NCLEX Review

• Key points about NCLEX

• NCLEX facts and Myths
• Types of questions
• Strategies to help succeed
• Practicing questions, rationales
• Review
 NCLEX
• Let me emphasize one important point: NCLEX is not like any test you have
ever taken
 Applying Your Knowledge
• Passing the NCLEX does not include learning and memorizing
a never-ending amount of content. Instead, the key is to take
what you DO know and apply it to concepts you may never
have heard of.
 Rumors

• There is a rumor floating around that if you don’t know the

answer on a standardized test, pick “C.” That is simply untrue;
it will not help you pass this particular exam. The key to
passing the NCLEX is to take the knowledge you do know and
apply it to new and different concepts.
 Core Content

• The core content is the information you must know without a

doubt and without hesitation if you wish to pass the NCLEX the
first time.
 Good News

• The good news is you do not have to know everything in the

world about nursing to pass the NCLEX.

• You have to refresh your core content knowledge and put this
knowledge into practice with test questions.
 Case In Point
• Let’s take a look at an example that includes core content that you should
know without a doubt and without hesitation.
Q. The nurse is caring for an 8-hour postop thyroidectomy client. Which
client symptom should concern the nurse the most?
• 1. Slight twitch of the left arm.
• 2. Depressed patellar reflex.
• 3. Blood pressure of 136/83 mm Hg, pulse of 72 beats/min, respiratory
rate of 18 breaths/min.
• 4. Occasional premature ventricular contractions (PVCs) noted per the
monitor.
Step by Step Process

• Step #1: Did you know that while reading this question your main focus
should include hypocalcemia?
• To answer this question, you have to use multi-logical thinking.
 Why Hypocalcemia?
• You have to be knowledgeable about a thyroidectomy and the related
complications.
• Remember: NCLEX questions usually focus on actual or potential
problems that can occur. There aren’t many “happy” NCLEX
questions.
• Note: After a thyroidectomy there is a chance the surgeon could
accidentally remove the parathyroid glands
 Parathyroid Glands
• Step #2: Now you need to know about the parathyroid
• Parathyroid glands are responsible for _______________,
which regulates __________________.

• So if removal of one or two parathyroid glands it results in

_________________.
 The nurse is caring for an 8-hour postop thyroidectomy
client. Which client symptom should concern the nurse the
most?
• Next, think about how fluctuations in calcium affect the body?
• If the serum calcium is raised, then the body will be
_________.

• If the serum calcium is lowered, the body will be ___________

or ____________.
 The nurse is caring for an 8-hour postop thyroidectomy
client. Which client symptom should concern the nurse the
most?
• Step #3: What can tightened or contracted muscles lead
to?_____________.

• When that arm starts to twitch, you should worry and assume the
worst: the client may be headed toward a seizure. The client’s patellar
reflex is depressed due to the effects of general anesthesia. Also, if the
calcium drops, the reflexes increase—not decrease. The vital signs
remain normal.
 The nurse is caring for an 8-hour postop thyroidectomy
client. Which client symptom should concern the nurse the
most?

• Step #4: Now we have arrived at the correct answer, #1. Muscle
twitching is a specific sign you must watch for in the care of the
post-thyroidectomy client.
 How is the NCLEX test different?

• If you want the exact explanation of how computer-adaptive

testing (CAT) is used, visit this site: www.ncsbn.org.

• The test is constantly changing according to the way YOU are

answering the question.
 Case In Point

• If you get a question right, your next question will either be of

the same level of difficulty or it may be a higher level of
difficulty. If you get an answer wrong, the level of difficulty
will drop down. If you get the next answer right, the level of
difficulty goes back up again.
 CASE IN POINT

• Imagine you work on a medical-surgical unit. You are

given your assignment of six acutely ill clients. Do you
know every detail listed in your clients’ charts? Of
course not! But, you are still responsible for caring for
these clients.
 Deadly Dilemma

• If you’ve never heard of a disease or illness that is

presented on the NCLEX®, then no one else has either!
This is most likely a distracter that the NCLEX® Lady
has cooked up
 How is it graded?

• NCLEX is not graded by a score.

• Basically, as far as passing is concerned, you have to show the
NCLEX Lady you are more consistently right than wrong when
answering test questions.
• At a minimum, you have to get more test questions RIGHT
than WRONG
 Test Questions are Different
• When you took a test in nursing school, you basically knew what
topics were going to be covered. For instance, you may have had a
cardiac and respiratory test. This test may have had 25 cardiac
questions and 25 respiratory questions.

• During NCLEX you will not read a question and say, “This is a
cardiac question.” You will more likely say, “Hmmmm, there are a
lot of things going on with this client.”
 Case in Point

• A question may ask you about a 50-year-old client who

undergoes in-vitro fertilization for her infertile daughter. During
the delivery, the client develops congestive heart failure (CHF),
which leads to a premature newborn.
 Some Facts
• The higher the level of question, the worse you feel and the better you are
doing.

• The number if questions your test ends on can in no way predict whether
you pass or fail
 Fiction

• If your computer does not cut off at 75 questions, that means

you are doing poorly on your test.
 Test Plan

• The National Council conducts studies every 3 years in an

effort to determine which skills nurses are utilizing in their first
6 months of practice.
 Here’s the breakdown
• Let’s look at the percentage for each category that will be on the test.
• Safe effective care environment  Management of care - 13 -19%
• Safety and Infection control – 8 – 14%
• Health and Promotion Maintenance  6 -12%
• Psychosocial Integrity  6- 12%
• Physiological Integrity  Basic care and Comfort 6 – 12%
•  Pharmacological and parenteral therapies 13 – 19%
•  Reduction of risk potential 13- 19%
•  Physiological adaptation 11-17%
 What’s in every category?
• Integrated Process

• Throughout the NCLEX exam you will find four major client needs
categories; these are the integrated processes. The integrated processes are
intertwined into each exam question. The processes are:
• 1. Nursing process
• 2. Caring
• 3. Communication and documentation
• 4. Teaching and learning
 Case in Point

• The Registered Nurse teaches skin care to a client who is receiving

external radiation therapy. Which of the following client statements would
alert the nurse that further teaching is indicated?
• 1. I will use a mild soap to wash the area.
• 2. I will handle the area very carefully.
• 3. I will limit my exposure to the sun.
• 4. I will wear loose clothing over the site.
 Types of Questions
• “alternate format” ( “innovative items”) style questions.
 Types of alternate format questions
• The types of alternate format questions you will encounter include
1. Select all that apply
2. Hot spot
3. Fill in the blank
4. Charts or exhibit items
5. Drag-and-drop items
 Strategies for Success
• Break it down!
• Here’s a way to break down a test question.
1. Read the stem (scenario) and figure out what the PROBLEM is.
2. Read the stem and figure out what you are supposed to be worried
about even if everything sounds great.
3. What is the WORST thing that can happen in this scenario?
4. Once you’ve got an idea about what the problem is, then select an
answer that fixes the problem.
 Case In Point

• Example: If the problem is HEMORRHAGE, then you should

not select an answer like “assess the vital signs.” Why? Because
“assessing” the vital signs does not FIX the PROBLEM or stop
the hemorrhage
 Some More Strategies
• What if I read a question and I have absolutely no idea what they are asking for? The first
thing to remember is this: If you are baffled, bewildered, or discombobulated, so is every
other nursing student in the country! Don’t come unglued.

• Imagine yourself at the bedside in this scenario.

• Do I have any idea about what I’m supposed to be WORRIED
about?
• pretend each answer is written on a separate index card; then
select which answer (if it were all by itself) sounds the safest as an
independent statement all alone.
 Cont’d Strategies
• When all 4 answers look good, it’s either a high level question or we don’t
know our core content on this topic.
 Cont’d

• If I asked you, “What does the skin feel like when someone
starts going into shock?” what will be your answer?
 Nursing Action
• A question that asks for a “nursing action” may mean you need to
select an answer where you are performing an assessment or
implementing a specific nursing action. Remember assessment and
implementation are two separate phases of the nursing process.
Nursing action doesn’t mean you have to pick a nonassessment–
related answer as assessment IS an action. You have to read the
scenario and figure out where you are in the nursing process prior to
selecting an answer.
 Nursing Action
• You have to make sure a proper assessment has been done first.
• After you read the stem (scenario), you will know if a proper assessment
has been performed. Then you can move on to an implementation answer.
• If an assessment has already been described in the stem of the question,
please do not pick an assessment answer. Move on, to the next phase of the
nursing process—implementation!
• If your client describes what is wrong, this is the client’s assessment, and
the client isn’t the one trying to get a nursing license. You need to perform
your OWN assessment prior to moving to implementation
 Strategies
• When you have answers such as “call the supervisor” or “call
the dietician,” you have to be suspicious. Why? Because the
NCLEX Lady would prefer YOU do something to help the
patient directly.

• Don’t pick answers that refer your client AWAY from your
care.
 Strategies

• Stay away from restraints, wheelchairs, and drugs (especially

invasive drugs) as long as you can when choosing an answer.
The NCLEX Lady does not like nurses who tie people down or
nurses who run to the medication cart for every little thing.
 Pain

• Pain never killed anybody.

• We are not saying pain is not important; it does need to be dealt
with immediately. Prior to selecting the “pain” answer, look for
an item that is more life threatening (increasing intracranial
pressure, shock, or hypoglycemia).
 Strategies dealing specifically with the hospital
and the physician.
1. You already have the order! Don’t sit there and say, “Oh, I
wonder if I have to have an order for that?” If it’s an option,
you have an order.
2. Do not use what you have seen in the hospital as a test-taking
strategy. Many times what you have seen does not have the
NCLEX seal of approval.
“Call the physician” answers:
• Be careful of this answer.
• There are times when calling the physician is the ONLY thing you can do.
Just make sure there is not a nursing answer you can select that will help
the client or problem first, prior to selecting this answer.
• However, don’t just pick any answer to avoid selecting, “call the
physician.” Sometimes this will be the answer because the physician is the
only one who can FIX the problem (based on the four options given).
 Don’t be Scared
• 1. Don’t be afraid to select an answer that says “sit with the client.”

• 2. Don’t be afraid to select an answer just because you’ve never seen it done.
If it’s safe, consider it to be a reasonable option
 Compliant Client

• Some tips that deal specifically with the client:

• #1 Your client is post-prostatectomy. He is complaining of
bladder spasms. What should you assess first?
• 1. The bladder for distension.
• 2. The catheter tubing for kinks.
 Complaint Client
• 2. We’ve all heard, “Treat the client, not the monitor.”

• POINT #2 This is a handy little tip to know if you have a client with
pulseless electrical activity (PEA). In other words, she has a rhythm on the
monitor and everything looks groovy up there. If you assume the client is
okay because she has a pretty rhythm on the monitor, you have just let
somebody die. (You aren’t going to get a license like that!) This client has
electrical activity showing up on the monitor, but no pulse. The electrical
part of the heart is working, but the pump has stopped. This is why we must
treat the client, not the monitor.
 Tackling Priority Questions

• You will see a lot of these questions on NCLEX.

• Few guidelines on how to answer – not all guidelines are
applicable for every priority question, but as we practice you
will learn how these guidelines will help.
• 1. 1. First, you need to realize the word “priority” changes
everything. It does not mean what would I do first.
 Priority Questions
• Priority means if I do not do one of the following, my client could die or
experience significant harm.
• 1. Ask yourself the following questions: When given four options, what’s the
ONE thing I’d better do? What’s the one thing I’d better tell the NCLEX
people I am going to do? If I do not do anything else, I promise I will do
this particular thing.
• 2. When selecting an answer: think killer answer.
 A killer answer is an answer that will bring death or some form of
harm to a client. You can “kill” someone physiologically or psychologically.
 Practice Question
• Remember to incorporate all the guidelines.
• The nurse is aware that the most serious side effect of the tocolytic
terbutaline sulfate (Brethine) is:
• 1. Respiratory depression
• 2. Pulmonary edema
• 3. Hypertension
• 4. Renal failure
 Knowledge: What’s a tocolytic? What’s
terbutaline sulfate (Brethine)?
1. Once you look at the answer you should be thinking “pick the KILLER
answer.” However, the answer has to be applicable. For instance, renal failure
(answer #4) will kill you but has nothing to do with this drug, so this answer is
out. (Renal failure is not applicable.)
2. You probably looked at respiratory depression (answer #1) and thought
“That’s It! Airway is always right!”
 Choices #2 and #3
• Everybody knows that, in general, drugs that promote breathing pump up
the vital signs, thus making people nervous and jittery. So, answer #3,
hypertension, is still in the ballgame.

• Now let’s look at answer #2. Is this answer possible? An answer must be
POSSIBLE in order for you to consider it. Could pulmonary edema even
happen with this drug?
 Knowledge
• this type of drug, HR goes __________
• When the heart rate goes ___________, what happens to the ventricles?
• Cardiac output __________
 Knowledge
• The same amount of blood remains in the cardiac system, so this blood has
got to go somewhere.

• If it’s not being pumped forward (remember the cardiac output has dropped)
• What will happen?
Cont’d

• Now we have 2 correct answers: #2 and #3. Pick

the KILLER answer
• #2 pulmonary edema
• #3 hypertension
How do you want the NCLEX lady to think of
you?
• Every time you select an answer on NCLEX you are sending a message to
the NCLEX people about the kind of nurse you are.
• You’ve got one shot at letting the person who wrote the question know that
you know what nursing action to take.
• Once you select your answer, that does not mean you are NOT going to do
the other options as well (especially if all four answers are correct and
applicable). It just means you’d better make sure the NCLEX® people know
you will do “this” if you do not do anything else
 Understanding the why?
• Understanding the why will keep you from selecting answers like “assess the
vital signs.”
 Practice Question
• A client has returned from a routine colonoscopy. The client is complaining of a
small amount of abdominal discomfort. The client informs the nurse that he
passed a drop of blood. Which action takes priority?
• 1. Taking the vital signs
• 2. Instructing the client to remain in the bed
• 3. Calling the physician
• 4. Administering PRN pain medication
 Be a pessimist

• Assume the worst

• Clinical Alert you may feel you are overacting thinking

like this. It is better to overact and possibly save somebody’s
life then to underreact.
 Worst thing that could happen?
• Based on the data (small amount of discomfort and a drop of blood post-
colonoscopy) what is the worst thing that could happen?
 Understanding the why?
• You have vast knowledge, so use it.
 Going back to some of the guidelines
• If the problem is hemorrhage or perforation, which answer will attack/fix
the problem?
• Let’s look at the answers individually.
• Answer #1 Taking the vitals.
 Guidelines
• #2 Once I pick my answer I’m COMMITTED to it. That’s it. You can’t do
anything else
 One of the rules
• This is the way you should think about all NCLEX questions. If you do not
tell the NCLEX people anything else in this scenario, you had better let them
know you know how important it is to notify the physician.

• DON’T LEAVE THEM WONDERING

 In NCLEX Nursing

• The word “priority” in this question means “If I can only do

ONE thing, what is the ONE thing I should do to keep this
client alive?”
 Answer #2: Instructing the client to remain in
bed.
• Will you select this answer? Yes or no? why?
 Answer #4: Administering PRN pain
medication
• Will you select this answer? Yes or no? why?
 Answer #3 Call the physician
• This is the correct answer – why?

• RULE If there is something you can do to fix the problem, do this first and
then notify the physician.

• Making the NCLEX lady happy

 Clinical Alert

• Procedure + Symptoms = Something Bad.

 Question

• The nurse is caring for a 30-week primagravida who is receiving magnesium

sulfate IV for premature contractions. The nurse is monitoring hourly urine
output. The first hour, urine output is 180 mL. The next hour, the urine output has
decreased to 140 mL. Based on this data, which action should take priority?
• 1. Notifying the physician
• 2. Stop the infusion
• 3. Decrease the infusion
• 4. Reassess the urine output in l5 minutes
 Refreshing Your Knowledge
• Magnesium sulfate (also known as mag-sulfate, Mg, MgSO4 )

• What is it?

• Why is monitoring hourly output important with this drug?

 Let’s Analyze the Answers
• Answer #1: Notifying the physician.

• Will you pick this answer why or why not?

 Answer #4: Reassess the urine output in l5
minutes.
• Will you pick this as an answer why or why not?
 Rule
• Never delay treatment

• You slowly leave the room saying, “I’ll be back in just l5 quick minutes. What
can happen in l5 minutes?” A lot can happen in l5 minutes
 Refresh your Knowledge
• Magnesium acts like a ____________.
• It is excreted from the body by the ____________.

• When urine output drops, what happens to magnesium?

 Refresh your Knowledge
• What will excess magnesium do to your respirations? So what can happen in
15 minutes?
 Now choices #2 and #3
• Which one did you select? Why?
• 2. Stop the infusion
• 3. Decrease the infusion
 Clinical Alert
• You are still allowing a client whose urine output has decreased to continue
receiving magnesium IV. No! You must assure the NCLEX people that you
will stop the infusion and not allow the client to receive any more until the
physician has been notified
 Battle Continues
• Here’s a problem you may be battling with now: Do I have an order to stop
the infusion!

• RULE : If it’s an option on NCLEX, I have an order!

 Experience Doesn’t Help

• An experienced nurse may handle this situation differently than

you.
 Deadly Distracter

• I realize the urine output numbers in the practice question are

good.
•
Other Words that
What is the most IMPORTANT action?
Mean Priority
• The most IMPORTANT action would be?
• The BEST action would be to?
• The BEST response would be?
• Your INITIAL response or action would be to?
• What would concern the nurse the MOST?
• What should be your FIRST ACTION?
• The most ESSENTIAL nursing action would be?
• Your IMMEDIATE response should be?
• The nurse’s NEXT action should be?
• The PRIMARY or VITAL nursing action would be to?
• The BEST action is?
 Management and Delegation
• What is delegation?
 The Five Rights of Delegation
• What are the five rights?
 Guidelines for selecting the right task
• Here are some guidelines and questions you may ask yourself when selecting the right task on
NCLEX.

• 1. Is it a task that reoccurs in daily care? For example, AM care and routine vitals signs occur in
daily care.
• 2. Is nursing judgment required? If nursing judgment is required, then you have to delegate this
task to someone that is qualified or retain the task for yourself.
• 3. Is the potential for risk minimal? Does the potential for harming the client exist if the task is
delegated?
• 4. Are the results predictable?
• 5. Does the task have a standard or unchanging procedure? Does the hospital have a procedure
for this task? Is there an outlined and detailed checklist of how to perform this task? In standard
procedures which are documented in the hospital’s policies and procedure manuals, the expected
outcome is know
 Guidelines for selecting the right circumstance

• Every client’s circumstance is different.

• 1. Does the complexity of the task match the competency of the delegate?
• HINT: Anytime a nurse is floated to an unfamiliar area and is given a
client assignment, consider him to be a brand new nurse all over again
no matter how many years of nursing experience he has.
• 2. Is supervision readily available?
 Guidelines for selecting the right person
• You’ll be working with several different levels of personnel with varying
degrees of expertise. Let’s pick the right person for the job.
• 1. What is the competency level of the delegatee?
 Guidelines for selecting the right
direction/communication
• Communication is an element of delegation we cannot forget. Some staff
members may require more direction than others.
• 1. Have you been specific in your communications?
•  What information will you tell:
Guidelines for the right supervision/evaluation

• You can’t delegate and forget it. You must follow up

 Recap
• Let’s recap the biggies here:
• Delegate to staff members who have been taught properly and can perform
the task in a safe manner.
• If the staff members have not been taught properly or if you have
concerns, you must supervise the task.
• Supervision does not necessarily mean to stand by the delegatee’s side unless
this is the first time the task is being performed.
• Make sure you follow up and evaluate the delegatee’s performance after the
task is completed.
 Hint

• Be aware that prior to any discharge teaching, an assessment

must be done by the RN to determine what needs teaching. In
an NCLEX question, however, you may have to select
appropriate discharge teaching for a LPN/VN to complete. The
key in this situation is to make sure that what is taught is
noncomplex, simple, and fairly the same for each client.
 General Rules to Answer Delegation and
Management Questions
• Management rules
• 1. Determine which client to see first.
• Choose the more acute, unstable client.

• What is an unstable client? Examples?

Example 1
• A 36-year-old single mother with 4 children is discharged home after a right
mastectomy. She has a lot of physiological and psychosocial problems,
causing her to be a complex client, but she is STABLE. She has been
discharged home!
Example 2

• What about a client with a cerebrovascular accident?

• The client sounds like he’s critical, but look at the data.
• When did the stroke happen? Is he having any acute
changes RIGHT NOW?
 Of the following two clients which one
requires your attention?
• A newly diagnosed diabetic who awakens with a quarter-sized foot ulcer.
Pedal pulses are present but weak. The morning glucose is 9.4 mmol/L.
Or
• Vital signs are obtained on a postpartum client who delivered 12 hours ago.
Four hours post-delivery her blood pressure was 118/70 mm Hg, now her
blood pressure is 140/80 mm Hg
 General Guidelines
• 1. Look at the complexity

• 2. The client who has the most problem is another good rule.

• 3. All clients will sound critical in each test question answer option. NCLEX
does this on purpose.
 Management

• Always remember, you should assess a client with a life-

threatening problem before visiting your other clients.
 Question
• You have two clients on your home health route that need to be seen today.
Who would you go see first?
• The client complaining of postop hip replacement pain.
• The diabetic client who is scheduled for a fasting blood sugar.
 What is the worst case scenario?
• What is the worst possible scenario that each client can experience?
• Which one is more life threatening?

• The client with postop hip pain.

• The diabetic client who is scheduled for a fasting blood sugar.
 Hint

• If all of the clients are having changes in their condition, then

you must consider how fast these changes are occurring. Ask
yourself: “Which client do I have the least amount of time to
work with?” In other words, which client is in the most
immediate danger?
. Never assign an unstable client to an LPN
• think of an “unstable” client as = change in their condition
Example:
• Your assigned client has a head injury; the intracranial pressure (ICP) is being
monitored. The client has noticeable pupillary changes. Is this an immediate
concern?
• A new admission is considered unstable—otherwise this client would not
have been admitted in the first place. The RN should retain this client for
herself.
• When making assignments, you must consider how much care each client is
going to require.
• The registered nurse has the ultimate responsibility and accountability for the
management of client care
 Question

• After a post-acetaminophen overdose the client is stable; will

you assign this client to an LPN?

• Why or why not?

 Think About it

• Acetaminophen kills the _______________.

• Which increases the risk for _______________.
 What did we learn from this question

• The word “after”

 Question

• A client presents to the ED after an acute asthma attack. The

client is admitted to your unit, where he is now sleeping with a
respiratory rate of 24 breaths per minute. A family member
remains in the room at the bedside. Is this a good client to
assign to the LPN working on your team that day?
 Nursing Process

• You used the nursing process throughout nursing school

to write care plans and to problem-solve when
delivering client care.
 Why is it Important in NCLEX?

• Fundamental to the practice of nursing.

 Phases of Nursing Process

• Same as nursing school.

 Let’s Review

• Let’s start with Infection Control

• List some universal precautions

 It’s Sterile Be Careful

• Sterile field

• What will you do to keep the sterile field safe?

 Latex Allergy

• Interventions:

• Products to be aware of:

 Skin Breakdown

• Stages of skin breakdown

 Abdominal Assessment
• Assessment
• Inspect
• Auscultate
• Percuss
• Palpate
 Referred Pain
Appendix: Pain referred to ….
Bladder
Liver
Spleen
Heart
 Cardiac Terms to Know
• Cardiac Output : __________ ejected by the heart in ____ min.

• Cardiac output = __________ x ___________

 Cardiac Terms to Know
• Stroke Volume =

Preload = The volume of blood returning to the ___________ of

the circulating ___________.
Afterload = The resistance against which the ___________ must
pump when ejecting blood.
 Normal Heart and Blood Flow
• Chambers and Valves (one way valves to direct blood flow)
• Blood enters __________ atrium  goes through __________
valve  enters _________ ventricle  goes through
_____________ valve into lungs  leaves lungs through
__________ veins  enters _________ atrium  goes through
mitral valve (bicuspid)  enters __________ ventricles  goes
through aortic valve out to the systemic circulation.
 Normal Heart Flow

• The chambers on the right side of the heart receive blood from
the ____________. The chambers on the left side pump
______________out of the heart to the rest of the body.

• A ___________ divides the right and left sides of the heart.

 Heart Failure
• Right sided heart failure:

• s/s

• Left- sided heart failure :

• s/s
 Management of Care
Q1. The nurse has received the client assignment for the day. Which client should the
nurse assess first?
• 1. The client who needs to receive subcutaneous insulin before breakfast
• 2. The client who has a nasogastric tube attached to intermittent suction
• 3. The client who is 2 days postoperative and is complaining of incisional
pain
• 4. The client who has a blood glucose level of 50 mg/ dL (2.8 mmol/ L)
and complaints of blurred vision
 Safety and Infection Control
Q2. The nurse prepares to care for a client on contact precautions who has a hospital-
acquired infection caused by methicillin resistant Staphylococcus aureus (MRSA). The
client has an abdominal wound that requires irrigation and has a tracheostomy attached
to a mechanical ventilator, which requires frequent suctioning. The nurse should
assemble which necessary protective items before entering the client’s room?
• 1. Gloves and gown
• 2. Gloves and face shield
• 3. Gloves, gown, and face shield
• 4. Gloves, gown, and shoe protectors
 Question

• An elderly client who receives intravenous therapy has a history of a

fractured femur, acute myocardial infarction, glaucoma, and hypothyroidism.
Which of these conditions most likely influences the rate at which fluids
should be infused for this client?
• A. Fractured femur.
• B. Acute myocardial infarction
• . C. Glaucoma.
• D. Hypothyroidism
 Question

• A client who receives intravenous fluid therapy and an intravenous injection of

diphenhydramine (Benadryl) suddenly complains of chest tightness and light-
headedness. The nurse notes that the client has a flushed face and an irregular pulse
of 120 beats/minute. Which is the most likely cause of this reaction in this client?
• A.Circulatory overload.
• B. Sepsis.
• C. Speed shock.
• D. Chylothorax
 Question
• Which test is most commonly used to determine the area of
myocardial damage during or after a myocardial infarction (MI)?
• A.Cardiac catheterization
• . B. Cardiac enzymes.
• C. Echocardiogram.
• D. Electrocardiogram
 Knowledge

• Cardiac catheterization is an ____________ procedure, that can

determine ____________ disease and may also locate damage,
but this is usually performed after other tests are completed.

• Cardiac enzymes can diagnose a MI but cannot determine the

location of damage.
Cont’d

• An echocardiogram is used to detect

_________________after a MI.

• An electrocardiogram is the ___________ and

_____________ way to determine the location of
myocardial damage.
 Question

• A client’s sodium is 122 mEq/L. Which action is a priority

nursing intervention?
• A. Obtaining vital signs every 15 minutes.
• B. Increasing fluid intake.
• C. Initiating seizure precautions.
• D. Implementing cardiac monitoring.
 Knowledge

• Normal sodium level is ___________ mEq/L.

• So what is happening with the client? Hypernatremia or

Hyponatremia
A. Obtaining vital signs every 15 minutes

• Why or why not?

 B. Increasing fluid intake.

• Why or why not ?

 D. Implementing cardiac monitoring.

• Why or why not?

• Test Taking strategy : Eliminate similar answers.

 C. Initiating Seizure Precautions

• Clients with hyponatremia are at risk for seizures.

 Question
• A nurse cares for a postoperative client who has become tachycardiac and
tachypneic. The client’s blood pressure is 88/60 mm Hg. Which action
should the nurse immediately take? Select all that apply.
• A. Monitor hourly urine output.
• B. Elevate the client’s feet.
• C. Draw blood for laboratory testing.
• D. Recheck vital signs.
 Question

• The nurse cares for a client with a heart rate of 112

beats/minute. Which could be the cause of this condition?
• A. Straining during a bowel movement.
• B. Suctioning.
• C. Fear, anger, or pain.
• D. Stress, pain, or vomiting.
 Common Strategic Words: Words That
Indicate the Need to Prioritize and
Words That Reflect Assessment
• Words That Indicate the Need to Prioritize :
• Best
• Early or late Essential
• First Highest
• priority Immediate
• Initial Most
• Most appropriate, Most important, Most likely, Next Primary Vital
 Words That Reflect
Assessment
• Ascertain Assess Check Collect Determine Find out Gather Identify Monitor
Observe Obtain information Recognize
 What can Drug Name endings tell you
• If they end in this They belong to this
• -caine Local anesthetics
• -cillin -
• -done Opiod analgesics
• -mycin
• -olol
• -pril
• -sone Steroids
• -statin
• -zide
 Questions

• The nurse is caring for a client who just returned from the recovery room
after undergoing abdominal surgery. The nurse should monitor for which
early sign of hypovolemic shock?
• 1. Sleepiness
• 2. Increased pulse rate
• 3. Increased depth of respiration
• 4. Increased orientation to surroundings
 Question
• The nurse provides medication instructions to a client about
• digoxin. Which statement by the client indicates an understanding of its adverse
effects?
• 1. “Blurred vision is expected.”
• 2. “If I am nauseated or vomiting, I should stay on liquids
• and take some liquid antacids.”
• 3. “This medication may cause headache and weakness
• but that is nothing to worry about.”
• 4. “If my pulse rate drops below 60 beats per minute I
• should let my health care provider know.”
 Question

• A client with a diagnosis of cancer is receiving morphine sulfate for pain.

The nurse should employ which priority action in the care of the client?
• 1. Monitor stools.
• 2. Encourage fluid intake.
• 3. Monitor urine output.
• 4. Encourage the client to cough and deep breath
 Steps of the Nursing process
• The steps include assessment, analysis, planning, implementation.
 Nursing Process
• Assessment – Assessment questions address the process of gathering
subjective and objective data.
• Analysis- Require understanding, critical thinking
• Planning- Require prioritizing client problems (actual client problems, not
potential problems)
• Implementation – Address the process or organizing and managing care,
counselling and teaching.
 Question

• A client who had an application of a right arm cast complains of pain at the
wrist when the arm is passively moved. What action should the nurse take
first?
• 1. Elevate the arm.
• 2. Document the findings.
• 3. Medicate with an additional dose of an opioid.
• 4. Check for paresthesia and paralysis of the right arm.
 Analysis Question – Second step of nursing
process
• The nurse reviews the arterial blood gas results of a client and notes the
following: pH 7.45, PCO2 30 mm Hg, and HCO3 22 mEq/ L (22 mmol/ L).
The nurse analyzes these results as indicating which condition?
• 1. Metabolic acidosis, compensated
• 2. Respiratory alkalosis, compensated
• 3. Metabolic alkalosis, uncompensated
• 4. Respiratory acidosis, uncompensated
 Question
• The nurse developing a plan of care for a client with a cataract understands
that which problem is the priority?
• 1. Concern about the loss of eyesight
• 2. Altered vision due to opacity of the ocular lens
• 3. Difficulty moving around because of the need for glasses
• 4. Becoming lonely because of decreased community immersion
 Question
• The nurse is caring for a hospitalized client with angina pectoris who begins to
experience chest pain. The nurse administers a nitroglycerin tablet sublingually as
prescribed, but the pain is unrelieved. The nurse should take which action next?
• 1. Reposition the client
• . 2. Call the client’s family.
• 3. Contact the health care provider.
• 4. Administer another nitroglycerin tablet.
 Question
• The nurse is caring for a client being admitted to the emergency department
with a chief complaint of anorexia, nausea, and vomiting. The nurse asks the
client about the home medications being taking. The nurse would be most
concerned if the client stated that which medication was being taken at
home?
• 1. Digoxin
• 2. Captopril
• 3. Losartan
• 4. Furosemide
 Question
• The nurse is evaluating the client’s response to treatment of a pleural
effusion with a chest tube. The nurse notes a respiratory rate of 20 breaths
per minute, fluctuation of the fluid level in the water seal chamber, and a
decrease in the amount of drainage by 30 mL since the previous shift. Based
on this information, which interpretation should the nurse make?
• 1. The client is responding well to treatment.
• 2. Suction should be decreased to the system.
• 3. The system should be assessed for an air leak.
• 4. Water should be added to the water seal chamber
 Question
• A client scheduled for bowel surgery states to the nurse, “I’m not sure if I
should have this surgery.” Which response by the nurse is appropriate?
• 1. “It’s your decision.”
• 2. “Don’t worry. Everything will be fine.”
• 3. “Why don’t you want to have this surgery?”
• 4. “Tell me what concerns you have about the surgery.”
 Question

• A client is to undergo a computed tomography (CT) scan of the abdomen

with oral contrast, and the nurse provides pre procedure instructions. The
nurse instructs the client to take which action in the pre procedure period?
• 1. Avoid eating or drinking after midnight before the test.
• 2. Limit self to only 2 cigarettes on the morning of the test.
• 3. Have a clear liquid breakfast only on the morning of the test.
• 4. Take all routine medications with a glass of water on the morning of the
test
 Question

• The nurse in charge of a long-term care facility is planning the client

assignments for the day. Which client should be assigned to the unlicensed
assistive personnel (UAP)?
• 1. A client on strict bed rest
• 2. A client with dyspnea who is receiving oxygen therapy
• 3. A client scheduled for transfer to the hospital for surgery
• 4. A client with a gastrostomy tube who requires tube feedings every 4 hours
 Religion and Dietary Preferences
• Buddhism – no alcohol, vegetarians, some eat fish but avoid beef.
• Hinduism – vegetarians, no beef or pork. Fasting rituals vary
• Islam- during month of Ramadan fasting occurs during the day time. No
pork and alcohol. Any meat ritually slaughtered are prohibited.
• Jehovah’s Witnesses - Any foods to which blood has been added are
prohibited. They can eat animal flesh that has been drained.
 Question
• An antihypertensive medication has been prescribed for a client with
hypertension. The client tells the clinic nurse that he would like to take an
herbal substance to help lower his blood pressure. The nurse should take
which action?
• 1. Advise the client to read the labels of herbal therapies closely.
• 2. Tell the client that herbal substances are not safe and should never be
used.
• 3. Encourage the client to discuss the use of an herbal substance with the
health care provider (HCP).
• 4. Tell the client that if he takes the herbal substance he will need to have his
blood pressure checked frequently.
 Question

• When communicating with a client who speaks a different language, which

best practice should the nurse implement?
• 1. Speak loudly and slowly.
• 2. Arrange for an interpreter to translate.
• 3. Speak to the client and family together.
• 4. Stand close to the client and speak loudly.
 Question

• The nurse hears a client calling out for help, hurries down the hallway to the client’s
room, and finds the client lying on the floor. The nurse performs an assessment,
assists the client back to bed, notifies the health care provider of the incident, and
completes an incident report. Which statement should the nurse document on the
incident report?
• 1. The client fell out of bed.
• 2. The client climbed over the side rails.
• 3. The client was found lying on the floor.
• 4. The client became restless and tried to get out of bed
 Questions
• Which identifies accurate nursing documentation notations? Select all that apply.

• 1. The client slept through the night.

• 2. Abdominal wound dressing is dry and intact without drainage
• . 3. The client seemed angry when awakened for vital sign
measurement.
• 4. The client appears to become anxious when it is time for respiratory
treatments. 5. The client’s left lower medial leg wound is 3 cm in length
without redness, drainage, or edema
 Question
• The nurse calls the heath care provider (HCP) regarding a new medication
prescription because the dosage prescribed is higher than the recommended
dosage. The nurse is unable to locate the HCP, and the medication is due to
be administered. Which action should the nurse take?
• 1. Contact the nursing supervisor.
• 2. Administer the dose prescribed.
• 3. Hold the medication until the HCP can be contacted.
• 4. Administer the recommended dose until the HCP can be located
 Question
• The nurse arrives at work and is told to report (float) to the intensive care
unit (ICU) for the day because the ICU is understaffed and needs additional
nurses to care for the clients. The nurse has never worked in the ICU. The
nurse should take which best action?
• 1. Refuse to float to the ICU based on lack of unit orientation.
• 2. Clarify with the team leader to make a safe ICU client assignment.
• 3. Ask the nursing supervisor to review the hospital policy on floating.
• 4. Submit a written protest to nursing administration, and then call the
hospital lawyer.
 Question
• The nurse is assigned to care for four clients. In planning client rounds,
which client should the nurse assess first?
• 1. A postoperative client preparing for discharge with a new medication
• 2. A client requiring daily dressing changes of a recent surgical incision
• 3. A client scheduled for a chest x-ray after insertion of a nasogastric tube
• 4. A client with asthma who requested a breathing treatment during the
previous shift
 Question
• The nurse employed in an emergency department is assigned to triage clients
coming to the emergency department for treatment on the evening shift. The
nurse should assign priority to which client?
• 1. A client complaining of muscle aches, a headache, and history of seizures
2. A client who twisted her ankle when rollerblading and is requesting
medication for pain
• 3. A client with a minor laceration on the index finger sustained while cutting
an eggplant
• 4. A client with chest pain who states that he just ate pizza that was made
with a very spicy sauce
 Question

• The registered nurse is planning the client assignments for the day. Which is
the most appropriate assignment for an unlicensed assistive personnel
(UAP)?
• 1. A client requiring a colostomy irrigation
• 2. A client receiving continuous tube feedings
• 3. A client who requires urine specimen collections
• 4. A client with difficulty swallowing food and fluids
 Question

• The charge nurse is planning the assignment for the day. Which factors should the
nurse remain mindful of when planning the assignment? Select all that apply.
• 1. The acuity level of the clients
• 2. Specific requests from the staff
• 3. The clustering of the rooms on the unit
• 4. The number of anticipated client discharges
• 5. Client needs and workers’ needs and abilities
 Question
• The nurse is caring for a client with heart failure. On assessment, the nurse
notes that the client is dyspneic, and crackles are audible on auscultation.
What additional manifestations would the nurse expect to note in this client
if excess fluid volume is present?
• 1. Weight loss and dry skin
• 2. Flat neck and hand veins and decreased urinary output
• 3. An increase in blood pressure and increased respirations
• 4. Weakness and decreased central venous pressure (CVP)
 Question
• Potassium chloride intravenously is prescribed for a client with hypokalemia.
Which actions should the nurse take to plan for preparation and
administration of the potassium? Select all that apply.
• 1. Obtain an intravenous (IV) infusion pump.
• 2. Monitor urine output during administration
• . 3. Prepare the medication for bolus administration.
• 4. Monitor the IV site for signs of infiltration or phlebitis.
• 5. Ensure that the medication is diluted in the appropriate volume of fluid
• . 6. Ensure that the bag is labeled so that it reads the volume of potassium in
the solution.
 Question
• The nurse is assessing a client with a suspected diagnosis of hypocalcemia.
Which clinical manifestation would the nurse expect to note in the client?
• 1. Twitching
• 2. Hypoactive bowel sounds
• 3. Negative Trousseau’s sign
• 4. Hypoactive deep tendon reflexes
 Question

• Which client is at risk for the development of a potassium level of 5.5

mEq/L (5.5 mmol/L)?
• 1. The client with colitis
• 2. The client with Cushing’s syndrome
• 3. The client who has been overusing laxatives
• 4. The client who has sustained a traumatic burn
 Knowledge

• Normal potassium levels are : ______ mmol/ L

• The client with Cushing’s syndrome or colitis and the client who has been
overusing laxatives are at risk for _____________
 Question

• The nurse caring for a client who has been receiving intravenous (IV)
diuretics suspects that the client is experiencing a fluid volume deficit. Which
assessment finding would the nurse note in a client with this condition?
• 1. Weight loss and poor skin turgor
• 2. Lung congestion and increased heart rate
• 3. Decreased hematocrit and increased urine output
• 4. Increased respirations and increased blood pressure
 Strategy
• Test-Taking Strategy: Focus on the subject, fluid volume deficit. Think about
the pathophysiology for fluid volume deficit and fluid volume excess to
answer correctly.

• Note that options 2, 3, and 4 are comparable or alike and are manifestations
associated with fluid volume excess.
 Question
• On review of the clients’ medical records, the nurse determines that which
client is at risk for fluid volume excess?

• 1. The client taking diuretics and has tenting of the skin

• 2. The client with an ileostomy from a recent abdominal surgery
• 3. The client who requires intermittent gastrointestinal suctioning
• 4. The client with kidney disease and a 12-year history of diabetes mellitus
 Question Select all that apply
• The nurse is reviewing laboratory results and notes that a client’s serum sodium level is 150
mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care
provider (HCP) and the HCP prescribes dietary instructions based on the sodium level.
Which acceptable food items does the nurse instruct the client to consume? Select all that
apply.
• 1. Peas
• 2. Nuts
• 3. Cheese
• 4. Cauliflower
• 5. Processed oat cereals
 Question
• The nurse is caring for a postoperative client who is receiving demand-dose
hydromorphone via a patient-controlled analgesia (PCA) pump for pain
control. The nurse enters the client’s room and finds the client drowsy and
records the following vital signs: temperature 97.2 °F (36.2 °C) orally, pulse
52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11
breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal
cannula. Which action should the nurse take next?
• 1. Document the findings.
• 2. Attempt to arouse the client.
• 3. Contact the health care provider (HCP) immediately.
• 4. Check the medication administration history on the PCA pump.
 Question
• postoperative client has been placed on a clear liquid diet. The nurse should
provide the client with which items that are allowed to be consumed on this
diet? Select all that apply.
• 1. Broth
• 2. Coffee
• 3. Gelatin
• 4. Pudding
• 5. Vegetable juice
• 6. Pureed vegetables
 Question
• The nurse is making initial rounds on the nursing unit to assess the condition
of assigned clients. Which assessment findings are consistent with
infiltration? Select all that apply.
• 1. Pain and erythema
• 2. Pallor and coolness
• 3. Numbness and pain
• 4. Edema and blanched skin
• 5. Formation of a red streak and purulent drainage
 Knowledge
• Infiltration : Infiltration is seepage of the IV fluid out of the vein and into
the surrounding interstitial spaces.

• Infiltration occurs when an access device has become dislodged or perforates

the wall of the vein or when venous backpressure occurs because of a clot or
venospasm.
 Question
• The nurse is assessing a client’s peripheral intravenous (IV) site after
completion of a vancomycin infusion and notes that the area is reddened,
warm, painful, and slightly edematous proximal to the insertion point of the
IV catheter. At this time, which action by the nurse is best?
• 1. Check for the presence of blood return.
• 2. Remove the IV site and restart at another site.
• 3. Document the findings and continue to monitor the IV site.
• 4. Call the health care provider (HCP) and request that the vancomycin be
given orally.
 Knowledge
• Phlebitis Phlebitis is an inflammation of the vein that can occur from
mechanical or chemical (medication) trauma or from a local infection.

• Phlebitis can cause the development of _____________

• Prevention and intervention: Change the venipuncture site every 72 to 96
hours in accordance with CDC recommendations and agency policy.
 Question
• The nurse has just received a prescription to transfuse a unit of packed red
blood cells for an assigned client. What action should the nurse take next?
• 1. Check a set of vital signs
• . 2. Order the blood from the blood bank.
• 3. Obtain Y-site blood administration tubing.
• 4. Check to be sure that consent for the transfusion has been signed.
 Question
• A client requiring surgery is anxious about the possible need for a blood
transfusion during or after the procedure. The nurse suggests to the client to
take which actions to reduce the risk of possible transfusion complications?
Select all that apply.
• 1. Ask a family member to donate blood ahead of time.
• 2. Give an autologous blood donation before the surgery
• . 3. Take iron supplements before surgery to boost hemoglobin levels.
• 4. Request that any donated blood be screened twice by the blood bank.
• 5. Take adequate amounts of vitamin C several days prior to the surgery
date.
 Question

• The nurse working in the emergency department (ED) is assessing a client who
recently returned from Liberia and presented complaining of a fever at home,
fatigue, muscle pain, and abdominal pain. Which action should the nurse take next?
• 1. Check the client’s temperature.
• 2. Contact the health care provider.
• 3. Isolate the client in a private room.
• 4. Check a complete set of vital signs.
 Question
• The nurse is teaching a client about coughing and deep-breathing techniques
to prevent postoperative complications. Which statement is most appropriate
for the nurse to make to the client at this time as it relates to these
techniques?
• 1. “Use of an incentive spirometer will help prevent pneumonia.”
• 2. “Close monitoring of your oxygen saturation will detect hypoxemia.”
• 3. “Administration of intravenous fluids will prevent or treat fluid
imbalance.”
• 4. “Early ambulation and administration of blood thinners will prevent
pulmonary embolism.”
 Question
• The nurse assesses a client’s surgical incision for signs of infection. Which
finding by the nurse would be interpreted as a normal finding at the surgical
site?
• 1. Red, hard skin
• 2. Serous drainage
• 3. Purulent drainage
• 4. Warm, tender skin
 Question

• The nurse has conducted preoperative teaching for a client scheduled for surgery in
1 week. The client has a history of arthritis and has been taking acetylsalicylic acid.
The nurse determines that the client needs additional teaching if the client makes
which statement?
• 1. “Aspirin can cause bleeding after surgery.”
• 2. “Aspirin can cause my ability to clot blood to be abnormal.”
• 3. “I need to continue to take the aspirin until the day of surgery.”
• 4. “I need to check with my health care provider about the need to stop the aspirin
before the scheduled surgery.”
 Substances That Can Affect the Client in Surgery
• Antibiotics
• Anticholinergics

• Anticoagulants, Antiplatelet, and thrombolytic

• Anticonvulsants
• Antidepressants
• Antidysrhythmics
• Antihypertensives
• Corticosteroids
• Diuretics
• Herbal substance
• Insulin
 Question
• The nurse is creating a plan of care for a client scheduled for surgery. The
nurse should include which activity in the nursing care plan for the client on
the day of surgery?
• 1. Avoid oral hygiene and rinsing with mouthwash.
• 2. Verify that the client has not eaten for the last 24 hours.
• 3. Have the client void immediately before going into surgery.
• 4. Report immediately any slight increase in blood pressure or pulse.
 Question

• The nurse receives a telephone call from the post-anesthesia care unit stating
that a client is being transferred to the surgical unit. The nurse plans to take
which action first on arrival of the client?
• 1. Assess the patency of the airway.
• 2. Check tubes or drains for patency.
• 3. Check the dressing to assess for bleeding.
• 4. Assess the vital signs to compare with preoperative measurements.
 Questions

• The nurse is monitoring the status of a postoperative client in the immediate

postoperative period. The nurse would become most concerned with which
sign that could indicate an evolving complication?
• 1. Increasing restlessness
• 2. A pulse of 86 beats/minute
• 3. Blood pressure of 110/70 mm Hg
• 4. Hypoactive bowel sounds in all 4 quadrants
 Question

• The nurse is caring for a client who is 1 day postoperative for a total hip
replacement. Which is the best position in which the nurse should place the
client?
• 1. Side-lying on the operative side
• 2. On the non operative side with the legs abducted
• 3. Side-lying with the affected leg internally rotated
• 4. Side-lying with the affected leg externally rotated
 Question
• The nurse is performing an assessment on an older adult client. Which
assessment data would indicate a potential complication associated with the
skin?
• 1. Crusting
• 2. Wrinkling
• 3. Deepening of expression lines
• 4. Thinning and loss of elasticity in the skin