NCLEX RN ACTUAL EXAM TEST BANK, REAL QUESTIONS & ANSWERS NCLEX
QUESTION 1
Which classificationof drugs is contraindicatedfor theclientwith hypertrophiccardiomyopathy?
A. Positiveinotropes
B. Vasodilators
C. Diuretics
D. Antidysrhythmics
Answer: A
Explanation:
(A) Positive inotropic agents should not be administered owing to their action of increasing myocardial contractility
Increased ventricular contractility would increase outflow tract obstruction in the client with hypertrophic
cardiomyopathy.(B) Vasodilatorsarenot typicallyprescribedbut arenot contraindicated.(C) Diuretics are used with
caution to avoid causing hypovolemi
A. (D) Antidysrhythmicsaretypicallyneededto treatbothatrialand ventriculardysrhythmias.
QUESTION 2
Signs and symptomsof an allergyattack includewhich of thefollowing?
A. Wheezingon inspiration
B. Increasedrespiratoryrate
C. Circumoralcyanosis
D. Prolongedexpiration
Answer: D
Explanation:
(A) Wheezingoccursduring expirationwhenair movementis impairedbecauseof constrictededematous bronchial lumin
A. (B) Respirationsaredifficult,but therateis frequentlynormal.(C) The circumoralareais usuallypale. Cyanosis is not
an earlysign of hypoxi
A. (D) Expiration is prolongedbecausethealveoliaregreatlydistendedand air trappingoccurs.
QUESTION 3
A clientconfidesto thenursethathe tastedpoison inhis eveningmeal.This wouldbean exampleof whattype of
hallucination?
A. Auditory
B. Gustatory
C. Olfactory
D. Visceral
Answer: B
Explanation:
(A) Auditory hallucinations involve sensory perceptions of hearing. (B) Gustatory hallucinations involve sensory
perceptionsof taste.(C) Olfactoryhallucinations involvesensoryperceptionsof smell.(D) Visceral
,hallucinationsinvolvesensoryperceptionsof sensation
,QUESTION
4 Which of thefollowingfindingswouldbeabnormalin a postpartalwoman?
A. Chills shortlyafterdelivery
B. Pulse rateof 60 bpm inmorningon first postdeliveryday
C. Urinary outputof 3000mL on the seconddayafterdelivery
D. An oral temperatureof 101F(38.3C) on thethird dayafterdelivery
Answer: D
Explanation:
(A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous resp
or to vasomotor changes. If not followedby a fever, it is clinicallyinnocuous. (B) The pulse rate during the immediate
postpartal period may be low but presents no cause for alarm. The body attempts to adapt thedecreased
to pressures
intra-abdominallyas wellas from thereduction ofbloodflow to thevascularbed.(C) Urinary output increases during
the early postpartal period (12
–24 hours) owing to diuresis. The kidneys must eliminate an estimated–3000 2000 mL of
extracellular fluid associated with a normal pregnancy. (D) A temperature of 100.4F(38C) may occur afterdeliveryas a
resultof exertionand dehydrationof labor.However, anytemperature greater than 100.4F needs further investigation to
identify anyinfectious process.
QUESTION 5
A six-month-old infanthas beenadmittedto theemergencyroom with febrileseizures. Intheteachingof the parents, the
nurse states that:
A. Sustainedtemperatureelevationover103Fis generallyrelatedto febrileseizures
B. Febrileseizuresdo not usuallyrecur
C. Thereis littlerisk of neurologicaldeficitand mentalretardationas sequelaeto febrileseizures
D. Febrileseizuresareassociatedwith diseasesof thecentralnervoussystem
Answer: C
Explanation:
(A) The temperature elevation related to febrile seizures generally exceeds 101F, and seizures occur during the
temperaturerise ratherthanaftera prolongedelevation.(B) Febrileseizuresmay recurand aremorelikely to do so when
the first seizure occurs in the 1st year of life. (C) There is little risk of neurological deficit, mental retardation,
teredor al
behavior secondary to febrile seizures. (D) Febrile seizures are associated with disease of the central nervous system.
QUESTION 6
A clientdiagnosedwith bipolardisordercontinuesto be hyperactiveand to loseweight.Which of the following nutritional
interventions would be most therapeutic for him at this time?
A. Small,frequentfeedingsof foodsthatcan becarried
B. Tube feedingswith nutritionalsupplements
C. Allowing him to eatwhenand whathe wants
D. Giving him a quiet placewherehe can sitdownto eatmeals
Answer: A
Explanation:
(A) The manic clientis unableto sit stilllong enoughto eatan adequatemeal. Small,frequentfeedingswith
, fingerfoodsallowhim to eatduring periodsof activity.(B) This typeof therapyshouldbe implementedwhen other
methods have been exhausted. (C) The manic client should not be in control of his treatment plan. This type of clien
mayforget to eat. (D) The manic client is unable to sit down to eat full meals.
QUESTION 7
A clientwith bipolardisordertaking lithium tellsthenursethathe has ringing in his ears,blurredvision, and diarrhe
A. The nursenoticesa slight tremorin his lefthand and a slurring patternto his speech.Which of the following actions by
the nurse is appropriate?
A. Administera statdoseof lithium as necessary.
B. Recognizethis as an expectedresponseto lithium.
C. Requestan orderfor a statbloodlithium level.
D. Give an oral doseof lithium antidote.
Answer: C
Explanation:
(A) Thesesymptomsareindicativeof lithium toxicity. A statdoseof lithium couldbefatal.
(B) Thesearetoxic effectsof lithium therapy.(C) The clientis exhibitingsymptomsof lithium toxicity, which maybe
validated bylab studies. (D) There is no known lithium antidote.
QUESTION 8
A diagnosisof hepatitisC is confirmedby a maleclient‘sphysician.The nurseshouldbeknowledgeableof the differences
between hepatitis A, B, and C. Which of the following are characteristics of hepatitis C?
A. The potentialfor chronic liver diseaseis minimal.
B. The onset ofsymptomsis abrupt.
C. The incubationperiodis 2–26 weeks.
D. Thereis an effectivevaccinefor hepatitisB, but not for hepatitisC.
Answer: C
Explanation:
(A) Hepatitis C and B may result in chronic liver disease. Hepatitis A has a low potential for chronic liver disease.
(B)
HepatitisC and B haveinsidiousonsets. HepatitisA hasan abruptonset.(C) Incubationperiodsare as follows: hepatitis
C is 2–26 weeks, hepatitis B is–20
6 weeks, and hepatitis A is–62 weeks. (D) Only hepatitis B has an effective vaccine.
QUESTION 9
Hypoxia is theprimaryproblemrelatedto near-drowningvictims.The first organthatsustainsirreversible damage after
submersion in water is the:
A. Kidney (urinarysystem)
B. Brain (nervoussystem)
C. Heart (circulatorysystem)
D. Lungs (respiratorysystem)
Answer: B
Explanation:
A+
QUESTION 1
Which classificationof drugs is contraindicatedfor theclientwith hypertrophiccardiomyopathy?
A. Positiveinotropes
B. Vasodilators
C. Diuretics
D. Antidysrhythmics
Answer: A
Explanation:
(A) Positive inotropic agents should not be administered owing to their action of increasing myocardial contractility
Increased ventricular contractility would increase outflow tract obstruction in the client with hypertrophic
cardiomyopathy.(B) Vasodilatorsarenot typicallyprescribedbut arenot contraindicated.(C) Diuretics are used with
caution to avoid causing hypovolemi
A. (D) Antidysrhythmicsaretypicallyneededto treatbothatrialand ventriculardysrhythmias.
QUESTION 2
Signs and symptomsof an allergyattack includewhich of thefollowing?
A. Wheezingon inspiration
B. Increasedrespiratoryrate
C. Circumoralcyanosis
D. Prolongedexpiration
Answer: D
Explanation:
(A) Wheezingoccursduring expirationwhenair movementis impairedbecauseof constrictededematous bronchial lumin
A. (B) Respirationsaredifficult,but therateis frequentlynormal.(C) The circumoralareais usuallypale. Cyanosis is not
an earlysign of hypoxi
A. (D) Expiration is prolongedbecausethealveoliaregreatlydistendedand air trappingoccurs.
QUESTION 3
A clientconfidesto thenursethathe tastedpoison inhis eveningmeal.This wouldbean exampleof whattype of
hallucination?
A. Auditory
B. Gustatory
C. Olfactory
D. Visceral
Answer: B
Explanation:
(A) Auditory hallucinations involve sensory perceptions of hearing. (B) Gustatory hallucinations involve sensory
perceptionsof taste.(C) Olfactoryhallucinations involvesensoryperceptionsof smell.(D) Visceral
,hallucinationsinvolvesensoryperceptionsof sensation
,QUESTION
4 Which of thefollowingfindingswouldbeabnormalin a postpartalwoman?
A. Chills shortlyafterdelivery
B. Pulse rateof 60 bpm inmorningon first postdeliveryday
C. Urinary outputof 3000mL on the seconddayafterdelivery
D. An oral temperatureof 101F(38.3C) on thethird dayafterdelivery
Answer: D
Explanation:
(A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous resp
or to vasomotor changes. If not followedby a fever, it is clinicallyinnocuous. (B) The pulse rate during the immediate
postpartal period may be low but presents no cause for alarm. The body attempts to adapt thedecreased
to pressures
intra-abdominallyas wellas from thereduction ofbloodflow to thevascularbed.(C) Urinary output increases during
the early postpartal period (12
–24 hours) owing to diuresis. The kidneys must eliminate an estimated–3000 2000 mL of
extracellular fluid associated with a normal pregnancy. (D) A temperature of 100.4F(38C) may occur afterdeliveryas a
resultof exertionand dehydrationof labor.However, anytemperature greater than 100.4F needs further investigation to
identify anyinfectious process.
QUESTION 5
A six-month-old infanthas beenadmittedto theemergencyroom with febrileseizures. Intheteachingof the parents, the
nurse states that:
A. Sustainedtemperatureelevationover103Fis generallyrelatedto febrileseizures
B. Febrileseizuresdo not usuallyrecur
C. Thereis littlerisk of neurologicaldeficitand mentalretardationas sequelaeto febrileseizures
D. Febrileseizuresareassociatedwith diseasesof thecentralnervoussystem
Answer: C
Explanation:
(A) The temperature elevation related to febrile seizures generally exceeds 101F, and seizures occur during the
temperaturerise ratherthanaftera prolongedelevation.(B) Febrileseizuresmay recurand aremorelikely to do so when
the first seizure occurs in the 1st year of life. (C) There is little risk of neurological deficit, mental retardation,
teredor al
behavior secondary to febrile seizures. (D) Febrile seizures are associated with disease of the central nervous system.
QUESTION 6
A clientdiagnosedwith bipolardisordercontinuesto be hyperactiveand to loseweight.Which of the following nutritional
interventions would be most therapeutic for him at this time?
A. Small,frequentfeedingsof foodsthatcan becarried
B. Tube feedingswith nutritionalsupplements
C. Allowing him to eatwhenand whathe wants
D. Giving him a quiet placewherehe can sitdownto eatmeals
Answer: A
Explanation:
(A) The manic clientis unableto sit stilllong enoughto eatan adequatemeal. Small,frequentfeedingswith
, fingerfoodsallowhim to eatduring periodsof activity.(B) This typeof therapyshouldbe implementedwhen other
methods have been exhausted. (C) The manic client should not be in control of his treatment plan. This type of clien
mayforget to eat. (D) The manic client is unable to sit down to eat full meals.
QUESTION 7
A clientwith bipolardisordertaking lithium tellsthenursethathe has ringing in his ears,blurredvision, and diarrhe
A. The nursenoticesa slight tremorin his lefthand and a slurring patternto his speech.Which of the following actions by
the nurse is appropriate?
A. Administera statdoseof lithium as necessary.
B. Recognizethis as an expectedresponseto lithium.
C. Requestan orderfor a statbloodlithium level.
D. Give an oral doseof lithium antidote.
Answer: C
Explanation:
(A) Thesesymptomsareindicativeof lithium toxicity. A statdoseof lithium couldbefatal.
(B) Thesearetoxic effectsof lithium therapy.(C) The clientis exhibitingsymptomsof lithium toxicity, which maybe
validated bylab studies. (D) There is no known lithium antidote.
QUESTION 8
A diagnosisof hepatitisC is confirmedby a maleclient‘sphysician.The nurseshouldbeknowledgeableof the differences
between hepatitis A, B, and C. Which of the following are characteristics of hepatitis C?
A. The potentialfor chronic liver diseaseis minimal.
B. The onset ofsymptomsis abrupt.
C. The incubationperiodis 2–26 weeks.
D. Thereis an effectivevaccinefor hepatitisB, but not for hepatitisC.
Answer: C
Explanation:
(A) Hepatitis C and B may result in chronic liver disease. Hepatitis A has a low potential for chronic liver disease.
(B)
HepatitisC and B haveinsidiousonsets. HepatitisA hasan abruptonset.(C) Incubationperiodsare as follows: hepatitis
C is 2–26 weeks, hepatitis B is–20
6 weeks, and hepatitis A is–62 weeks. (D) Only hepatitis B has an effective vaccine.
QUESTION 9
Hypoxia is theprimaryproblemrelatedto near-drowningvictims.The first organthatsustainsirreversible damage after
submersion in water is the:
A. Kidney (urinarysystem)
B. Brain (nervoussystem)
C. Heart (circulatorysystem)
D. Lungs (respiratorysystem)
Answer: B
Explanation:
A+
