UNIT I NCLEX-RN Exam Questsions, Answers and Explanations

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UNIT I NCLEX-RN® Exam Preparation Level of Cognitive Ability: Applying Level of Cognitive Ability: Applying The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. O... n the basis of these findings, the nurse should implement which action? 1. Remove the IV. 2. Apply a warm compress. 3. Check for a blood return. 4. Measure the area of infiltration. Safe and Effective Care Environment Management of Care The nurse has received the client assignment for the day. Which client should the nurse assess first? 1. The client who needs to receive subcutaneous insulin before breakfast 2. The client who has a nasogastric tube attached to intermittent suction 3. The client who is 2 days postoperative and is complaining of incisional pain 4. The client who has a blood glucose level of 50 mg/ dL (2.8 mmol/ L) and complaints of blurred vision Safety and Infection Control The nurse prepares to care for a client on contact precautions who has a hospital-acquired infection caused by methicillin resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator, which requires frequent suctioning. The nurse should assemble which necessary protective items before entering the client’s room? 1. Gloves and gown 2. Gloves and face shield 3. Gloves, gown, and face shield 4. Gloves, gown, and shoe protectors. Health Promotion and Maintenance Health Promotion and Maintenance The nurse is choosing age-appropriate toys for a toddler. Which toy is the best choice for this age? 1. Puzzle 2. Toy soldiers 3. Large stacking blocks 4. A card game with large pictures Psychosocial Integrity A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which client statement indicates an understanding of this stress reduction measure? 1. “This will help only if I play music at the same time.” 2. “This will work for me only if I am alone in a quiet area.” 3. “I need to do this only when I lie down in case I fall asleep.” 4. “The best thing about this is that I can use it anywhere, anytime.” Basic Care and Comfort Aclient with Parkinson’s disease develops akinesia while ambulating, increasing the risk for falls. Which suggestion should the nurse provide to the client to alleviate this problem? 1. Use a wheelchair to move around. 2. Stand erect and use a cane to ambulate. 3. Keep the feet close together while ambulating and use a walker. 4. Consciously think about walking over imaginary lines on the floor. . Pharmacological and Parenteral Therapies The nurse monitors a client receiving digoxin for which early manifestation of digoxin toxicity? 1. Anorexia 2. Facial pain 3. Photophobia 4. Yellow color perception Reduction of Risk Potential A magnetic resonance imaging (MRI) study is prescribed for a client with a suspected brain tumor. The nurse should implement which action to prepare the client for this test? 1. Shave the groin for insertion of a femoral catheter. 2. Remove all metal-containing objects from the client. 3. Keep the client NPO (nilper os; nothing bymouth) for 6 hours before the test. 4. Instruct the client in inhalation techniques for the administration of the radioisotope. Physiological Adaptation A client with renal insufficiency has a magnesium level of 3.5 mEq/ L (1.75 mmol/ L). On the basis of this laboratory result, the nurse interprets which sign as significant? 1. Hyperpnea 2. Drowsiness 3. Hypertension 4. Physical hyperactivity A prescription reads: acetaminophen liquid, 650 mg orally every 4 hours PRN for pain. The medication label reads: 500 mg/15 mL. The nurse prepares how many milliliters to administer 1 dose? Fill in the blank. Record your answer using one decimal place. Formula: Desired Available  volume¼ mL 650 mg 500 mg  15 mL¼ 19:5 mL The emergency department nurse is caring for a child suspected of acute epiglottitis. Which interventions apply in the care of the child? Select all that apply. 1. Obtain a throat culture. 2. Ensure a patent airway. 3. Prepare the child for a chest x-ray. 4. Maintain the child in a supine position. 5. Obtain a pediatric-size tracheostomy tray. 6. Place the child on an oxygen saturation monitor. A client who experienced a myocardial infarction is being monitored via cardiac telemetry. The nurse notes the sudden onset of this cardiac rhythm on the monitor (refer to figure) and immediately takes which action 1. Takes the client’s blood pressure 2. Initiates cardiopulmonary resuscitation (CPR) 3. Places a nitroglycerin tablet under the client’s tongue 4. Continues to monitor the client and then contacts the health care provider (HCP) The nurse should place the client in which position to administer an enema? (Refer to the figures in 1 to 4.) 1 (top), 2, 3, or 4 [Show More]

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