NCLEX RN EXIT EXAMS 2023 WIRH NGN
1. 1. Question
1 point(s)
Category: Pharmacological and Parenteral Therapies
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?
o A. Decrease in arterial oxygen saturation (SaO2) when
measured with a pulse oximeter
o B. Increase in systemic blood pressure
o C. Presence of premature ventricular contractions
(PVCs) on a cardiac monitor
o D. Increase in intracranial pressure (ICP)
o E. A drop in serum potassium levels as indicated in the
latest lab results
o F. Observation of a widening QRS complex on the
ECG
Incorrect
Correct Answer: C. Presence of premature ventricular
contractions (PVCs) on a cardiac monitor.
In the context of acute myocardial infarction, the priority is to
manage life-threatening arrhythmias. Lidocaine is specifically
indicated for the treatment of ventricular arrhythmias, such as
PVCs, which can be indicative of an increased risk for more
serious arrhythmias like ventricular tachycardia or ventricular
fibrillation. The presence of PVCs on a cardiac monitor would be
the most immediate concern that lidocaine can address in this
scenario. While the other factors listed are important to monitor,
, they are not the primary indications for lidocaine administration
in the context of arrhythmia management.
2. 2. Question
1 point(s)
Category: Pharmacological and Parenteral Therapies
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?
o A. Report incidents of diarrhea
o B. Avoid foods high in vitamin K
o C. Use a straight razor when shaving
o D. Take aspirin for pain relief
o E. Monitor for signs of bleeding, such as bruising or black
tarry stools
o F. Check blood pressure regularly at home
o G. Inform all healthcare providers about the anticoagulant
therapy
Incorrect
Correct Answer: B. Avoid foods high in vitamin K
Clients taking warfarin should be educated about maintaining a
consistent intake of vitamin K, as it is necessary for the clotting
cascade, and warfarin works by inhibiting the effects of vitamin
K, thereby reducing the blood’s ability to clot. Sudden increases
in vitamin K intake can decrease the effectiveness of warfarin
and increase the risk of clot formation. Clients should also be
advised to report any incidents of diarrhea (A) since it can affect
the absorption of the medication and potentially lead to unstable
anticoagulation levels. Using a straight razor (C) is not advised
due to the increased risk of bleeding; a safety razor or electric
razor would be safer alternatives. Taking aspirin for pain relief
(D) is not recommended without a physician’s approval because
aspirin can increase the risk of bleeding when taken with an
, anticoagulant. Monitoring for signs of bleeding (E), checking
blood pressure regularly (F), and informing all healthcare
providers about anticoagulant therapy (G) are also important
instructions for a patient on warfarin therapy, but avoiding foods
high in vitamin K is directly related to the effectiveness of the
anticoagulant medication and is thus the priority teaching point.
3. 3. Question
1 point(s)
Category: Reduction of Risk Potential
In 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?
o A. Leaving the hair intact
o B. Shaving the area
o C. Clipping the hair in the area
o D. Removing the hair with a depilatory
o E. Applying a small amount of water-soluble gel to tame
the hair without cutting
o F. Use a sterile surgical scalpel to trim the hair as close to
the skin as possible without causing abrasions
Incorrect
Correct Answer: C. Clipping the hair in the area
Clipping is preferred over shaving in this scenario because it
reduces the potential for creating microabrasions that can
increase infection risk, which is especially important in a patient
with sensitive skin. Chemical depilatories (D) are not
recommended due to the patient’s history of allergies and
sensitive skin. Leaving the hair intact (A) could interfere with the
securement of the I.V. and increase the risk of infection. Water-
1. 1. Question
1 point(s)
Category: Pharmacological and Parenteral Therapies
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?
o A. Decrease in arterial oxygen saturation (SaO2) when
measured with a pulse oximeter
o B. Increase in systemic blood pressure
o C. Presence of premature ventricular contractions
(PVCs) on a cardiac monitor
o D. Increase in intracranial pressure (ICP)
o E. A drop in serum potassium levels as indicated in the
latest lab results
o F. Observation of a widening QRS complex on the
ECG
Incorrect
Correct Answer: C. Presence of premature ventricular
contractions (PVCs) on a cardiac monitor.
In the context of acute myocardial infarction, the priority is to
manage life-threatening arrhythmias. Lidocaine is specifically
indicated for the treatment of ventricular arrhythmias, such as
PVCs, which can be indicative of an increased risk for more
serious arrhythmias like ventricular tachycardia or ventricular
fibrillation. The presence of PVCs on a cardiac monitor would be
the most immediate concern that lidocaine can address in this
scenario. While the other factors listed are important to monitor,
, they are not the primary indications for lidocaine administration
in the context of arrhythmia management.
2. 2. Question
1 point(s)
Category: Pharmacological and Parenteral Therapies
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?
o A. Report incidents of diarrhea
o B. Avoid foods high in vitamin K
o C. Use a straight razor when shaving
o D. Take aspirin for pain relief
o E. Monitor for signs of bleeding, such as bruising or black
tarry stools
o F. Check blood pressure regularly at home
o G. Inform all healthcare providers about the anticoagulant
therapy
Incorrect
Correct Answer: B. Avoid foods high in vitamin K
Clients taking warfarin should be educated about maintaining a
consistent intake of vitamin K, as it is necessary for the clotting
cascade, and warfarin works by inhibiting the effects of vitamin
K, thereby reducing the blood’s ability to clot. Sudden increases
in vitamin K intake can decrease the effectiveness of warfarin
and increase the risk of clot formation. Clients should also be
advised to report any incidents of diarrhea (A) since it can affect
the absorption of the medication and potentially lead to unstable
anticoagulation levels. Using a straight razor (C) is not advised
due to the increased risk of bleeding; a safety razor or electric
razor would be safer alternatives. Taking aspirin for pain relief
(D) is not recommended without a physician’s approval because
aspirin can increase the risk of bleeding when taken with an
, anticoagulant. Monitoring for signs of bleeding (E), checking
blood pressure regularly (F), and informing all healthcare
providers about anticoagulant therapy (G) are also important
instructions for a patient on warfarin therapy, but avoiding foods
high in vitamin K is directly related to the effectiveness of the
anticoagulant medication and is thus the priority teaching point.
3. 3. Question
1 point(s)
Category: Reduction of Risk Potential
In 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?
o A. Leaving the hair intact
o B. Shaving the area
o C. Clipping the hair in the area
o D. Removing the hair with a depilatory
o E. Applying a small amount of water-soluble gel to tame
the hair without cutting
o F. Use a sterile surgical scalpel to trim the hair as close to
the skin as possible without causing abrasions
Incorrect
Correct Answer: C. Clipping the hair in the area
Clipping is preferred over shaving in this scenario because it
reduces the potential for creating microabrasions that can
increase infection risk, which is especially important in a patient
with sensitive skin. Chemical depilatories (D) are not
recommended due to the patient’s history of allergies and
sensitive skin. Leaving the hair intact (A) could interfere with the
securement of the I.V. and increase the risk of infection. Water-
