NCLEX NGN Pre-Test Questions and Answer
1.A nurse is assigned to care for a client with chronic renal failure who
is undergoing hemodialysis through an internal 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
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-
ANS A, B, C, D
2.A nurse is evaluating outcomes for a client with Guillain-Barre syndrome. Which
outcome does the nurse recognize as optimal respiratory outcomes for the client?
a. Normal deep tendon reflexes
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
ANS D, E
3.A nurse of the telemetry unit is caring for a client who has had a MI and is now
attached to a cardiac monitor. The nurse is monitoring the client's cardiac rhythm
,and nots ventricular fibrillation. Which nursing intervention should the nurse take
first?
a. Calling the rapid response team
b. Preparing the client for cardioversion
c. Asking the client to bear down and cough
d. Preparing to administer diltiazem
ANS A
The pattern of ventricular fibrillation is identified and can be a result afte
a patient with an MI. VF makes the patient feel faint, then loses
consciousness and becomes pulseless and apneic (BP and heart sounds
absent). Treatment is to terminate
VF and covert it into a rhythm via defibrillation-> call a rapid and initiate
CPR. Cardioversion is used for ventricular or supraventricular
tachydysrhythmias.
4.A nurse developing a plan of care for a client with a spinal cord injury includes
measures to prevent autonomic dysreflexia (hyperreflexia). Which intervention
does the nurse incorporate into the plan to prevent this compli- cation?
a. Keeping the fan running in the client's room
b. Keeping the linens wrinkle free under the client
c. Limiting bladder catheterization to once every 12 hours
d. Avoiding the administration of enemas and rectal suppositories
ANS B
The most frequent cause of autonomic dysreflexias are a distended
bladder and impacted feces. Other causes include stimulation of the skin
,by tactile, thermal, or painful stimuli. The nurse renders care in such a
way as to minimize these risks.
5.A nurse provides home care instructions to a client who has been fitted with a
halo device to treat a cervical fracture. Which statement by the client indicates
the need for further teaching?
a. I need to get more fluids and fiber into my diet
b. I should cut my food into small pieces before I eat
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
ANS C Cleanse the skin under the wool liner each day to prevent rashes
and soars.
6.A nurse is caring for a client with increased intracranial pressure. In which
position should the nurse maintain the client?
a. Supine with the head extended
b. Side lying with the neck flexed
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees
ANS D
Proper positioning promotes venous drainage from the cranium to
minimize ICP.
7.A client with a basilar skull fracture has clear fluid leaking from the ears. The
nurse should take which action first?
, a. Asses the clear fluid for protein
b. Check the clear fluid for glucose
c. Place cotton calls or dry gauze loosely in the ears
d. Use an otoscope to assess the tympanic membrane for rupture
ANS B CSF contains glucose not protein.
8.A nurse is caring for a client who has just undergone cardioversion. Which
intervention is the nurse's priority after this procedure.
a. Administer oxygen
b. Monitoring the BP
c. Administering antidysrhythmic medications
d. Monitoring the client's LOC
ANS A
ABC's of nursing. All other choices are correct, but not priority.
9.A client with diabetes mellitus who is scheduled to have blood drawn for
determination of the glycosylated hemoglobin (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?
a. Detect diabetic complications
b. Assess long-term glycemic control
c. Determine whether the client is at risk for hypoglycemia
d Determine whether the prescribed insulin dosage is correct
ANS B
1.A nurse is assigned to care for a client with chronic renal failure who
is undergoing hemodialysis through an internal 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
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-
ANS A, B, C, D
2.A nurse is evaluating outcomes for a client with Guillain-Barre syndrome. Which
outcome does the nurse recognize as optimal respiratory outcomes for the client?
a. Normal deep tendon reflexes
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
ANS D, E
3.A nurse of the telemetry unit is caring for a client who has had a MI and is now
attached to a cardiac monitor. The nurse is monitoring the client's cardiac rhythm
,and nots ventricular fibrillation. Which nursing intervention should the nurse take
first?
a. Calling the rapid response team
b. Preparing the client for cardioversion
c. Asking the client to bear down and cough
d. Preparing to administer diltiazem
ANS A
The pattern of ventricular fibrillation is identified and can be a result afte
a patient with an MI. VF makes the patient feel faint, then loses
consciousness and becomes pulseless and apneic (BP and heart sounds
absent). Treatment is to terminate
VF and covert it into a rhythm via defibrillation-> call a rapid and initiate
CPR. Cardioversion is used for ventricular or supraventricular
tachydysrhythmias.
4.A nurse developing a plan of care for a client with a spinal cord injury includes
measures to prevent autonomic dysreflexia (hyperreflexia). Which intervention
does the nurse incorporate into the plan to prevent this compli- cation?
a. Keeping the fan running in the client's room
b. Keeping the linens wrinkle free under the client
c. Limiting bladder catheterization to once every 12 hours
d. Avoiding the administration of enemas and rectal suppositories
ANS B
The most frequent cause of autonomic dysreflexias are a distended
bladder and impacted feces. Other causes include stimulation of the skin
,by tactile, thermal, or painful stimuli. The nurse renders care in such a
way as to minimize these risks.
5.A nurse provides home care instructions to a client who has been fitted with a
halo device to treat a cervical fracture. Which statement by the client indicates
the need for further teaching?
a. I need to get more fluids and fiber into my diet
b. I should cut my food into small pieces before I eat
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
ANS C Cleanse the skin under the wool liner each day to prevent rashes
and soars.
6.A nurse is caring for a client with increased intracranial pressure. In which
position should the nurse maintain the client?
a. Supine with the head extended
b. Side lying with the neck flexed
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees
ANS D
Proper positioning promotes venous drainage from the cranium to
minimize ICP.
7.A client with a basilar skull fracture has clear fluid leaking from the ears. The
nurse should take which action first?
, a. Asses the clear fluid for protein
b. Check the clear fluid for glucose
c. Place cotton calls or dry gauze loosely in the ears
d. Use an otoscope to assess the tympanic membrane for rupture
ANS B CSF contains glucose not protein.
8.A nurse is caring for a client who has just undergone cardioversion. Which
intervention is the nurse's priority after this procedure.
a. Administer oxygen
b. Monitoring the BP
c. Administering antidysrhythmic medications
d. Monitoring the client's LOC
ANS A
ABC's of nursing. All other choices are correct, but not priority.
9.A client with diabetes mellitus who is scheduled to have blood drawn for
determination of the glycosylated hemoglobin (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?
a. Detect diabetic complications
b. Assess long-term glycemic control
c. Determine whether the client is at risk for hypoglycemia
d Determine whether the prescribed insulin dosage is correct
ANS B
