NCLEX TIPS: ( NCLEX questions and some pointers )

(…some questions have incomplete choices….just refer to your Saunders for some of the
topics mentioned……) 

1) BILI-BLANKET DO’S AND DON’TS

One method of phototherapy in the hospital or at home is a fiber-optic blanket
(bili-blanket). It consists of a fiber-optic pad (A), a cable connector (B), and a
light generating box (C). Use of the bili-blanket is simple and safe as long as the
directions for use are followed.

DO make sure the light source box is on a flat, non-absorbent surface. Do not
place on carpet or sit on the crib mattress.
DO make sure as much of the infant’s skin is in direct contact with the light pad.
Diapers should be worn.
DO have the disposable cover as the ONLY material between the light-emitting
side of the pad and infant’s skin. Clothing may be worn over the pad.
DO leave the light pad on when holding or feeding your baby.
DO turn off light when bathing your infant.
DO change the disposable cover if it becomes soiled.
DO use a 3-prong plug for safety.
DO set the intensity knob on the light box to the highest setting.

DON’T use the light-emitting pad without a disposable cover.

DON’T directly expose your baby’s eyes to the covered light pad.
DON’T sit anything on top of the light source box or the fiber optic cable
***they asked how to properly pull out the electric cord..

2) In Sengstaken Blakemore tube, there are two balloons, one in the stomach and one in
the esophageal part, a pair of scissors is kept near the patient at all times in case balloons
migrate superiorly and cause respiratory obstruction in non-intubated patients. The whole
tube can be cut and removed.

3) What are the usual virus used for bioterrorism. (select all that applies.)

4) Question on LOW ALARM SOUND -- means what?....disconnected tubing

5) HIGH ALRAM SOUND-- pt needs suctioning

6) About Clostridium Difficile, how to control infection, isolation precaution( use

disposable stethoscope is the answer)

7) C/I in coumadin but at the same time needed to be avoided by a pt. Getting
constipated, for fear of bleeding.

8) Can parvovirus be used as bioterrorist agent? definitely NO!

9) Select all that applies: topic was about :

COUMADIN, HOW TO START HEPLOCK,SEQUENCE OF HEIMLICH

MANEUVER, SEQUENCE ON RAPID INTUBATION and EMRGENCY
DRUGS..

10) Compound fracture of left radius – position after long cast is applied

11) CVA – ® weakness with receptive aphasia – instructions on tooth brushing

12) Lyme’s disease ( types of travelers at risk)

13) Heart failure with HPN. What to question. Select all that apply (medications)

14) Management for thrombocytopenia

15) Pls read on the ffg:

PPD is now TST-tuberculin skin testing

captopril
duramorph
zafirlukast
vardenafil (like viagra)
zelnorm for irritable bowel disease
Le Veen shunt
digoxin toxicity

16) Rocky mountain dse- type of clothing

17) Thallium scan health teaching

18) Ileostomy care…..Stoma Care…….Colostomy care

19) Tranylcypromine SO4 (Parnate) MAO – foods to avoid

20) Mother feeding a month old child with GERD. What to question

21) Child with Hyperbilirubinemia. Parent teaching

22) 14 y.o. pregnant mother. Caloric requirement

23) Postmature infant

24) Obsessive Compulsive disorder – indicates that the teaching is effective

25) Chest PT- when to perform

26) BPH on Proscar. Adverse effect

27) Father asks what is the action of Vit K to the newborn

28) Incentive spirometer correct usage

29) Nitroglycerin spray (Nitrolingual)

30) Diversional activity for an 8 y.o. child

31) Child with chickenpox has severe itching and ------. How to prevent secondary
infection?

32) Bacterial meningitis room

33) Sterile techniques are done only by nurses…..remember that

ASSESSMENT,TEACHING AND EVALUATION should not be
delegated.

34) abdominal aortic aneurysm= s/s and positioning

35) pls read about aging process… a lot of questions re: elderly

36) cerebral palsy- feeding technique

37) clept lip/palate- type of nipples

38) diverticulitis/diverticulosis

39) Pls. check the word “assent”…means: to agree to something or express agreement….
research from Encarta. This was encountered for the 3rd time now.

40) RSV…Contact precaution, not respiratory precaution

41) Rubella vaccine…not recommended to pt. undergoing infertility test

42) Flu vaccine….don’t give it to pts w/ allergy to eggs

43) Clozaril… need for blood exam

44) Pls. read on post management of the ffg: HIP replacement, Below the knee
amputation and Above the knee amputation
45) Level of fundus 20 hrs after…. At the umbilicus

0 ) hernia- type of repair, post op care

47) Utilize blood and body fluids precaution which is STANDARD (Formerly known
as universal)

1. Hand hygiene
2. Gloves when in contact with blood and body fluids
3. Goggles if splashes are likely to happen
4. Gowning if soiling is likely
5. the use of 1 mouth barrier for cpr
6. never recap used needles and sharps, place them in a biohazard container
7. the use of needleless system
8. in cases of needle sticks/ prick…. wash the area, report, assessment of the
nurse's blood and patient plus possible prophylaxis

48)

Who needs
For a patient with alcoholism, they will have
vitamin B and
an increase need for vitamin B; think of B
who needs
and Bottle.
vitamin C?
In a client that smokes, they will have an
increase need for vitamin C. Think of C for
"Smoking has
cigarettes, and associate it with smoking).
a C in
cigarettes."

In shock the blood pressure goes down and

Shock: the pulse goes up to compensate for loss of
circulation.
Opposite of
increased ICP HINT: Remember that in increased ICP, this
in BP and is the exact opposite: BP goes up and pulse
Pulse. rate goes down.

49) ST. JOHN'S WORT

- use to treat mild to moderate depression, anxiety disorders, hysteria, menstruation,

 contusions, myalgia and insomnia.
- has demonstrated antibiotic effects, increasing wound and burn healing
- works by stimulating multiple receptors.

50) All about MRSA…NCLEX’s favorite ( delegation, prioritization, precaution,

management and room assignments )

FACTORS AFFECTING SUSCEPTIBILITY TO MRSA

M ultiple or prolonged antibiotic therapy

R esistance to pennicilin, erhthromycin and tetracycline
S kin open lesions and open wounds
A gressive procedures and invasive indwelling catheters

MANAGEMENT & PREVENTION OF SPREAD

(ABC)
A void monotherapy to prevent emergence of additional drug resistance
B odily secretions must be properly handled
C ontact precaution (eyes, hands, body)
D rug of choice VANCOMYCIN
E quipment, instruments (stethoscope) should only be used by the patient (esp with
extensive infections)
F ingernalis must be kept short
G GGG gloves, gowns and goggles (if splashes are likely to happen)
H andwashing or hand hygiene (first line of prevention)
I solation (cohorting-same organism but should be 3 feet separation)

What is MRSA?
The acronym MRSA stands for methicillin-resistant Staphylococcus aureus.

Common clinical manifestations:

1. Folliculitis - infection of a hair follicle.

2. Carbuncle - deep seated pyogenic (pus-producing) infection of the skin and
subcutaneous tissue.
3. Impetigo - a contagious superficial pyoderma (any pyogenic infection of the skin)
often caused in conjunction with Streptococcus pyogenes
4. Mastitis (inflammation of the breast) - occurs in 1 - 3% of nursing mothers.
5. Wound infections.
6. Osteomyelitis - bone infection.
7. Food poisoning - usually occurs 2 - 6 hours after ingestion of food containing high
concentration of carbohydrates such as custard filled bakery, potato salads and ice cream.
8. Toxic shock syndrome - a severe illness characterized by a sudden onset of high fever,
profuse watery diarrhea, myalgia, followed by hypotension and, in severe cases shock.
Typically occurring in young women ages 15 - 25 using tampons. Starts abruptly during
menses.
9. Scalded skin syndrome - most commonly in children and neonates. Starts abruptly with
perioral (around the mouth) erythema, sunburn-like rash rapidly turning bright red
spreading to bullae (large vesicle appearing as a circumscribed area) in 2-3 days and
desquamating (peeling) within 5 days.
10. Septicemia/endocarditis - associated with age extremes, cardiovascular disease,
diabetes, and heroin addicts.
11. Pneumonia - rare event with S. aureus unless preceded with influenza pneumonia or
aspiration.
12. Neonatal skin lesions - sometimes occurring in hospital nurseries. Often attributed to
hospital staff members (poor hand washing practices) or vaginally colonized mothers.

Incubation period
The incubation period (the time period that the organism gains entry into a patient until
the appearance of the first sign(s) of symptom(s) or infection) for S. aureus infection is
variable and indefinite. Occurs commonly around 4 - 10 days.

Reservoir
Common reservoir for Staphylococcus aureus including MRSA is primarily humans.
Other animals are rarely involved

Mode of transmission
Since Staphylococcus aureus colonizes the anterior nares, auto-infection) is responsible
for many infections that occur in a health-care and community setting. Patients with
purulent drainage that can not be contained are the most common source of possible
epidemic spread. Airborne transmission is rare. Fomite (inanimate objects) is also rare.
Health-care workers can contribute to the spread of S. aureus if they do not perform
common hygienic behavior (i.e., washing of hands, wearing gloves)

Risk factors that should increase the level of suspicion for MRSA:

• History of MRSA infection or colonization

• History in the past year of:
o Hospitalization
o Admission to a long term care facility (nursing home, skilled nursing, or hospice)
o Dialysis and end-stage renal disease
o Diabetes mellitus
o Surgery
o Permanent indwelling catheters or medical devices that pass through the skin into the
body
o Injection drug use
• High prevalence of MRSA in local community or patient population (as indicated by
results of local antimicrobial susceptibility testing, clinical experience and surveillance
data)
• Recent and/or frequent antibiotic use
• Close contact with someone known to be infected or colonized with MRSA
• Recurrent skin disease
• Crowded living conditions (e.g., homeless shelters)
• Incarceration
• Infection among sports participants who have:
o Skin-to-skin contact
o Pre-existing skin damage
o Shared clothing and/or equipment
• Certain populations (e.g., Pacific Islanders, Alaskans Natives, Native Americans)
• Outbreaks of MRSA have been reported among men who have sex with men
• Also consider MRSA in patients with SSTI and poor response to b-lactam antibiotics

Information for patients with S. aureus infection (including MRSA) and their caregivers6
Patients with S. aureus infections including MRSA, their family members and close
contacts should be thoroughly counseled about measures to prevent spread of infection.
Drainage from S. aureus infections, wound dressings and other materials contaminated
with wound drainage are highly infectious.

Infection control messages for patients to prevent transmission of S. aureus SSTI,

including MRSA include:
1. Keep wounds and lesions covered with clean, dry bandages. This is especially
important when drainage is present.
2. Wash hands with soap and warm water or alcohol-based hand rub after touching
infected skin and bandages. Put disposable waste (e.g., dressings, bandages) in a separate
trash bag and close the bag tightly before throwing it out with the regular garbage.
3. Advise family members, other close contacts to wash their hands frequently with soap
and warm water, especially if they change your bandages or touch the infected area or
anything that might have come in contact with the infected area.
4. Consider using clean, disposable, non sterile gloves to change bandages.
5. Do not share personal items (e.g., towels, washcloths, razors, clothing, or uniforms) or
other items that may have been contaminated by wound drainage.
6. Disinfect all non-clothing (and non-disposable) items that come in contact with the
wound or wound drainage with a solution of one tablespoon of household bleach mixed
in one quart of water (must be prepared fresh each day) or a store-bought, household
disinfectant.
7. Wash soiled linens and clothes with hot water and laundry detergent. Drying clothes in
a hot dryer, rather than air-drying, may also help kill bacteria in clothes.
8. Wash utensils and dishes in the usual manner with soap and hot water or using a
standard home dishwasher.
9. Avoid participating in contact sports or other skin-to-skin contact until the infection has
healed.
10. Be sure to tell any healthcare providers who treat you that you have a MRSA, a
“resistant staph infection.”

Infection control practices

Handwashing
Personnel should wash their hands after contact with patients regardless if gloves are
worn. The use of an antimicrobial soap remains controversial. This measure is based on
the assumption that soaps that contain antimicrobial agents will remove MRSA from the
skin more effectively than standard soap. There is little convincing evidence that this
practice is necessary, and its cost-effectiveness has not been established. It is not what
you wa
Masks
The use of masks for caring for a patient with MRSA pneumonia is based on the
assumption that S. aureus can be spread by droplet transmission (similar to tuberculosis).
There is little evidence to support that S. aureus creates this type of aerosol. Masks are
not generally recommended for this type of patient or burn patients.
Housekeeping practices
Use common housekeeping practices for environmental cleaning (facility's procedures) of
a room containing a MRSA infected patient. Common disinfectants such as quaternary
ammonium compounds can use for general cleaning. Phenolics or hypochlorite solutions
are unnecessary.
Laundry and personnel clothing of infected MRSA patients
There is absolutely no need to wash any linens or clothing separately containing
suppurative material from an infected MRSA patient. The normal processing of linen, i.e.,
temperature of water, detergents, sours (to reduce the alkali pH to a slightly acid
condition in order to match human skin's pH), rinsing and drying will eliminate this
organism from such materials.
Dietary dishes
There is absolutely no need to use disposal dishes for someone who is infected with
MRSA. The normal processing of dishes will eliminate this organism.
Common-use equipment
Patients who require whirlpools and foot baths should not be denied this service because
they have an infection caused by MRSA. There is no need to delay this service until the
end of the day or week to allow other patients to use these types of equipment first.
Follow the procedures for cleaning as recommended by the manufacturer. You can place
an infected MRSA patient any time during the day in common-use equipment regardless
of the number of uninfected patients schedule to use them.
Microbiological cultures
Under no circumstance should a healthcare facility submit routine environmental cultures
to determine if MRSA is in the area. Unless epidemiological data strongly suggests that
such items were responsible for spread, environmental cultures should be discouraged.
Patient placement

To isolate a patient who is infected with MRSA the following criteria should be used:
Can the infection be contained with proper dressing?
Is the hygiene of the patient questionable?
Does the patient have mental competence?
Can the patient comply with appropriate hand washing procedures?
Can the staff comply with Standard Precautions?
Room placement
If a private room can not be obtained for isolation and a potential roommate is required
for placement, the following criteria should be used:
Does the potential roommate have any of the following?
Open wounds [ ]
tracheotomy [ ]
NG tube [ ]
G-tube [ ]
Indwelling Foley catheter [ ]
IV sites [ ]
If the answer to any of the above is yes [x], this is not a potential roommate.
If there is an already known colonized or infected patient, then cohorting would be the
most logical procedure.

Isolation systems
Contact isolation (private room) is the preferred method of containment for a patient who
is infected with MRSA. This is based on the assumption that the drainage can not be
contained and the hygiene of the patient is suspect.
MRSA carriers
There is absolutely no need to work restrict staff members who carry MRSA in their
nares or other sites unless they have skin lesions or hygiene is suspect.
Decolonization
Sometimes a patient has recurrent infections caused by MRSA. The physician should be
knowledgeable in the combination therapy that is required if decolonization is going to be
attempted. It is important to note here that decolonization does not always work. The
patient is being subjected to more antibiotics which could cause other factors such as
elimination of indigenous flora (giving rise to Clostridium difficile pseudomembraneous
colitis) or development of more resistant organisms.
Summation
MRSA is a contact organism. Standard precautions (formerly known as Universal
Precautions) when followed, should control the spread of this organism. It is important
that all members of healthcare facilities be in-serviced on the epidemiology of
Staphylococcus aureus as well as other organisms such as vancomycin-resistant
Enterococcus sp. that are endemic to an institution. This document that you have just read
should be placed on all nursing stations so that the epidemiology on MRSA is fully
understood.
51) Prioritization…..Delegation….

Some questions will have all assessment or all implementation as

answers. In this case, you'll have to go with the *BEST* answer. How
to come-up with that is by process of elimination. Read each answer
& ask yourself...."What will the outcome be?" "Is this a true
statement?" If it is...then consider that answer response...but if it's
false...then throw it out. "Does it follow the ABCs?" When following
the ABCs... "will the answer choices make sense?" ie....if the question
is based on a circulation problem & you see a resp & a circulation
choice among the four answers...then by all means pick the
circulatory answer because it fits with the stem of the
question/situation (use your common sense or *critical thinking* skills
here). Ask yourself..."Would a prudent nurse do this or not?" When
you see a question that suggests "further teaching is necessary" or a
senario wherein you, the RN know an UAP or a LPN is performing
something inappropriately, then you'll be looking for an answer with a
"negative" or "wrong" statement. Read each answer & ask
yourself..."Is this a true statement?" & if it is...then throw that
statement out.

As far as delegation, Kaplan stresses that the RN is ultimately

responsible for all tasks delegated. In reality LPNs can be given a lot
of tasks that require assessment/gathering, planning, & evaluating
loads of information...BUT in terms of the NCLEX-RN...they can't
do ANY assessing, planning, evaluation, OR initial teaching. That is
entirely the role of the RN on that exam! Also, LPNs can only be
given patients that are hemodynamically *STABLE*. They can't be
given any patients that require constant monitoring for evaluation
purposes. LPNs are only allowed to implement written orders from
MDs/APNs & follow instructions given to them by the RNs in charge
to cover their patients. As far as the UAPs (unlicensed assistive
personnel)...they can only be given the most basic of psychomotor
nursing tasks like taking vital signs on stable patients...assisting with
ADLs & ambulating patients for therapy & again...no assessing,
planning and evaluation...etc.

Another thing....MDs/APNs/Nsg Mgt/other interdisciplinary

dept/personnel such as MSW/Chaplains/Resp/Occup/Physical
Therapists are *ALWAYS* available to the NCLEX-RN staff nsg!
These people are multiple & fruitful...but remember this.... *DO NOT
PASS THE BUCK TO THEM* !!! You have to assume that there are
standing….if not written orders for your patients...remember...this is a
*perfect world*. If you see in your answer choice where "call the
physician", "contact a supervisor from another dept", "refer grieving
families to the Chaplain", for example, before you've exhausted
everything that YOU as the RN can do for the patient...don't pick
those answers. If though, you read that everything was done for the
patient, i.e. O2 was started, the patient was repositioned, high vent
alarms & you've disconnect the patient & started bagging...then &
only then do you contact the physician, supervisor, Resp
Therapist...etc. You may be asked questions on what to do for a
patient based on their ABGs or common labs...you'll have to know the
normal values & what's expected when they're abnormal & know
where to go from there. The only other time that you will "pass the
buck" is when an UAP or a LPN observed something wrong with
another RN's patient. You are not suppose to assess that patient
since you don't know that patient's base vitals & situation. Only then
would you inform either that RN or contact your supervisor (staying
within your chain of command)...or both. Questions that suggest a
UAP of 12 years or a LPN of 20 years observes a new grad RN do
something that they know (or feel) isn't right. What do you do?
Confront said nurse, observed said nurse in their duties, or ask the
reporting personnel to elaborate on how they come to feel this way.
Unless what the UAP/LPN seen is unsafe...then you as the RN would
ask that personnel to explain their concerns further.

--- just lifted this advice, hope this helps…..

0 Which of the following places a client to the development of ovarian cancer?

SELECT ALL THAT APPLY:
 A. Nulliparity
B. Genetic predisposition
C. White women
D. Regular menses
E. Asian Women
F. More frequent between 11 to 19 years of age

Correct Answer: A, B, C

Risk factors for the development

of Ovarian Cancer are as follows

Think of the acronym OVARIAN:

Ovarian dysfunction
Vaginal use of talcum powder
Alcohol
Race - White women & family history
Infertility
Age - Peak=5th decade of life
Nulliparity

53) Situation: an electrician is fixing a light bulb & you are assisting him with ecart in
front of you closed & locked, a JCAHO inspector is around, your back on
him, & calls you what's the first thing to do...a) greet him b)shake hands
c)ignore him d)turn your back & acknowledge him. ans: C - IGNORE HIM,
you must never leave the ecart out of your sight, when there is someone like the
electrician fixing it in front of you, just ignore the inspector

54) After immediate post operative hysterctomy patient to observe (or) Nursing
care includes

a) Observe vaginal bleeding

b) Urine output
c) Vital signs

55) Which statement best describes the effects of immobility in children?

A) Immobility prevents the progression of language and fine motor development

 B) Immobility in children has similar physical effects to those found in adults
C) Children are more susceptible to the effects of immobility than are adults
D) Children are likely to have prolonged immobility with subsequent complications

The correct answer is B:

Care of the immobile child includes efforts to prevent complications of muscle
atrophy, contractures, skin breakdown, decrease metabolism and bone
demineralization. Secondary alterations also occur in the cardiovascular,
respiratory and renal systems. Similar effects and alterations occur in adults.

56) Which of the following sports can be safely recommended for patients with
Hemophilia?

Horseback riding, Outdoor rock climbing, golf, or racquetball. The

correct answer is: GOLF

Safe and can be recommended for most people with hemophilia.

Recommended sports in which most individuals with hemophilia can participate
safely: *aquatic/water exercises *archery *elliptical machine
*frisbee *golf *hiking *tai chi(martial arts) *sailing *snorkeling *stationary bike
*swimming*walking

57) Following change-of-shift report on an orthopedic unit, which client should the nurse
see first?
A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
C) 72 year-old recovering from surgery after a hip replacement 2 hours ago
D) 75 year-old who is in skin traction prior to planned hip pinning surgery.

The answer is C because it is the least stable among the four choices. Patients
undergoing such surgery are at high risk of fat embolism especially during the
first 72 hours. She may be at risk of fat embolism.

58) A client arrives in the emergency room ff. an eye injury from a chemical solution.
The nurse would do which of the ff. first?
 1. Test the eye pH with litmus paper.
2. Irrigate the eye.
3. Cover the eye with sterile saline solution and contact the physician.
4. Place a pressure dressing on the eye until the physician arrives.

59) Which nursing intervention will be most effective in helping a withdrawn client to
develop relationship skills?

A) Offer the client frequent opportunities to interact with 1 person

B) Provide the client with frequent opportunities to interact with other clients
C) Assist the client to analyze the meaning of the withdrawn behavior
D) Discuss with the client the focus that other clients have similar problems

The correct answer is A: Offer the client frequent opportunities to interact with 1
person. The withdrawn client is uncomfortable in social interaction. The nurse-
client relationship is a corrective relationship in which the client learns both
tolerance and skills for relationships.

60) When planning care for client with small bowel obstruction, what should the nurse
consider as her primary goal?
a. report of pain relief.
b. maintenance of body weight
c. maintenance of fluid balance
d. reestablishment of bowel pattern

Answer is C, maintenance of fluid balance. The primary action of the small

intestines is absorption of nutrients.
Pain is a physiologic symptom. What varies among individual, is the tolerance to
pain. All human beings have the same threshold to pain, meaning the amount of
stimulus to evoke pain is the same. However, the tolerance varies. That's the
reason why some may tend to bear it without taking meds, like what Filipinos are
known for.

61) A nurse suffers a needle stick while treating an AIDS patient. What should the
nurse do?

A) Talk to a counselor.
B) Start AZT treatment.
C) Make an appointment with a social worker.
D) Nothing.
62) WHAT DOES UMBRELLA EFFECT MEAN?

you have four chioces right? and one of it contains all the all the answer...
a.assess heart rate
b.ssess Pulse rate
c.heck temperature
d. assess vital signs

Vital signs - it contains all of them..like an "umbrella"

Choose an option which is:

*more inclusive
* more benefits for the patient
* drugs with lesser side effect
* or sometimes, (educated guess) the longest option in the exam

63) During Disaster drill, which of the ff. Pts should you discharge to empty one bed?
a. pt. with glas. coma scale of 3
b. pt with head trauma and injury to C4 level
c. pt with CAD with bp of 189/98 and RR of 28
d. pt w/ ESRD with BUN 20, potassium of 5.5

64) As the RN responsible for a client in isolation, which can be delegated to the
practical nurse (PN)?

A.)Reinforcement of isolation precautions

B) Assessment of the client's attitude about infection control
C) Evaluation of staffs' compliance with control measures
D) Observation of the client's total environment for risks

65) While examining a new mother, she asks you about PKU. Which of the
following statements about PKU is true?

A)The effects of PKU cannot be reversed with the correct treatment.

B) PKU does not cause mental problems.
C) The lab values of PKU cannot be determined by a Guthrie test.
D) The urine shows low levels of phenylpyruvic acid.

* PKU causes permanent damage

66) A thirty-year old blind patient has been admitted to your ward. Which of the
following is your primary responsibility as charge nurse?
 A) Inform your supervisor.
B) Communicate your patient's needs to others.
C) Create a secure environment for the patient.
D) Contact a specialist.

67) A woman who is trying to get pregnant asks a nurse how she can increase her
intake of folic acid. Which of the following foods contains the highest
concentrations?

A) Potatoes.
B) Dairy products.
C) Green vegetables.
D) White meat

68) A father asks you when he should begin his child's potty training. Which of the
following is true:

A) A child should begin potty training as soon as s/he is 3 years old.

B) The most important aspect of potty training is giving praise.
C) The child must be able to understand instruction before toilet training can
begin.
D) The most important aspect of potty training is the child's mental and physical
abilities.

69) A parent calls your floor after discovering that her child drank washing up
liquid half an hour before. Which of the following should the nurse tell
the parent?

A) Call the Poison Control Center.

B) Force the child to drink milk.
C) Bring the child to the ER as quickly as possible.
D) Not to worry, the child will be fine.

70) A nurse who is assigned to the emergency department needs to understand that
gastric lavage is a priority in which situation?

A) An infant who has been identified as suffering from botulism

B) A toddler who has eaten a number of ibuprofen tablets
C) A preschooler who has swallowed powdered plant food
D) A school aged child who has taken a handful of vitamins

71) A child, age 8, is immobilized with a hip spica cast. To minimize the child's feelings
of isolation, the nurse should:
 A. let the child visit the playroom daily.
B. sit with the child for an hour in the room.
C. place a telephone in the child's room.
D. arrange a visit by a cooperative child from the same unit.

Rationale: School-age children need peer interaction and thrive on peer approval
and acceptance. Allowing the child to visit the playroom daily provides a non
threatening atmosphere for peer interaction and helps the child feel less isolated.
Sitting with the child for an hour wouldn't foster the necessary peer interaction.
Placing a telephone in the child's room would allow the child to communicate
with family and friends but could reinforce feelings of isolation. Having another
child visit would be appropriate only if the child is of the same age-group.

72) Cor pulmonale as a s/e of left sided failure. s/s to expect

a. Crackles, frothy sputum

b. Distended neck veins, bipedal edema

c. Pulmonary edema

COR PULMONALE is failure of the right side of the heart caused by prolonged
high blood pressure in the pulmonary artery and right ventricle of the
heart.

CAUSE:
Any condition that leads to prolonged high blood pressure in the arteries or veins
of the lungs (called pulmonary hypertension) will be poorly tolerated by the R
ventricle of the heart. When this R ventricle fails to properly pump against these
abnormally high pressures, this is called cor pulmonale.

Symptoms - 6'S

S/S of right sided heart failure

Shortness of breath
Symptoms of underlying disorders (wheezing, coughing)
Swelling of the feet or ankles
Skin-cyanosis
Sounds-Abnormal heart sounds

Diagnostic Test
 Echocardiogram (heart ultrasound)
Chest X-ray
CAT scan of the chest
Pulmonary function tests
Swan-Ganz catheterization
V/Q scan
Measurement of blood oxygen by arterial blood gas (ABG)
Lung biopsy (rarely performed)
Blood antibody tests
Blood test for brain natriuretic peptide (BNP) -- a new blood test to detect heart
failure

Treatment (ABC OF COR PULMONALE)

A dminister O2
B edrest
C alcium channel blockers
D iuretic, diet low in salt
E noxaparin, heparin or coumadin (anticoagulants)
F requent follow-up
G iving supplemental oxygen
H eart/lung transplant
I nstruct to avoid triggering factors (smoking)

73) What to check before giving KCl?

The answer is urine output.

Or Assess renal function
Creatinine Level
BUN

Check K+ level. Never ever push KCL IV as bolus or your patient will
immediately have a cardiac arrythmia. It is incorporated with NSS and given at a
set rate. KCL can burn skin and veins in large doses. Doses are adjusted based on
patients age and physical stability. After giving, monitor the heart rythmn.

Remember in NCLEX "No pee No K" it means always check urine output before
giving K
74) A client is admitted with increased ascites related to cirrhosis. Which nursing
diagnosis should receive top priority?

A. Fatigue
B. Excessive fluid volume
C. Ineffective breathing pattern
D. Imbalanced nutrition: Less than body requirements

No indication in the question to support that pt. has actual problem with
breathing, the client is high risk for this problem, so this option is wrong., and no
indication in the question to support fatigue , so eliminate.
simply..A,C,D all are potential problems. Ascites is the acumulation of fluids, so
B IS THE CORRECT.

75) Incorrect statement regarding hiatal hernia

a. maintain fowler’s position after eating

b. avoid eating before going to sleep
c. place binder to prevent heartburn

76) Which one should need further teaching to parents whose child is on apnea monitor:

a. The leads are removed whenever the baby takes a bath

b. The leads are located just below the nipple line
c. The monitor is attached to an extension cord and mounted near the wall
d. The monitor is in the kitchen area where most of the family members take their
meals

The key words are NEEDING FURTHER TEACHING. This means you select
the answer (among the options) that is WRONG or the most wrong for a child on
an apnea monitor.

a.) The leads are removed whenever the baby takes a bath - This is proper/correct
care so it is does not require further teaching.

b.) The leads are located just below the nipple line - This is the correct placement,
so the parents do not require further teaching.

c.) The monitor is attached to an extension cord and mounted near the wall -
BEST ANSWER. It is considered a safety hazard (fire) to use extension cords
(household extension cords) with medical equipment. In addition, cords along the
floor are a hazard for tripping and falling. Because of the safety issue (remember
NCLEX is asking about SAFE and EFFECTIVE care) the parents need further
teaching if they were to do this.
 d.) The monitor is in the kitchen area where most of the family members take
their meals.- This audio monitor should be place where it can be heard. The child
is monitored directly, but there is an audio monitor/alarm that would sound if the
child has an apneic episode. This is correct procedure, so no further teaching is
required.

77) Which of these clients would the nurse recommend keeping in the hospital during
an internal disaster at that facility?

A) An adolescent diagnosed with sepsis 7 days ago and whose vital signs are
maintained within low normal limits.
B) A middle-aged woman known to have had an uncomplicated myocardial
infarction 4 days ago
C) An elderly man admitted 2 days ago with an acute exacerbation of
ulcerative colitis
D) A young adult in the second day of treatment for an overdose of
acetometaphen

C…. is the only unstable one, and this condition exacebates, high risk for
electrolyte imbalance

78) A client had an accident with brow laceration and fractured of the jaw. Suturing of
the laceration and maxillary pinning was done. Which of the following
action of the nurse is appropriate? The answer– keep wire cutter at bedside

79) Food processing…..

A) frozen food can be defrost for up to six hours....

B) Frozen food which has been defrost can be return back to fridge...
C) Cook perishable food should cover and cool....
D) Frozen food should be defrost by using hot water....

Food processing…..
A) frozen food can be defrost for up to six hours.....NOT the best answer. Leaving
frozen food out of the freezer for this length of time will accomplish the goal of
defrosting the item, but at the same time harmful bacteria can replicate and the
end result is the person can become sick when they ingest the item. Therefore this
is an inappropriate and unsafe method of defrosting frozen food.

B) Frozen food which has been defrosted can be return back to fridge...NOT the
best answer. Frozen food that has been defrosted must be cooked first before
refrigerating it in order to kill harmful bacteria.
 C) Cook perishable food should be covered and cooled.... BEST ANSWER. Of all
the available choices, this is least likely to promote the growth of
bacteria/microorganisms that can cause a food borne illness.

D) Frozen food should be defrosted by using hot water....NOT the best answer.
Using this method of defrosting facilitates bacterial growth.

Source of the information supporting the best answer: USDA (United States
Department of Argiculture)

80) A client with diabetes mellitus (type I). NPH insulin given at 8:00 am- When do you
expect the effect?

A) at noon
B) late afternoon
C) early afternoon
D) early evening

81) What is the priority for a hypertensive client on CAPTOPRIL( capoten)

a. encourage to take medicine with meals

b. discuss need for potassium supplement
c. If client misses a dose, take 2 doses at next scheduled time
d. Instruct client to take drug one hour before
meals

D - captopril taken on empty stomach at least 1- 2hrs before meal not to decrease
absorption

82) A client with anxiety is manifesting nervousness. What herbal drug is prescribed?

a.) saw palmetto

b.) ma huang
c.) kava kava*
d.) gingko biloba

saw palmetto - used for txt of BPH

gingko bilboa - for memory
kava kava - The effect on the nerve centres is at first stimulating, then depressing.
It can also be used as local anaesthetic it relieves pain and has an aphrodisiac
effect; it has also an antiseptic effect on the urine
Ma huang - is also known as Ephedra. It causes appetite suppression and increases
metabolic rate. It can also lead to hypertension, nervousness, insomnia,
 palpitations, hyperglycemia, and anxiety.

83) WHERE DO YOU PUT PT WITH HEP A

a ) PRIVATE ROOM DOOR CLOSE -ans
b) with mrsa patient
c) with copd pt

84) The sterile technique is broke when

a) The sterile field and supplies are wet

b) Clean the area peripheral to center

The sterile field and supplies are wet - there are wet areas/items which are sterile
(suture, alcohol swab etc).
*Clean the area peripheral to center - General Principle applies to aseptic
technique "inner to outer".

85) Mother called a nurse from home stating that her child having chicken
pox..which of the following statements by the mother needs immediate
follow up?

a. father of the child with liver failure

b. sibling with anemia
c. child just had tonsillectomy
d. child has intermittent low grade fever

a.) Father of the child with liver failure - BEST ANSWER. Rationale: VZIG
(varicella immune globulin) should be administered as soon as possible, but no
later than 96 hours after exposure to chickenpox. Varicella can seriously affect the
liver and this patient, is not only immunocompromised but they already have liver
disease. Therefore their varicella immune status needs to be determined ASAP so
that appropriate treatment can be started. FYI, the revised adult immunization
guidelines call for patients with chronic liver disease (including alcohol induced
liver disease) to receive varicella immunization, if they are not immune to the
disease.

b.) Sibling with anemia - Not the best answer (see above rationale). Also,
"anemia" without a qualifying adjective (i.e. aplastic, sickle cell, etc.) implies
deficient number of red blood cells and decreased oxygen carrying capacity. The
problem the child would evidence would be related to oxygenation. They are in
fact more susceptible to infection, but their WBCs aren't affected. The patient in
response A, is at greater risk.
 c.) Child just had tonsillectomy-Not the best answer. Remember in priority
questions you have to make a determination as to who is sickest, or who needs
care first. You would in fact be concerned about this patient, but in response A you
have a limited period of time to treat and prevent further disease or death.
Response A, will die without proper care and treatment. Response C isn't "as
critical". There are infection control issues with this answer, i.e. child had ENT
surgical procedure during period of communicability and this infection is spread
via droplet route, so hospital notification would have to occur.

d.) Child has intermittent low grade fever-This is anticipated associated symptom.
Parents would be instructed to avoid aspirin products to prevent Reye's syndrome
from occurring.

86) Who will u see first:

a.) black and blue at the lumbo sacral area

b.) shiny white pearls at the fountain in the gums
c.) red spots at the trunk that blanches when pressed
d.) irregular blue and red spots at the buccal membrane

a.) black and blue at the lumbo sacral area – Mongolian spot common in Asian
NB
b.) shiny white pearls at the fountain in the gums – commonly found in NB
which generally shed in a few weeks time

c.) red spots at the trunk that blanches when pressed. – may be due to viral
infection such as Herpes wherein rashes starts at the trunk (rashes blanches when
pressed while a rash that doesn’t blanch when pressed it may be a petechiae or
purpura)

d.) irregular blue and red spots at the buccal membrane – Koplik’s spot seen
commonly with patients with measles is described as small, grain-of-sand sized,
irregular, bright red spots with blue-white centres, occurring on the inside of the
cheek (buccal mucosa)

Subcutaneous emphysema occurs when air enters the tissue under the skin
covering the chest wall or neck. This can happen due to stabbing, gun shot
wounds, other penetrations, or blunt trauma it can often be seen as a smooth
bulging of the skin. When a health care provider feels the skin (palpates), it
produces an unusual crackling sensation as the gas is pushed through the tissue.
 I think its C….double check this pls

87) During NGT insertion what should be avoided

a.) normal saline

b.) sterile water
c) mineral oil

88.) The nurse is teaching basic infant care to a group of first-time parents. The nurse
should explain that a sponge bath is recommended for the first 2 weeks of life
because:

a) New parents need time to learn how to hold the baby.

b) The umbilical cord needs time to separate.
c) Newborn skin is easily traumatized by washing.
d) The chance of chilling the baby outweighs the benefits of bathing.

Answer B is correct. The umbilical cord needs time to dry and fall off
before putting the infant in the tub. Although answers A, C, and D might
be important, they are not the primary answer to the question.

89.) In aging patient is tidal volume capacity increase or decrease?

1. There is no change in total lung capacity/tidal lung capacity (the total volume
of air receives in each breathe), however residual volume and functional residual
capacity increase.

2. High fat diet is correlated to stomach cancer and some kinds of cancers

0 A 43-year-old African American male is admitted with sickle cell anemia. The nurse
plans to assess circulation in the lower extremities every 2 hours. Which of
the following outcome criteria would the nurse use?

a) Body temperature of 99°F or less

b) Toes moved in active range of motion
c) Sensation reported when soles of feet are touched
d) Capillary refill of < 3 seconds

Answer D is correct. It is important to assess the extremities for blood vessel

occlusion in the client with sickle cell anemia because a change in capillary refill
 would indicate a change in circulation. Body temperature, motion, and sensation
would not give information regarding peripheral circulation; therefore, answers A,
B, and C are incorrect.

91) A 30-year-old male from Haiti is brought to the emergency department in sickle cell
crisis. What is the best position for this client?

a) Side-lying with knees flexed

b) Knee-chest
c) High Fowler's with knees flexed
d) Semi-Fowler's with legs extended on the bed

Answer D is correct. Placing the client in semi-Fowler’s position provides the

best oxygenation for this client. Flexion of the hips and knees, which includes the
knee-chest position, impedes circulation and is not correct positioning for this
client. Therefore, answers A, B, and C are incorrect.

92) A 25-year-old male is admitted in sickle cell crisis. Which of the following
interventions would be of highest priority for this client?

a) Taking hourly blood pressures with mechanical cuff

b) Encouraging fluid intake of at least 200mL per hour
c) Position in high Fowler's with knee gatch raised
d) Administering Tylenol as ordered

Answer B is correct. It is important to keep the client in sickle cell crisis hydrated
to prevent further sickling of the blood. Answer A is incorrect because a
mechanical cuff places too much pressure on the arm. Answer C is incorrect
because raising the knee gatch impedes circulation. Answer D is incorrect because
Tylenol is too mild an analgesic for the client in crisis.

93) Which of the following foods would the nurse encourage the client in sickle cell
crisis to eat?

a) Peaches
b) Cottage cheese
c) Popsicle
d) Lima beans

Answer C is correct. Hydration is important in the client with sickle cell disease
to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high
fluid content. The foods in answers A, B, and D do not aid in hydration and are,
therefore, incorrect.
94) A newly admitted client has sickle cell crisis. The nurse is planning care based on
assessment of the client. The client is complaining of severe pain in his feet and
hands. The pulse oximetry is 92. Which of the following interventions would be
implemented first? Assume that there are orders for each intervention.

a) Adjust the room temperature

b) Give a bolus of IV fluids
c) Start O2
d) Administer meperidine (Demerol) 75mg IV push

Answer C is correct. The most prominent clinical manifestation of sickle cell

crisis is pain. However, the pulse oximetry indicates that oxygen levels are low;
thus, oxygenation takes precedence over pain relief. Answer A is incorrect
because although a warm environment reduces pain and minimizes sickling, it
would not be a priority. Answer B is incorrect because although hydration is
important, it would not require a bolus. Answer D is incorrect because Demerol is
acidifying to the blood and increases sickling.

95) The nurse is instructing a client with iron-deficiency anemia. Which of the following
meal plans would the nurse expect the client to select?

a) Roast beef, gelatin salad, green beans, and peach pie

b) Chicken salad sandwich, coleslaw, French fries, ice cream
c) Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
d) Pork chop, creamed potatoes, corn, and coconut cake

Answer C is correct. Egg yolks, wheat bread, carrots, raisins, and green, leafy
vegetables are all high in iron, which is an important mineral for this client. Roast
beef, cabbage, and pork chops are also high in iron, but the side dishes
accompanying these choices are not; therefore, answers A, B, and D are incorrect

96) Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and
hypoxemia. Which of the following activities would the nurse recommend?

a) A family vacation in the Rocky Mountains

b) Chaperoning the local boys club on a snow-skiing trip
c) Traveling by airplane for business trips
d) A bus trip to the Museum of Natural History

Answer D is correct. Taking a trip to the museum is the only answer that does not
pose a threat. A family vacation in the Rocky Mountains at high altitudes, cold
temperatures, and airplane travel can cause sickling episodes and should be
avoided; therefore, answers A, B, and C are incorrect.
97) The nurse is conducting an admission assessment of a client with vitamin B12
deficiency. Which of the following would the nurse include in the physical
assessment?

a) Palpate the spleen

b) Take the blood pressure
c) Examine the feet for petechiae
d) Examine the tongue

Answer D is correct. The tongue is smooth and beefy red in the client with
vitamin B12 deficiency, so examining the tongue should be included in the
physical assessment. Bleeding, splenomegaly, and blood pressure changes do not
occur, making answers A, B, and C incorrect.

98) An African American female comes to the outpatient clinic. The physician suspects
vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation
of this type of anemia, what body part would be the best indicator?

a) Conjunctiva of the eye

b) Soles of the feet
c) Roof of the mouth
d) Shins

Answer C is correct. The oral mucosa and hard palate (roof of the mouth) are the
best indicators of jaundice in dark-skinned persons. The conjunctiva can have
normal deposits of fat, which give a yellowish hue; thus, answer A is incorrect.
The soles of the feet can be yellow if they are calloused, making answer B
incorrect; the shins would be an area of darker pigment, so answer D is incorrect.

99) The nurse is conducting a physical assessment on a client with anemia. Which of the
following clinical manifestations would be most indicative of the anemia?

a) BP 146/88
b) Respirations 28 shallow
c) Weight gain of 10 pounds in 6 months
d) Pink complexion

Answer B is correct. When there are fewer red blood cells, there is less
hemoglobin and less oxygen. Therefore, the client is often short of breath, as
indicated in answer B. The client with anemia is often pale in color, has weight
loss, and may be hypotensive. Answers A, C, and D are within normal and,
therefore, are incorrect.
100) The nurse is teaching the client with polycythemia vera about prevention of
complications of the disease. Which of the following statements by the client
indicates a need for further teaching?

a) "I will drink 500mL of fluid or less each day."

b) "I will wear support hose when I am up."
c) "I will use an electric razor for shaving."
d) "I will eat foods low in iron."

Answer A is correct. The client with polycythemia vera is at risk for thrombus
formation. Hydrating the client with at least 3L of fluid per day is important in
preventing clot formation, so the statement to drink less than 500mL is incorrect.
Answers B, C, and D are incorrect because they all contribute to the prevention of
complications. Support hose promotes venous return, the electric razor prevents
bleeding due to injury, and a diet low in iron is essential to preventing further red
cell formation.

101) A 33-year-old male is being evaluated for possible acute leukemia. Which of the
following would the nurse inquire about as a part of the assessment?

a) The client collects stamps as a hobby.

b) The client recently lost his job as a postal worker.
c) The client had radiation for treatment of Hodgkin's disease as a teenager.
d) The client's brother had leukemia as a child.

Answer C is correct. Radiation treatment for other types of cancer can result in
leukemia. Some hobbies and occupations involving chemicals are linked to
leukemia, but not the ones in these answers; therefore, answers A and B are
incorrect. Answer D is incorrect because the incidence of leukemia is higher in
twins than in siblings.

102) An African American client is admitted with acute leukemia. The nurse is assessing
for signs and symptoms of bleeding. Where is the best site in examining for the
presence of petechiae?

a) The abdomen
b) The thorax
c) The earlobes
d) The soles of the feet

Answer D is correct. Petechiae are not usually visualized on dark skin. The soles
of the feet and palms of the hand provide a lighter surface for assessing the client
for petichiae. Answers A, B, and C are incorrect because the skin might be too
 dark to make an assessment.

103) A client with acute leukemia is admitted at the oncology unit. Which of the
following would be most important for the nurse to inquire?

a) "Have you noticed a change in sleeping habits recently?"

b) "Have you had a respiratory infection in the last 6 months?"
c) "Have you lost weight recently?"
d) "Have you noticed changes in your alertness?"

Answer B is correct. The client with leukemia is at risk for infection and has often
had recurrent respiratory infections during the previous 6 months. Insomnolence,
weight loss, and a decrease in alertness also occur in leukemia, but bleeding
tendencies and infections are the primary clinical manifestations; therefore,
answers A, C, and D are incorrect.

104) Which of the following would be the priority nursing diagnosis for the adult client
with acute leukemia?

a) Oral mucous membrane, altered related to chemotherapy

b) Risk for injury related to thrombocytopenia
c) Fatigue related to the disease process
d) Interrupted family processes related to life-threatening illness of a family
member

Answer B is correct. The client with acute leukemia has bleeding tendencies due
to decreased platelet counts, and any injury would exacerbate the problem. The
client would require close monitoring for hemorrhage, which is of higher priority
than the diagnoses in answers A, C, and D, which are incorrect.

105) A 21-year-old male with Hodgkin's lymphoma is a senior at the local university. He
is engaged to be married and is to begin a new job upon graduation. Which of the
following diagnoses would be a priority for this client?

a) Sexual dysfunction related to radiation therapy

b) Anticipatory grieving related to terminal illness
c) Tissue integrity related to prolonged bed rest
d) Fatigue related to chemotherapy

Answer A is correct. Radiation therapy often causes sterility in male clients and
would be of primary importance to this client. The psychosocial needs of the
 client are important to address in light of the age and life choices. Hodgkin’s
disease, however, has a good prognosis when diagnosed early. Answers B, C, and
D are incorrect because they are of lesser priority.

106) A client has autoimmune thrombocytopenic purpura. To determine the client's

response to treatment, the nurse would monitor:

a) Platelet count
b) White blood cell count
c) Potassium levels
d) Partial prothrombin time (PTT)

Answer A is correct. Clients with autoimmune thrombocytopenic purpura (ATP)

have low platelet counts, making answer A the correct answer. White cell counts,
potassium levels, and PTT are not affected in ATP; thus, answers B, C, and D are
incorrect.

107) The home health nurse is visiting a client with autoimmune thrombocytopenic
purpura (ATP). The client's platelet count currently is 80, It will be most
important to teach the client and family about:

a) Bleeding precautions
b) Prevention of falls
c) Oxygen therapy
d) Conservation of energy

Answer A is correct. The normal platelet count is 120,000–400, Bleeding occurs

in clients with low platelets. The priority is to prevent and minimize bleeding.
Oxygenation in answer C is important, but platelets do not carry oxygen. Answers
B and D are of lesser priority and are incorrect in this instance.

108) A client with a pituitary tumor has had a transphenoidal hyposphectomy. Which of
the following interventions would be appropriate for this client?

a) Place the client in Trendelenburg position for postural drainage

b) Encourage coughing and deep breathing every 2 hours
c) Elevate the head of the bed 30°
d) Encourage the Valsalva maneuver for bowel movements

Answer C is correct. Elevating the head of the bed 30° avoids pressure on the
sella turcica and alleviates headaches. Answers A, B, and D are incorrect because
 Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial
pressure.

109) The client with a history of diabetes insipidus is admitted with polyuria, polydipsia,
and mental confusion. The priority intervention for this client is:

a) Measure the urinary output

b) Check the vital signs
c) Encourage increased fluid intake
d) Weigh the client

Answer B is correct. The large amount of fluid loss can cause fluid and electrolyte
imbalance that should be corrected. The loss of electrolytes would be reflected in
the vital signs. Measuring the urinary output is important, but the stem already
says that the client has polyuria, so answer A is incorrect. Encouraging fluid
intake will not correct the problem, making answer C incorrect. Answer D is
incorrect because weighing the client is not necessary at this time.

110) A client with hemophilia has a nosebleed. Which nursing action is most appropriate
to control the bleeding?

a) Place the client in a sitting position with the head hyperextended

b) Pack the nares tightly with gauze to apply pressure to the source of bleeding
c) Pinch the soft lower part of the nose for a minimum of 5 minutes
d) Apply ice packs to the forehead and back of the neck

Answer C is correct. The client should be positioned upright and leaning forward,
to prevent aspiration of blood. Answers A, B, and D are incorrect because direct
pressure to the nose stops the bleeding, and ice packs should be applied directly to
the nose as well. If a pack is necessary, the nares are loosely packed.

111) A client has had a unilateral adrenalectomy to remove a tumor. To prevent

complications, the most important measurement in the immediate post-operative
period for the nurse to take is:
a) Blood pressure
b) Temperature
c) Output
d) Specific gravity

Answer A is correct. Blood pressure is the best indicator of cardiovascular

collapse in the client who has had an adrenal gland removed. The remaining gland
might have been suppressed due to the tumor activity. Temperature would be an
indicator of infection, decreased output would be a clinical manifestation but
 would take longer to occur than blood pressure changes, and specific gravity
changes occur with other disorders; therefore, answers B, C, and D are incorrect.

112) A client with Addison's disease has been admitted with a history of nausea and
vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-
Medrol). Which of the following interventions would the nurse implement?

a) Glucometer readings as ordered

b) Intake/output measurements
c) Sodium and potassium levels monitored
d) Daily weights

Answer A is correct. IV glucocorticoids raise the glucose levels and often require
coverage with insulin. Answer B is not necessary at this time, sodium and
potassium levels would be monitored when the client is receiving mineral
corticoids, and daily weights is unnecessary; therefore, answers B, C, and D are
incorrect.

113) A client had a total thyroidectomy yesterday. The client is complaining of tingling
around the mouth and in the fingers and toes. What would the nurses' next action
be?
a) Obtain a crash cart
b) Check the calcium level
c) Assess the dressing for drainage
d) Assess the blood pressure for hypertension

Answer B is correct. The parathyroid glands are responsible for calcium

production and can be damaged during a thyroidectomy. The tingling is due to
low calcium levels. The crash cart would be needed in respiratory distress but
would not be the next action to take; thus, answer A is incorrect. Hypertension
occurs in thyroid storm and the drainage would occur in hemorrhage, so answers
C and D are incorrect.

0 A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a
weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The
client is diagnosed with hypothyroidism. Which of the following nursing
diagnoses is of highest priority?

a) Impaired physical mobility related to decreased endurance

b) Hypothermia r/t decreased metabolic rate
c) Disturbed thought processes r/t interstitial edema
d) Decreased cardiac output r/t bradycardia
 Answer D is correct. The decrease in pulse can affect the cardiac output and lead
to shock, which would take precedence over the other choices; therefore, answers
A, B, and C are incorrect.

1 The client presents to the clinic with a serum cholesterol of 275mg/dL and is
placed on rosuvastatin (Crestor). Which instruction should be given to the client?

a) Report muscle weakness to the physician.

b) Allow six months for the drug to take effect.
c) Take the medication with fruit juice.
d) Ask the doctor to perform a complete blood count before starting the
medication.

Answer A is correct. The client taking antilipidemics should be encouraged to

report muscle weakness because this is a sign of rhabdomyositis. The medication
takes effect within 1 month of beginning therapy, so answer B is incorrect. The
medication should be taken with water because fruit juice, particularly grapefruit,
can decrease the effectiveness, making answer C incorrect. Liver function studies
should be checked before beginning the medication, not after the fact, making
answer D incorrect.

2 The client is admitted to the hospital with hypertensive crises. Diazoxide

(Hyperstat) is ordered. During administration, the nurse should:

a) Utilize an infusion pump

b) Check the blood glucose level
c) Place the client in Trendelenburg position
d) Cover the solution with foil

Answer B is correct. Hyperstat is given IV push for hypertensive crises, but it

often causes hyperglycemia. The glucose level will drop rapidly when stopped.
Answer A is incorrect because the hyperstat is given by IV push. The client
should be placed in dorsal recumbent position, not a Trendelenburg position, as
stated in answer C. Answer D is incorrect because the medication does not have
to be covered with foil.

3 The 6-month-old client with a ventral septal defect is receiving Digitalis for
regulation of his heart rate. Which finding should be reported to the doctor?

0 Blood pressure of 126/80

1 Blood glucose of 110mg/dL

2 Heart rate of 60bpm

3 Respiratory rate of 30 per minute

Answer C is correct. A heart rate of 60 in the baby should be reported

immediately. The dose should be held if the heart rate is below 100bpm. The
blood glucose, blood pressure, and respirations are within normal limits; thus
answers A, B, and D are incorrect.

0 The client admitted with angina is given a prescription for nitroglycerine. The
client should be instructed to:

0 Replenish his supply every 3 months

1 Take one every 15 minutes if pain occurs

2 Leave the medication in the brown bottle

3 Crush the medication and take with water

Answer C is correct. Nitroglycerine should be kept in a brown bottle (or even a

special air- and water-tight, solid or plated silver or gold container) because of its
instability and tendency to become less potent when exposed to air, light, or
water. The supply should be replenished every 6 months, not 3 months, and one
tablet should be taken every 5 minutes until pain subsides, so answers A and B are
incorrect. If the pain does not subside, the client should report to the emergency
room. The medication should be taken sublingually and should not be crushed, as
stated in answer D.

1 The client is instructed regarding foods that are low in fat and cholesterol. Which
diet selection is lowest in saturated fats?

0 Macaroni and cheese

1 Shrimp with rice

2 Turkey breast

3 Spaghetti

Answer C is correct. Turkey contains the least amount of fats and cholesterol.
Liver, eggs, beef, cream sauces, shrimp, cheese, and chocolate should be avoided
by the client; thus, answers A, B, and D are incorrect. The client should bake meat
rather than frying to avoid adding fat to the meat during cooking.

2 The client is admitted with left-sided congestive heart failure. In assessing the
clien for edema, the nurse should check the:
0 Feet
1 Neck

2 Hands

3 Sacrum

Answer B is correct. The jugular veins in the neck should be assessed for
distension. The other parts of the body will be edematous in right-sided
congestive heart failure, not left-sided; thus, answers A, C, and D are incorrect.

3 The nurse is checking the client's central venous pressure. The nurse should place
the zero of the manometer at the:

a) Phlebostatic axis
b) PMI
c) Erb's point
d) Tail of Spence

Answer A is correct. The phlebostatic axis is located at the fifth intercostals space
midaxillary line and is the correct placement of the manometer. The PMI or point
of maximal impulse is located at the fifth intercostals space midclavicular line, so
answer B is incorrect. Erb’s point is the point at which you can hear the valves
close simultaneously, making answer C incorrect. The Tail of Spence (the upper
outer quadrant) is the area where most breast cancers are located and has nothing
to do with placement of a manometer; thus, answer D is incorrect.

4 The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered

concomitantly to the client with hypertension. The nurse should:

a) Question the order

b) Administer the medications
c) Administer separately
d) Contact the pharmacy

Answer B is correct. Zestril is an ACE inhibitor and is frequently given with a

diuretic such as Lasix for hypertension. Answers A, C, and D are incorrect
because the order is accurate. There is no need to question the order, administer
the medication separately, or contact the pharmacy.

5 The best method of evaluating the amount of peripheral edema is:

 a) Weighing the client daily
b) Measuring the extremity
c) Measuring the intake and output
d) Checking for pitting

Answer B is correct. The best indicator of peripheral edema is measuring the

extremity. A paper tape measure should be used rather than one of plastic or cloth,
and the area should be marked with a pen, providing the most objective
assessment. Answer A is incorrect because weighing the client will not indicate
peripheral edema. Answer C is incorrect because checking the intake and output
will not indicate peripheral edema. Answer D is incorrect because checking for
pitting edema is less reliable than measuring with a paper tape measure.

6 A client with vaginal cancer is being treated with a radioactive vaginal implant.
The client's husband asks the nurse if he can spend the night with his wife. The nurse
should explain that:

a) Overnight stays by family members is against hospital policy.

b) There is no need for him to stay because staffing is adequate.
c) His wife will rest much better knowing that he is at home.
d) Visitation is limited to 30 minutes when the implant is in place.

Answer D is correct. Clients with radium implants should have close contact
limited to 30 minutes per visit. The general rule is limiting time spent exposed to
radium, putting distance between people and the radium source, and using lead to
shield against the radium. Teaching the family member these principles is
extremely important. Answers A, B, and C are not empathetic and do not address
the question; therefore, they are incorrect.

125) The physician has prescribed Novalog insulin for a client with diabetes mellitus.
Which statement indicates that the client knows when the peak action of the
insulin occurs?

a) "I will make sure I eat breakfast within 10 minutes of taking my

insulin."
b) "I will need to carry candy or some form of sugar with me all the
time."
c) "I will eat a snack around three o'clock each afternoon."
d) "I can save my dessert from supper for a bedtime snack."
 Answer A is correct. Novalog insulin onsets very quickly, so food should be
available within 10–15 minutes of taking the insulin. Answer B does not address a
particular type of insulin, so it is incorrect. NPH insulin peaks in 8–12 hours, so a
snack should be eaten at the expected peak time. It may not be 3 p.m. as stated in
answer C. Answer D is incorrect because there is no need to save the dessert until
bedtime.

126)A client with leukemia is receiving Trimetrexate. After reviewing the client's chart,
the physician orders Wellcovorin (leucovorin calcium). The rationale for
administering leucovorin calcium to a client receiving Trimetrexate is to:

a) Treat iron-deficiency anemia caused by chemotherapeutic agents

b) Create a synergistic effect that shortens treatment time
c) Increase the number of circulating neutrophils
d) Reverse drug toxicity and prevent tissue damage

Answer D is correct. Leucovorin is the antidote for Methotrexate and

Trimetrexate which are folic acid antagonists. Leucovorin is a folic
acid derivative. Answers A, B, and C are incorrect because Leucovorin
does not treat iron deficiency, increase neutrophils, or have a synergistic
effect.

127)A 4-month-old is brought to the well-baby clinic for immunization. In addition to

the DPT and polio vaccines, the baby should receive:

a) Hib titer
b) Mumps vaccine
c) Hepatitis B vaccine
d) MMR

Answer A is correct. The Hemophilus influenza vaccine is given at 4 months with

the polio vaccine. Answers B, C, and D are incorrect because these vaccines are
given later in life.

128)The physician has prescribed Nexium (esomeprazole) for a client with erosive
gastritis. The nurse should administer the medication:

a) 30 minutes before meals

b) With each meal
c) In a single dose at bedtime
d) 30 minutes after meals
 Answer B is correct. Proton pump inhibitors such as Nexium and Protonix should
be taken with meals, for optimal effect. Histamine-blocking agents such as Zantac
should be taken 30 minutes before meals, so answer A is incorrect. Tagamet can
be taken in a single dose at bedtime, making answer C incorrect. Answer D does
not treat the problem adequately and, therefore, is incorrect.

129) A client on the psychiatric unit is in an uncontrolled rage and is threatening other
clients and staff. What is the most appropriate action for the nurse to take?

a) Call security for assistance and prepare to sedate the client.

b) Tell the client to calm down and ask him if he would like to play cards.
c) Tell the client that if he continues his behavior he will be punished.
d) Leave the client alone until he calms down.

Answer A is correct. If the client is a threat to the staff and to other clients the
nurse should call for help and prepare to administer a medication such as Haldol
to sedate him. Answer B is incorrect because simply telling the client to calm
down will not work. Answer C is incorrect because telling the client that if he
continues he will be punished is a threat and may further anger him. Answer D is
incorrect because if the client is left alone he might harm himself.

130) When the nurse checks the fundus of a client on the first postpartum day, she notes
that the fundus is firm, is at the level of the umbilicus, and is displaced to the
right. The next action the nurse should take is to:

a) Check the client for bladder distention

b) Assess the blood pressure for hypotension
c) Determine whether an oxytocic drug was given
d) Check for the expulsion of small clots

Answer A is correct. If the fundus of the client is displaced to the side, this might
indicate a full bladder. The next action by the nurse should be to check for bladder
distention and catheterize, if necessary. The answers in B, C, and D are actions
that relate to postpartal hemorrhage.

131)A client is admitted to the hospital with a temperature of 99.8°F, complaints of

blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are
consistent with a diagnosis of:

a) Pneumonia
b) Reaction to antiviral medication
c) Tuberculosis
d) Superinfection due to low CD4 count
 Answer C is correct. A low-grade temperature, blood-tinged sputum, fatigue, and
night sweats are symptoms consistent with tuberculosis. If the answer in A had
said pneumocystis pneumonia, answer A would have been consistent with the
symptoms given in the stem, but just saying pneumonia isn’t specific enough to
diagnose the problem. Answers B and D are not directly related to the stem.

132)The client is seen in the clinic for treatment of migraine headaches. The drug
Imitrex (sumatriptan succinate) is prescribed for the client. Which of the
following in the client's history should be reported to the doctor?

a) Diabetes
b) Prinzmetal's angina
c) Cancer
d) Cluster headaches

Answer B is correct. If the client has a history of Prinzmetal’s angina, he should

not be prescribed triptan preparations because they cause vasoconstriction and
coronary spasms. There is no contraindication for taking triptan drugs in clients
with diabetes, cancer, or cluster headaches making answers A, C, and D incorrect.

133)The client with suspected meningitis is admitted to the unit. The doctor is
performing an assessment to determine meningeal irritation and spinal nerve root
inflammation. A positive Kernig's sign is charted if the nurse notes:

a) Pain on flexion of the hip and knee

b) Nuchal rigidity on flexion of the neck
c) Pain when the head is turned to the left side
d) Dizziness when changing positions

Answer A is correct. Kernig’s sign is positive if pain occurs on flexion of the hip
and knee. The Brudzinski reflex is positive if pain occurs on flexion of the head
and neck onto the chest so answer B is incorrect. Answers C and D might be
present but are not related to Kernig’s sign.

134)The client with Alzheimer's disease is being assisted with activities of daily
living when the nurse notes that the client uses her toothbrush to brush her hair.
The nurse is aware that the client is exhibiting:

a) Agnosia
b) Apraxia
c) Anomia
d) Aphasia
 Answer B is correct. Apraxia is the inability to use objects appropriately. Agnosia
is loss of sensory comprehension, anomia is the inability to find words, and
aphasia is the inability to speak or understand so answers A, C, and D are
incorrect.

135)The client with dementia is experiencing confusion late in the afternoon and
before bedtime. The nurse is aware that the client is experiencing what is
known as:

a) Chronic fatigue syndrome

b) Normal aging
d) Sundowning
e) Delusions

Answer C is correct. Increased confusion at night is known as "sundowning"

syndrome. This increased confusion occurs when the sun begins to set and
continues during the night. Answer A is incorrect because fatigue is not
necessarily present. Increased confusion at night is not part of normal aging;
therefore, answer B is incorrect. A delusion is a firm, fixed belief; therefore,
answer D is incorrect.

136)The client with confusion says to the nurse, "I haven't had anything to eat all day
long. When are they going to bring breakfast?" The nurse saw the client in the day
room eating breakfast with other clients 30 minutes before this conversation.
Which response would be best for the nurse to make?

a) "You know you had breakfast 30 minutes ago."

c) "I am so sorry that they didn't get you breakfast. I'll report it to the
charge nurse."
d) "I'll get you some juice and toast. Would you like something else?"
e) "You will have to wait a while; lunch will be here in a little while."

Answer D is correct. Nausea and gastrointestinal upset are very common in

clients taking acetlcholinesterase inhibitors such as Exelon. Other side effects
include liver toxicity, dizziness, unsteadiness, and clumsiness. The client might
already be experiencing urinary incontinence or headaches, but they are not
necessarily associated; and the client with Alzheimer’s disease is already
confused. Therefore, answers A, B, and C are incorrect.
137)The nurse is caring for a client hospitalized with a facial stroke. Which diet selection
would be suited to the client?

a) Roast beef sandwich, potato chips, pickle spear, iced tea

b) Split pea soup, mashed potatoes, pudding, milk
c) Tomato soup, cheese toast, Jello, coffee
d) Hamburger, baked beans, fruit cup, iced tea

138)A woman is going to have a mammography, which will you be most concerned
about and need to report?

a.) powders and lotions used under the armpit.

b.) a permanent pacemaker.

Typically in NCLEX priority questions all responses are actions that should be
taken in the situation described in the question. The test-taker is asked which is
the most important. Therefore it would seem that reporting the pacemaker is a
higher priority. In addition this question had asked which needs to be reported.
NCLEX is evaluating the test-taker's knowledge about what can be
handled/addressed by the nurse. The powder and lotions should be removed
completely by either the nurse or the client before the mammogram (the question
indicated the time frame was before the procedure). This is part of safe and
effective care for clients in this situation. Once these products are removed they
are no longer a concern.

In the end the NCLEX test takers have to make up their own mind, which is the
best answer. These questions help those studying for the exam to consider the
underlying rationale for the best answer.

139)Rationale for giving the ffg.

1. D5LR to patients with Dengue Fever?

2. D5.3NaCl to patients with CRF

The reason for giving D5LR in DF is that it serves as alternative fluid if plasma
expander is not yet available. It expands intravascular space to prevent vascular
collapse so as to prevent shock. D5 0.3 Nacl is given in pts with CRF to prevent
hyperkalemia. Remember this fluid has no K+ and you would not place ur pt into
congestion that is why it is given.

140) What to check before giving Epoetin Alfa?

 Check for epilepsy or a history of seizures. Epoetin alfa may cause
seizures. Be careful if you drive or do anything that requires to be awake
and alert.

141) WHAT DIET MOST APPROPRIATE FOR PT WITH

HEPATOENCEPHALOPATHY?

Low protein diet to reduce ammonia production. However, dietary counseling is

important, as too little protein in the diet can contribute to malnutrition. Lactulose
may be given to prevent intestinal bacteria from creating ammonia, and as a
laxative to evacuate blood from the intestines. Neomycin may also be used to
reduce ammonia production by intestinal bacteria

142) When to give Atacid with Tagamet

a.) Antacid given 1 hour after tagamet

b.) Antacid is given with Tagamet
c.) Antacid given 1 hour before Tagamet
d.) Antacid given 30 min before Tagamet

143) A corner of a room is on fire, what to do first?

a.) evacuate the residents

b.) put out the fire
c.) activate the alarm
d.) put the oxygen off

144) Patient with rhematoid arthritis, what to prioritize?

a.) Give anti inflammatory drug before exercising?

b.) Exercise immidiately upon waking up
c.) warm compress the hand before exercising the wrist

145) Medical surgical is full...need to move patient to OB ward.....which patient to move

first

a.)13y/o with rheumatic fever

b.) 23 y/o with pyelonephritis
c.) 45 y/o with SLE (lupus)
d.) 33 y/o with PCP
146) The mother of a 6 month old states that she has started her infant on 2% milk .
Which of the following would be the nurse's best response?

a.)"Your baby will probably be fine with this milk"

b.)"The baby should be switched to whole milk"
c.)"You need to keep the infant on formula"
d.) "You need to switch to formula right now"

147) TB pt understands that he can reduce the risk of spreading his disease if he
states?

a.) i wont sleep in same room w/ my wife for 1-2 months

b.) i will stay away from pregnant women and children
c.) i will use plastic utensil when i eat

148) Allergic to sulfa would not to take?

a.) ma huang
b.) Echinacea

149) Client with allergy to sudafed ..which of the statements is correct?

a.) i will take valerian

b.) i will take ma huang
c.) i will take echinacea for acute viral inf.
d.) i will take black cohosh

150) PATIENT IS PRESCRIBED FOR INDERAL (PROPRANALOL) BEFORE

TAKING THE MEDICATION

a.) TO COUNT THE PULSE

b.) AFTER TAKING THE MEDICATION, LIE DOWN FOR 30 MIN
c.) CHECK BP

151) Alzheimer's patient, incontinent of urine during the night times. The nursing care
includes

a) Offers bed pan every 2 hours

b) Limit fluids during evening times
c) Foley's catheter
152) A young patient most likely to get lead poisoning if?

a. he is drinking from a ceramic pitcher.

b. father refurnishes old furniture at their home

153) A client is receiving O2 via nasal cannula.when providing nursing,which or the

following intervention would be appropriate

a) determine that adequate mist is supplied

b) inspect the nares and ears 4 skin breakdown
c) lubricate the tips of cannula b4 insertion
d) maintain sterile techniqueto when handling cannula

154) A mother tells the nurse that she wants her 4 year old to stop sucking her thumb.
When developing the teaching plan for this mother, which of the following
would the nurse expect to suggest?

a.) Apply a special medicine that tastes terrible on the thumb

b.) Get the child to agree to stop the thumb sucking
c.) Remind the child every time the mother sees the thumb in her mouth
d.) Put the child in "time-out" every time the mother observes thumb sucking

155) A nurse is coming back from her lunch break. Which of the ff patients shld she
assess first?

a.).A pt. that has dissociative personality disorder and goes into the room of an
anxious pt's room
b.). Bipolar pt. that is singing loudly in the activity room.
c.). Deppressed pt. lying on the floor on fetal position.
d.) Delirium pt. pacing up and down the hall, admiring the painting on the wall

156) Risk Factor of colorectal cancer

a.) female
b.) High fiber diet
c.) Bowel inflamatery disease
d.) Irritable bowel syndrome
 157) The nursing team consist of RN who has been practicing for 6 mos.,LPN/LVN
been practicing for 15 years and a nursing assistant who has been practicing for 5
years.The RN should care for which of the following client?

a.) a client 1 day post op after internal fixation of fractured femur

b.) a patient receiving diltiazem and dilantin
c.) a client who is to recieve 2 packed cells prior to an upper endoscopy
procedure
d.) a client who was admitted yesterday with exhaustion and diagnosis of
acute bipolar disorder...

158) What to do first b4 crutch walking?.... take bp lying down & sitting down or
give pain medication first.

159) If you are a Community health nurse w/c one to see first…. 26 y.o with scheduled
terbutaline inhalation or 45 y.o. who needs lithium refill

160) Patient diagnosed with myocardial infarction has lots of crushing chest

pain, what should nurse do first?

a. give morphineÂ

b. administer O2

c. check vital signs

d. start an IV

161) A nurse in the psychiatric ward is making rounds. Which of the below patient
should receive his/her medication FIRST.

a) a patient who is scheduled to have her anxiety med.

b) a patient who just returned from her group therapy and is to receive her

anxiety med.
c) a patient with bi-polar who is wringing her hands and pacing down the
hallways.
d) a patient with depression who has not spoken to staff for several days

162)A 2 year old year old with a suspected diagnosis of hearing impairment. Which of
the following action by the child contribute to the diagnosis?
 A) Child talking few words
B) Child plays alone with other children around
C) Gesture and pointing what he wants

163) Check all that apply what would you expect to see in the aging process:

a.)shortness of breath
b.) dry skin
c.)loss of vision
d.)thin nails
e.)long memory loss

164) Early sign of acute otitis media

a.) hearing loss

b.) rolling of head from side to side
c.) purulent ear discharge
d.) ?

165) Appendicitis what to report to the M.D

a. pain at periumbilical area

b. abdominal distention
c. pain unrelieved by meds

166)Food to question in Diverticulosis

a. fats
b. carbohydrates
c. fiber
d. amino acid

167) Which of the ff is an incorrect statement made by the student nurse about infection
control?

a.) hand washing is the single most effective way of preventing the spread of
infection.
b.) autoclaving kills all pathogenic microorganisms including spores.
c.) autoclaved items is considered sterile until 6mos only.
d.) the skin can never be sterile.
168) Home O2 therapy. Client need further teaching when she state that

a. change my cotton blanket to wool

b. If I experienced a dry mucous membrane, I will put water in the humidifier
c. Telling the family members not to smoke
d. Checked all electrical wirings

169) While a client is being prepared for discharge, the nasogastric (NG) feeding tube
becomes clogged. To remedy this problem and teach the client's family how to
deal with it at home, what should the nurse do?

a) Irrigate the tube with cola.

b) Advance the tube into the intestine.
c) Apply intermittent suction to the tube.
d) Withdraw the obstruction with a 30-ml syringe.

170) A pt. has cor pulmonale as a s/e of left sided heart failure, What are the expected s/s
a) Crackles,frothy sputum
b) Distended neck vein,bi-pedal edema
c) Pulmonary edema
d) Anxiety

171) Which of the ff pt. would the nurse see first

a.) a child with vomiting 4x

b.) a child who had abdominal pain few hours said"my pain is gone"
c.) a child with cough

172)The pt with injury..which of the ff is a correct statement

a.)injury at C2 level,can move independently

a.) C4 can eat alone
b.) T3 can walk alone
c.) T6 dress independently

173) Prioritize:
 a.) Patient call out (to go to the bathroom)
b.) Angry relative about incorrect food tray being left with diabetic mother
c.) Patient calls out bleeding
d.) Doctor on the phone

174) The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's
disease. Which side effect is most often associated with this drug?

a) Urinary incontinence
b) Headaches
c) Confusion
d) Nausea

175) A pt. on heparin infusion, he told the nurse that "his gums bleed when brushing the
teeth", the should do first?
a) notify doctor.
b) stop the infusion.
c) do ptt test
d) give protamine sulfate

Goodluck and Godbless to all!!!!!!!!!!

//compiled by VMH

************************************************************************
------------------NCLEX tips from Sir Darius------------------

NCLEX 2005

32. You have an 80 year old client, what would be a normal aging process?
a. problem with light accommodation
b. increase sensation to pain
c. tingling or sensation at tip of extremities

33. You have a 45 year old who had a Salpingo-oophorectomy hysterectomy. What would
patient say to let you know they understood teaching?
a. I will have to take estrogen for life.
b. I will take estrogen until I am 65.
c. I will take estrogen when I have.

34. A patient on a detox unit went home and upon return told the nurse that he snorted
cocaine this weekend. What should the nurse do?
 a. You should not be seen in the hall
b. You will be ask to leave the program
c. Monitor the vital signs
d. What triggered this drug use over the weekend.
35. As a community health nurse, you have 4 patients with ESRD or hospice and the
caregivers are supposed to call and report to the nurse everyday. Which patient to
see first?
a. a patient who had a new IV line started yesterday evening.

36. A patient on chemotherapy skin is red and irritated. What could possible cause this?
a. frequent bathing daily
b. applying an abrasive ointment
c. drying with a soft cloth

37. A group of patients on radiation therapy. Which one would be cause for intervention?
a. a patient who has prostate cancer with radium seed implants with a 4
year old on his lap
b. a client on external radiation talking to a pregnant woman

38. A client with anorexia. What would be of concern?

a. amenorrhea for 2 months
b. weakness for two weeks
c. hair loss
d. enamel

NCLEX 2005

Geriatrics

0 58 year old woman, what is the most significant in this age?

0 Kyphosis (b) Presbycussis Feedback
Normal aging in the mouth – decrease taste in food

Pharmacology

0 What should be a concern to the nurse when Lactulose is ordered?

0 Pt who has not had bowel movement 3 days ago
1 Pt who has not eaten for a day
2 Spironolactone
3 Action of tagamet in Cystitis
4 Action of Parlodel

1 What to do when administering heparin?

0 Pull back on syringe
1 Massage area after administration
2 Wait to see if hematoma will form
Cancer

0 Highest risk for colon cancer

0 History of Inflammatory Bowel Disease and Colostomy
1 Pt with rectal polyps
2 Pt who smoke
Delegation
0 What should you delegate to a nurses aide
0 ambulate a pt with lobectomy 1 hour ago
1 flush the BGT

2. A nurse have a group of pts, which one can she assign to the CNA?

(a) A pt. with PCP who needs a bath

(b) A pt. who needs dressing change for a decubitus
(c) A pt. who had surgery and needs ambulation

Psychiatric Nursing
What should concern to the nurse
0 child who remains quiet during venipuncture
1 toddler who falls occasionally when
2 walking

Feedback:
0 Domestic violence, main reason for staying with abusive spouse

1 Study chemotherapy drug (methotrexate) i.e bone marrow depression

2 Depression

3 Schizophrenic patient, how does the nurse know that group therapy is working –
come on time for session

4 Post traumatic Stress Syndrome, s & s – insomnia and anxious

5 OCD, ritualistic behavior has started and Pt has a phone call, what should the
nurse tell the caller – call back

6 Delirium tremens, why is shadow in the environment contraindicated

7 The nurse is talking to the spouse of a pt who’s husband had a prostatectomy

when the spouse said “ we will not be intimate anymore”. The nurse will say

0 What does intimate mean to you?

1 Can you tell me more about your relationship?
2 There is difficulty getting an erection after this surgery
8 Husband had an MI. Wife says I don’t know what I would do if I lose him he is
my best friend. Nurse’s response

A.) It’s nice that you can to your husband

B.) What makes you think he is going to die?
C.) Would you like for me to call a family member to stay with you?

9 Trying to find out about a pt’s religion. What question would you ask?

0 What higher being or something

1 What is your religion?
2 Would you like to inform your spiritual adviser about your hospitalization?

11.Pt in labor came in with bruise on neck and arm. What would the nurse do?

A) Ask pt about bruise on neck and arm

B) Try to find out about pts delivery plan

12.A nurse suspects that co-worker is drinking on the job. What should the nurse do?

A) Confront the co-worker about the drinking

B) Watch and report to the supervisor
C) Sit and wait until they have proof
D) Do you need help with pt. care?

13) A parent is terminally ill. How do adult children show that they are coping
effectively?

A) We are planning how we are going to organize care for parent

B) We already began to accept the lost by grieving and crying
C) We reminisce with mom about the good time.

14) The nurse is having a staff meeting to discuss safety for an Alzheimers pt.

A) Encourage staff client to reorient client

B) Place food trays on client in chair
C) Apply a restraint
D) Put alarm on exit doors

15) An Alzheimers client is at home but has the tendency to keep going out side.
What should he do?

A) Put sensors on doors

B) Have the family security guard check client
C) When the days are nice go outside with the client for a walks ??
16) The nurse is talking to a group of adults who were raped in childhood. How would
she know that they are developing high self-esteem?

A) I will be going back to college to get a degree

B) They say that I am attractive
C) I go out dates regularly
D) I feel good in familiar environment

Gastrointestinal

1. Hepatic Encephalopathy need to restrict

0 protein (b) K (c) carbohydrates

2.Child with Tylenol poisoning, what do you assess – right upper quadrant pain and
jaundice

Feedback from another candidate:

0 Pt who just had an ileostomy 2 days ago, states she is going for vacation, what
will the nurse say – it is too soon but you can still travel with an ileostomy
1 Ulcerative colitis and Crohn’s disease
2 Sengstaken Blakemore tube
3 Stool in ulcerative colitis
4 Colostomy irrigation, solution for initial irrigation

Neurologic

1. Most indicator of Amyotrophic Lateral Sclerosis

0 unilateral weakness
1 abnormal involuntary movement
2 paralysis from legs to up

1 Parkinsons disease – serves small bites of food

2 Cranial Nerve III
3 Myasthenia Gravis, appropriate nursing diagnosis
4 Spinal Cord Injury, purpose pt ask why he is being taken for surgery

Shock

0 Most indicator of Septic Shock

0 Hypertension and increase leukocytes count
1 Hypotension and decrease urinary output
Respiratory

1. Ventilator low pressure alarm sounds

0 suction the pt
1 check whether the tube is disconnected
2 the pt is fighting the ventilator
1 Child with inspiratory stridor, what do you assess – ask the mother if they were
remodeling the house few days ago

Feedback from Another Candidate:

A pt is on mechanical ventilator, when the machine starts beeping, who does the nurse
checks first – machine or the pt.
2 PPD test positive for AFB, what will you teach the pt –
3 Breath sounds
4 Chest tube, has bubbling in the suction bottle, what does it tells the nurse
5 Why soft diet in emphysema
6 How to conduct a pulmonary assessment?

A) Place hand around sternum with thumbs touching and feel when diaphgram rises
B) Listen to pt. making sound
C) have pt. breathe in and out listen with a stethoscope

GUT

0 Hemodialysis pt was the following situation, which one should you attend first

0 blood oozing continuously through AV shunt

1 respiration is 32

1 Lower UTI
(a) drainage with pus (b) hesitancy in urination

2 Home technique for catheterization – clean technique

3 Kidney transplant, what would alert the nurse

(a) abdominal tenderness (b) burning sensation during urination (c) 1.8
kg weight gain since transplant a week ago

4 After kidney transplant, pt has urine 1200 cc /day - is it normal or abnormal

6. Glomerulonephritis and Nephrotic syndrome

7. You have a pt with an Ileal Conduit. How would you know that teaching was
effective?
0 For several weeks my urine will be cloudy
1 I will hook up my bag to a drainage system at night
2 I can’t wait for my bag to be ¾ full to empty it

Musculoskeletal

1. Hip replacement, type of exercise

(a) full ROM (b) Quadriceps setting exercise (c) Internal and external
rotation (d) adduction and abduction

2. Crutch walking gait

Endocrine

1. Pt with hypoglycemia, orage juice was given, what do you give next
(a)a bottle of cola (b) a bolus of candy (c) peanut butter

2. Pancreatitis, which one should concern the nurse

0 increase serum amylase (b) upper right quadrant pain
Feedback from another Candidate:

3. Continuous subcutaneous infusion of Insulin, what are you going to teach patient

4. A diabetic pt has no control over his blood sugar, during assessment what will you ask
the pt – use of prednisone

5. Differencce between type I and Type II Diabetes Melitus

6. Hyperglycemia in DM, what should the nurse do first

5 Urine testing in DM, collection of urine specimen

OB
1. PMS, effective teaching
0 Limit intake of chocolate
1 Maintain complex carbohydrates
2 Limit caffeine and tea

Feedback from another Candidate 11/01

2. After an elective abortion of 10 weeks, what is the nursing priority?

3. First phase of labor
4. Use of pitocin
5. Difference between true and false signs of labor
6. Rhogam, criteria
7. Late deceleration
8. PID, s & s – severe lower abdominal pain/ purulent vaginal discharge
9. Premenstrual syndrome
10. Toxemia of pregnancy
11. Purpose of forceps delivery
12. Relief of hypertension in pregnancy
13. Magnesium sulfate, criteria prior to administration
14. Why BSE is done 7 days after menstruation
15. Position of pt in transitional phase of the first stage of labor
16. The nurse is talking to a group of pregnant mothers and she would like to discuss
about sex during pregnancy. What would the nurse say?

0 Sex during pregnancy will cause harm to the fetus

1 In the second trimester the woman has no interst in sex
2 If the couple had a good sex life before the pregnancy there should not be any
change in their sex life
3 It is likely that the couple will experience some change in their sex life

Pediatric
1. Physical competence of 2month old child
2. Purpose of putting newborn
3. Cystic Fibrosis, effectiveness of therapy – clear lung sound
4. Mother refuse immunization for her child – find out her reason
5. Cross-eye in newborn, explanation by the nurse -
6. Aspirin poisoning, what should the nurse do first

1. Mother of a 10 month infant complained about the baby getting up during the night
and disturbing other family members. How can the nurse help her to get the child
to sleep?

0 Leave a bottle of water in the crib

1 Let child cry longer before checking on child
2 Enroll child in infant exercise program

3. A mother comes to the clinic with a 4 month old and a set of 18 month old twins. The
4 month old has a diaper rash and is in the stroller and the only time he gets out of the
stroller is for a check in the examination table. One twin is eating chocolate covered
peanut candy sitting quietly in the chair, while the mom is attending to the other twin
who is being examined. What is a good thing for the nurse to teach about?

0 Hygiene
1 Safety
2 Dental caries
4. Mother complains of being frustrated trying to teach her child toilet training, so she
asks the nurse for help. What should the nurse tell her?

0 Put a diaper on the child at night

1 Review
2 Let mom know that child will let her know when he is ready

5. Preschool child

0 37 inches
1 56 inches
2 Tie shoe lace

6. The nurse is assessing a group of infants.What should be cause for concern?

A) negative moro tonic neck reflex

B) A 5 mnth. old with negative palmar grasp

7. A pt has Bells Palsy. What will pt say to let you know he understands the disease?

A) I heard its related to a stroke

B) I heard that some people have a complete recovery
C) Constant lacrimation
TRIAGE

8. You are a nurse working a emergency room and you have these pt.s. Who would you
see first

0 17 yr. old with amputated toe and 2nd degree burn

1 7 yr old with a fractured femur or tibia and crying
2 70 yr old with chest contusion and restless

9. You have these pts and they are roommates, which one of these room assignments
would you question?

0 A 6 month old with RSV and a 5 month old with RSV

1 Hemophiliac in a private room
2 A pt with Bronchiolitis and a pt with a fracture

10. A 2 day old infant is asleep and needs to be assessed. What should the nurse do first

A)Take an axillary temp.

B) Measure the head circumference
C) Listen to the bowel sound
11. Client admitted with DKA. What order to carry out first?

A) Etablished or initiate blood glucose level

B) Check BUN result
C) Administer 0.9 normal saline
D) Insert catheter

12. You are going out on home visits to see 4 pt’s who live within 3 miles of each other.
Which one will you see first?

A) A pt who had abdominal surgery and needs abdominal packing and dressing
change
B) A pt who is on IV antibiotics that is due within an hour

Integumentary

1. Characteristic of 2nd degree burn – waxy white and pain

2. Why increase fluids in burn
3. Precipitant factor to SCC

EENT
Glaucoma, early s & s

CD

0 A child who is about to take OPV, what is contraindicated

0 signs and symptoms of cold
1 taking steroid therapy

1 HIV
(a) use separate utensils (b) use chlorox to wash drainage spill

2 Wound precaution – gown and gloves

3 Nurse doing health promotion to stop/modify risky behavior. Who needs to

modify their behavior?
0 A pt with vaginal wart and multiple sexual partners
1 A pt whose sister had a breast cancer
2 An electrician who has prostate cancer

Legal

Which one require incident report – a patient with brochoscopy eat food served
Physical Assessment
Auscultation of the Chest

0 use the diaphragm (b) use the bell

Difference of chest pain in MI and pulmonary embolism

You need to assess the abdomen.Which one do you carry out first?

a) abdominal girth
b) ascultate
c) palpate
d) percuss

1) What would be a cause for concern?

a) capilliary refill 4 – 6 seconds

Others
0 purpose of hospice care- for terminally ill pt so that they can die with dignity

GUT

0 Renal failure, the patient will have

0 hyperkalemia b. hypokalemia

1 Glomerulonephritis, what will you intervene?

a. hypertension b. hypotension

3. Urinary Tract Infection, signs and symptoms

a. penile discharge with pus b. hesitancy on urination

4. Discharge teaching for TURP?

* Perineal exercise

5. Hemodialysis patient has the following situations, which one do you attend
first?
a. blood oozing continuously through AV shunt
b. respiration is 32

6. Lower UTI
a. drainage with pus b. hesistancy on urination
 7.Kidney transplant, what would alert the nurse
a. abdominal tenderness
b. burning sensation during urination
c. 1.8 kg weight gain since transplant a week ago

8. After kidney transplant, patient has urine 1200 cc/day. Is it normal or

abnormal?

9. Glomerulonephritis and Nephrotic syndrome.

PEDIA

1. View of death by preschooler?

* Prolonged sleep

2. Study newborn reflexes

* I had two questions

3. When would you intervene as RN?

* a 10 month old baby can’t transfer a toy from hand to hand

4. Baby born to cocaine mother, signs and symptoms

5. Toy for 2 month old

6. A question about formula for a 5 month old baby

* do not mix cereal in it

7. Sickle cell crisis, nursing intervention

* narcotic and hydration

8. Hypospadias, what can the nurse observe when patient urinate?

9. Study cleft lip and cleft palate

* type of feeding device

10. Why Vitamin K given to newborn?

11. Meningococcal meningitis, universal precautions

12. Physical competence of 2 month old child

 13. Purpose of putting newborn in warmer

14. Cross eye in newborn explanation by the nurse

15. Aspirin poisoning, what should the nurse do first

16. A child with esophageal fistula

a. projectile vomiting b. potential for aspiration

17. Toy for two year old

rocking horse

ONCOLOGY-MS

1. Leukemia is hospitalized, safety question

remove fresh plants from the bedside

RESPIRATORY-MS

0 COPD patient understanding of illness

0 I will use separate bathroom
b. I will cover my nose and mouth when coughing

DRUGS

1. Tenormin, side effect

2. Oncovin, side effect

3. Theophylline, toxic effect

* bradycardia and vomiting

4. Tagamet and Maalox, how to administer

a. give together
b. give both after meals
c. give 1 hour apart

PSYCH
1. Milieu therapy, for manic patient
* quiet, non-stimulating with neutral pale colors
 2. Food for manic patient
* cookies, carrot stick, raisin

3. Manic patient disturbing the group, what should you do?

4. Post ECT, nursing intervention

CARDIO
0 Community health nurse, which patient to see first
a. patient w/ leg pain
b. give insulin with blood glucose at 250

2. Signs and symptoms of pacemaker failure

PROCEDURE

1. Purpose of incentive spirometer

2. Care of the patient with chest tube

3. Thoracentesis, position

4. How to collect 24 hour urine specimen

5. Foley catheter insertion, procedure

GASTRO

1. Ileostomy, how do you know that patient is coping well

2. Risk for cancer of the stomach

VASCULAR

1. Aplastic anemia, nursing diagnosis

high risk for infection
NEURO

1. Cervical injury, common complication

autonomic dysreflexia

ENDOCRINE

1. Study hypothyroidism and hyperthyroidism

COMMUNICABLE DISEASE

1. Who is at risk for Hepatitis B?

a. hemodialysis patient
b. restaurant worker
c. office worker
OB
1. When to give rubella, pregnant woman is concern of receiving it
give after birth before discharge

SKIN
1. Treatment for decubitus ulcer

PSYCHIATRY

0 A schizophrenic pt. In a day room with other pts. Is yelling loudly and staring at
the wall what will the psyche nurse say?

0 Tell pt. That yelling in the day room is inappropriate to stop.

1 Stay outside the day room and watch the pt. Yell until he stops
2 Take the other pts. Out of the day room
3 Tell the pt. If he does not stop yelling he will be reprimanded

1 A bipolar pt. with manic is due to get haldol but the pt. told the nurse he is
refusing to take the medicine. What action by the head nurse is appropriate and aware
that the medicating nurse got 4 people to hold the pt. down so she can give the med. to
the patient.

0 Tell the med. nurse that her action is inappropriate

1 Make sure that the other pts. Are not around the pt. during the procedure.
2 Tell the nurse that the pt. can refuse the med.

2 Pt. with Personality and behavioral problem. How will you know pt. is making
progress
0 Pt. who calls relatives home several times a day and ask them to visit
1 Pt. who witnesses a pt. fighting and walks away

3 You are orienting a group of nurses to a mental unit, what do is appropriate as you
begin your orientation?

a. Tell the nurses the prevalence of mental disorders in the community

b. Tell the nurses the number of admissions to the unit
c. Let the nurses tell you their feelings toward the mentally ill
4 A mother delivered a baby with cleft lip, she says, “I can’t believe this, what a
mesh.” What response is best first?

a. Your child is so beautiful hair and clear eyes, & the md should see you soon
b. Don’t worry, the lip will be taken care of
c. I know you are upset but this can be taken care of before the child is 1
year old.

5 Mother is talking with the nurse, said she’s worried about her teen age daughter,
what is the sign of suicide for most teenagers?

0 avoid all friends & sleeping more than usual

1 always go out with friends and taking drugs

6 Read anorexia nervosa

8. Very quiet during IV insertion

a. abused child

7 Milieu therapy for manic pt.

0 quiet, non stimulating with neutral pale colors

8 Food for manic pt.

a. cookies, carrot stick, raisin

10. Manic pt disturbing the group, what should you do?

11. Post ECT, nursing intervention

GASTRO

0 Pt. with Cholecystitis that is caused by calcium oxalate which diet is good

0 Fiber and grain

1 Chicken and potatoes
2 Tofu and ?

1 Pt. with esophageal varices signs of rupture of the varices

0 Upper gastrointestinal bleeding

1 Tachycardia
2 Hypertension

2 What question would you ask a patient with Crohn’s disease or ulcerative colitis?

0 How many times do you move your bowel?

1 Do you have pain when you move your bowel?
2 Do you eat foods high in fiber?

3 Which statements indicate pt’s understanding of ileal conduit

a. I may need no colostomy bag
b. My urine may be cloudy for weeks.

4 Effect of pancreatic enzyme

0 decrease diarrhea
1 increase appetite
2 decrease steatorrhea

5 Paracentesis

0 Frequently check BP
1 Encourage to cough

7. Ileostomy, how do you know that pt is coping well

ENDOCRINE

1. Diabetic pt shows understanding

a. “I will not use moisturizer on my feet”

2. Pancreatitis, which one need to be reported to the md stat?

a. Increase amylase
b. LUQ pain
c. Sensorineural changes

3. Hyperthyroidism:
a. Insomia and restlessness

CARDIO

0 A community health nurse is teaching a group of pts. about coronary artery

disease. Which of the following is true.

0 African-American male have more CAD than caucasian male

1 People with high density lipoprotein is at risk for CAD

1 Which of the following is not a contraindication of pace maker?

0 Do not go near a microwave

1 Don’t take showers but take bath

2 A pt’s relative was talking to you about prevention of CAD. What is an

appropriate answer to give initially?

a. Increased high lipids

b. Exercise by walking
c. Change your attitude of eating food high in selenium

3 MRI, pt understands the procedure

0 I will put myself NPO

1 An earplug will be put on my ears in order not to hear the noise

4 Cardiac cath, what should concern the nurse?

0 capillary refill 4 seconds

5 S & s of pacemaker failure

RENAL

0 Intravenous pylogram

0 Are you allergic to eggs

1 Do you have any reactions after a procedure

OB

0 A perimenopausal woman suffers from hot flashes what is the best nursing
intervention
0 High protein food

1 A pt on magnesium sulfate, effectiveness

0 a reflex of +2
1 having convulsion

2 Exercise for a patient with incontinence

0 Kegel exercise

3 Active phase of labor, type of breathing :

0 breath through paper bag
4 Pt in labor on continuous epidural anesthesia, what to check?
0 BP
1 Pulse

5 During labor, umbilical cord was visible at the vagina, what should the nurse do?
0 push it back with gloved hand
1 notify the doctor
2 put pt on knee chest position & check FHR

6 Which of these observations during labor is caused by placenta insufficiency?

0 early decelerations
1 late decelerations
2 variable decelerations

7 A pt after delivery with uterus shifted to the right

0 call the doctor
1 massage the fundus with open hands
2 ask pt to void

8 Position for a woman in active labor

0 Supine
1 Trendelenburg
2 Left lateral

10. Papsmear, class I, what does it mean?

ONCOLOGY

0 External radiation therapy, the area develop skin redness & scaly, need further
teaching when pt:
0 cover with gauze
1 expose to air & keep dry
2 bath with water
3 apply mentholiptus oil to affected area

1 Internal radiation therapy, understood the teaching

0 My visitors should wear protective leads
1 I will tell my relatives to stay only for 30 minutes

2 Leukemia is hospitalized, safety question

0 remove fresh plants from the bedside.

NEURO

0 A pt. with autonomic dysflexia

 a. Has a very high BP or High pulse

1 Head injury what is a sign that pt. is deteriorating

0 Decerebrate
1 Doll eye reflex
2 Babinski

2 A pt. on coma for 3 days, pt is improving

0 able to hold your hand
1 able to turn his head when talking about him
2 able to sit up without assistance

3 Left hemianopsia, nursing action

0 approach him from the left side
1 let pt get up from the left side
2 let pt see an object with his left eye

4 Parkinson’s disease for discharge, what teaching

0 chew small bite food placed on both sides of the mouth
1 place pt in sitting position with hip slightly lean forward infront.

5 Myasthenia gravis teaching:

0 rest before eating

6 Epilepsy, a question on safety issue

0 Pt. can swim under adult supervision

TRIAGE

0 Which baby should you see first?

0 A baby whose lower extremities are pink and upper part of the body is pale
1 A baby with a red rubbery nodule with a rough surface on the chest
2 A baby whose pulse oximeter is 91%

1 Which pt. are you going to see first

0 Pt. with stiff neck
1 Pt. with fractured bone protruding out

2 Which pt. to see first

0 Pt. with RBC of 100,000

3 Who would you see first?

0 a pt. with temp. 38.6 ˚F
1 a pt. with pH 7.25 and PCO2 56.

4 Who would you see first?

 0 WBC 12,000
1 Platelet 69,000
2 Hb 12-14 gm

5 Who would you see first?

0 75 year old with heart beat of 110
1 75 year old with slow reaction

6 What would you intervene?

0 a pt on coumadin with prolonged PT
1 a pt coming to ER c/o of abdominal pain
2 a pt with severe abdominal pain at the lower quadrant

7 Following pts are taking medications, which pt to see first?

0 Clonazepam with dizziness
1 Valium with headache
2 Lithium carbonate with contraceptive pills

COMMUNICABLE DISEASE

0 A new admitted pt. is told that he is HIV+ what information will the nurse give to
help decrease the pt’s stress level.
0 How do you usually deal with stress
1 I will bring another HIV+ pt. to talk to you
2 This information will be confidential

1 Aside from universal precaution, what do you do to a pt with VRE?

0 wear a mask
1 wear a mask & glove
2 isolation
3 close the door

2 What shows a positive result in a TB pt?

0 10 mm erythema
1 10 mm induration on the skin

3 Chlostridium deficil precaution

0 private room
1 gown, gloves & mask

4 Clostridium deficile

5 Which one will prevent spread of infection in a day care center?

0 Immunizations for staffs for Hepatitis A
1 Changing the diaper changer top cover every 2 hours
2 Sending soiled clothing home in plastic bag.
6 S & s of measles:

OTHERS

0 A pt’s spouse complains to the nurse that her husband stay awake in the night
wandering around in the house. What assessment should the nurse make
0 Ask about the pt’s wake resting time
1 If the drink red wine before bedtime
2 If he has problem with alcohol

1 A pt. who is admitted in the hospital. The nurse should be aware that all teaching
starts
0 The day of discharge
1 The day of admission
2 When the pt. is getting better

2 Which pt. to discharge home to make room for new admission

0 Pt. with hernio 24 hours ago
1 Mastectomy 24 hours with drainage
2 Pt. diagnosed with DKA 48 hours ago

3 A woman had hip surgery, what would you intervene

0 pt. trying to get out of bed
1 pt bending at the waist

4 Pt. with mastitis, shows understanding

0 “I will not breastfeed my child”
1 “I will breastfeed on the healthy breast”
2 “I will empty my breast”

5 Understanding of a pt on coumadin
0 “I will not take my multivitamin tablet”
1 “I will take green leafy vegetables”

6 Nurse’s aide is always angry with a pt for soiling her diaper all the time. What would
the nurse say to the aide?
0 What time do you spend with the pt?
1 Let’s sit down & talk about this pt.

7 NIDDM, what shows understanding

0 I will take my insulin injection as prescribed
1 I will take my oral drug when due

8 Who is to be made an incident report first?

0 Staff seen sleeping in an empty room
1 Pt. for bronchoscopy NPO but ate a small part of food served in the
afternoon.

9 Positioning for a patient with head injury

0 lying flat
1 lying supine
2 lying with head of bed elevated at 30 degrees

10 Thoracentesis, position

11 How to collect 24 hour urine specimen

12 Foley catheter insertion, procedure

IV

0 A pt. with IV infiltration was given a compress. Which one is nursing intervention
a. When pt. regulates the heat pad after the nurse sets it

RESPIRATORY

0 Which cause vent high alarm to sound

0 Cuff leakage
1 Water in tubing

1 Pulmonary edema
0 crackles and rales on inspiration

2 Bronchovesicular breath sound

0 normal sound
1 abnormal sound

3 Bronchial asthma, what should be administered first?

0 short acting bronchodilators every 4 hours
1 steroid long acting bronchodilator

4 Chest tube abnormality, priority to report to MD

0 drain 300cc in one hour
1 no fluctuation in water seal

5 Pt for bronchoscopy before sending the pt, the nurse should cjeck if
0 client is NPO for 6 hours
1 pt can cough & breath

6 When auscultating the lungs use:

0 diaphragm
1 bell

7 Position for thoracentesis

8 A question on tracheostomy

9 Which one will necessitate to call a Dr. with Pleurovac?

0 continuous bubbling in the waterseal
1 intermittent bubbling in the water seal
2 moderate amount of bloody drainage in the suction chamber

10 Which one to see first?

a. a pt. with COPD
b. 4 years old with bronchial asthma who is restless
c. pt with diabetes mellitus who is confused

12. How to use incentive spirometer

13. COPD pt understanding of illness

a. I will use separate bathroom
b. I will cover my nose & mouth when coughing

14. Purpose of incentive spirometer

15. Care of pt with chest tube

PEDIATRICS
0 Which pt. will you see first
a. Tetralogy of Fallot

1 Reye’s syndrome, how do you know condition is worsening

0 Increase abd. girth
1 Increase irritability

2 2 ½ yrs. old in spica cast what toy to give

0 pounding board
1 squeaky toy

3 3 yr. old in a mist tent which toy can you give them
0 Stuff animal
1 Bean bird with color
2 Big center pieces of puzzle

4 Which one would you intervene when an infant is sucking?

0 quiet feeding
1 noise on feeding

5 An 8 month old child is to have another food included, what to give?

0 grapes
1 toasted bread
2 fruit juices

6 How do you feed a child with cleft palate?

a. cup and spoon
b. straw and cup

7 Toy for a 1 year old

0 colored pictures around the wall
1 building a brick of 6 steps
2 pulling toy

8 A child with esophageal fistula

0 projectile vomiting
1 potential for aspiration

9 Toy for 2 year old

a. rocking horse

10 View of death by preschooler

a. prolonged sleep

11 Study newborn reflexes

0 I had 2 questions

12 Universal precautions
0 Meningococcal meningitis

13 When would you intervene as RN

0 a 10 month old baby can’t transfer a toy from hand to hand

14 Baby born to cocaine mother, s & s

15 Diet for glomerulonephritis

17. A question about formula for a 5 month old baby

a. do not mix cereal in it

18. Hypospadias, what can the nurse observe when the pt urinate?
 PHARMACOLOGY

0 Which drug will you give first

0 Nafcillin
1 Digoxin
2 Heparin
3 Fentanyl

1 What shows Bactrim is working on a pt with prostatitis?

0 Increased WBC in the urine
1 Decreased WBC in the urine
2 Decreased RBC in the urine

2 A pt is to take Heparin 1,500 units an hour. 30,000 units in 500ml is the supply, how
many ml/hour will you give?
0 20ml
1 25ml
2 46ml

3 Side effect of amphogel:

4 A pt with primary hypertension is being visited by a community health nurse. Pt states,

“I have a terrible headache & started to fall, what should you do first?
0 ask pt’s brother to dial 911
1 ask pt’s brother if pt consumed high sodium diet

5 Study Heparin therapy:

7. Tenormin side effect

7 Oncovin, s/s

9. Theophylline, toxic effect

a. bradycardia & vomiting

GERIATRICS

0 Aging process take place in the mouth of an elderly

0 brown pigmentation below the tongue
1 skin folds around the hard palate
2 brown pigmentation on the mucosal lining

2. Normal changes in aging

GUT

0 Renal failure, the pt will have

0 hyperkalemia
1 hypokalemia

1 Urinary urgency
0 I nearly soak myself before getting to the bathroom

2 Glomerulonephritis, what will you intervene?

0 hypertension
1 hypotension
3 UTI, s & s:
0 penile discharge with pus
1 hesitancy on urination
4 Discharge teaching for TURP
0 Perineal exercise

MUSCULO-SKELETAL

0 Post hip replacement (days postop not mentioned), what is the exercise to affected site
0 full range of motion
1 quadriceps exercise
2 internal rotation
3 abduction & adduction

1 Signs of fat embolism

0 increase resp. pulse & BP
1 hypotension
2 confusion

2 Which action will prevent contracture in a pt with AKA?

0 Lying prone after 24 hours
1 Elevate stump on pillow after 24 hours
2 Raise foot of bed
3 Lying supine position

4. Crutch walking gait

EENT

0 Glaucoma, s & s:
0 halos around light

PHYSICAL ASSESSMENT

0 In palpating the abdomen, what do you do first?

0 palpate the lower abdomen first
1 palpate the four quadrants

NCLEX MARCH, 2005

0 8 yr. old child with glomerulonephritis, what is the early indication that child is
improving?

0 decrease BP
1 increase urine output

1 Pt with renal insufficiency taking Lasix has the following orders, what will you
question?

0 Captopril
1 Aminoglycoside
2 Ca Channel Blocker

2 Pt with angina experiencing chest pain has taken 3 tablets of NTG SL, but still has
pain, what to do next?
0 Have blood sent to lab to analyze for cardiac enzymes
1 Check breath sounds
2 Give O2
3 Alert cardiac resuscitation team

3 Pt with T4 injury complaining of headache. After putting pt in a semi-sitting

position what to do next?

0 Check vital signs

1 Check if patient is constipated

4 Who is high risk for renal calculi?

0 Addison’s disease
1 Hyperparathyroidism

5 Who to refer to primary health care for further follow-up?

0 Elderly with CRF w/K 5.4

1 Female 8 weeks AOG hct 38 Hgb 12

6 A new nurse has been hired, what must she prioritize?

0 Completing a patient’s NCP who has been admitted 4 hrs ago

1 Informing attending physician that pt’s VP Scan result has arrived

7 Pedia nurse has been pulled and assigned to MS ward, the charge nurse assign her
to what patient?

0 Pt after TURP who is about to be discharged

1 Newly admitted patient with bleeding history
2 Pt transferred from ICU 2 days ago, to have enteral feeding

8 Home discharge care of patient after Right BKA, what not to include?

0 ice cap for pain

1 continue Coumadin tx
2 put pillow to keep hips flexed
3 return for blood extraction

9 Pt with celiac disease, right choice of food,

0 hotdog instead of cheeseburger

1 peanut butter and banana for lunch
10 Pt. after ileostomy verbalizing, “I don’t know what to do, I can’t go back to my
job with this appliance.” Best response by the nurse,

0 I’ll refer you to support groups

1 I’ll call the therapist something?
2 I’d like to know more about your job

11 Best measure to gauge infant’s pain.

0 Pain pathways in infants are very immature

1 Change in the character of the infant’s cry
2 Infant is lying quietly

12 Pt with hyperthyroidism, check all that apply,

0 vs q4
1 Keep room warm
2 Check capillary refill
3 Keep eyes lubricated with eyedrops
4 Give low CHO diet

13 Pt with anorexia, immediate goal to stabilize her nutrition. What is the best way to
meet this?

0 Have patient draw a portrait of self

1 Know triggering points of her eating behavior

14 Pt with dementia, alzheimer’s type, what must be included in pt’s history?

0 Pt’s ADL
1 Client’s family for support
2 Medications pt is taking

15 Which patient to attend first?

0 Pt with GCS 5 since admission 3 days ago

1 Pt hypophysectomy 2 hours ago with U/O of 2400 since surgery

16 Pt with renal failure taking digoxin, what pat’s statement needs further
evaluation?

0 Lately I have no appetite and would skip meals

1 I have gain some weight

17 Pt with Primary HPN, which pt statement best describes understanding of the dse
0 I drink 2-3 glass of wine
1 I don’t like cooking anymore since food taste bland without salt
2 I started exercising

18 Patient prone to osteoporosis

0 menopause patient taking HRT

1 perimenopause pt on low CHON diet
2 elderly who exercises 2-3 x week
3 elderly pt with renal insufficiency

19 Pt with pneumocystis carinii, which roommate?

0 AIDS
1 Hepa B
2 Pneumonia with Chlamydia infection

20 Principle of infection control:

0 gowns and gloves – pediculosis capitis pt

1 mask-pt with MRS infection
2 handwashing after taking BP and before palpating abdomen pt with Guillaine
Barre

21 Pt with mononucleosis:

0 avoid kissing for 4 months

1 Bed rest
2 Avoid visitors until antibiotic tx completed

22 One year old patient on mist tent:

0 lubricate lips to keep moisture

1 put staffed toys inside tent

23 Pt with colon CA asking for risk

0 alcoholics are prone to colon CA

1 eating diet high in fruits in vegetables

24 Pt G5P4, gave birth to baby with wt 6 lbs, 2 hr ago, what to do first?

0 check perineum for lacerations

1 encourage to empty bladder

25 Pt with acute pancreatitis, which findings will concern the nurse?

0 hypoactive BS
1 decreased BS

26 Pt for mammogram, what to af the pt?

0 allergy
1 when pt last used cream and powders
2 when last meal

27 Pt to undergo electromyelogram and nerve conduction. What to tell patient?

0 anesthesia will be given

1 tingling sensation

28 Pt with pernicious anemia, check all that apply

0 pt forgetting something
1 tingling sensation
2 dizziness when eyes closed

29 Pt admitted dx dehydration, measure that pt is improving?

0 urine sg 1.030
1 u/o 40cc/hr
2 water intake 2400/24 hr

30 Pt with placenta previa, check all that apply:

0 bed rest
1 IE q4
2 Internal fetal monitor
3 VS

31 Epidural anesthesia 3 hr ago with urinary retention

0 use bedpan
1 use bedside commode
2 do prn order catheterization

32 Correct method of examining abdomen:

0 Inspect abdomen then palpate

1 Inspect abdomen then percuss
2 Inspect abdomen then auscultate
33 Pt with automatic defibrillator:

0 Do not go to places with metal detector

1 Teach pt that microwave oven will interfere with function

34 Pt have rubella vaccine, what to question:

0 allergy to yeast
1 pt sexually active

35 Newborn developed erythroblastosis fetalis:

0 rh-mother with rh + fetus

NCLEX TIPS
May 13, 2004

1. Which of the following is a characteristic sign of SLE?

a. Rash on the face across the bridge of the nose and cheeks
b. Fatigue
c. Fever
d. Elevated rbc count

2. A child is scheduled for tonsillectomy. Which of the following presents the highest
risk of aspiration during surgery?
a. Difficulty swallowing
b. Presence of loose teeth
c. Bleeding during surgery
d. Exudate in the throat area

3. A client with Parkinson’s has risk for falls due to abnormal gait. The nurse assesses
that the client gait is:
a. Broad based and waddling
b. Accelerating and walking on toes
c. Unsteady and staggering
d. Shuffling and propulsive

4. Which of the following indicates early signs of alcohol withdrawal?

a. Anxiety, temor, insomnia, tachycardia
b. Delusions, fever, vomiting, agitation
5. The chief clinical manifestation that the nurse would expect in the early stages of
cataract formation is:
a. Eye pain
b. Floating spots
c. Blurred vision
d. Diplopia

6. Which of the following assessment data indicates a potential complication

associated with dementia?
a. Presence of personal hygienic care
b. Improvement in sleeping
c. Absence of sundowner syndrome
d. Confabulation

7. Abruptio placentae can trigger DIC. The nurse would suspect this is a client if the
nurse observes
a. Pain and swelling of the calf of one leg
b. Rapid clotting times
c. Laboratory values indicating increased platelets
d. Petechiae, oozing from injection sites, and hematuria

8. The nurse is performing an admission assessment on a client with bladder CA.

which of the following would the nurse most likely to expect?
a. Hematuria
b. Burning
c. Urgency
d. Frequency

9. The nurse is caring for a child with right to left shunt. The most common
assessment finding in this disorder is
a. Cyanosis
b. Diaphoresis
c. Growth retardation
d. These children are asymptomatic

10. A client is admitted to the hospital and has a diagnosis of early stage of CRF. Which
of the following does the nurse expect to note on assessment?
a. Polyuria
b. Edema
c. Oliguria
d. Anuria

11. The nurse tells the client that she is now beginning the second stage of labor. The
nurse realizes that the client understands this stage when she says
 a. I’m having bloody show
b. My cervix is completely dilated
c. My membranes are now ruptured
d. The contractions are intense

12. A 3 year old child is diagnosed with encopresis. Which of the following is a sign of
this disorder?
a. Nausea and vomiting
b. Diarrhea
c. Evidence of soiled clothing
d. Malaise and anorexia

13. A client has developed atrial fibrillation with a ventricular rate of 150 per minute.
The nurse assesses the client for
a. Hypotension and dizziness
b. Nausea and vomiting
c. Hypertension and headache
d. Flat neck veins

14. A client has developed hepatitis A after eating contaminated oysters. Which of the
following signs and symptoms are expected?
a. Dark stools
b. LUQ discomfort
c. Malaise
d. Weight gain

15. When assessing a client with ulcerative colitis, which of the following findings
would the nurse report to the physician?
a. Bloody diarrhea
b. Hypotension
c. A hemoglobin level of 12 mg/dL
d. Rebound tenderness

16. Which of the following is a characteristic sign of Lymes Disease Stage I?

a. Signs of neurological disorders
b. Enlarged and inflamed joints
c. Arthalgias
d. Flulike symptoms

17. Which of the following is not a sign of testicular cancer?

a. Painless testicular swelling
b. Heavy sensation in the scrotum
c. Alopecia
d. Back pain
18. Which of the following data is a sign of paralytic ileus in a patient with acute
pancreatitis and a history of alcoholism?
a. Firm, nontender mass palpable at the lower right costa margin
b. Severe constant pain with rapid onset
c. Inability to pass flatus
d. Loss of anal sphincter control

19. A client is receiving external radiation to the neck for cancer of the larynx. The
most likely side effect to be expected is
a. Constipation
b. Dyspnea
c. Sore throat
d. Diarrhea

20. The client has experienced pulmonary embolism. The nurse assesses for which of
the following symptoms most commonly reported?
a. Dyspnea noted when deep breaths are taken
b. Hot, flushed feeling
c. Chest pain that occurs suddenly
d. Sudden chills and fevers

NCLEX
NOVEMBER 24, 2004

Computation:

0 Doctor’s order is Ceftriaxone T gm.Q8 hours. The stock is T gm in 50 ml D5w.

How the nurse regulate the pump to deliver the 50 ml in 30 minutes.

Answer: 100 ml/hr.

1 The patient has to receive 1 mili unit of Pitocin/hr. The stock is 10 units 10 1000
ml LR. How many ml/hr should the patient received?

Select all that apply questions (8-10 items answered)

0 Medicines that affect hearing problem (garamycin, Lasix)
1 Benefits of enteric coated medicines
2 Signs and symptoms you should watch in patient with hepatic encephalopathy

Other Questions:
0 How “assent” is applied in Pediatrics? (First time I encountered this word) I
chose, nurse can give medicine even without the presence of parents.”

1 Anorexia nervosa
2 St. John’s wort in depression

3 What to give to patient with BPH? (Choices are 4 herbal medicines; ginger, ginco
biloba, other 2 I forgot.)

4 S/E of Motrin, Valium, Glucophage

5 Acid base balance

6 A high alarm system of the ventilator made sound. What to check? I choose,
“check for water collection that blocked the tubing.”

7 More questions about nursing priorities.”

NCLEX TIPS
DECEMBER 13, 2005

TOPICS:

0 Rheumatoid Arthritis

1 Intussuceptions

2 Hirschprungs dis

3 Myasthenia graves

4 Safety and health promotion

NCLEX Questions Nov. 4, 2004

0 A person with head injury, who will you see first:

0 Unresponsive but confused
1 Decrease Glasgow coma scale of 10-14
2 Decorticate posturing
3 Decerebrate posturing

1 Computation: D/A x quantity of solution

2 S/E of Fentanyl intradermal patch
0 Increase temperature
1 Urinary retention
2 Constipation
3 Hypo tension

3 Over dosage of Verapamil (Calan)

0 Hypo tension and headache

4 How will you know that Propylthiuracil (PTU) is effective?

0 Increase TSH
1 Decrease PR
2 Increase T4 in blood

5 A patient with Digoxin and Lasix, what will you assess first?
0 Patellar reflex 1
1 Arterial pulse 1, cold extremities

6 An infant is given Lasix, what is the proper nursing action?

0 Mix drug with little amount of milk
1 Mix drug in a bottle of milk
2 Give drug 1 hour before and 2 hours after giving milk

7 A patient with Alzheimer has a wound, what will you tell the patient?
0 I must clean your wound to prevent you from infection.
1 I will just to go back to clean your wound.

8 A paranoid tells the nurse, “Don’t go near me, you might infect me with a
disease”, what will you respond?
0 I will not infect you with a disease
1 It might be frightening for you to think that you will have a disease

9 Patient assignment with AIDS patient?

0 Patient with streptococcal disease
1 Hepatitis B, with clay colored stool
2 Patient on 2 weeks antibiotic therapy who now has diarrhea

10 Who will you intervene first?

0 Patient with dysphagia eating mashed potato with gravy
1 A quadriplegia patient in semi-Fowlers position before bed bath
2 Turning the patient using his inner arm

11 How will you transfer an obese patient?

0 Transferring using a Hoyer lift
1 Positioning using a wide base of support
2 Asking another assistant to help move the patient
12 Who is prone to osteoporosis?
0 65 year old female with a small frame
1 An obese 60 year old, a chronic alcoholic
2 An adult make, lifting heavy objects

13 Who is prone to beast CA:

0 An adult female on high fat diet
1 A nulliparous woman with menarche at 10

14 A rape victim what will you assess first:

0 Refer to legal authority
1 Asking the patient what had happened
2 Bring patient to a private room and check for physical injuries
3 Bring a support person

15 What is the proper nursing intervention:

0 RSV on droplet precaution
1 Scabies on contact precaution

16 A patient with scleroderma, what will you prioritize:

0 Dysphagia

17 Patient with rheumatoid arthritis, what to prioritize?

0 Give anti-inflammatory drug before exercising
1 Exercise immediately upon waking up
2 Warm compress the hand before exercising the wrist

18 Patient with intermittent claudication, what will you do to improve condition?

0 Teach patient to gradually increase activity
1 Warm compress the extremeties

19 Patient on calcium therapy, how will you facilitate effectiveness of drug?

0 Give water soluble vitamin
1 Give protein
2 Give fat soluble vitamin

20 Patient with intermittent claudication:

0 Lower the legs

21 Patient with hearing aid, how will you assess if the hearing aid is malfunctioning?
0 I can hear soft whistling sound when I use my hearing aid
1 I cant hear well in a crowded place
2 I still do lip reading to better hear

22 Normal breath sound to a 40 year old:

0 Vesicular breath sound at the base of the lung
23 Who will you see first:
0 Patient who receive 8 “u” insulin 1 hr ago with blood glucose level of 300mg/D1
and had just received a meal tray
1 Patient 6 days post-op colostomy with dark red stoma

24 Patient is allergic to aspirin and penicillin, what will you not give:
0 Gentamycin
1 Coumadin
2 Cephalosporin
3 Streptomycin

25 Nurse charged with negligence:

0 Patient given with vancomycin who is allergic to aminoglycoside
1 Nurse passed by an accident scene and refuse to help

26 Patient with antisocial behavior, what will you expect:

0 Depressed and isolated
1 Sexually aggressive
2 No remorse

27 An ICU nurse was transferred to psych ward, patient assignment:

0 A depressed patient who took overdose of Thorazine 12 hrs ago
1 Schizophrenic and aggressive
2 Bipolar patient who took overdose of drug 48 hrs ago

28 On apnea monitor, who will you intervene:

0 Apnea monitor attached to an extension cord and plugged from a different room
1 Apnea monitor removed when not turned on
2 The mother verbalized that she will use the neighbor telephone if she needs help

29 A nurse who attended a convention suddenly complains of chest pain, verbalizes,

“I think I’m having an MI, what will you prioritize”
0 Check PR
1 Call for help
2 Bring to hospital
3 Let patient lie down for 15 minutes

30 A patient will be given nitroglycerin what will you prioritize:

0 Check BP before giving nitroglycerin
1 Wash area with previous nitroglycerin patch and apply a new one
2 Put patch at the apical area
3 Let patient lie down for 15 min. after giving nitroglycerin

31 Post adrenalectomy patient 48 hrs, what will you prioritize

0 Check BP
1 Check PR
2 Check breath sounds

32 Who will you prioritize:

0 Patient with Multiple Sclerosis with blurring of vision
1 Patient with Myasthenia Graves with dysphagia

33 Patient with facial laceration:

0 Are you in pain?
1 Tell me what happened?
2 Can you hear me?

34 Patient with C3 injury, what to prioritize:

0 Provide manual stimulation to facilitate bowel evacuation
1 Bladder training
2 Crede’s maneuver to facilitate urinary elimination

35 Who will you see first:

0 Black and blue mark at the lumbosacral area
1 Shiny white pearls at the found in the gums
2 Red spots found at the trunk that blanches when pressed
3 Irregular blue and red spots at the buccal membrance

36 Cardiac catheter at right leg, what will you assess first:

0 Uneven temperature at both legs, cooler at the left side
1 4 cm blood at the catheter site

37 Patient with 20% burn 2nd degree partial thickness, what will you do first:
0 Monitor intake and output
1 Clean the wound every other day with half strength hydrogen peroxide

38 Patient diagnosed with CVA:

0 Give thrombolytic within 3 hours from the time CVA was diagnosed

39 Patient in home health care undergoing chemotherapy, what will you do?
0 Pour all unused chemotherapeutic agents in a drain and flush it twice
1 Don’t allow children to use the bathroom for 2 days
2 Put all chemotherapeutic agents in a biohazard container and put it in a trash
3 Leave the patient alone in the room while undergoing chemotherapy

NCLEX TIPS
April I, 2004

0 Side effects of Quinidine

0 Vomiting
1 Restlessness
 1 Immobilized client for an extended period, the need for tilt table
0 Prevent hypertension
1 Encourage circulation of skin

2 Neostigmine for myasthenia gravis acts as

0 Replacing deficient neurotransmitter
1 Blocking action of cholinesterase

3 A client with CVA has a R Hemiplegia. The BP should not be obtained by

using the R arm
0 Procedure inaccurate reading
1 Precipitate formation of thrombus

4 Study paranoid schizo

5 Obsessive compulsive behavior
6 Suicide manifestation
7 Accident prevention for toddler
8 Abruption placenta
9 Side effects of carbamazepine
10 A client on Glucagon
11 Manifestation of client on DKA

NCLEX TIPS
DECEMBER 23, 2004

0 Signs/symptoms of Guillain-Barre Syndrome.

1 S/S of Myastemia Gravi’s
2 Echinacea (immune system booster)
0 use up to 8 weeks only to prevent over stimulation of immune system.
3 External trianging (2 questions here)
1 prioritize ambulatory patients and those that have greater chances of
survival. (accident site)
4 Internal trianging (3 question here)
2 use ABC’s when prioritizing. (Hospital ER).
5 Computations and conversion (I got 6 of these)
There were no choices given. You have to compute and give your answer.
0 conversion between apothecary and metric systems
(Equivalent ang mga ito. It has to be memorized)
1 IV calculations
3 flow rates
4 infusion time
2 calculating infusions ordered by unit dosage per hour (this is my last question) I
forgot the problem but here is the calculation I used:
Step I:
 Known amount of med in solution = Amount of med/ml
Total volume of diluent (or convertion/ml)

Step II:
Dose per hour desired = infusion rate (ml/hr)
Concentration/ml
3 medication dosage
desired _ X Q = dosage
available
6 Innovative questions:
0 age related changes in a 70 years old man.
1 Develop mental milestones of an 8-month-old infant
2 Check all that pertains to TB
7 Many question on:
0 Room assignments
1 Delegations
5 a nurse from surgical dept. was transferred to pedia.
6 a nurse from ortho was transferred to surgery
7 what if patient may be assigned to an LPN
(remember LPN’s can perform all implementations but never to
assessment and teaching discharge)
2 Age-appropriate toys
8 toddler
9 5 month old infant
10 9 year old boy
8 Patient on lasix – watch out for hypokalemia
9 Patient with myxedema – cold intolerance (this is my first question)

REMINDERS:

0 Take your time in answering questions

1 There are choices that looked like they are correct but when you read again there
are catches. BEWARE!
2 Do not apply actual experience. Use the textbook (or ideal) situations all the time.

NCLEX TIPS
Venus Joy Bugayong
May 13, 2004

0 Which of the following is a characteristic sign of SLE?

0 Rash on the face across the bridge of the nose and cheeks
1 Fatigue
2 Fever
3 Elevated rbc count
1 A child is scheduled for tonsillectomy. Which of the following presents the
highest risk of aspiration during surgery?

0 Difficulty swallowing
1 Presence of loose teeth
2 Bleeding during surgery
3 Exudates in the throat area

2 A client with Parkinson’s disease has risk for falls due to abnormal gait. The nurse
assesses that the client gait is

0 Board based and wadding

1 Accelerating and walking on toes
2 Unsteady and staggering
3 Shuffling and propulsive

3 Which of the following indicates early signs of alcohol withdrawal?

0 Anxiety, temor, insomnia, tachycardia

1 Disorientation, diaphoresis, insomnia
2 Delusions, fever, vomiting, agitation

4 The chief clinical manifestation that a nurse would expect in the early stages of
cataract formation is

0 Eye pain
1 Floating spots
2 blurred vision
3 Diplopia

5 Which of the following assessment data indicates a potential complication

associated with dementia?

0 Presence of personal hygienic care

1 Improvement in sleeping
2 Absence of sundowner syndrome
3 Confabulation

6 Abruptio placentae can trigger DIC. The nurse would suspect this is a client if the
nurse observes

0 Pain and swelling of the calf of one leg

1 Rapid clotting times
2 Laboratory values indicating increased platelets
3 Petechiae, oozing from injection sites, and hematuria
7 The nurse is performing an admission assessment on a client with bladder CA.
Which of the following would the nurse most likely to expect?

0 Hematuria
1 Burning
2 Urgency
3 Frequency

8 The nurse is caring for a child with right to left shunt. The most common
assessment finding in this disorder is

0 Cyanosis
1 Diaphoresis
2 Growth retardation
3 These children are asymptomatic

9 A client is admitted to the hospital and has a diagnosis of early stage of CRF.
Which of the following does the nurse expect to note on assessment?
0 Polyuria
1 Edema
2 Oliguria
3 Anuria

10 The nurse tells the client that she is now beginning the second stage of labor. The
nurse realizes that the client understands this stage when she says

0 I’m having bloody show

1 My cervix is completely dilated
2 My membranes are now ruptured
3 The contractions are intense

11 A 3 year old child is diagnosed with encopresis. Which of the following is a sign
of this disorder?

0 Nausea and vomiting

1 Diarrhea
2 Evidence of soiled clothing
3 Malaise and anorexia

12 A client has developed atrial fibrillation with a ventricular rate of 150 per minute.
The nurse assess the client for

0 Hypotension and dizziness

1 Nausea and vomiting
2 Hypertension and headache
3 Flat neck veins

13 A client has developed hepatitis A after eating contaminated oysters. Which of the
following signs and symptoms are expected?

0 Dark stools
1 LUQ discomfort
2 Malaise
3 Weight gain

14 When assessing a client with ulcerative colitis, which of the following findings
would the nurse report to the physician?

0 Bloody diarrhea
1 Hypotension
2 A hemoglobin level of 12 mg/dL
3 Rebound tenderness

15 Which of the following is a characteristic sign of Lyme Disease Stage I?

0 Signs of neurological disorders

1 Enlarged and inflamed joints
2 Arthralgias
3 Flulike symptoms

16 Which of the following not a sign of testicular cancer?

0 Painless testicular swelling

1 Heavy sensation in the scrotum
2 Alopecia
3 Back pain

17 Which of the following data is a sign of paralytic ileus in a patient with acute
pancreatitis and a history of alcoholism?

0 Firm, nontender mass palpable at the lower right costa margin

1 Severe constant pain with rapid onset
2 Inability to pass flatus
3 Loss of anal sphincter control

18 A client is receiving external radiation to the neck for cancer of the larynx. The
most likely side effect to be expected is

0 Constipation
1 Dyspnea
2 Sore throat
3 Diarrhea
19 The client has experienced pulmonary embolism. The nurse assess for which of
the following symptoms most commonly reported?

0 Dyspnea noted when deep breaths are taken

1 Hot, flushed feeling
2 Chest paint hat occurs suddenly
3 Sudden chills and fever

------------end-------------

Thanks to Sir Darius for sharing these NCLEX tips!

GOODLUCK and GODBLESS!!!!!!!!!!!!

//VMH ……..Congrats in advance, you’ll

make it… just give your
very BEST!