NCLEX -Practice questions

NCLEX -Practice questions Leave the first rating Students also studied Terms in this set (329) Save 75 Free NCLEX Questions - c/o Brilli...75 terms carey47Preview Prioritization NCLEX questions 28 terms madisoncastello Preview MED/SURG Final NCLEX questions 116 terms m3clevelandPreview NCLEX 110 term kan The nurse is providing care for several patients that arrived at the convenient care at the same time. Which patient will the nurse assess first?

• 15 year old with a severe headache, stiff neck, and

high temp. [meningitis]

• 27 year old with a fever, vomiting, abdominal cramping,

and diarrhea. [dehydration]

• 62 year old with arthritis and having severe pain.
• 43 year old with dysuria, severe burning with urination

and fever. [UTI] A Paramedics call the charge nurse. They are coming in with

• patients involved in a motor vehicle accident. Which

patient does the nurse plan to see first based on the report?

• A 26 year old screaming of pain. Has a visible right

knee deformity and weak lower extremity pulses.[circulation]

• A 22 year old female who is responsive to painful

stimuli, pulse rate 118 beats per minute with no visible traumas or injuries. [intracranial hemorrhage]

• A 6 year old boy with a visible deformity to the

forearm and crying.

• an 8 year old girl with a cut on the forehead, crying

intensely with a pulse rate of 126 beats per minute.B - Patient might be experiencing internal hemorrhage and go into a hypovolemic shock

The nurse provides care for a patient with diabetes insipidus. Which nursing diagnosis is most appropriate?

• Fluid volume deficit related to excess urine output.
• Hyponatremia related to high sodium excretion. [not a

Nanda nursing diagnoses]

• Risk for fluid volume overload related to decreased

urine output [ deficit not overload]

• Hyperglycemia is related to reduced insulin and

cortisol production. [diabetes mellitus] A - DI is deficiency of secretion of antidiuretic hormone or decreased response to ADH. This results in massive water excretion. Thus, fluid volume deficit A patient right after post hypophysectomy. He is thirsty and has frequent urination. Which action does the nurse take first?

• Check the glucose in urine
• Encourage drinking water
• Check urine specific gravity
• Call the surgeon

C -Post-op, diabetes insipidus can temporarily occur due to low ADH Which Outcome indicates that the intervention for a patient with syndrome of inappropriate antidiuretic hormone {SIADH} has been effective?

• Decreased serum osmolality
• Serum sodium is decreased
• Increased urine output
• Increased urine osmolality

C- Increased urine output - sign that treatment is effective The nurse performs a newborn assessment. Which finding does the nurse report to the physician?

• Pink patch on the back of the neck
• Bluish skin over the sacral gluteal area
• A rectal temperature of 98*F
• A respiratory rate of 24 breaths per minute

D: normal resp rate ~ 30-60; Pink patch ~ {stork bite} normal, bluish skin ~

{mangolian spots} normal;, Newborn 0-2yr old, Infants <1 yr old The oncology nurse is giving a teach about risk factors and demographics of lung cancer at a gathering at the local community clinic. Which group of individuals has the highest risk for lung cancer?A)African Americans

• Caucasians
• South East Asians
• Latins

A

The SpO2 of a lung cancer patient drops from 92% to 85% during ambulation. Which action does the nurse take next?

• This is a normal drop in response to activity with lung

cancer patients

• Relocate the oximetry probe to the earlobe during

activity

• Obtain an order for supplemental oxygen to be used

during activity

• Obtain an order for ABGs to verify the arterial oxygen

saturation C-supplemental o2 is needed to increase supply of oxygen during activity; the probe was reading well at 92%, no need to relocate The nurse moves a patient from the bed to a chair. Which technique does the nurse use to maintain proper body mechanics?(Select all that apply)

• A wide stance with one foot back and one to the front

B )Use upper back muscles when pulling patient to a stand

• Position yourself between the chair and the patient
• Hold patient at arms length when standing
• Pivot toward the chair using leg muscles

A,E A 50 year old patient who just had a heart attack. He is prescribed enteric coated aspirin. Which action does the nurse take in this situation?

• Administer the aspirin with a lot of water via

nasogastric tube.

• Obtain a blood type and crossmatch for transfusion.
• Check his past medical history for peptic ulcer disease
• Get a 6 lead electrocardiogram prior to administering

the aspirin C - peptic ulcer disease is a contraindication for non-enteric coated aspirin {normal can cause peptic ulcers}. Enteric coated meds can not be crushed & given through NG The patient gets his medication via NGT, which medication does the nurse need to call the provider for?

• KCL oral solution
• Phenytoin
• Captopril tablet
• Aspirin- EC

D- Aspirin EC {enteric coated} should not be crushed The nurse provides pre-op teaching for a patient. Which kind of anesthesia alters the level of consciousness?(Select all that apply}

• General anesthesia
• Topical anesthesia
• Regional anesthesia
• local anesthesia
• conscious sedation

A,E

The nurse provides care for a patient who had an unexpected death during a night shift. The patient has many tubes and drains in place. The nurse is performing postmortem care of the deceased patient. Which action by the nurse is appropriate when managing the tubes prior to a scheduled autopsy?

• Discontinue tubes and drains and send to autopsy with

the body

• Discontinue tubes and drains and put them in

biohazardous bags

• Keep all tubes and drains in place in the patient's body
• Keep Iv tubes in place but remove drains.

C -If an autopsy is to be performed, any tubes or drains will be left in place to be assessed and cultured, then removed by the medical examiner The nurse auscultates a patient's bowel sounds. Which finding is most important for the nurse to report to the physician?

• Bruit sound over the abdominal aorta
• Irregular bowel sounds
• Uninterrupted bowel sounds over the ileocecal area
• Absent bowel sounds for a whole 1 minute

A- burit signifies a turbulence ~ Abdominal Aortic Aneurysm {AAA} - emergent; Listen for 3-5 minutes, small bowel sounds are continuous {fluid}, bowel are not "regular" A patient is scheduled to receive an IV antibiotic q 8 hours, next dose is at 2p.m. The patient is prescribed peak and trough blood levels. At which time does the nurse schedule the trough level to be drawn?

A) 1430

B) 1500

C) 1330

D) 1400

C - a trough level is drawn approximately 30 minutes before the next scheduled dose Patient is getting gentamicin IV every 8 hours. The provider ordered a gentamicin peak. If the medication is administered at 10 am over one hour, at which time should the nurse draw the gentamicin peak?

• 10 am just before giving the dose
• 12 noon

C) 11:30 am

D) 5:30 pm just before the next due dose

C - peak occurs 30 minutes after to completion of IV drug