NCLEX - National Council Licensure Examination Test #22 1 — Questions and Answers
Question 1: A nurse is caring for a client who is 24 hours post-thyroidectomy. The client reports tingling around the mouth and in the fingertips. Which finding should the nurse assess for next?
- Positive Chvostek's sign (Correct answer)
- Elevated blood pressure
- Increased urinary output
- Bradycardia and hypotension
Correct answer: Positive Chvostek's sign
Tingling around the mouth and fingertips after thyroidectomy suggests hypocalcemia due to accidental removal or damage to the parathyroid glands. Chvostek's sign (facial muscle twitching when tapping the cheek) is a classic indicator of hypocalcemia and should be assessed immediately.
Question 2: A nurse is assessing a client receiving a blood transfusion who develops chills, low back pain, and red-tinged urine 15 minutes after the infusion begins. Which action should the nurse take first?
- Stop the transfusion immediately (Correct answer)
- Slow the infusion rate and notify the provider
- Administer diphenhydramine as prescribed
- Obtain a urine specimen for urinalysis
Correct answer: Stop the transfusion immediately
The client is exhibiting signs of an acute hemolytic transfusion reaction, which is life-threatening. The priority action is to stop the transfusion immediately to prevent further hemolysis, then maintain IV access with normal saline and notify the provider.
Question 3: A nurse is caring for a client with chronic kidney disease who has a serum potassium level of 6.2 mEq/L. Which finding on the cardiac monitor requires the nurse's immediate attention?
- Peaked T waves (Correct answer)
- Prolonged PR interval
- Sinus bradycardia at 58 beats/min
- ST-segment depression
Correct answer: Peaked T waves
Hyperkalemia first manifests on the ECG as peaked (tall, narrow) T waves. This is an early and critical sign of cardiac toxicity from elevated potassium and requires immediate intervention to prevent progression to ventricular fibrillation or asystole.
Question 4: A nurse is reinforcing teaching with a client who has been prescribed warfarin therapy. Which statement by the client indicates a need for further teaching?
- 'I will take aspirin if I develop a headache.' (Correct answer)
- 'I will have my INR checked regularly.'
- 'I should use a soft-bristled toothbrush.'
- 'I will inform my dentist that I take warfarin.'
Correct answer: 'I will take aspirin if I develop a headache.'
Aspirin inhibits platelet aggregation and, when combined with warfarin, significantly increases the risk of bleeding. The client should be instructed to avoid aspirin and NSAIDs and to use acetaminophen for pain relief unless otherwise directed by the provider.
Question 5: A nurse is assessing a client who is 8 hours postoperative following an appendectomy. The client reports pain rated 7/10 and has absent bowel sounds and a firm, distended abdomen. Which action should the nurse take first?
- Notify the surgeon of the findings (Correct answer)
- Administer the prescribed analgesic
- Encourage the client to ambulate
- Insert a nasogastric tube as ordered
Correct answer: Notify the surgeon of the findings
A firm, distended abdomen with absent bowel sounds in the early postoperative period may indicate peritonitis or internal bleeding, both of which are surgical emergencies. The nurse must notify the surgeon immediately before administering pain medication or initiating other interventions.
Question 6: A nurse is caring for a client with tuberculosis (TB) who is being discharged home. Which instruction is most important for the nurse to include?
- Take all prescribed medications for the full duration of therapy (Correct answer)
- Wear a surgical mask whenever leaving the home for the first week
- Avoid sharing eating utensils with household members
- Schedule follow-up chest X-rays every 6 months indefinitely
Correct answer: Take all prescribed medications for the full duration of therapy
Completing the full course of anti-TB medications (typically 6–9 months) is the most critical instruction because stopping early or skipping doses leads to treatment failure and the development of multidrug-resistant TB, a serious public health threat.
NCLEX - National Council Licensure Examination Test #22 1
A nurse is caring for a client who is 24 hours post-thyroidectomy.
The client reports tingling around the mouth and in the fingertips.
Which finding should the nurse assess for next?