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🩺 NCLEX Masters Quiz |
🩺 NCLEX Masters Quiz
Question 1 of 4
A nurse is caring for a patient with chronic kidney disease. Which dietary choice is most appropriate?
Rationale: Patients with CKD require low-potassium and low-sodium diets. Chicken breast is appropriate, while bananas, potatoes, and ham are high in potassium or sodium and should be limited.
Which patient behavior indicates a correct understanding of insulin glargine administration?
Rationale: Insulin glargine is a long-acting insulin and should be taken consistently once daily at the same time. It must not be mixed with other insulins.
A nurse is performing tracheostomy care. Which action helps reduce the risk of infection?
Rationale: Sterile technique prevents contamination. The inner cannula is often removed for cleaning. The stoma area must be cleaned properly using sterile saline or approved solutions.
What should the nurse include when educating a patient about levothyroxine therapy?
Rationale: Levothyroxine should be taken in the morning on an empty stomach for optimal absorption. Calcium interferes with absorption, and the drug is often required for lifelong therapy.
Which nursing intervention promotes safety for a patient at risk of aspiration?
Rationale: Elevating the head of the bed reduces aspiration risk. Straws may worsen aspiration in some cases, and lying flat after meals is contraindicated.
A nurse is preparing to give oral potassium chloride. Which condition requires withholding the dose?
Rationale: Potassium supplements should be held if the serum level is elevated to avoid risk of hyperkalemia. Normal vitals and nonspecific muscle symptoms do not require withholding.
Which assessment finding suggests early signs of hypoxia?
Rationale: Early hypoxia typically presents as restlessness and increased heart rate. Cyanosis and bradypnea are late signs. Clubbing suggests chronic hypoxia.
A nurse is caring for a patient with a central line. What action reduces the risk of infection?
Rationale: Hand hygiene is the most critical step in preventing central line-associated bloodstream infections (CLABSI). Dressing should be changed per protocol, and sterile saline is used—not tap water.
A nurse is preparing to administer a unit of packed red blood cells. Which action is essential to prevent a transfusion reaction?
Rationale: Proper patient identification is the most critical step in preventing transfusion reactions. Using dextrose fluids or improper warming techniques can cause complications, and blood should not be left at room temperature for extended periods.
A patient who received IV morphine is now unresponsive with shallow respirations. What is the nurse’s priority intervention?
Rationale: Unresponsiveness and shallow breathing following morphine administration suggest opioid overdose. Naloxone reverses opioid effects rapidly. Other actions do not address the root cause and delay life-saving intervention.
Which symptom in a patient with diabetes warrants immediate follow-up?
Rationale: Blurred vision and dizziness may signal hypoglycemia or hyperglycemia with complications like diabetic retinopathy or vascular instability. These symptoms need urgent evaluation. The others may reflect less emergent concerns.
Which instruction is appropriate for a patient using a fentanyl transdermal patch?
Rationale: Heat increases fentanyl absorption and may cause overdose. Patches are typically changed every 72 hours, applied to intact skin, and should be disposed of securely—often by flushing or in approved disposal containers.
A nurse is assessing a patient with suspected appendicitis. Which finding warrants immediate provider notification?
Rationale: Sudden relief followed by abdominal rigidity may indicate rupture of the appendix and onset of peritonitis. This is a surgical emergency. The other findings are consistent with appendicitis but not necessarily emergent.
A nurse is caring for a patient with suspected Clostridium difficile infection. What is the appropriate isolation precaution?
Rationale: C. difficile requires contact precautions. Alcohol-based sanitizers are ineffective, so soap and water must be used for hand hygiene. Airborne and droplet precautions are not necessary for this infection.
A nurse is caring for a patient with a new tracheostomy. Which nursing intervention prevents accidental decannulation?
Rationale: Securing the tracheostomy tube with ties or sutures prevents displacement or accidental removal, especially during initial post-op care. Petroleum jelly is not routinely used. Hourly suctioning risks trauma, and prone positioning compromises airway stability.
A nurse is teaching a patient with iron-deficiency anemia about dietary sources of iron. Which food is most appropriate?
Rationale: Red meat is one of the best sources of heme iron, which is highly absorbable. Plant-based and dairy items provide minimal iron and are less effective for correcting deficiency.
A nurse is monitoring a patient receiving magnesium sulfate for preeclampsia. Which finding requires immediate intervention?
Rationale: Magnesium toxicity may present with loss of deep tendon reflexes. This requires immediate attention and potential reversal with calcium gluconate. Other vitals are within acceptable limits.
Which activity should a nurse discourage in a patient recovering from a detached retina repair?
Rationale: Bending increases intraocular pressure and may disrupt healing of a repaired retina. Positioning, diet modifications, and stool softeners help avoid strain and support recovery.
A nurse is assessing a patient with suspected appendicitis. Which finding warrants immediate provider notification?
Rationale: Sudden relief followed by abdominal rigidity may indicate rupture of the appendix and onset of peritonitis. This is a surgical emergency. The other findings are consistent with appendicitis but not necessarily emergent.
A nurse is caring for a patient with suspected Clostridium difficile infection. What is the appropriate isolation precaution?
Rationale: C. difficile requires contact precautions. Alcohol-based sanitizers are ineffective, so soap and water must be used for hand hygiene. Airborne and droplet precautions are not necessary for this infection.
Which intervention is most appropriate for a patient experiencing chemotherapy-induced nausea?
Rationale: Preemptive administration of antiemetics helps prevent chemotherapy-induced nausea. High-fat foods may worsen nausea, and comfort measures alone don’t replace pharmacologic intervention.
A nurse is teaching fall prevention to an older adult living at home. Which recommendation is most effective?
Rationale: Environmental modifications like removing rugs and improving lighting significantly reduce fall risk. Slipper socks may lack grip, and medication timing or fall-cushioning techniques are not primary strategies.
A nurse is caring for a patient with a history of seizure disorder. Which intervention is most appropriate during a seizure?
Rationale: Turning the patient on their side prevents aspiration, and head protection reduces trauma risk. Inserting objects into the mouth or restraining limbs can cause injury. Upright positioning compromises safety.
A nurse is teaching a patient with celiac disease about dietary restrictions. Which food should be avoided?
Rationale: Whole wheat bread contains gluten, which triggers autoimmune responses in celiac disease. The other listed foods are gluten-free and typically safe if prepared without additives.
A nurse is caring for a patient receiving IV vancomycin. Which finding requires immediate intervention?
Rationale: Vancomycin is nephrotoxic. A drop in urine output may indicate kidney injury and warrants immediate action. Flushing may suggest "red man syndrome" but is typically rate-related. The other findings are less urgent.
A nurse is performing post-op care for a patient after abdominal surgery. Which intervention reduces the risk of pneumonia?Which finding requires immediate action in a patient receiving total parenteral nutrition (TPN)?
Rationale: Severe hyperglycemia is a critical complication of TPN that must be addressed immediately. Redness, modest weight gain, and normal urine output are notable but not emergent in comparison.
A nurse is teaching a patient how to prevent a urinary tract infection (UTI). Which statement indicates effective understanding?
Rationale: Urinating after intercourse helps flush bacteria from the urethra. Adequate hydration, proper hygiene (front to back), and avoiding urine retention reduce UTI risk.
Which lab value in a patient taking lithium requires provider notification?
Rationale: Therapeutic lithium levels range from 0.6–1.2 mEq/L. Levels above 1.5 mEq/L suggest toxicity and require intervention. Other labs are within normal limits.
A nurse observes a client with Alzheimer’s disease wandering into other patients’ rooms. What is the most appropriate response?
Rationale: Gentle redirection preserves dignity and reduces stress. Restraints, sedation, or punitive responses are inappropriate and may worsen confusion or agitation.
A nurse is caring for a patient post-thyroidectomy. Which finding requires immediate attention?
Rationale: Stridor is a high-pitched breath sound that signals airway obstruction, often due to swelling or bleeding after thyroid surgery. It is a medical emergency. Hoarseness and mild pain are expected, and slight swelling is usually monitored.
Which action helps minimize risk of infection when inserting a urinary catheter?
Rationale: Sterile technique is essential for preventing catheter-associated urinary tract infections (CAUTIs). Clean gloves are inadequate, and ointment is not recommended. Speed does not substitute for proper asepsis.
A nurse is reviewing lab results for a patient on enoxaparin therapy. Which finding requires action?
Rationale: Enoxaparin may cause heparin-induced thrombocytopenia (HIT). A platelet count below 100,000/mm³ can signal this adverse effect. The other labs are within acceptable ranges and do not suggest complications.
What is the priority nursing intervention for a patient receiving IV insulin for diabetic ketoacidosis (DKA)?
Rationale: Insulin drives potassium into cells, potentially causing hypokalemia. Monitoring potassium during DKA treatment is critical. Oral fluids, sub-Q insulin, and sodium restriction are not priorities in this emergent situation.
Which dietary recommendation is appropriate for a patient with diverticulosis?
Rationale: A high-fiber diet promotes bowel regularity and prevents complications like diverticulitis. Low-residue diets and elimination of nutritious plant foods are not recommended unless inflammation is present.
A nurse is monitoring a patient on digoxin therapy. Which electrolyte imbalance most increases the risk of digoxin toxicity?
Rationale: Low potassium levels enhance the effects of digoxin and increase the risk of toxicity, including cardiac arrhythmias. Sodium, magnesium, and calcium imbalances are less directly associated with digoxin toxicity.
What is the nurse’s priority assessment after administering a dose of lorazepam IV?
Rationale: Lorazepam is a sedative that can depress the central nervous system and respiratory function. Monitoring consciousness and breathing is essential post-administration. The other assessments are not immediately relevant.
A nurse is caring for a postoperative patient who suddenly develops shortness of breath, chest pain, and tachycardia. What is the nurse’s priority action?
Rationale: Sudden chest pain and respiratory distress following surgery are classic signs of pulmonary embolism—a life-threatening complication. The nurse must immediately support oxygenation and initiate further assessment. Delayed action can result in rapid deterioration.
A nurse is caring for a patient receiving high-dose corticosteroid therapy. Which assessment finding requires immediate intervention?
Rationale: Corticosteroids can cause psychosis and altered mental status, especially at high doses. Confusion and disorientation may signal serious neuropsychiatric effects that must be addressed immediately. Other side effects are expected and manageable.
A nurse is assessing a patient with suspected increased intracranial pressure (ICP). Which combination of findings is most concerning?
Rationale: This triad—bradycardia, hypertension, and irregular respirations—is known as Cushing’s triad and signals late-stage increased ICP. It requires immediate intervention to prevent brain herniation.
A nurse receives a postoperative patient who begins complaining of severe leg pain, swelling, and warmth. What is the most appropriate immediate action?
Rationale: Symptoms suggest possible DVT, a serious postoperative complication. Ambulation and heat may worsen the condition. Provider notification and diagnostic testing are priority.
A nurse is caring for a patient with liver cirrhosis who exhibits confusion, a musty breath odor, and asterixis. What is the nurse’s priority intervention?
Rationale: Confusion, sweet/musty breath odor, and asterixis indicate hepatic encephalopathy. Lactulose is used to reduce ammonia levels, which contributes to altered mental status in liver disease.
A patient receiving IV vancomycin complains of itching, flushing, and facial redness during infusion. What should the nurse do first?
Rationale: Red Man Syndrome is a histamine-mediated reaction related to rapid vancomycin infusion. Slowing the rate is the first action. Discontinuation is not required unless symptoms progress to anaphylaxis.
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