NCLEX RN ACTUAL EXAM 2024 QUESTIONS
AND ANSWERS WITH RATIONA LE.
Question 1:
A client diagnosed with pneumonia is prescribed antibiotics. The nurse understands that the primary purpose of administering antibiotics is to:
a) Reduce fever
b) Provide symptomatic relief
c) Kill or inhibit bacterial growth
d) Increase oxygen saturation
Answer 1:
c) Kill or inhibit bacterial growth
Rationale 1:
Antibiotics are prescribed for bacterial infections. They work by either killing bacteria
or inhibiting their growth. In the case of pneumonia, which is often caused by bacteria, antibiotics are essential to eradicate the infection.
Question 2:
A postoperative client is receiving patient-controlled analgesia (PCA) for pain management. The nurse educates the client on the importance of not allowing anyone else to push the PCA button. What is the rationale behind this instruction?
a) To prevent overdose
b) To conserve medication
c) To maintain patient autonomy
d) To prevent infection
Answer 2:
a) To prevent overdose Rationale 2:
Patient-controlled analgesia (PCA) allows the client to self-administer pain medication within prescribed limits. Allowing others to push the button can lead to an unintentional overdose of medication, as they may not be aware of the patient's pain level or previous doses.
Question 3:
A client is admitted with heart failure, and the nurse is monitoring for symptoms of fluid overload. Which assessment finding indicates fluid retention?
a) Decreased blood pressure
b) Decreased respiratory rate
c) Pitting edema in the lower extremities
d) Increased urine output
Answer 3:
c) Pitting edema in the lower extremities
Rationale 3:
Pitting edema in the lower extremities is a classic sign of fluid retention or fluid overload. In heart failure, the heart's inability to pump effectively can lead to the accumulation of fluid in the extremities.
Question 4:
A client is prescribed warfarin (Coumadin) for deep vein thrombosis (DVT) prophylaxis. The nurse instructs the client to avoid excessive intake of which vitamin?
a) Vitamin A
b) Vitamin B6
c) Vitamin C
d) Vitamin K Answer 4:
d) Vitamin K
Rationale 4:
Warfarin is an anticoagulant that works by inhibiting the synthesis of clotting factors,
which are vitamin K-dependent. Consistent intake of vitamin K-containing foods is important to maintain a stable dose of warfarin.
Question 5:
A client with type 1 diabetes is admitted with symptoms of diabetic ketoacidosis (DKA). The nurse knows that the priority intervention is to:
a) Administer regular insulin
b) Provide a high-carbohydrate diet
c) Encourage fluid restriction
d) Monitor blood glucose every 12 hours
Answer 5:
a) Administer regular insulin
Rationale 5:
The priority in treating diabetic ketoacidosis (DKA) is to correct the hyperglycemia and ketoacidosis. Regular insulin is the medication of choice to lower blood glucose levels quickly and suppress ketone production.
Question 6:
A client is prescribed furosemide (Lasix) for the treatment of hypertension. The nurse should closely monitor which electrolyte imbalance associated with the use of furosemide?
a) Hypernatremia
b) Hypokalemia
c) Hypercalcemia d) Hypermagnesemia
Answer 6:
b) Hypokalemia
Rationale 6:
Furosemide is a loop diuretic that can lead to potassium loss, resulting in hypokalemia. Monitoring potassium levels is crucial to prevent complications such as
cardiac dysrhythmias.
Question 7:
A client is diagnosed with iron-deficiency anemia. The nurse should encourage the client to increase intake of which dietary sources to enhance iron absorption?
a) Dairy products
b) Whole grains
c) Vitamin C-rich foods
d) High-fiber foods
Answer 7:
c) Vitamin C-rich foods
Rationale 7:
Vitamin C enhances the absorption of non-heme iron found in plant-based foods. Encouraging the client to consume foods rich in vitamin C, such as citrus fruits, can help improve iron absorption.
Question 8:
A pregnant client is scheduled for a non-stress test (NST). The nurse explains to the client that the purpose of the NST is to assess:
a) Fetal heart rate variability
b) Fetal lung maturity
c) Amniotic fluid volume
AND ANSWERS WITH RATIONA LE.
Question 1:
A client diagnosed with pneumonia is prescribed antibiotics. The nurse understands that the primary purpose of administering antibiotics is to:
a) Reduce fever
b) Provide symptomatic relief
c) Kill or inhibit bacterial growth
d) Increase oxygen saturation
Answer 1:
c) Kill or inhibit bacterial growth
Rationale 1:
Antibiotics are prescribed for bacterial infections. They work by either killing bacteria
or inhibiting their growth. In the case of pneumonia, which is often caused by bacteria, antibiotics are essential to eradicate the infection.
Question 2:
A postoperative client is receiving patient-controlled analgesia (PCA) for pain management. The nurse educates the client on the importance of not allowing anyone else to push the PCA button. What is the rationale behind this instruction?
a) To prevent overdose
b) To conserve medication
c) To maintain patient autonomy
d) To prevent infection
Answer 2:
a) To prevent overdose Rationale 2:
Patient-controlled analgesia (PCA) allows the client to self-administer pain medication within prescribed limits. Allowing others to push the button can lead to an unintentional overdose of medication, as they may not be aware of the patient's pain level or previous doses.
Question 3:
A client is admitted with heart failure, and the nurse is monitoring for symptoms of fluid overload. Which assessment finding indicates fluid retention?
a) Decreased blood pressure
b) Decreased respiratory rate
c) Pitting edema in the lower extremities
d) Increased urine output
Answer 3:
c) Pitting edema in the lower extremities
Rationale 3:
Pitting edema in the lower extremities is a classic sign of fluid retention or fluid overload. In heart failure, the heart's inability to pump effectively can lead to the accumulation of fluid in the extremities.
Question 4:
A client is prescribed warfarin (Coumadin) for deep vein thrombosis (DVT) prophylaxis. The nurse instructs the client to avoid excessive intake of which vitamin?
a) Vitamin A
b) Vitamin B6
c) Vitamin C
d) Vitamin K Answer 4:
d) Vitamin K
Rationale 4:
Warfarin is an anticoagulant that works by inhibiting the synthesis of clotting factors,
which are vitamin K-dependent. Consistent intake of vitamin K-containing foods is important to maintain a stable dose of warfarin.
Question 5:
A client with type 1 diabetes is admitted with symptoms of diabetic ketoacidosis (DKA). The nurse knows that the priority intervention is to:
a) Administer regular insulin
b) Provide a high-carbohydrate diet
c) Encourage fluid restriction
d) Monitor blood glucose every 12 hours
Answer 5:
a) Administer regular insulin
Rationale 5:
The priority in treating diabetic ketoacidosis (DKA) is to correct the hyperglycemia and ketoacidosis. Regular insulin is the medication of choice to lower blood glucose levels quickly and suppress ketone production.
Question 6:
A client is prescribed furosemide (Lasix) for the treatment of hypertension. The nurse should closely monitor which electrolyte imbalance associated with the use of furosemide?
a) Hypernatremia
b) Hypokalemia
c) Hypercalcemia d) Hypermagnesemia
Answer 6:
b) Hypokalemia
Rationale 6:
Furosemide is a loop diuretic that can lead to potassium loss, resulting in hypokalemia. Monitoring potassium levels is crucial to prevent complications such as
cardiac dysrhythmias.
Question 7:
A client is diagnosed with iron-deficiency anemia. The nurse should encourage the client to increase intake of which dietary sources to enhance iron absorption?
a) Dairy products
b) Whole grains
c) Vitamin C-rich foods
d) High-fiber foods
Answer 7:
c) Vitamin C-rich foods
Rationale 7:
Vitamin C enhances the absorption of non-heme iron found in plant-based foods. Encouraging the client to consume foods rich in vitamin C, such as citrus fruits, can help improve iron absorption.
Question 8:
A pregnant client is scheduled for a non-stress test (NST). The nurse explains to the client that the purpose of the NST is to assess:
a) Fetal heart rate variability
b) Fetal lung maturity
c) Amniotic fluid volume
