NCLEX FULL FINAL ACTUAL REAL EXAM - COMPLETE 300
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES | (VERIFIED ANSWERS) | ALREADY GRADED
A+||BRAND NEW VERSION!!
NCLEX
1. A 38-year-old female is brought to the Emergency Department with complaints
of her "heart beating out of her chest". She is diaphoretic, tachypneic and her
BP is 70/40. The cardiac monitor shows supraventricular tachycardia. Valsalva
maneuvers and three doses of Adenosine have not been successful. The nurse
should immediately:
a.) prepare the patient for synchronized cardioversion.
b.) give Epinephrine 1 mg IV and repeat in 3 minutes.
c.) give Adenosine 6 mg IV per protocol.
d.) perform unilateral carotid massage. - - ANS - -a.) prepare the patient
for synchronized cardioversion.
2. A patient arrives at the emergency department complaining of mid-sternal
chest pain. Which of the following nursing action should take priority?
A. A complete history with emphasis on preceding events.
B. An electrocardiogram.
C. Careful assessment of vital signs.
D. Chest exam with auscultation. - - ANS - -Answer: C
, The priority nursing action for a patient arriving at the ED in distress is always
assessment of vital signs. This indicates the extent of physical compromise and
provides a baseline by which to plan further assessment and treatment. A
thorough medical history, including onset of symptoms, will be necessary and it
is likely that an electrocardiogram will be performed as well, but these are not
the first priority. Similarly, chest exam with auscultation may offer useful
information after vital signs are assessed.
3. A nurse is caring for a patient who has had hip replacement. The nurse should
be most concerned about which of the following findings?
A. Complaints of pain during repositioning.
B. Scant bloody discharge on the surgical dressing.
C. Complaints of pain following physical therapy.
D. Temperature of 101.8 F (38.7 C). - - ANS - -Answer: D
Post-surgical nursing assessment after hip replacement should be principally
concerned with the risk of neurovascular complications and the development
of infection. A temperature of 101.8 F (38.7 C) postoperatively is higher than the
low grade that is to be expected and should raise concern. Some pain during
repositioning and following physical therapy is to be expected and can be
managed with analgesics. A small amount of bloody drainage on the surgical
dressing is a result of normal healing.
4. Emergency department triage is an important nursing function. A nurse
working the evening shift is presented with four patients at the same time.
Which of the following patients should be assigned the highest priority?
, A. A patient with low-grade fever, headache, and myalgias for the
past 72 hours.
B. A patient who is unable to bear weight on the left foot, with
swelling and bruising following a running accident.
C. A patient with abdominal and chest pain following a large, spicy
meal.
D. A child with a one-inch bleeding laceration on the chin but
otherwise well after falling while jumping on his bed. - - ANS -
-Answer: C
Emergency triage involves quick patient assessment to prioritize the need for
further evaluation and care. Patients with trauma, chest pain, respiratory
distress, or acute neurological changes are always classified number one
priority. Though the patient with chest pain presented in the question recently
ate a spicy meal and may be suffering from heartburn, he also may be having
an acute myocardial infarction and require urgent attention. The patient with
fever, headache and muscle aches (classic flu symptoms) should be classified
as non-urgent. The patient with the foot injury may have sustained a sprain or
fracture, and the limb should be x-rayed as soon as is practical, but the
damage is unlikely to worsen if there is a delay. The child's chin laceration may
need to be sutured but is also non-urgent.
5. A nurse cares for a patient who has a nasogastric tube attached to low suction
because of a suspected bowel obstruction. Which of the following arterial blood
gas results might be expected in this patient?
A. pH 7.52, PCO2 54 mm Hg.
B. pH 7.42, PCO2 40 mm Hg.
C. pH 7.25, PCO2 25 mm Hg.
D. pH 7.38, PCO2 36 mm Hg. - - ANS - -Answer: A
, A patient on nasogastric suction is at risk of metabolic alkalosis as a result of
loss of hydrochloric acid in gastric fluid. Of the answers given, only answer A
(pH 7.52, PCO2 54 mm Hg) represents alkalosis. Answer B is a normal blood
gas. Answer C represents respiratory acidosis. Answer D is borderline normal
with slightly low PCO2.
6. A patient is admitted to the emergency department after sustaining abdominal
injuries and a broken femur from a motor vehicle accident. The patient is pale,
diaphoretic, and is not talking coherently. Vital signs upon admission are
temperature 98 F (36 C), heart rate 130 beats/minute, respiratory rate 34
breaths/minute, blood pressure 50/40 mmHg. The healthcare provider suspects
which type of shock?
a.) Hypovolemic
b.) Cardiogenic
c.) Neurogenic
d.) Septic - - ANS - -a.) Hypovolemic
7. The healthcare provider is caring for a patient who has septic shock. Which of
these should the healthcare provider administer to the patient first?
a.) Antibiotics to treat the underlying infection.
b.) Corticosteroids to reduce inflammation.
c.) IV fluids to increase intravascular volume.
d.) Vasopressors to increase blood pressure. - - ANS - -c.) IV fluids to
increase intravascular volume.
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES | (VERIFIED ANSWERS) | ALREADY GRADED
A+||BRAND NEW VERSION!!
NCLEX
1. A 38-year-old female is brought to the Emergency Department with complaints
of her "heart beating out of her chest". She is diaphoretic, tachypneic and her
BP is 70/40. The cardiac monitor shows supraventricular tachycardia. Valsalva
maneuvers and three doses of Adenosine have not been successful. The nurse
should immediately:
a.) prepare the patient for synchronized cardioversion.
b.) give Epinephrine 1 mg IV and repeat in 3 minutes.
c.) give Adenosine 6 mg IV per protocol.
d.) perform unilateral carotid massage. - - ANS - -a.) prepare the patient
for synchronized cardioversion.
2. A patient arrives at the emergency department complaining of mid-sternal
chest pain. Which of the following nursing action should take priority?
A. A complete history with emphasis on preceding events.
B. An electrocardiogram.
C. Careful assessment of vital signs.
D. Chest exam with auscultation. - - ANS - -Answer: C
, The priority nursing action for a patient arriving at the ED in distress is always
assessment of vital signs. This indicates the extent of physical compromise and
provides a baseline by which to plan further assessment and treatment. A
thorough medical history, including onset of symptoms, will be necessary and it
is likely that an electrocardiogram will be performed as well, but these are not
the first priority. Similarly, chest exam with auscultation may offer useful
information after vital signs are assessed.
3. A nurse is caring for a patient who has had hip replacement. The nurse should
be most concerned about which of the following findings?
A. Complaints of pain during repositioning.
B. Scant bloody discharge on the surgical dressing.
C. Complaints of pain following physical therapy.
D. Temperature of 101.8 F (38.7 C). - - ANS - -Answer: D
Post-surgical nursing assessment after hip replacement should be principally
concerned with the risk of neurovascular complications and the development
of infection. A temperature of 101.8 F (38.7 C) postoperatively is higher than the
low grade that is to be expected and should raise concern. Some pain during
repositioning and following physical therapy is to be expected and can be
managed with analgesics. A small amount of bloody drainage on the surgical
dressing is a result of normal healing.
4. Emergency department triage is an important nursing function. A nurse
working the evening shift is presented with four patients at the same time.
Which of the following patients should be assigned the highest priority?
, A. A patient with low-grade fever, headache, and myalgias for the
past 72 hours.
B. A patient who is unable to bear weight on the left foot, with
swelling and bruising following a running accident.
C. A patient with abdominal and chest pain following a large, spicy
meal.
D. A child with a one-inch bleeding laceration on the chin but
otherwise well after falling while jumping on his bed. - - ANS -
-Answer: C
Emergency triage involves quick patient assessment to prioritize the need for
further evaluation and care. Patients with trauma, chest pain, respiratory
distress, or acute neurological changes are always classified number one
priority. Though the patient with chest pain presented in the question recently
ate a spicy meal and may be suffering from heartburn, he also may be having
an acute myocardial infarction and require urgent attention. The patient with
fever, headache and muscle aches (classic flu symptoms) should be classified
as non-urgent. The patient with the foot injury may have sustained a sprain or
fracture, and the limb should be x-rayed as soon as is practical, but the
damage is unlikely to worsen if there is a delay. The child's chin laceration may
need to be sutured but is also non-urgent.
5. A nurse cares for a patient who has a nasogastric tube attached to low suction
because of a suspected bowel obstruction. Which of the following arterial blood
gas results might be expected in this patient?
A. pH 7.52, PCO2 54 mm Hg.
B. pH 7.42, PCO2 40 mm Hg.
C. pH 7.25, PCO2 25 mm Hg.
D. pH 7.38, PCO2 36 mm Hg. - - ANS - -Answer: A
, A patient on nasogastric suction is at risk of metabolic alkalosis as a result of
loss of hydrochloric acid in gastric fluid. Of the answers given, only answer A
(pH 7.52, PCO2 54 mm Hg) represents alkalosis. Answer B is a normal blood
gas. Answer C represents respiratory acidosis. Answer D is borderline normal
with slightly low PCO2.
6. A patient is admitted to the emergency department after sustaining abdominal
injuries and a broken femur from a motor vehicle accident. The patient is pale,
diaphoretic, and is not talking coherently. Vital signs upon admission are
temperature 98 F (36 C), heart rate 130 beats/minute, respiratory rate 34
breaths/minute, blood pressure 50/40 mmHg. The healthcare provider suspects
which type of shock?
a.) Hypovolemic
b.) Cardiogenic
c.) Neurogenic
d.) Septic - - ANS - -a.) Hypovolemic
7. The healthcare provider is caring for a patient who has septic shock. Which of
these should the healthcare provider administer to the patient first?
a.) Antibiotics to treat the underlying infection.
b.) Corticosteroids to reduce inflammation.
c.) IV fluids to increase intravascular volume.
d.) Vasopressors to increase blood pressure. - - ANS - -c.) IV fluids to
increase intravascular volume.
