Fundamentals Quiz # 3 | NCLEX

An infant is experiencing respiratory depression immediately after a vaginal delivery using epidural analgesia with morphine.  The health care provider prescribes 0.1 mg/kg naloxone IM to be given STAT once.  The client weighs 3600 grams and naloxone 0.4 mg/mL is available.  How many milliliters will the nurse administer?  Record your answer using one decimal place.

Ten minutes after an infusion of packed red blood cells (PRBCs) is initiated through a central venous catheter (CVC), the client has shortness of breath and slight chest tightness.  What initial actions would be appropriate for the nurse to complete?  Select all that apply.

A postoperative client with obesity and diabetes mellitus has an abdominal incision and is at risk for poor wound healing.  Which interventions should the nurse include in the plan of care to promote wound healing and prevent dehiscence?  Select all that apply.

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client.  The client explains that the bruises are from bumping into furniture and the wall in the wheelchair.  What is the priority nursing action?

As the nurse begins to assist with ambulation of a 9-year-old who is one day post appendectomy, the child cries out, “It hurts too much.  I can’t do it.”  What is the first action by the nurse?

A student nurse assesses and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus (MRSA) who is on contact precautions.  The registered nurse intervenes when the student performs which action?

A nurse prepares to administer an intermittent enteral feeding via nasogastric tube to a client with a prescription for gastric residual checks before each feeding.  The nurse obtains a gastric residual volume of 80 mL.  Which action should the nurse perform next?

The charge nurse is notified that a client is being admitted with a diagnosis of active shingles with a disseminated rash.  Which room assignment is most appropriate for this client?

A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch.  What should be the nurse’s initial action?

An elderly client is brought to the emergency department with lethargy, chills, and sharp chest pain with deep breathing.  Pulse oximeter shows 93% on room air and respirations are 24/min.  What is the nurse’s initial action?

An unlicensed assistive personnel (UAP) is aiding a client recovering from a right-sided cerebrovascular accident with resulting mild oropharyngeal dysphagia.  The client has been placed on a dysphagia diet.  Which actions require intervention by the registered nurse?  Select all that apply.

The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with urinary tract infection.  To promote client safety, which intervention is most important for the charge nurse to implement?

A nurse is reviewing the most recent laboratory results of a client on the telemetry floor.  The client is currently asymptomatic, and the telemetry monitor indicates sinus rhythm.  Which of the following critical values is most likely due to laboratory error?

An adolescent client is brought to the emergency department after being in a serious motor vehicle crash.  The client is undergoing cardiopulmonary resuscitation.  The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing.  Which is an example of the ethical principle of beneficence when responding to the client’s family?

The charge nurse is planning assignments for the day.  Which clients will require the nursing staff to institute contact precautions?  Select all that apply.

An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis.  The client becomes angry with the unlicensed assistive personnel (UAP), who is trying to help the client bathe.  Later, the UAP expresses frustration with the client to the registered nurse.  Which statement would be the most appropriate response?

A nurse prepares a client for knee arthroscopy requiring general anesthesia.  Which actions should the nurse complete?  Select all that apply.

One unit of packed RBCs (PRBCs) is prescribed for a client experiencing complications of sickle cell anemia.  Which of the following actions by the nurse are appropriate?  Select all that apply.  See the exhibit button for additional information.

The 70-year-old client with type 2 diabetes and hypertension is scheduled for ureteral stent removal in 2 hours.  The preoperative protocol ECG is done in the inpatient unit, and results indicate a “possibly acute” ST segment elevation.  What action is most important for the nurse to take?

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision.  Which actions should the nurse take?

A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV.  What is the nurse’s priority action?

A pediatric client weighing 66 lb is prescribed ibuprofen 5 mg/kg by mouth every 6 hr PRN for fever.  It is available as an oral solution of 20 mg/mL.  How many milliliters (mL) of ibuprofen should be given to the client per dose?  Record your answer using one decimal place.

A nurse on the telemetry unit is preparing client medications in the medication room at the nurse’s station.  The nurse should perform which actions to be consistent with client safety practices related to medication administration?  Select all that apply.

A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases.  Which action is appropriate currently?

A nurse is teaching a parent of an infant about administration of an oral medication.  What should be included in the teaching?  Select all that apply.

An unconscious client is brought to the emergency department by the paramedics after being hit by a car.  An emergency craniotomy is required.  The client has no identification.  What action should be taken next?

The charge nurse must assign rooms to 4 clients who are scheduled for admission.  Which client has the highest priority for a private room assignment?

The charge nurse in the cardiac intensive care unit responds to a client room where a resuscitation effort is in progress.  The client’s immediate family member refuses to leave the room.  How should the charge nurse handle this situation?

The charge nurse is instructing a new graduate nurse on performing postmortem care.  Which client situations might cause the nurse to delay or not perform postmortem care?  Select all that apply.

The nurse is teaching a postoperative client to use a volume-oriented incentive spirometer device.  Place the teaching steps in the proper order. All options must be used. Fill in the blank with the correct order (example: 7543).

• 1. Exhale normally and place the mouthpiece in the mouth
• 2. Exhale slowly around the mouthpiece
• 3. Hold breath for at least 2-3 seconds
• 4. Inhale deeply, until piston is elevated to predetermined level
• 5. Seal lips tightly on mouthpiece

The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity.  Which of the following client statements indicate that teaching has been effective?  Select all that apply.

The client has a dislocated shoulder and the nurse is assisting the health care provider with bedside procedural moderate sedation (conscious sedation).  During the procedure, the client becomes restless and cries out “Help me!”  What action should the nurse take first?

The nurse is preparing to irrigate the ears of a 67-year-old client with impacted cerumen.  Place the following steps for ear irrigation in the correct order. All options must be used. Fill in the blank with the correct order (example: 7543).

• 1. Assess the client for fever, ear infection, or tympanic membrane injury
• 2. Gently irrigate the ear canal with a slow, steady flow of solution
• 3. Place a towel and an emesis basin under the ear
• 4. Place the client in a sitting position with the head tilted toward the affected ear
• 5. Straighten the ear canal by pulling the pinna up and back

A student nurse prepares to change a large wet-to-damp sterile wound dressing and uses a disposable moisture-proof sterile drape to set up the sterile field.  The precepting nurse intervenes when the student performs which action?

The nurse observes an ambulating client begin to experience a tonic-clonic seizure.  Which nursing actions should be implemented immediately?  Select all that apply.

A nurse preparing to insert a peripheral IV catheter dons clean gloves, applies a tourniquet to the client’s arm, and identifies a venipuncture site.

Place the remaining steps in the   order.
All options must be used.
Write your answer as a sequence of numbers (e.g., 123456).

Options:

1. Advance the catheter hub while retracting the style.

2. Anchor the vein by holding the skin taut.

3. Apply a transparent dressing
4. Cleanse the selected site using an antiseptic swab

5. Insert the needle bevel-side up until blood return is observed

6. Remove the stylet and attach the extension or infusion set

The nurse plans to start an IV line to infuse 2 units of packed red blood cells for a stable 42-year-old client with a gastrointestinal bleed.  Which IV catheter size is best?

The nurse is providing postmortem care for a client who has died after a long hospitalization.  The client had a do-not-resuscitate prescription in place at the time of death.  Which of the following interventions should the nurse include during postmortem care in preparation for transfer to the funeral home?  Select all that apply.

The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness.  The client is flushed, sweating, nauseated, and slightly tachycardic.  Which action is most appropriate currently?

The nurse plans to administer 9:00 AM medications via the nasogastric (NG) route to a client with an NG tube.  The nurse contacts the primary health care provider (PHCP) to clarify which prescriptions that are contraindicated using this route?  Select all that apply.

The nurse on the IV therapy team is making rounds in the intensive care unit on clients with central venous catheters.  Which central line should be removed earliest to prevent infection?

The nurse is preparing to transfer a client from the bed to the chair for the first time.  The client has generalized weakness and is unable to follow instructions.  Which would be the most appropriate method for the nurse to use to transfer this client safely?

The nurse prepares to administer medications to a client.  Which of the following client data are acceptable for use as client identifiers?  Select all that apply.

A student nurse is preparing to administer the hepatitis B vaccine to a newborn.  Which statement by the student nurse requires the preceptor to provide further teaching?

An adult client has developed diarrhea 24 hours after the initiation of total enteral nutrition via nasogastric tube.  The client is receiving a hypertonic formula.  What is the best nursing action?

An elderly client with end-stage renal disease who has refused dialysis is admitted to a long-term care facility for rehabilitation following hospitalization.  The next day, the client becomes agitated and says to the nurse, “I’ve got to get back home to my things.  I have so much to do.”  Which is the most likely interpretation of this client’s behavior?

An adult client is admitted with back pain and found to have a metastatic tumor on the spine.  The health care provider (HCP) explains that the client has few months to live and is likely to become totally paralyzed below the waist soon.  The next day, the client tells the nurse of wanting to be discharged despite the HCP’s recommendation that the client stay a few more days.  Which is the most appropriate initial response by the nurse?

It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip.  The client has been disoriented to time, place, and person since admission.  The client moans frequently and grimaces when moving.  He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530.  He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed.  The client’s spouse and child are to arrive at 0900.  Which intervention should the nurse carry out first?

The nurse recognizes that which factors place a client at increased risk for falls?  Select all that apply.

The registered nurse observes a graduate nurse who is inserting a small-bore nasojejunal feeding tube.  Which action by the graduate nurse requires intervention by the registered nurse?