2024/2025 NCLEX PN REVIEWED !! !! !!
QUESTIONS AND ANSWERS
!! !! !! !!
!!
!!
!!
!!
!!
!!
!!
!!
!!
The !!nurse !!is !!taking !!the !!health !!history !!of !!a !!patient !!being !!treated !!for !!Emphysema
!!and !!Chronic !!Bronchitis. !!After !!being !!told !!the !!patient !!has !!been !!smoking !!cigarettes
!!for !!30 !!years, !!the !!nurse !!expects !!to !!note !!which !!assessment !!finding? !!
!!
1. Increase !!in !!Forced !!Vital !!Capacity !!(FVC) !!
2. A !!narrowed !!chest !!cavity !!
3. Clubbed !!fingers !! !!
4. An !!increased !!risk !!of !!cardiac !!failure !!- !!CORRECT !!ANSWER-3. !!Clubbed !!fingers !!- !!
CORRECT !!
Clubbed !!fingers !!are !!a !!sign !!of !!a !!long-term, !!or !!chronic, !!decrease !!in !!oxygen !!levels. !!
!!
The !!nurse !!is !!taking !!the !!health !!history !!of !!a !!70-year-old !!patient !!being !!treated !!for !!a
!!Duodenal !!Ulcer. !!After !!being !!told !!the !!patient !!is !!complaining !!of !!epigastric !!pain, !!the
!!nurse !!expects !!to !!note !!which !!assessment !!finding? !!
!!
1. Melena !!
2. Nausea !!
3. Hernia !!
4. !!Hyperthermia !!- !!CORRECT !!ANSWER-1. !!Melena !!- !!CORRECT !!
Melena !!is !!the !!finding !!that !!there !!are !!traces !!of !!blood !!in !!the !!stool !!which !!presents !!as
!!black, !!tarry !!feces. !!This !!is !!a !!common !!manifestation !!of !!Duodenal !!Ulcers, !!since !!the
!!Duodenum !!is !!further !!down !!the !!gastric !!anatomy. !!
!!
A !!nurse !!is !!providing !!discharge !!teaching !!for !!a !!patient !!with !!severe
!!Gastroesophogeal !!
Reflux !!Disease. !!Which !!of !!these !!statements !!by !!the !!patient !!indicates !!a !!need !!for
!!more !!
!!
teaching?
!!
1. !!"I'm !!going !!to !!limit !!my !!meals !!to !!2-3 !!per !!day !!to !!reduce !!acid !!secretion." !!
!!
2. !!"I'm !!going !!to !!make !!sure !!to !!remain !!upright !!after !!meals !!and !!elevate !!my !!head
!!when !!I !!
!!
sleep"
!!
3. "I !!won't !!be !!drinking !!tea !!or !!coffee !!or !!eating !!chocolate !!any !!more." !!
!!
4. "I'm !!going !!to !!start !!trying !!to !!lose !!some !!weight." !!- !!CORRECT !!ANSWER-1. !!"I'm
!!going !!to !!limit !!my !!meals !!to !!2-3 !!per !!day !!to !!reduce !!acid !!secretion." !!
,CORRECT !!- !!Large !!meals !!increase !!the !!volume !!and !!pressure !!in !!the !!stomach !!and
!!delay !!gastric !!emptying. !!It's !!recommended !!instead !!to !!eat !!4-6 !!small !!meals !!a !!day. !!
!!
The !!nurse !!in !!the !!Emergency !!Room !!is !!treating !!a !!patient !!suspected !!to !!have !!a
!!Peptic !!
Ulcer. !!On !!assessing !!lab !!results, !!the !!nurse !!finds !!that !!the !!patient's !!blood !!pressure !!is
!!95/60, !!pulse !!is !!110 !!beats !!per !!minute, !!and !!the !!patient !!reports !!epigastric !!pain. !!What
!!is !!the !!PRIORITY !!intervention? !!
!!
1. Start !!a !!large-bore !!IV !!in !!the !!patient's !!arm !!
2. Ask !!the !!patient !!for !!a !!stool !!sample !!
3. Prepare !!to !!insert !!an !!NG !!Tube !!
4. Administer !!intramuscular !!morphine !!sulphate !!as !!ordered !!- !!CORRECT !!ANSWER-1.
!!
Start !!a !!large-bore !!IV !!in !!the !!patient's !!arm !!
CORRECT !!- !!The !!nurse !!should !!suspect !!that !!the !!patient !!is !!haemorrhaging !!and !!will
!!need !!need !!a !!fluid !!replacement !!therapy, !!which !!requires !!a !!large !!bore !!IV. !!
!!
A !!female !!patient !!with !!atrial !!fibrillation !!has !!the !!following !!lab !!results: !!Hemoglobin !!of
!!11 !!g/dl, !!a !!platelet !!count !!of !!150,000, !!an !!INR !!of !!2.5, !!and !!potassium !!of !!2.7 !!mEq/L.
!!Which !!result !!is !!critical !!and !!should !!be !!reported !!to !!the !!physician !!immediately? !!
!!
1. Hemoglobin !!11 !!g/dl !!
2. Platelet !!of !!150,000 !!
3. INR !!of !!2.5 !!
4. Potassium !!of !!2.7 !!mEq/L !!- !!CORRECT !!ANSWER-4. !!Potassium !!of !!2.7 !!mEq/L
!!CORRECT !!- !!A !!potassium !!imbalance !!for !!a !!patient !!with !!a !!history !!of !!dysrhythmia
!!can !!be !!life-threatening !!and !!can !!lead !!to !!cardiac !!distress. !!
!!
While !!receiving !!normal !!saline !!infusions !!to !!treat !!a !!GI !!bleed, !!the !!nurse !!notes !!that
!!the !!patient's !!lower !!legs !!have !!become !!edematous !!and !!auscultates !!crackles !!in !!the
!!lungs. !!What !!should !!the !!nurse !!do !!first? !!
!!
1. Stop !!the !!saline !!infusion !!immediately !!
2. Notify !!Physician !!
3. Elevate !!the !!patient's !!legs !!
4. Continue !!the !!infusion, !!since !!these !!are !!normal !!findings !!- !!CORRECT !!ANSWER-1.
!!Stop !!the !!saline !!infusion !!immediately !!
CORRECT !!- !!the !!patient !!has !!a !!fluid !!volume !!overload !!as !!a !!result !!of !!overly !!rapid
!!fluid !!replacement. !!The !!nurse !!should !!stop !!the !!infusion !!and !!notify !!the !!physician. !!
!!
The !!nurse !!is !!working !!in !!a !!support !!group !!for !!clients !!with !!HIV. !!Which !!point !!is
!!most !!
!!
important !!for !!the !!nurse !!to
!!stress?
!!
1. !!They !!must !!inform !!household !!members !!of !!their !!condition !!
, !!
2. !!They !!must !!take !!their !!medications !!exactly !!as
!!prescribed
!!
3. !!They !!must !!abstain !!from !!substance
!!use
!!
4. !!They !!must !!avoid !!large !!crowds !!- !!CORRECT !!ANSWER-2. !!They !!must !!take
!!their
!!
medications !!exactly !!as
!!prescribed
CORRECT !!- !!Antiretrovirals !!must !!be !!taken !!exactly !!as !!prescribed !!to !!prevent
!!drug-
resistant !!strains. !!Even !!missed !!doses !!can !!reduce !!the !!effectiveness !!of !!future
!!treatment.
!!
A !!nurse !!finds !!a !!30-year-old !!woman !!experiencing !!anaphylaxis !!from !!a !!bee !!sting.
!!Emergency !!personnel !!have !!been !!called. !!The !!nurse !!notes !!the !!woman !!is !!breathing
!!but !!short !!of !!breath. !!Which !!of !!the !!following !!interventions !!should !!the !!nurse !!do !!first? !!
!!
1. Initiate !!cardiopulmonary !!resuscitation !!
2. Check !!for !!a !!pulse !! !!
3. Ask !!the !!woman !!if !!she !!carries !!an !!emergency !!medical !!kit !!
4. Stay !!with !!the !!woman !!until !!help !!comes !!- !!CORRECT !!ANSWER-3. !!Ask !!the !!woman
!!if !!she !!carries !!an !!emergency !!medical !!kit !!
CORRECT !!- !!Many !!patients !!who !!have !!a !!known !!history !!of !!anaphylaxis !!carry !!epi-
pens !!in !!their !!pockets !!or !!belongings. !!This !!is !!the !!best !!way !!to !!stop !!a !!hypersensitivity
!!reaction !!before !!it !!becomes !!life-threatening. !!
!!
A !!man !!is !!prescribed !!lithium !!to !!treat !!bipolar !!disorder. !!The !!nurse !!is !!most !!concerned
!!about
!!
lithium !!toxicity !!when !!he !!notices !!which !!of !!these !!assessment
!!findings?
!!
1. The !!patient !!states !!he !!had !!a !!manic !!episode !!a !!week !!ago !!
2. The !!patient !!states !!he !!has !!been !!having !!diarrhea !!every !!day !!
3. The !!patient !!has !!a !!rashy !!pruritis !!on !!his !!arms !!and !!legs !!
4. The !!patient !!presents !!as !!severely !!depressed !!
5. The !!patient's !!lithium !!level !!is !!1.3 !!mcg/L !!- !!CORRECT !!ANSWER-2. !!The !!patient
!!states !!he !!has !!been !!having !!diarrhea !!every !!day !!
Correct !!- !!Persistent !!diarrhea !!can !!lead !!to !!dehydration, !!which !!can !!increase !!the !!risk
!!of !!lithium !!toxicity. !!
!!
A !!65 !!year !!old !!man !!is !!prescribed !!Flomax !!(Tamsulosin) !!for !!Benign !!Prostatic
!!Hyperplasia. !!
!!
The !!patient !!lives !!in !!an !!upstairs !!apartment. !!The !!nurse !!is !!most !!concerned !!about
!!which
QUESTIONS AND ANSWERS
!! !! !! !!
!!
!!
!!
!!
!!
!!
!!
!!
!!
The !!nurse !!is !!taking !!the !!health !!history !!of !!a !!patient !!being !!treated !!for !!Emphysema
!!and !!Chronic !!Bronchitis. !!After !!being !!told !!the !!patient !!has !!been !!smoking !!cigarettes
!!for !!30 !!years, !!the !!nurse !!expects !!to !!note !!which !!assessment !!finding? !!
!!
1. Increase !!in !!Forced !!Vital !!Capacity !!(FVC) !!
2. A !!narrowed !!chest !!cavity !!
3. Clubbed !!fingers !! !!
4. An !!increased !!risk !!of !!cardiac !!failure !!- !!CORRECT !!ANSWER-3. !!Clubbed !!fingers !!- !!
CORRECT !!
Clubbed !!fingers !!are !!a !!sign !!of !!a !!long-term, !!or !!chronic, !!decrease !!in !!oxygen !!levels. !!
!!
The !!nurse !!is !!taking !!the !!health !!history !!of !!a !!70-year-old !!patient !!being !!treated !!for !!a
!!Duodenal !!Ulcer. !!After !!being !!told !!the !!patient !!is !!complaining !!of !!epigastric !!pain, !!the
!!nurse !!expects !!to !!note !!which !!assessment !!finding? !!
!!
1. Melena !!
2. Nausea !!
3. Hernia !!
4. !!Hyperthermia !!- !!CORRECT !!ANSWER-1. !!Melena !!- !!CORRECT !!
Melena !!is !!the !!finding !!that !!there !!are !!traces !!of !!blood !!in !!the !!stool !!which !!presents !!as
!!black, !!tarry !!feces. !!This !!is !!a !!common !!manifestation !!of !!Duodenal !!Ulcers, !!since !!the
!!Duodenum !!is !!further !!down !!the !!gastric !!anatomy. !!
!!
A !!nurse !!is !!providing !!discharge !!teaching !!for !!a !!patient !!with !!severe
!!Gastroesophogeal !!
Reflux !!Disease. !!Which !!of !!these !!statements !!by !!the !!patient !!indicates !!a !!need !!for
!!more !!
!!
teaching?
!!
1. !!"I'm !!going !!to !!limit !!my !!meals !!to !!2-3 !!per !!day !!to !!reduce !!acid !!secretion." !!
!!
2. !!"I'm !!going !!to !!make !!sure !!to !!remain !!upright !!after !!meals !!and !!elevate !!my !!head
!!when !!I !!
!!
sleep"
!!
3. "I !!won't !!be !!drinking !!tea !!or !!coffee !!or !!eating !!chocolate !!any !!more." !!
!!
4. "I'm !!going !!to !!start !!trying !!to !!lose !!some !!weight." !!- !!CORRECT !!ANSWER-1. !!"I'm
!!going !!to !!limit !!my !!meals !!to !!2-3 !!per !!day !!to !!reduce !!acid !!secretion." !!
,CORRECT !!- !!Large !!meals !!increase !!the !!volume !!and !!pressure !!in !!the !!stomach !!and
!!delay !!gastric !!emptying. !!It's !!recommended !!instead !!to !!eat !!4-6 !!small !!meals !!a !!day. !!
!!
The !!nurse !!in !!the !!Emergency !!Room !!is !!treating !!a !!patient !!suspected !!to !!have !!a
!!Peptic !!
Ulcer. !!On !!assessing !!lab !!results, !!the !!nurse !!finds !!that !!the !!patient's !!blood !!pressure !!is
!!95/60, !!pulse !!is !!110 !!beats !!per !!minute, !!and !!the !!patient !!reports !!epigastric !!pain. !!What
!!is !!the !!PRIORITY !!intervention? !!
!!
1. Start !!a !!large-bore !!IV !!in !!the !!patient's !!arm !!
2. Ask !!the !!patient !!for !!a !!stool !!sample !!
3. Prepare !!to !!insert !!an !!NG !!Tube !!
4. Administer !!intramuscular !!morphine !!sulphate !!as !!ordered !!- !!CORRECT !!ANSWER-1.
!!
Start !!a !!large-bore !!IV !!in !!the !!patient's !!arm !!
CORRECT !!- !!The !!nurse !!should !!suspect !!that !!the !!patient !!is !!haemorrhaging !!and !!will
!!need !!need !!a !!fluid !!replacement !!therapy, !!which !!requires !!a !!large !!bore !!IV. !!
!!
A !!female !!patient !!with !!atrial !!fibrillation !!has !!the !!following !!lab !!results: !!Hemoglobin !!of
!!11 !!g/dl, !!a !!platelet !!count !!of !!150,000, !!an !!INR !!of !!2.5, !!and !!potassium !!of !!2.7 !!mEq/L.
!!Which !!result !!is !!critical !!and !!should !!be !!reported !!to !!the !!physician !!immediately? !!
!!
1. Hemoglobin !!11 !!g/dl !!
2. Platelet !!of !!150,000 !!
3. INR !!of !!2.5 !!
4. Potassium !!of !!2.7 !!mEq/L !!- !!CORRECT !!ANSWER-4. !!Potassium !!of !!2.7 !!mEq/L
!!CORRECT !!- !!A !!potassium !!imbalance !!for !!a !!patient !!with !!a !!history !!of !!dysrhythmia
!!can !!be !!life-threatening !!and !!can !!lead !!to !!cardiac !!distress. !!
!!
While !!receiving !!normal !!saline !!infusions !!to !!treat !!a !!GI !!bleed, !!the !!nurse !!notes !!that
!!the !!patient's !!lower !!legs !!have !!become !!edematous !!and !!auscultates !!crackles !!in !!the
!!lungs. !!What !!should !!the !!nurse !!do !!first? !!
!!
1. Stop !!the !!saline !!infusion !!immediately !!
2. Notify !!Physician !!
3. Elevate !!the !!patient's !!legs !!
4. Continue !!the !!infusion, !!since !!these !!are !!normal !!findings !!- !!CORRECT !!ANSWER-1.
!!Stop !!the !!saline !!infusion !!immediately !!
CORRECT !!- !!the !!patient !!has !!a !!fluid !!volume !!overload !!as !!a !!result !!of !!overly !!rapid
!!fluid !!replacement. !!The !!nurse !!should !!stop !!the !!infusion !!and !!notify !!the !!physician. !!
!!
The !!nurse !!is !!working !!in !!a !!support !!group !!for !!clients !!with !!HIV. !!Which !!point !!is
!!most !!
!!
important !!for !!the !!nurse !!to
!!stress?
!!
1. !!They !!must !!inform !!household !!members !!of !!their !!condition !!
, !!
2. !!They !!must !!take !!their !!medications !!exactly !!as
!!prescribed
!!
3. !!They !!must !!abstain !!from !!substance
!!use
!!
4. !!They !!must !!avoid !!large !!crowds !!- !!CORRECT !!ANSWER-2. !!They !!must !!take
!!their
!!
medications !!exactly !!as
!!prescribed
CORRECT !!- !!Antiretrovirals !!must !!be !!taken !!exactly !!as !!prescribed !!to !!prevent
!!drug-
resistant !!strains. !!Even !!missed !!doses !!can !!reduce !!the !!effectiveness !!of !!future
!!treatment.
!!
A !!nurse !!finds !!a !!30-year-old !!woman !!experiencing !!anaphylaxis !!from !!a !!bee !!sting.
!!Emergency !!personnel !!have !!been !!called. !!The !!nurse !!notes !!the !!woman !!is !!breathing
!!but !!short !!of !!breath. !!Which !!of !!the !!following !!interventions !!should !!the !!nurse !!do !!first? !!
!!
1. Initiate !!cardiopulmonary !!resuscitation !!
2. Check !!for !!a !!pulse !! !!
3. Ask !!the !!woman !!if !!she !!carries !!an !!emergency !!medical !!kit !!
4. Stay !!with !!the !!woman !!until !!help !!comes !!- !!CORRECT !!ANSWER-3. !!Ask !!the !!woman
!!if !!she !!carries !!an !!emergency !!medical !!kit !!
CORRECT !!- !!Many !!patients !!who !!have !!a !!known !!history !!of !!anaphylaxis !!carry !!epi-
pens !!in !!their !!pockets !!or !!belongings. !!This !!is !!the !!best !!way !!to !!stop !!a !!hypersensitivity
!!reaction !!before !!it !!becomes !!life-threatening. !!
!!
A !!man !!is !!prescribed !!lithium !!to !!treat !!bipolar !!disorder. !!The !!nurse !!is !!most !!concerned
!!about
!!
lithium !!toxicity !!when !!he !!notices !!which !!of !!these !!assessment
!!findings?
!!
1. The !!patient !!states !!he !!had !!a !!manic !!episode !!a !!week !!ago !!
2. The !!patient !!states !!he !!has !!been !!having !!diarrhea !!every !!day !!
3. The !!patient !!has !!a !!rashy !!pruritis !!on !!his !!arms !!and !!legs !!
4. The !!patient !!presents !!as !!severely !!depressed !!
5. The !!patient's !!lithium !!level !!is !!1.3 !!mcg/L !!- !!CORRECT !!ANSWER-2. !!The !!patient
!!states !!he !!has !!been !!having !!diarrhea !!every !!day !!
Correct !!- !!Persistent !!diarrhea !!can !!lead !!to !!dehydration, !!which !!can !!increase !!the !!risk
!!of !!lithium !!toxicity. !!
!!
A !!65 !!year !!old !!man !!is !!prescribed !!Flomax !!(Tamsulosin) !!for !!Benign !!Prostatic
!!Hyperplasia. !!
!!
The !!patient !!lives !!in !!an !!upstairs !!apartment. !!The !!nurse !!is !!most !!concerned !!about
!!which
