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NCLEX-PN REVIEW QUESTIONS WITH 100% CORRECT SOLUTIONS
"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?
- "I'm going to limit my meals to 2-3 per day to reduce acid secretion."
- "I'm going to make sure to remain upright after meals and elevate my head when I sleep"
- "I won't be drinking tea or coffee or eating chocolate any more."
4. "I'm going to start trying to lose some weight." - CORRECT ANSWER 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?
- Start a large-bore IV in the patient's arm
- Ask the patient for a stool sample
- Prepare to insert an NG Tube
4. Administer intramuscular morphine sulphate as ordered - CORRECT ANSWER 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." "The nurse is working in a support group for clients with HIV. Which point is most important for the nurse to stress?
- They must inform household members of their condition
- They must take their medications exactly as prescribed
- They must abstain from substance use
4. They must avoid large crowds - CORRECT ANSWER 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?
- Initiate cardiopulmonary resuscitation
- Check for a pulse
- Ask the woman if she carries an emergency medical kit
4. Stay with the woman until help comes - CORRECT ANSWER 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 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?
- Hypotension
- Tachycardia
- Back Pain
4. Difficulty Urinating - CORRECT ANSWER 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?
- Back Pain
- Fever and Chills
- Risk for Bleeding
4. Dizziness - CORRECT ANSWER 3. Risk for Bleeding
Correct - A confused patient is at risk for injuring themselves and at risk for hemorrhage should an injury occur" "A patient asks the nurse why they must have a heparin injection. What is the nurse's best response?
- "Heparin will dissolve clots that you have."
- "Heparin will reduce the platelets that make your blood clot"
"Which of these clients is likely to receive sublingual morphine?
- A 75-year-old woman in a hospice program
- A 40-year-old man who just had throat surgery
- 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." "In educating clients on ways to manage pain, which topic can be appropriately delegated to a LPN/LVN who will continue under supervision?
- Acupuncture
- Guided Imagery
- Alternating Rest/Activity
4. Over the counter medications - 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." "The nurse assesses a patient suspected of having an asthma attack. Which of the following is a common clinical manifestation of this condition?
- Audible crackles and orthopnea
- An audible wheeze and use of accessory muscles
- Audible crackles and use of accessory muscles
4. Audible wheeze and orthopnea - CORRECT ANSWER 2. An audible wheeze and use of
accessory muscles Correct - Both of these are associated with asthma." "The nurse assesses a patient suspected of having meningitis. Which of the following is a common clinical manifestation of this condition?
- A high WBC count and decreased level of consciousness
- A high WBC count and manic activity
- 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. consciousness." "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?
- Check the patient's last BUN
- Ask the patient to increase their fluid intake
- Ask the physician to order a diuretic
4. Notify the physician of this finding - 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?
- Acyclovir (Zovirax)
- Mannitol (Osmitrol)
- Lactated Ringer's
4. Phenytoin (Dilantin) - 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. ." "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?
- Slurred speech
- Sudden dizziness
- Masklike facial expression
4. Stooped Posture - CORRECT ANSWER 2. Sudden dizziness
the baseline. What should the nurse expect to be the next course of action ordered by the physician?
- Assess the patient for decreased level of consciousness
- Administer Normal Saline
- Insert an NG Tube
4. Connect and read an EKG - 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." "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?
- Immobilize the cervical area to prevent further injury
- Monitor the patient's level of consciousness to prevent neurologic deterioration
- 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 -
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 nurse knows that which of these patients are at greatest risk for a stroke?
- A 60-year old male who weighs 270 pounds, has atrial fibrillation, and has had a TIA in the past.
- A 75-year old male who has frequent migraines, drinks a glass of wine every day, and is Hispanic.
- 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." "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?
- INR is 3 seconds long
- Heart rate is 110 beats per minute
- Intracranial Pressure is 22 mm/Hg
4. Blood pressure is 140/80 - 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" "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?
- "Age is the biggest factor contributing to cataracts."
- "Unprotected exposure to UV lights can cause cataracts"
- "Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts."
- "Unfortunately, there is really nothing you can do to prevent cataracts, but they are amongst
the most easily treated eye conditions." - 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." "A nurse is educating a patient about bimatoprost (Lumigan) eyedrops for the treatment of Glaucoma. Which of the following indicates that the patient has a correct understanding of the expected outcomes following treatment?
- "I should be experiencing less blurriness in my central field of vision"
- "This medication won't help my vision at all, but will keep it from getting worse."
- "My peripheral vision should be increasing back to its normal state, but will take a few weeks to do so."
4. "This medication will help my eye restore intraocular fluid and increase intraocular pressure" -
CORRECT ANSWER 2. "This medication won't help my vision at all, but will keep it from getting
worse." Correct - Glaucoma cannot be cured, just treated. Treatment revolves around preventing further deterioration."
Correct - This is the correct mechanism of action for Vitamin D" "A nurse is caring for a patient with a cast on the right leg. Which of these assessment findings would most concern the nurse?
- The capillary refill time is 2 seconds
- The patient complains of itching and discomfort
- The cast has a foul-smelling odor
4. The patient is on antibiotics - CORRECT ANSWER 3. The cast has a foul-smelling odor
Correct - A foul-smelling odor is a sign of infection or a pressure ulcer within the cast. Other symptoms include a feeling of warmth, tightness and pain." "A nurse is asked by a patient to describe in layman's terms an overview of the condition called osteomyelitis. What would be the nurse's best response?
- "Osteomyelitis is a gradual breakdown and weakening of your bones. It's most often age- related."
- "Osteomyelitis is caused by not having enough Vitamin D, which in turn causes a your bones to be softer and de-mineralized."
- "Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your bone from outside or inside your body."
4. "This is a question that should be directed to your Healthcare Provider." - CORRECT
ANSWER 3. "Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your
bone from outside or inside your body." Correct - This appropriately explains osteomyelitis" "The infection control nurse is assigned to a patient with osteomyelitis related to a heel ulcer. The wound is 5cm in diameter and the drainage saturates the dressing so that it must be changed every hour. What is her priority intervention?
- Place the patient under contact precautions
- Use strict aseptic technique when caring for the wound
- Place another dressing to reinforce the first one
4. Elevate the patient's leg to prevent more drainage - CORRECT ANSWER 1. Place the patient
under contact precautions
Correct - A patient with an infectious wound, especially one not adequately contained by a dressing, should be put under contact precautions." "A nurse in the emergency room receives a patient who had his left elbow fractured in a fight. He had waited 5 hours before coming to the emergency room. His left hand has an unequal radial pulse, is swollen, and is numb and tingling. What is the nurse's priority intervention?
- Place the patient in a supine position
- Ask the patient to rate his pain on a scale of 1 to 10.
- Wrap the fractured area with a snug dressing
4. Start an IV in the other arm. - CORRECT ANSWER 4. Start an IV in the other arm.
Correct - Starting an IV is a nursing priority prior to emergency surgery. The patient may be in the late stages of Acute Compartment Syndrome and may need a fasciotomy, in which the surgeon relieves pressure by making an incision into the affected area." "A nurse is caring for a female patient 24 hours after a hip fracture. The patient is on bedrest. The nurse knows that which regular assessment or intervention is essential for detecting or preventing the complication of Fat Embolism Syndrome?
- Performing passive, light, range of motion exercises on the hip as tolerated.
- Assess the patient's mental status for drowsiness or sleepiness.
- Assess the pedal pulse and capillary refill in the toes.
4. Administer a stool softener as ordered - CORRECT ANSWER 2. Assess the patient's mental
status for drowsiness or sleepiness. Correct - A decreased Level of Consciousness is the earliest sign of FES, caused by decreased oxygen level." "What is the overarching nursing concern when caring for patients being treated with splints, casts, or traction?
- To assess for and prevent neurovascular complications or dysfunction
- To ensure adequate nutrition during the healing process
- To provide patient education for maintenance of splints, casts, or traction in the community.
4. To treat acute pain - CORRECT ANSWER 1. To assess for and prevent neurovascular
complications or dysfunction Correct - This is the priority nursing diagnosis for patients with extremity fractures." "What nursing action demonstrates the nurse understands the priority nursing diagnosis when caring for patients being treated with splints, casts, or traction?
Correct - This is an indication of a life-threatening aortic aneurysm. Palpating or percussing is dangerous to the patient's life." "A nurse understands that which of these patients are at risk for developing Oral Candidiasis, a type of stomatitis?
- A 77-year old woman in a long-term care facility taking an antibiotic
- A 35-year old man who has had HIV for 6 years
- A 40-year old man who is undergoing chemotherapy
4. An 80-year old woman with dentures - CORRECT ANSWER 1. A 77-year old woman in a long-
term care facility taking an antibiotic Correct - This patient has the most risk factors for developing Candidiasis. Candidiasis is caused most commonly by long-term antibiotic therapy, immunosupressive therapy (chemotherapy, radiation, or corticosteroids), older age, living in a long-term care facility, diabetes, having dentures, and poor oral hygiene." "What nursing intervention demonstrates that the nurse understands the priority nursing diagnosis when caring for oral cancer patients with extensive tumor involvement and/or a high amount of secretions?
- The nurse uses a pen pad to communicate with the patient
- The nurse provides oral care every 2 hours
- The nurse listens for bowel sounds every 4 hours.
4. The nurse suctions as needed and elevates the head of the bed - CORRECT ANSWER 04. The
nurse suctions as needed and elevates the head of the bed Correct - This intervention is in response to Ineffective Airway Clearance, which is the priority nursing diagnosis." "A patient has been taking a mood stabilizing medication, but is afraid of needles. They ask the nurse what medication would NOT require regular lab testing. What is the nurse's best response?
- Valproic Acid (Depakote)
- Clozapine (Clozaril)
- Lithium
4. Risperidone (Risperdal) - CORRECT ANSWER 4. Risperidone (Risperdal)
Correct - Risperidone is the only drug that does not require blood draws." "A patient is deciding whether they should take the live influenza vaccine (nasal spray), or the inactivated influenza vaccine (shot). The nurse reviews the client's history. Which condition would NOT contraindicate the nasal (live vaccine) route of administration?
- The patient takes long-term corticosteroids
- The patient is not feeling well today
- The patient is 55 years old
4. The patient has young children - CORRECT ANSWER 4. The patient has young children
Correct - This is not a contraindication. It would only be a contraindication for the live vaccine if the young children were immunocompromised, but this is not stated." "A patient asks the nurse whether he is a good candidate to use a CPAP machine. The nurse reviews the client's history. Which condition would contraindicate the use of a CPAP machine?
- The patient is in the late-stage of dementia.
- The patient has a history of bronchitis
- The patient has had suicidal gestures/attempts in the past
4. The patient is on beta-blockers - CORRECT ANSWER 1. The patient is in the late-stage of
dementia. Correct - Having an inability to follow commands and understand instructions independently is a contraindication for a CPAP machine, which can only function correctly with proper installation and use." "The nurse is caring for a patient who has recently had a successful catheter ablation. Which assessment finding demonstrates a successful outcome of this procedure?
- The patient is free of electrolyte imbalances
- The patient's WBC count is within normal limits
- The patient's EKG reading is regular
4. The patient's urine output is 45mL/hour - CORRECT ANSWER 3. The patient's EKG reading is
regular Correct - A catheter ablation is a procedure used to treat arrhythmias, especially SVT. A catheter is inserted through the femoral vein or artery, and threaded to the conduction fiber in the heart causing the arrhythmia. A radiofrequency energy uses heat to destroy this fiber, preventing further arrhythmia." "Application - The nurse is caring for a patient who has the following labs: Creatinine 2.5mg/dL, WBC 11,000 cells/mL, and Hemoglobin of 12 g/dL. Based on this information, which of these orders would the nurse question?
- Administer 30 Units of Lantus Daily
- CT of the spine with contrast
- X-ray of the abdomen and chest
"The nurse is doing an intake screening for a patient with hypertension. They have been taking ramapril for 4 weeks. Which statement made by the patient would be most important for the nurse to pass on to the physician?
- "I get dizzy when I get out of bed."
- "I'm urinating much more than I used to."
- "I've been running on the treadmill 10 minutes each day."
4. "I can't get rid of this cough." - CORRECT ANSWER 4. "I can't get rid of this cough."
Correct - A common adverse effect of ACE inhibitors is a persistent, dry cough. A medication change to another class of antihypertensives, like an ARB, may be needed" "The nurse in the emergency room sees a patient who has been abusing alprazolam (Xanax). The patient reports that he suddenly stopped taking Xanax about 24 hours ago. He presents with a visible tremor, is pacing, expresses fear, and has impaired concentration and memory. Which of these intervention takes priority?
- Have the patient lie down on a stretcher with bedrails up
- Give the patient a cup of water to drink and a small amount of food
- Assure the patient that he will be okay
4. Alert the physician that the patient needs Xanax - CORRECT ANSWER 1. Have the patient lie
down on a stretcher with bedrails up Correct - The 1-4 day period after Xanax withdrawal is the most dangerous. Xanax is a benzodiazepine and withdrawal symptoms include life-threatening seizures. Having the patient lie down with bedrails up is part of seizure precautions and is the first priority" "A nurse cares for a child that is diagnosed with Hepatitis A. Which of these following precautions would be most important to take to prevent transmission of this infectious disease?
- Encourage the Hepatitis A vaccine for family members and siblings
- Use needleless systems if possible, otherwise use careful needle precautionary measures
- Teach the child and enforce strict and frequent hand washing
4. Teach the child and family the dangers of contaminated food and water - CORRECT
ANSWER 3. Teach the child and enforce strict and frequent hand washing
Correct - Hand washing is the single most effective way to prevent transmission of Hepatitis A. Hepatitis A is a virus transmitted via the oral-fecal route and lives on human hands." "A nurse is treating a patient suspected to have Hepatitis. The nurse notes on assessment that the patient's eyes are yellow-tinged. Which of these diagnostic results would further assist in confirming this diagnosis?
- Decreased serum Bilirubin
- Elevated serum ALT levels
- Low RBC and Hemoglobin with increased WBCs
4. Increased Blood Urea Nitrogen level - CORRECT ANSWER 2. Elevated serum ALT levels
Correct - ALT is a liver enzyme, and hepatitis is a liver disease. Elevated liver enzymes will often signal liver damage." "Which of these patients would the nurse suspect as having the greatest risk of contracting Hepatitis B?
- A sexually active 45-year old man who has Type 1 Diabetes
- A 75-year old woman who lives in a crowded nursing home
- A child who lives in a country with poor sanitation and hygiene standards
4. A sexually active 23-year old man who works in a hospital - CORRECT ANSWER 4. A sexually
active 23-year old man who works in a hospital Correct - This person is both sexually active and works in a healthcare environment." "The nurse calculates the IV flow rate of a patient receiving lactated ringer's solution. The patient is to receive 2000mL of Lactated Ringer's over 36 hours. The IV infusion set has a drop factor of 15 drops per milliliter. The nurse should set the IV to deliver how many drops per minute?
- 8
- 10
- 14
4. 18 - CORRECT ANSWER 3. 14
Correct - Drops Per Minute = Milliliters x Drop Factor / Time in Minutes" "The nurse calculates the IV flow rate of a patient receiving an antibiotic. The patient is to receive 100mL of the antibiotic over 30 minutes. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should set the IV to deliver how many drops per minute? 11 19 26
33 - CORRECT ANSWER 33
Correct - Drops Per Minute = Milliliters x Drop Factor / Time in Minutes" "Which of the following statements made by a client during an individual therapy session would the nurse most identify as reflecting schizoaffective disorder?
"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?
- Stop the saline infusion immediately
- Notify Physician
- Elevate the patient's legs
4. Continue the infusion, since these are normal findings - CORRECT ANSWER 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." "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?
- The patient states he had a manic episode a week ago
- The patient states he has been having diarrhea every day
- The patient has a rashy pruritis on his arms and legs
- The patient presents as severely depressed
5. The patient's lithium level is 1.3 mcg/L - CORRECT ANSWER 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 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?
- Diarrhea and Vomiting
- Dizziness and Drowsiness
- Metallic taste
4. Hypoglycemia - CORRECT ANSWER 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?
- Induce vomiting
- Hold the next dose of Lithium
- Administer an anti-emetic
4. Give the next dose of Lithium - CORRECT ANSWER 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 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?
- "I'm feeling extremely thirsty. I'm going to get some water after this."
- "I can feel my heart racing."
- "My shoulder and arm is hurting."
4. "My blood pressure reading is 158/80" - 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." "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?
- Call a cardiac code and implement emergency measures
- Check the patient's oxygen saturation
- Inform the physician that the patient has Congestive Heart Failure
Encourage the patient to limit activity - 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." "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?
- Vertigo
- Hypotension
- Palpitations
4. Nagging, dry cough - CORRECT ANSWER 2. Hypotension
Correct - The patient is particularly at risk for hypotension due to possible dehydration from fluid loss." "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?
- Severe and persistent diarrhea
- Intense pain in the toe
- Yellow-tinged sclera
