NCLEX IFC - Rundown

1. Upon arriving on the unit one morning, the nurse discovers a sign taped to the door of a patient’s room stating
“PATIENT IS BLIND. PROVIDE ASSISTANCE.” The nurse is aware that this violates the patient’s right to:
a. safe care
b. privacy
c. privileged communication
d. habeas corpus

2. An informed consent must be obtained for:

a. An echocardiogram
b. An electroencephalography
c. A colonoscopy
d. A sonography

3. A multigravida patient at 37 weeks’ gestation is scheduled for a biophysical profile. Which of the following would the
nurse instruct the patient to do before the test?
a. Drink 1 to 2 L fluid
b. Remain NPO after midnight before the test
c. Plan to remain in the clinic for 4 hours after the test
d. Eat a high-fiber meal after the test

4. When suctioning the respiratory tract of a patient, it is recommended that the suctioning period not exceed how many
seconds?
a. 5 seconds
b. 10 seconds
c. 15 seconds
d. 20 seconds

5. The physician orders a gavage feeding for an infant. To determine the length of tube needed to reach the stomach,
the nurse should:
a. Advance the tube until resistance is met
b. Advance the tube as far as necessary to aspirate gastric contents
c. Measure from the mouth to the umbilicus and add half the distance
d. Measure the distance from the nose to the earlobe to the epigastric area of the abdomen

6. The nurse should explain to the newly pregnant primigravida that the fetal heartbeat will first be heard with:
a. A fetoscope around 8 weeks
b. A fetoscope at 12 to 14 weeks
c. An electronic Doppler after 17 weeks
d. An electronic Doppler at 10 to 12 weeks

7. A patient who has type 1 diabetes had a nonstress test that was reactive. The nurse would recognize that the patient
understood what she was taught about the result when she is overheard telling her husband that the test was:
a. Normal, due to an increase in FHR with fetal movement
b. Abnormal, due to a decrease in FHR with fetal movement
c. Abnormal, due to an increase in FHR with maternal movement
d. Normal, due to the FHR remaining unchanged with maternal movement

8. Phenylketonuria (PKU) testing is performed on a 4-day old infant. The nurse plans to explain to the mother that the
purpose of this genetic screening is to determine:
a. If the infant is positive for PKU
b. If the mother is a carrier for PKU
c. The incidence of the disease in the populations
d. The risk for the infant’s later development of PKU

9. Which of the following actions, if performed by the nurse, would be considered negligence?

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 a. Obtaining a Guthrie blood test on 4-day-old infant
b. Massaging a lotion on the abdomen of a 30-year-old diagnosed with aortic aneurysm
c. Instructing a 5-year-old asthmatic to blow on a pinwheel
d. Playing kickball with a 10-year-old with juvenile arthritis (JA)

10. The nurse on the postsurgical unit receives a patient that was transferred from the post anesthesia care unit and is
planning care for this patient. The nurse understands that staff would begin planning for this patient’s discharge at
which point during the hospitalization?
a. Upon admission to the surgical unit
b. During the transfer from PACU to the postsurgical unit
c. When able to perform activities of daily living independently
d. When assessed by the physician for the first time after surgery

11. A nursing team consists of an RN/LPN, and a nursing assistant. The nurse should assign which of the following
patients to the LPN/LVN?
a. A 65-year-old patient with diabetes who requires a dressing change for a stasis ulcer
b. A 40-year-old patient with cancer of the bone complaining of pain
c. A 50-year-old patient with terminal cancer being transferred to hospice home care
d. A 28-year-old patient with a fracture of the right leg who asks to use the urinal

12. A patient with exacerbation of chronic obstructive pulmonary disease (COPD) and pneumonia has the following
arterial blood gas (ABG) results: pH: 7.30, partial pressure of arterial carbon dioxide: 50 mmHg, partial pressure of
arterial oxygen: 75 mmHg, and bicarbonate: 24 mEq/L. The nurse anticipates which intervention?
a. Increase oxygen via face mask
b. Encourage coughing and deep breathing
c. Administer sodium bicarbonate
d. No intervention is needed, ABG values are normal

13. A cardiologist prescribes digoxin (Lanoxin) 125 mcg by mouth every morning for a patient diagnosed with heart
failure. The pharmacy dispenses tablets that contain 0.25 mg each. How many tablets should the nurse administer in
each dose?
Answer: ________________

14. Which of the following signs or symptoms would indicate a need for colposcopy and biopsy for human papillomavirus?
a. Rash on the palms of the hands and soles of the feet
b. Chancre sore noted on the vulva and perineal area
c. A crusted ulcer inside the vagina and the labia
d. 2 to 3 mm soft, red, papillary swellings either singly or in clusters noted on the genitalia

15. A patient has been instructed on the use of an incentive spirometer. The nurse evaluates that the patient understood
the instructions if the patient performs which of the following actions?
a. Maintains a supine position while using the spirometer
b. Inhales rapidly, exhales into the spirometer to reach the indicator and waits 10 seconds before repeating the
process
c. Exhales completely, places mouth around mouthpiece before inhaling slowly to reach the indicator, removes
mouthpiece, holds breath and exhales slowly
d. Purses lips tightly around mouthpiece, inhales slowly and deeply and exhales slowly into the spirometer until
spirometer reaches indicator mark

16. Which of the following represents the best advice to give a diabetic patient about eye examinations?
a. Examinations should be scheduled every year
b. Examinations should be scheduled every 2 years
c. Changes in vision do not necessitate immediate medical attention
d. Examinations should be performed by an optometrist

17. After sustaining a closed head injury, a patient is prescribed Phenytoin (Dilantin) 100 mg IV every 8 hours for seizure
prophylaxis. Which nursing interventions are necessary when administering Phenytoin?

Select all that apply:

a. Administer Phenytoin through any peripheral IV site

b. Mix IV dose in mixtures containing dextrose 5% in water
c. Administer an IV bolus no faster than 50 mg/min
d. Monitor electrocardiogram (ECG), blood pressure, and respiratory status continuously when administering
Phenytoin IV
e. Don’t use an inline filter when administering the drug

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 f. Know that early toxicity may cause drowsiness, nausea, vomiting, nystagmus, ataxia, dysarthria, tremor, and
slurred speech

18. Who among the following patients needs to be referred for immediate cancer screening?
a. 55-year-old black patient with history of frequent urinary tract infection
b. 68-year-old black female who had her first baby at age 37, and whose aunt died of breast cancer
c. 40-year-old white menopausal female with vague abdominal discomforts
d. 20-year-old smoker who works as a prostitute whose pap smear in the past 2 years have yielded negative
results

19. The nurse removes a patient’s surgical abdominal dressing and notes a thin yellow drainage, separation of the
incision line, and the presence of underlying tissue. The nurse should take which priority action?
a. Apply a Betadine-soaked sterile dressing
b. Leave the incision open to the air to dry the area
c. Irrigate the wound and apply a dry sterile dressing
d. Apply a sterile dressing soaked with normal saline

20. An immunocompromised child is being admitted to a four-bedded area in the pediatric intensive care unit. Which
patient should be moved to make room for the new admission?
a. A child with plaster immobilization of a closed fracture
b. A child with a full-thickness thermal burn
c. A child with aspiration pneumonia
d. A child with a vaso-occlusive crisis of sickle cell anemia

21. A nurse is about to begin a nasogastric tube feeding. In order to render safe care for this patient, the nurse must first:
a. Don sterile gloves
b. Administer water first
c. Check gastric residual
d. Refrigerate feedings

22. A patient has a hematocrit of 19%. Which of the following statements, if made by the patient would be directly related
to the low hematocrit?
a. “I feel chest pressure.”
b. “I feel like I have to vomit.”
c. “I have a headache.”
d. “I have a funny taste in my mouth.”

23. The nurse in charge of a medical unit is informed that there are six patients for admission during a very busy shift.
Which of the following combinations of roommates would the nurse want to avoid?
a. A confused elderly patient and a 48-year-old with a severe migraine headache
b. A 24-year-old post-abortion and a 38-year-old minister with abdominal pain
c. A 68-year-old patient who had a cerebral vascular accident (CVA) and an 18-year-old motorcycle accident
with CHI
d. A 48-year-old with pneumonia and a 28-year-old on chemotherapy

24. Which of the following results from Cushing disease?

a. Postural hypotension, decreased tolerance of stress, and a weak irregular pulse
b. Psychosis, diabetes mellitus, osteoporosis and hypertension
c. Polyuria, extreme fatigue and postural hypertension
d. Excessive thirst, polyuria, and diabetes mellitus

25. The signs and symptoms of cardiogenic shock are:

a. A drop in systolic pressure 10 mmHg below systolic baseline with headaches and rapid shallow respirations
b. Rapid shallow respirations, polyuria and a drop in blood pressure below patient’s baseline
c. Cold pale skin, bounding pulse, hyperventilation and tachycardia
d. Poor tissue perfusion, cold, pale, clammy skin and a drop in systolic blood pressure of 30 mmHg below
baseline

26. A patient is admitted to the hospital with a disease characterized by rapid development of symmetric weakness and
lower motor neuron flaccid paralysis that ascends to upper extremities. The nurse recognizes these are
characteristics of which of the following diseases?
a. Huntington’s disease
b. Guillain-Barre syndrome
c. Multiple sclerosis
d. Myasthenia

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27. A nurse is assessing a patient who is at risk of developing acute renal failure (ARF). The nurse would become
concerned if which of the following assessments was made?
a. Urine output 30 mL/hr for at least 3 hours, blood urea nitrogen (BUN) 10 mg/dL, creatinine 1.2 mg/dL
b. Urine output 40 mL/hr for the last 3 hours, BUN 15 mg/dL, creatinine 2.1 mg/dL
c. Urine output 20 mL/hr for the last 3 hours, BUN 35 mg/dL, creatinine 2.1 mg/dL
d. Urine output 60 mL/hr for the last 3 hours, BUN 40 mg/dL, creatinine 1.1 mg/dL

28. A community health nurse provides an educational session on the risk factors of cervical cancer to the women in local
community. The nurse determines that further teaching is needed if a woman attending the session has which of the
following?
a. Caucasian race
b. Early age of first pregnancy
c. Prostitution as profession
d. Sexually transmitted disease

29. A patient with agoraphobia experiences severe panic attacks when attempting to leave the house. This patient’s
outpatient treatment plan includes behavioral therapy to systematically decrease the amount of anxiety that occurs
when leaving the house. Which statement best reflects successful therapy?
a. The patient leaves the house and experiences palm sweating
b. The patient leaves the house and experiences shortness of breath
c. The patient leaves the house and controls anxiety with an anxiolytic agent
d. The patient stands outside the door to the house and holds onto the doorknob

30. The patient is on Coumadin. Which food is appropriate?

a. Spinach
b. Green leafy and yellow vegetables
c. Bread and milk
d. Cabbage

31. Which of the following play activities is appropriate for a patient with juvenile rheumatoid arthritis:
a. Volleyball
b. Skipping rope
c. Painting
d. Riding a bicycle

32. Which of the following patients is at risk for developing breast cancer?
a. African-American, nulliparous
b. Australian, multiparous
c. Jewish, breastfeeding woman
d. Asian, with history of being hit by a ball on the chest

33. The nurse is caring for several patients with fractures. Which patient is most at risk for embolus?
a. A 4-year-old with a wrist fracture
b. A 20-year-old with a femur fracture
c. A 35-year-old with an ulnar fracture
d. A 75-year-old with rib fractures

34. A nurse is caring for the following group of patients on the clinical nursing unit. The nurse interprets that which of
these patients is most at risk for the development of pulmonary embolism?
a. A 65-year-old man out of bed 1 day after prostate resection
b. A 73-year-old woman who has just had a pinning of a hip fracture
c. A 25-year-old woman with diabetic ketoacidosis
d. A 38-year-old woman with confusion after an automobile accident

35. A nurse is assigned care for a patient who has just undergone eye surgery. The nurse plans to instruct the patient that
which of the following activities is permitted in the postoperative period?
a. Reading
b. Watching television
c. Bending over
d. Lifting objects

36. A patient with tuberculosis (TB) is to be started on rifampicin (Rifacin). The nurse provides instruction to the patient
and tells the patient:
a. That yellow-colored skin is common
b. To wear glasses instead of contact lens
c. To always take the medication on an empty stomach
d. That as soon as the cultures come back negative, the medication may be stopped

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37. A nurse is administering an oral dose of erythromycin (E-mycin) to an assigned patient. The nurse administers this
medication with a:
a. Full glass of milk
b. Full glass of water
c. Sip of orange juice
d. Any citrus beverage

38. A patient receiving a dose of intravenous vancomycin (Vancocin) develops chills, tachycardia, syncope, and flushing
of the face and trunk. The nurse interprets that:
a. The patient is allergic to the medication
b. The medication has interacted with another medication the patient is receiving
c. The medication is infusing too rapidly
d. The patient is experiencing upper airway obstruction

39. A patient has an order to be given beclomethasone (Beclovent) by the intranasal route. The patient also has an order
for a nasal decongestant. The nurse plans to:
a. Administer the beclomethasone 15 minutes before the decongestant
b. Administer the decongestant 15 minutes before beclomethasone
c. Administer the beclomethasone immediately before the decongestant
d. Administer the decongestant immediately before the beclomethasone

40. A nurse assesses an elderly patient for signs of potential abuse. Which of the following psychosocial factors obtained
during the assessment places the patient at risk for abuse?
a. The patient is completely dependent on family members for receiving food and medicine
b. The patient shows signs and symptoms of depression
c. The patient resides in a low-income neighborhood
d. The patient has a chronic illness

41. A substance abuse clinic nurse is providing dietary instructions to patients. A patient asks the nurse about the foods
that are high in thiamine. The nurse tells the patient that which food is especially rich on this vitamin?
a. Chicken
b. Broccoli
c. Pork
d. Milk

42. A nurse has conducted medication instructions with a patient receiving lovastatin (Mevacor). The nurse determines
that the patient understands the effect of the medication if the patient stated the need to adhere to the periodic
evaluation of serum:
a. Triglyceride levels
b. Liver function
c. Blood glucose levels
d. Bleeding times

43. A nurse instructs a patient to have a low-fat diet. The patient indicates an understanding of this diet by choosing which
of the following from the menu?
a. Liver, potato salad, sherbet
b. Shrimp, bacon salad
c. Turkey breast, broiled rice, angel food cake
d. Lean hamburger steak, macaroni and cheese

44. A patient is experiencing blockage of the eustachian tubes. The nurse teaches the patient that which activity may
forcibly open the eustachian tube?
a. Performing the Valsalva maneuver
b. Tapping the side of the head lightly
c. Placing large, soft cotton balls in the ears
d. Chewing food using exaggerated mouth movements

45. A nurse is teaching a patient with pulmonary sarcoidosis about long-term ongoing management. The nurse plans to
include which of the following in the instruction?
a. Need for daily corticosteroid therapy
b. Usefulness of home oxygen equipment
c. Need for follow-up chest x-ray evaluation every 6 months
d. Importance of incentive spirometer daily

46. A patient is diagnosed with hyperphosphatemia. The nurse encourages the patient to limit intake of which of the
following items that exacerbates the condition?

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 a. Bananas
b. Grapes
c. Coffee
d. Carbonated beverages

47. A patient has a nosebleed. What is the first action of the nurse?
a. Assess for trauma
b. Check the blood pressure
c. Instruct not to pick the nose
d. Check the pulse

48. A nurse is conducting a health screening clinic. The nurse interprets that which of the following patients participating
in the screening has the greatest need for instruction to lower the risk of developing respiratory disease?
a. A 50-year-old smoker with cracked asbestos lining on basement pipes in the home
b. A 40-year-old smoker who works in a hospital
c. A 36-year old who works with pesticides
d. A 25-year-old whose hobby is woodworking

49. A nurse is teaching a patient how to stand on crutches. The nurse tells the patient to place the crutches:
a. 8 inches to the front and side of the toes
b. 3 inches to the front and side of the toes
c. 20 inches to the front and side of the toes
d. 15 inches to the front and side of the toes

50. A nurse finds a bedridden patient unresponsive and is preparing to open an airway. Which of the following methods
of opening the airway is appropriate?
a. The jaw thrust method
b. The head tilt chin lift technique
c. The chest thrust method
d. The chin to sternum method

51. Which of the following group of manifestations is not associated with congenital anomaly?
a. Bluish discoloration on the buttocks and a 10% weight loss in a two-week-old baby
b. Short stature, webbed neck, low posterior hair line, widely spaced nipples and underdeveloped reproductive
organs
c. Acrocyanosis, jaundice that begins on the second day after birth and simian crease across the palms of both
hands
d. Brow sweating during feeding, machinery like murmur on auscultation of heart sound in a two-month-old baby

52. An older patient with delirium becomes disoriented at night. The nurse should initiate which action first to assist the
patient?
a. Turn off the television and radio, and use a nightlight
b. Keep soft lighting and the television on during the night
c. Change the patient’s room to one nearer the nurses’ station
d. Play soft instrumental music all night, and keep the lights on

53. A hospitalized patient with a history of alcohol abuse tells the nurse, “I’m leaving now. I have to go. I don’t want any
more treatment. I have things that I have to do right away.” What action would the nurse take when a patient decides
to leave against medical advice?
a. Call the nursing supervisor
b. Call security to block all exit areas
c. Place the patient in seclusion, and contact the primary health care provider for further instruction
d. Tell the patient that he or she must contact the primary health care provider before leaving the hospital

54. A post myocardial infarction patient is scheduled for a multigated acquisition (MUGA) scan. The nurse ensures that
which item is in place before the procedure?
a. Signed informed consent
b. Notification of allergies to iodine to shellfish
c. Assisting with ambulation
d. Instituting seizure precautions

55. A nurse notes that a patient’s lithium level is 3.9 mEq/L. The nurse implements which priority intervention?
a. Determining visual acuity
b. Monitoring intake and output
c. Assisting with ambulation
d. Instituting seizure precautions

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56. What should the nurse assess the patient for prior to allowing transition from liquid to solid food?
a. Appetite
b. Level of consciousness
c. Presence of bowel sounds
d. Chewing ability

57. Based on assessment and diagnostic evaluation, it has been determined that a patient has Lyme disease Stage II.
The nurse assesses the patient for which of the following that is most indicative of this stage?
a. Erythematous rash
b. Neurological deficits
c. Headache
d. Lethargy

58. A patient is being admitted to the hospital with a diagnosis of urolithiasis and ureteral colic. The nurse assesses the
patient for pain that is:
a. Dull and aching in the costovertebral area
b. Sharp and radiating posterior to the spinal column
c. Excruciating, wavelike and radiating toward the genitalia
d. Aching and cramp-like throughout the abdomen

59. A nurse is reviewing the results of a sweat test performed on a child with cystic fibrosis. The nurse would expect to
note which finding?
a. A sweat sodium concentration less than 40 mEq/L
b. A sweat potassium concentration less than 40 mEq/L
c. A sweat potassium concentration greater than 40 mEq/L
d. A sweat chloride concentration greater than 60 mEql/L

60. A patient is admitted to the hospital with a diagnosis of right lower lobe pneumonia. The nurse auscultates the right
lower lobe, expecting to note which of the following types of breath sounds?
a. Bronchial
b. Bronchovesicular
c. Vesicular
d. Absent

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