NCLEX NGN RN ACTUAL EXAM LATEST MAY 2023
TEST BANK 150 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES AGRADE
A nurse in the intensive care unit is caring for a client in the immediate postoperative
period following abdominal surgery. The nurse receives several prescriptions. Which
prescription should the nurse initiate first? Click on the exhibit button for additional
information. - ANSWER>>Normal saline 2 L via rapid IV bolus.
A housekeeping employee tells the staff nurse of having a headache and asks for
acetaminophen. How should the nurse respond? - ANSWER>>Refer employee to the
employee health provider.
The school nurse assesses an 8-year-old with a history of asthma. The nurse notes mild
wheezing and coughing. Which action should the nurse perform first? -
ANSWER>>Assess the client's peak expiratory flow.
A client comes to the community mental health clinic seeking treatment for severe
anxiety associated with a recent job promotion that requires a 30-minute commute via
train. The nurse recognizes that this client most likely suffers from which psychological
disorder? - ANSWER>>Agoraphobia
A client who is diagnosed with breast cancer asks the nurse, "Am I going to die?" Which
statement by the nurse promotes a therapeutic relationship? - ANSWER>>"People with
cancer experience fear of dying; tell me about your concerns."
The nurse is reinforcing education to the caregivers of a 9-year-old client diagnosed
with scarlet fever. The client has a history of type 1 diabetes mellitus. Which statement
by the caregivers indicates that further teaching is needed? - ANSWER>>"We will not
administer insulin if our child is unable to eat."
A client is diagnosed with right-sided Bell's palsy. What instructions should the nurse
give this client for care at home? Select all that apply. - ANSWER>>1. Apply a patch to
the right eye at night.
3. Chew on the left side.
4. Maintain meticulous oral hygiene.
- Bell's palsy is an inflammation of the cranial nerve VII (facial) that causes motor and
sensory alterations. Clients are usually managed as outpatients, with corticosteroids to
reduce inflammation, and taught eye/oral care. In Bell's palsy, the eyelids do not close
properly. This may result in eye dryness and risk of corneal abrasions. However,
weakness of teh lower eyelid may cause excessive tearing due to overflow in some
clients. Facial muscle weakness results in poor chewing and food retention.
The spouse brings a client to the emergency department due to erratic behavior and
expressions of despair. The emergency department is extremely busy with many
, clients. When the triage nurse asks if the client feels suicidal now, the client shrugs the
shoulders. What initial action should the triage nurse take? - ANSWER>>Place the
client in an inside hallway with one-on-one observation.
The orthopedic health care provider instructs a client with a fractured femur, who has
been non-weight bearing for the past 5 weeks, to progress to full weight bearing on the
right leg. which advanced crutch gait that most closely resembles normal walking should
the office nurse teach the client? - ANSWER>>4-point gait
- there are 5 crutch gaits: 2-, 3-, 4-point, swing-to, and swing-through
`A nurse administers an intramuscular (IM) injection using the Z-track method
technique. Place the steps in chronological order. All options must be used. -
ANSWER>>4. Pull the skin 1-1 1/2" (2.5-3.5 cm) laterally and away from the injection
site.
3. Hold the skin taut with non-dominant hand and insert needle at a 90-degree angle.
2. Inject medication slowly with dominant hand while maintaining traction
6. Wait 10 seconds after injecting the medication and withdraw the needle.
Release the hold on the skin, allowing the layers to slide back to their original position.
1. Apply gentle pressure at the injection site but do not massage.
The clinic nurse is teaching a client about levothyroxine, which the health care provider
has prescribed for newly diagnosed hypothyroidism. Which statement made by the
client indicates that further teaching is needed? - ANSWER>>"If this makes my stomach
upset, I will take it with an antacid."
- will impair the absorption of levothyroxine (Synthroid). -- Antacids, calcium and iron
preparations.
- should take levothyroxine on an empty stomach, preferably in the morning, separately
from other medications
The nurse is reviewing laboratory results for several prenatal clients. Which finding is
most important to report to the health care provider? - ANSWER>>Client at 24 weeks
gestation with hemoglobin of 9 g/dL (90 g/L) and hematocrit of 29%
- during the second half of pregnancy, the fetus beings to store iron, depleting maternal
stores. Hemoglobin <11 g/dL in the first or third trimester or <10.5 g/dL in the second
trimester is considered low.
A client with obesity has just started taking orlistat. Which statement by the client
indicates a need for further teaching? - ANSWER>>"I have started taking a daily
multivitamin with my dinner-time dose of medication."
- Orlistat is a lipase inhibitor that prevents the breakdown and absorption of fats from
the intestine - interferes with fat-soluble vitamin uptake
The nurse on the medical-surgical unit receives report on assigned clients. Which client
warrants immediate attention? - ANSWER>>Client with epigastric pain after endoscopic
retrograde cholangiopancreatography.
TEST BANK 150 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES AGRADE
A nurse in the intensive care unit is caring for a client in the immediate postoperative
period following abdominal surgery. The nurse receives several prescriptions. Which
prescription should the nurse initiate first? Click on the exhibit button for additional
information. - ANSWER>>Normal saline 2 L via rapid IV bolus.
A housekeeping employee tells the staff nurse of having a headache and asks for
acetaminophen. How should the nurse respond? - ANSWER>>Refer employee to the
employee health provider.
The school nurse assesses an 8-year-old with a history of asthma. The nurse notes mild
wheezing and coughing. Which action should the nurse perform first? -
ANSWER>>Assess the client's peak expiratory flow.
A client comes to the community mental health clinic seeking treatment for severe
anxiety associated with a recent job promotion that requires a 30-minute commute via
train. The nurse recognizes that this client most likely suffers from which psychological
disorder? - ANSWER>>Agoraphobia
A client who is diagnosed with breast cancer asks the nurse, "Am I going to die?" Which
statement by the nurse promotes a therapeutic relationship? - ANSWER>>"People with
cancer experience fear of dying; tell me about your concerns."
The nurse is reinforcing education to the caregivers of a 9-year-old client diagnosed
with scarlet fever. The client has a history of type 1 diabetes mellitus. Which statement
by the caregivers indicates that further teaching is needed? - ANSWER>>"We will not
administer insulin if our child is unable to eat."
A client is diagnosed with right-sided Bell's palsy. What instructions should the nurse
give this client for care at home? Select all that apply. - ANSWER>>1. Apply a patch to
the right eye at night.
3. Chew on the left side.
4. Maintain meticulous oral hygiene.
- Bell's palsy is an inflammation of the cranial nerve VII (facial) that causes motor and
sensory alterations. Clients are usually managed as outpatients, with corticosteroids to
reduce inflammation, and taught eye/oral care. In Bell's palsy, the eyelids do not close
properly. This may result in eye dryness and risk of corneal abrasions. However,
weakness of teh lower eyelid may cause excessive tearing due to overflow in some
clients. Facial muscle weakness results in poor chewing and food retention.
The spouse brings a client to the emergency department due to erratic behavior and
expressions of despair. The emergency department is extremely busy with many
, clients. When the triage nurse asks if the client feels suicidal now, the client shrugs the
shoulders. What initial action should the triage nurse take? - ANSWER>>Place the
client in an inside hallway with one-on-one observation.
The orthopedic health care provider instructs a client with a fractured femur, who has
been non-weight bearing for the past 5 weeks, to progress to full weight bearing on the
right leg. which advanced crutch gait that most closely resembles normal walking should
the office nurse teach the client? - ANSWER>>4-point gait
- there are 5 crutch gaits: 2-, 3-, 4-point, swing-to, and swing-through
`A nurse administers an intramuscular (IM) injection using the Z-track method
technique. Place the steps in chronological order. All options must be used. -
ANSWER>>4. Pull the skin 1-1 1/2" (2.5-3.5 cm) laterally and away from the injection
site.
3. Hold the skin taut with non-dominant hand and insert needle at a 90-degree angle.
2. Inject medication slowly with dominant hand while maintaining traction
6. Wait 10 seconds after injecting the medication and withdraw the needle.
Release the hold on the skin, allowing the layers to slide back to their original position.
1. Apply gentle pressure at the injection site but do not massage.
The clinic nurse is teaching a client about levothyroxine, which the health care provider
has prescribed for newly diagnosed hypothyroidism. Which statement made by the
client indicates that further teaching is needed? - ANSWER>>"If this makes my stomach
upset, I will take it with an antacid."
- will impair the absorption of levothyroxine (Synthroid). -- Antacids, calcium and iron
preparations.
- should take levothyroxine on an empty stomach, preferably in the morning, separately
from other medications
The nurse is reviewing laboratory results for several prenatal clients. Which finding is
most important to report to the health care provider? - ANSWER>>Client at 24 weeks
gestation with hemoglobin of 9 g/dL (90 g/L) and hematocrit of 29%
- during the second half of pregnancy, the fetus beings to store iron, depleting maternal
stores. Hemoglobin <11 g/dL in the first or third trimester or <10.5 g/dL in the second
trimester is considered low.
A client with obesity has just started taking orlistat. Which statement by the client
indicates a need for further teaching? - ANSWER>>"I have started taking a daily
multivitamin with my dinner-time dose of medication."
- Orlistat is a lipase inhibitor that prevents the breakdown and absorption of fats from
the intestine - interferes with fat-soluble vitamin uptake
The nurse on the medical-surgical unit receives report on assigned clients. Which client
warrants immediate attention? - ANSWER>>Client with epigastric pain after endoscopic
retrograde cholangiopancreatography.
