Exam Cram NCLEX-PN PRACTICE
QUESTIONS
A 24 year-old female client is scheduled for surgery in the morning. Which of the following is the
primary responsibility of the nurse?
A. taking the vital signs
B. obtaining the permit
C. explaining the procedure
D. Checking the lab work - ANS - A. taking the vital signs
why?
the primary responisblity of the nurse is to take the vital signs before any surgery.
answers B,C and D are the responsibility of the doctor.
\A 25 year old male is brought to the ER with a piece of metal in his eye. Which action by the
nurse is correct?
A. Use a magnet to remove the object
B. Rinse the eye thoroughly with saline
C. Cover both eyes with paper cups
D. Patch the affected eye only - ANS - C. Cover both eyes with paper cups
why?
Covering both eyes prevents consensual movement of the affected eye.
\A 5 year old is admitted to the unit following a tonsillectomy. Which of the following would
indicate a complication of the surgery?
A. Decreased appetite
B. A low-grade fever
C. Chest congestion
D. Constant swallowing - ANS -
\A 6 year old with cerebral palsy functions at the level of an 18 month old. Which finding would
support that assessment?
A. She dresses herself
B. She pulls a toy behind her
C. She can build a tower of eight blocks
D. She can copy a horizontal or vertical line. - ANS -
,\A 6-month-old client is admitted with possible intussuception. Which question during the
nursing history is least helpful in obtaining information regarding this diagnosis?
A. "tell me about the pain"
B."what does his vomit look like?"
C." Describe his usual diet."
D. " have you noticed changes in his adominal size?" - ANS - C." Describe his usual diet."
why?
The least-helpful questions are those describing his usual diet. A, B, and D are useful in
determining the extent of disease process and thus, are incorrect
\A 70 year old man who is recovering from a stroke exhibits signs of unilateral neglect. Which
behavior is suggested of unilateral neglect?
A. The client is observed by shaving only one side of his face
B. The client is unable to distinguish between two tactile stimuli presented simultaneously
C. The client is unable to complete a range a vision without turning his head side to side
D. The client is unable to carry out cognitive and motor activity at the same time - ANS - A. The
client is observed by shaving only one side of his face
why?
The client with unilateral neglect will neglect one side of the body
\A client arrives in the emergency room with a possible fractured femur. The nurse should
anticipate an order for:
A. Trendelenburg position
B. Ice to the entire extremity
C. Bucks traction
D. An abduction pillow - ANS - C. Bucks traction
why?
The client with a fractured femur will be placed in Bucks traction to realign the leg and decrease
spasms and pain.
\A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks. Which lab
finding indicates that the medication is having the desired effect?
A. Neutrophil count of 60%
B. Basophil count of 0.5%
C. Monocyte count of 2%
D. Reticlocyte count of 1% - ANS - D. Reticlocyte count of 1 %
, why?
Cyanocolamine is a B12 medication that is used for pernicious anemia, and a reticulocyte count
of 1% indicates that it is having the desired effect.
\A client has rectal cancer and is scheduled for an abdominal perineal resection. What should
be the priority nursing care during the post-op period?
A. Teaching how to irrigate the illeostomy
B. Stopping electrolytes loss in the incisional area
C. Encouraging a high fiber diet
D. Facilitating perineal wound drainage - ANS - D. Facilitating perineal wound drainage
why?
the client with a perineal resection will have a perineal incision. Drains will be used to facilitate
wound drainage. This will help prevent infection of the surgical site. The client will not have an
illestomy. as in answer A he will have some electrolyte loss, but treatment is not focused on
preventing the loss, so answer B is incorrect A high fiber diet in answer C is not ordered at this
time.
\A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The
nurse should be most careful to monitor the client for which dysrhythmia during this procedure?
A. Bradycardia
B. Tachycardia
C. Premature ventricular beats
D. Heart block - ANS - A. Bradycardia
why?
Suctioning can cause a vagal response and bradycardia.
\A client is 2 days post-operative colon resection. After a coughing episode, the client's wound
eviscerates. Which nursing action is most appropriate?
A. Reinsert the protruding organ and cover with 4x4s
B. Cover the wound with a sterile 4x4 and ABD dressing
C. Cover the wound with a sterile saline-soaked dressing
D. Apply an abdominal binder and manual pressure to the wound - ANS - C. Cover the wound
with a sterile saline-soaked dressing.
why?
If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked
dressing.
QUESTIONS
A 24 year-old female client is scheduled for surgery in the morning. Which of the following is the
primary responsibility of the nurse?
A. taking the vital signs
B. obtaining the permit
C. explaining the procedure
D. Checking the lab work - ANS - A. taking the vital signs
why?
the primary responisblity of the nurse is to take the vital signs before any surgery.
answers B,C and D are the responsibility of the doctor.
\A 25 year old male is brought to the ER with a piece of metal in his eye. Which action by the
nurse is correct?
A. Use a magnet to remove the object
B. Rinse the eye thoroughly with saline
C. Cover both eyes with paper cups
D. Patch the affected eye only - ANS - C. Cover both eyes with paper cups
why?
Covering both eyes prevents consensual movement of the affected eye.
\A 5 year old is admitted to the unit following a tonsillectomy. Which of the following would
indicate a complication of the surgery?
A. Decreased appetite
B. A low-grade fever
C. Chest congestion
D. Constant swallowing - ANS -
\A 6 year old with cerebral palsy functions at the level of an 18 month old. Which finding would
support that assessment?
A. She dresses herself
B. She pulls a toy behind her
C. She can build a tower of eight blocks
D. She can copy a horizontal or vertical line. - ANS -
,\A 6-month-old client is admitted with possible intussuception. Which question during the
nursing history is least helpful in obtaining information regarding this diagnosis?
A. "tell me about the pain"
B."what does his vomit look like?"
C." Describe his usual diet."
D. " have you noticed changes in his adominal size?" - ANS - C." Describe his usual diet."
why?
The least-helpful questions are those describing his usual diet. A, B, and D are useful in
determining the extent of disease process and thus, are incorrect
\A 70 year old man who is recovering from a stroke exhibits signs of unilateral neglect. Which
behavior is suggested of unilateral neglect?
A. The client is observed by shaving only one side of his face
B. The client is unable to distinguish between two tactile stimuli presented simultaneously
C. The client is unable to complete a range a vision without turning his head side to side
D. The client is unable to carry out cognitive and motor activity at the same time - ANS - A. The
client is observed by shaving only one side of his face
why?
The client with unilateral neglect will neglect one side of the body
\A client arrives in the emergency room with a possible fractured femur. The nurse should
anticipate an order for:
A. Trendelenburg position
B. Ice to the entire extremity
C. Bucks traction
D. An abduction pillow - ANS - C. Bucks traction
why?
The client with a fractured femur will be placed in Bucks traction to realign the leg and decrease
spasms and pain.
\A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks. Which lab
finding indicates that the medication is having the desired effect?
A. Neutrophil count of 60%
B. Basophil count of 0.5%
C. Monocyte count of 2%
D. Reticlocyte count of 1% - ANS - D. Reticlocyte count of 1 %
, why?
Cyanocolamine is a B12 medication that is used for pernicious anemia, and a reticulocyte count
of 1% indicates that it is having the desired effect.
\A client has rectal cancer and is scheduled for an abdominal perineal resection. What should
be the priority nursing care during the post-op period?
A. Teaching how to irrigate the illeostomy
B. Stopping electrolytes loss in the incisional area
C. Encouraging a high fiber diet
D. Facilitating perineal wound drainage - ANS - D. Facilitating perineal wound drainage
why?
the client with a perineal resection will have a perineal incision. Drains will be used to facilitate
wound drainage. This will help prevent infection of the surgical site. The client will not have an
illestomy. as in answer A he will have some electrolyte loss, but treatment is not focused on
preventing the loss, so answer B is incorrect A high fiber diet in answer C is not ordered at this
time.
\A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The
nurse should be most careful to monitor the client for which dysrhythmia during this procedure?
A. Bradycardia
B. Tachycardia
C. Premature ventricular beats
D. Heart block - ANS - A. Bradycardia
why?
Suctioning can cause a vagal response and bradycardia.
\A client is 2 days post-operative colon resection. After a coughing episode, the client's wound
eviscerates. Which nursing action is most appropriate?
A. Reinsert the protruding organ and cover with 4x4s
B. Cover the wound with a sterile 4x4 and ABD dressing
C. Cover the wound with a sterile saline-soaked dressing
D. Apply an abdominal binder and manual pressure to the wound - ANS - C. Cover the wound
with a sterile saline-soaked dressing.
why?
If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked
dressing.
