NCLEX STUDY-CRIS QUESTIONS AND ANSWERS
100-Sickle-cell crisis. Which of the following nursing actions should the nurse take
FIRST? - Answers :Begin an IV with normal saline. Dehydration perpetuates cell
sickling; intake should be at least 200 cc/hour
Which of the following patients should the nurse see FIRST? - Answers :A patient
complaining of chest pain with asymmetrical chest movement CORRECT— indicates
flail; monitor for shock, give humidified oxygen, manage pain, monitor ABGs noted.
Which of the following patients should the nurse see FIRST? - Answers :A 9-year-old
who has used a weapon toward his mother and caused physical harm to others.A 9-
year-old who has used a weapon toward his mother and caused physical harm to
others.
Which of the following patients should the nurse see FIRST? - Answers :A patient who
took 10 methylphenidate (Ritalin) and has a blood pressure of 160/100.CORRECT—
most unstable patient; assess for restlessness, dilated pupils, tremors, and seizures.
Stimulant like amphetamines, improves alertesness and concentration.
Which of the following patients should the nurse see FIRST? - Answers :A 35-year-old
who had a hysterosalpingogram is experiencing tachycardia, and has a generalized
rash.(2) CORRECT— x-ray of the cervix, uterus, and fallopian tubes performed after the
injection of a contrast medium; assess for allergy to shellfish or iodine; requires
immediate attention because patient having an allergic reaction
A client with a pacemaker calls to report that he just had an episode of dizziness and
shortness of breath. - Answers :The Rn should ask "What is your pulse?"
client receiving warfarin (Coumadin) 5 mg PO daily for DVT. The nurse learns the client
operates a horse ranch - Answers :Carry a cell phone and dressings and tape.
nurse should assign a nursing assistant to care for - Answers :A client diagnosed with a
CVA 2 weeks ago requiring assistance ambulating.
The nurse counsels a client diagnosed with degenerative joint disease - Answers
:"Place your joints in their functional position."maintains mobility of joints
The nurse prepares a client for a skin biopsy. Which of the following statements, if made
by the client, should the nurse report to the physician? - Answers :"I have been taking
aspirin for my aching joints."aspirin can increase the risk for bleeding and should be
reported
A man hospitalized for alcohol abuse comes to the nurses' station and asks the nurse if
he can go to the cafeteria to get something to eat. When told that his privileges do not
include visiting the cafeteria, the patient becomes verbally abusive. - Answers :Calmly
, but firmly escort the patient to his room. Limit-setting, ensures safety; patient with
substance abuse needs consistent, undivided staff approach, clearly defined
expectations, as well as limit-setting; avoid threats and promises
Which of the following patients should the nurse see FIRST? - Answers :A 7-year-old
with burns on the face.(2) CORRECT— burns can be life-threatening to children;
airway, breathing, and circulation are major concerns; cardiopulmonary complications
may result from exposure to electrical current, inhalation of toxic fumes, hypovolemia,
and shock
Which of the following patients should the nurse see FIRST? - Answers :A patient with a
fasting blood glucose of 517 mg/dL.CORRECT— normal is 60 to 110 mg/dL; requires
immediate attention; administer regular insulin
Which of the following patients should the nurse see FIRST? - Answers :A patient
receiving haloperidol (Haldol) experiencing an oculogyric .crisis.CORRECT— eyes are
locked upward; acute dystonic reaction; notify physician and physician will order an
anticholinergic agent to correct this reaction
Which of the following patients should the nurse see FIRST? - Answers :A patient
diagnosed with hemophilia complaining of joint pain. CORRECT— joint pain indicates
bleeding; treatment includes factor VIII, RICE ( r est, i ce, c ompression, and e levation)
Two days after insertion, the chest tube is accidentally pulled out of the pleural space -
Answers :Apply pressure with a dressing that is tented on one side. ) CORRECT—
decreases chance that atmospheric air will enter pleural space and allows for escape of
pleural air
90-patient hospitalized for a head injury. The client is receiving 0.9% sodium chloride at
100 cc/h and has an indwelling Foley catheter in place. The nurse notes the patient's
urinary output is 1,000 cc in 3 hours. - Answers :Measure the urine specific gravity.
CORRECT— low specific gravity (1.001 and 1.005) is characteristic of diabetes
insipidus; head injury causes interference with production or release of ADH; record I
and O, urine specific gravity, and daily weight; ensure client's intake of fluid and
administer DDAVP
Which of the following clients should the nurse see FIRST? - Answers :An unconscious
client with left-sided tracheal shift from midlineCORRECT—first sign of a tension
pneumothorax; airway and breathing take priorit
Which of the following messages should the nurse respond to FIRST? - Answers :The
mother of a 15-year-old reports her son is threatening to jump off a bridge and has
access to a gun.
CORRECT— using Maslow Hierarchy of Needs theory to prioritize, physiological issues
take priority over psychological issues; patient is at risk for self harm and must be seen
first; observe for safety
100-Sickle-cell crisis. Which of the following nursing actions should the nurse take
FIRST? - Answers :Begin an IV with normal saline. Dehydration perpetuates cell
sickling; intake should be at least 200 cc/hour
Which of the following patients should the nurse see FIRST? - Answers :A patient
complaining of chest pain with asymmetrical chest movement CORRECT— indicates
flail; monitor for shock, give humidified oxygen, manage pain, monitor ABGs noted.
Which of the following patients should the nurse see FIRST? - Answers :A 9-year-old
who has used a weapon toward his mother and caused physical harm to others.A 9-
year-old who has used a weapon toward his mother and caused physical harm to
others.
Which of the following patients should the nurse see FIRST? - Answers :A patient who
took 10 methylphenidate (Ritalin) and has a blood pressure of 160/100.CORRECT—
most unstable patient; assess for restlessness, dilated pupils, tremors, and seizures.
Stimulant like amphetamines, improves alertesness and concentration.
Which of the following patients should the nurse see FIRST? - Answers :A 35-year-old
who had a hysterosalpingogram is experiencing tachycardia, and has a generalized
rash.(2) CORRECT— x-ray of the cervix, uterus, and fallopian tubes performed after the
injection of a contrast medium; assess for allergy to shellfish or iodine; requires
immediate attention because patient having an allergic reaction
A client with a pacemaker calls to report that he just had an episode of dizziness and
shortness of breath. - Answers :The Rn should ask "What is your pulse?"
client receiving warfarin (Coumadin) 5 mg PO daily for DVT. The nurse learns the client
operates a horse ranch - Answers :Carry a cell phone and dressings and tape.
nurse should assign a nursing assistant to care for - Answers :A client diagnosed with a
CVA 2 weeks ago requiring assistance ambulating.
The nurse counsels a client diagnosed with degenerative joint disease - Answers
:"Place your joints in their functional position."maintains mobility of joints
The nurse prepares a client for a skin biopsy. Which of the following statements, if made
by the client, should the nurse report to the physician? - Answers :"I have been taking
aspirin for my aching joints."aspirin can increase the risk for bleeding and should be
reported
A man hospitalized for alcohol abuse comes to the nurses' station and asks the nurse if
he can go to the cafeteria to get something to eat. When told that his privileges do not
include visiting the cafeteria, the patient becomes verbally abusive. - Answers :Calmly
, but firmly escort the patient to his room. Limit-setting, ensures safety; patient with
substance abuse needs consistent, undivided staff approach, clearly defined
expectations, as well as limit-setting; avoid threats and promises
Which of the following patients should the nurse see FIRST? - Answers :A 7-year-old
with burns on the face.(2) CORRECT— burns can be life-threatening to children;
airway, breathing, and circulation are major concerns; cardiopulmonary complications
may result from exposure to electrical current, inhalation of toxic fumes, hypovolemia,
and shock
Which of the following patients should the nurse see FIRST? - Answers :A patient with a
fasting blood glucose of 517 mg/dL.CORRECT— normal is 60 to 110 mg/dL; requires
immediate attention; administer regular insulin
Which of the following patients should the nurse see FIRST? - Answers :A patient
receiving haloperidol (Haldol) experiencing an oculogyric .crisis.CORRECT— eyes are
locked upward; acute dystonic reaction; notify physician and physician will order an
anticholinergic agent to correct this reaction
Which of the following patients should the nurse see FIRST? - Answers :A patient
diagnosed with hemophilia complaining of joint pain. CORRECT— joint pain indicates
bleeding; treatment includes factor VIII, RICE ( r est, i ce, c ompression, and e levation)
Two days after insertion, the chest tube is accidentally pulled out of the pleural space -
Answers :Apply pressure with a dressing that is tented on one side. ) CORRECT—
decreases chance that atmospheric air will enter pleural space and allows for escape of
pleural air
90-patient hospitalized for a head injury. The client is receiving 0.9% sodium chloride at
100 cc/h and has an indwelling Foley catheter in place. The nurse notes the patient's
urinary output is 1,000 cc in 3 hours. - Answers :Measure the urine specific gravity.
CORRECT— low specific gravity (1.001 and 1.005) is characteristic of diabetes
insipidus; head injury causes interference with production or release of ADH; record I
and O, urine specific gravity, and daily weight; ensure client's intake of fluid and
administer DDAVP
Which of the following clients should the nurse see FIRST? - Answers :An unconscious
client with left-sided tracheal shift from midlineCORRECT—first sign of a tension
pneumothorax; airway and breathing take priorit
Which of the following messages should the nurse respond to FIRST? - Answers :The
mother of a 15-year-old reports her son is threatening to jump off a bridge and has
access to a gun.
CORRECT— using Maslow Hierarchy of Needs theory to prioritize, physiological issues
take priority over psychological issues; patient is at risk for self harm and must be seen
first; observe for safety
