NCLEX RN ACTUAL >> QUESTIONS AND ANSWERS 2024 LATEST
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NCLEX RN
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NCLEX RN
NCLEX RN ACTUAL >> QUESTIONS AND ANSWERS 2024 LATEST
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?
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NCLEX RN ACTUAL >> QUESTIONS AND
ANSWERS 2024 LATEST
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. Increase in Forced Vital Capacity (FVC)
Forced Vital Capacity is the volume of air exhaled from full inhalation to full exhalation.
A patient with COPD would have a decrease in FVC. Incorrect.
2. A narrowed chest cavity
A patient with COPD often presents with a 'barrel chest,' which is seen as a widened
chest cavity. Incorrect.
3. Clubbed fingers - CORRECT
Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels.
4. An increased risk of cardiac failure
Although a patient with these conditions would indeed be at an increased risk for
cardiac failure, this is a potential complication and not an assessment finding. Incorrect.
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.
2. Nausea
Nausea may be present, but is a generalized symptom and by itself doesn't indicate a
Duodenal Ulcer. Incorrect.
,3. Hernia
A Hernia is a protrusion of a segment of the abdomen through another abdominal
structure. It is not associated with an Ulcer and is a condition, not an assessment
finding. Incorrect.
4. Hyperthermia
Hyperthermia, a high temperature, is not an assessment finding of a Duodenal Ulcer.
Incorrect
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. "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.
2. "I'm going to make sure to remain upright after meals and elevate my head when I
sleep"
Incorrect - This is a correct verbalization of health promotion for GERD.
3. "I won't be drinking tea or coffee or eating chocolate any more."
Incorrect - This is a correct verbalization of health promotion for GERD.
4. "I'm going to start trying to lose some weight."
Incorrect - This is a correct verbalization of health promotion for GERD.
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.
2. Ask the patient for a stool sample
Incorrect - While this is useful in the diagnosis and assessment of Peptic Ulcer Disease,
it is not the priority intervention.
3. Prepare to insert an NG Tube
Incorrect - While this intervention may be used in the later stages of Peptic Ulcer
Disease, it is not the first and priority intervention.
4. Administer intramuscular morphine sulphate as ordered
Incorrect - While this is an important intervention to manage pain, it is not the priority
intervention.
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. Hemoglobin 11 g/dl
This is below normal, but a normal female hemoglobin is 12-14. There is a more critical
lab result.
2. Platelet of 150,000
This is also below the normal values, but is not the most critical lab result.
3. INR of 2.5
This is a therapeutic range for a patient who is taking an anticoagulant for atrial
fibrillation
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 - .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.
2. Notify Physician
This is not the first action the nurse should take.
3. Elevate the patient's legs
This would help with the edema, but is not a priority
4. Continue the infusion, since these are normal findings
This is not a normal finding
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 - .1. They must inform household members of their
condition
Incorrect - Each patient has a right to privacy of their medical condition. It is their choice
whether they inform household members.
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.
1. bInitiate bcardiopulmonary bresuscitation
2. bCheck bfor ba bpulse b
3. bAsk bthe bwoman bif bshe bcarries ban bemergency bmedical bkit
4. bStay bwith bthe bwoman buntil bhelp bcomes b- b.1. bInitiate bcardiopulmonary bresuscitation
Incorrect b- bCPR bis bpremature bat bthis bpoint, band bthere bis banother baction bthat bcan bbe
btaken bfirst.
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