NCLEX-RN EXAM PREPARATION QUESTIONS AND WELL GRADED ANSWERS 100% GUARANTEED A+
A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed to receive
oxytocin intravenously after delivery of the placenta. Which of the following signs would indicate to
the nurse that the placenta is about to be delivered?
- The cord lengthens outside the vagina.
- There is decreased vaginal bleeding.
- The uterus cannot be palpated.
- The uterus changes to discoid shape.
The cord lengthens outside the vagina
A nurse on the pediatric floor is caring for a toddler refusing to take liquid acetaminophen for fever.
What would be the best option?
- Allow the parent to hold the child and give the medication.
- Explain to the child why it is important.
- Call the healthcare provider to change the order.
- Give it up and try again in a couple hours.
Allow the parent to hold the child and give the medication
An 11-year-old child is sent to the school nurse reporting difficulty reading the blackboard in the
classroom. The nurse assesses that the child does not have difficulty reading a laptop screen or
reading books. What is the best action by the nurse?
- Request that the child be screened for myopia.
- Inform the teacher that the child has strabismus.
- Try to determine the cause of the child's photophobia.
- Call the parents to discuss therapy for hyperopia.
Request that the child be screened for myopia
While caring for a mother and her 1-day-old neonate born vaginally at 30 weeks' gestation, the nurse
explains about the neonate's need for gavage feeding at this time instead of the mother's plan for
bottle feeding. What should the nurse include as the rationale for this feeding plan?
- The neonate has difficulty coordinating sucking, swallowing, and breathing.
- A high-calorie formula, presently needed at this time, is more easily delivered via gavage.
- Gavage feedings can minimize the neonate's increased risk of developing hypoglycemia.
- This type of feeding, easily given in the isolette, decreases the neonate's risk of cold stress.
The neonate has difficulty coordinating sucking, swallowing, and breathing
The nurse is teaching the parents of a child with sickle cell disease. What information should the nurse
give the family on how to prevent sickle cell crisis?
- Avoid exercising in cool temperatures.
- Drink at least 2 quarts (2.3 liters) of fluids per day.
- Stay away from other teenagers.
- Avoid physical activity.
Drink at least 2 quarts (2.3 liters) of fluids per day
,After the first breastfeeding, the client asks the nurse, "How often should I try to breastfeed?" What
frequency should the nurse recommend?
- at least every hour for the first 48 hours
- every 2 to 3 hours for the first 48 hours
- every 4 to 5 hours for the first 5 days after childbirth
- whenever she desires, until weaning occurs
Every 2 to 3 hours for the first 48 hours
A client with heart failure is given a prescription for torsemide. Two days after the drug therapy is
started, which sign indicates the drug is having the intended outcome? The client:
- has an improved appetite and is eating better.
- weighs 7 lbs (3 kg) less than the client did 2 days ago.
- is less thirsty than before the drug therapy.
- has clearer urine since starting torsemide.
Weights 7 lbs (3 kg) less than the client did 2 days ago
A 10-month-old infant is brought to the well-baby clinic for a follow-up visit. The mother tells the
nurse that she has been having trouble feeding her infant any solid foods. The infant only prefers
breastfeeding and pushes food from the mouth. To help correct this problem, the nurse should:
instruct the mother that tongue thrusting is the infant's way of rejecting food.
- instruct the mother to place the food further back and to the side of the - - infant's mouth.
- instruct the mother to offer small, bite-size food.
- instruct the mother to limit the infant's breast milk.
instruct the mother to place the food further back and to the side of the infant's mouth
A postpartum mother is concerned about a noted decrease in her breast milk production. Which
response by the nurse best addresses this mother's concern?
- Decrease supplemental feedings with formula.
- Suggest the mother consume a diet high in vitamin C.
- Have several alcoholic beverages for relaxation.
- Feed the infant less frequently.
Decrease supplemental feedings with formula
The nurse is assessing a client with bipolar disorder during a follow-up appointment after initiating
treatment with lithium carbonate. Which symptom would cause the nurse to suspect lithium toxicity?
- black tongue
- increased tearing
- constipation
- persistent GI upset
Persistent GI upset
Which assessment findings indicates that epoetin alfa is having a therapeutic effect?
- neutrophil count 8.0 × 109/L
- hemoglobin 12 g/dL
,- platelet count 150 × 109/L
- white blood cell count 7.0 × 109/L
hemoglobin 12 g/dL
A client with a subarachnoid hemorrhage is prescribed a 1,000 mg loading dose of I.V. phenytoin.
What information is most important when administering this dose?
- Therapeutic drug levels should be maintained between 20 and 30 mg/ml.
- Rapid phenytoin administration can cause cardiac arrhythmias.
- Phenytoin should be mixed in dextrose in water before administration.
- Phenytoin should be administered through an I.V. catheter in the client's hand.
Rapid phenytoin administration can cause cardiac arrhtyhmias
An unconscious client in the emergency department is given IV naloxone due to an overdose of
heroin. Which findings would indicate a therapeutic response to the naloxone? Select all that apply.
- decreased pulse rate
- warm moist skin
- dilated pupils
- increased respirations
- consciousness
- increased respirations
- consciousness
The nurse should teach the client that signs of digoxin toxicity include:
- rash over the chest and back.
- increased appetite.
- visual disturbances such as seeing yellow spots.
- elevated blood pressure.
visual disturbances such as seeing yellow spots
A client arrives in the emergency department with an ischemic stroke. What should the nurse do
before the client receives tissue plasminogen activator (t-PA)?
- Ask what medications the client is taking.
- Complete a history and health assessment.
- Identify the time of onset of the stroke.
- Determine if the client is scheduled for any surgical procedures.
Identify the time of onset of the stroke
The client who is 28 weeks gestation is at the obstetric (OB) clinic reviewing lab work. The human
immunodeficiency virus (HIV) test is positive, and treatment is indicated. Which medication should
the nurse expect to administer that will help to prevent transmission of the virus to the fetus?
- zidovudine
- fluvastatin
- dimenhydrinate
- disulfiram
, Zidovudine
The nurse should warn a client who is taking a benzodiazepine about using which medication in
combination with his current medication?
- antacids
- acetaminophen
- vitamins
- aspirin
Antacids
The nurse instructs the client in mixing and administering regular and NPH insulin. Which statement
indicates that the client needs additional instruction?
- "I draw up the regular insulin first."
- "I shake the bottle of NPH insulin before drawing it up."
- "I store the insulin in a cool place."
- "I insert the needle at a 90-degree angle."
"I shake the bottle of NPH insulin before drawing it up."
When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor
which laboratory value?
- serum sodium
- serum potassium
- serum creatinine
- serum calcium
Serum creatinine
The primary care provider prescribes an intravenous infusion of oxytocin to induce labor in a 22-year-
old primigravida client with insulin-dependent diabetes at 39 weeks' gestation. The fetus is in a
cephalic position, and the client's cervix is dilated 1 cm. What should the nurse do before starting the
oxytocin induction?
- Administer a 500 mL bolus of intravenous fluid to prevent hypotension.
- Continuously monitor fetal heart rate and contraction pattern for at least 20 minutes.
- Insert an indwelling urinary catheter to determine intake and output accurately.
- Call the anesthesiologist to begin administration of epidural anesthesia.
Continuously monitor fetal heart rate and contraction pattern for at least 20 minutes
A health care provider prescribes gentamicin for a client with peritonitis. The client has preexisting
impaired vision and hearing. The nurse should:
- give the drug as prescribed.
- question whether the drug is appropriate for treatment of peritonitis.
- question the prescription because gentamicin could cause further hearing impairment.
- question the prescription because gentamicin could cause further visual impairment.
question the prescription because gentamicin could cause further hearing impairment.
A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed to receive
oxytocin intravenously after delivery of the placenta. Which of the following signs would indicate to
the nurse that the placenta is about to be delivered?
- The cord lengthens outside the vagina.
- There is decreased vaginal bleeding.
- The uterus cannot be palpated.
- The uterus changes to discoid shape.
The cord lengthens outside the vagina
A nurse on the pediatric floor is caring for a toddler refusing to take liquid acetaminophen for fever.
What would be the best option?
- Allow the parent to hold the child and give the medication.
- Explain to the child why it is important.
- Call the healthcare provider to change the order.
- Give it up and try again in a couple hours.
Allow the parent to hold the child and give the medication
An 11-year-old child is sent to the school nurse reporting difficulty reading the blackboard in the
classroom. The nurse assesses that the child does not have difficulty reading a laptop screen or
reading books. What is the best action by the nurse?
- Request that the child be screened for myopia.
- Inform the teacher that the child has strabismus.
- Try to determine the cause of the child's photophobia.
- Call the parents to discuss therapy for hyperopia.
Request that the child be screened for myopia
While caring for a mother and her 1-day-old neonate born vaginally at 30 weeks' gestation, the nurse
explains about the neonate's need for gavage feeding at this time instead of the mother's plan for
bottle feeding. What should the nurse include as the rationale for this feeding plan?
- The neonate has difficulty coordinating sucking, swallowing, and breathing.
- A high-calorie formula, presently needed at this time, is more easily delivered via gavage.
- Gavage feedings can minimize the neonate's increased risk of developing hypoglycemia.
- This type of feeding, easily given in the isolette, decreases the neonate's risk of cold stress.
The neonate has difficulty coordinating sucking, swallowing, and breathing
The nurse is teaching the parents of a child with sickle cell disease. What information should the nurse
give the family on how to prevent sickle cell crisis?
- Avoid exercising in cool temperatures.
- Drink at least 2 quarts (2.3 liters) of fluids per day.
- Stay away from other teenagers.
- Avoid physical activity.
Drink at least 2 quarts (2.3 liters) of fluids per day
,After the first breastfeeding, the client asks the nurse, "How often should I try to breastfeed?" What
frequency should the nurse recommend?
- at least every hour for the first 48 hours
- every 2 to 3 hours for the first 48 hours
- every 4 to 5 hours for the first 5 days after childbirth
- whenever she desires, until weaning occurs
Every 2 to 3 hours for the first 48 hours
A client with heart failure is given a prescription for torsemide. Two days after the drug therapy is
started, which sign indicates the drug is having the intended outcome? The client:
- has an improved appetite and is eating better.
- weighs 7 lbs (3 kg) less than the client did 2 days ago.
- is less thirsty than before the drug therapy.
- has clearer urine since starting torsemide.
Weights 7 lbs (3 kg) less than the client did 2 days ago
A 10-month-old infant is brought to the well-baby clinic for a follow-up visit. The mother tells the
nurse that she has been having trouble feeding her infant any solid foods. The infant only prefers
breastfeeding and pushes food from the mouth. To help correct this problem, the nurse should:
instruct the mother that tongue thrusting is the infant's way of rejecting food.
- instruct the mother to place the food further back and to the side of the - - infant's mouth.
- instruct the mother to offer small, bite-size food.
- instruct the mother to limit the infant's breast milk.
instruct the mother to place the food further back and to the side of the infant's mouth
A postpartum mother is concerned about a noted decrease in her breast milk production. Which
response by the nurse best addresses this mother's concern?
- Decrease supplemental feedings with formula.
- Suggest the mother consume a diet high in vitamin C.
- Have several alcoholic beverages for relaxation.
- Feed the infant less frequently.
Decrease supplemental feedings with formula
The nurse is assessing a client with bipolar disorder during a follow-up appointment after initiating
treatment with lithium carbonate. Which symptom would cause the nurse to suspect lithium toxicity?
- black tongue
- increased tearing
- constipation
- persistent GI upset
Persistent GI upset
Which assessment findings indicates that epoetin alfa is having a therapeutic effect?
- neutrophil count 8.0 × 109/L
- hemoglobin 12 g/dL
,- platelet count 150 × 109/L
- white blood cell count 7.0 × 109/L
hemoglobin 12 g/dL
A client with a subarachnoid hemorrhage is prescribed a 1,000 mg loading dose of I.V. phenytoin.
What information is most important when administering this dose?
- Therapeutic drug levels should be maintained between 20 and 30 mg/ml.
- Rapid phenytoin administration can cause cardiac arrhythmias.
- Phenytoin should be mixed in dextrose in water before administration.
- Phenytoin should be administered through an I.V. catheter in the client's hand.
Rapid phenytoin administration can cause cardiac arrhtyhmias
An unconscious client in the emergency department is given IV naloxone due to an overdose of
heroin. Which findings would indicate a therapeutic response to the naloxone? Select all that apply.
- decreased pulse rate
- warm moist skin
- dilated pupils
- increased respirations
- consciousness
- increased respirations
- consciousness
The nurse should teach the client that signs of digoxin toxicity include:
- rash over the chest and back.
- increased appetite.
- visual disturbances such as seeing yellow spots.
- elevated blood pressure.
visual disturbances such as seeing yellow spots
A client arrives in the emergency department with an ischemic stroke. What should the nurse do
before the client receives tissue plasminogen activator (t-PA)?
- Ask what medications the client is taking.
- Complete a history and health assessment.
- Identify the time of onset of the stroke.
- Determine if the client is scheduled for any surgical procedures.
Identify the time of onset of the stroke
The client who is 28 weeks gestation is at the obstetric (OB) clinic reviewing lab work. The human
immunodeficiency virus (HIV) test is positive, and treatment is indicated. Which medication should
the nurse expect to administer that will help to prevent transmission of the virus to the fetus?
- zidovudine
- fluvastatin
- dimenhydrinate
- disulfiram
, Zidovudine
The nurse should warn a client who is taking a benzodiazepine about using which medication in
combination with his current medication?
- antacids
- acetaminophen
- vitamins
- aspirin
Antacids
The nurse instructs the client in mixing and administering regular and NPH insulin. Which statement
indicates that the client needs additional instruction?
- "I draw up the regular insulin first."
- "I shake the bottle of NPH insulin before drawing it up."
- "I store the insulin in a cool place."
- "I insert the needle at a 90-degree angle."
"I shake the bottle of NPH insulin before drawing it up."
When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor
which laboratory value?
- serum sodium
- serum potassium
- serum creatinine
- serum calcium
Serum creatinine
The primary care provider prescribes an intravenous infusion of oxytocin to induce labor in a 22-year-
old primigravida client with insulin-dependent diabetes at 39 weeks' gestation. The fetus is in a
cephalic position, and the client's cervix is dilated 1 cm. What should the nurse do before starting the
oxytocin induction?
- Administer a 500 mL bolus of intravenous fluid to prevent hypotension.
- Continuously monitor fetal heart rate and contraction pattern for at least 20 minutes.
- Insert an indwelling urinary catheter to determine intake and output accurately.
- Call the anesthesiologist to begin administration of epidural anesthesia.
Continuously monitor fetal heart rate and contraction pattern for at least 20 minutes
A health care provider prescribes gentamicin for a client with peritonitis. The client has preexisting
impaired vision and hearing. The nurse should:
- give the drug as prescribed.
- question whether the drug is appropriate for treatment of peritonitis.
- question the prescription because gentamicin could cause further hearing impairment.
- question the prescription because gentamicin could cause further visual impairment.
question the prescription because gentamicin could cause further hearing impairment.
