Date Published: December 6, 2016 They say practice makes perfect and when it comes to passing the NCLEX that is certainly the case. ATI Nursing Education wants to share 20 NCLEX practice questions to help you perfect your test-taking skills and knowledge. PS: Don’t forget to scroll to the end of the article for answers and rationales. Question 1: A nurse cares for a toddler who has a decreased appetite, an erratic eating pattern, and fussiness at mealtime. Which recommendation should be made to the parents?
Question 2: A nurse provides care for a client who is 1-day post-partum following a vaginal delivery. Which task can be delegated to the assistive personnel (AP)?
Question 3: A nurse plans teaching for a client who has coronary artery disease. Which dietary recommendation is most important?
Question 4: A client who has endometrial cancer is receiving sealed internal radiation therapy. Which actions should the nurse implement? Select all that apply.
Question 5: A nurse cares for a group of clients who are experiencing symptoms of withdrawal from alcohol. Which finding requires immediate follow-up?
Question 6: A nurse provides discharge teaching for a client who had a below-knee amputation. Which instructions should the nurse include? Select all that apply.
Question 7: A toddler is dehydrated as the result of complications from varicella-zoster virus. Fluid filled vesicles are observed on the face and chest. Which actions should the nurse implement? Select all that apply.
Question 8: A nurse explains how to recognize an impending attack to the parents of a child who has asthma. Which symptoms should be discussed? Select all that apply.
Question 9: A nurse administers 12 units lispro insulin at 0700 to a client. Within which time frame must the morning meal be served?
Question 10: During an admission assessment a client responds with rhyming statements such as “tip, rip, dip and hip”. The nurse recognizes this speech pattern is associated with which mental health disorder?
Question 11: A nurse cares for a client who is one hour post vaginal delivery. Which findings are an early sign of postpartum hemorrhage?
Question 12: A nurse provides care for a client who has severe anemia and received a transfusion of packed RBCs. Which data indicates the goal of therapy has been met?
NOTE: Blood and blood products are used to increase intravascular volume, replace clotting factors, replace components of blood, replace blood loss, and improve oxygen carrying capacity. Question 13: A client who has severe burns is receiving total parenteral nutrition (TPN). Which lab value indicates therapeutic effectiveness of TPN?
Question 14: A nurse provides care for a client who reports sudden onset of sweating, shortness of breath, dizziness, and pounding heart. Which ABG value should be expected?
Question 15: A client who is at 30 weeks of gestation states, “I may be in labor.” Which findings should the nurse anticipate?
Question 16: A client who sustained a head injury has an intracranial pressure (ICP) monitor reading of 12 mm Hg. Which action should the nurse take?
Question 17: A nurse provides teaching to a client who is scheduled for a colonoscopy. Which statements should be included? Select all that apply.
Question 18: A client reports shortness of breath and has the following cardiac rhythm. Which medication should the nurse prepare to administer?
Question 19: A nurse provides education to a client recently diagnosed with Addison’s disease. Which symptoms should be discussed? Selection all that apply.
Question 20: An older adult who has facial drooping, a weak cough, and absent gag reflex is admitted for treatment. Which action should the nurse implement?
Related Read: Job Market Stats Every Nursing Student Should Know Answers & RationalesAnswer & Rationale, Question 1 Correct Answer: 4 Rationale 1.Portion should not be increased. It is more significant to provide nutritious foods rather than focus on the amount consumed. Large adult size portions contribute to a feeling of being overwhelmed. 2.It’s normal for a toddler to experience a decreased appetite and decreased nutritional need. They often become picky and fussy eaters. Food that is offered as a reward for eating becomes associated with approval. The child may overeat for non-nutritive reasons. 3.Excessive consumption of fruit juice is associated with dental caries, obesity and metabolic syndrome. The child should consume no more than 6 ounces per day of 100% juice. The nurse should suggest alternatives with fewer empty calories and greater nutritional value. 4. CORRECT. Toddlers prefer the routine of consistent mealtimes. Frequent nutritious planned snacks can replace a meal, but shouldn’t replace a regular sit-down meal. Nibbling and snacking is a way to ensure proper nutrition when appropriate foods are offered. Nutritious snacks include several small pieces of food such as crackers, carrots, sliced cold meat, and raisins. Answer & Rationale, Question 2 Correct Answer: 1 RNs are responsible for supervising tasks assigned to PNs and APs. RNs cannot delegate the nursing process, client education, or tasks that require clinical judgement (for example unstable clients). Examples of tasks that can be delegated to the AP include: activities of daily living (ADLs), bathing, grooming, dressing, toileting, ambulating, feeding (without swallowing precautions), positioning, routine tasks, bed making, specimen collection, intake and output, and vital signs (for stable clients). The five rights of delegation include: right task, right circumstance, right person, right communication, and right supervision. Delegation is based on individual client needs, facility policies, job descriptions, state nurse practice acts, and professional standards. Rationale: 1.CORRECT. Obtaining vital signs may be delegated (right task) as long as the client is stable (right circumstance). In the scenario, the client is 1 day postpartum and there is no indication the client is unstable. 2.This would not be appropriate delegation. Demonstrating implies client education which is within the scope of practice for a RN. 3.This would not be appropriate delegation. Evaluating effectiveness would involve the nursing process which is within the scope of practice for a PN or RN. 4.This would not be appropriate delegation. Providing instruction involves client education which is within the scope of practice for an RN. Answer & Rationale, Question 3 Correct Answer: 1 Rationale: 1.CORRECT: Atherosclerosis is the primary risk factor in the development of coronary artery disease (CAD). Health promotion efforts are aimed at eliminating saturated and trans saturated fatty acids by preparing foods that are baked or broiled in place of frying or stewing in lard and oils. 2.Limiting dietary sodium intake is more of a concern for a client with heart failure rather than a client with CAD. Chili peppers, lemon, herbs and spices may be used to enhance the flavor of foods. 3.Selecting almond milk as a beverage rather than a soft drink offers more nutritional value. Soft drinks do not provide any nutritional benefit and contain very high sugar content. This option will help reduce weight and maintain glucose levels. A client with CAD should be primarily concerned with decreasing intake of saturated fats. 4.This recommendation is appropriate but is not the most important. Corn flour is lower in fat and calories and higher in fiber than white flour. Corn and wheat flour are good substitutes for a client who is overweight and/or managing diabetes mellitus. A health promotion effort for a client with CAD is to eliminate the risk of atherosclerosis. Answer & Rationale, Question 4 Correct Answer: 1, 5 Rationale Internal radiation therapy is an example of brachytherapy. With brachytherapy, the radiation source is within the patient and comes into contact with the tumor for a specific amount of time. The patient emits radiation and is a potential hazard to others. Internal radiation therapy can involve an unsealed source or a sealed source. Solid or sealed sources are implanted near the tumor and can be permanent or temporary. Clients with temporary implants may be hospitalized for several days during treatment or stronger radiation implants may be left in place for only an hour or so at a time. The client is radioactive only when the implant is in place.
Answer & Rationale, Question 5 Correct Answer: 3 Rationale
Answer & Rationale, Question 6 Correct Answer: 1, 3, 4, 6 Rationale
Answer & Rationale, Question 7 Correct Answer: 1,2,4,5 Rationale
Answer & Rationale, Question 8 Correct Answer: 1, 3, 4, 5 Rationale
Answer & Rationale, Question 9 Correct Answer: 1 Rationale
Answer & Rationale, Question 10 Correct Answer: 4 Rationale
Answer & Rationale, Question 11 Correct Answer: 3 Rationale
Answer & Rationale, Question 12 Correct Answer: Correct Answer: 1 Rationale
Answer & Rationale, Question 13 Correct Answer: 3 TPN provides a nutritionally complete solution. It can be used when caloric needs are very high, when duration of therapy is greater than 7 days or when the solution to be administered is hypertonic (greater than 10% dextrose). It can only be administered in a central vein. Desired therapeutic effects of TPN include improved nutritional status, weight maintenance or gain, and positive nitrogen balance. Evidence to support this include: maintenance of baseline or weight gain (up to 1 kg/day), serum albumin 3.5 to 5.0 g/dL and prealbumin 15 to 36 mg/dL. Rationale
Answer & Rationale, Question 14 Correct Answer: 2 Normal ABG values are pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg, HCO3 21 to 28 mEq/L, and PaO2 80 to 100 mm Hg. Rationale
Answer & Rationale, Question 15 Correct Answer: 3 Rationale
Answer & Rationale, Question 16 Correct answer: 1 Rationale
Answer & Rationale, Question 17 Correct answer: 1, 3, 4, 5 Rationale
Answer & Rationale, Question 18 Correct answer: 1 Rationale The ECG represents sinus bradycardia in which the heart rate is less than 60 beats per minute. Causes of sinus bradycardia include a hyper-effective heart (in well-conditioned athletes), excessive vagal stimulation (parasympathetic) from carotid sinus massage, vomiting, suctioning, Valsalva maneuvers (bearing down or gagging). Increased parasympathetic stimuli may result from hypoxia, inferior wall myocardial infarction, and medications such as beta-adrenergic blockers, calcium channel blockers, and digitalis. Lyme’s disease and hypothyroidism can also cause bradycardia. Clients with sinus bradycardia can be asymptomatic or symptomatic.
Answer & Rationale, Question 19 Correct answer: 1,2,4,5 Rationale Adrenocortical insufficiency is also known as Addison’s disease. It is caused by damage or dysfunction of the adrenal cortex. Causes of primary Addison’s disease include idiopathic immune dysfunction (majority of cases), tuberculosis, histoplasmosis, adrenalectomy, cancer, and radiation therapy to the abdomen. Causes of secondary Addison’s disease include steroid withdrawal, hypophysectomy, pituitary neoplasm, and high dose radiation of the pituitary gland or entire brain.
Answer & Rationale, Question 20 Correct Answer: 4 Rationale
How do you deal with CKD?Ten ways to manage kidney disease. Control your blood pressure.. Meet your blood glucose goal if you have diabetes.. Work with your health care team to monitor your kidney health.. Take medicines as prescribed.. Work with a dietitian to develop a meal plan.. Make physical activity part of your routine.. Aim for a healthy weight.. How do you get glomerulonephritis?Causes of glomerulonephritis
Glomerulonephritis is often caused by a problem with your immune system. Sometimes it's part of a condition such as systemic lupus erythematosus (SLE) or vasculitis. In some cases, it can be caused by infections, such as: HIV.
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