RN NCLEX LEARNING SYSTEM 3.0 EXAM LATEST UPDATED 2024
QUESTIONS WITH DETAILED ANSWERS
A nurse is reviewing the laboratory reports of a client who has been taking warfarin
for atrial fibrillation. Which of the following results should the nurse report to the
provider immediately?
A.
PT 18 seconds
B.
Platelet count 160,000/mm^3
C.
Hct 43%
D.
INR 5.5
Correct Answer: D.
INR 5.5
When using the urgent vs nonurgent approach to client care, the nurse should determine
that the priority laboratory result is an INR of 5.5. A client who is taking warfarin for the
treatment of atrial fibrillation is expected to have an INR in the range of 2 to 3. A level of 5.5
is considered a critical value and places the client at risk of bleeding; therefore, the nurse
should report this result to the provider immediately.
A nurse is caring for a client who was brought to the emergency department by
friends after a reported heroin overdosed. Which of the following findings should the
nurse expect to assess?
A.
Temperature 39.2°C (102.6°F)
B.
Respiratory rate 30/min
C.
Pinpoint pupils
D.
Severe abdominal cramping
,Correct Answer: C.
Pinpoint pupils
Pinpoint pupils are an expected finding in opioid toxicity. Increased pupil size is seen in
opioid withdrawal.
A nurse is teaching a client who has a new prescription for sucralfate for a duodenal
ulcer. Which of the following client statements indicates an understanding of the
teaching?
A.
"I should take this medication with my meals and at bedtime."
B.
"I should only have to take this medication for about 2 weeks."
C.
"I should wait at least 30 minutes before taking this medication after I take an
antacid."
D.
"I should swallow these tablets whole."
Correct Answer: C.
"I should wait at least 30 minutes before taking this medication after I take an antacid."
The nurse should recognize that antacids can raise the gastric pH above 4, which can
interfere with the effects of sucralfate. To minimize these interactions, sucralfate should be
taken at least 30 minutes apart from antacids.
A nurse is teaching a client who has a new diagnosis of angina and has a prescription
for isosorbide mononitrate 10 mg PO twice daily. Which of the following client
statements indicates an understanding of the teaching?
A.
"I can take my second dose of medication no later than 9:00 PM."
B.
"I should change positions slowly when getting out of bed."
C.
"If I miss a dose, I should double the next dose."
D.
"I should notify my provider if I experience a headache while taking this medication."
,Correct Answer: B.
"I should change positions slowly when getting out of bed."
The nurse should identify that isosorbide mononitrate is an antianginal medication that
produces vasodilation. Therefore, this medication can cause orthostatic hypotension. Clients
should change positions slowly upon rising to minimize the effects of orthostatic
hypotension.
A nurse is preparing a discharge teaching plan for a 6-year-old client with asthma
who has several prescription medications using metered-dose inhalers (MDIs). Which
of the following interventions should the nurse include in the plan?
A.
Add a spacer to each MDI
B.
Instruct the child to inhale more rapidly than usual when using an MDI
C.
Ask the provider to change the child's medications from inhaled to oral formulations
D.
Administer oxygen by facemask along with the MDI
Correct Answer: A.
Add a spacer to each MDI
MDIs are difficult to use correctly; even when properly used, only a portion of the medication
is delivered to the lungs. A spacer applied to an MDI can make up for a lack of hand-lung
coordination by increasing the amount of medication delivered to the lungs.
A nurse is providing teaching to a client who is scheduled to start taking
hydrochlorothiazide for hypertension. The nurse instructs the client to eat foods that
are rich in potassium. Which of the following statements by the client indicates an
understanding of the teaching?
A.
"This medication will not work unless I have enough potassium."
B.
"Potassium will increase the therapeutic effect of my blood pressure medication."
, C.
"Potassium will lower my blood pressure."
D.
"This medication can cause a loss of potassium."
Correct Answer: D.
"This medication can cause a loss of potassium."
Hydrochlorothiazide can result in hypokalemia caused by excessive potassium excretion
from the kidneys. The client should supplement his diet with potassium-rich foods to avoid
the occurrence of hypokalemia. Foods that are high in potassium include bananas, raisins,
baked potatoes, pumpkins, and milk.
A nurse is providing teaching to a client who has a prescription for famotidine to
treat a gastric ulcer. Which of the following statements should the nurse include in
the teaching?
A.
"This medication is more effective when taken on an empty stomach."
B.
"You should take this medication with an antacid for pain control."
C.
"This medication is less effective for people who smoke."
D.
"You should expect to experience dizziness when taking this medication."
Correct Answer: C.
"This medication is less effective for people who smoke."
The nurse should instruct the client that smoking interferes with the effectiveness of
famotidine. If a client taking famotidine smokes, the nurse should encourage the client to
quit smoking or, if unable quit, to avoid smoking after the last dose of the day.
A nurse is monitoring a client who is receiving phenytoin IV for the treatment of
status epilepticus. Which of the following findings should the nurse identify as an
adverse effect of the medication?
A.
Hypertension
QUESTIONS WITH DETAILED ANSWERS
A nurse is reviewing the laboratory reports of a client who has been taking warfarin
for atrial fibrillation. Which of the following results should the nurse report to the
provider immediately?
A.
PT 18 seconds
B.
Platelet count 160,000/mm^3
C.
Hct 43%
D.
INR 5.5
Correct Answer: D.
INR 5.5
When using the urgent vs nonurgent approach to client care, the nurse should determine
that the priority laboratory result is an INR of 5.5. A client who is taking warfarin for the
treatment of atrial fibrillation is expected to have an INR in the range of 2 to 3. A level of 5.5
is considered a critical value and places the client at risk of bleeding; therefore, the nurse
should report this result to the provider immediately.
A nurse is caring for a client who was brought to the emergency department by
friends after a reported heroin overdosed. Which of the following findings should the
nurse expect to assess?
A.
Temperature 39.2°C (102.6°F)
B.
Respiratory rate 30/min
C.
Pinpoint pupils
D.
Severe abdominal cramping
,Correct Answer: C.
Pinpoint pupils
Pinpoint pupils are an expected finding in opioid toxicity. Increased pupil size is seen in
opioid withdrawal.
A nurse is teaching a client who has a new prescription for sucralfate for a duodenal
ulcer. Which of the following client statements indicates an understanding of the
teaching?
A.
"I should take this medication with my meals and at bedtime."
B.
"I should only have to take this medication for about 2 weeks."
C.
"I should wait at least 30 minutes before taking this medication after I take an
antacid."
D.
"I should swallow these tablets whole."
Correct Answer: C.
"I should wait at least 30 minutes before taking this medication after I take an antacid."
The nurse should recognize that antacids can raise the gastric pH above 4, which can
interfere with the effects of sucralfate. To minimize these interactions, sucralfate should be
taken at least 30 minutes apart from antacids.
A nurse is teaching a client who has a new diagnosis of angina and has a prescription
for isosorbide mononitrate 10 mg PO twice daily. Which of the following client
statements indicates an understanding of the teaching?
A.
"I can take my second dose of medication no later than 9:00 PM."
B.
"I should change positions slowly when getting out of bed."
C.
"If I miss a dose, I should double the next dose."
D.
"I should notify my provider if I experience a headache while taking this medication."
,Correct Answer: B.
"I should change positions slowly when getting out of bed."
The nurse should identify that isosorbide mononitrate is an antianginal medication that
produces vasodilation. Therefore, this medication can cause orthostatic hypotension. Clients
should change positions slowly upon rising to minimize the effects of orthostatic
hypotension.
A nurse is preparing a discharge teaching plan for a 6-year-old client with asthma
who has several prescription medications using metered-dose inhalers (MDIs). Which
of the following interventions should the nurse include in the plan?
A.
Add a spacer to each MDI
B.
Instruct the child to inhale more rapidly than usual when using an MDI
C.
Ask the provider to change the child's medications from inhaled to oral formulations
D.
Administer oxygen by facemask along with the MDI
Correct Answer: A.
Add a spacer to each MDI
MDIs are difficult to use correctly; even when properly used, only a portion of the medication
is delivered to the lungs. A spacer applied to an MDI can make up for a lack of hand-lung
coordination by increasing the amount of medication delivered to the lungs.
A nurse is providing teaching to a client who is scheduled to start taking
hydrochlorothiazide for hypertension. The nurse instructs the client to eat foods that
are rich in potassium. Which of the following statements by the client indicates an
understanding of the teaching?
A.
"This medication will not work unless I have enough potassium."
B.
"Potassium will increase the therapeutic effect of my blood pressure medication."
, C.
"Potassium will lower my blood pressure."
D.
"This medication can cause a loss of potassium."
Correct Answer: D.
"This medication can cause a loss of potassium."
Hydrochlorothiazide can result in hypokalemia caused by excessive potassium excretion
from the kidneys. The client should supplement his diet with potassium-rich foods to avoid
the occurrence of hypokalemia. Foods that are high in potassium include bananas, raisins,
baked potatoes, pumpkins, and milk.
A nurse is providing teaching to a client who has a prescription for famotidine to
treat a gastric ulcer. Which of the following statements should the nurse include in
the teaching?
A.
"This medication is more effective when taken on an empty stomach."
B.
"You should take this medication with an antacid for pain control."
C.
"This medication is less effective for people who smoke."
D.
"You should expect to experience dizziness when taking this medication."
Correct Answer: C.
"This medication is less effective for people who smoke."
The nurse should instruct the client that smoking interferes with the effectiveness of
famotidine. If a client taking famotidine smokes, the nurse should encourage the client to
quit smoking or, if unable quit, to avoid smoking after the last dose of the day.
A nurse is monitoring a client who is receiving phenytoin IV for the treatment of
status epilepticus. Which of the following findings should the nurse identify as an
adverse effect of the medication?
A.
Hypertension
