NCLEX NGN RN Questions

NCLEX NGN RN Questions

• A nurse is monitoring the neurological status of a client who underwent

craniotomy 3 days ago. Which signs or symptoms would prompt the nurse to notify the primary health care provider immediately?

• Disorientation to date
• Pupils equal and reactive at 4 mm
• Mild headache relieved by acetaminophen with codeine

d. Pain with forward flexion of the neck onto the chest:

Answer:

D A complication of cranial surgery is meningitis.

• A man calls the clinic and tells the nurse that he sustained a bee sting on

his leg while working in his yard. The client states that he is not allergic to bees and wants to know how to treat the sting. The nurse tells the client to first take which action?

• Place a cool compress on the sting site
• Apply an antipruritic lotion to the sting site
• Apply a topical corticosteroid to the sting site

d. Take an oral antihistamine such as diphenhydramine (Benadryl):

Answer:

A

• A nurse is assigned to conduct an admission assessment of a client who

was treated in the emergency department after attempting suicide by cutting her wrists with a razor blade. When the client arrives at the nursing unit, the nurse should take which action first?

• Ask the client to sign a no-harm contract
• Ask the client to report any suicidal thoughts immediately
• Place the client under suicide precautions with 15-minute checks
• Check the dressings that were placed over the client's wrists in the

emergency department:

Answer:

D First assess the physical state of the patient for safety then implement precautions.

• A nurse is preparing to administer digoxin to a client with heart failure.

When assessing the client, the nurse notes an apical pulse rate of 58 beats/min. Also, the client complains of anorexia and nausea. Which action

should the nurse take first on the basis of these assessment findings?

• Contact the primary health care provider
• Administer an as-needed antiemetic
• Check the most recent digoxin level

d. Administer the digoxin with an antacid:

Answer:

C

• A nurse is assessing a client who has undergone radical neck dissection

for the treatment of cancer. The nurse hears stridor when auscultating over the trachea. On the basis of this finding, which is the priority nursing action?

• Assess the client's pulse oximetry Incorrect
• Place the client in a supine position
• Contact the primary health care provider

d. Administer a nebulizer treatment with the use of a bronchodilator:

Answer:

C Stridor indication there is an obstruction and the HCP should be notified immediately.The patient should be placed in high Fowlers and pulse oximetry can be completed by is not the priority.

• A nurse is caring for a hospitalized child with newly diagnosed type 1

diabetes mellitus who received NPH and regular humulin insulin at 7:30 a.m.

At 11 a.m. the child suddenly complains of dizziness, headache, and a shaky feeling. The nurse immediately takes which action?

• Contacts the physician
• Gives the child milk to drink
• Arranges to have the child's lunch tray delivered early

d. Prepares to administer intravenous 5% dextrose solution:

Answer:

B

• A client with a diagnosis of preeclampsia suddenly begins to exhibit

seizure activity. Which is the first action on the part of the nurse?

• Calling the physician
• Inserting an oral airway
• Turning the client on her side

d. Noting the time of the seizure:

Answer:

C

• A nurse is preparing to administer an injection of vitamin K to a newborn.

At which site would the nurse select to administer the medication?:

Answer:

3 The preferred injection site for the administration of vitamin K in the newborn is the lateral aspect of the middle third of the vastus lateralis muscle (the newborn's thigh). This muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication

• A nurse performs a bedside glucose test on a newborn infant whose

mother has diabetes mellitus and obtains a reading of (2.164 mmol/L)35 mg/dL. The nurse would take which action first?Ask the mother to breastfeed the newborn Bottle-feed the newborn with diluted glucose Start an intravenous line for the administration of glucose

Ask the laboratory to perform a blood glucose test immediately:

Answer:

D Normal newborn levels are 40 mg/dL or greater. Glucose levels of less than (2.22-2.298 mmol/L))40 to 45 mg/dL measured with bedside glucose screening should be reported and verified in the laboratory. Although feeding is an intervention, the result of a bedside glucose must be verified by the laboratory.Some infants need IV glucose to maintain glucose balance and prevent damage to the brain.

• A pregnant woman is being admitted to the maternity unit. The woman

tells the nurse that she felt a large gush of fluid from her vagina on the way to the hospital. The nurse detects a fetal heart rate of 90 beats/min. On physical examination, the nurse finds that the umbilical cord is protruding from the vagina. Which actions should the nurse perform? Select all that apply.Placing the woman in knee-chest position Administering oxygen at 2 to 4 L/min by nasal cannula Administering terbutaline to stop contractions With two gloved fingers, exerting upward pressure, into the vagina, on the presenting part Wrapping the cord loosely in a sterile towel saturated with warm sterile normal

saline solution:

Answer:

A, C, D

Oxygen should be administered at 8-10 L/min via face mask

• A nurse provides information to the mother of a child with diarrhea

about signs and symptoms that indicate the need to call the primary health care provider. Which statement by the mother indicates the need for further instruction?"I'll call the doctor if she gets dizzy and acts sick." "I'll call the doctor if she has severe stomach cramps." "I'll call the doctor if her temperature is 102°F (38.9°C) or higher." "I'll call the physician if she goes longer than 6 hours without urinating.":

Answer:

C Call doctor at temperature above 100.

• A nurse reviewing the medical history of an infant experiencing

gastroesophageal reflux (GER) would expect to note documentation of which other issue?Refusal to suck Frequent diarrhea Recurrent otitis media

Inability to pass stools:

Answer:

C Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media resulting from pooling of secretions in the nasopharynx during sleep are characteristics of all types of GER.

• A nurse reviewing the record of a child with suspected acute poststreptococcal

glomerulonephritis notes that the child recently had a streptococcal throat infection that was treated with antibiotics. Which diagnostic test will confirm the presence of acute poststreptococcal glomerulonephritis does the nurse expect to find?Throat culture Blood urea nitrogen (BUN) Antistreptolysin (ASO) titer

White blood cell (WBC) count:

Answer:

C

• In caring for a child admitted to the hospital with Kawasaki disease, the

nurse should monitor the child most closely for signs which complication?