NCLEX RN PEARSON PRACTICE SOLUTION
BUNDLE ALL QUESTIONS AND WELL
ELABORATED ANSWERS WITH
RATIONALES STUDY SHEET COMPLETE
GUARANTEED TO PASS
⩥ The clinic nurse is conducting health screenings. Which of the
following client assessment findings indicates that client teaching is
needed about the risk for stroke? Select all that apply.
1.‐ Weight 205 lbs and height 5 feet 4 inches
2.‐ Blood pressure 164/92 mmHg
3.‐ Eats bran for breakfast daily
4.‐ Smokes 1/2 pack cigarettes per day
5.‐ Serum cholesterol level is 172 mg/dL
Answer: 1.‐ Weight 205 lbs and height 5 feet 4 inches
2.‐ Blood pressure 164/92 mmHg
4.‐ Smokes 1/2 pack cigarettes per day
Obesity, hypertension, and smoking are modifiable risk factors for
stroke. Hypercholesterolemia (cholesterol level greater than 200 mg)
would also be a risk factor, but this client's level is less than 200 mg/dL.
Eating a diet containing fiber helps keep cholesterol levels low and is
not a risk factor for stroke.
,⩥ Which of the following actions would the nurse take to maintain
medical asepsis when caring for a client with diabetes mellitus on the
medical nursing unit who requires irrigation of a leg ulcer and insulin
injections? Select all that apply.
1.‐ Wash hands before and after client care.
2.‐ Wear personal protective equipment during the dressing change.
3.‐ Recap a needle after administering insulin.
4.‐ Change the dressing for a diabetic ulcer using sterile gloves.
5.‐ Wipe the rubber stopper on the insulin vial before withdrawing dose.
Answer: 1.‐ Wash hands before and after client care.
2.‐ Wear personal protective equipment during the dressing change.
5.‐ Wipe the rubber stopper on the insulin vial before withdrawing dose.
Options 1, 2, and 5 are core principles of medical asepsis. Option 3
violates principles of medical asepsis. Option 4 uses principles of
surgical asepsis. Option 6 is unrelated to the needs of this client.
⩥ Laboratory test results indicate a client is in the nadir period that
follows administration of a chemotherapy drug. Which drug should the
nurse avoid administering to this client at this time?
1.‐ Acetaminophen (Tylenol)
2.‐ Ibuprofen (Motrin)
3.‐ Diphenhydramine (Benadryl)
4.‐ Guanefesin (Robitussin)
Answer: 2.‐ Ibuprofen (Motrin)
, RBCs, WBCs, and platelet counts may be decreased during the nadir
period following administration of chemotherapy that has hematological
toxicity. Medications that inhibit platelet aggregation should be avoided
during the nadir period following antineoplastic therapy. Aspirin,
ibuprofen, and indomethacin are examples of some of these agents.
⩥ The newborn nursery has recently formed a unit policy and procedure
committee. The nurse, while attending and participating in the meetings,
determines that which nurse exemplifies a situational leader?
1.‐ The nurse who offers suggestions, asks questions, and guides the
group toward achieving group goals.
2.‐ The nurse who recognizes the group's need for autonomy and
abdicates responsibility.
3.‐ The nurse who relies on the organization's rules, policies, and
procedures to direct the group's work.
4.‐ The nurse who recognizes that leadership style depends on the
readiness and willingness of the group or the individuals to perform the
assigned tasks.
Answer: 4.‐ The nurse who recognizes that leadership style depends on
the readiness and willingness of the group or the individuals to perform
the assigned tasks.
A situational leader recognizes that leadership style depends on the
readiness and willingness of the group or the individuals to perform the
assigned tasks. The democratic or participative leader offers suggestions,
asks questions, and guides the group toward achieving the group goals.
The laissez‐faire leader recognizes the group's need for autonomy and
BUNDLE ALL QUESTIONS AND WELL
ELABORATED ANSWERS WITH
RATIONALES STUDY SHEET COMPLETE
GUARANTEED TO PASS
⩥ The clinic nurse is conducting health screenings. Which of the
following client assessment findings indicates that client teaching is
needed about the risk for stroke? Select all that apply.
1.‐ Weight 205 lbs and height 5 feet 4 inches
2.‐ Blood pressure 164/92 mmHg
3.‐ Eats bran for breakfast daily
4.‐ Smokes 1/2 pack cigarettes per day
5.‐ Serum cholesterol level is 172 mg/dL
Answer: 1.‐ Weight 205 lbs and height 5 feet 4 inches
2.‐ Blood pressure 164/92 mmHg
4.‐ Smokes 1/2 pack cigarettes per day
Obesity, hypertension, and smoking are modifiable risk factors for
stroke. Hypercholesterolemia (cholesterol level greater than 200 mg)
would also be a risk factor, but this client's level is less than 200 mg/dL.
Eating a diet containing fiber helps keep cholesterol levels low and is
not a risk factor for stroke.
,⩥ Which of the following actions would the nurse take to maintain
medical asepsis when caring for a client with diabetes mellitus on the
medical nursing unit who requires irrigation of a leg ulcer and insulin
injections? Select all that apply.
1.‐ Wash hands before and after client care.
2.‐ Wear personal protective equipment during the dressing change.
3.‐ Recap a needle after administering insulin.
4.‐ Change the dressing for a diabetic ulcer using sterile gloves.
5.‐ Wipe the rubber stopper on the insulin vial before withdrawing dose.
Answer: 1.‐ Wash hands before and after client care.
2.‐ Wear personal protective equipment during the dressing change.
5.‐ Wipe the rubber stopper on the insulin vial before withdrawing dose.
Options 1, 2, and 5 are core principles of medical asepsis. Option 3
violates principles of medical asepsis. Option 4 uses principles of
surgical asepsis. Option 6 is unrelated to the needs of this client.
⩥ Laboratory test results indicate a client is in the nadir period that
follows administration of a chemotherapy drug. Which drug should the
nurse avoid administering to this client at this time?
1.‐ Acetaminophen (Tylenol)
2.‐ Ibuprofen (Motrin)
3.‐ Diphenhydramine (Benadryl)
4.‐ Guanefesin (Robitussin)
Answer: 2.‐ Ibuprofen (Motrin)
, RBCs, WBCs, and platelet counts may be decreased during the nadir
period following administration of chemotherapy that has hematological
toxicity. Medications that inhibit platelet aggregation should be avoided
during the nadir period following antineoplastic therapy. Aspirin,
ibuprofen, and indomethacin are examples of some of these agents.
⩥ The newborn nursery has recently formed a unit policy and procedure
committee. The nurse, while attending and participating in the meetings,
determines that which nurse exemplifies a situational leader?
1.‐ The nurse who offers suggestions, asks questions, and guides the
group toward achieving group goals.
2.‐ The nurse who recognizes the group's need for autonomy and
abdicates responsibility.
3.‐ The nurse who relies on the organization's rules, policies, and
procedures to direct the group's work.
4.‐ The nurse who recognizes that leadership style depends on the
readiness and willingness of the group or the individuals to perform the
assigned tasks.
Answer: 4.‐ The nurse who recognizes that leadership style depends on
the readiness and willingness of the group or the individuals to perform
the assigned tasks.
A situational leader recognizes that leadership style depends on the
readiness and willingness of the group or the individuals to perform the
assigned tasks. The democratic or participative leader offers suggestions,
asks questions, and guides the group toward achieving the group goals.
The laissez‐faire leader recognizes the group's need for autonomy and
