NCLEX RN Practice Test

The correct approach to eye irrigation involves allowing the fluid to flow from the inner canthus (near the nose) outward to the outer canthus. This helps prevent the spread of contaminants from one area of the eye to another or to the opposite eye. Incorrect options, such as flushing toward the inner canthus or directly onto the cornea, increase the risk of spreading infections or causing additional irritation to sensitive structures of the eye.

The correct answer is to verify the prescription with the prescribing physician. When the medication label and the electronic health record (EHR) contain discrepancies, confirming with the prescriber ensures the correct medication is administered and protects the client from potential harm. Administering the medication without clarification risks medication error. Researching independently in pharmacology references without direct confirmation leaves room for misinterpretation and does not adhere to the nursing process. Holding the medication without addressing the issue also delays appropriate treatment and does not resolve the problem.

The correct answer ensures the nurse addresses a potential underlying cause of the symptoms and minimizes the risk of serious complications. Clear wound drainage might indicate a seroma, surgical site issues, or other underlying problems, while symptoms of light-headedness could suggest changes in hydration or circulation. Placing the client flat helps stabilize circulation via enhanced venous return, reducing the immediate risk of hypotension and further complications. Other options are appropriate but do not address the priority in this specific scenario. For example, notifying the healthcare provider is important, but the nurse should first stabilize the client before escalating care. Increasing oral fluids is a longer-term intervention but does not address the current symptoms, and a neurological assessment is not the most relevant action for this context.

The correct answer lists specific warning signs such as fever above 100.4°F, foul-smelling discharge, and heavy bleeding with clots, all of which may indicate serious post-partum complications like infection or hemorrhage. It provides clear and actionable advice for when to seek medical attention. The second option is incorrect because mild fatigue and uterine cramping are common parts of postpartum recovery unless they become severe or worsen over time. The third option is incorrect as spotting alone, especially in small amounts, may be normal and does not always require follow-up unless it is accompanied by other concerning symptoms. The fourth option is also incorrect because changes in lochia color are expected as a normal part of the healing process unless accompanied by other significant symptoms such as fever or odor.

The correct answer focuses on understanding and addressing the client’s expressed concerns by providing a physical and emotional environment conducive to reducing their anxiety. This approach respects the client’s autonomy and need for control over their environment. Encouraging adaptation with relaxation techniques or distractions may be helpful tools but fail to resolve the underlying concern of the shared space. Simply explaining the standard practice of shared rooms and assuring monitoring prioritizes institutional policies over the individual’s psychological needs, which does not align with therapeutic care principles.

Medications should always be handled according to organizational policies and safety standards. Storing medications in a locked, controlled environment helps prevent unauthorized access, medication errors, and theft. Refrigerated medications must be stored at the correct temperature, but this action alone does not address the broader requirement for safe medication storage. Verifying the count of controlled substances is an important task but focuses more on accountability than overall storage safety. Placing medications on an open shelf is unsafe because it allows for improper access and increases the risk of errors or diversion.

Because the heart rate is below the ordered threshold, the nurse should immediately reduce the infusion rate as directed. This follows the titration parameters and helps prevent further bradycardia. Increasing the rate would likely worsen the bradycardia, keeping it unchanged ignores the order, and stopping the infusion and calling the provider is unnecessary unless additional signs of instability are present.

The correct answer is focused on anxiety, as the observed non-verbal behaviors-withdrawal, avoidance of eye contact, and restlessness-align with common signs of emotional distress. Further assessment and emotional support are necessary to address the underlying issue. The incorrect answers incorrectly attribute the behavior to physical causes (e.g., unmanaged pain or medication side effects) or minimize its significance as routine post-operative behavior. Misinterpreting these cues can result in missed opportunities to appropriately address a client's emotional needs.

The correct answer ensures adherence to strict aseptic technique during catheter care and solution exchanges, as this is the primary method of preventing peritonitis, a common and serious complication of peritoneal dialysis. Maintaining sterile conditions minimizes contamination of the peritoneal cavity and infection risk. The other options, while important for overall care, do not directly reduce the risk of peritonitis. For example, monitoring the color of the effluent is essential for detecting an infection that has already occurred but does not prevent it.

The nurse should assess for other signs of fluid imbalance, such as weight changes, edema, or decreased blood pressure, to confirm fluid retention or a developing issue. Reduced urinary output in combination with IV fluid administration could indicate renal impairment, fluid overload, or improper hydration status. Simply waiting or taking another measurement without additional evaluation may delay identifying a potentially critical issue. Documenting without taking initial further action does not address the client’s immediate needs.

Ensuring the client gives informed consent is essential as it is a legal and ethical requirement before any surgical procedure. This step confirms that the client understands the nature, risks, and benefits of the procedure and agrees to it voluntarily. While completing a thorough preoperative checklist and gathering lab results are necessary, they are secondary to informed consent, which is a prerequisite for proceeding with surgery. Administering prescribed medications typically occurs closer to the procedure and must not precede verification of informed consent.

A sudden increase in the amount of bleeding or passing large blood clots can indicate a post-partum hemorrhage, which is a serious complication requiring immediate medical attention. While it's common to have moderate bleeding and occasional small clots in the post-partum period, significant changes in volume or size of clots are not normal. Fever suggests infection, but it is not specific to abnormal bleeding. Mild cramping is expected as the uterus contracts, and slight pain during breastfeeding is a normal response to oxytocin release.

The correct step to take first when using any piece of medical equipment is to verify that it is functioning properly. Ensuring that the suction machine is operational and ready for use prevents potential delays during an emergency and ensures the client’s safety. Simply attaching the tubing does not guarantee functionality. Adjusting the suction pressure without first confirming the machine works could lead to delays. Cleaning the exterior is a routine task but is not immediately relevant to ensuring the suction machine is safe to use in this context.

The correct answer is focused on assessing whether the client is mentally and emotionally prepared to engage in the teaching process. Readiness to learn encompasses factors such as understanding the purpose of the education, emotional stability, and potential stressors. Starting education without assessing readiness may lead to poor retention or implementation of the information. Providing written materials or involving family members should occur after ensuring the client is ready to learn.

The correct answer is to assess for signs of bleeding because a sudden drop in BP with tachycardia (increased HR) is often a compensatory response to hypovolemia caused by hemorrhage or significant fluid loss, which requires immediate evaluation and intervention. While increasing IV fluids might seem logical, initiating this without confirming bleeding can delay identifying the underlying issue and worsen the condition. Checking oxygen saturation does not directly address the hemodynamic instability, and notifying the healthcare provider promptly should occur after assessing and gathering critical information to relay.

The correct answer focuses on ensuring patient and staff safety through immediate action. Moving patients and staff to a safe location, such as interior rooms or areas without windows, minimizes the risk of harm from debris or structural damage. While other options, like informing staff or checking emergency supplies, are important, they do not directly and immediately address the safety of patients and staff in this dangerous situation. Planning and communication can be integrated after securing safety.

Option 0, asking the client to describe previous methods they’ve used to manage stressful situations, is the most appropriate intervention. This approach allows the nurse to assess the client’s existing coping mechanisms by exploring how they have handled similar stressors in the past. Understanding these coping strategies provides valuable insight into the client's resilience, problem-solving abilities, and emotional regulation. It also allows the nurse to identify strengths to reinforce and areas that may need additional support.

In contrast, Option 1 offers general reassurance without focusing on assessment, which limits the ability to gather actionable information regarding coping strategies. Option 2 involves providing a plan for the client, which bypasses the critical first step of understanding the client’s current strategies and preferences. Option 3 addresses emotional overwhelm but does not explore the client’s coping resources or behaviors, making it a less comprehensive option for evaluating the client’s abilities to manage stressors effectively.

The correct answer is to stop the infusion, place the client on their left side, and lower the head of the bed. This positioning helps prevent air from traveling to the pulmonary circulation by trapping the embolus in the right atrium, while halting the infusion prevents further complications. Administering oxygen is also essential to improve oxygenation in the presence of hypoxia. Simply notifying the healthcare provider or monitoring the client delays immediate life-saving actions. Encouraging deep breathing along with routine monitoring does not address the embolus, and administering oxygen without addressing the embolus positioning would be incomplete care.

The correct answer is to withhold the medication and contact the provider for clarification or an alternative. Penicillin allergies can pose a significant risk of reaction, and many antibiotics, such as amoxicillin, share similar structures that can result in cross-sensitivity. Administering a medication with a known potential for causing an allergic reaction can compromise client safety. The other options are incorrect because they either delay action to address the allergy (e.g., reviewing hospital policies or contacting the pharmacy) or proceed with unnecessary risk, as monitoring for a reaction rather than intervening is not a safe practice in this scenario.

The correct answer is to discard the compromised equipment and set up a new sterile field. Moisture breaches sterility because it allows microorganisms from the surface underneath to contaminate the sterile area. Continuing the procedure or attempting to 'repair' a sterile field with additional supplies is unsafe, as sterility cannot be restored once it has been compromised. Ignoring the issue or attempting to dry the area does not align with infection prevention principles and puts the client at risk for infection.