Mixed Deck — All NCLEX Topics Flashcards
100 cards from real NCLEX practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 20 Mixed Deck — All NCLEX Topics flashcards as text
A patient has taken an overdose of aspirin. Which of the following should a nurse most closely monitor for during acute management of this patient?
Answer: Onset of pulmonary edema
Aspirin (salicylate) overdose is a serious condition that can lead to various complications, including direct toxicity to the lungs. This toxicity can cause non-cardiogenic pulmonary edema, which is a life-threatening accumulation of fluid in the lungs. Monitoring for this acute respiratory complication is crucial during the management of aspirin overdose.
The nurse is reinforcing teaching for a client starting iron supplements. Which statement shows understanding?
Answer: I may have dark stools while taking this medication.
Dark, tarry stools are a common and expected side effect of iron supplements, caused by unabsorbed iron passing through the digestive system. Educating the client about this normal change helps prevent unnecessary alarm and ensures medication adherence. This understanding is crucial for clients starting iron therapy.
A nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply.
Answer: Monitor the client's ability to void.
Nurses should decline to witness legal documents like wills to avoid potential conflicts of interest or accusations of undue influence. Witnessing a will can compromise the nurse's professional objectivity and role, especially if the client's competency or the will's validity is later questioned. It is best practice for nurses to maintain a clear boundary and avoid involvement in such legal matters.
Which hand hygiene technique is most effective for preventing the spread of Clostridioides difficile (C. diff) spores?
Answer: Soap and water handwashing for at least 20 seconds
C. difficile forms spores that are NOT killed by alcohol-based hand sanitizers. Soap and water with vigorous friction for at least 20 seconds is required to physically remove spores from the hands. This is a critical distinction from most other pathogens where alcohol rub is equally effective.
A client is admitted with a GI bleed and hematemesis. Which finding indicates the client is developing hemorrhagic shock?
Answer: Blood pressure 88/58, HR 124, pale and diaphoretic
Hemorrhagic shock is characterized by hypotension (BP 100), pallor, and diaphoresis from decreased cardiac output and compensatory sympathetic activation. These are emergency findings requiring immediate IV access, fluid resuscitation, blood products, and urgent endoscopy.
The PN is caring for a client with a latex allergy. Which item commonly found in the clinical environment may contain latex?
Answer: Tourniquets, some IV tubing, and stethoscope tubing
Latex is found in many clinical items: rubber gloves, blood pressure cuffs, tourniquets, IV tubing injection ports, catheter balloons, stethoscope tubing, and tape backings. A latex-safe environment requires latex-free substitutes for all equipment. Cross-reactivity foods include bananas, avocados, kiwi, and chestnuts.
He likewise stresses the need for all the employees to follow orders and instructions from him and not from anyone else. Which of the following principles does he refer to?
Answer: Unity of command
Unity of command is a fundamental management principle stating that each employee should report to only one supervisor to avoid conflicting orders and confusion. Julius's instruction that employees follow orders exclusively from him and no one else directly embodies this principle. This ensures clear lines of authority and accountability within the organizational structure.
A nurse is caring for a client with a chest tube connected to a water-seal drainage system. Which observation indicates the system is functioning properly?
Answer: Gentle tidaling in the water-seal chamber with respirations
Gentle tidaling (fluctuation) in the water-seal chamber that corresponds with respirations indicates the system is patent and functioning correctly.
A nurse is monitoring a client in active labor. The fetal heart rate monitor shows late decelerations with each contraction. What is the priority nursing action?
Answer: Reposition the client to the left lateral position, administer O₂ via face mask, and notify the provider
Late decelerations (FHR nadir after contraction peak) indicate uteroplacental insufficiency — reduced oxygen delivery to the fetus. Priority actions: (1) reposition to left lateral (relieves aortic/caval compression, improves placental perfusion), (2) administer O₂ by face mask at 8–10 L/min, (3) stop oxytocin if infusing, (4) notify provider. Left lateral position is the priority first step.
A client with hypertension states they stopped taking their medication because they felt fine. What is the nurse’s best response?
Answer: Explain that hypertension may have no symptoms but still needs treatment.
Hypertension is often asymptomatic, meaning clients may feel fine despite having dangerously high blood pressure. It is crucial to educate the client that untreated hypertension can lead to severe long-term complications like heart attack, stroke, and kidney disease. Emphasizing the importance of consistent medication adherence, even without symptoms, is vital for preventing these adverse outcomes.
A charge nurse asks the PN to float to the ICU to care for a critically ill ventilated client. The PN has no ICU experience. What is the appropriate response?
Answer: Communicate your specific competency limitations to the charge nurse and request a buddy assignment or limited scope within your competence
Nurses have a professional and legal obligation to practice within their scope of competence. The appropriate response is to communicate specific limitations (not blanket refusal), offer to perform tasks within competence (standard assessments, oral medications), and request a buddy system for complex tasks beyond training. This protects patient safety and meets professional standards.
A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses’ next action be?
Answer: Check the calcium level
A total thyroidectomy removes the thyroid gland, which is anatomically close to the parathyroid glands. Damage to or accidental removal of the parathyroid glands during surgery can lead to hypoparathyroidism, resulting in decreased parathyroid hormone (PTH) production. PTH regulates calcium levels, so a decrease leads to hypocalcemia. Tingling around the mouth and in the fingers and toes (paresthesias) are classic early symptoms of hypocalcemia, making checking the calcium level the priority.
During assessment, the nurse notices a client has a new productive cough with yellow-green sputum. What should the nurse do?
Answer: Notify the healthcare provider.
A new productive cough with yellow-green sputum is a significant clinical finding that strongly suggests a bacterial respiratory infection, such as bronchitis or pneumonia. This change in sputum color and consistency indicates an inflammatory process requiring medical evaluation. Notifying the healthcare provider is the appropriate nursing action to ensure timely diagnosis, potential antibiotic treatment, and prevention of worsening symptoms.
Which question is helpful in determining the study’s credibility?
Answer: Do the participants recognize the experience as their own?
Credibility in qualitative research refers to the truth value of the findings, ensuring that the research accurately represents the experiences of the participants. A key way to establish credibility is through member checking, where the researcher shares findings with participants to confirm that the descriptions and interpretations resonate with their own experiences. This ensures the participants recognize the experience as their own.
The nurse is reviewing a client's medication administration record and notes the client received the wrong dose of insulin 30 minutes ago. What is the priority action?
Answer: Immediately assess the client, notify the provider, and complete an incident report
After a medication error, priorities are: (1) assess the client for adverse effects (hypoglycemia from excess insulin), (2) notify the provider immediately for orders to monitor and treat, (3) complete an incident report per facility policy, and (4) document the client's condition and actions taken in the medical record. Patient safety first, then reporting.
A patient is admitted to the same day surgery unit for liver biopsy. Which of the following laboratory tests assesses coagulation? Select all that apply.
Answer: Partial thromboplastin time.
For a liver biopsy, assessing coagulation is crucial due to the risk of bleeding. Partial thromboplastin time (PTT) and Prothrombin time (PT) measure the function of different coagulation pathways, indicating how long it takes for blood to clot. A platelet count assesses the number of platelets, which are essential for forming a clot plug. Together, these tests provide a comprehensive picture of a patient's clotting ability.
The nurse is caring for a client with a permanent pacemaker. Which finding requires immediate action?
Answer: Hiccups and muscle twitching over the pacemaker site
Hiccups and muscle twitching near the pacemaker pocket suggest lead displacement or pacemaker malfunction with inadvertent stimulation of the diaphragm or pectoral muscles. This requires immediate notification of the provider and evaluation of pacemaker function. Lead displacement is a common early post-implant complication.
After discussing the possible effects of the low patient satisfaction rate, the staff started to list down possible strategies to solve the problems head-on. Should they decide to vote on the best change strategy, which of the following strategies is referred to this?
Answer: Majority rule
When a group decides to 'vote on the best change strategy,' they are employing the decision-making method of majority rule. This strategy involves making a decision based on the preference of more than half of the group members. It is a common and efficient way to reach a conclusion when consensus is not achievable or practical.
A nurse discovers a medication error made by another nurse earlier in the shift. The medication did not cause patient harm. What is the nurse's ethical and professional obligation?
Answer: Complete an incident report, notify the charge nurse and physician, and document in the patient record
All medication errors, whether or not harm occurred, must be reported via an incident (variance) report, disclosed to the provider, and documented objectively in the medical record. Transparency and accurate reporting are essential for patient safety, quality improvement, and legal protection.
A newborn's Apgar score at 1 minute is 6. What is the priority nursing action?
Answer: Stimulate and provide respiratory support
A 1-minute Apgar of 6 indicates moderate distress, so stimulation and respiratory support are the priority.