NCLEX NGN Pre-Test Questions & Correct
Answers.
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 - Correct
Answer A, 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 - Correct Answer D, 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 - Correct Answer A
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 - Correct Answer B
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 - Correct Answer
C
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 - Correct Answer D
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 - Correct Answer B
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 - Correct Answer A
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 - Correct Answer B
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
Answers.
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 - Correct
Answer A, 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 - Correct Answer D, 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 - Correct Answer A
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 - Correct Answer B
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 - Correct Answer
C
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 - Correct Answer D
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 - Correct Answer B
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 - Correct Answer A
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 - Correct Answer B
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
