NCLEX QUESTIONS

A nurse is verifying a medication calculation completed by a nursing student prior to administration. The adult client is to receive ampicillin 150 mg/kg/day IV divided in six even doses with a maximum dose of 12 g/day. The client's weight is 80 kg. How many mg/dose will the client receive? Record your answer using whole number.

2000mg

While monitoring a pregnant client's blood pressure, it increases to a dangerous level, and the nurse starts to see early persistent decelerations on the electronic fetal monitor. The healthcare provider is notified and the client is prepped for cesarean section. After surgery the care provider's orders read: Resume all pre-op orders. What is the nurse's priority action(s)? Select all that apply. A: Resume orders B: Hold orders C: Obtain new orders from physician C: Ask supervisor if you can "resume orders"

B&C: The JCAHO's medication standard MM.3.20 requires organizations to prohibit blanket reinstatement of orders, which could include the following: 1) resume all medications, 2) continue home medications, and/or 3) obtain home medications. Blanket orders are dangerous because healthcare providers could forget to include previous medications that could be vital, or nurses and pharmacists may misinterpret the order. The nurse should hold all orders, call the healthcare provider, and obtain new orders.

A nurse is supervising a new graduate registered nurse who is caring for a client hospitalized with active tuberculosis (TB). Which action by the new graduate requires the nurse to intervene? A: A box of tissues is brought to the client from the supply room. B:A surgical face mask is applied before entering the client's room

B: A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the client's room because the HEPA mask can filter out 100% of small airborne particles. All of the other interventions are correct and appropriate for the nurse to perform.

An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. What should the nurse advise the mother to do? A: Notify the health care provider (HCP) immediately to adjust the treatment plan. B: Remove any unsafe items from the area in which the infant is mobile. C: Confine infant in one room D:Remove splint for play and wear at night

B: Safety is the priority in caring for this infant. Infants adapt easily, increasing mobility even with a splint in place. Therefore, the mother needs to ensure that the area in which the infant is mobile is safe. There is no need to contact the HCP to alter the treatment plan. Confining the infant to one room may not allow the child to achieve normal development. The child needs different environments for maximum development. The infant needs to wear the splint as prescribed by the HCP to ensure optimal healing.

The nurse from the nursery is bringing a newborn to a mother's room. The nurse took care of the mother yesterday and knows the mother and baby well. The nurse should implement which action to ensure the safest transition of the infant to the mother? A: Assess whether the mother is able to ambulate to care for the infant. B: Complete the hospital identification procedure with mother and infant. C: Assess need for diapers and formula for infant care.

B:ID is always done regardless of how well mother is known

While hospitalized, a child develops a Clostridium difficile infection. The nurse can anticipate adding which type of precautions for this client? A: droplet B: contact C: airborne D: standard

B; Contact precautions are used for serious illnesses that are easily transmitted by direct client contact or by contact with items in the client's environment. Clostridium difficile infection is an example of an infection that is spread in this manner.

A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/h. What is the priority intervention to maintain safety for this client? A: Maintain continuous fetal monitoring. B:Assess reflexes, clonus, visual disturbances, and headache. C: Have family stay at the bedside. D: Liver lab tests done every 4 hours.

B; In preeclampsia, frequent assessment of maternal reflexes, clonus, visual disturbances, and headache give clear evidence of the condition of the maternal CNS system

A nurse is teaching the parents of a young child how to handle suspected poisoning. If the child ingests poison, the parents should first A: Call an ambulance. B: Call the poison control center. C: Drink Ipecac syrup D: Punish child for bad behavior

B; before intervening in any way, the parents should first call the poison control center for specific instructions. Ipecac syrup is no longer recommended for the ingestion of poisons. The parents may have to call an ambulance after calling the poison control center. Punishment for being bad isn't appropriate because the parents are responsible for making the environment safe.

A client with chronic progressive multiple sclerosis is learning to use a walker. What instruction will best ensure the client's safety? A: Maintain a firm grip on the front bar as you step into the walker." B: Set the back legs down first then step into the walker. C:Place the walker directly in front of you and step into it as you move it forward. D: Use a walker with wheels for easier mobility

C: When the client places the walker directly in front of them, they create a stable base for forward movement and reduces the likelihood of falls. The client shouldn't set the back leg down first because this creates an unstable base that could lead to a fall. The client should firmly grip the side bars; doing so provides a more stable base of support than gripping the front bar. The nurse shouldn't suggest that the client use a walker with wheels. Only a physician or physical therapist may order a walker with wheels.

A nurse notes the following laboratory values for a client receiving chemotherapy: white blood cell count 6000/µL, red blood cell count (RBC) 3.7 million cells/cm3, hematocrit 35%, platelet count 80,000 mm3. Which order would the nurse question? A: semiprivate room B: Restricted diet C: rectal temperatures every 4 hours D: activity as tolerated

C; The platelet count indicated that the client is a risk for bleeding. The low RBC can cause fatigue, so the activity order is appropriate. The hematocrit is reflective of the low RBC count. The white blood cell count is normal, so a semiprivate room or restricted diet is acceptable.

A client has soft wrist restraints to prevent the client from pulling out the nasogastric tube. Which nursing intervention should be implemented while the restraints are on the client? A: Remove the restraints every 4 hours to provide skin care. B: Secure restraints to side rails C: Tightly secure restraints to prevent movement D: Check on the client every 30 minutes while the restraints are on.

D; The application of restraints places the client in a vulnerable, confined position. The nurse should check on the client every 30 minutes while restrained to make sure that the client is safe. The client should be able to move while the restraints are in place. The restraints should be removed every 2 hours to provide skin care and exercise the extremities. Restraints should not be secured to the side rails; they should be secured to the movable bed frame so that when the bed is adjusted the restraints will not be pulled too tightly