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NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS
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NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS
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NCLEX COMPREHENSIVE EXAMQUESTIONS AND ANSWERS
Enalapril maleate is prescribed for a hospitalized client. Which assessment does the
nurse perform as a priority before administering the medication? - Answer-Checking the
client's blood pressure
Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used
to treat hypertension. One common side effect is postural hypotension. Therefore the
nurse would check the client's blood pressure immediately before administering each
dose. Checking 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 associated
with this mediation.
A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse
provides instructions to the client about the test. Which statement by the client indicates
a need for further instruction? - Answer-"I need to drink citrate of magnesia the night
before the test and give myself a Fleet enema on the morning of the test."
Rationale: An upper GI series involves visualization of the esophagus, duodenum, and
upper jejunum by means of the use of a contrast medium. It involves swallowing a
contrast medium (usually barium), which is administered in a flavored milkshake. Films
are taken at intervals during the test, which takes about 30 minutes. No special
preparation is necessary before a GI series, except that NPO status must be maintained
for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to
hasten elimination of the barium. Barium that remains in the colon may become hard
and difficult to expel, leading to fecal impaction.
A nurse on the evening shift checks a health care provider's prescriptions and notes that
the dose of a prescribed medication is higher than the normal dose. The nurse calls the
health care provider's answering service and is told that the health care provider is off
for the night and will be available in the morning. The nurse should: - Answer-Ask the
answering service to contact the on-call health care provider
Rationale: The nurse has a duty to protect the client from harm. A nurse who believes
that a health care provider's prescription may be in error is responsible for clarifying the
prescription before carrying it out. Therefore the nurse would not administer the
medication; instead, the nurse would withhold the medication until the dose can be
clarified. The nurse would not wait until the next morning to obtain clarification. It is
premature to call the nursing supervisor.
An emergency department (ED) nurse is monitoring a client with suspected acute
myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit.
The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the
,monitor, checks the client's carotid pulse, and determines that the PVCs are not
resulting in perfusion. The appropriate action by the nurse is: - Answer-Asking the ED
health care provider to check the client
Rationale: PVCs are a result of increased irritability of ventricular cells. Peripheral
pulses may be absent or diminished with the PVCs themselves because the decreased
stroke volume of the premature beats may in turn decrease peripheral perfusion.
Because other rhythms also cause widened QRS complexes, it is essential that the
nurse determine whether the premature beats are resulting in perfusion of the
extremities. This is done by palpating the carotid, brachial, or femoral artery while
observing the monitor for widened complexes or by auscultating for apical heart sounds.
In the situation of acute MI, PVCs may be considered warning dysrhythmias, possibly
heralding the onset of ventricular tachycardia or ventricular fibrillation. Therefore the
nurse would not tell the client that the PVCs are expected. Although the nurse will
continue to monitor the client and document the findings, these are not the most
appropriate actions of those provided. The most appropriate action would be to ask the
ED health care provider to check the client.
NPO status is imposed 8 hours before the procedure on a client scheduled to undergo
electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse
checks the client's record and notes that the client routinely takes an oral
antihypertensive medication each morning. The nurse should: - Answer-Administer the
antihypertensive with a small sip of water
Rationale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8
hours before treatment to help prevent aspiration. Exceptions include clients who
routinely receive cardiac medications, antihypertensive agents, or histamine (H2)
blockers, which should be administered several hours before treatment with a small sip
of water. Withholding the antihypertensive and administering it at bedtime and
withholding the antihypertensive and resuming administration on the day after the ECT
are incorrect actions, because antihypertensives must be administered on time;
otherwise, the risk for rebound hypertension exists. The nurse would not administer a
medication by way of a route that has not been prescribed.
A client who recently underwent coronary artery bypass graft surgery comes to the
health care provider's office for a follow-up visit. On assessment, the client tells the
nurse that he is feeling depressed. Which response by the nurse is therapeutic? -
Answer-"Tell me more about what you're feeling."
Rationale: When a client expresses feelings of depression, it is extremely important for
the nurse to further explore these feelings with the client. In stating, "This is a normal
response after this type of surgery" the nurse provides false reassurance and avoids
addressing the client's feelings. "It will take time, but, I promise you, you will get over the
depression" is also a false reassurance, and it does not encourage the expression of
feelings. "Every client who has this surgery feels the same way for about a month" is a
generalization that avoids the client's feelings.
,A client in labor experiences spontaneous rupture of the membranes. The nurse
immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the
amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which
action should be the nurse's priority? - Answer-Contacting the health care provider
Rationale: The FHR is assessed for at least 1 minute when the membranes rupture.
The nurse also checks the quantity, color, and odor of the amniotic fluid. The fluid
should be clear (often with bits of vernix) and have a mild odor. Fluid with a foul or
strong odor, cloudy appearance, or yellow coloration suggests chorioamnionitis and
warrants notifying the health care provider. A large amount of vernix in the fluid
suggests that the fetus is preterm. Greenish, meconium-stained fluid may be seen in
cases of postterm gestation or placental insufficiency. Checking the fluid for protein is
not associated with the data in the question. Although the nurse would continue to
monitor the client and the FHR and would document the findings, contacting the health
care provider is the priority.
A nurse has assisted a health care provider in inserting a central venous access device
into a client with a diagnosis of severe malnutrition who will be receiving parenteral
nutrition (PN). After insertion of the catheter, the nurse immediately plans to: - Answer-
Call the radiography department to obtain a chest x-ray
Rationale: One major complication associated with central venous catheter placement is
pneumothorax, which may result from accidental puncture of the lung. After the catheter
has been placed but before it is used for infusions, its placement must be checked with
an x-ray. Hanging the prescribed bag of PN and starting the infusion at the prescribed
rate and infusing normal saline solution through the catheter at a rate of 100 mL/hr to
maintain patency are all incorrect because they could result in the infusion of solution
into a lung if a pneumothorax is present. Although the nurse may obtain a blood glucose
measurement to serve as a baseline, this action is not the priority.
A rape victim being treated in the emergency department says to the nurse, "I'm really
worried that I've got HIV now." What is the appropriate response by the nurse? -
Answer-"Let's talk about the information that you need to determine your risk of
contracting HIV."
Rationale: HIV is a concern of rape victims. Such concern should always be addressed,
and the victim should be given the information needed to evaluate his or her risk.
Pregnancy may occur as a result of rape, and pregnancy prophylaxis can be offered in
the emergency department or during follow-up, once the results of a pregnancy test
have been obtained. However, stating, "You're more likely to get pregnant than to
contract HIV" avoids the client's concern. Similarly, "HIV is rarely an issue in rape
victims" and "Every rape victim is concerned about HIV" are generalized responses that
avoid the client's concern.
, A client is taking prescribed ibuprofen, 200 mg orally four times daily, to relieve joint
pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is
causing nausea and indigestion. The nurse should tell the client to: - Answer-Take the
medication with food
Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication. Side effects include
nausea (with or without vomiting) and dyspepsia (heartburn, indigestion, or epigastric
pain). If gastrointestinal distress occurs, the client should be instructed to take the
medication with milk or food. The nurse would not instruct the client to stop the
medication or instruct the client to adjust the dosage of a prescribed medication; these
actions are not within the legal scope of the role of the nurse. Contacting the health care
provider is premature, because the client's complaints are side effects that occasionally
occur and can be relieved by taking the medication with milk or food.
The night nurse is caring for a client who just had a craniotomy. The nurse is monitoring
the client's Jackson-Pratt drain that is being maintained on suction. The nurse notes that
a total of 200 mL of red drainage has drained from the Jackson-Pratt (J-P) tube in the
last 8 hours. What action should the nurse take?
Document the amount in the client's record.
Discontinue the Jackson-Pratt drain from suction.
Continue to monitor the amount and color of the drainage.
Notify the primary health care provider immediately of the amount of drainage. -
Answer-Notify the primary health care provider immediately of the amount of drainage.
▪ Measure drainage from the drain every 8 hours, and record the amount and color.
▪ Notify the PHCP if drainage is more than the normal amount of 30 to 50 mL per shift.
▪ Notify the PHCP immediately of excessive amounts of drainage or a saturated head
dressing.
Lorazepam 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client
for the management of anxiety. The nurse prepares the medication as prescribed and
administers the medication over a period of: - Answer-3 minutes
Rationale: Lorazepam is a benzodiazepine. When administered by IV injection, each 2
mg or fraction thereof is administered over a period of 1 to 5 minutes. Ten seconds and
30 seconds are brief periods. Thirty minutes is a lengthy period.
A nurse, conducting an assessment of a client being seen in the clinic for symptoms of
a sinus infection, asks the client about medications that he is taking. The client tells the
nurse that he is taking nefazodone hydrochloride . On the basis of this information, the
nurse determines that the client most likely has a history of: - Answer-Depression
Rationale: Nefazodone hydrochloride is an antidepressant used as maintenance
therapy to prevent relapse of an acute depression. Diabetes mellitus, hypethyroidism,
and coronary artery disease are not treated with this medication.
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