NCLEX PRACTICE QUESTIONS AND ANSWERS
1. Question1 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 about the administration of this medication?
A. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter
B. Increase in systemic blood pressure
C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor
D. Increase in intracranial pressure (ICP)
E. A drop in serum potassium levels as indicated in the latest lab results
F. Observation of a widening QRS complex on the ECG
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. Question1 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?
A. Report incidents of diarrhea
B. Avoid foods high in vitamin K
C. Use a straight razor when shaving
D. Take aspirin for pain relief
E. Monitor for signs of bleeding, such as bruising or black tarry stools
F. Check blood pressure regularly at home
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. Question1 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?
A. Leaving the hair intact
B. Shaving the area
C. Clipping the hair in the area
D. Removing the hair with a depilatory
E. Applying a small amount of water-soluble gel to tame the hair without cutting
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.
1. Question1 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 about the administration of this medication?
A. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter
B. Increase in systemic blood pressure
C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor
D. Increase in intracranial pressure (ICP)
E. A drop in serum potassium levels as indicated in the latest lab results
F. Observation of a widening QRS complex on the ECG
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. Question1 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?
A. Report incidents of diarrhea
B. Avoid foods high in vitamin K
C. Use a straight razor when shaving
D. Take aspirin for pain relief
E. Monitor for signs of bleeding, such as bruising or black tarry stools
F. Check blood pressure regularly at home
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. Question1 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?
A. Leaving the hair intact
B. Shaving the area
C. Clipping the hair in the area
D. Removing the hair with a depilatory
E. Applying a small amount of water-soluble gel to tame the hair without cutting
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.
