NCLEX ACTUAL EXAM 2022
The nurse receives a client from the post anesthesia care unit following a left femoral-
popliteal bypass graft procedure. Which of the following assessments requires immediate
notification of the health care provider?
• Left foot is cool to the touch
• Absent lef t pedal pulse using Doppler analysis
• Inability to palpate the left pedal pulse
• Acute pain in the left lower leg
Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the
left lower leg are important findings, they all require additional nursing assessment prior to
contacting the health care provider. In clients without palpable pedal pulses, the next step in the
assessment is to perform a Doppler analysis. The inability to locate the left pedal pulse using the
Doppler analysis requires immediately notifying the health care provider.
Ref # 1028
There's a new medication order that reads: "administer 1 gtt ciprofloxacinsolution OD Q 4
h" What action should the nurse take?
Call the prescriber to clarify and rewrite the order
Abbreviations, symbols and dose designations can be misinterpreted and lead to medication
errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when
communicating medical information. The abbreviation "Q" should be written out as "every."
Although "gtt" is not on the official "Do Not Use List", it's best to use "drop" instead. Asking
other nurses to interpret an order is a potentially dangerous "workaround." The nurse should call
the health care provider who prescribed the medication and clarify the order.
Ref # 1440
Which individual is at greatest risk for the development of hypertension?
45 year-old African-American attorney
The incidence of hypertension is greater among African-Americans than other groups in the
United States. The incidence among the Hispanic population is rising.
Ref # 2446
1 A woman, who delivered five days ago and who had been diagnosed with pregnancy
,induced hypertension (PIH), calls a hospital triage nurse hotline to ask for advice. She
states, "I have had the worst headache for the past two days.It pounds and by the middle of
the afternoon everything I look at looks wavy.
Nothing I have taken helps." What should the nurse do next?
Ask the client to stay on the line, get the address, and send an ambulance to the home The woman
is at risk for seizure activity. The ambulance needs to bring the woman to the hospital for
evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and eclampsia
prior to, during, or after delivery; this may occur up to 10 days after delivery.
Ref # 2065
A client expresses anger when a call light is not answered within five minutes.The client
demanded a blanket. How should the nurse respond?
"I see this is frustrating for you. I have a few minutes so let's talk."
This is the best response because it gives credence to the client's feelings and then concerns. To
say "let's talk" and ask a why question is not a therapeutic approach because it does not
acknowledge or validate the client's feelings. To apologize and not notice the client's feelings is
inappropriate. To say it could have waited a few minutes is rude and non-accepting of the client's
verbalized needs.
Ref # 2134
The client is admitted to an ambulatory surgery center and undergoes a rightinguinal
orchiectomy. Which option is the priority before the client can be discharged to home
Post-operative pain is managed
An orchiectomy is the surgical removal of one or both testicles. It is usually performed to treat
cancer (testicular, prostate or cancer of the male breast), but it may also be performed to prevent
cancer (with an undescended testicle.) Due to the location of the incision, pain management is the
priority. Most men will be able to eat regularly when they get home; they should at least tolerate
liquids before discharge. It's important that the client is able to get up and walk with assistance,
but this is not the priority.
Psychological counseling may be needed as part of long-term aftercare, but this is not an
immediate priority.
Ref # 1524
A nurse is teaching a group of adults about modifiable cardiac risk factors.Which of
, NCLEX ACTUAL EXAM 2022
the following should the nurse focus on first?
Smoking cessation
Smoking cessation is the priority for clients at risk for cardiac disease. Smoking's effects result
in reduction of cell oxygenation and constriction of the blood vessels. All of the other factors
should be addressed at some point in time.
Ref # 1721
The clinic nurse is assisting with medical billing. The nurse uses the DRG(Diagnosis Related
Group) manual for which purpose?
Determine reimbursement for a medical diagnosis
DRGs are the basis of prospective payment plans for reimbursement for Medicare
clients. Other insurance companies often use it as a standard for determining payment.
KEYWORDS DRGdiagnosis related group
Reimbursemen
Ref # 1328
A nurse is planning care for a 2 year-old hospitalized child. Which issue will produce the
most stress at this age? Separation anxiety While a toddler will experience all of the stresses,
separation from parents is the major stressor. Separation anxiety peaks in the toddler years.
Ref # 2319
The nurse is reviewing the laboratory results for several clients. Which of the laboratory
result indicates a client with partly compensated metabolic acidosis?PaCO2 30 mm Hg
Metabolic acidosis can be caused by many conditions, including renal failure, shock, severe
diarrhea, dehydration, diabetic acidosis, and salicylate poisoning. With metabolic acidosis, you
should expect a low pH (less than 7.35) and a low HCO3 (less than 22 mEq/L.) Compensation
means the body is trying to get the pH back in balance; therefore, a pure metabolic acidosis
should elicit a compensatory decrease in PaCO3 (normal is 35-45 mm Hg.) The hemoglobin
is within normal limits (WNL) for both males and females. The chloride and sodium results are
also WNL.
Ref # 2391
3 A client with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA)has died.
, Which type of precautions is appropriate to use when performing postmortem care?
Contact precautionsThe resistant bacteria remain alive for up to three days after the client dies.
Therefore, contact precautions must still be used. The body should also be labeled as MRSA-
contaminated so that the funeral home staff can protect themselves as well. Gown and gloves are
required.
Ref # 1436
A client has a chest tube inserted immediately after surgery for a left lower lobectomy.
During the repositioning of the client during the first postop check,the nurse notices 75
mL of a dark, red fluid flowing into the collection chamberof the chest drain system. What
is the appropriate nursing action?
Continue to monitor the rate of drainage It is not unusual for blood to collect in the chest and be
released into the chest drain when the client changes position this soon after surgery. The dark
color of the blood indicates it is not active bleeding inside of the chest. Sanguinous drainage
should be expected within the initial 24 hours postop, progressing to serosanguinous and then to
a serous type. If the drainage exceeds 100 mL/hr, the nurse should call the surgeon.
Ref # 1623 A client is transported to the emergency department after a motor vehicle
accident. When assessing the client 30 minutes after admission, the nursenotes several
physical changes. Which finding would require the nurse's immediate attention? Tracheal
deviation
Tracheal deviation is a sign that a mediastinal shift has occurred, most likely due to a tension
pneumothorax. Air escaping from the injured lung into the pleural cavity causes pressure to
build, collapsing the lung and shifting the mediastinum to the opposite side. This obstructs
venous return to the heart, leading to circulatory instability and may result in cardiac arrest. This
is a medical emergency, requiring emergency placement of a chest tube to remove air from the
pleural cavity relieving the pressure.
Ref # 1319 The client is diagnosed with cystic fibrosis (CF). The nurse would expect the
client to be treated with oral pancreatic enzymes and which type ofdiet? High fat, high-
calorie CF affects the cells that produce mucus, sweat and digestive juices.
Someone with CF needs a high-energy diet that includes high-fat and high-calorie foods, extra
fiber to prevent intestinal blockage and extra salt (especially during hot weather.) People with CF
are at risk for osteoporosis and need calcium and dairy products. Someone with celiac disease or
with a gluten intolerance, not CF, needs a gluten-free diet.
The nurse receives a client from the post anesthesia care unit following a left femoral-
popliteal bypass graft procedure. Which of the following assessments requires immediate
notification of the health care provider?
• Left foot is cool to the touch
• Absent lef t pedal pulse using Doppler analysis
• Inability to palpate the left pedal pulse
• Acute pain in the left lower leg
Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the
left lower leg are important findings, they all require additional nursing assessment prior to
contacting the health care provider. In clients without palpable pedal pulses, the next step in the
assessment is to perform a Doppler analysis. The inability to locate the left pedal pulse using the
Doppler analysis requires immediately notifying the health care provider.
Ref # 1028
There's a new medication order that reads: "administer 1 gtt ciprofloxacinsolution OD Q 4
h" What action should the nurse take?
Call the prescriber to clarify and rewrite the order
Abbreviations, symbols and dose designations can be misinterpreted and lead to medication
errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when
communicating medical information. The abbreviation "Q" should be written out as "every."
Although "gtt" is not on the official "Do Not Use List", it's best to use "drop" instead. Asking
other nurses to interpret an order is a potentially dangerous "workaround." The nurse should call
the health care provider who prescribed the medication and clarify the order.
Ref # 1440
Which individual is at greatest risk for the development of hypertension?
45 year-old African-American attorney
The incidence of hypertension is greater among African-Americans than other groups in the
United States. The incidence among the Hispanic population is rising.
Ref # 2446
1 A woman, who delivered five days ago and who had been diagnosed with pregnancy
,induced hypertension (PIH), calls a hospital triage nurse hotline to ask for advice. She
states, "I have had the worst headache for the past two days.It pounds and by the middle of
the afternoon everything I look at looks wavy.
Nothing I have taken helps." What should the nurse do next?
Ask the client to stay on the line, get the address, and send an ambulance to the home The woman
is at risk for seizure activity. The ambulance needs to bring the woman to the hospital for
evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and eclampsia
prior to, during, or after delivery; this may occur up to 10 days after delivery.
Ref # 2065
A client expresses anger when a call light is not answered within five minutes.The client
demanded a blanket. How should the nurse respond?
"I see this is frustrating for you. I have a few minutes so let's talk."
This is the best response because it gives credence to the client's feelings and then concerns. To
say "let's talk" and ask a why question is not a therapeutic approach because it does not
acknowledge or validate the client's feelings. To apologize and not notice the client's feelings is
inappropriate. To say it could have waited a few minutes is rude and non-accepting of the client's
verbalized needs.
Ref # 2134
The client is admitted to an ambulatory surgery center and undergoes a rightinguinal
orchiectomy. Which option is the priority before the client can be discharged to home
Post-operative pain is managed
An orchiectomy is the surgical removal of one or both testicles. It is usually performed to treat
cancer (testicular, prostate or cancer of the male breast), but it may also be performed to prevent
cancer (with an undescended testicle.) Due to the location of the incision, pain management is the
priority. Most men will be able to eat regularly when they get home; they should at least tolerate
liquids before discharge. It's important that the client is able to get up and walk with assistance,
but this is not the priority.
Psychological counseling may be needed as part of long-term aftercare, but this is not an
immediate priority.
Ref # 1524
A nurse is teaching a group of adults about modifiable cardiac risk factors.Which of
, NCLEX ACTUAL EXAM 2022
the following should the nurse focus on first?
Smoking cessation
Smoking cessation is the priority for clients at risk for cardiac disease. Smoking's effects result
in reduction of cell oxygenation and constriction of the blood vessels. All of the other factors
should be addressed at some point in time.
Ref # 1721
The clinic nurse is assisting with medical billing. The nurse uses the DRG(Diagnosis Related
Group) manual for which purpose?
Determine reimbursement for a medical diagnosis
DRGs are the basis of prospective payment plans for reimbursement for Medicare
clients. Other insurance companies often use it as a standard for determining payment.
KEYWORDS DRGdiagnosis related group
Reimbursemen
Ref # 1328
A nurse is planning care for a 2 year-old hospitalized child. Which issue will produce the
most stress at this age? Separation anxiety While a toddler will experience all of the stresses,
separation from parents is the major stressor. Separation anxiety peaks in the toddler years.
Ref # 2319
The nurse is reviewing the laboratory results for several clients. Which of the laboratory
result indicates a client with partly compensated metabolic acidosis?PaCO2 30 mm Hg
Metabolic acidosis can be caused by many conditions, including renal failure, shock, severe
diarrhea, dehydration, diabetic acidosis, and salicylate poisoning. With metabolic acidosis, you
should expect a low pH (less than 7.35) and a low HCO3 (less than 22 mEq/L.) Compensation
means the body is trying to get the pH back in balance; therefore, a pure metabolic acidosis
should elicit a compensatory decrease in PaCO3 (normal is 35-45 mm Hg.) The hemoglobin
is within normal limits (WNL) for both males and females. The chloride and sodium results are
also WNL.
Ref # 2391
3 A client with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA)has died.
, Which type of precautions is appropriate to use when performing postmortem care?
Contact precautionsThe resistant bacteria remain alive for up to three days after the client dies.
Therefore, contact precautions must still be used. The body should also be labeled as MRSA-
contaminated so that the funeral home staff can protect themselves as well. Gown and gloves are
required.
Ref # 1436
A client has a chest tube inserted immediately after surgery for a left lower lobectomy.
During the repositioning of the client during the first postop check,the nurse notices 75
mL of a dark, red fluid flowing into the collection chamberof the chest drain system. What
is the appropriate nursing action?
Continue to monitor the rate of drainage It is not unusual for blood to collect in the chest and be
released into the chest drain when the client changes position this soon after surgery. The dark
color of the blood indicates it is not active bleeding inside of the chest. Sanguinous drainage
should be expected within the initial 24 hours postop, progressing to serosanguinous and then to
a serous type. If the drainage exceeds 100 mL/hr, the nurse should call the surgeon.
Ref # 1623 A client is transported to the emergency department after a motor vehicle
accident. When assessing the client 30 minutes after admission, the nursenotes several
physical changes. Which finding would require the nurse's immediate attention? Tracheal
deviation
Tracheal deviation is a sign that a mediastinal shift has occurred, most likely due to a tension
pneumothorax. Air escaping from the injured lung into the pleural cavity causes pressure to
build, collapsing the lung and shifting the mediastinum to the opposite side. This obstructs
venous return to the heart, leading to circulatory instability and may result in cardiac arrest. This
is a medical emergency, requiring emergency placement of a chest tube to remove air from the
pleural cavity relieving the pressure.
Ref # 1319 The client is diagnosed with cystic fibrosis (CF). The nurse would expect the
client to be treated with oral pancreatic enzymes and which type ofdiet? High fat, high-
calorie CF affects the cells that produce mucus, sweat and digestive juices.
Someone with CF needs a high-energy diet that includes high-fat and high-calorie foods, extra
fiber to prevent intestinal blockage and extra salt (especially during hot weather.) People with CF
are at risk for osteoporosis and need calcium and dairy products. Someone with celiac disease or
with a gluten intolerance, not CF, needs a gluten-free diet.
