Archer NCLEX
The nurse is caring for assigned patients; which of the following patients should the nurse
identify is at highest risk for falling?
A. 88-year-old admitted with a chest tube secondary to pneumothorax and history of
dementia.
B. 44-year-old admitted with heart failure, has a peripheral IV, and receiving IV furosemide.
C. A 33-year-old man was admitted for cholecystitis, is receiving hydromorphone via IV, and
has a peripheral IV. D. A 28-year-old man who was admitted with bacteremia, is diaphoretic,
and is receiving fluids through an intravenous line. A. 88-year-old admitted with a chest tube
secondary to pneumothorax and history of dementia.
The LPN is asked to check the client's respirations. Which of the following should the LPN
perform?
A. Count 30 seconds with one hand on the patient's chest. B. Count the respirations for
one minute while simultaneously checking the client's pulse.
C. Observe and count respirations for 30 seconds, then multiply by two without mentioning
to the client that the respirations are being counted.
D. If respirations are irregular, ask the patient to rest for 10 minutes, then reassess the
respiratory rate.
B. While simultaneously checking the client's pulse, count the breaths for one minute. The
son of a client with early Alzheimer's disease states, "I'm tired of hearing Dad talk about the
all the time." What is the best response from the nurse? A. "You should be more
understanding of his disease and patient with him." B. "He is quite anxious at this stage.
Reliving the past helps him become calm again."
C. "He has lost his short-term memory but can still remember events from long ago."
D. "Just remind him when he repeats himself and that will reinforce better behavior."
C. "He has lost his short-term memory but can still remember events from long ago."
You are caring for a 1 month-old infant who has a sudden cardiac arrest. Which pulse
should you palpate to determine circulatory status?
A. Brachial
B. Femoral
C. Carotid
D. Popliteal
A. Brachial
The nurse is visiting a patient who was recently prescribed antihypertensive medications.
Which statement, if made by the patient, requires follow-up?
A. "After taking my metoprolol, my pulse drops." B. "I started taking my furosemide right
before I went to sleep."
C."1 am seasoning my foods without salt while on lisinopril."
D. I wear my clonidine patch for seven days.
B. "I started taking my furosemide right before I went to sleep."
Which of the following maternal infections can increase the risk of congenital heart defects
in the fetus?
A. Parainfluenza
, B. Adenovirus
C. Rubella
D. Measles
C. Rubella
The nurse is caring for a patient with a Sengstaken-Blakemore tube. She performs her
safety checks at the beginning of the shift and ensures which af the following priority items is
readily avalable at the bedside?
A.Trach kit
B. Scissors
C.Obturator
D. Yaunker
B. Scissors
After breakfast, a diabetic patient receives ten units of regular insulin and twenty units of
NPH insulin daily. What should the nurse do next after completing the usual insulin
preparation steps? A. Draw up NPH insulin first because it is clear.
B. Either insulin can be drawn first as long as 30 units are given.
C. Draw up Regular insulin first because it is clear.
D. Administer each type of insulin separately for accuracy.
C. First, make regular insulin because it's obvious. The nurse is taking care of a client with
Encopresis. Which of the following descriptions of Encopresis is correct? A. Frequent,
difficult-to-pass stools that persist for more than two weeks. B. Voluntary or involuntary fecal
incontinence in children over the age of 4 who were previously toilet trained.
C. Involuntary fecal incontinence in children over the age of 4 who were previously toilet
trained.
D. unable to pass stool as a result of feces impaction. B. fecal incontinence in children
over the age of four who were previously toilet-trained, whether involuntary or voluntary.
Right patient
Right medication
Right dose
The right path Right time
Right documentation
Exactly why Right response
The patient receives two divided daily doses of 200 mg PO phenytoin. What instruction from
the nurse is incorrect?
A. "You will need annual labs to determine the medication level in your body."
B. "Remember never to skip a dose of this medication."
C. "While you are taking this medication, you need to take in more vitamin D." D. "Practice
good oral hygiene and go to the dentist on a regular basis." A. "In order to ascertain your
body's medication level, you will need annual lab tests. Digoxin is being given to the
15-year-old patient with congestive heart failure by the nurse. She is aware that before
giving the medication, she should check the pulse rate and hold it for a pulse that is less
than _____. 70
A client's education about risk factors that can be changed and those that can't is being
reinforced by the LPN. Which of the following is most likely able to be corrected?
A. Genetic predisposition
B. Lifestyle choices
C. Depression
D. All of the above
The nurse is caring for assigned patients; which of the following patients should the nurse
identify is at highest risk for falling?
A. 88-year-old admitted with a chest tube secondary to pneumothorax and history of
dementia.
B. 44-year-old admitted with heart failure, has a peripheral IV, and receiving IV furosemide.
C. A 33-year-old man was admitted for cholecystitis, is receiving hydromorphone via IV, and
has a peripheral IV. D. A 28-year-old man who was admitted with bacteremia, is diaphoretic,
and is receiving fluids through an intravenous line. A. 88-year-old admitted with a chest tube
secondary to pneumothorax and history of dementia.
The LPN is asked to check the client's respirations. Which of the following should the LPN
perform?
A. Count 30 seconds with one hand on the patient's chest. B. Count the respirations for
one minute while simultaneously checking the client's pulse.
C. Observe and count respirations for 30 seconds, then multiply by two without mentioning
to the client that the respirations are being counted.
D. If respirations are irregular, ask the patient to rest for 10 minutes, then reassess the
respiratory rate.
B. While simultaneously checking the client's pulse, count the breaths for one minute. The
son of a client with early Alzheimer's disease states, "I'm tired of hearing Dad talk about the
all the time." What is the best response from the nurse? A. "You should be more
understanding of his disease and patient with him." B. "He is quite anxious at this stage.
Reliving the past helps him become calm again."
C. "He has lost his short-term memory but can still remember events from long ago."
D. "Just remind him when he repeats himself and that will reinforce better behavior."
C. "He has lost his short-term memory but can still remember events from long ago."
You are caring for a 1 month-old infant who has a sudden cardiac arrest. Which pulse
should you palpate to determine circulatory status?
A. Brachial
B. Femoral
C. Carotid
D. Popliteal
A. Brachial
The nurse is visiting a patient who was recently prescribed antihypertensive medications.
Which statement, if made by the patient, requires follow-up?
A. "After taking my metoprolol, my pulse drops." B. "I started taking my furosemide right
before I went to sleep."
C."1 am seasoning my foods without salt while on lisinopril."
D. I wear my clonidine patch for seven days.
B. "I started taking my furosemide right before I went to sleep."
Which of the following maternal infections can increase the risk of congenital heart defects
in the fetus?
A. Parainfluenza
, B. Adenovirus
C. Rubella
D. Measles
C. Rubella
The nurse is caring for a patient with a Sengstaken-Blakemore tube. She performs her
safety checks at the beginning of the shift and ensures which af the following priority items is
readily avalable at the bedside?
A.Trach kit
B. Scissors
C.Obturator
D. Yaunker
B. Scissors
After breakfast, a diabetic patient receives ten units of regular insulin and twenty units of
NPH insulin daily. What should the nurse do next after completing the usual insulin
preparation steps? A. Draw up NPH insulin first because it is clear.
B. Either insulin can be drawn first as long as 30 units are given.
C. Draw up Regular insulin first because it is clear.
D. Administer each type of insulin separately for accuracy.
C. First, make regular insulin because it's obvious. The nurse is taking care of a client with
Encopresis. Which of the following descriptions of Encopresis is correct? A. Frequent,
difficult-to-pass stools that persist for more than two weeks. B. Voluntary or involuntary fecal
incontinence in children over the age of 4 who were previously toilet trained.
C. Involuntary fecal incontinence in children over the age of 4 who were previously toilet
trained.
D. unable to pass stool as a result of feces impaction. B. fecal incontinence in children
over the age of four who were previously toilet-trained, whether involuntary or voluntary.
Right patient
Right medication
Right dose
The right path Right time
Right documentation
Exactly why Right response
The patient receives two divided daily doses of 200 mg PO phenytoin. What instruction from
the nurse is incorrect?
A. "You will need annual labs to determine the medication level in your body."
B. "Remember never to skip a dose of this medication."
C. "While you are taking this medication, you need to take in more vitamin D." D. "Practice
good oral hygiene and go to the dentist on a regular basis." A. "In order to ascertain your
body's medication level, you will need annual lab tests. Digoxin is being given to the
15-year-old patient with congestive heart failure by the nurse. She is aware that before
giving the medication, she should check the pulse rate and hold it for a pulse that is less
than _____. 70
A client's education about risk factors that can be changed and those that can't is being
reinforced by the LPN. Which of the following is most likely able to be corrected?
A. Genetic predisposition
B. Lifestyle choices
C. Depression
D. All of the above
