NCLEX Remediation: Quiz 1 Exam QUESTIONS AND
ANSWERS (LATEST UPDATE 2024) ALREADY PASSED
A client is being discharged home after a routine hip replacement surgery. The
nurse is instructing the client on how to prevent postoperative complications.
What statements by the client would indicate the need for further teaching?
Select all that apply. - ✔✔✔-"Avoiding pain medication will prevent constipation."
"I should drink plenty of liquids like iced tea or coffee."
"Limiting fiber is necessary to avoid diarrhea."
The nurse is caring for a Vietnamese client diagnosed with tuberculosis. The client
speaks limited English. What should the nurse do to ensure the client and family
receives the most accurate information? Select all that apply. - ✔✔✔-Provide
culturally sensitive education.
Encourage family members to obtain a tuberculosis skin test.
Urge all family and close contact community members to seek and complete
treatment to enhance compliance.
Rationale: As always, the nurse must provide culturally sensitive education.
Because tuberculosis is highly contagious, all family members and close
community members should have a tuberculosis skin test, seek treatment, and
remain compliant. A full course of 6-9 months of treatment is needed to prevent
,re-infection. Instructions written in English are not helpful for the client with
limited English skills. Washing dishes by hand is not the best way to prevent
infection; rather a dishwasher should be used if available.
Test Taking Strategy: Focus on the strategic word most to select correct options
that relate to appropriate teaching for both the client and family members. Also,
focusing on the data in the question will assist in answering. Review: Tuberculosis
The nurse is observing the cardiac monitor of a client and notes this cardiac
rhythm (refer to figure). What is the initial nursing action? - ✔✔✔-Check for a
pulse
Rationale: Ventricular tachycardia can be stable or unstable depending on
whether the client has a pulse or not. In this case, assessing the client's pulse is
the initial action. Obtaining a 12 lead ECG and notifying the health care provider
may be necessary but are not initial actions. Initiating CPR may be necessary of
the ventricular tachycardia becomes unstable and cardiac arrest occurs.
Test-Taking Strategy: Note eh strategic word, initial. Use the steps of the nursing
process and recall that assessment is the first step and the first action to take.
Review: Ventricular Tachycardia
A mother brings her 9-month-old child to see the pediatrician and has concerns
that the child may have a developmental delay because the child cannot roll over
yet. for the nurse should ask the mother about which risk factors associated with
a developmental delay? Select all that apply. - ✔✔✔-Chronic illness
Environmental exposure to toxins
Income
Low birth weight
,The nurse in a pediatric unit is planning the staff assignments for children with
developmental delays. When planning the assignment, the nurse decides to assign
those children who have social or emotional delays amongst different nurses.
Which children should be assigned to different nurses? Select all that apply. -
✔✔✔-A child with generalized anxiety disorder
A child with autism
The nurse is caring for a client admitted to the hospital for shortness of breath and
edema in both lower extremities. The client is prescribed furosemide 40mg by the
intravenous route once daily. What information in the chart would warrant the
nurse to verify continuing the prescription with the health care provider (HCP)?
Refer to chart.
History and Physical:
• Expiratory rales on auscultation
• Peripheral Vascular Disease (PVD)
Laboratory Findings:
• Blood pressure 145/94 mmHg
• Serum Potassium 3.5 mEq/L (3.5 mmol/L)
Medications:
• Lisinopril 20mg orally daily
• Atorvastatin 10mg orally at bedtime - ✔✔✔-Potassium level of 3.5 mEq/L (3.5
mmol/L)
Rationale: Furosemide is a potassium-losing diuretic. The serum potassium level
of 3.5mEq/L (3.5 mmol/L) is on the lower limit of normal, and the nurse should
anticipate that the potassium level would drop with the administration of
furosemide. Therefore, the nurse should verify continuing the prescription if this
, potassium level was noted. Expiratory rales are an expected finding with fluid
overload and furosemide would be an appropriate treatment. Atorvastatin and
peripheral vascular disease are not impacted by the administration of furosemide.
Test-Taking Strategy: Focus on the subject, the need to verify continuing the
prescription. Note the data in the question and that the client is receiving
furosemide. Recall that furosemide is a potassium-losing diuretic. Think about the
side and adverse effects of this medication to answer correctly. Review:
furosemide
A nurse employed at a nursing home is caring for a client who has recently been
transferred from the hospital to the nursing home. The client is confused and is
acting out. The nurse suspects the client is suffering from relocation stress. The
nurse should include which helpful actions in the plan of care? Select all that
apply. - ✔✔✔-Ensure the client is an active part of decision making regarding their
care.
Encourage friends and family to visit frequently.
Establish a trusting relationship with the client as soon as possible.
Rationale: Relocation stress can occur when a client is removed from their usual
surrounding such as home. In order to provide safe and quality care, encourage
friends and family to visit the client often and establish a trusting relationship with
the client as soon as possible. It is important for the client to have an active role in
decision-making. In order to lessen confusion, the nurse should provide the client
time to become familiar with the immediate surroundings such as his or her room
before allowing or encouraging ambulation to new surroundings; allowing the
client to move around the halls as desired may increase confusion and acting-out
behaviors. Likewise, changing the client's room frequently may increase
confusion.
ANSWERS (LATEST UPDATE 2024) ALREADY PASSED
A client is being discharged home after a routine hip replacement surgery. The
nurse is instructing the client on how to prevent postoperative complications.
What statements by the client would indicate the need for further teaching?
Select all that apply. - ✔✔✔-"Avoiding pain medication will prevent constipation."
"I should drink plenty of liquids like iced tea or coffee."
"Limiting fiber is necessary to avoid diarrhea."
The nurse is caring for a Vietnamese client diagnosed with tuberculosis. The client
speaks limited English. What should the nurse do to ensure the client and family
receives the most accurate information? Select all that apply. - ✔✔✔-Provide
culturally sensitive education.
Encourage family members to obtain a tuberculosis skin test.
Urge all family and close contact community members to seek and complete
treatment to enhance compliance.
Rationale: As always, the nurse must provide culturally sensitive education.
Because tuberculosis is highly contagious, all family members and close
community members should have a tuberculosis skin test, seek treatment, and
remain compliant. A full course of 6-9 months of treatment is needed to prevent
,re-infection. Instructions written in English are not helpful for the client with
limited English skills. Washing dishes by hand is not the best way to prevent
infection; rather a dishwasher should be used if available.
Test Taking Strategy: Focus on the strategic word most to select correct options
that relate to appropriate teaching for both the client and family members. Also,
focusing on the data in the question will assist in answering. Review: Tuberculosis
The nurse is observing the cardiac monitor of a client and notes this cardiac
rhythm (refer to figure). What is the initial nursing action? - ✔✔✔-Check for a
pulse
Rationale: Ventricular tachycardia can be stable or unstable depending on
whether the client has a pulse or not. In this case, assessing the client's pulse is
the initial action. Obtaining a 12 lead ECG and notifying the health care provider
may be necessary but are not initial actions. Initiating CPR may be necessary of
the ventricular tachycardia becomes unstable and cardiac arrest occurs.
Test-Taking Strategy: Note eh strategic word, initial. Use the steps of the nursing
process and recall that assessment is the first step and the first action to take.
Review: Ventricular Tachycardia
A mother brings her 9-month-old child to see the pediatrician and has concerns
that the child may have a developmental delay because the child cannot roll over
yet. for the nurse should ask the mother about which risk factors associated with
a developmental delay? Select all that apply. - ✔✔✔-Chronic illness
Environmental exposure to toxins
Income
Low birth weight
,The nurse in a pediatric unit is planning the staff assignments for children with
developmental delays. When planning the assignment, the nurse decides to assign
those children who have social or emotional delays amongst different nurses.
Which children should be assigned to different nurses? Select all that apply. -
✔✔✔-A child with generalized anxiety disorder
A child with autism
The nurse is caring for a client admitted to the hospital for shortness of breath and
edema in both lower extremities. The client is prescribed furosemide 40mg by the
intravenous route once daily. What information in the chart would warrant the
nurse to verify continuing the prescription with the health care provider (HCP)?
Refer to chart.
History and Physical:
• Expiratory rales on auscultation
• Peripheral Vascular Disease (PVD)
Laboratory Findings:
• Blood pressure 145/94 mmHg
• Serum Potassium 3.5 mEq/L (3.5 mmol/L)
Medications:
• Lisinopril 20mg orally daily
• Atorvastatin 10mg orally at bedtime - ✔✔✔-Potassium level of 3.5 mEq/L (3.5
mmol/L)
Rationale: Furosemide is a potassium-losing diuretic. The serum potassium level
of 3.5mEq/L (3.5 mmol/L) is on the lower limit of normal, and the nurse should
anticipate that the potassium level would drop with the administration of
furosemide. Therefore, the nurse should verify continuing the prescription if this
, potassium level was noted. Expiratory rales are an expected finding with fluid
overload and furosemide would be an appropriate treatment. Atorvastatin and
peripheral vascular disease are not impacted by the administration of furosemide.
Test-Taking Strategy: Focus on the subject, the need to verify continuing the
prescription. Note the data in the question and that the client is receiving
furosemide. Recall that furosemide is a potassium-losing diuretic. Think about the
side and adverse effects of this medication to answer correctly. Review:
furosemide
A nurse employed at a nursing home is caring for a client who has recently been
transferred from the hospital to the nursing home. The client is confused and is
acting out. The nurse suspects the client is suffering from relocation stress. The
nurse should include which helpful actions in the plan of care? Select all that
apply. - ✔✔✔-Ensure the client is an active part of decision making regarding their
care.
Encourage friends and family to visit frequently.
Establish a trusting relationship with the client as soon as possible.
Rationale: Relocation stress can occur when a client is removed from their usual
surrounding such as home. In order to provide safe and quality care, encourage
friends and family to visit the client often and establish a trusting relationship with
the client as soon as possible. It is important for the client to have an active role in
decision-making. In order to lessen confusion, the nurse should provide the client
time to become familiar with the immediate surroundings such as his or her room
before allowing or encouraging ambulation to new surroundings; allowing the
client to move around the halls as desired may increase confusion and acting-out
behaviors. Likewise, changing the client's room frequently may increase
confusion.
