NCLEX EXAM PREVIEW - Students also studied Terms in this set Science...

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NCLEX EXAM PREVIEW

110 terms kandykat1012Preview 75 Free NCLEX Questions - c/o Brilli...75 terms carey47Preview NCLEX Practice Questions Exam 1 40 terms J_NavPreview Simple 121 terms Kor The nurse plans education for a client who requires significant lifestyle changes to promote health and decrease the risk for disease. Which actions should the nurse implement when developing the client's teaching plan? Place the choices in the correct sequence. All choices must be used.

1.Assess the patient's readiness/willingness to learn.

2.Plan interesting and interactive learning activities.

3.Evaluate the effectiveness of the teaching/learning.

• Identify the purpose and need for education

4-1-2-3

The pediatric nurse provides care for clients in an acute care hospital setting. Which client requires the nurse's immediate attention?

• A toddler, diagnosed with croup, who gags during self-

feeding.

• An adolescent whose intravenous (IV) catheter site is

puffy and cool to the touch.

• A preschooler who is crying from pain but refusing

medication.

• A school-ager, admitted for the treatment of acute

asthma, who lacks audible wheezing.

• A school-ager, admitted for the treatment of acute asthma, who lacks audible

wheezing.An acute asthma exacerbation threatens the client's airway and breathing. A lack of wheezing indicates poor or absent ventilation with the lungs; therefore, this is a potentially life-threatening finding that requires immediate action by the nurse

• NOT CORRECT coughing is NORMAL with croup and can cause gagging

during meals - WNL

B. NOT CORRECT: infiltration, discontinue the IV but not most important

C. NOT CORRECT: Not priority

The nurse prepares to assist during the bronchoscopy for a client. The client asks the nurse to explain what will occur during the procedure. In which order does the nurse present the steps of the procedure? Place the options in the correct sequence. All options must be used.

• The bronchoscope is advanced past the vocal cords.
• An IV is started and the patient is sedated.
• The bronchoscope is advanced into the windpipe.
• The bronchoscope is moved into the lung(s).
• The bronchoscope is inserted through the mouth or

the nose.

2-5-1-3-4

The parent of a preschooler discusses play behaviors with the nurse. Which parental comment indicates to the nurse a need for additional instruction?A."We play sing-along songs while traveling in the car."

• "I have noticed a recent interest in dressing up and

acting."

• "We put a play gym in the backyard for swinging and

climbing."

• "I allow my child to watch educational television in the

afternoon."

D. CORRECT ANSWER

"I allow my child to watch educational television in the afternoon." This parental statement indicates a need for additional instruction regarding appropriate play behaviors during the preschool stage of development. Television should be limited to no more than one hour a day for the preschool age client; instead physical activity should be encouraged.The nurse receives an order to administer a newly released drug to a client. Which action does the nurse take before administering this drug?

• Ask for information from a nurse who already gave the

drug.

• Consult the existing drug formulary kept on the nursing

unit.

• Ask the pharmacy for the information sheet and clarify

proper administration.

• Review adverse effects and warnings for the newly

released medication.

C- CORRECT ANSWER

Ask the pharmacy for the information sheet and clarify proper administration.This answer is correct because this answer option best ensures client safety. By obtaining the medication information sheet, the nurse can review specific details related to the newly released medication. Additionally, the pharmacy can clarify any questions about medication administration or nursing considerations for the drug.The nurse is assisting in the care of a client admitted to a burn unit after acquiring second and third degree burns to 15% of the body. Which IV fluid does the nurse expect to be ordered?A.0.9% Normal Saline (NS)

• 0.45% Normal Saline
• Dextrose 5% in Water (D5W)

D.Lactated Ringers (LR)

D CORRECT ANSWER

Lactated Ringers (LR) This answer is correct because lactated ringers solution is the preferred choice for fluid replacement in clients with burns. Lactated ringers is isotonic and most closely mimics blood plasma concentration and contains electrolytes to help replace those lost due to cellular damage. Intravenous (IV) lactated ringers (LR) fluid is given during the first 24 hours, and weight-based fluid replacement formulas (like the Parkland Formula) consider the total body surface area burned along with the client's weight in kilograms to calculate the client's estimated fluid replacement needs.

The nurse is caring for an older adult client in an acute care setting. The client has a history of urinary urgency and limited ambulation ability. Which is the best intervention to safely meet the client's needs?

• Initiating a bladder control program with the client
• Placing a portable commode at the client's bedside
• Assigning personnel to assist the client to the

bathroom hourly

• Assuring that the client is able to reach the call light for

a

B CORRECT ANSWER

Placing a portable commode at the client's bedside Clients with urinary urgency and limited ambulation ability present a special challenge. The best way to accommodate this client's special needs for easy and safe access to a bathroom is to place a commode at the client's bedside.The obstetric nurse monitors a fetal heart rate (FHR) during a non-stress test for a pregnant client. Which result causes the nurse the greatest concern?

• Fetal movement causes an acceleration of 15

beats/minute of the FHR for 15 seconds

• After being quiet for 20 minutes, the fetus is stimulated

by rubbing the client's abdomen.C.After 40 minutes of monitoring, the FHR is unchanged and the fetus is nonreactive to stimulation.

• Intermittent fetal movement is accompanied by an

accelerated FHR.

C CORRECT ANSWER

After 40 minutes of monitoring, the FHR is unchanged and the fetus is nonreactive to stimulation.A FHR that is unchanged for 40 minutes, along with a nonreactive fetus is indicative of possible fetal compromise due to hypoxia, are abnormal findings that should cause the nurse concern.The nurse is making a home safety visit to a client with Parkinson disease. Which finding alerts the nurse to the greatest safety concern?A.The client's clothing is not buttoned or zipped properly.

• The client lacks a raised seat for a regular height toilet.
• The client walks up a short flight of steps to the

bedroo D.The client's stove is across the room from the kitchen table.

D CORRECT ANSWER

The client's stove is across the room from the kitchen table.This is a potential safety hazard as the client with Parkinson is at risk for falls due to loss of coordinated movement and may also have signs of tremor. This places the client at risk for a fall while walking from the stove to the kitchen table with potentially hot substances.The nurse in an allergist's office is instructed to prepare a client for allergy skin testing. Which action is essential for the nurse to perform for the testing procedure?

• Administer oral antihistamines one hour prior to

testing.

• Draw a diagram on the client's back with a duplicate on

paper.

• Validate the client has avoided exposure to suspected

allergens.

• Review the client's medical history involving events of

anaphylaxis.

B CORRECT ANSWER

Draw a diagram on the client's back with a duplicate on paper.It is essential for the nurse to draw a diagram on the client's back with a duplicate on paper so that the substance that causes a reaction can be identified during the allergy skin testing.

An older adult client is adamant about going home following discharge from an acute care facility. In response to the nurse's concern, the client agrees to a home care evaluation. Which finding by the home health nurse warrants arranging for outside assistance for the client?

• The client has a family member who will monitor

medications.

• The client plans to have daily deliveries of food from

local restaurants.

• The client completed occupational therapy to learn

about self-care.

• The client has agreed to arrange for a home safety

alarm system.

B CORRECT ANSWER

The client plans to have daily deliveries of food from local restaurants.Many older adult clients are on a fixed income or require a specific diet based on medical diagnoses. Ordering food daily from local restaurants can become expensive and could result in a diet that can exacerbate current diagnoses; therefore, this finding warrants the implementation of outside assistance for the client to meet self-care needs in the home environment.The medical-surgical nurse, a member of the quality improvement (QI) committee, is tasked to research interventions to decrease the likelihood that clients, diagnosed with congestive heart failure (CHF), from being rehospitalized within three weeks of acute care discharge. Which QI initiative is most likely to decrease the need for acute care management for clients diagnosed with CHF?

• Present dietary teaching to the client prior to

discharge.

• Review symptoms indicative for exacerbation with the

client.

• Provide each client with a scale to monitor daily

weights.

• Arrange for a home care nurse to assess the client

monthly.

C CORRECT ANSWER

Provide each client with a scale to monitor daily weights.While clients are taught to monitor daily weights as an important aspect of CHF management, many may not have access to a scale and, if they do it may not be reliable; therefore, providing each client with a scale for daily weight monitoring is an appropriate QI initiative that can be implemented to reduce the need for readmission to the hospital.A client receiving chemotherapy reports severe pain from oral lesions. The health care provider (HCP) orders lidocaine gel. Which method does the nurse implement for treatment with this medication?

• Directs the client to swish the medication around in the

mouth and then swallow

• Instructs the client to use a sterile swab to apply the

medication to the sores.

• Explains that the nurse will apply the medication to the

lesions with a cotton swab.

• Asks the client to distribute medication with their

tongue and spit out excess.

C CORRECT ANSWER

Explains that the nurse will apply the medication to the lesions with a cotton swab.This answer is correct because the client should use a cotton swab or provided applicator to apply the gel. The client should wash hands before and after medication administration. Clients should be advised to wait an hour after medication before drinking or eating.