Nclex Ncsbn Sample Questions And Correct Verified Answers Update 2024/2025 Best Exam Solu, Exams of Nursing

Download Nclex Ncsbn Sample Questions And Correct Verified Answers Update 2024/2025 Best Exam Solu and more Exams Nursing in PDF only on Docsity! Nclex Ncsbn Sample Questions And Correct Verified Answers Update 2024/2025 Best Exam Solution Graded A+ For Success The nurse is planning care for a client with moderate Alzheimer's disease (AD). Which of the following interventions should the nurse include in the client's plan of care? 1. Encourage the client to reminisce about happy memories. 2. Confront the client when inappropriate or agitated behaviors occur. 3. Administer to the client the cholinesterase inhibitor to reverse the course of AD. 4. Provide the client with information about activity choices in the morning so the client can make plans for the day. - CORRECT ANSWERS The nurse is teaching a client how to ambulate using crutches. Which of the following information should the nurse include? 1. "Use your hands and arms to support your body weight." 2. "Wear slippers when ambulating with the crutches in your home." 3. "Maintain the crutches 12 in (30 cm) in front of your feet while standing." 4. "Adjust the hand grips of the crutches so that your elbows are fully extended." - CORRECT ANSWERS The nurse has taught a client with multiple sclerosis (MS). Which of the following statements by the client would indicate a correct understanding of the teaching? 1. "I will complete all of my household chores in the morning when I am well rested." 2. "I have learned how to massage my bladder to help empty my bladder completely." 3. "I will take a hot bath in the evening to help me relax if I have had a stressful day at work." 4. "I should expect the blurred vision to resolve after I have received medications for several weeks." - CORRECT ANSWERS The nurse in the emergency department (ED) is caring for a 41-year-old male client. Click to highlight the findings below that would require follow-up. Nurses' Notes Emergency Department 1100: Client reports nausea, loss of appetite, vomiting, fever, and constipation for the past 2 weeks and abdominal pain rated 7/10 on the Numerical Rating Scale for 1 week. Client states, "The abdominal pain started after my 7-year-old child accidentally kicked me in the stomach." Client plays soccer with the child once a week. Vital signs: T 103.4° F (39.7° C), P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air. No significant past medical or surgical history. Body mass index (BMI) of 32. Drinks alcohol only during social occasions, usually 3 beverages. Smokes cigarettes during social occasions. - CORRECT ANSWERS The nurse in the emergency department (ED) is caring for a 41-year-old male client. Nurses' Notes Emergency Department 1100: Client reports nausea, loss of appetite, vomiting, fever, and constipation for the past 2 weeks and abdominal pain rated 7/10 on the Numerical Rating Scale for 1 week. Client states, "The abdominal pain started after my 7-year-old child accidentally kicked me in the stomach." Client plays soccer with the child once a week. Vital signs: T 103.4° F (39.7° C), P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air. No significant past medical or surgical history. Body mass index (BMI) of 32. Drinks alcohol only during social occasions, usually 3 beverages. Smokes cigarettes during social occasions. For each assessment finding below, click to specify if the finding is consistent with the disease process of bowel obstruction, appendicitis, or ruptured spleen. Each finding may support more - CORRECT ANSWERS Nclex Ncsbn Sample Questions And Correct Verified Answers Update 2024/2025 Best Exam Solution Graded A+ For Success The charge nurse has received a change-of-shift report on the following clients in labor. The charge nurse should ask a staff member to first see the client in the 1. first stage of labor who has an oral temperature of 99.7° F (37.6° C) 2. first stage of labor whose contractions are occurring every 30 seconds 3. second stage of labor who has respirations of 26 4. second stage of labor whose contractions are lasting for 60 seconds - CORRECT ANSWERS The nurse is observing a staff member caring for a client who has chickenpox. Which of the following actions by the staff member would require the nurse to intervene? 1. placing the client in a private room with monitored negative air pressure 2. placing a box of disposable face shields outside the client's room 3. placing an alcohol-based hand rub in the client's room for hand hygiene 4. placing a surgical mask on the client during transport out of the client's room - CORRECT ANSWERS The nurse is caring for a client who reports feeling faint and is experiencing the cardiac rhythm shown in the electrocardiogram (ECG) strip below. 1. Administer the client's prescribed beta blocker. 2. Prepare for transcutaneous pacing. 3. Instruct the client to perform the Valsalva maneuver. 4. Begin chest compressions. 5. Assess the client for angina. - CORRECT ANSWERS The nurse has attended a staff education program about caring for clients who are receiving positive pressure mechanical ventilation. Which of the following statements by the nurse would indicate a correct understanding of the teaching? 1. "Clients should avoid range-of-motion (ROM) exercises until weaned from ventilation." 2. "Clients may develop stress ulcers and gastrointestinal bleeding." 3. "Clients will be chemically paralyzed to improve oxygenation." 4. "Clients will experience diuresis and polyuria." - CORRECT ANSWERS The charge nurse must transfer a female client from the medical-surgical unit to the maternity unit to make a bed available. It would be most appropriate for the nurse to transfer the client who is 1. 28 years old, had a right mastectomy and has a closed-wound drainage system 2. 49 years old, has diabetes mellitus (type 2) and has begun receiving insulin 3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours 4. 70 years old, has a fractured left tibia and had an external fixation device applied 48 hours ago - CORRECT ANSWERS The nurse has been made aware of the following client situations. The nurse should first assess the client with 1. heart failure who has a productive cough and is anxious 2. regional enteritis (Crohn's disease) who is reporting cramping abdominal pain and diarrhea 3. idiopathic thrombocytopenic purpura (ITP) who has petechiae on the trunk and is reporting heavy menses 4. chronic obstructive pulmonary disease (COPD) who has dyspnea with exertion and is using accessory muscles to breathe - CORRECT ANSWERS Nclex Ncsbn Sample Questions And Correct Verified Answers Update 2024/2025 Best Exam Solution Graded A+ For Success The nurse is assessing an older adult client who is scheduled for discharge and is at risk for falls. Which of the following are extrinsic risk factors for falling? Select all that apply. 1. uneven stairs 2. throw rugs 3. hemiparesis 4. dim lighting 5. confusion - CORRECT ANSWERS The nurse is caring for a 3-year-old client with impetigo. Which of the following infection control precautions should the nurse implement? Select all that apply. 1. Wear a surgical mask when bathing the client. 2. Wear a protective gown when changing the client's bed linens. 3. Keep the door to the client's room closed. 4. Place a box of clean gloves outside the client's door. 5. Place a surgical mask on the client during transport to other departments. - CORRECT ANSWERS The nurse is evaluating a staff member's care of a client with active pulmonary tuberculosis (TB). Which of the following actions by the staff member would indicate to the nurse an understanding of the principles of infection control for tuberculosis isolation? 1. instructing visitors to wash their hands before entering the client's room 2. putting on a mask, gown, and gloves before entering the client's room 3. placing tissues and a trash receptacle within the client's reach 4. asking the client to put on a clean mask each time someone enters the room - CORRECT ANSWERS The nurse in the pediatric unit is preparing to admit a client with rubeola (measles). The nurse should assign the client to a 1. private room at the end of the hallway 2. private room with monitored negative air pressure 3. room with a client who has chickenpox 4. room with a client who has atopic dermatitis (eczema) - CORRECT ANSWERS The charge nurse is observing the following client situations. It would require intervention if a 1. client with hepatitis B (HBV) is eating food brought into the facility by a visitor 2. visitor is sitting on the side of the bed of a client with acute pancreatitis 3. staff member is entering the room of a client with Haemophilus influenzae meningitis wearing a protective gown and gloves 4. family member of a client with mycoplasma pneumonia leaves the door to the client's room open - CORRECT ANSWERS The nurse is reviewing the orders of a client who has acute kidney injury. Which of the following orders should the nurse clarify? 1. computed tomography (CT) scan of the abdomen with intravenous contrast media 2. urine specimen for urinalysis 3. blood specimen for arterial blood gas (ABG) 4. referral to registered dietitian for parenteral nutrition evaluation - CORRECT ANSWERS The nurse is planning a staff education program about caring for clients with restraints. Which of the following information should the nurse include? 1. "Restraints should be removed once during a shift to perform passive range-of-motion (ROM) exercises for the client." 2. "Restraints should be secured to the side rails of the client's bed for quick release." 3. "Restraints require an order from the primary health care provider." 4. "Restraints may be used p.r.n. for clients who are confused." - CORRECT ANSWERS Nclex Ncsbn Sample Questions And Correct Verified Answers Update 2024/2025 Best Exam Solution Graded A+ For Success The nurse is caring for a client with active pulmonary tuberculosis (TB). Which of the following should the nurse include in the client's plan of care? 1. placing the client in a private room with the door open 2. putting a surgical mask on the client during transport to the radiology department 3. instructing the primary caregivers to wear surgical masks when caring for the client 4. instituting the standards for droplet precautions while caring for the client - CORRECT ANSWERS The home-health nurse is teaching the parents of a 4-year-old client with impetigo. Which of the following information should the nurse include? 1. "Put a surgical mask on your child when around siblings." 2. "Cleanse the lesions with a povidone-iodine solution daily." 3. "Apply petroleum jelly to the lesions daily." 4. "Instruct your child not to use the same towels as siblings." - CORRECT ANSWERS The nurse has attended a staff education program about bioterrorism. Which of the following statements by the nurse would require follow-up? 1. "Botulism is transmitted by ingestion of contaminated canned foods." 2. "Hemorrhagic fever is spread by direct contact with blood or body fluids." 3. "Anthrax is spread through direct contact with the bacteria and its spores." 4. "Bubonic plague is transmitted from person to person via airborne droplets." - CORRECT ANSWERS The nurse observes a coworker who is assessing a client's thoracic expansion. Which of the following would indicate that the coworker is using the correct assessment technique? 1. percussion from the apex of the scapula downward on each side 2. placement of the hands flat on the back with the thumbs at the level of the tenth ribs pointing to the spine, then asking the client to inhale 3. measurement of the anteroposterior diameter of the chest 4. placement of the palms at the level of the tenth ribs with thumbs pointing to the xiphoid process, then asking the client to inhale - CORRECT ANSWERS The nurse at a health fair is talking with a client who is in perimenopause and is experiencing hot flashes. Which of the following lifestyle modifications would be appropriate for the nurse to recommend? 1. increasing fluid intake 2. exercising daily 3. decreasing sodium intake 4. wearing clothing in layers - CORRECT ANSWERS The nurse in a community-based setting is teaching clients over 65 years of age about health promotion activities. Which of the following information should the nurse include? 1. "Purchase all of your prescribed medications at the same pharmacy." 2. "Schedule an appointment for a vision screening every 3 years." 3. "Participate in daily aerobic exercises for 60 minutes." 4. "Increase your intake of fat-soluble vitamins." - CORRECT ANSWERS Nclex Ncsbn Sample Questions And Correct Verified Answers Update 2024/2025 Best Exam Solution Graded A+ For Success The nurse is screening clients for those at increased risk for developing cancer. At highest risk for developing leukemia is the client who 1. received more than 3 blood transfusions 2. has a magnetic resonance imaging (MRI) scan annually 3. has polycythemia vera and requires phlebotomy treatments 4. had colon cancer and received chemotherapy treatments - CORRECT ANSWERS The nurse is caring for an older adult client in the postoperative period. The nurse should know that this client, compared with younger clients in the postoperative period, will have an increased need for 1. oral hygiene 2. analgesics 3. high-calorie foods 4. early mobilization - CORRECT ANSWERS The nurse is planning a staff education program about the prevention of urinary tract infections (UTls) in children. Which of the following information should the nurse include? Select all that apply. 1. "Teach the child to perform Kegel exercises." 2. "Encourage the child to empty the bladder completely." 3. "Encourage the child to maintain an adequate fluid intake." 4. "Teach the child how to properly cleanse the perineal area." 5. "Offer the child noncarbonated, decaffeinated beverage choices." - CORRECT ANSWERS The nurse is teaching the family member of a client with moderate Alzheimer's disease (AD). Which of the following interventions should the nurse include in the teaching? Select all that apply. 1. Use distraction when the client becomes agitated. 2. Place calendars within clear view of the client. 3. Use short, simple sentences and provide step-by-step instructions for the client. 4. Avoid reminiscing with the client about past experiences in order to avoid feelings of loss and loneliness. 5. Encourage the client to participate in a daytime exercise program to promote restful sleep at night. - CORRECT ANSWERS The nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client. Which of the following actions should the nurse take? 1. Assess the client's recent urine output. 2. Prime a Y- tubing blood administration set with lactated Ringer's solution. 3. Ensure that the client has a peripheral venous access device (VAD) that is 24-gauge or larger. 4. Verify with another nurse that the client's room number is on both the blood product label and the client's identification band. - CORRECT ANSWERS The nurse is assessing the coping strategies of a client who had a myocardial infarction (MI) 3 days ago. Which of the following statements by the client would indicate ineffective coping? 1. "I know that stopping smoking will be difficult." 2. "I plan to attend a cardiac rehabilitation support group." 3. "I have trouble believing this has really happened to me." 4. "I have let down my family because I will not be able to financially support them any longer." - CORRECT ANSWERS The hospice nurse has taught an in-home caregiver about comfort care for a client at the end of life. Which of the following statements by the caregiver would require follow-up? 1. "I have been Nclex Ncsbn Sample Questions And Correct Verified Answers Update 2024/2025 Best Exam Solution Graded A+ For Success source. 2. Ask another nurse whether the prescribed dose is a safe dose. 3. Clarify that the dose is correct with the primary health care provider. 4. Contact the pharmacist to verify the safe dosage range for the medication. - CORRECT ANSWERS The nurse is caring for a client who is receiving a high dose of a phenothiazine. When evaluating the client for a life-threatening syndrome related to the medication, it would be a priority for the nurse to report 1. dry mouth 2. orthostatic hypotension 3. fever 4. photophobia - CORRECT ANSWERS The nurse is caring for a client who is receiving a blood transfusion and states, "I feel chilled and am having back pain." Which of the following actions should the nurse take? Select all that apply. 1. Stop the transfusion. 2. Check the client's vital signs. 3. Notify the client's primary health care provider. 4. Return the blood and infusion tubing to the blood bank. 5. Infuse 5% dextrose in water through the intravenous catheter. 6. Administer a dose of an antiemetic prescribed p.r.n. to the client. - CORRECT ANSWERS The nurse is preparing a staff education program about total parenteral nutrition (TPN). Which of the following information should the nurse include? Select all that apply. 1. "The TPN intravenous tubing should be changed once a week." 2. "TPN can be administered through a peripherally inserted central catheter (PICC)." 3. "Clients receiving TPN should be weighed daily." 4. "An infusion pump is used to deliver TPN." 5. "Serum glucose levels should be monitored in clients receiving TPN." - CORRECT ANSWERS The nurse has taught a client with bipolar I disorder who is experiencing a manic episode and is receiving lithium. Which of the following statements by the client would indicate a correct understanding of the teaching? 1. "I will increase my oral fluid intake to 2 to 3 L daily while taking the medication." 2. "I will experience an improvement in my condition 5 weeks after starting the medication." 3. "I should decrease my intake of dietary sodium after starting the medication." 4. "I should limit time spent in a sauna to 1 hour weekly while taking the medication." - CORRECT ANSWERS The nurse has administered haloperidol to a client with schizophrenia who is agitated. Which of the following findings would require immediate follow-up? 1. continued lack of motivation 2. reports of muscle stiffness 3. inappropriate emotional expressions 4. difficulty focusing due to blurred vision - CORRECT ANSWERS The nurse is teaching a client who is receiving newly prescribed propylthiouracil. Which of the following information should the nurse include? 1. "Carry emergency identification with you listing your condition and medication regimen." 2. "The medication dose will need to be reduced if you Nclex Ncsbn Sample Questions And Correct Verified Answers Update 2024/2025 Best Exam Solution Graded A+ For Success develop agranulocytosis." 3. "You will experience weight loss if the medication is effective." 4. "Increase your daily intake of foods containing iodine." - CORRECT ANSWERS The nurse is preparing to administer a beta blocker to a client. Which of the following would be a contraindication to administer the medication? 1. heart block 2. myocardial infarction (MI) 3. heart failure 4. angina pectoris - CORRECT ANSWERS The nurse is planning a staff education program about informed consent. Which of the following information should the nurse include? Select all that apply. 1. "The main value of informed consent is for protection against lawsuits." 2. "Clients may withdraw consent after signing the informed consent form." 3. "Clients must sign the informed consent form before receiving preprocedural medication." 4. "Nurses witness the signing of the informed consent form to confirm that consent is voluntary." 5. "The signed consent form serves as evidence that the informed consent process has taken place." - CORRECT ANSWERS The nurse has taught a client who is receiving alendronate. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply. 1. "I will take alendronate a half hour before I eat breakfast." 2. "I should avoid weight-bearing exercises while taking alendronate." 3. "I should discontinue alendronate if I experience nausea or vomiting." 4. "I will need to remain in an upright position for 30 minutes after I take alendronate." 5. "I should notify my primary health care provider if I experience difficulty swallowing while taking alendronate." - CORRECT ANSWERS The nurse is developing a plan of care for a client with a spinal cord injury at C5 who has an indwelling urethral catheter. Which of the following would be a priority for the nurse to include in the plan of care? 1. encouraging the client to drink 6 to 8 glasses of fluid per day 2. maintaining the urine collection bag in a dependent position 3. teaching the client about foods high in fiber 4. assessing the color of the urine output - CORRECT ANSWERS The nurse has been made aware that the following 4 clients require assistance. The nurse should first assist the client who had 1. an abdominal hysterectomy 5 hours ago and is reporting severe incisional pain 2. a transurethral resection of the prostate (TURP) yesterday and whose catheter has become disconnected 3. a lumbar laminectomy 2 days ago and is reporting that the feet are still numb 4. a spinal cord injury at T2 two weeks ago and is currently diaphoretic and nauseated - CORRECT ANSWERS The nurse has taught a client who has a positive laboratory test result for human immunodeficiency virus (HIV) infection. The client is scheduled for a viral load test. Which of the following statements by the client would indicate a correct understanding of the teaching? 1. "The viral load test is used to Nclex Ncsbn Sample Questions And Correct Verified Answers Update 2024/2025 Best Exam Solution Graded A+ For Success determine my response to the treatment regimen I am receiving for HIV." 2. "The viral load test can rapidly detect HIV-specific antibodies in the blood." 3. "I will be able to decrease the dosage of my prescribed medications if my viral load is low." 4. "I am unlikely to develop acquired immune deficiency syndrome (AIDS) if my viral load is high." - CORRECT ANSWERS The nurse is teaching a client who is scheduled for a 24-hour urine collection. Which of the following information should the nurse include? Select all that apply. 1. "You will be asked to urinate when starting the collection, and the initial urine will be discarded." 2. "A sign will be posted on the bathroom door as a reminder to save your urine." 3. "You will be asked to void at the end of the designated time period to complete the urine collection." 4. "You should discard urine that is dark or pink in color." 5. "The collected urine will be sent to the laboratory at the end of each shift." - CORRECT ANSWERS The nurse has taught a client with diabetes mellitus (type 2) about foot care. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply. 1. "I will check my shoes for foreign objects prior to putting them on." 2. "I should use a large, coarse file to remove dry skin from a bunion." 3. "I will apply a petroleum-based ointment between my toes after bathing." 4. "I should avoid crossing my legs to prevent decreased circulation to my feet." 5. "I should wear new shoes for a few hours for several days until they fit well." - CORRECT ANSWERS The nurse is teaching a client who is scheduled for a total hip arthroplasty via a posterior approach. Which of the following information should the nurse include? Select all that apply. 1. "The type of prosthesis used is based on the muscle strength and joint function of your upper extremities." 2. "Do not bend the affected hip more than 90 degrees after surgery." 3. "Skin preparation and cleansing is mandatory before surgery." 4. "Use an elevated toilet seat for at least 6 weeks after surgery." 5. "You can resume sexual intercourse after surgery if your partner is in a dependent position." - CORRECT ANSWERS The nurse is caring for a client who is receiving an intravenous infusion via a peripheral venous access device (VAD). The client reports sharp pain at the VAD site. The nurse notes the intravenous fluid is infusing more slowly than prescribed. The nurse should recognize that the client is most likely experiencing 1. venous spasm 2. nerve damage 3. septicemia 4. hematoma - CORRECT ANSWERS The nurse has attended a staff education program about obtaining blood specimens from a central venous access device (VAD). Which of the following statements by the nurse would require follow- up? 1. "I will use a 3 mL syringe to flush the catheter port." 2. "The injection cap should be cleansed with antiseptic and allowed to air-dry." 3. "I will aspirate 5 mL of blood and discard the syringe in the biohazard container before obtaining the specimen." 4. "The infusion should be turned off for at least 1 minute before the specimen is aspirated." - CORRECT ANSWERS Nclex Ncsbn Sample Questions And Correct Verified Answers Update 2024/2025 Best Exam Solution Graded A+ For Success The nurse is assessing a client with suspected mononucleosis. Which of the following findings would support a diagnosis of mononucleosis? 1. polyarthralgia 2. costovertebral pain 3. cervical lymphadenopathy 4. left lower quadrant (LLQ) tenderness - CORRECT ANSWERS The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. It would be most appropriate for the nurse to assign UAP to 1. apply a continuous passive motion (CPM) device to the affected extremity of a client who had a total knee replacement 2. change the bed linens for a client who was admitted 1 hour ago following a closed-head injury and is comatose 3. reposition a client with hydrocephalus who has a headache and is vomiting 4. place in the prone position a client who had an above-the-knee amputation (AKA) 1 day ago - CORRECT ANSWERS The nurse in the inpatient psychiatric unit is leading a support group for clients. It would be a priority for the nurse to intervene if the client with 1. bipolar I disorder is experiencing a manic episode, is moving the legs, and is looking around the room restlessly 2. borderline personality disorder is saying that another group member is too disturbed to be attending the session 3. major depressive disorder is sitting quietly with the eyes downcast 4. schizophrenia is rocking in place and copying the gestures of another client in the group - CORRECT ANSWERS The nurse has observed a staff member tell a client with bipolar disorder that there will be consequences for making negative comments about conditions in the facility. When the nurse meets privately with the staff member, which of the following statements would be most appropriate for the nurse to make to the staff member? 1. "Threatening a client can result in the immediate dismissal of a staff member." 2. "Staff members who have difficulty with control issues often seek power over clients." 3. "Clients have a right to provide feedback about services without fear of punishment." 4. "Staff should set limits with clients in a nonjudgmental manner." - CORRECT ANSWERS The nurse has been made aware of the following client situations. The nurse should first assess the client 1. with chronic obstructive pulmonary disease (COPD) who is using pursed-lip breathing after ambulating in the hallway 2. with pericarditis who has a systolic blood pressure that is 20 mm Hg higher during expiration than during inspiration 3. who had a total abdominal hysterectomy (TAH) 12 hours ago and has saturated 1 perineal pad in the past 5 hours 4. who has Guillain-Barré syndrome and has had an increase in the vital capacity over the past 4 hours - CORRECT ANSWERS The nurse in the psychiatric unit is administering medications when a client with a borderline personality disorder approaches and asks to talk. The nurse suggests having a talk in 1 hour. The client shouts, "I'll wait, but you will be sorry!" and then picks up a pitcher of water and throws it onto the floor. 1. Offer to listen to the client while continuing to administer the medications. 2. Suggest that the client take a p.r.n. prescribed medication for agitation. 3. Ask another nurse to finish Nclex Ncsbn Sample Questions And Correct Verified Answers Update 2024/2025 Best Exam Solution Graded A+ For Success administering the medications, and talk with the client. 4. Request assistance from several nearby staff members with controlling the client's behavior. - CORRECT ANSWERS The nurse is talking with a client who has a positive laboratory test result for human immunodeficiency virus (HIV) infection. Which of the following statements by the client would require follow-up? 1. "I try to eat a well-balanced diet." 2. "I avoid crowds when I go outside the house." 3. "I am taking a vitamin C tablet daily to help prevent infections." 4. "I take echinacea every day to help improve my immune system." - CORRECT ANSWERS The nurse is planning a staff education program about informed consent. Which of the following information should the nurse include? Select all that apply. 1. "An individual designated by a power of attorney for health care can provide informed consent despite the competency of the client." 2. "The nurse has a duty to insist that the client repeat what has been said about a procedure for which consent is necessary." 3. "The primary health care provider must disclose the risks if the client declines a recommended procedure." 4. "The client should sign the consent form prior to receiving prescribed opioids." 5. "Informed consent is not needed for emergency procedures that are in the client's best interest." - CORRECT ANSWERS The nurse is caring for a client who has a prescription for an intravenous infusion of 0.45% sodium chloride (halfstrength saline). The nurse notes the client is receiving 5% dextrose in water. Which of the following actions should the nurse take first? 1. Change the intravenous fluid to the prescribed fluid. 2. Notify the primary health care provider. 3. Complete an incident report. 4. Assess the client. - CORRECT ANSWERS The nurse is caring for a client in the first stage of labor and observes that a segment of the umbilical cord is visible in the vaginal opening after rupture of the client's amniotic membranes. Which of the following actions should the nurse take? 1. Instruct the client to lie on her left side. 2. Attempt to place the umbilical cord back into the uterus. 3. Assist the client into a knee-chest position. 4. Administer an intravenous tocolytic agent. - CORRECT ANSWERS The nurse is preparing to administer an aminoglycoside. Which of the following laboratory test results should the nurse review before administering the medication? 1. serum electrolyte level and serum uric acid level 2. hemoglobin (Hgb) and white blood cell (WBC) count 3. serum ammonia level and serum glucose level 4. blood urea nitrogen (BUN) and serum creatinine - CORRECT ANSWERS The nurse is talking with a client who is scheduled for endoscopic retrograde cholangiopancreatography (ERCP) in 2 hours in the outpatient department. Which of the following questions would be important for the nurse to ask? Select all that apply. 1. "How will you be getting home after the procedure?" 2. "Do you have access to a thermometer after you leave here?" 3. Nclex Ncsbn Sample Questions And Correct Verified Answers Update 2024/2025 Best Exam Solution Graded A+ For Success "What allergies do you have?" 4. "Are you wearing dentures?" 5. "Do you have external hemorrhoids?" - CORRECT ANSWERS The nurse is assessing a client who had cardiac catheterization 2 hours ago. Which of the following findings would require immediate follow-up? 1. blood pressure, 104/70 mm Hg 2. 1+ pedal pulse of the affected extremity 3. heart rate, 98 4. urine output of 100 mL for the past 2 hours - CORRECT ANSWERS The nurse has taught the parent of a 9-year-old child who has been newly diagnosed with bacterial conjunctivitis. Which of the following statements by the parent would indicate a correct understanding of the teaching? 1. "The infection produces profuse watery discharge." 2. "I should clean my child's eyelids and eyelashes with soap and water prior to instilling the medication." 3. "My child's eyes may be sensitive to light until the infection resolves." 4. "The prescribed corticosteroid eyedrops should be used for 1 week." - CORRECT ANSWERS The nurse is talking with a client who has diabetes mellitus (type 1) and is receiving insulin via an infusion pump. Which of the following statements by the client would require follow-up? 1. "I need a bolus dose of insulin prior to a meal." 2. "I should refill the pump with short-duration insulin." 3. "I can decrease serum glucose monitoring to twice daily." 4. "I will change the infusion needle every 2 to 3 days." - CORRECT ANSWERS The nurse is caring for a client who is scheduled for a spinal fusion in 1 hour. Which of the following situations would require follow-up? Select all that apply. 1. The nurse notes that the client signed the consent form 1 week ago. 2. The nurse determines that the last analgesia the client received was yesterday afternoon. 3. The client states, "I need to find out why the surgery is needed before I sign the consent form." 4. The nurse administers the prescribed preoperative sedation after the client signs the consent form. 5. The client states, "I am afraid to sign the consent form because I know I am going to die during the surgery." 6. The client states, "The surgery may result in some paralysis, but the resolution of the pain is worth the risk to me." - CORRECT ANSWERS The charge nurse must transfer a client from a locked psychiatric unit to an unlocked unit in order to make a bed available. The charge nurse should recommend for transfer the client with 1. depression who has suddenly become more animated and involved in unit activities 2. bipolar I disorder who is experiencing a manic episode, is disrobing, and is laughing with other clients 3. schizophrenia who is withdrawn and requires assistance with activities of daily living (ADL) 4. dementia who is delusional about being poisoned by staff members - CORRECT ANSWERS The nurse in the emergency department (ED) is assessing a client with multiple injuries that occurred as a result of a motor vehicle collision. Which of the following findings should receive highest