NCLEX PN Exam 2025 | Latest Actual
Exam Test Bank | 600 Questions |
Versions A & B | Verified Answers +
Detailed Rationales | A+ Study Material
You are caring for a 14-month-old diagnosed with severe iron deficiency anemia. She is
admitted for a blood transfusion and is started on oral iron supplementation. When you
change her diaper, you note a dark black stool. What are the appropriate nursing
actions?
Select ALL
A. Notify the healthcare provider.
B. Document the finding.
C. Continue with your assessment.
D. Administer the oral iron supplement as prescribed - Answer Choices B, C, and D are
correct.
B is correct. Black stools are an expected response to iron supplementation. It is an
appropriate nursing action to document this finding in the chart, but no further action is
needed.
C is correct. Black stools are an expected response to iron supplementation. It is an
appropriate nursing action to continue with your assessment. Since the finding is
expected, no other steps are necessary.
D is correct. Black stools are an expected response to iron supplementation. It is an
appropriate nursing action to administer the oral iron supplement as prescribed.
Choice A is incorrect. Black stools are an expected response to iron supplementation.
The nurse doesn't need to notify the healthcare provider of this.
NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological
therapies, Pediatrics Hematology
The nurse is re-educating on discharge instructions to a patient who has chronic
diabetes insipidus (DI). Which of the following patient statements would indicate a
correct understanding of the discharge instructions?
A. "I will need to drink no more than 800 ml per day."
B. "I will need to weigh myself at the same time every day."
C. "I should increase salty snacks in my diet."
D. "I need to log my fluid intake and urine output." - Answer Choice B is correct.
A patient with chronic diabetes insipidus (DI) is instructed to weigh themselves daily.
This weight should be taken with the same scale and obtained after the first-morning
void.
Choices A, C, and D are incorrect. Fluid restrictions would be appropriate for a patient
with syndrome of inappropriate antidiuretic hormone (SIADH). This would not be
appropriate for DI as the patient will need to consume more fluids to replace those that
are lost. Salty snacks are not encouraged because this may hasten the hypernatremia
1
,associated with this disease. Logging intake and output are not useful because this
provides a crude way of assessing fluid status.
This nurse is caring for a patient who is receiving prescribed ketorolac. Which of the
following findings would indicate a therapeutic response?
Select all that apply.
A. Decreased pain
B. Increased urinary output
C. Decreased blood pressure
D. Decreased temperature
E. Increased muscle coordination - Answer Choices A and D are correct
Ketorolac is a medication used to treat pain and pyrexia. A patient exhibiting a decrease
in pain and having a decrease in temperature would be a therapeutic response.
Choices B, C, and E are incorrect. Ketorolac does not therapeutically lower blood
pressure, increase urinary output, or increase muscle coordination. Medications that
could be used to lower blood pressure would be agents such as lisinopril, atenolol, etc.
Agents used to increase urinary output would be diuretics such as furosemide. The
improvement in muscle coordination may be achieved by medications such as
levodopa-carbidopa.
Which of the following falls under the right time of the 8 rights of medication
administration?
Select all that apply.
A. Have a second nurse independently calculate the medication dosage.
B. Double-check the last time that the medication was administered.
C. Verify the frequency with which the medication is ordered.
D. Document the pertinent vital signs. - Answer Choices B and C are correct.
B is correct. Double-checking the last time the medication was administered is a part of
the right time step in the 8 rights of medication administration. This is important because
the nurse needs to verify that she is giving the dose correctly and that it is not being
administered too frequently based upon the previous administration.
C is correct. Verifying the frequency with which the medication is ordered is a part of the
right time step in the 8 rights of medication administration. The nurse needs to verify
that the frequency with which the medication is being ordered will be safe not just for
this dose but for the cumulative dosage if the medication is being administered more
than once. For example, with acetaminophen, one dose of 1,000 mg may be
appropriate, but administering this dosage q4 would result in a daily intake of 6,000 mg
of acetaminophen, far above the maximum of 4,000 mg. This is why the right frequency
is a part of the right time step in the 8 rights of medication administration.
The nurse is caring for a primigravida patient with the following clinical data. The nurse
should take which of the following actions based on the result?
See the exhibit.-> Test: Nonstress test Result: Reactive
2
,A. Inform the patient of the normal finding.
B. Prepare the patient for a contraction stress test.
C. Arrange for a repeat test.
D. Inquire if the patient ate prior to the test. - Answer Choice A is correct.
A reactive NST is an expected finding and indicates fetal well-being.
Steroids have many different effects on the body. Which of the following are potential
effects of glucocorticoids?
Select all that apply.
A. Psychosis
B. Immunosuppression
C. Hypoglycemia
D. Hyperkalemia - Answer Choices A and B are correct.
A is correct. Glucocorticoids can have severe effects on your patient's mood. Some of
the potential mood changes you may observe in your patient are depression, psychosis,
euphoria, and insomnia. It is essential to know your patients' baseline and warn them of
the potential changes they will experience while taking these medications.
B is correct. Glucocorticoids alter the body's defense mechanism, making them
immunosuppressed. This puts them at risk for infections. While your patient is taking
glucocorticoids, it is essential to monitor them for infection by watching their
temperatures, WBC counts, and CRP. Any indication of infection should be taken
seriously, as it is quite common for these patients to develop infections quickly.
The nurse is conducting a health screening at a local health fair. Which of the following
should the nurse recognize as a risk factor for developing testicular cancer? Select all
that apply.
A. Cryptorchidism
B. Human immunodeficiency virus (HIV)
C. Vasectomy
D. Family history
E. Herpes simplex virus (HSV) - Answer Choices A, B, and D are correct. Risk factors
for testicular cancer include cryptorchidism, human immunodeficiency virus (HIV), and
family history. Cryptorchidism ( Choice A) refers to undescended testicle where the
testicle fails to descend to its normal position in the scrotum. Undescended testicles are
associated with decreased fertility, testicular torsion, inguinal hernias, and increased
risk of testicular germ cell tumors. HIV-positive ( Choice B) men have an increased risk
of developing testicular cancer, according to a study. Family history ( Choice D) of
testicular cancer is another risk factor, with an 8-10 times increased risk if the man has
a sibling with testicular cancer.
The nurse is caring for a patient with a percutaneous endoscopic gastrostomy tube in a
long-term care setting. Prior to starting the scheduled bolus feeding, the nurse is unable
to auscultate the patient's bowel sounds and notes 80 cc gastric residual volume. Of the
following, which action would be the nurse's first priority?
3
, A. Notify the physician
B. Hold bolus and recheck residual volume in 1 hour
C. Check for abdominal distension
D. Reposition the patient in semi-Fowler's position - Answer Choice C is correct.
If no bowel sounds are present, the nurse should then assess the patient's abdomen for
changes from baseline, such as tenderness or distension. If no changes from baseline,
this bolus may be administered as ordered.
This nurse is caring for a patient who is receiving prescribed methylergonovine. Which
of the following findings would indicate a therapeutic response?
A. Increased blood pressure
B. Decreased postpartum bleeding
C. Decreased uterine tone
D. Increased urinary output - Answer Choice B is correct. Methylergonovine is an
alkaloid medication used in the management of postpartum hemorrhage (PPH). This
medication causes vasoconstriction, therefore, decreasing postpartum bleeding.
A diabetic patient receives ten units of Regular insulin and 20 units of NPH insulin each
day after breakfast. After following the usual preparation steps for administering insulin,
what should the nurse do next?
A. Draw up NPH insulin first because it is clear.
B. Either insulin can be drawn first as long as 30 units are given.
C. Draw up Regular insulin first because it is clear.
D. Administer each type of insulin separately for accuracy. - Answer Choice C is
correct.
Regular (short-acting) insulin is clear. NPH (intermediate-acting) is cloudy. Giving one
injection is more efficient and comfortable for the patient. REMEMBER: ALWAYS
CLEAR BEFORE CLOUDY or remember the mnemonic: RN = Regular to NPH.
The nurse is caring for a patient receiving lactulose. Which of the following finding would
indicate a therapeutic response?
A. Increased liver enzymes
B. Increased level of consciousness
C. Decreased urinary calcium
D. Increased gastric pH - Answer Choice B is correct.
Lactulose is indicated for patients with hyperammonemia secondary to cirrhosis of the
liver. Increased ammonia levels cause a patient to develop altered mental status
(hepatic encephalopathy). A patient receiving this medication will have increased bowel
movements as that is the primary way of excreting the excess ammonia.
**Acid Reflux (GERD)**
Primary Symptom
4
Exam Test Bank | 600 Questions |
Versions A & B | Verified Answers +
Detailed Rationales | A+ Study Material
You are caring for a 14-month-old diagnosed with severe iron deficiency anemia. She is
admitted for a blood transfusion and is started on oral iron supplementation. When you
change her diaper, you note a dark black stool. What are the appropriate nursing
actions?
Select ALL
A. Notify the healthcare provider.
B. Document the finding.
C. Continue with your assessment.
D. Administer the oral iron supplement as prescribed - Answer Choices B, C, and D are
correct.
B is correct. Black stools are an expected response to iron supplementation. It is an
appropriate nursing action to document this finding in the chart, but no further action is
needed.
C is correct. Black stools are an expected response to iron supplementation. It is an
appropriate nursing action to continue with your assessment. Since the finding is
expected, no other steps are necessary.
D is correct. Black stools are an expected response to iron supplementation. It is an
appropriate nursing action to administer the oral iron supplement as prescribed.
Choice A is incorrect. Black stools are an expected response to iron supplementation.
The nurse doesn't need to notify the healthcare provider of this.
NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological
therapies, Pediatrics Hematology
The nurse is re-educating on discharge instructions to a patient who has chronic
diabetes insipidus (DI). Which of the following patient statements would indicate a
correct understanding of the discharge instructions?
A. "I will need to drink no more than 800 ml per day."
B. "I will need to weigh myself at the same time every day."
C. "I should increase salty snacks in my diet."
D. "I need to log my fluid intake and urine output." - Answer Choice B is correct.
A patient with chronic diabetes insipidus (DI) is instructed to weigh themselves daily.
This weight should be taken with the same scale and obtained after the first-morning
void.
Choices A, C, and D are incorrect. Fluid restrictions would be appropriate for a patient
with syndrome of inappropriate antidiuretic hormone (SIADH). This would not be
appropriate for DI as the patient will need to consume more fluids to replace those that
are lost. Salty snacks are not encouraged because this may hasten the hypernatremia
1
,associated with this disease. Logging intake and output are not useful because this
provides a crude way of assessing fluid status.
This nurse is caring for a patient who is receiving prescribed ketorolac. Which of the
following findings would indicate a therapeutic response?
Select all that apply.
A. Decreased pain
B. Increased urinary output
C. Decreased blood pressure
D. Decreased temperature
E. Increased muscle coordination - Answer Choices A and D are correct
Ketorolac is a medication used to treat pain and pyrexia. A patient exhibiting a decrease
in pain and having a decrease in temperature would be a therapeutic response.
Choices B, C, and E are incorrect. Ketorolac does not therapeutically lower blood
pressure, increase urinary output, or increase muscle coordination. Medications that
could be used to lower blood pressure would be agents such as lisinopril, atenolol, etc.
Agents used to increase urinary output would be diuretics such as furosemide. The
improvement in muscle coordination may be achieved by medications such as
levodopa-carbidopa.
Which of the following falls under the right time of the 8 rights of medication
administration?
Select all that apply.
A. Have a second nurse independently calculate the medication dosage.
B. Double-check the last time that the medication was administered.
C. Verify the frequency with which the medication is ordered.
D. Document the pertinent vital signs. - Answer Choices B and C are correct.
B is correct. Double-checking the last time the medication was administered is a part of
the right time step in the 8 rights of medication administration. This is important because
the nurse needs to verify that she is giving the dose correctly and that it is not being
administered too frequently based upon the previous administration.
C is correct. Verifying the frequency with which the medication is ordered is a part of the
right time step in the 8 rights of medication administration. The nurse needs to verify
that the frequency with which the medication is being ordered will be safe not just for
this dose but for the cumulative dosage if the medication is being administered more
than once. For example, with acetaminophen, one dose of 1,000 mg may be
appropriate, but administering this dosage q4 would result in a daily intake of 6,000 mg
of acetaminophen, far above the maximum of 4,000 mg. This is why the right frequency
is a part of the right time step in the 8 rights of medication administration.
The nurse is caring for a primigravida patient with the following clinical data. The nurse
should take which of the following actions based on the result?
See the exhibit.-> Test: Nonstress test Result: Reactive
2
,A. Inform the patient of the normal finding.
B. Prepare the patient for a contraction stress test.
C. Arrange for a repeat test.
D. Inquire if the patient ate prior to the test. - Answer Choice A is correct.
A reactive NST is an expected finding and indicates fetal well-being.
Steroids have many different effects on the body. Which of the following are potential
effects of glucocorticoids?
Select all that apply.
A. Psychosis
B. Immunosuppression
C. Hypoglycemia
D. Hyperkalemia - Answer Choices A and B are correct.
A is correct. Glucocorticoids can have severe effects on your patient's mood. Some of
the potential mood changes you may observe in your patient are depression, psychosis,
euphoria, and insomnia. It is essential to know your patients' baseline and warn them of
the potential changes they will experience while taking these medications.
B is correct. Glucocorticoids alter the body's defense mechanism, making them
immunosuppressed. This puts them at risk for infections. While your patient is taking
glucocorticoids, it is essential to monitor them for infection by watching their
temperatures, WBC counts, and CRP. Any indication of infection should be taken
seriously, as it is quite common for these patients to develop infections quickly.
The nurse is conducting a health screening at a local health fair. Which of the following
should the nurse recognize as a risk factor for developing testicular cancer? Select all
that apply.
A. Cryptorchidism
B. Human immunodeficiency virus (HIV)
C. Vasectomy
D. Family history
E. Herpes simplex virus (HSV) - Answer Choices A, B, and D are correct. Risk factors
for testicular cancer include cryptorchidism, human immunodeficiency virus (HIV), and
family history. Cryptorchidism ( Choice A) refers to undescended testicle where the
testicle fails to descend to its normal position in the scrotum. Undescended testicles are
associated with decreased fertility, testicular torsion, inguinal hernias, and increased
risk of testicular germ cell tumors. HIV-positive ( Choice B) men have an increased risk
of developing testicular cancer, according to a study. Family history ( Choice D) of
testicular cancer is another risk factor, with an 8-10 times increased risk if the man has
a sibling with testicular cancer.
The nurse is caring for a patient with a percutaneous endoscopic gastrostomy tube in a
long-term care setting. Prior to starting the scheduled bolus feeding, the nurse is unable
to auscultate the patient's bowel sounds and notes 80 cc gastric residual volume. Of the
following, which action would be the nurse's first priority?
3
, A. Notify the physician
B. Hold bolus and recheck residual volume in 1 hour
C. Check for abdominal distension
D. Reposition the patient in semi-Fowler's position - Answer Choice C is correct.
If no bowel sounds are present, the nurse should then assess the patient's abdomen for
changes from baseline, such as tenderness or distension. If no changes from baseline,
this bolus may be administered as ordered.
This nurse is caring for a patient who is receiving prescribed methylergonovine. Which
of the following findings would indicate a therapeutic response?
A. Increased blood pressure
B. Decreased postpartum bleeding
C. Decreased uterine tone
D. Increased urinary output - Answer Choice B is correct. Methylergonovine is an
alkaloid medication used in the management of postpartum hemorrhage (PPH). This
medication causes vasoconstriction, therefore, decreasing postpartum bleeding.
A diabetic patient receives ten units of Regular insulin and 20 units of NPH insulin each
day after breakfast. After following the usual preparation steps for administering insulin,
what should the nurse do next?
A. Draw up NPH insulin first because it is clear.
B. Either insulin can be drawn first as long as 30 units are given.
C. Draw up Regular insulin first because it is clear.
D. Administer each type of insulin separately for accuracy. - Answer Choice C is
correct.
Regular (short-acting) insulin is clear. NPH (intermediate-acting) is cloudy. Giving one
injection is more efficient and comfortable for the patient. REMEMBER: ALWAYS
CLEAR BEFORE CLOUDY or remember the mnemonic: RN = Regular to NPH.
The nurse is caring for a patient receiving lactulose. Which of the following finding would
indicate a therapeutic response?
A. Increased liver enzymes
B. Increased level of consciousness
C. Decreased urinary calcium
D. Increased gastric pH - Answer Choice B is correct.
Lactulose is indicated for patients with hyperammonemia secondary to cirrhosis of the
liver. Increased ammonia levels cause a patient to develop altered mental status
(hepatic encephalopathy). A patient receiving this medication will have increased bowel
movements as that is the primary way of excreting the excess ammonia.
**Acid Reflux (GERD)**
Primary Symptom
4
