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2023 RN test 3 NCLEX questions well
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Qs A nurse in a long-term care facility is on an interprofessional safety committee focusing on protecting older adults from injury and trauma. Which action does the nurse suggest they prioritize? a. Ensuring proper function of fire alarms b. Preventing exposure to temperature extremes c. Screening for partner or elder abuse d. Maintaining clutter free rooms and hallways - ANS✔✔ d. Falls among older adults are the most common cause of hospital admissions for trauma, therefore rooms and hallways should be free of clutter. Elder abuse, fires, and temperature extremes are also significant hazards for older adults but are not the most common cause of trauma admissions. IPV occurs more frequently in adults as opposed to older adults. Qs An experienced nurse and new graduate nurse are caring for a confused older adult who gets out of bed and wanders. The preceptor intervenes when observing which action by the graduate nurse? a. Raising all four side rails to keep the patient in bed b. Performing documentation in the patient's room c. Suggesting obtaining a patient "sitter" d. Using a bed alarm to alert staff the patient leaving the bed - ANS✔✔
a. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails. People of small stature are more likely to be injured slipping through or between the side rails. A history of falls from a bed with raised side rails carries a significant risk for a serious incident. The nurse uses creative measures while promoting safety and respect for the patient's dignity. Qs The hospital's fire alarm sounds, and an announcement is made that there is a fire in a patient room. What is the priority for nurses on the unit? a. Removing patients from the room or vicinity b. Attempting to put out the fire with water or appropriate extinguishers c. Closing all the doors on the unit to contain the fire d. Running to the closest unit and requesting help - ANS✔✔ a. The nurse uses the acronym RACE and rescues and/or removes the patient and those in nearby rooms as the safety priority. Sounding the alarm and extinguishing the fire are important after the patient is safe. Remaining on the unit allows you to assist patients and is more appropriate; assistance can be summoned by phone. Qs A nurse is filing a safety event report for a confused patient who fell while getting out of bed. Which action is most appropriate during documentation? a. Including suggestions on how to prevent the incident from recurring b. Providing minimal information about the incident c. Discussing the details with the patient before documenting them d. Recording the circumstances and effect on the patient in the health record - ANS✔✔
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d. This allows the resident to be on the move and be more likely to find their room when they want to return. Many facilities use this kind of approach, rather than restrict patients' movements. Identifying the patient's door with their photo and a balloon may resolve the issue without restraints. Using the geriatric chair and sheets are forms of physical restraint. Leaving the bed in the high position is a safety risk and would likely result in a fall. Qs A nurse has exhausted every effort to keep a confused, postoperative patient safe and in bed. Following The Joint Commission guidelines for use of restraints, which nursing action reflects safe practice? a. Positioning the patient in the supine position prior to applying wrist restraints b. Ensuring that two fingers can be inserted between the restraint and patient's wrist c. Applying a cloth restraint to the left hand of the patient with an IV catheter in the right wrist d. Tying an elbow restraint to the raised side rail of the patient's bed - ANS✔✔ b. The nurse should be able to place two fingers between the restraint and a patient's wrist or ankle. Restraining the patient in a supine position increases the risk of aspiration. Due to the IV in the right wrist, alternative forms of restraints should be tried, such as a cloth mitt or an elbow restraint. Securing the restraint to a side rail may injure the patient when the side rail is lowered. Qs During the admission process, a nurse orients an older adult to their hospital room. What is the current safety priority? a. Explaining how to use the telephone b. Introducing the patient to their roommate
c. Reviewing the hospital policy on visiting hours d. Demonstrating how to operate the call bell - ANS✔✔ d. Teaching the patient to use the call bell is a safety priority; knowing how to use the phone, meeting the roommate, and knowledge of visiting hours will not necessarily prevent an accidental injury. Qs A nurse works in a facility stating they support a culture of safety. What will the nurse expect to find operationalized in this culture? Select all that apply. a. Support for reporting errors and near misses without blame b. Nurses being the employees responsible for safety in the organization c. Commitment of resources to address actual/potential safety issues d. Emphasis placed on individuals, their departments, and resources e. Promotion of teamwork and collaboration throughout the organization f. Administrators' and managers' commitment to safe operations - ANS✔✔ a, c, e, f. The key features of a culture of safety include: (1) acknowledging the high-risk nature of health care and the commitment to safe operations, (2) maintaining a blame- free environment where reporting is protected and expected, (3) promoting teamwork and collaboration to prevent and seek solutions to patient safety issues, and (4) valuing safety as a focus in all health care facilities, the home, workplace, and community. Qs A school nurse is teaching about adolescent safety with students entering high school. What will the nurse include in the discussion about the major causes of death in this group? Select all that apply. a. Choking
A nurse observes involuntary muscle jerking in a sleeping patient. What action will the nurse take next? a. No action is necessary; this is normal in stage 1 sleep. b. Report the neurologic deficit to the health care provider. c. Lower the temperature in the patient's room. d. Awaken the patient, as this is an indication of night terrors. - ANS✔✔ a. Involuntary muscle jerking occurs in stage I NREM sleep and is a normal finding. No further actions are needed for this patient. Qs A nurse working the night shift is watching the monitors on a telemetry unit and observes a slight increase in a patient's vital signs during sleep. Which of these points will the nurse correlate to changes in vital signs? Select all that apply. a. They are aware of his surroundings at this point. b. They are in delta sleep at this time. c. It would be most difficult to awaken them at this time. d. This is most likely an NREM stage. e. This stage constitutes around 20% to 25% of total sleep. f. The muscles are relaxed in this stage. - ANS✔✔ c, e. This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20% to 25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. In stage IV NREM sleep (delta sleep), the muscles are relaxed, whereas small muscle twitching may occur in REM sleep.
Qs A nurse working in a sleep lab observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. a. REM sleep constitutes much of the sleep cycle of a preschool child. b. By age 8 years, most children no longer take naps. c. Sleep needs usually decrease when physical growth peaks. d. Many adolescents do not get enough sleep. e. Total sleep decreases in adults with a decrease in stage IV sleep. f. Sleep is less sound in older adults, and stage IV sleep may be absent. - ANS✔✔ d, e, f. Many adolescents do not get enough sleep due to the demands of school, activities, and part-time employment. Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older adults, and stage IV sleep is absent or considerably decreased. REM sleep constitutes much of the sleep cycle of a young infant, and by the age of 5 years, most children no longer nap. Sleep needs usually increase when physical growth peaks. Qs A nurse is providing education in a senior center on sleep and sleep hygiene in older adults. What teaching point will the nurse include? a. Drinking a cup of regular tea at night induces sleep. b. Using alcohol moderately promotes a deep sleep. c. Eating a bedtime snack high in tryptophan and carbohydrates improves sleep. d. Exercising right before bedtime can hinder sleep. - ANS✔✔ c. The nurse would teach that having a small bedtime snack high in tryptophan and carbohydrates improves sleep. Regular tea contains caffeine and increases alertness.
f. Patient taking low-dose aspirin prophylactically - ANS✔✔ b, c, e. Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications are seen as additional common causes of sleep problems. Qs A nurse in a pediatric unit notes a school-aged child snores and appears to have labored breathing during sleep. Which assessment question could the nurse ask the patient or parents? a. "Do you have trouble sleeping?" b. "Have you missed a lot of school due to not feeling well?" c. "Have you been wetting the bed lately?" d. "Do you have a history of high blood pressure?" - ANS✔✔ c. OSA (pediatric) is defined by the presence of snoring, labored/obstructed breathing, enuresis, or daytime consequences (hyperactivity or other neurobehavioral problems, sleepiness, fatigue). Adults, children, and adolescents with symptoms of OSA, including snoring, should have polysomnography to confirm the diagnosis. Although OSA may cause insomnia, this is not the primary diagnosis in this case. Narcolepsy is a condition characterized by excessive daytime sleepiness and frequent overwhelming urges to sleep or inadvertent daytime lapses into sleep. Hypertension is a consequence of OSA in adults. Qs At an annual health and wellness visit, the parent of an adolescent reports a teacher's concerns that their child is sleepy at school during class time. Which information will the nurse share with the parent and child? Select all that apply. a. Adolescents typically need 8 to 10 hours of sleep each night.
b. Demands on the adolescent's time causes them to sleep longer hours. c. Insufficient sleep can lead to daytime sleepiness. d. Adolescents require reduced sleep in the teen years. e. The adolescent could benefit from a sleep study for insomnia. - ANS✔✔ a, c. Adolescents require 8 to 10 hours of sleep nightly; however, demands on their time cut into the needed sleep. Insufficient sleep can lead to daytime sleepiness. Qs A nurse recommends that a patient with a sleep disorder keep a sleep diary. Which data will the nurse ask the patient to document? Select all that apply. a. Daily mental activities b. Daily physical activities c. Morning and evening body temperature d. Daily measurement of fluid intake and output e. Presence of anxiety or worries affecting sleep f. Morning and evening blood pressure readings - ANS✔✔ a, b, e. A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure is typically kept in the graphic record. Qs A nurse in a rehabilitation facility develops a plan to help promote patients' sleep. What interventions will the nurse include in the plan? Select all that apply a. Maintain a consistent bedtime and time to awaken.
A nursing student is caring for an older adult with arthritis who states she did not sleep well and was "up all night to use the bathroom." To help promote sleep, the student plans to discuss re-timing which medication with the primary nurse? a. Furosemide (diuretic) 10:00 AM, 10:00 PM b. Melatonin 9:00 PM c. Acetaminophen 10:00 AM, 10:00 PM d. Artificial tears every 8 hours, 8:00 AM, 2:00 PM, 8:00 PM - ANS✔✔ a. It is best to administer diuretics in the morning or early evening to prevent nocturia. Melatonin promotes sleep and rest. Acetaminophen can relieve arthritis pain and help promote rest. Artificial tears, used for dry eyes, will not affect sleep. Qs A nurse caring for patients on a surgical unit should implement which recommendation to promote sleep? Select all that apply a. Keep the room light dimmed during the day. b. Maintain a cool temperature in the room for sleep. c. Keep the door of the room open for fresh air. d. Offer a hypnotic to patients on a regular basis. e. Offer pain medication prior to sleep, as needed. f. Provide earplugs if the patient agrees. - ANS✔✔ b, e, f. The nurse should keep the room cool and provide earplugs and eye masks if desired. The nurse should maintain a bright room environment during daylight hours and dim lights in the evening, keeping the door of the room closed to keep out extraneous noise. Sleep aid medications should only be offered as prescribed with the knowledge that they can become habit forming.
Qs A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in older adults. Which is the best action for these patients? a. Increase physical activities during the day. b. Encourage short periods of napping during the day. c. Increase fluids during the evening. d. Dispense diuretics during the afternoon hours. - ANS✔✔ a. In order to promote sleep in the older adult, the nurse should encourage daily physical activity such as walking or water aerobics. The nurse discourages napping during the day, decreases fluids at night, and dispenses diuretics in the morning (or early evening when necessary). Qs A patient experiencing menopause tells the nurse at the medical clinic that she would like to try a CAH hormonal sleep aid like her friend uses. What information can the nurse give the patient? a. Melatonin, an over-the-counter hormonal sleep aid, has varied effectiveness. b. Lavender is a hormonal scented sleep aid. c. Lorazepam, a naturally occurring benzodiazepine, is recommended for sleep. d. Valerian is a natural hormonal sleep aid. - ANS✔✔ a. Melatonin, used as a complementary or alternate to traditional pharmacologic agents, is a hormone thought to regulate the sleep-wake cycle. Valerian is an herb; lavender is a plant used for aromatherapy and relaxation. Benzodiazepines are pharmacologic medications used to decrease anxiety and promote sleep and relaxation. Qs
says it is, existing whenever the person says it does, even if the cause is not clearly established." Pain is a complex, unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain may be classified according to its duration, its location or source, its mode of transmission, or its etiology. Qs
- A nurse in a rehabilitation facility is evaluating patients with chronic pain to develop an interprofessional plan of care. Which patients would the nurse identify who could benefit from a multimodal approach to pain management? Select all that apply. a. Patient receiving chemotherapy for bladder cancer b. Adolescent who had an appendectomy c. Patient who is experiencing a ruptured aneurysm d. Patient with fibromyalgia requesting pain medication e. Patient having back pain related to an accident that occurred last year f. Patient experiencing pain from second-degree burns - ANS✔✔ a, d, e. Chronic pain is pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period. Examples are cancer pain, fibromyalgia pain, and back pain. Acute pain is generally rapid in onset and varies in intensity from mild to severe, as occurs with an emergency appendectomy, a ruptured aneurysm, and pain from burns. Qs
- A patient reports diffuse abdominal pain that is difficult to localize. The nurse documents this as which type of pain? a. Cutaneous b. Visceral c. Superficial Somatic -
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b. Visceral pain, which is poorly localized and can originate in body organs in the abdomen. Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue. A paper cut that produces sharp pain with a burning sensation is an example of cutaneous pain. Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain. Qs
- Which question by the nurse will be most helpful in determining whether a patient who is experiencing a myocardial infarction has referred pain? a. "Did your chest pain last 2 minutes or less? b. "Was the pain on the surface of your chest?" c. "Is this pain in your residual limb shooting or burning?" d. "Are you having any arm or shoulder pain?" - ANS✔✔ d. Referred pain is perceived in an area distant from its point of origin, whereas transient pain is brief and passes quickly. One example is the pain of MI (heart attack) that can be felt in the shoulder or chest, among other areas. Superficial pain originates in the skin or subcutaneous tissue. Phantom pain may occur in a person who has had a body part amputated, either surgically or traumatically. Qs
- A nurse is caring for patients who are nonverbal. What are examples of behavioral responses to pain? Select all that apply. a. Cradling a wrist that was injured in a car accident b. Moaning and crying from abdominal pain c. Increasing pulse following a myocardial infarction d. Striking out at a nurse who attempts to provide a bath
b. Substance P c. Endorphins d. Serotonin - ANS✔✔ c. Endorphins are produced at neural synapses at various points along the CNS pathway. They are powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria. It is thought that endorphins are released through pain relief measures, such as relaxation techniques. Prostaglandins, substance P, and serotonin (a hormone that can act to stimulate smooth muscles, inhibit gastric secretion, and produce vasoconstriction) are neurotransmitters or substances that either excite or inhibit target nerve cells. Qs
- The nurse applies the gate control theory of pain to provide pain relief to a patient with chronic lower back pain. What nursing intervention will help relieve pain by "closing the gate"? a. Encouraging regular use of analgesics b. Applying moist heat to the area at intervals c. Reviewing the pain experience with the patient d. Ambulating the patient after administering medication - ANS✔✔ d. While many analgesics are ordered on a PRN (as needed) basis, patients should be taught that it is more difficult to relieve pain that prevent it. The patient should not wait until pain is severe or unbearable to request pain medication. Few people become addicted to the medications if used for a short period of time. Pain following surgery can be controlled and should not be considered a natural part of the experience that will lessen in time. Qs
- A postoperative patient asks the nurse about pain management following surgery. What teaching will the nurse provide? a. "Avoid asking for pain medication often, as it can be addictive." b. "It is better to wait until the pain is severe before asking for pain medication." c. "It's natural to have pain after surgery; it will lessen in intensity in a few days." d. "You will be more comfortable if you take the medication at regular intervals." - ANS✔✔ b. The gate control theory states that a limited amount of sensory information can be processed by the nervous system at any given moment. When too much information is sent through, certain cells in the spinal column interrupt the signal as if closing a gate, interfering with pain perception. Nursing measures such as applying warmth to the lower back stimulate the large nerve fibers to close the gate and block the pain. The other choices do not involve attempts to stimulate large nerve fibers that interfere with pain transmission as explained by the gate control theory. Qs
- The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient? a. CRIES b. COMFORT c. FLACC d. FACES - ANS✔✔ a. The CRIES Pain Scale is a tool intended for use with neonates and infants from 0 to 6 months. The COMFORT Scale, used to assess pain and distress in critically ill pediatric patients, relies on six behavioral and two physiologic factors that determine the level of analgesia needed to adequately relieve pain in these children. The FLACC Scale (F—Faces, L—Legs, A—Activity, C—Cry, C—Consolability) was designed for infants and children from age 2 months to 7 years who are unable to validate the presence or severity of pain. The
