NCLEX RN ACTUAL EXAM TEST BANK, REAL QUESTIONS & ANSWERS NCLEX
w w w w w w w w w w
QUESTION 1 w
Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy?
w w w w w w w w w w w
A. Positive inotropes
w w
B. Vasodilators
w
C. Diuretics
w
D. Antidysrhythmics
w
Answer: A w
wExplanation:
(A) Positive inotropic agents should not be administered owing to their action of increasing myocardial
w w w w w w w w w w w w w w
wcontractility. Increased ventricular contractility would increase outflow tract obstruction in the client with
w w w w w w w w w w w w
whypertrophic cardiomyopathy. (B) Vasodilators are not typically prescribed but are not contraindicated. (C)
w w w w w w w w w w w w
wDiuretics are used with caution to avoid causing hypovolemi
w w w w w w w w
A. (D) Antidysrhythmics are typically needed to treat both atrial and ventricular dysrhythmias.
w w w w w w w w w w w w
QUESTION 2 w
Signs and symptoms of an allergy attack include which of the following?
w w w w w w w w w w w
A. Wheezing on inspiration
w w w
B. Increased respiratory rate
w w w
C. Circumoral cyanosis
w w
D. Prolonged expiration
w w
Answer: D w
wExplanation:
(A) Wheezing occurs during expiration when air movement is impaired because of constricted edematous bronchial
w w w w w w w w w w w w w w
wlumin
A. (B) Respirations are difficult, but the rate is frequently normal. (C) The circumoral area is usually pale. Cyanosis
w w w w w w w w w w w w w w w w w w
wis not an early sign of hypoxi
w w w w w w
A. (D) Expiration is prolonged because the alveoli are greatly distended and air trapping occurs.
w w w w w w w w w w w w w w
QUESTION 3 w
A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of
w w w w w w w w w w w w w w w w w w w w w w
hallucination?
w
A. Auditory
w
B. Gustatory
w
C. Olfactory
w
D. Visceral
w
Answer: B w
wExplanation:
(A) Auditory hallucinations involve sensory perceptions of hearing. (B) Gustatory hallucinations involve
w w w w w w w w w w w
wsensory perceptions of taste. (C) Olfactory hallucinations involve sensory perceptions of smell. (D) Visceral
w w w w w w w w w w w w w
hallucinations involve sensory perceptions of sensation
w w w w w
,QUESTION
4 Which of the following findings would be abnormal in a postpartal woman?
w w w w w w w w w w w w
A. Chills shortly after delivery w w w
B. Pulse rate of 60 bpm in morning on first postdelivery day
w w w w w w w w w w
C. Urinary output of 3000 mL on the second day after delivery
w w w w w w w w w w
D. An oral temperature of 101F (38.3C) on the third day after delivery
w w w w w w w w w w w
Answer: D w
wExplanation:
(A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous
w w w w w w w w w w w w w w w w
wresponse or to vasomotor changes. If not followed by a fever, it is clinically innocuous. (B) The pulse rate
w w w w w w w w w w w w w w w w w w
wduring the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt
w w w w w w w w w w w w w w w w w w
wto the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. (C)
w w w w w w w w w w w w w w w w w w
wUrinary output increases during the early postpartal period (12–24 hours) owing to diuresis. The kidneys must
w w w w w w w w w w w w w w w
weliminate an estimated 2000–3000 mL of extracellular fluid associated with a normal pregnancy. (D) A
w w w w w w w w w w w w w w
wtemperature of 100.4F (38C) may occur after delivery as a result of exertion and dehydration of labor. However,
w w w w w w w w w w w w w w w w w
wanytemperature greater than 100.4F needs further investigation to identify any infectious process.
w w w w w w w w w w w
QUESTION 5 w
A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the
w w w w w w w w w w w w w w w w w
parents, the nurse states that:
w w w w w
A. Sustained temperature elevation over 103F is generally related to febrile seizures
w w w w w w w w w w
B. Febrile seizures do not usually recur w w w w w
C. There is little risk of neurological deficit and mental retardation as sequelae to febrile seizures
w w w w w w w w w w w w w w
D. Febrile seizures are associated with diseases of the central nervous system
w w w w w w w w w w
Answer: C w
wExplanation:
(A) The temperature elevation related to febrile seizures generally exceeds 101F, and seizures occur during the
w w w w w w w w w w w w w w w
wtemperature rise rather than after a prolonged elevation. (B) Febrile seizures may recur and are more likely to do
w w w w w w w w w w w w w w w w w w
wso when the first seizure occurs in the 1st year of life. (C) There is little risk of neurological deficit, mental
w w w w w w w w w w w w w w w w w w w w
wretardation, or altered behavior secondary to febrile seizures. (D) Febrile seizures are associated with disease of
w w w w w w w w w w w w w w w
wthe central nervous system.
w w w
QUESTION 6 w
A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following
w w w w w w w w w w w w w w w w w
nutritional interventions would be most therapeutic for him at this time?
w w w w w w w w w w w
A. Small, frequent feedings of foods that can be carried
w w w w w w w w
B. Tube feedings with nutritional supplements
w w w w
C. Allowing him to eat when and what he wants w w w w w w w w
D. Giving him a quiet place where he can sit down to eat meals
w w w w w w w w w w w w
Answer: A w
wExplanation:
(A) The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with
w w w w w w w w w w w w w w w w w w w
,finger foods allow him to eat during periods of activity. (B) This type of therapy should be implemented when
w w w w w w w w w w w w w w w w w w
wother methods have been exhausted. (C) The manic client should not be in control of his treatment plan. This
w w w w w w w w w w w w w w w w w w
wtype of client may forget to eat. (D) The manic client is unable to sit down to eat full meals.
w w w w w w w w w w w w w w w w w w w
QUESTION 7 w
A client with bipolar disorder taking lithium tells the nurse that he has ringing in his ears, blurred vision, and
w w w w w w w w w w w w w w w w w w w
diarrhe
w
A. The nurse notices a slight tremor in his left hand and a slurring pattern to his speech. Which of the following
w w w w w w w w w w w w w w w w w w w w w
actions by the nurse is appropriate?
w w w w w w
A. Administer a stat dose of lithium as necessary.
w w w w w w w w
B. Recognize this as an expected response to lithium.
w w w w w w w w
C. Request an order for a stat blood lithium level.
w w w w w w w w w
D. Give an oral dose of lithium antidote.
w w w w w w w
Answer: C w
wExplanation:
(A) These symptoms are indicative of lithium toxicity. A stat dose of lithium could be fatal.
w w w w w w w w w w w w w w
(B) These are toxic effects of lithium therapy. (C) The client is exhibiting symptoms of lithium toxicity, which
w w w w w w w w w w w w w w w w
wmay be validated by lab studies. (D) There is no known lithium antidote.
w w w w w w w w w w w w
QUESTION 8 w
A diagnosis of hepatitis C is confirmed by a male client‘s physician. The nurse should be knowledgeable of the
w w w w w w w w w w w w w w w w w w
differences between hepatitis A, B, and C. Which of the following are characteristics of hepatitis C?
w w w w w w w w w w w w w w w w
A. The potential for chronic liver disease is minimal.
w w w w w w w
B. The onset of symptoms is abrupt.
w w w w w
C. The incubation period is 2–26 weeks.
w w w w w
D. There is an effective vaccine for hepatitis B, but not for hepatitis C.
w w w w w w w w w w w w
Answer: C w
wExplanation:
(A) Hepatitis C and B may result in chronic liver disease. Hepatitis A has a low potential for chronic liver
w w w w w w w w w w w w w w w w w w w
wdisease. (B) Hepatitis C and B have insidious onsets. Hepatitis A has an abrupt onset. (C) Incubation periods are
w w w w w w w w w w w w w w w w w w
was follows: hepatitis C is 2–26 weeks, hepatitis B is 6–20 weeks, and hepatitis A is 2–6 weeks. (D) Only
w w w w w w w w w w w w w w w w w w w
whepatitis B has an effective vaccine. w w w w w
QUESTION 9 w
Hypoxia is the primary problem related to near-drowning victims. The first organ that sustains irreversible
w w w w w w w w w w w w w w
damage after submersion in water is the:
w w w w w w w
A. Kidney (urinary system) w w
B. Brain (nervous system) w w
C. Heart (circulatory system) w w
D. Lungs (respiratory system) w w
Answer: B w
Explanation:
w
A+
, (A) The kidney can survive after 30 minutes of water submersion. (B) The cerebral neurons sustain irreversible
w w w w w w w w w w w w w w w w
wdamage after 4–6 minutes of water submersion. (C) The heart can survive up to 30 minutes of water submersion.
w w w w w w w w w w w w w w w w w w
(D) The lungs can survive up to 30 minutes of water submersion.
w w w w w w w w w w w
QUESTION 10 w
Which of the following activities would be most appropriate during occupational therapy for a client with
w w w w w w w w w w w w w w w
bipolar disorder?
w w
A. Playing cards with other clients w w w w
B. Working crossword puzzles w w
C. Playing tennis with a staff member w w w w w
D. Sewing beads on a leather belt w w w w w
Answer: C w
wExplanation:
(A) This activity is too competitive, and the manic client might become abusive toward the other clients. (B)
w w w w w w w w w w w w w w w w w
wDuring mania, the client‘s attention span is too short to accomplish this task. (C) This activity uses gross motor
w w w w w w w w w w w w w w w w w w
wskills, eases tension, and expands excess energy. A staff member is better equipped to interact therapeutically
w w w w w w w w w w w w w w w
wwith clients. (D) This activity requires the use of fine motor skills and is very tedious.
w w w w w w w w w w w w w w w
QUESTION 11 w
A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2
w w w w w w w w w w w w w w w w w w w
months, his family describes him as being ―on the move,‖ sleeping
w w w w w w w w w w w
3–4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial
w w w w w w w w w w w w w w
assessment with the client, the nurse would expect him to exhibit which of the following?
w w w w w w w w w w w w w w w
A. Short, polite responses to interview questions
w w w w w
B. Introspection related to his present situation w w w w w
C. Exaggerated self-importance w
D. Feelings of helplessness and hopelessness w w w w
Answer: C w
wExplanation:
(A) During the manic phase of bipolar disorder, clients have short attention spans and may be abusive toward
w w w w w w w w w w w w w w w w w
wauthority figures. (B) Introspection requires focusing and concentration; clients with mania experience flight of
w w w w w w w w w w w w w
wideas, which prevents concentration.
w w w
(C) Grandiosity and an inflated sense of self-worth are characteristic of this disorder. (D) Feelings of
w w w w w w w w w w w w w w w
whelplessness and hopelessness are symptoms of the depressive stage of bipolar disorder.
w w w w w w w w w w w
QUESTION 12 w
Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality.
w w w w w w w w w w w w w
When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy
w w w w w w w w w w w w w w w
is:
w
A. 70 mg/dL and 120 mg/dL
w w w w
B. 100 mg/dL and 200 mg/dL
w w w w
C. 40 mg/dL and 130 mg/dL
w w w w
D. 90 mg/dL and 200 mg/dL
w w w w
A+
w w w w w w w w w w
QUESTION 1 w
Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy?
w w w w w w w w w w w
A. Positive inotropes
w w
B. Vasodilators
w
C. Diuretics
w
D. Antidysrhythmics
w
Answer: A w
wExplanation:
(A) Positive inotropic agents should not be administered owing to their action of increasing myocardial
w w w w w w w w w w w w w w
wcontractility. Increased ventricular contractility would increase outflow tract obstruction in the client with
w w w w w w w w w w w w
whypertrophic cardiomyopathy. (B) Vasodilators are not typically prescribed but are not contraindicated. (C)
w w w w w w w w w w w w
wDiuretics are used with caution to avoid causing hypovolemi
w w w w w w w w
A. (D) Antidysrhythmics are typically needed to treat both atrial and ventricular dysrhythmias.
w w w w w w w w w w w w
QUESTION 2 w
Signs and symptoms of an allergy attack include which of the following?
w w w w w w w w w w w
A. Wheezing on inspiration
w w w
B. Increased respiratory rate
w w w
C. Circumoral cyanosis
w w
D. Prolonged expiration
w w
Answer: D w
wExplanation:
(A) Wheezing occurs during expiration when air movement is impaired because of constricted edematous bronchial
w w w w w w w w w w w w w w
wlumin
A. (B) Respirations are difficult, but the rate is frequently normal. (C) The circumoral area is usually pale. Cyanosis
w w w w w w w w w w w w w w w w w w
wis not an early sign of hypoxi
w w w w w w
A. (D) Expiration is prolonged because the alveoli are greatly distended and air trapping occurs.
w w w w w w w w w w w w w w
QUESTION 3 w
A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of
w w w w w w w w w w w w w w w w w w w w w w
hallucination?
w
A. Auditory
w
B. Gustatory
w
C. Olfactory
w
D. Visceral
w
Answer: B w
wExplanation:
(A) Auditory hallucinations involve sensory perceptions of hearing. (B) Gustatory hallucinations involve
w w w w w w w w w w w
wsensory perceptions of taste. (C) Olfactory hallucinations involve sensory perceptions of smell. (D) Visceral
w w w w w w w w w w w w w
hallucinations involve sensory perceptions of sensation
w w w w w
,QUESTION
4 Which of the following findings would be abnormal in a postpartal woman?
w w w w w w w w w w w w
A. Chills shortly after delivery w w w
B. Pulse rate of 60 bpm in morning on first postdelivery day
w w w w w w w w w w
C. Urinary output of 3000 mL on the second day after delivery
w w w w w w w w w w
D. An oral temperature of 101F (38.3C) on the third day after delivery
w w w w w w w w w w w
Answer: D w
wExplanation:
(A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous
w w w w w w w w w w w w w w w w
wresponse or to vasomotor changes. If not followed by a fever, it is clinically innocuous. (B) The pulse rate
w w w w w w w w w w w w w w w w w w
wduring the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt
w w w w w w w w w w w w w w w w w w
wto the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. (C)
w w w w w w w w w w w w w w w w w w
wUrinary output increases during the early postpartal period (12–24 hours) owing to diuresis. The kidneys must
w w w w w w w w w w w w w w w
weliminate an estimated 2000–3000 mL of extracellular fluid associated with a normal pregnancy. (D) A
w w w w w w w w w w w w w w
wtemperature of 100.4F (38C) may occur after delivery as a result of exertion and dehydration of labor. However,
w w w w w w w w w w w w w w w w w
wanytemperature greater than 100.4F needs further investigation to identify any infectious process.
w w w w w w w w w w w
QUESTION 5 w
A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the
w w w w w w w w w w w w w w w w w
parents, the nurse states that:
w w w w w
A. Sustained temperature elevation over 103F is generally related to febrile seizures
w w w w w w w w w w
B. Febrile seizures do not usually recur w w w w w
C. There is little risk of neurological deficit and mental retardation as sequelae to febrile seizures
w w w w w w w w w w w w w w
D. Febrile seizures are associated with diseases of the central nervous system
w w w w w w w w w w
Answer: C w
wExplanation:
(A) The temperature elevation related to febrile seizures generally exceeds 101F, and seizures occur during the
w w w w w w w w w w w w w w w
wtemperature rise rather than after a prolonged elevation. (B) Febrile seizures may recur and are more likely to do
w w w w w w w w w w w w w w w w w w
wso when the first seizure occurs in the 1st year of life. (C) There is little risk of neurological deficit, mental
w w w w w w w w w w w w w w w w w w w w
wretardation, or altered behavior secondary to febrile seizures. (D) Febrile seizures are associated with disease of
w w w w w w w w w w w w w w w
wthe central nervous system.
w w w
QUESTION 6 w
A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following
w w w w w w w w w w w w w w w w w
nutritional interventions would be most therapeutic for him at this time?
w w w w w w w w w w w
A. Small, frequent feedings of foods that can be carried
w w w w w w w w
B. Tube feedings with nutritional supplements
w w w w
C. Allowing him to eat when and what he wants w w w w w w w w
D. Giving him a quiet place where he can sit down to eat meals
w w w w w w w w w w w w
Answer: A w
wExplanation:
(A) The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with
w w w w w w w w w w w w w w w w w w w
,finger foods allow him to eat during periods of activity. (B) This type of therapy should be implemented when
w w w w w w w w w w w w w w w w w w
wother methods have been exhausted. (C) The manic client should not be in control of his treatment plan. This
w w w w w w w w w w w w w w w w w w
wtype of client may forget to eat. (D) The manic client is unable to sit down to eat full meals.
w w w w w w w w w w w w w w w w w w w
QUESTION 7 w
A client with bipolar disorder taking lithium tells the nurse that he has ringing in his ears, blurred vision, and
w w w w w w w w w w w w w w w w w w w
diarrhe
w
A. The nurse notices a slight tremor in his left hand and a slurring pattern to his speech. Which of the following
w w w w w w w w w w w w w w w w w w w w w
actions by the nurse is appropriate?
w w w w w w
A. Administer a stat dose of lithium as necessary.
w w w w w w w w
B. Recognize this as an expected response to lithium.
w w w w w w w w
C. Request an order for a stat blood lithium level.
w w w w w w w w w
D. Give an oral dose of lithium antidote.
w w w w w w w
Answer: C w
wExplanation:
(A) These symptoms are indicative of lithium toxicity. A stat dose of lithium could be fatal.
w w w w w w w w w w w w w w
(B) These are toxic effects of lithium therapy. (C) The client is exhibiting symptoms of lithium toxicity, which
w w w w w w w w w w w w w w w w
wmay be validated by lab studies. (D) There is no known lithium antidote.
w w w w w w w w w w w w
QUESTION 8 w
A diagnosis of hepatitis C is confirmed by a male client‘s physician. The nurse should be knowledgeable of the
w w w w w w w w w w w w w w w w w w
differences between hepatitis A, B, and C. Which of the following are characteristics of hepatitis C?
w w w w w w w w w w w w w w w w
A. The potential for chronic liver disease is minimal.
w w w w w w w
B. The onset of symptoms is abrupt.
w w w w w
C. The incubation period is 2–26 weeks.
w w w w w
D. There is an effective vaccine for hepatitis B, but not for hepatitis C.
w w w w w w w w w w w w
Answer: C w
wExplanation:
(A) Hepatitis C and B may result in chronic liver disease. Hepatitis A has a low potential for chronic liver
w w w w w w w w w w w w w w w w w w w
wdisease. (B) Hepatitis C and B have insidious onsets. Hepatitis A has an abrupt onset. (C) Incubation periods are
w w w w w w w w w w w w w w w w w w
was follows: hepatitis C is 2–26 weeks, hepatitis B is 6–20 weeks, and hepatitis A is 2–6 weeks. (D) Only
w w w w w w w w w w w w w w w w w w w
whepatitis B has an effective vaccine. w w w w w
QUESTION 9 w
Hypoxia is the primary problem related to near-drowning victims. The first organ that sustains irreversible
w w w w w w w w w w w w w w
damage after submersion in water is the:
w w w w w w w
A. Kidney (urinary system) w w
B. Brain (nervous system) w w
C. Heart (circulatory system) w w
D. Lungs (respiratory system) w w
Answer: B w
Explanation:
w
A+
, (A) The kidney can survive after 30 minutes of water submersion. (B) The cerebral neurons sustain irreversible
w w w w w w w w w w w w w w w w
wdamage after 4–6 minutes of water submersion. (C) The heart can survive up to 30 minutes of water submersion.
w w w w w w w w w w w w w w w w w w
(D) The lungs can survive up to 30 minutes of water submersion.
w w w w w w w w w w w
QUESTION 10 w
Which of the following activities would be most appropriate during occupational therapy for a client with
w w w w w w w w w w w w w w w
bipolar disorder?
w w
A. Playing cards with other clients w w w w
B. Working crossword puzzles w w
C. Playing tennis with a staff member w w w w w
D. Sewing beads on a leather belt w w w w w
Answer: C w
wExplanation:
(A) This activity is too competitive, and the manic client might become abusive toward the other clients. (B)
w w w w w w w w w w w w w w w w w
wDuring mania, the client‘s attention span is too short to accomplish this task. (C) This activity uses gross motor
w w w w w w w w w w w w w w w w w w
wskills, eases tension, and expands excess energy. A staff member is better equipped to interact therapeutically
w w w w w w w w w w w w w w w
wwith clients. (D) This activity requires the use of fine motor skills and is very tedious.
w w w w w w w w w w w w w w w
QUESTION 11 w
A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2
w w w w w w w w w w w w w w w w w w w
months, his family describes him as being ―on the move,‖ sleeping
w w w w w w w w w w w
3–4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial
w w w w w w w w w w w w w w
assessment with the client, the nurse would expect him to exhibit which of the following?
w w w w w w w w w w w w w w w
A. Short, polite responses to interview questions
w w w w w
B. Introspection related to his present situation w w w w w
C. Exaggerated self-importance w
D. Feelings of helplessness and hopelessness w w w w
Answer: C w
wExplanation:
(A) During the manic phase of bipolar disorder, clients have short attention spans and may be abusive toward
w w w w w w w w w w w w w w w w w
wauthority figures. (B) Introspection requires focusing and concentration; clients with mania experience flight of
w w w w w w w w w w w w w
wideas, which prevents concentration.
w w w
(C) Grandiosity and an inflated sense of self-worth are characteristic of this disorder. (D) Feelings of
w w w w w w w w w w w w w w w
whelplessness and hopelessness are symptoms of the depressive stage of bipolar disorder.
w w w w w w w w w w w
QUESTION 12 w
Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality.
w w w w w w w w w w w w w
When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy
w w w w w w w w w w w w w w w
is:
w
A. 70 mg/dL and 120 mg/dL
w w w w
B. 100 mg/dL and 200 mg/dL
w w w w
C. 40 mg/dL and 130 mg/dL
w w w w
D. 90 mg/dL and 200 mg/dL
w w w w
A+
