NCLEX RN Exam Review

NCLEX RN Exam Review A client who has amyotrophic lateral sclerosis is having frequent episodes of dysphagia. Which of the following referrals is appropriate for the nurse to make currently?

• Physical Therapist
• Speech Pathologist
• Registered Dietitian
• Occupational Therapist

(ANS- 2. Speech Pathologist

A client who has chronic progressive dementia exhibits symptoms of malnutrition.Which action is needed at this time?

• Notify social services about concern for abuse.
• Initiate a consult for physical therapy to visit daily.
• Ask home care services to provide written instructions.
• Arrange a meeting with the interprofessional team to coordinate care?

(ANS- 4. Arrange a meeting with the interprofessional team to coordinate care?

A nurse should recognize which of the following clients are likely to need rehabilitation services after hepatization? (SATA)

• School-age child who is recovering from an appendectomy.
• Client who had a cesarean delivery for a breech presentation.
• An adult client who has left hemiplegia after a stroke.
• An adult client who is recovering from Guillain-Barre syndrome.
• An older adult client who had a left hip replacement.
• An adolescent client who required hospitalization due to asthma.

(ANS-

• An adult client who has left hemiplegia after a stroke.
• An adult client who is recovering from Guillain-Barre syndrome.
• An older adult client who had a left hip replacement.

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A nurse is assigned to a group of clients. Which of the following has an increased risk of aspiration while eating? (SATA)

• A client who has a new diagnosis of gastroesophageal reflux disease.
• A client who has admitted with a diagnosis of cerebrovascular accident.
• A client who is 4 hr. post-op and received general anesthesia.
• A client who is 8 hr. following traumatic laryngeal nerve damage.
• A client who continually experiences prolonged coughing episodes.

(ANS-

• A client who has admitted with a diagnosis of cerebrovascular accident.
• A client who is 4 hr. post op and received general anesthesia.
• A client who is 8 hr. following traumatic laryngeal nerve damage.
• A client who continually experiences prolonged coughing episodes.

A client is receiving packed RBCs and becomes tachypneic. The client's temperature changes from 36.8*C (98.4*F) to 38.4*C (101.2*F). Which of the nursing interventions should the nurse perform first.

• Give 750 mg acetaminophen orally.
• Collect blood and urine specimens for analysis.
• Administer and IV infusion of 0.9% sodium chloride.
• Stop the infusion and return the blood to the lab.

(ANS- 4. Stop the infusion and return the blood to the lab.

A nurse receives a request from four clients at the same time. Which of the following clients should the nurse address first? A client who

• Needs to void 1 hr. after removal of an indwelling urinary catheter.
• Reports restlessness and shortness of breath following surgery for a fractured

femur.

• Asks for a stool softener 2 days following surgery.
• Demands to take prescribed insulin early the spouse is bringing dinner.

(ANS- 2. Reports restlessness and shortness of breath following surgery for a fractured femur.

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After receiving the report, a nurse should plan to access the clients in which priority order?

• A 9-month-old who is receiving hydration therapy with IV fluids infusion

peripherally.

• A 6-year-old who is receiving continuous chemotherapy via a central venous

catheter.

• A 14-year-old who is awaiting discharge instructions receiving prednisone

therapy.

• An 8-year-old who is 2 days postoperative with an indwelling urinary catheter.

(ANS- 1st) 2. A 6-year-old who is receiving continuous chemotherapy via a central venous catheter.2nd) 1. A 9-month-old who is receiving hydration therapy with IV fluids infusion peripherally.3rd) 4. An 8-year-old who is 2 days postoperative with an indwelling urinary catheter.4th) 3. A 14-year-old who is awaiting discharge instructions receiving prednisone therapy.

A nurse received the report and should plan to see which of the following client first?

• A client at 39 weeks of gestation who is having contractions over 5 min

lasting45 to 60 seconds.

• A client who is pregnant and has a blood glucose level of 150mg/dl.
• A client at 33 weeks of gestation who is receiving magnesium sulfate IV.
• A client 1 day postpartum who has changed perineal pads twice in the last 7 hr.

(ANS- 3. A client at 33 weeks of gestation who is receiving magnesium sulfate IV.

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After receiving the report, which of the following clients should the nurse see first?

• A client who was admitted with kidney stones and is crying with back pain.
• A client who had chest discomfort prior to admission and is now requesting

coffee.

• A client who is scheduled for surgery and needs the linen changed.
• A client who is to receive one unit of packed RBCs today and needs an IV

restarted.(ANS- 1. A client who was admitted with kidney stones and is crying with back pain.

The nurse should triage which of the following clients first?

• Vomiting, photosensitivity, and stiff neck.
• Elevated temperature, sore throat, and fatigue.
• A guarded gait and a bruised, edematous ankle.
• Cloudy urine with painful urination.

(ANS- 1. Vomiting, photosensitivity, and stiff neck.

• Rights of Delegation

(ANS- Right Person Right Task Right Circumstance Right Direction/Communication Right Supervision/Evaluation

Scope of Practice RN - LPN -

UAP –

(ANS- RN - Unstable clients, Assessments, Initiate Care Plans, Initial Teaching, Blood Productions, IV Fluids and IV Push Medications.LPN - Stable clients, Gather data, Contribute to Care Plan, Reinforce Teaching, Monitor IVFs and Blood Transfusions, Administer Piggybacks.

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