NCLEX Practice Test 2

A nurse cares for a patient with a head injury after a boating accident. The nurse knows that which of the following is an EARLY sign of increased ICP?

The nurse cares for a patient on an acute cardiac unit. The nurse writes her note for the next shift. It is vital to communicate which of the following information to the next shift?

A 55-year-old male patient arrives at the ER with anterior epistaxis that has not resolved after an hour of applying pressure. Which of the following instructions, if given to the UAP by the nurse, would be considered CORRECT?

Before administering a nasogastric feeding to a preterm infant, the nurse aspirates residual fluid from the stomach. Place the following actions in order.

The nurse on an oncology unit is administering Cisplatin to a patient. The nurse knows that which of the following symptoms, if reported by the patient, is expected with this type of medication?

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The nurse reads from the doctor’s order “Give 0.1 mL of PPD”, then prepares to administer the medication. Which technique shown below is the most correct way to give a PPD?

A patient being treated for uterine cancer has just had an internal radiation implant placed. The fire alarm sounds and, without thinking, the patient stands up. The radiation implant falls out and onto the floor. What is the NEXT action the nurse should take?

The nurse has just received report on four patients in her assignment. Which of the following patients should the nurse see FIRST?

You are a nurse on a medical/surgical unit who is caring for a patient with Grave’s Disease. The patient has just returned from a thyroidectomy. Which of the following statements from the patient would require further assessment by the nurse?

A charge nurse on the cardiac unit observes a new graduate nurse as she suctions a patient with a tracheostomy. What action, if performed by the graduate nurse, would require intervention from the charge nurse?

A patient is recovering from pacemaker insertion surgery. Which of the following, if stated by the patient, reflects a correct understanding of discharge instructions?

Which of the following actions, if made by the student nurse, are examples of primary prevention?

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The nurse works on a medical/surgical unit and cares for a patient receiving Lanoxin (Digoxin) and Furosemide (Lasix). The nurse knows that which of the following, if reported by the patient, must be assessed IMMEDIATELY?

A nurse is reviewing the laboratory test results for all four of her diabetic clients. Which of the following, if reported by the lab, indicates poor diabetic control?

An older patient is scheduled for hip replacement surgery in twelve hours. As the nurse reviews the health history, she notes that the patient has a history of alcoholism. Which of the following actions should be taken to best care for this patient?

The home care nurse visits a patient two days after cataract extraction and implant. Which of the following statements, if made by the patient, requires further teaching?

A physician on the medical/surgical unit orders Mellaril (thioridazine hydrochloride) 75mg PO once daily for one of the nurse’s patients. The pharmacy sends up liquid Mellaril with a concentration of 30mg/mL. How much Mellaril, in mL, will the nurse give for ONE dose?

Which of the following must be performed by an RN and NOT a UAP (unlicensed assistive personnel)?

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The nurse knows that care for a patient with Bell’s palsy will include which of the following?

A patient taking Fluoxetine Hcl (Prozac) asks the nurse when the medication will start to work. The patient started this medication two weeks ago. The nurse’s response is CORRECT if she states:

The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided?

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A 90-year-old female has been bedridden for two weeks. Which of the following complications, if observed by the nurse, is NOT expected?

A patient with lung cancer is admitted to the ER for crackles in the lungs, sudden onset of confusion, and decreased urine output. Which of the following lab results is consistent with this complication?

The home health nurse visits a patient with HIV who lives alone in her apartment. Which of the following observations the nurse makes while in the patient’s home is MOST concerning?

The nurse cares for a patient with AIDS who has acquired jiroveci pneumonia. Which of the following precautions levels is appropriate for this patient?

The nurse cares for a client in balanced suspension traction. The client complains of pain in the affected extremity, and the nurse administers the prescribed pain medication. An hour later, the client tells the nurse that the pain has gotten worse instead of better. Which of the following assessments are necessary before the nurse calls the physician?

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The nursing team includes two RNs, one LPN, a nursing assistant, and a nurse reassigned from the postpartum unit. The nurse should consider the assignments appropriate if the reassigned nurse cares for which of the following patients?

The nurse cares for a patient on the psychiatric unit who has been diagnosed with depression. Which of the following statements, if made by the patient to the nurse, would require IMMEDIATE intervention?

The nurse works at an outpatient health center and receives a call from an adolescent girl who was recently prescribed the birth control pill. She describes “an awful leg cramp that turned the skin red.” Which of the following statements, if made by the nurse to the patient, is CORRECT?

A patient with antisocial personality disorder enters the private meeting room of a nursing unit as a nurse is meeting with a different patient. Which of the following statements by the nurse is BEST?

A patient is being discharged from the hospital after being diagnosed with lupus erthematosus. The patient is advised to follow up with what to monitor their condition?

The nurse is taking care of a client who underwent a thyroidectomy. Upon assessment, the nurse noticed muscle spasm and twitching of the client’s face similar to the image below. This is called ____________ and is an indication of ___________.

A nurse working on a neurology unit cares for a patient diagnosed with CVA. The patient is experiencing difficulty in talking but can understand everything the nurse says. The nurse suspects damage to what part of the patient’s brain?

A nurse observes a student nurse assess infants in the nursery. Which of the following, if observed by the nurse, would require an IMMEDIATE intervention?

A Hindu patient dies after a long, drawn-out battle with pancreatic cancer. The family is gathered by the bedside. Which of the following interventions, if offered by the nurse, would be MOST appropriate?

When caring for a patient who experienced a head injury in a car accident, the nurse observes a bruised section behind the patient’s ear. The nurse knows that this type of marking is known as:

Which of the following statements apply to the proper use of a cane?

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A patient has been prescribed the medication spironolactone (aldasterone). When preparing the patient for discharge, the nurse should include which of the following instructions?

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The nurse cares for a patient twelve hours after left lower leg amputation. The nurse medicates the client for pain before instituting which of the following actions?

The nurse in the outpatient care clinic cares for a client diagnosed with heart failure. Which of the following orders, if written by the physician, should the nurse question?

A patient comes into the ER with COPD exacerbation and is having difficulty breathing. What action, if performed by the nurse, would be considered negligence?

The nurse cares for a client diagnosed with bipolar disorder on the psychiatric unit. Which of the following, if noted by the nurse, is an unexpected outcome for this patient?

A patient is ordered to undergo a CT scan with contrast dye. The most important action for the nurse to take in regard to patient safety is to:

A 101-year-old patient with end stage renal disease is refusing to take her medications “because they don’t work and I’m going to die soon anyway.” Which of the following responses is most correct?

The nurse receives a report on the medical/surgical unit. Which of the following clients should the nurse see FIRST?

A patient is ordered to receive omeprazole (Prilosec) 40mg PO daily. The pharmacy dispenses Prilosec 20mg capsules. How many capsules should the nurse administer to this patient for a single dose?

A patient with a history of schizophrenia is admitted to the acute psychiatric care unit. He mutters to himself as the nurse attempts to take a history and yells, “I don’t want to answer any more questions! There are too many voices in this room!” Which of the following assessment questions should the nurse ask NEXT?

A 9-year-old weighs 55 pounds and is to receive cefuroxime sodium 750 mg IV every 6 hours. The recommended dose of cefuroxime sodium for children older than 1 month is 50-133 mg/kg every 24 hours. Is the ordered dose within the recommended limits? (YES or NO) __________

The psychiatric unit processed four new admissions on the previous shift. Which of the new patients should the admissions nurse see FIRST?

The wife of a client with PTSD (post traumatic stress disorder) communicates to the nurse that she is having trouble dealing with her husband’s condition at home. Which of the following suggestions made by the nurse is CORRECT?

Which of the following diets, if given by the dietician to the patient, would be considered an appropriate measure for a patient on a low residue diet?

The nurse answers the phone on a busy medical/surgical floor. A family member requests information on a patient by name. What response, if given by the nurse, is CORRECT?

A patient has been admitted with symptoms of BPH. Which of the following complaints, if observed by the nurse, requires follow-up?

A cast is applied to a thirteen-month-old girl for the treatment of talipes equinovarus (clubfoot). Which of the following instructions is essential for the nurse to give the child’s mother regarding her care while in the cast?

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The nurse in the neurology unit cares for a patient diagnosed with CVA who is ready to go home today. The patient suffers from hemiplegia and dysphagia. Which of the following statements, if made by the patient’s wife, indicates that further teaching is necessary?

A patient has recovered and it is time for the physician to pull the chest tube out. During the procedure, the nurse instructs the patient to:

A patient is brought to the ER by family members. The patient states that yesterday evening, she was having tingling and numbness in the toes of both feet. Today, she complains of bilateral muscle weakness in her legs. Which of the following pieces of information, if found in the patient’s history, are most relevant to her condition?

A new mother is admitted to the acute psychiatric unit with severe postpartum depression. She is tearful and states, “I don’t know why this happened to me! I was so excited for my baby to come, but now I don’t know!” Which of the following responses by the nurse is MOST therapeutic?

A hospital has been notified that an alleged inhalation anthrax exposure has occurred at the local post office. Which of the following below is the correct personal protective equipment (PPE) that the response team would wear?

The nurse assesses the following risk factors for coronary artery disease (CAD) in a patient. Which factors are classified as genetic and physiological?

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An adolescent male tells the nurse that he recently found out his friend has testicular cancer and he is worried he has it too. He describes a soft, movable mass that has not altered in size and is not painful. What is the nurse’s BEST response?

The medical/surgical nurse watches a student nurse prepare a sterile field. Which of the following actions, if performed by the student nurse, requires further instruction?

A patient with dementia has been identified as having a high BUN in lab results. Which of the following non-pharmacological actions would be best for the nurse to take?

An 8-year-old patient is admitted with a suspected fractured of the ulna. An x-ray is taken, and the nurse correctly identifies this type of fracture as:

The physician has determined that a client in respiratory distress requires intubation. Organize the following steps in preparing to assist the physician with rapid-sequence intubation in chronological order (with 1 being the first step in this procedure):

A patient learns he is scheduled for an IV pyelogram. He asks the nurse what can be expected for this test. The nurse correctly states that:

A nurse cares for a patient who cannot turn by using an overhead lift. The nurse knows that which of the following is the MOST important actions to follow in terms of safety?

The nurse works on a unit caring for chronic pain management patients. A UAP (unlicensed assistive personnel) is pulled from another unit to help out the busy floor. An hour into the shift, the UAP asks the nurse “What is with the patient in room five? He says he’s in pain, but he’s watching TV!” Which of the following is the nurse’s BEST response?

The nurse is caring for a confused patient with an IV catheter. The patient habitually tugs at the IV tubing with his left hand and has almost dislodged it. What is the LEAST amount of restraint that will still maintain the patient’s safety?

Which of the following assessments, performed on a patient after a myelogram, is most important in regard to patient safety?

A patient on several medications is being cared for on a medical/surgical unit by the nurse. Which of the following laboratory values, if reported to the nurse, would require follow-up?

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The medical/surgical nurse cares for a middle-aged patient with a wound infected with MRSA (Methicillin-resistant Staphylococcus aureus). Which of the following protective safety items, if worn by the nurse, would be considered appropriate?

Which of the following nursing considerations is most important to prevent a rise in ICP for a patient with meningitis?

The nurse gives a presentation on suicide prevention in high school populations. Which of the following risk factors listed below is accurate in regard to suicide?

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A patient is started on a daily amount of Phenytoin (Dilantin) 200mg PO in two divided doses. What instruction, if given by the nurse to the patient, is INCORRECT?