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 highvtemperature,v isvnotvanvassessmentvfindingvofvavDuodenalv Ulcer.v Incorrect
Avnursev isvprovidingv dischargev teachingvforv avpatientvwithv severev Gastroesophogealv RefluxvDis
e
ase.vWhichvofvthesevstatementsvbyvthevpatientvindicatesv avneedvforv morevteaching?
1.v"I'mvgoingvtov limitvmyv mealsvtov2-
3vperv dayv tov reducev acidvsecretion."
,v
2.v"I'mvgoingvtov makev surevtovremainvuprightvaſterv mealsvandvelevatev myv headv whenv Ivsleep
"
3
.v"Iv won'tvbevdrinkingvteav orvcoffeev orveatingvchocolatev anyvmore."
4.v"I'mvgoingvtov startvtryingvtov losevsomev weight."v-vCORRECTv ANSWERv-
1.v"I'mvgoingvtov limitvmyv mealsvtov2-
3vperv dayv tov reducev acidvsecretion."
CORRECTv -
Largev mealsvincreasevthev volumevandv pressurevinv thevstomachv andvdelayvgastricv emptying.vIt'
s
recommendedv insteadvtov eatv4-6vsmallvmealsvavday.
2.v"I'mvgoingvtov makev surevtovremainvuprightvaſterv mealsvandvelevatev myv headv whenv Ivsleep
"
Incorrectv-vThisvisvav correctvverbalizationvofv healthvpromotionvforv GERD.
3.v"Iv won'tvbevdrinkingvteav orvcoffeev orveatingvchocolatev anyvmore.
"
Incorrectv-vThisvisvav correctvverbalizationvofv healthvpromotionvforv GERD.
4.v"I'mvgoingvtov startvtryingvtov losevsomev weight."
Incorrectv-vThisvisvav correctvverbalizationvofv healthvpromotionvforv GERD.
Thevnursev invthevEmergencyvRoomv isvtreatingvavpatientvsuspectedvtov havevavPepticvUlcer.v Onv a
s
sessingvlabvresults,vthevnursev findsvthatvthevpatient'svbloodvpressurev isv95/60,v pulsevisv110vbea
t
svpervminute,vandv thevpatientvreportsvepigastricvpain.vWhatvisvthevPRIORITYv intervention?
1.vStartvavlarge-borev IVvinv thevpatient'svarm
2.vAskvthevpatientvforv avstoolv sample
3.vPreparevtov insertvanvNGv Tube
4.vAdministervintramuscularv morphinev sulphatevasvorderedv -vCORRECTv ANSWERv-
1.vStartvavlarge-borev IVvinv thevpatient'svarm
,v
CORRECTv -
Thevnursev shouldvsuspectvthatv thevpatientvisvhaemorrhagingvandv willvneedv needv avfluidv repla
c
ementvtherapy,v whichvrequiresv avlargev borev IV.
2.vAskvthevpatientvforv avstoolv sample
Incorrectv-
Whilevthisvisvusefulvinvthev diagnosisvandv assessmentvofvPepticvUlcervDisease,v itvisvnotvthevpri
or
ityvintervention.
3.vPreparevtov insertvanvNGv Tube
Incorrectv-
Whilevthisvinterventionvmayv bevusedvinv thevlatervstagesv ofvPepticvUlcervDisease,vitvisvnotvthev
fir
stv andvpriorityvintervention.
4.vAdministervintramuscularv morphinev sulphatevasvordered
Incorrectv-
Whilevthisvisvanvimportantvinterventionvtovmanagev pain,vitvisvnotvthevpriorityvintervention
.
Avfemalevpatientvwithv atrialv fibrillationvhasvthevfollowingv labvresults:vHemoglobinvofv11v g/dl,va
plateletvcountvofv150,000,v anvINRvofv2.5,vandv potassiumv ofv2.7vmEq/L.vWhichv resultvisvcriticalv
a
ndvshouldvbevreportedv tov thevphysicianv immediately?
1.vHemoglobinv 11vg/dl
2.vPlateletvofv150,000
3.vINRvofv2.5
4.vPotassiumvofv 2.7vmEq/Lv -vCORRECTv ANSWERv-1.vHemoglobinv 11vg/dl
Thisvisvbelowvnormal,vbutvavnormalvfemalevhemoglobinv isv12-
14.vTherev isvavmorev criticalvlabvresult.
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 highvtemperature,v isvnotvanvassessmentvfindingvofvavDuodenalv Ulcer.v Incorrect
Avnursev isvprovidingv dischargev teachingvforv avpatientvwithv severev Gastroesophogealv RefluxvDis
e
ase.vWhichvofvthesevstatementsvbyvthevpatientvindicatesv avneedvforv morevteaching?
1.v"I'mvgoingvtov limitvmyv mealsvtov2-
3vperv dayv tov reducev acidvsecretion."
,v
2.v"I'mvgoingvtov makev surevtovremainvuprightvaſterv mealsvandvelevatev myv headv whenv Ivsleep
"
3
.v"Iv won'tvbevdrinkingvteav orvcoffeev orveatingvchocolatev anyvmore."
4.v"I'mvgoingvtov startvtryingvtov losevsomev weight."v-vCORRECTv ANSWERv-
1.v"I'mvgoingvtov limitvmyv mealsvtov2-
3vperv dayv tov reducev acidvsecretion."
CORRECTv -
Largev mealsvincreasevthev volumevandv pressurevinv thevstomachv andvdelayvgastricv emptying.vIt'
s
recommendedv insteadvtov eatv4-6vsmallvmealsvavday.
2.v"I'mvgoingvtov makev surevtovremainvuprightvaſterv mealsvandvelevatev myv headv whenv Ivsleep
"
Incorrectv-vThisvisvav correctvverbalizationvofv healthvpromotionvforv GERD.
3.v"Iv won'tvbevdrinkingvteav orvcoffeev orveatingvchocolatev anyvmore.
"
Incorrectv-vThisvisvav correctvverbalizationvofv healthvpromotionvforv GERD.
4.v"I'mvgoingvtov startvtryingvtov losevsomev weight."
Incorrectv-vThisvisvav correctvverbalizationvofv healthvpromotionvforv GERD.
Thevnursev invthevEmergencyvRoomv isvtreatingvavpatientvsuspectedvtov havevavPepticvUlcer.v Onv a
s
sessingvlabvresults,vthevnursev findsvthatvthevpatient'svbloodvpressurev isv95/60,v pulsevisv110vbea
t
svpervminute,vandv thevpatientvreportsvepigastricvpain.vWhatvisvthevPRIORITYv intervention?
1.vStartvavlarge-borev IVvinv thevpatient'svarm
2.vAskvthevpatientvforv avstoolv sample
3.vPreparevtov insertvanvNGv Tube
4.vAdministervintramuscularv morphinev sulphatevasvorderedv -vCORRECTv ANSWERv-
1.vStartvavlarge-borev IVvinv thevpatient'svarm
,v
CORRECTv -
Thevnursev shouldvsuspectvthatv thevpatientvisvhaemorrhagingvandv willvneedv needv avfluidv repla
c
ementvtherapy,v whichvrequiresv avlargev borev IV.
2.vAskvthevpatientvforv avstoolv sample
Incorrectv-
Whilevthisvisvusefulvinvthev diagnosisvandv assessmentvofvPepticvUlcervDisease,v itvisvnotvthevpri
or
ityvintervention.
3.vPreparevtov insertvanvNGv Tube
Incorrectv-
Whilevthisvinterventionvmayv bevusedvinv thevlatervstagesv ofvPepticvUlcervDisease,vitvisvnotvthev
fir
stv andvpriorityvintervention.
4.vAdministervintramuscularv morphinev sulphatevasvordered
Incorrectv-
Whilevthisvisvanvimportantvinterventionvtovmanagev pain,vitvisvnotvthevpriorityvintervention
.
Avfemalevpatientvwithv atrialv fibrillationvhasvthevfollowingv labvresults:vHemoglobinvofv11v g/dl,va
plateletvcountvofv150,000,v anvINRvofv2.5,vandv potassiumv ofv2.7vmEq/L.vWhichv resultvisvcriticalv
a
ndvshouldvbevreportedv tov thevphysicianv immediately?
1.vHemoglobinv 11vg/dl
2.vPlateletvofv150,000
3.vINRvofv2.5
4.vPotassiumvofv 2.7vmEq/Lv -vCORRECTv ANSWERv-1.vHemoglobinv 11vg/dl
Thisvisvbelowvnormal,vbutvavnormalvfemalevhemoglobinv isv12-
14.vTherev isvavmorev criticalvlabvresult.
