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NCLEX RN NEXT GENERATION EXAM 2 PREDICTOR VERIFIED QUESTIONS AND CORRECT DETAILED ANSWERS WITH DETAILED RATIONALES GRADED A+ GUARANTEED PASS ACE

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NCLEX RN NEXT GENERATION EXAM 2 PREDICTOR VERIFIED QUESTIONS AND CORRECT DETAILED ANSWERS WITH DETAILED RATIONALES GRADED A+ GUARANTEED PASS ACE The nurse is caring for a client who is receiving a high dose of a phenothiazine. When evaluating the client for a life-threatening syndrome related to the medication, it would be a priority for the nurse to report 1. dry mouth 2. orthostatic hypotension 3. fever 2 NCLEX RN NEXT GENERATION EXAM 4. photophobia 3. fever Rationale: Phenothazine side effects include ABCDEFG -- Anticholinergic (dry mouth), blurry vision, constipation, drowsiness, EPS, Photosensitivity, and agranulocytosis. Fever would be a complication of agranulocytosis and requires the nurse to report. The nurse has administered haloperidol to a client with schizophrenia who is agitated. Which of the following findings would require immediate follow-up? 1. continued lack of motivation 2. reports of muscle stiffness 3. inappropriate emotional expressions 4. difficulty focusing due to blurred vision 3. inappropriate emotional expressions Rationale: Haloperidol has ABCDEFG side effects. Muscle stiffness would be considered EPS and needs follow-up for possible medication administration The nurse is teaching a client who is scheduled for a 24-hour urine collection. Which of the following information should the nurse include? Select all that apply. 3 NCLEX RN NEXT GENERATION EXAM 1. "You will be asked to urinate when starting the collection, and the initial urine will be discarded." 2. "A sign will be posted on the bathroom door as a reminder to save your urine." 3. "You will be asked to void at the end of the designated time period to complete the urine collection." 4. "You should discard urine that is dark or pink in color." 5. "The collected urine will be sent to the laboratory at the end of each shift." 1, 2, 3 24 hour urine collection: First urine of the day (right after awakening) is discarded. Save all urine, a sign posted on the door is a helpful reminder. Lastly, void at the end of the designated time period to record all of the urine output in a 24 hour period and send to the lab. Don't send at the end of each shift because the collection is not completed yet. The nurse is planning a staff education program about client privacy. Which one of the following scenarios should the nurse include as an example of a violation of client privacy? 1. Discussing with an unlicensed assistive personnel (UAP) that the UAP's assigned client will require a smaller condom catheter. 2. Sharing the client's blood alcohol level (BAL) test result with the police officer who brought the client to the emergency department (ED). 3. Responding to the call light of the client who is assigned to another nurse and needs assistance in the bathroom. 4. Allowing a nursing student who has been assigned to the client to review the client's medical record. 4. With heart failure who has a productive cough and is restless. Rationale:

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Instelling
NCLEX RN NEXT GENERATION
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NCLEX RN NEXT GENERATION

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1
NCLEX RN NEXT GENERATION EXAM
NCLEX RN NEXT GENERATION EXAM 2
PREDICTOR VERIFIED QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
DETAILED RATIONALES GRADED A+
GUARANTEED PASS ACE




The nurse is caring for a client who is receiving a high dose of a phenothiazine.

When evaluating the client for a life-threatening syndrome related to the medication, it
would be a priority for the nurse to report

1. dry mouth

2. orthostatic hypotension

3. fever

, 2
NCLEX RN NEXT GENERATION EXAM
4. photophobia




3. fever

Rationale:
Phenothazine side effects include ABCDEFG -- Anticholinergic (dry mouth), blurry vision,
constipation, drowsiness, EPS, Photosensitivity, and agranulocytosis. Fever would be a
complication of agranulocytosis and requires the nurse to report.




The nurse has administered haloperidol to a client with schizophrenia who is agitated.

Which of the following findings would require immediate follow-up?

1. continued lack of motivation

2. reports of muscle stiffness

3. inappropriate emotional expressions

4. difficulty focusing due to blurred vision


3. inappropriate emotional expressions

Rationale:
Haloperidol has ABCDEFG side effects. Muscle stiffness would be considered EPS and needs
follow-up for possible medication administration


The nurse is teaching a client who is scheduled for a 24-hour urine collection.

Which of the following information should the nurse include? Select all that apply.

, 3
NCLEX RN NEXT GENERATION EXAM
1. "You will be asked to urinate when starting the collection, and the initial urine will be
discarded."

2. "A sign will be posted on the bathroom door as a reminder to save your urine."

3. "You will be asked to void at the end of the designated time period to complete the urine
collection."

4. "You should discard urine that is dark or pink in color."

5. "The collected urine will be sent to the laboratory at the end of each shift."




1, 2, 3
24 hour urine collection: First urine of the day (right after awakening) is discarded. Save all
urine, a sign posted on the door is a helpful reminder. Lastly, void at the end of the
designated time period to record all of the urine output in a 24 hour period and send to the
lab. Don't send at the end of each shift because the collection is not completed yet.




The nurse is planning a staff education program about client privacy.
Which one of the following scenarios should the nurse include as an example of a violation
of client privacy?
1. Discussing with an unlicensed assistive personnel (UAP) that the UAP's assigned client will
require a smaller condom catheter.
2. Sharing the client's blood alcohol level (BAL) test result with the police officer who
brought the client to the emergency department (ED).
3. Responding to the call light of the client who is assigned to another nurse and needs
assistance in the bathroom.
4. Allowing a nursing student who has been assigned to the client to review the client's
medical record.




4. With heart failure who has a productive cough and is restless.

Rationale:

, 4
NCLEX RN NEXT GENERATION EXAM
A productive cough (pink, frothy sputum) is indicative of pulmonary edema which is life
threatening. Treatment would be to improve cardiac output by placing client in High-
Fowler's, giving them O2, receiving mechanical ventilation, and medications.




The nurse has become aware of the following client situations.
The nurse should first assess the client:
1. Who had a right pneumonectomy 24 hours ago and is in the High-Fowler's position while
lying on the right side.
2. With chronic obstructive pulmonary disease (COPD) who is using pursed-lip breathing and
reporting hemoptysis.
3. Who had a wedge resection of the left lung 24 hours ago and is sitting in the High-Fowler's
position.
4. With heart failure who has a productive cough and is restless.
2. The client is sleeping but is easily aroused.
The nurse is caring for a 3-year-old client with a cerebral concussion who is being observed


overnight in the pediatric unit.


Which of the following observations would be most significant for the nurse to report to the
oncoming shift?
1. The client has a blood pressure of 94/58 mmHg and an apical pulse of 90.
2. The client is sleeping but is easily aroused.
3. The client's pupils are equal and reactive to light.
4. The client has an axillary temperature of 99.0 F (37.2 C) and respirations of 24.
1. Closed reduction of a fractured tibia with cast applications 1 hour ago and is reporting that
the casted leg feels hot.

Rationale:
Pain, tightness, or a hot feeling can indicate that the cast is on too tight.
2. It is normal to feel nauseous after coming off of anesthesia.

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NCLEX RN NEXT GENERATION

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