NCLEX Practice Questions 002 N N N
The nurse is administering vancomycin 1 g every 12 hours for a soft tissue infection. The nurse
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reminds the client to report symptoms associated with one of the serious side effects of the
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drug, ototoxicity. Which of the following statements by the client indicates to the nurse that the
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client may be experiencing this adverse reaction? A. "I hear ringing in my ear." B. "The IV is
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burning." C. "My skin is very itchy." D. "I have a bad taste in my mouth." - CORRECT ANSWER-A.
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"I hear ringing in my ear." (CORRECT: Tinnitus may indicate that ototoxicity is developing.) B.
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"The IV is burning." (A feeling that the IV is burning is not related to the development of
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ototoxicity.) C. "My skin is very itchy." (Itchiness of the skin is not related to the development of
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ototoxicity.) D. "I have a bad taste in my mouth." (The sensation of a bad taste in the mouth is
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not related to the development of ototoxicity.)
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The nurse is preparing to administer a unit of PRBCs to an anemic client. After obtaining the
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blood from the blood bank, the nurse must begin administering it within which of the following
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periods? A. 15 min B. 30 min C. 45 min D. 60 min - CORRECT ANSWER-A. 15 min (The nurse has
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up to 30 min to begin administering the blood product.) B. 30 min (CORRECT: After obtaining
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the blood product from the blood bank, the nurse must begin administering the product within
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30 min.) C. 45 min (This time period is too long.) D. 60 min (This time period is too long.)
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A client is scheduled to have surgery the following day. The client tells the nurse, "I'm very
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scared. I have never had surgery before and am afraid that I might not make it through." Which
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of the following responses by the nurse is the MOST appropriate? A. "Why do you feel this
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way?" B. "Don't worry, you will be fine." C. "Why don't we take some time to explore why you
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feel this way?" D. "It's completely normal to be scared. You will be taken care of. Tell me how
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you are feeling." - CORRECT ANSWER-A. "Why do you feel this way?" (Avoid asking 'why'
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questions because they imply disapproval with what the client is saying.) B. "Don't worry, you
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will be fine." (Telling the client not to worry, and that the client will be fine, dismisses the
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client's feelings and provides for false reassurances.) C. "Why don't we take some time to
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, explore why you feel this way?" (The nurse must remain within the nursing scope of practice.
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The nurse is not a therapist, so asking the client to explore his feelings with the nurse would not
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be appropriate.) D. "It's completely normal to be scared. You will be taken care of. Tell me how
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you are feeling." (CORRECT: A response that tells the client that it is normal to be scared, and
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that he will be taken care of, and asks how he is feeling, normalizes the client's experience,
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provides some reassurance, and allows him to verbalize.)
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The nurse is performing an initial assessment of an adult from a culture the nurse is not familiar
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with, and asks about the client's use of alternative therapies. The client says, irritably, "Do you
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have to ask all these questions?" Which of the following is the BEST explanation for what the
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nurse should do in response? A. Ask the question, because the nurse might learn about
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therapies used by a different culture. B. Ask the question, because knowledge about actual use
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of other therapies is imperative. C. Don't ask the question, because it is important to not upset
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the irritable client any further. D. Don't ask the question, because the client needs to choose to
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initiate discussion of other therapies. - CORRECT ANSWER-A. Ask the question, because the
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nurse might learn about therapies used by a different culture. (The client is the focus, not the
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nurse's education.) B. Ask the question, because knowledge about actual use of other therapies
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is imperative. (CORRECT: The need to discuss the use of these adjunct therapies with clients in
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all settings is imperative. This is important because it could affect or interfere with other
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treatment modalities.) C. Don't ask the question, because it is important to not upset the
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irritable client any further. (The client might become impatient, but that does not mean that the
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nurse shortens her clinical review.) D. Don't ask the question, because the client needs to
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choose to initiate discussion of other therapies. (The nurse needs to ask critical questions to get
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the complete clinical picture.)
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The client is an intoxicated male on the med/surg unit who attempts to get out of bed every few
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minutes. He is unsteady on his feet, and the nurse is concerned that he will fall if he does get
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out of bed. The doctor writes an order for the nurse to place wrist restraints to maintain the
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client's safety and prevent him from falling. The man refuses the restraints. The nurse should
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take which of the following actions: A. Place the restraints in compliance with hospital policy. B.
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Refrain from placing restraints to honor the client's wishes, because he has the right to refuse
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care. C. Call the physician for advice on how to proceed. D. Check on the client every hour to
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ensure his safety. - CORRECT ANSWER-A. Place the restraints in compliance with hospital policy.
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(CORRECT: The nurse should place the restraints in compliance with hospital policy. This is a
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circumstance where the client's risk of harm and promotion of safety trumps the client's right to
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refuse.) B. Refrain from placing restraints to honor the client's wishes, because he has the right
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The nurse is administering vancomycin 1 g every 12 hours for a soft tissue infection. The nurse
N N N N N N N N N N N N N N N N
reminds the client to report symptoms associated with one of the serious side effects of the
N N N N N N N N N N N N N N N N
drug, ototoxicity. Which of the following statements by the client indicates to the nurse that the
N N N N N N N N N N N N N N N N
client may be experiencing this adverse reaction? A. "I hear ringing in my ear." B. "The IV is
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burning." C. "My skin is very itchy." D. "I have a bad taste in my mouth." - CORRECT ANSWER-A.
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"I hear ringing in my ear." (CORRECT: Tinnitus may indicate that ototoxicity is developing.) B.
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"The IV is burning." (A feeling that the IV is burning is not related to the development of
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ototoxicity.) C. "My skin is very itchy." (Itchiness of the skin is not related to the development of
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ototoxicity.) D. "I have a bad taste in my mouth." (The sensation of a bad taste in the mouth is
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not related to the development of ototoxicity.)
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The nurse is preparing to administer a unit of PRBCs to an anemic client. After obtaining the
N N N N N N N N N N N N N N N N
blood from the blood bank, the nurse must begin administering it within which of the following
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periods? A. 15 min B. 30 min C. 45 min D. 60 min - CORRECT ANSWER-A. 15 min (The nurse has
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up to 30 min to begin administering the blood product.) B. 30 min (CORRECT: After obtaining
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the blood product from the blood bank, the nurse must begin administering the product within
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30 min.) C. 45 min (This time period is too long.) D. 60 min (This time period is too long.)
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A client is scheduled to have surgery the following day. The client tells the nurse, "I'm very
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scared. I have never had surgery before and am afraid that I might not make it through." Which
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of the following responses by the nurse is the MOST appropriate? A. "Why do you feel this
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way?" B. "Don't worry, you will be fine." C. "Why don't we take some time to explore why you
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feel this way?" D. "It's completely normal to be scared. You will be taken care of. Tell me how
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you are feeling." - CORRECT ANSWER-A. "Why do you feel this way?" (Avoid asking 'why'
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questions because they imply disapproval with what the client is saying.) B. "Don't worry, you
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will be fine." (Telling the client not to worry, and that the client will be fine, dismisses the
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client's feelings and provides for false reassurances.) C. "Why don't we take some time to
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, explore why you feel this way?" (The nurse must remain within the nursing scope of practice.
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The nurse is not a therapist, so asking the client to explore his feelings with the nurse would not
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be appropriate.) D. "It's completely normal to be scared. You will be taken care of. Tell me how
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you are feeling." (CORRECT: A response that tells the client that it is normal to be scared, and
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that he will be taken care of, and asks how he is feeling, normalizes the client's experience,
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provides some reassurance, and allows him to verbalize.)
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The nurse is performing an initial assessment of an adult from a culture the nurse is not familiar
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with, and asks about the client's use of alternative therapies. The client says, irritably, "Do you
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have to ask all these questions?" Which of the following is the BEST explanation for what the
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nurse should do in response? A. Ask the question, because the nurse might learn about
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therapies used by a different culture. B. Ask the question, because knowledge about actual use
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of other therapies is imperative. C. Don't ask the question, because it is important to not upset
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the irritable client any further. D. Don't ask the question, because the client needs to choose to
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initiate discussion of other therapies. - CORRECT ANSWER-A. Ask the question, because the
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nurse might learn about therapies used by a different culture. (The client is the focus, not the
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nurse's education.) B. Ask the question, because knowledge about actual use of other therapies
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is imperative. (CORRECT: The need to discuss the use of these adjunct therapies with clients in
N N N N N N N N N N N N N N N N
all settings is imperative. This is important because it could affect or interfere with other
N N N N N N N N N N N N N N N
treatment modalities.) C. Don't ask the question, because it is important to not upset the
N N N N N N N N N N N N N N N
irritable client any further. (The client might become impatient, but that does not mean that the
N N N N N N N N N N N N N N N N
nurse shortens her clinical review.) D. Don't ask the question, because the client needs to
N N N N N N N N N N N N N N N
choose to initiate discussion of other therapies. (The nurse needs to ask critical questions to get
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the complete clinical picture.)
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The client is an intoxicated male on the med/surg unit who attempts to get out of bed every few
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minutes. He is unsteady on his feet, and the nurse is concerned that he will fall if he does get
N N N N N N N N N N N N N N N N N N N N
out of bed. The doctor writes an order for the nurse to place wrist restraints to maintain the
N N N N N N N N N N N N N N N N N N
client's safety and prevent him from falling. The man refuses the restraints. The nurse should
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take which of the following actions: A. Place the restraints in compliance with hospital policy. B.
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Refrain from placing restraints to honor the client's wishes, because he has the right to refuse
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care. C. Call the physician for advice on how to proceed. D. Check on the client every hour to
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ensure his safety. - CORRECT ANSWER-A. Place the restraints in compliance with hospital policy.
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(CORRECT: The nurse should place the restraints in compliance with hospital policy. This is a
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circumstance where the client's risk of harm and promotion of safety trumps the client's right to
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refuse.) B. Refrain from placing restraints to honor the client's wishes, because he has the right
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