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NCLEX RN MOCK PREPARATION
COMPLETE SOLUTION
The nurse is teaching a family member of a client with a terminal illness the signs of impending death. Which statement by a family member indicates the need for further teaching?
- I will continue to talk in normal tones
- Decreases in respirations my happen
- Death is soon, if their shoulders are cool
- They may prefer to sleep rather than talk
ANSWER : Death is soon, if their shoulders are cool
The systems of the body will begin to function erratic and slower as death approaches. As the feedback of the circulatory system fails, the client will have fluctuating temperature control. As death process continues, the circulatory system in the extremities will fail. The arms and legs will become cooler. The family member will require further teaching regarding indicators of approaching death.A medical-surgical LPN has been sent to a short-staffed pediatric unit. The charge nurse knows what client would be most appropriate for this LPN?
- 3 month old child with nonorganic failure to thrive
- 14 year old with exacerbation of cystic fibrosis
- 5 year old newly admitted with epiglottitis
- 10 year old with type 1 diabetes mellitus
ANSWER : 10 year old with type 1 diabetes mellitus
Prior to removal of cataracts, the client is to receive eye drops in both eyes. The nurse knows what actions takes priority/
- Remove any exudate around eyes with warm water
- Instill exact number of drops into lower conjunctival sac
- Instruct client to look upward when drops are instilled
- Avoid dropping the medication directly on the cornea
ANSWER : Avoid dropping the medication directly on the cornea.
The most important safety consideration when instilling eye drops is to avoid dropping the medication directly onto the cornea. The extreme sensitivity of the cornea before, and after, eye surgery could cause serious eye problems.Which side effect of vincristine should the nurse immediately report to the primary healthcare provider?
- Nausea
- Fatigue
- Paresthesia
- Anorexia
ANSWER : Paresthesia
Vincristine - chemotherapeutic drug that could cause paresthesia - needs dose mod or d/c The nurse is admitting an 8 month old infant to the pediatric unit. For what major developmental stressor in this infant should the nurse plan interventions?
- Fear of unknown
- Loss of daily routine
- Body image disturbance
- Separation anxiety
ANSWER : Separation anxiety
The nurse is caring for a client with multiple episodes of diarrhea and suspected Clostridium Difficile (C. diff). Which interventions should be included in the plan of care? Select all that apply.
- Institute contact precautions only after confirmation of stool culture
- Instituting contact precautions for all who enter the client's room
- Using alcohol based foam for hand hygiene
- Dedicating equipment for use only in the client's room
- Requesting antidiarrheal medication for the client
ANSWER : - Instituting contact precautions for all who enter the client's room
- Dedicating equipment for use only in the client's room.
- Administer the calculated medication dosage
- Call the HCP to clarify the dosage
- Ask another nurse to calculate the dosage
- Notify the pharmacy setting for the calculated dosage.
antidiarrheals could cause further irritation A nurse is preparing to administer an insulin infusion to a client. The nurse calculates the infusion pump setting as 9 mL/hr. What should the nurse do next?
ANSWER : Ask another nurse to calculate the dosage.
Insulin is a high alert drug.`A post-operative client becomes anxious and reports acute onset of chest pain when taking a deep breath and shortness of breath. Initial vital signs obtained by the nurse reveals tachycardia, hemoptysis, and a pulse oximeter reading of 90%. What intervention should the nurse initiate first?
- Administer oxygen
- Obtain a blood pressure reading
- Connect to cardiac monitor.
- Raise head of bed to 90 degrees
- Piggy back oxytocin into main IV fluid
- Monitor for early decelerations
- D/C if contractions last longer than 90 seconds
- Maintain one on one care
- Check fetal heart tones hourly
- D/C if contractions last longer than 90 seconds (to avoid hyperstimulation of the uterus and
ANSWER : Raise head of bed to 90 degrees - to facilitate maximum lung expansion and decrease venous return to the right side of the heart to decrease pressure in the pulmonary vascular system.A nurse is planning care for a laboring client who is about to be started on oxytocin. What interventions should the nurse include in this plan of care? Select all that apply.
ANSWER : - PB oxytocin into main IV fluid (so when oxy is d/c the main IV fluid is resumed quickly)
fetal distress)
- Maintain 1:1 care (to monitor for complications)
External fetal monitoring should begin prior to oxytocin administration. A reactive fetal heart rate tracing should be obtained over 30 minutes Which intervention should the nurse recommend to the adult child who is caring for an elderly parent diagnosed with Alzheimer's disease (AD)?
- Give parent small dog for company and comfort
- Reset the water heater to 125 degrees F to prevent burns
- Place mirrors in multiple locations so parent sees image of self
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