Page 1 of 210
“EXAM 4 NCLEX QUESTIONS PRACTICE BURNS
CHAPTER 25 BURNS 2026 ”LATEST EXAM 2026
– 2027 SOLVED QUESTIONS & ANSWERS
VERIFIED 100% GRADED A+ (LATEST VERSION)
WELL REVISED 100% GUARANTEE PASS
Exam 4 NCLEX questions
The RN is caring for a patient with a hypertensive crisis who is receiving
sodium nitroprusside (Nipride). Which of the following nursing actions can the
nurse delegate to an experienced LPN/LVN?
a. Titrate nitroprusside to maintain BP at 160/100 mm Hg.
b. Evaluate effectiveness of nitroprusside therapy on BP.
c. Set up the automatic blood pressure machine to take BP every 15 minutes.
d. Assess the patient's environment for adverse stimuli that might increase
BP.
ANS: C
LPN/LVN education and scope of practice include correct use of common equipment
such as automatic blood pressure machines. The other actions require more nursing
judgment and education and should be done by RNs.
Which assessment finding for a patient who is receiving furosemide (Lasix) to
treat stage 2 hypertension is most important to report to the health care
provider?
a. Blood glucose level of 180 mg/dL
b. Blood potassium level of 3.0 mEq/L
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c. Early morning BP reading of 164/96 mm Hg
d. Orthostatic systolic BP decrease of 12 mm Hg
ANS: B
Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-
threatening dysrhythmias. The health care provider should be notified of the
potassium level immediately and administration of potassium supplements initiated.
The elevated blood glucose and BP also indicate a need for collaborative
interventions but will not require action as urgently as the hypokalemia. An
orthostatic drop of 12 mm Hg is common and will require intervention only if the
patient is symptomatic.
The charge nurse observes a new RN doing discharge teaching for a
hypertensive patient who has a new prescription for enalapril (Vasotec). The
charge nurse will need to intervene if the new RN tells the patient to
a. check the BP with a home BP monitor every day.
b. move slowly when moving from lying to standing.
c. increase the dietary intake of high-potassium foods.
d. make an appointment with the dietitian for teaching.
ANS: C
The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a
possible adverse effect. The other teaching by the new RN is appropriate for a
patient with newly diagnosed hypertension who has just started therapy with
enalapril.
Which nursing action should the nurse take first in order to assist a patient
with newly diagnosed stage 1 hypertension in making needed dietary
changes?
a. Have the patient record dietary intake for 3 days.
b. Give the patient a detailed list of low-sodium foods.
c. Teach the patient about foods that are high in sodium.
d. Help the patient make an appointment with a dietitian.
ANS: A
The initial nursing action should be assessment of the patient's baseline dietary
intake through a 3-day food diary. The other actions may be appropriate, but
assessment of the patient's baseline should occur first.
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A client is taking clonidine (Catapres) for treatment of hypertension. The nurse
should teach the client about which of the following common adverse effects
of this drug? Select all that apply.
1. Dry mouth.
2. Hyperkalemia.
3. Impotence.
4. Pancreatitis.
5. Sleep disturbance.
1, 3, 5.
Clonidine (Catapres) is a central-acting adrenergic antagonist. It reduces
sympathetic outflow from the central nervous system. Dry mouth, impotence, and
sleep disturbances are possible adverse effects. Hyperkalemia and pancreatitis are
not anticipated with use of this drug.
Metoprolol (Toprol XL) is added to the pharmacologic therapy of a diabetic
female diagnosed with stage 2 hypertension initially treated with Furosemide
(Lasix) and Ramipril (Altace). An expected therapeutic effect is:
1. Decrease in heart rate.
2. Lessening of fatigue.
3. Improvement in blood sugar levels.
4. Increase in urine output.
1.
The effect of a beta blocker is a decrease in heart rate, contractility, and afterload,
which leads to a decrease in blood pressure. The client at first may have an increase
in fatigue when starting the beta blocker. The mechanism of action does not improve
blood sugar or urine output.
In teaching the hypertensive client to avoid orthostatic hypotension, the nurse
should emphasize which of the following instructions? Select all that apply.
1. Plan regular times for taking medications.
2. Arise slowly from bed.
3. Avoid standing still for long periods.
4. Avoid excessive alcohol intake.
5. Avoid hot baths.
2, 3.
Changing positions slowly and avoiding long periods of standing may limit the
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occurrence of orthostatic hypotension. Scheduling regular medication times is
important for blood pressure management but this aspect is not related to the
development of orthostatic hypotension. Excessive alcohol intake and hot baths are
associated with vasodilation.
An industrial health nurse at a large printing plant finds a male employee's
blood pressure to be elevated on two occasions 1 month apart and refers him
to his private physician. The employee is about 25 lb overweight and has
smoked a pack of cigarettes daily for more than 20 years. The client's
physician prescribes atenolol (Tenormin) for the hypertension. The nurse
should instruct the client to:
1. Avoid sudden discontinuation of the drug.
2. Monitor the blood pressure annually.
3. Follow a 2-g sodium diet.
4. Discontinue the medication if severe headaches develop.
1.
Atenolol is a beta-adrenergic antagonist indicated for management of hypertension.
Sudden discontinuation of this drug is dangerous because it may exacerbate
symptoms. The medication should not be discontinued without a physician's order.
Blood pressure needs to be monitored more frequently than annually in a client who
is newly diagnosed and treated for hypertension. Clients are not usually placed on a
2-g sodium diet for hypertension.
The nurse teaches a client, who has recently been diagnosed with
hypertension, about dietary restrictions: a low-calorie, low-fat, low-sodium
diet. Which of the following menu selections would best meet the client's
needs?
1. Mixed green salad with blue cheese dressing, crackers, and cold cuts.
2. Ham sandwich on rye bread and an orange.
3. Baked chicken, an apple, and a slice of white bread.
4. Hot dogs, baked beans, and celery and carrot sticks.
3.
Processed and cured meat products, such as cold cuts, ham, and hot dogs, are all
high in both fat and sodium and should be avoided on a low-calorie, low-fat, low-salt
diet. Dietary restrictions of all types are complex and difficult to implement with
clients who are basically asymptomatic.
“EXAM 4 NCLEX QUESTIONS PRACTICE BURNS
CHAPTER 25 BURNS 2026 ”LATEST EXAM 2026
– 2027 SOLVED QUESTIONS & ANSWERS
VERIFIED 100% GRADED A+ (LATEST VERSION)
WELL REVISED 100% GUARANTEE PASS
Exam 4 NCLEX questions
The RN is caring for a patient with a hypertensive crisis who is receiving
sodium nitroprusside (Nipride). Which of the following nursing actions can the
nurse delegate to an experienced LPN/LVN?
a. Titrate nitroprusside to maintain BP at 160/100 mm Hg.
b. Evaluate effectiveness of nitroprusside therapy on BP.
c. Set up the automatic blood pressure machine to take BP every 15 minutes.
d. Assess the patient's environment for adverse stimuli that might increase
BP.
ANS: C
LPN/LVN education and scope of practice include correct use of common equipment
such as automatic blood pressure machines. The other actions require more nursing
judgment and education and should be done by RNs.
Which assessment finding for a patient who is receiving furosemide (Lasix) to
treat stage 2 hypertension is most important to report to the health care
provider?
a. Blood glucose level of 180 mg/dL
b. Blood potassium level of 3.0 mEq/L
, Page 2 of 210
c. Early morning BP reading of 164/96 mm Hg
d. Orthostatic systolic BP decrease of 12 mm Hg
ANS: B
Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-
threatening dysrhythmias. The health care provider should be notified of the
potassium level immediately and administration of potassium supplements initiated.
The elevated blood glucose and BP also indicate a need for collaborative
interventions but will not require action as urgently as the hypokalemia. An
orthostatic drop of 12 mm Hg is common and will require intervention only if the
patient is symptomatic.
The charge nurse observes a new RN doing discharge teaching for a
hypertensive patient who has a new prescription for enalapril (Vasotec). The
charge nurse will need to intervene if the new RN tells the patient to
a. check the BP with a home BP monitor every day.
b. move slowly when moving from lying to standing.
c. increase the dietary intake of high-potassium foods.
d. make an appointment with the dietitian for teaching.
ANS: C
The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a
possible adverse effect. The other teaching by the new RN is appropriate for a
patient with newly diagnosed hypertension who has just started therapy with
enalapril.
Which nursing action should the nurse take first in order to assist a patient
with newly diagnosed stage 1 hypertension in making needed dietary
changes?
a. Have the patient record dietary intake for 3 days.
b. Give the patient a detailed list of low-sodium foods.
c. Teach the patient about foods that are high in sodium.
d. Help the patient make an appointment with a dietitian.
ANS: A
The initial nursing action should be assessment of the patient's baseline dietary
intake through a 3-day food diary. The other actions may be appropriate, but
assessment of the patient's baseline should occur first.
, Page 3 of 210
A client is taking clonidine (Catapres) for treatment of hypertension. The nurse
should teach the client about which of the following common adverse effects
of this drug? Select all that apply.
1. Dry mouth.
2. Hyperkalemia.
3. Impotence.
4. Pancreatitis.
5. Sleep disturbance.
1, 3, 5.
Clonidine (Catapres) is a central-acting adrenergic antagonist. It reduces
sympathetic outflow from the central nervous system. Dry mouth, impotence, and
sleep disturbances are possible adverse effects. Hyperkalemia and pancreatitis are
not anticipated with use of this drug.
Metoprolol (Toprol XL) is added to the pharmacologic therapy of a diabetic
female diagnosed with stage 2 hypertension initially treated with Furosemide
(Lasix) and Ramipril (Altace). An expected therapeutic effect is:
1. Decrease in heart rate.
2. Lessening of fatigue.
3. Improvement in blood sugar levels.
4. Increase in urine output.
1.
The effect of a beta blocker is a decrease in heart rate, contractility, and afterload,
which leads to a decrease in blood pressure. The client at first may have an increase
in fatigue when starting the beta blocker. The mechanism of action does not improve
blood sugar or urine output.
In teaching the hypertensive client to avoid orthostatic hypotension, the nurse
should emphasize which of the following instructions? Select all that apply.
1. Plan regular times for taking medications.
2. Arise slowly from bed.
3. Avoid standing still for long periods.
4. Avoid excessive alcohol intake.
5. Avoid hot baths.
2, 3.
Changing positions slowly and avoiding long periods of standing may limit the
, Page 4 of 210
occurrence of orthostatic hypotension. Scheduling regular medication times is
important for blood pressure management but this aspect is not related to the
development of orthostatic hypotension. Excessive alcohol intake and hot baths are
associated with vasodilation.
An industrial health nurse at a large printing plant finds a male employee's
blood pressure to be elevated on two occasions 1 month apart and refers him
to his private physician. The employee is about 25 lb overweight and has
smoked a pack of cigarettes daily for more than 20 years. The client's
physician prescribes atenolol (Tenormin) for the hypertension. The nurse
should instruct the client to:
1. Avoid sudden discontinuation of the drug.
2. Monitor the blood pressure annually.
3. Follow a 2-g sodium diet.
4. Discontinue the medication if severe headaches develop.
1.
Atenolol is a beta-adrenergic antagonist indicated for management of hypertension.
Sudden discontinuation of this drug is dangerous because it may exacerbate
symptoms. The medication should not be discontinued without a physician's order.
Blood pressure needs to be monitored more frequently than annually in a client who
is newly diagnosed and treated for hypertension. Clients are not usually placed on a
2-g sodium diet for hypertension.
The nurse teaches a client, who has recently been diagnosed with
hypertension, about dietary restrictions: a low-calorie, low-fat, low-sodium
diet. Which of the following menu selections would best meet the client's
needs?
1. Mixed green salad with blue cheese dressing, crackers, and cold cuts.
2. Ham sandwich on rye bread and an orange.
3. Baked chicken, an apple, and a slice of white bread.
4. Hot dogs, baked beans, and celery and carrot sticks.
3.
Processed and cured meat products, such as cold cuts, ham, and hot dogs, are all
high in both fat and sodium and should be avoided on a low-calorie, low-fat, low-salt
diet. Dietary restrictions of all types are complex and difficult to implement with
clients who are basically asymptomatic.
