NCLEX Questions
NCLEX Question: 11 - 2 - 13
1) The client diagnosed with a panic attack disorder in the busy day room of a psychiatric unit
becomes anxious, starts to hyperventilate and tremble, and is diaphoretic. Which intervention
should the nurse implement first?
a. Administer the benzodizephoine alprazolam (Xanax)
b. Discuss what caused the client to have a panic attack
c. Escort the client from the day room to a quiet area
d. Instruct unlicensed assistive personnel to take the client’s vital signs
Answer C: The first intervention is to remove the client from the busy day room to a quiet area
to help decrease the anxiety attack. Providing medication for an anxiety attack is important, but
it will take at least 15-30 min for the medication to treat the physiologic
signs/symptoms. Therefore, this is not the first intervention. The nurse should discuss the panic
attack and what prompted it, but it is not the nurse’s first action. The client’s vital signs should
be taken, but this is not the nurse’s first intervention.
NCLEX Question: 11-16-13
2) Which of the following should be included in the care plan for a client admitted with acute
renal colic?
A.
Inserting an indwelling urinary catheter
B. Straining all urine
C. Maintaining T-tube patency
D. Limiting fluid intake to 1 to 2 liters/day.
Correct answer: B
RATIONALE: The urine of a client with renal colic should be strained through gauze to assess
for the presence of calculi. Invasive catheterization isn’t done because it increases the risk of
infection. A T-Tube is used to drain bile from the biliary tract. Fluids are increased for a client
with renal colic; 3-4 liters/day are recommended to facilitate passage of calculi.
NCLEX Question: 11 – 25-13
2) Which of the following should be included in the care plan for a client admitted with acute
renal colic?
A.
Inserting an indwelling urinary catheter
B. Straining all urine
C. Maintaining T-tube patency
D. Limiting fluid intake to 1 to 2 liters/day.
Correct answer: B
RATIONALE: The urine of a client with renal colic should be strained through gauze to assess
for the presence of calculi. Invasive catheterization isn’t done because it increases the risk of
infection. A T-Tube is used to drain bile from the biliary tract. Fluids are increased for a client
with renal colic; 3-4 liters/day are recommended to facilitate passage of calculi.
a.
b.
c.
d.
e.
NCLEX Question: 12 – 3 – 14
The client diagnosed with a brain tumor is ordered the osmotic diuretic mannitol (Osmitrol) to be
given intravenously. Which interventions for this medication should the nurse implement?
Select all that apply.
Inspect the bottle for crystals
Record intake and output every 8 hours
Auscultate the client’s lung fields
Perform a neurological examination
Have a calcium gluconate at the bedside
Answer A, B, C: Mannitol can crystallize in the containers in which it is packaged, and the
crystals must not be infused into the client. The nurse should inspect the bottle for crystals
before beginning the administration. Any client receiving a diuretic should be monitored for
intake and output to determine if the client is excreting more than the intake. Mannitol is an
osmotic diuretic and works by pulling fluid from the tissues into the blood vessels. Clients
diagnosed with heart failure may develop fluid volume overload. Therefore, the nurse should
assess lung sounds before administering this medication. The nurse does not have to perform a
neurological exam for this medication. The nurse should do this for the disease
diagnosis. Calcium gluconate will not affect this medication, nor is it an antidote.
NCLEX QUESTION: 1 – 13 – 14
The client diagnosed with a brain tumor is ordered the osmotic diuretic mannitol (Osmitrol) to be
given intravenously. Which interventions for this medication should the nurse implement?
Select all that apply.
a.
Inspect the bottle for crystals
b.
Record intake and output every 8 hours
c.
Auscultate the client’s lung fields
d.
Perform a neurological examination
e.
Have a calcium gluconate at the bedside
Answer A, B, C: Mannitol can crystallize in the containers in which it is packaged, and the
crystals must not be infused into the client. The nurse should inspect the bottle for crystals
before beginning the administration. Any client receiving a diuretic should be monitored for
intake and output to determine if the client is excreting more than the intake. Mannitol is an
osmotic diuretic and works by pulling fluid from the tissues into the blood vessels. Clients
diagnosed with heart failure may develop fluid volume overload. Therefore, the nurse should
assess lung sounds before administering this medication. The nurse does not have to perform a
neurological exam for this medication. The nurse should do this for the disease
diagnosis. Calcium gluconate will not affect this medication, nor is it an antidote.
NCLEX Question: 1 – 20 – 14
1. A nurse’s laboring client is experiencing decelerations that occur after the onset of the
contraction and do not end until after the contraction is completed. The fetal heart rate
variability is minimal. Which interventions should the nurse initiate? Select all that apply:
a. Increase intravenous fluids
b. Administer oxygen via facemask
c. Increase the Pitocin
d. Turn the client to her left side
e. Reassess in 30 minutes
Rationale:
The question is describing a late deceleration. Interventions for this condition include: a. b.
d. Answer C. would not be correct ,as increasing the Pitocin could make late decels worse, and
answer E. is not correct because the nurse needs to reassess continually, not in 30 mins.
NCLEX Question: 2 – 3 – 14
The client on the medical unit is exhibiting peaked T waves on the electrocardiogram. Which
interventions should the nurse implement? List in order of priority.
a. Assess the client for leg and muscle cramps
b. Check the serum potassium level
c. Notify the health-care provider
d. Arrange for a transfer to the telemetry floor
e. Administer Kayexalate, a cation resin
Answer: A, B, C, E, D – The nurse should assess to determine if the client is symptomatic of
hyperkalemia. A peaked T wave is indicative of hyperkalemia, therefore, the nurse should
obtain a potassium level. Hyperkalemia is a life-threatening situation because of the risk of
cardiac dysrhythmia, therefore, the nurse should notify the health-care provider. Kayexalate is a
medication that will help remove potassium through the gastrointestinal system and should be
administered to decrease the potassium level. The client should be monitored continuously for
cardiac dysrhythmias so a transfer to the telemetry unit is warranted.
NCLEX Question: 2 – 10 – 14
A toddler is admitted with a seizure disorder. According to the parents, the client stops breathing
and turns blue after having a seizure. The physician prescribes phenytoin (Dilantin). Before
discharge, the nurse teaches the parents how to handle seizures. Which instruction should the
nurse include?
A. Give the client the medication as soon as a seizure begins.
B. Place a tongue blade in the client’s mouth during a seizure.
C. Remove nearby objects that could cause injury during a seizure.
D. Keep the medication in the client’s room so that it won’t be forgotten.
Correct Answer: C
Rationale: The nurse should be sure to teach parents how to prevent injury during a seizure.
The nurse should explain that placing something in the mouth—even medication or a tongue
blade—increases the risk of airway obstruction. Also, the nurse should advise the parents to
keep all medications out of the reach of children.
NCLEX Question: 2 – 17 - 14
A patient with decreased cardiac contractility is in the emergency room. The provider is
considering a bolus of IV fluids. What would be the concern with this, given your knowledge of
the Frank Starling principle?
A. Initially, extra fluids may produce improved cardiac contractility. However, if too much fluid
is given, cardiac output will decrease.
B. There is no concern. Extra fluid will always help this patient.
C. Cardiac output might decrease right away, but there will always be better contractility with
additional fluids.
D. None of the above.
Answer: A.