NCLEX Health Care Assessment Practice Exam With Answers (1200 Solved Questions)

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HURST REVIEW NCLEX-RN Readiness
Exam 1, Hurst Practice Exam 2, Hurst
Review Test # 3,
The primary healthcare provider has prescribed phenytoin 100 mg intravenous push
(IVP) stat for an adult client. What is the least amount of time that the nurse can safely
administer this medication?
1. 1 minute
2. 2 minutes
3. 5 minutes
4. 10 minutes - 2. Correct: The rate of IV administration should not exceed 50 mg/min.
for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients
because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can
safely be delivered over a period of at least 2 minutes.
1. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and
1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the
risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered
over a period of at least 2 minutes. Giving this dose over only one minute could lead to
these or other potential harmful effects.
3. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and
1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the
risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered
over a period of at least 2 minutes. Five minutes would be longer than required to be
able to safely administer the medication.
4. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and
1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the
risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered
over a period of at least 2 minutes. Ten minutes is much longer than required to be able
to safely administer the medication.
A client, hospitalized with possible acute pancreatitis secondary to chronic cholecystitis,
has severe abdominal pain and nausea. The client is kept NPO, an NG tube is inserted,
and IV fluids are being administered. What is the rationale for the client being NPO with
an NG tube to low suction?
1. Relieve nausea
2. Reduce pancreatic secretions
3. Control fluid and electrolyte imbalance

4. Remove the precipitating irritants - 2. Correct: In clients with pancreatitis, the
pancreatic enzymes cannot exit the pancreas. These enzymes, when activated, begin
to digest the pancreas itself. The enzymes become activated in the pancreas when fluid
or food accumulates in the stomach. The goal in treating this client is to stop the
activation of the pancreatic enzymes. Treatment is focused on keeping the stomach
empty and dry. This allows the pancreas time to rest and heal. Note: Autodigestion
(pancreas digesting itself) is painful for the client and can lead to other problems such
as bleeding.
1. Incorrect: The primary purpose of the NG tube to suction is to keep the stomach
empty and dry to decrease pancreatic enzyme production, not to relieve nausea.
3. Incorrect: Because gastric contents are removed, the NG tube to suction may lead to
fluid and electrolyte disturbances rather than helping to control them.
4. Incorrect: Although the food in the stomach causes the pancreatic enzymes to
become activated in the pancreas due to the obstruction, the food is not considered an
irritant. Precipitating irritants are not a part of the pathophysiology occurring with
pancreatitis.
The nurse is working with a committee at the local school to develop an emergency
preparedness plan for tornados. What should be included in the plan?
1. Identification of safe zones.
2. Methods for accounting for all people present in the building.
3. Warning system activation.
4. Identification of the gymnasium as the routine safe place.
5. Regular practice protocols. - 1., 2., 3. & 5. Correct: Everyone should be aware of
safe zones within the school. Personnel should be given this information and signs
posted in safe zones. There must be systems in place to accurately determine the
number of people in the building at any given time. There also must be a system in
place to alert personnel and students of tornado warnings. Regular practice prepares
everyone for an actual event.
4. Incorrect: Gymnasiums are not considered safe places due to wide expanse of roof.
Safe zones should be on interior walls, no windows, and a strong concrete floor if
possible.
What should a nurse teach family members prior to them entering the room of a client
who has agranulocytosis?
1. Meticulous hand washing is needed.
2. Do not visit if you have any infection.
3. The client must wear a mask.
4. Children under 12 may not visit.
5. Flowers are not allowed in the room. - 1., 2., 4., & 5. Correct: Protective isolation is
needed for this client because of the presence of a low white blood cell count. We are
protecting the client from acquiring an infection. So any visitors will need to have

meticulous hand washing prior to entering. The visitor should not enter if he or she has
any type of infection. To decrease the risk of infection, small children should not visit.
Even the mildest symptom of infection could be detrimental to the client. Flowers have
bacteria and should not be brought into the room.
3. Incorrect: A mask must be worn by the visitor, not the client. The mask is worn by
visitors to prevent a possible spread of an airborne infection to the
immunocompromised client.
A client diagnosed with major depression has been taking a selective serotonin
reuptake inhibitor for the past 6 weeks. When visiting the mental health center, the
nurse discusses the medication and response with the client. The nurse's assessment
reveals that the client is confused about the date and about the prescribed dosage of
the medication. Which question would be most important for the nurse to ask to further
assess the situation?
1. Are you having trouble sleeping at night?
2. Do you have periods of muscle jerking?
3. Are you having any sexual dysfunction?
4. Is your mood improving? - 2. Correct: Myoclonus, high body temperature, shaking,
chills, and mental confusion are some of the symptoms of serotonin syndrome. This
client may be having symptoms of this adverse reaction which, if severe, can be fatal.
1. Incorrect: Sleep disturbances are common with depression. Selective serotonin
reuptake inhibitors (SSRIs) may cause insomnia; however, there is a more pertinent
question needed for assessment of this client. You should be concerned with the more
serious or life-threatening issue.
3. Incorrect: Sexual dysfunction may occur with the SSRIs; however, the client is
exhibiting significant symptoms of an adverse reaction which would take priority.
4. Incorrect: The response to the SSRI medications is important; however, there is a
more significant issue in this case. The possible serotonin syndrome is a serious
situation that would be the priority for the nurse to address.
A client diagnosed with serotonin syndrome is admitted to the unit. The nurse is familiar
with this adverse reaction to the serotonin reuptake inhibitors. Which symptoms can the
nurse expect on assessment?
1. Fever and shivering
2. Agitation
3. Decreased body temperature
4. Constipation
5. Increased heart rate - 1., 2. & 5. Correct: Serotonin syndrome is a group of
symptoms that can result from the use of certain serotonin reuptake inhibitors. These
symptoms can range from mild to severe and include high body temperature, agitation,
increased reflexes, diaphoresis, tremors, dilated pupils and diarrhea. The client is likely
to experience shivering with fever. Increased heart rate and blood pressure are also

commonly experienced. More severe symptoms, including muscle rigidity and seizures,
can occur. If not treated, serotonin syndrome can be fatal.
3. Incorrect: Increased body temperature is expected as is increased diaphoresis.
4. Incorrect: Diarrhea, not constipation, is a symptom of serotonin syndrome.
The emergency department nurse is assessing a client who presents with severe
epigastric pain. The client reports that three rolls of calcium carbonate were consumed
in the past eight hours to treat the indigestion. Which blood gas report does the nurse
associate with this situation?
1. pH - 7.49, pCO2 - 40, HCO3 - 30
2. pH - 7.32, pCO2 - 48, HCO3 - 20
3. pH - 7.38, pCO2 - 52, HCO3 - 32
4. pH - 7.29, pCO2 - 54, HCO3 - 26 - 1. Correct: These ABGs are indicative of
metabolic alkalosis. The pH is high, the pCO2 is within normal limits and the bicarb is
high (alkalosis). So, the excess Tums (calcium carbonate) could have caused metabolic
alkalosis.
2. Incorrect: The client is not hypoventilating and would not be in metabolic acidosis
because he ate 3 rolls of Tums which is a base. These ABGs are indicative of acidosis.
The pH is low (acidosis), the pCO2 is high (acidosis) and the bicarb is low (acidosis).
3. Incorrect: The client is not a long-term COPD client as these ABGs might suggest.
These ABGs are indicative of fully compensated respiratory acidosis. The pH is normal.
The pCO2 is high (as with chronic retention) and the bicarb is high to help compensate.
4. Incorrect: These ABGs are the result of an acute ventilation problem. They are
indicative of respiratory acidosis. The pH is low, the pCO2 is high, and the bicarb is
normal. No compensation has begun at this point.
Which prescriptions would the nurse recognize as being appropriate for the client with
shingles?
1. Private room
2. Negative pressure airflow
3. Respirator mask
4. Face Shield
5. Positive pressure room - 1., 2. & 3. Correct: According to the current standards of
Standard Precautions per the CDC, the client with shingles should be placed on
airborne precautions which require the use of a private room with negative pressure
airflow and a N-95 respirator mask.
4. Incorrect: A face shield is used when there is risk of splashing or spraying of blood or
body fluids. This is not required for airborne precautions.

5. Incorrect: Negative pressure is required in order to prevent the airborne infection from
spreading outside of the room. Positive pressure is used only in protective environments
such as when immunocompromised clients require protection from potential infectious
agents outside of the room.
A healthy newborn has just been delivered and placed in the care of the nurse. What
nursing actions should the nurse initiate?
Place in the correct priority order.
Assess newborn's airway and breathing.
Bulb suction excessive mucus.
Assess newborn's heart rate.
Place identification bands on newborn and mom.
Administer sterile ophthalmic ointment containing 0.5% erythromycin. - Remember
Maslow's hierarchy of needs will guide your assessment. First, Assess newborn's
airway and breathing. The most critical change that a newborn must make
physiologically is the initiation of breathing. The nurse should assess the newborn's
crying. If the cry is weak, it may indicate a respiratory disturbance. Other signs of
respiratory compromise may include: stridor, grunting, retractions, apnea or diminished
breath sounds. Normal respiration are 30 - 60 breaths a minute.
Second, Bulb suction excessive mucus. It is important to assure that the throat and
nose are kept clean of secretions to prevent respiratory distress.
Third, Assess newborn's heart rate. If there is no respiratory distress, the nurse
continues the assessment by checking the heart rate and other vital signs.
Fourth, Place identification bands on newborn and mom. These are critical for ensuring
babies and moms will be appropriately matched at all times but does not take priority
over respiration and circulation.
Fifth, Administer sterile ophthalmic ointment containing 0.5% erythromycin. This is a
legally required prophylactic eye treatment to prevent Neisseria gonorrhea. However,
this would never be a priority over Maslow's hierarchy of needs.
What information should a nurse include when educating a client regarding buccal
administration of a medication?
1. This route allows the medication to get into the bloodstream faster than the oral route.
2. Stinging may occur after placing the medication in the cheek.
3. If swallowed, the medication may be inactivated by gastric secretions.
4. The buccal dose of medication will need to be increased from the oral dose.
5. Remove the tablet from buccal area after 15 seconds. - 1., 2., & 3. Correct: These
are correct statements about buccal administration of medication. Buccal administration

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involves the medication being placed between the gums and cheek, where it dissolves
and becomes absorbed into the bloodstream. The cheek area has many capillaries that
allow the medication to be absorbed quickly without having to pass through the
digestive system. The degree of stinging experienced depends on the medication being
administered. Some effects of certain medications can be lessened by digestive
processes.
4. Incorrect: When given by the buccal route, the medication does not go through the
digestive system. This means that the medication is not metabolized through the liver,
and thus a lower dose can be used.
5. Incorrect: Placement should be maintained until the tablet is dissolved in order to get
the dosage and effects desired.
Which signs and symptoms would the nurse expect to see in a client who has taken
prednisone for two months?
1. Weight loss
2. Decreased wound healing
3. Hypertension
4. Decreased facial hair
5. Moon face - 2., 3. & 5. Correct: Decreased wound healing is a side effect with
prolonged steroid use due to the immunosuppressive effects. All steroid medications,
such as prednisone, can lead to sodium retention which then leads to dose related fluid
retention. Hypertension is seen due to this fluid and sodium retention. Cushingoid
appearance (moon face) is a side effect that is created from the abnormal redistribution
of fat from prolonged steroid use.
1. Incorrect: Within one month after corticosteroid administration, weight gain is seen
rather than weight loss.
4. Incorrect: Facial and body hair increase with prolonged steroid use. This excessive
growth of body hair, known as hirsutism, is one of the numerous potential side effects of
prednisone.
A nurse is at highest risk for blood-borne exposure during which situation?
1. When removing a needle from the syringe.
2. While placing a suture needle into the self-locking forceps.
3. Prior to inserting the intravenous (IV) line, the client moves causing a needle stick to
the nurse.
4. A clean needle sticks the nurse through blood-soiled gloves. - 4. Correct: A clean
needle that moves through blood-soiled gloves to stick the nurse is considered to be
potentially contaminated and results in a blood-borne exposure. All other answers are
considered a clean stick.
1. Incorrect: This is considered a clean stick. The needle is sterile initially and has not
been contaminated prior to removal of the needle from the syringe.

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2. Incorrect: This is considered a clean stick since the suture needle has not been
inserted into the client prior to the needle stick.
3. Incorrect: This is considered a clean stick. The IV insertion device is sterile and has
not been contaminated since it was not inserted into the client.
A new nurse is preparing to give a medication to a nine month old client. After checking
a drug reference book, the nurse crushes the tablet and mixes it into 3 ounces of
applesauce. The new nurse proceeds to the client's room. What priority action should
the supervising nurse take?
1. Tell the new nurse to recheck the drug reference book before administering the
medication.
2. Suggest that the new nurse reconsider the client's developmental needs.
3. Check the prescription order and the client dose.
4. Observe the new nurse administer the medication. - 2. Correct: Mixing medication
with applesauce is appropriate in some circumstances, but the volume of 3 ounces is
excessive for a nine month old. The nurse will want to make sure the client gets all of
the medication. Additionally, applesauce may or may not have been introduced into the
diet, and it is inappropriate to introduce a new food during an illness.
1. Incorrect: There is nothing in the stem about a problem with the medication dose or
route.
3. Incorrect: There is nothing in the stem about a problem with the medication dose or
route.
4. Incorrect: This is an appropriate action. However, it is not the priority over ensuring
that the new nurse knows how to appropriately prepare the medication for this client.
An adult client has just returned to the nursing care unit following a gastroscopy. Which
intervention should the nurse include on the plan of care?
1. Vital sign checks every 15 min x 4
2. Supine position for 6 hours
3. NPO until return of gag reflex
4. Irrigate NG tube every 2 hours
5. Raise four side rails - 1., & 3. Correct: Vital signs post procedure are important to
monitor for any post-procedure complications such as bleeding or any signs of
respiratory compromise. VS are checked frequently for the first hour post procedure.
Any client who has a scope inserted down the throat and has received numbing
medication in the back of the throat to depress the gag reflex should be kept NPO until
the gag reflex returns.
2. Incorrect: Supine position for 6 hours is contraindicated. The HOB should be
elevated. In the event the client vomits, he/she is less likely to aspirate with the HOB
elevated. Supine position for 6 hours is used after a heart catheterization.

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4. Incorrect: A client who is going for a gastroscopy procedure cannot have a nasal
gastric tube. An NG tube would interfere with the procedure.
5. Incorrect: Raising all side rails is a form of restraint. Have the bed in low locked
position. Raise three side rails, and have call light within reach.
The family member of a schizophrenic client asks the nurse why the client is receiving
chlorpromazine and benztropine. What is the best response by the nurse?
1. The chlorpromazine makes the benztropine more effective so a smaller dose of both
drugs can be used.
2. Benztropine is given to treat the side effects produced by the chlorpromazine.
3. Chlorpromazine is used for severe hiccups that can occur with the use of
benztropine.
4. Chlorpromazine is used for psychosis and benztropine is used for preventing
agranulocytosis. - 2. Correct: Benztropine is used to treat parkinsonism of various
causes and drug-induced extrapyramidal reactions seen with chlorpromazine, which is
an antipsychotic agent. Extrapyramidal symptoms are neurologic disturbances in the
area of the brain that controls motor coordination. This disruption can cause symptoms
that mimic Parkinson's disease, including stiffness, rigidity, tremor, drooling and the
classic "mask like" facial expression. These symptoms can be treated and are reversible
using such medications as benztropine.
1. Incorrect: Chlorpromazine does not potentiate the effects of benztropine, so dosage
regulation is not appropriate.
3 Incorrect: Chlorpromazine can be used for severe hiccups, but the hiccups are not the
result of using benztropine. Chlorpromazine is also used for psychosis in the
schizophrenic client.
4. Incorrect:
Benztropine is not used to prevent agranulocytosis.
A nurse is planning to provide information regarding suicide to a high school assembly.
What information should the nurse include?
1. Do not keep secrets for the suicidal person.
2. Express concern for a person expressing thoughts of suicide.
3. Teens often don't mean what they say, so only take suicide seriously if grades are
dropping as well.
4. Inform group of suicide intervention sources.
5. Do not leave a suicidal person alone. - 1., 2., 4. & 5. Correct: If a person reveals that
suicide is being considered, this should never be kept secret. Help should be sought for
the person immediately. It is also important to be direct and non-secretive with suicidal
clients. It is appropriate to express concern for their thoughts. The use of empathy,
warmth and concern indicates to the client that their feelings are being understood and
viewed as real, which helps to build trust with the client. Resources for assistance are

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important to include in all health teaching programs. The teens need to know what
resources are readily available if someone is considering suicide. The client
contemplating suicide should not be left alone. This is for the client's safety until further
assistance can be obtained
3. Incorrect: Most clients who commit suicide have told at least one person that they
were contemplating suicide before thy actually committed the act. Therefore, suicidal
comments should be considered important risk factors that require evaluation, and all
comments should be taken seriously. Anyone expressing suicidal feelings needs
immediate attention.
The nurse is caring for a client who was admitted to the hospital following a severe
motor vehicle crash (MVC) in which the client was trapped in the car for several hours.
The client is being closely monitored for the development of renal failure. Which
assessment finding would warrant immediate reporting?
1. Creatinine 1.1 mg/dl (97.24 mmol/L)
2. Urinary output of 150 mL per hour.
3. Gradual increase of BUN levels.
4. Calcium levels of 9.0 mg/dL (2.25 mmol/L) - 3. Correct. Gradual accumulation of
nitrogenous wastes results in elevated BUN and serum creatinine. This is an indication
of impaired renal function.
1. Incorrect. This is a normal creatinine level. Gradual accumulation of nitrogenous
wastes from impaired renal function results in elevated BUN and serum creatinine.
2. Incorrect. This is a normal output level. This level alone would not necessarily be an
indicator of acute renal failure and that value alone would not warrant reporting it to the
primary healthcare provider.
4. Incorrect. Calcium level of 9.0 mg/dL (2.25 mmol/L) is considered normal. When
observing for renal functioning you would assess the BUN and creatinine levels. In
addition, the calcium level may drop (hypocalcemia) in renal failure inverse relationship
change due to the rising serum phosphate levels. However, the calcium level presented
is within normal limits (WNL).
A female client taking captopril for hypertension tells the clinic nurse that she is planning
to get pregnant. What recommendation should the nurse make?
1. "Captopril can be taken safely during pregnancy, but we will need to decrease your
dose so you do not become hypotensive."
2. "We will need to increase your dose of captopril once you become pregnant."
3. "In order to prevent neural tube defects, start taking folic acid."
4. "Captopril can cause serious harm to an unborn baby, so you must prevent
pregnancy while taking this medication. " - 4. Correct: Captopril should not be taken
during pregnancy because serious harm (possibly fatal) to the unborn baby can result
when taken during pregnancy.

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1. Incorrect: Captopril should not be taken during pregnancy because serious harm
(possibly fatal) to the unborn baby can result when taken during pregnancy.
2. Incorrect: Captopril should not be taken during pregnancy because serious harm
(possibly fatal) to the unborn baby can result when taken during pregnancy.
3. Incorrect: Captopril should not be taken during pregnancy because serious harm
(possibly fatal) to the unborn baby can result when taken during pregnancy. The
problem being presented in the stem is not related to general prevention of neural tube
defects. Folic acid would not prevent the harm to the fetus caused by captopril.
A client diagnosed with glomerulonephritis presents with generalized malaise, weight
gain, generalized edema, and flank pain. The primary healthcare provider prescribes
antibiotics and strict bedrest. What is the best explanation to give the client regarding
the strict bedrest prescription?
1. Promotes diuresis
2. Prevents injury
3. Promotes rest
4. Stimulates RBC production - 1. Correct: Bedrest and the supine position promote
diuresis. When the client is supine, there is a gradual shift of fluids away from the legs
toward the thorax, abdomen and head. This increased volume causes the right atrium of
the heart to stretch and release ANP, which leads to diuresis: renal blood flow increases
due to vasodilation, and aldosterone and ADH secretion are inhibited.
2. Incorrect: Bedrest can keep the client from falling and injuring self; however, that is
not why it has been prescribed.
3. Incorrect: Promotion of rest is good, but this is not why the primary healthcare
provider prescribed it. Simply promoting does not help improve the symptoms listed.
The reason the client needs bedrest should focus on relieving the symptoms listed in
the stem.
4. Incorrect: No relationship between bedrest and red blood cell production exists.
A newly admitted client with schizophrenia has an unkempt appearance and needs to
attend to personal hygiene. Which statement by the nurse is most therapeutic?
1. A shower will make you feel better.
2. It is time to take a shower.
3. Have you thought about taking a shower?
4. I need you to take a shower. - 2. Correct: Schizophrenia is a thought disorder. Many
clients with schizophrenia are concrete thinkers and have difficulty making decisions.
The nurse needs to be direct, clear and concise in communicating with the client. This is
a direct, clear and concise statement that guides the client to perform the needed
activity.

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1. Incorrect: Many clients with schizophrenia are concrete thinkers. The nurse needs to
be direct, clear and concise in communicating with the client. The client may not
comprehend how the shower improves the overall sense of well-being and would
remain reluctant to take the shower.
3. Incorrect: Clients diagnosed with schizophrenia often have trouble making decisions.
The client needs to be guided with simple, direct instructions.
4. Incorrect: This focuses on the nurse's need, not the client's need. Do not select
answers that focus on the nurse. This does not improve the client's decision making
ability nor does it provide guidance to the client for meeting the hygiene needs.
Which clients would be appropriate for the RN to assign to an LPN/LVN?
1. Seventy four year old client with unstable angina who needs teaching for a scheduled
cardiac catheterization.
2. Sixty year old client experiencing chest pain scheduled for a graded exercise test.
3. Forty eight year old client who is five days post right-sided cerebral vascular accident
(CVA).
4. Eighty four year old client with heart disease and mild dementia.
5. Newly admitted ninety year old client with decreased urinary output, altered level of
consciousness, and temperature of 100.8°F (38.2°C)
6. Sixty six year old client with chronic emphysema experiencing mild shortness of
breath. - 3., 4., 6. Correct: The client who is five days post CVA is one of the most
stable clients and could be assigned to the LPN/LVN. There is nothing in the option to
indicate that this client is unstable. There is no indication that the eighty-four year old
client with heart disease and dementia is unstable so this client can be assigned to the
LPN/LVN. The client with chronic emphysema will experience shortness of breath.
There is nothing to indicate that this client is unstable.
1. Incorrect: This client is unstable and should be cared for by the RN. Additionally, the
RN is responsible for teaching.
2. Incorrect: This client is experiencing chest pain and is thus considered unstable and
should be cared for by the RN.
5. Incorrect: This client has s/s that could indicate sepsis, so is considered unstable and
should not be assigned to the LPN/LVN.
While examining a client's health history, which data indicates to the nurse that the client
is at increased risk for developing cancer?
1. Family history
2. Alcohol consumption
3. Spicy diet
4. Human papillomavirus
5. Tobacco use - 1., 2., 4., & 5. Correct: Family history of cancer increases the risk for
having the same type of cancer. Alcohol and tobacco use increase the risk of cancer.

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When used together, they have a synergistic effect. Human papillomavirus (HPV)
increases the risk of cervical, head, and neck cancers.
3. Incorrect: Although there are some dietary factors associated with cancer
development, a spicy diet does not necessarily increase the risk of cancer.
A nurse is caring for a client admitted with chronic fatigue and weakness. During the
physical assessment, the nurse notes jaundiced sclera, abdominal distension, swelling
in the legs and ankles, and bruises in various stages of healing throughout the body.
What nursing interventions should the nurse initiate?
1. Measure abdomen
2. Monitor intake and output
3. Obtain daily weight
4. Place on fall precautions
5. Provide three meals per day
6. Dangle legs - 1., 2., 3., & 4. Correct: The symptoms presented are indicative of liver
disease. Measuring abdominal girth will monitor for accumulating ascitic fluid. Clients
with liver disease have fluid volume problems, so daily weight and I&O are indicated.
This client is at risk for injury related to chronic fatigue and weakness, so fall prevention
is indicated. The client may need help eating if fatigue is severe.
5. Incorrect: Poor tolerance to larger meals may be due to abdominal distension and
ascites. Clients should eat smaller, more frequent meals (6/day). The recommended
diet is high calorie and low sodium with protein regulated based on liver function.
Between meal snacks should be provided.
6. Incorrect: Elevating legs enhances venous return and reduces edema in extremities.
Dangling the leg would cause the fluid in the lower extremities to accumulate more.
A client experiencing chest pain is prescribed an intravenous infusion of nitroglycerin.
After the infusion is initiated, the occurrence of which symptom would prompt the nurse
to discontinue the nitroglycerin?
1. Frontal headache
2. Orthostatic hypotension
3. Decrease in intensity of chest pain
4. Cool, clammy skin - 4. Correct: This assessment finding of cool, clammy skin is an
indication of decreased cardiac output that could be the result of too much
vasodilatation. Cardiac output could continue to decrease if the nitroglycerin is not
discontinued.
1. Incorrect: A headache is an expected common side effect of nitroglycerin
administration. The headache is treated with medication.
2. Incorrect: A decrease in blood pressure when rising from a supine or sitting position is
a common effect of the vasodilatation that occurs with the administration of
nitroglycerin. The client should be advised to change positions slowly.

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3. Incorrect: The decrease in the intensity of the client's chest pain is the desired
outcome of the nitroglycerin administration.
During an assessment interview with a client, what alternative healing modalities should
the nurse inquire about?
1. "Tell me about your use of teas, herbs, and vitamins."
2. "What traditional or folk remedies are used in your family?"
3. "Do you meditate, pray, or use relaxation techniques for healing purposes?"
4. "What prescription medications are you taking?"
5. "What alternative therapies have you used?" - 1., 2., 3., & 5. Correct: These are all
inquiries the nurse should make when conducting an assessment interview in order to
find out about alternative healing modalities. Alternative or complementary medicine is
used to describe over 1800 therapies practiced around the world. Approximately 65 to
80% of the world's population use non-conventional (alternative) healing modalities.
These alternative healing modalities can be such things as: Natural products (herbs,
dietary supplements, etc.) mind and body practices (yoga, mediation, prayer, etc.), folk
remedies and other non-traditional practices.
4. Incorrect: Prescription medications would be part of traditional, western medicine.
Although the nurse needs to find out what prescription medications are being taken, it is
not part of alternative medicine.
The nurse in the emergency department suspects that a client's lesion is caused by
anthrax. What assessment question is most important?
1. Have you traveled out of the United States recently?
2. Have you recently worked with any farm animals or any animal-skin products?
3. Have you experienced any gastrointestinal upset recently?
4. Have you eaten any home-canned foods recently? - 2. Correct: Cutaneous anthrax
may be contracted by working with contaminated animal-skin products. Anthrax is found
in nature and commonly infects wild and domestic hoofed animals.
1. Incorrect: Cutaneous anthrax is also found in the United States, so asking about
travel abroad would not be necessary.
3. Incorrect: Cutaneous anthrax can be contracted by spores entering cuts or abrasions
in the skin. This is cutaneous anthrax that causes edema, itching and macule or papule
formation, resulting in ulceration. Ingestion of anthrax can cause GI symptoms such as
nausea and vomiting, abdominal pain, and bloody diarrhea. Inhalation of anthrax may
result in flu-like symptoms that progress to severe respiratory distress.
4. Incorrect: This question would be appropriate if botulism were suspected in a client.
When preparing a client for surgery, the nurse realizes the operative permit has not
been signed. The client tells the nurse he understands the procedure, but received his

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preoperative medication approximately 10 minutes ago. What would be the appropriate
action by the nurse?
1. Have the client sign the permit, as he verbalizes understanding.
2. Witness the form after having the client sign it.
3. Have his wife sign the form as she witnessed his statement that he understands.
4. Call the surgical area and explain that the surgery will have to be cancelled. - 4.
Correct: The client must sign the operative permit or any other legal document prior to
taking preoperative drugs that can affect judgment and decision-making capacity.
1. Incorrect: The client's verbal understanding does not override the fact that he has
received medication that can alter thought processes and decision-making.
2. Incorrect: Witnessing would not make this document legal. The consent would not be
valid because the client has already received the pain medication that could alter the
thought process.
3. Incorrect: When a client is of legal age (unless an emancipated minor) and of sound
mind, it would be inappropriate for the spouse to sign the form for surgery. In order to be
valid it must be the client who signs it, unless there is a legal power of attorney, durable
power of attorney, or healthcare surrogate.
A child is being admitted with possible rheumatic fever. What assessment data would be
most important for the nurse to obtain from the parent?
1. 102° F (38.89° C) temperature that started 2 days previously.
2. History of pharyngitis approximately 4 weeks ago.
3. Vomiting for 3 days.
4. A cough that started about 1 week earlier. - 2. Correct: Rheumatic fever is often the
result of untreated or improperly treated group A β-hemolytic streptococcal infections
(GABHS), such as pharyngitis. Therefore, the history of pharyngitis or upper respiratory
infection is a key assessment finding for establishing a diagnosis of rheumatic fever.
Subsequent development of rheumatic fever usually occurs 2 to 6 weeks following the
GABHS, so the assessment should include a remote history of pharyngitis.
1. Incorrect: The fever with rheumatic fever is usually low grade and is considered a
minor manifestation of rheumatic fever.
3. Incorrect: Vomiting is not a commonly associated symptom with rheumatic fever and
is not considered a major manifestation of rheumatic fever. Although the child may have
a history of vomiting, this finding would not be specific to rheumatic fever.
4. Incorrect: A cough is not an associated symptom of rheumatic fever. The time frame
for the development of rheumatic fever is not appropriate if the cough started 1 week
earlier, even if it had been associated with an upper respiratory streptococcal infection.

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The primary healthcare provider has prescribed phenytoin 100 mg intravenous push
(IVP) stat through a non-tunneled central venous catheter lumen with no other
medication or fluid infusing. In what order should the nurse administer this prescription?
Cleanse access port
Connect 10 mL normal saline to access port
Gently aspirate for blood
Flush saline using push-pause method
Administer phenytoin
Flush with normal saline, then with heparin - Proper administration of medication
through a non-tunneled central venous catheter:
First, cleanse the access port. Failure to cleanse the port first would increase the risk of
infection from contamination when the port is accessed.
Second, connect 10 mL normal saline to access port. This 10 mL syringe will be
connected to first check patency and then for flushing prior to medication administration.
At least 10 mL of normal saline is used to flush central lines.
Third, gently aspirate for blood.
Fourth, flush saline using push-pause method. This method is utilized to help clear the
catheter of blood or drugs that could potentially adhere to the internal surface of the
central line catheter. This creation of turbulent flow from pausing then pushing causes
swirling of the fluid and theoretically removes blood and medications from the walls of
the catheter, which reduces the risk of occlusion in the catheter.
Fifth, administer phenytoin.
Sixth, flush with normal saline, then with heparin. Standard flushing solutions used most
frequently for central venous access devices include normal saline and/or heparinized
sodium chloride. Low dose heparin flushes are generally used to fill the lumen of the
central line between use in order to prevent thrombus formation and maintain patency of
the catheter for a longer period of time.
An elderly male, diagnosed with chronic renal failure and depression, lives alone. Which
question should the home health nurse ask first when assessing this client?
1. Have you had suicidal thoughts in the past?
2. How are you feeling today?
3. Have you had thoughts of harming yourself?
4. Do you have guns in your home? - 3. Correct: Suicide assessment should begin
with direct questions about the presence of suicidal thinking. The nurse should
recognize that elderly men are at higher risk for committing suicide, especially those
with a history of depression, chronic illness and isolation.

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National Council Licensure Examination

NCLEX Health Care Assessment Practice Exam With Answers (1200 Solved Questions)

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