NCLEX-RN Practice Exam 6

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

Correct!Wrong!

The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand. Options A, C, and D: If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but these are not the first actions requested in the stem. A tort is a wrongful act to the client or his belongings and is not indicated in this instance.

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

Correct!Wrong!

During ECT, the client will have a grand mal seizure. This indicates completion of the electroconvulsive therapy. Options A, B, and C do not indicate that the ECT has been effective.

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?

Correct!Wrong!

The vital signs are abnormal and should be reported immediately. Option A: Continuing to monitor the vital signs can result in deterioration of the client’s condition. Option C: Asking the client how he feels will only provide subjective data. Option D: Assigning an unstable client to an LPN is inappropriate.

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

Correct!Wrong!

Enterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated to ensure that no eggs remain. Because a single treatment is usually sufficient, there is usually good compliance. The family should then be tested again in 2 weeks to ensure that no eggs remain. Answers A, C, and D are incorrect statements.

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

Correct!Wrong!

It is not necessary to wear gloves to take the vital signs of the client. If the client has active infection with methicillin-resistant Staphylococcus aureus, gloves should be worn. Options A, B, and C: The health care workers indicate knowledge of infection control by their actions.

A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:

Correct!Wrong!

Always remember your ABCs (airway, breathing, circulation) when selecting an answer. Option A: does not apply for a child who has undergone a tonsillectomy. Options B and D: Although these nursing diagnoses might be appropriate for this child, risk for aspiration should have the highest priority.

The client is having fetal heart rates of 90–110 bpm during the contractions. The first action the nurse should take is:

Correct!Wrong!

The normal fetal heart rate is 120–160 bpm; 100–110bpm is bradycardia. The first action would be to turn the client to the left side and apply oxygen. Option A: Repositioning the monitor is not indicated at this time. Option C: Asking the client to ambulate is not the best action for clients experiencing bradycardia. Option D: There is no data to indicate the need to move the client to the delivery room at this time.

A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?

Correct!Wrong!

The nurse should encourage rooming-in to promote parent-child attachment. It is okay for the parents to be in the room for assessment of the child. Options A and B: Allowing the child to have items that are familiar to him is allowed and encouraged. Option D: Telling the child that screaming is inappropriate behavior is not part of the nurse’s responsibilities.

Which of the following is a characteristic of a reassuring fetal heart rate pattern?

Correct!Wrong!

Accelerations with movement are normal. Options A, B, and C: These assessments indicate ominous findings on the fetal heart monitor.

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