Next generation NCLEX-PN ACTUAL EXAM
SEPTEMBER AND OCTOBER VERIFIED 100%
GURANTEED
the nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal
approach. the nurse should be particularly alert to:
A. Nasal congestion
B. Abdominal Tenderness
C. Muscle Tetany
D. Oliguria
A. Nasal congestion
why?
removal of the pituitary gland is usually done by transsphernoidal approach through the nose. Nasal
congestion further interferes with the airway.
A client with cancer is a, admitted to the oncology unit. Stat lab values revel Hgb 12.6, WBC 6500,
K+1.9, uric acid 7.0, Na+136, and platelets 178,000. The nurse evaluates that the client is experiencing
which of the following?
A. Hypernatremia
B. Hypokalemia
C. Myelosuppression
D. Leukocytosis
B. Hypokalemia
why?
Hypokalemia is evident from the lab values listed. The other laboratory findings are within normal
limits. making answers A,C and D incorrect
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
,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.
The nurse is working in the emergency room when a client arrives with severe burns of the left arm,
hands, face, and neck. which action should receive priority?
A. starting an IV?
B. Applying oxygen
C.Obtaining blood gas
D. Medicating the client foe pain
B. Applying oxygen
why?
the client with burns to the neck needs airway assessments and supplemental oxygen, so applying
oxygen is priority. the next action should be to start an IV and medicate for pain.
The nurse is visiting a home health client with osteoporosis. The client has a new prescription for
alendronate (Fosamax). Which instructions should be given to the client
A. rest in bed after taking the medication for at least 30 mins
B. Avoid rapid movements after taking the medication
C. Take medication with water only
D. Allow at least 1 hour between taking the medicine and taking other medications
C. Take medication with water only
why?
Fosmax should be taken with water only. The client should also remain upright for at least 30 mins
after taking the medication.
The nurse is making initial rounds on a client with a C5 fracture and crutchfield thongs. Which
equipment should be kept at the bedside?
A. A pair of forceps
B. A torque wrench
C. A pair or wire cutters
D. A screwdriver
B. A torque wrench
why?
,A tourque wrench is kept at the bedside to tighten and loosen the screws of crutchfield tongs. This
wrench controls the amount of pressure that is placed on the screws.
An infant weighs 7 pounds at birth. The excpectd weight by 1 year should be:
A. 10 pounds
B.12 pounds
C. 18 pounds
D. 21 pounds
D. 21 pounds
why?
A birth weight of 7 pounds would indicate 21 pounds in 1 year or triple the his birth weight.
A client is admitted with a Ewing's sacroma. which symptoms would be expected due to this tumor's
location?
A. Hemiplegia
B. Aphasia
C. Nausea
D. Bone Pain
D. Bone Pain
why?
Sacroma is a type of bone cancer, therefor, bone pain would be expected
The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol).
Which labatory value might be a indicate a serious side effect of this drug?
A. Uric acid of 5mg/dL
B. Hematoccrit of 33%
C. WBC 2,000 per cubic millimeter
D. Platelets 150,000 per cubic millimeter
C. WBC 2,000 per cubic millimeter
why?
Tegratol can suppress the bone marrow and decrease the white blood cells count; thus, a lab value of
WBC 2,000 per cubic millimeter indicates side effects of the drug.
, 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?"
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
The nurse is assisting a client with diverticulosis to select appropiate foods. Which food should be
avoided?
A. Bran
B. Fresh Peaches
C. Cucumber salad
D. Yeast Rolls
C. Cucumber salad
why?
the client with diverticulitis should avoid foods with seeds.
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
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.
SEPTEMBER AND OCTOBER VERIFIED 100%
GURANTEED
the nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal
approach. the nurse should be particularly alert to:
A. Nasal congestion
B. Abdominal Tenderness
C. Muscle Tetany
D. Oliguria
A. Nasal congestion
why?
removal of the pituitary gland is usually done by transsphernoidal approach through the nose. Nasal
congestion further interferes with the airway.
A client with cancer is a, admitted to the oncology unit. Stat lab values revel Hgb 12.6, WBC 6500,
K+1.9, uric acid 7.0, Na+136, and platelets 178,000. The nurse evaluates that the client is experiencing
which of the following?
A. Hypernatremia
B. Hypokalemia
C. Myelosuppression
D. Leukocytosis
B. Hypokalemia
why?
Hypokalemia is evident from the lab values listed. The other laboratory findings are within normal
limits. making answers A,C and D incorrect
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
,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.
The nurse is working in the emergency room when a client arrives with severe burns of the left arm,
hands, face, and neck. which action should receive priority?
A. starting an IV?
B. Applying oxygen
C.Obtaining blood gas
D. Medicating the client foe pain
B. Applying oxygen
why?
the client with burns to the neck needs airway assessments and supplemental oxygen, so applying
oxygen is priority. the next action should be to start an IV and medicate for pain.
The nurse is visiting a home health client with osteoporosis. The client has a new prescription for
alendronate (Fosamax). Which instructions should be given to the client
A. rest in bed after taking the medication for at least 30 mins
B. Avoid rapid movements after taking the medication
C. Take medication with water only
D. Allow at least 1 hour between taking the medicine and taking other medications
C. Take medication with water only
why?
Fosmax should be taken with water only. The client should also remain upright for at least 30 mins
after taking the medication.
The nurse is making initial rounds on a client with a C5 fracture and crutchfield thongs. Which
equipment should be kept at the bedside?
A. A pair of forceps
B. A torque wrench
C. A pair or wire cutters
D. A screwdriver
B. A torque wrench
why?
,A tourque wrench is kept at the bedside to tighten and loosen the screws of crutchfield tongs. This
wrench controls the amount of pressure that is placed on the screws.
An infant weighs 7 pounds at birth. The excpectd weight by 1 year should be:
A. 10 pounds
B.12 pounds
C. 18 pounds
D. 21 pounds
D. 21 pounds
why?
A birth weight of 7 pounds would indicate 21 pounds in 1 year or triple the his birth weight.
A client is admitted with a Ewing's sacroma. which symptoms would be expected due to this tumor's
location?
A. Hemiplegia
B. Aphasia
C. Nausea
D. Bone Pain
D. Bone Pain
why?
Sacroma is a type of bone cancer, therefor, bone pain would be expected
The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol).
Which labatory value might be a indicate a serious side effect of this drug?
A. Uric acid of 5mg/dL
B. Hematoccrit of 33%
C. WBC 2,000 per cubic millimeter
D. Platelets 150,000 per cubic millimeter
C. WBC 2,000 per cubic millimeter
why?
Tegratol can suppress the bone marrow and decrease the white blood cells count; thus, a lab value of
WBC 2,000 per cubic millimeter indicates side effects of the drug.
, 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?"
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
The nurse is assisting a client with diverticulosis to select appropiate foods. Which food should be
avoided?
A. Bran
B. Fresh Peaches
C. Cucumber salad
D. Yeast Rolls
C. Cucumber salad
why?
the client with diverticulitis should avoid foods with seeds.
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
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.
