NCLEX Study Guide 2024 Questions and Answers with verified solutions

NCLEX Study Guide 2024 Questions and Answers with verified solutions A charge nurse is making client assignments for a critical care step=down unit. Which client would be MOST appropriate to assign to a new graduate registered nurse (RN)? A. A client admitted for diabetic ketoacidosis that is on a insulin drip B. A client that is scheduled for discharged today that has a new colostomy C. A client admitted for a postoperative infection that is receiving IV antibiotics D, A client that is scheduled for a pacemaker insertion procedure during the shift. - ANS -C. A client admitted for a postoperative infection that is receiving IV antibiotics Explanation: The skills, education, experience of nursing staff, ins addition to client acuity, must be considered when making client assignments. Caring for any of these clients is within the new RN's scope of practice; however, the client receiving IV antibiotics is most appropriate as car includes administration of IV antibiotics, monitoring vital signs, and assessing for signs of infection. These are skills that could reasonable be expected of a new RN. New graduate nurses have least amount of experience and specialized knowledge and therefor should be assigned the least complex clients. Takeaway: The complexity of care and competency of nursing staff must be considered when making client care assignments. The most appropriate client assignment for a new graduate nurse is one that does not require specialized training or knowledge. Topic: Assignment A charge nurse is supervising administration of blood transfusion to a client with a gastrointestinal bleed by a registered nurse (RN) who is assisted by a licensed practical nurse (LPN) and an unlicensed assistive personnel (UPA). The charge nurse should INTERVENE if the RN? A. Asks the LPN to report the color of the client's next bowel movement B. Asks the LPN to draw blood for a repeat hemoglobin levels after transfusion C. Ask the UAP to measure the vital signs before beginning the transfusion D. Ask the UAP to sit with the client during the first 15 minutes of the transfusion. - ANS -D. Ask the UAP to sit with the client during the first 15 minutes of the transfusion. Explanation: RN should only delegate tasks that satisfy the five rights (RIGHT PERSON, RIGHT TASK, RIGHT CIRCUMSTANCE, RIGHT DIRECTION & COMMUNICATION, RIGHT SUPERVISION & EVALUATION of delegation and are within the delegatee's scope of practice. During the first 15 minutes of a blood transfusion, the RN should assess the client's response to the transfusion and intervene to correct any development complications (e.g., slow or stop transfusion). Tasks requiring assessment and clinical judgment cannot be delegated to either a licensed practical nurse (LPN) or an unlicensed assistive personnel (UAP). Takeaway: The Rn must remain with a client during the first 15 minutes of a blood transfusion to recognize complications and intervene as needed. Takes requiring assessment and clinical judgment cannot be delegated. Topic: Managing care A client diagnosed with a head injury undergoes preparation for a lumbar puncture. Which action will the nurse take FIRST? A. Obtain informed consent B. Measure pre-procedure vital signs C. Explain the procedure to client D. Locate a lumbar puncture tray. - ANS -B. Measure pre-procedure vital signs Explanation: A client is admitted with flammatory bowel syndrome (Crohn's disease). When planning care for the health care team, which would be included? Select all that apply? A. Lactulose therapy B. High-fiber diet C. High protein milkshakes D. Corticosteroid therapy E. Anti-diarrhea therapy - ANS -D. Corticosteroid therapy E. Anti-diarrhea therapy Explanation: Treat very all that apply as a true or false statement A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse should NEXT assess the client for the presence of which condition? A. Thirst B. Polyuria C. Decreased blood pressure D. Crackles on accusation of the lungs - ANS -D. Crackles on accusation of the lungs Explanation: To much fluid in there lungs and they are hyperbolic A client with type I diabetes mellitus has a Glasgow coma scale of 9, only responds to painful stimuli, and a blood glucose level of 35 mg/dL (1.9 mmol/L). What should the nurse do FIRST? A. Administer dextrose 50% IVP now B. Assess sweating, pallor or shakiness C Help the patient to eat 15 grams of carbohydrates D. Obtain the patients heart rate and blood pressure - ANS -A. Administer dextrose 50% IVP now Answer & Rationale: Ask Priority action of what to do FIRST Problem: Type I diabetes, Glasgow coma scale of 9 , blood glucose 35- hypoglycemic Solution: Interventions to do now to prevent worst possible outcome Explanation: Stab client with IV push A nurse is assessing a client at 34 weeks gestation and auscultates a fetal heart rate of 90 bpm Bia doppler. Which of the following should the nurse do FIRST? A. Notify the healthcare provider B. Check the maternal heart rate C. Document the fetal heart rate D. Initiate a fetal non-stress test. - ANS -B. Check the maternal heart rate A. Notify the healthcare provider C. Document the fetal heart rate D. Initiate a fetal non-stress test. DID not get to answer this one NOT SURE IF ITS RIGHT. A patient is admitted to the hospital for Diazepam overdose. What its the antidote for this medication? A. Naloxone B. Fomepizole C. Flumazenil D. Protamine sulfate - ANS -C. Flumazenil Explanation: Naloxone: a medication approved by the Food and Drug Administration (FDA) designed to rapidly reverse opioid overdose (such as heroin, morphine, and oxycodon) Fomepizole: is used as an antidote in confirmed or suspected methanol or ethylene glycol poisoning (alcohol) Flumazenil" is a benzodiazepine antagonist. The primary FDA-approved clinical uses for flumazenil include reversal agents for benzodiazepine overdose and postoperative sedation from benzodiazepine anesthetics Protamine sulfate: to counteract the effect of heparin given before and after surgery and after dialysis. A patient is experiencing Digoxin toxicity. What is the antidote for this medication? A. Naloxone B. Digibind C. Acetycysteine D. Protamine sulfate - ANS -B. Digibind Explanation: Digibind: an antidote to treat a life-threatening overdose of digoxin or digitoxin. Client with ulcerative colitis ... INTERVENTIONS? select all that apply A. Discuss plans to decrease client's stress B. Give analgesics as prescribed C. Limit fluids to 500ml per day D. Increased protein foods with meals E. Monitor input and output closely F. Recommend high fiber and low calorie diet - ANS -A. Discuss plans to decrease client's stress B. Give analgesics as prescribed D. Increased protein foods with meals E. Monitor input and output closely