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- Question 1 1 out of 1 points Which dietary adjustments does the nurse recommend to an older adult client asking what changes she should institute to prevent or manage constipation? Correct Answer : C. “Include plenty of fiber.” Respons e Feedbac k : Older adults are prone to constipation. To manage or prevent constipation, teach the older client to drink eight glasses of water daily and to take in plenty of fiber. These guidelines are good for other clients as well. The other suggestions will not prevent or help manage constipation.Cognitive Level: ComprehensionNCLEX Blueprint: Health Promotion and Maintenance (Self-Care) - Question 2 0 out of 1 points The strategy to avoid medication errors endorsed by the Institute for Safe Medication Practices (ISMP) to differentiate products with look-alike names is referred to as Correct Answer : D. tallman lettering. Respons e Feedback :
T a l l m a n l e t t e r i n g i s a t e r m c o i n e d b y I S M P t o d e s cribe the practice of using unique letter characteristics of similar drug names known to have been confused with one another. Tallman lettering is used to differentiate
solution. The nurse working at this level of critical thinking makes choices based on careful examination of situations and alternatives; whether or not the physician is open to nursing input is not relevant.Cognitive level: applicationNCLEX Blueprint: Management of care
- Question 4 0 out of 1 points A nurse is caring for a client with stress incontinence. The nurse knows that which effect could have led to such a condition? Correct Answer : D. Loss of muscle tone Respons e Feedbac k : The nurse should know that the loss of muscle tone leads to stress incontinence in the elderly. The bladder muscles become weak, which also leads to urinary retention and dribbling as stress incontinence. Reduced bladder capacity, decreased urine formation, and reduced renal blood flow are common problems associated with the urinary system as a result of advanced age, but they do not specifically lead to stress incontinence.Cognitive Level: ApplicationNCLEX Blueprint: Management of Care - Question 5 1 out of 1 points A client will be undergoing palliative surgery. The client’s daughter asks what this means. What is the nurse’s best response? Correct A. Answer:
“The surgery will relieve the symptoms but will not cure your father.” Respons e Feedbac k: The purpose of palliative surgery is to improve the client’s quality of life by reducing or eliminating distressing symptoms. It does not cure a health problem and often does not prolong life.Cognitive level: comprehensionNCLEX Blueprint: Basic care and comfort
- Question 6 1 out of 1 points The nursery nurse identifies a newborn at significant risk for hypothermic alteration in thermoregulation because the patient is Correct Answer : B. low birth weight. Respons e Feedbac k : Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant born at term is not considered at significant risk. A well- nourished infant is not at significant risk.Cognitive Level: applicationNCLEX Blueprint: Physiological Adaptation - Question 7 1 out of 1 points The priority nursing intervention for a patient suspected to be hypothermic would be to Correct D. Answer:
A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine? Correct Answer : B. The client’s current weight-bearing status Respons e Feedbac k: This is the most important information the nurse needs to know to identify the safest method of transfer.Cognitive Level: ComprehensionNCLEX Blueprint: Reduction in Risk Potential
- Question 10 1 out of 1 points A client with tuberculosis asks the nurse if visitors will need to wear masks. What response by the nurse is most accurate? Correct Answer : A. “Everyone who enters your room must wear a mask to protect themselves from tuberculosis.” Respons e Feedbac k : Tuberculosis is highly contagious and spread by inhalation of airborne droplets. Airborne precautions would be initiated, requiring everyone to wear a special particulate respirator fit-tested mask. Individuals who have had tuberculosis in the past can be re-exposed and develop the active form of the disease again. Cognitive Level: ApplicationNCLEX Blueprint: Safety and Infection Control - Question 11 1 out of 1 points
The nurse is removing personal protective equipment (PPE). Which item should be removed first? Correct Answer : B. Gloves Respons e Feedbac k : The gloves are removed first because they are usually the most contaminated PPE and must be removed to avoid contamination of clean areas of the other PPE during their removal. The gown is removed second, then the mask or face shield, and finally, the hair covering.Cognitive level: applicationNCLEX Blueprint: Safety and infection control
- Question 12 1 out of 1 points For a client with a nursing diagnosis of excess fluid volume, the nurse is alert to which one of the following signs and symptoms? Correct Answer : B. Hypertensi on Respons e Feedbac k : Hypertension is a symptom of fluid volume excess. A weak, thready pulse is associated with fluid volume deficit. A bounding pulse is a symptom of fluid volume excess. Dry mucous membranes and flushed skin are both symptomatic of fluid volume deficit, not excess.Cognitive Level: ComprehensionNCLEX Blueprint: Physiological Adaptation - Question 13 1 out of 1 points
1 out of 1 points A client enters the emergency department (ED) with an injury to the wrist. In assessment, the nurse notes that the area is red, warm, and edematous. What is the nurse’s best action? Correct Answer : D. Assess circulation and elevate the extremity. Respons e Feedbac k : Blood flow to the area of injury is increased, causing edema. Edema at the site of injury protects the area from further injury by creating a cushion. A heating pad would enhance circulation to the area. Injecting pain medication and starting an IV infusion of a vasoconstricting drug would not be warranted. The best action is to elevate the extremity after ensuring adequate circulation.Cognitive Level: ApplicationNCLEX Blueprint: Reduction of Risk Potential
- Question 16 1 out of 1 points The nurse is instructing a client how to appropriately dress an infant in cold weather. Which of the following instructions would be most important for the nurse to include? Correct Answer : C. “Place a cap on the infant’s head.” Respons e Feedbac k : All interventions are correct, but because of the many blood vessels close to the skin surface in the head, infants lose approximately one third of their body heat through the head. Therefore, to prevent heat loss, it is most important to cover the head.Cognitive Level:
applicationNCLEX Blueprint: Health promotion and maintenance
- Question 17 0 out of 1 points Before the nurse brings the client to the operating room (OR) for knee surgery, the client reports to the nurse that he did not mark the operative knee with the surgeon. What is the priority action of the nurse? Correct Answer : C. Call the surgeon to mark the site with the client before transfer to the OR. Respons e Feedbac k: According to The Joint Commission, the surgical site should be marked by both the client and the surgeon before anesthesia is administered and surgery begins when the surgery involves a specific side.Cognitive Level: Application NCLEX Blueprint: Safety and Infection Control - Question 18 1 out of 1 points The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating a Correct Answer : C. portal of entry.
Correct Answer : C. "Talk with your physician about a calcium supplement." Respons e Feedbac k : Calcium strengthens the bones. A calcium supplement will help strengthen bones as they may be affected by aging, illness, or trauma. Walking several miles will help strengthen the bones but a calcium supplement is a good addition. Wearing proper shoes and standing slowly to prevent dizziness is important but they will not prevent fractures.Cognitive level: applicationNCLEX Blueprint: Pharmacology and Parental therapies
- Question 21 1 out of 1 points A client received general anesthesia for a surgical procedure. Which of the following assessments will the nurse complete first for this client? Correct Answer : C. Airway Respons e Feedbac k : Clients often require assistance in maintaining a patent airway after use of general anesthesia. The first assessment the nurse should make is that of the client’s airway. The surgical dressing, intravenous sites, and pain can be assessed after the client’s airway has been established.Cognitive Learning: ApplicationNCLEX Blueprint: reduction of risk - Question 22 1 out of 1 points
The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates Correct Answer : C. red, sweaty skin. Respons e Feedbac k : With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill.Cognitive Level: applicationNCLEX Blueprint: Physiological Adaptation
- Question 23 1 out of 1 points An 80-year-old male patient is in the ICU status fractured femur and MVA. You are making rounds and notice he is somnolent, with no response to verbal or physical stimulation. He has been on round the clock opioids doses q 4 hours. The best immediate course of nursing action is to Correct Answer : B. stop opioid; consider administering naloxone, call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status. Respons e Feedbac k : Stop opioid; consider administering naloxone; call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status; notify primary or anesthesia provider; and monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and
control inflammation. Respons e Feedbac k : Medications for RA are intended to control the inflammation that results from the body's hyperimmune response. Autoimmune diseases like RA are chronic and currently have no curative treatments. Autoimmune diseases like RA are caused by hyperimmune response. The immune system needs to be suppressed, not enhanced. While the medications used for RA might help with pain management, the goal of medication intervention is to manage the inflammation.Cognitive Level: ApplicationNCLEX Blueprint: Health promotion and Maintenance
- Question 26 1 out of 1 points A 25-year-old client is admitted to a healthcare facility with complaints of fever, vomiting, and watery diarrhea for 2 days. On examination, the client has dry skin, delayed skin turgor, and hypotension. What is the most likely nursing diagnosis? Correct Answer : D. Deficient fluid volume Respons e Feedbac k: Deficient fluid volume related to vomiting and diarrhea as evidenced by hypotension, dry mouth, dry skin, and delayed skin turgor is the most likely nursing diagnosis. Impaired urinary elimination is a nursing diagnosis only if there is a change in urine volume, which is not mentioned in this case. Acute gastroenteritis and infective diarrhea are not nursing diagnoses.Cognitive Level: ApplicationNCLEX Blueprint: Physiological adaptation - Question 27 0 out of 1 points The client’s temperature is 101.1°F. Which is the correct conversion
to centigrade? Correct Answer : B.
° C Respons e Feedbac k: To convert Fahrenheit to centigrade, subtract 32 from the temperature, and multiply by 5/9.Cognitive Level: applicationNCLEX Blueprint: Pharmacological and parental therapy
- Question 28 1 out of 1 points The nurse is providing discharge teaching for a client following a liver transplant. Which statement by the client indicates that additional teaching is needed? Correct Answer : A. “If I develop an infection, I should stop taking the steroid preparation.” Respons e Feedbac k : Immunosuppressive agents should not be stopped without consultation with the transplantation physician, even if an infection is present. Stopping immunosuppressive therapy endangers the transplanted organ.Cognitive level: applicationNCLEX Blueprint: Pharmacological and Parental therapy - Question 29 1 out of 1 points An 82-year-old client is admitted for dehydration. The daughter asks the nurse why this may have happened. The nurse educates
- Question 31 1 out of 1 points A nurse in a delivery room is assisting with the delivery of a newborn. After delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: Correct Answer : C. drying the infant with a warm blanket Respons e Feedbac k: Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress and heat from the newborn’s body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction. Convection occurs as air moves across the newborn’s skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface (indirect contact).Cognitive level: applicationNCLEX Blueprint: basic care and comfort - Question 32 0 out of 1 points Which of the following interventions would be appropriate for a client who has a fever? Choose all that apply. Correct Answers : A. Put an ice pack on the client’s neck and axillae. C.
Offer the client fluids to drink every 1 to 2 hours. Respons e Feedbac k : If ice packs are used, they are applied to the groin, neck, or axillae. A fever increases metabolic needs, so fluids are necessary to prevent dehydration. A blanket would help with heat retention. A tympanic thermometer is not appropriate when an accurate temperature is needed, as when a client has a fever.Cognitive level: applicationNCLEX Blueprinting: Health promotion and maintenance
- Question 33 1 out of 1 points A nurse in a delivery room is assisting with the delivery of a newborn. After delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: Correct Answer : C. drying the infant with a warm blanket Respons e Feedbac k : Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress and heat from the newborn’s body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction. Convection occurs as air moves across the newborn’s skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface (indirect contact).Cognitive level: applicationNCLEX Blueprint: basic care and comfort
