NCLEX-RN TEST 1 NGN QUESTIONS AND
ANSWERS
1.The nurse witnesses the collapse of a child while outdoors. The child is
not breathing and has a pulse of 50/min. The nurse calls emergency
services and initiates rescue breathing. After 2 minutes of rescue breaths,
the child is still not breathing and is pale with a pulse of 30/min. What is the
nurse's next action?: 1. Initiate chest compressions
Rescue breathing is performed at a rate of 1 breath every 2-3 seconds.
If the pulse remains <60/min and there are signs of poor perfusion (skin
pallor), the nurse should initiate chest compressions and reassess the
pulse every 2 minutes
2.The charger nurse is responsible for making room assignments multiple
clients. Which pari of client assignments to a shared room is appropriate?:
3. Client who had a bowel resection 1 day ago and client with asthma
exacerbation.
When making room assignments, it is important to remember that a
client with an active or suspected infection should not be paired with a
client who has a fresh surgical wound or is immunocompromised. A
client having an asthma exacerbation does not have an infection and is
not at risk for spreading infection to a client who had a recent bowel
,resection surgery.
3.The clinic nurse is assessing a client who is being treated for depression
and suicidal ideation. Which client statement best indicates that the client
is not currently at risk for suicide?: 2. "I plan to attend my grandchild's
graduation next month"
Clients receiving treatment for depression and suicidal ideation must be
carefully monitored for indications of increasing suicidal intent. During a
client interview, the nurse should assess:
- Access to psychiatric medications
- Availability of help during a crisis (counselor, family)
- Future goals and plans
- Home and environment risks
- Overall affect and level of energy
- Possible access to weapons
Clients who articulate long-term personal goals and family milestones
are less likely to attempt death by suicide
4.The nurse is caring for a client who had an anterior wall myocardial infarc-
tion 2 days ago. The telemetry technician notifies the nurse at 8:30 AM that
the client is in ventricular trigeminy. What is the nurse's priority
intervention?: 1. Administer potassium supplement
,In ventricular trigeminy, premature ventricular contractions (PVCs)
occur every third heartbeat. Myocardial injury (eg, myocardial
infarction) predisposes the client to ectopy (eg, PVCs), which increases
the client's risk for lethal dysrhythmias (eg, ven- tricular tachycardia).
PVCs are caused and/or exacerbated by hypoxia, electrolyte
imbalances, emotional stress, stimulants, fever, and exercise.
This client's morning laboratory results show hypokalemia (potassium
<3.5 mEq/L [3.5 mmol/L]); therefore, the priority is treatment of the
underlying cause of the ectopy by administering the prescribed
potassium replacement (Option 1). Health care providers (HCPs) often
prescribe electrolyte replacement algorithms to clients at risk for
electrolyte imbalances (eg, myocardial injury, receiving diuretics) unless
a contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L],
anuric, weight
<99.2 lb [45 kg]).
5.The nurse cares for a client with a terminal disease who created a do
not attempt resuscitation (DNAR) directive. The client stops breathing and
loses their pulse. The client's adult child states, "Please, do whatever you
can to save them!" Which intervention is appropriate?: 3. Explain the
client's resuscitation directive to the client's child
Clients can create a do not attempt resuscitation (DNAR) directive
instructing that CPR and other life-saving measures be withheld. With an
advance directive in place, the client's wishes should be followed, even
, if they conflict with the wishes of loved ones
6.The nurse in the cardiac intensive care unit receives report on 4 clients.
Which client should the nurse assess first?: 2. Client who underwent
coronary artery stent placement via femoral approach 3 hours ago and
is reporting severe back pain
A client who undergoes percutaneous coronary intervention (PCI) and
intracoronary stent placement using the femoral approach is at
increased risk for retroperitoneal hemorrhage. Administration of
antithrombotic drugs before, during, and after PCI can exacerbate
potentially life-threatening bleeding from the femoral artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign),
hematoma forma- tion, and diminished distal pulses can be early signs
of bleeding into the retroperi- toneal space and require immediate
intervention (eg, notify health care provider, serial complete blood
count, CT scan of the abdomen)
7.The nurse is reviewing the medical history of a client who has sustained a
right tibia/fibula fracture from a fall. The nurse identifies which finding as
most likely to hinder healing?: 4. Peripheral arterial disease
Bone healing depends on multiple factors, including nutrition, adequate
circulation, and age. A client with peripheral arterial disease has
ANSWERS
1.The nurse witnesses the collapse of a child while outdoors. The child is
not breathing and has a pulse of 50/min. The nurse calls emergency
services and initiates rescue breathing. After 2 minutes of rescue breaths,
the child is still not breathing and is pale with a pulse of 30/min. What is the
nurse's next action?: 1. Initiate chest compressions
Rescue breathing is performed at a rate of 1 breath every 2-3 seconds.
If the pulse remains <60/min and there are signs of poor perfusion (skin
pallor), the nurse should initiate chest compressions and reassess the
pulse every 2 minutes
2.The charger nurse is responsible for making room assignments multiple
clients. Which pari of client assignments to a shared room is appropriate?:
3. Client who had a bowel resection 1 day ago and client with asthma
exacerbation.
When making room assignments, it is important to remember that a
client with an active or suspected infection should not be paired with a
client who has a fresh surgical wound or is immunocompromised. A
client having an asthma exacerbation does not have an infection and is
not at risk for spreading infection to a client who had a recent bowel
,resection surgery.
3.The clinic nurse is assessing a client who is being treated for depression
and suicidal ideation. Which client statement best indicates that the client
is not currently at risk for suicide?: 2. "I plan to attend my grandchild's
graduation next month"
Clients receiving treatment for depression and suicidal ideation must be
carefully monitored for indications of increasing suicidal intent. During a
client interview, the nurse should assess:
- Access to psychiatric medications
- Availability of help during a crisis (counselor, family)
- Future goals and plans
- Home and environment risks
- Overall affect and level of energy
- Possible access to weapons
Clients who articulate long-term personal goals and family milestones
are less likely to attempt death by suicide
4.The nurse is caring for a client who had an anterior wall myocardial infarc-
tion 2 days ago. The telemetry technician notifies the nurse at 8:30 AM that
the client is in ventricular trigeminy. What is the nurse's priority
intervention?: 1. Administer potassium supplement
,In ventricular trigeminy, premature ventricular contractions (PVCs)
occur every third heartbeat. Myocardial injury (eg, myocardial
infarction) predisposes the client to ectopy (eg, PVCs), which increases
the client's risk for lethal dysrhythmias (eg, ven- tricular tachycardia).
PVCs are caused and/or exacerbated by hypoxia, electrolyte
imbalances, emotional stress, stimulants, fever, and exercise.
This client's morning laboratory results show hypokalemia (potassium
<3.5 mEq/L [3.5 mmol/L]); therefore, the priority is treatment of the
underlying cause of the ectopy by administering the prescribed
potassium replacement (Option 1). Health care providers (HCPs) often
prescribe electrolyte replacement algorithms to clients at risk for
electrolyte imbalances (eg, myocardial injury, receiving diuretics) unless
a contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L],
anuric, weight
<99.2 lb [45 kg]).
5.The nurse cares for a client with a terminal disease who created a do
not attempt resuscitation (DNAR) directive. The client stops breathing and
loses their pulse. The client's adult child states, "Please, do whatever you
can to save them!" Which intervention is appropriate?: 3. Explain the
client's resuscitation directive to the client's child
Clients can create a do not attempt resuscitation (DNAR) directive
instructing that CPR and other life-saving measures be withheld. With an
advance directive in place, the client's wishes should be followed, even
, if they conflict with the wishes of loved ones
6.The nurse in the cardiac intensive care unit receives report on 4 clients.
Which client should the nurse assess first?: 2. Client who underwent
coronary artery stent placement via femoral approach 3 hours ago and
is reporting severe back pain
A client who undergoes percutaneous coronary intervention (PCI) and
intracoronary stent placement using the femoral approach is at
increased risk for retroperitoneal hemorrhage. Administration of
antithrombotic drugs before, during, and after PCI can exacerbate
potentially life-threatening bleeding from the femoral artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign),
hematoma forma- tion, and diminished distal pulses can be early signs
of bleeding into the retroperi- toneal space and require immediate
intervention (eg, notify health care provider, serial complete blood
count, CT scan of the abdomen)
7.The nurse is reviewing the medical history of a client who has sustained a
right tibia/fibula fracture from a fall. The nurse identifies which finding as
most likely to hinder healing?: 4. Peripheral arterial disease
Bone healing depends on multiple factors, including nutrition, adequate
circulation, and age. A client with peripheral arterial disease has
