Archer NCLEX questions from lectures
A 45-year-old man is rushed to the ER with reports of substernal chest pain and diaphoresis.
cardiac troponin levels were taken and found to be elevated. the er nurse understands that
nursing interventions would focus on which priority?
a. increase oxygenation to the heart and reduce the hearts workload
b. prevent complications and confirm a diagnosis of myocardial infarction
c. alleviate the pts. anxiety - ANS-a
A client has just been transferred back to this room following a below knee amputation of
the right leg. the nurse is closely monitoring the client. which sign would prompt the nurse to
assess further as it could indicates developing complication?
a. The client is becoming increasingly agitated b. client has a blood pressure of 187/78
mmHg.
c. client has a pulse rate of 89bpm
d. hypoactive bowel sounds were found upon auscultation of 4 quadrants - ANS-a
A client in septic shock in the ICU is receiving a Dopamine infusion. The nurse observes
that the client's blood pressure is 195/120 mm Hg during the assessment. Which initial
nursing action would the nurse take? a. discontinue dopamine
b. notify your doctor. c. administer furosemide
d. assess the clients GCS - ANS-
A client was admitted for pneumothorax and has received a chest tube attached to a
three-chamber chest drainage system. at nighttime, the client has become disoriented, got
out of bed, and has stepped on the drainage device causing it to break and lose its seal.
Immediate nursing intervention should be:
a. Clamp the chest tube proximally to the client's thorax with the forceps. b. take the chest
tube and attach it directly to the low wall suction
c. keep the end of the chest tube sterile and contact the physician
d. Fill a container with sterile water with the chest tube's end - ANS-d A nurse is caring for a
client receiving digoxin. the clients most recent serum digoxin level was 2.5ng/mL which of
the following priority nursing actions should the nurse take? SATA
a. withhold the clients scheduled dose
b. take the medication as directed c. examine the client's urination. d. assess the clients
most recent sodium level
e. assess the clients heart rate and rhythm - ANS-a
e
A nurse is conducting preoperative teaching to a client who will undergo surgery in 1 week.
which response by the client would prompt the nurse to give additional teaching?
a. aspirin can possibly cause bleeding even after surgery
b. aspiring can adversely affect my clotting ability.
c. i should stop aspirin one day prior to my surgery
d. it is essential that I discuss the possibility of quitting aspirin prior to the surgery with my
doctor. - ANS-c A client with accelerated HTN is receiving discharge instructions from a
nurse. His home medications include calcium supplements for osteoporosis, omeprazole for
, heartburn, furosemide, and lisinopril. Which of the client's statements demonstrates the need
for additional nifedipine education? SATA
a. This medication may cause my gums to swell. b. i will avoid getting up too quickly from
sitting or lying position
c. it is highly likely that i will get constipated from this drug
d. I will keep taking nifedipine - ANS-a if I get a cough and my tongue gets swollen. b
a nurse is taking care of a client with severe burns. because of fluid shifting, the nurse
knows tha the focus of attention is preventing hypovolemic shock. which is the best
intervention to address this?
a. administer dopamine as ordered
b. applies medical antishock trousers
c. infuse IV fluids are indicated
d. infuse FFP - ANS-c
A client with severe burns is being cared for by a nurse who is aware that the patient is at
risk for which of the following conditions? a. hypovolemic shock
b. distributive shock
c. cardiovascular shock d. obstructive shock - ANS-a
The client is admitted for having unstable angina. The nurse caring for the client
understands that nitroglycerin should not be given to the client if he manifests which sign or
symptom?
a. atrial fibrillation
b. a blood pressure of 78/59 mm Hg.
c. headache
d. a warm flushed feeling - ANS-b
The nurse is answering phones in the general practice clinic and receives a call from a pt.
who is experiencing leg pain after starting atorvastatin. which of the following instructions,
when given by the nurse, is the best course of action?
a. continue taking the medication as this is an expected side effect.
b. stop taking the medication and make an appointment for next week. c. stretch for 20
minutes or take a warm shower
d, stop taking the medication and go to the clinic right away. - ANS-d The nurse is assigned
to care for a patient with a chloride level of 90mEq/L. She is aware of which of the following
is responsible for the electrolyte imbalance: SATA
a. fluid volume excess
b. Metabolic acidosis
c. vomiting
d. constipation - ANS-a
c
The nurse is caring for a client receiving morphine sulfate for severe pain. the nurse should
implement all of the following actions except
a. administer morphine only when the client complains of pain
b. Make sure there is always naloxone available. c. check the clients' respirations before
giving morphine
d, provide a high fiber diet - ANS-a
The nurse is caring for a patient who has a chloride level of 115 mEq/L. She is getting
ready to administer which of the following medications. (SATA)
a. bicarbonate
A 45-year-old man is rushed to the ER with reports of substernal chest pain and diaphoresis.
cardiac troponin levels were taken and found to be elevated. the er nurse understands that
nursing interventions would focus on which priority?
a. increase oxygenation to the heart and reduce the hearts workload
b. prevent complications and confirm a diagnosis of myocardial infarction
c. alleviate the pts. anxiety - ANS-a
A client has just been transferred back to this room following a below knee amputation of
the right leg. the nurse is closely monitoring the client. which sign would prompt the nurse to
assess further as it could indicates developing complication?
a. The client is becoming increasingly agitated b. client has a blood pressure of 187/78
mmHg.
c. client has a pulse rate of 89bpm
d. hypoactive bowel sounds were found upon auscultation of 4 quadrants - ANS-a
A client in septic shock in the ICU is receiving a Dopamine infusion. The nurse observes
that the client's blood pressure is 195/120 mm Hg during the assessment. Which initial
nursing action would the nurse take? a. discontinue dopamine
b. notify your doctor. c. administer furosemide
d. assess the clients GCS - ANS-
A client was admitted for pneumothorax and has received a chest tube attached to a
three-chamber chest drainage system. at nighttime, the client has become disoriented, got
out of bed, and has stepped on the drainage device causing it to break and lose its seal.
Immediate nursing intervention should be:
a. Clamp the chest tube proximally to the client's thorax with the forceps. b. take the chest
tube and attach it directly to the low wall suction
c. keep the end of the chest tube sterile and contact the physician
d. Fill a container with sterile water with the chest tube's end - ANS-d A nurse is caring for a
client receiving digoxin. the clients most recent serum digoxin level was 2.5ng/mL which of
the following priority nursing actions should the nurse take? SATA
a. withhold the clients scheduled dose
b. take the medication as directed c. examine the client's urination. d. assess the clients
most recent sodium level
e. assess the clients heart rate and rhythm - ANS-a
e
A nurse is conducting preoperative teaching to a client who will undergo surgery in 1 week.
which response by the client would prompt the nurse to give additional teaching?
a. aspirin can possibly cause bleeding even after surgery
b. aspiring can adversely affect my clotting ability.
c. i should stop aspirin one day prior to my surgery
d. it is essential that I discuss the possibility of quitting aspirin prior to the surgery with my
doctor. - ANS-c A client with accelerated HTN is receiving discharge instructions from a
nurse. His home medications include calcium supplements for osteoporosis, omeprazole for
, heartburn, furosemide, and lisinopril. Which of the client's statements demonstrates the need
for additional nifedipine education? SATA
a. This medication may cause my gums to swell. b. i will avoid getting up too quickly from
sitting or lying position
c. it is highly likely that i will get constipated from this drug
d. I will keep taking nifedipine - ANS-a if I get a cough and my tongue gets swollen. b
a nurse is taking care of a client with severe burns. because of fluid shifting, the nurse
knows tha the focus of attention is preventing hypovolemic shock. which is the best
intervention to address this?
a. administer dopamine as ordered
b. applies medical antishock trousers
c. infuse IV fluids are indicated
d. infuse FFP - ANS-c
A client with severe burns is being cared for by a nurse who is aware that the patient is at
risk for which of the following conditions? a. hypovolemic shock
b. distributive shock
c. cardiovascular shock d. obstructive shock - ANS-a
The client is admitted for having unstable angina. The nurse caring for the client
understands that nitroglycerin should not be given to the client if he manifests which sign or
symptom?
a. atrial fibrillation
b. a blood pressure of 78/59 mm Hg.
c. headache
d. a warm flushed feeling - ANS-b
The nurse is answering phones in the general practice clinic and receives a call from a pt.
who is experiencing leg pain after starting atorvastatin. which of the following instructions,
when given by the nurse, is the best course of action?
a. continue taking the medication as this is an expected side effect.
b. stop taking the medication and make an appointment for next week. c. stretch for 20
minutes or take a warm shower
d, stop taking the medication and go to the clinic right away. - ANS-d The nurse is assigned
to care for a patient with a chloride level of 90mEq/L. She is aware of which of the following
is responsible for the electrolyte imbalance: SATA
a. fluid volume excess
b. Metabolic acidosis
c. vomiting
d. constipation - ANS-a
c
The nurse is caring for a client receiving morphine sulfate for severe pain. the nurse should
implement all of the following actions except
a. administer morphine only when the client complains of pain
b. Make sure there is always naloxone available. c. check the clients' respirations before
giving morphine
d, provide a high fiber diet - ANS-a
The nurse is caring for a patient who has a chloride level of 115 mEq/L. She is getting
ready to administer which of the following medications. (SATA)
a. bicarbonate
