NCLEX Key Exam Guide Questions and Integral Marking Scheme version 2024/2025
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Course
Nclex
Institution
Nclex
NCLEX Key Exam Guide Questions and Integral Marking Scheme version 2024/2025
Telemetry nurse notifies med surg that they need to give them a pt. Which pt should go to med surg unit?
- mag of 1.6
- scheduled for cardiac cath next morning
- digoxin of 2.4
- chest discomfort reported during ca...
NCLEX Key Exam Guide Questions and
Integral Marking Scheme version 2024/2025
Telemetry nurse notifies med surg that they need to give them a
pt. Which pt should go to med surg unit?
- mag of 1.6
- scheduled for cardiac cath next morning
- digoxin of 2.4
- chest discomfort reported during cardiac stress test - correct
answer mag of 1.6 (wrong, picked d)
Rationale: mag should be 1.3-2.1 so is stable, cardiac cath isn't
stable- need to monitor rhythms, digoxin level is 0.5-2.0 so this is
unstable and high, chest discomfort during test indicates poor
response to workload and is unstable pt
Hcp prescribes metoclopramide to be given for pt 30mins before
cisplatin is given. Pt asks nurse why metoclopramide is given.
What is best response?
- meto will prevent or reduce side effects caused by cis
- meto increases cis effectiveness
- cis prevents or reduces meto side effects
- cis increases meto effectiveness - correct answer meto
prevents or reduces side effects of cis (correct)
Rationale: meto (helps with stomach/esophagus issues) is
prescribed to reduce cis side effects (antineoplastic)
,Med surg nurse to patient ratio is 1:10. First action by nurse?
- document situation in writing
- refuse pt assignment
- delegate tasks to lpn
- notify nursing supervisor - correct answer notify the nursing
supervisor (correct)
Rationale: this is the priority action of this unsafe situation, this
will allow other nurses to be floated to this unit to help
Pt with ms says, "i have poor concentration and difficulty
pronouncing words" nurse notes pt has slow speech and is
slurred. Which pt statement indicates further teaching is
needed?
- sit up straight when i talk and i will feel confident
- i will turn tv off when speaking and look at who i am talking to
- during conversation i will build up to my most important points
- if words fail me, i will draw a picture - correct answer during
a conversation, i will carefully build up to my most important
points (correct)
Rationale: pt needs to be taught to make most important points
first so fatigue doesn't onset before them
Young adult scheduled for emergency appendectomy. Hcp
explains the procedure and now the pt states "no one is removing
any organs from my body because it is against my religious
beliefs. I'm leaving" the pt's mom insist the pt gets the operation.
Which response does nurse make to pt?
, - i am going to apply restraints
- let us contact the chaplain to mitigate situation
- iv diazepam will help to calm your nerves before the procedure
- it is your decision to reduce medical treatment - correct
answer it is your decision to refuse medical treatment (correct)
Rationale: competent pt has the right to make personal choices
without interference, diazepam is a chemical restraint!!!
Lpn says to rn, " you may want to check on pt recently recently
diagnosed with pancreatic cancer. I'm not sure how well things
are going" nurse enters room and finds pt quietly looking out the
window. Pt doesn't look at the nurse. Which is the most
appropriate response by the nurse?
- sleep problems are common during stressful times. Have you
been sleeping?
- tell me what you know about your diagnosis and the treatment
you will receive
- how would you describe your overall health status up to this
time in your life?
- how have you handled any health problems you experienced in
the past - correct answer tell me what you know about your
diagnosis and the treatment you will receive (wrong, picked d)
Rationale: most important to determine the pt's perception of
health problem and this is an open ended questions, asking about
coping with past problems doesn't address the current problem,
overall health status may influence coping but this option doesn't
address concern
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