NCLEX Exam Practice Question of the Week - 12/28/11

Elsevier NCLEX Exam Review

Question: A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse would document the GTPAL for this client as:


1.  G = 3, T = 2, P = 0, A = 0, L = 1
2.  G = 2, T = 1, P = 0, A = 0, L = 1
3.  G = 1, T = 1, P = 1, A = 0, L = 1
4.  G = 2, T = 0, P = 0, A = 0, L = 1

NCLEX Exam Practice Question of the Week - 12/21/11

Elsevier NCLEX Exam Review

Question: The mother of a 15-month-old child who is immunosuppressed asks about continuation of the childhood vaccines. Which immunizations are not recommended to be given to the child during immunosuppression?


1 Diphtheria, tetanus, and pertussis (DTaP); hepatitis B
2 Haemophilus influenzae B
3 Varicella; measles, mumps, and rubella (MMR)
4 Inactivated polio; diphtheria, tetanus, and pertussis (DTaP)

NCLEX Exam Practice Question of the Week - 12/14/11

Elsevier NCLEX Exam Review

Question: A nurse is assessing a 3-week-old infant admitted to the pediatric unit with hydrocephalus. What finding identifies a complication requiring immediate attention?


1. Tense anterior fontanel
2. Uncoordinated eye/muscle movement
3. Larger head circumference than chest circumference
4. Inability to support the head while in the prone position

NCLEX Exam Practice Question of the Week - 12/7/11

Elsevier NCLEX Exam Review

Question: Which intervention is most appropriate for a client diagnosed with a schizoid personality disorder?


1. Assist the client to enter a group recreation activity.
2. Convince the client that the nursing staff is trying to be helpful.
3. Help the client learn to trust the staff through selected experiences.
4. Arrange the unit environment so that contact with other clients is limited.

NCLEX Exam Practice Question of the Week - 11/30/11

Elsevier NCLEX Exam Review

Question: What will the nurse teach the client with diabetes regarding exercise in his or her treatment program?          


1. During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insulin                 
2. With an increase in activity, the body will use more carbohydrates; therefore more insulin will be required                           
3. The increase in activity results in an increase in the use of insulin; therefore the client should decrease his or her carbohydrate intake                                                                                    
4. Exercise will improve pancreatic circulation and stimulate the islets of Langerhans to increase the production of intrinsic insulin

NCLEX Exam Practice Question of the Week - 11/23/11

Elsevier NCLEX Exam Review

Question: A practitioner plans to have a client with the diagnosis of bipolar disorder continue taking lithium after discharge. The nurse identifies that the teaching about the medication plan is understood when the client states "I know that this medication:   



1. should be stopped if illness is suspected."                                      
2. may need to be taken for the rest of my life."                                    
3. causes no serious side effects when taken correctly."                     
4. will require me to increase the dosage at the beginning of a manic episode."

NCLEX Exam Practice Question of the Week - 11/16/11

Elsevier NCLEX Exam Review

Question: A nurse is teaching a community group about a low-fat, low-sodium diet. Which menu choices would be appropriate? (Select all that apply.)                                                              


1. Fresh fruit platter with a glass of skim milk                                      
2. Tuna salad with mayonnaise dressing and saltine crackers            
3.Cheeseburger with lettuce and tomato, and french fries                          
4. Ham and cheese sandwich on white bread, and chicken soup           
5. Baked chicken without the skin, rice, and steamed asparagus

NCLEX Exam Practice Question of the Week - 11/9/11

Elsevier NCLEX Exam Review

Question: An infant has just returned to the nursing unit after a surgical  repair of a cleft lip on the right side. The nurse places the infant in which best position at this time?                                         



1. Prone position                                                                                           
2. On the stomach                                                                                        
3. Left lateral position                                                                                    
4. Right lateral position

NCLEX Exam Practice Question of the Week - 11/2/11

Elsevier NCLEX Exam Review

Question: A multipara is admitted to the birthing room in active labor. Her vital signs are temperature, 98° F; pulse, 70 beats per minute; respirations, 18 per minute; and blood pressure, 126/76. A vaginal examination reveals a cervix that is 90% effaced and 7cm dilated with the vertex presenting at 2+ station. The client is complaining of pain and asks for medication. Which medication should be avoided because it may cause respiratory depression in the newborn?                                                                                             



1. Naloxone (Narcan)                                                                                  
2. Lorazepam (Ativan)                                                                                 
3. Meperidine (Demerol)                                                                             
4. Promethazine (Phenergan)

NCLEX Exam Practice Question of the Week - 10/26/11

Elsevier NCLEX Exam Review

Question: On the first postoperative day the nurse assesses a client's colostomy stoma and notes that it is moist and dark pink with no obvious drainage. Which action should the nurse consider taking?                                                                                    


1. Document the normal findings.                                                             
2. Consult the enterostomal therapist.                                                      
3. Irrigate the ostomy with normal saline.                                                
4. Palpate the abdomen around the stoma.

NCLEX Exam Practice Question of the Week - 10/19/11

Elsevier NCLEX Exam Review

Question: To prevent complications of immobility, what would be the most effective activities to implement for a client on the first postoperative day after a colon resection?    


1. Turn, cough, and deep-breathe every 30 minutes around the clock                                                                                                              
2. Get the client out of bed and ambulate to a bedside chair                  
3. Provide passive range of motion three times a day                           
4. Immobility is not a concern on the first postoperative day

NCLEX Exam Practice Question of the Week - 10/12/11

Elsevier NCLEX Exam Review

Question: Nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring?             


1. 5 minutes                                                                                                    
2. 15 minutes                                                                                                
3. 40 minutes                                                                                                  
4. 45 minutes

NCLEX Exam Practice Question of the Week - 10/5/11

Elsevier NCLEX Exam Review

Question: A 38-year-old gravida VII, para VI woman has just delivered an 8 pound, 5 ounce newborn. What complication should the nurse monitor for during the fourth stage of labor?

1. Uterine shock                                                                                          
2. Uterine atony                                                                                          
3. Uterine involution                                                                                     
4. Cardiogenic shock

NCLEX Exam Practice Question of the Week - 09/28/11

Elsevier NCLEX Exam Review

Question: During a well-woman physical examination, a young woman is diagnosed with a primary genital herpes lesion. When completing the client's history, the nurse would anticipate the client to report:                                                                                



1. Anuria                                                                                                        
2. Pruritus                                                                                                        
3. Leukorrhea                                                                                               
4. Dyspareunia

NCLEX Exam Practice Question of the Week - 09/21/11

Elsevier NCLEX Exam Review

Question: A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 100 beats/min. The nurse determines that the client is experiencing which of the following dysrhythmias?             

1. Sinus tachycardia                                                                                      
2. Ventricular fibrillation                                                                            
3. Ventricular tachycardia                                                                        
4. Premature ventricular contractions

NCLEX Exam Practice Question of the Week - 09/14/11

Elsevier NCLEX Exam Review

Question: A client who has an above-the-knee amputation is fitted with a prosthesis. The nurse evaluates the client's response to the prosthesis. Which indicates that the prosthesis fits the residual limb correctly?                                                                            


1. Absence of phantom limb sensation                                                  
2. Uneven wearing down of the heels of the shoes                                
3. Shrinkage of the end portion of the residual limb                          
4. Darkened skin areas surrounding the end of the residual limb

NCLEX Exam Practice Question of the Week - 09/7/11

Elsevier NCLEX Exam Review

Question: A client addicted to narcotics has a daily appointment to receive methadone hydrochloride. The nurse understands that methadone:                                                                                                

1. Allows symptom-free detoxification of narcotic addiction.             
2. Converts narcotic use from an illicit to a legally controlled drug.
3. Provides postoperative pain control without causing narcotic dependence.                                                                                              
4. Counteracts the depressive effects of long-term opiate use on cardiac muscle.

NCLEX Exam Practice Question of the Week 08/31

Elsevier NCLEX Exam Review

Question: A client with a diagnosis of acute coronary syndrome is on a cardiac monitor. The nurse interprets the monitor rhythm to be ventricular tachycardia at a rate of 160 beats/min. The client is awake and coherent, and oxygen is being administered at a rate of 6 L/min via a nasal cannula. What is the first nursing action?  



1. Immediately defibrillate                                                                       
2. Administer lidocaine IV push                                                               
3. Initiate transvenous pacing                                                                 
4. Administer adenosine IV push

NCLEX Exam Practice Question of the Week 08/24

Elsevier NCLEX Exam Review

Question: A nurse expects a child with a diagnosis of reactive attachment disorder to:                                                                             


1. Have been physically abused                                                          
2. Try to cling to the mother on separation                                           
3. Be able to develop just superficial relationships with others                                                                                                        
4. Have a more positive relationship with the father than with the mother

NCLEX Exam Practice Question of the Week - 08/17

Elsevier NCLEX Exam Review

Question: A nurse is caring for a client in labor.  The nurse determines that the client is beginning the second stage of labor when which of the following assessments is noted?
1. The contractions are regular.
2. The membranes have ruptured.
3. The cervix is dilated completely.
4. The client begins to expel clear vaginal fluid.

NCLEX Exam Practice Question of the Week - 08/10/11

Elsevier NCLEX Exam Review

 Question: After a grand mal seizure, what nursing action is the highest priority?

1. Loosen or remove constricting clothing and protect client from injuring himself or herself.
2. Maintain a patent airway by turning the client on his side and suctioning, if necessary.
3. Remain with the client and administer anticonvulsant medications as ordered by the physician.
4. Describe and record events before the onset of the seizure, during the seizure, and after the seizure.

NCLEX Exam Practice Question of the Week - 08/03/11

Elsevier NCLEX Exam Review

 Question: When a recently hospitalized client has a tentative diagnosis of opioid addiction, the nurse should assess the client for signs and symptoms related to opioid withdrawal. List them in the order that they will occur as the client progresses through withdrawal.

1. Runny nose
2. Muscle twitching
3. Return of appetite
4. Flulike syndromes

NCLEX Exam Practice Question of the Week - 07/27/11

Elsevier NCLEX Exam Review

Question: The nurse is evaluating the status of the client who had a craniotomy 3 days ago. The nurse would suspect that the client is developing meningitis as a complication of surgery if the client exhibits:

1. A negative Kernig sign
2. Absence of nuchal rigidity
3. A positive Brudzinski sign
4. A Glasgow Coma Scale score of 15

NCLEX Exam Practice Question of the Week 07/20

Elsevier NCLEX Exam Review

Question: Which structural defect should a nurse suspect in a newborn with excessive salivation and drooling, accompanied by coughing and choking?

1. Cleft lip
2. Cleft palate
3. Pyloric stenosis
4. Tracheoesophageal fistula

NCLEX Exam Practice Question of the Week 07/13

Question: The doctor has indicated that ampicillin and gentamicin are to be given piggyback in the same hour, every 6 hours (12-6-12-6). How would the nurse administer these drugs?

1. Give both drugs together IV push.
2. Give each drug separately, flushing between drugs
3. Retrograde both drugs into the tubing
4. Give one drug every 4 hours and one every 6 hours.

NCLEX Exam Practice Question of the Week 07/06

Question: The nurse teaches a pregnant client why she needs a folic acid supplement. Which neonatal disorder does this prevent?

1. Phenylketonuria
2. Down syndrome
3. Neural tube defects
4. Erythroblastosis fetalis

NCLEX Exam Practice Question of the Week 06/29

Elsevier NCLEX Exam Review
Question: The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/min. Which of the following would be a correct interpretation based on these characteristics?

1. Sinus bradycardia
2. Sick sinus syndrome
3. Normal sinus syndrome
4. First-degree heart block

NCLEX Exam Practice Question of the Week 06/22

Elsevier NCLEX Exam Review

Question: A 40-year-old woman has been diagnosed with hepatitis A and asks the nurse if other members of her family are at risk for "catching" the disease. The nurse's response should be based on the understanding that hepatitis A is transmitted primarily:

1. during sexual intercourse
2. by contact with infected body secretions.
3. through fecal contamination of food or water.
4. through kissing that involves contact with mucous membranes.

NCLEX Exam Practice Question of the Week 06/15

Elsevier NCLEX Exam Review

Question: The nurse is caring for a client who has exophthalmos associated with her thyroid disease. What is the cause of exophthalmos?

1. Fluid and edema in the retro-orbital tissues, which increases pressure behind the eyes
2. Impaired vision, which causes the client to squint in order to focus
3. Increased intraocular pressure from an increase in circulating thyroid
4. Decrease in extraocular eye movements, which results in the "thyroid stare"

NCLEX Exam Practice Question of the Week - 06/08/11

Elsevier NCLEX Exam Review

Question: A practitioner orders additional diagnostic studies to assess a client's acid-base status. The laboratory value that indicates metabolic acidosis is:

1. Urine pH of 8.4
2. Gastric content pH of 6.0
3. Venous serum pH of 7.28
4. Arterial plasma pH of 7.40

NCLEX Exam Practice Question of the Week - 06/01/11

Elsevier NCLEX Exam Review

Question: A nurse is caring for a child after spinal fusion for scoliosis treatment. The child complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. Based on these findings, the nurse should take which action?

1. Notify the physician.

2. Administer an antiemetic.

3. Increase the intravenous fluids.

4. Place the child in a Sims' position.

NCLEX Exam Practice Question of the Week - 05/25/11

Elsevier NCLEX Exam Review

Question: When a client is taking theophylline (Theo-Dur), which is the highest priority for the nurse to include in the plan of care?

1. Restrict the client's fluid intake.

2. Instruct the client to report lethargy and fatigue.

3. Assess the client for hypertension and polyuria.

4. Monitor the client for therapeutic plasma levels of the drug.

NCLEX Exam Practice Question of the Week - 05/18/11

Elsevier NCLEX Exam Review

Question: When talking with a client who has been receiving paroxetine (Paxil), the nurse identifies that more clarification is needed when the client states:

1. "I will be a little drowsy in the mornings."
2. "I'm expecting to feel somewhat better but I may need other therapy."
3. "I've been on the medication for 8 days now and I don't feel any better."
4. "I know I will probably have to take this medication for several months."

NCLEX Exam Practice Question of the Week - 05/11/11

Elsevier NCLEX Exam Review

Question: The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify that which client is most typical of a victim of abuse?

1. A 75-year-old man with moderate hypertension.
2. A 68-year-old man with newly diagnosed cataracts
3. A 90-year-old woman with advanced Parkinson's disease
4. A 70-year-old woman with early diagnosed Lyme disease

NCLEX Exam Practice Question of the Week - 05/04/11

Elsevier NCLEX Exam Review

Question: What is the priority nursing action for the client who is complaining of nausea in the recovery room after gastric resection?

1. Evaluate the nasogastric tube for patency.
2. Call the physician for the antiemetic order.
3. Place client in semi-Fowler's position so that he will not aspirate.
4. Medicate the client with a narcotic analgesic.

NCLEX Exam Practice Question of the Week - 04/27/11

Elsevier NCLEX Exam Review

Question: A nurse is assessing the family dynamics of a suspected abusive family. What behavior is expected? Select all that apply.

1. Child cringes when approached
2. Child has unexplained healed injuries
3. Parents are overly affectionate toward the child
4. Child lies still while surveying the environment
5. Parents give detailed accounts of the child's injuries

NCLEX Exam Practice Question of the Week - 04/20/11

Elsevier NCLEX Exam Review

Question: A nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which of the following findings?

1. Inflammation
2. Serous drainage
3. Pain at a pin site
4. Purulent drainage

NCLEX Exam Practice Question of the Week - 04/13/11

Elsevier NCLEX Exam Review

Question: A lecithin-sphingomyelin (L/S) ratio is ordered for a primigravida client at 35 weeks' gestation. What is the goal of this test?

1. To determine fetal lung maturity.
2. To evaluate the level of maternal-fetal estriol production
3. To check the position of the fetal head
4. To test the intrauterine fetal-placental circulation

NCLEX Exam Practice Question of the Week - 04/06/11

Elsevier NCLEX Exam Review

Question: A client gives birth to a full-term newborn with an 8/9 Apgar score. List the initial nursing care in order of their priority.

1. Place in heated crib

2. Perform physical assessment

3. Apply identification band to mother and infant

4. Instill antibiotic prophylaxis and administer vitamin K

NCLEX Exam Practice Question of the Week - 03/30/11

Question: The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instruction(s) should the nurse provide? Select all that apply.

1. Use sunscreen when participating in outdoor activities.

2. Wear a hat, opaque clothing, and sunglasses when in the sun.

3. Avoid sun exposure in the late afternoon and early evening hours.

4. Examine your body monthly for any lesions that may be suspicious.

5. Sunscreen should be applied every 8 hours.

NCLEX Exam Practice Question of the Week - 03/23/11

Question: The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would be appropriate nursing interventions with this client? Select all that apply.

1. Use active listening skills to seek information from the client.
2. Encourage the client to describe the problem as she sees it.
3. Ask the client to tell you exactly what she thinks is happening.
4. Tell the client that she is delusional and you can help her.
5. Explain to the client that most people are not investigated by the CIA or FBI.
6. Reassure the client that you are not with the CIA.

NCLEX Exam Practice Question of the Week - 03/16/11

Question: A client with Crohn's disease is admitted to the hospital with a history of chronic, bloody diarrhea, weight loss, and signs of general malnutrition. The client has anemia, a low serum albumin level, and signs of negative nitrogen balance. The nurse concludes that the client's health status is related to a major deficiency of:

1. Iron
2. Protein
3. Vitamin C
4. Linoleic acid

NCLEX Exam Practice Question of the Week - 03/09/11

Question: A nurse has conducted discharge teaching with a client diagnosed with tuberculosis. The client has been taking medication for 11⁄2 weeks. The nurse evaluates that the client has understood the information if the client makes which of the following statements?

1. "I need to continue drug therapy for 2 months."
2. "I can't shop at the mall for the next 6 months."
3. "I can return to work if a sputum culture comes back negative."
4. "I should not be contagious after 2 to 3 weeks of medication therapy."

NCLEX Exam Practice Question of the Week - 03/02/11

Question: While a client's wife is visiting she observes the client's chest drainage system and begins to nervously question the nurse regarding the amount of bloody drainage in the system. What is the best response from the nurse?

1. "Your husband has been really sick; this must be a very difficult time. Let's sit down and talk about it."
2. "I have checked all of the equipment and it is working fine; you do not need to worry about it."
3. "The system is draining collected fluid from around the lungs. The drainage is expected and does not mean that he is bleeding."
4. "The chest tube is draining the secretions from his chest; it is important for him to deep-breathe frequently."