NCSBN ON-LINE REVIEW NCLEX EXAM
1.A client has been hospitalized after an automobile accident. A full leg cast was applied in the
emergency room. The most important reason for the nurse to elevate the casted leg is to
A) Promote the client's comfort
B) Reduce the drying time
C) Decrease irrita...
ncsbn on line review nclex exam 1a client has been hospitalized after an automobile accident a full leg cast was applied in the emergency room the most important reason for the nurse to elevate the
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NCSBN ON-LINE REVIEW NCLEX EXAM
1.A client has been hospitalized after an automobile accident. A full leg cast was applied in the
emergency room. The most important reason for the nurse to elevate the casted leg is to
A) Promote the client's comfort
B) Reduce the drying time
C) Decrease irritation to the skin D) Improve venous return
D: Improve venous return. Elevating the leg both improves venous return and reduces swelling. Client
comfort will be improved as well.
2. The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the
appropriate sequence to teach the client?
A) Clean the meatus, begin voiding, then catch urine stream
B) Void a little, clean the meatus, then collect specimen
C) Clean the meatus, then urinate into container
D) Void continuously and catch some of the urine
A: Clean the meatus, begin voiding, then catch urine stream. A clean catch urine is difficult to obtain
and requires clear directions. Instructing the client to carefully clean the meatus, then void naturally
with a steady stream prevents surface bacteria from contaminating the urine specimen. As starting
and stopping flow can be difficult, once the client begins voiding it’s best to just slip the container into
the stream. Other responses do not reflect correct technique
3. Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
C) 72 year-old recovering from surgery after a hip replacement 2 hours ago
D) 75 year-old who is in skin traction prior to planned hip pinning surgery.
C: Look for the client who has the most imminent risks and acute vulnerability. The client who
returned from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first.
The 16 year-old should be seen next because it is still the first post-op day. The 75 year-old is
potentially vulnerable to age-related physical and cognitive consequences in skin traction should be
seen next. The client who can safely be seen last is the 20 year-old who is 2 weeks post-injury.
4. A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is
independent. What should the nurse document to most accurately describe the client's condition?
,A) Comatose, breathing unlabored
B) Glascow Coma Scale 8, respirations regular
C) Appears to be sleeping, vital signs stable
D) Glascow Coma Scale 13, no ventilator required
B: Glascow Coma Scale 8, respirations regular. The Glascow Coma Scale provides a standard reference
for assessing or monitoring level of consciousness. Any score less than 13 indicates a neurological
impairment. Using the term comatose provides too much room for interpretation and is not very
precise.
5. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse
monitor to determine therapeutic response to the drug?
A) Bleeding time
B) Coagulation time
C) Prothrombin time
D) Partial thromboplastin time
C: Prothrombin time. Coumadin is ordered daily, based on the client''s prothrombin time (PT). This
test evaluates the adequacy of the extrinsic system and common pathway in the clotting cascade;
Coumadin affects the Vitamin K dependent clotting factors.
6.A client with moderate persistent asthma is admitted for a minor surgical procedure. On
admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is
complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse
do first?
A) Notify both the surgeon and provider
B) Administer the prn dose of albuterol
C) Apply oxygen at 2 liters per nasal cannula
D) Repeat the peak flow reading in 30 minutes
B: Administer the prn dose of albuterol. Peak flow monitoring during exacerbations of asthma is
recommended for clients with moderate-to-severe persistent asthma to determine the severity of the
exacerbation and to guide the treatment. A peak flow reading of less than 50% of the client''s baseline
reading is a medical alert condition and a short-acting beta-agonist must be taken immediately.
7.A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to
include at the change of shift report?
,A) The client lost 2 pounds in 24 hours
B) The client’s potassium level is 4 mEq/liter.
C) The client’s urine output was 1500 cc in 5 hours
D) The client is to receive another dose of Lasix at 10 PM
C: The client’s urine output was 1500 cc in 5 hours. Although all of these may be correct information
to include in report, the essential piece would be the urine output.
8.A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these
findings noted on the initial nursing assessment requires quick intervention by the nurse?
A) a report of 10 pounds weight loss in the last month
B) a comment by the client "I just can't sit still."
C) the appearance of eyeballs that appear to "pop" out of the client's eye sockets
D) a report of the sudden onset of irritability in the past 2 weeks
C: the appearance of eyeballs that appear to "pop" out of the client''s eye sockets. Exophthalmos or
protruding eyeballs is a distinctive characteristic of Graves'' Disease. It can result in corneal abrasions
with severe eye pain or damage when the eyelid is unable to blink down over the protruding eyeball.
Eye drops or ointment may be needed.
9. The nurse has performed the initial assessments of 4 clients admitted with an acute episode of
asthma. Which assessment finding would cause the nurse to call the provider immediately?
A) prolonged inspiration with each breath
B) expiratory wheezes that are suddenly absent in 1 lobe
C) expectoration of large amounts of purulent mucous
D) appearance of the use of abdominal muscles for breathing
B: expiratory wheezes that are suddenly absent in 1 lobe. Acute asthma is characterized by expiratory
wheezes caused by obstruction of the airways. Wheezes are a high pitched musical sounds produced
by air moving through narrowed airways. Clients often associate wheezes with the feeling of tightness
in the chest. However, sudden cessation of wheezing is an ominous or bad sign that indicates an
emergency -- the small airways are now collapsed.
10. During the initial home visit, a nurse is discussing the care of a client newly diagnosed with
Alzheimer's disease with family members. Which of these interventions would be most helpful at this
time?
A) leave a book about relaxation techniques
, B) write out a daily exercise routine for them to assist the client to do
C) list actions to improve the client's daily nutritional intake
D) suggest communication strategies
D: suggest communication strategies. Alzheimer''s disease, a progressive chronic illness, greatly
challenges caregivers. The nurse can be of greatest assistance in helping the family to use
communication strategies to enhance their ability to relate to the client. By use of select verbal and
nonverbal communication strategies the family can best support the client’s strengths and cope with
any aberrant behavior.
11. An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a
blood pressure from 160/100 to
180/110 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding
should the nurse report immediately to the provider?
A) Slurred speech
B) Incontinence
C) Muscle weaknessD) Rapid pulse
A: Slurred speech. Changes in speech patterns and level of conscious can be indicators of continued
intracranial bleeding or extension of the stroke. Further diagnostic testing may be indicated.
12. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which
statement from the parent indicates that teaching has been inadequate?
A) "I will keep the cast uncovered for the next day to prevent burning of the skin."
B) "I can apply an ice pack over the area to relieve itching inside the cast."
C) "The cast should be propped on at least 2 pillows when my child is lying down."
D) "I think I remember that my child should not stand until after 72 hours."
D: "I think I remember that my child should not stand until after 72 hours.". Synthetic casts will
typically set up in 30 minutes and dry in a few hours. Thus, the client may stand within the initial 24
hours. With plaster casts, the set up and drying time, especially in a long leg cast which is thicker than
an arm cast, can take up to 72 hours. Both types of casts give off a lot of heat when drying and it is
preferable to keep the cast uncovered for the first 24 hours. Clients may complain of a chill from the
wet cast and therefore can simply be covered lightly with a sheet or blanket. Applying ice is a safe
method of relieving the itching.
13. Which blood serum finding in a client with diabetic ketoacidosis alerts the nurse that immediate
action is required?
A) pH below 7.3
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