NCLEX EXAM1 QUESTIONS WITH ANSWERS CORRECTLY TESTED AND VERIFIED SOLUTIONS 2023/2024 UPDAT, Exams of Nursing

Download NCLEX EXAM1 QUESTIONS WITH ANSWERS CORRECTLY TESTED AND VERIFIED SOLUTIONS 2023/2024 UPDAT and more Exams Nursing in PDF only on Docsity! NCLEX EXAM1 QUESTIONS WITH ANSWERS CORRECTLY TESTED AND VERIFIED SOLUTIONS 2023/2024 UPDATES 1. A client is to receive digoxin 0.125 mg intravenously. The available dosage of digoxin is 500 mcg/2 mL. The nurse should administer how many milliliters based on the prescribed dosage? Fill in the blank. 0.5 2. The nurse is assigned to care for four clients. Which is the best intervention to prevent the spread of infection between clients? Use proper hand-washing techniques consistently. 3. The nurse is preparing the client's morning prescribed NPH insulin dose and notices a clumpy precipitate inside the insulin vial. Which action should the nurse implement? Draw the dose from a new vial. 4. A client breathing independently with a tracheostomy is coughing up copious secretions onto the tracheostomy dressing. The nurse plans which intervention to reduce the risk of respiratory infection in this client? Change the tracheostomy dressing as needed. 5. When a client's nasogastric (NG) tube stops draining, which intervention should the nurse implement to maintain client safety? Verify the tube placement according to agency procedure. 6. A primary health care provider prescribes lipids (fat emulsion) for a client who is receiving total parenteral nutrition (TPN). The nurse should explain to the client that the fat emulsion is administered for which reason? To provide essential fatty acids 7. The nurse is preparing to administer eardrops to an infant. The nurse should plan to proceed by taking which step to assure the appropriate instillation of the medication? Pull down and back on the auricle, and direct the solution toward the wall of the ear canal. 8. The nurse inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing, but as the nurse starts to slowly advance the NG tube with each swallow, the client begins to gag. Which action if taken by the nurse at this point would indicate a need for further instruction regarding the insertion of an NG tube? Continuing to advance the tube to the desired distance 9. The nurse assists the primary health care provider with the removal of a chest tube. During the procedure, the nurse instructs the client to perform which action? Take a deep breath and hold it. 10. The nurse is evaluating a client's use of a cane for left-sided weakness. The nurse should intervene and determine the client needs further teaching if the client is observed taking which action? Moving the cane when the right leg is moved 11. The home care nurse has been caring for an older client diagnosed with chronic pruritus. The nurse determines that the client has followed through with the suggested measures to promote skin hydration when they make which statement? "I've stopped taking a daily shower or tub bath." 12. A client with a right leg fracture is prescribed a non–weight-bearing status. Which finding indicates that the client demonstrates compliance with this restriction? Does not bear weight on the right leg 13. The nurse is teaching a client how to use a peak flowmeter. Which statement by the client indicates that further teaching is needed? "I should always ensure that my lips are loosely around the mouthpiece." 14. The nurse is caring for a client with an endotracheal tube that is attached to a mechanical ventilator when the high-pressure alarm sounds. The nurse determines that the cause of the alarm is likely a result of which occurrence? A kink in the ventilator circuit 15. The health care provider prescribes carvedilol 12.5 mg for the client with cardiomyopathy. Carvedilol is available in 25-mg tablets. How many tablets should the nurse administer? Fill in the blank. 0.5 16. The nurse is listening to a lecture on chest tube removal. Which statement indicates that teaching has been effective? “Petrolatum gauze is usually used to cover the chest tube insertion site." 17. A client has been taught to use a walker to aid with mobility after the add to the 250-mL IV bag to administer the correct dose? Fill in the blank. 5 ml 31. The nurse mentor is observing a new nurse change the ties for a client with a tracheostomy. Which action, if performed by the new nurse, indicates a need for further instruction? Positioning the client in a supine position before the procedure 32. The nurse is caring for an obese client on a weight loss program. Which method should the nurse use to most accurately assess the program's effectiveness? Monitor the client's weight. 33. A client has been taught to use a walker to aid with mobility after the internal repair of a hip fracture. The nurse determines the need for further teaching when the client is observed taking which action when walking? Advancing the walker with reciprocal motion 34. The nurse is preparing to provide oral care to the client who has full upper and lower dentures. Which interventions should the nurse implement during care of the dentures? Select all that apply. Hold the dentures close to water. Fill the emesis basin with tepid water. Put the dentures in a secure place to prevent loss. 35. Which is the most important laboratory result for the nurse to present to the primary health care provider on a client who is receiving total parenteral nutrition (TPN)? Serum electrolyte levels 36. A client receiving morphine sulfate as patient-controlled anesthesia (PCA) is found with respirations of 4 breaths per minute and is unresponsive to verbal stimuli. The nurse quickly identifies the respiratory depression and prepares to implement the prescribed naloxone 2 mg. Naloxone is available as 0.4 mg/1 mL. How many milliliters should the nurse administer? Fill in the blank. 5 ml 37. The nurse is preparing to do tracheostomy care on a client. Which tracheostomy care items should the nurse obtain to perform this procedure? Tracheostomy care kit, sterile saline and water, and a suction kit 38. The nurse creates a teaching plan regarding the administration of eardrops for the parents of a 6-year-old child. The nurse tells the parents that, when administering the drops, which action is appropriate? Pull the ear up and back. 39. Ampicillin/sulbactam sodium, 150 mg in 100 mL of normal saline, is to be administered over a time period of 30 minutes. The drop factor is 10 drops per mL. The nurse should set the flow rate at how many drops per minute (gtt/min)? Fill in the blank. Round your answer to the nearest whole number. 33 drops/min 40. The nurse is teaching a client how to stand on crutches. What information should the nurse give the client related to placement of the crutches? Place the crutches 6 inches to the front and side of the toes. 41. The nurse prepares to place a client in a sitting position in a chair. Which body alignment guidelines should the nurse implement? Select all that apply. The head is erect. The thighs are parallel and in a horizontal plane The client's arms are supported on the armrest or in the lap. 42. The nurse observes that a client's nasogastric tube has suddenly stopped draining. The tube is connected to suction, the machine is on and functioning, and all connections are snug. The tube is secured properly and does not appear to have been dislodged. After checking placement, the nurse gently flushes the tube with 30 mL of normal saline, but the tube still is not draining. How should the nurse analyze the problem? Channels of gastric secretions may be bypassing the holes in the tube, and turning the client will promote stomach emptying. 43. A client with a diagnosed neurological disorder has a sudden rise in intracranial pressure. The health care provider prescribes mannitol 50 g intravenous stat. Available are vials of mannitol in a concentration of 12.5 g/50 mL. How many milliliters should the nurse administer? Fill in the blank. 500 ml 44. The nurse is assigned to care for a client on contact precautions. On review of the client's record, the nurse notes that the client has a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy that is attached to a mechanical ventilator and requires frequent suctioning. The nurse gathers supplies before entering the client's room and should implement wearing which priority protective items? Select all that apply. Gown Glove s Goggl es 45. The client is admitted with a diagnosis of acute coronary syndrome, and the health care provider prescribes one loading dose of clopidogrel 300 mg to be taken orally. Clopidogrel is available as 75-mg tablets. How many tablets should the nurse administer? Fill in the blank. 4 46. The nurse is preparing a discharge plan for a client who has undergone total knee replacement and is being admitted to an intensive 3-week rehabilitation program. Which type of services/settings would most meet the client's needs? Select all that apply. Skilled nursing facility Freestanding rehabilitation center Rehabilitation unit within the hospital 47. A health care provider prescribes 25 mg of promethazine to be mixed with 35 mg of meperidine every 4 hours as needed for pain. The promethazine vial reads "50 mg/1 mL." The meperidine vial reads "50 mg/1 mL." To correctly administer the two medications together, the nurse should expect to administer a total of how many milliliters? Fill in the blank. 1.2 ml 48. The nurse provides dietary instruction to the parents of a child with a diagnosis of cystic fibrosis. The nurse should tell the parents that which diet plan should be followed? High in calories 49. The nurse should determine which factors as contributing to stress incontinence in a female client? Select all that apply. Obesit round the answer to the nearest whole number. 31 62. A client diagnosed with cancer is placed on permanent total parenteral nutrition as a means of providing nutrition. Which is the rationale for the nurse to include psychosocial support when planning care for this client? The client will need to adjust to the idea of living without eating by the usual route. 63. A client is to receive lorazepam 1 mg intravenously (IV) for severe anxiety. Lorazepam 4 mg/mL is available. How many milliliters should the nurse administer? Fill in the blank. 0.25ml 64. A health care provider prescribes 500 mg of amoxicillin suspension every 8 hours. The medication label indicates that there is 125 mg/5 mL. How many milliliters should the nurse administer? Fill in the blank. 20ml 65. A client is to receive 238 g of polyethylene glycol diluted in 64 oz of Gatorade as a bowel preparation the day before a scheduled colonoscopy. How many milliliters did the client consume thus far if the client already drank six 8-oz glasses of the mixed solution? Fill in the blank. 1440ml 66. When a client requests pain medication, the nurse administers a ventrogluteal intramuscular injection. After administration of the injection, what should the nurse do first? Apply gentle pressure to the injection site. 67. A child with the diagnosis of Hirschsprung's disease has a temporary colostomy. The nurse provides instructions to the parents about colostomy care at home. Which statement by the parents indicates their understanding of the instructions? "We will report signs of skin breakdown." 68. The nurse hangs a 1000-mL intravenous (IV) solution of D5W (5% dextrose in water) at 9 am and sets the infusion controller device to administer 100 gtt/min via microdrip infusion set (60 gtt = 1 mL). On assessment of the IV infusion, the nurse expects that the remaining amount of solution in the IV bag at 2 pm will be represented at which level? Fill in the blank and round to the nearest whole number. 500ml 69. A client who is receiving total parenteral nutrition (TPN) tells the nurse, "I'm not sure that I want to receive an infusion of lipids because it could make me obese." Which initial action should the nurse take? Inquire how illness affects the client's self-concept. 70. A health care provider prescribes 1000 mL of 0.9% normal saline to infuse intravenously over 6 hours. The drop factor is 15 drops/1 mL. The nurse should set the flow rate at how many drops per minute (gtt/min)? Fill in the blank. Round your answer to the nearest whole number. 42 71. A client prescribed albuterol sulfate by inhalation cannot cough up secretions. The nurse should teach the client which action to best help clear the bronchial secretions? Increase the amount of fluids consumed every day. 72. The nurse enters a client's room with a pulse oximetry machine and tells the client that the health care provider has prescribed continuous oxygen saturation readings. The client's face changes to one of apprehension. The nurse should quickly and effectively alleviate the client's anxiety by explaining which concept about pulse oximetry? It is painless and safe. 73. A provider has just inserted a Cantor (nasointestinal) tube in a client with a bowel obstruction. When the procedure is complete, the nurse assists the client into which position initially to maximize the effect of the tube? Right side 74. A client receiving morphine sulfate as patient-controlled anesthesia (PCA) is found with respirations of 4 breaths per minute and is unresponsive to verbal stimuli. The nurse quickly identifies the respiratory depression and prepares to implement the prescribed naloxone 2 mg. Naloxone is available as 0.4 mg/1 mL. How many milliliters should the nurse administer? Fill in the blank. 5ml 75. A client who has undergone internal fixation after fracturing a left hip has developed a reddened left heel. What equipment should the nurse obtain to manage this problem? Alternating pressure mattress 76. While preparing to administer cefazolin 1 g in 50 mL over ½ hour, the nurse sets the infusion pump to the correct time frame. At how many milliliters per hour should the nurse set the infusion pump? Fill in the blank. 100 ml/hr 77. An infant requires 60 mg of acetaminophen. It is available as 80 mg/mL. How many milliliters should the nurse administer? Fill in the blank. 0.75ml 78. A client is prescribed cefepime 1 g intravenously every 12 hours. The medication is to be diluted in 100 mL of D5W and to be run over 30 minutes. The nurse should set the flow rate at how many drops per minute (gtt/min) using a 15-gtt/mL IV tubing? Fill in the blank. 50 79. Which area of the chest drainage unit should the nurse plan to fill to prevent atmospheric air from reentering the pleural space? Refer to figure. c-red 80. A health care provider prescribes a one-time dose of 100 mcg of folic acid intravenously. The medication vial reads "0.15 mg/2 mL." How many milliliters should the nurse administer? Fill in the blank. Round your answer to one decimal place. 1.3ml 81. A health care provider prescribes 1000 mL of normal saline to infuse over 12 hours. The drop factor is 15 gtt per 1 mL. The nurse should prepare to set the flow rate at how many drops per minute? 21 82. The nurse is preparing to initiate a bolus enteral feedings via nasogastric (NG) tube to a client. Which action represents safe practice by the nurse? Verifying correct nasogastric tube position with aspiration and administration of air bolus with auscultation 83. A 56-kg client with anemia requires iron supplementation. The recommended dose is elemental iron 3 mg per kilogram per day in three divided doses. How many milligrams of elemental iron should this client receive per dose? 56 mg/dose 84. The suggested treatment for the prevention of malaria is doxycycline daily during time of exposure. The recommended dosage is 200 mg/day. How many tablets should the nurse tell the client to take each day? 2 85. The nurse is instructing the client in the proper use of an inhaler. Arrange the actions in the order that they should be performed. All options must be used. Take off the cap and shake the inhaler. Breathe out all of quickly." 100. The nurse is observing a new nurse who is caring for a client with a newly placed gastrostomy tube. Which action by the new nurse requires the need for further teaching? Adding 12 hours of product to the bag for a client with a continuous feeding in order to prevent bacterial growth 101. The nurse teaching an older client about general hygienic measures for foot and nail care should include which instructions? Select all that apply. Apply lanolin or baby oil if dryness is noted along the feet. Pat the feet dry thoroughly after washing and dry well between toes. 102. The nurse is preparing to perform nasotracheal suctioning on a client. In which position does the nurse place the client's bed to perform this procedure effectively? Refer to figure. A 103. A client has a continuous catheter irrigation postoperatively after having a transurethral resection of the prostate. The nurse notes that fluid is entering the bladder, but none is draining from the bladder. In which priority order should the nurse implement assessment actions? Assess drainage tubing for kinking. Assess the bladder for distention. Ask the client about bladder spasms and discomfort. Review intake and output record. Perform a bladder scan to evaluate the amount of fluid in the bladder. 104. The nurse observes clients to evaluate for the correct height of crutches. The nurse should determine that which client is correctly fitted with crutches? Two to three fingers fit between the client's axillae and the top of the crutches. 105. A health care provider prescribes one 325-mg iron sulfate tablet orally twice daily. Each 325-mg tablet contains 65 mg of elemental iron. How many milligrams of elemental iron will this client receive per day? 130 mg/day 106. A health care provider prescribes 75 mg of prednisone to be taken orally daily. The medication bottle reads "50 mg per scored tablet." How many tablets should the nurse administer? 1.5 tablets 107. A client using crutches is not allowed to bear any weight on the affected leg. Which type of walking gait should the client be taught? Three-point 108. The nurse is caring for a client receiving mechanical ventilation when the high-pressure alarm sounds. Which actions are appropriate for the nurse to plan to take? Select all that apply. Suction the client. Auscultate breath sounds. Insert an oral airway to prevent biting. 109. The nurse is planning to obtain an arterial blood gas (ABG) from the radial artery of a client with a diagnosis of chronic obstructive pulmonary disease (COPD). To prevent bleeding after the procedure, which priority activity should the nurse plan time for after the arterial blood is drawn? Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes 110. A client has a newly fractured fibula that was plaster casted in the emergency department. Because the client will need to use crutches, which crutch-walking gait should the nurse teach the client before discharge? Three-point gait 111. A stable client with left-sided weakness will begin ambulating with a cane. To promote client safety, where should the nurse plan to be positioned in relation to the client? Slightly behind the client's left side and have the client move the cane forward about 1 foot followed by the left leg, and then move the right leg forward ahead of the cane and the left leg 112. The nurse is suctioning the airway of a client with a tracheostomy. Which intervention is appropriate for the performance of this procedure? Insert the catheter until coughing or resistance is felt. 113. The health care provider has prescribed a bolus of diltiazem for a client experiencing diagnosed uncontrolled atrial fibrillation. The prescription reads to bolus 0.25 mg/kg over 2 minutes. The client's weight is 154 lb. How many milligrams of diltiazem should the nurse administer to the client? 17.5mg 114. A client with a diagnosed neurological disorder has a sudden rise in intracranial pressure. The health care provider prescribes mannitol 50 g intravenous stat. Available are vials of mannitol in a concentration of 12.5 g/50 mL. How many milliliters should the nurse administer? 200 ml 115. The nurse has finished suctioning a client. Which parameter should the nurse use to best determine the effectiveness of suctioning? Clear breath sounds 116. A health care provider prescribes 1 unit of packed red blood cells (PRBCs) to infuse over 4 hours. The unit of blood contains 250 mL. The drop factor is 15 drops/mL. At how many drops per minute should the nurse set the intravenous (IV) flow rate? 16 drop/min 117. A registered nurse assigns a new nurse to care for a client with a diagnosis of active tuberculosis and explains the use of a particulate respirator (N95 respiratory mask). Which observation best indicates that the new nurse understands how to use the particulate respirator appropriately? The strap is readjusted if air is detected escaping around the nose area. 118. A postpartum nurse has instructed a new mother regarding how to bathe her newborn. The nurse demonstrates the procedure to the mother and, on the following day, asks the mother to perform the procedure. Which observation by the nurse indicates that the mother is performing the procedure correctly? The mother begins to wash the newborn infant by starting with the eyes and face. 119. The nurse has administered approximately half of a high- cleansing enema when the client reports pain and cramping. Which nursing action is appropriate? Clamping the tubing for 30 seconds and restarting the flow at a slower rate 120. A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry. What should the nurse plan to do to ensure accurate readings on the oximeter? Ask the client to limit motion in the hand attached to the pulse oximeter. 121. A client has had a nasointestinal (NI) tube in place for 24 hours. Which assessment finding indicates that the tube is properly located in the intestine? 137. The nurse is reviewing the discharge instructions for a client who had a skin biopsy. Which statement by the client indicates a need for further teaching? "I will return tomorrow to have the sutures removed." 138. A health care provider's prescription reads "theophylline 250 mg in 500 mL normal saline to infuse at 50 mL/hr." How many milligrams of aminophylline should the client receive every hour? Fill in the blank. 25mg 139. The client is admitted with a diagnosis of acute coronary syndrome, and the health care provider prescribes one loading dose of clopidogrel 300 mg to be taken orally. Clopidogrel is available as 75-mg tablets. How many tablets should the nurse administer? 4 tab 140. The health care provider's prescription reads, heparin sodium 25,000 units in 250 mL 5% dextrose in water to infuse intravenously continuously at a rate of 800 units per hour. To ensure that the solution infuses safely at the rate prescribed, the nurse should set the intravenous pump to how many milliliters per hr? 8 141. A client prescribed albuterol sulfate by inhalation cannot cough up secretions. The nurse should teach the client which action to best help clear the bronchial secretions? Increase the amount of fluids consumed every day. 142. Which action should the nurse take when suctioning the airway of a client with a tracheostomy? Inserts the catheter until coughing or resistance is felt 143. The nurse is preparing to provide oral care to the client who has full upper and lower dentures. Which interventions should the nurse implement during care of the dentures? Select all that apply. Hold the dentures close to water. Fill the emesis basin with tepid water. Put the dentures in a secure place to prevent loss. 144. Which priority precaution should the nurse specifically implement when caring for a hospitalized child diagnosed with rubeola (measles)? Wearing a mask 145. A client diagnosed with both a wound infection and osteomyelitis is to receive hyperbaric oxygen therapy. During the therapy, which priority intervention should the nurse implement? Ensuring that oxygen is being delivered 146. The nurse prepares to give an intramuscular injection using the Z- track technique. Which should the nurse do initially to administer the medication? Select a large, deep muscle for the intramuscular injection site. 147. The nurse admits a client who is demonstrating right-sided weakness, aphasia, and urinary incontinence. The woman's daughter states, "If this is a stroke, it's the kiss of death." What initial response should the nurse make? "You feel your mother is dying?" 148. A primary health care provider has seen a client diagnosed with Crohn's disease and has prescribed a complete blood cell (CBC) count. The nurse provides instructions to the client, who will be reporting to the laboratory in the morning to have the blood drawn for the test. Which information should the nurse give the client regarding this test? No special preparation is necessary. 149. A client is monitored for residual urine every 8 hours. Which are the most appropriate actions for the nurse to implement to complete this prescription? Select all that apply. Have client void then do a bladder scan. If residual urine is less than 100 mL, continue to monitor. 150. The nurse is caring for a client with a nasogastric tube who has a prescription to have the tube irrigated once every 8 hours. The nurse ensures that which solution is placed in the client's room to be used for the irrigation when the client's serum electrolyte results indicate a potassium level of 4.5 mEq/L (4.5 mmol/L) and a sodium level of 132 mEq/L (132 mmol/L)? Normal saline 151. Which are the most potential modes of human immunodeficiency virus (HIV) transmission? Select all that apply. Breast milk Needlestick injury Transfusion of HIV infected blood Inconsistent use of protective equipment 152. The nurse assesses the environmental safety of a client receiving home oxygen therapy. Which observation by the nurse indicates that the client needs further teaching to ensure safety? Oxygen concentrator propped against a wall 153. The nurse is checking the laboratory results of an adult client and notes that the blood urea nitrogen (BUN) level is 15 mg/dL (5.4 mmol/L). Based on this laboratory result, which action should the nurse take? Inform the client that the result is normal. 154. The nurse is encouraging a client to cough and deep breathe after cardiac surgery. The nurse should ensure that which item is available to assist the client to maximize the effectiveness of this procedure? Incisional splinting device 155. The nurse has inserted a nasogastric tube (NG) and prepares to check for accurate tube placement. What is the least reliable method for checking tube placement? Placing the end of the tube in water to check for bubbling 156. An Arab Muslim female client has been stabilized following an assault in the parking lot of a local restaurant. The nurse manager is making assignments for the oncoming shift. Which action by the nurse manager is the most appropriate to ensure the client's comfort? Assign the client a female nurse for every shift. 157. The nurse caring for a client who has had a cystoscopy determines that the client needs additional teaching if the client verbalizes which intention/expectation? Expect episodes of bright red bleeding. 158. The nurse is planning a teaching session with the client who was recently diagnosed with gastric ulcers and who is questioning why antacids prescribed need to be taken at bedtime. Which information regarding sleep cycles should the nurse include? Select all that apply. The rapid eye movement (REM) sleep stage is characterized by an increase of gastric secretion. During the non–rapid eye movement (NREM) stage of sleep cycle, all body functions slow down. 159. The nurse has given a prescribed subcutaneous injection to a client with acquired immunodeficiency syndrome (AIDS). Which action should the nurse implement to best dispose of the used needle and syringe?