NCLEX-RN QUESTIONS WITH INSIGHTFUL SOLUTIONS.
When a central venous catheter dressing becomes moist or loose, what should
a nurse do first?
A.Draw a circle around the moist spot and note the date and time.
B.Notify the physician.
C.Remove the dressing, clean the site, and apply a new dressing.
D. Remove the catheter, check for catheter integrity, and send the tip for
culture. - accurate answers-C
The nurse is caring for a 65-year-old male client with a history of ischemic
heart disease who has been admitted to the ICU following a myocardial
infarction. The client is currently receiving lidocaine I.V. to manage his
ventricular ectopy, which has been persistent. Which of the following factors
would be most important for the nurse to consider in relation to the
administration of this medication?
A. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse
oximeter
B. Increase in systemic blood pressure
C. Presence of premature ventricular contractions (PVCs) on a cardiac
monitor
D. Increase in intracranial pressure (ICP)
E. A drop in serum potassium levels as indicated in the latest lab results
F. Observation of a widening QRS complex on the ECG - accurate answers-C
A 72-year-old male patient with a history of atrial fibrillation and controlled
hypertension has been initiated on warfarin therapy. Upon assessment of the
patient's history, it was revealed that he has a history of peptic ulcer. This
patient also has a recent history of a peptic ulcer. Given the client's medical
history and current medication regimen, which of the following instructions
should the nurse prioritize when providing discharge teaching?
A. Report incidents of diarrhea
B. Avoid foods high in vitamin K
C. Use a straight razor when shaving
D. Take aspirin for pain relief
E. Monitor for signs of bleeding, such as bruising or black tarry stools
F. Check blood pressure regularly at home
,G. Inform all healthcare providers about the anticoagulant therapy - accurate
answers-B
n a busy surgical unit, a nurse is preparing to insert an I.V. catheter for a 33-
year-old patient who is scheduled for elective surgery and has a notably hairy
forearm where the I.V. is to be placed. The patient is allergic to a variety of
adhesives and has sensitive skin that is prone to irritation. Given these
considerations, how should the nurse manage excess hair at the intended
catheter insertion site?
A. Leaving the hair intact
B. Shaving the area
C. Clipping the hair in the area
D. Removing the hair with a depilatory
E. Applying a small amount of water-soluble gel to tame the hair without
cutting
F. Use a sterile surgical scalpel to trim the hair as close to the skin as possible
without causing abrasions - accurate answers-C
A nurse is tasked with the education of an elderly female patient who has been
recently diagnosed with osteoporosis. The patient leads a sedentary lifestyle,
has a diet low in calcium, has undergone menopause ten years prior, and has a
visibly kyphotic posture. In planning the education for this patient, which of
the following complications should the nurse emphasize as the most
significant risk associated with osteoporosis, especially considering the
patient's profile?
A. Increased susceptibility to bone fractures from minimal trauma
B. Consequences of long-term estrogen deficiency post-menopause
C. The impact of sustained negative calcium balance on bone density
D. The progression of spinal deformities such as a kyphotic curvature
E. Potential for height loss over time due to vertebral compression
F. Risk of developing chronic pain associated with skeletal weakness -
accurate answers-A
A community health nurse is conducting a workshop on breast health for a
group of women with diverse backgrounds, ranging from those who have
never performed Breast Self-Examination (BSE) to some who have had benign
, breast conditions in the past. As part of the educational session, the nurse
emphasizes the importance of BSE for the early detection of potential breast
anomalies. What should the nurse identify as the primary goal for these
women in performing regular BSE?
A. To detect any cancerous lumps early in their development
B. To identify areas of thickness or fullness that differ from the rest of the
breast tissue
C. To notice any changes in the breast tissue from what is normal for each
individual
D. To differentiate between fibrocystic masses and other types of breast
lumps
E. To promote self-awareness of breast health and encourage routine health
screening
F. To understand the normal texture and appearance - accurate answers-C
During the endorsement, which of the following clients should the on-duty
nurse assess first?
A. The 58-year-old client who was admitted 2 days ago with heart failure,
blood pressure of 126/76 mm Hg, and a respiratory rate of 22
breaths/minute.
B. The 89-year-old client with end-stage right-sided heart failure, blood
pressure of 78/50 mm Hg, and a "do not resuscitate" order.
C. The 62-year-old client who was admitted 1 day ago with thrombophlebitis
and is receiving L.V. heparin.
D. The 75-year-old client who was admitted 1 hour ago with new-onset atrial
fibrillation and is receiving L.V. diltiazem (Cardizem). - accurate answers-D
The nurse is attending to a 35-year-old patient presenting to the emergency
department with difficulty breathing, audible inspiratory and expiratory
wheezes, and a significant reduction in peak expiratory flow rate. The patient
has a known history of asthma and is currently experiencing an exacerbation.
Which of the following medication classes should the nurse anticipate
administering first to address the patient's immediate needs?
A. Beta-adrenergic blockers
B. Bronchodilators
C. Inhaled steroids
When a central venous catheter dressing becomes moist or loose, what should
a nurse do first?
A.Draw a circle around the moist spot and note the date and time.
B.Notify the physician.
C.Remove the dressing, clean the site, and apply a new dressing.
D. Remove the catheter, check for catheter integrity, and send the tip for
culture. - accurate answers-C
The nurse is caring for a 65-year-old male client with a history of ischemic
heart disease who has been admitted to the ICU following a myocardial
infarction. The client is currently receiving lidocaine I.V. to manage his
ventricular ectopy, which has been persistent. Which of the following factors
would be most important for the nurse to consider in relation to the
administration of this medication?
A. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse
oximeter
B. Increase in systemic blood pressure
C. Presence of premature ventricular contractions (PVCs) on a cardiac
monitor
D. Increase in intracranial pressure (ICP)
E. A drop in serum potassium levels as indicated in the latest lab results
F. Observation of a widening QRS complex on the ECG - accurate answers-C
A 72-year-old male patient with a history of atrial fibrillation and controlled
hypertension has been initiated on warfarin therapy. Upon assessment of the
patient's history, it was revealed that he has a history of peptic ulcer. This
patient also has a recent history of a peptic ulcer. Given the client's medical
history and current medication regimen, which of the following instructions
should the nurse prioritize when providing discharge teaching?
A. Report incidents of diarrhea
B. Avoid foods high in vitamin K
C. Use a straight razor when shaving
D. Take aspirin for pain relief
E. Monitor for signs of bleeding, such as bruising or black tarry stools
F. Check blood pressure regularly at home
,G. Inform all healthcare providers about the anticoagulant therapy - accurate
answers-B
n a busy surgical unit, a nurse is preparing to insert an I.V. catheter for a 33-
year-old patient who is scheduled for elective surgery and has a notably hairy
forearm where the I.V. is to be placed. The patient is allergic to a variety of
adhesives and has sensitive skin that is prone to irritation. Given these
considerations, how should the nurse manage excess hair at the intended
catheter insertion site?
A. Leaving the hair intact
B. Shaving the area
C. Clipping the hair in the area
D. Removing the hair with a depilatory
E. Applying a small amount of water-soluble gel to tame the hair without
cutting
F. Use a sterile surgical scalpel to trim the hair as close to the skin as possible
without causing abrasions - accurate answers-C
A nurse is tasked with the education of an elderly female patient who has been
recently diagnosed with osteoporosis. The patient leads a sedentary lifestyle,
has a diet low in calcium, has undergone menopause ten years prior, and has a
visibly kyphotic posture. In planning the education for this patient, which of
the following complications should the nurse emphasize as the most
significant risk associated with osteoporosis, especially considering the
patient's profile?
A. Increased susceptibility to bone fractures from minimal trauma
B. Consequences of long-term estrogen deficiency post-menopause
C. The impact of sustained negative calcium balance on bone density
D. The progression of spinal deformities such as a kyphotic curvature
E. Potential for height loss over time due to vertebral compression
F. Risk of developing chronic pain associated with skeletal weakness -
accurate answers-A
A community health nurse is conducting a workshop on breast health for a
group of women with diverse backgrounds, ranging from those who have
never performed Breast Self-Examination (BSE) to some who have had benign
, breast conditions in the past. As part of the educational session, the nurse
emphasizes the importance of BSE for the early detection of potential breast
anomalies. What should the nurse identify as the primary goal for these
women in performing regular BSE?
A. To detect any cancerous lumps early in their development
B. To identify areas of thickness or fullness that differ from the rest of the
breast tissue
C. To notice any changes in the breast tissue from what is normal for each
individual
D. To differentiate between fibrocystic masses and other types of breast
lumps
E. To promote self-awareness of breast health and encourage routine health
screening
F. To understand the normal texture and appearance - accurate answers-C
During the endorsement, which of the following clients should the on-duty
nurse assess first?
A. The 58-year-old client who was admitted 2 days ago with heart failure,
blood pressure of 126/76 mm Hg, and a respiratory rate of 22
breaths/minute.
B. The 89-year-old client with end-stage right-sided heart failure, blood
pressure of 78/50 mm Hg, and a "do not resuscitate" order.
C. The 62-year-old client who was admitted 1 day ago with thrombophlebitis
and is receiving L.V. heparin.
D. The 75-year-old client who was admitted 1 hour ago with new-onset atrial
fibrillation and is receiving L.V. diltiazem (Cardizem). - accurate answers-D
The nurse is attending to a 35-year-old patient presenting to the emergency
department with difficulty breathing, audible inspiratory and expiratory
wheezes, and a significant reduction in peak expiratory flow rate. The patient
has a known history of asthma and is currently experiencing an exacerbation.
Which of the following medication classes should the nurse anticipate
administering first to address the patient's immediate needs?
A. Beta-adrenergic blockers
B. Bronchodilators
C. Inhaled steroids
