NCLEX NGN Pre-Test
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 answersA, 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?
g. Normal deep tendon reflexes
h. Improved skeletal muscle tone
i. Absences of paresthesias in the lower extremities
j. Clear sound in the lower lung fields bilaterally
k. pO2 of 85 mmHg and pCO2 of 40 mmHg correct answersD, 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?
l. Calling the rapid response team
m.Preparing the client for cardioversion
n. Asking the client to bear down and cough
o. Preparing to administer diltiazem correct answersA
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?
p. Keeping the fan running in the client's room
q. Keeping the linens wrinkle free under the client
r. Limiting bladder catheterization to once every 12 hours
s.Avoiding the administration of enemas and rectal suppositories
correct answersB 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 answersC
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?
e. Supine with the head extended
f. Side lying with the neck flexed
g. Supine with the head turned to the side
h. Head midline and elevated 30-45 degrees correct answersD
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?
i. Asses the clear fluid for protein
j. Check the clear fluid for glucose
k. Place cotton calls or dry gauze loosely in the ears
l.Use an otoscope to assess the tympanic membrane for rupture
correct answersB 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.
m.Administer oxygen
n. Monitoring the BP
o. Administering antidysrhythmic medications
p. Monitoring the client's LOC correct answersA
ABC's of nursing. All other choices are correct, but not priority.
A client with diabetes mellitus who is scheduled to have blood drawn for
determination of the glycosylated hemoglobin (HbA1c) level asks the nurse
why the test is necessary if he is performing blood glucose monitoring at
home. Which is the best response for the nurse to provide?
q. Detect diabetic complications
r. Assess long-term glycemic control
s. Determine whether the client is at risk for hypoglycemia
d Determine whether the prescribed insulin dosage is correct correct
answersB
, A nurse caring for a client with acquired immunodeficiency syndrome is
monitoring the client for signs of complications. Which of the following
would cause the nurse to suspect infection with Pneumocystis jirovec? SATA
a. Diarrhea
b. Tachypnea
c. Pedal edema
d. Intermittent fever
e. Dyspnea with ambulating
f. Expectoration of frothy mucus correct answersB, D, E
A opportunistic respiratory infection associated with AIDs that causes
dyspnea, nonproductive cough, intermittent fever, fatigue, anorexia,
tachypnea, wt. loss.
Zidovudine is prescribed for a client with AIDS. The nurse tells the
client that it is important to report back to the clinic as scheduled for
which follow-up diagnostic?
g. Blood glucose checks
h. Blood pressure checks
i. Complete blood counts (CBC)
j. Electrocradiographic studies correct answersC
Zidovudine is an antiviral medication that cause cause agranulocytosis
and anemia.
After a non-immunocompromised client undergoes a Mantoux test for TB
infection, an area of induration 6 mm wide developed. The client asks the
nurse what this result means. Which is the best response?
k. We'll have to repeat the test because the result was inconclusive
l. The swollen area is small, so that means your test result is negative
m.You've been exposed to TB so you will need to have a chest x-ray
n.You need to get started on medication right away because you
have TB correct answersB
Indurations less than 10 mm (non-immunocompromised) and 5 mm
(immunocompromised) is considered a negative result after 48-72 hrs.
Results greater indicate exposure and possible TB infection. Morse testing
(x-ray) will be needed.
A clients arterial blood gases are analyzed; pH 1.49, paO2 97 mmHg, HCO3-
22 mEq/L. Which acid base balance disturbance does the nurse identify from
these results?
o. Metabolic acidosis
p. Metabolic alkalosis
q. Respiratory acidosis
r. Respiratory alkalosis correct answersD
RAcidosis: paCo2 >45 mmHg and RAlkalosis is paCo2 <35 mmHg. MAcidosis
is HCO3- is less than 22 mEq/L and MAlkalosis is HCO3- greater than 26
mEq/L.
A client has recently been diagnosed with deep vein thrombosis of the right
leg. Which of the following interventions of the nurse immediately
implement?
s. Elevating the foot of the bed 6 inches
t. Placing ice packs on and under the right leg
u. Documenting the need for hourly calf measurements
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 answersA, 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?
g. Normal deep tendon reflexes
h. Improved skeletal muscle tone
i. Absences of paresthesias in the lower extremities
j. Clear sound in the lower lung fields bilaterally
k. pO2 of 85 mmHg and pCO2 of 40 mmHg correct answersD, 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?
l. Calling the rapid response team
m.Preparing the client for cardioversion
n. Asking the client to bear down and cough
o. Preparing to administer diltiazem correct answersA
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?
p. Keeping the fan running in the client's room
q. Keeping the linens wrinkle free under the client
r. Limiting bladder catheterization to once every 12 hours
s.Avoiding the administration of enemas and rectal suppositories
correct answersB 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 answersC
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?
e. Supine with the head extended
f. Side lying with the neck flexed
g. Supine with the head turned to the side
h. Head midline and elevated 30-45 degrees correct answersD
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?
i. Asses the clear fluid for protein
j. Check the clear fluid for glucose
k. Place cotton calls or dry gauze loosely in the ears
l.Use an otoscope to assess the tympanic membrane for rupture
correct answersB 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.
m.Administer oxygen
n. Monitoring the BP
o. Administering antidysrhythmic medications
p. Monitoring the client's LOC correct answersA
ABC's of nursing. All other choices are correct, but not priority.
A client with diabetes mellitus who is scheduled to have blood drawn for
determination of the glycosylated hemoglobin (HbA1c) level asks the nurse
why the test is necessary if he is performing blood glucose monitoring at
home. Which is the best response for the nurse to provide?
q. Detect diabetic complications
r. Assess long-term glycemic control
s. Determine whether the client is at risk for hypoglycemia
d Determine whether the prescribed insulin dosage is correct correct
answersB
, A nurse caring for a client with acquired immunodeficiency syndrome is
monitoring the client for signs of complications. Which of the following
would cause the nurse to suspect infection with Pneumocystis jirovec? SATA
a. Diarrhea
b. Tachypnea
c. Pedal edema
d. Intermittent fever
e. Dyspnea with ambulating
f. Expectoration of frothy mucus correct answersB, D, E
A opportunistic respiratory infection associated with AIDs that causes
dyspnea, nonproductive cough, intermittent fever, fatigue, anorexia,
tachypnea, wt. loss.
Zidovudine is prescribed for a client with AIDS. The nurse tells the
client that it is important to report back to the clinic as scheduled for
which follow-up diagnostic?
g. Blood glucose checks
h. Blood pressure checks
i. Complete blood counts (CBC)
j. Electrocradiographic studies correct answersC
Zidovudine is an antiviral medication that cause cause agranulocytosis
and anemia.
After a non-immunocompromised client undergoes a Mantoux test for TB
infection, an area of induration 6 mm wide developed. The client asks the
nurse what this result means. Which is the best response?
k. We'll have to repeat the test because the result was inconclusive
l. The swollen area is small, so that means your test result is negative
m.You've been exposed to TB so you will need to have a chest x-ray
n.You need to get started on medication right away because you
have TB correct answersB
Indurations less than 10 mm (non-immunocompromised) and 5 mm
(immunocompromised) is considered a negative result after 48-72 hrs.
Results greater indicate exposure and possible TB infection. Morse testing
(x-ray) will be needed.
A clients arterial blood gases are analyzed; pH 1.49, paO2 97 mmHg, HCO3-
22 mEq/L. Which acid base balance disturbance does the nurse identify from
these results?
o. Metabolic acidosis
p. Metabolic alkalosis
q. Respiratory acidosis
r. Respiratory alkalosis correct answersD
RAcidosis: paCo2 >45 mmHg and RAlkalosis is paCo2 <35 mmHg. MAcidosis
is HCO3- is less than 22 mEq/L and MAlkalosis is HCO3- greater than 26
mEq/L.
A client has recently been diagnosed with deep vein thrombosis of the right
leg. Which of the following interventions of the nurse immediately
implement?
s. Elevating the foot of the bed 6 inches
t. Placing ice packs on and under the right leg
u. Documenting the need for hourly calf measurements
