NCLEX review questions
A client reports pain in his right lower extremity. The physician orders codeine 60 mg and aspirin grains X PO every 4 hours, as needed for pain. Each codeine tablet contains 15 mg of codeine. Each aspirin contains 325 mg of aspirin. Which of the following should the nurse administer? 1. 2 codeine tablets and 4 aspirin tablets 2. 4 codeine tablets and 3 aspirin tablets 3. 4 codeine tablets and 2 aspirin tablets 4. 3 codeine tablets and 3 aspirin tablets
Answer: 4 codeine tablets and 2 aspirin tablets Needed info: 60 mg = 1 grain 60/x = 15/1 x = 4 10 grains = 600 mg 325/1 = 600/x x = 1.8 (round to 2)
A nurse in the outpatient clinic evaluates the Mantoux test of a client whose history indicates that she has been treated during the past year for an AIDS-related infection. The nurse should document that there was a positive reaction if there is an area of induration measuring which of the following? 1. 1mm 2. 3mm 3. 5mm 4. 7mm
Answer: 7mm Needed info: given intradermally in the forearm; read in 48-72 hours, 10mm induration (hard area under the skin) = significant (positive) reaction. Greater than 5mm for clients with AIDS = positive reaction. Does not mean active disease is present but indicates exposure to TB or the presence of inactive (dormant) disease. Multiple puncture test done for routine screening Greater than 5mm area positive for client with HIV-infection history.
The nurse in the newborn nursery has just received report. Which of the following infants should the nurse see FIRST? 1. A 2-day old infant who is lying quietly alert with a heart rate of 185. 2. A 1-day old infant who is crying and has a bulging anterior fontanel. 3. A 12-hour old infant who is being held, with respirations that are 45 breaths per minute and irregular. 4. A 5-hour old infant who is sleeping and whose hands and feet are blue bilaterally.
Answer: A 2-day old infant who is lying quietly alert with a heart rate of 185. Remember: ABC's (airway, breathing, and circulation) Infant has tachycardia; normal resting rate is 120-160; requires further investigation
The nurse is caring for clients on the surgical floor and has just received the report from the previous shift. Which of the following clients should the nurse see FIRST? 1. A 35-year old admitted 3 hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on the dressing. 2. A 43-year old who had a mastectomy 2 days ago; 23 mL of serosanguinous fluid noted in the Jackson-Pratt drain. 3. A 59-year old with a collapsed lung due to an accident; no drainage noted in the previous 8 hours. 4. A 62-year old who had an abdominal-perineal resection 3 days ago; client reports chills.
Answer: A 62-year old who had an abdominal-perineal resection 3 days ago; client reports chills. At risk for peritonitis; should be assessed for further symptoms of infection.
The nurse is caring for clients in the outpatient clinic. Which of the following phone calls should the nurse return FIRST? 1. A client with hep A who states, "My arms and legs are itching." 2. A client with a cast on the right leg who states, "I have a funny feeling in my right leg." 3. A client with osteomyelitis of the spine who states, "I am so nauseous that I can't eat." 4. A client with rheumatoid arthritis who states, "I am having trouble sleeping."
Answer: A client with a cast on right leg who states, " I have a funny feeling in my right leg." May indicate neurovascular compromise; requires immediate assessment.
The nursing team consists of 1 RN, 2 LPNs/LVNs, and 3 NAPs. The RN should care for which of the following clients? 1. A client with a chest tube who is ambulating in the hall. 2. A client with a colostomy who requires assistance with colostomy irrigation. 3. A client with a right-sided cerebrovascular accident (CVA) who requires assistance with bathing. 4. A client who is refusing medication to treat cancer of the colon.
Answer: A client with is refusing medication to treat cancer of the colon. Requires the assessment skills of the RN. Needed info: Determine nursing care required to meet clients' needs; take into account time required, complexity of activities, acuity of client, infection control issues. Consider knowledge and abilities of staff members and decide which staff person is best able to provide care. Give assignments to staff members (assign responsibility for total client care; avoid assigning only procedures). Provide additional help as needed.
The school nurse notes that a first-grade child is scratching her head almost constantly. It would be MOST important for the nurse to take which of the following actions? 1. Discuss basic hygiene with the parents. 2. Instruct the child not to sleep with her dog. 3. Inform the parents that they must contact an exterminator. 4. Observe the scalp for small white specks.
Answer: Observe the scalp for small white specks. Nits (eggs) appear as small, white, oval flakes attached to hair shaft. Needed info: Pediculosis (lice). Assessment: scalp-white eggs (nits) on hair shafts, itchy; body-macules and papules; pubis-red macules. Nursing consideration: OTC pyrethrin (RID, A-200), permethrin 1% (Nix); kills both lice
A nurse plans for care of a client with anemia who is reporting weakness. Which of the following tasks should the nurse assign to nursing assistive personnel? 1. Listening to the client's breath sounds 2. Setting up the client's lunch tray 3. Obtaining a diet history 4. Instructing the client on how to balance rest and activity
Answer: Set up a client's lunch tray. Standard, unchanging procedure; decreases cardiac work load.
A 1-day old newborn diagnosed with intrauterine growth retardation is observed by the nurse to be restless, irritable, and fist-sucking, and having a high-pitched, shrill cry. Based on this data, which of the following actions should the nurse take FIRST? 1. Massage the infants back 2. Tightly swaddle the infant in a flexed position. 3. Schedule feeding times every 3 to 4 hours 4. Encourage eye contact with the infant during feedings
Answer: Tightly swaddle the infant in a flexed position. Promotes infant's comfort and security. Needed info: Drug withdrawal may manifest from as early as 12 hours after birth up to 10 days after delivery. Symptoms: high-pitched cry, hyperreflexia, decreased sleep, diaphoresis, tachypnea, excessive mucus, vomiting, uncoordinated sucking. Nursing care: assess muscle tone, irritability, vital signs; administer phenobarbital as ordered; report symptoms of respiratory distress; reduce stimulation; provide adequate nutrition/fluids; monitor mother/child interactions.
The home care nurse is visiting a client during the icteric phase of hepatitis of unknown etiology. The nurse would be MOST concerned if the client made which of the following statements? 1. "I must not share eating utensils with my family." 2. "I must use my own bath towel." 3. "Im glad that my husband and I can continue to have intimate relations." 4. "I must eat small, frequent feedings."
Answer: "Im glad that my husband and I can continue to have intimate relations." Avoid sexual contact until serologic indicators return to normal. Needed info: (Hep A) high risk groups include young children, institutions for custodial care, international travelers; transmission by fecal/oral, poor sanitation; nursing considerations include prevention, improved sanitation, treat with gamma globulin early post-exposure, no preparation of food. (Hep B) high risk groups include drug addicts, fetuses from infected mothers, homosexually active men, transfusions, health care workers; transmission by parenteral, sexual contact, blood/body fluids; nursing considerations include vaccine, immune globulin. (Hep C) high risk groups include transfusions, international travelers; transmission by blood/body fluids; nursing considerations include great potential for chronicity.
The nurse is leading an inservice about management issues. The nurse would intervene if another nurse made which of the following statements? 1. "It is my responsibility to ensure that the consent form has been signed and attached to the client's chart prior to surgery." 2. "It is my responsibility to witness the signature of the client before surgery is performed." 3. "It is my responsibility to provide a detailed description of the surgery." 4. "It is my responsibility to answer questions that the client may have prior to surgery."
Answer: "It is my responsibility to provide a detailed description of the surgery." Physician should provide explanation.
The nurse visits a neighbor who is at 20 weeks' gestation. The neighbor reports nausea, headache and blurred vision. The nurse notes that the neighbor appears nervous, is diaphoretic, and is experiencing tremors. It would be MOST important for the nurse to ask which of the following questions? 1. "Are you having menstrual-like cramps?" 2. "When did you last eat or drink?" 3. "Have you been diagnosed with diabetes?" 4. "Have you been lying on the couch?"
Answer: "When did you last eat or drink?" Classic symptoms of hypoglycemia; offer carbohydrates. Needed info: Assessment: irritability, confusion, tremors, blurring of vision, coma, seizures, hypotension, tachycardia, skin cool and clammy, diaphoresis. Plan/Implementation: liquids containing sugar if conscious, skim milk is ideal if tolerated; dextrose 50% IV if unconscious, glucagon: follow with additional carbohydrate in 15 minutes; determine and treat cause; client education; exercise regimen.
Which of the following actions by the nurse would certainly be considered negligence? 1. Inserting a 16 Fr nasogastric tube and aspirating 15 mL of gastric contents. 2. Administering meperidine IM to a client prior to using the incentive spirometer. 3. Turning and repositioning a client once every 8 hours post-abdominal surgery. 4. Initially administering blood at 5 mL per minute for 15 minutes.
Answer: Turning and repositioning a client once every 8 hours post-abdominal surgery. Postoperative clients should be turned and repositioned every 2 hours after surgery to promote circulation and reduce the risk of skin break down (except if contraindicated, such as in neurologic or musculoskeletal surgery demanding immobilization) Needed info: Negligence is unintentional failure of nurse to perform an act that a reasonable person would or would not perform in similar circumstances; can be an act of commission or omission. Standards of care: the actions that other nurses would do in the same or similar circumstances that provide for quality client care. Nurse practice acts: state laws that determine the scope of the practice of nursing.
While inserting a nasogastric tube, the nurse should use which of the following protective measures? 1. Gloves, gown, goggles, and surgical cap 2. Sterile gloves, mask, plastic bags, and gown 3. Gloves, gown, mask and goggles 4. Double gloves, goggles, mask, and surgical cap
Answer: gloves, gown, mask and goggles Needed info: Mask, eye protection, face shield protect mucous membrane exposure; used if activities are likely to generate splash or sprays. Gowns used if activities are likely to generate splashes or sprays. Must use universal precautions on ALL clients; prevent skin and mucous membrane exposure when contact with blood or other body fluids is anticipated
To determine the structural relationship of one hospital department with another, the nurse should consult which of the following? 1. Organizational chart 2. Job descriptions 3. Personnel policies 4. Policies and Procedures Manual
Answer: organizational chart Delineates the overall organization structure, showing which departments exist and their relationships with one another both laterally and vertically.
The nurse reinforces teaching for a client after a right mastectomy and axillary lymph node dissection. Which statement by the client requires further intervention by the nurse? Select all that apply. 1. "I will wear gloves and long sleeves while I am in my garden." 2. "The risk for arm swelling will decrease one year after my treatment is completed." 3. "I will sleep with my right arm elevated on a small flat pillow from now on." 4. "If my right arm begins to feel heavy, I should contact my clinician." 5. "It will be necessary for me to wear a compression bandage for the rest of my life."
Answers are 2, 3, and 5 1. Will wearing gloves and long sleeves while gardening prevent lymphedema? Yes. Any injury to the right arm, including insect bites or scrapes, may become infected and cause lymphedema. This is a correct action. Eliminate. 2. Will arm swelling decrease one year after the mastectomy procedure? No. The client is at risk for lymphedema for the rest of their life. This statement is not true. Select the answer. 3. Will arm elevation on a small flat pillow decrease the risk of lymphedema? No. The arm should be elevated above the level of the heart at night. It is an incorrect action. Select this answer. 4. Arm heaviness is a sign of lymphedema development. Client instruction includes notifying clinician if the involved arm feels heavy, has decreased muscle function, or has numbness and tingling. This is a correct action. Eliminate 5. Will a client need to wear a compression bandage for the rest of their life? No. Compression bandages may be used if the client develops acute lymphedema. Compression bandages are not routinely used after mastectomy and lymph node dissection. Select this answer.
The LPN/LVN prepares to administer an intramuscular injection to a 6 month old. Where should the injection be given?
For infants, IM injection should be given in the middle third of the anterior thigh (vastus lateralis muscle), between the midline anterior thigh and the midline lateral thigh. To identify the IM injection site, locate the greater trochanter, then the knee joint; divide the area between the trochanter and the knee joint into thirds and note the middle third; then locate the area between the midline anterior thigh and the midline of the outer aspect of the thigh.
The LPN/LVN cares for a client diagnosed with Parkinson's disease. The LPN/LVN observes that the client has tremors of the hands and slurred speech. The family reports that the client appears depressed. What is the PRIORITY of care for this client? 1. Provide a clock and calendar in the client's room. 2. Encourage the client to perform range of motion exercises. 3. Ask the family about the client's favorite television shows. 4. Assist the client to sit on the edge of the bed before ambulation.
Remember that physical and safety needs take priority over psychosocial needs.
The LPN/LVN prepares to reinforce instructions for a client about the use of an incentive spirometer. Arrange the following steps in the order the client should perform them. All options must be used. 1. Seal lips around the mouthpiece. 2. Assume semi-Fowler's or high Fowler's position. 3. Exhale slowly and cough 4. Hold breath for 3-5 seconds. 5. Inhale slowly and deeply.
The answer is 2, 1 ,5 ,4, & 3 What is the purpose of incentive spirometer? To open the alveoli and lower airway passages and increase oxygenation. What position enables the client to inhale deeply to promote lung expansion? The upright position (2). Before the client inhales through the mouthpiece, there must be a tight seal (1). In order to make the volume indicator move, the client must inhale slowly and deeply (5). To achieve maximum expansion of the lungs, the client should hold the inhalation for 3 to 5 seconds (4). The last step is slow exhalation (3), which will continue to promote expansion of the lower airways.
The LPN/LVN prepares to administer 1 liter of normal saline at a rate of 125 mL/hr. The drop factor for the intravenous tubing is 15 drops per mL. What is the drip rate per minute? Round to the nearest whole number.
The answer is 31 gtt/min Formula: 125 mL/hr over 60 min Times 125 mL and 15 drops = 1,875 Divide 1,875 drops/mL by 60min = 31.25 drops per minute = round to 31 drops
The nurse is interviewing a client who is being treated for obsessive-compulsive disorder (OCD). Which of the following is the most important question the nurse should ask this client? 1. "Do you find yourself forgetting simple things?" 2. "Do you find it hard to stay on a task?" 3. "Do you have trouble controlling upsetting thoughts?" 4. "Do you experience feelings of panic in a closed area?"
The answer is..."Do you have trouble controlling upsetting thoughts?" Obsessive-compulsive disorder is characterized by a history of obsessions and compulsions. Obsessions are recurrent and persistent thoughts, ideas, impulses, or images that are experienced as intrusive and senseless. The client may know that the thoughts are ridiculous or morbid but cannot stop, forget, or control them. Compulsions are repetitive behaviors performed in a certain way to prevent discomfort and neutralize anxiety.
A client is telling the nurse about his perception of his thought patterns. Which of the following statements by the client would validate the diagnosis of schizophrenia? 1. "I can't get the same thoughts out of my head." 2. "I know I sometimes feel on top of the world, then suddenly down." 3. "Sometimes I look up and wonder where I am." 4. "It's clear that this is an alien laboratory and I am in charge."
The answer is..."It's clear that this is an alien laboratory and I am in charge." Illogical, disorganized thoughts are typical of schizophrenia. Schizophrenia is generally characterized by delusions (grandiose, religious, paranoid, nihilistic, or delusions of reference or influence), confusion, hallucinations, and illusions (misinterpretations of real external stimuli).
A nursing team consists of an RN, an LPN/LVN, and an NAP. The nurse should assign which of the following clients to the LPN/LVN? 1. A 72-yo client with diabetes who requires a dressing change for a stasis ulcer 2. A 42-yo client with cancer of the bone reporting pain 3. A 55-yo client with terminal cancer being transferred to hospice home care 4. A 23-yo client with a fracture of the right leg who asks to use the urinal
The answer is...A 72-yo client with diabetes who requires a dressing change for a stasis ulcer. A stable client with an expected outcome. LPN/LVN assists with implementation of care; performs procedures; differentiates normal from abnormal; cares for stable clients with predictable conditions; has knowledge of asepsis and dressing changes; administers medications (varies with educational background and state nurse practice act).
The nurse on a postpartum unit is preparing 4 clients for discharge. It would be most important for the nurse to refer which of the following clients for home care? 1. A 15-year old primipara who delivered a 7-lb male 2 days ago 2. An 18-year old multipara who delivered a 9-lb female by cesarean section 2 days ago 3. A 20-year old multipara who delivered 1 day ago and is reporting cramping 4. A 22-year old who delivered by cesarean section and is reporting burning on urination.
The answer is...a 22 year old who delivered by cesarean section and is reporting burning on urination. Unstable client, indicates urinary tract infection, requires follow-up Need to meet the clients needs. Physical stability is the nurses first concern. Most unstable client should be seen first.
Which of the following actions by the nurse would be considered negligence? 1. Obtaining a Guthrie blood test on a 4-day old infant. 2. Massaging lotion on the abdomen of a 3-year old diagnosed with Wilms' tumor. 3. Instructing a 5-year old asthmatic to blow on a pinwheel. 4. Playing kickball with a 10-year old with juvenile arthritis (JA).
The answer is...massaging lotion on the abdomen of a 3-year old diagnosed with Wilms' tumor. Manipulation of mass may cause dissemination of cancer cells. Negligence is the unintentional failure of the nurse to perform an act that a reasonable person would or would not perform in similar circumstances; can be an act of commission or omission.
