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NCLEX REVIEW QUESTIONS WITH COMPLETE RATIONALES /75 FREE NCLEX QUESTIONS - C/O BRILLIANTNURSE.COM
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NCLEX REVIEW QUESTIONS WITH COMPLETERATIONALES /75 FREE NCLEX QUESTIONS - C/O
BRILLIANTNURSE.COM
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 Correct Answer: 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
3. Hernia
4. Hyperthermia Correct Answer: 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." Correct Answer: 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"
Incorrect - This is a correct verbalization of health promotion for GERD.
3. "I won't be drinking tea or coffee or eating chocolate any more."
Incorrect - This is a correct verbalization of health promotion for GERD.
4. "I'm going to start trying to lose some weight."
Incorrect - This is a correct verbalization of health promotion for GERD.
The nurse in the Emergency Room is treating a patient suspected to have a Peptic Ulcer. On
assessing lab results, the nurse finds that the patient's blood pressure is 95/60, pulse is 110 beats
per minute, and the patient reports epigastric pain. What is the PRIORITY intervention?
1. Start a large-bore IV in the patient's arm
2. Ask the patient for a stool sample
3. Prepare to insert an NG Tube
4. Administer intramuscular morphine sulphate as ordered Correct Answer: 1. Start a large-bore IV in
the patient's arm
CORRECT - The nurse should suspect that the patient is haemorrhaging and will need need a fluid
replacement therapy, which requires a large bore IV.
2. Ask the patient for a stool sample
Incorrect - While this is useful in the diagnosis and assessment of Peptic Ulcer Disease, it is not the
priority intervention.
3. Prepare to insert an NG Tube
Incorrect - While this intervention may be used in the later stages of Peptic Ulcer Disease, it is not the
first and priority intervention.
4. Administer intramuscular morphine sulphate as ordered
Incorrect - While this is an important intervention to manage pain, it is not the priority intervention.
,A female patient with atrial fibrillation has the following lab results: Hemoglobin of 11 g/dl, a platelet
count of 150,000, an INR of 2.5, and potassium of 2.7 mEq/L. Which result is critical and should be
reported to the physician immediately?
1. Hemoglobin 11 g/dl
2. Platelet of 150,000
3. INR of 2.5
4. Potassium of 2.7 mEq/L Correct Answer: 1. Hemoglobin 11 g/dl
This is below normal, but a normal female hemoglobin is 12-14. There is a more critical lab result.
2. Platelet of 150,000
This is also below the normal values, but is not the most critical lab result.
3. INR of 2.5
This is a therapeutic range for a patient who is taking an anticoagulant for atrial fibrillation
4. Potassium of 2.7 mEq/L
CORRECT - A potassium imbalance for a patient with a history of dysrhythmia can be life-threatening
and can lead to cardiac distress.
While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patient's lower
legs have become edematous and auscultates crackles in the lungs. What should the nurse do first?
1. Stop the saline infusion immediately
2. Notify Physician
3. Elevate the patient's legs
4. Continue the infusion, since these are normal findings Correct Answer: 1. Stop the saline infusion
immediately
CORRECT - the patient has a fluid volume overload as a result of overly rapid fluid replacement. The
nurse should stop the infusion and notify the physician.
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 Correct Answer: 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.
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 Correct Answer: 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
5. The patient's lithium level is 1.3 mcg/L Correct Answer: 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.
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