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40 items Comprehensive NCLEX review answer key
1. Which individual is at greatest risk for developing hypertension?
A) 45 year-old African American attorney
B) 60 year-old Asian American shop ownerC) 40 year-old Caucasian nurseD)55 year-old Hispanic teacherThe correct answer is A: 45 year-old African American attorney The incidence of hypertension is greater among African Americans than other groups in the US. Theincidence among the Hispanic population is rising.2. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago isseen in the emergency department. Which of these orders should the nurse do first?
A) Gastric lavage PRN
B) Acetylcysteine (mucomyst) for age per pharmacyC) Start an IV Dextrose 5% with 0.33% normal saline to keep vein openD) Activated charcoal per pharmacyThe correct answer is A: Gastric lavage PRN Removing as much of the drug as possible isthe first step in treatment for this drug overdose. This is best done by gastric lavage. Thenext drug to give would be activated charcoal, then mucomyst and lastly the IV fluids.3. Which complication of cardiac catheterization should the nurse monitor for in the initial 24hours after the procedure?A) angina at rest
B) thrombus formation
C) dizzinessD) falling blood pressureThe correct answer is B: thrombus formation Thrombus formation in the coronary arteries isa potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occursalong with hemorrhage of the insertion site which is associated with the first 12 hours afterthe procedure.4. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degreesFahrenheit. The priority nursing goal for this client isA) Maintain fluid and electrolyte balanceB) Control nausea
C) Manage pain
D) Prevent urinary tract infectionThe correct answer is C: Manage pain The immediate goal of therapy is to alleviate theclient’s pain.5. What would the nurse expect to see while assessing the growth of children during theirschool age years?A) Decreasing amounts of body fat and muscle massB) Little change in body appearance from year to yearC) Progressive height increase of 4 inches each year
D) Yearly weight gain of about 5.5 pounds per year
 
The correct answer is D: Yearly weight gain of about 5.5 pounds per year School agechildren gain about 5.5 pounds each year and increase about 2 inches in height.6. At a community health fair the blood pressure of a 62 year-old client is 160/96. The clientstates “My blood pressure is usually much lower.” The nurse should tell the client to
A) go get a blood pressure check within the next 48 to 72 hours
B) check blood pressure again in 2 monthsC) see the health care provider immediatelyD) visit the health care provider within 1 week for a BP checkThe correct answer is A: go get a blood pressure check within the next 48 to 72 hours Theblood pressure reading is moderately high with the need to have it rechecked in a few days.The client states it is ‘usually much lower.’ Thus a concern exists for complications such asstroke. However immediate check by the provider of care is not warranted. Waiting 2months or a week for follow-up is too long.7. The hospital has sounded the call for a disaster drill on the evening shift. Which of theseclients would the nurse put first on the list to be discharged in order to make a roomavailable for a new admission?
A) A middle aged client with a history of being ventilator dependent for over 7years and admitted with bacterial pneumonia five days ago
B) A young adult with diabetes mellitus Type 2 for over 10 years and admitted withantibiotic induced diarrhea 24 hours agoC) An elderly client with a history of hypertension, hypercholesterolemia and lupus, and wasadmitted with Stevens-Johnson syndrome that morningD) An adolescent with a positive HIV test and admitted for acute cellulitus of the lower leg48 hours agoThe correct answer is A: A middle aged client with a history of being ventilator dependentfor over 7 years and admitted with bacterial pneumonia five days ago The best candidate fordischarge is one who has had a chronic condition and is most familiar with their care. Thisclient in option A is most likely stable and could continue medication therapy at home.8. A client has been newly diagnosed with hypothyroidism and will take levothyroxine(Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes thatthis medication:
A) Should be taken in the morning
B) May decrease the client's energy levelC) Must be stored in a dark containerD) Will decrease the client's heart rateThe correct answer is A: Should be taken in the morning Thyroid supplement should betaken in the morning to minimize the side effects of insomnia9. A 3 year-old child comes to the pediatric clinic after the sudden onset of findings thatinclude irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaningforward, tongue protruding, drooling and suprasternal retractions. What should the nurse dofirst?A) Prepare the child for x-ray of upper airwaysB) Examine the child's throatC) Collect a sputum specimen
D) Notify the healthcare provider of the child's status
 
The correct answer is D: Notify the health care provider of the child''s status These findingssuggest a medical emergency and may be due to epiglottises. Any child with an acute onsetof an inflammatory response in the mouth and throat should receive immediate attention ina facility equipped to perform intubation or a tracheostomy in the event of further orcomplete obstruction.10. In children suspected to have a diagnosis of diabetes, which one of the followingcomplaints would be most likely to prompt parents to take their school age child forevaluation?A) PolyphagiaB) Dehydration
C) Bed wetting
D) Weight lossThe correct answer is C: Bed wetting In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a schoolage child is readily detected by the parents11. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. Thenurse recognizes that this condition most frequently follows which type of infection?A) Trichomoniasis
B) Chlamydia
C) StaphylococcusD) StreptococcusThe correct answer is B: Chlamydia Chlamydial infections are one of the most frequentcauses of salpingitis or pelvic inflammatory disease.12. An RN who usually works in a spinal rehabilitation unit is floated to the emergencydepartment. Which of these clients should the charge nurse assign to this RN?A) A middle-aged client who says "I took too many diet pills" and "my heart feels like it isracing out of my chest."B) A young adult who says "I hear songs from heaven. I need money for beer. I quitdrinking 2 days ago for my family. Why are my arms and legs jerking?"
C) An adolescent who has been on pain medications for terminal cancer with aninitial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10
D) An elderly client who reports having taken a "large crack hit" 10 minutes prior to walkinginto the emergency roomThe correct answer is c: An adolescent who has been on pain medications for terminalcancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 Nurses who are floated to other units should be assigned to a client who has minimalanticipated immediate complications of their problem. The client in option C exhibits opoidtoxicity with the pinpoint pupils and has the least risk of complications to occur in the nearfuture.13. When teaching a client with coronary artery disease about nutrition, the nurse shouldemphasizeA) Eating 3 balanced meals a dayB) Adding complex carbohydrates
C) Avoiding very heavy meals
D) Limiting sodium to 7 gms per day
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