NCLEX-RN Practice Questions with Nurse Brennan

Question 1: A client with atrial fibrillation is prescribed warfarin. What daily activity should the nurse instruct the client to be cautious about?

A. Eating fiber-rich foods

B. Drinking grapefruit juice

C. Using a consistent amount of vitamin K

D. Taking walks for exercise

Correct Answer: C. Using a consistent amount of vitamin K

Rationale: Warfarin therapy requires careful monitoring of dietary vitamin K intake, as it can influence the effectiveness of the medication and the International Normalized Ratio (INR). Clients should maintain a consistent amount of vitamin K in their diet. Grapefruit juice does not typically affect warfarin but can interact with other medications. Fiber and exercise are generally safe.

Question 2: A nurse is providing care to a post-operative client who is at risk for deep vein thrombosis (DVT). Which intervention would be the most effective in preventing this complication?

A. Applying warm compresses to the client’s legs

B. Encouraging ambulation as soon as possible

C. Massaging the client’s calves regularly

D. Maintaining the client in a high-Fowler's position

Correct Answer: B. Encouraging ambulation as soon as possible

Rationale: Early ambulation is one of the most effective interventions to prevent DVT as it improves circulation and prevents blood stagnation in the legs. Warm compresses and calf massages are not standard DVT prevention measures and could potentially be harmful if a clot is present. High-Fowler's positioning is not related to preventing DVT.

Question 3: A nurse is teaching a client newly diagnosed with type 2 diabetes about foot care. Which statement by the client indicates a need for further instruction?

A. "I will inspect my feet daily for blisters or sores."

B. "I should go barefoot at home to keep my feet aired out."

C. "I will trim my toenails straight across to prevent ingrown nails."

D. "I’ll wear well-fitting shoes to protect my feet."

Correct Answer: B. "I should go barefoot at home to keep my feet aired out."

Rationale: Clients with diabetes should be advised against going barefoot to reduce the risk of injury or infection. Inspecting feet daily, trimming toenails straight across, and wearing well-fitting shoes are appropriate foot care measures to prevent complications.

Question 4: A client is prescribed digoxin for heart failure. Which symptom should the nurse teach the client to report immediately as a sign of digoxin toxicity?

A. Increased urine output

B. Shortness of breath

C. Visual disturbances, such as halos

D. Increased appetite

Correct Answer: C. Visual disturbances, such as halos

Rationale: Visual disturbances are a hallmark sign of digoxin toxicity, including seeing halos around lights. Other symptoms of toxicity may include nausea, vomiting, and confusion. Increased urine output can occur with improved heart function. Shortness of breath can indicate worsening heart failure, but not specifically digoxin toxicity. Increased appetite is unrelated.

Question 5: A nurse is reviewing laboratory values for a client receiving heparin therapy. Which lab test is most important to monitor the effectiveness of the therapy?

A. Platelet count

B. Hemoglobin and hematocrit

C. Activated partial thromboplastin time (aPTT)

D. Prothrombin time (PT)

Correct Answer: C. Activated partial thromboplastin time (aPTT)

Rationale: The activated partial thromboplastin time (aPTT) is used to monitor the therapeutic effects of heparin. It helps ensure that the dose is within the therapeutic range, minimizing the risk of bleeding or clotting. PT is used to monitor warfarin therapy, while platelet counts and hemoglobin/hematocrit levels, although important, are not specific to heparin effectiveness.

Question 6: A client receives a new prescription for nitroglycerin tablets for angina. Which instruction is crucial for the nurse to include during patient education?

A. "Store the tablets in your refrigerator."

B. "Take a tablet every 15 minutes until chest pain subsides."

C. "You may experience a headache after taking this medication."

D. "If chest pain persists after one tablet, wait an hour before taking another."

Correct Answer: C. "You may experience a headache after taking this medication."

Rationale: Headaches are a common side effect of nitroglycerin due to its vasodilatory effects. The tablets should be stored at room temperature in a dark bottle, not refrigerated. The standard instruction is to take one tablet every 5 minutes, up to a total of three doses, and seek emergency help if the pain persists after the first dose.