NCLEX RN
STUDY GUIDE
GRADED A
, NCSBN ON-LINE REVIEW 2021-2022
1.A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room.
The most
important reason for the nurse to elevate the casted leg is to
Promote the client's
comfort Reduce the
drying time Decrease
irritation to the skin
Improve venous return
D: Improve venous return. Elevating the leg both improves venous return and reduces swelling. Client
comfort will be improved as well.
The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the
appropriate sequence to teach the client?
Clean the meatus, begin voiding, then catch
urine stream Void a little, clean the meatus,
then collect specimen Clean the meatus, then
urinate into container
Void continuously and catch some of the urine
A: Clean the meatus, begin voiding, then catch urine stream. A clean catch urine is difficult to obtain
and requires clear directions. Instructing the client to carefully clean the meatus, then void naturally
with a steady stream prevents surface bacteria from contaminating the urine specimen. As starting
and stopping flow can be difficult, once the client begins voiding it’s best to just slip the container into
the stream. Other responses do not reflect correct technique
Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
16 year-old who had an open reduction of a fractured wrist
10 hours ago 20 year-old in skeletal traction for 2 weeks
since a motor cycle accident 72 year-old recovering from
surgery after a hip replacement 2 hours ago 75 year-old
who is in skin traction prior to planned hip pinning surgery.
C: Look for the client who has the most imminent risks and acute vulnerability. The client who returned
from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first. The 16
year- old should be seen next because it is still the first post-op day. The 75 year- old is potentially
vulnerable to age-related physical and cognitive consequences in skin traction should be seen next.
The client who can safely be seen last is the 20 year-old who is 2 weeks post-injury.
A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is
independent. What should the nurse document to most accurately describe the client's condition?
Comatose, breathing unlabored
Glascow Coma Scale 8, respirations
regular Appears to be sleeping, vital
signs stable Glascow Coma Scale 13, no
ventilator required
B: Glascow Coma Scale 8, respirations regular. The Glascow Coma Scale provides a standard
reference for assessing or monitoring level of consciousness. Any score less than 13 indicates a
neurological impairment. Using the term comatose provides too much room for interpretation and is
not very precise.
When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse
monitor to determine therapeutic response to the drug?
Bleeding time
Coagulation
time
Prothrombin
time
Partial thromboplastin time
C: Prothrombin time. Coumadin is ordered daily, based on the client''s prothrombin time (PT). This test
evaluates the adequacy of the extrinsic system and common pathway in the clotting cascade;
Coumadin affects the Vitamin K dependent clotting factors.
client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak
flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest
tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first?
,Notify both the surgeon and
provider Administer the prn
dose of albuterol
Apply oxygen at 2 litDeroswpnelorandaesdalbcya: nkinsuhlea |
Repeat the peak flow reaDdisintrgibiunti3o0n omf itnhuistedsocument is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study Material
A) The client lost 2 pounds in 24 hours
The client’s potassium level is 4 mEq/liter.
The client’s urine output was 1500 cc in 5 hours
The client is to receive another dose of Lasix at 10 PM
C: The client’s urine output was 1500 cc in 5 hours. Although all of these may be correct
information to include in report, the essential piece would be the urine output.
8.A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted
on the initial
nursing assessment requires quick intervention by the nurse?
a report of 10 pounds weight loss in the
last month a comment by the client "I just
can't sit still."
the appearance of eyeballs that appear to "pop" out of the
client's eye sockets a report of the sudden onset of irritability in
the past 2 weeks
C: the appearance of eyeballs that appear to "pop" out of the client''s eye sockets. Exophthalmos or
protruding eyeballs is a distinctive characteristic of Graves'' Disease. It can result in corneal abrasions
with severe eye pain or damage when the eyelid is unable to blink down over the protruding eyeball.
Eye drops or ointment may be needed.
The nurse has performed the initial assessments of 4 clients admitted with an acute
episode of asthma. Which assessment finding would cause the nurse to call the provider
immediately?
prolonged inspiration with each breath
expiratory wheezes that are suddenly absent in 1
lobe expectoration of large amounts of purulent
mucous appearance of the use of abdominal
muscles for breathing
B: expiratory wheezes that are suddenly absent in 1 lobe. Acute asthma is characterized by expiratory
wheezes caused by obstruction of the airways. Wheezes are a high pitched musical sounds produced
by air moving through narrowed airways. Clients often associate wheezes with the feeling of tightness
in the chest. However, sudden cessation of wheezing is an ominous or bad sign that indicates an
emergency -- the small airways are now collapsed.
10. During the initial home visit, a nurse is discussing the care of a client newly diagnosed with
Alzheimer's disease with family members. Which of these interventions would be most helpful at
this time?
leave a book about relaxation techniques
write out a daily exercise routine for them to assist the
client to do list actions to improve the client's daily
nutritional intake
suggest communication strategies
D: suggest communication strategies. Alzheimer''s disease, a progressive chronic illness, greatly
challenges caregivers. The nurse can be of greatest assistance in helping the family to use
communication strategies to enhance their ability to relate to the client. By use of select verbal and
nonverbal communication strategies the family can best support the client’s strengths and cope with
any aberrant behavior.
11. An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood
pressure from 160/100 to 180/110 over the past 2 hours. The nurse has also noted increased lethargy.
Which assessment finding should the nurse report immediately to the provider?
Slurred
speech
Incontinence
Muscle
weakness
Rapid pulse
A: Slurred speech. Changes in speech patterns and level of conscious can be indicators of continued
intracranial bleeding or extension of the stroke. Further diagnostic testing may be indicated.
A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which
STUDY GUIDE
GRADED A
, NCSBN ON-LINE REVIEW 2021-2022
1.A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room.
The most
important reason for the nurse to elevate the casted leg is to
Promote the client's
comfort Reduce the
drying time Decrease
irritation to the skin
Improve venous return
D: Improve venous return. Elevating the leg both improves venous return and reduces swelling. Client
comfort will be improved as well.
The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the
appropriate sequence to teach the client?
Clean the meatus, begin voiding, then catch
urine stream Void a little, clean the meatus,
then collect specimen Clean the meatus, then
urinate into container
Void continuously and catch some of the urine
A: Clean the meatus, begin voiding, then catch urine stream. A clean catch urine is difficult to obtain
and requires clear directions. Instructing the client to carefully clean the meatus, then void naturally
with a steady stream prevents surface bacteria from contaminating the urine specimen. As starting
and stopping flow can be difficult, once the client begins voiding it’s best to just slip the container into
the stream. Other responses do not reflect correct technique
Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
16 year-old who had an open reduction of a fractured wrist
10 hours ago 20 year-old in skeletal traction for 2 weeks
since a motor cycle accident 72 year-old recovering from
surgery after a hip replacement 2 hours ago 75 year-old
who is in skin traction prior to planned hip pinning surgery.
C: Look for the client who has the most imminent risks and acute vulnerability. The client who returned
from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first. The 16
year- old should be seen next because it is still the first post-op day. The 75 year- old is potentially
vulnerable to age-related physical and cognitive consequences in skin traction should be seen next.
The client who can safely be seen last is the 20 year-old who is 2 weeks post-injury.
A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is
independent. What should the nurse document to most accurately describe the client's condition?
Comatose, breathing unlabored
Glascow Coma Scale 8, respirations
regular Appears to be sleeping, vital
signs stable Glascow Coma Scale 13, no
ventilator required
B: Glascow Coma Scale 8, respirations regular. The Glascow Coma Scale provides a standard
reference for assessing or monitoring level of consciousness. Any score less than 13 indicates a
neurological impairment. Using the term comatose provides too much room for interpretation and is
not very precise.
When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse
monitor to determine therapeutic response to the drug?
Bleeding time
Coagulation
time
Prothrombin
time
Partial thromboplastin time
C: Prothrombin time. Coumadin is ordered daily, based on the client''s prothrombin time (PT). This test
evaluates the adequacy of the extrinsic system and common pathway in the clotting cascade;
Coumadin affects the Vitamin K dependent clotting factors.
client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak
flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest
tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first?
,Notify both the surgeon and
provider Administer the prn
dose of albuterol
Apply oxygen at 2 litDeroswpnelorandaesdalbcya: nkinsuhlea |
Repeat the peak flow reaDdisintrgibiunti3o0n omf itnhuistedsocument is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study Material
A) The client lost 2 pounds in 24 hours
The client’s potassium level is 4 mEq/liter.
The client’s urine output was 1500 cc in 5 hours
The client is to receive another dose of Lasix at 10 PM
C: The client’s urine output was 1500 cc in 5 hours. Although all of these may be correct
information to include in report, the essential piece would be the urine output.
8.A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted
on the initial
nursing assessment requires quick intervention by the nurse?
a report of 10 pounds weight loss in the
last month a comment by the client "I just
can't sit still."
the appearance of eyeballs that appear to "pop" out of the
client's eye sockets a report of the sudden onset of irritability in
the past 2 weeks
C: the appearance of eyeballs that appear to "pop" out of the client''s eye sockets. Exophthalmos or
protruding eyeballs is a distinctive characteristic of Graves'' Disease. It can result in corneal abrasions
with severe eye pain or damage when the eyelid is unable to blink down over the protruding eyeball.
Eye drops or ointment may be needed.
The nurse has performed the initial assessments of 4 clients admitted with an acute
episode of asthma. Which assessment finding would cause the nurse to call the provider
immediately?
prolonged inspiration with each breath
expiratory wheezes that are suddenly absent in 1
lobe expectoration of large amounts of purulent
mucous appearance of the use of abdominal
muscles for breathing
B: expiratory wheezes that are suddenly absent in 1 lobe. Acute asthma is characterized by expiratory
wheezes caused by obstruction of the airways. Wheezes are a high pitched musical sounds produced
by air moving through narrowed airways. Clients often associate wheezes with the feeling of tightness
in the chest. However, sudden cessation of wheezing is an ominous or bad sign that indicates an
emergency -- the small airways are now collapsed.
10. During the initial home visit, a nurse is discussing the care of a client newly diagnosed with
Alzheimer's disease with family members. Which of these interventions would be most helpful at
this time?
leave a book about relaxation techniques
write out a daily exercise routine for them to assist the
client to do list actions to improve the client's daily
nutritional intake
suggest communication strategies
D: suggest communication strategies. Alzheimer''s disease, a progressive chronic illness, greatly
challenges caregivers. The nurse can be of greatest assistance in helping the family to use
communication strategies to enhance their ability to relate to the client. By use of select verbal and
nonverbal communication strategies the family can best support the client’s strengths and cope with
any aberrant behavior.
11. An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood
pressure from 160/100 to 180/110 over the past 2 hours. The nurse has also noted increased lethargy.
Which assessment finding should the nurse report immediately to the provider?
Slurred
speech
Incontinence
Muscle
weakness
Rapid pulse
A: Slurred speech. Changes in speech patterns and level of conscious can be indicators of continued
intracranial bleeding or extension of the stroke. Further diagnostic testing may be indicated.
A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which
