352 Practice Questions
The order on the MAR is for Amoxicillin 500 mg PO every 8 hours. The label on the bottle of Amoxicillin states 250 mg/5 mL. How much Amoxicillin should the nurse administer to the client? 5 mL 1.0 mL 10 mL 15 mL
10 mL - What you know is 250 mg per 5 mL. What you need is how many mL in 500 mg. 250x=2500 . when you solve for X, you get 10.
The nurse is caring for a client who had surgery 2 days ago. The nurse correctly recognizes which of the following as having the greatest ability to reduce the incidence of deep vein thrombosis (DVT)? A) Early ambulation B) Compression stockings C) Pre-operative exercise D) Frequent turning in bed in the post-surgery period
A) - Although compression stockings are helpful in reducing the incidence of DVTs, early ambulation after surgery is the key to prevention.
The nurse is caring for a client who just underwent a mastectomy of the left breast with lymph node removal. The nurse is reviewing the vital signs taken and documented earlier by the UAP (Unlicensed assistive personnel). Which documentation requires follow-up from the UAP? A) BP 110/70, sitting, left arm B) HR/pulse 85, radial C) RR 18 D) Temp 97.8 (F)/36.5 (C)
A) - The challenging part of this question is that all of the vital signs are within normal limits. If you look at this application level question, you are given a situation in which there is a cue you need to find. The cue is that the client had a left mastectomy and lymph nodes removal. That means that her left arm should NOT be used for blood pressures and she should have a limb-alert bracelet. So the nurse should follow up with the UAP to be sure they know not to use the left arm for blood pressures in the future and be sure the client did have a limb alert bracelet on. It is possible that the UAP documented the arm incorrectly, and again, that would require follow-up from the nurse to ensure accurate documentation.
Which of the following statements by the female client would indicate that she is at high risk for recurrent urinary tract infections? A) "I can usually hold my urine 8-10 hours" B) I take a warm plain water tub bath every evening" C) "I wipe from front to back after voiding" D) "I drink a lot of water during the day"
A) - The distractor in this question is the answer about bathing. Sometimes students answer questions based upon information they obtain in their "every day life". However, NCLEX uses evidence. Bathing does not increase the risk of UTI unless the client uses harsh soaps or bubble baths (which does have evidence that increase the risk of UTI in women).
The plan of care includes screening using the Braden Scale twice a day. The nurse knows this screening is used to determine which of the following? A) Predicting the risk of pressure injuries B) Predicting the risk of client falls C) Predicting the degree of client immobility D) Predicting the degree of healing of a wound
A) Braden scale screens for predicting the client's risk of pressure injuries. We have also used a screening tool for fall risk, but that isn't the Braden scale.
The nurse is assessing the client who has an indwelling/foley catheter. Previous documentation of the client's urine characteristics are that the urine was clear yellow with no foul smelling odor. Based upon the urine in the drainage bag now (light Orange with some turbidity) , what would be the priority action for the nurse? A) Notify the provider B) Empty the bag and document the amount, color, clarity and odor C) Encourage the client to drink more oral fluids D) No action is needed at this time
A) This urine is very different from previous assessments. This could be indicative of blood which is a priority.
The nursing student is documenting in a client's medical record. Which of the following actions would require follow up from the clinical instructor? Select all that apply. A) The nursing student uses the abbreviation qhs when referring to a medication the client takes each night before bed B) The nursing student uses the phrase "the client is lonely and frustrated" C) The nursing student documents observations that were seen, heard, smelled for felt D) The nursing student documents care as soon as it is performed
A,B - The abbreviation qhs is on the list of error-prone abbreviations in Craven Table 10-1 (ISMP List of Error-Prone Abbreviations) The phrase used in the answer choice is subjective and interpreted instead of documenting the observations of client behavior. If the statement was the client states "I am feeling lonely and frustrated", that would be acceptable.
The 87 year old client with dementia who is admitted for IV fluid replacement after dehydration is screened as high risk for falls. As the admitting nurse, which interventions do you initiate to keep this client safe? Select all that apply. A) Keep personal belongings and call light within reach of the client B) Utilize a bed or chair alarm whenever the client is unattended C) Check on the client hourly and encourage toileting with each check D) Place all 4 side rails on the bed up to ensure the client doesn't fall out of bed
A,B,C - 4 siderails up on a bed is considered a restraint and can only be used after all other options have been exhausted and with a provider order. The other options are all necessary to implement for a client who is a high risk for falls.
A client diagnosed with Risk for Impaired Skin Integrity is being assessed by the nurse. Which of the following would be important areas to assess? Select all that apply. A) Behind the ears for a client receiving supplemental oxygen B) Elbows C) Under compression stockings on ankles and heels D) Skin beneath the urinary catheter tubing on leg
A,B,C,D
The client is ordered to have a non-rebreather face mask. The nurse prepares for this by: (select all that apply) A) Applying an oxygen device that is a mask that goes over the nose and mouth and has a reservoir bag beneath it B) The oxygen flowmeter is set at 12-15 l/minute C) Adding humidity to the oxygen D) Not adding humidity to the oxygen
A,B,D - The key to the use of a non-rebreather for oxygen delivery is that it is a mask with a reservoir (typically a bag at the base of the mask), the flowmeter is set at 12-15 l/minute and humidity is not added (you don't want to get liquid into the reservoir bag). This is a device that is used for short term management of acute respiratory distress. It is an all-or-nothing device. Once you don't need 90-100% oxygen, change devices to deliver smaller amounts
The student nurse is watching the nursing instructor recap a needle. In which situation(s) would this be acceptable? Select all that apply. A) After the instructor draws up the insulin and is waiting for an independent double check from another nurse B) After the instructor injects subcutaneous heparin into the client's abdomen when there is no needle guard or sheath to engage C) After the instructor administers a flu shot to the client and the red sharps container is in the client's bathroom D) After the instructor reconstitutes the powder medication and draws it up to give to the client IV push
A,D - It is never appropriate to recap a needle after it has been injected into a client as you risk blood contamination (HIV and hepatitis). It is appropriate to passively recap (recap after the medication is drawn up but before injection) when you are not ready to administer immediately. That could be when obtaining an independent double check by another nurse or when preparing to give an IVP medication.
The client with decreased blood pressure is ordered a "bolus of normal saline". The nurse goes into the supply closet to obtain the IV fluid and looks for a bag with which of the following printed on it? A) 0.9% Sodium Chloride B) 0.45% Sodium Chloride C) Dextrose 5% in Water D) Lactated Ringers
B) - 0.9% sodium chloride is known as normal saline. 0.45% sodium chloride is known as 1/2 normal saline. Dextrose 5% in water is known as D5W.
The nurse is caring for a client who has recently had an indwelling urinary catheter removed after being placed for surgery. It is 6 hours after removal and the client still has not voided. The bladder feels full upon palpation by the nurse. According to best practice, what intervention should the nurse perform first? A) Reinsert an indwelling urinary catheter and try to remove again tomorrow B) Perform a bladder scan C) Perform an in and out or straight catheterization D) Wait 3 more hours and see if the client can void on their own
B) - Although you may do all of these interventions, the question asks which one would you do FIRST. Based upon best practice, a bladder scan would be the first intervention to determine if the bladder is full or not. If the bladder is not full, then you may increase intake and wait a few more hours. If the bladder is full, you will want to empty the bladder using in and out catheterization. Neither of these is an immediate indication for an indwelling catheter placement due to the risk of infection.
The nurse is preparing to perform wound care on several clients. In which situation would it be important for the nurse to wear sterile gloves? Select all that apply. A) Emptying a wound drain B) Irrigating and packing a deep wound C) Applying a dry dressing to a superficial wound D) Applying a hydrocolloid dressing to a pressure injury
B) - It's important in this question to notice that the question asks about the use of sterile gloves, which differs from "clean" procedure gloves. While all gloves protect the nurse against blood and body fluids as part of standard precautions, sterile gloves are important to protect the client from infection, too. Risks for infection are times when the nurse invades the body (such as a deep wound) or during surgery.
The client is experiencing intermittent chest pain and receiving Nitroglycerin sublingually. The client is unfamiliar with this route of medication and asks to learn more about it. Which of the following statements by the nurse should be questioned? A) Medication given sublingually should be placed under the tongue and allowed to dissolve B) Medication given sublingually absorbs slowly into the bloodstream and takes longer to work than that given orally and swallowed into the stomach C) Medication given sublingually is not influenced by stomach acids and doesn't need to be broken down into the stomach D) The acceptable abbreviation for the sublingual route is SL
B) - Medication given sublingually absorbs more quickly because it avoids first pass.
The nurse is caring for an elderly client with altered mental status and urinary incontinence. What nursing interventions would be most appropriate? A) Encourage the client to increase their coffee intake B) Schedule toileting at least every 2 hours C) Provide medications to improve bowel function D) Request a provider order to insert indwelling/Foley catheter
B) - Since coffee is a diuretic and urinary irritant, it will only increase frequency of urination. Meds for bowel function have no impact and a foley is not indicated for this problem. Scheduled toileting will help to reduce incontinent episodes.
The client is ordered Diphenhydramine (Benadryl) 25 mg IV push stat. Which is the correct procedure for this type of administration? A) Scrub the injection port with alcohol, flush with normal saline and give Diphenhydramine over 2 minutes. B) Scrub the injection port with alcohol, flush with normal saline, give Diphenhydramine over 2 minutes and flush with normal saline. C) Scrub the injection port with alcohol, give Diphenhydramine over 2 minutes and flush with normal saline. D) Scrub the injection port with alcohol, give Diphenhydramine over 2 minutes
B) - To give IV push correctly, you need to scrub the hub, flush with normal saline, give the medication at the correct rate and then flush again with NS at the same rate (remember how much medication is still in the IV tubing that needs to be flushed in).
The nurse is creating a plan of care for the adult client. Which nursing diagnosis stem is most appropriate using the information from the documentation in the medical record below. Vital Signs Temp 37.0 C/98.6 F Pulse 110 Respiratory Rate 36 Blood Pressure 140/90 Oxygen Saturation 88% Pain 3/10 A) Risk for falls B) Impaired gas exchange C) Chronic pain D) Acute confusion
B) - the BEST answer is impaired gas exchange based upon increased RR and low O2 sat
The nurse is creating a plan of care for the adult client. Which client-focused outcome is most appropriate for this client? Vital Signs Temp 37.0 C/98.6 F Pulse 110 Respiratory Rate 36 Blood Pressure 140/90 Oxygen Saturation 88% Pain 3/10 A) The client will have decreased BP to 130/80 within the next 3 days. B) The client will have adequate oxygenation as evidenced by oxygen saturations greater than 92%, RR less than 22 and no use of accessory muscles for breathing within the next 48 hours C) The client will not fall during this hospitalization D) The client will have a pain level of 0/10 without the use of pain medication by the end of the shift
B) First you need to recognize that although the client had an elevated BP, and some pain, the priority here is oxygenation (decreased O2 sat, elevated RR)
The provider orders a non-rebreather face mask for a client who is in respiratory distress. The nurse prepares to implement the provider order knowing that this type of oxygen delivery does which of the following? Select all that apply. A) Requires a low oxygen flow to prevent rebreathing of carbon dioxide B) Delivers an FiO2 of up to 90% when used properly C) Works best for clients with ventilation problems D) Prongs should be placed in the nostrils with the curvature toward the client's mouth E) Is only used for acute respiratory distress F) The oxygen tubing should be attached to the yellow medical air flowmeter G) Requires that the reservoir bag stays deflated to work effectively
B,E - The nonrebreather face mask is used for acute respiratory distress and delivers up to 90% oxygen. There are no prongs (that is nasal cannula) and the tubing should always be attached to the green oxygen flowmeter at 12-15 liter/minute. The bag below the mask should be and stay inflated throughout.
The nursing student comments to the nursing instructor that when drawing up medication from a vial, they keep getting too much air in the syringe. Which of the following can contribute to getting air into the syringe? A) The syringe is the wrong size B) The needle gauge is the wrong size C) The needle is not in fluid the whole time D) The student is drawing up the medication too slowly
C) - Getting air into the syringe usually isn't affected by the syringe or even the needle size. Air happens when the needle isn't in fluid the whole time. So when you draw up medication, always ensure the needle is low enough in the vial that is in fluid the whole time.
Which one of the following factors would be most important for the nurse to consider when determining the angle at which to insert the needle for a subcutaneous injection? A) size of the syringe B) the needle gauge C) amount of subcutaneous tissue D) position of the bevel
C) - The amount of subcutaneous tissue is the most important factor to consider when deciding on the angle at which to insert the needle. Thin or emaciated patient with little subcutaneous tissue need to have the needle inserted at less of an angle. Patients who have large amount of subcutaneous tissue can tolerate up to a 90 degree angle. Gauge, size of the syringe, or position of the bevel has no bearing on the angle used.
The student nurse is going to administer an influenza vaccine. Which of the following actions by the student should concern the nursing instructor? A) The student chooses a 20-22 gauge needle B) The student chooses a 1 inch needle C) The student states that the correct site for administration is the abdomen D) The student rubs the injection site after administration
C) - The influenza vaccine is given intramuscular. For IM injections, a needle length of 1-1.5 inches and gauge of 20-22 is appropriate. It is appropriate, and often helpful, to rub IM injections to help absorption into the muscle. Appropriate sites are muscles like the deltoid, rectus femoris, vastus lateralis and ventrogluteal. The abdominal tissue is appropriate for subcutaneous injections.
The elderly client is having difficulty hearing and it is discovered that the right ear has excessive wax buildup. The nurse obtains a prescription from the provider for Debrox ear wax removal. The client has had this done before and questions which of the following actions by the nurse? A) The client is instructed to turn on their left side B) The solution is warmed to body temperature prior to instilling C) The pinna of the ear is pulled down and back D) The tragus of the ear is gently massaged after releasing the pinna
C) - The pinna should be pulled and and back for adults and down and back for children under 3
The nurse is performing an assessment on a bedridden adult client. Which assessment causes the nurse to take action? A) HR/Pulse 83/minute B) Blood Pressure 112/78 C) Oxygen Saturation of 87% D) Respirations 16/minute
C) - generally should be at or above 95%
After correctly positioning a client for a urinary catheterization procedure, the nurse sets up a sterile field and opens the sterile items placing the supplies on the area. The nurse hears an emergency page for another client on the unit. Which of the following would be the most appropriate nursing action? A) Explain the situation to the client needing catheterization, leave the sterile supplies in place, attend to the emergency and return to complete the procedure B) Ensure the client's safety, cover the field with a sterile towel, respond to the emergency and return to complete the procedure. C) Continue quickly with the procedure, then assist with the emergency, checking back with the client as soon as possible. D) Ensure the client's safety, discard the sterile equipment, respond to the emergency and start the procedure over again.
D) - A client emergency needs to be addressed quickly. However, the nurse's first responsibility is ensuring this client's safety being attended to. Sterile equipment is considered contaminated if left unattended and therefore must be thrown away. The nurse needs to prioritize care appropriately; thus the nurse needs to respond to the patient emergency rather than continue with the catherization and return with new supplies and start over
Upon completion of care for the client on contact isolation precautions, which action by the student nurse indicates more education is necessary? A) The student removes the gloves before the gown B) The student removes the PPE prior to leaving the client's room C) The student performs hand hygiene after removing PPE D) The student removes the gown before the gloves
D) - PPE removal should follow the order of Gloves, Goggles, Gown, Mask, Wash hands. This question is asking which choice the student did INCORRECTLY (requires more education). So the correct answer is removing the gown before the gloves. Gloves are the MOST contaminated, so they should come off before anything else.
The nurse assesses the client and observes clubbing of the nail beds, cyanosis, hypotension and restlessness. Which of those does the nurse know is an early sign of hypoxemia? A) Clubbing of the nail beds B) Bradycardia C) Hypotension D) Restlessness
D) - You may have been distracted by the answer of clubbing of the nails. Although clubbing can result from long-term hypoxia, it is not an early sign. Bradycardia and Hypotension can also result in late signs once a client starts with respiratory failure. Restlessness and/or confusion is a common and early sign of a client with hypoxemia.
The nurse is caring for a client who will be discharged at home with an abdominal incision. When preparing a teaching plan for a family member who will be performing dressing changes after discharge, which of the following concepts would be most important to emphasize in this plan? A) signs of wound healing B) when to return to the surgeon for the staples or sutures will be removed C) surgical asepsis when performing wound care D) handwashing prior to wound care
It is not unusual for a client to be sent home prior to complete healing of a wound, especially if they or a home caregiver can perform the wound care. While all of these could be correct, the most important of all of these would be handwashing to prevent infection.
