200+ NCLEX-RN Questions (and Answers)
By Minute Help Guides
© 2011 by Minute Help, Inc.
Published at SmashWords
Disclaimer
These questions are based on the NCLEX examination, but this book is not officially endorsed by the National Council of State Boards of Nursing. The book is meant to help you, but the questions presented here vary from the actual examination. Use at your discretion.
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Management
A newly hired registered nurse is attending the facility’s orientation program for new members of the nursing staff. During the program, the facility’s organizational chart is presented. Which of the following statements inaccurately describes an organizational chart?
The lateral lines define the division of labor.
The vertical line explains the lines of authority.
It formally displays the structural relationship of one department with another.
Administrative roles are generally demonstrated in vertical and horizontal dotted lines.
Answer: D – Administrative roles are generally shown in solid lines, which can either be vertical or horizontal. Staff positions and advisory boards are demonstrated by dotted lines. Organizations contain both a formal structure and an informal structure. An organizational chart formally displays the structural relationship of one department with another. The other options are correct.
A registered nurse works in the adult ward. The RN reviews the chart and takes note of the tasks that should be completed within the day. The RN notes that informed consents should be have been signed by the following clients except:
A 55-year-old male client scheduled for thoracentesis.
A 50-year-old female client scheduled for transvaginal ultrasound.
A 29-year-old male client suspected of meningitis, scheduled for lumbar puncture.
A 43-year-old female client scheduled for a 12-lead ECG.
Answer: D – A client scheduled for a 12-lead ECG does not need to sign an informed consent. An informed consent is a legal document, which indicates that the facility has obtained a client’s permission to have his or her body touched. In general, all invasive diagnostic tests and treatments need informed consents. The nurse should not obtain an informed consent. The physician is responsible for this. It is the role of the nurse to ensure that the client understands the details in the consent.
A registered nurse is caring for a 67-year-old female client who has a history of chronic bronchitis. The client had an appendectomy 24 hours ago. When creating the client’s care plan, which of the following interventions has the highest priority?
Administer oxygen with a rate of at 5 liters per minute.
Turn the client every 2 hours.
Encourage the client to perform deep breathing exercises, with a splint against the wound.
Administer nebulization treatments every hour.
Answer: B – The priority of the nurse is to turn the client every 2 hours. Hypostatic pneumonia is a life-threatening complication, which occurs after a surgery due to immobility. Turning every 2 hours ensures that respiratory secretions are not allowed to pool in the lungs. Accumulated secretions are a good breeding ground for bacteria. The client has a history of chronic obstructive pulmonary disease, which increases her risk for pneumonia. Administration of oxygen is helpful, but it does not prevent the buildup of an environment that encourages respiratory complications. The client should perform deep breathing exercises at least once every hour. Nebulization is not necessary in this case.
A registered nurse is caring for an 85-year-old male client with Alzheimer’s disease, stage 7. The client is placed on a two-point restraint due to increasing agitation and aggression. The nurse ensures client safety by assessing the client’s skin integrity:
Every 30 minutes
Every 8 hours
Every 2 hours
Every shift
Answer: A – The client’s skin integrity should be assessed every 30 minutes. The restraints are released every 2 hours to avoid injuries and to promote mobility. Restraints can impede the circulation of blood and may encourage muscle stiffness and weakness. Checking the client’s skin integrity every 8, 2 or 12 hours increases the client’s risk for complications.
A registered nurse is creating a care plan for a female elderly who is admitted due to diarrhea, weakness and increasing irritability. The RN is delegating tasks to the nursing staff. The following nursing interventions are appropriately delegated to the LVN/LPN except:
Monitoring fluid intake and output.
Performance of initial assessment.
Providing oral re-hydration.
Administration of oral medications prescribed.
Answer: B – Initial assessment of vital signs and symptoms associated with dehydration is not appropriately delegated to the LVN/LPN. Although LVN/LPNs may assess the clients, the RN should perform the initial assessment. Monitoring of fluid intake and output, administration of oral medications and oral hydration can be safely delegated to an LPN.
A charge nurse in the adult ward is planning the distribution of client assignments to a nursing team. The team consists of an RN, an LVN/LPN and a nursing assistant. A student nurse is also included to assist the team during the shift. The charge nurse delegated the tasks appropriately to the following staff members except:
A student nurse assigned to give tepid sponge bath to a client who has a temperature of 100.8°F.
A registered nurse is assigned to a client with a chest tube drainage system.
A nursing assistant assigned to insert an indwelling catheter to an elderly client with benign prostatic hyperplasia.
A licensed practical nurse assigned to monitor a client who is receiving packed RBCs.
Answer: C – Inserting an indwelling catheter to an elderly client with BPH is not appropriately delegated to the nursing assistant. This procedure requires use of strict aseptic techniques, requiring the skills of an LVN/LPN or RN. A student nurse may assist the team by providing a tepid sponge bath to a client with low-grade fever. A registered nurse assigned to a client with a chest tube drainage system is appropriate. LVN/LPNs are not allowed to hang packed RBCs, but it is within their scope of practice to monitor clients during transfusions.
A client diagnosed with bladder cancer is admitted to the unit for another session of chemotherapy. The registered nurse caring for the client delegated tasks to different members of the nursing team. Which of the following delegations is inappropriately given to the LVN/LPN?
Monitoring of the client’s fluid intake and urinary output.
Administration of ondasteron, PO.
Administration of cisplatin, IV.
Monitoring the client’s vital signs every 2 hours.
Answer: C – Administration of cisplatin is inappropriately delegated to the LVN/LPN. Chemotherapeutic medications like cisplatin should be administered by the RN. The LPN may monitor the client’s fluid intake and urinary output and vital signs. These activities are within the LPN’s scope of practice. The nurse may administer ondasteron by mouth. This medication is an oral medication that alleviates nausea and vomiting.
A registered nurse is assigned to care for an obese 55-year-old client, who was admitted due to a viral infection of the meninges. Irritability and confusion were noted. While providing the client a bed bath, the RN was called by the charge nurse. The client was draped and the nurse went out to talk to the charge nurse for a minute. When the RN comes back, the client is found lying on the floor. The side rails are not raised. What is the initial action of the nurse?
Help the client return to bed.
Assess the client.
Proceed to the nurse’s station to ask for help.
Make an incident report.
Answer: B – The initial action of the nurse is to assess the client for any signs of injury. Option A is a correct intervention but it is not the initial action of the nurse. Transfer to bed may be done if the client’s condition permits it. Option C is not correct, as the nurse should first assess the client to ensure safety. An incident report is necessary, but it is done after all the needed interventions are performed.
The cardiologist of one of the clients in the unit contacted the registered nurse through a telephone call. The physician is about to order a new medication for a client. When receiving a telephone order, the RN should keep in mind of which of the following guidelines?
Orders through telephone calls are unacceptable and should not be received by the RN.
Telephone calls are accepted if the client’s condition requires immediate interventions.
The physician should co-sign the telephone order anytime.
Only the RNs are allowed to receive telephone orders regardless of the situation.
Answer: B – The RN should keep in mind that telephone calls are acceptable if the client’s condition requires immediate interventions. With advanced technology, most facilities prefer sending of fax or computer generated orders to avoid errors. The physician should countersign the telephone order within 24 hours of giving the order. Other members of the nursing staff like the LPN may obtain and transcribe telephone orders, although this may vary from one facility to another.
The charge nurse in an adult care unit is making the initial rounds at the start of the shift. After seeing and briefly assessing every client in the unit, the charge nurse would first refer which client to the physician?
A client complaining of substernal chest pain not relieved by nitroglycerine.
A client who has a blood pressure of 150/100 while at rest.
A client diagnosed with congestive heart failure with puffy eyes, respiratory rate is 32 breaths per minute.
A post-appendectomy client with a soaked abdominal dressing.
Answer: A- The client complaining of substernal chest pain not relieved by nitroglycerine should be the first client to be referred to the physician. Chest pain unrelieved by nitroglycerins strongly suggests myocardial infarction. The client in option B has to have his or her blood pressure re-checked in 30 minutes. The client with puffy eyes and tachypnea and the client with soaked abdominal dressing require referral but they are not the priority of the nurse.
A registered nurse is teaching a group of student nurses about the ethical codes in the nursing practice. The nurse asked a series of questions to evaluate the effectiveness of instruction. Which of the following statements made by one of the students about ethical codes indicate that further teaching is necessary?
“Ethical codes provide broad principles used to evaluate client care.”
“One of the ethical codes for nurses to follow is the American Nurses Association Code of Ethics.”
“Ethical codes are legally binding.”
“The Code for Nurses is developed by the International Council of Nurses.”
Answer: C – Ethical codes are not legally binding. Ethical codes provide broad principles to evaluate client care. In most states, the board of nursing has the authority to admonish nurses for unprofessional conduct. Specific ethical codes for nurses are the American Nurses Association Code of Ethics and The Code for Nurses by the International Council of Nurses.
A female client is brought to the emergency department by the EMS after a few individuals alerted 911 about a woman who was found lying on the street, unconscious. Initial investigation suggests that the client was hit by a car. The client has no identification cards with her. Initial assessment suggests that the client has a severe head injury, which requires an emergency craniotomy. Regarding the informed consent for the surgery, which of the following is the most appropriate action of the health care team?
Transport the client to the operating room for craniotomy.
Ask the EMS to sign the informed consent for the client.
Ask for police assistance in order to identify the client and locate her family members.
Consult the facility’s ethical committee.
Answer: A – The most appropriate action of the health care team is to transport the client to the operating room. In this situation, the surgery may proceed without an informed consent as delaying the treatment to obtain an informed consent are more likely to bring about fatal complications. Asking the EMS team is not appropriate. Asking for police assistance to locate the client’s family members and consulting the ethical committee may delay the treatment.
Two nurses from the same unit are having their coffee in the cafeteria. Nurse A tells Nurse B that their nursing supervisor is having an illicit affair with Dr. Smith, who is married. A nurse from another unit overheard the story and begins to tell the nurses in her unit about the affair. Nurse A can be charged with which legal tort?
Negligence
Assault
Libel
Slander
Answer: D – Nurse A can be charged with slander. Defamation occurs when something unproven or untrue is said, which is referred to as slander, or written, which is known as libel. Both types of defamation cause injury to a person’s good name and reputation. Assault is threatening or putting another person in fear of offensive contact. Negligence involves actions of the nurse that fall below the standard of care.
A registered nurse is documenting the nursing interventions performed on an elderly client with emphysema. After reviewing the most recent entry, the nurse realizes that an error was made. Which of the following is the best way to correct the error?
Draw one line through the inaccurate information, initial and date the line and make the correction.
Consult the nurse in charge.
Use a whiteout to delete the error, and then write in the correct information.
Make another entry, correcting the error.
Answer: A – The best way to correct the error is to draw one line through the inaccurate information and then initial and date the line. Consulting the nurse in charge is not necessary. Using a whiteout to erase a detail of information is prohibited. Making another entry to correct the error is not necessary.
An 80-year-old female client informs the registered nurse that she has just finished writing her living will. The client says that nobody is around to be her witness and so, she asks the nurse if she can be a witness to her signature. Which of the following responses made by RN is correct?
“Anyone can be a witness, except me as I am directly involved with your care. The supervisor can be your witness.”
“I will see our nursing supervisor to give assistance regarding your request.”
“Of course, I can sign as a witness to your signature.”
“I am sorry, but I cannot be a witness. You have to find your own.”
Answer: B – The correct response is informing the client that he or she will speak with the nursing supervisor to give her assistance. Living wills have to be signed by the client, and someone must witness her signature. Most states prohibit any employee of the facility where the client is seeking care from becoming a witness. The nursing supervisor cannot be a witness. Option D does not address the concerns of the client and is non-therapeutic.
A registered nurse enters the bathroom and finds the LVN/LPN drinking a bottle of rum. The vocational/practical nurse is showing signs of alcohol intoxication. Which of the following actions is the best initial action of the RN when dealing with a co-worker who is intoxicated with alcohol?
Call security
Call the nurse supervisor
Close the door and make an incident report
Lock the door and wait until the co-worker regains clear mental function
Answer: B – The best initial action of the RN is to call the nurse supervisor or manager. The registered nurse has the responsibility to report co-workers who are physically or mentally impaired on duty. The LVN/LPN’s condition may harm the clients under her care. Calling the security is more appropriate after the initial interventions are provided. The nurse should make an incident report, but it is not the first action of the nurse. Waiting for the co-worker to regain mental function is a passive approach and is not correct in this situation.
A newly hired registered nurse is ordered to administer an oral medication to a client. After carrying out the order, the client is showing signs of drug overdose. Immediate interventions are performed and the client’s symptoms are managed effectively. An incident report is made by the RN. The RN who committed the error understands that the incident report is mainly used as a:
Formal report for the state board of nursing.
Method to promote improved quality care.
Basis for suspension.
Formal document to be kept as a personnel file.
Answer: B – Incident reports are mainly used to promote improved quality care and risk management. It allows the agency to review the quality of care and to determine any potential risks of the current regulations or practices. Based on the given situation, the report will not be used as a basis for suspension nor will it be submitted to the state board of nursing. It is not kept as a personnel file.
A newly graduated female nurse is hired as a staff member of a psychiatric unit. During the orientation, the new nurse asks the training staff member if there is a need of obtaining her own professional liability insurance. The most appropriate response of the training staff member is:
“No, there is no need for that. You are protected by the agency’s professional liability policies.”
“Yes, you have to have your own professional liability insurance. It can be your protection against malpractice law suits.”
“It is expensive and it is not necessary.”
“You may consider it. However, it benefits the physicians the most because suits are usually filed against them and the agency.”
Answer: B – The most appropriate response is to consider getting professional liability insurance, as it can be the nurse’s best protection against malpractice lawsuits. There is a misconception that nurses are protected by the agency’s professional liability policies. When a nurse is sued, the agency is likely to be sued for the nurse’s actions.
A registered nurse is receiving telephone orders from the physician of a female client who is admitted due to myasthenia gravis. The RN understands that when receiving telephone orders, the following guidelines should be kept in mind except:
The date and time of the order is entered into the client’s chart.
Sign the order, beginning with t.o., write the physician’s name, and then sign the order.
Have one of the nursing staff to witness the order; the witness does not need to sign in the chart.
The physician should sign the documented telephone order within 24 hours.
Answer: C – Another member of the nursing staff may witness the order; he or she should also sign the entry made into the client’s chart. Telephone orders are acceptable in a case where a client needs the ordered intervention or treatment immediately. The date and time of the order is written in the chart, along with the physician’s name, the nurse’s signature and signature of the witness. The order has to be countersigned by the physician within 24 hours.
A registered nurse is teaching a group of student nurses about the physician’s orders. To evaluate the effectiveness of instructions, the RN asks the group a series of questions about the topic. Which of the following statements made by one of the students indicates that further teaching is necessary?
“A nurse should clarify with the physician if the order is either unclear or inappropriate.”
“If the nurse believes that the order is inaccurate, he or she is not obligated to carry out the order.”
“If no resolution occurs regarding the order in question, the nurse should contact the nurse supervisor.”
“If a nurse carries out an inaccurate order, he or she is legally responsible for any harm that it may cause the client.”
Answer: D – The nurse carrying out an inaccurate order may be legally responsible for any harm caused to the client. If the nurse believes that an order is inappropriate, he or she should clarify this to the physician. If a resolution not achieved, the nurse should inform the nurse supervisor about it. A registered nurse is an independent health care provider, and he or she is not obligated to carry out an order if it is believed to be inappropriate.
A nurse educator is teaching a class of student nurses about the Patient Self-Determination Act. Before ending the teaching session, the nurse educator asks the students a series of questions to evaluate their understanding about the topic. The teaching session is successful if a student nurse made the following statements except:
“It became a law in the United States in 1990.”
“It is implemented in all health care institutions.”
“If a client signs an advance directive at the time of admission, it must be documented in the medical record.”
“It is not the duty of the agency to determine about the existence of an advance directive.”
Answer: D – It is the duty of the agency to ask a client if an advance directive is in existence. The Patient Self-Determination Act is implemented in all health care institutions when it became a law in the United States in 1990. If the client has an existing advance directive or if an advance directive is signed at the time of admission, it must be documented in the medical record.
A female client with breast cancer, stage IV is admitted to the facility for a surgery. The client asks, “What is a Do Not Resuscitate order? What is it all about?” The nurse is not correct if which of the following responses is given to the client?
“You must write the DNR order by yourself before or during the admission. It is reviewed by the physician if you indicated a desire to be allowed to expire, if you stop breathing or if your heart stops beating.”
“It is reviewed regularly according to the agency’s policy. It is usually reviewed every 3 days.”
“Everyone in the agency must know whether or not you have a DNR order.”
“You or your legal representative must provide informed consent for the DNR order.”
Answer: A – The DNR order must be written by the physician when a client has indicated that she be allowed to die if her breathing stops or if her stops breathing. An informed consent is necessary for a DNR order. The client or a legal representative should sign the consent first before it takes effect. The DNR is reviewed according to the agency’s policy. In most facilities, it is reviewed every 3 days. All health care personnel should know whether or not the client has a DNR order.
A registered female nurse of a cardiovascular unit has been the unit’s nurse supervisor for the past 3 years. The nurse supervisor is focused and maintains control at all times by making decisions and solving problems by herself. During conflicts, she makes her commands for resolution. The nurse supervisor is demonstrating which leadership style?
Autocratic leadership
Democratic leadership
Laissez-faire leadership
Situational leadership
Answer: A – The nurse is demonstrating autocratic leadership. This type of leader maintains strong control by making decisions and solving problems by herself. Instead of asking suggestions, this leader commands rather than give suggestions when resolving conflicts. Democratic leadership believes that each member of the team should have an input into the achievement of goals and problem solving. Laissez-faire leadership is described as inactive, non-directive and passive. Situational leadership is a combination of styles based on the current situation.
A nurse educator is teaching a group of student nurses about the different types of leadership styles employed by nursing supervisors or managers in actual settings. The nurse educator asks one of the students to describe the characteristics of a laissez-faire leadership. Which of the following statements made by a student nurse is inaccurate?
“It assumes a non-directive and inactive approach.”
“The leadership responsibilities are assumed by the members of the group.”
“It is assumed according to the needs of the group.”
“Uncooperative behavior by the group may be acceptable.”
Answer: D – Situational leadership, not laissez-faire, is assumed according to the needs of the group. A laissez-faire leadership is non-directive and inactive, where leadership responsibilities are assumed by members of the group. Uncooperative behavior of the group may be acceptable, which results from the leader’s lack of limit setting.
The registered nurse understands that managerial functions include the following: Planning, Organizing, Directing, Controlling and Decision-Making. The nurse manager demonstrates which function whenever he or she uses a performance standard as criteria for measuring the success of a newly implemented wound care protocol?
Planning
Organizing
Controlling
Decision-making
Answer: C – The nurse manager demonstrates controlling whenever he or she uses a performance standard as criteria for measuring the success of a newly implemented wound care protocol. Planning includes determining objectives and identifying methods to achieve a goal. Organizing involves use of resources to achieve the objectives. Decision-making involves identification of problems and consideration of various options.
A registered nurse is assigned in the triage area of the facility’s emergency department. An earthquake occurred in the area and the injured are brought to the ER for treatment. Which of the following clients has the highest priority for treatment?
An 8-year-old client with minor lacerations.
A 20-year-old client with a fractured left leg.
A 12-year-old demonstrating signs of asthma, without respiratory distress.
A 20-year-old client who sustained chemical splashes to the eyes.
Answer: D – The 20-year-old client who sustained chemical splashes to the eyes has the highest priority for treatment. Chemical splashes to the eyes, in addition to chest pain, severe respiratory distress, limb amputation and acute neurological deficits, need emergent treatment. Emergent is priority 1. Option B is classified as non-urgent or priority 3. Options B and C are classified as urgent or priority 2.
A client is brought to the triage area of the emergency department. The client is complaining of severe abdominal pain, probably due to a renal stone. The client receives the urgent classification or priority 2. The registered nurse understands that:
The client may be treated in more than 2 hours; evaluation is done every 1 to 2 hours thereafter.
Treatment should be treated within 1 to 2 hours; evaluation is done every 30 to 60 minutes thereafter.
The client needs immediate attention; continuous evaluation is needed.
The client’s condition has life-threatening conditions.
Answer: B – A client who is classified as priority 2 or urgent should be treated within 1 to 2 hours with continuous evaluation every 30 to 60 minutes thereafter. Option A is more applicable to priority 3 or non-urgent clients. Options C and D are more applicable to clients who are classified as priority 1 or emergent.
A registered nurse activated the fire alarm after finding out that a client’s room is on fire. Which of the following statements should the RN keep in mind if a fire occurs inside the health care agency?
Immediately activate the emergency response plan.
The nurse cares for the victims by attending those with life-threatening conditions.
Immediately activate the triage system.
Immediately declare a federal emergency.
Answer: A – In case of a disaster inside the facility, the nurse should immediately activate the emergency response plan for fires and respond to the disaster by following the directions identified in the plan. Options B and C are appropriate disaster responses occurring in a community setting. The nurse cannot declare a federal emergency.
A registered nurse is caring for a client with congestive heart failure. The RN is delegating tasks to the nursing team, which includes an LVN/LPN and a nursing assistant. When delegating and assigning tasks, which of the following considerations would the RN keep in mind at all times?
Delegating a task is also delegating his or her accountability.
A vocational nurse may perform tasks that a nursing assistant can perform.
An evaluation is not necessary.
Avoidance of giving deadline as a consideration to the delegatee.
Answer: B – A vocational nurse may perform tasks that a nursing assistant can perform. When delegating a task, the accountability stays with the delegator, or the registered nurse. An evaluation is necessary. Although a task is delegated, the RN should give a deadline to the delegatee.
Registered nurse A and registered nurse B are applying for a vacation leave on the same week. The nurse supervisor informed both nurses that although both requests can be accommodated, only one of the RNs can be allowed to go on a leave for that particular week. RN A has applied for vacation leave two months ago. RN B applied for a vacation two weeks ago due to a family affair overseas. RN A gave in and says, “She can have a vacation leave first. I want her to have fun with her family. I’m sure my family and I can re-schedule.” RN A is demonstrating which type of conflict resolution style?
Avoidance
Accommodation
Competition
Compromise
Answer: B – The conflict resolution style of RN A is accommodation. Individuals who use this style are often unassertive, with a constant aim to satisfy others. Individuals who use avoidance neither pursue their goals nor assist others to pursue them. Competition involves an individual who pursues his or her own needs at the expense of others. Compromise involves an individual who is assertive and cooperative.
Physiological Adaptation
A nurse is caring for a postpartum client who gave birth to a 7.5-pound baby girl 12 hours ago. Labor and delivery were unremarkable. During the physical assessment, which of the following signs or symptoms would first alert the nurse to initiate interventions that control hemorrhage?
Change of blood pressure from 130/80 to 120/75.
Pulse rate from 80 to 100/min
Respiratory rate from 16 breaths/min to 20 breaths/min.
A temperature of 100.8OF.
Answer: B – The earliest sign of postpartum hemorrhage is an increase of the pulse rate. Blood loss stimulates the heart to pump faster. By increasing the heart rate, the body is able to compensate for the decreasing blood volume. Blood pressure decreases as the blood volume drops, but it is not the earliest indicator of hemorrhage. Slight increase in temperature and respiratory rate are also expected during postpartum hemorrhage but they are not the first sign of blood loss.
On the fourth stage of labor, the client is bleeding excessively. The nurse notes that for the past 2 hours, the client has been soaking more than 1 maxi pad per hour. On palpation, the fundus feels firm and contracted. Based on these findings, which of the following is the priority action of the nurse?
Document the findings.
Massage the fundus.
Notify the physician.
Administer oxytocin, as ordered.
Answer: C – If the client is showing signs of excessive bleeding but the fundus is firm, the nurse should suspect a lacerated cervix or vagina. These findings are not documented as normal. The fundus is contracted; massage is not necessary. Oxytocin contracts the uterine muscles; it is not administered in this case because the uterus feels firm. The priority action of the nurse is to notify the physician.
A nurse is caring for an adult client who has been diagnosed with chronic renal failure. The client has been receiving hemodialysis for the past 2 years. When caring for the client, the nurse would implement which of the following interventions?
Encourage the client to drink at least 1500 ml per day.
Offer foods high in calcium.
Weigh daily before breakfast.
Instruct client to decrease his intake of phosphorus and potassium.
Answer: C – The nurse should obtain the client’s daily weight, preferably before breakfast. Weighing before the first meal of the day is the most accurate method of monitoring fluid retention. Fluid intake should be restricted. Consumption of phosphorus and potassium should be controlled. Smaller meals and between-meals are recommended.
A nurse is monitoring the chest tube drainage system attached to a client who was admitted due to pneumothorax. During the assessment, the nurse observes intermittent bubbling in the water seal compartment. What is the next action of the nurse?
Document the findings.
Notify the physician.
Assess for an air leak.
Clamp the tubing.
Answer: A – Intermittent bubbling in the water seal compartment should be documented as normal. This observation indicates that the drainage system continually removes trapped air from the pleural space, which consequently allows lung re-expansion. An air leak should be suspected if continuous bubbling during inspiration and expiration occur.
A 50-year-old female comes to the emergency department complaining of chest pain and abdominal pain, more specifically on the upper part of the abdomen. The client further reported that she has been experiencing some changes in her bowel movement for the past month. For the past 2 weeks, her stools are often black and tarry. Based on these findings, which of the following nursing actions is the most appropriate?
Administer morphine.
Obtain vital signs.
Initiate ECG monitoring.
Assist the client in supine position, flat on bed.
Answer: B – The most appropriate action of the nurse is to obtain the client’s vital signs. Administration of morphine and ECG monitoring needs an order from the physician. Positioning is within the scope of nursing, but asking the client to lie flat on bad, in supine position, can worsen or aggravate the pain. The nurse should assist the client in low-Fowler’s position with the knees flexed.
A nurse in a well-baby clinic is assessing a 6-month-old infant who is scheduled for immunization. During the assessment, which of the following findings would alert the nurse to refer the infant to the physician?
The anterior fontanel is not completely ossified.
The tonic neck reflex is absent.
The Moro reflex is not elicited.
The posterior fontanel is not completely ossified.
Answer: D – If the infant’s posterior fontanel is not completely fused, immediate referral to a physician is necessary. The posterior fontanel closes from 2 to 3 months of life. The anterior fontanel closes from 12 and 18 months of age. Tonic reflex disappears on the fourth month. The Moro reflex is disappears by the 5th month.
A registered nurse is reviewing the medical records of the clients who are assigned to her care during the shift. The nurse determines that from the list, which client has the greatest risk for fluid volume deficit?
A client with a colostomy.
A client who requires wound irrigations every 3 hours.
A client with a syndrome of inappropriate anti-diuretic hormone.
A client who is on steroid therapy.
Answer: A – The client with a colostomy has the greatest risk for fluid volume deficit. Vomiting, diarrhea, tachypnea and conditions that increase the urinary output can cause fluid volume deficit. Clients who require irrigations, clients on steroid therapy and clients diagnosed with SIADH may all cause water retention.
A client is diagnosed with carcinoma of the pancreas. The client reports extreme muscle weakness and muscle cramps. A laboratory test reveals a serum sodium level of 120 mEq/L. A diagnosis of SIADH was made. Which of the following nursing interventions are appropriate for the client?
Increase fluid intake.
Administer desmopressin acetate, as ordered.
Limit intake of milk, cheese and other processed meats.
Administer demeclocycline, as ordered.
Answer: D – The client may be administered with demeclocycline. This drug has the ability to antagonize the effects of antidiuretic hormone. Some tumors may stimulate the synthesis and secretion ADH, which may lead to hyponatremia. The nurse must restrict the client's fluid intake. Foods high in salt, such as processed meats may be restricted. Desmopressin is an antidiuretic hormone, and administering this medication will worsen the condition.
A registered nurse is giving discharge instructions to the mother of a 7-year-old child who underwent a tonsillectomy. During the first few days, which of the following nursing instructions is the most appropriate for the client?
Rinse the child’s mouth with a mouthwash or salt water.
Offer orange or citrus fruit juices.
Discourage the use of straws to drink fluids.
Increase intake of milk.
Answer: C – The child should be discouraged from drinking fluids with the use of straws. The mother should make sure that sharp objects like straws are not inserted into the mouth. Sharp materials can disrupt the clot at the affected site. Increasing intake of milk may encourage mucus production. Orange or other citrus fruit juices, salt water and mouthwashes can be irritating to healing tissues.
A 7-year-old boy is diagnosed with hemophilia. The nurse understands that in spite of the diagnosis, the child should be given opportunities to achieve his developmental tasks. The nurse would encourage the child’s mother to allow the boy to participate in which leisure activities?
Swimming
Baseball
Basketball
Football
Answer: A – The nurse should inform the child’s parents that swimming is a non-contact sport. The child can safely enjoy this physical activity without increasing his risk for trauma. Baseball, basketball and football are physical activities that involve a risk for trauma from direct contact or falling.
A nurse is standing at the nurse’s station when out of nowhere, a visitor of one of the clients in the unit clutches her throat and is unable to speak a word, breathe or cough. When the nurse asks if she cannot breathe, the visitor nods yes. Which of the following responses is the most appropriate?
To establish the airway, use the head-tilt- chin lift maneuver.
Attempt rescue breathing.
Apply external chest compressions.
Perform Heimlich maneuver.
Answer: D – The most appropriate action of the nurse is to perform the Heimlich maneuver. The client is choking, which is manifested by inability to cough or speak. If a conscious client acknowledges that that he or she is choking, Heimlich maneuver can be performed. The head-tilt-chin lift maneuver is performed on unconscious clients with signs of neck or cervical injuries.
A registered nurse is assigned to care for 4 clients during the shift. After reviewing their charts, the nurse determines that which client has the greatest risk of developing of respiratory alkalosis?
A client who was just admitted from the postanesthesia unit.
A client who is on labor.
A client with chronic renal failure.
A client with type 2 diabetes.
Answer: B – A client who is on labor has the greatest risk for respiratory alkalosis. At certain stages of labor, a client’s respirations increase significantly, causing the decrease of PaCO2 and increasing the pH.
A client comes to the facility presenting with fatigue, fever and chest pain. Further evaluation revealed that the pain worsens with inspiration. A precordial friction rub is audible on auscultation. The patient is most likely diagnosed with:
Myocarditis
Endocarditis
Cardiac tamponade
Pericarditis
Answer: D – Pericarditis involves inflammation of the pericardium, the layer that protects the heart from infection and trauma. Pericarditis is manifested by precordial pain in the anterior chest that is aggravated by breathing and swallowing. Unmanaged pericarditis may result in severe complications like heart failure and cardiac tamponade.
A registered nurse is caring for a client who is demonstrating the signs of pregnancy induced hypertension. Magnesium sulfate is ordered. The nurse’s priority physical assessment after the administration of the medication is which of the following?
Blood pressure
Respiratory rate
Temperature
Capillary refill time
Answer: B – Administration of magnesium sulfate increases the client’s risk for respiratory depression. The nurse should monitor the client’s respiratory rate and make a report if the rate goes below 12 breaths per minute.
A 30-year-old female consulted the registered nurse due to weight loss and weakness. The patient informs the nurse that although she has the biggest appetite, she continues to lose a lot of weight. She reports increased sweating, diarrhea and intolerance to heat. The patient is most likely diagnosed with:
Hypothyroidism
Hypoparathyroidism
Hyperthyroidism
Hyperparathryoidism
Answer: C – Based on the manifestations, the patient is most likely diagnosed with hyperthyroidism. In contrast to hyperthyroidism, hypothyroidism is characterized by weight gain, anorexia and cold intolerance. Hypoparathyroidism is manifested by tingling sensations, tetani and numbness around the mouth. Hyperparathyroidism is manifested by bone pain, fractures and weakness.
A client presents with truncal obesity and a buffalo hump over the upper back. On physical examination, the nurse notes that the patient has thin, easily bruised skin and purple striae in the abdomen. The client is diagnosed with Cushing’s disease. Laboratory findings reveal the following except?
Hypokalemia
Hypernatremia
Hyperglycemia
Hypercalcemia
Answer: D – Hypocalcemia, not hypercalcemia occurs with Cushing’s disese. Cushing’s disease is caused by excessive cortisol secretion. Excessive amounts of cortisol may interfere with the absorption of calcium.
A 46-year-old female comes to the physician office complaining of severe abdominal pain, which is located in the right upper quadrant of the abdomen. The client says the pain radiates to the back and to the right shoulder. The patient says the pain usually occurs after meals. Breathing does not aggravate the pain. Based on the initial findings, the patient is most likely experiencing:
Cholecystitis
Hepatitis
Cholelithiasis
Appendicitis
Answer: B – Based on the client’s manifestations, the client is most likely experiencing the signs and symptoms of cholelithiasis. The pain associated with cholelithiasis usually occurs after meals. This finding is in contrast to cholecystitis pain, where the pain involves the entire right upper quadrant and occurs in 12 to 18 hours.
A client who has a history of congestive heart failure comes to the facility due to shortness of breath and edema in the lower extremities. Physical examination of the lower extremities reveals edema with slight indentation. The pit recovery time is 30 seconds. The edema is classified as:
Grade 1+
Grade 2+
Grade 3+
Grade 4+
Answer: C – The edema is classified as Grade 2+ edema. Grade 2+ edema is described as a slight indentation, with a recovery time of 20 to 40 seconds. Grade 1+ edema is barely visible, returning to normal in less than 20 seconds. Grade 3+ edema is manifested by deep pitting, with a recovery time of about 50 seconds. Grade 4+ edema has a pit recovery time of more than 60 seconds.
A client with a history of emphysema is admitted to the facility due to increased shortness of breath and wheezing. A nebulization treatment consisting of bronchodilator and glucocorticoid is administered. Which of these findings indicate that the treatment has been successful?
A decrease in heart rate
Increase in wheezing on auscultation
Pink, frothy sputum
Decrease in shortness of breath.
Answer: D – A decrease in shortness of breath indicates that the treatment has been successful. COPD diseases are characterized by limited airflow due to increased accumulation of respiratory secretions and swelling of the bronchi. With wider airways and looser respiratory secretions, shortness of breath is relieved.
Before a surgery, the nurse is teaching a client about the proper techniques of diaphragmatic breathing exercises. The client asks the nurse of the main goal of this intervention. Which of the following responses made by the nurse is the most appropriate?
“These exercises will decrease alveolar ventilation.”
“These exercises will help dilate your bronchioles.”
“These exercises will increase your vital capacity.”
“Diaphragmatic exercises increase residual volume.”
Answer: B – Diaphragmatic breathing exercises can help dilate the bronchioles. In COPD, the bronchioles are constricted during exhalation mainly due to pressure changes in the lungs. These exercises will help the clients keep the bronchioles open during exhalation.
A client comes to the emergency department, complaining of shortness of breath. After a thorough physical examination and a complete diagnostic work up, the client is diagnosed with emphysema. Oxygen therapy was also initiated. As the nurse prepares to bathe the client, the nurse keeps in mind of which of the following interventions before starting the nursing care?
Lower the head of bed and turn the client to his or her side.
Position the client in supine position.
Slightly elevate the head of the bed.
Increase the flow rate of oxygen to up to 6 L/minute.
Answer: C – Before bathing, the nurse should slightly elevate the head of the bed. Clients with emphysema cannot tolerate lying flat due to the combined effects of inelastic alveoli and of the compression of the abdominal organs against the lungs. The rate of oxygen flow should not be increased or decreased without the order from the physician.
A nurse is caring for a client who underwent a right femoral popliteal bypass. About 24 hours after the surgery, the nurse finds the client’s right leg cool and pale. From these findings, which of the following is the first action of the nurse?
Wrap a blanket around the affected leg.
Check the distal pulses
Elevate the affected extremity above the level of the heart.
Notify the physician.
Answer: B – The first action of the nurse is to check the distal pulses. The nurse must first assess for the occurrence of complications. The leg can be kept warm by wrapping a blanket around it; however, the nurse must first assess the extremity for any complications. Elevating the leg may promote venous return; however, it decreases the flow of the arterial blood. The physician should be notified after the initial assessment of the distal sites.
A nurse is assessing a two-month-old child in a well-baby clinic. The nurse lays the infant in a supine position and flexes the knee to 90-degrees at the hips, and then abducts both hips until the knees make contact with the table. The mother asks the purpose of the actions of the nurse. Which of the following responses made by the nurse is correct?
To examine the child for lower motor neuron deficit.
To evaluate the flexibility of the child’s lower extremities.
To check for the occurrence of hip dislocation
To assess for the extremities’ growth and development.
Answer: C – The maneuver aims to check for the occurrence of hip dislocation. If dislocation is in existence, the nurse may feel or hear a click. The leg strength and the flexibility are assessed but the situation involves a test that mainly screens for congenital hip dysplasia.
A nurse is performing a nasopharyngeal suctioning, when the client’s pulse oximeter alarm sets off. The nurse checks the reading, and the pulse oximeter indicates that the client’s oxygen saturation level is at 87%. Which of the following is the next action of the nurse?
Stop, keep the suction catheter inserted, and then wait a few minutes before starting to suction.
Stop the suction; administer oxygen to client.
Continue suctioning for 10 to 15 minutes more.
Withdraw the suction and ask the client to perform cough exercises.
Answer: B – The next action of the nurse is to stop the suction, and then administer oxygen to the client. The pulse oximeter indicates that the client is not getting sufficient amounts of oxygen, so the nurse has to stop. Oxygen is administered to increase the saturation. Although withdrawing the suction is correct, asking the client to perform cough exercises before administering oxygen is not recommended.
A client comes to the emergency department, complaining of severe dyspnea and shortness of breath. On assessment, wheezing is both heard on inspiration and expiration. The immediate action of the nurse is to do which of the following?
Initiate intubation.
Administer of inhaled beta-adrenergic agents, as ordered.
Administer oxygen.
Administer inhaled corticosteroids, as ordered.
Answer: B – The initial action of the nurse is to administer inhaled beta-adrenergic agent, a bronchodilator. Intubation must be avoided. Administration of oxygen is only useful when the airways are dilated. After inhaling the beta-adrenergic agent, the client inhales a dose of corticosteroids. Administration of inhaled corticosteroids is given after the administration of beta-adrenergics.
Safety and Infection Control – RN
A registered nurse is caring for a client who has a BMI of 32. The client requires assistance during ambulation. Carrying and lifting are greatly required during care. The nurse understands that to prevent injuries, proper body mechanics should be followed. Which of the following actions of the nurse demonstrates proper body mechanics?
Tightening the abdominal muscles when lifting.
Maintaining straight legs when carrying or lifting the client.
Twisting the body when reaching.
Keeping the client far from the body during lifting.