NCLEX RN ACTUAL EXAM QUESTIONS and Answers 2022 with explanation. A++ GUARANTEED

NCLEX RN ACTUAL EXAM

QUESTIONS and Answers 2022 with

explanation. A++ GUARANTEED

NCLEX RN ACTUAL EXAM

QUESTIONS and Answers 2022 with

explanation. A++ GUARANTEED

GOOD LUCK!!!!

The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal bypass graft procedure. Which of the following assessments requires immediate notification of the health

care provider? • Left foot is cool to the touch • Absent lef t pedal pulse using Doppler analysis • Inability to palpate the left pedal pulse • Acute pain in the left lower leg Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the left

lower leg are important findings, they all require additional nursing assessment prior to contacting the

health care provider. In clients without palpable pedal pulses, the nextstep in the assessment is to

perform a Doppler analysis. The inability to locate the left pedal pulse using the Doppler analysis

requires immediately notifying the health care provider. Ref # 1028

There's a new medication order that reads: "administer 1 gtt ciprofloxacin

solution OD Q 4 h" What action should the nurse take?

Call the prescriber to clarify and rewrite the order Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating medical information. The abbreviation "Q" should be written out as "every." Although "gtt" is not on the official "Do Not Use List", it's best to use "drop" instead. Asking other nurses to interpret an order is a potentially dangerous "workaround." The nurse should call the health care provider who prescribed the medication and clarify the order. Ref # 1440 Which individual is at greatest risk for the development of hypertension? 45 year-old African-American attorney The incidence of hypertension is greater among African-Americansthan other groups in the United States. The incidence among the Hispanic population is rising. Ref # 2446

A woman, who delivered five days ago and who had been diagnosed with

pregnancy induced hypertension (PIH), calls a hospital triage nurse hotline to

ask for advice. She states, "I have had the worst headache for the past two days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps." What should the nurse do next?

Ask the client to stay on the line, get the address, and send an ambulance to the home

The woman is at risk for seizure activity. The ambulance needsto bring the woman to the hospital for evaluation and treatment. For at-risk clients, PIH may progressto preeclampsia and eclampsia prior to, during, or after delivery; this may occur up to 10 days after delivery. Ref # 2065

A client expresses anger when a call light is not answered within five minutes. The client demanded a blanket. How should the nurse respond?

"I see this isfrustrating for you. I have a few minutes so let's talk." This is the best response because it gives credence to the client's feelings and then concerns. To say

"let's talk" and ask a why question is not a therapeutic approach because it does not acknowledge or validate the client'sfeelings. To apologize and not notice the client'sfeelingsisinappropriate. To say it could have waited a few minutes isrude and non-accepting of the client's verbalized needs.

Ref # 2134

The client is admitted to an ambulatory surgery center and undergoes a right

inguinal orchiectomy. Which option is the priority before the client can be discharged to home

Post-operative pain is managed An orchiectomy is the surgical removal of one or both testicles. It is usually performed to treat cancer

(testicular, prostate or cancer of the male breast), but it may also be performed to prevent cancer (with an undescended testicle.) Due to the location of the incision, pain management is the priority. Most men will be able to eat regularly when they get home; they should at least tolerate liquids before discharge.

It's important that the client is able to get up and walk with assistance, but thisis not the priority. Psychological counseling may be needed as part of long-term aftercare, but this is not an immediate priority. Ref # 1524

A nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first?

Smoking cessation Smoking cessation is the priority for clients at risk for cardiac disease. Smoking's effects result in reduction of cell oxygenation and constriction of the blood vessels. All of the other factors should be

addressed at some point in time. Ref # 1721

The clinic nurse is assisting with medical billing. The nurse uses the DRG

(Diagnosis Related Group) manual for which purpose? Determine reimbursement for a medical diagnosis DRGs are the basis of prospective payment plans for reimbursement for Medicare clients. Other

insurance companies often use it as a standard for determining payment. KEYWORDS DRG

diagnosis related group reimbursement

Ref # 1328

A nurse is planning care for a 2 year-old hospitalized child. Which issue will

produce the most stress at this age? Separation anxiety While a toddler will experience all of the stresses,separation from parentsisthe majorstressor. Separation anxiety peaksin the toddler years. Ref # 2319

The nurse is reviewing the laboratory results for several clients. Which of the

laboratory result indicates a client with partly compensated metabolic acidosis?

PaCO2 30 mm Hg Metabolic acidosis can be caused by many conditions, including renal failure, shock, severe diarrhea, dehydration, diabetic acidosis, and salicylate poisoning. With metabolic acidosis, you should expect a

low pH (lessthan 7.35) and a low HCO3 (less than 22 mEq/L.) Compensation means the body istrying

to get the pH back in balance; therefore, a pure metabolic acidosis should elicit a compensatory decrease in PaCO3 (normal is 35-45 mm Hg.) The hemoglobin is within normal limits (WNL) for both males and females. The chloride and sodium results are also WNL. Ref # 2391

A client with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA)

has died. Which type of precautions is appropriate to use when performing

postmortem care? Contact precautionsThe resistant bacteria remain alive for up to three days after the client dies. Therefore, contact precautions must still be used. The body should also be labeled as MRSA-contaminated so that the funeral home staff can protect themselves as well. Gown and gloves are required.

Ref # 1436

A client has a chest tube inserted immediately after surgery for a left lower

lobectomy. During the repositioning of the client during the first postop check, the nurse notices 75 mL of a dark, red fluid flowing into the collection chamber of the chest drain system. What is the appropriate nursing action?

Continue to monitor the rate of drainage It is not unusual for blood to collect in the chest and be

released into the chest drain when the client changes position this soon after surgery. The dark color of the blood indicatesit is not active bleeding inside of the chest. Sanguinous drainage should be expected within the initial 24 hours postop, progressing to serosanguinous and then to a serous type. If the

drainage exceeds 100 mL/hr, the nurse should call the surgeon. Ref # 1623 A client is transported to the emergency department after a motor vehicle accident. When assessing the client 30 minutes after admission, the nurse notes several physical changes. Which finding would require the nurse's

immediate attention? Tracheal deviation

Tracheal deviation is a sign that a mediastinal shift has occurred, most likely due to a tension pneumothorax. Air escaping from the injured lung into the pleural cavity causes pressure to build, collapsing the lung and shifting the mediastinum to the opposite side. This obstructs venous return to

the heart, leading to circulatory instability and may result in cardiac arrest. This is a medical emergency,

requiring emergency placement of a chest tube to remove air from the pleural cavity relieving the pressure.

Ref # 1319 The client is diagnosed with cystic fibrosis (CF). The nurse would

expect the client to be treated with oral pancreatic enzymes and which type of

diet? High fat, high-calorie CF affects the cellsthat produce mucus,sweat and digestive juices. Someone with CF needs a high-energy diet that includes high-fat and high-calorie foods, extra fiber to

prevent intestinal blockage and extra salt (especially during hot weather.) People with CF are atrisk for osteoporosis and need calcium and dairy products. Someone with celiac disease or with a gluten

intolerance, not CF, needs a gluten-free diet.

Ref # 1646 The nurse is assessing a 4 year-old child who is in skeletal traction 24

hours after surgical repair of a fractured femur. The child is crying and reports

having severe pain. The right foot is pale and there is no palpable pulse. What action should the nurse take first? Notify the health care provider Pain and absence of a pulse within 48-72 hours after a severe injury to an extremity suggests acute compartment syndrome. This condition occurs when there's a build up of pressure within the muscles; this pressure decreases blood

flow and can cause muscle and nerve damage. Acute compartment syndrome is a medical emergency. Surgery is needed immediately; delaying surgery can lead to permanent damage to the extremity.

Ref # 1927 The nurse is examining a 2 year-old child with a tentative diagnosis of

Wilm's tumor. The nurse would be most concerned about which statement by the mother? "Urinary output seems to be less over the past two days." Wilm's tumor is a malignant tumor of the kidney that can lead to kidney dysfunction; therefore, a

recent decrease in urinary output should be investigated further asit may be a sign of renal dysfunction.

Increasing abdominal girth is a common finding in Wilm's tumor, but does not require immediate

intervention by the nurse. Ref # 1370 A child is treated with succimer for lead poisoning. Which of these assessments should the nurse perform first? Check complete blood count (CBC) with

differential Succimer (Chemet) is used in the management of lead or other heavy metal poisoning. Although it has generally well tolerated and has a relatively low toxicity, it may cause neutropenia. Therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1200/µ Ref # 1773The client with a T-2 spinal cord injury reports having a "pounding" headache. Further assessment by the nurse reveals excessive sweating, rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of

50. What action should the nurse take next? Check the client for bladder distention and the urinary catheter for kinks These are findings of autonomic dysreflexia, also called hyperreflexia. This

response occurs in clients with a spinal cord injury above the T-6 level. It is typically initiated by any noxious stimulus below the level of injury such as a full bladder, an enema or bowel movement, fecal

impaction, uterine contractions, changing of the catheter and vaginal or rectal examinations. The

stimulus creates an exaggerated response of the sympathetic nervous system and can be a life- threatening event. The BP istypically extremely high. The priority action of the nurse is to identify and relieve the cause of the stimulus. Ref # 2144 A 67 year-old client is admitted with substernal chest pressure that radiates to the jaw. The admitting diagnosis is acute myocardial infarction (MI). What should be the priority nursing diagnosis for this client during the first 24

hours? Altered tissue perfusion In the immediate post MI period, altered tissue perfusion is priority, as an area of myocardial tissue has been damaged by a lack of blood flow and oxygenation. Interventions should be directed toward promoting tissue perfusion and oxygenation. The other problems are also

relevant, but tissue perfusion is the priority.

Ref # 1740An external disaster has occurred in the town. The triage nurse from

the emergency department is transported to the site and assigned to triage the

injured. Which of these clients would the nurse tag as "to be seen last" by the

providers at the scene? A middle-aged person with deep abrasions that are over 90% of the body The clients that are least likely to survive are to be tagged as the "last to be seen." Deep abrasions are usually treated assecond or third degree burns because the fluid lossis great.

ref # 1750The nurse is caring for a client who is in the advanced stage of multiple myeloma. Which action should be included in the plan of care? Careful repositioning Multiple myeloma occurs when abnormal plasma cells (myeloma cells) collect in several bones. This disease may also harm other tissues and organs, especially the kidneys. This type of cancer causes hypercalcemia, renal failure, anemia,and bone damage. Because multiple myeloma can cause erosion of

bone mass and fractures, extra care should be taken when moving or positioning a client due to the risk of pathological fractures.

Ref # 2332

The nurse is teaching the client with chronic renal failure (CRF) about medications. The client questions the purpose of taking aluminum hydroxide. What is the best explanation for the nurse to give the client about the therapeutic

effects of this medication? It decreases serum phosphate Aluminum binds phosphates that tend to accumulate in the client with chronic renal failure due to decreased filtration capacity of the kidney. Antacids such as Amphojel are commonly used to decrease serum phosphate.