NCSBN NCLEX QUESTIONS
A 12 year-old child, admitted with a broken arm, is waiting for a scheduled
surgery. The nurse finds the child crying and unwilling to talk. What would be the
most appropriate initial response by the nurse?
1Reassure the child that the surgery will go fine with no problems
2Provide privacy with encouragement to work through feelings
3Distract the child with a choice of activities to do while waiting for surgery
4Make arrangements for friends to visit as soon as possible - ANS - 2
\A 14 month-old child ingests a half a bottle of baby aspirin (81 mg) tablets. Which
finding should a nurse expect to see in the child?
1Hypothermia
2Nausea and vomiting
3Hypoventilation
4Bradycardia - ANS - 2
\A 16 month-old child has just been admitted to the hospital. As the nurse
assigned to this child enters the hospital room for the first time, the toddler runs
to the mother, clings to her and begins to cry. What should be the next action of
the nurse?
1Arrange to change client-care assignments
2Discuss with the parent the appropriate use of "time-out"
3Explain to the mother that the child needs extra attention
4Explain to the parent that this behavior is expected - ANS - 4
\A 2 day-old infant born with spina bifida and meningomyocele is recovering after
an initial surgery. As the nurse accompanies the grandparents for their first visit
since the child's birth, which of these responses might the nurse expect from the
grandparents?
1Anger
2Disbelief
3Depression
4Frustration - ANS - 2
\A 2-year-old child is brought to the pediatrician's office by the parents, who
report that the child has been having diarrhea for two days. What nutritional
information should the nurse provide to the parents?
1Keep the child fasting, give them nothing to eat, and return the next day.
2Give the child only clear liquids and gelatin for 24 hours.
3Continue a regular diet and add electrolyte replacement drinks.
4Give the child bananas, apples, rice and toast as tolerated. - ANS - 3
,\A 20-year-old male client who has a profuse, purulent urethral discharge with
painful urination is seen at a community health clinic. Which information will be
most important for the nurse to obtain?
1Sexual orientation
2Recent sexual contacts
3Immunization history
4Contraceptive preference - ANS - 2
\A 28-year-old is transferred to the emergency department (ED) via ambulance
with a traumatic head injury. The client is awake and reports having a headache
and some amnesia. What are the priority nursing interventions for this client?
(Select all that apply.) - ANS - Correct Response
Assess vital signs and neurological function
Assess the airway
Prepare for CT imaging of the head
Assess the wound for presence of drainage or bruising on the head
\A 3 year-old child is brought to the health clinic. The grandmother reports that
the child is always "scratching his bottom" and is "extremely irritable." Based on
this information, which health issue would the nurse assess for initially?
1Pinworm
2Scabies
3Ringworm
4Allergies - ANS - 1
\A 6 month-old infant is being treated for developmental hip dysplasia and has
been placed in a hip spica plaster cast. Which discharge information is important
for the nurse to reinforce with the parents?
1Turn the baby every two hours using the abduction stabilizer bar
2Check frequently for swelling in the baby's feet
3Gently rub the skin with a cotton swab to relieve itching
4Place favorite books and push-pull toys in the crib - ANS - 2
\A 6 year-old child is hospitalized with findings of moderate edema, gross
hematuria and mild hypertension associated with the diagnosis of acute
glomerulonephritis (AGN). Which nursing intervention would be appropriate for
this client?
1Weigh the child twice per shift
2Relieve boredom through physical activity
3Institute seizure precautions
4Encourage the child to eat protein-rich foods - ANS - 3
\A 68-year-old, postmenopausal, female client has been prescribed tamoxifen for
breast cancer with bone metastases. The nurse should reinforce teaching about
which potential adverse drug effect?
,1Stroke-like symptoms
2Seizures
3Symptoms of hypocalcemia
4Insomnia - ANS - 1
Tamoxifen is an antineoplastic drug, commonly prescribed for clients with breast
cancer or for clients who are at high risk for developing breast cancer. The most
common adverse drug effects (ADEs) are hot flashes, fluid retention, vaginal
discharge, nausea, vomiting and menstrual irregularities. In women with bone
metastases, tamoxifen may cause transient hypercalcemia. Because of its
estrogen agonist actions, tamoxifen poses a small risk of thromboembolic
events, including deep vein thrombosis, pulmonary embolism and stroke.
\A child diagnosed with thalassemia has received several blood transfusions
during the past three days. What lab value is the priority for the nurse to monitor
with this client?
1Hemoglobin level
2Platelet count
3Blood urea nitrogen level
4Neutrophil percentage - ANS - 1
A normal hemoglobin range for children is approximately 11 to 13 gm/dL.
Thalassemia, also called Cooley's anemia, is a genetic defect that causes anemia,
i.e., a condition in which the blood contains below-normal hemoglobin levels.
Hemoglobin is the oxygen-carrying protein component of the red blood cell
(RBC).
\A child has severe burns to the lower extremities. A diet high in protein and
carbohydrates is recommended. The nurse should care for this client with the
knowledge that the most important reason for such a diet is to achieve which
result?
1Provide a well-balanced nutritional intake
2Promote healing and strengthen the immune system
3Spare protein catabolism to meet metabolic and healing needs
4 stimulate increased peristalsis and nutrient absorption - ANS - 3
\A child is admitted to the hospital for emergency surgery. The child's parent
reports several allergies. Which of these allergies should all the operative health
care personnel be notified about?
1Perfumed soap
2Shellfish
3Balloons
4Mold - ANS - 3
\A child is admitted to the unit with the suspected diagnosis of pertussis
(whooping cough). What is the priority nursing intervention for this child?
, 1. Maintain hydration and encourage fluids
2. Implement droplet precautions
3. Monitor respiratory rate and oxygen saturation
4. Anti- infective therapy - ANS - 2
\A client at risk for a stroke has been prescribed clopidogrel. Which information is
most important for the nurse to reinforce with the client?
1"You must take the medication on an empty stomach."
2"If you miss a dose, take a double dose the next day."
3"You must have your lab tests checked weekly."
4"You must stop the medication a week before your surgery." - ANS - 4
Clopidogrel is an oral antiplatelet drug with similar effects to aspirin. The drug is
taken for secondary prevention of myocardial infarction, ischemic stroke and
other vascular events. Clopidogrel prevents platelet aggregation. Like all other
antiplatelet drugs, clopidogrel poses a risk of serious bleeding. Clopidogrel
should be discontinued 5 to 7 days before elective surgery.
\A client becomes acutely short of breath with an SpO2 (oxygen saturation) of
82%. Which oxygen delivery system should the nurse apply that would provide
the highest concentrations of oxygen to the client?
1Simple face mask
2Partial rebreather mask
3Venturi mask
4Non-rebreather mask - ANS - 4
\A client comes to the community health clinic with symptoms of gonorrhea.
Which intervention should the nurse implement first?
1Discuss the risk of infertility with the client.
2Collect a urethral swab from the client.
3Instruct the client to notify past sexual partners.
4Obtain information about the client's recent sexual encounters. - ANS - 4
\A client diagnosed with autism begins to eat with both hands. The nurse can
best handle the behavior by using which approach?
1Commenting "I believe you know better than to eat with your hands."
2Removing the food and stating "You can't have any more food until you use the
spoon."
3Jokingly stating "Well, I guess fingers sometimes work better than spoons."
4Placing the spoon in the client's hand and stating "Use the spoon to eat your
food." - ANS - 4
\A client diagnosed with bipolar disorder has been referred to social services for
possible placement in a community halfway house after discharge. The social
worker telephones the nurse and asks for information about the client's mental
A 12 year-old child, admitted with a broken arm, is waiting for a scheduled
surgery. The nurse finds the child crying and unwilling to talk. What would be the
most appropriate initial response by the nurse?
1Reassure the child that the surgery will go fine with no problems
2Provide privacy with encouragement to work through feelings
3Distract the child with a choice of activities to do while waiting for surgery
4Make arrangements for friends to visit as soon as possible - ANS - 2
\A 14 month-old child ingests a half a bottle of baby aspirin (81 mg) tablets. Which
finding should a nurse expect to see in the child?
1Hypothermia
2Nausea and vomiting
3Hypoventilation
4Bradycardia - ANS - 2
\A 16 month-old child has just been admitted to the hospital. As the nurse
assigned to this child enters the hospital room for the first time, the toddler runs
to the mother, clings to her and begins to cry. What should be the next action of
the nurse?
1Arrange to change client-care assignments
2Discuss with the parent the appropriate use of "time-out"
3Explain to the mother that the child needs extra attention
4Explain to the parent that this behavior is expected - ANS - 4
\A 2 day-old infant born with spina bifida and meningomyocele is recovering after
an initial surgery. As the nurse accompanies the grandparents for their first visit
since the child's birth, which of these responses might the nurse expect from the
grandparents?
1Anger
2Disbelief
3Depression
4Frustration - ANS - 2
\A 2-year-old child is brought to the pediatrician's office by the parents, who
report that the child has been having diarrhea for two days. What nutritional
information should the nurse provide to the parents?
1Keep the child fasting, give them nothing to eat, and return the next day.
2Give the child only clear liquids and gelatin for 24 hours.
3Continue a regular diet and add electrolyte replacement drinks.
4Give the child bananas, apples, rice and toast as tolerated. - ANS - 3
,\A 20-year-old male client who has a profuse, purulent urethral discharge with
painful urination is seen at a community health clinic. Which information will be
most important for the nurse to obtain?
1Sexual orientation
2Recent sexual contacts
3Immunization history
4Contraceptive preference - ANS - 2
\A 28-year-old is transferred to the emergency department (ED) via ambulance
with a traumatic head injury. The client is awake and reports having a headache
and some amnesia. What are the priority nursing interventions for this client?
(Select all that apply.) - ANS - Correct Response
Assess vital signs and neurological function
Assess the airway
Prepare for CT imaging of the head
Assess the wound for presence of drainage or bruising on the head
\A 3 year-old child is brought to the health clinic. The grandmother reports that
the child is always "scratching his bottom" and is "extremely irritable." Based on
this information, which health issue would the nurse assess for initially?
1Pinworm
2Scabies
3Ringworm
4Allergies - ANS - 1
\A 6 month-old infant is being treated for developmental hip dysplasia and has
been placed in a hip spica plaster cast. Which discharge information is important
for the nurse to reinforce with the parents?
1Turn the baby every two hours using the abduction stabilizer bar
2Check frequently for swelling in the baby's feet
3Gently rub the skin with a cotton swab to relieve itching
4Place favorite books and push-pull toys in the crib - ANS - 2
\A 6 year-old child is hospitalized with findings of moderate edema, gross
hematuria and mild hypertension associated with the diagnosis of acute
glomerulonephritis (AGN). Which nursing intervention would be appropriate for
this client?
1Weigh the child twice per shift
2Relieve boredom through physical activity
3Institute seizure precautions
4Encourage the child to eat protein-rich foods - ANS - 3
\A 68-year-old, postmenopausal, female client has been prescribed tamoxifen for
breast cancer with bone metastases. The nurse should reinforce teaching about
which potential adverse drug effect?
,1Stroke-like symptoms
2Seizures
3Symptoms of hypocalcemia
4Insomnia - ANS - 1
Tamoxifen is an antineoplastic drug, commonly prescribed for clients with breast
cancer or for clients who are at high risk for developing breast cancer. The most
common adverse drug effects (ADEs) are hot flashes, fluid retention, vaginal
discharge, nausea, vomiting and menstrual irregularities. In women with bone
metastases, tamoxifen may cause transient hypercalcemia. Because of its
estrogen agonist actions, tamoxifen poses a small risk of thromboembolic
events, including deep vein thrombosis, pulmonary embolism and stroke.
\A child diagnosed with thalassemia has received several blood transfusions
during the past three days. What lab value is the priority for the nurse to monitor
with this client?
1Hemoglobin level
2Platelet count
3Blood urea nitrogen level
4Neutrophil percentage - ANS - 1
A normal hemoglobin range for children is approximately 11 to 13 gm/dL.
Thalassemia, also called Cooley's anemia, is a genetic defect that causes anemia,
i.e., a condition in which the blood contains below-normal hemoglobin levels.
Hemoglobin is the oxygen-carrying protein component of the red blood cell
(RBC).
\A child has severe burns to the lower extremities. A diet high in protein and
carbohydrates is recommended. The nurse should care for this client with the
knowledge that the most important reason for such a diet is to achieve which
result?
1Provide a well-balanced nutritional intake
2Promote healing and strengthen the immune system
3Spare protein catabolism to meet metabolic and healing needs
4 stimulate increased peristalsis and nutrient absorption - ANS - 3
\A child is admitted to the hospital for emergency surgery. The child's parent
reports several allergies. Which of these allergies should all the operative health
care personnel be notified about?
1Perfumed soap
2Shellfish
3Balloons
4Mold - ANS - 3
\A child is admitted to the unit with the suspected diagnosis of pertussis
(whooping cough). What is the priority nursing intervention for this child?
, 1. Maintain hydration and encourage fluids
2. Implement droplet precautions
3. Monitor respiratory rate and oxygen saturation
4. Anti- infective therapy - ANS - 2
\A client at risk for a stroke has been prescribed clopidogrel. Which information is
most important for the nurse to reinforce with the client?
1"You must take the medication on an empty stomach."
2"If you miss a dose, take a double dose the next day."
3"You must have your lab tests checked weekly."
4"You must stop the medication a week before your surgery." - ANS - 4
Clopidogrel is an oral antiplatelet drug with similar effects to aspirin. The drug is
taken for secondary prevention of myocardial infarction, ischemic stroke and
other vascular events. Clopidogrel prevents platelet aggregation. Like all other
antiplatelet drugs, clopidogrel poses a risk of serious bleeding. Clopidogrel
should be discontinued 5 to 7 days before elective surgery.
\A client becomes acutely short of breath with an SpO2 (oxygen saturation) of
82%. Which oxygen delivery system should the nurse apply that would provide
the highest concentrations of oxygen to the client?
1Simple face mask
2Partial rebreather mask
3Venturi mask
4Non-rebreather mask - ANS - 4
\A client comes to the community health clinic with symptoms of gonorrhea.
Which intervention should the nurse implement first?
1Discuss the risk of infertility with the client.
2Collect a urethral swab from the client.
3Instruct the client to notify past sexual partners.
4Obtain information about the client's recent sexual encounters. - ANS - 4
\A client diagnosed with autism begins to eat with both hands. The nurse can
best handle the behavior by using which approach?
1Commenting "I believe you know better than to eat with your hands."
2Removing the food and stating "You can't have any more food until you use the
spoon."
3Jokingly stating "Well, I guess fingers sometimes work better than spoons."
4Placing the spoon in the client's hand and stating "Use the spoon to eat your
food." - ANS - 4
\A client diagnosed with bipolar disorder has been referred to social services for
possible placement in a community halfway house after discharge. The social
worker telephones the nurse and asks for information about the client's mental
