NURS 216 NCLEX Practice Exam update 2020 - Washington Adventist University | NURS216 NCLEX Practice Exam update 2020

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1. The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4 year-old child? A) "I strap the infant car se... at on the front seat to face backwards." B) "I place my infant in the middle of the living room floor on a blanket to play with my 4 year old while I make supper in the kitchen." C) "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the four year old naps on the sofa." D) "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper." Review Information: The correct answer is D: "I have the four year-old hold and help feed the four month-old a bottle in the kitchen while I make supper." The infant seat is to be placed on the rear seat. Small children and infants are not to be left unsupervised. Infants are to be placed on their "back when they go back" to sleep or are lying in a crib. A 4 year-old could assist with the care of an infant with proper supervision. This enhances bonding with the infant and the developmental needs of the preschooler to "help" and not feel left out. 2. Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take? A) Record the information on the chart B) Give information about advance directives C) Assume that this client wishes a full code D) Refer this issue to the unit secretary Review Information: The correct answer is B: Give information about advance directives For each admission, nurses should request a copy of the current advance directive. If there is none, the nurse must offer information about what an advance directive implies. It is then the client’s choice to sign it. In option 1 just recording the information is not sufficient. In option 3 the nurse should not assume that the client has been informed of choices for emergency care. In option 4 this represents an inappropriate delegation approach. 3. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to A) Maintain the airway B) Administer epinephrine 1:1000 as ordered C) Monitor for hypotension with shock D) Administer diphenhydramine as ordered Review Information: The correct answer is B: Administer epinephrine 1:1000 as ordered .All the answers are correct given the circumstances. The correct sequence of care is to administer the epinephrine, then maintain airway. In the early stages of anaphylaxis, when the patient has not lost consciousness and is normatensive, administering the epinephrine and then applying the oxygen, watching for hypotension and shock are later responses. The prevention of a severe crisis is maintained by using diphenhydramine. 4. Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category? An infant with intermittent buldging anterior fontonel between crying episodes A toddler with severe deep abrasions over 98% of the body A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture A school-age child with singed eyebrows and hair on the arms Review Information: The correct answer is B: A toddler with severe deep abrasions over 98% of the body .This child has the least chance of survival. Severe deep abrasions are to be thought of as second and third degree burns. The child has great risk of shock and infection combined. 5. When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse’s best action is to change whichever item is incorrect to the correct information use the bracelet and admission form until a replacement is supplied notify the admissions office and wait to apply the bracelet make a corrected identification bracelet for the client Review Information: The correct answer is C: notify the admissions office and wait to apply the bracelet The Admissions Office has the responsibility to verify the client’s identity and keep all the records in the system consistent. Making the changes puts the client at risk for misidentification. Using an incorrect identification bracelet is unsafe. Making a new bracelet on the unit is not appropriate. 6. The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken? Leave the order for the oncoming staff to follow-up Contact the charge nurse for an interpretation Ask the pharmacy for assistance in the interpretation Call the provider for clarification Review Information: The correct answer is D: Call the provider for clarification Relying on anyone else''s interpretation is very risky. When in doubt, check it out with the person who wrote the illegible order. Order entry systems help to minimize this problem. 7. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to: A) check the cartoid pulse B) deliver 5 abdominal thrusts C) give 2 rescue breaths D) open the client's airway Review Information: The correct answer is D: open the client''s airway According to the ABCs of CPR the first step in rescuing an unresponsive victim after checking responsiveness and calling for help is to open the victims airway. The airway must be opened appropriately before the need for rescue breaths can be determined. The pulse is assessed, after breathing is evaluated. The need for abdominal thrusts is determined by inability to achieve chest rise when ventilation is attempted. 8. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action? A) Ask the client if there are any breathing problems B) Have the client void as much as possible C) Check the vital signs D) Ausculate the lungs Review Information: The correct answer is D: Ausculate the lungs All of the options would be part of the evaluation for the effects of the large amount of fluid in a short period of time. However the worst result is heart failure with lung congestion so the auscultation of the lungs is the priority action. The sequence of actions would be 4 1 3 2. 9. Following change-of-shift report on an orthopedic unit, which client should the nurse see first? 16 year-old who had an open reduction of a fractured wrist 10 hours ago 20 year-old in skeletal traction for 2 weeks since a motor cycle accident 72 year-old recovering from surgery after a hip replacement 2 hours ago 75 year-old who is in skin traction prior to planned hip pinning surgery. Review Information: The correct answer is C: 72 year-old recovering from surgery after a hip replacement 2 hours ago Look for the client who is in the least stable condition. The client who returned from surgery 2 hours ago is at risk for hemorrhage and should be seen first. The 16 year-old should be seen next because it is still the first post-op day. The 75 year-old in skin traction should be seen next. The client who can safely be seen last is the 20 year-old who is 2 weeks post-injury. 10. A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make? Why don’t we now have the client turn back to the left side. That was done correctly. Did you have any problems with the insertion? Let’s check to see if the suppository is in far enough. Did you feel any stool in the intestinal tract? Review Information: The correct answer is B: That was done correctly. Did you have any problems with the insertion? Left side-lying position is the optimal position for the client receiving rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication. After a short time it will not hurt the client to turn in any manner. The suppository should be somewhat melted after 10 to 15 minutes. The other responses are incorrect since no data is in the stem to support such comments. 11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care? A) airborne precautions B) droplet precautions C) contact precautions D) compromised host precautions Review Information: The correct answer is C: contact precautions The resistant bacteria remain alive for up to 3 days post death. Therefore, contact precautions must still be implemented. Also label the body so that the funeral home staff can protect themselves as well. Gown and gloves are required. 12. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching?A) Void a little, clean the meatus, then collect specimen B) clean the meatus, begin voiding, then catch urine stream C) Clean the meatus, then urinate into container D) Void continuously and catch some of the urine Review Information: The correct answer is B: clean the meatus, begin voiding, then catch urine stream A clean catch urine is difficult to obtain and requires clear directions. Instructing the client to carefully clean the meatus, then void naturally with a steady stream prevents surface bacteria from contaminating the urine specimen. As starting and stopping flow can be difficult, once the client begins voiding it''s best to just slip the container into the stream. Other responses are not correct technique. 13. The provider orders Lanoxin (digoxin) 0.125 mg po and furosomide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily? A) spaghetti B) watermelon C) chicken D) tomatoes Review Information: The correct answer is B: watermelon Watermelon is high in potassium and will replace any potassium lost by the diuretic. The other foods are not high in potassium. 14. A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? A) Look up the policy on needle sticks B) Contact employee health services C) Immediately wash the hands with vigor D) Notify the supervisor and risk management Review Information: The correct answer is C: Immediately wash the hands with vigor The immediate action of vigorously washing will help remove possible contamination. Then the sequence would then be options 4, 1, 2. 15. As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? A) Ask the student: "What did you forget to do?” B) Stop. Tell me why aspiration is needed. C) Loudly state: “You forgot to aspirate.” D) Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.” Review Information: The correct answer is D: Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.” This action is a direct threat to the client if the medication enters into the blood stream instead of the muscle. The purpose of aspiration with IM injections is to prevent the injection of the drug directly into the blood stream. Option 4 protects the client and is the most professional. 16. A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? A) Comatose, breathing unlabored B) Glascow Coma Scale 8, respirations regular C) Appears to be sleeping, vital signs stable D) Glascow Coma Scale 13, no ventilator required Review Information: The correct answer is B: Glascow Coma Scale 8, respirations regular The Glascow Coma Scale provides a standard reference for assessing or monitoring level of consciousness. Any score less than 13 indicates a neurological impairment. Using the term comatose provides too much room for interpretation and is not very precise. 17. A client enters the emergency department unconscious via ambulance from the client’s work place. What document should be given priority to guide the direction of care for this client? The statement of client rights and the client self determination act Orders written by the health care provider A notarized original of advance directives brought in by the partner The clinical pathway protocol of the agency and the emergency department Review Information: The correct answer is C: A notarized original of advance directives brought in by the partner This document specifies the client''s wishes. 18. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? An admission at the change of shifts with atrial fibrillation and heart failure - PN Client who had a major stroke 6 days ago - PN nursing student A child with burns who has packed cells and albumin IV running - charge nurse An elderly client who had a myocardial infarction a week ago - UAP Review Information: The correct answer is A: An admission at the change of shifts with atrial fibrillation and heart failure - PN The care for a new admissions should be performed by an RN. Since the client was admitted at the change of shifts, the stability of the client would not have been established. The charge nurse should take this client. The PN could monitor the IV fluids in option C. Tasks that do not require independent judgment should be delegated. The nurse may delegate the care for a stable client to a UAP. 19. A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? A) Increased temperature and lethargy B) Restlessness and increased mucus production C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor Review Information: The correct answer is B: Restlessness and increased mucus production This infant could be experiencing gastroesophageal reflux, or could be allergic to the formula. Restlessness, irritability and increased mucus production can develop if an allergy is present. Soy based formula is often recommended. 20. 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) "The 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 increased abdominal girth. The parents'' report that clothing is tight is significant, and should be followed by additional assessments. 21. A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse? Ask the teenager to wait until a parent or legal guardian can be contacted Withhold treatment until telephone consent can be obtained from the partner Refer the teenager to a community pediatric hospital emergency department Proceed with the triage process in the same manner as any adult client Review Information: The correct answer is D: Proceed with the triage process 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. 22. A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)? Converse with the client to determine if the mucuous membranes are impaired Report hourly outputs of less than 30 ml/hr Monitor client's ability for movement in the bed Check skin turgor every 4 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. 23. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? Our child had chickenpox 6 months ago. Strep throat went through all the children at the day care last month. Both ears were infected over 3 months age. Last week both feet had a fungal skin infection. Review Information: The correct answer is B: Strep throat went through all the children at the day care last month. Evidence supports a strong relationship between infection with Group A streptococci and subsequent rheumatic fever (usually within 2 to 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. 24. A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the nurse should be to Discuss the feeling of reluctance with an objective peer or supervisor Limit contacts with the client to avoid reinforcement of the manipulative behaviorConfront the client about the negative effects of behaviors on other clients and staff 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 experiences 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 nurseclient relationship. 25. 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 to the staff, the other clients, or the client upon himself. 26. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? A) Pain related to ischemia B) Risk for altered elimination: constipation C) Risk for complication: dysrhythmias D) Anxiety related to pain 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. 27. The provisions of the law for the Americans with Disabilities Act require nurse managers to A) Maintain an environment free from associated hazards B) Provide reasonable accommodations for disabled individuals C) Make all necessary accommodations for disabled individuals D) Consider both mental and physical disabilities 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." 28. A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance? A) "I have problems with diarrhea." B) "I have difficulty falling asleep." C) "I have diminished sexual function." D) "I often feel jittery." Review Information: The correct answer is C: "I have diminished sexual function." Inderal, beta-blocking agent used in hypertension, prohibits the release of epinephrine into the cells; this may result in hypotension which results in decreased libido and impotence. 29. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate? "I will keep the cast for the next day uncovered to prevent burning of the skin." "I can apply an ice pack over the area to relieve itching inside the cast." "The cast should be propped on at least 2 pillows when my child is lying down." "I think I remember that standing cannot be done until after 72 hours." Review Information: The correct answer is D: "I think I remember that standing cannot be done until after 72 hours." Applying ice is a safe method of relieving the itching. Synthetic casts will typically set up in 30 minutes and dry in a few hours. Thus, standing can be done within the initial 24 hours. With plaster casts the set up and drying time, especially in a long leg cast which is thicker than an arm cast, can take up to 72 hours to dry. Both types of cast give off a lot of heat when drying and it is preferred to keep the cast uncovered in the initial 24 hours. Clients may complain of chilling from the wet cast and therefore can simply be covered lightly with a sheet or blanket. 30. Which statement best describes time management strategies applied to the role of a nurse manager? A) Schedule staff efficiently to cover the needs on the managed unit B) Assume a fair share of direct client care as a role model C) Set daily goals with a prioritization of the work D) Delegate tasks to reduce work load associated with direct care and meetings Review Information: The correct answer is C: Set daily goals with a prioritization of the work Time management strategies include setting goals and prioritization . This is similar to time management of direct care for clients 31. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these? 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. 32. A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching? A) "I will only have to wear this for 6 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 6 months." The brace must be worn long-term, during periods of growth, usually for 1 to 2 years. It is used to correct curvature of the spine. 33. 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 selfscheduling knowing that this method will A) Improve the quality of care B) Decrease staff turnover C) Minimize the amount of overtime payouts D) Improve team morale Review Information: The correct answer is D: Improve team morale Nurses are more satisfied when opportunites exist for autonomy and control. The nurse manager becomes the facilitator of scheduling rather than the decisionmaker of the schedule when self-scheduling exists. 34. 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. 35. The nurse manager hears a health care provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the health care provider's complaints. The nurse manager's next action should be to Walk up to the health care provider and quietly state: "Stop this unacceptable behavior." Allow the staff nurse to handle this situation without interference Notify the of the other administrative persons of a breech of professional conduct Request an immediate private meeting with the health care provider and staff nurse Review Information: The correct answer is D: Request an immediate private meeting with the health care provider and staff nurse Assertive communication respects the needs of all parties to express themselves, but not at the expense of others. The nurse manager needs first to protect clients and other staff from this display and come to the assistance of the nurse employee. [Show More]

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