NCLEX RN TEST EVALUATION ANSWERS AND
QUESTIONS SET A+
✔✔The charge nurse in a long-term care facility has made client care assignments for
unlicensed assistive personnel (UAP). Which of the following statements by the charge
nurse would provide the best information to a UAP about the assignment?
1."The client needs assistance to get out of bed."
2."The client needs to have food cut into bite-sized pieces."
3."The client needs range-of-motion (ROM) exercises every 4 hours."
4."The client needs frequent perineal care." - ✔✔2."The client needs to have food cut
into bite-sized pieces."
✔✔The nurse is collecting data from a client with right-sided heart failure. Which of the
following findings would be consistent with right-sided heart failure? Select all that
apply.
1.edema
2.dyspnea
3.dry cough
4.weight gain
5.jugular vein distention (JVD) - ✔✔1.edema
2.dyspnea
✔✔The nurse has reinforced teaching with a client who is receiving prescribed
vardenafil. Which of the following statements by the client would indicate a correct
understanding of the teaching? Select all that apply.
1."I will take the medication one hour before I engage in sexual activity."
2."I may experience a headache and facial flushing."
3."I can continue to take prescribed isosorbide mononitrate."
4."I should notify my primary health care provider if I have pain in my jaw."
5."I can take an additional dose of the medication if I do not experience the desired
effects within three hours." - ✔✔1,
,✔✔The charge nurse in a long-term care facility has made client care assignments for
unlicensed assistive personnel (UAP). Which of the following statements by the charge
nurse would provide the best directions to a UAP about the assignment?
1."The client with a urinary tract infection (UTI) should drink two pitchers of water this
shift."
2."The client with mild dementia needs assistance with bathing."
3."The client who had a stroke needs to ambulate in the hallway."
4."The client with peripheral neuropathy should receive good skin care." - ✔✔2."The
client with mild dementia needs assistance with bathing."
✔✔The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients.
Which of the following activities would be appropriate for the nurse to assign to a UAP?
1.removing a condom catheter for the male client who has a fractured pelvis
2.providing discharge teaching to the client with chronic obstructive pulmonary disease
(COPD)
3.evaluating the pain level for the client who had an abdominal hysterectomy several
hours ago
4.determining the effectiveness of an antianxiety medication for the client with moderate
Alzheimer's disease (AD) - ✔✔1.removing a condom catheter for the male client who
has a fractured pelvis
✔✔The nurse is assisting with the admission of a client who is scheduled for a colon
resection. Which of the following statements made by the client would be most
important for the nurse to clarify?
1."I take acetaminophen for occasional headaches."
2."I had successful cataract surgery two years ago."
3."I usually have a few glasses of wine in the evening."
4."I have urinary incontinence when I sneeze." - ✔✔3."I usually have a few glasses of
wine in the evening."
✔✔The nurse is reinforcing discharge instructions with a client taking prescribed
isosorbide dinitrate. The nurse should reinforce that the client should avoid
1.exposure to sunlight
2.sudden position changes
3.vigorous exercise
4.taking antacids - ✔✔2.sudden position changes
✔✔When collecting data on a 4-month-old client with gastroenteritis, the nurse
observes an irregular area of dark blue pigmentation on the client's sacral area. The
nurse should first
1.determine whether this finding is normal for an infant of the client's racial background
2.ask the client's parent whether the child has shown any tendency toward bleeding
3.report the finding to the charge nurse as evidence of possible child abuse
4.apply gentle pressure to the area to check for tenderness - ✔✔1.determine whether
this finding is normal for an infant of the client's racial background
, ✔✔The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients.
Which of the following activities would be appropriate to assign to UAP? Select all that
apply.
1.bathing the client who has an altered mental status
2.assisting the client who uses a walker to ambulate
3.checking the vital signs of the client who has a peripheral venous access device
(VAD)
4.adjusting the prescribed oxygen flow rate for the client based on oxygen saturation
levels
5.measuring the oral intake and urine output for the client who has an indwelling
urethral catheter - ✔✔2.assisting the client who uses a walker to ambulate
✔✔The nurse is reinforcing teaching about sleep and rest at home for a client who had
a vaginal delivery 24 hours ago. Which of the following information should the nurse
reinforce?
1."Take a nap when your baby is sleeping."
2."Perform all of your household chores in the morning, when you have more energy."
3."Wake up and go to sleep at the same time every day."
4."On the weekend, plan and prepare all meals for the week to prevent fatigue." -
✔✔1."Take a nap when your baby is sleeping."
✔✔The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients.
Which of the following activities would be appropriate for the nurse to assign to UAP?
1.obtaining vital signs from the client with major depression
2.providing medication teaching to the client with schizophrenia
3.monitoring medication side effects of the client with bipolar I disorder
4.telephoning the primary health care provider to report the intake and output
information from the client with anorexia nervosa (AN) - ✔✔1.obtaining vital signs from
the client with major depression
✔✔The nurse is preparing to administer prescribed regular insulin to a client. Which of
the following routes should the nurse understand can be used to administer regular
insulin? Select all that apply.
1.subcutaneous
2.oral
3.intravenous
4.intramuscular
5.intradermal - ✔✔1,3
✔✔The nurse is talking with the spouse of a client who has malignant melanoma and is
terminally ill. Which of the following statements by the spouse would be essential to
follow up?
1."I give my spouse the prescribed pain medication regularly even though the
medication causes my spouse to become drowsy."
QUESTIONS SET A+
✔✔The charge nurse in a long-term care facility has made client care assignments for
unlicensed assistive personnel (UAP). Which of the following statements by the charge
nurse would provide the best information to a UAP about the assignment?
1."The client needs assistance to get out of bed."
2."The client needs to have food cut into bite-sized pieces."
3."The client needs range-of-motion (ROM) exercises every 4 hours."
4."The client needs frequent perineal care." - ✔✔2."The client needs to have food cut
into bite-sized pieces."
✔✔The nurse is collecting data from a client with right-sided heart failure. Which of the
following findings would be consistent with right-sided heart failure? Select all that
apply.
1.edema
2.dyspnea
3.dry cough
4.weight gain
5.jugular vein distention (JVD) - ✔✔1.edema
2.dyspnea
✔✔The nurse has reinforced teaching with a client who is receiving prescribed
vardenafil. Which of the following statements by the client would indicate a correct
understanding of the teaching? Select all that apply.
1."I will take the medication one hour before I engage in sexual activity."
2."I may experience a headache and facial flushing."
3."I can continue to take prescribed isosorbide mononitrate."
4."I should notify my primary health care provider if I have pain in my jaw."
5."I can take an additional dose of the medication if I do not experience the desired
effects within three hours." - ✔✔1,
,✔✔The charge nurse in a long-term care facility has made client care assignments for
unlicensed assistive personnel (UAP). Which of the following statements by the charge
nurse would provide the best directions to a UAP about the assignment?
1."The client with a urinary tract infection (UTI) should drink two pitchers of water this
shift."
2."The client with mild dementia needs assistance with bathing."
3."The client who had a stroke needs to ambulate in the hallway."
4."The client with peripheral neuropathy should receive good skin care." - ✔✔2."The
client with mild dementia needs assistance with bathing."
✔✔The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients.
Which of the following activities would be appropriate for the nurse to assign to a UAP?
1.removing a condom catheter for the male client who has a fractured pelvis
2.providing discharge teaching to the client with chronic obstructive pulmonary disease
(COPD)
3.evaluating the pain level for the client who had an abdominal hysterectomy several
hours ago
4.determining the effectiveness of an antianxiety medication for the client with moderate
Alzheimer's disease (AD) - ✔✔1.removing a condom catheter for the male client who
has a fractured pelvis
✔✔The nurse is assisting with the admission of a client who is scheduled for a colon
resection. Which of the following statements made by the client would be most
important for the nurse to clarify?
1."I take acetaminophen for occasional headaches."
2."I had successful cataract surgery two years ago."
3."I usually have a few glasses of wine in the evening."
4."I have urinary incontinence when I sneeze." - ✔✔3."I usually have a few glasses of
wine in the evening."
✔✔The nurse is reinforcing discharge instructions with a client taking prescribed
isosorbide dinitrate. The nurse should reinforce that the client should avoid
1.exposure to sunlight
2.sudden position changes
3.vigorous exercise
4.taking antacids - ✔✔2.sudden position changes
✔✔When collecting data on a 4-month-old client with gastroenteritis, the nurse
observes an irregular area of dark blue pigmentation on the client's sacral area. The
nurse should first
1.determine whether this finding is normal for an infant of the client's racial background
2.ask the client's parent whether the child has shown any tendency toward bleeding
3.report the finding to the charge nurse as evidence of possible child abuse
4.apply gentle pressure to the area to check for tenderness - ✔✔1.determine whether
this finding is normal for an infant of the client's racial background
, ✔✔The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients.
Which of the following activities would be appropriate to assign to UAP? Select all that
apply.
1.bathing the client who has an altered mental status
2.assisting the client who uses a walker to ambulate
3.checking the vital signs of the client who has a peripheral venous access device
(VAD)
4.adjusting the prescribed oxygen flow rate for the client based on oxygen saturation
levels
5.measuring the oral intake and urine output for the client who has an indwelling
urethral catheter - ✔✔2.assisting the client who uses a walker to ambulate
✔✔The nurse is reinforcing teaching about sleep and rest at home for a client who had
a vaginal delivery 24 hours ago. Which of the following information should the nurse
reinforce?
1."Take a nap when your baby is sleeping."
2."Perform all of your household chores in the morning, when you have more energy."
3."Wake up and go to sleep at the same time every day."
4."On the weekend, plan and prepare all meals for the week to prevent fatigue." -
✔✔1."Take a nap when your baby is sleeping."
✔✔The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients.
Which of the following activities would be appropriate for the nurse to assign to UAP?
1.obtaining vital signs from the client with major depression
2.providing medication teaching to the client with schizophrenia
3.monitoring medication side effects of the client with bipolar I disorder
4.telephoning the primary health care provider to report the intake and output
information from the client with anorexia nervosa (AN) - ✔✔1.obtaining vital signs from
the client with major depression
✔✔The nurse is preparing to administer prescribed regular insulin to a client. Which of
the following routes should the nurse understand can be used to administer regular
insulin? Select all that apply.
1.subcutaneous
2.oral
3.intravenous
4.intramuscular
5.intradermal - ✔✔1,3
✔✔The nurse is talking with the spouse of a client who has malignant melanoma and is
terminally ill. Which of the following statements by the spouse would be essential to
follow up?
1."I give my spouse the prescribed pain medication regularly even though the
medication causes my spouse to become drowsy."
