NCLEX NGN PRE-TEST QUESTIONS / STUDY GUIDE COMPLETE QUESTION
AND CORRECT DETAILED ANSWERS & RATIONALES / 2025
1. A nurse is assigned to care for a client with chron- A, B, C, D
ic 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
2. A nurse is evaluating outcomes for a client with D, E
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 extremi-
ties
d. Clear sound in the lower lung fields bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg
3. A nurse of the telemetry unit is caring for a client A
who has had a MI and is now attached to a cardiac The pattern of ventricular fibril-
monitor. The nurse is monitoring the client's car- lation is identified and can be a
diac rhythm and nots ventricular fibrillation. Which result after a patient with an MI.
, NCLEX NGN PRE-TEST QUESTIONS / STUDY GUIDE COMPLETE QUESTION
AND CORRECT DETAILED ANSWERS & RATIONALES / 2025
nursing intervention should the nurse take first? VF makes the patient feel faint,
a. Calling the rapid response team then loses consciousness and
b. Preparing the client for cardioversion becomes pulseless and apneic
c. Asking the client to bear down and cough (BP and heart sounds absent).
d. Preparing to administer diltiazem Treatment is to terminate VF and
covert it into a rhythm via defib-
rillation-> call a rapid and initi-
ate CPR. Cardioversion is used
for ventricular or supraventricu-
lar tachydysrhythmias.
4. A nurse developing a plan of care for a client with B
a spinal cord injury includes measures to prevent The most frequent cause of au-
autonomic dysreflexia (hyperreflexia). Which inter- tonomic dysreflexias are a dis-
vention does the nurse incorporate into the plan to tended bladder and impact-
prevent this complication? ed feces. Other causes include
a. Keeping the fan running in the client's room stimulation of the skin by tactile,
b. Keeping the linens wrinkle free under the client thermal, or painful stimuli. The
c. Limiting bladder catheterization to once every 12 nurse renders care in such a way
hours as to minimize these risks.
d. Avoiding the administration of enemas and rec-
tal suppositories
5. A nurse provides home care instructions to a client C
who has been fitted with a halo device to treat Cleanse the skin under the wool
a cervical fracture. Which statement by the client liner each day to prevent rashes
indicates the need for further teaching? and soars.
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
, NCLEX NGN PRE-TEST QUESTIONS / STUDY GUIDE COMPLETE QUESTION
AND CORRECT DETAILED ANSWERS & RATIONALES / 2025
to prevent sweating
d. I have to check the pin sites everyday and watch
for signs of infection
6. A nurse is caring for a client with increased in- D
tracranial pressure. In which position should the Proper positioning promotes
nurse maintain the client? venous drainage from the crani-
a. Supine with the head extended um to minimize ICP.
b. Side lying with the neck flexed
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees
7. A client with a basilar skull fracture has clear fluid B
leaking from the ears. The nurse should take which CSF contains glucose not pro-
action first? tein.
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 mem-
brane for rupture
8. A nurse is caring for a client who has just un- A
dergone cardioversion. Which intervention is the ABC's of nursing. All other choic-
nurse's priority after this procedure. es are correct, but not priority.
a. Administer oxygen
b. Monitoring the BP
c. Administering antidysrhythmic medications
d. Monitoring the client's LOC
9. A client with diabetes mellitus who is scheduled to B
have blood drawn for determination of the glyco-
sylated hemoglobin (HbA1c) level asks the nurse
AND CORRECT DETAILED ANSWERS & RATIONALES / 2025
1. A nurse is assigned to care for a client with chron- A, B, C, D
ic 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
2. A nurse is evaluating outcomes for a client with D, E
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 extremi-
ties
d. Clear sound in the lower lung fields bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg
3. A nurse of the telemetry unit is caring for a client A
who has had a MI and is now attached to a cardiac The pattern of ventricular fibril-
monitor. The nurse is monitoring the client's car- lation is identified and can be a
diac rhythm and nots ventricular fibrillation. Which result after a patient with an MI.
, NCLEX NGN PRE-TEST QUESTIONS / STUDY GUIDE COMPLETE QUESTION
AND CORRECT DETAILED ANSWERS & RATIONALES / 2025
nursing intervention should the nurse take first? VF makes the patient feel faint,
a. Calling the rapid response team then loses consciousness and
b. Preparing the client for cardioversion becomes pulseless and apneic
c. Asking the client to bear down and cough (BP and heart sounds absent).
d. Preparing to administer diltiazem Treatment is to terminate VF and
covert it into a rhythm via defib-
rillation-> call a rapid and initi-
ate CPR. Cardioversion is used
for ventricular or supraventricu-
lar tachydysrhythmias.
4. A nurse developing a plan of care for a client with B
a spinal cord injury includes measures to prevent The most frequent cause of au-
autonomic dysreflexia (hyperreflexia). Which inter- tonomic dysreflexias are a dis-
vention does the nurse incorporate into the plan to tended bladder and impact-
prevent this complication? ed feces. Other causes include
a. Keeping the fan running in the client's room stimulation of the skin by tactile,
b. Keeping the linens wrinkle free under the client thermal, or painful stimuli. The
c. Limiting bladder catheterization to once every 12 nurse renders care in such a way
hours as to minimize these risks.
d. Avoiding the administration of enemas and rec-
tal suppositories
5. A nurse provides home care instructions to a client C
who has been fitted with a halo device to treat Cleanse the skin under the wool
a cervical fracture. Which statement by the client liner each day to prevent rashes
indicates the need for further teaching? and soars.
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
, NCLEX NGN PRE-TEST QUESTIONS / STUDY GUIDE COMPLETE QUESTION
AND CORRECT DETAILED ANSWERS & RATIONALES / 2025
to prevent sweating
d. I have to check the pin sites everyday and watch
for signs of infection
6. A nurse is caring for a client with increased in- D
tracranial pressure. In which position should the Proper positioning promotes
nurse maintain the client? venous drainage from the crani-
a. Supine with the head extended um to minimize ICP.
b. Side lying with the neck flexed
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees
7. A client with a basilar skull fracture has clear fluid B
leaking from the ears. The nurse should take which CSF contains glucose not pro-
action first? tein.
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 mem-
brane for rupture
8. A nurse is caring for a client who has just un- A
dergone cardioversion. Which intervention is the ABC's of nursing. All other choic-
nurse's priority after this procedure. es are correct, but not priority.
a. Administer oxygen
b. Monitoring the BP
c. Administering antidysrhythmic medications
d. Monitoring the client's LOC
9. A client with diabetes mellitus who is scheduled to B
have blood drawn for determination of the glyco-
sylated hemoglobin (HbA1c) level asks the nurse
