NCLEX PN ACTUAL QUESTIONS AND ANSWERS
1. The nurse is providing care for a client diagnosed with Graves' disease. Which of the
following nursing interventions should be included in the client's care to provide
maximum comfort?
A. Apply extra blankets on the client's bed.
B. Assign the client to a room with another client.
C. Maintain the client's room at a cool temperature.
D. Order the client a diet that is low in carbohydrates.
2. A 52-year-old hospitalized client who was sitting in a chair has suddenly slumped over.
The client is not breathing and is pulseless, and cardiopulmonary resuscitation (CPR) is
in progress by another nurse. Which action would prompt the nurse to intervene?
A. There is full recoil of the client's chest between compressions.
B. CPR is performed at a rate of 90-100 compressions per minute.
C. Each compression is delivered hard and fast on the client's chest.
D. D. CPR is paused for a pulse check when prompted by the code leader.
3. A client who was treated for emphysema and cellulitis with leg ulcerations is being
discharged home with home health care services. The nurse knows that discharge
planning for this client should involve which materials and equipment? Select all that
apply.
A. Bedside commode
B. Incentive spirometer
, C. Wound care supplies
D. Portable oxygen machine
E. Epinephrine injectable pen
4. A parent brings a 12-month-old child to the pediatrician's office for an influenza
vaccination. Before administering the immunization, the nurse notes the child is acting
fussy, is warm and flushed, and has rhinorrhea. Which of the following is the nurse's
priority action?
A. Assess the child for additional symptoms of febrile illness.
B. Advise the parent that the immunization will need to be given at a later date
because the child has a fever.
C. Provide the child with cool fluids to reduce the fever and applying an anesthetic
cream to the injection site.
D. Notify the pediatrician and obtaining an order for an antipyretic.
5. The nurse is caring for a client who is ordered a clear liquid diet. Which of the following
items are permitted on this type of diet? Select all that apply.
i. Apple juice
ii. Chicken broth
iii. Gelatin
iv. Ice cream
v. Pudding
A. 1, 4
, B. 2, 3
C. 1, 2, 3
D. 3, 4, 5
6. The nurse has just completed administering a client's morning dosage of NPH insulin.
The client asks the nurse, "If my blood sugar is going to drop, when will it occur?"
Which of the following is the nurse's best response?
A. 2 to 4 hours after the administration of the insulin
B. 4 to 12 hours after the administration of the insulin
C. 16 to 18 hours after the administration of the insulin
D. 18 to 24 hours after the administration of the insulin
7. The nurse has received a report on a client with amyotrophic lateral sclerosis (ALS) who
is unable to move his upper arms but has gross motor function of his right hand. The
client is awake and alert. Which of the following actions is most appropriate to establish a
system of communication for this client?
A. Supply the client with the standard call bell on the right side of his body near his
hand.
B. Provide the client with a touch-sensor call-button that requires a light tap to
activate.
C. Round on the client every two hours to assess his status and see if he needs
anything.
D. Provide contact phone numbers on the communication board in the client's room
at his eye level.
, 8. The nurse is participating in the care of a client with end-stage renal failure. The
physician orders a palliative care consult because the client wishes no further medical
interventions. Which of the following should the nurse anticipate based on her knowledge
of palliative care?
A. Decreasing pain medication administration
B. Decreasing the amount of supplemental oxygen administered
C. Increasing oral and intravenous fluid amounts
D. Increasing the administration of anti-anxiety medications
9. Use the following to answer questions.
Nurse's Notes
1100: The client is readmitted to the hospital following aortic valve replacement with
repair of aortic aneurysm. His surgery was performed 3 weeks prior to his readmission.
He was discharged on post-op day 5. His course was uncomplicated, and he states he felt
well at home for about 10 days. He has just been admitted to the nursing unit. Starting
about 10 days after he got home, he developed chest discomfort that was constant but
worse with deep inspiration. He was not able to perform his incentive spirometry as well
as at the time of discharge. He states that his appetite and fluid intake have also declined.
The client also states he normally urinates at least 5 times/day and now only urinates 2-3
times/day. The urine is odorous and dark in color. He has a frequent, dry, unproductive
cough. For the past 5 days, he has noted increasing shortness of breath and inability to
walk very far without resting. On examination, the nurse notes that breath sounds are
clear but decreased bilaterally at bases. The nurse also notes that heart sounds are not
easily identified.
1. The nurse is providing care for a client diagnosed with Graves' disease. Which of the
following nursing interventions should be included in the client's care to provide
maximum comfort?
A. Apply extra blankets on the client's bed.
B. Assign the client to a room with another client.
C. Maintain the client's room at a cool temperature.
D. Order the client a diet that is low in carbohydrates.
2. A 52-year-old hospitalized client who was sitting in a chair has suddenly slumped over.
The client is not breathing and is pulseless, and cardiopulmonary resuscitation (CPR) is
in progress by another nurse. Which action would prompt the nurse to intervene?
A. There is full recoil of the client's chest between compressions.
B. CPR is performed at a rate of 90-100 compressions per minute.
C. Each compression is delivered hard and fast on the client's chest.
D. D. CPR is paused for a pulse check when prompted by the code leader.
3. A client who was treated for emphysema and cellulitis with leg ulcerations is being
discharged home with home health care services. The nurse knows that discharge
planning for this client should involve which materials and equipment? Select all that
apply.
A. Bedside commode
B. Incentive spirometer
, C. Wound care supplies
D. Portable oxygen machine
E. Epinephrine injectable pen
4. A parent brings a 12-month-old child to the pediatrician's office for an influenza
vaccination. Before administering the immunization, the nurse notes the child is acting
fussy, is warm and flushed, and has rhinorrhea. Which of the following is the nurse's
priority action?
A. Assess the child for additional symptoms of febrile illness.
B. Advise the parent that the immunization will need to be given at a later date
because the child has a fever.
C. Provide the child with cool fluids to reduce the fever and applying an anesthetic
cream to the injection site.
D. Notify the pediatrician and obtaining an order for an antipyretic.
5. The nurse is caring for a client who is ordered a clear liquid diet. Which of the following
items are permitted on this type of diet? Select all that apply.
i. Apple juice
ii. Chicken broth
iii. Gelatin
iv. Ice cream
v. Pudding
A. 1, 4
, B. 2, 3
C. 1, 2, 3
D. 3, 4, 5
6. The nurse has just completed administering a client's morning dosage of NPH insulin.
The client asks the nurse, "If my blood sugar is going to drop, when will it occur?"
Which of the following is the nurse's best response?
A. 2 to 4 hours after the administration of the insulin
B. 4 to 12 hours after the administration of the insulin
C. 16 to 18 hours after the administration of the insulin
D. 18 to 24 hours after the administration of the insulin
7. The nurse has received a report on a client with amyotrophic lateral sclerosis (ALS) who
is unable to move his upper arms but has gross motor function of his right hand. The
client is awake and alert. Which of the following actions is most appropriate to establish a
system of communication for this client?
A. Supply the client with the standard call bell on the right side of his body near his
hand.
B. Provide the client with a touch-sensor call-button that requires a light tap to
activate.
C. Round on the client every two hours to assess his status and see if he needs
anything.
D. Provide contact phone numbers on the communication board in the client's room
at his eye level.
, 8. The nurse is participating in the care of a client with end-stage renal failure. The
physician orders a palliative care consult because the client wishes no further medical
interventions. Which of the following should the nurse anticipate based on her knowledge
of palliative care?
A. Decreasing pain medication administration
B. Decreasing the amount of supplemental oxygen administered
C. Increasing oral and intravenous fluid amounts
D. Increasing the administration of anti-anxiety medications
9. Use the following to answer questions.
Nurse's Notes
1100: The client is readmitted to the hospital following aortic valve replacement with
repair of aortic aneurysm. His surgery was performed 3 weeks prior to his readmission.
He was discharged on post-op day 5. His course was uncomplicated, and he states he felt
well at home for about 10 days. He has just been admitted to the nursing unit. Starting
about 10 days after he got home, he developed chest discomfort that was constant but
worse with deep inspiration. He was not able to perform his incentive spirometry as well
as at the time of discharge. He states that his appetite and fluid intake have also declined.
The client also states he normally urinates at least 5 times/day and now only urinates 2-3
times/day. The urine is odorous and dark in color. He has a frequent, dry, unproductive
cough. For the past 5 days, he has noted increasing shortness of breath and inability to
walk very far without resting. On examination, the nurse notes that breath sounds are
clear but decreased bilaterally at bases. The nurse also notes that heart sounds are not
easily identified.
