75 NEXT GENERATION NCLEX Questions
Comprehensive NCLEX Practice Questions and Review
Get ready for your NCLEX exam with high yield NCLEX practice questions with rationales. Let’s Get Started! “Scroll Down” to the bottom of the page for the answers and explanations.
1. A client is admitted to the emergency department with chest pain and suspected myocardial infarction. Which of the following 3 interventions should the nurse perform?
A. Administer aspirin
B. Administer nitroglycerin
C. Administer heparin
D. Administer morphine
E. Administer beta blockers
F. Administer angiotensin-converting enzyme (ACE) inhibitors
G. Administer thrombolytic therapy
2. A patient is admitted to the hospital with acute renal failure. The nurse should monitor the patient for which of the following complications? Select all that apply.
A. Hyperkalemia
B. Hypoglycemia
C. Hyponatremia
D. Hypotension
E. Hypertension
F. Hypocalcemia
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3. A client with chronic bronchitis is prescribed bronchodilator therapy. Which of the following are common types of bronchodilators used to treat chronic bronchitis? Select all that apply.
A. Albuterol
B. Ipratropium
C. Montelukast
D. Theophylline
E. Fluticasone
F. Budesonide
Your Answer:
4. A 65-year-old female client presents to the clinic with complaints of back pain and loss of height. She has a family history of osteoporosis. Which interventions should the nurse suggest to prevent osteoporosis? Select all that apply.
A. Increase daily calcium intake
B. Engage in regular weight-bearing exercise
C. Limit sun exposure
D. Increase alcohol intake
E. Stop smoking
F. Take vitamins
5. A client with congestive heart failure is receiving digoxin therapy. Which of the following symptoms may indicate toxicity? (Select all that apply.)
A. Nausea and vomiting
B. Visual disturbances
C. Confusion and disorientation
D. Bradycardia
E. Hypertension
F. Hypotension
6. A client is admitted to the emergency department with symptoms of a pulmonary embolism. Which of the following diagnostic tests is most appropriate for confirming the diagnosis?
A. Chest X-ray
B. Electrocardiogram (ECG)
C. D-dimer test
D. Computed tomography (CT) pulmonary angiography
E. MRI
7. A patient is diagnosed with Cushing’s disease. The nurse should expect to observe which of the following symptoms? Select all that apply.
A. Weight loss
B. Moon face
C. Muscle wasting
D. Hypotension
E. Hyperglycemia
F. Hyperpigmentation
8. A client with congestive heart failure is being discharged from the hospital. Which of the following instructions should the nurse provide to the client? (Select all that apply.)
A. Follow a low-sodium diet
B. Limit fluid intake
C. Weigh yourself daily
D. Take diuretics as prescribed
E. Increase physical activity gradually
F. Take calcium channel blockers as prescribed
9. A client with COPD is experiencing an exacerbation and is having difficulty breathing. Which of the following interventions are appropriate for the nurse to implement? Select three interventions.
A. Administering oxygen
B..Administering a short-acting bronchodilator
C Administering a long-acting bronchodilator
D. Administering an inhaled corticosteroid
E. Administering a nebulizer treatment
F. Administering a mucolytic agent
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10. Which of the following signs and symptoms are commonly seen in patients with deep vein thrombosis? Select all that apply
A. Painful swelling in the affected limb
B. Warmth and redness in the affected limb
C. Palpitations and tachycardi
D. Shortness of breath
E. Elevated blood pressure
F. Cyanosis in the affected limb
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11. A client with a history of myocardial infarction is being discharged from the hospital. Which of the following instructions should the nurse provide to the client? (Select all that apply.)
A. Follow a low-fat diet
B. Engage in regular exercise
C. Take nitroglycerin as needed for chest pain
D. Avoid caffeine and alcohol
E. Take beta blockers as prescribed
F. Monitor blood pressure at home
G. Stop taking aspirin if experiencing gastrointestinal upset
H. Avoid over-the-counter medications
12. A patient with acute renal failure is receiving treatment with continuous renal replacement therapy (CRRT). The nurse should be aware of which of the following nursing interventions? Select 3 interventions.
A. Monitor electrolyte levels
B. Assess the access site for signs of infection
C. Monitor for bleeding
D. Administer heparin to prevent clotting
E. Encourage fluid intake
13. A patient with acute renal failure is at risk for which of the following complications? Select all that apply.
A. Metabolic alkalosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Respiratory acidosis
E. Anemia
F. Thrombocytopenia
14. A patient with end-stage renal disease is undergoing hemodialysis. The nurse should monitor the patient for which 2 complications?
A. Hypotension
B. Hypertension
C. Hyperkalemia
D. Hypokalemia
E. Hypoglycemia
F. Hyperglycemia
15. A patient with traumatic brain injury has an increased intracranial pressure (ICP). Which interventions should the nurse implement to decrease the ICP? Select all that apply.
a. Administering corticosteroids
b. Elevating the head of the bed 30 degrees
c. Administering mannitol
d. Providing hyperventilation to maintain a PaCO2 level of 30-35 mmHg
e. Maintaining a quiet and dark environment
f. Restricting fluid intake
16. A patient with a brain tumor has a sudden increase in ICP. Which interventions should the nurse implement to decrease the ICP? Select all that apply.
a. Administering oxygen therapy
b. Administering antiseizure medications
c. Administering hypertonic saline
d. Administering a diuretic
e. Administering a beta-blocker
f. Elevating the head of the bed 45 degrees
17: A client is being treated for a pulmonary embolism with anticoagulant therapy. Which of the following interventions is most important for the nurse to implement?
A) Monitoring for bleeding
B) Administering oxygen
C) Administering pain medication
D) Administering intravenous fluids
18. A patient with Cushing’s disease is prescribed medication to manage their symptoms. The nurse should be aware of which of the following nursing interventions? Select all that apply.
A. Monitor for signs of infection
B. Monitor for signs of hypoglycemia
C. Administer medications as ordered
D. Encourage a high-sodium diet
E. Monitor for signs of fluid overload
F. Educate the patient on stress management techniques
19. A patient with Addison’s disease presents to the clinic for a follow-up appointment. Which of the following symptoms should the nurse expect to observe? Select all that apply.
A. Hyperpigmentation of the skin
B. Weight gain
C. Hypotension
D. Hypoglycemia
E. Muscle wasting
F. Increased appetite
20. A patient with Addison’s disease is experiencing a crisis and requires immediate treatment. The nurse should expect which of the following interventions to be ordered? Select all that apply.
A. Intravenous (IV) fluids
B. Administration of corticosteroids
C. Administration of insulin
D. Administration of potassium
E. Administration of glucose
F. Dialysis
21. A patient with Addison’s disease is prescribed medication to manage their symptoms. The nurse should be aware of which of the following nursing interventions? Select all that apply.
A. Monitor for signs of infection
B. Monitor for signs of hyperkalemia
C. Administer medications as ordered
D. Encourage a low-sodium diet
E. Monitor for signs of dehydration
F. Educate the patient on stress management techniques
22. A patient with Crohn’s disease is admitted to the hospital with a flare-up of symptoms. Which of the following interventions should the nurse implement? Select all that apply.
A. Administer IV corticosteroids
B. Initiate total parenteral nutrition (TPN)
C. Encourage a high-fiber diet
D. Administer antidiarrheal medication
E. Monitor for signs of dehydration
F. Administer antibiotics
23. A patient with Crohn’s disease is being discharged from the hospital. Which of the following instructions should the nurse include in the teaching plan? Select all that apply.
A. Follow a low-fiber diet
B. Avoid dairy products
C. Take antidiarrheal medication as needed
D. Avoid NSAIDs
E. Get regular exercise
F. Schedule regular colonoscopies
24. A patient with Crohn’s disease is experiencing a severe flare-up of symptoms. Which of the following medications may be used to treat the flare-up? Select all that apply.
A. Infliximab
B. Azathioprine
C. Methotrexate
D. Mesalamine
E. Prednisone
F. Sulfasalazine
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25. A 30-year-old male presents to the emergency department with severe abdominal pain localized to the right lower quadrant. The patient reports nausea and vomiting, and a fever of 38.5°C. Upon physical examination, the patient’s abdomen is tender to palpation in the right lower quadrant, and a rebound tenderness is noted. The nurse recognizes that these symptoms are consistent with which of the following conditions? Select all that apply:
a) Appendicitis
b) Cholecystitis
c) Pancreatitis
d) Diverticulitis
e) Gastritis
f) Gastroenteritis
26. A 25-year-old female presents to the emergency department with severe abdominal pain that started around her belly button and has migrated to the lower right quadrant over the past several hours. The patient reports nausea and vomiting, and a fever of 37.9°C. Upon physical examination, the patient’s abdomen is tender to palpation in the right lower quadrant, and rebound tenderness is noted. The nurse recognizes that these symptoms are consistent with which of the following conditions? Select all that apply:
a) Appendicitis
b) Cholecystitis
c) Pancreatitis
d) Diverticulitis
e) Gastritis
f) Gastroenteritis
27. A patient who had a recent surgery is at risk of developing deep vein thrombosis (DVT). Which of the following interventions can help prevent the development of DVT? Select all that apply.
A. Administering oxygen therapy
B. Encouraging the patient to ambulate frequently
C. Applying compression stockings
D. Administering anticoagulant therapy
E. Elevating the affected limb
F. Encouraging the patient to remain in bed
28: A client with COPD is being discharged from the hospital and has been prescribed home oxygen therapy. Which of the following are appropriate interventions for the nurse to implement to promote client safety and prevent complications? (Select 4 interventions.)
A) Educating the client on the use of oxygen therapy
B) Ensuring that the client has a fire extinguisher in the home
C) Instructing the client to avoid smoking and open flames D) Encouraging the client to perform regular physical activity
E) Instructing the client to avoid high altitude travel
F) Monitoring the client’s oxygen saturation levels
29. A patient has been prescribed warfarin (Coumadin) for anticoagulation. Which of the following are important nursing considerations for this patient? Select all that apply.
a. Monitor for signs of bleeding
b. Administer aspirin for headache or pain
c. Check for signs of thrombocytopenia
d. Monitor for signs of stroke or embolism
e. Encourage the patient to eat foods high in vitamin K
f. Hold the medication if the patient’s PT/INR is within therapeutic range
30. Which of the following medications is commonly used for anticoagulation? Select all that apply.
a. Warfarin (Coumadin)
b. Heparin
c. Enalapril (Vasotec)
d. Rivaroxaban (Xarelto)
e. Metoprolol (Lopressor)
f. Atorvastatin (Lipitor)
31. A patient has been started on heparin therapy for the treatment of a deep vein thrombosis. Which of the following nursing interventions should be included in the patient’s care?
1 Monitor the patient for signs of bleeding.
2 Administer the heparin subcutaneously
3 Administer the heparin intravenously
4 Obtain frequent blood draws for coagulation studies
5 Use a soft-bristled toothbrush for oral care
6 Assess for signs and symptoms of thrombocytopenia
32. A 54-year-old patient with end-stage renal disease is undergoing peritoneal dialysis. The home health nurse should be aware of which of the following nursing interventions? Select all that apply.
A. Monitor electrolyte levels
B. Assess the access site for signs of infection
C. Monitor for bleeding
D. Administer heparin to prevent clotting
E. Encourage fluid intake
F. Monitor for peritonitis
33. A patient undergoing hemodialysis is at risk for which 4 complications?
A. Infection
B. Bleeding
C. Thrombosis
D. Hypothermia
E. Hypovolemia
F. Hypernatremia
34. A patient with a head injury is at risk for increased ICP. Which signs and symptoms should the nurse monitor for? Select all that apply.
a. Bradycardia
b. Hypotension
c. Hypertension
d. Pupillary changes
e. Seizures
f. Decreased level of consciousness
35. A patient is brought to the emergency department with sudden onset of weakness on the right side of the body, difficulty speaking, and drooping of the right side of the face. Which of the following interventions is appropriate for a patient with a suspected stroke? Select all that apply.
a. Administer alteplase within 4.5 hours of symptom onset
b. Perform a CT scan of the head
c. Initiate anticoagulation therapy
e. Monitor blood pressure frequently
f. Administer oxygen therapy
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36. A patient with a history of atrial fibrillation is admitted to the hospital with a suspected stroke. Which of the following 3 interventions are appropriate for preventing further stroke?
a. Administer anticoagulation therapy
b. Initiate statin therapy
c. Encourage a healthy diet and exercise
d. Administer antiplatelet therapy
e. Monitor blood pressure frequently
f. Administer oxygen therapy
37. A patient with a hip fracture is at risk for developing complications. Which of the following interventions should the nurse implement to prevent these complications? Select all that apply.
a) Encourage early mobilization
b) Administer IV fluids
c) Provide adequate pain control
d) Perform passive range of motion exercises
e) Monitor for signs of infection
f) Encourage the patient to bear weight on the affected hip
38. A patient with a hip fracture is scheduled to undergo surgery. Which of the following preoperative interventions should the nurse implement? Select all that apply.
a) Administer prophylactic antibiotics
b) Instruct the patient to remain NPO after midnight
c) Apply compression stockings
d) Administer analgesics as needed
e) Administer preoperative sedation
f) Assess the patient’s cognitive status
39 A patient with heart failure is taking digoxin and furosemide. The nurse should monitor the patient for which of the following potential drug interactions? Select all that apply.
a. Hypokalemia
b. Hyperkalemia
c. Hypomagnesemia
d. Hypermagnesemia
e. Ototoxicity
f. Nephrotoxicity
g. Anticoagulation
40: A client with congestive heart failure is admitted to the hospital with shortness of breath, cough, and orthopnea. Which of the following interventions should the nurse prioritize? (Select 3 interventions.)
A) Administer supplemental oxygen
B) Administer diuretics
C) Administer beta blockers
D) Administer calcium channel blockers
E) Administer vasodilators
F) Administer inotropes
41. Which of the following clients are at risk for osteoporosis? Select all that apply.
A. A 25-year-old male who plays basketball
B. A 40-year-old female who smokes
C. A 50-year-old male who takes steroid medications
D. A 65-year-old female who has a family history of osteoporosis
E. A 75-year-old male who drinks alcohol daily
F. A 80-year-old female who takes calcium supplements
42. A 70-year-old female client with osteoporosis is admitted to the hospital with a fractured hip. Which interventions should the nurse prioritize for this client? Select all that apply.
A. Administer pain medication as ordered
B. Encourage the client to ambulate as soon as possible
C. Place the client in a prone position to prevent pressure ulcers
D. Implement fall prevention measures
E. Monitor for signs of infection
F. Provide the client with calcium supplements
43. A nurse is caring for a client with bipolar disorder who is exhibiting signs of mania. Which of the following interventions should the nurse implement? Select all that apply.
A) Encourage the client to participate in group therapy sessions
B) Administer lithium as prescribed
C) Provide a quiet and non-stimulating environment
D) Allow the client to sleep as needed during the day
E) Teach the client relaxation techniques
F) Encourage the client to engage in high-stress activities such as exercise or work
44. A nurse is caring for a client with bipolar disorder who is taking lithium. The nurse should monitor the client for which of the following adverse effects? Select all that apply.
A) Tremors
B) Constipation
C) Polyuria
D) Tinnitus
E) Nausea and vomiting
F) Weight gain
45. A nurse is caring for a client with bipolar disorder who is taking valproic acid. The nurse should monitor the client for which of the following adverse effects? Select all that apply.
A) Hair loss
B) Diarrhea
C) Hyperactivity
D) Liver toxicity
E) Respiratory depression
F) Peripheral edema
46 A patient with depression has been prescribed a selective serotonin reuptake inhibitor (SSRI) medication. Which of the following statements about SSRIs are correct? (Select all that apply.)
A. SSRIs increase the availability of serotonin in the brain
B. SSRIs are the first-line treatment for bipolar disorder
C. SSRIs can cause sexual dysfunction
D. SSRIs are not associated with any withdrawal symptoms
E. SSRIs can increase the risk of bleeding
F. SSRIs have a rapid onset of action
47 A patient with depression is being treated with electroconvulsive therapy (ECT). Which of the following statements about ECT are correct? (Select all that apply.)
A. ECT can cause memory loss
B. ECT is a last-resort treatment for depression
C. ECT is usually given under general anesthesia
D. ECT can cause permanent brain damage
E. ECT is contraindicated in patients with a history of seizures
F. ECT is effective for treating severe depression
48 A nurse is assessing a newborn for signs of respiratory distress. Which of the following should the nurse consider as potential risk factors for respiratory distress in the newborn? Select all that apply.
a. Maternal diabetes
b. Post-term gestation
c. C-section delivery
d. Premature rupture of membranes
e. Use of prenatal steroids
f. Hypoglycemia
49 A nurse is providing care for a newborn with jaundice. Which of the following should the nurse monitor for in the newborn? Select all that apply.
a. Hypertension
b. Hypothermia
c. Hypoglycemia
d. Kernicterus
e. Dehydration
f. Poor feeding
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50 A nurse is caring for a newborn with neonatal abstinence syndrome (NAS) due to maternal opioid use during pregnancy. Which of the following symptoms should the nurse expect to observe in the newborn? Select all that apply.
a. Tremors
b. Hyperthermia
c. Irritability
d. Tachycardia
e. Hypotonia
51 A pregnant woman with gestational diabetes is in labor. The nurse is assessing the newborn for signs of macrosomia. Which of the following are signs of macrosomia in a newborn? Select all that apply.
a) Birth weight above 4,000 grams
b) Length above 50 cm
c) Head circumference above 35 cm
d) Shoulder dystocia during delivery
e) Hypoglycemia in the first 24 hours of life
f) Respiratory distress at birth
52 A newborn is born with Hirschsprung disease. Which of the following clinical manifestations should the nurse expect to assess in the newborn? Select 3 that apply:
a. Delayed passage of meconium
b. Abdominal distension
c. Ribbon-like stools
d. Diarrhea
e. Constipation
f. Vomiting
53 The nurse is caring for a newborn with Hirschsprung disease. Which of the following nursing interventions should be included in the plan of care? Select all that apply:
a. Administer stool softeners
b. Encourage breastfeeding
c. Teach parents how to perform anal irrigation
d. Monitor for signs of enterocolitis
e. Monitor for signs of dehydration
f. Encourage early introduction of solid foods
54 The nurse is providing discharge teaching to the parents of a newborn with Hirschsprung disease. Which of the following instructions should the nurse include in the teaching?Select all that apply:
a. Schedule regular follow-up appointments with the healthcare provider
b. Teach parents how to perform anal dilation
c. Instruct parents to avoid rectal temperatures
d. Encourage parents to provide a high-fiber diet
e. Teach parents how to perform colonic massage
f. Instruct parents to seek immediate medical attention if the newborn develops a fever or abdominal distension
55 A 2-year-old child is brought to the clinic by the parents for a routine check-up. The nurse practitioner suspects the child is at risk for anemia. Which of the following factors may put the child at risk for anemia? Select all that apply.
A. Consuming a diet rich in iron
B. Recent illness with fever
C. Excessive milk consumption
D. Regular intake of vitamin C supplements
E. Exposure to lead
F. Being breastfed for at least 6 months
56 A 10-year-old child is brought to the emergency department with symptoms of dehydration. The nurse is assessing the child and suspects the child may be experiencing diabetic ketoacidosis (DKA). Which of the following signs and symptoms are consistent with DKA? Select all that apply.
A. Rapid breathing
B. Increased thirst
C. Flushed skin
D. Vomiting
E. Abdominal pain
F. Fruity breath odor
57 A 6-month-old infant is brought to the clinic for a well-baby check-up. The nurse practitioner suspects the infant may be experiencing developmental delays. Which of the following risk factors may contribute to developmental delays in infants? Select all that apply.
A. Family history of developmental delays
B. Premature birth
C. Lack of interaction with parents
D. Exposure to lead
E. Limited access to healthcare
F. Excessive crying
58 A 4-year-old child presents to the clinic with complaints of ear pain and fever. The nurse suspects otitis media. Which of the following signs and symptoms are commonly associated with this condition? Select all that apply.
a) Difficulty hearing
b) Loss of appetite
c) Irritability
d) Nausea and vomiting
e) Tugging or pulling at the affected ear
f) Clear discharge from the ear
59 The nurse is providing discharge teaching to the parents of a 2-year-old child who was recently diagnosed with otitis media. Which of the following instructions should the nurse include? Select all that apply.
a) Administer antibiotics as prescribed
b) Administer pain medication as needed
c) Avoid giving the child liquids for 24 hours
d) Encourage the child to lie on the affected side
e) Follow up with the healthcare provider as scheduled
f) Use a warm compress to relieve pain
60 A 30-year-old female presents to the clinic with complaints of heavy menstrual bleeding. She reports that her menstrual periods are lasting more than 7 days and she is changing her tampon or pad every hour or less. Which of the following could be possible causes of menorrhagia? Select all that apply.
A) Endometrial polyps
B) Ovarian cysts
C) Endometriosis
D) Adenomyosis
E) Hypothyroidism
F) Uterine fibroids
61 A 25-year-old female presents to the emergency department complaining of heavy vaginal bleeding for the past 12 hours. She reports that she has soaked through multiple pads and has passed several large clots. Which of the following interventions would be appropriate for this patient? Select all that apply.
A) Administer IV fluids
B) Order a complete blood count (CBC)
C) Perform a pelvic exam
D) Administer hormonal contraception
E) Order a pelvic ultrasound
F) Administer tranexamic acid
62 A 23-year-old female presents to the clinic with complaints of amenorrhea. Which of the following can be a cause of amenorrhea? Select all that apply.
A) Polycystic ovary syndrome (PCOS)
B) Thyroid dysfunction
C) Endometriosis
D) Anorexia nervosa
E) Pregnancy
F) Ovarian cancer
63 A 32-year-old female presents with complaints of missed periods for the past 6 months. She has a history of anemia and heavy menstrual bleeding in the past. Which of the following can be a cause of her condition? Select all that apply.
A) Pregnancy
B) Hypothyroidism
C) Endometriosis
D) Uterine fibroids
E) Hyperthyroidism
F) Ovarian cancer
64 A new mother presents to the clinic with complaints of breast pain and tenderness. She is breastfeeding her 2-week-old infant and has noticed redness and swelling on one breast. The mother also reports feeling fatigued and having a low-grade fever.Which of the following interventions should the nurse recommend to manage mastitis in a breastfeeding mother? Select all that apply.
A. Encourage the mother to continue breastfeeding frequently from both breasts.
B. Advise the mother to stop breastfeeding from the affected breast until the infection resolves.
C. Instruct the mother to apply heat to the affected breast to alleviate discomfort.
D. Recommend the use of a breast pump to empty the affected breast if the infant is unable to do so effectively.
E. Educate the mother on the use of ibuprofen to manage pain and inflammation.
F. Suggest the mother take antibiotics as prescribed by her healthcare provider.
65. A nurse is caring for a patient with sepsis. Which interventions are appropriate for this patient? Select all that apply.
a. Administering broad-spectrum antibiotics
b. Starting a vasopressor to maintain blood pressure
c. Providing oxygen therapy to maintain adequate oxygen saturation
d. Administering high-dose corticosteroids
e. Monitoring urine output
f. Restricting fluid intake
66 A patient with sepsis is receiving intravenous fluids to maintain blood pressure. Which of the following laboratory values should the nurse monitor to assess for fluid overload? Select all that apply.
a. Sodium
b. Potassium
c. Hemoglobin
d. Hematocrit
e. BUN (blood urea nitrogen)
f. Creatinine
67 A nurse is caring for a patient diagnosed with osteomyelitis. Which interventions should the nurse implement to promote healing and prevent the spread of infection? Select all that apply.
a. Administering antibiotics as ordered
b. Implementing standard precautions
c. Elevating the affected limb
d. Applying heat to the affected area
e. Encouraging ambulation
f. Providing adequate hydration
68 A nurse is caring for a patient with osteomyelitis who has developed a fever and increased pain at the site of infection. Which interventions should the nurse implement to manage the patient’s symptoms and prevent complications? Select all that apply.
a. Administering pain medication as ordered
b. Administering antibiotics as ordered
c. Encouraging the patient to ambulate frequently
d. Monitoring the patient’s vital signs
e. Applying cold compresses to the affected area
f. Administering antipyretics as ordered
69 The nurse is caring for a patient with a central line. Which of the following interventions should the nurse implement to prevent central line infections? Select all that apply.
a. Perform hand hygiene before and after dressing changes.
b. Change the dressing on the central line daily.
c. Use sterile technique when accessing the central line.
d. Change the central line tubing every 24 hours.
e. Use a chlorhexidine-impregnated dressing for the central line.
f. Encourage the patient to avoid touching the central line site.
70 The nurse is caring for a patient with a suspected central line infection. Which of the following interventions should the nurse implement? Select all that apply.
a. Remove the central line.
b. Obtain blood cultures from the central line and a peripheral site.
c. Administer broad-spectrum antibiotics.
d. Change the central line dressing.
e. Assess the patient for signs and symptoms of sepsis.
f. Notify the healthcare provider.
71 The nurse is caring for a patient with a known history of methicillin-resistant Staphylococcus aureus (MRSA) infection. Which actions should the nurse take when applying contact precautions to this patient? Select all that apply.
A. Wear a gown when entering the patient’s room.
B. Wear a mask when providing patient care.
C. Wear gloves when entering the patient’s room.
D. Ensure the patient has a private room.
E. Remove the gown before leaving the patient’s room.
F. Cleanse hands before and after removing gloves.
72 The nurse is caring for a patient who has been placed on contact precautions for a Clostridium difficile infection. Which actions should the nurse take when providing patient care? Select all that apply.
A. Wear a mask when entering the patient’s room.
B. Use soap and water to cleanse hands.
C. Use an alcohol-based hand sanitizer to cleanse hands.
D. Use a disposable blood pressure cuff.
E. Place the patient in a private room.
F. Discard used supplies in a regular trash can.
73 The nurse is performing a sterile dressing change for a patient with a surgical wound. Which of the following actions are appropriate for maintaining aseptic technique? Select all that apply.
A. Donning sterile gloves
B. Using sterile instruments
C. Touching the sterile field with sterile gloves
D. Opening the sterile packages in advance
E. Using a non-sterile saline solution
F. Cleaning the wound with a non-sterile solution
74 The nurse is teaching a group of nursing students about aseptic technique. Which of the following statements by the students indicates a need for further teaching? Select all that apply.
A. “Aseptic technique is important to prevent the spread of infection.”
B. “Hand hygiene is a key component of aseptic technique.”
C. “It is important to wear gloves when coming into contact with body fluids.”
D. “A clean environment is essential for aseptic technique.”
E. “Sterile gloves should be worn for all procedures.”
F. “The use of sterile instruments is necessary for all procedures.”
75 A nurse is preparing to perform a sterile dressing change on a patient’s surgical incision. Which actions are appropriate for the nurse to take to maintain sterile technique during the procedure? Select all that apply.
a. Wear sterile gloves and gown.
b. Disinfect the skin with an alcohol swab.
c. Use sterile forceps to handle sterile items.
d. Touch the inside of the sterile glove with ungloved fingers.
e. Allow the sterile field to be touched by non-sterile items.
f. Keep the sterile field within sight and above waist level.
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ANSWERS: NCLEX High Yield Questions
For more Questions for NCLEX, ANCC and AANP
1. Correct answer: A, B, D. Rationale: The first-line therapy for managing myocardial infarction includes administering aspirin, nitroglycerin, and morphine to reduce platelet aggregation, dilate coronary arteries, and reduce myocardial oxygen demand. Heparin, beta-blockers, ACE inhibitors, thrombolytic therapy, and calcium channel blockers may also be used in the management of myocardial infarction, but they are not administered for all clients and are not part of the initial interventions.
2 Correct answer: A Rationale: In acute renal failure, the kidneys are unable to filter waste products from the blood, leading to an accumulation of potassium in the body, which can result in hyperkalemia. Hypertension (fluid overload) and other electrolyte abnormalities may occur.
3 Correct answers: A and B Rationale: Albuterol and ipratropium are both common types of bronchodilators used to treat bronchitis and COPD. Montelukast is a leukotriene receptor antagonist used to treat asthma. Theophylline is a methylxanthine bronchodilator that is not typically used as a first-line therapy for COPD. Fluticasone and budesonide are both inhaled corticosteroids used to treat asthma and COPD, but they are not bronchodilators.
4. Correct answers: A, B, E Rationale: Osteoporosis is a condition in which bones become fragile and brittle due to the loss of calcium and other minerals. Clients who are at risk for osteoporosis should engage in interventions that help to preserve bone mass, such as increasing daily calcium intake, engaging in regular weight-bearing exercise, and stopping smoking. Vitamin D supplements are also important, as this vitamin helps the body absorb calcium. Sun exposure can help the body produce vitamin D, but clients should take precautions to avoid excessive sun exposure, as this can increase the risk of skin cancer. Alcohol intake should be limited, as excessive alcohol consumption can decrease bone density.
5. Correct answer: A, B, C, D Rationale: Digoxin toxicity can occur in clients receiving this medication for congestive heart failure. Symptoms of toxicity include nausea and vomiting, visual disturbances, confusion and disorientation, and bradycardia. Hypertension and hypotension are not associated with digoxin toxicity.
You’re doing great on NCLEX High Yield Questions GI, keep up the good work and pass your board exam!
6. Correct answer: D Rationale: A chest X-ray may show some signs of a pulmonary embolism, but it is not sensitive or specific enough to confirm the diagnosis. An ECG may show signs of right ventricular strain, but it is also not specific for a pulmonary embolism. A D-dimer test may be used to rule out a pulmonary embolism, but it is not specific enough to confirm the diagnosis. The gold standard for diagnosing a pulmonary embolism is a CT pulmonary angiography, which can show the location and size of the clot.
7. Correct answers: B, C, E Rationale: Cushing’s disease is a condition in which the body produces too much cortisol. Symptoms may include a round face (moon face), muscle wasting, hyperglycemia, and hyperpigmentation of the skin. Weight gain, not weight loss, is a common symptom. Hypertension, not hypotension, is also common.
8. Correct answer: A, B, C, D Rationale: Following a low-sodium diet, limiting fluid intake, weighing yourself daily, and taking diuretics as prescribed are all important instructions for a client with congestive heart failure to follow to help manage fluid overload and prevent exacerbations. Increasing physical activity gradually may also be appropriate for some clients, but it should be done under the guidance of a healthcare provider. Taking calcium channel blockers is not a standard intervention for congestive heart failure management.
9. Correct answers: A, B, and E Rationale: Administering oxygen is the most important intervention for a client experiencing an exacerbation of COPD. Administering a short-acting bronchodilator, such as albuterol, can help to relieve bronchospasm and improve airflow. Administering a long-acting bronchodilator or an inhaled corticosteroid may be appropriate for maintenance therapy, but they are not the first-line treatments for an exacerbation. Administering a nebulizer treatment, such as with albuterol or ipratropium, can help to deliver medication directly to the lungs and improve breathing. Administering a mucolytic agent, such as acetylcysteine, may be appropriate for clients with excessive mucus production, but it is not typically used for acute exacerbations of COPD.
10. Correct answers: A, B, D Rationale: Painful swelling in the affected limb is a common sign of DVT, along with warmth and redness. Shortness of breath is also a common sign of DVT, which may indicate the presence of a pulmonary embolism. Palpitations and tachycardia are not commonly seen in patients with DVT. Elevated blood pressure is not a specific sign of DVT. Cyanosis in the affected limb is a late sign of DVT and is not commonly seen in the early stages of the condition.
11. Correct answer: A, B, C, E, F Rationale: Following a low-fat diet, engaging in regular exercise, taking nitroglycerin as needed for chest pain, taking beta blockers as prescribed, and monitoring blood pressure at home are all important instructions for a client with a history of myocardial infarction to follow. Avoiding caffeine and alcohol, stopping aspirin if experiencing gastrointestinal upset, and avoiding over-the-counter medications are not necessary for all clients with a history of myocardial infarction and may be based on individualized factors.
12. Correct answers: A, B, C Rationale: CRRT is a type of dialysis used for patients with acute renal failure. The nurse should monitor the patient for electrolyte imbalances, assess the access site for signs of infection, and monitor for bleeding due to anticoagulation therapy. Heparin is often administered to prevent clotting in the dialysis circuit. Fluid intake is usually restricted, and diuretics are not given since the purpose of CRRT is to remove excess fluid from the body.
13. Correct answers: B, E Rationale: Acute renal failure can lead to metabolic acidosis due to the accumulation of metabolic waste products in the body. Anemia may also occur due to decreased production of erythropoietin, a hormone produced by the kidneys that stimulates red blood cell production. Respiratory alkalosis and acidosis are not typically associated with acute renal failure. Thrombocytopenia may occur in some cases, but it is not a common complication.
14. Correct answers: A, C Rationale: Hemodialysis involves the use of a machine to filter waste products from the blood. Hypotension may occur during the procedure due to fluid shifts, and hyperkalemia may occur due to the removal of potassium from the blood during dialysis. Hypertension is not a common complication of hemodialysis. Hypokalemia is less likely to occur since potassium is not typically removed during dialysis. Hypoglycemia and hyperglycemia are also not common complications of hemodialysis.
15. Correct answers: B, C, D Rationale: Elevating the head of the bed 30 degrees promotes venous drainage from the head and decreases cerebral blood volume, which decreases ICP. Mannitol is an osmotic diuretic that decreases cerebral edema and ICP. Hyperventilation lowers PaCO2, causing cerebral vasoconstriction and decreasing cerebral blood flow and ICP. Corticosteroids are not routinely used for ICP reduction. Maintaining a quiet and dark environment is important to reduce stimuli and agitation, but does not directly decrease ICP. Fluids are restricted to prevent cerebral edema, but fluid restriction alone will not decrease ICP.
16 Correct answers: C, D, F Rationale: Hypertonic saline is an osmotic diuretic that draws water from brain tissue and reduces cerebral edema, thus decreasing ICP. Diuretics help to decrease cerebral edema and ICP. Elevating the head of the bed 45 degrees promotes venous drainage from the head and decreases cerebral blood volume, which decreases ICP. Oxygen therapy and antiseizure medications may be indicated for other reasons, but will not directly decrease ICP. Beta-blockers are not used for ICP reduction.
17. Correct answer: A Rationale: Anticoagulant therapy can increase the risk of bleeding, so monitoring for bleeding is the most important intervention for a client being treated for a pulmonary embolism. Administering oxygen and pain medication may be appropriate interventions based on the client’s symptoms, but they are not the most important. Administering intravenous fluids may also be appropriate, but it is not the priority intervention
18. Correct answers: A, B, C, E, F Rationale: Patients with Cushing’s disease are at increased risk for infections and hypoglycemia due to the effects of excess cortisol on the immune system and glucose metabolism. Medications may be prescribed to manage symptoms, and the nurse should administer them as ordered. A high-sodium diet is not typically recommended since patients with Cushing’s disease are at increased risk for hypertension and fluid overload. The nurse should monitor the patient for signs of fluid overload and educate the patient on stress management techniques to help manage symptoms.
19. Correct answers: A, C, E Rationale: Addison’s disease is a condition in which the adrenal glands do not produce enough cortisol and aldosterone. Symptoms may include hyperpigmentation of the skin, hypotension, and muscle wasting. Weight loss, not weight gain, is a common symptom. Patients with Addison’s disease are also at increased risk for hypoglycemia, not hyperglycemia, due to the effects of cortisol on glucose metabolism. Increased appetite is not a common symptom.
20. Correct answers: A, B, D Rationale: An Addisonian crisis is a life-threatening condition that can occur when the adrenal glands are unable to produce enough cortisol and aldosterone. Treatment may include intravenous fluids, administration of corticosteroids, and administration of potassium since patients with Addison’s disease are at risk for hypokalemia. Insulin and glucose administration would be indicated for the management of hyperglycemia, not hypoglycemia. Dialysis is not typically indicated for the treatment of Addison’s disease.
21. Correct answers: A, B, C, E, F Rationale: Patients with Addison’s disease are at increased risk for infections and hyperkalemia due to the effects of insufficient aldosterone production. Medications may be prescribed to manage symptoms, and the nurse should administer them as ordered. A low-sodium diet is not typically recommended since patients with Addison’s disease are at increased risk for hypotension and dehydration. The nurse should monitor the patient for signs of dehydration and educate the patient on stress management techniques to help manage symptoms.
22. Answer: A, B, E Rationale: During a flare-up of Crohn’s disease, the patient may experience abdominal pain, diarrhea, and malnutrition. Intravenous corticosteroids can help reduce inflammation and promote healing of the intestinal lining. Total parenteral nutrition can provide necessary nutrients while allowing the bowel to rest. The patient may be at risk for dehydration due to diarrhea, so monitoring for signs of dehydration is important.
23. Answer: B, D, E Rationale: A low-fiber diet is not recommended for Crohn’s disease as it can worsen symptoms. However, avoiding dairy products can be helpful for some patients. NSAIDs can increase inflammation in the gut and should be avoided. Regular exercise can help improve overall health and reduce stress, which can trigger symptoms. Colonoscopies may be necessary for surveillance of the disease but are not typically done on a regular basis.
24. Answer: A, E Rationale: Infliximab and other biologic agents can be used to treat severe flare-ups of Crohn’s disease. Prednisone and other corticosteroids may also be used to reduce inflammation. Azathioprine, methotrexate, and mesalamine are typically used for maintenance therapy rather than for acute flare-ups. Sulfasalazine is used primarily for the treatment of ulcerative colitis.
25. Correct answers: a, d Rationale: The symptoms of severe abdominal pain localized to the right lower quadrant, nausea and vomiting, fever, and tenderness to palpation with rebound tenderness are indicative of appendicitis. Diverticulitis can also present with similar symptoms, including abdominal pain, fever, and tenderness to palpation, but the pain is typically located in the left lower quadrant. Cholecystitis, pancreatitis, gastritis, and gastroenteritis can present with abdominal pain and nausea/vomiting, but the pain is not typically localized to the right lower quadrant and rebound tenderness is not present.
26. Correct answer: a Rationale: The symptoms of severe abdominal pain that migrates from the belly button to the lower right quadrant, nausea and vomiting, fever, and tenderness to palpation with rebound tenderness are indicative of appendicitis. Cholecystitis, pancreatitis, diverticulitis, gastritis, and gastroenteritis can present with abdominal pain and nausea/vomiting, but the pain is not typically localized to the right lower quadrant with rebound tenderness.
27. Correct answers: B, C, D Rationale: Encouraging the patient to ambulate frequently helps promote blood flow in the legs, reducing the risk of blood clot formation. Applying compression stockings also helps promote venous blood return and prevent stasis. Administering anticoagulant therapy, such as heparin or enoxaparin, can also help prevent the formation of blood clots. Administering oxygen therapy and elevating the affected limb are not specific interventions for preventing DVT. Encouraging the patient to remain in bed can increase the risk of DVT formation.
28. Correct answers: A, B, C, and F Rationale: Educating the client on the use of oxygen therapy is important to ensure that the client understands how to use the equipment safely and effectively. Ensuring that the client has a fire extinguisher in the home is important in case of a fire caused by oxygen use. Instructing the client to avoid smoking and open flames is important to prevent a fire or explosion. Encouraging the client to perform regular physical activity can help to improve lung function and overall health, but it is not directly related to oxygen therapy. Instructing the client to avoid high altitude travel is important because the reduced oxygen.
29. Correct answers: a, c, d Rationale: Warfarin is an anticoagulant that works by inhibiting vitamin K-dependent clotting factors in the liver. Therefore, it is important to monitor for signs of bleeding and thrombocytopenia, as well as signs of stroke or embolism. Aspirin should be avoided as it can increase the risk of bleeding. Foods high in vitamin K should be limited, as vitamin K can counteract the effects of warfarin. The medication should be held if the patient’s PT/INR is above or below the therapeutic range.
30. Correct answers: a, b, d Rationale: Warfarin and heparin are commonly used for anticoagulation. Rivaroxaban is another medication that is used for anticoagulation, as it inhibits factor Xa. Enalapril, metoprolol, and atorvastatin are medications that are used for hypertension, heart failure, and hyperlipidemia, respectively, and do not have anticoagulant properties.
31. Correct answers: 1, 3 Rationale: Monitoring the patient for signs of bleeding is essential because heparin can cause bleeding. Signs of bleeding may include unusual bruising, petechiae, tarry stools, and hematuria. Heparin can be given subcutaneously, but in this case, the patient is being treated for a deep vein thrombosis. Intravenous heparin is preferred for initial anticoagulation therapy.
32. Correct answers: A, B, F Rationale: Peritoneal dialysis involves the use of the patient’s peritoneum as a dialysis membrane. The nurse should monitor the patient for electrolyte imbalances, assess the access site for signs of infection, and monitor for peritonitis, which is a common complication of peritoneal dialysis. Bleeding is not typically associated with peritoneal dialysis, and heparin is not used since the patient’s blood does not come into contact with a dialysis circuit. Fluid intake may be restricted in some cases.
33.Correct answers: A, B, C, E Rationale: Hemodialysis involves the use of a dialysis machine and a circuit that comes into contact with the patient’s blood, increasing the risk of infection and bleeding. Thrombosis may occur in the dialysis circuit or in the patient’s blood vessels. Hypothermia is not a common complication since the dialysis machine is designed to maintain the patient’s body temperature. Hypovolemia may occur due to fluid removal during dialysis. Hypernatremia is less likely to occur since sodium is not typically removed during dialysis.
34. Correct answers: A, C, D, F Rationale: Bradycardia is a sign of increased ICP due to pressure on the vagus nerve. Hypertension is a compensatory mechanism to maintain cerebral perfusion pressure. Pupillary changes, such as unequal or dilated pupils, can indicate herniation of the brain stem. Decreased level of consciousness can indicate a decrease in cerebral blood flow and increased ICP. Hypotension is not a typical sign of increased ICP. Seizures may occur with head injury, but are not specific to increased ICP.
35. Answer: A, B, E Rationale: Administering alteplase within 4.5 hours of symptom onset is recommended for patients with an ischemic stroke who meet the eligibility criteria. Performing a CT scan of the head can help identify the type of stroke (ischemic or hemorrhagic) and rule out other conditions that may mimic stroke symptoms. Monitoring blood pressure is important. Anticoagulation therapy is not indicated for acute stroke management and can increase the risk of hemorrhage. Oxygen therapy may be administered if the patient is hypoxic, but routine use of oxygen is not recommended.
36. Answer: A, B, D Rationale:Administering anticoagulation therapy, such as warfarin or direct oral anticoagulants, is recommended for patients with atrial fibrillation to prevent stroke.Initiating statin therapy can help reduce the risk of future strokes by lowering cholesterol levels and stabilizing atherosclerotic plaques.Administering antiplatelet therapy, such as aspirin or clopidogrel, can also help reduce the risk of future strokes.
37.Answer: A, C, E Rationale: Encouraging early mobilization, providing adequate pain control, and monitoring for signs of infection are important interventions to prevent complications in a patient with a hip fracture. Administering IV fluids, performing passive range of motion exercises, and encouraging the patient to bear weight on the affected hip are not appropriate interventions and may actually increase the risk of complications
38. Answer: A, B, C, D Rationale: Administering prophylactic antibiotics, instructing the patient to remain NPO after midnight, applying compression stockings, and administering analgesics as needed are appropriate preoperative interventions for a patient with a hip fracture. Administering preoperative sedation and assessing the patient’s cognitive status may also be appropriate, but they are not as essential as the other interventions.
39. Correct answers: A, C, E Rationale: Furosemide is a loop diuretic that can cause hypokalemia, hypomagnesemia, and ototoxicity. When taken with digoxin, the risk of digoxin toxicity increases due to hypokalemia and hypomagnesemia. Ototoxicity is also a potential side effect of furosemide. Hypermagnesemia, nephrotoxicity, and anticoagulation are not typical drug interactions with digoxin and furosemide.
40. Correct answer: A, B, E Rationale: When a client with congestive heart failure is admitted to the hospital with symptoms of exacerbation, the priority interventions include administering supplemental oxygen, administering diuretics to reduce fluid overload, and administering vasodilators to reduce afterload and improve cardiac output. Beta blockers and calcium channel blockers may be used in the management of congestive heart failure, but they are not typically used in the acute management of exacerbations. Inotropes may also be used in severe cases, but they are not a first-line intervention.
41 Correct answers: B, C, D, E Rationale: Osteoporosis is more common in females and in older adults, particularly those with a family history of the disease. Risk factors for osteoporosis include smoking, excessive alcohol consumption, low calcium and vitamin D intake, and the use of certain medications, such as steroids. Engaging in weight-bearing exercise can help prevent osteoporosis, but basketball is not a risk factor for the disease. Taking calcium supplements can also help prevent osteoporosis.
42 Correct answers: A, B, D Rationale: Fractured hip is a common complication of osteoporosis. The nurse should prioritize pain management for this client by administering pain medication as ordered. Encouraging the client to ambulate as soon as possible can also help prevent complications such as pneumonia and deep vein thrombosis. Fall prevention measures, such as bed rails and non-slip footwear, are important to prevent further injury. The client should not be placed in a prone position, as this can increase the risk of pressure ulcers. Monitoring for signs of infection and providing calcium supplements are important interventions for clients with osteoporosis, but they are not the priority for a client with a fractured hip.
43 Correct answers: B, C, E Rationale: Lithium is a medication that is often prescribed to manage symptoms of mania. A quiet and non-stimulating environment can help decrease stimulation and prevent exacerbation of manic symptoms. Relaxation techniques, such as deep breathing or meditation, can help the client calm down and manage their symptoms.
44 Correct answers: A, C, D Rationale: Tremors, polyuria (increased urine output), and tinnitus (ringing in the ears) are all adverse effects of lithium. Constipation and weight gain are not commonly associated with lithium use. Nausea and vomiting can be an adverse effect of lithium but is not specific to this medication and can be caused by a variety of factors.
45 Correct answers: A, B, D Rationale: Hair loss, diarrhea, and liver toxicity are all adverse effects of valproic acid. Hyperactivity, respiratory depression, and peripheral edema are not commonly associated with this medication. It is important for the nurse to monitor the client’s liver function tests regularly to detect any signs of liver toxicity.
46 Correct answers: A, C, E Rationale: SSRIs work by inhibiting the reuptake of serotonin in the brain, leading to an increase in its availability. SSRIs are not the first-line treatment for bipolar disorder, as they can cause manic episodes. Sexual dysfunction is a common side effect of SSRIs, and they can increase the risk of bleeding due to their effect on platelet function. SSRIs can also cause withdrawal symptoms if stopped abruptly.
47 Correct answers: A, C, F Rationale: ECT is a treatment for severe depression that involves passing an electrical current through the brain to induce a seizure. It is not a last-resort treatment, but it is typically used when other treatments have failed. ECT is usually given under general anesthesia to minimize discomfort and reduce the risk of injury during the seizure. ECT can cause memory loss, but this is usually temporary. There is no evidence that ECT causes permanent brain damage. ECT is contraindicated in patients with a history of certain medical conditions, such as recent heart attack or stroke, but not in those with a history of seizures. ECT is an effective treatment for severe depression, but it is not without risks and side effects.
48 Answer: A, B, D, E Rationale: Maternal diabetes, post-term gestation, premature rupture of membranes, and use of prenatal steroids can increase the risk of respiratory distress in the newborn.
49 Answer: B, D, F Rationale: Jaundice in the newborn can lead to the development of kernicterus, a type of brain damage caused by high levels of bilirubin in the blood. The newborn may also have poor feeding due to the jaundice and may become hypothermic as a result.
50Answer: A, C, D, E Rationale: Neonatal abstinence syndrome is a group of symptoms that can occur in a newborn who was exposed to opioids during pregnancy. Symptoms of NAS can include tremors, irritability, tachycardia, and hypotonia. Hyperthermia is not typically a symptom of NAS, and hypoglycemia may or may not be present depending on the individual case.
51 Answer: a) Birth weight above 4,000 grams and d) Shoulder dystocia during delivery. Rationale: Macrosomia is a condition in which the baby is significantly larger than average, usually defined as a birth weight above 4,000 grams. Shoulder dystocia occurs when the baby’s shoulder becomes impacted behind the mother’s pubic bone during delivery and is a common complication of macrosomia. While length and head circumference may be increased in a macrosomic baby, they are not definitive indicators. Hypoglycemia and respiratory distress are potential complications of macrosomia, but they are not necessarily present in all cases.
52 Answer: A, B, C Rationale: Hirschsprung disease is a congenital disorder in which there is an absence of ganglion cells in the submucosal and myenteric plexuses of the colon. The absence of these cells results in functional obstruction of the colon, leading to delayed passage of meconium, abdominal distension, and ribbon-like stools.
53 Answer: A, B, C, D, E Rationale: Nursing interventions for a newborn with Hirschsprung disease include administering stool softeners to prevent fecal impaction, encouraging breastfeeding to promote gastrointestinal motility, teaching parents how to perform anal irrigation to help manage fecal retention, monitoring for signs of enterocolitis (an inflammation of the colon caused by bacterial infection), and monitoring for signs of dehydration. Early introduction of solid foods is not recommended as it may exacerbate the obstruction.
54 Answer: A, C, F Rationale: Discharge teaching for parents of a newborn with Hirschsprung disease should include scheduling regular follow-up appointments with the healthcare provider, instructing parents to avoid rectal temperatures to prevent bowel perforation, and instructing parents to seek immediate medical attention if the newborn develops a fever or abdominal distension (which may indicate enterocolitis). Anal dilation and colonic massage are not typically performed in the home setting. Providing a high-fiber diet may be recommended later in life, but not during the newborn period.
55 Answer: B, C Rationale: Anemia is a common condition in children and is often caused by nutritional deficiencies or chronic illnesses. Consuming a diet rich in iron and regular intake of vitamin C supplements can help prevent anemia. However, recent illness with fever and excessive milk consumption can increase the risk of anemia. Exposure to lead can also cause anemia. Breastfeeding for at least 6 months is recommended to provide the baby with adequate iron.
56 Answer: A, D, F Rationale: Diabetic ketoacidosis is a life-threatening complication of diabetes that occurs when the body produces high levels of ketones due to insulin deficiency. Symptoms of DKA include rapid breathing, increased thirst, vomiting, abdominal pain, and fruity breath odor. Flushed skin is not a common symptom of DKA.
57 Answer: A, B, C, D, E Rationale: Developmental delays can occur in infants due to a variety of factors. Risk factors for developmental delays include family history of developmental delays, premature birth, lack of interaction with parents, exposure to lead, and limited access to healthcare. Excessive crying is a common behavior in infants but is not a risk factor for developmental delays.
58 Answer: C, E Rationale: Otitis media is an infection of the middle ear that commonly occurs in children. Signs and symptoms of otitis media may include ear pain, fever, irritability, tugging or pulling at the affected ear, and difficulty hearing. Loss of appetite and nausea/vomiting are not typically associated with otitis media. Clear discharge from the ear is not typically associated with otitis media but may be seen in cases of otitis externa (infection of the outer ear).
59 Answer: A, B, E Rationale: Antibiotics are commonly prescribed to treat otitis media. Pain medication may also be prescribed to manage ear pain. It is important to encourage the child to stay hydrated and continue to offer fluids. There is no need to avoid liquids for 24 hours. Encouraging the child to lie on the affected side may actually exacerbate symptoms. It is important to follow up with the healthcare provider as scheduled to ensure that the infection has resolved. A warm compress may provide some relief but is not typically recommended as a first-line treatment for otitis media. 60 Answer: A, C, D, F Rationale: Menorrhagia, defined as heavy or prolonged menstrual bleeding, can be caused by a variety of conditions. Endometrial polyps, endometriosis, adenomyosis, and uterine fibroids are all benign conditions that can lead to menorrhagia. Ovarian cysts may cause abnormal uterine bleeding but are not a common cause of heavy menstrual bleeding. Hypothyroidism can cause menstrual irregularities, but it is not commonly associated with menorrhagia.
61 Answer: A, B, C, E Rationale: The patient’s presentation is concerning for acute heavy menstrual bleeding, which can be a medical emergency. Appropriate interventions would include administering IV fluids to address any volume depletion, ordering a CBC to assess for anemia, performing a pelvic exam to assess for any signs of trauma or bleeding, and ordering a pelvic ultrasound to evaluate the uterus and ovaries. Hormonal contraception may be used in the long-term management of menorrhagia, but it is not appropriate for acute management of heavy bleeding. Tranexamic acid is a medication that can be used to decrease heavy menstrual bleeding, but it is not typically used in the emergency setting.
62 Answer: A, B, D, E Rationale: Amenorrhea is defined as the absence of menstrual periods in women of reproductive age. Polycystic ovary syndrome (PCOS), thyroid dysfunction, and anorexia nervosa are common causes of secondary amenorrhea, where a woman who has previously had regular periods stops menstruating for at least 3 months. Pregnancy is also a cause of amenorrhea. Endometriosis and ovarian cancer may cause abnormal bleeding or irregular periods, but they are not common causes of amenorrhea.
63 Answer: A, B, C, D Rationale: The patient’s history of heavy menstrual bleeding and missed periods for 6 months suggests a possible case of menorrhagia, which is heavy and prolonged menstrual bleeding. Possible causes of menorrhagia include pregnancy, hypothyroidism, endometriosis, and uterine fibroids. Hyperthyroidism can cause irregular menstrual bleeding, but not necessarily heavy bleeding. Ovarian cancer is not a common cause of menorrhagia.
64 Answer: A, D, F Rationale: Mastitis is an infection of the breast tissue that can occur in lactating women. The infection is usually caused by bacteria entering the breast through a cracked or sore nipple. Treatment for mastitis involves antibiotics to clear the infection, frequent and effective emptying of the affected breast, and pain management. Therefore, options A, D, and F are correct. The mother should be encouraged to continue breastfeeding frequently from both breasts to promote milk flow and prevent further engorgement. Breastfeeding from the affected breast should not be stopped unless the mother is unable to do so due to pain or other issues. The use of a breast pump can be recommended to empty the affected breast if the infant is unable to do so effectively. Heat application is not recommended for mastitis as it can increase inflammation. Ibuprofen can be used to manage pain and inflammation, but it should not be the only treatment. Antibiotics are necessary to treat the infection and prevent complications. Therefore, option B and C are incorrect
65 Correct answers: A, B, C, and E Rationale: Sepsis is a potentially life-threatening condition that can occur when the body’s response to infection causes injury to its own tissues and organs. Interventions for sepsis include administering broad-spectrum antibiotics to control the infection, starting a vasopressor to maintain blood pressure, providing oxygen therapy to maintain adequate oxygen saturation, and monitoring urine output to assess renal function. High-dose corticosteroids are not typically used in the management of sepsis, and fluid restriction is not recommended.
66 Correct answers: A, B, E, and F Rationale: Patients with sepsis are often given intravenous fluids to help maintain blood pressure. However, excessive fluid administration can lead to fluid overload, which can exacerbate organ dysfunction. The nurse should monitor the patient’s serum sodium and potassium levels, as well as BUN and creatinine levels, to assess renal function and the potential for fluid overload. Hemoglobin and hematocrit levels are not as helpful in assessing fluid status.
67 Answer: A, B Rationale: Antibiotics are the primary treatment for osteomyelitis. Standard precautions should be implemented to prevent the spread of infection. Elevation and heat are not indicated for osteomyelitis. Ambulation may not be feasible for some patients with osteomyelitis due to pain or immobility. Adequate hydration is important for overall health, but is not specific to the treatment of osteomyelitis.
68 Answer: A, B, D, F Rationale: Pain medication and antibiotics are important for managing the patient’s symptoms and treating the infection. Vital signs should be monitored to assess for signs of sepsis or other complications. Ambulation may be contraindicated due to pain or immobility. Cold compresses are not indicated for osteomyelitis, as this can exacerbate inflammation. Antipyretics can help manage the patient’s fever.
69 Correct answers: A, C, E Rationale: Hand hygiene is important to prevent the introduction of microorganisms into the central line. Sterile technique should be used when accessing the central line to prevent contamination. The use of a chlorhexidine-impregnated dressing has been shown to decrease the risk of central line infections. Changing the dressing daily and changing the central line tubing every 24 hours are not evidence-based practices and may increase the risk of infection. Encouraging the patient to avoid touching the central line site is important, but it is not enough to prevent central line infections
70 Correct answers: B, C, E, F Rationale: Removing the central line may be necessary, but it should not be the first intervention unless the patient is showing signs of severe sepsis. Blood cultures should be obtained from the central line and a peripheral site to determine the source of the infection. Broad-spectrum antibiotics should be administered to cover a wide range of potential pathogens until the results of the blood cultures are available. The patient should be assessed for signs and symptoms of sepsis, which can be life-threatening if left untreated. The healthcare provider should be notified of the suspected infection and the interventions that have been implemented. Changing the central line dressing may be necessary, but it is not as important as obtaining blood cultures and administering antibiotics.
71 Correct Answers: A, C, D, F Rationale: Contact precautions are used for patients with known or suspected infections that can be transmitted by direct or indirect contact. The nurse should wear a gown and gloves when entering the patient’s room to prevent the transmission of MRSA. The patient should be placed in a private room to decrease the risk of transmission. The nurse should also cleanse their hands before and after removing gloves to prevent the spread of infection. Masks are not typically used for contact precautions unless there is a risk of airborne transmission. The gown should be removed after leaving the patient’s room to prevent the spread of microorganisms.
72 Correct Answers: B, D, E Rationale: Contact precautions are used for patients with known or suspected infections that can be transmitted by direct or indirect contact. Clostridium difficile infection is typically spread through fecal-oral transmission, so the nurse should use soap and water to cleanse their hands rather than alcohol-based hand sanitizer. A disposable blood pressure cuff should be used to prevent the spread of microorganisms. The patient should be placed in a private room to decrease the risk of transmission. Used supplies should be discarded in a designated biohazard container rather than a regular trash can. Masks are not typically used for contact precautions unless there is a risk of airborne transmission.
73 Answer: A, B Rationale: Donning sterile gloves and using sterile instruments are appropriate actions to maintain aseptic technique during a sterile dressing change. Touching the sterile field with sterile gloves is not recommended as it can contaminate the field. Opening the sterile packages in advance is also not recommended as it can compromise the sterility of the field. Using a non-sterile saline solution and cleaning the wound with a non-sterile solution are not appropriate actions for maintaining aseptic technique.
74 Answer: D, E Rationale: A clean environment is important for infection control, but it does not necessarily ensure aseptic technique. Sterile gloves should only be worn for procedures that require sterile technique, while non-sterile gloves can be worn for procedures that require clean technique.
75 Answer: A, C, F. Rationale: Wearing sterile gloves and gown, using sterile forceps to handle sterile items, and keeping the sterile field within sight and above waist level are all appropriate actions for the nurse to take to maintain sterile technique during the procedure. Disinfecting the skin with an alcohol swab is also appropriate, but it is not specific to maintaining sterile technique. Touching the inside of the sterile glove with ungloved fingers or allowing the sterile field to be touched by non-sterile items would break sterile technique and increase the risk of infection.
Our next question set will include questions on arrhythmias, pneumonia, the most appropriate action to address other vascular symptoms, NCLEX and nurse review on UTI, ulcerative colitis, and Crohns to help you pass the boards. Stay tuned for our NCLEX high yield podcast so you can listen to NCLEX questions on the go.
