NCLEX Questions
A charge nurse is observing a newly licensed RN irrigate a patient's
ear, which is impacted with cerumen. Which of the following
actions requires the charge RN to intervene? A. Visualizing the
eardrum before irrigating B. Instilling 50 mL of fluid with each
irrigation C. Using firm, continuous pressure while irrigating D.
Warming the irrigation fluid to at least 37C (98F) - B. Instilling
50 mL of fluid with each irrigation (RAT) When irrigating a
patient's ear the RN should use no more than 5 - 10 mL of
irrigating fluid at a time to decrease the chance of stimulating the
vestibular nerve of the inner ear, which would result in N&V or
dizziness. A charge nurse is preparing an educational session for a
group of new nurses to review patient rights under the law. Which
of the following statements should the RN make? A. "Information
regarding clients should remain confidential until after their death."
B. "Failure to report suspected maltreatment or neglect of a
disabled adult is a felony in all states." C. "As long as client identity
is disguised, their health information can be shared between
professionals on the internet." D. "In the event a client threatens
harm to others, medications can be administered without consent."
- D. "In the event a client threatens harm to others, medications
can be administered without consent." (RAT) The charge nurse
should inform the participants that their primary commitment is
to the client and their priority is always to advocate for and
protect their health and safety. During an emergency situation, if
the client is threatening harm to self or others, medications can be
administered without the client's consent and without a court
,order. (NOTE) Because laws vary from state to state, nurses should
become familiar with the requirements as it relates to reporting
neglect or maltreatment of clients. The nurse should inform the
participants that in most states failure to report the suspected
neglect, physical maltreatment, or exploitation of a disabled adult
results in a misdemeanor charge - (B) is incorrect. A charge nurse
is teaching the patient how to identify the difference between
antisocial personality d/o and narcissistic personality disorder.
Please use the mnemonic CALLOUS MAN to describe antisocial
personality d/o. - C - conduct d/o before age 15yr, charming A -
arrests L - lies L - lacks a superego & empathy for others O -
obligations not honored U - unstable, can't plan ahead S - sense of
entitlement, seductive, not safe M - manipulative, $ problems &
irresponsible A - aggressive and assaultive N - not calm, actions
are impulsive A charge RN is teaching a group of unit nurses about
the policy for patients who have a history of MRSA. Which of the
following information should the nurse include? A. A patient who
has a history of MRSA will need antibiotics B. A patient who has a
Hx of MRSA can develop immunity to the infection C. A patient
who has a Hx of MRSA requires a protective environment D. A
patient who has a Hx of MRSA can still transmit the infection - D.
A patient who has a Hx of MRSA can still transmit the infection A
charge RN on a peds unit receives the lab results for several
patients. Which of the following results should the nurse report to
the provider? A. A patient who has DKA and a blood sugar of 375
mg/dL B. A patient who has leukemia and a Hct of 32% - A. A
patient who has DKA and a blood sugar of 375 mg/dL (RAT) The
initial goal of therapy for DKA is a BS below 240 mg/dL. To
accomplish this, the patient should receive regular insulin via
continous IV infusion, and the RN should monitor the blood sugar
hourly. The RN should report the patients result so that the MD
can adjust the insulin dosage. (NOTE) (B) is incorrect because a
,decreased Hct is an expected finding with leukemia A community
health nurse is performing patient triage while participating in a
disaster drill. The RN should recommend that which of the
following patients receives treatment first? A. Hemothorax B. Open
humerus fracture C. Multiple deep abrasions on the arms and face
D. Superficial partial - thickness burns on both legs - A.
Hemothorax (RAT) a hemothorax if life-threatening, but with chest
- tube insertion and stabilization the patient is likely to survive.
(NOTE) A patient who has multiple deep abrasions does not have
an immediate threat to life and can wait for treatment; therefore,
the RN should recommend that another patient receive treatment
first. A hospice nurse is visiting with the family member of a
patient. The family member states that the patient has insomnia
almost nightly. Which of the following practices should the RN
identify as contributing to the patients insomnia? A. The patient
watches TV in her bed during the day B. The patient drinks warm
milk before bedtime C. The patient goes to bed at 2200 every
night D. The patient gets up to use the bathroom once during the
night - A. The patient watches TV in her bed during the day (RAT)
To promote sleep, the patient should avoid watching TV in bed. She
should be in bed only for sleep or sexual activities. (NOTE) Warm
milk provides L-tryptophan, an amino acid that promotes sleep (B)
is incorrect A nurse in a pediatric emergency dept is caring for
four patients. The nurse should suspect possible abuse with which of
the following patients? A. A 14-month-old toddler who has
recently learned to walk and has many bruises on bony
prominences in various stages of healing B. A 9-month-old infant
who reportedly nearly drowned after climbing into the tub and
turning on the water C. A 6-year-old toddler who has a fracture
of the tibia and fibula, which reportedly occurred while riding a
bicycle D. A 3-year-old toddler who has burns in a splash pattern
over the face and chest, reportedly sustained when a tablecloth was
, pulled, spilling a teapot - B. A 9-month-old infant who reportedly
nearly drowned after climbing into the tub and turning on the
water (RAT) The nurse should identify that, while a 9-month-old
might have the ability to climb into the tub, it is unlikely that he
could turn the water on. The nurse should suspect possible abuse
because the reported cause of the accident seems inconsistent with
the developmental abilities of most 9-month-old infants. (NOTE)
Toddlers have recently mastered walking and experience many falls
and collisions. Because the bruises are in various stages of healing
and are located over bony prominences, this likely indicates falling
on several occasions (A) is incorrect A nurse is assessing a patient
who has a psychotic d/o and a new script for haloperidol. The
patient is pacing in the hallway and states, " I can't seem to sit
still." Which of the following extrapyramidal side effects is the
patient likely experiencing? A. Dystonia B. Parkinsonism C. Tardive
dyskinesia D. Akathisia - D. Akathisia (RAT) Akathisia is an
extrapyramidal adverse effect characterized by the client's report
of a sense of inner restlessness and by observable behaviors such as
pacing, rocking forward and backward in a chair, and constant
foot tapping. (NOTE) Tardive dyskinesia is an irreversible finding
characterized by involuntary movements of extremities (C) is
incorrect A nurse is assessing a patient who has multi - resistant
tuberculosis and takes ethambutol. The nurse should identify which
of the following findings as an adverse effect of this medication? A.
Mottling of the extremities B. Orange-red urine and bodily
secretions C. Yellowing of the sclera D. Loss of red/green color
discrimination - D. Loss of red/green color discrimination (RAT)
Ethambutol is an antitubercular medication that impairs RNA
synthesis. A common adverse reaction is the loss of red/green color
discrimination due to optic neuritis. The nurse should notify the
provider of this findings and expect a prescription to discontinue
the medication. A nurse is assessing a patient who is receiving