NCSBN NCLEX TEST PREP
QUESTIONS WITH 100% CERTIFIED
ANSWERS
A client is admitted to the hospital with endocarditis. The nurse understands that which
risk factors can lead to the development of endocarditis? (Select all that apply.) -
Answer- Oral abscess with tooth extraction
History of aortic valve replacement
Placement of an arteriovenous fistula for hemodialysis
Placement of a central venous access device
The nurse is reviewing the chart of a client who was recently diagnosed with coronary
artery disease due to atherosclerosis. Which factors most likely contributed to the
development of this disease? (Select all that apply.) - Answer- Mother died of a
myocardial infarction
Low-density lipoprotein (LDL) level of 149 mg/dL
History of diabetes mellitus
Used to smoke 40 packs per year until one year ago
The target LDL level for a client is less than 100 mg/dL.
The nurse is evaluating a client who was admitted for a small bowel obstruction and
dehydration. Which observation by the nurse would indicate that the dehydration is
improving?
1The client has normoactive bowel sounds.
2The client voided 300 mL of urine in the past two hours.
3The client denies any nausea or vomiting.
4The client reports the passing of flatus. - Answer- 2
A client is admitted to the telemetry unit with syncope due to sinus bradycardia. Which
intervention should the nurse include in the client's plan of care?
1Maintain the client on bedrest.
2Administer a stool softener daily.
3Implement seizure precautions.
4Discuss the client's wishes for organ donation. - Answer-
A client is admitted to the telemetry unit with syncope due to sinus bradycardia. Which
intervention should the nurse include in the client's plan of care?
1Maintain the client on bedrest.
2Administer a stool softener daily.
3Implement seizure precautions.
4Discuss the client's wishes for organ donation. - Answer- 2
,To avoid a vasovagal response (i.e., the slowing of the heart rate caused by bearing
down when trying to defecate) and the risk for another syncopal episode, it is important
to ensure that the client's bowel movements are soft and easily expelled. The client
should also be instructed to avoid holding their breath or bearing down (Valsalva
maneuver).
A client diagnosed with iron deficiency anemia is prescribed ferrous sulfate suspension
orally. Which instruction would be most appropriate for the nurse to give to the client
regarding this medication?
1"You should use a straw when taking this medication."
2'Taking this medication will turn your urine dark orange in color."
3"Diarrhea is a common side effect when taking this medication."
4"You should take the medication with food to enhance absorption." - Answer- 1
Because liquid iron can stain the teeth, the most appropriate instruction is to use a straw
The nurse is caring for a client with severe iron deficiency anemia. Which interventions
should the nurse include in the client's plan of care? (Select all that apply.) - Answer-
Instruct assistive personnel to allow the client to rest during care activities.
Monitor the client for palpitations and orthostatic hypotension.
Review the client's medical record for NSAID use.
Encourage the client to eat more green leafy vegetables and beans.
Monitor the client's stool for color, consistency and frequency.
The nurse is caring for a client with a diagnosis of pericarditis. The unlicensed assistive
person reports to the nurse that the client's last set of vital signs were blood pressure of
84/40 mm Hg, respiratory rate of 28 breaths/minute, heart rate of 112 and the client
seemed short of breath. The nurse examines the client and also notes the presence of
jugular vein distention. What should the nurse do next?
1Administer the prescribed metoprolol.
2Notify the health care provider.
3Place the client on nothing by mouth status.
4Obtain a 12-lead electrocardiogram. - Answer- 2
risk for cardiac tamponade due to jugular vein distention
The nurse in the outpatient clinic is reviewing the medical record of a client diagnosed
with Raynaud's disease. What information from the client's health history would support
this diagnosis? (Select all that apply.) - Answer- The client works in an office setting as
a typist.
The client smokes two packs of cigarettes per day.
Warfarin is listed on the medication reconciliation form.
The client complains of brittle fingernails that break easily.
Fingers become cyanotic when exposed to cold objects.
A client is admitted to the cardiology unit for treatment for recurrent supraventricular
tachycardia. Which observation by the nurse would best indicate that the client's
condition can be considered hemodynamically stable?
,1The client denies any chest pain and capillary refill is less than three seconds.
2The client's blood pressure is 88/40 mm Hg.
3The client's pulse oximeter reads 91% on three liters nasal cannula.
4The client's cardiac monitor shows a heart rate of 170 beats per minute. - Answer- 1
A client with a history of chronic alcohol use disorder is admitted to the inpatient unit
with a serum magnesium level of 1.0 mEq/L. Which intervention should the nurse
implement first?
1Assess the client's deep tendon reflexes.
2Order the client a meal with foods high in magnesium.
3Obtain the client's heart rate and oxygen saturation.
4Place the client on fall risk and seizure precautions. - Answer- 3
The nurse administered furosemide to a client with acute pulmonary edema. Which
observation by the nurse would indicate that the client is experiencing an adverse side
effect of the medication?
1The client exhibits exertional dyspnea with walking.
2The client reports muscle cramps in both legs.
3The client's blood pressure is 104/60 mm Hg.
4The client's weight decreased by 2 lbs. in two days. - Answer- 2
Muscle cramps and spasms while receiving diuretic therapy could indicate hypokalemia,
an adverse drug effect of furosemide because this is a potassium wasting diuretic
The nurse is reviewing the plan of care for a client with peripheral artery disease who
has a history of leg pain with walking. Which interventions should the nurse include in
the client's plan of care? (Select all that apply). - Answer- Enroll the client in an exercise
program that involves low-impact activities.
Assist the client in selecting food items that are low in saturated fats and cholesterol.
Reinforce teaching on the importance of not walking without shoes on.
Assist the client in enrolling in a smoking cessation program.
The nurse is caring for a client admitted with sickle cell crisis. Which medication is the
drug of choice for pain management with this client?
1Meperidine
2Ibuprofen
3Acetaminophen
4Hydromorphone - Answer- 4
The nurse is planning care for a client newly diagnosed with essential hypertension.
Which interventions should the nurse include in the client's plan of care? (Select all that
apply.) - Answer- Encourage the client to take daily, 30-minute walks.
Explain the negative effects of hypertension on
, Evaluate the client's understanding of a low-sodium diet.
Evaluate the client's ability to take their own blood pressure.
The nurse is assisting in developing a plan of care for a client who is on complete
bedrest due to a spinal cord injury. Which intervention is most important for the nurse to
include?
1Apply pneumatic compression devices to both legs.
2Turn and reposition the client every shift.
3Insert an indwelling urinary catheter.
4Administer a daily enema. - Answer- 1
The nurse is reinforcing teaching for a client who was newly diagnosed with asthma.
Clients with asthma should demonstrate understanding of which of the following?
(Select all that apply.) - Answer- Clients must understand the use of medications
including quick-relief (rescue) and long-acting (maintenance) therapies. Clients use the
peak flow meter to assess effectiveness of medication or breathing status. An acute
attack can be a medical emergency and knowing where and how to seek medical care
is important. Certain conditions (triggers) can exacerbate an attack and should be
avoided.
A client is seen at the primary care clinic for allergic rhinitis. Which clinical
manifestations should the nurse expect with this diagnosis? (Select all that apply.) -
Answer- Common symptoms of allergic rhinitis are due primarily to the release of
immune mediators such as histamine, prostaglandins, eosinophils and cytokines. This
leads to sneezing, runny nose with clear discharge, nasal congestion and an increased
eosinophil counts. Symptoms may appear similar to a cold. Due to drainage, the client's
sense of smell can be altered.
The nurse is caring for a client with a dry chest tube drainage system due to a left
tension pneumothorax. Two hours ago, the health care provider (HCP) changed the
chest tube prescription to water seal only. When entering the client's room, the nurse
finds the client to be short of breath, tachypneic and with an oxygen saturation (SpO2)
of 84%. On auscultation, the nurse notes absent breath sounds to the left upper lobe.
What action should the nurse take first?
1Apply oxygen via nasal cannula
2Document all interventions in the client's medical record
3Notify the appropriate HCP
4Request a chest X-ray - Answer- 1
The nurse is planning care for a client admitted to the hospital with influenza. Which
interventions should the nurse include in the client's plan of care? (Select all that apply.)
- Answer- Antiviral agents, such as oseltamivir, are used to shorten the course and
reduce symptoms of the flu. Droplet transmission-based precautions are indicated to
prevent the spread of the flu. To avoid further transmission of the illness, visitors with
QUESTIONS WITH 100% CERTIFIED
ANSWERS
A client is admitted to the hospital with endocarditis. The nurse understands that which
risk factors can lead to the development of endocarditis? (Select all that apply.) -
Answer- Oral abscess with tooth extraction
History of aortic valve replacement
Placement of an arteriovenous fistula for hemodialysis
Placement of a central venous access device
The nurse is reviewing the chart of a client who was recently diagnosed with coronary
artery disease due to atherosclerosis. Which factors most likely contributed to the
development of this disease? (Select all that apply.) - Answer- Mother died of a
myocardial infarction
Low-density lipoprotein (LDL) level of 149 mg/dL
History of diabetes mellitus
Used to smoke 40 packs per year until one year ago
The target LDL level for a client is less than 100 mg/dL.
The nurse is evaluating a client who was admitted for a small bowel obstruction and
dehydration. Which observation by the nurse would indicate that the dehydration is
improving?
1The client has normoactive bowel sounds.
2The client voided 300 mL of urine in the past two hours.
3The client denies any nausea or vomiting.
4The client reports the passing of flatus. - Answer- 2
A client is admitted to the telemetry unit with syncope due to sinus bradycardia. Which
intervention should the nurse include in the client's plan of care?
1Maintain the client on bedrest.
2Administer a stool softener daily.
3Implement seizure precautions.
4Discuss the client's wishes for organ donation. - Answer-
A client is admitted to the telemetry unit with syncope due to sinus bradycardia. Which
intervention should the nurse include in the client's plan of care?
1Maintain the client on bedrest.
2Administer a stool softener daily.
3Implement seizure precautions.
4Discuss the client's wishes for organ donation. - Answer- 2
,To avoid a vasovagal response (i.e., the slowing of the heart rate caused by bearing
down when trying to defecate) and the risk for another syncopal episode, it is important
to ensure that the client's bowel movements are soft and easily expelled. The client
should also be instructed to avoid holding their breath or bearing down (Valsalva
maneuver).
A client diagnosed with iron deficiency anemia is prescribed ferrous sulfate suspension
orally. Which instruction would be most appropriate for the nurse to give to the client
regarding this medication?
1"You should use a straw when taking this medication."
2'Taking this medication will turn your urine dark orange in color."
3"Diarrhea is a common side effect when taking this medication."
4"You should take the medication with food to enhance absorption." - Answer- 1
Because liquid iron can stain the teeth, the most appropriate instruction is to use a straw
The nurse is caring for a client with severe iron deficiency anemia. Which interventions
should the nurse include in the client's plan of care? (Select all that apply.) - Answer-
Instruct assistive personnel to allow the client to rest during care activities.
Monitor the client for palpitations and orthostatic hypotension.
Review the client's medical record for NSAID use.
Encourage the client to eat more green leafy vegetables and beans.
Monitor the client's stool for color, consistency and frequency.
The nurse is caring for a client with a diagnosis of pericarditis. The unlicensed assistive
person reports to the nurse that the client's last set of vital signs were blood pressure of
84/40 mm Hg, respiratory rate of 28 breaths/minute, heart rate of 112 and the client
seemed short of breath. The nurse examines the client and also notes the presence of
jugular vein distention. What should the nurse do next?
1Administer the prescribed metoprolol.
2Notify the health care provider.
3Place the client on nothing by mouth status.
4Obtain a 12-lead electrocardiogram. - Answer- 2
risk for cardiac tamponade due to jugular vein distention
The nurse in the outpatient clinic is reviewing the medical record of a client diagnosed
with Raynaud's disease. What information from the client's health history would support
this diagnosis? (Select all that apply.) - Answer- The client works in an office setting as
a typist.
The client smokes two packs of cigarettes per day.
Warfarin is listed on the medication reconciliation form.
The client complains of brittle fingernails that break easily.
Fingers become cyanotic when exposed to cold objects.
A client is admitted to the cardiology unit for treatment for recurrent supraventricular
tachycardia. Which observation by the nurse would best indicate that the client's
condition can be considered hemodynamically stable?
,1The client denies any chest pain and capillary refill is less than three seconds.
2The client's blood pressure is 88/40 mm Hg.
3The client's pulse oximeter reads 91% on three liters nasal cannula.
4The client's cardiac monitor shows a heart rate of 170 beats per minute. - Answer- 1
A client with a history of chronic alcohol use disorder is admitted to the inpatient unit
with a serum magnesium level of 1.0 mEq/L. Which intervention should the nurse
implement first?
1Assess the client's deep tendon reflexes.
2Order the client a meal with foods high in magnesium.
3Obtain the client's heart rate and oxygen saturation.
4Place the client on fall risk and seizure precautions. - Answer- 3
The nurse administered furosemide to a client with acute pulmonary edema. Which
observation by the nurse would indicate that the client is experiencing an adverse side
effect of the medication?
1The client exhibits exertional dyspnea with walking.
2The client reports muscle cramps in both legs.
3The client's blood pressure is 104/60 mm Hg.
4The client's weight decreased by 2 lbs. in two days. - Answer- 2
Muscle cramps and spasms while receiving diuretic therapy could indicate hypokalemia,
an adverse drug effect of furosemide because this is a potassium wasting diuretic
The nurse is reviewing the plan of care for a client with peripheral artery disease who
has a history of leg pain with walking. Which interventions should the nurse include in
the client's plan of care? (Select all that apply). - Answer- Enroll the client in an exercise
program that involves low-impact activities.
Assist the client in selecting food items that are low in saturated fats and cholesterol.
Reinforce teaching on the importance of not walking without shoes on.
Assist the client in enrolling in a smoking cessation program.
The nurse is caring for a client admitted with sickle cell crisis. Which medication is the
drug of choice for pain management with this client?
1Meperidine
2Ibuprofen
3Acetaminophen
4Hydromorphone - Answer- 4
The nurse is planning care for a client newly diagnosed with essential hypertension.
Which interventions should the nurse include in the client's plan of care? (Select all that
apply.) - Answer- Encourage the client to take daily, 30-minute walks.
Explain the negative effects of hypertension on
, Evaluate the client's understanding of a low-sodium diet.
Evaluate the client's ability to take their own blood pressure.
The nurse is assisting in developing a plan of care for a client who is on complete
bedrest due to a spinal cord injury. Which intervention is most important for the nurse to
include?
1Apply pneumatic compression devices to both legs.
2Turn and reposition the client every shift.
3Insert an indwelling urinary catheter.
4Administer a daily enema. - Answer- 1
The nurse is reinforcing teaching for a client who was newly diagnosed with asthma.
Clients with asthma should demonstrate understanding of which of the following?
(Select all that apply.) - Answer- Clients must understand the use of medications
including quick-relief (rescue) and long-acting (maintenance) therapies. Clients use the
peak flow meter to assess effectiveness of medication or breathing status. An acute
attack can be a medical emergency and knowing where and how to seek medical care
is important. Certain conditions (triggers) can exacerbate an attack and should be
avoided.
A client is seen at the primary care clinic for allergic rhinitis. Which clinical
manifestations should the nurse expect with this diagnosis? (Select all that apply.) -
Answer- Common symptoms of allergic rhinitis are due primarily to the release of
immune mediators such as histamine, prostaglandins, eosinophils and cytokines. This
leads to sneezing, runny nose with clear discharge, nasal congestion and an increased
eosinophil counts. Symptoms may appear similar to a cold. Due to drainage, the client's
sense of smell can be altered.
The nurse is caring for a client with a dry chest tube drainage system due to a left
tension pneumothorax. Two hours ago, the health care provider (HCP) changed the
chest tube prescription to water seal only. When entering the client's room, the nurse
finds the client to be short of breath, tachypneic and with an oxygen saturation (SpO2)
of 84%. On auscultation, the nurse notes absent breath sounds to the left upper lobe.
What action should the nurse take first?
1Apply oxygen via nasal cannula
2Document all interventions in the client's medical record
3Notify the appropriate HCP
4Request a chest X-ray - Answer- 1
The nurse is planning care for a client admitted to the hospital with influenza. Which
interventions should the nurse include in the client's plan of care? (Select all that apply.)
- Answer- Antiviral agents, such as oseltamivir, are used to shorten the course and
reduce symptoms of the flu. Droplet transmission-based precautions are indicated to
prevent the spread of the flu. To avoid further transmission of the illness, visitors with
