NCLEX 101 FINAL TEST
Comprehensive Exam
1. Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment
does the nurse perform as a priority before administering the medication?
A)Checking the client's blood pressure
Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to
treat hypertension. One common side effect is postural hypotension. Therefore the nurse
would check the client’s blood pressure immediately before administering each dose.
Checking the client’s peripheral pulses, the results of the most recent potassium level, and
the intake and output for the previous 24 hours are not specifically associated with this
mediation.
2. A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse
provides instructions to the client about the test. Which statement by the client indicates
a need for further instruction?
C) "I need to drink citrate of magnesia the night before the test and give myself a Fleet
enema on the morning of the test." ."
Rationale: An upper GI series involves visualization of the esophagus, duodenum, and
upper jejunum by means of the use of a contrast medium. It involves swallowing a
contrast medium (usually barium), which is administered in a flavored milkshake. Films
are taken at intervals during the test, which takes about 30 minutes. No special
preparation is necessary before a GI series, except that NPO status must be maintained
for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to
hasten elimination of the barium. Barium that remains in the colon may become hard
and difficult to expel, leading to fecal impaction.
3.A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a
prescribed medication is higher than the normal dose. The nurse calls the physician's
answering service and is told that the physician is off for the night and will be available in the
morning. The nurse should:
B)Ask the answering service to contact the on-call physician
Rationale: The nurse has a duty to protect the client from harm. A nurse who believes
that a physician’s prescription may be in error is responsible for clarifying the
prescription before carrying it out. Therefore the nurse would not administer the
medication; instead, the nurse would withhold the medication until the dose can be
clarified. The nurse would not wait until the next morning to obtain clarification. It is
premature to call the nursing supervisor.
4. An emergency department (ED) nurse is monitoring a client with suspected acute
myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The
nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor,
checks the client's carotid pulse, and determines that the PVCs are not resulting in
,perfusion. The appropriate action by the nurse is:
B) Asking the ED physician to check the client
,Rationale: PVCs are a result of increased irritability of ventricular cells. Peripheral pulses
may be absent or diminished with the PVCs themselves because the decreased stroke
volume of the premature beats may in turn decrease peripheral perfusion. Because
other rhythms also cause widened QRS complexes, it is essential that the nurse
determine whether the premature beats are resulting in perfusion of the extremities.
This is done by palpating the carotid, brachial, or femoral artery while observing the
monitor for widened complexes or by auscultating for apical heart sounds. In the
situation of acute MI, PVCs may be considered warning dysrhythmias, possibly
heralding the onset of ventricular tachycardia or ventricular fibrillation. Therefore the
nurse would not tell the client that the PVCs are expected. Although the nurse will
continue to monitor the client and document the findings, these are not the most
appropriate actions of those provided. The most appropriate action would be to ask the
ED physician to check the client.
Test-Taking Strategy: Use the process of elimination. Recalling the significance of PVCs
after acute MI and noting the strategic words "not perfusing" will direct you to the
correct option. Review the significance of PVCs after acute MI if you had difficulty with
this question.
5.
NPO status is imposed 8 hours before the procedure on a client scheduled to undergo
electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks
the client's record and notes that the client routinely takes an oral antihypertensive
medication each morning. The nurse should:
A) Administer the antihypertensive with a small sip of water
Rationale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8
hours before treatment to help prevent aspiration. Exceptions include clients who
routinely receive cardiac medications, antihypertensive agents, or histamine (H2)
blockers, which should be administered several hours before treatment with a small sip
of water. The nurse would not administer a medication by way of a route that has not been
prescribed.
Test-Taking Strategy: Use the process of elimination. Use your knowledge of the principles
of medication administration to help eliminate the option that involves administering the
medication by way of a route other than the prescribed one. Recalling that
antihypertensives must be administered on a regular schedule will assist you in
eliminating the options that involve withholding the medication. Review preprocedure
care for the client scheduled for ECT if you had difficulty with this question.
6.
A client who recently underwent coronary artery bypass graft surgery comes to the
physician's office for a follow-up visit. On assessment, the client tells the nurse that he is
feeling depressed. Which response by the nurse is therapeutic?
A) "Tell me more about what you’re feeling."
Rationale: When a client expresses feelings of depression, it is extremely important for the
nurse to further explore these feelings with the client
Remember to always focus on the client’s feelings.
, 7.
A client in labor experiences spontaneous rupture of the membranes. The nurse immediately
counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The
nurse notes that the fluid is yellow and has a strong odor. Which of the following actions
should be the nurse’s priority?
A) Contacting the physician
Rationale: The FHR is assessed for at least 1 minute when the membranes rupture. The
nurse also checks the quantity, color, and odor of the amniotic fluid. The fluid should be
clear (often with bits of vernix) and have a mild odor. Fluid with a foul or strong odor,
cloudy appearance, or yellow coloration suggests chorioamnionitis and warrants notifying
the physician. A large amount of vernix in the fluid suggests that the fetus is preterm.
Greenish, meconium-stained fluid may be seen in cases of postterm gestation or
placental insufficiency. Checking the fluid for protein is not associated with the data in
the question. Although the nurse would continue to monitor the client and the FHR and
would document the findings, contacting the physician is the priority.
Test-Taking Strategy: Focus on the data in the question and note the strategic word
"priority." Noting the words "yellow and has a strong odor" will direct you to the correct
option.
8.
A nurse has assisted a physician in inserting a central venous access device into a client with
a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After
insertion of the catheter, the nurse immediately plans to:
A) Call the radiography department to obtain a chest x-ray
Rationale: One major complication associated with central venous catheter placement is
pneumothorax, which may result from accidental puncture of the lung. After the catheter
has been placed but before it is used for infusions, its placement must be checked with
an x-ray
Test-Taking Strategy: Note the strategic word “immediately.” Use the ABCs — airway,
breathing, and circulation. Recalling that pneumothorax is a complication of the insertion
of this type of catheter will direct you to the correct option
9.
A rape victim being treated in the emergency department says to the nurse, "I’m really worried
that I’ve got HIV now." What is the appropriate response by the nurse?
D) "Let's talk about the information that you need to determine your risk of contracting
HIV."
Feedback: CORRECT
Rationale: HIV is a concern of rape victims. Such concern should always be addressed,
and the victim should be given the information needed to evaluate his or her risk.
Pregnancy may occur as a result of rape, and pregnancy prophylaxis can be offered in
the emergency department or during follow-up, once the results of a pregnancy test
Comprehensive Exam
1. Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment
does the nurse perform as a priority before administering the medication?
A)Checking the client's blood pressure
Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to
treat hypertension. One common side effect is postural hypotension. Therefore the nurse
would check the client’s blood pressure immediately before administering each dose.
Checking the client’s peripheral pulses, the results of the most recent potassium level, and
the intake and output for the previous 24 hours are not specifically associated with this
mediation.
2. A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse
provides instructions to the client about the test. Which statement by the client indicates
a need for further instruction?
C) "I need to drink citrate of magnesia the night before the test and give myself a Fleet
enema on the morning of the test." ."
Rationale: An upper GI series involves visualization of the esophagus, duodenum, and
upper jejunum by means of the use of a contrast medium. It involves swallowing a
contrast medium (usually barium), which is administered in a flavored milkshake. Films
are taken at intervals during the test, which takes about 30 minutes. No special
preparation is necessary before a GI series, except that NPO status must be maintained
for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to
hasten elimination of the barium. Barium that remains in the colon may become hard
and difficult to expel, leading to fecal impaction.
3.A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a
prescribed medication is higher than the normal dose. The nurse calls the physician's
answering service and is told that the physician is off for the night and will be available in the
morning. The nurse should:
B)Ask the answering service to contact the on-call physician
Rationale: The nurse has a duty to protect the client from harm. A nurse who believes
that a physician’s prescription may be in error is responsible for clarifying the
prescription before carrying it out. Therefore the nurse would not administer the
medication; instead, the nurse would withhold the medication until the dose can be
clarified. The nurse would not wait until the next morning to obtain clarification. It is
premature to call the nursing supervisor.
4. An emergency department (ED) nurse is monitoring a client with suspected acute
myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The
nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor,
checks the client's carotid pulse, and determines that the PVCs are not resulting in
,perfusion. The appropriate action by the nurse is:
B) Asking the ED physician to check the client
,Rationale: PVCs are a result of increased irritability of ventricular cells. Peripheral pulses
may be absent or diminished with the PVCs themselves because the decreased stroke
volume of the premature beats may in turn decrease peripheral perfusion. Because
other rhythms also cause widened QRS complexes, it is essential that the nurse
determine whether the premature beats are resulting in perfusion of the extremities.
This is done by palpating the carotid, brachial, or femoral artery while observing the
monitor for widened complexes or by auscultating for apical heart sounds. In the
situation of acute MI, PVCs may be considered warning dysrhythmias, possibly
heralding the onset of ventricular tachycardia or ventricular fibrillation. Therefore the
nurse would not tell the client that the PVCs are expected. Although the nurse will
continue to monitor the client and document the findings, these are not the most
appropriate actions of those provided. The most appropriate action would be to ask the
ED physician to check the client.
Test-Taking Strategy: Use the process of elimination. Recalling the significance of PVCs
after acute MI and noting the strategic words "not perfusing" will direct you to the
correct option. Review the significance of PVCs after acute MI if you had difficulty with
this question.
5.
NPO status is imposed 8 hours before the procedure on a client scheduled to undergo
electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks
the client's record and notes that the client routinely takes an oral antihypertensive
medication each morning. The nurse should:
A) Administer the antihypertensive with a small sip of water
Rationale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8
hours before treatment to help prevent aspiration. Exceptions include clients who
routinely receive cardiac medications, antihypertensive agents, or histamine (H2)
blockers, which should be administered several hours before treatment with a small sip
of water. The nurse would not administer a medication by way of a route that has not been
prescribed.
Test-Taking Strategy: Use the process of elimination. Use your knowledge of the principles
of medication administration to help eliminate the option that involves administering the
medication by way of a route other than the prescribed one. Recalling that
antihypertensives must be administered on a regular schedule will assist you in
eliminating the options that involve withholding the medication. Review preprocedure
care for the client scheduled for ECT if you had difficulty with this question.
6.
A client who recently underwent coronary artery bypass graft surgery comes to the
physician's office for a follow-up visit. On assessment, the client tells the nurse that he is
feeling depressed. Which response by the nurse is therapeutic?
A) "Tell me more about what you’re feeling."
Rationale: When a client expresses feelings of depression, it is extremely important for the
nurse to further explore these feelings with the client
Remember to always focus on the client’s feelings.
, 7.
A client in labor experiences spontaneous rupture of the membranes. The nurse immediately
counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The
nurse notes that the fluid is yellow and has a strong odor. Which of the following actions
should be the nurse’s priority?
A) Contacting the physician
Rationale: The FHR is assessed for at least 1 minute when the membranes rupture. The
nurse also checks the quantity, color, and odor of the amniotic fluid. The fluid should be
clear (often with bits of vernix) and have a mild odor. Fluid with a foul or strong odor,
cloudy appearance, or yellow coloration suggests chorioamnionitis and warrants notifying
the physician. A large amount of vernix in the fluid suggests that the fetus is preterm.
Greenish, meconium-stained fluid may be seen in cases of postterm gestation or
placental insufficiency. Checking the fluid for protein is not associated with the data in
the question. Although the nurse would continue to monitor the client and the FHR and
would document the findings, contacting the physician is the priority.
Test-Taking Strategy: Focus on the data in the question and note the strategic word
"priority." Noting the words "yellow and has a strong odor" will direct you to the correct
option.
8.
A nurse has assisted a physician in inserting a central venous access device into a client with
a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After
insertion of the catheter, the nurse immediately plans to:
A) Call the radiography department to obtain a chest x-ray
Rationale: One major complication associated with central venous catheter placement is
pneumothorax, which may result from accidental puncture of the lung. After the catheter
has been placed but before it is used for infusions, its placement must be checked with
an x-ray
Test-Taking Strategy: Note the strategic word “immediately.” Use the ABCs — airway,
breathing, and circulation. Recalling that pneumothorax is a complication of the insertion
of this type of catheter will direct you to the correct option
9.
A rape victim being treated in the emergency department says to the nurse, "I’m really worried
that I’ve got HIV now." What is the appropriate response by the nurse?
D) "Let's talk about the information that you need to determine your risk of contracting
HIV."
Feedback: CORRECT
Rationale: HIV is a concern of rape victims. Such concern should always be addressed,
and the victim should be given the information needed to evaluate his or her risk.
Pregnancy may occur as a result of rape, and pregnancy prophylaxis can be offered in
the emergency department or during follow-up, once the results of a pregnancy test
