NAXLEX OA (All Correct Answers!)

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

Whether they contain fruit or pulp

3 multiple choice options

The nurse is caring for a client with type 2 diabetes mellitus who had surgery for a large bowel resection with a colostomy placement. The client has now developed hyperglycemia which require self injections of insulin after discharge. When designing the postoperative plan of care, which outcome statement should the nurse use?

The client will adhere to the medication regimen after discharge

3 multiple choice options

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

"I can only give medical Information to your child because they are legally an adult."

3 multiple choice options

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

Risk for impaired skin integrity

3 multiple choice options

The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

"While touching the client's forearm, asks, "Would you like to talk about it?"

3 multiple choice options

The nurse is interviewing a client with lower abdominal pain and dysuria and needs to question the client about sexual activity. Which approach is best for the nurse to use?

Begin with questions that are less sensitive in nature

3 multiple choice options

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

Positive external places

3 multiple choice options

The nurse is caring for a client one week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

A well approximated incision site

3 multiple choice options

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

Bend the arm by flexing the ulnar to the humerus

3 multiple choice options

A nurse stops at a motor vehicle collision to provide help for a victim who is trapped in an overturned running vehicle. The nurse turns off the engine key, and asks the client to wiggle the fingers because the client's head is impinged on the roof and the neck is bent to the left shoulder. After Emergency Medical Services (EMS) arrive, the nurse reports that the victim is conscious, but is not able to talk, and then the nurse leaves the scene. Which legal action can be taken in this situation?

Good Samaritan immunity

3 multiple choice options

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

Puts on new gloves when entering a client's room

3 multiple choice options

The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that. the client understands proper crutch walking?

Progresses to foot touchdown and weight bearing of affected leg

3 multiple choice options

Which client assessment should the nurse perform during nasopharyngeal suctioning?

Observe the client's skin and mucous membranes

3 multiple choice options

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

Ensure bevel of the needle is pointing up

3 multiple choice options

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Raises the head of the bed to 60 degrees

3 multiple choice options

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2L/min via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

Verify placement of pulse oximeter

3 multiple choice options

An older adult tells the clinic nurse about frequently awakening during the night and often not being able to go back to sleep. Which action(s) should the nurse suggest to the client to help improve sleep? (Select all that apply.)

Establish a regular time for going to bed and getting up

Avoid drinking caffeinated beverages late in the day

3 multiple choice options

The nurse notices a male client grimacing as he moves from the bed to the chair, but when asked about his pain he denies having any pain. Which intervention should the nurse implement first?

Ask the client what is making him grimace

3 multiple choice options

The nurse is teaching a client about use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

Washes hands before handling the needle and syringe

3 multiple choice options

A client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer. The client is suspected to have a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Monitor the client's white blood cell count

Send wound drainage for culture and sensitivity

Institute contact precautions for staff and visitors

1 multiple choice option

A client is admitted to the rehabilitation unit following a cerebrovascular accident, which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which is the best first response by the nurse?

Dressing must be a frustrating experience for you

3 multiple choice options

The nurse is obtaining a systolic blood pressure by palpation while inflating the cuff the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

Inflate the blood pressure cuff to 120 mm Hg

3 multiple choice options

The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

Reporting a change in a client's condition to the healthcare provider

3 multiple choice options

An unlicensed assistive personnel (UAP) is assigned to feed a client who has received a prescription to institute droplet precautions for a bacterial meningitis infection. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client

3 multiple choice options

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

Perform oropharyngeal suctioning

3 multiple choice options

A client with chronic fecal incontinence is crying because of being embarrassed for not getting to bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?

Assist to a bedside commode 30 mins after meals

3 multiple choice options

CASE STUDY:

History and Physical: The client is a 64-year-old female with a 3 day history of cough and chest pain. She recently began to have difficulty breathing . Cardiac causes of chest pain were ruled out with laboratory tests . The client will be admitted for presumed pneumonia . The client has a history of type 2 diabetes mellitus . She takes insulin glargine 12 units in the morning and 10 units in the evening .

What medication error prevention techniques would have helped to avoid this error? Select all that apply.

Document all medication in the electronic record as soon as it is given

Involve and educate clients in medication administration

3 multiple choice options

CASE STUDY:

History and Physical: The client is an 81-year-old male with a history of hypertension, heart failure, and seasonal allergies. He was admitted for pneumonia 3 days ago and is currently in the intermediate care unit. He lives with his daughter and her family. She reports that he is active and compliant with his medication regime. He walks the dog every morning and has no signs of cognitive decline at home.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Actions to take:

1. Place a hydrocolloid dressing over the area

2. Request a prescription for antibiotic ointment from the physician

Potential conditions:

Stage 2 pressure injury

Parameters to monitor:

1. Nutritional intake

2. Skin integrity

A client tells the nurse about starting an aerobic workout program to lose weight and help with insomnia. The client states that it still takes over an hour to fall asleep at night. Which action should the nurse implement?

Ask the client to describe the exercise schedule that he has been following

3 multiple choice options

A client is admitted with reports of shortness of breath, dyspnea on exertion, and chest pressure. The healthcare provider prescribes a medic is unfamiliar to the nurse. When checking the drug handbook, the nurse reads that the prescribed amount is an unusually large dose. Which action should the nurse take?

Verify the prescribed dosage with healthcare provider

3 multiple choice options

When providing health teaching to older adult clients, which action is most important for the nurse to implement?

Use everyday language when explaining issues

3 multiple choice options

The nurse is inserting a urinary catheter that has been prescribed for the client. When the tip of the catheter re-emerges at insertion site, which action should the nurse take next?

Obtain a new catheter

3 multiple choice options

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter the previous shift. Which information is most important for the nurse to obtain?

When the client voided following catheter removal

3 multiple choice options

A client is in contact isolation due to stage IV coccyx wound infected with methicillin resistant staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client's room. In which order should the nurse perform the interventions?

Restart the IV, perform tracheostomy care, change coccyx dressing

3 multiple choice options

The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. What action should the nurse implement?

Use positive reinforcement to affirm that the procedure is being performed correctly.

3 multiple choice options

The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, "Streptomycin 1 gram/2.5 mL." How many milliliters should the nurse administer?

(Enter numerical value only. If rounding is required, round to the nearest tenth.)

0.5 mL

3 multiple choice options

A nurse is reviewing a client's laboratory results and notes a blood glucose result of 104 mg/dL (5.8 mmol/L). The reference range is 74 to 106 mg/dL (4.1 to 5.9 mmol/L). Which action should the nurse take?

B. Start a high-fiber diet

The glucose level is within the normal range but on the higher end. Promoting a high-fiber diet can help maintain stable glucose levels and support long-term glucose control, especially if the client is at risk for impaired glucose tolerance.

3 multiple choice options

A nurse is reviewing a client's orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?

Make the client NPO

3 multiple choice options

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

Provide a back rub at bedtime

3 multiple choice options

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

C. Determine the client's activity tolerance:

Assessing the client's activity tolerance is an appropriate next step in the nursing process. While the observed upright posture and smooth, steady gait are positive indicators of mobility, understanding the client's overall activity tolerance provides valuable insight into their functional capacity and ability to perform activities of daily living safely. This assessment helps tailor care interventions to meet the client's individual needs and promotes optimal independence and quality of life.

3 multiple choice options

The nurse is teaching the client to self-administer a dose of low-molecular-weight heparin (LMWH) SUBQ. Which instruction should the nurse include?

Inject the abdominal area at least 2 in (5.1 cm) from the umbilicus

3 multiple choice options

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse constitutes a tort?

Placing a client in restraints without having a healthcare provider's order

3 multiple choice options

The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a counter top. Which action should the nurse implement?

Communicate the colleague's activities to the unit charge nurse

3 multiple choice options

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

Ask another nurse to witness the medication being discarded

3 multiple choice options

Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?

Instruct the client in use of the prescribed patient-controlled analgesia (PCA) pump

3 multiple choice options

When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?

Reassess and turn the client in 30 minutes

3 multiple choice options

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?

The technique is intended to maintain straight spinal alignment

3 multiple choice options

A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 1 to 10. After placing a call to the healthcare provider, which action should the nurse implement?

Instruct the client to use guided imagery and slow rhythmic breathing

3 multiple choice options

The nurse is caring for a adult with obstructive sleep apnea. The nurse should recognize the client is at greater risk for the development of which complication?

Hypertension

3 multiple choice options

The healthcare provider prescribes nasogastric tube (NGT) insertion for a client with a postoperative ileus. During insertion, the client begins to gag. Which action should the nurse take?

Give the client a few sips of water to drink.

3 multiple choice options

The nurse receives a new prescription to administer oxygen at 3L / minute via a nasal cannula to maintain an oxygen saturation between 90 and 100% for an adult client. The nurse obtains an oxygen saturation reading 85% and after repositioning the oximeter on a different finger, obtains a second reading of 87% Which action should the nurse take next?

Securely place the prongs of the cannula in the nostrils

3 multiple choice options

The healthcare provider prescribes cefixime oral suspension 200 mg PO twice a day for an older adult who has difficulty swallowing tablets. The bottle is labeled, "Cefixime for Oral Suspension, USP 100 mg per 5 mL." How many mL should the nurse administer daily? (Enter numerical value only.)

20

3 multiple choice options

An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first?

Determine the size and depth of skin breakdown over the sacral area

3 multiple choice options

A client is requesting medicine for pain 30 minutes after receiving morphine sulfate 5 mg intravenously. Which intervention should the nurse implement next?

Reassess the client and the level of pain

3 multiple choice options

CASE STUDY:

History and Physical: The emergency department (ED) is caring for a 9-month-old male client who was brought to the ED for nasal congestion, cough, fever, and difficulty breathing. The client and his sister both attend daycare daily while their parents are at work. The sister has been acting a bit run down but has not had a fever or oxygen deficit.

For each statement, click to indicate whether the statement is true or false.

A. Hand washing only needs to be performed when exiting the client's room. FALSE

B. This client requires contact and droplet precautions. TRUE

C. A gown and gloves should be worn any time there is potential for contact with secretions. TRUE

D. A mask should always be worn when in the client's room. TRUE

E. This client would require a private room if admitted. TRUE

CASE STUDY:

History and Physical: The client is a 36-year-old female who is in the clinic today for insomnia. She reports that she started having trouble sleeping 2 years ago after her father's death. She has no medical problems and has never had surgery. She takes an oral contraceptive and a multivitamin daily. She does not smoke but drinks 1 to 2 glasses of wine every evening.

Which other recommendation(s) could the nurse give to help the client have better sleep? Select all that apply.

Avoid alcohol in the evening

Try to go to bed and awaken at the same time every day

Avoid naps

3 multiple choice options

CASE STUDY:

History and Physical: The client is a 56-year-old woman who had an anteroposterior spinal fusion 2 days ago. She tolerated the procedure well and has been progressively increasing her walking distance.

Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.

Assess for sources of pain other than the surgical site

Give a dose of 2.5 mg of morphine

Consult with the surgeon about the pain level

Helping the client walk around the room

3 multiple choice options

The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

Ask the client to describe the intensity of the pain being experienced

3 multiple choice options

While suctioning a client's nasopharynx, the nurse observes that the patient's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?

Complete the intermittent suction of the nasopharynx

3 multiple choice options

When conducting diet teaching for a client who is on a postoperative clear-liquid diet, which foods should the nurse encourage the client to consume? Select all that apply.

Carbonated drinks, gelatin, broth

Water, tea, ice chips

3 multiple choice options

When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first?

Position the client supine for a few minutes

3 multiple choice options

The home health nurse is reviewing the personal care needs of an elderly client who lives alone. Which client assessment findings indicate the need to assign unlicensed assistive personnel (UAP) to provide routine foot care and file the client's toenails? (Select all that apply.)

Shuffling gait

Syncope when bending

Hand tremors

1 multiple choice option

A small, round raised area appears under the client's skin as the practical nurse administers an intradermal medication. What action should the nurse take?

Document the site where the medication was given

3 multiple choice options

What equipment should the nurse use to most accurately measure a 2 mL dose of a viscous liquid solution to be administered orally?

A 3 mL syringe

3 multiple choice options

A client reports pain, numbness, and tingling sensations in the lower legs. How should the nurse document this finding?

Neuropathic pain

3 multiple choice options

When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?

Release and reinsert the flowmeter in the wall outlet

3 multiple choice options

The nurse is evaluating the fluid balance of the client who was admitted yesterday with dehydration and who has been receiving iv fluids since admission. An increase in which parameter indicates to the nurse that the client is rehydrating?

Urinary output

3 multiple choice options

The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the clients foot in a basin of warm water placed on the bed. What action should the nurse take?

Remove the basin of water from the client's bed immediately

3 multiple choice options

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Degree of neurosensory impairment

3 multiple choice options

After an intravenous antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

Notify the healthcare provider

3 multiple choice options

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

Smoking cessation

3 multiple choice options

The nurse observes a decrease in a client's level of consciousness. Which vital sign should the nurse obtain first?

Respiratory rate

3 multiple choice options

CASE STUDY:

History and Physical: The client is a 44-year-old with cerebral palsy who is non-verbal and has a severe intellectual disability. He requires total care at home, which is provided by his two sisters, a home health nurse, and an unlicensed home health aide. The client is currently in the hospital for a lower respiratory infection.

Identify from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Potential conditions: Overflow urinary incontinence

Actions to take:

1. Provide skin care

2. Place an incontinence containment product under the client

Parameters to monitor:

1. Intake and output

2. Post-void residual

A client who had surgery 3 days ago is sitting with head of bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?

Lower the bed prior to helping the client to move up in bed

3 multiple choice options

The nurse is providing dietary education to a client newly diagnosed with Type 2 diabetes mellitus. Which information should the nurse provide?

Counting carbohydrates will ensure glucose levels stay within a normal range

3 multiple choice options

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

Reference Range: Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Determine apical pulse rate and rhythm

2 multiple choice options

The nurse is assessing a client who reports a 3 day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing?

Reference Range:

Urine Specific Gravity [1.005 to 1.03]

1.035

3 multiple choice options

After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

Enter the occurrence after the 1400 notes and identify as "late entry"