NCLEX 2024 STUDY GUIDE NEW LATEST VERSION
QUESTIONS WITH CORRECT ANSWERS WITH
RATIONALE GRADED A+
Which of the following clients should the nurse INVESTIGATE further for
potential child abuse?
A. 1 year old client who has bright red cheeks and a raised, bumpy rash
bilaterally on the arms and legs
B. A 5 month old client who has influenza and a 4 cm bluish-gray
asymmetrical marking on the left buttocks
C. A 10 year old client who has scratched shins and a clavicle fracture and
reports falling while skateboarding
D. A 7 month old client with palm burns whose caregiver says the client
climbed up the sink and grabbed a hot iron - correct answer✔✔D. A 7
month old client with palm burns whose caregiver says the client climbed
up the sink and grabbed a hot iron
The nurse is carting for a 8kg, 1 year old client who underwent a complete
cardiac repair for tetralogy of pallor 8 hours ago.
Which of the following findings would REQUIRE IMMEDIATE follow-up?
Select all that apply
A. 1+ radial and femoral pulses
B. Temperature of 100 F (37.7 C)
C. Urine output of 5 mL in the last hour
D. Pinkish-tan colored chest tube drainage
E. Chest tube drainage of 19 mL in one hour
F. Median sternotomy dressing has 2 mL of dried blood. - correct
answer✔✔A. 1+ radial and femoral pulses
C. Urine output of 5 mL in the last hour
explanation: TETRALOGY IS a combination of four congenital (present at
birth) heart defects.
,The defects occur together and change the way blood flows through the
heart and lungs.
The nurse discusses developmental milestones with the caregivers pod
several clients.
Which finding REPORTED by a caregiver REQUIRES follow-up by the
nurse?
A. A 19 month old who often falls while running through the house
B. A 22 month old who can say 4 words including "mom" and "more"
C. An 18 month old who is able to build a tower containing 3 wooden
blocks
D. A 24-month who plays with a doll bedside a friend without asking the
friend to play - correct answer✔✔B. A 22 month old who can say 4 words
including "mom" and "more"
The nurses is caring for an 8-month old client diagnosed with pertussis.
Which of the following INTERCEPTIONS should the nurse ANTICIPATE
implementing? Select all that apply.
A. Initiating droplet precautions
B. Providing humidified oxygen
C. Administering a bronchodilator
D. Providing suctioning as needed
E. Administering antiviral medications
F. Encouraging frequent, small feedings - correct answer✔✔A. Initiating
droplet precautions
B. Providing humidified oxygen
D. Providing suctioning as needed
F. Encouraging frequent, small feedings
Ex:
Pertussis (whooping cough) is a highly contagious bacterial upper
respiratory infection that causes coughing spells filled by sharp inhalation
that creates a
,The experienced pediatric intensive care registered nurse is preempting a
newly licensed registered nurse who received repot on 4 clients.
Which of the following ACTIONS taken by the new nurse REQUIRES the
experienced nurse to intervene?
A. Placing a client with varicella in a negative pressure isolation room.
B. Performing oropharyngeal suctioning on a drooling client with croup.
C. Placing an infant in prone position following myelomeningocele repair.
D, Drawing up insulin lisper before NPH insulin in the same syringe for a
client with diabetes. - correct answer✔✔B. Performing oropharyngeal
suctioning on a drooling client with croup. ??????
The nurse receives report on four assigned pediatric clients.
Which client should the nurse ASSESS first?
A. A 2 year old client with a history of Kawasaki disease who just began
vomiting and appears restless
B. A 12 year old client with acute rheumatic fever who is making sporadic
arm movements and grimacing
C. A 3 month old client with coarctation of the aorta (COA) on a ventilator
who is pale and has weak femoral pulses
D. A 6 month old client with ventricular septal defect (VSD) who
experiences labored breathing when placed supine. - correct answer✔✔A.
A 2 year old client with a history of Kawasaki disease who just began
vomiting and appears restless
Ex:
Kawasaki disease (KD) is an acute, self resolving vasculitis affecting mostly
small and medium-sized vessels, especially the coronary arteries. KD
weakens vessel was and can cause coronary aneurysm (abnormal bulging
of the vasculature) and myocarditis (inflammation of the myocardium)
Coronary artery aneurysm increases the risk for coronary thrombosis and
myocardial infarction (MI), making KD the most common cause of MI in
children. Vomiting and restlessness can indicate MI in young children.
, The nurse is caring for a client with suspected benign prostatic hyperplasia.
Which of the following client statements SUPPORTS the diagnosis of
benign prostatic hyperplasia? Select all that apply.
A. "I am having frequent constipation"
B "I recently noticed some blood in my urine."
C. "I wake up several times at night to urinate."
D. "I have had urinate more frequently lately."
E. "When I try to urinate, I have difficulty getting started."
F. "When I am urinating, it is more of a dribble than a stream."
G. "I have noticed that my scrotum feels more swollen than normal." -
correct answer✔✔B "I recently noticed some blood in my urine."
C. "I wake up several times at night to urinate."
D. "I have had urinate more frequently lately."
E. "When I try to urinate, I have difficulty getting started."
F. "When I am urinating, it is more of a dribble than a stream."
Ex:
Benign prostatic hyperplasia (BPH) is enlargement of the prostate gland
that results in storage/irritative and obstructive symptoms, together termed
lower urinary tract symptoms (LUTS).
Obstructive symptoms occurs as the urethra is compressed, which requires
the bladder to contract more forcefully to excrete urine and can cause
urinary retention . the earliest sign of BPH is diminished caliber and force of
urine when voiding. other obstruction symptoms include delay or hesitancy
when clients attempt to urinate, difficulty in maintaining the urine stream
(I.e. intermittency), and dribbling after voiding.
Store/irritative symptoms are caused by irritation, inflammation, or infection
and include urinary frequency, nocturne (3 or more voids during the night),
urgency, dysuria, or hematuria
Ket takeaway:
Clinical manifestation of benign prostatic hyperplasia include:
Nocturia
QUESTIONS WITH CORRECT ANSWERS WITH
RATIONALE GRADED A+
Which of the following clients should the nurse INVESTIGATE further for
potential child abuse?
A. 1 year old client who has bright red cheeks and a raised, bumpy rash
bilaterally on the arms and legs
B. A 5 month old client who has influenza and a 4 cm bluish-gray
asymmetrical marking on the left buttocks
C. A 10 year old client who has scratched shins and a clavicle fracture and
reports falling while skateboarding
D. A 7 month old client with palm burns whose caregiver says the client
climbed up the sink and grabbed a hot iron - correct answer✔✔D. A 7
month old client with palm burns whose caregiver says the client climbed
up the sink and grabbed a hot iron
The nurse is carting for a 8kg, 1 year old client who underwent a complete
cardiac repair for tetralogy of pallor 8 hours ago.
Which of the following findings would REQUIRE IMMEDIATE follow-up?
Select all that apply
A. 1+ radial and femoral pulses
B. Temperature of 100 F (37.7 C)
C. Urine output of 5 mL in the last hour
D. Pinkish-tan colored chest tube drainage
E. Chest tube drainage of 19 mL in one hour
F. Median sternotomy dressing has 2 mL of dried blood. - correct
answer✔✔A. 1+ radial and femoral pulses
C. Urine output of 5 mL in the last hour
explanation: TETRALOGY IS a combination of four congenital (present at
birth) heart defects.
,The defects occur together and change the way blood flows through the
heart and lungs.
The nurse discusses developmental milestones with the caregivers pod
several clients.
Which finding REPORTED by a caregiver REQUIRES follow-up by the
nurse?
A. A 19 month old who often falls while running through the house
B. A 22 month old who can say 4 words including "mom" and "more"
C. An 18 month old who is able to build a tower containing 3 wooden
blocks
D. A 24-month who plays with a doll bedside a friend without asking the
friend to play - correct answer✔✔B. A 22 month old who can say 4 words
including "mom" and "more"
The nurses is caring for an 8-month old client diagnosed with pertussis.
Which of the following INTERCEPTIONS should the nurse ANTICIPATE
implementing? Select all that apply.
A. Initiating droplet precautions
B. Providing humidified oxygen
C. Administering a bronchodilator
D. Providing suctioning as needed
E. Administering antiviral medications
F. Encouraging frequent, small feedings - correct answer✔✔A. Initiating
droplet precautions
B. Providing humidified oxygen
D. Providing suctioning as needed
F. Encouraging frequent, small feedings
Ex:
Pertussis (whooping cough) is a highly contagious bacterial upper
respiratory infection that causes coughing spells filled by sharp inhalation
that creates a
,The experienced pediatric intensive care registered nurse is preempting a
newly licensed registered nurse who received repot on 4 clients.
Which of the following ACTIONS taken by the new nurse REQUIRES the
experienced nurse to intervene?
A. Placing a client with varicella in a negative pressure isolation room.
B. Performing oropharyngeal suctioning on a drooling client with croup.
C. Placing an infant in prone position following myelomeningocele repair.
D, Drawing up insulin lisper before NPH insulin in the same syringe for a
client with diabetes. - correct answer✔✔B. Performing oropharyngeal
suctioning on a drooling client with croup. ??????
The nurse receives report on four assigned pediatric clients.
Which client should the nurse ASSESS first?
A. A 2 year old client with a history of Kawasaki disease who just began
vomiting and appears restless
B. A 12 year old client with acute rheumatic fever who is making sporadic
arm movements and grimacing
C. A 3 month old client with coarctation of the aorta (COA) on a ventilator
who is pale and has weak femoral pulses
D. A 6 month old client with ventricular septal defect (VSD) who
experiences labored breathing when placed supine. - correct answer✔✔A.
A 2 year old client with a history of Kawasaki disease who just began
vomiting and appears restless
Ex:
Kawasaki disease (KD) is an acute, self resolving vasculitis affecting mostly
small and medium-sized vessels, especially the coronary arteries. KD
weakens vessel was and can cause coronary aneurysm (abnormal bulging
of the vasculature) and myocarditis (inflammation of the myocardium)
Coronary artery aneurysm increases the risk for coronary thrombosis and
myocardial infarction (MI), making KD the most common cause of MI in
children. Vomiting and restlessness can indicate MI in young children.
, The nurse is caring for a client with suspected benign prostatic hyperplasia.
Which of the following client statements SUPPORTS the diagnosis of
benign prostatic hyperplasia? Select all that apply.
A. "I am having frequent constipation"
B "I recently noticed some blood in my urine."
C. "I wake up several times at night to urinate."
D. "I have had urinate more frequently lately."
E. "When I try to urinate, I have difficulty getting started."
F. "When I am urinating, it is more of a dribble than a stream."
G. "I have noticed that my scrotum feels more swollen than normal." -
correct answer✔✔B "I recently noticed some blood in my urine."
C. "I wake up several times at night to urinate."
D. "I have had urinate more frequently lately."
E. "When I try to urinate, I have difficulty getting started."
F. "When I am urinating, it is more of a dribble than a stream."
Ex:
Benign prostatic hyperplasia (BPH) is enlargement of the prostate gland
that results in storage/irritative and obstructive symptoms, together termed
lower urinary tract symptoms (LUTS).
Obstructive symptoms occurs as the urethra is compressed, which requires
the bladder to contract more forcefully to excrete urine and can cause
urinary retention . the earliest sign of BPH is diminished caliber and force of
urine when voiding. other obstruction symptoms include delay or hesitancy
when clients attempt to urinate, difficulty in maintaining the urine stream
(I.e. intermittency), and dribbling after voiding.
Store/irritative symptoms are caused by irritation, inflammation, or infection
and include urinary frequency, nocturne (3 or more voids during the night),
urgency, dysuria, or hematuria
Ket takeaway:
Clinical manifestation of benign prostatic hyperplasia include:
Nocturia
