NCLEX NGN PRE-TEST QUESTIONS AND 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 - Answers
:A, B, C, D
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 - Answers :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 - Answers :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 - Answers :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 - Answers :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
e. Dyspnea with ambulating
f. Expectoration of frothy mucus - Answers :B, D, E
A opportunistic respiratory infection associated with AIDs that causes dyspnea,
nonproductive cough, intermittent fever, fatigue, anorexia, tachypnea, wt. loss.
Zidovudine is prescribed for a client with AIDS. The nurse tells the client that it is
important to report back to the clinic as scheduled for which follow-up diagnostic?
a. Blood glucose checks
b. Blood pressure checks
c. Complete blood counts (CBC)
d. Electrocradiographic studies - Answers :C
Zidovudine is an antiviral medication that cause cause agranulocytosis and anemia.
After a non-immunocompromised client undergoes a Mantoux test for TB infection, an
area of induration 6 mm wide developed. The client asks the nurse what this result
means. Which is the best response?
a. We'll have to repeat the test because the result was inconclusive
b. The swollen area is small, so that means your test result is negative
c. You've been exposed to TB so you will need to have a chest x-ray
d. You need to get started on medication right away because you have TB - Answers :B
Indurations less than 10 mm (non-immunocompromised) and 5 mm
(immunocompromised) is considered a negative result after 48-72 hrs. Results greater
indicate exposure and possible TB infection. Morse testing (x-ray) will be needed.
A clients arterial blood gases are analyzed; pH 1.49, paO2 97 mmHg, HCO3- 22 mEq/L.
Which acid base balance disturbance does the nurse identify from these results?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis - Answers :D
RAcidosis: paCo2 >45 mmHg and RAlkalosis is paCo2 <35 mmHg. MAcidosis is HCO3-
is less than 22 mEq/L and MAlkalosis is HCO3- greater than 26 mEq/L.
A client has recently been diagnosed with deep vein thrombosis of the right leg. Which
of the following interventions of the nurse immediately implement?
a. Elevating the foot of the bed 6 inches
b. Placing ice packs on and under the right leg
c. Documenting the need for hourly calf measurements
d. Performing the need for hourly calf measurements - Answers :A
, DVT treatment includes bed rest, leg elevation, and application of warm, moist heat.
Elevation decreases the venous pressure with relieves edema and pain. ROM cause
cause the thrombus to mobilize to the lungs causing PEs.
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 - Answers :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 - Answers :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 - Answers :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 - Answers :C
Cleanse the skin under the wool liner each day to prevent rashes and soars.
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 - Answers
:A, B, C, D
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 - Answers :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 - Answers :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 - Answers :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 - Answers :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
e. Dyspnea with ambulating
f. Expectoration of frothy mucus - Answers :B, D, E
A opportunistic respiratory infection associated with AIDs that causes dyspnea,
nonproductive cough, intermittent fever, fatigue, anorexia, tachypnea, wt. loss.
Zidovudine is prescribed for a client with AIDS. The nurse tells the client that it is
important to report back to the clinic as scheduled for which follow-up diagnostic?
a. Blood glucose checks
b. Blood pressure checks
c. Complete blood counts (CBC)
d. Electrocradiographic studies - Answers :C
Zidovudine is an antiviral medication that cause cause agranulocytosis and anemia.
After a non-immunocompromised client undergoes a Mantoux test for TB infection, an
area of induration 6 mm wide developed. The client asks the nurse what this result
means. Which is the best response?
a. We'll have to repeat the test because the result was inconclusive
b. The swollen area is small, so that means your test result is negative
c. You've been exposed to TB so you will need to have a chest x-ray
d. You need to get started on medication right away because you have TB - Answers :B
Indurations less than 10 mm (non-immunocompromised) and 5 mm
(immunocompromised) is considered a negative result after 48-72 hrs. Results greater
indicate exposure and possible TB infection. Morse testing (x-ray) will be needed.
A clients arterial blood gases are analyzed; pH 1.49, paO2 97 mmHg, HCO3- 22 mEq/L.
Which acid base balance disturbance does the nurse identify from these results?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis - Answers :D
RAcidosis: paCo2 >45 mmHg and RAlkalosis is paCo2 <35 mmHg. MAcidosis is HCO3-
is less than 22 mEq/L and MAlkalosis is HCO3- greater than 26 mEq/L.
A client has recently been diagnosed with deep vein thrombosis of the right leg. Which
of the following interventions of the nurse immediately implement?
a. Elevating the foot of the bed 6 inches
b. Placing ice packs on and under the right leg
c. Documenting the need for hourly calf measurements
d. Performing the need for hourly calf measurements - Answers :A
, DVT treatment includes bed rest, leg elevation, and application of warm, moist heat.
Elevation decreases the venous pressure with relieves edema and pain. ROM cause
cause the thrombus to mobilize to the lungs causing PEs.
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 - Answers :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 - Answers :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 - Answers :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 - Answers :C
Cleanse the skin under the wool liner each day to prevent rashes and soars.
