NCLEX EXAM REVIEW

A 64-year-old client has just had total hip replacement surgery. The physician orders heparin 8,000 units to be administered subcutaneously. The label on the heparin vial reads: "Heparin 10,000 units/ml." How many milliliters of heparin should the nurse draw up in the syringe to administer the correct dose? Record your answer using one decimal place. Your Response: • 0.8 Correct response: • 0.8 Explanation: The following formula is used to calculate drug dosages: dose on hand/quantity on hand = dose desired/X. In this example, the equation is as follows: 10,000 units/ml = 8,000 units/X; X = 0.8 ml. Question 2 See full question A nurse records a client’s finger stick blood glucose level and gives 2 units of regular insulin as ordered. At the next scheduled blood glucose assessment, the nurse realizes that he/she previously tested and administered the insulin to the wrong client. What is the nurse’s priority action related to this incident? You Selected: • Assess both clients and call the appropriate physicians to notify them of the errors. Correct response: • Assess both clients and call the appropriate physicians to notify them of the errors. Explanation: Remediation: Question 3 See full question The unit secretary who transcribes the health care provider’s (HCP’s) prescriptions asks the nurse to interpret an illegible prescription. The nurse should clarify the prescription with the: You Selected: • pharmacist. Correct response: • HCP. Explanation: Remediation: Question 4 See full question A parent asks the nurse about head lice (pediculosis capitis) infestation during a visit to the clinic. Which symptom should the nurse tell the parent is most common in a child infected with head lice? You Selected: • itching of the scalp Correct response: • itching of the scalp Explanation: Remediation: Question 5 See full question The nurse notes that a neonate’s Apgar score at 5 minutes was 9. The nurse interprets this as indicating which information about the neonate? You Selected: • The neonate was in stable condition. Correct response: • The neonate was in stable condition. Explanation: Remediation: Question 6 See full question The nurse tells the student nurse that they will be visiting a family that experienced a stillbirth at 38 weeks gestation. The student nurse begins to cry and says, “I can’t possibly participate in the visit. I just found out I am pregnant. I can’t deal with the thought of losing a baby in pregnancy.” What is the nurse’s most appropriate response to the student nurse? You Selected: • Tell the student nurse it is okay to cry and encourage her to talk about the way she is feeling. Correct response: • Tell the student nurse it is okay to cry and encourage her to talk about the way she is feeling. Explanation: Question 7 See full question A client with pernicious anemia asks why she must take vitamin B12 injections forever. Which is the nurse's best response? You Selected: • “The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient amounts of a factor that allows the vitamin to be absorbed.” Correct response: • “The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient amounts of a factor that allows the vitamin to be absorbed.” Explanation: Remediation: Question 8 See full question A client who is being treated for nonhealing diabetic foot ulcers tells the nurse angrily, “I am so frustrated with my doctors. The wound care doctor tells me this will not heal and I need to have my toes amputated and another doctor tells me I need to keep going with the antibiotics and dressing changes so I can save my foot. I just want to go home!” After listening to the client’s concerns, the nurse should: You Selected: • contact the client’s case manager to set up a care conference. Correct response: • contact the client’s case manager to set up a care conference. Explanation: Remediation: Question 9 See full question Guaifenesin 300 mg four times a day has been prescribed as an expectorant. The dosage strength of the liquid is 200 mg/5 mL. How many milliliters should the nurse administer for each dose? Record your answer using one decimal place. Your Response: • 1.5 Correct response: • 7.5 Explanation: 300 mg/X = 200 mg/5 mL X = 7.5 mL. Remediation: Question 10 See full question While preparing medication for a client in labor, the observes a co-worker slipping a vial of morphine into their side pocket. The nurse should: You Selected: • notify the supervisor of the unit. Correct response: • notify the supervisor of the unit.