75 NCLEX QUESTIONS WITH CORRECT SOLUTIONS LATEST UPDATE 2023/2024 GRADED A+ BEST EXAM SOL, Exams of Nursing

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The nurse is taking the health history of a patient being treated for Emphysema and Chronic Bronchitis. After being told the patient has been smoking cigarettes for 30 years, the nurse expects to note which assessment finding?

1. Increase in Forced Vital Capacity (FVC)
2. A narrowed chest cavity
3. Clubbed fingers
4. An increased risk of cardiac failure - correct answer ✅1. Increase in Forced Vital Capacity (FVC) Forced Vital Capacity is the volume of air exhaled from full inhalation to full exhalation. A patient with COPD would have a decrease in FVC. Incorrect.
5. A narrowed chest cavity A patient with COPD often presents with a 'barrel chest,' which is seen as a widened chest cavity. Incorrect.
6. Clubbed fingers - CORRECT Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels.
7. 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.

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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 - correct answer ✅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.
5. Nausea Nausea may be present, but is a generalized symptom and by itself doesn't indicate a Duodenal Ulcer. Incorrect.
6. 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.
7. Hyperthermia Hyperthermia, a high temperature, is not an assessment finding of a Duodenal Ulcer. Incorrect

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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." - correct answer ✅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.
5. "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.
6. "I won't be drinking tea or coffee or eating chocolate any more." Incorrect - This is a correct verbalization of health promotion for GERD.
7. "I'm going to start trying to lose some weight."

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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 - correct answer ✅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.
5. 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.
6. 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.
7. Administer intramuscular morphine sulphate as ordered

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Incorrect - While this is an important intervention to manage pain, it is not the priority intervention. A female patient with atrial fibrillation has the following lab results: Hemoglobin of 11 g/dl, a platelet count of 150,000, an INR of 2.5, and potassium of 2.7 mEq/L. Which result is critical and should be reported to the physician immediately?

1. Hemoglobin 11 g/dl
2. Platelet of 150,
3. INR of 2.
4. Potassium of 2.7 mEq/L - correct answer ✅1. Hemoglobin 11 g/dl This is below normal, but a normal female hemoglobin is 12-14. There is a more critical lab result.
5. Platelet of 150, This is also below the normal values, but is not the most critical lab result.
6. INR of 2. This is a therapeutic range for a patient who is taking an anticoagulant for atrial fibrillation
7. Potassium of 2.7 mEq/L CORRECT - A potassium imbalance for a patient with a history of dysrhythmia can be life-threatening and can lead to cardiac distress.

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While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patient's lower legs have become edematous and auscultates crackles in the lungs. What should the nurse do first?

1. Stop the saline infusion immediately
2. Notify Physician
3. Elevate the patient's legs
4. Continue the infusion, since these are normal findings - correct answer ✅1. Stop the saline infusion immediately CORRECT - the patient has a fluid volume overload as a result of overly rapid fluid replacement. The nurse should stop the infusion and notify the physician.
5. Notify Physician This is not the first action the nurse should take.
6. Elevate the patient's legs This would help with the edema, but is not a priority
7. Continue the infusion, since these are normal findings This is not a normal finding The nurse is working in a support group for clients with HIV. Which point is most important for the nurse to stress?

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1. They must inform household members of their condition
2. They must take their medications exactly as prescribed
3. They must abstain from substance use
4. They must avoid large crowds - correct answer ✅1. They must inform household members of their condition Incorrect - Each patient has a right to privacy of their medical condition. It is their choice whether they inform household members.
5. They must take their medications exactly as prescribed CORRECT - Antiretrovirals must be taken exactly as prescribed to prevent drug-resistant strains. Even missed doses can reduce the effectiveness of future treatment.
6. They must abstain from substance use Incorrect - While substance use should be discouraged, using safe practices with needles can prevent transmission of HIV.
7. They must avoid large crowds Incorrect - Avoiding large crowds to prevent infection is a priority in the later stages of HIV, when the patient has AIDS. A nurse finds a 30-year-old woman experiencing anaphylaxis from a bee sting. Emergency personnel have been called. The nurse notes the woman is breathing but short of breath. Which of the following interventions should the nurse do first?

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1. Initiate cardiopulmonary resuscitation
2. Check for a pulse
3. Ask the woman if she carries an emergency medical kit
4. Stay with the woman until help comes - correct answer ✅1. Initiate cardiopulmonary resuscitation Incorrect - CPR is premature at this point, and there is another action that can be taken first.
5. Check for a pulse This is the first step when assessing for initiation of CPR, but CPR is not the best and first course of action for this situation. The woman is still breathing, which means CPR is not necessary at this time.
6. Ask the woman if she carries an emergency medical kit CORRECT - Many patients who have a known history of anaphylaxis carry epi-pens in their pockets or belongings. This is the best way to stop a hypersensitivity reaction before it becomes life-threatening.
7. Stay with the woman until help comes Incorrect - While this should be done, it's not the best and first course of action. A man is prescribed lithium to treat bipolar disorder. The nurse is most concerned about lithium toxicity when he notices which of these assessment findings?

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1. The patient states he had a manic episode a week ago
2. The patient states he has been having diarrhea every day
3. The patient has a rashy pruritis on his arms and legs
4. The patient presents as severely depressed
5. The patient's lithium level is 1.3 mcg/L - correct answer ✅1. The patient states he had a manic episode a week ago Incorrect - Having a manic episode is not an indication of lithium toxicity. This finding indicates that the lithium is not effective or is not at a therapeutic level.
6. The patient states he has been having diarrhea every day Correct - Persistent diarrhea can lead to dehydration, which can increase the risk of lithium toxicity.
7. The patient has a rashy pruritis on his arms and legs Incorrect - This is not a symptom of lithium toxicity
8. The patient presents as severely depressed Incorrect - Having a depressive episode is not an indication of lithium toxicity. This finding indicates that the lithium is not effective or is not at a therapeutic level.
9. The patient's lithium level is 1.3 mcg/L This is within the therapeutic range of lithium

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A 65 year old man is prescribed Flomax (Tamsulosin) for Benign Prostatic Hyperplasia. The patient lives in an upstairs apartment. The nurse is most concerned about which side effect of Flomax?

1. Hypotension
2. Tachycardia
3. Back Pain
4. Difficulty Urinating - correct answer ✅1. Hypotension Correct - Hypotension can lead to dizziness and a risk for injury to the patient.
5. Tachycardia Tachycardia can be a side effect of Flomax, but is not an immediate safety risk, nor is it a common side effect.
6. Back Pain Back Pain can be a side effect of Floma, but is not a safety risk
7. Difficulty Urinating Dysuria is a symptom of Benign Prostatic Hyperplasia, not a side effect of Flomax

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A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin?

1. Back Pain
2. Fever and Chills
3. Risk for Bleeding
4. Dizziness - correct answer ✅1. Back Pain Incorrect - Back pain, while it can occur, is not an immediate concern
5. Fever and Chills Incorrect - Fever and Chills, while it can occur, is not an immediate concern
6. Risk for Bleeding Correct - A confused patient is at risk for injuring themselves and at risk for hemorrhage should an injury occur
7. Dizziness Incorrect - Dizziness is not a side effect of Heparin A female patient is prescribed metformin for glucose control. The patient is on NPO status pending a diagnostic test. The nurse is most concerned about which side effect of metformin?
8. Diarrhea and Vomiting

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2. Dizziness and Drowsiness
3. Metallic taste
4. Hypoglycemia - correct answer ✅1. Diarrhea and Vomiting Incorrect - While these may occur, the patient is at higher risk for another adverse effect.
5. Dizziness and Drowsiness Incorrect - While these may occur, the patient is at higher risk for another adverse effect.
6. Metallic taste Incorrect - While this may occur, the patient is at higher risk for another adverse effect.
7. Hypoglycemia Correct - The patient is at risk because she is on NPO status and continuing to take an anti-glycemic drug. The nurse is reviewing the lab results of a patient taking lithium for schizoaffective disorder. The lab results show that the blood lithium value is 1.7 mcg/L. What would the nurse take as the priority action?
8. Induce vomiting
9. Hold the next dose of Lithium
10. Administer an anti-emetic

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4. Give the next dose of Lithium - correct answer ✅1. Induce vomiting Incorrect - This may be warranted for a severe lithium toxicity, but would be premature at this point. Gastric lavage may be attempted if the patient presents within one hour of ingestion, and fluids will be given to restore kidney function and promote the clearance of Lithium from the body..
5. Hold the next dose of Lithium Correct - Lithium's therapeutic range is 0.5-1.5mcg/L, and begins toxicity at 1.5mcg/L
6. Administer an anti-emetic Incorrect - While minor toxicity can cause vomiting and nausea, this is not a priority action
7. Give the next dose of Lithium Incorrect - Lithium's therapeutic range is 0.5-1.5mcg/L, and begins toxicity at 1.5mcg/L A patient asks the nurse why they must have a heparin injection. What is the nurse's best response?
8. "Heparin will dissolve clots that you have."
9. "Heparin will reduce the platelets that make your blood clot"
10. "Heparin will work better than warfarin."

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4. "Heparin will prevent new clots from developing." - correct answer ✅1. "Heparin will dissolve clots that you have." Incorrect - Heparin does not do this.
5. "Heparin will reduce the platelets that make your blood clot" Incorrect - Heparin does not do this
6. "Heparin will work better than warfarin." Incorrect - Heparin has a different mechanism of action than warfarin, and a different route of administration, but achieve similar results.
7. "Heparin will prevent new clots from developing." Correct -This is a correct statement. The nurse is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the troponin T value is at 5. ng/mL. Which of these interventions, if not completed already, would take priority over the others?
8. Put the patient in a 90 degree position
9. Check whether the patient is taking diuretics
10. Obtain and attach defibrillator leads
11. Check the patient's last ejection fraction - correct answer ✅1. Put the patient in a 90 degree position

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Incorrect - This position is optimal for helping a patient breathe, but is not the priority action in an emergency situation.

2. Check whether the patient is taking diuretics Incorrect - Diuretics play a role in CHF by decreasing fluid volume, but this patient is likely having an acute myocardial infarction.
3. Obtain and attach defibrillator leads Correct - This patient is undergoing an emergency cardiac event. Normal Troponin T levels are less than 0.2 ng/mL. Ventricular Fibrillation is the cause of death in most cases of deaths due to sudden cardiac arrest. Defibrillation is the most important action to take to prevent death.
4. Check the patient's last ejection fraction Incorrect - Ejection fraction is a test used to gauge the severity of CHF, not an emergency cardiac arrest. A nurse is caring for a patient undergoing a stress test on a treadmill. The patient turns to talk to the nurse. Which of these statements would require the most immediate intervention?
5. "I'm feeling extremely thirsty. I'm going to get some water after this."
6. "I can feel my heart racing."
7. "My shoulder and arm is hurting."
8. "My blood pressure reading is 158/80" - correct answer ✅1. "I'm feeling extremely thirsty. I'm going to get some water after this."

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Incorrect - This does not require immediate intervention. This is a common response to exercise and activity.

2. "I can feel my heart racing." Incorrect - This does not require immediate intervention. This is a common response to exercise and activity.
3. "My shoulder and arm is hurting." Correct - Unilateral arm and shoulder pain is one of the classic symptoms of myocardial ischemia. The stress test should be halted.
4. "My blood pressure reading is 158/80" Incorrect - This does not require immediate intervention. Moderate elevation in blood pressure is a common response to exercise and activity. The nurse is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the BNP (B-type Natriuretic Peptide) value is a 615 pg/ml. What would the nurse take as the priority action?
5. Call a cardiac code and implement emergency measures
6. Check the patient's oxygen saturation
7. Inform the physician that the patient has Congestive Heart Failure Encourage the patient to limit activity - correct answer ✅1. Call a cardiac code and implement emergency measures

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Incorrect - There is no evidence that the patient is undergoing a cardiac arrest.

2. Check the patient's oxygen saturation Correct - An elevated BNP indicates that there is decreased cardiac output. A priority intervention would be to ensure proper oxygenation after an assessment.
3. Inform the physician that the patient has Congestive Heart Failure Incorrect - Although BNP suggests Congestive Heart Failure, it is not used in itself to diagnose CHF. An elevated BNP can also be caused by dysrhythmias or renal disease.
4. Encourage the patient to limit activity Incorrect - This is an intervention that can help treat CHF, but not a priority action at this time. A nurse is caring for a patient after a coronary angiogram. Which of these actions taken by the nursing assistant would most require the nurse's immediate intervention?
5. The nursing assistant fills the patient's pitcher with ice cold drinking water
6. The nursing assistant elevates the head of the bed to 60 degrees for a meal
7. The nursing assistant refills the ice pack laying on the insertion site

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4. The nursing assistant places an extra pillow under the patient's head on request - correct answer ✅1. The nursing assistant fills the patient's pitcher with ice cold drinking water Incorrect - It is recommended to generously hydrate after a coronary angiogram to excrete contrast medium, reducing kidney toxicity
5. The nursing assistant elevates the head of the bed to 60 degrees for a meal Correct - For 3-6 hours after a coronary angiogram (depending on the insertion site), the patient should have their bed no higher than 30 degrees and be on bedrest.
6. The nursing assistant refills the ice pack laying on the insertion site Incorrect - An ice pack or dressing is recommended to be placed on the insertion site to minimize risk of bleeding.
7. The nursing assistant places an extra pillow under the patient's head on request Incorrect - An extra pillow will not violate any post-procedural protocols for coronary angiogram. A man is has been taking lisinopril for CHF. The patient is seen in the emergency room for persistent diarrhea. The nurse is concerned about which side effect of lisinopril?
8. Vertigo

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2. Hypotension
3. Palpitations
4. Nagging, dry cough - correct answer ✅1. Vertigo Incorrect - While this may occur, the patient is at higher risk due to another adverse effect.
5. Hypotension Correct - The patient is particularly at risk for hypotension due to possible dehydration from fluid loss.
6. Palpitations Incorrect - While this may occur, the patient is at higher risk for another adverse effect.
7. Nagging, dry cough Incorrect - While this is a common side effect, the patient is at higher risk for another adverse effect.. The nurse is taking the health history of a patient being treated for sickle cell disease. After being told the patient has severe generalized pain, the nurse expects to note which assessment finding?
8. Severe and persistent diarrhea
9. Intense pain in the toe
10. Yellow-tinged sclera

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4. Headache - correct answer ✅1. Severe and persistent diarrhea Incorrect - This is not a manifestation of sickle cell disease
5. Intense pain in the toe Incorrect - Gout is a manifestation of Polycythemia Vera, in which the there is an overabundance of red blood cells
6. Yellow-tinged sclera Correct - Jaundice is a common clinical finding of sickle cell disease, caused by bilirubin released from damaged or destroyed RBCs
7. Headache Incorrect - While this may occur, it is not indicative or a classic symptom of sickle cell disease. A client with Multiple Sclerosis reports a constant, burning, tingling pain in the shoulders. The nurse anticipates that the physician will order which medication for this type of pain?
8. alprazolam (Xanax)
9. Corticosteroid injection
10. gabapentin (Neurontin)
11. hydrocodone/acetaminophen (Norco) - correct answer ✅1. alprazolam (Xanax) Incorrect - alprazolam is used to reduce anxiety

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2. Corticosteroid injection Incorrect - Corticosteroid injections are used to reduce inflammation in a localized area, often due to joint breakdown. In MS patients it is used to treat acute exacerbations ("flare-ups"), but the symptoms described do not constitute an acute exacerbation.
3. gabapentin (Neurontin) Correct - Anticonvulsants like gabapentin are often the first line of treatment for nerve pain
4. hydrocodone/acetaminophen (Norco) Incorrect - Opioids would not be the appropriate medication to treat nerve pain. Which of these clients is likely to receive sublingual morphine?
5. A 75-year-old woman in a hospice program
6. A 40-year-old man who just had throat surgery
7. A 20-year-old woman with trigeminal neuralgia
8. A 60-year-old man who has a painful incision - correct answer ✅1. A 75- year-old woman in a hospice program Correct - Sublingual morphine is often used in hospice because the patients are unable to swallow, and intravenous access can be painful and not conducive to palliative care.

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2. A 40-year-old man who just had throat surgery Incorrect - Patients who have surgery most likely have an Intravenous line
3. A 20-year-old woman with trigeminal neuralgia Incorrect - Morphine would not be the first choice for nerve pain
4. A 60-year-old man who has a painful incision Incorrect - Although Morphine would be an appropriate medications, there is no indication that it should be administered sublingually In educating clients on ways to manage pain, which topic can be appropriately delegated to a LPN/LVN who will continue under supervision?
5. Acupuncture
6. Guided Imagery
7. Alternating Rest/Activity
8. Over the counter medications - correct answer ✅1. Acupuncture Incorrect - This is outside the nursing scope of practice and requires special training or education
9. Guided Imagery Incorrect - This also requires additional training or education

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3. Alternating Rest/Activity Correct - This is within the nursing scope of practice and within the training and education provided to all nurses. It is safe to use and a standard treatment.
4. Over the counter medications Incorrect - This is outside the nursing scope of practice. A healthcare provider (doctor, nurse practitioner, or physician's assistant) should be consulted before taking over the counter medications. The nurse assesses a patient suspected of having an asthma attack. Which of the following is a common clinical manifestation of this condition?
5. Audible crackles and orthopnea
6. An audible wheeze and use of accessory muscles
7. Audible crackles and use of accessory muscles
8. Audible wheeze and orthopnea - correct answer ✅1. Audible crackles and orthopnea Incorrect - Crackles indicate fluid in the lungs, which is not a cause of asthma. Orthopnea is not associated with asthma.
9. An audible wheeze and use of accessory muscles Correct - Both of these are associated with asthma.
10. Audible crackles and use of accessory muscles

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Incorrect - Crackles indicate fluid in the lungs, which is not a cause of asthma.

4. Audible wheeze and orthopnea Incorrect - Orthopnea is not associated with asthma. The nurse assesses a patient suspected of having meningitis. Which of the following is a common clinical manifestation of this condition?
5. A high WBC count and decreased level of consciousness
6. A high WBC count and manic activity
7. A low WBC count and manic activity
8. A low WBC count and decreased level of consciousness - correct answer ✅1. A high WBC count and decreased level of consciousness Correct - Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness.
9. A high WBC count and manic activity Incorrect - Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness.
10. A low WBC count and manic activity Incorrect - Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness.

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4. A low WBC count and decreased level of consciousness Incorrect - Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness. A patient is being treated in the Neurology Unit for Meningitis. Which of these is a priority assessment for the nurse to make?
5. Assess the patient for nuchal rigidity
6. Determine the patient's past exposure to infectious organisms
7. Check the patient's WBC lab values
8. Monitor for increased lethargy and drowsiness - correct answer ✅1. Assess the patient for nuchal rigidity Incorrect - Although neck stiffness can be a symptom of Meningitis, it is not used to define meningitis, neither is it a sign of further neurological deterioration.
9. Determine the patient's past exposure to infectious organisms Incorrect - Although this is an important part of the history gathering process, and meningitis is most often caused by a viral or bacterial infection, it is not the priority assessment.
10. Check the patient's WBC lab values Incorrect - Although WBCs do rise during an infection like Mengingitis, it is not the priority assessment.