NCLEX practice questions Exam 2

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NCLEX 3500

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1. The surgery for a client scheduled for an 8:00am

procedure is delayed until 11:00am. What is the

appropriate nursing action regarding administration of preoperative prophylactic antibiotic?

A. Administer at 8:00am as originally prescribed

B. Adjust the administration time to be given at 10:00am

• Do not administer, as preoperative prophylactic

antibiotics are optional

• Hold the antibiotic until immediately following surgery,

then administer

B. Adjust the administration time to be given at 10:00am

• The nurse is caring for a client who is to undergo

surgery at 6:00 AM today. Which assessment data will the

nurse communicate immediately to the surgeon an anesthesia provider? Select all that apply.

• Blood pressure 130/72 mmHg
• Potassium 3.5 mEq/L
• Diffuse rash on upper torso
• Took 600 milligrams of aspirin yesterday

E. Has not had food or water since 9:00 PM last night

• Diffuse rash on upper torso
• Took 600 milligrams of aspirin yesterday

• A nurse is verifying informed consent for a client who is

having a paracentesis. Which of the following action should the nurse take? Select all that apply.

• Explain to the client the purpose of having the

procedure

• Inform the client of risks to having the procedure
• Ensure the client understands information about the

procedure

• Witness the client signed the consent form
• Determine if the client is capable of understanding the

reason for the procedure

• Ensure the client understands information about the procedure
• Witness the client signed the consent form
• Determine if the client is capable of understanding the reason for the

procedure

• While applying compression stockings and pneumatic

compression devices, a client questions the purpose of these devices. What is the appropriate nursing response?

• "These will help to prevent blood clots."
• "They make your legs feel more comfortable."
• "These prevent skin breakdown from immobility."
• "The use of these right after surgery makes is easier to

start to ambulate."

• "These will help to prevent blood clots."
• A nurse is planning care for a client to prevent

postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care?

• Encourage use of incentive spirometer every two

hours

• Instruct the client to splint the incision when coughing

and deep breathing

• Reposition the client every two hours
• Administer antibiotic therapy
• Assist with early ambulation
• Encourage use of incentive spirometer every two hours
• Instruct the client to splint the incision when coughing and deep breathing
• Reposition the client every two hours
• Assist with early ambulation

. A nurse is caring for a client who reports nausea and vomiting 2 days postoperative following a hysterectomy.Which of the following actions should the nurse perform first?

• Assess bowel sounds
• Administer antiemetic medications
• Restart prescribed IV fluids
• Insert a prescribed nasogastric tube (NGT)
• Assess bowel sounds

The nurse has just received report on a group of clients.Which client is the nurse's first priority?

• A 50 year old who is 1 day postoperative from

abdominal surgery and is receiving 2 L oxygen by nasal cannula.

• A 55 year old was admitted yesterday with pneumonia

and is receiving antibiotics and oxygen through a nasal cannula.

• A 45 year old who is being discharged with a new

prescription for home oxygen therapy by nasal cannula.

• A 60 year old admitted 2 hours ago with a history of

COPD who has a 90-pack-year smoking history and is receiving 50% oxygen by Venturi mask.

• A 60 year old admitted 2 hours ago with a history of COPD who has a 90-pack-

year smoking history and is receiving 50% oxygen by Venturi mask.Which statements made by a client going home with a tracheostomy indicate to the nurse the need for further teaching about correct tracheostomy care? (Select all that apply.) "I can only take baths, but no showers." (1) "I will be unable to wear a necklace." (2) "I should put cotton or foam over the tracheostomy hole." (3) "I will have to learn to suction myself." (4) "I will notify my primary health care provider if my secretions develop a foul odor." (5) "I can only take baths, but no showers." (1) "I will be unable to wear a necklace." (2) "I should put cotton or foam over the tracheostomy hole." (3) The nurse has just received report on a group of clients.Which client is the nurse's first priority?

• A 62 year old with chronic obstructive pulmonary

disease (COPD) being discharged with an oxygen saturation of 90%

• A 42 year old with lung cancer who needs an IV

antibiotic administered before going to surgery

• A 22 year old with cystic fibrosis (CF) who has an

elevated temperature and a respiratory rate of 38 breaths/min

• A 52 year old with end-stage pulmonary fibrosis and

an oxygen saturation of 89%

• A 22 year old with cystic fibrosis (CF) who has an elevated temperature and a

respiratory rate of 38 breaths/min Which problem experienced by a man with late-stage lung cancer is the priority for immediate action by the nurse?

• Anorexia and weight loss
• Pain rating of 9 on a 0-10 scale
• Constipation for 2 days
• Extreme fatigue
• Pain rating of 9 on a 0-10 scale

An 81-year-old client who came to the ED has been admitted to the medical-surgical unit with a diagnosis of suspected pneumonia.She reports having a productive cough and fever for 2 days.Assessment reveals that she is flushed and short of breath when talking.She has a history of type 2 diabetes mellitus and hypertension, and no known allergies. A chest x-ray, CBC, and basic metabolic panel (electrolytes, BUN, creatinine) were done in the ED. A saline lock is inserted into her right forearm Upon arrival to the unit, blood glucose and vital signs are obtained.BG—239 mg/dL BP—138/88 mm Hg HR—128 RR—36 breaths/min O2 saturation—88% (room air) Temperature—101.6º F Which vital sign or test result requires immediate nursing intervention?

• Blood pressure
• Respiratory rate
• Temperature
• Blood glucose
• Respiratory rate

After consulting with the health care provider, these

orders are received:

Full liquid diabetic diet IV fluids 1000 mL .9 NS at 60 mL/hr Oxygen at 2 L per nasal cannula Blood cultures × 3 and urinalysis Tylenol grain × every 4 hour for temperature above 101º F Cefazolin (Ancef) 1 g IVP every 8 hour Which order will the nurse implement first?

• Blood cultures and urinalysis
• Cefazolin 1 g IVP every 8 hours
• Oxygen at 2 L per nasal cannula
• IV fluids 1000 mL .9 NS at 60 mL/hr
• Oxygen at 2 L per nasal cannula

Two hours later, the client has a weak cough, crackles in both lower lobes, and an SpO2 reading of 90% by pulse oximetry.What interventions will the nurse implement at this time?Helping her to cough and deep breathe at least every 2 hours; teaching incentive spirometry every hour while awake; encouraging the client to consume 3 L of fluid per day; monitoring intake and output; and administering bronchodilators if ordered.