NCLEX questions (brilliantnurse.com)

The nurse realizes that the nursing assistant needs further teaching if she observes the nursing assistant: Walking the postoperative client with leg pain Bathing the client using soap and water Changing the bed of the client in traction from top to bottom Feeding the client using a disposable spoon and fork

Correct! The client with leg pain might be experiencing a deep vein thrombus. Activities that can dislodge the clot can result in pulmonary embolus. The client should be returned to bed immediately and the finding should be reported to the physician. Answer B is incorrect because there is no contraindication to using soap and water to bathe the client. If the client is in traction, it is often easier to change the bed from top to bottom; therefore, Answer C is incorrect. Answer D is incorrect because disposable utensils are suitable for use when feeding the client.

The nurse is preparing to make rounds. Which client should be seen first?: A 1-year-old with hand-and-foot syndrome A 69-year-old with congestive heart failure A 40-year-old with resolving pancreatitis A 56-year-old with Cushing's disease

Correct! The nurse should first see the client with congestive heart failure in order to evaluate the client's respirations. This client is in the most immediate danger. Answer A is incorrect because the 1 year old with hand foot syndrome is experiencing swelling and pain in the joints related to sickle cell anemia. This client can be seen after the client in Answer B. Answers C and D are incorrect because the client with resolving pancreatitis and the client with Cushing's disease is more stable than the client with congestive heart failure

A category four tornado has injured 50 people from the community. The nurse is responsible for in field triage. According to triage protocol, which client should betreated last? The 30-year-old with lacerations to the neck and face The 70-year-old with chest pain and shortness of breath. The 6-year-old with fixed, dilated pupils who is nonresponsive The 40-year-old with tachypnea and tachycardia

Correct! The six-year-old with fixed, dilated pupils who is unresponsive is unlikely to survive. According to disaster triage protocol, priority is given to those clients who are expected to survive with fewer resource expenditures. Answers A, B, and D are incorrect for this reason.

The nurse is preparing to administer four medications to the client with dysphagia.Which medication should be administered first? Conjugated estrogen (Premarin) Furosemide (Lasix) Ceclor (cephaclor) Diphenhydramine (Benadryl)

Lasix Furosemide (Lasix) is a diuretic commonly used to treat congestive heart failure and hypertension. This drug should be given first to ensure that the client receives medication to treat potential life-threatening condition. Answers A, C, and D are incorrect because these drugs can be given after the furosemide (Lasix).

A nursing assistant has reported to work late for the last three days. Which action should be taken first? Document the lateness in the employee's record Terminate the employee immediately Discuss the problem with the employee Confront the employee during the change of shift

Yes! .Discussing the problem with the employee will allow the employee to explain the lateness. This action should be taken first. Answer A is incorrect because documentation will be done after the meeting. Answer B is incorrect because the employee should be given the opportunity to explain the lateness. The employee should also be told what action will be taken if the problem is not corrected. Answer D is incorrect because the employee should be confronted privately.!

The nurse observes a co-worker striking a client with Alzheimer's disease. The coworker can be charged with: Battery Assault Malpractice Negligence

Yes! Battery, an intentional tort, refers to physical contact in an offensive manner without the intent to do harm. Striking the client is a form of battery. Answer B is incorrect because assault, also an intentional tort, refers to threatening or attempting violence without physical contact. Answer C is incorrect because malpractice refers to unreasonable lack of skill in performing professional duties that results in injury or death of the client. Answer D is incorrect because negligence refers to acts of omission or commission that results in injury to the client or the client's property. Malpractice and negligence are examples of unintentional torts.

During morning report, the nurse is told that the postoperative client has complained of unremitting pain during the night. Although she has been given pain medication several times, there seems to be no change in the client's condition. Which action should the nurse take at this time? Call the doctor and ask for a change in the client's medication Perform a head-to-toe assessment Administer another dose of the client's prescribed analgesic Ask the client whether she is addicted to pain medications

Yes! Because the client has had no relief from pain, even with administration of pain medication, the nurse should fully assess the cause of the pain. Answer A is incorrect because an assessment should be done prior to changing the medication. Answer C is incorrect because administration of an analgesic has done little to relieve the client's pain during the night; therefore, it is unlikely that another dose will offer relief. Answer D is incorrect because there is no data to suggest that the client is addicted and implies an assumption on the part of the nurse.

Four clients have been assigned to the nurse for a home visit. Which client should the nurse visit first? A 65-year-old with diabetes and venous stasis ulcers A 10-year-old with spina bifida who performs daily self catheterization A 75-year-old with a stroke who receives peg tube feedings A 35-year-old with systemic lupus who complains of blurred vision and headaches

Yes! Complaints of headache and blurred vision by the client with SLE can indicate increasing hypertension, which accompanies renal failure, stroke, and myocardial infarction. Answers A, B, and C are incorrect because these clients have more stable conditions; therefore they can be visited later.!

The nurse is caring for an infant with suspected Munchausen's syndrome. While making rounds, the nurse finds the mother putting something in the infant's bottle. The nurse should: Remove the bottle and report the incident to the charge nurse Ask the mother what she added to the infant's bottle Check to see whether the infant becomes ill after taking the bottle Request that a dietician visit with the mother

Yes! Munchausen's syndrome (abuse by proxy) occurs when illness is caused by the caregiver. Removing the bottle and reporting the incident to the charge nurse can prevent further injury to the infant and provide a means of therapeutic intervention. Answer B is incorrect because of a lack of therapeutic communication between the nurse and mother. Answer C is incorrect because further harm might come to the infant. Answer D is incorrect because the problem is not with the infant's diet.

The nursing staff of a local clinic is made up of two registered nurses and two licensed practical nurses. Which duty is within the scope of practice of the licensed practical nurse? Administering a monthly infusion of Remicade to a client with rheumatoid arthritis Removing sutures from a client following abdominal surgery Changing a peg tube in a client with a stroke Flushing a Groshong catheter in a client receiving chemotherapy

Yes! Removing sutures is within the scope of practice of the LPN. Answers A, C, and D are incorrect because they involve skills outside the scope of practice of the LPN.

The charge nurse is making assignments for the day. Which client should be cared for by the RN? A client receiving radiation therapy for Graves' disease A client with cachexia who is receiving total parenteral nutrition A client who is three days post-gastrectomy A client with an above-the-knee amputation

Yes! TPN is infused via central line; therefore, the client should be cared for by the RN. The RN should assess the client for complications associated with the use of TPN, which include injury during central line placement, sepsis, and metabolic disturbances. Answers A, C, and D are incorrect because the clients can be cared for by the LPN.!

The charge nurse is responsible for assigning clients to share a semi-private room. Which two clients can be assigned to share the room? The 15-year-old with pneumonia and a 10-year-old with human immunovirus The 30-year-old with leukemia receiving chemotherapy and the 25-year-old with bronchitis The 60-year-old with gastroenteritis and the 65-year-old with Cushing's disease The 70-year-old with diabetes and the 75-year-old with a fractured hip

Yes! The 70-year-old with diabetes and the 75-yearold with a fractured hip can be assigned to the semi-private room because neither one has an infection or is immune compromised. Answer A is incorrect because the client with pneumonia can infect the client with human immunovirus. Answer B is incorrect because the client with bronchitis poses a risk of infection to the client with leukemia. Answer C is incorrect because the client with gastroenteritis poses a risk of infection to the client with Cushing's disease due to immunosuppression.!

The nurse is caring for a client with tuberculosis. Which of the following is not a part of the client's care? Keeping the client's door closed at all times Wearing an N95 mask only when providing direct care Maintaining the client in a room with at least six exchanges of fresh air per hour Providing phototherapy with a source of ultraviolet light

Yes! The N95 mask should be worn when the nurse is in the room of a client with TB, not just when providing direct care. Answers A, C, and D are incorrect choices because they are a part of the care for the client with tuberculosis.

The nurse observes the nursing assistant speaking harshly to an elderly client. Which action is most appropriate? Ask the nursing assistant to speak in a lower tone because he is disturbing the other clients Report the nursing assistant to the charge nurse Reassign the nursing assistant to a younger client Call the nursing assistant aside to discuss the observation

Yes! The best action is to call the nursing assistant aside and explore the reason for her harsh behavior toward the elderly client. The nurse's priority action should be to protect the client. Answer A is incorrect because this answer does not address the problem. Answer B is incorrect because this answer does not foster a resolution of the problem. Answer C is incorrect because this answer does not ensure that the nursing assistant will behave differently toward a younger client.

The nursing staff consists of two registered nurses, two licensed vocational nurses, and a certified nursing assistant. The skills of the nursing assistant are best suited to: Feeding a client with Alzheimer's dementia Bathing a client with a central line Obtaining vital signs on a client with pneumonia Collecting the output from a client with preeclampsia

Yes! The certified nursing assistant is prepared to provide basic care, such as feeding or bathing, to clients with predictable conditions such as Alzheimer's dementia. Answer B is incorrect because the nursing assistant will not know what to do if problems are encountered with a central line. Answer C is incorrect because the nurse, not the nursing assistant, is best suited to assess the vital signs of a client with a respiratory infection. Answer D is incorrect because the client with preeclampsia will require hourly output measurements; therefore the output should be measured by the nurse.!

Four clients arrive in the emergency room. Which client should receive priority? The client with burns of the chest and neck The client with gastroenteritis The client with a migraine headache The client with a fractured tibia

Yes! The client with burns of burns chest and neck should be seen first because he is at risk for airway obstruction. Answers B, C, and D are incorrect because these clients do not take priority over the client with potential airway obstruction.!

Which task is best delegated to the licensed practical nurse? Beginning an infusion of platelets Inserting a nasogastric tube Flushing a central venous catheter Administering intravenous dexamethasone (Decadron)

Yes! The licensed practical nurse is skilled in the insertion of nasogastric feeding tubes. Answers A, C, and D are incorrect because these are tasks are best performed by the registered nurse. Some states allow the licensed practical nurse to obtain certification in intravenous administration; however, IV administration cannot be performed by licensed practical nurses in all states. Nurses should be familiar with the nurse practice act in the state in which they practice.!

While making rounds, the nurse smells smoke coming from a client's room. On checking the room, the nurse finds a fire in the trash can. The nurse should give priority to: Activating the fire alarms Locating the unit fire extinguisher Moving the client to a safe location Evacuating all the clients to another unit

Yes! The nurse should give priority to ensuring the safety of the client who is in harm's way; therefore, the client should be moved to a safe location. Answers A and B are performed after the client is moved; therefore, they are incorrect. Answer D is incorrect because the unit should not be evacuated unless there is a danger to others.

The nurse observes a co-worker putting a contaminated dressing on the client's bedside table. Which action is most appropriate? Remove the contaminated dressing and clean the surface of the bedside table with a hypochlorite solution Wait until after the co-worker finishes and then request housekeeping to completely clean the room Remove the contaminated dressing and place it in the client's waste can Ask the co-worker why he placed the contaminated dressing on the client's bedside table

Yes! The nurse should remove the contaminated dressing and clean the surface of the bed side table with a hypochlorite solution. A hypochlorite solution is one part bleach and ten parts water. Answer B is incorrect because there is no indication that the entire room needs cleaning. Answer C is incorrect because the dressing should be placed in a red bag before placing in the waste can. Answer D is incorrect because asking why is nontherapeutic. The nurse should discuss the proper disposal of contaminated articles with the co-worker.

Which task must be performed by the registered nurse? Hanging a bag of total parenteral nutrition solution Inserting an indwelling urinary catheter Administering a vaginal suppository Checking the weights used with skeletal traction

Yes! The registered nurse should be assigned to hang total parenteral nutrition solution. Total parenteral nutrition, administered by central line, contains lipids and other nutrients needed by the client in negative nitrogen balance. Answer B is incorrect because the licensed practical nurse can insert an indwelling urinary catheter. Answer C is incorrect because the licensed practical nurse can administer a vaginal suppository. Answer D is incorrect because the licensed practical nurse can check the weights used with skeletal traction.