NCLEX NGN Pre-Test Questions with Verified Answers Rated A
A nurse is assigned to care for a client with chronic renal
failure who is undergoing hemodialysis through an in-
ternal AV fistula in the RA. Which intervention should the
nurse implement in caring for the client? SATA
a. Assessing the radial pulse in the right extremity
b. Using the LA ti take BP readings
c. Drawing pre-dialysis blood specimens from the LA A, B, C, D
d. Assessing the area over the AV fistula for a bruit and
three each shift
e. Placing a pressure dressing over the site after each
dialysis treatment
f. Administering IV fluids through the venous site of the AV
fistula as needed
A nurse is evaluating outcomes for a client with Guil-
lain-Barre syndrome. Which outcome does the nurse rec-
ognize as optimal respiratory outcomes for the client?
a. Normal deep tendon reflexes
D, E
b. Improved skeletal muscle tone
c. Absences of paresthesias in the lower extremities
d. Clear sound in the lower lung fields bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg
A nurse of the telemetry unit is caring for a client who has
A
had a MI and is now attached to a cardiac monitor. The
The pattern of ventricular fibrillation is identified and can
nurse is monitoring the client's cardiac rhythm and nots
be a result after a patient with an MI. VF makes the patient
ventricular fibrillation. Which nursing intervention should
feel faint, then loses consciousness and becomes pulse-
the nurse take first?
less and apneic (BP and heart sounds absent). Treatment
a. Calling the rapid response team
is to terminate VF and covert it into a rhythm via defibrilla-
b. Preparing the client for cardioversion
tion-> call a rapid and initiate CPR. Cardioversion is used
c. Asking the client to bear down and cough
for ventricular or supraventricular tachydysrhythmias.
d. Preparing to administer diltiazem
, NCLEX NGN Pre-Test Questions with Verified Answers Rated A
A nurse developing a plan of care for a client with a spinal
cord injury includes measures to prevent autonomic dys-
B
reflexia (hyperreflexia). Which intervention does the nurse
The most frequent cause of autonomic dysreflexias are
incorporate into the plan to prevent this complication?
a distended bladder and impacted feces. Other caus-
a. Keeping the fan running in the client's room
es include stimulation of the skin by tactile, thermal, or
b. Keeping the linens wrinkle free under the client
painful stimuli. The nurse renders care in such a way as
c. Limiting bladder catheterization to once every 12 hours
to minimize these risks.
d. Avoiding the administration of enemas and rectal sup-
positories
A nurse provides home care instructions to a client who
has been fitted with a halo device to treat a cervical frac-
ture. Which statement by the client indicates the need for
further teaching?
C
a. I need to get more fluids and fiber into my diet
Cleanse the skin under the wool liner each day to prevent
b. I should cut my food into small pieces before I eat
rashes and soars.
c. I need to put powder under the vest twice a day to
prevent sweating
d. I have to check the pin sites everyday and watch for
signs of infection
A nurse is caring for a client with increased intracranial
pressure. In which position should the nurse maintain the
client? D
a. Supine with the head extended Proper positioning promotes venous drainage from the
b. Side lying with the neck flexed cranium to minimize ICP.
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees
A client with a basilar skull fracture has clear fluid leaking
from the ears. The nurse should take which action first?
B
a. Asses the clear fluid for protein
CSF contains glucose not protein.
b. Check the clear fluid for glucose
c. Place cotton calls or dry gauze loosely in the ears
, NCLEX NGN Pre-Test Questions with Verified Answers Rated A
d. Use an otoscope to assess the tympanic membrane for
rupture
A nurse is caring for a client who has just undergone
cardioversion. Which intervention is the nurse's priority
after this procedure. A
a. Administer oxygen ABC's of nursing. All other choices are correct, but not
b. Monitoring the BP priority.
c. Administering antidysrhythmic medications
d. Monitoring the client's LOC
A client with diabetes mellitus who is scheduled to have
blood drawn for determination of the glycosylated he-
moglobin (HbA1c) level asks the nurse why the test is
necessary if he is performing blood glucose monitoring
at home. Which is the best response for the nurse to
provide?
B
a. Detect diabetic complications
b. Assess long-term glycemic control
c. Determine whether the client is at risk for hypo-
glycemia
d Determine whether the prescribed insulin dosage is
correct
A nurse caring for a client with acquired immunodeficien-
cy syndrome is monitoring the client for signs of compli-
cations. Which of the following would cause the nurse to
suspect infection with Pneumocystis jirovec? SATA B, D, E
a. Diarrhea A opportunistic respiratory infection associated with AIDs
b. Tachypnea that causes dyspnea, nonproductive cough, intermittent
c. Pedal edema fever, fatigue, anorexia, tachypnea, wt. loss.
d. Intermittent fever
e. Dyspnea with ambulating
f. Expectoration of frothy mucus
A nurse is assigned to care for a client with chronic renal
failure who is undergoing hemodialysis through an in-
ternal AV fistula in the RA. Which intervention should the
nurse implement in caring for the client? SATA
a. Assessing the radial pulse in the right extremity
b. Using the LA ti take BP readings
c. Drawing pre-dialysis blood specimens from the LA A, B, C, D
d. Assessing the area over the AV fistula for a bruit and
three each shift
e. Placing a pressure dressing over the site after each
dialysis treatment
f. Administering IV fluids through the venous site of the AV
fistula as needed
A nurse is evaluating outcomes for a client with Guil-
lain-Barre syndrome. Which outcome does the nurse rec-
ognize as optimal respiratory outcomes for the client?
a. Normal deep tendon reflexes
D, E
b. Improved skeletal muscle tone
c. Absences of paresthesias in the lower extremities
d. Clear sound in the lower lung fields bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg
A nurse of the telemetry unit is caring for a client who has
A
had a MI and is now attached to a cardiac monitor. The
The pattern of ventricular fibrillation is identified and can
nurse is monitoring the client's cardiac rhythm and nots
be a result after a patient with an MI. VF makes the patient
ventricular fibrillation. Which nursing intervention should
feel faint, then loses consciousness and becomes pulse-
the nurse take first?
less and apneic (BP and heart sounds absent). Treatment
a. Calling the rapid response team
is to terminate VF and covert it into a rhythm via defibrilla-
b. Preparing the client for cardioversion
tion-> call a rapid and initiate CPR. Cardioversion is used
c. Asking the client to bear down and cough
for ventricular or supraventricular tachydysrhythmias.
d. Preparing to administer diltiazem
, NCLEX NGN Pre-Test Questions with Verified Answers Rated A
A nurse developing a plan of care for a client with a spinal
cord injury includes measures to prevent autonomic dys-
B
reflexia (hyperreflexia). Which intervention does the nurse
The most frequent cause of autonomic dysreflexias are
incorporate into the plan to prevent this complication?
a distended bladder and impacted feces. Other caus-
a. Keeping the fan running in the client's room
es include stimulation of the skin by tactile, thermal, or
b. Keeping the linens wrinkle free under the client
painful stimuli. The nurse renders care in such a way as
c. Limiting bladder catheterization to once every 12 hours
to minimize these risks.
d. Avoiding the administration of enemas and rectal sup-
positories
A nurse provides home care instructions to a client who
has been fitted with a halo device to treat a cervical frac-
ture. Which statement by the client indicates the need for
further teaching?
C
a. I need to get more fluids and fiber into my diet
Cleanse the skin under the wool liner each day to prevent
b. I should cut my food into small pieces before I eat
rashes and soars.
c. I need to put powder under the vest twice a day to
prevent sweating
d. I have to check the pin sites everyday and watch for
signs of infection
A nurse is caring for a client with increased intracranial
pressure. In which position should the nurse maintain the
client? D
a. Supine with the head extended Proper positioning promotes venous drainage from the
b. Side lying with the neck flexed cranium to minimize ICP.
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees
A client with a basilar skull fracture has clear fluid leaking
from the ears. The nurse should take which action first?
B
a. Asses the clear fluid for protein
CSF contains glucose not protein.
b. Check the clear fluid for glucose
c. Place cotton calls or dry gauze loosely in the ears
, NCLEX NGN Pre-Test Questions with Verified Answers Rated A
d. Use an otoscope to assess the tympanic membrane for
rupture
A nurse is caring for a client who has just undergone
cardioversion. Which intervention is the nurse's priority
after this procedure. A
a. Administer oxygen ABC's of nursing. All other choices are correct, but not
b. Monitoring the BP priority.
c. Administering antidysrhythmic medications
d. Monitoring the client's LOC
A client with diabetes mellitus who is scheduled to have
blood drawn for determination of the glycosylated he-
moglobin (HbA1c) level asks the nurse why the test is
necessary if he is performing blood glucose monitoring
at home. Which is the best response for the nurse to
provide?
B
a. Detect diabetic complications
b. Assess long-term glycemic control
c. Determine whether the client is at risk for hypo-
glycemia
d Determine whether the prescribed insulin dosage is
correct
A nurse caring for a client with acquired immunodeficien-
cy syndrome is monitoring the client for signs of compli-
cations. Which of the following would cause the nurse to
suspect infection with Pneumocystis jirovec? SATA B, D, E
a. Diarrhea A opportunistic respiratory infection associated with AIDs
b. Tachypnea that causes dyspnea, nonproductive cough, intermittent
c. Pedal edema fever, fatigue, anorexia, tachypnea, wt. loss.
d. Intermittent fever
e. Dyspnea with ambulating
f. Expectoration of frothy mucus
