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NCLEX Sample Test

Below is just a sample of what you will be tested on during your state boards. The preparation course for the NCLEX® will help you increase your thinking skills and show you the best method to answer the questions correctly.

Practice Test Questions and answers taken from Good Thinking: Study skills and test taking for nursing students © STAT Nursing Consultants (2003.)

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Questions

1. A client who has been on a ventilator for two days experiences acute respiratory distress accompanied by distended neck veins. The best action of the nurse is to:

a. hand ventilate the client.
b. prepare for chest tube insertion.
c. call the physician immediately.
d. perform emergency chest decompression.

2. A 78-year-old client is admitted for open reduction of a wrist fracture. That night she is found wandering in the hallway near the fire alarm. When the nurse calls the client's name, the client says, "If you come any closer to me I'll pull this fire alarm. You're a drug addict. I saw you taking drugs out of the cabinet." The best response by the nurse would be:

a. "I'm concerned you'll hurt your arm. I'll ask someone to take you back to your room."
b. "Older adults often become confused when they're in a new place. I'll help you back to your room."
c. "Please don't pull the fire alarm. You'll wake up everyone else.
d. "You are in City Hospital. I am not a drug addict. I'll escort you to your room."

3. A client with a diagnosis of septic shock is placed on triple intravenous antibiotic therapy. What would indicate that the client is responding well to therapy?

a. Arterial blood gas: pH 7.30, PaCO2 50 mm Hg, HCO3 24 mEq/L.
b. Cardiac output of 3.0 L/min.
c. Urine output of 30 cc/hr.
d. Systemic vascular resistance is below normal.

4. After receiving report for the 3pm-11p.m. shift, which client should the nurse care for first?

a. A woman with Crohn's disease who is ordered a potassium infusion for a K+ level of 2.7.
b. A woman with cystic fibrosis who is scheduled to receive chest physiotherapy.
c. A man with sepsis who needs to have a gentamycin trough level drawn for the 4pm dose.
d. A man with a bleeding ulcer and is receiving a platelet infusion for a platelet level of 148,000.

5. An 8-year-old is scheduled for an elective surgery. On physical examination, the child is noted to have a greenish yellow vaginal discharge. Surgery is canceled and antibiotics are prescribed. Which intervention is most appropriate at this time?

a. Interview all members of the child's household separately.
b. Enroll the mother in a parenting skills class.
c. Reschedule the adenoidectomy for two days after the last dose of antibiotics.
d. Teach the parents how and when to give the antibiotics prescribed.

Answers

1. The correct answer is a. The question is asking what the nurse should do when a client on a ventilator has these symptoms. When acute respiratory distress occurs along with neck vein distension, cyanosis and tracheal shift are evident, a tension pneumothorax has probably occurred. The client should be removed from the machine and ventilated by hand. Then the physician should be notified (option c). Equipment for chest tube insertion should be gathered (option b) so it will be ready for immediate use by the physician. Emergency chest decompression (option d) should only be attempted after specific training and if the physician will be delayed.

Nursing Process: Implementation Client Need: Safe, Effective Care Environment

2. The correct answer is a. The question is asking how to respond to a cognitively impaired older adult who is disoriented and threatening to pull the fire alarm. The client is in a state of delirium with cognitive changes probably related to the new hospital environment. The client should be approached matter of factly. Messages should be given firmly and clearly, since the client is confused and upset. This response also provides empathy about the reason for the hospitalization and also suggests she may talk with someone else that she doesn't perceive as threatening. Teaching or explaining should not be done while the client is confused and agitated (option b). The client generally is not capable of reasoning appropriately due to the cognitive changes which accompany delirium but will be able to accept these ideas when more lucid. Asking the client not to do what she has threatened to do (option c) is based on the assumption she can make that judgment. This response also places the nurse in a power struggle where the client feels threatened and will act to decrease that anxiety in any way she can. It is better for the nurse to take charge of the situation until the client becomes calmer. The client does need to be reoriented to her surroundings (option d). In this case, however, the client may not believe the information since she feels threatened by the nurse. Rather, the client's anxiety may be decreased by relating to someone else with whom she may feel more secure at the time.

Nursing Process: Implementation Client Need: Physiological Integrity

3. The correct answer is c. The question is asking which option shows a more normal reading for a client in septic shock. Clients with septic shock often have renal failure and 30 cc/hr is a normal minimum urine output. The arterial blood gases (ABG's) given are of a client with respiratory acidosis (option a). A normal cardiac output is approximately 5.0 L/min (option b). A low systemic vascular resistance (SVR) is consistent with continuing shock (option c).

Nursing Process: Analysis Client Need: Physiological Integrity

4. The correct answer is a. The question asked which client should be cared for first. A K+ level of 2.7 is very low and the client is at risk for developing cardiac complications (dysrrhymias). Chest physiotherapy is important but not the priority. There is no indication that the client is in respiratory distress (option b). A Gentamycin trough can be drawn immediately before the next dose and therefore is not the first priority (option c). A client with a low platelet count and active bleeding does have the potential to hemorrhage, however this client is currently receiving a platelet infusion to correct this problem and does not need to be cared for first (option d).

Nursing Process: Analysis Client Need: Physiological Integrity

5. The correct answer is a. The question is asking how to proceed when a child has vaginal greenish drainage. The child demonstrates clinical manifestations of gonorrhea, a sexually transmitted disease. Sexual abuse should be suspected and investigation consisting of separate interviews with all household members is indicated. Parenting skills are taught, if needed, after a thorough investigation (option b). Rescheduling the surgery is not the priority and avoids the immediate problem of suspected sexual abuse (option c). While the nurse would teach when and how to give the antibiotics prescribed, it also avoids the problem of suspected sexual abuse (option d).

Nursing Process: Implementation Client Need: Physiological Integrity

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NCLEX Sample Test

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