NCLEX practice question 6

1. A child who ingested 15 maximum strength acetaminophen tablets 45 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

C) Start an IV Dextrose 5% with 0.33% normal saline to keep vein open

D) Activated charcoal per pharmacy

The correct answer is A: Gastric lavage PRN

Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids

2.      Which of these statements best describes the characteristic of an effective reward-feedback system?

A)               Specific feedback is given as close to the event as possible

B)                 Staff are given feedback in equal amounts over time

C)               Positive statements are to precede a negative statement

D)               Performance goals should be higher than what is attainable

The correct answer is A: Specific feedback is given as close to the event as possible

Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if the standards are clearly understood.

3.      A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

A)               A 2 month old infant with a history of rolling off the bed and has buldging fontanels with crying

B)                 A teenager who got a singed beard while camping

C)               An elderly client with complaints of frequent liquid brown colored stools

D)               A middle aged client with intermittent pain behind the right scapula

The correct answer is B: A teenager who got singed a singed beard while camping

This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.

4.      What would the nurse expect to see while assessing the growth of children during their school age years?

A)               Decreasing amounts of body fat and muscle mass

B)                 Little change in body appearance from year to year

C)               Progressive height increase of 4 inches each year

D)               Yearly weight gain of about 5.5 pounds per year

The correct answer is D: Yearly weight gain of about 5.5 pounds per year

School age children gain about 5.5 pounds each year and increase about 2 inches in height.

5.      Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test?

A)               Client must be NPO before the examination

B)                 Enema to be administered prior to the examination

C)               Medicate client with Lasix 20 mg IV 30 minutes prior to the examination

D)               No special orders are necessary for this examination

The correct answer is D: No special orders are necessary for this examination

No special preparation is necessary for this examination

6.      A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?

A)               Raise the side rails on the bed

B)                 Place the call bell within reach

C)               Instruct the client to remain in bed

D)               Have the client empty bladder

The correct answer is D: Have the client empty bladder

The first step in the process is to have the client void prior to administering the pre-operative medication. The other actions follow this initial step in this sequence: 4 3 1 2

7.      A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is

A)               Maintain fluid and electrolyte balance

B)                 Control nausea

C)               Manage pain

D)               Prevent urinary tract infection

The correct answer is C: Manage pain The immediate goal of therapy is to alleviate the client’s pain

8.      A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?

A)               The muscles

B)                 The cerebellum

C)               The kidneys

D)               The leg bones

The correct answer is A: All striated muscles

Rhabdomyosarcoma is the most common children''s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word and is “myo” which typically means muscle.

9.      A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?

A)               Gravida 4 para 2

B)                 Gravida 2 para 1

C)               Gravida 3 para 1

D)               Gravida 3 para 2

The correct answer is C: Gravida 3 para 1

Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).

10. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?

A)               Blood pressure 94/60

B)                 Heart rate 76

C)               Urine output 50 ml/hour

D)               Respiratory rate 16

The correct answer is A: Blood pressure 94/60

Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100; systolic B/P over 100) in order to safely administer both medications.

source: NCSBN