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2024 NCLEX PRACTICE QUESTIONS WITH CORRECT SOLUTIONS
"A nurse is caring for a clinet who has multiple sclerosis and is receiving interferon beta-1a. The nurse should identify that which of the following client statements indicates a potential adverse effect of the medication? a. my body aches all over b. i have abdominal cramping c. my hair seems to be thinning
d. it hurts when i urinate - CORRECT ANSWER My body aches all over
-adverse effects of interferon beta-1a include flu-like symptoms" "A nurse is performing a nonstress test (NST) on a client who is at 41 weeks of gestation. The client asks what the purpse of the test is/ Which of the following responses should the nurse provide? a. this test will determine if you are likely to deliver within the next week b. this test will help determine if your baby is healthy c. this test can see how you baby responds when you have contractions
d. this test will determine if you're baby's lungs are mature - CORRECT ANSWER This test will
help determine if your baby is healthy
- This NST is used as a prenatal fetal assessment, it tracks fetal heart rate patterns expected with fetal movement and can help identify fetal distress" "A nurse cares for a client receiving chemotherapy. The latest blood work shows: platelet count 18,000/mm WBC count of 5,000/mm Which intervention does the nurse implement? a. respiratory transmission precautions b. contact transmission precautions c. bleeding precautions
d. neutropenic precautions - CORRECT ANSWER Bleeding precautions
-normal platelet count is 150,000-400,000/mm bleeding precautions should be implemented with a platelet count less than"
"A nurse is accepting a transfer from the postanesthesia care unit (PACU) of a client who has had a subtotal thyroidectomy. Which of the following pieces of equipment should the nurse have available at the bedside for this client? a. cardiac monitor b. defibrillator c. thoracotomy tray
d. tracheostomy tray - CORRECT ANSWER Tracheostomy tray
-laryngeal edema is common after thyroidectomy, which can result in airway obstruction and emergency intubation can be difficult due to the swelling so a nurse should have this tray -thoracotomy = for chest tube insertion" "A nurse is providing dietary teaching to a client who has late-stage chronic kidney disease (CKD). Which of the following nutrients should the nurse instruct the client to increase her diet? a. calcium b. phosphorus c. potassium
d. sodium - CORRECT ANSWER Calcium
-CKD can cause hypocalcemia due to reduced production of vitamin D which is needed for calcium absorption -Clients with CKD can develop hyperphosphatemia, hyperkalemia and hypernatremia" "The nurse assesses a client who has new onset atrial fibrillation. The ventricular rate is 145 beats/min. What does the nurse expect to observe? a. head and neck pain b. bilateral lower extremity swelling c. distended jugular veins
d. dizziness and dyspnea - CORRECT ANSWER Dizziness and dyspnea
-uncontrolled atrial fibrillation can result in acute drop in cardiac output. s/s are dizziness and shortness of breath -bilateral lower swelling = high salt, stay in position too long, heart failure, kidney failure, etc -distended jugular signs of chronic heart failure, fluid overload, pulmonary hypertension, cardiac tamponade"
-pancrelipase is for children with cystic fibrosis - pancreatic enzyme to aid in digestion" "A nurse is preparing to administer digoxin to a client. Which of the following findings should the nurse identify as a contraindication to the client receiving this medication? a. blood pressure 180/70 mmHg b. oxygen saturation rate 94% c. heart rate 51/min
d. respiratory rate 21/min - CORRECT ANSWER Heart rate 51/min
-digoxin slows down the heart rate" "A nurse is caring for an older adlut client who has chronic obstructive pulmonary disease (COPD) with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? a. respiratory alkalosis b. respiratory acidosis c. metabolic alkalosis
d. metabolic acidosis - CORRECT ANSWER Respiratory acidosis
-common COPD complication occurs because clients are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs" "A nurse is completing dietary teaching with a client who has heart failure and is presribed a 2g sodium diet. Which of the following statements by the client indicates an understanding of the teaching? a. I should use salt sparingly while cooking b. I can have yogurt as a dessert c. I should use baking soda when I bake
d. I should use canned vegetables instead of frozen - CORRECT ANSWER I can have yogurt as a
dessert -yogurt is low in fat and sodium and is a good source of calcium and protein" "A nurse is preparing a client who has a brain tumor for computed tomography (CT). Which of the following factors affects the manner in which the nurse will prepare the client for the scan?
a. no food or fluids consumed for 4hr b. difficulty recalling recent events c. development of hives when eating shrimp
d. paresthesias in both hands - CORRECT ANSWER Development of hives when eating shrimp
-allergy to shellfish is a contraindication for the use of contrast media" "A nurse is teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. Which of the following topics should the nurse include? a. smoking cessation b. benefits of a diet high in cruciferous vegetables c. new types of ostomy appliances
d. importance of colonoscopy screening starting at age 50 years old - CORRECT ANSWER
Importance of colonoscopy screening starting at age 50 years old -Primary (action that prevents the development of a disease) smoking cessation and benefits of diet in cruciferous vegetables -Secondary (actions that promotes early detection of disease) screening -Tertiary (action that minimizes the effects of long-term disease or disability) ostomy appliances" "A nurse is teaching a client who has a new prescription for sucralfate for a duodenal ulcer. Which of the following client statements indicates an understanding of teaching? a. I should only take this medication with my meals and at bedtime b. I should only have to take this medication for about 2 weeks c. I should wait at least 30 minutes before taking this medication after I take an antacid
d. I should swallow these tablets whole - CORRECT ANSWER I should wait at least 30 minutes
before taking this medication after I take an antacid -antacids can raise the gastric pH above 4 and can interfere with sucralfate, so these interactions should be taking 30 minutes apart from antacids -should also be taken 1 hour before meals and at bedtime" "While performing passive range of motion (PROM), the client reports discomfort with an abduction exercise. After stopping the exercise, which action does the nurse take next?
d. hydromorphone - CORRECT ANSWER Methadone
-opioid medication used for pain management and treatment of withdrawl manifestations in clients with opioid use disorder -Methylnaltrexone = treat opioid-induced constipation -Naloxone = treat opioid overdose" "The nurse provides education to the breastfeeding patient of a 4-month-old infant who plans to return to work soon. Which parental statement indicates to the nurse the need for additional teaching regarding infant nutrition? a. I will thaw my pumped milk in a warm cup of water b. I will heat up my baby's bottle of breastmilk in the microwave c. I will store my pumped milk in the freezer
d. I plant to start rice cereal when my baby is 6 months old - CORRECT ANSWER I will heat up
my baby's bottle of breastmilk in the microwave
- To prevent oral burns from uneven warming of the milk, breastmilk must never be thawed or warmed in a microwave oven note: rice cereal and other solid foods can be introduced at 5-6 months of age" "A charge nurse is observing a newly licensed nurse irrigate a client's ear, which is impacted with cerumen. Which of the following actions requires the charge nurse to intervene? a. visualizing the eardrum before irrigating b. instilling 50 mL of fluid with each irrigation c. using frim, continuous pressure while irrigating
d. warming the irrigation fluid to at least 37 C (98 F) - CORRECT ANSWER Instilling 50 mL of
fluid with each irrigation
- should use no more than 5 to 10 mL of irrigating fluid at a time to decrease the chance of stimulating the vestibular nerve of the inner ear" "A nurse in an emergency department is assessing a school-aged child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider?
a. excessively prolonged expiration b. increased diaphoresis c. increased production of frothy sputum
d. sudden decrease in wheezing - CORRECT ANSWER Sudden decrease in wheezing
- indicates child is experiencing decreased air movement and" "A nurse is assessing an infant who develops respiratory distress, absence of breath sounds on one side, and deviation of the trachea away from the affected side. Based on these manifestations, which of the following conditions is the infant experiencing? a. tension pneumothorax b. flail chest c. pulmonary contusion
d. fractured rib - CORRECT ANSWER Tension pneumothorax
- the infant may also become cyanotic and show asymmetry of the thorax
- Flail chest = pulling of traumatized rib area inward during inspiration and outward during expiration
- Pulmonary contusion = decreased breath sounds, tachycardia, tachypnea, and blood-tinged secretions
- Fractured rib = pain and ecchymosis (bruise) in area of trauma, swelling and muscle spasms" "A nurse is providing teaching to a client who has COPD about maintaining proper nutrition. Which of the following statements by the client indicates an understanding of the teching? a. I will increase my fluid intake when I eat a meal b. I will eat more cold foods at meals rather than hot foods c. I will avoid high-fat foods like butter and gravies
d. I will cook my meals instead of eating convenience foods - CORRECT ANSWER I will eat more
cold foods at meals rather than hot foods
- cold foods provide a decreased feeling of fullness compared to hot foods (remember we want to increase nutrition)" "A nurse is providing teaching to a client who has a new prescription for clozapine. Which of the following statement should the nurse include in the teaching?
"A nurse is planning care for a client who has AIDS and has developed stomatitis. Which of the following interventions should the nurse include in the plan of care. a. rinse the mouth with chlorhexidine solution every 2 hr b. limit fluid intake with meals c. provide oral hygiene with a firm-bristled toothbrush after each meal
d. avoid salty foods - CORRECT ANSWER Avoid salty foods
- stomatitis is an inflammation of the mucosa of the mouth, usually with ulcerations - spicy and acidic or salty food should be avoided for preventing further irritation" "A nurse is teaching a client who has type 1 diabetes mellitus about a new subcutaneous insulin infusion pump. Which of the following pieces of information should the nurse include in the teaching? a. plan to use a type of short-duration insulin in the infusion pump b. replace the infusion pump set every 4 days c. turn off the infusion pump for at least 3 hours each day
d. move the infusion pump catheter 1.27 cm (0.5 in) away from the old site - CORRECT
ANSWER Plan to use a type of short-duration insulin in the infusion pump
- this subcutaneous insulin infusion pump should be replaced every 1 to 3 days, there should be constant infusion and the catheter infusion site should be moved at lease 2.54 cm (1 in) away from old site to maintain tissue integrity" "A nurse at a pediatric clinic is assessing a 5-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? a. head lagging when the infant is pulled from a lying to a sitting position b. absence of startle and crawl reflexes c. inability to pick up a rattle after dropping it
d. rolling from back to side - CORRECT ANSWER Head lagging when the infant is pulled from a
lying to a sitting position
- at 5 months = infant should hav eno head lag
- startle reflex disappears by the age of 4 months
- the crawl reflex disappears around 6 weeks
- at 5 months the infant can follow a dropped object but can't pick it up until 6 months
- at 4 months the infant should be able to roll form back to side" "A nurse is providing teaching to a client who has constipation. Which of the following instruction should the nurse include? a. use bismuth subsalicylate regularly b. consume a low-fiber diet c. eat yogurt with live cultures
d. use bisacodyl suppositories regularly - CORRECT ANSWER Eat yogurt with live cultures
- bismuth subsalicylate (antidiarrheal)
- use bisacodyl suppositories regularly can result in decreased defecation reflexes" "A nurse is planning care for a client following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan? a. position the client with her legs adducted b. internally rotate the client's affected hip c. place a pillow between the client's legs
d. instruct the client to avoid flexing her hip more than 95 degrees - CORRECT ANSWER Place a
pillow between the client's legs
- The nurse should plan to place a pillow or a wedge between the client's legs to reduce the risk of hip dislocation
- the nurse should place the client with her legs abducted
- the nurse should avoid internal rotation
- the nurse should instruct the client to avoid flexing her hip more than 90 degrees (all of this is done to reduce hip dislocation)" "A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child? a. cutting figures from colored paper b. drawing stick figures using crayons c. riding a tricycle
d. building towers with blocks - CORRECT ANSWER Building towers with blocks
c. naloxone
d. acetaminophen - CORRECT ANSWER Chlordiazepoxide
- benzodiazepines are the most effective medication for alcohol withdrawal
- disulfiram - used to help overcome drinking problems, once detox is accomplished
- naloxone - antidote for opioid overdose
- acetaminophen and alcohol increases the client's risk of liver damage" "A nurse is reviewing the laboratory reports of a client who is receiving enteral feedings. Which of the following lab values indicates a complication of enteral feeding that the nurse should report to the provider? a. sodium 143 mEq/L b. potassium 4.2 mEq/L c. BUN 25 mg/dL
d. glucose 185 mg/dL - CORRECT ANSWER BUN 25 mg/dL
- BUN level of 25 is above (10-20) indicating dehydration which is an enteral feeding complication
- glucose of 185 is within expected range (<200) for casual blood glucose and does not indicate a complication of enteral feeding" "A nurse is teaching a client who is postpartum about keeping the newborn safe. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. i will put bumper pads in the crib b. i will warm my baby's formula in the microwave on a low setting c. i will place my baby on his stomach to sleep
d. i will purchase a firm mattress for the crib - CORRECT ANSWER I will purchase a firm
mattress for the crib
- a firm mattress leaves no gaps between it and the crib rails help prevent suffocation" "A nurse is caring for a client who is at 38 weeks of gestation and is receiving an oxytocin IV for labor augmentation. The nurse notes variable decelerations on the FHR tracing. Which of the following actions should the nurse take first?
a. place the client in a side-lying position b. discontinue the oxytocin infusion c. apply oxygen to the client via a face mask
d. check for umbilical cord prolapse - CORRECT ANSWER Place the client in a side-lying
position
- the nurse should act quick to restore the oxygen supply to the fetus. Variable decelerations reflect an umbilical cord prolapse; therefore, the nurse should act immediately to help shift the pressure of the presenting part off the cord (moving patient on side is always first action!)
- the nurse should discontinue oxytocin since proceeding birth should be stopped at this time (just not first action)
- the nurse should administer oxygen to prevent fetal hypoxia however this is not first action
- the nurse should perform or assist with vaginal examination of umbilical cord prolapse because this can cause variable decelerations however this is not first action" "A nurse is caring for a client from the Middle East who has celiac disease. Which of the following actions should the nurse perform regarding the client's diet? a. provide foods prepared according to kosher dietary law b. ask the kitchen to prepare grits to meet the client's dietary need for grains c. determine the client's dietary preferences
d. prepare the diet tray and include vegetable and barley soup - CORRECT ANSWER Determine
the client's dietary preferences
- the nurse should assess the client's dietary habits before planning to meet dietary needs" "A nurse is caring for a client whose wounds are covered with heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources? a. Cadaver skin b. Pig skin c. Amniotic membranes
d. Beef collagen - CORRECT ANSWER Pig skin
a. aldolase b. lipase c. amylase
d. lactic dehydrogenase - CORRECT ANSWER Amylase
pancreatitis is the most common diagnosis for marked elevations of serum amylase. Amylase levels peak in 20-30 hours and returns to expected range within 2-3 days.
- Aldolase caused by inflammation of muscle
- Lipase level in pancreatitis
- Lactic dehydrogenase increases in anemia, leukemia or liver damage" "A nurse is conducting a risk assessment for clients who are prescribed medications that can cause orthostatic hypotention. Which of the following medications requires a follow-up by the nurse? a. phenelzine b. escitalopram oxalate c. galantamine
d. naltrexone - CORRECT ANSWER Phenelzine
-MAOI for depression and mental health = lightheaded, dizzy and orthostatic hypotension are common side effects
- Escitalopram oxalate = SSRI for depression
- Galantamine = cholinergic for improved cognition, Alzheimer's
- Naltrexone = decrease alcohol craving" "A nurse is caring for a client with alcohol use disorder who has undergone detoxification. Which of the following medications should the nurse expect the provider to prescribe to assist the client with maintaining sobriety? a. varenicline b. clonidine c. buprenorphine
d. disulfiram - CORRECT ANSWER Disulfiram
-helps clients abstain from alcohol
- Varenicline = reduce nicotine craving
- Clonidine = treat heroin withdrawal
- Buprenorphine = treat opioid withdrawal" "A nurse is providing teaching about disease-management strategies to a 9-year-old client who has cystic fibrosis. Which of the following statements should the nurse include? a. thorough and effective pulmonary clearance can help prevent the need for a lung transplant when you get older b. you should eat these kinds of foods because they will help you grow big and strong c. you're mucus is thick because cystic fibrosis interferes with how you're glands work
d. you're medication follows a certain schedule to help you sleep better - CORRECT ANSWER
You're mucus is thick because cystic fibrosis interferes with how you're glands work" “A nurse is caring for a client who has a depressed skull fracture of the bone that makes up the larger part of the upper and side wall of the cranium. This fracture is located on which of the following bones? a. sphenoid b. occipital c. parietal
d. frontal - CORRECT ANSWER Parietal
-sphenoid forms part of face -occipital is the back of the skull -frontal is the front of the skull"
"What is the primary dietary alteration for a client who has heart failure? - CORRECT ANSWER
Sodium Restriction ex: turkey sandwich with whole-wheat bread" "A nurse is teaching a client with cystic fibrosis about daily chest physiotherapy. Which of the following is the purpose of these treatments? a. to encourage deep breaths b. to mobilize secretions in the airways c. to dilate the bronchioles
d. to stimulate the cough reflex - CORRECT ANSWER To mobilize secretions in the airways
- the purpose is to loosen and promote the drainage of secretions from the lungs"
-during tension-building phase violence is often minor and the recipient might rationalize it" "A nurse cares for an adult client who is on the organ transplant waiting list. Which factor is most important for selecting a donor-recipient match? a. age of client b. tissue compatibility c. immediate need
d. gender - CORRECT ANSWER Tissue compatibility
- compatible tissue and blood types are the most important factors when matching a donor to a recipient" "A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following adverse effects? a. diarrhea b. increased serum albumin c. hypoglycemia
d. peritonitis - CORRECT ANSWER Peritonitis
(when the thin layer of tissue inside abdomen becomes inflamed) -note peritoneal dialysis can cause decreased serum albumin" "A nurse is assessing a client who is receiving hemodialysis for the first time. Which of the following findings indicates that the client is developing dialysis disequilibrium syndrome (DDS)? a. elevated BUN b. bradycardia c. headache
d. temperature 39.2 C (102.5 F) - CORRECT ANSWER Headache
(DDS is a CNS disorder that can develop in clients who are new to dialysis due to rapid removal of solutes and changes in blood pH - causes headaches, nausea, voming, decreased LOC, seizures, restlessness, coma, death -elevated BUN increases DDS risk -client would have tachycardia, not bradycardia -temperature indicates infection" "A nurse is planning care for a client who has a physical dependence on alprazolam and must discontinue the medication. Which of the following actions should the nurse include in the plan? a. taper the medication gradually over several weeks
b. encourage participation in stimulating physical activity c. monitor the client for a return of anxiety for up to 72 hr following discontinuation of the medication
d. implement restraints and seclusion as needed - CORRECT ANSWER Taper the medication
gradually over several weeks -Alprazolam (Xanax) - benzodiazepines = anti anxiety" "A client with emphysema is short of breath. The nurse assists the client into which position? a. supine with pillows under the legs b. lying to the left side c. leaning back in a recliner
d. sitting upright and leaning forward - CORRECT ANSWER Sitting upright and leaning forward
-emphysema is a lung disease that causes breathlessness (usually caused by cigarette smoking, no cure)" "A nurse is assessing a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction? a. severe hypertension b. low body temperature c. sudden oliguria
d. decreased respirations - CORRECT ANSWER Sudden oliguria
-acute intravascular hemolytic reaction causes acute kidney injury resulting in oliguria and hemoglobinuria (blood in urine)" "A nurse in a provider's office is assessing a client who is crying and states "It's my child's first day of school." The nurse should recognize that the child is experiencing which of the following types of loss? a. actual loss b. maturational loss c. perceived loss
d. situational loss - CORRECT ANSWER Maturational loss
- loss is tied to normal, expected life change
- situational loss is sudden and unpredictable (losing job)
