NCLEX practice questions

Nurse in the making (& some bootcamp) practice questions for the NCLEX

The nurse is reviewing the lab results of several clients. Which finding should the nurse report to the health care provider first?

a. Client who has a sodium level of 140 mEq/L

b. Client who reports nausea with a lithium level of 1.8 mEq/L

c. Client with a heart rate of 62 bpm who has a digoxin level of 1.4 mg/mL

d. A pregnant woman whose fibrinogen level is 500 mg/dL

b.

This patient has mild lithium toxicity. Lithium has a narrow therapeutic range of 0.6 - 1.2 mEq/L.

You walk into your client’s room and they say, “I haven’t gotten any sleep while being in the hospital.” Which response by the nurse illustrates a therapeutic communication with this client?

a. “Don’t worry, you will sleep well tonight.”

b. “You're having trouble sleeping while being in the hospital?”

c.“I’m sorry.”

d.“I would have a hard time sleeping here also.”

b.

This is an open-ended question and shows active listening skills, both of which displays a therapeutic response.

You are a nurse working in a LTC facility. You are caring for a client with end-stage Alzheimer’s disease. What communication techniques are appropriate to use when speaking with your client? SATA

a. Asking open-ended questions

b. Speaking loudly so they can hear you

c. Turn up the TV so they can hear it

d. Use simple statements & questions

e. Face the client while speaking to them

d. & e.

The nurse should use simple statements & questions when communicating to a patient w/ Alzheimer’s disease.

The nurse should face the client directly when speaking to avoid any confusion.

The nurse working in an OBGYN clinic is collecting data from a pregnant client who is 8 weeks pregnant. Which of the following statements by the client needs further intervention?

a. Client reports breast tenderness

b. Client reports feeling extreme fatigue

c. Client reports vaginal discharge that is white

d. Client is taking Enalapril for hypertension

d.

ACE inhibitors. Remember the suffix for ACE inhibitors is “PRIL.” These medications are teratogenic, meaning they cause harm to the developing fetus and they are not to be taken during pregnancy.

The nurse in the emergency department receives report on 4 clients. Which client should be seen first?

a. A 55-year old who is NPO asking for a snack

b. A 60-year old who has a mean arterial pressure of 80 mmHG

c. A 20-year old who has a capillary refill of less than 3 seconds

d. A 35- year old whose right hand is cooler than his left hand

d.

This patient needs immediate attention and should be assessed first due to the risk of losing his hand due to inadequate perfusion and blood supply. This finding could mean that a thrombus (clot) has formed, hemorrhage is occurring, infection or circulatory impairment has occurred.

A client is scheduled for an elective laparoscopic cholecystectomy. The nurse should notify the health care provider (HCP) about what findings before the surgery?

a. Platelet count of 300,000/mm^3

b. Temperature of 100.4 F (38 C) with a mild cough

c. WBC count of 9,000/mm^3

d. Hemoglobin 15 g/dL and hematocrit 48%

b.

This may indicate the patient has an infection. Therefore the surgery would have to be moved to a different time when the patient is no longer showing signs and symptoms of an infection.

The nurse observes a new nurse performing chest compression on a 75-year old male. Which of the following would indicate the need for further teaching?

a. Compressing the chest to a depth of at least 2 inches

b. Placing the heel of the hand on the center of the chest

c. Compression rate of 140 - 160/min

d. Allowing the chest to recoil completely after each compression

c.

This is too fast. The compression rate should be 100 - 120/min.

A client taking furosemide for chronic heart failure is experiencing constipation. What should the nurse recommend to the client to help alleviate constipation?

a. Drink more fluids during the day, especially warm tea

b. Increase the amount of fiber in your diet

c. Exercise more frequently

d. Take warm showers

b.

Increasing fibers is the best way to alleviate constipation in this client. (Exercise is great, but clients with heart failure may not be able to tolerate more frequent exercise due to becoming easily fatigued.)

The nurse is precepting a nursing student caring for a client with Glaucoma. The student is administering Travoprost, an ophthalmic medication. Which action by the student indicates a need for further teaching?

a. Has the client tilt their head back slightly when administering the eye drops

b. Removes dried secretions with a moistened gauze by wiping from the outer to the inner canthus

c. Holds the dropper 1- 2 cm above the conjunctiva sac and drops the medication directly into the sac

d. Has the client close the eyelids and gently apply pressure to the nasolacrimal duct for 30 - 60 seconds

b.

The proper way to clean dried secretions is to use sterile gauze and wipe from inner to outer canthus to prevent bacteria from entering the eye.

The charge nurse is making assignments for the day. Which client assignment should the nurse who is pregnant receive for the day?

a. A 10-year old client with parvovirus B-19 infection admitted after having a mild rash

b. A 18-month old with a rash on the face, sore throat, and a low-grade fever, suspected to have Rubella

c. A 14-year old with herpes simplex virus 1 (HSV-1) and has a cold sore on her lip

d. A 7-year old client admitted for severe throat pain with positive group A streptococcus cultures

d.

Group A streptococcus does not pose a risk to the developing fetus, this would be the best patient for the pregnant nurse to be assigned to.

The nurse is caring for a client with bipolar disorder who is in an acute manic episode. Which dinner should the nurse choose as the most appropriate option to promote client nutrition?

a. Baked potato, spinach, croissants, and milk

b. Baked lasagna, salad, and water

c. Cheeseburger, orange slices, and a strawberry milkshake

d. Chicken noodle soup, a dinner roll, and iced tea

c.

This is easily consumed while on the go because it is “finger food.”

A nurse who is precepting a nursing student observes the nursing students donning personal protective equipment (PPE). Which series of steps performed by the nursing student indicates that no further teaching is needed?

a. Mask/respirator, hand hygiene, gown, goggles/face shield, gloves

b. Hand hygiene, gown, mask/respirator, goggles/face shield, gloves

c. Gown, gloves, mask/respirator, hand hygiene

d. Hand hygiene, mask/respirator, gown, goggles/face shield, gloves

b.

The correct way to don PPE. TIP: don means to put on an item of clothing.

The nurse is doing discharge teaching with a client with newly diagnosed type 1 diabetes. The nurse is teaching the client how to mix regular insulin and NPH insulin in the same syringe. Which of the following actions would require further teaching?

a. Withdrawing the regular insulin first

b. Withdrawing the NPH insulin first

c. Injects air into NPH insulin vial first

d. Injecting an amount of air equal to the desired dose of insulin into each vial

b.

This is the incorrect way to mix regular insulin and NPH insulin. You should withdraw regular insulin first. (Inject air into NPH, Inject air into Regular, withdraw Regular, withdraw NPH)

A 42-year-old male client comes into the emergency department with a thermal burn injury. You are the oncoming nurse receiving the following vital signs. Blood pressure: 70/40; heart rate: 140 bpm; respiratory rate: 23/min. The patient is faint in color and you are having difficulty finding his pedal pulse. Which action will the nurse take first?

a. Get a doppler device to find the pedal pulse

b. Obtain an electrocardiogram (ECG)

c. Document your findings and continue to do hourly vital signs

d. Begin IV fluids

d.

When a patient has burns, think SHOCK. This is especially true since the vital signs indicate shock. Administering IV fluids is the priority action.

The nurse is caring for a client with chest trauma. Assessment reveals headache, sleepiness, and confusion. Oxygen saturation is reading 87%. Which acid-base imbalance does the nurse suspect this patient is experiencing?

pH = 7.31; PaO2 = 77; PaCO2 = 54; HCO3 = 24

a. Respiratory acidosis

b. Metabolic acidosis

c. Respiratory alkalosis

d. Metabolic alkalosis

a.

Low pH <7.35 & High PaCO2 >45 mm Hg

*Remember Respiratory = Opposite

A parent comes into the clinic with her 4 -year old son who is sick with the flu. Which of the following statements made by the parent would require further education and intervention by the nurse?

a. “I gave my child a strawberry popsicle this morning for hydration”

b. “My son was complaining that his body ached so I gave him Ibuprofen”

c. “My son had severe nausea so I gave him Bismuth subsalicylate”

d. “I’ve been giving him Acetaminophen every 4 hours for his fever”

c.

You should not give a child salicylates (Aspirin). It increases the risk of developing Reye’s syndrome which causes brain & liver damage to children with recent viral infections.

The nurse is caring for clients on a medical-surgical floor. The nurse gets a report from the previous nurse. Based on this report which client would be the first priority to assess?

a. A client with a deep vein thrombosis in their left leg who missed the last dose of Coumadin

b. A client with COPD who has an O2 saturation of 90% and diminished breath sounds

c. A client with sepsis who is developing petechiae

d. A client with type 2 diabetes whose last chem stick read 160 mg/dL

c.

Clients with sepsis are at risk for a life-threatening condition called disseminated intravascular coagulation (DIC). A classic sign of DIC is petechiae. This client would take priority!

The nurse is evaluating a client with bipolar disorder who was prescribed lithium therapy a few months ago. Which statement made by the client would cause the most concern?

a. “I’ve been napping more than normal this week.”

b. “My mouth has been so dry since being on this medication.”

c. “I’ve gained 4 lbs since being on this medication.”

d. “I’ve had diarrhea for the past couple of days. I think I have the stomach flu.”

d.

Dehydration and sodium loss from vomiting or diarrhea can cause lithium levels to go up in the bloodstream, leading to TOXICITY. This statement should cause the most concern!

The school nurse is helping with a field trip for 3rd graders. An 8-year-old who is conscious has clammy skin, sweating, and is shaking. The client has type 1 diabetes controlled with insulin detemir & NPH. What is the most suitable action by the nurse?

a. Give an IM injection of glucagon

b. Give the child a peanut butter and jelly sandwich

c. Administer Lispro (a fast-acting insulin) in the abdomen

d. Provide 4 oz of fruit juice

d.

When treating a hypoglycemic patient, it’s good to go by the “15X15X15 rule.” 15 grams of carbohydrates, recheck blood glucose in 15 min, and repeat 15 grams of carbohydrate if blood sugar remains low.

Peanut butter and jelly sandwich is a good option for after the client's blood sugar improves but fruit juice is a better option to help raise blood sugar quickly.

IM glucagon is administered for hypoglycemic patients who are unconscious. This patient is conscious, so this would not be an appropriate action.

The nurse in the emergency department received a client with severe head and back injuries from a recent Motor Vehicle Accident (MVA). The nurse will perform what action to best visualize the airway?

a. Jaw-thrust maneuver in the supine position on a backboard

b. Jaw-thrust maneuver in Fowler's position

c. Head-tilt chin-lift in supine position on a backboard

d. Head-tilt chin-lift in Trendelenburg position

a.

The nurse should not use the head-tilt chin-lift because it does not stabilize the alignment of the head & neck and placing a patient in Fowler's position with a suspected spinal injury could lead to spinal cord damage and therefore should be avoided.

A nurse working in the emergency department has four clients arrive at the same time. Which client should the nurse see first?

a. A 80-year old who is complaining of frequent liquid colored stools

b. A 50-year old who complains of pain in his knees

c. A 20-year old who got a singed beard while camping with his friends

d. A 1-month old infant who is crying from hitting his head and has bulging fontanelles while crying

c.

A singed (burnt) beard or any singed hair near the face is most likely a result of inhaling smoke. This can cause injury to the lungs or carbon monoxide poisoning and is very dangerous. Remember your ABC's: airway always takes priority. This patient is most likely to be in immediate danger, so the nurse would need to see this patient first.

Our initial thought is that the bulging of the fontanels is concerning. But the question states the infant is crying. It’s important to know that when the baby is crying, laying down, or vomiting, it's normal to have bulging fontanelles. If the bulging fontanelles were absent of these things, it could indicate increased ICP. Therefore, this patient is not in immediate danger.

You are taking the history of a 17-year-old female client who has a BMI of 17. She reports restricting herself from eating, fear of gaining weight, and reports severe constipation. Which of the following would you most suspect?

a. Bulimia nervosa

b. Binge eating disorder

c. Anorexia nervosa

d. Refeeding syndrome

c.

This patient is showing signs and symptoms of anorexia nervosa: self-restriction from eating, BMI <18.5, constipation, and fear of gaining weight.

The registered nurse (RN) on a busy med-surg unit has assistance from the licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which tasks would be most suitable to assign to the LPN? SATA

a. Discharge teaching to a client with heart failure

b. Assisting with linen change, feeding, and bathing a client with Parkinson's disease

c. Performing wound care and sterile dressing change for a client with a stasis ulcer

d. Repositioning a client every 2 hours with a stage 1 pressure ulcer

e. Administering a schedule analgesic to a client with chronic back pain

c. & e.

This is a suitable task for the LPN to do. Wound care and sterile procedures are suitable for the RN to assign to the LPN.

This pain rating is expected for a patient with chronic back pain. The analgesic can safely be administered by the LPN.

A client who was admitted from the emergency department for myocardial infarction (MI) is receiving Alteplase (tPA). Knowing this medication and its adverse effects, the nurse should plan to prioritize which of the following?

a. Observe for signs of bleeding

b. Monitor signs of kidney failure

c. Keep the client NPO until after the infusion is complete

d. Observe for any neurological changes

a.

Alteplase (tPA) is a thrombolytic drug; the drug breaks down blood clots for treatment of myocardial infarction, ischemic stroke, blood clots, etc. Observing for signs of bleeding is the main priority when a patient is receiving this medication! Though, monitoring for neurological changes and kidney failure are both important they are not the primary concerns.

A 58-year old male client was admitted to your med-surg unit with coronary artery disease. He is being discharged home with a prescription for sublingual nitroglycerin (NTG) to treat angina. After educating the client about the medication, which of the following statements made by the client indicates the teaching was effective? SATA

a. I should sit down before taking this medication

b. I will call 911 if my pain doesn't get better or worse within 5 minutes of taking the first tablet

c. I should swallow the tablet

d. If I experience flushing, I will call 911 immediately

e. I can expect to have a headache when taking this medication

a., b. , & e.

Nitroglycerin is a vasodilator that causes dizziness and orthostatic hypotension. The client should lie or sit down before taking this medication.

If the client has worsening or unimproved pain after 5 minutes after the first tablet, the emergency medical services (EMS) should be called.

Headaches are a normal side effect of nitroglycerin due to the drug’s vasodilation effect. 911 does not need to be called.

A nurse is assessing a newborn with an infection from candida albicans. Which of the following assessments support this?

a. Fine, soft hair that covered the baby’s entire body

b. Small, white cysts on the newborns palatinate

c. White, cheesy like substance that covers the newborn's skin

d. White patches on the tongue and palate

d.

Oral candidiasis (thrush) present as white patches on the tongue and palate. They do not scrape off and bleed when touched.

You are caring for a client with Graves’ disease. Which of the following signs and symptoms would you expect to see? SATA

a. Extreme fatigue

b. Weight loss

c. Exophthalmos

d. Sensitivity to Cold

e. Hyperactivity

b., c., & e.

Clients with hyperthyroidism have a lot of energy and ↑ metabolism so they tend to lose weight despite having ↑ appetites. Clients with hyperthyroidism may have exophthalmos, this is when the eyes bulge due to inflammation. Clients with hyperthyroidism have a lot of energy!

The charge nurse on a med-surg floor is making assignments for the day. Which assignment is most appropriate?

a. LPN assigned to a newly admitted client with COPD who is having trouble breathing

b. UAP assigned to feed a patient with a recent stroke who is on aspiration precautions

c. LPN assigned to a client who is receiving blood for a gastrointestinal bleed

d. RN assigned to a client who is being transferred to the intensive care unit due to a pulmonary embolism

d.

This is within the RN’s scope of practice. A patient who is being transferred to the ICU is unstable. The registered nurse is the only one who should care for unstable clients. This is the only acceptable answer to this question!

You are educating your client who was recently diagnosed with insomnia on ways to improve their sleep. The nurse should include which intervention to improve the client’s sleep?

a. Eat 2 ounces of chocolate before bedtime

b. Drink 1 glass (12 oz) of red wine 2 hours before bedtime

c. Take a walk 3 hours before bedtime

d. Sleep with a continuous positive airway pressure (CPAP) machine

c.

Non-strenuous exercises such as leisurely walking can reduce the client's stress level and relax the muscles. This is an appropriate intervention.

The nurse is caring for a client who is receiving IV heparin and oral warfarin. You receive the following laboratory values for your client: aPTT is 4 times the control value. PT/INR is 1.5 times the control value. Which of the following actions would be appropriate to make at this time?

a. Administer a vitamin K injection

b. Hold the next warfarin dose

c. Decrease the heparin rate

d. Re-educate the client about their vegetable consumption

c.

The patient's control value is higher than the therapeutic range. This increases their chances of bleeding; the heparin rate should be decreased.

The nurse is caring for a client admitted for a recent myocardial infarction (MI) 18 hours ago. Which finding should be reported to the health care provider (HCP)?

a. The CNA tells you they have a temperature of 100.4 F

b. The client reports nausea and vomiting

c. You hear a new s3 heart sound during your assessment

d. Premature ventricular contraction (PVC) occasionally seen on the EKG strip

c.

S3 heart sounds are due to rapid ventricular filling in early diastole. This finding may indicate pulmonary congestion which may indicate signs of heart failure! This should be reported to the HCP immediately, it is the most concerning finding.

The nurse on the med surg floor is doing discharge teaching for a client with peripheral artery disease (PAD). Which of the following statements by the client indicates the need for further education? SATA

a. I will use a heating pad to promote circulation

b. I elevate my legs while watching tv

c. I will perform daily skin care and apply moisturizing lotion

d. I will dangle my legs off the bed while sitting

e. I will join a gym and walk on the treadmill

a. & b.

Most patients with PAD have impaired sensation and may burn themselves without feeling it. Heating pads should be avoided. Further education is needed.
Remember: elevation is appropriate for vein problems (PVD), not arterial problems. Further education is needed.

The nurse on a cardiac floor is reviewing the lab results of a client who is receiving warfarin for atrial fibrillation. The patient’s INR is 5.0. Which of the following actions should the nurse take?

a. Anticipate infusing fresh frozen plasma

b. Continue with the morning dose of warfarin

c. Request a prescription to administer protamine

d. Request a prescription to administer Vitamin K

d.

Vitamin K is the correct antidote for warfarin overdose and this would be an appropriate action to take by the nurse.

A 25-year-old male patient who weighs 70 kg has sustained burns to the back of the right arm, posterior trunk, front of the left leg, and their anterior head and neck. Using the Rule of Nines, calculate the total body surface area percentage that is burned.

a. 38%

b. 55%

c. 40.5%

d. 36%

d.

Back of right arm - 4.5%
Posterior trunk - 18%
Front of left leg - 9%
Anterior head & neck- 4.5%

Four clients experienced a burn. Which client should the nurse be most concerned about getting an infection?

a. A client who is 13 years old with a first-degree burn on their leg

b. A client who has burned himself in the past

c. A client with burned areas including the hands & perineum

d. A client who had a burn that took place in an open field

c.

Open areas of the body such as the ears, perineum, mouth are more prone to infection because bacteria can easily enter. We are most concerned about infection in this patient.

A 19-year-old female is prescribed isotretinoin for severe cystic acne. Which instruction is most important for the nurse to reinforce?

a. Use sunscreen while outside, even if it's cloudy

b. Do not break, crush, or chew the capsules

c. Use two forms of contraception while on this medication

d. Apply eyes drops when wearing contacts to lubricate the eyes

c.

Isotretinoin is teratogenic, meaning it can cause serious harm to the developing fetus while in the mother’s womb. This patient should take precautions to not become pregnant while using this medication.

You are educating your nulliparous client about the signs of “true” labor. Which of the following statements made by the client indicates the need for further education?

a. True labor is felt in the back and above the umbilicus

b. True labor is when contractions get more intense with walking

c. During true labor, I may experience bloody show

d. True labor begins in my lower back and radiates to my abdomen

a.

This is a false statement and shows the client needs further teaching. This is a sign of false labor.

A client comes into the emergency department with suspected carbon monoxide poisoning from a house fire. Which manifestations would correlate with this finding?

a. Oxygen saturation of 83%

b. Cherry red color of the mucous membranes

c. Singed hair on the face

d. Nasal flaring and trouble breathing

b.

This is a typical and very specific sign of CO poisoning. Carbon monoxide travels faster than oxygen, making CO bind to hgb first. This results in vasodilation and a “cherry red” color of the mucous membranes.

A client gives birth within 2 hours of arriving on your floor. She has a smooth delivery and delivers the placenta 5 minutes later. You as the labor & delivery nurse assess the fundus and notes that the uterus is midlines and boggy. Which action should the nurse take first?

a. Increase IV oxytocin rate

b. Notify the health care provider

c. Perform fundal massage

d. Check for hemorrhage

c.

Fundal massages stimulate the contraction of the uterine smooth muscle.

A mother with uncontrolled diabetes mellitus just gave birth to a newborn at term gestation. When caring for the newborn, which clinical finding would alarm the nurse?

a. Respiration of 50

b. APGAR score of 8

c. Cyanosis of the hands & feet

d. Jitteriness

d.

A mother with uncontrolled diabetes increases the newborn’s risk for hypoglycemia (because glucose supply is cut off at birth). Common signs of hypoglycemia are jitteriness, hypotonia, lethargy, and irritability. These signs would alarm the nurse.

A client is admitted to the ambulatory unit for an endoscopy. The nurse administered diazepam 1 mg intravenously for sedation and titrates the dosage up to 2.5 mg. The client's blood pressure begins to drop (83/65) and starts to show signs of respiratory depression (periods of apnea & oxygen saturation of 84%). The nurse should administer which antidote drug?

a. Naloxone

b. Flumazenil

c. Atropine

d. Protamine Sulfate

b.

Flumazenil is the antidote for benzodiazepines which commonly end in “-zolam or “-zepam”

The nurse is assessing a 38-week newborn 2 hours after a precipitous vaginal delivery. What findings can be expected during this time in the newborn? SATA

a. Skin on the nose blanches to a yellowish hue

b. Blueness of the hands and feet

c. Assessment of the umbilical cord shows one artery and one vein

d. White pearl-like cysts on the palate

e. Toes hyperextend when the lateral sole surface is stroked

b., d., & e.

Blueness of hands & feet is called Acrocyanosis. This is a normal finding when the neonate is transitioning to extrauterine life. This finding is expected.

Peal-like cysts on the palate are called epstein pearls and are benign. You can educate the parents that they will disappear in a few weeks. This is a normal finding and does not need further intervention.

Hyperextended toes after a stroke of lateral sole is called the Babinksi reflex and is a normal finding at birth. This reflex should disappear around 1 year of age. This is a normal finding and does not need further intervention.

The nurse is reviewing the laboratory results for her four clients. Which lab result would be most important for the nurse to report to the primary health care provider?

a. Client with atrial fibrillation who takes warfarin and has an INR of 1.4

b. Client with sepsis receiving Azithromycin who has a creatinine level of 0.8 mg/dL

c. Client with a catheter-associated urinary tract infections (CAUTI) who has a white blood cell count of 15,000/mm

d. Client who has elective cholecystectomy with a hematocrit of 45% and a hemoglobin of 14 g/dL

a.

A client on Warfarin (Coumadin) should have an INR of 2-3. This patient is at increased risk for stroke and the nurse needs to report this to the primary health care provider.

The nurse working on a mental health unit has a client with general anxiety disorder who has been prescribed diazepam. Which statement made by the client indicates that the nurse’s teaching has been effective?

a. I can skip doses on days I am not experiencing anxiety

b. I will take this medication before I go to bed

c. I will use sunscreen while in the sun because this medication makes me sensitive to sunlight

d. I will eliminate foods such as chocolates, aged cheese, & fermented meats from my diet while on this medication

b.

Benzodiazepines commonly cause sedation which can interfere with daytime activities such as work and driving. So the best time to take this medication is at night. This statement indicates that teaching has been effective.

A nurse in the cardiac intensive care unit is caring for a client with a continuous infusion of dopamine. Which assessment finding indicates that the infusion rate may need to be adjusted?

a. Central venous pressure of 4 mmHg

b. Heart rate of 125 beats/min

c. Mean arterial pressure is 82 mmHg

d. Systemic vascular resistance is 1000 dynes/sec/cm^5

b.

Dopamine is an Intropin. This causes vasoconstriction in order to improve hemodynamic status in clients with heart failure or shock. It increases heart rate and blood pressure. However, it can increase HR and BP too much causing tachycardia and arrhythmias. A heart rate of 125 should warrant the nurse to make adjustments to the infusion rate.

The nurse is caring for a client with congestive heart failure and is about to administer their morning dose of spironolactone (Aldactone). Which of the following lab values should be reported before giving the scheduled medication?

a. Calcium: 10 mg/dL

b. Sodium: 132 mEq/L

c. Potassium: 5.3 mEq/L

d. Chloride: 102 mEq/L

c.

Spironolactone (Aldactone) is a potassium-sparing diuretic, which means a potential complication is hyperkalemia. Think of “S” as sparing. The normal potassium value is 3 - 5 mEq/L. Therefore, this patient's potassium value is too high and should be reported before giving the scheduled mediation.

The nurse is performing a postpartum assessment on a woman 6 hours after delivery of a term infant. Which assessment finding should be reported to the health care provider?

a. Oral Temperature of 100.1 F

b. A gush of lochia appears as the uterus is massaged

c. White blood cell count of 14,000/mm3

d. Foul-smelling lochia

d.

Foul smelling lochia, fever (>100.4 F ), abdominal tenderness, and tachycardia may all be signs of endometrial infection and should be reported to the health care provider.

The nurse on a med surg unit is caring for a patient with severe diarrhea and dehydration. The nurse determines that the client has received adequate fluid replacement from which of the following lab values?

a. Blood urea nitrogen 11 mg/dL

b. Blood urea nitrogen 4 mg/dL

c. Specific gravity 1.040

d. Creatinine 1.8 mg/dL

a.

Normal BUN is 7 - 20 mg/dL. This is within normal range and indicates the client has received adequate fluid replacement.

A client with generalized anxiety disorder has received a new prescription for fluoxetine. The nurse should teach the client about which possible side effect?

a. Weight loss

b. Sexual dysfunction

c. Sedation

d. Skin rash

b.

Remember the 3 S’s of SSRIs (Sexual dysfunction, stomach upset, serotonin syndrome). The nurse should teach the client about this possible side effect.

The nurse is teaching a mother of a newborn on ways to prevent sudden infant death syndrome (SIDS). Which of the following statements made by the mother requires further teaching?

a. I will place the infant on their back for naps and bedtime

b. I will be sure to place blankets in the crib so they don’t get too cold

c. I will not let my baby sleep in the same bed as me

d. I will avoid exposure to tobacco smoke

b.

Extra items should be removed from the crib because they could strangle or suffocate the infant. This statement requires further teaching.

A client in active labor with a cervical dilation of 5 cm and who is 80% effaced is having contractions. You as the labor nurse are monitoring her contractions. Which uterine assessment finding would require intervention?

a. Contraction duration of 70 seconds

b. Contraction frequency of every 4 minutes

c. Contraction intensity of 50 mmHg

d. Uterine resting tone of 30 mmHg

d.

Uterine resting tone should not exceed 20 mmHg. The uterus must relax in order for the fetus to get oxygen. So a uterus that is not relaxing enough puts the fetus at risk. This assessment would require further intervention.

The nurse is discussing common health issues with the parents of a teenager. Which of the statements made by the parents would indicate that the adolescent may have Anorexia Nervosa?

a. My child's teeth are starting to erode

b. My child has a fear of gaining weight

c. My child has stopped going to the gym

d. My child binge eats when they are stressed

b.

This is a classic symptom of anorexia nervosa. The child will restrain himself from food because they are so fearful of gaining weight.

The nurse is caring for a client with a newly diagnosed seizure disorder. The healthcare provider prescribes seizure precautions for the client. The nurse prepares to initiate which intervention?

a. Place restraints on the client to prevent injury

b. Prepare to insert a urinary catheter

c. Set up suction equipment at the bedside

d. Remove all linen from the bed

c.

This is part of seizure precautions: setting up suction equipment and oxygen. This would be an appropriate nursing intervention.

A client receiving magnesium sulfate has a drop in their urinary output from 140 mL at 10 AM to 100 mL at 11 AM. What would be the priority nursing intervention?

a. Call the primary healthcare provider

b. Decrease the infusion

c. Stop the infusion

d. Reassess in 15 minutes

c.

YES! This patient is at risk for magnesium toxicity and the magnesium infusion should be stopped. This is the priority nursing intervention.

A client comes into the emergency department after being in a MVA. After imaging studies, it's found that the client has a fracture to the jawbone. Your assessment shows that there is severe edema around the face and jaw, drooling, and blood in the mouth. The client rates their pain 8 out of 10. What is the priority nursing intervention?

a. Administer an analgesic for pain

b. Administer nasal oxygen at 2 L/min

c. Suction the mouth and oropharynx

d. Apply an ice pack to the face

c.

Excessive saliva and edema can compromise the airway making this the priority nursing intervention.

The nurse is assessing a client after receiving a nitroglycerin infusion for a client with a recent myocardial infarction. Which clinical finding is the priority concern?

a. Client appears flushed

b. Client reports a headache

c. Client report feeling very dizzy & lightheaded

d. Client reports feeling nervous

c.

This indicates profound hypotension, which means low blood pressure. The organs are not being perfused with blood if hypotension is occurring. This would be a priority action & the infusion should be decreased or discontinued!

The nurse on a med surg floor is getting a report from the nurse on the night shift. The following clients have family members reporting concerns. Which client should the nurse see first?

a. A client with a Glasgow coma score of 9 and is no longer responding when called

b. Client who has a migraine and is reporting pain 10/10

c. A client who is waiting to be discharged and is becoming impatient

d. A client with amyotrophic lateral sclerosis is experiencing weakness

a.

Glascow coma score of 9 is not good. A patient with a GCS of 8 or lower is classified as a coma “When you are 8, intubate.” This patient's GCS of 9 indicates they have a declining neurological status which threatens the airway and breathing (ABC’s)! This patient is the priority concern!

A client who had cardiac surgery 28 hours ago has a urine output of 19 mL/hr at 0900 and 18mL/hr at 1000. The client received a 500 mL bolus of IV fluid. The client’s blood urea nitrogen is 45 mg/dL and the serum creatinine is 2.2 mg/dL. A nurse interprets the client is at risk for:

a. Hypovolemia

b. Hypotension

c. Urinary tract Infection

d. Acute renal failure

d.

This patient's BUN and creatinine levels are high! An elevated BUN and an elevated serum creatinine level indicates the client is at risk for kidney damage.

A client has a prescription for hydrochlorothiazide due to edema from heart failure. The nurse should monitor which adverse effects related to the administration of this medication?

a. Hypouricemia, hyperkalemia

b. Fluid volume overload, hypoglycemia

c. Hypokalemia, sulfa allergy

d. Hyperkalemia, hypoglycemia, penicillin allergy

c.

Thiazide diuretics such as hydrochlorothiazide are sulfa-based medication; clients with a sulfa allergy are at high risk for an allergic reaction. Thiazide diuretics are potassium wasting drugs. This is why hypokalemia is a potential ADR.

A nurse caring for a client with a chronic obstructive pulmonary disease (COPD) exacerbation. The client is also receiving insulin due to a history of type 2 diabetes mellitus. The client has been received dexamethasone. The nurse anticipates the need for which of the following?

a. Monitoring and recording intake and output

b. Stopping the medication once the symptoms stop

c. Closely monitor for hypotension

d. Increasing the insulin dose

d.

Corticosteroids like dexamethasone increase blood sugar, which means the diabetic client would need more insulin to counteract this rise in blood sugar.

A pediatric nurse gets assigned to a child who was admitted due to persistent vomiting. The nurse knows this child is at greatest risk for which of the following?

a. Diarrhea

b. Metabolic acidosis

c. Hyperactive bowel sounds

d. Metabolic alkalosis

d.

Vomiting causes your body to lose HCl (an acid) which leads to an increased risk for alkalosis.
The question states the child is vomiting persistently so we know the child is at risk for metabolic alkalosis!

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. What statement should the nurse make to the client?

a. Sounds like an infection, you may need antibiotics

b. The vaginal discharge may be bothersome, but it’s normal during pregnancy

c. You should call and ask your healthcare provider

d. Use tampons if the discharge is bothersome

b.

Thin, colorless vaginal discharge is called Leukorrhea. It begins around the first trimester of pregnancy. This is a normal finding and is the best statement for the nurse to say.

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder?

a. A 24-year-old woman who runs marathons

b. A 42-year-old man who has COPD

c. A 68-year-old man who had recent knee surgery

d. A 65-year-old woman who smokes cigarettes

d.

Smoking increases your risk of osteoporosis! This client is at the most risk for developing osteoporosis.

A client at 13 weeks gestation arrives at the clinic for her appointment. The nurse is reviewing her history and obtains a list of her current medications. The nurse recognizes which of the following medications should be clarified to the health care provider immediately? SATA

a. Lisinopril

b. Albuterol

c. Insulin Aspart

d. Isotretinoin

e. Lithium

f. Levothyroxine

a., d., & e.

These are teratogenic drug, which should be avoided during pregnancy.

The nurse receives reports on 4 clients. Which client should the nurse assess first?

a. A client who recently received a thyroidectomy with a temperature of 100.1 F who reports feeling anxious

b. A client who received a dose of nitroglycerin and reports a bad headache

c. A client with pancreatitis who report pain rating 7 out of 10 and has a heart rate of 98 beats/min

d. A client with a continuous bladder irrigation who reports bladder spasms

a.

This client is showing signs of a thyroid storm. After a thyroidectomy, thyroid hormone levels may stay elevated causing a thyroid storm (an acute and life-threatening emergency). This patient should be seen by the nurse first!

A client is receiving lithium carbonate 900 mg/day for bipolar disorder. The laboratory notifies the nurse that the client's lithium levels are 1.0 mEq/L. Based on this result, what is the most appropriate action the nurse could take?

a. Decrease the dosage

b. Discontinue the medication immediately

c. Continue at the current dosage

d. Increase the dosage

c.

The patient's current lithium level is 1.0 mEq/L. This is within normal range so no adjustments need to be made at this time!

A nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse accurately tells the client that fetal circulation consists of:

a. Umbilical arteries that carry oxygenated blood to the fetus

b. Umbilical veins that carry deoxygenated blood to the fetus

c. Two umbilical veins & one umbilical artery

d. Two umbilical arteries & one umbilical vein

d.

This is an accurate statement about fetal circulation.

A client is found to be comatose and hypoglycemia with a blood sugar of 50 mg/dL. What nursing action is implemented first?

a. Infuse 1000 mL of D5W over a 12-hour period

b. Administer 50% glucose intravenously

c. Check the client's urine for the presence of sugar and acetone

d. Encourage the client to drink orange juice with added sugar

b.

This is the correct answer because the hypoglycemic client needs immediate attention. This is the quickest and most appropriate intervention!

You as the nurse are caring for a client with diabetes mellitus who previously had been well controlled with glyburide daily, but recently their fasting blood glucose levels have been 190 to 210 mg/dL. Which medication may have contributed to the client's hyperglycemia?

a. Prednisone

b. Atenolol

c.  Phenelzine

d. Allopurinol

a.

NCLEX TIP: Corticosteroids cause a spike in blood sugar!

A client with chronic heart failure is being discharged home with furosemide and sustained-release potassium chloride tablets. Which instructions should the nurse give to the client regarding the potassium supplements?

a. Take potassium tablets on an empty stomach

b. If you can’t swallow the pill, you can crush it and mix it with pudding

c. A diet rich in protein and vitamin D will help with absorption

d. Take it with a full glass of water and stay sitting upright afterward

d.

This is the correct instruction when teaching a client how to take potassium supplements! Flushing the pill with water will help to avoid potential erosion and esophagitis.

The nurse is doing discharge teaching for a postpartum client who is breast-feeding. Which instruction should the nurse include?

a.  Birth control measures are unnecessary while breast-feeding

b. The diet should include additional fluids

c. Prenatal vitamins should be discontinued

d. Soap should be used to cleanse the breasts

b.

A breastfeeding mother should drink additional fluids to produce breast milk. (Fun fact: breast milk is mostly made up of water!)

The nurse is monitoring a client with a peptic ulcer. Which assessment finding would most likely indicate a perforated ulcer?

a. Bradycardia

b. Numbness in the legs

c. Nausea & vomiting

d. A rigid, boardlike abdomen

d.

A rigid, boardlike abdomen is a classic sign of a gastrointestinal (GI) bleed such as a perforated ulcer. This finding would most likely indicate a perforated ulcer.

The nurse is teaching an underweight and malnourished client who was recently diagnosed with type 1 diabetes about the proper methods/techniques when giving insulin. Which one of the following shows a proper technique?

a. Pinch the skin up and use a 90-degree angle

b. Massage the area of injection after injecting the insulin

c. Warm the skin with a warm towel or washcloth prior to the injection

d. Use a 45-degree angle with the skin pinched up

d.

For a thin client, you want to use a 45-degree angle with the skin pinched up.

The nurse is caring for a client who just returned from the recovery room after undergoing an Appendectomy. The nurse identifies which of the following is an early sign of hypovolemic shock?

a. Sleepiness

b. Tachycardia

c. Increase depth of respirations

d. Increase orientation to surroundings

b.

Increased HR and decreased blood pressure are two two early signs of hypovolemic shock.

The nurse reviews the arterial blood gas results of a client and notes the following: pH = 7.45, PCO2 = 30 mmHg, and HCO3 = 22 mEq/L. The nurse analyzes these results as indicating which condition?

a. Metabolic acidosis, compensated

b. Respiratory alkalosis, compensated

c. Metabolic alkalosis, uncompensated

d. Respiratory acidosis, uncompensated

b.

A client scheduled for bowel surgery states to the nurse, “I don’t know if I want this surgery.” Which response by the nurse is appropriate?

a. It’s totally up to you

b. Don’t worry. Everything will be fine

c. Why don’t you want to have this surgery?

d. Tell me the concerns you have about this surgery

d.

This is an open-ended question that requires active listening by the nurse. This is the appropriate response by the nurse and shows therapeutic communication!

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action?

a.  “Stay as still as you can”

b. “Exhale very quickly”

c. “Inhale and exhale quickly”

d. Instruct the client on how to perform Valsalva maneuver

d.

This is the proper technique when removing a chest tube. The Valsalva maneuver is when you take a deep breath, exhale, and bear down.

Four clients enter the emergency department at the same time. Which client should the nurse see first?

a. 69-year-old with pain, swelling, erythema, and warmth in the left leg.

b. 70-year-old client with left lower abdominal pain and vomiting for 2 days

c. 25-year-old client with sudden-onset radiating chest pain and heart rate of 110/min

d. 30-year-old with diabetes who has lost there insulin glargine

c.

The 69-year-old client most likely has a Deep Vein thrombosis (DVT) and will need anticoagulants. DVT can lead to pulmonary embolism but there is no indication of this happening in the question (signs of PE: SOB, cough with blood, pain in back passing out, etc). A client having a myocardial infarction is a priority concern.

Client b. may have diverticulitis. Although they should be seen promptly, the client with a suspected myocardial infarction should be seen first!

SUDDEN, CRUSHING, RADIATING are keywords that may indicate a myocardial infarction. Patient c. is the primary concern. An ECG should be performed immediately and the client should be placed on a cardiac monitor.

Glargine is a long-acting insulin. Long-acting insulins have no peak and they last all day. This patient's glucose may rise slightly but long term uncontrolled diabetes is what damages the vessel, not a single exposure. This client is not the highest priority.

A client with end-stage renal disease who was recently placed on a Do Not Resuscitate (DNR) code status is admitted to the medical floor. The nurse walks into the room and finds the patient passed out and appears to not be breathing. Which of the following actions should the nurse take first?

a. Initiate high quality CPR

b. Call the health care provider

c. Check the apical pulse

d. Active the code blue system

c.

Checking the apical pulse is the appropriate action at this time. You will need to confirm the patient is not breathing and has passed.

The nurse provides teaching for a client prescribed disulfiram for alcohol abstinence. Which of the following statements by the client indicates the need for further teaching?

a. “I can take liquid cold and cough medications if I am feeling sick”

b. “I will wear a bracelet altering others of being on disulfiram therapy”

c. “I will abstain from alcohol for 2 weeks after the last does”

d. “I understand that disulfiram therapy does not cure alcoholism”

a.

This statement does not indicate that teaching has been effective. The client needs to avoid alcohol while on this medication. That means all things containing alcohol! Cold and cough medications contain alcohol and would produce an unpleasant response.

A client who is receiving total parenteral nutrition (TPN) complains of nausea, abdominal pain, and excessive thirst. Which of the following actions should be done by the nurse?

a. Check the client's vital signs

b. Call the health care provider

c. Slow down the rate of the infusion

d. Check the client's blood glucose

d.

The patient is showing signs of hyperglycemia. Taking the blood sugar would confirm this finding.  Interventions should be taken such as changing the TPN treatment or administering insulin.

The nurse is assessing an adolescent that has been admitted for evaluation of exercise weight loss over several months. Which of the following signs & symptoms would support a diagnosis of anorexia nervosa? SATA

a. Dehydration

b. Poor appetite

c. Amenorrhea

d. Tachycardia

e. Muscle loss

f. Constipation

a., c., e., f.

Anorexic patients starve themselves and experience loss of fluids! Dehydration would support a diagnosis of anorexia nervosa.

The body is in starvation mode and is deteriorating. This makes the normal body function decrease or stop (example: their period). This finding would support a diagnosis of anorexia nervosa.

Muscle loss is due to the weight loss and starvation state. This finding would support a diagnosis of anorexia nervosa.

Anorexic patients are dehydrated. This can cause constipation! This finding would support a diagnosis of anorexia nervosa.

A high schooler, who recently began his senior year, tells the nurse: “I can’t seem to study for my tests. Every time I try to study, my mind begins to wander.”  Which of the following statements by the nurse shows a therapeutic response?

a. “Stop making excuses and start making a detailed study schedule”

b. “I wouldn't worry, you seem smart enough to pass college”

c. “Why can’t you study?”

d. “You are having difficulty focusing?”

d.

Restating demonstrates therapeutic communication! It lets the client know whether or not the statement was understood. It gives them a chance to continue or clarify what they meant. This is therapeutic communication.

A client who recently experienced a right tibia fracture is learning about the proper use of crutches from the nurse. Which comment made by the client indicates a need for further teaching?

a. “To descend stairs, I will move my crutches and my unaffected leg first, followed by the affected leg”

b. “My crutches should be 1-2 inches below my axilla”

c. “When rising from a chair, I will place crutches on my affected side, lean forward, and push off from the chair with one hand.”

d. “I should rest my body weight mostly on my hands”

a.

This statement is incorrect. When walking down the stairs the affected leg should descend first, followed by the unaffected leg!

Down with the bad & up with the good.

The nurse has been assigned 4 clients. Who should the nurse see first?

a. A client with type 2 diabetes who was admitted for debridement of a foot ulcer

b. A client with COPD exacerbation who has an O2 saturation of 90%

c. An adolescent client post appendectomy reporting pain

d. A client with epilepsy reporting an odd smell in the room

d.

This client is most likely experiencing an aura; this means a seizure may follow. We know that airway management is a primary concern for a seizing patient. This patient should be seen first due to risk of injury, risk for aspiration, and possibly a compromised airway!

A client with chronic kidney failure has their morning labs drawn. The laboratory results show that the client’s magnesium level is 3.3 mEq/L. The nurse interprets which sign as being most significant?

a. Tachycardia

b. Drowsiness

c. Hypertension

d. Physical Hyperactivity

b.

This is a sign of hypermagnesemia. The client’s Mg level is 3.3 mEq/L which is considered Mg toxicity! Remember Mg is a sedative so if you have too much Mg in the blood, everything will be low and sedated (low energy, low HR, low BP, low RR).

The nurse is caring for a client w/ systemic lupus erythematosus (SLE). Which of the following findings should receive the highest priority?

a. weakness, malaise, & fatigue

b. butterfly-shaped rash on the face

c. elevated erythrocyte sedimentation rate (ESR)

d. elevated blood urea nitrogen (BUN) & creatinine

d.

a. & c. are typical findings in autoimmune diseases & b. is a hallmark of lupus. A complication of lupus is the spread of inflammation to the organs, causing lupus nephritis (inflammation of the kidneys) or lupus pericarditis.

A nurse working on a cardiac/neuro step-down unit is caring for a client with a history of seizures. Which nursing actions apply to the care of a client who is having a seizure? SATA

a. Note duration of the seizure

b. Restrain the client

c. Stay with the client

d. Insert an oral airway

e. Loosen clothing around the client's neck

f. Place the client in a lateral side-lying position

a., c., e., & f.

The nurse should stay with the client to reduce risk for injury and to observe and time the seizure. You should never leave a seizing patient. The nurse should stay with the client to reduce risk for injury and to observe and time the seizure. Loosening the clothing around the clients neck ensures a patent airway. Laterl side-lying decreases the risk for aspiration because the saliva can drain out the side of the mouth.

The nurse on a MedSurg floor is assigned a group of clients. The nurse knows which client taking acetaminophen would pose a higher risk?

a. 45 year old male with a history of cocaine use

b. 39 year old male who abuses alcohol

c. 19 year old female who has asthma

d. 31 year old male with arthritis

b.

Acetaminophen is hepatotoxic. Chronic alcohol use can also lead to alcoholic hepatotoxicity. A client who abuses alcohol and takes acetaminophen puts the client at risk for hepatic failure!  

A client on the psychiatric unit tells the day shift nurse: "The night nurse stole stuff from my room while I was sleeping." What is the nurse's best response?

a. "What did the nurse steal from you?"

b. "A nurse working here would never steal."

c. "Tell me more about what you saw."

d. "You must have incorrectly interpreted what you were seeing."

c.

Using open-ended questions allows the nurse to explore the client's feelings in a nonjudgmental way. It does not show approval or disapproval. This is a therapeutic response made by the nurse.

The nurse is caring for a client who just underwent a left mastectomy. The nurse should plan to place the left arm in which position?

a. Elevated on a pillow

b. Level with the left atrium

c. Dependent to the left atrium

d. Elevated above shoulder level

a.

Elevating the operative arm promotes drainage without impairing circulation to the arm.

The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?

a. The nail beds

b. The skin in the sacral area

c. The skin in the abdominal area

d. The membranes in the ear canal

a.

Jaundice, if present, is best assessed in the sclera, nail beds, and mucous membranes. This area will provide the BEST data regarding the presence of jaundice.

The nurse on a med surg floor is caring for a patient with diabetes. Which of the following findings should take priority when the nurse is assessing the skin?

a. Redness of the face & chest

b. Scleroderma on the upper back & neck

c. Vitiligo

d. Small abrasion on toe

d.

Diabetic patients have impaired wound healing. A small abrasion for a diabetic can pose a serious risk. Diabetics have poor blood flow which makes the extremities less capable of fighting infections. This finding should receive priority.

The nurse is teaching a diabetic client about proper foot care. Which of the following statements indicates teaching has been effective? SATA

a. “I will wear open toe flip flops to let my feet air out”

b. “I will not apply a heating pad directly to my feet”

c. "I will be sure to cross my legs when sitting for long periods of time”

d. “I will apply an oil on my feet to prevent them from drying out”

e. “I will report any non-healing injuries to my health care provider (HCP)”

b., d., & e.

The nurse is caring for a client with aphasia. What interventions should the nurse include when communicating with this client? SATA

a. Use open-ended questions

b. Do not push communication if the client is tired

c. Present one thought at a time

d. Talk louder when speaking to the client

e. Give the client time to generate a response

b., c., & e.

The nurse is caring for a client who recently underwent a coronary artery bypass graft. The client received morphine sulfate 4 mg IVP 30 minutes ago and has a respiratory rate of 10 breaths/minute. What is the nurse’s priority intervention?

a. Notify the primary health care provider

b. Administer naloxone 0.4 mg IVP

c. Reassess the client's respiratory rate in 15 minutes

d. Deliver rescue breaths at 30 breath/min via a bag-valve mask

b.

Naloxone is the antidote for opioids such as morphine

A client is admitted to the emergency room with a diagnosis of acute myocardial infarction. The client tells the nurse, “I’m scared. I think I’m going to die.” Which of the following responses by the nurse would be most appropriate?

a. "Everything is going to be fine. We’ll take good care of you.”

b. “I know what you mean. I thought I was having a heart attack once."

c. “I’ll call your doctor so you can discuss it with him.”

d. “It’s normal to feel frightened. We’re doing everything we can for you.”

d.

This shows active listening, recognizing the client's feelings, and assuring the client without giving false hope. (Therapeutic communications)

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? SATA

a. Explain how to collect 24-hour urine to client

b. Document the client's input & output

c. Take a tympanic temperature on the client every two hours

d. Report the client's pulse oximetry reading every hour

e. Perform postural drainage and chest physiotherapy on the client

b., c., & d.

The UAP can document I&O’s! The UAP can take vital signs but can not interpret them.