NCLEX QUESTIONS AND ANSWERS NEW STUDY REVIEW SOLUTION

NCLEX QUESTIONS AND ANSWERS NEW STUDY REVIEW SOLUTION

QUESTIONS AND ANSWERS 2022

one unit of packed red blood cells is infusing into a client over a 4-hour period.the unit of blood contains 250 mL.the drop factor is 15 drops (gtt) per 1 mL.the nurse determines that the flow rate should be set at how many drops per minute? - 16 drops per minute

rationale

total volume x gtt factor / time in minutes = gtt/min

250 mL x 15 gtt / 240 (4hr x 60 min) = 3750/240 = 16

ketoconazole is prescribed for an assigned client.the nurse prepares to administer the medication in which manner? - with food

rationale ketoconazole is an antifungal medication. it should be administered with food to minimize gastrointestinal irritation.the medication requires acidity and should be administered at least 2 hours apart from an antacid.

the nurse is caring for an older adult client who has recently lost her husband.the client says, no one cares about me anymore. all the people i loved are dead.which response by the nurse is therapeutic? - you must be feeling all alone at this point

rationale the client is experiencing loss and is feeling hopeless.the therapeutic response by the nurse is the one that attempts to translate words into feelings.

the client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously.the nurse caring for the client anticipates that which diagnostic study will be prescribed?

• pulmonary function studies

rationale bleomycin is an antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis.pulmonary function studies along with hematological, hepatic, and renal function tests need to be monitored.the nurse needs to monitor lung sounds for dyspnea and adventitious sounds, which could indicate pulmonary toxicity.the medication needs to be discontinued immediately if pulmonary toxicity occurs.

a pediatric nurse arrives at work and is told to report to the ED for the day because the ED is expecting numerous victims arriving following a train crash.the nurse has never worked in the ED and is anxious about floating in this area.which is the appropriate nursing action - discuss her anxieties and concerns with the nursing supervisor about floating?

rationale floating is an acceptable legal practice used by hospitals to solve their understaffing problems.legally, the nurse cannot refuse to flat unless a union contract guarantees that nurses can only work in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks.when encountered with this situation, the nurse should discuss any anxieties and concerns with the supervisor about floating

a client is complaining of abdominal pain and nausea.the prescription is as follows; give meperidine (Demerol) 25 mg intramuscularly, hydroxyzine (Vistaril) 25 mg IM stat.hydroxyzine is available 50 mg/mL demerol is available in 25 mg/0.5 mL.the nurse should combine the doses in one syringe for administration to the ventrogluteal muscle.how many mL should the nurse administer in total? - 1 mL

rationale

desired / available x quantity = mL per dose

25 / 50 mg x 1 mL = 0.5mL (Vistaril)

25 mg / 50 mg x 0.5 mL = 0.5 mL (Demerol)

0.5 + 0.5 = 1 mL

the nurse knows that litigation involving nurses is common because of which reasons?select all that apply. - clients are better educated about health care // clients are better informed about their rights // clients have a higher expectation about the care they receive

rationale the reasons that health-care related litigation involving nurses is common is because clients are more educated, more aware of their rights, and have a higher expectation regarding the care they receive.lawsuits involving nurses are not common because of an expectation of monetary gain or because nurses are not trusted.

which client is most likely at risk to become a victim of elder abuse? - a 90-year-old woman with advanced Parkinson's disease

rationale elder abuse is widespread and occurs among all subgroups of the population.it includes physical and psychological abuse, the misuse of property, and the violation of rights.the typical abuse victim is a woman of advanced age with few social contacts and at least one physical or mental impairment that limits her ability to perform activities of daily living.in addition, the client usually lives alone or with the abuser and depends on the abuser for care.

the LPN is assisting in the care of a client who is receiving Pitocin (oxytocin) to induce labor.the LPN plans to notify the RN immediately if which is noted? - the uterus becomes hyperstimulated

rationale induction of labor is the initiation of labor through mechanical or pharmacological means.oxytocin is a synthetic hormone that stimulates uterine contractions and is a medication commonly used to induce labor.a major danger associated with this medication is hyperstimulation of uterine contractions, which decreases placental perfusion and causes fetal distress.for this reason, the oxytocin infusion must be discontinued if signs of uterine hyperstimulation occur.early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress.

a nursing student is asked to discuss HIV during a clinical conference.the nursing student should include which correct item in the discussion? - HIV virus attacks the immune system by destroying T lymphocytes

rationale the virus attacks the immune system by destroying T lymphocytes.children born to HIV-positive women test positive for HIV antibody, not HIV virus.this is actually a measure of maternal antibody and not indicative of true infection.T4 cells are depleted in number and cannot signal B cells to form protective antibodies to fight off the invading virus.

the nurse is caring for a client with a fractured tibia and fibula.eight hours after a long leg cast was applied, the client began to report an increase in pain level even after administration of the prescribed dose of opioid analgesic.

which is the initial nursing action? - check the neurovascular status of the toes on the casted leg

rationale an increase in pain level in an extremity at risk for neurovascular compromise (compartment syndrome) is often the first sign of increasing pressure in a compartment, in this case, the casted extremity.the nurse needs to obtain additional data in order to determine whether the HCP needs to be notified immediately or whether other interventions are appropriate.

the nurse is caring for a client with gout who is taking colchicine (Colcrys).the client has been instructed to restrict the diet to low-purine foods.which food should the nurse instruct the client to avoid while taking this medication/ - scallops

rationale Colchicine is a medication used for clients with gout to inhibit the reabsorption of uric acid by the kidney and promote excretion of uric acid in the urine.uric acid is produced when purine is catabolized.clients are instructed to modify their diet and limit excessive purine intake.high-purine foods to avoid or limit include organ meats, roe, sardines, scallops, anchovies, broth, mincemeat, herring, shrimp, mackerel, gravy, and yeast

the nurse is discharging a client from the hospital who was given a prescription for atorvastatin (Lipitor).the nurse should tell the client to report which adverse effect to the HCP immediately? - muscle pain and weakness

rationale atorvastatin can injure muscle tissue. the muscle injury can progress to myositis, which is muscle inflammation associated with moderate elevation of creatine kinase (CK) an enzyme released from injured muscle.myositis, in turn, may progress to potentially fatal rhabdomyolysis, associated with a marked elevation of CK and possibly with renal failure.

the nurse is caring for a client with glaucoma.which medication prescribed for the client should the nurse question? - atropine sulfate (Isopto Atropine)

rationale mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye

the nurse employed in a psychiatric unit receives a client assignment for the day.which client assigned to the nurse is at the highest risk for committing suicide? - a client with severe depression and cancer