The father of a one-day-old son works the evening shift (3 PM to 11 PM) at another hospital. Which
of the following plans would be a priority to meet the needs of this father?
1. Encourage the father to call his wife a
...
The father of a one-day-old son works the evening shift (3 PM to 11 PM) at another hospital. Which
of the following plans would be a priority to meet the needs of this father?
1. Encourage the father to call his wife after work.
2. Instruct the father about visiting policy and suggest AM visitation.
3. Adjust visiting hours to meet the new parents’ needs.
4. Present a change of visiting hours to the appropriate hospital committee.
Strategy: Answers are implementation. Determine the outcome of each answer. Is it desired?
(1) inflexible
(2) inflexible
(3) correct–role of nurse is to be a family and client advocate; this provides individualized care not
a priority, although it may be an appropriate long-range goal
(4) not a priority, although it may be an appropriate long-range goal
2. The nurse believes a coworker is diverting narcotics. The nurse approaches the nurse manager to
report the suspicions. Which of the following statements by the nurse is BEST?
1. “After my coworker has been on duty, the patients often need repeated doses of pain
medication. I have seen her/him sleeping on duty three times.”
2. “I saw my coworker downtown after work. S/he was acting really strange, like s/he didn’t even
recognize me.”
3. “I think my coworker is stealing narcotics because s/he is always acting euphoric and seems
high.”
4. “My coworker is hanging around with drug dealers, and I think I saw tracks on her/his arms.”
Strategy: All answers are assessment. Determine how each relates to the situation.
(1) correct—report objective information that can be verified; clues to possible substance abuse
by staff include memory lapses, frequent absences from the floor, increased number of clients
reporting unrelieved pain or insomnia
(2) subjective observation
(3) subjective observation
(4) “hanging around with drug dealers” is subjective
NCLEX Question Trainer Explanations
Test 7
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3. A woman with chronic obstructive pulmonary disease (COPD) is admitted with an acute
exacerbation. Her vital signs are: BP 162/100, pulse 78, respirations 30 and labored with
wheezing. The nurse should question which of the following orders?
1. Theophylline (Somophyllin) 0.7 mg/kg/hr IV.
2. Tetracycline hydrochloride (Sumycin) 250 mg IM qd.
3. Ipratropium bromide (Atrovent) inhaler 2 inhalations qid.
4. Propranolol hydrochloride (Inderal) 40 mg PO bid.
Strategy: You are looking for an incorrect medication. Think about the action of each drug.
(1) drug of choice for acute asthma
(2) broad spectrum antibiotic, not contraindicated
(3) blocks parasympathetic stimulation and decreases mucus; used with asthma
(4) correct—beta-blocker that blocks beta adrenergic impulses to the bronchial tree that cause
bronchodilation resulting in increased bronchoconstriction
4. A husband and wife meet at the mental health clinic to make an appointment for family therapy.
Suddenly, the wife begins to sob loudly. As the nurse approaches, the husband says, “I guess we
just don’t get along.” Which of the following responses by the nurse is MOST appropriate?
1. “Your wife seems to be upset by the situation.”
2. “Perhaps you should both go home now.”
3. “Try to think about what precipitated her crying.”
4. “The situation is difficult for both of you.”
Strategy: Remember therapeutic communication.
(1) nontherapeutic; emphasis is placed on wife, not the situation
(2) nontherapeutic; closes off communication
(3) nontherapeutic; appears to blame the husband for precipitating the wife’s behavior, would
cause him to react defensively
(4) correct—therapeutic; avoids blaming, focuses on feelings of both husband and wife
5. A client on chemotherapy has a WBC count of 1,200/mm3. Which of the following nursing actions
should the nurse take FIRST?
1. Check temperature q4h.
2. Monitor urine output.
3. Assess for bleeding gums.
4. Obtain an order for blood cultures.
Strategy: Determine how each assessment relates to a low white count.
(1) correct—important to monitor for infection which would be evidenced by an elevated
temperature in a client with a low WBC
(2) important because of problems of increased uric acid excretion from chemotherapeutic drugs
but should not be done first
(3) would be associated with a low platelet count
(4) would be done if the temperature were elevated to determine the type of organism involved
NCLEX Question Trainer
51
6. A woman is in active labor with her first child when her membranes rupture. She voices a concern
to the nurse that she is afraid of having a “dry labor.” Which of the following responses by the
nurse would be MOST appropriate?
1. “The amniotic fluid provides only minimal lubrication for the labor process.”
2. “The amniotic sac may impede the progress of labor and is often ruptured artificially.”
3. “Labor is only slightly more difficult with early rupture of the amniotic sac.”
4. “Because there is limited amniotic fluid, additional fluids will be supplied.”
Strategy: “MOST” indicates there may be more than one answer that you like.
(1) amniotic fluid cushions fetus, allows freedom of movement for musculoskeletal development,
facilitates symmetrical growth, maintains constant body temperature, is a source of oral fluids,
and collects wastes
(2) correct—sometimes done to assist or induce labor
(3) does not make labor more difficult
(4) no additional fluids will be supplied
7. The nurse is performing an ice massage for a client in chronic pain. The nurse is MOST concerned
if which of the following is observed?
1. Redness or inflammation of the tissue.
2. Mottling or graying of the tissue.
3. The client states that she feels a burning and tingling sensation in the area.
4. The client state that she feels a numbness and a cold sensation in the area.
Strategy: “MOST concerned” indicates a complication.
(1) indicates inflammation
(2) correct—site should be observed every five minutes for signs of tissue intolerance, including
blanching, mottling, or graying
(3) usually indicates ischemia or sensorineural impairment
(4) expected outcome of numbness, which would lead to decreased pain perception
8. The nurse is caring for a client with a complete heart block. The nurse should question which of
the following orders?
1. Administer lidocaine (Xylocaine) 50 mg IV push for PVCs in excess of six per minute.
2. Administer atropine sulfate (Atropine) 0.05 mg IV for symptomatic bradycardia.
3. Anticipate scheduling the client for a temporary pacemaker if the pulse continues to decrease.
4. Mix 10 cc of 1:5,000 solution of isoproterenol (Isuprel) in 500 cc D5W for sustained
bradycardia below 30.
Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?
(1) correct—in complete heart block, the AV node blocks all impulses from the SA node so the
atria and ventricles beat independently; because lidocaine suppresses ventricular irritability, it
may diminish the existing ventricular response; cardiac depressants are contraindicated in the
presence of complete heart block
(2) appropriate treatment
(3) appropriate treatment
(4) appropriate treatment
Preparation for the Nursing Licensure Examination
52
9. The nurse is caring for a client who had a cholecystectomy. Which of the following observations is
MOST important for the nurse to report to the next shift?
1. Resting after receiving IM pain medication.
2. No bowel sounds present.
3. IV infusing at 100 cc/h.
4. Breath sounds decreased in both lower lobes.
Strategy: Priority question. Remember Maslow and the ABCs.
(1) psychosocial; not a priority
(2) physical; expected finding after surgery due to decrease in peristalsis from anesthetic agents
(3) physical; not a priority
(4) correct—physical; incision for a cholecystectomy is high on the abdominal wall, which
inhibits ventilatory movement; decreased breath sounds might indicate a complication of
pneumonia
10. The nurse in the outpatient clinic plans care for a 65-year-old woman with left-sided weakness
due to a cerebral vascular accident (CVA). The client has a history of hypertension and
osteoporosis. It is MOST important for the nurse to encourage the client to
1. increase the amount of calcium in her daily diet.
2. increase the amount of vitamin D in her daily diet.
3. increase the amount of time she is exposed to sunlight.
4. increase her activities that involve weight-bearing.
Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?
(1) diet should have adequate calcium, should increase intake in middle age to protect against
skeletal demineralization; not most important
(2) adequate serum levels of vitamin D needed for calcium to be absorbed from GI tract, should
increase intake in middle age to protect against skeletal demineralization; not most important
(3) vitamin D is synthesized in the skin with exposure to sunshine; not most important for this
patient
(4) correct—weight bearing and exercise primary ways to develop high-density bones, decrease
bone reabsorption and stimulate bone formation; would also help maintain mobility with leftsided weakness
NCLEX Question Trainer
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11. The homecare nurse is visiting a young adult with a diagnosis of hepatitis A. Which of the
following statements, if made by the client to the nurse, indicates that further teaching is needed?
1. “I have been very careful to wash my hands after I go to the bathroom.”
2. “I have had to take Tylenol several times this week for this sinus infection I have.”
3. “I have been very careful not to handle my child’s toys or eating utensils.”
4. “My husband has been preparing all of the meals since I’ve been sick.”
Strategy: “Further teaching is needed” indicates you are looking for an incorrect response.
(1) because hepatitis A is spread by the oral-rectal route, it is important to protect others by
practicing good hand-washing techniques and avoiding contact with items that will be placed
in others’ mouths
(2) correct—client should be cautioned about taking any drugs not approved by the health care
provider; may become dangerous because of the liver’s inability to detoxify and excrete them
(3) because hepatitis A is spread by the oral-rectal route, it is important to protect others by
practicing good hand-washing techniques and avoiding contact with items that will be placed
in others’ mouths
(4) because hepatitis A is spread by the oral-rectal route, it is important to protect others by
practicing good hand-washing techniques and avoiding contact with items that will be placed
in others’ mouths
12. The nurse is caring for a client in a manic phase of bipolar affective disorder. It is MOST
important for the nurse to offer which of the following meals?
1. Tuna salad sandwich and orange slices.
2. Bologna sandwich and french fries
3. Milkshake and banana.
4. Fried chicken and tossed salad.
Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired
(1) correct—manic clients need nutritious finger foods; foods contain protein, carbohydrates,
vitamin C, and fiber
(2) finger foods, but little nutritive value
(3) finger foods, not as balanced
(4) too difficult to eat in manic phase
13. Which of the following actions should the nurse instruct the client to complete FIRST to establish
a normal urinary pattern?
1. Urinate every two hours.
2. Record each time you urinate.
3. Keep a record of your daily fluid intake.
4. Stay near a bathroom.
Strategy: Answers are all implementations. Determine the outcome of each answer. Is it desired?
(1) client should start voiding every 2 h and gradually progress to 3–4 h
(2) second thing to do
(3) correct—client needs to know how much and when he ingests fluid
(4) appropriate, but not the first thing to do
Preparation for the Nursing Licensure Examination
54
14. The nurse is receiving reports about four pregnant women in active labor who have been admitted
to the labor and delivery unit. Which of the following women should the nurse see FIRST?
1. A 27-year-old nullipara at 38-weeks gestation, has a cervical dilatation of 2 cm, fetus in
transverse lie with baseline FHT of 155 bpm.
2. A 32-year-old multipara at term, cervical dilatation of 8 cm, fetus in a vertex presentation with
the presenting part at +2 station.
3. A 22-year-old nullipara at term, cervical dilatation of 10 cm, 100% effaced, fetus presenting as
left occiput posterior with short-term variability of the FHT at 3–5 beats.
4. A 34-year-old multipara at 37-weeks gestation, has intact amniotic membranes, cervical
dilatation of 3 cm, and fetus in a frank breech presentation with the presenting part at 0
station.
Strategy: Determine who is the least stable client.
(1) delivery is not imminent
(2) correct—transition phase of labor and delivery quick for many multipara woman
(3) nullipara women usually have a longer second stage than multipara women
(4) labor has not progressed very far
15. The nurse is planning care for a client who had surgery for an ileal conduit two days ago. It is
MOST important for the nurse to take which of the following actions?
1. Remove the appliance regularly and clean the skin with antiseptic solution.
2. Apply a close-fitting drainage bag to the stoma.
3. Massage the skin around the stoma with an emollient.
4. Expose the area around the stoma to air twice a day.
Strategy: Answers are implementations. Determine the outcome of each answer. Is it desired?
(1) soap and water should be used to clean the skin, not an antiseptic solution
(2) correct—primary preventative measure to prevent urine from contacting the skin
(3) would hinder the application of the bag for urine collection
(4) unnecessary; would not help prevent skin breakdown
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