NCLEX NGN PRE-TEST QUESTIONS AND ANSWERS
LATEST 2024 VERSION VERIFIED RATIONALE
GRADED A+
A child who is HIV-positive is scheduled to receive a mumps, measles, and rubella (MMR) vaccine. The
laboratory results show the CD4+ as 1000 cells/mm3. Which nursing action is appropriate?
Administering the vaccine
Contacting the primary health care provider
Asking the laboratory to repeat the CD4+ test
Informing the child's mother that the vaccine must not be administered at this time - ansA
The normal CD4+ count is 500 to 1600 cells/mm3. Because this child's CD4+ count is 1000 cells/mm3,
the nurse would administer the vaccine.
A child with osteosarcoma who required amputation of a lower limb is experiencing phantom limb pain.
The nurse attempts to comfort the child by providing which explanation?
The pain is a normal, temporary condition
The pain occurs because nerves have been cut
This pain will go away once a prosthesis is used
Pain medication may be needed for life to alleviate the discomfort - ansA
Phantom limb pain is a temporary condition that some people who undergo amputation experience. This
sensation of burning, aching, or cramping in the missing limb is most distressing to the client. The child
should be reassured that the condition is normal.
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
b. Placing ice packs on and under the right leg
c. Documenting the need for hourly calf measurements
d. Performing the need for hourly calf measurements - ansA
DVT treatment includes bed rest, leg elevation, and application of warm, moist heat. Elevation decreases
the venous pressure with relieves edema and pain. ROM cause cause the thrombus to mobilize to the
lungs causing PEs.
,NCLEX NGN PRE-TEST QUESTIONS AND ANSWERS
LATEST 2024 VERSION VERIFIED RATIONALE
GRADED A+
A client hospitalized on a mental health unit with schizophrenia tells the nurse, "The voices in my head
say that I'm worthless and that I don't deserve to be alive." What is the nurse's priority concern for this
client?
Ineffective coping skills
Perceptual disturbances
Chronic low self-esteem
Risk for self-directed violence - ansD
A client in a manic state emerges from her room wearing provocative clothing and quickly enters the
dayroom. She announces to the group that she is the star of a burlesque show and will begin her
performance shortly. Which is the priority nursing action?
Ask the client to go to her room and to change her clothes
Tell the client firmly that burlesque shows are not allowed in the nursing unit
Tell the client that her bathroom privileges are being suspended because of her behavior
Quietly and firmly assist the client to her room and help her dress in appropriate clothes - ansD
A client who has just received a diagnosis of asthma says to the nurse, "This is just another nail in my
coffin." Which response by the nurse is therapeutic?
"Do you think that having asthma will kill you?"
"You seem very distressed at learning that you have asthma."
"I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your coffin.'"
"Asthma is a very treatable condition, but it's important to learn how to properly administer your
medications. Let's practice with your inhalant." - ansB
A client who is 8 weeks pregnant reads her electronic medical record via a patient portal. She contacts
the clinic and asks the nurse to explain a "positive Hegar sign." Which is the best answer for the nurse to
provide?
"You are able to feel fetal movement."
"A soft blowing sound can be heard with a stethoscope."
, NCLEX NGN PRE-TEST QUESTIONS AND ANSWERS
LATEST 2024 VERSION VERIFIED RATIONALE
GRADED A+
"The lower part of your uterus is softer than when you are not pregnant."
"You are experiencing irregular painless contractions during the pregnancy." - ansC
Softening and compressibility of the lower uterine segment, occurring around the sixth week of
pregnancy, is called the Hegar sign.
A client who is delusional says to the nurse, "Terrorists have been sent here to kill me." How should the
nurse respond to the client?
"No one is going to kill you."
"Your medication is making you feel like this."
"Are you worried that people are trying to hurt you?"
"What makes you think that terrorists were sent to hurt you?" - ansC
A client who was sexually assaulted a year ago is self-contained and calm while discussing the assault.
The client says to the nurse, "It still doesn't seem real." The nurse is considering requesting a referral to a
mental health professional because which defense mechanism has been used for an extensive period of
time?
Denial
Projection
Rationalization
Intellectualization - ansA
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.
LATEST 2024 VERSION VERIFIED RATIONALE
GRADED A+
A child who is HIV-positive is scheduled to receive a mumps, measles, and rubella (MMR) vaccine. The
laboratory results show the CD4+ as 1000 cells/mm3. Which nursing action is appropriate?
Administering the vaccine
Contacting the primary health care provider
Asking the laboratory to repeat the CD4+ test
Informing the child's mother that the vaccine must not be administered at this time - ansA
The normal CD4+ count is 500 to 1600 cells/mm3. Because this child's CD4+ count is 1000 cells/mm3,
the nurse would administer the vaccine.
A child with osteosarcoma who required amputation of a lower limb is experiencing phantom limb pain.
The nurse attempts to comfort the child by providing which explanation?
The pain is a normal, temporary condition
The pain occurs because nerves have been cut
This pain will go away once a prosthesis is used
Pain medication may be needed for life to alleviate the discomfort - ansA
Phantom limb pain is a temporary condition that some people who undergo amputation experience. This
sensation of burning, aching, or cramping in the missing limb is most distressing to the client. The child
should be reassured that the condition is normal.
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
b. Placing ice packs on and under the right leg
c. Documenting the need for hourly calf measurements
d. Performing the need for hourly calf measurements - ansA
DVT treatment includes bed rest, leg elevation, and application of warm, moist heat. Elevation decreases
the venous pressure with relieves edema and pain. ROM cause cause the thrombus to mobilize to the
lungs causing PEs.
,NCLEX NGN PRE-TEST QUESTIONS AND ANSWERS
LATEST 2024 VERSION VERIFIED RATIONALE
GRADED A+
A client hospitalized on a mental health unit with schizophrenia tells the nurse, "The voices in my head
say that I'm worthless and that I don't deserve to be alive." What is the nurse's priority concern for this
client?
Ineffective coping skills
Perceptual disturbances
Chronic low self-esteem
Risk for self-directed violence - ansD
A client in a manic state emerges from her room wearing provocative clothing and quickly enters the
dayroom. She announces to the group that she is the star of a burlesque show and will begin her
performance shortly. Which is the priority nursing action?
Ask the client to go to her room and to change her clothes
Tell the client firmly that burlesque shows are not allowed in the nursing unit
Tell the client that her bathroom privileges are being suspended because of her behavior
Quietly and firmly assist the client to her room and help her dress in appropriate clothes - ansD
A client who has just received a diagnosis of asthma says to the nurse, "This is just another nail in my
coffin." Which response by the nurse is therapeutic?
"Do you think that having asthma will kill you?"
"You seem very distressed at learning that you have asthma."
"I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your coffin.'"
"Asthma is a very treatable condition, but it's important to learn how to properly administer your
medications. Let's practice with your inhalant." - ansB
A client who is 8 weeks pregnant reads her electronic medical record via a patient portal. She contacts
the clinic and asks the nurse to explain a "positive Hegar sign." Which is the best answer for the nurse to
provide?
"You are able to feel fetal movement."
"A soft blowing sound can be heard with a stethoscope."
, NCLEX NGN PRE-TEST QUESTIONS AND ANSWERS
LATEST 2024 VERSION VERIFIED RATIONALE
GRADED A+
"The lower part of your uterus is softer than when you are not pregnant."
"You are experiencing irregular painless contractions during the pregnancy." - ansC
Softening and compressibility of the lower uterine segment, occurring around the sixth week of
pregnancy, is called the Hegar sign.
A client who is delusional says to the nurse, "Terrorists have been sent here to kill me." How should the
nurse respond to the client?
"No one is going to kill you."
"Your medication is making you feel like this."
"Are you worried that people are trying to hurt you?"
"What makes you think that terrorists were sent to hurt you?" - ansC
A client who was sexually assaulted a year ago is self-contained and calm while discussing the assault.
The client says to the nurse, "It still doesn't seem real." The nurse is considering requesting a referral to a
mental health professional because which defense mechanism has been used for an extensive period of
time?
Denial
Projection
Rationalization
Intellectualization - ansA
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.
