NCLEX Brain Buster Questions
NCLEX Brain Buster Questions
NCLEX Brain Buster Questions
Na+
K+
Ca+
Mg+
• 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.
• 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.
Orthostatic hypotension
“I will eat lightly salted pretzels and potato chips for snacks”
“I can eat canned soup and a sandwich for lunch each day”
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
“Keep toenails cut close to the skin to avoid breakage of the nails”
“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”
Guaifenesin 15 mg daily
Captopril 40 mg PO daily
Losartan 80 mg PO daily
Hand tremors
Irregular heart rhythm
Increased perspiration
Insomnia and anxiety
Exophthalmos
Obesity
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.
• Solution: Remember LEVothyroxine LEAVES those thyroid hormones in the body which
makes everything amped up
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.
• 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.
• Solution: Think about teaching. With Rifampin, think RED like a reef, “REEF-ampin”.
Bodily fluids can turn red.
• 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
Urinary Retention
Neuropathic pain
Depression
Mood-stabilizer
Dysrhythmia
“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.”
Early accelerations
Early decelerations
Fetal heart rate of 176 beats per minute
Sinusoidal fetal heart rate
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.
Garlic
Saw palmetto
Black cohosh
Niacin
“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.”
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.
Respiratory
Integumentary
Cardiovascular
Gastrointestinal
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.
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
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.
Measles
Mumps
Pneumococcal conjugate
Rubella
Varicella
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
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?
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.
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
An Apgar score of 6
An Apgar score of 7
An Apgar score of 8
An Apgar score of 9
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
• 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
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?
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”
Open all medication packages while at the client bedside just before
administration
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