NCLEX PRACTICE QUESTIONS WITH COMPLETE SOLUTIONS

After receiving report at the start of the evening shift, which of the following clients should the nurse attend to first? (a) A 34-year-old man undergoing treatment for non-Hodgkin lymphoma with a potassium level of 7.5 mEq/L. (b) A 21-year-old woman with sickle cell anemia with pain of 6 on a scale of 1-10. (c) A 55-year-old woman with ovarian cancer waiting to be discharged. (d) A 72-year-old man with chronic obstructive pulmonary disease (COPD) and a pulse oximetry of 96% on room air. - Correct answer: (a) A 34-year-old man undergoing treatment for non-Hodgkin lymphoma with a potassium level of 7.5 mEq/L. Rationale: Hyperkalemia is a potentially serious condition that, in a client undergoing treatment for non-Hodgkin lymphoma, could indicate tumour lysis syndrome. Patient (b) should be attended to, but her condition is not as urgent. Patients (c) and (d) do not require immediate attention. A 34-year-old woman who developed Stevens-Johnson syndrome while undergoing treatment with carbamazepine (Tegretol) is being transferred in stable condition from the intensive care unit to the medical unit. There are 4 beds available. The nurse knows the best choice of roommates for this client is which of the following? (a) A 40-year-old man with methicillin-resistant Staphylococcus aureus (MRSA). (b) A 28-year-old woman diagnosed with diarrhea. (c) A 72-year-old man with fever of unknown origin. (d) A 68-year-old woman with atrial fibrillation . - Correct answer: (d) A 68-year-old woman with atrial fibrillation. Rationale: A client with Stevens-Johnson syndrome is likely to have severe skin integrity issues, including blistering and skin shedding, which can place the client at high risk for infection. Atrial fibrillation is not an infectious process. All other patients may be an infection risk for an individual with altered skin integrity. A 72-year-old man who had a stroke is being transferred from a medical unit to a rehabilitation centre. The nurse case manager is assisting in the process. The nurse knows that the goals of case management include which of the following? Select all that apply. (a) Improving the coordination of care (b) Increasing referrals to local organizations (c) Reducing the fragmentation of care (d) Discharging clients quickly - Correct answer: (a) Improving the coordination of care; and (c) Reducing the fragmentation of care Rationale: Some of the primary goals of case management are to improve the coordination of care and to reduce fragmentation of care. The other options are not goals of case management. A pregnant woman at 15 weeks' gestation is scheduled for an amniocentesis. As the client is being prepped for the procedure, it becomes clear to the nurse that the client doesn't fully understand the risks and benefits associated with the procedure. Which of the following describe the nurse's role in obtaining informed consent? Select all that apply. (a) Explain the risks and benefits associated with the procedure. (b) Describe alternatives to the procedure. (c) Witness the client's signature on the consent form. (d) Advocate for the client by ensuring she is making an informed decision. - Correct answer: (c) Witness the client's signature on the consent form; and (d) Advocate for the client by ensuring she is making an informed decision. Rationale: Some of the nurse's roles in the informed consent process are to witness the signature on the consent form, and to advocate for the client by ensuring she has been provided the necessary information to make an informed decision. It is the physician's duty to provide information to the client-related risks and benefits, and to provide alternatives. A well-known actor has been admitted to an ambulatory surgical unit. The nurse notices a staff member who is not involved in the client's care reading his medical record. The nurse knows she should FIRST do which of the following? (a) Nothing. The staff member has a hospital ID badge and is authorized to read the medical record. (b) Inform the staff member that without a legitimate need for the information, staff should not be reading the medical record. (c) Tell the client his medical records have been read by an unauthorized individual. (d) Page the physician and ask if it's acceptable for the staff member to access the medical records. - Correct answer: (b) Inform the staff member that without a legitimate need for the information, staff should not be reading the medical record. Rationale: An individual not involved in the care of the client does not have a legitimate need to access the medical record. The nurse should protect the client's right to privacy by ensuring only authorized individuals access medical records. The nurse is learning how to use the hospital's new electronic medication administration record (eMAR). The nurse knows this tool has the potential to do which of the following? Select all that apply. (a) Reduce medication administration errors. (b) Improve access to information at the point of care. (c) Eliminate the need for the nurse to document medication administration. (d) Eliminate the need for the nurse to verify dose calculations. - Correct answer: (a) Reduce medication administration errors; and (b) Improve access to information at the point of care. Rationale: eMARs have the potential to reduce medication administration errors and to improve access to client information at the point of care. It is always the nurse's responsibility to document medication administration and to verify doses of drugs being administered. The nurse uses the Internet to receive electrocardiogram results from a client living in a nursing home. The nurse knows this type of information technology is best described as which of the following? (a) Encryption (b) Telecommunications (c) Telehealth (d) Nursing informatics - Correct answer: (c) Telehealth. Rationale: Telehealth uses transmissions via telecommunications technology to transmit health information remotely. Encryption refers to the conversion of information to code during transmission to keep the information secure. Telecommunications refers to the electronic transmission of data over phone-based lines. Nursing informatics refers to a specialty of nursing that integrates nursing and computer science The nurse in a maternity unit is caring for a client who has just delivered twins. The client voices concern about her ability to manage when she gets home. Which of the following statements best illustrates quality care delivery by the nurse? Select all that apply. (a) "Just focus on how lucky you are to have two healthy babies." (b) "We can arrange for follow-up visits with a home health nurse." (c) "Here is some information on support groups for parents of multiples." (d) "You will find it easier to formula-feed your babies at home." - Correct answer: (b) "We can arrange for follow-up visits with a home health nurse."; and (c) "Here is some information on support groups for parents of multiples." Rationale: A referral to home health care provides the client with opportunities for support and assistance during this transition; and a referral to support groups provides the client with opportunities for support and assistance during this transition. The other options are not appropriate for a new mother expressing concerns about her ability to cope. The nurse is caring for a client newly diagnosed with diabetes, and performs the following tasks. Place the tasks the nurse would perform in the appropriate order. All options must be used. (a) The nurse establishes a goal with the client to be able to self-administer insulin injections. (b) The nurse assesses the client's level of knowledge about how to administer insulin injections. (c) The nurse evaluates the client while self-administering insulin injections. (d) The nurse establishes the diagnosis of knowledge deficit. - Correct answer: (b) The nurse assesses the client's level of knowledge about how to administer insulin injections. (d) The nurse establishes the diagnosis of knowledge deficit. (a) The nurse establishes a goal with the client to be able to self-administer insulin injections. (c) The nurse evaluates the client while self-administering insulin injections.