NCLEX-PN Test-Bank (200 Questions with Answers and Explanation)
1. The nurse is caring for a client scheduled for removal of a pituitary tumor using
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transsphenoidal approach. The nurse should be particularly alert for:
A. Nasal congestion
B. Abdominal tenderness
C. Muscle tetany
D. Oliguria
Answer A: Removal of the pituitary gland is usually done by a transsphenoidal approach,
through the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are
not correct because they are not directly associated with the pituitary gland.
2. A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6,
WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the
client is experiencing which of the following?
A. Hypernatremia
B. Hypokalemia
C. Myelosuppression
D. Leukocytosis
Answer B: Hypokalemia is evident from the lab values listed. The other laboratory findings are
within normal limits, making answers A, C, and D
incorrect.3. A 24-year-old female client is scheduled for surgery in the morning. Which of the
following is the primary responsibility of the nurse?
A. Taking the vital signs
B. Obtaining the permit
C. Explaining the procedure
D. Checking the lab work
Answer A: The primary responsibility of the nurse is to take the vital signs before any surgery.
The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are
incorrect for this question.
4. The nurse is working in the emergency room when a client arrives with severe burns of
the left arm, hands, face, and neck. Which action should receive priority?
A. Starting an IV
B. Applying oxygen
C. Obtaining blood gases
D. Medicating the client for pain
Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen,
so applying oxygen is the priority. The next action should be to start an IV and medicate for pain,
making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor.
5. The nurse is visiting a home health client with osteoporosis. The client has a new
prescription for alendronate (Fosamax). Which instruction should be given to the client?
A. Rest in bed after taking the medication for at least 30 minutes
B. Avoid rapid movements after taking the medication
C. Take the medication with water onlyD. Allow at least 1 hour between taking the medicine and taking other medications
Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen,
so applying oxygen is the priority. The next action should be to start an IV and medicate for pain,
making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor.
6. The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs.
Which equipment should be kept at the bedside?
A. A pair of forceps
B. A torque wrench
C. A pair of wire cutters
D. A screwdriver
Answer B: A torque wrench is kept at the bedside to tighten and loosen the screws of crutchfield
tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of
forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are
incorrect.
7. An infant weighs 7 pounds at birth. The expected weight by 1 year should
be:
A. 10 pounds
B. 12 pounds
C. 18 pounds
D. 21 poundsAnswer D: A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth
weight. Answers A, B, and C therefore are incorrect.
8. A client is admitted with a Ewing’s sarcoma. Which symptoms would be expected due to
this tumor’s location?
A. Hemiplegia
B. Aphasia
C. Nausea
D. Bone pain
Answer D: Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers
A, B, and C are not specific to this type of cancer and are incorrect.
9. The nurse is caring for a client with epilepsy who is being treated with carbamazepine
(Tegretol). Which laboratory value might indicate a serious side effect of this drug?
A. Uric acid of 5mg/dL
B. Hematocrit of 33%
C. WBC 2,000 per cubic millimeter
D. Platelets 150,000 per cubic millimeter
Answer C: Tegretol can suppress the bone marrow and decrease the white blood cell count; thus,
a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and
D are within normal limits, and answer B is a lower limit of normal; therefore, answers A, B, and
D are incorrect.10. A 6-month-old client is admitted with possible intussuception. Which question during the
nursing history is least helpful in obtaining information regarding this diagnosis?
A. “Tell me about his pain.”
B. “What does his vomit look like?”
C. “Describe his usual diet.”
D. “Have you noticed changes in his abdominal size?”
Answer C: The least-helpful questions are those describing his usual diet. A, B, and D are useful
in determining the extent of disease process and, thus, are incorrect.
11. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food
should be avoided?
A. Bran
B. Fresh peaches
C. Cucumber salad
D. Yeast rolls
Answer C: The client with diverticulitis should avoid foods with seeds. The foods in answers A,
B, and D are allowed; in fact, bran cereal and fruit will help prevent constipation.
12. A client has rectal cancer and is scheduled for an abdominal perineal resection. What
should be the priority nursing care during the post-op period?
A. Teaching how to irrigate the illeostomy
B. Stopping electrolyte loss in the incisional area
C. Encouraging a high-fiber dietD. Facilitating perineal wound drainage
Answer D: The client with a perineal resection will have a perineal incision. Drains will be used
to facilitate wound drainage. This will help prevent infection of the surgical site. The client will
not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not
focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not
ordered at this time.
13. The nurse is performing discharge teaching on a client with diverticulitis who has been
placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet?
A. Roasted chicken
B. Noodles
C. Cooked broccoli
D. Custard
Answer C: The client with diverticulitis should avoid eating foods that are
gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as
those listed in answers A, B, and D are allowed.
14. The nurse is caring for a new mother. The mother asks why her baby has lost weight
since he was born. The best explanation of the weight loss is:
A. The baby is dehydrated due to polyuria.
B. The baby is hypoglycemic due to lack of glucose.
C. The baby is allergic to the formula the mother is giving him.
D. The baby can lose up to 10% of weight due to meconium stool, loss of extracellular fluid,
and initiation of breast-feeding.Answer D: After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding
cause the infant to lose body mass. There is no evidence to indicate dehydration, hypoglycemia,
or allergy to the infant formula; thus, answers A, B, and C are incorrect.
15. The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the
health history would not be common for this diagnosis?
A. Foul breath
B. Dysphagia
C. Diarrhea
D. Chronic hiccups
Answer C: Diarrhea is not common in clients with mouth and throat cancer. All the findings in
answers A, B, and D are expected findings.
16. A removal of the left lower lobe of the lung is performed on a client with lung cancer.
Which post-operative measure would usually be included in the plan?
A. Closed chest drainage
B. A tracheostomy
C. A mediastinal tube
D. Percussion vibration and drainage
Answer A: The client with a lung resection will have chest tubes and a drainage-collection
device. He probably will not have a tracheostomy or mediastinal tube, and he will not have an
order for percussion, vibration, or drainage. Therefore, answers B, C, and D are incorrect.17. Six hours after birth, the infant is found to have an area of swelling over the right parietal
area that does not cross the suture line. The nurse should chart this finding as:
A. A cephalohematoma
B. Molding
C. Subdural hematoma
D. Caput succedaneum
Answer A: A swelling over the right parietal area is a cephalohematoma, an area of bleeding
outside the cranium. This type of hematoma does not cross the suture line because it is outside
the cranium but beneath the periosteum. Answer B, molding, is overlapping of the bones of the
cranium and, thus, incorrect. In answer C, a subdural hematoma, or intracranial bleeding, is
ominous and can be seen only on a CAT scan or x-ray. A caput succedaneum, in answer D,
crosses the suture line and is edema.
18. The nurse is assisting the RN with discharge instructions for a client with an implantable
defibrillator. What discharge instruction is essential?
A. “You cannot eat food prepared in a microwave.”
B. “You should avoid moving the shoulder on the side of the pacemaker site for 6 weeks.”
C. “You should use your cellphone on your right side.”
D. “You will not be able to fly on a commercial airliner with the defibrillator in place.”
Answer C: The client with an internal defibrillator should learn to use any battery-operated
machinery on the opposite side. He should also take his pulse rate and report dizziness or
fainting. Answers A, B, and D are incorrect because the client can eat food prepared in the
microwave, move his shoulder on the affected side, and fly in an airplane.
19. A client in the cardiac step-down unit requires suctioning for excess mucous secretions.
The nurse should be most careful to monitor the client for which dysrhythmia during this
procedure?A. Bradycardia
B. Tachycardia
C. Premature ventricular beats
D. Heart block
Answer A: Suctioning can cause a vagal response and bradycardia. Answer B is unlikely and,
therefore, not most important, although it can occur.
Answers C and D can occur as well, but they are less likely.
20. The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal
aortic aneurysm. Which assessment is most crucial during the preoperative period?
A. Assessment of the client’s level of anxiety
B. Evaluation of the client’s exercise tolerance
C. Identification of peripheral pulses
D. Assessment of bowel sounds and activity
Answer C: The assessment that is most crucial to the client is the identification of peripheral
pulses because the aorta is clamped during surgery. This decreases blood circulation to the
kidneys and lower extremities. The nurse must also assess for the return of circulation to the
lower extremities. Answer A is of lesser concern, answer B is not advised at this time, and
answer D is of lesser concern than answer A.
21. A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to
include which statement in the teaching session?
A. “You will be sitting for the examination procedure.”
B. “Portions of the procedure will cause pain or discomfort.”
C. “You will be given some medication to anesthetize the area.”D. “You will not be able to drink fluids for 24 hours before the study.”
Answer B: Portions of the exam are painful, especially when the sample is being withdrawn, so
this should be included in the session with the client. Answer A is incorrect because the client
will be positioned prone, not in a sitting position, for the exam. Anesthesia is not commonly
given before this test, making answer C incorrect. Answer D is incorrect because the client can
eat and drink following the test.
22. The nurse is performing an assessment on a client with possible pernicious anemia.
Which data would support this diagnosis?
A. A weight loss of 10 pounds in 2 weeks
B. Complaints of numbness and tingling in the extremities
C. A red, beefy tongue
D. A hemoglobin level of 12.0gm/dL
Answer C: A red, beefy tongue is characteristic of the client with pernicious anemia. Answer A, a
weight loss of 10 pounds in 2 weeks, is abnormal but is not seen in pernicious anemia.
Numbness and tingling, in answer B, can be associated with anemia but are not particular to
pernicious anemia. This is more likely associated with peripheral vascular diseases involving
vasculature. In answer D, the hemoglobin is low normal.
23. A client arrives in the emergency room with a possible fractured femur. The nurse should
anticipate an order for:
A. Trendelenburg position
B. Ice to the entire extremity
C. Buck’s traction
D. An abduction pillowAnswer C: The client with a fractured femur will be placed in Buck’s traction to realign the leg
and to decrease spasms and pain. The Trendelenburg position is the wrong position for this
client, so answer A is incorrect. Ice might be ordered after repair, but not for the entire extremity,
so answer B is incorrect. An abduction pillow is ordered after a total hip replacement, not for a
fractured femur; therefore, answer D is incorrect.
24. A client with cancer is to undergo an intravenous pyelogram. The nurse should:
A. Force fluids 24 hours before the procedure
B. Ask the client to void immediately before the study
C. Hold medication that affects the central nervous system for 12 hours pre- and post-test
D. Cover the client’s reproductive organs with an x-ray shield
Answer B: The client having an intravenous pyelogram will have orders for laxatives or enemas,
so asking the client to void before the test is in order. A full bladder or bowel can obscure the
visualization of the kidney ureters and urethra. In answers A, C, and D, there is no need to force
fluids before the procedure, to withhold medications, or to cover the reproductive organs.
25. The nurse is caring for a client with a malignancy. The classification of the primary tumor
is Tis. The nurse should plan care for a tumor:
A. That cannot be assessed
B. That is in situ
C. With increasing lymph node involvement
D. With distant metastasis
Answer B: Cancer in situ means that the cancer is still localized to the primary site. Cancer is
graded in terms of tumor, grade, node involvement, and mestatasis. Answer A is incorrect
because it is an untrue statement.
Answer C is incorrect because T indicates tumor, not node involvement. Answer D is incorrect
because a tumor that is in situ is not metastasized.26. A client is 2 days post-operative colon resection. After a coughing episode, the client’s
wound eviscerates. Which nursing action is most appropriate?
A. Reinsert the protruding organ and cover with 4×4s
B. Cover the wound with a sterile 4×4 and ABD dressing
C. Cover the wound with a sterile saline-soaked dressing
D. Apply an abdominal binder and manual pressure to the wound
Answer C: If the client eviscerates, the abdominal content should be covered with a sterile
saline-soaked dressing. Reinserting the content should not be the action and will require that the
client return to surgery; thus, answer A is incorrect. Answers B and D are incorrect because they
are not appropriate to this case.
27. The nurse is preparing a client for surgery. Which item is most important to remove
before sending the client to surgery?
A. Hearing aid
B. Contact lenses
C. Wedding ring
D. Artificial eye
Answer B: It is most important to remove the contact lenses because leaving them in can lead to
corneal drying, particularly with contact lenses that are not extended-wear lenses. Leaving in the
hearing aid or artificial eye will not harm the client. Leaving the wedding ring on is also allowed;
usually, the ring is covered with tape. Therefore, answers A, C, and D are incorrect.
28. The nurse on the 3–11 shift is assessing the chart of a client with an abdominal aneurysm
scheduled for surgery in the morning and finds that the consent form has been signed, but the
client is unclear about the surgery and possible complications. Which is the most appropriate
action?A. Call the surgeon and ask him or her to see the client to clarify the information
B. Explain the procedure and complications to the client
C. Check in the physician’s progress notes to see if understanding has been documented
D. Check with the client’s family to see if they understand the procedure fully
Answer A: It is the responsibility of the physician to explain and clarify the procedure to the
client. Answers B, C, and D are incorrect because they are not within the nurse’s purview.
29. When assessing a client for risk of hyperphosphatemia, which piece of information is
most important for the nurse to obtain?
A. A history of radiation treatment in the neck region
B. A history of recent orthopedic surgery
C. A history of minimal physical activity
D. A history of the client’s food intake
Answer A: Previous radiation to the neck might have damaged the parathyroid glands, which are
located on the thyroid gland, and interfered with calcium and phosphorus regulation. Answer B
has no significance to this case; answers C and D are more related to calcium only, not to
phosphorus regulation.
30. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium
of 170meq/L. What behavior changes would be most common for this client?
A. Anger
B. Mania
C. Depression
D. PsychosisAnswer B: The client with serum sodium of 170meq/L has hypernatremia and might exhibit
manic behavior. Answers A, C, and D are not associated with hypernatremia and are, therefore,
incorrect.
31. The nurse is obtaining a history of an 80-year-old client. Which statement made by the
client might indicate a possible fluid and electrolyte imbalance?
A. “My skin is always so dry.”
B. “I often use a laxative for constipation.”
C. “I have always liked to drink a lot of ice tea.”
D. “I sometimes have a problem with dribbling urine.”
Answer B: Frequent use of laxatives can lead to diarrhea and electrolyte loss. Answers A, C, and
D are not of particular significance in this case and, therefore, are incorrect.
32. A client visits the clinic after the death of a parent. Which statement made by the client’s
sister signifies abnormal grieving?
A. “My sister still has episodes of crying, and it’s been 3 months since Daddy
died.”
B. “Sally seems to have forgotten the bad things that Daddy did in his lifetime.”
C. “She really had a hard time after Daddy’s funeral. She said that she had a sense of
longing.”
D. “Sally has not been sad at all by Daddy’s death. She acts like nothing has happened.”Answer D: Abnormal grieving is exhibited by a lack of feeling sad; if the client’s sister appears
not to grieve, it might be abnormal grieving. This family member might be suppressing feelings
of grief. Answers A, B, and C are all normal expressions of grief and, therefore, incorrect.
33. The nurse recognizes that which of the following would be most appropriate to wear
when providing direct care to a client with a cough?
A. Mask
B. Gown
C. Gloves
D. Shoe covers
Answer A: If the nurse is exposed to the client with a cough, the best item to wear is a mask. If
the answer had included a mask, gloves, and a gown, all would be appropriate, but in this case,
only one item is listed; therefore, answers B and C are incorrect. Shoe covers are not necessary,
so answer D is incorrect.
34. The nurse is caring for a client with a diagnos [Show Less]