NCLEX Comprehensive Exam Questions and Answers.
Enalapril maleate is prescribed for a hospitalized client. Which assessment does the
nurse perform as a priority before administering the medication? - Correct Answer
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? - Correct Answer "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: - Correct Answer 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: - Correct Answer 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: - Correct Answer
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? - Correct Answer "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
feelings. "Every client who has this surgery feels the same way for about a month" is a
generalization that avoids the client's feelings.
A client in labor experiences spontaneous rupture of the membranes. The nurse
immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the
amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which action
should be the nurse's priority? - Correct Answer Contacting the health care provider
Rationale: The FHR is assessed for at least 1 minute when the membranes rupture. The
nurse also checks the quantity, color, and odor of the amniotic fluid. The fluid should be
clear (often with bits of vernix) and have a mild odor. Fluid with a foul or strong odor,
cloudy appearance, or yellow coloration suggests chorioamnionitis and warrants notifying
the health care provider. A large amount of vernix in the fluid suggests that the fetus is
preterm. Greenish, meconium-stained fluid may be seen in cases of postterm gestation
or placental insufficiency. Checking the fluid for protein is not associated with the data in
the question. Although the nurse would continue to monitor the client and the FHR and
would document the findings, contacting the health care provider is the priority.
A nurse has assisted a health care provider in inserting a central venous access device
into a client with a diagnosis of severe malnutrition who will be receiving parenteral
nutrition (PN). After insertion of the catheter, the nurse immediately plans to: - Correct
Answer Call the radiography department to obtain a chest x-ray
Rationale: One major complication associated with central venous catheter placement is
pneumothorax, which may result from accidental puncture of the lung. After the catheter
has been placed but before it is used for infusions, its placement must be checked with
an x-ray. Hanging the prescribed bag of PN and starting the infusion at the prescribed
rate and infusing normal saline solution through the catheter at a rate of 100 mL/hr to
maintain patency are all incorrect because they could result in the infusion of solution into
a lung if a pneumothorax is present. Although the nurse may obtain a blood glucose
measurement to serve as a baseline, this action is not the priority.
A rape victim being treated in the emergency department says to the nurse, "I'm really
worried that I've got HIV now." What is the appropriate response by the nurse? - Correct
, Answer "Let's talk about the information that you need to determine your risk of
contracting HIV."
Rationale: HIV is a concern of rape victims. Such concern should always be addressed,
and the victim should be given the information needed to evaluate his or her risk.
Pregnancy may occur as a result of rape, and pregnancy prophylaxis can be offered in
the emergency department or during follow-up, once the results of a pregnancy test have
been obtained. However, stating, "You're more likely to get pregnant than to contract
HIV" avoids the client's concern. Similarly, "HIV is rarely an issue in rape victims" and
"Every rape victim is concerned about HIV" are generalized responses that avoid the
client's concern.
A client is taking prescribed ibuprofen, 300 mg orally four times daily, to relieve joint pain
resulting from rheumatoid arthritis. The client tells the nurse that the medication is
causing nausea and indigestion. The nurse should tell the client to: - Correct Answer
Take the medication with food
Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication. Side effects include
nausea (with or without vomiting) and dyspepsia (heartburn, indigestion, or epigastric
pain). If gastrointestinal distress occurs, the client should be instructed to take the
medication with milk or food. The nurse would not instruct the client to stop the
medication or instruct the client to adjust the dosage of a prescribed medication; these
actions are not within the legal scope of the role of the nurse. Contacting the health care
provider is premature, because the client's complaints are side effects that occasionally
occur and can be relieved by taking the medication with milk or food.
Lorazepam 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client
for the management of anxiety. The nurse prepares the medication as prescribed and
administers the medication over a period of: - Correct Answer 3 minutes
Rationale: Lorazepam is a benzodiazepine. When administered by IV injection, each 2
mg or fraction thereof is administered over a period of 1 to 5 minutes. Ten seconds and
30 seconds are brief periods. Thirty minutes is a lengthy period.
A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a
sinus infection, asks the client about medications that he is taking. The client tells the
nurse that he is taking nefazodone hydrochloride . On the basis of this information, the
nurse determines that the client most likely has a history of: - Correct Answer Depression
Enalapril maleate is prescribed for a hospitalized client. Which assessment does the
nurse perform as a priority before administering the medication? - Correct Answer
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? - Correct Answer "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: - Correct Answer 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: - Correct Answer 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: - Correct Answer
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? - Correct Answer "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
feelings. "Every client who has this surgery feels the same way for about a month" is a
generalization that avoids the client's feelings.
A client in labor experiences spontaneous rupture of the membranes. The nurse
immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the
amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which action
should be the nurse's priority? - Correct Answer Contacting the health care provider
Rationale: The FHR is assessed for at least 1 minute when the membranes rupture. The
nurse also checks the quantity, color, and odor of the amniotic fluid. The fluid should be
clear (often with bits of vernix) and have a mild odor. Fluid with a foul or strong odor,
cloudy appearance, or yellow coloration suggests chorioamnionitis and warrants notifying
the health care provider. A large amount of vernix in the fluid suggests that the fetus is
preterm. Greenish, meconium-stained fluid may be seen in cases of postterm gestation
or placental insufficiency. Checking the fluid for protein is not associated with the data in
the question. Although the nurse would continue to monitor the client and the FHR and
would document the findings, contacting the health care provider is the priority.
A nurse has assisted a health care provider in inserting a central venous access device
into a client with a diagnosis of severe malnutrition who will be receiving parenteral
nutrition (PN). After insertion of the catheter, the nurse immediately plans to: - Correct
Answer Call the radiography department to obtain a chest x-ray
Rationale: One major complication associated with central venous catheter placement is
pneumothorax, which may result from accidental puncture of the lung. After the catheter
has been placed but before it is used for infusions, its placement must be checked with
an x-ray. Hanging the prescribed bag of PN and starting the infusion at the prescribed
rate and infusing normal saline solution through the catheter at a rate of 100 mL/hr to
maintain patency are all incorrect because they could result in the infusion of solution into
a lung if a pneumothorax is present. Although the nurse may obtain a blood glucose
measurement to serve as a baseline, this action is not the priority.
A rape victim being treated in the emergency department says to the nurse, "I'm really
worried that I've got HIV now." What is the appropriate response by the nurse? - Correct
, Answer "Let's talk about the information that you need to determine your risk of
contracting HIV."
Rationale: HIV is a concern of rape victims. Such concern should always be addressed,
and the victim should be given the information needed to evaluate his or her risk.
Pregnancy may occur as a result of rape, and pregnancy prophylaxis can be offered in
the emergency department or during follow-up, once the results of a pregnancy test have
been obtained. However, stating, "You're more likely to get pregnant than to contract
HIV" avoids the client's concern. Similarly, "HIV is rarely an issue in rape victims" and
"Every rape victim is concerned about HIV" are generalized responses that avoid the
client's concern.
A client is taking prescribed ibuprofen, 300 mg orally four times daily, to relieve joint pain
resulting from rheumatoid arthritis. The client tells the nurse that the medication is
causing nausea and indigestion. The nurse should tell the client to: - Correct Answer
Take the medication with food
Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication. Side effects include
nausea (with or without vomiting) and dyspepsia (heartburn, indigestion, or epigastric
pain). If gastrointestinal distress occurs, the client should be instructed to take the
medication with milk or food. The nurse would not instruct the client to stop the
medication or instruct the client to adjust the dosage of a prescribed medication; these
actions are not within the legal scope of the role of the nurse. Contacting the health care
provider is premature, because the client's complaints are side effects that occasionally
occur and can be relieved by taking the medication with milk or food.
Lorazepam 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client
for the management of anxiety. The nurse prepares the medication as prescribed and
administers the medication over a period of: - Correct Answer 3 minutes
Rationale: Lorazepam is a benzodiazepine. When administered by IV injection, each 2
mg or fraction thereof is administered over a period of 1 to 5 minutes. Ten seconds and
30 seconds are brief periods. Thirty minutes is a lengthy period.
A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a
sinus infection, asks the client about medications that he is taking. The client tells the
nurse that he is taking nefazodone hydrochloride . On the basis of this information, the
nurse determines that the client most likely has a history of: - Correct Answer Depression
