HURST NCLEX-RN REVIEW, NCLEX-RN

HURST NCLEX-RN REVIEW, NCLEX-RN

QUESTIONS AND ANSWER S, HURST

NURSING EXAM, RN LICENSURE PREP,

CLINICAL JUDGMENT TE ST, HURST

REVIEW, NCLEX STUDY MATERIAL

Question : A new nurse is preparing to give a medication to a

nine month old client. After checking a drug reference book, the nurse crushes the tablet and mixes it into 3 ounces of applesauce. The new nurse proceeds to the client's room.What priority action should the supervising nurse take?

• Tell the new nurse to recheck the drug reference book

before administering the medication.

• Suggest that the new nurse reconsider the client's

developmental needs.

• Check the prescription order and the client dose.
• Observe the new nurse administer the medication.

Correct Answer: 2. Correct: Mixing medication with applesauce is appropriate in some circumstances, but the volume of 3 ounces is excessive for a nine month old. The nurse will want to make sure the client gets all of the medication. Additionally, applesauce may or may not have been introduced into the diet, and it is inappropriate to introduce a new food during an illness.

Question : A home health nurse inspects the home of a client

scheduled to be discharged home after receiving care for a cerebrovascular accident with generalized weakness.What safety interventions should the nurse recommend based on findings within the home?

• Place ramp over the front steps.
• Move client's bedroom downstairs.
• Remove throw rugs.
• Secure furniture so client can use for support.
• Apply nonskid strips to shower stall.

Correct Answer: 1., 2., 3., 5. Correct: The client will have difficulty navigating the steps, both outside and inside the home. The client may trip on throw rugs, and shower stalls are slippery when wet. These things, along with the generalized weakness, makes the client more prone to falls.These interventions will promote safety for the client and decrease the risk of falling.

Question : Which factors should the nurse include when

teaching a parent about risk factors for otitis media?

• Breast-feeding
• Contact with siblings
• Day care attendance
• Season of the year

Correct Answer: 2., 3. & 4. Correct: Contact with siblings, day care attendance, and season of the year all increase a

child's risk of developing otitis media. Otitis media usually follows or accompanies an upper respiratory infection or the common cold. The exposure to upper respiratory infections is increased when other siblings are in the home and when the child attends daycare. More upper respiratory infections occur during times when the climate changes and during the winter months.

Question : The nurse on a neuro rehabilitation unit is caring

for a client with a T4 lesion. The client suddenly reports a severe, pounding headache. Profuse diaphoresis is noted on the forehead. The blood pressure is 180/112 and the heart rate is 56. What interventions should the nurse initiate?

• Place client supine with legs elevated.
• Assess bladder and bowel for distention.
• Examine skin for pressure areas.
• Eliminate drafts.
• Remove triggering stimulus.
• Administer hydralazine if BP does not return to normal.

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Question : The school nurse has identified a large outbreak of

viral conjunctivitis among one middle school class and plans to educate these students on this illness. Which data should the nurse be sure to include?

• Use personal handkerchief to wipe the eye of discharge.
• Light cold compresses over the eyes several times a day

will ease discomfort.

• Do not share towels or linens.
• Discard all makeup and use new makeup after infection

resolves.

• Wash hands frequently with soap and water.

Correct Answer: 2., 3., 4. & 5. Correct: All of these measures will promote comfort and decrease risk of transmitting infection. Clients should also avoid touching the eyes and shaking hands/touching other. Cool compresses provide symptomatic relief.

Question : The charge nurse is making assignments for one

RN and one LPN/VN on a pediatric unit. Which clients would be most appropriate for the charge nurse to assign to the RN?

• 2 year old with asthma receiving IV medication.
• 6 year old with new onset seizures.
• 12 year old with colitis receiving TPN.
• 2 month old with urinary tract infection.
• 10 year old paraplegic needing assistance with bowel

training.Correct Answer: 1., 2., 3. Correct: These clients should be assigned to the RN as they will require more frequent assessment due to the nature of each diagnosis and have a