Issues and Trends in Nursing: Essential Knowledge for Today and Tomorrow
Student Elements

NCLEX Review

Please read each question and select your answer from the choices provided. You must complete all of the questions in order to view your results. At the end of each exam, you have the option to e-mail your results to your instructor.

1:  A nursing diagnosis of the potential for altered skin integrity is identified for a patient with ulcerative colitis who is experiencing frequent diarrheal stools. Which patient action would help prevent perianal breakdown?
A: A sitz bath is used for 20 minutes after each stool.
B: A soap suds enema is given to clear the colon of fecal matter.
C: The perianal area is cleansed using an antimicrobial scrub, rinsed, and dried.
D: The perianal area is cleansed with mild soap and water and dried.

2:  The nurse is caring for a hospitalized patient who has a urine output of 250 cc in a 24-hour period. Which term would the nurse use when analyzing and documenting the patient's urine output?
A: Enuresis.
B: Anuria.
C: Azotemia.
D: Oliguria.

3:  Which item is inappropriate for a patient whose dietary prescription is for clear liquids?
A: Ice cream.
B: Popsicle.
C: Gelatin.
D: Broth.

4:  A patient is receiving enteral feedings via a gastrostomy tube. What is the priority nursing diagnosis for this patient?
A: Risk for constipation.
B: Impaired gas exchange.
C: Body image disturbance.
D: Risk for aspiration.

5:  A patient has dysphagia. Which nursing action is most appropriate for this patient?
A: Monitor intake and output, and encourage fluid intake.
B: Elevate the head of the bed, and observe for signs of aspiration.
C: Ensure an emesis basin is available, and plan to administer an antiemetic if needed.
D: Prepare for the insertion of subclavian venous catheter for parenteral nutrition.

6:  A patient with chronic renal failure who is on hemodialysis is placed on a low-protein diet. The patient asks, "Why do I have to be concerned with protein?" What is the best response by the nurse about the purpose of this diet?
A: Waste products, like urea, build up as a result of protein breakdown, and the kidneys are not able to rid the body of the wastes.
B: Because the kidneys have failed, a smaller amount of protein is needed to produce essential amino acids.
C: In the presence of renal disease, a normal amount of protein intake will cause hyperkalemia when the protein is broken down by the body.
D: A low-protein diet will cause hypoalbuminemia, which can increase colloid osmotic pressure and prevent fluid overload.

7:  A patient has daily weights ordered. Which action should be avoided to ensure an accurate weight?
A: The same scale should be used.
B: The scale should be balanced at zero.
C: The patient's weight should be taken at different times each day.
D: The patient should wear the same clothing during each measurement.

8:  The healthcare provider orders that the patient's temperature be taken every 4 hours. When the nurse attempts to obtain the patient's oral temperature, the patient informs the nurse that he has just had some ice chips. What is the most appropriate nursing action?
A: Wait 15 minutes and return to take the oral temperature.
B: Provide a sip of warm water, wait 5 minutes, and take the temperature.
C: Document that a temperature was unable to be obtained.
D: Proceed to take the oral temperature.

9:  A patient is confused and has pulled out a peripheral IV catheter. Which alternative therapy might the nurse consider prior to using restraints?
A: Obtain an order for sedation.
B: Place mittens on the patient's hands.
C: Involve family members in reorienting the patient.
D: Apply additional tape to IV sites.

10:  What is the best method for the assessment of fluid volume increases?
A: Daily weight.
B: Serum sodium.
C: Tissue turgor.
D: Intake and output.

11:  What is the most appropriate site at which to assess a patient for central cyanosis?
A: Oral mucosa.
B: Nail beds.
C: Earlobes.
D: Eyelids.

12:  What is the most appropriate site for a nurse to assess for jaundice on a dark-skinned patient?
A: Palms of the hands.
B: Around the mouth.
C: Sclera.
D: Trunk.

13:  Which patient is most likely to receive total parenteral nutrition?
A: A patient with acute gastritis.
B: A patient with a complete bowel obstruction.
C: A patient who has been vomiting for the past hour.
D: A patient who has undergone a cholecystectomy.

14:  The nurse is monitoring a postoperative patient who weighs 60 kilograms. What hourly urine output rate should the nurse report?
A: 20 mL/h
B: 60 mL/h
C: 100 mL/h
D: 140 mL/h

15:  The nurse is discussing the side effects of an alkylating chemotherapy medication, cyclophosphamide (Cytoxan). The patient asks about hair loss associated with the medication. Which statement is accurate and should be included in the discussion?
A: "Most individuals do not lose their hair after taking the medication."
B: "Hair loss is common, including your eyebrows and eyelashes."
C: "Most patients get fitted for a wig, because the hair loss will be permanent."
D: "Individuals lose their hair, but it usually grows back nice and thick."

16:  The nurse is preparing to insert an indwelling urinary catheter in a female patient who is being prepared for an operative procedure. Which statement about catheter insertion is true?
A: Clean technique should always be used for the insertion procedure.
B: The catheter balloon should be inflated with 20 cc of sterile water.
C: Advance the catheter 2 to 3 inches into the urinary meatus.
D: Lubrication of the catheter tip prior to its insertion can result in urinary tract infections.

Optional: Enter your name and your instructor's E-mail address to have your results E-mailed to him or her.
Your Name:
Instructor's E-mail Address:
Your E-mail Address:

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