NCLEX EXAM QUESTIONS WITH
100% ACCURATE ANSWERS .
The nurse employed in an emergency department is assigned to triage clients
coming to the emergency department for treatment on the evening shift. The
nurse should assign priority to which client?
A) A client complaining of muscle aches, a headache, and malaise
B) A client who twisted her ankle when she fell while rollerblading
C) A client with a minor laceration on the index finger sustained while cutting
an eggplant
D) A client with chest pain who states that he just ate hot wings that was
made with a very spicy sauce. ✔️✔️- Correct Answer-D- In an emergency
department, triage involves brief client assessment to classify clients
according to their need for care and includes establishing priorities of
care. The type of illness or injury, the severity of the problem, and the
resources available govern the process. Clients with trauma, chest pain,
severe respiratory distress or cardiac arrest, limb amputation, and acute
neurological deficits, or who have sustained chemical splashes to the
eyes, are classified as emergent and are the number 1 priority.
A nurse has received the assignment for the day shift. After making initial rounds
and checking all of the assigned clients, which client should the nurse plan to
care for first?
A) A client who is ambulatory
B) A client scheduled for physical therapy at 1 pm
C) A client with a fever who is diaphoretic and restless ✔️✔️
D) A postoperative client who has just received pain medication - Correct
Answer-C- The nurse should plan to care for the client who has a fever and
is diaphoretic and restless first because this client's needs are the priority.
The client who is ambulatory and the client scheduled for physical therapy
later in the day do not have priority needs related to care. Waiting for pain
medication to take effect before providing care to the postoperative client
is best.
You are monitoring a 53-year-old client who is undergoing a treadmill stress test.
Which client-finding will require the most immediate action?
A) Blood pressure of 152/ 88 mm Hg
B) Heart rate of 134 beats/ min
C) Oxygen saturation of 91%
D) Chest pain level of 3 (on a scale of 10 ✔️✔️- Correct Answer-D- Chest pain
in a client undergoing a stress test indicates myocardial ischemia and is
an indication to stop the testing to avoid ongoing ischemia, injury, or
, infarction. Moderate elevations in blood pressure and heart rate and slight
decreases in oxygen saturation are a normal response to exercise and are
expected during stress testing.
You are reviewing the complete blood count for a patient who has been admitted
for knee arthroscopy. Which value is most important to report to the physician
before surgery?
A) Hematocrit of 33%
B) Hemoglobin level of 10.9 g/ dL
C) Platelet count of 426,000/ mm3
D) White blood cell counts of 16,000/ mm3✔️✔️ - Correct Answer-D-
Centers for Disease Control and Prevention (CDC) guidelines for the
prevention of surgical site infections indicate that surgery should be
postponed when there is evidence of a pre-existing infection such
as an elevation in white blood cell count. The other values are
slightly abnormal, but would not be likely to cause postoperative
problems for knee arthroscopy.
What is the priority nursing diagnosis for a client experiencing a migraine
headache?
A) Acute Pain related to biologic and chemical factors ✔️✔️
B) Anxiety related to change in or threat to health status
C) Hopelessness related to deteriorating physiologic condition
D) Risk for Injury related to side effects of medical therapy - Correct
Answer-A- The priority for interdisciplinary care for the client
experiencing a migraine headache is pain management.
All of the other nursing diagnoses are accurate, but none of them is urgent like
the issue of pain, which is often incapacitating. You have just received a change-
of-shift report for the burn unit. Which client should you assess first?
A) Client with deep partial-thickness burns on both legs who reports
severe and continuous leg pain
B) Client who has just arrived from the emergency department with
facial burns sustained in a house fire ✔️✔️
C) Client who has just been transferred from the post anesthesia care
unit after having skin grafts applied to the anterior chest
D) Client admitted 3 weeks ago with full-thickness leg and buttock
burns who has been waiting for 3 hours to receive discharge
teaching - Correct Answer-B- Facial burns are frequently associated
with airway inflammation and swelling, so this client requires the
most immediate assessment. The other clients also require rapid
assessment or interventions, but not as urgently as the client with
facial burns.
100% ACCURATE ANSWERS .
The nurse employed in an emergency department is assigned to triage clients
coming to the emergency department for treatment on the evening shift. The
nurse should assign priority to which client?
A) A client complaining of muscle aches, a headache, and malaise
B) A client who twisted her ankle when she fell while rollerblading
C) A client with a minor laceration on the index finger sustained while cutting
an eggplant
D) A client with chest pain who states that he just ate hot wings that was
made with a very spicy sauce. ✔️✔️- Correct Answer-D- In an emergency
department, triage involves brief client assessment to classify clients
according to their need for care and includes establishing priorities of
care. The type of illness or injury, the severity of the problem, and the
resources available govern the process. Clients with trauma, chest pain,
severe respiratory distress or cardiac arrest, limb amputation, and acute
neurological deficits, or who have sustained chemical splashes to the
eyes, are classified as emergent and are the number 1 priority.
A nurse has received the assignment for the day shift. After making initial rounds
and checking all of the assigned clients, which client should the nurse plan to
care for first?
A) A client who is ambulatory
B) A client scheduled for physical therapy at 1 pm
C) A client with a fever who is diaphoretic and restless ✔️✔️
D) A postoperative client who has just received pain medication - Correct
Answer-C- The nurse should plan to care for the client who has a fever and
is diaphoretic and restless first because this client's needs are the priority.
The client who is ambulatory and the client scheduled for physical therapy
later in the day do not have priority needs related to care. Waiting for pain
medication to take effect before providing care to the postoperative client
is best.
You are monitoring a 53-year-old client who is undergoing a treadmill stress test.
Which client-finding will require the most immediate action?
A) Blood pressure of 152/ 88 mm Hg
B) Heart rate of 134 beats/ min
C) Oxygen saturation of 91%
D) Chest pain level of 3 (on a scale of 10 ✔️✔️- Correct Answer-D- Chest pain
in a client undergoing a stress test indicates myocardial ischemia and is
an indication to stop the testing to avoid ongoing ischemia, injury, or
, infarction. Moderate elevations in blood pressure and heart rate and slight
decreases in oxygen saturation are a normal response to exercise and are
expected during stress testing.
You are reviewing the complete blood count for a patient who has been admitted
for knee arthroscopy. Which value is most important to report to the physician
before surgery?
A) Hematocrit of 33%
B) Hemoglobin level of 10.9 g/ dL
C) Platelet count of 426,000/ mm3
D) White blood cell counts of 16,000/ mm3✔️✔️ - Correct Answer-D-
Centers for Disease Control and Prevention (CDC) guidelines for the
prevention of surgical site infections indicate that surgery should be
postponed when there is evidence of a pre-existing infection such
as an elevation in white blood cell count. The other values are
slightly abnormal, but would not be likely to cause postoperative
problems for knee arthroscopy.
What is the priority nursing diagnosis for a client experiencing a migraine
headache?
A) Acute Pain related to biologic and chemical factors ✔️✔️
B) Anxiety related to change in or threat to health status
C) Hopelessness related to deteriorating physiologic condition
D) Risk for Injury related to side effects of medical therapy - Correct
Answer-A- The priority for interdisciplinary care for the client
experiencing a migraine headache is pain management.
All of the other nursing diagnoses are accurate, but none of them is urgent like
the issue of pain, which is often incapacitating. You have just received a change-
of-shift report for the burn unit. Which client should you assess first?
A) Client with deep partial-thickness burns on both legs who reports
severe and continuous leg pain
B) Client who has just arrived from the emergency department with
facial burns sustained in a house fire ✔️✔️
C) Client who has just been transferred from the post anesthesia care
unit after having skin grafts applied to the anterior chest
D) Client admitted 3 weeks ago with full-thickness leg and buttock
burns who has been waiting for 3 hours to receive discharge
teaching - Correct Answer-B- Facial burns are frequently associated
with airway inflammation and swelling, so this client requires the
most immediate assessment. The other clients also require rapid
assessment or interventions, but not as urgently as the client with
facial burns.
