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NCLEX QUESTION TRAINER EXPLANATIONS
TEST 2
1. The home care nurse is performing an assessment of a client with pneumonia secondary to
chronicpulmonary disease. Which of the following goals is MOST appropriate?
1. Maintain and improve the quality of oxygenation.
2. Improve the status of ventilation.
3. Increase oxygenation of peripheral circulation.
4. Correct the bicarbonate deficit.
Strategy: Determine the outcome of each answer.
(1) primary problem is not level of oxygenation, but the level of carbon dioxide contributing to an
acidotic state
(2) correct–to improve the quality of ventilation would refer to levels of carbon dioxide and oxygen
(3) not appropriate for the situation
(4) not appropriate for the situation
2. A 34-year-old man comes to the clinic for the results of a glycosylated hemoglobin assay (HbA1c).
Which statement, if made by the client to the nurse, indicates an understanding of this procedure?
1. “This test is performed by sticking my finger and measuring the results.”
2. “This test needs to be performed in the morning before I eat breakfast.”
3. “This test indicates how well my blood sugar has been controlled the past 6-8 weeks.”
4. “I must follow my diet carefully for several days before the test.”
Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?
(1) 3-5 ml of blood is needed
(2) timing of test is not important
(3) correct–when RBCs are being formed, sugar is attached (glycosylated) and remains attached
throughout the life of the RBC
(4) current blood sugar doesn't affect test
3. The nurse recognizes which of these symptoms as characteristic of a panic attack?
1. Palpitations, decreased perceptual field, diaphoresis, fear of going crazy.
2. Decreased blood pressure, chest pain, choking feeling.
3. Increased blood pressure, bradycardia, shortness of breath.
4. Increased respiratory rate, increased perceptual field, increased concentration ability.
Strategy: Think about each answer.
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(1) correct–panic disorders are characterized by recurrent, unpredictable attacks of intense
apprehension or terror that can render a client unable to control a situation or to perform simple
tasks; client can experience palpitations, chest pain, shortness of breath, a decrease in perceptual
field, and a fear of "losing it" or going crazy
(2) not accurate because typically the client has increased blood pressure related to stimulation of the
sympathetic nervous system
(3) heart rate would be increased due to stimulation of the sympathetic nervous system
(4) client's perceptual field is decreased during a panic attack; client becomes less aware of his/her
surroundings, and his/her performance is inhibited
4. The physician diagnoses Graves’ disease for a 28-year-old woman seen in the clinic. The nursewould
expect the client to exhibit which of the following symptoms?
1. Lethargy in the early morning.
2. Sensitivity to cold.
3. Weight loss of 10 lb in 3 weeks. 4. Reduced deep tendon reflexes.
(1) will be restless
(2) have heat intolerance due to increased metabolic rate
(3) correct–increased metabolic rate causes weight loss even with increased appetite
(4) reflexes will be hyperactive
5. During an initial interview at an outpatient clinic, a 34-year-old single mother tells the nurse that shehas
always had difficulty forming relationships and is worried that her 7-year-old daughter will have the same
problem. Which of the following statements, if made by the nurse, is BEST?
1. “Children develop trust from birth to 18 months of age.”
2. “Children develop trust from 18 months to three years of age.”
3. “Children develop trust from three to six years of age.”
4. “Children develop trust from six to twelve years of age.”
Strategy: "BEST" indicates discrimination is required. Topic of question is unstated. Read answer
choices to determine topic.
(1) correct–Erikson states that trust results from interaction with dependable, predictable primary
caretaker
(2) toddler stage concerns autonomy verses shame and doubt
(3) preschool state concerns initiative versus guilt
(4) latency or school age stage concerns industry versus inferiority
6. Which of the following nursing interventions is MOST important when caring for a client who has
justbeen placed in physical restraints?
1. Prepare PRN dose of psychotropic medication.
2. Check that the restraints have been applied correctly.
3. Review hospital policy regarding duration of restraints.
4. Monitor the client’s needs for hydration and nutrition while restrained.
Nursing ...
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Strategy: Answers are a mix of assessment and implementation. Is this a situation that requires
assessment? Yes. Is there an appropriate assessment? Yes.
(1) implementation; inappropriate for the client in restraints
(2) correct–assessment; while a client is restrained, physiological integrity is important; monitoring
positioning, tightness, and peripheral circulation is essential; nurse documents the client's response
and clinical status after being restrained
(3) implementation; all staff members involved in a restraint event must be aware of hospital policy
before using restraints
(4) assessment; important to attend to client's nutrition and hydration after the client is safely restrained
7. The geriatric residents of a long-term care facility are engaged in a reminiscing group. The nurseknows
that the primary goal of this type of group activity is to
1. provide psychosocial educational opportunities for stress and coping.
2. provide an avenue for physical exercise.
3. provide an environment for social interaction and companionship.
4. reorient and provide a reality test for confused clients.
Strategy: Think about each answer.
(1) is not primary goal of a reminiscing group
(2) is not primary goal of a reminiscing group
(3) correct–primary goal of a reminiscing group for geriatric clients is to review and share their life
experiences with the group members
(4) groups that facilitate orientation to time, person, place, and current events are called reality
orientation groups
8. The nurse is aware that which of the following assessments would be indicative of hypocalcemia?
1. Constipation.
2. Depressed reflexes.
3. Decreased muscle strength.
4. Positive Trousseau’s sign.
Strategy: Think about the cause of each answer.
(1) symptom associated with hypercalcemia (2)
symptom associated with hypercalcemia
(3) symptom associated with hypercalcemia
(4) correct–positive Trousseau's sign is indicative of neuromuscular hyperreflexia associated with
hypocalcemia
9. When obtaining a specimen from a client for sputum culture and sensitivity (C and S), the nurseknows
that which of the following instructions is BEST?
1. After pursed-lip breathing, cough into a container.
2. Upon awakening, cough deeply and expectorate into a container.
3. Save all sputum for three days in a covered container.
Nursing ...
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4. After respiratory treatment, expectorate into a container.
Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?
(1) coughing into a container is indicated, but not pursed-lip breathing
(2) correct–specimens should be obtained in the early morning because secretions develop during the
night
(3) appropriate for acid-fast stain for TB
(4) earliest specimen is most desirable
10. A patient has a Levin tube connected to intermittent low suction. At 7 AM, the nurse charts that there is
235 cc of greenish drainage in the suction container. At 3 PM, the nurse notes that there is 445 cc of
greenish drainage in the suction container. Twice during the shift, the nurse irrigates the Levin tube with
30 cc of normal saline, as ordered by the physician. What is the actual amount of drainage from the
nasogastric tube for the 7 to 3 shift?
1. 150 cc. 2. 210 cc. 3. 295 cc.
4. 385 cc.
Strategy: Think about each answer.
(1) correct–445 – 235 = 210 – 60 = 150
(2) does not subtract 60 cc of fluid used to irrigate Levin tube
(3) does not take into account solution added to container during day shift; does not subtract for fluids
used to irrigate Levin tube
(4) does not subtract 235 cc that was in container from night shift
11. The nurse is caring for a patient during a radium implant. During the removal of the implant, it isMOST
important for the nurse to take which of the following actions?
1. Clean the radium implant carefully with a disinfectant (alcohol or bleach) using long forceps.
2. Handle the radium carefully using forceps and rubber latex gloves.
3. Chart the date and time of removal along with the total time of implant treatment.
4. Double-bag the radium implant before the person from radiology removes it from the room.
Strategy: Answers are all implementation. Determine the outcome of each answer. Is it desired?
(1) at no time should the nurse or client handle the radium; radiology department is responsible for
handling implant
(2) at no time should the nurse or client handle the radium; radiology department is responsible for
handling implant
(3) correct–important that accurate documentation be maintained on the internal radium implant
(4) at no time should the nurse or client handle the radium; radiology department is responsible for
handling implant
12. The physician prescribes lithium carbonate (Lithobid) 300 mg PO QID for a 47-year-old woman.
Thenurse in the outpatient clinic teaches the client about the medication. The nurse should encourage
the client to make sure her diet has adequate
Nursing ...
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NCLEX QUESTION TRAINER EXPLANATIONS
TEST 2
1. The home care nurse is performing an assessment of a client with pneumonia secondary to
chronicpulmonary disease. Which of the following goals is MOST appropriate?
1. Maintain and improve the quality of oxygenation.
2. Improve the status of ventilation.
3. Increase oxygenation of peripheral circulation.
4. Correct the bicarbonate deficit.
Strategy: Determine the outcome of each answer.
(1) primary problem is not level of oxygenation, but the level of carbon dioxide contributing to an
acidotic state
(2) correct–to improve the quality of ventilation would refer to levels of carbon dioxide and oxygen
(3) not appropriate for the situation
(4) not appropriate for the situation
2. A 34-year-old man comes to the clinic for the results of a glycosylated hemoglobin assay (HbA1c).
Which statement, if made by the client to the nurse, indicates an understanding of this procedure?
1. “This test is performed by sticking my finger and measuring the results.”
2. “This test needs to be performed in the morning before I eat breakfast.”
3. “This test indicates how well my blood sugar has been controlled the past 6-8 weeks.”
4. “I must follow my diet carefully for several days before the test.”
Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?
(1) 3-5 ml of blood is needed
(2) timing of test is not important
(3) correct–when RBCs are being formed, sugar is attached (glycosylated) and remains attached
throughout the life of the RBC
(4) current blood sugar doesn't affect test
3. The nurse recognizes which of these symptoms as characteristic of a panic attack?
1. Palpitations, decreased perceptual field, diaphoresis, fear of going crazy.
2. Decreased blood pressure, chest pain, choking feeling.
3. Increased blood pressure, bradycardia, shortness of breath.
4. Increased respiratory rate, increased perceptual field, increased concentration ability.
Strategy: Think about each answer.
Nursing ...
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(1) correct–panic disorders are characterized by recurrent, unpredictable attacks of intense
apprehension or terror that can render a client unable to control a situation or to perform simple
tasks; client can experience palpitations, chest pain, shortness of breath, a decrease in perceptual
field, and a fear of "losing it" or going crazy
(2) not accurate because typically the client has increased blood pressure related to stimulation of the
sympathetic nervous system
(3) heart rate would be increased due to stimulation of the sympathetic nervous system
(4) client's perceptual field is decreased during a panic attack; client becomes less aware of his/her
surroundings, and his/her performance is inhibited
4. The physician diagnoses Graves’ disease for a 28-year-old woman seen in the clinic. The nursewould
expect the client to exhibit which of the following symptoms?
1. Lethargy in the early morning.
2. Sensitivity to cold.
3. Weight loss of 10 lb in 3 weeks. 4. Reduced deep tendon reflexes.
(1) will be restless
(2) have heat intolerance due to increased metabolic rate
(3) correct–increased metabolic rate causes weight loss even with increased appetite
(4) reflexes will be hyperactive
5. During an initial interview at an outpatient clinic, a 34-year-old single mother tells the nurse that shehas
always had difficulty forming relationships and is worried that her 7-year-old daughter will have the same
problem. Which of the following statements, if made by the nurse, is BEST?
1. “Children develop trust from birth to 18 months of age.”
2. “Children develop trust from 18 months to three years of age.”
3. “Children develop trust from three to six years of age.”
4. “Children develop trust from six to twelve years of age.”
Strategy: "BEST" indicates discrimination is required. Topic of question is unstated. Read answer
choices to determine topic.
(1) correct–Erikson states that trust results from interaction with dependable, predictable primary
caretaker
(2) toddler stage concerns autonomy verses shame and doubt
(3) preschool state concerns initiative versus guilt
(4) latency or school age stage concerns industry versus inferiority
6. Which of the following nursing interventions is MOST important when caring for a client who has
justbeen placed in physical restraints?
1. Prepare PRN dose of psychotropic medication.
2. Check that the restraints have been applied correctly.
3. Review hospital policy regarding duration of restraints.
4. Monitor the client’s needs for hydration and nutrition while restrained.
Nursing ...
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16
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Strategy: Answers are a mix of assessment and implementation. Is this a situation that requires
assessment? Yes. Is there an appropriate assessment? Yes.
(1) implementation; inappropriate for the client in restraints
(2) correct–assessment; while a client is restrained, physiological integrity is important; monitoring
positioning, tightness, and peripheral circulation is essential; nurse documents the client's response
and clinical status after being restrained
(3) implementation; all staff members involved in a restraint event must be aware of hospital policy
before using restraints
(4) assessment; important to attend to client's nutrition and hydration after the client is safely restrained
7. The geriatric residents of a long-term care facility are engaged in a reminiscing group. The nurseknows
that the primary goal of this type of group activity is to
1. provide psychosocial educational opportunities for stress and coping.
2. provide an avenue for physical exercise.
3. provide an environment for social interaction and companionship.
4. reorient and provide a reality test for confused clients.
Strategy: Think about each answer.
(1) is not primary goal of a reminiscing group
(2) is not primary goal of a reminiscing group
(3) correct–primary goal of a reminiscing group for geriatric clients is to review and share their life
experiences with the group members
(4) groups that facilitate orientation to time, person, place, and current events are called reality
orientation groups
8. The nurse is aware that which of the following assessments would be indicative of hypocalcemia?
1. Constipation.
2. Depressed reflexes.
3. Decreased muscle strength.
4. Positive Trousseau’s sign.
Strategy: Think about the cause of each answer.
(1) symptom associated with hypercalcemia (2)
symptom associated with hypercalcemia
(3) symptom associated with hypercalcemia
(4) correct–positive Trousseau's sign is indicative of neuromuscular hyperreflexia associated with
hypocalcemia
9. When obtaining a specimen from a client for sputum culture and sensitivity (C and S), the nurseknows
that which of the following instructions is BEST?
1. After pursed-lip breathing, cough into a container.
2. Upon awakening, cough deeply and expectorate into a container.
3. Save all sputum for three days in a covered container.
Nursing ...
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17
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4. After respiratory treatment, expectorate into a container.
Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?
(1) coughing into a container is indicated, but not pursed-lip breathing
(2) correct–specimens should be obtained in the early morning because secretions develop during the
night
(3) appropriate for acid-fast stain for TB
(4) earliest specimen is most desirable
10. A patient has a Levin tube connected to intermittent low suction. At 7 AM, the nurse charts that there is
235 cc of greenish drainage in the suction container. At 3 PM, the nurse notes that there is 445 cc of
greenish drainage in the suction container. Twice during the shift, the nurse irrigates the Levin tube with
30 cc of normal saline, as ordered by the physician. What is the actual amount of drainage from the
nasogastric tube for the 7 to 3 shift?
1. 150 cc. 2. 210 cc. 3. 295 cc.
4. 385 cc.
Strategy: Think about each answer.
(1) correct–445 – 235 = 210 – 60 = 150
(2) does not subtract 60 cc of fluid used to irrigate Levin tube
(3) does not take into account solution added to container during day shift; does not subtract for fluids
used to irrigate Levin tube
(4) does not subtract 235 cc that was in container from night shift
11. The nurse is caring for a patient during a radium implant. During the removal of the implant, it isMOST
important for the nurse to take which of the following actions?
1. Clean the radium implant carefully with a disinfectant (alcohol or bleach) using long forceps.
2. Handle the radium carefully using forceps and rubber latex gloves.
3. Chart the date and time of removal along with the total time of implant treatment.
4. Double-bag the radium implant before the person from radiology removes it from the room.
Strategy: Answers are all implementation. Determine the outcome of each answer. Is it desired?
(1) at no time should the nurse or client handle the radium; radiology department is responsible for
handling implant
(2) at no time should the nurse or client handle the radium; radiology department is responsible for
handling implant
(3) correct–important that accurate documentation be maintained on the internal radium implant
(4) at no time should the nurse or client handle the radium; radiology department is responsible for
handling implant
12. The physician prescribes lithium carbonate (Lithobid) 300 mg PO QID for a 47-year-old woman.
Thenurse in the outpatient clinic teaches the client about the medication. The nurse should encourage
the client to make sure her diet has adequate
Nursing ...
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18
