NCLEX NGN Pre-Test Questions and Answers Rated A
A nurse is assigned to care for a client with makes the patient feel faint, then loses
chronic renal failure who is undergoing consciousness and becomes pulseless and
hemodialysis through an internal AV fistula in the apneic (BP and heart sounds absent). Treatment
RA. Which intervention should the nurse is to terminate VF and covert it into a rhythm via
implement in caring for the client? SATA defibrillation-> call a rapid and initiate CPR.
a. Assessing the radial pulse in the right Cardioversion is used for ventricular or
extremity supraventricular tachydysrhythmias.
b. Using the LA ti take BP readings
c. Drawing pre-dialysis blood specimens from the
LA A nurse developing a plan of care for a client with
d. Assessing the area over the AV fistula for a a spinal cord injury includes measures to prevent
bruit and three each shift autonomic dysreflexia (hyperreflexia). Which
e. Placing a pressure dressing over the site after intervention does the nurse incorporate into the
each dialysis treatment plan to prevent this complication?
f. Administering IV fluids through the venous site a. Keeping the fan running in the client's room
of the AV fistula as needed - ANSWERS - b. Keeping the linens wrinkle free under the client
A, B, C, D c. Limiting bladder catheterization to once every
12 hours
d. Avoiding the administration of enemas and
A nurse is evaluating outcomes for a client with rectal suppositories - ANSWERS - B
Guillain-Barre syndrome. Which outcome does The most frequent cause of autonomic
the nurse recognize as optimal respiratory dysreflexias are a distended bladder and
outcomes for the client? impacted feces. Other causes include stimulation
a. Normal deep tendon reflexes of the skin by tactile, thermal, or painful stimuli.
b. Improved skeletal muscle tone The nurse renders care in such a way as to
c. Absences of paresthesias in the lower minimize these risks.
extremities
d. Clear sound in the lower lung fields bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg - A nurse provides home care instructions to a
ANSWERS - D, E 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 nurse of the telemetry unit is caring for a client a. I need to get more fluids and fiber into my diet
who has had a MI and is now attached to a b. I should cut my food into small pieces before I
cardiac monitor. The nurse is monitoring the eat
client's cardiac rhythm and nots ventricular c. I need to put powder under the vest twice a
fibrillation. Which nursing intervention should the day to prevent sweating
nurse take first? d. I have to check the pin sites everyday and
a. Calling the rapid response team watch for signs of infection - ANSWERS - C
b. Preparing the client for cardioversion Cleanse the skin under the wool liner each day to
c. Asking the client to bear down and cough prevent rashes and soars.
d. Preparing to administer diltiazem -
ANSWERS - A
The pattern of ventricular fibrillation is identified A nurse is caring for a client with increased
and can be a result after a patient with an MI. VF intracranial pressure. In which position should the
, NCLEX NGN Pre-Test Questions and Answers Rated A
nurse maintain the client? d Determine whether the prescribed insulin
a. Supine with the head extended dosage is correct - ANSWERS - B
b. Side lying with the neck flexed
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees - A nurse caring for a client with acquired
ANSWERS - D immunodeficiency syndrome is monitoring the
Proper positioning promotes venous drainage client for signs of complications. Which of the
from the cranium to minimize ICP. following would cause the nurse to suspect
infection with Pneumocystis jirovec? SATA
a. Diarrhea
A client with a basilar skull fracture has clear fluid b. Tachypnea
leaking from the ears. The nurse should take c. Pedal edema
which action first? d. Intermittent fever
a. Asses the clear fluid for protein e. Dyspnea with ambulating
b. Check the clear fluid for glucose f. Expectoration of frothy mucus -
c. Place cotton calls or dry gauze loosely in the ANSWERS - B, D, E
ears A opportunistic respiratory infection associated
d. Use an otoscope to assess the tympanic with AIDs that causes dyspnea, nonproductive
membrane for rupture - ANSWERS - B cough, intermittent fever, fatigue, anorexia,
CSF contains glucose not protein. tachypnea, wt. loss.
A nurse is caring for a client who has just Zidovudine is prescribed for a client with AIDS.
undergone cardioversion. Which intervention is The nurse tells the client that it is important to
the nurse's priority after this procedure. report back to the clinic as scheduled for which
a. Administer oxygen follow-up diagnostic?
b. Monitoring the BP a. Blood glucose checks
c. Administering antidysrhythmic medications b. Blood pressure checks
d. Monitoring the client's LOC - c. Complete blood counts (CBC)
ANSWERS - A d. Electrocradiographic studies -
ABC's of nursing. All other choices are correct, ANSWERS - C
but not priority. Zidovudine is an antiviral medication that cause
cause agranulocytosis and anemia.
A client with diabetes mellitus who is scheduled
to have blood drawn for determination of the After a non-immunocompromised client
glycosylated hemoglobin (HbA1c) level asks the undergoes a Mantoux test for TB infection, an
nurse why the test is necessary if he is area of induration 6 mm wide developed. The
performing blood glucose monitoring at home. client asks the nurse what this result means.
Which is the best response for the nurse to Which is the best response?
provide? a. We'll have to repeat the test because the result
a. Detect diabetic complications was inconclusive
b. Assess long-term glycemic control b. The swollen area is small, so that means your
c. Determine whether the client is at risk for test result is negative
hypoglycemia c. You've been exposed to TB so you will need to
A nurse is assigned to care for a client with makes the patient feel faint, then loses
chronic renal failure who is undergoing consciousness and becomes pulseless and
hemodialysis through an internal AV fistula in the apneic (BP and heart sounds absent). Treatment
RA. Which intervention should the nurse is to terminate VF and covert it into a rhythm via
implement in caring for the client? SATA defibrillation-> call a rapid and initiate CPR.
a. Assessing the radial pulse in the right Cardioversion is used for ventricular or
extremity supraventricular tachydysrhythmias.
b. Using the LA ti take BP readings
c. Drawing pre-dialysis blood specimens from the
LA A nurse developing a plan of care for a client with
d. Assessing the area over the AV fistula for a a spinal cord injury includes measures to prevent
bruit and three each shift autonomic dysreflexia (hyperreflexia). Which
e. Placing a pressure dressing over the site after intervention does the nurse incorporate into the
each dialysis treatment plan to prevent this complication?
f. Administering IV fluids through the venous site a. Keeping the fan running in the client's room
of the AV fistula as needed - ANSWERS - b. Keeping the linens wrinkle free under the client
A, B, C, D c. Limiting bladder catheterization to once every
12 hours
d. Avoiding the administration of enemas and
A nurse is evaluating outcomes for a client with rectal suppositories - ANSWERS - B
Guillain-Barre syndrome. Which outcome does The most frequent cause of autonomic
the nurse recognize as optimal respiratory dysreflexias are a distended bladder and
outcomes for the client? impacted feces. Other causes include stimulation
a. Normal deep tendon reflexes of the skin by tactile, thermal, or painful stimuli.
b. Improved skeletal muscle tone The nurse renders care in such a way as to
c. Absences of paresthesias in the lower minimize these risks.
extremities
d. Clear sound in the lower lung fields bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg - A nurse provides home care instructions to a
ANSWERS - D, E 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 nurse of the telemetry unit is caring for a client a. I need to get more fluids and fiber into my diet
who has had a MI and is now attached to a b. I should cut my food into small pieces before I
cardiac monitor. The nurse is monitoring the eat
client's cardiac rhythm and nots ventricular c. I need to put powder under the vest twice a
fibrillation. Which nursing intervention should the day to prevent sweating
nurse take first? d. I have to check the pin sites everyday and
a. Calling the rapid response team watch for signs of infection - ANSWERS - C
b. Preparing the client for cardioversion Cleanse the skin under the wool liner each day to
c. Asking the client to bear down and cough prevent rashes and soars.
d. Preparing to administer diltiazem -
ANSWERS - A
The pattern of ventricular fibrillation is identified A nurse is caring for a client with increased
and can be a result after a patient with an MI. VF intracranial pressure. In which position should the
, NCLEX NGN Pre-Test Questions and Answers Rated A
nurse maintain the client? d Determine whether the prescribed insulin
a. Supine with the head extended dosage is correct - ANSWERS - B
b. Side lying with the neck flexed
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees - A nurse caring for a client with acquired
ANSWERS - D immunodeficiency syndrome is monitoring the
Proper positioning promotes venous drainage client for signs of complications. Which of the
from the cranium to minimize ICP. following would cause the nurse to suspect
infection with Pneumocystis jirovec? SATA
a. Diarrhea
A client with a basilar skull fracture has clear fluid b. Tachypnea
leaking from the ears. The nurse should take c. Pedal edema
which action first? d. Intermittent fever
a. Asses the clear fluid for protein e. Dyspnea with ambulating
b. Check the clear fluid for glucose f. Expectoration of frothy mucus -
c. Place cotton calls or dry gauze loosely in the ANSWERS - B, D, E
ears A opportunistic respiratory infection associated
d. Use an otoscope to assess the tympanic with AIDs that causes dyspnea, nonproductive
membrane for rupture - ANSWERS - B cough, intermittent fever, fatigue, anorexia,
CSF contains glucose not protein. tachypnea, wt. loss.
A nurse is caring for a client who has just Zidovudine is prescribed for a client with AIDS.
undergone cardioversion. Which intervention is The nurse tells the client that it is important to
the nurse's priority after this procedure. report back to the clinic as scheduled for which
a. Administer oxygen follow-up diagnostic?
b. Monitoring the BP a. Blood glucose checks
c. Administering antidysrhythmic medications b. Blood pressure checks
d. Monitoring the client's LOC - c. Complete blood counts (CBC)
ANSWERS - A d. Electrocradiographic studies -
ABC's of nursing. All other choices are correct, ANSWERS - C
but not priority. Zidovudine is an antiviral medication that cause
cause agranulocytosis and anemia.
A client with diabetes mellitus who is scheduled
to have blood drawn for determination of the After a non-immunocompromised client
glycosylated hemoglobin (HbA1c) level asks the undergoes a Mantoux test for TB infection, an
nurse why the test is necessary if he is area of induration 6 mm wide developed. The
performing blood glucose monitoring at home. client asks the nurse what this result means.
Which is the best response for the nurse to Which is the best response?
provide? a. We'll have to repeat the test because the result
a. Detect diabetic complications was inconclusive
b. Assess long-term glycemic control b. The swollen area is small, so that means your
c. Determine whether the client is at risk for test result is negative
hypoglycemia c. You've been exposed to TB so you will need to
