NCLEX-RN Exam Pack Set 4 75

NCLEX-RN Exam Pack Set 4 (75 Questions & Answers Updated 2022)

1.1. Question

Which action(s) should you delegate to the experienced nursing assistant when caring for a patient with a thrombotic stroke with residual left-sided weakness? Select all that apply.

• Assist the patient to reposition every 2 hours.
• Reapply pneumatic compression boots.
• Remind the patient to perform active ROM.
• Check extremities for redness and edema.

Correct Answer: A, B, & C.

The experienced nursing assistant would know how to reposition the patient and how to reapply compression boots and would remind the patient to perform activities he has been taught to perform.

oOption D: Assessing for redness and swelling (signs

of deep venous thrombosis {DVT}) requires additional education and is still appropriate to the professional nurse.2. Question The patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant who will feed the patient?

• Position the patient sitting up in bed before

you feed her.

• Check the patient’s gag and swallowing reflexes.

• Feed the patient quickly because there are three more

waiting.

• Suction the patient’s secretions between bites of

food.

Correct Answer: A. Position the patient sitting up in bed

before you feed her.Positioning the patient in a sitting position decreases the risk of aspiration.

oOption B: The nursing assistant is not trained to

assess gag or swallowing reflexes.

oOption C: The patient should not be rushed during

feeding.

oOption D: A patient who needs to be suctioned

between bites of food is not handling secretions and is at risk for aspiration. This patient should be assessed further before feeding.3. Question You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patient complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Which collaborative intervention must be accomplished first?

• Administer codeine 15 mg orally for the patient’s

headache.

• Infuse ceftriaxone (Rocephin) 2000 mg IV to

treat the infection.

• Give acetaminophen (Tylenol) 650 mg orally to reduce

the fever.

• Give furosemide (Lasix) 40 mg IV to decrease

intracranial pressure.

Correct Answer: B. Infuse ceftriaxone (Rocephin) 2000 mg

IV to treat the infection.

Untreated bacterial meningitis has a mortality rate approaching 100%, so rapid antibiotic treatment is essential.

oOption A: Pain medications may be given after

treating the infection that is most probably causing it.

oOption C: Acetaminophen should be given to

decrease the fever after administering the antibiotics first.

oOption D: Furosemide will help reduce CNS

stimulation and irritation and should be implemented as soon as possible.4. Question You are mentoring a student nurse in the intensive care unit (ICU) while caring for a patient with meningococcal meningitis. Which action by the student requires that you intervene immediately?

• The student enters the room without putting on

a mask and gown.

• The student instructs the family that visits are

restricted to 10 minutes.

• The student gives the patient a warm blanket when

he says he feels cold.

• The student checks the patient’s pupil response to

light every 30 minutes.

Correct Answer: A. The student enters the room without

putting on a mask and gown.Meningococcal meningitis is spread through contact with respiratory secretions so use of a mask and gown is required to prevent the spread of the infection to staff members or other patients. The other actions may not be appropriate but they do not require intervention as rapidly.

oOption B: The presence of a family member at the

bedside may decrease patient confusion and agitation.

oOption C: Patients with hyperthermia frequently

complain of feeling chilled, but warming the patient is not an appropriate intervention.

oOption D: Checking the pupil response to light is

appropriate, but it is not needed every 30 minutes and

is uncomfortable for a patient with photophobia.

Focus: Prioritization

5. Question A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic- clonic seizures. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising? Select all that apply.

• Document the onset time, nature of seizure activity,

and postictal behaviors for all seizures.

• Administer phenytoin (Dilantin) 200 mg PO

daily.

• Teach the patient about the need for good oral

hygiene.

• Develop a discharge plan, including physician visits

and referral to the Epilepsy Foundation.

• Gather information about the seizure activity

Correct Answer: B & E

Administration of medications that are not a high risk is included in LPN education and scope of practice. Collection of data about the seizure activity may be accomplished by an LPN/LVN who observes initial seizure activity. An LPN/LVN would know to call the supervising RN immediately if a patient started to seize.

oOption A: Documentation is a nursing responsibility.

oOption C: Patient education must be accomplished by

the registered nurse because it is within their scope of practice.

oOption D: Planning of care is a complex activity that

requires RN level education and scope of practice.6. Question While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these nursing actions will you implement first if the patient has a seizure?