Question 1
PharmacologyA patient is prescribed digoxin 0.25 mg PO daily for heart failure. Before administering the medication, what is the MOST important assessment the nurse should perform?
✅ Correct Answer: B
Rationale: Before administering digoxin (a cardiac glycoside), the nurse MUST assess the apical pulse for 1 full minute. If the pulse is <60 bpm in adults, HOLD the medication and notify the provider due to risk of bradycardia and heart block.
Why other answers are wrong:
- A) Blood pressure monitoring is important but NOT the priority for digoxin
- C) Respiratory rate is not directly affected by digoxin
- D) Pupil response is unrelated to digoxin administration
🎯 NCLEX Tip: For cardiac medications, always think "What vital sign does this drug affect?" Digoxin = HEART RATE (pulse check required).
Question 2
PharmacologyA patient receiving warfarin (Coumadin) therapy should avoid which of the following foods?
✅ Correct Answer: C
Rationale: Warfarin is a Vitamin K antagonist. Foods HIGH in Vitamin K (spinach, kale, broccoli, Brussels sprouts) can DECREASE warfarin effectiveness, increasing clot risk. Patients should maintain CONSISTENT Vitamin K intake (not eliminate, but stay consistent).
Why other answers are wrong:
- A) Bananas/oranges are high in potassium (relevant for ACE inhibitors, not warfarin)
- B) Dairy/eggs don't significantly interact with warfarin
- D) Meat doesn't affect warfarin (protein is fine)
🎯 NCLEX Tip: Warfarin + Vitamin K = ANTAGONIST relationship. Green leafy vegetables = HIGH Vitamin K.
Question 3
PharmacologyA patient with type 2 diabetes is prescribed metformin (Glucophage). The nurse should teach the patient to report which side effect immediately?
✅ Correct Answer: A
Rationale: Muscle pain and weakness can indicate LACTIC ACIDOSIS, a rare but life-threatening complication of metformin. Other signs include hyperventilation, abdominal pain, and extreme fatigue. This requires IMMEDIATE discontinuation and emergency treatment.
Why other answers are wrong:
- B) Mild GI upset (nausea, diarrhea) is COMMON and expected with metformin
- C) Increased urination is not a metformin side effect (think diabetes itself or SGLT2 inhibitors)
- D) Dry mouth is unrelated to metformin
🎯 NCLEX Tip: Metformin's serious complication = LACTIC ACIDOSIS. Watch for muscle pain, SOB, slow heart rate.
Question 4
PharmacologyA patient is receiving an IV infusion of heparin. Which laboratory value should the nurse monitor to evaluate the effectiveness of the medication?
✅ Correct Answer: D
Rationale: aPTT (activated partial thromboplastin time) is the lab test used to monitor IV HEPARIN therapy. Therapeutic range is 1.5-2.5 times the control value (typically 60-80 seconds). aPTT measures intrinsic pathway of coagulation.
Why other answers are wrong:
- A) Platelet count monitors for HIT (heparin-induced thrombocytopenia), not effectiveness
- B) INR monitors WARFARIN (oral anticoagulant), not heparin
- C) H&H monitors for bleeding complications, not drug effectiveness
🎯 NCLEX Tip: Remember: HEPARIN = aPTT | WARFARIN = INR/PT. Don't confuse these!
Question 5
PharmacologyA patient taking lisinopril (Zestril) for hypertension develops a persistent dry cough. What should the nurse do FIRST?
✅ Correct Answer: B
Rationale: Persistent dry cough is a COMMON side effect of ACE inhibitors (drugs ending in -pril). It's caused by bradykinin buildup. The nurse should notify the provider, who may switch the patient to an ARB (angiotensin receptor blocker like losartan), which doesn't cause cough.
Why other answers are wrong:
- A) Cough syrup won't help drug-induced cough (needs medication change)
- C) Fluids won't resolve ACE inhibitor cough
- D) Don't hold medication without provider order (BP control needed)
🎯 NCLEX Tip: ACE inhibitors (-pril) = DRY COUGH (common, non-dangerous). Switch to ARB (-sartan) if intolerable.
Question 6
PharmacologyA patient receiving morphine sulfate for post-operative pain has a respiratory rate of 8 breaths/minute. What is the nurse's PRIORITY action?
✅ Correct Answer: C
Rationale: Respiratory rate <12 breaths/minute indicates OPIOID-INDUCED RESPIRATORY DEPRESSION — a life-threatening emergency. Naloxone (Narcan) is the opioid antagonist that reverses respiratory depression immediately. ABC priority: AIRWAY/BREATHING comes first!
Why other answers are wrong:
- A) Monitoring is inadequate when respiratory rate is critically low (patient could stop breathing)
- B) Decreasing dose doesn't reverse existing respiratory depression
- D) You should notify provider AFTER giving naloxone (don't delay life-saving treatment)
🎯 NCLEX Tip: Opioid overdose = Naloxone IMMEDIATELY. Respiratory rate <12 = DANGER ZONE.
Question 7
PharmacologyA patient with hypothyroidism is prescribed levothyroxine (Synthroid). When should the nurse instruct the patient to take this medication?
✅ Correct Answer: A
Rationale: Levothyroxine should be taken in the MORNING on an EMPTY STOMACH (30-60 minutes before breakfast) for maximum absorption. Food, calcium, and iron supplements decrease absorption.
Why other answers are wrong:
- B) Food decreases absorption significantly
- C) Bedtime dosing can cause insomnia (thyroid hormone increases energy)
- D) Milk/antacids contain calcium which blocks absorption
🎯 NCLEX Tip: Levothyroxine = Morning + Empty stomach + Wait 30 min before eating.
Question 8
PharmacologyA patient taking furosemide (Lasix) should be monitored for which electrolyte imbalance?
✅ Correct Answer: D
Rationale: Furosemide (Lasix) is a LOOP DIURETIC that causes potassium LOSS. Patients are at risk for HYPOKALEMIA (low potassium), which can cause cardiac arrhythmias, muscle weakness, and cramping. Monitor potassium levels and teach patients to eat potassium-rich foods (bananas, oranges, potatoes).
Why other answers are wrong:
- A) Loop diuretics WASTE potassium (not retain it)
- B) Sodium is also lost, causing HYPOnatremia (not hyper)
- C) Calcium levels aren't significantly affected by furosemide
🎯 NCLEX Tip: Loop diuretics (Lasix, Bumex) = WASTE potassium. Potassium-sparing diuretics (spironolactone) = RETAIN potassium.
Question 9
PharmacologyA patient is prescribed prednisone 40 mg PO daily for an acute asthma exacerbation. The nurse should teach the patient to take this medication:
✅ Correct Answer: B
Rationale: Corticosteroids like prednisone should be taken WITH FOOD or MILK to minimize GI irritation and ulcer risk. Steroids increase stomach acid production and can cause gastric bleeding if taken on empty stomach.
Why other answers are wrong:
- A) Empty stomach increases GI upset and ulcer risk
- C) Bedtime dosing can cause insomnia (steroids are stimulating)
- D) Grapefruit juice interacts with many medications but isn't recommended here
🎯 NCLEX Tip: Steroids = Take with FOOD + Morning dose (avoid insomnia) + NEVER stop abruptly (taper needed).
Question 10
PharmacologyA patient receiving IV potassium chloride (KCl) complains of burning pain at the IV site. What should the nurse do FIRST?
✅ Correct Answer: A
Rationale: Burning pain during IV potassium infusion indicates possible INFILTRATION or PHLEBITIS. Potassium is highly irritating to tissues and can cause severe damage if infiltrated. STOP the infusion IMMEDIATELY, assess the site, and notify the provider.
Why other answers are wrong:
- B) Slowing the rate doesn't address infiltration/phlebitis risk
- C) Don't apply heat before assessing for infiltration
- D) Documentation is important but NOT the first action (patient safety first!)
🎯 NCLEX Tip: IV potassium = NEVER give IV push (fatal arrhythmia risk). Must dilute + infuse slowly via pump. Burning = STOP!
Question 11
Medical-SurgicalA patient with COPD has an oxygen saturation of 88% on room air. What is the MOST appropriate oxygen delivery device?
✅ Correct Answer: C
Rationale: COPD patients are HYPOXIC DRIVE breathers — their respiratory drive is triggered by LOW oxygen (not high CO2 like normal). High-flow oxygen can SUPPRESS their drive to breathe! Use LOW-FLOW oxygen (1-3 L/min nasal cannula) with target SpO2 88-92% (NOT 95%+).
Why other answers are wrong:
- A) Non-rebreather = TOO MUCH oxygen for COPD (can stop breathing!)
- B) 8 L/min is too high for COPD patients
- D) 50% FiO2 is excessive for COPD (start low, titrate up slowly)
🎯 NCLEX Tip: COPD = LOW-flow O2 (1-3 L/min). Target SpO2 = 88-92% (NOT 95%+). Too much O2 = respiratory arrest!
Question 12
Medical-SurgicalA patient with heart failure has +3 pitting edema in both ankles. Which dietary instruction is MOST important?
✅ Correct Answer: B
Rationale: Heart failure patients MUST restrict sodium (2 grams/day or less) because sodium causes fluid retention, worsening edema and heart workload. Teach patients to avoid processed foods, canned soups, deli meats, and added salt.
Why other answers are wrong:
- A) Protein intake isn't the primary concern for edema
- C) Dairy restriction isn't necessary (unless lactose intolerant)
- D) INCREASING fluids worsens heart failure! Should RESTRICT fluids (1.5-2 L/day max)
🎯 NCLEX Tip: Heart failure = Low sodium + Fluid restriction + Daily weights + Elevate legs.
Question 13
Medical-SurgicalA patient with pneumonia has crackles (rales) in both lung bases. What position should the nurse place the patient in to promote optimal breathing?
Your Answer:
Correct Answer: B
Rationale: High-Fowler's position (sitting upright at 60-90 degrees) uses gravity to reduce pressure on the diaphragm, allowing maximum lung expansion and easier breathing. This is the best position for patients with respiratory distress, pneumonia, or fluid in lungs.
Why other answers are wrong:
- A) Supine position makes breathing HARDER (diaphragm pushes up on lungs)
- C) Trendelenburg (head down) worsens respiratory distress significantly
- D) Lateral position doesn't optimize lung expansion like upright positioning
NCLEX Tip: Respiratory distress = Sit them UP! High-Fowler's = best oxygenation position.
Question 14
Medical-SurgicalA patient with diabetes mellitus has a blood glucose of 450 mg/dL and is lethargic. The nurse notes fruity breath odor. What is the PRIORITY nursing action?
Your Answer:
Correct Answer: C
Rationale: This patient has signs of DIABETIC KETOACIDOSIS (DKA): high glucose, lethargy, fruity breath (acetone). DKA is life-threatening! Priority = establish IV access for RAPID fluid resuscitation and IV regular insulin. Dehydration and acidosis must be corrected STAT.
Why other answers are wrong:
- A) Orange juice = for HYPOglycemia! This patient is HYPERglycemic (450 mg/dL)
- B) Checking ketones confirms DKA but isn't the PRIORITY action (treat first!)
- D) NPH is LONG-acting insulin; DKA needs REGULAR (short-acting) insulin IV
NCLEX Tip: DKA = HIGH glucose + Fruity breath + Dehydration. Treatment = IV fluids + IV REGULAR insulin + Potassium.
Question 15
Medical-SurgicalA patient is admitted with acute pancreatitis. Which laboratory value would the nurse expect to be elevated?
Your Answer:
Correct Answer: B
Rationale: Acute pancreatitis causes ELEVATED serum AMYLASE and lipase (pancreatic enzymes leak into bloodstream). Amylase rises within 2-12 hours and is a key diagnostic marker. Lipase stays elevated longer and is more specific.
Why other answers are wrong:
- A) Calcium DECREASES in pancreatitis (hypocalcemia due to fat necrosis)
- C) Hemoglobin isn't directly affected by pancreatitis
- D) Sodium may decrease but isn't the diagnostic marker
NCLEX Tip: Pancreatitis = Elevated AMYLASE + Lipase. Also think: NPO status + NG tube + pain control.
Question 16
Medical-SurgicalA patient is receiving a blood transfusion. Fifteen minutes after starting, the patient develops fever (101.2°F), chills, and back pain. What should the nurse do FIRST?
Your Answer:
Correct Answer: B
Rationale: Fever, chills, and back pain during transfusion indicate ACUTE HEMOLYTIC REACTION (most serious transfusion reaction, can be fatal). STOP transfusion IMMEDIATELY, keep IV open with normal saline (new tubing), notify provider, monitor urine output (kidney damage risk).
Why other answers are wrong:
- A) Slowing rate doesn't stop the reaction! Must STOP completely
- C) Don't give medications before stopping transfusion (delay treatment)
- D) Vital signs can be taken AFTER stopping transfusion (patient safety first!)
NCLEX Tip: Transfusion reaction = STOP + Keep vein open with NS (new tubing) + Notify MD + Monitor urine output.
Question 17
Medical-SurgicalA patient with cirrhosis has ascites. The nurse should monitor for which complication?
Your Answer:
Correct Answer: B
Rationale: Severe ascites (fluid accumulation in abdomen) pushes UP on the diaphragm, restricting lung expansion and causing RESPIRATORY DISTRESS. This is a serious complication requiring paracentesis (fluid removal). Also monitor abdominal girth daily.
Why other answers are wrong:
- A) Cirrhosis typically causes HYPOtension (not hypertension)
- C) Hyperglycemia isn't directly related to ascites
- D) Tachycardia is more common than bradycardia
NCLEX Tip: Ascites complications = Respiratory distress + Infection (spontaneous bacterial peritonitis) + Hernias. Measure abdominal girth daily!
Question 18
Medical-SurgicalA patient is scheduled for surgery in 2 hours. Which finding should the nurse report to the surgeon IMMEDIATELY?
Your Answer:
Correct Answer: B
Rationale: ASPIRIN is an antiplatelet drug that increases bleeding risk for 7-10 days after last dose! Taking aspirin 3 days ago means the patient has INCREASED BLEEDING RISK during surgery. Surgeon needs to know IMMEDIATELY to decide if surgery should be postponed.
Why other answers are wrong:
- A) BP 130/84 is slightly elevated but acceptable for surgery
- C) 10 hours NPO is appropriate (meets NPO requirements)
- D) Temperature is normal (no infection)
NCLEX Tip: Pre-op assessment = Report: Aspirin use (bleeding risk), fever/infection, pregnancy, loose teeth, allergies.
Question 19
PediatricsA 3-year-old child with croup is admitted with a barking cough and inspiratory stridor. What is the PRIORITY nursing intervention?
Your Answer:
Correct Answer: B
Rationale: Croup causes upper airway inflammation and edema. COOL MIST humidified oxygen helps reduce airway swelling, improve oxygenation, and ease breathing. This is PRIORITY for maintaining airway (ABC!). May also give racemic epinephrine nebulizer and dexamethasone.
Why other answers are wrong:
- A) Croup is VIRAL (not bacterial) — antibiotics don't help
- C) Fluids are important but AIRWAY comes first (ABC priority)
- D) Chest PT is for mobilizing secretions (not appropriate for airway swelling)
NCLEX Tip: Croup = Barking cough + Stridor + Cool mist + Racemic epinephrine + Dexamethasone. Keep child calm!
Question 20
PediatricsA 6-month-old infant is receiving their immunizations. Which vaccine should the nurse NEVER administer to a child with a severe egg allergy?
Your Answer:
Correct Answer: B
Rationale: Most influenza vaccines are grown in EGGS and contain egg protein. Patients with severe egg allergy may have anaphylactic reaction. Now there are egg-free flu vaccines available, but traditional flu shots are contraindicated with severe egg allergy.
Why other answers are wrong:
- A) DTaP doesn't contain egg protein (safe for egg allergy)
- C) Hepatitis B is egg-free (safe)
- D) Rotavirus vaccine is oral and egg-free (safe)
NCLEX Tip: Egg allergy = Avoid traditional FLU vaccine. Also avoid MMR if severe egg allergy (contains minimal egg protein).
Question 21
PediatricsA toddler is admitted with suspected epiglottitis. Which nursing action is CONTRAINDICATED?
Your Answer:
Correct Answer: B
Rationale: NEVER examine the throat or use a tongue depressor with suspected epiglottitis! This can cause complete airway obstruction and respiratory arrest. Keep child calm, upright, don't agitate them. Let them sit on parent's lap. Emergency intubation setup must be ready.
Why other answers are wrong:
- A) Upright position is CORRECT (helps keep airway open)
- C) Continuous O2 monitoring is appropriate
- D) Emergency equipment is essential (airway can close suddenly)
NCLEX Tip: Epiglottitis = NO throat exam + Keep calm + Upright position + 4 D's (Drooling, Dysphagia, Dysphonia, Distress).
Question 22
PediatricsA child with iron deficiency anemia is prescribed ferrous sulfate liquid. The nurse should teach the parents to:
Your Answer:
Correct Answer: B
Rationale: Liquid iron can STAIN TEETH permanently. Use a STRAW or dropper placed at back of mouth, then rinse mouth with water after administration. Also teach: give with vitamin C (orange juice) for better absorption, expect dark/black stools (normal), give on empty stomach if tolerated.
Why other answers are wrong:
- A) Milk DECREASES iron absorption (calcium blocks it)
- C) Empty stomach is better for absorption (give with OJ, not milk/food)
- D) Antacids BLOCK iron absorption
NCLEX Tip: Iron supplement = Straw (prevent staining) + Vitamin C (increase absorption) + Empty stomach + Black stools are normal.
Question 23
PediatricsA 5-year-old with acute glomerulonephritis has periorbital edema and dark "cola-colored" urine. Which dietary restriction is MOST important?
Your Answer:
Correct Answer: C
Rationale: Acute glomerulonephritis causes sodium and fluid retention → edema and hypertension. SODIUM RESTRICTION is crucial to prevent worsening edema and control blood pressure. Also monitor: I&O, daily weights, blood pressure, and protein in urine.
Why other answers are wrong:
- A) Calcium restriction isn't needed for glomerulonephritis
- B) Severe protein restriction not typically needed (mild restriction if nephrotic syndrome)
- D) Carbohydrates don't need restriction
NCLEX Tip: Glomerulonephritis = Recent strep infection + Cola-colored urine + Edema + HTN + Restrict sodium & fluids.
Question 24
PediatricsA child with nephrotic syndrome has massive proteinuria and edema. The nurse should monitor for which complication?
Your Answer:
Correct Answer: B
Rationale: Nephrotic syndrome causes massive protein loss, including IMMUNOGLOBULINS (antibodies). This leaves children IMMUNOCOMPROMISED with HIGH INFECTION RISK. Also monitor for peritonitis, pneumonia, and cellulitis. Protein loss also causes hypoalbuminemia → severe edema.
Why other answers are wrong:
- A) HYPOkalemia is more common than hyperkalemia
- C) Hyperglycemia isn't a direct complication
- D) Constipation isn't a priority complication
NCLEX Tip: Nephrotic syndrome = Proteinuria + Hypoalbuminemia + Edema + Infection risk + Hyperlipidemia.
Question 25
PediatricsA child with leukemia is receiving chemotherapy. Which snack should the nurse AVOID offering?
Your Answer:
Correct Answer: B
Rationale: Chemotherapy causes NEUTROPENIA (low WBC = immunocompromised). Patients need NEUTROPENIC DIET: NO fresh fruits/vegetables (may carry bacteria), NO undercooked foods, NO unpasteurized products. Fresh fruit salad has bacteria risk! Only cooked/canned fruits allowed.
Why other answers are wrong:
- A) Crackers and cheese are safe (no raw/fresh produce)
- C) Pudding is safe (pasteurized dairy)
- D) Cooked pasta is safe
NCLEX Tip: Neutropenic precautions = NO fresh fruits/veggies + NO flowers/plants in room + NO sick visitors.
Question 26
Maternal-NewbornA pregnant woman at 32 weeks gestation has a blood pressure of 160/110 mmHg, 3+ proteinuria, and reports a severe headache. What is the PRIORITY nursing action?
Your Answer:
Correct Answer: B
Rationale: This patient has SEVERE PREECLAMPSIA (BP >160/110 + proteinuria + symptoms). PRIORITY = Administer magnesium sulfate IV to prevent SEIZURES (eclampsia). Magnesium sulfate is a CNS depressant that prevents seizures. Also: maintain seizure precautions, dim lights, limit stimulation.
Why other answers are wrong:
- A) Left lateral position is good but not the PRIORITY (prevents seizures first!)
- C) DTRs are assessed BEFORE and DURING mag sulfate therapy (important but not first)
- D) Delivery may be needed but stabilize with magnesium first
NCLEX Tip: Severe preeclampsia = Magnesium sulfate (prevent seizures) + Monitor DTRs + Have calcium gluconate ready (antidote).
Question 27
Maternal-NewbornA patient receiving magnesium sulfate for preeclampsia has absent deep tendon reflexes and a respiratory rate of 10 breaths/minute. What is the nurse's PRIORITY action?
Your Answer:
Correct Answer: B
Rationale: Absent DTRs and respiratory rate <12 indicate MAGNESIUM TOXICITY (CNS depression). STOP infusion IMMEDIATELY! Prepare to give calcium gluconate (antidote). Magnesium toxicity can cause respiratory arrest and cardiac arrest.
Why other answers are wrong:
- A) Continuing monitoring is dangerous (patient could stop breathing!)
- C) IV fluids don't reverse magnesium toxicity
- D) Stop infusion FIRST, then notify provider (don't delay treatment)
NCLEX Tip: Magnesium toxicity signs = Absent DTRs + RR <12 + Decreased urine output. Antidote = Calcium gluconate.
Question 28
Maternal-NewbornA newborn's Apgar score at 1 minute is 6 (heart rate 110, slow respiratory effort, some flexion, grimace, pink body/blue extremities). What is the MOST appropriate nursing action?
Your Answer:
Correct Answer: B
Rationale: Apgar score 4-6 = MODERATELY DEPRESSED newborn. Provide gentle stimulation (drying, rubbing back) and OXYGEN support to improve respiratory effort and oxygenation. Reassess at 5 minutes. Score should improve with intervention.
Why other answers are wrong:
- A) Score of 6 needs INTERVENTION (not routine care)
- C) Chest compressions only if heart rate <60 despite ventilation (this baby's HR = 110)
- D) Warmer is good but doesn't address respiratory effort (needs oxygen/stimulation)
NCLEX Tip: Apgar scoring: 7-10 = normal, 4-6 = moderate depression (stimulate + O2), 0-3 = severe (resuscitate!).
Question 29
Maternal-NewbornA breastfeeding mother reports her nipples are cracked and sore. What is the BEST nursing advice?
Your Answer:
Correct Answer: C
Rationale: Cracked/sore nipples are almost always caused by POOR LATCH or positioning. Teaching proper latch technique is the BEST solution (baby's mouth should cover most of areola, not just nipple). Also: air dry nipples, express colostrum/milk on nipples (healing properties), use lanolin if needed.
Why other answers are wrong:
- A) Don't stop breastfeeding! Fix the latch problem instead
- B) Lanolin helps but doesn't FIX the cause (poor latch)
- D) Limiting time doesn't address the problem (latch technique is key)
NCLEX Tip: Breastfeeding problems → Check LATCH first! Sore nipples = poor latch. Engorgement = nurse frequently.
Question 30
Maternal-NewbornA postpartum patient has a firm uterine fundus displaced to the right of the midline. What is the MOST likely cause?
Your Answer:
Correct Answer: B
Rationale: A FULL BLADDER pushes the uterus up and to the RIGHT (or left). This is a common postpartum finding. Solution: have patient void (or catheterize if unable). After bladder emptying, fundus should return to midline and appropriate height.
Why other answers are wrong:
- A) Normal involution = fundus at MIDLINE (not displaced)
- C) Atony = BOGGY/soft fundus (this one is FIRM)
- D) Retained placenta causes soft, high fundus with heavy bleeding
NCLEX Tip: Fundus displaced = FULL BLADDER. Boggy fundus = ATONY (massage + Pitocin). Fundal height: at umbilicus → ↓1 cm/day.
Question 31
Maternal-NewbornA newborn has a white, cheesy coating on the skin. The nurse should document this finding as:
Your Answer:
Correct Answer: B
Rationale: VERNIX CASEOSA is the white, cheesy, protective coating on newborn skin (especially full-term babies). It's NORMAL and protects skin in utero. Don't wash it off immediately — massage into skin or let it absorb (has moisturizing and antimicrobial properties).
Why other answers are wrong:
- A) Milia = white pinpoint facial bumps (blocked sebaceous glands)
- C) Lanugo = fine, downy body hair (more common in preterm babies)
- D) Acrocyanosis = bluish hands/feet (normal in first 24 hours)
NCLEX Tip: Normal newborn findings = Vernix (white coating), Lanugo (fine hair), Milia (white bumps), Acrocyanosis (blue hands/feet).
Question 32
Maternal-NewbornA newborn's mother is Rh-negative and the baby is Rh-positive. The mother did NOT receive RhoGAM during pregnancy. What should the nurse administer within 72 hours postpartum?
Your Answer:
Correct Answer: B
Rationale: Rh-negative mother + Rh-positive baby = risk of Rh sensitization (mother develops antibodies against Rh+ blood). RhoGAM must be given within 72 HOURS postpartum to PREVENT sensitization (protects FUTURE pregnancies). Also given at 28 weeks gestation and after any bleeding event.
Why other answers are wrong:
- A) Hep B vaccine goes to BABY (not mother)
- C) Vitamin K goes to BABY (prevent bleeding)
- D) Eye ointment goes to BABY (prevent infection)
NCLEX Tip: RhoGAM = Rh-negative mom + Rh-positive baby. Give at 28 weeks, after delivery (within 72 hrs), after miscarriage/abortion.
Question 33
Mental HealthA patient with major depression tells the nurse, "I'm worthless and my family would be better off without me." What is the nurse's PRIORITY response?
Your Answer:
Correct Answer: C
Rationale: This statement suggests SUICIDAL IDEATION. The nurse MUST assess for suicide risk directly by asking: "Are you thinking about harming yourself?" or "Do you have a plan?" Direct questions are APPROPRIATE and don't "plant ideas." Safety is PRIORITY!
Why other answers are wrong:
- A) "Why" questions are non-therapeutic (patient may not know why)
- B) False reassurance is non-therapeutic (dismisses feelings)
- D) Minimizing feelings is non-therapeutic and dangerous
NCLEX Tip: Suicide risk assessment = Ask DIRECTLY about: Ideation → Plan → Means → Previous attempts. Direct questions are SAFE and necessary!
Question 34
Mental HealthA patient with bipolar disorder in the manic phase is pacing rapidly, speaking loudly, and refusing to sit for meals. What is the BEST nursing intervention?
Your Answer:
Correct Answer: B
Rationale: Manic patients have EXCESSIVE ENERGY and can't sit still. They're at risk for malnutrition/dehydration because they won't sit for meals. Offer HIGH-CALORIE, HIGH-PROTEIN finger foods (sandwiches, cheese sticks, granola bars) they can eat while pacing. Meet patient where they are!
Why other answers are wrong:
- A) Insisting/forcing increases agitation (they CAN'T sit still)
- C) Restriction is punitive and worsens agitation
- D) Medication is important but doesn't address immediate nutrition needs
NCLEX Tip: Mania = High energy + Poor judgment + Risk for exhaustion. Provide: Finger foods, safety, calm environment, redirect energy.
Question 35
Mental HealthA patient with schizophrenia tells the nurse, "The CIA is controlling my thoughts through the television." What is the BEST therapeutic response?
Your Answer:
Correct Answer: B
Rationale: When responding to DELUSIONS (false fixed beliefs), NEVER argue or agree. Acknowledge the patient's belief while presenting reality: "I understand you believe that, but I don't share that belief." This is respectful, doesn't reinforce delusion, and maintains therapeutic relationship.
Why other answers are wrong:
- A) Arguing with delusions is non-therapeutic (won't change belief, damages trust)
- C) "Why" questions are non-therapeutic + reinforce delusion
- D) Turning off TV reinforces delusion (implies threat is real)
NCLEX Tip: Delusions = Don't argue + Don't reinforce + Acknowledge feelings + Present reality. Focus on patient's FEELINGS, not content of delusion.
Question 36
Mental HealthA patient is admitted after a suspected overdose. The patient is drowsy with slurred speech, pinpoint pupils, and respiratory rate of 8 breaths/minute. What substance is MOST likely involved?
Your Answer:
Correct Answer: B
Rationale: This clinical picture indicates OPIOID OVERDOSE (heroin, fentanyl, morphine): drowsiness, slurred speech, PINPOINT PUPILS (classic sign!), and respiratory depression. Treatment = Naloxone (Narcan) + respiratory support + maintain airway.
Why other answers are wrong:
- A) Cocaine = STIMULANT (dilated pupils, tachycardia, agitation)
- C) Methamphetamine = STIMULANT (dilated pupils, hyperactivity, paranoia)
- D) LSD = HALLUCINOGEN (dilated pupils, hallucinations, altered perception)
NCLEX Tip: Opioid overdose = Pinpoint pupils + Respiratory depression + Drowsiness. Stimulant overdose = DILATED pupils + Tachycardia + Agitation.
Question 37
Mental HealthA patient with generalized anxiety disorder is hyperventilating and reports tingling in fingers and dizziness. What should the nurse do FIRST?
Your Answer:
Correct Answer: B
Rationale: Hyperventilation causes "blowing off" too much CO2 → RESPIRATORY ALKALOSIS → tingling, numbness, dizziness, lightheadedness. Treatment = REBREATHING CO2 by breathing into cupped hands or paper bag. This helps restore normal CO2 levels. Also teach slow, deep breathing techniques.
Why other answers are wrong:
- A) Oxygen worsens the problem (need more CO2, not O2!)
- C) Blood glucose isn't related to hyperventilation
- D) Code blue is unnecessary (not a life-threatening emergency)
NCLEX Tip: Hyperventilation = Too little CO2 (alkalosis) → Rebreathe into paper bag. Stay calm, coach slow breathing: "Breathe with me."
Question 38
FundamentalsA patient has a stage 3 pressure injury on the sacrum. Which intervention is MOST important?
Your Answer:
Correct Answer: C
Rationale: Stage 3 pressure injury = full-thickness skin loss with visible subcutaneous fat (deep wound). PREVENTION of worsening = reposition every 2 hours to relieve pressure, use pressure-relieving devices, assess skin, keep clean/moist. Also: high-protein diet for healing.
Why other answers are wrong:
- A) NEVER massage reddened/damaged areas (can cause more tissue damage)
- B) Heat can increase inflammation/damage (not recommended)
- D) Wounds need MOIST environment for healing (not open to air)
NCLEX Tip: Pressure injury staging: Stage 1 (red, intact) → Stage 2 (partial-thickness blister) → Stage 3 (full-thickness, fat visible) → Stage 4 (muscle/bone exposed).
Question 39
FundamentalsA patient is receiving continuous tube feedings via NG tube. The nurse should place the patient in which position?
Your Answer:
Correct Answer: B
Rationale: Semi-Fowler's position (head elevated 30-45 degrees) is required during AND for 30-60 minutes AFTER tube feedings to PREVENT ASPIRATION. Gravity helps keep formula in stomach and reduces regurgitation risk. Also check residuals before each feeding.
Why other answers are wrong:
- A) Flat/supine position INCREASES aspiration risk (formula can reflux)
- C) Trendelenburg position would cause aspiration!
- D) Right lateral doesn't prevent aspiration like elevated HOB
NCLEX Tip: Tube feeding safety = Elevate HOB 30-45° + Check residuals + Verify placement (pH test, X-ray) + Check for bowel sounds.
Question 40
FundamentalsA patient with neutropenia (low white blood cell count) should be placed in which type of isolation?
Your Answer:
Correct Answer: C
Rationale: Neutropenia (low WBC) = immunocompromised patient at HIGH risk for infection. PROTECTIVE (REVERSE) ISOLATION protects the PATIENT from others (not others from patient). Private room, limit visitors, no sick visitors, no fresh fruits/vegetables/flowers, strict hand hygiene.
Why other answers are wrong:
- A) Contact precautions = protect others FROM patient (MRSA, C. diff)
- B) Droplet precautions = protect others FROM patient (flu, meningitis)
- D) Airborne precautions = protect others FROM patient (TB, measles, varicella)
NCLEX Tip: Neutropenia = Reverse/Protective isolation (protect PATIENT). Other isolations = protect OTHERS from patient.
Question 41
FundamentalsA patient is prescribed enoxaparin (Lovenox) 40 mg subcutaneously. Which injection site is MOST appropriate?
Your Answer:
Correct Answer: B
Rationale: Enoxaparin (Lovenox) is a low-molecular-weight heparin given SUBCUTANEOUSLY in the ABDOMEN (at least 2 inches from umbilicus). Rotate sites. DO NOT expel air bubble from syringe. DO NOT massage site after injection (can cause bruising). DO NOT aspirate.
Why other answers are wrong:
- A) Deltoid = IM injection site (not for Lovenox)
- C) Vastus lateralis = IM injection site (not for Lovenox)
- D) Ventrogluteal = IM injection site (not for Lovenox)
NCLEX Tip: Lovenox/Heparin subQ = Abdomen + Don't expel air bubble + Don't massage + Don't aspirate + Rotate sites.
Question 42
FundamentalsA patient with Clostridium difficile (C. diff) infection requires which type of precautions?
Your Answer:
Correct Answer: B
Rationale: C. difficile requires CONTACT PRECAUTIONS (private room, gown/gloves for all contact, dedicated equipment). IMPORTANT: Use SOAP AND WATER for hand hygiene (alcohol-based sanitizer does NOT kill C. diff spores!). Also used for MRSA, VRE, scabies.
Why other answers are wrong:
- A) Standard precautions alone are insufficient (needs contact precautions)
- C) Droplet = respiratory transmission (flu, meningitis)
- D) Airborne = airborne transmission (TB, measles, varicella)
NCLEX Tip: C. diff = Contact precautions + SOAP AND WATER (not alcohol sanitizer). MRSA, VRE, scabies = also contact precautions.
Question 43
FundamentalsA patient with tuberculosis requires which type of isolation room?
Your Answer:
Correct Answer: B
Rationale: Tuberculosis (TB) requires AIRBORNE PRECAUTIONS with NEGATIVE PRESSURE ROOM (air flows INTO room, not out). Staff/visitors wear N95 respirator masks (not surgical masks). Also for measles, varicella (chickenpox), disseminated herpes zoster. Patient wears surgical mask when leaving room.
Why other answers are wrong:
- A) Standard room doesn't contain airborne pathogens
- C) Positive pressure = for immunocompromised patients (protective isolation)
- D) TB requires PRIVATE room (can't have roommate)
NCLEX Tip: TB, measles, varicella = Airborne precautions + Negative pressure room + N95 mask for staff + Private room.
Question 44
PharmacologyA patient taking phenytoin (Dilantin) for seizures should be monitored for which side effect?
Your Answer:
Correct Answer: B
Rationale: Phenytoin (Dilantin) commonly causes GINGIVAL HYPERPLASIA (overgrowth of gum tissue). Teach patients: good oral hygiene, regular dental care, brush/floss after meals. Other side effects: nystagmus (eye twitching), ataxia, drowsiness. Therapeutic level: 10-20 mcg/mL.
Why other answers are wrong:
- A) Urinary retention isn't a phenytoin side effect
- C) Phenytoin doesn't cause hyperkalemia
- D) Tachycardia is more common than bradycardia
NCLEX Tip: Phenytoin (Dilantin) = Gingival hyperplasia + Nystagmus + Ataxia. Teach: Good oral care + Don't stop abruptly (seizure risk).
Question 45
PharmacologyA patient is prescribed albuterol (Proventil) inhaler and fluticasone (Flovent) inhaler. In which order should the nurse teach the patient to use these inhalers?
Your Answer:
Correct Answer: B
Rationale: Use BRONCHODILATOR (albuterol) FIRST to open airways, THEN use CORTICOSTEROID (fluticasone) so it can penetrate deeper into lungs. Wait 1-5 minutes between inhalers. After using fluticasone, RINSE MOUTH to prevent oral thrush (fungal infection).
Why other answers are wrong:
- A) Wrong order (corticosteroid can't penetrate if airways are tight)
- C) Order matters for effectiveness!
- D) Both inhalers are typically prescribed for daily use
NCLEX Tip: Inhaler order = Bronchodilator FIRST (opens airways), then Corticosteroid. Rinse mouth after corticosteroid (prevent thrush).
Question 46
PharmacologyA patient receiving gentamicin (an aminoglycoside antibiotic) should be monitored for which serious adverse effects?
Your Answer:
Correct Answer: B
Rationale: Aminoglycosides (gentamicin, tobramycin, amikacin) can cause NEPHROTOXICITY (kidney damage) and OTOTOXICITY (hearing loss/balance problems). Monitor: serum creatinine, BUN, peak/trough levels, hearing tests. Report: decreased urine output, elevated creatinine, tinnitus (ringing in ears), dizziness.
Why other answers are wrong:
- A) Liver toxicity isn't the primary concern with aminoglycosides
- C) Bone marrow suppression occurs with different antibiotics (chloramphenicol)
- D) Stevens-Johnson syndrome occurs with sulfonamides
NCLEX Tip: Aminoglycosides (-mycin drugs) = Nephrotoxicity (kidney) + Ototoxicity (ears). Monitor: BUN/Creatinine + Peak/trough levels + Hearing.
Question 47
PharmacologyA patient taking spironolactone (Aldactone) should avoid which food?
Your Answer:
Correct Answer: B
Rationale: Spironolactone is a POTASSIUM-SPARING DIURETIC that can cause HYPERKALEMIA (high potassium). Patients should AVOID high-potassium foods (bananas, oranges, potatoes, tomatoes, salt substitutes). Monitor potassium levels regularly. Signs of hyperkalemia: muscle weakness, irregular heartbeat, nausea.
Why other answers are wrong:
- A) Leafy greens are high in Vitamin K (relevant for warfarin, not spironolactone)
- C) Dairy products don't significantly interact with spironolactone
- D) Whole grains are safe to eat
NCLEX Tip: Potassium-SPARING diuretics (spironolactone) = AVOID high-potassium foods. Loop diuretics (Lasix) = NEED potassium supplements.
Question 48
Medical-SurgicalA patient with chronic kidney disease has a potassium level of 6.8 mEq/L. Which medication should the nurse expect to administer FIRST?
Your Answer:
Correct Answer: B
Rationale: Potassium 6.8 mEq/L = SEVERE HYPERKALEMIA (life-threatening cardiac arrhythmia risk!). PRIORITY = Calcium gluconate IV to STABILIZE CARDIAC MEMBRANE (protects heart). Then give treatments to LOWER potassium: regular insulin + dextrose (shifts K into cells), Kayexalate (removes K from body), Lasix (excretes K), dialysis.
Why other answers are wrong:
- A) Lasix helps eliminate K but doesn't PROTECT heart immediately
- C) Kayexalate removes K but takes hours (not immediate cardiac protection)
- D) Insulin + dextrose shifts K into cells but calcium protects heart FIRST
NCLEX Tip: Severe hyperkalemia treatment order: 1) Calcium gluconate (protect heart), 2) Insulin + dextrose (shift K in), 3) Kayexalate (remove K).
Question 49
Medical-SurgicalA patient returns from surgery with a Jackson-Pratt drain. The nurse notes the drain bulb is fully expanded. What action should the nurse take?
Your Answer:
Correct Answer: B
Rationale: Jackson-Pratt (JP) drain works by NEGATIVE PRESSURE (suction). A fully EXPANDED bulb = NO SUCTION (not working properly). The nurse should EMPTY drainage and COMPRESS (squeeze) bulb to re-establish suction. A properly functioning JP drain has a COMPRESSED/FLAT bulb. Measure and document drainage.
Why other answers are wrong:
- A) Expanded bulb is NOT normal (means no suction)
- C) Nurse can't remove drain (provider removes when drainage minimal)
- D) Don't clamp drain (prevents drainage, increases infection risk)
NCLEX Tip: JP drain = COMPRESSED bulb = working suction. Expanded bulb = NOT working (empty and compress it).
Question 50
Medical-SurgicalA patient with a chest tube suddenly develops respiratory distress and absence of breath sounds on the affected side. The nurse notices the chest tube has become disconnected. What is the nurse's IMMEDIATE action?
Your Answer:
Correct Answer: C
Rationale: If chest tube becomes disconnected, IMMEDIATELY place the end of the tubing in STERILE WATER (creates water seal, prevents air from entering pleural space). This prevents tension pneumothorax. Then reconnect to drainage system with new sterile connector, assess patient, notify provider. NEVER leave chest tube open to air!
Why other answers are wrong:
- A) Call provider AFTER securing tube in sterile water (patient safety first!)
- B) Don't reconnect contaminated equipment (infection risk + need sterile connector)
- D) Oxygen helps but doesn't prevent pneumothorax (seal tube first!)
NCLEX Tip: Chest tube disconnected = IMMERSE in sterile water immediately. Never clamp chest tube except during bottle change!