NCLEX Comprehensive Exam
Enalapril maleate is prescribed for a hospitalized client. Which assessment does the nurse perform as a
priority before administering the medication? - CORRECT ANS 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? - CORRECT ANS "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: - CORRECT ANS 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: -
CORRECT ANS 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: -
CORRECT ANS 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? - CORRECT ANS "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? - CORRECT ANS 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: - CORRECT ANS 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? - CORRECT ANS "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, 300 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: - CORRECT ANS 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.
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: - CORRECT ANS 3 minutes
Enalapril maleate is prescribed for a hospitalized client. Which assessment does the nurse perform as a
priority before administering the medication? - CORRECT ANS 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? - CORRECT ANS "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: - CORRECT ANS 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: -
CORRECT ANS 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: -
CORRECT ANS 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? - CORRECT ANS "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? - CORRECT ANS 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: - CORRECT ANS 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? - CORRECT ANS "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, 300 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: - CORRECT ANS 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.
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: - CORRECT ANS 3 minutes
