75 NCLEX ACTUAL EXAM LATEST UPDATED 2024 QUESTIONS WITH VERIFIED ANSWERS GRADED A+, Exams of Nursing

Download 75 NCLEX ACTUAL EXAM LATEST UPDATED 2024 QUESTIONS WITH VERIFIED ANSWERS GRADED A+ and more Exams Nursing in PDF only on Docsity! 1 75 NCLEX ACTUAL EXAM LATEST UPDATED 2024 QUESTIONS WITH VERIFIED ANSWERS GRADED A+ 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 - solution ✅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 2 3. Hernia 4. Hyperthermia - solution ✅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." - solution ✅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" 5 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 - solution ✅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. 6 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 - solution ✅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 7 5. The patient's lithium level is 1.3 mcg/L - solution ✅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 - solution ✅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. 10 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." - solution ✅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 11 4. Check the patient's last ejection fraction - solution ✅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" - solution ✅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." 12 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 - solution ✅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 assistant would most require the nurse's immediate intervention? 15 1. alprazolam (Xanax) 2. Corticosteroid injection 3. gabapentin (Neurontin) 4. hydrocodone/acetaminophen (Norco) - solution ✅1. alprazolam (Xanax) Incorrect - alprazolam is used to reduce anxiety 2. Corticosteroid injection Incorrect - Corticosteroid injections are used to reduce inflammation in a localized area, often due to joint breakdown. In MS patients it is used to treat acute exacerbations ("flare-ups"), but the symptoms described do not constitute an acute exacerbation. 3. gabapentin (Neurontin) Correct - Anticonvulsants like gabapentin are often the first line of treatment for nerve pain 4. hydrocodone/acetaminophen (Norco) Incorrect - Opioids would not be the appropriate medication to treat nerve pain. Which of these clients is likely to receive sublingual morphine? 1. A 75-year-old woman in a hospice program 2. A 40-year-old man who just had throat surgery 3. A 20-year-old woman with trigeminal neuralgia 4. A 60-year-old man who has a painful incision - solution ✅1. A 75-year-old woman in a hospice program Correct - Sublingual morphine is often used in hospice because the patients are unable to swallow, and intravenous access can be painful and not conducive to palliative care. 2. A 40-year-old man who just had throat surgery Incorrect - Patients who have surgery most likely have an Intravenous line 3. A 20-year-old woman with trigeminal neuralgia 16 Incorrect - Morphine would not be the first choice for nerve pain 4. A 60-year-old man who has a painful incision Incorrect - Although Morphine would be an appropriate medications, there is no indication that it should be administered sublingually In educating clients on ways to manage pain, which topic can be appropriately delegated to a LPN/LVN who will continue under supervision? 1. Acupuncture 2. Guided Imagery 3. Alternating Rest/Activity 4. Over the counter medications - solution ✅1. Acupuncture Incorrect - This is outside the nursing scope of practice and requires special training or education 2. Guided Imagery Incorrect - This also requires additional training or education 3. Alternating Rest/Activity Correct - This is within the nursing scope of practice and within the training and education provided to all nurses. It is safe to use and a standard treatment. 4. Over the counter medications Incorrect - This is outside the nursing scope of practice. A healthcare provider (doctor, nurse practitioner, or physician's assistant) should be consulted before taking over the counter medications. The nurse assesses a patient suspected of having an asthma attack. Which of the following is a common clinical manifestation of this condition? 1. Audible crackles and orthopnea 2. An audible wheeze and use of accessory muscles 17 3. Audible crackles and use of accessory muscles 4. Audible wheeze and orthopnea - solution ✅1. Audible crackles and orthopnea Incorrect - Crackles indicate fluid in the lungs, which is not a cause of asthma. Orthopnea is not associated with asthma. 2. An audible wheeze and use of accessory muscles Correct - Both of these are associated with asthma. 3. Audible crackles and use of accessory muscles Incorrect - Crackles indicate fluid in the lungs, which is not a cause of asthma. 4. Audible wheeze and orthopnea Incorrect - Orthopnea is not associated with asthma. The nurse assesses a patient suspected of having meningitis. Which of the following is a common clinical manifestation of this condition? 1. A high WBC count and decreased level of consciousness 2. A high WBC count and manic activity 3. A low WBC count and manic activity 4. A low WBC count and decreased level of consciousness - solution ✅1. A high WBC count and decreased level of consciousness Correct - Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness. 2. A high WBC count and manic activity Incorrect - Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness. 3. A low WBC count and manic activity 20 2. Ask the patient to increase their fluid intake Incorrect - Increasing oral intake without other interventions will increase risk of increased ICP and fluid overload. 3. Ask the physician to order a diuretic Incorrect - This is premature and would not be the correct intervention. 4. Notify the physician of this finding Correct - Vancomycin is a nephrotoxic drug and can cause impaired renal perfusion, which would cause a decreased urine output. This is a serious adverse effect and should be reported to the physician. A patient is being admitted to the ICU with a severe case of encephalitis. Which of these drugs would the nurse not be expect to be prescribed for this condition? 1. Acyclovir (Zovirax) 2. Mannitol (Osmitrol) 3. Lactated Ringer's 4. Phenytoin (Dilantin) - solution ✅1. Acyclovir (Zovirax) Incorrect- Acyclovir is a common antiviral drug for the treatment of viral encephalitis 2. Mannitol (Osmitrol) Incorrect - Mannitol is a hyperosmolar drug that helps reduce Intracranial Pressure by acting as a diuretic and decreasing fluid in the body. 3. Lactated Ringer's Correct - Lactated Ringer's solution is often used in fluid replacement therapy, which is not warranted if a patient is at risk for high ICP. 4. Phenytoin (Dilantin) Incorrect - Phenytoin is an anticonvulsant and is often used to prevent seizures, which can complicate and worsen a patient's neurological state. 21 The nurse is treating a patient who has Parkinson's Disease. Which of these practices would not be included in the care plan? 1. Decrease the calorie content of daily meals to avoid weight gain 2. Allow the patient extra time to respond to questions and do ADLs 3. Use thickened liquids and a soft diet 4. Encourage the patient to hold the spoon when eating - solution ✅1. Decrease the calorie content of daily meals to avoid weight gain Correct - Calorie content should be increased for patients with Parkinson's Disease because of dysphagia (difficulty swallowing), as well as calories burned due to muscle rigidity. 2. Allow the patient extra time to respond to questions and do ADLs Incorrect - This is a best practice when working with PD patients. 3. Use thickened liquids and a soft diet Incorrect - This is often used to reduce the risk of aspiration 4. Encourage the patient to hold the spoon when eating Incorrect - The patient should be encouraged to perform ADLs as independently as possible. A 45-year old woman is prescribed ropinirole (Requip) for Parkinson's Disease. The patient is living at home with her daughter. The nurse is most concerned about which side effect of ropinirole? 1. Slurred speech 2. Sudden dizziness 3. Masklike facial expression 4. Stooped Posture - solution ✅1. Slurred speech Incorrect - Slurred speech is a common symptom of PD, not a side effect of this drug. 22 2. Sudden dizziness Correct - Dizziness and orthostatic hypotension are serious adverse effects of this drug that can lead to an increased risk of falls. Ropinirole's drug class is a dopamine agonist, which mimic dopamine in the brain (PD is characterized by a lack of dopamine). 3. Masklike facial expression Incorrect - Masklike facial expression is a common symptom of PD, not a side effect of this drug. 4. Stooped Posture Incorrect - Stooped Posture is a common symptom of PD, not a side effect of this drug. The nurse is taking the health history of a patient being treated for Parkinson's Disease. After being told the patient has classic symptoms of Parkinson's, the nurse expects to note which assessment finding? 1. Tremors 2. Low Urine Output 3. Exaggerated arm movements 4. Risk for Falls - solution ✅1. Tremors Correct - Tremors is one of four cardinal signs of PD: the other three are rigidity, bradykinesia (slow movements), and postural instability 2. Low Urine Output Incorrect - This is not a relevant symptom to PD 3. Exaggerated arm movements Incorrect - A symptom of PD would be rigidity and slow arm movements, rather than exaggeration of arm movements 4. Risk for Falls Incorrect - This is not an assessment finding. This is a nursing diagnosis. 25 Incorrect - An NG tube would not be relevant in this situation. 4. Connect and read an EKG Incorrect - An EKG would not be needed in this situation. A nurse is caring for a patient who is suspected to have sustained a spinal cord injury. What best describes the overarching principles used to guide the care for this type of condition? 1. Immobilize the cervical area to prevent further injury 2. Monitor the patient's level of consciousness to prevent neurologic deterioration 3. Help the patient with activities of daily living and provide emotional and physical support to help them adjust to their injury 4. Facilitate tissue perfusion to the spinal cord while maintaining airway and breathing - solution ✅1. Immobilize the cervical area to prevent further injury Incorrect - While this is an essential part of caring for a spinal cord injury, it does not adequately describe guiding principles for a complete plan of care 2. Monitor the patient's level of consciousness to prevent neurologic deterioration Incorrect - While this is an essential part of caring for a spinal cord injury, it does not adequately describe guiding principles for a complete plan of care 3. Help the patient with activities of daily living and provide emotional and physical support to help them adjust to their injury Incorrect - These are important in the later stages of a spinal cord injury after the patient has been stabilized, but at this point would be premature. 4. Facilitate tissue perfusion to the spinal cord while maintaining airway and breathing Correct - Maintaining airway, breathing, and circulation is both essential and guides the overall plan of care for a patient with a spinal cord injury. A 23-year-old woman is admitted to the infusion clinic after a Multiple Sclerosis Exacerbation. The physician orders methylprednisolone infusions (Solu-Medrol). The nurse would expect which of the following outcomes after administration of this medication? 26 1. A decrease in muscle spasticity and involuntary movements 2. A slowed progression of Multiple Sclerosis related plaques 3. A decrease in the length of the exacerbation 4. A stabilization of mood and sleep - solution ✅1. A decrease in muscle spasticity and involuntary movements Incorrect - While muscle spasticity and involuntary movements can be symptoms of MS, a corticosteroid infusion is not meant to directly treat these symptoms. 2. A slowed progression of Multiple Sclerosis related plaques Incorrect - Special drugs like Interferon Beta, Natalizumab, or Glatiramir acetate are used as first-line treatments to slow the progression of MS. While corticosteroids can be used in conjunction with these drugs on a long-term basis, they would not be infused. They would be taken orally. 3. A decrease in the length of the exacerbation Correct - A methylprednisolone infusion is the first line of treatment during an acute exacerbation and is used to decrease the length and severity of a relapse. 4. A stabilization of mood and sleep Incorrect - Some of the frequent side effects of a Methylprednisolone infusion are anxiety, insomnia, and mood swings. A nurse knows that which of these patients are at greatest risk for a stroke? 1. A 60-year old male who weighs 270 pounds, has atrial fibrillation, and has had a TIA in the past. 2. A 75-year old male who has frequent migraines, drinks a glass of wine every day, and is Hispanic. 3. A 40-year old female who has high cholesterol and uses oral contraceptives 27 4. A 65-year old female who is African American, has sickle cell disease and smokes cigarettes. - solution ✅1. A 60-year old male who weighs 270 pounds, has atrial fibrillation, and has had a TIA in the past. Correct - Common risk factors for developing stroke include: Atrial fibrillation, arteriosclerosis, previous stroke or ischemic attack, heart surgery, valvular heart disease, diabetes, smoking, substance abuse,obesity, sedentary lifestyle, oral contraceptive use, genetic tendency, migraines, older age, male, African American/Hispanic/American Indian, Sickle Cell Anemia, and brain trauma. This man has the greatest risk based on these risk factors. 2. A 75-year old male who has frequent migraines, drinks a glass of wine every day, and is Hispanic. Incorrect - See Common Risk Factors for Developing a Stroke. 3. A 40-year old female who has high cholesterol and uses oral contraceptives Incorrect - See Common Risk Factors for Developing a Stroke. 4. A 65-year old female who is African American, has sickle cell disease and smokes cigarettes. Incorrect - See Common Risk Factors for Developing a Stroke. A nurse frequently treats patients in the 72-hour period after a stroke has occurred. The nurse would be most concerned about which of these assessment findings? 1. INR is 3 seconds long 2. Heart rate is 110 beats per minute 3. Intracranial Pressure is 22 mm/Hg 4. Blood pressure is 140/80 - solution ✅1. INR is 3 seconds long Incorrect - This is actually within a therapeutic range for clotting times for patients with coagulation risks. A normal INR is .9-1.2 seconds, while a therapeutic INR can be as high as 3.5 seconds. 2. Heart rate is 110 beats per minute Incorrect - While tachycardia is a concern, general tachycardia without other associated symptoms would not pose an immediate danger, and is not of greater priority than the next answer. 30 1. "You should wait more than 1 minute between different medications." 2. "Your routine is very good! Can you demonstrate it for me?" 3. "It is actually not the best practice to close your eyes after instilling eyedrops." 4. "You should actually be pressing your finger in the other corner of the eye." - solution ✅1. "You should wait more than 1 minute between different medications." Correct - It is recommended to wait 10-15 minutes between different eyedrop medications to give them time to absorb an avoid one medication washing another one out. 2. "Your routine is very good! Can you demonstrate it for me?" Incorrect - There is something wrong with what the patient described as his routine. After the nurse corrects this, a return demonstration would be appropriate. 3. "It is actually not the best practice to close your eyes after instilling eyedrops." 4. "You should actually be pressing your finger in the other corner of the eye." Incorrect - THis is not true. A nurse would evaluate which of these patients as appropriate candidates for a closed MRI without contrast, based on the information given? 1. A 20-year old woman who has unexplained joint pain and a low BMI. 2. A 35-year old woman with Multiple Sclerosis and has been trying to conceive. 3. A 67-year old man who has had an open-heart surgery 4 years ago. 4. A 40-year old woman who has been in a hypomanic state for the last 2 days. - solution ✅1. A 20-year old woman who has unexplained joint pain and a low BMI. Correct - MRI can be used to diagnose musculoskeletal disorders, and this patient has no contraindications to an MRI. 2. A 35-year old woman with Multiple Sclerosis and has been trying to conceive. 31 Incorrect - Pregnant women, or women who have a possibility of being pregnant, are not recommended to receive MRIs. 3. A 67-year old man who has had an open-heart surgery 4 years ago. Incorrect - Patients with pacemakers, stents, or implants should not have MRIs. More information would have to be gathered about this patient before an MRI can be done. 4. A 40-year old woman who has been in a hypomanic state for the last 2 days. Incorrect - Hypomania is a mild form of mania, and a patient with hypomania would have a very difficult time laying still in a supine position for up to an hour. Sedation may be required, which requires more information and assessment of this patient. A nurse is caring for a patient in the cardiac care unit who is taking bumetanide (Bumex) and is diagnosed with Parkinson's Disease. An unlicensed assistive personnel is assisting with feeding the patient. Which of these foods would the nurse stress for the patient to eat most? 1. Foods containing the least amount of salt 2. Foods containing the most amount of potassium 3. Foods containing the most amount of calories 4. Foods containing the most amount of fiber - solution ✅1. Foods containing the least amount of salt Incorrect - While this is a good practice, in light of the information given, this is not the greatest priority. 2. Foods containing the most amount of potassium Correct - Bumex is a loop diuretic and can cause hypokalemia. Ensuring potassium is included in the diet is a priority and can directly avoid a hypokalemic crisis. 3. Foods containing the most amount of calories Incorrect - While this is a good practice, in light of the information given, this is not the greatest priority. 4. Foods containing the most amount of fiber 32 Incorrect - While this is a good practice, in light of the information given, this is not the greatest priority. A nurse knows that which of these patients are at greatest risk for a developing osteoporosis? 1. An 80-year old man who has a thin build 2. A 48-year old african american female who smokes cigarettes and drinks alcohol 3. A 55-year old female with an estrogen deficiency 4. A 70-year old caucasian female who takes oral corticosteroids - solution ✅1. An 80-year old man who has a thin build Incorrect - Age and thin build are two primary risk factors, but another patient has more. 2. A 48-year old african american female who smokes cigarettes and drinks alcohol Smoking cigarettes and drinking alcohol are both primary risk factors, but being African American actually decreases the risk for osteoporosis 3. A 55-year old female with an estrogen deficiency Incorrect - Only two risk factors are present: being female, and having an estrogen deficiency. While her age is somewhat advanced, 65+ years of age is the 'cut-off' for having a risk factor in women. 4. A 70-year old caucasian female who takes oral corticosteroids Correct - This patient has by far the most risk factors, 3 of which are primary and one secondary. Age, gender, ethnicity are three primary risk factors, while her corticosteroid treatment is the secondary risk factor, bringing her total up to four. A 30-year old Caucasian woman who works the night shift has been found to have early bone loss and has a high risk for osteomalacia and bone degradation. She asks the nurse exactly why she should take Vitamin D supplements. What is the nurse's best response? 1. "It's a standard part of the overall nutritional treatment for the prevention of osteomalacia" 2. "It helps your intestines absorb calcium, which is important for bone formation." 35 A nurse is asked by a patient to describe in layman's terms an overview of the condition called osteomyelitis. What would be the nurse's best response? 1. "Osteomyelitis is a gradual breakdown and weakening of your bones. It's most often age- related." 2. "Osteomyelitis is caused by not having enough Vitamin D, which in turn causes a your bones to be softer and de-mineralized." 3. "Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your bone from outside or inside your body." 4. "This is a question that should be directed to your Healthcare Provider." - solution ✅1. "Osteomyelitis is a gradual breakdown and weakening of your bones. It's most often age- related." Incorrect - This sentence describes osteoporosis 2. "Osteomyelitis is caused by not having enough Vitamin D, which in turn causes a your bones to be softer and de-mineralized." Incorrect - This sentence describes osteomalacia 3. "Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your bone from outside or inside your body." Correct - This appropriately explains osteomyelitis 4. "This is a question that should be directed to your Healthcare Provider." Incorrect - A nurse is qualified to educate the patient on this subject matter The infection control nurse is assigned to a patient with osteomyelitis related to a heel ulcer. The wound is 5cm in diameter and the drainage saturates the dressing so that it must be changed every hour. What is her priority intervention? 1. Place the patient under contact precautions 36 2. Use strict aseptic technique when caring for the wound 3. Place another dressing to reinforce the first one 4. Elevate the patient's leg to prevent more drainage - solution ✅1. Place the patient under contact precautions Correct - A patient with an infectious wound, especially one not adequately contained by a dressing, should be put under contact precautions. 2. Use strict aseptic technique when caring for the wound Incorrect - Although this is dependent on each facility's policy, it is no longer a common practice to use aseptic technique on a "dirty" wound. Clean technique is more often used. 3. Place another dressing to reinforce the first one Incorrect - This is a questionable intervention, and will not promote the safety of this patient and other patients. 4. Elevate the patient's leg to prevent more drainage Incorrect - Patients with heel ulcers should have their heels elevated to prevent pressure, not the whole leg elevated to prevent drainage. A nurse in the emergency room receives a patient who had his left elbow fractured in a fight. He had waited 5 hours before coming to the emergency room. His left hand has an unequal radial pulse, is swollen, and is numb and tingling. What is the nurse's priority intervention? 1. Place the patient in a supine position 2. Ask the patient to rate his pain on a scale of 1 to 10. 3. Wrap the fractured area with a snug dressing 4. Start an IV in the other arm. - solution ✅1. Place the patient in a supine position Incorrect - While this may be a beneficial intervention if the arm is also elevated to prevent swelling, this is not a priority intervention. 2. Ask the patient to rate his pain on a scale of 1 to 10. Incorrect - While assessing pain is a part of the 6 P's of neurovascular assessment, the question asks for an intervention based on already alarming assessment findings. 37 3. Wrap the fractured area with a snug dressing Incorrect - The assessment findings indicate the patient may have Acute Compartment Syndrome. Causing more external pressure with a dressing will only exacerbate the condition. 4. Start an IV in the other arm. Correct - Starting an IV is a nursing priority prior to emergency surgery. The patient may be in the late stages of Acute Compartment Syndrome and may need a fasciotomy, in which the surgeon relieves pressure by making an incision into the affected area. A nurse is caring for a female patient 24 hours after a hip fracture. The patient is on bedrest. The nurse knows that which regular assessment or intervention is essential for detecting or preventing the complication of Fat Embolism Syndrome? 1. Performing passive, light, range of motion exercises on the hip as tolerated. 2. Assess the patient's mental status for drowsiness or sleepiness. 3. Assess the pedal pulse and capillary refill in the toes. 4. Administer a stool softener as ordered - solution ✅1. Performing passive, light, range of motion exercises on the hip as tolerated. Incorrect - Immobilization and prevention of motion is the best way to reduce risk for fat embolism. 2. Assess the patient's mental status for drowsiness or sleepiness. Correct - A decreased Level of Consciousness is the earliest sign of FES, caused by decreased oxygen level. 3. Assess the pedal pulse and capillary refill in the toes. Incorrect - While assessing pedal pulse is important during a neurovascular assessment, it is not relevant to FES. Capillary refill is the least reliable indicator of poor perfusion 4. Administer a stool softener as ordered Incorrect - While this is an important intervention for patients on bedrest, it is not an intervention relevant to FES 40 The nurse in the day surgery centre cares for a patient who has undergone an endoscopic procedure with general anesthesia. The nurse understands that which nursing consideration is a priority immediately after an endoscopic procedure? 1. Raise the siderails of the patient's bed 2. Do not offer fluids, food or any oral intake 3. Check the temperature of the patient 4. Teach the patient to avoid aspirin or NSAIDS - solution ✅1. Raise the siderails of the patient bed Incorrect - This is a general intervention that applies to all post-procedure care, and not the biggest priority. 2. Do not offer fluids, food or any oral intake Correct - Endoscopies involve passing a tube through the mouth into the esophagus or upper GI. Anesthesia is often given to inactivate the gag reflex, making the patient vulnerable to aspiration. 3.Check the temperature of the patient Incorrect - While it is important to monitor the temperature for signs of infection or sepsis, these problems do not occur until hours or days later. 4. Teach the patient to avoid aspirin or NSAIDS Incorrect - This is part of the preparation for an endoscopic procedure, not post-procedural care A nurse is preparing to palpate and percuss a patient's abdomen as part of the assessment process. Which of these findings would cause the nurse to immediately discontinue this part of the assessment? 1. The patient states "That sounds like it might hurt me." 2. There is a pulsating mass on the upper middle abdomen. 3. The patient has black, tarry stools and anemia 4. The patient has had an endoscopic procedure two days prior - solution ✅1. The patient states "That sounds like it might hurt me." 41 Incorrect - While the nurse should address this concern with the patient, this does not necessarily mean the assessment should be stopped. 2. There is a pulsating mass on the upper middle abdomen. Correct - This is an indication of a life-threatening aortic aneurysm. Palpating or percussing is dangerous to the patient's life. 3. The patient has black, tarry stools and anemia Incorrect - These are common symptoms of GI bleed, and don't contraindicate percussion and palpation. 4. The patient has had an endoscopic procedure two days prior Incorrect - An endoscopic procedure two days prior does not contraindicate percussion and palpation. A nurse understands that which of these patients are at risk for developing Oral Candidiasis, a type of stomatitis? 1. A 77-year old woman in a long-term care facility taking an antibiotic 2. A 35-year old man who has had HIV for 6 years 3. A 40-year old man who is undergoing chemotherapy 4. An 80-year old woman with dentures - solution ✅1. A 77-year old woman in a long-term care facility taking an antibiotic Correct - This patient has the most risk factors for developing Candidiasis. Candidiasis is caused most commonly by long-term antibiotic therapy, immunosupressive therapy (chemotherapy, radiation, or corticosteroids), older age, living in a long-term care facility, diabetes, having dentures, and poor oral hygiene. 2. A 35-year old man who has had HIV for 6 years Incorrect - Another patient has the most/more relevant risk factors for developing Candidiasis. 3. A 40-year old man who is undergoing chemotherapy Incorrect - Another patient has the most/more relevant risk factors for developing Candidiasis. 42 4. An 80-year old woman with dentures Incorrect - Another patient has the most/more relevant risk factors for developing Candidiasis. What nursing intervention demonstrates that the nurse understands the priority nursing diagnosis when caring for oral cancer patients with extensive tumor involvement and/or a high amount of secretions? 1. The nurse uses a pen pad to communicate with the patient 2. The nurse provides oral care every 2 hours 3. The nurse listens for bowel sounds every 4 hours. 4. The nurse suctions as needed and elevates the head of the bed - solution ✅1. The nurse uses a pen pad to communicate with the patient Incorrect - This intervention is in response to impaired verbal communication, which is not the priority nursing diagnosis. 2. The nurse provides oral care every 2 hours Incorrect - This intervention is in response to impaired oral mucous membrane, which is not the priority nursing diagnosis. 3. The nurse listens for bowel sounds every 4 hours. Incorrect - This assessment is not relevant to the patient's condition 4. The nurse suctions as needed and elevates the head of the bed Correct - This intervention is in response to Ineffective Airway Clearance, which is the priority nursing diagnosis. A patient has been taking a mood stabilizing medication, but is afraid of needles. They ask the nurse what medication would NOT require regular lab testing. What is the nurse's best response? 1. Valproic Acid (Depakote) 2. Clozapine (Clozaril) 45 2. The patient's WBC count is within normal limits Incorrect - This does not demonstrate the purpose a catheter ablation 3. The patient's EKG reading is regular Correct - A catheter ablation is a procedure used to treat arrhythmias, especially SVT. A catheter is inserted through the femoral vein or artery, and threaded to the conduction fiber in the heart causing the arrhythmia. A radiofrequency energy uses heat to destroy this fiber, preventing further arrhythmia. 4. The patient's urine output is 45mL/hour Incorrect - This does not demonstrate the purpose a catheter ablation Application - The nurse is caring for a patient who has the following labs: Creatinine 2.5mg/dL, WBC 11,000 cells/mL, and Hemoglobin of 12 g/dL. Based on this information, which of these orders would the nurse question? 1. Administer 30 Units of Lantus Daily 2. CT of the spine with contrast 3. X-ray of the abdomen and chest 4. Administer heparin subcutaneous 5,000 Units every 12 hours - solution ✅1. Administer 30 Units of Lantus Daily Incorrect - None of the above labs contraindicate this order 2. CT of the spine with contrast Correct - The creatinine level of this patient indicates impaired kidney function. Contrast is nephrotoxic and is contraindicated for patients with nephropathy. 3. X-ray of the abdomen and chest Incorrect - None of the above labs contraindicate this order 4. Administer heparin subcutaneous 5,000 Units every 12 hours 46 Incorrect - None of the above labs contraindicate this order Application - A nurse is caring for a patient admitted in the emergency room for an ischemic stroke with marked functional deficits. The physician is considering the use of fibrinolytic therapy with TPA (tissue plasminogen activator). Which history-gathering question would not be important for the nurse to ask? 1. "What time was the first time you noticed symptoms appearing consistently?" 2. "Have you been taking any blood thinners like heparin, lovenox, or warfarin?" 3. "Have you had another stroke or head trauma in the previous 3 months?" 4. "Have you had any blood transfusions within the previous year?" - solution ✅1. "What time was the first time you noticed symptoms appearing consistently?" Incorrect - This is a relevant question because TPA is usually used no more than 5-6 hours after onset. This is the timeframe that damage to tissue is still reversible. 2. "Have you been taking any blood thinners like heparin, lovenox, or warfarin?" Incorrect - This is a relevant question because current anticoagulant use, or an INR of greater than 1.7, is a contraindication to TPA use. 3. "Have you had another stroke or head trauma in the previous 3 months?" Incorrect - This is a relevant question because having a stroke or head trauma in the last 3 months contraindicates TPA use 4. "Have you had any blood transfusions within the previous year?" Correct - This is not a relevant question and would not affect the decision to use TPA A patient is being discharged from the med-surgical unit. The patient has a history of gastritis. The nurse questions the patient on his usual routine at home. Which of these statements would alert the nurse that additional teaching is required? 1. "I avoid NSAIDS. I only take a daily aspirin for my heart health." 2. "I always avoid eating hot and spicy foods" 3. "I will continue taking my antacids with or immediately after meals" 47 4. "I will only drink coffee once a week, if even that often." - solution ✅1. "I avoid NSAIDS. I only take a daily aspirin for my heart health." Correct - Aspirin is classified as an NSAID and can exacerbate already existing stomach problems. Aspirin should be avoided just like any NSAID for patients with gastritis. 2. "I always avoid eating hot and spicy foods" Incorrect - This is a good practice for patients with gastritis 3. "I will continue taking my antacids with or immediately after meals" Incorrect - This is a good practice for patients with gastritis 4. "I will only drink coffee once a week, if even that often." Incorrect - This is a good practice for patients with gastritis. Coffee is not recommended for patients with gastritis. A nurse is meeting a patient in their home. The patient has been taking Naproxen for back pain. Which statement made by the patient most indicates that the nurse needs to contact the physician? 1. "I get an upset stomach if I don't take Naproxen with my meals." 2. "My back pain right now is about a 3/10." 3. "I get occasional headaches since taking Naproxen" 4. "I have ringing in my ears." - solution ✅1. "I get an upset stomach if I don't take Naproxen with my meals." Incorrect - This is a common and less severe side effect of Naproxen 2. "My back pain right now is about a 3/10." Incorrect - Although a 3/10 is bordering on the acceptable amount of pain, this would not be the most pressing issue at hand. 3. "I get occasional headaches since taking Naproxen" Incorrect - This is a common and less severe side effect of Naproxen 50 Correct - Hand washing is the single most effective way to prevent transmission of Hepatitis A. Hepatitis A is a virus transmitted via the oral-fecal route and lives on human hands. 4. Teach the child and family the dangers of contaminated food and water Incorrect - Although this is a valuable teaching point, it is not the priority intervention. A nurse is treating a patient suspected to have Hepatitis. The nurse notes on assessment that the patient's eyes are yellow-tinged. Which of these diagnostic results would further assist in confirming this diagnosis? 1. Decreased serum Bilirubin 2. Elevated serum ALT levels 3. Low RBC and Hemoglobin with increased WBCs 4. Increased Blood Urea Nitrogen level - solution ✅1. Decreased serum Bilirubin Incorrect - Bilirubin levels correlate with the appearance of Jaundice. An increased serum bilirubin would be the expected finding for this patient. 2. Elevated serum ALT levels Correct - ALT is a liver enzyme, and hepatitis is a liver disease. Elevated liver enzymes will often signal liver damage. 3. Low RBC and Hemoglobin with increased WBCs Incorrect - This is not a common finding for Hepatitis patients 4. Increased Blood Urea Nitrogen level Incorrect - BUN is an indicator of renal (kidney) health, not hepatic (liver) function. Which of these patients would the nurse suspect as having the greatest risk of contracting Hepatitis B? 1. A sexually active 45-year old man who has Type 1 Diabetes 2. A 75-year old woman who lives in a crowded nursing home 51 3. A child who lives in a country with poor sanitation and hygiene standards 4. A sexually active 23-year old man who works in a hospital - solution ✅1. A sexually active 45- year old man who has Type 1 Diabetes Incorrect - This person is sexually active, but it is not specified with how many partners. Having Type 1 Diabetes is not a risk factor for Hepatitis. 2. A 75-year old woman who lives in a crowded nursing home Incorrect - Age is not a risk factor for Hepatitis B, and close living accommodations is a stronger risk factor for Hepatitis A and E, which are oral-fecal transmissions. 3. A child who lives in a country with poor sanitation and hygiene standards Incorrect - This is a relevant risk factor for Hepatitis A and E 4. A sexually active 23-year old man who works in a hospital Correct - This person is both sexually active and works in a healthcare environment. The nurse calculates the IV flow rate of a patient receiving lactated ringer's solution. The patient is to receive 2000mL of Lactated Ringer's over 36 hours. The IV infusion set has a drop factor of 15 drops per milliliter. The nurse should set the IV to deliver how many drops per minute? 1. 8 2. 10 3. 14 4. 18 - solution ✅18 Incorrect 2. 10 Incorrect 3. 14 Correct - Drops Per Minute = Milliliters x Drop Factor / Time in Minutes 52 4. 18 Incorrect The nurse calculates the IV flow rate of a patient receiving an antibiotic. The patient is to receive 100mL of the antibiotic over 30 minutes. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should set the IV to deliver how many drops per minute? 11 19 26 33 - solution ✅11 Incorrect 19 Incorrect 26 Incorrect 33 Correct - Drops Per Minute = Milliliters x Drop Factor / Time in Minutes Which of the following statements made by a client during an individual therapy session would the nurse most identify as reflecting schizoaffective disorder? 1. "I just want to stab myself with this pen." 2. "What's the point in life anyways?" 3. "My thoughts are racing because of the conspiracies against me." 4. "I hear voices every day and sometimes see old friends that don't exist." - solution ✅1. "I just want to stab myself with this pen." Incorrect - This is a suicidal ideation, but not a classic symptom of schizoaffective disorder