NCLEX-RN Practice Test Questions

Go to Question #1 of the NCLEX-RN Practice Test

NCLEX-RN Practice Test Questions The NCLEX examination should not be taken lightly; if it were easy to pass…everyone would do it, right? It is a rather tough comprehensive examination related to the huge amount of information you are expected to know from your nursing school courses and clinical experiences. There will be questions that immediately ring a bell…and then there will be some you’ll hardly ever remember ever discussing. There really is no guaranteed way of studying that will result in your success for the NCLEX your first go around, it will be tricky to remember all that information! However, practicing a few NCLEX questions on a daily basis is a good habit to form starting from the very beginning of nursing school…do not wait until the last minute to study and cram. The following NCLEX practice questions we have prepared for you will be an extremely great way to study in order to get you on the right track to be prepared for your big exam!

The process of administering the NCLEX examination has been modified from how it used to be and we have technology to thank for that. The improved NCLEX examination now follows the method that is referred to as a Computerized Adaptive Test (CAT). CAT is a new and improved way of administering the examination that merges computer technology with modern measurement theory, with the main goal of increasing the efficiency of the entire exam process for each and every candidate.

With use of the CAT method here is essentially what happens:

  • Every time an exam question is answered, the computer system will re-estimate the ability of that specific candidate based on all their previous answers along with the level of difficulty of the items that they have been presented with so far.
  • The computer then will select the next test question that you should have a 50% chance of answering correctly based on the ability of each and every candidate.
  • This method works to ensure that each question you are given is not too easy or too hard, but rather based solely upon your ability as measured by the CAT system and what you should be expected to know in order to perform as a competent nurse.
  • Each question you are asked during your exam will target your knowledge level, so each time you answer a question the estimate of your ability will become more and more precise to ultimately determine your final result on how well you do on the NCLEX, which is either pass or fail.

At this point you should be aware of what to expect leading up to your NCLEX exam, as well as on the day of your exam!  It only makes sense that the NCLEX is intimidating because it is important that professionals who have chosen to be responsible for the lives of others on a daily basis are competent in all areas of nursing in order to deliver the most optimal care without errors.  Take this time now to study the questions below in order to be prepared to ace your NCLEX the first time and get that “RN” behind your name that you have always dreamed of!

1. An elderly patient is found lying on the floor of his hospital room. The patient was on fall precautions. Which of the following actions is most appropriate for the nurse to take first in this situation?

A. Assess the patient for any injuries
B. Notify the patient’s physician
C. Ask another staff member to assist you to get the patient back into bed
D. Ask the patient why he tried to get up without assistance

Question 1: Correct Answer and Rationale
Correct Answer: A
Using the nursing process, the first action the nurse should carry out is to completely assess the patient for injuries and any other changes in their condition in order to provide any nursing interventions that may be needed, such as applying pressure to bleeding, immobilizing a possible broken joint, etc. The nurse should definitely notify the patient’s physician, however it is not the first action that should be taken. The nurse should also seek assistance for help in getting the patient back into bed for the safety of both the patient and staff, but this is not the first action that should be taken either. Finally, it is always important to determine why the patient got out of bed without assistance in order to implement new interventions that may help to prevent future falls, but it is not the initial action the nurse should take.

 

2. A staff registered nurse (RN) is preparing to insert an IV for patient that has been ordered to have morphine 10mg IVP. Using time management skills, which of the following actions should the RN take first?

A. Enter the room and perform hand hygiene
B. Explain the procedure to the patient
C. Mentally go over the procedure when collecting supplies before entering the room
D. Eject excess medication from the prefilled syringe

Question 2: Correct Answer and Rationale
Correct Answer: C
The initial action the RN should take is to mentally think over the procedure to ensure that she has all of the supplies that are going to be needed, this way she will be able to avoid wasting time by having to make more trips to get supplies. Hand hygiene should be performed upon entrance to the room; this should not be the very first action. The RN should explain the procedure to the patient immediately prior to performing the task and inserting the IV, this should not be the first action. Once the IV is inserted and patent, the RN should eject/waste any excess medication from the prefilled syringe if needed, so the patient receives the correct amount, so this would also not be the first action.

 

3. An RN on a medical-surgical unit is in charge of making nurse-patient assignments at the beginning of the shift. Which task should the nurse delegate to the licensed practical nurse (LPN)?

A. Instructing a patient on how to perform wound care
B. Obtaining vital signs on a patient who is 2 hours post-operative after a cardiac catheterization
C. Administration of 1 unit of fresh frozen plasma (FFP)
D. Developing a care plan for a newly admitted patient

Question 3: Correct Answer and Rationale
Correct Answer: B
It is within the scope of practice of the LPN to monitor a patient who is 2 hours post-op after a cardiac catheterization, so she can get their vital signs and record them. The RN is responsible for any patient education, whereas an LPN can only reinforce patient education. The RN is responsible for administering blood components; it is not within the scope of the LPN. The RN is the one responsible for developing a care plan for a new admission to the unit, whereas it is within the scope of practice for an LPN to only suggest additions to the care plans.

 

4. As a nurse, you are preparing to transfer an adult patient who is 72 hours postoperative from surgery, back to a long-term care facility. Which of the following should you include in the transfer report? (Select all that apply).

A. Patient’s vital signs on the day of admission
B. Patient’s medical diagnosis
C. Type of anesthesia that was used
D. Patient’s advance directive status
E. Any needs for special equipment

Question 4: Correct Answer and Rationale
Correct Answer: B, D, E
The nurse giving transfer report should only include information that is pertinent and that the following nurse at the next facility will need in order to provide the best care. Vital signs on the day of admission are not pertinent, rather the most recent vital signs would be. The type of anesthesia that was used is not pertinent for the transfer report at this point either, unless there were complications. What the patient has been diagnosed with is pertinent in order to adjust care, along with the code status of the patient, and if there is any special equipment that the long-term facility will need in order to provide the best care.

 

5. An RN is attending an interprofessional conference for a patient who has sustained a recent C6 spinal cord injury. The patient was a construction worker. Which of the following members of the healthcare team should also participate in planning care for this patient? (Select all that apply).

A. Psychologist
B. Vocational counselor
C. Speech therapist
D. Physical therapist
E. Occupational therapist

Question 5: Correct Answer and Rationale
Correct Answer: A, B, D, E
The patient will need the assistance of a psychologist in order to adapt to any psychological impacts the injury has caused due to being so active immediately prior to the accident and all that being taken away so quickly. The patient will also need assistance from a vocational counselor in order to explore any options for reemployment in the future. A speech therapist will not be needed because speech and/or swallowing problems will not be anticipated for this patient. A physical therapist will need to attend the conference because they will be the ones to assist the patient with mobility skills and help to maintain muscle strength. Finally, an occupational therapist will also be needed so the patient can learn how to perform their activities of daily living again with possible deficits.

 

6. The RN has taken over care for a patient and their condition is declining. Upon reviewing their medical records, the nurse notices that the patient’s do not resuscitate (DNR) order has expired. Which of the following actions should the nurse take in this situation?

A. Anticipate that CPR will be initiated should the patient go into cardiac arrest
B. Call the physician to determine whether the order should be reinstated immediately
C. Assume that the patient does not want to be resuscitated and take no action should cardiac arrest occur
D. Write a note on the front of the physician order sheet asking for the DNR to be reordered

Question 6: Correct Answer and Rationale
Correct Answer: B
The nurse should immediately call the physician in order to determine whether or not the order should be reinstated, which is the action that should be taken to ensure the patient’s wishes are carried out. Without a current DNR order, the nurse must initiate emergency resuscitation, which most likely would not be consistent with the patient’s wishes. In addition, without a current DNR order, writing a note on the physician order sheet will likely delay resolving the problem at hand.

 

7. A newly licensed nurse is preparing to start an IV. Which of the following sources should the nurse use in order to best review the procedure and the standard at which it should be performed?

A. A more experienced nurse
B. Web site explaining the task
C. State nurse practice act
D. Institutional policy and procedure manual

Question 7: Correct Answer and Rationale
Correct Answer: D
The policy and procedure manual will provide instructions on how to perform the procedure that is consistent with established standards; therefore the nurse should use this resource first. A more experienced nurse on the unit may not perform the task according to the policy and procedure. A web site may not provide consistent information in order to correctly do the task. The nurse practice act identifies a scope of practice and other aspects of the law, but it does not set standards for performing a task.

 

8. A nurse observes a nursing assistant reprimanding a patient for not using the urinal properly. The nursing assistant threatens to put a brief on the patient if he does not use the urinal more carefully next time. Which tort is the nursing assistant committing?

A. Assault
B. Battery
C. Invasion of privacy
D. False imprisonment

Question 8: Correct Answer and Rationale
Correct Answer: A
Assault is conduct that makes a person fear that he or she will be harmed. Battery is the actual physical contact without a person’s consent that could possibly cause harm. Invasion of privacy is the unauthorized release of a patient’s private information. False imprisonment is when a patient is restrained against their will, including use of both physical and chemical restraints, and refusing to allow a patient to leave a facility.

 

9. A nursing assistant reports that the blood sugar of a patient was 58 mg/dL a half hour before lunch. The patient’s morning blood sugar was 285 mg/dL. The patient is observed to be asymptomatic at this time despite their low blood sugar result, plus the next dose of insulin is scheduled to be administered at this time. Which of the following actions should the nurse take first?

A. Phone the laboratory in order to obtain a STAT serum glucose level
B. Recalibrate the glucometer and recheck the blood sugar
C. Inform the nursing assistant to go ahead and give the patient 120 mL of orange juice
D. Administer the insulin as ordered

Question 9: Correct Answer and Rationale
Correct Answer: B
Due to the blood sugar being 285 mg/dL just a few hours prior to this reading, it is unlikely that it has dropped to 58 mg/dL at this time. Therefore, the first thing the nurse should do herself should be to recalibrate the glucometer and obtain another reading before taking any other actions. Calling the laboratory to obtain a STAT serum glucose level may be unnecessary right at this moment and could even add cost to the patient’s care. The nurse should refrain from allowing the nursing assistant to give the patient orange juice because it is unlikely that the blood glucose is low enough at this time. Also, before administering insulin, an accurate blood sugar reading needs to be obtained.

 

10. A nurse finds out that a patient was administered an antihypertensive medication in error. Arrange the following actions in the appropriate order that the nurse should follow in this situation.

A. Complete an incident report
B. Notify the risk manager
C. Monitor the vital signs
D. Call the patient’s physician
E. Instruct the patient to remain in bed until further notice

Question 10: Correct Answer and Rationale
Correct Answer: C, E, D, A, B
In this situation the nurse should first monitor the patient’s vital signs to see how the medication has affected the blood pressure. Then, the nurse should educate the patient to remain in bed in order to prevent falls should they get up and experience any dizziness. Next, the nurse should phone the physician and explain the situation with the most recent blood pressure value. Once the physician is notified, the nurse and complete an incident report that is very thorough and accurate. Finally, the incident should be reported to the risk manager.

 

11. A community is experiencing an outbreak of meningitis, and hospital beds are in urgent need. Which of the following patient should the charge nurse recommend for discharge?

A. 70 year old admitted 24 hours prior with pneumonia and dehydration
B. 65 year old female who sustained a fall with a hip fracture, who is schedule for hip replacement the next day
C. 50 year old with type 2 diabetes admitted for rotator cuff surgery
D. 58 year old male admitted 12 hours ago with angina and a history of CABG 1 year ago

Question 11: Correct Answer and Rationale
Correct Answer: C
This patient is stable and can be safely discharged at this time. The 70 year old patient is unstable and at risk for complications such as fluid volume deficit and cannot be safely discharged. The 65 year old patient is also unstable, and discharge would place her more at risk for causing further damage to her hip. Finally, the 58 year old is at risk for a cardiac event, discharging him would not be safe at this time.

 

12. A nurse is educating a patient who is taking iron supplements about what other foods aid in its absorption into the body. Which of the following food choices made by the patient would indicate that they understood the teaching?

A. Green beans
B. Orange juice
C. Milk
D. Baked potato

Question 12: Correct Answer and Rationale
Correct Answer: B
Vitamin C aids in the absorption of iron, and orange juice is a great source of vitamin C. Green beans, milk and baked potatoes do not aid in iron absorption.

 

13. A nurse is caring for a patient who routinely takes warfarin (Coumadin). Which of the following food choices should the nurse advise the patient to limit in their diet?

A. Ice cream
B. Broccoli
C. Orange juice
D. Chicken

Question 13: Correct Answer and Rationale
Correct Answer: B
Broccoli is a green leafy vegetable and is a good source of vitamin K. The patient should avoid excess consumption of vitamin K because in excess it has a negative response to the effects of warfarin. Ice cream, orange juice and chick do not effect coagulation.

 

14. A nurse is teaching a nutritional class on minerals and electrolytes. Which of the following food sources would provide the best amounts of magnesium when consumed?

A. Canned soup
B. Yogurt
C. Nuts
D. Tomatoes

Question 14: Correct Answer and Rationale
Correct Answer: C
Of the foods listed, nuts are the best source of magnesium and should be included in the diet if needed. Canned soup contains sodium, yogurt would be a good source of calcium, and tomatoes are a good source of potassium.

 

15. Which of the following clinical findings are associated with hypothyroidism?

A. Diarrhea
B. Increased heart rate
C. Decreased metabolic demand
D. Weight loss

Question 15: Correct Answer and Rationale
Correct Answer: C
Hypothyroidism will most likely decrease the metabolic demand of your body, making all the processes slower than normal. Diarrhea, increased heart rate and weight loss would most likely be signs of hyperthyroidism.

 

16. Which of the following medications should the nurse be aware of that decreases the body’s rate of metabolism?

A. amitriptyline
B. prednisone
C. somatropin
D. levothyroxine

Question 16: Correct Answer and Rationale
Correct Answer: A
Amitriptyline is a tricyclic antidepressant used for treating depression and decreases that body’s rate of metabolism. Prednisone is a glucocorticoid that is used for suppressing the immune system and inflammation; therefore it increases the metabolic rate. Somatropin is used as a growth hormone and increases the metabolic rate. Levothyroxine is used for the treatment of hypothyroidism and increases the metabolic rate.

 

17. A nurse is calculating BMI for a number of patients. Which of the following BMI results indicates an overweight patient?

A. 27
B. 30
C. 24
D. 32

Question 17: Correct Answer and Rationale
Correct Answer: A
Overweight is defined as an increased body weight in relation to height, indicated by a BMI of 25 to 29.9. Obesity is an excess amount of body fat indicated by a BMI greater than or equal to 30. Normal/healthy weight is indicated by a BMI of 18.5 to 24.9.

 

18. A nurse is teaching a nutritional class to a group of females. Which of the following should the nurse include as risk factors for developing osteoporosis? (Select all that apply).

A. Obesity
B. Cigarette smoking
C. Family history
D. Inactivity
E. Hyperlipidemia

Question 18: Correct Answer and Rationale
Correct Answer: B, C, D
Cigarette smoking may increase the risk of osteoporosis. Also, osteoporosis tends to run in families and tends to occur more in those who are inactive. Weight-bearing exercises should be discussed as primary prevention measures to decrease their risk. Weight loss, instead of obesity, can lead to a decreased intake of dietary calcium and vitamin D leading to development of osteoporosis. Hyperlipidemia is not a risk factor.

 

19. You are caring for a patient who has a urinary tract infection (UTI). The patient reports pain and a sensation of burning upon urination, along with cloudy urine with an odor. Which of the following would be your priority intervention as the nurse?

A. Offer a warm sitz bath
B. Administer an antibiotic
C. Encourage increased fluids
D. Recommend to the patient they should drink cranberry juice

Question 19: Correct Answer and Rationale
Correct Answer: B
The greatest risk to the patient at this time is injury to their renal system from the UTI. Therefore, the most important intervention would be to give an antibiotic ASAP.Offering a warm sitz bath and encouraging increased fluids will provide only temporary relief. In addition, drinking cranberry juice may help to prevent a UTI in the future.

 

20.You are admitting a patient with a kidney stone. Which of the following findings would you expect to note in your assessment?

A. Bradycardia
B. Nocturia
C. Bradypnea
D. Diaphoresis

Question 20: Correct Answer and Rationale
Correct Answer: D
Diaphoresis is a manifestation that is noted with a patient with a kidney stone. Other symptoms you will see would be the opposite of the other choices and would include: tachycardia, oliguria, and tachypnea.

 

21. During your completion of discharge instructions with a patient who has passed a calcium oxalate stone, which of the following food choices should you instruct them to avoid in the future? Select all that apply.

A. Red meat
B. Black tea
C. Cheese
D. Whole grains
E. Spinach

Question 21: Correct Answer and Rationale
Correct Answer: B, E
Both black tea and spinach contain calcium oxalate and should be avoided for prevention of this type of kidney stone. Red meat, cheese, and whole grains contain magnesium ammonium phosphate and donot need to be avoided in this situation.

 

22. You are providing instructions to your patient prior to a mammogram. Which of the following should you instruct your patient to avoid prior to their procedure?

A. Deodorant
B. Multivitamin
C. Sexual intercourse
D. Exercise

Question 22: Correct Answer and Rationale
Correct Answer: A
Application of deodorant or powder can cause a shadow to appear when the mammogram is done.Taking a multivitamin, having sexual intercourse, and exercising does not alter accuracy of a mammogram.

 

23. You are reviewing the medical record of your patient with premenstrual syndrome (PMS). Which of the following medications are used to treat PMS? (Select all that apply).

A. fluoxetine
B. spironolactone
C. ethinyl estradiol/drospirenone
D. ferrous sulfate
E. methylergonovine

Question 23: Correct Answer and Rationale
Correct Answer: A, B, C
Fluoxetine is an SSRI that is used to treat the emotional symptoms of PMS (irritability & mood swings), plus it can also treat physical symptoms. Spironolactone is a diuretic that can reduce bloating and weight gain that accompanies PMS. Oral contraceptives that contain drospirenone help to reduce symptoms of PMS.Oral iron supplements are only used to treat anemia related to dysfunctional bleeding and methylergonovine is used to treat postpartum hemorrhage.

 

24. It is up to you to provide support to your patient who has a recent diagnosis of endometriosis. You should reinforce to your patient that which of the following conditions is a complication of endometriosis?

A. Insulin resistance
B. Pelvic inflammatory disease (PID)
C. Infertility
D. Vaginitis

Question 24: Correct Answer and Rationale
Correct Answer: C
Infertility is a complication because overgrowth of endometrial tissue can block the fallopian tubes. Insulin resistance is a complication of polycystic ovary syndrome, vaginitis is usually caused by an infection, and PID is caused by an infection of the pelvic organs.

 

25. The nurse is assessing a patient who has a cast on his arm due to a compound fracture. Which of the following findings is an early indication of neurovascular compromise?

A. Pallor
B. Paralysis
C. Paresthesia
D. Pulselessness

Question 25: Correct Answer and Rationale
Correct Answer: C
Paresthesia is an early sign of neurovascular compromise that may even suggest compartment syndrome. Pulselessness, paralysis and pallor are late signs, all of which suggest compartment syndrome.

 

26. An ER nurse is planning care for a patient who has a left hip fracture. Which of the following devices should the nurse anticipate for immobilization?

A. Skeletal traction
B. Buck’s traction
C. Halo traction
D. Gardner-Wells traction

Question 26: Correct Answer and Rationale
Correct Answer: B
Buck’s traction is a temporary immobilization device applied in order to decrease muscle spasms and immobilize the extremity until surgery is done. Skeletal traction is applied surgically to long bone fractures. Halo traction immobilizes the cervical spine. Gardner-Wells traction uses tongs to immobilize and realign the cervical spine.

 

27. Your patient has osteoarthritis (OA) of their knees and fingers. Which manifestations should you expect to find during your admission assessment? (Select all that apply).

A. Limp when walking
B. Heberden’s nodes
C. Enlarged joints
D. Swelling of all joints
E. Small body frame

Question 27: Correct Answer and Rationale
Correct Answer:A, B, C
Heberden’s nodes are enlarged nodules on the distal interphalangeal joints of the hands and feet in OA. Enlarged joints may be observed due to bone hypertrophy. Patient may limp when they walk from the pain and inflammation in the localized joint.Swelling and pain of all joints along with having a small body frame both can beassociated with rheumatoid arthritis (RA) instead.

 

28. You are providing teaching to your patient related to a new prescription for methotrexate for severe psoriasis. Which of the following pieces of information should you be sure to include?

A. Drink a glass of wine daily
B. Monitor for evidence of infection
C. Monitor kidney function tests regularly
D. Expect increased bruising

Question 28: Correct Answer and Rationale
Correct Answer: B
You should be sure to instruct the patient to monitor themselves for infection, such as by watching for fever and/or sore throat. Methotrexate can cause blood dyscrasias, such as a decrease in the white blood cells, which would lead to a decrease in them being able to fight off infections.Patient should not drink alcohol because it could cause liver damage when consumedwith this medication. Liver function tests should be frequently monitored rather than kidney function tests. Patients should not expect increased bruising, rather they should report any increase in bruising because methotrexate can cause blood dyscrasias, such asthrombocytopenia.

 

29. Your patient has Seborrheic keratosis on the forehead and nose. Upon your assessment which characteristics of this condition should you expect to observe? (Select all that apply).

A. Waxy appearance of the lesions
B. Black, rough lesions
C. Pruritus of the lesions
D. Purplish skin stain around the lesions
E. Wart-like surface of the lesions

Question 29: Correct Answer and Rationale
Correct Answer: A, B, E
Seborrheic keratosis lesions appear waxy in texture. They are tan, brown or black in color that are rough and become irritated due to friction. A wart-like surface is also common and generally the lesions are removed for cosmetic reasons. Seborrheic keratosis may become irritated but they are not pruritic, and the lesions do not have a purplish stain around them.

 

30. Which of the following is the proper classification of a burn if your patient presents with a severe sunburn?

A. Superficial
B. Full-thickness
C. Superficial partial-thickness
D. Deep partial-thickness

Question 30: Correct Answer and Rationale
Correct Answer: A
Sunburn is superficial because it causes damage to only the top layer of skin. A superficial partial-thickness burn can be caused by a flame and will damage the entire epidermis. A deep partial-thickness burn can be caused by a grease burn, which affects the deep layers of this skin. A full-thickness burn can be caused by tar, which will affect the dermis and sometimes even down into the subcutaneous fat.

 

31. You are preparing to administer fentanyl to a patient who was admitted 24 hours ago following deep partial-thickness and full-thickness burns to over 60% of the body. You should plan to use which route to give this medication?

A. Transdermal
B. Subcutaneous (SQ)
C. Intravenous (IV)
D. Intramuscular (IM)

Question 31: Correct Answer and Rationale
Correct Answer: C
The IV route is used to give pain medication to a patient who has a major burn during the emergent phase. Once IV access is established, it is the most rapid way in which patients will experience pain relief. SQ and IM injections should be avoided due to risk of infection. The transdermal route should not be used due to the amount and risk of tissue damage.

 

32. Another nurse is taking care of a patient with diabetes insipidus (DI). Which of the following urinalysis findings should the nurse expect to find?

A. Absence of glucose
B. Decreased specific gravity
C. Presence of ketones
D. Presence of red blood cells (RBCs)

Question 32: Correct Answer and Rationale
Correct Answer: B
The urine of a patient with DI will be dilute with a specific gravity of less than 1.005. A patient with DI would be expected to have glucose in their urine. Ketones and RBCs being present in the urine is rather indicative of diabetes mellitus instead of DI.

 

33. When reviewing the characteristics of hyperthyroidism with peers, which of the following should the nurse make sure to include? (Select all that apply).

A. Dry skin
B. Intolerance to heat
C. Constipation
D. Palpitations
E. Weight loss
F. Bradycardia

Question 33: Correct Answer and Rationale
Correct Answer: B, D, E
Hyperthyroidism increases metabolism in a patient, so heat intolerance is expected along with palpitations, weight loss and moist skin. Constipation, dry skin and bradycardia would rather be found in hypothyroidism.

 

34. You are caring for a patient who has a prescription for levodopa (Sinemet). Which of the following should you advise her to limit in her diet?

A. Tyramine
B. Vitamin C
C. Magnesium
D. Vitamin B6

Question 34: Correct Answer and Rationale
Correct Answer: D
Vitamin B6 should be limited because it increases the metabolism of levodopa which decreases its therapeutic effects. Tyramine should be limited for a patient taking an MAOI, due to causing an increase in blood pressure. Vitamin C should be limited for a patient taking proton pump inhibitors, which can affect how effective the medication is. Calcium should not be limited ever, unless the patient is allergic.

 

35. Another nurse is caring for a patient who experienced a cervical spine injury 24 hours ago. Which of the following types of prescribed medications should that nurse clarify with the physician?

A. Muscle relaxants
B. Glucocorticoids
C. H2 antagonists
D. Plasma expanders

Question 35: Correct Answer and Rationale
Correct Answer: A
The patient will still be in spinal shock 24 hours after the injury has occurred. The patient will not experience muscles spasms until after the spinal shock has resolved. Therefore, muscle relaxants at this time would not be necessary. All of the other prescribed medications would be appropriate to administer during this time period.

 

36.A nurse is assessing a client who is in respiratory distress. She should recognize that which of the following may cause a low pulse oximetry reading? (Select all that apply).

A. Nail polish
B. Inadequate peripheral circulation
C. Hyperthermia
D. Increased Hgb level
E. Edema

Question 36: Correct Answer and Rationale
Correct Answer: A, B, E
Nail polish, inadequate peripheral circulation and edema can all result in a low reading while obtaining a pulse oximetry level. Hypothermia and a decreased Hgb level would result in low readings, which are the opposites of the choices listed in the question.

 

37. Your assignment for the shift includes assessing a patient following a bronchoscopy. Which of the following findings should you report to the physician?

A. Bronchospasms
B. Sore throat
C. Blood-tinged sputum
D. Dry, nonproductive cough

Question 37: Correct Answer and Rationale
Correct Answer: A
Bronchospasms should indicate to the nurse that the patient is having difficulty breathing and maintaining a patent airway. The physician should be notified immediately. A sore throat, blood-tinged sputum and a dry, nonproductive cough are all normal following a bronchoscopy.

 

38. Which of the following manifestations would be expected if your patient was suspected to have Meniere’s disease?

A. Unilateral hearing loss
B. Bilateral tympanic membranes observed to be red & bulging.
C. A purulent lesion in the external ear canal
D. Recent history of traveling in an airplane

Question 38: Correct Answer and Rationale
Correct Answer: A
Unilateral sensorineural hearing loss is a clinical finding in Meniere’s disease. Meniere’s disease is an inner ear disorder. A purulent lesion in the external ear canal is not an expected finding. Bilateral tympanic membranes that appear red and bulging are associated with a middle ear infection. Changes in air pressure due to traveling in an airplane would affect the middle ear.

 

39. Your patient has just been admitted following surgical evacuation of a subdural hematoma. Which of the following would you carry out as your priority assessment of their condition?

A. Pupillary response
B. Cranial nerve function
C. Glasgow Coma Scale
D. Oxygen saturation

Question 39: Correct Answer and Rationale
Correct Answer: D
In this situation you would use the airway, breathing, circulation (ABC) method to establish your priorities. Assessment of oxygen saturation would be the priority action, because brain tissue can only survive for 3 minutes before permanent damage begins to occur. All the other actions are important but are not priority immediately upon admission.

 

40. Which of the following assessment findings would indicate an increased intracranial pressure (ICP) in your patient who has sustained a gunshot wound to the head? (Select all that apply).

A. Headache
B. Hypotension
C. Dilated pupils
D. Decorticate posturing
E. Tachycardia

Question 40: Correct Answer and Rationale
Correct Answer: A, C, D
A headache, dilated pupils, and decorticate or decerebrate posturing are all findings of an increased ICP. Bradycardia and hypertension would also be signs of an increased ICP, not tachycardia and hypotension.

 

41. You are caring for a patient who has an increased ICP and the physician just prescribed mannitol (Osmitrol). Which of the following adverse effects should you be aware to monitor for when administering mannitol?

A. Hyperglycemia
B. Hyponatremia
C. Hypervolemia
D. Oliguria

Question 41: Correct Answer and Rationale
Correct Answer: B
Mannitol is a powerful osmotic diuretic & adverse effects include electrolyte imbalances such as hyponatremia. Hyperglycemia is not an adverse effect of mannitol. Hypovolemia is an adverse effect and should be monitored. Polyuria is also an adverse effect that should be monitored.

 

42. Which of the following assessment findings would be expected if your patient has experienced a left-hemispheric stroke?

A. Difficulty with impulse control
B. Poor judgment
C. Loss of depth perception
D. Inability to recognize familiar objects

Question 42: Correct Answer and Rationale
Correct Answer: D
If a patient has had a left-hemispheric stroke, they will demonstrate an inability to recognize familiar objects, which is also known as Agnosia. All the other findings would be associated with a right-hemispheric stroke.

 

43. A physician has order a patient to receive furosemide 8 mg/kg via IV push Q6h. Medication label reads 500mg/5mL. How many mL will you prepare if the patient weighs 56 kg?

Question 43: Correct Answer and Rationale
Correct Answer: 4.48 mL

 

44. A nurse on the unit is having trouble getting a patient aroused following an esophagogastroduodenoscopy (EGD). Which of the following is the priority action by the nurse?

A. Evaluate the laboratory findings from before the EGD
B. Allow the patient to sleep
C. Assess the patient’s airway
D. Increase the rate of IV fluid administration

Question 44: Correct Answer and Rationale
Correct Answer: C
Using the ABC priority-setting framework (Airway, Breathing, Circulation), the priority intervention in this situation would be the patient’s airway maintenance. Evaluation of the laboratory results prior to the procedure is important, but it is not the priority. Allowing the patient to rest and increasing the rate of the IV are also important, but both are not priority actions.

 

45. A nurse is educating a patient about a fecal occult blood test, which requires obtaining three stool specimens. Which of the following statements by the patient indicates an understanding of the teaching?

A. “I’m glad I don’t have to follow any special diet at this time.”
B. “I will continue taking my Coumadin while I complete these tests.”
C. “This test determines if I have parasites in my bowel.”
D. “This is an easy way to rule out having colon cancer.”

Question 45: Correct Answer and Rationale
Correct Answer: D
Fecal occult blood testing is a screening procedure for colon cancer. Patients are instructed to avoid consuming red meat prior to obtaining stool specimens for fecal occult blood testing because this can interfere with the results. Patients are also instructed to stop taking their Coumadin and other anti-coagulants prior to obtaining these stool specimens because it can also interfere with the results. These tests do not identify any parasites present in the stool.

 

46. An RN is caring for a patient who had a paracentesis. Which of the following findings during her assessment would indicate that the bowel was perforated during the procedure?

A. Pallor
B. Elevated temperature
C. Complaint of upper chest pain
D. Decreased urinary output

Question 46: Correct Answer and Rationale
Correct Answer: B
Fever is an indication of bowel perforation that could have happened during a paracentesis. Pallor, or pale skin, is not an indication of a perforated bowel. A report of sharp, constant abdominal pain would be associated with a perforated bowel. Finally, decreased urinary output would be associated with a perforated bladder.

 

47. A nurse is admitting a patient who has bleeding esophageal varices. The nurse should anticipate a physician order for which of the following medications?

A. ranitidine
B. terlipressin
C. propranolol
D. Metoclopramide

Question 47: Correct Answer and Rationale
Correct Answer: B
Terlipressin constricts blood vessels and is used to treat bleeding esophageal varices, so there should be an order for this medication. Most likely, ranitidine would be administered only following a surgical procedure for bleeding esophageal varices. Propranolol is not used for patients who are actively bleeding; however it may be given prophylactically to decrease portal hypertension. Metoclopramide works to decrease the motility of the esophagus and stomach.

 

48. A nurse is educating a patient who has a new diagnosis of pernicious anemia due to chronic gastritis. Which of the following should be included in the education?

A. A monthly injection of a medication will be required
B. Increased production of intrinsic factor is occurring
C. Cells producing gastric acid have been damaged
D. Vitamin K supplements will be administered

Question 48: Correct Answer and Rationale
Correct Answer: A
A monthly injection of vitamin B12 will be necessary in order to treat pernicious anemia. Parietal cell damage would result in a decrease in the production of intrinsic factor. Damage to parietal cells has happened, which leads to this condition. Vitamin K supplements would be given to a patient with a bleeding disorder, not pernicious anemia.

 

49. A nurse is performing her assessment on a 6 month old infant. Which of the following reflexes should the infant exhibit?

A. Moro
B. Plantar grasp
C. Stepping
D. Tonic neck

Question 49: Correct Answer and Rationale
Correct Answer: B
The plantar grasp should be observed by infants from birth to 8 months of age. The moro reflex should be observed in infants from birth to 4 months of age. The stepping reflex should be observed by infants from birth to 4 weeks of age. Finally, the tonic neck reflex is exhibited by infants from birth to 3-4 months of age.

 

50. As a nurse, you are caring for a patient that has come into the office requesting a pregnancy test. She tells you that her last menstrual period was on April 8. The final result of the test is positive. Using Nagele’s rule, what will be her estimated date of birth?

A. January 15
B. January 1
C. July 15
D. July 1

Question 50: Correct Answer and Rationale
Correct Answer: A
Nagele’s rule calculates the estimated date of birth by subtracting 3 months, adding 7 days and adjusting the year from the start of the last menstrual period.

 

51. A nurse is assessing a patient who has been taking prednisone following an exacerbation of COPD. Which of the following findings during the assessment would be the highest priority?

A. Blood glucose at 0800 of 140 mg/dL
B. Patient reports a weight gain of 4 pounds in the last 6 months
C. Patient complains of having a sore throat
D. Patient reports insomnia

Question 51: Correct Answer and Rationale
Correct Answer: C
The greatest risk to the patient who is taking prednisone is an infection due to immunosuppression, so this is the priority. The blood glucose in this situation is above the expected reference range and important, but it is not the priority. Weight gain is also important; however it is not the priority. Finally, insomnia is also important but not the biggest concern at this point.

 

52. A patient is diagnosed with an ectopic pregnancy, which of the following medications should the nurse anticipate that the medical provider will order?

A. methylergonovine
B. indomethacin
C. methotrexate
D. betamethasone

Question 52: Correct Answer and Rationale
Correct Answer: C
Methotrexate is prescribed in order to inhibit cell division and enlargement of the embryo in an ectopic pregnancy. Plus, it works to prevent rupture of the fallopian tube. Corticosteroids, such as Betamethasone, are prescribed to stimulate fetal lung development if preterm delivery is expected. Methergine is used to treat postpartum hemorrhage. Indocin is used to treat preterm labor.

 

53. An experienced nurse is discussing the possible causes of variable decelerations with a nurse new to the unit. Which of the following should the experienced nurse include in the teaching? (Select all that apply)

A. Short umbilical cord
B. Polyhydramnios
C. Umbilical cord compression
D. Nuchal cord
E. Uteroplacental insufficiency

Question 53: Correct Answer and Rationale
Correct Answer: A, C, D
Short umbilical cord, umbilical cord compression and nuchal cord are possible causes of variable decelerations. Oligohydramnios, rather than polyhydramnios, would cause variable declerations. Uteroplacental insufficiency would result in late decelerations.

 

54. A nurse in a clinic is reviewing the laboratory reports of a patient who is suspected to have cholelithiasis. Which of the following would be an expected finding?

A. Serum cholesterol 171 mg/dL
B. WBC 9,511/uL
C. Serum albumin 4.1 g/dL
D. Direct bilirubin 2.1 mg/dL

Question 54: Correct Answer and Rationale
Correct Answer: D
The finding of direct bilirubin at 2.1 mg/dL is outside the normal limits and is increased in this particular patient. An expected finding for a patient with cholelithiasis is a serum cholesterol greater than 200 mg/dL. The WBC count is within the normal range and in a patient with cholelithiasis; this level would likely be elevated due to inflammation. The serum albumin level is within normal limits and is not an indicator of cholelithiasis.

 

55. When completing an admission assessment of a patient who has pancreatitis, which of the following should be an expected finding?

A. Pain that is relieved upon defecation
B. Report of pain being worse when sitting upright
C. Epigastric pain that radiates to the left shoulder
D. Pain in the upper right quadrant that radiates to the right shoulder

Question 55: Correct Answer and Rationale
Correct Answer: C
A patient with pancreatitis will report severe, boring epigastric pain that radiates to their back, left flank area and/or left shoulder. A patient with pancreatitis will also report their pain is relieve with vomiting, not defecation. Also, they will state that their pain is worse when lying down or when eating, not when they sit upright.

 

56. The nurse should be aware that which types of hepatitis are transmitted via the fecal-oral route? (Select all that apply).

A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D
E. Hepatitis E

Question 56: Correct Answer and Rationale
Correct Answer: A, E
Both hepatitis A and hepatitis E are spread via the fecal-oral route. Hepatitis B and hepatitis C are both transmitted via blood, and hepatitis D occurs as a co-infection along with hepatitis B.

 

57. A medical-surgical RN has been assigned a patient with hepatitis B who also has ascites. Which of the following actions should the nurse include in the plan of care?

A. Weekly weight of patient
B. Measure abdominal girth 7.5 cm above the umbilicus
C. Initiate contact precautions
D. Provide a high-calorie, high-carbohydrate diet

Question 57: Correct Answer and Rationale
Correct Answer: D
A high-calorie, high-carbohydrate diet is recommended for patients with hepatitis B. Daily weights are obtained in order to monitor fluid status, not weekly weights. Abdominal girth should be measured over the largest part of the abdomen, which varies from patient to patient. Finally, hepatitis B is transmitted via blood; therefore standard precautions will be sufficient.

 

58. A nurse is caring for a patient who has cirrhosis. Which of the following medications can the nurse expect that she will be administering to the patient? (Select all that apply).

A. Diuretic
B. Opioid analgesic
C. Lactulose
D. Sedative
E. Beta-blocker

Question 58: Correct Answer and Rationale
Correct Answer: A, C, E
In cirrhosis, diuretics will facilitate removing excess fluid from the body. Lactulose is ordered for a patient who has cirrhosis in order to eliminate ammonia that has built up in the bloodstream. Beta-blockers are administered to a patient with cirrhosis to prevent any bleeding from varices. Opioid analgesics and sedatives are metabolized in the liver, so they should not be administered to a patient with cirrhosis.

 

59. As a nurse, you are providing education to a patient who is to have an x-ray of the kidneys, ureters and bladder (KUB). Which of the following statements should you definitely include in your teaching?

A. “The procedure will determine whether a kidney stone is present.”
B. “Contrast dye is given during this procedure.”
C. “You will need to lie in a prone position during this procedure.”
D. “An enema will be necessary before your KUB.”

Question 59: Correct Answer and Rationale
Correct Answer: D
A KUB can identify renal calculi, strictures, calcium deposits and/or obstructions. No contrast dye will be used for a KUB. The patient will also not have to have an enema before their exam. Finally, during the KUB you will be asked to lie supine, not prone.

 

60. A nurse in a dialysis clinic is caring for a patient who is receiving hemodialysis and develops disequilibrium syndrome. Which of the following is the most appropriate action by the nurse?

A. Monitor the patient for hypertension
B. Administer an opioid medication
C. Assess the level of consciousness
D. Increase the dialysis exchange rate

Question 60: Correct Answer and Rationale
Correct Answer: C
The nurse should assess the level of consciousness of the patient as a priority because a change in the urea levels can cause increased intracranial pressure, which ultimately will decrease the level of consciousness. This particular patient would be more at risk for hypotension, not hypertension. In this case the nurse should not administer an opioid, however the physician may order a medication to decrease seizure activity instead. The dialysis rate should be decreased if the patient develops disequilibrium syndrome to slow the changes in fluid and electrolyte status.

 

61. You are caring for a patient after a spontaneous vaginal birth. Which of the following hormones should the nurse know decreases after the delivery of the placenta? (Select all that apply).

A. Luteinizing hormone
B. Placental enzyme insulinase
C. Progesterone
D. Estrogen
E. Thyroid stimulating

Question 61: Correct Answer and Rationale
Correct Answer: B, C, D
Estrogen, progesterone and placental enzyme insulinase all decrease after the delivery of the placenta. Whereas, thyroid stimulating hormone and luteinizing hormones are not decreased at that time.

 

62. A nurse is teaching new parents the importance of administering Aquamephyton to their newborn. Which of the following is an appropriate response by the nurse when educating the parents on what this medication will do?

A. “Aquamephyton will provide immunity.”
B. “Aquamephyton will prevent cold stress.”
C. “Aquamephyton will assist with blood clotting.”
D. “Aquamephyton will assist the bowel to mature.”

Question 62: Correct Answer and Rationale
Correct Answer: C
Aquamephyton will assist with blood clotting. Vitamin K, or Aquamephyton, is deficient in newborns because their colon is sterile. In order for vitamin K to be produced, there must be bacteria available. Once a newborn is fed for the first time, bacteria will be produced. Until that point, the newborn will be at risk of hemorrhagic disease because vitamin K is required in order to activate clotting factors. Vitamin K does not carry out the other options listed.

 

63. Which of the following instructions should the nurse include when informing the parents about administering digoxin to their infant?

A. “Do not offer your baby fluids after giving the medication.
B. “Give the correct dose of medication at regularly scheduled times.”
C. “Digoxin increases the heart rate of your baby.”
D. “If your baby was to vomit up a dose, you should repeat it just to make sure he gets the right amount.”

Question 63: Correct Answer and Rationale
Correct Answer: B
“Give the correct dose of medication at regularly scheduled times.” Digoxin can be given without food or fluids. Digoxin will slow the heart rate because it increases contractility of the heart. It is not recommended to repeat a dose if your baby was to vomit because it is virtually impossible to determine how much medication was actually lost.

 

64. Which of the following immunizations should the nurse plan to administer to a 2 month old infant?

A. Inactivated poliovirus (IPV)
B. Rotavirus (RV)
C. Diphtheria, tetanus, pertussis (DTaP)
D. Pneumococcal (PCV)
E. Haemophilus influenza type b (Hib)
F. Hepatitis A (HepA)

Question 64: Correct Answer and Rationale
Correct Answer: B, C, D, E
The other immunizations are administered at different ages throughout childhood.

 

65. During change of shift report a nurse is told that a patient has become stuporous. When doing his assessment, which of the following findings should the nurse expect to observe?

A. Patient has a Glasgow Coma Scale (GCS) score less than 7
B. Patient exhibit decorticate rigidity
C. Patient arouses briefly in response to a sternal rub
D. Patient is alert, but disoriented to place and time

Question 65: Correct Answer and Rationale
Correct Answer: C
A patient who is stuporous requires vigorous or painful stimuli to elicit a response. A GCS score of less than 7 indicates a comatose level of consciousness, rather than stuporous. There will not be abnormal posturing; such as decorticate rigidity, rather this would also be in a comatose patient. Finally, a stuporous client is not alert.

 

66. A nurse is caring for a patient that who smokes and has been diagnosed with lung cancer. The patient states, “I am coughing because I have that cold that everyone has had that’s been going around.” Which of the following defense mechanisms is the patient using?

A. Sublimation
B. Denial
C. Reaction formation
D. Displacement

Question 66: Correct Answer and Rationale
Correct Answer: B
This statement is an example of denial, which is pretending the truth is not reality in order to cope with the anxiety of acknowledging what is real. Sublimation is dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression. Reaction formation is overcompensating or demonstrating the opposite behavior of what is felt. Finally, displacement is shifting feelings related to an object, person, or situation to something less threatening.

 

67. A nurse is performing an assessment of her patient immediately following an electroconvulsive therapy (ECT) procedure. Which of the following should she expect to find? (Select all that apply).

A. Tachycardia
B. Memory loss
C. Paralytic ileus
D. Hypotension
E. Nausea

Question 67: Correct Answer and Rationale
Correct Answer: A, B, E
Transient short-term memory loss, tachycardia and nausea are all expected findings immediately following ECT. Paralytic ileus is not an expected finding of ECT and the blood pressure is expected to be elevated immediately following ECT.

 

68. A psychiatric nurse is leading an educational session about the indications for ECT. Which of the following situations would be appropriate to include in this educational session?

A. Bipolar disorder with rapid cycling
B. Dysthymic disorder
C. Borderline personality disorder
D. Acute withdrawal from substance abuse

Question 68: Correct Answer and Rationale
Correct Answer: A
Of the situations listed, ECT would be indicated for treatment for the patient with bipolar disorder with rapid cycling. ECT has not been found effective for the other patient situations listed above.

 

69. A nurse is caring for a patient who has a history of alcohol abuse. The patient is no longer experiencing withdrawal signs and symptoms. Which of the following medications should the nurse anticipate that she will be administering to the patient to assist them with maintaining abstinence from alcohol use?

A. carbamazepine
B. bupropion
C. chlordiazepoxide
D. disulfiram

Question 69: Correct Answer and Rationale
Correct Answer: D
Disulfiram is given to patients in order to help maintain alcohol abstinence. Carbamazepine and chlordiazepoxide are indicated for acute alcohol withdrawal. Bupropion is indicated for nicotine withdrawal.

 

70. While performing your assessment on a patient who has bulimia nervosa with purging behaviors, which of the following would be an expected finding? (Select all that apply).

A. Mottling of the skin
B. Hypokalemia
C. Slightly elevated body weight
D. Presence of lanugo on the face
E. Amenorrhea

Question 70: Correct Answer and Rationale
Correct Answer: B, C
Patients with bulimia nervosa maintain weight that is within the normal range, or that is just slightly higher. Hypokalemia is also an expected finding of this condition. Mottling of the skin, presence of lanugo, and amenorrhea are all expected findings of anorexia nervosa rather than bulimia.

 

71. A nurse is providing their patient with education on a new prescription called fluoxetine for treatment of generalized anxiety disorder. Which of the following statements indicate that the patient understands the correct use of this medication?

A. “I will be at risk for weight loss with long-term use of this medication.”
B. “I will follow and low-sodium diet while taking this medication.”
C. “I will need to discontinue this medication slowly.”
D. “I will take the medication at bedtime.”

Question 71: Correct Answer and Rationale
Correct Answer: C
When discontinuing fluoxetine, the patient should taper the medication slowly as directed by their physician in order to reduce the risk of withdrawal symptoms. When taking this medication, the patient will be more at risk for weight gain and hyponatremia. Finally, the patient should be instructed to take the medication in the morning to minimize any sleep disturbances that could happen if it is taken at bedtime.

 

72. The labor and delivery nurse should be aware that physiologic jaundice in a newborn is caused by which of the following?

A. Failure of the ductus venosus to close
B. An ABO incompatibility
C. A lack of surfactant
D. An immature liver

Question 72: Correct Answer and Rationale
Correct Answer: D
If a newborn has an immature liver, this causes physiologic jaundice. Physiological jaundice is not associated with failure of the ductus venosus to close. An ABO incompatibility would cause pathologic jaundice instead. Lack of surfactant is not associated with jaundice.

 

78. When caring for a patient with Meniere’s disease, which of the following should the nurse encourage them to limit in their diet to better manage their signs and symptoms?

A. Sugars
B. Fats
C. Salt
D. Carbohydrates

Question 78: Correct Answer and Rationale
Correct Answer: C
Patients with Meniere’s disease should limit their dietary intake of salt to better manage their signs and symptoms. The other foods do not have to be limited in their dietary intake.

 

79. Which of the following electrolytes must be maintained within normal limits constantly while a patient is receiving lithium?

A. Magnesium
B. Sodium
C. Potassium
D. Chloride

Question 79: Correct Answer and Rationale
Correct Answer:B
Sodium must be monitored closely and kept steady at all times when taking lithium. Deviations, even minor ones, from the normal sodium levels can cause toxicity. Lithium dosages are not related to amounts of potassium, chloride or magnesium in the body.

 

80. A nurse is caring for a patient who is taking a newly prescribed medication called phenelzine. Which of the following are adverse effects of this medication that the nurse could possibly observe? (Select all that apply).

A. Elevated blood sugar
B. Priapism
C. Headache
D. Orthostatic hypertension
E. Bruxism

Question 80: Correct Answer and Rationale
Correct Answer: C, D
Both headache and orthostatic hypertension are adverse effects of this medication. An elevated blood sugar is not an adverse effect of phenelezine. Priapism is an adverse effect of trazodone and bruxism is an adverse effect of SSRI’s, not phenelzine.

 

81. A patient has a new prescription for valproic acid. The nurse should inform the patient of the need for routine monitoring of which of the following, in order to ensure the medication is not exerting any negative effects?

A. Serum sodium and potassium
B. Creatinine and BUN
C. AST/ALT and LDH
D. WBC and granulocyte counts

Question 81: Correct Answer and Rationale
Correct Answer: C
AST/ALT and LDH are laboratory tests performed to monitor the liver. These are necessary when patients take valproic acid due to the right for hepatotoxicity. Baseline levels of the other laboratory values may be collected prior to initiating use of valproic acid, however routine monitoring of them are not necessary.

 

82. A nurse is assessing a 4 year old for indications of autism spectrum disorder (ASD). For which of the following indications should the nurse assess for that most relates to that specific disorder?

A. Somatic problems
B. Destructiveness
C. Repetitive counting
D. Impulsive behavior

Question 82: Correct Answer and Rationale
Correct Answer: C
Repetitive actions and strict routines are an indication of ASD. Somatic problems are an indication of PTSD. Destructiveness is an indication of conduct disorder. Impulsive behavior is an indication of ADHD.

 

83. A registered nurse at a community mental health clinic is performing chart reviews of multiple patients. Which of the following situations would be an example of a patient who experienced a maturational crisis?

A. Rape
B. Marriage
C. Loss of a job
D. Severe physical illness

Question 83: Correct Answer and Rationale
Correct Answer: B
Marriage is an example of a maturational crisis, which naturally occurs across the lifespan. Rape is an adventitious crisis, meaning it is not part of everyday life. Loss of a job and having a severe physical illness are both referred to as a situational crisis.

 

84. An emergency room nurse is performing her assessment on a child who is reporting abdominal pain. As the nurse is conducting her head-to-toe assessment, which of the following findings should alert the nurse to possible abuse? (Select all that apply).

A. Abdominal rebound tenderness
B. Areas of ecchymosis on torso
C. Mismatched clothing
D. Abrasions on knees
E. Round burn marks on forearms

Question 84: Correct Answer and Rationale
Correct Answer: B, E
Any areas of ecchymosis on the torso, back or buttocks should alert the nurse to possible abuse, plus round burn marks anywhere on the body can indicate cigarette burns and should alert the nurse to possible abuse. Abdominal rebound tenderness may indicate appendicitis, rather than abuse. Mismatched clothing would most likely be consistent with the age of the child and their developmental stage. Minor injuries to the arms and legs, such as abrasions, are common in this age group and would not be suspicious.

 

85. A hospital is hosting a community wide blood pressure screening for the general public to attend. This would be an example of which of the following levels of care?

A. Secondary
B. Preventive
C. Tertiary
D. Primary

Question 85: Correct Answer and Rationale
Correct Answer: D
A screening such as this is an attempt to detect any undiagnosed disease at its earliest stage, which is an example of primary care. Secondary care includes any hospital-based care in an emergency setting or on a clinical unit. Preventive care includes things such as immunizations or providing education in hopes of minimizing risk factors for illness. Tertiary care includes more specialized care located regionally, such as burn or cancer centers once the illness has progressed or for a more serious condition.

 

86. An RN is making assignments for patient care to a LPN at the start of their shift. Which of the following tasks should the LPN question?

A. Providing nasopharyngeal suctioning for a patient with pneumonia
B. Assisting a patient to use an incentive spirometer 24 hours after surgery
C. Replacing the cartridge and tubing on a patient-controlled analgesia PCA pump
D. Collecting a clean-catch urine specimen from a previously admitted patient

Question 86: Correct Answer and Rationale
Correct Answer: C
The LPN should question the RN regarding the PCA pump because the RN is responsible for maintaining these pumps at all times. All the other tasks mentioned are within the scope of practice of an LPN.

 

87. Upon completion of a sterile dressing change, the nurse has removed the sterile pack from its outside cover and placed it on a clean work surface. Which of the following flaps should the nurse unfold first?

A. The flap furthest from the body
B. The left side flap
C. The right side flap
D. The flap closest to the body

Question 87: Correct Answer and Rationale
Correct Answer: A
The priority during a sterile procedure is to indeed maintain sterility to minimize risk of infection which would compromise the health and safety of the patient. Therefore, the nurse must pull the top flap (which is the one furthest away from her body) away from her body first, because if not she will risk touching part of the inner surfaces of the wrap which would contaminate it. The right and left side flaps should not be unfolded first. The flap closest to the body is the innermost flap and the last one to be unfolded.

 

88. A nurse has taken over care for a patient who presents with linear clusters of vesicles that appear to contain fluid with some crusts. Which of the following should the nurse immediately suspect?

A. Systemic lupus erythematosus (SLE)
B. Herpes zoster
C. Ringworm
D. Allergic reaction

Question 88: Correct Answer and Rationale
Correct Answer: B
Vesicles that follow a linear pattern along a unilateral nerve can indicate herpes zoster. A red, swollen rash that covers sections of both cheeks can indicate SLE. Red circles with white centers occur with ringworm. A pink rash that covers a majority of the body is most likely an allergic reaction.

 

89. You are caring for a patient that reports a severe sore throat, pain when he swallows, and swollen lymph nodes. You should be aware that the patient is experiencing which of the following stages of infection?

A. Convalescence
B. Incubation
C. Prodromal
D. Illness

Question 89: Correct Answer and Rationale
Correct Answer: D
The illness stage is when the patient experiences signs and symptoms that are specific to the infection. The stage of convalescence is when the acute symptoms of the infection fade. The incubation period consists of the time when the pathogen first enters the body prior to the onset of any signs and symptoms of the infection. The prodromal stage consists of nonspecific clinical indications of the infection.

 

90. Being aware of fire safety is a definite must within your facility, you must always be prepared and ready to help take action should an emergency occur. Knowing that, which of the following types of fire extinguishers are for electrical fires?

A. Class B
B. Class E
C. Class A
D. Class C

Question 90: Correct Answer and Rationale
Correct Answer: D
Class C fire extinguishers are used for electrical fires. Class B fire extinguishers are used for flammable liquids and fires caused by gas. There is no such thing as a class E fire extinguisher. Class A fire extinguishers are used for paper, wood, upholstery, rags or other types of trash fires.

 

91. A newly licensed nurse should understand that which of the following patient positions would inhibit chest expansion the most?

A. Lateral
B. Semi – Folwer’s
C. Orthopneic
D. Prone

Question 91: Correct Answer and Rationale
Correct Answer: D
When a patient is in the prone position they are lying flat on their abdomen with their head turned to one side. The prone position is ideal for those who undergo throat surgery for the most optimal drainage; however it is the position that mostly inhibits chest expansion for the best air exchange. Lateral positioning means the patient is laying on his/her side. Semi – Fowler’s positioning means the patient is lying on their back with the head of the bed slightly elevated. The orthopneic position allows for the best chest expansion and is greatly beneficial to those patients with COPD.

 

92. According to the Centers for Disease Control and Prevention (CDC), which immunizations should the nurse inform the parents that are recommended for their adolescent to receive? (Select all that apply).

A. Herpes zoster
B. Varicella
C. Seasonal influenza
D. Rotavirus
E. Human papilloma virus (HPV)

Question 92: Correct Answer and Rationale
Correct Answer: B, C, E
The CDC recommends the seasonal influenza, HPV, and varicella immunizations during adolescence. The rotavirus vaccination should be administered at or before 8 months of age and the herpes zoster vaccination should be administered during middle adulthood, typically in those age 60 or older.

 

93. Prior to performing a physical examination on a patient, the nurse should know that which part of her hand should be used during palpation for the most optimal assessment of the patient’s skin temperature?

A. Palmar surface
B. Base of fingers
C. Fingertips
D. Dorsal surface

Question 93: Correct Answer and Rationale
Correct Answer: D
The dorsal surface (back) of the hand is the most sensitive to temperature. The palmar surface and base of the fingers are especially sensitive to vibration, not temperature. The fingertips are sensitive to pulsation, position, texture, size and consistency, not temperature.

 

94. When preparing for her examination the student nurse should be aware that which of the following cranial nerves are responsible for the movement and strength of the tongue?

A. CN IX
B. CN III
C. CN XII
D. CN VIII

Question 94: Correct Answer and Rationale
Correct Answer: C
Cranial nerve XII (hypoglossal) is responsible for the movement and strength of the tongue. CN IX (glossopharyngeal) is responsible for assessing the mouth for movement of the soft palate and gag reflex. CN III (oculomotor) is responsible for performing extraocular movements. CN VIII (auditory) is responsible for hearing.

 

95. The nurse is preparing to auscultate the apical pulse on a patient. At which position should she place her stethoscope on the patient’s chest in order to reach this cardiac landmark and be able to record the correct pulse?

A. Just right of the sternum at the second intercostal space (ICS)
B. Left mid-clavicular line at the fifth ICS
C. Just left of the sternum at the fourth ICS
D. Just left of the sternum at the second ICS

Question 95: Correct Answer and Rationale
Correct Answer: B
The nurse should hear the apical pulse at the left mid-clavicular line at the fifth ICS. The aortic landmark can be found just right of the sternum at the second ICS. The tricuspid landmark can be found just left of the sternum at the fourth ICS. The pulmonic landmark can be found just left of the sternum at the second ICS.

 

96. A community health nurse is preparing an educational program on communicable diseases. When discussing routes of transmission, which of the following should the nurse include as an airborne illness?

A. Malaria
B. Salmonella
C. Clostridium Difficile
D. Influenza

Question 96: Correct Answer and Rationale
Correct Answer: D
Of the conditions listed above influenza is transmitted via the airborne route. Malaria is a vector-borne illness, such as being transferred by mosquitoes. Salmonella is a food-borne illness, such as from undercooked or contaminated meats. Clostridium difficile (C.Diff) is spread by contact.

 

97. Upon reviewing the common emergency management protocol for patients during a cardiac emergency situation, the nurse should be aware that which of the following is an appropriate medication to administer via the IV route?

A. atropine
B. epinephrine
C. dobutamine
D. dopamine

Question 97: Correct Answer and Rationale
Correct Answer: B
Administration of IV epinephrine during a cardiac emergency would be an appropriate action by the nurse because it works to increase the heart rate, improve cardiac output and helps to promote bronchodilation. IV atropine is no longer used during the crisis period in an emergency situation. Dobutamine and dopamine IV are administered during the post-resuscitation phase after the emergency crisis has been resolved.

 

98. A registered nurse is responsible for a patient who has suffered from a traumatic head injury and has an intraventricular catheter placed in the brain to monitor their ICP. The RN should monitor the patient for which of the following complications related to the intraventricular catheter?

A. Infection
B. Hypertension
C. Headache
D. Aphasia

Question 98: Correct Answer and Rationale
Correct Answer: A
Infection is the complication a patient with an intraventricular catheter should be monitored for; strict asepsis should be used at all times to avoid exposing the patient to infection, which would most likely be a life-threatening situation that could result in meningitis. The nurse should definitely monitor the patient for all the other options too, which would also be complications; however they are not directly related to the intraventricular catheter.

 

99. One of the patients you are responsible for this shift is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements made by the patient indicates to you that they know how to use the PCA?

A. “I’ll be careful about pushing that button so I don’t have an overdose.”
B. “I will ask my son to push the dose button when I am sleeping.”
C. “I should tell the nurse if the pain doesn’t stop after using the PCA.”
D. “I’ll wait to use the PCA until it’s absolutely necessary.”

Question 99: Correct Answer and Rationale
Correct Answer: C
PCA is a method of delivering pain medication via an electronic device. The patient is able to self-administer pain medication on an as-needed basis and if the patient does not feel like their pain is completely relieved to keep them at a comfortable level, they should immediately notify the nurse so the pain management plan can be adjusted for the most optimal relief. A PCA device has timing control and/or lockout mechanisms built in so patients cannot overdose; the patient will be unable to self-administer pain medication until a set minimum time interval has passed with each dose. The patient should be the only one to control the use of the PCA pump because they are the best source of how bad their pain is, not a family member, unless of course a patient is not able to operate the PCA, and then other measures will be discussed. The patient should be instructed to use the PCA when he or she begins to feel pain, not until it gets intolerable and becomes absolutely necessary. The goal of a PCA is to help prevent unnecessary worsening of the pain and to use less pain medication in the long run.

 

100. A nurse is caring for a patient who just suffered from a generalized seizure. Which of the following actions should the nurse take first?

A. Assess the patient for injuries
B. Monitor the patient’s vital signs
C. Keep the patient in a side-lying position
D. Reorient the patient to the environment

Question 100: Correct Answer and Rationale
Correct Answer: C
The nurse should keep the patient in a side-lying position because the greatest risk to the patient is aspiration during the postictal phase, this way any secretions can drain from the mouth. All the remaining options are important and should be carried out with time after the seizure, however they are not the most important.

 

101. As a RN you are educating a female patient at discharge regarding a new prescription for phenytoin. Which of the following information should you include with your instructions?

A. Watch for receding gums when taking this medication
B. Take the medication at the same time each day
C. Consider taking oral contraceptives when on this medication
D. Provide a urine sample to test for therapeutic levels of this medication

Question 101: Correct Answer and Rationale
Correct Answer: B
The nurse should instruct the patient to take the medication at the same time each day in order to achieve the most optimal effects. Phenytoin causes overgrowth of the gums, not receding of them. Effectiveness of contraceptives is decreased, so you should not instruct your female patient to take them while taking this medication. Periodic blood tests are used to determine therapeutic levels of this medication, not urine samples.

 

102. A nurse is reinforcing teaching with a patient who has Parkinson’s disease and has received a new prescription for bromocriptine from their physician. Which of the following instructions should be included in the patient education?

A. Report any skin discoloration
B. Limit exposure to heat
C. Rise slowly when standing
D. Increase intake of carbohydrates

Question 102: Correct Answer and Rationale
Correct Answer: C
The nurse should inform the patient that orthostatic hypertension is a common adverse effect of bromocriptine, therefore rising slowly when standing up will decrease the risk of any dizziness or feelings of becoming lightheaded. Skin discoloration is not an adverse effect of this medication. The patient should avoid the cold (not heat), because an adverse effect of bromocriptine is Raynaud’s phenomenon. The patient should increase their intake of fiber (not carbs) in the diet because an adverse effect of this medication is constipation.

 

103. When working in a long-term care facility, you are developing a care plan for a patient with stage 5 of Alzheimer’s disease. Which of the following interventions would you include?

A. Provide protective undergarments
B. Assist patient with ADLs
C. Thicken all liquids
D. Use a gait belt for ambulation

Question 103: Correct Answer and Rationale
Correct Answer: B
A patient in stage 5 of Alzheimer’s disease requires assistance with ADLs as increasing cognitive deficits continue to emerge. Generally not until stages 6 and 7 of Alzheimer’s disease, does the patient experiences episodes of urinary and fecal incontinence. Ambulation and swallowing difficulties are generally findings once the patient advances more into stage 7 of the disease.

 

104. When reviewing the medical record of a patient with a malignant brain tumor, you note that the patient has a positive Romberg sign. Which of the following tasks should the nurse take in order to assess for this sign?

A. Ask patient to blink their eyes
B. Have the patient stand erect with their eyes closed
C. Observe for any facial drooping
D. Stroke the lateral aspect of the sole of the foot

Question 104: Correct Answer and Rationale
Correct Answer: B
A positive Romberg sign is indicated when a patient loses their balance while attempting to stand erect with their eyes closed, so in order to assess for it the nurse should ask the patient to stand erect and close their eyes. Asking the patient to blink their eyes and observing for facial drooping both assess cranial nerve function, which is not part of the Romberg exam. Babinski’s sign is elicited by stroking the lateral aspect of the sole of the foot.

 

105. A patient with an expanding brain tumor has a prescription for dexamethasone and would like the nurse to review the likely effects of the medication with them. Which of the following are appropriate statements by the nurse?

A. “You will need to monitor yourself for low blood sugar.”
B. “You may notice weight gain.”
C. “It is given to reduce swelling of the brain.”
D. “Tumor growth will be delayed.”
E. “It can cause you to retain fluids.”

Question 105: Correct Answer and Rationale
Correct Answer: B, C, E
Dexamethasone is a common steroid that is prescribed to reduce swelling of the brain. Both weight gain and fluid retention are adverse effects of this medication. The patient may experience high blood sugar results when taking dexamethasone and it does not affect tumor growth, it is just given to prevent any brain swelling.

 

106. One of the patients you have been assigned to has ALS and new prescription for riluzole. As their nurse, you are responsible for their education regarding their new medication. Which of the following instructions should you give them?

A. “Drink a glass of milk with the medication.”
B. “Monitor your blood pressure daily.”
C. “Avoid consuming alcoholic beverages.”
D. “Take this medication immediately prior to eating.”

Question 106: Correct Answer and Rationale
Correct Answer: C
You should make sure the patient understands that riluzole is toxic to the liver, so alcoholic beverages should be avoided in order to decrease the risk of liver damage. Riluzole should be taken on an empty stomach every 12 hours, either 1 hour before or 2 hours after meals and it does not affect the blood pressure.

 

107. A home health nurse is educating a patient with myasthenia gravis (MG) about the risk factors that can exacerbate the disease. Which of the following statements made by the patient indicates a need for further teaching?

A. “I have suction equipment at home in case I start to choke.”
B. “I will soak in a warm bath every day.”
C. “I ordered a medical ID bracelet to wear.”
D. “I should take my medication 45 minutes before meals.”

Question 107: Correct Answer and Rationale
Correct Answer: B
The nurse should inform the patient that hot temperatures and hot water can cause an exacerbation of MG, so the patient should be instructed to avoid this if at all possible. The other options are all appropriate for the MG condition and the patient should be encouraged to follow through with them.

 

108. A nurse in a health clinic is taking care of a patient who is complaining of having frequent migraine headaches. The patient asks about foods that may trigger headaches to occur. Which of the following should the nurse recommend that the patient avoid in their diet?

A. Salted cashews
B. Fresh asparagus
C. Frozen strawberries
D. Baked salmon

Question 108: Correct Answer and Rationale
Correct Answer: A
The nurse should instruct the patient to avoid consuming salted cashews because nuts contain tyramine, which may trigger migraine headaches. Fruits and vegetables are not sources of tyramine, so there is no harm in consuming these. Fish that is smoked contains tyramine and should be avoided; however baked salmon does not contain tyramine and is not a trigger for migraines.

 

109. A nurse on the medical-surgical unit is caring for an older adult patient with diabetes mellitus. The patient reports loss of his peripheral vision. Which of the following is this patient at a particular risk for?

A. Macular degeneration
B. Angle-closure glaucoma
C. Cataracts
D. Open-angle glaucoma

Question 109: Correct Answer and Rationale
Correct Answer: D
The nurse should anticipate that her patient is experiencing open-angle glaucoma at this time due to his loss of peripheral vision, which is an indicator. Those with macular degeneration will experience loss of central vision. A patient with angle-closure glaucoma will most likely experience severe pain and nausea instead. Finally, a patient who has cataracts will complain of a general decrease in vision and sensitivity to lights.

 

110. Upon performing an otoscopic exam on a patient, which of the following should the nurse note as an unexpected finding?

A. Malleus visible behind the tympanic membrane (TM)
B. Black cerumen that partially occludes the TM
C. Flaky skin in the external ear canal near the TM
D. Pearly, gray TM

Question 110: Correct Answer and Rationale
Correct Answer: B
Cerumen (ear wax) in the ear varies from light to dark yellowish-brown in color. Therefore, black cerumen should be unexpected and may indicate the presence of blood. All the other findings by the nurse are expected when performing an otoscopic exam.

 

111. A patient you are caring for is suspected to have Meniere’s disease. Which of the following would be an expected finding of this condition?

A. Bulging, red bilateral tympanic membranes
B. Unilateral hearing loss
C. Presence of a purulent lesion in the external ear canal
D. Recent history of airplane travel

Question 111: Correct Answer and Rationale
Correct Answer: B
Meniere’s disease is an inner ear disorder and unilateral sensorineural hearing loss is an expected clinical finding. Bulging, red bilateral TM would be associated with a middle ear infection. A purulent lesion in the external ear canal would be not be an expected finding of this particular condition. Changes in air pressure from recent airplane travel would affect the middle ear.

 

112. At the start of your shift you are receiving report on a patient who has sustained a head injury and is to receive mannitol due to an increased ICP. You should be aware that which of the following is an adverse effect of this medication that you should monitor the patient closely for?

A. Hyperglycemia
B. Oliguria
C. Hyponatremia
D. Hypervolemia

Question 112: Correct Answer and Rationale
Correct Answer: C
Mannitol is a powerful osmotic diuretic to decrease the amount of excess fluid within the tissues; therefore its adverse effects include causing electrolyte imbalances, such as hyponatremia. Hyperglycemia would not be an adverse effect. This medication would cause polyuria, not oliguria, due to removing excess fluid from the body, which the nurse should monitor for. Finally, hypovolemia is an adverse effect of mannitol, not hypervolemia.

 

113. As a newly licensed RN you are getting report about a patient that has sustained a right-hemispheric stroke. Which of the following should you be aware of that are expected findings when performing your shift assessment? (Select all that apply).

A. Left hemiplegia
B. Lack of awareness
C. Loss of depth perception
D. Impulse control difficulty
E. Aphasia

Question 113: Correct Answer and Rationale
Correct Answer: A, B, C, D
A patient who has experienced a right-hemispheric stroke will most likely experience a left-sided hemiplegia, a lack of awareness of their surroundings, a loss of depth perception, and impulse control difficulty (such as the urgency to urinate). Aphasia on the other hand would most likely be experienced by someone who had a left-hemispheric stroke.

 

114. A registered nurse is caring for a patient who has a C4 spinal injury. Which of the following should the nurse recognize the patient as being the most at risk for?

A. Stress ulcer
B. Paralytic ileus
C. Neurogenic shock
D. Respiratory compromise

Question 114: Correct Answer and Rationale
Correct Answer: D
Using the (ABC) airway, breathing and circulation priority-setting framework, the greatest risk to this patient would be respiratory compromise due to the location of the spinal injury. Maintenance of their airway and being able to immediately provide respiratory support if needed is the priority. The other options are complications, but they do not pose the greatest risk at this time.

 

115. A nurse is responsible for a patient this shift who has experienced a cervical spine injury approximately 24 hours ago. Which of the following types of medications should the nurse clarify with the prescribing physician?

A. Plasma expanders
B. Muscle relaxants
C. H2 antagonists
D. Glucocorticoids

Question 115: Correct Answer and Rationale
Correct Answer: B
This patient will still be in spinal shock 24 hours after their injury. The patient will not yet be experiencing muscle spasms until after the spinal shock has resolved, therefore the muscle relaxants will not be necessary at this time. The other options would be appropriate for administration at this point in the patient’s situation.

 

116. When caring for a patient with a chest tube and drainage system, you observe that the chest tube has accidentally been removed. Which of the following actions should you take first in this situation?

A. Assess the patient’s respiratory status
B. Place the tubing in sterile water to restore the water seal
C. Place tape around the insertion site
D. Apply sterile gauze to the insertion site

Question 116: Correct Answer and Rationale
Correct Answer: D
Using the airway, breathing and circulation (ABC) priority-setting framework, the application of sterile gauze to the site should be the very first action you should take because this will allow air to escape and will reduce the risk of a tension pneumothorax developing. The remaining actions are all appropriate and should follow suit in this situation, however they are not the first actions that should be taken.

 

117. If your patient is experiencing dyspnea and is to receive oxygen continuously, which of the following devices would deliver a precise amount of oxygen to them?

A. Venturi mask
B. Nonrebreather mask
C. Nasal cannula
D. Simple face mask

Question 117: Correct Answer and Rationale
Correct Answer: A
A venture mask incorporates an adapter that allows a precise amount of oxygen to be delivered to the patient. A nonrebreather mask, a nasal cannula and a simple face mask only deliver an approximated amount of oxygen.

 

118. A community health nurse is hosting an educational event related to tuberculosis (TB). Which of the following clinical manifestations should be included in the education regarding this condition that the public should be aware of?(Select all that apply).

A. Persistent cough
B. Purulent sputum
C. Fatigue
D. Weight gain
E. Night sweats

Question 118: Correct Answer and Rationale
Correct Answer: A, B, C, E
Having a persistent cough, purulent sputum, experiencing frequent fatigue and having night sweats are all signs and symptoms that will most likely warrant a diagnosis of TB. Weight loss, instead of weight gain, would be another manifestation.

 

119. A patient on your unit has a pulmonary embolism (PE). Which of the following clinical signs should you expect to observe when assessing this patient? (Select all that apply).

A. Petechiae
B. Tachycardia
C. Pleural friction rub
D. Hypertension
E. Bradypnea

Question 119: Correct Answer and Rationale
Correct Answer: A, B, C
Petechiae, tachycardia and auscultation of a pleural friction rub are all signs of a PE. Tachypnea and hypotension would be findings of PE, not bradypnea and hypertension.

 

120. A nurse notices that on the telemetry monitor her patient is experiencing a current heart rate of 46 beats per minute. She notifies the physician of the finding. She should anticipate that the physician will manage this situation via which option?

A. Administration of IV lidocaine
B. Insertion of a pacemaker
C. Defibrillation
D. Synchronized cardioversion

Question 120: Correct Answer and Rationale
Correct Answer: B
A patient with bradycardia is a candidate for insertion of a pacemaker to increase the heart rate. Administration of IV lidocaine would be used in patients with a pulseless ventricular dysrhythmia in order to stimulate any cardiac electricity and function. Defibrillation would be used when a patient has ventricular fibrillation or pulseless ventricular tachycardia. Synchronized cardioversion is used when a patient has a dysrhythmia such as atrial fibrillation, supraventricular tachycardia (SVT), or ventricular tachycardia with a pulse.

 

121. A patient asks the nurse, “Why did my doctor tell me to take 1 aspirin per day?” Which of the following responses would be most appropriate by the nurse?

A. “Aspirin will reduce the formation of blood clots that could cause you to have a heart attack.”
B. “Aspirin relieves headaches that are caused by other medications.”
C. “Aspirin will work to dissolve any clots that are forming in your coronary arteries.”
D. “Aspirin relieves any pain that is due to myocardial ischemia.”

Question 121: Correct Answer and Rationale
Correct Answer: A
The nurse should respond with something similar to option A because when aspirin is taken it decreases platelet aggregation that can end up leading to a heart attack. Other medications can cause headaches, but taking 1 aspirin daily is not prescribed for any analgesic effects. Aspirin also does not dissolve clots. Finally, taking 1 aspirin daily would not be sufficient enough to alleviate any pain that is caused by myocardial ischemia.

 

122. A nurse is completing a physical assessment on a patient during the admission process and notices they have a history of mitral valve insufficiency. Which of the following would be an expected finding of this?

A. Crackles in the lung bases
B. Splenomegaly
C. Hoarseness
D. Petechiae

Question 122: Correct Answer and Rationale
Correct Answer: A
Crackles in the lung bases would be an expected finding in a patient with pulmonary congestion due to mitral valve insufficiency. Hepatomegaly, not splenomegaly, would be an expected finding in this situation. Hoarseness is an expected finding in a patient who has mitral valve stenosis. Petechiae would be expected if the patient had infective endocarditis.

 

123. A nurse is taking care of patient with severe peripheral arterial disease (PAD). The nurse should expect that the patient will be the most comfortable in which of the following positions in order to sleep?

A. In a side-lying, recumbent position
B. With the head of the bed elevated
C. With the affected limb hanging from the bed
D. With the affected limb elevated on pillows

Question 123: Correct Answer and Rationale
Correct Answer: C
The patient will most likely be the most comfortable if they can dangle the affected extremity off of the bed because the most relief comes when it is in a dependent position. The other sleeping positions will not provide the most comfort or promote the most optimal circulation to the affected area(s).

 

124. A nurse is caring for a patient and is currently reviewing a new prescription for an afterload-reducing medication. The nurse should understand that this medication will be administered for which of the following types of shock?

A. Hypovolemic
B. Obstructive
C. Distributive
D. Cardiogenic

Question 124: Correct Answer and Rationale
Correct Answer: D
Reducing afterload will allow the heart to pump more effectively and better perfuse the tissues to meet the demands of the body, which is needed for the patient in cardiogenic shock. In obstructive shock, the high afterload is due to an obstruction of blood flow and afterload-reducing agents would not remove the obstruction. This type of medication would not be given to someone with distributive shock because the patient already would be experiencing a decreased afterload. Finally, fluid replacement and reduction of further fluid loss are the focus when it comes to management of hypovolemic shock.

 

125. Why should the nurse remain with a patient during the first 15 minutes of a blood transfusion?

A. To obtain blood specimens
B. To explain the procedure to the patient
C. To assess for adverse reactions
D. To verify that the blood being transfused is correct

Question 125: Correct Answer and Rationale
Correct Answer: C
Assessment of the patient during the first 15 minutes of the transfusion is important because this is when most blood reactions occur, so the nurse should remain in the room with the patient during that crucial time. Blood specimens should only be obtained in the event of a blood reaction or approximately 2 hours after the completion of the transfusion to determine how effective the transfusion was. Explanation of the procedure and consent to perform the transfusion should be completed prior to even beginning administration of blood products. Verification that the blood is correct for the particular patient should be done with at least 2 nurses prior to the start of the transfusion to avoid any errors.
P. Shreffler

About P. Shreffler

P. Shreffler started her nursing career in 2010 as a Licensed Practical Nurse (LPN). After working for almost five years she decided it was time to go back to college and further her education. In June of 2015 she passed her NCLEX on the first attempt and can finally put that RN behind her name! Her background has been in the long-term care setting for these past 5 years with a small amount of experience in acute care during RN school. I am excited at where my career may take me and I enjoy knowing that I may make the difference in many, many lives down the road!
No Posts for this author.