NCLEX
Answer & Rationale
NCLE
,NCLEX
“BRAIN BUSTER” QUESTION
A client who is diagnosed with congestive heart failure
is scheduled to receive an intravenous push (IVP) dose
of furosemide, 40 mg. As the nurse reviews the client’s
morning labs, the following results are noted:
Na+ 135 mEq/L; K+ 3.1 mEq/L; Ca + 8.5 mg/dL; and
Mg+ 2.1 mg/dL. Which lab result should be
reported to the provider immediately?
Na+
K+
Ca+
Mg+
Answer & Rationale
• Ask: Lab results to report immediately
• Problem: Heart failure with scheduled furosemide IV push
• Solution: Remember furosemide leaves the body dry. Low fluid (because it makes
you pee) and we lose potassium so this will decrease the potassium
even further.
1. Incorrect - Na+ level of 135 mEq/L is within normal limits
3. Correct - K+ level of 3.1 mEq/L already low; furosemide is K+ wasting & will
further deplete potassium levels.
3. Incorrect - Ca+ level of 8.5 mg/dL is within normal limits
4. Incorrect - Mg+ level of 2.1 mg/dL is within normal limits
,NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides care for a client who is recovering
from an acute myocardial infarction (MI). The
client’s cardiac rhythm indicates a rate of 180
beats/minute with monomorphic, wide QRS
complexes. Which rhythm does the nurse
identify based on the current data?
Bundle branch block
Sinus tachycardia
Ventricular pacing
Ventricular tachycardia
Answer & Rationale
• Ask: Which cardiac rhythm
• Problem: Heart rate of 180 beats/min with wide QRS after MI
• Solution: Name the rhythm…Think about it - the rate is fast and it has something to do with
the ventricles because the QRS complexes are wide and monomorphic
1. Incorrect - A bundle branch block is a QRS complex that is wider than 0.12 seconds.
2. Incorrect - Sinus tach is regular, normal & upright P waves before each QRS, rate faster
than 100 beats BPM, QRS complexes and PR intervals are WNL
3. Incorrect - Ventricular pacing is a rhythm in which pacer spikes are noted before each
QRS complex.
4. Correct - Ventricular tachycardia has a rapid rate and wide QRS complexes that
are greater than 0.12 seconds.
, NCLEX
“BRAIN BUSTER” QUESTION
A client newly transferred to the unit presents
with a rapidly declining respiratory status
after becoming septic. Which assessment
finding requires the nurse to contact the
healthcare provider (HCP)?
See below for nurse’s notes.
Crackles in both lung bases
A decline in PaCO2
Hypoxemia unresponsive to treatment
Temperature 102* (38.9*C)
Answer & Rationale
• Ask: Findings requiring HCP notification
• Problem: Sepsis with respiratory decline, decreasing PaO2, & increasing CO2
• Solution: Think about findings to share with the HCP that leads to the worst
possible outcome. Consider hypoxia
1. Incorrect - Crackles are expected in acute respiratory syndrome and would not require
contacting the HCP.
2. Incorrect - The decline in PaCO2 is a positive finding thus does not require HCP notification
3. Correct - Hypoxemia that does not respond to treatment is the hallmark sign of
acute respiratory syndrome and has a high mortality rate.
4. Incorrect - A temperature of 102 F is an expected finding for a client who is diagnosed
with sepsis and does not need to be reported to the HCP.
Answer & Rationale
NCLE
,NCLEX
“BRAIN BUSTER” QUESTION
A client who is diagnosed with congestive heart failure
is scheduled to receive an intravenous push (IVP) dose
of furosemide, 40 mg. As the nurse reviews the client’s
morning labs, the following results are noted:
Na+ 135 mEq/L; K+ 3.1 mEq/L; Ca + 8.5 mg/dL; and
Mg+ 2.1 mg/dL. Which lab result should be
reported to the provider immediately?
Na+
K+
Ca+
Mg+
Answer & Rationale
• Ask: Lab results to report immediately
• Problem: Heart failure with scheduled furosemide IV push
• Solution: Remember furosemide leaves the body dry. Low fluid (because it makes
you pee) and we lose potassium so this will decrease the potassium
even further.
1. Incorrect - Na+ level of 135 mEq/L is within normal limits
3. Correct - K+ level of 3.1 mEq/L already low; furosemide is K+ wasting & will
further deplete potassium levels.
3. Incorrect - Ca+ level of 8.5 mg/dL is within normal limits
4. Incorrect - Mg+ level of 2.1 mg/dL is within normal limits
,NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides care for a client who is recovering
from an acute myocardial infarction (MI). The
client’s cardiac rhythm indicates a rate of 180
beats/minute with monomorphic, wide QRS
complexes. Which rhythm does the nurse
identify based on the current data?
Bundle branch block
Sinus tachycardia
Ventricular pacing
Ventricular tachycardia
Answer & Rationale
• Ask: Which cardiac rhythm
• Problem: Heart rate of 180 beats/min with wide QRS after MI
• Solution: Name the rhythm…Think about it - the rate is fast and it has something to do with
the ventricles because the QRS complexes are wide and monomorphic
1. Incorrect - A bundle branch block is a QRS complex that is wider than 0.12 seconds.
2. Incorrect - Sinus tach is regular, normal & upright P waves before each QRS, rate faster
than 100 beats BPM, QRS complexes and PR intervals are WNL
3. Incorrect - Ventricular pacing is a rhythm in which pacer spikes are noted before each
QRS complex.
4. Correct - Ventricular tachycardia has a rapid rate and wide QRS complexes that
are greater than 0.12 seconds.
, NCLEX
“BRAIN BUSTER” QUESTION
A client newly transferred to the unit presents
with a rapidly declining respiratory status
after becoming septic. Which assessment
finding requires the nurse to contact the
healthcare provider (HCP)?
See below for nurse’s notes.
Crackles in both lung bases
A decline in PaCO2
Hypoxemia unresponsive to treatment
Temperature 102* (38.9*C)
Answer & Rationale
• Ask: Findings requiring HCP notification
• Problem: Sepsis with respiratory decline, decreasing PaO2, & increasing CO2
• Solution: Think about findings to share with the HCP that leads to the worst
possible outcome. Consider hypoxia
1. Incorrect - Crackles are expected in acute respiratory syndrome and would not require
contacting the HCP.
2. Incorrect - The decline in PaCO2 is a positive finding thus does not require HCP notification
3. Correct - Hypoxemia that does not respond to treatment is the hallmark sign of
acute respiratory syndrome and has a high mortality rate.
4. Incorrect - A temperature of 102 F is an expected finding for a client who is diagnosed
with sepsis and does not need to be reported to the HCP.
