#1
(75 QUESTIONS)
Nclexrn-01-001
Question tag: hypertension
Question category: physiological integrity, reduction of risk
potential which individual is at greatest risk for developing
hypertension?
• A. 45-year-old african-american attorney
• B. 60-year-old asian-american shop owner
• C. 40-year-old caucasian nurse
• D. 55-year-old hispanic teacher
Correct answer: a: 45-year-old african american attorney
• Option a: african-americans develop high blood
pressure at younger ages than other groups in the us.
Researchers have uncovered that african-americans
respond differently to hypertensive drugs than other
groups of people. They are also found out to be more
sensitive to salt, which increases the risk of developing
hypertension.
• Option b: the incidence of hypertension in asian-
americans does not appear to be significantly higher
than the general population, according to limited us
data.
, • Option c: the racial disparity in hypertension and
hypertensionrelated outcomes has been recognized for
decades with africanamericans with greater risks than
caucasians.
• Option d: hypertension prevalence rates in hispanics
may vary by gender and country of origin. Hispanic
americans overall have relatively low levels of
hypertension, despite elevated levels of diabetes and
obesity.
Nclexrn-01-002
Question tag: acetaminophen
Question category: physiological integrity, pharmacological and
parenteral therapies
A 15-year-old female who ingested 15 tablets of maximum
strength acetaminophen 45 minutes ago is rushed to the
emergency department. Which of these orders should the nurse
do first?
• A. Gastric lavage
• B. Administer acetylcysteine (mucomyst) orally
• C. Start an iv dextrose 5% with 0.33% normal saline to
keep the vein open
• D. Have the patient drink activated charcoal mixed with
water
Correct answer: a. Gastric lavage
• Option a: acetaminophen overdose is extremely toxic
to the liver causing hepatotoxicity. Early symptoms of
hepatic damage include nausea, vomiting, abdominal
pain, and diarrhea. If not treated immediately, hepatic
necrosis occurs and may lead to death. Removing as
, much of the drug as possible is the first step in
treatment for acetaminophen overdose, this is best
done through gastric lavage. Gastric lavage (irrigation)
and aspiration consist of flushing the stomach with
fluids and then aspirating the fluid back out. This
procedure is done in life-threatening cases such as
acetaminophen toxicity and only if less than one (1)
hour has occurred after ingestion.
• Option b: the oral formulation of acetylcysteine is the
drug of choice for the treatment of acetaminophen
overdose but should be done after gi decontamination
with activated charcoal. Liver damage is minimized by
giving acetylcysteine (mucomyst), the antidote for
acetaminophen. Acetylcysteine reduces injury by
substituting for depleted glutathione in the reaction
that converts the toxic metabolite of acetaminophen to
its nontoxic form. When given within 8 hours of
acetaminophen toxicity, acetylcysteine is effective in
preventing severe liver injury. It is administered orally
or intravenously.
• Option c: intermittent iv infusion with dextrose 5%
may be considered for late-presenting or chronic
ingestion.
• Option d: oral activated charcoal (ac) avidly adsorbs
acetaminophen and may be administered if the patient
presents within 1 hour after ingesting a potentially toxic
dose. Charcoal should not be administered immediately
before or with antidotes since it can effectively adsorb
it and neutralize the benefits.
Nclexrn-01-003
Question tag: cardiac catheterization
Question category: safe and effective care environment,
management of care
, Which complication of cardiac catheterization should the nurse
monitor for in the initial 24 hours after the procedure?
• A. Angina at rest
• B. Thrombus formation
• C. Dizziness
• D. Falling blood pressure
Correct answer: b. Thrombus formation
A thrombus formation may prevent blood from flowing normally
through the circulatory system, which may become an embolism,
and block the flow of blood towards major organs in the body.
• Option a: the reported incidence of myocardial
infarction with angina at rest is less than 0.1%, and is
mostly influenced by patientrelated factors like the
extent and severity of underlying cardiovascular-related
diseases and technique-related factors.
• Options c & d: a falling bp and dizziness occur along
with hemorrhage of the insertion site which is
associated with the first 12 hours after the procedure.
Nclexrn-01-004
Question tag: renal calculi, flank pain
Question category: physiological integrity, basic care and
comfort
A client is admitted to the emergency room with renal calculi and
is complaining of moderate to severe flank pain and nausea. The
client’s temperature is 100.8 degrees fahrenheit. The priority
nursing goal for this client is:
• A. Maintain fluid and electrolyte balance