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NCLEX 3000 EXAM STUDY QUESTIONS AND ANSWERS |WITH COMPLETE RATIONALES
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NCLEX 3000 EXAM STUDY QUESTIONS AND ANSWERS |WITH COMPLETE RATIONALES The nurse is checking a client's I.V. infusion rate at the beginning of her shift. The nursing Kardex states that the infusion should run at 125 ml/hour. To verify the I.V. drip rate, the nurse must know the drip factor, whi...

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  • October 7, 2024
  • 107
  • 2024/2025
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EMILLYCHARLOTTE 2024/2025 ACADEMIC YAER ©2024 EMILLYCHARLOTTE. ALL RIGHTS RESERVED
FIRST PUBLISH SEPTEMBER 2024




NCLEX 3000 EXAM STUDY
QUESTIONS AND ANSWERS |WITH
COMPLETE RATIONALES

The nurse is checking a client's I.V. infusion rate at the beginning of her shift. The nursing Kardex states

that the infusion should run at 125 ml/hour. To verify the I.V. drip rate, the nurse must know the drip

factor, which is:




1. the number of milliliters in one drop.


2. the number of drops in one milliliter.


3. the number of drops per minute to be infused.


4. the number of drops per hour to be infused. - Answer✔✔-2. RATIONALES: The drip factor is the

number of drops in one milliliter, not the number of milliliters in one drop. The drip rate refers to the

number of drops infused per minute. The flow rate is the number of milliliters, not the number of drops,

infused per hour.


The nurse transcribes the following physician's order onto the client's medication record:


September 15, 2005


Administer 10 gtt of timolol maleate (Timoptic) ophthalmic solution AU daily.




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,EMILLYCHARLOTTE 2024/2025 ACADEMIC YAER ©2024 EMILLYCHARLOTTE. ALL RIGHTS RESERVED
FIRST PUBLISH SEPTEMBER 2024


John Bloom, MD


Which components of the medication order should the nurse question?




Select all that apply:




1. Number of drops


2. Route


3. Type of medication


4. Signature


5. Frequency of administration


6. Date - Answer✔✔-1, 2. RATIONALES: To ensure that medication errors don't occur, the nurse must

follow the "six rights" of safe medication administration: right drug, right dose, right route, right time,

right client, and right documentation. The number of drops is too great to be instilled into the eye. The

medication wouldn't be effective because the dose is too large and would run out. Normally, the

physician orders 1 or 2 drops to be instilled into the eye. As the order is written, the eye medication

would be administered in both ears (AU). Abbreviations should be avoided when possible to prevent

medication errors.


The nurse administers albuterol (Proventil), as prescribed, to a client with emphysema. Which finding

indicates that the drug is producing a therapeutic effect?




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,EMILLYCHARLOTTE 2024/2025 ACADEMIC YAER ©2024 EMILLYCHARLOTTE. ALL RIGHTS RESERVED
FIRST PUBLISH SEPTEMBER 2024


1. Respiratory rate of 22 breaths/minute


2. Dilated and reactive pupils


3. Urine output of 40 ml/hour


4. Heart rate of 100 beats/minute - Answer✔✔-1. RATIONALES: In a client with emphysema, albuterol is

used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its

therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no

effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse,

not therapeutic, effect.


The nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe.

How should the nurse proceed?




1. Irrigate continuously until the solution becomes clear or all of the solution has been used.


2. Moisten the area around the wound with normal saline after the irrigation.


3. Apply a wet-to-dry dressing to the wound after the irrigation.


4. Rapidly instill a stream of irrigating solution into the wound. - Answer✔✔-1. RATIONALES: To wash

away tissue debris and drainage effectively, the nurse should irrigate the wound until the solution

becomes clear or all of the solution has been used. After the irrigation, the nurse should dry the area

around the wound; moistening it promotes microorganism growth and skin irritation. When the area is

dry, the nurse should apply a sterile dressing, rather than a wet-to-dry dressing. The nurse always should

instill the irrigating solution gently; rapid or forceful instillation can damage tissues.



Page 3/107

, EMILLYCHARLOTTE 2024/2025 ACADEMIC YAER ©2024 EMILLYCHARLOTTE. ALL RIGHTS RESERVED
FIRST PUBLISH SEPTEMBER 2024


A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide

which instruction?




1. "Take your temperature every 4 hours."


2. "Increase your fluid intake to 2 to 3 L per day."


3. "Apply an antibacterial dressing to the incision daily."


4. "Be aware that your urine will be cherry red for 5 to 7 days." - Answer✔✔-2. RATIONALES: Increasing

fluid intake flushes the renal calculi fragments through — and prevents obstruction of — the urinary

system. Measuring temperature every 4 hours isn't needed. Lithotripsy doesn't require an incision.

Hematuria may occur for a few hours after lithotripsy but then should disappear.


A 2-year-old child with a tracheostomy suddenly becomes diaphoretic and has an increased heart rate,

an increased respiratory rate, and a decreased oxygen saturation level. Which of the following should be

the nurse's first action?




1. Suction the tracheostomy.


2. Turn the child to a side-lying position.


3. Administer pain medication.


4. Perform chest physiotherapy. - Answer✔✔-1. RATIONALES: Diaphoresis, increased heart rate,

increased respiratory effort, and decreased oxygen saturation are signs that mucus is partially occluding

the airway. The child needs suctioning immediately to prevent full occlusion. Turning the child to a side-

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