NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success, Exams of Nursing

Download NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success and more Exams Nursing in PDF only on Docsity! Option C. Grunting occurs when an infant attempts to maintain an adequate functional residual capacity in the face of poorly compliant lungs by partial glottic closure. As the infant prolongs the expiratory phase against this partially closed glottis, there is a prolonged and increased residual volume that maintains the airway opening and also an audible expiratory sound. Option E: Nasal flaring occurs when the nostrils widen while breathing and is a sign of troubled breathing or respiratory distress. Correct Answers: C, E, F, & G NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success 1.1. Question While assessing a one-month-old infant, which of the findings warrants further investigation by the nurse? Select all that apply. o A. Abdominal respirations o B. Irregular breathing rate o C. Inspiratory grunt o D. Increased heart rate with crying o E. Nasal flaring o F. Cyanosis o G. Asymmetric chest movement NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success • 2. Question A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a preoperative client. List the order in which the nurse must carry out the following actions prior to the administration of preoperative medications. View Answers: NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success o Option F: Cyanosis refers to the bluish discoloration of the skin and indicates a decrease in oxygen attached to the red blood cells in the bloodstream. o Option G: Asymmetric chest movement occurs when the abnormal side of the lungs expands less and lags behind the normal side. This indicates respiratory distress. o Option A: Abdominal respiration is normal among infants and young children. Since their intercostal muscles are not yet fully developed, they use their abdominal muscles much more to pull the diaphragm down for breathing. o Option B: Newborns can have irregular breathing patterns ranging from 30 to 60 breaths per minute with short periods of apnea (15 seconds). o Option D: An increase in heart rate is normal for an infant during activity (including crying). NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o 4. Question Which individual is at the greatest risk for developing hypertension? o A. 45-year-old African-American attorney NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Correct Answer: Gravida 3 para 1 Gravida is the number of confirmed pregnancies and each pregnancy is only counted one time, even if the pregnancy was a multiple gestation (i.e., twins, triplets). Para (parity) indicates the total number of pregnancies that have reached viability (20 weeks) regardless of whether the infants were born alive. Thus, for this woman, she is now pregnant, had 2 prior pregnancies, Option A: African-Americans develop high blood pressure at younger ages than other groups in the US. Researchers have uncovered that African-Americans respond differently to hypertensive drugs than other groups of people. They are also found out to be more sensitive to salt, which increases the risk of developing hypertension. Option B: The incidence of hypertension in Asian- Americans does not appear to be significantly higher than the general population, according to limited US data. Option C: The racial disparity in hypertension and hypertension-related outcomes has been recognized for decades with African-Americans with greater risks than Caucasians. Option D: Hypertension prevalence rates in Hispanics may vary by gender and country of origin. Hispanic Americans overall have relatively low levels of hypertension, despite elevated levels of diabetes and obesity. Correct Answer: A: 45-year-old African American attorney NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o B. 60-year-old Asian-American shop owner o C. 40-year-old Caucasian nurse o D. 55-year-old Hispanic teacher • 5. Question A 15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45 minutes ago is rushed to the emergency department. Which of these orders should the nurse do first? o A. Gastric lavage o B. Administer acetylcysteine (Mucomyst) orally o C. Start an IV Dextrose 5% with 0.33% normal saline to keep the vein open NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o D. Have the patient drink activated charcoal mixed with water Correct Answer: A. Gastric lavage o Option A: Acetaminophen overdose is extremely toxic to the liver causing hepatotoxicity. Early symptoms of hepatic damage include nausea, vomiting, abdominal pain, and diarrhea. If not treated immediately, hepatic necrosis occurs and may lead to death. Removing as much of the drug as possible is the first step in treatment for acetaminophen overdose, this is best done through gastric lavage. Gastric lavage (irrigation) and aspiration consist of flushing the stomach with fluids and then aspirating the fluid back out. This procedure is done in life-threatening cases such as acetaminophen toxicity and only if less than one (1) hour has occurred after ingestion. o Option B: The oral formulation of acetylcysteine is the drug of choice for the treatment of acetaminophen overdose but NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option A: The reported incidence of myocardial infarction with angina at rest is less than 0.1%, and is mostly influenced by patient-related factors like the extent and severity of underlying cardiovascular- related diseases and technique-related factors. Options C & D: A falling BP and dizziness occur along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure. Correct Answer: B. Thrombus formation A thrombus formation may prevent blood from flowing normally through the circulatory system, which may become an embolism, and block the flow of blood towards major organs in the body. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? o A. Angina at rest o B. Thrombus formation o C. Dizziness o D. Falling blood pressure • 7. Question A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is: NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Correct Answer: C. Manage pain NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o A. Maintain fluid and electrolyte balance o B. Control nausea o C. Manage pain o D. Prevent urinary tract infection NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option A: IV hydration in the setting of acute renal colic is controversial. Whereas some authorities believe that IV fluids hasten the passage of the stone through the urogenital system, others express concern that additional hydrostatic pressure exacerbates the pain of renal colic. Option B: Because nausea and vomiting frequently accompany acute renal colic, antiemetics often play a role in renal colic therapy. Several antiemetics have a sedating effect that is often helpful. Option D: Overuse of the more effective antibiotic agents leaves only highly resistant bacteria, but failure to adequately treat a UTI complicated by an obstructing calculus can result in potentially life- threatening urosepsis and pyonephrosis. Managing pain is always a priority because it ultimately improves the quality of life. The cornerstone of ureteral colic management is analgesia, which can be achieved most expediently with parenteral narcotics or nonsteroidal anti-inflammatory drugs (NSAIDs). NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success • 8. Question What would the nurse expect to see while assessing the growth of children during their school-age years? o A. Decreasing amounts of body fat and muscle mass o B. Little change in body appearance from year NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission? NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option B: The client with antibiotic-induced diarrhea still needs continuous strict monitoring as the blood sugar levels may become unstable and dehydration is still possible. Option C: Stevens-Johnson syndrome (SJS) is a rare, serious disorder of the skin and mucous membranes. It’s usually a reaction to medication that starts with flu-like symptoms, followed by a painful rash that spreads and blisters. Option D: Cellulitis is often an underestimated complication of HIV disease, but they are responsible for an appreciable morbidity. Correct Answer: A. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago. The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o A. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago. o B. A young adult with diabetes mellitus Type 2 for over ten (10) years and admitted with antibiotic-induced diarrhea 24 hours ago. o C. An elderly client with a history of hypertension, hypercholesterolemia, and lupus, and was admitted with Stevens-Johnson syndrome that morning. o D. An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success hours ago. • 11. Question A 25-year-old male client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option A: If epiglottitis is seriously considered, no imaging studies are required. In less-clear cases, imaging studies are occasionally helpful in establishing the diagnosis or excluding epiglottitis. Option B: Examining the child’s throat should not be attempted because it may compromise respiratory effort. Option C: There are no indications for the collection of sputum specimens. These findings suggest a medical emergency and may be due to epiglottitis. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate care. Option A: Polyphagia or extreme hunger is one of the most common symptoms of diabetes both among adults and children. Option B: Dehydration is not a symptom of type 1 diabetes, but it can be one of the many complications. Option D: Unintentional weight loss would develop gradually in a child with type 1 diabetes. Correct Answer: C. Bedwetting One of the first symptoms of type 1 diabetes in children is bedwetting. Bedwetting in a school-age child is readily detected by the parents. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success • 13. Question In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school-age child for evaluation? o A. Polyphagia o B. Dehydration o C. Bedwetting o D. Weight loss NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success • 14. Question NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option B: Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease. Chlamydial bacteria could travel up toward the vagina or cervix into the reproductive organs. Option A: Trichomoniasis is a very common sexually transmitted disease, but it rarely predisposes to pelvic inflammatory disease. Options C & D: Staphylococcus and streptococcus may cause PID but it rarely occurs. Correct Answer: B. Chlamydia NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? o A. Trichomoniasis o B. Chlamydia o C. Staphylococcus o D. Streptococcus • 15. Question A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option A: Discomfort at the IV insertion site may indicate inflammation or infection of the site. Option B: Morphine is a strong painkiller indicated for severe pain. Option D: The pump is working correctly if there is only 50 ml left at noon. Correct Answer: C. The level of the drug is 100 ml at 8 AM and is 80 ml at noon The minimal dose of 10 mL per hour which would be 40 mL given in a four (4) hour period. Only 60 mL should be left at noon. The pump is not functioning when more than expected medicine is left in the container. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success • 17. Question Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for morphine drip is not working? o A. The client complains of discomfort at the IV insertion site o B. The client states “I just can’t get relief from my pain.” o C. The level of the drug is 100 ml at 8 AM and is 80 ml at noon o D. The level of the drug is 100 ml at 8 AM and NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success o Option A: Eating a balanced diet should be a part of the management of a client with coronary artery disease. o Option B: Complex carbohydrates decrease inflammation and help decrease the risk of plaque build-up in the arteries. o Option C: People with cardiovascular diseases should have a limit of less than 1.5 Option A: Discomfort at the IV insertion site may indicate inflammation or infection of the site. Option B: Morphine is a strong painkiller indicated for severe pain. Option D: The pump is working correctly if there is only 50 ml left at noon. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success is 50 ml at noon • 18. Question NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option A: Too much exposure to electrical energy can become a hazard to one’s health. Option C: Mind-body balance refers to yoga. Option D: Low-impact aerobic exercises are easier on the joints but are not part of chiropractic medicine. Correct Answer: B. Spinal column manipulation The theory underlying chiropractic is that interference with the transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by the misalignment of the vertebrae. Manipulation reduces subluxation. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response? o A. Electrical energy fields o B. Spinal column manipulation o C. Mind-body balance o D. Exercise of joints • 19. Question The nurse is performing a neurological assessment on a client post right cerebrovascular accident. Which NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Correct Answer: C. Moist, productive cough Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva, and digestive juices. Normally, these NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o C. Moist, productive cough o D. Meconium ileus NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option A: A positive sweat test is one of the indications of cystic fibrosis. Option B: A patient with CF experiences frequent greasy, bulky stools or difficulty with bowel movements as the thick mucus blocks the intestines. Option D: Meconium ileus is one of the early signs of CF. causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts, and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success • 21. Question The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should o A. Place a call to the client’s health care provider for instructions o B. Send him to the emergency room for evaluation o C. Reassure the client’s wife that the symptoms are transient NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Correct Answer: B. Send him to the emergency room for evaluation This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client’s best interest. o Option A: Waiting to call for instructions may delay the diagnosis of the patient. o Option C: Reassuring the wife is since it is not a transient symptom. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o D. Instruct the client’s wife to call the doctor if his symptoms become worse NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option A: The instruction in option A is vague and does not specifically tell the patient how to determine if the activity is already appropriate for him. Option C: Having a glass of wine is not recommended for a client who just had a myocardial infarction. Option D: Having an active walking program does not guarantee that the client has regained strength for strenuous activity. Correct Answer: B. “When you can climb 2 flights of stairs without problems, it is generally safe.” There is a risk of cardiac rupture at the point of the myocardial infarction for about six (6) weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by healthcare providers. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o B. “When you can climb 2 flights of stairs without problems, it is generally safe.” o C. “Have a glass of wine to relax you, then you can try to have sex.” • 24. Question A triage nurse has these four (4) clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first? o A. A 2-month-old infant with a history of rolling off the bed and has bulging fontanelle with crying NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o B. A teenager who got a singed beard while camping o C. An elderly client with complaints of frequent liquid brown colored stools o D. A middle-aged client with intermittent pain behind the right scapula NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option A: When an infant is crying, the fontanels may look like they are bulging. Option C: The client in Option C can wait to be seen within the first hour. Option D: The client in Option D does not have a life- threatening condition but will still require immediate pain relief. Correct Answer: B. A teenager who got a singed beard while camping This client is in the greatest danger with a potential of respiratory distress. Any client with singed facial hair has been exposed to heat or fire in close range that could have caused serious damage to the interior of the lungs. Note that the interior lining of the lungs has no nerve fibers so the client will not be aware of swelling. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success • 25. Question While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child’s developmental needs? o A. “I want to protect my child from any falls.” o B. “I will set limits on exploring the house.” o C. “I understand the need to use those new skills.” NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success temperature • 27. Question The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq potassium chloride in 1000 ml of 5% dextrose in water IV. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option A: Narrow QRS complex indicates fast cardiac rhythms (generally more than 100 beats/min) with a QRS duration of 100 ms or less. Option B: A short PR interval (<120 ms) is seen with preexcitation syndromes and AV nodal (junctional) rhythm. Option D: Prominent U waves are characteristic of hypokalemia. Correct Answer: C. Tall peaked “T” waves A tall peaked T wave is a sign of hyperkalemia. The healthcare provider should be notified regarding discontinuing the medication. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued? o A. Narrowed QRS complex o B. Shortened “PR” interval o C. Tall peaked "T" waves o D. Prominent “U” waves • 28. Question A nurse prepares to care for a 4-year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body? NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Correct Answer: A. All striated muscles NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o A. All striated muscles o B. The cerebellum o C. The kidneys o D. The leg bones NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Correct Answer: C. Force fluids and reassess blood pressure Orthostatic hypotension, a decrease in systolic blood pressure of more than 15 mmHg, and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicate volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. o Option A: Fluids may not be necessarily protein-rich. o Option B: Restricting fluids could NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about: NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option A: Stroke volume is calculated using measurements of ventricle volumes from an echocardiogram and subtracting the volume of the blood in the ventricle at the end of a beat (called end- systolic volume) from the volume of blood just prior to the beat (called end-diastolic volume). Option B: Cardiac output is calculated by multiplying the stroke volume by the heart rate. Option C: The CVP can be measured either manually using a manometer or electronically using a transducer. Correct Answer: D. Left ventricular functioning The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o A. Stroke volume o B. Cardiac output o C. Venous pressure o D. Left ventricular functioning • 32. Question A nurse enters a client’s room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is: o A. Start a peripheral IV o B. Initiate high-quality chest compressions NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Correct Answer: B. Initiate high- quality chest compressions NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o C. Establish an airway o D. Obtain the crash cart NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Correct Answer: D. Progressive placental insufficiency Postmature or post-term pregnancy is a prolonged pregnancy that exceeds the limits of 38 to 42 weeks (normal term pregnancy). Infants of such pregnancy are considered postmature or dysmature if there is evidence that placental insufficiency has occurred and interfered with fetal growth. It occurs in 12% of all pregnancies. The placenta loses its adequacy to function after 42 weeks, after which it acquires calcium deposits which decrease the blood perfusion, supply of oxygen and nutrients to the fetus. o Options A, B, & C: Excessive fetal weight, NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success • 34. Question The nurse practicing in a maternity setting recognizes that the postmature fetus is at risk due to: o A. Excessive fetal weight o B. Low blood sugar levels o C. Depletion of subcutaneous fat o D. Progressive placental insufficiency • 35. Question The nurse is caring for a client who had a total hip replacement seven (7) days ago. Which statement by the cli t requires the n rse’s immediat attention? NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success o Option C: Increase in urine output is the desired effect of diuretics, which is given with digoxin. o Option D: A respiratory rate of 16 is within the NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o A. I have bad muscle spasms in my lower leg of the affected extremity. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o B. “I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.” o C. “I have to use the bedpan to pass my water at least every 1 to 2 hours.” o D. “It seems that the pain medication is not working as well today.” Correct Answer: B. “I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.” The nurse would be concerned about all of these comments, however, the most life-threatening is option B. Clients who had hip or knee surgery are at higher risk for the development of postoperative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Without prophylaxis (e.g., anticoagulation medications), deep vein thrombosis can develop within 7 to 14 days following the surgery and can lead to pulmonary embolism. The nurse should be aware of NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Correct Answer: D. Decreased appetite Furosemide is a loop diuretic that is used for pulmonary edema, edema in heart failure, nephrotic syndrome, and hypertension. Furosemide causes a loss of potassium unless a supplement or a potassium-rich diet is taken. A decrease in appetite is caused by hypokalemia. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias, reduced urine osmolality, altered level of consciousness. o Option A: Weight gain is not a negative side effect of furosemide. o Option B: Edema of the ankles are indications for the administration of furosemide. o Option C: Gastric irritability is not a side Correct Answer: B. Improve the client’s nutrition status Venous stasis occurs when venous blood collects and stagnates in the lower leg due to incompetent venous valves. Eventually, little oxygen and nutrients are supplied NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o B. Edema of the ankles o C. Gastric irritability o D. Decreased appetite • 37. Question The nurse is caring for a 27-year-old female client with venous stasis ulcer. Which nursing intervention would be most effective in promoting healing? o A. Apply dressing using sterile technique o B. Improve the client’s nutrition status o C. Initiate limb compression therapy o D. Begin proteolytic debridement NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success extremities causing the cells to die or necrose. This ultimately leads to the formation of venous stasis ulcers characterized by shallow but large brown wounds with irregular margins that typically develop on the lower leg or ankle. The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. Nutritional deficiencies are common causes of venous ulcers. Alterations in the diet to include foods high in protein, iron, zinc, and vitamins C and A are encouraged to promote wound healing. o Option A: Dressings are often used under compression bandages to promote faster healing and prevent adherence of the bandage to the ulcer. A wide range of dressings are available, including hydrocolloids (e.g., Duoderm), foams, hydrogels, pastes, and simple non-adherent dressings. o Option C: Compression therapy is the standard of care for venous ulcers and chronic venous insufficiency. A recent NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success Cochrane review found that venous ulcers heal more quickly with compression therapy than without. Methods include inelastic, elastic, and intermittent pneumatic compression. Compression therapy reduces edema, improves venous reflux, enhances healing of ulcers, and reduces pain. o Option D: Removal of necrotic tissue and bacterial burden through debridement has long been used in wound care to enhance healing. Debridement may be sharp (e.g., using a curette or scissors), enzymatic, mechanical, biologic (i.e., using larvae), or autolytic. • 38. Question Which of these statements best describes the characteristics of an effective reward-feedback system? o A. Specific feedback is given as close to the event as possible NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option B: Patients with multiple sclerosis should not exercise to the point of fatigue as strenuous physical exercise raises body temperature and may aggravate symptoms. Option E: Continuous exercise with no rest periods is contraindicated for patients with multiple sclerosis Correct answers: B & E. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success routine.” o D. “Proper stretching should be done before starting my routine.” o E. “I should exercise continuously without rest.” NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success • 40. Question During the evaluation of the quality of home care for a client with Alzheimer’s disease, the priority for the nurse is to reinforce which statement by a family member? o A. “At least two (2) full meals a day are eaten.” o B. “We go to a group discussion every week at our community center.” o C. “We have safety bars installed in NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success who wants to exercise. The patient should be advised to take short rest periods, preferably lying down. Again, extreme fatigue may contribute to the exacerbation of symptoms. o Option A: Exercises should include activities that would strengthen weak muscles because diminishing muscle strength is often a primary concern in multiple sclerosis. These activities include lifting weights and resistance exercises. o Option C: Aerobic exercises help promote muscle efficiency, increase flexibility, improves mood, and helps eliminate stress. o Option D: Muscle stretching should be included prior to exercise as this helps minimize muscle spasticity and contractures Correct Answer: C. We have safety bars installed in the bathroom and have 24-hour alarms on the doors. Note all options are correct statements. However, safety is most important to reinforce. o Option C: Ensuring safety of the client with increasing memory loss is a priority of home NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success the bathroom and have 24-hour alarms on the doors.” o D. “The medication is not a problem to have it taken three (3) times a day.” NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success • 42. Question A nurse is reviewing a patient’s past medical history (PMH). The history indicates the patient has photosensitive reactions to medications. Which of the following drugs is associated with photosensitive reactions? Select all that apply. o A. Ciprofloxacin (Cipro) o B. Sulfonamide NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success prematurity, hemorrhage, and ocular defects when given anytime during pregnancy and fetal warfarin syndrome when given during the first trimester. o Option B: Finasteride (Propecia, Proscar). Also has a pregnancy category X which has a high risk of causing permanent damage to the fetus. o Option C: Celecoxib (Celebrex). Large doses cause birth defects in rabbits; Pregnancy category C. o Option D: Clonidine (Catapres). Crosses the placenta but no adverse fetal effects have been observed. o Option E: Transdermal nicotine (Habitrol). Nicotine replacement products have been assigned to pregnancy category C (nicotine Correct Answer: A, B, C, D, and E. Photosensitivity is an extreme sensitivity to ultraviolet (UV) rays from the sun and other light sources. A type of photosensitivity called Phototoxic reactions are caused NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o C. Norfloxacin (Noroxin) o D. Sulfamethoxazole and Trimethoprim (Bactrim) o E. Isotretinoin (Accutane) o F. Nitro-Dur patch NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success body interact with UV rays from the sun. Anti- infectives are the most common cause of this type of reaction. o Option A: Ciprofloxacin is used to treat a variety of bacterial infections. Ciprofloxacin belongs to a class of drugs called quinolone antibiotics. It works by stopping the growth of bacteria. This antibiotic treats only bacterial infections. It will not work for virus infections (such as common cold, flu). Unnecessary use or overuse of any antibiotic can lead to its decreased effectiveness. o Option B: Sulfonamides are synthetic bacteriostatic antibiotics that competitively inhibit conversion of p- aminobenzoic acid to dihydropteroate, which bacteria need for folate synthesis and ultimately purine and DNA synthesis. Humans do not synthesize folate but acquire it in their diet, so their DNA synthesis is less affected. o Option C: Norfloxacin is an antibiotic in a group of drugs called fluoroquinolones. Norfloxacin fights bacteria in the body. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option A: Sulfasalazine may discolor the urine or skin to orange-yellow color. Sulfasalazine is used to treat ulcerative colitis (UC), and to decrease the frequency of UC attacks. Sulfasalazine will not cure ulcerative colitis, but it can reduce the number of attacks you have. Option B: Levodopa may discolor the urine, saliva, or sweat to a dark brown color. Levodopa is in a class of medications called central nervous system agents. It works by being converted to dopamine in the brain. Carbidopa is in a class of medications called decarboxylase inhibitors. It works by preventing levodopa from being broken down before it reaches the brain. Correct Answer: D. Aspirin Aspirin is not known to cause discoloration of the urine. Side effects and complications of taking aspirin include stroke caused by a burst blood vessel. The Food and Drug Administration doesn’t recommend aspirin therapy for the prevention of heart attacks in people who haven’t already had a heart attack, stroke or another cardiovascular condition. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success • 43. Question A patient tells you that her urine is starting to look discolored. If you believe this change is due to medication, which of the following of the patient’s medication does not cause urine discoloration? o A. Sulfasalazine o B. Levodopa o C. Phenolphthalein o D. Aspirin NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success o Option F: Nitro-Dur patch is used to prevent chest pain or angina. Its side effects are headache, lightheadedness, nausea, and NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success • 44. Question You are responsible for reviewing the nursing unit’s refrigerator. Which of the following drugs, if found inside the fridge, should be removed? o A. Nadolol (Corgard) o B. Opened (in-use) Humulin N injection o C. Urokinase (Kinlytic) o D. Epoetin alfa IV (Epogen) Correct Answer: A. Corgard Nadolol (Corgard) is stored at room temperature between 59 to 86 ºF (15 and 30 ºC) away from heat, moisture, and light. Do not store in the bathroom and keep the bottle tightly closed. o Option B: Humulin N injection if unopened NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success o Option C: Phenolphthalein can discolor the urine to a red color. Phenolphthalein is often used as an indicator in acid-base titrations. For this application, it turns colorless in acidic NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success (not in use) is stored in the fridge and can be used until the expiration date, or stored at room temperature and used within 31 days. If opened (in-use), store the vial in a refrigerator or at room temperature and use within 31 days. Store the injection pen at room temperature (do not refrigerate) and use within 14 days. Keep it in its original container protected from heat and light. Do not draw insulin from a vial into a syringe until you are ready to give an injection. Do not freeze insulin or store it near the cooling element in a refrigerator. Throw away any insulin that has been frozen. o Option C: Urokinase (Kinlytic) is refrigerated at 2–8°C. Lyophilized Urokinase although stable at room temperature for 3 weeks, should be stored desiccated below -18°C. Upon reconstitution Urokinase should be stored at 4°C between 2-7 days and for future use below -18°C. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option A: Before reporting to a social worker, it is imperative to start a prophylaxis to reduce viral replication. Option C: Pentamidine is an antimicrobial medication given to prevent and treat pneumocystis pneumonia. Option D: It is natural to have strong emotions after an exposure to HIV in the workplace. The healthcare Correct Answer: B. Start prophylactic AZT treatment Azidothymidine (AZT) treatment is the most critical intervention. It is an antiretroviral medication used to prevent and treat HIV/AIDS by reducing the replication of the virus. Post-exposure prophylaxis (PEP) for HIV is a treatment to suppress the virus and prevent infection after exposure. PEP should be taken within 72 hours of possible exposure to HIV, so it is important to seek treatment quickly. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success • 46. Question A second-year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most significant action that the nursing student should take? o A. Immediately see a social worker o B. Start prophylactic AZT treatment o C. Start prophylactic Pentamidine treatment o D. Seek counseling NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success immune surveillance by “arming” myeloid effector cells such as basophils and mast cells with IgD antibodies reactive against mucosal antigens, including commensal and pathogenic microbes. o Option C: IgE antibodies cause the body to react against foreign substances such as pollen, spores, animal dander. IgE antibodies are found in the lungs, skin, and mucous membranes. They are involved in allergic NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success • 47. Question A thirty-five-year-old male has been an insulin- dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect? o A. Atherosclerosis o B. Diabetic nephropathy o C. Autonomic neuropathy o D. Somatic neuropathy Correct Answer: C. Autonomic neuropathy Autonomic neuropathy (also known as Diabetic Autonomic Neuropathy) affects the autonomic nerves, which control the bladder, intestinal tract, NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success worker might feel anger, fear, blame, or depression. During the difficult time of prevention treatment and waiting, they may want to seek support. Try an employee- assistance program or local mental health NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success and genitals, among other organs. Paralysis of the bladder is a common symptom of this type of neuropathy, as manifested by bladder urgency and inability to start urination. o Option A: Atherosclerosis, or hardening of the arteries, is a condition in which plaque builds up inside the arteries. Plaque is made of cholesterol, fatty substances, cellular waste products, calcium, and fibrin (a clotting material in the blood). o Option B: Diabetic nephropathy (DN) is typically defined by macro albuminuria— that is, a urinary albumin excretion of more than 300 mg in a 24-hour collection—or macroalbuminuria and abnormal renal function as represented by an abnormality in serum creatinine, calculated creatinine clearance, or glomerular filtration rate (GFR). Clinically, diabetic nephropathy is characterized by a progressive increase in proteinuria and an increased need to urinate. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option A: Diverticulosis is a condition that develops when pouches (diverticula) form in the wall of the large intestine; most people don’t have symptoms. Option C: Hypocalcemia is low calcium levels in the blood; it is asymptomatic in mild forms but can cause paresthesia, tetany, muscle cramps, and carpopedal spasms in severe hypocalcemia. Option D: Irritable bowel syndrome is a widespread condition involving recurrent abdominal pain and diarrhea or constipation, often associated with stress, depression, anxiety, or previous intestinal infection. Correct Answer: B. Hypercalcemia Hypercalcemia can cause polyuria, severe abdominal pain, and confusion. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success A 24-year-old female is admitted to the ER due to confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Based on the presenting signs and symptoms, which of the following would you most likely suspect? o A. Diverticulosis o B. Hypercalcemia o C. Hypocalcemia o D. Irritable bowel syndrome • 50. Question Rhogam is most often used to treat mothers that have a NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success infant. o A. RH positive, RH positive o B. RH positive, RH negative o C. RH negative, RH positive NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o D. RH negative, RH negative Correct Answer: C. RH negative, RH positive Rhogam prevents the production of anti-RH antibodies in the mother that has an Rh-positive fetus. o Option A: RhoGAM is a prescription medicine that is used to prevent Rh immunization, a condition in which an individual with Rh-negative blood develops antibodies after exposure to Rh-positive blood. o Option B: If the father or baby is not conclusively shown to be Rh-negative, RhoGAM should be given to an Rh-negative mother in the following clinical situations to prevent Rh immunization: after delivery of an Rh-positive baby; routine prevention of Rh immunization at 26 to 28 weeks of pregnancy; maternal or fetal bleeding during pregnancy from certain conditions; or an actual or threatened pregnancy loss at any stage. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success Correct Answer: D. The effects of PKU are reversible. Phenylketonuria (PKU) is an inherited disorder that increases the levels of phenylalanine (a building block of proteins) in the blood. If PKU is not treated, phenylalanine can build up to harmful levels in the body, causing intellectual disability and other serious health problems. The signs and symptoms of PKU vary from mild to severe. The most severe form of this disorder is known as classic PKU. Infants with classic PKU appear normal until they are a few months old. Without treatment, these children develop a permanent intellectual disability. Seizures, delayed development, behavioral problems, and psychiatric disorders are also common. Untreated individuals may have a musty or mouse-like odor as a side effect of excess phenylalanine in the body. Children with classic PKU tend to have lighter skin and hair than unaffected family members and are also likely to have skin disorders such as eczema. The effects of PKU stay with the infant throughout their life (via Genetic Home Reference). o Option A: The Guthrie test as a bacterial NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success inhibition assay was formerly used, but now being replaced by tandem mass spectrometry. The Guthrie test, also called the PKU test, is a diagnostic tool to test infants for phenylketonuria a few days after birth. To administer the Guthrie test, doctors use Guthrie cards to collect capillary blood from an infant’s heel, and the cards are saved for later testing. o Option B: Phenylalanine is present in high concentrations in the urine because of its increased build up in the body. In addition to its role in protein production, phenylalanine is used to make other important molecules in the body, several of which send signals between different parts of the body. Phenylalanine has been studied as a treatment for several medical conditions, including skin disorders, depression, and pain o Option C: Without treatment, children affected with PKU develop a permanent intellectual disability. Seizures, delayed NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success development, behavioral problems, and psychiatric disorders are also common. Untreated individuals may have a musty or mouse-like odor as a side effect of excess phenylalanine in the body. Children with classic PKU tend to have lighter skin and NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option A: Letting others know is correct, so that the other staff may become aware of the patient’s condition. However, this is not a priority. Option B: Before communication with the supervisor, the charge nurse must secure the environmental safety of the client first. Option C: Continuously updating the patient on the social environment is also correct, but this can come after securing the client’s safety. Correct Answer: D. Provide a secure environment for the patient. This patient’s safety is your primary concern. Patient safety protocols can help reduce medical mistakes and prevent adverse patient outcomes. When the goal is to help people, it seems obvious that it’s important to work to protect them from unintended or unexpected harm. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success A 50-year-old blind and deaf patient has been admitted to your floor. As the charge nurse, your primary responsibility for this patient is? o A. Let others know about the patient’s deficits. o B. Communicate with your supervisor your patient safety concerns. o C. Continuously update the patient on the social environment. o D. Provide a secure environment for the patient. • 54. Question NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success A patient is getting discharged from a skilled nursing facility (SNF). The patient has a history of severe COPD and PVD. The patient is primarily concerned about his ability to breathe easily. Which of the following would be the best instruction for this patient? o A. Deep breathing techniques to increase oxygen levels. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Option A: Deep breathing exercises can help the client’s lungs from becoming more damaged. When one has healthy lungs, breathing is natural and easy. You breathe in and out with the diaphragm doing about 80 percent of the work to fill the lungs with a mixture of oxygen and other gases, and then send the waste gas out. Option B: Coughing may help clear the airway, however, it may not be as effective as taking bronchodilators. Coughing moves mucus out of the large airways. However, moving mucus out of the small airways requires airway clearance techniques (ACTs). This is why coughing should be done with other ACTs. Option D: Changing the level of oxygen at home without asking the healthcare provider is not recommended. Correct Answer: C. Cough following bronchodilator utilization The bronchodilator will allow a more productive cough. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success o B. Cough regularly and deeply to clear airway passages. o C. Cough following bronchodilator utilization. o D. Decrease CO2 levels by increased oxygen take output during meals. • 55. Question A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present? o A. Slow pulse rate o B. Weight gain NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Correct Answer: C. Oily skin The skin would be dry and not oily. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success American and White men and women. An elevated total white blood cell (WBC) count is a risk factor for atherosclerotic vascular disease. • 56. Question A mother has recently been informed that her child has Down’s syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down’s syndrome? o A. Simian crease o B. Brachycephaly o C. Oily skin o D. Hypotonicity NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2022) assured success Correct Answer: D. Observe for signs of bleeding Bleeding is the priority concern for a client taking thrombolytic medication. The primary mechanism of all thrombolytics is the conversion of plasminogen to the active form, plasmin, which then degrades fibrin. This proteolysis can occur with fibrin-bound plasminogen on the surface of thrombi and the unbound form within the plasma. The unbound plasmin generated degrades fibrin but also fibrinogen, NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success • 57. Question A client with myocardial infarction is receiving tissue plasminogen activator, alteplase (Activase, tPA). While on the therapy, the nurse plans to prioritize which of the following? o A. Observe for neurological changes o B. Monitor for any signs of renal failure o C. Check the food diary o D. Observe for signs of bleeding NCLEX-RN Exam Pack Set 1 (75 Questio & Answers Updated 2022) assured success o Option A: Simian crease refers to a single crease across the palm of the hand and is prominent among those with Down’s syndrome. o Option B: Brachycephaly is described as a shortening of the occipitofrontal diameter (front to the back of the head) of the fetal head. Postnatally, it is well established that babies with Down syndrome often had signs of brachycephaly in utero. o Option D: Patients with Down syndrome have low muscle tone or hypotonia, and Correct Answer: D. Observe for signs of bleeding Bleeding is the priority concern for a client taking thrombolytic medication. The primary mechanism of all thrombolytics is the conversion of plasminogen to the active form, plasmin, which then degrades fibrin. This proteolysis can occur with fibrin-bound plasminogen on the surface of thrombi and the unbound form within the plasma. The unbound plasmin generated degrades fibrin but also fibrinogen, Option B: Yellow vegetables are great sources of vitamins, such as vitamins A, B6, C, folate, magnesium, fiber, riboflavin, phosphorus, and potassium. Red meat is rich in protein, saturated fat, iron, zinc, and vitamin B. Option C: Carrots are a rich source of vitamin A from beta carotene, K1 (phylloquinone), and vitamin B6. Option D: Milk is a rich source of calcium. Milk is an excellent source of many vitamins and minerals, including vitamin B12, calcium, riboflavin, and phosphorus. It’s often fortified with other vitamins, especially vitamin D. Correct Answer: A. Green vegetables and liver Green vegetables and liver are a great source of folic acid. NCLEX-RN Exam Pack Set 1 (75 Questions & Answers Updated 2023) assured success • 58. Question A patient asks a nurse, “My doctor recommended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acids?” o A. Green vegetables and liver o B. Yellow vegetables and red meat o C. Carrots o D. Milk NCLEX-RN Exam P ck Set 1 (75 Questions & Answers Updated 2022) assured success o Option B: Although current guidelines do not include renal dysfunction as a contraindication to tPA therapy, some clinicians hesitate to administer tPA because of a tendency of bleeding in these patients. o Option C: Having a food diary is not related to the use of medication. Thrombolytic therapy is indicated in patients with evidence of ST- segment elevation MI (STEMI) or presumably new left bundle-branch block (LBBB) presenting within 12 hours of the onset of symptoms if