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NCLEX RN MOCK PREPARATION COMPLETE SOLUTION, Exams of Nursing

Chamberlain College of NursingNursing

NCLEX RN MOCK PREPARATION COMPLETE SOLUTION NCLEX RN MOCK PREPARATION COMPLETE SOLUTION NCLEX RN MOCK PREPARATION COMPLETE SOLUTION

Typology: Exams

2023/2024

Available from 08/27/2024

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NCLEX RN MOCK PREPARATION
COMPLETE SOLUTION
The nurse is teaching a family member of a client with a terminal illness the signs of impending
death. Which statement by a family member indicates the need for further teaching?
- I will continue to talk in normal tones
- Decreases in respirations my happen
- Death is soon, if their shoulders are cool
- They may prefer to sleep rather than talk
ANSWER : Death is soon, if their shoulders are cool
The systems of the body will begin to function erratic and slower as death approaches. As the
feedback of the circulatory system fails, the client will have fluctuating temperature control. As
death process continues, the circulatory system in the extremities will fail. The arms and legs will
become cooler. The family member will require further teaching regarding indicators of
approaching death.
A medical-surgical LPN has been sent to a short-staffed pediatric unit. The charge nurse knows
what client would be most appropriate for this LPN?
- 3 month old child with nonorganic failure to thrive
- 14 year old with exacerbation of cystic fibrosis
- 5 year old newly admitted with epiglottitis
- 10 year old with type 1 diabetes mellitus
ANSWER : 10 year old with type 1 diabetes mellitus
Prior to removal of cataracts, the client is to receive eye drops in both eyes. The nurse knows
what actions takes priority/
- Remove any exudate around eyes with warm water
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NCLEX RN MOCK PREPARATION

COMPLETE SOLUTION

The nurse is teaching a family member of a client with a terminal illness the signs of impending death. Which statement by a family member indicates the need for further teaching?

  • I will continue to talk in normal tones
  • Decreases in respirations my happen
  • Death is soon, if their shoulders are cool
  • They may prefer to sleep rather than talk ANSWER : Death is soon, if their shoulders are cool The systems of the body will begin to function erratic and slower as death approaches. As the feedback of the circulatory system fails, the client will have fluctuating temperature control. As death process continues, the circulatory system in the extremities will fail. The arms and legs will become cooler. The family member will require further teaching regarding indicators of approaching death. A medical-surgical LPN has been sent to a short-staffed pediatric unit. The charge nurse knows what client would be most appropriate for this LPN?
  • 3 month old child with nonorganic failure to thrive
  • 14 year old with exacerbation of cystic fibrosis
  • 5 year old newly admitted with epiglottitis
  • 10 year old with type 1 diabetes mellitus ANSWER : 10 year old with type 1 diabetes mellitus Prior to removal of cataracts, the client is to receive eye drops in both eyes. The nurse knows what actions takes priority/
  • Remove any exudate around eyes with warm water
  • Instill exact number of drops into lower conjunctival sac
  • Instruct client to look upward when drops are instilled
  • Avoid dropping the medication directly on the cornea ANSWER : Avoid dropping the medication directly on the cornea. The most important safety consideration when instilling eye drops is to avoid dropping the medication directly onto the cornea. The extreme sensitivity of the cornea before, and after, eye surgery could cause serious eye problems. Which side effect of vincristine should the nurse immediately report to the primary healthcare provider?
  • Nausea
  • Fatigue
  • Paresthesia
  • Anorexia ANSWER : Paresthesia Vincristine - chemotherapeutic drug that could cause paresthesia - needs dose mod or d/c The nurse is admitting an 8 month old infant to the pediatric unit. For what major developmental stressor in this infant should the nurse plan interventions?
  • Fear of unknown
  • Loss of daily routine
  • Body image disturbance
  • Separation anxiety ANSWER : Separation anxiety
  • Obtain a blood pressure reading
  • Connect to cardiac monitor.
  • Raise head of bed to 90 degrees ANSWER : Raise head of bed to 90 degrees - to facilitate maximum lung expansion and decrease venous return to the right side of the heart to decrease pressure in the pulmonary vascular system. A nurse is planning care for a laboring client who is about to be started on oxytocin. What interventions should the nurse include in this plan of care? Select all that apply.
  • Piggy back oxytocin into main IV fluid
  • Monitor for early decelerations
  • D/C if contractions last longer than 90 seconds
  • Maintain one on one care
  • Check fetal heart tones hourly ANSWER : - PB oxytocin into main IV fluid (so when oxy is d/c the main IV fluid is resumed quickly)
  • D/C if contractions last longer than 90 seconds (to avoid hyperstimulation of the uterus and fetal distress)
  • Maintain 1:1 care (to monitor for complications) External fetal monitoring should begin prior to oxytocin administration. A reactive fetal heart rate tracing should be obtained over 30 minutes Which intervention should the nurse recommend to the adult child who is caring for an elderly parent diagnosed with Alzheimer's disease (AD)?
  • Give parent small dog for company and comfort
  • Reset the water heater to 125 degrees F to prevent burns
  • Place mirrors in multiple locations so parent sees image of self
  • Make floors and walls different colors. ANSWER : Make floors and walls different colors. Place the steps in order that the nurse should take to administer a subcutaneous injection.
  • Perform hand hygiene
  • Inject the needle and administer the medication
  • Hold syringe and pinch the skin with nondominant hand
  • Remove the needle cap by pulling it straight off
  • Apply gloves and locate the injection site
  • Cleanse site with antiseptic swab
  • Dispose the syringe in sharps container. ANSWER : - Perform hand hygiene
  • Apply gloves and locate the injection site
  • Cleanse site with antiseptic swab
  • Remove the needle cap by pulling it straight off
  • Hold syringe and pinch the skin with nondominant hand
  • Inject the needle and administer the medication
  • Dispose the syringe in sharps container. The nurse is cleaning and dressing a foot ulcer of a diabetic client. Which actions are appropriate? Select all that apply.
  • Uses a clean basin and washcloth to clean the ulcer
  • Wears sterile gloves to clean the ulcer
  • Cleans ulcer with normal saline
  • Warms saline bottle in microwave for 1 minute
  • Set up sterile field and open packages
  • Wash hands and apply clean gloves
  • Clean burn and place sterile dressing. ANSWER : - Medicate client with pain medication
  • wash hands and apply sterile gloves
  • set up sterile field and open packages
  • remove the old dressing and discard
  • wash hands and apply sterile gloves
  • clean burn and place sterile dressing. A traumatized soldier goes to the infirmary after being told he almost died in a gun battle. He tells the nurse, "I do not remember any of the details of this event. What is wrong with me?" What is the nurse's best response?
  • I understand you are upset, but you will have to go back to your unit sooner or later
  • You are repressing this event because it was frightening and painful for you
  • In my professional opinion, you are trying to undo what happened in the battle.
  • You are splitting from the bad you, so that the good you survives ANSWER : You are repressing this event because it was frightening and painful for you A client wishing to stop smoking receives a prescription for buproprion from the healthcare provider. What educational points should the nurse include regarding this medication? Select all that apply
  • This medication can cause a false positive drug screening test
  • Alcohol intake should be limited to two drinks per day
  • Nicotine gum may be prescribed in addition to bupropion
  • an increased interest in sexual activity occurs while taking this medication
  • Smoking can continue for 1 week after starting this medication

ANSWER : - This medication can cause a false positive drug screening test

  • Nicotine gum may be prescribed in addition to bupropion
  • Smoking can continue for 1 week after starting this medication Bupropion ANSWER : Wellbutrin An antidepressant medication prescribed for major depressive disorder and seasonal affective disorder. Used to help people stop smoking by reducing craving and other withdrawal effects Can cause a false positive drug screen Nicotine gum or patches may also be prescribed - bupropion is a nicotine free prescription The client can continue to smoke for about 1 week after starting the medicine. Recommended length of therapy for smoking cessation is 7 to 12 weeks. Drinking alcohol may increase the risk of seizures, especially if the client drinks a lot and then quits suddenly A child with acute lymphocytic leukemia (ALL) is receiving chemotherapy through a single lumen Groshong catheter. During the infusion, the child reports nausea and has vomited. The primary HCP has prescribed ondansetron IV. What action should the nurse take?
  • Ask the primary HCP for an oral antiemetic
  • Give ondansetron IVPB with the chemotherapy
  • Wait until chemotherapy is complete to infuse ondansetron
  • Stop chemotherapy temporarily and flush line to give ondansetron. ANSWER : Stop chemotherapy temporarily and flush line to give ondansetron. A Groshong catheter is implanted when other venous access sites are no longer useable.

A client admitted with biliary atresia has just arrived on the pediatric unit. The unit is very busy and the other RNs are busy with other clients at this moment. What action by the charge nurse would be most appropriate?

  • Instruct the unlicensed assistive personnel to obtain clients vital signs and weight
  • Assign an LPN/VN to perform the initial nursing history and physical assessment
  • Have an LPN/VN collect data on the client and report results to RN
  • Inform one of the RNs that a new client is on the floor and that a nursing history should be completed as soon as possible. ANSWER : Have an LPN/VN collect data on the client and report results to RN The nurse is preparing to administer scheduled medications for a client. Which medication would require clarification prior to administration? Exhibit: Client chart information: Diagnosis: Heart failure. Current vital signs: BP 110/64, HR 70, R 18 Allergies: Sulfonamides Lab results: Glucose 98; Sodium 142; K 3.8; Digoxin level 0. Diet: 2 gm sodium
  • Digoxin
  • Sacubitril/valsartan
  • Bumetanide
  • Potassium chloride ANSWER : Bumetanide
  • a loop diuretic - and can cause a cross sensitivity in a person allergic to sulfonamides Sacubitril/valsartan

ANSWER : Entresto A combination medications used to reduce the risk of cardiovascular death and hospitalization for HF. Do not take this medication within 36 hours of any ACE inhibitor or other ARB med. Watch for hypotension, hyperkalemia, and impaired renal function. Which assessment finding in a client 5 hours post open cholecystectomy would require the nurse to notify the surgeon?

  • Absent bowel sounds
  • Jackson Pratt drain has 90 mL of blood
  • Urinary output of 180 mL since return from surgery
  • Client report of abdominal pain of 8/ ANSWER : Jackson Pratt drain has 90 mL of blood
  • An open cholecystectomy will usually result in the placement of a drain. The drainage should be green (bile). Blood is a problem and needs immediate intervention. The nurse is observing a new RN explain phototherapy to the mother of a newborn with a bilirubin of 12 mg/dL one day after birth. The nurse determines the new Rn understands the phototherapy process when what statements are made to the mother? Select all that apply.
  • The infant's eyes must be covered throughout the session
  • The heat from the light may cause some harmless swelling in the arms
  • Body temperature must be checked frequently to monitor for fever
  • It is important to restrict feedings during the phototherapy sessions
  • We check bilirubin levels several times daily to be sure it's decreasing. ANSWER : - The infant's eyes must be covered throughout the light session
  • Body temperature must be checked frequently to monitor for fever
  • We check bilirubin levels several times daily to be sure it's decreasing.

ANSWER : A confused client with a closed head injury had hand mitts applied after pulling out an IV A client has been admitted with a stroke on the left side of the brain. What clinical manifestations does the nurse expect to find when assessing this client? Select all that apply

  • Right sided hemiplegia
  • Depression
  • Impaired language comprehension
  • Impulsiveness
  • Impaired speech ANSWER : - Right sided hemiplegia
  • Depression
  • Impaired language comprehension
  • Impaired speech Cholelithiasis ANSWER : gallstones The bile becomes super saturated with cholesterol. This leads to precipitation of cholesterol which presents as gall stones. Clients should avoid foods high in fat - fried foods, cheeses, milk, custard, ice cream, pies, and cakes, red meats, baked beans. The charge nurse on the pediatric unit has several tasks that need to be completed. What tasks can be assigned to the UAP? Select all that apply.
  • Obtain a urine sample from an infant
  • Empty a NG canister for client with ileus
  • Feed a child with bilateral burns of the hands
  • Change an ostomy appliance on child with stoma
  • Ambulate an adolescent two days post appendectomy ANSWER : - Feed a child with bilateral burns of the hands
  • Ambulate an adolescent two days post appendectomy During client care rounds, the nurse reports that a client coughs frequently after taking anything by mouth. The dietician recommends a swallow evaluation for the client. The primary HCP writes the prescription. Which statement best describes this process?
  • Collaboration with the ancillary care providers
  • Collaboration between the primary HCP and dietician
  • Collaboration with the risk management team
  • Collaboration among members of the multi-disciplinary team. ANSWER : Collaboration among members of the multi-disciplinary team. The nurse has been assigned four clients. Who should the nurse see first?
  • A client with diabetes admitted for debridement of a foot ulcer
  • A client with epilepsy reporting an odd smell in the room
  • A client with exacerbation of COPD reporting dyspnea
  • An adolescent client post appendectomy reporting pain ANSWER : A client with epilepsy reporting an odd smell in the room A client with a new single chamber pacemaker is receiving instructions prior to discharge. What statement by the client indicates to the nurse the need to review the instructions again?
  • I can use a cell phone on the side opposite my pacemaker
  • I must check and then record my heart rate every day
  • It is safe for me to go through the new airport security
  • I need monthly pacemaker checks to assess pacer function

The pathology report on a client diagnosed with urolithiasis reveals calcium oxalate stones. Which food selections by the client would indicate to the nurse that the client understands the prescribed low oxalate diet?

  • Spinach
  • Raspberries
  • Almonds
  • 100% bran cereal
  • Bananas
  • Raisins ANSWER : Bananas and raisins - fruits provide valuable amounts of water, fiber, and antioxidants, all of which may help lower your risk for kidney stone symptoms. Many fruits are considered low-oxalate, which means they contain less than 2 milligrams per serving -- bananas, cherries, grapefruit, grapes, mangoes, melons, green and yellow plums, and nectarines. Raspberries are the most significant fruit source of oxalate - 1 cup contains 48 mg The nurse is talking with the mom of a preschooler at the well-child visit. The mom reports that her 3 year old has a lot of energy and sleeps 9 hours per night. What assessment questions should the nurse ask in response to this comment? Select all that apply.
  • Nothing, as this is normal for preschoolers
  • Does your child take naps during the day?
  • Does your child wake up spontaneously or do you wake her?
  • Does your child appear rested upon awakening?
  • Does your child have trouble settling down for sleep? ANSWER : options 2- Preschoolers typically require 11-13 hours of sleep per day. The child may be supplementing nighttime sleep with long naps. It is important to determine if the child has to be awakened after nine hours or if the child awakens spontaneously. The child may have to be awakened due to mom's work schedule. The adequacy of rest should be determined, as the child is sleeping less than is typical.

How should the nurse assist a post-operative client in transferring from the bed to a chair?

  • Have the client look down and watch their feet as they move
  • Tell the client to bend at the waist to lower the center of gravity
  • Place a walker away from the bed so the client can lean forward while standing
  • Ensure the client's feet are as wide apart as the hips ANSWER : Ensure the client's feet are as wide apart as the hips. -this maintains the client's horizontal center of gravity A nurse is caring for a client who has chest pain. Which statement made by the client leads the nurse to suspect angina instead of a myocardial infarction?
  • I became dizzy when I stood up
  • I was nauseated and began vomiting
  • The pain started in my chest and stopped after I sat down
  • The pain was not relieved after taking 3 nitroglycerine tablets. ANSWER : The pain started in my chest and stopped after I sat down. - Chest pain brought on by exercise and stopped with rest is the hallmark of angina. If it were an MI the pain would continue even with rest or position changes.
  • Dizziness indicates orthostatic hypotension and is not definitive for angina or MI
  • Vomiting is a symptom of an MI and is a bad sign related to the acute pain from the MI. This type of pain stimulates the vagus nerve, which causes the HR, BP, and cardiac output to decrease A client in the emergency department with acute onset of fever, headache, stiff neck, N/V, and mental status changes. What interventions should the nurse initiate? Select all that apply.
  • Elevate HOB 30 degrees
  • Pad side rails
  • Provide sponge bath is temperature greater than 101 F
  • Initiate airborne isolation precautions

A widening pulse pressure is an indication of increasing ICP; however, if the client was developing Cushing's triad, the pulse would decrease rather than increase. A client diagnosed with Addison's disease has been prescribed prednisolone. Which statement by the client indicates that the client's medication instructions for prednisolone have been effective?

  • I should avoid foods high in protein
  • I will take prednisolone in thr morning
  • I need to schedule an eye examination every 2 years
  • Infections will be reduced while taking prednisolone ANSWER : I will take prednisolone in the morning. The body's production of cortisol is at a higher level in the morning. Clients should be encouraged to consume a high protein diet to avoid decreased muscle mass and help wound healing. Yearly eye examinations are recommended. Prolonged therapy can result in cataracts and glaucoma. Prednisolone is an anti-inflammatory and immune suppressant. Can mask infection symptoms. A client is suspected of having pheochromocytoma. The nurse is explaining the process of a Vanillylmandelic acid (VMA) urine test to be complete at home. What statements made by the client indicates the need for further teaching? Select all that apply.
  • I need to keep the urine in the fridge during the 24 hours
  • I will have to stay well-hydrated to get enough urine to test
  • It does not matter what I eat or drink during this process
  • I need to throw away my first voiding when I start this test
  • I should void at the end of the 24 hours and keep that urine. ANSWER : - I need to keep the urine in the fridge during the 24 hours
  • I will have to stay well-hydrated to get enough urine to test
  • It does not matter what I eat or drink during this process

The collected urine needs to be kept cold, but should never be placed in the refrigerator with the client's food. There is no minimum amount of urine needed for the test. The week before the test, the client needs to eliminate vanilla products. Which observations should the home health nurse discuss with the parents of a two year old regarding potential safety threats in the home? Select all that apply

  • Security gates at the stairs
  • Cleaning supplies under sink cabinet
  • No blinds on windows
  • use of space heaters
  • Water heater temperature 140 F
  • Use of tablecloths ANSWER : Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Which actions should be instituted by each unit's charge nurse? Select all that apply.
  • Turn on local news for up-to-date information on the train derailment.
  • Prepare a list of clients who could quickly be discharged or transferred
  • Determine which personnel could be sent to the command center
  • Notify clients that the disaster plan has been put into effect
  • Alert all off-duty personnel to stand by in case of call-in ANSWER : - Prepare a list of clients who could quickly be discharged or transferred
  • Determine which personnel could be sent to the command center
  • Alert all off-duty personnel to stand by in case of call-in. The nurse is caring for a client with a diagnosis of major depression. The client began taking a selective serotonin reuptake inhibitor three days ago. The client states, "I am just not feeling