RN NCLEX practice test

The RN, LPCN, and UAP are providing care for clients on the nursing unit. Which tasks could be completed only by the RN? - Administration of routine meds - Dressing changes - Assessment of newly admitted clients - Calling the primary healthcare provider about lab results - Teaching the diabetic client foot care

- Assessment of newly admitted clients - Teaching the diabetic client foot care

Where should a nurse place the stethoscope when auscultating heart sounds - First intercostal space right of the sternum to hear sounds from the pulmonic valve area - Fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area - Second intercostal space to the right of the sternum to hear sounds from the aortic valve area - Third intercostal space in the midclavicular line to hear sounds from the mitral area - Apex of the heart to hear the loudest 2nd heart sound

- Fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area - Second intercostal space to the right of the sternum to hear sounds from the aortic valve area

The nurse is caring for a client diagnosed with chronic renal failure who has been taking Epoetin alfa for 2 months. What should the nurse monitor for pertaining to Epoetin alfa during the client's clinic visit? - Hypertension - Halitosis - Hemoptysis - Oliguria - Dependent edema

- Hypertension - Hemoptysis - Dependent edema Epoetin alfa can cause or worsen high blood pressure, induce rapid weight gain, and swelling of feet and hands. Clients may experience coughing up of blood as a result of a rapid increased number of RBCs

A client is being cared for on the orthopedic unit following a football game injury which resulted in a fracture of the left tibia and fibula. An open reduction of the fracture has been performed and a leg cast was applied. The client begins reporting an increase in the pain level (9/10) that is not relieved by the current Morphine dosing, and is experiencing a sensation that "pins are sticking" in the left foot. What action by the nurse is needed? - Increase the PCA dosing of Morphine - Elevate the foot of the bed - Perform neurovascular checks - Apply ice around the sides of the cast - Prepare for possible bivalving of the cast - Notify primary healthcare provider

- Perform neurovascular checks - Prepare for possible bivalving of the cast - Notify primary healthcare provider In identifying compartment syndrome, perform neurovascular checks on the extremity. Bivalving the cast may relieve pressure. If this does not relieve the pressure, the client may need emergency surgery to perform a fasciotomy to restore circulation and prevent nerve and vascular damage, including necrosis.

What should the nurse include when teaching a client diagnosed with Grave's disease who is scheduled to receive radioactive iodine? - Stay 6 feet from people for 2 weeks - This medication is given intravenously as a one-time dose - Radioactive iodine will leave the body in urine and saliva within a few days - You cannot receive radioactive iodine if you are pregnant - Radioactive iodine is absorbed by the parathyroid glands

- Radioactive iodine will leave the body in urine and saliva within a few days - You cannot receive radioactive iodine if you are pregnant

A nurse is observing two unlicensed assistive personnel (UAP) changing sheets for an immobile, obese client. What unacceptable action by the UAPs would require the nurse to intervene? - Stands straight with feet together - Asks client to lift head off of bed - Pulls draw sheet with both hands - Faces slightly toward head of bed

- Stands straight with feet together

The primary healthcare provider prescribed 0.125 mg of digoxin daily for a client. On hand, the nurse has digoxin 0.25 mg/mL. How many mLs of digoxin should the nurse administer? - 5 mL - 3 mL - 0.5 mL - 0.3 mL

0.5 mL

When preparing an intramuscular injection for a neonate, which needle should a nurse select? - 18 G, 7/8 inch - 21 G, 1 inch - 25 G, 5/8 inch - 25 G, 1.5 inch

25 G, 5/8

The community health care nurse plans to educate a client diagnosed with tuberculosis how to avoid spreading the disease to others. What should the nurse include when educating this client? - Wear an N95 respirator when around family at home - Have adult family members get the TB vaccine - Complete TB medication regimen - Live at a sanatorium until cured of TB

Complete TB medication regimen

A client has been admitted for evaluation of severe anxiety and new onset panic attacks following the loss of a spouse. Which client factor would the nurse consider most important in developing a plan of care? - Available support system - Perception of the situation - Desire to return to work - Coping mechanisms

Coping mechanisms

Two hours post chest tube insertion, the nurse notes 100 mL of dark bloody drainage in the collection chamber of the closed drainage unit. What action should the nurse take? - Document the findings - Notify the primary healthcare provider - Decrease the amount of suction - Use a padded hemostat to clamp the chest tube

Document the findings A chest tube is inserted to remove air, blood, or exudate from the pleural space. So 100 mL of dark bloody drainage would not be unusual over the first two hours.

Opisthotonos

Extreme arching of the back and retraction of the neck, seen with tetanus

5 P's of compartment syndrome

pain, pallor, pulselessness, paralysis, paresthesia

A client is admitted to the hospital due to a left-sided cerebrovascular accident. Which interventions should the nurse initiate? - Apply splint nightly to affected extremities - Approach client from the right side - Provide full range of motion once a shift - Elevate left extremities on a pillow - Place pillow in the right axilla - Wrap affected hand into a fist

- Apply splint nightly to affected extremities - Place pillow in the right axilla With a left-sided stroke, the right side of the body is affected. Applying a splint at night to the affected extremity will prevent flexion of that extremity. Prolonged flexion leads to contractures. Prevent adduction of the affected shoulder with a pillow placed in the axilla Vision is controlled by the left side of the brain. Vision on the right side of both eyes may have decreased (hemianopia) due to this left-sided stroke, so approach the client from the left side Provide full range of motion four or five times a day to maintain joint mobility Left sided cerebrovascular accident = right sided paralysis - the right extremities should be elevated on a pillow to prevent dependent edema Fingers should be positioned so that they are minimally flexed to prevent contracture in the hand

A nurse is planning a health fair in a Hispanic community composed of primarily young adults. What would be essential for the nurse to provide to this community at the health fair? - Blood pressure screening - Glucose monitoring - Influenza vaccination - BMI calculation - Test urine for protein - Pneumococcal vaccination

- Blood pressure screening - Glucose monitoring - Influenza vaccination - BMI calculation - Test urine for protein - young adults: 18-40 years Hispanics have a higher incidence of death from heart disease and stroke. BP monitoring is essential to detect and control hypertension. Diabetes is prevalent. Flu vaccination is recommended for all ethnicities. Obesity is high at >70%. Chronic renal failure is a high risk particularly since diabetes is prevalent Pneumococcal vaccine is recommended for older adults >65

What signs/symptoms would the nurse expect to assess in a client diagnosed with Guillain-Barre syndrome? - Opisthotonos - Seizures - Paresthesia - Hemiplegia - Hypotonia - Muscle aches

- Paresthesia - Hypotonia - Muscle aches Guillain-Barre is an acute, rapidly progressing, and potentially fatal form of polyneuritis. It is characterized by ascending, symmetric paralysis affecting the cranial and peripheral nerves. S/s include paresthesia, hypotonia, areflexia, muscle aches, cramps, orthostatic hypotension, hypertension, bradycardia, facial flushing, facial weakness, dysphagia, and respiratory distress Weakness begins symmetrically in the feet and progresses upward; the client gets better in reverse order

A nurse is caring for a client who has been prescribed clonazepam for 6 months. What education should the nurse provide to the client? - Your glucose level should be monitored while prescribed clonazepam - You may experience dry skin periodically while prescribed clonazepam - Schedule appointments to have clonazepam administered intravenously - A long-term prescription of clonazepam should be discontinued gradually

A long-term prescription of clonazepam should be discontinued gradually The physical symptoms of abruptly discontinuing clonazepam including nausea, feeling tired, and headache.. Integumentary symptoms include rash, alopecia, and hirsutism Clonazepam is administered by mouth, tablet and disintegrating tablet

While completing the admission history on an elderly client diagnosed with Alzheimer's disease, the client's spouse begins to sob and states, "After all these years, we won't be together anymore." What would be the best response by the nurse? - You can come to visit anytime you want to - Would you like to see the room and facilities? - Let's find a quiet place to sit and talk - You did the best you could in this situation

Let's find a quiet place to sit and talk

A nurse has provided postpartum discharge instructions to a client who had a cesarean section. What statement by the client would indicate to the nurse that further teaching is necessary? - I will relax and contract my pelvic floor muscles 10 times, eight times a day - Driving is permitted in one week if I am pain free - Lifting anything heavier than my baby is not advised - I will not cross my legs while sitting

Driving is permitted in one week if I am pain free - should wait until after the three week postpartum appointment to drive; client will not have the abdominal muscles to press down on the brake pedal in an emergency

Which nursing action takes priority once a term infant has been delivered vaginally? - Apply identification bands - Apply eye ointment - Dry the baby - Obtain footprints

Dry the baby - cold stress is the biggest danger to a newborn - evaporation will rapidly cool the baby, which can cause hypoglycemia and respiratory distress. The stimulus of drying the skin also promotes vigorous crying and lung expansion in most healthy infants Eye prophylaxis may be delayed until the end of the first hour after birth without adverse effects. Because the ointment may temporarily blur the infant's vision, parents may wish to delay treatment for a short time during initial bonding

The housekeeper and a nurse, having lunch together in the staff lounge, begin discussing the housekeeper's neighbor who has been admitted to the floor. The housekeeper occasionally helps the neighbor with shopping and cleaning. The conversation is overheard by the unit secretary, though no names were mentioned. The conversation is reported to the nurse manager, who determines the situation reflects what HIPAA criteria? - Not permissible because the housekeeper is not medical personnel - Is permissible since the housekeeper does care for the neighbor - Not permissible despite family stating housekeeper is "Like family" - Is permissible given that no other family members are available now

Not permissible because the housekeeper is not medical personnel

A client being treated in the intensive care unit following methamphetamine intoxication states, "Snakes are crawling all over the room, get me out of here!" How does the nurse document this assessment finding? - Delusions - Hallucinations - Flashbacks - Depersonalization

Hallucinations

The nurse identifies that additional teaching about skin care is needed when an 80 year old client makes what statement? - I shower 3-4 times per week - I apply moisturizer at least daily - I bathe in the tub at least 6 times per week - I drink 64 ounces (1.89 L) of liquid per day

I bathe in the tub at least 6 times per week

Which goal is the most important for the nurse to address for a client admitted to the cardiac rehabilitation unit? - Reduction of anxiety - Referral to community resources - Identification of lifestyle changes - Verbalization of energy-conservation techniques

Identification of lifestyle changes

A newly appointed nurse manager on the unit has a stable staff who have worked together for 5 or more years. The unlicensed assistive personnel (UAPs) are accustomed to informally arranging their lunch time; however, the nurse manager has implemented a plan to assign breaks and lunch. The UAPs are angry and refuse to change to the new system. What should be the nurse manager's first action in this situation? - Plan a unit staff meeting to discuss the problem and receive input for resolution - Inform the staff that the plan will be implemented and those not following the plan will be disciplined - Ask the charge nurse to address the problem daily as it occurs - Plan a meeting with all UAPs to discuss the problem and reason for the new assignments

Plan a unit staff meeting to discuss the problem and receive input for resolution

A client is seen at the clinic two weeks after starting amitriptyline. The client reports improved sleep patterns and appetite, but no change in feelings of sadness or depression. What comment by the nurse is most appropriate? - Would you like me to ask the doctor to increase your dose? - You might need to be changed to a different medication - Tell me what type of situations make you feel depressed - Some medications take a little longer to improve moods

Some medications take a little longer to improve moods