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Nclex Review Questions Answers, ( Morethan 1000 Q & A), Verified And Correct Answers.
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Nclex Review Questions Answers, ( Morethan 1000 Q & A), Verified And Correct Answers.
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NCLEX Review QuestionsA 3 day post-operative client with a left knee replacement is reporting chills and nausea. Temperature:
100.8ºF/38.2ºC, pulse: 94, respiration: 28 and blood pressure is 146/90. What is the nurse's best action?
1. Call the surgeon immediately.
2. Administer extra strength acetaminophen per prescription.
3. Assess the surgical site.
4. Offer extra blankets and increase fluids.:
1. Correct: The client's symptoms are indicative of infection, and the primary healthcare provider needs to be notified and
may want diagnostic tests performed. The other actions are appropriate to treat the symptoms and provide comfort, but
they are not the best action to fix the problem.
2. Incorrect: While this may be appropriate, it may also delay treatment of the problem, which is infection. Remember, you
can only pick one answer to fix the problem and this action will only treat the symptoms.
3. Incorrect: The primary healthcare provider may want the site assessed, but this also delays treatment. Since you can
only pick one option, this is not the best.
4. Incorrect: Comfort measures are always appropriate, but this is not the best action available.
2.A 3-year-old child refuses to take a prescribed medication. Which statements by the mother, regarding the child's
refusal, indicate to the nurse that parental education is needed?
1. "My child is trying to make me angry".
2. "I feel like such a bad mother when my child acts this way".
3. "I promise my child a reward for taking medicine".
4. "I am unfazed by my child's actions".
5. "My child doesn't have to take medicine if he doesn't want to".: 1., 2. & 5. Correct: If the mother feels the child is
trying to "make her angry" she may respond with inappropriate discipline. The nurse can help the mother understand that
developing independence is one of the developmental tasks of a child this age, and that the movement toward
independence reflects good, not bad, parenting. The child must take the prescribed medicine in order to get well.
3. Incorrect: Rewarding the client for taking medication is not contraindicated.
4. Incorrect: Being "unfazed" by the child's actions does not reflect bad parenting.
Option 1 is true. The nurse needs to educate the parent.
Option 2 is true. The nurse needs to educate the parent regarding a 3 year old's typical behavior.
Option 3 is false, as further teaching would not be necessary if the parent made this statement.
Option 4 is false, as further teaching would not be necessary if the parent made this statement.
Option 5 is true. The child needs the medication or it would not have been prescribed.
3.A 6 year old admitted from the emergency department (ED) with a fractured tibia is scheduled for surgery in the
morning. All of the private rooms are full so the child must be admitted to a semi-private room. What room
assignment is appropriate for the nurse to make for this client?
1. Rooming with an 8 year old in sickle cell crisis.
2. Rooming with a 2 year old admitted with bacteremia.
3. Rooming with a 3 year old with pneumonia.
4. Rooming with a 4 year old with gastroenteritis.: 1. Correct: Sickle cell disease and a child in a sickle cell crisis is not
considered contagious. This is the only option that does not have an infectious process, so this would be the best room
assignment for the child with the fracture. In addition, the children are close in age with the same development tasks, so
activities for the children may be similar.
2. Incorrect: Bacteremia is an infectious process in which there is viable bacteria in the blood stream. The source of the
infection is not noted. The child with a fracture who will be having surgery should not be placed in a room with a child who
has a known infection.
3. Incorrect: The child with pneumonia has an infectious process that may be viral or bacterial. The child with the fracture
, should not be assigned to this room due to the risk of air-borne exposure to the infectious agent.
4. Incorrect: Gastroenteritis is a diarrheal illness with inflammation in the stomach and small intestine. This is contagious,
so if all possible, this child should be kept in a private room, so other children would be less likely to contract the
gastroenteritis. It may be viral, bacterial, or parasitic in origin. The child with the fracture should not be assigned to the
room with the child with gastroenteritis.
4.A 9 month old with asthma symptomology has montelukast sodium oral granules prescribed. What is the most
appropriate way for the nurse to instruct the parent on how to administer the medication?
1. Mix the granules with a spoonful of baby food such as applesauce.
2. Pour the granules directly on the back of the infant's tongue.
3. Dissolve the granules in an 8 ounce (240 mL)bottle of juice.
4. Administer the medication in the morning mixed in a bowl of rice cereal.: 1. Correct: Applesauce is an appropriate
baby food for a 9 month old infant. The medication is being mixed with a very small amount of baby food to facilitate all of
the medication being consumed.
2. Incorrect: Although the medication can be administered directly into the mouth, a 9 month old is not likely to tolerate
medication granules being placed in the back of the mouth and would likely spit the medication out or gag when the
medication is placed in the back of the mouth,
3. Incorrect: The medication is being placed in too much juice. The infant might not drink this amount and would not
receive all of the medication ordered.
4. Incorrect: If the child does not eat the entire amount of the cereal, the child would not receive the prescribed dose of the
medication.
5.A 12 year old female, with a history of juvenile rheumatoid arthritis, is being admitted for re-evaluation. The child
reported these symptoms for the last week: temperature of 102.9ºF/39.4ºC at 4:00 pm every day, increased pain in
joints, loss of appetite, and fatigue. What would be an appropriate room assignment by the charge nurse?
1. Private room only.
2. Rooming with a 12 year old male in skeletal traction due to a fractured femur.
3. Rooming with a 10 year old female that has been admitted for sickle cell disease.
4. Rooming with a 14 month old female that has been admitted for orthopedic surgery.: 3. Correct: The appropriate
answer is to room her with the 10 year old being worked up for sickle cell disease. This is an acceptable age/sex to pair
as roommates. Each has a chronic illness and this allows them to see how another person with limitations adjusts.
1. Incorrect: It is not necessary for this child to be in a private room. The fever at a particular time of the day is a symptom
of juvenile rheumatoid arthritis and does not mean an infection.
2. Incorrect: It would be inappropriate to room her with a 12 year old male due to opposite sex and age.
4. Incorrect: The 12 year old who is in p
6.A 15 year old is being admitted with pelvic inflammatory disease. Which client could the charge nurse assign the
new admit to room with?
1. 18 year old who sustained a compound fracture.
2. 15 year old diagnosed with anorexia nervosa.
3. 13 year old admitted with pneumonia.
4. 14 year old who is taking steroids for chronic asthma.: 1. Correct: The best choice would be the client with a
fracture who is also an adolescent. Neither of these clients require visitor limiting or potential to transmit infections.
2. Incorrect: Usually adolescents with anorexia nervosa losing weight are put on a behavior modification program, and
visitors are limited. Therefore, it would probably be best if this client did not have a roommate.
3. Incorrect: Pneumonia could be contagious and should not have a roommate. This client could be on contact or droplet
precautions.
4. Incorrect: Long term steroid therapy could make this client immunosuppressed. Visitors should be limited and a private
room would be recommended.
7.A 16 year old female student is escorted to the school nurse after fainting in gym class. The student tells the nurse,
"I just got weak from running." Upon examination, the nurse notes poor skin turgor, dry mucous membranes, and
erosion of tooth enamel from her front teeth. Height is 5'4" (162.56 cm) and weight is 110 lbs (50 kg). The student
, reports muscle pain in the legs. Based on this data, what should the nurse suspect?
1. Anorexia Nervosa
2. Bulimia Nervosa
3. Obesity
4. Physical violence: 2. Correct: This client is exhibiting the signs of bulimia nervosa. Additionally, the client will binge on
excess calories, and then purge through vomiting and the use of laxatives, diuretics, and enemas. Weight fluctuates:
usually within normal limits or slightly under or slightly overweight. Tears in the esophageal and gastric mucosa can occur.
Due to vomiting, tooth enamel can erode.
1. Incorrect: Gross distortion of body image, refusal to eat, grossly underweight and malnourished. Characteristics of
anorexia nervosa. The client is at the low end of the weight range for her height, but not underweight.
3. Incorrect: Obesity occurs from eating more than the body needs. Weight is more than 20% over expected body weight.
They do not purge. This client's BMI of 18.9 is normal, not obese.
4. Incorrect: There is no indication that this is physical violence. The client may report headaches, dizziness and accidents
such as falls. However, this client does not have any signs and symptoms of battering such as bruises, scars or burns.
8.An 18 month old is admitted to the unit with a diagnosis of pertussis. The mother asks the nurse, "How did my
child get this disease? I didn't think anyone got that anymore." What is the appropriate response by the nurse?
1. "Pertussis is a common childhood disease since there is no vaccine."
2. "Since not all children are immunized against pertussis, the disease has reemerged."
3. "Your baby got this disease because you didn't have your child immunized."
4. "Since your child is already sick, let's just focus on getting well.": 2. Correct: This is a correct statement.
Therapeutic communication means providing information that will help clients make better choices.
Not all parents have had their children immunized against pertussis, so this disease is being seen in clients again. DPaT
should be given at 2, 4 and 6 months of age. A booster is given at 15-18 months old and then at 4-6 years old.
1. Incorrect: This is not true. There is a vaccine. DPaT should be given at 2, 4, and 6 months of age. A booster is given at
15-18 months old and then at 4-6 years old.
3. Incorrect: Don't be confrontational. This puts the mother on the defensive. This is not therapeutic communication.
Giving one's own opinion, evaluating, moralizing or implying one's values by using words such as "nice" "bad" "right"
"wrong" "should" and "ought". "You shouldn't do that. It is wrong". Everyone who does not get immunized gets the
disease.
4. Incorrect: Do not change the subject. This does not address the mother's concern. Changing the subject, or introducing
new topic inappropriately, can create anxiety. The nurse needs to address the mother's question of how the child
contracted the disease.
9.An 18 month-old weighing 22 pounds is admitted to the pediatric unit with a diagnosis of dehydration. A
replacement bolus of normal saline at 20 mL/kg is ordered to be administered intravenously over 40
minutes.: Using ratio proportion:
First, convert 22 pounds to kilograms (22/2.2) = 10 kg
20 mL/kg = 20 x 10 kg = 200 mL
200 mL/40 minutes = x mL/60 minutes (in an hour)
200 x 60 = 12000/40 = 300 mL/hr
Using dimensional analysis:
20 mL/kg x 1 kg/2.2 lb x 22 lb x 60 min/hr x 1/40 min = 300 mL/hr
10.An 18 year old football player is admitted to the ortho unit after a femur fracture. He is scheduled for a rod to be
placed in the morning, but suddenly develops severe shortness of breath, a petechial rash on his chest, and
unstable vital signs. What should the nurse do first?
1. Decrease rate of IV fluids.
2. Neurovascular checks of affected leg.
3. Elevate the head of the bed.
4. Call the active response team.: 4. Correct: The client is exhibiting symptoms of a fat embolism, particularly with the
petechial rash on his chest and severe shortness of breath. Due to his age, high risk behaviors with contact sports, and
the large long bone fracture, he is the classic example of a client that may experience a fat embolus. This constitutes a
, medical emergency and activation of the response team.
1. Incorrect: This does not affect breathing here and will do nothing to resolve the fat embolism.
2. Incorrect: Neurovascular checks of the leg will not help the client's breathing and are not the first priority for the nurse.
3. Incorrect: The nurse may elevate HOB to assist with breathing unless client is hypotensive. Either way, this is not the
best first answer.
11.A 19 year old client preparing to enter college asks the clinic nurse about immunizations. What immunizations
should the nurse suggest the client discuss with the primary health care provider?
1. Meningococcal conjugate vaccine
2. Tdap vaccine
3. HPV vaccine
4. Seasonal flu vaccine
5. Hepatitis B
6. Polio: 1., 2., 3., 4, & 5. Correct: These vaccine are specifically recommended for young adults ages 19-24.
Meningococcal conjugate vaccine is recommended as it protects against bacterial meningitis. It is required for students
living in a dorm. Tdap vaccine protects against tetanus, diphtheria, and pertussis. HPV vaccine protects against the
human papillomavirus, which causes most cases of cervical and anal cancers, as well as genital warts. Seasonal flu
vaccine is recommended. Hepatitis B is a blood-born infection, which can also be transmitted through sexual activity.
6. Incorrect: The inactivated polio (IPV) vaccine is a 4-dose series given during early childhood. IPV is not routinely
recommended for children aged 18 years or older.
12.A20 year old client has been admitted to the hospital with a diagnosis of preeclampsia. The charge nurse has only
semiprivate rooms available. What roommate would be most appropriate for the new admission?
1. An adolescent primigravida with many visitors.
2. A 25 year old post induction for fetal demise.
3. A 35 year old awaiting discharge after a total abdominal hysterectomy (TAH).
4. A 30 year old post dilation and curettage (D&C) who enjoys knitting.: 4. CORRECT: A client with preeclampsia will
be experiencing stress and elevated blood pressure. There is a risk of seizures, and therefore a calm, relaxed
environment would provide the most therapeutic setting for the client. The 30 year old client is ideal because knitting is a
quiet activity. Additionally, a D&C is a relatively uncomplicated procedure and this client will most likely soon be
discharged, leaving the preeclampsia client alone in that room.
1. INCORRECT: Although the client is close in age to the adolescent, the teenaged primigravida has many young visitors
which would create noise or confusion in the environment. Since this client is suffering from preeclampsia, a quiet
environment is necessary to prevent other complications such as seizures. This adolescent would not be the best
roommate.
2. INCORRECT: The client is admitted with a diagnosis of preeclampsia, which means elevated blood pressure, edema
and the possibility of seizures. A quiet calm environment would be crucial for this client. The 25 year old client is close in
age; however, that client has experienced a fetal demise and delivery of that fetus. There will most likely be grieving,
multiple family members, and tension in that environment which would not be helpful to the client with preeclampsia.
3. INCORRECT: Though there is a large age difference, that issue does not impact whether this client would be an
appropriate roommate. A client with preeclampsia needs a restful, calm environment to prevent further complications.
Depending on the reason for the total abdominal hysterectomy (TAH), this client may require special teaching, referrals for
further care and treatment, or emotional support for an unexpected diagnosis. The charge nurse knows this may be too
hectic of an environment for the client with preeclampsia.
13.A35 year old client asks a clinic nurse how to find out if the client is overweight or obese. The client weighs 135
pounds and is 5 feet 2 inches tall. What should the nurse educate the client about?
1. Calculating body mass index
2. Measuring abdominal circumference
3. Determining lean body mass
4. Finding the nearest hydrostatic testing location: 1. Correct: Calculating body mass index (BMI) would determine if
the client is considered overweight or obese.
2. Incorrect: BMI is the most efficient way to determine if a client is overweight or obese. Measuring the abdominal
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