NEW 2022 NCLEX-RN PRACTICE TEST WITH COMPLETE

NEW 2022 NCLEX-RN PRACTICE TEST WITH COMPLETE

SOLUTION

A client is admitted to the emergency department (ED). The family reports the client had a sudden onset of left-sided facial droop and slurred speech at home. The nurse observes left-sided muscle weakness. Which is the most important question for the nurse to ask?

• "What over-the-counter medications does your parent take?"
• "What was your parent doing when the symptoms began?"
• "When did you notice the onset of your parent's symptoms?"
• "Does your parent have a history of high blood pressure?" - answerCorrect: 3

Rationale: Time is of the essence when providing care to a client who experiences ischemic stroke, as thrombolytic therapy is only effective for 4.5 to 6 hours from onset of sx. This is the priority assessment question as thrombolytic therapy can restore circulation for this client.

2:A hemorrhagic stroke may be precipitated by strenous activity. This question is important to differentiate whether the client is experiencing a hemorrhagic or ischemic stroke but not the priority.

4: HTN or high blood pressure is a common risk factor for all types of stroke. Although this is an appropriate assessment question, it does not address the here and now.

The nurse meets with the parent of an adolescent male who presents for an annual health maintenance visit. The parent voices concern that the child has recently become clumsy and uncoordinated. Which response by the nurse is correct?

• "Your son might have attention deficit hyperactivity disorder."
• "I'll talk with the health care provider about assessing for subtle motor dysfunction."
• "Your son's clumsiness is expected at this age."

4. "This may be an early sign of depression." - answerCorrect: 3

Rationale: Adolescent males experience a rapid rate of physical growth, which can cause clumsiness and a lack of coordination. This statement is accurate and addresses the parent's concern.

1,4: This is a false statement about clumsiness and lack of coordination in adolescent males, as these manifestations are not associated with attention deficit hyperactivity disorder (ADHD) nor depression. Therefore, this response by the the nurse is not correct.

2: Inappropriate for the nurse tos uggest to HCP the need to assess for subtle motor dysfunction.

*The client diagnosed with chronic lymphocytic leukemia (CLL) is scheduled for a bone marrow aspiration and biopsy. The client says, "I am frightened. I have never had this test before, and I don't know what to expect." Which statements will the nurse include when responding to the client's concerns? (Select all that apply.)

• "We will move you to the operating room where the test is always performed."
• "The bone in the front of your chest will be used for the biopsy specimen."
• "A tight pressure dressing will be placed over the test site after the procedure."
• "You will not feel any discomfort as the local anesthetic is injected."
• "There is a risk of bleeding, so we will monitor the test site frequently." - answerCorrect: 3,4

Rationale: A bone marrow biopsy can cause bleeding and a pressure dressing is applied to reduce the risk of bleeding. Therefore, both are accurate and appropriate for the nurse t o include in teaching.

1: BMA/biopsy may be done in a client room or treatment room. OR is not required.

2: Sternum may be used for BMA but not enough marrow available for biopsy.

4: Client will feel some stinging and discomfort during bone marrow biopsy. This is false

reassurance.

*The LPN/LVN reporting to the nurse says, "You may want to see the client recently diagnosed with pancreatic cancer. I am not sure how well things are going." The nurse enters the room and finds the client sitting quietly, looking out the window. As the nurse approaches the client, the client does not look at the nurse. Which is the most appropriate response by the nurse?

• "Sleep problems are common during times of stress. Have you had difficulty sleeping?"
• "Tell me what you know about your diagnosis and the treatment you will receive."
• "How would you describe your overall health status up to this time of your life?"
• "How have you handled any health problems you experienced in the past?" - answerCorrect: 2

Rationale: MOST imp't to determine client's perception of the health problem. Open-ended statement.

Strategy: need to address the problem and better to ask open-ended questions. It is more imp't to deal with the here and now.

*The nurse provides care for the client immediately after arrival in the emergency department (ED). Emergency personnel report that the client was involved in a head-on collision with immediate loss of consciousness. Which is the first action taken by the nurse?

• Determine Glasgow Coma Scale (GCS) score.
• Assess bilateral blood pressure.
• Check bilateral pupillary response to light.

4. Determine oxygen saturation levels. - answerCorrect: 4

Rationale: When prioritizing care for a client, nurse uses the ABC's (airway, breathing, circulation). Oxygen saturation levels allow the nurse to monitor the client's airway (priority).

1: GCS is used to assess ABC and neuro status for clients c head trauma. It is appropriate but too broad and will take longer.

2: Assessing BP is monitoring for circulation. However, airway is priority and increases in arterial CO2 will increase ICP.

3: Nurse assesses neuro status (eg. PERRLA) after ABC.

At a rehabilitation center for clients with spinal cord injuries (SCIs), the nurse conducts an orientation session for a group of unlicensed assistive personnel (UAP). Which statement is most important for the nurse to include?

• "The clients may appear angry at times."
• "Obtain the client's permission before touching the client."
• "Most clients arrive believing they will walk out of here."
• "Personnel in this environment often need counseling." - answerCorrect: 2

Rationale: This statement provides the UAP c info needed to provide care for a client c SCI.Therefore, this isa priority when delegating tasks to the UAP who provides client care.

1,3,4: MAY be true but does not provide info regarding care for SCI patients.

*The home care nurse instructs a client diagnosed with multiple sclerosis (MS). The client states, "I have poor concentration and difficulty pronouncing words." The nurse notes that the client's speech is slow and slurred. Which client statement indicates to the nurse that further teaching is necessary?

• "I will sit up straight when I talk and will feel confident."
• "I will turn off the TV when speaking and look at the person with whom I am talking."
• "During a conversation, I will carefully build up to my most important points."

4. "If words fail me, I will draw a picture." - answerCorrect: 3

Rationale: Verbal communication often causes fatigue for MS clients. Therefore, client is taught to