NCLEX Question Trainer Explanations
Test 6
1. The nurse returns to the nurse’s station after making client rounds and finds four phone messages.
Which of the following messages should the nurse return FIRST?
1. A client with hepatitis A who states, “My arms and legs are itching.”
2. A client with a cast on the right leg who states, “I have a funny feeling in my right leg.”
3. A client with osteomyelitis of the spine who states, “I am so nauseous that I can’t eat.”
4. A client with arthritis who states, “I am having trouble sleeping at night.”
Strategy: Eliminate the most stable clients.
(1) caused by accumulation of bile salts under the skin; treat with calamine lotion and
antihistamines
(2) correct—may indicate neurovascular compromise; requires immediate assessment
(3) requires follow-up but not highest priority
(4) requires assessment but not the highest priority
2. Following hip replacement surgery, an elderly client is ordered to begin ambulation with a walker.
Which of the following statements by the nurse is BEST?
1. “Sit in a low chair for ease in getting up to use the walker.”
2. “Make sure rubber caps are in place on all four legs of the walker.”
3. “You will begin weight-bearing on the affected hip soon.”
4. “Practice tying your own shoes before you begin ambulating.”
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six
weeks
(2) correct—intact rubber caps should be present on walker legs to prevent accidents
(3) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six
weeks
(4) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six
weeks
37
,Preparation for the Nursing Licensure Examination
3. A 22-year-old woman comes to the hospital at term in the early stages of labor. A diagnosis of
complete placenta previa is made. It would be MOST important for the nurse to take which of the
following actions?
1. Start an IV of terbutaline (Brethine) and monitor the patient’s vital signs closely.
2. Prepare the patient for an immediate cesarean section.
3. Maintain the patient on bedrest until spontaneous vaginal delivery is achieved.
4. Monitor the patient’s length and duration of contractions.
Strategy: Answers are both assessments and implementations. Is the assessment appropriate?
No. Determine the outcome of each implementation. Is it desired?
(1) implementation, Brethine used to delay delivery in preterm labor
(2) correct—implementation, cannot deliver vaginally
(3) implementation, cannot deliver vaginally
(4) assessment, cannot deliver vaginally, cesarean section must be performed
4. Which of the following nursing observations would indicate to the nurse that a child with epiglottitis
is having an early complication of hypoxemia?
1. Heart rate of 148 beats per minute.
2. Bluish discoloration of the skin.
3. Bluish discoloration around the mouth.
4. Difficulty swallowing.
Strategy: Determine how each answer choice relates to epiglottitis.
(1) correct—heart rate correlates with hypoxemia and is an early finding, along with restlessness
(2) cyanosis, late sign
(3) circumoral cyanosis, late sign
(4) sign of epiglottitis
5. After stabilizing a client with severe multiple trauma injuries from a motor vehicle accident, which
of the following actions by the nurse is BEST?
1. Limit visiting hours to promote optimal rest.
2. Arrange for clergy to visit with the client and family as requested.
3. Arrange for a psychologist to visit with the family.
4. Arrange for the family to meet with a social worker to discuss financial aid.
Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired?
(1) inappropriate
(2) correct—would provide the appropriate spiritual support necessary during a crisis
(3) inappropriate for the data given in the situation
(4) inappropriate for the data given in the situation
38
, NCLEX Question Trainer
6. The nurse’s aide comes to take a woman by wheelchair for a magnetic resonance imaging (MRI)
scan of the head and neck. Which of the following observations, if made by the nurse, would
require an intervention?
1. The woman removes her dentures and gives them to her husband.
2. The woman’s vital signs are: BP 120/70, pulse 80, respirations 12, temperature 99°F (37.3°C).
3. The woman has a nitroglycerine patch on her right chest area.
4. The woman has red nail polish on her fingers and toes.
Strategy: “Require an intervention” indicates an incorrect action.
(1) should be removed before the test
(2) results are within normal limits
(3) correct—should be removed before the test
(4) unnecessary to check capillary refill
7. The neonatal nurse is instructing the family of a newborn about an apnea monitor. The nurse
should be MOST concerned if a family member makes which of the following statements?
1. “We will be able to leave our baby for brief periods of time.”
2. “We plan to sleep by our baby’s crib.”
3. “We can remove the monitor during our baby’s bath.”
4. “A family member will closely watch the monitor all the time.
Strategy: “MOST concerned” indicates that you are looking for an incorrect statement.
(1) appropriate behavior
(2) appropriate behavior
(3) appropriate behavior
(4) correct—indicates a feeling that monitor may not let them know if their infant stops breathing
8. A 20-year-old client has a cast applied for a fracture of the right femur. Three hours later, the client
complains that it is hot and painful under his cast. Which of the following is the MOST appropriate
action for the nurse to take?
1. Assess the cast for wet spots and increase air circulation in the room.
2. Check the circulation in his casted extremity and change the client’s position.
3. Take the client’s temperature and observe him for other signs of infection.
4. Medicate the client for pain and notify the physician of his complaint.
Strategy: Answers are a mix of assessments and implementations. Does this situation require
assessment? Yes.
(1) heat is sign of pressure
(2) correct—heat is sign of pressure, pressure limits circulation
(3) too early to see signs of infection
(4) all complaints must be investigated, medication would mask signs of pressure, assessment
first step
39
, Preparation for the Nursing Licensure Examination
9. A 30-year-old woman is admitted to the hospital with dry mucous membranes and decreased
skin turgor. The woman's vital signs are BP 120/70, temperature 101°F (38.3°C), pulse 88,
respirations 14. Laboratory tests indicate the serum sodium is 150 mEq/L and the Hct is 48%.
The nurse would expect the physician to order which of the following IV fluids?
1. D5 NS.
2. 0.45% NaCl.
3. 0.9% NaCl.
4. Lactated Ringer’s.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) hypertonic solutions contraindicated in dehydration
(2) correct—hypotonic solution, shifts fluid into intracellular space to correct dehydration
(3) isotonic solution, not best with dehydration
(4) isotonic solution used to replace electrolytes
10. Which of the following plans would be MOST appropriate for the nurse to use to prepare a
10-year-old for a cardiac catheterization?
1. Show a videotape specifically prepared for children about cardiac catheterization.
2. Provide the child with a pamphlet about the procedure and encourage him to read it.
3. Draw a picture of a heart and explain where the tube will go and what the doctor will see.
4. Present a puppet show explaining the anatomy and physiology of the heart.
Strategy: Think about the developmental stage of a 10-year-old.
(1) video will provide correct information but is not best preparation for a school-age child
(2) pamphlet will contain correct information but is not best preparation for a school-age child
(3) correct—this plan will best prepare the child for the procedure
(4) would be more appropriate for a younger child
11. Which of the following nursing actions is MOST important to provide a patient with effective pain
relief?
1. Teach the patient about his pain.
2. Establish a trusting relationship with the patient.
3. Determine how various relaxation techniques affect the pain.
4. Provide alternative measures to relieve pain.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) not most important
(2) correct—necessary to work with patient to identify interventions to relieve pain
(3) part of intervention and evaluation phase
(4) only a portion of interventions used to relieve pain
40
Test 6
1. The nurse returns to the nurse’s station after making client rounds and finds four phone messages.
Which of the following messages should the nurse return FIRST?
1. A client with hepatitis A who states, “My arms and legs are itching.”
2. A client with a cast on the right leg who states, “I have a funny feeling in my right leg.”
3. A client with osteomyelitis of the spine who states, “I am so nauseous that I can’t eat.”
4. A client with arthritis who states, “I am having trouble sleeping at night.”
Strategy: Eliminate the most stable clients.
(1) caused by accumulation of bile salts under the skin; treat with calamine lotion and
antihistamines
(2) correct—may indicate neurovascular compromise; requires immediate assessment
(3) requires follow-up but not highest priority
(4) requires assessment but not the highest priority
2. Following hip replacement surgery, an elderly client is ordered to begin ambulation with a walker.
Which of the following statements by the nurse is BEST?
1. “Sit in a low chair for ease in getting up to use the walker.”
2. “Make sure rubber caps are in place on all four legs of the walker.”
3. “You will begin weight-bearing on the affected hip soon.”
4. “Practice tying your own shoes before you begin ambulating.”
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six
weeks
(2) correct—intact rubber caps should be present on walker legs to prevent accidents
(3) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six
weeks
(4) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six
weeks
37
,Preparation for the Nursing Licensure Examination
3. A 22-year-old woman comes to the hospital at term in the early stages of labor. A diagnosis of
complete placenta previa is made. It would be MOST important for the nurse to take which of the
following actions?
1. Start an IV of terbutaline (Brethine) and monitor the patient’s vital signs closely.
2. Prepare the patient for an immediate cesarean section.
3. Maintain the patient on bedrest until spontaneous vaginal delivery is achieved.
4. Monitor the patient’s length and duration of contractions.
Strategy: Answers are both assessments and implementations. Is the assessment appropriate?
No. Determine the outcome of each implementation. Is it desired?
(1) implementation, Brethine used to delay delivery in preterm labor
(2) correct—implementation, cannot deliver vaginally
(3) implementation, cannot deliver vaginally
(4) assessment, cannot deliver vaginally, cesarean section must be performed
4. Which of the following nursing observations would indicate to the nurse that a child with epiglottitis
is having an early complication of hypoxemia?
1. Heart rate of 148 beats per minute.
2. Bluish discoloration of the skin.
3. Bluish discoloration around the mouth.
4. Difficulty swallowing.
Strategy: Determine how each answer choice relates to epiglottitis.
(1) correct—heart rate correlates with hypoxemia and is an early finding, along with restlessness
(2) cyanosis, late sign
(3) circumoral cyanosis, late sign
(4) sign of epiglottitis
5. After stabilizing a client with severe multiple trauma injuries from a motor vehicle accident, which
of the following actions by the nurse is BEST?
1. Limit visiting hours to promote optimal rest.
2. Arrange for clergy to visit with the client and family as requested.
3. Arrange for a psychologist to visit with the family.
4. Arrange for the family to meet with a social worker to discuss financial aid.
Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired?
(1) inappropriate
(2) correct—would provide the appropriate spiritual support necessary during a crisis
(3) inappropriate for the data given in the situation
(4) inappropriate for the data given in the situation
38
, NCLEX Question Trainer
6. The nurse’s aide comes to take a woman by wheelchair for a magnetic resonance imaging (MRI)
scan of the head and neck. Which of the following observations, if made by the nurse, would
require an intervention?
1. The woman removes her dentures and gives them to her husband.
2. The woman’s vital signs are: BP 120/70, pulse 80, respirations 12, temperature 99°F (37.3°C).
3. The woman has a nitroglycerine patch on her right chest area.
4. The woman has red nail polish on her fingers and toes.
Strategy: “Require an intervention” indicates an incorrect action.
(1) should be removed before the test
(2) results are within normal limits
(3) correct—should be removed before the test
(4) unnecessary to check capillary refill
7. The neonatal nurse is instructing the family of a newborn about an apnea monitor. The nurse
should be MOST concerned if a family member makes which of the following statements?
1. “We will be able to leave our baby for brief periods of time.”
2. “We plan to sleep by our baby’s crib.”
3. “We can remove the monitor during our baby’s bath.”
4. “A family member will closely watch the monitor all the time.
Strategy: “MOST concerned” indicates that you are looking for an incorrect statement.
(1) appropriate behavior
(2) appropriate behavior
(3) appropriate behavior
(4) correct—indicates a feeling that monitor may not let them know if their infant stops breathing
8. A 20-year-old client has a cast applied for a fracture of the right femur. Three hours later, the client
complains that it is hot and painful under his cast. Which of the following is the MOST appropriate
action for the nurse to take?
1. Assess the cast for wet spots and increase air circulation in the room.
2. Check the circulation in his casted extremity and change the client’s position.
3. Take the client’s temperature and observe him for other signs of infection.
4. Medicate the client for pain and notify the physician of his complaint.
Strategy: Answers are a mix of assessments and implementations. Does this situation require
assessment? Yes.
(1) heat is sign of pressure
(2) correct—heat is sign of pressure, pressure limits circulation
(3) too early to see signs of infection
(4) all complaints must be investigated, medication would mask signs of pressure, assessment
first step
39
, Preparation for the Nursing Licensure Examination
9. A 30-year-old woman is admitted to the hospital with dry mucous membranes and decreased
skin turgor. The woman's vital signs are BP 120/70, temperature 101°F (38.3°C), pulse 88,
respirations 14. Laboratory tests indicate the serum sodium is 150 mEq/L and the Hct is 48%.
The nurse would expect the physician to order which of the following IV fluids?
1. D5 NS.
2. 0.45% NaCl.
3. 0.9% NaCl.
4. Lactated Ringer’s.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) hypertonic solutions contraindicated in dehydration
(2) correct—hypotonic solution, shifts fluid into intracellular space to correct dehydration
(3) isotonic solution, not best with dehydration
(4) isotonic solution used to replace electrolytes
10. Which of the following plans would be MOST appropriate for the nurse to use to prepare a
10-year-old for a cardiac catheterization?
1. Show a videotape specifically prepared for children about cardiac catheterization.
2. Provide the child with a pamphlet about the procedure and encourage him to read it.
3. Draw a picture of a heart and explain where the tube will go and what the doctor will see.
4. Present a puppet show explaining the anatomy and physiology of the heart.
Strategy: Think about the developmental stage of a 10-year-old.
(1) video will provide correct information but is not best preparation for a school-age child
(2) pamphlet will contain correct information but is not best preparation for a school-age child
(3) correct—this plan will best prepare the child for the procedure
(4) would be more appropriate for a younger child
11. Which of the following nursing actions is MOST important to provide a patient with effective pain
relief?
1. Teach the patient about his pain.
2. Establish a trusting relationship with the patient.
3. Determine how various relaxation techniques affect the pain.
4. Provide alternative measures to relieve pain.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it
desired?
(1) not most important
(2) correct—necessary to work with patient to identify interventions to relieve pain
(3) part of intervention and evaluation phase
(4) only a portion of interventions used to relieve pain
40
