NCLEX exams questions and answers

Question 1:

A patient with a history of chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy at 2 liters per minute via nasal cannula. The nurse notices the patient is short of breath with an oxygen saturation of 88%. What is the nurse’s priority action?

A) Increase the oxygen to 4 liters per minute.
B) Encourage the patient to take deep breaths.
C) Sit the patient up in a high Fowler’s position.
D) Call the healthcare provider for further orders.

Answer:
C) Sit the patient up in a high Fowler’s position.

Rationale: For a patient with COPD, a priority intervention is to optimize oxygenation without dramatically increasing oxygen flow, which could suppress respiratory drive. Sitting the patient upright helps to improve lung expansion and oxygenation.

Question 2:

A 72-year-old client with type 2 diabetes is admitted with an infected foot ulcer. Which of the following would be most important for the nurse to assess?

A) Capillary refill
B) Blood glucose levels
C) Peripheral pulses
D) Blood pressure

Answer:
B) Blood glucose levels

Rationale: Infection can cause blood glucose levels to rise. Monitoring blood glucose in a diabetic patient with an infection is critical to avoid complications like hyperglycemia and diabetic ketoacidosis.

Question 3:

The nurse is caring for a postoperative patient who is receiving morphine through a patient-controlled analgesia (PCA) pump. The patient’s respiratory rate is 8 breaths per minute, and the patient is difficult to arouse. What should the nurse do first?

A) Administer naloxone as prescribed.
B) Stop the PCA pump.
C) Increase the oxygen flow rate.
D) Stimulate the patient to breathe.

Answer:
A) Administer naloxone as prescribed.

Rationale: Naloxone is an opioid antagonist that can reverse respiratory depression caused by morphine. Administering it is the immediate action to address the patient’s low respiratory rate and difficulty in arousal.

Question 4:

A nurse is educating a patient with hypertension on the DASH (Dietary Approaches to Stop Hypertension) diet. Which of the following foods should the nurse recommend?

A) Canned soup
B) Fresh fruits and vegetables
C) Processed meats
D) Full-fat dairy products

Answer:
B) Fresh fruits and vegetables

Rationale: The DASH diet emphasizes fresh fruits, vegetables, whole grains, and lean proteins to help manage blood pressure. Processed and high-sodium foods like canned soup and processed meats should be limited.

Question 5:

A nurse is assessing a patient who recently started taking lisinopril for hypertension. Which symptom should the nurse report to the healthcare provider immediately?

A) Dry cough
B) Dizziness when standing
C) Swelling of the lips and tongue
D) Increased urination

Answer:
C) Swelling of the lips and tongue

Rationale: Swelling of the lips and tongue may indicate angioedema, a potentially life-threatening side effect of ACE inhibitors like lisinopril that requires immediate medical attention.

Set 2

Fundamentals of Nursing

1. A nurse is planning care for a client with difficulty swallowing. Which intervention should be included?

   • A) Have the client sit upright at 90 degrees during meals.
   • Answer: A) Have the client sit upright at 90 degrees during meals.

2. The nurse is assessing a client’s pain level. Which is the most reliable indicator of the existence and intensity of pain?

   • A) Client’s self-report of pain
   • Answer: A) Client’s self-report of pain

3. A nurse is teaching a group of new parents about safe infant sleep. What position should infants be placed in to sleep?

   • A) On their back
   • Answer: A) On their back

4. The nurse is inserting a urinary catheter in a male patient. Which technique is essential?

   • A) Use sterile gloves
   • Answer: A) Use sterile gloves

5. When assessing a client with a wound, what indicates the need for immediate intervention?

   • A) Redness, swelling, and foul odor
   • Answer: A) Redness, swelling, and foul odor

Pharmacology

1. A patient is prescribed warfarin. Which statement indicates the need for further teaching?

   • A) “I will increase my intake of green leafy vegetables.”
   • Answer: A) “I will increase my intake of green leafy vegetables.”

2. Which food should a client taking MAOIs avoid?

   • A) Aged cheese
   • Answer: A) Aged cheese

3. A client is prescribed digoxin. Which side effect should the nurse instruct the client to report immediately?

   • A) Visual disturbances
   • Answer: A) Visual disturbances

4. A client taking lithium should be taught to:

   • A) Maintain a normal salt intake.
   • Answer: A) Maintain a normal salt intake.

5. A client is prescribed furosemide. Which lab value is most important to monitor?

• A) Potassium
• Answer: A) Potassium

Maternity Nursing

1. The nurse is assessing a pregnant client at 20 weeks’ gestation. Which finding requires immediate intervention?

• A) Facial swelling
• Answer: A) Facial swelling

1. What is the purpose of a nonstress test in pregnancy?

• A) Assess fetal well-being
• Answer: A) Assess fetal well-being

1. Which of the following would indicate that a client is in the latent phase of labor?

• A) Cervix is 3 cm dilated
• Answer: A) Cervix is 3 cm dilated

1. What is the first action the nurse should take when caring for a newborn immediately after birth?

• A) Dry the newborn to prevent heat loss.
• Answer: A) Dry the newborn to prevent heat loss.

1. Which medication is given to prevent hemorrhage in a postpartum client?

• A) Oxytocin
• Answer: A) Oxytocin

Pediatrics

1. Which vaccine is contraindicated for an infant with an allergy to eggs?

• A) MMR
• Answer: A) MMR

1. A child with asthma is prescribed a bronchodilator. Which side effect should the nurse monitor for?

• A) Tachycardia
• Answer: A) Tachycardia

1. What intervention should the nurse implement for a child with dehydration?

• A) Start an IV for fluid replacement
• Answer: A) Start an IV for fluid replacement

1. When should solid foods be introduced to an infant’s diet?

• A) At around 6 months
• Answer: A) At around 6 months

1. A 4-year-old is scheduled for surgery. What is the best way to prepare them?

• A) Allow them to play with a doll and “pretend” the surgery
• Answer: A) Allow them to play with a doll and “pretend” the surgery

Medical-Surgical Nursing

1. What is a priority intervention for a client with COPD who has an oxygen saturation of 88%?

• A) Sit the client in a high Fowler’s position
• Answer: A) Sit the client in a high Fowler’s position

1. A client with heart failure has edema. Which dietary restriction is most important?

• A) Sodium
• Answer: A) Sodium

1. Which lab value is most critical for a client with chronic kidney disease?

• A) Potassium
• Answer: A) Potassium

1. For a client with diabetes, which is a sign of hypoglycemia?

• A) Sweating and tremors
• Answer: A) Sweating and tremors

1. What intervention should be prioritized for a client with a hemoglobin level of 7 g/dL?

• A) Blood transfusion
• Answer: A) Blood transfusion

Set 3

The nurse is taking the health history of a patient being treated for Emphysema and Chronic Bronchitis. After being told the patient has been smoking cigarettes for 30 years, the nurse expects to note which assessment finding?

1. Increase in Forced Vital Capacity (FVC)
2. A narrowed chest cavity
3. Clubbed fingers
4. An increased risk of cardiac failure

Ans: 3. Clubbed fingers – CORRECT
Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels.

The nurse is taking the health history of a 70-year-old patient being treated for a Duodenal Ulcer. After being told the patient is complaining of epigastric pain, the nurse expects to note which assessment finding?

1. Melena
2. Nausea
3. Hernia
4. Hyperthermia

1. Melena – CORRECT
Melena is the finding that there are traces of blood in the stool which presents as black, tarry feces. This is a common manifestation of Duodenal Ulcers, since the Duodenum is further down the gastric anatomy.

A nurse is providing discharge teaching for a patient with severe Gastroesophogeal Reflux Disease. Which of these statements by the patient indicates a need for more teaching?

1. “I’m going to limit my meals to 2-3 per day to reduce acid secretion.”

2. “I’m going to make sure to remain upright after meals and elevate my head when I sleep”

3. “I won’t be drinking tea or coffee or eating chocolate any more.”

4. “I’m going to start trying to lose some weight.”

Ans: 1. “I’m going to limit my meals to 2-3 per day to reduce acid secretion.”
CORRECT – Large meals increase the volume and pressure in the stomach and delay gastric emptying. It’s recommended instead to eat 4-6 small meals a day.

The nurse in the Emergency Room is treating a patient suspected to have a Peptic Ulcer. On assessing lab results, the nurse finds that the patient’s blood pressure is 95/60, pulse is 110 beats per minute, and the patient reports epigastric pain. What is the PRIORITY intervention?

1. Start a large-bore IV in the patient’s arm
2. Ask the patient for a stool sample
3. Prepare to insert an NG Tube
4. Administer intramuscular morphine sulphate as ordered

1. Start a large-bore IV in the patient’s arm
CORRECT – The nurse should suspect that the patient is haemorrhaging and will need need a fluid replacement therapy, which requires a large bore IV.

A female patient with atrial fibrillation has the following lab results: Hemoglobin of 11 g/dl, a platelet count of 150,000, an INR of 2.5, and potassium of 2.7 mEq/L. Which result is critical and should be reported to the physician immediately?

1. Hemoglobin 11 g/dl
2. Platelet of 150,000
3. INR of 2.5
4. Potassium of 2.7 mEq/L

Ans: 4. Potassium of 2.7 mEq/L
CORRECT – A potassium imbalance for a patient with a history of dysrhythmia can be life-threatening and can lead to cardiac distress.

While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patient’s lower legs have become edematous and auscultates crackles in the lungs. What should the nurse do first?

1. Stop the saline infusion immediately
2. Notify Physician
3. Elevate the patient’s legs
4. Continue the infusion, since these are normal findings

Ans: 1. Stop the saline infusion immediately
CORRECT – the patient has a fluid volume overload as a result of overly rapid fluid replacement. The nurse should stop the infusion and notify the physician.

The nurse is working in a support group for clients with HIV. Which point is most important for the nurse to stress?

1. They must inform household members of their condition
2. They must take their medications exactly as prescribed
3. They must abstain from substance use
4. They must avoid large crowds

Ans: 2. They must take their medications exactly as prescribed
CORRECT – Antiretrovirals must be taken exactly as prescribed to prevent drug-resistant strains. Even missed doses can reduce the effectiveness of future treatment.

A nurse finds a 30-year-old woman experiencing anaphylaxis from a bee sting. Emergency personnel have been called. The nurse notes the woman is breathing but short of breath. Which of the following interventions should the nurse do first?

1. Initiate cardiopulmonary resuscitation
2. Check for a pulse
3. Ask the woman if she carries an emergency medical kit
4. Stay with the woman until help comes

Ans: 3. Ask the woman if she carries an emergency medical kit
CORRECT – Many patients who have a known history of anaphylaxis carry epi-pens in their pockets or belongings. This is the best way to stop a hypersensitivity reaction before it becomes life-threatening.

A man is prescribed lithium to treat bipolar disorder. The nurse is most concerned about lithium toxicity when he notices which of these assessment findings?

1. The patient states he had a manic episode a week ago
2. The patient states he has been having diarrhea every day
3. The patient has a rashy pruritis on his arms and legs
4. The patient presents as severely depressed
5. The patient’s lithium level is 1.3 mcg/L

Ans: 2. The patient states he has been having diarrhea every day
Correct – Persistent diarrhea can lead to dehydration, which can increase the risk of lithium toxicity.

A 65 year old man is prescribed Flomax (Tamsulosin) for Benign Prostatic Hyperplasia. The patient lives in an upstairs apartment. The nurse is most concerned about which side effect of Flomax?

1. Hypotension
2. Tachycardia
3. Back Pain
4. Difficulty Urinating

Ans: 1. Hypotension
Correct – Hypotension can lead to dizziness and a risk for injury to the patient.

A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin?

1. Back Pain
2. Fever and Chills
3. Risk for Bleeding
4. Dizziness

Ans: 3. Risk for Bleeding
Correct – A confused patient is at risk for injuring themselves and at risk for hemorrhage should an injury occur

A female patient is prescribed metformin for glucose control. The patient is on NPO status pending a diagnostic test. The nurse is most concerned about which side effect of metformin?

1. Diarrhea and Vomiting
2. Dizziness and Drowsiness
3. Metallic taste
4. Hypoglycemia

Ans: 4. Hypoglycemia
Correct – The patient is at risk because she is on NPO status and continuing to take an anti-glycemic drug.

The nurse is reviewing the lab results of a patient taking lithium for schizoaffective disorder. The lab results show that the blood lithium value is 1.7 mcg/L. What would the nurse take as the priority action?

1. Induce vomiting
2. Hold the next dose of Lithium
3. Administer an anti-emetic
4. Give the next dose of Lithium

Ans:  2. Hold the next dose of Lithium
Correct – Lithium’s therapeutic range is 0.5-1.5mcg/L, and begins toxicity at 1.5mcg/L

A patient asks the nurse why they must have a heparin injection. What is the nurse’s best response?

1. “Heparin will dissolve clots that you have.”
2. “Heparin will reduce the platelets that make your blood clot”
3. “Heparin will work better than warfarin.”
4. “Heparin will prevent new clots from developing.”

Ans: 4. “Heparin will prevent new clots from developing.”
Correct -This is a correct statement.

The nurse is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the troponin T value is at 5.3 ng/mL. Which of these interventions, if not completed already, would take priority over the others?

1. Put the patient in a 90 degree position
2. Check whether the patient is taking diuretics
3. Obtain and attach defibrillator leads
4. Check the patient’s last ejection fraction

1. Put the patient in a 90 degree position
Incorrect – This position is optimal for helping a patient breathe, but is not the priority action in an emergency situation.

2. Check whether the patient is taking diuretics
Incorrect – Diuretics play a role in CHF by decreasing fluid volume, but this patient is likely having an acute myocardial infarction.

Correct Answer: 3. Obtain and attach defibrillator leads
Correct – This patient is undergoing an emergency cardiac event. Normal Troponin T levels are less than 0.2 ng/mL. Ventricular Fibrillation is the cause of death in most cases of deaths due to sudden cardiac arrest. Defibrillation is the most important action to take to prevent death.

4. Check the patient’s last ejection fraction
Incorrect – Ejection fraction is a test used to gauge the severity of CHF, not an emergency cardiac arrest.

A nurse is caring for a patient undergoing a stress test on a treadmill. The patient turns to talk to the nurse. Which of these statements would require the most immediate intervention?

1. “I’m feeling extremely thirsty. I’m going to get some water after this.”
2. “I can feel my heart racing.”
3. “My shoulder and arm is hurting.”
4. “My blood pressure reading is 158/80”

1. “I’m feeling extremely thirsty. I’m going to get some water after this.”
Incorrect – This does not require immediate intervention. This is a common response to exercise and activity.

2. “I can feel my heart racing.”
Incorrect – This does not require immediate intervention. This is a common response to exercise and activity.

Correct Answer:  3. “My shoulder and arm is hurting.”
Correct – Unilateral arm and shoulder pain is one of the classic symptoms of myocardial ischemia. The stress test should be halted.

4. “My blood pressure reading is 158/80”
Incorrect – This does not require immediate intervention. Moderate elevation in blood pressure is a common response to exercise and activity.

The nurse is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the BNP (B-type Natriuretic Peptide) value is a 615 pg/ml. What would the nurse take as the priority action?

1. Call a cardiac code and implement emergency measures
2. Check the patient’s oxygen saturation
3. Inform the physician that the patient has Congestive Heart Failure
Encourage the patient to limit activity

1. Call a cardiac code and implement emergency measures
Incorrect – There is no evidence that the patient is undergoing a cardiac arrest.

Correct Answer: 2. Check the patient’s oxygen saturation
Correct – An elevated BNP indicates that there is decreased cardiac output. A priority intervention would be to ensure proper oxygenation after an assessment.

3. Inform the physician that the patient has Congestive Heart Failure
Incorrect – Although BNP suggests Congestive Heart Failure, it is not used in itself to diagnose CHF. An elevated BNP can also be caused by dysrhythmias or renal disease.

4. Encourage the patient to limit activity
Incorrect – This is an intervention that can help treat CHF, but not a priority action at this time.

A nurse is caring for a patient after a coronary angiogram. Which of these actions taken by the nursing assistant would most require the nurse’s immediate intervention?

1. The nursing assistant fills the patient’s pitcher with ice cold drinking water
2. The nursing assistant elevates the head of the bed to 60 degrees for a meal
3. The nursing assistant refills the ice pack laying on the insertion site
4. The nursing assistant places an extra pillow under the patient’s head on request

1. The nursing assistant fills the patient’s pitcher with ice cold drinking water
Incorrect – It is recommended to generously hydrate after a coronary angiogram to excrete contrast medium, reducing kidney toxicity

Correct Answer: 2. The nursing assistant elevates the head of the bed to 60 degrees for a meal
Correct – For 3-6 hours after a coronary angiogram (depending on the insertion site), the patient should have their bed no higher than 30 degrees and be on bedrest.

3. The nursing assistant refills the ice pack laying on the insertion site
Incorrect – An ice pack or dressing is recommended to be placed on the insertion site to minimize risk of bleeding.

4. The nursing assistant places an extra pillow under the patient’s head on request
Incorrect – An extra pillow will not violate any post-procedural protocols for coronary angiogram.

A man is has been taking lisinopril for CHF. The patient is seen in the emergency room for persistent diarrhea. The nurse is concerned about which side effect of lisinopril?

1. Vertigo
2. Hypotension
3. Palpitations
4. Nagging, dry cough

1. Vertigo
Incorrect – While this may occur, the patient is at higher risk due to another adverse effect.

Correct Answer: 2. Hypotension
Correct – The patient is particularly at risk for hypotension due to possible dehydration from fluid loss.

3. Palpitations
Incorrect – While this may occur, the patient is at higher risk for another adverse effect.

4. Nagging, dry cough
Incorrect – While this is a common side effect, the patient is at higher risk for another adverse effect..

The nurse is taking the health history of a patient being treated for sickle cell disease. After being told the patient has severe generalized pain, the nurse expects to note which assessment finding?

1. Severe and persistent diarrhea
2. Intense pain in the toe
3. Yellow-tinged sclera
4. Headache

1. Severe and persistent diarrhea
Incorrect – This is not a manifestation of sickle cell disease

2. Intense pain in the toe
Incorrect – Gout is a manifestation of Polycythemia Vera, in which the there is an overabundance of red blood cells

Correct Answer:  3. Yellow-tinged sclera
Correct – Jaundice is a common clinical finding of sickle cell disease, caused by bilirubin released from damaged or destroyed RBCs

4. Headache
Incorrect – While this may occur, it is not indicative or a classic symptom of sickle cell disease.

A client with Multiple Sclerosis reports a constant, burning, tingling pain in the shoulders. The nurse anticipates that the physician will order which medication for this type of pain?

1. alprazolam (Xanax)
2. Corticosteroid injection
3. gabapentin (Neurontin)
4. hydrocodone/acetaminophen (Norco)

1. alprazolam (Xanax)
Incorrect – alprazolam is used to reduce anxiety

2. Corticosteroid injection
Incorrect – Corticosteroid injections are used to reduce inflammation in a localized area, often due to joint breakdown. In MS patients it is used to treat acute exacerbations (“flare-ups”), but the symptoms described do not constitute an acute exacerbation.

Correct Answer:  3. gabapentin (Neurontin)
Correct – Anticonvulsants like gabapentin are often the first line of treatment for nerve pain

4. hydrocodone/acetaminophen (Norco)
Incorrect – Opioids would not be the appropriate medication to treat nerve pain.

Which of these clients is likely to receive sublingual morphine?

1. A 75-year-old woman in a hospice program
2. A 40-year-old man who just had throat surgery
3. A 20-year-old woman with trigeminal neuralgia
4. A 60-year-old man who has a painful incision

Correct Answer: 1. A 75-year-old woman in a hospice program
Correct – Sublingual morphine is often used in hospice because the patients are unable to swallow, and intravenous access can be painful and not conducive to palliative care.

2. A 40-year-old man who just had throat surgery
Incorrect – Patients who have surgery most likely have an Intravenous line

3. A 20-year-old woman with trigeminal neuralgia
Incorrect – Morphine would not be the first choice for nerve pain

4. A 60-year-old man who has a painful incision
Incorrect – Although Morphine would be an appropriate medications, there is no indication that it should be administered sublingually

In educating clients on ways to manage pain, which topic can be appropriately delegated to a LPN/LVN who will continue under supervision?

1. Acupuncture
2. Guided Imagery
3. Alternating Rest/Activity
4. Over the counter medications

1. Acupuncture
Incorrect – This is outside the nursing scope of practice and requires special training or education

2. Guided Imagery
Incorrect – This also requires additional training or education

Correct Answer:  3. Alternating Rest/Activity
Correct – This is within the nursing scope of practice and within the training and education provided to all nurses. It is safe to use and a standard treatment.

4. Over the counter medications
Incorrect – This is outside the nursing scope of practice. A healthcare provider (doctor, nurse practitioner, or physician’s assistant) should be consulted before taking over the counter medications.

The nurse assesses a patient suspected of having an asthma attack. Which of the following is a common clinical manifestation of this condition?

1. Audible crackles and orthopnea
2. An audible wheeze and use of accessory muscles
3. Audible crackles and use of accessory muscles
4. Audible wheeze and orthopnea

1. Audible crackles and orthopnea
Incorrect – Crackles indicate fluid in the lungs, which is not a cause of asthma. Orthopnea is not associated with asthma.

Correct Answer:  2. An audible wheeze and use of accessory muscles
Correct – Both of these are associated with asthma.

3. Audible crackles and use of accessory muscles
Incorrect – Crackles indicate fluid in the lungs, which is not a cause of asthma.
4. Audible wheeze and orthopnea
Incorrect – Orthopnea is not associated with asthma.

The nurse assesses a patient suspected of having meningitis. Which of the following is a common clinical manifestation of this condition?

1. A high WBC count and decreased level of consciousness
2. A high WBC count and manic activity
3. A low WBC count and manic activity
4. A low WBC count and decreased level of consciousness

Correct Answer: 1. A high WBC count and decreased level of consciousness
Correct – Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness.

2. A high WBC count and manic activity
Incorrect – Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness.

3. A low WBC count and manic activity
Incorrect – Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness.

4. A low WBC count and decreased level of consciousness
Incorrect – Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness.

A patient is being treated in the Neurology Unit for Meningitis. Which of these is a priority assessment for the nurse to make?

1. Assess the patient for nuchal rigidity
2. Determine the patient’s past exposure to infectious organisms
3. Check the patient’s WBC lab values
4. Monitor for increased lethargy and drowsiness

1. Assess the patient for nuchal rigidity
Incorrect – Although neck stiffness can be a symptom of Meningitis, it is not used to define meningitis, neither is it a sign of further neurological deterioration.

2. Determine the patient’s past exposure to infectious organisms
Incorrect – Although this is an important part of the history gathering process, and meningitis is most often caused by a viral or bacterial infection, it is not the priority assessment.

3. Check the patient’s WBC lab values
Incorrect – Although WBCs do rise during an infection like Mengingitis, it is not the priority assessment.

Correct Answer: 4. Monitor for increased lethargy and drowsiness
Correct – Lethargy and drowsiness indicate a decreased level of consciousness, which is the cardinal sign of increased ICP (Intracranial Pressure), which can be life-threatening.

The nurse is caring for clients in the pediatric unit. A 6-year patient is admitted who has 2nd and 3rd degree burns on his arms. The nurse should assign the new patient to which of the following roommates?

1. A 4-year old with sickle-cell disease
2. A 12-year old with chickenpox
3. A 6-year old undergoing chemotherapy
4. A 7-year old with a high temperature

Correct Answer: 1. A 4-year old with sickle-cell disease
Correct – The nurse should be concerned about the burn patient’s vulnerability to infection. Sickle cell disease is not a communicable disease.

2. A 12-year old with chickenpox
Incorrect – Chickenpox is a communicable disease

3. A 6-year old undergoing chemotherapy
Incorrect – This patient is already immunosuppressed and should not have a roommate regardless.

4. A 7-year old with a high temperature
Incorrect – An unspecified fever is often indicative of an infection of some type.

A patient with Meningitis is being treated with Vancomycin intravenously 3 times per day. The nurse notes that the urine output during the last 8 hours was 200mL. What is the nurse’s priority action?

1. Check the patient’s last BUN
2. Ask the patient to increase their fluid intake
3. Ask the physician to order a diuretic
4. Notify the physician of this finding

1. Check the patient’s last BUN
Incorrect – This may be relevant to nephrotoxicity and poor urine output, but is not the priority action. An assessment finding has already been done and indicates an immediate intervention.

2. Ask the patient to increase their fluid intake
Incorrect – Increasing oral intake without other interventions will increase risk of increased ICP and fluid overload.

3. Ask the physician to order a diuretic
Incorrect – This is premature and would not be the correct intervention.

Correct Answer: 4. Notify the physician of this finding
Correct – Vancomycin is a nephrotoxic drug and can cause impaired renal perfusion, which would cause a decreased urine output. This is a serious adverse effect and should be reported to the physician.

A patient is being admitted to the ICU with a severe case of encephalitis. Which of these drugs would the nurse not be expect to be prescribed for this condition?

1. Acyclovir (Zovirax)
2. Mannitol (Osmitrol)
3. Lactated Ringer’s
4. Phenytoin (Dilantin)

1. Acyclovir (Zovirax)
Incorrect- Acyclovir is a common antiviral drug for the treatment of viral encephalitis

2. Mannitol (Osmitrol)
Incorrect – Mannitol is a hyperosmolar drug that helps reduce Intracranial Pressure by acting as a diuretic and decreasing fluid in the body.

Correct Answer: 3. Lactated Ringer’s
Correct – Lactated Ringer’s solution is often used in fluid replacement therapy, which is not warranted if a patient is at risk for high ICP.

4. Phenytoin (Dilantin)
Incorrect – Phenytoin is an anticonvulsant and is often used to prevent seizures, which can complicate and worsen a patient’s neurological state.

The nurse is treating a patient who has Parkinson’s Disease. Which of these practices would not be included in the care plan?

1. Decrease the calorie content of daily meals to avoid weight gain
2. Allow the patient extra time to respond to questions and do ADLs
3. Use thickened liquids and a soft diet
4. Encourage the patient to hold the spoon when eating

Correct Answer:  1. Decrease the calorie content of daily meals to avoid weight gain
Correct – Calorie content should be increased for patients with Parkinson’s Disease because of dysphagia (difficulty swallowing), as well as calories burned due to muscle rigidity.

2. Allow the patient extra time to respond to questions and do ADLs
Incorrect – This is a best practice when working with PD patients.

3. Use thickened liquids and a soft diet
Incorrect – This is often used to reduce the risk of aspiration

4. Encourage the patient to hold the spoon when eating
Incorrect – The patient should be encouraged to perform ADLs as independently as possible.

A 45-year old woman is prescribed ropinirole (Requip) for Parkinson’s Disease. The patient is living at home with her daughter. The nurse is most concerned about which side effect of ropinirole?

1. Slurred speech
2. Sudden dizziness
3. Masklike facial expression
4. Stooped Posture

1. Slurred speech
Incorrect – Slurred speech is a common symptom of PD, not a side effect of this drug.

Correct Answer: 2. Sudden dizziness
Correct – Dizziness and orthostatic hypotension are serious adverse effects of this drug that can lead to an increased risk of falls. Ropinirole’s drug class is a dopamine agonist, which mimic dopamine in the brain (PD is characterized by a lack of dopamine).

3. Masklike facial expression
Incorrect – Masklike facial expression is a common symptom of PD, not a side effect of this drug.

4. Stooped Posture
Incorrect – Stooped Posture is a common symptom of PD, not a side effect of this drug.

The nurse is taking the health history of a patient being treated for Parkinson’s Disease. After being told the patient has classic symptoms of Parkinson’s, the nurse expects to note which assessment finding?

1. Tremors
2. Low Urine Output
3. Exaggerated arm movements
4. Risk for Falls

Correct Answer: 1. Tremors
Correct – Tremors is one of four cardinal signs of PD: the other three are rigidity, bradykinesia (slow movements), and postural instability

2. Low Urine Output
Incorrect – This is not a relevant symptom to PD

3. Exaggerated arm movements
Incorrect – A symptom of PD would be rigidity and slow arm movements, rather than exaggeration of arm movements

4. Risk for Falls
Incorrect – This is not an assessment finding. This is a nursing diagnosis.

A nurse enters a patient’s room and finds them unconscious with a rhythmic jerking of all four extremities. The patient is foaming heavily at the mouth. The patient was on seizure precautions and the bedrails are up and padded. What is the nurse’s priority action?

1. Administer Lorazepam (Ativan)
2. Turn the patient to his/her side
3. Call the physician
4. Suction the patient

1. Administer Lorazepam (Ativan)
Incorrect – If a seizure lasts more than 5 minutes, it is called Status epilepticus and can be life-threatening. Physicians will often order anxiolytics or sedatives to treat this condition. However, at this point it would not be appropriate for the nurse to administer this drug.

Correct Answer: 2. Turn the patient to his/her side
Correct – Turning the patient to the side will keep the airway open, which is the first priority

3. Call the physician
Incorrect – This would be a priority action after ensuring the patient’s safety, or in the case of Status epilepticus

4. Suction the patient
Incorrect – This intervention is warranted, but after an assessment of the patient’s airway, since forcing a suction catheter into a patient’s mouth is a last resort.

A nurse is giving a discharge education to a patient who has been diagnosed with epilepsy. Which of these teachings would she stress the most?

1. Avoid doing alcohol and drugs
2. Follow up with the neurologist, physician, or other health care provider as prescribed
3. Do not stop taking anticonvulsants, even if seizures have stopped
4. Wear a medical alert bracelet or carry an ID card indicating epilepsy

1. Avoid doing alcohol and drugs
Incorrect – Although this is a general teaching that would be applied to any hospital discharge situation, it is not the priority to be stressed.

2. Follow up with the neurologist, physician, or other health care provider as prescribed
Incorrect – Although this is correct to include in discharge education, following this instruction is not directly contributing to their safety, so is not the priority.

Correct Answer: 3. Do not stop taking anticonvulsants, even if seizures have stopped
Correct – Following this instruction is essential for their safety, since stopping anti-epileptic drugs suddenly can cause seizures and an increased chance of status epilecticus

4. Wear a medical alert bracelet or carry an ID card indicating epilepsy
Incorrect – Although this is correct to include in discharge education, following this instruction is not directly contributing to their safety, so is not the priority.

The nurse is caring for a patient in the ICU who has had a spinal cord injury. She observes that his last blood pressure was 100/55, and his pulse is 48. These have both trended downwards from the baseline. What should the nurse expect to be the next course of action ordered by the physician?

1. Assess the patient for decreased level of consciousness
2. Administer Normal Saline
3. Insert an NG Tube
4. Connect and read an EKG

1. Assess the patient for decreased level of consciousness
Incorrect – An assessment has already been made, and an intervention is warranted.

Correct Answer: 2. Administer Normal Saline
Correct – The patient is entering neurogenic shock. Normal saline will replace fluid volume, treating the hypotension and bradycardia symptomatically. Atropine sulfate is also commonly used to increase the heart rate.

3. Insert an NG Tube
Incorrect – An NG tube would not be relevant in this situation.

4. Connect and read an EKG
Incorrect – An EKG would not be needed in this situation.

A nurse is caring for a patient who is suspected to have sustained a spinal cord injury. What best describes the overarching principles used to guide the care for this type of condition?

1. Immobilize the cervical area to prevent further injury
2. Monitor the patient’s level of consciousness to prevent neurologic deterioration
3. Help the patient with activities of daily living and provide emotional and physical support to help them adjust to their injury
4. Facilitate tissue perfusion to the spinal cord while maintaining airway and breathing

1. Immobilize the cervical area to prevent further injury
Incorrect – While this is an essential part of caring for a spinal cord injury, it does not adequately describe guiding principles for a complete plan of care

2. Monitor the patient’s level of consciousness to prevent neurologic deterioration
Incorrect – While this is an essential part of caring for a spinal cord injury, it does not adequately describe guiding principles for a complete plan of care

3. Help the patient with activities of daily living and provide emotional and physical support to help them adjust to their injury
Incorrect – These are important in the later stages of a spinal cord injury after the patient has been stabilized, but at this point would be premature.

Correct Answer: 4. Facilitate tissue perfusion to the spinal cord while maintaining airway and breathing
Correct – Maintaining airway, breathing, and circulation is both essential and guides the overall plan of care for a patient with a spinal cord injury.

A 23-year-old woman is admitted to the infusion clinic after a Multiple Sclerosis Exacerbation. The physician orders methylprednisolone infusions (Solu-Medrol). The nurse would expect which of the following outcomes after administration of this medication?

1. A decrease in muscle spasticity and involuntary movements
2. A slowed progression of Multiple Sclerosis related plaques
3. A decrease in the length of the exacerbation
4. A stabilization of mood and sleep

1. A decrease in muscle spasticity and involuntary movements
Incorrect – While muscle spasticity and involuntary movements can be symptoms of MS, a corticosteroid infusion is not meant to directly treat these symptoms.

2. A slowed progression of Multiple Sclerosis related plaques
Incorrect – Special drugs like Interferon Beta, Natalizumab, or Glatiramir acetate are used as first-line treatments to slow the progression of MS. While corticosteroids can be used in conjunction with these drugs on a long-term basis, they would not be infused. They would be taken orally.

Correct Answer: 3. A decrease in the length of the exacerbation
Correct – A methylprednisolone infusion is the first line of treatment during an acute exacerbation and is used to decrease the length and severity of a relapse.

4. A stabilization of mood and sleep
Incorrect – Some of the frequent side effects of a Methylprednisolone infusion are anxiety, insomnia, and mood swings

A nurse knows that which of these patients are at greatest risk for a stroke?

1. A 60-year old male who weighs 270 pounds, has atrial fibrillation, and has had a TIA in the past.

2. A 75-year old male who has frequent migraines, drinks a glass of wine every day, and is Hispanic.

3. A 40-year old female who has high cholesterol and uses oral contraceptives

4. A 65-year old female who is African American, has sickle cell disease and smokes cigarettes.

Correct Answer: 1. A 60-year old male who weighs 270 pounds, has atrial fibrillation, and has had a TIA in the past.
Correct – Common risk factors for developing stroke include: Atrial fibrillation, arteriosclerosis, previous stroke or ischemic attack, heart surgery, valvular heart disease, diabetes, smoking, substance abuse,obesity, sedentary lifestyle, oral contraceptive use, genetic tendency, migraines, older age, male, African American/Hispanic/American Indian, Sickle Cell Anemia, and brain trauma. This man has the greatest risk based on these risk factors.

2. A 75-year old male who has frequent migraines, drinks a glass of wine every day, and is Hispanic.
Incorrect – See Common Risk Factors for Developing a Stroke.

3. A 40-year old female who has high cholesterol and uses oral contraceptives
Incorrect – See Common Risk Factors for Developing a Stroke.

4. A 65-year old female who is African American, has sickle cell disease and smokes cigarettes.
Incorrect – See Common Risk Factors for Developing a Stroke.

A nurse frequently treats patients in the 72-hour period after a stroke has occurred. The nurse would be most concerned about which of these assessment findings?

1. INR is 3 seconds long
2. Heart rate is 110 beats per minute
3. Intracranial Pressure is 22 mm/Hg
4. Blood pressure is 140/80

1. INR is 3 seconds long
Incorrect – This is actually within a therapeutic range for clotting times for patients with coagulation risks. A normal INR is .9-1.2 seconds, while a therapeutic INR can be as high as 3.5 seconds.

2. Heart rate is 110 beats per minute
Incorrect – While tachycardia is a concern, general tachycardia without other associated symptoms would not pose an immediate danger, and is not of greater priority than the next answer.

Correct Answer: 3. Intracranial Pressure is 22 mm/Hg
Correct – The patient is at greatest risk for an increased ICP resulting from edema 72 hours after a stroke. A target ICP should be less than or equal to 15-20 mm/Hg

4. Blood pressure is 140/80
Incorrect – Blood pressure is often kept higher than usual following a stroke to maintain perfusion. Systolic BP higher than 180, or diastolic BP higher than 105, would be the upper limit and required intervention. 140/80 would not pose an immediate danger to the patient’s health.

A nurse is caring for a patient scheduled to have cataract surgery. The patient asks why they developed cataracts and how they can prevent it from happening again. What is the nurse’s best response?

1. “Age is the biggest factor contributing to cataracts.”
2. “Unprotected exposure to UV lights can cause cataracts”
3. “Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts.”
4. “Unfortunately, there is really nothing you can do to prevent cataracts, but they are amongst the most easily treated eye conditions.”

1. “Age is the biggest factor contributing to cataracts.”
Incorrect – While true, this answer leaves out many other contributing factors to cataracts and does not address prevention.

2. “Unprotected exposure to UV lights can cause cataracts”
Incorrect – While true, this answer is not complete

Correct Answer: 3. “Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts.”
Correct – This answer covers the most common contributing factors for cataracts and includes preventable risk factors.

4. “Unfortunately, there is really nothing you can do to prevent cataracts, but they are amongst the most easily treated eye conditions.”
Incorrect – While most cataracts are age-related cataracts, there are still ways to prevent eye damage and cataract development.

A patient with Glaucoma is verbalizing his daily medication routine to the nurse. He states he has two different eyedrop medications, both every twelve hours. He washes his hands, instills the drops, closes his eyes gently, and presses his finger to the corner of his eye nearest his nose. After waiting 1 minute with his eyes closed, he instills the other medication in the same way. What is the nurse’s best response?

1. “You should wait more than 1 minute between different medications.”

2. “Your routine is very good! Can you demonstrate it for me?”

3. “It is actually not the best practice to close your eyes after instilling eyedrops.”

4. “You should actually be pressing your finger in the other corner of the eye.”

Correct Answer: 1. “You should wait more than 1 minute between different medications.”
Correct – It is recommended to wait 10-15 minutes between different eyedrop medications to give them time to absorb an avoid one medication washing another one out.

2. “Your routine is very good! Can you demonstrate it for me?”
Incorrect – There is something wrong with what the patient described as his routine. After the nurse corrects this, a return demonstration would be appropriate.

3. “It is actually not the best practice to close your eyes after instilling eyedrops.”

4. “You should actually be pressing your finger in the other corner of the eye.”
Incorrect – THis is not true.

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