Test your mastery in critical thinking for NCLEX-RN Exam 2024 (1) April 28, 2024April 26, 2024 by Sarab Ghumman Test your mastery in critical thinking in NCLEX-RN exam. Take this exam and check your knowledge regarding NCLEX-RN exam 1 / 15 While preparing to insert a peripheral IV line, the nurse notices scarring near the client's left axilla. The client confirms a history of left breast cancer and modified radical mastectomy. Which actions should the nurse take? Select all that apply. Advance the entire stylet into the vein upon venipuncture. Insert the IV line into the most distal site of the right arm. Place an appropriate precaution sign above the bed. Review the medical record for history of mastectomy. Teach the client to keep the left arm in a dependent position. 2 / 15 The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room? Isolation gown, surgical mask, goggles, and gloves. Isolation gown and surgical mask. N95 respirator mask. Surgical mask 3 / 15 The emergency department nurse receives a client with extensive injuries to the head and upper back. The nurse will perform what action to allow the best visualization of the airway? Head-tilt-chin-lift in the supine position on a backboard. Head-tilt-chin-lift in the Trendelenburg position. Jaw-thrust maneuver in semi-fowler's position. Jaw-thrust maneuver in the supine position on a backboard. 4 / 15 The nurse is educating the client in preparation for discharge from the hospital when the client begins crying and states, "I was diagnosed with a conversion disorder, so the health care provider must think I'm crazy". Which statement would be the best reply to the client? Conversion disorder is a diagnosis that acknowledges that your symptoms are real, even if there isn't a physical cause. I am very sorry to hear this, but are you sure that's what the provider meant? Maybe you misunderstood. The health care provider is probably wrong. I'll give you the information my health care provider used. Why do you think the health care provider diagnosed you with a conversion disorder? 5 / 15 The nurse is assessing a client with a history of alcohol use disorder who had an emergency appendectomy 3 days ago. Which of the following findings would indicate that the client is experiencing delirium tremens? Select all that apply. Bradypnea Diaphoresis Hallucinations Lethargy Tachycardia 6 / 15 The nurse is caring for a client who had an endoscopic procedure yesterday to stop upper gastrointestinal bleeding and who started a clear liquid diet today. Which of the following foods would be appropriate to offer to the client? SELECT ALL THAT APPLY. Apple juice Chicken broth Cranberry juice Cream of chicken soup Unsweetened tea Vanilla ice cream 7 / 15 The nurse is providing postoperative care to a patient who had a laparoscopic cholecystectomy 4 hours ago. Which intervention is the priority? Apply antiembolism stockings. Assist with early ambulation. Encourage a low fat diet. Offer stool softeners. 8 / 15 The nurse is caring for a client with acute pancreatitis admitted 2 days ago. Which assessment finding is most concerning? Blood glucose levels for the past 24 hours are more than 250 mg/dL Client is lying with knees drawn up to the abdomen to alleviate pain. Five large, liquid stools that are yellow and foul smelling. Temperature of 102.2 F (39.C) with increasing abdominal pain. 9 / 15 The nurse cares for group of clients in a medical surgical unit. The client with which diagnosis and condition requires the most immediate assistance by the nurse? Post cholecystectomy, reporting incision pain of a 5 on a scale of 1-10. Post open reduction of the right femur, reporting nausea. Type 1 diabetes mellitus with a blood glucose of 55 mg/dL (3.1 mmol/L) Type 2 diabetes mellitus with a blood glucose of 250 mg/dL (13.9 mmol/L) 10 / 15 A new reassigned nurse enters a hospital room at the beginning of the shift and finds the client unconscious and unresponsive. Resuscitation is initiated and then continued by the rapid response team. The nurse realizes that there is a do not resuscitate (DNR) prescription posted in the client's chart. Which action is correct? Stop all resuscitation activity immediately. Continue resuscitation until DNR status is verified with health care provider. If client shows any signs of life, follow advanced cardiovascular support protocol until stable. Once resuscitation has begun, complete it regardless of client code status. 11 / 15 An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis. Blood pressure is 80/60 mmHg. Which prescribed intervention should the nurse implement first? Administer IV antibiotics. Infuse bolus of IV normal saline Prepare to assist with lumbar puncture Transport client for head CT Scan 12 / 15 The nurse is providing teaching to the parents of a 3-year-old child with a new diagnosis of atopic dermatitis. Which of the following instructions should be included in the teaching? Select all that apply. Apply emollient cream soon after a bath. Dress the child in wool pajamas with sleeves. Give an oral antihistamine before bedtime. Keep the child's nail well-trimmed and filed. Thoroughly rub the skin dry after baths. 13 / 15 The nurse is reinforcing education to a client newly prescribed levetiracetam for seizures. Which statement made by the client indicates a need for further instruction? Drowsiness is a common side effect of this medication and will improve over time. I can begin driving again after I have been on this medication for a few weeks. I need to immediately report any new or increased anxiety when on this medication. I need to immediately report any new rash when on this medication. 14 / 15 A Nurse in the emergency department is caring for a homeless client just brought in with frostbite to the fingers and toes. The client is experiencing numbness, assessment shows mottled skin. Which interventions should be included in the client's plan of care? Select all that apply. Apply occlusive dressings after rewarming Elevate affected extremities after rewarming Massage the areas to increase circulation Provide adequate analgesia Provide continuous warm water soaks 15 / 15 The nurse is caring for a 65-year-old male client with a history of ischemic heart disease who has been admitted to the ICU following a myocardial infarction. The client is currently receiving lidocaine I.V. to manage his ventricular ectopy, which has been persistent. Which of the following factors would be most important for the nurse to consider in relation to the administration of this medication? A. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter B. Increase in systemic blood pressure C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor D. Increase in intracranial pressure (ICP) E. A drop in serum potassium levels as indicated in the latest lab results. F. Observation of a widening QRS complex on the ECG Your score isThe average score is 22% 0% Restart quiz