Nclex rn question and answer with rationale

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BASED ON:
Lippincott Q&A Review for NCLEX-RN®

Designed to help pre-licensure nursing students prepare to take the licensing examination. Students and faculty also use the book as a study guide and practice tests for preparing for faculty-made examinations. The book is designed to support the four major content areas in pre-licensure programs: obstetrics, pediatrics, medical-surgical, and mental health nursing. Within each of the four sections, chapters are organized around common health problems. When studying, students can select examinations that parallel the content in a particular course in a variety of curricula.

This consistently bestselling NCLEX-RN review book features more than 5,000 high-level questions that prompt active learning and higher-order thinking. The questions support the National Council of State Boards of Nursing (NCSBN) 2016 RN test plan and are written in the style used on the licensing examination. Other features include the use of all the types of alternate-format questions found on the licensing examination, detailed rationale for both correct and incorrect answers, information about the NCLEX-RN, study tips, and a "Content Mastery and Test-Taking Self Analysis" grid by which students can chart their own progress and modify study plans as needed.

Key Features
Revision of the organization of the comprehensive tests to include tests of varying length; this will allow students to practice taking shorter and longer tests so they can estimate their concentration and fatigue level.
All questions reviewed and updated as needed for appropriateness for Canadian nursing practice.
Greater emphasis on pharmacology and management of care questions (delegation, prioritization, and leadership), as per the NCLEX-RN test plan.
Additional questions about older adults.
Additional questions requiring students to make clinical decisions.
Adherence to the NCLEX-RN 2016 test plan and Practice Analysis (to be released fall/spring 2015).
Questions formulated based on frequency of nursing actions as per NCSBN Practice Analysis.
Added information on test preparation and study plans; more information on taking computerized tests (a need identified in the Canadian market).
Color highlights for alternate-format questions to emphasize them for students and potential adopters (students and faculty who want to be assured of availability of these types of questions). As per market review, color highlights will NOT be used in comprehensive exams to simulate more accurately the questions that are NOT highlighted on the actual NCSBN NCELX-RN exam.
Conversion grid from metric to imperial to assist students in both the United States and Canada to become familiar with these differences in measurements; all questions will be written to include both types of measurements.
Continued use of high-level questions and teaching rationale.

Fundamentals of nursing are courses that educate about the basic principles and procedures of nursing. The course highlights the significance of the fundamental needs of humans and the competence in fundamental skills as prerequisite knowledge to providing extensive nursing care.

Read and analyze each question carefully and chose the best answer/s from the choices provided. At the end of these practice tests, correct answers along with the explanation are given.

1. The nurse is caring for a client diagnosed with an infectious disease. Before instituting the appropriate isolation precaution, which information is important for the nurse to identify?

A. The organisms’ susceptibility to antibiotics
B. The client’s susceptibility to the organism
C. The organism’s Gram-staining characteristics
D. The organism’s mode of transmission

2. After performing a procedure with a client diagnosed with an infectious disease, the nurse starts to doff the personal protective equipment (PPE). Which action when doffing limits the risk of transmission of the infectious pathogens?

A. Pulling the fingers of the gloves off gently.
B. Pulling the gloves gently inside-out just below the cuff.
C. Washing the gloves before removing them.
D. Pulling off the gloves first then turning them inside out.

3. The nurse collects used equipment after a sterile procedure to be brought in for cleaning and sterilization using the autoclave. Which statement identifies the reason for using an autoclave for sterilizing hospital equipment?

A. More equipment can be sterilized at the same time.
B. It uses a lower temperature for sterilization.
C. The equipment is penetrated better with the pressurized steam.
D. Less damage to the equipment occurs with pressurized steam.

4. A client diagnosed with stage 2 pressure injury is discovered to have methicillin-resistant Staphylococcus aureus (MRSA). Which action does the nurse perform to institute the appropriate precautions?

A. Keep the client with another client who has an upper respiratory infection.
B. Wear a clean gown and gloves when caring for the client.
C. Provide an N95 mask for anyone who enters the client’s room.
D. Send all the garbage from the client’s room to biohazard waste.

5. The nurse is caring for a client who requires protective isolation. Which client can be safely paired with this client during a client-care assignment?

A. A client diagnosed with unstable diabetes mellitus
B. A client diagnosed with a urinary tract infection
C. A client who underwent a surgical repair of a perforated bowel
D. A client with a stage 3 pressure injury

6. A client receives 30 mg of codeine orally for pain. After five minutes, the client vomits. Which action by the nurse is next?

A. Administer the medication again.
B. Observe the client’s vomitus.
C. Call the health care provider immediately.
D. Tell the client that nothing can help anymore.

7. The nurse assesses a client with reports of abdominal pain. Which initial action by the nurse is correct?

A. Assess any of the four quadrants.
B. Assess the second or third quadrant.
C. Assess the symptomatic quadrant last.
D. Assess the symptomatic quadrant first.

8. The nurse is caring for a client experiencing pain. After reports of severe pain, the client promptly falls asleep before the nurse can assess. Which statement by the nurse regarding the client’s pain is correct?

A. “The client is faking the pain.”
B. “The client has a low pain threshold.”
C. “The client’s pain was relieved.”
D. “The client must have taken a pain medication.”

9. The nurse applies a warm compress to a client’s sore and painful lower extremities. The client asks for the reason why a warm and not a cold compress is being used. Which statement by the nurse is correct?

A. “Only a warm compress can reduce the pain and discomfort.”
B. “A warm compress can increase the blood circulation.”
C. “Using warm compress minimizes the muscle spasms.”
D. “Warm compresses prevent the occurrence of hemorrhage.”

10. A postoperative client is being assessed by the nurse. Which assessment finding does the nurse document as subjective?

A. Laboratory results
B. Vital signs
C. Pain description
D. ECG patterns

11. The nurse palpates the client’s midclavicular line. Which finding is the nurse assessing?

A. The client’s systolic blood pressure
B. One of the client’s vital signs
C. The client’s apical pulse
D. Any sign of heart murmurs

12. A client is being asked by the nurse to perform the Romberg test. Which position does the client assume?

A. The client stands with both feet together.
B. The client sits down with both arms at the side.
C. The client stands with both arms stretched forward.
D. The client assumes the Trendelenburg position in bed.

13. The nurse auscultates a client’s chest using a stethoscope. Which function by the bell or diaphragm of the stethoscope is correct?

A. The bell is used to detect thrills.
B. The diaphragm is used to detect low-pitched sounds.
C. The bell detects high-pitched sounds the most.
D. The diaphragm can detect high-pitched sounds best.

14. The new nurse performs an assessment of a client’s abdomen. Which actions by the nurse are correct?

A. The nurse assesses for distention, tenderness, and discoloration around the umbilicus.
B. The nurse percusses first, then measures the abdominal girth and inspects the abdomen.
C. The nurse auscultates the abdomen first, then performs percussion, and finally, palpates the abdomen.
D. The nurse percusses the abdomen first, then performs palpation, and lastly auscultation.

15. The nurse is caring for an older adult client who refuses to eat or drink. Which assessment finding does the nurse expect from the client?

A. A weak, rapid pulse
B. An increased blood pressure
C. Distention of the jugular vein
D. Moist mucous membranes

16. The nurse provides discharge teaching to a client about ear medication administration. Which action best determines that the client understood the nurse’s teaching?

A. Let the client repeat the nurse’s instructions verbally.
B. Perform the administration while the client asks questions.
C. Ask the client to perform the administration of ear medication.
D. Assess whether the client has used an ear medication before.

17. The nurse reviews the health care provider’s orders and sees an order for penicillin every six hours. During the assessment, the nurse noted that the client has no known allergies. After administering the medication, the nurse notices a fine rash on the client’s skin. Which action by the nurse is best?

A. Administer the medication again and notify the provider.
B. Apply cornstarch soaks to areas with rashes.
C. Withhold the medication and notify the health care provider.
D. Administer the medication together with an antihistamine.

18. The nurse prepares to administer iron dextran intramuscularly to an older adult client. Which action by the nurse prevents tracking of the medication?

A. Administers the medication using the Z-track method.
B. Use the shortest needle possible when using the Z-track method.
C. Massage the injection area carefully after administration.
D. Administer the medication with the needle at a 45-degree angle.

19. The nurse administers medication to a client in capsule form. The client reports difficulty swallowing the capsule. Which action by the nurse is next?

A. Open the capsule and mix the contents with applesauce.
B. Dissolve the contents of the capsule in a glass of water.
C. Crush the capsule and place the medication under the tongue.
D. Check if a liquid preparation is available at the pharmacy.

20. Before administration of the client’s medication, the nurse verifies the client’s identity first. Which action by the nurse during verification is correct?

A. Check the client’s identification band first.
B. Call out the client’s last name loudly and clearly.
C. Ask the client to provide their last and first name.
D. Check the client’s name on the client’s bed.

21. Several clients in the nurse’s unit have fallen off the bed despite the consistent use of side rails. Which statement about side rails is correct?

A. Side rails should be prohibited from inpatient units.
B. Side rails add stability and guidance for the client.
C. Side rails are deterrents that prevent the risk of falls.
D. Side rails are ineffective for clients who are mobile.

22. The newly hired nurse is assigned to a very disoriented client with soft wrist restraints. The nurse asks the head nurse for the purpose of the client’s restraints. Which response by the head nurse is correct?

A. “The restraints will reduce the client’s confusion.”
B. “The restraints discourage the client from ambulating alone.”
C. “The restraints prevent the client from injuring themselves.”
D. “The restraints prevent the client from becoming violent.”

23. A client was prescribed the use of a soft wrist safety device. Which finding does the nurse consider abnormal when assessing this client?

A. Capillary refill of two seconds
B. Cool, pale fingers
C. Reddened, warm palm area
D. Pinkish nail beds

24. The nurse prepares to transfer an immobile client from the bed to a chair. Which action by the nurse is correct?

A. Lower the head of the bed into a flat position.
B. Place the chair with its back to the bed.
C. Let the client dangle their legs at the side of the bed.
D. Rapidly lift the client from the bed to the chair.

25. A client has orders for the initiation of continuous enteral feeding. Which action by the nurse is essential during the feeding?

A. Warming the formula before administration
B. Elevating the head of the bed prior to feeding
C. Placing the client on a left-side-lying position
D. Hanging enough formula good for 24 hours

26. The nurse is caring for a client with a Jackson-Pratt wound drain and prepares to clean the area around it. Which action by the nurse is best?

A. Cleaning the site briskly using alcohol wipes.
B. Cleaning in a circular motion from the center outward.
C. Wearing sterile gloves, mask, and gown before cleaning.
D. Removing the drain first before cleaning the area around it.

27. The nurse is caring for a client receiving furosemide. Which dietary teaching does the nurse include in the plan of care?

A. Eat foods high in protein such as lean red meat.
B. Increase the intake of fresh, green vegetables.
C. Consume foods rich in fiber such as corn.
D. Include fruits like bananas and oranges in the diet.

28. The nurse is caring for a client with open ulceration in the left leg. During the assessment, the nurse observes visible granulation tissue in the wound. Which dressing does the nurse anticipate for this type of wound?

A. Occlusive semiocclusive dressing
B. Hydrocolloid dressing
C. Dry sterile dressing
D. Plastic-film dressing

29. The nurse assesses a client who underwent a tonsillectomy and observes lethargy. The client reports a sore throat. In which position does the nurse place the client?

A. High-Fowler’s position
B. Semi-Fowler’s position
C. Side-lying position
D. Supine position

30. The nurse assesses a client with reports of rectal bleeding and has a history of hip replacement two weeks ago. Which position does the nurse avoid placing the client in?

A. Dorsal recumbent position
B. Semi-Fowler’s position
C. Sim’s position
D. Supine position

Answers and Rationale

What are the most common questions on the NCLEX?

Top 10 Most Common Types of NCLEX Questions.
Prioritization. ... .
Illness and disease. ... .
Diagnosis. ... .
Treatment Plans and Patient Communication. ... .
Safety and Care Environment. ... .
People Skills. ... .
Procedures and Physiological Adaptation. ... .
Interpreting Information..

How can I get better answering questions for NCLEX?

8 Steps of NCLEX Question Analysis.
Read the whole question. ... .
Ask yourself first. ... .
Think about the types. ... .
Focus on each question answer. ... .
Decide if the answers are wrong, right, and possible. ... .
Rank your correct and possible options. ... .
Reread the question after choosing “finalists” ... .
Make a decision and don't look back..

What questions are on NCLEX

Exam Outline Review.
Management of Care: 17%-23% of questions..
Safety and Infection Control: 9%-15% of questions..
Health Promotion and Maintenance: 6%-12% of questions..
Psychosocial Integrity: 6%-12% of questions..
Basic Care and Comfort: 6%-12% of questions..
Pharmacological and Parenteral Therapies: 12%-18% of questions..

What is the best question bank for NCLEX

1. UWorld NCLEX Prep. UWorld is one of the highest-rated prep courses by both experts and student users. It is designed to offer an extensive bank of sample questions that mirror the style and difficulty of questions that will be on the exam.

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