Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Corre, Exams of Nursing

Download Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Corre and more Exams Nursing in PDF only on Docsity! Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success Which of the following actions would be appropriate for the nurse to take? Select all that apply. 1. Administer the client's prescribed beta blocker. 2. Prepare for transcutaneous pacing. 3. Instruct the client to perform the Valsalva maneuver. 4. Begin chest compressions. 5. Assess the client for angina. 1. Encourage the client to reminisce about happy memories. Rationale: 1. Is correct because it is possible for AD patients to retain long-term memories. 2. Redirect is protocol for dementia. Don't confront, they can't learn. 3. AD is irreversible. 4. In the moderate AD, dementia has already progressed to where the patient needs help with ADL's & planning daily activities. Asking them to plan can frustrate them & cause distress. Structured, pleasant activities that consider the person's likes & interests are the best. - CORRECT ANSWERS The nurse is planning care for a client with moderate Alzheimer's Disease (AD). Which of the following interventions should the nurse include in the client's plan of care? 1. Encourage the client to reminisce about happy memories. 2. Confront the client when inappropriate or agitated behaviors occur. 3. Administer to the client the cholinesterase inhibitor to reverse the course of AD. 4. Provide the client with information about activity choices in the morning so the client can make plans for the day. 1. "Use your hands and arms to support your body weight." Rationale: 1. Is true, but watch out if it isn't 2-3 finger-widths, because crutch paralysis can occur. S/S: Paresis & Paresthesias in wrist & hands. Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success 2. Is a fall risk. 3. Crutches should be 6 inches in front & 6 inches lateral. 4. Elbow should be bent at a 30 degree angle. - CORRECT ANSWERS The nurse is teaching a client how to ambulate using crutches. Which of the following information should the nurse include? 1. "Use your hands and arms to support your body weight." 2. "Wear slippers when ambulating with the crutches in your home." 3. "Maintain the crutches 12inch (30cm) in front of your feet while standing." 4. "Adjust the hand grips of the crutches so that your elbows are fully extended." 4. "I should expect the blurred vision to resolve after I have received medications for several weeks." Rationale: MS causes nerve damage & can result in optic neuritis (Vision loss, blurry vision). In most cases it resolves itself in 4-12 weeks, but medications (steroids can speed up the process & resolve it quicker. 1. MS patients should not exert themselves too much at one time. Space out activities & allow time for rest. 2. Urinary retention is primarily treated by medication (bethanochol), and exercises can aid with it but are not the primary treatment. 3. Hot temperatures are bad for MS and can worsen symptoms. Your nerves are already messed up and extra heat can stress the body into overdrive. - CORRECT ANSWERS The nurse has taught a client with multiple sclerosis (MS). The charge nurse has received a change-of-shift report on the following clients in labor. The charge nurse should ask a staff member to first see the client in the 1. First stage of labor who has an oral temperature of 99.7F (37.6 C) 2. First stage of labor whose contractions are occurring every 30 seconds 3. Second stage of labor who has respirations of 26. 4. Second stage of labor whose contractions are lasting for 60 seconds. - CORRECT ANSWERS 2. First stage of labor whose contractions are occurring every 30 seconds Rationale: Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success Ruptured Spleen: Pain level. - CORRECT ANSWERS The nurse in the emergency department is caring for a 41-year-old male client. Nurse's Notes: 11:00: Client reports nausea, loss of appetite, vomiting, fever, and constipation for the past 2 weeks and abdominal pain rated 7/10 on the Numerical Rating Scale for 1 week. Client states "The abdominal pain started after my 7-year-old child accidentally kicked me in the stomach." Client plays soccer with the child once a week. Vital signs: T 103.4 F (39.7 C), P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air. No significant past medical or surgical history. Body mass index (BMI) 32. Drinks alcohol only during social occasions, usually 3 beverages. Smokes cigarettes during social occasions. For each assessment finding below, click to specify if the finding is consistent with the disease process of bowel obstruction, appendicitis, or ruptured spleen. Each finding may support more than 1 disease process. Answer: •Anemia •Peritonitis •Septic Shock - CORRECT ANSWERS The nurse in the emergency department is caring for a 41-year-old male client. Nurse's Notes: 11:00: Client reports nausea, loss of appetite, vomiting, fever, and constipation for the past 2 weeks and abdominal pain rated 7/10 on the Numerical Rating Scale for 1 week. Client states "The abdominal pain started after my 7-year-old child accidentally kicked me in the stomach." Client plays soccer with the child once a week. Vital signs: T 103.4 F (39.7 C), P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air. No significant past medical or surgical history. Body mass index (BMI) 32. Drinks alcohol only during social occasions, usually 3 beverages. Smokes cigarettes during social occasions. Select the 3 complications the client is at risk for developing. •Anemia •Peritonitis •Septic Shock Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success •Hypovolemia •Dysrhythmias •Cardiac Arrest Answer: Answers: Indicated: •Clear liquid diet •Soapsuds enema •Abdominal girth measurements •Abdominal Computed Tomography (CT) scan NOT indicated: •Heating pad to abdomen - CORRECT ANSWERS The nurse in the emergency department is caring for a 41-year-old male client. Nurse's Notes: 11:00: Client reports nausea, loss of appetite, vomiting, fever, and constipation for the past 2 weeks and abdominal pain rated 7/10 on the Numerical Rating Scale for 1 week. Client states "The abdominal pain started after my 7-year-old child accidentally kicked me in the stomach." Client plays soccer with the child once a week. Vital signs: T 103.4 F (39.7 C), P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air. No significant past medical or surgical history. Body mass index (BMI) 32. Drinks alcohol only during social occasions, usually 3 beverages. Smokes cigarettes during social occasions. The nurse has reviewed the Nurses' Notes from 11:30. For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client. 2. "Clients may develop stress ulcers and gastrointestinal bleeding." Rationale: Positive pressure ventilation increases the likelihood of developing stress ulcers and bleeding. - CORRECT ANSWERS The nurse has attended a staff education program about caring for clients who are receiving positive pressure mechanical ventilation. Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success Which of the following statements by the nurse would indicate a correct understanding of the teaching? 1. "Clients should avoid range-of motion (ROM) exercises until weaned from ventilation." 2. "Clients may develop stress ulcers and gastrointestinal bleeding." 3. "Clients will be chemically paralyzed to improve oxygenation." 4. "Clients will experience diuresis and polyuria." 3. 56-years-old, has hepatitis C (HCV) and has been afebrile for 24 hours. - CORRECT ANSWERS The charge nurse must transfer a female client from the medical-surgical unit to the maternity unit to make a bed available. It would be most appropriate for the nurse to transfer the client who is 1. 28-years-old, had a right mastectomy and has a closed-wound drainage system. 2. 49-years-old, has diabetes mellitus (type 2) and has begun receiving insulin. 3. 56-years-old, has hepatitis C (HCV) and has been afebrile for 24 hours. 4. 70-years-old, has a fractures left tibia and had an external fixation device applied 48 hours ago. 1. Heart failure who has a productive cough and is anxious. Rationale: The productive cough (Pink, frothy sputum) indicates pulmonary edema. The patient's anxiety may be caused by decreased perfusion. - CORRECT ANSWERS The nurse has been made aware of the following client situations. The nurse should first assess the client with 1. Heart failure who has a productive cough and is anxious. 2. Regional enteritis (Crohn's Disease) who is reporting cramping abdominal pain and diarrhea. 3. Idiopathic thrombocytopenic purpura (ITP) who has petechiae on the trunk and is reporting heavy menses. 4. Chronic obstructive pulmonary disease (COPD) who has dyspnea with exertion and is using accessory muscles to breathe. 1. Assisting a client with atrial fibrillation to shower. Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success 3. The client's pupils are equal and reactive to light. 4. The client has an axillary temperature of 99.0 F (37.2 C) and respirations of 24. 1. Closed reduction of a fractured tibia with cast applications 1 hour ago and is reporting that the casted leg feels hot. Rationale: Pain, tightness, or a hot feeling can indicate that the cast is on too tight. 2. It is normal to feel nauseous after coming off of anesthesia. 3. Knee pain is expected after knee surgery. 4. Right shoulder pain is common in laparoscopic cholecystectomy due to gas left in the abdomen after the procedure. This will resolve on its own. - CORRECT ANSWERS The nurse in the same-day surgical center has received a change-of-shift report on the following clients. The nurse should first see the client who had: 1. Closed reduction of a fractured tibia with cast applications 1 hour ago and is reporting that the casted leg feels hot. 2. Extraction of a cataract lens 2 hours ago and is reporting nausea. 3. An arthroscopy of the right knee 3 hours ago and is reporting knee pain rated as 4 on a scale of 0 (no pain) to 10 (severe pain). 4. A laparoscopic cholecystectomy 4 hours ago and is reporting right shoulder pain. 2. Obtain a referral to a physical therapist for the client. Rationale: Ataxia is lack of muscle control in the arms and legs, which leads to lack of balance, coordination, and walking. Physical therapy is the area of referral for this type of issue. 1. Thick liquids is for dysphagia. 3. This is always indicated, not just in this circumstance. 4. This can be a tool for patients with expressive aphasia. - CORRECT ANSWERS The nurse is planning care for a client with multiple sclerosis (MS) who has ataxia. Which of the following interventions should the nurse include in the client's plan of care? Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success 1. Add thickener to thin liquids for the client. 2. Obtain a referral to a physical therapist for the client. 3. Face the client directly when speaking with the client. 4. Provide a board with pictures to help the client communicate needs. 1. Breast cancer who had a mastectomy 2 days ago and has had 25mL of drainage from the closed-wound drainage system in the past 12 hours. Rationale: This is very little blood in 12 hours for a surgery that was only 2 days ago. The nurse should assess for obstruction of the drainage system which could be life-threatening if not resolved. - CORRECT ANSWERS The home-health nurse is assigned to visit the following clients who live within 3 miles (4.8km) of one of another. The nurse should first visit the client with: 1. Breast cancer who had a mastectomy 2 days ago and has had 25mL of drainage from the closed-wound drainage system in the past 12 hours. 2. Lung cancer who received a dose of chemotherapy 2 weeks ago and has a temperature of 101.1 F (38.4 C) 3. Chronic obstructive pulmonary disease (COPD) who is reporting expectorating large amounts of thick, yellow mucus. 4. Diabetes mellitus (type 1) who had a right below-the-knee amputation (BKA) and is reporting having right toe pain. 2. Who had a total knee replacement 24 hours ago, is restless, and has a petechial rash on the chest. Rationale: A petechial rash is indicative of DIC or a fat embolus. - CORRECT ANSWERS The nurse has become aware of the following client situations. The nurse should first assess the client: 1. Who had a total abdominal hysterectomy (TAH) 1 day ago and is unable to void 7 hours after the indwelling urethral catheter was removed. 2. Who had a total knee replacement 24 hours ago, is restless, and has a petechial rash on the chest. Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success 3. With bacterial pneumonia who has bronchial breath sounds auscultated between the scapulae and a temperature of 103.3 F (39.6 C). 4. With hepatic cirrhosis who has an elevated aspartate aminotransferase (AST) level and respirations of 24. 4. Implement droplet precautions. - CORRECT ANSWERS The nurse is planning care for a pediatric client being admitted with pertussis. Which one the following interventions should the nurse include in the client's plan of care? 1. Keep the client NPO. 2. Place a dehumidifier in the client's room. 3. Encourage the client to ambulate frequently. 4. Implement droplet precautions. 3. Wearing a protective gown when entering the room of a client with Escherichia coli O157.H7 who is incontinent. Rationale: E. coli is contact precautions; wear a gown whenever coming in contact with bodily fluids which is highly likely with an incontinent patient. 1. H.flu is droplet precautions. 2. Strep is droplet, and RSV is contact. 4. They will infect each other, they need private rooms. - CORRECT ANSWERS The nurse has attended a staff education program about infection control precautions. It would indicate a correct understanding of the teaching if the nurse is observed: 1. Wearing a particulate respirator mask (N95) when entering the room of a client with Haemophilus influenzae pneumonia. 2. Placing a client with streptococcal pneumonia in a room with a client who has respiratory syncytial virus (RSV). 3. Wearing a protective gown when entering the room of a client with Escherichia coli O157.H7 who is incontinent. 4. Placing a client with pediculosis capitis (head lice) in a room with a client who has scabies. 1. Uneven stairs. Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success 1. Client with hepatitis B (HBV) is eating food brought into the facility by a visitor. 2. Visitor is sitting on the side of the bed of a client with acute pancreatitis. 3. Staff member is entering the room of a client with Haemophilus influenzae meningitis wearing a protective gown and gloves. 4. Family member of a client with mycoplasma pneumonia leaves the door to the client's room open. 1. Computed tomography (CT) scan of the abdomen with intravenous contrast media. Rationale: CT's use iodinated contrast which is harmful to the kidneys and therefore is contraindicated in a client with AKI. - CORRECT ANSWERS The nurse is reviewing the orders of a client who has acute kidney injury. Which of the following orders should the nurse clarify? 1. Computed tomography (CT) scan of the abdomen with intravenous contrast media. 2. Urine specimen for urinalysis. 3. Blood specimen for arterial blood gas (ABG). 4. Referral to registered dietitian for parenteral nutrition evaluation. 3. "Restraints require an order from the primary health care provider." Rationale: 1. Restraints are removed every 2 hours for ROM exercises, toileting, and fluids. Assess every 15 minutes for the first hour, and then every 30 minutes. 2. Restraints should be secured to the bed, not the side rails. 4. Restraints are never PRN. - CORRECT ANSWERS The nurse is planning a staff education program about caring for clients with restraints. Which of the following should the nurse include? 1. "Restraints should be removed once during a shift to perform passive range-of-motion (ROM) exercises for the client." 2. "Restraints should be secured to the side rails of the client's bed for quick release." 3. "Restraints require an order from the primary health care provider." Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success 4. "Restraints may be used PRN for clients who are confused." 2. Putting a surgical mask on the client during transport to the radiology department. Rationale: 1. The door should be closed. 4. TB is airborne precautions, not droplet. - CORRECT ANSWERS The nurse is caring for a client with active pulmonary tuberculosis (TB). Which of the following should the nurse include in the client's plan of care? 1. Placing the client in a private room with the door open. 2. Putting a surgical mask on the client during transport to the radiology department. 3. Instructing the primary caregivers to wear surgical masks when caring for the client. 4. Instituting the standards for droplet precautions while caring for the client. 4. "Instruct your child not to use the same towels as siblings." Rationale: Impetigo is highly contagious through contact. Towels can easily spread the infection. 1. Impetigo is contact precautions; a surgical mask would be for airborne. - CORRECT ANSWERS The home-health nurse is teaching the parents of a 4-year-old client with impetigo. Which of the following information should the nurse include? 1. "Put a surgical mask on your child when around siblings." 2. "Cleanse the lesions with a povidone-iodine solution daily." 3. "Apply petroleum jelly to the lesions daily." 4. "Instruct your child not to use the same towels as siblings." 4. "Bubonic plague is transmitted from person to person via airborne droplets." Rationale: Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success It is actually spread through flea bites and contact with infected skin. 1. Botulism is transmitted by foods. Ex: Babies getting botulism from honey. 2. Infectious diseases that affect clotting and is spread by blood or body fluids. 3. Anthrax=Contact. - CORRECT ANSWERS The nurse has attended a staff education program about bioterrorism. Which of the following statements by the nurse would require follow-up? 1. "Botulism is transmitted by ingestion of contaminated canned foods." 2. "Hemorrhagic fever is spread by direct contact with blood or body fluids." 3. "Anthrax is spread through direct contact with the bacteria and its spores." 4. "Bubonic plague is transmitted from person to person via airborne droplets." 4. Placement of the palms at the level of the tenth ribs with thumbs pointing to the xiphoid process, then asking the client to inhale. - CORRECT ANSWERS The nurse observes a coworker who is assessing a client's thoracic expansion. Which of the following would indicate that the coworker is using the correct assessment technique? 1. Percussion from the apex of the scapula downward on each side. 2. Placement of the hands flat on the back with the thumbs at the level of the tenth ribs pointing to the spine, then asking the client to inhale. 3. Measurement of the anteroposterior diameter of the chest. 4. Placement of the palms at the level of the tenth ribs with thumbs pointing to the xiphoid process, then asking the client to inhale. 4. Wearing clothing in layers. - CORRECT ANSWERS The nurse at a health fair is talking with a client who is in perimenopause and is experiencing hot flashes. Which of the following lifestyle modifications would be appropriate for the nurse to recommend? 1. Increasing fluid intake. 2. Exercising daily. 3. Decreasing sodium intake. 4. Wearing clothing in layers. Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success Which of the following actions should the nurse take? 1. Assess the client's recent urine output. 2. Prime a Y-tubing blood administration set with lactated Ringer's solution. 3. Ensure that the client has a peripheral venous access device (VAD) that is 24-gauge or larger. 4. Verify with another nurse that the client's room number is on both the blood product label and the client's identification band. 4. "I have let down my family because I will not be able to financially support them any longer." - CORRECT ANSWERS The nurse is assessing the coping strategies of a client who had a myocardial infarction (MI) 3 days ago. Which of the following statements by the client would indicate ineffective coping? 1. "I know that stopping smoking will be difficult." 2. "I plan to attend a cardiac rehabilitation support group." 3. "I have trouble believing this has really happened to me." 4. "I have let down my family because I will not be able to financially support them any longer." 4. "Sitting upright seems to reduce the client's noisy breathing more than lying down in the bed." Rationale: It is common for hospice patients to have "death rattle," which are loud, wet respirations. The correct intervention is to reposition them laterally, not upright! Never suction them. Hospice is characterized as making the patient as comfortable as possible so if they have less anxiety with a fan, let them continue using it. Offering foods is okay, but don't force them to eat. - CORRECT ANSWERS The hospice nurse has taught an in-home caregiver about comfort care for a client at the end of life. Which of the following statements by the caregiver would require follow-up? 1. "I have been applying petroleum jelly to keep the client's lips moist." 2. "I have been offering healthy foods frequently to keep up the client's strength." 3. "A blowing fan seems to be less anxiety-producing for the client than an oxygen mask." 4. "Sitting upright seems to reduce the client's noisy breathing more than lying down in the bed." Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success 1. The client gave consent voluntarily. 2. The client received adequate disclosure. 4. The client understands the scheduled procedure or treatment. Rationale: 3. The PCP explains the procedure and the nurse witnesses the consent. Only 1 RN is needed to witness this. - CORRECT ANSWERS The nurse is witnessing the client's signature on a consent form. Which of the following conditions should the nurse recognize must be met to ensure the consent is valid? Select all that apply. 1. The client gave consent voluntarily. 2. The client received adequate disclosure. 3. The consent form is witnessed by 2 health care professionals. 4. The client understands the scheduled procedure or treatment. 5. The consent form is signed within 24 hours of the scheduled procedure or treatment. 3. "You did the best you could in very difficult circumstances." 5. "You are safe here." Rationale: 2. You wouldn't promote a shower yet because the nurse needs to collect physical evidence. - CORRECT ANSWERS The nurse is talking with a client who has been sexually assaulted. The client states, "I never should have walked home late at night. I am to blame for what has happened to me." Which of the following would be an appropriate response for the nurse to make? Select all that apply. 1. "The police officers who brought you into the hospital will be with you during this interview." 2. "You should take a warm, calming shower in order to feel more relaxed." 3. "You did the best you could in very difficult circumstances." 4. "Sometimes the victim's behavior causes the violence." Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success 5. "You are safe here." 1. Establish a daily routine for the client. 2. Assist the client to void every 2 hours. 3. Introduce self upon interacting with the client. 4. Display a clock and calendar in the client's room. - CORRECT ANSWERS The nurse is planning care for a client with moderate Alzheimer's disease (AD). Which of the following interventions should the nurse include in the client's plan of care? Select all that apply. 1. Establish a daily routine for the client. 2. Assist the client to void every 2 hours. 3. Introduce self upon interacting with the client. 4. Display a clock and calendar in the client's room. 5. Keep the client's television on during the day to distract the client. 2. Refuses to go to sleep at night. - CORRECT ANSWERS A parent is discussing with discussing with the nurse about the behaviors of a 4-year-old child following the death of a grandparent. The nurse should understand that the child may be experiencing dysfunctional grieving if the parent reports that the child: 1. Conducts mock funerals with stuffed animals. 2. Refuses to go to sleep at night. 3. Continues to talk about the grandparents coming to visit. 4. Asks to play with the grandparent while at the cemetery. 1. "I will eat steamed, fresh broccoli with herbs and spices for an evening meal." Rationale: Veggies are low sodium, and herbs and spices are great substitutes for salt. - CORRECT ANSWERS The nurse has taught a client who has been ordered a low-sodium diet about appropriate food choices. Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success Rationale: There's no need to restrict fluids or diet. Diet does not cause diverticulitis exacerbations. - CORRECT ANSWERS The nurse is teaching a client newly diagnosed with diverticulosis. Which of the following information should the nurse include? 1. "Limit your daily fluid intake to 2L to avoid bloating." 2. "You may be prescribed a bulk-forming laxative." 3. "Limit your intake of dairy products such as milk and yogurt." 4. "You should avoid consuming cooked vegetables." 1. Check the medication dosage in a medication reference source. - CORRECT ANSWERS The nurse is preparing to administer lorazepam 2mg, IV, now to a client who is scheduled for surgery in 30minutes. The nurse is unfamiliar with the dosage for the medication. Which of the following actions should the nurse take next? 1. Check the medication dosage in a medication reference source. 2. Ask another nurse whether the prescribed dose is a safe dose. 3. Clarify that the dose is correct with the primary health care provider. 4. Contact the pharmacist to verify the safe dosage range for the medication. 3. Fever. Rationale: Phenothiazine side effects include ABCDEFG- anti-cholinergic (dry mouth), blurry vision, constipation, drowsiness, EPS, photosensitivity, and agranulocytosis. Fever would be a complication of agranulocytosis and requires the nurse to report. - CORRECT ANSWERS The nurse is caring for a client who is receiving a high dose of a phenothiazine. When evaluating the client for a life-threatening syndrome related to the medication, it would be a priority for the nurse to report: 1. Dry mouth. 2. Orthostatic hypotension. 3. Fever. 4. Photophobia. Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success 1. Stop the transfusion. 2. Check the client's vital signs. 3. Notify the client's primary health care provider. 4. Return the blood and infusion tubing to the blood bank. Rationale: Back pain and chills are symptoms of hemolytic transfusion reaction (wrong blood type). Must stop infusion, check vital signs, and notify the provider. 5. NS is used to keep the line open, not dextrose in water. - CORRECT ANSWERS The nurse is caring for a client who is receiving a blood transfusion and states, "I feel chilled and am having back pain." Which of the following actions should the nurse take? Select all that apply. 1. Stop the transfusion. 2. Check the client's vital signs. 3. Notify the client's primary health care provider. 4. Return the blood and infusion tubing to the blood bank. 5. Infuse 5% dextrose in water through the intravenous catheter. 6. Administer a dose of an antiemetic prescribed PRN to the client. 2. "TPN can be administered through a peripherally inserted central catheter (PICC)." 3. "Clients receiving TPN should be weighed daily." 4. "An infusion pump is used to deliver TPN." 5. "Serum glucose levels should be monitored in clients receiving TPN." Rationale: 1. TPN tubing is changed daily (every 24 hours.) - CORRECT ANSWERS The nurse is preparing a staff education program about total parenteral nutrition (TPN). Which of the following information should the nurse include? Select all that apply. 1. "The TPN intravenous tubing should be changed once a week." 2. "TPN can be administered through a peripherally inserted central catheter (PICC)." Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success 3. "Clients receiving TPN should be weighed daily." 4. "An infusion pump is used to deliver TPN." 5. "Serum glucose levels should be monitored in clients receiving TPN." 1. "I will increase my oral fluid intake to 2 to 3 L daily while taking the medication." Rationale: Getting dehydrated can increase risk for lithium toxicity. 2. Takes about 1-3 weeks to work. 3. Do not go on a low sodium diet because it can decrease lithium elimination and cause lithium toxicity. 4. Sweating too much can cause you to lose too much sodium. - CORRECT ANSWERS The nurse has taught a client with bipolar I disorder who is experiencing a manic episode and is receiving lithium. Which of the following statements by the client would indicate a correct understanding of the teaching? 1. "I will increase my oral fluid intake to 2 to 3 L daily while taking the medication." 2. "I will experience an improvement in my condition 5 weeks after starting the medication." 3. "I should decrease my intake of dietary sodium after starting the medication." 4. "I should limit time spent in a sauna to 1 hour weekly while taking the medication." 2. Reports of muscle stiffness. Rationale: Muscle stiffness is one of the extrapyramidal symptoms (EPS). When taking haloperidol and needs immediate intervention. - CORRECT ANSWERS The nurse has administered haloperidol to a client with schizophrenia who is agitated. Which of the following findings would require immediate follow-up? 1. Continued lack of motivation. 2. Reports of muscle stiffness. 3. Inappropriate emotional expressions. Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply. 1. "I will take alendronate a half hour before I eat breakfast." 2. "I should avoid weight-bearing exercises while taking alendronate." 3. "I should discontinue alendronate if I experience nausea or vomiting." 4. "I will need to remain in an upright position for 30 minutes after I take alendronate." 5. "I should notify my primary health care provider if I experience difficulty swallowing while taking alendronate. 2. Maintaining the urine collection bag in a dependent position. Rationale: The drainage bag should always be below the level of the bladder to prevent back flow. - CORRECT ANSWERS The nurse is developing a plan of care for a client with a spinal cord injury at C5 who has an indwelling urethral catheter. Which of the following would be a priority for the nurse to include in the plan of care? 1. Encouraging the client to drink 6 to 8 glasses of fluid per day. 2. Maintaining the urine collection bag in a dependent position. 3. Teaching the client about foods high in fiber. 4. Assessing the color of the urine output. 4. A spinal cord injury at T2 two weeks ago and is currently diaphoretic and nauseated. Rationale: 1. This needs to be addressed, but not immediately. 2. This patient is at risk for infection and urinary retention, but not immediately life- threatening. 3. Numb feet is concerning, but could be a normal part of the recovery process. Not immediately life-threatening. - CORRECT ANSWERS The nurse has been made aware that the following 4 clients require assistance. The nurse should first assist the client who had: 1. An abdominal hysterectomy 5 hours ago and is reporting severe incisional pain. Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success 2. A transurethral resection of the prostate (TURP) yesterday and whose catheter has become disconnected. 3. A lumbar laminectomy 2 days ago and is reporting that the feet are still numb. 4. A spinal cord injury at T2 two weeks ago and is currently diaphoretic and nauseated. 1. "The viral load test is used to determine my response to the treatment regimen I am receiving for HIV." Rationale: Repeat viral load tests performed every 4-6 weeks until viral load falls below the assays limit of detection. The decrease the viral load the better. On the other hand with CD4 cells the increase, the better. CD4 under 200 or/and AIDS defining illness (Candidiasis, pneumonia) is AIDS. - CORRECT ANSWERS The nurse has taught a client who has a positive laboratory test result for human immunodeficiency virus (HIV) infection. The client is scheduled for a viral load test. Which of the following statements by the client would indicate a correct understanding of the teaching? 1. "The viral load test is used to determine my response to the treatment regimen I am receiving for HIV." 2. "The viral load test can rapidly detect HIV-specific antibodies in the blood." 3. "I will be able to decrease the dosage of my prescribed medications if my viral load is low." 4. "I am unlikely to develop acquired immune deficiency syndrome (AIDS) if my viral load is high." 1. "You will be asked to urinate when starting the collection, and the initial urine will be discarded." 2. "A sign will be posted on the bathroom door as a reminder to save your urine." 3. "You will be asked to void at the end of the designated time period to complete the urine collection." Rationale: 24-hour urine collection: 1st urine of the day (right after awakening) is discarded. Save all urine, a sign posted on the door is a helpful reminder. Lastly, void at the end of the designated time period to record all of the urine output in a 24-hour period and send to the lab. Don't send at the end of each shift because the collection is not completed yet. - Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success CORRECT ANSWERS The nurse is teaching a client who is scheduled for a 24-hour urine collection. Which of the following information should the nurse include? Select all that apply. 1. "You will be asked to urinate when starting the collection, and the initial urine will be discarded." 2. "A sign will be posted on the bathroom door as a reminder to save your urine." 3. "You will be asked to void at the end of the designated time period to complete the urine collection." 4. "You should discard urine that is dark or pink in color." 5. "The collected urine will be sent to the laboratory at the end of each shift." 1. "I will check my shoes for foreign objects prior to putting them on." 4. "I should avoid crossing my legs to prevent decreased circulation to my feet." 5. "I should wear new shoes for a few hours for several days until they fit well." Rationale: 1. Diabetics are at risk for feet injuries. 2. Do NOT use files on feet, they can injure themselves. 3. Do NOT apply lotion between toes because it can cause maceration and skin breakdown. Dry carefully between toes. 4. This is correct because diabetics have poor perfusion and peripheral neuropathy. 5. Diabetics should always wear good fitting shoes and never walk barefoot. - CORRECT ANSWERS The nurse has taught a client with diabetes mellitus (type 2) about foot care. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply. 1. "I will check my shoes for foreign objects prior to putting them on." 2. "I should use a large, coarse file to remove dry skin from a bunion." 3. "I will apply a petroleum-based ointment between my toes after bathing." 4. "I should avoid crossing my legs to prevent decreased circulation to my feet." 5. "I should wear new shoes for a few hours for several days until they fit well." Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success 1. Dancing is a weight-bearing exercise that can help strengthen bones and reduce the risk of osteoporosis. - CORRECT ANSWERS The nurse has taught about preventing osteoporosis to a 45-year-old client who has had a hysterectomy and bilateral salpingo-oophorectomy. Which of the following statements by the client would indicate correct understanding of the teaching? 1. "I will begin to take dancing lessons." 2. "I will get more rest at night." 3. "I will take a multivitamin supplement daily." 4. "I will add more fiber to my diet." 1. Ask the client to open and close the fist multiple times. - CORRECT ANSWERS The nurse is preparing to insert a peripheral venous access device (VAD) for a client. Which of the following actions should the nurse take? 1. Ask the client to open and close the fist multiple times. 2. Tap the client's vein multiple times to promote dilation. 3. Apply the tourniquet 9 to 10 inch (22.5 to 25 cm) above the venipuncture site. 4. Palpate for a vein after cleansing the selected site. 1. Dizziness and confusion. Rationale: 3. Vesicular breath sounds are normal breath sounds. - CORRECT ANSWERS The nurse is assessing a newly admitted client who sustained partial-thickness (second-degree) burns to the anterior thorax in a house fire. Which of the following findings would require immediate follow-up? 1. Dizziness and confusion. 2. Hypoactive bowel sounds and nausea. 3. Vesicular breath sounds throughout the lung fields. 4. Pain rated 5 on a scale of 0 (no pain) to 10 (severe pain) 3. "I should elevate the head of the bed on 6 inch (15cm) blocks." - CORRECT ANSWERS The nurse has taught a client with a hiatal hernia about interventions for the condition. Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success Which of the following statements by the client would indicate a correct understanding of the teaching? 1. "I will consume 3 regular-sized meals daily." 2. "Wearing an abdominal binder can help relieve symptoms." 3. "I should elevate the head of the bed on 6 inch (15cm) blocks." 4. "Eating foods with a high fat content will increase gastric emptying." 1. Dyspareunia. Rationale: This means pain with intercourse. - CORRECT ANSWERS The nurse is assessing a client with suspected endometriosis. Which of the following findings would support a diagnosis of endometriosis? 1. Dyspareunia. 2. Hot flashes. 3. Weight gain. 4. Amenorrhea. 1. Elevated serum uric acid. 2. A swollen, red joint. 3. Reports of moderate fatigue. 5. Pain associated with movement of the affected extremity. Rationale: 4. Distal joints would be warm to touch. 6. Low fat milks can decrease occurrence of gout attacks. - CORRECT ANSWERS The nurse is assessing a client with suspected gout. Which of the following findings would support a diagnosis of gout? Select all that apply. 1. Elevated serum uric acid. 2. A swollen, red joint. Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success 3. Reports of moderate fatigue. 4. Distal extremities cool to touch. 5. Pain associated with movement of the affected extremity. 6. Intolerance of dairy products. 4. Spontaneous bruising. Rationale: The liver has a role in synthesizing coagulating factors. Damage to the liver impairs coagulation. 1. Steatorrhea indicates a pancreatic problem. - CORRECT ANSWERS The nurse is assessing a client with cirrhosis. Which of the following findings would be consistent with a diagnosis of cirrhosis? 1. Steatorrhea. 2. Deep vein thrombosis (DVT). 3. High fever. 4. Spontaneous bruising. 3. Chancre lesions. - CORRECT ANSWERS The nurse is assessing a male client who has suspected syphilis. Which of the following findings would support a diagnosis of syphilis? 1. Urethritis. 2. Conjunctivitis. 3. Chancre lesions. 4. Penile discharge. 3. Spastic paralysis below the level of injury. - CORRECT ANSWERS The nurse has attended a staff education program about spinal shock following acute spinal cord injury. Follow-up is required if the nurse states that manifestations of spinal shock include. 1. Bowel dysfunction. 2. Bladder dysfunction. Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success It would be most appropriate for the nurse to assign UAP to: 1. Apply a continuous passive motion (CPM) device to the affected extremity of a client who had a total knee replacement. 2. Change the bed linens for a client who was admitted 1 hour ago following a closed-head injury and is comatose. 3. Reposition a client with hydrocephalus who has a headache and is vomiting. 4. Place in the prone position a client who had an above-the-knee amputation (AKA) 1 day ago. 1. Bipolar 1 disorder is experiencing a manic episode, is moving the legs, and is looking around the room restlessly. Rationale: These actions indicate that they could become a danger to others or themselves and should be removed from the situation. - CORRECT ANSWERS The nurse in the inpatient psychiatric unit is leading a support group for clients. It would be a priority for the nurse to intervene if the client with: 1. Bipolar 1 disorder is experiencing a manic episode, is moving the legs, and is looking around the room restlessly. 2. Borderline personality disorder is saying that another group member is too disturbed to be attending the session. 3. Major depressive disorder is sitting quietly with the eyes downcast. 4. Schizophrenia is rocking in place and copying the gestures of another client in the group. 3. "Clients have a right to provide feedback about services without fear of punishment." Rationale: 4. This is incorrect because the staff member wasn't even setting a proper limit. They should be taught that they cannot limit clients feedback about the unit. - CORRECT ANSWERS The nurse has observed a staff member tell a client with bipolar disorder that there will be consequences for making negative comments about conditions in the facility. When the nurse meets privately with the staff member, which of the following statements would be most appropriate for the nurse to make to the staff member? 1. "Threatening a client can result in the immediate dismissal of a staff member." Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success 2. "Staff members who have difficulty with control issues often seek power over clients." 3. "Clients have a right to provide feedback about services without fear of punishment." 4. "Staff should set limits with clients in a nonjudgmental manner." 3. Who had a total abdominal hysterectomy (TAH) 12 hours ago and has saturated 1 perineal pad in the past 5 hours. - CORRECT ANSWERS The nurse has been made aware of the following client situations. The nurse should first assess the client: 1. With chronic obstructive pulmonary disease (COPD) who is using pursed-lip breathing after ambulating in the hallway. 2. With pericarditis who has a systolic blood pressure that is 20 mmHg higher during expiration than during inspiration. 3. Who had a total abdominal hysterectomy (TAH) 12 hours ago and has saturated 1 perineal pad in the past 5 hours. 4. Who has Guillain-Barre syndrome and has had an increase in the vital capacity over the past 4 hours. 4. "I take echinacea every day to help improve my immune system." Rationale: Echinacea consumption every day can damage the liver and immunosuppressed the client. - CORRECT ANSWERS The nurse is talking with a client who has a positive laboratory test result for human immunodeficiency virus (HIV) infection. Which of the following statements by the client would require follow-up? 1. "I try to eat a well-balanced diet." 2. "I avoid crowds when I go outside the house." 3. "I am taking a vitamin C tablet daily to help prevent infections." 4. "I take echinacea every day to help improve my immune system." 4. Request assistance from several nearby staff members with controlling the client's behavior. - CORRECT ANSWERS The nurse in the psychiatrist unit is administering medications when a client with a borderline personality disorder approaches and asks to talk. The nurse suggests having a talk in 1 hour. The client shouts, "I'll wait. but you will be sorry!" and then picks up a pitcher of water and throws it onto the floor. Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success Which of the following actions should the nurse take? 1. Offer to listen to the client while continuing to administer the medications. 2. Suggest that the client take a PRN prescribed medication for agitation. 3. Ask another nurse to finish administering the medications, and talk with the client. 4. Request assistance from several nearby staff members with controlling the client's behavior. 2. "The nurse has a duty to insist that the client repeat what has been said about a procedure for which consent is necessary." 3. "The primary health care provider must disclose the risks if the client declines a recommended procedure." 5. "Informed consent is not needed for emergency procedures that are in the client's best interest." Rationale: 1. The POA only steps in when the client is not able to make decisions for themselves. 4. The client should sign the consent form before any procedure or treatment, not specifically before receiving opioids. - CORRECT ANSWERS The nurse is planning a staff education program about informed consent. Which of the following information should the nurse include? Select all that apply. 1. "An individual designated by a power of attorney for health care can provide informed consent despite the competency of the client." 2. "The nurse has a duty to insist that the client repeat what has been said about a procedure for which consent is necessary." 3. "The primary health care provider must disclose the risks if the client declines a recommended procedure." 4. "The client should sign the consent form prior to receiving prescribed opioids." 5. "Informed consent is not needed for emergency procedures that are in the client's best interest." 4. Assess the client. - CORRECT ANSWERS The nurse is caring for a client who has a prescription for an intravenous infusion of 0.45% sodium chloride (half-strength saline). The nurse notes the client is receiving 5% dextrose in water. Which of the following actions should the nurse take first? Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success 3. "I can decrease serum glucose monitoring to twice daily." - CORRECT ANSWERS The nurse is talking with a client who has diabetes mellitus (type 1) and is receiving insulin VIA an infusion pump. Which of the following statements by the client would require follow-up? 1. "I need a bolus dose of insulin prior to a meal." 2. "I should refill the pump with short-duration insulin." 3. "I can decrease serum glucose monitoring to twice daily." 4. "I will change the infusion needle every 2 to 3 days." 3. The client states, "I need to find out why the surgery is needed before I sign the consent form." 5. The client states, "I am afraid to sign the consent form because I know I am going to die during the surgery." - CORRECT ANSWERS The nurse is caring for a client who is scheduled for a spinal fusion in 1 hour. Which of the following situations would require follow-up? Select all that apply. 1. The nurse notes that the client signed the consent form 1 week ago. 2. The nurse determines that the last analgesia the client received was yesterday afternoon. 3. The client states, "I need to find out why the surgery is needed before I sign the consent form." 4. The nurse administers the prescribed pre-operative sedation after the client signs the consent form. 5. The client states, "I am afraid to sign the consent form because I know I am going to die during the surgery." 6. The client states, "The surgery may result in some paralysis, but the resolution of the pain is worth the risk to me." 3. Schizophrenia who is withdrawn and requires assistance with activities of daily living (ADL). - CORRECT ANSWERS The charge nurse must transfer a client from a locked psychiatric unit to an unlocked unit in order to make a bed available. The charge nurse should recommend for transfer the client with: 1. Depression who has suddenly become more animated and involved in unit activities. 2. Bipolar I disorder who is experiencing a manic episode, is disrobing, and is laughing with other clients. Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success 3. Schizophrenia who is withdrawn and requires assistance with activities of daily living (ADL). 4. Dementia who is delusional about being poisoned by staff members. 3. Hematoma on the left side of the neck. - CORRECT ANSWERS The nurse in the emergency department (ED) is assessing a client with multiple injuries that occurred as a result of a motor vehicle collision. Which of the following findings should receive highest priority? 1. Avulsion injury of the left index finger. 2. Deep laceration on the right forearm with blood oozing from the surface. 3. Hematoma on the left side of the neck. 4. Open fracture of the right tibia and fibula. 2. With an abdominal aortic aneurysm who reports recent onset of low back pain. - CORRECT ANSWERS The nurse has received information about assigned clients. The nurse should first assess the client: 1. With multiple sclerosis (MS) who had an indwelling urethral catheter removed 5 hours ago and has not been able to urinate. 2. With an abdominal aortic aneurysm who reports recent onset of low back pain. 3. Who had coronary artery bypass graft (CABG) surgery 2 days ago and reports sternal pain when coughing. 4. Who has bacterial pneumonia and is requesting a cough suppressant. 2. The client has been encouraged to maintain a high-calorie, high-protein diet. - CORRECT ANSWERS The nurse that cared for a client with chronic obstructive pulmonary disease (COPD) who lost more than 10% of ideal body weight has been named in a lawsuit charging negligence. Which of the following entries in the client's medical record would help refute the charge of negligence? 1. The client has been instructed to eat 3 large meals daily. 2. The client has been encouraged to maintain a high-calorie, high-protein diet. 3. The client has been encouraged to drink fluids with meals to promote digestion. 4. The client has been instructed to exercise 30 minutes before eating to improve appetite. Nclex-Rn Exam Preview Questions And Answers Latest Update 2024/2025 All Answers 100% Correct Verified Best Graded A+ For Success 1. 22-gauge catheter inserted into the right hand. - CORRECT ANSWERS The documenting care for a client who had a peripheral venous access device (VAD) inserted 10 minutes ago. Which of the following would be the best example of correct documentation for the nurse to include in the client's medical record? 1. 22-gauge catheter inserted into the right hand. 2. Secured the site with paper tape to avoid skin tears. 3. Infusion started slowly due to reports of coolness at the site. 4. Labeled site, tubing, and intravenous fluid bag. 2. Arterial blood gas (ABG) results for the client who has an acid-base imbalance. - CORRECT ANSWERS The nurse is caring for assigned clients. It would be most important for the nurse to monitor: 1. Serum lipase levels for the client with hypercholesterolemia. 2. Arterial blood gas (ABG) results for the client who has an acid-base imbalance. 3. Serum glucose levels for the client with diabetes insipidus (DI). 4. Adrenocorticotropic hormone (ACTH) levels for the client who has a fluid imbalance. 3. "The charge nurse is working with staff nurses and the nurse manager to develop shared goals and a plan for the new staffing format." - CORRECT ANSWERS The nurse is planning a staff education program about collaborative conflict resolution strategies. Which of the following would best describe implementation of a collaborative conflict resolution strategy? 1. "A staff nurse is working with the nurse manager and offering suggestions about an upcoming new procedure." 2. "The clinical nurse leader is flattered by being asked to help create a clinical ladder for nursing staff members." 3. "The charge nurse is working with staff nurses and the nurse manager to develop shared goals and a plan for the new staffing format." 4. "A new nurse has offered to work on a holiday in exchange for having the following weekend off."