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NCLEX-PN Review Questions (1).
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NCLEX-PN Review Questions (1).
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NCLEX-PN Review Questions3. Clubbed fingers - CORRECT
Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels. - ANS-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
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. - ANS-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. "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. - ANS-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."
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. - ANS-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
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. - ANS-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
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. - ANS-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
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. - ANS-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
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. - ANS-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
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. - ANS-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
1. Hypotension
Correct - Hypotension can lead to dizziness and a risk for injury to the patient. - ANS-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
3. Risk for Bleeding
Correct - A confused patient is at risk for injuring themselves and at risk for hemorrhage should
an injury occur - ANS-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
4. Hypoglycemia
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