NCLEX Practice Exam 6

Question 1

The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:

Accepted Answer

File a formal reprimand

Answer

Charting medication that was not given is a serious professional misconduct and a patient safety violation. The initial and appropriate action for a charge nurse is to address this formally through the facility's disciplinary process, which typically begins with a formal reprimand. This allows for documentation, investigation, and potential further action if necessary.

Question 2

The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective?

Accepted Answer

The client has a grand mal seizure.

Answer

The therapeutic effect of electroconvulsive therapy (ECT) is achieved by intentionally inducing a generalized seizure, often described as a grand mal seizure. This controlled seizure activity is the desired physiological response that leads to the significant therapeutic benefits for severe depression and other mental health conditions.

Question 3

The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority?

Accepted Answer

Contacting the physician

Answer

The client's vital signs (BP 90/50, pulse 132, respirations 30) are significantly abnormal and indicate potential hemodynamic instability, such as hypovolemic shock or hemorrhage, which are serious post-operative complications. These critical findings require immediate medical evaluation and intervention. Therefore, contacting the physician is the highest priority action.

Question 4

The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?

Accepted Answer

The entire family should be treated.

Answer

Enterobiasis, or pinworm infection, is highly contagious and easily spreads among individuals living in close proximity, primarily through the fecal-oral route. To effectively eradicate the infection and prevent rapid reinfection, it is essential to treat all household members simultaneously, regardless of whether they are symptomatic.

Question 5

The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?

Accepted Answer

The nurse wears gloves to take the client’s vital signs.

Answer

Routine vital signs, such as temperature, pulse, respirations, and blood pressure, do not typically involve contact with blood, body fluids, or non-intact skin. Therefore, wearing gloves for these routine assessments is generally unnecessary and indicates a misunderstanding of standard precautions and when personal protective equipment is required.

NCLEX Practice Test

NCLEX Practice Test

NCLEX Practice Exam 6