NCLEX Style Practice Questions

NCLEX Style Practice Questions Leave the first rating Students also studied Terms in this set (39) Science MedicineNursing Save 75 Free NCLEX Questions - c/o Brilli...75 terms carey47Preview NCLEX-RN Practice Questions For 2...Teacher 33 terms TutorDkPreview Virtual ati- NCLEX-style Questions ...10 terms Antonio_Acosta6 Preview NCLEX 40 terms J_N A client who is using patient-controlled analgesia (PCA) is asleep. The nurse observes a family member pushing the PCA button for the sleeping client. What does the nurse say to the visitor?

• "Please allow the client to push the button when

needed."

• "Please don't touch any equipment in the client's room."
• "Thank you. I am sure the client appreciated that."
• "The client is asleep and is not in pain."

Answer: A. "Please allow the client to push the button when needed."

Rationale: The "PC" in "PCA" means "patient-controlled," so having someone else push the button and administer analgesia defeats the purpose. More important, this action could cause oversedation and possible serious safety issues. Telling the family member not to touch any equipment in the client's room is not only nonspecific, it is also disrespectful. Expressing appreciation is inappropriate because the nurse is condoning an unauthorized and potentially unsafe action.The fact that the client is asleep does not mean that the client is pain-free.A client with osteoarthritis pain tells the nurse, "I take two arthritis-strength Tylenol (650 mg) every 8 hours." How does the nurse respond?

• "Aspirin would be a better, more effective choice for

your pain relief."

• "More Tylenol is needed to provide effective pain relief

for you."

• "That is the appropriate dose of Tylenol for your pain."
• "You will need to have routine liver and kidney function

laboratory tests." Answer: D. "You will need to have routine liver and kidney function laboratory tests." Rationale: Clients taking Tylenol, especially high doses of it, should be reminded to have routine liver and kidney function laboratory testing done, because hepatotoxicity and nephrotoxicity are adverse effects associated with long-term use. Acetaminophen (Tylenol) is a better choice for pain relief than aspirin because it has fewer side effects on the gastrointestinal system, such as bleeding.The client is actually taking more than the recommended upper limit of Tylenol; no more than 3600 mg daily should be used, and no more than 2400 mg for older adults.

A client reports increasing pain during dressing changes.Which interventions are recommended for the client?(Select All That Apply)

• Assistance by the client with the dressing change
• Distraction
• Epidural analgesic
• Music therapy
• Premedication
• Transcutaneous electrical nerve stimulation (TENS)

Answer: B. Distraction, D. Music therapy,

• Premedication

Rationale: Distraction stimulates efferent nerve fibers and reduces the client's perception of painful experiences. Music therapy provides a distraction and can reduce the client's pain perception; efferent nerve fibers are stimulated.Premedication before painful treatments is a good method of controlling pain during treatment. Involving the client in an uncomfortable dressing change would tend to increase the client's perception of pain; it is a better tactic to distract the client. Although epidural analgesia is effective, it is a method of providing pain relief that requires an epidural catheter to be in place; the use of such an invasive procedure would not be indicated for pain relief during a dressing change. Use of a TENS unit is effective in controlling certain types of pain, such as incisional pain; its use during a dressing change would not be feasible.Which statement is true about assessing pain in an older adult client?

• The nurse should assess for present and past pain.
• Older adults typically believe that expressing pain is

acceptable.

• Older adults are at great risk for undertreated pain.
• Older adults usually believe that pain signifies a minor

illness.

Answer: C. Older adults are at great risk for undertreated pain.

Rationale: Older adults are at great risk for undertreated pain because of

outdated beliefs by some health care providers about older adults' pain sensitivity, tolerance, and ability to take opioids. The nurse should assess only for present pain. Older adults often believe that expressing pain is unacceptable.Older adults often believe that pain signifies a major illness.Which client does the RN arriving for duty assess first?

• 27-year-old who has chronic severe back pain with

movement

• A 51-year-old with lung cancer who reports pain

"whenever I cough"

• 56-year-old with acute pancreatitis who reports

increasing abdominal pain

• A 63-year-old who reports ongoing pain associated

with rheumatoid arthritis

Answer: C. 56-year-old with acute pancreatitis who reports increasing abdominal

pain

Rationale: Because acute pain is a biological warning signal, the nurse should

assess the client with pancreatitis for complications such as bleeding or perforation that may be causing the client's increasing pain. The clients with back pain, lung cancer pain, and rheumatoid arthritis have chronic pain; they should be assessed and treated as rapidly as possible, but the client with acute pain takes priority.A newly admitted client who was in an automobile accident has a concussion and is reporting pain from a fractured femur and broken fingers. Which staff member does the charge nurse on the orthopedic unit assign to care for this client?

• An experienced RN travel nurse who arrived on the

unit this morning

• An LPN/LVN who has worked on the orthopedic unit

for 6 years

• The neurology unit RN who has floated to the

orthopedic unit

• The RN orthopedic case manager who is responsible

for discharge planning

Answer: C. The neurology unit RN who has floated to the orthopedic unit

Rationale: The RN from the neurology unit will have the skills and experience

needed to assess the neurologic and orthopedic status of this client, as well as the client's pain status. The travel RN may have the expertise to care for the client, but will not be familiar with hospital policies or equipment. The LPN/LVN does not have the education or scope of practice to be assigned the care of this complex client, although the RN may delegate some aspects of the client's care to the LPN/LVN. The case manager's expertise involves coordinating discharge for the client rather than caring for the client during the acute hospitalization.

The nurse is assessing the nutritional status of an older adult client. Which statement made by the client needs to be explored further?

• "Although I enjoy eating sweets and desserts, I need to

balance them with healthier foods."

• "For protein in my diet, I like to get the fish sandwich at

the fast-food drive-through at least three times a week."

• "To keep my bowel movements regular, I try to eat

some fresh fruits or vegetables each day."

• "With less activity and exercise in my life these days, I

should reduce my total calorie intake." Answer: B. "For protein in my diet, I like to get the fish sandwich at the fast-food drive-through at least three times a week." Rationale: Fast food is a contributor to high carbohydrate and caloric intake in older adults. Because fast food is relatively inexpensive and convenient, this population tends to abuse it, thus gaining weight from unhealthy calories. Older adults do enjoy sweets and desserts because their taste acuity changes, but they still need to eat a variety of foods that are high in protein and vitamins, as well as with different textures and fiber content. Consuming fresh fruits and vegetables is characteristic of a healthy lifestyle in older adults; this practice will help keep bowel habits routine. As older adults begin to lead a more sedentary lifestyle, they should decrease their caloric intake to match a diminished basal metabolic rate.A 72-year-old client admitted to the hospital for congestive heart failure has a history of a fractured hip due to a previous fall. The client is taking oxycodone- acetaminophen as needed for pain secondary to a recent dental procedure. Which risk factor puts this client at greatest risk for a fall?

• Age
• Diagnosis
• History of Fall
• Narcotic Use

Answer: C. History of Fall

Rationale: The client's recent history of falling is the single most important

predictor for falls. Adults age 80 years and older and those with multiple diagnoses are at higher risk for falls. Oxycodone- acetaminophen may cause mental changes, but this isn't the best answer.The RN at a skilled nursing facility is supervising a staff of LPN/LVNs and nursing assistants. Which of these nursing actions does the RN delegate to a nursing assistant?

• Admitting a new client with multiple bruises over the

upper thighs

• Assisting a client with chronic joint stiffness to ambulate
• Making hourly assessments on a client with delirium

and dementia

• Monitoring a confused client who has been placed in a

jacket restraint

Answer: B. Assisting a client with chronic joint stiffness to ambulate

Rationale: Nursing assistant education and scope of practice include ambulation

of stable clients. The other nursing actions require broader education and scope of practice and should be done by licensed nurses. Admission of a new client who has clinical manifestations that may have been caused by abuse is the responsibility of the RN. The RN should assess the client with acute problems such as delirium and dementia. LPN/LVN education and scope of practice include monitoring, re-positioning, and toileting of clients who require restraints.The nurse is talking to a group of active senior citizens about making healthy lifestyle choices. Which suggestion is most important in promoting health and safety?

• "Continue to eat healthy foods, especially protein."
• "Seek counseling for depression, because it is not a

normal part of aging."

• "Stop driving when your vision, motor skills, and

confidence begin to diminish."

• "Walk 30 minutes three to five times a week."

Answer: C. "Stop driving when your vision, motor skills, and confidence begin to diminish."

Rationale: Motor vehicle crashes are the most common cause of injury-related

death for those between 65 and 74 years of age. To promote health and safety, driving should be discontinued when vision, reflexes, or confidence begin to suffer. Eating healthy foods and exercise promote health but not safety.Encouraging good mental health promotes well-being but not safety.

An older adult client who lives with her daughter is admitted to the hospital. During the admission assessment, the nurse notes strong body odor, several large pressure ulcers, and limb contractures. What does the nurse do first?

• Asks the daughter about the ulcers and contractures
• Contacts the hospital social worker
• Gives the client a bath
• Notifies the health care provider

Answer: B. Contacts the hospital social worker

Rationale: The social worker will assess the client's situation and will contact the appropriate authorities if needed. Asking the daughter sets up a potential confrontation that need not be handled by the nurse. The client should be given a bath, but this is not the first action to be taken. Notifying the health care provider will be appropriate at a later time, but is not the best action to take at this point.The licensed practice nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first?

• 84-year-old man recently admitted with pneumonia,

RR 28, SpO2 89%

• 54-year-old woman admitted after surgery for

fractured arm, BP 160/86 mm Hg, HR 72

• 63-year-old man with venous ulcers from diabetes,

temperature 37.3° C (99.1° F), HR 84

• 77-year-old woman with left mastectomy 2 days ago,

RR 22, BP 148/62

Answer: A. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%

Rationale: SpO2 89% is a critical value and requires immediate attention. Other

values require attention but are not life threatening.A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 lbs. Her

vital signs on admission are: HR 112, BP 138/82, RR 22,

tympanic temperature 36.8° C (98.2° F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy?

A. Temperature: 37° C (98.6° F)

B. Radial pulse: 112

C. Respiratory rate: 24

D. Oxygen saturation: 96%

E. Blood pressure: 134/78

Answer: D. Oxygen saturation: 96%

Rationale: Oxygen saturation is an assessment of oxygen perfusion. Respiratory

rate assesses ventilation, radial pulse and blood pressure assess the cardiovascular system, and temperature is an assessment of thermal regulation.The nurse observes a nursing student taking a blood pressure (BP) on a patient. The nurse notes that the student very slowly deflates the cuff in an attempt to hear the sounds. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. Which of the following BP readings made by the student is most likely caused by an incorrect technique?

• 96/40 mm Hg
• 110/66 mm Hg
• 130/90 mm Hg
• 156/82 mm Hg

Answer: C. 130/90 mm Hg

Rationale: Deflating the cuff too slowly will result in a false-high diastolic blood pressure.Which patient is at highest risk for tachycardia?

• A healthy basketball player during warmup exercise
• A patient admitted with hypothermia
• A patient with a fever of 39.4° C (103° F)
• A 90-year-old male taking beta blockers

Answer: C. A patient with a fever of 39.4° C (103° F)

Rationale: Fever elevates metabolism by 10%, resulting in an increased heart rate to remove the heat produced. Hypothermia and beta blockers decrease heart rate. Healthy athletes have a lower heart rate as a result of conditioning.