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NCLEX-RN Exam Pack Set 4 (75Questions & Answers Updated2022).
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NCLEX-RN Exam Pack Set 4 (75Questions & Answers Updated
2022)
1. 1. Question
Which action(s) should you delegate to the experienced nursing
assistant when caring for a patient with a thrombotic stroke with
residual left-sided weakness? Select all that apply.
o A. Assist the patient to reposition every 2 hours.
o B. Reapply pneumatic compression boots.
o C. Remind the patient to perform active ROM.
o D. Check extremities for redness and edema.
Correct Answer: A, B, & C.
The experienced nursing assistant would know how to reposition
the patient and how to reapply compression boots and would
remind the patient to perform activities he has been taught to
perform.
o Option D: Assessing for redness and swelling (signs
of deep venous thrombosis {DVT}) requires additional
education and is still appropriate to the professional
nurse.
2. Question
The patient who had a stroke needs to be fed. What instruction
should you give to the nursing assistant who will feed the
patient?
o A. Position the patient sitting up in bed before
you feed her.
o B. Check the patient’s gag and swallowing reflexes.
, o C. Feed the patient quickly because there are three more
waiting.
o D. Suction the patient’s secretions between bites of
food.
Correct Answer: A. Position the patient sitting up in bed
before you feed her.
Positioning the patient in a sitting position decreases the risk of
aspiration.
o Option B: The nursing assistant is not trained to
assess gag or swallowing reflexes.
o Option C: The patient should not be rushed during
feeding.
o Option D: A patient who needs to be suctioned
between bites of food is not handling secretions and is
at risk for aspiration. This patient should be assessed
further before feeding.
3. Question
You have just admitted a patient with bacterial meningitis to the
medical-surgical unit. The patient complains of a severe
headache with photophobia and has a temperature of 102.60 F
orally. Which collaborative intervention must be
accomplished first?
o A. Administer codeine 15 mg orally for the patient’s
headache.
o B. Infuse ceftriaxone (Rocephin) 2000 mg IV to
treat the infection.
o C. Give acetaminophen (Tylenol) 650 mg orally to reduce
the fever.
o D. Give furosemide (Lasix) 40 mg IV to decrease
intracranial pressure.
Correct Answer: B. Infuse ceftriaxone (Rocephin) 2000 mg
IV to treat the infection.
,Untreated bacterial meningitis has a mortality rate approaching
100%, so rapid antibiotic treatment is essential.
o Option A: Pain medications may be given after
treating the infection that is most probably causing it.
o Option C: Acetaminophen should be given to
decrease the fever after administering the antibiotics
first.
o Option D: Furosemide will help reduce CNS
stimulation and irritation and should be implemented
as soon as possible.
4. Question
You are mentoring a student nurse in the intensive care unit (ICU)
while caring for a patient with meningococcal meningitis. Which
action by the student requires that you intervene immediately?
o A. The student enters the room without putting on
a mask and gown.
o B. The student instructs the family that visits are
restricted to 10 minutes.
o C. The student gives the patient a warm blanket when
he says he feels cold.
o D. The student checks the patient’s pupil response to
light every 30 minutes.
Correct Answer: A. The student enters the room without
putting on a mask and gown.
Meningococcal meningitis is spread through contact with
respiratory secretions so use of a mask and gown is required to
prevent the spread of the infection to staff members or other
patients. The other actions may not be appropriate but they do
not require intervention as rapidly.
o Option B: The presence of a family member at the
bedside may decrease patient confusion and agitation.
o Option C: Patients with hyperthermia frequently
complain of feeling chilled, but warming the patient is
not an appropriate intervention.
o Option D: Checking the pupil response to light is
appropriate, but it is not needed every 30 minutes and
, is uncomfortable for a patient with photophobia.
Focus: Prioritization
5. Question
A 23-year-old patient with a recent history of encephalitis is
admitted to the medical unit with new-onset generalized tonic-
clonic seizures. Which nursing activities included in the patient’s
care will be best to delegate to an LPN/LVN whom you are
supervising? Select all that apply.
o A. Document the onset time, nature of seizure activity,
and postictal behaviors for all seizures.
o B. Administer phenytoin (Dilantin) 200 mg PO
daily.
o C. Teach the patient about the need for good oral
hygiene.
o D. Develop a discharge plan, including physician visits
and referral to the Epilepsy Foundation.
o E. Gather information about the seizure activity
Correct Answer: B & E
Administration of medications that are not a high risk is included
in LPN education and scope of practice. Collection of data about
the seizure activity may be accomplished by an LPN/LVN who
observes initial seizure activity. An LPN/LVN would know to call
the supervising RN immediately if a patient started to seize.
o Option A: Documentation is a nursing responsibility.
o Option C: Patient education must be accomplished by
the registered nurse because it is within their scope of
practice.
o Option D: Planning of care is a complex activity that
requires RN level education and scope of practice.
6. Question
While working in the ICU, you are assigned to care for a patient
with a seizure disorder. Which of these nursing actions will you
implement first if the patient has a seizure?
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