Exam (elaborations)
NClex Readiness Part 1 exam
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NClex Readiness Part 1 NClex Readiness Part 1 NClex Readiness Part 1
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NClex Readiness Part 1What intervention is essential prior to starting a client on atorvastatin therapy?
1. Assessing for muscle strength
2. Assessing the client's dietary intake
3. Determining if the client is on digoxin therapy
4. Monitoring liver function tests - verified answer 2. Assessing the client's dietary intake
The nurse provides discharge instructions to a client at 14 weeks gestation who has received a
prophylactic cervical cerclage. Which client statement indicates an understanding of teaching?
1. "I need to be on bed rest for the duration of my pregnancy."
2. "I will notify my health care provider if I start having low back aches."
3. "Pelvic pressure is to be expected after cerclage placement."
4. "The cerclage will be removed once my baby is at 28 weeks." - verified answer 2. "I will notify
my health care provider if I start having low back aches."
During the first prenatal assessment, the client reports the last normal menstrual period starting on
March 1 and ending on March 5, but also slight spotting on March 23. The client had unprotected
intercourse on March 15. Using Naegele's rule, what is the estimated date of birth?
1. December 8
2. December 12
3. December 22
4. December 30 - verified answer 1. December 8
A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic
lupus erythematosus. Which intervention related to the drug's adverse effects should the nurse
include in the teaching plan?
1. Have an ophthalmologic examination every 6 months
2. Take the medication on an empty stomach
3. Take vitamin D and calcium supplements
4. Wear a Medic Alert bracelet - verified answer 1. Have an ophthalmologic examination every 6
months
,The nurse is caring for a client diagnosed with Guillain-Barré syndrome (GBS) after a recent
gastrointestinal (GI) illness. Monitoring for which of the following is a nursing care priority for this
client?
1. Diaphoresis with facial flushing
2. Hypoactive or absent bowel sounds
3. Inability to cough or lift the head
4. Warm, tender, and swollen leg - verified answer 3. Inability to cough or lift the head
The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse
assess for a pulsus paradoxus?
1. Check for variation in amplitude of QRS complexes on the electrocardiogram strip
2. Compare apical and radial pulses for any deficit
3. Measure the difference between Korotkoff sounds auscultated during expiration and throughout
the respiratory cycle
4. Multiply diastolic blood pressure (DBP) by 2, add systolic blood pressure (SBP), and divide the
result by 3; [(DBP x 2) + (SBP)]/3 - verified answer 3. Measure the difference between Korotkoff
sounds auscultated during expiration and throughout the respiratory cycle
The nurse is developing a nutritional plan for a 6-month-old who has recently been started on solid
foods. Which of the following recommendations has the highest priority in the plan?
1. Canned baby food is more expensive than food prepared at home
2. Finger foods can be introduced before the child has teeth
3. New foods should be introduced at least 5-7 days apart
4. Rice cereal can be mixed with cow's milk to increase nutritional intake - verified answer 3.
New foods should be introduced at least 5-7 days apart
A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis.
The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value
would indicate that the heparin infusion needs to be turned off?
1. Hematocrit of 30% (0.30)
2. Partial thromboplastin time of 110 seconds
3. Platelet count of 80,000/mm3 (80 x 109/L)
4. Prothrombin time of 11 seconds - verified answer 2. Partial thromboplastin time of 110
seconds
,An 84-year-old client with oxygen-dependent chronic obstructive pulmonary disease is admitted
with an exacerbation and steady weight loss. The client has been in the hospital 4 times over the last
several months and is "tired of being poked and prodded." Which topic would be most important for
the nurse to discuss with this client's health care team?
1. Need for discharge to a skilled nursing facility
2. Nutritional consult with instructions on a high-calorie diet
3. Option of palliative care
4. Physical therapy prescription to promote activity - verified answer 3. Option of palliative care
The nurse working on the inpatient psychiatric unit is preparing to administer 9:00 AM medications
to a client. The medication administration record is shown in the exhibit. On assessment, the client is
tremulous, exhibits muscle rigidity, and has a temperature of 101.1 F (38.4 C). Which action should
the nurse take?
1. Give all medications, including acetaminophen, and reassess in 30 minutes
2. Hold the haloperidol, give acetaminophen, and reassess in 30 minutes
3. Hold the haloperidol and notify the health care provider (HCP) immediately
4. Hold the hydrochlorothiazide and notify the HCP immediately - verified answer 3. Hold the
haloperidol and notify the health care provider (HCP) immediately
A client, who has been hospitalized for 3 days with major depressive disorder, has stayed in the
room and not gotten out of bed except for toileting. The nurse enters the room to remind the client
that breakfast will be served in the dining room in 20 minutes. The client says, "I'm not hungry and I
don't feel like doing anything." What is the best response by the nurse?
1. "I will help you get ready; then we can walk to the dining room together."
2. "I'll have breakfast brought to your room."
3. "It's okay. You can join us when you are ready."
4. "You'll feel better when you get up." - verified answer 1. "I will help you get ready; then we
can walk to the dining room together."
The public health nurse conducts a program at the community senior citizen center about preventing
falls at home. Which statement made by a participant indicates that further education is needed?
1. "I bought a new nightlight for the hallway to the bathroom."
2. "I feel so much more secure wearing my electronic fall alert device."
3. "I walk in my stockings at home because it helps to relieve my bunion pain."
, 4. "My daughter helped me secure the small, thin rug in my kitchen with strong tape." - verified
answer 3. "I walk in my stockings at home because it helps to relieve my bunion pain."
A 15-year-old parent brings a 4-month-old infant for a well-baby checkup. The parent tells the nurse
that the baby cries all the time; the parent has tried everything to keep the infant quiet but nothing
works. What is the priority nursing action?
1. Advise the parent to give a pacifier whenever the infant cries
2. Ask the parent to describe what is done to "keep the baby quiet"
3. Assess the infant's pattern and frequency of crying
4. Explore the parent's support system - verified answer 3. Assess the infant's pattern and
frequency of crying
A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting fires
and flooding in collapsed buildings. Multiple victims arrive at the triage area. Which client should the
nurse care for first?
1. Client with charred, leathery skin over entire back, chest, and legs
2. Client with cool skin, shivering from sitting in water until rescued
3. Client with diabetes who was unable to take prescribed insulin today
4. Client with high-pitched, crowing inspiratory respirations - verified answer 4. Client with high-
pitched, crowing inspiratory respirations
The charge nurse in the cardiac intensive care unit responds to a client room where a resuscitation
effort is in progress. The client's immediate family member refuses to leave the room. How should
the charge nurse handle this situation?
1. Call security to escort the family member to the waiting room
2. Have the family member stand or sit in an area that is not in the staff's way
3. Inform the family member that relatives are not allowed in rooms during emergency situations
4. Let the family member stay and assign a staff person to explain what is happening - verified
answer 4. Let the family member stay and assign a staff person to explain what is happening
The nurse prepares to administer clozapine to a client with schizophrenia. Which client statement
would require priority investigation before administering the medication?
1. "I have gained a few pounds since I started this medication."
2. "I have had a sore throat for 3 days and feel feverish today."
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