NCLEX Questions

The nurse plans to administer an injection of heparin to a client. Which technique for heparin administration is appropriate? The nurse: A. selects a 1.5-inch (3.8-cm), 21-gauge needle for the injection. B. makes the injection into the deltoid muscle. C. applies gentle pressure to the site for 5 to 10 seconds after the injection. D. aspirates with the plunger to check for entry into the blood vessel before injecting the heparin.

C. applies gentle pressure to the site for 5 to 10 seconds after the injection.

A nurse is administering daunorubicin through a peripheral I.V. line when the client complains of burning at the insertion site. The nurse notes no blood return from the catheter and redness at the I.V. site. The client is most likely experiencing which complication? A. erythema B. flare C. extravasation D. thrombosis

C. extravasation

The nurse is preparing to give an IM injection. to an underweight client. Which site is the safest because it has the fewest amount of blood vessels and major nerves located in the area? A. deltoid B. dorsogluteal C. vastus lateralis D. triceps

C. vastus lateralis

Thee nurse is administering an intradermal injection (see the accompanying figure). The nurse should: A. withdraw the needle. B. report an adverse reaction to the medication. C. instruct the client to massage the area for 1 minute. D. aspirate the medication and administer the medication at another site.

A. withdraw the needle.

A child has a prescription to receive 250 mL of IV fluids every 4 hours. The nurse should set the infusion pump using to run at which flow rate? A. 10 mL/hour B. 25 mL/hour C. 42 mL/hour D. 63 mL/hour

D. 63 mL/hour

A client is to have an insertion of a peripheral venous access device (VAD). After explaining the procedure to the client, the nurse will perform the steps from first to last in which order? All options must be used. 1. Insert the VAD with the bevel up at a 10- to 30-degree angle. 2. Observe for blood return in the flashback chamber. 3. Apply clean gloves and cleanse the insertion site with an antiseptic swab. 4. Apply the tourniquet and select a vein for inserting the VAD.

1. Apply the tourniquet and select a vein for inserting the VAD. 2. Apply clean gloves and cleanse the insertion site with an antiseptic swab. 3. Insert the VAD with the bevel up at a 10- to 30-degree angle. 4. Observe for blood return in the flashback chamber.

The nurse is starting a peripheral intravenous line. Place the steps in the order that the nurse should perform them. All options must be used. · Place sterile transparent dressing over venipuncture site. · Cleanse site with antiseptic solution. · Fill the extension tubing with normal saline and apply slide clamp. · Perform venipuncture. · When blood returns through lumen of the needle, advance catheter into vein. · Apply a tourniquet 3 to 4 in (7.5 to 10 cm) above the venipuncture site.82

1. Fill the extension tubing with normal saline and apply slide clamp. 2. Apply a tourniquet 3 to 4 in (7.5 to 10 cm) above the venipuncture site. 3. Cleanse site with antiseptic solution. 4. Perform venipuncture. 5. When blood returns through lumen of the needle, advance catheter into vein. 6. Place sterile transparent dressing over venipuncture site.

The client is admitted to the hospital for hernia repair. What gauge of IV catheter would the nurse deem appropriate for this client? A. 18 B. 20 C. 22 D. 24

A. 18

A client is to receive 1,000 mL of lactated Ringer's over 10 hours. The drip factor is A. 25 gtt/min B. 33 gtt/min C. 28 gtt/min D. 14 gtt/min

A. 25 gtt/min

A nurse notes that a client's I.V. insertion site is red, swollen, and warm to the touch. Which action should the nurse take first? A. Discontinue the I.V. infusion. B. Apply a warm, moist compress to the I.V. site. C. Check the I.V. infusion for patency. D. Apply an ice pack to the I.V. site.

A. Discontinue the I.V. infusion.

The nurse is removing a client's intravenous catheter before discharge from the hospital. What are appropriate nursing considerations prior to the intravenous catheter removal? Select all that apply. A. Donning personal protective equipment. B. Explaining the need for the catheter removal. C. Reviewing current medication therapy for anticoagulants. D. Identifying the client with two identifiers. E. Obtaining a tourniquet.

A. Donning personal protective equipment. B. Explaining the need for the catheter removal. C. Reviewing current medication therapy for anticoagulants. D. Identifying the client with two identifiers.

A physician orders an I.V. bolus injection of diltiazem hydrochloride for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus? A. Gently aspirate the I.V. catheter to check for a blood return. B. Insert a second I.V. line into the opposite arm. C. Warm the I.V. medication to room temperature. D. Place a tourniquet on the arm in which the injection will be administered.

A. Gently aspirate the I.V. catheter to check for a blood return.

Which technique for administering the tuberculin skin test is correct? A. Hold the needle and syringe almost parallel to the client's skin. B. Pinch the skin when inserting the needle. C. Aspirate before injecting the medication. D. Massage the site after injecting the medication.

A. Hold the needle and syringe almost parallel to the client's skin.

The nurse is preparing to start an IV infusion. Before inserting the needle into a vein, the nurse applies a tourniquet to the client's arm. Which finding indicates the tourniquet has been applied correctly? A. The veins are distended. B. The veins do not "roll." C. The arm is immobilized. D. Arterial circulation is occluded.

A. The veins are distended.

A client has an intravenous line in place for 3 days and begins to state discomfort at the insertion site. Based on the nurse's progress note, what condition has most likely occurred? Progress Note: "Intravenous site assessed and found to have blanching around the site, swelling, and coolness to the touch. Laboratory results include a white blood cell count within normal limits." A. infiltration B. phlebitis C. infection D. infection and infiltration

A. infiltration

A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client? A. "Monitor fluid intake and output every 4 hours." B. "The client remains free of signs and symptoms of phlebitis." C. "Edema and warmth are noted at I.V. insertion site." D. "There is a risk for infection related to I.V. insertion."

B. "The client remains free of signs and symptoms of phlebitis."

The nurse is to administer an I.M. injection into a client's left vastus lateralis muscle. The nurse notes that the muscle is quivering as landmarks are assessed. How should the nurse respond? A. Have the client lie supine and flex the foot. B. Choose another site for injection. C. Have the client lie on the left side. D. Distract the client during the injection.

B. Choose another site for injection.

When assessing an intravenous site, the nurse observes edema and a red line. The client also reports pain at the insertion site. What actions would be appropriate? A. Slow the infusion rate and apply warm compresses to the site. B. Discontinue the infusion and apply a warm compress to the I.V. site. C. Reposition the I.V. access device to lessen the vein irritation. D. Apply antibacterial ointment to the I.V. site and slow the I.V. infusion.

B. Discontinue the infusion and apply a warm compress to the I.V. site.

A client receiving an intravenous infusion states that, "My arm is feeling cool." Which priority action should be taken? A. Provide a blanket. B. Remove the intravenous catheter. C. Assess the intravenous site. D. Teach the client about expected side effects of intravenous infusion.

B. Remove the intravenous catheter.

The nurse is administering 5,000 units heparin subcutaneously to a client. (See the accompanying image.) What step should the nurse include in administration? A. Deposit the heparin deep in the muscle. B. Use a shorter needle. C. Insert the needle at a 30-degree angle. D. Aspirate prior to injecting the heparin.

B. Use a shorter needle.

A 10-year-old child presents to the emergency department with dehydration. A physician orders 1 L of normal saline solution be administered at a rate of 60 ml/hour. While preparing the infusion, a nurse notices that the I.V. pump's safety inspection sticker has expired. Which action should the nurse take next? A. After starting the fluids, contact the maintenance department and request a pump inspection. B. Hang the fluids without the pump, carefully calculating the drip rate by visual inspection. C. Take the pump out of commission and locate a pump with a valid inspection sticker. D. Begin the infusion of the fluids while looking for a pump with a valid inspection sticker.

C. Take the pump out of commission and locate a pump with a valid inspection sticker.

A client comes to the clinic for diagnostic allergy testing. The nurse understands that intradermal injections are used for such testing based on which principle? A. Intradermal injection is less painful. B. Intradermal drugs are easier to administer. C. Intradermal drugs have fast onset of action. D. Intradermal drugs diffuse more slowly.

D. Intradermal drugs diffuse more slowly.

The nurse is teaching a client how to administer subcutaneous insulin injections. Which injection site should the client use? A. deltoid B. rectus femoris C. vastus lateralis D. anterior aspect of the thigh

D. anterior aspect of the thigh

A client's intravenous catheter has become occluded. The nurse knows that the reason for the occlusion is: A. dressing and tape above the I.V. insertion site. B. an I.V. infusion rate of 75 mL per hour. C. localized infection. D. thrombosis at the site.

D. thrombosis at the site.

The nurse is administering a tuberculin skin test. Place the steps for administering the tuberculin skin test in the correct order. All options must be used. · Draw up intermediate-strength purified protein derivative. · Create a wheal that is 6 to 10 mm in diameter. · Remove the tuberculin syringe and dispose of the tuberculin syringe. · Obtain a tuberculin syringe, a half-inch, 26-gauge needle, and purified protein derivative. · Inject 0.1 ml of the purified protein derivative. · Clean forearm area with alcohol.

1. Obtain a tuberculin syringe, a half-inch, 26-gauge needle, and purified protein derivative. 2. Draw up intermediate-strength purified protein derivative. 3. Clean forearm area with alcohol. 4. Inject 0.1 ml of the purified protein derivative. 5. Create a wheal that is 6 to 10 mm in diameter. 6. Remove the tuberculin syringe and dispose of the tuberculin syringe.

The nurse is caring for a client with an I.V. line. During care of the I.V. line, the nurse would be required to wear protective gloves in which situations? Select all that apply. A. when inserting the I.V. B. When discontinuing the I.V. C. When changing the I.V. site D. When spiking a new I.V. bag E. When priming the I.V. tubing

A. when inserting the I.V. B. When discontinuing the I.V. C. When changing the I.V. site

The nurse is precepting a graduate nurse and preparing to give infant immunizations. The preceptor asks the graduate, "Infant injections should only be given in which muscle?" What is the best response by the graduate nurse? A. "rectus femoris" B. "deltoid" C. "vastus lateralis" D. "gluteus maximus"

C. "vastus lateralis"

The nurse is preparing to give a medication that comes in an ampule.. Place the steps that the nurse would do in order to prepare giving the medication. All options must be used. · Tap the stem of the ampule. · Perform hand hygiene. · . Invert the ampule and withdraw the medication into the syringe. · Attach the filter needle to the syringe and insert the tip of the needle into the ampule. · Tap the syringe and expel the air carefully by pushing on the plunger. · Wrap a small gauze pad around the neck of the ampule and break off the top of the ampule

1. Perform hand hygiene. 2. Tap the stem of the ampule. 3. Wrap a small gauze pad around the neck of the ampule and break off the top of the ampule. 4. Attach the filter needle to the syringe and insert the tip of the needle into the ampule. 5. Invert the ampule and withdraw the medication into the syringe. 6. Tap the syringe and expel the air carefully by pushing on the plunger.

The client presents to the OB-GYN clinic for her routine subcutaneous (SQ) medroxyprogesterone acetate injection. Which are the best sites for the nurse to administer this type of injection? Select all that apply. A. vastus lateralis B. abdomen C. gluteal D. deltoid E. thigh

B. abdomen E. thigh

When starting the client's intravenous infusion line, the nurse applies a tourniquet and selects the site for inserting the needle. When should the nurse remove the tourniquet? A. when the skin has been cleansed B. as soon as the needle is in the vein C. as soon as the needle is positioned under the skin D. when the needle has been secured with tape

B. as soon as the needle is in the vein