NCLEX Review Study Guide (Summer 2024)
1. A child with 20% second and third degree burns is admitted to the burn
center. The child weighs 44lbs (20 kg). The nurse has started an IV infusion
of lactated ringer solution and inserted an indwelling catheter. Which of the
findings indicate that the child is going into shock?
(Select all that apply)
a. Urinary output is 25ml/hr
b. Client is confused
c. Pain is 7 on a pain scale 1-10
d. Heart rate is elevated
e. Blood pressure is dropping: Client is confused
Heart rate is elevated
Blood pressure is dropping
2. A 17 year old high school senior calls the clinic because she thinks she
might have gonorrhea. She wants to be seen but wants assurances that no
one will know. Which is the most appropriate response by the nurse?
a. "Because you are underage, you will need your parent's consent to treat
you"
b. "We can treat you without your parent's consent, but they have the right to
review your medical record"
c. "We can see you without your parents consent, but have to report any
positive results to the public health department"
d. "We can see you, treat any infection, and will not share your results with
anyone": "We can see you without your parents consent, but have to report any
positive results to the public health department"
3. The parents of a child with sickle cell anemia ask about the chances of
sickle cell disease occurring in future children. The nurse responds based
on knowledge that both parents are carriers. What is the risk of one of their
children having the disease?
a. one chance in five for each pregnancy
b. one chance in four for each pregnancy
c. one chance in three for each pregnancy
, NCLEX Review Study Guide (Summer 2024)
d. one chance in two for each pregnancy: one chance in four for each pregnancy
4. The nurse assesses a client's risk for breast cancer. Which finding would
be considered a risk factor?
a. Menopause before age 40
b. Early onset of menstruation
c. Having more than 2 children
d. Breastfeeding longer than 2 years.: Early onset of menstruation
5. The nurse determines that a client's abdominal wound has eviscerated.
What should the nurse do first?
a. Notify the healthcare provider
b. Reinsert the protruding viscera into the abdominal cavity.
c. Place the client in reverse Trendelenburg's position
d. Cover the wound with sterile saline-moistened dressing: Cover the wound
with sterile saline-moistened dressing
6. An older adult is admitted to the hospital with sudden onset of severe pain
in the back, flank, and abdomen. The client reports feeling weak; the blood
pressure is 68/31 mm hg. There has been no urine output. Bilateral leg pulses
are weak, although bruit and pulsation are noted at the umbilicus. What action
should the nurse take first?
a. Obtain consent for emergency surgery
b. Assess leg pulses with a Doppler test
c. Palpate the abdomen for presence of a mass
d. Start an IV infusion.: Start an IV infusion
7. A preterm infant born 2 hours ago at 34 weeks' gestation is experiencing
rapid respirations, grunting, no breathe sounds on one side, and shift in
location of heart sounds. The nurse should prepare to assist with which
procedure?
a. Placement of the neonate on a ventilator
b. Administration of bronchodilators through the nares
c. Suctioning of the neonate's nares with wall suction
, NCLEX Review Study Guide (Summer 2024)
d. Insertion of a chest tube into the neonate: Insertion of a chest tube into the
neonate
8. The nurse is evaluating a client who is using a flow incentive spirometer
following abdominal surgery 1 day ago. The client is performing the
procedure correctly when the client does what?
Select all that apply
a. inhales before using the spirometer
b. inhales for 3 second following fully expanding the lungs
c. coughs after suing the spirometer
d. uses the spirometer once every 8 hours
e. exhales passively before using the spirometer again
f. sits upright: inhales for 3 second following fully expanding the lungs coughs
after suing the spirometer
exhales passively before using the spirometer again
sits upright
9. A client receiving chemotherapy for metastatic colon cancer is admitted to
the hospital because of prolonged vomiting. Assessment findings include
irregular pulse of 120 bpm, blood pressure 88/48 mm Hg, respiratory rate of
14 breathes/min, serum potassium of 2.9 mEq/L (2.9 mmol/L) and arterial
blood gas -pH 7.46, PCO2 45 mm Hg (6.0 kPA), P)2 95 mm HG (12.6 kPa),
bicarbonate level 29 mEq/L (29 mmol/L) The nurse should implement which
prescription first?
a. oxygen at 4L per nasal cannula
b. repeat laboratory work in 4 hours
c. D5W 45% NS with KCl 40 mEq/L at 125 mL/h
d. 12 lead ECG: D5W 45% NS with KCl 40 mEq/L at 125 mL/h
10. The nurse observes a constant gentle bubbling in the water-seal column
of a water-seal chest drainage system. What action should the nurse take?
a. continue monitoring as usual; this is expected
b. check the connectors between the chest and drainage tubes and where the
drainage tube enters the chest drainage system.
, NCLEX Review Study Guide (Summer 2024)
c. decrease the suction, and continue observing the system for changes in
bubbling during the next several hours.
d. Notify the healthcare provider.: check the connectors between the chest and
drainage tubes and where the drainage tube enters the chest drainage system.
11. A client experienced a pneumothorax after the placement of central
venous pressure line. Which assessment supports a diagnosis of
pneumothorax?
a. sudden, sharp pain on the affected side
b. tracheal deviation toward the affected side
c. bradypnea and elevated blood pressure
d. presence of crackles and wheezes.: sudden, sharp pain on the affected side
12. An adult comes into the emergency department with crushing
substernal chest pain that radiates to the shoulder and left arm. The
admitting diagnosis is acute myocardial infraction. Prescription include
oxygen by nasal cannula at 4 L/min, complete blood count, a chest
radiography, a 12 lead electrocardiogram (ECG), and 2 mg of morphine
sulfate given IV. After applying oxygen which prescription should the nurse
implement next?
a. 12 lead electrocardiogram (ECG)
b. Chest radiograph
c. Morphine
4. Complete blood count: Morhpine
13. A 5 month old infant is brought to the emergency department with
vomiting and diarrhea, which the parent states started 3 days ago. The nurse
should conduct a focused assessment for which signs and symptoms?
Select all that apply
a. decreased or absent tearing
b. dry mucous membranes
c. sunken fontanel
d. clear, pale, yellow urine
e. bounding pulse: decreased or absent tearing
1. A child with 20% second and third degree burns is admitted to the burn
center. The child weighs 44lbs (20 kg). The nurse has started an IV infusion
of lactated ringer solution and inserted an indwelling catheter. Which of the
findings indicate that the child is going into shock?
(Select all that apply)
a. Urinary output is 25ml/hr
b. Client is confused
c. Pain is 7 on a pain scale 1-10
d. Heart rate is elevated
e. Blood pressure is dropping: Client is confused
Heart rate is elevated
Blood pressure is dropping
2. A 17 year old high school senior calls the clinic because she thinks she
might have gonorrhea. She wants to be seen but wants assurances that no
one will know. Which is the most appropriate response by the nurse?
a. "Because you are underage, you will need your parent's consent to treat
you"
b. "We can treat you without your parent's consent, but they have the right to
review your medical record"
c. "We can see you without your parents consent, but have to report any
positive results to the public health department"
d. "We can see you, treat any infection, and will not share your results with
anyone": "We can see you without your parents consent, but have to report any
positive results to the public health department"
3. The parents of a child with sickle cell anemia ask about the chances of
sickle cell disease occurring in future children. The nurse responds based
on knowledge that both parents are carriers. What is the risk of one of their
children having the disease?
a. one chance in five for each pregnancy
b. one chance in four for each pregnancy
c. one chance in three for each pregnancy
, NCLEX Review Study Guide (Summer 2024)
d. one chance in two for each pregnancy: one chance in four for each pregnancy
4. The nurse assesses a client's risk for breast cancer. Which finding would
be considered a risk factor?
a. Menopause before age 40
b. Early onset of menstruation
c. Having more than 2 children
d. Breastfeeding longer than 2 years.: Early onset of menstruation
5. The nurse determines that a client's abdominal wound has eviscerated.
What should the nurse do first?
a. Notify the healthcare provider
b. Reinsert the protruding viscera into the abdominal cavity.
c. Place the client in reverse Trendelenburg's position
d. Cover the wound with sterile saline-moistened dressing: Cover the wound
with sterile saline-moistened dressing
6. An older adult is admitted to the hospital with sudden onset of severe pain
in the back, flank, and abdomen. The client reports feeling weak; the blood
pressure is 68/31 mm hg. There has been no urine output. Bilateral leg pulses
are weak, although bruit and pulsation are noted at the umbilicus. What action
should the nurse take first?
a. Obtain consent for emergency surgery
b. Assess leg pulses with a Doppler test
c. Palpate the abdomen for presence of a mass
d. Start an IV infusion.: Start an IV infusion
7. A preterm infant born 2 hours ago at 34 weeks' gestation is experiencing
rapid respirations, grunting, no breathe sounds on one side, and shift in
location of heart sounds. The nurse should prepare to assist with which
procedure?
a. Placement of the neonate on a ventilator
b. Administration of bronchodilators through the nares
c. Suctioning of the neonate's nares with wall suction
, NCLEX Review Study Guide (Summer 2024)
d. Insertion of a chest tube into the neonate: Insertion of a chest tube into the
neonate
8. The nurse is evaluating a client who is using a flow incentive spirometer
following abdominal surgery 1 day ago. The client is performing the
procedure correctly when the client does what?
Select all that apply
a. inhales before using the spirometer
b. inhales for 3 second following fully expanding the lungs
c. coughs after suing the spirometer
d. uses the spirometer once every 8 hours
e. exhales passively before using the spirometer again
f. sits upright: inhales for 3 second following fully expanding the lungs coughs
after suing the spirometer
exhales passively before using the spirometer again
sits upright
9. A client receiving chemotherapy for metastatic colon cancer is admitted to
the hospital because of prolonged vomiting. Assessment findings include
irregular pulse of 120 bpm, blood pressure 88/48 mm Hg, respiratory rate of
14 breathes/min, serum potassium of 2.9 mEq/L (2.9 mmol/L) and arterial
blood gas -pH 7.46, PCO2 45 mm Hg (6.0 kPA), P)2 95 mm HG (12.6 kPa),
bicarbonate level 29 mEq/L (29 mmol/L) The nurse should implement which
prescription first?
a. oxygen at 4L per nasal cannula
b. repeat laboratory work in 4 hours
c. D5W 45% NS with KCl 40 mEq/L at 125 mL/h
d. 12 lead ECG: D5W 45% NS with KCl 40 mEq/L at 125 mL/h
10. The nurse observes a constant gentle bubbling in the water-seal column
of a water-seal chest drainage system. What action should the nurse take?
a. continue monitoring as usual; this is expected
b. check the connectors between the chest and drainage tubes and where the
drainage tube enters the chest drainage system.
, NCLEX Review Study Guide (Summer 2024)
c. decrease the suction, and continue observing the system for changes in
bubbling during the next several hours.
d. Notify the healthcare provider.: check the connectors between the chest and
drainage tubes and where the drainage tube enters the chest drainage system.
11. A client experienced a pneumothorax after the placement of central
venous pressure line. Which assessment supports a diagnosis of
pneumothorax?
a. sudden, sharp pain on the affected side
b. tracheal deviation toward the affected side
c. bradypnea and elevated blood pressure
d. presence of crackles and wheezes.: sudden, sharp pain on the affected side
12. An adult comes into the emergency department with crushing
substernal chest pain that radiates to the shoulder and left arm. The
admitting diagnosis is acute myocardial infraction. Prescription include
oxygen by nasal cannula at 4 L/min, complete blood count, a chest
radiography, a 12 lead electrocardiogram (ECG), and 2 mg of morphine
sulfate given IV. After applying oxygen which prescription should the nurse
implement next?
a. 12 lead electrocardiogram (ECG)
b. Chest radiograph
c. Morphine
4. Complete blood count: Morhpine
13. A 5 month old infant is brought to the emergency department with
vomiting and diarrhea, which the parent states started 3 days ago. The nurse
should conduct a focused assessment for which signs and symptoms?
Select all that apply
a. decreased or absent tearing
b. dry mucous membranes
c. sunken fontanel
d. clear, pale, yellow urine
e. bounding pulse: decreased or absent tearing
