NCLEX RN Practice Test

The correct answer is true. High-risk medications, such as anticoagulants, insulin, and chemotherapy agents, carry a significant risk of causing harm if administered incorrectly. Verifying these medications with another licensed healthcare provider helps minimize the chances of dosing errors, incorrect patient administration, or other critical mistakes. This practice not only ensures patient safety but is also a standard protocol in many healthcare facilities. Other answers, such as suggesting no secondary verification is necessary, are incorrect because they disregard the protocols designed to mitigate risks associated with these medications.

The correct answer is to check the system for any obstruction or kink as mechanical issues (e.g., blocked or repositioned tubing) are common causes of increased airway pressure. This approach prioritizes a systems-based evaluation before proceeding to interventions such as suctioning or manual ventilation. Increasing oxygen settings without identifying the underlying cause is inappropriate because it does not address the problem. Suctioning should only follow if there are indications of secretion build-up after clearing the system.

Screening for visual acuity is the most appropriate answer in this scenario because the client’s symptoms are directly related to changes in vision, which are common in middle-aged and older adults due to conditions like presbyopia and cataracts. Visual acuity tests, such as the Snellen chart or near vision tests, help determine the client’s ability to see objects clearly at various distances and can guide appropriate referrals or corrective measures. While other screenings, such as retinal exams or nutritional evaluations, may be relevant depending on the client's history, they don't directly address the client's reported symptoms. Mental health screenings, though important, are unrelated to the client's current concern.

The correct answer focuses on tailoring education to the specific health risks prevalent in the community, such as type 2 diabetes and heart disease. By incorporating strategies like promoting healthy diet changes and regular exercise, the intervention directly targets modifiable risk factors. The incorrect answers represent interventions that, while potentially beneficial, do not specifically address the modifiable health risks highlighted in the scenario. Encouraging medication adherence assumes individuals are already diagnosed and on medication, which excludes a significant portion of the population that may not yet be diagnosed. Providing general stress management techniques does not adequately address the physiological contributors to the conditions in this population. Finally, organizing screenings alone does not directly educate the population about actionable changes to reduce their risks.

At 9 months, infants are typically able to pull themselves to a standing position, one of the gross motor developmental milestones. It shows the child has achieved muscle strength, coordination, and development appropriate for their age. Smiling back at caregivers is a normal social milestone seen as early as 6-8 weeks, not specific to 9 months. Rolling over from back to front is typically expected by 6 months. Saying simple single words, such as 'mama' or 'dada,' may occur around 12 months, but this milestone is not expected by 9 months. Therefore, 'pulling to a standing position' is the correct answer.

The correct answer emphasizes both client safety and effective use of the walker to prevent falls. It encourages the client to maintain a clear walking path, which reduces the risk of tripping or stumbling due to clutter. Encouraging rubber-tipped ends on walkers, installing grab bars, and removing rugs are also important safety precautions but go beyond the scope of this specific teaching session. These aspects might require additional instructions or referrals for home modifications.

The correct answer is to notify the healthcare provider about the client’s recent weight gain and breathing difficulties. These signs indicate worsening fluid retention and potential decompensation of CHF, which requires prompt medical evaluation to possibly adjust medications or treatment. Assessing dietary sodium intake is important but does not directly address the acute symptoms of worsening CHF. Education about daily weight monitoring is beneficial, but the situation demands immediate action to address the client’s compromised status. Increasing diuretic dosage independently would exceed the nurse’s scope of practice and could pose risks without provider approval.

This statement is true. Using a cold solution during ear irrigation can lead to dizziness, vertigo, or nausea. This occurs because cold solutions stimulate the vestibular system within the inner ear, which controls balance and spatial orientation. To avoid complications, the irrigation solution should be warmed to body temperature, approximately 98.6°F (37°C).

Age-appropriate cancer screenings, such as a colonoscopy for individuals over 50, are essential aspects of preventive care. Colon cancer is highly treatable when caught early, and national guidelines strongly encourage regular screening starting at age 50. Although other answers may involve important preventive measures, they do not align specifically with the highest priority or guidelines for the client’s age group. For example, a mammogram is more age-specific for women aged 40–74, and general hydration or skin care is not tied to national preventive health priorities.

The correct answer is an assessment for depression. Changes in appetite, social withdrawal, and mood are potential symptoms of adolescent depression, which can significantly impact a client's well-being if left unaddressed. Screening for depression can help identify depressive symptoms early, enabling appropriate interventions. While screening for eating disorders might also seem relevant due to changes in appetite, the broader behavioral changes and withdrawal suggest depression might be more likely. A vision screening or a nutritional screening would not directly address the presenting symptoms and are therefore not the most appropriate choices in this scenario.

Colorectal cancer screening is recommended to begin at age 45 for individuals at average risk. This is important for the early detection and prevention of cancer, as early-stage cancers are often more treatable. The other options target different priorities or age groups: breast cancer screening typically begins at age 40 or 50 based on individual risk factors and guidelines, bone density testing is usually reserved for individuals over 65 or who have risk factors for osteoporosis, and prostate cancer screening often begins at 50 for those at average risk.

Ensuring frequent rounding is the best choice because it proactively monitors the client's needs, reducing the likelihood of them attempting unsafe movements. Bed alarms are useful but not a substitute for effective human supervision and timely assistance. Educating the client about their fall risk is helpful but does not replace active prevention measures. Placing a fall-risk placard assists the team but does not directly reduce immediate risk.

The correct answer emphasizes the importance of therapeutic communication in addressing non-verbal cues. A tense jaw, crossed arms, and lack of eye contact may indicate stress, discomfort, or reluctance to verbally express feelings. Acknowledging the client's body language and inviting an open conversation establishes rapport and trust. Failing to explore these cues could result in unaddressed concerns or hindered communication. Suggesting sedation or waiting for the client to initiate a discussion would ignore the opportunity to address the client's potential stress or discomfort promptly.

Encouraging the client to voice their feelings and offering emotional support addresses their psychosocial concerns while fostering open communication. It validates their feelings and helps build trust, which is critical in end-of-life care. By contrast, urging the client to discuss their feelings with their family too soon may not account for their readiness to do so. Shifting the focus to pain management or encouraging silence may not address their current emotional needs.

The correct answer focuses on actively listening to the client's concerns without judgment while using an empathetic and open-ended statement. This approach encourages the client to share more about their feelings, facilitates trust, and demonstrates the nurse's commitment to understanding the client’s perspective. Offering advice, suggesting solutions, or prematurely minimizing their concerns does not promote effective therapeutic communication and may lead the client to feel dismissed.