NUR 265 Unit 2-3 NCLEX Questions ANSWERS 2023/24 Galen College
1.The nurse is caring for a client that has developed atrial fibrillation, with a
... [Show More] ventricular rate of
150/minute. The nurse should assess the client for which of the following clinical manifestations?
a. Flat neck veins
b. Nausea and vomiting
c. Hypotension and dizziness
d. Hypertension and headache
2. The nurse is caring for the client who had cardiac surgery 24 hrs ago has urine output averaging 20
mLs/hr for the last 2 hours. The client received a single bolus of 500 mL of fluid. Urine output for the
subsequent hour was 25mLs. Daily lab results indicate BUN 45 mg/dL & creatinine of 2.2 mg/dL. Based
on these findings the nurse would anticipate that the client is at risk for which problem?
a. Hypovolemia
b. Glomerulonephritis
c. Acute kidney injury
d. Urinary tract infection
3. The nurse is caring for a client who is wearing a continuous cardiac monitor, which begins to alarm.
The nurse can see no electronical complexes on the screen. Which of the following should the nurse do
first?
a. Call a code
b. Call the health care provider
c. Check the client’s status & lead placement
d. Press the record button on the EKG monitor
4. The nurse is caring for a client who frequently has sudden burst of ventricular tachycardia on the
monitor. What should the nurse be most concerned about with this dysrhythmia?
a. It is impossible to convert to a normal rhythm.
b. It can develop into a ventricular fibrillation at any point.
c. It is uncomfortable for the client, giving a since of impending doom.
d. It produces a high cardiac output that quickly leads to myocardial ischemia.
5. The nurse is caring for a client who is having frequent PVCs. Which of the following would be an
assessment priority?
a. Sensation of palpations
b. Causative factors, such as caffeine
c. Blood pressure & oxygen saturation
d. Precipitating factors, such as infection
6. The nurse is assessing a client’s response after a cardioversion. Which of the following assessment
would be a priority?
a. Blood pressure
b. Status of airway
c. Oxygen flow rate
d. Level of consciousness
7. The nurse is caring for a client who had AAA repair yesterday. The client has an IV infusion at a rate of
150mL/hr, unchanged from the last 10 hours. The client’s urine output for the last 3 hours has been 90,
50, and 28mLs. The BUN is 35, creatinine 1.8mg dL. Which of the following nursing actions is a priority?
a. Check the urine specific gravity
b. Put the IVF on a pump so the infusion rate is sure to stay the same
c. Check to see if the client had a serum blood albumin level drawn
d. Call the healthcare provider
8. The nurse is reviewing the following prescriptions for the assigned clients. It would require follow up
with the PCHP if a client who
a. has liver failure and has been prescribed lactulose 30 mg PO Daily.
b. has CAD and has been prescribed ASA 325mg PO Daily.
c. has CKD and was prescribed spironolactone 50mg PO Daily
d. had benign angina and was prescribed Nitro tabs, PRN
9. The nurse is caring for the following clients. It would be a priority to schedule an interdisciplinary
conference for the client who is
a. 70-year-old, lives with a spouse, retired, will be discharged home after scheduled dialysis fistula declot surgery.
b. 56-year-old, married with grown kids, lives 3 hours away, works as a day care worker, needs
paracentesis weekly.
c. 45-year-old, lives with a partner, works as an executive, recently diagnosed with AKI, being treated
medically.
d. 39-year-old, single mother of 3 children, works as an elementary school teacher, is scheduled to have
a heart catheterization tomorrow.
10. A newly-hired nurse is providing care to assigned clients. It would require follow up by the nurse
preceptor if the newly hired nurse
a. questions whether a prescribed aminoglycoside should be given before hemodialysis.
b. anticipates administering anticoagulation therapy to a client who has developed DIC.
c. walks the client to the bathroom during the peritoneal dialysis (PD) dwell cycle.
d. applies a pressure dressing on a client’s arteriovenous (AV) fistula between hemodialysis treatments.
11. The nurse is reviewing the laboratory values of a client who had a prosthetic valve replacement 3
days ago and is receiving a continuous heparin infusion and Coumadin. Which of the following lab
values would be a priority to follow up?
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