NCLEX ACTUAL EXAM (NEXT GENERATION) COMPLETE QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED A+
A 65 year old man is prescribed Flomax (Tamsulosin) for Benign Prostatic Hyperplasia.
The patient lives in an upstairs apartment. The nurse is most concerned about which
side effect of Flomax?
1. Hypotension
2. Tachycardia
3. Back Pain
4. Difficulty Urinating
1. Hypotension
EXPLANATION:
Correct - Hypotension can lead to dizziness and a risk for injury to the
patient.
A man is receiving heparin subcutaneously. The patient has dementia and lives
at home with a part-time caretaker. The nurse is most concerned about which side
effect of heparin?
1. Back Pain
2. Fever and Chills
3. Risk for Bleeding
4. Dizziness
1. Risk for Bleeding
2. EXPLANATION:
Correct - A confused patient is at risk for injuring themselves and at risk for hemorrhage
should an injury occur
,A female patient is prescribed metformin for glucose control. The patient is on
NPO status pending a diagnostic test. The nurse is most concerned
about which side effect of metformin?
1. Diarrhea and Vomiting
2. Dizziness and Drowsiness
3. Metallic taste
4. Hypoglycemia
4. Hypoglycemia
Correct - The patient is at risk because she is on NPO status and continuing to
take an anti-glycemic drug.
The nurse is reviewing the lab results of a patient taking lithium for
schizoaffective disorder. The lab results show that the blood lithium value is
1.7 mcg/L. What would the nurse take as the priority action?
1. Induce vomiting
2. Hold the next dose of Lithium
3. Administer an anti-emetic
4. Give the next dose of Lithium
2. Hold the next dose of Lithium
Correct - Lithium's therapeutic range is 0.5-1.5mcg/L, and begins toxicity at 1.5mcg/L
,A patient asks the nurse why they must have a heparin injection. What is the
nurse's best response?
1. "Heparin will dissolve clots that you have."
2. "Heparin will reduce the platelets that make your blood clot"
3. "Heparin will work better than warfarin."
4. "Heparin will prevent new clots from developing."
4. "Heparin will prevent new clots from developing."
Correct -This is a correct statement.
The nurse is reviewing the lab results of a patient who has presented in the
Emergency Room. The lab results show that the troponin T value is at 5.3
ng/mL. Which of these interventions, if not completed already, would take
priority over the others?
1. Put the patient in a 90 degree position
2. Check whether the patient is taking diuretics
3. Obtain and attach defibrillator leads
4. Check the patient's last ejection fraction
3. Obtain and attach defibrillator leads
Correct - This patient is undergoing an emergency cardiac event. Normal
Troponin T levels are less than 0.2 ng/mL. Ventricular Fibrillation is the cause of
death in most cases of deaths due to sudden cardiac arrest. Defibrillation is the
most important action to take to prevent death.
, A nurse is caring for a patient undergoing a stress test on a treadmill. The
patient turns to talk to the nurse. Which of these statements would require the
most immediate intervention?
1. "I'm feeling extremely thirsty. I'm going to get some water after this."
2. "I can feel my heart racing."
3. "My shoulder and arm is hurting."
4. "My blood pressure reading is 158/80"
3. "My shoulder and arm is hurting."
Correct - Unilateral arm and shoulder pain is one of the classic symptoms of
myocardial ischemia. The stress test should be halted.
The nurse is reviewing the lab results of a patient who has presented in the
Emergency Room. The lab results show that the BNP (B-type Natriuretic
Peptide) value is a 615 pg/ml. What would the nurse take as the priority
action?
1. Call a cardiac code and implement emergency measures
2. Check the patient's oxygen saturation
3. Inform the physician that the patient has Congestive Heart Failure
Encourage the patient to limit activity
2. Check the patient's oxygen saturation
Correct - An elevated BNP indicates that there is decreased cardiac output.
A priority intervention would be to ensure proper oxygenation after an assessment.