NCSBN NCLEX RN Exam Questions and Answers with
Rationales – A+ Graded
Question 1
The nurse who is caring for clients over the age of 70, implements a teaching plan about diet. Using knowledge based on
age-related changes, the nurse will emphasize which of the following factors?
A. Add high protein supplements to your diet
B. Make at least half your grains whole grain
C. Follow the DASH eating plan
D. Look for foods fortified with iron and other minerals
Correct Answer
B
Anyone, regardless of age, should eat a balanced diet of nutrient-packed foods. However, the diet of the older adult
without other chronic health issues should include an increase of fiber and whole grains. The DASH diet is recommended
to reduce blood pressure, but there is nothing to indicate this client is hypertensive. Older adults should eat lean proteins
but don't necessarily need protein supplements. They should also look for foods fortified with vitamins B12 and D, as well
as calcium.
Page 1 of 118
,Question 2
A 2-year-old child has just been diagnosed with cystic fibrosis. The child's parent asks the nurse what the most important
concerns are at this time. Which is the appropriate response from the nurse?
A. "Thick, sticky secretions from the lungs are a constant challenge."
B. "Cystic fibrosis results in nutritional concerns that can be dealt with."
C. "You will work with a team of experts and have access to a support group."
D. "There is a high probability of life-long complications."
Correct Answer
A
The primary factor, and the one responsible for many of the clinical manifestations of cystic fibrosis, is mechanical
obstruction caused by the increased viscosity of mucous gland secretions.Because of the increased viscosity of bronchial
mucus, there is greater resistance to ciliary action (probably secondary to infection and ciliary destruction), a slower flow
rate of mucus and incomplete expectoration, which also contributes to the mucus obstruction. This retained mucus
serves as an excellent medium for bacterial growth. Reduced oxygen-carbon dioxide exchange causes variable degrees of
hypoxia, hypercapnia and acidosis.In severe cases, progressive lung involvement, compression of pulmonary blood
vessels and progressive lung dysfunction frequently lead to pulmonary hypertension, cor pulmonale, respiratory failure
and death. Pulmonary complications are present in almost all children with cystic fibrosis, but the onset and extent of
involvement are variable.
Page 2 of 118
,Question 3
An older adult client, admitted after a fall at home, begins to seize and loses consciousness. What action by a nurse is
appropriate to do next?
A. Stay with client and monitor the condition
B. Collect pillows and pad the side rails of the bed
C. Place an oral airway in the mouth and suction
D. Announce a cardiac arrest and plan to assist with intubation
Correct Answer
A
For the client's safety, remain at the bedside and observe respirations, the movements of the extremities and level of
consciousness. Prepare to clear the airway or suction if obstructed. If suction equipment is not at the bedside, request
that someone else get it for you, rather than leaving the client. Do not place anything in the client's mouth. For safety, do
not leave the client unattended. A cardiac arrest should only be announced if pulse or respirations are absent after the
seizure.
Page 3 of 118
, Question 4
An 80 year-old client diagnosed with pneumonia is exhibiting new onset confusion. The client is pulling at tubes and items
near the bed and trying to get out of bed. Which intervention would be most appropriate?
A. Request an order for restraints
B. Frequently remind the client to stay in bed
C. Request an order for antianxiety medication
D. Arrange for a sitter to stay with the client
Correct Answer
D
Clients treated for pneumonia often develop new cognitive impairments; confusion or delirium is common. Although no
one wants someone to fall out of bed or pull out tubes, restraints should always be used as a last resort. A less restrictive
approach would be to arrange for a sitter to stay with the client. Use of antianxiety medications, such as benzodiazepines,
should be avoided in the elderly because they increase the risk of cognitive impairment, delirium and falls.
Page 4 of 118
Rationales – A+ Graded
Question 1
The nurse who is caring for clients over the age of 70, implements a teaching plan about diet. Using knowledge based on
age-related changes, the nurse will emphasize which of the following factors?
A. Add high protein supplements to your diet
B. Make at least half your grains whole grain
C. Follow the DASH eating plan
D. Look for foods fortified with iron and other minerals
Correct Answer
B
Anyone, regardless of age, should eat a balanced diet of nutrient-packed foods. However, the diet of the older adult
without other chronic health issues should include an increase of fiber and whole grains. The DASH diet is recommended
to reduce blood pressure, but there is nothing to indicate this client is hypertensive. Older adults should eat lean proteins
but don't necessarily need protein supplements. They should also look for foods fortified with vitamins B12 and D, as well
as calcium.
Page 1 of 118
,Question 2
A 2-year-old child has just been diagnosed with cystic fibrosis. The child's parent asks the nurse what the most important
concerns are at this time. Which is the appropriate response from the nurse?
A. "Thick, sticky secretions from the lungs are a constant challenge."
B. "Cystic fibrosis results in nutritional concerns that can be dealt with."
C. "You will work with a team of experts and have access to a support group."
D. "There is a high probability of life-long complications."
Correct Answer
A
The primary factor, and the one responsible for many of the clinical manifestations of cystic fibrosis, is mechanical
obstruction caused by the increased viscosity of mucous gland secretions.Because of the increased viscosity of bronchial
mucus, there is greater resistance to ciliary action (probably secondary to infection and ciliary destruction), a slower flow
rate of mucus and incomplete expectoration, which also contributes to the mucus obstruction. This retained mucus
serves as an excellent medium for bacterial growth. Reduced oxygen-carbon dioxide exchange causes variable degrees of
hypoxia, hypercapnia and acidosis.In severe cases, progressive lung involvement, compression of pulmonary blood
vessels and progressive lung dysfunction frequently lead to pulmonary hypertension, cor pulmonale, respiratory failure
and death. Pulmonary complications are present in almost all children with cystic fibrosis, but the onset and extent of
involvement are variable.
Page 2 of 118
,Question 3
An older adult client, admitted after a fall at home, begins to seize and loses consciousness. What action by a nurse is
appropriate to do next?
A. Stay with client and monitor the condition
B. Collect pillows and pad the side rails of the bed
C. Place an oral airway in the mouth and suction
D. Announce a cardiac arrest and plan to assist with intubation
Correct Answer
A
For the client's safety, remain at the bedside and observe respirations, the movements of the extremities and level of
consciousness. Prepare to clear the airway or suction if obstructed. If suction equipment is not at the bedside, request
that someone else get it for you, rather than leaving the client. Do not place anything in the client's mouth. For safety, do
not leave the client unattended. A cardiac arrest should only be announced if pulse or respirations are absent after the
seizure.
Page 3 of 118
, Question 4
An 80 year-old client diagnosed with pneumonia is exhibiting new onset confusion. The client is pulling at tubes and items
near the bed and trying to get out of bed. Which intervention would be most appropriate?
A. Request an order for restraints
B. Frequently remind the client to stay in bed
C. Request an order for antianxiety medication
D. Arrange for a sitter to stay with the client
Correct Answer
D
Clients treated for pneumonia often develop new cognitive impairments; confusion or delirium is common. Although no
one wants someone to fall out of bed or pull out tubes, restraints should always be used as a last resort. A less restrictive
approach would be to arrange for a sitter to stay with the client. Use of antianxiety medications, such as benzodiazepines,
should be avoided in the elderly because they increase the risk of cognitive impairment, delirium and falls.
Page 4 of 118
