NCLEX Test Taking Strategy Questions
1. The nurse is providing post-operative care to a craniotomy client. Diabetes insipidus
is suspected when the client’s urine output suddenly increases significantly. Which
action takes highest priority?
o 1. Monitoring urine output
o 2. Checking pulse
o 3. Checking blood pressure
o 4. Assessing level of
consciousness Rationale:
3. Correct: This is the best answer because we are “worried” this client is going into
SHOCK. So…..you better be checking a BP. This is a time where checking the BP is
appropriate. If we “assume the worst” I better check a blood pressure. It could have
dropped out the bottom.
1. Incorrect: Continuing to monitor U/O is important but I need to find out if they are
already shocky.
2. Incorrect: Checking the pulse is a good thing, but, not as important as checking the BP.
4. Incorrect: If my client is going into shock the highest priority is to assess the BP.
2. The client is being treated for fluid volume deficit. Which is an expected
outcome of successful treatment?
o 1. Resolution of orthostatic hypotension
o 2. Maintenance of weight loss
o 3. Compliance with sodium restricted diet
o 4. Maintenance of serum Na above 148
mEq Rationale:
1. Correct: When you are in a fluid volume deficit your blood pressure goes down
when you stand up and it’s called orthostatic hypotension. Successful treatment would
resolve this.
Day 4 1
,2. Incorrect: When I have lost a lot of volume, my weight goes down, so if I am
better, my weight should go up.
3. Incorrect: Who needs to adhere to dietary sodium restrictions? People who are in fluid
volume excess.
4. Incorrect: If your serum sodium is above 148, hypernatremia is the same thing as
dehydration, so this means that you are still sick.
Page 2 of 40
,3. The nurse in the intensive care unit is caring for a client receiving hemodynamic
monitoring. When planning for a client’s care, which nursing diagnoses associated with
hemodynamic monitoring may be utilized by the nurse? Select all that apply.
1. Decreased cardiac output
2. Fluid volume deficit
3. Fluid volume excess
4. Ineffective tissue perfusion
5. Ineffective airway
Rationale:
1., 2., 3. & 4. Correct: Nursing diagnoses, associated with hemodynamic monitoring, that
may be utilized by the nurse include decreased cardiac output, fluid volume deficit, fluid
volume excess, and ineffective tissue perfusion. These nursing diagnoses relate to the
pathophysiologic processes that alter one of the four hemodynamic mechanisms that
support normal cardiovascular function: preload, afterload, heart rate, and contractility.
5. Incorrect: Ineffective Airway would not be associated with hemodynamic monitoring.
4. The nurse is caring for a client that has two IV access sites. One is a 20 gauge antecubital
peripheral IV that was started yesterday for blood and has normal saline (NS) at keep vein
open rate. The other is a double lumen central line catheter with one port for Total
Parental Nutrition and the other is used for blood samples. Where is the best site for the
nurse to administer 20 mEq of potassium chloride (KCL) in 100 mL of normal saline(NS)
over 4 hours?
o 1. Central line port that is being used for lab draws
o 2. Same line with the Total Parental Nutrition
o 3. Large bore antecubital
o 4. Start another peripheral
IV Rationale:
1. Correct: Yes- K is very hard on the veins, give it through the central line.
2. Incorrect: No, never put anything through a line with Total Parental Nutrition.
3. Incorrect: Second best choice- but it will burn.
4. Incorrect: No, a central line is needed.
Day 4 3
, 5. The nurse is caring for a client that has metabolic acidosis secondary to acute renal
failure. What is the initial client response to this problem?
o 1. Respiratory rate increases to blow off acid.
o 2. Respiratory rate decreases to conserve acid and buffer the kidneys response.
o 3. Kidneys will excrete hydrogen and retain bicarb.
o 4. Sodium will shift to cells and buffer the hydrogens.
Rationale:
1. Correct: Yes, acute renal failure causes metabolic acidosis and the body is trying to
breathe faster to blow off some acid. The respiratory response is fast.
2. Incorrect: No, the client’s respiratory rate is fast, not slow.
3. Incorrect: This will happen, later. Did not we say about 48 hours? Not initial response.
4. Incorrect: Sodium is extracellular electrolyte, not an intracellular electrolyte.
6. The client presents to the emergency department with nausea, vomiting and anorexia
for the last few days. An EKG on admission reveals an arrhythmia. Which electrolytes
imbalance is suspected?
o 1. Hypercalcemia
o 2. Hypokalemia
o 3. Hypermagnesemia
o 4. Hyponatremia
Rationale:
2. Correct: The client has been vomiting so the electrolytes losses are potassium,
hydrogen and chloride. The anorexia further complicates the condition because we get
potassium from the foods we eat. The one electrolyte we worry about with arrhythmias is
potassium.
1. Incorrect: What has calcium got to do with nausea and vomiting? Nothing
3. Incorrect: Magnesium is loss through the lower GI tract and Hypermagnesemia is not
related to dysrhythmias.
Page 4 of 40
1. The nurse is providing post-operative care to a craniotomy client. Diabetes insipidus
is suspected when the client’s urine output suddenly increases significantly. Which
action takes highest priority?
o 1. Monitoring urine output
o 2. Checking pulse
o 3. Checking blood pressure
o 4. Assessing level of
consciousness Rationale:
3. Correct: This is the best answer because we are “worried” this client is going into
SHOCK. So…..you better be checking a BP. This is a time where checking the BP is
appropriate. If we “assume the worst” I better check a blood pressure. It could have
dropped out the bottom.
1. Incorrect: Continuing to monitor U/O is important but I need to find out if they are
already shocky.
2. Incorrect: Checking the pulse is a good thing, but, not as important as checking the BP.
4. Incorrect: If my client is going into shock the highest priority is to assess the BP.
2. The client is being treated for fluid volume deficit. Which is an expected
outcome of successful treatment?
o 1. Resolution of orthostatic hypotension
o 2. Maintenance of weight loss
o 3. Compliance with sodium restricted diet
o 4. Maintenance of serum Na above 148
mEq Rationale:
1. Correct: When you are in a fluid volume deficit your blood pressure goes down
when you stand up and it’s called orthostatic hypotension. Successful treatment would
resolve this.
Day 4 1
,2. Incorrect: When I have lost a lot of volume, my weight goes down, so if I am
better, my weight should go up.
3. Incorrect: Who needs to adhere to dietary sodium restrictions? People who are in fluid
volume excess.
4. Incorrect: If your serum sodium is above 148, hypernatremia is the same thing as
dehydration, so this means that you are still sick.
Page 2 of 40
,3. The nurse in the intensive care unit is caring for a client receiving hemodynamic
monitoring. When planning for a client’s care, which nursing diagnoses associated with
hemodynamic monitoring may be utilized by the nurse? Select all that apply.
1. Decreased cardiac output
2. Fluid volume deficit
3. Fluid volume excess
4. Ineffective tissue perfusion
5. Ineffective airway
Rationale:
1., 2., 3. & 4. Correct: Nursing diagnoses, associated with hemodynamic monitoring, that
may be utilized by the nurse include decreased cardiac output, fluid volume deficit, fluid
volume excess, and ineffective tissue perfusion. These nursing diagnoses relate to the
pathophysiologic processes that alter one of the four hemodynamic mechanisms that
support normal cardiovascular function: preload, afterload, heart rate, and contractility.
5. Incorrect: Ineffective Airway would not be associated with hemodynamic monitoring.
4. The nurse is caring for a client that has two IV access sites. One is a 20 gauge antecubital
peripheral IV that was started yesterday for blood and has normal saline (NS) at keep vein
open rate. The other is a double lumen central line catheter with one port for Total
Parental Nutrition and the other is used for blood samples. Where is the best site for the
nurse to administer 20 mEq of potassium chloride (KCL) in 100 mL of normal saline(NS)
over 4 hours?
o 1. Central line port that is being used for lab draws
o 2. Same line with the Total Parental Nutrition
o 3. Large bore antecubital
o 4. Start another peripheral
IV Rationale:
1. Correct: Yes- K is very hard on the veins, give it through the central line.
2. Incorrect: No, never put anything through a line with Total Parental Nutrition.
3. Incorrect: Second best choice- but it will burn.
4. Incorrect: No, a central line is needed.
Day 4 3
, 5. The nurse is caring for a client that has metabolic acidosis secondary to acute renal
failure. What is the initial client response to this problem?
o 1. Respiratory rate increases to blow off acid.
o 2. Respiratory rate decreases to conserve acid and buffer the kidneys response.
o 3. Kidneys will excrete hydrogen and retain bicarb.
o 4. Sodium will shift to cells and buffer the hydrogens.
Rationale:
1. Correct: Yes, acute renal failure causes metabolic acidosis and the body is trying to
breathe faster to blow off some acid. The respiratory response is fast.
2. Incorrect: No, the client’s respiratory rate is fast, not slow.
3. Incorrect: This will happen, later. Did not we say about 48 hours? Not initial response.
4. Incorrect: Sodium is extracellular electrolyte, not an intracellular electrolyte.
6. The client presents to the emergency department with nausea, vomiting and anorexia
for the last few days. An EKG on admission reveals an arrhythmia. Which electrolytes
imbalance is suspected?
o 1. Hypercalcemia
o 2. Hypokalemia
o 3. Hypermagnesemia
o 4. Hyponatremia
Rationale:
2. Correct: The client has been vomiting so the electrolytes losses are potassium,
hydrogen and chloride. The anorexia further complicates the condition because we get
potassium from the foods we eat. The one electrolyte we worry about with arrhythmias is
potassium.
1. Incorrect: What has calcium got to do with nausea and vomiting? Nothing
3. Incorrect: Magnesium is loss through the lower GI tract and Hypermagnesemia is not
related to dysrhythmias.
Page 4 of 40
