NCSBN NCLEX RN CERTIFICATION
EVALUATION TESTED QUESTIONS AND
VERIFIED RESPONSES GRADED A+
⩥ The home health nurse observes the client change an ileostomy pouch.
Which action is best to help prevent skin breakdown?
A. Use deodorant soaps the contain lotion to clean the stoma
B. Change the stoma pouch daily
C. Apply antiseptic cream to reddened stoma
D. Make sure the skin around the stoma is wrinkle-free
Answer: D
The ileostomy pouch should be changed approximately every 5 to 7
days; the bag should be emptied about every 4 to 6 hours. Before
applying a pouch, the stoma and skin around the stoma should be gently
cleaned using mild soap and water and allowed to dry. A skin barrier
powder or other skin prep can be applied to intact skin around the stoma
- but not to the stoma. The skin around the stoma should be dry and
wrinkle-free before applying a new pouch or wafer to ensure a tight,
leak-free seal.
⩥ A nurse is caring for a client who is receiving a blood transfusion and
develops urticaria one-half hour after the transfusion has begun. What is
the first action the nurse should take?
,A. Slow the rate of infusion
B. Stop the infusion
C. Take vital signs and observe for further deterioration
D. Administer Benadryl and continue the infusion
Answer: B
This is an indication of an allergy to the plasma protein. The priority
action of the nurse is to stop the transfusion by disconnecting at the IV
insertion site. The nurse should then start a saline line at the IV insertion
site and notify the health care provider.
⩥ A client has end-stage renal disease. Which of these statements made
by the client indicates a correct understanding of the issues related to
this disease?
A. "I can expect to have periods of little urine and then sometimes a lot
of urine."
B. "I have to go for epoetin (Procrit) injections at the health
department."
C. "I know I have a high risk of clot formation since my blood is thick
from too many red cells."
D. "My bones will be stronger with this disease since I will have higher
calcium than normal."
Answer: B
,Anemia in end-stage renal failure is caused by reduced endogenous
erythropoietin production in the kidney. Anemia in primary end-stage
renal disease is treated with subcutaneous injections of Procrit or
Epogen to stimulate the bone marrow to produce red blood cells. With
kidney failure, too much phosphorus can build up in the blood and
calcium is pulled from the bones, resulting in weakened bones. The
statement about producing variable amounts of urine is incorrect, as the
client will produce little to no urine at this stage of the disease.
⩥ The ICU nurse works in a rural hospital that has a remote electronic
ICU monitoring system (eICU.) What is one of the best reasons for
having access to an eICU?
A. An ICU nurse and intensivist remotely monitor ICU clients around
the clock
B. An ICU nurse is on-call to answer questions when needed
C. Clients can ask the intensivist for a second opinion
D. Less staff is needed on site when a remote eICU is available
Answer: A
Using cameras, microphones, and high-speed computer data lines, the
eICU involves having an experienced ICU nurse and practicing
intensivist monitoring ICU clients in remote locations around the clock.
The eICU does not change the ratio of nurses to clients at the bedside,
but it does make the nurse's bedside time more productive and assistance
from their remote colleagues is only a push button away.
, ⩥ The client is diagnosed with tuberculosis (TB). The nurse understands
that the treatment plan for this client will involve what type of drug
therapy?
A. Administering two antituberculosis drugs
B. Aminoglycoside antibiotics
C. An anti-inflammatory agent
D. High doses of B complex vitamins
Answer: A
In order to prevent drug-resistant strains of TB, clients are always
prescribed at least two different antitubercule medications. Rifampin and
isoniazid are the most effective drugs used to treat TB and are always
used together, for at least six months. Additional medications, such as
pyrazinamide and either streptomycin or ethambutol, may also be
prescribed. Vitamin B6 is usually prescribed to help prevent expected
side effect of isoniazid.
⩥ While working a 12-hour night shift, the nurse has a "near miss" and
catches an error before administering a new medication to the client.
Which factors could have contributed to the near miss? (Select all that
apply.)
A. The nurse works in the intensive care unit (ICU)
B. The nurse has worked on the same unit for five years
C. The nurse is assigned more clients than usual due to staffing issues
EVALUATION TESTED QUESTIONS AND
VERIFIED RESPONSES GRADED A+
⩥ The home health nurse observes the client change an ileostomy pouch.
Which action is best to help prevent skin breakdown?
A. Use deodorant soaps the contain lotion to clean the stoma
B. Change the stoma pouch daily
C. Apply antiseptic cream to reddened stoma
D. Make sure the skin around the stoma is wrinkle-free
Answer: D
The ileostomy pouch should be changed approximately every 5 to 7
days; the bag should be emptied about every 4 to 6 hours. Before
applying a pouch, the stoma and skin around the stoma should be gently
cleaned using mild soap and water and allowed to dry. A skin barrier
powder or other skin prep can be applied to intact skin around the stoma
- but not to the stoma. The skin around the stoma should be dry and
wrinkle-free before applying a new pouch or wafer to ensure a tight,
leak-free seal.
⩥ A nurse is caring for a client who is receiving a blood transfusion and
develops urticaria one-half hour after the transfusion has begun. What is
the first action the nurse should take?
,A. Slow the rate of infusion
B. Stop the infusion
C. Take vital signs and observe for further deterioration
D. Administer Benadryl and continue the infusion
Answer: B
This is an indication of an allergy to the plasma protein. The priority
action of the nurse is to stop the transfusion by disconnecting at the IV
insertion site. The nurse should then start a saline line at the IV insertion
site and notify the health care provider.
⩥ A client has end-stage renal disease. Which of these statements made
by the client indicates a correct understanding of the issues related to
this disease?
A. "I can expect to have periods of little urine and then sometimes a lot
of urine."
B. "I have to go for epoetin (Procrit) injections at the health
department."
C. "I know I have a high risk of clot formation since my blood is thick
from too many red cells."
D. "My bones will be stronger with this disease since I will have higher
calcium than normal."
Answer: B
,Anemia in end-stage renal failure is caused by reduced endogenous
erythropoietin production in the kidney. Anemia in primary end-stage
renal disease is treated with subcutaneous injections of Procrit or
Epogen to stimulate the bone marrow to produce red blood cells. With
kidney failure, too much phosphorus can build up in the blood and
calcium is pulled from the bones, resulting in weakened bones. The
statement about producing variable amounts of urine is incorrect, as the
client will produce little to no urine at this stage of the disease.
⩥ The ICU nurse works in a rural hospital that has a remote electronic
ICU monitoring system (eICU.) What is one of the best reasons for
having access to an eICU?
A. An ICU nurse and intensivist remotely monitor ICU clients around
the clock
B. An ICU nurse is on-call to answer questions when needed
C. Clients can ask the intensivist for a second opinion
D. Less staff is needed on site when a remote eICU is available
Answer: A
Using cameras, microphones, and high-speed computer data lines, the
eICU involves having an experienced ICU nurse and practicing
intensivist monitoring ICU clients in remote locations around the clock.
The eICU does not change the ratio of nurses to clients at the bedside,
but it does make the nurse's bedside time more productive and assistance
from their remote colleagues is only a push button away.
, ⩥ The client is diagnosed with tuberculosis (TB). The nurse understands
that the treatment plan for this client will involve what type of drug
therapy?
A. Administering two antituberculosis drugs
B. Aminoglycoside antibiotics
C. An anti-inflammatory agent
D. High doses of B complex vitamins
Answer: A
In order to prevent drug-resistant strains of TB, clients are always
prescribed at least two different antitubercule medications. Rifampin and
isoniazid are the most effective drugs used to treat TB and are always
used together, for at least six months. Additional medications, such as
pyrazinamide and either streptomycin or ethambutol, may also be
prescribed. Vitamin B6 is usually prescribed to help prevent expected
side effect of isoniazid.
⩥ While working a 12-hour night shift, the nurse has a "near miss" and
catches an error before administering a new medication to the client.
Which factors could have contributed to the near miss? (Select all that
apply.)
A. The nurse works in the intensive care unit (ICU)
B. The nurse has worked on the same unit for five years
C. The nurse is assigned more clients than usual due to staffing issues
