NCLEX Examination Review Questions

NCLEX Examination Review Questions Submitted by kharris401 on 4/16/2019 12:46:19 PM

Points Awarded 13 Points Missed 0 Percentage 100%

• Five minutes after receiving a preoperative sedative medication by IV injection, a patient

asks the nurse to get up to go to the bathroom to urinate. Which of the following is the most appropriate action for the nurse to take?

• Assist patient to bathroom and stay next to door to assist patient back to bed when

done.

• Allow patient to go to the bathroom since the onset of the medication will be more than 5

minutes.

• Offer the patient to use the urinal/bedpan after explaining the need to maintain safety.
• Ask patient to hold the urine for a short period of time since a urinary catheter will be

placed in the operating room.

The prime issue after administration of either sedative or opioid analgesic medications is safety.Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance.

Points Earned: 1/1

Correct Answer: C

Your Response: C

• Which of the following is the primary reason for prioritizing the determination of the

patient's current medications during a preoperative assessment?

• Routine medications are usually withheld the day of surgery, requiring dosage and

schedule adjustments.

• Some medications may alter the patient’s perceptions about surgery.
• Some medications may interact with anesthetics, altering the potency and effect of the

drugs.

• Anesthetics alter renal and hepatic function, causing toxicity by other drugs.

Drug interactions may occur between prescribed medications and anesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that they have been communicated to the anesthesiologist.

Points Earned: 1/1

Correct Answer: C

Your Response: C

• As the nurse is preparing a patient for surgery, the patient refuses to remove a wedding

ring. Which of the following is the most appropriate action by the nurse?

• Note the presence of the ring in the nurse’s notes of the chart.
• Insist the patient remove the ring.
• Explain that the hospital will not be responsible for the ring.

• Tape the ring securely to the finger.

It is customary policy to tape a patient's wedding band to the finger and make a notation on the preoperative checklist that the ring is taped in place.

Points Earned: 1/1

Correct Answer: D

Your Response: D

• While performing preoperative teaching, the patient asks when she needs to stop drinking

water before the surgery. Based on the most recent practice guidelines established by the

American Society of Anesthesiologists, the nurse tells the patient that:

• She must be NPO after breakfast.
• She needs to be NPO after midnight.
• She can drink clear liquids up to 2 hours before surgery.
• She can drink clear liquids up until she is taken to the OR.

Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidenced-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight.

Points Earned: 1/1

Correct Answer: C

Your Response: C

• The nurse is admitting a patient to the same day surgery unit. The patient tells the nurse

that he was so nervous he had to take kava last evening to help him sleep. Which of the following nursing actions would be most appropriate?

• Inform the anesthesiologist of the patient’s ingestion of kava.
• Tell the patient that using kava to help sleep was a good idea.
• Tell the patient that the kava should continue to help him relax before surgery.
• Inform the patient about the dangers of taking herbal medicines without consulting his

health care provider.

Kava may prolong the effects of certain anesthetics. Thus the anesthesiologist needs to be informed of recent ingestion of this herbal supplement.

Points Earned: 1/1

Correct Answer: A

Your Response: A

• The nurse would be alerted to the occurrence of malignant hyperthermia when the patient

demonstrates:

• Hypocapnia
• Muscle rigidity
• Decreased body temperature
• Confusion upon arousal from anesthesia

Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles occurring secondary to exposure to certain anesthetic agents in susceptible patients. Hypoxemia, hypercarbia, and dysrhythmias may also be seen with this disorder.

Points Earned: 1/1

Correct Answer: B

Your Response: B

• Before admitting a patient to the operating room, the nurse recognizes that which of the

following must be attached to the chart of all patients?

• A functional status evaluation
• Renal and liver function tests
• A physical examination report
• An electrocardiogram

It is essential to have a physical examination report attached to the chart of a patient going for surgery. This document explains in detail the overall status of the patient for the surgeon and other members of the surgical team.

Points Earned: 1/1

Correct Answer: C

Your Response: C

• Unless contraindicated by the surgical procedure, which of the following positions is

preferred for the unconscious patient immediately postoperative?

• Supine
• Lateral
• Semi-Fowler’s
• High-Fowler’s

Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if vomiting. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated.

Points Earned: 1/1

Correct Answer: B

Your Response: B

• A postoperative patient is transferred from the postanesthesia unit to the medical-surgical

nursing floor. The nurse notes that the patient has an order for D5 ½ NS to infuse at 125 ml/hr. Until an IV pump is available, the nurse regulates the IV flow rate at which of the following drops (gtts)/min, noting that the tubing has a drop factor of 10 drops/ml?

• 13 gtts/min
• 31 gtts/min
• 31 gtts/min
• 21 gtts/min

Points Earned: 1/1

Correct Answer: D

Your Response: D

• The nurse is preparing to administer cefazolin (Ancef) 2 grams in 100 ml IVPB to a

postoperative patient. Which of the following IV rates will infuse this medication over 20 minutes?

• 100 ml/hr
• 150 ml/hr
• 200 ml/hr
• 300 ml/hr

Points Earned: 1/1

Correct Answer: D

Your Response: D

• The nurse is working on a surgical floor and is preparing to receive a postoperative

patient from the post anesthesia unit. Which of the following should be the nurse's initial action upon the patient's arrival?

• Check the physician’s postoperative orders.
• Assess the patient’s pain.
• Check the rate of the IV infusion.
• Assess the patient’s vital signs.

The highest priority action by the nurse is to assess the physiologic stability of the patient. This is in part accomplished by taking the patient's vital signs. The other actions can then take place in rapid sequence.

Points Earned: 1/1

Correct Answer: D

Your Response: D

• When assessing a patient's surgical dressing on the first postoperative day, the nurse

notes new bright-red drainage about 5 cm in diameter. In response to this finding, the nurse should do which of the following?

• Assess the patient’s blood pressure and heart rate.
• Remove the dressing and assess the surgical incision.
• Recheck the dressing in 1 hour for increased drainage.
• Notify the surgeon of a potential hemorrhage.

The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report the findings as a whole.

Points Earned: 1/1

Correct Answer: A

Your Response: A

• In planning postoperative interventions to promote ambulation, coughing, deep

breathing, and turning, the nurse recognizes that which of the following actions will best enable the patient to achieve the desired outcomes?

• Giving the patient positive feedback when the activities are completed.
• Administering adequate analgesics to promote relative freedom from pain.
• Warning the patient about possible complications if the activities are not

performed.

• Asking the patient to verbalize understanding of and demonstrate performance of

activity.