ANS: D
The patient's history and symptoms suggest possible tension pneumothorax, a medical
emergency. The other patients also require assessment as soon as possible, but tension
pneumothorax will require immediate treatment to avoid death from inadequate cardiac output
or hypoxemia.
Question: Which factors will the nurse consider when calculating the CURB-65 score for a
patient with pneumonia (select all that apply)?
a. Age
b. Blood pressure
c. Respiratory rate
d. Oxygen saturation
e. Presence of confusion
f. Blood urea nitrogen (BUN) level - CORRECT ANSWER✔✔ANS: A, B, C, E, F
Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure
(decreased), respiratory rate (increased), and age (65 and older). The other information is also
essential to assess, but are not used for CURB-65 scoring.
Question: The nurse notes new onset confusion in an older patient who is normally alert and
oriented. In which order should the nurse take the following actions? (Put a comma and a space
between each answer choice [A, B, C, D].)
a. Obtain the oxygen saturation.
b. Check the patient's pulse rate.
c. Document the change in status.
d. Notify the health care provider - CORRECT ANSWER✔✔ANS:
A, B, D, C
Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or
perfusion problems should be the first action by the nurse. Airway and oxygenation should be
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assessed first, then circulation. After assessing the patient, the nurse should notify the health
care provider. Finally, documentation of the assessments and care should be done.
Question: A nurse is collecting data regarding a client after a thyroidectomy and notes that the
client has developed hoarseness and a weak voice. Which nursing action is appropriate?
1. Check for signs of bleeding.
2. Administer calcium gluconate.
3. Notify the registered nurse immediately.
4. Reassure the client that this is usually a temporary condition. - CORRECT ANSWER✔✔*4.
Reassure the client that this is usually a temporary condition.*
*rationale* Weakness and hoarseness of the voice can occur as a result of trauma of the
laryngeal nerve. If this develops, the client should be reassured that the problem will subside in
a few days. Unnecessary talking should be discouraged. It is not necessary to notify the
registered nurse immediately. These signs do not indicate bleeding or the need to administer
calcium gluconate.
Question: A nurse is reviewing discharge teaching with a client who has Cushing's syndrome.
Which statement by the client indicates that the instructions related to dietary management
were understood?
1. "I can eat foods that contain potassium."
2. "I will need to limit the amount of protein in my diet."
3. "I am fortunate that I can eat all the salty foods I enjoy."
4. "I am fortunate that I do not need to follow any special diet." - CORRECT ANSWER✔✔*1. "I
can eat foods that contain potassium."*
*rationale* A diet that is low in calories, carbohydrates, and sodium but ample in protein and
potassium content is encouraged for a client with Cushing's syndrome. Such a diet promotes
weight loss, the reduction of edema and hypertension, the control of hypokalemia, and the
rebuilding of wasted tissue.
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The nurse is educating a pregnant client who has gestational diabetes. Which of the following
statements should the nurse make to the client? Select all that apply.
a. Cakes, candies, cookies, and regular soft drinks should be avoided.
b. Gestational diabetes increases the risk that the mother will develop diabetes later in life.
c. Gestational diabetes usually resolves after the baby is born.
d. Insulin injections may be necessary.
e. The baby will likely be born with diabetes
f. The mother should strive to gain no more weight during the pregnancy. - CORRECT
ANSWER✔✔ANS: A, B, C, D
Gestational diabetes can occur between the 16th and 28th week of pregnancy.
If not responsive to diet and exercise, insulin injections may be necessary.
Concentrated sugars should be avoided.
Weight gain should continue, but not in excessive amounts.
Usually, gestational diabetes disappears after the infant is born. However, diabetes can develop
5 to 10 years after the pregnancy.
NCLEX STYLE EXAM ALL QUESTIONS AND CORRECT
DETAILED SOLUTIONS LATEST UPDATED VERSION JUST
RELEASED
Question: The nurse provides discharge teaching for a patient who has two fractured ribs from
an automobile accident. Which statement, if made by the patient, would indicate that teaching
has been effective?
a. "I am going to buy a rib binder to wear during the day."
b. "I can take shallow breaths to prevent my chest from hurting."
c. "I should plan on taking the pain pills only at bedtime so I can sleep."
d. "I will use the incentive spirometer every hour or two during the day." - CORRECT
ANSWER✔✔ANS: D
Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This
can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and
taking pain medications only at night are likely to result in atelectasis
Question: The nurse is caring for a patient who has a right-sided chest tube after a right lower
lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel
(UAP)?
a. Document the amount of drainage every eight hours.
b. Obtain samples of drainage for culture from the system.
c. Assess patient pain level associated with the chest tube.
d. Check the water-seal chamber for the correct fluid level. - CORRECT ANSWER✔✔ANS: A
UAP education includes documentation of intake and output. The other actions are within the
scope of practice and education of licensed nursing personnel.
Question: After change-of-shift report, which patient should the nurse assess first?
a. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet
b. 28-year-old with a history of a lung transplant and a temperature of 101° F (38.3° C)
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c. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain
d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion -
CORRECT ANSWER✔✔ANS: D
The patient's history and symptoms suggest possible tension pneumothorax, a medical
emergency. The other patients also require assessment as soon as possible, but tension
pneumothorax will require immediate treatment to avoid death from inadequate cardiac output
or hypoxemia.
Question: Which factors will the nurse consider when calculating the CURB-65 score for a
patient with pneumonia (select all that apply)?
a. Age
b. Blood pressure
c. Respiratory rate
d. Oxygen saturation
e. Presence of confusion
f. Blood urea nitrogen (BUN) level - CORRECT ANSWER✔✔ANS: A, B, C, E, F
Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure
(decreased), respiratory rate (increased), and age (65 and older). The other information is also
essential to assess, but are not used for CURB-65 scoring.
Question: The nurse notes new onset confusion in an older patient who is normally alert and
oriented. In which order should the nurse take the following actions? (Put a comma and a space
between each answer choice [A, B, C, D].)
a. Obtain the oxygen saturation.
b. Check the patient's pulse rate.
c. Document the change in status.
d. Notify the health care provider - CORRECT ANSWER✔✔ANS:
A, B, D, C
Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or
perfusion problems should be the first action by the nurse. Airway and oxygenation should be
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assessed first, then circulation. After assessing the patient, the nurse should notify the health
care provider. Finally, documentation of the assessments and care should be done.
Question: A nurse is collecting data regarding a client after a thyroidectomy and notes that the
client has developed hoarseness and a weak voice. Which nursing action is appropriate?
1. Check for signs of bleeding.
2. Administer calcium gluconate.
3. Notify the registered nurse immediately.
4. Reassure the client that this is usually a temporary condition. - CORRECT ANSWER✔✔*4.
Reassure the client that this is usually a temporary condition.*
*rationale* Weakness and hoarseness of the voice can occur as a result of trauma of the
laryngeal nerve. If this develops, the client should be reassured that the problem will subside in
a few days. Unnecessary talking should be discouraged. It is not necessary to notify the
registered nurse immediately. These signs do not indicate bleeding or the need to administer
calcium gluconate.
Question: A nurse is reviewing discharge teaching with a client who has Cushing's syndrome.
Which statement by the client indicates that the instructions related to dietary management
were understood?
1. "I can eat foods that contain potassium."
2. "I will need to limit the amount of protein in my diet."
3. "I am fortunate that I can eat all the salty foods I enjoy."
4. "I am fortunate that I do not need to follow any special diet." - CORRECT ANSWER✔✔*1. "I
can eat foods that contain potassium."*
*rationale* A diet that is low in calories, carbohydrates, and sodium but ample in protein and
potassium content is encouraged for a client with Cushing's syndrome. Such a diet promotes
weight loss, the reduction of edema and hypertension, the control of hypokalemia, and the
rebuilding of wasted tissue.
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The nurse is educating a pregnant client who has gestational diabetes. Which of the following
statements should the nurse make to the client? Select all that apply.
a. Cakes, candies, cookies, and regular soft drinks should be avoided.
b. Gestational diabetes increases the risk that the mother will develop diabetes later in life.
c. Gestational diabetes usually resolves after the baby is born.
d. Insulin injections may be necessary.
e. The baby will likely be born with diabetes
f. The mother should strive to gain no more weight during the pregnancy. - CORRECT
ANSWER✔✔ANS: A, B, C, D
Gestational diabetes can occur between the 16th and 28th week of pregnancy.
If not responsive to diet and exercise, insulin injections may be necessary.
Concentrated sugars should be avoided.
Weight gain should continue, but not in excessive amounts.
Usually, gestational diabetes disappears after the infant is born. However, diabetes can develop
5 to 10 years after the pregnancy.
