nclex practice questions Flashcards

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1. An adult client is placed in behavioral restraints. What is the longest time a single written order can cover?
2. Within its time limits, how long in total can an original restraint or seclusion order be renewed?
3. Once restraint or seclusion has started, how soon must a physician or licensed independent practitioner see and evaluate the client?
4. A provider wants an as-needed order for wrist restraints in case a client becomes aggressive overnight. Why can't the nurse accept it?
5. When a restraint really is the only viable option, when should it be removed?
6. A confused, nonviolent client keeps pulling at an IV line, and soft wrist restraints are applied. Is this a medical or a behavioral restraint?
7. A client is kicking staff and threatening to hurt others, and restraints are applied. What type of restraint is this?
8. When does raising the side rails count as a restraint?
9. Name interventions a long-term care unit can use instead of restraints.
10. Diversion has not calmed a restless client. Which further measures still count as alternatives to restraints?
11. After restraints are applied, which basic needs must the nurse make sure are still met?
12. Which physical complications can the immobility caused by restraints lead to?
13. How can a restraint itself cause a fall or a death?
14. What is seclusion?
15. A client feels light-headed every time they stand up. Which fall risk factor does this point to?
16. What device should the nurse use when helping a client transfer or walk?
17. Where should a hospitalized client's cane or walker be kept?
18. A client has just been helped back into bed. Which three safety steps finish the transfer?
19. Name the three categories of transmission-based precautions.
20. Which hand hygiene method should staff use when caring for a client with C. difficile infection?
21. How can antibiotic treatment lead to C. diff diarrhea?
22. Why do infection control measures target the links in the chain of infection?
23. A nurse is stuck by a used needle. What should happen first?
24. What are the most common causes of blood-borne pathogen exposure for nurses?
25. Which two methods of hand hygiene are accepted?
26. Which concepts does a nurse use to decide which client need comes first?
27. On Maslow's pyramid, which needs take top priority?
28. Besides Maslow and the ABCs, what else does the nurse weigh when ranking client problems?
29. What does the primary survey check at every client encounter?
30. List the components of the nursing process.
31. Which mnemonic helps a nurse write an outcome statement with all five required components?
32. A client becomes anxious, restless, and newly confused. Which oxygenation problem can these be early signs of?
33. Is cyanosis an early or a late sign of hypoxia?
34. An adult's resting heart rate is 112. What oxygenation problem can this be an early sign of?
35. What SpO2 target range is often used for a client with COPD?
36. A client is short of breath. How does raising the head of the bed to high Fowler's help?
37. In Fowler's position, at what angle is the head of the bed placed?
38. Why is an incentive spirometer commonly prescribed after surgery?
39. How does pursed-lip breathing help a client with dyspnea?
40. Which clients are at risk for aspiration that could lead to pneumonia and hypoxia?
41. Why is swallowing food dangerous for a client with dysphagia?
42. What is the most dangerous adverse effect of opioid analgesics?
43. Who should be given naloxone?
44. Which effects should the nurse keep monitoring for in a client receiving opioids?
45. Over a client's sacrum, the skin is intact with a localized area of redness that does not blanch. What stage of pressure injury is this?
46. A heel wound shows partial-thickness skin loss with exposed dermis. What stage of pressure injury is it?
47. A pressure injury has full-thickness tissue loss with visible fat, but no exposed cartilage, tendon, ligament, muscle, or bone. What stage is it?
48. What separates a Stage 4 pressure injury from a Stage 3?
49. Why is a deep Stage 4 pressure injury often less painful than expected?
50. Why can a Stage 1 pressure injury be hard to detect on darkly pigmented skin?
51. What does the Braden Scale measure?
52. To help prevent shear, at what angle should a client's position be kept, when appropriate?
53. For a bed-bound client, how high should the head of the bed be raised, and how often should they be turned?
54. Which signs and symptoms are expected with hyperkalemia?
55. If hyperkalemia keeps worsening, what can the ECG abnormalities progress to?
56. A client taking a potassium-wasting diuretic has had several days of vomiting. Which electrolyte imbalance is the client at risk for?
57. Which signs and symptoms suggest hypokalemia?
58. Which symptoms are expected with hyponatremia?
59. What can cause hyponatremia?
60. Tapping over the facial nerve makes the client's facial muscles twitch. What is this sign, and what does it suggest?
61. A hand spasm develops after a blood pressure cuff is kept inflated above systolic pressure for three minutes. What is this sign?
62. How can prolonged immobilization cause hypercalcemia?
63. Which findings are expected with hypermagnesemia?
64. Which type of IV solution is used to raise blood pressure in a client with fluid volume deficit?
65. Is 0.45% sodium chloride an isotonic, hypotonic, or hypertonic solution?
66. What are hypotonic IV fluids used to treat?
67. A hypertonic solution containing sodium is infusing. Which lab value should be monitored closely?
68. Name common causes of deficient fluid volume.
69. Which routine measurement gives important clues about a client's fluid balance?
70. How many bowel movements per week typically leads to a diagnosis of constipation?
71. If constipation is suspected, where should the nurse palpate for stool?
72. What expected outcome is set when treating constipation?
73. An older adult has normal bladder control but arthritis makes it hard to reach the toilet in time. What type of incontinence is this?
74. A client with an infection suddenly becomes confused. Is this more consistent with delirium or dementia?
75. How does dementia progress over time?
76. Once the cause of delirium is found, how is it treated?
77. What is the most common surgical complication in older adults?
78. A client with Alzheimer's becomes agitated and confused as daylight fades each evening. What is this called?
79. What do the letters in SBAR stand for?
80. English is not a client's primary language. What should the nurse arrange before teaching?
81. A client wears glasses and hearing aids. What should the nurse check before talking with them?
82. What are the two main sections of HIPAA?
83. What makes a client's consent informed?
84. Who signs informed consent if the client is a minor or has been deemed incompetent?
85. When interviewing a client about pain, which type of question helps the client elaborate?
86. A family begins grieving when a loved one receives a terminal diagnosis, before any death. What type of grief is this?
87. What is the common name for terminal secretions at the end of life?
88. Why is polypharmacy a safety concern?
89. What is the leading cause of legal blindness in people over 60?

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