It is very important in passing the US Licensure exam that you practice a lot of NCLEX Questions for familiarization. Check the sample below and take note of the approach of each NCLEX-type items.
Instructions: Choose the letter of the best answer.
1. An adult male is admitted for Crohn’s Disease treatment. Which data is MOST significant when the nurse checks his nutritional status?
A. Bleeding gums
B. Dry skin
C. Facial rubor
D. Anthropometric measurements
Anthropometric measurements are the prime parameters used to measure stored fat and muscle in the body.
2. During the nurse’s rounds, she notices the patient’s chest tube (attached to a water seal drainage system) is dislodged from the chest. What will be the MOST appropriate nursing intervention?
A. call the physician
B. reinsert another chest tube
C. cover the insertion site with petroleum gauze.
D. Instruct client to remain calm and breathe deeply until help arrives
Covering the site with petroleum gauze will prevent air from entering the chest cavity.
3. A young man was injured when his car was hit by another car, he is bleeding profusely from a 3-inch gash on his left leg. As a nurse on the scene, what is the BEST approach to control the bleeding?
A. Apply direct pressure to the wound
B. Remove the injured man away from the car
C. Elevate the extremity
D. Wrap a tourniquet around the wound
Direct pressure to the wound will aid in the development of a blood clot, which is the first step in wound healing.
4. A 50 y/o woman is having chemotherapy treatment for breast cancer. She asks the nurse how chemotherapeutic drugs work. The MOST accurate explanation would include which statement?
A. They affect all rapidly dividing cells
B. Molecular structure of the DNA segment is altered
C. Chemotherapy stimulates cancer cells to divide
D. The cancer cells are sensitive to drug toxins
There are numerous mechanisms of action for chemotherapeutic drugs, but most affect rapidly dividing cells.
5. Jane, a 2y/o patient undergone a cleft palate repair. A PRIORITY post op plan of care for Jane includes teaching her mother to
A. resume toilet training after she is up and around
B. use a cup or a wide bowl spoon for feeding
C. be aware that she will be more prone to respiratory infections since her airway is smaller
D. know that no further treatment will be needed until her adult teeth come in at age 6
Care must be taken to not put anything in the mouth that could damage the suture line
6. An 18 y/o woman is admitted with a working diagnosis of anorexia nervosa. What will the nurse include in the patient’s plan of care?
A. Do surprise weights
B. Observe the patient during and an hour after each meal
C. Provide health teaching regarding the importance of an adequate diet
D. Allow plenty of time to eat each meal
The patient with anorexia nervosa may discard or hide the food or even induce vomiting after a meal if unsupervised.
7. The maternity nurse is attending to a patient in labor. She is 8cm dilated. During this stage of labor, which of the statements the nurse expect her to make?
A. leave her presence most of the time
B. offer her sips of water
C. during contractions, offer her back rub
D. provide warm blankets
The counterpressure performing back rubs during a contraction may soothe discomfort.
8. A patient with complaints of chest pain was rushed to the e.r. Which priority action should the nurse do initially?
a) Administer morphine sulfate IV
b) Initiate venous access
c) Oxygen administration via nasal cannula
d) Complete physical assessment and patient history taking
Priority nursing action is to administer oxygen to patients with chest pain. Chest pain is caused by insufficient myocardial oxygenation.
9. An 8 year old patient is diagnosed of having cystic fibrosis. The Attending physician ordered to perform Chest Physiotherapy. The said procedure should be performed
A. at least 30 minutes before meals
B. after suctioning
C. before postural drainage
D. before an aerosol treatment
Chest percussion is done before meals to prevent vomiting.
10. The nurse plans to frequently assess a post-thyroidectomy patient for?
b) Hypoactive deep tendon reflex
Hypocalcemia occurs when there is accidental removal or destruction of parathyroid tissue during surgical removal of the thyroid gland. Laryngospasm is one of the clinical manifestations of tetany, an indicator of hypocalcemia.