NCLEX-RN EXAM REVIEW

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NCLEX-RN EXAM REVIEW

133 terms Family_firstPreview Nursing Teacher frea The nurse receives a telephone call from the post- anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action on arrival of the client?

• assess the potency of the airway
• check tubes or drains for patency
• check the dressing to assess for bleeding
• assess the vital signs to compare with preoperative

measurement a

rationale: ABC's (airway, breathing, circulation)

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select All That Apply.

• auscultating lung sounds
• obtaining the client's temperature
• assessing the strength of peripheral pulses
• obtaining information about the clients respirations
• performing a musculoskeletal and neurological

examination

• asking the client about a family history of any illness or

disease a, b, d

The nurse understands that which statement is correct regarding respiratory rates?

• infants have a lower respiratory rate than adults
• healthy adults breathe between 12 and 20 times a

minute

• a compensatory response to a fever is to breathe at a

slower rate

• an increase in intracranial pressure results in an

increased rate b rationale: fever increases RR in attempts to blow off the heat; ICP cause Th (slow down breathing) While auscultating a patient's lungs, the nurse notes diminished breath sounds at the base of the right lung.What action should the nurse take next?

• refer the patient for a chest x-ray
• listen to the base of the patient's left lung
• notify the patient's primary care provider
• palpate the patient's lung fields bilaterally

b

rationale: always compare; tasks should be carried out before notifying

The nurse assess the vital signs of a 12-month old infant with respiratory infection and notes the respiratory rate is 35 breaths/minute. On the basis of this finding, which action is most appropriate?

• administer oxygen
• document the finding
• notify the health care provider
• reassess the respiratory rate in 15 minutes

b The nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being appropriate method, indicates the need for further teaching?

• taking a rectal temperature for a client who has

undergone nasal surgery

• taking an oral temperature for a client with a cough and

nasal congestion

• taking an axillary temperature for a client who has just

consumed hot coffee

• taking a temporal temperature on the neck behind the

ear for a client who is diaphoretic b

A staff nurse is precasting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates a need for further teaching regarding pain management?

• "I will be sure to ask my client what his pain level is on a

scale of 0 to 10"

• "I know that I should follow up after giving medication

to make sure it is effective."

• "I know that pain in the older client might manifest as

sleep disturbances or depression."

• "I will be sure to cue in to any indication that the client

may be exaggerating their pain.d A client receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the health care provider (HCP), and the HCP initially prescribes that the solution and tubing be changed. What should the nurse do with the discontinued materials?

• discard them in the unit trash
• return them to the hospital pharmacy
• save them for return to the manufacturer
• prepare to send them to the laboratory for culture

d the nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate?

• increase oral fluids
• document the finding
• notify the health care provider (HCP)
• elevate the head of bed to 90 degrees

b The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees to identify which client as most typically a victim of abuse?

• a man who has moderate hypertension
• a man who has newly diagnosed cataracts
• a woman who has advanced Parkinson's disease
• a woman who has early diagnosed Lyme disease

c

The nurse enters the client's room and finds the client

drowsy and records the following vital signs: temperature

97.2 F (36.2 C) orally, pulse 52 beats per minute, blood pressure 101/58 mmHg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next?

• document the findings
• attempt to arouse the client
• contact the health care provider immediately
• check the medication administration history on the

PCA pump b The nurse is testing extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?

• test the corneal reflexes
• test the 6 cardinal positions of gaze
• test visual acuity, using a Snellen eye chart
• test sensory function by asking the client to close the

eyes and then lightly touching the forehead, cheeks, and chin b The nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery.During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior?

• reflecting a cultural value
• an acceptance of treatment
• client agreement to required procedures
• client understanding of the preoperative procedures

a When communicating with a client who speaks a different language, which best practice should the nurse implement?

• speak loudly and slowly
• arrange for an interpreter to translate
• speak to the client and family together
• stand close to the client and speak loudly

b