NCLEX NCLEX-PN Exam Dumps

NCLEX NCLEX-PN Sample Question Answers

Question # 1

If your patient is acutely psychotic, which of the following independent nursing interventions would not be appropriate?

A. Conveying calmness with one on one interaction
B. Recognizing and dealing with your own feelings to prevent escalation of thepatient’s anxiety level
C. Encourage client participation in group therapy
D. Listen and identify causes of their behavior

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Question # 2

Which of the following syndromes associated with incomplete lesions of the spinal cord is a result of damage to one-half of the spinal cord? 

A. Brown-Séquard syndrome
B. posterior cord syndrome
C. central cord syndrome
D. cauda equina syndrome

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Question # 3

A client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure. The nurse tries torefocus the client. The nurse notes that the client is frequently startled by noises in the hall. Assessment reveals rapid speech, trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to feeling nervous and having trouble sleeping. Based on the assessment, the nurse documents that the client has: 

A. mild anxiety.
B. moderate anxiety.
C. severe anxiety.
D. a panic attack.

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Question # 4

A 64 year-old Alzheimer’s patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure?

A. Secure the restraints to the bed rails on all extremities.
B. Notify the physician that restraints have been placed properly.
C. Communicate with the patient and family the need for restraints.
D. Position the head of the bed at a 45 degree angle.

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Question # 5

A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?

A. temperature of 102° F and a productive cough
B. arterial blood gases (ABGs) with a PaO2 of 92 and PaCO2 of 40 mmHg
C. trachea deviating to the right
D. barrel-chested appearance

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Question # 6

Metformin (Glucophage) is administered to clients with type II diabetes mellitus. Metformin is an example of:

A. an antihyperglycemic agent.
B. a hypoglycemic agent.
C. an insulin analogue.
D. a pancreatic alpha cell stimulant.

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Question # 7

An nurse is instructing a patient on the order of sensations with the application of an ice water bath for a swollen right ankle. Which of the following is the correct order of sensations experienced with an ice water bath?

A. cold, burning, aching, and numbness
B. burning, aching, cold, and numbness
C. aching, cold, burning and numbness
D. cold, aching, burning and numbness

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Question # 8

A 20-year-old male client had a diving accident with subsequent paraplegia. He says to thenurse, “No woman will ever want to marry me now.” Which of the following responses bythe nurse is most therapeutic?

A. “Don’t worry. Maybe you’ll meet a paraplegic woman.”
B. “There is someone for everyone in this world.”
C. “You are still an attractive man, even though you can’t walk.”
D. “Tell me more about your feelings on this issue.”

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Question # 9

A patient has recently been prescribed Zidovudine (Retrovir). The patient has AIDS. Whichof the following side effects should the patient specifically watch out for?

A. Weakness and SOB
B. Fever and anemia
C. Hypertension and SOB
D. Fever and hypertension

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Question # 10

A client reports that someone is in the room and trying to kill him. The nurse’s best response is:

A. “No one is in your room. Let’s get you more medicine.”
B. “I do not see anyone, but you seem to be very frightened.”
C. “No one can hurt you here.”
D. “Just tell the person to go away.”

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Question # 11

A twenty-one year old man suffered a concussion and the MD ordered a MRI. The patientasks, “Will they allow me to sit up during the MRI?” The correct response by the nurseshould be.

A. “I will have to talk to the doctor about letting you sit upright during the test.”
B. “You will be positioned in the reverse Trendelenburg position to maximizethe view of thebrain.”
C. “The radiologist will let you know.”
D. “You will have to lie down on your back during the test.”

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Question # 12

A thirty-seven year-old female in room 307 has a diagnosis of acquired immune deficiency syndrome (AIDS). Which of the following situations requires nurse intervention? 

A. A certified nursing assistant states, “The patient in 307 is not wearing glovesshaving her legs.” 
B. A nursing assistant at the nursing station states, “The patient in 307 has arespiratory rate of 16.”
C. A nursing student in the cafeteria states, “Dr.Jones told the patient in room307 that she was going to die.” 
D. A certified nursing assistant states, “Dr. Jones hasn’t made rounds thismorning.”

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Question # 13

A nurse is reviewing a patient’s current Lithium levels. Which of the following values isoutside the therapeutic range?

A. 1.0 mEq/L
B. 1.1 mEq/L
C. 1.2 mEq/L
D. 1.3 mEq/L

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Question # 14

A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client’s needs at this time?

A. asking whether another individual wants to be her support person
B. assuring her that the nursing triage group will be with her at all times
C. telling her you will try to locate her family
D. reinforcing the woman’s confidence in her own abilities to cope and maintain a sense of control

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Question # 15

A nurse is caring for a patient in the step down unit. The patient has signs of increasedintracranial pressure. Which of the following is not a sign of increased intracranialpressure?

A. Bradycardia
B. Increased pupil size bilaterally
C. Change in LOC
D. Vomiting

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Question # 16

A nurse has been assigned a patient who has recently been diagnosed with Guillain-Barre’Syndrome. Which of the following statements is the most applicable when discussing theimpairments with Guillain-Barre’ Syndrome with the patient?

A. Guillain-Barre’ Syndrome gets better after 5 years in almost all cases.
B. Guillain-Barre’ Syndrome causes limited sensation in the abdominal region.
C. Guillain-Barre’ Syndrome causes muscle weakness in the legs.
D. Guillain-Barre’ Syndrome does not effect breathing in severe cases.

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Question # 17

In hanging a parenteral IV fluid that is to be infused by gravity, rather than with an infusion pump, the nurse notes that the IV tubing is available in different drop factors. Which tubing is a microdrop set?

A. 15 drops per milliliter
B. 60 drops per milliliter
C. 20 drops per milliliter
D. 10 drops per milliliter

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Question # 18

Medical records indicate a patient has developed a condition of respiratory alkalosis. Which of the following clinical signs would not apply to a condition of respiratory alkalosis? 

A. Muscle tetany
B. Syncope
C. Numbness
D. Anxiety

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Question # 19

The nurse sustains a needle puncture that requires HIV prophylaxis. Which of the followingmedication regimens should be used?

A. an antibiotic such as Metronidazole and a protease inhibitor (Saquinivir)
B. two non-nucleoside reverse transcriptase inhibitors
C. one protease inhibitor such as Nelfinavir
D. two protease inhibitors

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Question # 20

How does the ANA define the psychiatric nursing role?

A. a specialized area of nursing practice that employs theories of human behavior as its science and the powerful use of self as its art
B. assisting the therapist to relieve the symptoms of clients
C. to solve clients’ problems and give them the answers
D. having a client committed to long-term therapy with the nurse

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Question # 21

Signs of internal bleeding include all of the following except: 

A. painful or swollen extremities.s  
B. a tender, rigid abdomen.  
C. vomiting bile.  
D. bruising.  

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Question # 22

A patient asks a nurse the following question. Exposure to TB can be identified best with which of the following procedures? Which of the following tests is the most definitive of TB?

A. Chest x-ray
B. Mantoux test
C. Breath sounds examination 
D. Sputum culture for gram-negative bacteria

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Question # 23

A 64 year-old male who has been diagnosed with COPD, and CHF exhibits an increase intotal body weight of 10 lbs. over the last few days. The nurse should:

A. Contact the patient’s physician immediately.
B. Check the intake and output on the patient’s flow sheet.
C. Encourage the patient to ambulate to reduce lower extremity edema.
D. Check the patient’s vitals every 2 hours.

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Question # 24

Which type of dressing is recommended to place over a site when a chest tube is removed by the physician?

A. transparent dressing
B. colloidal dressing
C. petrolatum gauze
D. nonadherent dressing

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Question # 25

The physician wants to know if a client is tolerating his total parenteral nutrition. Which of the following laboratory tests is likely to be ordered?

A. triglyceride level
B. liver function tests
C. a glucose tolerance test
D. a complete blood count

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Question # 26

A gastroenterologist should be consulted for clients suffering from:

A. digestive system diseases.
B. urinary system diseases.
C. female reproductive system diseases.
D. nervous system diseases.

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Question # 27

A 24 year-old man has been admitted to the hospital due to work-related back injury. Thepatient’s wife would like to see the patient’s chart. The nurse should:

A. Provide the chart to the patient’s wife following verbal approval by the patient.
B. Provide the chart to the patient’s wife after consulting with the patient’s physician.
C. Get written approval from the patient prior to providing the wife with chart informationand call the MD about the patient’s request.
D. Tell the patient’ wife, a copy of the patient’s medical record is on-file with medicalrecords.

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Question # 28

A 62 year-old female is being seen on a home visit by a nurse. The patient reports she has been taking Premarin for years. Which of the following would indicate an over-dosage?

A. Lower extremity edema  
B. Sensory changes in the upper extremities  
C. Increased occurrence of fractures  
D. Decreased peripheral blood flow  

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Question # 29

A patient has been diagnosed with diabetes mellitus. Which of the following is not a clinical sign of diabetes mellitus?

A. Polyphagia
B. Polyuria
C. Metabolic acidosis
D. Lower extremity edema

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Question # 30

A woman seeks assistance because she recently remembered childhood sexual abuse.The nurse should include which of the following goals for this client?

A. prosecuting the perpetrator
B. managing symptoms of anxiety and fear
C. determining if the memories are real
D. collaborating the client’s story

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Question # 31

A paraplegic client is in the hospital to be treated for an electrolyte imbalance. Which level of care is the client currently receiving?

A. primary prevention
B. secondary prevention
C. tertiary prevention 
D. health promotion

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Question # 32

After the client discusses her relationship with her father, the nurse says, “Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?” This is an example of:

A. verbalizing the implied.  
B. seeking consensual validation.  
C. encouraging evaluation.  
D. suggesting collaboration.  

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Question # 33

A 14 year-old boy has been admitted to a mental health unit for observation and treatment. The boy becomes agitated and starts yelling at nursing staff members. What should the nurse first response be? 

A. Create an atmosphere of seclusion for the boy according to procedures.
B. Remove other patients from the area via wheelchairs for added speed.
C. Ask the patient, “What is making you mad?”
D. Ask the patient, “Why are you doing this, have you thought about what yourparents might say?”

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Question # 34

The nurse working with elderly clients should keep in mind that falls are most likely tohappen to elderly who are:

A. in their 80s.
B. living at home.
C. hospitalized.
D. living on only Social Security income.

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Question # 35

A 32-year-old female frequently comes to her primary care provider with vague complaints of headache, abdominal pain, and trouble sleeping. In the past, the physician has dutifully prescribed medication, but little else. Which of the following comments by the nurse to the physician is appropriate?

A. “Often women who are victims of domestic violence suffer vague symptoms such as abdominal pain.”
B. “Often women become offended if asked about their safety in relationships.”  
C. “It is mandatory that all women be questioned about domestic violence.”  
D. “How would you feel to know that her partner is beating her and you didn’t ask?”  

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Question # 36

A nurse working a surgical unit, notices a patient is experiencing SOB, calf pain, and warmth over the posterior calf. All of these may indicate which of the following medical conditions?

A. Patient may have a DVT. 
B. Patient may be exhibiting signs of dermatitis.
C. Patient may be in the late phases of CHF.
D. Patient may be experiencing anxiety after surgery.

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Question # 37

A nurse is caring for a patient who has recently been diagnosed with fibromyalgia andCOPD. Which of the following tasks should the nurse delegate to a nursing assistant?

A. Transferring the patient to the shower.
B. Ambulating the patient for the first time.
C. Taking the patient’s breath sounds
D. Educating the patient on monitoring fatigue

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Question # 38

A nurse is caring for a retired MD. The MD asks the question, “What type of cells secrete insulin?” The correct answer is: 

A. alpha cells
B. beta cells
C. CD4 cells
D. helper cells

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Question # 39

Issues addressed in ethics committees include all of the following except: 

A. nonpayment of bills.  
B. euthanasia.  
C. starting or stopping treatment.  
D. use of feeding tubes.  

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Question # 40

Which of the following symptoms is not indicative of autonomic dysreflexia in the client with a spinal cord injury? 

A. sudden onset of headache
B. flushed face
C. hypotension
D. nasal congestion

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Question # 41

While admitting a client to an acute-care psychiatric unit, the nurse asks about substanceabuse based on knowledge that:

A. psychiatric illness is more prevalent in addicted populations.
B. people with psychiatric disorders are more prone to substance abuse.
C. substance disorders are easily detected and diagnosed in acute-care psychiatricsettings.
D. undetected substance problems have no real effect on treatment of psychiatricdisorders.

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Question # 42

A client is 36 hours post-op a TKR surgery. 270 cc’s of sero-sanguinous accumulates in thesurgical drains. What action should the nurse take?

A. Notify the doctor
B. Empty the drain
C. Do nothing
D. Remove the drain

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Question # 43

The home health nurse has made a visit to an 85-year-old female client’s home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?

A. The client should remove all scatter rugs from the floor and minimize clutter.  
B. The client should not get up and move around the house.  
C. The client does not need to install a raised toilet and grab bar because she is able to walk on her own.
D. The client should wear a robe and socks while walking in the house.  

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Question # 44

A nurse is working in a pediatric clinic and a 25 year-old mother comes in with a 4 week-old baby. The mother is stress out about loss of sleep and the baby exhibits signs of colic. Which of the following techniques should the nurse teach the mother?

A. Distraction of the infant with a red object
B. Prone positioning techniques
C. Tapping reflex techniques
D. Neural warmth techniques

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Question # 45

A nurse working in a pediatric clinic observes bruises on the body of a four year-old boy. The parents report the boy fell riding his bike. The bruises are located on his posterior chest wall and gluteal region. The nurse should:

A. Suggest a script for counseling for the family to the doctor on duty.  
B. Recommend a warm bath for the boy to decrease healing time.  
B. Recommend a warm bath for the boy to decrease healing time.  
D. Recommend ROM to the patient’s spine to decrease healing time.  

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Question # 46

The nurse is teaching a client about communicable diseases and explains that a portal of entry is:

A. a vector.
B. a source, like contaminated water.
C. food.
D. the respiratory system.

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Question # 47

A nurse is caring for a retired MD. The MD asks the question, “What type of cells createexocrine secretions?” The correct answer is:

A. alpha cells
B. beta cells
C. acinar cells
D. plasma cells

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Question # 48

A 26-year-old single woman is knocked down and robbed while walking her dog one evening. Three months later, she presents at the crisis clinic, stating that she cannot put this experience out of her mind. She complains of nightmares, extreme fear of being outside or alone, and difficulty eating and sleeping. What is the best response by the nurse?

A. “I will ask the physician to prescribe medication for you.”  
B. “That must have been a very difficult and frightening experience. It might be helpful to talk about it.
C. “In the future, you might walk your dog in a more populated area or hire someone else to take over this task.”  
D. “Have you thought of moving to a safer neighborhood?”  

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Question # 49

A nurse suspects a patient is developing Bell’s Palsy. The nurse wants to test the function of cranial nerve VII. Which of the following would be the most appropriate testing procedures?

A. Test the taste sensation over the back of the tongue and activation of the facial muscles.
B. Test the taste sensation over the front of the tongue and activation of the facial muscles.
C. Test the sensation of the facial muscles and sensation of the back of the tongue.
D. Test the sensation of the facial muscles and sensation of the front of the tongue.

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Question # 50

Following an automobile accident that caused a head injury to an adult client, the nurse observes that the client sleeps for long periods of time. The nurse determines that the client has experienced injury to the:

A. hypothalamus.
B. thalamus.
C. cortex.
D. medulla.

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Question # 51

A small amount of bubbling is seen in the water seal of a pleural drainage system when aclient coughs. What should the nurse do?

A. Consider it a normal finding.
B. Check the system for leaks.
C. Clamp the chest tube.
D. Change the drainage system.

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Question # 52

A 32 year-old male with a complaint of dizziness has an order for Morphine via. IV. The nurse should do which of the following first? 

A. Check the patient’s chest x-ray results.  
B. Retake vitals including blood pressure.  
C. Perform a neurological screen on the patient.  
D. Request the physician on-call assess the patient.  

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Question # 53

A mother of a newborn notices a nurse placing liquid in her baby’s eyes. Which of the following is an inaccurate statement about the need for eyedrops following birth?

A. Eyedrops following birth help reduce the risk of eye infection.
B. Eyedrops are required by the law.
C. Eyedrops will keep the eye moist.
D. Eyedrops are required by law every 6 hours following birth.

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Question # 54

Which of the following lab values would indicate symptomatic AIDS in the medical chart?(T4 cell count per deciliter)

A. Greater than 1000 cells per deciliter
B. Less than 500 cells per deciliter
C. Greater than 2000 cells per deciliter
D. Less than 200 cells per deciliter

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Question # 55

The nurse who was not promoted tells another friend, “I knew I’d never get the job. The hospital administrator hates me.” If she actually believes this of the administrator, who, in reality, knows little of her, she is demonstrating: 

A. compensation.
B. reaction formation.
C. projection.
D. denial.

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Question # 56

A nurse assesses a 83 year-old female’s venous ulcer for the second time that is locatednear the right medial malleolus. The wound is exhibiting purulent drainage and the patienthas limited mobility in her home. Which of the options is the best course of action?

A. Encourage warm water soaks to the right foot.
B. Notify the case manager of the purulent drainage.
C. Determine the patient’s pulse in the right ankle.
D. Recommend increased activity to reduce the purulent drainage.

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Question # 57

Which of the following is responsible for laws mandating the reporting of certain infections and diseases?

A. Centers for Disease Control and Prevention (CDC)
B. individual state laws
C. National Institute of Health Research (NIH)
D. Health and Human Services (HHS)

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Question # 58

A patient has recently been prescribed (Norvasc). Which of the following side effect/sshould the patient specifically watch out for?

A. Hypotension and Angina
B. Hypertension
C. Lower extremity edema
D. Peripheral sensory loss and SOB

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Question # 59

A nurse is screening patients for various vaccines. Which of the following vaccines is contraindicated during pregnancy?

A. Diphtheria
B. Hepatitis B
C. Mumps
D. Tetanus

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Question # 60

A nurse doing a home health visit consults with a male patient that has a diagnosis of CAD and COPD. The patient is currently taking Ventolin, Azmacort, Aspirin, and Theophylline. The patient complains of upset stomach, nausea and feeling uncomfortable. The nurse should:

A. Contact the patient’s physician immediately
B. Recommend the patient position himself in right sidelying.
C. Recommend the patient schedule a doctor’s visit the next day.
D. Recommend a hold on the drug-Azmacort

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Question # 61

A nurse is implementing a community awareness campaign about accidental poisoning. Which of the following should she teach in the class?  

A. The child should be given milk.
B. The child should be given syrup of Ipecac
C. The poison control center should be contacted
D. The child should be taken to the ER

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Question # 62

A nurse gave medications to the wrong client. She stated the client responded to the name called. What is the nurse’s appropriate documentation?

A. Note in medication records the drug given
B. The client was not hurt, no need for documentation
C. Note the client’s orientation
D. Completely fill out an incident report

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Question # 63

A nurse reviewed the arterial blood gas reading of a 25 year-old male. The nurse should be able to conclude the patient is experiencing which of the following conditions?Bicarbonate ion-25 mEq/lPH-7.41PaCO2-29 mmHgPaO2-54 mmHg(FiO2)-.22 

A. metabolic acidosis
B. respiratory acidosis
C. metabolic alkalosis
D. respiratory alkalosis 

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Question # 64

A newborn has been delivered. An Apgar score is given. What does this scoring system indicate?

A. heart rate, respiratory effort, color, muscle tone, reflex irritability  
B. heart rate, bleeding, cyanosis, edema  
C. bleeding, reflex, edema  
D. respiratory effort, heart rate, seizures  

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Question # 65

Why is it often necessary to draw a complete blood count and differential (CBC/differential) when a client is being treated with an antiepileptic drug (AED)?

A. The hematocrit is adversely affected because of an increased vascular volume.
B. AEDs affect immune modulators increasing the risk of infection.
C. AEDs induce white blood cell reduction.
D. A side effect of some AEDs is blood dyscrasia.

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Question # 66

The best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus is: 

A. Impaired Skin Integrity.
B. Knowledge Deficit: New Diabetes Diagnosis.
C. Alteration in Nutrition: More than Body Requirements.
D. Fluid Volume Deficit.

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Question # 67

To manage time most effectively, the nurse responds to which of the following stimuli first:

A. the physician’s loud verbal direction.
B. the nursing supervisor who is going to a meeting.
C. unit staff leaving on a break.
D. the care needs of the returning postoperative client just exiting the elevator.

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Question # 68

Mr. Lee comes to the clinic with thick green drainage around his eyelids. The nurse examiner takes his history and performs a physical examination, beginning with an eye history. General information the nurse should seek is: 

A. type of employment.  
B. burning or itchy sensation in the eyes.  
C. position of the eyelids.  
D. existence of floaters.  

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Question # 69

A nursing care plan for a client with sleep problems has been implemented. All of thefollowing should be expected outcomes except:

A. the client reports no episodes of awakening during the night.
B. the client falls asleep within 1 hour of going to bed.
C. the client reports satisfaction with his amount of sleep.
D. the client rates sleep as an 8 or more on the visual analog scale.

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Question # 70

A client taking isotretinoin (Accutane) tells the nurse that she is pregnant. What should the nurse teach this client?

A. Her pregnancy is threatened, and the fetus is at risk for teratogenesis.
B. She has a reportable condition, and the pregnancy must be terminated.
C. Accutane is a Category D drug, which means it is unsafe in pregnancy.
D. Her pregnancy must be followed carefully by a genetic specialist.

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Question # 71

A nurse is administering an antibiotic to a 4 year old girl, who does not have an identification bracelet. What action should the nurse take?

A. Ask another staff member who the child is.
B. Ask the child’s mother to state the child’s name.
C. Ask the child for her name.
D. Withhold the medication until an ID bracelet can be set-up.

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Question # 72

A nurse is assessing a 18 year-old female who has recently suffered a TBI. The nurse notes a slower pulse and impaired respiration. The nurse should report these findings immediately to the physician, due to the possibility the patient is experiencing which of the following conditions?

A. Increased intracranial pressure
B. Increased function of cranial nerve X
C. Sympathetic response to activity
D. Meningitis

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Question # 73

The only time that an individual may receive medical care without giving informed consent is:

A. when the durable power of attorney for health care is not available.
B. in an emergency, life-or-death situation. 
C. when the physician is not available for discussion with the client.
D. when they (clients) are not able to speak for themselves.

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