NCLEX Examination Review Questions

Submitted by kharris401 on 4/16/2011 12:46:19 PM

Points Awarded 13
Points Missed 0
Percentage 100%

1. Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks
the nurse to get up to go to the bathroom to urinate. Which of the following is the most
appropriate action for the nurse to take?

A. Assist patient to bathroom and stay next to door to assist patient back to bed when done.
B. Allow patient to go to the bathroom since the onset of the medication will be more than 5
minutes.
C. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety.
D. Ask patient to hold the urine for a short period of time since a urinary catheter will be
placed in the operating room.
The prime issue after administration of either sedative or opioid analgesic medications is safety.
Because the medications affect the central nervous system, the patient is at risk for falls and
should not be allowed out of bed, even with assistance.
Points Earned: 1/1

Correct Answer: C

Your Response: C

2. Which of the following is the primary reason for prioritizing the determination of the patient's
current medications during a preoperative assessment?

A. Routine medications are usually withheld the day of surgery, requiring dosage and
schedule adjustments.
B. Some medications may alter the patient’s perceptions about surgery.
C. Some medications may interact with anesthetics, altering the potency and effect of the
drugs.
D. Anesthetics alter renal and hepatic function, causing toxicity by other drugs.
Drug interactions may occur between prescribed medications and anesthetic agents used during
surgery. For this reason, it is important to take a careful medication history and check that they
have been communicated to the anesthesiologist.
Points Earned: 1/1

Correct Answer: C

Your Response: C

3. As the nurse is preparing a patient for surgery, the patient refuses to remove a wedding ring.
Which of the following is the most appropriate action by the nurse?
 A. Note the presence of the ring in the nurse’s notes of the chart.
B. Insist the patient remove the ring.
C. Explain that the hospital will not be responsible for the ring.
D. Tape the ring securely to the finger.
It is customary policy to tape a patient's wedding band to the finger and make a notation on the
preoperative checklist that the ring is taped in place.
Points Earned: 1/1

Correct Answer: D

Your Response: D

4. While performing preoperative teaching, the patient asks when she needs to stop drinking
water before the surgery. Based on the most recent practice guidelines established by the
American Society of Anesthesiologists, the nurse tells the patient that:

A. She must be NPO after breakfast.

B. She needs to be NPO after midnight.
C. She can drink clear liquids up to 2 hours before surgery.
D. She can drink clear liquids up until she is taken to the OR.
Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2
hours. Evidenced-based practice no longer supports the long-standing practice of requiring
patients to be NPO after midnight.
Points Earned: 1/1

Correct Answer: C

Your Response: C

5. The nurse is admitting a patient to the same day surgery unit. The patient tells the nurse
that he was so nervous he had to take kava last evening to help him sleep. Which of the
following nursing actions would be most appropriate?

A. Inform the anesthesiologist of the patient’s ingestion of kava.

B. Tell the patient that using kava to help sleep was a good idea.
C. Tell the patient that the kava should continue to help him relax before surgery.
D. Inform the patient about the dangers of taking herbal medicines without consulting his
health care provider.
Kava may prolong the effects of certain anesthetics. Thus the anesthesiologist needs to be
informed of recent ingestion of this herbal supplement.
Points Earned: 1/1

Correct Answer: A

Your Response: A

6. The nurse would be alerted to the occurrence of malignant hyperthermia when the patient
demonstrates:
 A. Hypocapnia
B. Muscle rigidity
C. Decreased body temperature
D. Confusion upon arousal from anesthesia
Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of
skeletal muscles occurring secondary to exposure to certain anesthetic agents in susceptible
patients. Hypoxemia, hypercarbia, and dysrhythmias may also be seen with this disorder.
Points Earned: 1/1

Correct Answer: B

Your Response: B

7. Before admitting a patient to the operating room, the nurse recognizes that which of the
following must be attached to the chart of all patients?

A. A functional status evaluation

B. Renal and liver function tests
C. A physical examination report
D. An electrocardiogram
It is essential to have a physical examination report attached to the chart of a patient going for
surgery. This document explains in detail the overall status of the patient for the surgeon and
other members of the surgical team.
Points Earned: 1/1

Correct Answer: C

Your Response: C

8. Unless contraindicated by the surgical procedure, which of the following positions is preferred
for the unconscious patient immediately postoperative?

A. Supine
B. Lateral
C. Semi-Fowler’s
D. High-Fowler’s
Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a
lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of
aspiration if vomiting. Once conscious, the patient is usually returned to a supine position with
the head of the bed elevated.
Points Earned: 1/1

Correct Answer: B

Your Response: B

9. A postoperative patient is transferred from the postanesthesia unit to the medical-surgical

nursing floor. The nurse notes that the patient has an order for D5 ½ NS to infuse at 125
ml/hr. Until an IV pump is available, the nurse regulates the IV flow rate at which of the
 following drops (gtts)/min, noting that the tubing has a drop factor of 10 drops/ml?

A. 13 gtts/min
B. 31 gtts/min
C. 31 gtts/min
D. 21 gtts/min

Points Earned: 1/1

Correct Answer: D

Your Response: D

10. The nurse is preparing to administer cefazolin (Ancef) 2 grams in 100 ml IVPB to a
postoperative patient. Which of the following IV rates will infuse this medication over
20 minutes?

A. 100 ml/hr
B. 150 ml/hr
C. 200 ml/hr
D. 300 ml/hr

Points Earned: 1/1

Correct Answer: D

Your Response: D

11. The nurse is working on a surgical floor and is preparing to receive a postoperative
patient from the postanesthesia unit. Which of the following should be the nurse's
initial action upon the patient's arrival?

A. Check the physician’s postoperative orders.

B. Assess the patient’s pain.
C. Check the rate of the IV infusion.
D. Assess the patient’s vital signs.
The highest priority action by the nurse is to assess the physiologic stability of the patient. This
is in part accomplished by taking the patient's vital signs. The other actions can then take place
in rapid sequence.
Points Earned: 1/1

Correct Answer: D

Your Response: D

12. When assessing a patient's surgical dressing on the first postoperative day, the nurse
notes new bright-red drainage about 5 cm in diameter. In response to this finding, the
 nurse should do which of the following?

A. Assess the patient’s blood pressure and heart rate.

B. Remove the dressing and assess the surgical incision.
C. Recheck the dressing in 1 hour for increased drainage.
D. Notify the surgeon of a potential hemorrhage.
The first action by the nurse is to gather additional assessment data to form a more complete
clinical picture. The nurse can then report the findings as a whole.
Points Earned: 1/1

Correct Answer: A

Your Response: A

13. In planning postoperative interventions to promote ambulation, coughing, deep

breathing, and turning, the nurse recognizes that which of the following actions will
best enable the patient to achieve the desired outcomes?

A.
Giving the patient positive feedback when the activities are completed.
B.
Administering adequate analgesics to promote relative freedom from pain.
C.
Warning the patient about possible complications if the activities are not performed.
D.
Asking the patient to verbalize understanding of and demonstrate performance of
activity.
Even when a patient understands the importance of postoperative activities, it is unlikely that the
best outcome will occur unless the patient has sufficient pain relief to cooperate.
Points Earned: 1/1

Correct Answer: B
Your Response: B

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NCLEX Examination Review Questions

Submitted by kharris401 on 4/16/2011 6:49:31 PM

Points Awarded 29
Points Missed 1
Percentage 97%

1. A patient has ptosis secondary to myasthenia gravis. Which of the following assessment
findings would the nurse expect to see in this patient?
 A. Redness and swelling of the conjunctiva
B. Dropping of the upper lid margin in one or both eyes
C. Redness, swelling, and crusting along the lid margins
D. Small, superficial white nodules along the lid margin
Ptosis is the term used to describe dropping of the upper lid margin, which may be either
unilateral or bilateral. Ptosis can be a result of mechanical causes, such as an eyelid tumor or
excess skin, or from myogenic causes such as myasthenia gravis.
Points Earned: 1/1

Correct Answer: B

Your Response: B

2. When assessing an adult patient's external ear canal and tympanum, the nurse would:

A. Ask the patient to tip his or her head towards the nurse.
B. Identify a pearl gray tympanic membrane as a sign of infection.
C. Gently pull the auricle up and backward to straighten the canal.
D. Identify a normal light reflex by the appearance of irregular edges.
When examining a patient's external ear canal and tympanum, the patient should be asked to tilt
the head towards the opposite shoulder. The nurse should grasp and gently pull the auricle up
and backward to straighten the canal. A healthy, normal tympanic membrane will appear pearl
gray, white, or pink and have a cone-shaped light reflex.
Points Earned: 1/1

Correct Answer: C

Your Response: C

3. When planning care for a patient with disturbed sensory perception related to increased
intraocular pressure caused by primary open-angle glaucoma, which of the following
elements should the nurse focus upon?

A. Recognizing that eye damage caused by glaucoma can be reversed in the early stages
B. Managing the pain experienced by patients with glaucoma that persists until the optic
nerve atrophies
C. Encouraging compliance with drug therapy for the glaucoma to prevent loss of vision
D. Giving anticipatory guidance about the eventual loss of central vision that will occur
Drug therapy is necessary to prevent the eventual vision loss that may occur as a consequence
of glaucoma. For this reason, the nurse should encourage the patient to remain compliant with
drug therapy.
Points Earned: 1/1

Correct Answer: C

Your Response: C

4. Which of the following statements is most appropriate when teaching a patient about timolol
(Timoptic) eye drops in the treatment of glaucoma?
 A. “You may feel some palpitations after instilling these eye drops.”
B. “You may have some temporary blurring of vision after instilling these eye drops.”
C. “You should keep your eyes closed for 15 minutes after instilling these eye drops.”
D. “You should withhold this medication if your blood pressure becomes elevated.”
It is common for patients to have a temporary blurring of vision for a few minutes after instilling
eye drops. This should not cause concern to the patient.
Points Earned: 1/1

Correct Answer: B

Your Response: B

5. Which of the following findings related to primary open-angle glaucoma would the nurse
expect to find when reviewing a patient's history and physical examination report?

A. Seeing colored halos around lights

B. Absence of pain or pressure
C. Blurred vision in the morning
D. Eye pain accompanied with nausea and vomiting
Primary open-angle glaucoma is typically symptom-free, which explains why patients can have
significant vision loss before diagnosis unless regular eye exams are being performed.
Points Earned: 1/1

Correct Answer: B

Your Response: B

6. When teaching a patient about the pathophysiology related to open-angle glaucoma, which of
the following statements made by the nurse is most appropriate?

A. “The lens enlarges with normal aging, pushing the iris forward, which then covers the
outflow channels of the eye.”
B. “There is a decreased flow of aqueous humor into the anterior chamber by the lens of the
eye blocking the papillary opening.”
C. “The retinal nerve is damaged by an abnormal increase in the production of aqueous
humor.”
D. “There is decreased draining of aqueous humor in the eye, causing pressure damage to
the optic nerve.”
With primary open-angle glaucoma, there is increased intraocular pressure because the aqueous
humor cannot drain from the eye. This leads to damage to the optic nerve over time.
Points Earned: 1/1

Correct Answer: D

Your Response: D

7. Which of the following instructions is most appropriate for a patient using contact lenses who
is diagnosed with bacterial conjunctivitis?
 A. Discard current all opened or used lens care products.
B. Put all used cosmetics in a plastic bag for 1 week to kill any bacteria before reusing.
C. Disinfect current contact lenses by soaking in a cleaning solution for 48 hours.
D. Disinfect all lens care products with the prescribed antibiotics drops for 1 week
postinfection.
The patient who wears contact lenses and develops infections should discard all opened or used
lens care products and cosmetics to decrease the risk of reinfection from contaminated products.
Points Earned: 1/1

Correct Answer: A

Your Response: A

8. The nurse who is reinforcing medication teaching with a patient with glaucoma while
administering a scheduled dose of pilocarpine would include which of the following
statements?

A. “This medication needs to be continued for at least 5 years after your initial diagnosis.”
B. “Prolonged eye irritation is an expected adverse effect of this medication.”
C. “It is important not to do activities requiring visual acuity immediately after
administration.”
D. “This medication will help to raise intraocular pressure to a near normal level.”
Pilocarpine causes blurred vision and difficulty in focusing, so it is important not to engage in any
activities requiring visual acuity until the vision clears.
Points Earned: 1/1

Correct Answer: C

Your Response: C

9. Before administration of timolol (Timoptic) eye drops for treatment of glaucoma, the nurse
would assess the patient for which of the following contraindications for the use of this
medicine?

A. Sinusitis
B. Chronic urinary tract infection
C. Chronic obstructive pulmonary disease
D. Migraine headaches
Timolol is a nonselective â-adrenergic blocker that could lead to bronchoconstriction and
bronchospasm. For this reason, it should not be used in patients with severe COPD.
Points Earned: 1/1

Correct Answer: C

Your Response: C

10. When administering eye drops to a patient with glaucoma, which of the following
nursing measures is most appropriate to minimize systemic effects of the medication?
 A. Have the patient put pressure on the inner canthus of the eye after administration.
B. Have the patient close the eyes and move them back and forth several times.
C. Apply pressure to each eyeball for a few seconds after administration.
D. Have the patient try to blink out excess medication immediately after
administration.
Systemic absorption can be minimized by applying pressure to the inner canthus of the eye.
Points Earned: 1/1

Correct Answer: A

Your Response: A

11. The nurse administering a scheduled dose of pilocarpine should place the drops in
which of the following areas?

A. Center of the eyeball

B. Lower conjunctival sac
C. Inner canthus
D. Outer canthus
Ocular medications such as pilocarpine should be instilled into the lower conjunctival sac. Never
apply eye drops directly to the cornea.
Points Earned: 1/1

Correct Answer: B

Your Response: B

12. During change-of-shift report, the outgoing nurse reports a new finding of petechiae in
a new patient admitted with a yet-to-be diagnosed hematologic disorder. On
assessment of this patient, the incoming nurse may expect to find:

A. Tiny, purple spots on skin

B. Large ecchymotic areas on skin
C. Hyperkeratotic papules and plaques
D. Small, raised red areas on the soles of the feet
Petechiae present as tiny, purple spots on the skin. Large ecchymotic areas are purpura;
hyperkeratotic papules and plaques represent actinic keratosis; and small raised red areas on the
soles of the feet signify Osler's nodes.
Points Earned: 1/1

Correct Answer: A

Your Response: A

13. Which of the following laboratory tests would be most important to check in a patient
presenting with purpura?

A. White blood cell count

B. Coagulation studies
 C. Serum electrolytes
D. Urinalysis
Purpura are areas of ecchymoses that may signify a bleeding disorder. Therefore it is most
important for the nurse to assess the patient's coagulation studies.
Points Earned: 1/1

Correct Answer: B

Your Response: B

14. Which of the following clinical manifestations would the nurse expect to find on
assessment of a patient admitted with cellulitis of the left foot?

A. Pallor and poor turgor

B. Cyanosis and coolness
C. Redness and swelling
D. Edema and brown skin discoloration
Cellulitis is a diffuse, acute inflammation of the skin. It is characterized by redness, swelling, and
heat in the affected area. These changes accompany the processes of inflammation and
infection.
Points Earned: 1/1

Correct Answer: C

Your Response: C

15. The nurse would assess a patient admitted with cellulitis for which of the following
localized signs?

A. Pain
B. Fever
C. Chills
D. Malaise
Pain, redness, heat, and swelling are all localized signs of cellulitis. Fever, chills, and malaise are
generalized, systemic manifestations of inflammation and infection.
Points Earned: 1/1

Correct Answer: A

Your Response: A

16. Which of the following interventions would be most helpful in managing a patient
newly admitted with cellulitis of the right foot?

A. Limiting ambulation to 3 times daily

B. Applying warm moist heat
C. Keeping the foot at or below heart level
D. Wrapping the foot snugly in warm blankets
The application of warm moist heat speeds the resolution of inflammation and infection when
accompanied by appropriate antibiotic therapy. It does this by increasing local circulation to the
affected area to bring macrophages to the area and carry off cellular debris.
Points Earned: 1/1

Correct Answer: B

Your Response: B

17. Which of the following laboratory results is the best indicator that a patient with
cellulitis is recovering from this infection?

A. WBC of 16,300/μl
B. WBC of 12,700/μl
C. WBC of 8,200/μl
D. WBC of 3,900/μl
The normal white blood cell count is generally 5,000 to 10,000/μl. For this reason, the patient's
level would be returning to normal if it was 8,200/μl, indicating recovery from cellulitis.
Points Earned: 1/1

Correct Answer: C

Your Response: C

18. The nurse is caring for a patient with second- and third-degree burns to 50% of the
body. The nurse prepares fluid resuscitation based on knowledge of the Parkland
(Baxter) formula that includes which of the following recommendations?

A. The total 24-hour fluid requirement should be administered in the first 8 hours.
B. One half of the total 24-hour fluid requirement should be administered in the first 8
hours.
C. One third of the total 24-hour fluid requirement should be administered in the first
4 hours.
D. One half of the total 24-hour fluid requirement should be administered in the first 4
hours.
Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid
requirement should be administered in the first 8 hours, one quarter of total fluid requirement
should be administered in the second 8 hours, and one quarter of total fluid requirement should
be administered in the third 8 hours.
Points Earned: 1/1

Correct Answer: B

Your Response: B

19. The nurse is caring for a patient with superficial partial-thickness burns of the face
sustained within the last 12 hours. Upon assessment, the nurse would expect to find
which of the following symptoms?
 A. Reddening of the skin
B. Blisters
C. Destruction of all skin layers
D. Damage to sebaceous glands
The clinical appearance of superficial partial-thickness burns includes erythema, blanching with
pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.
Points Earned: 1/1

Correct Answer: A

Your Response: A

20. The nurse is caring for a patient with partial- and full-thickness burns to 65% of the
body. When planning nutritional interventions for this patient, the nurse uses which of
the following dietary choices?

A. Whatever the patient requests

B. High caloric and protein foods
C. Full liquids only
D. High protein and low sodium foods
A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can
occur and is characterized by protein breakdown and increases gluconeogenesis. Caloric needs
are often in the 5000 kcal range. Failure to supply adequate calories and protein leads to
malnutrition and delayed healing.
Points Earned: 0/1

Correct Answer: B

Your Response: D

21. A patient is admitted to the emergency department with first and second degree burns
after being involved in a house fire. Which of the following assessment findings would
alert the nurse to the presence of an inhalation injury?

A. Singed nasal hair

B. Generalized pallor
C. Burns on the upper extremities
D. History of being involved in a large fire
Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal
hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous
sputum, history of being burned in an enclosed space, and "cherry red" skin color.
Points Earned: 1/1

Correct Answer: A

Your Response: A

22. When caring for a patient with an electrical burn injury, the nurse would question a
health care provider's order for:
 A. Urine for myoglobulin
B. Mannitol 75 g IV
C. Lactated Ringer’s at 25 ml/hr
D. Sodium bicarbonate 24 mEq every 4 hours
Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular
necrosis (ATN). Treatment consists of infusing lactated Ringer's at a rate sufficient to maintain
urinary output at 75 to 100 ml/hr. Mannitol can also be used to maintain urine output. Sodium
bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the
presence of myoglobin. An infusion rate of 25 ml/hr is not sufficient to maintain adequate urine
output in prevention and treatment of ATN.
Points Earned: 1/1

Correct Answer: C

Your Response: C

23. A patient is admitted with first- and second-degree burns covering the face, neck,
entire right upper extremity, and the right anterior trunk area. Using the rule of nines,
the nurse would calculate the extent of these burns as being:

A. 9%
B. 18%
C. 27%
D. 36%
Using the rule of nines, the face and neck together encompass 9% of the body area; the right
upper arm encompasses 9% of the body area; and the entire anterior trunk encompasses 18%
of the body area. Since the patient has burns on only the right side of the anterior trunk, the
nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the
three areas together, the nurse would correctly calculate the extent of this patient's burns to
cover approximately 27% of the total body surface area.
Points Earned: 1/1

Correct Answer: C

Your Response: C

24. When admitting a patient with the diagnosis of labyrinthitis, the nurse would expect to
find which of the following manifestations supporting this diagnosis? (Select all that
apply.)

A. Vertigo
B. Tinnitus
C. Nystagmus
D. Hypotension
Labyrinthitis is an inflammation of the inner ear affecting the cochlear and/or vestibular portion
of the labyrinth. Symptoms include vertigo, tinnitus, nystagmus, and hearing loss on the affected
side.
Points Earned: 3/3
 Correct Answer: A, B, C

Your Response: A, B, C

25. The nurse is planning care for a patient with partial- and full-thickness skin destruction
related to burn injury of the lower extremities. Which of the following interventions
would the nurse expect to include in this patient's care? (Select all that apply.)

A. Daily cleansing and debridement

B. Administration of diuretics
C. Escharotomy
D. Application of topical antimicrobial agent
An escharotomy (a scalpel incision through full-thickness eschar) is frequently required to
restore circulation to compromised extremities. Daily cleansing and debridement as well as
application of an antimicrobial ointment are expected interventions used to minimize infection
and enhance wound healing. With full-thickness burns, myoglobin and hemoglobin released into
the bloodstream can occlude renal tubules. Adequate fluid replacement and diuretics are used to
prevent this occlusion.
Points Earned: 4/4

Correct Answer: A, B, C, D
Your Response: A, B, C, D

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