October 3, 2024

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NCLEX – RN Question Bank

1 / 85

1. The nurse is supervising a graduate nurse (GN) on a telemetry unit. An assigned client develops asystole with no pulse, and emergency care interventions are initiated. Which action by the GN would cause the supervising nurse to intervene?

2 / 85

2. The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulsus paradoxus?

 

3 / 85

3. In working with a rape victim, which of the following is most important?

4 / 85

4. The nurse is reviewing the lab results of a client with pancreatitis. Which of the following serum amylase levels is consistent with this diagnosis?

5 / 85

5. A third-grade child is referred to the mental health clinic by the school nurse because he is fearful, anxious, and socially isolated. After meeting with the client, the nurse talks with his mother, who says, “It’s that school nurse again. She’s done nothing but try to make trouble for our family since my son started school. And now you’re in on it.” The nurse should respond by saying:

6 / 85

6. A nurse in a pediatric clinic is preparing to administer ear drops to a 5-year-old. Which is an appropriate action by the nurse?

2.  3.  4.

7 / 85

7. The health care provider has just informed a client who has diabetes and chronic kidney disease of the need to start dialysis. The client tearfully says to the nurse, “I don’t know what I’m going to do; everything was so overwhelming before, and now there is this.” How should the nurse respond?

.  2.  3.  4.

8 / 85

8. The nurse assessing a client notices pearly white plaque-like lesions on the mouth mucosa. The nurse understands that which client is at highest risk for oral candidiasis?

 

 

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9. The nurse is assessing a client with a calcium level of 6.5 mg/dL. Which symptom should the nurse expect to find?

10 / 85

10. When planning the care for a client who is being abused, which of the following measures is most important to include?

11 / 85

11. A client is being seen in the clinic after receiving an external breast prosthesis after a mastectomy. What question from the nurse best evaluates the effectiveness of the prosthesis on body image

 

12 / 85

12. The charge registered nurse (RN) on a medical-surgical unit is responsible for making assignments. Which assignment made by the RN is most appropriate?

1. 2.  3.  4.

13 / 85

13. A client’s laboratory results show a fasting blood glucose level of 130 mg/dL. What condition does this value indicate?

14 / 85

14. A nurse is teaching a postpartum client about cord care for the newborn. Which statement by the client indicates a need for further teaching?

15 / 85

15. A married female client has been referred to the mental health center because she is depressed. The nurse notices bruises on her upper arms and asks about them. After denying any problems, the client starts to cry and says, “He didn’t really mean to hurt  me, but I hate for the kids to see this. I’m so worried about them.” Which of the following is the most crucial information for the nurse to determine?

16 / 85

16. A client with massive trauma and possible spinal cord injury is admitted to the emergency department following a motorcycle collision. Which assessment finding leads the nurse to suspect neurogenic shock?

17 / 85

17. The oncology nurse is caring for a client with tumor lysis syndrome. Which prescription should the nurse question?

18 / 85

18. The nurse receives report on several postpartum clients who gave birth at term gestation. Which client should the nurse assess first?

19 / 85

19. The nurse is assessing a 70-year-old client with a long history of type 2 diabetes mellitus for sudden, severe nausea, diaphoresis, dizziness, and fatigue in the emergency department. Which hospital protocol would be the most appropriate to follow initially?

 

 

1.  2.  3.  4.

20 / 85

20. Which of the following is a key nursing intervention for a patient at risk of TLS?

21 / 85

21. The nurse notes that a client’s platelet count is 90,000/µL. Which is the most appropriate intervention?

22 / 85

22. The nurse in an outpatient clinic is caring for a client with Addison disease who has been taking hydrocortisone 20 mg daily for the last 8 years. Which client data is most important to report to the health care provider?

23 / 85

23. The oncoming nurse is receiving report on 4 clients. Which should be the priority assessment?

2. 3. 4.

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24. A nurse is caring for a client on a mechanical ventilator. The ventilator is sounding an alarm and displaying an alert about low tidal volumes. The nurse has checked all connections and the endotracheal tube, but the alarm persists and the client’s oxygen saturation is dropping. What should the nurse do next?

25 / 85

25. A client’s complete blood count (CBC) shows a hemoglobin level of 7.8 g/dL. Which clinical manifestation should the nurse anticipate?

26 / 85

26. The nurse assesses a newborn with skin discoloration in the lumbar area, as shown in the exhibit. What would be an appropriate action for the nurse to complete? Click the exhibit button for additional information.

Exhibit

Birthmarks in babies, children and teens | Raising Children Network

 

 

 

 

27 / 85

27. A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running. The spouse says to the nurse, “If I hadn’t come home early from work, my spouse would be dead. I can’t believe this is happening.” What is the best response by the nurse?

28 / 85

28. Which electrolyte imbalance is most commonly associated with Tumor Lysis Syndrome?

29 / 85

29. A client’s lab results indicate a white blood cell (WBC) count of 15,000/mm³. What might this lab value suggest?

30 / 85

30. The triage nurse is assessing an unvaccinated 4-month-old infant for fever, irritability, and open-mouthed drooling. After the infant is successfully treated for epiglottitis, the parents wonder how this could have been avoided. Which response by the nurse would be most appropriate?

1. 2.  3.  4. “There is nothing you could have done; the important thing is that your child is safe now.”

31 / 85

31. The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching?

32 / 85

32. Upon arrival in the post-anesthesia care unit, the nurse performs the initial assessment of a client who had surgery under general anesthesia. Which assessment finding prompts the nurse to notify the health care provider immediately?

33 / 85

33. The nurse plans teaching for an adolescent client being discharged home with a Boston brace for treatment of scoliosis. Which instruction will the nurse include in the discharge teaching plan

34 / 85

34. What is a common symptom of hyperphosphatemia in a patient with TLS?

35 / 85

35. What is the primary purpose of administering IV fluids to a patient with TLS?

36 / 85

36. After months of counseling, a client abused by her husband tells the nurse that she has decided to stop treatment. There has been no abuse during this time, and she feels better able to cope with the needs of her husband and children. In discussing this decision with the client, the nurse should:
1.
2.
3.
4.

37 / 85

37. A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off?

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38. A client is admitted to the labor and delivery unit with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures should the nurse include in this client’s plan of care? Select all that apply.

39 / 85

39. The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with urinary tract infection. To promote client safety, which intervention is most important for the charge nurse to implement?

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40. What is the first-line treatment for hyperuricemia in TLS?

41 / 85

41. The initial prenatal laboratory screening results of a client at 12 weeks gestation indicate a rubella titer status of nonimmune. What will the nurse anticipate as the plan of care for this client?

42 / 85

42. What is the primary cause of Tumor Lysis Syndrome?

43 / 85

43. A client with latent tuberculosis has been taking oral isoniazid (INH) 300 mg daily for 2 months. The client tells the nurse that for the past week she has had numbness, a burning sensation, and tingling in her hands and feet. Additional intake of which of the following would most likely have prevented this?

1. Folic acid 2. Vitamin B 3.  4.

44 / 85

44. What socioeconomic indicators would the nurse identify as risk factors for a 2-month-old infant to develop failure to thrive (FTT)? Select all that apply.

45 / 85

45. A client’s laboratory results show a serum sodium level of 128 mEq/L. Which of the following findings should the nurse expect?

46 / 85

46. The nurse is reviewing the medication administration record of a client with atrial fibrillation. Which of the following should the nurse monitor before giving these medications? Select all that apply. Click the exhibit button for more information.

M

47 / 85

47. A client with AIDS treated for intractable seizures is transferred from the intensive care unit to the medical unit. There are 4 semiprivate room beds available. Which room assignment does the charge nurse choose as the best option for this client?

 

 

 

 

 

48 / 85

48. A client with chronic kidney disease has a serum potassium level of 6.2 mEq/L. Which action should the nurse take first?

49 / 85

49. The nurse is teaching a class of expectant parents about infant safety. Which statement by a class participant indicates a need for further instruction?

50 / 85

50. The public health nurse conducts a program at the community senior citizen center about preventing falls at home. Which statement made by a participant indicates that further education is needed?

51 / 85

51. The student nurse and the registered nurse are caring for a mechanically ventilated client with an acute lung injury. Which statement by the student nurse indicates a need for further education?

52 / 85

52. The parents of a 5-year-old ask the school nurse for advice on how to tell their child about being adopted. Which developmentally appropriate thought about adoption by the child does the nurse counsel the parents to anticipate?

53 / 85

53. The hospital nurse coming on duty notifies the unit of a delay due to a motor vehicle accident. The off-going nurse has an important appointment and must leave on time. How should the off-going nurse handle the situation?

54 / 85

54. The nurse has provided education for a client newly prescribed alprazolam for generalized anxiety disorder. Which client statement indicates that teaching has been effective?

1. “Eliminating aged cheeses and processed meats from my diet is essential.” 2.  3. 4.

55 / 85

55. A client with chronic heart failure developed an intractable cough and an incident of angioedema after starting enalapril. Which prescription does the nurse anticipate for this client?

56 / 85

56. A client has been on long-term therapy with esomeprazole. What is essential for the nurse to ask the client?

57 / 85

57. A client tells the nurse that she has been raped but has not reported it to the police. After determining whether the client was injured, whether it is still possible to collect evidence, and whether to file a report, the nurse’s next priority is to offer which of the following to the client?

58 / 85

58.
The nurse is assessing a client diagnosed with tuberculosis who started taking rifapentine a week ago. Which statement by the client warrants further assessment and intervention by the nurse?

59 / 85

59. A patient with TLS is at risk for which of the following cardiac complications?

60 / 85

60. The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness. The client is flushed, sweating, nauseated, and slightly tachycardic. Which action is most appropriate at this time?

61 / 85

61. Which medication is used to treat hyperkalemia by shifting potassium into cells?

62 / 85

62. The unlicensed assistive personnel (UAP) reports finding a reddened area on a client’s sacrum during a bath. What is the nurse’s priority action?

63 / 85

63. A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse?

64 / 85

64. During a routine clinic visit, the nurse is providing education to a 24-year-old female client with Marfan syndrome and aortic root dilation. Which statement made by the nurse is appropriate ?

1.  2.  3.  4.

65 / 85

65. The nurse is conducting a pain assessment on a client with dysuria. Which pain description is most likely associated with pyelonephritis?

66 / 85

66. Which laboratory test result is most indicative of TLS?

67 / 85

67. The presence of which symptom suggests that a patient with TLS might be experiencing hypocalcemia?

68 / 85

68. A client with suspected abuse describes her husband as a good man who works hard and provides well for his family. She does not work outside the home and states that she is proud to be a wife and mother just like her own mother. The nurse interprets the family pattern described by the client as best illustrating which of the following as characteristic of abusive families?

69 / 85

69. A nurse is assessing a client who is being abused. The nurse should assess the client for which characteristic? Select all that apply.

70 / 85

70. The mother of a school-aged child tells the nurse that, “For most of the past year, my husband was unemployed and I worked a second job. Twice during the year I spanked my son repeatedly when he refused to obey. It has not happened again. Our family is back to normal.” After assessing the family, the nurse decides that the child is still at risk for abuse. Which of the following observations best supports this conclusion?

71 / 85

71. A client with a mandibular fracture who has the upper and lower teeth wired together begins to choke on excessive oral secretions. What is the nurse’s immediate action?

72 / 85

72. The nurse just administered routine immunizations to a healthy 15-month-old. What information should the nurse provide the caregivers before they leave the clinic?

73 / 85

73. The nurse is teaching the home health client how to perform colostomy irrigation. Which client action reveals that further teaching is required?

74 / 85

74. During shift change, the night nurse notices that the graduate nurse administered IV dopamine instead of the prescribed norepinephrine for a client with sepsis. What should the night nurse do first?

1.  2.  3.  4.

75 / 85

75. Which client does the nurse assess first after receiving morning report?

 

76 / 85

76. The nurse is preparing to administer IV cefazolin to a client with cellulitis. The client’s allergies are listed as amoxicillin, ciprofloxacin, and sulfa drugs. What should the nurse do first?

 

77 / 85

77. A client diagnosed with trigeminal neuralgia is given a prescription of carbamazepine by the health care provider. Which intervention does the nurse add to this client’s care plan?

78 / 85

78. The nurse on the medical unit finishes receiving the change of shift hand-off report at 7:30 AM. Which assigned client should the nurse see first?

 

79 / 85

79. Yesterday, the client was weaned from the mechanical ventilator and an intravenous infusion of lorazepam. The client has been alert and oriented for 24 hours but is now experiencing confusion. The nurse now evaluates new-onset confusion by assessing the client’s sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy. The nurse suspects which condition in this client?

80 / 85

80. A client is brought to the emergency department by emergency medical services with a flaccid right arm and leg and lack of verbal response. The stroke alert team is initiated. The nurse takes which priority action?

81 / 85

81. The nurse is conducting a health-screening clinic at an industrial work site. The nurse should be most concerned about which client’s risk for metabolic syndrome?

82 / 85

82. The charge nurse on a telemetry unit is training a new registered nurse (RN). The charge nurse assists the new RN in prioritizing assessments of multiple clients. Which client should be assessed first?

83 / 85

83. A client has an INR of 4.5 while on warfarin therapy. Which action should the nurse take?

84 / 85

84. When caring for a client who was a victim of a crime, the nurse is aware that recovery from any crime can be a long and difficult process depending on the meaning it has for the client. Which of the following should the nurse establish as a victim’s ultimate goal in reconstructing his or her life?
1.
2.
3.
4.

85 / 85

85. A client’s lab results show a blood urea nitrogen (BUN) level of 25 mg/dL and a creatinine level of 1.8 mg/dL. What do these findings suggest?

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ABG Analysis

ABG Analysis

Mastering ABG analysis is essential for nursing practice and success on the NCLEX. Each question in this set emphasizes key concepts, including the identification of acid-base imbalances, physiological responses, and their implications for patient care. A strong grasp of these principles will enhance your ability to assess and respond effectively to patients' needs in various clinical situations.

The number of attempts remaining is 5

1 / 50

A patient with diabetes presents with a fruity odor on their breath. ABG results show: pH 7.25, PaCO2 40 mmHg, HCO3- 15 mEq/L. What condition is this indicative of?

2 / 50

Which of the following scenarios would likely lead to respiratory alkalosis?

3 / 50

A patient with an acute asthma attack is likely to have which of the following ABG results?

4 / 50

ABG results show: pH 7.48, PaCO2 42 mmHg, HCO3- 30 mEq/L. What does this indicate?

5 / 50

A patient presents with confusion and lethargy. ABG analysis reveals pH 7.34, PaCO2 55 mmHg, HCO3- 26 mEq/L. Which of the following interventions is the priority?

6 / 50

A nurse notices a patient has rapid, shallow breathing. The patient’s ABG shows: pH 7.45, PaCO2 30 mmHg, HCO3- 22 mEq/L. What is the likely diagnosis?

7 / 50

Which of the following can lead to metabolic alkalosis?

8 / 50

If a patient is experiencing metabolic alkalosis, which ABG result might be expected?

9 / 50

Which patient condition would most likely cause metabolic alkalosis?

10 / 50

A patient with a history of excessive alcohol consumption presents with ABG results: pH 7.30, PaCO2 40 mmHg, HCO3- 15 mEq/L. What is the likely diagnosis?

11 / 50

A patient’s ABG shows: pH 7.45, PaCO2 48 mmHg, HCO3- 36 mEq/L. What condition does this most likely indicate?

12 / 50

A patient is experiencing respiratory distress and has an ABG result of pH 7.32, PaCO2 52 mmHg, HCO3- 24 mEq/L. What does this indicate?

13 / 50

A patient with renal failure shows ABG results of pH 7.25, PaCO2 40 mmHg, HCO3- 16 mEq/L. This indicates:

14 / 50

A patient’s ABG indicates a pH of 7.50, what should the nurse suspect?

15 / 50

In a patient with respiratory acidosis, what is the expected change in the kidneys?

16 / 50

A patient presents with a high HCO3- level and a pH of 7.50. What could this indicate?

17 / 50

A patient with chronic kidney disease shows signs of acidosis. What ABG change would be expected?

18 / 50

A patient in renal failure presents with pH 7.30 and HCO3- 15 mEq/L. What is the expected respiratory response?

19 / 50

A patient is hyperventilating due to anxiety. What would you expect their ABG results to show?

20 / 50

What is a common cause of metabolic acidosis?

21 / 50

ABG results show: pH 7.45, PaCO2 35 mmHg, HCO3- 21 mEq/L. What is the interpretation?

22 / 50

A patient has a pH of 7.39, PaCO2 of 52 mmHg, and HCO3- of 28 mEq/L. This patient is likely experiencing:

23 / 50

ABG results show: pH 7.40, PaCO2 32 mmHg, HCO3- 19 mEq/L. Which acid-base balance does this indicate?

24 / 50

A patient has a pH of 7.30, PaCO2 30 mmHg, HCO3- 18 mEq/L. What is the most likely diagnosis?

25 / 50

The nurse is interpreting ABG results: pH 7.50, PaCO2 30 mmHg, HCO3- 24 mEq/L. What condition is indicated?

26 / 50

A patient is hypoventilating after a drug overdose. What would their ABG likely show?

27 / 50

A patient with chronic kidney disease has a pH of 7.35 and HCO3- of 18 mEq/L. What is the likely diagnosis?

28 / 50

A patient has a pH of 7.39, PaCO2 of 52 mmHg, and HCO3- of 28 mEq/L. This patient is likely experiencing:

29 / 50

A patient with severe dehydration would likely exhibit which of the following ABG results?

30 / 50

In a patient with a suspected pulmonary embolism, what ABG changes might you expect?

31 / 50

What is the normal range for arterial blood pH?

32 / 50

Which of the following ABG values would indicate respiratory alkalosis?

33 / 50

ABG results show: pH 7.47, PaCO2 38 mmHg, HCO3- 29 mEq/L. The nurse should assess for which of the following?

34 / 50

A patient presents with tachycardia and muscle cramps. ABG analysis shows: pH 7.50, PaCO2 38 mmHg, HCO3- 30 mEq/L. What should the nurse assess for?

35 / 50

The nurse is caring for a patient with COPD. Which ABG result would indicate respiratory acidosis?

36 / 50

A patient with chronic respiratory acidosis may develop:

37 / 50

A patient with renal failure presents with ABG results: pH 7.32, PaCO2 42 mmHg, HCO3- 16 mEq/L. What does this indicate?

38 / 50

A patient with a history of COPD is experiencing respiratory acidosis. Which intervention is most appropriate?

39 / 50

A nurse is reviewing ABG results: pH 7.35, PaCO2 50 mmHg, HCO3- 25 mEq/L. Which condition is most likely?

40 / 50

In which condition would you expect to see a decreased HCO3- level?

41 / 50

If a patient’s ABG shows a pH of 7.28, what should the nurse suspect?

42 / 50

A patient presents with tachypnea and lightheadedness. Which ABG finding would be expected?

43 / 50

A patient presents with confusion and fatigue. Their ABG results show: pH 7.28, PaCO2 58 mmHg, HCO3- 22 mEq/L. What condition do these findings suggest?

44 / 50

ABG results show: pH 7.38, PaCO2 48 mmHg, HCO3- 26 mEq/L. This indicates which type of compensation?

45 / 50

A nurse reviews an ABG report: pH 7.35, PaCO2 55 mmHg, HCO3- 22 mEq/L. Which nursing diagnosis is appropriate?