NURSING 216 Nclex Practice with Answers
1. The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4 year-old child?
Review Information: The correct answer is D: "I have the four year-old hold an...
1. The nurse knows that which statement by the mother indicates that
the mother understands safety precautions with her four month-old Leave the order for the oncoming staff to follow-up
infant and her 4 year-old child? Contact the charge nurse for an interpretation
A) "I strap the infant car seat on the front seat to face backwards." Ask the pharmacy for assistance in the interpretation
"I place my infant in the middle of the living room floor on a Call the provider for clarification
B) blanket to play with my 4 year old while I make supper in the Review Information: The correct answer is D: Call the provider for clarification
kitchen." Relying on anyone else''s interpretation is very risky. When in doubt, check it out
"My sleeping baby lies so cute in the crib with the little buttocks with the person who wrote the illegible order. Order entry systems help to
C) minimize this problem.
stuck up in the air while the four year old naps on the sofa."
"I have the 4 year-old hold and help feed the four month-old a
D) 7. An adult client is found to be unresponsive on morning rounds. After checking
bottle in the kitchen while I make supper."
for responsiveness and calling for help, the next action that should be taken by
Review Information: The correct answer is D: "I have the four the nurse is to:
year-old hold and help feed the four month-old a bottle in the kitchen
A) check the cartoid pulse
while I make supper." The infant seat is to be placed on the rear seat.
Small children and infants are not to be left unsupervised. Infants are B) deliver 5 abdominal thrusts
to be placed on their "back when they go back" to sleep or are lying in C) give 2 rescue breaths
a crib. A 4 year-old could assist with the care of an infant with proper D) open the client's airway
supervision. This enhances bonding with the infant and the Review Information: The correct answer is D: open the client''s airway
developmental needs of the preschooler to "help" and not feel left out. According to the ABCs of CPR the first step in rescuing an unresponsive victim
after checking responsiveness and calling for help is to open the victims airway.
2. Upon completing the admission documents, the nurse learns that The airway must be opened appropriately before the need for rescue breaths can
the 87 year-old client does not have an advance directive. What action be determined. The pulse is assessed, after breathing is evaluated. The need for
should the nurse take? abdominal thrusts is determined by inability to achieve chest rise when ventilation
A) Record the information on the chart is attempted.
B) Give information about advance directives
C) Assume that this client wishes a full code 8. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse
discovers that 800 ml has been infused after 4 hours. What is the priority
D) Refer this issue to the unit secretary
nursing action?
Review Information: The correct answer is B: Give information
A) Ask the client if there are any breathing problems
about advance directives
For each admission, nurses should request a copy of the current B) Have the client void as much as possible
advance directive. If there is none, the nurse must offer information C) Check the vital signs
about what an advance directive implies. It is then the client’s choice D) Ausculate the lungs
to sign it. In option 1 just recording the information is not sufficient. Review Information: The correct answer is D: Ausculate the lungs
In option 3 the nurse should not assume that the client has been All of the options would be part of the evaluation for the effects of the large
informed of choices for emergency care. In option 4 this represents an amount of fluid in a short period of time. However the worst result is heart failure
inappropriate delegation approach. with lung congestion so the auscultation of the lungs is the priority action. The
sequence of actions would be 4 1 3 2.
3. A nurse administers the influenza vaccine to a client in a clinic.
Within 15 minutes after the immunization was given, the client 9. Following change-of-shift report on an orthopedic unit, which client should the
complains of itchy and watery eyes, increased anxiety, and difficulty nurse see first?
breathing. The nurse expects that the first action in the sequence of
care for this client will be to 16 year-old who had an open reduction of a fractured wrist 10 hours
A) Maintain the airway ago
B) Administer epinephrine 1:1000 as ordered 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
72 year-old recovering from surgery after a hip replacement 2 hours
C) Monitor for hypotension with shock
ago
D) Administer diphenhydramine as ordered
75 year-old who is in skin traction prior to planned hip pinning surgery.
Review Information: The correct answer is B: Administer Review Information: The correct answer is C: 72 year-old recovering from
epinephrine 1:1000 as ordered .All the answers are correct given the surgery after a hip replacement 2 hours ago
circumstances. The correct sequence of care is to administer the Look for the client who is in the least stable condition. The client who returned
epinephrine, then maintain airway. In the early stages of anaphylaxis, from surgery 2 hours ago is at risk for hemorrhage and should be seen first. The
when the patient has not lost consciousness and is normatensive, 16 year-old should be seen next because it is still the first post-op day. The 75
administering the epinephrine and then applying the oxygen, watching year-old in skin traction should be seen next. The client who can safely be seen
for hypotension and shock are later responses. The prevention of a last is the 20 year-old who is 2 weeks post-injury.
severe crisis is maintained by using diphenhydramine.
10. A nurse observes a family member administer a rectal suppository by having
4. Which of these children at the site of a disaster at a child day care the client lie on the left side for the administration. The family member pushed
center would the triage nurse put in the "treat last" category? the suppository until the finger went up to the second knuckle. After 10 minutes
the client was told by the family member to turn to the right side and the client
An infant with intermittent buldging anterior fontonel between crying
did this. What is the appropriate comment for the nurse to make?
episodes
Why don’t we now have the client turn back to the left side.
A toddler with severe deep abrasions over 98% of the body
That was done correctly. Did you have any problems with the
A preschooler with 1 lower leg fracture and the other leg with an upper
insertion?
leg fracture
Let’s check to bracelet
identification see if theissuppository is in afar
unsafe. Making enough.
new bracelet on the unit is not appropriate.
A school-age child with singed eyebrows and hair on the arms
Did you feel any stool in the intestinal tract?
Review Information: The correct answer is B: A toddler with severe
deep abrasions over 98% of the body .This child has the least chance 6. The nurse is having difficulty reading the health care provider'swritten order
of survival. Severe deep abrasions are to be thought of as second and that was written right before the shift change. Whataction should be taken?
third degree burns. The child has great risk of shock and infection
combined.
5. When admitting a client to an acute care facility, an identification
bracelet is sent up with the admission form. In the event these do not
match, the nurse’s best action is to
change whichever item is incorrect to the correct information
,Review Information: The correct answer is B: That was done
correctly. Did youhave any problems with the insertion?
Left side-lying position is the optimal position for the client
receiving rectal medications. Due to the position of the descending
colon, left side-lying allows themedication to be inserted and move
along the natural curve of the intestine and facilitates retention of
the medication. After a short time it will not hurt the clientto turn
in any manner. The suppository should be somewhat melted after
10 to 15minutes. The other responses are incorrect since no data is
in the stem to support such comments.
11. A client with a diagnosis of Methicillin resistant Staphylococcus
aureus (MRSA)has died. Which type of precautions is the
appropriate type to use when performing postmortem care?
A) airborne precautions
B) droplet precautions
C) contact precautions
D) compromised host precautions
Review Information: The correct answer is C: contact precautions
The resistant bacteria remain alive for up to 3 days post death.
Therefore, contactprecautions must still be implemented. Also
label the body so that the funeral home staff can protect
themselves as well. Gown and gloves are required.
12. The nurse is reviewing with a client how to collect a
clean catch urinespecimen. Which sequence is
appropriate teaching?
,A) Void a little, clean the meatus, then collect specimen An elderly client who had a myocardial infarction a week ago - UAP
Review Information: The correct answer is A: An admission at the change of
B) clean the meatus, begin voiding, then catch urine stream
shifts with atrial fibrillation and heart failure - PN
C) Clean the meatus, then urinate into container The care for a new admissions should be performed by an RN. Since the client
D) Void continuously and catch some of the urine was admitted at the change of shifts, the stability of the client would not have
Review Information: The correct answer is B: clean the meatus, been established. The charge nurse should take this client. The PN could monitor
begin voiding, then catch urine stream the IV fluids in option C. Tasks that do not require independent judgment should
A clean catch urine is difficult to obtain and requires clear directions. be delegated. The nurse may delegate the care for a stable client to a UAP.
Instructing the client to carefully clean the meatus, then void naturally
with a steady stream prevents surface bacteria from contaminating 19. A mother brings her 3 month-old into the clinic, complaining that the child
the urine specimen. As starting and stopping flow can be difficult, seems to be spitting up all the time and has a lot of gas. The nurse expects to find
once the client begins voiding it''s best to just slip the container into which of the following on the initial history and physical assessment?
the stream. Other responses are not correct technique. A) Increased temperature and lethargy
B) Restlessness and increased mucus production
13. The provider orders Lanoxin (digoxin) 0.125 mg po and
furosomide 40 mg every day. Which of these foods would the nurse C) Increased sleeping and listlessness
reinforce for the client to eat at least daily? D) Diarrhea and poor skin turgor
A) spaghetti Review Information: The correct answer is B: Restlessness and increased
B) watermelon mucus production
This infant could be experiencing gastroesophageal reflux, or could be allergic to
C) chicken
the formula. Restlessness, irritability and increased mucus production can develop
D) tomatoes if an allergy is present. Soy based formula is often recommended.
Review Information: The correct answer is B: watermelon
Watermelon is high in potassium and will replace any potassium lost 20. As the nurse takes a history of a 3 year-old with neuroblastoma, what
by the diuretic. The other foods are not high in potassium. comments by the parents require follow-up and are consistent with the diagnosis?
A) "The child has been listless and has lost weight."
14. A nurse is stuck in the hand by an exposed needle. What
B) "The urine is dark yellow and small in amounts."
immediate action should the nurse take?
C) "Clothes are becoming tighter across her abdomen."
A) Look up the policy on needle sticks
D) "We notice muscle weakness and some unsteadiness."
B) Contact employee health services
C) Immediately wash the hands with vigor
D) Notify the supervisor and risk management Review Information: The correct answer is C: "Clothes are becoming tighter
across her abdomen."
One of the most common signs of neuroblastoma is increased abdominal girth.
Review Information: The correct answer is C: Immediately wash
The parents'' report that clothing is tight is significant, and should be followed by
the hands with vigor
additional assessments.
The immediate action of vigorously washing will help remove possible
contamination. Then the sequence would then be options 4, 1, 2.
21. A 16 year-old enters the emergency department. The triage nurse identifies
that this teenager is legally married and signs the consent form for treatment.
15. As the nurse observes the student nurse during the administration
What would be the appropriate action by the nurse?
of a narcotic analgesic IM injection, the nurse notes that the student
begins to give the medication without first aspirating. What should the
nurse do? Ask the teenager to wait until a parent or legal guardian can be
contacted
A) Ask the student: "What did you forget to do?”
Withhold treatment until telephone consent can be obtained from the
B) Stop. Tell me why aspiration is needed.
partner
C) Loudly state: “You forgot to aspirate.”
Refer the teenager to a community pediatric hospital emergency
Walk up and whisper in the student’s ear “Stop. Aspirate. Then department
D)
inject.”
Proceed with the triage process in the same manner as any adult client
Review Information: The correct answer is D: Proceed with the triage process
Review Information: The correct answer is D: Walk up and whisper
in the same manner as any adult client
in the student’s ear “Stop. Aspirate. Then inject.”
Minors may become known as an "emancipated minor" through marriage,
This action is a direct threat to the client if the medication enters into
pregnancy, high school graduation, independent living or service in the military.
the blood stream instead of the muscle. The purpose of aspiration
Therefore, this client, who is married, has the legal capacity of an adult.
with IM injections is to prevent the injection of the drug directly into
the blood stream. Option 4 protects the client and is the most
22. A newly admitted elderly client is severely dehydrated. When planning care for
professional.
this client, which task is appropriate to assign to an unlicensed assistive personnel
(UAP)?
16. A client with Guillain Barre is in a nonresponsive state, yet vital
signs are stable and breathing is independent. What should the nurse
document to most accurately describe the client's condition? Converse with the client to determine if the mucuous membranes are
impaired
A) Comatose, breathing unlabored Report hourly outputs of less than 30 ml/hr
B) Glascow Coma Scale 8, respirations regular Monitor client's ability for movement in the bed
C) Appears to be sleeping, vital signs stable Check skin turgor every 4 hours
D) Glascow Coma Scale 13, no ventilator required Review Information: The correct answer is B: Report output of less than 30
ml/hr
Review Information: The correct answer is B: Glascow Coma Scale
When directing a UAP, the nurse must communicate clearly about each delegated
8, respirations regular
task with specific instructions on what must be reported. Because the RN is
The Glascow Coma Scale provides a standard reference for assessing
responsible for all care-related decisions, only implementation tasks should be
or monitoring level of consciousness. Any score less than 13 indicates
assigned because they do not require independent judgment.
a neurological impairment. Using the term comatose provides too
much room for interpretation and is not very precise.
23. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic
fever. Which statement by the parent would cause the nurse to suspect an
17. A client enters the emergency department unconscious via
association with this disease?
ambulance from the client’s work place. What document should be
given priority to guide the direction of care for this client? Our child had chickenpox 6 months ago.
Strep throat went through all the children at the day care last month.
Both ears were infected over 3 months age.
The statement of client rights and the client self determination act
Last week both feet had a fungal skin infection.
Orders written by the health care provider
A notarized original of advance directives brought in by the partner
The clinical pathway protocol of the agency and the emergency Review Information: The correct answer is B: Strep throat went through all the
department children at the day care last month.
Evidence supports a strong relationship between infection with Group A
Review Information: The correct answer is C: A notarized original
streptococci and subsequent rheumatic fever (usually within 2 to 6 weeks).
of advance directives brought in by the partner
, Discuss the feeling of reluctance with an objective peer or supervisor
Limit contacts with the client to avoid reinforcement of the
manipulative behavior
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