Comprehensive NCLEX Answer Key

Nclex Comp
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  40 items Comprehensive NCLEX review answer key 1. Which individual is at greatest risk for developing hypertension? A) 45 year-old African American attorney B) 60 year-old Asian American shop oner!) 0 year-old !aucasian nurse#)$$ year-old %ispanic teacher&he correct anser is A' $ year-old African American attorney &he incidence of hypertension is greater among African Americans than other groups in the (. &he incidence among the %ispanic population is rising.*. A child ho ingested 1$ ma+imum strength acetaminophen ta,lets $ minutes ago is seen in the emergency department. Which of these orders should the nurse do first? A) Gastric lavage PRN B) Acetylcysteine mucomyst) for age per pharmacy!) tart an / #e+trose $ ith 0. normal saline to keep vein open#) Activated charcoal per pharmacy&he correct anser is A' 2astric lavage 345 4emoving as much of the drug as possi,le is the first step in treatment for this drug overdose. &his is ,est done ,y gastric lavage. &he ne+t drug to give ould ,e activated charcoal then mucomyst and lastly the / fluids.. Which complication of cardiac catheteri7ation should the nurse monitor for in the initial * hours after the procedure?A) angina at rest B) thrombus formation !) di77iness#) falling ,lood pressure&he correct anser is B' throm,us formation &hrom,us formation in the coronary arteries is a potential pro,lem in the initial * hours aftera cardiac catheteri7ation. A falling B3 occurs along ith hemorrhage of the insertion site hich is associated ith the first 1* hours after the procedure. . A client is admitted to the emergency room ith renal calculi and is complaining of moderate to severe flank pain and nausea. &he client8s temperature is 100.9 degrees :ahrenheit. &he priority nursing goal for this client isA) ;aintain fluid and electrolyte ,alanceB) !ontrol nausea  C) anage !ain #) 3revent urinary tract infection&he correct anser is !' ;anage pain &he immediate goal of therapy isto alleviate the client8s pain.$. What ould the nurse e+pect to see hile assessing the groth of children during their school age years?A) #ecreasing amounts of ,ody fat and muscle massB) <ittle change in ,ody appearance from year to year!) 3rogressive height increase of inches each year ) #early $eight gain of about 5%5 !ounds !er year &he correct anser is #' =early eight gain of a,out $.$ pounds per year chool age children gain a,out $.$ pounds each year and increase a,out * inches in height.6. At a community health fair the ,lood pressure of a 6* year-old client is 160>6. &he client states @;y ,lood pressure is usually much loer. &he nurse should tell the client to A) go get a blood !ressure chec& $ithin the ne't 4( to * hours B) check ,lood pressure again in * months!) see the health care provider immediately#) visit the health care provider ithin 1 eek for a B3 check&he correct anser is A' go get a ,lood pressure check ithin the ne+t 9 to * hours &he ,lood pressure reading is moderately high ith theneed to have it rechecked in a fe days. &he client states it is Cusually much loer.8 &hus a concern e+ists for complications such as stroke. %oever immediate check ,y the provider of care is not arranted. Waiting * months or a eek for follo-up is too long.. &he hospital has sounded the call for a disaster drill on the evening shift. Which of these clients ould the nurse put first on the list to ,e discharged in order to make a room availa,le for a ne admission? A) A middle aged client $ith a history of being ventilator de!endent for over  years and admitted $ith bacterial !neumonia five days ago B) A young adult ith dia,etes mellitus &ype * for over 10 years and admitted ith anti,iotic induced diarrhea * hours ago!) An elderly client ith a history of hypertension hypercholesterolemia and lupus and as admitted ith tevens-Dohnson syndrome that morning#) An adolescent ith a positive %/ test and admitted for acute cellulitus of the loer leg 9 hours ago  &he correct anser is A' A middle aged client ith a history of ,eing ventilator dependent for over  years and admitted ith ,acterial pneumonia five days ago &he ,est candidate for discharge is one ho has had a chronic condition and is most familiar ith their care. &his client in option A is most likely sta,le and could continue medication therapy at home.9. A client has ,een nely diagnosed ith hypothyroidism and ill take levothyro+ine ynthroid) $0 mcg>day ,y mouth. As part of the teaching plan the nurse emphasi7es that this medication' A) +hould be ta&en in the morning B) ;ay decrease the clientEs energy level!) ;ust ,e stored in a dark container#) Will decrease the clientEs heart rate&he correct anser is A' hould ,e taken in the morning &hyroid supplement should ,e taken in the morning to minimi7e the side effects of insomnia. A  year-old child comes to the pediatric clinic after the sudden onset of findings that include irrita,ility thick muffled voice croaking on inspiration hot to touch sit leaning forard tongue protruding drooling and suprasternal retractions. What should the nurse do first?A) 3repare the child for +-ray of upper airaysB) F+amine the childEs throat!) !ollect a sputum specimen ) Notify the healthcare !rovider of the child,s status &he correct anser is #' 5otify the health care provider of the childEEs status &hese findings suggest a medical emergency and may ,e due toepiglottises. Any child ith an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility eGuipped to perform intu,ation or a tracheostomy in the event of further or complete o,struction.10. n children suspected to have a diagnosis of dia,etes hich one of the folloing complaints ould ,e most likely to prompt parents to take their school age child for evaluation?A) 3olyphagiaB) #ehydration C) Bed $etting #) Weight loss&he correct anser is !' Bed etting n children fatigue and ,ed etting are the chief complaints that prompt parents to take their childfor evaluation. Bed etting in a school age child is readily detected ,y  the parents11. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. &he nurse recogni7es that this condition most freGuently follos hich type of infection?A) &richomoniasis B) Chlamydia !) taphylococcus#) treptococcus&he correct anser is B' !hlamydia !hlamydial infections are one of the most freGuent causes of salpingitis or pelvic inflammatory disease.1*. An 45 ho usually orks in a spinal reha,ilitation unit is floated tothe emergency department. Which of these clients should the charge nurse assign to this 45?A) A middle-aged client ho says H took too many diet pillsH and Hmy heart feels like it is racing out of my chest.HB) A young adult ho says H hear songs from heaven.  need money for ,eer.  Guit drinking * days ago for my family. Why are my arms and legs Ierking?H C) An adolescent $ho has been on !ain medications for terminal cancer $ith an initial assessment finding of !in!oint !u!ils and a rela'ed res!iratory rate of . #) An elderly client ho reports having taken a Hlarge crack hitH 10 minutes prior to alking into the emergency room&he correct anser is c' An adolescent ho has ,een on pain medications for terminal cancer ith an initial assessment finding of pinpoint pupils and a rela+ed respiratory rate of 10 5urses ho are floated to other units should ,e assigned to a client ho has minimal anticipated immediate complications of their pro,lem. &he client in option ! e+hi,its opoid to+icity ith the pinpoint pupils and has the least risk of complications to occur in the near future.1. When teaching a client ith coronary artery disease a,out nutrition the nurse should emphasi7eA) Fating  ,alanced meals a dayB) Adding comple+ car,ohydrates C) Avoiding very heavy meals #) <imiting sodium to  gms per day&he correct anser is !' Avoiding very heavy meals Fating large heavy meals can pull ,lood aay from the heart for digestion and is dangerous for the client ith coronary artery disease.
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