NCLEX-RN EXAM 2020/* 130 Questions well answered*//NCLEX-RN EXAM 2020/* 130 Questions well answered*/

NCLEX-RN EXAM 2020 1. Which of the following signs or symptoms indicates a possible nutritional deficiency? Pale conjunctiva 2. A nurse is preparing to insert a small-bore nasogastric feeding tube for a client's enteral feedings. In which method does the nurse measure the correct length of the tube? From the tip of the nose to the earlobe to the xiphoid process 3. In which of the following ways can a nurse promote sleep for a client who is experiencing insomnia? Give the client a pair of socks to wear if his feet become cold 4. A client is complaining of pain that starts in the shoulder and travels down the length of his arm. This type of pain is referred to as: Radiating pain 5. A client with an enlarged prostate is having trouble starting his flow of urine when using the bathroom. Another name for this condition is: Hesitancy 6. A nurse is preparing to irrigate a client's colostomy. Which of the following situations is a contraindication for this type of irrigation? The client has diverticulitis 7. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? The client was found lying on the floor. 8. A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? Transport the victim to the operating room for surgery. 9. Which of the following statements best describes substance P? Substance P is found in the dorsal horn of the spinal column 10. The primary purpose of a patient care meeting or conference is to determine which of the following? How the healthcare team can best meet the patient's needs. 11. Who should be members of a patient care conference? ALL members of the healthcare team and the patient/resident. 12. The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? Reassess the client. 13. The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action? Clarify with the team leader to make a safe ICU client assignment. 14. The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co- worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? Call the nursing supervisor. 15. A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? "I will call the nursing supervisor to seek assistance regarding your request." 16. The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which actions to correct the error? Select all that apply. i. Document the correct information and end with the nurse's signature and title. ii. Draw 1 line through the error, initialing and dating it. 17. Who is legally able to make decisions for the patient or resident during a patient care conference when the patient is not mentally able to make decisions on their own? Only the health care proxy 18. Which of the following is an example of physical abuse? A slap to the person's hand 19. Which of the following is an example of emotional abuse? Threatening the person 20. Which of the following is an example of emotional neglect? Ignoring and isolating a person 21. The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition (PN) bag of an assigned client is empty. Which solution should the nurse hang until another PN solution is mixed and delivered to the nursing unit? 10% dextrose in water 22. The nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 1 hour behind. Which action should the nurse take? Ensure that the fat emulsion infusion rate is infusing at the prescribed rate 23. A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse should next assess the client for the presence of which condition? Crackles on auscultation of the lungs 24. The nurse is caring for a restless client who is beginning nutritional therapy with parenteral nutrition (PN). The nurse should plan to ensure that which action is taken to prevent the client from sustaining injury? Secure all connections in the PN system. 25. A client receiving parenteral nutrition (PN) complains of a headache. The nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse determines that the client is experiencing which complication of PN therapy? Hypervolemia 26. A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first? Slow the IV infusion. 27. The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride. The nurse also needs to hang an IV infusion of piperacillin/tazobactam. The client has one IV site. The nurse should plan to take which action first? Check compatibility of the medication and IV fluids. 28. The nurse is completing a time tape for a 1000-mL intravenous (IV) bag that is scheduled to infuse over 8 hours. The nurse has just placed the 1100 marking at the 500-mL level. The nurse would place the mark for 1200 at which numerical level (mL) on the time tape? Fill in the blank. 375ml 29. Patients have a right to . ALL of their health related information 30. You are working the 8 am to 4 pm shift. You begin to vomit at 3 pm and you do not think that you are able to continue working. You decide to immediately go home without notifying your RN supervisor. You have Seriously abandoned the patients 31. A patient has a goal of eating at least 50% of each meal. The patient refuses to eat so a nurse force feeds the patient in order for them to reach their goal of eating at least 50% of the meal. The nurse has committed against this patient. Battery 32. You see a patient lying on the floor of the bathroom. You are NOT assigned to this patient. What is the first thing that you should do? Observe the patient for any injuries and call out for help. 33. You are taking care of 5 patients today. One of your patients wants water; another needs help walking to the bathroom; another just stated that they have chest pain; and another is crying because his daughter did not visit him today. Which patient care problem must you deal with first? The chest pain 34. Which identifies accurate nursing documentation notations? Select all that apply. i. The client slept through the night. ii. Abdominal wound dressing is dry and intact without drainage. iii. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. 35. A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? Observing care provided to the client without the client's permission 36. Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the UAP that making this accusation has violated which legal tort? Slander 37. You are taking care of 7 patients today. One of your residents wants water; another needs help walking to the bathroom; another just stated that they have chest pain; and another is crying because his daughter did not visit him today. Which patient care is the lowest in