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WorksheetsNCLEX Sample Test 1
Total questions: 50
Worksheet time: 1hrs 9mins
The nurse in a small town is caled to a neighbor's house in the middle of a blizzard The roads are impassable. The neighbor wormari states she is in the 39th week of gestation with her second baby and has been having contractions for several hiours. The nurse determines
the woman is beginning the second stage of labor. Which action is most important for the
nurse to take?
Time the frequency of the contractions.
Assess the type of vaginal discharge.
Monitor the strength of her contractions.
Observe the perineum.
The new registered nurse asks the nurse mentor to check on 4 clients who are receiving oxygen therapy. It is most important for the nurse mentor to ask the new nurse which question?
"Which client should I see first?"
"Have you completed your assessment?
"What are your specific concerns?"
" Don't you think you should be able to care for the clients?"
The nurse completes a vell-child assessment on a 20-month-old client. The child's parent
says, "I eam extra money by growing houseplants in the house." Which response by the
nurse is most appropriate?
"How did you get into that business?"
"What a great opportunity."
"You should not have plants in your home"
"Where do you keep the plants?"
The nurse reviews the health records for clients who are receiving medications. The nurse determincs which client is at risk to develop problems with hearing?
A client receiving furosemide and indomethacin.
A client receiving metfcrmin and alendronate
A client receiving paroxetine and cholestyramine.
A client receiving spironolactone and cefaclor.
An older client is diagnosed with a hemorrhagic stroke. The unlicensed assistive personnel (UAP) informs the nurse the client ate half of the food on the tray The food left on the tray looks as if someone drew a straight line down the center of the plate. The food was eaten only on one side of the line. Which instruction by the nurse is most important?
"Offer the clicnt a snack later in the day."
"Tell me which foods the cient omitted.
"Rotate the plate so that the remaining food is on the other side."
"Ask the client's family to assist with the next meal.
A client is in labor at term. The client's blood pressure is 182/88 and fetal heart rate (FHR) is 132–134 with minimal beat-to-beat variability. The bloody show is dark red and there is more bleeding than anticipated. The abdomen is firm between contractions and back pain is reported. The nurse prepares for which likely complication?
Placenta previa.
Abruptio placenta.
Miscarriage.
Imminent delivery.
The nurse cares for a 4-year-old client on the pediatric unit. The child is unable to go to sleep while in the hospital. It is most important for the nurse to take which action?
Turn out the light and close the door.
Encourage the child to exercise during the evening.
Identify the child's home bedtime rituals.
Ask the child's siblings to sit during the evening.
A client rectums from surgery for a total hip arthroplasty. The hip has a large surgical dressing and a collapsible drainage device. Which finding 2 hours after surgery requires the nurse to call the health care provider?
A small amount of bloody drainage is on the dressing.
The client reports increased pain at the surgical site.
A harsh hollow sound is auscultated over the trachea.
The client's blood pressure is 136/86 mm Hg.
The nurse cares for an elderly client. The client reports muscle weakness and drowsiness. The nurse notes decreased deep tendon reflexes and hypotension. Which action does the
nurse take first?
Escorts the client to an emergency department.
Assesses for Chorstek s sign.
Measures the client's intake and output
Asks the client if antacids have been taken.
An infant is diagnosed with congenital heart disease. The nurse notes the infant becomes easily fatigued during feedings and the pulse and respiration increase. The nurse takes which action?
Feed the infant soon after awakening.
Change the infant's diaper before feeding.
Increase the caloric content of the feeding to 30 kcal/cz.
Mix rice cereal in the formula.
The nurse evaluates assignments on the unit. The assignments are appropriate if the nurse
assigns the LPN/LVN to which client?
A client with type 1 diabetes mellitus scheduled for discharge.
A client newly admitted to the unit with chest pain.
A client receiving chemotherapy.
A client diagnosed with myasthenia gravis.
The nurse is approached by an LPN/LVN from a different team. The LPN/LVN is concerned because one of the clients is diagnosed with COPD and the RN (a new graduate) is giving the client oxygen at 2 L/min. Which response by the nurse is most appropriate?
"I will assess the client for oxygen toxicity"
"Are you concerned about the oxygen or the new graduate s competency?"
"Please tell me more about your concerns."
"Leave the oxygen in place."
A client has used continuous ambulatory peritoneal dialysis (CAPD) for one year. The client states, "Today l infused 2L of dialyses and 1200 mL returned." Which response by the nurse is best?
"Record the difference as intake."
"When was your last bowel movement?"
"Are you having shoulder pain?"
"Increase your fluid intake."
The nurse cares for a client following a scleral buckling. Which nursing action is most
important?
Remove all reading material.
Assess for nausea.
Assess drainage from affected eye.
drigate affected eye every 3 hours
The nurse in the outpatient clinic has four unscheduled clients waiting to see the health care
provider. Which client does the nurse see first?
A client reporting a sore throat and nasal drainage.
A client with a history of kidney stones reporting severe flank pain.
A client reporting redness and pain in the left great toe.
A client receiving dioxin reporting nausea and vomiting.
The home care nurse visits a client diagnosed with type 1 diabetes mellitus (DM). The client takes insulin in the morning and evening. The nurse identifies that which laboratory value best measures the overall therapeutic response to management of type 1 DM?
Hemoglobin A1c 5% of total Hb.
Fasting blood glucose 128 mg/dL (7.1 mmol/L).
Blood pressure 130/82 mm Hg.
Serum amylase 100 Somogyi U/dL (1 67 ukat/L).
A child is diagnosed with impetigo. The nurse notes the infection has not improved. The nurse learns the parent has not been caring for the child's skin because it "takes too much time." It is most important for the nurse to assess for which finding?
White patches on buccal mucosa.
Hearing loss.
Respiratory wheezing.
Periodontal edema.
The change-of-shift report is being given. The charge nurse overhears two nurses exchanging loud, rude remarks about one nurse's excessive use of overtime. Which statement by the charge nurse is most appropriate?
"I want to see both of you in my office right away."
"Please lower your voices and finish the change-of-shift report."
"I want the two of you to stop yelling and work this problem out"
'Both of you are goɔd nurses and are under a lot of stress right now.
A 14-year-old is hospitalized with a diagnosis of anorexia nervosa. The nurse identifies which activity is most appropriate for this client?
Making jewelry with the occupational therapist.
Exercising in the physical therapy department
Assisting the dietitian plan the week's menus
Reading teen magazines with other same-aged clients.
The nurse cares for children in the outpatient pediatric clinic. It is most important for the nurse to perform tuberculosis screening on which child?
A child just returned from a 2-week trip to Europe.
A child recently moved to an apartment because the family lost their home.
A child with a live-in caregiver who just emigrated from Latin America.
A child who weighed 4 lb, 10 cz ( 1.8 kg) at birth.
The nurse administers morphine sulfate to an adult client. The nurse expects to observe which finding?
Client states is feeling better.
Client is talking with visitors.
Client appears to be physically relaxed.
Client is no longer crying or moaning.
The nurse receives change-of-shift report. Which client does the nurse see first?
A client diagnosed with chronic obstructive pulmonary disease (COPD) with a Pa02 of 70 mm Hg (9.3 kPa).
A client diagnosed with type 1 diabetes mellitus and who was just informed the spouse was seriously injured.
A client scheduled to leave for the operating room in 30 minutes for a hear valve replacement.
A client 10 hours postop after a right mastectomy and reporting wet sheets under the back.
The nurse receives report on the medical/surgical unit. Which client does the nurse see first?
A client newly diagnosed with type 1 diabetes who had a myocardial infarction 2 days ago.
A client diagnosed with one-sided heart failure and glaucoma.
A client diagnosed with chronic obstructive pulmonary disease (COPD) and psoriasis.
A client diagnosed with rheumatoid arthritis and malnutrition
The emergency management team notifies the emergency department nurse to expect 50 victims in about 15 minutes. Which action does the nurse take first?
Contacts the hospital nursing supervisor.
Tells the emergency management team to re-route 25 victims.
Activates the hospital's disaster plan.
informs the emergency department nurses they must work overtime.
A young adult female is diagnosed with type 1 diabetes mellitus. Two days after admission, the client begins reporting severe nausea. Which action does the nurse take first?
Determines the most recent fasting serum glucose level.
Performs a comprehensive client assessment.
Asks the client if pregnancy is a possibility
Administers an ordered oral antisemeitic medication
A client is diagnosed with gastroesophageal reflex disease (GERD). The nurse teaches about diet. The
nurse determines the teaching is successful if the client selects which menu?
Pork loin, lettuce and tomato salad with vinegar and oil dressing, jello, and cola.
Cheddar cheese omelet, spinach salad, chocolate brownie, and milk.
Broiled chicken, cream of broccoli soup, rice pudding, and apple juice.
Baked salmon with lemon butter, baked potato, mint chocolate chip ice cream, and lemonade.
The nurse in the pediatric clinic receives a phone call from the parent of a 3-year-old child. The parent
reports the child has a sore throat, a temperature of 102' F (39° C), and has suddenly begun drooling.
Which suggestion does the nurse make first?
"Place a cold water vaporizer in your child's room."
"Take your child to the emergency department immediately."
Look into your child's throat and tell me what you see.
"Frequently offer your child oral fluids.
An older client is newly diagnosed with type 1 diabetes mellitus. The nurse prepares for discharge. The
client is alert and oriented and lives alone in the home. It is most important for the nurse to assess for
which finding?
Client's vision and manual dexterity.
Client's understanding of diabetes.
Client's need for visits from the home care nurse.
Client's ability to perform blood glucose montiorning.
An older adult client lies down in balanced suspension traction for a compound fracture of the femur. The
client reports, "My hands, feet, and nose feel cold.' Which action does the nurse take first?
Provides the client with more blankets.
Assesses for dependent edema.
Assesses the client for exhaling when moving.
Increases the temperature of the room.
A disaster alarm has been declared at the hospital are many clients are expected unit is considered for discharge within the next hour? (Select all that apply.)
A multi para client who delivered over an intact perineum 12 hours ago.
A postpartum client with an infection who has been on antibiotics for the past 24 hours.
A 2-day-old infant delivered by a mother receiving intrapartum antibiotic therapy for vaginal group B-streptococcus (GBs).
A 3-day-old breast-feeding infant with a total serum bilirubin of 12 mg/dL (205.25 pmol/L)
A 2-day-old infant on oxygen therapy being assessed tor a possible cardiac deformity.
A 6-month-old client is diagnosed with rota virus, severe diarrhea, and dehydration. The nurse places the infant in which room?
Semiprivate room with a 2-year-old in traction due to a fracture.
Semiprivate room with a 9-month old admitted for a shunt revision.
Private room that is close to the nurse's station.
Any private room that is available.
The student nurse administers cardiology to an older client. The client refuses the medication, saying, "Go away. It makes me dizzy." The nurse intervenes if the student
nurse makes which statement?
"If you don't take this medication, you will be restrained."
"This medication will help control your blood pressure."
"Adverse effects of this medication make some clients feel uncomfortable."
"When do you notice the dizziness?"
A client is scheduled for a 24-hour creatinine clearance test. The nurse provides instructions. Which client statement indicates further teaching is required?
"I will save all of my urine during the 24 hours and keep it refrigerated."
I will drink as much fluid as I want before and during the test"
I will use the specimen collection time to catch up on my reading
"I will eat a high-protein meal before the test begins."
A client comes to the emergency department reporting acute back pain. The client denies any chronic illness, allergies, or previous hospitalizations. Which is the
nurse's best initial response?
"We'll get this pain under control in no time.
"Are you sure you've never been in the hospital before?"
"Did you fall, lift something heavy, or turn the wrong way?"
"On a scale of 1 to 10, with 10 being the worst, rate the pain you are experiencing."
A client is admitted to the psychiatric unit with a diagnosis of "bipolar disorder manic phase." The student nurse plans activities for the client. The nurse should intervene if
the student nurse chooses which activity?
Volleyball.
Painting
Walking.
Dancing
The nurse cares for a client diagnosed with a recurrence of colon cancer. The client says, "I am dreading taking chemotherapy again." Which response by the nurse is most appropriate?
"There are web sites that provide information about chemotherapy."
"Have you discussed this with your health care provider?"
"I can give you a handout about now to treat the adverse effects of chemotherapy."
"What are your concerns about taking chemotherapy?"
A primipara client is in labor. The cervix is 5 cm dilated and 100% effaced and the fetal head is at-1 station. The membranes rupture and the fluid is clear. Which action
does the nurse take first?
Ambulates the client for 15 minutes and evaluates the fetal heart rate every 30 minutes.
Prepares for delivery and notifies the care provider.
Applies an electronic fetal monitor and starts an IV.
Encourages the client to void every 1-2 hours and takes the temperature every hour.
The nurse administers promethazıne 25 mg IM to a client reporting nausea and vomiting. After receiving the medication, the client reports dizziness when standing
up. Which action does the nurse take first?
Notifies health care provider.
Monitors severity of symptoms.
Instructs client to ask for assistance before ambulating.
Assesses client's hydration status.
A client receives aminophylline 0.7 mg/kg/h by continuous V infusion into the left arm. It is most important for the nurse to observe for which finding?
Slowed pulse and reduced blood pressure.
Constipation and decreased bowel sounds
Palpitations and nervousness.
Difficulty voiding and oliguria
A child weighing 20 kg is stung by a bee. The parent reports the child developed a large welt, red rash, and shortness of breath. The parent asks the nurse, "What should I do if my child gets stung again?" Which response by the nurse is best?
"Make a paste of baking soda and water and apply it to the sting"
"Remove the stinger and immediately apply ice to the site."
"Give 12.5 mg of diphenhydramine by mouth."
"Administer 0.15 mg of epinephrine by auto injector."
A client is in hemorrhagic shock from injuries sustained in a fall. It is most important for the nurse to take which action?
Obtain vital signs.
Identify the source of bleeding.
Elevate the head of the bed 30°
Administer 0.9% NaC IV.
The nurse provides care for a client receiving a heparin drip via an infusion pump. The health care provider prescribes warfarin 5 mg PO. Which action does the nurse
take next?
Administers medication as prescribed.
Notifies the health care provider
Checks the most recent partial thromboplastin time.
Assesses client for signs/symptoms of bleeding.
The nurse instructs a client receiving citalopram 20 mg daily. The nurse determines further teaching is needed if the client makes which statement?
"This medication helps me with my depression."
"I will notify my health care provider if I show signs of hyperactivity and mania."
"I will see improvement in my symptoms in 1 to 4 weeks."
"If I experience a fever, I will take acetaminophen."
A client receives chlordiazepoxide. It is most important for the nurse to make which assessment?
Diarrhea and euphoria.
Drowsiness and confusion.
Anorexia and dry mouth.
Skeletal muscle spasms and insomnia.
The nurse in the psychiatric emergency department assesses 4 clients. Which client does the nurse see first?
A client raped 30 minutes ago who expresses feelings of self-blame, anxiety, and worthlessness.
A client who witnessed a child stabbed to death 2 weeks ago experiencing
A client who indicates an intent to kill self and reports access to a gun.
A client is admitted to a rehabilitation center for management of a cervical spine injury. The client reports a severe headache. Which action does the nurse take first?
Administers an analgesic medication
Asks the client to rank the pain from 1 to 10.
Places the client in a sitting position.
Obtains the client's blood pressure
A client is admitted to a rehabilitation center for management of a cervical spine injury.
The client reports a severe headache. Which action does the nurse take first?
Scrambled eggs, whole wheat toast, banana, skim milk.
Baked chicken leg, macaroni and cheese, spinach, milkshake.
Poached halibut, brown rice, carrots, apple cobbler.
Guacamole with pita bread, lettuce, tomato juice.
The nurse cares for an older client The client is diagnosed with terminal lung cancer. The client becomes very angry when told about the diagnosis. The client curses, throws objects, and hits the nursing assertive person and LPN/LVN when they attempt to provide care It is most important for the nurse to take which action?
Inform the client that injury or risk of injury to staff is not acceptable.
Report the behaviors to the health care provider immediately.
Send all other staff out of the room.
Administer the prescribed artianxiety medication with full glass of water.
A client demonstrates manipulative behavior. The nurse evaluates the client's care. The nurse intervenes if which interaction is observed?
. The staff establishes limits on the client's man pulative behavior.
The staff discusses the consequences of manipulative behavior with the client.
The staff decreases the demands on the client.
The staff decreases the demands on the client.
The nurse on a college campus is informed by the microbiology department that they accidentally received a shipment of highly toxic, contagious bacteria. Which action should the nurse take first?
Determine if adequate supplies of antibiotics are available.
Order necessary equipment and supplies.
Contact the Red Cross.
Identify who was exposed to the shipment.
