NSG 326 Week 2 NCLEX questions

A nurse provides teaching on hand hygiene to a client. Which of the following client statements indicates to the nurse a need for further teaching?

"I should wash my hands until they appear clean"

How should a nurse remove personal protective equipment when leaving the client's room? (Move the nursing actions into the box on the right, placing them in the selected order of performance. All steps must be used.)

glove eyewear gown mask perform hand hygiene

While assessing a client's dressing, a nurse notes a watery red drainage. The nurse should document this drainage as which of the following?

serosanguineous

A nurse notes a provider frequently arrives to the unit with bloodshot eyes and smells like alcohol after lunch. Which of the following is an appropriate action for the nurse to take?

notify the nurse manager or charge nurse of the concerns

A nurse observes that a client's spouse is sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is a therapeutic nursing response?

"tell me what is concerning you"

A nurse is preparing to administer vancomycin (Vancocin) to a client following anthrax exposure. The provider prescribes 15 mg/kg every 12 hr. The client weighs 198 lb. How many mg should the nurse administer with each dose? (Round to the nearest whole number.)

1350 mg

A nurse visits an older adult client at home who is recovering from bronchitis. The client reports to the nurse he has a persistent cough and is taking 2 teaspoons (tsp) of cough elixir as needed. The client shows the nurse the bottle, which is labeled dextromethorphan 7.5 mg per 5 mL. How many mg does the nurse calculate that the client has been taking with each dose?

15 mg

A nurse receives a prescription to administer thioridazine (Mellaril) 200 mg PO three times a day for a client who has schizophrenia. Available is thioridazine 100 mg tablets. How many tablets should the nurse administer per dose? (Round to the nearest whole number).

2

A nurse is providing discharge teaching to the parent of a child who is prescribed 10 mL of diphenhydramine (Benadryl) elixir every 4 hr as needed for an allergic response. How many tsp of diphenhydramine should the nurse instruct the parent to administer per dose?

2 tsp

A nurse is preparing to administer midazolam (Versed) 0.2 mg/kg via IV bolus. The client weighs 220 lb. How many mg should the nurse administer? (Round to the nearest whole number.)

20 mg

A nurse receives a prescription to administer olanzapine (Zyprexa) 7.5 mg PO for an adolescent client who has bipolar disorder. Available is olanzapine 2.5 mg tablets. How many tablets should the nurse administer per dose? (Round to the nearest whole number).

3

A postoperative client is prescribed an IV infusion of D5 Ringer's Lactate at 120 mL/hr. The tubing has a drop factor of 20 gtt/mL. The nurse should set the IV flow rate to how many gtt/min?

40 gtt/min

A nurse is preparing to administer liquid mycostatin (Nystatin) 600,000 units PO TID. Available is mycostatin 100,000 units/mL. How many mL should the nurse administer per dose? (Round to the nearest whole number.)

6 ml

information mWhich of the following statements made by a nurse regarding the use of a patient-controlled analgesia (PCA) pump should concern the charge nurse?

I discarded the remaining 2 mg of morphine from the PCA pump. Please document you witnessed it.

A nurse observes a licensed practical nurse (LPN) administer the prescribed benzylpenicillin (Penicillin G) injection to a client. Which of the following actions should prompt the nurse to intervene?

The LPN injects needle 5.08 (2in) below the acromion process

A nurse is preparing to administer the first dose of IV cefoxitin (Mefoxin) to a client who was admitted with a diagnosis of urinary sepsis. Which of the following findings in the client's medical record should cause the nurse to question this prescription?

a documented allergy to amoxicillin-clabulanate

Several nurses were discussing risk factors of transmission when a client has human immunodeficiency virus (HIV). Which of the following individuals are at greatest risk for exposure to HIV?

a phlebotomist who collects blood from a client who has HIV

Evaluating the morning complete blood cell count (CBC) and white blood cell (WBC) differential for an adolescent female client, a nurse notes the following results. Which of the following is the appropriate analysis of the results?

acute infection

A nurse observes a student dispense the prescribed enoxaparin (Lovenox) to a client. Which of the following indicates appropriate medication administration?

applying pressure to site for 2 min after injection

A nurse observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse take?

approach the man and ask why he is making copies

A nurse is preparing to perform a client's blood glucose monitoring. Identify the sequence of steps the nurse should follow. (Move the steps of blood glucose monitoring into the box on the right, placing them in the selected order of performance. All steps must be used.)

check expiration date on test strips perform a quality control test perform hand hygiene cleanse puncture site apply blood sample on test strip document results

After administering morning medications, a nurse realizes that the nifedipine (Procardia) prescribed for one client was inadvertently administered to the client's roommate. The nurse's priority action should be to

check the clients vital signs

A postoperative client is receiving hydromorphone HCL (Dilaudid) via a PCA pump and reports continuous pain. Which of the following should be the nurse's initial action?

check the display on the PCA pump

A nurse is providing education on site rotation for insulin injections to a client who is newly diagnosed with type I diabetes mellitus. Which of the following reasons should the nurse include in the teaching for site rotation?

decreases the risk for lipoatrophy with insulin injections

While assessing a client who is receiving intravenous (IV) therapy via his left forearm, the nurse notes that the site is red, swollen, and painful, and that the surrounding tissues are hard. The nurse's first action should be which of the following?

discontinue the existing IV line

A public health nurse is visiting an older adult client who lives with a family member. The nurse assesses the client and identifies several bruises in various stages of healing. The client explains that the bruises are a result of "clumsiness," and the client's family member agrees. However, based on the location and distribution of the bruises, the nurse suspects the client may be abused. Which of the following actions should the nurse should take first?

follow the agencies guidelines for reporting suspected abuse

The charge nurse is on a team with an assistive personnel (AP) who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take first to recognize the AP's contributions to client care?

give positive feedback directly to the AP

A nurse is teaching a client ways to avoid emergence of multidrug-resistant organisms. Which of the following information should the nurse include in the teaching?

infections become resistant to high doses of antibiotics

Which of the following should the nurse consider when selecting written educational materials for a client who is scheduled for a procedure the next day? (Select all that apply.)

materials should be culturally diverse information must be accurate materials should be written in the clients spoken language materials should be distributed to the client in advance

A nurse is preparing to write an order received from a provider. To prevent medication errors, which of the following entries is the correct way to write an order?

metformin 500mg one tablet daily

When several clients develop watery diarrhea on a medical unit, the nurse suspects Clostridium difficile​. Which of the following actions should the nurse plan to implement while waiting for the lab results?

placing all clients who have symptoms on contact precautions

A nurse overhears two assistive personnel (AP) discussing a hospitalized client while in the cafeteria. Which of the following is the most appropriate nursing action?

quietly tell the APs that this is not appropriate

While obtaining a blood specimen from a client's peripherally inserted venous catheter line, the nurse contaminates his gloved hand with blood. Upon completion of the task, the nurse should

remove the gloves carefully and perform handwashing

The nurse is caring for a client who is getting ready for ambulatory surgery. After the nurse places the IV, the client indicates pain. The nurse should

remove the iv and have another nurse attempt to reinsert an IV into a new site

When checking on a confused client, a nurse finds that the client has fallen out of bed after climbing over the side rails. After determining that the client is uninjured, the nurse assists the client back to bed and contacts the provider to assess the client. The nurse then completes a variance report detailing the incident. Which of the following should be the next nursing action the nurse completes?

submit the variance report to the nurse manager

The nurse is working with a group of clients assisted by an assistive personnel (AP). The nurse should make which of the following determinations before delegating a task to the AP?

that the task is within the AP's scope of practice

A nurse who is caring for a client discusses strategies to promote rest and sleep. Which of the following statements indicates a need for further teaching?

"i will walk briskly for 30 minutes before bedtime"

Upon inspection of a client's skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which of the following statement by the nurse describes a stage 3 pressure ulcer?

"there is full thickness skin loss with a crater."

A nurse prepares to administer 3,800 units of heparin sodium (Heparin) which is available in 5,000 units/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number.)

0.80 ml

Which of the following clients should the nurse recognize as meeting the criteria for the application of a restraint?

a client who pulls at his central venous catheter

Which of the following statements should the nurse include in the teaching?

advance the catheter 2 inches after urine begins to flow

New IV pumps are being delivered to a medical-surgical floor. Which of the following training options should the charge nurse use to best evaluate staff competency with the new equipment?

allow time during the workday when each nurse can demonstrate proficiency

Following a tornado, a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. The nurse should determine that, of the four clients assigned, it is possible to discharge a client who

has chronic Crohn's disease and is 1 day preoperative for an ileostomy

A nurse is preparing to teach a client who has a low literacy level. Which of the following methods should the nurse include?

have 2 to 3 information sessions

A nursing unit has recently implemented new actions designed to reduce medication errors. Which of the following methods of evaluation is appropriate to measure the results of these new actions?

the number of medication errors before and after the actions were implemented