NURSING NUR 2811C VERSION 3 SUMMARY: NCLEX-RN Practice Test Questions with Answers
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Course
NUR 2811C
Institution
Miami Dade College, Miami
VERSION 3 SCREEN SHOTS:
1. SATA. Older male in ER has become increasingly confused in 3 days; nursing action?
Determine oxygen saturation rate and breath sounds.
Evaluate polypharmacy for possible drug interactions.
Obtain urine and sensitivity for possible UTI.
2. Pt. with bipo...
VERSION 3 SCREEN SHOTS:
1. SATA. Older male in ER has become increasingly confused in 3 days; nursing action?
Determine oxygen saturation rate and breath sounds.
Evaluate polypharmacy for possible drug interactions.
Obtain urine and sensitivity for possible UTI.
2. Pt. with bipolar disorder reports not taking his Depakote for 6 mo; nurse assessment?
Affect
3. Female pt. with pyelonephritis is concerned about dialysis; nurse best initial response?
Explain the relationship between chronic kidney infection, renal failure, and dialysis.
4. Sickle cell c/o pain in fingers; underlying pathophysiology for pain in sickle cell crisis?
Sickled red blood cells do not flow through small blood vessels leading to vasocclusion and
ischemia.
5. Pt. at clinical reports new onset of pyrosis and dyspepsia; action has highest priority?
Instruct the client about the side effects of reflux disease.
6. Pt. bathing with inelastic skin turgor, large pendulous breasts, and a soft, flaccid abdomen.
Teach the client to dry the skin well between skin folds.
7. Which symptom is characteristic of ureteral colic in the client diagnosed with renal calculi?
Chills, fever, and dysuria.
8. Suspected GuillianBarre syndrome; which comment is significant to diagnosis?
“About two weeks ago, I missed a day at work because I had a bad cold.
9. Pt. with burns to posterior neck; which intervention to prevent contractures at injury site?
Actively turn head from side to side 90 degrees hourly.
10. Pt. having anxiety reaction when crossing over a bay bridge; action to implement?
Teach client to listen to music or audio books while driving.
11. Assessing normal development of 9monthold; information to obtain?
Can the child sit alone?
12. Parkinson’s meds; symptom management requires a balance among neurotransmitters?
Acetylcholine and dopamine.
13. Pt. with SARS returned from China in isolation; which intervention in plan of care?
Require use of gown, gloves, and N95 mask.
14. DKA pt. on sliding scale regular insulin; intervention important to implement?
Confer with the healthcare provider about a continuous IV insulin infusion
,15. Teacher thinks she is pregnant (neg test at night) but is on tetracycline for acne; instructions?
Use first voiding of the day for accurate results of pregnancy test.
16. Child with rheumatoid arthritis has a viral infection and fever/ taking aspirin for arthritis.
Stop taking aspirin and give different NSAID.
17. Pt. admitted with possible head injury and spinal cord injury; priority assessment?
Respiratory status
18. Caring for pt. with acute MI; observation warrants immediate intervention?
The telemetry displays ventricular bigenminy.
19. 2 day posttotal laryngectomy transferred to private room is anxious; intervention?
Answer the client’s call signal in person quickly after he calls.
20. Child with HF receiving Lasix with potassium of 3.0 mEq/L; important assessment?
Cardiac rhythm and heart rate.
21. Child coming to ER with hx of flulike symptoms for past week; equipment to assemble?
Mechanical Ventilator.
22. What script anticipate for pt. with increased ICP secondary to head injury?
Mannitol (Osmitrol).
23. Pt. is cigarette smoker and alcohol drinker is postcholecystectomy but tremulous, agitated,
febrile, and disoriented; this is likely the finding of what?
Impending delirium tremors.
24. Pt. paranoia and homicidal ideation in ER saying daughter lives in TV; thought disorder?
Easily changes the subject.
25. Infant on Captopril for HF; which finding indicates med effectiveness?
Blood pressure decreased from 125/85 on admission to 106/60 today.
26. Pt. fell at home and is on labetalol and ranitidine; intervention to include in plan of care?
Frequent monitoring of blood pressure.
27. Pt. with mitral stenosis at 28weeks gestation; what investigate first?
Persistent cough.
28. Home care of child with cystic fibrosis; parental action shows understanding?
Gives pancreatic enzymes before every meal and snack.
29. Child admitted with possible nephrotic syndrome; parent statement goes with diagnosis?
“I couldn’t get my son’s socks and shoes in this morning.”
,30. Pt. scheduled for laminectomy with back pain r/t intervertebral disk; preop teaching about
numbness and tingling in lower extremities occurs due to?
Manipulation of nerves and muscles during surgery.
1) A nurse is planning care for a child who has scabies and he keeps itching…
ANS: Keep nails trimmed short and have him wear mittens
2) An acute care hospital has a disaster something about an outage and a generator. The UAP
asks the charge nurse what she can do to help…
ANS: Tell clients to stay in their rooms
3) Discharge teaching to a patient with heart failure what parameter is most important for weight
monitoring…
ANS: Weigh themselves at the same time everyday
4) Patient with metabolic syndrome is going to start exercising what is most important to tell
him…
ANS: Monitor BP as exercise increases
6) Patient c/o pain distal to insertion site, what action should the nurse implement?
ANS: Remove
7) A seriously ill patient that has a DNR is transferred to a medical facility in another state that
does not honor that what should the nurse implement?
ANS: Honor clients wishes
8) Question regarding taking a sample for sputum out of a water chamber from a patient with a
chest tube insertion for a person on a trach, where do you take the sample from?
ANS: Rubberized port at bottom of the catheter chamber
9) A patient is in the acute phase of burn to prevent auto contamination when changing dressings
how should you do it?
ANS: Change each dressing separately
10) The nurse enters a client’s room with his morning meds. Patient states he will take them
later. What action should the nurse take?
ANS: make a deal him on a time to return and give the meds
11) A client has returned from China and has SARS. What will you do before coming into
contact with him?
ANS: Gown, gloves, n95 mask
, 12) A client admitted with chest tightness respiratory acidosis an increase in which lab would
show this?
ANS: PaCO2
13) Male client bladder always feels full
14) Question on palpate lymph nodes on a child which is of concern?
ANS: large, warm, nontender
15) A Patient who is diabetic has DKA and is receiving insulin using a sliding scale, his blood
sugar has been 520540. What action should the nurse take?
ANS: call physician and to get order for IV insulin
16) An adult has 110 BPM what intervention should the nurse implement first?
17) A nurse makes a home visit for parents of a child with cystic fibrosis, how would the nurse
know that they are following treatments at home?
ANS: give pancreatic enzymes with each snack
18) Peptic ulcer disease
19) A nurse observes a mother in a hallway punishing her 3 year old child for wetting his pants,
what action should the nurse take?
ANS: provide toilet training pants and calming the mother
20) Laminectomy for a herniated intercerbral disc, when conducting preoperative teaching what
should the nurse implement?
21) When conducting an assessment on a 6 month old infant...
ANS: Keep child on your lap
22) Patient comes in vomiting…
ANS: Maintain NPO status
23) A mother who is breastfeeding 2 days postop has inverted nipples…
ANS: use a breast shield
24) Smoking 2 packs a day has COPD??
25) A male client has anxiety when driving over the bay bridge which would you suggest to help
address this fear?
ANS: Listen to music
26) Using the parkland formula for a patient with burns 4ml x Patients weight in kg which is
76kg x whatever % of burns, which is 40%. SO it is 4ml x 76kg x 40% =
ANS: 12,160
27) Question about MONO (kissing disease)
ANS: Ellen BARRE (something like that I don’t remember how to spell it!)
28) A patient with bilateral hearing aids it is ringing…
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