NCLEX RN WITH NGN EXAM / NGN NCLEX RN
ACTUAL EXAM 1 LATEST 2024/2025 COMPLETE 100
APPROVED QUESTIONS AND WELL ELABORATED
ANSWERS (CORRECT VERIFIED ANSWERS) LATEST
UPDATED VERSION |GUARANTEED SUCCESS
(REVISED EXAM)
The nurse witnesses the collapse of a child while outdoors. The child is
not breathing and has a pulse of 50/min. The nurse calls emergency
services and initiates rescue breathing. After 2 minutes of rescue
breaths, the child is still not breathing and is pale with a pulse of
30/min. What is the nurse's next action?
Answer- Initiate chest compressions
Rescue breathing is performed at a rate of 1 breath every 2-3 seconds.
If the pulse remains <60/min and there are signs of poor perfusion (skin
pallor), the nurse should initiate chest compressions and reassess the
pulse every 2 minutes
The charger nurse is responsible for making room assignments multiple
clients. Which pari of client assignments to a shared room is
appropriate?
Answer- Client who had a bowel resection 1 day ago and client with
asthma exacerbation.
,When making room assignments, it is important to remember that a
client with an active or suspected infection should not be paired with a
client who has a fresh surgical wound or is immunocompromised. A
client having an asthma exacerbation does not have an infection and is
not at risk for spreading infection to a client who had a recent bowel
resection surgery.
The clinic nurse is assessing a client who is being treated for depression
and suicidal ideation. Which client statement best indicates that the
client is not currently at risk for suicide?
Answer- "I plan to attend my grandchild's graduation next month"
Clients receiving treatment for depression and suicidal ideation must be
carefully monitored for indications of increasing suicidal intent. During
a client interview, the nurse should assess:
- Access to psychiatric medications
- Availability of help during a crisis (counselor, family)
- Future goals and plans
- Home and environment risks
- Overall affect and level of energy
- Possible access to weapons
,Clients who articulate long-term personal goals and family milestones
are less likely to attempt death by suicide
The nurse is caring for a client who had an anterior wall myocardial
infarction 2 days ago. The telemetry technician notifies the nurse at
8:30 AM that the client is in ventricular trigeminy. What is the nurse's
priority intervention?
Answer- 1. Administer potassium supplement
In ventricular trigeminy, premature ventricular contractions (PVCs)
occur every third heartbeat. Myocardial injury (eg, myocardial
infarction) predisposes the client to ectopy (eg, PVCs), which increases
the client's risk for lethal dysrhythmias (eg, ventricular tachycardia).
PVCs are caused and/or exacerbated by hypoxia, electrolyte
imbalances, emotional stress, stimulants, fever, and exercise.
This client's morning laboratory results show hypokalemia (potassium
<3.5 mEq/L [3.5 mmol/L]); therefore, the priority is treatment of the
underlying cause of the ectopy by administering the prescribed
potassium replacement (Option 1). Health care providers (HCPs) often
prescribe electrolyte replacement algorithms to clients at risk for
electrolyte imbalances (eg, myocardial injury, receiving diuretics) unless
a contraindication exists (eg, serum creatinine >1.5 mg/dL [133
µmol/L], anuric, weight <99.2 lb [45 kg]).
, The nurse cares for a client with a terminal disease who created a do
not attempt resuscitation (DNAR) directive. The client stops breathing
and loses their pulse. The client's adult child states, "Please, do
whatever you can to save them!" Which intervention is appropriate?
Answer- Explain the client's resuscitation directive to the client's child
Clients can create a do not attempt resuscitation (DNAR) directive
instructing that CPR and other life-saving measures be withheld. With
an advance directive in place, the client's wishes should be followed,
even if they conflict with the wishes of loved ones
The nurse in the cardiac intensive care unit receives report on 4 clients.
Which client should the nurse assess first?
Answer- Client who underwent coronary artery stent placement via
femoral approach 3 hours ago and is reporting severe back pain
A client who undergoes percutaneous coronary intervention (PCI) and
intracoronary stent placement using the femoral approach is at
increased risk for retroperitoneal hemorrhage. Administration of
antithrombotic drugs before, during, and after PCI can exacerbate
potentially life-threatening bleeding from the femoral artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign),
hematoma formation, and diminished distal pulses can be early signs of
bleeding into the retroperitoneal space and require immediate
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