EAQ NCLEX-RN Exam

The registered nurse delegates the task of feeding a 90-year-old client suffering from dysphagia to the unlicensed assistive personnel (UAP) who has previously performed this task. The client died of choking and aspiration after being fed by the UAP. Which right of delegation was violated for this client?

The nurse is performing a primary assessment on a client who fell down the stairs. Which priority nursing action benefits the client?
Monitoring the client for hemorrhage
Anticipating for rapid blood component administration
Inserting 16-gauge at the antecubital area for intravenous line
Infusing warm intravenous fluids at a rate of 8 drops per minute

What is the priority nursing intervention for a client during the immediate postoperative period?

Sodium bicarbonate

Sodium bicarbonate decreases the potassium level. It works by increasing the movement of potassium from the blood into the cells. The body stores potassium inside the cells, with only a small amount in the bloodstream. Electrical defibrillation should not be applied indiscriminately to the client in asystole. This is not only fruitless but also detrimental, eliminating any possibility of recovering a rhythm. Furosemide is a diuretic commonly used for heart failure. There is no indication for anticoagulation therapy.

A client with the diagnosis of myocardial infarction is admitted to the intensive care unit, and a pulmonary artery catheter is inserted for hemodynamic monitoring. Therapy is administered to maintain the pulmonary artery wedge pressure at 16 to 20 mm Hg to optimize stroke volume. The client's pulmonary artery wedge pressure increases to 24 mm Hg. What does the nurse consider as the most likely reason for this change?

The nurse is caring for some clients with chronic anemia who are on blood transfusion therapy. The nurse notices that one of the clients requires immediate treatment. Which client is the nurse addressing in this situation?
Client with itching
Client with flushing
Client with pruritus
Client with wheezing

A client is admitted to the hospital with a diagnosis of heart failure and acute pulmonary edema. The healthcare provider prescribes furosemide 40 mg intravenous (IV) stat to be repeated in 1 hour. What nursing action will best evaluate the effectiveness of the furosemide in managing the client's condition?

The nurse is caring for a client who is on a cardiac rhythm monitor. The nurse notes that the client's P waves are of normal configuration and that each P wave is followed by a QRS complex. All intervals are normal as well, but the client's heart rate is 112 beats per min. How will the nurse interpret this rhythm?

The nurse is performing triage based on tier levels for a group of clients who were impacted by a tornado. Which client conditions should receive higher priority?

Select all that apply.
Active hemorrhage
Respiratory distress
Chest pain with diaphoresis
Stroke
skin rash
Displaced or multiple fractures

After an acute episode of upper gastrointestinal (GI) bleeding, a client vomits undigested medications and reports severe epigastric and abdominal pain. The client has absent bowel sounds, rigid abdomen, a pulse rate of 134, and shallow respirations of 32 per minute. The primary healthcare provider has been contacted. What should be the nurse's next priority?

A client who has been experiencing chest pain and vomiting for several hours is admitted to the hospital with a diagnosis of myocardial infarction. The client is transferred immediately to the cardiac intensive care unit. The client's potassium level is below the expected range. Considering this laboratory result, what should the nurse monitor the client's electrocardiogram (ECG) for?

A client is admitted to the burn unit with partial-thickness burns over 30% of the body surface area. Twenty-four hours later, the client, who has an intravenous (IV) line of 5% dextrose in saline running, has tremors, twitching, and signs of disorientation. During the past hour the urinary output was 110 mL. What should the nurse do next?

A client is admitted with 50% of the body surface area burned. The nurse caring for the client 48 hours after admission reviews the client's laboratory results: urine specific gravity, 1.015; urine output, 50 mL/hr; hematocrit, 42 (0.42 volume fraction); albumin, 3.6 g/dL (36 g/L); and pulmonary arterial wedge pressure, 10 mm Hg. Which conclusion will the nurse draw based upon the laboratory results?

The nurse is caring for a client with wound dressings to the burns on 55% of the body. The dressing changes are very painful, and the client rates them 7/10 on the pain scale. The client has morphine 2 mg to be administered by mouth every 2 hours as needed. When planning the client's care, when does the nurse decide to administer the medication?

A male client who sustained a head injury is admitted to the hospital. The client is able to open his eyes to pain stimulus and to localize the pain, but the verbal response is found to be confused. What would be the score of the client based on the Glasgow coma scale. Record your answer as a whole number.

The nurse notices that the client's cardiac rhythm has become irregular; QRS complexes are missing after some of the P waves. The nurse also notes that the PR intervals become progressively longer until a P wave stands without a QRS; then the PR interval is normal with the next beat and starts the cycle again with each successive PR interval getting longer until there is a missing QRS. The nurse notifies the primary healthcare provider. Which rhythm does the nurse share with the provider?

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A client presenting to the emergency department with chest pain and dizziness is found to be having a myocardial infarction and subsequently suffers cardiac arrest. The healthcare team is able to successfully resuscitate the client. Lab work shows that the client now is acidotic. How does the nurse interpret the cause of the acidosis?