NCSBN NCLEX QUESTIONS

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NCSBN NCLEX QUESTIONS

408 terms ANNEMARIEBISHOP Preview NCLEX Practice Questions Exam 1 40 terms J_NavPreview PEARS 199 term Can nurse does ED triage. unemancipated minor requests treatment. registration clerk states they need guardian's consent for treatment. which is the nurse's next action?

• triage after guardian consent obtained
• ask minor about medical reason for seeking treatment
• request HCP perform medical screening exam
• notify nursing supervisor

ask the minor about the medical reason for seeking treatment (wrong, picked d) rationale: unemancipated minors may consent to medical treatment if they have specific medical conditions- pregnancy/STI/substance abuse/mental health, not appropriate for nurse to notify nursing supervisor before assessing situation and determining whether consent is required nurse makes med surg unit assignments. LPN assigned to client with localized herpes zoster. LPN tells nurse "i have never had chickenpox" which response by nurse is most appropriate?

• use standard precautions when caring for this pt
• you will be fine, airborne precautions needed
• your client assignment will be changed
• why are you concerned about providing care for this pt?

your client assignment will be changed (wrong, picked a) rationale: localized herpes zoster is shingles, if you care for pt with herpes zoster you could get chickenpox from them

caring for pregnant and postpartum pts. which client does the nurse see 1st?

• 6wks gestation, LPN can't get fetal heart tones with doptone
• 5 days postpartum, bright red bloody discharge
• 22 wks gestation, feels fetal movement 4times per hour
• 2 days postpartum, has urinary incontinence
• days postpartum pt reporting bright red, blood discharge (correct)

rationale: bloody discharge (rubra lochia) should only last 1-3 days - need to monitor amount and color in addition to vital signs, fetal heart tones can't be heard until 8-12 wks, less than 3 fetal movements in 1 hour could indicate fetal issue, urinary incontinence is normal during postpartum- teach kegels pt has CLL is scheduled for bone marrow aspiration and biopsy. pt says, "i'm frightened i haven't had this test before and i don't know what to expect" which statements will nruse include when responding to pt's concerns? SATA

• we will move you to operating room where test is always performed
• bone in the front of the chest will be used for biopsy
• a tight pressure dressing will be placed over test site after procedure
• you will not feel any discomfort as the local anesthetic is injected
• risk of bleeding present, so will monitor test site frequently

tight pressure dressing placed over testing site after procedure & there is a risk of bleeding, so we will monitor the test site frequently rationale: bone marrow aspiration/biopsy can be done in pt room or a treatment room not OR, don't use sternum for biopsy, pressure dressing helps with bleeding, sting/discomfort during biopsy, can cause bleeding nurse speaks with pt and spouse who have been undergoing family counseling. pt's spouse states " you never take any responsibility for the messes you always cause" which response by nurse is best?

• why do you say that?
• blaming is not effective
• let's focus only on positives
• when is the last time you two had a vacation

blaming isn't effective (wrong, picked c) rationale: don't ask why, telling them blaming isn't effective helps keep focus on both people, "only" isn't a good word pt diagnosed with malnutrition has continuous enteral feedings through newly placed gastrostomy tube. which actions will nurse include in plan of care? SATA

• cover insertion site with adhesive bandage
• add 8 hours of feeding to bag at a time
• rotate gastrostomy tube 360 degrees once daily
• auscultate for whoosh of air through gastrostomy tube
• check for slight in and out movement of gastrostomy tube

rotate gastrostomy tube 360 degrees once daily & check for slight in and out movement of gastrostomy tube rationale: insertion site should be covered with sterile bandage to reduce infection risk until stoma is healed, only 4 hours of enteral feeding added to bag at a time to reduce bacterial contamination, rotate 360 degrees daily to reduce risk of skin irritation and breakdown, don't insert air for gastrostomy rube assessment, slight in/out indicates tube isn't embedded in wall of stomach

nurse asses pt for potential spousal abuse. nurse is most concerned if pt makes which statement?

• it's my fault because I push my spouses buttons
• my spouse and i often disagree on many things
• we have talked about divorce multiple time
• i used to be so happy, but now I am not

it's my fault because i push my spouse's buttons (correct) rationale: spousal abuse victim accept blame often and feel helpless and compliant, should also follow up on option D but not the most concerning thing nurse has guillian barre pt. flaccid paralysis of both legs, history of coronary artery bypass 3 wks ago, 20 yr history of HTN and high cholesterol, recently diagnosed with T2DM. nurse prepares to apply anti-embolism stockings to both legs. which priority action does nurse implement?

• bilateral pretibial edema
• palpate both calves for pain
• ask the reason for stocking application
• bilateral pedal pulse strength

bilateral pedal pulse strength (correct) rationale: some edema is expected when immobile and stocking will reduce the edema, VTE would be a contraindication for stocking but calf pain isn't always present with DVT and pain is a psychosocial idea, best indication of peripheral arterial disease and circulation is to monitor pedal pulses, decreased circulation would be contraindicated for stocking so need to assess ASAP pt approaches traige desk reporting exposure to chemicals after truck overturn. pt has powder and unknown liquid substance on clothes. pt is diaphoretic and having difficulty breathing. which action does nurse take first?

• escort pt to decontamination room
• notify HCP
• put on appropriate PPE
• deliver high flow oxygen via mask

put on appropriate PPE (wrong, picked a) rationale: first priority is to protect self with PPE, then escort to room to prevent spread, then call HCP, then oxygen 50mg/kg ampicillin every 6 hours. 18 lbs. available in 125mh/5ml. how many ml per dose?16 ml most appropriate place to obtain capillary glucose sample?outside of pointer finger

During a urinary bladder catheter insertion with a size 16 catheter on the 68-year-old male, the nurse feels increased resistance. Which is the most appropriate action for the nurse to take?

• Withdraw the catheter and apply more lubricant.
• Instruct the client to take a deep breath and bear down.
• Stop catheter insertion and instruct client to take deep breaths.
• Withdraw the catheter and notify the health care provider.

stop insertion and instruct pt to take deep breaths (Correct) rationale: take deep breaths will relax urethral muscles and allow passage through prostate gland, valsalva maneuver will not allow passage, don't complete withdraw cath and then re-insert this increases risk of infection, determine is there is an issue before calling HCP ED assess pt with tonic clonic epilepsy. pt's spouse says pt is taking phenytoin as prescribed, but hasn't been feeling well lately. which pt observation is most concerning?

• red brown urine, constipation
• acne, hirsutism, gingival hyperplasia
• ataxia, slurred speech, nystagmus
• left arm in sling, walking with limp

ataxia, slurred speech, nystagmus (wrong, picked b) rationale: slurred speech and ataxia are airway concerns = highest priority over anything else pt on IV midazolam after procedure. blood pressure is increasing, oxygen sats falling, now 1/10 pain and nausea, arouses to commands now.best action?

• recheck BP in 15 mins
• administer ondansetron
• 12 lead EKG
• assist client to get dressed

recheck BP in 15 mins (wrong, picked b) rationale: midazolam causes hypotension and the elevated BP puts patient at risk for stroke, appropriate to assess BP every 15 mins because it is still increasing = priority nurse admits pt postpartum, instruction about postpartum care have been effective if which statement is given?

• i will call for assistance the first time i want to get out of bed
• i can expect to pass clots the size of golf balls for the first 24 hrs
• i will use lanolin on my nipple while breast feeding the baby
• i will allow my baby to not suck on nipple for more than 5 mins each breast

i will call for assistance the first time I want to get out of bed (wrong, picked b)

rationale: want clots to be smaller than a golf ball,