NCLEX RN NEWEST 2024/2025 (3 LATEST VERSIONS) TEST BANK ACTUAL EXAM 2500 QS & AS, Exams of Nursing

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NCLEX RN NEWEST 2024/2025 (3 LATEST

VERSIONS) TEST BANK ACTUAL EXAM

2500 QUESTIONS AND CORRECT

DETAILED ANSWERS WITH

RATIONALES/A GRADE

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?

1. Diarrhea and Vomiting
2. Dizziness and Drowsiness
3. Metallic taste
4. Hypoglycemia - ans1. 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.

3. Metallic taste Incorrect - While this may occur, the patient is at higher risk for another adverse effect.
4. Hypoglycemia Correct - The patient is at risk because she is on NPO status and continuing to take an anti-glycemic drug. 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?
5. Hemoglobin 11 g/dl
6. Platelet of 150,
7. INR of 2.
8. Potassium of 2.7 mEq/L - ans1. Hemoglobin 11 g/dl This is below normal, but a normal female hemoglobin is 12 - 14. There is a more critical lab result.
9. Platelet of 150, This is also below the normal values, but is not the most critical lab result.
10. INR of 2. This is a therapeutic range for a patient who is taking an anticoagulant for atrial fibrillation
11. 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. 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?

1. Vertigo
2. Hypotension
3. Palpitations
4. Nagging, dry cough - ans1. 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.

4. Nagging, dry cough Incorrect - While this is a common side effect, the patient is at higher risk for another adverse effect.. 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?
5. The patient states he had a manic episode a week ago
6. The patient states he has been having diarrhea every day
7. The patient has a rashy pruritis on his arms and legs
8. The patient presents as severely depressed
9. The patient's lithium level is 1.3 mcg/L - ans1. 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.
10. 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.
11. The patient has a rashy pruritis on his arms and legs Incorrect - This is not a symptom of lithium toxicity
12. 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.
13. The patient's lithium level is 1. mcg/L This is within the therapeutic

range of lithium 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 - ans1. 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

3. Risk for Bleeding Correct - A confused patient is at risk for injuring themselves and at risk for hemorrhage should an injury occur
4. Dizziness Incorrect - Dizziness is not a side effect of Heparin A nurse cares for a child that is diagnosed with Hepatitis A. Which of these following precautions would be most important to take to prevent transmission of this infectious disease?
5. Encourage the Hepatitis A vaccine for family members and siblings
6. Use needleless systems if possible, otherwise use careful needle precautionary measures
7. Teach the child and enforce strict and frequent hand washing
8. Teach the child and family the dangers of contaminated food and water - ans1. Encourage the Hepatitis A vaccine for family members and siblings Incorrect - Although this is a valuable point for patient education, this does not take the priority, since the patient is still at risk of transmitting Hepatitis A to others right now.
9. Use needleless systems if possible, otherwise use careful needle precautionary measures Incorrect - Hepatitis A is transmitted through the fecal-oral route.
10. Teach the child and enforce strict and frequent hand washing Correct - Hand washing is the single most effective way to prevent transmission of Hepatitis A. Hepatitis A is a virus transmitted via the oral- fecal route and lives on human hands.
11. Teach the child and family the dangers of contaminated food and water Incorrect - Although this is a valuable teaching point, it is not the priority intervention. A 23-year-old woman is admitted to the infusion clinic after a Multiple

Sclerosis Exacerbation. The physician orders methylprednisolone infusions (Solu-Medrol). The nurse would expect which of the following outcomes after administration of this medication?

1. A decrease in muscle spasticity and involuntary movements
2. A slowed progression of Multiple Sclerosis related plaques
3. A decrease in the length of the exacerbation
4. A stabilization of mood and sleep - ans1. A decrease in muscle spasticity and involuntary movements Incorrect - While muscle spasticity and involuntary movements can be symptoms of MS, a corticosteroid infusion is not meant to directly treat these symptoms.
5. A slowed progression of Multiple Sclerosis related plaques Incorrect - Special drugs like Interferon Beta, Natalizumab, or Glatiramir acetate are used as first-line treatments to slow the progression of MS. While corticosteroids can be used in conjunction with these drugs on a long-term basis, they would not be infused. They would be taken orally.
6. A decrease in the length of the exacerbation Correct - A methylprednisolone infusion is the first line of treatment during an acute exacerbation and is used to decrease the length and severity of a relapse.
7. A stabilization of mood and sleep Incorrect - Some of the frequent side effects of a Methylprednisolone infusion are anxiety, insomnia, and mood swings. A 30 - year old Caucasian woman who works the night shift has been found to have early bone loss and has a high risk for osteomalacia and bone degradation. She asks the nurse exactly why she should take Vitamin D supplements. What is the nurse's best response?
8. "It's a standard part of the overall nutritional treatment for the prevention of osteomalacia"

2. "It helps your intestines absorb calcium, which is important for bone formation."
3. "It stimulates skin cells to produce calcium, which is then released into the bloodstream to be used for bone formation."
4. "Vitamin D supplements should not be taken by someone of your age." - ans1. "It's a standard part of the overall nutritional treatment for the prevention of osteomalacia" Incorrect - While this is true, it doesn't answer the woman's question.
5. "It helps your intestines absorb calcium, which is important for bone formation."

Correct - This is the correct mechanism of action for Vitamin D

3. "It stimulates skin cells to produce calcium, which is then released into the bloodstream to be used for bone formation." Incorrect- This is not the correct mechanism of action for Vitamin D
4. "Vitamin D supplements should not be taken by someone of your age." Incorrect - Vitamin D supplements should be taken for patients who are homebound, institutionalized, or by some other limitations, unable to meet daily requirements. This woman works the night shift, which may limit her ability to absorb Vitamin D naturally. A 45-year old woman is prescribed ropinirole (Requip) for Parkinson's Disease. The patient is living at home with her daughter. The nurse is most concerned about which side effect of ropinirole?
5. Slurred speech
6. Sudden dizziness
7. Masklike facial expression
8. Stooped Posture - ans1. Slurred speech Incorrect - Slurred speech is a common symptom of PD, not a side effect of this drug.
9. Sudden dizziness Correct - Dizziness and orthostatic hypotension are serious adverse effects of this drug that can lead to an increased risk of falls. Ropinirole's drug class is a dopamine agonist, which mimic dopamine in the brain (PD is characterized by a lack of dopamine).
10. Masklike facial expression Incorrect - Masklike facial expression is a common symptom of PD, not a side effect of this drug.
11. Stooped Posture Incorrect - Stooped Posture is a common symptom of PD, not a side effect of this drug.

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 - ans1. 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.

3. Back Pain Back Pain can be a side effect of Floma, but is not a safety risk
4. Difficulty Urinating Dysuria is a symptom of Benign Prostatic Hyperplasia, not a side effect of Flomax 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?
5. alprazolam (Xanax)
6. Corticosteroid injection
7. gabapentin (Neurontin)
8. hydrocodone/acetaminophen (Norco) - ans1. alprazolam (Xanax) Incorrect - alprazolam is used to reduce anxiety
9. 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.
10. gabapentin (Neurontin) Correct - Anticonvulsants like gabapentin are often the first line of treatment for nerve pain
11. hydrocodone/acetaminophen (Norco) Incorrect - Opioids would not be the appropriate medication to treat nerve pain.

A nurse enters a patient's room and finds them unconscious with a rhythmic jerking of all four extremities. The patient is foaming heavily at the mouth. The patient was on seizure precautions and the bedrails are up and padded. What is the nurse's priority action?

1. Administer Lorazepam (Ativan)
2. Turn the patient to his/her side
3. Call the physician
4. Suction the patient - ans1. Administer Lorazepam (Ativan) Incorrect - If a seizure lasts more than 5 minutes, it is called Status epilepticus and can be life-threatening. Physicians will often order anxiolytics or sedatives to treat this condition. However, at this point it would not be appropriate for the nurse to administer this drug.

2. Turn the patient to his/her side Correct - Turning the patient to the side will keep the airway open, which is the first priority
3. Call the physician Incorrect - This would be a priority action after ensuring the patient's safety, or in the case of Status epilepticus
4. Suction the patient Incorrect - This intervention is warranted, but after an assessment of the patient's airway, since forcing a suction catheter into a patient's mouth is a last resort. 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?
5. Initiate cardiopulmonary resuscitation
6. Check for a pulse
7. Ask the woman if she carries an emergency medical kit
8. Stay with the woman until help comes - ans1. Initiate cardiopulmonary resuscitation Incorrect - CPR is premature at this point, and there is another action that can be taken first.
9. 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.
10. 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.

3. Stay with the woman until help comes Incorrect - While this should be done, it's not the best and first course of action. A nurse frequently treats patients in the 72 - hour period after a stroke has occurred. The nurse would be most concerned about which of these assessment findings?
4. INR is 3 seconds long
5. Heart rate is 110 beats per minute
6. Intracranial Pressure is 22 mm/Hg
7. Blood pressure is 140/80 - ans1. INR is 3 seconds long

Incorrect - This is actually within a therapeutic range for clotting times for patients with coagulation risks. A normal INR is .9-1.2 seconds, while a therapeutic INR can be as high as 3.5 seconds.

2. Heart rate is 110 beats per minute Incorrect - While tachycardia is a concern, general tachycardia without other associated symptoms would not pose an immediate danger, and is not of greater priority than the next answer.
3. Intracranial Pressure is 22 mm/Hg Correct - The patient is at greatest risk for an increased ICP resulting from edema 72 hours after a stroke. A target ICP should be less than or equal to 15 - 20 mm/Hg
4. Blood pressure is 140/ Incorrect - Blood pressure is often kept higher than usual following a stroke to maintain perfusion. Systolic BP higher than 180, or diastolic BP higher than 105, would be the upper limit and required intervention. 140/80 would not pose an immediate danger to the patient's health. A nurse in the emergency room receives a patient who had his left elbow fractured in a fight. He had waited 5 hours before coming to the emergency room. His left hand has an unequal radial pulse, is swollen, and is numb and tingling. What is the nurse's priority intervention?
5. Place the patient in a supine position
6. Ask the patient to rate his pain on a scale of 1 to 10.
7. Wrap the fractured area with a snug dressing
8. Start an IV in the other arm. - ans1. Place the patient in a supine position Incorrect - While this may be a beneficial intervention if the arm is also elevated to prevent swelling, this is not a priority intervention.
9. Ask the patient to rate his pain on a scale of 1 to 10. Incorrect - While assessing pain is a part of the 6 P's of neurovascular assessment, the question asks for an intervention based on already

alarming assessment findings.

3. Wrap the fractured area with a snug dressing Incorrect - The assessment findings indicate the patient may have Acute Compartment Syndrome. Causing more external pressure with a dressing will only exacerbate the condition.
4. Start an IV in the other arm. Correct - Starting an IV is a nursing priority prior to emergency surgery. The patient may be in the late stages of Acute Compartment Syndrome and may need a fasciotomy, in which the surgeon relieves pressure by making an incision into the affected area.

A nurse is asked by a patient to describe in layman's terms an overview of the condition called osteomyelitis. What would be the nurse's best response?

1. "Osteomyelitis is a gradual breakdown and weakening of your bones. It's most often age-related."
2. "Osteomyelitis is caused by not having enough Vitamin D, which in turn causes a your bones to be softer and de-mineralized."
3. "Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your bone from outside or inside your body."
4. "This is a question that should be directed to your Healthcare Provider." - ans1. "Osteomyelitis is a gradual breakdown and weakening of your bones. It's most often age-related." Incorrect - This sentence describes osteoporosis
5. "Osteomyelitis is caused by not having enough Vitamin D, which in turn causes a your bones to be softer and de-mineralized." Incorrect - This sentence describes osteomalacia
6. "Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your bone from outside or inside your body." Correct - This appropriately explains osteomyelitis
7. "This is a question that should be directed to your Healthcare Provider." Incorrect - A nurse is qualified to educate the patient on this subject matter A nurse is caring for a female patient 24 hours after a hip fracture. The patient is on bedrest. The nurse knows that which regular assessment or intervention is essential for detecting or preventing the complication of Fat Embolism Syndrome?
8. Performing passive, light, range of motion exercises on the hip as

tolerated.

2. Assess the patient's mental status for drowsiness or sleepiness.
3. Assess the pedal pulse and capillary refill in the toes.
4. Administer a stool softener as ordered - ans1. Performing passive, light, range of motion exercises on the hip as tolerated. Incorrect - Immobilization and prevention of motion is the best way to reduce risk for fat embolism.
5. Assess the patient's mental status for drowsiness or sleepiness. Correct - A decreased Level of Consciousness is the earliest sign of FES, caused by decreased oxygen level.
6. Assess the pedal pulse and capillary refill in the toes.

Incorrect - While assessing pedal pulse is important during a neurovascular assessment, it is not relevant to FES. Capillary refill is the least reliable indicator of poor perfusion

4. Administer a stool softener as ordered Incorrect - While this is an important intervention for patients on bedrest, it is not an intervention relevant to FES 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
8. The nursing assistant places an extra pillow under the patient's head on request - ans1. 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
9. 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.
10. 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.
11. 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 nurse is caring for a patient in the cardiac care unit who is taking bumetanide (Bumex) and is diagnosed with Parkinson's Disease. An unlicensed assistive personnel is assisting with feeding the patient. Which of these foods would the nurse stress for the patient to eat most?

1. Foods containing the least amount of salt
2. Foods containing the most amount of potassium
3. Foods containing the most amount of calories
4. Foods containing the most amount of fiber - ans1. Foods containing the least amount of salt Incorrect - While this is a good practice, in light of the information given, this is not the greatest priority.
5. Foods containing the most amount of potassium

Correct - Bumex is a loop diuretic and can cause hypokalemia. Ensuring potassium is included in the diet is a priority and can directly avoid a hypokalemic crisis.

3. Foods containing the most amount of calories Incorrect - While this is a good practice, in light of the information given, this is not the greatest priority.
4. Foods containing the most amount of fiber Incorrect - While this is a good practice, in light of the information given, this is not the greatest priority. A nurse is caring for a patient scheduled to have cataract surgery. The patient asks why they developed cataracts and how they can prevent it from happening again. What is the nurse's best response?
5. "Age is the biggest factor contributing to cataracts."
6. "Unprotected exposure to UV lights can cause cataracts"
7. "Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts."
8. "Unfortunately, there is really nothing you can do to prevent cataracts, but they are amongst the most easily treated eye conditions." - ans1. "Age is the biggest factor contributing to cataracts." Incorrect - While true, this answer leaves out many other contributing factors to cataracts and does not address prevention.
9. "Unprotected exposure to UV lights can cause cataracts" Incorrect - While true, this answer is not complete
10. "Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts." Correct - This answer covers the most common contributing factors for cataracts and includes preventable risk factors.
11. "Unfortunately, there is really nothing you can do to prevent cataracts,

but they are amongst the most easily treated eye conditions." Incorrect - While most cataracts are age-related cataracts, there are still ways to prevent eye damage and cataract development. 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?

1. "I'm feeling extremely thirsty. I'm going to get some water after this."
2. "I can feel my heart racing."
3. "My shoulder and arm is hurting."

4. "My blood pressure reading is 158/80" - ans1. "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.
5. "I can feel my heart racing." Incorrect - This does not require immediate intervention. This is a common response to exercise and activity.
6. "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.
7. "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. A nurse is caring for a patient who is suspected to have sustained a spinal cord injury. What best describes the overarching principles used to guide the care for this type of condition?
8. Immobilize the cervical area to prevent further injury
9. Monitor the patient's level of consciousness to prevent neurologic deterioration
10. Help the patient with activities of daily living and provide emotional and physical support to help them adjust to their injury
11. Facilitate tissue perfusion to the spinal cord while maintaining airway and breathing - ans1. Immobilize the cervical area to prevent further injury Incorrect - While this is an essential part of caring for a spinal cord injury, it does not adequately describe guiding principles for a complete plan of care
12. Monitor the patient's level of consciousness to prevent neurologic deterioration Incorrect - While this is an essential part of caring for a spinal cord injury, it does not adequately describe guiding principles for a complete plan of care

3. Help the patient with activities of daily living and provide emotional and physical support to help them adjust to their injury Incorrect - These are important in the later stages of a spinal cord injury after the patient has been stabilized, but at this point would be premature.
4. Facilitate tissue perfusion to the spinal cord while maintaining airway and breathing Correct - Maintaining airway, breathing, and circulation is both essential and guides the overall plan of care for a patient with a spinal cord injury. A nurse is caring for a patient with a cast on the right leg. Which of these assessment findings would most concern the nurse?

1. The capillary refill time is 2 seconds
2. The patient complains of itching and discomfort
3. The cast has a foul-smelling odor
4. The patient is on antibiotics - ans1. The capillary refill time is 2 seconds Incorrect - A capillary refill time of 2 seconds is within normal limits. Capillary refill is the least reliable method of assessing neurovascular integrity.
5. The patient complains of itching and discomfort Incorrect - This is a common effect of a cast
6. The cast has a foul-smelling odor Correct - A foul-smelling odor is a sign of infection or a pressure ulcer within the cast. Other symptoms include a feeling of warmth, tightness and pain.
7. The patient is on antibiotics Incorrect - This is not an assessment finding and is not relevant to this situation. A nurse is educating a patient about bimatoprost (Lumigan) eyedrops for the treatment of Glaucoma. Which of the following indicates that the patient has a correct understanding of the expected outcomes following treatment?
8. "I should be experiencing less blurriness in my central field of vision"
9. "This medication won't help my vision at all, but will keep it from getting worse."
10. "My peripheral vision should be increasing back to its normal state, but will take a few weeks to do so."
11. "This medication will help my eye restore intraocular fluid and increase intraocular pressure" - ans1. "I should be experiencing less blurriness in my central field of vision" Incorrect - Cataracts cause blurriness in the central field of vision, while Glaucoma presents as loss of the field of