NCLEX

“BRAIN BUSTER” QUESTION

The nurse is assessing the patient who is
1 hour post esophagogastroduodenoscopy Join for free!

identify as the highest priority to

report to the provider?

Temperature of 101.5 F (38.6C).

Patient reports a sore throat.
Patient’s indwelling catheter has 300mL of clear
yellow urine.
Patient is currently eating ice chips without

Answer & Rationale

• Ask:

• Problem: 1 hour post EGD

• Solution: Findings that could indicate worst potential outcome for the patient

1. Correct - temperature may indicate infection and potential perforation

2. Incorrect - sore throat is expected
3. Incorrect - 300 mL of clear urine is normal
NCLEX
“BRAIN BUSTER” QUESTION
Which adverse effects should the nurse
monitor for in a hospitalized patient with
an order for aspirin 325 mg every 6
hours with a diagnosis of cluster
headaches? Select all that apply.

The presence of dark melana in the stool.

Decreased heart rate.
Increased ecchymosis noted on the extremities.
Increased blood pressure.
Tinnitus noted on an exam.

Answer & Rationale

• Ask: Adverse effects of aspirin
• Problem: aspirin (anti-platelet) > easy bleeding, big risk for toxicity
• Solution: adverse effects, things that are side effects, not normal, something
that can harm the pt

1. Correct - dark stools can indicate bleeding in the GI

2. Incorrect - decreased heart rate not an adverse effect of aspirin
3. Correct - bruising can indicate bleeding from anti-platelets/decreased clotting
4. Incorrect - increased blood pressure is not effect of aspirin
5. Correct - tinnitus can indicate toxicity > toxic kidneys and toxic ears
NCLEX
“BRAIN BUSTER” QUESTION
A patient with bleeding esophageal varices
has had a Sengstaken-Blakemore tube
placed to help prevent and control
bleeding. What should the nurse do
first if this tube becomes
displaced?

Auscultate patient’s bowel sounds in all 4

quadrants.
Immediately raise the head of bed to at least 30
degrees.
Promply trim the tube and deflate the balloon.
Quickly call the medical response team.

Answer & Rationale

• Ask: Priority action or what to do first

• Problem: Esophageal varices bleed and tube is coming out

• Solution: Actions to do right now to prevent patient from choking

1. Incorrect - listening to bowel sounds does nothing for patient’s airway

2. Incorrect - raising head of the bed 30 degrees does nothing for the patient
3. Correct - cutting balloon, deflating it keeps airway patent and keeps
patient from choking on the obstruction
4. Incorrect - calling for medical response does nothing for the patient right now
NCLEX
“BRAIN BUSTER” QUESTION
A patient is 2 hours status post paracentesis. After
the unlicensed assistive personnel(UAP) assisted the
patient out of bed, the UAP reports to the nurse,
“The patient got dizzy and stumbled while I was
helping with transfer to the chair.” What
intervention should the nurse perform
first?

Assess the patient immediately.

Call the health care provider immediately.
Request assistance from physical therapy.
Suggest the UAP monitor vital signs.

Answer & Rationale

• Ask: Priority action of what to do now

• Problem: Dizzy patient who stumbled to the chair per UAP

• Solution: Safety and assessment

1. Correct - assess patient to ensure safety

2. Incorrect - calling for HCP does nothing for the patient right now
3. Incorrect - assistance from the PT does nothing for the patient right now
4. Incorrect - UAP to monitor vital signs does nothing to do ensure safety
NCLEX
“BRAIN BUSTER” QUESTION
The nurse is completing a percutaneous
endoscopic gastrostomy (PEG) feeding on a
patient who had the PEG tube placed
one week ago. The nurse notices that
the tube has become dislodged.
What is the priority action?

Apply sterile gloves and reinsert the PEG tube into the
existing tract immediately.

Prepare to insert a Foley catheter into the PEG tube incision site.

Immediately notify the primary care provider who placed

the PEG tube.

Obtain a nasogastric tube (NGT) for medications and

feedings.

Answer & Rationale

• Ask: Priority action of what to do now
• Problem: PEG tube dislodged with feeding > Think PEG tube needs to be
replaced ASAP since hole closes fast
• Solution: Correct actions by the nurse to prevent worst possible outcome of
PEG tube hole closing
1. Incorrect - outside of nurse’s scope of practice
2. Incorrect - not appropriate to use Foley catheter in the incision site
3. Correct - contact HCP immediately to make them aware and replace tube
4. Incorrect - need order for new feeding tube
NCLEX
“BRAIN BUSTER” QUESTION
The registered nurse reviews the documents below, and
begins the infusion of KCL at 50 mL/hr into the patient right
forearm IV. After the infusion begins the patient reports
stinging and pain at the site. What is the nurse’s first action?
• Laboratory Results
• Potassium 2.5 mEq/L
• Medication Administration Record (MAR)
• 20 mEq potassium (KCl) in 100 mL of normal saline to infuse
over 2 hours IVPB.

Apply an ice pack at the IV insertion site for comfort.

Stop the medication and check for any signs of
infiltration.
Immediately stop IV medication and notify HCP.
Slow the rate of infusion by half and notify HCP.

Answer & Rationale

• Ask: First action
• Problem: Stinging pain at the site of an infusing KCL (potassium chloride)
• Solution: Anything that burns or stings at the IV site - always stop the infusion
and assess client or slow the infusion and assess client
1. Incorrect - always stop and assess any IV causing the problem
2. Correct - stop and assess
3. Incorrect - stop and assess client, NOT stop and notify the HCP
4. Incorrect - slowing the rate of the infusion may only be done after you stop first
and assess the client
NCLEX
“BRAIN BUSTER” QUESTION
Which assessment findings does the nurse
expect in a client who is non compliant
with their treatment plan of chronic
congestive heart failure?
Select all that apply.

Blood pressure of 160/96 mm Hg.

Crackles in the bases of the lungs.
Elevated central venous pressure.
Jugular vein distension.
Pitting edema of the lower extremities.

Answer & Rationale

• Ask: Expected assessment findings

• Problem: Client who’s noncompliant with their heart failure treatment plan

• Solution: Manifestations of fluid volume overload

1. Correct - high blood pressure, high fluid equals high pressures all over the body
2. Correct - crackles - wet lungs
3. Correct - High CVP - high pressures all over the body
4. Correct - JVD
5. Correct - peripheral pitting edema
NCLEX
“BRAIN BUSTER” QUESTION
A client with Addison disease presents with abdominal
pain. The client experiences a decline in systolic blood
pressure of 30 mm Hg, has a heart rate increase
from 75 to 100/min and develops new confusion.
Which action(s) should be implemented in
order to prevent the Addisonian crisis?
Select all that apply.

Give prescribed hydrocortisone 100 mg IVP.

Administer morphine 2 mg IVP every 2 hours for pain.

Begin potassium 40 mEq PO every 12 hours as prescribed.

Start an IV infusion of normal saline with 5% dextrose.

Give Phenergan 12.5 mg IVP every 4 hours PRN nausea.

Answer & Rationale

• Ask: Actions to prevent this Addisonian crisis
• Problem: client has Addison’s disease with abdominal pain, systolic blood
pressure that is dropping by 30, heart rate increasing by 100 and they’re
getting confused > Addison’s - add steroids, treat dehydration, dextrose IV
• Solution: Interventions that the client needs right now
1. Correct - hydrocortisone is a steroid
2. Incorrect - morphine does NOT prevent the problem
3. Incorrect - potassium is high, client DON’T need more
4. Correct - fluid and dextrose is needed to prevent dehydration and 4. hypoglycemia
5. Incorrect - phenergan does NOT prevent the problem here
NCLEX
“BRAIN BUSTER” QUESTION
Which clinical manifestation(s) would
be observed in a client with Cushing
syndrome? Select all that apply.

Easy bruising.

Increased blood glucose.

Increased blood pressure.

Increased potassium.

Increased abdominal girth.

Decreased weight.

Answer & Rationale

• Ask: Clinical manifestations
• Problem: Cushing syndrome - too much cortisol
• Solution: Findings that are expected
1. Correct - easy bruising from loss of collagen from high steroids
2. Correct - hyperglycemia from cortisol
3. Correct - hypertension from metabolic changes
4. Incorrect - hyperkalemia or high potassium is from Addison’s
5. Correct - central obesity from too much cortisol
6. Incorrect - decreased weight is with Addison’s
NCLEX
“BRAIN BUSTER” QUESTION
Which clinical manifestation(s) can be
associated with a diagnosis of primary
adrenal insufficiency (Addison disease)?
Select all that apply.

A tanned looking skin color.

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 - absence of steroids
• Solution: Signs and symptoms seen with Addison client

1. Correct - added pigmentation because of increased ACTH

2. Correct - loss of appetite and eight loss is present
3. Incorrect - increased body with Cushing’s, clients are usually big, round, and hairy
4. Correct - orthostatic hypotension is present, everything is low
5. Incorrect - striae is seen on clients with Cushing’s
NCLEX
“BRAIN BUSTER” QUESTION
Which clinic client would be most
important for the nurse to call the
health provider about first?

Patient diagnosed with Addison disease taking a new

prescription of corticosteroids and reporting changes in
mood.
Patient who needs to have a refill of their levothyroxine
medication called into the pharmacy.
Patient with hyperthyroidism who has new onset of fever
with a temperature reading of 101.5 F (38.6 C).
Patient with type II diabetes mellitus who reports blood
sugars of 220-275 mg/dL (12.2 mmol/L - 15.3 mmol/L) in
the past week.

Answer & Rationale

• Ask: Most important client
• Problem: Client to report first
• Solution: Who dies first

1. Incorrect - client with Addison’s disease on new steroids > new mood changes which is an
expected side effect
2. Incorrect - client who needs levothyroxine refill is usually never critical right now
3. Correct - client with hyperthyroidism has sign and symptoms of potential
thyrotoxicosis which is life threatening
4. Incorrect - client with type 2 diabetes with hyperglycemia over a week is not most important
NCLEX
“BRAIN BUSTER” QUESTION
Which precaution(s) is/are priority to teach
a 29 year old female client treated with
radioactive iodine for hyperthyroidism?
Select all that apply.

“If you are breastfeeding, you may continue to do so

when you get home.”
“Disposable eatery tools should be used for your
meals.”
“Wash anything you use separately from the rest of
the family.”
“You should use a different toilet from other family
members.”
“No visitors who may be pregnant.”

Answer & Rationale

• Ask: Precautions to teach
• Problem: Radioactive iodine for hypothyroidism
> Anything radioactive is very toxic - no exposure to other people
• Solution: Cautions client should take with radioactive treatment

1. Incorrect - breastfeeding is a big NO, big contraindication

2. Correct - disposing eatery will prevent exposure to others
3. Correct - wash used items in separate laundry bins
4. Correct - use exclusive toilets/separate toilets
5. Correct - avoid pregnant women to avoid exposure to the fetus
NCLEX
“BRAIN BUSTER” QUESTION
Which diet education should the nurse
include for a client newly diagnosed with
hyperthyroidism?
Select all that apply.

Do not drink caffeinated beverages and eat spicy foods.

Choose 3 meals and 3 snacks daily that has increased
protein.
Clearly communicate why diet should be a low-
carbohydrate diet.
Consume at high calorie diet about 4000-5000 calories/day.
Encourage the patient to increase high-soluble fiber
foods in the diet.

Answer & Rationale

• Ask: Education to give
• Problem: Hyperthyroidism - vital signs are high, client is losing weight like crazy
• Solution: Diet best for client

1. Correct - caffeine and spice are stimulants - can make things more elevated
2. Correct - increased frequency of eating matches the increased metabolic rate
3. Incorrect - client needs normal and high carbs
4. Correct - high calories for high everything
5. Incorrect - more fiber means more bowel movements
NCLEX
“BRAIN BUSTER” QUESTION
Which sign(s) and/or symptom(s) are
expected to be present in a client with
Graves’ disease?
Select all that apply.

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

Answer & Rationale

• Ask: Which sign and symptom
• Problem: Graves’ disease - hyperthyroidism
• Solution: Manifestations that are likely with this hyperstate
1. Correct - hand tremors from someone who is on hyperstate
2. Correct - irregular heart rhythm & tachycardia, hyperstate
3. Correct - increased sweating from increased metabolic rate and heat intolerance
4. Correct - insomnia, hyper energy, anxiety increase metabolic rate
5. Correct - exophthalmos, eyes are “exiting” the body in hyperstate
6. Incorrect - obesity is seen in hypothyroidism
NCLEX
“BRAIN BUSTER” QUESTION

Which client is at risk for developing

syndrome of inappropriate antidiuretic
hormone (SIADH)?

A patient with rheumatoid arthritis.

A patient with diabetes mellitus.
A patient with a long history of sciatica.
A patient with small cell lung cancer.

Answer & Rationale

• Ask: Which client

• Problem: Highest risk for SIADH, client had too much ADH

• Solution: Clients with SIADH risk factor

1. Incorrect - rheumatoid arthritis is NOT a risk factor

2. Incorrect - diabetes is NOT a risk factor
3. Incorrect - sciatica is NOT a risk factor
4. Correct - small cell lung cancer is a HUGE risk factor for SIADH - can secrete
ADH which adds the H2O
NCLEX
“BRAIN BUSTER” QUESTION
A client with a head injury develops
syndrome of inappropriate antidiuretic
hormone (SIADH). Which data should the
nurse expect to assess in a client
with this condition? Select all that
apply.

Decreased urine output.

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

Answer & Rationale

• Ask: Which clinical manifestations
• Problem: SIADH > Think too much ADH that adds to H2O
• Solution: Findings with SIADH

1. Correct - decreased urinary output because client stops urinating

2. Incorrect - decreased serum osmolality from water dilution>low liquidy labs
3. Correct - elevated urine specific gravity - very heavy weighty urine
4. Correct - decreased serum osmolality from water dilution>low liquidy labs
5. Correct - decreased sodium from dilution
NCLEX
“BRAIN BUSTER” QUESTION
A client with type I diabetes mellitus has
a Glasgow coma scale score of 9, only
responds to painful stimuli, and a blood
glucose level of 35 mg/dL (1.9 mmol/L).
What should the nurse do first?

Administer dextrose 50% IVP now.

Assess for sweating, pallor or shakiness.
Help the patient to eat 15 grams of
carbohydrates.
Obtain the patient’s heart rate and blood
pressure.

Answer & Rationale

• Ask: Priority action of what to do first

• Problem: Type 1 diabetic, Glasgow coma scale score of 9, blood glucose of

35 - hypoglycemic

• Solution: Interventions to do now to prevent worst possible outcome

1. Correct - client needs glucose now, stab client with IV push

2. Incorrect - more assessment does nothing for the client
3. Incorrect - No PO for someone who has decreased level of consciousness
4. Incorrect - heart rate or blood pressure does nothing for the client right now
NCLEX
“BRAIN BUSTER” QUESTION
What finding on a client who has
just returned to the unit following a
thyroidectomy requires immediate
nursing intervention?

Calcium 8.6 mg/dL (2.15 mmol/L).

Pulse of 115/min.
Audible stridor.
Reports of incisional pain.

Answer & Rationale

• Ask: Which needs immediate intervention
• Problem: Post thyroidectomy
• Solution: Findings that indicate the worst potential outcome, what is going to
kill the client the fastest
1. Incorrect - calcium level is normal
2. Incorrect - increased heart rate post op is expected
3. Correct - stridor (high pitch) or voice changes after thyroidectomy is priority.
Think airway obstruction which is a life threatening issue
4. Incorrect - incisional pain is expected after any surgery
NCLEX
“BRAIN BUSTER” QUESTION
A type 1 diabetic client on intensive insulin
therapy reports to the nurse a plan to fast
for the next three days. What is the
most important nursing action?

Check the patient’s history of glycemic control and

physical stability.
Call the provider to follow up on adjusting the
insulin therapy.
Caution the patient of the risk of fasting as a type 1
diabetic.
Tell the patient that a dietitian referral is needed
for planning meals.

Answer & Rationale

• Ask: Most important action
• Problem: Type 1 diabetic client for intense insulin treatment that is fasting for 3 days
> Think fasting on insulin- huge risk for hypoglycemia
• Solution: Something that assesses the client further
1. Correct - assessing to see if the client is able to carry out the fast safely,
MOST CORRECT
2. Incorrect - don’t make changes yet until you confirm it’s safe for the client
3. Incorrect - client can fast if it can be done safely
4. Incorrect - dietitian is helpful but always assess the client first
NCLEX
“BRAIN BUSTER” QUESTION
The registered nurse is teaching a student
about the care of a client who just
underwent a total thyroidectomy. Which
assessment finding should the nurse
emphasize to the student as being
most critical?

Blood pressure of 140/90 mmHg.

Pulse 80 and irregular.
High pitched labored breathing.
Oxygen saturation of 88%.

Answer & Rationale

• Ask: Most critical finding
• Problem: client underwent a total thyroidectomy
> Think ABCs - airway, breathing, circulation
• Solution: What kills the client first
1. Incorrect - elevated blood pressure post op is normal
2. Incorrect - pulse of 80 and irregular may be normal for the client
3. Correct - high pitched labored breathing > think stridor - upper airway obstruction
4. Incorrect - low O2 sat is expected
NCLEX
“BRAIN BUSTER” QUESTION
A client diagnosed with diabetic ketoacidosis (DKA)
is experiencing polyuria, polydipsia, and polyphagia.
Upon assessment the client has a temperature of
102.6 F (39.2 C), acetone breath, deep respirations
at a rate of 28/min with dry, cracked lips.
Which is the priority nursing diagnosis
for this client?

Risk for infection.

Deficient knowledge.
Fluid volume deficit.
Imbalanced nutrition.

Answer & Rationale

• Ask: Priority nursing diagnosis

• Problem: DKA, temperature 102.6, acetone breath, respiration rate of 28

• Solution: Client’s most important issue

1. Incorrect - risk for infection is NOT the priority issue

2. Incorrect - deficient knowledge is NOT a priority issue
3. Correct - fluid volume deficit > DKA - treat the dry
4. Incorrect - imbalanced nutrition is NOT a priority issue
NCLEX
“BRAIN BUSTER” QUESTION
A patient with diabetes mellitus type 1 is admitted to
the med-surg unit status post vaginal hysterectomy.
The patient received 5 units of regular insulin SC
and atenolol 50 mg PO in the recovery room.
Which comment by the unlicensed assistive
personnel requires immediate
intervention by the nurse?

“I changed out the patient’s perineal pad 4 times in

the past hour.”
“I encouraged the client to perform range of motion
exercises on her legs while in bed.”
“I emptied 600mL of clear, yellow urine out of the
patient’s bedpan 15 minutes ago.”
“The patient’s vital signs are 110/60 mm Hg, heart
rate 60, with respirations of 14.”

Answer & Rationale

• Ask: Comments that require immediate intervention
• Problem: Post-vaginal hysterectomy > Big bleed, infection, diabetic patient
• Solution: Findings that could indicate worst potential outcome for the patient

1. Correct - frequent changing of the pad may indicate a hemorrhage

2. Incorrect - range of motion exercises are encouraged and are appropriate but
NOT priority here
3. Incorrect - 600 mL of urinary output is normal
4. Incorrect - normal vital signs are NOT concerning
NCLEX
“BRAIN BUSTER” QUESTION
Which action(s) should be implemented
when a nurse is caring for a patient with
a lower airway infection to facilitate
airway clearance?
Select all that apply.

Administer benzonatate 200mg PO.

Apply chest percussion, vibration and postural
drainage.
Encourage slow breathing techniques.
Position patient in prone position to facilitate
drainage.
Teach importance of increasing oral fluids.

Answer & Rationale

• Ask: Which actions to do
• Problem: Lower airway infection > Think airway clearance, possibly lots of
fluids, antibiotics, get patient moving and coughing
• Solution: Interventions to do with patient
1. Incorrect - benzonatate is a cough suppressant which will suppress the cough
2. Correct - pulmonary hygiene helps clear the airway
3. Incorrect - encourage deep breathing techniques
4. Incorrect - prone position helps drain fluid from the back of the lungs
5. Correct - increasing fluids helps to loosen secretions and helps move it out of the body
NCLEX
“BRAIN BUSTER” QUESTION
Which teaching is important for the nurse
to teach about a new prescription of
lisinopril? Select all that Apply.

Include Bananas, oranges, cantaloupe, honeydew, apricots for the

patient to add to their diet.
Instruct patient to sit on the side of the bed for a minute before
standing in the morning.
Review the apical pulse monitoring video with patient and do a
teach back demonstration.
Remind the patient to return to have daily blood draws to
determine therapeutic drug levels.
Teach the patient how to obtain apical pulse and hold medication
if <60/min.
Review the blood pressure monitoring video with patient and do a
teach back demonstration.

Answer & Rationale

• Ask: Important teaching

• Problem: Patient taking lisinopril > Think Lisinopril is an ACE inhibitor anti-hypertensive,
decrease blood pressure

• Solution: Education that patient needs when taking this medication

1. Incorrect - risk for hyperkalemia, minimize potassium intake

2. Correct - postural hypotension is a side effect of the medication
3. Incorrect - apical pulse doesn’t need to be checked
4. Incorrect - daily blood draws are not necessary
5. Incorrect - apical pulse is for digoxin
6. Correct - patient needs to monitor blood pressure while taking the “-prils”
NCLEX
“BRAIN BUSTER” QUESTION
Which lab level(s) would have these
desired changes for a client with
hyperlipidemia after treatment
with simvastatin?
Select all that apply.

ALT from 19 U/L to 79 U/L.

HDL from 49 mg/dL to 30 mg/dL.
LDL from 178 mg/dL to 98 mg/dL.
Complete cholesterol level from 259 mg/dL to 178 mg/dL.
Blood triglycerides from 300 mg/dL to normal 140 mg/dL.

Answer & Rationale

• Ask: Which lab values
• Problem: Desired for simvastatin > Think statins decrease cholesterol levels
• Solution: Therapeutic outcome of this medication

1. Incorrect - increased ALT

2. Incorrect - increase HDL, only one that should be high over 40
3. Correct - decrease LDL
4. Correct - decrease in cholesterol
5. Correct - decrease in triglycerides
NCLEX
“BRAIN BUSTER” QUESTION
The nurse has a group of clients on a med surg
floor. One of the clients in the group has a
history of AFib and is taking diltiazem 120 mg
daily. You understand that this client has a
positive outcome by what indications?
Select all that Apply.

The patient has no clinical manifestations of CVA.

The patient’s AFib now is a normal sinus rhythm.
The patient’s CNA reported a BP of 124/76 mm Hg.
The patient’s CNA reported a pulse dropping from
108 to 72.
The patient’s atrial rate should be the same as the
ventricular rate. The rate dropped from 160/min to
72/min.

Answer & Rationale

• Ask: Positive outcomes of this medication
• Problem: client with a history of AFib taking diltiazem > AFib is erratic atrial
rhythm. Diltiazem - calcium channel blocker calms the heart, stabilizes the rate and
rhythm
• Solution: Findings that indicate the medication is working correctly
1. Incorrect - client is not taking the medication for a CVA stroke, doesn’t calm the heart
2. Incorrect - medication won’t convert an atrial rate
3. Incorrect - medication reduce blood pressure but client is taking it for AFib
4. Correct - decrease in heart rate indicates correction in AFib
5. Correct - decrease in heart rate calms the heart with the calcium channel blocker
NCLEX
“BRAIN BUSTER” QUESTION
A client is prescribed dabigatran twice
daily. Which client statement indicates
to the nurse a need for more education?
Select all that Apply.

“I will be sure to drink 8 oz of clear liquid with the capsule.”

“I will let my NP or physician know if I urinate a lite red
color.”
“I will not stop taking this medication unless my provider
tells me to do so.”
“I will take dabigatran on an empty to avoid gas or small
stomach discomfort.”
“I will keep it in my daily pill container with divider and use
a daily planner to make sure I take it every day.”

Answer & Rationale

• Ask: Incorrect client statements
• Problem: Dabigatran
> Think dabigatran is a new blood thinner given to prevent clots
• Solution: Incorrect remarks
1. Incorrect - medication should be taken with liquid
2. Incorrect - red color in urine may indicate a bleed
3. Incorrect - medication should not be discontinued unless advised
4. Correct - taking on an empty stomach can damage GI lining
5. Correct - keep medication in original packet, not taken out until use
NCLEX
“BRAIN BUSTER” QUESTION
Which teaching by the charge nurse about
food-drug interactions and risks while
taking warfarin should the student
nurse intervene to clarify the
teaching? Select all that Apply.

“Do not increase your usual intake of foods containing

vitamin K.”
“If you begin taking any over-the-counter, all natural
medications, notify the health care provider.”
“You should eat a lot of kale while on this medication.”
“You will need to have your blood tested regularly while
on this medication.”
“Wear good flip flops when walking.”

Answer & Rationale

• Ask: Incorrect teaching
• Problem: Food to drug interactions with a risk of warfarin blocking
> Warfarin is a blood thinner, client has a high risk of bleeding. Vitamin K blocks the effects
of warfarin
• Solution: Incorrect statements - high risk for bleeding, what kills client first
1. Incorrect - vitamin K can block warfarin’s blood thinning effects leading to more clots
2. Incorrect - HCP should be made aware of any over the counter natural remedies, could
increase risk for bleeding
3. Correct - Kale is a green leafy high in vitamin K that blocks the meds leading to clot,
avoid excess amount of green leafy
4. Incorrect - blood tests are required when in warfarin
5. Correct - wear closed shoes, think risk for injury, increased risk for bleeding
NCLEX
“BRAIN BUSTER” QUESTION
Which food(s) should the nurse
encourage the client to monitor
intake while on warfarin?

Select all that apply.

Apricots.
Kale.
Green tea.
Sauerkraut.
Turnip Greens.
Raisins.

Answer & Rationale

• Ask: Which foods
• Problem: Taking warfarin > Warfarin is a blood thinner. Vitamin K blocks the
effects of warfarin, found in green leafy vegetables
• Solution: What to monitor for the intake for client
1. Incorrect - apricots are high in potassium
2. Correct - kale is a green leafy veg high in vit K
3. Correct - green tea is green and leafy
4. Correct - sauerkraut is a cabbage, green and leafy
5. Correct - turnips have green leafy stem
6. Incorrect - raisins aren’t green and leafy
NCLEX
“BRAIN BUSTER” QUESTION
Which teaching is important for the
nurse to teach about a new prescription
of lisinopril? Select all that Apply.

Include Bananas, oranges, cantaloupe, honeydew, apricots for the

patient to add to their diet.
Instruct patient to sit on the side of the bed for a minute before
standing in the morning.
Review the apical pulse monitoring video with patient and do a
teach back demonstration.
Remind the patient to return to have daily blood draws to
determine therapeutic drug levels.
Teach the patient how to obtain apical pulse and hold medication
if <60/min.
Review the blood pressure monitoring video with patient and do a
teach back demonstration.

Answer & Rationale

• Ask: Important teaching
• Problem: client taking lisinopril > Think Lisinopril is an ACE inhibitor anti-
hypertensive, decrease blood pressure
• Solution: Education that client needs when taking this medication

1. Incorrect - risk for hyperkalemia, minimize potassium intake

2. Correct - postural hypotension is a side effect of the medication
3. Incorrect - apical pulse doesn’t need to be checked
4. Incorrect - daily blood draws are not necessary
5. Incorrect - apical pulse is for digoxin
6. Correct - client needs to monitor blood pressure while taking the “-prils”
NCLEX
“BRAIN BUSTER” QUESTION
Which client report has ‘highest rank’ for
the nurse to follow-up with after starting
‘nitroglycerin trinitrate drip’ for
myocardial infarction?

Short of breath when doing running in place.

Feeling jittery when walking.
Dizziness when standing.
Having heartburn and angina relieved by nitro.

Answer & Rationale

• Ask: Which client to report
• Problem: Nitroglycerin trinitrate drip has been started > Nitro is a vasodilator
that helps with hypertension. Biggest risk - dizziness when standing, falls
• Solution: Priority signs and symptoms client is experiencing
1. Incorrect - shortness of breath with activity is expected
2. Incorrect - feeling jittery when walking is expected as well as with a headache
3. Correct - dizziness upon standing indicates serious hypotension, client will fall
4. Incorrect - chest pain relieved with nitro is the reason we’re giving it, as well as
lowering blood pressure
NCLEX
“BRAIN BUSTER” QUESTION
Which statement by the client indicates
a need for further instructions about
digoxin 0.25 mg PO every-other-day?
Select all that Apply

“Before I take this medication, I should check my heart

rate.”
“If I have trouble reading road signs, I should call my
healthcare provider (HCP).”
“If I start having nause and vomiting, I will call my HCP.”
“Prior to taking this medication, I need to check my
blood pressure.”
“If I see a white flashing light when looking around at
object, I need to notify my doctor right away.”

Answer & Rationale

• Ask: Incorrect client statements
• Problem: Digoxin 0.25 mg PO > Digoxin is an inotropic that decreases heart rate - deeper
contraction, decreases heart rate. “Big 3” to look for in toxicity - nausea, vomiting, difficult
reading with visual disturbances
• Solution: Incorrect client statements

1. Incorrect - heart rate should be assessed before taking med

2. Incorrect - visual disturbances is a sign and symptom of digoxin toxin
3. Incorrect - nausea & vomiting is a sign and symptom of digoxin toxicity
4. Correct - blood pressure doesn’t need to be taken before taking digoxin
5. Correct - flashing lights is a sign of retinal detachment but still should be reported to HCP
NCLEX
“BRAIN BUSTER” QUESTION
Which client statement should the nurse
report to the physician who recently
prescribed thiazide diuretic and
diltiazem for the client?
Select all that Apply.

“I enjoy plantains fruit each sunrise with my cereal.”

“I have been drinking black cohosh tea with licorice
drops for my GERD.”
“I take my thiazide diuretic at 8 am.”
“When I first stand up out of bed, I get a little dizzy
so but that is ok.”
“I have been taking non caffeinated tea with
spearming for my GERD.”

Answer & Rationale

• Ask: Which client statements
• Problem: clients taking thiazide diuretic and diltiazem
> Think increased urinary output, fluid loss, and calcium channel blocker.
Thiazide makes body dry, fluid loss, and potassium loss. Diltiazem is a calcium
channel blocker, calms the heart, lowering blood pressure and heart rate
• Solution: Remarks that indicate safety, safety risk with this medication

1. Incorrect - okay to eat plantains, potassium foods are appropriate with thiazides
2. Correct - licorice fruits can cause hypokalemia, licorice lowers potassium
3. Incorrect - thiazides are taken in morning bc client is going to urinate a lot
4. Correct - persistently getting dizzy needs to be reported
5. Incorrect - non caffeinated tea with mint is okay
NCLEX
“BRAIN BUSTER” QUESTION
Which client teaching about amlodipine
is a nursing priority?
Select all that Apply.

Dry, hacking cough.

Edema of the legs.
Sexual dysfunction.
Lightheadedness.
Extreme sleepiness.

Answer & Rationale

• Ask: Priority teaching
• Problem: Amlodipine
> Think Amlodipine is a calcium channel blocker treating hypertension
• Solution: Teaching that should be provided to client to prevent worst possible outcome

1. Incorrect - dry, hacking cough is a side effect of an ACE inhibitor, NOT a calcium channel blocker
2. Correct - peripheral edema, huge sign an symptom of worsening heart failure & an
adverse effect of drug
3. Incorrect - sexual dysfunction is a side effect of beta blocker medication
4. Correct - lightheadedness, dizzy adverse effect, huge safety with falls
5. Correct - extreme sleepiness, too much calm
NCLEX
“BRAIN BUSTER” QUESTION
Which report is the priority concern for the
nurse caring for a client with elevated blood
pressure and insulin resistance diabetes
that has recently been prescribed
hydrochlorothiazide?
Select all that Apply.

Leg muscle cramping.

Lightheadedness when standing.
Morning serum glucose level of 150 mg/dL.
Palpitations.
Photosensitivity.

Answer & Rationale

• Ask: Priority concerns
• Problem: client with elevated blood pressure prescribed hydrochlorothiazide
> “-ides” help the body get dry - potassium loss, fluid loss. Potassium pumps muscles
• Solution: Findings that indicate the worst potential outcome
1. Correct - leg cramping may indicate low potassium leading to cardiac issues
2. Incorrect - postural hypotension is an expected side effect
3. Incorrect - elevated glucose of 150 is not too high
4. Correct - palpitations can indicate life threatening cardiac issue, heart arrhythmia
5. Incorrect - Photosensitivity is expected side effect, NOT a priority
NCLEX
“BRAIN BUSTER” QUESTION
Which adverse effect is the nurse avoiding
by administering a client’s prescribed
160 mg of furosemide by IV piggyback
over 60 minutes?
Select all that Apply.

Bradypnea.
Sodium level of 132.
Hypovolemia.
Potassium level of 3.5.
Tinnitus.

Answer & Rationale

• Ask: Which adverse effect avoided
• Problem: Furosemide given IV piggyback over 60 minutes
> Think slow infusion to avoid ototoxicity - key sign is tinnitus, which indicates
renal function problem. Two ringing of the ears means two kidneys affected
• Solution: Reason to give medication slow
1. Incorrect - bradypnea, NOT an adverse effect
2. Incorrect - hyponatremia or low sodium, NOT adverse effect
3. Incorrect - hypovolemia or low fluid volume, NOT adverse effect
4. Incorrect - normal potassium, NOT adverse effect
5. Correct - ototoxicity of the ears, BIGGEST adverse effect
NCLEX
“BRAIN BUSTER” QUESTION
Which medication is presumably the cause
of a diabetic client’s echocardiogram
indicating bradycardia?
Select all that Apply.

Atorvastatin 80 mg PO once a day.

Labetalol 100 mg PO twice a day.
Metformin 500 mg once daily.
Albuterol 120 mcg prn.

Answer & Rationale

• Ask: Which medication can cause
• Problem: Bradycardia - low heart rate caused by beta blockers that puts
brakes on the heart
• Solution: Meds that can cause a decrease in the heart rate

1. Incorrect - “-statins” help blood vessels to stay clean from cholesterol, nothing to do
with cardiac vitals
2. Correct - “-lol” ending drugs are beta blockers, cause decrease of heart rate &
blood pressure
3. Incorrect - metformin is a diabetic drug, doesn’t decrease heart rate
4. Incorrect - albuterol doesn’t decrease heart rate
NCLEX
“BRAIN BUSTER” QUESTION
Which statement by the client with a
blood pressure of 180/91 and 241mg/
dL cholesterol taking amlodipine
and atorvastatin would necessitate
intervention by the nurse?

“I have been better about exercising for 20

minutes multiple times a week.”
“I had a can of grapefruit juice.”
“I have limited my alcohol intake to only a few
times per week now.”
“I consistently eat one spinach salad a week to
be sure I get that fiber.”

Answer & Rationale

• Ask: Incorrect client statements
• Problem: Amlodipine and atorvastatin
> Blood pressure lowering drug and anti cholesterol drug. “-depine” declines blood
pressure & heart rate, “-statin” blood vessels are clean. Adverse effects - sore
muscles, toxic liver, avoid grapefruit, take at night
• Solution: Remarks by client that are not true

1. Incorrect - skip it because physical exercise is appropriate

2. Correct - grapefruit juice blocks statins
3. Incorrect - skip, limit alcohol intake
4. Incorrect - eating spinach weekly is appropriate
NCLEX
“BRAIN BUSTER” QUESTION
Which client statement about taking
warfarin for preventing blood clots for
a mechanical heart valve replacement
indicates a need for further
education? Select all that Apply.

“I will eat a small amount of green leafy vegetables.”

“I will eat broccoli and turnip greens three times a
week and have extra helping occasionally.”
“Warfarin is set to be taken at 8:00 AM every day.”
“I will try to keep International Normalized Ratio
between 4 and 6.”
“If I am on antibiotics, International Normalized Ratio
will be affected.”

Answer & Rationale

• Ask: Which client statements
• Problem: client taking warfarin > Think warfarin is an anticoagulant - increased
risk for bleed. Vitamin K blocks warfarin effect
• Solution: Incorrect client statements
1. Incorrect - small amount of green leafy veggies is okay, keep vitamin K low
2. Correct - “extra helping”- can’t have too much leafy greens because high vit K
means high risk for clots, will block warfarin’s effects
3. Incorrect - it’s appropriate to take medication same time daily
4. Correct - INR between 2.5 and 3.5 for valve replacements
5. Incorrect - antibiotics affect INR levels, antibiotics kill vit K-producing bacteria
NCLEX
“BRAIN BUSTER” QUESTION
Based on the nursing history and medication
administration record, which prescribed medication
should the nurse contact the health care provider about?
See chart below.

Assessment data: Vital signs:

Worsening crackles lower and Blood pressure: 112/62 mm Hg
middle lobes. Pulse: 82/min
Sudden jugular vein distension. Respirations: 24/min
New 2+ pedal edema. Oxygen saturation:
90% on room air

Aspirin 81 mg PO daily.
Simvastatin 20 mg daily.
Torsemide 20 mg IV daily.
Carvedilol 50 mg twice daily.

Answer & Rationale

• Ask: What med to question
• Problem: Worsening crackles in the lungs, sudden JVD
>Think fluid retention, new pedal edema - fluid volume overload and heart failure.
What kills client first
• Solution: Med that are not appropriate for the worsening heart failure - over the
counter drugs, beta blockers

1. Incorrect - aspirin is an antiplatelet, does NOT affect worsening heart failure

2. Incorrect - simvastatin is a cholesterol lowering drug, does NOT affect worsening heart failure
3. Incorrect - torsemide helps drain the fluid
4. Correct - carvedilol is a beta blocker, bad for worsening heart failure & asthmatic clients
NCLEX
“BRAIN BUSTER” QUESTION
Which finding reveals spironolactone
prescribed for a client already taking
furosemide to treat chronic
hypertension is working
effectively in the body?

Systolic blood pressure that is reducing by 5 mm

Hg biweekly.
Laboratory report of serum glucose 150 mg/dL.
Laboratory report of serum potassium level of 4.8
mEq/L.
Laboratory report of serum sodium 142 mEq/L.

Answer & Rationale

• Ask: Findings that reveals effectiveness
• Problem: clients taking 2 diuretics - spironolactone & furosemide
> Think 2 diuretics, one is potassium-sparing, the other one is potassium-wasting
• Solution: Positive outcomes of spironolactone
1. Incorrect - addition of medication, NOT for blood pressure control
2. Incorrect - medication does NOT increase glucose, hyperglycemia is NOT a
positive finding
3. Correct - normal potassium indicates sparing potassium with spironolactone
4. Incorrect - normal sodium level, NOT what we’re looking for
NCLEX
“BRAIN BUSTER” QUESTION
Which medication does the nurse anticipate
an immediate dosage change for a client in
exacerbative congestive heart failure (CHF)
reporting bilateral lower extremity +4
edema and an increase in weight of
5 lb (2.3 kg) in the last 48 hours?

Furosemide 2 mg PO once daily.

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

Answer & Rationale

• Ask: Which medication needs to change
• Problem: Exacerbation of heart failure with severe edema & weight gain
>Think retaining fluid, heart failure, heavy fluid. #1 drug for heavy fluid issue for
heart failure is “ide” ending diuretics
• Solution: Number 1 medication to give for fluid volume overload - “-ide” ending
1. Correct - “-ide” ending loop diuretics are given to clients experiencing fluid overload
2. Incorrect - valsartan lowers blood pressure, does NOT control fluid retention directly
3. Incorrect - metoprolol is a beta blocker, does NOT control fluid retention directly
4. Incorrect - isosorbide is a vasodilator which lowers blood pressure, does NOT control
fluid retention directly
NCLEX
“BRAIN BUSTER” QUESTION
Which laboratory value(s) should a nurse monitor
before giving the medications listed below to a client?
Select all that apply.
MEDICATION ADMINISTRATION RECORD:
Allergies: None
Medications Time
Methylprednisolone 10 mg PO daily 0900
Atenolol 50 mg PO daily 0900
Digoxin 0.5 mg PO daily 1300
Tinzaparin 40 mg SC q 12 hours 0900 and 2100

Digoxin level.
Serum blood glucose.
PT/INR.
Platelet count.
Serum potassium.

Answer & Rationale

• Ask: Which lab values
• Problem: To monitor before giving the medication
> Think worst case possible scenario
• Solution: Labs that can affect the client from the meds they’re taking

1. Correct - digoxin levels are assessed because it is a toxin

2. Correct - blood glucose are checked when in steroids, steroids increase sugar
3. Incorrect - PT/INR are NOT affected by “-parins”
4. Correct - platelet count can be affected by heparin
5. Correct - potassium levels are checked, low potassium can make digoxin toxicity
even worse
NCLEX
“BRAIN BUSTER” QUESTION
What side effects should the nurse
instruct the client beginning a new
prescription of lisinopril to report
immediately?
Select all that Apply.

“If you have a nagging cough.”

“If you feel lightheadedness and your blood pressure
is 90/60.”
“If you have nausea.”
“If your tongue feels tingling or mouth feels swollen.”
“If you have generalized weakness.”

Answer & Rationale

• Ask: Side effects to report immediately
• Problem: Starting lisinopril
> Think “-pril” is an ACE inhibitor - lowers blood pressure, NOT heart rate
• Solution: What to report immediately
1. Incorrect - nagging cough is an expected side effect
2. Correct - hypotension can lead to injury
3. Incorrect - nausea is an expected side effect for any medication
4. Correct - angioedema swells the tongue, tingling mouth
5. Incorrect - general weakness is an expected side effect of the medication
NCLEX
“BRAIN BUSTER” QUESTION
Which is the priority reason for the nurse to
contact the health care provider regarding a
client who is 4 hours postoperative
knee surgery with continuous spinal
anesthesia (CSA)?
Select all that Apply.

The patient reports feeling his left and right foot now
since the surgery was 4 hours ago.
The patient is prescribed fondaparinux 2.5 mg
subcutaneous.
The patient’s bilateral LLE pain is 1/10.
The patient has postoperative hemoglobin of 11.1 g/dL.
The patient has not urinated and foley was
discontinued immediately after surgery.

Answer & Rationale

• Ask: Priority reasons
• Problem: Why to contact the HCP for a 4-hour post knee surgery on continuous
spinal anesthesia > Think bleeding and sensation complications
• Solution: Findings that can cause the worst potential outcome

1. Incorrect - intact sensation of both lower legs is appropriate

2. Correct - no anticoags with an epidural catheter in place, BIG risk for bleeding
3. Incorrect - minimal bilateral leg pain is good
4. Incorrect - decreased hemoglobin is expected with after every surgery
5. Correct - urinary retention - want to keep foley in place with continuous spinal
anesthesia
NCLEX
“BRAIN BUSTER” QUESTION
Which statement by the client indicates
understanding of the teaching the
nurse gave regarding use of
nitro-stat patches?

“I should continue taking vardenafil 20 mg PO

daily.”
“I should discontinue the medication and report
any pain in my head that I experience.”
“I will move where the patch is placed each time
as I change it on my chest or arm.”
“I will discontinue the use of the patch while I
bathe in the morning.”

Answer & Rationale

• Ask: Correct client statement
• Problem: Nitro-stat patch
> Think nitro is a vasodilator, patch is for transdermal
• Solution: Remarks by the client that is true regarding the patch

1. Incorrect - ED drugs ending in ”-afil” will kill when given with nitro, massive vasodilation
leading to hypotension
2. Incorrect - don’t DC medication because headache is expected
3. Correct - different skin sites every time you change the patch, prevent skin
breakdown & irritation
4. Incorrect - okay to wear nitro patch when showering
NCLEX
“BRAIN BUSTER” QUESTION
A client is seen in the emergency department
for an elevated troponin of 2.01 and angina
non-relieved with a prescription for alteplase
therapy. Which information should the
nurse immediately report to the HCP?
Select all that Apply.

Sphygmomanometer reading of 150/88 mm Hg.

Currently on menstrual cycle.
History of tangled abnormal blood vessels connecting
arteries and veins in the brain or arteriovenous
malformation (AVM).
Reporting angina of 10+ on a scale of 0-10 not relieved
by Nitro tablets.
A long term history of migraine headaches.

Answer & Rationale

• Ask: What info to report now
• Problem: Elevated troponin, angina & alteplase
> Think high bleed risk. For “-ase” ending drugs, clarify prescription for recent
accidents/trauma & angina, aneurysm, AV malformations - don’t give alteplase.
• Solution: Findings that the HCP should be aware of to avoid worst possible outcome
1. Incorrect - 150/88 mm Hg is slightly elevated, but NOT a contraindication for medication
2. Incorrect - menses is not abnormal info, but NOT contraindicated
3. Correct - history of AV malformation, rupture and bleed inside the brain
4. Correct - unrelieved angina may indicate MI
5. Incorrect - history of migraine is not urgent, chronic issue
NCLEX
“BRAIN BUSTER” QUESTION
Which teaching is important for the nurse
to teach about a new prescription of
lisinopril? Select all that Apply.

Include Bananas, oranges, cantaloupe, honeydew, apricots for the

patient to add to their diet.
Instruct patient to sit on the side of the bed for a minute before
standing in the morning.
Review the apical pulse monitoring video with patient and do a
teach back demonstration.
Remind the patient to return to have daily blood draws to
determine therapeutic drug levels.
Teach the patient how to obtain apical pulse and hold medication
if <60/min.
Review the blood pressure monitoring video with patient and do a
teach back demonstration.

Answer & Rationale

• Ask: Important teaching
• Problem: client taking lisinopril
> Think Lisinopril is an ACE inhibitor anti-hypertensive, decrease blood pressure
• Solution: Education that client needs when taking this medication

1. Incorrect - risk for hyperkalemia, minimize potassium intake

2. Correct - postural hypotension is a side effect of the medication
3. Incorrect - apical pulse doesn’t need to be checked
4. Incorrect - daily blood draws are not necessary
5. Incorrect - apical pulse is for digoxin
6. Correct - client needs to monitor blood pressure while taking the “-prils”
NCLEX
“BRAIN BUSTER” QUESTION
Which clinical manifestation(s)
are characteristic of congenital
hypothyroidism in a 2 month old infant?
Select all that apply.

Bradycardia.
Lethargy.
Dry skin.
Excess diaphoresis.
Constipation.

Answer & Rationale

• Ask: Which clinical manifestations are a characteristic of this condition
• Problem: Congenital hypothyroidism in a 2 month old infant
• Solution: Identify clinical manifestations of congenital hypothyroidism

1. Correct - lack of TH impacts cardiovascular function leading to bradycardia

2. Correct - due to alterations in central nervous system function caused by lack
of TH, pediatric pt is likely to experience lethargy
3. Correct - lack of TH cause alterations in integumentary system leading to dry skin
4. Incorrect - sweating decreasing pt with congenital hypothyroidism
NCLEX
“BRAIN BUSTER” QUESTION
Which actions does the urgent care nurse
implement when providing care to a
preschool-age patient who ingested an
unknown amount of aspirin at home?
Select all that apply.

Prepare acetylcysteine.
Administer activated charcoal as prescribed.
Prepare for gastric lavage.
Tell the parents to administer ipecac at home by
oral preparation.
Obtain baseline vital signs.

Answer & Rationale

• Ask: What to do
• Problem: A preschooler may have taken some aspirin
> Think aspirin toxicity - prevent absorption
• Solution: Intervention or what to do for this child right now

1. Incorrect - acetylcysteine is the antidote for acetaminophen

2. Correct - activated charcoal will bind and decrease absorption with aspirin
3. Incorrect - aspiration risk with gastric lavage
4. Incorrect - aspiration risk with ipecac
5. Correct - assess patient for aspirin toxicity, usually tinnitus
NCLEX
“BRAIN BUSTER” QUESTION
What is the priority nursing intervention
for a child who begins to have a seizure
from a high fever?

Give aspirin to decrease fever.

Prepare to give diazepam 5mg IM.
Remain and monitor O2 saturation.
Use jaw-thrust maneuver to open the airway.

Answer & Rationale

• Ask: What is the priority nursing intervention
• Problem: Child who begins to have a seizure from a high fever
• Solution: Identify the priority intervention. Use principles of ABCs

1. Incorrect - aspirin is not given to children due to the risk of developing Reye’s syndrome
2. Incorrect - child may or may not need diazepam so look for a better intervention
3. Correct - priority is to assess oxygen saturation which are characteristics of
seizures and breathing status
4. Incorrect - nurse may or may not need to use jaw-thrust maneuver to open the airway
NCLEX
“BRAIN BUSTER” QUESTION
Which discharge instruction(s) are
appropriate to include for the parent
of a 2.5-year-old child with group A
streptococcal pharyngitis?
Select all that apply.

Even if your child says that they feel ok, take all the
amoxicillin prescribed.
Feed your child soft foods and cool fluids, including plenty
of water.
Give liquid acetaminophen, aspirin, or ibuprofen for pain
and discomfort.
Keep your child home from school for at least 14 days to
ensure not spreading.
Throw away the old toothbrush and replace 24 hours after
starting amoxicillin.

Answer & Rationale

• Ask: Which discharge instructions are appropriate

• Problem: Including discharge instructions of a parent to a 2.5-year-old child with group A

streptococcal pharyngitis

• Solution: Identify appropriate discharge instructions. Consider age of patient

1. Correct - ALWAYS give ALL prescribed antibiotics regardless of how the patient feels, failure to do so
leaves strongest pathogens behind and leaves high risk for an even more serious infection
2. Correct - soft cool foods and fluids will be soothing, water should be given regularly
3. Incorrect - pediatric patients are at risk for developing Reye’s syndrome if medicated with aspirin,
acetaminophen and ibuprofen are often recommended
4. Incorrect - child needs to be kept away from daycare or school for 24 hours after antibiotics are
started, child needs to be afebrile before returning
5. Correct - old toothbrushes are considered to be contaminated making reinfection possible, new
toothbrush should be provided 24 hours after starting antibiotics
NCLEX
“BRAIN BUSTER” QUESTION
Which action(s) should the
nurse expect a developmentally
appropriate 2-year-old to perform?
Select all that apply.

Assemble a small large print puzzle.

Draw a circle unassisted.
Jump with a jump rope.
Runs without falling.
States the child’s own name.

Answer & Rationale

• Ask: Which action(s) should the nurse expect
• Problem: A developmentally appropriate 2-year-old to perform
• Solution: Actions of a developmentally appropriate 2-year-old

1. Incorrect - Assembling a small, large print puzzle is not expected from a 2-year-old.
2. Incorrect - The ability to independently draw a circle is beyond the development of a
2-year-old.
3. Incorrect - Jumping a jump rope is not within the expected development of a 2-year-old.
4. Incorrect - At the age of 2 years, falling when running is expected.
5. Correct - At the age of 2 years, it is expected the child will be able to state the child’s own name.
NCLEX
“BRAIN BUSTER” QUESTION
While receiving methotrexate for psoriasis,
which comment made by the patient
indicates to the nurse that additional
education is needed?

“I am aware that I cannot have alcoholic beverages

while on this medication.”
“I am starting to feel better so I don’t need to take
any annual immunizations.”
“I will contact the health care provider if my eyes or
skin turn yellow.”
“I will avoid crowds while taking this medication
because of my immune system.”

Answer & Rationale

• Ask: Incorrect patient statements
• Problem: Patients taking Methotrexate
> Think it is immunosuppressive, used for chemo, major risk for infection
• Solution: Remarks made by the patient that are false regarding this medication

1. Incorrect - you CAN’T take this medication with alcohol

2. Correct - taking vaccines are recommended, huge risk for infection with
methotrexate
3. Incorrect - HCP should be notified for signs and symptoms of liver disease
4. Incorrect - avoid large crowds, big risk for infection
NCLEX
“BRAIN BUSTER” QUESTION
The nurse is teaching a patient with a new
diagnosis of systemic lupus erythematosus
(SLE). Which patient statement(s) indicates
correct understanding?
Select all that apply.

“I need to make sure I have an influenza vaccination.”

“I can enjoy being out in the sun for several hours
every day.”
“I will call my health care provider if I ever develop a
fever.”
“I will make lifestyle changes and try to avoid stress.”
“I will use antimicrobial soap to wash irritated skin areas.”

Answer & Rationale

• Ask: Correct patient statements
• Problem: SLE - lupus, autoimmune disease with inflammation and organ damage
• Solution: Remarks that indicate patient understands SLE

1. Correct - flu vaccinations are used to protect against illnesses

2. Incorrect - avoid prolonged sun exposure to prevent skin rash and damage to the skin -
trigger to SLE
3. Correct - HCP needs to be aware of a fever
4. Correct - stress is a trigger which can increase complications and worsen flare ups
5. Incorrect - mild soap and water is used to prevent infections
NCLEX
“BRAIN BUSTER” QUESTION
The nurse is instructing a class of high
school students about the ways to prevent
spreading hepatitis A. Which of the
following statements indicate a
need for further education?
Select all that apply.

“I need to spermicides and/or condoms to keep from

contracting hepatitis A.”
“I should get a yearly vaccination to prevent hepatitis A.”
“I should always use condoms if I ever become sexually active.”
“I should wash my hands often to prevent contraction of
hepatitis A.”
“I know there is a special mask to keep from getting hepatitis A.”

Answer & Rationale

• Ask: Incorrect statements
• Problem: Preventing the spread of hepatitis A > fecal-oral route
• Solution: Routes of administration to get hepatitis A

1. Correct - hepatitis A is NOT transmitted via sex

2. Correct - hepatitis A is NOT given in 2 doses in terms of vaccination
3. Correct - hepatitis A is NOT transmitted via sex
4. Incorrect - hand washing is important to decrease fecal-oral contamination
5. Correct - hepatitis A is NOT transmitted due to respiratory route