1. A nurse is caring for a client with a below-the-knee amputation. What should the nurse encourage the client to do to prepare the residual limb for a prosthesis?

  • Abduct the residual limb when ambulating.
  • Dangle the residual limb off the bed frequently.
  • Soak the residual limb in warm water twice a day.
  • Press the end of the residual limb against a pillow periodically.

2. An IV infusion of magnesium sulfate is prescribed for a client with severe preeclampsia. The dose is twice the usual adult dose. When a nurse questions the dosage, the health care provider insists that it is the desired dose and directs the nurse to administer the medication. How should the nurse respond to this directive?

  • Administer the dose and monitor the client.
  • Withhold the dose and notify the nurse manager.
  • Administer the dose and document it on the client’s record.
  • Withhold the dose and notify the director of the obstetric department.

3. A client with severe preeclampsia is hospitalized. What should a nurse do first to ensure her physical safety?

  • Decrease environmental stimuli.
  • Place her on seizure precautions.
  • Administer the prescribed sedatives.
  • Strictly monitor her intake and output.

4. A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client?

  • Determine the client’s emotional state.
  • Give prescribed drugs to promote bronchiolar dilation.
  • Provide education about the impact of a family history.
  • Encourage the client to use an incentive spirometer routinely.

5. A nurse is assessing a newborn. What finding indicates the need for follow-up care?

  • Babinski reflex is positive.
  • Head circumference is 33 cm.
  • Hips are abducted at 30 degrees.
  • Umbilical cord has three vessels.

Read more: NCLEX Practice Exam Questions

 1. A client who is at 26 weeks’ gestation arrives at the clinic for her scheduled examination. Her blood pressure is 150/86. She tells the nurse that she has gained 5 pounds in the last 2 weeks. What is the priority nursing action?

  • Test the client’s urine for albumin.
  • Take the client’s body temperature.
  • Prepare the client for a vaginal examination.
  • Schedule the client for an appointment in a week.

2. A new mother refuses to look at her newborn who has a severe birth defect. What is the nurse’s most therapeutic approach?

  • Request that the family try to distract her.
  • Clarify why she should stop blaming herself for the baby’s handicap.
  • Reinforce the explanation of the handicap and allow time for her to discuss her fears.
  • Wait until she has sufficiently recovered from the stress of birth and then bring the baby to her again.

3. An African-American woman is diagnosed with primary hypertension. She asks, “Is hypertension a disease of African- American people?” What is the nurse’s best response?

  • “The prevalence of hypertension is about equal for women of all races.”
  • “The higher-risk population is composed of African- American men and women.”
  • “The highest-risk population consists of older Caucasian- American men and women.”
  • “The prevalence of hypertension is greater for African- American women than for African-American men.”

4. An infant born with hydrocephalus is to be discharged after insertion of a ventriculoperitoneal shunt. Which common complication of this type of surgery should the nurse explain to the parents to prepare them for their child’s discharge?

  • Violent involuntary muscle contractions
  • Eyes with sclerae visible above the irises
  • Excessive fluid accumulation in the abdomen
  • Fever accompanied by decreased responsiveness

5. Parents are considering a bone marrow transplant for their child who has recurrent leukemia. The parents ask the nurse for clarification about the procedure. What is the best response by the nurse?

  • “It is rarely performed in children.”
  • “The immune system must be destroyed before a transplant can take place.”
  • “The hematopoietic stem cells are surgically implanted in the bone marrow.”
  • “It is a simple procedure with little preparation needed, and the stem cells are infused as in a blood transfusion.”

Read more: Computer Adaptive Test 2024

 1. A high school nurse observes a 14-year-old female rubbing her scalp excessively in the gym. The most appropriate course of action for the nurse to do is:

    Request a private evaluation of the female's scalp from her parents.
    Contact the female's parents about the observations.
    Observe the hairline and scalp for possible signs of lice.
    Contact the student's physician.

2. A thirty-seven-year-old female in room 307 has a diagnosis of acquired immune deficiency syndrome (AIDS). Which of the following situations requires nurse intervention?

    A certified nursing assistant states, "The patient in 307 is not wearing gloves shaving her legs."
    A nursing assistant at the nursing station states, "The patient in 307 has a respiratory rate of 16."
    A nursing student in the cafeteria states, "Dr. Jones told the patient in room 307 that she was going to die."
    A certified nursing assistant states, "Dr. Jones hasn't made rounds this morning."

3. Medical records indicate a patient has developed a condition of respiratory alkalosis. Which of the following clinical signs would not apply to a condition of respiratory alkalosis?

    Muscle tetany
    Syncope
    Numbness
    Anxiety

4. Which of the following is not considered one of the five rights of medication administration?

    client
    drug
    dose
    routine

5. A nurse has been instructed to place an IV line in a patient that has active TB and HIV. Which of the following safety equipment should wear the nurse?

    Sterile gloves, mask, and goggles
    Surgical cap, gloves, mask, and proper shoe wear
    Double gloves, gown, and mask
    Goggles, mask, gloves, and gown

Read more: Free NCLEX-PN CAT Practice Tests

 1. An infant who was just circumcised is to be discharged with his parents. What should the nurse include in the discharge instructions about postcircumcision care?

  • Apply diapers loosely.
  • Withhold feedings for 6 hours.
  • Cleanse the site with alcohol daily.
  • Expect some bleeding for 48 hours.

2. A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. What is the primary focus of nursing care during this immediate phase?

  • Inhibiting urinary tract infections
  • Preventing contractures and atrophy
  • Avoiding flexion or hyperextension of the spine
  • Preparing the client for vocational rehabilitation

3. A client asks for and receives instruction regarding birth control methods. She elects to use a diaphragm with a spermicide. What disadvantage of using a diaphragm should be explained to the client?

  • It fails half the time when used alone.
  • It is physically uncomfortable when in place.
  • Thrombus formation and pulmonary emboli may occur.
  • Some women find insertion and removal to be objectionable.

4. A nurse is caring for a client in labor. What client response indicates that the transition phase of labor probably has begun?

  • Assumes the lithotomy position
  • Perspires and has a flushed face
  • Indicates back and perineal pain
  • Exhibits decreases in frequency of contractions

5. A male client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client’s wife indicates that further teaching is required?

  • “I must touch the shunt several times a day to feel for the bruit.”
  • “I have to take his blood pressure every day in the arm with the fistula.”
  • “He will have to be very careful at night not to lie on the arm with the fistula.”
  • “We really should check the fistula every day for signs of redness and swelling.”

Read more: NCLEX Practice Exam

 1. A health care provider informs a client that a T-tube will be in place after an abdominal cholecystectomy and a choledochostomy. What should the nurse include in the preoperative teaching for this client regarding the primary reason why a T-tube is necessary?

  • Drains bile from the cystic duct.
  • Keeps the common bile duct patent.
  • Prevents abscess formation at the surgical site.
  • Provides a port for contrast dye in a cholangiogram.

2. In the immediate postoperative period after a gastrectomy, the client’s nasogastric tube is draining a light-red liquid. For how long should the nurse expect this type of drainage?

  • 1 to 2 hours
  • 3 to 4 hours
  • 10 to 12 hours
  • 24 to 48 hours

3. A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome?

  • Low-residue, bland diet
  • Small, frequent feeding schedule
  • Fluid intake less than half a quart
  • Low-protein, high-carbohydrate diet

4. An external monitor is placed on the abdomen of a client admitted in active labor. The nurse identifies that during each contraction, the fetal heart rate decelerates as the contraction peaks. What should the nurse do next?

  • Help the client to a knee-chest position to avoid cord compression.
  • Notify the health care provider because of possible head compression.
  • Monitor the fetal heart rate until it returns to baseline when the contraction ends.
  • Place the client in a semi-Fowler position to prevent compression of the vena cava.

5. A client who has had thoracic surgery is admitted to the postanesthesia care unit (PACU). What should the nurse do after the chest tube is attached to a disposable plastic waterseal drainage system?

  • Ensure the security of the connections from the client to the drainage unit.
  • Empty the drainage container and measure and record the amount once a day.
  • Verify that there is vigorous bubbling in the wet suction control compartment.
  • Check that the fluid level in the water seal compartment increases with expiration.

Read more: NCLEX Renewal Practice Test