NCLEX RN 2021 Review
5 Rights of Delegation - ANSWER Right Person
Right Task
Right Circumstance
Right Direction/Communication
Right Supervision/Evaluation
A 54 yo client recently diagnosed with diabetes mellitus asks about diet and exercise
management. The nurse recognizes a need for further education based on which
statement by the client?
1. I need to carry glucose tablets to the gym
2. It is okay to exercise of my blood sugar is less than 240 mg/dL
3. I should not eat before running, to prevent complications
4. It is important to walk 20 minutes a day to improve my health. - ANSWER 3. I should
not eat before running, to prevent complications
A child who has a rash and fluid-filled blisters across the face and chest is confirmed to
have varicella. Which action should the nurse take?
1. Administer amoxicillin P.O. TID
2. Give one doe of the varicella vaccine
3. Implement airborne and contact precautions
4. Place the client in a private room and provide positive airflow - ANSWER 3.
Implement airborne and contact precautions
A child who has a rash and fluid-filled blisters across the face and chest is confirmed to
have varicella. Which action should the nurse take?
1. Administer amoxicillin P.O. TID
2. Give one dose of the varicella vaccine.
3. Implement airborne and contact precautions.
4. Place the client in a private room and provide positive airflow. - ANSWER 3.
Implement airborne and contact precautions.
A child who has hemophilia is being discharge home. The nurse should teach the
parents to use which measures if a child sustains an injury? (SATA)
1. Pace ice over the injured tissue
2. Provide passive range of motion
3. Apply pressure directly if bleeding
4. Soak the affected area in warm water
5. Keep injured extremity above the heart
,6. Administer replacement clotting factors - ANSWER 1. Pace ice over the injured tissue
3. Apply pressure directly if bleeding
5. Keep injured extremity above the heart
6. Administer replacement clotting factors
A client asks the nurse, "should I skip my injection of glargine because I have not eaten
for 8 hrs.?" The client's glucose is 106 mg/dL. Which action should the nurse perform?
1. Delay administration until morning
2. Offer sips of orange juice and reassess
3. Administer the medication as prescribed
4. Hold the insulin and document the action - ANSWER 3. Administer the medication as
prescribed
A client developed herpes simplex. The nurse documents that the client has which of
the following type of skin lesions?
1. vesicle
2. pustule
3. nodule
4. wheal - ANSWER 1. vesicle
A client develops swelling of the eyes, face, tongue, and lips after administration of
intravenous penicillin. Which action should the nurse perform first?
1. Give diphenhydramine 25 mg IV
2. Administer epinephrine 0.2 mL IM
3. Raise dead of bed to 45* or higher
4. Prepare to administer a 1-liter fluid bolus. - ANSWER 2. Administer epinephrine 0.2
mL IM
A client develops swelling of the eyes, face, tongue, and lips after administration of
intravenous penicillin. Which action should the nurse perform first?
1. Give diphenhydramine 25 mg IV
2. Administrator epinephrine 0.2 mL IM
3. Raise HOD to 45* or higher
4 Prepare to administer 1 liter fluids bolus - ANSWER 2. Administrator epinephrine 0.2
mL IM
A client diagnosed with pneumonia received ceftriaxone 1g IV ever 12 hrs. for 4 days.
Which of the following statements should be of most concert to the nurse?
1. My IV site is a little tender
2. I still have a productive cough
3. I feel nauseated very time I eat
4. I have had runny diarrhea all day - ANSWER 4. I have had runny diarrhea all day
A client diagnosed with pneumonia received ceftriaxone 1g IV every 12 hrs. for 4 days.
Which of the following statement should be of most concern to the nurse?
1. My IV site is a little tender
,2. I still have a productive cough
3. I feel nauseated ever time I eat
4. I have had runny diarrhea all day - ANSWER 4. I have had runny diarrhea all day
A client has a sealed radiation implant. Which action should the nurse implement?
(SATA)
1. Save linens in the client room.
2. Assign client to a private room
3. Limit each visitor to 30 minutes a day.
4. instruct friends to stand 3 feet from client.
5. Place a "Caution: Radioactive Material" sign on door. - ANSWER 1. Save linens in
the client room.
2. Assign client to a private room
3. Limit each visitor to 30 minutes a day.
5. Place a "Caution: Radioactive Material" sign on door.
A client has excessive bleeding during the third stage of labor. Which of the following
pre-existing medical conditions should cause the nurse to question a prescription for
methylergonovine?
1. Chronic depression
2. Transfusion reaction
3. Migraine headaches
4. Gestational hypertension - ANSWER 4. Gestational hypertension
A client has iron-deficiency anemia. The nurse anticipates that which of the following
abnormalities will be present during inspection of the nailbeds?
1. pink color
2. cyanosis
3. jaundice
4. pallor - ANSWER 4. pallor
A client has iron-deficiency anemia. The nurse anticipates that which of the following
abnormalities will be present during the inspection of the nailbeds?
1. Pint color
2. cyanosis
3. jaundice
4. pallor - ANSWER 4. pallor.
A client in the ICU is receiving an IV of D5W 1/2 NS at 75 mL/hr. Electrolyte studies
reveal: Na+ 143, K+ 3.1, and chloride 98. The client develops the PVCs. The nurse
should?
1. draw stat ABGs to determine changes in PO2
2. obtain a Rx to add K+ to the current IV
3. obtain a Rx to change the IV to D5W at 100 mL/hr.
4. use standing orders and administer lidocaine - ANSWER 2. obtain a Rx to add K+ to
the current IV
, A client is alert and oriented, but anxious and short of breath. After vagal maneuvers
and medication administration the cardiac rhythm has not changed. The nurse should
prepare to assist with which procedure?
1. Defibrillation
2. Cardioversion
3. Echocardiogram
4. Pacemaker insertion - ANSWER 2. Cardioversion
A client is newly prescribed isosorbide mononitrate. Upon review of the client's
admission history, which of the following findings should concern the nurse most?
1. Use of vardenafil
2. Administration of metoprolol
3. Report of frequent headaches
4. History of myocardial infarction - ANSWER 1. Use of vardenafil
A client is prescribed levothyroxine. Which of the following symptoms should concern
the nurse most?
1. Weight loss
2. Palpitations
3. Heat intolerance
4. Increased appetite - ANSWER 2. Palpitations
A client is receiving digoxin. The nurse should instruct the client to notify the provider of
which of the following finding? (SATA)
1. Blurred vision
2. Muscle weakness
3. Nausea and vomiting
4. Irregular heart rhythm
5. Increased urine output - ANSWER 1. Blurred vision
2. Muscle weakness
3. Nausea and vomiting
4. Irregular heart rhythm
A client is receiving magnesium sulfate 1 g per hr. The nurse is unable to elicit a patellar
deep tendon reflex and respirations are 10/min. Which of the following is the priority
nursing action?
1. Review previous laboratory results.
2. Verify infusion rate of medication.
3. Prepare to administer calcium gluconate.
4. Arrange for an emergency cesarean birth. - ANSWER 3. Prepare to administer
calcium gluconate.
A client is receiving packed RBCs and becomes tachypneic. The client's temperature
changes from 36.8*C (98.4*F) to 38.4*C (101.2*F). Which of the nursing interventions
should the nurse perform first.
5 Rights of Delegation - ANSWER Right Person
Right Task
Right Circumstance
Right Direction/Communication
Right Supervision/Evaluation
A 54 yo client recently diagnosed with diabetes mellitus asks about diet and exercise
management. The nurse recognizes a need for further education based on which
statement by the client?
1. I need to carry glucose tablets to the gym
2. It is okay to exercise of my blood sugar is less than 240 mg/dL
3. I should not eat before running, to prevent complications
4. It is important to walk 20 minutes a day to improve my health. - ANSWER 3. I should
not eat before running, to prevent complications
A child who has a rash and fluid-filled blisters across the face and chest is confirmed to
have varicella. Which action should the nurse take?
1. Administer amoxicillin P.O. TID
2. Give one doe of the varicella vaccine
3. Implement airborne and contact precautions
4. Place the client in a private room and provide positive airflow - ANSWER 3.
Implement airborne and contact precautions
A child who has a rash and fluid-filled blisters across the face and chest is confirmed to
have varicella. Which action should the nurse take?
1. Administer amoxicillin P.O. TID
2. Give one dose of the varicella vaccine.
3. Implement airborne and contact precautions.
4. Place the client in a private room and provide positive airflow. - ANSWER 3.
Implement airborne and contact precautions.
A child who has hemophilia is being discharge home. The nurse should teach the
parents to use which measures if a child sustains an injury? (SATA)
1. Pace ice over the injured tissue
2. Provide passive range of motion
3. Apply pressure directly if bleeding
4. Soak the affected area in warm water
5. Keep injured extremity above the heart
,6. Administer replacement clotting factors - ANSWER 1. Pace ice over the injured tissue
3. Apply pressure directly if bleeding
5. Keep injured extremity above the heart
6. Administer replacement clotting factors
A client asks the nurse, "should I skip my injection of glargine because I have not eaten
for 8 hrs.?" The client's glucose is 106 mg/dL. Which action should the nurse perform?
1. Delay administration until morning
2. Offer sips of orange juice and reassess
3. Administer the medication as prescribed
4. Hold the insulin and document the action - ANSWER 3. Administer the medication as
prescribed
A client developed herpes simplex. The nurse documents that the client has which of
the following type of skin lesions?
1. vesicle
2. pustule
3. nodule
4. wheal - ANSWER 1. vesicle
A client develops swelling of the eyes, face, tongue, and lips after administration of
intravenous penicillin. Which action should the nurse perform first?
1. Give diphenhydramine 25 mg IV
2. Administer epinephrine 0.2 mL IM
3. Raise dead of bed to 45* or higher
4. Prepare to administer a 1-liter fluid bolus. - ANSWER 2. Administer epinephrine 0.2
mL IM
A client develops swelling of the eyes, face, tongue, and lips after administration of
intravenous penicillin. Which action should the nurse perform first?
1. Give diphenhydramine 25 mg IV
2. Administrator epinephrine 0.2 mL IM
3. Raise HOD to 45* or higher
4 Prepare to administer 1 liter fluids bolus - ANSWER 2. Administrator epinephrine 0.2
mL IM
A client diagnosed with pneumonia received ceftriaxone 1g IV ever 12 hrs. for 4 days.
Which of the following statements should be of most concert to the nurse?
1. My IV site is a little tender
2. I still have a productive cough
3. I feel nauseated very time I eat
4. I have had runny diarrhea all day - ANSWER 4. I have had runny diarrhea all day
A client diagnosed with pneumonia received ceftriaxone 1g IV every 12 hrs. for 4 days.
Which of the following statement should be of most concern to the nurse?
1. My IV site is a little tender
,2. I still have a productive cough
3. I feel nauseated ever time I eat
4. I have had runny diarrhea all day - ANSWER 4. I have had runny diarrhea all day
A client has a sealed radiation implant. Which action should the nurse implement?
(SATA)
1. Save linens in the client room.
2. Assign client to a private room
3. Limit each visitor to 30 minutes a day.
4. instruct friends to stand 3 feet from client.
5. Place a "Caution: Radioactive Material" sign on door. - ANSWER 1. Save linens in
the client room.
2. Assign client to a private room
3. Limit each visitor to 30 minutes a day.
5. Place a "Caution: Radioactive Material" sign on door.
A client has excessive bleeding during the third stage of labor. Which of the following
pre-existing medical conditions should cause the nurse to question a prescription for
methylergonovine?
1. Chronic depression
2. Transfusion reaction
3. Migraine headaches
4. Gestational hypertension - ANSWER 4. Gestational hypertension
A client has iron-deficiency anemia. The nurse anticipates that which of the following
abnormalities will be present during inspection of the nailbeds?
1. pink color
2. cyanosis
3. jaundice
4. pallor - ANSWER 4. pallor
A client has iron-deficiency anemia. The nurse anticipates that which of the following
abnormalities will be present during the inspection of the nailbeds?
1. Pint color
2. cyanosis
3. jaundice
4. pallor - ANSWER 4. pallor.
A client in the ICU is receiving an IV of D5W 1/2 NS at 75 mL/hr. Electrolyte studies
reveal: Na+ 143, K+ 3.1, and chloride 98. The client develops the PVCs. The nurse
should?
1. draw stat ABGs to determine changes in PO2
2. obtain a Rx to add K+ to the current IV
3. obtain a Rx to change the IV to D5W at 100 mL/hr.
4. use standing orders and administer lidocaine - ANSWER 2. obtain a Rx to add K+ to
the current IV
, A client is alert and oriented, but anxious and short of breath. After vagal maneuvers
and medication administration the cardiac rhythm has not changed. The nurse should
prepare to assist with which procedure?
1. Defibrillation
2. Cardioversion
3. Echocardiogram
4. Pacemaker insertion - ANSWER 2. Cardioversion
A client is newly prescribed isosorbide mononitrate. Upon review of the client's
admission history, which of the following findings should concern the nurse most?
1. Use of vardenafil
2. Administration of metoprolol
3. Report of frequent headaches
4. History of myocardial infarction - ANSWER 1. Use of vardenafil
A client is prescribed levothyroxine. Which of the following symptoms should concern
the nurse most?
1. Weight loss
2. Palpitations
3. Heat intolerance
4. Increased appetite - ANSWER 2. Palpitations
A client is receiving digoxin. The nurse should instruct the client to notify the provider of
which of the following finding? (SATA)
1. Blurred vision
2. Muscle weakness
3. Nausea and vomiting
4. Irregular heart rhythm
5. Increased urine output - ANSWER 1. Blurred vision
2. Muscle weakness
3. Nausea and vomiting
4. Irregular heart rhythm
A client is receiving magnesium sulfate 1 g per hr. The nurse is unable to elicit a patellar
deep tendon reflex and respirations are 10/min. Which of the following is the priority
nursing action?
1. Review previous laboratory results.
2. Verify infusion rate of medication.
3. Prepare to administer calcium gluconate.
4. Arrange for an emergency cesarean birth. - ANSWER 3. Prepare to administer
calcium gluconate.
A client is receiving packed RBCs and becomes tachypneic. The client's temperature
changes from 36.8*C (98.4*F) to 38.4*C (101.2*F). Which of the nursing interventions
should the nurse perform first.
