NCLEX RN Exam Review Answers

NCLEX RN Exam Review Answers Related

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You have noticed that the last several patients you have cared for have had questionable blood pressure readings from their arterial lines. When checked against cuff pressures, a discrepancy has been noted, and further investigation has revealed faulty transducers. This is not the first product issue with this company. What positive step could you take to help resolve this situation?

  • A. Use the old stock from a previous company
  • B. Verify the cuff pressures every hour to ensure accuracy
  • C. Notify the risk manager
  • D. Form a peer workgroup to evaluate new products
Correct Answer: D

Rationale: Forming a peer workgroup to evaluate new products would be an excellent opportunity for collaboration among peers, management, and the purchasing department. When clinicians are engaged to work toward solutions that address patient care issues, they experience more empowerment and control over their work environments.

Choice A is incorrect because using old stock from a previous company does not address the root cause of the faulty transducers from the current company. Choice B is incorrect as verifying cuff pressures every hour does not directly address the issue of faulty transducers. Choice C is less effective than forming a peer workgroup as it involves only notifying the risk manager without involving a collaborative effort to resolve the product issue.

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A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?

  • A. Tactile hallucinations
  • B. Tardive dyskinesia
  • C. Restlessness and muscle rigidity
  • D. Reports of hearing disturbing voices
Correct Answer: C

Rationale: Benztropine (Cogentin) is an anticholinergic medication used to treat extrapyramidal symptoms, such as restlessness and muscle rigidity, which are common side effects of antipsychotic medications like haloperidol. Tactile hallucinations and reports of hearing disturbing voices are symptoms of schizophrenia that would typically be addressed by the antipsychotic medication (haloperidol) itself. Tardive dyskinesia, a potential side effect of long-term antipsychotic use, would require discontinuation of the antipsychotic medication rather than administration of benztropine.

A family member is complaining that the lights are too dim in the middle of the night when she comes in to visit her husband. What is the most objective response?

  • A. Patients sleep better with the lights dimmed.
  • B. The nightshift nurses prefer to work with less light.
  • C. It's time for him to sleep, and you should, too.
  • D. There's a reason we do that. Let me share a research study with you.
Correct Answer: D

Rationale: The most objective response in this situation is to explain to the family member that there is a specific reason for dimming the lights and offer to share a research study to provide evidence-based information. By doing so, it helps the family member understand that the care provided is based on established practices and research, potentially alleviating her concerns and ensuring that her husband receives appropriate care. Choices A, B, and C do not address the family member's concern or provide a rationale backed by evidence, making them less suitable responses in this context.

Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been placed in the unit walls. Which action would be the most therapeutic response?

  • A. Confront the delusional material directly by telling Gio that this simply is not so.
  • B. Tell Gio that this must seem frightening to him but that you believe he is safe here.
  • C. Tell Gio to wait and talk about these beliefs in his one-on-one counseling sessions.
  • D. Isolate Gio when he begins to talk about these beliefs.
Correct Answer: B

Rationale: The most therapeutic response in this situation is to acknowledge Gio's feelings of fear and validate his experience by expressing empathy ('this must seem frightening to him'). By reassuring Gio that he is safe in the current environment, the nurse can help reduce his anxiety and build trust. Choice A is not recommended as directly confronting delusional beliefs may lead to increased distress and resistance. Choice C delays addressing Gio's concerns and may not provide immediate support. Choice D of isolating Gio can worsen his feelings of paranoia and distrust in the treatment setting.

What is a key principle of patient teaching that must take place to ensure patient safety?

  • A. Family members should be present
  • B. Teaching must be documented
  • C. Understanding must be confirmed
  • D. Teaching should be provided by multiple staff members
Correct Answer: C

Rationale: A key principle of patient teaching that ensures patient safety is the confirmation of understanding. To ensure patient safety, it is crucial to confirm that the patient comprehends the information provided. This confirmation can be achieved by having the patient repeat back the information or demonstrate understanding through return demonstration. Documenting the patient's understanding is essential to track the effectiveness of the teaching session and ensure that the patient is equipped with the necessary knowledge for their safety. Family members being present or having multiple staff members provide teaching may be beneficial in certain situations, but the primary focus should be on confirming the patient's understanding to enhance safety and promote effective learning.

A client with schizophrenia is taking loxapine. Which of the following findings should the nurse identify as the most important to report?

  • A. Spasms of the tongue and face
  • B. Orthostatic hypotension
  • C. Dry mouth
  • D. Increased appetite
Correct Answer: A

Rationale: Spasms of the muscles of the tongue, face, neck, and back are indicative of acute dystonia, an extrapyramidal manifestation associated with loxapine use. Acute dystonia is a serious condition that can lead to airway obstruction and respiratory compromise. Therefore, the nurse should prioritize reporting this finding to prevent potential harm to the client. Orthostatic hypotension, dry mouth, and increased appetite are common side effects of antipsychotic medications but are not as immediately life-threatening as acute dystonia. Monitoring and managing these side effects are essential for the client's overall well-being, but they do not pose the same level of urgency as addressing acute dystonia.

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