Nclex- Cris-test I (New 2026/ 2027
Update) Questions & Answers {Grade A}
100% Correct (Verified Solutions)
The nurse cares for the client immediately after an ileostomy procedure. Which is the
best INITIAL action for the nurse to take during client teaching?
1. Schedule the teaching demonstrations during family visits.
2. Encourage the client to discuss any concerns and to ask questions.
3. Show a video demonstrating ileostomy care.
4. Perform care for the ileostomy until the client is able to do it herself. 1)
Implementation: outcome not desired; must assess client's readiness to learn first
2) - Correct answer - Assessment: outcome desired; ventilate feelings and assess
readiness to learn
3) Implementation: outcome not desired; needs to be ready to learn
4) Implementation: outcome not desired; won't assist in adjustment
The nurse cares for an 84-year-old man who appears disheveled, restless and
confused. The nurse prepares to administer medication and observes that the client's
armband is missing. Which is the MOST appropriate action for the nurse to take?
,1. Ask the client's roommate to identify the client.
2. Ask the client to state his name.
3. Ask another nurse to identify the client.
4. Look in the chart at the picture of the client. 1) Implementation: outcome not desired;
"passing the buck;" mental status of roommate unknown
2) Implementation: outcome not desired; client confused
3) Implementation: outcome not desired; "passing the buck"; must check identification
4) - Correct answer - Implementation: outcome desired; only way to positively identify
client
The nurse performs an assessment of a newborn boy. The nurse is MOST concerned if
which of the by which observation?
1. The respiratory rate is 40 per minute with short periods of apnea.
2. The heart rate is 140 beats per minute with variation during sleeping and waking
states.
3. A sudden loud noise causes abduction of the infant's arms and flexion of his elbows.
,4. Stroking the outer sole of the infant's foot upward causes his toes to curl
downward. 1) Assessment: outcome not a problem; 30-60 breaths/min with periods
of apnea; normal
2) Assessment: outcome not a problem; 120-160/minute; varies while asleep and awake
3) Assessment: outcome not a problem; startle reflex; normal until 4 months
4) - Correct answer - Assessment: outcome not expected and is a problem; Babinski
reflex; in newborn, should see dorsiflexion of big toe
The nurse cares for the client diagnosed with type 2 diabetes. The client is scheduled
for a renal computed tomography scan with contrast media at 10 a.m. The nurse is
MOST concerned if the client makes which statement?
1. "My blood sugar was 124 mg/dL this morning."
2. "I drank a glass of water at midnight."
3. "Sometimes I get dizzy when I first get out of bed."
4. "I took my metformin (Glucophage ER) at 6 A.M. this morning." 1) Assessment:
outcome not desired but not priority; further assessment needed
2) Implementation: outcome not a problem; NPO for 8 hours prior to scan
, 3) Assessment: outcome not desired but not priority; possible orthostatic hypotension;
further assessment needed
4) - Correct answer - Implementation: outcome not desired and priority; metformin
should be held for 48 hours prior to tomography with contrast media; risk lactic
acidosis with potential renal damage
The nurse cares for clients in a mental health center. The nurse observes the client,
formerly homeless and malnourished, diagnosed with chronic schizophrenia putting
food from lunch into a plastic bag. Which statement by the nurse is MOST appropriate?
1. "We don't allow people to take food from the dining room."
2. "What are you going to do with the food?"
3. "We will be serving snacks and juice at 3 P.M."
4. "Let's go watch a movie with the others." 1) Implementation: outcome not desired;
judgmental; non-therapeutic communication
2) Assessment: outcome not desired; non-therapeutic; "why" questions make client
defensive, feel threatened
Update) Questions & Answers {Grade A}
100% Correct (Verified Solutions)
The nurse cares for the client immediately after an ileostomy procedure. Which is the
best INITIAL action for the nurse to take during client teaching?
1. Schedule the teaching demonstrations during family visits.
2. Encourage the client to discuss any concerns and to ask questions.
3. Show a video demonstrating ileostomy care.
4. Perform care for the ileostomy until the client is able to do it herself. 1)
Implementation: outcome not desired; must assess client's readiness to learn first
2) - Correct answer - Assessment: outcome desired; ventilate feelings and assess
readiness to learn
3) Implementation: outcome not desired; needs to be ready to learn
4) Implementation: outcome not desired; won't assist in adjustment
The nurse cares for an 84-year-old man who appears disheveled, restless and
confused. The nurse prepares to administer medication and observes that the client's
armband is missing. Which is the MOST appropriate action for the nurse to take?
,1. Ask the client's roommate to identify the client.
2. Ask the client to state his name.
3. Ask another nurse to identify the client.
4. Look in the chart at the picture of the client. 1) Implementation: outcome not desired;
"passing the buck;" mental status of roommate unknown
2) Implementation: outcome not desired; client confused
3) Implementation: outcome not desired; "passing the buck"; must check identification
4) - Correct answer - Implementation: outcome desired; only way to positively identify
client
The nurse performs an assessment of a newborn boy. The nurse is MOST concerned if
which of the by which observation?
1. The respiratory rate is 40 per minute with short periods of apnea.
2. The heart rate is 140 beats per minute with variation during sleeping and waking
states.
3. A sudden loud noise causes abduction of the infant's arms and flexion of his elbows.
,4. Stroking the outer sole of the infant's foot upward causes his toes to curl
downward. 1) Assessment: outcome not a problem; 30-60 breaths/min with periods
of apnea; normal
2) Assessment: outcome not a problem; 120-160/minute; varies while asleep and awake
3) Assessment: outcome not a problem; startle reflex; normal until 4 months
4) - Correct answer - Assessment: outcome not expected and is a problem; Babinski
reflex; in newborn, should see dorsiflexion of big toe
The nurse cares for the client diagnosed with type 2 diabetes. The client is scheduled
for a renal computed tomography scan with contrast media at 10 a.m. The nurse is
MOST concerned if the client makes which statement?
1. "My blood sugar was 124 mg/dL this morning."
2. "I drank a glass of water at midnight."
3. "Sometimes I get dizzy when I first get out of bed."
4. "I took my metformin (Glucophage ER) at 6 A.M. this morning." 1) Assessment:
outcome not desired but not priority; further assessment needed
2) Implementation: outcome not a problem; NPO for 8 hours prior to scan
, 3) Assessment: outcome not desired but not priority; possible orthostatic hypotension;
further assessment needed
4) - Correct answer - Implementation: outcome not desired and priority; metformin
should be held for 48 hours prior to tomography with contrast media; risk lactic
acidosis with potential renal damage
The nurse cares for clients in a mental health center. The nurse observes the client,
formerly homeless and malnourished, diagnosed with chronic schizophrenia putting
food from lunch into a plastic bag. Which statement by the nurse is MOST appropriate?
1. "We don't allow people to take food from the dining room."
2. "What are you going to do with the food?"
3. "We will be serving snacks and juice at 3 P.M."
4. "Let's go watch a movie with the others." 1) Implementation: outcome not desired;
judgmental; non-therapeutic communication
2) Assessment: outcome not desired; non-therapeutic; "why" questions make client
defensive, feel threatened
