Hard NCLEX Questions ANSWERS Explained

Hard NCLEX Questions (2022) ANSWERS Explained The nurse is making assignments for the next shift. Which client can be assigned to a licensed practical nurse/licensed vocational nurse (LPN/LVN)? Select all that apply.

• A client who just had coronary artery bypass graft (CABG)
• A client who needs assistance with colostomy irrigation C. A client who needs initial admission

assessment

• A client who has C3 to C5 spine injury
• A client who is receiving glargine subcutaneously - B and E

R: An LPN/LVN can perform colostomy irrigation and administer subcutaneous injections. A client who just had CABG is unstable and needs to be monitored by an RN. The initial admission assessment should also be performed by an RN. C3 to C5 injury may cause respiratory compromise.Possible paralysis of diaphragm due to phrenic nerve involvement may occur. This client is unstable and should be assigned to an RN.

A nurse is assigned four clients. Which client should the nurse see first?

• A 50-year-old client with diverticulitis
• A 50-year-old client three days post myocardial infarction
• A 33-year-old client with a recent diagnosis of Guillain-Barré syndrome
• A 17-year-old client 24 hours post appendectomy - C

R:Guillain-Barré syndrome is characterized by ascending paralysis and potential respiratory failure.The order of client assessment should follow client priorities, with disorders of airway, breathing, and then circulation seen first. There is no information to suggest that the client with post myocardial infarction has an arrhythmia or other complication. There is no evidence to suggest hemorrhage or perforation for the remaining clients as a priority of care.

A nurse is working with an unlicensed assistive personnel (UAP). Which clients should the nurse assign to the UAP? Select all that apply.

• Adult client who had abdominal surgery yesterday and requires a dressing change.
• Adult client newly diagnosed with diabetes who is learning to administer insulin.
• Adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours.
• Young adult client who requires tube feedings.
• Older adult client who had hip replacement surgery and needs to walk in the hall with a walker. -

C and E

R: The UAP can assist clients ambulate and take vital signs. It is within the RN scope of practice to teach the client to administer insulin, change dressings, and administer tube feedings.

A nurse is preparing to help a client with weakness in his or her right leg move from the bed to a chair. Where should the nurse place the chair? - 45 degrees to the bed on the left side

R: The nurse should place the wheelchair at a 45 degree angle or parallel to the bed on the client's strong side to help prevent a fall.

The nurse teaches the parents of a 2-year-old child how to instill antibiotic eardrops. Which statement about the direction to pull on the earlobe indicates that the child's father has understood the teaching?

• "I should pull the earlobe down and backward."
• "I should pull the earlobe up and forward."
• "I should pull the earlobe up and backward."

• "I should pull the earlobe down and outward." - A

R: For children aged 3 years and younger, the external auditory canal is straightened by gently pulling the earlobe down and backward.

For an older child or an adult, the earlobe is gently pulled up and backward.

The nurse is caring for a client in the newborn nursery. Which of the following are appropriate actions for the nurse to take that will help to prevent neonatal infection? Select all that apply.

• Good hand washing technique
• Keeping the umbilical cord covered with sterile gauze C. Separate gown technique
• Isolation of infected infants with communicable disease
• Hand sanitizer with points of contact - A, D, E

The nurse should give which discharge instructions about thermal injury to a client with peripheral vascular disease? Select all that apply.

• "Avoid sunburn during the summer."
• "Choose loose, soft, cotton socks."
• "Use an electric blanket when you are sleeping."
• "Wear extra socks in the winter."
• "Warm the fingers or toes by using an electric heating pad." - A,B,D

R: The client should recognize the signs of potential thermal dangers to prevent skin breakdown and wear clean, loose, soft cotton socks so that the feet are comfortable, air can circulate, and moisture is absorbed. In the winter or if the client has cold feet, the client should be encouraged to wear an extra pair of socks and a larger shoe size. Getting a sunburn during the summer puts the

client at risk for tissue injury and skin breakdown. Using a heating pad to warm the feet or using an electric blanket places the client at risk for injury and should be avoided.

The nurse has assisted the health care provider (HCP) at the bedside with insertion of a left subclavian, triple lumen catheter in a client admitted with lung cancer. Suddenly, the client

becomes restless and tachypneic. The nurse should: - Assess for breath sounds

R:The nurse should first assess for bilateral breath sounds since a complication of central line insertion is a pneumothorax, which would cause an increase in respiratory rate and drop in oxygen, causing irritability. The nurse should also assess blood pressure and heart rate for the complication of bleeding. A chest x-ray will be performed to determine correct placement and complications. A central line was most likely placed because peripheral IV access was not available or adequate for the client. Repositioning may be considered after assessments are done.

When preparing to draw up 8 units of a short-acting insulin and 20 units of a long-acting insulin in

the same syringe, the nurse should:

• Draw up the long-acting insulin first.
• Use a high-dose insulin syringe.
• Draw up either insulin first.
• Inject air in the vial with the long-acting insulin first. - D

R: The air is injected into the long-acting insulin first. Air is then injected into the short-acting insulin and the short-acting insulin is withdrawn. Then the long-acting insulin is withdrawn. It does matter which insulin is drawn up first because the nurse does not want to contaminate the short- acting insulin with the long-acting insulin. It is not necessary to use a high-dose insulin syringe to prepare 28 units of insulin.

A client with type 1 diabetes mellitus asks the nurse about taking ginseng at home. How should the nurse respond to the client?

• "Taking ginseng will increase the risk of hypoglycemia."
• "There are no therapeutic benefits of ginseng."
• "You can take the ginseng to help improve your memory."