NGN NCLEX COMPLETE GUIDE QUESTIONS
AND ANSWERS CORRECT ANSWERS AND
SOLUTIONS
◉ The nurse notes the presence of a P wave, QRS complex, flattened
T waves, and occasional U waves on a client's cardiac monitor screen.
Fill in the correct missing information by choosing from the lists of
options in the drop-down menus. Answer: The nurse should suspect
Your Answer: hypokalemiaCorrect Answer: hypokalemia
because of the
Your Answer: flattened T waves and occasional U wavesCorrect
Answer: flattened T waves and occasional U waves
Rationale:Cardiac changes in hypokalemia include impaired
repolarization, resulting in a flattening of the T wave and eventually
the emergence of a U wave. Therefore, the nurse should suspect
hypokalemia. The incidence of potentially lethal ventricular
dysrhythmias is increased in hypokalemia. The nurse should
immediately assess the client's vital signs and cardiac status for signs
of hypokalemia. The nurse should also check the client's most recent
serum potassium level and then contact the primary health care
provider to report the findings and obtain prescriptions to treat the
hypokalemic state.
◉ The nurse is preparing a client for a chest x-ray and notes that the
client is wearing a religious medal on a chain around the neck. What
,should the nurse do with regard to this personal item? Click to
highlight the correct answer from the options provided. Answer: The
nurse should: (Select 1 option)
✓Ask the client if the chain and medal can be removed during the
procedure.
Because: (Select 1 option)
✓The chain and medal may have cultural significance.
Rationale:Before certain diagnostic procedures, it is typical to have a
client remove personal objects that are worn on the body because of
client safety and the possibility of compromising test results.
Therefore, the nurse should ask the client about the significance of
such an item and its removal because it may have cultural or spiritual
significance. If so, the nurse should ask the client if the item can be
either removed temporarily or placed on another part of the body
during the procedure if appropriate.
◉ While preparing a client for surgery scheduled in 1 hour, the client
states to the nurse: "I have changed my mind. I don't want this
surgery." Click to highlight the correct answer from the options
provided. Answer: The nurse should: (Select 1 option)
Cancel the surgery.
Contact the surgeon.
✓Discuss the client's concerns.
Call the identified support person.
Because: (Select 1 option)
Client consent is required prior to any procedure.
,✓Further questions or concerns should be determined and addressed.
Ethical considerations are important for a client undergoing surgery.
The nursing scope of practice places limitations on how the nurse can
respond.
Rationale:If the client indicates that he or she does not want a
prescribed therapy, treatment, or procedure such as surgery, the nurse
should further investigate the client's request. If the client indicates
that he or she has changed his or her mind about surgery, the nurse
should assess the client and explore with the client his or her concerns
about not wanting the surgery. The nurse would then withhold further
surgical preparation and contact the surgeon to report the client's
request so that the surgeon can discuss the consequences of not
having the surgery with the client. Further assessment and follow-up
related to the client's request need to be done. It is the client's right to
refuse treatment; however, further investigation is needed so the
interventions can be tailored to specific needs.
◉ The nurse notes that there has been an increase in the number of
intravenous (IV) site infections that developed in the clients being
cared for on the nursing unit. How should the nurse proceed to
implement a quality improvement program?For each action, click to
specify whether the action would be:
Indicated: an action that the nurse should take to resolve the problem
Non-essential: an action that the nurse could take without harming the
client, but the action would not be likely to address the problem
Contraindicated: an action that could harm the client and should not
be taken Answer: Collect identifying patient information
, Contraindicated
Note the mental status of the client
Non-essential
Note primary and secondary diagnoses of clients affected
Indicated
Note the type of IV catheter used
Indicated
Note the type of IV site dressings being used
Indicated
Note the medication types being infused
Non-essential
Note frequency of assessments of IV sites
Indicated
Note the expected duration of the IV site
Non-essential
Note care procedures to the IV site
Indicated
Note frequency of changing IV sites
Indicated
Rationale:Quality improvement, also known as performance
improvement, focuses on processes or systems that significantly
contribute to client safety and effective client care outcomes; criteria
are used to monitor outcomes of care and to determine the need for
change to improve the quality of care. If the nurse notes a particular
AND ANSWERS CORRECT ANSWERS AND
SOLUTIONS
◉ The nurse notes the presence of a P wave, QRS complex, flattened
T waves, and occasional U waves on a client's cardiac monitor screen.
Fill in the correct missing information by choosing from the lists of
options in the drop-down menus. Answer: The nurse should suspect
Your Answer: hypokalemiaCorrect Answer: hypokalemia
because of the
Your Answer: flattened T waves and occasional U wavesCorrect
Answer: flattened T waves and occasional U waves
Rationale:Cardiac changes in hypokalemia include impaired
repolarization, resulting in a flattening of the T wave and eventually
the emergence of a U wave. Therefore, the nurse should suspect
hypokalemia. The incidence of potentially lethal ventricular
dysrhythmias is increased in hypokalemia. The nurse should
immediately assess the client's vital signs and cardiac status for signs
of hypokalemia. The nurse should also check the client's most recent
serum potassium level and then contact the primary health care
provider to report the findings and obtain prescriptions to treat the
hypokalemic state.
◉ The nurse is preparing a client for a chest x-ray and notes that the
client is wearing a religious medal on a chain around the neck. What
,should the nurse do with regard to this personal item? Click to
highlight the correct answer from the options provided. Answer: The
nurse should: (Select 1 option)
✓Ask the client if the chain and medal can be removed during the
procedure.
Because: (Select 1 option)
✓The chain and medal may have cultural significance.
Rationale:Before certain diagnostic procedures, it is typical to have a
client remove personal objects that are worn on the body because of
client safety and the possibility of compromising test results.
Therefore, the nurse should ask the client about the significance of
such an item and its removal because it may have cultural or spiritual
significance. If so, the nurse should ask the client if the item can be
either removed temporarily or placed on another part of the body
during the procedure if appropriate.
◉ While preparing a client for surgery scheduled in 1 hour, the client
states to the nurse: "I have changed my mind. I don't want this
surgery." Click to highlight the correct answer from the options
provided. Answer: The nurse should: (Select 1 option)
Cancel the surgery.
Contact the surgeon.
✓Discuss the client's concerns.
Call the identified support person.
Because: (Select 1 option)
Client consent is required prior to any procedure.
,✓Further questions or concerns should be determined and addressed.
Ethical considerations are important for a client undergoing surgery.
The nursing scope of practice places limitations on how the nurse can
respond.
Rationale:If the client indicates that he or she does not want a
prescribed therapy, treatment, or procedure such as surgery, the nurse
should further investigate the client's request. If the client indicates
that he or she has changed his or her mind about surgery, the nurse
should assess the client and explore with the client his or her concerns
about not wanting the surgery. The nurse would then withhold further
surgical preparation and contact the surgeon to report the client's
request so that the surgeon can discuss the consequences of not
having the surgery with the client. Further assessment and follow-up
related to the client's request need to be done. It is the client's right to
refuse treatment; however, further investigation is needed so the
interventions can be tailored to specific needs.
◉ The nurse notes that there has been an increase in the number of
intravenous (IV) site infections that developed in the clients being
cared for on the nursing unit. How should the nurse proceed to
implement a quality improvement program?For each action, click to
specify whether the action would be:
Indicated: an action that the nurse should take to resolve the problem
Non-essential: an action that the nurse could take without harming the
client, but the action would not be likely to address the problem
Contraindicated: an action that could harm the client and should not
be taken Answer: Collect identifying patient information
, Contraindicated
Note the mental status of the client
Non-essential
Note primary and secondary diagnoses of clients affected
Indicated
Note the type of IV catheter used
Indicated
Note the type of IV site dressings being used
Indicated
Note the medication types being infused
Non-essential
Note frequency of assessments of IV sites
Indicated
Note the expected duration of the IV site
Non-essential
Note care procedures to the IV site
Indicated
Note frequency of changing IV sites
Indicated
Rationale:Quality improvement, also known as performance
improvement, focuses on processes or systems that significantly
contribute to client safety and effective client care outcomes; criteria
are used to monitor outcomes of care and to determine the need for
change to improve the quality of care. If the nurse notes a particular
