NCSBN NCLEX RN EXAM 1 TEST BANK With
Questions And Answers Actual Exam New
Complete V erified Questions And Correct
Detailed Answers With Rationales | Already
Graded A+
A client is receiving cisplatin chemotherapy. The nurse should monitor for which major side
effect?
A) Cardiotoxicity
B) Nephrotoxicity
C) Hepatotoxicity
D) Neurotoxicity in the hands and feet only
Correct Answer: B
Rationale: Cisplatin is highly nephrotoxic due to its direct toxic effect on the renal tubules.
Aggressive hydration before, during, and after administration, along with monitoring of serum
creatinine, BUN, and urine output, is essential to prevent acute kidney injury. While ototoxicity
and peripheral neuropathy are also common, nephrotoxicity is the most dose-limiting and
potentially life-threatening adverse effect. Cardiotoxicity is more associated with anthracyclines
such as doxorubicin, and hepatotoxicity is less common with cisplatin. Amifostine or mannitol
may be used for renal protection in some protocols.
The nurse is admitting a client with suspected acute myocardial infarction. Which
electrocardiogram (ECG) finding is most consistent with ST-elevation myocardial infarction
(STEMI)?
A) ST-segment depression in multiple leads
B) T-wave inversion
C) ST-segment elevation in contiguous leads
D) Prolonged PR interval
Correct Answer: C
Page 1 of 153
,Rationale: ST-segment elevation in two or more contiguous leads is the hallmark ECG finding of
STEMI, indicating acute transmural myocardial injury. This requires immediate reperfusion
therapy (percutaneous coronary intervention or thrombolytics) within the recommended time
frame because “time is muscle.” ST depression and T-wave inversion are more typical of non-
ST-elevation MI (NSTEMI) or ischemia, while PR prolongation relates to conduction delays.
Rapid recognition of STEMI is critical for improving outcomes and reducing mortality. The
nurse should also assess for pain, administer oxygen, aspirin, and notify the provider
immediately.
A 4-year-old child is brought to the emergency department after ingesting an unknown amount
of acetaminophen. Which laboratory value is most important to monitor?
A) Serum acetaminophen level 4 hours after ingestion
B) Complete blood count
C) Serum electrolytes
D) Liver enzymes only after 48 hours
Correct Answer: A
Rationale: The Rumack-Matthew nomogram uses a serum acetaminophen level drawn at least 4
hours after ingestion to predict the risk of hepatotoxicity and guide antidote (N-acetylcysteine)
administration. Early measurement is essential because treatment is most effective when started
within 8–16 hours. Liver enzymes may rise later (peak at 72–96 hours), but waiting for them is
not appropriate for initial management. Complete blood count and electrolytes are secondary
unless complications develop. Prompt use of the nomogram can prevent fulminant hepatic
failure.
The nurse is providing care to a client with anorexia nervosa who has a body mass index of 14.
Which intervention has the highest priority?
A) Encourage the client to verbalize feelings about body image
B) Monitor vital signs and daily weights strictly
C) Allow the client to choose preferred meals from the menu
D) Teach the client about long-term nutritional needs
Correct Answer: B
Rationale: Clients with severe anorexia nervosa are at high risk for life-threatening complications
including cardiac dysrhythmias, electrolyte imbalances (especially hypokalemia and
hypophosphatemia during refeeding), and refeeding syndrome. Close monitoring of vital signs,
Page 2 of 153
,daily weights, and strict intake/output is the highest priority to detect and prevent medical
instability. Psychological support and nutritional education are important but come after ensuring
physiological stability. Refeeding must be done gradually under close supervision to avoid
refeeding syndrome, which can cause fatal fluid shifts and cardiac arrest.
A client with Parkinson’s disease is prescribed levodopa/carbidopa. The nurse should advise the
client to avoid:
A) High-protein meals close to medication times
B) Foods rich in vitamin B6
C) Caffeine-containing beverages
D) Dairy products entirely
Correct Answer: A
Rationale: Large amounts of dietary protein can compete with levodopa for transport across the
blood-brain barrier, reducing its effectiveness and causing “on-off” fluctuations in symptoms.
The client should take the medication 30–60 minutes before meals or separate protein intake
from dosing times. Vitamin B6 can interfere with some older Parkinson’s medications but has
less impact with modern formulations. Caffeine and dairy do not have major interactions with
levodopa/carbidopa. Proper timing of meals and medication improves symptom control and
quality of life.
The nurse is assessing a client with suspected deep vein thrombosis (DVT) in the right calf.
Which finding is most concerning?
A) Unilateral calf swelling and warmth
B) Positive Homans’ sign (pain on dorsiflexion)
C) Mild redness over the calf
D) Client reports occasional leg cramps at night
Correct Answer: A
Rationale: Unilateral swelling, warmth, and pain are classic signs of DVT. The presence of these
findings warrants immediate further evaluation with duplex ultrasound and possible initiation of
anticoagulation to prevent pulmonary embolism. Homans’ sign is no longer considered reliable
or specific and can actually dislodge a clot if performed vigorously. Mild redness or nocturnal
cramps are less specific and can occur in many conditions. Early detection and treatment of DVT
significantly reduce the risk of life-threatening pulmonary embolism.
Page 3 of 153
, A client is scheduled for a colonoscopy. Which pre-procedure instruction is most important for
the nurse to reinforce?
A) “You may eat a light breakfast the morning of the procedure.”
B) “Take all your regular medications with a sip of water on the day of the test.”
C) “Complete the entire bowel preparation solution as instructed.”
D) “You will be able to drive yourself home after the sedation wears off.”
Correct Answer: C
Rationale: Adequate bowel cleansing is critical for successful visualization during colonoscopy.
Incomplete preparation can lead to missed lesions, prolonged procedure time, or the need to
reschedule. Clients must follow a clear liquid diet and consume the full volume of the prescribed
laxative solution. Regular medications may need adjustment (especially anticoagulants or
diabetes medications), eating is not allowed on the morning of the procedure, and the client must
have a responsible adult to drive home due to sedation effects. Good bowel prep directly impacts
the quality and safety of the procedure.
The nurse is caring for a client receiving continuous enteral tube feeding. The client suddenly
develops diarrhea. What is the most appropriate initial nursing action?
A) Stop the feeding and notify the healthcare provider
B) Slow the feeding rate and reassess in 1 hour
C) Change to a different formula type immediately
D) Administer an antidiarrheal medication as ordered
Correct Answer: B
Rationale: Diarrhea is a common complication of enteral nutrition and is often related to the rate
or concentration of the feeding rather than infection or formula intolerance initially. Slowing the
infusion rate allows the gastrointestinal tract to adjust while the nurse assesses for other causes
(medications, infection, or hyperosmolar formula). Abruptly stopping the feeding can lead to
unnecessary caloric deficit, and changing the formula or giving antidiarrheals should only be
done after evaluating the situation and consulting the provider if needed. Monitoring
intake/output and skin integrity is also important.
A client with chronic alcoholism is admitted with confusion, ataxia, and nystagmus. The nurse
recognizes these symptoms as consistent with:
A) Alcohol withdrawal delirium
Page 4 of 153
Questions And Answers Actual Exam New
Complete V erified Questions And Correct
Detailed Answers With Rationales | Already
Graded A+
A client is receiving cisplatin chemotherapy. The nurse should monitor for which major side
effect?
A) Cardiotoxicity
B) Nephrotoxicity
C) Hepatotoxicity
D) Neurotoxicity in the hands and feet only
Correct Answer: B
Rationale: Cisplatin is highly nephrotoxic due to its direct toxic effect on the renal tubules.
Aggressive hydration before, during, and after administration, along with monitoring of serum
creatinine, BUN, and urine output, is essential to prevent acute kidney injury. While ototoxicity
and peripheral neuropathy are also common, nephrotoxicity is the most dose-limiting and
potentially life-threatening adverse effect. Cardiotoxicity is more associated with anthracyclines
such as doxorubicin, and hepatotoxicity is less common with cisplatin. Amifostine or mannitol
may be used for renal protection in some protocols.
The nurse is admitting a client with suspected acute myocardial infarction. Which
electrocardiogram (ECG) finding is most consistent with ST-elevation myocardial infarction
(STEMI)?
A) ST-segment depression in multiple leads
B) T-wave inversion
C) ST-segment elevation in contiguous leads
D) Prolonged PR interval
Correct Answer: C
Page 1 of 153
,Rationale: ST-segment elevation in two or more contiguous leads is the hallmark ECG finding of
STEMI, indicating acute transmural myocardial injury. This requires immediate reperfusion
therapy (percutaneous coronary intervention or thrombolytics) within the recommended time
frame because “time is muscle.” ST depression and T-wave inversion are more typical of non-
ST-elevation MI (NSTEMI) or ischemia, while PR prolongation relates to conduction delays.
Rapid recognition of STEMI is critical for improving outcomes and reducing mortality. The
nurse should also assess for pain, administer oxygen, aspirin, and notify the provider
immediately.
A 4-year-old child is brought to the emergency department after ingesting an unknown amount
of acetaminophen. Which laboratory value is most important to monitor?
A) Serum acetaminophen level 4 hours after ingestion
B) Complete blood count
C) Serum electrolytes
D) Liver enzymes only after 48 hours
Correct Answer: A
Rationale: The Rumack-Matthew nomogram uses a serum acetaminophen level drawn at least 4
hours after ingestion to predict the risk of hepatotoxicity and guide antidote (N-acetylcysteine)
administration. Early measurement is essential because treatment is most effective when started
within 8–16 hours. Liver enzymes may rise later (peak at 72–96 hours), but waiting for them is
not appropriate for initial management. Complete blood count and electrolytes are secondary
unless complications develop. Prompt use of the nomogram can prevent fulminant hepatic
failure.
The nurse is providing care to a client with anorexia nervosa who has a body mass index of 14.
Which intervention has the highest priority?
A) Encourage the client to verbalize feelings about body image
B) Monitor vital signs and daily weights strictly
C) Allow the client to choose preferred meals from the menu
D) Teach the client about long-term nutritional needs
Correct Answer: B
Rationale: Clients with severe anorexia nervosa are at high risk for life-threatening complications
including cardiac dysrhythmias, electrolyte imbalances (especially hypokalemia and
hypophosphatemia during refeeding), and refeeding syndrome. Close monitoring of vital signs,
Page 2 of 153
,daily weights, and strict intake/output is the highest priority to detect and prevent medical
instability. Psychological support and nutritional education are important but come after ensuring
physiological stability. Refeeding must be done gradually under close supervision to avoid
refeeding syndrome, which can cause fatal fluid shifts and cardiac arrest.
A client with Parkinson’s disease is prescribed levodopa/carbidopa. The nurse should advise the
client to avoid:
A) High-protein meals close to medication times
B) Foods rich in vitamin B6
C) Caffeine-containing beverages
D) Dairy products entirely
Correct Answer: A
Rationale: Large amounts of dietary protein can compete with levodopa for transport across the
blood-brain barrier, reducing its effectiveness and causing “on-off” fluctuations in symptoms.
The client should take the medication 30–60 minutes before meals or separate protein intake
from dosing times. Vitamin B6 can interfere with some older Parkinson’s medications but has
less impact with modern formulations. Caffeine and dairy do not have major interactions with
levodopa/carbidopa. Proper timing of meals and medication improves symptom control and
quality of life.
The nurse is assessing a client with suspected deep vein thrombosis (DVT) in the right calf.
Which finding is most concerning?
A) Unilateral calf swelling and warmth
B) Positive Homans’ sign (pain on dorsiflexion)
C) Mild redness over the calf
D) Client reports occasional leg cramps at night
Correct Answer: A
Rationale: Unilateral swelling, warmth, and pain are classic signs of DVT. The presence of these
findings warrants immediate further evaluation with duplex ultrasound and possible initiation of
anticoagulation to prevent pulmonary embolism. Homans’ sign is no longer considered reliable
or specific and can actually dislodge a clot if performed vigorously. Mild redness or nocturnal
cramps are less specific and can occur in many conditions. Early detection and treatment of DVT
significantly reduce the risk of life-threatening pulmonary embolism.
Page 3 of 153
, A client is scheduled for a colonoscopy. Which pre-procedure instruction is most important for
the nurse to reinforce?
A) “You may eat a light breakfast the morning of the procedure.”
B) “Take all your regular medications with a sip of water on the day of the test.”
C) “Complete the entire bowel preparation solution as instructed.”
D) “You will be able to drive yourself home after the sedation wears off.”
Correct Answer: C
Rationale: Adequate bowel cleansing is critical for successful visualization during colonoscopy.
Incomplete preparation can lead to missed lesions, prolonged procedure time, or the need to
reschedule. Clients must follow a clear liquid diet and consume the full volume of the prescribed
laxative solution. Regular medications may need adjustment (especially anticoagulants or
diabetes medications), eating is not allowed on the morning of the procedure, and the client must
have a responsible adult to drive home due to sedation effects. Good bowel prep directly impacts
the quality and safety of the procedure.
The nurse is caring for a client receiving continuous enteral tube feeding. The client suddenly
develops diarrhea. What is the most appropriate initial nursing action?
A) Stop the feeding and notify the healthcare provider
B) Slow the feeding rate and reassess in 1 hour
C) Change to a different formula type immediately
D) Administer an antidiarrheal medication as ordered
Correct Answer: B
Rationale: Diarrhea is a common complication of enteral nutrition and is often related to the rate
or concentration of the feeding rather than infection or formula intolerance initially. Slowing the
infusion rate allows the gastrointestinal tract to adjust while the nurse assesses for other causes
(medications, infection, or hyperosmolar formula). Abruptly stopping the feeding can lead to
unnecessary caloric deficit, and changing the formula or giving antidiarrheals should only be
done after evaluating the situation and consulting the provider if needed. Monitoring
intake/output and skin integrity is also important.
A client with chronic alcoholism is admitted with confusion, ataxia, and nystagmus. The nurse
recognizes these symptoms as consistent with:
A) Alcohol withdrawal delirium
Page 4 of 153
