NCLEX type questions with Rationales
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A patient has been receiving chemotherapy and radiation for
a diagnosis of non-Hodgkin's lymphoma. In your morning as-
sessment, you notice the patient has new onset facial edema, C. Superior Vena Cava Syndrome (SVCS)
distention of head and neck veins, and dyspnea. Which oncologic
emergency would be suspected? The manifestations in the patient are all seen in SVCS in addition
to headache, seizures, and often a mediastinal mass found on
a. Hypercalcemia a chest x-ray. This complication is common with lung cancer,
b. Spinal Cord Compression metastatic breast cancer, and non-Hodgkin's lymphoma
c. Superior Vena Cava Syndrome (SVCS)
d. Tumor Lysis Syndrome (TLS)
B, D, E
B. In patients with cirrhosis, especially if they have esophageal
or gastric varices as a comorbidity, use of aspirin and NSAIDs
is discouraged. The damage cirrhosis causes to the liver lowers
When providing education to a patient newly diagnosed with cir-
its ability to assist in clotting and taking aspirin and NSAIDs,
rhosis, what information should be included? (select all that apply)
which also have anticoagulant properties, can increase the risk of
hemorrhage
a. Inform the patient that cirrhosis is an acute condition that can
be alleviated with the correct drug regimen
D. Patient should be informed of signs and symptoms to look for
b. Avoid aspirin and NSAIDs to prevent hemorrhage
that may indicate worsening of their condition. These can include
c. Limit alcohol consumption to one drink per week
peripheral edema (swelling in extremities), signs of bleeding, as-
d. Teach symptoms of complications and when to seek medical
cites (build-up of fluid in peritoneal cavity), alterations in mental
attention
status, asterixis (flapping tremors), etc. If any of these symptoms
e. Avoid hepatotoxic over-the-counter (OTC) drugs
occur, the patient should seek medical attention right away
E. OTC drugs that may be toxic to the liver (ex: acetaminophen in
high doses) should be avoided because the damage that cirrhosis
causes to the liver makes it unable to metabolize those drugs
A nurse is teaching a patient about prevention of a second UTI.
Which of the statements made by the patient requires further
intervention?
A. "I will stop taking my antibiotic once the symptoms are gone."
a. "I will stop taking my antibiotic once the symptoms are gone."
It is important to take all antibiotics as prescribed. Symptoms may
b. "I should consider drinking unsweetened cranberry juice in my
improve 1-2 days after therapy, but organisms maybe still present.
diet."
c. "I will urinate regularly approximately every 3-4 hours"
d. "I will remember to drink fluids adequately."
A nursing student is teaching a patient about management of A, C
constipation. The nursing instructor would intervene if the student
made which statement? (Select all that apply) A. Do not overuse laxatives and enemas because they cause
dependence. People who overuse them are unable to have a
a. The use of laxatives and enemas will help free up blockage. bowel movement without them.
b. Eat foods with high fiber like raw vegetables and beans
c. Drink about 3 quarts of fluid including coffee and energy drinks. C. Fluid soften hard stools. Drink 2 L per day. Drink water or fruit
d. Establish a regular time to defecate. juices. Avoid caffeinated coffee, tea, and cola. Caffeine stimulate
e. Exercise about 3 times a week. fluid loss through urination.
A nurse is reviewing lab values for a patient admitted to the
hospital for acute pancreatitis, what lab values would the nurse
A, C, D
expect to see? (Select all that apply.)
The primary diagnostic tests for acute pancreatitis are serum
a. Elevated Serum Amylase
amylase and lipase. The serum amylase level is usually elevated
b. Decreased Phosphorus
early and remains elevated for 24 to 72 hours.
c. Decreased Calcium
d. Elevated Serum Lipase
The nurse knows, which of the following patients is most at risk of
having another flair up of their chronic pancreatitis? B. A 23-year-old male, who was hospitalized with spleen injury
after a MVA, who states he drinks several times a week with
a. A 72-year-old female, who enjoys eating fried foods regularly his friends, and takes NSAIDs to treat abdominal pain from his
and states she prefers to eat late dinners just before bedtime. accident.
b. A 23-year-old male, who was hospitalized with spleen injury
, NCLEX type questions with Rationales
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after a MVA, who states he drinks several times a week with
his friends, and takes NSAIDs to treat abdominal pain from his
accident. This patient is most at risk for aggravating his chronic pancreatitis
c. A 56-year-old male, who prefers drinking milk instead of water he drinks heavily and sustained abdominal trauma recently which
with meals, and states his diet consists of mostly legumes and puts him at higher risk. Encourage the patient to eliminate alcohol
fish. intake, especially if he or she has had any previous episodes of
d. A 28-year-old female, with poly cystic ovarian syndrome and a pancreatitis. Recurrent attacks of pancreatitis may become milder
BMI of 31, who states she binges on sweets when she is feeling or disappear with the discontinuance of alcohol use.
stressed from work and school.
C, D, E
A 43 year old woman is diagnosed with gastroesophageal reflux
disease (GERD). What guidelines can the nurse provide to her for
C. Eating before bedtime should be avoided to prevent food from
managing her symptoms? SELECT ALL THAT APPLY.
traveling back up the esophagus. It is recommended that patients
with GERD avoid eating within 3 hours of bedtime.
a. Lie down after eating to relieve pressure
b. Having peppermint or tea after eating can soothe any discomfort
D. Eating small, frequent meals can help prevent over distention
c. Avoid late night snacking
of the stomach. This reduces symptoms of GERD.
d. Eating small, more frequent meals is better than eating a few
large meals per day
E. Drinking fluids between meals, but not with meals will help
e. Drinking fluids between meals and not with meals can help
prevent over distention of the stomach. This reduces symptoms
prevent reflux
of GERD
A 26 year old male presents to the Emergency Department with 2
days of bloody stools, abdominal cramping, and watery diarrhea.
He is diagnosed with E. coli poisoning. When explaining what he
ate the past few days, which items might you suspect as the E. D. A cheeseburger and fries
coli carrying culprit?
Contaminated beef, pork, milk, cheese, and cookie dough are the
a. A bowl of oatmeal with brown sugar and raisins most common sources of E. coli food poisoning
b. Vegetable soup
c. A chocolate brownie
d. A cheeseburger and fries
A, B, D
A. Direct renal damage from exposure to nephrotoxic agents such
Which of the following are considered nursing interventions for
as cisplatin and high dose-methotrexate can be a complication
patients going through radiation or chemotherapy? (Select all that
from treatment. Therefore, labs for BUN and creatinine levels must
apply)
be continuously monitored.
a. Monitor BUN and creatinine levels
B. Infection is a major cause of death in cancer patients because
b. Teach patient to avoid large crowds
of low WBC's, especially neutrophils. It is recommended that be-
c. Encourage patient to get at least 60 min of direct sunlight per
cause of immune suppression while undergoing treatment, it is
day
best to avoid large crowds.
d. Monitor platelet counts
e. High fiber diet to prevent constipation
D. Because spontaneous bleeding can occur with platelet counts
<20,000, it is important that the nurse must monitor platelet
counts.
Lifestyle modifications are crucial for the management and pre-
vention of gastroesophageal reflux disease (GERD). Which of the
B. Avoid alcohol and caffeinated beverages
following is a strategy for good management to teach a patient
who was recently diagnosed?
Caffeinated beverages, as well as alcohol, cause an almost imme-
diate, marked decrease in lower esophageal sphincter pressure.
a. Eat a small meal close to bedtime to ease the onset of GERD
Because of this, alcohol and caffeinated beverages should be
b. Avoid alcohol and caffeinated beverages
avoided.
c. Avoid taking sucralfate (Carafate)
d. If a PPI is being taken, it is best to take it right before bedtime
When providing education about diet for a patient who has had a
A, C, D
history of gout and urinary calculi, the nurse should tell the patient
to avoid or limit which of the following food selections (SELECT
The treatment for a patient with a history of uric acid urinary calculi
ALL THAT APPLY)
is reduce urinary concentration of uric acid. Alkalinize urine with
potassium citrate. Administer allopurinol. Reduce dietary purines.
a. Liver
, NCLEX type questions with Rationales
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b. Corn Also, foods high in purine include sardines, herring, mussels, liver,
c. Mussels kidney, goose, goose, venison, meat soups, sweet breads. Foods
d. Salmon moderate in purine; chicken, salmon, crab, veal, mutton, bacon,
e. Tomatoes pork, beef, ham.
B. Diabetic Ketoacidosis
A 12-year-old patient presents with poor skin turgor, dry mu-
cus membranes, tachycardia, orthostatic hypotension, lethargy,
Diabetic Ketoacidosis is seen mostly in type 1 diabetes. It is a
weakness, and has rapid deep respirations with a sweet fruity
profound deficiency in insulin is characterized by hyperglycemia,
odor. The nurse suspects this patient is suffering from:
ketosis, acidosis, and dehydration. The body has begun to break
down fats and proteins for energy from the lack for glucose enter-
a. Hyperosmolar hyperglycemic syndrome
ing the cell. This caused all the above signs and symptoms. Acido-
b. Diabetic Ketoacidosis
sis causes Kussmaul respirations too in an attempt to compensate
c. Insulin excess
for acidotic state. Increased acetone can cause a sweet fruity odor
d. Dehydration
on the breath
A 65-year-old patient is receiving hemodialysis. They are on Norco
B, C
for post-surgical pain, and Benazepril for hypertension. The pa-
tient starts to unexpectedly bleed out from his surgical incision.
B. Protamine sulfate would be used in this situation as the unex-
What would you do and why? (Select all that apply)
pected bleeding is likely caused by the Heparin in the hemodial-
ysis machine.
a. Give Vitamin K to help the blood clot
b. Give protamine sulfate to stem the excessive bleeding
C. Stopping hemodialysis would stop the influx of heparin from the
c. Stop hemodialysis to focus on the bleeding
machine. Heparin is used to prevent clotting in the machine.
d. Put pressure on the surgical site to slow the bleeding
A student nurse is explaining the probable sites for an arteriove-
nous fistula to the patient. Which statement does the preceptor
know suggests understanding of placement on the part of the
B. Cephalic or basilic vein with radial artery
student nurse?
The brachial or basilic vein with the radial artery are used with an
a. Brachial and antecubital area
arteriovenous fistula
b. Cephalic or basilic vein with radial artery
c. Femoral vein
d. Internal jugular
The nurse is doing discharge teaching for a patient with a new
diagnosis of thrombocytopenia. Which statement, if made by the B, C, E
patient, would indicate that the patient understands the teaching?
(SELECT ALL THAT APPLY) B. Talk with your HCP before you have any invasive procedures
done, such as pedicures, manicures, or dental cleanings.
a. "I can't wait to get back to my weights class at the gym!"
b. "I will talk with my Dr. before my pedicure appointment next C. Any medications or herbal supplements that prolong bleeding,
week." such as aspirin, should be avoided.
c. "I will stop taking my herbal supplements and over the counter
medications until I speak with my Dr." E. Headache and/or vision changes are a manifestation of bleed-
d. "I will replace my toothbrush with one with medium bristles." ing.
e. "I will contact my Dr. if I get a headache, or my vision changes."
A patient's arterial blood gas (ABG) results are: PH; 7.31, PaCO2; C. . Respiratory acidosis, uncompensated
54 mmHg, HCO3; 25 mEq/L. What kind of acid-base imbalance is
this? Respiratory acidosis occurs whenever the person hypoventilates.
[This] leads to a buildup of CO2, resulting in an accumulation
a. Metabolic acidosis, uncompensated of carbonic acid in the blood. Renal compensatory mechanisms
b. Respiratory alkalosis, compensated begin to operate within 24 hours. The kidneys conserve HCO3
c. Respiratory acidosis, uncompensated (bicarbonate) and secrete increased concentrations of H+ (hydro-
d. Metabolic alkalosis, uncompensated gen) into the urine. Until the renal mechanisms have an effect, the
e. Respiratory acidosis, compensated serum HCO3 level will usually be normal, and then it will increase.
A, D, F
A patient diagnosed with chronic kidney disease questions the
nurse on his possibility of a kidney transplant. The nurse knows A. Contraindications to transplantation include disseminated ma-
that which of the following factors would cause the patient to be lignancies, refractory or untreated cardiac disease, chronic res-
unable to receive a kidney transplant (select all that apply): piratory failure, extensive vascular disease, chronic infection, and
unresolved psychosocial disorders.
Study online at https://quizlet.com/_8n7iqc
A patient has been receiving chemotherapy and radiation for
a diagnosis of non-Hodgkin's lymphoma. In your morning as-
sessment, you notice the patient has new onset facial edema, C. Superior Vena Cava Syndrome (SVCS)
distention of head and neck veins, and dyspnea. Which oncologic
emergency would be suspected? The manifestations in the patient are all seen in SVCS in addition
to headache, seizures, and often a mediastinal mass found on
a. Hypercalcemia a chest x-ray. This complication is common with lung cancer,
b. Spinal Cord Compression metastatic breast cancer, and non-Hodgkin's lymphoma
c. Superior Vena Cava Syndrome (SVCS)
d. Tumor Lysis Syndrome (TLS)
B, D, E
B. In patients with cirrhosis, especially if they have esophageal
or gastric varices as a comorbidity, use of aspirin and NSAIDs
is discouraged. The damage cirrhosis causes to the liver lowers
When providing education to a patient newly diagnosed with cir-
its ability to assist in clotting and taking aspirin and NSAIDs,
rhosis, what information should be included? (select all that apply)
which also have anticoagulant properties, can increase the risk of
hemorrhage
a. Inform the patient that cirrhosis is an acute condition that can
be alleviated with the correct drug regimen
D. Patient should be informed of signs and symptoms to look for
b. Avoid aspirin and NSAIDs to prevent hemorrhage
that may indicate worsening of their condition. These can include
c. Limit alcohol consumption to one drink per week
peripheral edema (swelling in extremities), signs of bleeding, as-
d. Teach symptoms of complications and when to seek medical
cites (build-up of fluid in peritoneal cavity), alterations in mental
attention
status, asterixis (flapping tremors), etc. If any of these symptoms
e. Avoid hepatotoxic over-the-counter (OTC) drugs
occur, the patient should seek medical attention right away
E. OTC drugs that may be toxic to the liver (ex: acetaminophen in
high doses) should be avoided because the damage that cirrhosis
causes to the liver makes it unable to metabolize those drugs
A nurse is teaching a patient about prevention of a second UTI.
Which of the statements made by the patient requires further
intervention?
A. "I will stop taking my antibiotic once the symptoms are gone."
a. "I will stop taking my antibiotic once the symptoms are gone."
It is important to take all antibiotics as prescribed. Symptoms may
b. "I should consider drinking unsweetened cranberry juice in my
improve 1-2 days after therapy, but organisms maybe still present.
diet."
c. "I will urinate regularly approximately every 3-4 hours"
d. "I will remember to drink fluids adequately."
A nursing student is teaching a patient about management of A, C
constipation. The nursing instructor would intervene if the student
made which statement? (Select all that apply) A. Do not overuse laxatives and enemas because they cause
dependence. People who overuse them are unable to have a
a. The use of laxatives and enemas will help free up blockage. bowel movement without them.
b. Eat foods with high fiber like raw vegetables and beans
c. Drink about 3 quarts of fluid including coffee and energy drinks. C. Fluid soften hard stools. Drink 2 L per day. Drink water or fruit
d. Establish a regular time to defecate. juices. Avoid caffeinated coffee, tea, and cola. Caffeine stimulate
e. Exercise about 3 times a week. fluid loss through urination.
A nurse is reviewing lab values for a patient admitted to the
hospital for acute pancreatitis, what lab values would the nurse
A, C, D
expect to see? (Select all that apply.)
The primary diagnostic tests for acute pancreatitis are serum
a. Elevated Serum Amylase
amylase and lipase. The serum amylase level is usually elevated
b. Decreased Phosphorus
early and remains elevated for 24 to 72 hours.
c. Decreased Calcium
d. Elevated Serum Lipase
The nurse knows, which of the following patients is most at risk of
having another flair up of their chronic pancreatitis? B. A 23-year-old male, who was hospitalized with spleen injury
after a MVA, who states he drinks several times a week with
a. A 72-year-old female, who enjoys eating fried foods regularly his friends, and takes NSAIDs to treat abdominal pain from his
and states she prefers to eat late dinners just before bedtime. accident.
b. A 23-year-old male, who was hospitalized with spleen injury
, NCLEX type questions with Rationales
Study online at https://quizlet.com/_8n7iqc
after a MVA, who states he drinks several times a week with
his friends, and takes NSAIDs to treat abdominal pain from his
accident. This patient is most at risk for aggravating his chronic pancreatitis
c. A 56-year-old male, who prefers drinking milk instead of water he drinks heavily and sustained abdominal trauma recently which
with meals, and states his diet consists of mostly legumes and puts him at higher risk. Encourage the patient to eliminate alcohol
fish. intake, especially if he or she has had any previous episodes of
d. A 28-year-old female, with poly cystic ovarian syndrome and a pancreatitis. Recurrent attacks of pancreatitis may become milder
BMI of 31, who states she binges on sweets when she is feeling or disappear with the discontinuance of alcohol use.
stressed from work and school.
C, D, E
A 43 year old woman is diagnosed with gastroesophageal reflux
disease (GERD). What guidelines can the nurse provide to her for
C. Eating before bedtime should be avoided to prevent food from
managing her symptoms? SELECT ALL THAT APPLY.
traveling back up the esophagus. It is recommended that patients
with GERD avoid eating within 3 hours of bedtime.
a. Lie down after eating to relieve pressure
b. Having peppermint or tea after eating can soothe any discomfort
D. Eating small, frequent meals can help prevent over distention
c. Avoid late night snacking
of the stomach. This reduces symptoms of GERD.
d. Eating small, more frequent meals is better than eating a few
large meals per day
E. Drinking fluids between meals, but not with meals will help
e. Drinking fluids between meals and not with meals can help
prevent over distention of the stomach. This reduces symptoms
prevent reflux
of GERD
A 26 year old male presents to the Emergency Department with 2
days of bloody stools, abdominal cramping, and watery diarrhea.
He is diagnosed with E. coli poisoning. When explaining what he
ate the past few days, which items might you suspect as the E. D. A cheeseburger and fries
coli carrying culprit?
Contaminated beef, pork, milk, cheese, and cookie dough are the
a. A bowl of oatmeal with brown sugar and raisins most common sources of E. coli food poisoning
b. Vegetable soup
c. A chocolate brownie
d. A cheeseburger and fries
A, B, D
A. Direct renal damage from exposure to nephrotoxic agents such
Which of the following are considered nursing interventions for
as cisplatin and high dose-methotrexate can be a complication
patients going through radiation or chemotherapy? (Select all that
from treatment. Therefore, labs for BUN and creatinine levels must
apply)
be continuously monitored.
a. Monitor BUN and creatinine levels
B. Infection is a major cause of death in cancer patients because
b. Teach patient to avoid large crowds
of low WBC's, especially neutrophils. It is recommended that be-
c. Encourage patient to get at least 60 min of direct sunlight per
cause of immune suppression while undergoing treatment, it is
day
best to avoid large crowds.
d. Monitor platelet counts
e. High fiber diet to prevent constipation
D. Because spontaneous bleeding can occur with platelet counts
<20,000, it is important that the nurse must monitor platelet
counts.
Lifestyle modifications are crucial for the management and pre-
vention of gastroesophageal reflux disease (GERD). Which of the
B. Avoid alcohol and caffeinated beverages
following is a strategy for good management to teach a patient
who was recently diagnosed?
Caffeinated beverages, as well as alcohol, cause an almost imme-
diate, marked decrease in lower esophageal sphincter pressure.
a. Eat a small meal close to bedtime to ease the onset of GERD
Because of this, alcohol and caffeinated beverages should be
b. Avoid alcohol and caffeinated beverages
avoided.
c. Avoid taking sucralfate (Carafate)
d. If a PPI is being taken, it is best to take it right before bedtime
When providing education about diet for a patient who has had a
A, C, D
history of gout and urinary calculi, the nurse should tell the patient
to avoid or limit which of the following food selections (SELECT
The treatment for a patient with a history of uric acid urinary calculi
ALL THAT APPLY)
is reduce urinary concentration of uric acid. Alkalinize urine with
potassium citrate. Administer allopurinol. Reduce dietary purines.
a. Liver
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b. Corn Also, foods high in purine include sardines, herring, mussels, liver,
c. Mussels kidney, goose, goose, venison, meat soups, sweet breads. Foods
d. Salmon moderate in purine; chicken, salmon, crab, veal, mutton, bacon,
e. Tomatoes pork, beef, ham.
B. Diabetic Ketoacidosis
A 12-year-old patient presents with poor skin turgor, dry mu-
cus membranes, tachycardia, orthostatic hypotension, lethargy,
Diabetic Ketoacidosis is seen mostly in type 1 diabetes. It is a
weakness, and has rapid deep respirations with a sweet fruity
profound deficiency in insulin is characterized by hyperglycemia,
odor. The nurse suspects this patient is suffering from:
ketosis, acidosis, and dehydration. The body has begun to break
down fats and proteins for energy from the lack for glucose enter-
a. Hyperosmolar hyperglycemic syndrome
ing the cell. This caused all the above signs and symptoms. Acido-
b. Diabetic Ketoacidosis
sis causes Kussmaul respirations too in an attempt to compensate
c. Insulin excess
for acidotic state. Increased acetone can cause a sweet fruity odor
d. Dehydration
on the breath
A 65-year-old patient is receiving hemodialysis. They are on Norco
B, C
for post-surgical pain, and Benazepril for hypertension. The pa-
tient starts to unexpectedly bleed out from his surgical incision.
B. Protamine sulfate would be used in this situation as the unex-
What would you do and why? (Select all that apply)
pected bleeding is likely caused by the Heparin in the hemodial-
ysis machine.
a. Give Vitamin K to help the blood clot
b. Give protamine sulfate to stem the excessive bleeding
C. Stopping hemodialysis would stop the influx of heparin from the
c. Stop hemodialysis to focus on the bleeding
machine. Heparin is used to prevent clotting in the machine.
d. Put pressure on the surgical site to slow the bleeding
A student nurse is explaining the probable sites for an arteriove-
nous fistula to the patient. Which statement does the preceptor
know suggests understanding of placement on the part of the
B. Cephalic or basilic vein with radial artery
student nurse?
The brachial or basilic vein with the radial artery are used with an
a. Brachial and antecubital area
arteriovenous fistula
b. Cephalic or basilic vein with radial artery
c. Femoral vein
d. Internal jugular
The nurse is doing discharge teaching for a patient with a new
diagnosis of thrombocytopenia. Which statement, if made by the B, C, E
patient, would indicate that the patient understands the teaching?
(SELECT ALL THAT APPLY) B. Talk with your HCP before you have any invasive procedures
done, such as pedicures, manicures, or dental cleanings.
a. "I can't wait to get back to my weights class at the gym!"
b. "I will talk with my Dr. before my pedicure appointment next C. Any medications or herbal supplements that prolong bleeding,
week." such as aspirin, should be avoided.
c. "I will stop taking my herbal supplements and over the counter
medications until I speak with my Dr." E. Headache and/or vision changes are a manifestation of bleed-
d. "I will replace my toothbrush with one with medium bristles." ing.
e. "I will contact my Dr. if I get a headache, or my vision changes."
A patient's arterial blood gas (ABG) results are: PH; 7.31, PaCO2; C. . Respiratory acidosis, uncompensated
54 mmHg, HCO3; 25 mEq/L. What kind of acid-base imbalance is
this? Respiratory acidosis occurs whenever the person hypoventilates.
[This] leads to a buildup of CO2, resulting in an accumulation
a. Metabolic acidosis, uncompensated of carbonic acid in the blood. Renal compensatory mechanisms
b. Respiratory alkalosis, compensated begin to operate within 24 hours. The kidneys conserve HCO3
c. Respiratory acidosis, uncompensated (bicarbonate) and secrete increased concentrations of H+ (hydro-
d. Metabolic alkalosis, uncompensated gen) into the urine. Until the renal mechanisms have an effect, the
e. Respiratory acidosis, compensated serum HCO3 level will usually be normal, and then it will increase.
A, D, F
A patient diagnosed with chronic kidney disease questions the
nurse on his possibility of a kidney transplant. The nurse knows A. Contraindications to transplantation include disseminated ma-
that which of the following factors would cause the patient to be lignancies, refractory or untreated cardiac disease, chronic res-
unable to receive a kidney transplant (select all that apply): piratory failure, extensive vascular disease, chronic infection, and
unresolved psychosocial disorders.
