Correct Answers with Rationales to Guarantee Your
First Attempt Success in NCLEX RN
A client with ascites is scheduled for a paracentesis. Which instruction should be
given to the client before the procedure?
a "You will need to lay flat during the procedure."
b. "You need to empty your bladder before the procedure."
c. "You will be asleep during the procedure."
d. "The doctor will inject a medication during the procedure."
The correct answer is b. "You need to empty your bladder before the
procedure."
Explanation: Emptying the bladder reduces the risk of bladder puncture during
the procedure, as the needle is inserted into the abdominal cavity.
A client's lab values reveal Hgb 12.6, WBC 6500cu.mm, K+ 1.9, uric acid 7.0,
Na+ 136, and platelets 178,000cu.mm. The nurse evaluates that the client is
experiencing which of the following?
a Hypernatremia
b Hypokalemia
c Myelosuppression
d Leukopenia
The correct answer is b Hypokalemia.
Explanation: The potassium level (K+) of 1.9 mEq/L is below the normal range
(3.5-5.0 mEq/L), indicating hypokalemia; other values are within normal limits.
,The nurse is caring for the client who has been in a coma for two months. He has
signed a donor card, but the wife is opposed to the idea of organ donation. How
should the nurse handle the topic of organ donation with the wife?
a Tell the wife that the hospital will honor her wishes regarding organ donation,
but contact the organ-retrieval staff.
b Tell her that because her husband signed a donor card, the hospital has the right
to take the organs upon the death of her husband.
c Explain that it is necessary for her to donate her husband's organs because he
signed the permit.
d Refrain from talking about the subject until after the death of her husband.
The correct answer is a Tell the wife that the hospital will honor her wishes
regarding organ donation, but contact the organ-retrieval staff.
Explanation: The wife's wishes take precedence as next of kin, but notifying the
organ retrieval team ensures protocol is followed without coercion.
Due to a high census, it has been necessary for a number of clients to be transferred
to other units within the hospital. Which client should be transferred to the
postpartum unit?
a A 66-year-old female with gastroenteritis
b A 40-year-old female with a hysterectomy
c A 27-year-old male with severe depression
d A 28-year-old male with ulcerative colitis
The correct answer is b A 40-year-old female with a hysterectomy.
Explanation: Postpartum units are equipped for post-surgical gynecological care
similar to hysterectomy recovery, unlike the other conditions which require
different specialized care.
Before administering Theo-Dur (theophylline), the nurse should check the
patient's:
,a output
b Blood pressure
c Pulse
d Temperature
The correct answer is c Pulse.
Explanation: Theophylline can cause tachycardia, so assessing the pulse rate is
essential to detect potential cardiac side effects before administration.
Which information should be given to the patient undergoing radiation therapy for
breast cancer?
a Avoid exposing radiation areas to sunlight during treatment time and for a year
after completion of therapy
b Moisturize the radiation site with oil-based lotion to prevent blistering
c Use bath oil when tub bathing to prevent drying and peeling
d Report redness and soreness of the area to the physician
The correct answer is a Avoid exposing radiation areas to sunlight during
treatment time and for a year after completion of therapy.
Explanation: Radiation sensitizes the skin to UV damage, increasing burn risk;
sun exposure should be avoided for at least a year post-treatment.
The charge nurse is making assignments for the day. After accepting the
assignment to care for a client with leukemia, the nurse tells the charge nurse that
her child has chickenpox. Which initial action should the charge nurse take?
a Change the nurse's assignment to another client.
b Explain to the nurse that there is no risk to the client.
c Ask the nurse if the chickenpox have crusted.
d Ask the nurse if she has ever had the chickenpox.
, The correct answer is d Ask the nurse if she has ever had the chickenpox.
Explanation: If the nurse has had chickenpox, she has immunity and poses no
risk; otherwise, reassignment may be needed to protect the immunocompromised
leukemia client.
Which statement is true regarding therapy with Levemir (insulin detemir)?
a The onset is 1-2 hours.
b It may be mixed with regular insulin.
c It peaks in 2-3 hours.
d The duration is 24 hours.
The correct answer is d The duration is 24 hours.
Explanation: Levemir is a long-acting insulin with a duration of up to 24 hours,
no peak, and onset of 1-2 hours; it should not be mixed with other insulins.
Which client should be assigned to the nursing assistant?
a The 18-year-old with a fracture to two cervical vertebrae
b The infant with meningitis with a temperature of 101°F
c The elderly client with a thyroidectomy four days ago
d The client with a thoracotomy two days ago
The correct answer is c The elderly client with a thyroidectomy four days ago.
Explanation: This client is stable post-op; the others require skilled nursing
assessment for complications like spinal instability, infection, or respiratory issues.
The physician has ordered the Schilling test for a patient with suspected pernicious
anemia. What other vitamin level is often assessed at the same time as the B12
level?
a Folic acid