NCLEX RN PAPER LATEST ANSWERS AND
QUESTIONS SET A+
✔✔The nurse is contributing to the plan of care for a client who sustained a spinal cord
injury at T1 five days ago. Which of the following interventions should the nurse
recommend including in the client's plan of care?
1.Limit the client's fluid intake to one liter daily.
2.Encourage the client to increase the intake of foods high in carbohydrates.
3.Request a prescription for a stool softener to be administered to the client daily.
4.Perform lower extremity passive range-of-motion (ROM) exercises for the client once
daily. - ✔✔3.Request a prescription for a stool softener to be administered to the client
daily.
✔✔The nurse is checking a client with disseminated herpes zoster (shingles) who is in a
private room. The nurse should understand the client may be developing sensory
isolation if the client reports the onset of
1.photophobia
2.headaches
3.anxiety
4.tremors - ✔✔1.photophobia
✔✔A client is admitted with severe pain in the left lower extremity. The client is
scheduled for a complete blood count (CBC), urinalysis, chest x-ray, and x-ray of the
lower extremities. The client asks the nurse, "Why do I have to have all these tests? The
pain is in my leg." Which of the following responses by the nurse will best help the client
deal with feelings of anxiety?
1."The tests will not take long to complete."
2."These tests are part of the admission procedure."
3."It must be difficult not understanding what is happening to you."
4."Perhaps that is something you need to discuss with your physician." - ✔✔3."It must
be difficult not understanding what is happening to you."
,✔✔The nurse is reinforcing teaching with a client who is at risk for coronary artery
disease (CAD). Which of the following information should the nurse reinforce? Select all
that apply.
1."Exercising once a week will decrease the risk for CAD."
2."You should maintain a body mass index (BMI) of less than 25."
3."You may continue to consume alcoholic beverages as you desire."
4."You should avoid exposure to environmental tobacco smoke."
5."A diet high in fruits, vegetables and unsaturated fats will decrease your risk for CAD."
- ✔✔1,2,5
✔✔The nurse is reinforcing teaching with a client who is receiving prescribed insulin
glargine. Which of the following information should the nurse reinforce?
1.After administering the insulin glargine the same syringe can be used to administer
regular insulin.
2.Extra vials of insulin glargine that have not been opened can be stored in the freezer.
3.Insulin glargine does not have a peak action time.
4.Insulin glargine should be administered 3 times each day 15 minutes before meals. -
✔✔3.Insulin glargine does not have a peak action time.
✔✔The nurse is preparing to insert an indwelling urethral catheter for an assigned
client. Which of the following statements by the client would be a priority to follow up?
1."I have had a catheter before and felt pressure when the catheter was placed."
2."I developed a rash on my neck when I ate shrimp several months ago."
3."I just urinated so I won't need a catheter placed."
4."I haven't been drinking many fluids lately." - ✔✔2."I developed a rash on my neck
when I ate shrimp several months ago."
✔✔The nurse in a rehabilitation facility is caring for a client who had a right knee
arthroplasty 8 days ago and has been diagnosed with pneumonia. The client is being
transferred to an acute care facility. It would be essential for the nurse to communicate
in the transfer report that
1.the discharge to home is anticipated for the client after 1 more week of physical
therapy
2.the client lives in a ranch home that requires climbing 2 stairs to get into the house
3.the most recent focused data collection reveals bilateral crackles (rales) auscultated in
the client's lungs
4.the client's spouse will be visiting the client at the hospital later today after leaving
work - ✔✔2.the client lives in a ranch home that requires climbing 2 stairs to get into the
house
✔✔The nurse is measuring a client for crutches. Which of the following actions should
the nurse take?
1.Measure the client's height and subtract 8 in (20 cm) to obtain the correct crutch
length.
, 2.Ask the client to stand upright and position the shoulder rest of the crutch 6 in (15 cm)
below the axilla.
3.Adjust the crutches so the client's elbows are at a 30-degree angle while the client's
hands are resting on the hand grips.
4.Measure from the anterior fold of the axillae to the toes of the client's feet and add 1 in
(2.5 cm) while the client is in a supine position. - ✔✔3.Adjust the crutches so the client's
elbows are at a 30-degree angle while the client's hands are resting on the hand grips.
✔✔The nurse is contributing to the plan of care for a client with gestational hypertension
who is at 32 weeks gestation. Which of the following should the nurse recommend be
included in the plan of care?
1.monitoring the client's urinary output
2.instructing the client to report any increase in fetal activity
3.instructing the client to use relaxation techniques to relieve a headache
4.minimizing the client's dietary intake of high-calcium foods - ✔✔1.monitoring the
client's urinary output
✔✔The nurse is collecting data from a client who has hypovolemic shock. Which of the
following findings would be consistent with hypovolemic shock? Select all that apply.
1.confusion
2.hypertension
3.decreased urine output
4.elevated respiratory rate
5.jugular vein distention (JVD) - ✔✔1,3,4
✔✔The nurse is collecting data from a client who had a kidney transplant 5 days ago.
Which of the following findings would require immediate intervention?
1.blood pressure, 154/96 mm Hg
2.blood urea nitrogen (BUN), 20 mg/dL (7.1 mmol/L)
3.urine output of 120 mL in the past 4 hours
4.incisional pain rated 5 on a scale of 0 (no pain) to 10 (severe pain) - ✔✔3
✔✔The charge nurse in a long-term care facility has just completed client care
assignments for unlicensed assistive personnel (UAP). Which of the following
statements by the charge nurse would provide the best direction to a UAP about the
assignment?
1."The client with heart failure should be weighed and have vital signs checked before
breakfast is served."
2."You will need to assist the client with mild Alzheimer's disease (AD) with activities of
daily living (ADL)."
3."You need to follow proper infection control precautions when assisting the client with
active pulmonary tuberculosis (TB)."
4."The client with paraplegia should have the monthly safety check completed on the
wheelchair." - ✔✔2."You will need to assist the client with mild Alzheimer's disease (AD)
with activities of daily living (ADL)."
QUESTIONS SET A+
✔✔The nurse is contributing to the plan of care for a client who sustained a spinal cord
injury at T1 five days ago. Which of the following interventions should the nurse
recommend including in the client's plan of care?
1.Limit the client's fluid intake to one liter daily.
2.Encourage the client to increase the intake of foods high in carbohydrates.
3.Request a prescription for a stool softener to be administered to the client daily.
4.Perform lower extremity passive range-of-motion (ROM) exercises for the client once
daily. - ✔✔3.Request a prescription for a stool softener to be administered to the client
daily.
✔✔The nurse is checking a client with disseminated herpes zoster (shingles) who is in a
private room. The nurse should understand the client may be developing sensory
isolation if the client reports the onset of
1.photophobia
2.headaches
3.anxiety
4.tremors - ✔✔1.photophobia
✔✔A client is admitted with severe pain in the left lower extremity. The client is
scheduled for a complete blood count (CBC), urinalysis, chest x-ray, and x-ray of the
lower extremities. The client asks the nurse, "Why do I have to have all these tests? The
pain is in my leg." Which of the following responses by the nurse will best help the client
deal with feelings of anxiety?
1."The tests will not take long to complete."
2."These tests are part of the admission procedure."
3."It must be difficult not understanding what is happening to you."
4."Perhaps that is something you need to discuss with your physician." - ✔✔3."It must
be difficult not understanding what is happening to you."
,✔✔The nurse is reinforcing teaching with a client who is at risk for coronary artery
disease (CAD). Which of the following information should the nurse reinforce? Select all
that apply.
1."Exercising once a week will decrease the risk for CAD."
2."You should maintain a body mass index (BMI) of less than 25."
3."You may continue to consume alcoholic beverages as you desire."
4."You should avoid exposure to environmental tobacco smoke."
5."A diet high in fruits, vegetables and unsaturated fats will decrease your risk for CAD."
- ✔✔1,2,5
✔✔The nurse is reinforcing teaching with a client who is receiving prescribed insulin
glargine. Which of the following information should the nurse reinforce?
1.After administering the insulin glargine the same syringe can be used to administer
regular insulin.
2.Extra vials of insulin glargine that have not been opened can be stored in the freezer.
3.Insulin glargine does not have a peak action time.
4.Insulin glargine should be administered 3 times each day 15 minutes before meals. -
✔✔3.Insulin glargine does not have a peak action time.
✔✔The nurse is preparing to insert an indwelling urethral catheter for an assigned
client. Which of the following statements by the client would be a priority to follow up?
1."I have had a catheter before and felt pressure when the catheter was placed."
2."I developed a rash on my neck when I ate shrimp several months ago."
3."I just urinated so I won't need a catheter placed."
4."I haven't been drinking many fluids lately." - ✔✔2."I developed a rash on my neck
when I ate shrimp several months ago."
✔✔The nurse in a rehabilitation facility is caring for a client who had a right knee
arthroplasty 8 days ago and has been diagnosed with pneumonia. The client is being
transferred to an acute care facility. It would be essential for the nurse to communicate
in the transfer report that
1.the discharge to home is anticipated for the client after 1 more week of physical
therapy
2.the client lives in a ranch home that requires climbing 2 stairs to get into the house
3.the most recent focused data collection reveals bilateral crackles (rales) auscultated in
the client's lungs
4.the client's spouse will be visiting the client at the hospital later today after leaving
work - ✔✔2.the client lives in a ranch home that requires climbing 2 stairs to get into the
house
✔✔The nurse is measuring a client for crutches. Which of the following actions should
the nurse take?
1.Measure the client's height and subtract 8 in (20 cm) to obtain the correct crutch
length.
, 2.Ask the client to stand upright and position the shoulder rest of the crutch 6 in (15 cm)
below the axilla.
3.Adjust the crutches so the client's elbows are at a 30-degree angle while the client's
hands are resting on the hand grips.
4.Measure from the anterior fold of the axillae to the toes of the client's feet and add 1 in
(2.5 cm) while the client is in a supine position. - ✔✔3.Adjust the crutches so the client's
elbows are at a 30-degree angle while the client's hands are resting on the hand grips.
✔✔The nurse is contributing to the plan of care for a client with gestational hypertension
who is at 32 weeks gestation. Which of the following should the nurse recommend be
included in the plan of care?
1.monitoring the client's urinary output
2.instructing the client to report any increase in fetal activity
3.instructing the client to use relaxation techniques to relieve a headache
4.minimizing the client's dietary intake of high-calcium foods - ✔✔1.monitoring the
client's urinary output
✔✔The nurse is collecting data from a client who has hypovolemic shock. Which of the
following findings would be consistent with hypovolemic shock? Select all that apply.
1.confusion
2.hypertension
3.decreased urine output
4.elevated respiratory rate
5.jugular vein distention (JVD) - ✔✔1,3,4
✔✔The nurse is collecting data from a client who had a kidney transplant 5 days ago.
Which of the following findings would require immediate intervention?
1.blood pressure, 154/96 mm Hg
2.blood urea nitrogen (BUN), 20 mg/dL (7.1 mmol/L)
3.urine output of 120 mL in the past 4 hours
4.incisional pain rated 5 on a scale of 0 (no pain) to 10 (severe pain) - ✔✔3
✔✔The charge nurse in a long-term care facility has just completed client care
assignments for unlicensed assistive personnel (UAP). Which of the following
statements by the charge nurse would provide the best direction to a UAP about the
assignment?
1."The client with heart failure should be weighed and have vital signs checked before
breakfast is served."
2."You will need to assist the client with mild Alzheimer's disease (AD) with activities of
daily living (ADL)."
3."You need to follow proper infection control precautions when assisting the client with
active pulmonary tuberculosis (TB)."
4."The client with paraplegia should have the monthly safety check completed on the
wheelchair." - ✔✔2."You will need to assist the client with mild Alzheimer's disease (AD)
with activities of daily living (ADL)."
