NCLEX Risk Reduction Questions

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 patient comes to the ER complaining of joint pain that began in his great toe. Which of the following risk factors, if seen in the patient’s history, does the nurse suspect triggered the patient’s condition?

The nurse enters a patient’s room and observes via the monitor that their vital signs are as follows: blood pressure 80/42, heart rate 118, respirations 32. The nurse will place the patient in which of the following positions?

A patient with a suspected broken femur begins to experience tachycardia, shortness of breath, and chest pain. Which of the following actions should the nurse take NEXT?

In which patient would the nurse expect to see a greenstick fracture?

A patient with a crush injury to her right arm calls the nurse and requests pain medicine, which the nurse administers as ordered. An hour later, the patient is still complaining of intense pain. Which of the following actions does the nurse take next?

A six-year-old boy with a casted left leg rings his call bell. Which of the following statements, if made by the nurse, requires an immediate intervention?

Which of the following skin manifestations in an infant MOST concerns the nurse?

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 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?

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

A patient with SCI (spinal cord injury) rings the call bell for the nurse and complains of a headache and nasal stuffiness. The patient asks for Advil and nasal spray. The nurse knows that the next correct action is to:

A nurse performs a home care visit to a patient performing peritoneal dialysis at home and observes the procedure. Which of the following actions by the patient would be considered incorrect?

The nurse performs discharge teaching for a patient with cystitis. Which of the following patient statements, if made by the patient to the nurse, reflects an INCORRECT understanding of instructions.

A patient with hyperparathyroidism is included in the graduate nurse’s assignment today. Which of the following symptoms, if reported by the patient to the nurse, would alert the nurse to a complication from the disease?

A graduate nurse is following around her preceptor on a PACU floor. The preceptor asks the graduate nurse to check Trousseau’s sign on a patient. The graduate nurse knows that she should:

The nurse knows that the care plan for a patient with a pheochromocytoma will involve which of the following?

A nurse cares for a patient after a hypophysectomy. The nurse knows that she should alert for which of the following potential signs of a serious complication?

A patient has just returned from a hypophysectomy and complains of “mucus” dripping from her nose. What action does the nurse take next?

The nurse assesses a patient on a medical/surgical unit. What assessment finding would prompt immediate investigation?

A nurse cares for patients in the emergency department of a large hospital. One of the nurse’s patients has acute right-sided abdominal pain and is suspected of having appendicitis. Which of the following, if overheard by the nurse, would prompt immediate intervention?

The nurse cares for patients on a medical/surgical unit. One of the nurse’s patients has just returned from a surgery to place a colostomy. The patient looks panicked and says to the nurse, “Should it look like that?!” The nurse responds:

A nurse prepares a patient who will receive a paracentesis. The patient asks if there is anything she can do to prepare for the procedure. The nurse states which of the following?

The nurse manager observes a graduate nurse care for patients on the unit. Which of the following observations, if made by the nurse manager, would require an intervention?

A nurse receives an order from the doctor to hang a new bag of TPN at 0900. When the nurse enters with the new bag at 0900, she notices the old bag is still running and has 150mL left of TPN solution. What action does the nurse take next?

The registered nurse who works on a medical/surgical unit cares for a patient with a feeding tube. What would cause the nurse to suspect that the feeding tube’s placement is incorrect?

A nurse cares for a patient who has just returned from an endoscopy. The patient complains of a sore throat. The nurse knows that:

A patient with AIDS comes to the clinic and tells the nurse he thinks he was exposed to tuberculosis a month ago. The nurse knows that the results of a PPD will be considered positive if induration measures at least:

A nurse works on the medical/surgical unit. A patient is admitted with a broken hip. Upon assessment, the nurse notes the patient is coughing and is running a lowgrade fever. Per the patient’s history, he complains of night sweats. What action does the nurse take first?

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 gets up in the middle of the night and forgets she has a chest tube in. The chest tube pulls out of her body and falls onto the floor. You, the nurse, walk by and perform what intervention?

A patient comes to the ER complaining of chest pain and difficulty breathing. The nurse listens to the patient’s breath sounds. The left sounds clear, while the right displays no sounds. What other symptoms might the nurse expect to see upon further assessment?

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

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:

A diabetic patient suddenly becomes confused and diaphoretic. Which of the following actions should the nurse take FIRST?

Which of the following is a finding that the nurse will be able to assess in a client with a pleural effusion?

SELECT ALL THAT APPLY:

During your clinical rounds, you assessed a client with a respiratory rate of 6 breaths/minute. Which of the following additional assessment data should immediately be gathered to determine the present status of this client?

The physician ordered a sputum culture and sensitivity test for a client with an admitting diagnosis of pulmonary tuberculosis. The nurse will instruct the client to do which of the following in order to obtain the specimen for this test?

A 36-year old female client is scheduled for a mastectomy in the morning. Which of the following is the primary responsibility of the nurse?

The incoming nurse received the day’s endorsement for her assigned clients. One particular client needs to be monitored for signs of thyroid storm. Which of the following are considered signs of thyroid storm?

SELECT ALL THAT APPLY:

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 primigravida at term is admitted to the birthing room in active labor. Later, when the client is 8 cm dilated, she tells the nurse that she has the urge to push. The nurse instructs her to pant-blow at this time because pushing could: