NCSBN NCLEX QUESTIONS

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NCSBN NCLEX QUESTIONS

408 terms ANNEMARIEBISHOP Preview NCLEX 110 term kan A nurse prepares to collect a blood specimen from a client. Which client identifiers does the nurse use before obtaining the sample?

• The client's date of birth
• The client's full name
• The medical record number

A client with leukemia is admitted for blood transfusions. Which data does the nurse recognize as increasing the client's risk of falls?

• The client reports having stress incontinence
• The client has a history of Parkinson disease.
• The client is prescribed diphenhydramine prior to the transfusion.
• The client uses a cane at home when ambulating.
• The client reports having fallen at home last week.
• The client has a history of Parkinson disease.
• The client is prescribed diphenhydramine prior to the transfusion.
• The client reports having fallen at home last week.

A client on the orthopedics floor after a knee replacement is prescribed a patient-controlled analgesia (PCA) pump with morphine. Which data indicates to the nurse that the client is experiencing an adverse response to the prescribed therapy?

Select All That Apply:

The client has a respiratory rate of 8 breaths/min.The client reports nausea and vomiting.The client reports pain of 9/10.The client has a blood pressure of 140/88 mmHg.The sleeping client is very difficult to arouse.

• The client has a respiratory rate of 8 breaths/min.
• The sleeping client is very difficult to arouse.

Adverse reactions to opioid medications include respiratory depression and decreased level of consciousness. They suggest that the client has received too much medication. If the respiratory depression is accompanied by a decreased level of consciousness, naloxone may be prescribed. High pain rating and high blood pressure are not associated with morphine PCA. Nausea and vomiting, along with constipation, are side effects of morphine, not adverse reactions.A facility uses the charting-by-exception method of documentation. When documenting physical data findings, which client finding allows the nurse to select "within defined limits"?Absent bowel sounds in left lower quadrant Apical pulse 72 beats/min. with systolic murmur Lung sounds clear in all fields 2+ bilateral pitting edema to mid-calf Lung sounds clear in all fields A client is prescribed restraints due to serious risk of harming themselves or others. Which items does the nurse include with documentation of the use of the restraints?

• That food, drink, and toileting were offered
• That the client refused the restraints
• That range of motion to the extremities was restrained
• That the client's behavior necessitated restraints
• The type, number, and location of restraints
• That food, drink, and toileting were offered
• That range of motion to the extremities was restrained
• That the client's behavior necessitated restraints
• The type, number, and location of restraints

A client two days after a hip replacement reports feeling bloated and that it has been two days since having a bowel movement. Which prescribed PRN medication does the nurse administer?Oxycodone 5 mg PO Docusate sodium 100 mg PR Magnesium hydroxide 400 mg PO Ondansetron 4 mg PO

• Magnesium hydroxide 400 mg PO

Magnesium hydroxide is a laxative that works by drawing water into the bowel and promoting peristalsis. This is the best first choice for a PRN medication for a client who has not had a bowel movement in two days. If the magnesium hydroxide does not work, the nurse can select the more invasive rectal suppository as the next choice.

A health care provider has prescribed amoxicillin 50 mg/kg/day every 12 hours for a toddler client who weighs 16 kg. The medication label reads "400 mg/5 mL." How many mL does the nurse administer for each dose? (Round to the nearest whole number.)

• mL

16 kg × 50 mg/kg = 800 mg per day. 2 doses = 400 mg per dose. Medication supplied is 400 mg/5 mL. The toddler receives 5 mL with each dose.During transfusion of RBCs, a client reports, "I feel have a rash and I itch everywhere." The nurse takes these actions in what order? (Place each option in order from first to last.)

• Stop the transfusion.
• Obtain vital signs.
• Administer PRN diphenhydramine.
• Notify the health care provider.

Explanation The symptoms of rash and itching are suggestive of an allergic blood transfusion reaction. The client is not exhibiting symptoms of anaphylaxis, such as wheezing and throat swelling, which would be a much more concerning allergic reaction. The nurse should first stop the blood transfusion. Prior to administering the prescribed antihistamine, the nurse should verify that the vital signs are stable. The health care provider would be notified after the diphenhydramine is given.When administering an older client's prescribed antibiotic, the client tells the nurse, "I don't want to take it." The adult child at the bedside instructs the nurse to give the client the medication. What action does the nurse take?Verify that the client understands the risks of withholding the medication.A client admitted with community-acquired pneumonia now reports feeling "much better." Which data collected by the nurse verifies this report?

• Completion of the prescribed ceftriaxone
• Harsh, non-productive cough
• Oxygen saturation 92% on 1 L/min. of oxygen
• WBC count of 8,000/mm3

WBC count of 8,000/mm3 A client with diabetes asks why the health care provider is checking kidney function before starting the prescribed metformin. Which response by the nurse is correct?"Metformin lowers blood sugars by decreasing glucose production in the liver but is contraindicated for clients with kidney disease." Metformin works by decreasing glucose production in the liver and is the most commonly used oral drug for the treatment of type 2 diabetes. It is contraindicated in clients with renal dysfunction, so health care providers will verify kidney function in clients with diabetes before prescribing the medication. Kidney disease is a common complication of diabetes.

A nurse has been caring for a client with advanced lung cancer for weeks when the client decides to discontinue treatment. The nurse accepts the client's choice using which ethical principle?Autonomy Nonmaleficence Veracity Fidelity

• Autonomy

*Autonomy is an ethical principle that states clients have a right to self-determination and to control choices about their health care.During assessment of a newly admitted client, a nurse notes a stage II pressure ulcer on the coccyx. The ulcer is 2 cm × 4 cm × 1 cm with a scant amount of drainage. Which dressing does the nurse place on the ulcer?Transparent adhesive film dressing Transparent adhesive film dressings are used for stage I and stage II pressure ulcers with little or no exudate. Because it is a semipermeable dressing, vapor can escape and oxygen can enter to reduce the chance of anaerobic bacterial growth. The dressing should be changed when fluids build up or when the dressing becomes loose.The client is prescribed sertraline 100 mg daily, morphine sulfate SR 30 mg twice per day, and ferrous sulfate 300 mg via a gastronomy tube.Which actions does the nurse take when administering the medications?

• Check the client's gastric aspirate pH.
• Determine the compatibility of medications.
• Flush with 15 mL of water between medications.

A nurse is assigned a group of clients. Which clients does the nurse recognize as being at risk for alterations in urinary elimination?

• An older adult admitted with heart failure on furosemide
• A school-aged child admitted with diabetic ketoacidosis on insulin
• A toddler admitted with pneumonia on levofloxacin
• A middle-aged client admitted with a deep vein thrombosis on enoxaparin.
• An adolescent admitted for knee surgery on morphine
• An older adult admitted with heart failure on furosemide
• A school-aged child admitted with diabetic ketoacidosis on insulin
• A toddler admitted with pneumonia on levofloxacin
• An adolescent admitted for knee surgery on morphine

The nurse is assigned several clients. Which clients are at risk of developing a deep vein thrombosis (DVT)?

• An adolescent with a history of hemophilia
• A middle-aged client who is an over-the-road truck driver
• A young adult client who is two weeks postpartum
• A school-age child with exacerbation of asthma
• An older adult client with open reduction and internal fixation of a fractured hip
• A middle-aged client who is an over-the-road truck driver
• A young adult client who is two weeks postpartum
• An older adult client with open reduction and internal fixation of a fractured hip