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EXAM CRAM NCLEX-PN PRACTICE QUESTIONS WITH RATIONALE
"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 - CORRECT ANSWER 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 - CORRECT ANSWER 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 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 - CORRECT ANSWER 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 - CORRECT ANSWER D. 21 pounds
why? A birth weight of 7 pounds would indicate 21 pounds in 1 year or triple the his birth weight." "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 - CORRECT ANSWER 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?" - CORRECT ANSWER 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"
why? Diarrhea is not common in clients with mouth and throat cancer" "The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge instruction is essential? A. "You cannot eat food prepared in a microwave." B. "You should avoid moving the should on the side of the pacemaker site for 6 weeks." C. "You should use your cellphone on your right side."
D. "You will not be able to fly on a commercial airliner with the defibrillator in place." - CORRECT
ANSWER C. "You should use your cellphone on your right side."
why? The client with an internal defibrilliator should learn to use any battery operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting." "A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure? A. Bradycardia B. Tachycardia C. Premature ventricular beats
D. Heart block - CORRECT ANSWER A. Bradycardia
why? Suctioning can cause a vagal response and bradycardia." "The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period? A. Assessment of the client's level of anxiety. B. Evaluation of the client's exercise tolerance C. Identification of peripheral pulses.
D. Assessment of bowel sounds and activity. - CORRECT ANSWER C. Identification of
peripheral pulses
why? The assessment that is most crucial to the client is identification of peripheral pulses because aorta is clammed during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities." "The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis? A. A weight loss of 10 pounds in 2 weeks. B. Complaints of numbness and tingling in the extremities. C. A red, beefy tongue.
D. A hemoglobin level of 12.0 gm/dL - CORRECT ANSWER C. A red, beefy tongue
why? A red, beefy tongue is characteristic of a client with pernicious anemia." "A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: A. Trendelenburg position B. Ice to the entire extremity C. Bucks traction
D. An abduction pillow - CORRECT ANSWER C. Bucks traction
why? The client with a fractured femur will be placed in Bucks traction to realign the leg and decrease spasms and pain." "A client with caner is to undergo an intravenous pyelogram. The nurse should: A. Force fluids 24 hours before the procedure. B. Ask the client to void immediately before the study. C. Hold medication that affects the central nervous system for 12 hours pre- and post-test.
D. Cover the client's reproductive organs with an x-ray shield. - CORRECT ANSWER B. Ask the
client to void immediately before the study.
why? It is most important to remove the contact lenses because leaving them in can lead to corneal drying, particularly with contact lenses that are not extended wear lenses." "When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain? A. A history of radiation treatment in the neck region B. A history of recent orthopedic surgery C. A history of minimal physical activity
D. A history of the client's food intake - CORRECT ANSWER A. A history of radiation treatment
in the neck region why? Previous radiation to the neck might have damaged parathyroid glands, which are located on the thyroid gland and interfered with calcium and phosphorus regulation." "A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170 meq/L. What behavioral changes would be common for this client? A. Anger B. Mania C. Depression
D. Pyschosis - CORRECT ANSWER B. Mania
why? The client with serum sodium of 170 meq/L has hypernatrimia and might exhibit manic behvior." "A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal grieving? A. "My sister still has episodes of crying and it's been 3 months since daddy died." B. "Sally seems to have forgotten the bad things that daddy did in his lifetime." C. "She really had a hard time after daddy's funeral. She said that she had a sense of longing."
D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened." -
CORRECT ANSWER D. "Sally has not been sad at all by daddy's death. She acts like nothing has
happened at all." why? Abnormal grieving is exhibited by a lack of feeling sad; if the client's sister appears not to grieve, it might be abnormal grieving. This family member might be suppressing feelings of grief." "The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough? A. Mask B. Gown C. Gloves
D. Shoe covers - CORRECT ANSWER A. Mask
why? If the nurse is exposed to the client with a cough, the best item to wear is a mask. If the answer had included a mask, gloves, and a gown, all would be appropriate." "A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate? A. Blood pressure every 15 minutes B. Insertion of a levine tube C. Cardiac monitoring
D. Dressing changes 2x per day - CORRECT ANSWER B. Insertion of a levine tube
why? The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a levine tube should be anticipated." "The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
"The nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should: A. Change the nursing assistant's assignment B. Explore the interaction with the nursing assistant C. Discuss the matter with the client's family
D. Initiate a group session with the nursing assistant. - CORRECT ANSWER B. Explore the
interaction with the nursing assistant why? The best action for the nurse to take is to explore the interaction with the nursing assistant. This will allow for clarification of the situation." "A home health nurse is planning for her daily visits. Which client should the home health nurse visit first? A. A client with AIDS being treated with Foscarnet B. A client with a fractured femur in a long leg cast C. A client with a laryngeal cancer with a laryngetomy
D. A client with diabetic ulcers to the left foot - CORRECT ANSWER C. A client with a laryngeal
cancer with a laryngetomy why? The client with laryngeal cancer has a potential airway alteration and should be seen first." "The nurse is assigned to care from infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin? A. Increase the infant's fluid intake B. Maintain the infant's body temp at 98.6 F C. Minimize tactile stimulation
D. Decrease caloric intake - CORRECT ANSWER A. Increase the infant's fluid intake
why? Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temp is important but will not assist in eliminating bilirubin."
"Which action by the novice nurse indicates need for further teaching? A. A nurse fails to wear gloves to remove a dressing B. The nurse applies the oxygen saturation monitor to the earlobe C. The nurse elevates the head of the bed to check blood pressure D. The nurse places the extremity to a dependent position to acquire a peripheral blood sample
CORRECT ANSWER A. A nurse fails to wear gloves to remove a dressing
why? The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction" "The nurse is preparing the client for a mammogram. To prepare the client for a mammogram, the nurse should tell the client: A. Restrict her fat intake for one week before the test B. To omit creams, powders, or deodorants before the exam C. The mammography replaces the need for self breast exams
D. That mammography requires higher does of radiation than an x-ray. - CORRECT ANSWER B.
To omit creams, powders, or deodorants before the exam. why? The client having the mammogram should be instructed to omit deodorants or powders beforehand because powders and deodorants can be interpreted as abnormal." "Which of the following roommates would be best for the client with gastric resection? A. A client with Chron's disease B. A client with pneuomia C. A client with gastritis
D. A client with phlebitis - CORRECT ANSWER D. A client with phlebitis
why? The most suitable roommate for the client with gastric resection is the client with phlebitis because phlebitis is an inflammation of the blood vessel and is not infectious."
A. A 10 year old with lacerations to the face B. A 15 year old with sternal bruising C. A 34 year old with fractured femur
D. A 50 year old with dislocation of the elbow - CORRECT ANSWER B. A 15 year old with sternal
bruising why? The teenager with sternal bruising might be experiencing airway and oxygenation problems and, thus, should be seen first." "The client is receiving peritoneal dialysis. If the dialysis returns cloudy the nurse should" A. Document the finding B. Send a specimen to the lab C. Strain the urine
D. Obtain a complete blood count - CORRECT ANSWER B. Send a specimen to the lab
why? If the dialysate returns cloudy, infection might be present and must be evaluated" "The client with cirrhosis of the liver is receiving lactulose. The nurse is aware that the ratio for the order of lactulose is : A. To lower the blood glucose level B. To lower the uric acid level C. To lower ammonia level
D. To lower the creatinine level - CORRECT ANSWER C. To lower ammonia level
why? Lactulose is administered to the client with cirrhosis to lower ammonia levels." "The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client's ability to care for himself. Which statement by the client indicates a need for follow-up after discharge?
A."I live by myself." B." I have trouble seeing." C. "I have a cat in the house with me."
D. " I usually drive myself to the doctor." - CORRECT ANSWER B. "I have trouble seeing"
why? A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help." "The client is receiving total parenteral nutrition (TPN). Which lab should be evaluated while the client is receiving TPN? A. Hemoglobin B. Creatinine C. Blood glucose
D. White blood cell count - CORRECT ANSWER C. Blood glucose
why? When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution that contains large amounts of glucose." "The client with a myocardial farction comes to the nurse's station stating that he is ready to go come because there is nothing wrong with him. Which defense mechanism is the client using? A. Rationalization B. Denial C. Projection
D. Conversion reaction - CORRECT ANSWER B. Denial
why? The client who says he has nothing wrong is in denial about his myocardial infarction." "Which lab test would be the least effective in making the diagnosis of myocardial infarction? A. AST B. Troponin C. CK-MB
Atropine sulfate is the antidote for Tensilon and is given to treat cholenergic crises" "The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam? A. "You will need to lay flat during the exam." B. "You need to empty your bladder before the procedure." C. "You will be alseep during the procedure."
D. "The doctor will injuect a medication to treat your illness during the procedure." - CORRECT
ANSWER B. "You need to empty your bladder before the procedure."
why? The client scheduled for a pericentesis should be told to empty the bladder, to prevent the risk of puncturing the bladder when the needle is inserted. A pericentesis is done to remove fluid from the peritoneal cavity." "To ensure safety while administering a Nitroglycerin patch, the nurse should: A. Wear gloves B. Shave the area where the patch should be applied C. Wash the area thoroughly with soap and rinse with hot water
D. Apply the patch to the buttocks - CORRECT ANSWER A. Wear gloves
why? To protect herself, the nurse should wear gloves when applying a nitroglycerin patch or cream." "A 25 year old male is brought to the ER with a piece of metal in his eye. Which action by the nurse is correct? A. Use a magnet to remove the object B. Rinse the eye thoroughly with saline C. Cover both eyes with paper cups
D. Patch the affected eye only - CORRECT ANSWER C. Cover both eyes with paper cups
why? Covering both eyes prevents consensual movement of the affected eye."
"The physician has order sodium warfrin ( Coumadin) for the client with thrombophlebitis. The order should be entered to administer the medication at: A. 0900 B. 1200 C. 1700
D. 2100 - CORRECT ANSWER C. 1700
why? Sodium warfarin is administered in the late afternoon, at approximately 1700 hours. this allows for accurate bleeding times to be drawn in the morning." "The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion? A. Secrurity guard B. RN C. LPN
D. The nursing assistant - CORRECT ANSWER B. RN
why? The RN is the only one of these who can legally put the client in seclusion. The only other healthcare worker who is allowed to initiate seclusion is the doctor." "The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal a pH of 7.36, CO2 at 45, O2 at 84, HCO3 at 28. The nurse would assess the client to be in: A. Uncompensated acidosis B. Compensated alkalosis C. Compensated respiratory acidosis
D. Uncompensated metabolic acidosis - CORRECT ANSWER C. Compensated respiratory
acidosis why? The client is experiencing compensated respiratory acidosis. The pH is within the normal range but is lower than 7.40, so it is on the acidic side. The CO2 level is elevated, the oxygen level is below normal, and the bicarb level is slightly elevated. In respiratory disorders, the pH will be in
"The physician has ordered a culture for the client with suspected Gonorrhea. The nurse should obtain what type of culture? A. Blood B. Nasopharyngeal secretions C. Stool
D. Genital secretions - CORRECT ANSWER D. Genital secretions
why? A culture for gonorrhea is taken from the genital secretions. The culture is placed in a warm environment, where it can grow nisseria gonorrhea" "The nurse is caring for a client with cerebral plasy. The nurse should provide frequent rest periods because: A: Grimacing and withering movements decrease with relaxation and rest. B. Hypoactive deep tendon reflexes become more active with rest C. Stretch reflexes become more increases with rest
D. Fine motor movements are improved - CORRECT ANSWER A. Grimacing and withering
movements decrease with relaxation and rest. why? Frequent rest periods help to relx tense muscles and preserve energy" "The nurse is making assignments for the day. Which client should be assigned to the nursing assistant? A. A client with Alzheimer's B. A client with pnuemonia C. A client with appendicitis
D. A client with thrombophebitis - CORRECT ANSWER A. A client with Alzheimer's
why? The client with Alzheimer's disease is the most stable of these clients and can be assigned to the nursing assistant, who can perform duties such as feeding and assisting the client with activities of daily living."
"A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by: A. Offering a hard candy B. Administering an analgesic medication C. Splinting swollen joints
D. Providing saliva substitue - CORRECT ANSWER D. Providing saliva substitute
why? Xerostomia is dry mouth, and offering the client a saliva substitute will help the most." "A home health nurse is making preparations for morning visits. Which of the following clients should the nurse visit first? A. A client with brain- attack (stroke) with tube feeding B. A client with congestive heart failure complaining of nighttime dyspnea C. A client with a thoracotomy 6 months ago
D. A client with Parkinson disease - CORRECT ANSWER B. The client with congestive heart
failure complaining of nighttime dyspnea why? The client with congestive heart failure who is complaining of nighttime dyspnea should be seen first because airway si number one in nursing care" "A client with glomerulonephritis is placed on a low sodium diet. Which of the following snacks is suitable for the client with low sodium restritctions? A. Peanut butter cookies B. Grilled cheese sandwich C. Cottage cheese and fruit
D. Fresh peach - CORRECT ANSWER D. Fresh peach
why? The fresh peach is the lowest in sodium of these choices" "Due to a high census, it had been necessary for a number of clients to be transferred to another unit within the hospital. Which client should be transferred to the post-partum unit?
