NCLEX NGN Pre-Test Questions With
Correct Answers
A nurse is assigned to care for a client with chronic renal failure who is
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undergoing hemodialysis through an internal AV fistula in the RA. Which
| | | | | | | | | | |
intervention should the nurse implement in caring for the client? SATA
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a. Assessing the radial pulse in the right extremity
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b. Using the LA ti take BP readings
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c. Drawing pre-dialysis blood specimens from the LA
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d. Assessing the area over the AV fistula for a bruit and three each shift
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e. Placing a pressure dressing over the site after each dialysis treatment
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f. Administering IV fluids through the venous site of the AV fistula as
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needed - CORRECT ANSWER✔✔-A, B, C, D
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A nurse is evaluating outcomes for a client with Guillain-Barre
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syndrome. Which outcome does the nurse recognize as optimal
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respiratory outcomes for the client?
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a. Normal deep tendon reflexes
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b. Improved skeletal muscle tone
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c. Absences of paresthesias in the lower extremities
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d. Clear sound in the lower lung fields bilaterally
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,e. pO2 of 85 mmHg and pCO2 of 40 mmHg - CORRECT ANSWER✔✔-D, E
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A nurse of the telemetry unit is caring for a client who has had a MI and
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is now attached to a cardiac monitor. The nurse is monitoring the
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client's cardiac rhythm and nots ventricular fibrillation. Which nursing
| | | | | | | | |
intervention should the nurse take first?
| | | | | |
a. Calling the rapid response team
| | | | |
b. Preparing the client for cardioversion
| | | | |
c. Asking the client to bear down and cough
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d. Preparing to administer diltiazem - CORRECT ANSWER✔✔-A
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The pattern of ventricular fibrillation is identified and can be a result
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after a patient with an MI. VF makes the patient feel faint, then loses
| | | | | | | | | | | | | |
consciousness and becomes pulseless and apneic (BP and heart sounds
| | | | | | | | | |
absent). Treatment is to terminate VF and covert it into a rhythm via
| | | | | | | | | | | | |
defibrillation-> call a rapid and initiate CPR. Cardioversion is used for
| | | | | | | | | | |
ventricular or supraventricular tachydysrhythmias.
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A nurse developing a plan of care for a client with a spinal cord injury
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includes measures to prevent autonomic dysreflexia (hyperreflexia).
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Which intervention does the nurse incorporate into the plan to prevent
| | | | | | | | | | |
this complication?
| |
a. Keeping the fan running in the client's room
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b. Keeping the linens wrinkle free under the client
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c. Limiting bladder catheterization to once every 12 hours
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,d. Avoiding the administration of enemas and rectal suppositories -
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CORRECT ANSWER✔✔-B
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The most frequent cause of autonomic dysreflexias are a distended
| | | | | | | | |
bladder and impacted feces. Other causes include stimulation of the
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skin by tactile, thermal, or painful stimuli. The nurse renders care in
| | | | | | | | | | | |
such a way as to minimize these risks.
| | | | | | | |
A nurse provides home care instructions to a client who has been fitted
| | | | | | | | | | | |
with a halo device to treat a cervical fracture. Which statement by the
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client indicates the need for further teaching?
| | | | | | |
a. I need to get more fluids and fiber into my diet
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b. I should cut my food into small pieces before I eat
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c. I need to put powder under the vest twice a day to prevent sweating
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d. I have to check the pin sites everyday and watch for signs of infection
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- CORRECT ANSWER✔✔-C
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Cleanse the skin under the wool liner each day to prevent rashes and
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soars.
|
A nurse is caring for a client with increased intracranial pressure. In
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which position should the nurse maintain the client?
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a. Supine with the head extended
| | | | |
b. Side lying with the neck flexed
| | | | | |
c. Supine with the head turned to the side
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, d. Head midline and elevated 30-45 degrees - CORRECT ANSWER✔✔-D
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Proper positioning promotes venous drainage from the cranium to
| | | | | | | |
minimize ICP.
| |
A client with a basilar skull fracture has clear fluid leaking from the ears.
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The nurse should take which action first?
| | | | | | |
a. Asses the clear fluid for protein
| | | | | |
b. Check the clear fluid for glucose
| | | | | |
c. Place cotton calls or dry gauze loosely in the ears
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d. Use an otoscope to assess the tympanic membrane for rupture -
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CORRECT ANSWER✔✔-B
| |
CSF contains glucose not protein.
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A nurse is caring for a client who has just undergone cardioversion.
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Which intervention is the nurse's priority after this procedure.
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a. Administer oxygen
| |
b. Monitoring the BP
| | |
c. Administering antidysrhythmic medications
| | |
d. Monitoring the client's LOC - CORRECT ANSWER✔✔-A
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ABC's of nursing. All other choices are correct, but not priority.
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Correct Answers
A nurse is assigned to care for a client with chronic renal failure who is
| | | | | | | | | | | | | |
undergoing hemodialysis through an internal AV fistula in the RA. Which
| | | | | | | | | | |
intervention should the nurse implement in caring for the client? SATA
| | | | | | | | | | |
a. Assessing the radial pulse in the right extremity
| | | | | | | |
b. Using the LA ti take BP readings
| | | | | | |
c. Drawing pre-dialysis blood specimens from the LA
| | | | | | |
d. Assessing the area over the AV fistula for a bruit and three each shift
| | | | | | | | | | | | | |
e. Placing a pressure dressing over the site after each dialysis treatment
| | | | | | | | | | |
f. Administering IV fluids through the venous site of the AV fistula as
| | | | | | | | | | | |
needed - CORRECT ANSWER✔✔-A, B, C, D
| | | | | | |
A nurse is evaluating outcomes for a client with Guillain-Barre
| | | | | | | | |
syndrome. Which outcome does the nurse recognize as optimal
| | | | | | | | |
respiratory outcomes for the client?
| | | | |
a. Normal deep tendon reflexes
| | | |
b. Improved skeletal muscle tone
| | | |
c. Absences of paresthesias in the lower extremities
| | | | | | |
d. Clear sound in the lower lung fields bilaterally
| | | | | | | |
,e. pO2 of 85 mmHg and pCO2 of 40 mmHg - CORRECT ANSWER✔✔-D, E
| | | | | | | | | | | | |
A nurse of the telemetry unit is caring for a client who has had a MI and
| | | | | | | | | | | | | | | |
is now attached to a cardiac monitor. The nurse is monitoring the
| | | | | | | | | | | |
client's cardiac rhythm and nots ventricular fibrillation. Which nursing
| | | | | | | | |
intervention should the nurse take first?
| | | | | |
a. Calling the rapid response team
| | | | |
b. Preparing the client for cardioversion
| | | | |
c. Asking the client to bear down and cough
| | | | | | | |
d. Preparing to administer diltiazem - CORRECT ANSWER✔✔-A
| | | | | | |
The pattern of ventricular fibrillation is identified and can be a result
| | | | | | | | | | |
after a patient with an MI. VF makes the patient feel faint, then loses
| | | | | | | | | | | | | |
consciousness and becomes pulseless and apneic (BP and heart sounds
| | | | | | | | | |
absent). Treatment is to terminate VF and covert it into a rhythm via
| | | | | | | | | | | | |
defibrillation-> call a rapid and initiate CPR. Cardioversion is used for
| | | | | | | | | | |
ventricular or supraventricular tachydysrhythmias.
| | | |
A nurse developing a plan of care for a client with a spinal cord injury
| | | | | | | | | | | | | |
includes measures to prevent autonomic dysreflexia (hyperreflexia).
| | | | | | |
Which intervention does the nurse incorporate into the plan to prevent
| | | | | | | | | | |
this complication?
| |
a. Keeping the fan running in the client's room
| | | | | | | |
b. Keeping the linens wrinkle free under the client
| | | | | | | |
c. Limiting bladder catheterization to once every 12 hours
| | | | | | | |
,d. Avoiding the administration of enemas and rectal suppositories -
| | | | | | | | |
CORRECT ANSWER✔✔-B
| |
The most frequent cause of autonomic dysreflexias are a distended
| | | | | | | | |
bladder and impacted feces. Other causes include stimulation of the
| | | | | | | | | |
skin by tactile, thermal, or painful stimuli. The nurse renders care in
| | | | | | | | | | | |
such a way as to minimize these risks.
| | | | | | | |
A nurse provides home care instructions to a client who has been fitted
| | | | | | | | | | | |
with a halo device to treat a cervical fracture. Which statement by the
| | | | | | | | | | | | |
client indicates the need for further teaching?
| | | | | | |
a. I need to get more fluids and fiber into my diet
| | | | | | | | | | |
b. I should cut my food into small pieces before I eat
| | | | | | | | | | |
c. I need to put powder under the vest twice a day to prevent sweating
| | | | | | | | | | | | | |
d. I have to check the pin sites everyday and watch for signs of infection
| | | | | | | | | | | | | |
- CORRECT ANSWER✔✔-C
| | |
Cleanse the skin under the wool liner each day to prevent rashes and
| | | | | | | | | | | |
soars.
|
A nurse is caring for a client with increased intracranial pressure. In
| | | | | | | | | | |
which position should the nurse maintain the client?
| | | | | | | |
a. Supine with the head extended
| | | | |
b. Side lying with the neck flexed
| | | | | |
c. Supine with the head turned to the side
| | | | | | | |
, d. Head midline and elevated 30-45 degrees - CORRECT ANSWER✔✔-D
| | | | | | | | |
Proper positioning promotes venous drainage from the cranium to
| | | | | | | |
minimize ICP.
| |
A client with a basilar skull fracture has clear fluid leaking from the ears.
| | | | | | | | | | | | |
The nurse should take which action first?
| | | | | | |
a. Asses the clear fluid for protein
| | | | | |
b. Check the clear fluid for glucose
| | | | | |
c. Place cotton calls or dry gauze loosely in the ears
| | | | | | | | | |
d. Use an otoscope to assess the tympanic membrane for rupture -
| | | | | | | | | | |
CORRECT ANSWER✔✔-B
| |
CSF contains glucose not protein.
| | | |
A nurse is caring for a client who has just undergone cardioversion.
| | | | | | | | | | |
Which intervention is the nurse's priority after this procedure.
| | | | | | | | | |
a. Administer oxygen
| |
b. Monitoring the BP
| | |
c. Administering antidysrhythmic medications
| | |
d. Monitoring the client's LOC - CORRECT ANSWER✔✔-A
| | | | | | |
ABC's of nursing. All other choices are correct, but not priority.
| | | | | | | | | |
