NCLEX/EXIT EXAM STUDY EXAM 2026–2027
EXAM QUESTIONS AND VERIFIED CORRECT
ANSWERS
A nurse manager in a pediatric facility is approached by a staff RN regarding
several telephone messages from clients. Which situation requires the most
immediate follow-up by the nurse?
a. A mother expressing concern that her baby refuses to take formula, stating the
infant's "soft spot" seems more sunken
b. A grandmother asking for immunization information, stating her 5-year-old
grandchild has
never been immunized.
c. A parent calling to ask if it is necessary to keep her child with a sore throat
home from school
d. A mother stating that she sent her child to school but is concerned about his
eye, which is pink
and painful - ANSWER: A. This situation indicates the infant is probably
dehydrated, and dehydration can lead to a rapid loss of physiologic integrity
in an infant. The nurse needs to respond to this first.
Which child requires the most immediate follow-up by a nurse?
a. A 10-month-old with yellow nasal mucous and a fever of 101, who is fussy
and crying loudly
b. A 5-year-old who has started wetting the bed and constantly requests
extra snacks and drinks
c. A 13-year-old who was injured while playing football the previous day and
now cannot bear weight on his foot due to severe pain
d. A 9-year-old who got hit on the head with a baseball bat and has a bruise
behind his ear and clear nasal discharge - ANSWER: D. Bruising behind the
ear following a head injury is referred to as a Battle sign, which
STUDOVA
, is an indication of a basilar skull fracture. Because the clear nasal drainage may
be CSF, this child needs the most immediate assessment to determine severity of
the head
injury.
A nurse manager is planning care for a teen with a possible fracture of the foot.
Which tasks can be assigned to the UAP assisting the nurse? SATA a. Palpate
for presence of pedal pulses b. Apply a cold pack to the teenager's foot
c. Explain to the client the difference between a fracture and a sprain
d. Use a numeric pain scale to assess the teen's pain level
e. Take the teen's vital signs - ANSWER: B, E
Applying a cold pack may be delegated to the UAP with sufficient instruction
and supervision. Taking VS is a common task delegated to a UAP as long as a
life-threatening complication has not occurred. Client teaching and assessment
is done by the nurse.
Which tasks should be assigned to an LPN, rather than a UAP? SATA a.
Check residual on a tube feeding for a child with a PEG tube
b. Transport an infant with rotavirus to the treatment room for IV insertion
c. Perform a straight catheterization for urine specimen collection
d. Take the tympanic temperature of an infant
e. Distribute a snack to a child with diabetes - ANSWER: A, C The UAP is
not usually trained to perform an invasive procedure such as
checking residual or sterile procedures such as catheterization. The UAP can safely
be assigned to transport clients, take vital signs, and can distribute snacks BUT the
UAP should not be assigned of selecting the snack.
Which client should be assigned to a staff RN, rather than a staff LPN? a.
A 2-year-old with diabetes who has been vomiting all night
b. A 4-year-old with a rash creating a slapped appearance on the face
STUDOVA
, c. An infant boy with a fever of 101 who has been pulling on his ear
d. A 2-month-old with a pulse of 140 who needs routine immunizations -
ANSWER: A. This child, who may be hyperglycemia and dehydrated,
requires the highest of nursing expertise for assessment and care. Option B is
probably fifth disease, and does not require RN expertise as much as option
A. Option C is most likely an ear infection, and is not as immediate as
another option. Option D shows a normal pulse rate and does not require
expertise of the RN.
A pediatric clinic has only one pulse oximeter available for continuous monitoring
of oxygen saturation. Which client should it be used on?
a. A 6-month-old with a hemoglobin of 10 who is receiving an iron
supplement
b. An 8-month-old who is vomiting and passing stools with a currant jelly
appearance
c. A 2-year-old who has a fever and enlarged tonsils covered with purulent
discharge
d. A 3-year-old with a sore throat who is drooling and sitting in a tripod
position - ANSWER: D. This child is manifesting signs of epiglottitis, an
acute condition that can rapidly lead to severe respiratory distress. This
child needs the pulse oximeter. The other options do not require
continuous pulse oximetry.
Which situation requires the most immediate action at a skilled care unit?
a. A resident with a colostomy tells the nurse manager that his
colostomy bag is very full and is about to pop
b. A resident who is hard of hearing turns her head away when the nurse
manager inquires about how she is feeling
c. A resident with incontinence has urinated on the floor while
ambulating from his room toward the dining room
STUDOVA
, d. A resident sitting in a wheelchair outside the shower room is wrapped in
a blanket and
states she is cold - ANSWER: C; this situation is a safety hazard and requires
immediate intervention because it increases the risk of falls. Persons who are
hard of hearing often turn their head in an effort to hear better. The nurse should
determine if that is the situation or if the resident has a problem, but it is not
priority.
Which situation requires the most immediate intervention by a nurse manager?
a. A UAP is demonstrating verbally abusive behaviors toward a resident with
dementia who is
confused and disoriented
b. A newly hired UAP asks for assistance to correctly measure and document the
fluid intake of a resident with dysphagia
c. A resident with Parkinson's disease is drooling excessively and refuses to
allow the staff to feed
him
d. A resident with Alzheimer's disease is agitated and demands to be released
from his geriatric
chair - ANSWER: A; abusive behavior toward any resident places the resident
at risk for further abuse that could potentially escalate to assault. The nurse
manager has an ethical responsibility to advocate for those residents unable
to defend themselves. Drooling is common in Parkinson's disease and is not
a risk to the resident; since the client in option D is secured in the chair, this
does not pose an immediate risk.
A client fell while attempting to transfer to the bedside commode without
calling for assistance. In responding to the situation, which tasks can be
delegated to the UAP? SATA a. Place covers around the resident for warmth if
needed
STUDOVA
EXAM QUESTIONS AND VERIFIED CORRECT
ANSWERS
A nurse manager in a pediatric facility is approached by a staff RN regarding
several telephone messages from clients. Which situation requires the most
immediate follow-up by the nurse?
a. A mother expressing concern that her baby refuses to take formula, stating the
infant's "soft spot" seems more sunken
b. A grandmother asking for immunization information, stating her 5-year-old
grandchild has
never been immunized.
c. A parent calling to ask if it is necessary to keep her child with a sore throat
home from school
d. A mother stating that she sent her child to school but is concerned about his
eye, which is pink
and painful - ANSWER: A. This situation indicates the infant is probably
dehydrated, and dehydration can lead to a rapid loss of physiologic integrity
in an infant. The nurse needs to respond to this first.
Which child requires the most immediate follow-up by a nurse?
a. A 10-month-old with yellow nasal mucous and a fever of 101, who is fussy
and crying loudly
b. A 5-year-old who has started wetting the bed and constantly requests
extra snacks and drinks
c. A 13-year-old who was injured while playing football the previous day and
now cannot bear weight on his foot due to severe pain
d. A 9-year-old who got hit on the head with a baseball bat and has a bruise
behind his ear and clear nasal discharge - ANSWER: D. Bruising behind the
ear following a head injury is referred to as a Battle sign, which
STUDOVA
, is an indication of a basilar skull fracture. Because the clear nasal drainage may
be CSF, this child needs the most immediate assessment to determine severity of
the head
injury.
A nurse manager is planning care for a teen with a possible fracture of the foot.
Which tasks can be assigned to the UAP assisting the nurse? SATA a. Palpate
for presence of pedal pulses b. Apply a cold pack to the teenager's foot
c. Explain to the client the difference between a fracture and a sprain
d. Use a numeric pain scale to assess the teen's pain level
e. Take the teen's vital signs - ANSWER: B, E
Applying a cold pack may be delegated to the UAP with sufficient instruction
and supervision. Taking VS is a common task delegated to a UAP as long as a
life-threatening complication has not occurred. Client teaching and assessment
is done by the nurse.
Which tasks should be assigned to an LPN, rather than a UAP? SATA a.
Check residual on a tube feeding for a child with a PEG tube
b. Transport an infant with rotavirus to the treatment room for IV insertion
c. Perform a straight catheterization for urine specimen collection
d. Take the tympanic temperature of an infant
e. Distribute a snack to a child with diabetes - ANSWER: A, C The UAP is
not usually trained to perform an invasive procedure such as
checking residual or sterile procedures such as catheterization. The UAP can safely
be assigned to transport clients, take vital signs, and can distribute snacks BUT the
UAP should not be assigned of selecting the snack.
Which client should be assigned to a staff RN, rather than a staff LPN? a.
A 2-year-old with diabetes who has been vomiting all night
b. A 4-year-old with a rash creating a slapped appearance on the face
STUDOVA
, c. An infant boy with a fever of 101 who has been pulling on his ear
d. A 2-month-old with a pulse of 140 who needs routine immunizations -
ANSWER: A. This child, who may be hyperglycemia and dehydrated,
requires the highest of nursing expertise for assessment and care. Option B is
probably fifth disease, and does not require RN expertise as much as option
A. Option C is most likely an ear infection, and is not as immediate as
another option. Option D shows a normal pulse rate and does not require
expertise of the RN.
A pediatric clinic has only one pulse oximeter available for continuous monitoring
of oxygen saturation. Which client should it be used on?
a. A 6-month-old with a hemoglobin of 10 who is receiving an iron
supplement
b. An 8-month-old who is vomiting and passing stools with a currant jelly
appearance
c. A 2-year-old who has a fever and enlarged tonsils covered with purulent
discharge
d. A 3-year-old with a sore throat who is drooling and sitting in a tripod
position - ANSWER: D. This child is manifesting signs of epiglottitis, an
acute condition that can rapidly lead to severe respiratory distress. This
child needs the pulse oximeter. The other options do not require
continuous pulse oximetry.
Which situation requires the most immediate action at a skilled care unit?
a. A resident with a colostomy tells the nurse manager that his
colostomy bag is very full and is about to pop
b. A resident who is hard of hearing turns her head away when the nurse
manager inquires about how she is feeling
c. A resident with incontinence has urinated on the floor while
ambulating from his room toward the dining room
STUDOVA
, d. A resident sitting in a wheelchair outside the shower room is wrapped in
a blanket and
states she is cold - ANSWER: C; this situation is a safety hazard and requires
immediate intervention because it increases the risk of falls. Persons who are
hard of hearing often turn their head in an effort to hear better. The nurse should
determine if that is the situation or if the resident has a problem, but it is not
priority.
Which situation requires the most immediate intervention by a nurse manager?
a. A UAP is demonstrating verbally abusive behaviors toward a resident with
dementia who is
confused and disoriented
b. A newly hired UAP asks for assistance to correctly measure and document the
fluid intake of a resident with dysphagia
c. A resident with Parkinson's disease is drooling excessively and refuses to
allow the staff to feed
him
d. A resident with Alzheimer's disease is agitated and demands to be released
from his geriatric
chair - ANSWER: A; abusive behavior toward any resident places the resident
at risk for further abuse that could potentially escalate to assault. The nurse
manager has an ethical responsibility to advocate for those residents unable
to defend themselves. Drooling is common in Parkinson's disease and is not
a risk to the resident; since the client in option D is secured in the chair, this
does not pose an immediate risk.
A client fell while attempting to transfer to the bedside commode without
calling for assistance. In responding to the situation, which tasks can be
delegated to the UAP? SATA a. Place covers around the resident for warmth if
needed
STUDOVA
