NCLEX Comprehensive Exam Questions And
Accurate Answers (A+ Graded)
Enalapril maleate is prescribed for a hospitalized client. What is the nurse's priority
assessment before administering the medication? ANSWER Checking the client's blood
pressure
Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor that is used to
treat hypertension. One common side effect related to this medication is postural
hypotension. Therefore, the nurse would monitor the client's blood pressure directly
before administering each dose. Monitoring the client's peripheral pulses, the results of
the most recent potassium level, and the intake and output for the previous 24 hours are
not specifically related to this mediation.
A client is scheduled to undergo an upper gastrointestinal series and the nurse
prepares the client for the test. Based on the following statements, which indicates that
the client requires further teaching? - ANSWER "I should drink citrate of magnesia the
night before the test and give myself a Fleet enema on the morning of the test."
An upper GI series is the visualization of the esophagus, duodenum, and upper jejunum
using a contrast medium. This involves swallowing the contrast medium, usually barium,
given as a flavored milkshake. Films are taken at intervals during the test that takes
about 30 minutes. No preparation is required prior to a GI series, except NPO status for
8 hours before the test. After an upper GI series, the client is ordered a laxative to speed
the elimination of the barium. Barium retained in the colon can become hard and difficult
to eliminate. A fecal impaction may occur.
A registered nurse working evening shift has reviewed a health care provider's
prescriptions and has determined that a dose of ordered medication is greater than the
usual dose. The nurse calls the health care provider's answering service and receives
the message that the health care provider is off for the evening and will be available in
the morning. The nurse should: ANSWER Ask the answering service to page the on-call
health care provider
An ED nurse is caring for a client suspected of having acute MI while the client awaits
transfer to the coronary intensive care unit. The nurse notices the sudden development
of PVCs on the monitor and counts the client's carotid pulse. The PVCs are not
, perfusing. The appropriate action by the nurse is: - ANSWER Asking the ED health care
provider to check the client
NPO status is ordered 8 hours prior to the procedure for a client who is to receive
electroconvulsive therapy (ECT) at 1 p.m. The nurse reviews the client's chart the
morning of the procedure and discovers that an oral antihypertensive medication is
taken every morning by the client. The nurse should: - ANSWER Administer the
antihypertensive with a small sip of water
A client who has undergone coronary artery bypass graft surgery comes to the health
care provider's office for a follow-up visit. While the nurse is assessing the client, he
tells the nurse that he is depressed. Which response by the nurse is therapeutic? -
ANSWER "Tell me more about what you're feeling."
A client who is in labor begins to experience spontaneous rupture of the membranes.
The nurse immediately starts counting the FHR for 1 full minute and then looks at the
amniotic fluid. The fluid is yellow and has an unpleasant odor. Which action is the
nurse's priority? ANSWER Notify the health care provider
The nurse has assisted a health care provider in the insertion of a central venous
access device for a client with severe malnutrition who will be receiving parenteral
nutrition (PN). Once the catheter has been inserted, the first nursing action is to: -
ANSWER Notify the radiography department to obtain a chest x-ray
A client who has been raped and is being treated in the emergency department turns to
the nurse and says, "I'm really concerned I now have HIV." What is the most appropriate
response by the nurse? - ANSWER "Let's discuss the information you will need to
identify your risk for HIV infection."
A client is prescribed ibuprofen, 300 mg po tid, for rheumatoid arthritis to relieve joint
pain. The client informs the nurse that the medication causes nausea and indigestion.
The nurse should instruct the client to: - ANSWER Take the medication with food
A patient's oral fluid intake is 120 mL during night shift, 800 mL during day shift and 650
mL during evening shift. A patient is administered an IV antibiotic every 12 hrs, diluted in
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