Category: NCLEX QBANK #1 PASTEXAMS QUESTIONS RECAPS
Question 1
A 64-year-old patient with a history of hypertension reports sudden chest tightness and
shortness of breath. Vital signs: BP 88/58, HR 122, RR 26, SpO₂ 90%.
What is the nurse’spriority action?
A) Administer IV beta-blocker
B) Place the patient in high Fowler’s position and apply oxygen
C) Obtain a 12-lead ECG
D) Start IV fluids rapidly
Correct Answer: B
Rationale: This patient is unstable (hypotension + hypoxia). Priority follows ABCs
(Airway, Breathing, Circulation). Oxygenation comes first. Positioning improves lung
expansion. ECG is important but not before stabilizing airway/breathing.
Question 2
A patient with heart failure is receiving furosemide. Which finding requires immediate
follow-up?
A) Potassium level 3.1 mEq/L
B) Urine output 1200 mL/day
C) Blood pressure 130/78 mmHg
D) Mild ankle edema
Correct Answer: A
Rationale: Furosemide causes potassium loss. A level of 3.1 = hypokalemia, which can
trigger fatal arrhythmias. This is priority over stable vitals or mild edema.
Question 3
A patient presents with chest pain radiating to the left arm. Which assessment finding is most
concerning?
A) ST-segment elevation on ECG
B) Heart rate of 95 bpm
,C) Blood pressure of 140/90 mmHg
D) History of stable angina
Correct Answer: A
Rationale: ST-segment elevation is a classic sign of an acute myocardial infarction (MI),
indicating myocardial injury that requires immediate intervention to prevent permanent
damage. While other findings are relevant, they do not indicate the same level of acute
emergency.
Question 4
A client hospitalized with chronic dyspepsia is diagnosed with gastric cancer. Which of the
following is associated with an increased incidence of gastric cancer?
A) Dairy products
B) Carbonated beverages
C) Refined sugars
D) Luncheon meats
Correct Answer: D
Rationale: Option D: Luncheon meats contain preservatives such as nitrites that have been
linked to gastric cancer. Options A, B, and C: Dairy products, carbonated beverages, and
refined sugars have not been found to increase the risk of gastric cancer; therefore, they are
incorrect.
Question 5
A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His
tentative diagnosis is antisocial personality disorder. In reviewing the client’s record, the
nurse would expect to find:
A) A history of consistent employment
B) A below-average intelligence
C) A history of cruelty to animals
D) An expression of remorse for his actions
Correct Answer: C
Rationale: Option C: A history of cruelty to people and animals, truancy, and setting fires
with a diagnosis of conduct disorder in children, which becomes a diagnosis of antisocial
personality disorder in adults. Option A: A client with an antisocial personality disorder does
,not hold consistent employment. Option B: IQ is usually higher than average. Option D: A
client with antisocial personality disorder lacks guilt or remorse for wrong-doing.
Question 6
The licensed vocational nurse may not assume the primary care for a client:
A) In the fourth stage of labor
B) Two days post-appendectomy
C) With a venous access device
D) With bipolar disorder
Correct Answer: C
Rationale: Option C: Only a trained nurse with experience and background in caring for a
venous access device can assume the primary care of the client. Options A, B, and D: The
licensed vocational nurse may care for the client in labor, the client post-operative client, and
the client with bipolar disorder.
Question 7
The physician has ordered dressings with Sulfamylon cream for a client with full-thickness
burns of the hands and arms. Before dressing changes, the nurse should give priority to:
A) Administering pain medication
B) Checking the adequacy of urinary output
C) Requesting a daily complete blood count
D) Obtaining a blood glucose by finger stick
Correct Answer: A
Rationale: Option A: Sulfamylon produces a painful sensation when applied to the burn
wound; therefore, the client should receive pain medication before dressing changes. Options
B, C, and D: These do not pertain to dressing changes for the client with burns, so they are
incorrect.
Question 8
A client with a history of heart failure is prescribed digoxin (Lanoxin) and furosemide
(Lasix). Which of the following should the nurse monitor most closely?
, A) Serum sodium level
B) Serum potassium level
C) Serum glucose level
D) Serum calcium level
Correct Answer: B
Rationale: Furosemide is a loop diuretic that causes the loss of potassium. Digoxin toxicity
is more likely to occur in the presence of hypokalemia. Therefore, monitoring the serum
potassium level is critical for a client taking both medications.
Question 9
A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the
following laboratory values should the nurse monitor to evaluate the effectiveness of the
therapy?
A) Prothrombin time (PT)
B) International Normalized Ratio (INR)
C) Activated partial thromboplastin time (aPTT)
D) Platelet count
Correct Answer: C
Rationale: The aPTT is used to monitor the effectiveness of heparin therapy. PT and INR are
used to monitor warfarin therapy. While platelet count is important to monitor for heparin-
induced thrombocytopenia, it does not evaluate the effectiveness of the anticoagulation.
Question 10
A client is admitted with a diagnosis of acute myocardial infarction. Which of the following
cardiac enzymes is the most specific indicator of myocardial damage?
A) Creatine kinase (CK)
B) CK-MB
C) Troponin I
D) Myoglobin
Correct Answer: C
Rationale: Troponin I is the most specific and sensitive marker for myocardial injury. It
remains elevated for several days after an MI. CK-MB is also specific but returns to normal
more quickly. Myoglobin is an early marker but is not specific to cardiac muscle.
Question 1
A 64-year-old patient with a history of hypertension reports sudden chest tightness and
shortness of breath. Vital signs: BP 88/58, HR 122, RR 26, SpO₂ 90%.
What is the nurse’spriority action?
A) Administer IV beta-blocker
B) Place the patient in high Fowler’s position and apply oxygen
C) Obtain a 12-lead ECG
D) Start IV fluids rapidly
Correct Answer: B
Rationale: This patient is unstable (hypotension + hypoxia). Priority follows ABCs
(Airway, Breathing, Circulation). Oxygenation comes first. Positioning improves lung
expansion. ECG is important but not before stabilizing airway/breathing.
Question 2
A patient with heart failure is receiving furosemide. Which finding requires immediate
follow-up?
A) Potassium level 3.1 mEq/L
B) Urine output 1200 mL/day
C) Blood pressure 130/78 mmHg
D) Mild ankle edema
Correct Answer: A
Rationale: Furosemide causes potassium loss. A level of 3.1 = hypokalemia, which can
trigger fatal arrhythmias. This is priority over stable vitals or mild edema.
Question 3
A patient presents with chest pain radiating to the left arm. Which assessment finding is most
concerning?
A) ST-segment elevation on ECG
B) Heart rate of 95 bpm
,C) Blood pressure of 140/90 mmHg
D) History of stable angina
Correct Answer: A
Rationale: ST-segment elevation is a classic sign of an acute myocardial infarction (MI),
indicating myocardial injury that requires immediate intervention to prevent permanent
damage. While other findings are relevant, they do not indicate the same level of acute
emergency.
Question 4
A client hospitalized with chronic dyspepsia is diagnosed with gastric cancer. Which of the
following is associated with an increased incidence of gastric cancer?
A) Dairy products
B) Carbonated beverages
C) Refined sugars
D) Luncheon meats
Correct Answer: D
Rationale: Option D: Luncheon meats contain preservatives such as nitrites that have been
linked to gastric cancer. Options A, B, and C: Dairy products, carbonated beverages, and
refined sugars have not been found to increase the risk of gastric cancer; therefore, they are
incorrect.
Question 5
A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His
tentative diagnosis is antisocial personality disorder. In reviewing the client’s record, the
nurse would expect to find:
A) A history of consistent employment
B) A below-average intelligence
C) A history of cruelty to animals
D) An expression of remorse for his actions
Correct Answer: C
Rationale: Option C: A history of cruelty to people and animals, truancy, and setting fires
with a diagnosis of conduct disorder in children, which becomes a diagnosis of antisocial
personality disorder in adults. Option A: A client with an antisocial personality disorder does
,not hold consistent employment. Option B: IQ is usually higher than average. Option D: A
client with antisocial personality disorder lacks guilt or remorse for wrong-doing.
Question 6
The licensed vocational nurse may not assume the primary care for a client:
A) In the fourth stage of labor
B) Two days post-appendectomy
C) With a venous access device
D) With bipolar disorder
Correct Answer: C
Rationale: Option C: Only a trained nurse with experience and background in caring for a
venous access device can assume the primary care of the client. Options A, B, and D: The
licensed vocational nurse may care for the client in labor, the client post-operative client, and
the client with bipolar disorder.
Question 7
The physician has ordered dressings with Sulfamylon cream for a client with full-thickness
burns of the hands and arms. Before dressing changes, the nurse should give priority to:
A) Administering pain medication
B) Checking the adequacy of urinary output
C) Requesting a daily complete blood count
D) Obtaining a blood glucose by finger stick
Correct Answer: A
Rationale: Option A: Sulfamylon produces a painful sensation when applied to the burn
wound; therefore, the client should receive pain medication before dressing changes. Options
B, C, and D: These do not pertain to dressing changes for the client with burns, so they are
incorrect.
Question 8
A client with a history of heart failure is prescribed digoxin (Lanoxin) and furosemide
(Lasix). Which of the following should the nurse monitor most closely?
, A) Serum sodium level
B) Serum potassium level
C) Serum glucose level
D) Serum calcium level
Correct Answer: B
Rationale: Furosemide is a loop diuretic that causes the loss of potassium. Digoxin toxicity
is more likely to occur in the presence of hypokalemia. Therefore, monitoring the serum
potassium level is critical for a client taking both medications.
Question 9
A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the
following laboratory values should the nurse monitor to evaluate the effectiveness of the
therapy?
A) Prothrombin time (PT)
B) International Normalized Ratio (INR)
C) Activated partial thromboplastin time (aPTT)
D) Platelet count
Correct Answer: C
Rationale: The aPTT is used to monitor the effectiveness of heparin therapy. PT and INR are
used to monitor warfarin therapy. While platelet count is important to monitor for heparin-
induced thrombocytopenia, it does not evaluate the effectiveness of the anticoagulation.
Question 10
A client is admitted with a diagnosis of acute myocardial infarction. Which of the following
cardiac enzymes is the most specific indicator of myocardial damage?
A) Creatine kinase (CK)
B) CK-MB
C) Troponin I
D) Myoglobin
Correct Answer: C
Rationale: Troponin I is the most specific and sensitive marker for myocardial injury. It
remains elevated for several days after an MI. CK-MB is also specific but returns to normal
more quickly. Myoglobin is an early marker but is not specific to cardiac muscle.
