20 NCLEX PRACTICE QUESTIONS

Date Published: December 6, 2016

They say practice makes perfect and when it comes to passing the NCLEX that is certainly the case. ATI Nursing Education wants to share 20 NCLEX practice questions to help you perfect your test-taking skills and knowledge.

PS: Don’t forget to scroll to the end of the article for answers and rationales.

20 NCLEX Questions

Question 1: A nurse cares for a toddler who has a decreased appetite, an erratic eating pattern, and fussiness at mealtime. Which recommendation should be made to the parents?

1. Increase the portion size for each meal.
2. Reward the child with a favorite dessert.
3. Offer fruit juice in a cup throughout the day.
4. Provide nutritious snacks at regular intervals.       

Question 2: A nurse provides care for a client who is 1-day post-partum following a vaginal delivery. Which task can be delegated to the assistive personnel (AP)?

1. Obtain vital signs.
2. Demonstrate car seat use.
3. Evaluate effectiveness of ice.
4. Provide instruction for breast care.

Question 3: A nurse plans teaching for a client who has coronary artery disease.  Which dietary recommendation is most important?

1. Prepare foods by broiling instead of frying.
2. Substitute fresh herbs for table salt.
3. Drink almond milk in place of soft drinks.
4. Eat tortillas made from corn rather than flour.

Question 4:  A client who has endometrial cancer is receiving sealed internal radiation therapy. Which actions should the nurse implement? Select all that apply.

1. Wear a lead apron when providing care.
2. Remove soiled dressings from the room.
3. Instruct visitors to wear a dosimeter badge.
4. Place dislodged source in biohazard container.
5. Do not allow women who are pregnant to visit.

Question 5: A nurse cares for a group of clients who are experiencing symptoms of withdrawal from alcohol. Which finding requires immediate follow-up?

1. Tremors
2. Inability to sleep
3. Hematemesis
4. Transient hallucinations

Question 6: A nurse provides discharge teaching for a client who had a below-knee amputation.  Which instructions should the nurse include? Select all that apply.

1. Dry socket after cleansing
2. Wear prosthesis at all times
3. Use clean, conformed liners
4. Assess for uneven shoe wear
5. Apply prosthesis prior to bathing
6. Inspect limb daily for skin inflammation

Question 7: A toddler is dehydrated as the result of complications from varicella-zoster virus.  Fluid filled vesicles are observed on the face and chest.   Which actions should the nurse implement? Select all that apply.

1. Place in negative air-flow room.
2. Provide surgical masks for visitors.
3. Cover lesions with sterile gauze dressing.
4. Explain guidelines for contact precautions to family.
5. Assure assigned nurse has a positive immune status.

Question 8: A nurse explains how to recognize an impending attack to the parents of a child who has asthma. Which symptoms should be discussed? Select all that apply.

1. Itching
2. High fever
3. Headache
4. Irritability
5. Abdominal discomfort

Question 9: A nurse administers 12 units lispro insulin at 0700 to a client. Within which time frame must the morning meal be served?

1. 15 minutes
2.  30 minutes
3.  45 minutes
4.  60 minutes

Question 10: During an admission assessment a client responds with rhyming statements such as “tip, rip, dip and hip”. The nurse recognizes this speech pattern is associated with which mental health disorder?

1. Mania
2. Anxiety
3. Depression
4. Schizophrenia

Question 11: A nurse cares for a client who is one hour post vaginal delivery. Which findings are an early sign of postpartum hemorrhage?

1. Ecchymosis and cardiac gallop
2. Thrombocytopenia and hyperreflexia
3. Increasing heart rate and enlarging uterus
4. Decreasing BP and fundus deviating to the right

Question 12: A nurse provides care for a client who has severe anemia and received a transfusion of packed RBCs.  Which data indicates the goal of therapy has been met?

1. Hemoglobin 12 g/dL
2. Platelets 150,000 mm³
3. Absence of additional bleeding
4. Increases consumption of vitamin C

NOTE: Blood and blood products are used to increase intravascular volume, replace clotting factors, replace components of blood, replace blood loss, and improve oxygen carrying capacity.

Question 13:  

A client who has severe burns is receiving total parenteral nutrition (TPN).  Which lab value indicates therapeutic effectiveness of TPN?

1. BUN 10 mg/dL
2. WBC 6,000/mm3
3. Albumin 4.0 g/dL
4. Potassium 4.5 mEq/L

Question 14: A nurse provides care for a client who reports sudden onset of sweating, shortness of breath, dizziness, and pounding heart.  Which ABG value should be expected?

1. pH 7.32, PaCO2 50, HCO3  25, PaO2  70
2. pH 7.50, PaCO2 30, HCO3  24, PaO2  90
3. pH 7.49, PaCO2 38, HCO3  30, PaO2  80
4. pH 7.30, PaCO2 35, HCO3  18, PaO2 85

Question 15:  A client who is at 30 weeks of gestation states, “I may be in labor.”  Which findings should the nurse anticipate?

1. Nausea and vomiting
2. Decrease vaginal discharge
3. Pelvic pressure and menstrual-like cramps
4. Irregular contractions that decrease with rest

Question 16: A client who sustained a head injury has an intracranial pressure (ICP) monitor reading of 12 mm Hg. Which action should the nurse take?

1. Continue to assess.
2. Notify the provider.
3. Administer mannitol.
4. Maintain supine position.

Question 17:  A nurse provides teaching to a client who is scheduled for a colonoscopy. Which statements should be included? Select all that apply.

1. Avoid colored liquids.
2. Report increase in flatus.
3. Discontinue daily aspirin dose.
4. Chill bowel cleansing solution.
5. Arrange for transportation home.

Question 18: A client reports shortness of breath and has the following cardiac rhythm. Which medication should the nurse prepare to administer?

1. atropine
2. adenosine
3. amlodipine
4. amiodarone

Question 19: A nurse provides education to a client recently diagnosed with Addison’s disease. Which symptoms should be discussed? Selection all that apply.

1. Salt craving
2. Weight loss
3. Hypertension
4. Hypoglycemia
5. Muscle weakness

Question 20: An older adult who has facial drooping, a weak cough, and absent gag reflex is admitted for treatment.  Which action should the nurse implement?

1. Offer small sips of clear fluids.
2. Provide a communication board.
3. Mix oral medications in applesauce.
4. Contact speech- language pathologist.

Related Read: Job Market Stats Every Nursing Student Should Know

Answers & Rationales

Answer & Rationale, Question 1

Correct Answer: 4

Rationale

1.Portion should not be increased. It is more significant to provide nutritious foods rather than focus on the amount consumed. Large adult size portions contribute to a feeling of being overwhelmed.

2.It’s normal for a toddler to experience a decreased appetite and decreased nutritional need.  They often become picky and fussy eaters.  Food that is offered as a reward for eating becomes associated with approval.  The child may overeat for non-nutritive reasons.

3.Excessive consumption of fruit juice is associated with dental caries, obesity and metabolic syndrome.  The child should consume no more than 6 ounces per day of 100% juice.  The nurse should suggest alternatives with fewer empty calories and greater nutritional value.

4. CORRECT. Toddlers prefer the routine of consistent mealtimes. Frequent nutritious planned snacks can replace a meal, but shouldn’t replace a regular sit-down meal. Nibbling and snacking is a way to ensure proper nutrition when appropriate foods are offered. Nutritious snacks include several small pieces of food such as crackers, carrots, sliced cold meat, and raisins.

Answer & Rationale, Question 2

Correct Answer: 1

RNs are responsible for supervising tasks assigned to PNs and APs. RNs cannot delegate the nursing process, client education, or tasks that require clinical judgement (for example unstable clients). Examples of tasks that can be delegated to the AP include: activities of daily living (ADLs), bathing, grooming, dressing, toileting, ambulating, feeding (without swallowing precautions), positioning, routine tasks, bed making, specimen collection, intake and output, and vital signs (for stable clients).

The five rights of delegation include: right task, right circumstance, right person, right communication, and right supervision. Delegation is based on individual client needs, facility policies, job descriptions, state nurse practice acts, and professional standards.

Rationale:

1.CORRECT. Obtaining vital signs may be delegated (right task) as long as the client is stable (right circumstance). In the scenario, the client is 1 day postpartum and there is no indication the client is unstable.

2.This would not be appropriate delegation. Demonstrating implies client education which is within the scope of practice for a RN.

3.This would not be appropriate delegation. Evaluating effectiveness would involve the nursing process which is within the scope of practice for a PN or RN.

4.This would not be appropriate delegation. Providing instruction involves client education which is within the scope of practice for an RN.

Answer & Rationale, Question 3

Correct Answer:  1

Rationale:

1.CORRECT:  Atherosclerosis is the primary risk factor in the development of coronary artery disease (CAD). Health promotion efforts are aimed at eliminating saturated and trans saturated fatty acids by preparing foods that are baked or broiled in place of frying or stewing in lard and oils.

2.Limiting dietary sodium intake is more of a concern for a client with heart failure rather than a client with CAD. Chili peppers, lemon, herbs and spices may be used to enhance the flavor of foods.

3.Selecting almond milk as a beverage rather than a soft drink offers more nutritional value. Soft drinks do not provide any nutritional benefit and contain very high sugar content.  This option will help reduce weight and maintain glucose levels.  A client with CAD should be primarily concerned with decreasing intake of saturated fats.

4.This recommendation is appropriate but is not the most important. Corn flour is lower in fat and calories and higher in fiber than white flour.  Corn and wheat flour are good substitutes for a client who is overweight and/or managing diabetes mellitus.  A health promotion effort for a client with CAD is to eliminate the risk of atherosclerosis.  

Answer & Rationale, Question 4

Correct Answer: 1, 5

Rationale

Internal radiation therapy is an example of brachytherapy. With brachytherapy, the radiation source is within the patient and comes into contact with the tumor for a specific amount of time. The patient emits radiation and is a potential hazard to others. Internal radiation therapy can involve an unsealed source or a sealed source. Solid or sealed sources are implanted near the tumor and can be permanent or temporary. Clients with temporary implants may be hospitalized for several days during treatment or stronger radiation implants may be left in place for only an hour or so at a time. The client is radioactive only when the implant is in place.

1.  CORRECT. Wearing a lead apron when providing care is recommended to protect the caregiver from radiation exposure. Always keep the front of the apron facing the client and do not turn so that the back of the caregiver is facing the client.
2. All dressings and bed linens must be saved in the client’s room until after the radioactive source is removed. After the source is removed, dispose of dressings and linens in the usual manner. Other equipment can be removed from the client’s room at any time without any special precautions and does not pose a hazard to others.
3. Visitors do not need to wear a dosimeter badge; rather the caregivers must wear a dosimeter badge when caring for clients who have radioactive implants. The badge does not protect but measures a person’s specific radiation exposure.  Visitors are limited to 30 minutes per day and must stay at least 6 feet from the client.  
4. If the source is dislodged, long-handled forceps should be used to deposit the source in a lead container left in the client’s room.  A dislodged radioactive source should never be handled with bare hands.
5. CORRECT.  Women who are pregnant (including caregivers) should not enter the room. In addition, if the caregiver is attempting to conceive, whether they are male or female, they should not perform direct client care.  Children younger than 16 should not be allowed to visit either. A “Caution: Radioactive Material” sign should be placed on the door to the client’s room.

Answer & Rationale, Question 5

Correct Answer: 3

Rationale

1. This is an expected finding and is not life-threatening. Withdrawal manifestations include tremors, transient hallucinations, inability to sleep, increased heart rate, respiratory rate, and temperature, abdominal cramping, and vomiting.
2. This is an expected finding and is not life-threatening. Withdrawal manifestations include tremors, transient hallucinations, inability to sleep, increased heart rate, respiratory rate, and temperature, abdominal cramping, and vomiting.       
3. CORRECT. The client needs to be seen immediately. Hematemesis is a symptom of rupture of associated esophageal varices.  The mortality rate with acute bleeding is 10% to 40% and is related to failure to control a bleeding episode.
4. This is an expected finding and is not life-threatening. Withdrawal manifestations include tremors, transient hallucinations, inability to sleep, increased heart rate, respiratory rate, and temperature, abdominal cramping, and vomiting.

Answer & Rationale, Question 6

Correct Answer:  1, 3, 4, 6

Rationale

1. CORRECT: To prevent skin breakdown and infection, it is important for the client to thoroughly clean and dry the socket.
2. The client should remove the prosthesis for hygiene; to monitor the skin for infections, drainage, redness, inflammation; and during hours of sleep.
3. CORRECT: Clean, well-fitted liners are necessary to prevent skin breakdown and to promote a secured prosthesis.
4. CORRECT: Shoes should fit symmetrically and evenly. This would indicate an accurate fit of the prosthetic limb.
5. The client should remove the prosthesis prior to bathing or showering to avoid damage to the device.
6. CORRECT: The skin should be assessed daily for signs of skin breakdown, drainage, infection, inflammation and/or shrinkage.

Answer & Rationale, Question 7

Correct Answer:  1,2,4,5

Rationale

1. CORRECT. The nurse should place the client on airborne precautions.   A private, negative air-flow room with at least six to twelve exchanges per hour is required.  All health care personnel should wear an N95 respirator each time they enter the room.
2. CORRECT. The nurse should provide surgical masks for visitors.  The nurse should also place a surgical mask on the client if transport outside of the private room is required.
3. The nurse should not routinely cover lesions with a sterile gauze dressing. The nurse may remove loose crusts that rub and irritate the skin.  Additional skin care measures may include:  provide daily baths, clothing, and linen changes; trim fingernails and apply mittens; keep child cool; apply calamine lotion.
4. CORRECT. The nurse should explain guidelines for contact precautions to the family.  In addition to airborne precautions, standard and contact precautions should be maintained until lesions are dry and crusted.
5. CORRECT. A positive immune status must be confirmed.  Evidence of immunity includes any of the following:  documentation of age-appropriate varicella vaccination; laboratory evidence of immunity or confirmation of disease; diagnosis or verification of a history of varicella by a health care provider. The varicella-zoster virus is very contagious and may cause serious complications.  Those at high risk include:  infants, adolescents, adults, women who are pregnant, and people who have weakened immune systems (from medications or disease).

Answer & Rationale, Question 8

Correct Answer: 1, 3, 4, 5

Rationale

1. CORRECT. Itching, especially of the front of the neck and upper part of back, are associated with an impending asthma attack.  Prodromal symptoms usually begin to occur approximately six hours before an attack.
2. Prodromal symptoms of an asthma attack include a low-grade fever.
3. CORRECT. Headache is not associated with asthma prodrome.
4. CORRECT. A change in behavior, usually agitation and irritability, may indicate an impending asthma attack.
5. CORRECT. Abdominal discomfort and anorexia are prodromal symptoms.

Answer & Rationale, Question 9

Correct Answer:  1

Rationale

1. CORRECT: The client should consume their meal immediately, but no longer than 15 minutes after receiving this rapid acting insulin. The onset of humalog insulin is 15-30 minute, peak time is 30 min to 2.5 hours, with a duration of 3-6 hours.
2. The client who receives regular insulin may delay their meal consumption to be within 30 minutes of the injection. The onset of regular insulin is 30-60 minutes, peak 1 to 5 hours, with a duration of 6-10 hours.
3. Serving the morning meal after 15 minutes places the client at risk to develop symptoms of hypoglycemia.
4. Serving the morning meal after 15 minutes places the client at risk to develop symptoms of hypoglycemia.

Answer & Rationale, Question 10

Correct Answer: 4

Rationale

1. A client experiencing mania would have rapid, pressured, continuous speech with frequent sudden topic changes known as flight of ideas.
2. A client experiencing anxiety would have a different speech pattern depending on the level of anxiety. For example, a client experiencing moderate anxiety may experience a change in voice pitch or voice tremors. A client with severe anxiety may have loud and rapid speech. At the panic-level of anxiety, a client may have dysfunctional speech.
3. A client experiencing depression may show little or no effort to interact. Speech is slowed, with decreased verbalization. The client may appear too tired to speak, have a delayed response, and sigh often.
4. CORRECT. This speech pattern is associated with psychotic disorders and schizophrenia. The client is exhibiting a type of speech called Clang association which is the meaningless rhyming of words, often in a forceful manner.

Answer & Rationale, Question 11

Correct Answer:   3

Rationale

1. Ecchymosis and cardiac gallop are not signs of early postpartum hemorrhage. Ecchymosis, a collection of blood under the tissue, may be caused by various conditions such as injury, autoimmune disorders, viral infections, medications, and thrombocytopenia.  A cardiac gallop is an abnormal third or fourth heart sound caused by decreased compliance of the ventricles.  This finding may be a sign of hypervolemia.
2. Thrombocytopenia is a laboratory finding that occurs in HELLP syndrome.  Hyperreflexia may be a characteristic finding of preeclampsia.
3. CORRECT. An increasing heart rate is often one of the first indicators of inadequate blood volume and the earliest sign of shock. The heart rate increases to keep cardiac output and mean arterial pressure at normal levels. A uterus that is enlarging may indicate clots are accumulating in the uterus and lead to uterine atony and postpartum hemorrhage.
4. Decreasing BP occurs with hypovolemia but is a late sign of hemorrhagic shock.  Systolic blood pressure changes are not always present in the initial stage of shock but occur as shock progresses and cardiac output decreases. A fundus that is high and deviated to the right is commonly associated with a distended bladder not postpartum hemorrhage.

Answer & Rationale, Question 12

Correct Answer: Correct Answer:  1

Rationale

1. CORRECT:  A hemoglobin of 12 g/dL would indicate a therapeutic response to therapy.  The expected pharmacologic action of packed RBCs is to increase the number of red blood cells and improve the hemoglobin.  One indication for the administration of packed RBCs is severe symptomatic anemia (Hgb 6 to 10 g/dL).
2. A platelet count of 150,000 mm³ would be a therapeutic response for a client who received a transfusion of platelets.  A platelet transfusion is indicated for thrombocytopenia (platelet count < 20,000 mm³) or for clients who are actively bleeding and have a platelet count of < 50,000 mm³.
3. The absence of bleeding is not related to the effect of administering packed RBCs.
4. Increasing the consumption of vitamin C (ascorbic acid) helps to increase the absorption of iron.  Vitamin C is found in citrus fruits (oranges, lemons), tomatoes, peppers, green leafy vegetables, and strawberries.

Answer & Rationale, Question 13

Correct Answer: 3

TPN provides a nutritionally complete solution. It can be used when caloric needs are very high, when duration of therapy is greater than 7 days or when the solution to be administered is hypertonic (greater than 10% dextrose). It can only be administered in a central vein. Desired therapeutic effects of TPN include improved nutritional status, weight maintenance or gain, and positive nitrogen balance. Evidence to support this include: maintenance of baseline or weight gain (up to 1 kg/day), serum albumin 3.5 to 5.0 g/dL and prealbumin 15 to 36 mg/dL.

Rationale

1. A BUN of 10 mg/dL is within normal range (10 to 20 mg/dL) however this is not an indicator of therapeutic effectiveness. It is an indicator of renal function and hydration. Monitoring the BUN and fluid status would be important assessments for complications related to TPN administration. Fluid and electrolyte imbalances are common with clients receiving TPN. The BUN becomes elevated with dehydration.
2. A WBC of 6, 000/mm3 is within normal range (5,000 to 10,000/mm3) however this is not an indicator of a therapeutic effect. It is important to monitor for signs and symptoms of infection as a potential complication of TPN administration.  
3. CORRECT. A serum albumin of 4.0 is within normal and desired range (3.5 to 5.0 g/dL) and indicates a therapeutic effect of TPN. Nutritional requirements for a client with a severe burn can exceed 5,000 kcal/day. Enteral nutrition is preferred however if the client’s gastrointestinal tract is not functioning or when the nutritional needs cannot be met by oral and enteral feeding, TPN may be required. TPN is usually the last resort because it is invasive and can lead to metabolic complications and infections.
4. A potassium level of 4.5 mEq/L is within normal range (3.5 to 5.0 mEq/L) however it is not an indicator of a therapeutic effect of TPN.  Electrolytes are frequently monitored for potential complications. Clients are at risk for metabolic imbalances related to TPN administration which can include: hyperglycemia, hypoglycemia, hyperkalemia, hypophosphatemia, hypocalcemia, dehydration and fluid overload.   

Answer & Rationale, Question 14

Correct Answer: 2

Normal ABG values are pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg, HCO3 21 to 28 mEq/L, and PaO2 80 to 100 mm Hg.

Rationale

1. This ABG value represents respiratory acidosis (↓pH, ↑PaCO2, ↓ PaO2) which can occur from under-elimination of hydrogen ions from respiratory depression (use of anesthetics and opioids), inadequate chest expansion, airway obstruction, and alveolar-capillary block.
2. CORRECT. The client is reporting symptoms characteristic of an acute attack. This ABG value represents respiratory alkalosis (↑pH, ↓ PaCO2) which can result from excessive loss of carbon dioxide. Examples of conditions that can cause this include: hyperventilation, anxiety, fear, mechanical ventilation, high altitudes, salicylate toxicity, and early stages of shock and acute pulmonary problems.
3. This ABG value represents metabolic alkalosis (↑pH, ↑ HCO3) which can occur from an increase of base components (antacids, blood transfusions, sodium bicarbonate, and total parenteral nutrition) or a decrease of acid components (prolonged vomiting, nasogastric suctioning, hypercortisolism, hyperaldosteronism, and thiazide diuretics).
4. This ABG value represents metabolic acidosis (↓pH, ↓ HCO3) which can occur from an over-production of hydrogen ions (diabetic ketoacidosis, starvation, heavy exercise, seizure activity, fever, hypoxia, ischemia and excessive ingestion of acids such as salicylate intoxication or ethanol intoxication),  an under-elimination of hydrogen ions (kidney failure), under-production of bicarbonate (kidney failure, pancreatitis, liver failure, dehydration) or over-elimination of bicarbonate (diarrhea).

Answer & Rationale, Question 15

Correct Answer:  3

Rationale

1. Nausea and vomiting is not a typical sign of preterm labor.
2. Vaginal discharge is common during pregnancy. The character or amount typically changes with preterm labor.  The discharge increases and may be thicker (mucoid) or thinner (watery), bloody, brown, or colorless.
3. CORRECT: Pelvic pressure or heaviness and painful, menstrual-like cramps are a symptom of preterm labor.
4. Uterine contractions increase in frequency with labor. They may be painful or painless with preterm labor and do not decrease with rest or fluids.

Answer & Rationale, Question 16

Correct answer: 1

Rationale

1. An intracranial pressure (ICP) monitor is a device inserted into the cranial cavity that records pressure and is connected to a monitor that shows a pressure waveform. Normal ICP is between 10 to 15 mm Hg. Increased ICP is a sustained elevation greater than 15 mm Hg.
2. CORRECT. An ICP reading of 12 mm Hg is within the normal range. The nurse would continue with ongoing neurological assessment including vital signs, pupillary function, cranial nerve function, Glasgow Coma Scale, and sensory and motor response.
3. The nurse would not need to notify the provider for an ICP reading of 12 mm Hg. This is within an expected/normal range.
4. Mannitol is not indicated for an ICP reading of 12 mm Hg.  Mannitol is an osmotic diuretic that can be used for increased ICP. Mannitol draws fluid from the brain into the blood.
5. The nurse should implement actions to avoid increasing ICP for a client who has sustained a head injury. Appropriate nursing actions would include maintaining the head of the bed at least 30 degrees to promote venous drainage and reduce ICP. Positioning the head of the bed at an angle less than 30 degrees can increase the ICP.    

Answer & Rationale, Question 17

Correct answer: 1, 3, 4, 5

Rationale

1. CORRECT. The client should consume a clear liquid diet the day before the colonoscopy and avoid red, orange, or purple (grape) beverages. The client is NPO after midnight or as prescribed by the provider.
2. Flatus, cramping, and a feeling of fullness are expected for several hours following the procedure. Prior to the colonoscopy the client will have an increase in watery diarrhea from the action of the bowel cleansing agents. Post-procedure, severe pain and guarding (manifestations of bowel perforation) or indications of hemorrhage must be reported.
3. CORRECT. The client should avoid certain medications such as aspirin, anticoagulants and antiplatelet medications for several days prior to the procedure or as instructed by the provider.
4. CORRECT. The patient is instructed to drink a liquid preparation to cleanse the bowel of feces the day before the colonoscopy. Sodium phosphate and GoLYTELY are examples. GoLYTELY is not used for older adults because of the risk of excessive fluid and electrolyte losses. Oral solutions can be chilled to help improve taste. Watery diarrhea usually begins an hour after administration. The patient may also require laxatives, suppositories (such as bisacodyl) or an enema.
5. CORRECT. Instruct the client to arrange for transportation home from the procedure. The client should be instructed not to drive or operate equipment for 12 to 18 hours after the colonoscopy.

Answer & Rationale, Question 18

Correct answer: 1 Rationale The ECG represents sinus bradycardia in which the heart rate is less than 60 beats per minute. Causes of sinus bradycardia include a hyper-effective heart (in well-conditioned athletes), excessive vagal stimulation (parasympathetic) from carotid sinus massage, vomiting, suctioning, Valsalva maneuvers (bearing down or gagging). Increased parasympathetic stimuli may result from hypoxia, inferior wall myocardial infarction, and medications such as beta-adrenergic blockers, calcium channel blockers, and digitalis.  Lyme’s disease and hypothyroidism can also cause bradycardia. Clients with sinus bradycardia can be asymptomatic or symptomatic. CORRECT. Atropine is the treatment for symptomatic sinus bradycardia. Atropine is a parasympatholytic or vagolytic agent. If the client experiences any of the following symptoms: fainting, dizziness, confusion, hypotension, diaphoresis, shortness of breath or chest pain and the underlying cause cannot be determined the treatment is atropine 0.5 mg IV, increasing intravascular volume with IV fluids and oxygen. If treatment of the underlying cause does not improve the heart rate, the client will require a pacemaker. Adenosine is not given for sinus bradycardia. Adenosine is an antidysrhythmic that is the drug of choice to treat paroxysmal supraventricular tachycardia (SVT) including Wolff-Parkinson-White (WPW) syndrome. Amlodipine is not given for sinus bradycardia. Amlodipine is a calcium channel blocker that is used to treat hypertension and angina (stable and variant types). Amiodarone is not given for sinus bradycardia. Amiodarone is an antidysrhythmic used in the treatment of life-threatening ventricular dysrhythmias, supraventricular arrhythmias, and atrial fibrillation.

Answer & Rationale, Question 19

Correct answer: 1,2,4,5

Rationale

Adrenocortical insufficiency is also known as Addison’s disease. It is caused by damage or dysfunction of the adrenal cortex. Causes of primary Addison’s disease include idiopathic immune dysfunction (majority of cases), tuberculosis, histoplasmosis, adrenalectomy, cancer, and radiation therapy to the abdomen. Causes of secondary Addison’s disease include steroid withdrawal, hypophysectomy, pituitary neoplasm, and high dose radiation of the pituitary gland or entire brain.

1. CORRECT. Salt craving is a manifestation of Addison’s disease related to the reduced aldosterone secretion. The client may also have hyponatremia and hypotension.
2. CORRECT. Weight loss is a manifestation of Addison’s disease related to decreased cortisol levels. Decreased cortisol levels result in poor glucose regulation with hypoglycemia. Glomerular filtration and gastric acid production decreases leading to reduced urea nitrogen excretion, which causes anorexia and weight loss.
3. Hypertension is not a manifestation of Addison’s disease. The client with Addison’s disease would experience hypotension related to the decrease in aldosterone secretion.
4. CORRECT. Hypoglycemia is a manifestation of Addison’s disease related to the decreased cortisol levels.
5. CORRECT. Muscle weakness is a manifestation of Addison’s disease resulting from a decrease in aldosterone.

Answer & Rationale, Question 20

Correct Answer:  4

Rationale

1. The nurse should recognize the client is exhibiting signs and symptoms of a stroke and should ensure the client remains NPO until a further assessment is completed to evaluate swallowing.
2. There is no indication the client’s ability to communicate is altered.  Additional assessments are needed to evaluate the client’s ability to communicate (receive, interpret, and express) prior to providing a communication board.
3. The nurse should not administer anything by mouth.  The client is at risk for aspiration.
4. CORRECT. The nurse should contact the speech-language pathologist and request an evaluation.  A speech-language pathologist will evaluate the client’s ability to swallow.  If dysphagia is present, the nurse should implement additional measures to prevent aspiration and promote nutrition.

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