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 keep ...

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 breathing 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 neonate 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. Hypoglycemia 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 sh.........................................CONTINUED