NCLEX 2 Test Questions with 100% Verified Answers
1. 3 The nurse is assessing a pediatric client with a diagnosis
of retinoblastoma. The nurse assesses for which most
common clinical finding for a child with this diagnosis?
1.
Blindness
2.
Strabismus
3.
Cat's-eye reflex
4.
Red, painful eye
2. 2, 3, 4, 5 A client who has heart failure receives an additional dose
of bumetanide as prescribed 4 hours after the daily dose.
The nurse assesses the client 15 minutes after adminis-
tering the medication and reminds the client to save all
urine in the bathroom. Sixty minutes later the nurse finds
the client on the floor, unresponsive, and bleeding from a
laceration. Which issues support the client's malpractice
claim? Select all that apply.
1.
Failure to replace body fluids
2.
Increased risk of hypotension
3.
Lack of follow-up nursing actions
4.
Increased need to protect the client
5.
Failure to teach the client adequately
, NCLEX 2 Test Questions with 100% Verified Answers
6.
Excessive bumetanide administration
3. 1, 2, 4 The nurse is caring for an older Appalachian client re-
covering from open heart surgery. In order to provide
culturally appropriate care, the nurse should be aware that
which aspects of reporting pain may be impacted by the
Appalachian culture? Select all that apply.
1.
Appalachian clients may want to appear to be stoic.
2.
Appalachian clients may be afraid of addiction tendencies.
3.
Appalachian clients may be very expressive in reporting
pain.
4.
Appalachian clients may not want to appear to be com-
plainers.
5.
Appalachian clients may not understand pain scale be-
cause of illiteracy.
4. 3, 5 The nurse evaluates that the older client has a need for
further teaching on how to promote sleep when the client
makes which statements? Select all that apply.
1.
"I swim three times a week."
2.
"I have stopped smoking cigars."
3.
, "I drink hot chocolate before bedtime."
4.
"I read for 40 minutes before bedtime."
5.
"I plan out my goals for work for the next day"
5. 2, 3, 5 A client asks the nurse to describe how her baby is devel-
oping at 12 weeks gestation. Which milestones should the
nurse identify as present at this time? Select all that apply.
1.
Can hear
2.
Sex recognizable
3.
Blood forming in marrow
4.
Testes descend into scrotum
5.
Kidneys able to secrete urine
6. 1 n the well-child clinic, the nurse observes an infant, age
10 months, playing with toys, bringing them to his mouth,
and passing the toys from one hand to the next. The
nurse determines the child is in which Jean Piaget's first
developmental stage?
1.
Sensorimotor
2.
Preoperational
1. 3 The nurse is assessing a pediatric client with a diagnosis
of retinoblastoma. The nurse assesses for which most
common clinical finding for a child with this diagnosis?
1.
Blindness
2.
Strabismus
3.
Cat's-eye reflex
4.
Red, painful eye
2. 2, 3, 4, 5 A client who has heart failure receives an additional dose
of bumetanide as prescribed 4 hours after the daily dose.
The nurse assesses the client 15 minutes after adminis-
tering the medication and reminds the client to save all
urine in the bathroom. Sixty minutes later the nurse finds
the client on the floor, unresponsive, and bleeding from a
laceration. Which issues support the client's malpractice
claim? Select all that apply.
1.
Failure to replace body fluids
2.
Increased risk of hypotension
3.
Lack of follow-up nursing actions
4.
Increased need to protect the client
5.
Failure to teach the client adequately
, NCLEX 2 Test Questions with 100% Verified Answers
6.
Excessive bumetanide administration
3. 1, 2, 4 The nurse is caring for an older Appalachian client re-
covering from open heart surgery. In order to provide
culturally appropriate care, the nurse should be aware that
which aspects of reporting pain may be impacted by the
Appalachian culture? Select all that apply.
1.
Appalachian clients may want to appear to be stoic.
2.
Appalachian clients may be afraid of addiction tendencies.
3.
Appalachian clients may be very expressive in reporting
pain.
4.
Appalachian clients may not want to appear to be com-
plainers.
5.
Appalachian clients may not understand pain scale be-
cause of illiteracy.
4. 3, 5 The nurse evaluates that the older client has a need for
further teaching on how to promote sleep when the client
makes which statements? Select all that apply.
1.
"I swim three times a week."
2.
"I have stopped smoking cigars."
3.
, "I drink hot chocolate before bedtime."
4.
"I read for 40 minutes before bedtime."
5.
"I plan out my goals for work for the next day"
5. 2, 3, 5 A client asks the nurse to describe how her baby is devel-
oping at 12 weeks gestation. Which milestones should the
nurse identify as present at this time? Select all that apply.
1.
Can hear
2.
Sex recognizable
3.
Blood forming in marrow
4.
Testes descend into scrotum
5.
Kidneys able to secrete urine
6. 1 n the well-child clinic, the nurse observes an infant, age
10 months, playing with toys, bringing them to his mouth,
and passing the toys from one hand to the next. The
nurse determines the child is in which Jean Piaget's first
developmental stage?
1.
Sensorimotor
2.
Preoperational
