Saunders NCLEX-RN Test Bank Questions And
Answers Practice Questions with Solutions Newest |
Already Graded A+
1. Which nursing diagnosis is most appropriate for a patient who is taking anticholinergic
medications?
A. Bradycardia
B. Urinary retention
C. Hypersalivation
D. Diarrhea
Answer: B
Rationale: Anticholinergic drugs block the action of acetylcholine, which can lead to decreased bladder
contractility and urinary retention. Diarrhea and hypersalivation are associated with cholinergic excess,
while bradycardia is not a typical effect of anticholinergic medications.
2. Which compound is primarily responsible for the transfer of genetic information from parents
to offspring?
A. Protein
B. Ribonucleic acid (RNA)
C. Deoxyribonucleic acid (DNA)
D. Adenosine triphosphate (ATP)
Answer: C
Rationale: It is now recognized that DNA is the most important body compound that serves to transfer
genes from parents to offspring.
3. During the immediate postoperative recovery period, what is the nurse's primary concern?
A. Airway, breathing, and circulation
B. Pain management and comfort
C. Fluid and electrolyte balance
D. Wound care and infection prevention
Answer: A
Rationale: After surgery and the termination of general anaesthesia, the nurse’s main concern should be
assessing the patient's airway, breathing, and circulation status.
Page 1
,4. A 22-year-old nursing student has been taking Excedrin Extra-Strength tablets for the past few
weeks to cope with the demands of the end of the semester and examination week. The patient
presents to the clinic today complaining of feeling exhausted. Which nursing diagnosis is most
appropriate?
A. Fatigue
B. Ineffective health maintenance
C. Risk for impaired liver function
D. Disturbed sleep pattern
Answer: D
Rationale: Excedrin Extra-Strength contains caffeine, a CNS stimulant, which can interfere with sleep
patterns.
5. A 60-year-old patient is started on several new medications and expresses concern about
forgetting to take them. What is the most helpful nursing intervention?
A. Help the patient obtain and learn to use a calendar or a pill container.
B. Ask a family member to call the patient daily to remind her to take her medications.
C. Advise the patient to take all medications at the same time each day regardless of the prescribed schedule.
D. Tell the patient to write down her medication schedule on a piece of paper.
Answer: A
Rationale: Calendars, pill containers, or diaries may be helpful to patients who may forget to take
prescribed drugs as scheduled. The nurse must ensure that the patient knows how to use these reminder
tools. Teaching the patient effective coping strategies is a helpful suggestion but will not help the patient
to remember to take medications. Reducing the number of drugs prescribed is not an appropriate action
by the nurse. Assuring the patient that she won't forget once she is accustomed to the routine is false
reassurance by the nurse and inappropriate when education is needed.
6. What is the correct method for administering medication through a nasogastric (NG) tube?
A. Using the barrel of the syringe, allow the fluid to flow via gravity into the NG tube.
B. Administer the medication by connecting the syringe to the NG tube and using a pump to infuse the fluid.
C. Attach a syringe and forcefully push the plunger to ensure rapid delivery of the medication.
D. Remove the plunger, pour the medication into the syringe, and then replace the plunger to push the
medication through.
Answer: A
Rationale: For NG tubes, medications are poured into the barrel of the syringe with the piston removed,
and fluid is allowed to flow via gravity into the tube. Never force any fluid into the tube. Flush the tubing
with 30 mL of tap water to ensure that the medication is cleared from the tube.
7. The nurse is caring for a patient who has been newly diagnosed with type 1 diabetes mellitus.
Which statement best illustrates an outcome criterion for this patient?
A. The patient's blood glucose levels remain within normal range at all times.
B. The patient demonstrates safe insulin self-administration technique.
C. The patient states that he understands the importance of foot care.
D. The patient verbalizes a willingness to attend diabetes education classes.
Page 2
,Answer: B
Rationale: Having the patient demonstrate safe insulin self-administration technique is a specific and
measurable outcome criterion. Following instructions and avoiding complications are not specific
criteria. Adherence to the new insulin treatment regimen is not objective and would be difficult to
measure.
8. Which nursing diagnosis is most appropriate for a patient receiving vitamin A therapy?
A. Ineffective health maintenance related to lack of knowledge about vitamin A therapy
B. Disturbed sensory perception (visual) related to night blindness
C. Risk for infection related to vitamin A therapy
D. Imbalanced nutrition: less than body requirements related to vitamin A deficiency
Answer: B
Rationale: Vitamin A deficiency causes night blindness.
9. Which ethnocultural group traditionally believes in harmony with nature and attributes disease
to malevolent spirits?
A. Asian Americans
B. Hispanic Americans
C. Indigenous peoples
D. African Americans
Answer: C
Rationale: Indigenous peoples believe in harmony with nature and view ill spirits as causing disease.
10. Which of the following is a physiological effect produced by both muscarinic and nicotinic
stimulation?
A. Neither muscarinic nor nicotinic stimulation
B. Both muscarinic stimulation and nicotinic stimulation
C. Only nicotinic stimulation
D. Only muscarinic stimulation
Answer: B
Rationale: Pupil constriction is mediated by the parasympathetic nervous system via muscarinic
receptors on the sphincter pupillae muscle. Nicotinic receptors are involved in ganglionic transmission
but not directly in pupil constriction. Sympathetic stimulation causes pupil dilation.
11. The nurse is evaluating a patient who is taking modafinil (Alertec). Which of the following is an
intended therapeutic effect of this medication?
A. Decreased anxiety
B. Improved memory
C. Reduced blood pressure
D. Increased wakefulness
Answer: D
Page 3
, Rationale: Modafinil is given to treat narcolepsy. Therefore, an intended therapeutic effect is increased wakefulness.
12. Which dietary information is important for a patient taking calcium supplements?
A. Calcium products bind with tetracyclines, making the antibiotic inactive.
B. Calcium supplements should be taken with a high-fiber meal to enhance absorption.
C. Calcium carbonate requires an acidic environment and should be taken with citrus juice.
D. Calcium supplements increase the risk of kidney stones when taken with vitamin D.
Answer: A
Rationale: Calcium products chelate or bind with tetracyclines, resulting in decreased effects of
tetracyclines. Foods high in calcium include milk and other dairy products, shellfish, and dark green
leafy vegetables. Oral calcium supplements should be taken with meals.
13. Which nursing diagnosis is most appropriate for a patient who has just received a prescription
for a new medication?
A. Deficient knowledge related to newly prescribed drug therapy
B. Ineffective health maintenance related to lack of medication education
C. Risk for injury related to adverse drug effects
D. Noncompliance related to new medication regimen
Answer: A
Rationale: The correct diagnosis is Deficient knowledge because the patient has just received a new
prescription and likely lacks sufficient understanding about the medication. Noncompliance implies a
conscious decision not to follow the regimen, which is not yet established. Risk for injury is not the
primary issue at this point, and Ineffective health maintenance is too broad and not specific to the new
prescription.
14. A patient arrives at the emergency department after piercing a finger with a fish hook during a
fishing trip. Which type of anesthesia is most appropriate for removal of the hook?
A. General anesthesia with endotracheal intubation
B. Infiltration of the area with tetracaine hydrochloride
C. Topical application of lidocaine spray
D. Regional nerve block at the wrist
Answer: B
Rationale: Infiltration anaesthesia is commonly used for minor surgical procedures. It involves injecting
the local anaesthetic solution intradermally, subcutaneously, or submucosally across the path of nerves
supplying the area to be anaesthetized. The local anaesthetic may be administered in a circular pattern
around the operative field.
15. A patient informs the nurse of her intention to start taking St. John's wort for depression. The
nurse should caution her about potential interactions with which of the following substances?
A. Selective serotonin reuptake inhibitors
B. Nonsteroidal anti-inflammatory drugs
C. Oral contraceptives
Page 4
Answers Practice Questions with Solutions Newest |
Already Graded A+
1. Which nursing diagnosis is most appropriate for a patient who is taking anticholinergic
medications?
A. Bradycardia
B. Urinary retention
C. Hypersalivation
D. Diarrhea
Answer: B
Rationale: Anticholinergic drugs block the action of acetylcholine, which can lead to decreased bladder
contractility and urinary retention. Diarrhea and hypersalivation are associated with cholinergic excess,
while bradycardia is not a typical effect of anticholinergic medications.
2. Which compound is primarily responsible for the transfer of genetic information from parents
to offspring?
A. Protein
B. Ribonucleic acid (RNA)
C. Deoxyribonucleic acid (DNA)
D. Adenosine triphosphate (ATP)
Answer: C
Rationale: It is now recognized that DNA is the most important body compound that serves to transfer
genes from parents to offspring.
3. During the immediate postoperative recovery period, what is the nurse's primary concern?
A. Airway, breathing, and circulation
B. Pain management and comfort
C. Fluid and electrolyte balance
D. Wound care and infection prevention
Answer: A
Rationale: After surgery and the termination of general anaesthesia, the nurse’s main concern should be
assessing the patient's airway, breathing, and circulation status.
Page 1
,4. A 22-year-old nursing student has been taking Excedrin Extra-Strength tablets for the past few
weeks to cope with the demands of the end of the semester and examination week. The patient
presents to the clinic today complaining of feeling exhausted. Which nursing diagnosis is most
appropriate?
A. Fatigue
B. Ineffective health maintenance
C. Risk for impaired liver function
D. Disturbed sleep pattern
Answer: D
Rationale: Excedrin Extra-Strength contains caffeine, a CNS stimulant, which can interfere with sleep
patterns.
5. A 60-year-old patient is started on several new medications and expresses concern about
forgetting to take them. What is the most helpful nursing intervention?
A. Help the patient obtain and learn to use a calendar or a pill container.
B. Ask a family member to call the patient daily to remind her to take her medications.
C. Advise the patient to take all medications at the same time each day regardless of the prescribed schedule.
D. Tell the patient to write down her medication schedule on a piece of paper.
Answer: A
Rationale: Calendars, pill containers, or diaries may be helpful to patients who may forget to take
prescribed drugs as scheduled. The nurse must ensure that the patient knows how to use these reminder
tools. Teaching the patient effective coping strategies is a helpful suggestion but will not help the patient
to remember to take medications. Reducing the number of drugs prescribed is not an appropriate action
by the nurse. Assuring the patient that she won't forget once she is accustomed to the routine is false
reassurance by the nurse and inappropriate when education is needed.
6. What is the correct method for administering medication through a nasogastric (NG) tube?
A. Using the barrel of the syringe, allow the fluid to flow via gravity into the NG tube.
B. Administer the medication by connecting the syringe to the NG tube and using a pump to infuse the fluid.
C. Attach a syringe and forcefully push the plunger to ensure rapid delivery of the medication.
D. Remove the plunger, pour the medication into the syringe, and then replace the plunger to push the
medication through.
Answer: A
Rationale: For NG tubes, medications are poured into the barrel of the syringe with the piston removed,
and fluid is allowed to flow via gravity into the tube. Never force any fluid into the tube. Flush the tubing
with 30 mL of tap water to ensure that the medication is cleared from the tube.
7. The nurse is caring for a patient who has been newly diagnosed with type 1 diabetes mellitus.
Which statement best illustrates an outcome criterion for this patient?
A. The patient's blood glucose levels remain within normal range at all times.
B. The patient demonstrates safe insulin self-administration technique.
C. The patient states that he understands the importance of foot care.
D. The patient verbalizes a willingness to attend diabetes education classes.
Page 2
,Answer: B
Rationale: Having the patient demonstrate safe insulin self-administration technique is a specific and
measurable outcome criterion. Following instructions and avoiding complications are not specific
criteria. Adherence to the new insulin treatment regimen is not objective and would be difficult to
measure.
8. Which nursing diagnosis is most appropriate for a patient receiving vitamin A therapy?
A. Ineffective health maintenance related to lack of knowledge about vitamin A therapy
B. Disturbed sensory perception (visual) related to night blindness
C. Risk for infection related to vitamin A therapy
D. Imbalanced nutrition: less than body requirements related to vitamin A deficiency
Answer: B
Rationale: Vitamin A deficiency causes night blindness.
9. Which ethnocultural group traditionally believes in harmony with nature and attributes disease
to malevolent spirits?
A. Asian Americans
B. Hispanic Americans
C. Indigenous peoples
D. African Americans
Answer: C
Rationale: Indigenous peoples believe in harmony with nature and view ill spirits as causing disease.
10. Which of the following is a physiological effect produced by both muscarinic and nicotinic
stimulation?
A. Neither muscarinic nor nicotinic stimulation
B. Both muscarinic stimulation and nicotinic stimulation
C. Only nicotinic stimulation
D. Only muscarinic stimulation
Answer: B
Rationale: Pupil constriction is mediated by the parasympathetic nervous system via muscarinic
receptors on the sphincter pupillae muscle. Nicotinic receptors are involved in ganglionic transmission
but not directly in pupil constriction. Sympathetic stimulation causes pupil dilation.
11. The nurse is evaluating a patient who is taking modafinil (Alertec). Which of the following is an
intended therapeutic effect of this medication?
A. Decreased anxiety
B. Improved memory
C. Reduced blood pressure
D. Increased wakefulness
Answer: D
Page 3
, Rationale: Modafinil is given to treat narcolepsy. Therefore, an intended therapeutic effect is increased wakefulness.
12. Which dietary information is important for a patient taking calcium supplements?
A. Calcium products bind with tetracyclines, making the antibiotic inactive.
B. Calcium supplements should be taken with a high-fiber meal to enhance absorption.
C. Calcium carbonate requires an acidic environment and should be taken with citrus juice.
D. Calcium supplements increase the risk of kidney stones when taken with vitamin D.
Answer: A
Rationale: Calcium products chelate or bind with tetracyclines, resulting in decreased effects of
tetracyclines. Foods high in calcium include milk and other dairy products, shellfish, and dark green
leafy vegetables. Oral calcium supplements should be taken with meals.
13. Which nursing diagnosis is most appropriate for a patient who has just received a prescription
for a new medication?
A. Deficient knowledge related to newly prescribed drug therapy
B. Ineffective health maintenance related to lack of medication education
C. Risk for injury related to adverse drug effects
D. Noncompliance related to new medication regimen
Answer: A
Rationale: The correct diagnosis is Deficient knowledge because the patient has just received a new
prescription and likely lacks sufficient understanding about the medication. Noncompliance implies a
conscious decision not to follow the regimen, which is not yet established. Risk for injury is not the
primary issue at this point, and Ineffective health maintenance is too broad and not specific to the new
prescription.
14. A patient arrives at the emergency department after piercing a finger with a fish hook during a
fishing trip. Which type of anesthesia is most appropriate for removal of the hook?
A. General anesthesia with endotracheal intubation
B. Infiltration of the area with tetracaine hydrochloride
C. Topical application of lidocaine spray
D. Regional nerve block at the wrist
Answer: B
Rationale: Infiltration anaesthesia is commonly used for minor surgical procedures. It involves injecting
the local anaesthetic solution intradermally, subcutaneously, or submucosally across the path of nerves
supplying the area to be anaesthetized. The local anaesthetic may be administered in a circular pattern
around the operative field.
15. A patient informs the nurse of her intention to start taking St. John's wort for depression. The
nurse should caution her about potential interactions with which of the following substances?
A. Selective serotonin reuptake inhibitors
B. Nonsteroidal anti-inflammatory drugs
C. Oral contraceptives
Page 4
