NCLEX Practice test 1 Questions and
Answers.
An emergency department (ED) nurse working triage has assessed four
clients. Which client should receive the highest priority?
1. Alert client who fell on the side walk. Skin warm and dry to the touch,
with a three inch laceration on the right knee continuously oozing dark red
liquid.
2. Elderly client who moans when the nurse asks, "Can you hear me?"
Respirations even/nonlabored. Skin slightly cool to touch with pale
nailbeds.
3. A client who "passed out" but regained consciousness when feet were
elevated. Awake and confused, with warm and dry skin.
4. An alert, responsive client who reports severe abdominal and shoulder
pain that began two hours after eating at a local fast food restaurant. Skin
is warm and dry - Correct Answer 2. Elderly client who moans when the
nurse asks, "Can you hear me?" Respirations even/nonlabored. Skin
slightly cool to touch with pale nailbeds.
-This client is responding to verbal stimuli by moaning and has an open
airway; but any client with an altered level of consciousness is at risk for
airway obstruction. The skin assessment indicates a circulation problem.
Which task should the nurse perform first?
1. Suctioning the tracheostomy.
2. Changing a colostomy bag that is leaking.
3. Performing an admission assessment on a client.
4. Administering pain medication to a postoperative client. - Correct
Answer 1. Correct: The tracheostomy tube must be suctioned to keep the
client's airway open. Suctioning the tracheostomy should take priority.
Remember, airway first.
The six bed Labor and Delivery area is full when the Emergency
Department nurse calls for a bed for a woman reporting low back pain,
,pelvic pressure and increased vaginal discharge at 36 weeks gestation.
Which would be the most appropriate action for the charge nurse?
1. Transfer a G4P4 who delivered full-term twins one hour ago to the
antepartum/postpartum floor.
2. Transfer a G3 P3 who delivered an 8 lb. newborn three hours ago to the
antepartum/postpartum floor.
3. Transfer an 8 hour postpartum G1P1 on Magnesium Sulfate for
eclampsia from the LDR unit to the ante/postpartum unit.
4. Request that the new client be admitted to the antepartum/postpartum
floor. - Correct Answer Transfer a G3 P3 who delivered an 8 lb. newborn
three hours ago to the antepartum/postpartum floor.
-The client and newborn are not in any present distress. Also the delivery
occurred 3 hours ago. This client would not be a risk and could be cared for
on the antepartum/postpartum floor.
Post cataract removal a client reports nausea and severe pain in the
operative eye. Which nursing intervention takes priority?
1. Administer morphine and ondansetron.
2. Reposition client to non-operative side.
3. Massage the canthus to unblock the lacrimal duct.
4. Notify the primary healthcare provider. - Correct Answer -Severe pain
with nausea indicates an increase in intraocular pressure and needs to be
reported at once. Eye damage can result if not resolved quickly. The
primary healthcare provider may prescribe medications or take the client
back to surgery.
Which statement by a student nurse indicates to the nurse educator that
teaching regarding witnessing consent signatures has been successful?
-Signing as a witness implies that the witness has observed the client
personally signing the consent form with no coercion.
-The witness does not have to be an RN.
-A witness is required to be over the age of 18. - Correct Answer
,A client has been on the mental health unit for three days and is requesting
to leave against medical advice (AMA). It has been determined that the
client is not suicidal. What should the nurse do?
1. Inform the primary healthcare provider that the client wishes to leave.
Protocols on the unit must be followed when someone is requesting to
leave AMA. The first step is to call the primary healthcare provider about
the client's desire to leave AMA. - Correct Answer
Make arrangements for a commitment hearing, as soon as possible only if
the client is not a threat or potential threat to self or others, the client may
leave - Correct Answer
unlicensed assistive personnel (UAP) cant do invasive tasks like removing
catheters or obtaining sterile specimens from indwelling catheter - Correct
Answer
Which nursing action is likely to improve client satisfaction and demonstrate
acts of beneficence?
1. Allowing clients to make their own decisions about care
2. Answering all questions posed by client in an honest manner
3. Reporting faulty equipment to the proper departments
4. Sitting at the bedside and listening to an elderly client - Correct Answer
Sitting at the bedside and listening to an elderly client
-Sitting and listening demonstrates kindness and compassion that are
consistent with the ethical term "beneficence." Beneficence is taking
positive action to help others and a desire to do good which is the core
principle of client advocacy.
Autonomy is the ethical principle illustrated here by supporting independent
decision making with clients.
Fidelity is the ethical principle illustrated here and refers to the concept of
keeping a commitment. It is based upon the virtue of caring. - Correct
Answer
Reporting faulty equipment is an act to promote... - Correct Answer -
nonmaleficence or to do no harm. This is the core of nursing ethics.
, A case manager is evaluating a client diagnosed with hemiplegia due to a
cerebral vascular accident who will need assistive devices upon discharge.
Which devices should the case manager include for this client?
1. Dinner plate food guards
2. Transfer belt
3. Raised toilet seat
4. Long handled shoe horn
5. Wide grip eating utensils
6. Button closures on clothes - Correct Answer 1., 2., 3., 4., & 5. Correct:
The goal is to promote self-care by the client as much as possible. The
case manager should evaluate the need for assistive devices to help with
eating, bathing, dressing, and ambulating. The dinner plate food guard will
prevent food from being pushed off the plate. The transfer belt will provide
safety for the client to get into a chair or back in bed. A raised toilet seat
makes it easier for the client to sit on the toilet without falling. The long-
handled shoe horn allows the client to put on shoes without assistance.
Wide grip utensils accommodate a weak grip.
6. Incorrect: It is hard for someone with hemiplegia to use buttons. Velcro
fasteners are best.
hemiplegia= paralysis of one side of the body. - Correct Answer
The nurse determines that a client does not have an advance directive. The
daughter is designated to make healthcare decisions in the event that the
client becomes incapacitated or unable to make informed decisions. Which
nursing actions are appropriate for this client?
You answered this question Incorrectly
* 1. Document the client's statement in the client's own words.
2. Provide information on advance directives to the client.
3. Inform the client that personnel are available to assist with completing
an advance directive.*
4. Avoid inquiring about a client's advance directive as this could cause the
client anxiety and concern.
5. Ask the daughter if she agrees with her mother's decision. - Correct
Answer 1., 2. & 3. Correct: The nurse should document the client's
statement in the client's own words. The nurse should provide the client
with information on advance directives and assurance that there are
hospital personnel to assist with completing the advance directive.
Answers.
An emergency department (ED) nurse working triage has assessed four
clients. Which client should receive the highest priority?
1. Alert client who fell on the side walk. Skin warm and dry to the touch,
with a three inch laceration on the right knee continuously oozing dark red
liquid.
2. Elderly client who moans when the nurse asks, "Can you hear me?"
Respirations even/nonlabored. Skin slightly cool to touch with pale
nailbeds.
3. A client who "passed out" but regained consciousness when feet were
elevated. Awake and confused, with warm and dry skin.
4. An alert, responsive client who reports severe abdominal and shoulder
pain that began two hours after eating at a local fast food restaurant. Skin
is warm and dry - Correct Answer 2. Elderly client who moans when the
nurse asks, "Can you hear me?" Respirations even/nonlabored. Skin
slightly cool to touch with pale nailbeds.
-This client is responding to verbal stimuli by moaning and has an open
airway; but any client with an altered level of consciousness is at risk for
airway obstruction. The skin assessment indicates a circulation problem.
Which task should the nurse perform first?
1. Suctioning the tracheostomy.
2. Changing a colostomy bag that is leaking.
3. Performing an admission assessment on a client.
4. Administering pain medication to a postoperative client. - Correct
Answer 1. Correct: The tracheostomy tube must be suctioned to keep the
client's airway open. Suctioning the tracheostomy should take priority.
Remember, airway first.
The six bed Labor and Delivery area is full when the Emergency
Department nurse calls for a bed for a woman reporting low back pain,
,pelvic pressure and increased vaginal discharge at 36 weeks gestation.
Which would be the most appropriate action for the charge nurse?
1. Transfer a G4P4 who delivered full-term twins one hour ago to the
antepartum/postpartum floor.
2. Transfer a G3 P3 who delivered an 8 lb. newborn three hours ago to the
antepartum/postpartum floor.
3. Transfer an 8 hour postpartum G1P1 on Magnesium Sulfate for
eclampsia from the LDR unit to the ante/postpartum unit.
4. Request that the new client be admitted to the antepartum/postpartum
floor. - Correct Answer Transfer a G3 P3 who delivered an 8 lb. newborn
three hours ago to the antepartum/postpartum floor.
-The client and newborn are not in any present distress. Also the delivery
occurred 3 hours ago. This client would not be a risk and could be cared for
on the antepartum/postpartum floor.
Post cataract removal a client reports nausea and severe pain in the
operative eye. Which nursing intervention takes priority?
1. Administer morphine and ondansetron.
2. Reposition client to non-operative side.
3. Massage the canthus to unblock the lacrimal duct.
4. Notify the primary healthcare provider. - Correct Answer -Severe pain
with nausea indicates an increase in intraocular pressure and needs to be
reported at once. Eye damage can result if not resolved quickly. The
primary healthcare provider may prescribe medications or take the client
back to surgery.
Which statement by a student nurse indicates to the nurse educator that
teaching regarding witnessing consent signatures has been successful?
-Signing as a witness implies that the witness has observed the client
personally signing the consent form with no coercion.
-The witness does not have to be an RN.
-A witness is required to be over the age of 18. - Correct Answer
,A client has been on the mental health unit for three days and is requesting
to leave against medical advice (AMA). It has been determined that the
client is not suicidal. What should the nurse do?
1. Inform the primary healthcare provider that the client wishes to leave.
Protocols on the unit must be followed when someone is requesting to
leave AMA. The first step is to call the primary healthcare provider about
the client's desire to leave AMA. - Correct Answer
Make arrangements for a commitment hearing, as soon as possible only if
the client is not a threat or potential threat to self or others, the client may
leave - Correct Answer
unlicensed assistive personnel (UAP) cant do invasive tasks like removing
catheters or obtaining sterile specimens from indwelling catheter - Correct
Answer
Which nursing action is likely to improve client satisfaction and demonstrate
acts of beneficence?
1. Allowing clients to make their own decisions about care
2. Answering all questions posed by client in an honest manner
3. Reporting faulty equipment to the proper departments
4. Sitting at the bedside and listening to an elderly client - Correct Answer
Sitting at the bedside and listening to an elderly client
-Sitting and listening demonstrates kindness and compassion that are
consistent with the ethical term "beneficence." Beneficence is taking
positive action to help others and a desire to do good which is the core
principle of client advocacy.
Autonomy is the ethical principle illustrated here by supporting independent
decision making with clients.
Fidelity is the ethical principle illustrated here and refers to the concept of
keeping a commitment. It is based upon the virtue of caring. - Correct
Answer
Reporting faulty equipment is an act to promote... - Correct Answer -
nonmaleficence or to do no harm. This is the core of nursing ethics.
, A case manager is evaluating a client diagnosed with hemiplegia due to a
cerebral vascular accident who will need assistive devices upon discharge.
Which devices should the case manager include for this client?
1. Dinner plate food guards
2. Transfer belt
3. Raised toilet seat
4. Long handled shoe horn
5. Wide grip eating utensils
6. Button closures on clothes - Correct Answer 1., 2., 3., 4., & 5. Correct:
The goal is to promote self-care by the client as much as possible. The
case manager should evaluate the need for assistive devices to help with
eating, bathing, dressing, and ambulating. The dinner plate food guard will
prevent food from being pushed off the plate. The transfer belt will provide
safety for the client to get into a chair or back in bed. A raised toilet seat
makes it easier for the client to sit on the toilet without falling. The long-
handled shoe horn allows the client to put on shoes without assistance.
Wide grip utensils accommodate a weak grip.
6. Incorrect: It is hard for someone with hemiplegia to use buttons. Velcro
fasteners are best.
hemiplegia= paralysis of one side of the body. - Correct Answer
The nurse determines that a client does not have an advance directive. The
daughter is designated to make healthcare decisions in the event that the
client becomes incapacitated or unable to make informed decisions. Which
nursing actions are appropriate for this client?
You answered this question Incorrectly
* 1. Document the client's statement in the client's own words.
2. Provide information on advance directives to the client.
3. Inform the client that personnel are available to assist with completing
an advance directive.*
4. Avoid inquiring about a client's advance directive as this could cause the
client anxiety and concern.
5. Ask the daughter if she agrees with her mother's decision. - Correct
Answer 1., 2. & 3. Correct: The nurse should document the client's
statement in the client's own words. The nurse should provide the client
with information on advance directives and assurance that there are
hospital personnel to assist with completing the advance directive.
