75 NCLEX QUESTIONS WITH CORRECT
ANSWERS
The nurse is taking the health history of a patient being treated for Emphysema and Chronic B
ronchitis. Aſter being told the patient has been smoking cigarettes for 30 years, the nurse exp
ects to note which assessment finding?
1. Increase in Forced Vital Capacity (FVC)
2. A narrowed chest cavity
3. Clubbed fingers
4. An increased risk of cardiac failure - CORRECT ANSWER -
1. Increase in Forced Vital Capacity (FVC)
Forced Vital Capacity is the volume of air exhaled from full inhalation to full exhalation. A pati
ent with COPD would have a decrease in FVC. Incorrect.
2. A narrowed chest cavity
A patient with COPD oſten presents with a 'barrel chest,' which is seen as a widened chest cav
ity. Incorrect.
3. Clubbed fingers - CORRECT
Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels.
4. An increased risk of cardiac failure
Although a patient with these conditions would indeed be at an increased risk for cardiac failu
re, this is a potential complication and not an assessment finding. Incorrect.
,The nurse is taking the health history of a 70-year-
old patient being treated for a Duodenal Ulcer. Aſter being told the patient is complaining of e
pigastric pain, the nurse expects to note which assessment finding?
1. Melena
2. Nausea
3. Hernia
4. Hyperthermia - CORRECT ANSWER -1. Melena - CORRECT
Melena is the finding that there are traces of blood in the stool which presents as black, tarry
feces. This is a common manifestation of Duodenal Ulcers, since the Duodenum is further dow
n the gastric anatomy.
2. Nausea
Nausea may be present, but is a generalized symptom and by itself doesn't indicate a Duoden
al Ulcer. Incorrect.
3. Hernia
A Hernia is a protrusion of a segment of the abdomen through another abdominal structure. I
t is not associated with an Ulcer and is a condition, not an assessment finding. Incorrect.
4. Hyperthermia
Hyperthermia, a highztemperature,z isznotzanzassessmentzfindingzofzazDuodenalz Ulcer.z Incorrect
Aznursez iszprovidingz dischargez teachingzforz azpatientzwithz severez Gastroesophogealz RefluxzDise
ase.zWhichzofzthesez statementsz byzthezpatientzindicatesz azneedzforz morezteaching?
1.z"I'mzgoingztoz limitzmyz mealsztoz 2-3zperz dayz toz reducez acidzsecretion."
,z
2.z"I'mzgoingztoz makez surez tozremainzuprightzaſterz mealszandzelevatez myz headz whenz Izsleep"
3.z"Izwon'tzbezdrinkingzteaz orzcoffeez orzeatingzchocolatez anyzmore."
4.z"I'mzgoingztoz startztryingztoz losezsomez weight."z-zCORRECTz ANSWERz-
1.z"I'mzgoingztoz limitzmyz mealsztoz 2-3zperz dayz toz reducez acidzsecretion."
CORRECTz -
Largez mealszincreasezthez volumezandzpressurez inz thezstomachzandzdelayzgastricz emptying.zIt's
recommendedz insteadztoz eatz4-6zsmallzmealszaz day.
2.z"I'mzgoingztoz makez surez tozremainzuprightzaſterz mealszandzelevatez myz headz whenz Izsleep"
Incorrectz-zThisziszazcorrectzverbalizationzofz healthzpromotionzforz GERD.
3.z"Izwon'tzbezdrinkingzteaz orzcoffeez orzeatingzchocolatez anyzmore."
Incorrectz-zThisziszazcorrectzverbalizationzofz healthzpromotionzforz GERD.
4.z"I'mzgoingztoz startztryingztoz losezsomez weight."
Incorrectz-zThisziszazcorrectzverbalizationzofz healthzpromotionzforz GERD.
Theznursez inzthezEmergencyzRoomz isztreatingzazpatientzsuspectedztoz havezazPepticzUlcer.z Onz as
sessingzlabzresults,ztheznursez findszthatzthezpatient'szbloodzpressurez isz95/60,z pulsezisz110z beat
szperzminute,z andz thezpatientzreportszepigastriczpain.zWhatziszthezPRIORITYz intervention?
1.zStartzazlarge-borez IVzinz thezpatient'szarm
2.zAskzthezpatientzforz azstoolz sample
3.zPrepareztoz insertzanzNGz Tube
4.zAdministerz intramuscularz morphinez sulphatezaszorderedz -zCORRECTz ANSWERz-
1.zStartzazlarge-borez IVzinz thezpatient'szarm
,z
CORRECTz -
Theznursez shouldz suspectzthatz thezpatientziszhaemorrhagingzandz willzneedz needz azfluidz replac
ementztherapy,z whichz requiresz azlargez borez IV.
2.zAskzthezpatientzforz azstoolz sample
Incorrectz-
Whilezthisziszusefulzinzthez diagnosiszandz assessmentzofzPepticzUlcerzDisease,z itzisznotzthezprior
ityzintervention.
3.zPrepareztoz insertzanzNGz Tube
Incorrectz-
Whilezthiszinterventionzmayz bezusedzinz thezlaterzstagesz ofzPepticzUlcerzDisease,zitzisznotzthezfir
stz andzpriorityzintervention.
4.zAdministerz intramuscularz morphinez sulphatezaszordered
Incorrectz-
Whilezthisziszanzimportantzinterventionztozmanagez pain,zitzisznotzthezpriorityzintervention.
Azfemalez patientzwithz atrialz fibrillationzhaszthezfollowingz labzresults:zHemoglobinzofz11z g/dl,za
plateletzcountzofz150,000,z anzINRzofz2.5,zandz potassiumz ofz2.7z mEq/L.zWhichz resultziszcriticalza
ndzshouldzbezreportedz toz thezphysicianz immediately?
1.zHemoglobinz 11zg/dl
2.zPlateletzofz150,000
3.zINRzofz2.5
4.zPotassiumzofz 2.7zmEq/Lz -zCORRECTz ANSWERz-1.zHemoglobinz 11zg/dl
Thisziszbelowznormal,zbutzaznormalzfemalezhemoglobinz isz12-
14.zTherez iszazmorez criticalzlabzresult.
ANSWERS
The nurse is taking the health history of a patient being treated for Emphysema and Chronic B
ronchitis. Aſter being told the patient has been smoking cigarettes for 30 years, the nurse exp
ects to note which assessment finding?
1. Increase in Forced Vital Capacity (FVC)
2. A narrowed chest cavity
3. Clubbed fingers
4. An increased risk of cardiac failure - CORRECT ANSWER -
1. Increase in Forced Vital Capacity (FVC)
Forced Vital Capacity is the volume of air exhaled from full inhalation to full exhalation. A pati
ent with COPD would have a decrease in FVC. Incorrect.
2. A narrowed chest cavity
A patient with COPD oſten presents with a 'barrel chest,' which is seen as a widened chest cav
ity. Incorrect.
3. Clubbed fingers - CORRECT
Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels.
4. An increased risk of cardiac failure
Although a patient with these conditions would indeed be at an increased risk for cardiac failu
re, this is a potential complication and not an assessment finding. Incorrect.
,The nurse is taking the health history of a 70-year-
old patient being treated for a Duodenal Ulcer. Aſter being told the patient is complaining of e
pigastric pain, the nurse expects to note which assessment finding?
1. Melena
2. Nausea
3. Hernia
4. Hyperthermia - CORRECT ANSWER -1. Melena - CORRECT
Melena is the finding that there are traces of blood in the stool which presents as black, tarry
feces. This is a common manifestation of Duodenal Ulcers, since the Duodenum is further dow
n the gastric anatomy.
2. Nausea
Nausea may be present, but is a generalized symptom and by itself doesn't indicate a Duoden
al Ulcer. Incorrect.
3. Hernia
A Hernia is a protrusion of a segment of the abdomen through another abdominal structure. I
t is not associated with an Ulcer and is a condition, not an assessment finding. Incorrect.
4. Hyperthermia
Hyperthermia, a highztemperature,z isznotzanzassessmentzfindingzofzazDuodenalz Ulcer.z Incorrect
Aznursez iszprovidingz dischargez teachingzforz azpatientzwithz severez Gastroesophogealz RefluxzDise
ase.zWhichzofzthesez statementsz byzthezpatientzindicatesz azneedzforz morezteaching?
1.z"I'mzgoingztoz limitzmyz mealsztoz 2-3zperz dayz toz reducez acidzsecretion."
,z
2.z"I'mzgoingztoz makez surez tozremainzuprightzaſterz mealszandzelevatez myz headz whenz Izsleep"
3.z"Izwon'tzbezdrinkingzteaz orzcoffeez orzeatingzchocolatez anyzmore."
4.z"I'mzgoingztoz startztryingztoz losezsomez weight."z-zCORRECTz ANSWERz-
1.z"I'mzgoingztoz limitzmyz mealsztoz 2-3zperz dayz toz reducez acidzsecretion."
CORRECTz -
Largez mealszincreasezthez volumezandzpressurez inz thezstomachzandzdelayzgastricz emptying.zIt's
recommendedz insteadztoz eatz4-6zsmallzmealszaz day.
2.z"I'mzgoingztoz makez surez tozremainzuprightzaſterz mealszandzelevatez myz headz whenz Izsleep"
Incorrectz-zThisziszazcorrectzverbalizationzofz healthzpromotionzforz GERD.
3.z"Izwon'tzbezdrinkingzteaz orzcoffeez orzeatingzchocolatez anyzmore."
Incorrectz-zThisziszazcorrectzverbalizationzofz healthzpromotionzforz GERD.
4.z"I'mzgoingztoz startztryingztoz losezsomez weight."
Incorrectz-zThisziszazcorrectzverbalizationzofz healthzpromotionzforz GERD.
Theznursez inzthezEmergencyzRoomz isztreatingzazpatientzsuspectedztoz havezazPepticzUlcer.z Onz as
sessingzlabzresults,ztheznursez findszthatzthezpatient'szbloodzpressurez isz95/60,z pulsezisz110z beat
szperzminute,z andz thezpatientzreportszepigastriczpain.zWhatziszthezPRIORITYz intervention?
1.zStartzazlarge-borez IVzinz thezpatient'szarm
2.zAskzthezpatientzforz azstoolz sample
3.zPrepareztoz insertzanzNGz Tube
4.zAdministerz intramuscularz morphinez sulphatezaszorderedz -zCORRECTz ANSWERz-
1.zStartzazlarge-borez IVzinz thezpatient'szarm
,z
CORRECTz -
Theznursez shouldz suspectzthatz thezpatientziszhaemorrhagingzandz willzneedz needz azfluidz replac
ementztherapy,z whichz requiresz azlargez borez IV.
2.zAskzthezpatientzforz azstoolz sample
Incorrectz-
Whilezthisziszusefulzinzthez diagnosiszandz assessmentzofzPepticzUlcerzDisease,z itzisznotzthezprior
ityzintervention.
3.zPrepareztoz insertzanzNGz Tube
Incorrectz-
Whilezthiszinterventionzmayz bezusedzinz thezlaterzstagesz ofzPepticzUlcerzDisease,zitzisznotzthezfir
stz andzpriorityzintervention.
4.zAdministerz intramuscularz morphinez sulphatezaszordered
Incorrectz-
Whilezthisziszanzimportantzinterventionztozmanagez pain,zitzisznotzthezpriorityzintervention.
Azfemalez patientzwithz atrialz fibrillationzhaszthezfollowingz labzresults:zHemoglobinzofz11z g/dl,za
plateletzcountzofz150,000,z anzINRzofz2.5,zandz potassiumz ofz2.7z mEq/L.zWhichz resultziszcriticalza
ndzshouldzbezreportedz toz thezphysicianz immediately?
1.zHemoglobinz 11zg/dl
2.zPlateletzofz150,000
3.zINRzofz2.5
4.zPotassiumzofz 2.7zmEq/Lz -zCORRECTz ANSWERz-1.zHemoglobinz 11zg/dl
Thisziszbelowznormal,zbutzaznormalzfemalezhemoglobinz isz12-
14.zTherez iszazmorez criticalzlabzresult.
