NCLEX Practice Questions And Answers
The nurse is caring for a client with Clostridium difficile colitis. Which of the following infection
control measures by the nurse are appropriate? Select all that apply:
1. Applies sterile gloves before performing client care
2. Ensures surgical masks are worn by staff in client's room
3. Requests that the client be assigned to a single-client room
4. Uses alcohol-based sanitizers for hand hygiene
5. Wears a single-use, disposable gown during client care - ANS 3, 5
Contact precautions Organisms:
- MDR organisms (eg, MRSA, VRE)
- Enteric organisms (eg, Clostridium difficile)
- Scabies
Infection-control measures:
-Hand hygiene (soap & water for C difficile)
- Nonsterile gloves
- Gown
- Private room preferred
- Use dedicated medical equipment that always stays in the patient's room
(Option 1) Clean, rather than sterile, gloves are required during care of a client with C difficile to
prevent transmission of infection to other individuals.
(Option 2) Surgical masks are required when caring for a client prescribed droplet isolation
precautions but are needed only in clients with contact isolation precautions if performing
activities with the possibility of body fluid splashing (eg, suctioning, wound care).
(Option 4) When caring for clients with C difficile, it is critical to perform hand hygiene with soap
and water, rather than alcohol-based sanitizers. Alcohol-based sanitizers are unable to
effectively kill spore-forming bacteria (eg, C difficile, anthrax).
The nurse is performing open endotracheal suctioning for a client with a tracheostomy tube.
Which of the following actions by the nurse are appropriate? Select all that apply:
1. Administers 100% oxygen prior to suctioning the client
2. Applies suction while withdrawing the catheter from the airway
3. Instills sterile normal saline into tracheostomy prior to suctioning
4. Limits suctioning to 20 seconds during each suction pass
5. Uses sterile gloves and technique throughout the procedure - ANS 1, 2, 5
,Open endotracheal (ET) suctioning is a skill used to clear secretions and maintain airway
patency. When performing ET suctioning to reduce the risk of complications (ex. pneumonia,
hypoxemia) or tracheal injury (ex. trauma, bleeding), the nurse preoxygenates with 100%
oxygen, applies suction only while withdrawing the catheter, uses sterile technique, and limits
each suction pass to ≤10 seconds
(Option 3) Instilling sterile normal saline solution or sterile water (ie, lavaging) in the client's
airway, a practice no longer supported by evidence, greatly increases the risk for infection by
potentially transporting bacteria from the upper airway into the lower airways.
(Option 4) Suctioning longer than 10 seconds increases risk for collapse of airway structures
(eg, alveoli, bronchioles) and hypoxemia (ie, oxygen saturation <90%).
The telemetry nurse is reviewing the cardiac monitors of 4 clients. Which cardiac rhythm is the
priority for intervention by the nurse?
1. Atrial fibrillation
2. Premature Ventricular Contractionss
3. Ventricular Fibrillation
4. Ventricular tachycardia - ANS 3
Ventricular fibrillation (VF) is a lethal arrhythmia characterized by disorganized electrical activity
in the heart ventricles. Because of this erratic electrical activity, the heart's muscles lose the
ability to contract, resulting in loss of blood flow and pulse (eg, cardiac arrest). Nurses who
identify a client with VF should immediately check the pulse, start CPR, and prepare the client
for defibrillation (Option 3).
(Option 1) Atrial fibrillation is a cardiac arrhythmia characterized by disorganized electrical
activity in the atria and an irregular pulse rate. Clients may experience this condition chronically
or in response to other medical conditions (eg, electrolyte imbalance). However, a client with VF
has no pulse and is the priority for care.
(Option 2) Premature ventricular contractions are abnormal electrical impulses in the ventricles
that may occur spontaneously or in response to heart irritants (eg, stimulant medications,
electrolyte alterations, pain). This arrhythmia is typically not harmful but requires monitoring by
the nurse.
(Option 4) Ventricular tachycardia, a potentially lethal dysrhythmia characterized by organized,
rapid firing of electrical activity within the ventricles, may impair perfusion and often leads to
cardiac arrest and/or VF. However, clients may have a pulse with ventricular tachycardia,
making the client with VF and no pulse the priority.
The nurse is preparing to administer medications to a client with an asthma exacerbation. Which
prescription should the nurse confirm with the health care provider prior to administration? Click
on the exhibit button for additional information.
Day 1, Day 5
,Hematocrit: 37% (0.37), 36% (0.36)
Platelets: 250,000/mm3 (250 × 109/L), 96,000/mm3 (96 × 109/L)
White blood cells: 9,100/mm3 (9.1 × 109/L), 15,000/mm3 (15.0 × 109/L)
Potassium: 3.8 mEq/L (3.8 mmol/L), 3.6 mEq/L (3.6 mmol/L)
1. Albuterol
2. Enoxaparin
3. Methylprednisone
4. Potassium chloride - ANS 2
A significant reduction in platelets after initiation of heparin or low-molecular-weight heparin (eg,
enoxaparin [Lovenox]) therapy can indicate heparin-induced thrombocytopenia (HIT), a severe,
potentially lethal complication. HIT is an immune reaction to heparin-based anticoagulants that
causes a drastic decrease in platelet count (ie, ≤50% of pretreatment levels and/or platelet
count <150,000/mm3 [150 × 109/L]) and a paradoxical increase in risk for arterial and venous
thrombosis (eg, deep venous thrombosis, pulmonary embolism).
The nurse should notify the health care provider immediately of decreased platelet levels and
anticipate stopping enoxaparin therapy and initiating a nonheparin anticoagulant (eg,
rivaroxaban, argatroban) (Option 2).
(Option 1) Beta-2 adrenergic agonists (eg, albuterol, salmeterol) are medications used to dilate
the airways. The nurse should clarify the prescription if hypokalemia or tachycardia, common
adverse effects, are present.
(Option 3) Methylprednisolone is a glucocorticoid medication used to reduce airway
inflammation in asthma. Glucocorticoids can cause an expected, transient elevation in the white
blood cell count during initiation of treatment.
(Option 4) Potassium chloride is an electrolyte replacement drug used to prevent and treat
hypokalemia (<3.5 mEq/L [3.5 mmol/L]). The nurse should clarify the prescription if
hyperkalemia or kidney injury is present. This client has an additional risk for low potassium due
to the continued use of albuterol.
The nurse is caring for a client at 39 weeks gestation in active labor who is receiving an oxytocin
infusion. The nurse notes persistent late decelerations on the fetal monitor. Which of the
following actions should the nurse take? Select all that apply:
1. Administer O2 via NRB face mask
2. Change maternal position to the left side
3. Discontinue oxytocin infusion
4. Notify the health care provider
5. Perform a nitrazine test - ANS 1, 2, 3, 4
The mnemonic VEAL CHOP may help nurses recall causes of fetal heart rate (FHR) changes
noted on monitor tracings.
, A late deceleration is a decrease in FHR that begins after a contraction, reaches its lowest point
(nadir) after the contraction peak, and then gradually returns to baseline. Late decelerations
indicate impaired fetal oxygenationassociated with decreased uteroplacental perfusion (eg, due
to maternal hypotension after epidural placement or uterine tachysystole). Chronic
uteroplacental insufficiency (eg, intrauterine growth restriction, preeclampsia, diabetes) may
also cause late decelerations.
Nursing actions to improve fetal perfusion and oxygenation include:
- Discontinuing uterotonics (eg, oxytocin [Pitocin]) to reduce uterine activity (Option 3)
- Changing maternal position to the left side to relieve compression of the inferior vena cava. If
the FHR tracing does not improve, a right-side position may be attempted (Option 2)
- Administering oxygen at 8-10 L/min via nonrebreather face mask to promote fetal oxygenation
(Option 1)
- Giving prescribed IV bolus of lactated Ringer solution or normal saline to improve placental
perfusion, especially during maternal hypotension
- Notifying the health care provider (Option 4)
(Option 5) Nitrazine pH tests are used to detect leaking amniotic fluid, most often if premature
(prelabor) rupture of membranes is suspected. This client is at term and in active labor.
The nurse is caring for a client with Bell palsy. Which of the following assessment findings does
the nurse expect? Select all that apply:
1. Change in lacrimation on the affected side
2. Electric shock-like pain in the lips and gums
3. Flattening of the nasolabial fold
4. Inability to smile symmetrically
5. Severe pain along the cheekbone - ANS 1, 3, 4
Bell palsy is peripheral, unilateral facial paralysis characterized by inflammation of the facial
nerve (cranial nerve VII) in the absence of a stroke or other causative agent/disease. Paralysis
of the motor fibers innervating the facial muscles results in flaccidity on the affected side.
Manifestations of Bell palsy include:
- Inability to completely close the eye on the affected side
- Alteration in tear production (eg, decreased tearing with extreme dryness, excessive tearing)
due to weakness of the lower eyelid muscle (Option 1)
- Flattening of the nasolabial fold on the side of the paralysis (Option 3)
- Inability to smile or frown symmetrically (Option 4)
- Alteration in the sensory fibers can cause loss of taste on the anterior two-thirds of the tongue.
(Options 2 and 5) Electric shock-like pain in the lips and gums and severe pain along the
cheekbone are symptoms of trigeminal neuralgia (cranial nerve V). With Bell palsy, the
trigeminal nerve may become hypersensitive and cause facial pain, but this is uncommon and
typically more indicative of trigeminal neuralgia.
