NCLEX Practice Exam 1 — Questions and Answers

Question 1: Which individual is at greatest risk for developing hypertension?

45 year-old African American attorney (Correct answer)
60-year-old Asian American shop owner
40-year-old Caucasian nurse
40-year-old Caucasian nurse

Correct answer: 45 year-old African American attorney

The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.

Question 2: A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first?

Acetylcysteine (mucomyst) for age per pharmacy
Start an IV Dextrose 5% with 0.33% normal saline to keep vein open
Activated charcoal per pharmacy
Gastric lavage PRN (Correct answer)

Correct answer: Gastric lavage PRN

Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids.

Question 3: Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?

angina at rest
thrombus formation (Correct answer)
dizziness
dizziness

Correct answer: thrombus formation

Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure.

Question 4: A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is:

Maintain fluid and electrolyte balance
Control nausea
Manage pain (Correct answer)
Prevent urinary tract infection

Correct answer: Manage pain

The immediate goal of therapy is to alleviate the client’s pain.

Question 5: What would the nurse expect to see while assessing the growth of children during their school age years?

Decreasing amounts of body fat and muscle mass
Little change in body appearance from year to year
Progressive height increase of 4 inches each year
Yearly weight gain of about 5.5 pounds per year (Correct answer)

Correct answer: Yearly weight gain of about 5.5 pounds per year

School age children gain about 5.5 pounds each year and increase about 2 inches in height.

Question 6: At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states “My blood pressure is usually much lower.” The nurse should tell the client to

go get a blood pressure check within the next 48 to 72 hours (Correct answer)
check blood pressure again in two (2) months
see the health care provider immediately
visit the health care provider within 1 week for a BP check

Correct answer: go get a blood pressure check within the next 48 to 72 hours

The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke. However, immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.

Question 7: The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission?

A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago. (Correct answer)
A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago.
An elderly client with a history of hypertension, hypercholesterolemia, and lupus, and was admitted with Stevens-Johnson syndrome that morning.
An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago

Correct answer: A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago.

The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.

Question 8: A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:

Should be taken in the morning (Correct answer)
May decrease the client’s energy level
Must be stored in a dark container
Will decrease the client’s heart rate

Correct answer: Should be taken in the morning

Thyroid supplement should be taken in the morning to minimize the side effects of insomnia

Question 9: A 3-year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?

Prepare the child for x-ray of upper airways
Examine the child’s throat
Collect a sputum specimen
Notify the healthcare provider of the child’s status (Correct answer)

Correct answer: Notify the healthcare provider of the child’s status

These findings suggest a medical emergency and may be due to epiglottises. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.

Question 10: In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation?

Polyphagia
Dehydration
Bed wetting (Correct answer)
Weight loss

Correct answer: Bed wetting

In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents.

Question 11: A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?

Trichomoniasis
Chlamydia (Correct answer)
Staphylococcus
Streptococcus

Correct answer: Chlamydia

Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.

Question 12: An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?

A middle-aged client who says “I took too many diet pills” and “my heart feels like it is racing out of my chest.”
A young adult who says “I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?”
An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 10. (Correct answer)
An elderly client who reports having taken a “large crack hit” 10 minutes prior to walking into the emergency room

Correct answer: An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 10.

Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opoid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future.

Question 13: When teaching a client with coronary artery disease about nutrition, the nurse should emphasize

Eating three (3) balanced meals a day
Adding complex carbohydrates
Avoiding very heavy meals (Correct answer)
Limiting sodium to 7 gms per day

Correct answer: Avoiding very heavy meals

Heavy meals increase the workload on the heart by diverting blood flow to the digestive system and increasing metabolic demand. For a client with coronary artery disease, this increased myocardial oxygen demand can precipitate angina or other cardiac events. Eating smaller, more frequent meals helps to reduce this cardiac strain, making it a safer nutritional approach.

Question 14: Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working?

The client complains of discomfort at the IV insertion site
The client complains of discomfort at the IV insertion site
The level of drug is 100 mL at 8 AM and is 80 mL at noon (Correct answer)
The level of the drug is 100 mL at 8 AM and is 50 mL at noon

Correct answer: The level of drug is 100 mL at 8 AM and is 80 mL at noon

A basal rate of 10 mL per hour means that over 4 hours (from 8 AM to noon), 40 mL of medication should have infused. If the drug level only decreased by 20 mL (from 100 mL to 80 mL), it indicates that the pump delivered less than half of the prescribed basal rate. This discrepancy strongly suggests that the pump is malfunctioning and not delivering the medication as ordered.

Question 15: The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response?

Electrical energy fields
Spinal column manipulation (Correct answer)
Mind-body balance
Exercise of joints

Correct answer: Spinal column manipulation

Chiropractic treatment is a healthcare profession focused on the diagnosis, treatment, and prevention of musculoskeletal disorders, particularly those affecting the spine. Chiropractors primarily use manual therapy, including spinal manipulation, to restore proper alignment and function of the body, believing this impacts overall health and well-being.

Question 16: The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention?

Decrease in level of consciousness (Correct answer)
Loss of bladder control
Altered sensation to stimuli
Emotional ability

Correct answer: Decrease in level of consciousness

A decrease in the level of consciousness (LOC) in a client post-CVA is a critical neurological change that can indicate worsening cerebral edema, increased intracranial pressure, or re-bleeding. This finding requires immediate assessment and intervention as it can rapidly lead to further brain damage, herniation, or other life-threatening complications.

Question 17: A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time?

Positive sweat test
Bulky greasy stools
Moist, productive cough (Correct answer)
Meconium ileus

Correct answer: Moist, productive cough

Cystic fibrosis is a progressive disease, and while a positive sweat test and meconium ileus are early indicators, and bulky greasy stools are common, a moist, productive cough typically develops later. This type of cough signifies significant lung damage and chronic infection, which usually progresses over time rather than being present at initial diagnosis in a young child.

Question 18: The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should

Place a call to the client’s health care provider for instructions
Send him to the emergency room for evaluation (Correct answer)
Reassure the client’s wife that the symptoms are transient
Instruct the client’s wife to call the doctor if his symptoms become worse

Correct answer: Send him to the emergency room for evaluation

Lethargy and confusion following a fall, especially in an elderly client, are red flag symptoms indicating a potential head injury such as a concussion or subdural hematoma. These neurological changes require immediate medical evaluation in an emergency room setting to diagnose the extent of injury and prevent further complications.

Question 19: Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test?

Client must be NPO before the examination
Enema to be administered prior to the examination
Medicate client with Lasix 20 mg IV 30 minutes prior to the examination
No special orders are necessary for this examination (Correct answer)

Correct answer: No special orders are necessary for this examination

A KUB (Kidney, Ureter, Bladder) radiograph is a plain X-ray of the abdomen used to visualize basic anatomical structures without the need for contrast. Therefore, it does not require any special client preparation such as NPO status, enemas, or specific medications prior to the examination.

Question 20: The nurse is giving discharge teaching to a client seven (7) days post myocardial infarction. He asks the nurse why he must wait six (6) weeks before having sexual intercourse. What is the best response by the nurse to this question?

“You need to regain your strength before attempting such exertion.”
“When you can climb 2 flights of stairs without problems, it is generally safe.” (Correct answer)
“Have a glass of wine to relax you, then you can try to have sex.”
“If you can maintain an active walking program, you will have less risk.”

Correct answer: “When you can climb 2 flights of stairs without problems, it is generally safe.”

The ability to climb two flights of stairs without experiencing chest pain or shortness of breath is a common and practical guideline for assessing a client's cardiac tolerance for activities like sexual intercourse after a myocardial infarction. This level of exertion indicates that the heart can safely handle the physiological demands of sexual activity. It provides a measurable benchmark for recovery.

Question 21: A triage nurse has these four (4) clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

A 2-month old infant with a history of rolling off the bed and has bulging fontanels with crying
A teenager who got a singed beard while camping (Correct answer)
An elderly client with complaints of frequent liquid brown colored stools
A middle-aged client with intermittent pain behind the right scapula

Correct answer: A teenager who got a singed beard while camping

A singed beard suggests potential airway involvement due to smoke inhalation or thermal injury, even if external burns appear minor. Airway compromise is a life-threatening emergency that can rapidly worsen, making this client the highest priority for immediate assessment and intervention to secure the airway.

Question 22: While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child’s developmental needs?

“I want to protect my child from any falls.”
“I will set limits on exploring the house.”
“I understand the need to use those new skills.” (Correct answer)
“I intend to keep control over our child.”

Correct answer: “I understand the need to use those new skills.”

Toddlers are in Erikson's stage of autonomy vs. shame and doubt, where they are driven to explore their environment and develop new skills. Acknowledging and supporting their need to use these new motor and cognitive abilities, even with supervision and safety measures, is crucial for fostering their independence and healthy development.

Question 23: The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is

Verify correct placement of the tube (Correct answer)
Check that the feeding solution matches the dietary order
Aspirate abdominal contents to determine the amount of last feeding remaining in stomach
Ensure that feeding solution is at room temperature

Correct answer: Verify correct placement of the tube

Verifying correct placement of the nasogastric tube is the most critical action before administering an enteral feeding. Incorrect placement, such as in the lungs, can lead to severe and potentially fatal complications like aspiration pneumonia. This step ensures patient safety and proper delivery of nutrition to the stomach or intestines.

Question 24: The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?

Narrowed QRS complex
Shortened “PR” interval
Tall peaked T waves (Correct answer)
Prominent “U” waves

Correct answer: Tall peaked T waves

Tall, peaked T waves are a classic electrocardiogram (EKG) finding indicative of hyperkalemia (high potassium levels). Since the client is receiving IV potassium, the appearance of this EKG pattern signals that the potassium infusion may be causing the client's potassium level to rise too high, warranting immediate discontinuation to prevent dangerous cardiac dysrhythmias.

Question 25: A nurse prepares to care for a 4-year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?

All striated muscles
The cerebellum (Correct answer)
The kidneys
The leg bones

Correct answer: The cerebellum

Rhabdomyosarcoma, a cancer of skeletal muscle, frequently occurs in the head and neck region in children. Tumors in this area, particularly parameningeal rhabdomyosarcomas, can invade or compress central nervous system structures, including the brain. Therefore, monitoring neurological function, such as cerebellar function (which controls balance and coordination), is crucial to detect potential complications or tumor progression.

Question 26: The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to

Achieve harmony
Maintain a balance of energy
Respect life
Restore yin and yang (Correct answer)

Correct answer: Restore yin and yang

In traditional Chinese medicine (TCM), health is fundamentally understood as a state of balance between the opposing forces of yin and yang. Illness is believed to arise from an imbalance or disruption of this vital equilibrium. Therefore, the primary goal of all TCM treatments is to restore the harmonious balance of yin and yang within the body to promote healing and well-being.

Question 27: During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mmHg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to

Increase fluids that are high in protein
Restrict fluids
Force fluids and reassess blood pressure (Correct answer)
Limit fluids to non-caffeine beverages

Correct answer: Force fluids and reassess blood pressure

The client's symptoms of decreased blood pressure, increased heart rate, and dizziness are indicative of hypovolemia or dehydration, which can be particularly concerning in cardiomyopathy. Forcing fluids can help increase circulating blood volume, potentially improving blood pressure and alleviating these symptoms. Reassessing blood pressure after fluid intake is essential to monitor the client's response and ensure improvement.

Question 28: The nurse prepares the client for insertion of a pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about:

Stroke volume
Cardiac output
Venous pressure
Left ventricular functioning (Correct answer)

Correct answer: Left ventricular functioning

A pulmonary artery catheter (Swan-Ganz) provides comprehensive hemodynamic monitoring, and its unique capability is to measure pulmonary artery wedge pressure (PAWP). PAWP is an indirect but accurate reflection of left ventricular end-diastolic pressure, thereby providing crucial information about the preload and overall functioning of the left ventricle.

Question 29: A nurse enters a client’s room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is

Start a peripheral IV
Initiate high-quality chest compressions (Correct answer)
Establish an airway
Obtain the crash cart

Correct answer: Initiate high-quality chest compressions

In a client with no pulse or respirations, the immediate priority after calling for help is to initiate high-quality chest compressions. Early and effective chest compressions are vital for maintaining blood flow to the brain and other vital organs, significantly improving the chances of survival during cardiac arrest.

Question 30: A client is receiving digoxin (Lanoxin) 0.25 mg daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?

Blood pressure 94/60 (Correct answer)
Heart rate 76
Urine output 50 ml/hour
Respiratory rate 16

Correct answer: Blood pressure 94/60

Metoprolol is a beta-blocker that can cause bradycardia and hypotension. Digoxin also slows the heart rate. A blood pressure of 94/60 mmHg is hypotensive, and administering metoprolol could further lower it, leading to hemodynamic compromise. This finding warrants immediate reporting to the healthcare provider before administering the medication.

Question 31: While assessing a 1-month-old infant, which finding should the nurse report immediately?

Abdominal respirations
Irregular breathing rate
Inspiratory grunt (Correct answer)
Increased heart rate with crying

Correct answer: Inspiratory grunt

An inspiratory grunt in an infant is a significant sign of respiratory distress. It indicates that the infant is trying to keep the alveoli open by exhaling against a partially closed glottis, which is an abnormal compensatory mechanism and requires immediate medical attention to assess and address the underlying respiratory issue.

Question 32: The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to

Excessive fetal weight
Low blood sugar levels
Depletion of subcutaneous fat
Progressive placental insufficiency (Correct answer)

Correct answer: Progressive placental insufficiency

Post-term pregnancy (post-mature fetus) carries risks primarily because the placenta begins to age and function less efficiently after the due date. This progressive placental insufficiency can lead to decreased oxygen and nutrient supply to the fetus, increasing the risk of fetal distress, meconium aspiration, and oligohydramnios.

Question 33: The nurse is caring for a client who had a total hip replacement four (4) days ago. Which assessment requires the nurse’s immediate attention?

I have bad muscle spasms in my lower leg of the affected extremity.
“I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.” (Correct answer)
“I have to use the bedpan to pass my water at least every 1 to 2 hours.”
“It seems that the pain medication is not working as well today.”

Correct answer: “I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.”

Sudden shortness of breath and a feeling of impending doom in a client post-total hip replacement are classic and critical signs of a pulmonary embolism (PE). PE is a life-threatening complication often caused by deep vein thrombosis (DVT) following orthopedic surgery and requires immediate medical intervention.

Question 34: A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?

Weight gain of 5 pounds
Edema of the ankles
Gastric irritability
Decreased appetite (Correct answer)

Correct answer: Decreased appetite

Furosemide (Lasix) is a loop diuretic that can cause electrolyte imbalances, particularly hypokalemia. Hypokalemia can manifest as gastrointestinal symptoms like decreased appetite, nausea, vomiting, and muscle weakness. Therefore, a decreased appetite in a client taking furosemide could indicate an electrolyte imbalance requiring further assessment and intervention.

Question 35: A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?

Gravida 4 para 2
Gravida 2 para 1
Gravida 3 para 1 (Correct answer)
Gravida 3 para 2

Correct answer: Gravida 3 para 1

Gravida refers to the total number of pregnancies, including the current one, the twins (one pregnancy), and the miscarriage (one pregnancy), totaling 3. Para refers to the number of pregnancies carried to viability (typically 20 weeks or more). The twins represent one viable pregnancy, while the miscarriage at 12 weeks does not count towards para. Thus, Gravida 3 Para 1.

Question 36: The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?

Apply dressing using sterile technique
Improve the client’s nutritional status (Correct answer)
Initiate limb compression therapy
Begin proteolytic debridement

Correct answer: Improve the client’s nutritional status

Optimal nutritional status is fundamental for effective wound healing. Adequate intake of protein, vitamins (especially C and A), and minerals (like zinc) is crucial for tissue repair, collagen synthesis, and immune function. Without proper nutrition, the body lacks the essential building blocks to repair tissue, making local wound care less effective in promoting healing of a venous stasis ulcer.

Question 37: A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?

Raise the side rails on the bed
Place the call bell within reach
Instruct the client to remain in bed
Have the client empty bladder (Correct answer)

Correct answer: Have the client empty bladder

Pre-operative medications like meperidine and promethazine can cause drowsiness and sedation, making it unsafe for the client to ambulate to the bathroom after administration. Atropine can also cause urinary retention. Therefore, having the client empty their bladder *before* administering these medications is a priority to ensure comfort, safety, and prevent complications like urinary retention.

Question 38: Which of these statements best describes the characteristic of an effective reward-feedback system?

Specific feedback is given as close to the event as possible (Correct answer)
Staff is given feedback in equal amounts over time
Positive statements are to precede a negative statement
Positive statements are to precede a negative statement

Correct answer: Specific feedback is given as close to the event as possible

Effective reward-feedback systems are designed to reinforce desired behaviors. Providing specific feedback immediately after an event helps individuals clearly connect their actions to the consequences, making the feedback more impactful and actionable. This immediacy and specificity are crucial for learning and behavior modification, as it allows for timely adjustments and strengthens the link between performance and outcome.

Question 39: A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which

Increase the heart rate
Lead to dehydration (Correct answer)
Are considered aerobic
May be competitive

Correct answer: Lead to dehydration

For clients with multiple sclerosis, thermoregulation can be impaired, making them more susceptible to heat intolerance and dehydration during exercise. Dehydration can exacerbate MS symptoms like fatigue and weakness, and can also lead to heat stroke, posing a serious health risk. Therefore, avoiding activities that lead to dehydration is a critical safety precaution to maintain the client's well-being during an exercise program.

Question 40: During the evaluation of the quality of home care for a client with Alzheimer’s disease, the priority for the nurse is to reinforce which statement by a family member?

At least two (2) full meals a day is eaten.
We go to a group discussion every week at our community center
We have safety bars installed in the bathroom and have 24-hour alarms on the doors. (Correct answer)
The medication is not a problem to have it taken three (3) times a day.

Correct answer: We have safety bars installed in the bathroom and have 24-hour alarms on the doors.

For a client with Alzheimer's disease, safety is the paramount concern in home care due to cognitive decline and increased risk of accidents. Installing safety bars prevents falls in the bathroom, a common hazard, and 24-hour alarms on doors address wandering, a frequent and dangerous behavior. These measures directly mitigate significant risks, making this statement the priority for the nurse to reinforce as it ensures the client's physical protection.

NCLEX Practice Exam 1

Which individual is at greatest risk for developing hypertension?