NCLEX practice questions

The nurse is completinga time tape for a 1000 mL IV bag that is scheduled to infuse over 8 hours. The nurse has just placed the 1100 making at the 500 mL level The nurse would place the mark for 1200 at which mL level on the time tape?

375 mL

The HCP prescribes an oral iron suspension for 3 months for a 2 year old with iron deficiency anemia. Which instructions should be given to parents? Select all that apply A. Admin doses between meals B. Admin doses with citrus juice C. Obtain full 3 month supply from pharm D. Place medicine at the back of the mouth E. Report black tarry stools to HCP immediately

A. Admin doses between meals B. Admin doses with citrus juice

The unit is staffed with an experienced RN, an experienced LPN, and an UAP. Which tasks can the charge nurse appropriately delegate to the UAP? Select all that apply A. Apply protective skin ointment after perineal cleansing B. Determine if a pt has adequate relief after admin of an analgesic C. Document daily wt for a pt with CHF D. Feed a pt who had a stroke 24 hrs after admission E. Perform passive ROM exercises for a pt on a ventilator

A. Apply protective skin ointment after perineal cleansing C. Document daily wt for a pt with CHF E. Perform passive ROM exercises for a pt on a ventilator

A 2 year old who swallowed an overdose of adult cough syrup is being d/ced from the ED. The parent says to the nurse, "From now on, I'm going to store all medicines in my top dresser drawer". Which is the best response by the nurse? A. Can you lock your dresser drawer? B. Make sure all you medicines have childproof caps C. That sounds like a safe plan D. You need to keep an eye on your child at all times

A. Can you lock your dresser drawer?

The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery Which of the following are expected findings? Select all that apply. A. Capillary glucose of 60mg/dL B. Holosystolic murmur auscultated at fourth intercostal space C. RR of 56 bpm D. Single transverse crease across palm of the hang E. White papules on bridge of nose

A. Capillary glucose of 60 mg/dL C. RR of 56 E. White papules on bridge of nose

The HCP suspects a fat embolism syndrome in a pt who has had multiple long bone fractures. Which findings does the nurse expect to assess to support his dx? Select all that apply A. Confusion and restlessness B. Increasing pain despite opioids C. Paresthesia of the affected extremity D. Petechiae over neck and chest E. Pulse oximeter showing hypoxia

A. Confusion and restlessness D. Petechiae over neck and chest E. Pulse oximeter showing hypoxia

A pt involved in a MVA presents to the ED with severe internal bleeding. The pt is severely hypotensive and unresponsive. The nurse anticipates that which IVF will most likely be Rxed? A. D5LR B. 1/3NS C. 1/2NS D. 1/4NS

A. D5LR

A pt with PN infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the pt in which position? A. On the left side, with head lower than feet B. On the left side, with head higher than feet C. On the right side, with head lower than feet D. On the right side, with head higher than feet

A. On the left side, with head lower than feet

The nurse is changing the central line dressing of a pt receiving PN and notes that the catheter insertion site appears reddened. The nurse should assess which item next? A. Pt's temp B. Expiration date of the bag C. Time of last dressing change D. Tightness of tubing connections

A. Pt's temp

A pt rings the call light and complains of pain at the IV site. The nurse assess the site and determines that phlebitis has developed. The nurse should take which actions to care for this pt? Select all that apply A. Remove the IV catheter at that site B. Apply warm, moist packs to the site C. Notify the HCP D. Start a new IV line in a proximal portion of the same vein E. Document the occurrence, actions taken, and the pt's response

A. Remove the IV catheter at that site B. Apply warm, moist packs to the site C. Notify the HCP E. Document the occurrence, actions taken, and the pt's response

A pt had a 1000 mL bag of D5NS hung at 1500. The nurse making rounds at 1545 finds that the pt is complaining of a pounding HA, is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The IV bag has 400 mL remaining. The nurse should take which action first? A. Slow the infusion rate B. Sit the pt up in bed C. Remove the IV catheter D. Call the HCP

A. Slow the infusion rate

The nurse, caring for a group of adults pts on an acute care med/surg unit determines that which pts would be the most likely candidates for PN? Select all that apply A. pt with extensive burns B. pt with cancer who is septic C. pt who has had an open cholecystectomy D. pt with severe exacerbation of Chron's E. pt with persistent N/V from chemo

A. pt with extensive burns B. pt with cancer who is septic D. pt with severe exacerbation of Crohns E pt with persistent N/V from chemo

The nurse has a Rx to hang a 1000 mL bag of D5W with 20mEq of KCl. The nurse also needs to hang a bag of piperacillin/tazobactam. The pt has one IV site. The nurse should plan to take which action first? A. Start a second IV site B. Check compatibility of the medication and IVF C. Mix the prepackaged piperacillin/tazobactam per agency policy D. Prime the tubing with the IVF and backprime the medication

B. Check compatibility of the medication and IVF

The student nurse is reviewing the medical record of a 4 year old dxed with failure to thrive. The nurse correctly ids which clinical and psychosocial factors that have likely contributed to the child's condition? Select all that apply A. Child has 3 older siblings B. Child is bottlefed 4 times a day and at bedtime C. Childs parent is incarcerated for spousal abuse D. Parent works part time as a teacher's aid E. Parent worries about having enough money to buy food F. The children eat at various times of the day in front of the TV

B. Child is bottlefed 4 times a day and at bedtime C. Childs parent is incarcerated for spousal abuse E. Parent worries about having enough money to buy food F. The children eat at various times of the day in front of the TV

IVFs had been infusing at 100 mL/hr via central line in the right internal jugular for approximately 24 hours to increase urine output and to maintain pt's BP. Upon entering the pt's room, the nurse notes that the pt is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previous data? A. Excessive bleeding B. Crackles in the lungs C. Incompatibility of the infusion D. Chest pain radiating to the left arm

B. Crackles in the lungs

The nurse is making initial rounds at the beginning of the shift and notes the PN bag of a pt is empty. Which solution should the nurse hang until another PN solution is mixed and delivered to the nursing unit? A. D5W B. D10W C. D5LR D. D5NS

B. D10W

A pt is being weaned from PN and is expected to begin taking solid food today. The ongoing solution has been 100mL/hr. The nurse anticipates that which Rx regarding PN solution will accompany the diet Rx? A. D/c the PN B. Decrease the PN rate to 50mL/hr C. Start 0/9% NS at 25mL/hr D. Continue current infusion rate prescriptions for PN

B. Decrease the PN rate to 50 mL/hr

Which findings in a newborn are considered abnormal and should be reported to the HCP? Select all that apply. A. Cyanosis of the hands and feet B. Decreased muscle tone C. HR of 150/min D. Sacral dimple E. Single artery in the umbilical cord

B. Decreased muscle tone D. Sacral dimple E. Single artery in the umbilical cord

Which nursing action is essential prior to initiating a new Rx for 500 mL of fat emulsion to infuse at 50 mL/hr? A. Ensure the pt does not have diabetes B. Determine whether the pt has an allergy to eggs C. Add regular insulin to the fat emulsion, using aseptic technique D. Contact the HCP to have a central line inserted for fat emulsion

B. Determine whether the pt has an allergy to eggs

A pt receives intermittent bolus enteral feedings through a NG tube. Which are the appropriate nursing actions prior to starting the feeding? Select all that apply. A. Discard aspirated residual volume in a biohazard container B. Flush the tube before and after the feeding C. Place the pt in Semi-Fowlers D. Start the feeding after obtaining a gastric residual volume <100 mL E. Start the feeding when the residual volume has a pH of 6

B. Flush the tube before and after the feeding C. Place the pt in Semi-Fowlers D. Start the feeding after obtaining a gastric residual volume <100 mL

The nurse supervises a graduate nurse who is teaching the parents of a 2 year old with acute diarrhea about home management. The nurse would need to intervene if she heard the graduate nurse say which? A. Dont admin antidiarrheal meds to your child B. Follow the bananas, rice, applesauce, and toast diet for the next few days C. Record the number of wet diapers and return to the clinic if you notice a decrease D. Use a skin barrier cream until diarrhea subsides

B. Follow the bananas, rice, applesauce, and toast diet for the next few days

The nurse provides a list of instructions to a pt being d/c to home with a PICC line. The nurse determines that the pt needs further instructions if the pt made which statement? A. I need to wear a MedicAlert tag or bracelet B. I need to restrict my activity while this catheter is in place C. I need to keep the insertion site protected when in the shower or bath D. I need to check the markings on the catheter each time the dressing is changed

B. I need to restrict my activity while this catheter is in place

The nurse is preparing to hang fat emulsion and notes that the fat globules are visible at the top of the solution. The nurse should take which action? A. Roll the bottle of solution gently B. Obtain a different bottle of solution C. Shake the bottle vigorously D. Run the bottle of solution under warm water

B. Obtain a different bottle of solution

The nurse is making initial rounds on the nursing unit to assess the condition of assigned pts. Which assessment findings are consistent with infiltration? A. Pain and erythema B. Pallor and coolness C. Numbness and pain D. Edema and blanched skin E. Formation of a red streak and purulent drainage

B. Pallor and coolness C. Numbness and pain D. Edema and blanched skin

The nurse has just received shift report. Which pt should be seen first? A. Pt 1day post op AAA repair who has hypoactive bowel sounds in all 4 quadrants B. Pt 2 day postop below the knee amputation who reports same-leg foot pain as 7 on pain scale C. Pt with DVT who is up to use the bathroom for the second time D. Pt with Raynaud's phenomenon who reports throbbing, tingling, and swelling of fingers in both hands

B. Pt 2 day postop below the knee amputation who reports same-leg foot pain as 7 on pain scale

The nurse is assessing a pt's peripheral IV site after completion of a vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best? A. Check for the presence of blood return B. Remove the IV site and restart another site C. Document the findings and continue to monitor site D. Call the HCP and request the vanc be given orally

B. Remove the IV site and restart another site

A pt has been discharged to home on PN. With each visit, the home care nurse should assess which parameter most closely in monitoring this therapy? A. pulse and weight B. temp and weight C. pulse and BP 4. temp and BP

B. temp and weight

The nurse reinforces teaching a pt on prescribed dabigatran for chronic a fib. Which statement by the pt indicates a need for further teaching? A. I will call my HCP if I notice red urine or blood in my stool B. I will not stop taking dabigatran even if I get a stomachache C. I will place capsules in my pill box so I will not forget to take a dose D. I will swallow the capsule whole with a full glass of water

C I will place capsules in my pill box so I will not forget to take a dose

The nurse is preparing to hang the first bag of PN solution via central line. The nurse should obtain which most essential piece of equipment before hanging the solution? A. Urine test strips B. BG monitor C. Electronic infusion pump D. Noninvasive BP monitor

C. Electronic infusion pump

The nurse is monitoring the status of a pt's fat emulsion infusion and notes that the infusion is 1 hour behind. Which action should the nurse take? A. Adjust the infusion rate to catch up over 1 hour B. Increase the infusion rate to catch up over the next 2 hours C. Ensure the fat emulsion infusion rate is infusing at the prescribed rate D. Adjust the rate to run wide open until the solution is back on time

C. Ensure the fat emulsion infusion rate is infusing at the prescribed rate

A highly intoxicated client was brought to the emergency department after found lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg. An hour later, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse anticipate taking next? A Admin atropine for bradycardia B. Admin nifedipine for HTN C. Have CT scan performed to r/o intracranial bleed D. Perform hourly neurologic checks with GCS

C. Have CT scan performed to r/o intracranial bleed

A pt receiving PN complains of a HA. The nurse notes that the pt has an increased BP, bounding pulse, JVD, and crackles bilaterally. The nurse determines that the pt is experiencing which complication of PN therapy? A. Sepsis B. Air embolism C. Hypervolemia D. Hyperglycemia

C. Hypervolemia

Which client best demonstrates recovery associated with a mental illness? A. One who demonstrates self-direction and responsibility regarding physical and psychosocial needs B. One who is receiving holistic care that addresses both physical and psychosocial needs C. One who lives, works, and is involved with family and friends to the highest level of ability D. One who, whie dxed with a mental illness, is able to demonstrate hope for the future

C. One who lives, works, and is involved with family and friends to the highest level of ability

The nurse is caring for a restless pt who is beginning PN. The nurse should plan to ensure that which action is taken to prevent the pt from sustaining injury? A. Calculate daily I&O B. Monitor temp once daily C. Secure all connections in the PN system D. Monitor BG levels every 12 hours

C. Secure all connections in the PN system

The nurse is inserting a IV line into a pt's vein. After the initial stick, the nurse would continue to advance the catheter in which situation? A. The catheter advances easily B. The vein is distended under the needle C. The pt doesn't complain of discomfort D. Blood return shows in the backflash chamber of the catheter

D. Blood return shows in the backflash chamber of the catheter

A pt is receiving PN in the home setting and has a weight gain of 5 lbs in 1 week. The nurse should next assess the pt for the presence of which condition? A. Thirst B. Polyuria C. Decreased BP D. Crackles on auscultation of the lungs

D. Crackles on auscultation of the lungs

A pt receiving PN suddenly develops a fever. The nurse notifies the HCP, and the HCP initially prescribes that the solution and tubing should be changed. What should the nurse do with the d/c materials? A. Discard them in the trash B. Return them to the pharmacy C. Save them for return to the manufacturer D. Prepare to send them to the lab for culture

D. Prepare to send them to the lab for culture

In the ICU, a pt is on mechanical ventilation after having undergone a fresh tracheostomy with retention sutures placed yesterday. The nurse hears the MV alarm sound and enters the room. The pt is coughing, RR are 40/min, HR is 132/min, and pulse ox is 80%. The nurse also see the tracheostomy tube lying on the pt's chest. What is the nurse's immediate action? A. Apply a rebreathing mask with high concentration of O2 at 12L/min B. Attempt to reinsert the tube with the oburator in place C. Insert a sterile catheter into the stoma and suction the airway D. Pull the retention sutures apart to lift the trachea and hold the stoma open

D. Pull the retention sutures apart to lift the trachea and hold the stoma open

The nurse is preparing the change the PN solution bag and tubing. The pt's central line is located in the right subclavian vein. The nurse asks the pt to take which essential action during the tubing change? A. Breathe normally B. Turn head to the right C. Exhale slowly and evenly D. Take a deep breath, hold it, and bear down

D. Take a deep breath, hold it, and bear down

The nurse monitors the pt receiving PN for complications of the therapy and should assess the pt for which manifestations of hyperglycemia? A. Fever, weak pulse, and thirst B. N/V and oliguria C. Sweating, chills, and abd pain D. Weakness, thirst, and increased urine output

D. Weakness, thirst, and increased urine output

A pt has just undergone insertion of a central line at the bedside under US. The nurse would be sure to check which results before initiating the flow rate of the pt's IVF at 100 mL/hr? A. serum osmolality B. serum electrolyte levels C. I&O record D. chest radiology results

D. chest radiology results

The nurse is giving report to a LPN who will be helping montior a patient who just had a total thyroidectomy. What will the nurse emphasize as most important to report immediately? A. Elevated BP B. HR irregularity C. Low O2 saturation D. Noisy breathing

D. noisy breathing