NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 20, Exams of Nursing

Download NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 20 and more Exams Nursing in PDF only on Docsity! NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 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 99.7F (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 2. First stage of labor whose contractions are occurring every 30 seconds Rationale: 1. Elevated temperature is normal during labor. 3. Increased respirations are normal during labor "pant-pant-blow" "hee-hee-hoo" breathing pattern. 4. Contractions shouldn't be longer than 90 seconds, 60 seconds is okay and normal. Second stage: 2-3 minutes apart, 60-90 seconds long, 10cm dilated, strong pain. 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 2. Placing a box of disposable face shields outside the client's room. Rationale: Varicella AKA chicken pox is an airborne precaution. Private, negative pressure room, universal precautions (hand sanitizer in room) and placing a surgical mask on client during transport are all correct interventions for varicella. 2. Prepare for transcutaneous pacing. NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ & 5. Assess the client for angina. Rationale: 1. Beta Blockers would further decrease HR. 2. External pacing stimulates the ventricles to pump at a set rate. 3. Valsalva maneuver would further decrease HR. 4. Chest compressions are for cardiac arrest. 5. Angina (Chest pain) can be caused by both tachycardia (most common) and bradycardia (rare but can happen). Therefore, assessment of angina is appropriate. - 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. Which of the following actions would be appropriate for the nurse to take? Select all that apply. 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. 1. Encourage the client to reminisce about happy memories. Rationale: 1. Is correct because it is possible for AD patients to retain long-term memories. 2. Redirect is protocol for dementia. Don't confront, they can't learn. 3. AD is irreversible. 4. In the moderate AD, dementia has already progressed to where the patient needs help with ADL's & planning daily activities. Asking them to plan can frustrate them & cause distress. Structured, pleasant activities that consider the person's likes & interests are the best. - CORRECT ANSWERS 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? NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ Appendicitis: Pain level. Ruptured Spleen: Pain level. - CORRECT ANSWERS The nurse in the emergency department is caring for a 41-year-old male client. Nurse's Notes: 11:00: 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) 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 than 1 disease process. Answer: •Anemia •Peritonitis •Septic Shock - CORRECT ANSWERS The nurse in the emergency department is caring for a 41-year-old male client. Nurse's Notes: 11:00: 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) 32. Drinks alcohol only during social occasions, usually 3 beverages. Smokes cigarettes during social occasions. Select the 3 complications the client is at risk for developing. •Anemia NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ •Peritonitis •Septic Shock •Hypovolemia •Dysrhythmias •Cardiac Arrest Answer: Answers: Indicated: •Clear liquid diet •Soapsuds enema •Abdominal girth measurements •Abdominal Computed Tomography (CT) scan NOT indicated: •Heating pad to abdomen - CORRECT ANSWERS The nurse in the emergency department is caring for a 41-year-old male client. Nurse's Notes: 11:00: 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) 32. Drinks alcohol only during social occasions, usually 3 beverages. Smokes cigarettes during social occasions. The nurse has reviewed the Nurses' Notes from 11:30. For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client. 2. "Clients may develop stress ulcers and gastrointestinal bleeding." NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ Rationale: Positive pressure ventilation increases the likelihood of developing stress ulcers and bleeding. - 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." 3. 56-years-old, has hepatitis C (HCV) and has been afebrile for 24 hours. - 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 fractures left tibia and had an external fixation device applied 48 hours ago. 1. Heart failure who has a productive cough and is anxious. Rationale: The productive cough (Pink, frothy sputum) indicates pulmonary edema. The patient's anxiety may be caused by decreased perfusion. - 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. NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 2. With chronic obstructive pulmonary disease (COPD) who is using pursed-lip breathing and reporting hemoptysis. 3. Who had a wedge resection of the left lung 24 hours ago and is sitting in the High-Fowler's position. 4. With heart failure who has a productive cough and is restless. 2. The client is sleeping but is easily aroused. - CORRECT ANSWERS The nurse is caring for a 3-year-old client with a cerebral concussion who is being observed overnight in the pediatric unit. Which of the following observations would be most significant for the nurse to report to the oncoming shift? 1. The client has a blood pressure of 94/58 mmHg and an apical pulse of 90. 2. The client is sleeping but is easily aroused. 3. The client's pupils are equal and reactive to light. 4. The client has an axillary temperature of 99.0 F (37.2 C) and respirations of 24. 1. Closed reduction of a fractured tibia with cast applications 1 hour ago and is reporting that the casted leg feels hot. Rationale: Pain, tightness, or a hot feeling can indicate that the cast is on too tight. 2. It is normal to feel nauseous after coming off of anesthesia. 3. Knee pain is expected after knee surgery. 4. Right shoulder pain is common in laparoscopic cholecystectomy due to gas left in the abdomen after the procedure. This will resolve on its own. - CORRECT ANSWERS The nurse in the same-day surgical center has received a change-of-shift report on the following clients. The nurse should first see the client who had: 1. Closed reduction of a fractured tibia with cast applications 1 hour ago and is reporting that the casted leg feels hot. 2. Extraction of a cataract lens 2 hours ago and is reporting nausea. NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 3. An arthroscopy of the right knee 3 hours ago and is reporting knee pain rated as 4 on a scale of 0 (no pain) to 10 (severe pain). 4. A laparoscopic cholecystectomy 4 hours ago and is reporting right shoulder pain. 2. Obtain a referral to a physical therapist for the client. Rationale: Ataxia is lack of muscle control in the arms and legs, which leads to lack of balance, coordination, and walking. Physical therapy is the area of referral for this type of issue. 1. Thick liquids is for dysphagia. 3. This is always indicated, not just in this circumstance. 4. This can be a tool for patients with expressive aphasia. - CORRECT ANSWERS The nurse is planning care for a client with multiple sclerosis (MS) who has ataxia. Which of the following interventions should the nurse include in the client's plan of care? 1. Add thickener to thin liquids for the client. 2. Obtain a referral to a physical therapist for the client. 3. Face the client directly when speaking with the client. 4. Provide a board with pictures to help the client communicate needs. 1. Breast cancer who had a mastectomy 2 days ago and has had 25mL of drainage from the closed- wound drainage system in the past 12 hours. Rationale: This is very little blood in 12 hours for a surgery that was only 2 days ago. The nurse should assess for obstruction of the drainage system which could be life-threatening if not resolved. - CORRECT ANSWERS The home-health nurse is assigned to visit the following clients who live within 3 miles (4.8km) of one of another. The nurse should first visit the client with: NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 1. Breast cancer who had a mastectomy 2 days ago and has had 25mL of drainage from the closed- wound drainage system in the past 12 hours. 2. Lung cancer who received a dose of chemotherapy 2 weeks ago and has a temperature of 101.1 F (38.4 C) 3. Chronic obstructive pulmonary disease (COPD) who is reporting expectorating large amounts of thick, yellow mucus. 4. Diabetes mellitus (type 1) who had a right below-the-knee amputation (BKA) and is reporting having right toe pain. 2. Who had a total knee replacement 24 hours ago, is restless, and has a petechial rash on the chest. Rationale: A petechial rash is indicative of DIC or a fat embolus. - CORRECT ANSWERS The nurse has become aware of the following client situations. The nurse should first assess the client: 1. Who had a total abdominal hysterectomy (TAH) 1 day ago and is unable to void 7 hours after the indwelling urethral catheter was removed. 2. Who had a total knee replacement 24 hours ago, is restless, and has a petechial rash on the chest. 3. With bacterial pneumonia who has bronchial breath sounds auscultated between the scapulae and a temperature of 103.3 F (39.6 C). 4. With hepatic cirrhosis who has an elevated aspartate aminotransferase (AST) level and respirations of 24. 4. Implement droplet precautions. - CORRECT ANSWERS The nurse is planning care for a pediatric client being admitted with pertussis. Which one the following interventions should the nurse include in the client's plan of care? 1. Keep the client NPO. 2. Place a dehumidifier in the client's room. 3. Encourage the client to ambulate frequently. 4. Implement droplet precautions. NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 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. 2. Private room with monitored negative air pressure. Rationale: Measles is airborne (MTV) and requires a private room with negative air pressure. - 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). 1. Client with hepatitis B (HBV) is eating food brought into the facility by a visitor. Rationale: HBV is spread through contact with body fluids including saliva, so it is important to intervene if the patient is eating and possibly sharing food with another person. - 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. NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 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. 1. Computed tomography (CT) scan of the abdomen with intravenous contrast media. Rationale: CT's use iodinated contrast which is harmful to the kidneys and therefore is contraindicated in a client with AKI. - 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. 3. "Restraints require an order from the primary health care provider." Rationale: 1. Restraints are removed every 2 hours for ROM exercises, toileting, and fluids. Assess every 15 minutes for the first hour, and then every 30 minutes. 2. Restraints should be secured to the bed, not the side rails. 4. Restraints are never PRN. - CORRECT ANSWERS The nurse is planning a staff education program about caring for clients with restraints. Which of the following 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." NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 4. "Restraints may be used PRN for clients who are confused." 2. Putting a surgical mask on the client during transport to the radiology department. Rationale: 1. The door should be closed. 4. TB is airborne precautions, not droplet. - CORRECT ANSWERS 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. 4. "Instruct your child not to use the same towels as siblings." Rationale: Impetigo is highly contagious through contact. Towels can easily spread the infection. 1. Impetigo is contact precautions; a surgical mask would be for airborne. - 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." 4. "Bubonic plague is transmitted from person to person via airborne droplets." NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 3. High-calorie foods 4. Early Mobilization 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." - CORRECT ANSWERS The nurse is planning a staff education program about the prevention of urinary tract infections (UTIs) 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 non-carbonated, decaffeinated beverage choices." 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. 5. Encourage the client to participate in a daytime exercise program to promote restful sleep at night. - 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. NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 4. Verify with another nurse that the client's room number is on both the blood product label and the client's identification band. Rationale: You always verify blood products with another nurse. Blood should only be given with normal saline and infused with an 18 or 20 gauge needle. - 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. 4. "I have let down my family because I will not be able to financially support them any longer." - 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." 4. "Sitting upright seems to reduce the client's noisy breathing more than lying down in the bed." Rationale: It is common for hospice patients to have "death rattle," which are loud, wet respirations. The correct intervention is to reposition them laterally, not upright! Never suction them. Hospice is characterized as making the patient as comfortable as possible so if they have less anxiety with a fan, let them continue NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ using it. Offering foods is okay, but don't force them to eat. - 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 applying petroleum jelly to keep the client's lips moist." 2. "I have been offering healthy foods frequently to keep up the client's strength." 3. "A blowing fan seems to be less anxiety-producing for the client than an oxygen mask." 4. "Sitting upright seems to reduce the client's noisy breathing more than lying down in the bed." 1. The client gave consent voluntarily. 2. The client received adequate disclosure. 4. The client understands the scheduled procedure or treatment. Rationale: 3. The PCP explains the procedure and the nurse witnesses the consent. Only 1 RN is needed to witness this. - CORRECT ANSWERS The nurse is witnessing the client's signature on a consent form. Which of the following conditions should the nurse recognize must be met to ensure the consent is valid? Select all that apply. 1. The client gave consent voluntarily. 2. The client received adequate disclosure. 3. The consent form is witnessed by 2 health care professionals. 4. The client understands the scheduled procedure or treatment. 5. The consent form is signed within 24 hours of the scheduled procedure or treatment. 3. "You did the best you could in very difficult circumstances." 5. "You are safe here." Rationale: NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 5. "I have arranged for my spouse to meet with a speech therapist twice each week to improve communication skills." - CORRECT ANSWERS The nurse is planning care for a client who has expressive aphasia after a left-sided stroke. Which of the following statements by the client's spouse would indicate a correct understanding of the client's communication abilities and interaction needs? Select all that apply. 1. "My spouse's response of "fine" when asked how the day has been may or may not be what my spouse meant to communicate." 2. "I can anticipate what my spouse wants to say, so I complete my spouse's sentences to make communication quicker." 3. "I will purchase a picture board to help my spouse express common needs, thoughts, and feelings that are difficult to communicate." 4. "My spouse's angry response when we have a conversation makes me hesitant to try further communication." 5. "I have arranged for my spouse to meet with a speech therapist twice each week to improve communication skills." 2. The foot is 2 inch (5cm) away from the foot plate. Rationale: The foot should be touching the foot plate. - CORRECT ANSWERS The nurse is caring for a client who is in Buck traction. Which of the following would require immediate intervention? 1. A pillow is placed under the knee. 2. The foot is 2 inch (5cm) away from the foot plate. 3. The weights attached to the puller are 6 inch (15cm) from the floor. 4. A pillow is placed under the lower leg with the heel off the bed. 2. "I will place a picture on the bathroom door to indicate which room in our home is the bathroom." Rationale: NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 4. This is dangerous, they can get lost. - CORRECT ANSWERS The nurse has taught the adult child caregiver of a client with moderate Alzheimer's disease (AD) about home care. Which of the following statements by the adult child would indicate a correct understanding of the teaching? 1. "I will only allow my parent to smoke while my parent is outdoors." 2. "I will place a picture on the bathroom door to indicate which room in our home is the bathroom." 3. "I will encourage family members to visit in large groups to keep my parents interested in the conversation." 4. "I will encourage my parent to take walks in the park when the weather permits to get the exercise needed." 2. "You may be prescribed a bulk-forming laxative." Rationale: There's no need to restrict fluids or diet. Diet does not cause diverticulitis exacerbations. - CORRECT ANSWERS The nurse is teaching a client newly diagnosed with diverticulosis. Which of the following information should the nurse include? 1. "Limit your daily fluid intake to 2L to avoid bloating." 2. "You may be prescribed a bulk-forming laxative." 3. "Limit your intake of dairy products such as milk and yogurt." 4. "You should avoid consuming cooked vegetables." 1. Check the medication dosage in a medication reference source. - CORRECT ANSWERS The nurse is preparing to administer lorazepam 2mg, IV, now to a client who is scheduled for surgery in 30minutes. The nurse is unfamiliar with the dosage for the medication. Which of the following actions should the nurse take next? 1. Check the medication dosage in a medication reference 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. NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 4. Contact the pharmacist to verify the safe dosage range for the medication. 3. Fever. Rationale: Phenothiazine side effects include ABCDEFG- anti-cholinergic (dry mouth), blurry vision, constipation, drowsiness, EPS, photosensitivity, and agranulocytosis. Fever would be a complication of agranulocytosis and requires the nurse to report. - 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. 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. Rationale: Back pain and chills are symptoms of hemolytic transfusion reaction (wrong blood type). Must stop infusion, check vital signs, and notify the provider. 5. NS is used to keep the line open, not dextrose in water. - 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. NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 2. "The medication dose will need to be reduced if you develop agranulocytosis." 3. "You will experience weight loss if the medication is effective." 4. "Increase your daily intake of foods containing iodine." 1. Heart block. Rationale: Beta blockers will further depress the cardiac rhythm. Beta blockers are indicated in MI, HF, and angina pectoris. - 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. 2. "Clients may withdraw consent after signing the informed consent form." 3. "Clients must sign the informed consent form before receiving pre-procedural 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." Rationale: 1. While informed consent does provide some legal protection, it's primary purpose is to respect the patient's autonomy and ensure they are fully aware of risks, benefits and alternatives before they agree to a procedure or treatment. - 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." NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 2. "Clients may withdraw consent after signing the informed consent form." 3. "Clients must sign the informed consent form before receiving pre-procedural 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." 1. "I will take alendronate a half hour before I eat breakfast." 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. Rationale: 2. Weight-bearing exercises are actually recommended for clients taking alendronate as they help to maintain bone density. 3. Nausea and vomiting are common side effects of alendronate, but do not necessarily require discontinuation of the medication. The client should discuss any side effects with their healthcare provider. - 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. 2. Maintaining the urine collection bag in a dependent position. Rationale: NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ The drainage bag should always be below the level of the bladder to prevent back flow. - 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. 4. A spinal cord injury at T2 two weeks ago and is currently diaphoretic and nauseated. Rationale: 1. This needs to be addressed, but not immediately. 2. This patient is at risk for infection and urinary retention, but not immediately life-threatening. 3. Numb feet is concerning, but could be a normal part of the recovery process. Not immediately life- threatening. - 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. 1. "The viral load test is used to determine my response to the treatment regimen I am receiving for HIV." Rationale: NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ •Do not twist the upper body when standing. •Sleep on the back for 1st 6 weeks. The patient may benefit from a shower chair or elevated seat from home use. Avoid bathing for 8 to 12 weeks (flexed and bent down in the tub). - 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." 4. Hematoma. Rationale: A hematoma is a collection of blood outside of a blood vessel, usually caused by trauma or injury. It can cause pain and swelling, and can also affect the rate of infusion by compressing the vein. - 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 in 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. 1. "I will use a 3mL syringe to flush the catheter port." NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ Rationale: A 10mL flush is appropriate. Obtaining blood specimens from a VAD: Stop IV infusion for at least a minute. Scrub cap for 10-15 seconds and allow to air dry. Pull back 5mL of discard blood and discard in biohazard container. Scrub cap again. Withdraw blood for specimen. Scrub, flush, and lock. Restart infusion. - 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 3mL syringe to flush the catheter port." 2. "The injection cap should be cleansed with antiseptic and allowed to air-dry." 3. "I will aspirate 5mL 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." 1. "I will begin to take dancing lessons." Rationale: 1. Dancing is a weight-bearing exercise that can help strengthen bones and reduce the risk of osteoporosis. - CORRECT ANSWERS The nurse has taught about preventing osteoporosis to a 45-year- old client who has had a hysterectomy and bilateral salpingo-oophorectomy. Which of the following statements by the client would indicate correct understanding of the teaching? 1. "I will begin to take dancing lessons." 2. "I will get more rest at night." 3. "I will take a multivitamin supplement daily." NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 4. "I will add more fiber to my diet." 1. Ask the client to open and close the fist multiple times. - CORRECT ANSWERS The nurse is preparing to insert a peripheral venous access device (VAD) for a client. Which of the following actions should the nurse take? 1. Ask the client to open and close the fist multiple times. 2. Tap the client's vein multiple times to promote dilation. 3. Apply the tourniquet 9 to 10 inch (22.5 to 25 cm) above the venipuncture site. 4. Palpate for a vein after cleansing the selected site. 1. Dizziness and confusion. Rationale: 3. Vesicular breath sounds are normal breath sounds. - CORRECT ANSWERS The nurse is assessing a newly admitted client who sustained partial-thickness (second-degree) burns to the anterior thorax in a house fire. Which of the following findings would require immediate follow-up? 1. Dizziness and confusion. 2. Hypoactive bowel sounds and nausea. 3. Vesicular breath sounds throughout the lung fields. 4. Pain rated 5 on a scale of 0 (no pain) to 10 (severe pain) 3. "I should elevate the head of the bed on 6 inch (15cm) blocks." - CORRECT ANSWERS The nurse has taught a client with a hiatal hernia about interventions for the condition. Which of the following statements by the client would indicate a correct understanding of the teaching? 1. "I will consume 3 regular-sized meals daily." 2. "Wearing an abdominal binder can help relieve symptoms." 3. "I should elevate the head of the bed on 6 inch (15cm) blocks." NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 3. Spastic paralysis below the level of injury. 4. Loss of sensation below the level of injury. 4. Avoid obtaining blood pressure measurements in the arm with the AV shunt. Rationale: 1. Sleep on unaffected side. 2. You would auscultate for the bruit and palpate for thrill to verify that the shunt is working. 3. No IV fluids through the shunt, just dialysis. - CORRECT ANSWERS The nurse is planning care for a client who has a arteriovenous (AV) shunt in the left arm. Which of the following interventions should the nurse include in the client's plan of care? 1. Instruct the client to protect the AV shunt by tucking the left arm under the body while sleeping. 2. Check for a bruit by palpating the AV shunt. 3. Administer prescribed intravenous fluids through the AV shunt. 4. Avoid obtaining blood pressure measurements in the arm with the AV shunt. 1. Tracheal deviation. - CORRECT ANSWERS The nurse is caring for a client who has a chest tube attached to a closed-chest drainage system. It would be a priority for the nurse to monitor the client for: 1. Tracheal deviation. 2. Pain at the insertion site. 3. Subcutaneous emphysema. 4. Redness or swelling at the insertion site. 1. Rheumatoid arthritis (RA) who has a 2-month-old infant. - CORRECT ANSWERS The nurse is caring for the following clients. The nurse should recommend a referral to an occupational therapist for the client with: 1. Rheumatoid arthritis (RA) who has a 2-month-old infant. NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 2. An intertrochanteric hip fracture who works as a surgeon. 3. Mononucleosis who is a college student. 4. Tendonitis who is a professional tennis player. 3. Assign the client to a private room with monitored negative air pressure. - CORRECT ANSWERS The nurse is preparing to admit a client who has pleuritic chest pain and is reporting a cough productive of yellow sputum for the past 1 week. The client has a pulse oximetry reading of 90% on room air. Which of the following infection control precautions should the nurse implement? 1. Use a stethoscope that is designated for use with the client only. 2. Wear sterile gloves when inserting a peripheral venous access device (VAD). 3. Assign the client to a private room with monitored negative air pressure. 4. Place a box of surgical masks inside the client's room. 1. "Use before touching medical equipment that will come in direct contact with the client." - CORRECT ANSWERS The nurse is planning a staff education program about infection control guidelines. Which of the following information about alcohol-based hand rub should the nurse include? 1. "Use before touching medical equipment that will come in direct contact with the client." 2. "Avoid using when moving your hands from a contaminated body site to a clean body site during client care." 3. "Avoid using before caring for clients who have severe neutropenia." 4. "Use after contact with body excretions that do not cause your hands to be visibly soiled." 3. Cervical lymphadenopathy. - CORRECT ANSWERS 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. NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 4. Left lower quadrant (LLQ) tenderness. 4. Place in the prone position a client who had an above-the-knee amputation (AKA) 1 day ago. - 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. 1. Bipolar 1 disorder is experiencing a manic episode, is moving the legs, and is looking around the room restlessly. Rationale: These actions indicate that they could become a danger to others or themselves and should be removed from the situation. - 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 1 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. 3. "Clients have a right to provide feedback about services without fear of punishment." NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 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." 4. Assess the client. - CORRECT ANSWERS The nurse is caring for a client who has a prescription for an intravenous infusion of 0.45% sodium chloride (half-strength 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. 3. Assist the client into a knee-chest position. - 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. 4. Blood urea nitrogen (BUN) and serum creatinine. Rationale: NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ Aminoglycosides are ototoxic and nephrotoxic. - 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. 1. "How will you be getting home after the procedure?" 2. "Do you have access to a thermometer after you leave here?" 3. "What allergies do you have?" - 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. "What allergies do you have?" 4. "Are you wearing dentures?" 5. "Do you have external hemorrhoids?" 2. 1+ pedal pulse of the affected extremity - 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 mmHg 2. 1+ pedal pulse of the affected extremity 3. Heart rate, 98 4. Urine output of 100mL for the past 2 hours NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 3. "My child's eyes may be sensitive to light until the infection resolves." Rationale: 2. Cleaning the eyelids and eyelashes is not necessary and may further irritate the eyes. 4. Bacterial conjunctivitis is typically treated with antibiotic eye drops or ointment. - CORRECT ANSWERS The nurse 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." 3. "I can decrease serum glucose monitoring to twice daily." - 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." 3. The client states, "I need to find out why the surgery is needed before I sign 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." - 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. NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ 1. Serum lipase levels for the client with hypercholesterolemia. 2. Arterial blood gas (ABG) results for the client who has an acid-base imbalance. 3. Serum glucose levels for the client with diabetes insipidus (DI). 4. Adrenocorticotropic hormone (ACTH) levels for the client who has a fluid imbalance. 3. "The charge nurse is working with staff nurses and the nurse manager to develop shared goals and a plan for the new staffing format." - CORRECT ANSWERS The nurse is planning a staff education program about collaborative conflict resolution strategies. Which of the following would best describe implementation of a collaborative conflict resolution strategy? 1. "A staff nurse is working with the nurse manager and offering suggestions about an upcoming new procedure." 2. "The clinical nurse leader is flattered by being asked to help create a clinical ladder for nursing staff members." 3. "The charge nurse is working with staff nurses and the nurse manager to develop shared goals and a plan for the new staffing format." 4. "A new nurse has offered to work on a holiday in exchange for having the following weekend off." 2. Contact the client's family to arrange for family members to be examined. - CORRECT ANSWERS The nurse is caring for a client who lives with a spouse and 2 adolescent children. The client has been admitted to a hospital for treatment of active pulmonary tuberculosis (TB). The local health department has been notified about the client's diagnosis. The nurse should recognize that after this notification the local health department will: 1. Schedule periodic examinations of the client's chest and sputum. 2. Contact the client's family to arrange for family members to be examined. 3. Immunize those persons with whom the client has been in contact. 4. Isolate members of the client's immediate family at home until diagnostic studies rule out TB. 2. 15-year-old client who is restless and has a distended, firm abdomen. - CORRECT ANSWERS The nurse is participating in a community-based disaster drill. NCLEX-RN Exam Preview With 113QUESTIONS & Answers 100% correctly verified latest update 2024/2024 rated A+ The nurse should give priority for treatment to a: 1. 2-year-old client with a bleeding scalp laceration and briskly reactive pupils. 2. 15-year-old client who is restless and has a distended, firm abdomen. 3. 30-year-old client who has a leg wound exposing the femur, a blood pressure of 120/76mmHg, and a pulse of 90. 4. 60-year-old client with heart failure whose pulse oximetry reading is 92% on room air and whose respirations are 26. 1. "Notify your primary health care provider if you experience unusual bruising." - CORRECT ANSWERS The nurse is teaching a client who is receiving newly prescribed clopidogrel. Which of the following information should the nurse include? 1. "Notify your primary health care provider if you experience unusual bruising." 2. "Avoid taking over-the-counter (OTC) medications containing acetaminophen." 3. "Avoid driving your car for a short time until your response to the medication is known." 4. "Have a blood specimen obtained every 3 months to check your serum albumin level." 4. 6-year-old child with a right long-leg cast whose toes on the affected extremity are swollen and cool to the touch. - CORRECT ANSWERS The nurse in a community-based setting has received the following telephone messages. The nurse should first return the telephone call to the parent of a: 1. 3-year-old child who sustained a concussion and was irritable when awakened every 2 hours during the night. 2. 4-year-old child with impetigo contagiosa who has eruptions spreading around the mouth and nose that are draining thin yellow fluid. 3. 5-year-old child with Ewing sarcoma who is receiving external radiation and the irradiated area appears reddened. 4. 6-year-old child with a right long-leg cast whose toes on the affected extremity are swollen and cool to the touch.