RN NCLEX LATEST EXAM 2024 -2025 TEST BANK
COMPLETE 800+ ACTUAL EXAM QUESTIONS
WITH CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) GRADED A+
The nurse is assessing a client with a lactose intolerance disorder for a suspected
diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note
in the client?
A. Twitching
B. Hypoactive bowel sounds
C. Negative Trousseau's sign
D. Hypoactive deep tendon reflexes - ANSWER - A
Rationale:
A client with lactose intolerance is at risk for developing hypocalcemia, because food
products that contain calcium also contain lactose. The normal serum calcium level is 9
to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25
mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed
by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or
Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular
excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety.
Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds,
abdominal cramping, and diarrhea.
The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL
(2 mmol/L). Which patterns would the nurse watch for on the electrocardiogram? Select
all that apply.
A. U waves
pg. 1
,B. Widened T wave
C. Prominent U wave
D. Prolonged QT interval
E. Prolonged ST segment - ANSWER - D, E
Rationale:
A client with Crohn's disease is at risk for hypocalcemia. The normal serum calcium
level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL
(2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a
client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A
shortened ST segment and a widened T wave occur with hypercalcemia. ST depression
and prominent U waves occur with hypokalemia.
The nurse reviews the electrolyte results of a client with chronic kidney disease and
notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the
nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that
apply.
A. ST depression
B. Prominent U wave
C. Tall peaked T waves
D. Prolonged ST segment
E. Widened QRS complexes - ANSWER - C, E
Rationale:
The client with chronic kidney disease is at risk for hyperkalemia. The normal potassium
level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0
mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated
with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS
complexes, and tall peaked T waves. ST depression and a prominent U wave occurs in
hypokalemia. A prolonged ST segment occurs in hypocalcemia.
pg. 2
,The nurse is assigned to care for a group of clients. On review of the clients' medical
records, the nurse determines that which client is most likely at risk for a fluid volume
deficit?
A. A client with an ileostomy
B. A client with heart failure
C. A client on long-term corticosteroid therapy
D. A client receiving frequent wound irrigations - ANSWER - A
Rationale:
A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs
of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that
cause increased respirations or increased urinary output, insufficient intravenous fluid
replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client
with heart failure or on long-term corticosteroid therapy or a client receiving frequent
wound irrigations is most at risk for fluid volume excess.
The nurse is caring for a client with a nasogastric tube that is attached to low suction.
The nurse monitors the client for manifestations of which disorder that the client is at
risk for?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis - ANSWER - B
Rationale:
Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess
of base (bicarbonate) that results from the accumulation of base or from a loss of acid
without a comparable loss of base in the body fluids. This occurs in conditions resulting
in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive
transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric
suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric
acid. The remaining options are incorrect interpretations.
pg. 3
, A client with a 3-day history of nausea and vomiting presents to the emergency
department. The client is hypoventilating and has a respiratory rate of 10 breaths per
minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of
120 beats per minute. Arterial blood gases are drawn and the nurse reviews the results,
expecting to note which finding?
A. A decreased pH and an increased Paco2
B. An increased pH and a decreased Paco2
C. A decreased pH and a decreased HCO3-
D. An increased pH and an increased HCO3- - ANSWER - D
Rationale:
Clients experiencing nausea and vomiting would most likely present with metabolic
alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase.
Symptoms experienced by the client would include a decrease in the respiratory rate
and depth, and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2
reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic
condition.
The nurse is caring for a client with diabetic ketoacidosis and documents that the client
is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select
all that apply.
A. Respirations that are shallow
B. Respirations that are increased in rate
C. Respirations that are abnormally slow
D. Respirations that are abnormally deep
E. Respirations that cease for several seconds - ANSWER - B, D
Rationale:
Kussmaul's respirations are abnormally deep and increased in rate. These occur as a
result of the compensatory action by the lungs. In bradypnea, respirations are regular
but abnormally slow. Apnea is described as respirations that cease for several seconds.
pg. 4
COMPLETE 800+ ACTUAL EXAM QUESTIONS
WITH CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) GRADED A+
The nurse is assessing a client with a lactose intolerance disorder for a suspected
diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note
in the client?
A. Twitching
B. Hypoactive bowel sounds
C. Negative Trousseau's sign
D. Hypoactive deep tendon reflexes - ANSWER - A
Rationale:
A client with lactose intolerance is at risk for developing hypocalcemia, because food
products that contain calcium also contain lactose. The normal serum calcium level is 9
to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25
mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed
by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or
Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular
excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety.
Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds,
abdominal cramping, and diarrhea.
The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL
(2 mmol/L). Which patterns would the nurse watch for on the electrocardiogram? Select
all that apply.
A. U waves
pg. 1
,B. Widened T wave
C. Prominent U wave
D. Prolonged QT interval
E. Prolonged ST segment - ANSWER - D, E
Rationale:
A client with Crohn's disease is at risk for hypocalcemia. The normal serum calcium
level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL
(2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a
client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A
shortened ST segment and a widened T wave occur with hypercalcemia. ST depression
and prominent U waves occur with hypokalemia.
The nurse reviews the electrolyte results of a client with chronic kidney disease and
notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the
nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that
apply.
A. ST depression
B. Prominent U wave
C. Tall peaked T waves
D. Prolonged ST segment
E. Widened QRS complexes - ANSWER - C, E
Rationale:
The client with chronic kidney disease is at risk for hyperkalemia. The normal potassium
level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0
mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated
with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS
complexes, and tall peaked T waves. ST depression and a prominent U wave occurs in
hypokalemia. A prolonged ST segment occurs in hypocalcemia.
pg. 2
,The nurse is assigned to care for a group of clients. On review of the clients' medical
records, the nurse determines that which client is most likely at risk for a fluid volume
deficit?
A. A client with an ileostomy
B. A client with heart failure
C. A client on long-term corticosteroid therapy
D. A client receiving frequent wound irrigations - ANSWER - A
Rationale:
A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs
of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that
cause increased respirations or increased urinary output, insufficient intravenous fluid
replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client
with heart failure or on long-term corticosteroid therapy or a client receiving frequent
wound irrigations is most at risk for fluid volume excess.
The nurse is caring for a client with a nasogastric tube that is attached to low suction.
The nurse monitors the client for manifestations of which disorder that the client is at
risk for?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis - ANSWER - B
Rationale:
Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess
of base (bicarbonate) that results from the accumulation of base or from a loss of acid
without a comparable loss of base in the body fluids. This occurs in conditions resulting
in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive
transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric
suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric
acid. The remaining options are incorrect interpretations.
pg. 3
, A client with a 3-day history of nausea and vomiting presents to the emergency
department. The client is hypoventilating and has a respiratory rate of 10 breaths per
minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of
120 beats per minute. Arterial blood gases are drawn and the nurse reviews the results,
expecting to note which finding?
A. A decreased pH and an increased Paco2
B. An increased pH and a decreased Paco2
C. A decreased pH and a decreased HCO3-
D. An increased pH and an increased HCO3- - ANSWER - D
Rationale:
Clients experiencing nausea and vomiting would most likely present with metabolic
alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase.
Symptoms experienced by the client would include a decrease in the respiratory rate
and depth, and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2
reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic
condition.
The nurse is caring for a client with diabetic ketoacidosis and documents that the client
is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select
all that apply.
A. Respirations that are shallow
B. Respirations that are increased in rate
C. Respirations that are abnormally slow
D. Respirations that are abnormally deep
E. Respirations that cease for several seconds - ANSWER - B, D
Rationale:
Kussmaul's respirations are abnormally deep and increased in rate. These occur as a
result of the compensatory action by the lungs. In bradypnea, respirations are regular
but abnormally slow. Apnea is described as respirations that cease for several seconds.
pg. 4
