NCLEX 10

1. Which of the following puts the layers of skin in correct order from right to left?

2. The Loop of Henle is located in which of the following body organs?

3. In which of the following methods should a nurse assess for scoliosis in a child?

4. Which of the following is an example of a natural family planning method?

5. Which of the following is an example of a teratogen?

6. An 8-year-old child has been diagnosed with infectious conjunctivitis. Discharge instructions will include:

7. A child is being discharged to home with a diagnosis of ringworm. Discharge instructions should include the information that:

8. A child presented to the ED with itchy scalp, irritation of the scalp, and infected areas on the child’s head. Assessment reveals lice and nits in the child’s hair. Discharge instructions will include:

9. Johnny Tate, a 2 year old boy, is hospitalized with pneumonia. This child will most likely _________.

10. Identify the developmental task with the correct age group.

11. A victim of a gunshot wound to the abdomen has been admitted to the hospital, accompanied by a police officer. When questioned, the officer states that the patient is a suspect in a homicide, which occurred as part of the same incident. A small child was killed as the result of a stray bullet. The patient is combative, yells that he’s in pain and demands medication. What is your most appropriate response?

12. Ruth is a 72-year-old patient who has been upset and crying all morning. When asked why she is upset, she turns toward the wall in silence. What collaborative process may be helpful in caring for this patient?

13. The previous charge nurse fell during her shift and was taken to the emergency room. You have been assigned to take over as charge nurse without any report. At the end of the shift, you have made the assignments for the next shift’s nurses and posted them. As the nurses come in, they begin to complain that the assignments make no sense, based on patient acuity. One refuses to take her assignment and threatens to go home. What could you have done to prevent their dissatisfaction?

14. You have noticed that the last several patients you have cared for have had questionable blood pressure readings from their arterial lines. When checked against cuff pressures, a discrepancy has been noted, and further investigation has revealed faulty transducers. This is not the first product issue with this company. What positive step could you take to help resolve this situation?

15. Which of the following is an organizational factor that affects workplace violence directed at nurses?

16. Your patient is concerned about their health insurance and the costs associated with their hospital care. Which of Maslow’s needs is your patient expressing?

17. Verbal bullying, among school aged children, threatens which of Maslow’s needs?

18. Physical bullying, among school aged children, threatens which of Maslow’s needs?

19. Your patient has had a very full and rewarding life. She has had a lot of success in her personal and professional life. She has achieved all of her goals and she has maximized her potential. This patient can be best described as a person who has achieved Maslow’s___________.

20. A “Living Will” is another term for ________________.

21. Another term for “health care proxy” is _______________.

22. A prescription for Amoxicillin 250 mg capsules, 1 cap po tid x 10 days should be filled with ____.

23. How many ounces make up one cup?

24. There are ______ ounces (oz.) in a pound (lb).

25. Milli- is equal to _____.

26. A fluid ounce is made up of how many mL?

27. Kilo- is equal to ______.

28. How many cc’s make up one pint?

29. How many quarts make up a gallon?

30. How many micrograms (mcg) make up 1 milligram (mg)?

31. There are _____ milligrams (mg) in a gram (g).

32. A teaspoonful is the same measurement as ___.

33. If a patient is receiving 7 liters of IV fluids over 10 hours, how many ml will the patient receive per minute?

34. If a patient is receiving 3.5 liters of IV fluids at a rate of 7 ml per minute how many hours will the IV fluid last?

35. Many nurses are not comfortable dealing with the topic of suicide with a patient who may be at risk. Of the following, what would be an appropriate action if a patient uses language indicative of suicidal intentions?

36. A client in a long-term care facility has developed reddened skin over the sacrum, which has cracked and started to blister. The nurse confirms that the client has not been assisted with turning while in bed. Which stage of pressure ulcer is this client exhibiting?

37. A nurse is preparing to administer a dose of platelets to a client. Which of the following actions must the nurse perform before giving the platelets?

38. According to the American Heart Association standards, high quality CPR for an adult includes all of the following EXCEPT:

39. One of your patients is dependent on a mechanical ventilator for their respiratory needs. The patient cannot breath on their own. Suddenly, the lights in the patient’s room and the entire nursing unit go off. You realize that the electric power has been lost. What is the first thing that you should do for this patient?

40. Which would be the first step when a patient passes out at the front desk?

41. When performing CPR, at what rate should chest compressions be applied?

42. Which acronym would BEST describe the procedure for assessing a patient that appears unconscious?

43. A nurse is caring for an 86-year old client with decreased visual acuity and who uses a cane for mobility. What should the nurse teach this client to reduce the risk of falling at home?

44. A nurse is preparing to assist a client from his bed into a wheelchair. Which action is essential to maintain client safety in this situation?

45. A 76 year old male patient is being admitted to the hospital with abdominal pain s/p a left total hip replacement five days ago. The patient has active bowel sounds, denies vomiting. The patient states his last bowel movement was this morning and was loose and brown. Which of the following has likely occurered?

46. A client who suffers from a neuromuscular disability wants to try Feldenkrais to increase some flexibility. Which of the following best describes this alternative healing method?

47. A new nurse is orienting to a geriatric medical-surgical unit. She questions why the unit protocol is to perform mouth care every 2 hours and as needed. The staff nurse explains that the following factors contribute to dry mouth in the older adult:

48. At the end of your shift, Sophie T. starts crying when you walk into their room. Sophie is usually very cheerful. You speak to Sophie and she tells you that she is very sad because she has not seen her family in weeks. What should you do?

49. The primary reason that people act out with disturbed behavior in a healthcare facility is because the person has a _________ problem.

50. The best way for a nurse, and a healthcare facility, to control the effects of poor and disruptive patient behavior is to _________________.

51. Identify the “trigger” type with the correct “trigger” that can possibly lead to disturbed behavior.

52. Jerry is a 55-year-old veteran who has been admitted after a motor vehicle accident with multiple injuries. His friend reported that he had been using synthetic marijuana prior to the accident, and that he also sees a psychiatrist at the VA hospital for an unknown diagnosis. He stated that Jerry sometimes gets “hyper” for no reason, starts “ranting” and becomes violent. Of the following, which general psychiatric disorder is characterized by a pattern of aggression or violence which includes irritability, agitation, and violent behavior during manic or psychotic episodes?

53. Of the following, which would NOT be helpful to include when developing Jerry’s plan of care?

54. Of the following, which often triggers an episode of violence or aggression by the patient with a psychiatric diagnosis that may involve violent behavior?

55. Which of the following is an appropriate tension-reduction intervention for the patient who may be escalating toward aggressive behavior?

56. Which of the following mental health situations is considered a psychiatric emergency?

57. A nurse is reading a rhythm strip from a cardiac monitor. She counts 6 QRS complexes within a 6-second strip. What is the heart rate?

58. All of the following are complications associated with hypothermia during the perioperative period EXCEPT:

59. A nurse is caring for a client who had a bone marrow transplant two weeks ago. Which of the following is most likely to cause an infection during this time period?

60. Which of the following actions is part of suture removal for a client following surgery?

61. Which of the following statements best describes postural drainage as part of chest physiotherapy?

62. Mr. R has come into the emergency room after an injury at work in which his upper body was pinned between two pieces of equipment. The nurse notes bruising in the upper abdomen and chest. He is complaining of sharp chest pain, he has difficulty with breathing, and his trachea is deviated to the left side. Which of the following conditions are these symptoms most closely associated with?

63. The physician has decided to perform a thoracentesis based on Mr. R’s assessment. Which of the following actions from the nurse is most appropriate?

64. A systolic blood pressure of 145 mm Hg is classified as:

65. You are caring for Thomas N. Thomas is 77 years old. He has edema, or swelling, in his legs and he has a fluid restriction in terms of his fluid intake. You have been assigned to weigh him daily. Based on these symptoms and the care that he is being given, what disorder is he most likely affected with?

66. Your patient has just died from a massive heart attack. As far as you know, patient had no other diseases, illnesses or infections. Should you still use standard precautions as you provide post mortem care?

67. The proper personal protective equipment necessary for collecting a sputum specimen would include: (Choose the BEST answer.)

68. Surgical asepsis is being performed when:

69. The most effective step of hand washing is:

70. MSDS sheets:

71. The most virulent blood borne pathogen is: (Choose the BEST answer.)

72. The NFPA diamond has four colors. The blue diamond:

73. Exhibit 2, ECG interpretation 1355: sinus tachycardia with frequent premature ventricular contractions. The unlicensed assistive personnel perform the ECG on the client (see exhibit 2). Which of the following current findings is the most concerning?

74. Exhibit 3 Vital signs 1355: T (36.4) 97.5°F orally; HR 118 bpm; BP 162/98 mm Hg; RR 20 breaths/min; Pulse oximetry 97% on room air; Pain 10/10._x000D_
_x000D_
Regarding the current assessment findings and vital signs, which of the following is the most important question for the nurse to ask the client?_x000D_

75. Exhibit 4 Provider’s Prescriptions/Orders 1406: – Establish IV access._x000D_
– CBC, BMP, PT/PTT, INR, Troponin._x000D_
– Urinalysis._x000D_
– CT chest/abdomen._x000D_
– X-ray of the left ankle and right knee._x000D_
– 50 mcg IV Fentanyl stat._x000D_
– 1000 mL of 0.9% sodium chloride._x000D_
_x000D_
The healthcare provider assesses the client and places prescriptions. Which additional laboratory tests should the nurse plan to obtain and discuss with the healthcare provider while establishing the IV?_x000D_