NCLEX-RN 250 QUESTIONS AND ANSWERS WITH RATIONALES STUDY GUIDE 2023
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Course
NCLEX-RN
Institution
NCLEX-RN
1. A nurse is assessing a client diagnosed with COPD. The patient tells the nurse that she has trouble
sleeping at night. Which question is most important for the nurse to ask next?
1) “Is your partner snoring and keeping you awake?”
2) “What do you eat before you go to bed?”
3) “How ...
NCLEX -RN 250 QUESTIONS AND ANSWERS STUDY GUIDE 2023 1. A nurse is assessing a client diagnosed with COPD. The patient tells the nurse that she has trouble sleeping at night. Which question is most important for the nurse to ask next? 1) “Is your partner snoring and keeping you awake?” 2) “What do you eat before you go to bed?” 3) “How many pillows do you sleep on at night?” 4) “Have you always been a light sleeper?” Rationale: The question of “How many pillows” is looking for orthopnea. Orthopnea is the inability to breathe unless upright, which accounts for poor sleep. The more pillows a person uses the more upright they will be, therefore indicating difficulty breat hing while laying. 2. The bed of a patient who has an indwelling urinary catheter (Foley) is found wet with urine. After determining that the catheter is patent, the nurse should: 1) Tell the patient to use the bedpan when there is an urge to void. 2) Insert a larger -size catheter. 3) Position a waterproof pad under the patient’s buttocks. 4) Provide perineal care whenever necessary. Rationale: Urine is leaking around the catheter and a larger -size catheter is required to avoid leakage. It is the role of the nurse to select the appropriate size catheter and perform the insertion. 3. A 4-year-old client is admitted for eye surgery. The nurse is performing the correct action in preparing the child for the procedure when she: 1) reads an age-appropriate illustrated book about eye surgery to the child. 2) draws a picture of the eye and explains what will happen. 3) informs the child that the procedure will take one hour. 4) uses dolls or puppets to explain how to get ready for surgery. Rationale: A 4 -year-old child will respond best to learning about the surgery by seeing a visual depiction using dolls because it is easiest for them to understand. 4. The nurse performs discharge teaching for a client with a left leg cast who will be using crutches to ambulate. Which of the following statements, if made by the patient to the nurse, would require further teaching? 1) “I will put all of my body weight on the handholds and keep it off my armpits.” 2) “When going upstairs, I will first lift my bad leg and then my good one.” 3) “I will remember not to scratch inside the cast.” 4) “When going downstairs, I will follow my bad leg with my good leg.” Rationale: Up with the good (unaffected leg) and down with the bad (affected leg). This allows for the most support and reduces the risk of a fall as the person is not using their bad leg to support all their weight as they ascend the steps. 5. A male neona te has just been circumcised. Which nursing intervention is part of the initial care of a circumcised neonate? 1) apply alcohol to the site 2) Change the diaper as needed 3) keep the neonate in supine position 4) apply petroleum gauze to the site for 24 hours Rationale: Petroleum gauze is applied to the site for the 1st 24 hours to prevent the skin edges from sticking to the diaper. neonates are initially kept in the prone position diapers are changed more frequently to inspect the site. 6. When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia? 1) bradycardia 2) hyperglycemia 3) metabolic alkalosis 4) shivering Rationale: hypothermic neonates become bradycardic proportional to the degree of core temp. Hypo glycemia is seen in hypothermic neonates. Shivering is rarely observed in neonates. metabolic acidosis, not alkalosis is seen due to slowed resp 7. After receiving a report from the night nurse, which of the following clients should the nurse see FIRST? 1) A 31-year-old woman refusing sucralfate before breakfast 2) A 40-year-old man with left-sided weakness asking for assistance to the commode 3) A 52-year -old woman reporting chills who is scheduled for a cholecystectomy 4) A 65-year-old man with a nasogastric tube who had a bowel resection yesterday Rationale: This patient is the one presenting the most alarming issue and is in the worst condition. Since he is in the worst condition it would be important for the nurse to see him first as the other patients can wait but he may not be able to. 8. The physician orders tobramycin sulfate 3 mg/kg IV every 8 hours for a 3 -year-old boy. The nurse enters the client’s room to administer the medication and discovers that the boy does not have an identification bracelet. Which of the following should the nurse do? 1) Ask the parents at the child’s bedside to state their child’s name. 2) Ask the child to say his first and last name. 3) Have a coworker identify the child before giving the medication. 4) Hold the medication until an identification bracelet can be obtained. Rationale: By asking the parents the name of the child you are ensuring that the rights of the medication are met, specifically that you are giving the right person the medication. It is best to ask the parents because the 3 -year-old may not understand and may not give you the correct answer. This also ensures the medication is given at the correct time. 9. A 21 -year-old woman in active labor is admitted to the labor suite. An hour later, the membranes rupture spontaneously. The nurse observes a glistening white cord protruding from the vagina. Which of the following actions should the nurse take FIRST? 1) Return to the nurses’ station and place an emergency call to the physician. 2) Administer oxygen by mask at 10–12 L/min and assess the mother’s vital signs. 3) Place a clean towel over the cord and wet it with sterile normal saline. 4) Apply manual pressure to the presenting part and have the mother assume a knee -chest position. Rationale: A prolapsed cord is an emergency situation. The nurse must relieve pressure on the cord to prevent fetal anoxia. To do this they will apply pressure t o the presenting part while the mother is in a knee -chest position. This is the only option that focuses on immediately treating the prolapsed cord. 10. A 50 -year-old male client comes to the nurses’ station and asks the nurse if he can go to the cafeteria to get something to eat. When told that his privileges do not include visiting the cafeteria, the client becomes verbally abusive. Which of the followin g approaches by the nurse would be MOST effective? 1) Tell the client to lower his voice, because he is disturbing the other clients. 2) Ask the client what he wants from the cafeteria and have it delivered to his room. 3) Calmly but firmly escort the client back to his room. 4) Assign the nursing assistive personnel (NAP) to accompany the client to the cafeteria. Rationale: The nurse should not reinforce abusive behavior. Clients need consistent and clearly defined expectations and limits. By not entertaining th is behaviour the nurse is setting an example that being verbally abusive is not how you get what you want. Also, while this answer is firm it is not rude to the client. 11. A cast is applied to a 9 -month -old girl for the treatment of talipes equinovarus. Which of the following instructions is MOST essential for the nurse to give to the child’s mother regarding her care? 1) Offer appropriate toys for her age. 2) Make frequent clinic visits for cast adjustment. 3) Provide an analgesic as needed. 4) Do circulatory checks of the casted extremity. Rationale: A possible complication that can occur after cast application is impaired circulation. Checking the child’s circulation is the highest priority. While the other options are all part of family teaching, checking circulation is the most important. 12. The home health nurse is going to start an IV with 5% dextrose in water (D5W) for a 76 -year-old woman. To perform the venipuncture, the nurse should start the IV with which of the following? 1) The veins of the client’s wrist on the non-domi nant side 2) The veins of the leg so it will not interfere with the client’s ability to feed herself 3) The dorsal veins of the client’s forearm on the non-dominant side 4) The dorsal surface of the client’s hand on the non-dominant side Rationale: This is the best site for the nurse to use for the IV because of its ease of access, availability of elastic veins, and limited use by the client. This will help the client to feel comfortable and decrease some of the chance of complications. 13. A 7-year-old girl with type 1 insulin -dependent diabetes mellitus (IDDM) has been homesick for several days and is brought to the Emergency Department by her parents. If the child is experiencing ketoacidosis, the nurse would expect to see which of the following lab results? 1) Serum glucose 140 mg/dL 2) Serum creatinine 5.2 mg/dL 3) Blood pH 7.28 4) Hematocrit 38% Rationale: Normal blood pH is 7.35 –7.45. A blood pH of 7.28 indicates diabetic ketoacidosis which is what the patient is experiencing. The other values are not indicative of diabetic ketoacidosis. 14. The nurse delivers external cardiac compressions to a client while performing cardiopulmonary resuscitation (CPR). Which of the following actions by the nurse is BEST? 1) Maintain a position close to the client’s side with the nurse’s knees apart. 2) Maintain vertical pressure on the client’s chest through the heel of the nurse’s hand. 3) Re-check the nurse’s hand position after every 10 chest compressions. 4) Check for a return of the client’s pulse after every 8 breaths by the nurse. Rationale: The nurse’s elbows should be locked, arms straight, with shoulders directly over hands. Incorrect pressure or improperly placed hands could cause injury to the client. 15. The nurse obtains a health history from a cli ent admitted with acute glomerulonephritis that is associated with beta -hemolytic Streptococcus. The nurse expects which of the following to be significant in the health history?
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