NGN NCLEX RN EXAM TEST BANK | ACCURATE AND VERIFIED 200
QUESTIONS AND ANSWERS WITH RATIONALES | EXPERT VERIFIED FOR
GUARANTEED PASS | GRADED A | LATEST UPDATE | ALL YOU NEED TO
ACE IT
1. The nurse is caring for a client with heart failure who is receiving
digoxin. Which of the following findings would indicate digoxin
toxicity?
A. Heart rate of 62 beats per minute
B. Serum potassium level of 4.0 mEq/L
C. Yellow-green halos around visual fields
D. Blood pressure of 130/80 mmHg
Correct Answer: C
Rationale: Yellow-green halos around visual fields are a classic sign of
digoxin toxicity. Other signs include nausea, vomiting, bradycardia, and
cardiac dysrhythmias. A heart rate of 62 is within normal limits.
Potassium of 4.0 is normal. Blood pressure of 130/80 is normal.
2. A client with chronic obstructive pulmonary disease (COPD) has an
arterial blood gas with pH 7.32, PaCO2 55 mmHg, HCO3 28 mEq/L, and
PaO2 70 mmHg. The nurse should interpret this as:
A. Respiratory acidosis with metabolic compensation
B. Respiratory alkalosis with metabolic compensation
C. Metabolic acidosis with respiratory compensation
D. Metabolic alkalosis with respiratory compensation
,Correct Answer: A
Rationale: The pH is low (acidosis), PaCO2 is elevated (respiratory), and
HCO3 is elevated (metabolic compensation). This indicates respiratory
acidosis with metabolic compensation, commonly seen in COPD clients
with carbon dioxide retention.
3. The nurse is assessing a client who has just returned from the post-
anesthesia care unit following a thyroidectomy. Which of the
following findings requires immediate intervention?
A. Client reports pain of 4/10 at the incision site
B. Client's voice is hoarse
C. Client reports tingling around the mouth
D. Client's temperature is 37.2°C (99.0°F)
Correct Answer: C
Rationale: Tingling around the mouth is a sign of hypocalcemia, which
can occur if the parathyroid glands were accidentally removed during
thyroidectomy. This can lead to life-threatening tetany and requires
immediate intervention. Hoarseness is expected after thyroid surgery.
Pain and mild temperature elevation are expected findings.
4. A client with schizophrenia is experiencing auditory hallucinations.
Which of the following nursing interventions is most appropriate?
A. Tell the client that the voices are not real
B. Ask the client what the voices are saying
C. Encourage the client to ignore the voices
D. Place the client in seclusion
,Correct Answer: B
Rationale: Asking the client what the voices are saying allows the nurse
to assess the content of the hallucinations and determine if the client is
at risk for harm. Telling the client the voices are not real can increase
anxiety and distrust. Ignoring voices is not realistic for the client.
Seclusion should only be used as a last resort for safety.
5. The nurse is preparing to administer a blood transfusion to a client.
Which of the following actions should the nurse take first?
A. Verify the client's identity using two identifiers
B. Prime the IV tubing with normal saline
C. Obtain baseline vital signs
D. Check the blood product expiration date
Correct Answer: A
Rationale: Verifying the client's identity using two identifiers is the most
critical step to prevent transfusion errors. While all options are
important steps in the transfusion process, client identification is the
priority to ensure the correct blood product is given to the correct
client.
6. A client with major depressive disorder is prescribed phenelzine.
The nurse should instruct the client to avoid which of the following
foods?
A. Apples and bananas
B. Chicken and fish
C. Aged cheese and red wine
D. Rice and pasta
, Correct Answer: C
Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI). Clients
taking MAOIs must avoid foods high in tyramine, including aged cheese,
red wine, smoked meats, and fermented foods, to prevent hypertensive
crisis. Apples, bananas, chicken, fish, rice, and pasta are safe to
consume.
7. The nurse is caring for a client with acute pancreatitis. Which of the
following laboratory findings would the nurse expect?
A. Decreased serum amylase
B. Elevated serum lipase
C. Decreased serum glucose
D. Elevated serum calcium
Correct Answer: B
Rationale: Serum lipase and amylase are elevated in acute pancreatitis
due to pancreatic enzyme release into the bloodstream. Serum glucose
may be elevated, not decreased. Serum calcium may be decreased due
to fat necrosis and saponification.
8. A client is receiving heparin therapy for a deep vein thrombosis. The
nurse should monitor which of the following laboratory values?
A. Prothrombin time (PT)
B. International normalized ratio (INR)
C. Activated partial thromboplastin time (aPTT)
D. Platelet count
QUESTIONS AND ANSWERS WITH RATIONALES | EXPERT VERIFIED FOR
GUARANTEED PASS | GRADED A | LATEST UPDATE | ALL YOU NEED TO
ACE IT
1. The nurse is caring for a client with heart failure who is receiving
digoxin. Which of the following findings would indicate digoxin
toxicity?
A. Heart rate of 62 beats per minute
B. Serum potassium level of 4.0 mEq/L
C. Yellow-green halos around visual fields
D. Blood pressure of 130/80 mmHg
Correct Answer: C
Rationale: Yellow-green halos around visual fields are a classic sign of
digoxin toxicity. Other signs include nausea, vomiting, bradycardia, and
cardiac dysrhythmias. A heart rate of 62 is within normal limits.
Potassium of 4.0 is normal. Blood pressure of 130/80 is normal.
2. A client with chronic obstructive pulmonary disease (COPD) has an
arterial blood gas with pH 7.32, PaCO2 55 mmHg, HCO3 28 mEq/L, and
PaO2 70 mmHg. The nurse should interpret this as:
A. Respiratory acidosis with metabolic compensation
B. Respiratory alkalosis with metabolic compensation
C. Metabolic acidosis with respiratory compensation
D. Metabolic alkalosis with respiratory compensation
,Correct Answer: A
Rationale: The pH is low (acidosis), PaCO2 is elevated (respiratory), and
HCO3 is elevated (metabolic compensation). This indicates respiratory
acidosis with metabolic compensation, commonly seen in COPD clients
with carbon dioxide retention.
3. The nurse is assessing a client who has just returned from the post-
anesthesia care unit following a thyroidectomy. Which of the
following findings requires immediate intervention?
A. Client reports pain of 4/10 at the incision site
B. Client's voice is hoarse
C. Client reports tingling around the mouth
D. Client's temperature is 37.2°C (99.0°F)
Correct Answer: C
Rationale: Tingling around the mouth is a sign of hypocalcemia, which
can occur if the parathyroid glands were accidentally removed during
thyroidectomy. This can lead to life-threatening tetany and requires
immediate intervention. Hoarseness is expected after thyroid surgery.
Pain and mild temperature elevation are expected findings.
4. A client with schizophrenia is experiencing auditory hallucinations.
Which of the following nursing interventions is most appropriate?
A. Tell the client that the voices are not real
B. Ask the client what the voices are saying
C. Encourage the client to ignore the voices
D. Place the client in seclusion
,Correct Answer: B
Rationale: Asking the client what the voices are saying allows the nurse
to assess the content of the hallucinations and determine if the client is
at risk for harm. Telling the client the voices are not real can increase
anxiety and distrust. Ignoring voices is not realistic for the client.
Seclusion should only be used as a last resort for safety.
5. The nurse is preparing to administer a blood transfusion to a client.
Which of the following actions should the nurse take first?
A. Verify the client's identity using two identifiers
B. Prime the IV tubing with normal saline
C. Obtain baseline vital signs
D. Check the blood product expiration date
Correct Answer: A
Rationale: Verifying the client's identity using two identifiers is the most
critical step to prevent transfusion errors. While all options are
important steps in the transfusion process, client identification is the
priority to ensure the correct blood product is given to the correct
client.
6. A client with major depressive disorder is prescribed phenelzine.
The nurse should instruct the client to avoid which of the following
foods?
A. Apples and bananas
B. Chicken and fish
C. Aged cheese and red wine
D. Rice and pasta
, Correct Answer: C
Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI). Clients
taking MAOIs must avoid foods high in tyramine, including aged cheese,
red wine, smoked meats, and fermented foods, to prevent hypertensive
crisis. Apples, bananas, chicken, fish, rice, and pasta are safe to
consume.
7. The nurse is caring for a client with acute pancreatitis. Which of the
following laboratory findings would the nurse expect?
A. Decreased serum amylase
B. Elevated serum lipase
C. Decreased serum glucose
D. Elevated serum calcium
Correct Answer: B
Rationale: Serum lipase and amylase are elevated in acute pancreatitis
due to pancreatic enzyme release into the bloodstream. Serum glucose
may be elevated, not decreased. Serum calcium may be decreased due
to fat necrosis and saponification.
8. A client is receiving heparin therapy for a deep vein thrombosis. The
nurse should monitor which of the following laboratory values?
A. Prothrombin time (PT)
B. International normalized ratio (INR)
C. Activated partial thromboplastin time (aPTT)
D. Platelet count
