UWorld NCLEX-RN TEST 1 AND 2 QUESTIONS AND ANSWERS VERIFIED

UWorld NCLEX-RN TEST 1 AND 2 QUESTIONS AND ANSWERS VERIFIEDA nurse coworker is called into work from home to help care for an influx of clients being admitted after a bus accident. While assisting the coworker prepare for incoming clients, the nurse becomes concerned that the coworker may be under the influence of an impairing substance. Which action by the nurse is best? 1. Ask another coworker to observe the individual to confirm the suspicion 2. Confront the coworker about the concern and offer emotional support 3. Speak with the nursing supervisor about the concern 4. Telephone the appropriate regulatory agency and make a report 3. A nurse is administering a rituximab infusion to a client with lymphoma in an oncology clinic. Which client symptom would be a priority to report to the health care provider? 1. Dizziness and sudden diarrhea 2. Nausea and onset of vomiting 3. New-onset tachypnea and dyspnea 4. Temperature of 101 F (38.3 C) 3. The student nurse plans postmortem care for an Orthodox Jewish client hospitalized for the last week with heart failure who did not sign consents for any postmortem actions. Which statement by the student would require further education by the supervising nurse? 1. "I will allow the family to remain with the client at all times." 2. "I will call the next of kin before providing any postmortem care." 3. "I will prepare the client for transfer to the morgue for autopsy." 4. "I will provide a sheet to be placed over the client's face." 3. The nurse is caring for a client with chronic pancreatitis. Which meal should the nurse recommend when assisting the client in selecting food items from a menu? 1. Baked tilapia with lemon wedge, sweet potatoes, and green peas 2. Cream of potato soup and roast beef sandwich on a croissant 3. Sautéed salmon, macaroni and cheese, string beans, and a biscuit 4. Shrimp enchiladas with tomato salsa, rice, cornbread, and refried beans 1. The nurse is preparing to change the dressing of a client's subclavian central venous catheter using a chlorhexidine gluconate (CHG)-impregnated patch and transparent adhesive dressing. Place the procedural steps in the correct order. All options must be used. Apply CHG patch over catheter insertion site and cover with a sterile transparent dressing Cleanse the site with CHG for at least 30 seconds using friction; allow to air dry completely Discard the clean gloves, perform hand hygiene, and apply sterile gloves Perform hand hygiene, don face mask, place a mask on the client, and apply clean gloves Remove old dressing and CHG-impregnated patch; assess insertion site Perform hand hygiene, don face mask, place a mask on the client, and apply clean gloves Remove old dressing and CHG-impregnated patch; assess insertion site Discard the clean gloves, perform hand hygiene, and apply sterile gloves Cleanse the site with CHG for at least 30 seconds using friction; allow to air dry completely Apply CHG patch over catheter insertion site and cover with a sterile transparent dressing Four clients enter the pediatric emergency department at the same time. Which client should the nurse see first? 1. 2-week-old with tricuspid atresia who has dusky lips and nailbeds 2. 5-week-old with forceful vomiting after every feeding who is crying 3. 12-month-old who was wheezing at home and is now lethargic with no wheezing 4. 3-year-old with fever who had a brief seizure at home and is asleep 3. The unlicensed assistive personnel (UAP) reports being splashed in the eye while emptying urine from the catheter bag of a client with AIDS. The UAP is afraid of becoming infected with HIV and requests immediate testing. What is the nurse's priority action? 1. Direct the UAP to immediately flush the eye with water at the unit's eyewash station 2. Reassure the UAP that the risk for HIV is low as urine does not transmit the virus 3. Refer the UAP to the occupational health department for postexposure prophylaxis 4. Send the UAP to the facility's emergency department for medical evaluation 1. The nurse prepares to administer a client's scheduled prandial regular insulin plus a correctional dose based on a sliding scale as the client's breakfast tray arrives. The client's fasting blood glucose level is 210 mg/dL (11.7 mmol/L). How many total units of regular insulin should the nurse administer? Click the exhibit button for additional information. Record your answer using a whole number. EXHIBIT: Medication administration record: Allergies: NKA Medications: -Regular insulin: 4 units subcutaneously with each meal (0800, 1200, 1700) -Regular insulin: per sliding scale, subcutaneously with each meal and before bed (0800, 1200, 1700, 2100) Sliding-Scale Blood Glucose Levels: 150 mg/dL - 0 units 150-199 mg/dL - 3 units 200-249 mg/dL - 6 units 250-299 mg/dL - 9 units 300-349 mg/dL - 12 units ≥350 mg/dL - 15 units; notify HCP Answer: 10 (units) The nurse is caring for a client taking escitalopram who reports no improvement of depressive feelings since starting the medication 2 months ago. What is the best response by the nurse? 1. "Have you had any recent changes or added stresses in your life?" 2. "It is too early to notice any difference. Please continue to take the medicine as prescribed." 3. "Let's talk more about how you have been taking this medication." 4. "We will talk with your health care provider about changing the prescription." 3. The nurse reinforces teaching to the parents of a 12-month-old who has begun weaning from breastfeeding. Which statement by the parents indicates that teaching has been effective? 1. "I can allow my child to sleep with a bottle for comfort while weaning." 2. "I can start substituting breastfeeding sessions with whole cow's milk." 3. "I should discourage my child from drinking milk to increase solid food intake." 4. "I will stop breastfeeding completely to expedite the weaning process." 2. The home health nurse is discussing the care needs of a client in the last stage of Huntington disease with the family. When the nurse recommends a hospital bed, the client's spouse becomes visibly upset and says, "No hospital bed. I'm just not ready for it yet." What is the best response by the nurse? 1. "A hospital bed will make your spouse's care easier." 2. "Are you not ready for this particular change?" 3. "What upsets you about having a hospital bed?" 4. "You seem upset. We don't have to talk about this right now." 3.A nurse in the intensive care unit is caring for a client in the immediate postoperative period following abdominal surgery. The nurse receives several prescriptions. Which prescription should the nurse initiate first? Click on the exhibit button for additional information. Normal saline 2 L via rapid IV bolus. A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond? Refer employee to the employee health provider. The school nurse assesses an 8-year-old with a history of asthma. The nurse notes mild wheezing and coughing. Which action should the nurse perform first? Assess the client's peak expiratory flow. A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-minute commute via train. The nurse recognizes that this client most likely suffers from which psychological disorder? Agoraphobia A client who is diagnosed with breast cancer asks the nurse, "Am I going to die?" Which statement by the nurse promotes a therapeutic relationship? "People with cancer experience fear of dying; tell me about your concerns." The nurse is reinforcing education to the caregivers of a 9-year-old client diagnosed with scarlet fever. The client has a history of type 1 diabetes mellitus. Which statement by the caregivers indicates that further teaching is needed? "We will not administer insulin if our child is unable to eat." A client is diagnosed with right-sided Bell's palsy. What instructions should the nurse give this client for care at home? Select all that apply. 1. Apply a patch to the right eye at night. 3. Chew on the left side. 4. Maintain meticulous oral hygiene. - Bell's palsy is an inflammation of the cranial nerve VII (facial) that causes motor and sensory alterations. Clients are usually managed as outpatients, with corticosteroids to reduce inflammation, and taught eye/oral care. In Bell's palsy, the eyelids do not close properly. This may result in eye dryness and risk of corneal abrasions. However, weakness of teh lower eyelid may cause excessive tearing due to overflow in some clients. Facial muscle weakness results in poor chewing and food retention. The spouse brings a client to the emergency department due to erratic behavior and expressions of despair. The emergency department is extremely busy with many clients. When the triage nurse asks if the client feels suicidal now, the client shrugs the shoulders. What initial action should the triage nurse take? Place the client in an inside hallway with one-on-one observation. The orthopedic health care provider instructs a client with a fractured femur, who has been non-weight bearing for the past 5 weeks, to progress to full weight bearing on the right leg. which advanced crutch gait that most closely resembles normal walking should the office nurse teach the client? 4-point gait - there are 5 crutch gaits: 2-, 3-, 4-point, swing-to, and swing-through `A nurse administers an intramuscular (IM) injection using the Z-track method technique. Place the steps in chronological order. All options must be used. 4. Pull the skin 1-1 1/2" (2.5-3.5 cm) laterally and away from the injection site. 3. Hold the skin taut with non-dominant hand and insert needle at a 90-degree angle. 2. Inject medication slowly with dominant hand while maintaining traction 6. Wait 10 seconds after injecting the medication and withdraw the needle. Release the hold on the skin, allowing the layers to slide back to their original position. 1. Apply gentle pressure at the injection site but do not massage. The clinic nurse is teaching a client about levothyroxine, which the health care provider has prescribed for newly diagnosed hypothyroidism. Which statement made by the client indicates that further teaching is needed? "If this makes my stomach upset, I will take it with an antacid." - will impair the absorption of levothyroxine (Synthroid). -- Antacids, calcium and iron preparations. - should take levothyroxine on an empty stomach, preferably in the morning, separately from other medications The nurse is reviewing laboratory results for several prenatal clients. Which finding is most important to report to the health care provider? Client at 24 weeks gestation with hemoglobin of 9 g/dL (90 g/L) and hematocrit of 29% - during the second half of pregnancy, the fetus beings to store iron, depleting maternal stores. Hemoglobin 11 g/dL in the first or third trimester or 10.5 g/dL in the second trimester is considered low. A client with obesity has just started taking orlistat. Which statement by the client indicates a need for further teaching? "I have started taking a daily multivitamin with my dinner-time dose of medication." - Orlistat is a lipase inhibitor that prevents the breakdown and absorption of fats from the intestine - interferes with fat-soluble vitamin uptake The nurse on the medical-surgical unit receives report on assigned clients. Which client warrants immediate attention? Client with epigastric pain after endoscopic retrograde cholangiopancreatography. - Perforation or irritation of these areas during the procedure can cause acute pancreatitis, a potentially life-threatening complication after an ERCP: s/s - acute epigastric or left upper quadrant pain, often radiating to the back, and a rapid rise in pancreatic enzymes (amylase. lipase) The home health care nurse reviews the laboratory results for 4 clients. Which laboratory value is most important for the nurse to report to the health care provider? Client with rheumatoid arthritis taking adalimumab has a WBC count of 14,000/mm3 Which emergency department client would be allowed to leave against medical advice after the risks are discussed with the primary health care provider? Client with coffee-ground emesis from chronic use of high-dose aspirin. - Issues that can make a client ineligible to leave AMA include danger to self or others, lack of consciousness, altered consciousness, mental illness, being under chemical influence, or a court decision. Parents may not refuse life-, limb-, or organ- saving treatment on behalf of their minor child for religious or personal reasons: if the parents deny critical treatments to the child, the hospital may seek protective custody Which of the following are examples of medical battery? Select all that apply. 3. The nurse administers 2 mg of morphine PRN to a difficult, alert client but tells the client it is saline. 4. The nurse inserts a needed urinary catheter even though a competent client refuses it The nurse is preparing to administer a scheduled dose of metoclopramide IV to a client with diabetic gastroparesis. Which clinical finding causes the nurse to question the prescription? Sucking lip motions. - Metoclopramide is a commonly used antiemetic medication that treats nausea, vomiting, and gastroparesis by increasing gastrointestinal motility and promoting stomach emptying. With extended use and/or high doses, metoclopramide may lead to the development of tardive dyskinesia, a movement disorder that is characterized by uncontrollable motions and is often irreversible. Clinical manifestations of tardive dyskinesia: Facial - Lip movement - smacking, sucking, puckering - tongue movement - protrusion, curling - grimace - brow furrow or twitch - excess blinking Clinical manifestations of tardive dyskinesia: extremities - foot tap - hand wringing - tremor or shake Clinical manifestations of tardive dyskinesia: neck and torso - rocking - torticollis - persistent neck flexion or extension A client admitted 3 days ago with upper gastrointestinal bleeding underwent an endoscopic procedure to stop the bleeding. The client is started on a clear liquid diet today. Which foods are appropriate for the nurse to offer the client. Select all that apply. 1. Apple juice 3. Chicken broth 5. Unsweetened tea