NCLEX-RN Exam: Practice Questions With Nurse Brennan (Part 4.)

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Below are 10 additional NCLEX practice questions to help supplement your NCLEX review:

NCLEX Practice Questions:

Question #1: A nurse is caring for a patient with congestive heart failure (CHF). Which assessment finding is most concerning for the nurse?

A. Decreased pedal edema

B. Blood pressure of 140/90 mm Hg

C. Weight gain of 2 pounds in 24 hours

D. Respiratory rate of 24 breaths per minute

Question #2: A client with a history of seizures is prescribed phenytoin (Dilantin) for seizure control. Which statement by the client indicates a need for further education?

A. "I will avoid drinking alcohol while on this medication"

B. "I should take this medication on an empty stomach"

C. "I need to have my blood levels of phenytoin checked regularly"

D. "I can stop taking the medication once I am seizure-free for a year."

Question #3: A client with a history of diabetes is admitted with a blood glucose level of 350 mg/dL. Which intervention should the nurse prioritize?

A. Start an IV line for hydration

B. Administer insulin as ordered

C. Monitor vital signs every 4 hours

D. Encourage the client to eat a candy bar

Question #4: A nurse is caring for a patient who has just undergone abdominal surgery. The patient is experiencing pain and has been prescribed opioid analgesics. What is the nurse's priority action regarding pain management for this patient?

A. Monitor the patient's respiratory rate

B. Administer the opioid analgesic as ordered

C. Provide non-pharmacological pain relief measures

D. Assess the patient's pain intensity using a pain scale

Question #5: A client is receiving heparin therapy for deep vein thrombosis (DVT). The nurse should monitor which lab value to assess the therapeutic effect of heparin?

A. Platelet count

B. Prothrombin time (PT)

C. International normalized ratio (INR)

D. Activated partial thromboplastin time (aPTT)

Question #6: A patient in the ICU is receiving mechanical ventilation. The nurse observes that the endotracheal tube is not properly secured and moves with each breath. What is the most appropriate action for the nurse to take?

A. Notify the healthcare provider

B. Reinsert the endotracheal tube

C. Administer a sedative to keep the patient calm

D. Document the observation and continue monitoring

Question #7: A 5-year-old child is diagnosed with acute otitis media. What medication is commonly prescribed for this condition?

A. Ibuprofen

B. Amoxicillin

C. Acetaminophen

D. Diphenhydramine

Question #8: A nurse is caring for a client with end-stage renal disease (ESRD) receiving hemodialysis. Which assessment finding should the nurse prioritize during the dialysis session?

A. Urine output

B. Skin integrity

C. Blood pressure

D. Respiratory rate

Question #9: A patient is scheduled for surgery and is concerned about post-operative pain management. The nurse should explain that pain management is crucial because:

A. Pain can lead to respiratory complications

B. Pain can cause excessive bleeding during surgery

C. Pain can slow down the surgical recovery process

D. Pain can lead to increased blood pressure and heart rate

Question #10: A nurse is assessing a client with schizophrenia who is experiencing worsening auditory hallucinations. The client is agitated and reports hearing voices commanding self-harm. What is the nurse's priority intervention?

A. Place the client in seclusion for safety

B. Administer a PRN antipsychotic medication

C. Conduct a group therapy session for the client

D. Encourage the client to share their hallucination experiences

NCLEX Practice Answers and Rationale:

Answer #1: C. Weight gain of 2 pounds in 24 hours

Rationale: Sudden weight gain in a patient with CHF is concerning, as it can indicate fluid retention and worsening heart failure. Monitoring daily weight is crucial in managing CHF, as a 2-pound gain in 24 hours or 5 pounds in a week may indicate worsening fluid overload.

Answer #2: D. "I can stop taking the medication once I am seizure-free for a year."

Rationale: Phenytoin is typically prescribed for the long-term management of seizures, and abruptly stopping the medication can lead to seizure recurrence. The other statements are correct: taking phenytoin on an empty stomach enhances absorption, avoiding alcohol is important to prevent interactions, and regular monitoring of blood levels is necessary to ensure therapeutic drug levels are maintained.

Answer #3: B. Administer insulin as ordered

Rationale: Elevated blood glucose levels in a diabetic client can lead to complications such as diabetic ketoacidosis. The priority is to bring the blood glucose level down to a safer range, which is achieved by administering insulin as prescribed.

Answer #4: A. Monitor the patient's respiratory rate

Rationale: When administering opioid analgesics, it is essential to monitor the patient's respiratory rate because opioids can depress the respiratory system and lead to respiratory depression. While administering the medication and assessing pain intensity are important, assessing the respiratory rate is the top priority to ensure the patient's safety and well-being. Non-pharmacological pain relief measures should also be provided, but they do not take precedence over monitoring for respiratory depression.

Answer #5: D. Activated partial thromboplastin time (aPTT)

Rationale: Heparin therapy is monitored by assessing the aPTT. It is used to measure the intrinsic pathway of coagulation and is the most appropriate indicator of heparin's therapeutic effect. Platelet count is monitored to detect thrombocytopenia, while PT and INR are more commonly used to monitor the effectiveness of warfarin therapy.

Answer #6: A. Notify the healthcare provider

Rationale: The endotracheal tube must be properly secured to prevent accidental extubation or displacement, which can be life-threatening. The nurse should notify the healthcare provider to address this issue promptly. Reinserting the tube is not within the nurse's scope of practice.

Answer #7: B. Amoxicillin

Rationale: Amoxicillin is commonly prescribed for the treatment of acute otitis media in children. It is an appropriate antibiotic choice for this bacterial infection.

Answer #8: C. Blood pressure

Rationale: Monitoring blood pressure is crucial during dialysis because rapid fluid removal can cause hypotension. It's essential to assess the client's blood pressure frequently and respond promptly to any hypotensive episodes to prevent complications such as dizziness, nausea, and potential cardiovascular issues.

Answer #9: D. Pain can lead to increased blood pressure and heart rate

Rationale: Pain can activate the body's stress response, leading to increased heart rate, blood pressure, and potential complications. Proper pain management is essential to reduce these physiological responses and promote better surgical outcomes.

Answer #10: B. Administer a PRN antipsychotic medication

Rationale: When a client with schizophrenia is experiencing worsening auditory hallucinations with commands for self-harm, the priority is to ensure the client's safety. Administering a PRN antipsychotic medication can help reduce the intensity of the hallucinations and alleviate agitation. It is essential to address the safety concern first.