NCLEX Questions (week 5)

The nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further teaching?

"I need to be sure to place my cup of coffee on the counter."

A mother tells the pediatrician's office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work, and they feel isolated and fearful. The nurse would suggest which to the mother?

"You should seek community after-school programs or activities for your children."

A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measures are necessary when caring for this client?

-Administering intermittent feeding through a 60-mL syringe with the plunger removed and the barrel attached to the gastrostomy tube -Monitoring the skin around the stoma site for skin irritation

The nurse is assigned to care for a client experiencing episodes of postural hypotension who will be discharged home soon. Which actions would the nurse take to ensure safety while transferring the client from the bed to the chair?

-Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair. -Put the client's shoes on to help the client avoid slipping on the floor during the transfer. -Question the client about feelings of dizziness.

The nurse is caring for a client who is receiving an intermittent feeding via a nasogastric (NG) tube. Before feeding the client via the NG tube, the nurse would take which actions?

-Check the placement of the tube - Aspirate the contents from the nasogastric tube. -Observe the characteristics and pH of the aspirate from the nasogastric tube.

While caring for a client admitted to the hospital with suspected seizure activity, the client acknowledges the use of the herbal supplement ginkgo, to the nurse. Which follow-up questions by the nurse would be most appropriate?

-Do you have a history of seizures? -Do you have a history of a clotting disorder? -How long and why have you been using ginkgo? -Have you been diagnosed with diabetes mellitus?

The nurse is planning to begin a continuous tube feeding on a client with a nasogastric (NG) tube. Which interventions would the nurse perform before initiating the feeding?

-Elevate the head of the bed to 45 degrees. -Irrigate the NG tube with saline. -Explain the procedure to the client.

The nurse is encouraging an older client who has difficulties with incontinence to participate in recreational therapy. Which nursing interventions would the nurse consider performing before assisting the client to go to the recreational therapy session?

-Encourage the client to use the restroom just before the activity. -Make sure the client is wearing a clean undergarment.

The nurse is inquiring about the client's use of complementary and alternative medicines (CAMs). The nurse would be most concerned with the client who uses which CAMs?

-Homeopathy -Herbal supplements

The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently?

Every hour

A licensed practical nurse (LPN) asks an assistive personnel (AP) to gather supplies in preparation for administering a tepid bath to a child with an elevated temperature. The LPN intervenes if the AP obtains which unnecessary item(s)?

A bottle of alcohol

The nurse is told that a client will be admitted to the hospital for a radiation implant. The nurse is asked to prepare for the admission of the client and plans which measure for this client?

Admit the client to a private room.

The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse would perform?

Aim at the base of the fire.

The nurse is providing eye care to an unconscious client. Which interventions are included in the procedure?

Cleanse each eye moving from the inner canthus to the outer canthus.

A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing?

Closes the roller clamp on the IV tubing

The nurse is reinforcing instructions to a client about safety measures while using oxygen in the home. The nurse determines that there is a need for further teaching if the client verbalized which statement?

Keep the oxygen concentrator as close to the room wall as possible.

The nurse employed in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which is the immediate action of the nurse?

Remove the clients from the waiting room.

The nurse is reinforcing instructions provided to a client with a continuous passive motion (CPM) machine. The nurse determines that there is a need for further teaching when the client states that he should perform which action?

Reset the degrees of flexion or extension according to comfort.

The nurse reinforces instructions to the parents of a newborn infant regarding car travel and safety seats. Which information related to the safety of the infant is correct?

Restrain in a car seat in the back seat in a semi-reclined, rear-facing position.

The registered nurse (RN) and a licensed practical nurse (LPN) are discussing total parenteral nutrition (TPN) with a client who is receiving TPN through a peripherally inserted central catheter (PICC). The client asks why the solution is being infused through a central catheter IV. The nurses explain that TPN is preferably infused through a central line for which reason?

There is greater blood flow with a central line IV to dilute the TPN, which is a concentrated solution and needs to be diluted to avoid damage to the blood vessel.

The nurse is caring for a hospitalized older client who has pulled out his IV for the second time. The nurse inserts a new IV. Which intervention would the nurse institute next for the client?

Wrap a light roll of gauze to cover the IV site.

The nurse is assisting with planning care for a client with an internal radiation implant. Which would be included in the plan of care?

-Wearing gloves when emptying the client's bedpan -Wearing a lead apron when providing direct care to the client

The nurse determines that the client has a proper fitting of the crutches when which criteria have been fulfilled?

-Handgrips are positioned so the elbows are bent approximately 30 degrees. -The space between the axilla and the top of the crutch pad is 1½ to 2 inches. -The nurse can place 3 to 4 fingerbreadths between the axilla and the crutch pad.

A client who is recovering from a brain attack (stroke) has residual dysphagia and is prescribed nectar-thickened liquids. The licensed practical nurse has instructed the assistive personnel (AP) in feeding technique. The nurse would intervene if the AP attempts to perform which activity?

Placing food on the affected side of the mouth

The nurse is preparing to suction a client through a tracheostomy tube. The nurse would perform which actions when performing this procedure?

-Preoxygenating the client before suctioning -Moistening the catheter tip in sterile saline solution before suctioning -Introducing the catheter into the tracheostomy tube using a sterile gloved hand