NGN NCLEX RN ACTUAL Exam
1. A nurse is reinforcing teaching with the parents of a toddler who has a
new diagnosis of asthma and a prescription for montelukast. Which of the
following instructions should the nurse include in the teaching?:
Answer:
Administer the medication to the toddler each evening
2. A nurse in an acute mental health facility is caring for a newly admitted
client. Which of the following should occur during the orientation phase of
the nurse-client relationship?:
Answer:
Defining responsibilities
3. A nurse is caring for a client who reports having a decrease in fetal movement
following an external cephalic version 6 hr ago. The nurse identifies the
fetus is in the right occiput anterior position. The nurse should place the fetal
heart monitor on which of the following sites to auscultate the fetal heart
rate?:
Answer:
Lower left
4. A charge nurse is observing a newly licensed nurse perform suctioning
for a client who has a tracheostomy. For which of the following actions by
the newly licensed nurse should the charge nurse intervene?:
Answer:
Suction for 30 seconds
5. A nurse is reviewing the medication administration record of a client
who takes atenolol PO and supplies a nitroglycerin transdermal patch daily.
Which of the following interactions should the nurse monitor with this
client?:
Answer:
Hypotension
6. A nurse in an acute care setting is preparing to administer medications
to a client. Which of the following actions should the nurse verify the client's
,identity?:
Answer:
Verify the client's identity using a photograph
7. A nurse in a provider's office is collecting data from a client who has
psoriasis. Which of the following statements made by the client should she
report to the provider?:
Answer:
"I try not to look at the scales on my body"
8. A nurse is completing chart reviews in a long-term care facility in response
to an increase in falls. Which of the following responses in the chart
should the nurse use to determine the potential causes of falls?:
Answer:
Medication record
9. A nurse is making client care assignments for an assistive personnel
(AP). Which of the following tasks should the nurse assign to the AP?:
Answer:
Complete post mortem care for a client who has died
10. A nurse is reinforcing teaching with a client who is taking allopurinol
about the risk for developing Stevens-Johnsons syndrome. For which of the
following manifestations should the nurse instruct the client to monitor and
report?:
Answer:
Skin rash with fever
11. A charge nurse in a long-term care facility is reinforcing teaching with
a group of nurses about fall precautions. Which of the following statements
made by the nurse indicates an understanding of the teaching?:
Answer:
"I will instruct the client to sit when putting on a pair of pants"
12. A nurse is recommending clients for discharge to allow for admission of
clients following a tornado disaster. Which of the following clients should the
nurse recommend for discharge?:
,Answer:
A client who has a sodium level of 140 mEq/L after one episode of diarrhea
13. A nurse is assisting with the plan of care for a newly
admitted client who
has anorexia nervosa. Which of the following interventions should the nurse
include in the plan?:
Answer:
Administer liquid supplements
14. An assistive personnel tells the charge nurse that her assignment is
too demanding. She angrily tells the nurse to reassign one of her tasks to
another AP. Which of the following actions should the nurse take to resolve
the conflict?:
Answer:
Ask the AP to discuss the issue in a private area
15. A nurse is supervising an assistive personnel (AP) obtain supplies for a
client who is on seizure precautions. Which of the following materials should
the AP place in the client's room?:
Answer:
Oral Suction Equipment
16. A charge nurse on a mental health unit is supervising a newly licensed
nurse. For which of the following actions by the newly licensed nurse should
the supervising nurse intervene?:
Answer:
Tells a client he will lose his phone privileges if he does not take his medication
17. A nurse is caring for a client who follows a kosher diet. Which of
thefollowing menu items should the nurse include in the meal tray?:
Answer:
Roasted Salmon
, 18. A nurse is reviewing information about advance directives with a
newly admitted client. Which of the following statements by the client
indicates anunderstanding of the information?:
Answer:
"Advance directives include a living will"
19. A nurse is collecting data from the caregiver of a client who has
Alzheimer's disease. The caregiver reports the client has difficulty sleeping
at night and wanders throughout the house. Which of the following interventions
should the nurse recommend?:
Answer:
Encourage the client to take frequentwalks during the day
20. A nurse is assisting in the care of a client who is 8hr postpartum and
has uterine atony with increased bleeding. Which of the following actions
shouldthe nurse take? (Select all that apply):
Answer:
Assist the client to empty her bladder
21. A nurse is reinforcing teaching with the support person of a client who is
inthe first stage of labor. Which of the following instructions should the
nurse include regarding effleurage?:
Answer:
"Gently stroke her abdomen during contractions"
22. A nurse is caring for an older adult client who is postoperative
following a total hip arthroplasty. The client is incontinent of stool and urine.
Which ofthe following actions should the nurse take to prevent skin
breakdown?:
Answer:
Use
a moisture barrier on the client's skin
23. A nurse is caring for a client who has terminal cancer. Which of the following
actions should the nurse take to promote the client's autonomy?:
Answer:
1. A nurse is reinforcing teaching with the parents of a toddler who has a
new diagnosis of asthma and a prescription for montelukast. Which of the
following instructions should the nurse include in the teaching?:
Answer:
Administer the medication to the toddler each evening
2. A nurse in an acute mental health facility is caring for a newly admitted
client. Which of the following should occur during the orientation phase of
the nurse-client relationship?:
Answer:
Defining responsibilities
3. A nurse is caring for a client who reports having a decrease in fetal movement
following an external cephalic version 6 hr ago. The nurse identifies the
fetus is in the right occiput anterior position. The nurse should place the fetal
heart monitor on which of the following sites to auscultate the fetal heart
rate?:
Answer:
Lower left
4. A charge nurse is observing a newly licensed nurse perform suctioning
for a client who has a tracheostomy. For which of the following actions by
the newly licensed nurse should the charge nurse intervene?:
Answer:
Suction for 30 seconds
5. A nurse is reviewing the medication administration record of a client
who takes atenolol PO and supplies a nitroglycerin transdermal patch daily.
Which of the following interactions should the nurse monitor with this
client?:
Answer:
Hypotension
6. A nurse in an acute care setting is preparing to administer medications
to a client. Which of the following actions should the nurse verify the client's
,identity?:
Answer:
Verify the client's identity using a photograph
7. A nurse in a provider's office is collecting data from a client who has
psoriasis. Which of the following statements made by the client should she
report to the provider?:
Answer:
"I try not to look at the scales on my body"
8. A nurse is completing chart reviews in a long-term care facility in response
to an increase in falls. Which of the following responses in the chart
should the nurse use to determine the potential causes of falls?:
Answer:
Medication record
9. A nurse is making client care assignments for an assistive personnel
(AP). Which of the following tasks should the nurse assign to the AP?:
Answer:
Complete post mortem care for a client who has died
10. A nurse is reinforcing teaching with a client who is taking allopurinol
about the risk for developing Stevens-Johnsons syndrome. For which of the
following manifestations should the nurse instruct the client to monitor and
report?:
Answer:
Skin rash with fever
11. A charge nurse in a long-term care facility is reinforcing teaching with
a group of nurses about fall precautions. Which of the following statements
made by the nurse indicates an understanding of the teaching?:
Answer:
"I will instruct the client to sit when putting on a pair of pants"
12. A nurse is recommending clients for discharge to allow for admission of
clients following a tornado disaster. Which of the following clients should the
nurse recommend for discharge?:
,Answer:
A client who has a sodium level of 140 mEq/L after one episode of diarrhea
13. A nurse is assisting with the plan of care for a newly
admitted client who
has anorexia nervosa. Which of the following interventions should the nurse
include in the plan?:
Answer:
Administer liquid supplements
14. An assistive personnel tells the charge nurse that her assignment is
too demanding. She angrily tells the nurse to reassign one of her tasks to
another AP. Which of the following actions should the nurse take to resolve
the conflict?:
Answer:
Ask the AP to discuss the issue in a private area
15. A nurse is supervising an assistive personnel (AP) obtain supplies for a
client who is on seizure precautions. Which of the following materials should
the AP place in the client's room?:
Answer:
Oral Suction Equipment
16. A charge nurse on a mental health unit is supervising a newly licensed
nurse. For which of the following actions by the newly licensed nurse should
the supervising nurse intervene?:
Answer:
Tells a client he will lose his phone privileges if he does not take his medication
17. A nurse is caring for a client who follows a kosher diet. Which of
thefollowing menu items should the nurse include in the meal tray?:
Answer:
Roasted Salmon
, 18. A nurse is reviewing information about advance directives with a
newly admitted client. Which of the following statements by the client
indicates anunderstanding of the information?:
Answer:
"Advance directives include a living will"
19. A nurse is collecting data from the caregiver of a client who has
Alzheimer's disease. The caregiver reports the client has difficulty sleeping
at night and wanders throughout the house. Which of the following interventions
should the nurse recommend?:
Answer:
Encourage the client to take frequentwalks during the day
20. A nurse is assisting in the care of a client who is 8hr postpartum and
has uterine atony with increased bleeding. Which of the following actions
shouldthe nurse take? (Select all that apply):
Answer:
Assist the client to empty her bladder
21. A nurse is reinforcing teaching with the support person of a client who is
inthe first stage of labor. Which of the following instructions should the
nurse include regarding effleurage?:
Answer:
"Gently stroke her abdomen during contractions"
22. A nurse is caring for an older adult client who is postoperative
following a total hip arthroplasty. The client is incontinent of stool and urine.
Which ofthe following actions should the nurse take to prevent skin
breakdown?:
Answer:
Use
a moisture barrier on the client's skin
23. A nurse is caring for a client who has terminal cancer. Which of the following
actions should the nurse take to promote the client's autonomy?:
Answer:
