NCLEX RN 2025 EXAM
QUESTIONS AND ANSWERS
BANK WITH RATIONALES
JANUARY 2025 UPDATE
100% VERIFIED
450 Q&A
,1. 1. Question
1 point(s)
Category: Pharmacological and Parenteral Therapies
The nurse is caring for a 65-year-old male client with a history of ischemic heart
disease who has been admitted to the ICU following a myocardial infarction. The
client is currently receiving lidocaine I.V. to manage his ventricular ectopy, which
has been persistent. Which of the following factors would be most important for
the nurse to consider in relation to the administration of this medication?
o A. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse
oximeter
o B. Increase in systemic blood pressure
o C. Presence of premature ventricular contractions (PVCs) on a cardiac
monitor
o D. Increase in intracranial pressure (ICP)
o E. A drop in serum potassium levels as indicated in the latest lab results
o F. Observation of a widening QRS complex on the ECG
Correct
Correct Answer: C. Presence of premature ventricular contractions (PVCs) on
a cardiac monitor.
In the context of acute myocardial infarction, the priority is to manage life-
threatening arrhythmias. Lidocaine is specifically indicated for the treatment of
ventricular arrhythmias, such as PVCs, which can be indicative of an increased risk
for more serious arrhythmias like ventricular tachycardia or ventricular fibrillation.
The presence of PVCs on a cardiac monitor would be the most immediate
concern that lidocaine can address in this scenario. While the other factors listed
are important to monitor, they are not the primary indications for lidocaine
administration in the context of arrhythmia management.
2. 2. Question
1 point(s)
Category: Pharmacological and Parenteral Therapies
, A 72-year-old male patient with a history of atrial fibrillation and controlled
hypertension has been initiated on warfarin therapy. Upon assessment of the
patient’s history, it was revealed that he has a history of peptic ulcer. This patient
also has a recent history of a peptic ulcer. Given the client’s medical history and
current medication regimen, which of the following instructions should the nurse
prioritize when providing discharge teaching?
o A. Report incidents of diarrhea
o B. Avoid foods high in vitamin K
o C. Use a straight razor when shaving
o D. Take aspirin for pain relief
o E. Monitor for signs of bleeding, such as bruising or black tarry stools
o F. Check blood pressure regularly at home
o G. Inform all healthcare providers about the anticoagulant therapy
Correct Answer: B. Avoid foods high in vitamin K
Clients taking warfarin should be educated about maintaining a consistent intake
of vitamin K, as it is necessary for the clotting cascade, and warfarin works by
inhibiting the effects of vitamin K, thereby reducing the blood’s ability to clot.
Sudden increases in vitamin K intake can decrease the effectiveness of warfarin
and increase the risk of clot formation. Clients should also be advised to report
any incidents of diarrhea (A) since it can affect the absorption of the medication
and potentially lead to unstable anticoagulation levels. Using a straight razor (C)
is not advised due to the increased risk of bleeding; a safety razor or electric razor
would be safer alternatives. Taking aspirin for pain relief (D) is not recommended
without a physician’s approval because aspirin can increase the risk of bleeding
when taken with an anticoagulant. Monitoring for signs of bleeding (E), checking
blood pressure regularly (F), and informing all healthcare providers about
anticoagulant therapy (G) are also important instructions for a patient on warfarin
therapy, but avoiding foods high in vitamin K is directly related to the
effectiveness of the anticoagulant medication and is thus the priority teaching
point.
, 3. 3. Question
1 point(s)
Category: Reduction of Risk Potential
In a busy surgical unit, a nurse is preparing to insert an I.V. catheter for a 33-year-
old patient who is scheduled for elective surgery and has a notably hairy forearm
where the I.V. is to be placed. The patient is allergic to a variety of adhesives and
has sensitive skin that is prone to irritation. Given these considerations, how
should the nurse manage excess hair at the intended catheter insertion site?
o A. Leaving the hair intact
o B. Shaving the area
o C. Clipping the hair in the area
o D. Removing the hair with a depilatory
o E. Applying a small amount of water-soluble gel to tame the hair without
cutting
o F. Use a sterile surgical scalpel to trim the hair as close to the skin as possible
without causing abrasions
Correct Answer: C. Clipping the hair in the area
Clipping is preferred over shaving in this scenario because it reduces the
potential for creating microabrasions that can increase infection risk, which is
especially important in a patient with sensitive skin. Chemical depilatories (D) are
not recommended due to the patient’s history of allergies and sensitive skin.
Leaving the hair intact (A) could interfere with the securement of the I.V. and
increase the risk of infection. Water-soluble gel (E) is not standard practice for
managing hair at an I.V. site and does not address the infection control issue. A
sterile surgical scalpel (F) is not typically recommended for hair removal in
preparation for I.V. insertion due to the risk of cuts and abrasions. Clipping is the
safest option that balances the need to reduce infection risk with the patient’s
sensitivity and allergy concerns.
4. 4. Question
QUESTIONS AND ANSWERS
BANK WITH RATIONALES
JANUARY 2025 UPDATE
100% VERIFIED
450 Q&A
,1. 1. Question
1 point(s)
Category: Pharmacological and Parenteral Therapies
The nurse is caring for a 65-year-old male client with a history of ischemic heart
disease who has been admitted to the ICU following a myocardial infarction. The
client is currently receiving lidocaine I.V. to manage his ventricular ectopy, which
has been persistent. Which of the following factors would be most important for
the nurse to consider in relation to the administration of this medication?
o A. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse
oximeter
o B. Increase in systemic blood pressure
o C. Presence of premature ventricular contractions (PVCs) on a cardiac
monitor
o D. Increase in intracranial pressure (ICP)
o E. A drop in serum potassium levels as indicated in the latest lab results
o F. Observation of a widening QRS complex on the ECG
Correct
Correct Answer: C. Presence of premature ventricular contractions (PVCs) on
a cardiac monitor.
In the context of acute myocardial infarction, the priority is to manage life-
threatening arrhythmias. Lidocaine is specifically indicated for the treatment of
ventricular arrhythmias, such as PVCs, which can be indicative of an increased risk
for more serious arrhythmias like ventricular tachycardia or ventricular fibrillation.
The presence of PVCs on a cardiac monitor would be the most immediate
concern that lidocaine can address in this scenario. While the other factors listed
are important to monitor, they are not the primary indications for lidocaine
administration in the context of arrhythmia management.
2. 2. Question
1 point(s)
Category: Pharmacological and Parenteral Therapies
, A 72-year-old male patient with a history of atrial fibrillation and controlled
hypertension has been initiated on warfarin therapy. Upon assessment of the
patient’s history, it was revealed that he has a history of peptic ulcer. This patient
also has a recent history of a peptic ulcer. Given the client’s medical history and
current medication regimen, which of the following instructions should the nurse
prioritize when providing discharge teaching?
o A. Report incidents of diarrhea
o B. Avoid foods high in vitamin K
o C. Use a straight razor when shaving
o D. Take aspirin for pain relief
o E. Monitor for signs of bleeding, such as bruising or black tarry stools
o F. Check blood pressure regularly at home
o G. Inform all healthcare providers about the anticoagulant therapy
Correct Answer: B. Avoid foods high in vitamin K
Clients taking warfarin should be educated about maintaining a consistent intake
of vitamin K, as it is necessary for the clotting cascade, and warfarin works by
inhibiting the effects of vitamin K, thereby reducing the blood’s ability to clot.
Sudden increases in vitamin K intake can decrease the effectiveness of warfarin
and increase the risk of clot formation. Clients should also be advised to report
any incidents of diarrhea (A) since it can affect the absorption of the medication
and potentially lead to unstable anticoagulation levels. Using a straight razor (C)
is not advised due to the increased risk of bleeding; a safety razor or electric razor
would be safer alternatives. Taking aspirin for pain relief (D) is not recommended
without a physician’s approval because aspirin can increase the risk of bleeding
when taken with an anticoagulant. Monitoring for signs of bleeding (E), checking
blood pressure regularly (F), and informing all healthcare providers about
anticoagulant therapy (G) are also important instructions for a patient on warfarin
therapy, but avoiding foods high in vitamin K is directly related to the
effectiveness of the anticoagulant medication and is thus the priority teaching
point.
, 3. 3. Question
1 point(s)
Category: Reduction of Risk Potential
In a busy surgical unit, a nurse is preparing to insert an I.V. catheter for a 33-year-
old patient who is scheduled for elective surgery and has a notably hairy forearm
where the I.V. is to be placed. The patient is allergic to a variety of adhesives and
has sensitive skin that is prone to irritation. Given these considerations, how
should the nurse manage excess hair at the intended catheter insertion site?
o A. Leaving the hair intact
o B. Shaving the area
o C. Clipping the hair in the area
o D. Removing the hair with a depilatory
o E. Applying a small amount of water-soluble gel to tame the hair without
cutting
o F. Use a sterile surgical scalpel to trim the hair as close to the skin as possible
without causing abrasions
Correct Answer: C. Clipping the hair in the area
Clipping is preferred over shaving in this scenario because it reduces the
potential for creating microabrasions that can increase infection risk, which is
especially important in a patient with sensitive skin. Chemical depilatories (D) are
not recommended due to the patient’s history of allergies and sensitive skin.
Leaving the hair intact (A) could interfere with the securement of the I.V. and
increase the risk of infection. Water-soluble gel (E) is not standard practice for
managing hair at an I.V. site and does not address the infection control issue. A
sterile surgical scalpel (F) is not typically recommended for hair removal in
preparation for I.V. insertion due to the risk of cuts and abrasions. Clipping is the
safest option that balances the need to reduce infection risk with the patient’s
sensitivity and allergy concerns.
4. 4. Question
