NCLEX Practice Questions and Answers, Exams of Nursing

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A 34-year-old woman who developed Stevens-Johnson syndrome while undergoing treatment with carbamazepine (Tegretol) is being transferred in stable condi�on from the intensive care unit to the medical unit. There are 4 beds available. The nurse knows the best choice of roommates for this client is which of the following?

(a) A 40-year-old man with methicillin-resistant Staphylococcus aureus (MRSA).

(b) A 28-year-old woman diagnosed with diarrhea.

(c) A 72-year-old man with fever of unknown origin.

(d) A 68-year-old woman with atrial fibrilla�on. - ansCorrect answer: (d) A 68-year-old woman with atrial fibrilla�on.

Ra�onale: A client with Stevens-Johnson syndrome is likely to have severe skin integrity issues, including blistering and skin shedding, which can place the client at high risk for infec�on. Atrial fibrilla�on is not an infec�ous process. All other pa�ents may be an infec�on risk for an individual with altered skin integrity.

A 72-year-old man who had a stroke is being transferred from a medical unit to a rehabilita�on centre. The nurse case manager is assis�ng in the process. The nurse knows that the goals of case management include which of the following? Select all that apply.

(a) Improving the coordina�on of care

(b) Increasing referrals to local organiza�ons

(c) Reducing the fragmenta�on of care

(d) Discharging clients quickly - ansCorrect answer: (a) Improving the coordina�on of care; and (c) Reducing the fragmenta�on of care

Ra�onale: Some of the primary goals of case management are to improve the coordina�on of care and to reduce fragmenta�on of care. The other op�ons are not goals of case management.

A nursing team consists of an RN, an LPN/ LVN, and a nursing assistant. The nurse should assign which of the following pa�ents to the LPN/LVN?

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(a) A 72-year-old pa�ent with diabetes who requires a dressing change for a stasis ulcer.

(b) A 42-year-old pa�ent with cancer of the bone complaining of pain.

(c) A 55-year-old pa�ent with terminal cancer being transferred to hospice home care.

(d) A 23-year-old pa�ent with a fracture of the right leg who asks to use the urinal. - ansCorrect answer: (a) A 72-year-old pa�ent with diabetes who requires a dressing change for a stasis ulcer.

Ra�onale: LPN/LVNs assist with implementa�on of care; performs procedures; differen�ates normal from abnormal; cares for stable pa�ents with predictable condi�ons; has knowledge of asepsis and dressing changes; administers medica�ons. Pa�ent (a) is stable with an expected outcome. Pa�ents (b) and (c) require assessment and nursing judgement; and Pa�ent (d) involves a standard unchanging procedure that can be assigned to the nursing assistant.

A pregnant woman at 15 weeks' gesta�on is scheduled for an amniocentesis. As the client is being prepped for the procedure, it becomes clear to the nurse that the client doesn't fully understand the risks and benefits associated with the procedure. Which of the following describe the nurse's role in obtaining informed consent? Select all that apply.

(a) Explain the risks and benefits associated with the procedure.

(b) Describe alterna�ves to the procedure.

(c) Witness the client's signature on the consent form.

(d) Advocate for the client by ensuring she is making an informed decision. - ansCorrect answer: (c) Witness the client's signature on the consent form; and

(d) Advocate for the client by ensuring she is making an informed decision.

Ra�onale: Some of the nurse's roles in the informed consent process are to witness the signature on the consent form, and to advocate for the client by ensuring she has been provided the necessary informa�on to make an informed decision. It is the physician's duty to provide informa�on to the client- related risks and benefits, and to provide alterna�ves.

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A registered nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant?

(a) A client requiring colostomy irriga�on

(b) A client receiving con�nuous tube feedings

(c) A client who requires stool specimen collec�ons

(d) A client who has difficulty swallowing food and fluids - ansCorrect answer: (c) A client who requires stool specimen collec�ons

Ra�onale: This ques�on addresses content related to delega�on in the subcategory Management of Care in the Client Needs category of Safe and Effec�ve Care Environment. Work that is delegated to others must be done consistent with the individual's level of exper�se and licensure or lack of licensure. In this situa�on, the most appropriate assignment for the nursing assistant is to care for the client who requires stool specimen collec�ons. Colostomy irriga�ons and tube feedings are not performed by unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for aspira�on. Remember, the health care provider needs to be competent and skilled to perform the assigned task or ac�vity.

A well-known actor has been admited to an ambulatory surgical unit. The nurse no�ces a staff member who is not involved in the client's care reading his medical record. The nurse knows she should FIRST do which of the following?

(a) Nothing. The staff member has a hospital ID badge and is authorized to read the medical record.

(b) Inform the staff member that without a legi�mate need for the informa�on, staff should not be reading the medical record.

(c) Tell the client his medical records have been read by an unauthorized individual.

(d) Page the physician and ask if it's acceptable for the staff member to access the medical records. - ansCorrect answer: (b) Inform the staff member that without a legi�mate need for the informa�on, staff should not be reading the medical record.

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Ra�onale: An individual not involved in the care of the client does not have a legi�mate need to access the medical record. The nurse should protect the client's right to privacy by ensuring only authorized individuals access medical records.

A�er receiving report at the start of the evening shi�, which of the following clients should the nurse atend to first?

(a) A 34-year-old man undergoing treatment for non-Hodgkin lymphoma with a potassium level of 7. mEq/L.

(b) A 21-year-old woman with sickle cell anemia with pain of 6 on a scale of 1-10.

(c) A 55-year-old woman with ovarian cancer wai�ng to be discharged.

(d) A 72-year-old man with chronic obstruc�ve pulmonary disease (COPD) and a pulse oximetry of 96% on room air. - ansCorrect answer: (a) A 34-year-old man undergoing treatment for non-Hodgkin lymphoma with a potassium level of 7.5 mEq/L.

Ra�onale: Hyperkalemia is a poten�ally serious condi�on that, in a client undergoing treatment for non- Hodgkin lymphoma, could indicate tumour lysis syndrome. Pa�ent (b) should be atended to, but her condi�on is not as urgent. Pa�ents (c) and (d) do not require immediate aten�on.

The nurse in a maternity unit is caring for a client who has just delivered twins. The client voices concern about her ability to manage when she gets home. Which of the following statements best illustrates quality care delivery by the nurse? Select all that apply.

(a) "Just focus on how lucky you are to have two healthy babies."

(b) "We can arrange for follow-up visits with a home health nurse."

(c) "Here is some informa�on on support groups for parents of mul�ples."

(d) "You will find it easier to formula-feed your babies at home." - ansCorrect answer: (b) "We can arrange for follow-up visits with a home health nurse."; and (c) "Here is some informa�on on support groups for parents of mul�ples."

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Ra�onale: A referral to home health care provides the client with opportuni�es for support and assistance during this transi�on; and a referral to support groups provides the client with opportuni�es for support and assistance during this transi�on. The other op�ons are not appropriate for a new mother expressing concerns about her ability to cope.

The nurse is caring for a client newly diagnosed with diabetes, and performs the following tasks. Place the tasks the nurse would perform in the appropriate order. All op�ons must be used.

(a) The nurse establishes a goal with the client to be able to self-administer insulin injec�ons.

(b) The nurse assesses the client's level of knowledge about how to administer insulin injec�ons.

(c) The nurse evaluates the client while self-administering insulin injec�ons.

(d) The nurse establishes the diagnosis of knowledge deficit. - ansCorrect answer:

(b) The nurse assesses the client's level of knowledge about how to administer insulin injec�ons.

(d) The nurse establishes the diagnosis of knowledge deficit.

(a) The nurse establishes a goal with the client to be able to self-administer insulin injec�ons.

(c) The nurse evaluates the client while self-administering insulin injec�ons.

Ra�onale: Nursing process - assessment, diagnosis, establishing outcomes/planning, and evalua�on.

The nurse is learning how to use the hospital's new electronic medica�on administra�on record (eMAR). The nurse knows this tool has the poten�al to do which of the following? Select all that apply.

(a) Reduce medica�on administra�on errors.

(b) Improve access to informa�on at the point of care.

(c) Eliminate the need for the nurse to document medica�on administra�on.

(d) Eliminate the need for the nurse to verify dose calcula�ons. - ansCorrect answer: (a) Reduce medica�on administra�on errors; and

(b) Improve access to informa�on at the point of care.

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Ra�onale: eMARs have the poten�al to reduce medica�on administra�on errors and to improve access to client informa�on at the point of care. It is always the nurse's responsibility to document medica�on administra�on and to verify doses of drugs being administered.

The nurse uses the Internet to receive electrocardiogram results from a client living in a nursing home. The nurse knows this type of informa�on technology is best described as which of the following?

(a) Encryp�on

(b) Telecommunica�ons

(c) Telehealth

(d) Nursing informa�cs - ansCorrect answer: (c) Telehealth.

Ra�onale: Telehealth uses transmissions via telecommunica�ons technology to transmit health informa�on remotely. Encryp�on refers to the conversion of informa�on to code during transmission to keep the informa�on secure. Telecommunica�ons refers to the electronic transmission of data over phone-based lines. Nursing informa�cs refers to a specialty of nursing that integrates nursing and computer science