NCLEX COMPREHENSIVE EXAM 2024 |
2025
NCLEX COMPREHENSIVE EXAM 2024 |2025 WITH GUARANTEED ACCURATE
ANSWERS
Enalapril maleate is prescribed for a hospitalized client. Which
assessment does the nurse perform as a priority before administering the
medication? - ACCURATE ANSWERS✔✔ Checking the client's blood
pressure
Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE)
inhibitor used to treat hypertension. One common side effect is postural
hypotension. Therefore the nurse would check the client's blood pressure
immediately before administering each dose. Checking the client's
peripheral pulses, the results of the most recent potassium level, and the
intake and output for the previous 24 hours are not specifically
associated with this mediation.
,A client is scheduled to undergo an upper gastrointestinal (GI) series,
and the nurse provides instructions to the client about the test. Which
statement by the client indicates a need for further instruction? -
ACCURATE ANSWERS✔✔ "I need to drink citrate of magnesia the
night before the test and give myself a Fleet enema on the morning of
the test."
Rationale: An upper GI series involves visualization of the esophagus,
duodenum, and upper jejunum by means of the use of a contrast
medium. It involves swallowing a contrast medium (usually barium),
which is administered in a flavored milkshake. Films are taken at
intervals during the test, which takes about 30 minutes. No special
preparation is necessary before a GI series, except that NPO status must
be maintained for 8 hours before the test. After an upper GI series, the
client is prescribed a laxative to hasten elimination of the barium.
Barium that remains in the colon may become hard and difficult to
expel, leading to fecal impaction.
A nurse on the evening shift checks a health care provider's prescriptions
and notes that the dose of a prescribed medication is higher than the
normal dose. The nurse calls the health care provider's answering service
and is told that the health care provider is off for the night and will be
available in the morning. The nurse should: - ACCURATE
ANSWERS✔✔ Ask the answering service to contact the on-call health
care provider
Rationale: The nurse has a duty to protect the client from harm. A nurse
who believes that a health care provider's prescription may be in error is
responsible for clarifying the prescription before carrying it out.
Therefore the nurse would not administer the medication; instead, the
,nurse would withhold the medication until the dose can be clarified. The
nurse would not wait until the next morning to obtain clarification. It is
premature to call the nursing supervisor.
An emergency department (ED) nurse is monitoring a client with
suspected acute myocardial infarction (MI) who is awaiting transfer to
the coronary intensive care unit. The nurse notes the sudden onset of
premature ventricular contractions (PVCs) on the monitor, checks the
client's carotid pulse, and determines that the PVCs are not resulting in
perfusion. The appropriate action by the nurse is: - ACCURATE
ANSWERS✔✔ Asking the ED health care provider to check the client
Rationale: PVCs are a result of increased irritability of ventricular cells.
Peripheral pulses may be absent or diminished with the PVCs
themselves because the decreased stroke volume of the premature beats
may in turn decrease peripheral perfusion. Because other rhythms also
cause widened QRS complexes, it is essential that the nurse determine
whether the premature beats are resulting in perfusion of the extremities.
This is done by palpating the carotid, brachial, or femoral artery while
observing the monitor for widened complexes or by auscultating for
apical heart sounds. In the situation of acute MI, PVCs may be
considered warning dysrhythmias, possibly heralding the onset of
ventricular tachycardia or ventricular fibrillation. Therefore the nurse
would not tell the client that the PVCs are expected. Although the nurse
will continue to monitor the client and document the findings, these are
not the most appropriate actions of those provided. The most appropriate
action would be to ask the ED health care provider to check the client.
NPO status is imposed 8 hours before the procedure on a client
scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the
, morning of the procedure, the nurse checks the client's record and notes
that the client routinely takes an oral antihypertensive medication each
morning. The nurse should: - ACCURATE ANSWERS✔✔ Administer
the antihypertensive with a small sip of water
Rationale: General anesthesia is required for ECT, so NPO status is
imposed for 6 to 8 hours before treatment to help prevent aspiration.
Exceptions include clients who routinely receive cardiac medications,
antihypertensive agents, or histamine (H2) blockers, which should be
administered several hours before treatment with a small sip of water.
Withholding the antihypertensive and administering it at bedtime and
withholding the antihypertensive and resuming administration on the
day after the ECT are incorrect actions, because antihypertensives must
be administered on time; otherwise, the risk for rebound hypertension
exists. The nurse would not administer a medication by way of a route
that has not been prescribed.
A client who recently underwent coronary artery bypass graft surgery
comes to the health care provider's office for a follow-up visit. On
assessment, the client tells the nurse that he is feeling depressed. Which
response by the nurse is therapeutic? - ACCURATE ANSWERS✔✔
"Tell me more about what you're feeling."
Rationale: When a client expresses feelings of depression, it is extremely
important for the nurse to further explore these feelings with the client.
In stating, "This is a normal response after this type of surgery" the nurse
provides false reassurance and avoids addressing the client's feelings. "It
will take time, but, I promise you, you will get over the depression" is
also a false reassurance, and it does not encourage the expression of
2025
NCLEX COMPREHENSIVE EXAM 2024 |2025 WITH GUARANTEED ACCURATE
ANSWERS
Enalapril maleate is prescribed for a hospitalized client. Which
assessment does the nurse perform as a priority before administering the
medication? - ACCURATE ANSWERS✔✔ Checking the client's blood
pressure
Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE)
inhibitor used to treat hypertension. One common side effect is postural
hypotension. Therefore the nurse would check the client's blood pressure
immediately before administering each dose. Checking the client's
peripheral pulses, the results of the most recent potassium level, and the
intake and output for the previous 24 hours are not specifically
associated with this mediation.
,A client is scheduled to undergo an upper gastrointestinal (GI) series,
and the nurse provides instructions to the client about the test. Which
statement by the client indicates a need for further instruction? -
ACCURATE ANSWERS✔✔ "I need to drink citrate of magnesia the
night before the test and give myself a Fleet enema on the morning of
the test."
Rationale: An upper GI series involves visualization of the esophagus,
duodenum, and upper jejunum by means of the use of a contrast
medium. It involves swallowing a contrast medium (usually barium),
which is administered in a flavored milkshake. Films are taken at
intervals during the test, which takes about 30 minutes. No special
preparation is necessary before a GI series, except that NPO status must
be maintained for 8 hours before the test. After an upper GI series, the
client is prescribed a laxative to hasten elimination of the barium.
Barium that remains in the colon may become hard and difficult to
expel, leading to fecal impaction.
A nurse on the evening shift checks a health care provider's prescriptions
and notes that the dose of a prescribed medication is higher than the
normal dose. The nurse calls the health care provider's answering service
and is told that the health care provider is off for the night and will be
available in the morning. The nurse should: - ACCURATE
ANSWERS✔✔ Ask the answering service to contact the on-call health
care provider
Rationale: The nurse has a duty to protect the client from harm. A nurse
who believes that a health care provider's prescription may be in error is
responsible for clarifying the prescription before carrying it out.
Therefore the nurse would not administer the medication; instead, the
,nurse would withhold the medication until the dose can be clarified. The
nurse would not wait until the next morning to obtain clarification. It is
premature to call the nursing supervisor.
An emergency department (ED) nurse is monitoring a client with
suspected acute myocardial infarction (MI) who is awaiting transfer to
the coronary intensive care unit. The nurse notes the sudden onset of
premature ventricular contractions (PVCs) on the monitor, checks the
client's carotid pulse, and determines that the PVCs are not resulting in
perfusion. The appropriate action by the nurse is: - ACCURATE
ANSWERS✔✔ Asking the ED health care provider to check the client
Rationale: PVCs are a result of increased irritability of ventricular cells.
Peripheral pulses may be absent or diminished with the PVCs
themselves because the decreased stroke volume of the premature beats
may in turn decrease peripheral perfusion. Because other rhythms also
cause widened QRS complexes, it is essential that the nurse determine
whether the premature beats are resulting in perfusion of the extremities.
This is done by palpating the carotid, brachial, or femoral artery while
observing the monitor for widened complexes or by auscultating for
apical heart sounds. In the situation of acute MI, PVCs may be
considered warning dysrhythmias, possibly heralding the onset of
ventricular tachycardia or ventricular fibrillation. Therefore the nurse
would not tell the client that the PVCs are expected. Although the nurse
will continue to monitor the client and document the findings, these are
not the most appropriate actions of those provided. The most appropriate
action would be to ask the ED health care provider to check the client.
NPO status is imposed 8 hours before the procedure on a client
scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the
, morning of the procedure, the nurse checks the client's record and notes
that the client routinely takes an oral antihypertensive medication each
morning. The nurse should: - ACCURATE ANSWERS✔✔ Administer
the antihypertensive with a small sip of water
Rationale: General anesthesia is required for ECT, so NPO status is
imposed for 6 to 8 hours before treatment to help prevent aspiration.
Exceptions include clients who routinely receive cardiac medications,
antihypertensive agents, or histamine (H2) blockers, which should be
administered several hours before treatment with a small sip of water.
Withholding the antihypertensive and administering it at bedtime and
withholding the antihypertensive and resuming administration on the
day after the ECT are incorrect actions, because antihypertensives must
be administered on time; otherwise, the risk for rebound hypertension
exists. The nurse would not administer a medication by way of a route
that has not been prescribed.
A client who recently underwent coronary artery bypass graft surgery
comes to the health care provider's office for a follow-up visit. On
assessment, the client tells the nurse that he is feeling depressed. Which
response by the nurse is therapeutic? - ACCURATE ANSWERS✔✔
"Tell me more about what you're feeling."
Rationale: When a client expresses feelings of depression, it is extremely
important for the nurse to further explore these feelings with the client.
In stating, "This is a normal response after this type of surgery" the nurse
provides false reassurance and avoids addressing the client's feelings. "It
will take time, but, I promise you, you will get over the depression" is
also a false reassurance, and it does not encourage the expression of
