NCLEX-ATA QUESTIONS AND ANSWERS
1) The nurse interacts with a patient diagnosed with schizophrenia. The nurse identifies
which of the following symptoms exhibited by the patient as positive symptoms of
schizophrenia?
Select all answers that apply: - Answers - (1) Delusions of persecution.
CORRECT-positive symptoms are excess or distortion of normal functions,
hallucinations, and delusions
(2) Poor eye contact.
negative symptoms indicate loss of normal function
(3) Incoherent thoughts.
CORRECT-positive symptom
(4) Poor grooming habits.
negative symptoms indicate loss of normal function
(5) Inappropriate affect.
negative symptoms indicate loss of normal function
(6) Social isolation.
negative symptoms indicate loss of normal function
2) The nursing team consists of an RN, two licensed practical/vocational nurses, and
three nursing assistants. The nurse determines that care is appropriate if a nursing
assistant is assigned to which of the following?
2) The nursing team consists of an RN, two licensed practical/vocational nurses, and
three nursing assistants. The nurse determines that care is appropriate if a nursing
assistant is assigned to which of the following? - Answers - Complete A.M. care for a
patient diagnosed with a head injury and a Glasgow coma scale of 5.
requires the assessment skills of the RN; Glasgow coma scale of 5 indicates coma
(2) Reposition a patient who has bloody drainage from a chest tube due to a right-sided
pneumothorax.
CORRECT-assistive personnel can reposition the client but cannot care for the chest
tubes
(3) Obtain a pulse oximetry reading for a patient diagnosed with hypertension
complaining of chest pain.
CORRECT-measuring oxygen saturation is a standard, unchanging procedure; instruct
to report any SpO2 reading lower than 90%
(4) Perform a dressing change for a patient diagnosed with osteomyelitis due to a dog
bite.
stable patient with expected outcome, assign to the LPN/LVN
(5) Administer tube feeding to a patient with dysphagia due to a cerebral vascular
accident.
stable patient with expected outcome, assign to the LPN/LVN
(6) Set up oxygen for a patient diagnosed with chronic obstructive pulmonary disease
with shortness of breath.
nurse should assess client and ensure that device is set up appropriately
,3) The home-care nurse visits a teenaged mother and her 2-week-old infant. The client
informs the nurse that she and the baby are temporarily living with her parents. During
the nursing interview, the client's mother brings the baby to the client and informs her
that it is time to feed the infant. Which of the following observations, if made by the
nurse, require further assessment?
Select all answers that apply: - Answers - (1) The client states that her baby feeds
every 5-6 hours.
CORRECT-not feeding frequently enough; bottle-fed infants should feed every 3-4
hours; breastfed infants should feed every 1.5-3 hours
(2) The client maintains eye-to-eye contact when feeding the infant.
indicates that the mother is bonding with the infant
(3) The client interrupts the feeding to take a phone call.
CORRECT-indicates distance between the mother and infant; nurse should further
assess mother-infant bonding
(4) The client strokes her infant's head during the feeding.
indicates mother-infant bonding
(5) The client discusses what she has been reading in a child-care book.
indicates that mother is interested in caring for her infant
(6) The client continues the interview with the nurse while feeding the infant.
allows the nurse to assess how mother and baby are interacting
4) The nurse observes a staff member wearing a scrub suit enter the room of a patient.
The nurse determines that the staff member is using the proper precautions when
caring for which of the following patients?
Select all answers that apply: - Answers - (1) A patient diagnosed with cancer
complaining of a sore mouth.
CORRECT-indicates Candida; standard precautions required
(2) A patient diagnosed with tuberculosis requiring administration of rifampin.
requires airborne precautions
(3) A patient diagnosed with herpes zoster with an ophthalmic infection.
CORRECT-caused by varicella virus; requires standard precautions; ophthalmic herpes
zoster considered a medical emergency
(4) A patient diagnosed with rubella requiring an IM injection.
requires droplet precautions
(5) A patient with a draining abscess that is uncovered.
abscess with no dressing requires contact precautions
(6) A patient diagnosed with Pneumocystis carinii pneumonia with an elevated
temperature.
CORRECT-protozoal infection, most common opportunistic infection of HIV; requires
standard precautions
5) The home-care nurse makes a home visit to a client diagnosed with rheumatoid
arthritis. The nurse determines that the client's care is appropriate if the client makes
which of the following statements?
, Select all answers that apply: - Answers - (1) "I take ibuprofen when I am having
trouble coping with the joint pain."
ibuprofen is NSAID; should be taken as prescribed and on time to ensure consistent
blood levels
(2) "I take a warm bath as soon as I get up in the morning."
CORRECT-decreases pain and increases mobility; encourage to use heat after periods
of rest
(3) "I carry this small purse in my hands when I go out."
increases pain in small joints; encourage to use large joints
(4) "I complete all of my daily chores first so that I can spend the afternoon resting."
should balance rest and activity to conserve energy
(5) "I swim at an indoor pool 3 days a week."
CORRECT-regular exercise increases muscle tone and enhances psychological well-
being
(6) "I like to sleep on my back with several pillows under my knees."
should lie flat with one pillow under head; do not elevate knees, may cause flexion
contractures
Key = Correct = Incorre
6) The nurse in the outpatient clinic performs patient teaching for a client receiving
cholestyramine (Questran). The nurse should include which of the following
instructions?
Select all answers that apply: - Answers - (1) Take the cholestyramine (Questran) with
meals.
CORRECT-appropriate action; never take powder dry because it will cause esophageal
irritation
(2) Increase intake of whole grain cereals.
1) The nurse interacts with a patient diagnosed with schizophrenia. The nurse identifies
which of the following symptoms exhibited by the patient as positive symptoms of
schizophrenia?
Select all answers that apply: - Answers - (1) Delusions of persecution.
CORRECT-positive symptoms are excess or distortion of normal functions,
hallucinations, and delusions
(2) Poor eye contact.
negative symptoms indicate loss of normal function
(3) Incoherent thoughts.
CORRECT-positive symptom
(4) Poor grooming habits.
negative symptoms indicate loss of normal function
(5) Inappropriate affect.
negative symptoms indicate loss of normal function
(6) Social isolation.
negative symptoms indicate loss of normal function
2) The nursing team consists of an RN, two licensed practical/vocational nurses, and
three nursing assistants. The nurse determines that care is appropriate if a nursing
assistant is assigned to which of the following?
2) The nursing team consists of an RN, two licensed practical/vocational nurses, and
three nursing assistants. The nurse determines that care is appropriate if a nursing
assistant is assigned to which of the following? - Answers - Complete A.M. care for a
patient diagnosed with a head injury and a Glasgow coma scale of 5.
requires the assessment skills of the RN; Glasgow coma scale of 5 indicates coma
(2) Reposition a patient who has bloody drainage from a chest tube due to a right-sided
pneumothorax.
CORRECT-assistive personnel can reposition the client but cannot care for the chest
tubes
(3) Obtain a pulse oximetry reading for a patient diagnosed with hypertension
complaining of chest pain.
CORRECT-measuring oxygen saturation is a standard, unchanging procedure; instruct
to report any SpO2 reading lower than 90%
(4) Perform a dressing change for a patient diagnosed with osteomyelitis due to a dog
bite.
stable patient with expected outcome, assign to the LPN/LVN
(5) Administer tube feeding to a patient with dysphagia due to a cerebral vascular
accident.
stable patient with expected outcome, assign to the LPN/LVN
(6) Set up oxygen for a patient diagnosed with chronic obstructive pulmonary disease
with shortness of breath.
nurse should assess client and ensure that device is set up appropriately
,3) The home-care nurse visits a teenaged mother and her 2-week-old infant. The client
informs the nurse that she and the baby are temporarily living with her parents. During
the nursing interview, the client's mother brings the baby to the client and informs her
that it is time to feed the infant. Which of the following observations, if made by the
nurse, require further assessment?
Select all answers that apply: - Answers - (1) The client states that her baby feeds
every 5-6 hours.
CORRECT-not feeding frequently enough; bottle-fed infants should feed every 3-4
hours; breastfed infants should feed every 1.5-3 hours
(2) The client maintains eye-to-eye contact when feeding the infant.
indicates that the mother is bonding with the infant
(3) The client interrupts the feeding to take a phone call.
CORRECT-indicates distance between the mother and infant; nurse should further
assess mother-infant bonding
(4) The client strokes her infant's head during the feeding.
indicates mother-infant bonding
(5) The client discusses what she has been reading in a child-care book.
indicates that mother is interested in caring for her infant
(6) The client continues the interview with the nurse while feeding the infant.
allows the nurse to assess how mother and baby are interacting
4) The nurse observes a staff member wearing a scrub suit enter the room of a patient.
The nurse determines that the staff member is using the proper precautions when
caring for which of the following patients?
Select all answers that apply: - Answers - (1) A patient diagnosed with cancer
complaining of a sore mouth.
CORRECT-indicates Candida; standard precautions required
(2) A patient diagnosed with tuberculosis requiring administration of rifampin.
requires airborne precautions
(3) A patient diagnosed with herpes zoster with an ophthalmic infection.
CORRECT-caused by varicella virus; requires standard precautions; ophthalmic herpes
zoster considered a medical emergency
(4) A patient diagnosed with rubella requiring an IM injection.
requires droplet precautions
(5) A patient with a draining abscess that is uncovered.
abscess with no dressing requires contact precautions
(6) A patient diagnosed with Pneumocystis carinii pneumonia with an elevated
temperature.
CORRECT-protozoal infection, most common opportunistic infection of HIV; requires
standard precautions
5) The home-care nurse makes a home visit to a client diagnosed with rheumatoid
arthritis. The nurse determines that the client's care is appropriate if the client makes
which of the following statements?
, Select all answers that apply: - Answers - (1) "I take ibuprofen when I am having
trouble coping with the joint pain."
ibuprofen is NSAID; should be taken as prescribed and on time to ensure consistent
blood levels
(2) "I take a warm bath as soon as I get up in the morning."
CORRECT-decreases pain and increases mobility; encourage to use heat after periods
of rest
(3) "I carry this small purse in my hands when I go out."
increases pain in small joints; encourage to use large joints
(4) "I complete all of my daily chores first so that I can spend the afternoon resting."
should balance rest and activity to conserve energy
(5) "I swim at an indoor pool 3 days a week."
CORRECT-regular exercise increases muscle tone and enhances psychological well-
being
(6) "I like to sleep on my back with several pillows under my knees."
should lie flat with one pillow under head; do not elevate knees, may cause flexion
contractures
Key = Correct = Incorre
6) The nurse in the outpatient clinic performs patient teaching for a client receiving
cholestyramine (Questran). The nurse should include which of the following
instructions?
Select all answers that apply: - Answers - (1) Take the cholestyramine (Questran) with
meals.
CORRECT-appropriate action; never take powder dry because it will cause esophageal
irritation
(2) Increase intake of whole grain cereals.
