NCLEX Sample Question 1

1. The nurse is caring for the mother of a newborn. The nurse recognizes that the mother
needs more teaching regarding cord care because she

1. keeps the cord exposed to the air.
2. washes her hands before sponge bathing her baby.
3. Correct washes the cord and surrounding area well with water at each diaper change.
4. checks it daily for bleeding and drainage.

Answer Rationale:
1. Exposure to air helps dry the cord.
2. Good hand washing is the prime mechanism for preventing infection.
3. Washing the surrounding area is fine but wetting the cord keeps it moist and
predisposes it to infection.
4. It is important to check for complications of bleeding and drainage that might occur.

Client Need Category: Growth and Development Through the Life Span

2. For a school nurse in a junior high school, it is important to check young teenage girls for
scoliosis. One way to assess this is to
1. have each girl walk in a straight line.
2. Correct have each girl bend over and measure shoulder height.
3. run fingers down the spine to feel for abnormalities.
4. watch as each girl does physical education activities to see if any abnormality is evident.

Answer Rationale:
1. Scoliosis is a lateral curvature. Girls with scoliosis may well be able to walk a straight line.
2. A quick assessment is to look for uneven shoulders. Ask the girl to bend over
and look at bra strap marks to see if one side is deeper.
3. The nurse is unlikely to detect scoliosis by running the fingers down the spine.
4. Watching the girls as they do physical education activities is unrealistic and not as likely to
pick up a potential problem as checking each girl individually.

Client Need Category: Prevention and Early Decection of Disease

3. An adult with chronic renal failure is receiving peritoneal dialysis. His acid-base balance
and electrolyte levels are now within normal limits. His hemoglobin is 9.2 and his
hematocrit is 30. The most likely cause of his anemia is

1. Incorrect hemodilution secondary to fluid retention.
2. Incorrect eating insufficient protein due to taste changes that occur with dialysis.
3. Correct failure of his kidneys to produce the hormone necessary to stimulate bone
marrow to produce red blood cells.
4. Incorrect hemolysis of red blood cells as they move past the membrane containing the
dialysis solution.

Answer Rationale:
1. Hemodilution can produce a drop in hematocrit. However, if the cause of the decrease in
hematocrit were fluid retention, one would expect to find corresponding decreases in
serum sodium. If the dialysis has corrected the electrolyte balance, it is unlikely that the
client would retain sufficient fluid to cause this drop in hematocrit. Hemodilution does not
usually produce such a drop in hemoglobin.
2. The cause of anemia in persons with chronic renal failure is lack of erythropoietin.
3. Erythropoietin produced by the kidneys is necessary to stimulate the bone
marrow to produce red blood cells. In chronic renal failure this hormone is not
produced.
4. Hemolysis does not occur with peritoneal dialysis because red blood cells do not move
outside the client’s own blood vessels, so there are no mechanical forces to harm them.

Client Need Category: Physiological Adaptation

4. Ms. E., 16 years old and 20 weeks pregnant, has attended a prenatal nutrition course at her
high school. The next day, the nurse knows she needs more instruction regarding proper
protein intake because she has chosen the following for lunch:
1. Incorrect roast chicken sandwich and ice cream cone.
2. Incorrect roast beef sandwich and vanilla pudding.
3. Incorrect fruit salad with cottage cheese and frozen yogurt.
4. Correct bacon, lettuce, and tomato sandwich and an apple.

Answer Rationale:
1. Poultry is a good source of protein as is ice cream.
2. Meat and puddings are recommended and good sources of protein.
3. Cheese and yogurt are good sources of protein.
4. There is very little protein in a bacon, lettuce, and tomato sandwich and an
apple.

Client Need Category: Basic Care and Comfort

5. Randy, age 8, is admitted with rheumatic fever. Which clinical finding indicates to the
nurse that Randy needs to continue taking the salicylates he had received at home?
1. Incorrect Chorea.
2. Correct Polyarthritis.
3. Incorrect Subcutaneous nodules.
4. Incorrect Erythema marginatum.

Answer Rationale:
1. Chorea is the restless and sudden aimless and irregular movements of the extremities
suddenly seen in persons with rheumatic fever, especially girls.
2. Polyarthritis is characterized by swollen, painful, hot joints that respond to
salicylates.
3. Subcutaneous nodules are nontender swellings over bony prominences sometimes seen in
persons with rheumatic fever.
4. Erythema marginatum is a skin condition characterized by nonpruritic rash, affecting
trunk and proximal extremities, seen in persons with rheumatic fever.

Client Need Category: Pharmacological and Parenteral Therapies

5. A young woman is to undergo a Tensilon test. The nurse is explaining the test to the client.
Which statement the client makes indicates the best understanding of the test?

1. Correct “A positive test will be evident within 1 minute of the Tensilon injection.”
2. Incorrect “The test is of diagnostic value in only about 20% of persons with myasthenia
gravis.”
3. Incorrect “If the test is positive I will feel an immediate decrease in muscle strength.”
4. Incorrect “Tensilon acts by blocking the action of acetylcholine at the myoneural junction.”

Answer Rationale:
1. A Tensilon test yields immediate results. If positive, the client almost
immediately has an increase in muscle strength.
2. The test is accurate in nearly all persons with myasthenia gravis.
3. Tensilon causes an increase in muscle strength.
4. Tensilon acts to increase the amount of acetylcholine available.

Client Need Category: Reduction of Risk Potential

7. The nurse in an outpatient mental health clinic has identified marital discord as a
significant problem for one of the clients. A client with this type of problem would be most
likely to be dealing with issues in which developmental phase?

1. Incorrect Trust vs. mistrust.
2. Incorrect Identity vs. role confusion.
3. Correct Intimacy vs. isolation.
4. Incorrect Generativity vs. stagnation.

Answer Rationale:
1. Trust vs. mistrust is the developmental stage in which infants learn to trust the world by
having their basic needs met in a consistent manner.
2. Identity vs. role confusion is the developmental stage in which adolescents face the issues
of “who am I” and “what am I going to do with my life.” This stage does not target
relationship issues specifically.
3. According to Erickson’s developmental stages intimacy vs. isolation is the stage
that targets intimate relationships.
4. Generativity vs. stagnation is the middle adult stage in which persons are concerned with
being productive and contributing to the greater society. This stage does not target
relationship issues specifically.

Client Need Category: Coping and Adaptation

8. A man is admitted to the nursing care unit with a diagnosis of cirrhosis. He has a long
history of alcohol dependence. During the late evening following his admission, he
becomes increasingly disoriented and agitated. Which of the following would the client be
least likely to experience?

1. Incorrect Diaphoresis and tremors.
2. Incorrect Increased blood pressure and heart rate.
3. Incorrect Illusions.
4. Correct Delusions of grandeur.

Answer Rationale:
1. Diaphoresis and tremors occur in the first phase of alcohol withdrawal.
2. The blood pressure and heart rate increase in the first phase of alcohol withdrawal.
3. Illusions are common in persons withdrawing from alcohol. Illusions occur most often in
dim artificial lighting where the environment is not perceived accurately.
4. Delusions of grandeur are symptomatic of manic clients, not clients
withdrawing from alcohol. The symptoms and history of alcohol abuse suggest
this client is in alcohol withdrawal.

Client Need Category: Psychosocial Adaptation

9. A young woman tells the nurse in the health clinic that her boyfriend has gonorrhea. He
told her about his disease after their last sexual experience three days ago. She wants to
know when she can expect symptoms. The nurse replies that the unusual time between
initial infection with Neisseria gonorrhoeae and the onset of symptoms is

1. Correct two to five days.
2. Incorrect five to seven days.
3. Incorrect one to two weeks.
4. Incorrect two to three weeks.

Answer Rationale:
1. The usual incubation period between infection with Neisseria gonorrhoeae and
onset of symptoms is two to five days.
2. The usual incubation period for Neisseria gonorrhoeae is two to five days.
3. The usual incubation period for Neisseria gonorrhoeae is two to five days.
4. The usual incubation period for Neisseria gonorrhoeae is two to five days.

Client Need Category: Reduction of Risk Potential

10. An adult woman is admitted to an isolation unit in the hospital after tuberculosis was
detected during a pre-employment physical. Although frightened about her diagnosis, she
is anxious to cooperate with the therapeutic regimen. The teaching plan includes
information regarding the most common means of transmitting the tubercle bacillus from
one individual to another. Which contamination is usually responsible?

1. Incorrect Hands.
2. Correct Droplet nuclei.
3. Incorrect Milk products.
4. Incorrect Eating utensils.

Answer Rationale:
1. Hands are the primary method of transmission of the common cold.
2. The most frequent means of transmission of the tubercle bacillus is by droplet
nuclei. The bacillus is present in the air as a result of coughing, sneezing, and
expectoration of sputum by an infected person.
3. The tubercle bacillus is not transmitted by means of contaminated food. Contact with
contaminated food or water could cause outbreaks of salmonella, infectious hepatitis,
typhoid, or cholera.
4. The tubercle bacillus is not transmitted by eating utensils. Some exogenous microbes can
be transmitted via reservoirs such as linens or eating utensils.

Client Need Category: Saftey and Infection Control

11. Sandra, an R.N., reports to work looking unkempt. Nancy, another R.N., approaches when
she notices her using uncoordinated movements. Sandra’s breath reeks of peppermints
and Nancy suspects Sandra may be intoxicated. What is the best initial nursing action for
Nancy to take?

1. Incorrect Call the supervisor and report Sandra.
2. Correct Confront Sandra, saying that she feels she is intoxicated, and relieve her of her
nursing duties immediately.
3. Incorrect Ignore the situation.
4. Incorrect Give Sandra a lecture about substance abuse and do nothing else.

Answer Rationale:
1. Calling the supervisor is a secondary measure after confronting the nurse and relieving the
nurse of her duties. You cannot always assume the supervisor will be immediately
available, and client safety should be addressed first.
2. When another nurse is unable to perform her nursing duties due to substance
abuse, she should not be allowed to continue them, as client safety is a primary
concern.
3. Ignoring the situation is against the professional code of conduct for nurses.
4. Sandra needs to be relieved of her duties. She probably would not benefit from a lecture in
her condition.

Client Need Category: Management of Care

12. An adult client has a comminuted fracture of the ulnar bone. He asks the nurse what type
of fracture this is. The nurse’s response is based on which of these understandings?

1. Correct The ulnar bone has been crushed and broken in several places.
2. Incorrect The two ends of the fractured ulnar bone are pulled apart and separated from each other.
3. Incorrect The ulnar bone has been broken in two and one end of the bone broke through the skin.
4. Incorrect Only one side of the ulnar bone is broken.

Answer Rationale:
1. A comminuted fracture usually results from a crush injury and results in fractured and
crushed bones. The bone is broken in several places.
2. A displaced bone occurs when the two ends of the fractured bone are pulled apart and
separated from each other.
3. A compound or open fracture occurs when the bone has been broken in two and one end of
the bone breaks through the skin.
4. A greenstick or incomplete fracture is when only one side of the bone is broken. A
greenstick fracture happens in children whose bones are still soft.

Client Need Category: Physiological Adaptation

13. The nurse is assessing a six-month-old child. Which developmental skills are normal and
should be expected?

1. Incorrect Speaks in short sentences.
2. Correct Sits alone.
3. Incorrect Can feed self with a spoon.
4. Incorrect Pulling up to a standing position.

Answer Rationale:
1. The child develops language skills between the ages of one and three.
2. A six-month-old child is learning to sit alone.
3. The child begins to use a spoon at 12-15 months of age.
4. The baby pulls himself to a standing position about ten months of age.

Client Need Category: Growth and Development Through the Life Span

14. An adult is scheduled to undergo an exploratory laparotomy in one hour. The nurse has
just received the order to administer his preoperative medication. What assessment is
essential for the nurse before administering the medication?

1. Incorrect The client’s ability to cough and deep breathe.
2. Correct Any drug hypersensitivity or allergy.
3. Incorrect The client’s understanding of the surgical procedure.
4. Incorrect Whether the client’s family is present and supportive.

Answer Rationale:
1. His ability to cough and deep breathe should be assessed earlier so that further teaching
can take place if needed. Once preoperative medications are administered, the client’s ability to retain information is impaired.
2. A complete drug history on every perioperative client is essential because of potential reactions to drugs. Drug hypersensitivity and allergic reactions must be assessed before preoperative medications are administered.
3. The client’s understanding should be assessed earlier so the nurse can do further teaching if indicated.
4. While it is optimal to have the family present, medication should be given as ordered so that the timing of the peak action is most beneficial to the client.

Client Need Category: Reduction of Risk Potential

15. An elderly client requiring abdominal wound packing tid complains about his wound care
to the nurse making morning rounds. He states that “everyone does it differently and at
any time they feel like it.” He is angry at being awakened at night for this procedure. The
best response for the nurse to make is

1. “The wound care is being done as ordered by your doctor.”
2. “I understand you’re upset at losing sleep. You can have medication to help you get back to
sleep.”
3. “Tell me what’s really bothering you.”
4. Correct “After rounds I’ll be back and we can plan your wound care.”

Answer Rationale:
1. This reply discounts the client’s feelings and concerns.
2. This response only addresses part of the problem with suggestion of an inappropriate
solution.
3. This response reflects a misunderstanding of the client’s complaints as a symptom of
another problem.
4. The nurse arranges to plan wound care with the client, thereby allowing him to
participate in his own care and addressing the source of his anger.

Client Need Category: Management of Care

16. A 38-year-old woman asks the nurse why she should have a mammogram. The best response for the nurse to make is

1. “Mammograms can diagnose breast cancer with nearly 100% accuracy.”
2. “Every sexually active woman needs to have a mammogram, since there is a correlation
between sexual intercourse and breast cancer.”
3. Correct “You are 38 years old. This is the appropriate time to have a baseline mammogram done.”
4. Incorrect “The dye, or contrast medium, used when you have a mammogram helps the radiologist see the difference between a tumor and a cyst.”

Answer Rationale:
1. Mammograms can detect tumors and other breast lesions when they are still too small to
be palpated (i.e., smaller than 1 cm). There is a documented false negative rate of 5-10%. A
client should not be promised nearly 100% accuracy.
2. There is no known correlation between sexual activity and breast cancer. A sexually active
woman under 35 would not need a mammogram unless there was a strong family history
of cancer or she had symptoms.
3. The schedule for mammogram testing recommended by the American Cancer
Society is a baseline between the ages of 35-40; once every 1-2 years between 40
and 50; and every year after age 50.
4. Mammograms do not use contrast media.

Client Need Category: Prevention and Early Decection of Disease

17. A two-year-old is to be admitted to the pediatric unit. His diagnosis is febrile seizures. In
preparing for his admission, which of the following is the most important nursing action?

1. Incorrect Order a stat admission CBC.
2. Incorrect Place a urine collection bag and specimen cup at the bedside.
3. Incorrect Place a cooling mattress on his bed.
4. Correct Pad the side rails of his bed.

Answer Rationale:
1. Preparing for routine laboratory studies is not as high a priority as preventing injury and
promoting safety.
2. Preparing for routine laboratory studies is not as high a priority as preventing injury and
promoting safety.
3. A cooling blanket must be ordered by the physician and is usually not used unless other
methods for the reduction of fever have not been successful.
4. The child has a diagnosis of febrile seizures. Precautions to prevent injury and
promote safety should take precedence.

Client Need Category: Saftey and Infection Control

18. Mr. K. comes to the nurses’ station complaining of shortness of breath, choking, dizziness,
and nausea. He says, “I think I’m going crazy or dying or something. I don’t know what
happened. Help me, help me.” When the nurse tries to ask about what happened, Mr. K.
can only say, “Help me, help me.” The best interpretation for the nurse to make regarding
his level of anxiety is

1. Incorrect mild.
2. Incorrect moderate.
3. Incorrect severe.
4. Correct panic.

Answer Rationale:
1. Mild anxiety enhances reasoning ability.
2. Moderate anxiety may reduce the ability to focus attention but is manageable.
3. Severe anxiety impairs problem solving, but behavior focused on obtaining relief is
possible.
4. Mr. K. has typical symptoms of a panic attack; especially indicative of panic is
his inability to focus on the nurse’s questions or other current events.

Client Need Category: Coping and Adaptation

19 Mr. T., 35, is admitted for bipolar illness, manic phase, after assaulting his landlord in an
argument over Mr. T’staying up all night playing loud music. Mr. T. is hyperactive,
intrusive, and has rapid, pressured speech. He has not slept in three days and appears thin
and disheveled. Which of the following is the most essential nursing action at this time?

1. Providing a meal and beverage for Mr. T. to eat in the dining room.
2. Providing linens and toiletries for Mr. T. to attend to his hygiene.
3. Consulting with the psychiatrist to order a hypnotic to promote sleep.
4. Correct Providing for client safety by limiting his privileges.

Answer Rationale:
1. Food and fluids are necessary. However, Mr. T.’s hyperactivity does not allow him to sit
quietly to eat. Finger foods “on the run” will provide needed nourishment.
2. When hyperactivity decreases, then approach Mr. T. regarding hygiene and grooming
needs.
3. Medications will be ordered. However, a thorough evaluation must be done first.
4. Mr. T. has been assaultive with the landlord and it is reasonable to expect that
he may be with peers and staff. His mental illness produces a hyperactive state
and poor judgment and impulse control. External controls such as limiting of
unit privileges will assist in feelings of security and safety.

Client Need Category: Psychosocial Adaptation

20 The nurse is teaching an adult who has ulcerative colitis. In developing the teaching plan which of the following foods should the nurse plan to instruct the client to avoid?

1. Incorrect Roast chicken and cooked spinach.
2. Incorrect Broiled liver and white rice.
3. Incorrect Cottage cheese and canned apricots.
4. Correct Pork chop and brown rice.

Answer Rationale:
1. Chicken is considered a mild meat and is acceptable as long as it does not have highly
spiced sauces. Cooked spinach is acceptable but a spinach salad would not be.
2. Broiled liver is acceptable as is white rice.
3. Cottage cheese is acceptable and canned apricots are allowed. Fresh apricots are not
allowed on a low-residue diet.
4. Persons with ulcerative colitis should be on a low-fiber (low- residue) diet. This
diet will provide the essential nutrients and is limited in high roughage content
which stimulates peristalsis and makes symptoms of ulcerative colitis worse.
Foods to be avoided include whole grains, nuts, raw fruits and vegetables,
caffeine, alcohol, tough meats, pork, and highly spiced meats.

Client Need Category: Basic Care and Comfort