NCLEX NGN Pre-Test Questions
A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis
through an internal AV fistula in the RA. Which intervention should the nurse implement in caring
for the client? SATA
a. Assessing the radial pulse in the right extremity
b. Using the LA ti take BP readings
c. Drawing pre-dialysis blood specimens from the LA
d. Assessing the area over the AV fistula for a bruit and three each shift
e. Placing a pressure dressing over the site after each dialysis treatment
f. Administering IV fluids through the venous site of the AV fistula as needed - ANSA, B, C, D
A nurse is evaluating outcomes for a client with Guillain-Barre syndrome. Which outcome does
the nurse recognize as optimal respiratory outcomes for the client?
a. Normal deep tendon reflexes
b. Improved skeletal muscle tone
c. Absences of paresthesias in the lower extremities
d. Clear sound in the lower lung fields bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg - ANSD, E
A nurse of the telemetry unit is caring for a client who has had a MI and is now attached to a
cardiac monitor. The nurse is monitoring the client's cardiac rhythm and nots ventricular
fibrillation. Which nursing intervention should the nurse take first?
a. Calling the rapid response team
b. Preparing the client for cardioversion
c. Asking the client to bear down and cough
d. Preparing to administer diltiazem - ANSA
The pattern of ventricular fibrillation is identified and can be a result after a patient with an MI.
VF makes the patient feel faint, then loses consciousness and becomes pulseless and apneic
(BP and heart sounds absent). Treatment is to terminate VF and covert it into a rhythm via
defibrillation-> call a rapid and initiate CPR. Cardioversion is used for ventricular or
supraventricular tachydysrhythmias.
A nurse developing a plan of care for a client with a spinal cord injury includes measures to
prevent autonomic dysreflexia (hyperreflexia). Which intervention does the nurse incorporate
into the plan to prevent this complication?
a. Keeping the fan running in the client's room
b. Keeping the linens wrinkle free under the client
c. Limiting bladder catheterization to once every 12 hours
d. Avoiding the administration of enemas and rectal suppositories - ANSB
,The most frequent cause of autonomic dysreflexias are a distended bladder and impacted
feces. Other causes include stimulation of the skin by tactile, thermal, or painful stimuli. The
nurse renders care in such a way as to minimize these risks.
A nurse provides home care instructions to a client who has been fitted with a halo device to
treat a cervical fracture. Which statement by the client indicates the need for further teaching?
a. I need to get more fluids and fiber into my diet
b. I should cut my food into small pieces before I eat
c. I need to put powder under the vest twice a day to prevent sweating
d. I have to check the pin sites everyday and watch for signs of infection - ANSC
Cleanse the skin under the wool liner each day to prevent rashes and soars.
A nurse is caring for a client with increased intracranial pressure. In which position should the
nurse maintain the client?
a. Supine with the head extended
b. Side lying with the neck flexed
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees - ANSD
Proper positioning promotes venous drainage from the cranium to minimize ICP.
A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should take
which action first?
a. Asses the clear fluid for protein
b. Check the clear fluid for glucose
c. Place cotton calls or dry gauze loosely in the ears
d. Use an otoscope to assess the tympanic membrane for rupture - ANSB
CSF contains glucose not protein.
A nurse is caring for a client who has just undergone cardioversion. Which intervention is the
nurse's priority after this procedure.
a. Administer oxygen
b. Monitoring the BP
c. Administering antidysrhythmic medications
d. Monitoring the client's LOC - ANSA
ABC's of nursing. All other choices are correct, but not priority.
A client with diabetes mellitus who is scheduled to have blood drawn for determination of the
glycosylated hemoglobin (HbA1c) level asks the nurse why the test is necessary if he is
performing blood glucose monitoring at home. Which is the best response for the nurse to
provide?
a. Detect diabetic complications
b. Assess long-term glycemic control
c. Determine whether the client is at risk for hypoglycemia
d Determine whether the prescribed insulin dosage is correct - ANSB
, A nurse caring for a client with acquired immunodeficiency syndrome is monitoring the client for
signs of complications. Which of the following would cause the nurse to suspect infection with
Pneumocystis jirovec? SATA
a. Diarrhea
b. Tachypnea
c. Pedal edema
d. Intermittent fever
e. Dyspnea with ambulating
f. Expectoration of frothy mucus - ANSB, D, E
A opportunistic respiratory infection associated with AIDs that causes dyspnea, nonproductive
cough, intermittent fever, fatigue, anorexia, tachypnea, wt. loss.
Zidovudine is prescribed for a client with AIDS. The nurse tells the client that it is important to
report back to the clinic as scheduled for which follow-up diagnostic?
a. Blood glucose checks
b. Blood pressure checks
c. Complete blood counts (CBC)
d. Electrocradiographic studies - ANSC
Zidovudine is an antiviral medication that cause cause agranulocytosis and anemia.
After a non-immunocompromised client undergoes a Mantoux test for TB infection, an area of
induration 6 mm wide developed. The client asks the nurse what this result means. Which is the
best response?
a. We'll have to repeat the test because the result was inconclusive
b. The swollen area is small, so that means your test result is negative
c. You've been exposed to TB so you will need to have a chest x-ray
d. You need to get started on medication right away because you have TB - ANSB
Indurations less than 10 mm (non-immunocompromised) and 5 mm (immunocompromised) is
considered a negative result after 48-72 hrs. Results greater indicate exposure and possible TB
infection. Morse testing (x-ray) will be needed.
A clients arterial blood gases are analyzed; pH 1.49, paO2 97 mmHg, HCO3- 22 mEq/L. Which
acid base balance disturbance does the nurse identify from these results?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis - ANSD
RAcidosis: paCo2 >45 mmHg and RAlkalosis is paCo2 <35 mmHg. MAcidosis is HCO3- is less
than 22 mEq/L and MAlkalosis is HCO3- greater than 26 mEq/L.
A client has recently been diagnosed with deep vein thrombosis of the right leg. Which of the
following interventions of the nurse immediately implement?
a. Elevating the foot of the bed 6 inches
A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis
through an internal AV fistula in the RA. Which intervention should the nurse implement in caring
for the client? SATA
a. Assessing the radial pulse in the right extremity
b. Using the LA ti take BP readings
c. Drawing pre-dialysis blood specimens from the LA
d. Assessing the area over the AV fistula for a bruit and three each shift
e. Placing a pressure dressing over the site after each dialysis treatment
f. Administering IV fluids through the venous site of the AV fistula as needed - ANSA, B, C, D
A nurse is evaluating outcomes for a client with Guillain-Barre syndrome. Which outcome does
the nurse recognize as optimal respiratory outcomes for the client?
a. Normal deep tendon reflexes
b. Improved skeletal muscle tone
c. Absences of paresthesias in the lower extremities
d. Clear sound in the lower lung fields bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg - ANSD, E
A nurse of the telemetry unit is caring for a client who has had a MI and is now attached to a
cardiac monitor. The nurse is monitoring the client's cardiac rhythm and nots ventricular
fibrillation. Which nursing intervention should the nurse take first?
a. Calling the rapid response team
b. Preparing the client for cardioversion
c. Asking the client to bear down and cough
d. Preparing to administer diltiazem - ANSA
The pattern of ventricular fibrillation is identified and can be a result after a patient with an MI.
VF makes the patient feel faint, then loses consciousness and becomes pulseless and apneic
(BP and heart sounds absent). Treatment is to terminate VF and covert it into a rhythm via
defibrillation-> call a rapid and initiate CPR. Cardioversion is used for ventricular or
supraventricular tachydysrhythmias.
A nurse developing a plan of care for a client with a spinal cord injury includes measures to
prevent autonomic dysreflexia (hyperreflexia). Which intervention does the nurse incorporate
into the plan to prevent this complication?
a. Keeping the fan running in the client's room
b. Keeping the linens wrinkle free under the client
c. Limiting bladder catheterization to once every 12 hours
d. Avoiding the administration of enemas and rectal suppositories - ANSB
,The most frequent cause of autonomic dysreflexias are a distended bladder and impacted
feces. Other causes include stimulation of the skin by tactile, thermal, or painful stimuli. The
nurse renders care in such a way as to minimize these risks.
A nurse provides home care instructions to a client who has been fitted with a halo device to
treat a cervical fracture. Which statement by the client indicates the need for further teaching?
a. I need to get more fluids and fiber into my diet
b. I should cut my food into small pieces before I eat
c. I need to put powder under the vest twice a day to prevent sweating
d. I have to check the pin sites everyday and watch for signs of infection - ANSC
Cleanse the skin under the wool liner each day to prevent rashes and soars.
A nurse is caring for a client with increased intracranial pressure. In which position should the
nurse maintain the client?
a. Supine with the head extended
b. Side lying with the neck flexed
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees - ANSD
Proper positioning promotes venous drainage from the cranium to minimize ICP.
A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should take
which action first?
a. Asses the clear fluid for protein
b. Check the clear fluid for glucose
c. Place cotton calls or dry gauze loosely in the ears
d. Use an otoscope to assess the tympanic membrane for rupture - ANSB
CSF contains glucose not protein.
A nurse is caring for a client who has just undergone cardioversion. Which intervention is the
nurse's priority after this procedure.
a. Administer oxygen
b. Monitoring the BP
c. Administering antidysrhythmic medications
d. Monitoring the client's LOC - ANSA
ABC's of nursing. All other choices are correct, but not priority.
A client with diabetes mellitus who is scheduled to have blood drawn for determination of the
glycosylated hemoglobin (HbA1c) level asks the nurse why the test is necessary if he is
performing blood glucose monitoring at home. Which is the best response for the nurse to
provide?
a. Detect diabetic complications
b. Assess long-term glycemic control
c. Determine whether the client is at risk for hypoglycemia
d Determine whether the prescribed insulin dosage is correct - ANSB
, A nurse caring for a client with acquired immunodeficiency syndrome is monitoring the client for
signs of complications. Which of the following would cause the nurse to suspect infection with
Pneumocystis jirovec? SATA
a. Diarrhea
b. Tachypnea
c. Pedal edema
d. Intermittent fever
e. Dyspnea with ambulating
f. Expectoration of frothy mucus - ANSB, D, E
A opportunistic respiratory infection associated with AIDs that causes dyspnea, nonproductive
cough, intermittent fever, fatigue, anorexia, tachypnea, wt. loss.
Zidovudine is prescribed for a client with AIDS. The nurse tells the client that it is important to
report back to the clinic as scheduled for which follow-up diagnostic?
a. Blood glucose checks
b. Blood pressure checks
c. Complete blood counts (CBC)
d. Electrocradiographic studies - ANSC
Zidovudine is an antiviral medication that cause cause agranulocytosis and anemia.
After a non-immunocompromised client undergoes a Mantoux test for TB infection, an area of
induration 6 mm wide developed. The client asks the nurse what this result means. Which is the
best response?
a. We'll have to repeat the test because the result was inconclusive
b. The swollen area is small, so that means your test result is negative
c. You've been exposed to TB so you will need to have a chest x-ray
d. You need to get started on medication right away because you have TB - ANSB
Indurations less than 10 mm (non-immunocompromised) and 5 mm (immunocompromised) is
considered a negative result after 48-72 hrs. Results greater indicate exposure and possible TB
infection. Morse testing (x-ray) will be needed.
A clients arterial blood gases are analyzed; pH 1.49, paO2 97 mmHg, HCO3- 22 mEq/L. Which
acid base balance disturbance does the nurse identify from these results?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis - ANSD
RAcidosis: paCo2 >45 mmHg and RAlkalosis is paCo2 <35 mmHg. MAcidosis is HCO3- is less
than 22 mEq/L and MAlkalosis is HCO3- greater than 26 mEq/L.
A client has recently been diagnosed with deep vein thrombosis of the right leg. Which of the
following interventions of the nurse immediately implement?
a. Elevating the foot of the bed 6 inches
