NCLEX 150 QUESTIONS ANSWERS AND CLINICAL REASONING
EXAM PREP # 4
1. A young adult who was in a motorcycle accident is brought to the
emergency room with a closed head injury with suspected subdural
hematoma. Although the client complains of a severe headache, he is alert
and answers questions appropriately. The nurse would question which of
the following orders?
1. “Promethazine (Phenergan) 25 mg IM 3 h.”
2. “Morphine sulfate 10 mg IM q3-4h.”
3. “Docusate sodium (Colace) 50 mg PO bid.”
4. “Ranitidine (Zantac) 50 mg IVPB q12h.”
Strategy: All answers are implementations. Determine the outcome of each
answer choice. Is it desired?
(1) H1 receptor blocker, used as an antiemetic
(2) correct–narcotic analgesic, causes CNS and respiratory depression,
contraindicated in head
injury because it masks signs of increased intracranial pressure
(3) stool softener, used for an immobilized patient
(4) H2 histamine antagonist, reduces acid production in stomach, prevents stress
ulcers
2. The nurse has just returned to the desk and has four phone messages to
return. Which of the following messages should the nurse return FIRST?
1. A woman in her first trimester of pregnancy complaining of heartburn.
2. A man complaining of heartburn that radiates to his jaw.
3. A woman complaining of hot flashes and difficulty sleeping.
4. A boy complaining of knee pain after playing basketball.
Strategy: Determine the least stable client.
(1) caused by reflux of gastric contents into esophagus, treatment is small frequent
meals, don’t
consume fluids with food, don’t wear tight clothing
(2) correct–indicates chest pain, needs to seek medical attention immediately
(3) caused by menopause, treat with hormone replacement therapy (HRT)
(4) should treat with rest and ice
3. A patient is admitted to the surgical unit with a diagnosis of rule out
intestinal obstruction. The nurse is preparing to insert a Salem sump NG
tube as ordered. In which of the following positions would it be BEST for the
nurse to place this patient during the procedure?
1. Head of bed elevated 30°–45°.
2. Head of bed elevated 60°–90°.
3. Side-lying with head elevated 15°.
4. Lying flat with head turned to the left side.
,Strategy: Remember the positioning strategy.
(1) not the best position
(2) correct–facilitates swallowing and movement of tube through GI tract
(3) not the best position
(4) not the best position
4. The nurse is monitoring the fluid status of a 63-year-old woman receiving
IV fluids following surgery. Which of the following symptoms would suggest
to the nurse that the patient has fluid volume overload?
1. Temperature 101°F (38.3°C), BP 96/60, pulse 96 and thready.
2. Cool skin, respiratory crackles, pulse 86 and bounding.
3. Complaints of a headache, abdominal pain, and lethargy.
4. Urinary output 700 cc/24 h, CVP of 5, and nystagmus.
Strategy: Determine how each answer choice relates to fluid volume
overload.
(1) indicates dehydration
(2) correct–will see bounding pulse, elevated BP, distended neck veins, edema,
headache, polyuria, diarrhea, liver enlargement
(3) symptoms could be from causes other than volume overload
(4) slightly reduced output, CVP would be elevated, normal CVP 4-10 mm/H2 O,
involuntary eye movements not seen
5. A woman has been recently diagnosed with systemic lupus and shares
with the nurse, “I am thinking about getting pregnant, but I don’t know
how I will be able to tolerate a pregnancy since I have lupus.” Which of the
following responses by the nurse is BEST?
1. “Most women find that they feel better when they are pregnant.”
2. “How long have you been in remission?”
3. “Women with lupus frequently have slightly longer gestations.”
4. “It is best to become pregnant within the first six months of diagnosis.”
Strategy: Answers are a mix of assessments and implementations. Does this
situation require assessment? Yes.
(1) maternal morbidity and mortality are increased with SLE
(2) correct–should be in remission for at least 5 months prior to conceiving
(3) gestation not affected by SLE
(4) recommended that a woman wait two years following diagnosis before conceiving
6. The multidisciplinary team decides to implement behavior modification
with a client. Which of the following nursing actions is of primary
importance during this time?
1. Confirm that all staff members understand and comply with the treatment plan.
2. Establish mutually agreed upon, realistic goals.
3. Ensure that the potent reinforcers (rewards) are important to the client.
4. Establish a fixed interval schedule for reinforcement.
,Strategy: All answers are implementations. Determine the outcome of each
answer choice. Is it desired?
(1) correct–to implement a behavior modification plan successfully, all staff members
need to be included in program development, and time must be allowed for
discussion of concerns from each nursing staff member; consistency and follow-
through is important to prevent or diminish the level of manipulation by the staff or
client during implementation of this program
(2) not of primary importance in designing an effective behavior modification
program
(3) not of primary importance in designing an effective behavior modification
program
(4) not of primary importance in designing an effective behavior modification
program
7. A client received six units of regular insulin three hours ago. The nurse
would be MOST concerned if which of the following was observed?
1. Kussmaul respirations and diaphoresis.
2. Anorexia and lethargy.
3. Diaphoresis and trembling.
4. Headache and polyuria.
Strategy: “MOST concerned” indicates a complication.
(1) Kussmaul respirations are signs of hyperglycemia
(2) not indicative of hypoglycemia
(3) correct–regular insulin peaks in two to four hours; indicates hypoglycemia; give
skim milk
(4) not indicative of hypoglycemia
8. The nursing assistant reports to the nurse that a client who is one-day
postoperative after an angioplasty is refusing to eat and states, “I just don’t
feel good.” Which of the following actions, if taken by the nurse, is BEST?
1. The nurse talks with the client about how he is feeling.
2. The nurse instructs the nursing assistant to sit with the client while he eats.
3. The nurse contacts the physician to obtain an order for an antacid.
4. The nurse evaluates the most recent vital signs recorded in the chart.
Strategy: Answers are a mix of assessments and implementations. Does this
situation require assessment? Yes. Is the assessment appropriate? Yes.
(1) correct–assessment required; monitor for closure of vessel, bleeding,
hypotension, dysrhythmias
(2) assess cause of problem before implementing
(3) assess cause of problem before implementing
(4) more important to assess what is happening now
, 9. The nurse prepares a 25-year-old woman for a cesarean section. The
patient says she had major surgery several years ago and asks if she will
receive a similar “shot” before surgery. The nurse’s response should be
based on an understanding that the preoperative medication given before a
cesarean section
1. contains a lower overall dosage of medication than is given before general
surgery.
2. contains reduced amounts of sedatives and hypnotics than are given before
general surgery.
3. contains reduced amounts of narcotics than are given before general surgery.
4. contains medications similar in type and dosages to those given before general
surgery.
Strategy: Think about the action of the medications.
(1) decreased dosage of narcotics are used
(2) dosages of sedatives and hypnotics will be similar
(3) correct–decreased so less narcotic crosses the placental barrier causing
respiratory depression
in the infant
(4) dosages of narcotics are reduced
10. The nurse is caring for an 11-year-old patient being treated for a
fractured right femur with balanced suspension traction with a Thomas
splint and Pearson attachment. The nurse notes that the patient’s left leg is
externally rotated. The nurse should
1. place a trochanter roll on the outer aspect of the thigh.
2. perform resistive range of motion of the left leg.
3. adduct and internally rotate the left leg.
4. instruct the patient to maintain the left leg in a neutral position.
Strategy: Answers are implementations. Determine the outcome of each
answer choice. Is it desired?
(1) correct–holds hip in neutral position and leg in normal alignment, entire weight of
leg cannot be held by props placed below knee
(2) exercise would not prevent future external rotation of the leg
(3) adduct (add to midline of body) does not change external rotation, internal
rotation is not beneficial, normal alignment is required
(4) leg will externally rotate unless propped in proper alignment
11. The nurse is preparing a five-year-old child for surgery. The nurse notes
that the child’s parents are divorced and have joint legal custody. The
informed consent for surgery has been signed by the mother. Which of the
following actions by the nurse is BEST?
1. Notify the physician.
2. Inform surgery.
3. Contact the father to obtain consent.
4. Continue the child’s preoperative preparation.
EXAM PREP # 4
1. A young adult who was in a motorcycle accident is brought to the
emergency room with a closed head injury with suspected subdural
hematoma. Although the client complains of a severe headache, he is alert
and answers questions appropriately. The nurse would question which of
the following orders?
1. “Promethazine (Phenergan) 25 mg IM 3 h.”
2. “Morphine sulfate 10 mg IM q3-4h.”
3. “Docusate sodium (Colace) 50 mg PO bid.”
4. “Ranitidine (Zantac) 50 mg IVPB q12h.”
Strategy: All answers are implementations. Determine the outcome of each
answer choice. Is it desired?
(1) H1 receptor blocker, used as an antiemetic
(2) correct–narcotic analgesic, causes CNS and respiratory depression,
contraindicated in head
injury because it masks signs of increased intracranial pressure
(3) stool softener, used for an immobilized patient
(4) H2 histamine antagonist, reduces acid production in stomach, prevents stress
ulcers
2. The nurse has just returned to the desk and has four phone messages to
return. Which of the following messages should the nurse return FIRST?
1. A woman in her first trimester of pregnancy complaining of heartburn.
2. A man complaining of heartburn that radiates to his jaw.
3. A woman complaining of hot flashes and difficulty sleeping.
4. A boy complaining of knee pain after playing basketball.
Strategy: Determine the least stable client.
(1) caused by reflux of gastric contents into esophagus, treatment is small frequent
meals, don’t
consume fluids with food, don’t wear tight clothing
(2) correct–indicates chest pain, needs to seek medical attention immediately
(3) caused by menopause, treat with hormone replacement therapy (HRT)
(4) should treat with rest and ice
3. A patient is admitted to the surgical unit with a diagnosis of rule out
intestinal obstruction. The nurse is preparing to insert a Salem sump NG
tube as ordered. In which of the following positions would it be BEST for the
nurse to place this patient during the procedure?
1. Head of bed elevated 30°–45°.
2. Head of bed elevated 60°–90°.
3. Side-lying with head elevated 15°.
4. Lying flat with head turned to the left side.
,Strategy: Remember the positioning strategy.
(1) not the best position
(2) correct–facilitates swallowing and movement of tube through GI tract
(3) not the best position
(4) not the best position
4. The nurse is monitoring the fluid status of a 63-year-old woman receiving
IV fluids following surgery. Which of the following symptoms would suggest
to the nurse that the patient has fluid volume overload?
1. Temperature 101°F (38.3°C), BP 96/60, pulse 96 and thready.
2. Cool skin, respiratory crackles, pulse 86 and bounding.
3. Complaints of a headache, abdominal pain, and lethargy.
4. Urinary output 700 cc/24 h, CVP of 5, and nystagmus.
Strategy: Determine how each answer choice relates to fluid volume
overload.
(1) indicates dehydration
(2) correct–will see bounding pulse, elevated BP, distended neck veins, edema,
headache, polyuria, diarrhea, liver enlargement
(3) symptoms could be from causes other than volume overload
(4) slightly reduced output, CVP would be elevated, normal CVP 4-10 mm/H2 O,
involuntary eye movements not seen
5. A woman has been recently diagnosed with systemic lupus and shares
with the nurse, “I am thinking about getting pregnant, but I don’t know
how I will be able to tolerate a pregnancy since I have lupus.” Which of the
following responses by the nurse is BEST?
1. “Most women find that they feel better when they are pregnant.”
2. “How long have you been in remission?”
3. “Women with lupus frequently have slightly longer gestations.”
4. “It is best to become pregnant within the first six months of diagnosis.”
Strategy: Answers are a mix of assessments and implementations. Does this
situation require assessment? Yes.
(1) maternal morbidity and mortality are increased with SLE
(2) correct–should be in remission for at least 5 months prior to conceiving
(3) gestation not affected by SLE
(4) recommended that a woman wait two years following diagnosis before conceiving
6. The multidisciplinary team decides to implement behavior modification
with a client. Which of the following nursing actions is of primary
importance during this time?
1. Confirm that all staff members understand and comply with the treatment plan.
2. Establish mutually agreed upon, realistic goals.
3. Ensure that the potent reinforcers (rewards) are important to the client.
4. Establish a fixed interval schedule for reinforcement.
,Strategy: All answers are implementations. Determine the outcome of each
answer choice. Is it desired?
(1) correct–to implement a behavior modification plan successfully, all staff members
need to be included in program development, and time must be allowed for
discussion of concerns from each nursing staff member; consistency and follow-
through is important to prevent or diminish the level of manipulation by the staff or
client during implementation of this program
(2) not of primary importance in designing an effective behavior modification
program
(3) not of primary importance in designing an effective behavior modification
program
(4) not of primary importance in designing an effective behavior modification
program
7. A client received six units of regular insulin three hours ago. The nurse
would be MOST concerned if which of the following was observed?
1. Kussmaul respirations and diaphoresis.
2. Anorexia and lethargy.
3. Diaphoresis and trembling.
4. Headache and polyuria.
Strategy: “MOST concerned” indicates a complication.
(1) Kussmaul respirations are signs of hyperglycemia
(2) not indicative of hypoglycemia
(3) correct–regular insulin peaks in two to four hours; indicates hypoglycemia; give
skim milk
(4) not indicative of hypoglycemia
8. The nursing assistant reports to the nurse that a client who is one-day
postoperative after an angioplasty is refusing to eat and states, “I just don’t
feel good.” Which of the following actions, if taken by the nurse, is BEST?
1. The nurse talks with the client about how he is feeling.
2. The nurse instructs the nursing assistant to sit with the client while he eats.
3. The nurse contacts the physician to obtain an order for an antacid.
4. The nurse evaluates the most recent vital signs recorded in the chart.
Strategy: Answers are a mix of assessments and implementations. Does this
situation require assessment? Yes. Is the assessment appropriate? Yes.
(1) correct–assessment required; monitor for closure of vessel, bleeding,
hypotension, dysrhythmias
(2) assess cause of problem before implementing
(3) assess cause of problem before implementing
(4) more important to assess what is happening now
, 9. The nurse prepares a 25-year-old woman for a cesarean section. The
patient says she had major surgery several years ago and asks if she will
receive a similar “shot” before surgery. The nurse’s response should be
based on an understanding that the preoperative medication given before a
cesarean section
1. contains a lower overall dosage of medication than is given before general
surgery.
2. contains reduced amounts of sedatives and hypnotics than are given before
general surgery.
3. contains reduced amounts of narcotics than are given before general surgery.
4. contains medications similar in type and dosages to those given before general
surgery.
Strategy: Think about the action of the medications.
(1) decreased dosage of narcotics are used
(2) dosages of sedatives and hypnotics will be similar
(3) correct–decreased so less narcotic crosses the placental barrier causing
respiratory depression
in the infant
(4) dosages of narcotics are reduced
10. The nurse is caring for an 11-year-old patient being treated for a
fractured right femur with balanced suspension traction with a Thomas
splint and Pearson attachment. The nurse notes that the patient’s left leg is
externally rotated. The nurse should
1. place a trochanter roll on the outer aspect of the thigh.
2. perform resistive range of motion of the left leg.
3. adduct and internally rotate the left leg.
4. instruct the patient to maintain the left leg in a neutral position.
Strategy: Answers are implementations. Determine the outcome of each
answer choice. Is it desired?
(1) correct–holds hip in neutral position and leg in normal alignment, entire weight of
leg cannot be held by props placed below knee
(2) exercise would not prevent future external rotation of the leg
(3) adduct (add to midline of body) does not change external rotation, internal
rotation is not beneficial, normal alignment is required
(4) leg will externally rotate unless propped in proper alignment
11. The nurse is preparing a five-year-old child for surgery. The nurse notes
that the child’s parents are divorced and have joint legal custody. The
informed consent for surgery has been signed by the mother. Which of the
following actions by the nurse is BEST?
1. Notify the physician.
2. Inform surgery.
3. Contact the father to obtain consent.
4. Continue the child’s preoperative preparation.
