NCLEX 1
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
4. Encourage the patient to limit activity
Check the patient's oxygen saturation - An elevated BNP indicates that there is decreased cardiac output. A priority intervention would be to ensure proper oxygenation after an assessment.
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
A 75-year-old woman in a hospice program -
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.
A nurse is caring for a patient with a cast on the right leg. Which of these assessment findings would most concern the nurse?
1. The capillary refill time is 2 seconds
2. The patient complains of itching and discomfort
3. The cast has a foul-smelling odor
4. The patient is on antibiotics
The cast has a foul-smelling odor
A foul-smelling odor is a sign of infection or a pressure ulcer within the cast. Other symptoms include a feeling of warmth, tightness and pain.
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"
"My shoulder and arm is hurting."
Unilateral arm and shoulder pain is one of the classic symptoms of myocardial ischemia. The stress test should be halted.
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
Melena -
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
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?
1. The nursing assistant fills the patient's pitcher with ice cold drinking water
2. The nursing assistant elevates the head of the bed to 60 degrees for a meal
3. The nursing assistant refills the ice pack laying on the insertion site
4. The nursing assistant places an extra pillow under the patient's head on request
The nursing assistant elevates the head of the bed to 60 degrees for a meal -
For 3-6 hours after a coronary angiogram (depending on the insertion site), the patient should have their bed no higher than 30 degrees and be on bedrest.
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
3. Audible crackles and use of accessory muscles
4. Audible wheeze and orthopnea
An audible wheeze and use of accessory muscles -
Both of these are associated with asthma.
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
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
Place the patient under contact precautions
A patient with an infectious wound, especially one not adequately contained by a dressing, should be put under contact precautions.
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
4. Check the patient's last ejection fraction
Obtain and attach defibrillator leads
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.
The home care nurse evaluates a client diagnosed with tuberculosis and receiving isoniazid, rifampin, and pyrazinamide. Which client statement requires further assessment by the nurse?
"I have gained 5 pounds since I started taking the medication."
"I cover my nose and mouth when I cough or sneeze."
"I drink a glass of wine with dinner each night."
"I have stopped eating tuna salad sandwiches."
"I drink a glass of wine with dinner each night."
An adverse reaction of isoniazid is hepatitis. Instruct a client to avoid ingesting alcohol when taking the medication.
A man is has been taking lisinopril for CHF. The patient is seen in the emergency room for persistent diarrhea. The nurse is concerned about which side effect of lisinopril?
1. Vertigo
2. Hypotension
3. Palpitations
4. Nagging, dry cough
Hypotension - The patient is particularly at risk for hypotension due to possible dehydration from fluid loss.
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)
Lactated Ringer's -
Lactated Ringer's solution is often used in fluid replacement therapy, which is not warranted if a patient is at risk for high ICP
A patient is admitted and complains of gastric pain, fever, and diarrhea. Which assessment finding should be reported to the healthcare provider immediately?
1. Abdominal distention
2. A bruit near the epigastric area
3. 3 episodes of vomiting in the last hour
4. Blood pressure of 160/90
A bruit near the epigastric area
A bruit in the aortic area signals the presence of an aneurysm. This is life-threatening and must be reported immediately.
A female patient is prescribed metformin for glucose control. The patient is on NPO status pending a diagnostic test. The nurse is most concerned about which side effect of metformin?
1. Diarrhea and Vomiting
2. Dizziness and Drowsiness
3. Metallic taste
4. Hypoglycemia
Hypoglycemia
The patient is at risk because she is on NPO status and continuing to take an anti-glycemic drug.
Which of the following steps is the final step that is used during the physical assessment of the abdomen?
Deep palpation is cautiously done after light palpation when necessary because the client’s responses to deep palpation may include their tightening of the abdominal muscles, for example, which will make the light palpation less effective for this assessment, particularly if an area of pain or tenderness has been palpated.
Inspection is typically the first step and percussion of the abdomen should be done prior to any palpation, particularly deep palpation.
The nurse is taking the health history of a patient being treated for sickle cell disease. After being told the patient has severe generalized pain, the nurse expects to note which assessment finding?
1. Severe and persistent diarrhea
2. Intense pain in the toe
3. Yellow-tinged sclera
4. Headache
Yellow-tinged sclera -
Jaundice is a common clinical finding of sickle cell disease, caused by bilirubin released from damaged or destroyed RBCs
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
Intracranial Pressure is 22 mm/Hg
The patient is at greatest risk for an increased ICP resulting from edema 72 hours after a stroke. A target ICP should be less than or equal to 15-20 mm/Hg
The nurse is caring for a patient who has recently had a successful catheter ablation. Which assessment finding demonstrates a successful outcome of this procedure?
1. The patient is free of electrolyte imbalances
2. The patient's WBC count is within normal limits
3. The patient's EKG reading is regular
4. The patient's urine output is 45mL/hour
The patient's EKG reading is regular -
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.
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
The patient states he has been having diarrhea every day
Persistent diarrhea can lead to dehydration, which can increase the risk of lithium toxicity.
A comprehensive health assessment includes:
A complete medical history, a general survey and a complete physical assessment.
A client with Multiple Sclerosis reports a constant, burning, tingling pain in the shoulders. The nurse anticipates that the physician will order which medication for this type of pain?
1. Alprazolam (Xanax)
2. Corticosteroid injection
3. Gabapentin (Neurontin)
4. Hydrocodone/acetaminophen (Norco)
Gabapentin (Neurontin) -
Anticonvulsants like gabapentin are often the first line of treatment for nerve pain
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.
A 20-year old woman who has unexplained joint pain and a low BMI.
MRI can be used to diagnose musculoskeletal disorders, and this patient has no contraindications to an MRI.
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
CT of the spine with contrast
The creatinine level of this patient indicates impaired kidney function. Contrast is nephrotoxic and is contraindicated for patients with nephropathy.
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
Stop the saline infusion immediately
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.
Select the age group that is accurately paired with the normal and recommended hours of sleep each day.
The Toddler -
The age group that is accurately paired with the normal and recommended hours of sleep each day is the toddler should sleep about 11 to 14 hours per day.
The neonate should sleep 14 to 17 hours per day; the preschool child should sleep 10 to 13 hours per day; and the school age child should sleep 9 to 11 hours per day.