PART 2 NCLEX QUESTION AND ANSWER 2020

1. A patient is admitted to the hospital with the diagnosis of primary

hyperthyroidism. A nurse checking the patient’s lab results which of the
following changes in laboratory findings?
A. elevated serum calcium. the parathyroid gland regulates
the calcium level in the blood
2. A patient with Addison’s disease ask a nurse for nutrition and diet
advice. Which of the following diet modifications is NOT
recommended? D. a restricted sodium diet
3. A patient with a history of diabetic mellitus is in the second post-
operative day following cholecystectomy. She has complained of
nausea and isn’t able to eat solid foods. The nurse enters the room to
find the patient confused and shaky. Which of the following is the most
likely explanation for the patient’s symptoms?
C. Hypoglycemia
4. A nurse assigned to the emergency department evaluates a patient who
underwent fiberoptic colonoscopy 18 hrs previously. The patient
reports increasing abdominal pain, fever , and chills. Which of the
following conditions poses the immediate concern?
A. Bowel perforation. Bowel perforation is the most
serious complication of fiberoptic colonoscopy.
5. A patient is admitted to the same day surgery unit for liver biopsy.
Which of the following laboratory test assesses coagulation?
A. Partial thromboplastin time
B. prothrombin time C. platelet count
6. A nurse is assessing a clinic patient with diagnoses of hepatitis A. which
of the following is the most likely route of transmission?
B. contaminated food
7. A leukaemia patient has a relative who wants to donate blood for
transfusion. Which of the following donor medical conditions would
prevent this? A. A history of Hep. A for 5 yrs. previously
8. A physician has diagnosed acute gastritis in a clinic patient. Which of
the following medications would be contraindicated for this patient?
A. Naproxen sodium (Naprosyn)
9. The nurse is conducting nutrition counselling for a patient with
cholecystitis. Which of the following information is important to
communicate? D. The patient should limit fatty foods
10.A patient admitted to the hospital with myocardial infarction develops
severe pulmonary edema. Which of the following symptoms should the
nurse expect the patient to exhibit?
D. air hunger. Patients with pulmonary edema experience air hunger,
anxiety, and agitation.
11.A nurse caring for several patients on the cardiac unit is told that one is
scheduled for implantation of automatic internal cardioverted-
defibrillator. Which of the following patients is most likely to have this
procedure?
C. A patient with history of ventricular tachycardia and
syncopal episodes.
12. A patient is scheduled for magnetic resonance imaging (MRI) scan for
suspected lung cancer. Which of the following is contraindication to the
study for this patient? B. The patient has a pacemaker
13. A nurse calls a physician with the concern that a patient has developed
a pulmonary embolism. Which of the following symptoms has the nurse
likely observed?
B. the patient suddenly complains of chest pain and SOB
14. A patient comes to the emergency department with abdominal pain.
Work up reveals the presence of a rapidly enlarging abdominal aortic
aneurysm. Which of the following actions should the nurse expect?
C. The patient will be admitted to the surgical unit and
resection will be scheduled
15. A patient with leukemia is receiving chemotherapy that is known to
depress bone marrow. A CBC (complete blood count) reveals a platelet
count of 25,000/microliter. Which of the following actions related
specifically to the platelet count should be included on the nursing care
plan?
D. Check for signs of bleeding, including examination of urine and
stool for blood.
16. A nurse in the emergency department is observing a 4-year-old child for
signs of increasing intracranial pressure after a fall from a bicycle,
 resulting in head trauma. Which of the following signs and symptoms
would be cause for concern? B. Repeated vomiting
17. A non-immunized child appears at the clinic with a visible rash. Which
of the following observations indicates the child may have rubeola
(measles)? B. A small blue-white spots are visible on the oral
mucosa
18.A child is seen in the emergency department for scarlet fever. Which of
the following descriptions of scarlet fever is NOT correct?
C. petechiae occur on the soft palate
19. A child weighing 30 kg arrives at the clinic with diffuse itching as the
result of an allergic reaction to an insect bite. Diphenhydramine
(Benadryl) 25 mg 3 times a day is prescribed. The correct pediatric dose
is 5mg/kg/day, which of the following best describes the prescribed drug
dose? B. the dose is too low
20. A mother of a 2-month-old infant brings the child to the clinic for a well
baby check. She is because she feels only one tests in scrotal sac.
Which of the following statements about the undescended testis is most
accurate? D. Normally, the testes descend by 1 yr. of age
21. A patient is admitted to the same day surgery unit for liver biopsy.
Which of the following laboratory tests assesses coagulation? Select all
that apply. A.PTT B. PT C platelet count
22.A patient is admitted to the hospital with suspected polycythemia vera.
Which of the following symptoms is consistent with diagnosis? Select all
that apply.
B. Increased clotting time C. Hypertension D. Headaches
23.The nurse is teaching the client how to use a metered dose inhaler to
administer a corticosteroid drug. Which of the following client indicates
that he is using the (MDI) correctly? Select all that apply.
A&D. the inhaler is held upright and amouth is rinsed with
water following administration
24.The nurse is teaching with polycythemia vera about potential
complications from this disease. Which manifestations would the nurse
include in the client’s teaching plan? Select all that apply.
B. Visual disturbance C. Headache D. orthopnea
E. gout. Polycethemia vera, a condition in which too
 many RBC’s are produced in the blood serum, can lead to an increase in
the hematocrit and hypervolemia, hyperviscosity, and hypertension
25. Which of the following would be priority assessment data to gather
from client who has been diagnosed with pneumonia? Select all that
apply.
A. Auscultation of breath sounds C. presence of chest pain and
E. color of nail beds
26. The nurse is teaching a client who has been diagnosed with TB how to
avoid spreading the disease to family members. Which statement(s) by
the client indicate(s) that he has understood the nurse instruction?
Select all that apply.
a. B, D, E. “I should always cover my mouth and nose when
sneezing.”,” I should use paper tissues to cough in and dispose of
them properly.”, “I can use regular plate and utensils whenever I
eat.”
27. The nurse is admitting a client with hypoglycemia. Identify the signs
and symptoms the nurse should expect. Select all that apply.
B. Palpitations C. Diaphoresis D. slurred speech
Palpitations, an adrenergic symptom, occur as the
glucose levels fall; the sympathetic nervous system is activated and
epinephrine and norepinephrine are secreted causing this response.
Diaphoresis is a sympathetic nervous system response that occurs as
epinephrine and norepinenhrine are released. Slurred speech is a
neuroglycopenic symptom; as the brain receives insufficient glucose, the
activity of the CNS becomes depressed.
28. Which adaptations should the nurse caring for a client with diabetic
ketoacidosis expect that the client exhibit? Select all that apply.
B. low PCO2 D. Acetone breath
29. When planning care for a client with ulcerative colitis who is
experiencing symptoms, which client care activities can the nurse
appropriately delegates to a unlicensed assistant? Select all that apply.
B, D, E. The nurse can delegate the following basic care
activities to the unlicensed assistant: providing skin care following bowel
movements, maintaining intake and output records, and obtaining the
client’s weight
30. Which of the following nursing diagnoses would be appropriate for a
client with heart failure? Select all that apply.
A. ineffective tissue perfusion related to decreased peripheral
blood flow secondary to decreased cardiac output.
C . decreased cardiac output related to structural and
functional changes