NUR 114
EXAM 2
NCLEX Style Questions w/
Rationales & Test Taking Strategies
Jefferson State Community College
This Document Description:
❖ This document contains NCLEX-style Exam
questions tailored to the NUR 114 course at
Jefferson State Community College.
❖ It covers core topics assessed in the course
and reflects the actual exam format and question style.
❖ Each question is followed by a correct answer, rationale, and
test-taking strategy to support exam preparation.
,The nurse is monitoring a child for bleeding after surgery for removal
of a brain tumor. The nurse checks the head dressing for the
presence of blood and notes a colorless drainage on the back of the
dressing. Which action would the nurse perform immediately?
1. Notify the surgeon.
2. Reinforce the dressing.
3. Document the findings and continue to monitor.
4. Circle the area of drainage and continue to monitor.
Answer: 1
Rationale: Colorless drainage on the dressing in a child after
craniotomy indicates the presence of cerebrospinal fluid and needs to
be reported to the surgeon immediately. Options 2, 3, and 4 are not the
immediate nursing action because they do not address the need for
immediate intervention to prevent complications.
Test-Taking Strategy: Note the strategic word, immediately. Eliminate
options 3 and 4 because they are comparable or alike and delay
necessary intervention. Also, note the words colorless drainage. This
would alert you quickly to the possibil- ity of the presence of
cerebrospinal fluid and direct you to the correct option.
A child undergoes surgical removal of a brain tumor. During the
postoperative period, the nurse notes that the child is restless, the
pulse rate is elevated, and the blood pressure has decreased
significantly from the baseline value. The nurse suspects that the
,child is in shock. Which is the most appropriate nursing action?
1. Notify the surgeon.
2. Place the child in a supine position.
3. Place the child in Trendelenburg's position.
4. Increase the flow rate of the intravenous fluids.
Answer: 1
Rationale: In the event of shock, the surgeon is notified immediately.
After craniotomy, a child is never placed in the supine or
Trendelenburg’s position because either position could increase
intracranial pressure (ICP) and the risk of bleeding. The head of the bed
needs to be elevated. Increasing intravenous fluids can cause an
increase in ICP.
Test-Taking Strategy: Focus on the subject, care for the child following
craniotomy, and note the strategic words, most appropriate. Eliminate
options 2 and 3 because these positions could increase ICP. Eliminate
option 4 because increasing the flow rate could also increase ICP. In
addition, the nurse would not increase intravenous fluids without a
surgeon’s prescription.
The parent of a 4-year-old child tells the pediatric nurse that the
child's abdomen seems to be swollen. During further assessment, the
parent tells the nurse that the child is eating well and that the activity
level of the child is unchanged. The nurse, suspecting the possibility
of Wilms' tumor, would plan to avoid which during the physical
, assessment?
1. Palpating the abdomen for a mass
2. Assessing the urine for the presence of hematuria
3. Monitoring the temperature for the presence of fever
4. Monitoring the blood pressure for the presence of hypertension
Answer: 1
Rationale: Wilms’ tumor is the most common intraabdominal and
kidney tumor of childhood. If Wilms’ tumor is suspected, the tumor
mass would not be palpated by the nurse. Excessive manipulation can
cause seeding of the tumor and spread of the cancerous cells.
Hematuria, fever, and hypertension are clinical manifestations
associated with Wilms’ tumor.
Test-Taking Strategy: Focus on the subject, the action to avoid.
Knowledge that this tumor is an intra-abdominal and kidney tumor will
assist in eliminating options 2 and 4 because of the relationship of
these options to renal function. Next, thinking about the effect of
palpating the tumor will direct you to the correct answer from the
remaining options.
The nurse provides a teaching session to the nursing staff regarding
osteosarcoma. Which statement by a member of the nursing staff
indicates a need for further instruction?
1. "The femur is the most common site of this sarcoma."
2. "The child does not experience pain at the primary tumor site."
EXAM 2
NCLEX Style Questions w/
Rationales & Test Taking Strategies
Jefferson State Community College
This Document Description:
❖ This document contains NCLEX-style Exam
questions tailored to the NUR 114 course at
Jefferson State Community College.
❖ It covers core topics assessed in the course
and reflects the actual exam format and question style.
❖ Each question is followed by a correct answer, rationale, and
test-taking strategy to support exam preparation.
,The nurse is monitoring a child for bleeding after surgery for removal
of a brain tumor. The nurse checks the head dressing for the
presence of blood and notes a colorless drainage on the back of the
dressing. Which action would the nurse perform immediately?
1. Notify the surgeon.
2. Reinforce the dressing.
3. Document the findings and continue to monitor.
4. Circle the area of drainage and continue to monitor.
Answer: 1
Rationale: Colorless drainage on the dressing in a child after
craniotomy indicates the presence of cerebrospinal fluid and needs to
be reported to the surgeon immediately. Options 2, 3, and 4 are not the
immediate nursing action because they do not address the need for
immediate intervention to prevent complications.
Test-Taking Strategy: Note the strategic word, immediately. Eliminate
options 3 and 4 because they are comparable or alike and delay
necessary intervention. Also, note the words colorless drainage. This
would alert you quickly to the possibil- ity of the presence of
cerebrospinal fluid and direct you to the correct option.
A child undergoes surgical removal of a brain tumor. During the
postoperative period, the nurse notes that the child is restless, the
pulse rate is elevated, and the blood pressure has decreased
significantly from the baseline value. The nurse suspects that the
,child is in shock. Which is the most appropriate nursing action?
1. Notify the surgeon.
2. Place the child in a supine position.
3. Place the child in Trendelenburg's position.
4. Increase the flow rate of the intravenous fluids.
Answer: 1
Rationale: In the event of shock, the surgeon is notified immediately.
After craniotomy, a child is never placed in the supine or
Trendelenburg’s position because either position could increase
intracranial pressure (ICP) and the risk of bleeding. The head of the bed
needs to be elevated. Increasing intravenous fluids can cause an
increase in ICP.
Test-Taking Strategy: Focus on the subject, care for the child following
craniotomy, and note the strategic words, most appropriate. Eliminate
options 2 and 3 because these positions could increase ICP. Eliminate
option 4 because increasing the flow rate could also increase ICP. In
addition, the nurse would not increase intravenous fluids without a
surgeon’s prescription.
The parent of a 4-year-old child tells the pediatric nurse that the
child's abdomen seems to be swollen. During further assessment, the
parent tells the nurse that the child is eating well and that the activity
level of the child is unchanged. The nurse, suspecting the possibility
of Wilms' tumor, would plan to avoid which during the physical
, assessment?
1. Palpating the abdomen for a mass
2. Assessing the urine for the presence of hematuria
3. Monitoring the temperature for the presence of fever
4. Monitoring the blood pressure for the presence of hypertension
Answer: 1
Rationale: Wilms’ tumor is the most common intraabdominal and
kidney tumor of childhood. If Wilms’ tumor is suspected, the tumor
mass would not be palpated by the nurse. Excessive manipulation can
cause seeding of the tumor and spread of the cancerous cells.
Hematuria, fever, and hypertension are clinical manifestations
associated with Wilms’ tumor.
Test-Taking Strategy: Focus on the subject, the action to avoid.
Knowledge that this tumor is an intra-abdominal and kidney tumor will
assist in eliminating options 2 and 4 because of the relationship of
these options to renal function. Next, thinking about the effect of
palpating the tumor will direct you to the correct answer from the
remaining options.
The nurse provides a teaching session to the nursing staff regarding
osteosarcoma. Which statement by a member of the nursing staff
indicates a need for further instruction?
1. "The femur is the most common site of this sarcoma."
2. "The child does not experience pain at the primary tumor site."
