75 NCLEX Questions – (NCLEX Questions Here are 75, completely Comp
hensive NCLEX Review questions with complete Rationales)
1. The nurse is taking the 1. Increase in Forced Vital Capacity (FVC)
health history of a patient Forced Vital Capacity is the volume of air exhaled from full inhala-
being treated for Emphyse- tion to full exhalation. A patient with COPD would have a decrease
ma and Chronic Bronchitis. in FVC. Incorrect.
After being told the patient
has been smoking cigarettes 2. A narrowed chest cavity
for 30 years, the nurse ex- A patient with COPD often presents with a 'barrel chest,' which is
pects to note which assess- seen as a widened chest cavity. Incorrect.
ment finding?
3. Clubbed fingers - CORRECT
1. Increase in Forced Vital Clubbed fingers are a sign of a long-term, or chronic, decrease in
Capacity (FVC) oxygen levels.
2. A narrowed chest cavity
4. An increased risk of cardiac failure
3. Clubbed fingers
Although a patient with these conditions would indeed be at an
4. An increased risk of car-
increased risk for cardiac failure, this is a potential complication
diac failure
and not an assessment finding. Incorrect.
2. The nurse is taking 1. Melena - CORRECT
the health history of a Melena is the finding that there are traces of blood in the stool
70-year-old patient being which presents as black, tarry feces. This is a common manifesta-
treated for a Duodenal Ulcer. tion of Duodenal Ulcers, since the Duodenum is further down the
After being told the patient gastric anatomy.
is complaining of epigastric
pain, the nurse expects to 2. Nausea
note which assessment find- Nausea may be present, but is a generalized symptom and by
ing? itself doesn't indicate a Duodenal Ulcer. Incorrect.
1. Melena 3. Hernia
2. Nausea 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.
, 75 NCLEX Questions – (NCLEX Questions Here are 75, completely Comp
hensive NCLEX Review questions with complete Rationales)
3. Hernia
4. Hyperthermia 4. Hyperthermia
Hyperthermia, a high temperature, is not an assessment finding
of a Duodenal Ulcer. Incorrect
3. A nurse is providing dis- 1. "I'm going to limit my meals to 2-3 per day to reduce acid
charge teaching for a pa- secretion."
tient with severe Gastroe- CORRECT - Large meals increase the volume and pressure in the
sophogeal Reflux Disease. stomach and delay gastric emptying. It's recommended instead
Which of these statements to eat 4-6 small meals a day.
by the patient indicates a
need for more teaching? 2. "I'm going to make sure to remain upright after meals and
elevate my head when I sleep"
1. "I'm going to limit my Incorrect - This is a correct verbalization of health promotion for
meals to 2-3 per day to re- GERD.
duce acid secretion."
3. "I won't be drinking tea or coffee or eating chocolate any
2. "I'm going to make sure to more."
remain upright after meals Incorrect - This is a correct verbalization of health promotion for
and elevate my head when I GERD.
sleep"
4. "I'm going to start trying to lose some weight."
3. "I won't be drinking tea Incorrect - This is a correct verbalization of health promotion for
or coffee or eating chocolate GERD.
any more."
4. "I'm going to start trying
to lose some weight."
4. The nurse in the Emergency 1. Start a large-bore IV in the patient's arm
Room is treating a patient CORRECT - The nurse should suspect that the patient is haemor-
suspected to have a Peptic rhaging and will need need a fluid replacement therapy, which
, 75 NCLEX Questions – (NCLEX Questions Here are 75, completely Comp
hensive NCLEX Review questions with complete Rationales)
Ulcer. On assessing lab re- requires a large bore IV.
sults, the nurse finds that
the patient's blood pressure 2. Ask the patient for a stool sample
is 95/60, pulse is 110 beats Incorrect - While this is useful in the diagnosis and assessment of
per minute, and the pa- Peptic Ulcer Disease, it is not the priority intervention.
tient reports epigastric pain.
3. Prepare to insert an NG Tube
What is the PRIORITY inter-
Incorrect - While this intervention may be used in the later stages
vention?
of Peptic Ulcer Disease, it is not the first and priority intervention.
1. Start a large-bore IV in the
4. Administer intramuscular morphine sulphate as ordered
patient's arm
Incorrect - While this is an important intervention to manage pain,
2. Ask the patient for a stool
it is not the priority intervention.
sample
3. Prepare to insert an NG
Tube
4. Administer intramuscular
morphine sulphate as or-
dered
5. A female patient with atri- 1. Hemoglobin 11 g/dl
al fibrillation has the follow- This is below normal, but a normal female hemoglobin is 12-14.
ing lab results: Hemoglobin There is a more critical lab result.
of 11 g/dl, a platelet count
of 150,000, an INR of 2.5, 2. Platelet of 150,000
and potassium of 2.7 mEq/L. This is also below the normal values, but is not the most critical lab
Which result is critical and result.
should be reported to the
3. INR of 2.5
physician immediately?
This is a therapeutic range for a patient who is taking an antico-
1. Hemoglobin 11 g/dl agulant for atrial fibrillation
2. Platelet of 150,000
4. Potassium of 2.7 mEq/L
, 75 NCLEX Questions – (NCLEX Questions Here are 75, completely Comp
hensive NCLEX Review questions with complete Rationales)
3. INR of 2.5 CORRECT - A potassium imbalance for a patient with a history
4. Potassium of 2.7 mEq/L of dysrhythmia can be life-threatening and can lead to cardiac
distress.
6. While receiving normal 1. Stop the saline infusion immediately
saline infusions to treat a CORRECT - the patient has a fluid volume overload as a result of
GI bleed, the nurse notes overly rapid fluid replacement. The nurse should stop the infusion
that the patient's lower legs and notify the physician.
have become edematous
and auscultates crackles in 2. Notify Physician
the lungs. What should the This is not the first action the nurse should take.
nurse do first?
3. Elevate the patient's legs
1. Stop the saline infusion This would help with the edema, but is not a priority
immediately
4. Continue the infusion, since these are normal findings
2. Notify Physician
This is not a normal finding
3. Elevate the patient's legs
4. Continue the infusion,
since these are normal find-
ings
7. The nurse is working in a 1. They must inform household members of their condition
support group for clients Incorrect - Each patient has a right to privacy of their medical
with HIV. Which point is most condition. It is their choice whether they inform household mem-
important for the nurse to bers.
stress?
2. They must take their medications exactly as prescribed
1. They must inform house- CORRECT - Antiretrovirals must be taken exactly as prescribed to
hold members of their con- prevent drug-resistant strains. Even missed doses can reduce the
dition effectiveness of future treatment.
2. They must take their
medications exactly as pre- 3. They must abstain from substance use
hensive NCLEX Review questions with complete Rationales)
1. The nurse is taking the 1. Increase in Forced Vital Capacity (FVC)
health history of a patient Forced Vital Capacity is the volume of air exhaled from full inhala-
being treated for Emphyse- tion to full exhalation. A patient with COPD would have a decrease
ma and Chronic Bronchitis. in FVC. Incorrect.
After being told the patient
has been smoking cigarettes 2. A narrowed chest cavity
for 30 years, the nurse ex- A patient with COPD often presents with a 'barrel chest,' which is
pects to note which assess- seen as a widened chest cavity. Incorrect.
ment finding?
3. Clubbed fingers - CORRECT
1. Increase in Forced Vital Clubbed fingers are a sign of a long-term, or chronic, decrease in
Capacity (FVC) oxygen levels.
2. A narrowed chest cavity
4. An increased risk of cardiac failure
3. Clubbed fingers
Although a patient with these conditions would indeed be at an
4. An increased risk of car-
increased risk for cardiac failure, this is a potential complication
diac failure
and not an assessment finding. Incorrect.
2. The nurse is taking 1. Melena - CORRECT
the health history of a Melena is the finding that there are traces of blood in the stool
70-year-old patient being which presents as black, tarry feces. This is a common manifesta-
treated for a Duodenal Ulcer. tion of Duodenal Ulcers, since the Duodenum is further down the
After being told the patient gastric anatomy.
is complaining of epigastric
pain, the nurse expects to 2. Nausea
note which assessment find- Nausea may be present, but is a generalized symptom and by
ing? itself doesn't indicate a Duodenal Ulcer. Incorrect.
1. Melena 3. Hernia
2. Nausea 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.
, 75 NCLEX Questions – (NCLEX Questions Here are 75, completely Comp
hensive NCLEX Review questions with complete Rationales)
3. Hernia
4. Hyperthermia 4. Hyperthermia
Hyperthermia, a high temperature, is not an assessment finding
of a Duodenal Ulcer. Incorrect
3. A nurse is providing dis- 1. "I'm going to limit my meals to 2-3 per day to reduce acid
charge teaching for a pa- secretion."
tient with severe Gastroe- CORRECT - Large meals increase the volume and pressure in the
sophogeal Reflux Disease. stomach and delay gastric emptying. It's recommended instead
Which of these statements to eat 4-6 small meals a day.
by the patient indicates a
need for more teaching? 2. "I'm going to make sure to remain upright after meals and
elevate my head when I sleep"
1. "I'm going to limit my Incorrect - This is a correct verbalization of health promotion for
meals to 2-3 per day to re- GERD.
duce acid secretion."
3. "I won't be drinking tea or coffee or eating chocolate any
2. "I'm going to make sure to more."
remain upright after meals Incorrect - This is a correct verbalization of health promotion for
and elevate my head when I GERD.
sleep"
4. "I'm going to start trying to lose some weight."
3. "I won't be drinking tea Incorrect - This is a correct verbalization of health promotion for
or coffee or eating chocolate GERD.
any more."
4. "I'm going to start trying
to lose some weight."
4. The nurse in the Emergency 1. Start a large-bore IV in the patient's arm
Room is treating a patient CORRECT - The nurse should suspect that the patient is haemor-
suspected to have a Peptic rhaging and will need need a fluid replacement therapy, which
, 75 NCLEX Questions – (NCLEX Questions Here are 75, completely Comp
hensive NCLEX Review questions with complete Rationales)
Ulcer. On assessing lab re- requires a large bore IV.
sults, the nurse finds that
the patient's blood pressure 2. Ask the patient for a stool sample
is 95/60, pulse is 110 beats Incorrect - While this is useful in the diagnosis and assessment of
per minute, and the pa- Peptic Ulcer Disease, it is not the priority intervention.
tient reports epigastric pain.
3. Prepare to insert an NG Tube
What is the PRIORITY inter-
Incorrect - While this intervention may be used in the later stages
vention?
of Peptic Ulcer Disease, it is not the first and priority intervention.
1. Start a large-bore IV in the
4. Administer intramuscular morphine sulphate as ordered
patient's arm
Incorrect - While this is an important intervention to manage pain,
2. Ask the patient for a stool
it is not the priority intervention.
sample
3. Prepare to insert an NG
Tube
4. Administer intramuscular
morphine sulphate as or-
dered
5. A female patient with atri- 1. Hemoglobin 11 g/dl
al fibrillation has the follow- This is below normal, but a normal female hemoglobin is 12-14.
ing lab results: Hemoglobin There is a more critical lab result.
of 11 g/dl, a platelet count
of 150,000, an INR of 2.5, 2. Platelet of 150,000
and potassium of 2.7 mEq/L. This is also below the normal values, but is not the most critical lab
Which result is critical and result.
should be reported to the
3. INR of 2.5
physician immediately?
This is a therapeutic range for a patient who is taking an antico-
1. Hemoglobin 11 g/dl agulant for atrial fibrillation
2. Platelet of 150,000
4. Potassium of 2.7 mEq/L
, 75 NCLEX Questions – (NCLEX Questions Here are 75, completely Comp
hensive NCLEX Review questions with complete Rationales)
3. INR of 2.5 CORRECT - A potassium imbalance for a patient with a history
4. Potassium of 2.7 mEq/L of dysrhythmia can be life-threatening and can lead to cardiac
distress.
6. While receiving normal 1. Stop the saline infusion immediately
saline infusions to treat a CORRECT - the patient has a fluid volume overload as a result of
GI bleed, the nurse notes overly rapid fluid replacement. The nurse should stop the infusion
that the patient's lower legs and notify the physician.
have become edematous
and auscultates crackles in 2. Notify Physician
the lungs. What should the This is not the first action the nurse should take.
nurse do first?
3. Elevate the patient's legs
1. Stop the saline infusion This would help with the edema, but is not a priority
immediately
4. Continue the infusion, since these are normal findings
2. Notify Physician
This is not a normal finding
3. Elevate the patient's legs
4. Continue the infusion,
since these are normal find-
ings
7. The nurse is working in a 1. They must inform household members of their condition
support group for clients Incorrect - Each patient has a right to privacy of their medical
with HIV. Which point is most condition. It is their choice whether they inform household mem-
important for the nurse to bers.
stress?
2. They must take their medications exactly as prescribed
1. They must inform house- CORRECT - Antiretrovirals must be taken exactly as prescribed to
hold members of their con- prevent drug-resistant strains. Even missed doses can reduce the
dition effectiveness of future treatment.
2. They must take their
medications exactly as pre- 3. They must abstain from substance use
