NCLEX-RN Practice Test 2023 (60 Questions with Explained Answers)

welcome to the 2023 NCLEX RN practice test this test will have 60 Questions with explained answers that will help you prepare for the test be sure to resuscitate the like button by turning it white question one which of the following laws allow a mentally stable patient to leave AMA against medical advice from a hospital a common law B precedent law C civil law D state law the correct answer is a common law common law allows a mentally stable patient to make their own health care decisions if a patient who is mentally competent wants to leave the hospital AMA then they have the right to do so question two you're the nurse caring for a patient who is newly diagnosed with CHF you may ask the UAP to perform all of the following tasks except a measure the patient's intake and output B educate the family on the reason for strict is and owes C provide Foley care d give the patient something to drink the correct answer is B educate the family on the reason for strict is and owes an unlicensed Personnel cannot educate therefore having a nurse aide to educate a family on a diagnosis of CHF is not permitted question three medical battery often occurs when a doctor or other health care provider denies you the chance to choose whether to get medical therapy the ACT may involve touching or other objectionable behavior and is done with intention which of the following is an example of medical battery a failure to diagnose B failure to provide proper treatment C performing a procedure without the consent of the patient D misdiagnosis the correct answer is C performing a procedure without the consent of the patient when someone hurts another person physically when they are in a medical environment it is called medical battery is defined as touching with the purpose to cause hurt or offense it is harmful if it causes harm of some kind performing an invasive procedure without a patient's consent is an example question four as it pertains to Medical competence nurses are required to deliver a level of care that avoids or minimizes risk what what is the term for this a non-beneficence b veracity c non-maleficence d beneficence the correct answer is C non-maleficence according to the non-maleficence principle it is wrong to cause harm to other people nurses are required to provide care in a way that does not cause harm to the patient question five in the event that you are unable to speak for yourself a health care proxy designates a trusted individual as your agent proxy or representative to communicate your intentions and make Health Care choices on your behalf the power of attorney will be the health care proxy which of the following individuals would need a health care proxy a a married man who is on the ventilator but able to communicate B and 87 year old with beginning stages of dementia c a 20 year old who is in a coma following an MVA d a deaf and mute man recovering from a stroke the correct answer is c a 20 year old who is in a coma following an MVA a 20 year old in a coma is not able to make medical decisions for themselves they would need a POA Health Care proxy to make any decisions about their medical needs question six what is the name of the act that states that when a patient is admitted to a health care institution the nurse has a legal obligation to explain and educate the patient about Advanced directives a patient self-determination act of 1990 B healthcare proxy Act of 1970 C power of attorney Act of 1992 D legal determination Act of 1975. the correct answer is a patient self-determination act of 1990 compliance with the patient self-determination act psda a federal legislation is required the aim of this law is to guarantee that patients rights to informed consent and protection and Health Care choices are upheld this means that all education should be provided to patients so that they may make an informed decision when it comes to their health question seven which of the following ensures that patients receive appropriate care patient Independence and decision-making rights patient respect privacy and access to a complaints mechanism a the health care act of 2010 B the patient's Bill of Rights C the health insurance portability and accountability act D the patient civil rights the correct answer is B the patient's Bill of Rights the patient's Bill of Rights ensures that the patient is entitled to appropriate care that they can independently make their own health care decisions that they are entitled to respect and privacy and that they have someone some entity to complain to when these Bill of Rights are not upheld each Hospital should have the Bill of Rights in a place for patients to view freely question eight it is imperative that the nurse advocate for the patient which of the following best describes a nurse advocating for a patient a giving an opinion on different Medical Treatments so that the patient can pick the best option b telling a patient who the best surgeon in the hospital is to perform his her surgery C explaining test results in depth after a physician has given the initial results D telling the patient that it is best for her to take her medication so that she does not become more ill the correct answer is C explaining test results in depth after a physician has given the initial results nurses act as advocates for patients in many ways one way is to explain anything that the patient does not understand if a physician explains something to a patient and they do not understand it it is your job as the nurse to ensure that they do this is an example of advocating for your patient question nine what is the term for something that often entails giving responsibility for the outcome while assigning non-licensed assistance people to execute activities or duties linked to Patient Care a delegation B autonomy c beneficence d validation the correct answer is a delegation delegation often entails giving responsibility for the outcome while assigning non-licensed assistance people to execute activities or duties linked to Patient Care making nursing decisions is a responsibility that can only be assigned by a qualified nurse question 10 what is the term for a collaborative approach that supports suggested treatment plans to ensure sure that patients with disabilities illnesses or injuries receive the proper Medical Care a delegation B case management C care plan D clinical approach the correct answer is B case management a collaborative process of assessment planning facilitation care coordination evaluation and advocacy for Alternatives and services to address an individuals and Family's complete Health needs to encourage high quality cost-effective results through communication and the use of existing resources question 11 you're a nurse working in the Intensive Care Unit a person calls and states that he is your patient's pastor and wants to update the prayer log about how the patient is doing the pastor is not on the patient's chart of people to share health information with what is the correct action for you to take a give the pastor an update since clergy and members of the church are a necessary part of the health care Team B tell the pastor to call the patient's room C explain to the pastor that you are not allowed to give the information requested because he is not on the patient's chart to give out information to D tell the pastor to call the family and request the information the correct answer is C explain to the pastor that you are not allowed to give the information requested because he is not on the patient's chart to give out information to the pastor is not on the patient's list of persons to share Phi with therefore it is the nurse's responsibility to kindly explain that to the pastor and not give out the Phi question 12 what is the name of the federal legislation that mandated the development of national standards to prevent the disclosure of sensitive patient health information without the patient's knowledge or consent a the self-delegation act of 2000 B the health insurance portability and accountability Act of 1996 C the civil law Act of 1979 D the health insurance portability and accessibility Act of 1996 the correct answer is B the health insurance portability and accountability Act of 1996 a federal legislation known as the health insurance portability and accountability Act of 1996 ipaa mandated the development of national standards to prevent the disclosure of sensitive patient health information without the patient's knowledge or consent it was signed by Bill Clinton on August 21 1996. question 13 there is a fire on a medical surgical unit on the second floor of the hospital after the nurse has rescued her patients what is the next step for the nurse to take a aim the fire extinguisher B set off the fire alarm C assess her patients D alarm the patients the correct answer is B set off the fire alarm the acronym race should be used to remember what the nurse should do in a fire rescue alarm contain extinguish the nurse should raise the fire alarm once rescuing patients question 14 a nurse in an assisted living cares for many different types of older adults with various health conditions the nurse knows that patients with sensory changes as they age are at a high risk of which of the following a isolation B depression C anxiety D decreased physical endurance the correct answer is a isolation as adults age and become older adults their senses change tremendously they may lose their hearing their taste may change their Vision May Decline and their sense of pain is altered these changes can be mentally detrimental to patients causing them to just want to be alone and isolated from their peers this puts these patients at a high risk for isolation question 15 the UAP walks into a patient's room who is on oxygen and smoking in his bathroom what should the UAP do immediately a notify the charge nurse B ask the patient to put out the cigarette C pull the fire alarm D turn off the oxygen the correct answer is B ask the patient to put out the cigarette the immediate intervention should be to have the patient put out the cigarette as the hospital contains lots of oxygen and it is highly flammable the charge nurse should be notified but it is not the most pertinent intervention question 16 a housekeeper is taking out the trash when he is stuck by a needle what is the appropriate next step for the housekeeper a washes hands with soap and water for 15 minutes B go to employee health immediately C report the incident to the charge nurse on The Unit D obtain the needle and place in a Sharps container the correct answer is a wash his hands with soap and water for 15 minutes if stuck by a needle a staff member should encourage the wound to bleed and wash with soap and water for at least 15 minutes the housekeeper should attempt to obtain the needle as there is a high risk of being stuck again the employee should go to employee health question 17 what is the acronym that is important to remember when using a fire extinguisher in a fire a race b car c race car D care the correct answer is a race the acronym race should be used to remember what the nurse should do in a fire rescue alarm contain extinguish the nurse should raise the fire alarm once rescuing patients question 18 what regulatory body is responsible for enforcing compliance with safety rules and procedures in hospitals a high pay B OSHA C CMS D CDC the correct answer is B OSHA hospitals can use a variety of materials developed by OSHA to assess their needs for worker safety put in place Safety and Health Management systems and improve their safe patient handling initiatives not only does preventing workplace accidents benefit employees but it also benefits patients and helps hospitals save money question 19 the nurse is caring for a patient who is placed in restraints the nurse notices that the restraints are tied to the bed rails what action should the nurse take first a leave the restraints this is the proper place to tie them B remove the restraints and tie them to the bed frame C report the incident to the charge nurse D ensure that the nurse can put two fingers between the patient's wrist and the restraint the correct answer is B remove the restraints and tie them to the bed frame restraints should never be tied to bed rails they should always be tied to the bed frame for patient and staff safety the nurse should ensure that they can place two fingers between the patient's wrist and the restraint and Report the incident to the charge nurse however these are not the priority interventions question 20. you're assessing a pre-teen with the father present the father explains that he is concerned that his child is experiencing depression which of the following is not an indicator that the patient is experiencing depression a crying when her friend passed in an MVA B loss of appetite c lower grades when she is usually an honor roll student D insomnia the correct answer is a crying when her friend passed in an MVA it is normal for people to cry during the grieving process crying in the event of a death does not constitute depression however the other three options here are symptoms of possible depression question 21 you're assessing a newborn and You Begin asking the mom if she wants immunizations for her infant the mom says no what is your best response to the mother a okay then here are the informative pamphlets in case you change your mind B As You Wish see I respect that decision if you would like informative pamphlets I can get them for you if not that is okay too d I respect that but you should know that there is a very high risk for these diseases that could be prevented in your child the correct answer is C I respect that decision if you would like informative pamphlets I can get them for you if not that is okay too as nurses we cannot force any intervention on a patient or parent answer C acknowledges that you respect the mother's decision to not immunize her child but also provides information to the mother without being pushy question 22 you're assessing a three-day-old newborn at his first doctor's appointment the infant was born at eight pounds five ounces which of the following would warrant concern for this infant a weight of eight pounds two ounces B weight of seven pounds 7.7 ounces C weight of seven pounds six ounces D weight of eight pounds 13 ounces the correct answer is C weight of seven pounds six ounces it is normal for newborns to lose up to ten percent of their birth weight however by one week old the newborn should be back up to his birth weight option C is a weight loss of more than 10 percent of the infant's birth weight question 23 you're caring for a patient who was recently diagnosed with glaucoma you know that which of the following ethnicities is at highest risk for glaucoma a African-American B Mexican American C Caucasian D Chinese the correct answer is a African-American African Americans are at the highest risk for glaucoma studies show that a a persons have thinner corneas than their European counterparts question 24 you're assessing a two-week-old breastfed infant which of the following would cause concern a mom states that the infant is having two to three wet diapers daily B the infant is eating eight to twelve times a day C the mother states that she usually lets the infant empty one breast before switching to the other breast D the mom states that it no longer hurts when the infant is nursing the correct answer is a mom states that the infant is having two to three wet diapers daily an infant should have five to six wet diapers daily breastfed infants eat eight to twelve times daily usually more than formula fed babies as breast milk is digested more quickly than formula if the infant is latched on and suckling properly the mother's nipple should not hurt the mother should also let the infant empty one breast before offering the second breast as the infant needs the hind milk question 25 you're educating a patient on why pap smears are so important for sexually active women what response by the patient lets you know that the patient understands the education provided a I cannot get HPV if I am on birth control therefore it is not necessary for me to have routine pap smears B I would know if I have HPV my boyfriend doesn't have any symptoms C HPV can cause cervical cancer later in life so I should have routine pap smears to prevent cancer D I am a gay woman I do not need to have routine pap smears because my risk for HPV is extremely low the correct answer is C HPV can cause cervical cancer later in life so I should have routine pap smears to prevent cancer HPV is a sexually transmitted infection that can live dormant in individuals for years most people never have symptoms or test positive for HPV it is a silent infection HPV leads to cervical cancer this is why it is so important for women to receive a routine pap smear birth control does not present HPV many men carry HPV and never know that they have it because there are no symptoms of HPV lesbian women still need routine pap smears regardless of the gender of their sexual partners question 26 a patient with a history of etoh abuse is being discharged from the hospital she states that she is currently still drinking heavy liquor throughout the day and wine at bedtime which of the following does the nurse anticipate being a part of the patient's care plan upon discharge a education for the patient on how to drink alcohol in moderation B prescription for Naltrexone if needed C psychiatric therapy for the patient to help them drink alcohol in moderation D educate the patient on how to increase their self-control the correct answer is B prescription for Naltrexone if needed this patient states that she is drinking alcohol heavily Naltrexone is prescribed to help patients not find pleasure when drinking alcohol this medication may be given to help the patient stop drinking alcohol therefore the nurse can anticipate it being a part of the discharge plans patients who are alcoholics are not able to drink alcohol in moderation or use self-control to keep from drinking alcohol therapy may be needed for this patient but is not the most likely to help the patient quit drinking in the near future question 27 a 30 year old patient's mother joins him in his pcp's office for an appointment for evaluation of psychotic symptoms that the patient has been experiencing the mother states that she has noticed that the patient is very withdrawn when around others he is beginning to make up words that make no sense to her and has been laughing very loudly at random which of the following diagnoses does the nurse anticipate for this patient a disorganized schizophrenia B bipolar 1 disorder C generalized anxiety disorder D cyclothymia the correct answer is a disorganized schizophrenia patients with disorganized schizophrenia are often withdrawn socially they make up words that make no sense to others and may laugh loudly randomly or at inappropriate times bipolar 1 disorder refers to patients who have had manic episodes for at least seven days in which they need immediate Medical Care the patient may experience both Manic and depressive episodes with bipolar 1 disorder the Hallmark of generalized anxiety disorder is excessive concern over commonplace problems and circumstances that endures for more than six months this worry causes physical issues for the patient like muscle tension and headaches cyclothymia is a disorder in which the patient experiences ups and downs but is not as severe as bipolar one or two disorder question 28. a 14 year old girl reports that she feels very ashamed after she binge eats so she takes many laxatives to offset what she eats when the nurse assesses the patient's teeth are yellow and chipped which of the following does the nurse anticipate for this patient a anorexia nervosa bulimia nervosa C binge eating disorder D restrictive eating disorder the correct answer is bulimia nervosa bulimia nervosa is identified when a patient binge eats usually for emotional reasons and then feels guilty and ashamed that they ate or ate as much as they did the patient decides to induce vomiting or takes laxatives and or diuretics to lose the weight that they think they have gained question 29 a patient is newly diagnosed with Alzheimer's disease this patient often experiences memory loss and takes longer to complete normal tasks which of the following should be included in this patient's plan of care at home a frequent reorientation B behavior therapy C CRT cognitive remediation therapy D Social intervention the correct answer is a frequent reorientation a patient with Alzheimer's disease is a disease in which patients Minds decline more and more over time it leads to memory loss and causes the patient to take longer to perform everyday activities even if they have performed them for years the patients need frequent reorientation to person place and time question 30 a parent brings their seven-year-old child with ADHD to the pediatric office for a well-child checkup which of the following interventions will be best for this patient a have the patient make the child sit as still as possible B allow the child to fidget as much as they need c give the child a toy to make them sit still D allow the child to run around the office to run out their energy the correct answer is B allow the child to fidget as much as they need children with ADHD should not be made to sit still giving the child a toy will not make a child with ADHD sit still it is not necessary to allow the child to run around the office simply allowing the child to fidget as they need is sufficient question 31 a mother presents to the pediatrician's office concerned for her five-year child with ASD autism spectrum disorder she states that her child will start kindergarten in two weeks and she is afraid that her child will not cope well which of the following May the nurse suggest to best help the child a tell the mom to explain to her child that she will love her new teacher B ask the mom if she is considered homeschooling her child C tell the mom that it is best to let the child tour the school especially the classroom and meet the teacher before starting the first day of school D encourage the mom to make a set bedtime for her child as kindergarten approaches the correct answer is C tell the mom that it is best to let the child tour the school especially the classroom and meet the teacher before starting the first day of school when a child with ASD has their schedule interrupted it can cause a significant amount of stress encouraging the mother to take the child to meet her teacher and see her school and classroom beforehand may make the first day of school a lot easier on the child the mother simply telling the child with ASD that she will love her teacher is inappropriate because a child of kindergarten age will not understand that reasoning option b is inappropriate while the child May thrive on a set bedtime this will not necessarily help calm the child's anxiety about school question 32 you are assessing a patient with a new ileostomy you notice that the ostomy is purple which of the following is most likely the issue with the new ileostomy a nothing this is normal since it is outside of the abdomen B the bowel has become ischemic see the stoma has become dry D the stoma the correct answer is B the bowel has become ischemic a stoma for any type of ostomy should be pink slash red and moist if the stoma is purple it has become ischemic and is a medical emergency because the patient can lose that part of their bowel question 33 you're caring for a patient with an enteral tube your Physician's orders say to bolus a 450 ml feeding before administering the bolus feed you aspirate 550 ML of gastric fluid which nursing action is most appropriate a administer the bolus feed per MD orders B hold the feed and notify the MD C hold the feed and give in three hours D flush the enteral tube with sterile water and administer bolus feed the correct answer is B hold the feed and notify the MD when providing enteral feeds to a patient if you aspirate more than 500 mL of gastric fluid it may indicate that the patient is not digesting the feedings sometimes doctors will write specific orders regarding when to hold enteral feedings if the doctor's orders are less than 500 mL the order should always be followed question 34. you're a nurse working in the DHS office in your county you are administering covid-19 vaccines which method will you use to ensure that the vaccine stays in the muscle and does not leak back into the subcutaneous tissue a inject at a 90 degree angle B aspirate before giving the injection and give only if you aspirate blood C leave the needle in the muscle after injection for 10 seconds D use the z-track method when administering the injection the correct answer is D use the z-track method when administering the injection while injecting at a 90 degree angle is correct the question asks what is the best way to ensure that the injection stays in the muscle and does not leak back into the subcutaneous tissue the evidence-based practice proves that the z-track method is the best way to prevent leakage when administering IM injections question 35 you're caring for a patient in an external fixation device what what is the most important nursing intervention for this patient a offer high protein meals B encourage the patient to ambulate often to prevent contractures C assess for excess redness around insertion sites D ensure the patient is in a left lateral position while in bed the correct answer is C assess for excess redness around insertion sites when a patient is in an external fixation device the insertion sites should be assessed often these sites can become infected easily excessive redness pus and or exudate can indicate infection at the insertion sites the patients are usually on bed rest and are in a Supine position question 36 the following are high risks when administering an enema to an older adult except a hypercalcemia b hyperphosphatemia c sepsis D bowel perforation the correct answer is a hypercal isemia as adults age the bowel becomes thinner the older adult is at a much higher risk of bowel perforation and sepsis due to bowel perforation than a younger adult the older adult patient is at a high risk for hyperphosphatemia because enemas such as a Fleet enema have an active ingredient of sodium phosphate older adults are also at a higher risk of hypocalcemia with these types of enemas too the following puts the older adult at a high risk of kidney failure and even death question 37 the nurse is caring for a child post-op day one from a tonsillectomy the patient has ibuprofen ordered as needed the order is for 150 milligrams q6 hours PRN for pain available as 100 milligrams over 5 ml how many ml will the nurse administer a 5 ml B 2.5 ml C 10 mL D 7.5 ml the correct answer is D 7.5 ml the available dose of ibuprof profin is 100 milligrams over 5 ml the patient needs 150 milligrams 100 milligrams is to 5 ml 150 milligrams is to x 750 milligrams equals 5x 750 milligrams divided by 100 x equals 7.5 ml question 38 a patient just received Humalog 3 units for a glucose of 233 at 8 AM when should you anticipate this patient needs to start eating his breakfast a before 9 am B 8 15 am C 8 45 am d before 9 30 am the correct answer is B 8 15 am Humalog is a fast-acting insulin if the patient was given Humalog at 8 AM they should eat within 15 to 30 minutes therefore B is the correct option question 39 a patient who is three hours post-op from a hysterectomy is ordered 7.5 milligrams morphine sulfate Q2 hours PRN for pain the pharmacy sends a vial constituted to five milligrams over 10 mL how many ml will the nurse give a 15 mL B 10 mL C 5 ml D 7.5 ml the correct answer is a 15 mL available as 5 milligrams over 10 mL but ordered is 7.5 milligrams 5 milligrams is to 10 mL 7.5 milligrams is 2x 75 milligrams equals 5x 75 divided by 5 equals 15 x equals 15 mL question 40. the physician orders an oxaparin sodium for a patient who is chair fast at what angle do you anticipate injecting this medication for a patient with a BMI of 23 a 45 degrees B 90 degrees C 180 degrees D 30 degrees the correct answer is a 45 degrees a patient with a BMI of 23 is within a normal weight range enoxaparin love knocks is injected into the Sub-Q tissue therefore it should be given at a 45 degree angle question 41 a mother of a 20 month old toddler tells you if the doctor would have prescribed him an antibiotic last week for this cold he has we wouldn't be back here again what is the best response to the mother a I understand your concern I will ask the doctor about an antibiotic B would you like me to suggest an antibiotic today C antibiotics do not work for viruses like the common cold D it is not necessary for your child to receive an antibiotic the correct answer is C antibiotics do not work for viruses like the common cold it is important for the nurse to educate the mother that antibiotics do not heal viruses option D dismisses the mother's concern for her child question 42 you're caring for a patient on Dilantin for seizures which of the following is the most important information to educate the patient on a this medication must be taken in the morning B be sure to take this on an empty stomach C do not abruptly stop taking this medication D be sure to lie down in a dark area after taking this medication the correct answer is C do not abruptly stop taking this medication it is very important to educate patients on seizure medications like Dilantin explaining to the patient that taking this medication abruptly can cause worse seizures is very important question 43 a patient is receiving IV Vancomycin 1500 milligrams daily for cellulitis of his right leg the patient's Vancomycin is scheduled for 9 A.M at which of the following times will the nurse draw a Vancomycin trough a 8 30 am B 8 30 PM C 9 30 A.M D 9 30 PM the correct answer is a 8 30 a.m a Vancomycin trough is a lab value to assess the lowest amount of Vancomycin in the blood it is often used to assess whether the medication is at a therapeutic level in the patient's body it is drawn right before the next due dose if the medication is due at 9 am then the trough should be drawn at 8 30 a.m and no earlier than 8 AM question 44 a child is ordered cephalexin for an ear infection which of the following medications would alert the nurse to clarify orders with the doctor if found on the patient's allergy list a penicillin B Vancomycin C Gentamicin D Augmentin the correct answer is a penicillin the antibiotic class known as penicillins includes amoxicillin you are more prone to develop an allergy to a class of medicines known as cephalosporins of which cephalexin is a part if you have a penicillin allergy patients who are allergic to penicillin should not use cephalexin the doctor's order should be clarified with the prescribing physician question 45 a patient is prescribed Warfarin for a recent blood clot which of the following foods should the patient be educated on to not consume a lettuce B eggs C milk D olives the correct answer is a lettuce patience on Warfarin should not consume foods high in vitamin K because vitamin K significantly reduces the effects of Warfarin leafy greens such as lettuce are high in vitamin K question 46 a nurse is providing an enema to a 75 year old female patient the following are high risks when administering an enema to an older adult except a hypercalcemia b hyperphosphatemia c sepsis D death the correct answer is a hypercalcemia as adults age the bowel becomes thinner the older adult is at at a much higher risk of bowel perforation and sepsis due to bowel perforation than a younger adult the older adult patient is at a high risk for hyperphosphatemia because enemas such as a Fleet enema have an active ingredient of sodium phosphate older adults are also at a higher risk of hypocalcemia with these types of enemas too the above conditions put the older adult at a high risk of kidney failure and even death question 47 an ed nurse is educating a 17 year old patient and her parents with a newly placed plaster cast to her left arm after sustaining a wrist fracture which of the following is the most important thing to educate the patient and parents on a reporting blue fingers immediately B keeping the arm in the sling provided C do not stick anything in the cast to scratch the skin D reporting fever immediately the correct answer is a reporting blue fingers immediately blue slash purple slash gray fingers May indicate lack of oxygen if the fingers become ischemic it becomes a medical emergency so that the patient does not lose their fingers question 48. the nurse is caring for an 87 year old new home health patient who has had an extended stay in the hospital after a fall that led to a broken hip that required a hip replacement followed by hospital-acquired pneumonia which of the following is most important for the nurse to educate the family on a ensure the patient's oxygen cord reaches to her bathroom B remove all throw rugs in the home C ensure the patient performs her breathing exercises daily D ensure the patient takes all medications as prescribed the correct answer is B remove all throw rugs in the home the number one thing to remember is the patient's safety while all the other options are good to remember for this patient we should focus on why she was in the hospital to begin with it was Falls removing the throw rugs in the home is the best intervention to prevent Falls for this patient question 49 the nurse is caring for a patient who recently suffered a stroke The Physician orders for the patient to be Advanced to a clear liquid diet from NPO before allowing the patient to drink which of the following is most important for the nurse to confirm a the patient's favorite drink B if the patient needs thickened liquids C if the patient is urinating D if the patient has vomited in 24 hours the correct answer is B if the patient needs thickened liquids before increasing their diet patients with dysphagia should have a thorough swallow examination especially if it is caused by a stroke or brain hemorrhage additional treatments in therapy would be necessary if clients were observed to exhibit aspiration or choking Tendencies during swallowing a speech pathologist can recommend thickened liquids if needed in this case a patient with a history of a stroke is cleared to drink this patient should be cleared by a speech pathologist before receiving fluids by mouth the nurse should check the patient's chart to see if the patient has an order for thickened liquids question 50 a nurse working in the Intensive Care Unit has a patient that is experiencing a sudden upper gastrointestinal B lead what is the most important intervention a place the patient in a Trendelenburg position B place the patient in a Supine position C put the patient in Reverse Trendelenburg D put the patient in a Sims position the correct answer is a place the patient in a Trendelenburg position using the Trendelenburg position for patients with a high risk of hypotension like with a large GI bleed can be helpful in reducing the risk of hypertension in order to increase surgical exposure of the pelvic organs the surgeon Friedrich trendelenberg invented the head down posture often known as the Trendelenburg position the Trendelenburg position then became a frequently used technique in treating patients with shock and hypertension the Trendelenburg posture has an increased cardiac output as its main consequence while this is not a long-term therapy initially placing the patient in a Trendelenburg position can help prevent hypertension question 51 the nurse is caring for a diabetic patient who the nurse finds sweating and only able to mumble words what is the first intervention for the nurse to take a give glucagon B check a pocket glucose reading C ask the patient when the last time they ate D give four units of insulin stat the correct answer is B check a POC glucose reading the first intervention should be to assess the glucose if the nurse learns that it is in fact hypoglycemia the patient should be treated promptly if a patient is only able to mumble they are likely not able to answer any questions from the nurse glucagon is given to patients who are unconscious insulin should never be given to a hypoglycemic patient question 52 a nurse working on a labor and delivery unit suspects that her patient is having a seizure what is the most important intervention for the nurse to provide a administer oxygen to the patient B place the patient in a sideline position C insert an intravenous IV line D call for immediate assistance from the health care team the correct answer is D call for immediate assistance from the health care team the most important intervention for the nurse to provide when suspecting that a patient is having a seizure on a labor and delivery unit is to call for immediate assistance from the health care team seizures can be a medical emergency and it is crucial to ensure prompt and appropriate management calling for assistance ensures that additional Health Care Professionals such as a physician or advanced practice provider can evaluate and provide the necessary care to the patient while other interventions such as administering oxygen placing the patient in a sideline position to prevent aspiration or inserting an IV line may be appropriate and important in certain circumstances calling for immediate assistance takes priority to ensure the patient's safety and well-being question 53 a nurse is assisting a physician at the patient's bedside with inserting a chest tube what is the most important intervention by the nurse a keep a sterile field B make sure the patient is comfortable C make sure the patient is still D have all supplies ready when the physician arrives the correct answer is a keep a sterile field the central line is a type of IV that will be inserted and its tip rests in the patient's heart this means that it must be a sterile procedure the nurse's concern should be maintaining a sterile field while ensuring the patient is comfortable and still is correct this patient is at a very high risk for infection so the sterile field should be kept typically a second nurse would be ensuring that the patient is comfortable and still question 54 a patient has just had a thoracentesis performed at the bedside which of the following is most important for the nurse to do a assess RR and sao2 B watch for drainage on the sterile dressing placed over the insertion site C have the patient lie supine for one hour post procedure D treat the patient for any pain they may have the correct answer is a assess RR and sao2 the plural space which surrounds the lungs can be sampled via a procedure known as thoracentesis Pleural fluid is a fluid that often only occurs as a thin layer in the space between the lungs and the chest wall the procedure involves a long needle that drains the lungs the patient is at risk for a pneumothorax the RR and sao2 should be monitored closely after the procedure is done a sterile dressing should be placed over the insertion site the patient is not required to lay supine after the procedure the nurse may give pain medication as prescribed but this is not the priority question 55 a patient who is three hours post procedure from a bronchoscopy the patient suddenly states that he has chest pain and is showing signs of shortness of breath which of the following does the nurse suspect a pneumonia B pneumothorax C myocardial infarction D stroke the correct answer is B pneumothorax a bronchoscopy can cause trauma to the lungs causing a pneumothorax The Telltale sign in this scenario is that the patient is suddenly experiencing chest pain and SOB during this procedure question 56 a nurse is about to assist the physician in a lumbar puncture for a patient with suspected bacterial meningitis the nurse knows that the patient should be placed in which position a lateral decubitus B prone C Sims D trendelenberg the correct answer is a lateral decubitis in order to perform a lumbar puncture the physician will have the patient in a lateral decubitus fetal position knees to chest the patient may assume this position by sitting with knees to chest as well question 57 an infant with hyperbilirubinemia has orders for phototherapy under the Billy light what is the most important education to provide to the parents a the infant must wear eye protection while under the light B the infant must take at least four ounces of milk per feeding C report any yellow stools immediately D the infant must have lotion rubbed on their skin twice daily the correct answer is a the infant must wear eye protection while under the light the Billy light phototherapy can cause eye damage to an infant the infant must have protective eyewear on at all times when they are under the light a newborn may not accept four ounces of milk per feed yellow stools are normal in a newborn it is not imperative that the infant have lotion rubbed on them twice day although the light can dry out their skin question 58 a patient in the ICU is on a ventilator following a diagnosis of covid-19 the patient has copious amounts of secretions in the lungs and must be suctioned often which of the following is the most important thing for the nurse to remember a suctioning too deep may cause bradycardia B the nurse must administer normal saline before suctioning C the respiratory therapist must be at the bedside before the nurse can suction the patient D ensure the patient is in a Supine position before suctioning the correct answer is a suctioning too deep may cause bradycardia in line suctioning on the ventilator stimulates the vagus nerve and may cause significant bradycardia this usually happens if the suction catheter is too deep it is not imperative to administer normal saline before suctioning it can however Aid in suctioning when the patient has thicker secretions the nurse is able to perform inline suctioning the patient does not have to be in a Supine position to suction question 59 a nurse is educating a patient on his diet to support optimal wound healing the patient asks the nurse what he can eat for lunch which of the following would be the best lunch option a baked chicken breast small side salad with Romaine lettuce with strawberry vinaigrette orange slices and a glass of unsweet tea BBQ pork sandwich on wheat bread baked potato fries and unsweet tea c chicken salad baked lays strawberries and Diet Coke D pot roast with potatoes and carrots with a side of vitamin D milk the correct answer is a baked chicken breast small side salad with Romaine lettuce with strawberry vinaigrette orange slices and a glass of unsweet tea wound healing is promoted by high levels of protein and vitamin C and low levels of glucose option A has a high level of protein chicken and vitamin C strawberry and orange and low glucose unsweet tea the other options provide less protein more carbs sugar and little to no vitamin C question 60 a patient who is three days post-surgery from a knee replacement was discharged from the hospital yesterday today he woke up with symptoms of a cold and states that he does not feel well which of the following are most important to report to the surgeon a a temperature of 100.8 B pain at the surgical site C small amount of brown Blood on the surgical dressing D stiffness in the knee the correct answer is a a temperature of 100.8 the patient is three days post-op from a knee replacement surgery the biggest concern is a fever due to the high risk for infection it is normal for a patient who has undergone knee replacement surgery to experience pain at the surgical site Brown Blood on the dressing is normal the knee will be stiff as it heals most patients require physical therapy as they heal thank you for watching this video we hope you enjoyed it click the first link in the description to take the free NCLEX practice test also check out these videos that can help you with your future studies don't forget to resuscitate the like button and subscribe to our Channel and please share this video with your fellow nursing friends

Channel: All Healthcare Careers

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Length: 49min 55sec (2995 seconds)

Published: Thu Jun 22 2023