NURSING STUDENTS - Which of these nursing actions will you impleme...

NCLEX-RN

ASSESSMENT FOR

NURSING STUDENTS

VERSION 2

2023/2024

• While working in the ICU, you are assigned to care for a patient with a seizure disorder.

Which of these nursing actions will you implement first if the patient has a seizure? Turn the patient to the side and protect the airway.

• A patient on the cardiac telemetry unit unexpectedly goes into ventricular fibrillation.

The advanced cardiac life support team prepares to defibrillate. Which of the following choices indicates the correct placement of the conductive gel pads? The right side of the sternum just below the clavicle and left of the precordium.

• A client with fever and urinary urgency must provide a urine specimen for culture and

sensitivity. The nurse should instruct the client to collect the specimen from the: middle stream of urine from the bladder

• Androgens are medically indicated in the management of all of the following except:

Bodybuilding

• A six-month-old infant has been admitted to the emergency room with febrile seizures. In

the teaching of the parents, the nurse states that: . There is little risk of neurological deficit and mental retardation as sequelae to febrile seizures

• A nurse is calculating a client's intake and output. During the last shift, the client has had

½ cup of gelatin, a skinless chicken breast, 1 cup of green beans, and 300 cc of water.The client has urinated 250 cc and has had 2 bowel movements. What is this client's intake and output for this shift? 420 cc intake, 250 cc output

• A client has an advance directive. How do you explain this to the client's? family? Say

that the advance directive is a legal document allowing the client to express his or her wishes in certain death situations

• In the client with a diagnosis of coronary artery disease, the nurse would anticipate the

complication of bradycardia with occlusion of which coronary artery? . Right coronary artery

• A nurse is administering a shot of Vitamin K to a 30 day-old infant. Which of the

following target areas is the most appropriate? Vastus lateralis

• A patient recently started on phenytoin (Dilantin) to control simple complex seizures is

seen in the outpatient clinic. Which information obtained during his chart review and

assessment will be of greatest concern? The white blood cell count is 2300/mm3

• The nurse performs an initial abdominal assessment on a patient newly admitted for

abdominal pain. The nurse hears what she describes as “clicks and gurgles in all four quadrants” as well as “swishing or buzzing sound heard in one or two quadrants.” Which of the following statements is correct? The frequency and intensity of bowel sounds varies depending on the phase of digestion. o B. In the presence of intestinal obstruction, bowel sounds will be louder and higher pitched. o C. A swishing or buzzing sound may represent the turbulent blood flow of a bruit and is not normal.

• A client is to receive a glycerin suppository. Which nursing action is appropriate when

administering a suppository? Applying a lubricant to the suppository

• A patient is taking insulin glargine injection daily. The nurse instructed the client that the

onset of action will likely happen? 2-4 hours after administration