NCLEX-RN
NCLEX RN Exam Review Answers
1. A client on lithium has diarrhea and vomiting. What should the nurse do first?
- A. Recognize this as a drug interaction
- B. Give the client Cogentin
- C. Reassure the client that these are common side effects of lithium therapy
- D. Hold the next dose and obtain an order for a stat serum lithium level
Correct answer: D
Rationale: Diarrhea and vomiting are manifestations of lithium toxicity. The priority action for the nurse is to hold the next dose of lithium and obtain an order for a stat serum lithium level to confirm toxicity. This ensures patient safety and prevents further harm. Recognizing it as a drug interaction is not the first step in this scenario. Cogentin is used to manage extrapyramidal symptoms (EPS) associated with antipsychotics, not lithium toxicity. Reassuring the client about these symptoms as common side effects of lithium therapy is inappropriate as they indicate a more serious issue than typical side effects like hand tremors, nausea, polyuria, and polydipsia.
2. You are caring for an infant who is just about 12 months old. Which assessment data is normal for the infant at this age?
- A. The infant had doubled their birth weight at twelve months.
- B. The infant had tripled their birth weight at twelve months.
- C. The mother reports that the infant is drinking 60 mLs per kilogram of its body weight.
- D.
Correct answer: A
Rationale:
3. What does an anti-kickback statute prevent?
- A. It prevents healthcare workers from providing food or hosting parties to celebrate special occasions at work.
- B. It promotes thorough and complete documentation when a client becomes injured.
- C. It forbids giving or accepting gifts to promote or provide referrals for certain services.
- D. It prevents physicians from ordering treatments that may require nursing care beyond the usual amount.
Correct answer: C
Rationale: An anti-kickback statute aims to prevent healthcare providers, clients, consultants, or related organizations from giving or accepting gifts to reward others for referrals of certain services. Choice A is incorrect because providing food or hosting parties at work is not the primary focus of anti-kickback statutes. Choice B is incorrect as it pertains more to documentation practices rather than gift-giving. Choice D is incorrect as it refers to the scope of physician orders and nursing care, not gift exchanges for referrals. The correct answer, as stated, aligns with the purpose of anti-kickback statutes to prevent improper incentives in healthcare relationships.
4. The family of a patient who is receiving therapeutic hypothermia states they do not understand why the patient is being kept so cold. What objective information can you provide to help address their concerns?
- A. Let them talk to another patient who has had the same therapy
- B. Provide research-based information about therapeutic hypothermia
- C. Connect them with the nurse manager
- D. Call the physician and ask him to talk to the family
Correct answer: B
Rationale: Providing research-based information about the benefits of therapeutic hypothermia for their loved one will provide evidence that this is an established therapy with generally positive outcomes. Families are certainly not expected to be familiar with critical care interventions, and their concerns should be addressed with evidence-based data whenever possible. Option A is not appropriate as sharing patient information violates privacy laws and does not address the family's concerns directly. Option C may not directly provide the detailed information the family needs to understand therapeutic hypothermia. Option D involves unnecessary escalation by immediately involving the physician, when providing education and information should be the initial step in addressing the family's concerns.
5. Which of the following clients have barriers to accessing healthcare?
- A. A 36-year-old client who must use a wheelchair for mobility
- B. A 44-year-old client who is visiting the United States on a visa from India
- C. An 81-year-old client who is unable to drive
- D. All of the above
Correct answer: D
Rationale: All of the provided clients have barriers to accessing healthcare. Clients with physical limitations, such as the 36-year-old client using a wheelchair, may face challenges in mobility and accessing healthcare facilities. The 44-year-old client from India visiting the United States on a visa may encounter barriers related to language, cultural differences, or insurance coverage. The 81-year-old client who is unable to drive may struggle with transportation to healthcare appointments. Therefore, all three clients face different barriers to accessing healthcare, making 'All of the above' the correct answer.
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