NCLEX-PN Questions
1. A client with atrial fibrillation who is receiving maintenance therapy with warfarin
sodium (Coumadin) has a prothrombin time (PT) of 30 seconds. Thenurse anticipates that
which of the following will be prescribed?: Holding thenext dose of warfarin sodium
The normal PT is 9.6 to 11.8 seconds for the adult male and 9.5 to 11.3 seconds for
the adult female. Because the value stated is extremely high (and perhaps near thecritical
range), the nurse should anticipate that the client would not receive further doses at this time.
If the level were too high, then the antidote (vitamin K) may be prescribed. Options 1,; adding
a dose of heparin 3: Increasing the next dose of warfarin sodium, and 4 Administering the next
dose of warfarin sodium would makethe client more toxic and prone to bleeding.
2. A client arrives in the emergency department complaining of chest painthat began 4 hours
ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL.
The nurse interprets that this result indicates:: A level that indicates a myocardial infarction
Troponins are regulatory proteins that are found in striated muscle. The troponins function
together in the contractile apparatus for striated muscle in the skeletal muscle and the
myocardium. Increased amounts of troponins are released into thebloodstream when an
infarction causes damage to the myocardium. A troponin T level greater than 0.1 to 0.2 ng/mL
is consistent with a myocardial infarction. A normal troponin I level is less than 0.6 ng/mL,
whereas a level greater than 1.5 ng/mLis consistent with a myocardial infarction. A troponin T
level of 0.6 is not normal, sooption 1 is incorrect. Troponin T does not test for angina or
gastritis; thus options 2and 4 are incorrect.
3. An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this
result is most likely the result of which of the followingfactors in the client's history?: Iron
deficiency anemia
The normal hemoglobin level for an adult female client is 12 to 15 g/dL. A low hemoglobin
level usually indicates anemia. Iron deficiency anemia can result in lower hemoglobin levels.
Options 1, 2, and 4 may increase hemoglobin. Heart failureand COPD may increase the
hemoglobin level as a result of the body's need for more oxygen-carrying capacity.
Dehydration may increase the hemoglobin level byhemoconcentration.
4. A client who is receiving a blood transfusion rings the call bell for the nurse. When
entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of
generalized itching. The nurse interprets thatthe client is experiencing:: A transfusion reaction
The signs and symptoms exhibited by the client are consistent with a transfusion reaction.
With bacteremia, the client would have a fever, which is not part of the clinical picture
presented. With fluid (circulatory) overload, the client would have crackles in addition to
,dyspnea. There is no correlation between the signs mentioned
in the question and hypovolemic shock. The signs identified in the question are indicative of
an allergic reaction, which is one type of blood transfusion reaction.
5. A nurse is doing a routine assessment of a client's peripheral IV site. Thenurse notes that
the site is cool, pale, and swollen and that the IV has stoppedrunning. The nurse determines that
which of the following has probably oc- curred?: Infiltration
An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneoustissue. The
pallor, coolness, and swelling are the result of IV fluid being deposited into the subcutaneous
tissue. When the pressure in the tissues exceeds the pressurein the tubing, the flow of the IV
solution will stop. The other three options identify complications that are likely to be
accompanied by warmth at the site rather than coolness.
6. A nurse is checking the insertion site of a peripheral IV catheter. The nursenotes the site to
be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV
catheter. The nurse interprets that this is likely the result of:: Phlebitis of the vein
Phlebitis at an IV site results in discomfort at the site and redness, warmth, and swelling
proximal to the IV catheter. The IV catheter should be removed, and a newIV line should be
inserted at a different site. The remaining options are incorrect; thesigns and symptoms in the
question are not associated with these conditions.
7. A nurse is collecting data from a client who is scheduled for surgery in 1 week in the
ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has
been taking acetylsalicylic acid (aspirin).Thenurse reports the information to the surgeon and
anticipates that the surgeonwill prescribe which of the following?: Discontinue the aspirin 48
hours before the scheduled surgery.
Anticoagulants alter normal clotting factors and increase the risk of hemorrhage.Aspirin has
properties that can alter the clotting mechanism and should thus be discontinued at least 48
hours before surgery.
8. A nurse is monitoring an adult client for postoperative complications. Which of the
following would be the most indicative of a potential postop- erative complication that
requires further observation?: A urinary output of 20mL/hour
, Urine output is maintained at a minimum of at least 30 mL/hour for an adult. An outputof less than
30 mL/hour for each of two consecutive hours should be reported to thesurgeon. A temperature
more than 37° C (100° F) or less than 36.1° C (97° F) anda falling systolic blood pressure less
than 90 mm Hg are to be reported. The client'spreoperative or baseline blood pressure is used
to make informed postoperative comparisons. Moderate or light serous drainage from the
surgical site is considerednormal.
9. A nurse is assisting with monitoring the functioning of a chest-tube drainage system in a
client who just returned from the recovery room after
a thoracotomy with wedge resection. Which findings would the nurse expectto note? Select all
that apply.:
10. A nurse is assisting with monitoring the functioning of a chest-tube drainage system in a
client who just returned from the recovery room after athoracotomy with wedge resection.
Which findings would the nurse expect tonote? Select all that apply.: 50 mL of drainage in the
drainage-collection chamberThe drainage system is maintained below the client's chest.
An occlusive dressing is in place over the chest-tube insertion site.
Fluctuation of water in the tube of the water-seal chamber during inhalation andexhalation
The bubbling of water in the water-seal chamber indicates air drainage from the client. This is
usually seen when intrathoracic pressure is greater than atmosphericpressure, and it may occur
during exhalation, coughing, or sneezing. Excessive bubbling in the water-seal chamber may
indicate an air leak, which is an unexpectedfinding. The fluctuation of water in the tube in the
water-seal chamber during inhalation and exhalation is expected. An absence of fluctuation may
indicate that thechest tube is obstructed, the lung has re-expanded, or no more air is leaking into
thepleural space. Gentle (not vigorous) bubbling should be noted in the suction-control
chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit
from the recovery room; however, drainage of more than 70 to 100 mL/hr is considered
excessive and requires health care provider notification. The chest-tube insertion site is covered
with an occlusive (airtight) dressing to prevent airfrom entering the pleural space. Positioning
the drainage system below the client'schest allows gravity to drain the pleural space.
11. The client at 38 weeks' gestation is admitted to the birthing center in early
labor. The client is carrying twins, and one of the fetuses is in a breech presen- tation. The nurse
assists with planning care for the client and identifies which of the following as the lowest
priority for the care of this client?: Measuring the
fundal height
Option 1 is a low priority, because fundal height should be measured at each antepartal clinic
visit; it is not a priority of care during the intrapartum period. Options2, 3, and 4 are all high
priorities. The twins should be monitored by dual electronic fetal monitoring, and any signs of
distress should be reported. Many health care providers choose to perform a cesarean birth if
1. A client with atrial fibrillation who is receiving maintenance therapy with warfarin
sodium (Coumadin) has a prothrombin time (PT) of 30 seconds. Thenurse anticipates that
which of the following will be prescribed?: Holding thenext dose of warfarin sodium
The normal PT is 9.6 to 11.8 seconds for the adult male and 9.5 to 11.3 seconds for
the adult female. Because the value stated is extremely high (and perhaps near thecritical
range), the nurse should anticipate that the client would not receive further doses at this time.
If the level were too high, then the antidote (vitamin K) may be prescribed. Options 1,; adding
a dose of heparin 3: Increasing the next dose of warfarin sodium, and 4 Administering the next
dose of warfarin sodium would makethe client more toxic and prone to bleeding.
2. A client arrives in the emergency department complaining of chest painthat began 4 hours
ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL.
The nurse interprets that this result indicates:: A level that indicates a myocardial infarction
Troponins are regulatory proteins that are found in striated muscle. The troponins function
together in the contractile apparatus for striated muscle in the skeletal muscle and the
myocardium. Increased amounts of troponins are released into thebloodstream when an
infarction causes damage to the myocardium. A troponin T level greater than 0.1 to 0.2 ng/mL
is consistent with a myocardial infarction. A normal troponin I level is less than 0.6 ng/mL,
whereas a level greater than 1.5 ng/mLis consistent with a myocardial infarction. A troponin T
level of 0.6 is not normal, sooption 1 is incorrect. Troponin T does not test for angina or
gastritis; thus options 2and 4 are incorrect.
3. An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this
result is most likely the result of which of the followingfactors in the client's history?: Iron
deficiency anemia
The normal hemoglobin level for an adult female client is 12 to 15 g/dL. A low hemoglobin
level usually indicates anemia. Iron deficiency anemia can result in lower hemoglobin levels.
Options 1, 2, and 4 may increase hemoglobin. Heart failureand COPD may increase the
hemoglobin level as a result of the body's need for more oxygen-carrying capacity.
Dehydration may increase the hemoglobin level byhemoconcentration.
4. A client who is receiving a blood transfusion rings the call bell for the nurse. When
entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of
generalized itching. The nurse interprets thatthe client is experiencing:: A transfusion reaction
The signs and symptoms exhibited by the client are consistent with a transfusion reaction.
With bacteremia, the client would have a fever, which is not part of the clinical picture
presented. With fluid (circulatory) overload, the client would have crackles in addition to
,dyspnea. There is no correlation between the signs mentioned
in the question and hypovolemic shock. The signs identified in the question are indicative of
an allergic reaction, which is one type of blood transfusion reaction.
5. A nurse is doing a routine assessment of a client's peripheral IV site. Thenurse notes that
the site is cool, pale, and swollen and that the IV has stoppedrunning. The nurse determines that
which of the following has probably oc- curred?: Infiltration
An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneoustissue. The
pallor, coolness, and swelling are the result of IV fluid being deposited into the subcutaneous
tissue. When the pressure in the tissues exceeds the pressurein the tubing, the flow of the IV
solution will stop. The other three options identify complications that are likely to be
accompanied by warmth at the site rather than coolness.
6. A nurse is checking the insertion site of a peripheral IV catheter. The nursenotes the site to
be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV
catheter. The nurse interprets that this is likely the result of:: Phlebitis of the vein
Phlebitis at an IV site results in discomfort at the site and redness, warmth, and swelling
proximal to the IV catheter. The IV catheter should be removed, and a newIV line should be
inserted at a different site. The remaining options are incorrect; thesigns and symptoms in the
question are not associated with these conditions.
7. A nurse is collecting data from a client who is scheduled for surgery in 1 week in the
ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has
been taking acetylsalicylic acid (aspirin).Thenurse reports the information to the surgeon and
anticipates that the surgeonwill prescribe which of the following?: Discontinue the aspirin 48
hours before the scheduled surgery.
Anticoagulants alter normal clotting factors and increase the risk of hemorrhage.Aspirin has
properties that can alter the clotting mechanism and should thus be discontinued at least 48
hours before surgery.
8. A nurse is monitoring an adult client for postoperative complications. Which of the
following would be the most indicative of a potential postop- erative complication that
requires further observation?: A urinary output of 20mL/hour
, Urine output is maintained at a minimum of at least 30 mL/hour for an adult. An outputof less than
30 mL/hour for each of two consecutive hours should be reported to thesurgeon. A temperature
more than 37° C (100° F) or less than 36.1° C (97° F) anda falling systolic blood pressure less
than 90 mm Hg are to be reported. The client'spreoperative or baseline blood pressure is used
to make informed postoperative comparisons. Moderate or light serous drainage from the
surgical site is considerednormal.
9. A nurse is assisting with monitoring the functioning of a chest-tube drainage system in a
client who just returned from the recovery room after
a thoracotomy with wedge resection. Which findings would the nurse expectto note? Select all
that apply.:
10. A nurse is assisting with monitoring the functioning of a chest-tube drainage system in a
client who just returned from the recovery room after athoracotomy with wedge resection.
Which findings would the nurse expect tonote? Select all that apply.: 50 mL of drainage in the
drainage-collection chamberThe drainage system is maintained below the client's chest.
An occlusive dressing is in place over the chest-tube insertion site.
Fluctuation of water in the tube of the water-seal chamber during inhalation andexhalation
The bubbling of water in the water-seal chamber indicates air drainage from the client. This is
usually seen when intrathoracic pressure is greater than atmosphericpressure, and it may occur
during exhalation, coughing, or sneezing. Excessive bubbling in the water-seal chamber may
indicate an air leak, which is an unexpectedfinding. The fluctuation of water in the tube in the
water-seal chamber during inhalation and exhalation is expected. An absence of fluctuation may
indicate that thechest tube is obstructed, the lung has re-expanded, or no more air is leaking into
thepleural space. Gentle (not vigorous) bubbling should be noted in the suction-control
chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit
from the recovery room; however, drainage of more than 70 to 100 mL/hr is considered
excessive and requires health care provider notification. The chest-tube insertion site is covered
with an occlusive (airtight) dressing to prevent airfrom entering the pleural space. Positioning
the drainage system below the client'schest allows gravity to drain the pleural space.
11. The client at 38 weeks' gestation is admitted to the birthing center in early
labor. The client is carrying twins, and one of the fetuses is in a breech presen- tation. The nurse
assists with planning care for the client and identifies which of the following as the lowest
priority for the care of this client?: Measuring the
fundal height
Option 1 is a low priority, because fundal height should be measured at each antepartal clinic
visit; it is not a priority of care during the intrapartum period. Options2, 3, and 4 are all high
priorities. The twins should be monitored by dual electronic fetal monitoring, and any signs of
distress should be reported. Many health care providers choose to perform a cesarean birth if
