NCLEX-PN Exam Fundamentals V1
1. The nurse is reading a client's urinalysis report.The nurse interprets whichitem found on the
report to be considered abnormal?: Positive protein
2. The nurse is assigned to care for a client on contact precautions. On reviewof the client's
record, the nurse notes that the client has a hospital-acquired infection caused by methicillin-
resistant Staphylococcus aureus (MRSA). Theclient has an abdominal wound that requires
irrigation and has a tracheostomyattached to a mechanical ventilator and requires frequent
suctioning. The nurse gathers supplies before entering the client's room and obtains which
necessary protective items?: Gloves, mask, gown, and goggles
3. The skin surrounding a postoperative client's abdominal wound is becom- ing irritated in
the area where the dressing tape is being reapplied with each dressing change. Which is the
appropriate nursing action?: Apply Montgomeryties.
4. The nurse monitors the postoperative client frequently, knowing that accu- mulated
secretions can lead to which problem?: Pneumonia
5. The medication prescribed is hydromorphone hydrochloride (Dilaudid), 3 mg
intramuscularly, every 4 hours as needed. The medication label reads hy- dromorphone
hydrochloride (Dilaudid), 4 mg/1 mL. The nurse should prepare to administer how many mL to
the client? Fill in the blank.: 0.75
6. The nurse is reinforcing instructions to a client regarding how to decrease the intake of
phosphorus in the diet. The nurse should tell the client that which food item contains the least
amount of phosphorus?: Oranges
7. Fentanyl 75 mcg intravenous push (IVP) has been prescribed by the healthcare provider.
The medication ampule reads fentanyl 50 mcg/mL. The nurse should prepare how many
milliliters to administer the correct dose? Fill in theblank and record your answer using one
decimal place.: 1.5
8. A client with a seizure disorder is taking phenytoin (Dilantin). A sample fora serum
phenytoin level is drawn, and the nurse determines that the next dose
of the medication may be administered if which laboratory result is noted?: 17mcg/mL
9. The nurse is reading the health care provider's (HCP's) progress notes inthe client's record
and sees that the HCP has documented "insensible fluid loss of approximately 800 mL daily."
Which client is at risk for this loss?: Clientwith a fast respiratory rate
10. The nurse is assigned to care for a client who has just returned to the nursing unit
following a renal biopsy. The nurse plans to do which action toproperly care for this client for
the remainder of the shift?: Test the urine foroccult blood.
11. The nurse is caring for a client who has a wound infection. Contact pre-cautions are being
followed. Which are correct actions by the nurse when using personal protective equipment
(PPE)? Select all that apply.: Perform hand hygiene after removal of PPE.
, Perform hand hygiene before donning any PPE.When removing PPE, always remove gloves
first
Protective eyewear and face shield are indicated if there is risk of splatter.
12. A client is receiving standard oral anticoagulant therapy with warfarin(Coumadin). The
result of a newly drawn international normalized ratio is
3.8 seconds. The nurse anticipates carrying out a prescription to do whichaction?: Hold the
next dose of warfarin.
13. A client's preoperative vital signs are temperature 98.6° F orally, apical pulse 80 beats per
minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure
168/94 mm Hg in the right arm. Based on theinterpretation of these findings, which action
should the nurse take first?: - Compare these values to those recorded previously.
14. The nurse is assisting with planning care for a client with an internal radiation implant.
Which should be included in the plan of care? Select all thatapply.: Wearing gloves when
emptying the client's bedpan
Keeping all linens in the room until the implant is removed Wearing a film (dosimeter) badge
when in the client's room Wearing a lead apron when providing direct care to the clien
15. The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A
kosher meal is delivered to the client. Which nursing actionis appropriate when assisting the
client with the meal?: Allowing the client tounwrap the utensils and prepare his own meal for
eating
16. The nurse is preparing to administer an intermittent tube feeding to a client.The nurse
aspirates 90 mL of residual from the tube. What should the nurse do with the aspirated
residual?: Reinstill the residual and administer the feeding.
17. The nurse is preparing to give a bed bath to an immobilized client with tuberculosis (TB).
The nurse should plan to wear which items when performingthis care?: Particulate respirator,
gown, and gloves
18. The intravenous prescription is 1000 mL of 0.9% NaCl (normal saline) to runover 12
hours. The drop factor is 15 gtts/1 mL. The nurse plans to adjust the flow rate to how many
gtts/minute? Fill in the blank and record the answer tothe nearest whole number.: 21
19. The nurse is encouraging a client who is incontinent to participate in recreational
therapy. Which nursing intervention should the nurse considerperforming first?: Change the
client's soiled disposable brief.
20. The nursing instructor asks the student to describe isotonic dehydra- tion. The student
1. The nurse is reading a client's urinalysis report.The nurse interprets whichitem found on the
report to be considered abnormal?: Positive protein
2. The nurse is assigned to care for a client on contact precautions. On reviewof the client's
record, the nurse notes that the client has a hospital-acquired infection caused by methicillin-
resistant Staphylococcus aureus (MRSA). Theclient has an abdominal wound that requires
irrigation and has a tracheostomyattached to a mechanical ventilator and requires frequent
suctioning. The nurse gathers supplies before entering the client's room and obtains which
necessary protective items?: Gloves, mask, gown, and goggles
3. The skin surrounding a postoperative client's abdominal wound is becom- ing irritated in
the area where the dressing tape is being reapplied with each dressing change. Which is the
appropriate nursing action?: Apply Montgomeryties.
4. The nurse monitors the postoperative client frequently, knowing that accu- mulated
secretions can lead to which problem?: Pneumonia
5. The medication prescribed is hydromorphone hydrochloride (Dilaudid), 3 mg
intramuscularly, every 4 hours as needed. The medication label reads hy- dromorphone
hydrochloride (Dilaudid), 4 mg/1 mL. The nurse should prepare to administer how many mL to
the client? Fill in the blank.: 0.75
6. The nurse is reinforcing instructions to a client regarding how to decrease the intake of
phosphorus in the diet. The nurse should tell the client that which food item contains the least
amount of phosphorus?: Oranges
7. Fentanyl 75 mcg intravenous push (IVP) has been prescribed by the healthcare provider.
The medication ampule reads fentanyl 50 mcg/mL. The nurse should prepare how many
milliliters to administer the correct dose? Fill in theblank and record your answer using one
decimal place.: 1.5
8. A client with a seizure disorder is taking phenytoin (Dilantin). A sample fora serum
phenytoin level is drawn, and the nurse determines that the next dose
of the medication may be administered if which laboratory result is noted?: 17mcg/mL
9. The nurse is reading the health care provider's (HCP's) progress notes inthe client's record
and sees that the HCP has documented "insensible fluid loss of approximately 800 mL daily."
Which client is at risk for this loss?: Clientwith a fast respiratory rate
10. The nurse is assigned to care for a client who has just returned to the nursing unit
following a renal biopsy. The nurse plans to do which action toproperly care for this client for
the remainder of the shift?: Test the urine foroccult blood.
11. The nurse is caring for a client who has a wound infection. Contact pre-cautions are being
followed. Which are correct actions by the nurse when using personal protective equipment
(PPE)? Select all that apply.: Perform hand hygiene after removal of PPE.
, Perform hand hygiene before donning any PPE.When removing PPE, always remove gloves
first
Protective eyewear and face shield are indicated if there is risk of splatter.
12. A client is receiving standard oral anticoagulant therapy with warfarin(Coumadin). The
result of a newly drawn international normalized ratio is
3.8 seconds. The nurse anticipates carrying out a prescription to do whichaction?: Hold the
next dose of warfarin.
13. A client's preoperative vital signs are temperature 98.6° F orally, apical pulse 80 beats per
minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure
168/94 mm Hg in the right arm. Based on theinterpretation of these findings, which action
should the nurse take first?: - Compare these values to those recorded previously.
14. The nurse is assisting with planning care for a client with an internal radiation implant.
Which should be included in the plan of care? Select all thatapply.: Wearing gloves when
emptying the client's bedpan
Keeping all linens in the room until the implant is removed Wearing a film (dosimeter) badge
when in the client's room Wearing a lead apron when providing direct care to the clien
15. The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A
kosher meal is delivered to the client. Which nursing actionis appropriate when assisting the
client with the meal?: Allowing the client tounwrap the utensils and prepare his own meal for
eating
16. The nurse is preparing to administer an intermittent tube feeding to a client.The nurse
aspirates 90 mL of residual from the tube. What should the nurse do with the aspirated
residual?: Reinstill the residual and administer the feeding.
17. The nurse is preparing to give a bed bath to an immobilized client with tuberculosis (TB).
The nurse should plan to wear which items when performingthis care?: Particulate respirator,
gown, and gloves
18. The intravenous prescription is 1000 mL of 0.9% NaCl (normal saline) to runover 12
hours. The drop factor is 15 gtts/1 mL. The nurse plans to adjust the flow rate to how many
gtts/minute? Fill in the blank and record the answer tothe nearest whole number.: 21
19. The nurse is encouraging a client who is incontinent to participate in recreational
therapy. Which nursing intervention should the nurse considerperforming first?: Change the
client's soiled disposable brief.
20. The nursing instructor asks the student to describe isotonic dehydra- tion. The student
