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90 Free NCLEX Practice Questions (Rationales and Video)

Passing the NCLEX comes down to 3 things . . . practice, practice, practice . . . okay and one more thing . . practice.

To help you get the NCLEX questions practice you need to pass we have created a ton of resources including our 3,500 Question Bank (Nursing Practice Questions), to an NCLEX Question Podcast, to courses and so much more.

This page here is designed to condense 90 of our top questions covering all of the NCSBN test topics into one resource that you can save for later and review at any time.

How to use this page:

  • Work through each question
  • Highlight the one you get wrong
  • Dive deep into the rationales for each question you got wrong or struggled with
  • Return and take those questions again

You will notice that in the title for each of the NCLEX questions there are two categories.  One includes the nursing category (OB, Peds, Cardiac etc) while the other includes the NCSBN testing category.  It is important that as you take the questions you take note of categories you are doing well with and those you are struggling with . . . focus on your struggle areas.

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While I am confident these questions will be helpful, if you want more practice questions set up in a testing format check out NPQ (our NCLEX Question Database) HERE.

NCLEX Question #1: Breathing Difficulties in a Patient with Scleroderma (Integumentary/Basic Care and Comfort)

Question:

A 36-year-old patient has been diagnosed with scleroderma and has breathing difficulties, including wheezing and dry cough. Which of the following skin changes would the nurse also expect to see upon assessment of this patient?

Answer:

D. Stiff, tight skin that is lighter or darker than surrounding skin

Rationale:

Scleroderma is an autoimmune disorder that can impact different parts of the body. Certain types of scleroderma may cause breathing difficulties; however, the condition can also cause skin changes that affect the patients movement. The patient with scleroderma is most likely to suffer skin changes such as stiff or tight skin that may be lighter or darker when compared to surrounding skin, ulcers on the fingertips, and small bumps under the surface of the skin.

 

NCLEX Question #2: Hypokalemia and Cardiac Arrhythmias (Labs/Basic Care and Comfort)

 

 

Question:

A patient who has been suffering from severe diarrhea has developed hypokalemia and cardiac arrhythmias as a result. Which of the following treatments would most likely be ordered for this patient to correct the situation?

Answer:

A. IV administration of potassium

Rationale: 

Hypokalemia occurs when there is not enough potassium; this decrease in potassium can cause life-threatening arrhythmias. Although hypokalemia may be treated in various ways by adding potassium to the diet, if the condition is severe enough that it is causing heart conduction changes, the patient should receive potassium as soon as possible to correct the situation, preferably through an IV.

NCLEX Question #3: General Adaptation Syndrome (Mental Health/Basic Care and Comfort)

 

Question:

Which of the following descriptions best defines general adaptation syndrome?

Answer:

C. The body’s response to stress over both short- and long-term periods

Rationale:

General adaptation syndrome is a stress response in which the body modifies its reaction to stress. Initially, the body alters its response in reaction to short-term stressful events. Over time, general adaptation syndrome develops as the body adapts to long-term or chronic levels of stress.

 

NCLEX Question #5: Type of Crutches Necessary for a Paraplegic (Musculoskeletal/Basic Care and Comfort)

 

Question:

A child was injured in an accident and has become a paraplegic. The child must use crutches on a permanent basis, most likely for the rest of his life. Which type of crutches would most commonly be used in this situation?

Answer: 

B.  Forearm crutches

Rationale: 

Crutches are used as methods of support for children or adults who cannot bear weight on their legs, such as after an injury. There are various types of crutches available, which are utilized depending on their need. Forearm crutches have a cuff that encircles the lower arm. These types of crutches tend to be used for long-term use, such as with braces when a child suffers paralysis, instead of axillary crutches, which are for short-term use.

 

NCLEX Question #6: Spica Cast on a Patient with Hip Dislocation (Muskuloskeletal/Basic Care and Comfort)

Question:

A nurse is working with a family whose child was born with developmental dislocation of the hip. The physician has applied a spica cast to the child. Which statement from the nurse best describes this type of cast to the child’s family?

Answer:

D.  “This cast will keep the hip joints in the correct position so they can heal.”

Rationale: 

A spica cast is a plaster cast applied to the hips and legs of a child born with developmental dislocation of the hip-a condition in which a baby is born with one or both hip joints dislocated. The cast places the hip joints into their sockets and keeps them in place for a period of time while they heal. The parents should be taught that the cast is in place for the specified period of time and it is not removed for elimination; some children are delayed in walking after the cast is removed, but they usually catch up to their peers.

NCLEX Question #7: Use of a Nosey Cup in a Stroke Patient (Neurology/Basic Care and Comfort)

 

 

Question:

A nurse is caring for an 80-year-old client who is in rehabilitation after having a stroke. The nurse is teaching the client about how to use a nosey cup. Which of the following best describes this device?

Answer:

B.   A cup that has a portion cut out of the front

Rationale: 

A nosey cup is a type of device that may be used by some patients who have difficulty with drinking liquids. The nosey cup has a portion cut out of the front so that the patient can lift the cup to the face to drink and does not need to tilt the head back. It can be used for those with difficulties swallowing liquids.

 

NCLEX Question #8: Contractures in a Patient with Huntington’s Disease (Neurology/Basic Care and Comfort)

Question:

A 78-year-old patient with Huntington’s disease has developed contractures from muscle atrophy. The nurse is reviewing his information after he has been admitted to the long-term care facility. Which best describes an appropriate outcome for this patient?

Answer:

C. The patient will participate in range of motion exercises to reduce the effects of the contractures

Rationale: 

Huntington’s disease is a progressive condition that can lead to muscle atrophy and potential contractures. The patient in this situation should be given a program of range of motion exercises in which he may need assistance. The nurse can help the patient to increase his range of motion and to prevent worsening of contractures by improving flexibility and reducing rigidity.

 

NCLEX Question #9: Activities of Daily Living in a Patient with Myasthenia Gravis (Neurology/Basic Care and Comfort)

Answer:

A.  Eating breakfast

Rationale: 

Myasthenia gravis is an autoimmune disorder characterized by weakness of skeletal muscles and fatigue with exertion. The patient would most likely have difficulties with performing activities of daily living that require exertion or use of muscles; this would include eating or grooming. It would be less difficult for a patient to participate in more passive activities.

NCLEX Question #10: Narcolepsy in a Traumatic Brain Injury Patient (Neurology/Basic Care and Comfort)

Answer:

C.  Loss of muscle control

Rationale: 

A patient who has suffered a traumatic brain injury is at high risk of developing sleep problems. Narcolepsy is a condition in which a person experiences excessive daytime sleepiness. He may also develop a condition known as cataplexy, in which he experiences occasional loss of muscle control while awake, which can be triggered by significant emotions, such as laughter or intense sadness.

NCLEX Question #11: Breathing Difficulties in a Patient with Spinal Cord Injury (Neuro/Basic Care and Comfort)

 

Answer:

A.  The patient has a Glasgow Coma Score of 8

Rationale: 

A spinal cord injury produces paresthesia below the level of the injury; paraplegia indicates an injury in which the patient cannot move the lower extremities, while quadriplegia is a higher-level injury where the patient often cannot move the upper or lower extremities. With a higher-level injury, the patient may also need breathing support; if the spinal cord was injured above the level that stimulates breathing, the patient may need intubation. Respiratory failure is an indication for intubation, as is a GCS result of <9, which indicates a decreased level of consciousness.

 

NCLEX Question #13: Effects of Blood Pressure and Pulse on Cardiogenic Shock (Cardiac/Health Promotion and Maintenance)

Answer:

D. Decreased cardiac contractility

Rationale: 

A patient with a cardiac condition is at risk of developing cardiogenic shock when the heart has been damaged enough that it is unable to effectively pump blood to perfuse vital organs. The patient will most often experience a decrease in blood pressure and a weak or thready pulse. Cardiac contractility, the degree of performance of the heart’s contractions, will also be diminished when cardiogenic shock develops.

 

NCLEX Question #14: Acromegaly and Pituitary Gland Tumor (Endocrine/Metabolic/Health Promotion and Maintenance)

Answer:

B.   benign tumors on the pituitary that cause excess secretion of growth hormone.

Rationale: 

A patient with acromegaly produces too much growth hormone as a result of small tumors that develop on the pituitary gland. The condition causes excess growth of tissue, resulting in enlarged hands, feet, and facial structures.

NCLEX Question #15 Tantrums in a 3-year-old (OB/Peds/ Health Promotion and Maintenance)

Answer:

B. Problems within parents’ marriage/relationship

C. Speech difficulties

D. Boredom

Rationale: 

It is normal and common for a 3-year-old child to have tantrums. Children of this age may have difficulty communicating, and tantrums are a method of expressing frustration. The child may also have tantrums because of factors such as inconsistent parenting and problems in the parents’ marriage.

 

NCLEX Question #16: Comforting a Preschool-Age Child (OB/Peds/Basic Care and Comfort)

Answer:

B. Art therapy

C. Watching a movie

D. Blowing bubbles

Rationale: 

A preschool-age child is at a different developmental age when compared to an infant or a school-age child. A child who is in preschool does not understand some of the concepts of medical care and would benefit from non-pharmacological interventions for comfort. The most appropriate activities for this age group include hands-on tasks such as art therapy; and distracting activities, such as watching a movie or blowing bubbles.

 

NCLEX Question #19: Method of Change (Mental Health/Health Promotion and Maintenance)

Answer:

C. The patient will more likely desire change after connecting with another person

Rationale: 

Change is necessary when a patient is exhibiting behaviors that are harmful to himself or others. Change can be implemented in many ways, but personal engagement, or talking, working with, and spending time with another person, can be effective in getting the message across about the high-risk behavior. With personal engagement, the patient is more likely to desire change because he feels a connection with another person.

 

NCLEX Question #20: Diabetic Peripheral Neuropathy (Neuro/Basic Care and Comfort)

Answer:

C.  Percutaneous electrical nerve stimulation

Rationale: 

Diabetic peripheral neuropathy can cause severe pain and nerve dysfunction in the extremities. The patient with this condition may need pain management methods, which could be through medications or through non-pharmacological methods, such as nerve stimulation.

NCLEX Question #21: Hypovolemic Shock and Proper Position (Cardiac/Health Promotion and Maintenance)

Answer:

D. Supine with the legs elevated

Rationale: 

The most appropriate position for the patient in shock is to have him lie supine with the legs elevated. This position promotes venous return from the lower extremities so that blood can flow back to the heart; the cardiovascular system does not have to work as hard and blood can be shunted to central organs until the patient receives appropriate treatment.

NCLEX Question #22: Social Isolation (Mental Health/Health Promotion and Maintenance)

Answer:

A.  Stated doubts about an ability to survive alone

B. Expressed feelings of abandonment or loneliness

C. Feelings of uselessness

Rationale: 

A patient who suffers from social isolation may feel lonely, he may have few friends, or he may suffer from isolation. The patient in this situation may express these feelings and may talk about other symptoms of the situations, such as an inability to care for himself without the help of others.

NCLEX Question #23: Self-care Deficit in a Stroke Patient (Neuro/Health Promotion and Maintenance)

Answer:

A. The patient will be able to dress himself appropriately

B. The patient will demonstrate how to use adaptive equipment effectively

C. The patient will be able to cope with having someone help with dressing tasks

Rationale: 

A patient who struggles with self-care deficit may have difficulties performing activities of daily living and other routine activities that were once commonplace. Appropriate outcomes for a patient with this nursing diagnosis focus on the patient improving his skills for self-care and his ability to cope when he needs help from others.

 

NCLEX Question #24: Heart Sounds(Cardiac/Health Promotion and Maintenance)

Answer:

A. mitral valve prolapse.

Rationale: 

When auscultating heart sounds, the nurse may hear a variety of different sounds; some are normal parts of the heart’s anatomy, while others indicate an abnormality. A systolic click is a high-pitched sound that is heard at the late part of systole. When this sound is heard, it can indicate mitral valve prolapse, causing abnormal blood flow through the heart.

 

NCLEX Question #25: Hemoglobin A1c and Diabetes (Labs/Health Promotion and Maintenance)

Answer:

C.  “This test checks how much sugar is coating the hemoglobin in your red blood cells; it can tell us your blood sugar levels for the past two months.”

Rationale: 

The hemoglobin A1C test, also called the glycosylated hemoglobin test, is part of diagnostic testing for diabetes. The test looks at the amount of glucose that is saturating the hemoglobin molecules within the red blood cells. The test can tell the provider about the patients blood glucose levels for the past 2 to 3 months: approximately the lifespan of the red blood cell.

 

NCLEX Question #26: Dysphagia in a Patient with ALS (Neuro/Basic Care and Comfort)

Answer:

C. Dysphagia

Rationale: 

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that causes a decline in respiratory function, including shortness of breath and an inability to cough. The patient is also at a nutritional risk because of muscle wasting and dysphagia. Other factors that may contribute to nutritional issues in the ALS patient include constipation, increased metabolic rate, and difficulties performing activities of daily living.

 

NCLEX Question #27: Blended Families (Fundamentals/Health Promotion and Maintenance)

Answer:

A.  There may be step-siblings in the family who do not share a biologic parent

B.  The parents come together after a previous divorce or death of a spouse

E.  The parents may add another child who becomes a half-sibling to the other children

Rationale: 

A blended family is one in which the parents come together after a previous divorce or death of a spouse. If children are part of the family, the children take on a step-parent who is not a biological parent to the child. The parents in these situations may add more children to the family; the new child becomes a half-sibling to the other children.

 

NCLEX Question #28: Authoritarian Parenting Style (OB/Peds/Health Promotion and Maintenance)

 

Answer:

C.  There are high expectations of each family member

E.  Punishment may involve withdrawal of approval

Rationale: 

A nurse who works with families may encounter various parenting styles. The authoritarian parenting style is one that is strict and where the parents exert a great amount of control over their children. The parents may physically punish the children or discipline them by withdrawal of approval.

NCLEX Question #29: Dehydration in an Athlete (Labs/Health Promotion and Maintenance)

Answer:

B.  Drink fluids starting several hours before exercise begins

Rationale: 

A person who exercises a great amount, such as with a student athlete, may be at risk of dehydration and electrolyte imbalance from water loss through sweat and respiration. The nurse should counsel the patient to drink electrolyte replacement beverages or water and to drink fluids throughout the entire period: before, during, and after exercising.

NCLEX Question #30: Palpation (GI/GU/Health Promotion and Maintenance)

Answer:

D.  The pads of the fingers

Rationale: 

When assessing a patient through palpation, the nurse may use different parts of the hand to find differing signs related to the patients condition. The pads of the fingers are best used for palpating pulsations, edema, and crepitus, as well as determining moisture content of the skin.

NCLEX Question #31: Palpation and Percussion of Abdomen (GI/GU/Health Promotion and Maintenance)

Answer:

C.  Inspection, auscultation, percussion, palpation

Rationale: 

When assessing any other part of the body, the nurse would normally perform the methods of assessment in the order of inspection, palpation, percussion, and then auscultation. However, when assessing the abdomen, the order of the techniques is different and should be instead done in the order of inspection, auscultation, percussion, and then palpation. This is because performing palpation or percussion could stimulate the patients gastrointestinal tract and the nurse may hear increased or decreased bowel sounds on later auscultation. The nurse should auscultate to hear bowel sounds first before palpation.

 

NCLEX Question #32: Precontemplation (Respiratory/Health Promotion and Maintenance)

Answer:

C. The patient has no plans to quit smoking

Rationale: 

The phases of change, such as when a person wants to make a change in lifestyle habits, go through a series that starts with no desire or thought to change all the way to making the change and following through with it. In the pre-contemplation phase of change, the patient has not yet thought about quitting smoking and may not have any desire to do so. With time and further teaching, the patient may move forward in the stages of change and make plans to quit.

NCLEX Question #33: Implementing Evidence-based Practice (Fundamentals/Management of Care)

Answer:

B.  The nurses on the unit report how the new standards have affected patient health status and bedside care

Rationale: 

Implementing evidence-based practice into care is one aspect of maintaining current practice standards. The nurse may learn of methods that continually improve patient care and implement them into practice, but she must also evaluate the effectiveness of the new practices. The best method of evaluation would be to ask the providers who use the new standards about their effectiveness.

NCLEX Question #34: Privacy and Confidentiality (Ethical/Legal/Management of Care)

Answer:

C.  “The nurse can make a copy of my medical record to send it to my friend.”

Rationale: 

Privacy and confidentiality are important aspects of maintaining patient security while he receives healthcare services. The nurse must educate the patient about his rights to privacy and security of his health information. The patient has a right to get a copy of his medical record, but the nurse cannot simply make a copy and send it to someone else at the patients request.

NCLEX Question #36: Impaired Infant/Child Attachment (OB/Peds/Health Promotion and Maintenance)

Answer:

A.  Assess the interactions between the parents and the child

C.  Respond to the child consistently with nurturance

D.  Provide positive feedback when the parents nurture the child

Rationale: 

Attachment is something that develops between parents and children from time spent together and learning to trust each other. Some children are not able to trust their caregivers and may have difficult attachments or may be unable to bond with their parents. The nurse can help in this situation by teaching the parents to respond consistently and by providing positive feedback and support for parents.

 

NCLEX Question #37: Risk Factors for Pancreatic Cancer (Oncology/Health Promotion and Maintenance)

Answer:

A.  Tobacco use

C.  Exposure to certain pesticides

Rationale: 

Cancer of the pancreas is a life-threatening condition that often has a poor prognosis. Risk factors for this type of cancer include such factors as tobacco use in the patient and exposure to certain toxic chemicals, such as pesticides.

NCLEX Question #38: Dyspnea (Respiratory/Basic Care and Comfort)

Answer:

C. Obesity

Rationale: 

Dyspnea, also known as breathlessness, is a state in which a person is unable to get enough air. Dyspnea may be acute, such as after an injury affecting the lungs or a panic attack, or it may be chronic in nature. Causes of chronic dyspnea include such conditions as heart disease, arrhythmias, asthma, COPD, bronchiectasis, and obesity.

NCLEX Question #39: Nutrition and COPD (Respiratory/Basic Care and Comfort)

Answer:

D. Achieve and maintain a healthy weight

Rationale: 

A patient with COPD suffers from a chronic disease that can progressively worsen if he does not take care of his health. As part of health education, the nurse must teach the patient important facts that will most support his overall health. If the patient is able to achieve and maintain a healthy weight, he will be more likely to have a healthy status overall, as obesity contributes to many complications of COPD, including difficulty breathing, poor stamina, and blood glucose abnormalities.

 

NCLEX Question #40: Dysphagia in a Stroke Patient (Neuro/Basic Care and Comfort)

Question:

A nurse is caring for a patient who is recovering from a stroke. The nurse arranges for a swallowing screening to be performed on this patient. Which best describes the purpose of this test?

Answer:

B. To assess the amount of dysphagia present

Rationale: 

A swallowing test would help the provider to determine the amount, if any, of food and liquid that a patient is able to swallow. A patient who requires a dysphagia diet may eat from different levels of food consistency based on what he is able to swallow.

NCLEX Question #41: Prostesis in amputation patient (Musculoskeletal/Basic Care and Comfort)

Answer:

D.  The level of the amputation

Rationale: 

Various factors go into determining the most appropriate type of prosthetic appliance to use for a patient who has had a limb amputation. The type of prosthetic may be determined by factors such as the level of the amputation, the patients functional abilities, and the condition of the remaining limb.

NCLEX Question #42: Communication with a Patient with Hearing Loss (Fundamentals/Basic Care and Comfort)

Answer:

B. Writing down pertinent information for the patient to read

Rationale: 

A patient with hearing loss and who has no assistive devices for hearing needs teaching through a method that promotes another one of the senses, such as through reading visual materials. It is not appropriate to shout at a patient, expect him to lip read, or mime the actions.

NCLEX Question #43: Urinary Incontinence in Spinal Cord Injury Patient (GI/GU/Basic Care and Comfort)

Question:

A patient with a spinal cord injury has difficulty determining when he needs to empty his bladder. The nurse teaches him about tapping to stimulate voiding. How would the nurse describe tapping to this patient?

Answer:

A.  The area over the bladder is tapped to stimulate the bladder muscles

Rationale: 

A patient with a spinal cord injury may be unable to control urine flow if he has little to no sensation in the bladder that tells the brain when it is time to empty the bladder. The nurse may teach the patient about some techniques that can stimulate urine flow. Tapping involves lightly tapping the area over the bladder with the fingertips to stimulate detrusor muscle contractions.

NCLEX Question # 44: Stress Incontinence (GI/GU/Basic Care and Comfort)

Question:

A patient with stress incontinence is undergoing treatment through rehabilitation of the pelvic floor muscles. Which statement by the patient suggests that he is responding to the treatment?

Answer:

C.  “I have not leaked urine the last several times I have coughed.”

Rationale: 

Stress incontinence describes a condition in which a patient leaks urine when there is increased pressure within the bladder, such as with coughing or sneezing. Treatment involves pelvic floor muscle rehabilitation and medications. The patient may find success when he is able to cough or laugh and not leak urine.

NCLEX Question #45: Skin Breakdown Related to Immobility (Musculoskeletal/Basic Care and Comfort)

Question:

A nurse is caring for a patient with reduced mobility following hip surgery. Which best describes how the nurse would intervene to prevent skin breakdown from immobility?

Answer:

A.  Use padding and cushions under the heels and other bony prominences

Rationale:

Skin breakdown is a consequence of immobility; a patient who moves very little is at risk of pressure ulcers because he cannot reposition himself to take the weight off of certain parts of the body. The nurse can help to prevent skin breakdown in a patient who has difficulty with repositioning by using padding under bony prominences to decrease the amount of pressure placed on these areas.

NCLEX Question #46: Skin Breakdown after Bruising (Integumentary/Basic Care and Comfort)

Question:

A patient has suffered a bruise on her elbow from being assisted in bed for repositioning. Which best describes how the nurse can prevent this injury from becoming a point of skin breakdown?

Answer:

A. Encourage the patient to increase fluid intake

Rationale: 

A patient with mobility impairments may be at risk of skin breakdown after being injured, even if the injury did not initially break the skin. The patient with a bruise may develop skin breakdown in the area if it is not properly maintained. The nurse should encourage fluid intake to maintain hydration and to keep the skin from drying out.

NCLEX Question #47: DVT Prevention (Cardiac/Basic Care and Comfort)

Question:

A nurse is preparing to apply thigh-high anti-embolism stockings to a patient with a history of DVT. The nurse notes that the patients legs have different measurements. Which response from the nurse is appropriate?

Answer:

B.  Choose antiembolism stockings of different sizes

Rationale: 

Before applying antiembolism stockings, the nurse must measure the size of the client’s legs. Occasionally, the measurements will be different between the legs and the nurse must use two different sizes of stockings. As long as the client is otherwise stable, the nurse can just choose a stocking of a different size.

NCLEX Question #48: Relaxation Therapy for Pain Management (Fundamentals/Basic Care and Comfort)

Question:

A nurse who is caring for a patient with chronic pain and recommends the patient undergoes relaxation therapy as part of pain management. How would relaxation therapy work in this situation?

Answer:

C.  Relaxation decreases anxiety, which can cause muscle tension and contribute to pain

Rationale: 

Relaxation exercises are useful in helping patients to stay calm and they may help with reducing symptoms of pain. Relaxation works by improving symptoms of anxiety, which can lead to muscle tension; this muscle tension further contributes to pain and may make the pain feel worse. By using relaxation, the patient may be able to reduce some of the contributing factors toward pain.

NCLEX Question #49: Palliative Care for and Oncology Patient (Oncology/Basic Care and Comfort)

Question:

A palliative care nurse is counseling a patient who is suffering from cancer. Which statement by the patient indicates that more education is needed about the treatment he receives through palliative care?

Answer:

D. “I can receive palliative care for my side effects of chemo, but my cancer pain has to be treated differently.”

Rationale: 

A palliative care nurse may work with a patient who has cancer to help with side effects of cancer treatments and to maintain quality of life. Palliative care is designed to promote comfort; if the patient is experiencing pain, the nurse can also help to find ways to manage the patients pain by working closely with the physician.

NCLEX Question #50: Palliative Care in Respiratory Patient (Respiratory/Basic Care and Comfort)

Question:

A patient with lung disease has decided to receive palliative care at home. The patient does not want his mother to be nearby while he is recovering, even though his wife has asked him to reconsider. Which response from the nurse would best support this patients choice?

Answer:

A.  “Your family is responsible for providing most of your care; you can decide who you want to help you.”

Rationale: 

A patient who is in palliative care receives support and help from the nurse but may often rely on family members to provide much of the care as well. If a patient does not want a specific family member near during treatments, he has the right to ask the person to stay away. The nurse should not interfere by coming between the patient and his family to decide about who should be present for care.

NCLEX Question #51: Lab Values in a Patient with Dehydration (Labs/Basic Care and Comfort)

Question: 

A nurse is caring for a client who is at high risk of dehydration. Which parameter would the nurse use for assessment if this patient were to become dehydrated?

Answer: 

A. Orthostatic hypotension

Rationale: 

A patient who is dehydrated may exhibit several clinical signs that indicate that the nurse needs to intervene to help increase the patients fluid intake. A patient who has lost weight, has elevated serum sodium, elevated BUN with decreased creatinine, and orthostatic hypotension is exhibiting signs of dehydration.

NCLEX Question #52: Calorie Counting for Weight Loss (GI/GU/Basic Care and Comfort)

Question:

A physician has ordered calorie counts for a patient who needs to lose weight. Which best describes how the nurse would instruct the client in this process?

Answer:

B. “This method teaches you common amounts of calories in foods and you keep track of what you eat every day.”

Rationale: 

Calorie counting is a method of weight loss that involves teaching a patient about calorie amounts in many foods and helping him keep track of how many calories he takes in every day. The patient may have a set amount of calories to meet as a daily goal. The nurse can teach the patient that this method of eating can help with weight loss but it is not an individualized plan just for the patient.

NCLEX Question #53: BMI in an Overweight Patient (Fundamentals/Basic Care and Comfort)

Question:

A 41-year-old patient is being seen at the primary care clinic for a physical exam. The patient is overweight and wants to talk to the nurse about losing weight. Choose the alternative that best explains the calculation of BMI.

Answer:

C.  BMI is a calculation of body fat that is based on weight and height of the patient

Rationale: 

Body mass index (BMI) is a measure of body fat that is calculated based on weight and height of the patient. It does not measure body fat directly. The BMI result then classifies the patient according to weight type: whether the patient is underweight, normal weight, overweight, or obese.

NCLEX Question #54: Heart Failure and Sodium Intake (Cardiac/Basic Care and Comfort)

Question:

A patient with heart failure has been ordered to reduce her sodium intake in order to better control her condition. Which best explains why reduction in sodium intake will affect symptoms of heart failure?

Answer:

D.  Too much sodium intake is associated with fluid retention

Rationale: 

Fluid retention is a risk for patients with volume overload associated with heart failure. Most patients with heart failure are counseled to avoid excess sodium and they often need to take medications to eliminate excess fluid from the body.

NCLEX Question #55: Nutrition and Alzheimer’s Disease (Neuro/Basic Care and Comfort)

Question:

A patient with Alzheimer’s disease has had difficulties eating and is not getting enough nutrients in his diet. The patients daughter asks the nurse if there is anything that can be done to improve his nutrition intake. Which recommendation should the nurse give?

Answer:

B.  Use less salt when cooking and serving food

Rationale: 

A patient with Alzheimer’s disease may develop malnutrition and weight loss from difficulties with eating. The family member of the patient with Alzheimer’s may provide a nutritious diet with reminders about how to use utensils and how to eat food if the person forgets. Increased sodium intake can contribute to high blood pressure in the patient and should be monitored with limited salt for cooking and serving.

NCLEX Question #56: Treatment for Urinary Incontinence (GI/GU/Basic Care and Comfort)

Question:

A 76-year-old patient has urinary incontinence diagnosed because of instability of the detrusor muscle. Which of the following describes a form of management of this type of incontinence? Select all that apply.

Answer:

A. Anticholinergic drugs, such as Ditropan

B. Bladder training

Rationale: 

Incontinence caused by instability of the detrusor muscle in the bladder leads to incomplete bladder emptying and leakage or urine between periods of voiding. The condition is typically managed with anticholinergic drugs and lifestyle changes, such as avoidance of caffeine, which stimulates the bladder. The patient may also undergo bladder training to increase the time between using the bathroom.

NCLEX Question #57: Cardiac Complications Caused by Immobility (Fundamentals/Basic Care and Comfort)

Question:

A nurse is caring for a patient who has been immobile for the past three weeks while recovering from surgery. The patient has been deteriorating in health because of his lack of activity. Based on the nurse’s knowledge of the effects of immobility, which describes the cardiovascular complications that can develop because of immobility? Select all that apply.

Answer:

C. DVT

D. Hypotension

E. Bradycardia

Rationale: 

Immobility causes complications throughout all body systems; cardiac complications tend to develop because of decreased activity levels and poor tissue perfusion. Examples of cardiovascular complications that can develop include deep vein thrombosis, hypotension, bradycardia, and cardiac arrhythmia.

NCLEX Question #58: Intervention for Pressure Ulcer (Integumentary/Basic Care and Comfort)

Question:

A nurse is working with a client who has been confined to his bed for the past week because of illness. While turning this patient, the nurse notes a stage II pressure ulcer on his sacrum. Which action is most appropriate in responding to this finding? Select all that apply.

Answer:

D. Support the patients nutrition and mobility

E. Relieve pressure using pillows or foam cushions

Rationale: 

Pressure ulcers are unfortunate consequences of immobility; if the nurse finds a pressure ulcer on a patient, she must respond quickly to avoid further complications. The nurse should apply a dressing and medication as ordered, as well as quickly relieve pressure from the site using foam cushions or pillows. The nurse must avoid donut-shaped ring devices for support as these place too much pressure in certain areas. The nurse also should not massage the site, as this can cause tissue damage.

NCLEX Question #59: Prone Position in ARDS (Respiratory/Basic Care and Comfort)

Question:

A nurse must position the patient prone after his diagnosis of acute respiratory distress syndrome (ARDS). Which of the following is a benefit of using this position? Select all that apply.

Answer:

A. Decreased atelectasis

C. Mobilization of secretions

D. Decreased fluid accumulation

Rationale: 

Prone positioning, or placing the patient face down with the head turned to the side, helps with pulmonary function in the patient diagnosed with ARDS. Studies have shown that patients who are positioned prone and who have respiratory conditions often have improved outcomes of decreased lung atelectasis, mobilization of secretions to enhance suctioning, and decreased fluid accumulation in the lung tissue.

NCLEX Question #60: TENS Device and Back Pain (Musculoskeletal/Basic Care and Comfort)

Question:

A nurse is using a TENS device to help a patient with his low back pain. Which of the following considerations should the nurse keep in mind when using this type of device? Select all that apply.

Answer:

A. The TENS unit involves electrical stimulation

C.  A pregnant patient may not be able to use TENS

D. A patient who has a monitor should not use TENS over leads

E.  TENS can cause damage to the skin

Rationale: 

A trans-electrical nerve stimulation (TENS) unit can be applied to certain parts of the body to stimulate nerves under the skin and help to control pain. When utilizing this method, the nurse should understand that it is an electrical current being used and could therefore injure the skin. It should not be used over monitor leads and its safety during pregnancy is not completely understood.

NCLEX Question #61: Full Liquid Diet after Surgery (GI/GU/Basic Care and Comfort)

Question:

A patient who is recovering from surgery has been ordered to have a full liquid diet. Which foods would the nurse provide for this patient that would be consistent with this diet? Select all that apply.

Answer:

A.  Ice cream

B.  Milk

E.  Pudding

Rationale: 

A full liquid diet is one given to a patient who is advancing in tolerance for food intake following a procedure or an illness that affects his digestion. Full liquids are those foods that are opaque in appearance and those that are liquid at room temperature. Examples include ice cream, cream soup, milk, and pudding.

NCLEX Question #62: Dysphagia in a Stroke Patient (Neuro/Basic Care and Comfort)

Question:

A nurse is caring for a patient who is recovering from a stroke and who has difficulties swallowing. The patient must have all liquids thickened to a nectar consistency. Which of the following is a true statement regarding this consistency of liquids? Select all that apply.

Answer:

A. Nectar-thick liquids can be poured.

C. An example of nectar-thick liquid would be cream soup.

E. A person can use a commercial thickening agent to get a liquid to nectar consistency.

Rationale: 

A person with dysphagia has difficulty swallowing food and liquids and may need to thicken liquids to avoid choking or aspiration. Liquids can be thickened to nectar, honey, or pudding consistencies. Nectar-thick liquids are pourable and can be thickened with a commercial thickening agent. An example would be a cream soup.

NCLEX Question #63: Activities of Daily Living (Fundamentals/Basic Care and Comfort)

Question:

A nurse is assessing a patient who is being admitted to the long-term care facility where she works. The nurse is utilizing the Katz Index of Independence in Activities of Daily Living. Which activities would the nurse assess for when considering activities of daily living? Select all that apply.

Answer:

C. Using the toilet

D. Transferring from the bed to the chair

E. Feeding self independently

Rationale: 

The Katz Index of Independence in Activities of Daily Living is a tool a nurse may use to assess a patients abilities to perform ADLs. The tool measures ADLs, but not instrumental activities of daily living, such as paying bills or running errands. Instead, the Katz tool measures such activities as toileting, transferring, eating, and grooming.

NCLEX Question #64: Pain Management in and Oncology Patient (Oncology/Basic Care and Comfort)

Question:

A patient who is dying of cancer tells the nurse that he is in extreme pain. Which of the following principles should the nurse adhere to when managing pain in a dying patient? Select all that apply.

Answer:

A.  Determine if the patient has developed drug tolerance

D.  Discuss increasing the dose of pain medication with the physician

E.  Monitor for side effects of increasing opioid use

Rationale: 

Cancer pain is common among dying patients; some healthcare providers do not like to administer high doses of pain medications because they fear addiction or side effects. A patient with cancer may develop medication tolerance and may need more pain medication as part of palliative care if he is dying.

NCLEX Question #65: Spinal Cord Stimulation (Pharmacology/Basic Care and Comfort)

Question:

A patient who is dying of cancer tells the nurse that he is in extreme pain. Which of the following principles should the nurse adhere to when managing pain in a dying patient? Select all that apply.

Answer:

A.  Determine if the patient has developed drug tolerance

D.  Discuss increasing the dose of pain medication with the physician

E.  Monitor for side effects of increasing opioid use

Rationale: 

Cancer pain is common among dying patients; some healthcare providers do not like to administer high doses of pain medications because they fear addiction or side effects. A patient with cancer may develop medication tolerance and may need more pain medication as part of palliative care if he is dying.

NCLEX Question #66: Role of Palliative Care (Oncology/Basic Care and Comfort)

Question:

The family member of a patient with lung cancer has asked the nurse about palliative care for the patient. Which describes when palliative care is appropriate for a patient? Select all that apply.

Answer:

A.  When the patient has a terminal condition

C.  When the patient seeks spiritual comfort in addition to physical comfort

E.  When the patient’s family also needs support

Rationale:

Palliative care describes comfort and symptom control for patients with significant illness. A patient may or may not have a terminal condition to receive palliative care. This type of care is holistic and includes the patient’s family when providing support.

NCLEX Question #67: Chronic Pain in Multiple Sclerosis (Fundamentals/Basic Care and Comfort)

Question:

A patient with chronic pain as a result of multiple sclerosis has requested music therapy for help with pain management. Which of the following describes music therapy for pain control? Select all that apply.

Answer:

A. Music therapy is an established health profession

B. Music therapy is a non-invasive form of treatment

D. Music therapy is associated with a decreased length of hospital stay among patients who use it

Rationale: 

Music therapy is a legitimate health profession established to provide support and comfort and to promote relaxation for a patient suffering from illness. Music therapy has been shown to reduce stress and pain among patients who use it; it may also decrease the length of inpatient hospital stays when used appropriately.

NCLEX Question #68: Nociceptive Pain (Musculoskeletal/Basic Care and Comfort)

Question:

A patient has come to the healthcare clinic complaining of pain in his left arm after an injury. Which describes the characteristics of nociceptive pain? Select all that apply.

Answer:

A.  Nociceptive pain may be localized to the area of injury

C.  Nociceptive pain is categorized as being either somatic or visceral pain

E.  Nociceptive pain can be referred pain

Rationale: 

Nociceptive pain describes a type of pain that occurs when there is damage to body tissue. A patient may experience this type of pain with a physical injury, such as a fracture or laceration. It is further categorized as being somatic or visceral pain and it can be referred from its original location and felt in another area of the body.

NCLEX Question #69: Mobility and Blood Clots (Cardiac/Basic Care and Comfort)

Question:

A nurse is teaching a client who has trouble with mobility about how best to decrease the risk of a blood clot. Which of the following statements made by the nurse is correct?

Answer:

A.  “Do not cross your legs when you sit in a chair.”

Rationale: 

A patient with mobility issues is at increased risk of thrombus formation from blood pooling in the extremities and venous stasis. The nurse should advise the client to move the legs and feet as much as possible, even if the patient cannot get up out of bed. The patient should also avoid crossing her legs while sitting, as this can slow venous return to the heart and cause blood to collect in the lower legs.

NCLEX Question #70: Pain Control After Surgery (Ethical/Legal/Basic Care and Comfort)

Question:

A nurse is caring for a patient who is recovering from surgery and is in pain at the incision site. The nurse has administered some medications to help control the patients pain, but she holds off from administering more because she does not want the patients respiratory rate to drop. Which is another example of a reason why some nurses fail to utilize appropriate pain management techniques when caring for a patient in pain?

Answer:

B.  The nurse is afraid the patient may become addicted to the medicine

Rationale: 

Some nurses, while having access to prn medications for helping patients, avoid giving medications, even when they are needed. In the example of a patient in pain, a nurse may avoid giving more pain medications because of misconceptions, such as a fear of the patient becoming addicted. The nurse must remain informed about the consequences and the positive outcomes of giving medications so that she can perform her job appropriately.

NCLEX Question #71: Visual Impairment (Fundamentals/Basic Care and Comfort)

Question:

A nurse is caring for a patient who is visually impaired. Which of the following interventions is most appropriate when working with this client?

Answer:

C. Explain procedures in a step-by-step manner

Rationale: 

When working with a patient who is visually impaired, the nurse must remember to explain those aspects to the client that he cannot see, in addition to explaining the other elements of his care. The nurse should never assume that the patient knows what she is doing. Through caring for this client, the nurse should explain her procedures in a step-by-step manner so that he can be informed.

NCLEX Question #72: Cataplexy and Sleeping Disorders (Neuro/Basic Care and Comfort)

Question:

Which sleep disorder is associated with cataplexy?

Answer:

A.  Narcolepsy

Rationale: 

Cataplexy describes an involuntary loss of muscle function that is temporary. Cataplexy is most commonly associated with narcolepsy, which involves increased sleepiness during the daytime. A patient with narcolepsy may take medications that act as stimulants to help keep him awake; some of these medications may also treat episodes of cataplexy.

NCLEX Question #73: Irrigation of NG Tube (GI/GU/Basic Care and Comfort)

Question:

A nurse is preparing to irrigate a patients nasogastric tube. She has assessed the patients abdomen and determined that the tip of the tube is located in the stomach. After drawing up 30 mL of normal saline into a syringe, the nurse prepares for the next step. Which best describes the next step in this process?

Answer:

D.  Clamp the suction and disconnect the tube

Rationale: 

When the nurse is preparing to irrigate a patients NG tube, she must first assure that it is in the proper location with the tip in the stomach. Following this, the nurse disconnects the tube from the suction so that she can instill fluid into the tube. Once fluid is instilled into the tube, the nurse then aspirates the fluid and can reconnect the tubing to suction.

NCLEX Question #74: Tumors and Sleep (Oncology/Basic Care and Comfort)

Question:

A 37-year-old patient with a spinal tumor has been having a difficult time sleeping. Which best explains how a tumor can make sleep more difficult for a patient with cancer?

Answer:

B.  The tumor may place pressure on parts of the body that can be uncomfortable

Rationale: 

Sleep problems are common among cancer patients; the medications, treatments, and the illness itself can cause multiple problems with a patient getting to sleep and staying asleep, as well as feeling refreshed after waking up. When a patient has a tumor, the growth can make sleep difficult when it compresses some parts of the body, leading to discomfort. A tumor may also be painful, it can cause a fever, or itching, or it may leave a person feeling very tired but unable to sleep.

 

NCLEX Question #75: Nurse Delegation, Ambulation After Knee Surgery (Prioritization/Delegation/Basic Care and Comfort)

Question:

A 16-year-old patient needs to get up to ambulate after having knee surgery. A nurse assigns a nursing assistant to ambulate the patient. Which of the following should the nurse consider when delegating this task to the nursing assistant?

Answer:

C.  The nursing assistant may need to use assistive devices, such as a gait belt

Rationale: 

Patient ambulation is an important part of healing, especially after surgery, as it increases patient mobility. A nursing assistant can assist a patient with ambulation when it is delegated by the RN, as long as the patient is stable for walking. The nursing assistant may not administer pain medications prior to ambulation.

NCLEX Question #76: Diagnosis of Sleep Apnea (Respiratory/Basic Care and Comfort)

Question:

A patient tells the nurse that she is afraid that she has sleep apnea. She says that she does not feel rested in the morning and that she snores. Her husband says that he notices that she seems to stop breathing on several occasions during the night. The client asks the nurse how sleep apnea is diagnosed. Which answer from the nurse is correct?

Answer:

D.   “You will most likely need a PSG, which is a nighttime sleep study.”

Rationale: 

A person with sleep apnea suffers from periods of apnea-absence of breathing-during the night while asleep. Sleep apnea causes disrupted sleep so that the person does not feel rested when awakening. Often, it is associated with snoring. Sleep apnea is diagnosed through a polysomnogram (PSG), which is an overnight sleep study.

NCLEX Question #77: Preventing Coronary Artery Disease (Cardiac/Health Promotion and Maintenance)

Question:

A 40-year-old patient is being seen for a health check-up and the nurse is providing information to him about prevention of coronary artery disease. Which best describes an appropriate goal for this patient that would be applied after teaching?

Answer:

A.  The patient will engage in healthy behaviors

Rationale: 

A patient who is at risk of coronary artery disease should receive teaching and education about the risks and complications associated with the condition, as well as lifestyle interventions that can be implemented to reduce the risk. Following these interventions, the nurse could develop an appropriate outcome for the patient that indicates that he has learned more about coronary artery disease. An example of an appropriate outcome is that the patient will make changes to engage in healthy behaviors.

 

NCLEX Question #78: Prevention of Anaphylactic Shock (Hematologic/Immunology/Health Promotion and Maintenance)

Question:

A nurse is teaching a patient about self-care at home after he has experienced an anaphylactic reaction to shellfish. For future reference for the patient, after exposure to shellfish, in order to best manage an allergic reaction and prevent anaphylactic shock, the nurse should counsel the patient to do what as an initial intervention?

Answer:

C.  Call 911

Rationale: 

A patient who is experiencing signs of an allergic reaction and who has suffered from anaphylaxis after a previous exposure to the substance should call 911 if he is at home or in the community. The patient needs rapid treatment to prevent the condition from advancing to anaphylactic shock. In cases when a patient has a known allergy to a particular substance, he may need a dose of epinephrine to keep on hand for symptom management; an Epi-Pen is an example of this medication that can be used at home. Even with use of epinephrine in response to an allergic reaction, the patient must still call for medical help.

NCLEX Question #79: Nerve Damage From Continuous Vibration (Musculoskeletal/Health Promotion and Maintenance)

Question:

A 61-year-old patient is being treated in the care clinic. The patient has been a school bus driver for 40 years and is asking the nurse about work-related injuries. Which symptoms would most likely develop in a person who works in conditions in which continuous vibration are present?

Answer:

C.  Numbness in the fingers

Rationale: 

Continuous vibration may be part of a work environment for some people who work with machinery or who drive large tractors or busses. Continuous vibration can cause damage to the joints and nerves over time. The patient would most likely experience numbness in the hands and fingers, loss of the feeling of touch, and poor grip.

NCLEX Question #80: Compensated vs Decompensated Shock (Neuro/Health Promotion and Maintenance)

Question:

A child is brought to the hospital for care after falling down some stairs and is in a state of neurogenic shock. The nurse performs an initial assessment on the patient. Which parameter best identifies whether the patient is in a state of compensated or decompensated shock?

Answer:

D.  A drop in blood pressure

Rationale: 

Shock can be divided into stages, depending on the body’s response to the illness or injury; the symptoms demonstrated during the different stages of shock indicate the stage and also guide the provider toward its treatment. Compensated shock occurs when the body is trying to maintain near-normal vital signs and perfusion, despite the injury to circulation and metabolism. Alternatively, decompensated shock is a state in which the body is no longer able to keep up and deterioration occurs. One of the most significant differences between compensated and decompensated shock is a drop in blood pressure, in which the body is no longer able to maintain intravascular pressure to perfuse vital organs.

 

NCLEX Question #81: Musculoskeletal symptoms in Pregnancy (OB/Peds/Health Promotion and Maintenance)

Question:

A patient who is 16 weeks’ pregnant is at the healthcare provider’s office for a routine prenatal exam. The nurse is educating the patient about pregnancy-related body changes that will most likely occur in the next several months. Which best describes a condition that affects the musculoskeletal system that occurs during pregnancy?

Answer:

C.  Leg cramps

Rationale: 

Pregnancy causes physical changes that can impact various body systems, including the musculoskeletal system. The pregnant patient may experience leg cramps, which often develop during the 2nd and 3rd trimesters and appear in the calves in the lower legs. Other musculoskeletal symptoms that the patient may experience include low back pain and carpal tunnel syndrome.

NCLEX Question #82: Exercise and Aging (Musculoskeletal/Health Promotion and Maintenance)

Question:

A 67-year-old patient complains to the nurse that while he used to run long distances and participate in marathons, he no longer has the stamina to run very far. Select all of the following that are associated with changes in exercise tolerance as a result of aging.

Answer:

B.  Decreased lean muscle mass

D.  Decreased testosterone secretion

E.  Increased bone loss

Rationale: 

As a person ages, his stamina and ability to exercise is decreased. While he may have once been able to exercise for long periods, aging results in decreased muscle mass, decreased hormone secretion, and increased bone loss that can negatively impact a person’s ability to exercise.

NCLEX Question #83: Stress Reduction in Pregnancy (Mental Health/Health Promotion and Maintenance)

Question:

A 35-year-old pregnant patient tells the nurse that she has been feeling significant stress in her life since she found out she was pregnant. Select all of the appropriate measures the nurse can suggest as part of stress reduction in a pregnant patient.

Answer:

B.  Find a hobby that is enjoyable

D.  Participate in meditation or yoga

E.  Learn about relaxation techniques

Rationale: 

Pregnancy, while enjoyable for some women, can be a significant source of stress for others. Stress can have a negative impact on the fetus if the mother suffers from prolonged stress during pregnancy. The nurse can help this patient with stress-reduction activities, such as mild exercise or participating in enjoyable activities.

NCLEX Question #84: Best Patient Position to assess Posterior Lung Sounds (Respiratory/Health Promotion and Maintenance)

Question:

A nurse needs to assess a patients back and listen to posterior lung sounds. In which position would it be most appropriate to place this patient?

Answer:

D.  High Fowler’s

Rationale: 

To assess the back and listen to posterior lung sounds, the nurse should place the client in the high Fowler’s position. In this position, the patient is sitting up with the head of the bed at a 90-degree angle. The high Fowler’s position is used for performing an assessment that would require the patient to sit up, such as the face and head, chest, and back.

NCLEX Question #85: Cardiac Changes Related to Aging (Cardiac/Health Promotion and Maintenance)

Question:

An 80-year-old patient is being seen at the primary care clinic for routine care. The nurse performs a physical assessment on the patient. Based on the potential changes in the cardiac system associated with aging, which instructions would the nurse most likely give to this patient?

Answer:

A.  Tell the patient to stand up or change positions slowly

Rationale: 

Cardiac changes associated with aging lead to orthostatic hypotension, in which the patient may experience a drop in blood pressure upon standing. The patient should be encouraged to turn and change positions slowly to avoid becoming lightheaded or dizzy due to the blood pressure decrease upon standing.

NCLEX Question #86: Hypothermia in an Infant (OB/Peds/Health Promotion and Maintenance)

Question:

A nurse working in the newborn nursery is caring for an infant who was born 3 hours ago. The infant’s axillary temperature is 97.0F and the nurse notes that his respiratory rate is 60/minute. Which action of the nurse is most appropriate?

Answer:

B.  Increase the heat on the radiant warmer and place a hat on the baby

Rationale: 

The infant in the above situation is demonstrating signs of hypothermia, as manifested by the decreased temperature and increased respiratory rate. The nurse should increase the patients temperature by placing the baby in a radiant warmer and putting a hat on the head, which is otherwise the main source of heat loss.

NCLEX Question #87: Assessment of Pain (GI/GU/Health Promotion and Maintenance)

Question:

A nurse is caring for a 15-year-old girl who is recovering from an appendectomy. The nurse is trying to assess the patients level of pain. Which question from the nurse would be most appropriate for determining the intensity of pain the patient is experiencing?

Answer:

C. “How would you rate your pain on a scale of 0-10?”

Rationale: 

The intensity of a patients pain describes how much pain the patient feels, whether it is a little or a lot. The nurse can best assess intensity of the patients pain by asking her to rate the amount of pain she is experiencing on a scale of 0 to 10, with 0 being “no pain” and 10 being “the worst pain.”

NCLEX Question #89: Complications of Gestational Diabetes (Endocrine/Metabolic/Health Promotion and Maintenance)

Question:

A pregnant client is in labor to deliver her baby. The mother is 39 weeks’ gestation and has had gestational diabetes during pregnancy. The mother has missed many prenatal appointments and admits that she has not checked her blood glucose levels or controlled her diet well, despite her diagnosis. Which of the following are risks to the infant as a result of uncontrolled gestational diabetes? Select all that apply.

Answer:

A.  Large body size

D.  Low blood glucose after birth

E.  An increased risk of obesity later in life

Rationale: 

Uncontrolled gestational diabetes can cause many complications for both the pregnant mother and the unborn child. Gestational diabetes results in an increase risk of infant macrosomia, or large body size. The infant may also have hypoglycemia after birth when he is no longer connected to the mother’s blood supply. Finally, infants born to mothers with gestational diabetes are at greater risk of developing obesity later in life.

 

NCLEX Question #90: Dehydration in the Elderly (Labs/Health Promotion and Maintenance)

Question:

An 86-year-old male patient is transferred from the long-term care facility where he lives to the hospital for treatment after falling in the hallway. The staff tell the nurse that he normally is not a fall risk and has been healthy and active, with little to no cognitive impairments. Upon admission, the patients laboratory workup indicates that he is severely dehydrated. Which of the following manifestations of dehydration would more likely develop in an older adult? Select all that apply.

Answer:

A.  Rapid breathing rate

B.  Confusion

C.  Convulsions

Rationale: 

Dehydration may be manifested slightly differently among elderly patients when compared to younger adults. An older adult patient may have standard symptoms of dehydration, including rapid respiratory rate and poor skin turgor, but the elderly patient may also suffer from other effects as well, such as confusion or convulsions.

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Date Published - Jul 7, 2016
Date Modified - Apr 18, 2019

Jon Haws RN

Written by Jon Haws RN

Jon Haws RN began his nursing career at a Level I Trauma ICU in DFW working as a code team nurse, charge nurse, and preceptor. Frustrated with the nursing education process, Jon started NRSNG in 2014 with a desire to provide tools and confidence to nursing students around the globe. When he's not busting out content for NRSNG, Jon enjoys spending time with his two kids and wife.