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NCLEX RN 2021 REVIEW WITH COMPLETE SOLUTION WITH QUESTIONS AND ANSWERS GRADED A
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NCLEX RN 2021 REVIEW WITH COMPLETE SOLUTION WITH QUESTIONS AND ANSWERS GRADED A
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NCLEX RN 2021 REVIEW WITH COMPLETESOLUTION GRADED A+ ALL ARE LATEST
SOLUTION
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 Correct Answers: 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? Correct Answers: 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. Correct Answers: 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. Correct Answers: 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.
4. Stop the infusion and return the blood to the lab. Correct Answers: 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. Correct Answers: 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. Correct Answers:
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. Correct Answers:
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. Correct
Answers: 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.
4. Cloudy urine with painful urination. Correct Answers: 1. Vomiting, photosensitivity, and stiff neck.
5 Rights of Delegation Correct Answers: Right Person
Right Task
Right Circumstance
Right Direction/Communication
Right Supervision/Evaluation
,Scope of Practice
RN -
LPN -
UAP - Correct Answers: 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. Correct
Answers: 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. Correct Answers: 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.
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. Correct Answers: 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. Correct Answers: 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. Correct Answers: 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. Correct Answers: 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. Correct Answers: 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.
5. The client has an unrepaired aortic aneurism.
6. The client initially received the wrong IV fluids. Correct Answers: 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.
5. The client has an unrepaired aortic aneurism.
A nurse contract the provider and questions the prescription of enoxaparin for a client who is allergic
to heparin. The provider directs the nurse to give the medication as prescribed. Which of the following
should be the priority action by the nurse?
1. Submit an incident report to the nurse manager.
2. Decline to administer the medication.
3. Document datils of the conversation in the medical record.
4. Immediately report this situation to the charge nurse. Correct Answers: 2. Decline to administer the
medication.
A client was recently placed in seclusion after exhibiting behaviors of acute mania. What is the
appropriate nursing action?
1. Review medical history for potential contraindications of seclusion.
2. Obtain a verbal prescription now and request a medical evaluation with 12 hr.
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