NCLEX RN 2021 Review with complete solution graded A+
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NCLEX RN 2021
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NCLEX RN 2021
A client who has amyotrophic lateral sclerosis is having frequent episodes of dysphagia. Which of the following referrals is appropriate for the nurse to make currently?
1. Physical Therapist
2. Speech Pathologist
3. Registered Dietitian
4. Occupational Therapist
2. Speech Pathologi...
nclex rn 2021 review with complete solution graded a
a client who has amyotrophic lateral sclerosis is having frequent episodes of dysphagia which of the following referrals is appropriate for the n
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NCLEX RN 2021 Review
A client who has amyotrophic lateral sclerosis is having frequent episodes of dysphagia.
Which of the following referrals is appropriate for the nurse to make currently?
1. Physical Therapist
2. Speech Pathologist
3. Registered Dietitian
4. Occupational Therapist - Answer 2. Speech Pathologist
A client who has chronic progressive dementia exhibits symptoms of malnutrition.
Which action is needed at this time?
1. Notify social services about concern for abuse.
2. Initiate a consult for physical therapy to visit daily.
3. Ask home care services to provide written instructions.
4. Arrange a meeting with the interprofessional team to coordinate care? - Answer 4.
Arrange a meeting with the interprofessional team to coordinate care?
A nurse should recognize which of the following clients are likely to need rehabilitation
services after hepatization? (SATA)
1. School-age child who is recovering from an appendectomy.
2. Client who had a cesarean delivery for a breech presentation.
3. An adult client who has left hemiplegia after a stroke.
4. An adult client who is recovering from Guillain-Barre syndrome.
5. An older adult client who had a left hip replacement.
6. An adolescent client who required hospitalization due to asthma. - Answer 3. An adult
client who has left hemiplegia after a stroke.
4. An adult client who is recovering from Guillain-Barre syndrome.
5. An older adult client who had a left hip replacement.
A nurse is assigned to a group of clients. Which of the following has an increased risk of
aspiration while eating? (SATA)
1. A client who has a new diagnosis of gastroesophageal reflux disease.
2. A client who has admitted with a diagnosis of cerebrovascular accident.
3. A client who is 4 hr. post-op and received general anesthesia.
4. A client who is 8 hr. following traumatic laryngeal nerve damage.
5. A client who continually experiences prolonged coughing episodes. - Answer 2. A
client who has admitted with a diagnosis of cerebrovascular accident.
3. A client who is 4 hr. post op and received general anesthesia.
4. A client who is 8 hr. following traumatic laryngeal nerve damage.
5. A client who continually experiences prolonged coughing episodes.
A client is receiving packed RBCs and becomes tachypneic. The client's temperature
changes from 36.8*C (98.4*F) to 38.4*C (101.2*F). Which of the nursing interventions
should the nurse perform first.
1. Give 750 mg acetaminophen orally.
2. Collect blood and urine specimens for analysis.
3. Administer and IV infusion of 0.9% sodium chloride.
, NCLEX RN 2021 Review
4. Stop the infusion and return the blood to the lab. - Answer 4. Stop the infusion and
return the blood to the lab.
A nurse receives a request from four clients at the same time. Which of the following
clients should the nurse address first? A client who
1. Needs to void 1 hr. after removal of an indwelling urinary catheter.
2. Reports restlessness and shortness of breath following surgery for a fractured femur.
3. Asks for a stool softener 2 days following surgery.
4. Demands to take prescribed insulin early the spouse is bringing dinner. - Answer 2.
Reports restlessness and shortness of breath following surgery for a fractured femur.
After receiving the report, a nurse should plan to access the clients in which priority
order?
1. A 9-month-old who is receiving hydration therapy with IV fluids infusion peripherally.
2. A 6-year-old who is receiving continuous chemotherapy via a central venous
catheter.
3. A 14-year-old who is awaiting discharge instructions receiving prednisone therapy.
4. An 8-year-old who is 2 days postoperative with an indwelling urinary catheter. -
Answer 1st) 2. A 6-year-old who is receiving continuous chemotherapy via a central
venous catheter.
2nd) 1. A 9-month-old who is receiving hydration therapy with IV fluids infusion
peripherally.
3rd) 4. An 8-year-old who is 2 days postoperative with an indwelling urinary catheter.
4th) 3. A 14-year-old who is awaiting discharge instructions receiving prednisone
therapy.
A nurse received the report and should plan to see which of the following client first?
1. A client at 39 weeks of gestation who is having contractions over 5 min lasting45 to
60 seconds.
2. A client who is pregnant and has a blood glucose level of 150mg/dl.
3. A client at 33 weeks of gestation who is receiving magnesium sulfate IV.
4. A client 1 day postpartum who has changed perineal pads twice in the last 7 hr. -
Answer 3. A client at 33 weeks of gestation who is receiving magnesium sulfate IV.
After receiving the report, which of the following clients should the nurse see first?
1. A client who was admitted with kidney stones and is crying with back pain.
2. A client who had chest discomfort prior to admission and is now requesting coffee.
3. A client who is scheduled for surgery and needs the linen changed.
4. A client who is to receive one unit of packed RBCs today and needs an IV restarted. -
Answer 1. A client who was admitted with kidney stones and is crying with back pain.
The nurse should triage which of the following clients first?
1. Vomiting, photosensitivity, and stiff neck.
2. Elevated temperature, sore throat, and fatigue.
3. A guarded gait and a bruised, edematous ankle.
, NCLEX RN 2021 Review
4. Cloudy urine with painful urination. - Answer 1. Vomiting, photosensitivity, and stiff
neck.
5 Rights of Delegation - Answer Right Person
Right Task
Right Circumstance
Right Direction/Communication
Right Supervision/Evaluation
Scope of Practice
RN -
LPN -
UAP - - Answer RN - Unstable clients, Assessments, Initiate Care Plans, Initial
Teaching, Blood Productions, IV Fluids and IV Push Medications.
LPN - Stable clients, Gather data, Contribute to Care Plan, Reinforce Teaching, Monitor
IVFs and Blood Transfusions, Administer Piggybacks.
UAP - Stable clients, Obtain Vital Signs, Gather specific date, Hygiene care, Bed
making, Feeding, Positioning, Ambulation.
A nurse is organizing care for four clients, which of the following tasks should the nurse
instruct the UAP to perform?
1. Measure the urine output from a client who was recently admitted with dehydration.
2. Bathe and shampoo hair for a client who was just admitted after a motor vehicle
crash.
3. Help a client who is requesting a bedpan after a lumbar puncture.
4. Decrease the oxygen on a nasal cannula for a client who is being discharged with
COPD. - Answer 1. Measure the urine output from a client who was recently admitted
with dehydration.
Which of the following tasks should a nurse assign to the experienced unlicensed
assistive personnel (UAP)? (SATA)
1. Completing intake and output measurements.
2. Feeding a client who has early dementia.
3. Explaining oral hygiene to a client receiving chemotherapy.
4. Bathing a client two days after a cerebrovascular accident.
5. Ambulating a client who is one-day post-hysterectomy.
6. Assisting a client who has hypertension select low-sodium snacks. - Answer 1.
Completing intake and output measurements.
2. Feeding a client who has early dementia
4. Bathing a client two days after a cerebrovascular accident.
5. Ambulating a client who is one-day post-hysterectomy.
A nurse is supervising care delegated to a UAP. The nurse should take corrective action
if which of the following is observed?
1. Allowing a client to sit in a bedside chair while discarding bathwater.
2. Pulling the curtain partially around the bed while performing perineal care.
, NCLEX RN 2021 Review
3. Raising the bed and lowing the side rail while repositioning a client.
4. Answering a call that rings the hospital telephone while the client is away. - Answer 2.
Pulling the curtain partially around the bed while performing perineal care.
A nurse delegates hygiene care for a client hospitalized with COPD to unlicensed
assistive personnel. Which of the following is the most appropriate instruction for the
nurse to give?
1. Delay hygiene care until one hour after breakfast.
2. Allow the client to nap with the lead of the bed elevated.
3. Encourage the client to participate in hygiene care.
4. Teach the client to breathe slowly and deeply. - Answer 1. Delay hygiene care until
one hour after breakfast.
An LPN reports the following data to the supervising RN regarding data collection for a
client who has congestive heart failure: Pulse oximetry 85%, respirations 48/min and
labored. What is the priority action at this time?
1. The LPN will administer IV Furosemide.
2. The respiratory therapist will be notified.
3. The client will be prepared for a chest x-ray.
4. The care of the client will be reassigned to an RN. - Answer 4. The care of the client
will be reassigned to an RN.
A nurse from the adult medical unit is assigned to the pediatric unit. Which of the
following would be an appropriate assignment?
1. A toddler admitted with epiglottitis.
2. A school-age child scheduled for excision of a Wilms tumor.
3. An infant who is recovering from repair of a cleft lip and palate.
4. A preschooler who had surgical fixation of a fractured humerus. - Answer 4. A
preschooler who had surgical fixation of a fractured humerus.
A nurse coordinates care for a client who had a cerebrovascular accident. Which of the
following tasks should be addressed by the Physical Therapist? (SATA)
1. Completing self-care.
2. Thickening clear liquids.
3. Using devices for walking.
4. Transferring from chair to bed.
5. Administering Albuterol treatment. - Answer 3. Using devices for walking.
4. Transferring from chair to bed.
A client is recovering from a cerebrovascular adducent and has orders to be transferred
to a rehabilitation center. Which of the following date should the nurse include in the
verbal report? (SATA)
1. The client has been married three times.
2. The client is moving all extremities well.
3. The client is being treated for hypertension.
4. The client has three children who visit daily.
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