Nclex- Rn Exam Preparation VERSION 2 REAL EXAM Paper with
100% correct answers 2023 Updated Summer qtr A+
The nurse is providing discharge teaching for the client with leukemia. The client should be told
to avoid:
A. Using oil- or cream-based soaps
B. Flossing between the teeth
C. The intake of salt
D. Using an electric razor
Correct Answer: B. Flossing between the teeth
The client who is immune-suppressed and has bone marrow suppression should be taught not to
floss his teeth because platelets are decreased.
o Option A: Oil or cream-based soap is allowed for leukemia patients because these will
prevent dry skin, which predisposes to skin injury.
o Option C: A healthy amount of salt in the patient’s food is allowed.
o Option D: The use of an electric razor is recommended because it reduces the risk of
injury to the skin that can cause bleeding.
The nurse is changing the ties of the client with a tracheostomy. The safest method of changing
the tracheostomy ties is to:
A. Apply the new tie before removing the old one.
o B. Have a helper present.
o C. Hold the tracheostomy with the nondominant hand while removing the old tie.
o D. Ask the doctor to suture the tracheostomy in place.
Correct Answer: A. Apply the new tie before removing the old one.
Leaving the old ties in place while securing the clean ties prevents inadvertent dislodging of the
tracheostomy tube.
o Option B: Having a helper is good, but the helper might not prevent the client from
coughing out the tracheotomy.
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o Option C: Hold the tracheostomy with the nondominant hand while removing the old tie
is not the best way to prevent the client from coughing out the tracheotomy.
o Option D: Asking the doctor to suture the tracheostomy in place is unnecessary.
• 3. Question
The nurse is monitoring a client following a lung resection. The hourly output from the chest
tube was 300mL. The nurse should give priority to:
A. Turning the client to the left side
B. Milking the tube to ensure patency
C. Slowing the intravenous infusion
D. Notifying the physician
Correct Answer: D. Notifying the physician
The output of 300 mL is indicative of hemorrhage and should be reported immediately.
o Option A: Turning the client to the left side does nothing to help the client.
o Options B and C: Milking the tube is done only with an order and will not help in this
situation, and slowing the intravenous infusion is not an appropriate action.
• 4. Question
The infant is admitted to the unit with tetralogy of fallot. The nurse would anticipate an order for
which medication?
o A. Digoxin
o B. Epinephrine
o C. Aminophylline
o D. Atropine
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Correct Answer: A. Digoxin
The infant with Tetralogy of Fallot involves four heart defects: A large ventricular septal defect
(VSD), Pulmonary stenosis, Right ventricular hypertrophy and, An overriding aorta. He will be
treated with digoxin to slow and strengthen the heart.
o Option B: One of the side effects of epinephrine is the pounding, fast, or irregular
heartbeat, which is detrimental to a patient with Tetralogy of Fallot.
o Option C: Increased or rapid heart rate is an adverse effect of aminophylline and should
be avoided for a patient with Tetralogy of Fallot.
o Option D: Atropine prevents or abolishes bradycardia.
• 5.
The nurse is educating the lady’s club in a self-breast exam. The nurse is aware that most
malignant breast masses occur in the Tail of Spence.
On the diagram below, select where the Tail of Spence is.
o A
o B
o C
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o D
Correct Answer: A.
The Tail of Spence is located in the upper outer quadrant of the breast.
Option B: Option B is the areola, a dark area of skin surrounding the nipple.
• 6. Question
The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a
ventricular septal defect will:
o A. Tire easily
o B. Grow normally
o C. Need more calories
o D. Be more susceptible to viral infections
Correct Answer: A. Tire easily
The toddler with a ventricular septal defect will tire easily. The hole (defect) occurs in the wall
(septum) that separates the heart’s lower chambers (ventricles) and allows blood to pass from the
left to the right side of the heart. The oxygen-rich blood then gets pumped back to the lungs
instead of out to the body, causing the heart to work harder.
o Options B and C: He will not grow normally but will not need more calories.
o Option D: He will be susceptible to bacterial infection, but he will be no more susceptible
to viral infections than other children.
• 7. Question
The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a
nonstress test can be ordered for this client to:
o A. Determine lung maturity
o B. Measure the fetal activity
o C. Show the effect of contractions on fetal heart rate
o D. Measure the wellbeing of the fetus
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