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NCLEX RN EXAM 2022/2023 COMPLETE BUDLE
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NCLEX EXAM PREDICTOR 2022 VERSION 2 With Question And Answers
NCLEX EXAM PREDICTOR 2022 VERSION 2 With Question And Answers NCLEX Predictor Version 2 1. The nurse shows a teenager how to use a metered dose inhaler ... [Show More] of ipratropium (Atrovent). Which statement, if made by the client to the nurse, indicates teaching is effective? 1. “I should use this medicine to stop the coughing that leads to an asthma attack” 2. “I should use this medicine if I begin to have an asthma attack” 3. “I should use this medicine right after I have an asthma attack” 4. “I should use this medicine to prevent an asthma attack” 2. An older client is scheduled for a magnetic resonance imaging MRI procedure. Which of the following statements, if made by the client to the nurse, should be reported to the technician before the test? 1. “I take medication to control my blood pressure” 2. “I have had diabetes for about 10 years now” 3. “I had a knee replacement 5 years ago” 4. “I am allergic to penicillin and sulfa medications” 3. The nurse makes the following observations of a 6 hour old newborn: axillary temperature 96.4 F (35.8 C), apical pulse 148, respirations irregular at 48/minute, black sticky stool, blood glucose 60mg/dL. It is most important for the nurse to take which action? 1. Feed the newborn 30mL of infant formula 2. Administer low flow oxygen to the newborn 3. Wrap the newborn in a warmed blanket 4. Perform a guaiac test on the newborns stool 4. A client is returned to the unit at 10AM after laparoscopic gallbladder surgery. The nurse plans to get the patient out of bed for the first time at 4PM. It is MOST important for the nurse to take which of the following actions? 1. Turn the patient from side to side at 2 PM 2. Offer pain medication to the patient at 3:30PM 3. Encourage the patient to use the incentive spirometer at 3PM 4. Cough and deep-breathe the patient at 2:30PM 5. The activity therapy staff takes a group of psychiatric patients on a trip to the zoo. The nurse should intervene with which of the following patients before their departure? 1. A 50 year old female who is having difficulty with sleeping, eating, and social interaction. 2. A 40 year old male who just received his third dose of trazodone (Desyrel) and is 20 pounds overweight. 3. A 42 year old female who has problems with decision making who paces continuously, wringing her hands. 4. A 38 year old female who is receiving chlorpromazine (Thorazine) and is wearing a sundress without a hat or sunglasses. (photosensitivity;causes sensitivity to sun) 6. A patient experiences skin eruptions due to an allergic reaction to a medication. The nurse demonstrates the BEST documentation with which of the following? 1. “Patient complains of rash and itching over most of his body. Patient is concerned about how it looks” 2. “Multiple red welts noted over trunk and both arms. Patient states that welts itch” 3. “Allergic skin reaction to medication experienced by patient. Started several hours ago” 4. “Vital signs stable. Patient scratching arms and chest area frequently” 7. An older client diagnosed with emphysema is admitted to the psychiatric unit for treatment of bipolar disorder. The client receives oxygen per nasal cannula. The client expresses concern to the nurse that someone will come in and change the amount of oxygen the client is receiving. INITIALLY, the nurse should take which of the following actions? 1. Schedule an in-service with the staff about emphysema 2. Place a sign above the patient’s bed stating that the oxygen level is not to be changed 3. Tell the patient she will be well cared for in the hospital 4. Convey the patient’s concern to the nursing staff 8. A teenager has a positive home pregnancy test and comes to the prenatal clinic. The girl is uncertain of the date of her last menstrual period. The nurse palpates the uterine fundus midway between the symphysis pubis and the umbilicus. Which statement by the nurse is BEST? 1. “You are 24 weeks pregnant. It is good that you came in for prenatal care” 2. “You are 30 weeks pregnant. Prenatal care is important for you and your baby” 3. “You are 16 weeks pregnant. Let’s talk about what that means” 4. “You are 8 weeks pregnant. Are your periods usually irregular?” 9. A client is admitted to the psychiatric unit with complaints of fatigue, inability to concentrate, lack of appetite, and repetitive thoughts. The client is reluctant to take the prescribed medications, fearing that they are harmful. After the nurse gives the client the medication, the nurse should take which of the following actions? 1. Instruct the client to open her mouth and move her tongue up and down and to each side while the nurse looks inside. 2. Ask the client if she has swallowed the medication completely. 3. Watch the client’s behavior to see if the medication is having its desired effect. 4. Observe the clients throat while she swallows several times after putting the medication in her mouth. 10. The nurse assesses a patient 72 hours after a total joint replacement of the right hip. Which finding requires an intervention by the nurse? 1. There is a pillow between the patients legs 2. The patient’s legs are internally rotated 3. The patients hip joint is flexed at a 70 degree angle when the patient sits in the chair 4. The patient has not requested pain medication for 12 hours. 11. A client newly diagnosed with Meniere’s disease plans a trip to an amusement park with the family. The client asks the clinic nurse which of the following rides is best. The nurse should suggest which of the following rides? 1. Roller coaster 2. Merry go round 3. Ferris wheel 4. Train 12. A client is discharged from the hospital after coronary bypass (CABG) surgery 3 days ago. During discharge teaching, the client asks the nurse “When can I resume sexual intercourse with my wife?” it is best for the nurse to make which of the following statements? 1. “You can resume sexual activity when you feel strong enough” 2. “You can resume sexual activity when you are able to walk one block without chest pain or discomfort” 3. “You may have difficulty maintaining an erection because of your recent surgery” 4. “You should abstain from sexual activity because it may be detrimental to your recovery” (one block or two flights of stairs without chest pain) 13. A woman complains to the nurse about the care provided to her husband by the nursing staff the previous night. Initially, the nurse should take which of the following actions? 1. Ask the wife to voice her expectations about a solution to the problem 2. Gain consensus with the woman on the specific steps that will be taken care for her husband 3. Explain to the wife that the problems she identified will be fixed 4. Notify the wife that everything possible is being done for her husband 14. A patient is restrained bodily by the nursing team. The hands of the nurse assigned to hold down the patients leg should be placed in which of the following positions? 1. One hand on the patients knee and the other hand on the patients ankle 2. One hand directly above the patient’s knee and the other hand directly above the patient’s ankle 3. Both hands side by side on the patients thighs 4. One hand at the patients groin and the other hand at the patients mid-calf area 15. The nurse in the community mental health center works with a client who is diagnosed with depression. Cognitive therapy is initiated. The nurse should take which of the following actions? 1. Assist the client to review past intellectual achievements 2. Help the client develop more positive thoughts 3. Help the client to identify the source of his depression 4. Change the client’s values and beliefs. Cognitive Therapy; determined that how individuals feel and behave is determined by how they think about the world and their place in it. 16. The nurse plans to perform a physical assessment of a young adult who has been deaf since birth. Although the client indicates using sign language, no interpreter is available. The nurse should take which action? 1. Face the client and speak slowly using low-pitched voice 2. Write out each question, and ask the client to write out each answer 3. Sit on the clients right side and use gestures and nonverbal clues 4. Show the client pictures of the parts of the body that will be examined 17. A patient received morphine 4 mg IV 2 hours ago for the complaints of postoperative pain. The patient turns on the call light and tells the nurse he has to go to the bathroom. The patient has bathroom privileges. The nurse should take which of the following actions? 1. Obtain a bedside commode for the patient to use 2. Provide a warmed fracture bedpan for the patient to use 3. Tell the patient to breathe deeply as he walks to the bathroom 4. Ask the patient sit on the side of the bed before proceeding to the bathroom Answer#4 18. The nurse cares for a patient on the psychiatric unit with a history of drug use and poor impulse control. After the patient’s mother visits, the patient begins pacing rapidly, with arms swinging, and kicking at chair legs. The nurse should approach the patient and take which of the following actions? 1. Sit in a chair several feet away from the patient and lean forward with hands clasped together 2. Stand facing the patient with legs apart, knees locked, and weight on back leg 3. Sit in a chair next to the patient and lean back with arms folded 4. Stand facing the patient, legs together, knees locked, with weight on both legs Answer#2 19. The nurse observes the nursing assistant giving morning care to an elderly client who has an area of warm, reddened skin on the sacrum that does not blanch with pressure. Which action by the nursing assistant requires an intervention by the nurse? 1. The aide cleanses and then applies A and D ointment to the reddened area 2. The aide firmly massages the reddened area in a circular motion 3. The aide placed a piece of sheepskin under the patients sacrum 4. The aide positions the patient on the left side with head of the bed flat Answer#2 (Stage Ipressure ulcer, do not massage can damage capillary beds and cause tissue necrosis) 20. The school nurse identifies several children who have food allergies. Which sequence should the nurse teach the staff to follow if an allergic reaction is observed in a child? 1. Call 911, call the physician, administer EpiPen, call the parents 2. Administer the EpiPen, call 911, call the physician, call the parents 3. Call the physician, administer the EpiPen, call 911, call the parents 4. Call the parents, administer the EpiPen, call the physician Answer#2 21. A client comes to the ER complaining of shortness of breath, fatigue, insomnia, and weight loss. The client states that the client’s company forced the client into early retirement. The client says that the client has been sick ever since the client stopped working. The nurse should take which of the following actions first? 1. Encourage the patient to find outlets for his job skills in a consultative or volunteer basis in the community 2. Help the client see a connection between his symptoms and emotions, while investigating each symptom 3. Tell the client that anger is an unacceptable reason to something being taken away 4. Explain to the client what retirement should be like, and contrast this with what he has experienced 22. The nurse teaches the woman diagnosed with type 1 diabetes who is pregnant for the first time. The nurse teaches the client that as the pregnancy advances, the client may require which implementation? 1. Decreased amounts of insulin 2. Increased amounts of insulin 3. Decreased amounts of carbohydrates in her diet 4. Increased amounts of protein in her diet Answer#2 23. The nurse cares for a patient after a colon resection. The patient has a Salem sump tube connected to intermittent suction. The patient asks the nurse, “When will I be able to eat?” Which is the BEST response by the nurse? 1. “You will be given a high-calorie, high-fiber diet in a few days” 2. “You will be started on clear liquids when we hear your stomach make noises” 3.”You can eat food when the NG tube is removed in about 5 to 6 days” 4. A soft diet will be given to you after you have your first bowel movement” 24. The nurse supervises care provided for a client immediately after cardioversion. Which observation, if made by the nurse, indicates the need for an intervention? 1. A cold cloth has been applied to the paddle sites on the patient’s chest 2. The patient’s dentures remain in a cup at the bedside 3. There is an NPO sign above the patients bed 4. The oxygen the patient was receiving before the procedure remains disconnected 25. The nurse cares for a client diagnosed with bursitis of the right shoulder. The nurse expects the client to experience which of the following? 1. Pain and numbness in the first two fingers and thumb of her right hand 2. Spasms of the right hand when a blood pressure cuff is initiated and left in place for 2 minutes 3. A constant dull ache originating in the neck and radiating down the right arm 4. Pain with extension, flexion, and internal rotation of the right arm 26. The nurse supervises care provided by the nursing assistive personnel (NAP) to the older client in the convalescent phase after a stroke. The nurse should intervene if which action is observed? 1. The client is supine with a pillow under the head 2. The client is positioned laterally on the left side with the head of the bed flat 3. The client sits with the head of the bed elevated and the knee gatch up 4. The client is positioned laterally on the right side with the head of the bed flat (Brain attack or CVA; keep head unaffected side, no neck flexion or extension, head of bed flat) 27. The nurse cares for a client who is receiving amitriptyline (Elavil) 25 mg q A.M. and 100 mg at HS. The nurse understands that the medication schedule will accomplish which of the following? 1. Make therapeutic use of an expected side effect of the medication 2. Decrease interference between digestion of food and absorption of medication 3. Utilize the increased permeability of the blood-brain barrier that occurs during sleep 4. Reduce the side effects experienced by the client (Antidepressant, tryciclic; it has a sedative effect, administer larger dose at night it causes increased sedation) 28. An older patient falls on the floor of the psychiatric unit. To determine the cause of the fall, it is MOST important for the nurse to do which of the following? 1. Check the patients eyeglasses 2. Examine the condition of the patients shoes 3. Monitor the patients’ blood pressure 4. Evaluate the floor where the patient fell 29. The nurse instructs a prenatal class for first-time mothers. A group of mothers state they are afraid because they have heard that babies often die in their sleep before their first birthday. The mothers ask what they can do to prevent this. It is BEST for the nurse to make which of the following responses? 1. it’s important for you to focus on your pregnancy and upcoming labor and not to focus onnegative things that may happen in the future 2. This does not happen very often. With good nutrition and loving care your babies should thrive and develop normally 3. Unfortunately, the cause of this condition is not definitely known, so there is little you cando to prevent this from happening 4. It’s best to position the baby on its back or side in bed. There seems to be an increase in this condition when babies are put to sleep on their stomach Answer#4 30. A client attends a support group for incest survivors at the community mental health center. The client tells the nurse, “I don’t get it. People keep telling me I talk just like my father. He’s the last person I’d want to act like!” which response by the nurse is BEST? 1. Genetically, you are like your father 2. You need to be more open-minded. I’m sure your father had some good qualities 3. Don’t worry about what everyone else is saying 4. Sometimes people unconsciously take on the characteristics of people who exert power over them To exert is to apply or use. Waleska=mami 31. The family of a patient admitted to the psychiatric unit 3 days ago arrives for a visit carrying two suitcases. The nurse informs the family that before they can proceed into the unit, the suitcases need to be searched. The family asks why this needs to be done. Which is the BEST response by the nurse? 1. “We know what is best for our patients” 2. “We have to make sure you’re not bringing contraband” 3. “Were just following the rules established by administration” 4. “Things that you may not think of as being harmful may be used for harm by the patient 32. The nurse asks the nursing assistant to obtain morning vital signs on several patients. It is best for the nurse to make which of the following statements? 1. “Go check the vital signs for the patient in rooms 321 and 322. Record your findings on this sheet and then return it to me” 2. “Today you’ll check patient’s vitals. Please start with rooms 321 and 322. Be sure to write them down” 3. “Since you have been taught to check vital signs for patients, you can take them on patients in rooms 321 and 322. Let me know your findings” 4. “The patients in room 321 and 322 need to have their morning vital signs taken. This allows us to compare the results to what the night nurse documented.” 33. The nurse reviews basic communication skills with a new group of nursing assistants. It is BEST for the nurse to make which of the following statements? 1. “Understanding nonverbal behavior assures success in interpersonal relationships 2. “Nonverbal behavior is best considered in combination with verbal communication” 3. “There is no specific meaning for each type of nonverbal behavior” 4. “Altering nonverbal behavior is a form of manipulation” 34. The nurse cares for a woman at 7 months gestation diagnosed with preeclampsia. The client comes to the outpatient clinic for her weekly checkup. The nurse is MOST concerned if which of the following is observed? 1. The clients temperature is 98.2 F (36.7 C) 2. The client has 2+ pitting edema of her feet 3. The client gained 1 pound since the last visit 4. The client’s skin is dry 35. A client with a history of arterial insufficiency is seen in the outpatient clinic. The client complains to the nurse about frequent awakenings during the night because of a burning numbness in the lower extremities. The nurse should advise the client to take which of the following actions? 1. Elevate the legs on several pillows 2. Get up and walk around the room 3. Place the legs in a dependent position 4. Perform leg exercises (Elevate veins; dangle arteries) [Show Less]
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NCLEX RN EXAM 2022-2023 130 QUESTIONS (VERIFIED PAPER)
NCLEX RN EXAM 2022-2023 130 QUESTIONS (VERIFIED PAPER) 1. Which of the following clients is at a higher risk of developing oral health problems? ... [Show More] a. A pregnant client b. A client with diabetes c. A client receiving chemotherapy d. Both b and c 2. Which nursing intervention is most appropriate to reduce environmental stimuli that may cause discomfort for a client? a. Loosen pressure dressings on wounds b. Use assistance to pull a client up in bed c. Check temperature of water used in a sponge bath d. Position the client prone 3. A client has developed a vitamin C deficiency. Which of the following symptoms might the nurse most likely see with this condition? a. Cracks at the corners of the mouth b. Altered mental status c. Bleeding gums and loose teeth d. Anorexia and diarrhea 4. Which of the following interventions should a nurse perform for a female client who is incontinent with impaired skin integrity? a. Turn the client at least every 8 hours b. Apply lotion to the skin before a bath c. Provide perineal care after the client uses the bathroom d. Bathe the client every 3 days 5. A nurse is caring for a client who died approximately one hour ago. The nurse notes that the client's temperature has decreased in the last hour since his death. Which of the following processes explains this phenomenon? a. Rigor mortis b. Postmortem decomposition c. Algor mortis d. Livor mortis 6. A nurse is calculating a client's intake and output. During the last shift, the client has had ½ cup of gelatin, a skinless chicken breast, 1 cup of green beans, and 300 cc of water. The client has urinated 250 cc and has had 2 bowel movements. What is this client's intake and output for this shift? a. 420 cc intake, 250 cc output b. 300 cc intake, 250 cc output c. 550 cc intake, 550 cc output d. 300 cc intake, 550 cc output 7. A nurse is caring for a client with ariboflavinosis. Which of the following foods should the nurse serve this client? a. Citrus fruits b. Milk c. Fish d. Potatoes 8. A client is taking a walk down the hallway when she suddenly realizes that she needs to use the restroom. Although she tries to make it to the bathroom on time, she is incontinent of urine before reaching the toilet. What type of incontinence does this situation represent? a. Reflex incontinence b. Urge incontinence c. Total incontinence d. Functional incontinence 9. Which of the following is an example of a positive effect of exercise on a client? a. Decreased basal metabolic rate b. Decreased venous return c. Decreased work of breathing d. Decreased gastric motility 10. You have taken the vital signs for your patient. They are normal for the patient. What should you do next? a. Report the vital signs to the doctor b. Write the vital signs on a scrap paper c. Call the family members d. Document them on the graphic VS form 11. Penny Thornton has had a stroke, or CVA. She is having difficulty eating on her own. Soon, she will be getting some assistive devices for eating meals. Which healthcare worker will be getting Penny these assistive devices? a. A physical therapist b. A speech therapist c. A social worker d. An occupational therapist 12. Which of the following is an example of emotional abuse? a. A slap to the person's hand b. Threatening the person c. Ignoring and isolating a person d. Leaving a patient soiled for hours 13. Which of the following is an example of emotional neglect? a. A slap to the person's hand b. Threatening the person c. Ignoring and isolating a person d. Leaving a patient soiled for hours 14. The duodenum: a. is the third section of the small intestine, which leads immediately to the colon. b. is the section of the stomach where the gall bladder delivers bile. c. is the section of the small intestine where the pancreas delivers insulin. d. None of the above. 15. The nurse is performing discharge teaching for Mrs. S after cardiac angioplasty. Her husband is present for the teaching. While explaining the prescription for antiplatelet medication to use at home, Mrs. S's husband states, "I don't think I can afford to refill that medication." What is the most appropriate response of the nurse? a. Don't worry, your insurance will cover it." b. I'll ask the physician if he can prescribe a medication that is more affordable." c. You should apply for Medicare to see if they can help you." d. This medication is essential for her care and should be given priority over all others that she is taking." 16. The discharge planning team is discussing plans for the dismissal of a 16- year old admitted for complications associated with asthma. The client's mother has not participated in any of the discharge planning process, but has stated that she wants to be involved. Which of the following reasons might prohibit this mother from participating in discharge planning? a. The client is an emancipated minor b. The mother has to work and is unavailable c. The client has a job and a driver's license d. The mother does not speak English 17. A nurse enters a client's room and finds her lying on the floor near the bathroom door. As the nurse provides assistance, the client states, "I thought I could get up on my own." What information must the nurse document in this situation? a. A statement explaining the condition the client was found in, quoting the client's words about the situation b. An explanation of how the fall happened and when the physician was notified c. An account of the conditions of the room that contributed to the client's fall d. A description of the client's condition and the reasons why she should have had assistance to the bathroom 18. Which of the following may be a cultural barrier that impacts a nurse's ability to provide care or education to the client? a. A nurse offers educational materials to a client that are written at an 8th grade reading level b. A Vietnamese woman wants to use steaming in addition to her prescription antibiotics c. A nurse uses pantomime to explain a procedure to a deaf client d. A Native American client requests a healing ritual before he will consider surgery 19. Which of the following is an example of low health literacy skills? a. A nurse's aide cannot calculate the correct IV rate for Ringer's lactate b. A client cannot read an admission form to sign it c. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine d. A client does not understand the treatment for his cholecystectomy 20. A 39-year old woman presents for treatment of excessive vaginal bleeding after giving birth to twins one week ago. Which nursing diagnosis is most appropriate in this situation? a. Knowledge Deficit related to post-partum blood loss b. Self-Care Deficit related to post-partum neglect c. Fluid Volume Deficit related to post-partum hemorrhage d. Body Image Disturbance related to body changes after delivery 21. Mr. K is admitted to the orthopedic unit one morning in preparation for a total knee replacement to start in two hours. Which of the following is a priority topic to instruct this client on admission? a. The approximate length of the surgery b. The type of anticoagulants that will be prescribed c. The time of the next meal of solid food d. The length of time until the client can return to work 22. Which of the following is an example of the intervention phase of the individualized nursing care plan for a client who receives a colostomy after a bowel resection? a. Taking a health history and performing a physical exam prior to the procedure b. Instructing the client about how to care for his colostomy stoma c. Developing goals that state the client will ambulate three times a day d. Determining that the client may need more support at home after dismissal 23. Which method best describes the use of evidence-based practice? a. Reading and analyzing research reports to see how they can be implemented into nursing practice b. Collecting data to determine how efficiently nursing practice is contributing to quality care c. Monitoring unit practices to determine compliance with Joint Commission standards d. Using the most effective, current, and applicable information available to guide nursing care for the best of the clients. 24. A public health nurse discovers that many of the children in the neighborhood where she works are developing lead toxicity. She implements a program to screen for lead exposures among clients in the community. This is an example of: a. Social justice b. Policy resources c. Autonomy d. Moral justification 25. Which of the following is an example of whistle blowing? a. A nurse contacts administration about a colleague who takes supplies to use for a mission trip b. A client sues a nurse because she failed to call the physician about his wound infection c. A nursing assistant calls for help when a client falls out of bed d. A client developed a sacral pressure ulcer when he was not turned in bed for over four hours 26. Which situation might require an occupational health nurse consult? a. A nurse is injured from using incorrect body mechanics to lift a client b. A nurse receives a subpoena to testify in court about a client's case c. A client who has been injured in a diving accident needs assistance with planning rehabilitation and surgery d. A nursing unit is implementing a new electronic health record system 27. Which of the following is the most appropriate example of anticipatory guidance for a 16- year old who has been hospitalized for an ankle fracture? a. Changes associated with puberty b. Driving and staying safe c. The health hazards of smoking d. Social media influences 28. Which action represents the evaluation stage of the plan of care? a. The nurse assigns a nursing diagnosis of Impaired Skin Integrity related to diminished skin circulation b. The nurse assesses the client's vital signs and asks about symptoms c. The nurse determines that the client is not meeting his set outcomes and makes revisions d. The nurse discusses the client's health history 29. Which of the following screening tools have been found to have a high diagnostic accuracy for screening for intimate partner violence? a. Hurt, Insult, Threaten and Scream (HITS) b. Humiliation, Afraid, Rape, and Kick (HARK) c. Slapped, Threatened and Thrown (STaT) d. All the above 30. What is the relationship between HIPPA and technological advances? a. Technology helps to foster HIPPA confidentiality. b. Computers help us to share information with others. c. Computer screens are not visible to others in the area. d. Technology places us at risk for HIPPA violations. 31. Which technological advance is MOST likely to place you at risk for HIPPA violations? a. Social media b. Word processing programs c. Spreadsheets d. Clouds and SOEs 32. A patient is having a colposcopy procedure performed. How should the patient be instructed to prepare for the procedure? a. NPO for 8-12 hours before the procedure. b. D/C all HTN Rx for two days prior to the procedure. c. Take three Dulcolax tablets and two containers of Miralax the day before to clear out the lower GI system. d. None of the above prep is necessary for this type of procedure. 33. A physician is explaining a procedure to a patient that may cure her recurring Staph infection. The doctor explains how the procedure is done, what to expect, the odds of the procedure curing the infection, and possible side effects and risks. The physician is: a. Preparing the patient to give informed consent. b. Protecting HIPAA by listing all of the steps of the procedure with the risks involved. c. Not required to inform the patient of any alternative therapies. d. None of the above. 34. Teresa is an 84-year-old with stage 4 ovarian cancer who has been admitted for a bowel obstruction. She recently stated that she has decided that she doesn't want any further aggressive care and is requesting to be placed under hospice care. Her husband and daughter are supportive of her decision. She spoke with her oncologist about it, and he stated that he did not agree, and wrote orders on her chart for chemotherapy. What would be the best first response to this situation? a. Give the patient a list of other oncologists b. Tell the family to report the doctor to the state quality board c. Notify the doctor that the patient refuses the chemotherapy d. Give the patient hospice information 35. Upon entering an elderly patient's room, you find a research assistant with a clipboard, obtaining consent to participate in a new study. After signing the form, the patient begins to ask questions about the study. The assistant smiles and says, "Don't worry about all that, we'll take good care of you. Now enjoy the chocolate I brought." What should your first response be? a. Ignore the patient's questions b. Stop the assistant and question the consent c. Notify the nurse manager d. Notify the research department 36. Monica is a 28-year-old nurse who had been admitted to the hospital after a near-drowning in which she suffered cardiac arrest and hypoxic encephalopathy. She has been stabilized and has a tracheostomy to room air. She has been on the general floor for several weeks, is in a persistent vegetative state, and has a very poor prognosis for any improvement in her neurological status. Monica had previously signed a living will, which indicated that she did not wish to receive enteral feedings to be kept alive if she had a terminal condition or was in a persistent vegetative state from other causes. Her parents have decided to move her to the hospice unit and have given permission for removal of her feeding tube. The patient care technician who has been caring for Monica is very distressed over this decision and feels that the parents are "killing" her. What would be an appropriate initial response? a. This will relieve the burden for her parents." b. Her parents have a right to make decisions for their child." c. Monica has stated her wishes and they should be honored." d. The ethics committee should be consulted." 37. Jack is a 2-month-old with a diagnosis of spinal muscular atrophy (SMA) type I. He has been admitted to the hospital for progressive respiratory difficulty. His parents have been informed that if he is not placed on ventilatory support, he will continue to decompensate and die of respiratory failure. Jack's physician discusses the poor prognosis of Jack's condition, and tells the parents that he will not be able to be removed from ventilatory support once it is initiated, due to his progressive neurological disease. After much discussion, the parents have decided to decline ventilatory support, agree to a do not resuscitate (DNR) order, and request hospice care for Jack. Another parent heard them discussing Jack's situation in the waiting room and says she could never do that to her baby. What is the most appropriate response to this parent? a. You never know what you'll do until you're in that situation." b. I can't discuss another patient's situation." c. They have been through too much already." d. You can contact administration with your concerns." 38. You have noticed that the last several patients you have cared for have had questionable blood pressure readings from their arterial lines. When checked against cuff pressures, a discrepancy has been noted, and further investigation has revealed faulty transducers. This is not the first product issue with this company. What positive step could you take to help resolve this situation? a. Use the old stock from a previous company b. Verify the cuff pressures every hour to ensure accuracy c. Notify the risk manager d. Form a peer workgroup to evaluate new products 39. The family of a patient who is receiving therapeutic hypothermia states they do not understand why the patient is being kept so cold. What objective information can you provide to help address their concerns? a. Let them talk to another patient who has had the same therapy b. Provide research-based information about therapeutic hypothermia c. Connect them with the nurse manager d. Call the physician and ask him to talk to the family 40. A family member is complaining that the lights are too dim in the middle of the night when she comes in to visit her husband. What is the most objective response? a. Patients sleep better with the lights dimmed." b. The nightshift nurses prefer to work with less light." c. It's time for him to sleep, and you should, too." d. There's a reason we do that. Let me share a research study with you." 41. You are attempting to teach the wife of a Greek patient how to administer his gastrostomy tube feedings once he returns home. She smiles and nods through your explanations, but when you ask her for a return demonstration, she looks confused and shakes her head. Her daughter enters the room and states that she does not speak English. What would be most helpful in this situation? a. Teach the daughter instead b. Teach both and ask the daughter to translate for you c. Contact a home health agency to provide care d. Provide a pamphlet with detailed instructions 42. What is a key principle of patient teaching that must take place to ensure patient safety? a. Family members should be present b. Teaching must be documented c. Understanding must be confirmed d. Teaching should be provided by multiple staff members 43. A client with adrenal insufficiency has a potassium level of 7.2 mEq/L. Which of the following signs or symptoms might the client exhibit with this result? a. Peaked T waves on the ECG b. Muscle spasms c. Constipation d. A prominent U wave on the ECG 44. A client is having difficulties reading an educational pamphlet. He cannot find his glasses. In order to read the words, he must hold the pamphlet at arm's length, which allows him to read the information. Which vision deficit does this client most likely suffer from? a. Cataracts b. Glaucoma c. Astigmatism d. Presbyopia 45. A nurse is caring for Mrs. T, a client with expressive aphasia. During a bath, she begins to gesture wildly and point toward the bath water, yet is unable to say anything. Which response from the nurse is most appropriate? a. Is something wrong with the bath water?" b. Just calm down, we'll finish your bath soon." c. Are you trying to tell me something?" d. Shall I turn on the television?" 46. A nurse is assisting a client with shampooing his hair while he is still in bed. While helping the client, the nurse raises the bed to approximately the level of her waist. What is the rationale for this action? a. To prevent shampoo from getting into the client's eyes b. To allow excess water to run off the edge of the bed c. To decrease strain on the nurse's back d. To prevent the client's hair from developing tangles 47. Which of the following signs or symptoms indicates a possible nutritional deficiency? a. Subcutaneous fat at the waist and abdomen b. Presence of papillae on the surface of the tongue c. Straight arms and legs d. Pale conjunctiva 48. A nurse is preparing to insert a small-bore nasogastric feeding tube for a client's enteral feedings. In which method does the nurse measure the correct length of the tube? a. From the tip of the nose to the xiphoid process b. From the tip of the nose to the earlobe to the xiphoid process c. From the earlobe to the xiphoid process d. From the tip of the nose to the earlobe to the umbilicus 49. One major difference between long term care and respite centers is the fact that long term care facilities: a. provide only physical care and respite centers give both physical and emotional care. b. provide care for residents on a long term basis and respite centers offer only outpatient services. c. provide care for residents on a long term basis and respite centers offer only temporary services. d. There is no difference. Long term care and respite care are the same. 50. A nurse is assisting Mrs. K, a client who is undergoing a lumbar puncture. Which of the following elements should the nurse use to instruct Mrs. K about this procedure? a. A lumbar puncture takes a sample of blood from the back, which will be analyzed by the lab b. The physician will insert a needle at the level of L4-L5 in the spinal cord c. Mrs. K should lie flat on her back for 24 hours following the procedure d. The risks of the procedure include nausea, rash, and hypotension 51. A nurse is caring for a client who has a right-sided chest tube. The chest tube shows 50 cc of serosanguinous fluid in the collection chamber and air bubbles are collecting in the water seal chamber. Which action is most appropriate of the nurse at this time? a. Do nothing; this is a normal response b. Strip the tubing to remove any clots c. Place a clamp on the tube near the client's chest d. Remove the collection chamber and connect the tubing to a new device 52. A nurse is caring for a client with a broken femur who is in a traction splint in bed. All of the following interventions are part of care of this client EXCEPT: a. Palpating the temperature of both feet b. Evaluating pulses bilaterally c. Turning the client to a side-lying position d. Relieving heel pressure by placing a pillow under the foot 53. A client is preparing to undergo a cystoscopy for stones. Which of the following statements indicates that the client understands the procedure? a. I better drink a lot of fluid now because I won't be able to after the test." b. I will probably see a little blood when I urinate." c. I will be able to go home after 3 days in the hospital." d. I won't need any pain medicine; this probably will not hurt." 54. Which of the following conditions may warrant a serum creatinine level? a. Rhabdomyolysis b. Digitalis toxicity c. Glomerulonephritis d. All answers are correct 55. Which nursing intervention is most appropriate to maintain the patency of a client's nasogastric tube? a. Maintain constant connection to low-intermittent suction b. Irrigate the tube as per physician order c. Suction the mouth and nose every shift d. Perform a daily fecal occult blood sample 56. A nurse is caring for a client who is having blood tests and who has an elevated lymphocyte level. Based on knowledge of cellular components, the nurse knows that these cells: a. Contain histamine and provide protection during allergic reactions b. Are involved in phagocytosis c. Provide protection and immunity against foreign substances d. Carry hemoglobin and oxygen to body tissues 57. Mrs. F has been diagnosed with hyperparathyroidism. Which of the following complications is Mrs. F at highest risk of developing? a. Hyponatremia b. Hypocalcemia c. Hypermagnesemia d. Hypercalcemia 58. Elderly patients are more prone to dehydration than younger people because the elderly . a. drink more coffee and tea b. have more stomach mucus production c. have more saliva d. have less sense of thirst 59. You are turning your patient in bed and you see that this confused and lethargic patient had loose car keys and lipstick in the bed and had been lying on them. What is this person at risk for because of all three of these factors: the confusion, lethargy and items in the bed? a. Falls b. Skin breakdown c. Apnea d. Lack of mobility 60. Select the age group that is coupled with an infectious disease that is most common in this age group. a. Infants: High billirubin b. Pre-School and School Age Children: Shingles c. Young Adults and Teenagers: Sexually transmitted diseases d. The Elderly: Malaria 61. A complication of osteoporosis is . a. rheumatoid arthritis b. gouty arthritis c. dorsal flexion d. joint deformity 62. One of the complications of complete bed rest and immobility is which of the following? a. Plantar flexion. b. Dorsal flexion c. Extension contractures d. Adduction contractures 63. A nurse finds one of her clients unresponsive in his room. He is not breathing and does not have a pulse. After calling for help, what is the next action of the nurse? a. Administer 2 ventilations b. Perform a head-tilt, chin lift to open the airway c. Begin chest compressions d. Perform a jaw thrust to open the airway 64. A nurse is caring for a client with severe mitral regurgitation and decreased cardiac output. The nurse assesses the client for mental status changes. What is the rationale for this intervention? a. Decreased cardiac output can cause hypoxia to the brain b. Mental status changes may be a side effect of the client's medication c. Mitral regurgitation is a complication associated with some neurological disorders d. The client may be confused about his diagnosis 65. A client is undergoing radiation therapy for treatment of thyroid cancer. Following the radiation, the client develops xerostomia. Which of the following best describes this condition? a. Cracks in the corners of the mouth b. Peeling skin from the tongue and gums c. Increased dental caries d. Dry mouth 66. A nurse is providing information for a woman who is 36 weeks' pregnant and who has hepatitis B. Which of the following statements from the client indicates understanding of this condition? a. Now I know I will need a cesarean section." b. My baby will need two shots soon after his birth." c. I will not be able to breastfeed." d. My baby's father does not need testing; I know I am the one with hepatitis." 67. A nurse is educating a client who was recently diagnosed with diverticulosis. What types of foods should the nurse recommend for this client? a. Whole grain cereal b. Eggs c. Cottage cheese d. Fish 68. A client is in need of hemodialysis for end-stage renal failure. The physician has inserted an AV fistula. Which of the following nursing interventions are appropriate when caring for this access site? a. Assess for clotting in fistula tubing b. Apply a dressing over the fistula site c. Assess for a bruit or thrill at the site of the fistula d. Assess circulation proximal to the fistula site 69. A client is brought into the emergency room where the physician suspects that he has cardiac tamponade. Based on this diagnosis, the nurse would expect to see which of the following signs or symptoms in this client? a. Fever, fatigue, malaise b. Hypotension and distended neck veins c. Cough and hemoptysis d. Numbness and tingling in the extremities 70. Based on Mr. W's diagnosis of MAC, which of the following information should be provided to this client? a. He should be started on antiretroviral therapy as ordered b. He is no longer just HIV-positive, he most likely has AIDS c. He should be tested for other illnesses, such as anemia d. Both b and c 71. All of the following are complications associated with hypothermia during the perioperative period EXCEPT: a. Decreased blood urea nitrogen levels b. Cardiac arrhythmias c. Decreased immunity d. Increased oxygen needs 72. A nurse is caring for a client who had a bone marrow transplant two weeks ago. Which of the following is most likely to cause an infection during this time period? a. Cytomegalovirus b. Varicella zoster virus c. Herpes simplex virus d. Hepatitis B virus 73. When reading a lab report, you notice that a patient's sample is described as having anisocytosis. Which of the following most accurately describes the patient's condition? a. The patient has an abnormal condition of skin cells. b. The patient's red blood cells vary in size. c. The patient has a high level of fat cells and is obese. d. The patient's cells are indicative of necrosis. 74. A patient with Bell's Palsy would have which of the following complaints? a. Paralysis of the right or left arm b. Malfunction of a certain cranial nerve c. A sub-condition of Cerebral Palsy d. A side effect of a stroke 75. A pathologic condition described as, "Increased intraocular pressure of the eye," is: a. Detached Retina b. Fovea Centralis c. Presbyopia d. Glaucoma 76. A physician believes that a patient may be experiencing pancreatitis. Which of the following tests would be best to diagnose this condition? a. CK and Troponin b. BUN and Creatinine c. Amylase and Lipase d. HDL and LDL Cholesterol Levels 77. Which of the following is an example of client handling equipment? a. Wheelchair b. Height-adjustable bed c. Shower chair d. Call light 78. Which practice will help to reduce the risk of a needlestick injury? a. Only expose the end of the needle once ready to enter the room for the procedure b. Always place the cap back on a needle after it has been used c. Keep a sharps container nearby where it can be easily accessed d. Pass needles between nurses by using the hand-over technique 79. Which of the following is an organizational factor that affects workplace violence directed at nurses? a. Clients who have short hospital stays b. The presence of security guards c. Restricted client areas d. Understaffing of nursing personnel 80. Which of the following actions of the nurse is most appropriate to reduce the risk of infection during the post-operative period? a. Flush the central line with heparin at least every four hours b. Administer narcotic analgesics prn c. Remove the urinary catheter as soon as the client is ambulatory d. Order a high-protein diet for the client 81. A nurse is assessing a client who is post-op day #1 after a hemilaminectomy. The nurse removes the dressing as ordered and notes that the incision appears slightly red, with a small amount of serous drainage coming from the site. The edges of the incision are approximated. What is the next action of the nurse? a. Assist the client to shower as ordered and monitor the site for further changes b. Instruct the client to lie prone to allow the site to dry c. Place antibiotic ointment and a sterile dressing over the site d. Notify the physician for an antibiotic order 82. A nurse is preparing to administer a dose of platelets to a client. Which of the following actions must the nurse perform before giving the platelets? a. Start an IV of ½ Normal Saline to administer with the platelets b. Ensure the container with the platelets is intact and not damaged c. Verify the client's name and address d. Check the client's chart to ensure he is not taking any antibiotics 83. Which of the following is an example of an environmental hazard that may put the nurse at risk of injury? a. Loud noise from the hospital maintenance system b. Airborne powder that contains latex c. Chemicals containing ethylene oxide d. All of the above e. Both b and c only 84. MSDS sheets: a. Contain the ordering information for each piece of equipment in the office. b. Are required by OSHA to be accessible to all employees of the office. c. Can be used to treat patients who have been injured in equipment accidents. d. None of the above. 85. The most virulent blood borne pathogen is: (Choose the BEST answer.) a. HCV b. HPV c. HIV d. HBV 86. The NFPA diamond has four colors. The blue diamond: a. indicates hazards to health. b. designates that it is safe to use water to put out this type of fire. c. indicates that ice is necessary to treat an injury with this type of chemical. d. indicates that the chemical may be incinerated upon disposal. 87. Which would be the first step when a patient passes out at the front desk? a. Call 911. b. Initiate CPR. c. Shake the patient and ask if he is ok. d. Check for a pulse. 88. When performing CPR, at what rate should chest compressions be applied? a. 100 per minute b. 60 per minute c. As quickly as possible. d. 200 per minute 89. Which acronym would BEST describe the procedure for assessing a patient that appears unconscious? a. WBC b. QRS c. XYZ d. ABC 90. A term that refers to a comprehensive set of thoughts or images of oneself is called: a. Global self b. Core self-concept c. Personal identity d. Ideal self 91. Which of the following interventions is most appropriate when supporting the psychosocial needs of a client who is experiencing negative side effects associated with chemotherapy? a. Read the client's discharge instructions well in advance of dismissal b. Provide medications to reduce nausea and vomiting c. Give simple instructions about self-care while in the hospital d. Determine the levels of support from significant others 92. Which of the following interventions is most appropriate when working with the family of a client who is being treated for substance abuse? a. Advocate for the client before the family b. Provide referrals for community resources and support groups c. Take the side of the family before the client d. Both b and c 93. A term used to describe members of the same group based on physiological characteristics, such as skin color or body structure is known as: a. Ethnicity b. Culture c. Race d. Minority 94. Which of the following is an example of non-reversible dementia? a. Pick's disease b. Syphilis c. Encephalopathy d. Hyperthyroidism 95. Which is a true statement regarding stress related disorders? a. Stress related disorders are only caused by stress b. Symptoms of stress related disorders would not exist if the client was not experiencing stress c. Stress related disorders are also called psychophysiologic disorders d. None of the above 96. Which of the following nursing outcomes is most appropriate during the crisis stage of caring for a victim of domestic violence? a. The client will verbalize community resources from which to seek shelter after discharge b. The client will write a plan to keep herself and her children safe c. The client will contact an attorney for help with pressing charges d. The client will be safe and receive treatment for injuries 97. Which of the following is a symptom associated with sensory overload? a. Disorientation b. Drowsiness c. Emotional lability d. Depression 98. A nurse is providing care for a client who has just died. Her son states, "She was the most wonderful mother. There was no one who was a better mother than she was. She was perfect." Which stage of grief is this son experiencing? a. Denial b. Anger c. Idealization d. Shock 99. Of the following, which would NOT be helpful to include when developing Jerry's plan of care? a. Limiting choices b. Providing structure c. Encouraging patient input d. Ensuring availability of prn medications 100. Patients have a right to . a. only enough information so they can comply with care b. ALL of their health related information c. small amounts of information so they do not get nervous d. moderate amounts of information unless they are old 101. Your patient ate an 8 ounce cup of Italian ice. How much will you record on the patient's Intake and Output form in terms of this patient's fluid intake? a. 240 cc b. 120 cc c. 8 cc d. 0 cc because Italian ice is not a fluid. 102. You are getting the patient ready to eat. The patient is on complete bed rest. You will put the head of the bed up at degrees or more. a. 10 b. 15 c. 20 d. 30 103. Cheryl M. has a serious swallowing disorder. She has asked you for a glass of water. The doctor has ordered honey thickness fluids for her. Water is not a honey thickness fluid. It is much thinner. What should you do? a. Tell the resident that she cannot have water. b. Give her applesauce instead of the water. c. Tell Cheryl that she is NPO until midnight. d. Thicken the water and give it to her. 104. You have been asked to record the amount of food that the person has eaten during each meal. What kinds of words or numbers would you use to record this food intake? a. A little, a moderate amount or all of the meal b. 50 cc, 100 cc or 500 cc of the meal c. 25%, 50% or 100% of the meal d. Either a or c 105. The heat-regulating center of the brain is the: a. Hypothalamus b. Pituitary Gland c. Pons d. Medulla Oblongata 106. The anatomic structure located in the middle of the heart which separates the right and left ventricles is the: a. Septum b. Sputum c. Separatator d. None of the above. 107. Which of the following boney landmarks is described by, "large, blunt, irregularly shaped process, such as that found on the lateral aspect of the proximal femur"? a. Tubercle b. Tuberosity c. Condyle d. Trochanter 108. The Atlas and the Axis: a. are found in the vertebrae. b. can be described as being cervical. c. are the first two bones that form the column for the spine on the superior aspect. d. All of the above. 109. The body system that functions to maintain fluid balance, support immunity and contains the spleen is the: a. Lymphatic System b. Digestive System c. Urinary System d. Reproductive System 110. Of the following, which often triggers an episode of violence or aggression by the patient with a psychiatric diagnosis that may involve violent behavior? a. Obtaining a history b. Asking for input into care c. Enforcing rules d. Taking a walk 111. Which of the following medications would NOT be an appropriate prn medication for use during an episode of aggression or violence for the patient with a psychiatric diagnosis? a. Olanzapine b. Meperidine c. Ziprasidone d. Haloperidol 112. Which of the following is an appropriate tension-reduction intervention for the patient who may be escalating toward aggressive behavior? a. Asking to speak to someone b. Asking to be alone c. Listening to music d. All of the above 113. Causes which contribute to delirium are often remembered as an acronym of the same name. What cause does the E in DELIRIUM represent? a. EEG b. EKG c. Electrolytes d. Echocardiogram 114. A nurse is preparing to administer a rectal suppository to a client. After applying gloves, checking the client's identification band, and closing the door, what is the next step of the nurse? a. Assist the client to lie in the Trendelenburg position b. Unwrap the suppository and lubricate the end c. Remove gloves and wash hands d. Record the date, time, and amount of suppository to give 115. Mr. F has been prescribed isocarboxazid, a monoamine oxidase inhibitor, as part of treatment for depression. Which of the following foods should the nurse instruct the client to avoid while taking this drug? a. Wine b. Sweet potatoes c. Spinach d. Apple juice 116. A nurse is preparing to administer digoxin to a client who suffers from heart failure. What must the nurse consider before administering this medication? a. The presence of pitting edema in the lower extremities b. The sound of rales on lung auscultation c. The rate of the apical pulse d. The presence of jaundiced skin 117. A client has been taking his antianxiety medications for four years, even though he no longer struggles with acute anxiety. Instead, he has a routine of taking the medication each evening and feels better knowing that he has taken it. Which of the following best describes this action? a. Physiologic need b. Physiologic dependence c. Drug abuse d. Drug habituation 118. Which of the following is a disadvantage of taking medication through an oral route? a. The drug may be absorbed too rapidly b. The drug may have a bad taste c. The drug is more expensive to use d. Both a and b 119. One tablespoon of medication is equal to how many milliliters of fluid? a. 5 ml b. 15 ml c. 30 ml d. 60 ml 120. A nurse asks her coworker to administer Mr. J's 12pm medication because she is running behind. Which of the following information must the nurse verify with Mr. J before giving him his medication? a. His name and address b. His name and hospital identification number c. His name and room number d. His name and diagnosis 121. Which of the following is more likely to occur with aging as a complication of medication administration? a. Increased renal function b. Increased gastrointestinal absorption c. Increased visual acuity d. Increased ratio of fat compared to lean body mass 122. Which of the following interventions should the nurse consider when giving an oral medication to a child? a. Mix the medication with milk to mask the taste b. Dilute the medication in a glass of water c. Refeed the medication if the child pushes it out with his tongue d. Mix the medication in a food the child enjoys 123. Which of the following solutions is compatible with administration of packed red blood cells? a. Lactated Ringer's b. 0.9% Normal Saline c. D5 ½ Normal Saline d. Normosol-R 124. Which of the following is an example of a colloid solution? a. 5% Dextrose in water (D5W) b. Albumin c. Lactated Ringer's d. Normal Saline 125. Which of the following best describes the cognitive development of an 18- month old child? a. The child can follow one-part directions b. The child understands the concept of "forever" c. The child can name six body parts d. The child has an attention span of approximately 5 minutes 126. Which of the following is an example of a fine motor skill? a. Jumping on a trampoline b. Brushing hair c. Standing on one foot d. Climbing a ladder 127. A child is being discharged to home with a diagnosis of ringworm. Discharge instructions should include the information that: a. The infection is caused by a worm and cannot be passed from person to person. b. The infection is caused by a virus and can be passed from person to person. c. The infection is caused by a bacteria and cannot be passed from person to person. d. The infection is caused by a fungus and can be passed from person to person. 128. Physical bullying, among school aged children, threatens which of Maslow's needs? a. Physical needs b. Love and belonging needs c. Safety needs d. All of the above 129. Your patient has had a very full and rewarding life. She has had a lot of success in her personal and professional life. She has achieved all of her goals and she has maximized her potential. This patient can be best described as a person who has achieved Maslow's . a. self actualization b. exploration c. closeness d. protection ANSWER A: This person has moved along Maslow's hierarchy and is now 130. At the end of life, many people have a fear of . a. insects b. rejection c. acceptance d. being alone [Show Less]
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NCLEX FINAL 2022-2023 (Solved Questions) (100% VERIFIED QUESTIONS AND ANSWERS)
NCLEX FINAL 2022-2023 (Solved Questions) (100% VERIFIED QUESTIONS AND ANSWERS) 1. A 24-year-old female client is scheduled for surgery in the morning. ... [Show More] Which of the following is the primary responsibility of the nurse? A. Taking the vital signs B. Obtaining the permit C. Explaining the procedure D. Checking the lab work 2. The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority? A. Starting an IV B. Applying oxygen C. Obtaining blood gases D. Medicating the client for pain 3. The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client? A. Rest in bed after taking the medication for at least 30 minutes B. Avoid rapid movements after taking the medication C. Take the medication with water only D. Allow at least 1 hour between taking the medicine and taking other medications 4. The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside? A. A pair of forceps B. A torque wrench C. A pair of wire cutters D. A screwdriver 5. An infant weighs 7 pounds at birth. The expected weight by 1 year should be: A. 10 pounds B. 12 pounds C. 18 pounds D. 21 pounds 6. A client is admitted with a Ewing’s sarcoma. Which symptoms would be expected due to this tumor’s location? A. Hemiplegia B. Aphasia C. Nausea D. Bone pain 7. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug? A. Uric acid of 5mg/dL B. Hematocrit of 33% C. WBC 2,000 per cubic millimeter D. Platelets 150,000 per cubic millimeter 8. A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? A. “Tell me about his pain.” B. “What does his vomit look like?” C. “Describe his usual diet.” D. “Have you noticed changes in his abdominal size?” 9. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided? A. Bran B. Fresh peaches C. Cucumber salad D. Yeast rolls 10. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? A. Teaching how to irrigate the illeostomy B. Stopping electrolyte loss in the incisional area C. Encouraging a high-fiber diet D. Facilitating perineal wound drainage 11. The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet? A. Roasted chicken B. Noodles C. Cooked broccoli D. Custard 12. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: A. Trendelenburg position B. Ice to the entire extremity C. Buck’s traction D. An abduction pillow 13. A client with cancer is to undergo an intravenous pyelogram. The nurse should: A. Force fluids 24 hours before the procedure B. Ask the client to void immediately before the study C. Hold medication that affects the central nervous system for 12 hours pre- and post-test D. Cover the client’s reproductive organs with an x-ray shield 14. The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor: A. That cannot be assessed B. That is in situ C. With increasing lymph node involvement D. With distant metastasis 15. A client is 2 days post-operative colon resection. After a coughing episode, the client’s wound eviscerates. Which nursing action is most appropriate? A. Reinsert the protruding organ and cover with 4×4s B. Cover the wound with a sterile 4×4 and ABD dressing C. Cover the wound with a sterile saline-soaked dressing D. Apply an abdominal binder and manual pressure to the wound [Show Less]
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National Council Licensure Examination(NCLEX-RN) VERSION V12.35 Verified Q&A for 2022/2023
NO.1 A depressed client is seen at the mental health center for follow-up after an attempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil),... [Show More] a monoamine oxidase (MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that the drug must accumulate to an effective level before symptoms are totally relieved. Symptom relief is expected to occur within: A. 10 days B. 2-4 weeks C. 2 months D. 3 months Answer: B Explanation: (A) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. (B) This answer is correct. Because MAO inhibitors are slow to act, it takes 2-4 weeks before improvement of symptoms is noted. (C) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. (D) This answer is incorrect. Therapeutic effects of the medication are noted within 1 month of drug therapy. NO.2 Cystic fibrosis is transmitted as an autosomal recessive trait. This means that: A. Mothers carry the gene and pass it to their sons B. Fathers carry the gene and pass it to their daughters C. Both parents must have the disease for a child to have the disease D. Both parents must be carriers for a child to have the disease Answer: D Explanation: (A) Cystic fibrosis is not an X-linked or sex-linked disease. (B) The only characteristic on the Y chromosome is the trait for hairy ears. (C) Both parents do not need to have the disease but must be carriers. (D) If a trait is recessive, two genes (one from each parent) are necessary to produce an affected child. NO.3 A 24-year-old client presents to the emergency department protesting "I am God." The nurse identifies this as a: A. Delusion B. Illusion C. Hallucination D. Conversion Answer: A Explanation: (A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations. NO.4 In acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe? A. Diazepam (Valium) B. Haloperidol (Haldol) C. Sertraline (Zoloft) D. Alprazolam (Xanax) Answer: B Explanation: (A) Diazepam is an antianxiety medication and is not designed to reduce psychotic symptoms. (B) Haloperidol is an antipsychotic medication and may be used until the lithium takes effect. (C) Sertraline is an antidepressant and is used primarily to reduce symptoms of depression. (D) Alprazolam is an antianxiety medication and is not designed to reduce psychotic symptoms. NO.5 A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints? A. Give fluids if the client requests them. B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed. C. Measure vital signs at least every 4 hours. D. Release restraints every 2 hours for client to exercise. Answer: D Explanation: (A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are applied and after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2 hours. (D) Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation. NO.6 The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child? A. Administer oral griseofulvin on an empty stomach for best results. B. Discontinue drug therapy if food tastes funny. C. May discontinue medication when the child experiences symptomatic relief. D. Observe for headaches, dizziness, and anorexia. Answer: D Explanation: (A) Giving the drug with or after meals may allay gastrointestinal discomfort. Giving the drug with a fatty meal (ice cream or milk) increases absorption rate. (B) Griseofulvin may alter taste sensations and thereby decrease the appetite. Monitoring of food intake is important, and inadequate nutrient intake should be reported to the physician. (C) The child may experience symptomatic relief after 48- 96 hours of therapy. It is important to stress continuing the drug therapy to prevent relapse (usually about 6 weeks). (D) The incidence of side effects is low; however, headaches are common. Nausea, vomiting, diarrhea, and anorexia may occur. Dizziness, although uncommon, should be reported to the physician. NO.7 A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to: A. Prevent systemic infection B. Promote diuresis C. Decrease ammonia formation D. Acidify the small bowel Answer: C Explanation: (A) Neomycin is an antibiotic, but this is not the Rationale for administering it to a client in hepatic coma. (B) Diuretics and salt-free albumin are used to promote diuresis in clients with cirrhosis of the liver. (C) Neomycin destroys the bacteria in the intestines. It is the bacteria in the bowel that break down protein into ammonia. (D) Lactulose is administered to create an acid environment in the bowel. Ammonia leaves the blood and migrates to this acidic environment where it is trapped and excreted. NO.8 A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care? A. Encourage the child to cough up blood if present. B. Give warm clear liquids when fully alert. C. Have child gargle and do toothbrushing to remove old blood. D. Observe for evidence of bleeding. Answer: D Explanation: (A) The nurse should discourage the child from coughing, clearing the throat, or putting objects in his mouth. These may induce bleeding. (B) Cool, clear liquids may be given when child is fully alert. Warm liquids may dislodge a blood clot. The nurse should avoid red- or brown-colored liquids to distinguish fresh or old blood from ingested liquid should the child vomit. (C) Gargles and vigorous toothbrushing could initiate bleeding. (D) Postoperative hemorrhage, though unusual, may occur. The nurse should observe for bleeding by looking directly into the throat and for vomiting of bright red blood, continuous swallowing, and changes in vital signs. NO.9 An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observe which of the following: A. Both lower extremities warm to touch with 2_pedal pulses B. Both lower extremities cyanotic when placed in a dependent position C. Decreased or absent pedal pulse in the left leg D. The left leg warmer to touch than the right leg Answer: C Explanation: (A) This statement describes a normal assessment finding of the lower extremities. (B) This assessment finding reflects problems caused by venous insufficiency. (C) Decreased or absentpedal pulses reflect a problem caused by arterial insufficiency. (D) The leg that is experiencing arterial insufficiency would be cool to touch due to the decreased circulation. NO.10 A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician? A. pH 7.39 B. White blood cell (WBC) count 10,000 WBCs/mm3 C. Hematocrit 60% D. Bleeding time of 4 minutes Answer: C Explanation: (A) Normal pH of arterial blood gases for an infant is 7.35-7.45. (B) Normal white blood cell count in an infant is 6,000-17,500 WBCs/mm3. (C) Normal hematocrit in infant is 28%-42%. A 60% hematocrit may indicate polycythemia, a common complication of cyanotic heart disease. (D) Normal bleeding time is 2-7 minutes. NO.11 A male client is experiencing extreme distress. He begins to pace up and down the corridor. What nursing intervention is appropriate when communicating with the pacing client? A. Ask him to sit down. Speak slowly and use short, simple sentences. B. Help him to recognize his anxiety. C. Walk with him as he paces. D. Increase the level of his supervision. Answer: C Explanation: (A) The nurse should not ask him to sit down. Pacing is the activity he has chosen to deal with his anxiety. The nurse dealing with this client should speak slowly and with short, simplesentences. (B) The client may already recognize the anxiety and is attempting to deal with it. (C) Walk with the client as he paces. This gives support while he uses anxiety-generated energy. (D) Increasing the level of supervision may be appropriate after he stops pacing. It would minimize self-injury and/or loss of control. NO.12 Prior to an amniocentesis, a fetal ultrasound is done in order to: A. Evaluate fetal lung maturity B. Evaluate the amount of amniotic fluid C. Locate the position of the placenta and fetus D. Ensure that the fetus is mature enough to perform the amniocentesis Answer: C Explanation: (A) Amniocentesis can be performed to assess for lung maturity. Fetal ultrasound can be used for gestational dating, although it does not separately determine lung maturity. (B) Ultrasound can evaluate amniotic fluid volume, which may be used to determine congenital anomalies. (C) Amniocentesis involves removal of amniotic fluid for evaluation. The needle, inserted through the abdomen, is guided by ultrasound to avoid needle injuries, and the test evaluates the position of the placenta and the fetus. (D) Amniocentesis can be performed as early as the 15th-17th week of pregnancy. NO.13 A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nagele's rule is: A. March 27 B. February 1 C. February 27 D. January 3 Answer: C Explanation: (A)March 27 is a miscalculation. (B) February 1 is a miscalculation. (C) February 27 is the correct answer. To calculate the estimated date of confinement using Nagele's rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result. (D) January 3 is a miscalculation. [Show Less]
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NCLEX RN ACTUAL EXAM TEST BANK OF REAL QUESTIONS & ANSWERS NCLEX 2022
QUESTION 1 Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy? A. Positive inotropes B. Vasodilator... [Show More] s C. Diuretics D. Antidysrhythmics Answer: A Explanation: (A) Positive inotropic agents should not be administered owing to their action of increasing myocardial contractility. Increased ventricular contractility would increase outflow tract obstruction in the client with hypertrophic cardiomyopathy. (B) Vasodilators are not typically prescribed but are not contraindicated. (C) Diuretics are used with caution to avoid causing hypovolemi A. (D) Antidysrhythmics are typically needed to treat both atrial and ventricular dysrhythmias. QUESTION 2 Signs and symptoms of an allergy attack include which of the following? A. Wheezing on inspiration B. Increased respiratory rate C. Circumoral cyanosis D. Prolonged expiration Answer: D Explanation: (A) Wheezing occurs during expiration when air movement is impaired because of constricted edematous bronchial lumin A. (B) Respirations are difficult, but the rate is frequently normal. (C) The circumoral area is usually pale. Cyanosis is not an early sign of hypoxi A. (D) Expiration is prolonged because the alveoli are greatly distended and air trapping occurs. QUESTION 3 A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination? A. Auditory B. Gustatory C. Olfactory D. Visceral Answer: B Explanation: (A) Auditory hallucinations involve sensory perceptions of hearing. (B) Gustatory hallucinations involve sensory perceptions of taste. (C) Olfactory hallucinations involve sensory perceptions of smell. (D) Visceral hallucinations involve sensory perceptions of sensation. QUESTION 4 Which of the following findings would be abnormal in a postpartal woman? A. Chills shortly after delivery B. Pulse rate of 60 bpm in morning on first postdelivery day C. Urinary output of 3000 mL on the second day after delivery D. An oral temperature of 101F (38.3C) on the third day after delivery Answer: D Explanation: (A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. (B) The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. (C) Urinary output increases during the early postpartal period (12–24 hours) owing to diuresis. The kidneys must eliminate an estimated 2000–3000 mL of extracellular fluid associated with a normal pregnancy. (D) A temperature of 100.4F (38C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4F needs further investigation to identify any infectious process. QUESTION 5 A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the parents, the nurse states that: A. Sustained temperature elevation over 103F is generally related to febrile seizures B. Febrile seizures do not usually recur C. There is little risk of neurological deficit and mental retardation as sequelae to febrile seizures D. Febrile seizures are associated with diseases of the central nervous system Answer: C Explanation: (A) The temperature elevation related to febrile seizures generally exceeds 101F, and seizures occur during the temperature rise rather than after a prolonged elevation. (B) Febrile seizures may recur and are more likely to do so when the first seizure occurs in the 1st year of life. (C) There is little risk of neurological deficit, mental retardation, or altered behavior secondary to febrile seizures. (D) Febrile seizures are associated with disease of the central nervous system. QUESTION 6 A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time? A. Small, frequent feedings of foods that can be carried B. Tube feedings with nutritional supplements C. Allowing him to eat when and what he wants D. Giving him a quiet place where he can sit down to eat meals Answer: A Explanation: (A) The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with finger foods allow him to eat during periods of activity. (B) This type of therapy should be implemented when other methods have been exhausted. (C) The manic client should not be in control of his treatment plan. This type of client may forget to eat. (D) The manic client is unable to sit down to eat full meals. QUESTION 7 A client with bipolar disorder taking lithium tells the nurse that he has ringing in his ears, blurred vision, and diarrhe A. The nurse notices a slight tremor in his left hand and a slurring pattern to his speech. Which of the following actions by the nurse is appropriate? A. Administer a stat dose of lithium as necessary. B. Recognize this as an expected response to lithium. C. Request an order for a stat blood lithium level. D. Give an oral dose of lithium antidote. Answer: C Explanation: (A) These symptoms are indicative of lithium toxicity. A stat dose of lithium could be fatal. (B) These are toxic effects of lithium therapy. (C) The client is exhibiting symptoms of lithium toxicity, which may be validated by lab studies. (D) There is no known lithium antidote. QUESTION 8 A diagnosis of hepatitis C is confirmed by a male client’s physician. The nurse should be knowledgeable of the differences between hepatitis A, B, and C. Which of the following are characteristics of hepatitis C? A. The potential for chronic liver disease is minimal. B. The onset of symptoms is abrupt. C. The incubation period is 2–26 weeks. D. There is an effective vaccine for hepatitis B, but not for hepatitis C. Answer: C Explanation: (A) Hepatitis C and B may result in chronic liver disease. Hepatitis A has a low potential for chronic liver disease. (B) Hepatitis C and B have insidious onsets. Hepatitis A has an abrupt onset. (C) Incubation periods are as follows: hepatitis C is 2–26 weeks, hepatitis B is 6–20 weeks, and hepatitis A is 2–6 weeks. (D) Only hepatitis B has an effective vaccine. QUESTION 9 Hypoxia is the primary problem related to near-drowning victims. The first organ that sustains irreversible damage after submersion in water is the: A. Kidney (urinary system) B. Brain (nervous system) C. Heart (circulatory system) D. Lungs (respiratory system) Answer: B Explanation: (A) The kidney can survive after 30 minutes of water submersion. (B) The cerebral neurons sustain irreversible damage after 4–6 minutes of water submersion. (C) The heart can survive up to 30 minutes of water submersion. (D) The lungs can survive up to 30 minutes of water submersion. QUESTION 10 Which of the following activities would be most appropriate during occupational therapy for a client with bipolar disorder? A. Playing cards with other clients B. Working crossword puzzles C. Playing tennis with a staff member D. Sewing beads on a leather belt Answer: C Explanation: (A) This activity is too competitive, and the manic client might become abusive toward the other clients. (B) During mania, the client’s attention span is too short to accomplish this task. (C) This activity uses gross motor skills, eases tension, and expands excess energy. A staff member is better equipped to interact therapeutically with clients. (D) This activity requires the use of fine motor skills and is very tedious. [Show Less]
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NCSBN TEST BANK FOR THE NCLEX RN 2022-2023 VERIFIED QUESTIONS and Answers with Rationale.
NCSBN TEST BANK FOR THE NCLEX RN 2022-2023 VERIFIED QUESTIONS and Answers with Rationale Question 1 A c. What document should be in guiding the car... [Show More] e of this client? A) Client Self Determination Act B) Physician's treatment orders C) Advance Directives. D) Clinical Pathway protocols Review Information: The correct answer is: C) Advance Directives. This document specifies the client's wishes Question 2 You are the of a health care team that consists of one licensed practical/vocational nurse, one nursing assistant , a nursing student and yourself. To whom is it appropriate to assign complete care for A) Yourself B) The nursing student C) The licensed vocational nurse D) The nursing assistant Review Information: The correct answer is:A) Yourself. While the nurse may delegate a bed bath for a stable client, this care should be performed by an RN for a new admission. Only tasks that do not require independent judgment should be delegated. 3Question 3 A mother brings her the clinic, complaining that the child seems to be The nurse expects to find which of the following on the initial history and physical assessment? A) Increased temperature and lethargy B) Rash and restlessness C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor Review Information: The correct answer is:B) Rash and restlessness. Question 4 As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? A) "The child has been listless and has lost weight." B) "Her urine is dark yellow and small in amounts." C) "Clothes are becoming tighter across her abdomen." D+) "We notice muscle weakness and some unsteadiness." Review Information: The correct answer is:C) "Clothes are becoming tighter across her abdomen.". One of the most common signs of neuroblastoma is increasing abdominal girth. The parents'' report that clothing is tight is significant, and should be followed by additional assessments. Question 5 A 16 year-old presents to the emergency department. The triage nurse finds that this teenager is legally married and signed the consent form for treatment. What would be the appropriate INITIAL action by the nurse? A) Refuse to see the client until a parent or legal guardian can be contacted B) Withhold treatment until telephone consent can be obtained from the spouse C) Refer the client to a community pediatric hospital emergency room D) Assess and treat in the same manner as any adult client Review Information: The correct answer is:D) Assess and treat in the same manner as any adult client. Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this client, who is married, has the legal capacity of an adult. Question 6 A newly admitted elderly client is severely dehydrated. When planning care for this client, which one of the following is an appropriate task for an Unlicensed Assistive Personnel (UAP)? A) Obtain a history of fluid loss B) Report output of less than 30 ml/hr C) Monitor response to IV fluids D) Check skin turgor every four hours Review Information: The correct answer is:B) Report output of less than 30 ml/hr. When directing a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be reported. Because the RN is responsible for all care-related decisions,only implementation tasks should be assigned because they do not require independent judgment. Question 7 The nurse is assessing a 4 year-old for possible rheumatic fever. Which of the following would the nurse suspect is related to this diagnosis? A) Diagnosis of chickenpox six months ago B) Exposure to strep throat in daycare last month C) Treatment for ear infection two months ago D) Episode of fungal skin infection last week Review Information: The correct answer is:B) Exposure to strep throat in daycare last month. Evidence supports a strong relationship between infection with Group A streptococci and subsequent rheumatic fever (usually within 2-6 weeks). Therefore, the history of playmates recovering from strep throat would indicate that the child diagnosed with rheumatic fever most likely also had strep throat. Sometimes, such an infection has no clinical symptoms. Question 8 When the nurse becomes aware of feeling reluctant to interact with a manipulative client, the BEST action by the nurse is to A) Discuss the feeling of reluctance with an objective peer or supervisor B) Limit contacts with the client to avoid reinforcing the manipulative behavior C) Confront the client regarding the negative effects of his/her behavior on others D) Develop a behavior modification plan that will promote more functional behavior Review Information: The correct answer is:A) Discuss the feeling of reluctance with an objective peer or supervisor. The nurse who is experiencing stress in the therapeutic relationship can gain objectivity through supervision. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse- client relationship. Question 9 A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action A) May result in charges of unlawful seclusion and restraint B) Leaves the nurse vulnerable for charges of assault and battery C) Was appropriate in view of the client's history of violence D) Was necessary to maintain the therapeutic milieu of the unit Review Information: The correct answer is:A) May result in charges of unlawful seclusion and restraint. Seclusion should only be used when there is an immediate threat of violence or threatening behavior. Question 10 A client has been admitted to the Coronary Care Unit with a Myocardial Infarction. Which of the following nursing diagnosis should have PRIORITY? A) Pain related to ischemia B) Risk for altered elimination: constipation C) Risk for complication: dysrhythmias D) Anxiety Review Information: The correct answer is:A) Pain related to ischemia. Pain is related to ischemia, and relief of pain will decrease myocardial oxygen demands, reduce blood pressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system and increased preload, further increasing myocardial demands. Question 11 The nurse manager who is responsible for hiring professional nursing staff is required to comply with the Americans with Disabilities Act. The provisions of the law require the nurse manager to A) Maintain an environment free from hazards B) Provide reasonable accommodations for disabled individuals C) Make all necessary accommodations for disabled individuals D) Consider only physical disabilities in making employment decisions Review Information: The correct answer is:B) Provide reasonable accommodations for disabled individuals. The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant's ability to perform the job and not discriminate on the basis of a disability. Employers also must make "reasonable accommodations. Question 12 The mother of a school-aged child in a long leg cast asks the nurse how to relieve itching inside the cast. Which of the following is appropriate for the nurse to suggest as a remedy? A) Scratching the outside of the cast vigorously, applying pressure over the area B) Blowing a hair dryer or heat lamp on the cast over the area that is itching C) Using a long, smooth piece of wood to gently scratch the affected area D) Applying an ice pack over the area of the cast that is affected Review Information: The correct answer is:D) Applying an ice pack over the area of the cast that is affected. Applying ice is a safe method of relieving the itching. Question 13 Which of the following BEST describes the application of time management strategies in the role of the nurse manager? A) Scheduling staff efficiently to cover client needs B) Assuming a fair share of the client care as a role model C) Setting daily goals to prioritize work D) Delegating tasks to reduce work load Review Information: The correct answer is:C) Setting daily goals to prioritize work. Time management strategies must include setting priorities and meeting goals. Question 14 The clinic nurse assesses a toddler with a tentative diagnosis of neuroblastoma. Symptoms the nurse observes that suggest this problem include A) Lymphedema and nerve palsy B) Hearing loss and ataxia C) Headaches and vomiting D) Abdominal mass and weakness Review Information: The correct answer is:D) Abdominal mass and weakness. Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline, weakness, pallor, anorexia, weight loss and irritability. Question 15 A fifteen year-old client has been placed in a Milwaukee Brace. Which one of the following statements from the client indicates the need for additional teaching? A) "I will only have to wear this for six months." B) "I should inspect my skin daily." C) "The brace will be worn day and night." D) "I can take it off when I shower." Review Information: The correct answer is:A) "I will only have to wear this for six months.". The brace must be worn long-term, usually for 1-2 years. Question 16 The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that A) Quality of care will improve B) Staff turnover should decrease C) Flexible scheduling will occur D) Team morale will improve Review Information: The correct answer is:D) Team morale will improve. Nurses are more satisfied with autonomy and control. The nurse manager becomes the facilitator of scheduling rather than the decision-maker of the schedule. Question 17 A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? A) Diffuse expiratory wheezing B) Loose, productive cough C) No relief from inhalant D) Fever and chills Review Information: The correct answer is:A) Diffuse expiratory wheezing. In asthma, the airways are narrowed - creating difficulty getting air in and a wheezing sound. [Show Less]
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RN NCLEX Questions and Answers 2022
RN NCLEX Questions and Answers 2022 A nurse is caring for an older adult client who has a new diagnosis of type 2 diabetes mellitus and reports diff... [Show More] iculty following the diet and remembering to take the prescribed medication. Which of the following actions should the nurse take to promote client compliance? (SATA) A. Ask the dietitian to assist with meal planning B. Contact the client's support system C. Assess for age-related cognitive awareness D. Encourage the use of a daily medication dispenser E. Provide educational materials for home use - Answer- A, B, D, E A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. On the basis of this test result, the nurse plans to teach the client about the need for which measure? A. Avoiding infection B. Taking in adequate fluids C. Preventing and recognizing hypoglycemia D. Preventing and recognizing hyperglycemia - Answer- D Rationale: The normal reference range for the glycosylated hemoglobin A1c is less than 6.0%. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Erythrocytes live for about 120 days, giving feedback about blood glucose for the past 120 days. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus, the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. The estimated average glucose for a glycosylated hemoglobin A1c of 8% is 205 mg/dL (11.42 mmol/L). Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes. The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? A. After a shower or bath B. While standing to void C. After having a bowel movement D. While lying in bed before arising - Answer- A Rationale: The nurse needs to teach the client how to perform a TSE. The nurse should instruct the client to perform the exam on the same day each month. The nurse should also instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. Palpation is easier and the client will be better able to identify any abnormalities. The client would stand to perform the exam, but it would be difficult to perform the exam while voiding. Having a bowel movement is unrelated to performing a TSE. The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. A. Auscultating lung sounds B. Obtaining the client's temperature C. Assessing the strength of peripheral pulses D. Obtaining information about the client's respirations E. Performing a musculoskeletal and neurological examination F. Asking the client about a family history of any illness or disease - Answer- A, B, D Rationale: A focused assessment focuses on a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete assessment includes a complete health history and physical examination and forms a baseline database. Assessing the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete assessment. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment. The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse should tell the parent that which factor motivates good and bad actions for the child at the preconventional level? A. Peer pressure B. Social pressure C. Parents' behavior D. Punishment and reward - Answer- D Rationale: In the preconventional stage, morals are thought to be motivated by punishment and reward. If the child is obedient and is not punished, then the child is being moral. The child sees actions as good or bad. If the child's actions are good, the child is praised. If the child's actions are bad, the child is punished. Options 1, 2, and 3 are not associated factors for this stage of moral development. The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure? A. Allow the newborn infant to signal a need. B. Anticipate all needs of the newborn infant. C. Attend to the newborn infant immediately when crying. D. Avoid the newborn infant during the first 10 minutes of crying. - Answer- A [Show Less]
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NEW 2022 NCLEX-RN PRACTICE EXAM: COMPLETE SOLUTION WITH RATIONALE
NEW 2022 NCLEX-RN PRACTICE EXAM: COMPLETE SOLUTION WITH RATIONALE A client is admitted to the emergency department (ED). The family reports the client... [Show More] had a sudden onset of left-sided facial droop and slurred speech at home. The nurse observes left-sided muscle weakness. Which is the most important question for the nurse to ask? 1. "What over-the-counter medications does your parent take?" 2. "What was your parent doing when the symptoms began?" 3. "When did you notice the onset of your parent's symptoms?" 4. "Does your parent have a history of high blood pressure?" - answerCorrect: 3 Rationale: Time is of the essence when providing care to a client who experiences ischemic stroke, as thrombolytic therapy is only effective for 4.5 to 6 hours from onset of sx. This is the priority assessment question as thrombolytic therapy can restore circulation for this client. 2:A hemorrhagic stroke may be precipitated by strenous activity. This question is important to differentiate whether the client is experiencing a hemorrhagic or ischemic stroke but not the priority. 4: HTN or high blood pressure is a common risk factor for all types of stroke. Although this is an appropriate assessment question, it does not address the here and now. The nurse meets with the parent of an adolescent male who presents for an annual health maintenance visit. The parent voices concern that the child has recently become clumsy and uncoordinated. Which response by the nurse is correct? 1. "Your son might have attention deficit hyperactivity disorder." 2. "I'll talk with the health care provider about assessing for subtle motor dysfunction." 3. "Your son's clumsiness is expected at this age." 4. "This may be an early sign of depression." - answerCorrect: 3 Rationale: Adolescent males experience a rapid rate of physical growth, which can cause clumsiness and a lack of coordination. This statement is accurate and addresses the parent's concern. 1,4: This is a false statement about clumsiness and lack of coordination in adolescent males, as these manifestations are not associated with attention deficit hyperactivity disorder (ADHD) nor depression. Therefore, this response by the the nurse is not correct. 2: Inappropriate for the nurse tos uggest to HCP the need to assess for subtle motor dysfunction. *The client diagnosed with chronic lymphocytic leukemia (CLL) is scheduled for a bone marrow aspiration and biopsy. The client says, "I am frightened. I have never had this test before, and I don't know what to expect." Which statements will the nurse include when responding to the client's concerns? (Select all that apply.) 1. "We will move you to the operating room where the test is always performed." 2. "The bone in the front of your chest will be used for the biopsy specimen." 3. "A tight pressure dressing will be placed over the test site after the procedure." 4. "You will not feel any discomfort as the local anesthetic is injected." 5. "There is a risk of bleeding, so we will monitor the test site frequently." - answerCorrect: 3,4 Rationale: A bone marrow biopsy can cause bleeding and a pressure dressing is applied to reduce the risk of bleeding. Therefore, both are accurate and appropriate for the nurse t o include in teaching. 1: BMA/biopsy may be done in a client room or treatment room. OR is not required. 2: Sternum may be used for BMA but not enough marrow available for biopsy. 4: Client will feel some stinging and discomfort during bone marrow biopsy. This is false reassurance. *The LPN/LVN reporting to the nurse says, "You may want to see the client recently diagnosed with pancreatic cancer. I am not sure how well things are going." The nurse enters the room and finds the client sitting quietly, looking out the window. As the nurse approaches the client, the client does not look at the nurse. Which is the most appropriate response by the nurse? 1. "Sleep problems are common during times of stress. Have you had difficulty sleeping?" 2. "Tell me what you know about your diagnosis and the treatment you will receive." 3. "How would you describe your overall health status up to this time of your life?" 4. "How have you handled any health problems you experienced in the past?" - answerCorrect: 2 Rationale: MOST imp't to determine client's perception of the health problem. Open-ended statement. Strategy: need to address the problem and better to ask open-ended questions. It is more imp't to deal with the here and now. *The nurse provides care for the client immediately after arrival in the emergency department (ED). Emergency personnel report that the client was involved in a head-on collision with immediate loss of consciousness. Which is the first action taken by the nurse? [Show Less]
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NCSBN TEST BANK - for the NCLEX-RN & NCLEX-PN, Updated 2022, Complete Questions & Answers, A+ Guide
NCSBN TEST BANK - for the NCLEX-RN & NCLEX-PN, Updated 2022, Complete Questions & Answers, A+ Guide
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