NCLEX Prep- Hurst questions
When disposing of waste in a client's room, the nurse would place which item(s) in a biohazard red bag? 1. Chest drainage unit 2. Doxorubicin IV bag and tubing 3. Staples removed from an abdominal incision 4. Tramadol 50 mg tablet prescribed but refused by client 5. Soiled dressing 6. Paper trash with identifying client information
Answers: 1 & 5 Chest drainage units should be capped and placed in a large red biohazard bag for disposal. Dressings soiled with human waste, blood, or body fluids should be disposed of in a red biohazard bag
The nurse is teaching a client about the use of a cane. Which is the correct cane technique? 1. Place the cane on weaker side of the body to support the weaker leg. Using the cane for support, the client should step forward with strong leg, and then move the weaker leg and cane forward to the strong leg. 2. Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. 3. Place cane on weaker side of body. The cane is placed forward 6 to 10 inches while the client advances weaker leg to the cane. 4. Place cane on stronger side of body to help support weaker leg. Using cane for support, step forward with the strong leg and then move the weaker leg and the cane forward to the strong leg.
2. Correct: Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. The body weight is divided between the strong leg and the cane.
Which is the correct method for removing personal protective equipment (PPE)? 1. Contaminated gloves should be removed in the client's room. 2. The glove that is removed first should be placed in the waste basket before the other glove is removed. 3. Remove face shield or goggles first. 4. Shoe covers should be removed last.
Answer: 1 Avoid contaminating self, others, or environment when removing equipment
While making evening rounds, the nurse discovers an elderly, confused client standing next to the bed with the IV pulled out, gown wet with urine and the side rails still in the up position. The client's arm band is on the floor. To ensure client safety, what is the most important intervention for the nurse to include in the plan of care? 1. Provide for scheduled toileting intervals. 2. Apply a restraining vest on the client at night. 3. Cover the IV site with a gauze dressing. 4. Remind client to ring call bell for the nurse.
Answer: 1 The client is confused and likely will not remember any verbal instructions. Therefore, the safest priority action would be to check on the client at regular intervals and assist the client with any bathroom needs at those times
The charge nurse is assigning an unlicensed assistive personnel (UAP) to take vital signs on a group of adult clients. The charge nurse would instruct the UAP that a rectal temperature is contraindicated for which client? 1. Client with thrombocytopenia. 2. Client with a fractured femur. 3. Client with an inguinal hernia. 4. Client with irritable bowel syndrome.
Answer: 1 Thrombocytopenia is the deficiency of platelets in the blood. Due to reduced platelet count, the clotting time fo the client's blood will be reduced. Inserting a rectal thermometer increases the client's risk of rectal trauma. If there is rectal bleeding from the insertion of the rectal thermometer, the client may experience increased bleeding due to their decreased platelet count
An unconscious client is admitted to the ICU with a closed head injury suffered in a fall. Despite aggressive efforts, the client expired within 24 hours. The nurse must complete postmortem care while awaiting the coroner. The nurse knows what action is not appropriate in this situation? 1. Remove indwelling catheter 2. Disconnect the ET tube from ventilator 3. Remove Hospital ID band 4. Cap all IV lines 5. Wash body head to toe
Answer: 1, 3 & 5 The client expired of injuries within 24 hours of being admitted to the hospital, which requires investigation by a coroner. It must be determined if death resulted from fall injuries or whether any action or lackthereof, by medical personnel contributed to the client's demise. When completing postmortem care on a "coroner's case", the nurse must leave all invasive lines and tubes in place for investigative purposes. Therefore, it would not be appropriate for the nurse to remove the foley catheter, although the urine can be emptied from the bag. It is also incorrect to remove any hospital identification bands. Washing the body should never be done since evidence could be disturbed or even removed.
Which discharge instruction should the nurse implement for a client diagnosed with insomnia? 1. eliminate chocolate in the evening 2. drink a glass of red wine 1 hour prior to bedtime 3. perform progressive relaxation techniques at bedtime 4. take acetaminophen/diphenhydramine 2 tablets at bedtime 5. Leisurely walk 3 hours prior to bedtime 6. Increase the air flow on the continuous positive airway pressure (CPAP) machine
Answer: 1, 3 &5 Consuming chocolate in the evening may cause insomnia. Chocolate contains caffeine and xanthines which are stimulates. The chemicals will suppress melatonin and increase the time to fall asleep. Progressive relaxation techniques are recommended to reduce insomnia. This exercise is a systematic relaxation and tensing of the muscle groups of the body. Insomnia is reduced by increasing muscle relaxation and decreasing the stress level of the client. Nonstrenuous exercises such as a leisure walk performed within 3 hours of bedtime promotes the reduction of the client's stress level.
The nursing unit manager is reviewing cardiopulmonary resuscitation protocols with a group of new nurses. When the unit manager asks for an indication of effective CPR on an adult, what new nurse response would be most accurate? 1. Chest wall visibly rises with rescue breathing. 2. Skin color and temperature becomes pink and warm. 3. There is a palpable femoral pulse with a compression. 4. A sinus beat appears on monitor during compression.
Answer: 3 CPR is considered effective if the nurse or medical personnel can palpate a femoral pulse with each chest compression. Thought the lay person is taught to assess a carotid pulse, the femoral pulse is used in a hospital setting
A home health nurse is educating a female client about home care considerations for intermittent catheterization. Which statement by the client would let the nurse know that the client understands what has been taught? 1. after insertion, I will tape the tubing to my lower abdomen 2. I will wash the rubber catheter thoroughly with soap and water after use. 3. it is important that I keep the drainage bag below the level of my bladder 4. Catheterization should be done hourly
Answer: 2 For intermittent catheterization in the home, the client should follow clean technique. Wash rubber catheters thoroughly with soap and water after use, then dry and store in a clean place. With intermittent catheterization, there is no drainage bag and it should be done first thing in the morning and just before going to bed at night. In most cases it should be done every 4-6 hours inbetween, but may need to be done more frequently if oral intake of fluids has increased.
The homecare nurse is visiting a client who recently had a miscarriage at 22 weeks. When is the most appropriate time for the nurse to discuss the topic of another pregnancy? 1. the topic should wait until the nurse builds rapport with the client 2. another pregnancy should not be discussed for at least 6 mo 3. wait until the client initiates the topic of future pregnancies 4. discussion should begin immediately upon the first home visit.
Answer: 3 A mother who has had a miscarriage will experience all, or some, of the Kubler-Ross's stages of death and dying, and therefore, each individual will have a unique response to the loss of a fetus. The best course of action by the nurse is to utilize therapeutic communication techniques and approach the client with open-ended statements. This allows the client to initiate the topic at whatever point is most appropriate for her own situation.
A nurse working in a clinic is planning to assess a client for any sensory deficits. What assessments should the nurse include? 1. Ask the client about any recent changes in vision 2. Observe the client's conversation with others 3. Assess two-point discrimination 4. Perform the Rinne test 5. Test near vision with the Snellen chart
Answers: 1, 2, 3 & 4 Physcial assessment determines whether the senses are impaired. During the physical examination, the nurse assessess vision and hearing and the olfactory, gustatory, tactile, and kinesthetic senses. The exam should reveal the client's specific visual and hearing abilities, perception of heat, cold, liht touch, pain in the limbs, and awareness of the position of body parts. Start with a history and ask about recent change sin vision. Observing client conversation with others can indicate hearing or communication problems. Two-point discrimination will assess tactile sense. The Rinne test assesses hearing. 5. Incorrect. Near vision is assessed by using the Rosenbaum eye chart. It consists of paragraphs of text or characters in different sizes on a 3.5 x 6.5 inch card. Be sure the client has a literacy appropriate for the text used.
The nurse receives new primary healthcare provider prescriptions on a client diagnosed with Addison's disease. What prescription should the nurse question? a. Weigh QD b. IV of NS at 125mL/hr c. MRI of pituitary gland d. Dehydroepiandosterone (DHEA) 5mg PO every other day
Answers: 1, 4 QD is listed on the Joint commisssion on Accreditation of Healthcare Organizations (JCAHO) official "do not use list of aabbreviations" this should be prescribed as "daily" same with "T.I.W" . It should be three "times a week" 2,3 are incorrect because these are both correct actions for Addison's disease and are written properly. An MRI might be suggested of the PG if testing indicates the client might have secondary adrenal insufficiency.
When inspecting the equipment in a client's room, what would the nurse recognize as electrical safety hazard(s)? 1. Flickering overhead light 2. Ground-fault circuit interrupter electrical sockets 3. Hospital labeled UL power strip 4. Bent electrical bed cord 5. Cracked electrical socket
Answers: 1, 4 & 5 Dim or flickering lights are indications that there is a possible electrical wiring problem. Use of a damaged electrical cord or socket increases the risk of an electrical fire, shock, or burn 2. INCORRECT. Ground-fault circuit interrupter (GFCI) electrical sockets should be in place in hospital and healthcare facilities. A GFCI socket will immediately cut off power if it detects someone receives a shock, helping prevent serious injury. 3. INCORRECT. While power strips are not ideal in the hospital setting, power strips that have been inspected and tagged with a hospital label may be used when multiple electrical outlets are required. Additionally, only power strips with the Underwriters Laboratories (UL) seal should be used.
The nurse is providing care for an elderly client who has a percutaneous endoscopic gastrostomy (PEG) feeding tube and is receiving continuous feeding. Which interventions should the nurse include when providing care? a. Add medications to enteral feeding formula b. change dressing around insertion site weekly c. Flush feeding tube with 30 mL warm tap water every 4 hours d. Maintain head of bed at 30 degree elevation e. Monitor for hypoglycemia
Answers: 3,4 All enteral feedings require flushing. Flush feeding tubes in adults with 30 mL of warm tap water every 4 hours during continuous feedings or before and after each intermittent feeding. To prevent aspiration, elevate the HOB to a minimum of 30 degrees, but preferably 45 degrees. a: Do not add medications to the enteral feedng formula. medications can interact with the formula and may cause the feeding tube to clog b. the dressing around the insertion site should be changed at least daily e. the elderly client is more likely to experience hyperglycemia rather than hypoglycemia. This is due to the high carb load in some enteral feeding formulas
A six month old infant has been admitted with a diagnosis of meningococcal meningitis. The primary healthcare provider has written multiple stat prescriptions. In what priority order should the nurse implement these prescriptions? Administer ceftriaxone 250 mg IV TID. Place client on droplet precautions. Prepare client for lumbar pucture. Start IV of D 5 ¼ NS at 25 mL/hr. Draw blood cultures every 8 hours x 3.
The Correct Order: Place client on droplet precautions. Start IV of D 5 ¼ NS at 25 mL/hr. Draw blood cultures every 8 hours x 3. Prepare client for lumbar pucture. Administer ceftriaxone 250 mg IV TID. First: Safety Second: Initiating IV Third: Blood work can be drawn when the IV is started, thus decreasing the number of needle sticks. The IV site may also be used to administer a small amount of sedation prior to the prescribed lumbar puncture. Fourth: Lumbar puncture Fifth: Administer antibiotics last to prevent false lab draws
