NGN / NCLEX Prep Questions & Rationales
Comprehensive Study Guide & Clinical Judgment Review
Question 1
The nurse notes the presence of a P wave, QRS complex, flattened T waves, and occasional U waves on a client's cardiac
monitor screen. Fill in the correct missing information by choosing from the lists of options in the drop-down menus.
Your Answer: hypokalemia | Correct Answer: hypokalemia
because of the:
Your Answer: flattened T waves and occasional U waves | Correct Answer: flattened T waves and occasional U waves
RATIONALE
Cardiac changes in hypokalemia include impaired repolarization, resulting in a flattening of the T wave and eventually the
emergence of a U wave. Therefore, the nurse should suspect hypokalemia. The incidence of potentially lethal ventricular
dysrhythmias is increased in hypokalemia. The nurse should immediately assess the client's vital signs and cardiac status for
signs of hypokalemia. The nurse should also check the client's most recent serum potassium level and then contact the primary
health care provider to report the findings and obtain prescriptions to treat the hypokalemic state.
Question 2
The nurse is preparing a client for a chest x-ray and notes that the client is wearing a religious medal on a chain around the
neck. What should the nurse do with regard to this personal item? Click to highlight the correct answer from the options
provided.
The nurse should: Ask the client if the chain and medal can be removed during the procedure.
Because: The chain and medal may have cultural significance.
RATIONALE
Before certain diagnostic procedures, it is typical to have a client remove personal objects that are worn on the body because of
client safety and the possibility of compromising test results. Therefore, the nurse should ask the client about the significance of
such an item and its removal because it may have cultural or spiritual significance. If so, the nurse should ask the client if the
item can be either removed temporarily or placed on another part of the body during the procedure if appropriate.
Question 3
While preparing a client for surgery scheduled in 1 hour, the client states to the nurse: "I have changed my mind. I don't
want this surgery." Click to highlight the correct answer from the options provided.
The nurse should: Cancel the surgery, Contact the surgeon, Discuss the client's concerns, Call the identified support
person.
Because: Client consent is required prior to any procedure. Further questions or concerns should be determined and
addressed. Ethical considerations are important for a client undergoing surgery. The nursing scope of practice places
limitations on how the nurse can respond.
RATIONALE
If the client indicates that he or she does not want a prescribed therapy, treatment, or procedure such as surgery, the nurse
should further investigate the client's request. If the client indicates that he or she has changed his or her mind about surgery, the
nurse should assess the client and explore with the client his or her concerns about not wanting the surgery. The nurse would
then withhold further surgical preparation and contact the surgeon to report the client's request so that the surgeon can discuss
the consequences of not having the surgery with the client. Further assessment and follow-up related to the client's request need
to be done. It is the client's right to refuse treatment; however, further investigation is needed so the interventions can be tailored
to specific needs.
NCLEX Prep Questions & Rationales Page 1 of 9
, Question 4
The nurse notes that there has been an increase in the number of intravenous (IV) site infections that developed in the
clients being cared for on the nursing unit. How should the nurse proceed to implement a quality improvement program?
For each action, click to specify whether the action would be Indicated, Non-essential, or Contraindicated.
Action Classification
Collect identifying patient information Contraindicated
Note the mental status of the client Non-essential
Note primary and secondary diagnoses of clients affected Indicated
Note the type of IV catheter used Indicated
Note the type of IV site dressings being used Indicated
Note the medication types being infused Non-essential
Note frequency of assessments of IV sites Indicated
Note the expected duration of the IV site Non-essential
Note care procedures to the IV site Indicated
Note frequency of changing IV sites Indicated
RATIONALE
Quality improvement focuses on processes or systems that significantly contribute to client safety and effective client care
outcomes. If an increase in IV site infections occurs, data should be collected including diagnoses, catheter type, site, dressings,
assessment frequency, care methods, and insertion duration. Data is then analyzed against evidence-based practice protocols.
Collecting identifying client information is contraindicated due to confidentiality. Client mental status, medication types, and
expected duration do not directly address infection control practices and are non-essential or non-contributory.
Question 5
The nurse performs an Allen's test on a client scheduled for an arterial blood gas draw from the radial artery. On release of
pressure from the ulnar artery, color in the hand returns after 20 seconds. How should the nurse interpret the finding?
The test result is: Abnormal (Your Answer: Abnormal / Correct Answer: Abnormal)
because: The time for color to return is prolonged (Your Answer: The time for color to return is prolonged / Correct Answer:
The time for color to return is prolonged)
RATIONALE
Failure to determine adequate collateral circulation before drawing an arterial blood gas specimen could result in severe ischemic
injury if radial artery damage occurs. Upon release of pressure on the ulnar artery, if pinkness fails to return within 6 to 7
seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for puncture. Another site must be
selected and the provider notified.
NCLEX Prep Questions & Rationales Page 2 of 9
Comprehensive Study Guide & Clinical Judgment Review
Question 1
The nurse notes the presence of a P wave, QRS complex, flattened T waves, and occasional U waves on a client's cardiac
monitor screen. Fill in the correct missing information by choosing from the lists of options in the drop-down menus.
Your Answer: hypokalemia | Correct Answer: hypokalemia
because of the:
Your Answer: flattened T waves and occasional U waves | Correct Answer: flattened T waves and occasional U waves
RATIONALE
Cardiac changes in hypokalemia include impaired repolarization, resulting in a flattening of the T wave and eventually the
emergence of a U wave. Therefore, the nurse should suspect hypokalemia. The incidence of potentially lethal ventricular
dysrhythmias is increased in hypokalemia. The nurse should immediately assess the client's vital signs and cardiac status for
signs of hypokalemia. The nurse should also check the client's most recent serum potassium level and then contact the primary
health care provider to report the findings and obtain prescriptions to treat the hypokalemic state.
Question 2
The nurse is preparing a client for a chest x-ray and notes that the client is wearing a religious medal on a chain around the
neck. What should the nurse do with regard to this personal item? Click to highlight the correct answer from the options
provided.
The nurse should: Ask the client if the chain and medal can be removed during the procedure.
Because: The chain and medal may have cultural significance.
RATIONALE
Before certain diagnostic procedures, it is typical to have a client remove personal objects that are worn on the body because of
client safety and the possibility of compromising test results. Therefore, the nurse should ask the client about the significance of
such an item and its removal because it may have cultural or spiritual significance. If so, the nurse should ask the client if the
item can be either removed temporarily or placed on another part of the body during the procedure if appropriate.
Question 3
While preparing a client for surgery scheduled in 1 hour, the client states to the nurse: "I have changed my mind. I don't
want this surgery." Click to highlight the correct answer from the options provided.
The nurse should: Cancel the surgery, Contact the surgeon, Discuss the client's concerns, Call the identified support
person.
Because: Client consent is required prior to any procedure. Further questions or concerns should be determined and
addressed. Ethical considerations are important for a client undergoing surgery. The nursing scope of practice places
limitations on how the nurse can respond.
RATIONALE
If the client indicates that he or she does not want a prescribed therapy, treatment, or procedure such as surgery, the nurse
should further investigate the client's request. If the client indicates that he or she has changed his or her mind about surgery, the
nurse should assess the client and explore with the client his or her concerns about not wanting the surgery. The nurse would
then withhold further surgical preparation and contact the surgeon to report the client's request so that the surgeon can discuss
the consequences of not having the surgery with the client. Further assessment and follow-up related to the client's request need
to be done. It is the client's right to refuse treatment; however, further investigation is needed so the interventions can be tailored
to specific needs.
NCLEX Prep Questions & Rationales Page 1 of 9
, Question 4
The nurse notes that there has been an increase in the number of intravenous (IV) site infections that developed in the
clients being cared for on the nursing unit. How should the nurse proceed to implement a quality improvement program?
For each action, click to specify whether the action would be Indicated, Non-essential, or Contraindicated.
Action Classification
Collect identifying patient information Contraindicated
Note the mental status of the client Non-essential
Note primary and secondary diagnoses of clients affected Indicated
Note the type of IV catheter used Indicated
Note the type of IV site dressings being used Indicated
Note the medication types being infused Non-essential
Note frequency of assessments of IV sites Indicated
Note the expected duration of the IV site Non-essential
Note care procedures to the IV site Indicated
Note frequency of changing IV sites Indicated
RATIONALE
Quality improvement focuses on processes or systems that significantly contribute to client safety and effective client care
outcomes. If an increase in IV site infections occurs, data should be collected including diagnoses, catheter type, site, dressings,
assessment frequency, care methods, and insertion duration. Data is then analyzed against evidence-based practice protocols.
Collecting identifying client information is contraindicated due to confidentiality. Client mental status, medication types, and
expected duration do not directly address infection control practices and are non-essential or non-contributory.
Question 5
The nurse performs an Allen's test on a client scheduled for an arterial blood gas draw from the radial artery. On release of
pressure from the ulnar artery, color in the hand returns after 20 seconds. How should the nurse interpret the finding?
The test result is: Abnormal (Your Answer: Abnormal / Correct Answer: Abnormal)
because: The time for color to return is prolonged (Your Answer: The time for color to return is prolonged / Correct Answer:
The time for color to return is prolonged)
RATIONALE
Failure to determine adequate collateral circulation before drawing an arterial blood gas specimen could result in severe ischemic
injury if radial artery damage occurs. Upon release of pressure on the ulnar artery, if pinkness fails to return within 6 to 7
seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for puncture. Another site must be
selected and the provider notified.
NCLEX Prep Questions & Rationales Page 2 of 9
