NCLEX Health Care Assessment Practice Exam With Answers (1200 Solved Questions)

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NCLEX Health Care Assessment Practice Exam With Answers (1200 Solved Questions) - Page 1 preview image

HURST REVIEW NCLEX-RN ReadinessExam 1, Hurst Practice Exam 2, HurstReview Test # 3,The primary healthcare provider has prescribed phenytoin 100 mg intravenous push(IVP) stat for an adult client. What is the least amount of time that the nurse can safelyadminister this medication?1. 1 minute2. 2 minutes3. 5 minutes4. 10 minutes -2. Correct: The rate of IV administration should not exceed 50 mg/min.for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clientsbecause of the risk of severe hypotension and cardiac arrhythmias. So 100 mg cansafely be delivered over a period of at least 2 minutes.1. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of therisk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be deliveredover a period of at least 2 minutes. Giving this dose over only one minute could lead tothese or other potential harmful effects.3. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of therisk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be deliveredover a period of at least 2 minutes. Five minutes would be longer than required to beable to safely administer the medication.4. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of therisk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be deliveredover a period of at least 2 minutes. Ten minutes is much longer than required to be ableto safely administer the medication.A client, hospitalized with possible acute pancreatitis secondary to chronic cholecystitis,has severe abdominal pain and nausea. The client is kept NPO, an NG tube is inserted,and IV fluids are being administered. What is the rationale for the client being NPO withan NG tube to low suction?1. Relieve nausea2. Reduce pancreatic secretions3. Control fluid and electrolyte imbalance

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4. Remove the precipitating irritants -2. Correct: In clients with pancreatitis, thepancreatic enzymes cannot exit the pancreas. These enzymes, when activated, beginto digest the pancreas itself. The enzymes become activated in the pancreas when fluidor food accumulates in the stomach. The goal in treating this client is to stop theactivation of the pancreatic enzymes. Treatment is focused on keeping the stomachempty and dry. This allows the pancreas time to rest and heal. Note: Autodigestion(pancreas digesting itself) is painful for the client and can lead to other problems suchas bleeding.1. Incorrect: The primary purpose of the NG tube to suction is to keep the stomachempty and dry to decrease pancreatic enzyme production, not to relieve nausea.3. Incorrect: Because gastric contents are removed, the NG tube to suction may lead tofluid and electrolyte disturbances rather than helping to control them.4. Incorrect: Although the food in the stomach causes the pancreatic enzymes tobecome activated in the pancreas due to the obstruction, the food is not considered anirritant. Precipitating irritants are not a part of the pathophysiology occurring withpancreatitis.The nurse is working with a committee at the local school to develop an emergencypreparedness plan for tornados. What should be included in the plan?1. Identification of safe zones.2. Methods for accounting for all people present in the building.3. Warning system activation.4. Identification of the gymnasium as the routine safe place.5. Regular practice protocols. -1., 2., 3. & 5. Correct: Everyone should be aware ofsafe zones within the school. Personnel should be given this information and signsposted in safe zones. There must be systems in place to accurately determine thenumber of people in the building at any given time. There also must be a system inplace to alert personnel and students of tornado warnings. Regular practice prepareseveryone for an actual event.4. Incorrect: Gymnasiums are not considered safe places due to wide expanse of roof.Safe zones should be on interior walls, no windows, and a strong concrete floor ifpossible.What should a nurse teach family members prior to them entering the room of a clientwho has agranulocytosis?1. Meticulous hand washing is needed.2. Do not visit if you have any infection.3. The client must wear a mask.4. Children under 12 may not visit.5. Flowers are not allowed in the room. -1., 2., 4., & 5. Correct: Protective isolation isneeded for this client because of the presence of a low white blood cell count. We areprotecting the client from acquiring an infection. So any visitors will need to have

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meticulous hand washing prior to entering. The visitor should not enter if he or she hasany type of infection. To decrease the risk of infection, small children should not visit.Even the mildest symptom of infection could be detrimental to the client. Flowers havebacteria and should not be brought into the room.3. Incorrect: A mask must be worn by the visitor, not the client. The mask is worn byvisitors to prevent a possible spread of an airborne infection to theimmunocompromised client.A client diagnosed with major depression has been taking a selective serotoninreuptake inhibitor for the past 6 weeks. When visiting the mental health center, thenurse discusses the medication and response with the client. The nurse's assessmentreveals that the client is confused about the date and about the prescribed dosage ofthe medication. Which question would be most important for the nurse to ask to furtherassess the situation?1. Are you having trouble sleeping at night?2. Do you have periods of muscle jerking?3. Are you having any sexual dysfunction?4. Is your mood improving? -2. Correct: Myoclonus, high body temperature, shaking,chills, and mental confusion are some of the symptoms of serotonin syndrome. Thisclient may be having symptoms of this adverse reaction which, if severe, can be fatal.1. Incorrect: Sleep disturbances are common with depression. Selective serotoninreuptake inhibitors (SSRIs) may cause insomnia; however, there is a more pertinentquestion needed for assessment of this client. You should be concerned with the moreserious or life-threatening issue.3. Incorrect: Sexual dysfunction may occur with the SSRIs; however, the client isexhibiting significant symptoms of an adverse reaction which would take priority.4. Incorrect: The response to the SSRI medications is important; however, there is amore significant issue in this case. The possible serotonin syndrome is a serioussituation that would be the priority for the nurse to address.A client diagnosed with serotonin syndrome is admitted to the unit. The nurse is familiarwith this adverse reaction to the serotonin reuptake inhibitors. Which symptoms can thenurse expect on assessment?1. Fever and shivering2. Agitation3. Decreased body temperature4. Constipation5. Increased heart rate -1., 2. & 5. Correct: Serotonin syndrome is a group ofsymptoms that can result from the use of certain serotonin reuptake inhibitors. Thesesymptoms can range from mild to severe and include high body temperature, agitation,increased reflexes, diaphoresis, tremors, dilated pupils and diarrhea. The client is likelyto experience shivering with fever. Increased heart rate and blood pressure are also

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commonly experienced. More severe symptoms, including muscle rigidity and seizures,can occur. If not treated, serotonin syndrome can be fatal.3. Incorrect: Increased body temperature is expected as is increased diaphoresis.4. Incorrect: Diarrhea, not constipation, is a symptom of serotonin syndrome.The emergency department nurse is assessing a client who presents with severeepigastric pain. The client reports that three rolls of calcium carbonate were consumedin the past eight hours to treat the indigestion. Which blood gas report does the nurseassociate with this situation?1. pH - 7.49, pCO2 - 40, HCO3 - 302. pH - 7.32, pCO2 - 48, HCO3 - 203. pH - 7.38, pCO2 - 52, HCO3 - 324. pH - 7.29, pCO2 - 54, HCO3 - 26 -1. Correct: These ABGs are indicative ofmetabolic alkalosis. The pH is high, the pCO2 is within normal limits and the bicarb ishigh (alkalosis). So, the excess Tums (calcium carbonate) could have caused metabolicalkalosis.2. Incorrect: The client is not hypoventilating and would not be in metabolic acidosisbecause he ate 3 rolls of Tums which is a base. These ABGs are indicative of acidosis.The pH is low (acidosis), the pCO2 is high (acidosis) and the bicarb is low (acidosis).3. Incorrect: The client is not a long-term COPD client as these ABGs might suggest.These ABGs are indicative of fully compensated respiratory acidosis. The pH is normal.The pCO2 is high (as with chronic retention) and the bicarb is high to help compensate.4. Incorrect: These ABGs are the result of an acute ventilation problem. They areindicative of respiratory acidosis. The pH is low, the pCO2 is high, and the bicarb isnormal. No compensation has begun at this point.Which prescriptions would the nurse recognize as being appropriate for the client withshingles?1. Private room2. Negative pressure airflow3. Respirator mask4. Face Shield5. Positive pressure room -1., 2. & 3. Correct: According to the current standards ofStandard Precautions per the CDC, the client with shingles should be placed onairborne precautions which require the use of a private room with negative pressureairflow and a N-95 respirator mask.4. Incorrect: A face shield is used when there is risk of splashing or spraying of blood orbody fluids. This is not required for airborne precautions.

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5. Incorrect: Negative pressure is required in order to prevent the airborne infection fromspreading outside of the room. Positive pressure is used only in protective environmentssuch as when immunocompromised clients require protection from potential infectiousagents outside of the room.A healthy newborn has just been delivered and placed in the care of the nurse. Whatnursing actions should the nurse initiate?Place in the correct priority order.Assess newborn's airway and breathing.Bulb suction excessive mucus.Assess newborn's heart rate.Place identification bands on newborn and mom.Administer sterile ophthalmic ointment containing 0.5% erythromycin. -RememberMaslow's hierarchy of needs will guide your assessment. First, Assess newborn'sairway and breathing. The most critical change that a newborn must makephysiologically is the initiation of breathing. The nurse should assess the newborn'scrying. If the cry is weak, it may indicate a respiratory disturbance. Other signs ofrespiratory compromise may include: stridor, grunting, retractions, apnea or diminishedbreath sounds. Normal respiration are 30 - 60 breaths a minute.Second, Bulb suction excessive mucus. It is important to assure that the throat andnose are kept clean of secretions to prevent respiratory distress.Third, Assess newborn's heart rate. If there is no respiratory distress, the nursecontinues the assessment by checking the heart rate and other vital signs.Fourth, Place identification bands on newborn and mom. These are critical for ensuringbabies and moms will be appropriately matched at all times but does not take priorityover respiration and circulation.Fifth, Administer sterile ophthalmic ointment containing 0.5% erythromycin. This is alegally required prophylactic eye treatment to prevent Neisseria gonorrhea. However,this would never be a priority over Maslow's hierarchy of needs.What information should a nurse include when educating a client regarding buccaladministration of a medication?1. This route allows the medication to get into the bloodstream faster than the oral route.2. Stinging may occur after placing the medication in the cheek.3. If swallowed, the medication may be inactivated by gastric secretions.4. The buccal dose of medication will need to be increased from the oral dose.5. Remove the tablet from buccal area after 15 seconds. -1., 2., & 3. Correct: Theseare correct statements about buccal administration of medication. Buccal administration

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involves the medication being placed between the gums and cheek, where it dissolvesand becomes absorbed into the bloodstream. The cheek area has many capillaries thatallow the medication to be absorbed quickly without having to pass through thedigestive system. The degree of stinging experienced depends on the medication beingadministered. Some effects of certain medications can be lessened by digestiveprocesses.4. Incorrect: When given by the buccal route, the medication does not go through thedigestive system. This means that the medication is not metabolized through the liver,and thus a lower dose can be used.5. Incorrect: Placement should be maintained until the tablet is dissolved in order to getthe dosage and effects desired.Which signs and symptoms would the nurse expect to see in a client who has takenprednisone for two months?1. Weight loss2. Decreased wound healing3. Hypertension4. Decreased facial hair5. Moon face -2., 3. & 5. Correct: Decreased wound healing is a side effect withprolonged steroid use due to the immunosuppressive effects. All steroid medications,such as prednisone, can lead to sodium retention which then leads to dose related fluidretention. Hypertension is seen due to this fluid and sodium retention. Cushingoidappearance (moon face) is a side effect that is created from the abnormal redistributionof fat from prolonged steroid use.1. Incorrect: Within one month after corticosteroid administration, weight gain is seenrather than weight loss.4. Incorrect: Facial and body hair increase with prolonged steroid use. This excessivegrowth of body hair, known as hirsutism, is one of the numerous potential side effects ofprednisone.A nurse is at highest risk for blood-borne exposure during which situation?1. When removing a needle from the syringe.2. While placing a suture needle into the self-locking forceps.3. Prior to inserting the intravenous (IV) line, the client moves causing a needle stick tothe nurse.4. A clean needle sticks the nurse through blood-soiled gloves. -4. Correct: A cleanneedle that moves through blood-soiled gloves to stick the nurse is considered to bepotentially contaminated and results in a blood-borne exposure. All other answers areconsidered a clean stick.1. Incorrect: This is considered a clean stick. The needle is sterile initially and has notbeen contaminated prior to removal of the needle from the syringe.

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2. Incorrect: This is considered a clean stick since the suture needle has not beeninserted into the client prior to the needle stick.3. Incorrect: This is considered a clean stick. The IV insertion device is sterile and hasnot been contaminated since it was not inserted into the client.A new nurse is preparing to give a medication to a nine month old client. After checkinga drug reference book, the nurse crushes the tablet and mixes it into 3 ounces ofapplesauce. The new nurse proceeds to the client's room. What priority action shouldthe supervising nurse take?1. Tell the new nurse to recheck the drug reference book before administering themedication.2. Suggest that the new nurse reconsider the client's developmental needs.3. Check the prescription order and the client dose.4. Observe the new nurse administer the medication. -2. Correct: Mixing medicationwith applesauce is appropriate in some circumstances, but the volume of 3 ounces isexcessive for a nine month old. The nurse will want to make sure the client gets all ofthe medication. Additionally, applesauce may or may not have been introduced into thediet, and it is inappropriate to introduce a new food during an illness.1. Incorrect: There is nothing in the stem about a problem with the medication dose orroute.3. Incorrect: There is nothing in the stem about a problem with the medication dose orroute.4. Incorrect: This is an appropriate action. However, it is not the priority over ensuringthat the new nurse knows how to appropriately prepare the medication for this client.An adult client has just returned to the nursing care unit following a gastroscopy. Whichintervention should the nurse include on the plan of care?1. Vital sign checks every 15 min x 42. Supine position for 6 hours3. NPO until return of gag reflex4. Irrigate NG tube every 2 hours5. Raise four side rails -1., & 3. Correct: Vital signs post procedure are important tomonitor for any post-procedure complications such as bleeding or any signs ofrespiratory compromise. VS are checked frequently for the first hour post procedure.Any client who has a scope inserted down the throat and has received numbingmedication in the back of the throat to depress the gag reflex should be kept NPO untilthe gag reflex returns.2. Incorrect: Supine position for 6 hours is contraindicated. The HOB should beelevated. In the event the client vomits, he/she is less likely to aspirate with the HOBelevated. Supine position for 6 hours is used after a heart catheterization.

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4. Incorrect: A client who is going for a gastroscopy procedure cannot have a nasalgastric tube. An NG tube would interfere with the procedure.5. Incorrect: Raising all side rails is a form of restraint. Have the bed in low lockedposition. Raise three side rails, and have call light within reach.The family member of a schizophrenic client asks the nurse why the client is receivingchlorpromazine and benztropine. What is the best response by the nurse?1. The chlorpromazine makes the benztropine more effective so a smaller dose of bothdrugs can be used.2. Benztropine is given to treat the side effects produced by the chlorpromazine.3. Chlorpromazine is used for severe hiccups that can occur with the use ofbenztropine.4. Chlorpromazine is used for psychosis and benztropine is used for preventingagranulocytosis. -2. Correct: Benztropine is used to treat parkinsonism of variouscauses and drug-induced extrapyramidal reactions seen with chlorpromazine, which isan antipsychotic agent. Extrapyramidal symptoms are neurologic disturbances in thearea of the brain that controls motor coordination. This disruption can cause symptomsthat mimic Parkinson's disease, including stiffness, rigidity, tremor, drooling and theclassic "mask like" facial expression. These symptoms can be treated and are reversibleusing such medications as benztropine.1. Incorrect: Chlorpromazine does not potentiate the effects of benztropine, so dosageregulation is not appropriate.3 Incorrect: Chlorpromazine can be used for severe hiccups, but the hiccups are not theresult of using benztropine. Chlorpromazine is also used for psychosis in theschizophrenic client.4. Incorrect:Benztropine is not used to prevent agranulocytosis.A nurse is planning to provide information regarding suicide to a high school assembly.What information should the nurse include?1. Do not keep secrets for the suicidal person.2. Express concern for a person expressing thoughts of suicide.3. Teens often don't mean what they say, so only take suicide seriously if grades aredropping as well.4. Inform group of suicide intervention sources.5. Do not leave a suicidal person alone. -1., 2., 4. & 5. Correct: If a person reveals thatsuicide is being considered, this should never be kept secret. Help should be sought forthe person immediately. It is also important to be direct and non-secretive with suicidalclients. It is appropriate to express concern for their thoughts. The use of empathy,warmth and concern indicates to the client that their feelings are being understood andviewed as real, which helps to build trust with the client. Resources for assistance are

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important to include in all health teaching programs. The teens need to know whatresources are readily available if someone is considering suicide. The clientcontemplating suicide should not be left alone. This is for the client's safety until furtherassistance can be obtained3. Incorrect: Most clients who commit suicide have told at least one person that theywere contemplating suicide before thy actually committed the act. Therefore, suicidalcomments should be considered important risk factors that require evaluation, and allcomments should be taken seriously. Anyone expressing suicidal feelings needsimmediate attention.The nurse is caring for a client who was admitted to the hospital following a severemotor vehicle crash (MVC) in which the client was trapped in the car for several hours.The client is being closely monitored for the development of renal failure. Whichassessment finding would warrant immediate reporting?1. Creatinine 1.1 mg/dl (97.24 mmol/L)2. Urinary output of 150 mL per hour.3. Gradual increase of BUN levels.4. Calcium levels of 9.0 mg/dL (2.25 mmol/L) -3. Correct. Gradual accumulation ofnitrogenous wastes results in elevated BUN and serum creatinine. This is an indicationof impaired renal function.1. Incorrect. This is a normal creatinine level. Gradual accumulation of nitrogenouswastes from impaired renal function results in elevated BUN and serum creatinine.2. Incorrect. This is a normal output level. This level alone would not necessarily be anindicator of acute renal failure and that value alone would not warrant reporting it to theprimary healthcare provider.4. Incorrect. Calcium level of 9.0 mg/dL (2.25 mmol/L) is considered normal. Whenobserving for renal functioning you would assess the BUN and creatinine levels. Inaddition, the calcium level may drop (hypocalcemia) in renal failure inverse relationshipchange due to the rising serum phosphate levels. However, the calcium level presentedis within normal limits (WNL).A female client taking captopril for hypertension tells the clinic nurse that she is planningto get pregnant. What recommendation should the nurse make?1. "Captopril can be taken safely during pregnancy, but we will need to decrease yourdose so you do not become hypotensive."2. "We will need to increase your dose of captopril once you become pregnant."3. "In order to prevent neural tube defects, start taking folic acid."4. "Captopril can cause serious harm to an unborn baby, so you must preventpregnancy while taking this medication. " -4. Correct: Captopril should not be takenduring pregnancy because serious harm (possibly fatal) to the unborn baby can resultwhen taken during pregnancy.

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1. Incorrect: Captopril should not be taken during pregnancy because serious harm(possibly fatal) to the unborn baby can result when taken during pregnancy.2. Incorrect: Captopril should not be taken during pregnancy because serious harm(possibly fatal) to the unborn baby can result when taken during pregnancy.3. Incorrect: Captopril should not be taken during pregnancy because serious harm(possibly fatal) to the unborn baby can result when taken during pregnancy. Theproblem being presented in the stem is not related to general prevention of neural tubedefects. Folic acid would not prevent the harm to the fetus caused by captopril.A client diagnosed with glomerulonephritis presents with generalized malaise, weightgain, generalized edema, and flank pain. The primary healthcare provider prescribesantibiotics and strict bedrest. What is the best explanation to give the client regardingthe strict bedrest prescription?1. Promotes diuresis2. Prevents injury3. Promotes rest4. Stimulates RBC production -1. Correct: Bedrest and the supine position promotediuresis. When the client is supine, there is a gradual shift of fluids away from the legstoward the thorax, abdomen and head. This increased volume causes the right atrium ofthe heart to stretch and release ANP, which leads to diuresis: renal blood flow increasesdue to vasodilation, and aldosterone and ADH secretion are inhibited.2. Incorrect: Bedrest can keep the client from falling and injuring self; however, that isnot why it has been prescribed.3. Incorrect: Promotion of rest is good, but this is not why the primary healthcareprovider prescribed it. Simply promoting does not help improve the symptoms listed.The reason the client needs bedrest should focus on relieving the symptoms listed inthe stem.4. Incorrect: No relationship between bedrest and red blood cell production exists.A newly admitted client with schizophrenia has an unkempt appearance and needs toattend to personal hygiene. Which statement by the nurse is most therapeutic?1. A shower will make you feel better.2. It is time to take a shower.3. Have you thought about taking a shower?4. I need you to take a shower. -2. Correct: Schizophrenia is a thought disorder. Manyclients with schizophrenia are concrete thinkers and have difficulty making decisions.The nurse needs to be direct, clear and concise in communicating with the client. This isa direct, clear and concise statement that guides the client to perform the neededactivity.

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1. Incorrect: Many clients with schizophrenia are concrete thinkers. The nurse needs tobe direct, clear and concise in communicating with the client. The client may notcomprehend how the shower improves the overall sense of well-being and wouldremain reluctant to take the shower.3. Incorrect: Clients diagnosed with schizophrenia often have trouble making decisions.The client needs to be guided with simple, direct instructions.4. Incorrect: This focuses on the nurse's need, not the client's need. Do not selectanswers that focus on the nurse. This does not improve the client's decision makingability nor does it provide guidance to the client for meeting the hygiene needs.Which clients would be appropriate for the RN to assign to an LPN/LVN?1. Seventy four year old client with unstable angina who needs teaching for a scheduledcardiac catheterization.2. Sixty year old client experiencing chest pain scheduled for a graded exercise test.3. Forty eight year old client who is five days post right-sided cerebral vascular accident(CVA).4. Eighty four year old client with heart disease and mild dementia.5. Newly admitted ninety year old client with decreased urinary output, altered level ofconsciousness, and temperature of 100.8°F (38.2°C)6. Sixty six year old client with chronic emphysema experiencing mild shortness ofbreath. -3., 4., 6. Correct: The client who is five days post CVA is one of the moststable clients and could be assigned to the LPN/LVN. There is nothing in the option toindicate that this client is unstable. There is no indication that the eighty-four year oldclient with heart disease and dementia is unstable so this client can be assigned to theLPN/LVN. The client with chronic emphysema will experience shortness of breath.There is nothing to indicate that this client is unstable.1. Incorrect: This client is unstable and should be cared for by the RN. Additionally, theRN is responsible for teaching.2. Incorrect: This client is experiencing chest pain and is thus considered unstable andshould be cared for by the RN.5. Incorrect: This client has s/s that could indicate sepsis, so is considered unstable andshould not be assigned to the LPN/LVN.While examining a client's health history, which data indicates to the nurse that the clientis at increased risk for developing cancer?1. Family history2. Alcohol consumption3. Spicy diet4. Human papillomavirus5. Tobacco use -1., 2., 4., & 5. Correct: Family history of cancer increases the risk forhaving the same type of cancer. Alcohol and tobacco use increase the risk of cancer.

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When used together, they have a synergistic effect. Human papillomavirus (HPV)increases the risk of cervical, head, and neck cancers.3. Incorrect: Although there are some dietary factors associated with cancerdevelopment, a spicy diet does not necessarily increase the risk of cancer.A nurse is caring for a client admitted with chronic fatigue and weakness. During thephysical assessment, the nurse notes jaundiced sclera, abdominal distension, swellingin the legs and ankles, and bruises in various stages of healing throughout the body.What nursing interventions should the nurse initiate?1. Measure abdomen2. Monitor intake and output3. Obtain daily weight4. Place on fall precautions5. Provide three meals per day6. Dangle legs -1., 2., 3., & 4. Correct: The symptoms presented are indicative of liverdisease. Measuring abdominal girth will monitor for accumulating ascitic fluid. Clientswith liver disease have fluid volume problems, so daily weight and I&O are indicated.This client is at risk for injury related to chronic fatigue and weakness, so fall preventionis indicated. The client may need help eating if fatigue is severe.5. Incorrect: Poor tolerance to larger meals may be due to abdominal distension andascites. Clients should eat smaller, more frequent meals (6/day). The recommendeddiet is high calorie and low sodium with protein regulated based on liver function.Between meal snacks should be provided.6. Incorrect: Elevating legs enhances venous return and reduces edema in extremities.Dangling the leg would cause the fluid in the lower extremities to accumulate more.A client experiencing chest pain is prescribed an intravenous infusion of nitroglycerin.After the infusion is initiated, the occurrence of which symptom would prompt the nurseto discontinue the nitroglycerin?1. Frontal headache2. Orthostatic hypotension3. Decrease in intensity of chest pain4. Cool, clammy skin -4. Correct: This assessment finding of cool, clammy skin is anindication of decreased cardiac output that could be the result of too muchvasodilatation. Cardiac output could continue to decrease if the nitroglycerin is notdiscontinued.1. Incorrect: A headache is an expected common side effect of nitroglycerinadministration. The headache is treated with medication.2. Incorrect: A decrease in blood pressure when rising from a supine or sitting position isa common effect of the vasodilatation that occurs with the administration ofnitroglycerin. The client should be advised to change positions slowly.

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3. Incorrect: The decrease in the intensity of the client's chest pain is the desiredoutcome of the nitroglycerin administration.During an assessment interview with a client, what alternative healing modalities shouldthe nurse inquire about?1. "Tell me about your use of teas, herbs, and vitamins."2. "What traditional or folk remedies are used in your family?"3. "Do you meditate, pray, or use relaxation techniques for healing purposes?"4. "What prescription medications are you taking?"5. "What alternative therapies have you used?" -1., 2., 3., & 5. Correct: These are allinquiries the nurse should make when conducting an assessment interview in order tofind out about alternative healing modalities. Alternative or complementary medicine isused to describe over 1800 therapies practiced around the world. Approximately 65 to80% of the world's population use non-conventional (alternative) healing modalities.These alternative healing modalities can be such things as: Natural products (herbs,dietary supplements, etc.) mind and body practices (yoga, mediation, prayer, etc.), folkremedies and other non-traditional practices.4. Incorrect: Prescription medications would be part of traditional, western medicine.Although the nurse needs to find out what prescription medications are being taken, it isnot part of alternative medicine.The nurse in the emergency department suspects that a client's lesion is caused byanthrax. What assessment question is most important?1. Have you traveled out of the United States recently?2. Have you recently worked with any farm animals or any animal-skin products?3. Have you experienced any gastrointestinal upset recently?4. Have you eaten any home-canned foods recently? -2. Correct: Cutaneous anthraxmay be contracted by working with contaminated animal-skin products. Anthrax is foundin nature and commonly infects wild and domestic hoofed animals.1. Incorrect: Cutaneous anthrax is also found in the United States, so asking abouttravel abroad would not be necessary.3. Incorrect: Cutaneous anthrax can be contracted by spores entering cuts or abrasionsin the skin. This is cutaneous anthrax that causes edema, itching and macule or papuleformation, resulting in ulceration. Ingestion of anthrax can cause GI symptoms such asnausea and vomiting, abdominal pain, and bloody diarrhea. Inhalation of anthrax mayresult in flu-like symptoms that progress to severe respiratory distress.4. Incorrect: This question would be appropriate if botulism were suspected in a client.When preparing a client for surgery, the nurse realizes the operative permit has notbeen signed. The client tells the nurse he understands the procedure, but received his

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NCLEX Health Care Assessment Practice Exam With Answers (1200 Solved Questions) - Page 15 preview image

preoperative medication approximately 10 minutes ago. What would be the appropriateaction by the nurse?1. Have the client sign the permit, as he verbalizes understanding.2. Witness the form after having the client sign it.3. Have his wife sign the form as she witnessed his statement that he understands.4. Call the surgical area and explain that the surgery will have to be cancelled. -4.Correct: The client must sign the operative permit or any other legal document prior totaking preoperative drugs that can affect judgment and decision-making capacity.1. Incorrect: The client's verbal understanding does not override the fact that he hasreceived medication that can alter thought processes and decision-making.2. Incorrect: Witnessing would not make this document legal. The consent would not bevalid because the client has already received the pain medication that could alter thethought process.3. Incorrect: When a client is of legal age (unless an emancipated minor) and of soundmind, it would be inappropriate for the spouse to sign the form for surgery. In order to bevalid it must be the client who signs it, unless there is a legal power of attorney, durablepower of attorney, or healthcare surrogate.A child is being admitted with possible rheumatic fever. What assessment data would bemost important for the nurse to obtain from the parent?1. 102° F (38.89° C) temperature that started 2 days previously.2. History of pharyngitis approximately 4 weeks ago.3. Vomiting for 3 days.4. A cough that started about 1 week earlier. -2. Correct: Rheumatic fever is often theresult of untreated or improperly treated group A β-hemolytic streptococcal infections(GABHS), such as pharyngitis. Therefore, the history of pharyngitis or upper respiratoryinfection is a key assessment finding for establishing a diagnosis of rheumatic fever.Subsequent development of rheumatic fever usually occurs 2 to 6 weeks following theGABHS, so the assessment should include a remote history of pharyngitis.1. Incorrect: The fever with rheumatic fever is usually low grade and is considered aminor manifestation of rheumatic fever.3. Incorrect: Vomiting is not a commonly associated symptom with rheumatic fever andis not considered a major manifestation of rheumatic fever. Although the child may havea history of vomiting, this finding would not be specific to rheumatic fever.4. Incorrect: A cough is not an associated symptom of rheumatic fever. The time framefor the development of rheumatic fever is not appropriate if the cough started 1 weekearlier, even if it had been associated with an upper respiratory streptococcal infection.

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NCLEX Health Care Assessment Practice Exam With Answers (1200 Solved Questions) - Page 16 preview image

The primary healthcare provider has prescribed phenytoin 100 mg intravenous push(IVP) stat through a non-tunneled central venous catheter lumen with no othermedication or fluid infusing. In what order should the nurse administer this prescription?Cleanse access portConnect 10 mL normal saline to access portGently aspirate for bloodFlush saline using push-pause methodAdminister phenytoinFlush with normal saline, then with heparin -Proper administration of medicationthrough a non-tunneled central venous catheter:First, cleanse the access port. Failure to cleanse the port first would increase the risk ofinfection from contamination when the port is accessed.Second, connect 10 mL normal saline to access port. This 10 mL syringe will beconnected to first check patency and then for flushing prior to medication administration.At least 10 mL of normal saline is used to flush central lines.Third, gently aspirate for blood.Fourth, flush saline using push-pause method. This method is utilized to help clear thecatheter of blood or drugs that could potentially adhere to the internal surface of thecentral line catheter. This creation of turbulent flow from pausing then pushing causesswirling of the fluid and theoretically removes blood and medications from the walls ofthe catheter, which reduces the risk of occlusion in the catheter.Fifth, administer phenytoin.Sixth, flush with normal saline, then with heparin. Standard flushing solutions used mostfrequently for central venous access devices include normal saline and/or heparinizedsodium chloride. Low dose heparin flushes are generally used to fill the lumen of thecentral line between use in order to prevent thrombus formation and maintain patency ofthe catheter for a longer period of time.An elderly male, diagnosed with chronic renal failure and depression, lives alone. Whichquestion should the home health nurse ask first when assessing this client?1. Have you had suicidal thoughts in the past?2. How are you feeling today?3. Have you had thoughts of harming yourself?4. Do you have guns in your home? -3. Correct: Suicide assessment should beginwith direct questions about the presence of suicidal thinking. The nurse shouldrecognize that elderly men are at higher risk for committing suicide, especially thosewith a history of depression, chronic illness and isolation.

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