1. After completing a thorough neurological and physical assessment of a patient who is admitted for a suspected stroke, a medical-surgical nurse anticipates the next step in the immediate care of this patient to include:
A) preparing for carotid Doppler ultrasonography.
B) administering tissue plasminogen activator.
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A) preparing for carotid Doppler ultrasonography.
B) administering tissue plasminogen activator.
C) obtaining a neurosurgical consultation.
D) obtaining a computed tomography scan of the head without contrast.
Answer: D) obtaining a computed tomography scan of the head without contrast.
2. An infant weighs 7 pounds at birth. The expected weight by 1 year
should be:
A. 10 pounds
B. 12 pounds
C. 21 pounds
D. 25 pounds
Answer: C. 21 pounds
should be:
A. 10 pounds
B. 12 pounds
C. 21 pounds
D. 25 pounds
Answer: C. 21 pounds
3. The nursing diagnosis for a patient with a myocardial infarction is activity intolerance. The plan of care includes the patient outcome criterion of:
A) experiencing no dyspnea on exertion.
B) agreeing to discontinue smoking.
C) ambulating 50 feet without experiencing dyspnea.
A) experiencing no dyspnea on exertion.
B) agreeing to discontinue smoking.
C) ambulating 50 feet without experiencing dyspnea.
D) tolerating activity well.
Answer: C) ambulating 50 feet without experiencing dyspnea.
4. A client with an abdominal aortic aneurysm is admitted in preparation
for surgery. Which of the following should be reported to the
doctor?
A. A negative Babinski reflex
B. An abdominal bruit
C. An elevated white blood cell count
D. Pupils that are equal and reactive to light
Answer: C. An elevated white blood cell count
5. Which action best describes a sentinel event alert?
A) Signaling the need for immediate investigation and response
B) Indicating that a community or institution is unsafe
C) Documenting the breakdown in communication during a shift report
D) Recording the harm done when a medication error occurs
Answer: A) Signaling the need for immediate investigation and response
6. Before administering Methytrexate orally to the client with cancer,
the nurse should check the:
A. IV site
B. Vital signs
C. Blood gases
D.Electrolytes
Answer: B. Vital signs
7. A patient's family does not know the patient's end-of-life care preferences, but assumes that they know what is best for the patient under the circumstances. This assumption reflects:
A) justice.
B) pragmatism.
C) paternalism.
D) veracity.
Answer: C) paternalism.
8. Which assignment should not be performed by the licensed practical
nurse?
A. Initiating a blood transfusion
B. Discontinuing a nasogastric tube
C. Inserting a Foley catheter
D. Obtaining a sputum specimen
Answer: A. Initiating a blood transfusion
9. During an assessment of a patient who sustained a head injury 24 hours ago, the medical-surgical nurse notes the development of slurred speech and disorientation to time and place. The nurse's initial action is to:
A) recheck the patient's neurologic status in 15 minutes.
B) continue the hourly neurologic assessments.
C) prepare the patient for emergency surgery.
D) inform the neurosurgeon of the patient's status.
Answer: D) inform the neurosurgeon of the patient's status.
10. The nurse is making assignments for the day. Which client should
be assigned to the nursing assistant?
A.A client with pneumonia
B. A client with appendicitis
C. A client with Alzheimer’s disease
D. A client with thrombophebitis
Answer; C. A client with Alzheimer’s disease
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Answer: C) ambulating 50 feet without experiencing dyspnea.
4. A client with an abdominal aortic aneurysm is admitted in preparation
for surgery. Which of the following should be reported to the
doctor?
A. A negative Babinski reflex
B. An abdominal bruit
C. An elevated white blood cell count
D. Pupils that are equal and reactive to light
Answer: C. An elevated white blood cell count
5. Which action best describes a sentinel event alert?
A) Signaling the need for immediate investigation and response
B) Indicating that a community or institution is unsafe
C) Documenting the breakdown in communication during a shift report
D) Recording the harm done when a medication error occurs
Answer: A) Signaling the need for immediate investigation and response
6. Before administering Methytrexate orally to the client with cancer,
the nurse should check the:
A. IV site
B. Vital signs
C. Blood gases
D.Electrolytes
Answer: B. Vital signs
7. A patient's family does not know the patient's end-of-life care preferences, but assumes that they know what is best for the patient under the circumstances. This assumption reflects:
A) justice.
B) pragmatism.
C) paternalism.
D) veracity.
Answer: C) paternalism.
8. Which assignment should not be performed by the licensed practical
nurse?
A. Initiating a blood transfusion
B. Discontinuing a nasogastric tube
C. Inserting a Foley catheter
D. Obtaining a sputum specimen
Answer: A. Initiating a blood transfusion
9. During an assessment of a patient who sustained a head injury 24 hours ago, the medical-surgical nurse notes the development of slurred speech and disorientation to time and place. The nurse's initial action is to:
A) recheck the patient's neurologic status in 15 minutes.
B) continue the hourly neurologic assessments.
C) prepare the patient for emergency surgery.
D) inform the neurosurgeon of the patient's status.
Answer: D) inform the neurosurgeon of the patient's status.
10. The nurse is making assignments for the day. Which client should
be assigned to the nursing assistant?
A.A client with pneumonia
B. A client with appendicitis
C. A client with Alzheimer’s disease
D. A client with thrombophebitis
Answer; C. A client with Alzheimer’s disease
Click here to download NCLEX RN Question Answers.pdf.
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