Week 2 NCLEX Questions

Week 2 NCLEX Questions 1. A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? a) Record the time and length of the seizure b) Restrain the client’s extremities. c) Place the client in a prone position. d) Monitor the client’s hemoglobin level. - Rationale: During a seizure, it is important that the nurse document the time and length of the seizure because you want to know if there are any problems in the brain activity. All the other choices are not appropriate to do during seizures. 2. A nurse is assisting with conducting a home hazard assessment for a client who has dementia. Which of the following indicates an understanding of home safety? a) An extension cord is secured under a rug. b) The edges of stairs are marked with brightly colored tape. c) A toaster is plugged in when not in use. d) The water heater is set to 55 degrees C (131 degrees F). - Rationale: If the patient has dementia, having brightly colored tape at the edges of stairs will prevent them from tripping and help them see the steps clearly. Option A is not correct because the rug is a tripping hazard. Option C is not correct because that is considered a fire hazard. Option D is not correct because they can burn themselves. 3. A nurse is planning to implement the Transforming Care at the bedside plan on a medical-surgical unit. Which of the following interventions should the nurse include in the plan? a) Require the nurse to spend 50% of their time at the bedside of clients. b) Perform change-of-shift report at the nurses’ station. c) Complete client rounds every 4 hours. d) Use a standardized communication tool. - Rationale: The nurse should use a standardized communication tool because it provides adequate care to clients and helps to avoid any confusion. It’s not A because you want to spend at least 60% of their time at the patient’s bedside. It’s not B, because you want to report at the patient’s bedside. It’s not C because the rounds should be completed every 2 hours. 4. A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? a) Pallor b) Cyanosis c) Jaundice d) Erythema - Rationale: The nurse should recognize cyanosis as an immediate intervention because it indicates hypoxia, which means tissues are not getting enough oxygen and poor circulation. 5. A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? a) “I will place the client on their side.” b) “I will go to the nurse’s station for assistance.” c) “I will note the time that the seizure began.” d) “I will prepare to insert an airway.” - Rationale: During a seizure, it’s important to stay with the patient and use the call light to get assistance. 6. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? a) Aim the hose as the base of the fire. b) Squeeze the handle of the extinguisher. c) Remove the safety pin from the extinguisher. d) Sweep the hose from side to side to dispense material. - Rationale: When you’re using a fire extinguisher, you want to remember the acronym P.A.S.S. which means: (1) pull the pin (2) aim at the base of the fire (3) squeeze the handle (4) sweep the extinguisher from side to side covering the area of the fire 7. A nurse in a provider’s clinic is taking a client’s age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process? a) Planning b) Evaluation c) Assessment d) Implementation - Rationale: Assessment is the correct answer because this is where you collect the patient’s data which includes age, height, weight, and vital signs. 8. A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first? a) Document the client’s food allergies in the medical record. b) Ask the client to identify the specific food allergies. c) Monitor the clients for indications of anaphylaxis d) Have epinephrine available for administration. - Rationale: When asking about allergies, it’s important to know their specific food allergies and their reactions to food allergies in order to know which ceratin foods are life-threatening to them. 9. During a team meeting, a staff nurse recommends placing a client, who is confused and wanders during the night, in restraints. Which of the following responses about the use of restraints should the nurse manager make? a) “Restraints can be used if a client’s family member requests them.” b) “Restraints are a safe method for preventing clients from falling.” c) “Restraints are considered a part of routine care.” d) “Restraints are used to prevent harm to clients and others.” - Rationale: The answer is D because you want to think about the nurse’s safety and other people’s safety. 10. A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take? a) Assign the client to a private room. b) Keep 4 side rails up while the client is in bed. c) Monitor the client at least once every hour. d) Request a PRN prescription for restraints. - Rationale: The nurse should monitor the client at least once every hour because it was mentioned that the client is at risk of falling, so it’s important to keep a close eye on them. It’s not A because it’s not really necessary for them to get a private room. It’s not B, because having 4 side rails up is considered a form of restraint. It’s not D, because PRN is not allowed for restraints.