............................................................................................................................ N C L E X Q U ES TI ON T R A I N ER
NCLEX QUESTION TRAINER EXPLANATIONS
TEST 2
1. The nurse is supervising care given to a group of patients on the unit. The nurse observes a staff
member entering a patient’s room wearing gown and gloves. The nurse knows that the staff
member is caring for which of the following patients?
1. An 18-month-old with respiratory syncytial virus.
2. A 4-year-old with Kawasaki disease.
3. A 10-year-old with Lyme’s disease.
4. A 16-year-old with infectious mononucleosis.
Strategy: Think about each answer.
(1) correct–acute viral infection; requires contact precautions; assign to private room or with other
RSV-infected children
(2) acute systemic vasculitis in children under 5; standard precautions
(3) connective tissue disease; standard precautions
(4) standard precautions
2. The nurse is assessing a client who has had a spinal cord injury. Which of the following assessment
findings would suggest the complication of autonomic dysreflexia?
1. Urinary bladder spasm pain.
2. Severe pounding headache.
3. Tachycardia.
4. Severe hypotension.
Strategy: Think about each answer.
(1) may be the cause of autonomic dysreflexia due to overfilling of the bladder, but pain is not
perceived
(2) correct–severe headache results from rapid onset of hypertension
(3) pulse will slow
(4) BP will increase
Nursing ........................................................................................................................................................................................................................................................................... 15
,P RE PA RA T I O N F OR TH E NU R SI N G L I C EN S U RE EX A M I N A T I O N ................................................
3. A 14-year-old client is scheduled for a below-knee (BK) amputation following a motorcycle accident.
The nurse knows preoperative teaching for this client should include
1. explaining that the client will be walking with a prosthesis soon after surgery.
2. encouraging the client to share his feelings and fears about the surgery.
3. taking the informed consent form to the client and asking him to sign it.
4. evaluating how the client plans to maintain his schoolwork during hospitalization.
Strategy: Remember therapeutic communication.
(1) fails to recognize his immediate concerns
(2) correct–discussing his feelings and fears is important in dealing with his anxiety due to a change
in body image and functioning
(3) client is underage; parents will need to sign the permit
(4) is more appropriate for the postoperative period of time than for the preoperative period
4. A 21-year-old woman at 16-weeks gestation undergoes an amniocentesis. The client asks the nurse
what the physician will learn from this procedure. The nurse’s response should be based on an
understanding that which of the following conditions can be detected by this test?
1. Tetralogy of Fallot.
2. Talipes equinovarus.
3. Hemolytic disease of the newborn.
4. Cleft lip and palate.
Strategy: Think about each answer.
(1) cardiac abnormality detected at birth; pulmonary stenosis, ventricular septal defect, overriding
aorta, hypertrophy of right ventricle
(2) congenital deformity detected at birth; foot twisted out of normal position, clubfoot
(3) correct–maternal antibodies destroy fetal RBCs; bilirubin secreted because of hemolysis
(4) congenital deformity detected at birth, midline fissure or opening into lip or palate
5. The nurse evaluates the nutritional intake of a 16-year-old girl at a camp for adolescents. The girl
eats all of the food provided to her at the camp cafeteria. Each of the day’s three meals contains
foods from all areas of the food pyramid, and each meal averages about 900 calories and 3 mg of
iron. The girl has been menstruating monthly for about two years. Which of the following
descriptions, if made by the nurse, BEST describes the girl’s intake if her weight is appropriate for her
height?
1. Her diet is low in calories and high in iron.
2. Her diet is low in calories and low in iron.
3. Her diet is high in calories and low in iron.
4. Her diet is high in calories and high in iron.
Strategy: Think about each answer.
(1) only 1,200-1,500 kcal/day required, and 15 mg/day of iron
(2) only 1,200-1,500 kcal/day required
(3) correct–900 x 3 = 2,700 calories/day and women need 1,200-1,500 kcal/day (men need 1,500-
1,800 kcal/day); 3 mg x 3 = 9 mg/day of iron and women need 15 mg/day of iron (men need 10
mg/day); with pregnancy 30 mg/day required
(4) 5 mg/day of iron required
16 ............................................................................................................................................................................................................................................................................ Nursing
, ............................................................................................................................ N C L E X Q U ES TI ON T R A I N ER
6. A client has returned from surgery with a fine, reddened rash noted around the area where Betadine
prep had been applied prior to surgery. Nursing documentation in the chart should include
1. the time and circumstances under which the rash was noted.
2. the explanation given to the client and family of the reason for the rash.
3. notation on an allergy list and notification of the doctor.
4. the need for application of corticosteroid cream to decrease inflammation.
Strategy: Answers are implementation. Determine the outcome of each answer. Is it desired?
(1) would be noted, but is not as high a priority
(2) inappropriate
(3) correct–suspected reaction to drugs should be reported to the doctor and noted on list of
possible allergies
(4) inappropriate
7. A client who is receiving a blood transfusion experiences a hemolytic reaction. The nurse would
anticipate which of the following assessment findings?
1. Hypotension, backache, low back pain, fever.
2. Wet breath sounds, severe shortness of breath.
3. Chills and fever occurring about an hour after the infusion started.
4. Urticaria, itching, respiratory distress.
Strategy: Think about each answer.
(1) correct–signs and symptoms of a hemolytic reaction include chills, headache, backache,
dyspnea, cyanosis, chest pains, tachycardia, and hypotension
(2) describes symptoms of circulatory overload
(3) describes a febrile or pyrogenic reaction
(4) describes an allergic reaction
8. The nurse is developing a comprehensive care plan for a young woman with an eating disorder. The
nurse refers this client to assertiveness skills classes. The nurse knows that this is an appropriate
intervention because this client may have problems with
1. aggressive behaviors and angry feelings.
2. self-identity and self-esteem.
3. focusing on reality.
4. family boundary intrusions.
Strategy: Think about each answer.
(1) these clients do have problems with feelings of anger; family therapy sessions can be helpful in
identifying some of these feelings and difficulties with family boundaries
(2) correct–clients with eating disorders experience difficulty with self-identity and self-esteem, which
inhibits their abilities to act assertively; some assertiveness techniques that are taught include
giving and receiving criticism, giving and accepting compliments, accepting apologies, being
able to say no, and setting limits on what they can realistically do rather than just doing what
others want them to do
(3) do not have problems with reality
(4) these clients do have problems with family boundary intrusion; family therapy sessions can be
helpful in identifying some of these feelings and difficulties with family boundaries
Nursing ........................................................................................................................................................................................................................................................................... 17
NCLEX QUESTION TRAINER EXPLANATIONS
TEST 2
1. The nurse is supervising care given to a group of patients on the unit. The nurse observes a staff
member entering a patient’s room wearing gown and gloves. The nurse knows that the staff
member is caring for which of the following patients?
1. An 18-month-old with respiratory syncytial virus.
2. A 4-year-old with Kawasaki disease.
3. A 10-year-old with Lyme’s disease.
4. A 16-year-old with infectious mononucleosis.
Strategy: Think about each answer.
(1) correct–acute viral infection; requires contact precautions; assign to private room or with other
RSV-infected children
(2) acute systemic vasculitis in children under 5; standard precautions
(3) connective tissue disease; standard precautions
(4) standard precautions
2. The nurse is assessing a client who has had a spinal cord injury. Which of the following assessment
findings would suggest the complication of autonomic dysreflexia?
1. Urinary bladder spasm pain.
2. Severe pounding headache.
3. Tachycardia.
4. Severe hypotension.
Strategy: Think about each answer.
(1) may be the cause of autonomic dysreflexia due to overfilling of the bladder, but pain is not
perceived
(2) correct–severe headache results from rapid onset of hypertension
(3) pulse will slow
(4) BP will increase
Nursing ........................................................................................................................................................................................................................................................................... 15
,P RE PA RA T I O N F OR TH E NU R SI N G L I C EN S U RE EX A M I N A T I O N ................................................
3. A 14-year-old client is scheduled for a below-knee (BK) amputation following a motorcycle accident.
The nurse knows preoperative teaching for this client should include
1. explaining that the client will be walking with a prosthesis soon after surgery.
2. encouraging the client to share his feelings and fears about the surgery.
3. taking the informed consent form to the client and asking him to sign it.
4. evaluating how the client plans to maintain his schoolwork during hospitalization.
Strategy: Remember therapeutic communication.
(1) fails to recognize his immediate concerns
(2) correct–discussing his feelings and fears is important in dealing with his anxiety due to a change
in body image and functioning
(3) client is underage; parents will need to sign the permit
(4) is more appropriate for the postoperative period of time than for the preoperative period
4. A 21-year-old woman at 16-weeks gestation undergoes an amniocentesis. The client asks the nurse
what the physician will learn from this procedure. The nurse’s response should be based on an
understanding that which of the following conditions can be detected by this test?
1. Tetralogy of Fallot.
2. Talipes equinovarus.
3. Hemolytic disease of the newborn.
4. Cleft lip and palate.
Strategy: Think about each answer.
(1) cardiac abnormality detected at birth; pulmonary stenosis, ventricular septal defect, overriding
aorta, hypertrophy of right ventricle
(2) congenital deformity detected at birth; foot twisted out of normal position, clubfoot
(3) correct–maternal antibodies destroy fetal RBCs; bilirubin secreted because of hemolysis
(4) congenital deformity detected at birth, midline fissure or opening into lip or palate
5. The nurse evaluates the nutritional intake of a 16-year-old girl at a camp for adolescents. The girl
eats all of the food provided to her at the camp cafeteria. Each of the day’s three meals contains
foods from all areas of the food pyramid, and each meal averages about 900 calories and 3 mg of
iron. The girl has been menstruating monthly for about two years. Which of the following
descriptions, if made by the nurse, BEST describes the girl’s intake if her weight is appropriate for her
height?
1. Her diet is low in calories and high in iron.
2. Her diet is low in calories and low in iron.
3. Her diet is high in calories and low in iron.
4. Her diet is high in calories and high in iron.
Strategy: Think about each answer.
(1) only 1,200-1,500 kcal/day required, and 15 mg/day of iron
(2) only 1,200-1,500 kcal/day required
(3) correct–900 x 3 = 2,700 calories/day and women need 1,200-1,500 kcal/day (men need 1,500-
1,800 kcal/day); 3 mg x 3 = 9 mg/day of iron and women need 15 mg/day of iron (men need 10
mg/day); with pregnancy 30 mg/day required
(4) 5 mg/day of iron required
16 ............................................................................................................................................................................................................................................................................ Nursing
, ............................................................................................................................ N C L E X Q U ES TI ON T R A I N ER
6. A client has returned from surgery with a fine, reddened rash noted around the area where Betadine
prep had been applied prior to surgery. Nursing documentation in the chart should include
1. the time and circumstances under which the rash was noted.
2. the explanation given to the client and family of the reason for the rash.
3. notation on an allergy list and notification of the doctor.
4. the need for application of corticosteroid cream to decrease inflammation.
Strategy: Answers are implementation. Determine the outcome of each answer. Is it desired?
(1) would be noted, but is not as high a priority
(2) inappropriate
(3) correct–suspected reaction to drugs should be reported to the doctor and noted on list of
possible allergies
(4) inappropriate
7. A client who is receiving a blood transfusion experiences a hemolytic reaction. The nurse would
anticipate which of the following assessment findings?
1. Hypotension, backache, low back pain, fever.
2. Wet breath sounds, severe shortness of breath.
3. Chills and fever occurring about an hour after the infusion started.
4. Urticaria, itching, respiratory distress.
Strategy: Think about each answer.
(1) correct–signs and symptoms of a hemolytic reaction include chills, headache, backache,
dyspnea, cyanosis, chest pains, tachycardia, and hypotension
(2) describes symptoms of circulatory overload
(3) describes a febrile or pyrogenic reaction
(4) describes an allergic reaction
8. The nurse is developing a comprehensive care plan for a young woman with an eating disorder. The
nurse refers this client to assertiveness skills classes. The nurse knows that this is an appropriate
intervention because this client may have problems with
1. aggressive behaviors and angry feelings.
2. self-identity and self-esteem.
3. focusing on reality.
4. family boundary intrusions.
Strategy: Think about each answer.
(1) these clients do have problems with feelings of anger; family therapy sessions can be helpful in
identifying some of these feelings and difficulties with family boundaries
(2) correct–clients with eating disorders experience difficulty with self-identity and self-esteem, which
inhibits their abilities to act assertively; some assertiveness techniques that are taught include
giving and receiving criticism, giving and accepting compliments, accepting apologies, being
able to say no, and setting limits on what they can realistically do rather than just doing what
others want them to do
(3) do not have problems with reality
(4) these clients do have problems with family boundary intrusion; family therapy sessions can be
helpful in identifying some of these feelings and difficulties with family boundaries
Nursing ........................................................................................................................................................................................................................................................................... 17
