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NCLEX 2026-RN Exam
Flashcards: Nursing
Procedures and Patient
Safety, Exams of
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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?
- Increase in Forced Vital Capacity (FVC)
- A narrowed chest cavity
- Clubbed fingers
4. An increased risk of cardiac failure - ANSWERS -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.
- A narrowed chest cavity A patient with COPD often presents with a 'barrel chest,' which is seen as a widened chest cavity. Incorrect.
- Clubbed fingers - CORRECT Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels.
- 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?
- Melena
- Nausea
- Hernia
4. Hyperthermia - ANSWERS -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.
4. "I'm going to start trying to lose some weight." - ANSWERS -
- "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.
- "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.
- "I won't be drinking tea or coffee or eating chocolate any more." Incorrect - This is a correct verbalization of health promotion for GERD.
- "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?
- Start a large-bore IV in the patient's arm
- Ask the patient for a stool sample
- Prepare to insert an NG Tube
- Administer intramuscular morphine sulphate as ordered -
ANSWERS -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.
- 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.
- 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.
- Administer intramuscular morphine sulphate as ordered 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?
- Hemoglobin 11 g/dl
- Platelet of 150,
- Continue the infusion, since these are normal findings -
ANSWERS -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.
- Notify Physician This is not the first action the nurse should take.
- Elevate the patient's legs This would help with the edema, but is not a priority
- 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?
- They must inform household members of their condition
- They must take their medications exactly as prescribed
- They must abstain from substance use
4. They must avoid large crowds - ANSWERS -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.
- 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.
- They must abstain from substance use Incorrect - While substance use should be discouraged, using safe practices with needles can prevent transmission of HIV.
- 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?
- Initiate cardiopulmonary resuscitation
- Check for a pulse
- Ask the woman if she carries an emergency medical kit
4. Stay with the woman until help comes - ANSWERS -1. Initiate
cardiopulmonary resuscitation Incorrect - CPR is premature at this point, and there is another action that can be taken first.
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.
- 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.
- The patient has a rashy pruritis on his arms and legs Incorrect - This is not a symptom of lithium toxicity
- 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.
- The patient's lithium level is 1.3 mcg/L This is within the therapeutic range of lithium 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?
- Hypotension
- Tachycardia
- Back Pain
4. Difficulty Urinating - ANSWERS -1. Hypotension
Correct - Hypotension can lead to dizziness and a risk for injury to the patient.
- Tachycardia Tachycardia can be a side effect of Flomax, but is not an immediate safety risk, nor is it a common side effect.
- Back Pain Back Pain can be a side effect of Floma, but is not a safety risk
- Difficulty Urinating Dysuria is a symptom of Benign Prostatic Hyperplasia, not a side effect of Flomax 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?
- Back Pain
- Fever and Chills
- Risk for Bleeding
4. Dizziness - ANSWERS -1. Back Pain
Incorrect - Back pain, while it can occur, is not an immediate concern
- Metallic taste Incorrect - While this may occur, the patient is at higher risk for another adverse effect.
- 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?
- Induce vomiting
- Hold the next dose of Lithium
- Administer an anti-emetic
4. Give the next dose of Lithium - ANSWERS -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..
- Hold the next dose of Lithium Correct - Lithium's therapeutic range is 0.5-1.5mcg/L, and begins toxicity at 1.5mcg/L
- Administer an anti-emetic Incorrect - While minor toxicity can cause vomiting and nausea, this is not a priority action
- 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?
- "Heparin will dissolve clots that you have."
- "Heparin will reduce the platelets that make your blood clot"
- "Heparin will work better than warfarin."
- "Heparin will prevent new clots from developing." -
ANSWERS -1. "Heparin will dissolve clots that you have."
Incorrect - Heparin does not do this.
- "Heparin will reduce the platelets that make your blood clot" Incorrect - Heparin does not do this
- "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.
- 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?
- "I'm feeling extremely thirsty. I'm going to get some water after this."
- "I can feel my heart racing."
- "My shoulder and arm is hurting."
4. "My blood pressure reading is 158/80" - ANSWERS -1. "I'm
feeling extremely thirsty. I'm going to get some water after this." Incorrect - This does not require immediate intervention. This is a common response to exercise and activity.
- "I can feel my heart racing." Incorrect - This does not require immediate intervention. This is a common response to exercise and activity.
- "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.
- "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?
- Call a cardiac code and implement emergency measures
- Check the patient's oxygen saturation
- Inform the physician that the patient has Congestive Heart Failure
Encourage the patient to limit activity - ANSWERS -1. Call a
cardiac code and implement emergency measures Incorrect - There is no evidence that the patient is undergoing a cardiac arrest.
- 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.
- 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.
- 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.
- 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?
- Vertigo
- Hypotension
- Palpitations
4. Nagging, dry cough - ANSWERS -1. Vertigo
Incorrect - While this may occur, the patient is at higher risk due to another adverse effect.
- Hypotension Correct - The patient is particularly at risk for hypotension due to possible dehydration from fluid loss.
- Palpitations
Incorrect - While this may occur, the patient is at higher risk for another adverse effect.
- 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?
- Severe and persistent diarrhea
- Intense pain in the toe
- Yellow-tinged sclera
4. Headache - ANSWERS -1. Severe and persistent diarrhea
Incorrect - This is not a manifestation of sickle cell disease
- Intense pain in the toe Incorrect - Gout is a manifestation of Polycythemia Vera, in which the there is an overabundance of red blood cells
- Yellow-tinged sclera Correct - Jaundice is a common clinical finding of sickle cell disease, caused by bilirubin released from damaged or destroyed RBCs
