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NCLEX REVISED STANDARD EXAM
The nurse is administering a magnesium sulfate infusion to a preeclamptic client and is preparing to administer a new bag. Which of the following findings would require immediate follow- up? A. Respiratory rate of 10 B. Continuous headache C. Blurred vision and flashes of light D. Urinary output 120 mL over 4 hours - ANSWER -C. Blurred vision and flashes of light The nurse is teaching a client with atrial fibrillation who is newly prescribed apixaban. Which of the following client statements would indicate understanding?
"It's normal for this medication to make my stool darker."
"I will need my blood drawn several times a week at first."
"I should never skip or double any doses of this medication."
"Taking ginkgo biloba with this medication can make it more effective." - ANSWER -2. "I will need my blood drawn several times a week at first."
The nurse is caring for a client who recently started taking rifampin as part of a multi-drug regimen for active tuberculosis (TB). Which of the following findings should receive the highest priority?
The client's sclera and skin appear yellow.
The client's contact lenses are stained red.
Client's repeat sputum culture is still positive for TB.
The client struggles to remember to take medications daily. - ANSWER -3. Client's repeat sputum culture is still positive for TB. The nurse is planning a staff education program about electroconvulsive therapy (ECT). Which of the following information should the nurse include?
Educate clients to eat a well-balanced meal prior to arriving for this procedure.
Clients can drive themselves home from this procedure after a short recovery period.
Clients should frequently be reoriented following ECT because confusion is common.
Clients need to wear a surgical mask when being transported. - ANSWER -1. Two clients with TB can share the same room. The nurse is caring for multiple clients in the emergency department. Which of the following client conditions would require the nurse to implement droplet precautions? Select all that apply.
Pulmonary tuberculosis with hemoptysis
Herpes simplex virus lesions on the mouth and nose
Diarrhea with stool culture positive for E. coli O157.H
Myalgias, chills, rigors, and a productive cough for 2 days
Sore throat with culture positive for group A Streptococcus - ANSWER - The nurse is administering an enema to a client when the client reports painful cramping. Which of the following actions should the nurse take?
Change the client's position to prone.
Advance the tube further into the colon.
Pause instillation and lower bag before resuming.
Discontinue instillation and notify health care provider. - ANSWER -3. Pause instillation and lower bag before resuming. The nurse is screening clients for those at risk for colorectal cancer. At highest risk for colorectal cancer is the client who
has dysphagia after experiencing a stroke
takes ibuprofen daily for chronic joint pain
consumes a diet high in red and processed meats
lost 200 lbs (90.7 kg) after a gastric bypass surgery - ANSWER -3. consumes a diet high in red and processed meats The intensive care unit nurse is supervising a coworker who is initiating a norepinephrine infusion for a client with septic shock. Which of the following actions by the coworker would demonstrate appropriate understanding of norepinephrine administration?
"I should go to bed by 9 p.m. and lay there to help make myself sleepy." - ANSWER - The nurse is caring for a 17-year-old client who was brought to the emergency department by his mother after sustaining head and neck trauma. Which of the following actions should the nurse take first?
Immobilize the cervical spine.
Provide supplemental oxygen.
Obtain a thorough history of injury.
Complete a neurological assessment. - ANSWER -1. Immobilize the cervical spine. The nurse is administering a vaccine to an 18-month-old child. Which of the following statements by the nurse demonstrates appropriate communication with a toddler-aged client? - ANSWER - The nurse is caring for a client who sustained burn injuries to the neck, chest, and around the entire left leg. The nurse observes the client is restless, has a hoarse voice, and has decreased pedal pulses in the left foot. Which of the following actions should the nurse take first?
Provide a dose of fentanyl 25 mg via IV push.
Prepare the client for an escharotomy of the left leg.
Start an IV bolus of warmed lactated Ringer's solution.
Administer high-flow oxygen via a non-rebreather mask. - ANSWER -4. Administer high-flow oxygen via a non-rebreather mask. The nurse is caring for a client who reports vomiting for the last week. Which of the following findings would be a priority for the nurse to report to the primary health care provider?
Client has no appetite.
Dizziness upon standing
Urine output of 20 mL/hr
Temperature of 100.2 F (37.9 C) - ANSWER -2. Dizziness upon standing The nurse has taught a client who is receiving newly prescribed fluoxetine.
"I only need to use this inhaler when I don't feel well and before I exercise." - ANSWER -4. "I only need to use this inhaler when I don't feel well and before I exercise." The charge nurse is observing the following client situations. It would require intervention if a nurse
administers oral pantoprazole to a client on an empty stomach
requests a dose of loperamide for a client with noninfectious diarrhea
holds a dose of polyethylene glycol for a client who had four bowel movements today
applies a scopolamine patch for a nauseated client with primary open-angle glaucoma - ANSWER -4. applies a scopolamine patch for a nauseated client with primary open-angle glaucoma The nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
Ensure the client stays seated.
Bring the client out into the milieu.
Turn off the radio and close the curtains.
Coach the client to practice deep, rapid breathing. - ANSWER -3. Turn off the radio and close the curtains. The nurse is caring for a client who is suspected of attempting a medication overdose. Which of the following findings would support a diagnosis of an opioid overdose?
Confused, diaphoretic, blood pressure is 150/90 mmHg
Appears agitated, pulse of 120 bpm, and reporting diarrhea
Pinpoint pupils, temperature is 94.8 F (34.9 C), respirations of 8 per minute
Slurred speech, labile mood, movements are uncoordinated with unsteady gait - ANSWER -3. Pinpoint pupils, temperature is 94.8 F (34.9 C), respirations of 8 per minute The nurse is caring for a newborn who is 3 hours old and has bluish mucous membranes, a respiratory rate of 70 breaths per min, an axillary temperature of 97.7 F (36.5 C), and mild
Which of the following actions should the nurse take?
Update the client's health record to ensure the client's decision is honored.
Contact the health care provider to notify them of the client's updated decision.
Contact the client's power of attorney to discuss updating the client's resuscitation status.
Explain to the client that advance directives are permanent and to wait to make a decision. - ANSWER -2. Contact the health care provider to notify them of the client's updated decision. A client with a new diagnosis of congestive heart failure (CHF) is being admitted to the telemetry unit. Which staff member is most appropriate to assign to complete the admission assessment and develop the client's plan of care?
A registered nurse (RN) who has worked on the telemetry unit for 1 year
A registered nurse (RN) who has been floated to the telemetry unit from the neuroscience intensive care unit (ICU)
A licensed practical nurse (LPN) who has worked on the telemetry unit for 10 years and has taken a course on CHF management
A registered nurse (RN) who has worked on the telemetry unit for 3 months and has just completed the organization's new-hire training program - ANSWER -1. A registered nurse (RN) who has worked on the telemetry unit for 1 year The nurse has attended a staff education program about healthcare workplace safety. It would indicate a correct understanding of the teaching if the nurse is observed
recapping a medication syringe before placing it in the sharps container
carrying blood-stained sheets down the hallway to the unit's biohazard closet
unplugging the client's IV pump by pulling the power cord away from the wall
instructing visitors to maintain a 6-foot (1.8 meters) distance from client with internal radioactive implant - ANSWER - The nurse is caring for a confused older adult client who is a fall risk and keeps attempting to get out of bed to go to the bathroom.
The nurse is preparing to administer oxygen via a non-rebreather mask for a client with hypoxemia. Which of the following actions should the nurse take?
Set the oxygen rate to 15 liters per minute.
Ensure the bag fully inflates during exhalation.
Apply petroleum jelly to the nares to prevent drying.
Ensure one-way valves on the facemask remain closed during exhalation. - ANSWER -2. Ensure the bag fully inflates during exhalation. The nurse has received a change-of-shift report on the following pediatric clients. It would be a priority for the nurse to follow up with the
7-year-old client recovering from a tonsillectomy who reports pain with swallowing
4-year-old client diagnosed with Kawasaki disease with a fever of 102.5°F (39.2°C)
6-year-old client with a tracheostomy who is coughing and has copious thick secretions
17-year-old client diagnosed with persistent asthma who had scheduled budesonide due 1 hour ago - ANSWER - The pediatric nurse is providing education to caregivers regarding nutrition and eating habits in children. Which of the following caregiver statements shows understanding?
"I give my child ice cream when he gets a good grade in school."
"My child must eat his entire plate of food before leaving the table."
"A handful of grapes are an appropriate snack for my 11-month- old child."
"It is okay if all my toddler eats is chicken nuggets and apples 2 days in a row." - ANSWER -4. "It is okay if all my toddler eats is chicken nuggets and apples 2 days in a row." The nurse is caring for a hospitalized 16-year-old client with type 1 diabetes. Which of the following nursing interventions is most appropriate to facilitate a sense of identity?
Write a list of goals for the client to accomplish each day.
"I should avoid lifting up my toddler for a few weeks."
"Quiet activities are preferred while recovering, such as reading."
"I will perform my post-operative coughing and deep breathing exercises hourly." - ANSWER -2. "I should avoid lifting up my toddler for a few weeks." The nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the client's plan of care?
Administer aspirin as needed for pain.
Place the client on neutropenic precautions.
Administer an enema if needed for constipation.
Request an alternative route for intramuscular injections. - ANSWER -4. Request an alternative route for intramuscular injections. The nurse is preparing to administer tizanidine to a client. Which of the following would be a contraindication to administer the medication?
Client is 76 years old.
Client is also taking ibuprofen for pain.
Client has non-alcoholic fatty liver disease.
Client has a herniated disc in the lumbar spine. - ANSWER -4. Client has a herniated disc in the lumbar spine. The nurse is observing a coworker administering subcutaneous insulin lispro to a client with diabetes. Which of the following actions by the coworker would require the nurse to intervene?
Administers insulin lispro 1 hour before meal trays arrive
Marks an expiration date on the vial that is 28 days from today
Stores the opened vial of insulin in a secure medication cabinet
Administers the injection into adipose tissue on the client's abdomen - ANSWER -2. Marks an expiration date on the vial that is 28 days from today Body System
