NCLEX Brain Buster Questions

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NCLEX

“BRAIN BUSTER” QUESTION


The nurse provides care for a client who presents to the
emergency department (ED) with restlessness, diarrhea,
nausea, vomiting, and heart palpitations. The client is
prescribed theophylline for the treatment of
asthma. Which laboratory and/or diagnostic test
should the nurse anticipate for this client?
Select all that apply.

Serum potassium level


Serum theophylline level
Electrocardiogram (ECG)
Electroencephologram (EEG)
Computed tomography (CT) scan

Answer & Rationale


• Ask: Tests to anticipate
• Problem: Theophylline for asthma; restless with diarrhea, nausea, vomiting, & heart palpitations
• Solution: Think of the worst case scenario
-Restlessness, N/V/D, & palpitations = S/S of theophylline toxicity
-Lab test = theophylline level (normal range of 10-20 mcg/mL)
1. Incorrect - Theophylline does not impact potassium levels
2. Correct - Drug toxicity is suspected, therapeutic range is 10 to 20 mcg/mL
3. Correct - Theophylline toxicity is associated with life-threatening cardiac dysrhythmia
4. Incorrect - While theophylline toxicity is associated with seizure activity, the current clinical
data does not warrant this diagnostic test.
5. Incorrect - A CT scan is not warranted to monitor a client for symptoms associated with
theophylline toxicity.
NCLEX
“BRAIN BUSTER” QUESTION
A client who is diagnosed with congestive heart failure
is scheduled to receive an intravenous push (IVP) dose
of furosemide, 40 mg. As the nurse reviews the client’s
morning labs, the following results are noted:
Na+ 135 mEq/L; K+ 3.1 mEq/L; Ca + 8.5 mg/dL; and
Mg+ 2.1 mg/dL. Which lab result should be
reported to the provider immediately?

Na+
K+
Ca+
Mg+

Answer & Rationale


• Ask: Lab results to report immediately
• Problem: Heart failure with scheduled furosemide IV push
• Solution: Remember furosemide leaves the body dry. Low fluid (because it makes
you pee) and we lose potassium so this will decrease the potassium
even further.
1. Incorrect - Na+ level of 135 mEq/L is within normal limits
3. Correct - K+ level of 3.1 mEq/L already low; furosemide is K+ wasting & will
further deplete potassium levels.
3. Incorrect - Ca+ level of 8.5 mg/dL is within normal limits
4. Incorrect - Mg+ level of 2.1 mg/dL is within normal limits
NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides care for a client who is recovering
from an acute myocardial infarction (MI). The
client’s cardiac rhythm indicates a rate of 180
beats/minute with monomorphic, wide QRS
complexes. Which rhythm does the nurse
identify based on the current data?

Bundle branch block


Sinus tachycardia
Ventricular pacing
Ventricular tachycardia

Answer & Rationale


• Ask: Which cardiac rhythm

• Problem: Heart rate of 180 beats/min with wide QRS after MI

• Solution: Name the rhythm…Think about it - the rate is fast and it has something to do with
the ventricles because the QRS complexes are wide and monomorphic

1. Incorrect - A bundle branch block is a QRS complex that is wider than 0.12 seconds.
2. Incorrect - Sinus tach is regular, normal & upright P waves before each QRS, rate faster
than 100 beats BPM, QRS complexes and PR intervals are WNL
3. Incorrect - Ventricular pacing is a rhythm in which pacer spikes are noted before each
QRS complex.
4. Correct - Ventricular tachycardia has a rapid rate and wide QRS complexes that
are greater than 0.12 seconds.
NCLEX
“BRAIN BUSTER” QUESTION
A client newly transferred to the unit presents
with a rapidly declining respiratory status
after becoming septic. Which assessment
finding requires the nurse to contact the
healthcare provider (HCP)?
See below for nurse’s notes.

Crackles in both lung bases


A decline in PaCO2
Hypoxemia unresponsive to treatment
Temperature 102* (38.9*C)

Answer & Rationale


• Ask: Findings requiring HCP notification

• Problem: Sepsis with respiratory decline, decreasing PaO2, & increasing CO2

• Solution: Think about findings to share with the HCP that leads to the worst
possible outcome. Consider hypoxia

1. Incorrect - Crackles are expected in acute respiratory syndrome and would not require
contacting the HCP.
2. Incorrect - The decline in PaCO2 is a positive finding thus does not require HCP notification
3. Correct - Hypoxemia that does not respond to treatment is the hallmark sign of
acute respiratory syndrome and has a high mortality rate.
4. Incorrect - A temperature of 102 F is an expected finding for a client who is diagnosed
with sepsis and does not need to be reported to the HCP.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides care for a client who is
diagnosed with Addison’s disease. Which
clinical manifestation does the nurse
anticipate for this client due to primary
adrenocortical insufficiency?
Select all that apply.

Skin color that is tanned in appearance

Anorexia and weight loss

Increased body or facial hair

Orthostatic hypotension

Purple or red striae on the abdomen

Answer & Rationale


• Ask: Clinical Manifestations
• Problem: Addison’s Disease
• Solution: Think Addison’s = “ADD some steroid”. We have an absence of steroids
so our clients appear skinny and frail with a dark tan.

1. Correct - Tanned pigmentation of the skin is expected for the client


diagnosed with primary adrenocortical insufficiency.
2. Correct - Anorexia with weight loss is an expected clinical manifestation.
3. Incorrect - Hirsutism is an expected clinical manifestation for the client who is
diagnosed with Cushing syndrome, not Addison’s disease.
4. Correct - Orthostatic hypotension is an expected clinical manifestation.
5. Incorrect - Striae on the abdomen is an expected finding for the client diagnosed
with Cushing syndrome, not Addison’s disease.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides discharge instructions for a
client who has been hospitalized four times in the
past twelve months for complications associated
with congestive heart failure (CHF). Which client
statement indicates an accurate understanding
of the information presented by the nurse?
Select all that apply.

“I will eat lightly salted pretzels and potato chips for snacks”

“I can eat canned soup and a sandwich for lunch each day”

“I will try to walk a mile each morning if it’s not raining”

“I will use salt-substitute to maintain good potassium levels”

“I will weigh myself every morning right after my shower”

Answer & Rationale


• Ask: Statements indicate understanding
• Problem: Teaching related to frequent hospitalizations for CHF
• Solution: Think of statements that show correct understanding of teaching

1. Incorrect - CHF patients should decrease Na+ and fluid intake. All of these food choices
contain sodium.
2. Incorrect - Education for CHF must include the importance of decreasing sodium and fluid
intake. Canned soup is high in sodium
3. Correct - Education for CHF includes encouragement of regular moderate exercise.
4. Correct - Diuretics can cause hypokalemia & the use of salt-substitute indicates
understanding. Digoxin, used to treat CHF, is impacted by serum K+
5. Correct - Education with CHF includes monitoring for symptoms indicative of worsening
heart failure (e.g., fluid volume excess, weight gain, edema).
NCLEX
“BRAIN BUSTER” QUESTION
Which education point will the registered nurse
(RN) provide to the client diagnosed with peripheral
neuropathy related to type 2 diabetes?
Select all that apply

“Avoid wearing socks to prevent an increase in sweating and skin irritation”

“Keep toenails cut close to the skin to avoid breakage of the nails”

“Check the water temperature in tubs with a thermometer prior to


entering the tub”

“Check your feet, especially between your toes, each day and report any
skin changes immediately”

“Always wear some type of shoe, even if it is sandals when walking in the
home or outdoors”

Answer & Rationale


• Ask: Which education to provide
• Problem: Peripheral neuropathy related to diabetes mellitus type II
• Solution: Before looking at the options- Think of two things you know about
peripheral neuropathy related to diabetes mellitus type II.
Memory Trick: Diabetes - Destroys the organs with THICK syrupy blood!
Diabetes = Diatreties - turns fingers & toes into sugary treats for bacteria peripheral
neuropathy—check feet/no heat.
- decreased sensation in the extremities
- increased risk of injury because of decreased sensation
1. Incorrect - The client should wear cotton socks to help absorb sweating and protect the feet.
2. Incorrect - The client should not cut the nails close to the skin, but should instead file the nails,
avoiding the skin.
3. Correct - The diabetic client with peripheral neuropathy has lost sensation in the
extremities so a thermometer is needed to discern accurate temperature.
4. Correct - The client with peripheral neuropathy cannot determine if there is injury to
the feet through sensation so daily inspection is necessary.
5. Incorrect - The client should always wear shoes when ambulating, but these shoes should be
closed toe/heel type shoes.
NCLEX
“BRAIN BUSTER” QUESTION
Which medication does the nurse expect the
healthcare provider (HCP) to prescribe for a
client who is diagnosed with heart failure and
reports a nagging cough and an incident
of angioedema with the use of
enalapril?

Alprazolam 0.75mg PO daily

Guaifenesin 15 mg daily

Captopril 40 mg PO daily

Losartan 80 mg PO daily

Answer & Rationale


• Ask: Best medication substitution
• Problem: Nagging cough & angioedema with enalapril
- Think side effects of ACE inhibitors end in “-pril” which are first
line drugs for HIGH blood pressure.
ARBs “-Sartan” is SSSecond line drug
• Solution: Substitution for ACE medication
1. Incorrect - “-pam” and “-lam” are benzos, nothing to do with blood pressure
2. Incorrect - guaifenesin is a cough medication, nothing to do with blood pressure
3. Incorrect - “-pril” which is another ACE
4. Correct - Sartans are used SSSecond, after ACE inhibitors if the side effects
are too much
NCLEX
“BRAIN BUSTER” QUESTION
Which clinical manifestation does the
nurse anticipate when providing care
for a client who is diagnosed with
Graves’ disease?
Select all that apply.

Hand tremors
Irregular heart rhythm
Increased perspiration
Insomnia and anxiety
Exophthalmos
Obesity

Answer & Rationale


• Ask: Anticipated clinical manifestations
• Problem: Graves’ Disease
• Solution: Think Graves’ Disease means Gains Disease. HYPERthyroidism.
Everything is high & hot so consider clinical manifestations that fall in this hyper and hot state.

1. Correct - Tremors of the fingers and the hands are an expected clinical manifestation for a
client who is diagnosed with Graves’ disease.
2. Correct - Heart palpitations or AFib are both clinical manifestations associated with Graves’ disease.
3. Correct - Increased metabolic rate caused by an increase in thyroid hormones causes heat
intolerance and increased perspiration.
4. Correct - Insomnia and anxiety are the direct result of the hypermetabolic rate that is caused by
the increases in thyroid hormones.
5. Correct - Hyperthyroidism causes tissue expansion of the muscle fibers located in the eye which
causes exophthalmos and a lag in the eyelid.
6. Incorrect - The increased metabolic rate associated with Graves’ disease causes a decreased appetite
leading to weight loss, not weight gain or obesity.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse is assessing a client who has
been taking levothyroxine for two
months for hypothyroidism. Which
client statements should the nurse
report? Select all that apply.

“I take my levothyroxine each morning with my coffee or a full


glass of grapefruit juice.”
“I eat breakfast about 30-60 minutes after taking levothyroxine
each morning.”
“I will notify my healthcare provider immediately if I develop a
sore throat/fever.”
“The extreme fatigue I was experiencing seems to be improving.”
“Each morning, I take levothyroxine, biotin, and a multivitamin.”

Answer & Rationale


• Ask: Incorrect statements

• Problem: Taking levothyroxine for two months

• Solution: Remember LEVothyroxine LEAVES those thyroid hormones in the body which
makes everything amped up

1. Correct - Coffee and grapefruit juice inhibit the absorption of levothyroxine.


2. Incorrect - Levothyroxine should be taken at the same time each morning, with a full
glass of water, on an empty stomach, 30-60 minutes prior to breakfast.
3. Incorrect - Agranulocytosis is an adverse effect of antithyroid medication and the client
should be instructed to notify the health care provider about symptoms of infection.
4. Incorrect - Extreme fatigue would indicate the client was still experiencing hypothyroid symptoms.
5. Correct - Multivitamins, when taken concurrently with levothyroxine, inhibit the
absorption of levothyroxine and administered at least 4 hours apart.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides discharge instructions to a client
who is diagnosed with peripheral arterial disease
(PAD). Which client statement indicates a need
for further instruction from the nurse?
Select all that apply.

“A heating pad should be used to restore circulation”


“Anytime I am resting, I should elevate my legs”
“I will begin walking around the neighborhood”
“Moisturizing lotion should be applied to my legs daily”
“Swelling is an expected finding with this disorder”

Answer & Rationale


• Ask: Statements needing clarification
• Problem: Discharge teaching for PAD
• Solution: Think about incorrect statements by the patient for PAD

1. Correct - Due to peripheral neuropathy, the client may be unable to detect burning
of the skin.
2. Correct - Clients with PAD should not elevate their legs for long periods as this
further decreases circulation to the extremities.
3. Incorrect - Moderate physical activity promotes circulation and should be encouraged for
clients with PAD.
4. Incorrect - Daily skin care, including moisturizing the extremities with lotion, is included in
the plan of care for clients with PAD.
5. Correct - Edema is expected in clients with peripheral venous insufficiency;
however, this is not an expected finding in clients with PAD
NCLEX
“BRAIN BUSTER” QUESTION
A client reports calf pain when walking from
the car to the supermarket. The pain stops
when walking stops. Which assessment
should the nurse perform?
Select all that apply.

Assess both ankles for venous stasis ulcers and dermatitis


Determine color and temperature of the lower extremities
Establish if the client monitors their blood pressure daily
Palpate presence and quality of dorsalis pedis pulses

Answer & Rationale


• Ask: Assessments to perform
• Problem: Client complaining of calf pain when walking from the car to the
market and it stops when walking stops
• Solution: Think about intermittent claudication (calf pain) think intermittent
“CALVE-ication”. When you’re walking, you have low oxygen to the
muscles.
1. Incorrect - Ankle edema, venous stasis ulcers, and dermatitis indicate PVD,
These symptoms are indicative of intermittent claudication indicating
peripheral PAD.
2. Correct -The nurse should immediately check for blood flow by monitoring
color, temperature changes & other PAD symptoms.
3. Incorrect - This is not relevant to determine if the client is experiencing
intermittent claudication and PAD.
4. Correct - The nurse should immediately check for blood flow by checking
the most distal pulses.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides medication teaching for a client who
is newly prescribed citalopram for major depressive
disorder. Which client statement indicates a correct
understanding of the education provided
by the nurse for this medication?
Select all that apply.

“I should expect some confusion as a result of this medication.”


“If I miss a dose, I should not double my next dose.”
“I will eat a well balanced diet and exercise to control weight gain.”
“I won’t stop this medication abruptly.”
“I might experience issues with sexual dysfunction.”
“When I begin to feel better, I can stop taking this medication.”

Answer & Rationale


• Ask: Correct client statement

• Problem: Education about citalopram

• Solution: Look for remarks that are true Remember the S’s. We don’t take St. John’s Wort
with SSRIs. SSRIs can increase the Suicidal ideations and often causes Sexual
dysfunction
1. Incorrect - Confusion, a symptom associated with serotonin syndrome, is an adverse
reaction to medication, not an expected side effect.
2. Correct - The client should not take a double dose if the medication is missed due to
the increased risk for serotonin syndrome.
3. Correct- This medication is associated with increased appetite which can cause weight gain.
4. Correct- Stopping this medication abruptly may cause withdrawal symptoms.
5. Correct - Many selective serotonin reuptake inhibitors (SSRIs) may cause sexual dysfunction.
6. Incorrect -This medication should not be stopped when symptoms of depression are better.
NCLEX
“BRAIN BUSTER” QUESTION
Which information should the nurse include
when providing medication teaching for
a client who is newly prescribed rifampin
300 mg PO twice daily?
Select all that apply.

Avoid wearing prescription contacts during treatment


Limit alcohol intake to only a few times per week
Report any red discoloration of urine and other body fluids
to the HCP immediately
Stop the medication if two sputum cultures come back negative
Use non-hormonal forms of birth control while taking this
medication

Answer & Rationale


• Ask: Information to include

• Problem: Education about Rifampin 300 mg po twice daily

• Solution: Think about teaching. With Rifampin, think RED like a reef, “REEF-ampin”.
Bodily fluids can turn red.

1. Correct - Rifampin causes an orange-red discoloration of bodily secretions, including


tears, which can permanently discolor contact lenses
2. Incorrect -The consumption of alcohol is contraindicated for the client who is prescribed
rifampin due to the increased risk of hepatotoxicity.
3. Incorrect - This is an expected side effect.
4. Incorrect - Three negative sputum cultures and a negative chest x-ray indicate medication
effectiveness.
5. Correct - Rifampin can interact with oral hormonal contraceptives causing them to be
ineffective for the prevention of pregnancy.
NCLEX
“BRAIN BUSTER” QUESTION
Which action should the nurse implement first
when providing care for a client being
admitted to the unit following stent placement
for treatment of an ST segment elevation
myocardial infarction (STEMI)?

Assess heart and lung sounds


Assess blood pressure first then other vitals
Obtain serial troponin levels
Place the client on telemetry

Answer & Rationale


• Ask: First action to implement

• Problem: Admission with STEMI

• Solution: Think about priority actions on monitoring cardiac rhythm and


circulatory function.

1. Incorrect - Initiating telemetry = immediate priority action on arrival to the unit.


2. Incorrect - Telemetry is first priority action; vital signs should be monitored
closely after.
3. Incorrect - Critical need to continue monitoring the client for dysrhythmias
immediately after STEMI so this is not the priority.
4. Correct - This is the priority action on arrival to unit post STEMI; VFib =
most common & lethal arrhythmia after MI.
NCLEX
“BRAIN BUSTER” QUESTION
A client with a head injury develops syndrome of
inappropriate antidiuretic hormone (SIADH).
Which clinical manifestations should the nurse
expect when assessing this client?
Select all that apply.

Decreased urine output


Elevated serum osmolality
Elevated urine specific gravity
Decreased serum osmolality
Decreased serum sodium

Answer & Rationale


• Ask: Clinical manifestations
• Problem: SIADH
• Solution: Think SIADH - SI we have a lot of water in the body…. ADH it adds the H2O.
SIADH results in elevated levels of antidiuretic hormone. Elevated ADH,
hypervolemia and decrease in serum osmolality and sodium. Think “S” for
SIADH as Soaked inside.
1. Correct - Urine output is decreased for the client who experiences SIADH.
2. Incorrect - The increase in total body water that occurs as a result of SIADH causes a
low serum osmolality due to dilution.
3. Correct - As antidiuretic hormone (ADH) continues to be secreted and water is
retained, the client experiences a high specific gravity of the urine.
4. Correct - Due to the increased total body water that is dilute, low serum
osmolality is expected for the client who is diagnosed with SIADH.
5. Correct - Due to the increased total body water that is dilute, decreased serum
sodium is expected for the client who is diagnosed with SIADH.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides care for a pediatric
client who is diagnosed with central
diabetes insipidus (DI). Which is the
priority action by the nurse in the
provision of care for this child?

Assessing the child’s daily activity


Monitoring intake & output (I&O)
Instructing the family on medication administration
Educating the child’s caregivers on symptoms of
water intoxication

Answer & Rationale


• Ask: Priority action

• Problem: Central Diabetes Insipidus (DI)

• Solution: Memory trick for DI: The “D” is draining fluid from the body into the
potty, leading to “D” for dehydration & dry Inside. Nursing
interventions: measuring I&Os and preventing dehydration

1. Incorrect - This is not the priority action by the nurse.


2. Correct - I&O provides essential information used to determine the need to
adjust medications; therefore, this is the priority action by the nurse.
3. Incorrect - The medication dose is based on the child’s I&O, thus is not the
priority action by the nurse.
4. Incorrect - Monitoring I&O is the priority nursing action as this information is
required for the therapeutic management of this disease process.
NCLEX
“BRAIN BUSTER” QUESTION
A client who is diagnosed with type 1 diabetes mellitus
(DM) reports abdominal pain, appears weak, and is
displaying Kussmaul respirations at 30 breaths/minute.
What prescription should the nurse implement in
the provision of care for this client?
Select all that apply.

Dextrose 50% by intravenous (IV) push


Draw blood for the prescribed serum potassium level
Obtain a STAT capillary blood glucose measurement
Regular insulin by IV infusion
Start an IV line and begin an infusion of 0.9% sodium chloride

Answer & Rationale


• Ask: Prescription to implement
• Problem: Type 1 diabetes with abdominal pain, weakness, & Kussmaul respirations
• Solution: Think about what could kill the client fastest. With type 1 diabetes, it’s
typically DKA. Memory trick for treatment of DKA: the DRY first, KILL the
sugar with insulin, and ALWAYS add potassium.
1. Incorrect - Intravenous administration of dextrose is not appropriate for the alert client
experiencing hyperglycemia.
2. Correct - A serum k+ level should be assessed at the start of insulin therapy
because insulin promotes k+ entrance in the cells causing further imbalances.
3. Correct - It is appropriate for the nurse to obtain a capillary blood glucose
measurement to confirm the probable diagnosis of diabetic ketoacidosis (DKA).
4. Correct - Insulin administration to treat hyperglycemia by IV infusion is an
expected medical prescription for the client who experiences DKA.
5. Correct - This priority intervention is implemented prior to infusion of regular
insulin to correct hypovolemia and serum glucose levels.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse notes that a client is prescribed
amitriptyline. Which reasons should
the nurse suspect this medication was
prescribed for this client?
Select all that apply

Urinary Retention
Neuropathic pain
Depression
Mood-stabilizer
Dysrhythmia

Answer & Rationale


• Ask: Reasons for medication
• Problem: Amitriptyline prescribed
• Solution: Amitriptyline is a TCA used to treat neuropathic pain, depression,
and insomnia. Memory trick: Amitriptyline sounds like “Amy trips
on things.” Side effects include falls, urinary retention, constipation,
blurred vision, dry eyes, & dysrhythmias.
1. Incorrect - Urinary retention is a side effect of amitriptyline, not an indication for use.
2. Correct - Amitriptyline is used to treat neuropathic pain.
3. Correct - Amitriptyline is used to treat insomnia.
4. Correct - Amitriptyline is used to treat mood disorders.
5. Incorrect - Dysrhythmia is a side effect of amitriptyline, not an indication for use.
NCLEX
“BRAIN BUSTER” QUESTION
A client receiving an intravenous (IV) infusion of
heparin has the following lab values: admission
platelet count of 210,000/mm3 (210 x 109/L) 48
hours ago and a current platelet count of
90,000/mm3 (90 x 109/L). Which action should
the nurse implement first based on the
current data?

Stop the heparin infusion


Reconfirm the results with a new blood specimen
Report the results to the healthcare provider (HCP)
Perform a head to toe assessment

Answer & Rationale


• Ask: Priority action
• Problem: Infusion of IV heparin w/ massive platelet drop
• Solution: Think huge bleed risk. Memory trick: anything less than 150 is very
iffy and anything less than 50 is very risky. Think about interventions to
prevent bleeding.

3. Correct - Stopping the infusion is the priority action due to potential


heparin-induced thrombocytopenia (HIT).
2. Incorrect - While it is appropriate to monitor platelet count, this action is not the
priority and allows the heparin to continue to infuse which increases the
risk for bleeding.
3. Incorrect - The results should be reported to the HCP; however, the priority action is to
stop the heparin infusion.
4. Incorrect - While it is appropriate to conduct an assessment, this action is not the priority
and allows the heparin to continue to infuse which increases the risk for bleeding.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides care for a hospitalized client who
is diagnosed with type 1 diabetes mellitus (DM).
Which prescription should the nurse clarify with
the healthcare provider (HCP)?

8 units of regular insulin by IV infusion for serum


glucose greater than 300 mg/dL
12 units of subcutaneous detemir insulin daily at 2000
16 units of subcutaneous lispro insulin daily at 1000
before breakfast
18 units of NPH insulin PO daily at 0700 for blood
glucose greater than 80 mg/dL

Answer & Rationale


• Ask: Incorrect prescription order

• Problem: Insulin dependent type 1 diabetic

• Solution: Think about insulin orders that are not right

1. Incorrect - Regular insulin is a short-acting insulin that is prescribed to treat


hyperglycemia.
2. Incorrect - Detemir insulin is a long-acting insulin that is prescribed and
administered one time per day to treat type 1 DM.
3. Incorrect - Lispro insulin is a fast-acting insulin that begins to work 15 minutes
post administration.
4. Correct - NPH insulin is an intermediate acting insulin with an onset of
action of 1 hour. Insulin is not administered orally.
NCLEX
“BRAIN BUSTER” QUESTION
A client who is newly diagnosed with asthma is prescribed
inhaled albuterol and beclomethasone. Which statements
should the nurse include when providing instruction
on the proper use of the prescribed medications?
Select all that apply.

“If you need both inhalers use the albuterol first to open the airway.”
“Rinse your mouth and swallow the water after use of beclomethasone.”
“Use the beclomethasone inhaler as a rescue medication if it is hard to
breathe.”
“Wash the mouthpiece of albuterol inhaler at least once a week.”
“Wash the mouthpiece of the beclomethasone inhaler daily to reduce
risk of thrush.”
“Do not use the beclomethasone if albuterol provides you with symptom
relief.”

Answer & Rationale


• Ask: Statements to include in teaching
• Problem: New prescriptions for albuterol & beclomethasone
• Solution: Remember that albuterol should be used before steroids. Bronchodilating
airways allows the steroids to get into the lower airways. Think: “Steroid
sink.”
1. Correct - Albuterol is a rescue inhaler that opens the client’s airways.
2. Incorrect - It is appropriate to rinse the mouth after, but not swallow the water.
3. Incorrect - Beclomethasone is a maintenance, not rescue medication.
4. Correct - The mouthpiece of the inhaler should be washed weekly to decrease
the risk for bacterial growth.
5. Correct - Beclomethasone can increase the client’s risk for developing fungal
infections (e.g., thrush) in the mouth.
6. Incorrect - Beclomethasone is a medication that is used daily for maintenance and is
not a rescue medication.
NCLEX
“BRAIN BUSTER” QUESTION
Which factor should the nurse recognize
as a potential contributor to the high
pressure alarm on a client who is
mechanically ventilated?
Select all that apply.

An air leak in the endotracheal (ET) tube


Obstruction in endotracheal tube
Client biting down on endotracheal tube
Client coughing vigorously
Ventilator tubing is kinked

Answer & Rationale


• Ask: Potential cause
• Problem: High pressure alarm on mechanical ventilator
• Solution: Think high pressure alarm is high blockage, then determine what’s
blocking the flow
1. Incorrect - A leak in the ET tube will decrease airway resistance & trigger the low-
pressure, not high-pressure limit alarm.
2. Correct - The accumulation of secretions within the ET tube can obstruct the
airway and increase airway resistance.
3. Correct - Biting down on the ET tube can cause an obstruction or kink the tubing.
4. Correct - Excessive coughing or bronchospasms decrease lung compliance &
increase the resistance & set off the high pressure alarm.
5. Correct - Ventilator tubing kinks can increase airway resistance & obstruct
airflow, causing high pressure alarm.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides care for a client who
is prescribed carbidopa-levodopa for the
treatment of Parkinson’s disease.
Which assessment finding indicates
that the medication is having
the desired effect?

Delusional episodes are minimal


Decreased episodes of syncope
Steady gait with movements that are fluid
Undisturbed sleep patterns

Answer & Rationale


• Ask: Assessment findings
• Problem: Desired effects of Carbidopa-levodopa
• Solution: Think: -dopa is for dopamine; it treats uncontrolled movements with
Parkinson’s disease. Desired outcome: less crazy movements.
1. Incorrect - Delusions are not common for clients diagnosed with Parkinson’s disease.
2. Incorrect - Syncope is not a common manifestation associated with Parkinson’s disease
3. Correct - Parkinson’s disease causes tremors and rigidity which leads to gait
instability.
4. Incorrect - Disturbed sleep patterns is not a common manifestation associated with
Parkinson’s disease.
NCLEX
“BRAIN BUSTER” QUESTION
A client with a patient-controlled analgesia (PCA) pump
receives 0.2 mg of hydromorphone every 5 minutes.
The client states, “My lower back hurts. I am pushing
the button every 5 minutes.” Which is a priority
nursing action for continued pain despite the
use of the prescribed PCA pump?
Select all that apply.

Contact the healthcare provider for an additional pharmacologic


pain medication
Complete a thorough pain evaluation
Request a prescription for a higher dosage of the current pain
medication
Review correct usage of the PCA pump with the client
Apply an ice pack to the client’s lower back
Document the data in the client’s medical record

Answer & Rationale


• Ask: Priority nursing action
• Problem: Persisting pain after using PCA pump
• Solution: Persistent pain. Assessment of pain. Think of the best option to do.

1. Incorrect - The nurse should implement nonpharmacologic pain management interventions


before contacting the HCP.
2. Correct - It is essential for the nurse to complete a thorough pain evaluation so that the
plan of care can be adjusted.
3. Incorrect -This action can be implemented after a thorough pain evaluation and the
administration of non pharmacological pain management strategies.
4. Incorrect - The PCA is being used correctly. In addition, education is not likely to be
comprehended by the client who is experiencing unrelieved acute pain.
5. Correct - The addition of non pharmacological strategies may provide the client with
pain relief and should be implemented prior to any medication changes.
6. Incorrect - Addressing the client’s pain with the implementation of nonpharmacologic
interventions is the priority action by the nurse.
NCLEX
“BRAIN BUSTER” QUESTION
Which data requires intervention by the nurse
when providing care for a client who is prescribed
both vancomycin and tobramycin?
Select all that apply.

Blood urea nitrogen (BUN) of 12 mg/dL


Creatinine over 1.3mg/dL
Erythropenia
Ecchymosis
Red spotted petechiae around chest

Answer & Rationale


• Ask: Which data requires intervention
• Problem: Prescribed vancomycin and tobramycin
• Solution: (Think: it’s a sin to give a -mycin. It kills the kidneys, leading to
nephrotoxicity and ototoxicity. Consider the type of toxicity.)
1. Incorrect - While an elevated BUN level can indicate nephrotoxicity, this BUN is within
normal range; therefore, this data does not require intervention by the
nurse.
2. Correct - These medications are nephrotoxic and the normal range for serum
creatinine is 0.6 to 1.2 mg/dL (53 to 106 mmol/L).
3. Incorrect - Ecchymosis is indicative of bleeding. The prescribed medications are not
associated with an increased risk for hemorrhage.
4. Incorrect - The prescribed medications are not associated with hepatotoxicity, an issue
that would impact the production of RBCs.
5. Incorrect - The prescribed medications are not associated with an increased risk for
hemorrhage.
NCLEX
“BRAIN BUSTER” QUESTION
Which intravenous fluid (IV) fluid
prescription should the nurse clarify
with the client’s healthcare
provider (HCP)?

Hypotonic IV fluids for a client with syndrome of inappropriate


antidiuretic hormone
Isotonic IV fluids for a client with significant blood loss after a
trauma
Isotonic IV fluids to be given as 1,000mL bolus for a client with
septic shock
Ringer’s lactate solution infusion for a client with hypovolemic
shock from a burn injury

Answer & Rationale


• Ask: Prescription requires clarification
• Problem: IV fluids ordered
• Solution: Look at the orders or prescriptions that are wrong
1. Correct - Hypotonic IV solutions are contraindicated in clients with SIADH
because these solutions will further dilute the client’s blood.
2. Incorrect - Isotonic fluids such as normal saline are expected and appropriate
for hypovolemia due to a bleed.
3. Incorrect - Fluid volume deficit & decreased BP can be treated with an isotonic
solution bolus of 0.9% NS as this expands the vascular volume and
increases blood pressure.
4. Incorrect - Lactated Ringer’s is often prescribed to replace fluid and electrolyte
imbalances caused by burn injuries.
NCLEX
“BRAIN BUSTER” QUESTION
A client is admitted for the treatment of pleural effusion.
Which is the priority nursing action, based on the
assessment data below, when the client’s chest tube
has drained 240 mL of bright red drainage the past hour?
Client assessment: A&O x 3; pain is 7 of 10 using
a numeric scale; pulse oximetry 90% on 2 L/min
nasal cannula (NC); heart rate is 92 beats/minute;
blood pressure is 100/62 mm Hg; and
respiration rate is 22 breaths/minute.

Administer prescribed morphine 4 mg by the IV route


for pain
Contact the healthcare provider (HCP)
Immediately raise the level of the client’s chest tube
Continue to monitor the client’s chest tube drainage

Answer & Rationale


• Ask: Priority action
• Problem: Pleural effusion; 240 mL bright red drainage from chest tube in hour;
O2 90% on 2L/min
• Solution: Think excessive blood loss. Anything greater than 100mL per hour is very
alarming. Consider interventions to prevent that worst possible outcome.
1. Incorrect - Pain is expected after insertion of a chest tube and administration of pain
medication is not the priority.
2. Correct - Drainage that is red, free-flowing or in large amounts greater than 100
mL per hour is indicative of hemorrhage.
3. Incorrect - A chest tube drainage system must always be placed below the level of the
chest and secured in an upright position.
4. Incorrect - While this is required as a normal nursing assessment as per facility
protocol, this is not the priority action based on the current data.
NCLEX
“BRAIN BUSTER” QUESTION
Which laboratory tests will the nurse
anticipate to receive orders to monitor
a client taking metformin for type 2
diabetes? Select all that apply.

Glycated hemoglobin (HgbA1c)


Cardiac enzymes
Liver enzymes
Creatinine
Brain natriuretic peptide (BNP)

Answer & Rationale


• Ask: Which labs to monitor
• Problem: Metformin for type 2 diabetes
• Solution: Think about a few things about monitoring a client on metformin
like glucose-related labs, labs that reflect toxicity (i.e. liver & kidney)
1. Correct - Glycated hemoglobin (HgbA1c) is used to monitor the
effectiveness of the medication.
2. Incorrect - Cardiac enzymes are not affected by this medication.
3. Correct - A major adverse effect of this drug is liver toxicity.
4. Correct - A major adverse effect of this drug is kidney toxicity.
5. Incorrect - This answer is not correct because the brain natriuretic peptide (BNP)
blood test is used to determine the extent of heart failure.
NCLEX
“BRAIN BUSTER” QUESTION
Which action implemented by the novice nurse in
the provision of care for a client who is intubated
and mechanically ventilated requires
intervention by the nurse preceptor?
Select all that apply.

Administers the prescribed PRN IV lorazepam 1mg to help the


client’s restlessness
Activates suctioning while placing the catheter in the endotracheal
(ET) tube
Preoxygenates client and increases oxygen during suctioning
Suctions the ET tube for at least 20 seconds per pass
Suctions client when the high-pressure alarm is sounding
Suctions client when rhonchi and visible secretions are present

Answer & Rationale


• Ask: Actions requiring intervention
• Problem: Intubated and on mechanical ventilation
• Solution: Looking for the incorrect actions by the new graduate nurse so think about
the wrong actions.
1. Incorrect - Restlessness can cause the client to fight the ventilator assisting with
breathing thus resulting in decreased oxygen exchange.
2. Correct - When suctioning a client’s ET tube, the nurse activates the suction when
removing the catheter and not with insertion.
3. Incorrect - Evidence-based practice (EBP) guidelines support oxygen supplementation
prior to and during suctioning.
4. Correct - Evidence-based practice (EBP) guidelines indicate that suctioning
should only occur for 10-15 seconds per pass.
5. Incorrect - The high pressure alarm may alert for a client whose airway is occluded due
to thick secretions.
6. Incorrect - This action by the novice nurse assists with airway clearance allowing for
adequate oxygenation.
NCLEX
“BRAIN BUSTER” QUESTION
Which fetal heart rate monitor tracings
indicates a need for priority nursing
intervention when providing care to
a laboring mother?

Early accelerations
Early decelerations
Fetal heart rate of 176 beats per minute
Sinusoidal fetal heart rate

Answer & Rationale


• Ask: Priority intervention
• Problem: Fetal heart rate monitor tracing
• Solution: To identify the need for priority intervention, apply the
characteristics of various heart rate monitoring tracing. Consider
normal vs abnormal; late decels typically are worse.
1. Incorrect - Early accelerations are category I.
2. Incorrect - Early decelerations are category I.
3. Incorrect - This is category II. While not predictive of abnormal fetal acid-base
status, this finding requires continued surveillance, but not priority
intervention by the nurse.
4. Correct - The true sinusoidal pattern is rare, but associated with increased
rates of fetal mortality and is the priority intervention.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse has several medications that are all
due at 0900. Determine what order the nurse
should administer medications to the
following clients. Label the clients 1-4
with 1 being the first priority and
4 being the last priority.

1 Inhaled steroid for chronic obstructive pulmonary disease;


client’s oxygen saturation is 92%
2 Blood pressure medication for hypertension; client’s blood
pressure is 146/88 mm Hg
3 Breathing treatment for asthma; client is displaying
wheezing and labored breathing
4 Scheduled ophthalmic drops for glaucoma; client is
reporting dry eyes

Answer & Rationale


• Ask: Order of priority
• Problem: Medication administration for multiple clients
• Solution: Think of two things you know about prioritization. Look for ABC issues first, then
safety. Also consider if needs are acute or chronic when deciding priority

Answer: 3124
#3. Acute problems take priority over chronic problems and this is the only acute client.
#1. Airway is priority, but this client is chronic with a stable O2 saturation.
#2. Blood pressure is a circulation issue and clients with airway/breathing issues are prioritized first.
#4. ABC issues should be addressed before the client with scheduled eye drops for glaucoma
NCLEX
“BRAIN BUSTER” QUESTION
Which action can be delegated appropriately
to an experienced unlicensed assistive
personnel (UAP)?
Select all that apply.

Applying a barrier cream to the skin after assessing a


client with bathing
Notify the healthcare provider of critical labs
Provide preoperative teaching about pain management
Perform sterile dressing changes to a client’s stage 3
pressure injury
Assuring bed is locked and height is at its lowest
position

Answer & Rationale


• Ask: Appropriate delegation
• Problem: Delegating actions to the UAP
• Solution: Think about the UAP’s scope of practice. Remember, unstable clients,
assessments, teachings, and medication administration cannot be delegated.
1. Correct - The UAP scope of practice is to assist with procedures that do not
require critical thinking or assessment and with activities of daily living.
2. Incorrect -This is outside the scope of practice for a UAP.
3. Incorrect - This action can only be performed by a registered nurse (RN) according to
the nurse practice act, RNs provide teaching to the client.
4. Incorrect - This is outside of the scope of practice for a UAP.
5. Correct - The UAP assists and supports the nursing staff by making sure safety
measures are in place before leaving a client’s room.
NCLEX
“BRAIN BUSTER” QUESTION
A client, with a family history of breast cancer,
is hesitant to take hormone replacement
therapy (HRT) to address hot flashes caused
by menopause. Which vitamin or herbal
preparation is a potential alternative
to HRT to address the client’s
hot flashes?

Garlic
Saw palmetto
Black cohosh
Niacin

Answer & Rationale


• Ask: Which vitamin/herbal preparation
• Problem: Menopausal with hot flashes; desires alternative treatment to HRT
• Solution: Think about alternative therapies. Black cohosh can lessen the severity
of hot flashes. It’s best for the client to discuss any herbal remedies with
their practitioner before use of any herbal remedies.

1. Incorrect - Garlic is an herbal remedy that boosts immunity, decreases inflammation,


and improves heart health.
2. Incorrect - Saw palmetto is an herbal remedy that is often used to promote prostate
health for male clients and may cause or exacerbate hot flashes in menopause.
3. Correct - Clients have found relief from hot flashes that are associated with
menopause through use of black cohosh, a herbal root remedy.
4. Incorrect - Niacin is a dietary supplement that may cause facial flushing which could
exacerbate hot flashes in menopause.
NCLEX
“BRAIN BUSTER” QUESTION
Which nursing action is appropriate for a
client who is admitted to the medical unit
for a worsening myasthenia gravis?
Select all that apply.

Administer neostigmine 1 mg IM before meals, as


prescribed
Contact the continence specialist for bowel training
Encourage foods such as scrambled eggs and milkshakes
Prepare to administer atropine 2 mg by IV push now
Remind the client of the importance of getting the
pneumonia vaccination

Answer & Rationale


• Ask: Appropriate nursing action
• Problem: Worsening myasthenia gravis
• Solution: Memory trick: for myasthenia gravis, think MG = Muscle Gravity issue,
where the body becomes weak, causing neuromuscular dysfunction.

1. Correct - Neostigmine is an anticholinesterase medication prescribed to treat the


symptoms of MG by decreasing the breakdown of acetylcholine.
2. Incorrect - Muscles that control bowel and bladder function are not affected with a
diagnosis of myasthenia gravis.
3. Correct - Since MG causes weakness in the muscles used for chewing, clients are
encouraged to eat foods that are easily chewed and swallowed.
4. Incorrect - Anticholinergic medication such as atropine would further decrease the
availability of ACh and worsen muscle weakness associated with MG..
5. Correct - Stress that is caused by physical illness can lead to myasthenic crisis so
clients should receive all recommended vaccinations.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides care for a client who is diagnosed
with multiple sclerosis (MS) and newly prescribed
interferon beta. Which instruction is most important
to include in the medication teaching session due
to the client’s increased risk for infection?

“Be sure to cleanse your skin with alcohol at least once a day”
“Fatigue and flu-like symptoms are expected with this medication”
“Avoid crowds and be sure to perform hand hygiene often”
“Report for an influenza screening immediately if you notice
yellowing of your skin.”

Answer & Rationale


• Ask: Which instruction is the most important to include
• Problem: A client with MS newly prescribed interferon
• Solution: Memory trick INTERFEREon interferes with the immune system
leading to an increased risk of infection & Flu-like s/s.
1. Incorrect - The use of alcohol on the skin is likely to cause impaired integrity
which increases the risk for infection.
2. Incorrect - These are adverse reactions to the prescribed medication thus the
client is taught to immediately report these findings should they occur.
3. Correct - Interferon beta causes immunosuppression so the client is taught
to avoid crowds and implement hand hygiene to decrease the
risk for infection.
4. Incorrect - Jaundice of the skin and yellowing of the sclera are indicators for
hepatotoxicity, not influenza.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse collects health history data for a client
who is newly diagnosed with Parkinson’s disease
and prescribed benztropine. Which client
statement indicates a contraindication
for the administration of the
prescribed medication?

“I have a family history of psychosis”


“I have a history of migraine headaches”
“I was diagnosed with narrow-angle glaucoma last year”
“I was diagnosed with peripheral neuropathy earlier
this year”

Answer & Rationale


• Ask: Statement indicates contraindication for medication
• Problem: Newly diagnosed with Parkinson’s Disease and prescribed benztropine
• Solution: Memory trick: with benztropine, think: “It’s like you’ve been tripping.”
This medication acts on blocking ACH in the central nervous system
and can cause falls; contraindicated in glaucoma, peptic ulcers,
duodenal & pyloric obstructions.
1. Incorrect - A family history of psychosis is not a contraindication for the prescribed
benztropine.
2. Incorrect - Based on the information given, this is not contraindicated even though
certain migraine medications have a risk of serotonin syndrome.
3. Correct - Benztropine is contraindicated in clients with narrow-angle
glaucoma as the medication increases intraocular pressure and
worsens glaucoma.
4. Incorrect - Peripheral neuropathy is not a contraindication to the use of
benztropine for the treatment of PD.
NCLEX
“BRAIN BUSTER” QUESTION
A young adult client is prescribed esomeprazole 40 mg PO
daily for gastroesophageal reflux disease (GERD) for the
past three years. The client has a history of frequent
gastritis within the last year; therefore, the health care
provider (HCP) discontinues the prescribed esomeprazole.
When the client asks the nurse why the medication
is being discontinued, which response by
the nurse is appropriate?

“You require antibiotic therapy for your gastritis and


esomeprazole is contraindicated.”
“The prescribed esomeprazole can increase your risk for
frequent infections.”
“An H-2 receptor antagonist is a better medication than
esomeprazole.”
“Misoprostol is a better medication for managing your condition.”

Answer & Rationale


• Ask: Appropriate response
• Problem: GERD with frequent gastritis; client questions discontinuation of esomeprazole
• Solution: Think about two things you know. It ends in -prazole, a PPI, that inhibits stomach
acid and increases the risk of GI infection such as gastritis.

1. Incorrect - The provider discontinued esomeprazole due to gastritis, not due to a need for antibiotic
therapy.
2. Correct - PPIs like esomeprazole decrease the production of the gastric acids that can
help protect the client from gastrointestinal infections.
3. Incorrect - This response fails to answer the client’s question; additionally, H2-receptor
antagonists also increase the risk for infection by decreasing gastric acid
production.
4. Incorrect - The nurse should address the client’s concern, not suggest another medication;
misoprostol is prescribed for NSAID induced peptic ulcer disease (PUD), not GERD.
NCLEX
“BRAIN BUSTER” QUESTION
Which action should the nurse initiate to
prepare a client who is diagnosed with
end-stage kidney disease for hemodialysis?
Select all that apply.

Administer the client’s morning dose of metoprolol and


enalapril
Assess heart and lung sounds and obtain present weight
Give subcutaneous heparin during dialysis to decrease clotting
Feel the fistula for the presence of a thrill and listen for a bruit
Review the client’s medical record for last post-dialysis weight

Answer & Rationale


• Ask: Action to take
• Problem: Preparing for hemodialysis
• Solution: Consider interventions to complete prior to the treatment.
1. Incorrect - The client could develop hypotension during dialysis and then uncontrolled
hypertension due to decreased drug concentrations post-dialysis.
2. Correct - Heart and lung sounds are always assessed and the client’s weight
provides information about how much fluid was removed during dialysis.
3. Incorrect - Once the client is connected to a dialysis machine, IV heparin is added to
the client’s blood to decrease the likelihood of clotting that can occur.
4. Correct - The fistula is assessed for a palpable thrill and/or audible bruit which
indicates patency. A lack of these findings could indicate thrombosis.
5. Correct - The client’s post-dialysis weight subtracted from pre-dialysis weight
determines the amount of fluid that is removed.
NCLEX
“BRAIN BUSTER” QUESTION
While providing education for implementing
home peritoneal dialysis (PD) to the client
and spouse, which priority intervention
will the nurse stress to the client?

Keep a record of weight daily


Follow sterile technique when caring for a PD catheter
Measure weight before and after performing PD
Adhere to the nutritional restrictions ordered

Answer & Rationale


• Ask: Priority intervention
• Problem: Implementing home peritoneal dialysis
• Solution: Think of the most important considerations for PD: safety and
infection prevention = priorities. Compliance means following fluid
& diet restrictions (protein and phosphorus)
1. Incorrect - This is a secondary intervention the nurse will instruct the client to
implement.
2. Correct - Following sterile technique when caring for the PD catheter helps
prevent peritonitis, the leading complication of peritoneal
dialysis.
3. Incorrect - This is a secondary intervention the nurse will instruct the client to
implement.
4. Incorrect - This is a secondary intervention the nurse will instruct the client to
implement.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides care for a client who is
prescribed fluorouracil for the treatment of
cancer. Which is a priority system for the
nurse to assess when monitoring for
complications associated with the
prescribed chemotherapeutic agent?

Respiratory
Integumentary
Cardiovascular
Gastrointestinal

Answer & Rationale


• Ask: Priority system to assess
• Problem: Prescribed fluorouracil for cancer treatment
• Solution: Two general actions of chemotherapy: decreases bone marrow and
leads to potential GI toxicity and damaged intestinal mucosa
1. Incorrect - The prescribed medication is not toxic to the client’s respiratory
system.
2. Incorrect - While skin changes can occur with most chemotherapeutic agents,
the prescribed medication is not toxic to the integumentary system.
3. Incorrect - The prescribed medication is not cardiotoxic.
4. Correct - The prescribed medication can cause gastrointestinal toxicity
which often manifests with massive diarrhea.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides care for a client who is diagnosed
with heart failure (HF) and is experiencing the
following symptoms: bilateral lower extremity
edema that is 4+ and a 5 pound (2.3 kg) weight
gain in the past 48 hours. Which medication
does the nurse anticipate an immediate
dosage change based on the current
data?

Furosemide 40mg PO once daily


Valsartan 40mg PO once daily
Metoprolol 100mg PO once daily
Isosorbide mononitrate 60mg PO once daily

Answer & Rationale


• Ask: Anticipated immediate medication dosage change
• Problem: Exacerbation of heart failure with severe edema weight gain
• Solution: Remember HF for heart fluid is HF for heavy fluid. The body is retaining too
much fluid. The #1 drug given for heavy fluid is -ide ending diuretics. -ides
make the body dry
1. Correct - This drug decreases fluid volume overload. During exacerbations, the
dosage is increased to enhance the impact & speed.
2. Incorrect - This medication is an angiotensin 2 receptor blocker and will not
immediately address the client’s fluid retention.
3. Incorrect - This medication is a beta blocker and will not immediately address the fluid
retention.
4. Incorrect - This medication is a nitrate and it will not immediately address the client’s
fluid retention.
NCLEX
“BRAIN BUSTER” QUESTION
Which clinical finding should the nurse expect when
assessing an infant with a left-to-right-sided
heart shunt? Select all that apply.

Clubbing of the fingers


Crackles and a heart murmur
Circumoral cyanosis when feeding
Decreased number of wet diapers
Diaphoresis during feedings

Answer & Rationale


• Ask: Expected clinical findings
• Problem: Left-to-right-sided heart shunt
• Solution: Think about infants with heart defects: oxygenation and oxygenation
becomes lower when feeding.

1. Incorrect - Clubbing of the fingers is associated with long-term cyanosis; however,


this is not an expected finding for an infant with a left-to-right-sided heart
shunt.
2. Correct - Crackles are anticipated with a L to R shunt due to CHF resulting
from overloading the heart with extra blood. A murmur is heard due
to the turbulence.
3. Incorrect - Mild cyanosis is sometimes associated with right-to-left heart shunts but
not left-to-right sided shunts. Left-to-right sided heart shunts are
considered acyanotic.
4. Correct - Decreased output occurs in a L to R sided heart shunt due to
decreased cardiac output causing decreased perfusion to the kidneys.
5. Correct - Sympathetic stimulation produces compensatory responses such as
diaphoresis during feedings; therefore, this is anticipated.
NCLEX
“BRAIN BUSTER” QUESTION
A client is prescribed beclomethasone/formoterol
for the treatment of chronic obstructive pulmonary
disease (COPD). When providing medication
teaching to the client, which statement indicates
to the nurse that additional instruction is
warranted? Select all that apply.

“I might experience joint or muscle pain as a side effect.”


“I will not smoke or use any tobacco products.”
“I will check with my doctor before taking any new medications.”
“I might have trouble sleeping because of this medication.”
“I will take this medication as soon as I have had trouble breathing.”
“I will wash my mouth with water and swallow for maximum
effectiveness.”

Answer & Rationale


• Ask: Incorrect statement
• Problem: Teaching for beclomethasone/formoterol
• Solution: Think this is a steroid and bronchodilator combination

1. Incorrect -Joint or muscle pain may be common side effects associated with the prescribed
medication, so this statement is accurate.
2. Incorrect - Smoking and the use of any tobacco products is avoided with the prescribed medication.
3. Incorrect - Due to the risk for drug to drug interactions, this statement indicates a correct
understanding of the information presented by the nurse.
4. Incorrect -Insomnia is an expected side effect of this medication.
5. Correct - Beclomethasone/formoterol is a maintenance medication and should not be
used as not a rescue medication.
6. Correct - It is not appropriate to swallow the water.
NCLEX
“BRAIN BUSTER” QUESTION
Which clinical manifestation noted in the
provision of client care should the nurse
immediately report to the health care
provider (HCP) due to the concern
of respiratory failure?
Select all that apply.

Inward chest movement on inspiration


Mental status changes
No sound of air movement on auscultation
An inability to speak more than one word without pausing
to breathe
A PaO2 level of 50mmHg and dyspnea
A PaCO2 level of 60mmHg and lethargy

Answer & Rationale


• Ask: Which manifestation to report immediately
• Problem: Respiratory failure
• Solution: Consider signs and symptoms of ineffective ventilation
1. Correct - Paradoxical breathing is a manifestation of respiratory failure that
indicates respiratory muscle fatigue.
2. Correct - Mental status changes may occur for clients who are at risk for
respiratory failure due to a lack of perfusion to the brain.
3. Correct - No sound of air movement on auscultation may be referred to as “silent
chest” & indicates that air is trapped in the lung & respiratory failure.
4. Correct - SOB that occurs with respiratory failure is often manifested with an
inability to speak more than one word without stopping to breathe.
5. Correct - Hypoxemia and dyspnea are indicators of impending respiratory failure.
6. Correct - Hypercapnia can eventually progress to respiratory acidosis.
NCLEX
“BRAIN BUSTER” QUESTION
A client in end stage renal failure taking
oral calcium acetate with meals wants
to take the medication after eating.
Which response should the
nurse make?

“That is fine as long as you take it after every meal”


“That is the best time to take it because it can irritate
your stomach otherwise”
“It works best if you take it right before eating”
“If you take it in the middle of your meal, you will
have fewer side effects”

Answer & Rationale


• Ask: Appropriate response
• Problem: Oral calcium for end stage renal failure taken after eating
• Solution: Calcium acetate is used to bind to phosphates in food and is best
absorbed on an empty stomach.

1. Incorrect - This answer is not correct because the absorption of the calcium acetate is
impaired by a full stomach, which decreases effectiveness.
2. Incorrect - Calcium acetate is not particularly known for causing gastric upset, and this
timing of the medication decreases the absorption of it.
3. Correct - It is prescribed to be taken right before meals because this is when
phosphate is ingested, best absorbed & most effective.
4. Incorrect - Taking the medication in the middle of the meal decreases absorption.
NCLEX
“BRAIN BUSTER” QUESTION
The critical care nurse provides care for a client
who is admitted for the treatment of head
trauma and prescribed mannitol to reduce
intracranial pressure (ICP). Which
electrolyte is the priority for the
nurse to monitor?

Potassium
Chloride
Magnesium
Sodium

Answer & Rationale


• Ask: Priority electrolyte to monitor
• Problem: Head trauma; prescribed mannitol to reduce ICP.
• Solution: Think about what you know about mannitol and which electrolyte to
monitor. Mannitol is an osmotic diuretic with rapid fluid shifts from the cell
into the vascular space. It can cause a loss of sodium and water.
1. Incorrect - Mannitol is an osmotic diuretic that causes the loss of sodium and water so
monitoring serum potassium levels is not a priority nursing action.
2. Incorrect - Mannitol is an osmotic diuretic that causes the loss of sodium and water so
monitoring serum chloride levels is not a priority nursing action.
3. Incorrect - Mannitol is an osmotic diuretic that causes the loss of sodium and water; so
monitoring serum magnesium levels is not a priority nursing action.
4. Correct - Mannitol causes the diuresis of sodium and water through the urination;
therefore, the nurse monitors the client’s serum sodium levels.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides care for a client with a history
of bipolar affective disorder who has become
increasingly lethargic and less responsive
through the shift after being admitted in acute
mania. Which is the nurse’s priority when
planning care for this client based on
the current data?

Altered thought process


Self-care deficit
Risk for dehydration
Risk for social isolation

Answer & Rationale


• Ask: Priority
• Problem: History of bipolar mania; increasingly lethargic
• Solution: Identify the most appropriate nursing diagnosis. Remember behavior
associated with bipolar mania and manifestations. Identify the nursing
diagnosis with the greatest risks.

1. Incorrect - The client’s physical needs take precedence over psychological needs.
2. Incorrect - This nursing diagnosis is appropriate for a client with bipolar affective
disorder; however, it is not the priority diagnosis at this time
3. Correct - A client who is diagnosed with BPAD may cycle through periods of
mania followed by depression and is at risk for malnutrition and
dehydration.
4. Incorrect - Impaired social isolation is an appropriate nursing diagnosis, but this is not
the priority diagnosis.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse is caring for a client taking a conventional
antipsychotic for schizophrenia. Which statement(s)
by the client’s family indicates teaching about
the medication is required?
Select all that apply.

“Length of treatment with this medication is usually 2-3 weeks.”


“Full therapeutic effect is expected in 4-6 weeks.”
“It is most probable that treatment with an antipsychotic will be life-long.”
“Conventional antipsychotics have less severe side effects than
newer medications.”
“Foods high in tyramine should be avoided while on this class of
medication.”

Answer & Rationale


• Ask: Statement indicates teaching required
• Problem: Taking conventional antipsychotic for schizophrenia
• Solution: Consider the key details around conventional antipsychotics.
Remember these kind of drugs take 4-6 weeks to take their full effect and
have more notable and severe side effects.
1. Correct - This answer is correct because treatment with conventional
antipsychotics for schizophrenia is longer than 2 to 3 weeks.
2. Incorrect - Full therapeutic effects of conventional antipsychotics are expected in 4-6 weeks.
3. Incorrect - This answer is not correct because treatment will most likely be life-long.
4. Correct - Generally conventional antipsychotics have more severe side effects,
such as EPS.
5. Correct - Foods high in tyramine should be avoided with monoamine oxidase
inhibitors (MAOIs), not typical antipsychotics.
NCLEX
“BRAIN BUSTER” QUESTION
A client who is diagnosed with major depressive disorder
was hospitalized twice in the past 4 months for suicidal
tendencies. The client tells the nurse, “I’m unemployed,
overweight, have no health insurance, feel alone, and
I just can’t do this anymore.” The client is currently
prescribed paroxetine but has not kept appointments
with the health care provider (HCP). Which
nursing diagnosis is most important
for this client?

Chronic low self-esteem


Disturbed thought process
Risk for self-harm
Risk for violence

Answer & Rationale


• Ask: Priority nursing diagnosis
• Problem: Major depressive disorder; two hospitalizations for suicidal tendencies in
4 months
• Solution: Remember that safety is top priority! Look for statements that point to
findings that can harm or kill the client.
1. Incorrect - This is an appropriate nursing diagnosis but it is not the most important
given the situation.
2. Incorrect - This is an appropriate nursing diagnosis but it is not the most important
given the situation.
3. Correct - The nurse’s priority in the provision of client care is to ensure safety;
therefore, this is the most appropriate nursing diagnosis.
4. Incorrect - This is an appropriate nursing diagnosis but it is not the most important
given the situation.
NCLEX
“BRAIN BUSTER” QUESTION
Which action should the nurse take to promote
therapeutic communication when providing
medication teaching to a client?
Select all that apply.

Explain the medication then leave the room


Assess both verbal and nonverbal cues of the client
Interrupt the client to provide more information about the
medication
Sit down and asks the client to provide more information about
the medication
Ask the client to share specific feelings about the diagnosis and
medications

Answer & Rationale


• Ask: Action to promote therapeutic communication
• Problem: Medication teaching
• Solution: Think of key things to consider with therapeutic communication. For
example, allowing the client to provide their own feelings, active listening,
clarifying insights, and understanding the client.
1. Incorrect - Abrupt departure prevents allowing the client time to ask questions or express
feelings, so this action does not facilitate therapeutic communication.
2. Correct - Therapeutic communication is an active form of listening that requires
respect and assessment of both nonverbal and verbal client cues.
3. Incorrect - This answer is not correct because interrupting shuts communication down and
is not therapeutic.
4. Correct - Therapeutic communication is active listening and requires time for the
client to express feelings in an unrushed and non-judgmental manner.
5. Correct - This allows the client time to express feelings about the disease process and
helps facilitate therapeutic communication.
NCLEX
“BRAIN BUSTER” QUESTION
Which immunization is anticipated for a
child who is human immunodeficiency
virus (HIV)-positive with a CD4
cell count of 500/mm3?
Select all that apply.

Measles
Mumps
Pneumococcal conjugate
Rubella
Varicella

Answer & Rationale


• Ask: Anticipated immunization in child
• Problem: HIV positive with a CD4 count of 500
• Solution: A child who is HIV positive is immunocompromised, so avoid live vaccines.
1. Incorrect - The measles vaccine is a live virus and should not be administered to this
client due to their compromised immune system.
2. Incorrect - The mumps vaccine is a live virus and should not be administered to this
client due to their compromised immune system.
3. Correct - Pneumococcal conjugate vaccine (PCV) is not a live virus and may be
administered to this client due to their compromised immune system.
4. Incorrect - The rubella vaccine is a live virus and should not be administered to this
client due to their compromised immune system.
5. Incorrect -The varicella vaccine is a live virus and should not be administered to this
client due to their compromised immune system.
NCLEX
“BRAIN BUSTER” QUESTION
Which vaccine is appropriate for a 1-year-
old pediatric client who is recovering from
Kawasaki disease and recently received
intravenous immunoglobulin (IVIG)
a few months ago?
Select all that apply

Haemophilus influenzae type b (Hib)


Hepatitis B (HepB)
Measles, Mumps, and Rubella (MMR)
Pneumococcal (PCV)
Varicella

Answer & Rationale


• Ask: Appropriate vaccines for 1-year old
• Problem: Recovering from Kawasaki disease and recently received IVIG
• Solution: Identify the age-appropriate vaccine and apply what you know about
Kawasaki treatment and timeline.
1. Correct - The HIB vaccine is inactivated and not live; therefore, it can be
administered to this child.
2. Correct - The hep B vaccine is inactivated and not live; therefore, it can be
administered to this child.
3. Incorrect - The MMR vaccine is live; therefore, it cannot be administered to this child.
4. Correct - The PCV vaccine is inactivated and not live; therefore, it can be
administered to this child.
5. Incorrect - The varicella vaccine is live; therefore, it cannot be administered to this child.
NCLEX
“BRAIN BUSTER” QUESTION
Which is a developmentally-appropriate
nursing action in the provision of care
for a 10-year-old client awaiting
an appendectomy?
Select all that apply.

Focus on any concerns about the appearance of the scar after the surgery
Help the child understand the long-term positive effects of the surgery
Help the child understand the procedure by showing simple pictures
Inform the client about the surgery 30 minutes before the procedure
Use correct terminology when referring to the anatomical parts of
the child

Answer & Rationale


• Ask: Developmentally appropriate activities
• Problem: 10 year old awaiting an appendectomy
• Solution: Identify developmentally appropriate actions. Apply what you know
about the milestones of a 10 year old and present age developmentally
appropriate materials of the procedure.
1. Incorrect - Scar appearance is not a big concern for a school-age client.
2. Incorrect - The school-age client is not concerned with long-term positive effects of
the surgery. Formal operational thinking occurs at age 12 (not 10).
3. Correct - Showing simple pictures to a school-age child appeals to concrete
thinking and is developmentally appropriate.
4. Incorrect - A school-age child should be provided with ample time to prepare for a
surgical procedure thus allowing comprehension and clarification.
5. Correct - This age group needs concrete communication to enhance
comprehension, such as the use of correct terminology.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse develops a plan of care for a preschool-age
client who requires medication administration.
Which action by the nurse is appropriate?
Select all that apply.

Ask the child, “Will you take your medicine now?”


Involve the child’s parents when administering an injection
Ask the child, “Do you want water or juice with your medicine?”
Allow the child to play with the syringe that is used to measure the
medication
Consult with the child’s practitioner to change the route of the
prescribed acetaminophen from rectal to oral

Answer & Rationale


• Ask: Appropriate action
• Problem: Medication administration to preschool aged client
• Solution: Think of 2 things we know about med admin for preschool age children -
Involving caregivers in the process and allow the preschooler to make simple and safe
choices

1. Incorrect - Asking a preschool-age client if they will take medication now is likely to result
in a response of no thus is counterproductive to the administration process.
2. Correct - Parental involvement often facilitates cooperation when administering
medication to a preschool-age client.
3. Correct - Providing the preschool-age child with simple choices in the process is
an appropriate action as it facilitates cooperation.
4. Correct - Allowing the child to play with equipment that is used in the process
facilitates familiarity thus enhances cooperation.
5. Correct - The rectal route can cause preschool-age children to experience distress
due to fear of bodily intrusion & mutilation.
NCLEX
“BRAIN BUSTER” QUESTION
The pediatric nurse provides care for an
infant who is diagnosed with tetralogy
of Fallot (ToF). Which nursing action is
appropriate when the infant becomes
cyanotic while being fed?

Administer albuterol 0.1mg/kg per nebulizer, as prescribed


Give humidified oxygen at 6 L/min via bi-nasal cannula, as
prescribed
Position the client with the knees drawn to the chest
Place the client in left lateral Sims position

Answer & Rationale


• Ask: Appropriate nursing action
• Problem: Tetralogy of Fallot; becoming cyanotic while being fed
• Solution: Think of what you know about cardiac defects and ToF. With
any cardiac defects, the biggest problem is oxygenation. The heart is having
problems pushing blood forward.
1. Incorrect - This is not an appropriate nursing action to address cyanosis during a
feeding for an infant who is diagnosed with ToF.
2. Incorrect - This nursing action will not adequately address the infant’s cyanosis
during feedings; therefore, this nursing action is not appropriate.
3. Correct - An infant who is diagnosed with ToF may experience hypercyanotic
or “Tet” spells, during feedings and this position alleviates cyanosis.
4. Incorrect - This position would not address the infant’s cyanosis; therefore, the
child would remain cyanotic if placed in the left lateral Sims position.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides care for a client who is in the
second stage of labor. The nurse notes that the
fetal head retracts back into the vagina after
the birth of the head. Which intervention
by the nurse is appropriate based
on current data?

Administration of IV terbutaline 2.5mcg/min, as prescribed


Obtain the vacuum extractor and call for another nurse to assist
Place downward pressure on the client’s symphysis pubis
Apply pressure on the fundus during contractions

Answer & Rationale


• Ask: Appropriate intervention
• Problem: Fetal head retracts back into the vagina after the birth of the head
• Solution: Identify the expected intervention and determine the cause of the
head retraction.

1. Incorrect - This may be prescribed to stop or delay preterm labor but is not
appropriate based on the current clinical data.
2. Incorrect - Obtaining a vacuum extractor to assist with the birth at this point
would not allow for the head control that is required when shoulder
dystocia occurs.
3. Correct - This is an appropriate intervention to help with the complication
of shoulder dystocia, as the current data indicates.
4. Incorrect - This does nothing to control the head as it descends out of the birth
canal and will not allow for widening of the pelvis which is required
with shoulder dystocia.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides care for a laboring client who is
receiving intravenous (IV) oxytocin at 20 mU/min.
Which nursing intervention is appropriate for this
client when late decelerations are noted
on the continuous fetal monitor?
Select all that apply.

Call the lab for the prescribed STAT nitrazine test


Administer methylergonovine 0.2mg by mouth, as prescribed
Inform the healthcare provider (HCP) of the current client data
Move the client onto her back
Suspend the infusion of the prescribed IV oxytocin

Answer & Rationale


• Ask: Specific intervention
• Problem: Oxytocin infusion and late decels
• Solution: Remember it’s never good to be LATE with late decels. Identify
inappropriate actions and identify probable causes of late decels. Which
action is contraindicated for the probable cause?
1. Incorrect - There is no need for this test at this time as it is prescribed early in the labor
process to determine if the amniotic bag of fluid has ruptured.
2. Incorrect - Methylergonovine is often prescribed to decrease the likelihood of
postpartum hemorrhage.
3. Correct - The laboring client who experiences late deceleration requires
further assessment by the HCP.
4. Incorrect - Late decels often indicate poor oxygenation. To enhance oxygenation
to the fetus, the laboring mother is placed on her left side, not on her back.
5. Correct - This will stop any continued decelerations of the fetal heart rate until
the situation can be analyzed and stabilized by the healthcare provider.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse completes an assessment for a
newborn client. Which manifestation should
the nurse report to the healthcare provider
(HCP) immediately? Select all that apply.

A positive Babinski
Large, bluish discoloration on the lower back
Posterior fontanel is triangular, soft, and flat
Sudden and loud noises do not startle the neonate
Thin, white vaginal discharge and swelling of the labia
White pinpoint papules on the neonate’s nose

Answer & Rationale


• Ask: Manifestations to report immediately
• Problem: Assessment of newborn client
• Solution: Think about related clinical manifestations when assessing newborns,
expected/not expected
1. Incorrect - A positive Babinski reflex is an expected finding for the newborn client.
2. Incorrect - This finding is indicative of a Mongolian spot. This is an abnormal finding
but not indicative of a potential complication.
3. Incorrect - This is an expected finding regarding the posterior fontanel.
4. Correct - A positive startle reflex is an expected finding. This neonate exhibits a
negative startle reflex which may be indicative of a neurological
complication.
5. Incorrect - Vaginal discharge and an edematous labia are findings in female newborn
clients in response to maternal hormones.
6. Incorrect - This finding is indicative of milia, a common finding on the newborn’s skin.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides care for a newborn client
immediately following birth. The neonate’s
assessment data is as follows: skin is blue; heart
rate is 112 beats/minute; regular crying noted;
movement and flexion of extremities is noted;
and whimpers when nares are suctioned.
Based on this data, which Apgar score is
appropriate for the nurse to assign to
this newborn?

An Apgar score of 6
An Apgar score of 7
An Apgar score of 8
An Apgar score of 9

Answer & Rationale


• Ask: Appropriate APGAR score for newborn
• Problem: Blue skin, HR 112, regular cry, movement noted, whimpers with nasal suction
• Solution: Think about APGAR score and apply knowledge related to a healthy
newborn with a higher score, then do calculations of score.
1. Incorrect - This is not an accurate Apgar score for this newborn based on the clinical data.
2. Correct - Appearance = 0; Pulse = 2; Grimace = 1; Activity = 2; and Respirations =
2; therefore, the Apgar score is 0 + 2 + 1 + 2 + 2 = 7.
3. Incorrect - This is not an accurate Apgar score for this newborn.
4. Incorrect - This is not an accurate Apgar score for this newborn.
NCLEX
“BRAIN BUSTER” QUESTION
Which statement is true when the
nurse provides care to a client with
an obstetric history of G5T1P2A1L2?
Select all that apply.

The client has a history of 2 births at or before 37 weeks 0 days


gestation
The client has a history of two pregnancies
The client has 2 living children
The client had one pregnancy that ended before 20 weeks
The client is not pregnant at this time

Answer & Rationale


• Ask: Which statement is true
• Problem: Obstetric history
• Solution: Remember what is true about each letter of GTPAL and combine that
knowledge to select the correct statements about the client’s obstetric
history
1. Correct - Childbirth at or before 37 full weeks’ gestation is considered preterm;
P2 indicates that this client has a hx of 2 births at or before 37 weeks, 0
days.
2. Incorrect - Based on the current clinical data, this client has a history of 5, not 2
pregnancies as indicated by G5.
3. Correct - The client has 2 living children as indicated by L2.
4. Correct - The client has had one abortion, either elective or spontaneous, as
indicated by A1.
5. Incorrect - Adding T (1), P (2), and A (1) indicates that the client has had 4 pregnancies.
Based on the G5 listed, this client must be pregnant at this time.
NCLEX
“BRAIN BUSTER” QUESTION
The nursing supervisors make rounds to the assigned
nursing units for the evening shift. Which scenario
requires the nursing supervisor to intervene
to protect client confidentiality?
Select all that apply.

During a client’s admission assessment the nurse privately asks, “Do you have a
history of any mental illness?”
A nurse who reports diagnostic testing results to the person who accompanies a
client to the hospital
A nurse reviews the medical record for a client previously cared for but not assigned
for the present shift
A nurse tells a transporter, “This client has weakness in the arms and legs due
to severe opioid abuse and alcohol withdrawal, so be cautious when providing
assistance from the bed to the wheelchair.”
The nurse writes a client’s last name and medical record number on a piece of paper
and posts to the front of the door to the room

Answer & Rationale


• Ask: Supervisor intervention

• Problem: Protecting client confidentiality

• Solution: Think about protecting client confidentiality and identifiers of incidents that give
too much information and think about the understanding and implementation of HIPAA laws
and privacy
1. Incorrect - This is not a violation of confidentiality but rather it is a necessary portion of the
admission history that is completed by the admitting nurse.
2. Correct - The person who accompanies a client to the hospital does not “need to know”
the results of a client’s diagnostic study results.
3. Correct - Only essential personnel who are directly involved in the care of a client
should review a client’s medical record.
4. Correct - While it is appropriate for the transporter that the client has weakness in the
arms and legs, there is no reason to tell this individual WHY.
5. Correct - Listing a client’s last name and medical record and posting this information in
a central location is a violation of client confidentiality.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse is caring for an elderly client with urinary
incontinence. The nurse angrily tells the client,
“If you can’t stop making messes, I’m going to put
in a catheter.” The nurse’s actions may be
considered which type(s) of legal violation(s)?
Select all that apply.

Battery
Assault
Malpractice
Intentional Tort
Libel

Answer & Rationale


• Ask: Which type of legal violation
• Problem: Nurse angry due to incontinence; “If you can’t stop I’m going to put in
a catheter.”
• Solution: Look at the legal violations. The nurse angrily threatened the client.
Assault occurs when someone threatens physical or psychological harm.
1. Incorrect - Battery in nursing consists of physically touching an individual without consent.
2. Correct - Assault occurs when someone threatens physical or psychological harm
that causes the client to be fearful.
3. Incorrect - Malpractice is considered a non-intentional tort and is composed of six
elements.
4. Correct - The nurse’s statement is an example of assault which is an example of
an intentional tort.
5. Incorrect - Libel occurs when someone uses false written statements to defame
another’s character.
NCLEX
“BRAIN BUSTER” QUESTION
A client with an indwelling urinary catheter
reports leakage around the insertion site.
Which intervention should the nurse
perform next?

Inspect the catheter tubing for kinks or obstructions


Ask the charge nurse to assess the client’s catheter
Discontinue the catheter and replace it with a larger size
Inject the catheter balloon with additional sterile saline

Answer & Rationale


• Ask: Next intervention
• Problem: Indwelling urinary catheter leaking around insertion site
• Solution: Assess the client, then assess the catheter tube. Remember,
assessment is always first in the nursing process.

1. Correct - Assessment is the first step of the nursing process and leakage is
often caused by obstruction.
2. Incorrect - The nurse who is assigned to provide care to the client is able to assess
the client’s catheter, not the charge nurse.
3. Incorrect - This action is appropriate after assessing the indwelling catheter system
for kinks and other obstructions.
4. Incorrect - Sterile water is used because saline crystallizes, resulting in incomplete
deflation of the balloon at the time of removal.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse is caring for a client who is 6 hours
postoperative following a nephrectomy. When
assessing the client, the nurse notes that the
client grimaces and/or groans every time
he moves. Which priority action does
the nurse take first?

Assess the client’s pain level and location


Assist the client to reposition
Administer hydrocodone pain medication
Assist the client to deep breathe and cough

Answer & Rationale


• Ask: Priority action
• Problem: 6 hours post-op for nephrectomy; grimacing/groaning with movement
• Solution: Always #1 assess the client first and determine if the client is in pain
and include the pain level and location. Then, do an intervention and
address the problem

1. Correct - This answer is correct because assessment is the first step in the
nursing process.
2. Incorrect - The nurse should first assess the client’s pain level and location, then
intervene.
3. Incorrect - The nurse should first assess the client’s pain level and location, then
intervene.
4. Incorrect - The client is demonstrating signs of being in pain. Once the pain is
addressed, the client will be more willing and able to deep breathe
and cough.
NCLEX
“BRAIN BUSTER” QUESTION
Which client statement indicates an accurate
understanding of the medication teaching
provided by the nurse related to the use of a
new prescription for apixaban as medical
management for deep vein thrombosis
(DVT)? Select all that apply.

“It is okay to eat green leafy vegetables each night for dinner”
“It is not ok for me to eat foods that are rich in vitamin K”
“I will take frequent resting periods every 2 hours”
“I can take aspirin, ibuprofen, and naproxen for aches and pains
while taking this medication”
“I can take acetaminophen for headaches while on this medication”

Answer & Rationale


• Ask: Indicates understanding
• Problem: Teaching for new prescription (apixaban for management of DVT)
• Solution: Think of remarks by the patient that are true regarding this medication.
Remember, apixaban is an anticoagulant. Even if you don’t know what
the medication was, look at DVT with any anticoagulant, big bleed risk.

1. Correct - A benefit of this medication to treat DVT is that there is no drug


to food interactions related to vitamin K.
2. Incorrect - This medication does not interact with foods rich in vitamin K.
3. Incorrect - The client with a DVT is taught to move around every 2 hours to
enhance circulation.
4. Incorrect - The client is taught to avoid any medication that increases the risk for
bleeding while prescribed an anticoagulant agent.
5. Correct - Acetaminophen does not increase the client’s risk for bleeding.
NCLEX
“BRAIN BUSTER” QUESTION
Which nursing action upholds client safety
guidelines regarding safe medication
administration? Select all that apply.

Check the medication against the original prescription before


administration

Do not give medications with out-of-date labels

Don clean gloves when touching unopened medication dose packages

Open all medication packages while at the client bedside just before
administration

Review the relevant coagulation studies before giving heparin, if it is


ordered

Answer & Rationale


• Ask: Correct action
• Problem: Safe medication administration
• Solution: Always think about safety and rights of medication administration.
DICE the drugs-dose, integrity, clarity, expiration date. Think about
actions that protect the client from medication harm.

1. Correct - The nurse checks the medication against the original prescription
ensuring that it is the right drug for safety.
2. Correct - Medications that are expired should not be administered to a client
as the potency cannot be guaranteed.
3. Incorrect - Gloves are not required when handling medication that is unopened.
4. Correct - Medications are administered individually and placed in a
medication cup for administration while at the client’s bedside.
5. Correct - While heparin may be prescribed for the client, it is inappropriate
to administer if coagulation studies indicate that there’s a bleeding risk.
NCLEX
“BRAIN BUSTER” QUESTION
The nurse provides care for a client who is prescribed
intravenous (IV) norepinephrine (NE). Which nursing action
is appropriate when the IV administration of the
prescribed medication causes the client to report
shooting pain and the skin is noted to be pale
along the vein pathway? Select all that apply.

Flush the line with normal saline and give PRN IV meperidine
Discontinue infusion promptly and disconnect IV tubing
Document findings as normal
Slow the infusion of norepinephrine and reassess in 15 minutes
Remove the IV line while aspirating the drug from the vein

Answer & Rationale


• Ask: Correct interventions
• Problem: Pain while administering IV norepinephrine; pale skin noted along vein
pathway
• Solution: Consider the right action to do for the client right now and consider extravasation

1. Incorrect - The client is likely experiencing infiltration or extravasation. The prescribed


medication is a known vesicant; therefore, the IV line is immediately discontinued.
2. Correct - When symptoms of infiltration and/or extravasation occur, this
should be done to avoid further damage to the tissues.
3. Incorrect - Shooting pain and pale skin along the vein pathway are not normal findings.
4. Incorrect - This allows the medication to continue to infuse outside of the vein
which increases the risk for tissue damage as this medication is a known vesicant.
5. Correct - This should be done when infiltration and/or extravasation occur
to prevent further damage to the tissues.

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