NCLEX PN

NCLEX-PN-SETS OF PREVIOUS ACTUAL TEST

CHRIS JAY

Question: 1

A nurse is implementing a community awareness campaign about accidental poisoning. Which of the following

should she teach in the class?

A. The child should be given milk.

B. The child should be given syrup of Ipecac

C. The poison control center should be contacted

D. The child should be taken to the ER

Answer: C

Explanation:

The poison control center should be contacted first.

Question: 2

If your patient is acutely psychotic, which of the following independent nursing interventions would not be

appropriate?

A. Conveying calmness with one on one interaction

B. Recognizing and dealing with your own feelings to prevent escalation of thepatient’s anxiety level

C. Encourage client participation in group therapy

D. Listen and identify causes of their behavior

Answer: C

Explanation:

Acutely psychotic patients will disrupt group activities.

Question: 3

A nurse runs into the significant other of a patient with end stage AIDS crying during her smoke break. Which of

the following is most appropriate action for the nurse to take?

A. Allow her to grieve by herself.

B. Tell her go ahead and cry, after all your husband’s pretty bad off.

C. Tell her you realize how upset she is, but you don’t want to talk about it now.

D. Approach her, offering tissues and encourage her to verbalize her feelings.

Answer: D

Explanation:

Being left alone during the grief process, isolates individuals. These individuals need an outlet for their feelings

and to talk to someone who is empathetic.

Question: 4

A patient is scheduled for electro-convulsive therapy treatment scheduled in the morning. What must the evening

nurse do to provide the client ECT treatment possible?

A. Patient signs an informed consent form

B. Patient is given morning medications

C. Patient gets a good night’s sleep

D. Patient has a good breakfast

Answer: A

Explanation:

An informed consent is required prior to surgery.

CHRIS JAY

Question: 5

A nurse is teaching a client about self-administration of Haldol 15 mg po hs. For which side effect/s must the

client seek medical attention?

A. SOB and fatigue

B. restlessness and muscle spasms

C. dry mouth

D. diarrhea

Answer: B

Explanation:

Muscle spasms and restlessness are side effects of Haldol

Question: 6

A nurse is assigned to do pre-operative teaching on a blind patient who is scheduled for surgery the following

morning. What teaching strategy would best fit the situation?

A. Verbal teaching in short sessions throughout the day

B. Pre-operative booklet on the surgery in Braille

C. Provide a tape for the client

D. Have the blind patient’s family member instruct the patient.

Answer: A

Explanation:

Information is smaller amounts is easier to retain. Teaching the day before the procedure is best accomplished in a

one on one format.

Question: 7

A nurse gave medications to the wrong client. She stated the client responded to the name called.

What is the nurse’s appropriate documentation?

A. Note in medication records the drug given

B. The client was not hurt, no need for documentation

C. Note the client’s orientation

D. Completely fill out an incident report

Answer: D

Explanation:

The incident report should always be filled out involving medication errors.

Question: 8

A violation of a patient’s confidentiality occurs if two nurses are discussing client information in which of the

following scenarios?

A. With a physical therapist treating the patient

B. With a social worker planning for discharge

C. With another nurse on duty to plan for break time

D. In the hallway outside the patient’s room.

Answer: D

Explanation:

Hallway discussions should not occur, because you do not who is listening, even though it may be a professional

CHRIS JAY

discussion.

Question: 9

A nurse is administering an antibiotic to a 4 year old girl, who does not have an identification bracelet. What action

should the nurse take?

A. Ask another staff member who the child is.

B. Ask the child’s mother to state the child’s name.

C. Ask the child for her name.

D. Withhold the medication until an ID bracelet can be set-up.

Answer: B

Explanation:

Timely delivery of medication can be given if the mother provides the child’s name. Do not rely on children to

identify their name correctly.

Question: 10

A client is 36 hours post-op a TKR surgery. 270 cc’s of sero-sanguinous accumulates in the surgical drains. What

action should the nurse take?

A. Notify the doctor

B. Empty the drain

C. Do nothing

D. Remove the drain

Answer: A

Explanation:

The physician should be notified if excessive drainage is noted from the surgical site.

Question: 11

A patient 3 hours post-op from a hysterectomy is complaining of intense pain at the incision site. When assessing

the patient the nurse notes a BP of 169/93, pulse 145 bpm and regular. What action should the nurse take?

A. Reassure patient that pain is normal following surgery.

B. Administer prn Nifedipine and assess client’s response.

C. Administer prn Meperidine HCL and assess client’s response.

D. Recheck BP and pulse rate every 20 minutes for the next hour.

Answer: C

Explanation:

A sinus tachycardia is a physiological response to pain. Treating the cause of the increased pulse rate requires

pain medication.

Question: 12

A nurse is reviewing a patient’s medical record. The record indicates the patient has limited shoulder flexion on the

left. Which plane of movement is limited?

A. Horizontal

B. Sagittal

C. Frontal

D. Vertical

Answer: B

CHRIS JAY

Explanation:

Sagittal motion occurs in the midline plane of the body.

Question: 13

Which of the following is not considered one of the five rights of medication administration?

A. client

B. drug

C. dose

D. routine

Answer: D

Explanation:

Dose, client, drug, route and time are considered the five rights of medication.

Question: 14

When giving an intramuscular injection to an infant. Which of the following sites is preferred?

A. Ventrogluteal region

B. Deltoid

C. Vastus lateralis

D. Dorsogluteal region

Answer: C

Explanation:

Vastus lateralis is the ideal choice for infants.

Question: 15

When choosing a needle gauge for an intramuscular injection in a 12 year old boy. Which of the following gauges

would you choose?

A. 27 gauge

B. 25 gauge

C. 22 gauge

D. 20 gauge

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