NCLEX RN

Correct Answer C. Turkey breast

Why this is the correct answer:

Turkey breast, especially when skinless, is very low in saturated fats and cholesterol compared to other options. It is a lean protein source and is often recommended in heart-healthy and low-cholesterol diets. Choosing lean poultry over high-fat meats and dairy helps reduce the risk of atherosclerosis and cardiovascular disease.

Why the other options are incorrect:

A. Macaroni and cheese

This dish is high in saturated fats due to cheese, butter, and milk, making it an unhealthy option for someone on a low-fat, low-cholesterol diet.

B. Shrimp with rice

Although rice is low-fat, shrimp is relatively high in cholesterol. It is not the best choice when trying to limit cholesterol intake.

D. Spaghetti with meat sauce

Meat sauces often contain ground beef, which is high in saturated fats unless prepared with lean cuts. This makes it less heart-healthy compared to turkey breast.

Correct Answer D. Aged cheese

Explanation:

Linezolid (Zyvox) is an oxazolidinone antibiotic that also acts as a monoamine oxidase inhibitor (MAOI). Patients taking linezolid must avoid foods high in tyramine, as ingestion can lead to dangerous hypertensive crises. Aged cheeses are especially high in tyramine and are strictly contraindicated.

Why the other options are incorrect:

A. Wheat bread

Contains no significant tyramine and is safe to eat while taking linezolid.

B. Honey

Honey is not a source of tyramine and poses no interaction with linezolid.

C. Oranges

While acidic, oranges do not contain tyramine and are safe for patients taking linezolid.

Correct Answer A. Complete blood count (CBC) and absolute neutrophil count

Explanation

Clozapine carries a boxed warning for severe neutropenia (agranulocytosis), which can be rapidly life-threatening due to overwhelming infection. Because of this unique, high-risk toxicity, ANC monitoring is mandated under clozapine REMS programs: obtain a baseline ANC and then check it at specific intervals (commonly weekly for 6 months, every 2 weeks for months 6–12, then monthly if stable). Treatment interruption or discontinuation is tied directly to ANC thresholds. No other clozapine adverse effect has this level of required, protocol-driven surveillance. Therefore, periodic CBC with ANC is the highest-priority ongoing measurement.

Why Other Options Are Wrong

B. Electrocardiogram

Clozapine can cause myocarditis and cardiomyopathy, and many protocols obtain a baseline ECG and monitor for cardiac symptoms, sometimes with early troponin/CRP checks. However, ECGs are not universally required at strict, ongoing intervals like ANC monitoring. QT prolongation is typically less pronounced with clozapine than with other antipsychotics, and ECG surveillance is guided by symptoms or comorbid risk rather than a mandated schedule. Thus, while important, ECGs are not the highest-priority periodic test.

C. Fasting blood sugar and fasting lipids

Metabolic syndrome (weight gain, dyslipidemia, insulin resistance) is a significant clozapine risk, and baseline plus periodic metabolic monitoring is recommended (e.g., baseline, 3 months, then at least annually). These labs inform long-term cardiometabolic risk and guide counseling or pharmacologic management. However, they do not address an acute, potentially fulminant toxicity like agranulocytosis. Compared with the REMS-mandated ANC schedule, metabolic labs are essential but not the single highest-priority periodic measure.

D. Height, weight, and waist circumference

Anthropometric monitoring is useful for early detection of clozapine-associated weight gain and central adiposity. Measuring weight and waist circumference at baseline and periodically supports prevention and treatment of metabolic complications. Nevertheless, these measures do not detect the most dangerous acute hematologic toxicity of clozapine. They should be performed routinely, but ANC monitoring remains the top priority due to its life-saving implications and regulatory requirements.

Correct Answer A. Taking a warm shower upon awakening

Explanation:

Clients with rheumatoid arthritis often experience morning stiffness due to inflammation and immobility during the night. Heat therapy, such as a warm shower or warm compresses, helps relax the muscles, increase circulation, and decrease stiffness, making it the best intervention for symptom relief in the morning.

Why the other options are incorrect:

B. Applying ice packs to the joints

Cold therapy is used more effectively for acute inflammation or flare-ups, not for routine morning stiffness.

C. Taking two aspirin before going to bed

Although aspirin can relieve pain and inflammation, it does not address the stiffness as effectively as heat therapy in the morning. Medication should

be taken as prescribed, not arbitrarily.

D. Going for an early morning walk

Exercise is important for joint health, but attempting to walk while joints are stiff and painful is not the best immediate intervention. Movement is more beneficial after stiffness has been relieved with heat.

The Correct Answer is B. Fluid volume deficit

The client’s hypotension (BP 68/34) and tachycardia (pulse 130) are classic signs of hypovolemic shock, most likely due to blood loss from trauma. The priority diagnosis is Fluid volume deficit because inadequate circulating blood volume is life-threatening and requires immediate intervention such as fluid resuscitation and blood replacement. Restoring circulating volume takes precedence before other concerns, as perfusion to all vital organs depends on it.

Why the other options are incorrect:

A. Alteration in cerebral tissue perfusion

Cerebral perfusion is compromised when blood pressure is critically low, but this stems from hypovolemia. Treating the fluid volume deficit is the priority to restore perfusion.

C. Ineffective airway clearance

The respiratory rate is 18 and there is no indication of obstruction or inadequate ventilation. Airway is intact at this point.

D. Alteration in sensory perception

This may occur as shock progresses, but it is not the immediate, life-threatening concern compared to fluid volume loss.

Correct Answer D. Withdraw the needle

Why this is the correct answer:

A sudden, severe, radiating “pins and needles” sensation during venipuncture signals nerve contact/trauma. Continuing the stick risks permanent nerve injury. The immediate priority is to stop the procedure and remove the needle, then apply gentle pressure, assess distal neurovascular status (sensation, movement, color, cap refill), document, and notify the appropriate provider/charge nurse. Avoid further attempts in that arm until evaluated.

Why the other options are incorrect:

A. Apply ice locally

Cold therapy is for later symptom relief. First, remove the offending stimulus (the needle). Ice without withdrawing the needle delays essential action and can worsen injury.

B. Apply lidocaine/prilocaine cream

Topical anesthetics do not treat nerve puncture and are not used mid-procedure. They would also delay needle removal.

C. Reassure the client

Empathy is important, but reassurance alone does not address the urgent risk. Stop the injury first by withdrawing the needle, then reassure and proceed with evaluation.

Correct Answer B. Distant heart tones and jugular venous distension

Why this is the correct answer:

These findings strongly suggest impending cardiac tamponade (part of Beck’s triad along with hypotension). Tamponade is a life-threatening complication of pericarditis requiring urgent evaluation (e.g., bedside echo) and preparation for pericardiocentesis.

Why the other options are incorrect:

A. Client reports chest pain that is worse with deep inspiration

Typical pleuritic pain of pericarditis; urgent but not the immediate red flag compared with signs of tamponade.

C. ECG showing ST segment elevations in all leads

Diffuse ST elevation is a classic, expected ECG pattern in acute pericarditis, not by itself an emergency indicator like tamponade signs.

D. Pericardial friction rub auscultated at the left sternal border

Hallmark of pericarditis and expected; does not by itself indicate hemodynamic compromise.

Correct Answer A. Close assessment for signs of bleeding is needed.

Explanation:

Normal prothrombin time (PT) is about 11–13 seconds. Therapeutic anticoagulation with warfarin usually prolongs PT to 1.5–2 times normal (around 18–24 seconds). A PT of 120 seconds is dangerously elevated, indicating a high risk for spontaneous bleeding. The priority is to closely assess the client for signs of bleeding and notify the physician immediately.

Why the other options are incorrect:

B. The dosage of Coumadin is inadequate to prevent thrombi

This is incorrect because the PT is excessively prolonged, showing the dose is too strong, not inadequate.

C. The client should limit the intake of foods rich in vitamin K

Vitamin K actually helps reverse warfarin effects. Limiting vitamin K intake further would worsen anticoagulation, not correct it.

D. Skipped doses should be made up by taking an additional dose

This is unsafe and contraindicated. Making up doses of warfarin can cause dangerous over-anticoagulation and bleeding.

Correct Answer A. Tomatoes

Why this is the correct answer:

Tomatoes contain vitamin C, which helps with iron absorption, but they are not a rich source of iron themselves. Clients with iron-deficiency anemia should be guided toward foods that are iron-dense, such as red meat, legumes, dried fruits, and nuts. While tomatoes can be included in the diet to aid absorption, they do not provide significant iron content.

Why the other options are incorrect:

B. Legumes

Beans, lentils, and peas are good plant-based sources of non-heme iron and are recommended in the diet for anemia.

C. Dried fruits

Raisins, apricots, and prunes are rich in iron and contribute significantly to improving iron intake.

D. Nuts

Nuts such as almonds and cashews provide moderate amounts of iron and are beneficial for clients with iron deficiency.