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NCLEX-PN Test-Bank (200 Questions with SOLUTIONs and Explanation)
CORRECT SOLUTION GRADED A
- The nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. The nurse should be particularly alert for: A. Nasal congestion B. Abdominal tenderness C. Muscle tetany D. Oliguria SOLUTION A: Removal of the pituitary gland is usually done by a transsphenoidal approach, through the nose. Nasal congestion further interferes with the airway. SOLUTIONs B, C, and D are not correct because they are not directly associated with the pituitary gland.
- A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following? A. Hypernatremia B. Hypokalemia C. Myelosuppression D. Leukocytosis SOLUTION B: Hypokalemia is evident from the lab values listed. The other laboratory findings are within normal limits, making SOLUTIONs A, C, and D incorrect.
- 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 SOLUTION A: The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in SOLUTIONs B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question.
- 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 gases D. Medicating the client for pain SOLUTION B: The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making SOLUTIONs A and C incorrect. SOLUTION D, obtaining blood gases, is ordered by the doctor.
- The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client? A. Rest in bed after taking the medication for at least 30 minutes B. Avoid rapid movements after taking the medication C. Take the medication with water only
SOLUTION D: A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth weight. SOLUTIONs A, B, and C therefore are incorrect.
- A client is admitted with a Ewing’s sarcoma. Which symptoms would be expected due to this tumor’s location? A. Hemiplegia B. Aphasia C. Nausea D. Bone pain SOLUTION D: Sarcoma is a type of bone cancer; therefore, bone pain would be expected. SOLUTIONs A, B, and C are not specific to this type of cancer and are incorrect.
- The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug? A. Uric acid of 5mg/dL B. Hematocrit of 33% C. WBC 2,000 per cubic millimeter D. Platelets 150,000 per cubic millimeter SOLUTION C: Tegretol can suppress the bone marrow and decrease the white blood cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. SOLUTIONs A and D are within normal limits, and SOLUTION B is a lower limit of normal; therefore, SOLUTIONs A, B, and D are incorrect.
- 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 his pain.” B. “What does his vomit look like?” C. “Describe his usual diet.” D. “Have you noticed changes in his abdominal size?” SOLUTION C: 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.
- The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided? A. Bran B. Fresh peaches C. Cucumber salad D. Yeast rolls SOLUTION C: The client with diverticulitis should avoid foods with seeds. The foods in SOLUTIONs A, B, and D are allowed; in fact, bran cereal and fruit will help prevent constipation.
- A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? A. Teaching how to irrigate the illeostomy B. Stopping electrolyte loss in the incisional area C. Encouraging a high-fiber diet
SOLUTION D: After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding cause the infant to lose body mass. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula; thus, SOLUTIONs A, B, and C are incorrect.
- The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis? A. Foul breath B. Dysphagia C. Diarrhea D. Chronic hiccups SOLUTION C: Diarrhea is not common in clients with mouth and throat cancer. All the findings in SOLUTIONs A, B, and D are expected findings.
- A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included in the plan? A. Closed chest drainage B. A tracheostomy C. A mediastinal tube D. Percussion vibration and drainage SOLUTION A: The client with a lung resection will have chest tubes and a drainage- collection device. He probably will not have a tracheostomy or mediastinal tube, and he will not have an order for percussion, vibration, or drainage. Therefore, SOLUTIONs B, C, and D are incorrect.
- Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as: A. A cephalohematoma B. Molding C. Subdural hematoma D. Caput succedaneum SOLUTION A: A swelling over the right parietal area is a cephalohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line because it is outside the cranium but beneath the periosteum. SOLUTION B, molding, is overlapping of the bones of the cranium and, thus, incorrect. In SOLUTION C, a subdural hematoma, or intracranial bleeding, is ominous and can be seen only on a CAT scan or x-ray. A caput succedaneum, in SOLUTION D, crosses the suture line and is edema.
- 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 shoulder 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.” SOLUTION C: The client with an internal defibrillator should learn to use any battery-operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting. SOLUTIONs A, B, and D are incorrect because the client can eat food prepared in the microwave, move his shoulder on the affected side, and fly in an airplane.
- 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?
D. “You will not be able to drink fluids for 24 hours before the study.” SOLUTION B: Portions of the exam are painful, especially when the sample is being withdrawn, so this should be included in the session with the client. SOLUTION A is incorrect because the client will be positioned prone, not in a sitting position, for the exam. Anesthesia is not commonly given before this test, making SOLUTION C incorrect. SOLUTION D is incorrect because the client can eat and drink following the test.
- 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 12.0gm/dL SOLUTION C: A red, beefy tongue is characteristic of the client with pernicious anemia. SOLUTION A, a weight loss of 10 pounds in 2 weeks, is abnormal but is not seen in pernicious anemia. Numbness and tingling, in SOLUTION B, can be associated with anemia but are not particular to pernicious anemia. This is more likely associated with peripheral vascular diseases involving vasculature. In SOLUTION D, the hemoglobin is low normal.
- 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. Buck’s traction D. An abduction pillow
SOLUTION C: The client with a fractured femur will be placed in Buck’s traction to realign the leg and to decrease spasms and pain. The Trendelenburg position is the wrong position for this client, so SOLUTION A is incorrect. Ice might be ordered after repair, but not for the entire extremity, so SOLUTION B is incorrect. An abduction pillow is ordered after a total hip replacement, not for a fractured femur; therefore, SOLUTION D is incorrect.
- A client with cancer 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 SOLUTION B: The client having an intravenous pyelogram will have orders for laxatives or enemas, so asking the client to void before the test is in order. A full bladder or bowel can obscure the visualization of the kidney ureters and urethra. In SOLUTIONs A, C, and D, there is no need to force fluids before the procedure, to withhold medications, or to cover the reproductive organs.
- The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor: A. That cannot be assessed B. That is in situ C. With increasing lymph node involvement D. With distant metastasis SOLUTION B: Cancer in situ means that the cancer is still localized to the primary site. Cancer is graded in terms of tumor, grade, node involvement, and mestatasis. SOLUTION A is incorrect because it is an untrue statement. SOLUTION C is incorrect because T indicates tumor, not node involvement. SOLUTION D is incorrect because a tumor that is in situ is not metastasized.
A. Call the surgeon and ask him or her to see the client to clarify the information B. Explain the procedure and complications to the client C. Check in the physician’s progress notes to see if understanding has been documented D. Check with the client’s family to see if they understand the procedure fully SOLUTION A: It is the responsibility of the physician to explain and clarify the procedure to the client. SOLUTIONs B, C, and D are incorrect because they are not within the nurse’s purview.
- 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 SOLUTION A: Previous radiation to the neck might have damaged the parathyroid glands, which are located on the thyroid gland, and interfered with calcium and phosphorus regulation. SOLUTION B has no significance to this case; SOLUTIONs C and D are more related to calcium only, not to phosphorus regulation.
- A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client? A. Anger B. Mania C. Depression D. Psychosis
SOLUTION B: The client with serum sodium of 170meq/L has hypernatremia and might exhibit manic behavior. SOLUTIONs A, C, and D are not associated with hypernatremia and are, therefore, incorrect.
- The nurse is obtaining a history of an 80-year-old client. Which statement made by the client might indicate a possible fluid and electrolyte imbalance? A. “My skin is always so dry.” B. “I often use a laxative for constipation.” C. “I have always liked to drink a lot of ice tea.” D. “I sometimes have a problem with dribbling urine.” SOLUTION B: Frequent use of laxatives can lead to diarrhea and electrolyte loss. SOLUTIONs A, C, and D are not of particular significance in this case and, therefore, are incorrect.
- 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.”
- 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 two times per day SOLUTION B: 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. SOLUTIONs A and C are incorrect because blood pressures are not required every 15 minutes, and cardiac monitoring might be needed, but this is individualized to the client. SOLUTION D is incorrect because there are no dressings to change on this client.
- 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: A. The client is at risk for evisceration. B. The client will require frequent dressing changes. C. The straps provide support for drains that are inserted in the incision. D. No sutures or clips are used to secure the incision. SOLUTION B: Montgomery straps are used to secure dressings that require frequent dressing changes because the client with a cholecystectomy usually has a large amount of drainage on the dressing. Montgomery straps are also used for clients who are allergic to several types of tape. This client is not at higher risk of evisceration than other clients, so SOLUTION A is incorrect. Montgomery straps are not used to secure the drains, so SOLUTION C is incorrect. Sutures or clips are used to secure the wound of the client who has had gallbladder surgery, so SOLUTION D is incorrect.
- The physician has ordered that the client’s medication be administered intrathecally. The nurse is aware that medications will be administered by which method? A. Intravenously B. Rectally C. Intramuscularly D. Into the cerebrospinal fluid SOLUTION D: Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client with metastases, the client with chronic pain, or the client with cerebrospinal infections. SOLUTIONs A, B, and C are incorrect because intravenous, rectal, and intramuscular injections are entirely different procedures.
- Which client can best be assigned to the newly licensed practical nurse? A. The client receiving chemotherapy B. The client post–coronary bypass C. The client with a TURP D. The client with diverticulitis SOLUTION D: The best client to assign to the newly licensed nurse is the most stable client; in this case, it is the client with diverticulitis. The client receiving chemotherapy and the client with a coronary bypass both need nurses experienced in these areas, so SOLUTIONs A and B are incorrect. SOLUTION D is incorrect because the client with a transurethral prostatectomy might bleed, so this client should be assigned to a nurse who knows how much bleeding is within normal limits.
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 laryngeal cancer with a laryngetomy D. A client with diabetic ulcers to the left foot SOLUTION C: The client with laryngeal cancer has a potential airway alteration and should be seen first. The clients in SOLUTIONs A, B, and D are not in immediate danger and can be seen later in the day.
- The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin? A. Increasing the infant’s fluid intake B. Maintaining the infant’s body temperature at 98.6°F C. Minimizing tactile stimulation D. Decreasing caloric intake SOLUTION A: Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temperature is important but will not assist in eliminating bilirubin; therefore, SOLUTION B is incorrect. SOLUTIONs C and D are incorrect because they do not relate to the question.
- The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority? A. Maintain the client’s systolic blood pressure at 70mmHg or greater B. Maintain the client’s urinary output greater than 300cc per hour
C. Maintain the client’s body temperature of greater than 33°F rectal D. Maintain the client’s hematocrit less than 30% SOLUTION A: When the cadaver client is being prepared to donate an organ, the systolic blood pressure should be maintained at 70mmHg or greater to ensure a blood supply to the donor organ. SOLUTIONs B, C, and D are incorrect because they are unnecessary actions for organ donation.
- Which action by the novice nurse indicates a need for further teaching? A. The nurse fails to wear gloves to remove a dressing. B. The nurse applies an oxygen saturation monitor to the ear lobe. C. The nurse elevates the head of the bed to check the blood pressure. D. The nurse places the extremity in a dependent position to acquire a peripheral blood sample. SOLUTION A: The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction. SOLUTIONs B, C, and D are incorrect because they indicate an understanding of the correct method of completing these tasks.
- The nurse is preparing a client for mammography. To prepare the client for a mammogram, the nurse should tell the client: A. To restrict her fat intake for 1 week before the test B. To omit creams, powders, or deodorants before the exam C. That mammography replaces the need for self-breast exams D. That mammography requires a higher dose of radiation than an x-ray
