NCLEX-RN TEST BANK 800+ QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+
NO.1 A depressed patient is seen at the mental health center for follow-up after an attempted
suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase ( MAO)
inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that
the drug must accumulate to an effective level before symptoms are totally relieved. Symptom
relief is expected to occur within:
• 10 days
• 2-4 weeks
• 2 months
• 3 months Answer: B Explanation:
( A) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. (
B) This answer is correct. Because MAO inhibitors are slow to act, it takes 2-4 weeks before
improvement of symptoms is noted.
( C) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. (
D) This answer is incorrect. Therapeutic effects of the medication are noted within 1 month of
drug therapy.
,NO.2 Cystic fibrosis is transmitted as an autosomal recessive trait. This means that:
A. Mothers carry the gene and pass it to their sons
B. Fathers carry the gene and pass it to their daughters
C. Both parents must have the disease for a child to have the disease
D. Both parents must be carriers for a child to have the disease
Answer: D Explanation:
( A) Cystic fibrosis is not an X-linked or sex-linked disease. (B) The only characteristic on the Y
chromosome is the trait for hairy ears. (C) Both parents do not need to have the disease but
must be carriers. (D) If a trait is recessive, two genes (one from each parent) are necessary to
produce an affected child.
NO.3 A 24-year-old patient presents to the emergency department protesting "I am God." The
nurse identifies this as a:
A. Delusion
B. Illusion
C. Hallucination
D. Conversion
Answer: A Explanation:
( A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory
experience. (C) Hallucination is a false sensory perception involving any of the senses. (D)
Conversion is the expression of intrapsychic conflict through sensory or motor manifestations.
NO.4 In acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4 weeks,
or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed
during the first few days or weeks of an acute episode to manage severe behavioral excitement
and acute psychotic symptoms. In addition to the lithium, which one of the following
medications might the physician prescribe? A. Diazepam (Valium)
B. Haloperidol (Haldol)
C. Sertraline (Zoloft)
D. Alprazolam (Xanax)
Answer: B Explanation:
,( A) Diazepam is an antianxiety medication and is not designed to reduce psychotic symptoms. (B
) Haloperidol is an antipsychotic medication and may be used until the lithium takes effect. (C)
Sertraline is an antidepressant and is used primarily to reduce symptoms of depression. (D)
Alprazolam is an antianxiety medication and is not designed to reduce psychotic symptoms.
NO.5 A violent patient remains in restraints for several hours. Which of the following
interventions is most appropriate while he is in restraints? A. Give fluids if the patient requests
them.
B. Assess skin integrity and circulation of extremities before applying restraints and as they are
removed.
C. Measure vital signs at least every 4 hours.
D. Release restraints every 2 hours for patient to exercise.
Answer: D Explanation:
( A) Fluids (nourishment) should be offered at regular intervals whether the patient requests (or
refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked
regularly while the patient is restrained, not only before restraints are applied and after they
are removed. (C) Vital signs should be checked at least every 2 hours. If the patient remains
agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2
hours. (D) Restraints should be released every 2 hours for exercise, one extremity at a time, to
maintain muscle tone, skin and joint integrity, and circulation.
NO.6 The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on
oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or
child?
A. Administer oral griseofulvin on an empty stomach for best results.
B. Discontinue drug therapy if food tastes funny.
C. May discontinue medication when the child experiences symptomatic relief.
D. Observe for headaches, dizziness, and anorexia.
Answer: D Explanation:
( A) Giving the drug with or after meals may allay gastrointestinal discomfort. Giving the drug
with a fatty meal (ice cream or milk) increases absorption rate. (B) Griseofulvin may alter taste
sensations and thereby decrease the appetite. Monitoring of food intake is important, and
inadequate nutrient intake should be reported to the physician. (C) The child may experience
symptomatic relief after 4896 hours of therapy. It is important to stress continuing the drug
therapy to prevent relapse (usually about 6 weeks). (D) The incidence of side effects is low;
, however, headaches are common. Nausea, vomiting, diarrhea, and anorexia may occur.
Dizziness, although uncommon, should be reported to the physician.
NO.7 A patient with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg
q6h via nasogastric tube. The rationale for this therapy is to:
A. Prevent systemic infection
B. Promote diuresis
C. Decrease ammonia formation
D. Acidify the small bowel
Answer: C Explanation:
( A) Neomycin is an antibiotic, but this is not the Rationale for administering it to a patient in
hepatic coma. (B) Diuretics and salt-free albumin are used to promote diuresis in patients with
cirrhosis of the liver. (C) Neomycin destroys the bacteria in the intestines. It is the bacteria in
the bowel that break down protein into ammonia. (D) Lactulose is administered to create an
acid environment in the bowel. Ammonia leaves the blood and migrates to this acidic
environment where it is trapped and excreted.
NO.8 A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing
measures should be included in the postoperative care?
A. Encourage the child to cough up blood if present.
B. Give warm clear liquids when fully alert.
C. Have child gargle and do toothbrushing to remove old blood.
D. Observe for evidence of bleeding.
Answer: D Explanation:
( A) The nurse should discourage the child from coughing, clearing the throat, or putting objects
in his
mouth. These may induce bleeding. (B) Cool, clear liquids may be given when child is fully alert.
Warm liquids may dislodge a blood clot. The nurse should avoid red- or brown-colored liquids
to distinguish fresh or old blood from ingested liquid should the child vomit. (C) Gargles and
vigorous toothbrushing could initiate bleeding. (D) Postoperative hemorrhage, though unusual,
may occur. The
nurse should observe for bleeding by looking directly into the throat and for vomiting of bright
red blood, continuous swallowing, and changes in vital signs.
CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+
NO.1 A depressed patient is seen at the mental health center for follow-up after an attempted
suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase ( MAO)
inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that
the drug must accumulate to an effective level before symptoms are totally relieved. Symptom
relief is expected to occur within:
• 10 days
• 2-4 weeks
• 2 months
• 3 months Answer: B Explanation:
( A) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. (
B) This answer is correct. Because MAO inhibitors are slow to act, it takes 2-4 weeks before
improvement of symptoms is noted.
( C) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. (
D) This answer is incorrect. Therapeutic effects of the medication are noted within 1 month of
drug therapy.
,NO.2 Cystic fibrosis is transmitted as an autosomal recessive trait. This means that:
A. Mothers carry the gene and pass it to their sons
B. Fathers carry the gene and pass it to their daughters
C. Both parents must have the disease for a child to have the disease
D. Both parents must be carriers for a child to have the disease
Answer: D Explanation:
( A) Cystic fibrosis is not an X-linked or sex-linked disease. (B) The only characteristic on the Y
chromosome is the trait for hairy ears. (C) Both parents do not need to have the disease but
must be carriers. (D) If a trait is recessive, two genes (one from each parent) are necessary to
produce an affected child.
NO.3 A 24-year-old patient presents to the emergency department protesting "I am God." The
nurse identifies this as a:
A. Delusion
B. Illusion
C. Hallucination
D. Conversion
Answer: A Explanation:
( A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory
experience. (C) Hallucination is a false sensory perception involving any of the senses. (D)
Conversion is the expression of intrapsychic conflict through sensory or motor manifestations.
NO.4 In acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4 weeks,
or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed
during the first few days or weeks of an acute episode to manage severe behavioral excitement
and acute psychotic symptoms. In addition to the lithium, which one of the following
medications might the physician prescribe? A. Diazepam (Valium)
B. Haloperidol (Haldol)
C. Sertraline (Zoloft)
D. Alprazolam (Xanax)
Answer: B Explanation:
,( A) Diazepam is an antianxiety medication and is not designed to reduce psychotic symptoms. (B
) Haloperidol is an antipsychotic medication and may be used until the lithium takes effect. (C)
Sertraline is an antidepressant and is used primarily to reduce symptoms of depression. (D)
Alprazolam is an antianxiety medication and is not designed to reduce psychotic symptoms.
NO.5 A violent patient remains in restraints for several hours. Which of the following
interventions is most appropriate while he is in restraints? A. Give fluids if the patient requests
them.
B. Assess skin integrity and circulation of extremities before applying restraints and as they are
removed.
C. Measure vital signs at least every 4 hours.
D. Release restraints every 2 hours for patient to exercise.
Answer: D Explanation:
( A) Fluids (nourishment) should be offered at regular intervals whether the patient requests (or
refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked
regularly while the patient is restrained, not only before restraints are applied and after they
are removed. (C) Vital signs should be checked at least every 2 hours. If the patient remains
agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2
hours. (D) Restraints should be released every 2 hours for exercise, one extremity at a time, to
maintain muscle tone, skin and joint integrity, and circulation.
NO.6 The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on
oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or
child?
A. Administer oral griseofulvin on an empty stomach for best results.
B. Discontinue drug therapy if food tastes funny.
C. May discontinue medication when the child experiences symptomatic relief.
D. Observe for headaches, dizziness, and anorexia.
Answer: D Explanation:
( A) Giving the drug with or after meals may allay gastrointestinal discomfort. Giving the drug
with a fatty meal (ice cream or milk) increases absorption rate. (B) Griseofulvin may alter taste
sensations and thereby decrease the appetite. Monitoring of food intake is important, and
inadequate nutrient intake should be reported to the physician. (C) The child may experience
symptomatic relief after 4896 hours of therapy. It is important to stress continuing the drug
therapy to prevent relapse (usually about 6 weeks). (D) The incidence of side effects is low;
, however, headaches are common. Nausea, vomiting, diarrhea, and anorexia may occur.
Dizziness, although uncommon, should be reported to the physician.
NO.7 A patient with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg
q6h via nasogastric tube. The rationale for this therapy is to:
A. Prevent systemic infection
B. Promote diuresis
C. Decrease ammonia formation
D. Acidify the small bowel
Answer: C Explanation:
( A) Neomycin is an antibiotic, but this is not the Rationale for administering it to a patient in
hepatic coma. (B) Diuretics and salt-free albumin are used to promote diuresis in patients with
cirrhosis of the liver. (C) Neomycin destroys the bacteria in the intestines. It is the bacteria in
the bowel that break down protein into ammonia. (D) Lactulose is administered to create an
acid environment in the bowel. Ammonia leaves the blood and migrates to this acidic
environment where it is trapped and excreted.
NO.8 A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing
measures should be included in the postoperative care?
A. Encourage the child to cough up blood if present.
B. Give warm clear liquids when fully alert.
C. Have child gargle and do toothbrushing to remove old blood.
D. Observe for evidence of bleeding.
Answer: D Explanation:
( A) The nurse should discourage the child from coughing, clearing the throat, or putting objects
in his
mouth. These may induce bleeding. (B) Cool, clear liquids may be given when child is fully alert.
Warm liquids may dislodge a blood clot. The nurse should avoid red- or brown-colored liquids
to distinguish fresh or old blood from ingested liquid should the child vomit. (C) Gargles and
vigorous toothbrushing could initiate bleeding. (D) Postoperative hemorrhage, though unusual,
may occur. The
nurse should observe for bleeding by looking directly into the throat and for vomiting of bright
red blood, continuous swallowing, and changes in vital signs.
