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o Option D: Assessing for redness and swelling (signs of deep venous thrombosis {DVT}) requires additional education and is still appropriate to the professional nurse.
Correct Answer: A, B, & C. The experienced nursing assistant would know how to reposition the patient and how to reapply compression boots and would remind the patient to perform activities he has been taught to perform.
NCLEX-RN Exam Pack Set 4 (
Questions & Answers Updated
1. 1. Question
Which action(s) should you delegate to the experienced nursing assistant when caring for a patient with a thrombotic stroke with residual left-sided weakness? Select all that apply.
o A. Assist the patient to reposition every 2 hours.
o B. Reapply pneumatic compression boots.
o C. Remind the patient to perform active ROM.
o D. Check extremities for redness and edema.
- Question The patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant who will feed the patient?
o A. Position the patient sitting up in bed before you feed her.
o B. Check the patient’s gag and swallowing reflexes.
o Option B: The nursing assistant is not trained to assess gag or swallowing reflexes. o Option C: The patient should not be rushed during feeding. o Option D: A patient who needs to be suctioned between bites of food is not handling secretions and is at risk for aspiration. This patient should be assessed further before feeding.
Correct Answer: A. Position the patient sitting up in bed before you feed her. Positioning the patient in a sitting position decreases the risk of aspiration.
Correct Answer: B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.
o C. Feed the patient quickly because there are three more waiting.
o D. Suction the patient’s secretions between bites of food.
You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patient complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Which collaborative intervention must be accomplished first?
o A. Administer codeine 15 mg orally for the patient’s headache.
o B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.
o C. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever.
o D. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure.
o Option A: Documentation is a nursing responsibility. o Option C: Patient education must be accomplished by the registered nurse because it is within their scope of practice. o Option D: Planning of care is a complex activity that requires RN level education and scope of practice.
Correct Answer: B & E Administration of medications that are not a high risk is included in LPN education and scope of practice. Collection of data about the seizure activity may be accomplished by an LPN/LVN who observes initial seizure activity. An LPN/LVN would know to call the supervising RN immediately if a patient started to seize.
A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic- clonic seizures. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising? Select all that apply.
o A. Document the onset time, nature of seizure activity, and postictal behaviors for all seizures.
o B. Administer phenytoin (Dilantin) 200 mg PO daily.
o C. Teach the patient about the need for good oral hygiene.
o D. Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.
o E. Gather information about the seizure activity
While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these nursing actions will you implement first if the patient has a seizure?
is uncomfortable for a patient with photophobia. Focus: Prioritization
o Option B: Administration of lorazepam should be the next action since it will act rapidly to control the seizure. o Option A: Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea. o Option D: Checking the level of consciousness is not appropriate during the seizure, because generalized tonic-clonic seizures are associated with a loss of consciousness.
Correct Answer: C. Turn the patient to the side and protect the airway. The priority action during a generalized tonic-clonic seizure is to protect the airway.
o A. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute.
o B. Administer lorazepam (Ativan) 1 mg IV.
o C. Turn the patient to the side and protect the airway.
o D. Assess level of consciousness during and immediately after the seizure.
A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the outpatient clinic. Which information obtained during his chart review and assessment will be of greatest concern?
o A. The gums appear enlarged and inflamed.
o B. The white blood cell count is 2300/mm3.
o C. Patient occasionally forgets to take the phenytoin until after lunch.
o D. Patient wants to renew his driver’s license next month.
All of these nursing activities are included in the care plan for a 78-year-old man with Parkinson’s disease who has been referred to your home health agency. Which ones will you delegate to a nursing assistant (NA)? Select all that apply.
o A. Check for orthostatic changes in pulse and blood pressure.
o B. Monitor for improvement in tremor after levodopa (L- dopa) is given.
o C. Remind the patient to allow adequate time for meals.
o D. Monitor for abnormal involuntary jerky movements of extremities.
o E. Assist the patient with prescribed strengthening exercises.
o F. Adapt the patient’s preferred activities to his level of function.
usually on one side of the head. It’s often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so severe that it interferes with daily activities. o Option B: Preoperative teaching must be done but it is not the nurse’s priority. A craniotomy is the surgical removal of part of the bone from the skull to expose the brain. Specialized tools are used to remove the section of bone called the bone flap. The bone flap is temporarily removed, then replaced after the brain surgery has been done. o Option C: The patient should be assessed soon, but does not have an urgent need. In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between your brain and the rest of your body. Eventually, the disease can cause permanent damage or deterioration of the nerves.
Correct Answer: A. Check for improvement in resident memory after medication therapy is initiated. LPN education and team leader responsibilities include checking for the therapeutic and adverse effects of medications. Changes in the residents’ memory would be communicated to the RN supervisor, who is responsible for overseeing the plan of care for each resident. o Option B: Assessment for changes on the Mini-Mental State Examination is an RN responsibility.
As the manager in a long-term-care (LTC) facility, you are in charge of developing a standard plan of care for residents with Alzheimer’s disease. Which of these nursing tasks is best to delegate to the LPN team leaders working in the facility?
o A. Check for improvement in resident memory after medication therapy is initiated.
o B. Use the Mini-Mental State Examination to assess residents every 6 months.
o C. Assist residents to the toilet every 2 hours to decrease the risk for urinary intolerance.
o D. Develop individualized activity plans after consulting with residents and family.
o Option B: Evaluation of patient response to medication requires the knowledge of an experienced RN. o Option D: Development and individualizing the plan of care require RN-level education and scope of practice.
Correct Answer: A, C, & E NA education and scope of practice includes taking pulse and blood pressure measurements. In addition, NAs can reinforce previous teaching or skills taught by the RN or other disciplines, such as speech or physical therapists.
o Option B: Increased blood glucose levels is an expected side effect but not an emergency. o Option C: The continued headache also indicates that the ICP may be elevated, but it is not a new problem. o Option D: The weight gain is a common adverse effect of dexamethasone that may require treatment, but is not an emergency.
Correct Answer: A. The patient does not recognize family members. The inability to recognize a family member is a new neurologic deficit for this patient, and indicates a possible increase in intracranial pressure (ICP). This change should be communicated to the physician immediately so that treatment can be initiated.
You are caring for a patient with recurrent glioblastoma who is receiving dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns you the most?
o A. The patient does not recognize family members.
o B. The blood glucose level is 234 mg/dL.
o C. The patient complains of a continued headache.
o D. The daily weight has increased 1 kg.
o Option C: Ineffective Therapeutic Regimen Management is not a priority as based on the statement. o Option D: Risk for falls is not the priority at this time. Falls are a leading cause of broken hips and other serious injuries in the elderly, and those with Alzheimer’s are at particularly high risk of falling. Problems with vision, perception, and balance increase as Alzheimer’s advances, making the risk of a fall more likely.
o Option A: This can be done after the treatment for any intracranial lesion has been implemented. o Option C: This intervention should be done but is not the priority. o Option D: Administration of phenytoin should be implemented as soon as possible, but the initial nursing activities should be directed toward treatment of any intracranial lesion.
Correct Answer: B. Transfer to radiology for a CT scan. The patient’s history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the patient to surgery to have the hematoma evacuated.
A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago, but “he didn’t have a scratch afterward.” She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first?
o A. Place on the hospital alcohol withdrawal protocol.
o B. Transfer to radiology for a CT scan.
o C. Insert a retention catheter to straight drainage.
o D. Give phenytoin (Dilantin) 100 mg PO.
Which of these patients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit?
o A. A 26-year-old patient with a basilar skull structure who has clear drainage coming out of the nose.
o B. A 42-year-old patient admitted several hours ago with a headache and diagnosed with a ruptured berry aneurysm.
o Option A: Food, medicines, and other things ingested can affect the consistency or color of the stool. o Option B: A formed stool may occur a week after the surgery. o Option D: The stool from a colostomy can be thin or thick liquid, or semiformed.
Correct Answer: C. Loose, bloody Normal bowel function and soft-formed stool usually do not occur until around the seventh day following surgery. The stool consistency is related to how much water is being absorbed.
Nurse Michelle should know that the drainage is normal four (4) days after a sigmoid colostomy when the stool is:
o A. Green liquid
o B. Solid formed
o C. Loose, bloody
o D. Semiformed
that struggle with severe anxiety or anxiety disorders. Tension headaches can be described as a heavy head, migraine, head pressure, or feeling like there is a tight band wrapped around their head. These headaches are due to a tightening of the neck and scalp muscles. o Option C: Hopelessness should be addressed as part of the nursing care plan, but it does not require urgency. Hopelessness can result when someone is going through difficult times or unpleasant experiences. A person may feel overwhelmed, trapped, or insecure, or may have a lot of self-doubts due to multiple stresses and losses. He or she might think that challenges are unconquerable or that there are no solutions to the problems and may not be able to mobilize the energy needed to act on his or her own behalf. o Option D: The risk for side effects is accurate, but it is not as urgent as the issue of pain, which is often incapacitating. Focus: Prioritization
o Option B: The client would not be able to see the call light on his right side because he can only see the left side. o Option C: Only the right half of the visual world can be seen by the client. o Option D: The most ideal place to put the call light is on the client’s right side to avoid any injuries.
Correct Answer: A. On the client’s right side The client has left visual field blindness. The client will see only from the right side. Homonymous hemianopsia is a condition in which a person sees only one side?right or left?of the visual world of each eye. The person may not be aware that the vision loss is happening in both eyes, not just one. An injury to the right part of the brain produces loss of the left side of the visual world of each eye.
Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia?
o A. On the client’s right side
o B. On the client’s left side
o C. Directly in front of the client
o D. Where the client like
A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse?
o A. Check respiration, circulation, neurological response
o B. Align the spine, check pupils, and check for hemorrhage
o C. Check respirations, stabilize the spine, and check the circulation
o Option B: A patent airway has been established the moment the nurse declares that the client is unconscious and calls for help. o Option C: This action can be done if there is an unwitnessed, unmonitored, unstable ventricular tachycardia when a defibrillator is not immediately available. o Option D: Administering two quick blows to the precordium is less effective and its use is more limited ideally.
Correct Answer: A. Call for help and note the time Having established, by stimulating the client, that the client is unconscious rather than sleep, the nurse should immediately call for help. This may be done by dialing the operator from the client’s phone and giving the hospital code for cardiac arrest and the client’s room number to the operator, or if the phone is not available, by pulling the emergency call button. Noting the time is important baseline information for cardiac arrest procedures.
Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse’s next action?
o A. Call for help and note the time
o B. Clear the airway
o C. Give two sharp thumps to the precordium and check the pulse
o D. Administer two quick blows
o Option B: AV conduction is not increased through nitroglycerin, and an increased heart may increase the blood pressure, which is contrary to the desired effects of nitroglycerin, o Option C: Contractility is not significantly affected by nitroglycerin. The desired vasodilatory effect increases perfusion and does not directly reduce oxygen consumption.
o Option A: Uninterrupted sleep for 8 hours is good, but it does not directly affect the production of acid. o Option B: Monitoring vital signs every 2 hours is unnecessary. It can be monitored every shift or every 4 hours. o Option D: Milk could aggravate the production of hydrochloric acid. The nutrients in milk, particularly fat, may stimulate the stomach to produce more acid.
Correct Answer: C. Make sure that the client takes food and medications at prescribed intervals. Food and drug therapy will prevent the accumulation of hydrochloric acid or will neutralize and buffer the acid that does accumulate.
Nurse Monett is caring for a client recovering from gastrointestinal bleeding. The nurse should:
o A. Plan care so the client can receive 8 hours of uninterrupted sleep each night.
o B. Monitor vital signs every 2 hours.
o C. Make sure that the client takes food and medications at prescribed intervals.
o D. Provide milk every 2 to 3 hours.
A male client was on warfarin (Coumadin) before admission and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?
o A. Stop the I.V. infusion of heparin and notify the physician.
o B. Continue treatment as ordered.
o C. Expect the warfarin to increase the PTT.
o Option A: The client may experience a severe headache if kept in a side-lying position. Spinal headaches are caused by leakage of spinal fluid through a puncture hole in the tough membrane (dura mater) that surrounds the spinal cord. o Option C: A supine position for 4 to 12 hours would prevent seepage of cerebrospinal fluid from the puncture site. There is no need to flex the knees.
Correct Answer: B. Flat on back To avoid the complication of a painful spinal headache that can last for several days, the client is kept flat in a supine position for approximately 4 to 12 hours postoperatively. Headaches are believed to be caused by the seepage of cerebrospinal fluid from the puncture site. By keeping the client flat, cerebral spinal fluid pressures are equalized, which avoids trauma to the neurons.
A client has undergone spinal anesthetic, it will be important that the nurse immediately position the client in:
o A. On the side, to prevent obstruction of the airway by the tongue
o B. Flat on back
o C. On the back, with knees, flexed 15 degrees
o D. Flat on the stomach, with the head, turned to the side
o Option A: If the application of the drainage appliance is delayed after surgery, the skin around the stoma would be most likely irritated and damaged due to the digestive enzymes present in the secretions of the drainage. o Option C: An ileostomy needs a drainage bag before it starts to function so that the secretions from the drainage would be caught up by the bag, preventing contamination of the skin. o Option D: The client would have irritated, damaged skin once the drainage comes out from the stoma and comes into contact with the skin.
o Option A: A blood pressure level of 110/70 mmHg is within normal limits. Increased intracranial pressure is caused by an increase in blood pressure. o Option B: A pulse rate of 95 bpm is within the normal range. When arterial blood pressure exceeds the intracranial pressure, blood flow to the brain is restored. The increased arterial blood pressure caused by the CNS ischemic response stimulates the baroceptors in the carotid bodies, thus slowing the heart rate drastically often to the point of bradycardia. o Option D: Anorexia is not related to increased intracranial pressure. Anorexia is an eating disorder characterized by abnormally low body weight, an intense fear of gaining weight, and a distorted perception of weight.
Correct Answer: C. The client is oriented when aroused from sleep and goes back to sleep immediately. This finding suggests that the level of consciousness is decreasing.
While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?
o A. Blood pressure has decreased from 160/90 to 110/70.
o B. Pulse is increased from 87 to 95, with an occasional skipped beat.
o C. The client is oriented when aroused from sleep and goes back to sleep immediately.
o D. The client refuses dinner because of anorexia.
o Option D: Lying on his stomach would be uncomfortable to a postoperative patient, and would cause a painful spinal headache from the spinal anesthesia.
