NCLEX-PN TEST-BANK ALL 200 QUESTIONS WITH ANSWERS AND DISCUSSIONS|EXPERT
VERIFIED
1. The nurse is caring for a client scheduled for removal of a pituitary tumor using the
transsphenoidal approach. The nurse should be particularly alert for:
A. Nasal congestion
B. Abdominal tenderness
C. Muscle tetany
D. Oliguria
Answer A: Removal of the pituitary gland is usually done by a transsphenoidal approach, through
the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are not correct
because they are not directly associated with the pituitary gland.
2. A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC
6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is
experiencing which of the following?
A. Hypernatremia
B. Hypokalemia
C. Myelosuppression
D. Leukocytosis
Answer B: Hypokalemia is evident from the lab values listed. The other laboratory findings are
within normal limits, making answers A, C, and D incorrect.
3. A 24-year-old female client is scheduled for surgery in the morning. Which of the following
is the primary responsibility of the nurse?
A. Taking the vital signs
B. Obtaining the permit
C. Explaining the procedure
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,D. Checking the lab work
Answer A: The primary responsibility of the nurse is to take the vital signs before any surgery. The
actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for
this question.
4. The nurse is working in the emergency room when a client arrives with severe burns of the
left arm, hands, face, and neck. Which action should receive priority?
A. Starting an IV
B. Applying oxygen
C. Obtaining blood gases
D. Medicating the client for pain
Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen, so
applying oxygen is the priority. The next action should be to start an IV and medicate for pain,
making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor.
5. The nurse is visiting a home health client with osteoporosis. The client has a new
prescription for alendronate (Fosamax). Which instruction should be given to the client?
A. Rest in bed after taking the medication for at least 30 minutes
B. Avoid rapid movements after taking the medication
C. Take the medication with water only
D. Allow at least 1 hour between taking the medicine and taking other medications
Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen, so
applying oxygen is the priority. The next action should be to start an IV and medicate for pain,
making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor.
6. The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs.
Which equipment should be kept at the bedside?
A. A pair of forceps
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,B. A torque wrench
C. A pair of wire cutters
D. A screwdriver
Answer B: A torque wrench is kept at the bedside to tighten and loosen the screws of crutchfield
tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of forceps,
wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are incorrect.
7. An infant weighs 7 pounds at birth. The expected weight by 1 year should be:
A. 10 pounds
B. 12 pounds
C. 18 pounds
D. 21 pounds
Answer D: A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth weight.
Answers A, B, and C therefore are incorrect.
8. A client is admitted with a Ewing’s sarcoma. Which symptoms would be expected due to
this tumor’s location?
A. Hemiplegia
B. Aphasia
C. Nausea
D. Bone pain
Answer D: Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers A, B,
and C are not specific to this type of cancer and are incorrect.
9. The nurse is caring for a client with epilepsy who is being treated with carbamazepine
(Tegretol). Which laboratory value might indicate a serious side effect of this drug?
A. Uric acid of 5mg/dL
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, B. Hematocrit of 33%
C. WBC 2,000 per cubic millimeter
D. Platelets 150,000 per cubic millimeter
Answer C: Tegretol can suppress the bone marrow and decrease the white blood cell count; thus, a
lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and D are
within normal limits, and answer B is a lower limit of normal; therefore, answers A, B, and D are
incorrect
10. A 6-month-old client is admitted with possible intussuception. Which question during the
nursing history is least helpful in obtaining information regarding this diagnosis?
A. “Tell me about his pain.”
B. “What does his vomit look like?”
C. “Describe his usual diet.”
D. “Have you noticed changes in his abdominal size?”
Answer C: The least-helpful questions are those describing his usual diet. A, B, and D are useful in
determining the extent of disease process and, thus, are incorrect.
11. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food
should be avoided?
A. Bran
B. Fresh peaches
C. Cucumber salad
D. Yeast rolls
Answer C: The client with diverticulitis should avoid foods with seeds. The foods in answers A, B,
and D are allowed; in fact, bran cereal and fruit will help prevent constipation.
12. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should
be the priority nursing care during the post-op period?
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VERIFIED
1. The nurse is caring for a client scheduled for removal of a pituitary tumor using the
transsphenoidal approach. The nurse should be particularly alert for:
A. Nasal congestion
B. Abdominal tenderness
C. Muscle tetany
D. Oliguria
Answer A: Removal of the pituitary gland is usually done by a transsphenoidal approach, through
the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are not correct
because they are not directly associated with the pituitary gland.
2. A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC
6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is
experiencing which of the following?
A. Hypernatremia
B. Hypokalemia
C. Myelosuppression
D. Leukocytosis
Answer B: Hypokalemia is evident from the lab values listed. The other laboratory findings are
within normal limits, making answers A, C, and D incorrect.
3. A 24-year-old female client is scheduled for surgery in the morning. Which of the following
is the primary responsibility of the nurse?
A. Taking the vital signs
B. Obtaining the permit
C. Explaining the procedure
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,D. Checking the lab work
Answer A: The primary responsibility of the nurse is to take the vital signs before any surgery. The
actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for
this question.
4. The nurse is working in the emergency room when a client arrives with severe burns of the
left arm, hands, face, and neck. Which action should receive priority?
A. Starting an IV
B. Applying oxygen
C. Obtaining blood gases
D. Medicating the client for pain
Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen, so
applying oxygen is the priority. The next action should be to start an IV and medicate for pain,
making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor.
5. The nurse is visiting a home health client with osteoporosis. The client has a new
prescription for alendronate (Fosamax). Which instruction should be given to the client?
A. Rest in bed after taking the medication for at least 30 minutes
B. Avoid rapid movements after taking the medication
C. Take the medication with water only
D. Allow at least 1 hour between taking the medicine and taking other medications
Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen, so
applying oxygen is the priority. The next action should be to start an IV and medicate for pain,
making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor.
6. The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs.
Which equipment should be kept at the bedside?
A. A pair of forceps
2|Page
,B. A torque wrench
C. A pair of wire cutters
D. A screwdriver
Answer B: A torque wrench is kept at the bedside to tighten and loosen the screws of crutchfield
tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of forceps,
wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are incorrect.
7. An infant weighs 7 pounds at birth. The expected weight by 1 year should be:
A. 10 pounds
B. 12 pounds
C. 18 pounds
D. 21 pounds
Answer D: A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth weight.
Answers A, B, and C therefore are incorrect.
8. A client is admitted with a Ewing’s sarcoma. Which symptoms would be expected due to
this tumor’s location?
A. Hemiplegia
B. Aphasia
C. Nausea
D. Bone pain
Answer D: Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers A, B,
and C are not specific to this type of cancer and are incorrect.
9. The nurse is caring for a client with epilepsy who is being treated with carbamazepine
(Tegretol). Which laboratory value might indicate a serious side effect of this drug?
A. Uric acid of 5mg/dL
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, B. Hematocrit of 33%
C. WBC 2,000 per cubic millimeter
D. Platelets 150,000 per cubic millimeter
Answer C: Tegretol can suppress the bone marrow and decrease the white blood cell count; thus, a
lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and D are
within normal limits, and answer B is a lower limit of normal; therefore, answers A, B, and D are
incorrect
10. A 6-month-old client is admitted with possible intussuception. Which question during the
nursing history is least helpful in obtaining information regarding this diagnosis?
A. “Tell me about his pain.”
B. “What does his vomit look like?”
C. “Describe his usual diet.”
D. “Have you noticed changes in his abdominal size?”
Answer C: The least-helpful questions are those describing his usual diet. A, B, and D are useful in
determining the extent of disease process and, thus, are incorrect.
11. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food
should be avoided?
A. Bran
B. Fresh peaches
C. Cucumber salad
D. Yeast rolls
Answer C: The client with diverticulitis should avoid foods with seeds. The foods in answers A, B,
and D are allowed; in fact, bran cereal and fruit will help prevent constipation.
12. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should
be the priority nursing care during the post-op period?
4|Page
