NCLEX Questions and answers correct and verified 100%

NCLEX Questions and answers correct and verified 100%NCLEX Questions and answers correct and verified 100% 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 answers-1. Increase in Forced Vital Capacity (FVC) Forced Vital Capacity is the volume of air exhaled from full inhalation to full exhalation. A patient with COPD would have a decrease in FVC. Incorrect. 2. A narrowed chest cavity A patient with COPD often presents with a 'barrel chest,' which is seen as a widened chest cavity. Incorrect. 3. Clubbed fingers - CORRECT Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels. 4. An increased risk of cardiac failure Although a patient with these conditions would indeed be at an increased risk for cardiac failure, this is a potential complication and not an assessment finding. Incorrect. 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 answers-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. 2. Nausea Nausea may be present, but is a generalized symptom and by itself doesn't indicate a Duodenal Ulcer. Incorrect. 3. Hernia A Hernia is a protrusion of a segment of the abdomen through another abdominal structure. It is not associated with an Ulcer and is a condition, not an assessment finding. Incorrect. 4. Hyperthermia Hyperthermia, a high temperature, is not an assessment finding of a Duodenal Ulcer. Incorrect 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 answers-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. 2. "I'm going to make sure to remain upright after meals and elevate my head when I sleep" Incorrect - This is a correct verbalization of health promotion for GERD. 3. "I won't be drinking tea or coffee or eating chocolate any more." Incorrect - This is a correct verbalization of health promotion for GERD. 4. "I'm going to start trying to lose some weight." Incorrect - This is a correct verbalization of health promotion for GERD. 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 answers-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. 2. Ask the patient for a stool sample Incorrect - While this is useful in the diagnosis and assessment of Peptic Ulcer Disease, it is not the priority intervention. 3. Prepare to insert an NG Tube Incorrect - While this intervention may be used in the later stages of Peptic Ulcer Disease, it is not the first and priority intervention. 4. Administer intramuscular morphine sulphate as ordered Incorrect - While this is an important intervention to manage pain, it is not the priority intervention. 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 answers-1. Hemoglobin 11 g/dl This is below normal, but a normal female hemoglobin is 12-14. There is a more critical lab result. 2. Platelet of 150,000 This is also below the normal values, but is not the most critical lab result. 3. INR of 2.5 This is a therapeutic range for a patient who is taking an anticoagulant for atrial fibrillation 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 answers-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. 2. Notify Physician This is not the first action the nurse should take. 3. Elevate the patient's legs This would help with the edema, but is not a priority 4. Continue the infusion, since these are normal findings This is not a normal finding 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 answers-1. They must inform household members of their condition Incorrect - Each patient has a right to privacy of their medical condition. It is their choice whether they inform household members. 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. 3. They must abstain from substance use Incorrect - While substance use should be discouraged, using safe practices with needles can prevent transmission of HIV. 4. They must avoid large crowds Incorrect - Avoiding large crowds to prevent infection is a priority in the later stages of HIV, when the patient has AIDS. 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 answers-1. Initiate cardiopulmonary resuscitation Incorrect - CPR is premature at this point, and there is another action that can be taken first. 2. Check for a pulse This is the first step when assessing for initiation of CPR, but CPR is not the best and first course of action for this situation. The woman is still breathing, which means CPR is not necessary at this time. 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. 3. Stay with the woman until help comes Incorrect - While this should be done, it's not the best and first course of action. 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 answers-1. The patient states he had a manic episode a week ago Incorrect - Having a manic episode is not an indication of lithium toxicity. This finding indicates that the lithium is not effective or is not at a therapeutic level. 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. 3. The patient has a rashy pruritis on his arms and legs Incorrect - This is not a symptom of lithium toxicity 4. The patient presents as severely depressed Incorrect - Having a depressive episode is not an indication of lithium toxicity. This finding indicates that the lithium is not effective or is not at a therapeutic level. 5. The patient's lithium level is 1.3 mcg/L This is within the therapeutic range of lithium 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 side effect of Flomax? 1. Hypotension 2. Tachycardia 3. Back Pain 4. Difficulty Urinating - correct answers-1. Hypotension Correct - Hypotension can lead to dizziness and a risk for injury to the patient. 2. Tachycardia Tachycardia can be a side effect of Flomax, but is not an immediate safety risk, nor is it a common side effect. 3. Back Pain Back Pain can be a side effect of Floma, but is not a safety risk 4. Difficulty Urinating Dysuria is a symptom of Benign Prostatic Hyperplasia, not a side effect of Flomax A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin? 1. Back Pain 2. Fever and Chills 3. Risk for Bleeding 4. Dizziness - correct answers-1. Back Pain Incorrect - Back pain, while it can occur, is not an immediate concern 2. Fever and Chills Incorrect - Fever and Chills, while it can occur, is not an immediate concern 3. Risk for Bleeding Correct - A confused patient is at risk for injuring themselves and at risk for hemorrhage should an injury occur 4. Dizziness Incorrect - Dizziness is not a side effect of Heparin A female patient is prescribed metformin for glucose control. The patient is on NPO status pending a diagnostic test. The nurse is most concerned about which side effect of metformin? 1. Diarrhea and Vomiting 2. Dizziness and Drowsiness 3. Metallic taste 4. Hypoglycemia - correct answers-1. Diarrhea and Vomiting Incorrect - While these may occur, the patient is at higher risk for another adverse effect. 2. Dizziness and Drowsiness Incorrect - While these may occur, the patient is at higher risk for another adverse effect. 3. Metallic taste Incorrect - While this may occur, the patient is at higher risk for another adverse effect. 4. Hypoglycemia Correct - The patient is at risk because she is on NPO status and continuing to take an anti-glycemic drug. The nurse is reviewing the lab results of a patient taking lithium for schizoaffective disorder. The lab results show that the blood lithium value is 1.7 mcg/L. What would the nurse take as the priority action? 1. Induce vomiting 2. Hold the next dose of Lithium 3. Administer an anti-emetic 4. Give the next dose of Lithium - correct answers-1. Induce vomiting Incorrect - This may be warranted for a severe lithium toxicity, but would be premature at this point. Gastric lavage may be attempted if the patient presents within one hour of ingestion, and fluids will be given to restore kidney function and promote the clearance of Lithium from the body.. 2. Hold the next dose of Lithium Correct - Lithium's therapeutic range is 0.5-1.5mcg/L, and begins toxicity at 1.5mcg/L 3. Administer an anti-emetic Incorrect - While minor toxicity can cause vomiting and nausea, this is not a priority action 4. Give the next dose of Lithium Incorrect - Lithium's therapeutic range is 0.5-1.5mcg/L, and begins toxicity at 1.5mcg/L A patient asks the nurse why they must have a heparin injection. What is the nurse's best response? 1. "Heparin will dissolve clots that you have." 2. "Heparin will reduce the platelets that make your blood clot" 3. "Heparin will work better than warfarin." 4. "Heparin will prevent new clots from developing." - correct answers-1. "Heparin will dissolve clots that you have." Incorrect - Heparin does not do this. 2. "Heparin will reduce the platelets that make your blood clot" Incorrect - Heparin does not do this 3. "Heparin will work better than warfarin." Incorrect - Heparin has a different mechanism of action than warfarin, and a different route of administration, but achieve similar results. 4. "Heparin will prevent new clots from developing." Correct -This is a correct statement. The nurse is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the troponin T value is at 5.3 ng/mL. Which of these interventions, if not completed already, would take priority over the others? 1. Put the patient in a 90 degree position 2. Check whether the patient is taking diuretics 3. Obtain and attach defibrillator leads 4. Check the patient's last ejection fraction - correct answers-1. Put the patient in a 90 degree position Incorrect - This position is optimal for helping a patient breathe, but is not the priority action in an emergency situation. 2. Check whether the patient is taking diuretics Incorrect - Diuretics play a role in CHF by decreasing fluid volume, but this patient is likely having an acute myocardial infarction. 3. Obtain and attach defibrillator leads Correct - This patient is undergoing an emergency cardiac event. Normal Troponin T levels are less than 0.2 ng/mL. Ventricular Fibrillation is the cause of death in most cases of deaths due to sudden cardiac arrest. Defibrillation is the most important action to take to prevent death. 4. Check the patient's last ejection fraction Incorrect - Ejection fraction is a test used to gauge the severity of CHF, not an emergency cardiac arrest. A nurse is caring for a patient undergoing a stress test on a treadmill. The patient turns to talk to the nurse. Which of these statements would require the most immediate intervention? 1. "I'm feeling extremely thirsty. I'm going to get some water after this." 2. "I can feel my heart racing." 3. "My shoulder and arm is hurting." 4. "My blood pressure reading is 158/80" - correct answers-1. "I'm feeling extremely thirsty. I'm going to get some water after this." Incorrect - This does not require immediate intervention. This is a common response to exercise and activity. 2. "I can feel my heart racing." Incorrect - This does not require immediate intervention. This is a common response to exercise and activity. 3. "My shoulder and arm is hurting." Correct - Unilateral arm and shoulder pain is one of the classic symptoms of myocardial ischemia. The stress test should be halted. 4. "My blood pressure reading is 158/80" Incorrect - This does not require immediate intervention. Moderate elevation in blood pressure is a common response to exercise and activity. The nurse is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the BNP (B-type Natriuretic Peptide) value is a 615 pg/ml. What would the nurse take as the priority action? 1. Call a cardiac code and implement emergency measures 2. Check the patient's oxygen saturation 3. Inform the physician that the patient has Congestive Heart Failure Encourage the patient to limit activity - correct answers-1. Call a cardiac code and implement emergency measures Incorrect - There is no evidence that the patient is undergoing a cardiac arrest. 2. Check the patient's oxygen saturation Correct - An elevated BNP indicates that there is decreased cardiac output. A priority intervention would be to ensure proper oxygenation after an assessment. 3. Inform the physician that the patient has Congestive Heart Failure Incorrect - Although BNP suggests Congestive Heart Failure, it is not used in itself to diagnose CHF. An elevated BNP can also be caused by dysrhythmias or renal disease. 4. Encourage the patient to limit activity Incorrect - This is an intervention that can help treat CHF, but not a priority action at this time. A nurse is caring for a patient after a coronary angiogram. Which of these actions taken by the nursing