NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS A+
GRADED
NCLEX COMPREHENSIVE EXAM
QUESTIONS AND ANSWERS A+
GRADED
Enalapril maleate is prescribed for a hospitalized client. Which assessment does the nurse perform
as a priority before administering the medication? - Ans-Checking the client's blood pressure
Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat
hypertension. One common side effect is postural hypotension. Therefore the nurse would check
the client's blood pressure immediately before administering each dose. Checking the client's
peripheral pulses, the results of the most recent potassium level, and the intake and output for the
previous 24 hours are not specifically associated with this mediation.
A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides
instructions to the client about the test. Which statement by the client indicates a need for further
instruction? - Ans-"I need to drink citrate of magnesia the night before the test and give myself a
Fleet enema on the morning of the test."
Rationale: An upper GI series involves visualization of the esophagus, duodenum, and upper
jejunum by means of the use of a contrast medium. It involves swallowing a contrast medium
(usually barium), which is administered in a flavored milkshake. Films are taken at intervals during
the test, which takes about 30 minutes. No special preparation is necessary before a GI series,
except that NPO status must be maintained for 8 hours before the test. After an upper GI series,
the client is prescribed a laxative to hasten elimination of the barium. Barium that remains in the
colon may become hard and difficult to expel, leading to fecal impaction.
A nurse on the evening shift checks a health care provider's prescriptions and notes that the dose of
a prescribed medication is higher than the normal dose. The nurse calls the health care provider's
answering service and is told that the health care provider is off for the night and will be available in
the morning. The nurse should: - Ans-Ask the answering service to contact the on-call health care
provider
Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a
health care provider's prescription may be in error is responsible for clarifying the prescription
before
,NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS A+
GRADED
carrying it out. Therefore the nurse would not administer the medication; instead, the nurse would
withhold the medication until the dose can be clarified. The nurse would not wait until the next
morning to obtain clarification. It is premature to call the nursing supervisor.
An emergency department (ED) nurse is monitoring a client with suspected acute myocardial
infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the
sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's
carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by
the nurse is: - Ans-Asking the ED health care provider to check the client
Rationale: PVCs are a result of increased irritability of ventricular cells. Peripheral pulses may be
absent or diminished with the PVCs themselves because the decreased stroke volume of the
premature beats may in turn decrease peripheral perfusion. Because other rhythms also cause
widened QRS complexes, it is essential that the nurse determine whether the premature beats are
resulting in perfusion of the extremities. This is done by palpating the carotid, brachial, or femoral
artery while observing the monitor for widened complexes or by auscultating for apical heart
sounds. In the situation of acute MI, PVCs may be considered warning dysrhythmias, possibly
heralding the onset of ventricular tachycardia or ventricular fibrillation. Therefore the nurse would
not tell the client that the PVCs are expected. Although the nurse will continue to monitor the client
and document the findings, these are not the most appropriate actions of those provided. The most
appropriate action would be to ask the ED health care provider to check the client.
NPO status is imposed 8 hours before the procedure on a client scheduled to undergo
electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the
client's record and notes that the client routinely takes an oral antihypertensive medication each
morning. The nurse should: - Ans-Administer the antihypertensive with a small sip of water
Rationale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours before
treatment to help prevent aspiration. Exceptions include clients who routinely receive cardiac
medications, antihypertensive agents, or histamine (H2) blockers, which should be administered
several hours before treatment with a small sip of water. Withholding the antihypertensive and
administering it at bedtime and withholding the antihypertensive and resuming administration on
the day after the ECT are incorrect actions, because antihypertensives must be administered on
time; otherwise, the risk for rebound hypertension exists. The nurse would not administer a
medication by way of a route that has not been prescribed.
A client who recently underwent coronary artery bypass graft surgery comes to the health care
provider's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling
,NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS A+
GRADED
depressed. Which response by the nurse is therapeutic? - Ans-"Tell me more about what you're
feeling."
Rationale: When a client expresses feelings of depression, it is extremely important for the nurse to
further explore these feelings with the client. In stating, "This is a normal response after this type of
surgery" the nurse provides false reassurance and avoids addressing the client's feelings. "It will
take time, but, I promise you, you will get over the depression" is also a false reassurance, and it
does not encourage the expression of feelings. "Every client who has this surgery feels the same way
for about a month" is a generalization that avoids the client's feelings.
A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts
the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that
the fluid is yellow and has a strong odor. Which action should be the nurse's priority? - Ans-
Contacting the health care provider
Rationale: The FHR is assessed for at least 1 minute when the membranes rupture. The nurse also
checks the quantity, color, and odor of the amniotic fluid. The fluid should be clear (often with bits
of vernix) and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or yellow
coloration suggests chorioamnionitis and warrants notifying the health care provider. A large
amount of vernix in the fluid suggests that the fetus is preterm. Greenish, meconium-stained fluid
may be seen in cases of postterm gestation or placental insufficiency. Checking the fluid for protein
is not associated with the data in the question. Although the nurse would continue to monitor the
client and the FHR and would document the findings, contacting the health care provider is the
priority.
A nurse has assisted a health care provider in inserting a central venous access device into a client
with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After
insertion of the catheter, the nurse immediately plans to: - Ans-Call the radiography department to
obtain a chest x-ray
Rationale: One major complication associated with central venous catheter placement is
pneumothorax, which may result from accidental puncture of the lung. After the catheter has been
placed but before it is used for infusions, its placement must be checked with an x-ray. Hanging the
prescribed bag of PN and starting the infusion at the prescribed rate and infusing normal saline
solution through the catheter at a rate of 100 mL/hr to maintain patency are all incorrect because
they could result in the infusion of solution into a lung if a pneumothorax is present. Although the
nurse may obtain a blood glucose measurement to serve as a baseline, this action is not the priority.
, NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS A+
GRADED
A rape victim being treated in the emergency department says to the nurse, "I'm really worried that
I've got HIV now." What is the appropriate response by the nurse? - Ans-"Let's talk about the
information that you need to determine your risk of contracting HIV."
Rationale: HIV is a concern of rape victims. Such concern should always be addressed, and the
victim should be given the information needed to evaluate his or her risk. Pregnancy may occur as a
result of rape, and pregnancy prophylaxis can be offered in the emergency department or during
follow- up, once the results of a pregnancy test have been obtained. However, stating, "You're more
likely to get pregnant than to contract HIV" avoids the client's concern. Similarly, "HIV is rarely an
issue in rape victims" and "Every rape victim is concerned about HIV" are generalized responses that
avoid the client's concern.
A client is taking prescribed ibuprofen, 300 mg orally four times daily, to relieve joint pain resulting
from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and
indigestion. The nurse should tell the client to: - Ans-Take the medication with food
Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication. Side effects include nausea
(with or without vomiting) and dyspepsia (heartburn, indigestion, or epigastric pain). If
gastrointestinal distress occurs, the client should be instructed to take the medication with milk or
food. The nurse would not instruct the client to stop the medication or instruct the client to adjust
the dosage of a prescribed medication; these actions are not within the legal scope of the role of
the nurse. Contacting the health care provider is premature, because the client's complaints are
side effects that occasionally occur and can be relieved by taking the medication with milk or food.
Lorazepam 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the
management of anxiety. The nurse prepares the medication as prescribed and administers the
medication over a period of: - Ans-3 minutes
Rationale: Lorazepam is a benzodiazepine. When administered by IV injection, each 2 mg or fraction
thereof is administered over a period of 1 to 5 minutes. Ten seconds and 30 seconds are brief
periods. Thirty minutes is a lengthy period.
A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus
infection, asks the client about medications that he is taking. The client tells the nurse that he is
taking nefazodone hydrochloride . On the basis of this information, the nurse determines that the
client most likely has a history of: - Ans-Depression
GRADED
NCLEX COMPREHENSIVE EXAM
QUESTIONS AND ANSWERS A+
GRADED
Enalapril maleate is prescribed for a hospitalized client. Which assessment does the nurse perform
as a priority before administering the medication? - Ans-Checking the client's blood pressure
Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat
hypertension. One common side effect is postural hypotension. Therefore the nurse would check
the client's blood pressure immediately before administering each dose. Checking the client's
peripheral pulses, the results of the most recent potassium level, and the intake and output for the
previous 24 hours are not specifically associated with this mediation.
A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides
instructions to the client about the test. Which statement by the client indicates a need for further
instruction? - Ans-"I need to drink citrate of magnesia the night before the test and give myself a
Fleet enema on the morning of the test."
Rationale: An upper GI series involves visualization of the esophagus, duodenum, and upper
jejunum by means of the use of a contrast medium. It involves swallowing a contrast medium
(usually barium), which is administered in a flavored milkshake. Films are taken at intervals during
the test, which takes about 30 minutes. No special preparation is necessary before a GI series,
except that NPO status must be maintained for 8 hours before the test. After an upper GI series,
the client is prescribed a laxative to hasten elimination of the barium. Barium that remains in the
colon may become hard and difficult to expel, leading to fecal impaction.
A nurse on the evening shift checks a health care provider's prescriptions and notes that the dose of
a prescribed medication is higher than the normal dose. The nurse calls the health care provider's
answering service and is told that the health care provider is off for the night and will be available in
the morning. The nurse should: - Ans-Ask the answering service to contact the on-call health care
provider
Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a
health care provider's prescription may be in error is responsible for clarifying the prescription
before
,NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS A+
GRADED
carrying it out. Therefore the nurse would not administer the medication; instead, the nurse would
withhold the medication until the dose can be clarified. The nurse would not wait until the next
morning to obtain clarification. It is premature to call the nursing supervisor.
An emergency department (ED) nurse is monitoring a client with suspected acute myocardial
infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the
sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's
carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by
the nurse is: - Ans-Asking the ED health care provider to check the client
Rationale: PVCs are a result of increased irritability of ventricular cells. Peripheral pulses may be
absent or diminished with the PVCs themselves because the decreased stroke volume of the
premature beats may in turn decrease peripheral perfusion. Because other rhythms also cause
widened QRS complexes, it is essential that the nurse determine whether the premature beats are
resulting in perfusion of the extremities. This is done by palpating the carotid, brachial, or femoral
artery while observing the monitor for widened complexes or by auscultating for apical heart
sounds. In the situation of acute MI, PVCs may be considered warning dysrhythmias, possibly
heralding the onset of ventricular tachycardia or ventricular fibrillation. Therefore the nurse would
not tell the client that the PVCs are expected. Although the nurse will continue to monitor the client
and document the findings, these are not the most appropriate actions of those provided. The most
appropriate action would be to ask the ED health care provider to check the client.
NPO status is imposed 8 hours before the procedure on a client scheduled to undergo
electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the
client's record and notes that the client routinely takes an oral antihypertensive medication each
morning. The nurse should: - Ans-Administer the antihypertensive with a small sip of water
Rationale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours before
treatment to help prevent aspiration. Exceptions include clients who routinely receive cardiac
medications, antihypertensive agents, or histamine (H2) blockers, which should be administered
several hours before treatment with a small sip of water. Withholding the antihypertensive and
administering it at bedtime and withholding the antihypertensive and resuming administration on
the day after the ECT are incorrect actions, because antihypertensives must be administered on
time; otherwise, the risk for rebound hypertension exists. The nurse would not administer a
medication by way of a route that has not been prescribed.
A client who recently underwent coronary artery bypass graft surgery comes to the health care
provider's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling
,NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS A+
GRADED
depressed. Which response by the nurse is therapeutic? - Ans-"Tell me more about what you're
feeling."
Rationale: When a client expresses feelings of depression, it is extremely important for the nurse to
further explore these feelings with the client. In stating, "This is a normal response after this type of
surgery" the nurse provides false reassurance and avoids addressing the client's feelings. "It will
take time, but, I promise you, you will get over the depression" is also a false reassurance, and it
does not encourage the expression of feelings. "Every client who has this surgery feels the same way
for about a month" is a generalization that avoids the client's feelings.
A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts
the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that
the fluid is yellow and has a strong odor. Which action should be the nurse's priority? - Ans-
Contacting the health care provider
Rationale: The FHR is assessed for at least 1 minute when the membranes rupture. The nurse also
checks the quantity, color, and odor of the amniotic fluid. The fluid should be clear (often with bits
of vernix) and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or yellow
coloration suggests chorioamnionitis and warrants notifying the health care provider. A large
amount of vernix in the fluid suggests that the fetus is preterm. Greenish, meconium-stained fluid
may be seen in cases of postterm gestation or placental insufficiency. Checking the fluid for protein
is not associated with the data in the question. Although the nurse would continue to monitor the
client and the FHR and would document the findings, contacting the health care provider is the
priority.
A nurse has assisted a health care provider in inserting a central venous access device into a client
with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After
insertion of the catheter, the nurse immediately plans to: - Ans-Call the radiography department to
obtain a chest x-ray
Rationale: One major complication associated with central venous catheter placement is
pneumothorax, which may result from accidental puncture of the lung. After the catheter has been
placed but before it is used for infusions, its placement must be checked with an x-ray. Hanging the
prescribed bag of PN and starting the infusion at the prescribed rate and infusing normal saline
solution through the catheter at a rate of 100 mL/hr to maintain patency are all incorrect because
they could result in the infusion of solution into a lung if a pneumothorax is present. Although the
nurse may obtain a blood glucose measurement to serve as a baseline, this action is not the priority.
, NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS A+
GRADED
A rape victim being treated in the emergency department says to the nurse, "I'm really worried that
I've got HIV now." What is the appropriate response by the nurse? - Ans-"Let's talk about the
information that you need to determine your risk of contracting HIV."
Rationale: HIV is a concern of rape victims. Such concern should always be addressed, and the
victim should be given the information needed to evaluate his or her risk. Pregnancy may occur as a
result of rape, and pregnancy prophylaxis can be offered in the emergency department or during
follow- up, once the results of a pregnancy test have been obtained. However, stating, "You're more
likely to get pregnant than to contract HIV" avoids the client's concern. Similarly, "HIV is rarely an
issue in rape victims" and "Every rape victim is concerned about HIV" are generalized responses that
avoid the client's concern.
A client is taking prescribed ibuprofen, 300 mg orally four times daily, to relieve joint pain resulting
from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and
indigestion. The nurse should tell the client to: - Ans-Take the medication with food
Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication. Side effects include nausea
(with or without vomiting) and dyspepsia (heartburn, indigestion, or epigastric pain). If
gastrointestinal distress occurs, the client should be instructed to take the medication with milk or
food. The nurse would not instruct the client to stop the medication or instruct the client to adjust
the dosage of a prescribed medication; these actions are not within the legal scope of the role of
the nurse. Contacting the health care provider is premature, because the client's complaints are
side effects that occasionally occur and can be relieved by taking the medication with milk or food.
Lorazepam 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the
management of anxiety. The nurse prepares the medication as prescribed and administers the
medication over a period of: - Ans-3 minutes
Rationale: Lorazepam is a benzodiazepine. When administered by IV injection, each 2 mg or fraction
thereof is administered over a period of 1 to 5 minutes. Ten seconds and 30 seconds are brief
periods. Thirty minutes is a lengthy period.
A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus
infection, asks the client about medications that he is taking. The client tells the nurse that he is
taking nefazodone hydrochloride . On the basis of this information, the nurse determines that the
client most likely has a history of: - Ans-Depression
