RN NCLEX Practice test questions random pull

The nurse is assisting with an education conference for graduate nurses about infant CPR. Which of the following statements are appropriate to include in the teaching? Select all that apply - A single rescuer responding to an unwitnessed infant arrest should perform 2 minutes of CPR before retrieving a defibrillator - Depth of chest compressions for infants should be half the depth of the anterior-posterior chest diameter - Rescuers should place the heel of one hand on the lower sternum when delivering chest compressions to infants - The ratio of chest compressions to breaths during CPR by a single rescuer is 15:2 for infants - You should assess the infant's brachial pulse for no longer than 10 seconds.

- A single rescuer responding to an unwitnessed infant arrest should perform 2 minutes of CPR before retrieving a defibrillator - You should assess the infants brachial pulse for no longer than 10 seconds. Depth of chest compressions: 1/3 of infant's chest Use two fingers or two thumbs on the sternum just below the nipple line Use 30:2 compression to breath ratio with single rescuers. 15:2 used when there are two rescuers.

The nurse if preparing to change a negative-pressure wound therapy dressing on a client's pressure ulcer. Which of the following action are appropriate at this time? Select all that apply. - Administer prescribed pain medication 30 minutes before the procedure - Apply skin protectant to intact skin surrounding the wound - Apply the foam dressing to the wound bed using clean technique - Cut the foam dressing slightly larger than the size of the wound - Ensure that the foam dressing shrinks after the device is turned on.

- Administer prescribed pain medication 30 minutes before the procedure - Apply skin protectant to intact skin surrounding the wound - Ensure that the foam dressing shrinks after the device is turned on

The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time? Select all that apply - Administer prescribed oral narcotics for throat pain - Administer warmed, humidified oxygen via facemask - Give the client ice chips to moisten the mouth - Provide mouth care with oral sponges - Start the client on incentive spirometer.

- Administer warmed, humidified oxygen via facemask - Provide mouth care with oral sponges - Start the client on incentive spirometer

The clinic nurse provides teaching for the parent of a child diagnosed with scabies. Which instructions should the nurse include in the teaching plan? Select all that apply. - All persons in close contact with the child need treatment - Apply the permethrin cream to all skin surfaces - Discard the child's stuffed animals - Fumigate all living areas in the home - Wash the child's clothing and bedding in hot water.

- All persons in close contact with the child need treatment - Apply the permethrin cream to all skin surfaces - Wash the child's clothing and bedding in hot water.

The nurse working in an intensive care unit receives a prescription from the primary health care provider to discontinue a triple-lumen subclavian central venous catheter. Which interventions will help prevent air embolism on removal? Select all that apply. - Applying an air-occlusive dressing - Instructing the client to bear down - Instructing the client to lie in a supine position - Pulling the line harder if there is resistance - Pulling the line out when the client is inhaling.

- Applying an air-occlusive dressing - Instructing the client to bear down - Instructing the client to lie in a supine position.

The nurse is reviewing discharge teaching for a client who had surgical repair of a retinal detachment. Which of the following instructions are appropriate for the nurse to include in the teaching? Select all that apply. - Avoid rubbing or scratching the affected eye - Avoid straining when having a bowel movement - Expect occasional flashes of light during recovery - Report any sudden pain to the health care provider - Rest the eyes by refraining from reading and writing.

- Avoid rubbing or scratching the affected eye - Avoid straining when having a bowel movement - Report any sudden pain to the health care provider - Rest the eyes by refraining from reading and writing

Procedure for bowel irrigation

- Fill the irrigation container with 500-1000 mL of lukewarm water, flush irrigation tubing, and reclamp; hang the container on a hook or intravenous pole - Instruct the client to sit on the toilet, place the irrigation sleeve over the stoma, extend the sleeve into the toilet, and place the irrigation container approximately 18-24 inches above the stoma - Lubricate cone-tipped irrigator, insert cone and attached catheter gently into the stoma, and hold in place. - Slowly open the roller clamp, allowing irrigation solution to flow for 5-10 minutes - Clamp the tubing if cramping occurs, until it subsides - Once the desired amount of solution is instilled, the cone is removed and feces is allowed to drain through the sleeve into the toilet.

A continuous regular insulin IV infusion of 0.2 units/kg/hr is prescribed for a 10-year-old client who weighs 51 lb and has diabetes mellitus. How many units per hour (units/hr) would the nurse administer to this client?

4.6 units/hr

The nurse is teaching the home health client how to perform colostomy irrigation. Which client action reveals that further teaching is required? - Attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma and holds it in place - Fills irrigation container with 500-1000 mL of lukewarm tap water and flushes the irrigation tubing - Hangs the irrigation container on a hook at the level of the shoulder approximately 22 inches above the stoma - Slowly opens the roller clamp, allowing the irrigation solution to flow, but clamps the tubing when cramping occurs

Attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place.

The night nurse receives a call at 4 AM from the laboratory regarding a client's blood cultures that have tested positive for bacteria. Which action by the nurse is appropriate at this time? - Call the answering service and speak to the health care provider now - Document the results of the culture in the client's medical record - Leave a message on the health care provider's office phone - Speak to the health care provider on rounds in the morning.

Call the answering service and speak to the health care provider now.

A float nurse from labor and delivery is assigned to the cardiac unit. Which client is most appropriate for the charge nurse to assign to the float nurse? - Client 3 days following a myocardial infarction who is on 6 L of oxygen and reports nausea - Client admitted for for hypertensive crisis with blood pressure of 154/92 mm Hg on amlodipine PO - Client with a demand pacemaker set at 70/min who has a ventricular rate of 65/min - Client with angina at rest who has normal troponin levels and normal sinus rhythm on ECG

Client admitted for hypertensive crisis with BP of 154/92 mm Hg on amlodipine PO

The nurse is documenting assessments of pregnant clients in the antepartum unit. Which client's assessment findings are most important to report to the health care provider? - Client at 28 weeks gestation with an asymptomatic systolic murmur - Client at 34 weeks gestation with +1 edema of bilateral lower extremeties - Client at 35 weeks gestation with painful genital lesions - Client at 39 weeks gestation with brownish, mucoid vaginal discharge.

Client at 35 weeks gestation with painful genital lesions.

The parent of a 7-month-old reports that the child has been crying and vomiting with a distended belly for the past 4 hours. The infant is now lying quietly in the parent's arms with a pulse of 200/min and respirations of 60/min. Which of the following components of SBAR communication is most important for the nurse to report to the health care provider? - Client has been ill for approximately 4 weeks - Client has improved from apparent earlier distress - Client is now lethargic with abnormal vital signs - Does the health care provider want to order a laxative?

Client is now lethargic with abnormal vital signs.

The nurse reviews laboratory test results for a pregnant client at 32 weeks gestation. What is the nurse's best action based on these results? Exhibit: Laboratory results : Hgb: 11.4 : Hct: 34% : RBCs: 5.3 : WBCs: 14k : Plats: 230k - Complete the client assessment and documentation - Draw another sample for repeat CBC - Prepare for transfusion of packed RBC - Request a prescription for iron supplementation

Complete the client assessment and documentation.

A nurse is caring for a client who is intubated and has a subclavian ventral venous catheter. Which nursing intervention is most important to prevent the spread of infection to this client? - Frequent hand hygiene - No artificial nails - Use of chlorhexidine bath wipes - Wearing personal protective equipment.

Frequent hand hygiene

Unstageable pressure injuries

Have full-thickness skin loss with slough and/or eschar in the base that prevents the nurse from fully visualizing the wound depth to determine the stage. Slough and eschar must be debrided before the wound can be staged.

A client with a 10-year history of methadone use for chronic leg pain is being treated with azithromycin for pneumonia. On the third hospital day, both medications are discontinued as the QT interval on EKG has lengthened, increasing arrhythmia risk. The client wants to be discharged against medical advice to return home and take the client's own medications to prevent going into withdrawal without the methadone. Which is the most appropriate nursing response? - I will ask the HCP to come talk with us so that we can develop a plan to prevent withdrawal while reducing your risk of heart problems - I will talk with the HCP about your concerns, but in the meantime it's important that you stay here - It's important that you stay in the hospital so that we can treat you quickly if you have problems - You have the right to make your own decisions, but you are at high risk for having heart problems if you go home right now.

I will ask the HCP to come talk with us so that we can develop a plan to prevent withdrawal while reducing your risk of heart problems.

The graduate nurse (GN) receives report on a postpartum client with an Rh-negative blood type. Which statement by the GN regarding the Rh immune globulin injection requires the preceptor to provide further teaching? - Additional doses of Rh immune globulin may be required if excessive fetomaternal hemorrhage is suspected - I should administer Rh immune globulin to the client within 72 hours after birth - If the maternal antibody screen is negative, I will hold Rh immune globulin and contact the health care provider - Rh immune globulin is not required if the newborn's blood type is Rh negative

If the maternal antibody screen is negative, I will hold Rh immune globulin and contact the health care provider

The nurse plans care for a client diagnosed with anorexia nervosa who is being admitted after failure of outpatient treatment. Which client outcome will the nurse prioritize? - Acknowledge poor interpersonal skills - Identifies new coping mechanisms - Increases caloric intake to gain weight - Verbalizes sources of conflict and anger.

Increases caloric intake to gain weight.

The registered nurse is counseling the parent of a child recently diagnosed with attention-deficit hyperactivity disorder (ADHD), combined type. Which statement by the parent requires an intervention? - I should offer a choice between 2 things for my child's clothes or meals - I will need to advocate for an individualized educational plan for my child - My child will outgrow this disorder around age 20 - When talking with my child, I should not be multi-tasking.

My child will outgrow this disorder around age 20

The nurse assessing a client's pain would expect the client to make which statement when describing the abdominal pain associated with appendicitis? - My pain is a burning sensation in my upper abdomen - My pain is an 8 out of 10 and on my left side below my belly button - My pain is excruciating in my lower abdomen above my right hip - My pain is intermittent in my abdomen and right shoulder.

My pain is excruciating in my lower abdomen above my right hip Pain associated with acute appendicitis typically begins in the periumbilical region and migrates to the area overlying the appendix (McBurney's point). The client will attempt to decrease pain by lying still with the right leg flexed and preventing increased intraabdominal pressure - avoiding coughing, sneezing, deep inhalation

The clinic nurse prepares to administer a newly prescribed dose of sumatriptan to a client with a migraine headache. Which item in the client's history would cause the nurse to question the prescription? - Blood urea nitrogen of 12 mg/dL - BMI of 34 kg/m2 recorded during today's examination - Past medical history of uncontrolled hypertension - Takes alprazolam as prescribed for anxiety

Past medical history of uncontrolled hypertension

Chronic vitamin B12 deficiency

Primarily supplied by animal products - May precipitate megaloblastic anemia and neurological symptoms across the entire nervous system, from peripheral nerves to the spinal cord and brain - Peripheral neuropathy - tingling and numbness - Neuromuscular impairment - gait problems, poor balance - Memory loss/dementia - in cases of severe/prolonged deficiencies.

The charge nurse must assign a room for a client who was transferred from a long-term care facility and is scheduled for extensive surgical debridement to remove infected tissue from an unstageable pressure injury. Which room assignment is the most appropriate for this client - Room A: Client with multiple myeloma who is being treated with corticosteroids - Room B: Client with diabetes mellitus and osteomyelitis receiving IV antibiotics. - Room C: Client with a gastrointestinal bleed who has a nasogastric tube - Room D: Client with influenza with a high fever who is receiving oseltamivir

Room C: client with a gastrointestinal bleed who has a nasogastric tube.

Sumatriptan

Selective serotonin agonist prescribed to treat migraine headaches, which are thought to be caused by dilated cranial blood vessels, and clients should be instructed to take a dose at the first sign of a migraine to help prevent and relieve symptoms. - Contraindicated in clients with coronary artery disease and uncontrolled hypertension because its vasoconstrictive properties increase the risk of angina, hypertensive urgent decreased cardiac perfusion, and acute myocardial infarction.

The nurse assesses a client who has followed a vegan diet for several years. Which client statement indicates a potential nutritional deficiency? - I have had some visual disturbances while driving at night - I have had trouble falling asleep over the past few months - Scaly patches of skin are developing on my elbows and knees - Sometimes my hands and feet get a tingling sensation

Sometimes my hands and feet get a tingling sensation

A 21-year-old client is being evaluated in the outpatient psychiatric clinic after starting isocarboxazid 2 weeks ago. Which of the client's statements needs to be addressed first? - I am not sleeping well at night and would like a sleeping aid - I do not know how well I will do on this restricted diet - I have been having quite a bit of nausea and constipation - This medicine is not working. I am so tired of being depressed.

This medication is not working; I am so tired of being depressed.

The nurse enters a client's room just as the unlicensed assistive personnel (UAP) is completing a bath and placing thigh-high anti-embolism stockings on the client. Which situation would cause the nurse to intervene? - UAP applies the anti-embolism stockings while maintaining the client in supine position - UAP carefully smoothes out any wrinkles over the length of the stockings - UAP checks that the toe opening of the stockings is located on the plantar side of the foot - UAP rolls down and folds over the excess material at the top of the stockings

UAP rolls down and folds over the excess material at the top of the stockings.

Negative-pressure wound therapy (NPWT)

Used to treat chronic wounds with impaired healing. Promotes wound healing and approximation by using negative pressure to remove fluid, exudate, and infectious organisms and encourages circulation of blood to the wound bed. A sterile foam dressing is cut to fit the wound, placed in the wound bed, and then covered with an occlusive dressing to create a seal. A vacuum-assisted closure unit is then connected to create negative pressure.