NCLEX Exam Review for January 2024

NCLEX Exam Review

A hospitalized client diagnosed with end-stage cancer has suddenly decided to discontinue treatment. The client requests no additional treatment, such as antibiotics, tube feedings, and mechanical ventilation. When acting as the client’s advocate, which action should a nurse take?

1. Respect the client’s wishes and indicate those wishes on the plan of care
2. Encourage the client to share the decision with the family and the client’s physician
3. Clarify other treatments that the client wishes to withhold
4. Wait until additional treatment is required and then decide what to do based on the client’s condition
   Answer: 2. In advocating for the client, the nurse should encourage the client to share the decision with family and the physician. To advocate for someone means to speak for that person when the person is unable to speak for him- or herself. The client is still able to make his or her own decisions, which will be better supported when the client shares with the family and physician.
   Although the wishes should be indicated on the plan of care, this nurse action does not demonstrate advocating for the client. A physician order is required to limit treatment. Although additional treatments should be discussed, the priority at this time is the discussion with the family and physician.
   Test Taking Tip Use the process of elimination. Note the key word “suddenly,” which indicates the decision is new.

An experienced nurse is orienting a new nurse caring for multiple clients on an oncology nursing unit. The experienced nurse explains to the new nurse that to advocate for clients, a nurse must be able to identify ethical issues and communicate the clients’ wishes to others. Which PRIMARY ROLE of the nurse advocate should the experienced nurse also explain to the new nurse?

1. Safeguard clients against abuse and violation of their rights.
2. Make decisions for clients based on the nurse’s knowledge and relationship
3. Assist clients in expressing their rights
4. Have knowledge of the clients’ values so the nurse can assist in the decision making
   Answer: 1. The primary role in advocacy is to keep the client safe — to safeguard clients against abuse and violation of their rights

Clients may not be able to advocate for themselves. The professional role of the nurse is to defend clients’ autonomy in decision making. The nurse must never make a treatment decision for clients. however, the nurse should keep clients informed about their treatment orders and their rights. Although it is important to know the clients’ values, it is not the primary role of the nurse advocate.

Test Taking Tip “Primary role” are key words. Recall that advocacy focuses on clients’ rights, thus eliminate options 2 and 4. Of the remaining two options, select the option that demonstrates a stronger nursing role.

A nurse ins instructing a Somali client about a lung resection scheduled for tomorrow. The client does not speak English. What is the best method of instruction for this client?

1. Obtaining a translator who can restate the words used to describe the surgery
2. Asking an English-speaking family member to translate what the nurse states
3. Obtaining an interpreter over the telephone
4. Using diagrams and pictures to describe a lung resection
   Answer: 4. The best method of instruction is to use nonverbal communication, such as illustrations, when unable to understand the language.

Whenever possible, obtain an interpreter rather than a translator. An interpreter will decode the words and provide the meaning behind the message. Avoid using relative s who may distort information or not be objective. An interpreter over the telephone is an option; however, it would be best to have the interpreter present.

Test Taking Tip The key words are “best method.” Apply knowledge of communicating with non-English-speaking clients.

A nurse took several courses in Spanish and studied in Central America for one semester. A supervisor asks the nurse to serve as an interpreter during orientation of a new Spanish-speaking nurse. Which information is most important for the nurse to know prior to agreeing to be an interpreter?

1. The facility policy on client interpretation services
2. The state mandates on the requirements of interpretation
3. The confirmation of interpreter skill level through test-taking
4. The need to support a new nurse since it was requested by the supervisor
   Answer: 2. Requirements for interpretation may be state mandated, or there may also be a facility policy. The prudent nurse should investigate the legal requirements and risks of interpretation before agreeing to be an interpreter.

Client interpretation policies would not apply. No test is required to determine interpreter skill level. Although it is important to support a new nurse, the nurse should not feel obligated to perform this task just because the supervisor requested the interpretation.

Test Taking Tip The key words are “most important.” Recall that legal and facility policies are typically developed for high-risk situations.

A client is experiencing increased dyspnea and chest pain. A physician is notified and orders an ECG to be done stat. The nurse has not done an ECG before and there is no ECG technician in the hospital at this time. Which steps should be taken by the nurse in performing an ECG? Place each answer option into the correct order.

1. Obtain the ECG machine
2. Place the ECG tracing in the medical record
3. Contact an experienced nurse or supervisor for assistance
4. Ask an experienced nurse or supervisor to teach the procedure for performing an ECG
5. Observe the experienced nurse or supervisor do the ECG
6. Call the physician to notify that the ECG is completed
7. Review the hospital policy on doing ECGs
   Answer: 4, 7, 2, 3, 5, 6, 1. The nurse should first review the hospital policy on doing ECGs and ask a nurse with experience for assistance. The new nurse should learn how to do an ECG, as it may be needed in the future, and should ask to learn from the experienced nurse. The nurse should obtain the ECG machine and observe the experienced nurse doing the ECG. the physician should then be notified that the ECG is complete. Finally, he nurse should place the ECG in the medical record.

Test Taking Tip Always follow organizational policies. Know that the nurse is at a legal risk when performing a task that has not been learned.

An adolescent client enters a clinic alone and discloses that he/she is HIV positive. The client has a productive cough and low-grade fever. Which is the best action by the nurse?

1. Nothing can be done without the consent of the parents
2. Educate the client concerning birth control, safe sex, and partner disclosure
3. Draw an HIV titer to confirm the HIV positive status of the client
4. Obtain a sexual risk history and notify the parents
   Answer: 2. The best action by the nurse is to educate the client concerning birth control, safe sex and partner disclosure.

Individuals diagnosed with HIV may receive treatment, including education and counseling, without consent of the parents. It is not necessary to redraw the HIV titer. Although it is important to obtain an updated sexual risk history, the parents do not need to be notified of the client’s clinic visit.

Test Taking Tip Note that options 1 and 4 both involve the parents, so either one or both of these options must be wrong. Of options 2 and 3, determine which demonstrates the role of the nurse.

A nurse is working in a busy emergency department with multiple admissions. Which clients would meet the requirement for mandatory reporting? SELECT ALL THAT APPLY.

1. A client who has a gunshot wound
2. A client who has meningitis
3. A child who has cigarette burns
4. A child who has respiratory syntactial virus (RSV)
5. A vulnerable adult who is admitted for dehydration
6. An adult client who has a broken hip from a fall
   Answer: 1, 2, 3, 4, 5. A gunshot wound, a communicable disease, an abused child and a vulnerable adult all require mandatory reporting through the Health and Human Services Your Health Information Privacy Rights Law.

An injury from a fall is not a situation for mandatory reporting.

Test Taking Tip Recall that injuries with weapons, communicable diseases, child abuse and vulnerable adults are reportable

The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? SELECT ALL THAT APPLY.

1. Position the client to prevent shoulder adduction
2. Turn and reposition the client every shift
3. Encourage the client to move the affected side
4. Perform quadriceps exercises three times a day
5. Instruct the client to hold the fingers in a fist
   Answer: 1, 3. Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising.

The client should be repositioned at least every two hours to prevent contractures, PNA, skin breakdown, and other complications of immobility. Quadriceps exercises are not recommended, but they must be done at least five times a day for ten minutes to help strengthn the muscles for walking. The fingers are positioned so that they are barely flexed to help prevent contracture of the hand.

Test Taking Tip Be sure to look at the intervals of time for any intervention. Because this is a “select all that apply” question, the test taker must read each answer option and decide if it is correct; one will not eliminate another.

The nurse is planning care for a client experiencing agnosia secondary to a CVA. Which collaborative intervention will be included in the plan of care?

1. Observe the client swallowing for possible aspiration
2. Position the client in a semi-Fowler’s position when sleeping
3. Place a suction setup at the client’s bedside during meals
4. Refer the client to an occupational therapist for evaluation
   Answer: 4. A collaborative intervention is an intervention in which another health-care discipline — in this case, OT — is used in the care of the client.

Agnosia is failure to recognize familiar objects; therefore, observing the client for aspiration is not appropriate. A semi-Fowler’s position is appropriate for sleeping, but inappropriate as an intervention specifically for agnosia. Placing suction at the bedside will help if the client has dysphagia, not agnosia.

Test Taking Hint Be sure to look at what the question is asking and see if the answer can be determined even if some terms are not understood. In this case, note that the question refers to “collaborative intervention.”

The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question?

1. A subcutaneous anticoagulant
2. An intravenous osmotic diuretic
3. An oral anticonvulsant
4. An oral proton pump inhibitor
   Answer: 2. An osmotic diuretic would be ordered in the acute phase to help decrease cerebral edema, but this medication would not be expected to be ordered in a rehabilitation unit.

The client in rehab is at risk for DVT; therefore a subcut anticoagulant is appropriate. Clients with head injuries are at risk for post-traumatic seizures; thus an oral aticonvulsant would be administered for seizure prophylaxis. The client is at risk for a stress ulcer; therefore an oral PPI would be appropriate.

Test Taking Hint The client is in the rehab unit and therefore must be stable. The use of any IV medication should be questioned under those circumstances, even if the test taker is not sure why the med may be considered.

The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as “high risk for immobility complications.” Which intervention would be included in the plan of care?

1. Position the client with the head of the bed elevated at intervals
2. Perform active range-of-motion exercises every four hours.
3. Turn the client every shift and massage bony prominences
4. Explain all procedures to the client before performing them
   Answer: 1. The head of the client’s bed should be elevated to help the lungs expand and prevent stasis of secretions that could lead to PNA.

Active ROM exercises require that the client participate in the activity, which is not possible in a coma patient. The client is at risk for pressure ulcers and should be turned more frequently than every shift, and research now shows that massaging bony prominences can increase the risk for tissue breakdown. The nurse should always talk to the client, even if he is in a coma, but this will not address the problem of immobility.

Test Taking Hint Whenever a client problem is written, interventions must address the specific problem, not the disease.

A client has a peripheral IV line with a piggyback line, oxygen at 2 liters per nasal cannula, a prn nebulizer treatment, and a chest tube connected to a chest drainage system. Several family members are present, wanting to be very helpful, and have been placing the oxygen back on when the nasal cannula slips, turning the IV pump off when it alarms, and placing the nebulizer tubing in the mouthpiece of the nebulizer. Which action by the nurse is required for the safe care of the client?

1. Inform the family that they are not allowed to touch any medical equipment
2. Inform the family that they must get help from clinical staff when there is a need to connect tubing or devices
3. Thank the family for noticing when tubing is disconnected and getting the client the treatment required
4. Inform the family that they are only allowed to turn off the IV pump alarm
   Answer: 2. The nurse should inform nonclinical staff, clients and their families that they must get help from clinical staff whenever there is a real or perceived need to connect or disconnect devices or infusions.

The family may touch the equipment; however, they should not operate any client care equipment including answering alarms and reconnecting tubing. The potential for incorrect reconnection exists. Tubing misconnections have resulted in death.

Test Taking TipApply knowledge of safety policies and guidelines. Note that only option 2 informs the family of the actions to take for tubing disconnections or devices that are alarming.

In assessing a client with a T12 spinal cord injury, which clinical manifestations would the nurse expect to find to support the diagnosis of spinal shock?

1. No reflex activity below the waist
2. Inability to move upper extremities
3. Complaints of a pounding headache
4. Hypotension and bradycardia
   Answer: 1. Spinal shock associated with SCI represents a sudden depression of reflex activity below the level of the injury. T12 is just above the waist; therfore, no reflex activity below the waist would be expected.

Assessment of the movement of the upper extremities would be more appropriate with a higher level of injury. Complaints of a pounding headache are not typical of a T12 spinal injury. Hypotension and tachycardia are signs of hypovolemic or septic shock, but these do not occur in spinal shock.

Test Taking Hint If the test taker doesn’t have any idea what the answer is, an attempt to relate the anatomical position of keywords in the question stem to words in the answer options is appropriate.

The nurse in the neurointensive care unit is caring for a client with a new C6 spinal cord injury who is breathing independently. Which nursing interventions should be implemented? Select all that apply.

1. Monitor the pulse oximetry reading
2. Provide pureed foods six times a day
3. Encourage ocughing and deep breathing
4. Assess for autonomic dysreflexia
5. Administer intravenous corticosteroids
   Answer: 1, 3, 5. Oxygen is administered initially to prevent hypoxemia, which can worsen the spinal cord injury; therefore, the nurse should determine how much oxygen is reaching the periphery. Breathing exercises are supervised by the nurse to increase the strength and endurance of inspiratory muscles, especially those of the diaphragm. Corticosteroids are administered to decrease inflammation, which will decrease edema, and help prevent edema from ascending up the spinal cord, causing breathing difficulties.

A C6 injury wouldn’t affect the client’s ability to chew and swallow, so pureed food is not necessary. Autonomic dysreflexia occurs during the rehab phase, not the acute phase.

Test Taking Hint The test taker must notice where the client is receiving care, which may be instrumental in being able to rule out incorrect answer options and help in identifying the correct answer. Remember Maslow’s hierarchy of needs.

The client with a C6 spinal cord injury is admitted to the emergency department complaining of a severe pounding headache and ahs a BP of 180/110. Which intervention should the emergency department nurse implement?

1. Keep the client flat in bed
2. Dim the lights in the room
3. Assess for bladder distention
4. Administer a narcotic analgesic
   Answer: 3. This is an acute emergency caused by exaggerated autonomic responses to stimuli and only occurs after spinal shock has resolved in the client with an SCI above T6. The most common cause is a full bladder.

Keeping the client flat will not address the client’s symptoms. Dimming the lights will not help the client’s condition. The nurse should always assess the client before administering medication.

Test Taking Hint The test taker should apply the nursing process when answering questions, and assessing the client comes first, before administering any type of med.

The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client?

1. Discuss how to correctly remove the insertion pins
2. Instruct the client to report reddened or irritated skin areas
3. Inform the client that the vest liner cannot be changed
4. Encourage the client to remain in the recliner as much as possible
   Answer: 2. Reddened areas, especially under the brace, must be reported because pressure ulcers can develop when wearing the appliance for an extended period.

The halo device is applied by inserting pins into the skull; the client cannot remove them. The pins should be checked for signs of infection. The vest liner should be changed for hygiene reasons, but the halo part is not removed. the client should be encouraged to ambulate to prevent immobility complications.

The nurse on the rehabilitation unit is caring for the following clients. Which client should the nurse assess first after receiving the change-of-shift report?

1. The client with a C6 spinal cord injury who is complaining of dyspnea and has crackles in the lungs
2. The client with an L4 SCI who is crying and very upset about being discharged home
   3.The client with an L2 SCI who is complaining of a headache and feeling very hot
3. The client with a T4 SCI who is unable to move the lower extremities
   Answer: 1. This client has signs/symptoms of a respiratory complication and should be assessed first.

The crying client is exhibiting a psychosocial need that should be addressed, but does not have priority over a physiological need. A client with a lower SCI wouldn’t be at risk for autonomic dysreflexia; therefore, a complaint of headache and feeling hot would not be a priority over an airway problem. The client with a T4 SCI would not be expected to move the lower extremities.

Test Taking Hint The nurse should assess the client who is at risk for dying or having some type of complication that requires intervention. Remember Maslow’s hierarchy of needs.

The 34 -year-old male client with a spinal cord injury is sharing with the nurse that he is worried about finding employment after being discharged from the rehabilitation unit. Which intervention should the nurse implement?

1. Refer the client to the American Spinal Cord Injury Association (ASIA)
2. Refer the client to the state rehabilitation commission
3. Ask the social worker about applying for disability
4. Suggest that the client talk with his significant other about this concern
   Answer: 2. The rehabilitation commission of each state will help evaluate and determine if the client can receive training or education for another occupation after injury.

The ASIA is an appropriate referral for living with his condition, but it does not help find gainful employment after the injury. The client is not asking about disability; he is concerned about employment. Suggesting a discussion with his significant other does not address the client’s concern.

Test Taking Hint If the question mentions a specific age for a client, the nurse should consider it when attempting to answer the question. Remember Erickson’s stages of growth and development

A nursing home client is confused and trying to get out of bed. The client suffered a broken hip from a fall 6 months ago and is unable to walk independently. Alternatives to restraints have been tried; however, the client continues to try to get out of bed. A decision has been made to apply restraints. Which type of restraint would be best for this client to prevent getting out of bed?

1. Jacket restraint
2. Bilateral ankle restraints
3. Mitten restraints
4. Belt restraint
   Answer: 1. A jacket restraint is the est restraint to prevent the client from getting out of bed as it secures both the shoulder and the waist and yet allows the client to turn from side to side.

The client would still be able to sit up and try to get out of bed with ankle restraints. Mitten restraints prevent the use of hands but still allow free arm movement. A belt restraint is less restrictive than a jacket.

Test Taking Tip The key phrase is “would be best.” Focus on the activity of the client to select the correct option.

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