RN FUNDAMENTALS NCLEX QUESTIONS AND ANSWERS 2022

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RN FUNDAMENTALS NCLEX QUESTIONS AND ANSWERS 2022 A nurse is preparing to care for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in the lungs. In addition to a gown and glove... s, the nurse will need which of the following? A. Face Sheild B. High-filtration mask C. Shoe Covers D. Surgical Cap - ANS-A. Face Shield Rationale: The nurse should choose personal protective equipment to prevent contamination from spraying blood or bodily fluids; therefore when caring for a client who has MRSA in the lungs the nurse should wear face sheild. A nurse is caring for a client who is recieving medication intramusculary. The nurse should recognize that this route A. increases infection rates B. is the safest option C. has the slowest absorption rate D. decreases the client's risk for infections - ANS-A. increases infection rates Rationale: Because the IM route breaks the skin integrity, the risk for infection increases. A nurse is caring for a client and performing blood glucose monitoring. Which of the following is an appropriate nursing intervention? A. wipe away the first drop of blood from the client's finger B. Gently massage the client's finger in a distal to proximal direction C. puncture the tip of the client's finger D. hold the clients finger in an elevated position prior to testing - ANS-A. wipe away the first drop of blood from the client's finger Rationale: the first drop of blood is typically more serous and contains fewer red blood cells A nurse is pplanning care for a client who has had a stroke resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an AP? (select all that apply) A. assist the client with a partial bed bath B. measure the client's BP after the nurse administers an antihypertensive medication C. test the client's swallowing ability by providing thickened liquids D. use a communication board to ask what the client wants for lunch E. Irrigate the client's indwelling catheter - ANS-A. Assist the client with a partial bed bath B. Measure the BP after the nurse administers antihypertensive meds D. Use a communication board to ask what the client wants for lunch A nurse is caring for a client who is at risk for hypokalemia. Which of the following foods should be included in the client's diet? A. Avocados B. Corn C. Asparagus D. Cucumbers - ANS-A. Avocados Rationale: The nurse should suggest the client eat avocados, which are an excellent dietary source of potassium A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to take the client's vital signs every 15 min and call him back in 1 hour. From the legal perspective, which of the following actions should the nurse taking next? A. Document the provider's statement in the medical record B. complete an incident report C. consult the facility's risk manager D. notify the nurse manager - ANS-D. Notify the nurse manager Rationale: The greatest risk to the client is not recieving timely intervention for this deterioration in physiological status; therefore, the next action the nurse should take is to activate the chaing of command to ensure the necessary care. A nurse is caring for a client who is combative in the emergency department. The provider orders wrist restraints after the client attempts to assault the admitting nurse. Which of the following actions is appropriate for the nurse to take? A. tie restraints to the lower edge of the side rail B. remove each restraint one at a time every 2 hours C. ensure 3 finger-widths of space between the restraint and the client's wrist D. use a square knot to securely tie the restraints to the bed - ANS-B. remove each restraint one at a time every 2 hours Rationale: the nurse should remove each restraint one at a time every 2 hours to allow the client to peform range of motion exercises and the nurse to perform neurovascular checks A nurse is preparing to perform nasopharyngeal suctioning for a client who is unable to couch up excessive secretions. Which of the following actions is appropriate? A. use the clean technique throughout the procedure B. insert the catheter as the client exhales C. apply suction for up to 20 seconds D. perform suctioning while removing the catheter - ANS-D. perform suctioning while removing the catheter Rationale: the nurse should apply intermittent suction as she rotates the catheter and withdraws it from the airway A nurse is planning to insert a peripheral IV catheter in an older adult client. Which of the following actions should the nurse plan to take? A. Insert the catheter at a 45 degree angle B. position the client arm in a dependent position C. shave excess hair from the insertion site D. initiate IV therapy in the veins of the hands - ANS-B. position the client's arm in the dependent position Rationale: the nurse should instruct the client to place his arm in the dependent postion, b/c the viens will distend due to gravity A nurse is checking a client's BP to assess for ortho hypo. Which of the following actions should the nurse take? A. obtain BP 30 min after each meal B. obtain BP immediately after the client ambulates C. obtain BP in each arm and leg D. obtain BP 2 min after assisting the client to a sitting position - ANS-D. Obtain BP 2 minutes after assisting the client to a sitting position Rationale: The nurse should obtain the BP with the client in the first supine, then the sitting and finally the standing positions. The nurse should wait 1-3 min after each position change A nurse is caring for a client who had a fasting blood sugar drawn at 0600. The client tells the nurse, "all I have had since midnight is water and some juice." Which of the following nursing actions is appropriate? A. document the caloric intake B. reschedule the lab test for the next morning C. notify the lab to obtain another specimen D. obtain a prescription for a glucose tolerance test - ANS-B. Reschedule this lab test for the nextmorning. Rationale: The nurse will reschedule this lab test B/C in order to ensure accuracy of a fasting blood sugar, the client should fast for 8-12 hrs before the sample is drawn A nurse is preparing to administer morphine 4 mg IV bolus to a client. Available is morphine 5mg/mL. Which of the following is an appropriate nursing intervention? CONTINUES... [Show More]

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