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NCLEX® READINESS EXAM ||VERIFIED EXAM|| MOST
RECENT EXAM ACTUAL COMPLETE REAL VERIFIED
EXAM QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) ALREADY GRADED A+ |
GUARANTEED SUCCESS!! NEWEST EXAM!!!
The nurse cares for the client with a client controlled
analgesia (PCA) pump. The nurse determines that the
client has pressed the button 11 times and received 6
doses of morphine during the last hour. Which is the
MOST appropriate action for the nurse to take?
1. Assess the patency of the PCA IV tubing.
2. Determine the client's understanding of the PCA pump
function.
3. Obtain an order to begin a PCA infusion of fentanyl.
4. Ask the client to describe the pain. - Answer-1)
Assessment: outcome not priority but may be appropriate;
if tubing is obstructed, alarm is activated
2) Assessment: outcome may be appropriate but not
priority; more important to determine pain level,
description of the pain, region and radiation of the pain,
and relieving factors
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3) Implementation: outcome not desired; more important
to assess severity of pain and pain relief first
4) CORRECT - Assessment: outcome priority; must
validate that client is in pain before implementation
A pregnant woman receives an epidural anesthetic. After
administration of the epidural anesthetic, the client's blood
pressure changes from 120/84 to 94/50. Which action by
the nurse is MOST appropriate?
1. Place the client flat on her back.
2. Elevate the head of the bed 30 degrees.
3. Place the client on her left side with her legs flexed.
4. Place the client supine with the foot of the bed
elevated. - Answer-1) Implementation: outcome not
desired; no increase in venous return
2) Implementation: outcome not desired; will decrease
venous return
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3) CORRECT - Implementation: outcome desired; will
increase venous return and cardiac output; fetal pressure
on inferior vena cava reduced
4) Implementation: outcome not desired; elevation of legs
will increase venous return, but fetal pressure on vena
cava will prevent blood return to heart
A nursing order, "Increase fluid intake" is written for a
client diagnosed with dehydration. Which finding BEST
indicates improving fluid status?
1. Urinary output of 1,500 mL in 24 hours.
2. Serum hematocrit 52%.
3. Oral fluid intake of 900 mL in 24 hours.
4. Blood pressure of 100/82. - Answer-1) CORRECT -
Assessment: outcome priority; increased amounts of
antidiuretic hormone secreted; urine output decreased and
concentrated
2) Assessment: outcome not priority; indicates that blood
is hemoconcentrated
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3) Assessment: outcome not priority; normal intake is
1,500 mL in 24 hours
4) Assessment: outcome not priority; normal BP is 120/80
The nurse cares for a client with a cuffed tracheostomy
tube. Before performing oral care, the nurse notes that the
client's tracheostomy cuff is inflated. Which of the following
is the MOST appropriate action for the nurse to take?
1. Leave the cuff inflated and suction through the
tracheostomy.
2. Deflate the cuff and suction through the tracheostomy
tube.
3. Inflate the cuff pressure to 40 mm Hg before suctioning.
4. Adjust the wall suction pressure to 160 to 180 mm Hg
before suctioning. - Answer-1) CORRECT -
Implementation: outcome desired; cuff inflation decreases
the risk of aspiration; cuff position and pressure should be
assessed frequently; swallowing and breathing will cause
tracheostomy tube movement
NCLEX® READINESS EXAM ||VERIFIED EXAM|| MOST
RECENT EXAM ACTUAL COMPLETE REAL VERIFIED
EXAM QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) ALREADY GRADED A+ |
GUARANTEED SUCCESS!! NEWEST EXAM!!!
The nurse cares for the client with a client controlled
analgesia (PCA) pump. The nurse determines that the
client has pressed the button 11 times and received 6
doses of morphine during the last hour. Which is the
MOST appropriate action for the nurse to take?
1. Assess the patency of the PCA IV tubing.
2. Determine the client's understanding of the PCA pump
function.
3. Obtain an order to begin a PCA infusion of fentanyl.
4. Ask the client to describe the pain. - Answer-1)
Assessment: outcome not priority but may be appropriate;
if tubing is obstructed, alarm is activated
2) Assessment: outcome may be appropriate but not
priority; more important to determine pain level,
description of the pain, region and radiation of the pain,
and relieving factors
,2|Page
3) Implementation: outcome not desired; more important
to assess severity of pain and pain relief first
4) CORRECT - Assessment: outcome priority; must
validate that client is in pain before implementation
A pregnant woman receives an epidural anesthetic. After
administration of the epidural anesthetic, the client's blood
pressure changes from 120/84 to 94/50. Which action by
the nurse is MOST appropriate?
1. Place the client flat on her back.
2. Elevate the head of the bed 30 degrees.
3. Place the client on her left side with her legs flexed.
4. Place the client supine with the foot of the bed
elevated. - Answer-1) Implementation: outcome not
desired; no increase in venous return
2) Implementation: outcome not desired; will decrease
venous return
,3|Page
3) CORRECT - Implementation: outcome desired; will
increase venous return and cardiac output; fetal pressure
on inferior vena cava reduced
4) Implementation: outcome not desired; elevation of legs
will increase venous return, but fetal pressure on vena
cava will prevent blood return to heart
A nursing order, "Increase fluid intake" is written for a
client diagnosed with dehydration. Which finding BEST
indicates improving fluid status?
1. Urinary output of 1,500 mL in 24 hours.
2. Serum hematocrit 52%.
3. Oral fluid intake of 900 mL in 24 hours.
4. Blood pressure of 100/82. - Answer-1) CORRECT -
Assessment: outcome priority; increased amounts of
antidiuretic hormone secreted; urine output decreased and
concentrated
2) Assessment: outcome not priority; indicates that blood
is hemoconcentrated
, 4|Page
3) Assessment: outcome not priority; normal intake is
1,500 mL in 24 hours
4) Assessment: outcome not priority; normal BP is 120/80
The nurse cares for a client with a cuffed tracheostomy
tube. Before performing oral care, the nurse notes that the
client's tracheostomy cuff is inflated. Which of the following
is the MOST appropriate action for the nurse to take?
1. Leave the cuff inflated and suction through the
tracheostomy.
2. Deflate the cuff and suction through the tracheostomy
tube.
3. Inflate the cuff pressure to 40 mm Hg before suctioning.
4. Adjust the wall suction pressure to 160 to 180 mm Hg
before suctioning. - Answer-1) CORRECT -
Implementation: outcome desired; cuff inflation decreases
the risk of aspiration; cuff position and pressure should be
assessed frequently; swallowing and breathing will cause
tracheostomy tube movement
