Answers and Rationale of Sample NCLEX Questions

View the Sample NCLEX Questions

1.  B  Administering supplemental oxygen to the patient is the first priority.  Administer oxygen to increase SpO₂ to greater than 90% to help prevent further cardiac damage.  Sublingual nitroglycerin and morphine are commonly administered after oxygen.

2.  D  Lower back pain results from expansion of the aneurysm.  The expansion applies pressure in the abdomen, and the pain is referred to the lower back.  Abdominal pain is the most common symptom resulting from impaired circulation.  Absent pedal pulses are a sign of no circulation and would occur after a ruptured aneurysm or in peripheral vascular disease.  Chest pain usually is associated with coronary artery or pulmonary disease.

3.  B  Cardiac output isn’t affected by hypertrophic cardiomyopathy because the size of the ventricle remains relatively unchanged.  Dilated cardiomyopathy, obliterative cardiomyopathy, and restrictive cardiomyopathy all decrease cardiac output.

4.  A The initial priority is to decrease oxygen consumption by sitting the patient down.  Administer sublingual nitroglycerin as you simultaneously do the ECG.  When the patient’s condition is stabilized, he can be returned to bed.

5.  C High Fowler’s position facilitates breathing by reducing venous return.  Lying flat and side-lying positions worsen breathing and increase the heart’s workload.

6.  C Abruptio placentae is a cause of DIC because it activates the clotting cascade after hemorrhage.  Thrombocytopenia results from decreased production of platelets.  ITP doesn’t have a definitive cause.  A patient with abruptio placentae wouldn’t get heparin and, as a result, wouldn’t be at risk for HATT.

7. D  In a trauma situation, the first blood product given is unmatched (0 negative) packed red blood cells.  Fresh frozen plasma often is used to replace clotting factors.  Lactated Ringer’s solution or 0.9% sodium chloride is used to increase volume and blood pressure, but too much of these crystalloids will dilute the blood and won’t improve oxygen-carrying capacity.

8.  C  Corticosteroids suppress eosinophils, lymphocytes, and natural-killer cells, inhibiting the natural inflammatory process in an infected or injured part of the body.  This helps resolve inflammation, stabilizes lysosomal membranes, decreases capillary permeability, and depresses phagocytosis of tissues by white blood cells, thus blocking the release of more inflammatory materials.  Excessive corticosteroid therapy can lead to Cushing syndrome.

9.  B  Zidovudine inhibits DNA synthesis in HIV, thus interfering with viral replication.  The drug doesn’t destroy the viral wall, stimulate the immune system, or promote HIV antibody excretion.

10. D  Showing this patient how to splint his chest wall will help decrease discomfort when coughing.  Holding in his coughs will only increase his pain.  Placing the head of the bed flat may increase the frequency of his cough and his work of breathing.  Increasing fluid intake will help thin his secretions, making it easier for him to clear them.

11. B  The patient having an acute asthma attack needs more oxygen delivered to his lungs and body.  Nebulized bronchodilators open airways and increase the amount of oxygen delivered.  The patient may not need cardiac monitoring because he’s only 19 years old, unless he has a medical history of cardiac problems.

12. A  Severe hypoxia after smoke inhalation typically is related to ARDS.  The other choices aren’t typically associated with smoke inhalation.

13. D  The chest tube isn’t removed until the patient’s lung has adequately reexpanded and is expected to stay that way.  One indication of reexpansion is the cessation of fluctuation in the water-seal chamber when suction isn’t applied.  The chest X-ray should show that the lung is reexpanded.  Drainage should be minimal before the chest tube is removed.  An ABG test isn’t necessary if clinical assessment criteria are met.

14. A  High-top sneakers are used to prevent footdrop and contractures in patients with neurologic conditions.  A consult with physical therapy is important to prevent footdrop, but you can use high-top sneakers independently.

15. C  The earliest sign of increased ICP is a change in mental status.  Bradycardia and widened pulse pressure occur later.  The patient may void a lot of very dilute urine if his posterior pituitary is damaged.

16. C  Phenytoin is compatible only with saline solutions; dextrose causes an insoluble precipitate to form.  You needn’t withhold additional anticonvulsants or use an in-line filter.

17. A  After surgical repair of the hip, keep the legs and hips abducted to stabilize the prosthesis in the acetabulum.

18. B  Acute pancreatitis is commonly associated with fluid isolation and accumulation in the bowel secondary to ileus or peripancreatic edema.  Fluid and electrolyte loss from vomiting is a major concern.  Therefore, your priority is to manage hypovolemia and restore electrolyte balance.  Pain control and nutrition also are important.  Patients are at risk for hyperglycemia, not hypoglycemia.

19. B  Positioning the patient on his right side with the bed flat will splint the biopsy site and minimize bleeding.  The other positions won’t do this and may cause more bleeding at the site or internally.

20. B  Precipitation of angina or cardiac arrhythmia is a potentially serious complication of hypothyroidism treatment.  Acute hemolytic reaction is a complication of blood transfusions.  Retinopathy typically is a complication of diabetes mellitus.  Thrombocytopenia doesn’t result from treating hypothyroidism.

21. B  Maintaining adequate fluid and replacing vasopressin are the main objectives in treating diabetes insipidus.  An excess of antidiuretic hormone leads to SIADH, causing the patient to retain fluid.  Diabetic ketoacidosis is a result of severe insulin insufficiency.

22. C  During periods of infection or illness, patients with Type 1 diabetes may need even more insulin to compensate for increased blood glucose levels.

23. A  A decreased hematocrit level is a sign of hematoma, a delayed complication of abdominal and vaginal hysterectomy.  Symptoms of hypovolemia include increased hematocrit and hemoglobin values.  Symptoms of a PE include dyspnea, chest pain, cough, hemoptysis, restlessness, and signs of shock.

24. C  Lactated Ringer’s solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn.  Albumin is used as adjunct therapy, not primary fluid replacement.  Dextrose isn’t given to burn patients during the first 24 hours because it can cause pseudodiabetes.  The patient is hyperkalemic from the potassium shift from the intracellular space to the plasma, so potassium would be detrimental.

25. C  Rolling a swab from the center outward is the right way to obtain a culture specimen from a wound.  Irrigating the wound washes away drainage, debris, and many of the colonizing or infecting microorganisms.  The outside of the wound and the dressing may be colonized with microorganisms that haven’t affected the wound, so specimens from these sites could give inaccurate results.