Nursing, 2nd Edition
The Ultimate Study Guide
Appendix B: NCLEX Question Formats
To pass the
The
Exercise 1
Select all that apply:
The nurse is reviewing data collected from a patient who is being treated for hypothyroidism. Which information indicates that the patient has had a positive outcome?
Sleeps 8 hours each night, waking up to go to the bathroom once.
Has bowel movements two times a week while on a high-fiber diet.
Gained 10 pounds since the initial clinic visit 6 weeks ago.
Was promoted at work because of increased work production.
Walks 2 miles within 30 minutes before work each morning.
From Wittmann-Price, R. A., & Thompson, B. R. (Eds.). (2010).
The answer can be found on page 273
Exercise 2
Select all that apply:
The hospital is expecting to receive survivors of a disaster. The charge nurse is directed to provide a list of patients for possible discharge. Which of the following patients would be placed on the list?
A patient who was admitted 3 days ago with urosepsis; white blood cell count is 5.4 mm3/μL.
A patient who was admitted 2 days ago after an acetaminophen overdose; creatinine is 2.1 mg/dL.
A patient who was admitted with stable angina and had two stents placed in the left anterior descending coronary artery 24 hours ago.
A patient who was admitted with an upper gastrointestinal bleed and had an endoscopic ablation 48 hours ago; hemoglobin is 10.8 g/dL.
The answer can be found on page 274
An example of an
Exercise 3
Fill in the blanks:
The nurse is calculating the client’s total intake and output to determine whether he has a positive or negative fluid balance. The intake includes the following:
1,200 mL
200 mL of vancomycin IV
Two 8-ounce glasses of juice
One 4-ounce cup of broth
One 6-ounce cup of water
Upon being emptied, the Foley bag was found to contain 350 mL of urine. What would the nurse document?
The answer can be found on page 274
Drag-and-drop questions are specific to the computer because the student uses a mouse or touch pad to place items in order. A hot spot is moving the mouse or the touch plate to a specific point on a diagram. An example of an
Exercise 4
Hot spot:
The nurse assesses a patient who has a possible brain tumor. The patient has difficulty coordinating voluntary muscle movement and balance. Which area of the brain is affected? (Please place an X at the appropriate spot.)
The answer can be found on page 275
An example of an ordering
Exercise 5
Ordering:
The nurse is inserting an indwelling urinary catheter into a female patient. Place the steps in the correct order:
_____ Ask the patient to bear down.
_____ Don clean gloves, and wash the perineal area.
_____ Place the client in a dorsal recumbent position.
_____ Advance the catheter 1.2 inches (2.5 to 5 cm).
_____ Inflate the balloon and pull back gently.
_____ Retract the labia with the nondominant hand.
_____ Use forceps with the dominant hand to cleanse the perineal area.
_____ Place drapes on the bed and over the perineal area.
_____ Apply sterile gloves.
_____ Advance the catheter 2 to 3 inches (5 to 7 cm) until urine drains.
_____ Test balloon, lubricate catheter, place antiseptic on cotton balls.
The answer can be found on page 275
An example of an
Exercise 6
Exhibit-format question:
A 52-year-old female patient admitted to the emergency department (ED) has had nausea and vomiting for 3 days and abdominal pain that is unrelieved after vomiting.
Skin: Pale, cool; patient shivering.
Respiration:
RR 30, lungs clear, SaO2 90.CV: R
RR (regular rate and rhythm) with mitral regurgitation; temperature 95°F (35°C),BP 96/60, pulse 132 and weak.Extremities: + 4 pulses, no edema of lower extremities.
GI: Hyperactive bowel sounds; vomited 100 mL of bile-colored fluid, positive abdominal tenderness.
GU: Foley inserted, no urine drained.
Hemoglobin 10.6 g/dL
Hematocrit 39%
White blood cells 8.0 mm3/μL
Sodium 150 mEq/L
Potassium 7.0 mEq/L
Blood urea nitrogen 132 mg/dL
Creatinine 8.2 mg/dL
Serum amylase 972
Serum lipase 1,380
Arterial blood gas pH 7.0
pO2 90 mmHg
pCO2 39 mmHg
HCO3 17 mEq/L
After reviewing the patient’s assessment findings and laboratory reports, the nurse determines that the priority for the plan of care should focus on:
Metabolic acidosis and oliguria
Respiratory acidosis and dyspnea
Metabolic alkalosis related to vomiting
Respiratory alkalosis resulting from abdominal pain
The answer can be found on page 276
Another strategy to use in studying for the
Exercise 7
Multiple-choice question:
After returning from a hip replacement, a patient with diabetes mellitus type 1 is lethargic, flushed, and feeling nauseated. Vital signs are
Notify the physician.
Check the patient’s glucose.
Administer an antiemetic.
Change the
The answer can be found on page 277
Exercise 8
Multiple-choice question:
The nurse is assigned to care for a patient with pneumonia. Which task can be delegated to the unlicensed assistive personnel by the RN?
Teaching a patient how to use the inhaler.
Listening to the patient’s lungs.
Checking the results of the patient’s blood work.
Counting the patient’s respiratory rate.
The answer can be found on page 277
Yet another strategy to use in analyzing
TABLE 1
| Positive | Negative |
| Which statement by the client indicates an understanding of the medication side effects? | Which statement by the client indicates a need for further teaching about the medication side effects? |
Therapeutic communication is one of the long-enduring basics of nursing care. As RNs, we provide therapy, not only through what we do but also through what and how we communicate with patients and families. Therapeutic communication is not what you would use in everyday conversation, because it is designed to be more purposeful. Therapeutic communication is nonjudgmental, direct, truthful, empathetic, and informative. Communication and documentation are among the important threads integrated throughout the
Exercise 9
Multiple-choice question:
An 11-year-old boy with acute lymphocytic leukemia (ALL) has been diagnosed with his second relapse following successful remissions after chemotherapy and radiation. The patient asks, “Am I going to die?” Which response by the nurse would be most helpful to the patient?
“Let’s talk about this after I speak with your parents.”
“Can you tell me why you feel this way?”
“You will need to discuss this with the oncologist.”
“You sound like you’d like to talk about it.”
The answer can be found on page 277
Answers
Exercise 1
Select all that apply:
The nurse is reviewing data collected from a patient who is being treated for hypothyroidism. Which information indicates that the patient has had a positive outcome?
Sleeps 8 hours each night, waking up to go to the bathroom once. YES; hypothyroidism causes severe fatigue; 8 hours of sleep and waking up once are normal.
Has bowel movements two times a week while on a high-fiber diet. NO; this may be constipation.
Gained 10 pounds since the initial clinic visit 6 weeks ago. NO; this is not an expected outcome.
Was promoted at work because of increased work production. YES; energy levels are expected to increase.
Walks 2 miles within 30 minutes before work each morning. YES; energy levels are expected to increase.
Exercise 2
Select all that apply:
The hospital is expecting to receive survivors of a disaster. The charge nurse is directed to provide a list of patients for possible discharge. Which of the following patients would be placed on the list?
A patient who was admitted 3 days ago with urosepsis; white blood cell count is 5.4 mm3/μL. YES; this patient has a normal WBC count and could be discharged.
A patient who was admitted 2 days ago after an acetaminophen overdose; creatinine is 2.1 mg/dL. NO; this patient has a high creatinine level and needs monitoring.
A patient who was admitted with stable angina and had two stents placed in the left anterior descending coronary artery 24 hours ago. YES; patients who have not had an
A patient who was admitted with an upper gastrointestinal bleed and had an endoscopic ablation 48 hours ago; hemoglobin is 10.8 g/dL. YES; the patient has no active bleeding, and the hemoglobin is stable.
Exercise 3
Fill in the blanks:
The nurse is calculating the client’s total intake and output to determine whether he has a positive or negative fluid balance. The intake includes the following:
1,200 mL
IV D5NSS200 mL vancomycin IV
Two 8-ounce glasses of juice
One 4-ounce cup of broth
One 6-ounce cup of water
Upon being emptied, the Foley bag was found to contain 350 mL of urine. What would the nurse document?
Total intake: 2,180 mL
Total output: −350 mL
Positive fluid balance: 1,830 mL
Exercise 4
Hot spot:
The nurse assesses a patient who has a possible brain tumor. The patient has difficulty coordinating voluntary muscle movement and balance. Which area of the brain is affected? (Please place an X at the appropriate spot.)
Exercise 5
Ordering:
The nurse is inserting an indwelling urinary catheter into a female patient. Place the steps in the correct order:
8. Ask the patient to bear down.
2. Don clean gloves, and wash the perineal area.
1. Place the client in a dorsal recumbent position.
10. Advance the catheter 1.2 inches (2.5 to 5 cm).
11. Inflate the balloon and pull back gently.
6. Retract the labia with the nondominant hand.
7. Use forceps with the dominant hand to cleanse the perineal area.
3. Place drapes on the bed and over the perineal area.
4. Apply sterile gloves.
9. Advance the catheter 2 to 3 inches (5 to 7 cm) until urine drains.
5. Test balloon, lubricate catheter, place antiseptic on cotton balls.
The sterile gloves are usually packaged under the drapes. Therefore, the drapes can be appropriately placed to set up a sterile field and drape the patient by touching their outer corners. The gloves are usually donned after the drapes are in place. It is not incorrect to place sterile gloves on prior to draping.
Exercise 6
Exhibit-format question:
A 52-year-old female patient admitted to the emergency department (ED) has had nausea and vomiting for 3 days and abdominal pain that is unrelieved after vomiting.
Skin: Pale, cool; patient shivering.
Respiration:
RR 30, lungs clear, SaO2 90.CV: R
RR (regular rate and rhythm) with mitral regurgitation; temperature 95°F (35°C),BP 96/60, pulse 132 and weak.Extremities: + 4 pulses, no edema of lower extremities.
GI: Hyperactive bowel sounds; vomited 100 mL of bile-colored fluid, positive abdominal tenderness.
GU: Foley inserted, no urine drained.
Hemoglobin 10.6 g/dL
Hematocrit 39%
White blood cells 8.0 mm3/μL
Sodium 150 mEq/L
Potassium 7.0 mEq/L
Blood urea nitrogen 132 mg/dL
Creatinine 8.2 mg/dL
Serum amylase 972
Serum lipase 1,380
Arterial blood gas pH 7.0
pO2 90 mmHg
pCO2 39 mmHg
HCO3 17 mEq/L
After reviewing the patient’s assessment findings and laboratory reports, the nurse determines that the priority for the plan of care should focus on:
Metabolic acidosis and oliguria. YES; the pH and HCO3 are decreased, and the patient has no urine output.
Respiratory acidosis and dyspnea. NO; the lungs are clear, and there is no other indication of respiratory acidosis.
Metabolic alkalosis related to vomiting. NO; the pH is low.
Respiratory alkalosis resulting from abdominal pain. NO; the pH is low, and the pCO2 is normal.
Exercise 7
Multiple-choice question:
After returning from a hip replacement, a patient with diabetes mellitus type 1 is lethargic, flushed, and feeling nauseated. Vital signs are
Notify the physician. NO; the nurse needs to further assess.
Check the patient’s glucose. YES; these are signs of hypoglycemia.
Administer an antiemetic. NO; this will not help.
Change the
Exercise 8
Multiple-choice question:
The nurse is assigned to care for a patient with pneumonia. Which task can be delegated to the unlicensed assistive personnel by the RN?
Teaching a patient how to use the inhaler. NO; an
Listening to the patient’s lungs. NO; an
Checking the results of the patient’s blood work. NO; an
Counting the patient’s respiratory rate. YES; unlicensed personnel can obtain vital signs.
Exercise 9
Multiple-choice question:
An 11-year-old boy with acute lymphocytic leukemia (ALL) has been diagnosed with his second relapse following successful remissions after chemotherapy and radiation. The patient asks, “Am I going to die?” Which response by the nurse would be most helpful to the patient?
“Let’s talk about this after I speak with your parents.” NO; this is not responding to the patient.
“Can you tell me why you feel this way?” NO; although this is not a completely wrong answer, it is more directive and may intimidate a child.
“You will need to discuss this with the oncologist.” NO; this is not responding to the patient’s question and is not at his developmental level.
“You sound like you’d like to talk about it.” YES; this is using probing to help the patient to dialogue.