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NCLEX EXAM QUESTIONS
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"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?
- Melena
- Nausea
- Hernia
4. Hyperthermia - CORRECT ANSWER 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.
- Nausea Nausea may be present, but is a generalized symptom and by itself doesn't indicate a Duodenal Ulcer. Incorrect.
- 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.
- Hyperthermia Hyperthermia, a high temperature, is not an assessment finding of a Duodenal Ulcer. Incorrect" "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.
- 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.
- 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.
- Administer intramuscular morphine sulphate as ordered Incorrect - While this is an important intervention to manage pain, it is not the priority intervention." "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.
- Notify Physician This is not the first action the nurse should take.
- Elevate the patient's legs This would help with the edema, but is not a priority
- Continue the infusion, since these are normal findings This is not a normal finding"
Back Pain can be a side effect of Floma, but is not a safety risk
- Difficulty Urinating Dysuria is a symptom of Benign Prostatic Hyperplasia, not a side effect of Flomax" "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 1. Back Pain
Incorrect - Back pain, while it can occur, is not an immediate concern
- Fever and Chills Incorrect - Fever and Chills, while it can occur, is not an immediate concern
- Risk for Bleeding Correct - A confused patient is at risk for injuring themselves and at risk for hemorrhage should an injury occur
- Dizziness Incorrect - Dizziness is not a side effect of Heparin" "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 1. Induce vomiting
Incorrect - This may be warranted for a severe lithium toxicity, but would be premature at this point. Gastric lavage may be attempted if the patient presents within one hour of ingestion, and fluids will be given to restore kidney function and promote the clearance of Lithium from the body..
- Hold the next dose of Lithium Correct - Lithium's therapeutic range is 0.5-1.5mcg/L, and begins toxicity at 1.5mcg/L
- Administer an anti-emetic Incorrect - While minor toxicity can cause vomiting and nausea, this is not a priority action
- Give the next dose of Lithium Incorrect - Lithium's therapeutic range is 0.5-1.5mcg/L, and begins toxicity at 1.5mcg/L" "The nurse is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the troponin T value is at 5.3 ng/mL. Which of these interventions, if not completed already, would take priority over the others?
- Put the patient in a 90 degree position
- Check whether the patient is taking diuretics
- Obtain and attach defibrillator leads
4. Check the patient's last ejection fraction - CORRECT ANSWER 1. Put the patient in a 90
degree position Incorrect - This position is optimal for helping a patient breathe, but is not the priority action in an emergency situation.
- Check whether the patient is taking diuretics Incorrect - Diuretics play a role in CHF by decreasing fluid volume, but this patient is likely having an acute myocardial infarction.
- Obtain and attach defibrillator leads Correct - This patient is undergoing an emergency cardiac event. Normal Troponin T levels are less than 0.2 ng/mL. Ventricular Fibrillation is the cause of death in most cases of deaths due to sudden cardiac arrest. Defibrillation is the most important action to take to prevent death.
- Check the patient's last ejection fraction Incorrect - Ejection fraction is a test used to gauge the severity of CHF, not an emergency cardiac arrest." "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
- Severe and persistent diarrhea
- Intense pain in the toe
- Yellow-tinged sclera
4. Headache - CORRECT ANSWER 1. Severe and persistent diarrhea
Incorrect - This is not a manifestation of sickle cell disease
- Intense pain in the toe Incorrect - Gout is a manifestation of Polycythemia Vera, in which the there is an overabundance of red blood cells
- Yellow-tinged sclera Correct - Jaundice is a common clinical finding of sickle cell disease, caused by bilirubin released from damaged or destroyed RBCs
- Headache Incorrect - While this may occur, it is not indicative or a classic symptom of sickle cell disease." "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.
- A 40-year-old man who just had throat surgery Incorrect - Patients who have surgery most likely have an Intravenous line
- A 20-year-old woman with trigeminal neuralgia Incorrect - Morphine would not be the first choice for nerve pain
- A 60-year-old man who has a painful incision Incorrect - Although Morphine would be an appropriate medications, there is no indication that it should be administered sublingually"
"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 1. Audible crackles and orthopnea
Incorrect - Crackles indicate fluid in the lungs, which is not a cause of asthma. Orthopnea is not associated with asthma.
- An audible wheeze and use of accessory muscles Correct - Both of these are associated with asthma.
- Audible crackles and use of accessory muscles Incorrect - Crackles indicate fluid in the lungs, which is not a cause of asthma.
- Audible wheeze and orthopnea Incorrect - Orthopnea is not associated with asthma." "A patient is being treated in the Neurology Unit for Meningitis. Which of these is a priority assessment for the nurse to make?
- Assess the patient for nuchal rigidity
- Determine the patient's past exposure to infectious organisms
- Check the patient's WBC lab values
4. Monitor for increased lethargy and drowsiness - CORRECT ANSWER 1. Assess the patient
for nuchal rigidity Incorrect - Although neck stiffness can be a symptom of Meningitis, it is not used to define meningitis, neither is it a sign of further neurological deterioration.
- Determine the patient's past exposure to infectious organisms Incorrect - Although this is an important part of the history gathering process, and meningitis is most often caused by a viral or bacterial infection, it is not the priority assessment.
- Check the patient's WBC lab values Incorrect - Although WBCs do rise during an infection like Mengingitis, it is not the priority assessment.
- Monitor for increased lethargy and drowsiness
- 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.
- Phenytoin (Dilantin) Incorrect - Phenytoin is an anticonvulsant and is often used to prevent seizures, which can complicate and worsen a patient's neurological state." "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 1. Slurred speech
Incorrect - Slurred speech is a common symptom of PD, not a side effect of this drug.
- Sudden dizziness Correct - Dizziness and orthostatic hypotension are serious adverse effects of this drug that can lead to an increased risk of falls. Ropinirole's drug class is a dopamine agonist, which mimic dopamine in the brain (PD is characterized by a lack of dopamine).
- Masklike facial expression Incorrect - Masklike facial expression is a common symptom of PD, not a side effect of this drug.
- Stooped Posture Incorrect - Stooped Posture is a common symptom of PD, not a side effect of this drug." "The nurse is taking the health history of a patient being treated for Parkinson's Disease. After being told the patient has classic symptoms of Parkinson's, the nurse expects to note which assessment finding?
- Tremors
- Low Urine Output
- Exaggerated arm movements
4. Risk for Falls - CORRECT ANSWER 1. Tremors
Correct - Tremors is one of four cardinal signs of PD: the other three are rigidity, bradykinesia (slow movements), and postural instability
- Low Urine Output Incorrect - This is not a relevant symptom to PD
- Exaggerated arm movements Incorrect - A symptom of PD would be rigidity and slow arm movements, rather than exaggeration of arm movements
- Risk for Falls Incorrect - This is not an assessment finding. This is a nursing diagnosis." "A nurse enters a patient's room and finds them unconscious with a rhythmic jerking of all four extremities. The patient is foaming heavily at the mouth. The patient was on seizure precautions and the bedrails are up and padded. What is the nurse's priority action?
- Administer Lorazepam (Ativan)
- Turn the patient to his/her side
- Call the physician
4. Suction the patient - CORRECT ANSWER 1. Administer Lorazepam (Ativan)
Incorrect - If a seizure lasts more than 5 minutes, it is called Status epilepticus and can be life- threatening. Physicians will often order anxiolytics or sedatives to treat this condition. However, at this point it would not be appropriate for the nurse to administer this drug.
- Turn the patient to his/her side Correct - Turning the patient to the side will keep the airway open, which is the first priority
- Call the physician Incorrect - This would be a priority action after ensuring the patient's safety, or in the case of Status epilepticus
- Suction the patient Incorrect - This intervention is warranted, but after an assessment of the patient's airway, since forcing a suction catheter into a patient's mouth is a last resort." "The nurse is caring for a patient in the ICU who has had a spinal cord injury. She observes that his last blood pressure was 100/55, and his pulse is 48. These have both trended downwards from the baseline. What should the nurse expect to be the next course of action ordered by the physician?
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 75-year old male who has frequent migraines, drinks a glass of wine every day, and is Hispanic. Incorrect - See Common Risk Factors for Developing a Stroke.
- A 40-year old female who has high cholesterol and uses oral contraceptives Incorrect - See Common Risk Factors for Developing a Stroke.
- A 65-year old female who is African American, has sickle cell disease and smokes cigarettes. Incorrect - See Common Risk Factors for Developing a Stroke." "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 1. "Age is the biggest factor
contributing to cataracts." Incorrect - While true, this answer leaves out many other contributing factors to cataracts and does not address prevention.
- "Unprotected exposure to UV lights can cause cataracts" Incorrect - While true, this answer is not complete
- "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.
- "Unfortunately, there is really nothing you can do to prevent cataracts, but they are amongst the most easily treated eye conditions." Incorrect - While most cataracts are age-related cataracts, there are still ways to prevent eye damage and cataract development." "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 1. "I should be experiencing less blurriness in my central field of vision"
Incorrect - Cataracts cause blurriness in the central field of vision, while Glaucoma presents as loss of the field of vision peripherally.
- "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.
- "My peripheral vision should be increasing back to its normal state, but will take a few weeks to do so."
Correct - MRI can be used to diagnose musculoskeletal disorders, and this patient has no contraindications to an MRI.
- A 35-year old woman with Multiple Sclerosis and has been trying to conceive. Incorrect - Pregnant women, or women who have a possibility of being pregnant, are not recommended to receive MRIs.
- A 67-year old man who has had an open-heart surgery 4 years ago. Incorrect - Patients with pacemakers, stents, or implants should not have MRIs. More information would have to be gathered about this patient before an MRI can be done.
- A 40-year old woman who has been in a hypomanic state for the last 2 days. Incorrect - Hypomania is a mild form of mania, and a patient with hypomania would have a very difficult time laying still in a supine position for up to an hour. Sedation may be required, which requires more information and assessment of this patient." "A nurse knows that which of these patients are at greatest risk for a developing osteoporosis?
- An 80-year old man who has a thin build
- A 48-year old african american female who smokes cigarettes and drinks alcohol
- A 55-year old female with an estrogen deficiency
4. A 70-year old caucasian female who takes oral corticosteroids - CORRECT ANSWER 1. An 80-
year old man who has a thin build Incorrect - Age and thin build are two primary risk factors, but another patient has more.
- A 48-year old african american female who smokes cigarettes and drinks alcohol Smoking cigarettes and drinking alcohol are both primary risk factors, but being African American actually decreases the risk for osteoporosis
- A 55-year old female with an estrogen deficiency Incorrect - Only two risk factors are present: being female, and having an estrogen deficiency. While her age is somewhat advanced, 65+ years of age is the 'cut-off' for having a risk factor in women.
- A 70-year old caucasian female who takes oral corticosteroids Correct - This patient has by far the most risk factors, 3 of which are primary and one secondary. Age, gender, ethnicity are three primary risk factors, while her corticosteroid treatment is the secondary risk factor, bringing her total up to four."
"A 30-year old Caucasian woman who works the night shift has been found to have early bone loss and has a high risk for osteomalacia and bone degradation. She asks the nurse exactly why she should take Vitamin D supplements. What is the nurse's best response?
- "It's a standard part of the overall nutritional treatment for the prevention of osteomalacia"
- "It helps your intestines absorb calcium, which is important for bone formation."
- "It stimulates skin cells to produce calcium, which is then released into the bloodstream to be used for bone formation."
4. "Vitamin D supplements should not be taken by someone of your age." - CORRECT ANSWER
- "It's a standard part of the overall nutritional treatment for the prevention of osteomalacia" Incorrect - While this is true, it doesn't answer the woman's question.
- "It helps your intestines absorb calcium, which is important for bone formation." Correct - This is the correct mechanism of action for Vitamin D
- "It stimulates skin cells to produce calcium, which is then released into the bloodstream to be used for bone formation." Incorrect- This is not the correct mechanism of action for Vitamin D
- "Vitamin D supplements should not be taken by someone of your age." Incorrect - Vitamin D supplements should be taken for patients who are homebound, institutionalized, or by some other limitations, unable to meet daily requirements. This woman works the night shift, which may limit her ability to absorb Vitamin D naturally." "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 1. The capillary refill time is 2 seconds
Incorrect - A capillary refill time of 2 seconds is within normal limits. Capillary refill is the least reliable method of assessing neurovascular integrity.
- The patient complains of itching and discomfort Incorrect - This is a common effect of a cast
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.
- Use strict aseptic technique when caring for the wound Incorrect - Although this is dependent on each facility's policy, it is no longer a common practice to use aseptic technique on a "dirty" wound. Clean technique is more often used.
- Place another dressing to reinforce the first one Incorrect - This is a questionable intervention, and will not promote the safety of this patient and other patients.
- Elevate the patient's leg to prevent more drainage Incorrect - Patients with heel ulcers should have their heels elevated to prevent pressure, not the whole leg elevated to prevent drainage." "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 1. Place the patient in a supine position
Incorrect - While this may be a beneficial intervention if the arm is also elevated to prevent swelling, this is not a priority intervention.
- Ask the patient to rate his pain on a scale of 1 to 10. Incorrect - While assessing pain is a part of the 6 P's of neurovascular assessment, the question asks for an intervention based on already alarming assessment findings.
- Wrap the fractured area with a snug dressing Incorrect - The assessment findings indicate the patient may have Acute Compartment Syndrome. Causing more external pressure with a dressing will only exacerbate the condition.
- 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 1. Performing passive, light,
range of motion exercises on the hip as tolerated. Incorrect - Immobilization and prevention of motion is the best way to reduce risk for fat embolism.
- 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.
- Assess the pedal pulse and capillary refill in the toes. Incorrect - While assessing pedal pulse is important during a neurovascular assessment, it is not relevant to FES. Capillary refill is the least reliable indicator of poor perfusion
- Administer a stool softener as ordered Incorrect - While this is an important intervention for patients on bedrest, it is not an intervention relevant to FES" "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.
- To ensure adequate nutrition during the healing process Incorrect - While this is a nursing concern, it is not the first priority
- To provide patient education for maintenance of splints, casts, or traction in the community. Incorrect - While this is a nursing concern, it is not the first priority
