Exam (elaborations)
NCLEX 3000 EXAM WITH DETAILED QUESTIONS WITH CORRECT ANSWERS
- Course
- Institution
NCLEX 3000 EXAM WITH DETAILED QUESTIONS WITH CORRECT ANSWERS...
[Show more]
Content preview
NCLEX 3000 EXAMThe nurse is checking a client's I.V. infusion rate at the beginning of her shift.
The nursing Kardex states that the infusion should run at 125 ml/hour. To verify
the I.V. drip rate, the nurse must know the drip factor, which is:
1. the number of milliliters in one drop.
2. the number of drops in one milliliter.
3. the number of drops per minute to be infused.
4. the number of drops per hour to be infused. - ANSWER 2. RATIONALES:
The drip factor is the number of drops in one milliliter, not the number of
milliliters in one drop. The drip rate refers to the number of drops infused per
minute. The flow rate is the number of milliliters, not the number of drops,
infused per hour.
The nurse transcribes the following physician's order onto the client's
medication record:
September 15, 2005
Administer 10 gtt of timolol maleate (Timoptic) ophthalmic solution AU daily.
John Bloom, MD
Which components of the medication order should the nurse question?
Select all that apply:
1. Number of drops
2. Route
3. Type of medication
4. Signature
5. Frequency of administration
6. Date - ANSWER 1, 2. RATIONALES: To ensure that medication errors don't
occur, the nurse must follow the "six rights" of safe medication administration:
right drug, right dose, right route, right time, right client, and right
,NCLEX 3000 EXAM
documentation. The number of drops is too great to be instilled into the eye. The
medication wouldn't be effective because the dose is too large and would run
out. Normally, the physician orders 1 or 2 drops to be instilled into the eye. As
the order is written, the eye medication would be administered in both ears
(AU). Abbreviations should be avoided when possible to prevent medication
errors.
The nurse administers albuterol (Proventil), as prescribed, to a client with
emphysema. Which finding indicates that the drug is producing a therapeutic
effect?
1. Respiratory rate of 22 breaths/minute
2. Dilated and reactive pupils
3. Urine output of 40 ml/hour
4. Heart rate of 100 beats/minute - ANSWER 1. RATIONALES: In a client
with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22
breaths/minute indicates that the drug has achieved its therapeutic effect
because fewer respirations are required to achieve oxygenation. Albuterol has
no effect on pupil reaction or urine output. It may cause a change in the heart
rate, but this is an adverse, not therapeutic, effect.
The nurse must irrigate a gaping abdominal incision with sterile normal saline,
using a piston syringe. How should the nurse proceed?
1. Irrigate continuously until the solution becomes clear or all of the solution
has been used.
2. Moisten the area around the wound with normal saline after the irrigation.
3. Apply a wet-to-dry dressing to the wound after the irrigation.
4. Rapidly instill a stream of irrigating solution into the wound. - ANSWER 1.
RATIONALES: To wash away tissue debris and drainage effectively, the nurse
should irrigate the wound until the solution becomes clear or all of the solution
has been used. After the irrigation, the nurse should dry the area around the
wound; moistening it promotes microorganism growth and skin irritation. When
the area is dry, the nurse should apply a sterile dressing, rather than a wet-to-dry
dressing. The nurse always should instill the irrigating solution gently; rapid or
forceful instillation can damage tissues.
,NCLEX 3000 EXAM
A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the
nurse should provide which instruction?
1. "Take your temperature every 4 hours."
2. "Increase your fluid intake to 2 to 3 L per day."
3. "Apply an antibacterial dressing to the incision daily."
4. "Be aware that your urine will be cherry red for 5 to 7 days." - ANSWER 2.
RATIONALES: Increasing fluid intake flushes the renal calculi fragments
through — and prevents obstruction of — the urinary system. Measuring
temperature every 4 hours isn't needed. Lithotripsy doesn't require an incision.
Hematuria may occur for a few hours after lithotripsy but then should disappear.
A 2-year-old child with a tracheostomy suddenly becomes diaphoretic and has
an increased heart rate, an increased respiratory rate, and a decreased oxygen
saturation level. Which of the following should be the nurse's first action?
1. Suction the tracheostomy.
2. Turn the child to a side-lying position.
3. Administer pain medication.
4. Perform chest physiotherapy. - ANSWER 1. RATIONALES: Diaphoresis,
increased heart rate, increased respiratory effort, and decreased oxygen
saturation are signs that mucus is partially occluding the airway. The child
needs suctioning immediately to prevent full occlusion. Turning the child to a
side-lying position won't remove mucus from the airway. The child may require
pain medication after his airway has been cleared if his condition warrants it.
Chest physiotherapy will help drain excess mucus from the lungs but not from a
tracheostomy.
A client in the emergency department is diagnosed with a communicable
disease. When complications of the disease are discovered, the client is
admitted to the hospital and placed in respiratory isolation. Which infection
warrants respiratory isolation?
1. Chickenpox
2. Impetigo
3. Measles
4. Cholera - ANSWER 3. RATIONALES: Measles warrants respiratory
isolation, which aims to prevent disease transmission primarily over short
, NCLEX 3000 EXAM
distances through the air (droplet transmission). Other infections necessitating
respiratory isolation include epiglottitis or pneumonia caused by Haemophilus
influenzae, erythema infectiosum, meningitis caused by H. influenzae or
meningococci, meningococcal pneumonia, meningococcemia, mumps, and
pertussis. Chickenpox calls for strict isolation; impetigo, contact isolation; and
cholera, enteric isolation.
The nurse is assisting in developing a teaching plan for a child with acute
poststreptococcal glomerulonephritis. What is the most important point to
address in this plan?
1. Infection control
2. Nutritional planning
3. Prevention of streptococcal pharyngitis
4. Blood pressure monitoring - ANSWER 4. RATIONALES: Because
poststreptococcal glomerulonephritis may cause severe, life-threatening
hypertension, the nurse must teach the parents how to monitor the child's blood
pressure. Infection control, nutritional planning, and prevention of streptococcal
pharyngitis are important but are secondary to blood pressure monitoring.
A school-age child is admitted to the facility with a diagnosis of acute
lymphoblastic leukemia (ALL). The nurse recognizes a nursing diagnosis of
Risk for infection. What is the most effective way for the nurse to reduce the
child's risk of infection?
1. Implementing reverse isolation
2. Maintaining standard precautions
3. Requiring staff and visitors to wear masks
4. Practicing thorough hand washing - ANSWER 4. RATIONALES: Both ALL
and its treatment cause immunosuppression. Thorough hand washing is the
single most effective way to prevent infection in an immunosuppressed client.
Reverse isolation doesn't significantly reduce the incidence of infection in
immunosuppressed clients; furthermore, isolation may cause psychological
stress. Standard precautions are intended mainly to protect caregivers from
contact with infectious matter, not to reduce the client's risk of infection. Staff
and others needn't wear masks when visiting because most infections are
transmitted by direct contact. Instead of relying on masks and other barrier
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Mirror. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $13.49. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
77333 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now