1.    Answer D.  Administering eye drops should be done in the lower conjunctival sac to ensure that the medication gets to eye. Option A is not done since some medications can irritate the cornea when placed directly in to it. Options B and C are not practiced because doing so cannot hold the medication into the eye. Its tendency would be, the medication would run out or flow out of the eyes.
2.    Answer A. Infiltration happens when the intravenous fluid does not enter the veins, instead it is diffused in the areas outside the vein which explains why the area is swollen and cool to touch. Option B happens when there is there is an inflammation of the vein in the site. It is characterized by pain, swelling, redness and it is warm to touch. Option C is manifested by pain, swelling, warm to touch, redness and fever is present in the client. Option D is expected when the client complains of feeling pain in the IV site and that you can see in the IV tubing that it is filled with air.
3.    Answer B. It is a priority nursing action to first assess the client’s IV site before doing anything. Once there is a report of pain in the site, plus edema and erythema, we check for the patency of the IV site, if it is not patent, then we discontinue the IV and apply warm compress to the IV site to lessen swelling. Options A and D are incorrect because such actions will not relieve the client from pain, edema and erythema. Option C is not indicated because there is no accurate indication that there is a bacterial infection in the site.
4.    Answer B. Quantity= desired dose/ available dose       0.125/ 0.25 = 0.5 tab. The nurse should dispense ½ tablet of Digoxin. Options A, C and D are all incorrect answer.
5.    Answer B. 41.66 or 42 gtts/min           
6.    Answer D. When a nurse is caring for quite a number of patients, to prevent the spread of infections among patients, she should know who are the possible carrier of infections and those who are at risk of acquiring one. Options A, B and C are inappropriate infection preventions that are indicated in this situation.
7.    Answer A. Stool for ova and parasites does not require a sterile technique because we are after for the presence of ova and parasites. And if we are looking for the presence of bacteria in the stool, sterile technique is not still utilized because normally there will be a lot of bacteria in the stool. Options B, C and D require a sterile technique in order to identify what bacterial growth is present in the specimen.
8.    Answer C. The patient is at greater risk of wound infection when he is punctured by a nail in the foot. He is at risk for acquiring tetanus infection once he is not given with tetanus toxoid immunization. The wound the nail creates is quite deep thus there is a great risk for infection. In the case of Option A, patients with colostomy is often given with antibiotics. Options B and D are incorrect because the wound created is not quite deep.
9.    Answer C. The skin is the first line of defense of the body against the infections. In cases of burns more than 20% of the body, this defense is weakened thus the person is greatly predisposed to developing different kinds of infection. Burns does not only affect the ability of the skin to defend the body but it also alters the immunity of the body. Options A, B and D may predispose a patient from the development of infections but cannot be considered as great as compared to burns.
10.    Answer C. Heat loss is achieved through different methods. Conduction happens when there is a direct contact of a material in the skin to achieve heat loss. In this case heat loss is achieved with the use of cooling blanket. Option A is achieved when body heat is diffused away from the body into the air via skin. Option B is achieved by moving air away from the body to replace the warmth the body has with the use of a fan. Option D is achieved with the use of water such as in tepid sponge baths.
11.    Answer C. The stages of grief includes: Denial, Anger, Bargaining, Depression and Acceptance. The stage of denial is when the patient is unable to acknowledge the existence of the diagnosis. In this stage, the patient would seek more opinions from other doctors because she cannot accept the fact of her diagnosis. Options A and D are an example of the stage anger, in which she asks a lot of questions regarding the reason of her sickness. Option D shows the acceptance of the patient.
12.    Answer A. Touching to provide support is a form of therapeutic communication. The use of touch reinforces caring feelings. Option B is non therapeutic. Option C is incorrect because the nurse is not in the position to tell the patient’s family of her prognosis. It is only done by the patient or when the patient requests the nurse to do so. Option D may correct but is not the best answer indicated in this situation.
13.    Answer C. Mrs. Estrada is undergoing the process of depression which is a normal in coping with the grief process. In order to be therapeutic for this patient, the nurse should accept this behavioural adaptation of the patient, since it is just normal. Options A, B and D are non therapeutic because this conditions do not allow the normal process of grieving.
14.    Answer C. The patient is experiencing fear because she herself has seen how her father died in the same age as she has in the present. Options A, B and D may be correct but are not indicated in the situation presented.
15.    Answer B. Bargaining is the stage when the patient tries new things in order for her to lengthen her life. She is willing to try therapies ranging from the conventional to non conventional methods of treating her cancer. Other options do not describe the grieving stage that Mrs. Estrada is experiencing.
16.    Answer B. The Licensure of Registered Professional Nurses protects its main consumers which are the patients. Other options are not the reason as to why nurses undergo licensing.
17.    Answer C. Incident reports are filled out in order to record details of unusual events occurring in the hospital and care of patients. In this case, the incident report is filled out in order to have an available data for quality control analysis and in the future when dealing with legal liabilities. Options A, B and D are incorrect because these are not the reason as to why nurses fill out incident reports.
18.    Answer A. Assault is threatening or attempting to inflict injuries to the patient. The verbalization of the nurse clearly shows that it is a case of an assault. Option B is touching the patient without consent. This is done by pinching or slapping the patient. Options C and D are forms of violations that the nurse can commit to a patient in line with the patients profession.
19.    Answer B. This is a case where the nurse committed an assault as manifested by the threatening behaviour of the nurse. Option A is achieved when you speak ill of a person. Option B is putting the threatening behaviour into action. Option D is committed when one talks ill of another through writing it in a published form.
20.    Answer C. Living will is a legal document that an individual uses to make known his wishes to prolong his life. It is also known as advanced directives. In this case, a living will gives consent to perform life sustaining medical intervention to prolong life in cases of emergency. Other options presented are incorrect because they do not describe what a living will is all about.
21.    Answer C. Consents allow the physician to do the medical procedures indicated for the patient. Prior to procedure, it is the doctor’s responsibility to obtain the patient’s consent and it is the responsibility of the nurse to let the patient sign the consent prior to the surgical procedure. Consent unsigned is like consent not given so it is a must that the nurse should tell the situation to the doctor performing the surgery. Options A, B and D are incorrect because they violate the legalities of the consent.
22.    Answer B. The owner of the chart is the patient himself so it is a must that before authorizing any individual to view the chart, authorization should secured and have someone review the chart with the patient’s physician cousin. Options A, C and D are the incorrect way of dealing such situations involving the patient’s chart.
23.    Answer C. When restraints are applied, it is a must for the nurse to assess the quality of the patient’s skin where the restraint is applied. The priority assessment should be done by assessing the patient’s capillary refill so as to ensure circulation of the extremity. Capillary refill of less than two seconds shows that there is a good circulation in that area. Options A, B and D are signs that the restraints applied are having negative effects to the patient’s extremity.
24.    Answer A. It is the preferred answer because right there in then you will be able to stop the discussion of the patient’s case in front of a lot of people. Option B may be correct because you are saving from humiliation the nursing assistance but it is not the preferred answer because doing so will allow further discussion of the case and more harm will be committed. Option C may be correct because in the first place you are not their immediate superior but not appropriate in this situation because it will further the discussion of the case thus allowing a lot of people to overhear it. Option D is the worst thing to do since you will not do anything to prevent it from happening.
25.    Answer A.Good Samaritan Act protects those who choose to lend a hand during emergency situations. In this act, the nurse is not liable to any laws once she helps an injured individual during this emergency. Options B, C and D are incorrect because these do not explain what the act is all about.

Situation: One important legal and safe nursing responsibility is concerned with administration of medications.

1.    A pediatric client has been diagnosed with conjunctivitis. The nurse is to administer eye drops 4 times a day. The nurse should administer the medication on to which of the following areas?
a.    Center of the cornea
b.    Sclera by the inner canthus
c.    C. Sclera by the outer canthus
d.    Lower conjunctival sac

2.     While assessing the client’s intravenous (IV) line, the nurse notes that the area is swollen and cool, causing the client discomfort. The nurse suspects which of the following problems:
a.    Infiltration
b.    Phlebitis
c.    Infection
d.    Air embolism

3.     The client is receiving a 5% dextrose in 0.45% NaCl intravevenously (IV) and report pain at the site, the nurse assesses the site and notes erythema and edema. What would be the appropriate action for the nurse to take?
a.    Slow the infusion rate
b.    Discontinue the IV and apply a warm compress to the IV site
c.    Apply antibiotic ointment to the IV site
d.    Gently pull back the IV access device to reposition it within the vein

4.    A patient’s medication order is to take digoxin 0.125 mg p.o. q.i.d. The nurse has on hand Lanoxin 0.25 mg tablet. The best course of action is to:
a.    Dispense 1 ½ tab
b.     Dispense ½ tab
c.     Dispense 2 tablets
d.     Return the medication to the pharmacy

5.    The patient is ordered 2000 ml of Lactated Ringer’s over 12 hours. The drop factor is 15gtts/ml. The nurse will regulate the IV to how many gtts/min?
a.    28 gtts/min
b.    42 gtts/min
c.    56 gtts/min
d.    14 gtts/min

Situation: The nurse is caring for a group of hospitalized patients.

6.    What should the nurse do first to prevent patient infections?
a.    Provide small bedside bags to dispose of used tissues
b.    Encourage staff to avoid coughing near patients
c.    Administer antibiotics as ordered
d.    Identify patients at risk

7.    The nurse must collect the following specimens. Which specimen collection does not require the use of surgical aseptic technique?
a.    Stool for ova and parasites
b.    Specimen for a throat culture
c.     Urine from a retention catheter
d.    Exudate from a wound for culture and sensitivity

8.    The nurse identifies that the greatest risk for a wound infection exists for a patient with a:
a.    Surgical creation of a colostomy
b.     First degree burn on the back
c.     Puncture of a foot by a nail
d.     Paper cut on the finger

9.    The nurse understands that the factor that places a patient at the greatest risk for developing an infection is:
a.    Implantation of a prosthetic device
b.    Presence of an indwelling catheter
c.    Burns more than twenty percent of the body
d.    Multiple puncture sites from laparascopic surgery

10.    The nurse is caring for a patient with high fever secondary septicemia. When the physician orders a cooling blanket, the nurse understands that it is used to achieved heat loss via:
a.    Radiation
b.    Convection
c.    Conduction
d.    Evaporation

Situation: The nurse is caring for Mrs. Estrada who has recently diagnosed with advanced cancer.

11.    Which statement reflects Kubler-Ross stage of denial in the grief process?
a.    “Why this have to happen to me now?”
b.    “My daughter will live with my sister after I am gone”
c.    “Maybe they mixed up my records with someone else’s”
d.    “How could this happen to me when I quit smoking cigarettes?”

12.     After the physician has informed Mrs. Estrada that her cancer is inoperable and the prognosis is poor, the patient begins to cry. The nurse should:
a.    Touch the patient’s hand to provide support
b.    Leave the room to give the patient privacy to cry
c.    Telephone the patient’s family to inform them of the diagnosis
d.    Ask the patient how she feels to encourage ventilation of feelings

13.    Mrs. Estrada became withdrawn and depressed. The nursing action that is most therapeutic is:
a.    Assisting the patient to focus on positive thoughts daily
b.    Explaining that the patient still accomplish goals
c.    Accepting the patient’s behavioral adaptation
d.    Offering the patient advice when appropriate

14.    Which is the most appropriate inference made by the nurse when a patient says, “I’m the same age as my father when he died. Am I going to die of my cancer?” The patient is experiencing:
a.    Grieving associated with perceived impending death
b.    Powerlessness associated with feelings of loss of control
c.    Fear associated with perceived threat to biological integrity
d.    Ineffective coping associated with inadequate psychological resources

15.    Mrs. Estrada is now willing to try new therapies. The nurse identifies that the patient is in what stage of Kubler-Ross’ stages of grieving?
a.    Denial
b.    Bargaining
c.    Depression
d.    Acceptance

Situation: The nurse should be aware of the legal principles associated with nursing practice.

16.    Licensure of Registered Professional Nurses is required necessarily to protect:
a.    Nurses
b.    Patients
c.    Common law
d.    Health care agencies

17.    A patient falls while getting out of bed unassisted. When completing and Incident Report, the nurse understands that it main purpose is to:
a.    Ensure that all parties have an opportunity to document what happened
b.    Help establish who is responsible for the incident
c.    Make available data available for quality control analysis
d.    Document the incident on the patient’s chart

18.    The nurse says. “If you do not let me do this dressing change, I will not let you eat dinner with other residents in the dining room”. This is an example of :
a.    Assault
b.    Battery
c.    Negligence
d.    Malpractice

19.    An anxious patient repeatedly uses the call bell to get the nurse to come to the room. Finally the nurse says to the patient, “If you keep ringing, there will come a time I won’t answer the bell.”This is an example of:
a.    Slander
b.    Assault
c.    Battery
d.    Libel

20.    A patient asks the nurse, “What is a Living Will?” the nurse should respond that it is a document that:
a.    Instructs a physician to withhold/withdraw life-sustaining procedures if death is near
b.    Enables a person to request medication to end life in a humane and dignified manner
c.    Gives consent to perform life-sustaining medical intervention during an emergency
d.    Wills ones organs to help others who need a transplant to sustain life

Situation: As a nurse you must be responsible for the needs of your client.

21.    Ms. R has been medicated for her surgery. The operating room (OR) nurse, when going through the client’s chart, realizes that the consent form has not been signed. Which of the following is the best action for the nurse to take?
a.    Assume it is emergency surgery and the consent is implied
b.    Give the consent form and have the client sign it
c.    Tell the physician that the consent form is not signed
d.    Have a family member sign the consent form

22.    Ms. R is a client on your medical-surgical unit. His cousin is a physician and wants to see the chart. Which of the following is the best response for the nurse to take?
a.    Hand the cousin the client’s chart to review
b.    Ask Ms. R to sign an authorization, and have someone review the chart with the cousin
c.    Call the attending physician and have the doctor speak with his cousin
d.    Tell the cousin that the request cannot be granted

23.    Ms. R has had both wrists restrained because she is agitated and pulls out her IV lines. Which of the following would the nurse observe if Ms. R is not suffering any ill effects from the restraints? That:
a.    She has difficulty moving her fingers and making a fist
b.    Her skin is reddened where the limits were tied around her wrist
c.    Ms. R’s capillary refill is less than two seconds
d.    The client complains of numbness and tingling in her hand

24.    The nurse is in the hospital’s public cafeteria and hears two nursing assistants talking about Ms. R in 406. They are using her name and discussing intimate details about her illness. Which of the following actions is best for the nurse to take?
a.    Go over and tell the nursing assistants that their actions are inappropriate, especially in  public place
b.    Wait and tell the assistants later that they were overheard discussing the client. Otherwise, they might be embarrassed.
c.    Tell the nursing assistants’ supervisor about the incident. It is the supervisor’s responsibility to address the issue
d.    Say nothing. It is not the nurse’s job and she is not responsible for the assistants’ actions

25.    A nurse comes up a motor vehicle accident when driving to work. The nurse administers care to the people involved. Under the Good Samaritan Act, the nurse could be liable:
a.    For nothing, any action is covered
b.    For gross negligence
c.    For not providing the standard care found in the hospital
d.    For not stopping and offering care

Answers and Rationale

More nclex review questions coming up.

Answers and Rationale