NCLEX RN CORRECT EXAMS ANSWERS AND
QUESTIONS SET A+
✔✔The nurse is caring for a client with disseminated intravascular coagulation (DIC).
Which of the following statements by the client would be essential to follow up?
1."I prefer to receive my medication subcutaneously rather than intramuscularly."
2."I have been taking 1 aspirin every day since I had a myocardial infarction (MI) 1 year
ago."
3."I held pressure on the puncture site for 5 minutes after the nurse drew blood from my
arm."
4."I have avoided blowing my nose today because I have had 2 episodes of epistaxis." -
✔✔2."I have been taking 1 aspirin every day since I had a myocardial infarction (MI) 1
year ago."
✔✔The nurse is caring for a client who has just returned from the radiology department
after having an upper gastrointestinal (UGI) series. Which of the following actions
should the nurse take first?
1.Administer the prescribed enema.
2.Give the prescribed multiple vitamin that was withheld prior to the procedure.
3.Determine whether follow-up x-rays are to be taken.
4.Verify the preliminary test results. - ✔✔4.Verify the preliminary test results.
✔✔The nurse is talking with a client who has schizophrenia. The client states, "I just
returned from Mars." Which of the following responses would be appropriate for the
nurse to make?
1."I need to tell you that you cannot talk about silly things here."
2."Why do you think you made that trip?"
3."How does it feel to be back?"
4."I am here to listen to your concerns." - ✔✔4."I am here to listen to your concerns."
,✔✔The nurse is assisting to admit a client with active pulmonary tuberculosis (TB).
Which of the following actions should the nurse take prior to the client's arrival?
1.Assign the client to room with a client who has pertussis if a private room is not
available.
2.Have a particulate respirator mask available for client transport.
3.Have particulate respirator masks available for staff who care for the client.
4.Post a sign outside the room restricting pregnant women from entering the room. -
✔✔3.Have particulate respirator masks available for staff who care for the client.
✔✔The nurse is collecting data from an 85-year-old male client. Which of the following
statements would be essential to follow up?
1."I find that it takes longer to do tasks such as balancing my checkbook."
2."I feel some stomach discomfort after eating a large meal."
3."I have awakened from sleep because of shortness of breath."
4."I have a problem starting a strong stream of urine." - ✔✔3."I have awakened from
sleep because of shortness of breath."
✔✔The nurse is observing a coworker suctioning a client with a tracheostomy. The
nurse should intervene if the coworker
1.applies suction as the catheter is being withdrawn
2.wears a face shield throughout the procedure
3.applies suction for 10 seconds at each pass of the catheter
4.wears clean, nonsterile gloves throughout the procedure - ✔✔4.wears clean,
nonsterile gloves throughout the procedure
✔✔what to do when the patient has pertussis? - ✔✔Wear a surgical mask when
assisting the client to eat or giving medications
✔✔The nurse is talking with the parent of a 3-month-old client. The parent expresses
concern that the infant is unable to roll over. Which of the following would be an
appropriate response for the nurse to make?
1."We should inform your child's primary health care provider about this delay."
2."Most infants are able to roll over between the ages of 4 to 6 months."
3."Does your infant smile in response to your smile?"
4."Is your infant able to pick up objects?" - ✔✔2."Most infants are able to roll over
between the ages of 4 to 6 months."
✔✔The nurse is preparing to assist a client who has recently developed a visual
impairment to ambulate. To ensure the client's safety, it would be appropriate for the
nurse to
1.hold the client's hand while walking next to the client
, 2.place one hand on the client's shoulder and walk in front of the client
3.apply a gait belt around the client's waist and walk at the client's side
4. instruct the client to hold onto the nurse's upper arm while the nurse walks slightly
ahead of the client - ✔✔4. instruct the client to hold onto the nurse's upper arm while the
nurse walks slightly ahead of the client
✔✔The nurse is caring for a client who has a prescription for darbepoetin 0.45 mcg/kg,
subcutaneously. The client weighs 190 lb (86 kg). The nurse has 100 mcg/mL of
solution available. How many mL should the nurse administer with each dose? Record
your answer using one decimal place. - ✔✔0.45mcg/kg X x/86X ml/100 mcg = 0.38 or
0.4
✔✔The nurse is contributing to the plan of care for a client with multiple sclerosis (MS).
Which of the following should the nurse recommend be included?
1.encouraging the client to perform aerobic exercise several times daily
2.limiting the amount of time that the client spends in a hot environment
3.offering the client between-meal snacks that are high in vitamin C
4.keeping the client's legs elevated when sitting upright in a chair - ✔✔2.limiting the
amount of time that the client spends in a hot environment
✔✔The nurse is caring for a client with pneumococcal pneumonia. Which of the
following statements by the client would require follow-up?
1."I have four cats."
2."I stopped smoking four years ago."
3."I usually swim twice a week."
4."I live with my 89-year-old mother." - ✔✔4."I live with my 89-year-old mother."
✔✔The nurse is contributing to a staff development conference about informed consent
for surgery. Which of the following information should the nurse suggest including?
1."The nurse must be present when the surgeon explains the surgical procedure to the
client."
2."All minors require a parent's or guardian's consent for a surgical procedure."
3."Clients cannot withdraw consent once consent has been obtained."
4."The nurse may sign the consent form as a witness to the client's signature." -
✔✔2."All minors require a parent's or guardian's consent for a surgical procedure."
✔✔The nurse is observing a newly hired nurse administer a client's transdermal patch.
The nurse should intervene if the newly hired nurse is observed
1.instructing the client to avoid massaging the patch
2.cleansing the client's skin with soap and water after removing the old patch
3.initialing the patch and writing the date and time the patch was applied on the patch
QUESTIONS SET A+
✔✔The nurse is caring for a client with disseminated intravascular coagulation (DIC).
Which of the following statements by the client would be essential to follow up?
1."I prefer to receive my medication subcutaneously rather than intramuscularly."
2."I have been taking 1 aspirin every day since I had a myocardial infarction (MI) 1 year
ago."
3."I held pressure on the puncture site for 5 minutes after the nurse drew blood from my
arm."
4."I have avoided blowing my nose today because I have had 2 episodes of epistaxis." -
✔✔2."I have been taking 1 aspirin every day since I had a myocardial infarction (MI) 1
year ago."
✔✔The nurse is caring for a client who has just returned from the radiology department
after having an upper gastrointestinal (UGI) series. Which of the following actions
should the nurse take first?
1.Administer the prescribed enema.
2.Give the prescribed multiple vitamin that was withheld prior to the procedure.
3.Determine whether follow-up x-rays are to be taken.
4.Verify the preliminary test results. - ✔✔4.Verify the preliminary test results.
✔✔The nurse is talking with a client who has schizophrenia. The client states, "I just
returned from Mars." Which of the following responses would be appropriate for the
nurse to make?
1."I need to tell you that you cannot talk about silly things here."
2."Why do you think you made that trip?"
3."How does it feel to be back?"
4."I am here to listen to your concerns." - ✔✔4."I am here to listen to your concerns."
,✔✔The nurse is assisting to admit a client with active pulmonary tuberculosis (TB).
Which of the following actions should the nurse take prior to the client's arrival?
1.Assign the client to room with a client who has pertussis if a private room is not
available.
2.Have a particulate respirator mask available for client transport.
3.Have particulate respirator masks available for staff who care for the client.
4.Post a sign outside the room restricting pregnant women from entering the room. -
✔✔3.Have particulate respirator masks available for staff who care for the client.
✔✔The nurse is collecting data from an 85-year-old male client. Which of the following
statements would be essential to follow up?
1."I find that it takes longer to do tasks such as balancing my checkbook."
2."I feel some stomach discomfort after eating a large meal."
3."I have awakened from sleep because of shortness of breath."
4."I have a problem starting a strong stream of urine." - ✔✔3."I have awakened from
sleep because of shortness of breath."
✔✔The nurse is observing a coworker suctioning a client with a tracheostomy. The
nurse should intervene if the coworker
1.applies suction as the catheter is being withdrawn
2.wears a face shield throughout the procedure
3.applies suction for 10 seconds at each pass of the catheter
4.wears clean, nonsterile gloves throughout the procedure - ✔✔4.wears clean,
nonsterile gloves throughout the procedure
✔✔what to do when the patient has pertussis? - ✔✔Wear a surgical mask when
assisting the client to eat or giving medications
✔✔The nurse is talking with the parent of a 3-month-old client. The parent expresses
concern that the infant is unable to roll over. Which of the following would be an
appropriate response for the nurse to make?
1."We should inform your child's primary health care provider about this delay."
2."Most infants are able to roll over between the ages of 4 to 6 months."
3."Does your infant smile in response to your smile?"
4."Is your infant able to pick up objects?" - ✔✔2."Most infants are able to roll over
between the ages of 4 to 6 months."
✔✔The nurse is preparing to assist a client who has recently developed a visual
impairment to ambulate. To ensure the client's safety, it would be appropriate for the
nurse to
1.hold the client's hand while walking next to the client
, 2.place one hand on the client's shoulder and walk in front of the client
3.apply a gait belt around the client's waist and walk at the client's side
4. instruct the client to hold onto the nurse's upper arm while the nurse walks slightly
ahead of the client - ✔✔4. instruct the client to hold onto the nurse's upper arm while the
nurse walks slightly ahead of the client
✔✔The nurse is caring for a client who has a prescription for darbepoetin 0.45 mcg/kg,
subcutaneously. The client weighs 190 lb (86 kg). The nurse has 100 mcg/mL of
solution available. How many mL should the nurse administer with each dose? Record
your answer using one decimal place. - ✔✔0.45mcg/kg X x/86X ml/100 mcg = 0.38 or
0.4
✔✔The nurse is contributing to the plan of care for a client with multiple sclerosis (MS).
Which of the following should the nurse recommend be included?
1.encouraging the client to perform aerobic exercise several times daily
2.limiting the amount of time that the client spends in a hot environment
3.offering the client between-meal snacks that are high in vitamin C
4.keeping the client's legs elevated when sitting upright in a chair - ✔✔2.limiting the
amount of time that the client spends in a hot environment
✔✔The nurse is caring for a client with pneumococcal pneumonia. Which of the
following statements by the client would require follow-up?
1."I have four cats."
2."I stopped smoking four years ago."
3."I usually swim twice a week."
4."I live with my 89-year-old mother." - ✔✔4."I live with my 89-year-old mother."
✔✔The nurse is contributing to a staff development conference about informed consent
for surgery. Which of the following information should the nurse suggest including?
1."The nurse must be present when the surgeon explains the surgical procedure to the
client."
2."All minors require a parent's or guardian's consent for a surgical procedure."
3."Clients cannot withdraw consent once consent has been obtained."
4."The nurse may sign the consent form as a witness to the client's signature." -
✔✔2."All minors require a parent's or guardian's consent for a surgical procedure."
✔✔The nurse is observing a newly hired nurse administer a client's transdermal patch.
The nurse should intervene if the newly hired nurse is observed
1.instructing the client to avoid massaging the patch
2.cleansing the client's skin with soap and water after removing the old patch
3.initialing the patch and writing the date and time the patch was applied on the patch
