NCLEX-RN Test 1 NGN
GRADED A+
The nurse witnesses the collapse of a 1. Initiate chest compressions
child while outdoors. The child is not
breathing and has a pulse of 50/min. The Rescue breathing is performed at a rate
nurse calls emergency services and ini- of 1 breath every 2-3 seconds. If the
tiates rescue breathing. After 2 minutes pulse remains <60/min and there are
of rescue breaths, the child is still not signs of poor perfusion (skin pallor), the
breathing and is pale with a pulse of nurse should initiate chest compressions
30/min. What is the nurse's next action? and reassess the pulse every 2 minutes
3. Client who had a bowel resection 1
day ago and client with asthma exacer-
bation.
When making room assignments, it is
The charger nurse is responsible for important to remember that a client with
making room assignments multiple an active or suspected infection should
clients. Which pari of client assignments not be paired with a client who has a
to a shared room is appropriate? fresh surgical wound or is immunocom-
promised. A client having an asthma ex-
acerbation does not have an infection
and is not at risk for spreading infection to
a client who had a recent bowel resection
surgery.
2. "I plan to attend my grandchild's grad-
uation next month"
Clients receiving treatment for depres-
sion and suicidal ideation must be care-
fully monitored for indications of increas-
The clinic nurse is assessing a client who
ing suicidal intent. During a client inter-
is being treated for depression and suici-
view, the nurse should assess:
dal ideation. Which client statement best
- Access to psychiatric medications
indicates that the client is not currently at
- Availability of help during a crisis (coun-
risk for suicide?
selor, family)
- Future goals and plans
- Home and environment risks
- Overall affect and level of energy
- Possible access to weapons
, NCLEX-RN Test 1 NGN
GRADED A+
Clients who articulate long-term person-
al goals and family milestones are less
likely to attempt death by suicide
1. Administer potassium supplement
In ventricular trigeminy, premature ven-
tricular contractions (PVCs) occur every
third heartbeat. Myocardial injury (eg,
myocardial infarction) predisposes the
client to ectopy (eg, PVCs), which in-
creases the client's risk for lethal dys-
rhythmias (eg, ventricular tachycardia).
PVCs are caused and/or exacerbated
by hypoxia, electrolyte imbalances, emo-
The nurse is caring for a client who had tional stress, stimulants, fever, and exer-
an anterior wall myocardial infarction 2 cise.
days ago. The telemetry technician noti-
fies the nurse at 8:30 AM that the client This client's morning laboratory re-
is in ventricular trigeminy. What is the sults show hypokalemia (potassium <3.5
nurse's priority intervention? mEq/L [3.5 mmol/L]); therefore, the prior-
ity is treatment of the underlying cause
of the ectopy by administering the pre-
scribed potassium replacement (Option
1). Health care providers (HCPs) often
prescribe electrolyte replacement algo-
rithms to clients at risk for electrolyte im-
balances (eg, myocardial injury, receiv-
ing diuretics) unless a contraindication
exists (eg, serum creatinine >1.5 mg/dL
[133 µmol/L], anuric, weight <99.2 lb [45
kg]).
3. Explain the client's resuscitation direc-
The nurse cares for a client with a ter-
tive to the client's child
minal disease who created a do not
attempt resuscitation (DNAR) directive.
Clients can create a do not attempt re-
The client stops breathing and loses
suscitation (DNAR) directive instructing
their pulse. The client's adult child states,
that CPR and other life-saving measures
"Please, do whatever you can to save
be withheld. With an advance directive
, NCLEX-RN Test 1 NGN
Study online at https://quizlet.com/_edx254
in place, the client's wishes should be
them!" Which intervention is appropri-
followed, even if they conflict with the
ate?
wishes of loved ones
2. Client who underwent coronary artery
stent placement via femoral approach 3
hours ago and is reporting severe back
pain
A client who undergoes percutaneous
coronary intervention (PCI) and intra-
coronary stent placement using the
femoral approach is at increased risk for
retroperitoneal hemorrhage. Administra-
The nurse in the cardiac intensive care tion of antithrombotic drugs before, dur-
unit receives report on 4 clients. Which ing, and after PCI can exacerbate poten-
client should the nurse assess first? tially life-threatening bleeding from the
femoral artery.
Hypotension, back pain, flank ecchymo-
sis (eg, Grey Turner sign), hematoma
formation, and diminished distal pulses
can be early signs of bleeding into the
retroperitoneal space and require imme-
diate intervention (eg, notify health care
provider, serial complete blood count, CT
scan of the abdomen)
4. Peripheral arterial disease
Bone healing depends on multiple fac-
The nurse is reviewing the medical his- tors, including nutrition, adequate circu-
tory of a client who has sustained a right lation, and age. A client with peripheral
tibia/fibula fracture from a fall. The nurse arterial disease has decreased perfusion
identifies which finding as most likely to to the extremities due to atherosclerot-
hinder healing? ic changes in the arteries. Without ade-
quate perfusion, the bone is not supplied
with the oxygen and nutrients required
for healing
Based on the nursing assessment
progress notes, what is the correct stag-
ing of the client's pressure injury? Click
on the exhibit button for additional infor-
, NCLEX-RN Test 1 NGN
Study online at https://quizlet.com/_edx254
WRONG
2. Stage 2: Stage 2 pressure injuries
have partial-thickness skin loss (abra-
sion, blister, or shallow crater). The skin
blisters or forms an open sore, and the
area around the sore may be red and
irritated. (shallow, open ulcer, red-pink
wound with no sloughing and possible
intact or ruptured blister)
Stage 1: Intact skin with nonblanchable
redness
Stage 2: Partial-thickness skin loss
(abrasion, blister, or shallow crater) in-
volving the dermis or epidermis; the
wound bed is red or pink and may be
shiny or dry
Stage 3: Full-thickness skin loss; subcu-
taneous fat is visible but not tendon, mus-
cle, or bone; tunneling may be present
Stage 4: Full-thickness skin loss with vis-
ible tendon, muscle, or bone; slough or
eschar (scabbing, dead tissue) may be
present; undermining and tunneling may
be present
Pressure injuries are described as "un-
stageable" if the base is covered by
necrotic tissue or eschar
4. Administer 37 units of insulin: 25 units
of NPH mixed with 12 units of regular
insulin in the same syringe, drawing up
the regular insulin first
Intermediate-acting insulins (NPH) can
be safely mixed with short-acting (reg-
ular) and rapid-acting (eg, lispro, as-
part) insulins in one syringe. Regular
insulin should be drawn into the sy-
GRADED A+
The nurse witnesses the collapse of a 1. Initiate chest compressions
child while outdoors. The child is not
breathing and has a pulse of 50/min. The Rescue breathing is performed at a rate
nurse calls emergency services and ini- of 1 breath every 2-3 seconds. If the
tiates rescue breathing. After 2 minutes pulse remains <60/min and there are
of rescue breaths, the child is still not signs of poor perfusion (skin pallor), the
breathing and is pale with a pulse of nurse should initiate chest compressions
30/min. What is the nurse's next action? and reassess the pulse every 2 minutes
3. Client who had a bowel resection 1
day ago and client with asthma exacer-
bation.
When making room assignments, it is
The charger nurse is responsible for important to remember that a client with
making room assignments multiple an active or suspected infection should
clients. Which pari of client assignments not be paired with a client who has a
to a shared room is appropriate? fresh surgical wound or is immunocom-
promised. A client having an asthma ex-
acerbation does not have an infection
and is not at risk for spreading infection to
a client who had a recent bowel resection
surgery.
2. "I plan to attend my grandchild's grad-
uation next month"
Clients receiving treatment for depres-
sion and suicidal ideation must be care-
fully monitored for indications of increas-
The clinic nurse is assessing a client who
ing suicidal intent. During a client inter-
is being treated for depression and suici-
view, the nurse should assess:
dal ideation. Which client statement best
- Access to psychiatric medications
indicates that the client is not currently at
- Availability of help during a crisis (coun-
risk for suicide?
selor, family)
- Future goals and plans
- Home and environment risks
- Overall affect and level of energy
- Possible access to weapons
, NCLEX-RN Test 1 NGN
GRADED A+
Clients who articulate long-term person-
al goals and family milestones are less
likely to attempt death by suicide
1. Administer potassium supplement
In ventricular trigeminy, premature ven-
tricular contractions (PVCs) occur every
third heartbeat. Myocardial injury (eg,
myocardial infarction) predisposes the
client to ectopy (eg, PVCs), which in-
creases the client's risk for lethal dys-
rhythmias (eg, ventricular tachycardia).
PVCs are caused and/or exacerbated
by hypoxia, electrolyte imbalances, emo-
The nurse is caring for a client who had tional stress, stimulants, fever, and exer-
an anterior wall myocardial infarction 2 cise.
days ago. The telemetry technician noti-
fies the nurse at 8:30 AM that the client This client's morning laboratory re-
is in ventricular trigeminy. What is the sults show hypokalemia (potassium <3.5
nurse's priority intervention? mEq/L [3.5 mmol/L]); therefore, the prior-
ity is treatment of the underlying cause
of the ectopy by administering the pre-
scribed potassium replacement (Option
1). Health care providers (HCPs) often
prescribe electrolyte replacement algo-
rithms to clients at risk for electrolyte im-
balances (eg, myocardial injury, receiv-
ing diuretics) unless a contraindication
exists (eg, serum creatinine >1.5 mg/dL
[133 µmol/L], anuric, weight <99.2 lb [45
kg]).
3. Explain the client's resuscitation direc-
The nurse cares for a client with a ter-
tive to the client's child
minal disease who created a do not
attempt resuscitation (DNAR) directive.
Clients can create a do not attempt re-
The client stops breathing and loses
suscitation (DNAR) directive instructing
their pulse. The client's adult child states,
that CPR and other life-saving measures
"Please, do whatever you can to save
be withheld. With an advance directive
, NCLEX-RN Test 1 NGN
Study online at https://quizlet.com/_edx254
in place, the client's wishes should be
them!" Which intervention is appropri-
followed, even if they conflict with the
ate?
wishes of loved ones
2. Client who underwent coronary artery
stent placement via femoral approach 3
hours ago and is reporting severe back
pain
A client who undergoes percutaneous
coronary intervention (PCI) and intra-
coronary stent placement using the
femoral approach is at increased risk for
retroperitoneal hemorrhage. Administra-
The nurse in the cardiac intensive care tion of antithrombotic drugs before, dur-
unit receives report on 4 clients. Which ing, and after PCI can exacerbate poten-
client should the nurse assess first? tially life-threatening bleeding from the
femoral artery.
Hypotension, back pain, flank ecchymo-
sis (eg, Grey Turner sign), hematoma
formation, and diminished distal pulses
can be early signs of bleeding into the
retroperitoneal space and require imme-
diate intervention (eg, notify health care
provider, serial complete blood count, CT
scan of the abdomen)
4. Peripheral arterial disease
Bone healing depends on multiple fac-
The nurse is reviewing the medical his- tors, including nutrition, adequate circu-
tory of a client who has sustained a right lation, and age. A client with peripheral
tibia/fibula fracture from a fall. The nurse arterial disease has decreased perfusion
identifies which finding as most likely to to the extremities due to atherosclerot-
hinder healing? ic changes in the arteries. Without ade-
quate perfusion, the bone is not supplied
with the oxygen and nutrients required
for healing
Based on the nursing assessment
progress notes, what is the correct stag-
ing of the client's pressure injury? Click
on the exhibit button for additional infor-
, NCLEX-RN Test 1 NGN
Study online at https://quizlet.com/_edx254
WRONG
2. Stage 2: Stage 2 pressure injuries
have partial-thickness skin loss (abra-
sion, blister, or shallow crater). The skin
blisters or forms an open sore, and the
area around the sore may be red and
irritated. (shallow, open ulcer, red-pink
wound with no sloughing and possible
intact or ruptured blister)
Stage 1: Intact skin with nonblanchable
redness
Stage 2: Partial-thickness skin loss
(abrasion, blister, or shallow crater) in-
volving the dermis or epidermis; the
wound bed is red or pink and may be
shiny or dry
Stage 3: Full-thickness skin loss; subcu-
taneous fat is visible but not tendon, mus-
cle, or bone; tunneling may be present
Stage 4: Full-thickness skin loss with vis-
ible tendon, muscle, or bone; slough or
eschar (scabbing, dead tissue) may be
present; undermining and tunneling may
be present
Pressure injuries are described as "un-
stageable" if the base is covered by
necrotic tissue or eschar
4. Administer 37 units of insulin: 25 units
of NPH mixed with 12 units of regular
insulin in the same syringe, drawing up
the regular insulin first
Intermediate-acting insulins (NPH) can
be safely mixed with short-acting (reg-
ular) and rapid-acting (eg, lispro, as-
part) insulins in one syringe. Regular
insulin should be drawn into the sy-
