Comprehensive Review NCLEX-RN Examination Fundamentals Review
A health care provider's prescription reads phenytoin ( Dilantin) 0.2g orally twice daily. The medication label states that each capsule is 100mg. The nurse prepares how many capsule(s) to administer one dose? Answer:________
ANSWER:
The community health nurse is providing a teaching session about terrorism to members of the community and is discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted by which route(s)? * Select all that apply.* A.) Bites from ticks or deer flies. B.) Inhalation of bacterial spores. C.) Through a cut or abrasion in the skin. D.) Direct contact with an infected individual. E.) Sexual contact with an infected individual. F.) Ingestion of contaminated under-cooked meat.
ANSWER: B.) Inhalation of bacterial spores. C.) Through a cut or abrasion in the skin. F.) Ingestion of contaminated under-cooked meat. * Rationale: Anthrax is caused by Bacillus anthracis and can be contracted through the digestive system or abrasions in the skin, or inhaled through the lungs. It cannot be spread from person to person or from animal to person.
A health care provider's prescription reads to administer an intravenous (IV) dose of 400,000 units of penicillin G benzathine (Bicillin) The lable on the 10 ml. ampule sent from the pharmacy reads penicillin G benzathine (Bicillin), 300,000 units/ml. The nurse prepares how much medication to administer the correct dose? Record your answer using one decimal place. Answer:__________
ANSWER: 1.3 ml. * Rationale: Desired x mL _____________ = milliliters per dose Available ** 400,00 units x 1mL ___________________ = 1.33mL = 1.3 mL 300,00 units
A health care provider's prescription reads potassium chloride 30 mEq to be added to 1000 ml normal saline (NS) and to be administered over a 10 hour period. The label on the medication bottle reads 40 mEq/20 ml. The nurse prepares how many milliliters of potassium chloride to administer the correct dose? Answer:________
ANSWER: 15 ml. *Rationale: Desired x ml ____________ = ml per dose Available ** 30 mEq x 20 ml ______________ = 15 ml. 40 mEq
A health care provider's prescription reads clindamycin phosphate (Cleocin Phosphate) 0.3g in 50 ml. normal saline (NS) to be administered intravenously over 30 minutes. The medication lable reads clindamycin phosphate ( Cleocin Phosphate) 900 mg in 6ml. The nurse prepares how many millliliters of the medication to administer the correct dose. Answer: ______
ANSWER: 2 ml. *Rationale: must convert 0.3 g to mg. Desired x ml ____________ = ml per dose Available ** 300 mg x 6ml 1800 _______________ = _____ = 2ml 900 mg 900
A health care provider's prescription reads 1000mL of normal saline (NS) to infuse over 12 hours. The drop factor is 15 drops (gtt) /1mL. The nurse prepares to set the flow rate at how many drops per minute? Record your answer to the nearest whole number. Answer: _________
ANSWER: 21 gtt/min. *Rationale: Total volume x Drop factor ________________________ = Drops per min. Time in minutes ** 1000 mL X 15 gtt 15,000 _________________ = ______ = 20.8 or 21 gtt. 720 minutes 720
The nurse is caring for a client with meningitis and implements which transmission-based precautions for this client? A.) Private room or cohort client. B.) Personal respiratory protection device. C.) Private room with negative airflow pressure. D.) Mask worn by staff when the client needs to leave the room.
ANSWER: A.) Private room or cohort client. * Rationale: Meningitis is transmitted by droplet infection. Precautions for this disease include a private room or cohort client and use of a standard precaution mask.
The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the emergency department. The nurse should take which initial action? A.) Prepare the triage rooms. B.) Activate the emergency response plan. C.) Obtain additional supplies from the central supply department. D.) Obtain additional nursing staff to assist in treating the casualties.
ANSWER: B.) Activate the emergency response plan. * Rationale: In an eternal disaster ( a disaster that occurs outside of the institution or agency), many victims may be brought to the emergency room for treatment. The initial nursing action must be to activate the emergency response plan. Once the emergency response plan is activated, the actions in the other options will occur.
The nurse is preparing to initiate an intravenous line containing a high dose of potassium chloride and plans to use an intravenous infusion pump. The nurse brings the pump to the beside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action? A.) Initiate the intravenous line without the use of a pump. B.) Contact the electrical maintenance department for assistance. C.) Plug in the pump cord in the available plug above the room sink. D.) Use an extension cord from the nurses' lounge for the pump plug.
ANSWER: B.) Contact the electrical maintenance department for assistance. *Rationale: Electrical equipment must be maintained in good working order and should be grounded; otherwise it presents a physical hazard.
The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation by the nurse indicates unsafe application of the safety device by the UAP? A.) Placing a safety knot in the safety device straps. B.) Safely securing the safety device straps to the side rails. C.) Applying safety device straps that do not tighten when force is applied against them. D.) Securing so that two fingers can slide easily between the safety device and the client's skin.
ANSWER: B.) Safely securing the safety device straps to the side rails. * Rationale: The safety device straps are secured to the bed frame and never to the side rail to avoid accidental injury in the event that the side rail is released.
The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the *next* nursing action? A.) Call for help. B.) Extinguish the fire. C.) Activate the fire alarm. D.) Confine the fire by closing the room door.
ANSWER: C.) Activate the fire alarm. * Rationale: The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire then is confined by closing all doors, and finally, the fire is extinguished.
A mother calls a neighbor who is a nurse and tells the nurse that her 3 year old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action? A.) Induce vomiting. B.) Call an ambulance. C.) Call the Poison Control Center. D.) Bring the child to the emergency department.
ANSWER: C.) Call the Poison Control Center. * Rationale: If a poisoning occurs, the Poison Control Center should be contacted immediately. Vomiting should not be induced if the victim is unconscious or if the substance ingested is a strong corrosive or petroleum product.
The nurse is giving a report to an unlicensed assistive personnel (UAP) who will be caring for a client who has hand restraints ( safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently? A.) Every 2 hours. B.) Every 3 hours. C.) Every 4 hours. D.) Every 30 minutes.
ANSWER: D.) Every 30 minutes. * Rationale: The neurovascular and circulatory status of the extremity should also be checked every 30 minutes. In addition , the safety device should be removed at least every 2 hours to permit muscle exercise and to promote circulation.
Contact precautions are initiated for a client with a health care associated ( nosocomial) infection caused by methicillin-resistant staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? A.) Gloves and gown. B.) Gloves and goggles. C.) Gloves, gown and shoe protectors. D.) Gloves, gown, goggles, and face shield.
ANSWER: D.) Gloves, gown, goggles, and face shield. *Rationale: Splashes of body secretion can occur when providing colostomy care.
The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention if noted in the plan indicates the need for revision of the plan? A.) Wearing gloves when emptying the client's bedpan. B.) Keeping all lines in the room until the implant is removed. C.) Wearing a lead apron when providing direct care to the client. D.) Placing the client in a semiprivate room at the end of the hallway.
ANSWER: D.) Placing the client in a semiprivate room at the end of the hallway. * Rationale: A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent accidental exposure of other clients to radiation. The remaining options identify accurate interventions for a client with an internal radiation implant and protect the nurse from exposure.
