Nclex Question AND Rationale (WEEK 1) + Predictor TEST PDF

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1. The nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first? 1. The client who has just been brought to the unit from the emergency department (ED) with no report of complaints. 2. The client who received pain medication 30 minutes ago for chest pain that was a level 3 on a 1-to-10 pain scale. 3. The client who had a cardiac catheterization in the morning and has palpable pedal pulses bilaterally. 4. The client who has been turning on the call light frequently and stating her care has been neglected. 2. The nurse on the cardiac unit is preparing to administer medications after receiving the morning change-of-shift report. Which medication should the nurse administer first? 1. The cardiac glycoside to the client who has an apical pulse of 58. 2. The loop diuretic to a client with a serum K+ level of 3.2 mEq/L. 3. The antidysrhythmic to the client in ventricular fibrillation. 4. The calcium-channel blocker who has a blood pressure of 110/68. 3. Which client should the telemetry nurse assess first after receiving the a.m. shift report? 1. The client diagnosed with deep vein thrombosis who has an edematous right calf. 2. The client diagnosed with mitral valve stenosis who has heart palpitations. 3. The client diagnosed with arterial occlusive disease who has intermittent claudication. 4. The client diagnosed with congestive heart failure who has pink frothy sputum. 4. The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. The 44-year-old client diagnosed with a myocardial infarction. 2. The 65-year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain. 5. The charge nurse is making assignments for a 30-bed cardiac unit staffed with three registered nurses (RNs), three licensed practical nurses (LPNs), and three unlicensed assistive personnel (UAPs). Which assignment is most appropriate by the charge nurse? 1. Assign an RN to perform all sterile procedures. 2. Assign an LPN to give all IV medications. 3. Assign an UAP to complete the a.m. care. 4. Assign an LPN to write the care plans.

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6. The nurse on a cardiac unit is discussing a client with the case manager. Which information should the nurse share with the case manager? 1. Discuss personal information the client shared with the nurse in confidence. 2. Provide the case manager with any information that is required for continuity of care. 3. Explain that client confidentiality prevents the nurse from disclosing information. 4. Ask the case manager to get the client’s permission before sharing information.

7. The nurse assesses erratic electrical activity on the telemetry reading while the client is talking to the nurse on the intercom system. Which task should the nurse instruct the UAP to implement? 1. Call a Code Blue immediately. 2. Check the client’s telemetry leads. 3. Find the nurse to check the client. 4. Remove the telemetry monitor. 8. The charge nurse on the cardiac unit has to float a nurse to the emergency department for the shift. Which nurse should be floated to the emergency department? 1. The nurse who has 4 years of experience on the cardiac unit. 2. The nurse who just transferred from critical care to the cardiac unit. 3. The nurse with 1 year of experience on the cardiac unit who has been on a week’s sick leave. 4. The nurse who has worked in the operating room for 2 years and in the cardiac unit for 3 years. 9. The cardiac nurse is preparing to administer one unit of blood to a client. Which interventions should the nurse implement? Rank in order of priority. 1. Infuse the unit of blood at 20 gtts/min the first 15 minutes. 2. Check the unit of blood and the client’s blood band with another nurse. 3. Initiate Y-tubing with normal saline via an 18-gauge angiocatheter. 4. Assess the client’s vital signs and lung sounds, and assess for a rash. 5. Obtain informed consent for the unit of blood from the client. 10. The charge nurse in the cardiac critical care unit is making rounds. Which client should the nurse see first? 1. The client with coronary artery disease who is complaining that the nurses are being rude and won’t answer the call lights. 2. The client diagnosed with an acute myocardial infarction who has an elevated creatinine phosphokinase-cardiac muscle (CPK-MB) level. 3. The client diagnosed with atrial fibrillation on an oral anticoagulant who has an International Normalized Ratio (INR) of 2.8.

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4. The client 2 days’ postoperative coronary artery bypass who is being transferred to the cardiac unit.

11. The nurse is preparing to administer digoxin 0.25 mg IVP to a client in severe congestive heart failure who is receiving D5W/0.9 NaCL at 25 mL/hr. Rank in order ofimportance. 1. Administer the medication over 5 minutes. 2. Dilute the medication with normal saline. 3. Draw up the medication in a tuberculin syringe. 4. Check the client’s identification band. 5. Clamp the primary tubing distal to the port.

12. The client is in the cardiac intensive care unit on dopamine, a vasoconstrictor, and B/P increases to 210/130. Which intervention should the intensive care nurse implement first? 1. Discontinue the client’s vasoconstrictor, dopamine. 2. Notify the client’s healthcare provider. 3. Administer the vasopressor hydralazine. 4. Assess the client’s neurological status. 13. The charge nurse is making client assignments in the cardiac critical care unit. Which client should be assigned to the most experienced nurse? 1. The client with acute rheumatic fever carditis who does not want to stay on bed rest. 2. The client who has the following ABG values: pH, 7.35; PaO2, 88; PaCO2, 44; HCO3, 22. 3. The client who is showing multifocal premature ventricular contractions (PVCs). 4. The client diagnosed with angina who is scheduled for a cardiac catheterization. 14. The primary cardiac nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which delegation task warrants intervention by the charge nurse of the cardiac unit? 1. The UAP is instructed to bathe the client who is on telemetry. 2. The UAP is requested to obtain a bedside glucometer reading. 3. The UAP is asked to assist with a portable chest x-ray. 4. The UAP is told to feed a client who is dysphagic. 15. The nurse is administering medications to clients in the cardiac critical care area. Which client should the nurse question administering the medication? 1. The client receiving a calcium channel blocker (CCB) who is drinking a glass of grapefruit juice. 2. The client receiving a beta-adrenergic blocker who has an apical heart rate of 62 beats/min. 3. The client receiving nonsteroidal anti-inflammatory drugs (NSAIDs) who has just finished eating breakfast. 4. The client receiving an oral anticoagulant who has an International Normalized Ratio (INR) of 2.8.

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1.) Ans Answer wer wer: 1. This client may or may not be stable. The client may have “no complaints” at this time, but the nurse must assess this client first to determine whatever the complaint was that brought the client to the ED has stabilized. This client should be seen first. MA MAKIN KIN KING GN NUR UR URSIN SIN SING G DE DECISI CISI CISION ON ONS: S: The test taker should use some tool as a reference to guide in the decisionmaking process. In this situation, Maslow’s Hierarchy of Needs should be applied. Physiological needs have priority over psychosocial ones 2.) Ans Answer wer wer:: 33.. The client in ventricular fibrillation is in a life-threatening situation; therefore, the antidysrhythmic, such as lidocaine or amiodorone, should be administered first MA DECISI MAKIN KIN KING GN NUR UR URSIN SIN SING G DECISI CISION ON ONS: S: The test taker should know which medications are priority, such as lifethreatening medications, insulin, and mucolytics (Carafate). These medications should be administered first by the nurse.

3.)

Answ Answer er 4. The client would not expect the client with congestive heart failure to have pink, frothy sputum because this is a sign of pulmonary edema. This client should be assessed first. MA MAKIN KIN KING GN NUR UR URSIN SIN SING G DE DECISI CISI CISION ON ONSS: The test taker must determine which sign/symptom is not expected for the disease process. If the sign/ symptom is not expected, then the nurse should assess the client first. This type of question is determining if the nurse is knowledgeable of signs/symptoms of a variety of disease processes.

4.) Ans Answer wer wer:: 33.. A new graduate should be able to complete a pre-procedural checklist and get this client to the catheterization lab. MA MAKIN KIN KING GN NUR UR URSIN SIN SING G DE DECISI CISI CISION ON ONS: S: When the test taker is deciding which client should be assigned to a new graduate, the most stable client should be assigned to the least experienced nurse.

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5.)

Answ Answer er 3. A UAP is capable of performing the morning care. This is an appropriate nursing task to delegate MA MAKIN KIN KING GN NUR UR URSIN SIN SING G DE DECISI CISI CISION ON ONS: S: An RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to a UAP. Tasks that cannot be delegated are nursing interventions that require nursing judgment. Remember that in most instances, options with the word “all” (options 1 and 2) can be eliminated because if the test taker can think of one time when some other level of licensure could safely perform the task, then the option automatically becomes wrong. 6.) Answer 2. The case manager’s job is to ensure continuity and adequacy of care for the client. This individual Answer has a “need to know.” MA MAKIN KIN KING GN NUR UR URSIN SIN SING G DE DECISI CISI CISION ON ONS: S: The test taker must be knowledgeable of the role of each member of the multidisciplinary healthcare team as well as HIPAA rules and regulations. These topics will be tested on the NCLEX-RN® exam.

7.) Ans Answer wer 2. The UAP should be instructed to check the telemetry lead placement; this reading cannot be ventricular fibrillation because the client is talking to the nurse over the intercom system. This telemetry is an artifact; therefore, the leads should be checked and the UAP MA MAKIN KIN KING GN NUR UR URSIN SIN SING G DE DECISI CISI CISION ON ONSS: An RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to a UAP. Tasks that cannot be delegated are nursing interventions requiring nursing judgment. 8.) Ans Answer wer 22. The nurse with critical care experience would be the best choice to float to the emergency department. MA MAKIN KIN KING GN NUR UR URSIN SIN SING G DE DECISI CISI CISION ON ONS: S: The nurse needs to know management issues for the RN-NCLEX®. The nurse with experience in certain areas of nursing would be most appropriate to float to the areas with related types of clients, such as critical care and the emergency department.

9.) Corr Correc ec ectt An Answ sw swer: er: 5, 4, 33,, 2, 1 5. The nurse must first obtain informed consent prior to administering the blood product. 4. The nurse needs to complete the pre-transfusion assessment including assessing for any signs of allergic reaction prior to administering the unit of blood. 3. The blood must be hung with Y-tubing and normal saline, and an 18-gauge angiocatheter is preferred. 2. The nurse must check the unit of blood from the laboratory with another nurse and with the client’s blood band. 1. During the first 15 minutes, the blood transfusion must be administered slowly to determine if the client is going

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MA MAKIN KIN KING GN NUR UR URSIN SIN SING G DE DECISI CISI CISION ON ONS: S: This is an alternate type of question included in the NCLEX-RN® blueprint. The nurse must be able to perform skills in the correct order. Obtaining informed consent and assessment should always be the first interventions. 10.) Ans Answer wer wer:: 1 The charge nurse is responsible for all clients. At times it is necessary to see clients with a psychosocial need before other clients who have situations that are expected and are not life threatening. MA MAKIN KIN KING GN NUR UR URSIN SIN SING G DE DECISI CISI CISION ON ONS: S: The test taker must determine if any of the assessment data is normal or abnormal for the client’s diagnosis. If the data is abnormal, then this client should be seen first. If the data is normal then a client with a psychosocial problem is the client the nurse should assess first. 11.) Corr Correc ec ectt An Answ sw swer: er: 3, 2, 44,, 5, 1 3. Because this is less than 1 mL, the nurse should draw this medication up in a 1mL tuberculin syringe to ensure accuracy of dosage. 2. The nurse should dilute the medication with normal saline to a 5- to 10-mL bolus to help decrease pain during administration and maintain the IV site longer. Administering 0.25 mg of digoxin in 0.5 mL is very difficult, if not impossible, to push over 5 full minutes, which is the manufacturer’s recommended administration rate. If the medication is diluted to a 5- to 10-mL bolus, it is easier for the nurse to administer the medication over 5 minutes. 4. The nurse must check two identifiers according to the Joint Commission safety guidelines. 5. The nurse should clamp the tubing between the port and the primary IV line so that the medication will enter the vein, not ascend up the IV tubing. 1. Cardiovascular and narcotic medications are administered over 5 minutes. MA MAKIN KIN KING GN NUR UR URSIN SIN SING G DE DECISI CISI CISION ON ONS: S: This is an alternate type of question that is included in the NCLEX-RN® blueprint. The nurse must be able to perform skills in the correct order.

12.) Ans Answer wer wer:: 1 The nurse should first discontinue the medication that is causing the increase in the client’s blood MA MAKIN KIN KING GN NUR UR URSIN SIN SING G DE DECISI CISI CISION ON ONS: S: The test taker should remember that when the client is in distress, do not assess. The nurse must intervene and take care of the client. If any of the options is assessment data the HCP will need or an intervention that will help the client, then the test taker should not select the option to notify the HCP. 13.) Ans Answer wer wer:: 3 Multifocal PVCs are an emergency and are possibly life threatening. An experienced nurse should care for this client. MA MAKIN KIN KING GN NUR UR URSIN SIN SING G DE DECISI CISI CISION ON ONS: S: The test taker must determine which client is the most unstable and would require the most experienced nurse, thus making this type of question an “except” question. Three clients are either stable or have non–life-threatening conditions

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14.) Ans Answer wer wer:: 4 This client is at risk for choking and is not stable; therefore, the charge nurse should intervene and not allow the UAP to feed this client MA MAKIN KIN KING GN NUR UR URSIN SIN SING G DE DECISI CISI CISION ON ONS: S: This is an “except” question. The test taker could ask which task is appropriate to delegate to the UAP; three options would be appropriate to delegate and one would not be. Remember the RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to the UAP

15.) Ans Answer wer wer:: 11. The client receiving a CCB should avoid grapefruit juice because it can cause the CCB to rise to toxic levels. Grapefruit juice inhibits cytochrome P450-3A4 found in the liver and the intestinal wall. This inhibition affects the metabolism of some drugs and can, as is the case with CCBs, lead to toxic levels of the drug. For this reason, the nurse should investigate any medications the client is taking if the client drinks grapefruit juice. MA MAKIN KIN KING GN NUR UR URSIN SIN SING G DE DECISI CISI CISION ON ONS: S: The test taker must be knowledgeable of medications. In most scenarios, there is no test-taking hint to help the test taker when answering medication questions except common nursing interventions, such as do not administer cardiac medications if client has AP...