NCLEX-PN Test #1 2 — Questions and Answers

Question 1: A client diagnosed with heart failure is prescribed furosemide (Lasix). Which assessment finding indicates the medication is effective?

Increased heart rate
Decreased urine output
Reduced peripheral edema (Correct answer)
Elevated blood pressure

Correct answer: Reduced peripheral edema

Furosemide is a loop diuretic that reduces fluid volume. Decreased peripheral edema indicates effective diuresis and reduced fluid overload.

Furosemide (Lasix) is a loop diuretic that inhibits sodium and chloride reabsorption in the ascending loop of Henle, promoting significant diuresis. In heart failure, excess fluid accumulates in the tissues causing peripheral edema, pulmonary congestion, and weight gain. Effective treatment with furosemide should result in increased urine output, reduced peripheral edema, decreased weight, and improved respiratory status. Decreased urine output would indicate the medication is not working. Increased heart rate and elevated blood pressure are not therapeutic goals of diuretic therapy.

Question 2: A nurse is collecting data on a client admitted with suspected appendicitis. Which finding is most consistent with this diagnosis?

Pain that improves with eating
Rebound tenderness at McBurney's point (Correct answer)
Left lower quadrant cramping
Profuse watery diarrhea

Correct answer: Rebound tenderness at McBurney's point

McBurney's point tenderness and rebound tenderness in the right lower quadrant are classic findings in appendicitis.

The appendix is located in the right lower quadrant at McBurney's point, which is one-third the distance from the anterior superior iliac spine to the umbilicus. Classic signs of appendicitis include right lower quadrant pain, rebound tenderness (pain upon release of pressure), guarding, nausea, vomiting, low-grade fever, and elevated white blood cell count. Pain typically begins as periumbilical pain that migrates to the right lower quadrant. Pain does not improve with eating. Left lower quadrant pain is associated with diverticulitis. Profuse diarrhea is not a typical feature of appendicitis.

Question 3: A practical nurse is caring for a client receiving a blood transfusion. Which sign should prompt the nurse to stop the transfusion immediately?

Slight decrease in temperature
Urticaria with facial flushing and dyspnea (Correct answer)
Mild anxiety about the procedure
Heart rate increase from 72 to 78 bpm

Correct answer: Urticaria with facial flushing and dyspnea

Urticaria with facial flushing and dyspnea indicate a potentially severe transfusion reaction requiring immediate discontinuation.

Transfusion reactions can range from mild to life-threatening. Signs of a severe allergic or anaphylactic reaction include urticaria (hives), facial flushing, dyspnea, wheezing, hypotension, and tachycardia. These symptoms require immediate action: stop the transfusion, maintain IV access with normal saline, notify the provider, and monitor vital signs. A slight temperature decrease is not concerning. Mild anxiety is a normal emotional response. A minor heart rate increase of 6 bpm is within normal variation. The nurse must always remain vigilant during blood transfusions, especially during the first 15 minutes when reactions are most likely to occur.

Question 4: Which nursing intervention is most important for preventing deep vein thrombosis (DVT) in a post-surgical client?

Restricting fluid intake
Encouraging early ambulation (Correct answer)
Keeping the head of bed flat
Applying warm compresses to the legs

Correct answer: Encouraging early ambulation

Early ambulation is the most effective nursing intervention for preventing DVT because movement promotes venous return and prevents blood stasis.

Virchow's triad identifies three factors contributing to DVT formation: venous stasis, endothelial injury, and hypercoagulability. Early ambulation is the most effective nursing intervention because it directly addresses venous stasis by activating the calf muscle pump, promoting venous return to the heart. Additional preventive measures include sequential compression devices, antiembolism stockings, adequate hydration, and anticoagulant prophylaxis as ordered. Restricting fluid intake would increase blood viscosity and DVT risk. Keeping the bed flat does not specifically prevent DVT. Warm compresses are used to treat existing DVT symptoms, not for prevention.

Question 5: A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which oxygen delivery method and flow rate is most appropriate?

Non-rebreather mask at 15 L/min
Simple face mask at 8 L/min
Nasal cannula at 1-2 L/min (Correct answer)
Venturi mask at 10 L/min

Correct answer: Nasal cannula at 1-2 L/min

Clients with COPD require low-flow oxygen (1-2 L/min via nasal cannula) because high concentrations may suppress their hypoxic respiratory drive.

In healthy individuals, elevated CO2 levels (hypercapnia) are the primary stimulus for breathing. In clients with chronic COPD, chronically elevated CO2 levels cause the chemoreceptors to become insensitive to CO2. Instead, low oxygen levels (hypoxemia) become the primary respiratory drive. Administering high concentrations of oxygen can eliminate this hypoxic drive, leading to respiratory depression or failure. Therefore, low-flow oxygen at 1-2 L/min via nasal cannula is recommended to maintain SpO2 at 88-92%. Non-rebreather masks deliver 80-100% O2, simple masks deliver 40-60% O2, and high-flow Venturi masks can deliver precise but higher concentrations — all are too high for standard COPD management.

Question 6: A client is admitted with a serum potassium level of 6.2 mEq/L. Which cardiac rhythm change should the nurse anticipate on the electrocardiogram?

Flattened T waves
Prolonged QT interval
Peaked (tall) T waves (Correct answer)
ST segment depression

Correct answer: Peaked (tall) T waves

Hyperkalemia (potassium above 5.0 mEq/L) characteristically produces tall, peaked T waves on the ECG.

Hyperkalemia affects cardiac conduction by altering the resting membrane potential of cardiac cells. The earliest and most characteristic ECG change is tall, peaked (tented) T waves, reflecting accelerated repolarization. As potassium levels continue to rise, progressive ECG changes include widened QRS complex, prolonged PR interval, loss of P waves, and eventually a sine wave pattern that can lead to ventricular fibrillation or asystole. Flattened T waves and ST depression are associated with hypokalemia. A serum potassium of 6.2 mEq/L is significantly elevated and requires urgent treatment, which may include IV calcium gluconate, insulin with glucose, sodium bicarbonate, and kayexalate.

NCLEX-PN Test #1 2

A client diagnosed with heart failure is prescribed furosemide (Lasix).
Which assessment finding indicates the medication is effective?