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Nclex c/o brilliant nurse EXAM NEWEST VERSION -2025/2026-
75+ Q AND ANS MOST POPULAR EXAM GUARANTEED
SUCCESS
A patient with Meningitis is being treated with Vancomycin intravenously 3 times
per day. The nurse notes that the urine output during the last 8 hours was 200mL.
What is the nurse's priority action?
1. Check the patient's last BUN
2. Ask the patient to increase their fluid intake
3. Ask the physician to order a diuretic
4. Notify the physician of this finding
1. Check the patient's last BUN
Incorrect - This may be relevant to nephrotoxicity and poor urine output, but is
not the priority action. An assessment finding has already been done and
indicates an immediate intervention.
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.
, 2
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
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.
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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."
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.
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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
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
Nclex c/o brilliant nurse EXAM NEWEST VERSION -2025/2026-
75+ Q AND ANS MOST POPULAR EXAM GUARANTEED
SUCCESS
A patient with Meningitis is being treated with Vancomycin intravenously 3 times
per day. The nurse notes that the urine output during the last 8 hours was 200mL.
What is the nurse's priority action?
1. Check the patient's last BUN
2. Ask the patient to increase their fluid intake
3. Ask the physician to order a diuretic
4. Notify the physician of this finding
1. Check the patient's last BUN
Incorrect - This may be relevant to nephrotoxicity and poor urine output, but is
not the priority action. An assessment finding has already been done and
indicates an immediate intervention.
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.
, 2
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
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.
, 3
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."
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
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
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
