Grade A+ NGN/NCLEX Prep Questions/Rationales with ans 2025
The nurse should suspect
Your Answer: hypokalemiaCorrect Answer: hypokalemia
because of the
Your Answer: flattened T waves and occasional U wavesCorrect
Answer: flattened T waves and occasional U waves
Rationale:Cardiac changes in hypokalemia include impaired re-
The nurse notes the presence of a P wave, QRS complex, flat-
polarization, resulting in a flattening of the T wave and eventually
tened T waves, and occasional U waves on a client's cardiac
monitor screen. Fill in the correct missing information by choosing the emergence of a U wave. Therefore, the nurse should suspect
from the lists of options in the drop-down menus. hypokalemia. The incidence of potentially lethal ventricular dys-
rhythmias is increased in hypokalemia. The nurse should immedi-
ately assess the client's vital signs and cardiac status for signs of
hypokalemia. The nurse should also check the client's most recent
serum potassium level and then contact the primary health care
provider to report the findings and obtain prescriptions to treat the
hypokalemic state.
The nurse should: (Select 1 option)
Ask the client if the chain and medal can be removed during the
procedure.
Because: (Select 1 option)
The chain and medal may have cultural significance.
The nurse is preparing a client for a chest x-ray and notes that the
client is wearing a religious medal on a chain around the neck. Rationale:Before certain diagnostic procedures, it is typical to
What should the nurse do with regard to this personal item? Click have a client remove personal objects that are worn on the body
to highlight the correct answer from the options provided. because of client safety and the possibility of compromising test
results. Therefore, the nurse should ask the client about the sig-
nificance of such an item and its removal because it may have
cultural or spiritual significance. If so, the nurse should ask the
client if the item can be either removed temporarily or placed on
another part of the body during the procedure if appropriate.
The nurse should: (Select 1 option)
Cancel the surgery.
Contact the surgeon.
Discuss the client's concerns.
Call the identified support person.
Because: (Select 1 option)
Client consent is required prior to any procedure.
Further questions or concerns should be determined and ad-
dressed.
Ethical considerations are important for a client undergoing
surgery.
The nursing scope of practice places limitations on how the nurse
While preparing a client for surgery scheduled in 1 hour, the client
can respond.
states to the nurse: "I have changed my mind. I don't want this
surgery." Click to highlight the correct answer from the options
Rationale:If the client indicates that he or she does not want
provided.
a prescribed therapy, treatment, or procedure such as surgery,
the nurse should further investigate the client's request. If the
client indicates that he or she has changed his or her mind about
surgery, the nurse should assess the client and explore with the
client his or her concerns about not wanting the surgery. The nurse
would then withhold further surgical preparation and contact the
surgeon to report the client's request so that the surgeon can
discuss the consequences of not having the surgery with the client.
Further assessment and follow-up related to the client's request
need to be done. It is the client's right to refuse treatment; however,
further investigation is needed so the interventions can be tailored
to specific needs.
The nurse notes that there has been an increase in the number of
intravenous (IV) site infections that developed in the clients being
cared for on the nursing unit. How should the nurse proceed to
implement a quality improvement program?For each action, click
to specify whether the action would be:
Indicated: an action that the nurse should take to resolve the problem
, Grade A+ NGN/NCLEX Prep Questions/Rationales with ans 2025
Non-essential: an action that the nurse could take without harming
, Grade A+ NGN/NCLEX Prep Questions/Rationales with ans 2025
Collect identifying patient information
Contraindicated
Note the mental status of the client
Non-essential
Note primary and secondary diagnoses of clients affected
Indicated
Note the type of IV catheter used
Indicated
Note the type of IV site dressings being used
Indicated
Note the medication types being infused
Non-essential
Note frequency of assessments of IV sites
Indicated
Note the expected duration of the IV site
Non-essential
Note care procedures to the IV site
Indicated
Note frequency of changing IV sites
Indicated
Rationale:Quality improvement, also known as performance im-
provement, focuses on processes or systems that significantly
contribute to client safety and effective client care outcomes;
criteria are used to monitor outcomes of care and to determine
the need for change to improve the quality of care. If the nurse
notes a particular problem, such as an increase in the number of
intravenous (IV) site infections, the nurse should collect data about
the problem. This should include information such as the primary
and secondary diagnoses of the clients developing the infection,
the type of IV catheters being used, the site of the catheter, IV
site dressings being used, frequency of assessment and methods
of care to the IV site, and length of time that the IV catheter was
inserted. Once these data are collected and analyzed, the nurse
should examine evidence-based practice protocols to identify the
best practices for care to IV sites to prevent infection. These
practices can then be implemented and followed by evaluation
of results based on the evidence-based practice protocols used.
Collecting identifying client information is contraindicated because
of confidentiality and is unnecessary in this quality improvement
effort. Noting the mental status of the clients can be done but is not
likely to address the problem. Noting the types of medications be-
ing infused can also be done, but will not address the problem of IV
site infection. Although it is helpful to know the expected duration
of the IV site, this information does not change infection control
practices in managing the IV site and is therefore considered a
non-essential action.
The test result is
Your Answer: Abnormal Correct Answer: Abnormal
because
Your Answer: The time for color to return is prolonge Correct
The nurse performs an Allen's test on a client scheduled for Answer: The time for color to return is prolonged
an arterial blood gas draw from the radial artery. On release of
pressure from the ulnar artery, color in the hand returns after 20 Rationale:Failure to determine the presence of adequate collateral
seconds. How should the nurse interpret the finding? Fill in the circulation before drawing an arterial blood gas specimen could
correct missing information by choosing from the lists of options result in severe ischemic injury to the hand if damage to the radial
in the drop-down menus. artery occurs with arterial puncture. Upon release of pressure on
the ulnar artery, if pinkness fails to return within 6 to 7 seconds, the
ulnar artery is insufficient, indicating that the radial artery should
not be used for obtaining a blood specimen. Another site needs to
be selected for the arterial puncture, and the primary health care
provider needs to be notified of the finding.
The nurse has just received a client from the postanesthesia care
unit (PACU) and is monitoring the client's vital signs. Click to
The nurse should suspect
Your Answer: hypokalemiaCorrect Answer: hypokalemia
because of the
Your Answer: flattened T waves and occasional U wavesCorrect
Answer: flattened T waves and occasional U waves
Rationale:Cardiac changes in hypokalemia include impaired re-
The nurse notes the presence of a P wave, QRS complex, flat-
polarization, resulting in a flattening of the T wave and eventually
tened T waves, and occasional U waves on a client's cardiac
monitor screen. Fill in the correct missing information by choosing the emergence of a U wave. Therefore, the nurse should suspect
from the lists of options in the drop-down menus. hypokalemia. The incidence of potentially lethal ventricular dys-
rhythmias is increased in hypokalemia. The nurse should immedi-
ately assess the client's vital signs and cardiac status for signs of
hypokalemia. The nurse should also check the client's most recent
serum potassium level and then contact the primary health care
provider to report the findings and obtain prescriptions to treat the
hypokalemic state.
The nurse should: (Select 1 option)
Ask the client if the chain and medal can be removed during the
procedure.
Because: (Select 1 option)
The chain and medal may have cultural significance.
The nurse is preparing a client for a chest x-ray and notes that the
client is wearing a religious medal on a chain around the neck. Rationale:Before certain diagnostic procedures, it is typical to
What should the nurse do with regard to this personal item? Click have a client remove personal objects that are worn on the body
to highlight the correct answer from the options provided. because of client safety and the possibility of compromising test
results. Therefore, the nurse should ask the client about the sig-
nificance of such an item and its removal because it may have
cultural or spiritual significance. If so, the nurse should ask the
client if the item can be either removed temporarily or placed on
another part of the body during the procedure if appropriate.
The nurse should: (Select 1 option)
Cancel the surgery.
Contact the surgeon.
Discuss the client's concerns.
Call the identified support person.
Because: (Select 1 option)
Client consent is required prior to any procedure.
Further questions or concerns should be determined and ad-
dressed.
Ethical considerations are important for a client undergoing
surgery.
The nursing scope of practice places limitations on how the nurse
While preparing a client for surgery scheduled in 1 hour, the client
can respond.
states to the nurse: "I have changed my mind. I don't want this
surgery." Click to highlight the correct answer from the options
Rationale:If the client indicates that he or she does not want
provided.
a prescribed therapy, treatment, or procedure such as surgery,
the nurse should further investigate the client's request. If the
client indicates that he or she has changed his or her mind about
surgery, the nurse should assess the client and explore with the
client his or her concerns about not wanting the surgery. The nurse
would then withhold further surgical preparation and contact the
surgeon to report the client's request so that the surgeon can
discuss the consequences of not having the surgery with the client.
Further assessment and follow-up related to the client's request
need to be done. It is the client's right to refuse treatment; however,
further investigation is needed so the interventions can be tailored
to specific needs.
The nurse notes that there has been an increase in the number of
intravenous (IV) site infections that developed in the clients being
cared for on the nursing unit. How should the nurse proceed to
implement a quality improvement program?For each action, click
to specify whether the action would be:
Indicated: an action that the nurse should take to resolve the problem
, Grade A+ NGN/NCLEX Prep Questions/Rationales with ans 2025
Non-essential: an action that the nurse could take without harming
, Grade A+ NGN/NCLEX Prep Questions/Rationales with ans 2025
Collect identifying patient information
Contraindicated
Note the mental status of the client
Non-essential
Note primary and secondary diagnoses of clients affected
Indicated
Note the type of IV catheter used
Indicated
Note the type of IV site dressings being used
Indicated
Note the medication types being infused
Non-essential
Note frequency of assessments of IV sites
Indicated
Note the expected duration of the IV site
Non-essential
Note care procedures to the IV site
Indicated
Note frequency of changing IV sites
Indicated
Rationale:Quality improvement, also known as performance im-
provement, focuses on processes or systems that significantly
contribute to client safety and effective client care outcomes;
criteria are used to monitor outcomes of care and to determine
the need for change to improve the quality of care. If the nurse
notes a particular problem, such as an increase in the number of
intravenous (IV) site infections, the nurse should collect data about
the problem. This should include information such as the primary
and secondary diagnoses of the clients developing the infection,
the type of IV catheters being used, the site of the catheter, IV
site dressings being used, frequency of assessment and methods
of care to the IV site, and length of time that the IV catheter was
inserted. Once these data are collected and analyzed, the nurse
should examine evidence-based practice protocols to identify the
best practices for care to IV sites to prevent infection. These
practices can then be implemented and followed by evaluation
of results based on the evidence-based practice protocols used.
Collecting identifying client information is contraindicated because
of confidentiality and is unnecessary in this quality improvement
effort. Noting the mental status of the clients can be done but is not
likely to address the problem. Noting the types of medications be-
ing infused can also be done, but will not address the problem of IV
site infection. Although it is helpful to know the expected duration
of the IV site, this information does not change infection control
practices in managing the IV site and is therefore considered a
non-essential action.
The test result is
Your Answer: Abnormal Correct Answer: Abnormal
because
Your Answer: The time for color to return is prolonge Correct
The nurse performs an Allen's test on a client scheduled for Answer: The time for color to return is prolonged
an arterial blood gas draw from the radial artery. On release of
pressure from the ulnar artery, color in the hand returns after 20 Rationale:Failure to determine the presence of adequate collateral
seconds. How should the nurse interpret the finding? Fill in the circulation before drawing an arterial blood gas specimen could
correct missing information by choosing from the lists of options result in severe ischemic injury to the hand if damage to the radial
in the drop-down menus. artery occurs with arterial puncture. Upon release of pressure on
the ulnar artery, if pinkness fails to return within 6 to 7 seconds, the
ulnar artery is insufficient, indicating that the radial artery should
not be used for obtaining a blood specimen. Another site needs to
be selected for the arterial puncture, and the primary health care
provider needs to be notified of the finding.
The nurse has just received a client from the postanesthesia care
unit (PACU) and is monitoring the client's vital signs. Click to
