NCLEX Weekly Questions Week 5 - August 9th, 2021 - Eduardo Perez

1. Question
A patient with Parkinson’s disease has a nursing diagnosis of Impaired Physical Mobility related
to neuromuscular impairment. You observe a nursing assistant performing all of these actions.
For which action must you intervene?

A. The NA assists the patient to ambulate to the bathroom and back to bed.
B. The NA reminds the patient not to look at his feet when he is walking.
C. The NA performs the patient’s complete bath and oral care.
D. The NA sets up the patient’s tray and encourages the patient to feed himself.

2. Question
The nurse is preparing to discharge a patient with chronic low back pain. Which statement by
the patient indicates that additional teaching is necessary?

A. “I will avoid exercise because the pain gets worse.”

B. “I will use heat or ice to help control the pain.”
C. “I will not wear high-heeled shoes at home or work.”
D. “I will purchase a rm mattress to replace my old one.”

3. Question
A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that
suddenly started a short time ago. Assessment of the patient reveals increased blood pressure
(168/94) and decreased heart rate (48/minute), diaphoresis, and ushing of the face and neck.
What action should you take rst?

A. Administer the ordered acetaminophen (Tylenol).

B. Check the Foley tubing for kinks or obstruction.
C. Adjust the temperature in the patient’s room.
D. Notify the physician about the change in status.

4. Question
Which patient should you, as charge nurse, assign to a new graduate RN who is orienting to
the neurologic unit?

A. A 28-year-old newly admitted patient with spinal cord injury.

B. A 67-year-old patient with stroke 3 days ago and left-sided weakness.
C. An 85-year-old dementia patient to be transferred to long-term care today.
D. A 54-year-old patient with Parkinson’s who needs assistance with bathing.

5. Question
A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority
assessment?

A. Determine the level at which the patient has intact sensation.

B. Assess the level at which the patient has retained mobility.
C. Check blood pressure and pulse for signs of spinal shock.
D. Monitor respiratory e ort and oxygen saturation level.

6. Question
You are pulled from the ED to the neurologic oor. Which action should you delegate to the
nursing assistant when providing nursing care for a patient with SCI?

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 A. Assess the patient's respiratory status every 4 hours.
B. Take the patient’s vital signs and record them every 4 hours.
C. Monitor nutritional status including calorie counts.
D. Have the patient turn, cough, and deep breathe every 3 hours.

7. Question
You are helping the patient with an SCI to establish a bladder-retraining program. What
strategies may stimulate the patient to void? Select all that apply.

A. Stroke the patient’s inner thigh.

B. Pull on the patient’s pubic hair.
C. Initiate intermittent straight catheterization.
D. Pour warm water over the perineum.
E. Tap the bladder to stimulate detrusor muscle.

8. Question
The patient with a cervical SCI has been placed in xed skeletal traction with a halo xation
device. When caring for this patient the nurse may delegate which action (s) to the LPN/
LVN? Select all that apply.

A. Check the patient’s skin for pressure from the device.

B. Assess the patient’s neurologic status for changes.
C. Observe the halo insertion sites for signs of infection.
D. Clean the halo insertion sites with hydrogen peroxide.

9. Question
You are preparing a nursing care plan for the patient with SCI including the nursing diagnosis
Impaired Physical Mobility and Self-Care De cit. The patient tells you, “I don’t know why we’re
doing all this. My life’s over.” What additional nursing diagnosis takes priority based on this
statement?

A. Risk for Injury related to altered mobility

B. Imbalanced Nutrition, Less Than Body Requirements
C. Impaired Adjustment to Spinal Cord Injury
D. Poor Body Image related to immobilization

10. Question
Which patient should be assigned to the traveling nurse, new to neurologic nursing care, who
has been in the neurologic unit for 1 week?

A. A 34-year-old patient newly diagnosed with multiple sclerosis (MS).

B. A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS).
C. A 56-year-old patient with Guillain-Barre syndrome (GBS) in respiratory distress.
D. A 25-year-old patient admitted with CA level spinal cord injury (SCI).

11. Question
The patient with multiple sclerosis tells the nursing assistant that after physical therapy she is
too tired to take a bath. What is your priority nursing diagnosis at this time?

A. Fatigue related to disease state

B. Activity Intolerance due to generalized weakness
C. Impaired Physical Mobility related to neuromuscular impairment
D. Self-care De cit related to fatigue and neuromuscular weakness

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 12. Question
The LPN/LVN, under your supervision, is providing nursing care for a patient with GBS. What
observation would you instruct the LPN/LVN to report immediately?

A. Complaints of numbness and tingling.

B. Facial weakness and di culty speaking.
C. Rapid heart rate of 102 beats per minute.
D. Shallow respirations and decreased breath sounds.

13. Question
The nursing assistant reports to you, the RN, that the patient with myasthenia gravis (MG) has
an elevated temperature (102.20 F), heart rate of 120/minute, rise in blood pressure (158/94),
and was incontinent of urine and stool. What is your best rst action at this time?

A. Administer an acetaminophen suppository

B. Notify the physician immediately
C. Recheck vital signs in 1 hour
D. Reschedule patient’s physical therapy session

14. Question
You are providing care for a patient with an acute hemorrhage stroke. The patient’s husband
has been reading a lot about strokes and asks why his wife did not receive alteplase. What is
your best response?

A. “Your wife was not admitted within the time frame that alteplase is usually given.”
B. “This drug is used primarily for patients who experience an acute heart attack.”
C. “Alteplase dissolves clots and may cause more bleeding into your wife’s brain.”
D. “Your wife had gallbladder surgery just 6 months ago and this prevents the use of
alteplase.”

15. Question
You are supervising a senior nursing student who is caring for a patient with a right hemisphere
stroke. Which action by the student nurse requires that you intervene?

A. The student instructs the patient to sit up straight, resulting in the patient’s puzzled
expression.
B. The student moves the patient’s tray to the right side of her over-bed tray.
C. The student assists the patient with passive range-of-motion (ROM) exercises.
D. The student combs the left side of the patient’s hair when the patient combs only the right
side.

16. Question
Which of the following arteries primarily feeds the anterior wall of the heart?

A. Circum ex artery
B. Internal mammary artery
C. Left anterior descending artery
D. Right coronary artery

17. Question
When do coronary arteries primarily receive blood ow?

A. During inspiration
B. During diastole

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 C. During expiration
D. During systole

18. Question
Which of the following illnesses is the leading cause of death in the US?

A. Cancer
B. Coronary artery disease
C. Liver failure
D. Renal failure

19. Question
Which of the following conditions most commonly results in CAD?

A. Atherosclerosis
B. DM
C. MI
D. Renal failure

20. Question
Atherosclerosis impedes coronary blood ow by which of the following mechanisms?

A. Plaques obstruct the vein

B. Plaques obstruct the artery
C. Blood clots form outside the vessel wall
D. Hardened vessels dilate to allow the blood to ow through

21. Question
Which of the following risk factors for coronary artery disease cannot be corrected?

A. Cigarette smoking
B. DM
C. Heredity
D. HPN

22. Question
Exceeding which of the following serum cholesterol levels signi cantly increases the risk of
coronary artery disease?

A. 100 mg/dl
B. 150 mg/dl
C. 175 mg/dl
D. 200 mg/dl

23. Question
Which of the following actions is the rst priority care for a client exhibiting signs and
symptoms of coronary artery disease?

A. Decrease anxiety
B. Enhance myocardial oxygenation
C. Administer sublingual nitroglycerin
D. Educate the client about his symptoms

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 24. Question
Medical treatment of coronary artery disease includes which of the following procedures?

A. Cardiac catheterization
B. Coronary artery bypass surgery
C. Oral medication administration
D. Percutaneous transluminal coronary angioplasty

25. Question
Prolonged occlusion of the right coronary artery produces an infarction in which of the
following areas of the heart?

A. Anterior
B. Apical
C. Inferior
D. Lateral

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