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75 Free NCLEX Questions with complete Rationales.

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75 Free NCLEX Questions with complete Rationales.

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75 Free NCLEX Questions with
complete Rationales.

The nurse is taking the health history of a patient being treated for Emphysema and Chronic Bronchitis. After
being told the patient has been smoking cigarettes for 30 years, the nurse expects to note which assessment
finding?



1. Increase in Forced Vital Capacity (FVC)

2. A narrowed chest cavity

3. Clubbed fingers

4. An increased risk of cardiac failure Answer- 1. Increase in Forced Vital Capacity (FVC)

Forced Vital Capacity is the volume of air exhaled from full inhalation to full exhalation. A patient with COPD
would have a decrease in FVC. Incorrect.



2. A narrowed chest cavity

A patient with COPD often presents with a 'barrel chest,' which is seen as a widened chest cavity. Incorrect.



3. Clubbed fingers - CORRECT

Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels.



4. An increased risk of cardiac failure

Although a patient with these conditions would indeed be at an increased risk for cardiac failure, this is a
potential complication and not an assessment finding. Incorrect.



The nurse is taking the health history of a 70-year-old patient being treated for a Duodenal Ulcer. After being

,told the patient is complaining of epigastric pain, the nurse expects to note which assessment finding?



1. Melena

2. Nausea

3. Hernia

4. Hyperthermia Answer- 1. Melena - CORRECT

Melena is the finding that there are traces of blood in the stool which presents as black, tarry feces. This is a
common manifestation of Duodenal Ulcers, since the Duodenum is further down the gastric anatomy.



2. Nausea

Nausea may be present, but is a generalized symptom and by itself doesn't indicate a Duodenal Ulcer.
Incorrect.



3. Hernia

A Hernia is a protrusion of a segment of the abdomen through another abdominal structure. It is not associated
with an Ulcer and is a condition, not an assessment finding. Incorrect.



4. Hyperthermia

Hyperthermia, a high temperature, is not an assessment finding of a Duodenal Ulcer. Incorrect



A nurse is providing discharge teaching for a patient with severe Gastroesophogeal Reflux Disease. Which of
these statements by the patient indicates a need for more teaching?



1. "I'm going to limit my meals to 2-3 per day to reduce acid secretion."



2. "I'm going to make sure to remain upright after meals and elevate my head when I sleep"



3. "I won't be drinking tea or coffee or eating chocolate any more."

,4. "I'm going to start trying to lose some weight." Answer- 1. "I'm going to limit my meals to 2-3 per day to
reduce acid secretion."

CORRECT - Large meals increase the volume and pressure in the stomach and delay gastric emptying. It's
recommended instead to eat 4-6 small meals a day.



2. "I'm going to make sure to remain upright after meals and elevate my head when I sleep"

Incorrect - This is a correct verbalization of health promotion for GERD.



3. "I won't be drinking tea or coffee or eating chocolate any more."

Incorrect - This is a correct verbalization of health promotion for GERD.



4. "I'm going to start trying to lose some weight."

Incorrect - This is a correct verbalization of health promotion for GERD.



The nurse in the Emergency Room is treating a patient suspected to have a Peptic Ulcer. On assessing lab
results, the nurse finds that the patient's blood pressure is 95/60, pulse is 110 beats per minute, and the
patient reports epigastric pain. What is the PRIORITY intervention?



1. Start a large-bore IV in the patient's arm

2. Ask the patient for a stool sample

3. Prepare to insert an NG Tube

4. Administer intramuscular morphine sulphate as ordered Answer- 1. Start a large-bore IV in the patient's arm

CORRECT - The nurse should suspect that the patient is haemorrhaging and will need need a fluid replacement
therapy, which requires a large bore IV.



2. Ask the patient for a stool sample

Incorrect - While this is useful in the diagnosis and assessment of Peptic Ulcer Disease, it is not the priority
intervention.

, 3. Prepare to insert an NG Tube

Incorrect - While this intervention may be used in the later stages of Peptic Ulcer Disease, it is not the first and
priority intervention.



4. Administer intramuscular morphine sulphate as ordered

Incorrect - While this is an important intervention to manage pain, it is not the priority intervention.



A female patient with atrial fibrillation has the following lab results: Hemoglobin of 11 g/dl, a platelet count of
150,000, an INR of 2.5, and potassium of 2.7 mEq/L. Which result is critical and should be reported to the
physician immediately?



1. Hemoglobin 11 g/dl

2. Platelet of 150,000

3. INR of 2.5

4. Potassium of 2.7 mEq/L Answer- 1. Hemoglobin 11 g/dl

This is below normal, but a normal female hemoglobin is 12-14. There is a more critical lab result.



2. Platelet of 150,000

This is also below the normal values, but is not the most critical lab result.



3. INR of 2.5

This is a therapeutic range for a patient who is taking an anticoagulant for atrial fibrillation



4. Potassium of 2.7 mEq/L

CORRECT - A potassium imbalance for a patient with a history of dysrhythmia can be life-threatening and can
lead to cardiac distress.

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