NCLEX RN Comprehensive Review (Exam Mode) By RNpedia.Com

1. The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention?

Decrease in level of consciousness

Loss of bladder control

Altered sensation to stimuli

Emotional ability

A further decrease in the level of consciousness would be indicative of a further progression of the CVA.

Explanation

A further decrease in the level of consciousness would be indicative of a further progression of the CVA.

2. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should:

Place a call to the client’s health care provider for instructions

Send him to the emergency room for evaluation

Reassure the client’s wife that the symptoms are transient

Instruct the client’s wife to call the doctor if his symptoms become worse

This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client’s best interest.

Explanation

This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client’s best interest.

3. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?

Blood pressure 94/60

Heart rate 76

Urine output 50 ml/hour

Respiratory rate 16

Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100; systolic B/P over 100) in order to safely administer both medications.

Explanation

Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100; systolic B/P over 100) in order to safely administer both medications.

4. A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is:

Start a peripheral IV

Initiate closed-chest massage

Establish an airway

Obtain the crash cart

Establishing an airway is always the primary objective in a cardiopulmonary arrest.

Explanation

Establishing an airway is always the primary objective in a cardiopulmonary arrest.

5. The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurse's immediate attention?

I have bad muscle spasms in my lower leg of the affected extremity.

"I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger."

"I have to use the bedpan to pass my water at least every 1 to 2 hours."

"It seems that the pain medication is not working as well today."

The nurse would be concerned about all of these comments. However the most life threatening is answer choice "I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.". Clients who have had hip or knee surgery are at greatest risk for development of post operative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Answer choice "I have to use the bedpan to pass my water at least every 1 to 2 hours." may indicate a urinary tract infection. answer choice "It seems that the pain medication is not working as well today." requires further investigation and is not life threatening.

Explanation

The nurse would be concerned about all of these comments. However the most life threatening is answer choice "I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.". Clients who have had hip or knee surgery are at greatest risk for development of post operative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Answer choice "I have to use the bedpan to pass my water at least every 1 to 2 hours." may indicate a urinary tract infection. answer choice "It seems that the pain medication is not working as well today." requires further investigation and is not life threatening.

6. A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:

Should be taken in the morning

May decrease the client’s energy level

Must be stored in a dark container

Will decrease the client’s heart rate

Thyroid supplement should be taken in the morning to minimize the side effects of insomnia

Explanation

Thyroid supplement should be taken in the morning to minimize the side effects of insomnia

7. Which individual is at greatest risk for developing hypertension?

45 year-old African American attorney

60 year-old Asian American shop owner

40 year-old Caucasian nurse

55 year-old Hispanic teacher

45 year-old African American attorney The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.

Explanation

45 year-old African American attorney The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.

8. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is

Verify correct placement of the tube

Check that the feeding solution matches the dietary order

Aspirate abdominal contents to determine the amount of last feeding remaining in stomach

Ensure that feeding solution is at room temperature

Proper placement of the tube prevents aspiration.

Explanation

Proper placement of the tube prevents aspiration.

9. While assessing a 1 month-old infant, which finding should the nurse report immediately?

Abdominal respirations

Irregular breathing rate

Inspiratory grunt

Increased heart rate with crying

Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant.

Explanation

Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant.

10. The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to

Achieve harmony

Maintain a balance of energy

Respect life

Restore yin and yang

For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang.

Explanation

For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang.

11. During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member?

At least 2 full meals a day is eaten.

We go to a group discussion every week at our community center.

We have safety bars installed in the bathroom and have 24 hour alarms on the doors.

The medication is not a problem to have it taken 3 times a day.

Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are correct statements. However, safety is most important to reinforce.

Explanation

Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are correct statements. However, safety is most important to reinforce.

12. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is

Maintain fluid and electrolyte balance

Control nausea

Manage pain

Prevent urinary tract infection

The immediate goal of therapy is to alleviate the client’s pain.

Explanation

The immediate goal of therapy is to alleviate the client’s pain.

13. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?

Narrowed QRS complex

Shortened "PR" interval

Tall peaked T waves

Prominent "U" waves

A tall peaked T wave is a sign of hyperkalemia. The health care provider should be notified regarding discontinuing the medication.

Explanation

A tall peaked T wave is a sign of hyperkalemia. The health care provider should be notified regarding discontinuing the medication.

14. A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?

All striated muscles

The cerebellum

The kidneys

The leg bones

Rhabdomyosarcoma is the most common children”s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word and is “myo” which typically means muscle.

Explanation

Rhabdomyosarcoma is the most common children”s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word and is “myo” which typically means muscle.

15. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?

Trichomoniasis

Chlamydia

Staphylococcus

Streptococcus

Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.

Explanation

Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.

16. Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test?

Client must be NPO before the examination

Enema to be administered prior to the examination

Medicate client with Lasix 20 mg IV 30 minutes prior to the examination

No special orders are necessary for this examination

No special preparation is necessary for this examination.

Explanation

No special preparation is necessary for this examination.

17. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?

Angina at rest

Thrombus formation

Dizziness

Falling blood pressure

Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure.

Explanation

Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure.

18. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question?

"You need to regain your strength before attempting such exertion."

"When you can climb 2 flights of stairs without problems, it is generally safe.”

"Have a glass of wine to relax you, then you can try to have sex."

"If you can maintain an active walking program, you will have less risk."

There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.

Explanation

There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.

19. The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?

Apply dressing using sterile technique

Improve the client’s nutrition status

Initiate limb compression therapy

Begin proteolytic debridement

The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other answers are correct, but without proper nutrition, the other interventions would be of little help.

Explanation

The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other answers are correct, but without proper nutrition, the other interventions would be of little help.

20. A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?

Prepare the child for x-ray of upper airways

Examine the child’s throat

Collect a sputum specimen

Notify the healthcare provider of the child’s status

These findings suggest a medical emergency and may be due to epiglottises. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.

Explanation

These findings suggest a medical emergency and may be due to epiglottises. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.

21. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to:

Increase fluids that are high in protein

Restrict fluids

Force fluids and reassess blood pressure

Limit fluids to non-caffeine beverages

Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.

Explanation

Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.

22. The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to:

Excessive fetal weight

Low blood sugar levels

Depletion of subcutaneous fat

Progressive placental insufficiency

The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia.

Explanation

The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia.

23. Which of these statements best describes the characteristic of an effective reward-feedback system?

Specific feedback is given as close to the event as possible

Staff are given feedback in equal amounts over time

Positive statements are to precede a negative statement

Performance goals should be higher than what is attainable

Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if the standards are clearly understood.

Explanation

Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if the standards are clearly understood.

24. When teaching a client with coronary artery disease about nutrition, the nurse should emphasize:

Eating 3 balanced meals a day

Adding complex carbohydrates

Avoiding very heavy meals

Limiting sodium to 7 gms per day

Eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease.

Explanation

Eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease.

25. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working?

The client complains of discomfort at the IV insertion site

The client states "I just can’t get relief from my pain."

The level of drug is 100 ml at 8 AM and is 80 ml at noon

The level of the drug is 100 ml at 8 AM and is 50 ml at noon

The minimal dose of 10 ml per hour which would be 40 ml given in a 4 hour period. Only 60 ml should be left at noon. The pump is not functioning when more than expected medicine is left in the container.

Explanation

The minimal dose of 10 ml per hour which would be 40 ml given in a 4 hour period. Only 60 ml should be left at noon. The pump is not functioning when more than expected medicine is left in the container.

26. A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which:

Increase the heart rate

Lead to dehydration

Are considered aerobic

May be competitive

The client must take in adequate fluids before and during exercise periods.

Explanation

The client must take in adequate fluids before and during exercise periods.

27. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs?

"I want to protect my child from any falls."

"I will set limits on exploring the house."

"I understand the need to use those new skills."

"I intend to keep control over our child."

Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.

Explanation

Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.

28. A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?

Raise the side rails on the bed

Place the call bell within reach

Instruct the client to remain in bedv

Have the client empty bladder

The first step in the process is to have the client void prior to administering the pre-operative medication.

Explanation

The first step in the process is to have the client void prior to administering the pre-operative medication.

29. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states "My blood pressure is usually much lower." The nurse should tell the client to

Go get a blood pressure check within the next 48 to 72 hours

Check blood pressure again in 2 months

See the health care provider immediately

Visit the health care provider within 1 week for a BP check

The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke. However immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.

Explanation

The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke. However immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.

30. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response?

Electrical energy fields

Spinal column manipulation

Mind-body balance

Exercise of joints

The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation.

Explanation

The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation.

31. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?

An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room

Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 10 exhibits opoid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future.

Explanation

Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 10 exhibits opoid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future.

32. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation?

Polyphagia

Dehydration

Bed wetting

Weight loss

In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents.

Explanation

In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents.

33. A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?

Gravida 4 para 2

Gravida 2 para 1

Gravida 3 para 1

Gravida 3 para 2

Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).

Explanation

Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).

34. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first?

Gastric lavage PRN

Acetylcysteine (mucomyst) for age per pharmacy

Start an IV Dextrose 5% with 0.33% normal saline to keep vein open

Activated charcoal per pharmacy

Gastric lavage PRN Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids.

Explanation

Gastric lavage PRN Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids.

35. What would the nurse expect to see while assessing the growth of children during their school age years?

Decreasing amounts of body fat and muscle mass

Little change in body appearance from year to year

Progressive height increase of 4 inches each year

Yearly weight gain of about 5.5 pounds per year

Yearly weight gain of about 5.5 pounds per year School age children gain about 5.5 pounds each year and increase about 2 inches in height.

Explanation

Yearly weight gain of about 5.5 pounds per year School age children gain about 5.5 pounds each year and increase about 2 inches in height.

36. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission?

An elderly client with a history of hypertension, hypercholesterolemia and lupus, and was admitted with Stevens-Johnson syndrome that morning

An adolescent with a positive HIV test and admitted for acute cellulitus of the lower leg 48 hours ago

The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.

Explanation

The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.

37. A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time?

Positive sweat test

Bulky greasy stools

Moist, productive cough

Meconium ileus

Moist, productive cough is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.

Explanation

Moist, productive cough is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.

38. A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure:

Right heart function

Left heart function

Renal tubule function

Carotid artery function

The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. The pressure readings are inferred from pressure measurements obtained on the right side of the circulation. Right-sided heart function is assessed through the evaluation of the central venous pressures (CVP).

Explanation

The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. The pressure readings are inferred from pressure measurements obtained on the right side of the circulation. Right-sided heart function is assessed through the evaluation of the central venous pressures (CVP).

39. A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

A 2 month old infant with a history of rolling off the bed and has bulging fontanels with crying

A teenager who got a singed beard while camping

An elderly client with complaints of frequent liquid brown colored stools

A middle aged client with intermittent pain behind the right scapula

A client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.

Explanation

A client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.

40. A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?

Weight gain of 5 pounds

Edema of the ankles

Gastric irritability

Decreased appetite

Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias.

Explanation

Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias.