Manila OK’d as NCLEX site

July 12, 2007

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US nursing boards council approves RP request
Nurses may take first exam in Manila Aug. 23


By RAYMUND F. ANTONIO

Filipino nursing graduates may now take the National Council Licensure Examination (NCLEX) in Manila after the National Council of State Boards of Nursing, Inc. (NCSBN) selected the country’s capital city as a new international NCLEX test site.

The NCSBN said it had approved the Philippine government’s request for the establishment of a testing center in Manila.

Dawn Kappel, NCSBN director for marketing and communications, said the examination appointments are scheduled on July 13, Friday and the NCLEX will be administered on August 23 at the International Pearson Professional Center in Manila.

"The Manila site was chosen in February by the NCSBN Board of Directors because of the deep commitment shown by the Philippine government to ensuring a secure test center," Kappel said.

The NCSBN is a nonprofit organization comprising the boards of nursing in 50 states, the District of Columbia and four United States territories.

He said the Manila test site will allow for greater customer service to nurses without compromising the goal of safeguarding the public health, safety and welfare of patients in the US.

The Commission on Filipinos Overseas (CFO), chaired by Secretary Dante Ang, initiated efforts last year to have the Philippines as a venue for the NCLEX.

The efforts were nearly scuttled by the controversial leakage in the June licensure nursing exam.

Filipino nurses are required to take the NCLEX exams, a standardized test, to get a license to work in the US. Each state board of nursing in the US uses the exam to determine the credentials of a nurse.

According to NCSBN, the NCLEX examination fee for examinees stands at 0 or R9,200 at current conversion rates. "Candidates who elect to take the NCLEX at an international site pay an additional 0 when they schedule their examination," it said.

Meanwhile, Professional Regulation Commission (PRC) Chairperson Leonor Tripon-Rosero said the result of this year’s nursing licensure examination, where 78,000 nursing graduates, including the "retakers", will be released in the last week of August.

The current international sites for NCLEX are in London, England; Hong Kong; Sydney, Australia; Toronto, Montreal, and Vancouver, Canada; Frankfurt, Germany; Mumbai, New Delhi, Hyderabad, Bangalore, and Chennai, India; Mexico City, Mexico; Taipei, Taiwan; and Chiyoda-ku and Yokohama, Japan.



the manila bulletin

Drug Administration

Basic Critical Thinking Guidelines for Safe Drug Administration

Before administration:

      • gather general baseline data
        • VS, lab results, allergies, co-morbidities, Ht, Wt; liver, pulmonary, renal, neuro, nutrition, hydration status
      • identify client factors
        • affects on drug action from age, cultural factors, history
      • determine purpose of therapy
        • indication for drug; desired therapeutic outcome
      • reconcile medication profile
        • with client, family, nursing staff, provider
      • verify prescription and client
        • dose, time, calculations, dosing range, dispensing method

After administration:

      • monitor client response
        • therapeutic effect, adverse effects, toxicity
      • document findings and act
        • data requiring action or follow-up nursing care
      • document nursing care
        • describe: care before and after, drug administration
      • evaluate care and process
        • describe: med errors, problems so others, agency benefit

Client teaching

      • instruct client and family about drug
        • what to report; how to administer; food, substances, activities to avoid; need for follow-up care and testing

Basic Nursing Care to Prevent or Minimize Common Adverse Effects of Drug Therapy

  • Adverse effect: nursing care, monitoring, teaching
    • nausea, vomiting, anorexia
      • collaborate for antiemetic, eliminate triggers, maintain NPO status
      • monitor F/E balance, bowel sounds and pattern, food intake
      • teaching: small, frequent meals, breathing techniques; avoid triggers
    • constipation
      • provide fluid, fiber, stool softener, encourage ambulation
      • monitor bowel sounds, pattern; review diet for fluid, fiber
      • teaching: increase fluid, fiber; ambulate; establish bowel habits
    • diarrhea
      • provide hygiene, skin care, close supervision to prevent injury
      • monitor bowel pattern, F/E balance, weakness, skin, cultures
      • teaching: increase fluid intake, wash hands, avoid irritating foods
    • rash, allergy
      • screen for allergies, previous reactions, provide skin care
      • monitor airway, breathing, BP, skin, pruritus, cultures
      • teaching: report dypsnea, pruritus, hives, worsening condition
    • hypotension, dizziness
      • maintain supine position, encourage fluids, review med profile
      • monitor VS, Sa02, EKG, level of consciousness, U/O
      • teaching: remain in bed; ask for help to stand; avoid alcohol, sedation

Basic Nursing Care to Prevent or Minimize Adverse Effects of a Drug Class or Type

  • Drug class or type with related adverse effects: nursing care, monitoring, and teaching
    • antihypertensives: orthostatic hypotension, F/E imbalance
      • assist with activity; eliminate drug interactions, vasodilators, CNS depressants
      • monitor BP, pulse, breath sounds, serum electrolyte levels, edema, dizziness
      • teaching: get help to stand, report dizziness; avoid alcohol, sedatives, OTC agents, caffeine
    • anticholinergic agents: dry mouth, constipation, blurred vision
      • provide sips of water, oral care; assist with activity; remove environmental hazards
      • monitor bowel pattern, vision, oral mucous membranes
      • teaching: frequent oral care, avoid dangerous activity, ask for help to stand
    • anticoagulants and antiplatelet agents: bleeding
      • minimize invasive procedures, shaving; provide gentle oral care; assist with activity
      • monitor bleeding, coagulation tests, CBC, bruising; remove adverse drug and food affects
      • teaching: avoid dangerous activity, wear Medic alert tag, avoid NSAIDs, alcohol
    • anticonvulsants: CNS depression, myelosuppression: infection and bleeding
      • assist with activity; protect airway, breathing; minimize invasive procedures
      • monitor seizure activity, CBC with diff, temperature, regional redness, swelling, or drainage
      • teaching: wear Medic-alert tag, avoid dangerous activity, wash hands, avoid crowds, need for follow-up care and testing
    • antidysrhythmics: new or more dangerous dysrhythmias, changes in BP
      • maintain F/E balance, SaO2 >95%, sinus rhythm; assist with position changes
      • monitor PFT, EKG, BP, pulse, SaO2, serum electrolytes, LOC
      • teaching: ask for help to stand, report irregular pulse, technique for counting pulse
    • antiinfective agents: renal and hepatic dysfunction
      • obtain cultures before administration, verify administration guidelines, screen for renal and hepatic dysfunction, allergy, nephrotoxic or hepatotoxic drugs
      • monitor RFT, LFT, jaundice, dark stool or urine, nausea and vomiting
      • report nausea, vomiting, dark stool or urine, jaundice; need for follow-up care and testing
    • loop, thiazide diuretics: circulatory collapse, myelosuppression, F/E imbalance, ototoxicity
      • verify infusion guidelines, B/P, serum electrolytes, and U/O before giving
      • monitor serum Na+ and K+, breath sounds, edema, BP, U/O
      • teaching: report palpitations, weakness, irregular pulse, decreased U/O, temperature
    • female hormones: thromboembolic disorders, increased risk of breast and endometrial cancer, hyperglycemia, hypercalcemia, depression, seizures
      • monitor peripheral perfusion, edema; leg pain, tenderness; serum Ca++, glucose
      • teaching: report lumps and abnormal bleeding, muscle twitching

NCLEX Practice 4

1. The nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness would the nurse recognize as increasing the risk to develop Reye's syndrome?

A) rubeola

B) meningitis

C) varicella

D) hepatitis

The correct answer is C: varicella

Varicella (chicken pox) and influenza are viral illnesses that have been identified as increasing the risk for Reye''s syndrome. Use of aspirin is contraindicated for children with these infections.

2. The parents of a child who has recently been diagnosed with asthma ask the nurse to explain the condition to them. The best response is "Asthma causes

A) the airway to become narrow and obstructs airflow."

B) air to be trapped in the lungs because the airways are dilated."

C) the nerves that control respiration to become hyperactive."

D) a decrease in the stress hormones which prevents the airways from opening."

The correct answer is A: the airway to become narrow and obstructs airflow."

Asthma is defined as airway obstruction or a narrowing that is characterized by bronchial irritability after exposure to various stimuli.

3. The nasogastric tube of a post-op gastrectomy client has stopped draining greenish liquid. The nurse should

A) irrigate it as ordered with distilled water

B) irrigate it as ordered with normal saline

C) place the end of the tube in water to see if the water bubbles

D) withdraw the tube several inches and reposition it

The correct answer is B: irrigate it as ordered with normal saline

Nasogastric tubes are only irrigated with normal saline to maintain patency.

4. A client arrived in the USA from a developing country 1 week ago. The client is to be admitted to the medical surgical unit with a diagnosis of AIDS. There is a history of these findings: unintended weight loss, drug abuse, night sweats, productive cough and a "feeling of being hot all the time." The nurse should assign the client to share a room with a client with the diagnosis of

A) Acute tuberculosis with a productive cough of discolored sputum for over three months

B) Lupus and vesicles on one side of the middle trunk from the back to the abdomen

C) Pseudomembranous colitis and C. difficile

D) Exacerbation of polyarthritis with severe pain

The correct answer is A: Acute tuberculosis with a productive cough of discolored sputum for over three months

The client being admitted has the classic findings of pulmonary tuberculosis. Of the available choices, the client in option A would be the most appropriate roommate. It is acceptable to put clients with similar diagnoses in the same room when no other alternative exists. Clients are considered contagious until the cough is eliminated with medications, which initially is a combination of 4 simultaneous drugs.

5. The mother of a burned child asks the nurse to clarify what is meant by a third degree burn. The best response by the nurse is

A) "The top layer of the skin is destroyed."

B) "The skin layers are swollen and reddened."

C) "All layers of the skin were destroyed in the burn."

D) "Muscle, tissue and bone have been injured."

The correct answer is C: "All layers of the skin were destroyed in the burn."

A third degree burn is a full thickness injury to dermis, epidermis and subcutaneous tissue.

6. The nurse is assessing a pregnant client in her third trimester. The parents are informed that the ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely due to what factor?

A) Sexually transmitted infection

B) Exposure to teratogens

C) Maternal hypertension

D) Chromosomal abnormalities

The correct answer is C: Maternal hypertension

Pregnancy induced hypertension is a common cause of late pregnancy fetal growth retardation. Vasoconstriction reduces placental exchange of oxygen and nutrients.

7. Which of these women in the labor and delivery unit would the nurse check first when the water breaks (ROM) for all of them within a 2 minute period?

A) A multigravida with station at +2, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 7 cm, and 50% effacement

B) A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement

C) A primipara with station at 0, contractions at 20 minutes apart with duration of 20 seconds, cervix dilated at 2 cm and 10% effacement

D) A primipara with station at 1, contractions at 15 minutes apart with duration of 35 seconds, cervix dilated at 5 cm and 50% effacement

he correct answer is B: A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement

When the station is -1 or -2 and the water breaks, the risk is greater for a prolapsed cord.

8. The recent increase in the reported cases of active tuberculosis (TB) in the United States is attributed to which factor?

A) The increased homeless population in major cities

B) The rise in reported cases of positive HIV infections

C) The migration patterns of people from foreign countries

D) The aging of the population located in group homes

The correct answer is B: The rise in reported cases of positive HIV infections

Between 1985 and 2002 there has been a significant increase in the reported cases of TB. The increase was most evident in cities with a high incidence of positive HIV infection. Positive HIV infection currently is the greatest known risk factor for reactivating latent TB infections.

9. The nurse has been teaching an apprehensive primipara who has had initial difficulty in nursing the newborn. What observation at the time of discharge suggests that initial breast feeding is effective?

A) The mother feels calmer and talks to the baby while nursing

B) The mother awakens the newborn to feed whenever it falls asleep

C) The newborn falls asleep after 3 minutes at the breast

D) The newborn refuses the supplemental bottle of glucose water

The correct answer is A: The mother feels calmer and talks to the baby while nursing

Early evaluation of successful breastfeeding can be measured by the client''s voiced confidence and satisfaction with the infant.

10. A nurse is teaching a class for new parents at a local community center. The nurse would stress that _______ is most hazardous for an 8 month-old child.

A) riding in a car

B) falling off a bed

C) an electrical outlet

D) eating peanuts

he correct answer is D: eating peanuts

Asphyxiation due to foreign materials in the respiratory tract is the leading cause of death in children younger than 6 years of age.

11. An unlicensed assistive staff member asks the nurse manager to explain the beliefs of a Christian Scientist who refuses admission to the hospital after a motor vehicle accident. The best response of the nurse would be which of these statements?

A) "Spiritual healing is emphasized and the mind contributes to the cure."

B) "The primary belief is that dietary practices result in health or illness."

C) "Fasting and prayer are initial actions to take in physical injury."

D) "Meditation is intensive in the initial 48 hours and daily thereafter."

The correct answer is A: "Spiritual healing is emphasized and the mind contributes to the cure."

For the Christian Scientist, a mind cure uses spiritual healing methods. For the believer, medical treatments may interfere with drawing closer to God.

12. For which of the following mother-baby pairs should the nurse review the Coombs' test in preparation for administering Rho (D) immune globulin within 72 hours of birth?

A) Rh negative mother with Rh positive baby

B) Rh negative mother with Rh negative baby

C) Rh positive mother with Rh positive baby

D) Rh positive mother with Rh negative baby

The correct answer is A: Rh negative mother with Rh positive baby

An Rh- mother who delivers an Rh+ baby may develop antibodies to the fetal red cells to which she may be exposed during pregnancy or at placental separation. If the Coombs test is negative, no sensitization has occurred. TheFor which of the following mother-baby pairs should the nurse review the Coomb''s'' test in preparation for administering Rho(D) immune globulin is given to block antibody formation in the mother.

13. After the shift report in a labor and delivery unit which of these clients would the nurse check first?

A) A middle aged woman with asthma and Type 1 diabetes mellitus has a BP of 150/94

B) A middle aged woman with a history of two prior vaginal term births is 2 cm dilated

C) A young woman who is a grand multipara has cervical dilation of 4 cm and is 50% effaced

D) An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum

The correct answer is D: An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum

This client has an actual complication. The others present with findings of potential complications.

14. While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say "no" to almost everything is an indication of what psychosocial skill?

A) Stubborn behavior

B) Rejection of parents

C) Frustration with adults

D) Assertion of control

The correct answer is D: Assertion of control

Negativity is a normal behavior in toddlers. The nurse must be aware that this behavior is an important sign of the child''s progress from dependency to autonomy and independence.

15. The nurse is caring for a client with end-stage heart failure. The family members are distressed about

the client's impending death. What action should the nurse do first?

A) Explain the stages of death and dying to the family

B) Recommend an easy-to-read book on grief

C) Assess the family's patterns for dealing with death

D) Ask about their religious affiliations

The correct answer is C: Assess the family''s patterns for dealing with death

When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that the client and their family''s needs are adequately identified in order to select the best nursing care approaches.

16. A client's admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client?

A) Moist mucous membranes

B) Urinary frequency

C) Poor skin turgor

D) Increased blood pressure

The correct answer is C: Poor skin turgor

The specific gravity value is high, indicating dehydration. Poor skin turgor (tenting of the skin) is consistent with this problem.

17. The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state: “We are concerned about the possible occurrence of sudden infant death syndrome (SIDS).” In order to take appropriate action, the nurse must understand that

A) The child is within the age group most susceptible to SIDS

B) The peak age for occurrence of SIDS is 8 to 12 months of age

C) The apnea monitor is not effective on a child in this age group

D) 95% of SIDS cases occur before 6 months of age

The correct answer is D: 95% of SIDS cases occur before 6 months of age

Peak age of SIDS occurrence is 2 to 4 months and 95% of cases occur by 6 months of age. It is the leading cause of death in infants 1 month to 1 year of age.

18. An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?

A) lung sounds

B) urine output

C) level of alertness

D) appetite

The correct answer is C: level of alertness

Assessing the level of consciousness (alert vs. lethargic vs. unresponsive) will help the provider determine the severity of the acute episode. If the client is alert, responses to questions about complaints can be followed-up quickly.

19. As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid

A) surfing

B) scuba diving

C) parasailing

D) swimming

The correct answer is B: scuba diving

The nurse would strongly emphasize the need for clients with history of spontaneous pneumothorax problems to avoid high altitudes, flying in unpressurized aircraft and scuba diving. The negative pressures could cause the lung to collapse again.

20. The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB?

A) Tuberculin skin testing

B) Sputum culture

C) White blood cell count

D) Chest x-ray

The correct answer is B: Sputum culture

The sputum culture is the most accurate method for determining the presence of active TB.

21. Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as the best initial approach?

A) Consider a liquid supplement to increase calories

B) Discuss consequences of an unbalanced diet with the child

C) Provide fruit, vegetable and protein snacks

D) Encourage the child to keep a daily log of foods eaten

The correct answer is B: Discuss consequences of an unbalanced diet with the child

It is important to educate the preadolescent as to appropriate diet, and the problems that might arise if diet is not adequate.

22. The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body?

A) the skin

B) the lungs

C) the muscles

D) bowel and bladde

The correct answer is A: the skin

A characteristic sign of rubeola is Koplik spots (small red spots with a bluish white center). These are found on the buccal mucosa about 2 days before and after the onset of the measles rash.

23. An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by

A) tachypnea

B) acidic byproducts

C) vomiting and dehydration

D) hyperpyrexia

The correct answer is A: tachypnea

Stimulation of respiratory center leads to hyperventilation, thus decreasing CO2 levels which causes respiratory alkalosis.

24. What is the major purpose of community health research?

A) Describe the health conditions of populations

B) Evaluate illness in the community

C) Explain the health conditions of families

D) Identify the health conditions of the environmen

he correct answer is A: Describe the health conditions of populations

Community health focuses upon aggregate population care.

25. Which action is most likely to ensure the safety of the nurse while making a home visit?

A) Observe no evidence of weapons in the home during the visit

B) Prior to the visit, review the client's record for any previous entries about violence

C) Remain alert at all times and leave if cues suggest the home is not safe

D) Carry a cell phone, pager and/or hand held alarm for emergencies

The correct answer is C: Remain alert at all times and leave if cues suggest the home is not safe

No person or equipment can guarantee nurses'' safety, although the risk of violence can be minimized. Beforem making initial visits, review referral information carefully and have a plan to communicate with agency staff. Schedule appointments with clients. When driving into an area for the first time, note potential hazards and sources of assistance. Become acquainted with neighbors. Be alert and confident while parking the car, walking to the client''s door, making the visit, walking back to the car, and driving away. LISTEN to clients. If they tell you to leave, do

so.

26. When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by

A) Reduced oxygen capacity of cells due to lack of iron

B) An imbalance between red cell destruction and production

C) Depression of red and white cells and platelets

D) Inability of sickle shaped cells to regenerate

The correct answer is B: An imbalance between red cell destruction and production

Anemia results when the rate of red cell destruction exceeds the rate of production through stimulated erythropoiesis in bone marrow (red cell life span shortened from 120 days to 12-20 days).

27. The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately?

A) Fecal impaction

B) Infrequent voiding

C) Stress incontinence

D) Burning with urination

The correct answer is A: Fecal impaction

The nurse should report fecal impaction or constipation which can cause obstruction of the bladder outlet. Bladder outlet obstruction is a common cause of urine retention in the elderly.

28. The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most likely to find?

A) Complaints of numbness and tingling in feet

B) Wheezing noted when lung sound auscultated

C) Excessive perspiration

D) Difficulty sleeping

The correct answer is A: Complaints of numbness and tingling in feet

A child who has unusual neurologic signs or symptoms, neuropathy, footdrop, or anemia that cannot be attributed to other causes may be suffering from lead poisoning. This most often occurs when a child ingests or inhales paint chips from lead-based paint or dust from remodeling in older buildings.

29. The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be high

A) calorie, low fat, low sodium

B) protein, low fat, low carbohydrate

C) protein, high calorie, unrestricted fat

D) carbohydrate, low protein, moderate fat

The correct answer is C: protein, high calorie, unrestricted fat

The child with Cystic Fibrosis needs a well balanced diet that is high in protein and calories. Fat does not need to be restricted.

30. The nurse is attending a workshop about caring for persons infected with hepatitis. Which characteristic is most appropriate when defining the incidence rate of hepatitis?

A) The number of persons in a population who develop hepatitis B during a specific period of time

B) The total number of persons in a population who have hepatitis B at a particular time

C) The percentage of deaths resulting from hepatitis B during a specific time

D) The occurrence of hepatitis B in the population at a particular time

he correct answer is A: The number of persons in a population who develop hepatitis B during a specific period of time

This is the correct definition of incidence of the disease.

31. In order to be effective in administering cardiopulmonary resuscitation to a 5 year-old, the

nurse must

A) assess the brachial pulses

B) breathe once every 5 compressions

C) use both hands to apply chest pressure

D) compress 80-90 times per minute

The correct answer is B: breathe once every 5 compressions

For a 5 year-old, the nurse should give 1 breath for every 5 compressions.

32. A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client?

A) Capillary refill less than 3 seconds

B) Pale mucous membranes

C) Respirations 36 breaths per minute

D) Complaints of fatigue when ambulating

The correct answer is A: Capillary refill less than 3 seconds

Since the hemoglobin and hematocrit are normal for an adult female, addition assessments should be normal. This capillary refill time is normal.

33. The nurse is providing home care for a client with heart failure and pulmonary edema. Which nursing diagnosis should have priority in planning care?

A) Impaired skin integrity related to dependent edema

B) Activity intolerance related to oxygen supply and demand imbalance

C) Constipation related to immobility

D) Risk for infection related to ineffective mobilization of secretions

The correct answer is B: Activity intolerance related to oxygen supply and demand imbalance

This is the primary problem due to decreased cardiac output related to heart failure. There is a reduction of oxygen, leading to findings of dyspnea and fatigue.

34. The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in

A) calcium

B) fiber

C) sodium

D) carbohydrate

The correct answer is C: sodium

The client with Meniere''s disease has an alteration in the balance of the fluid in the inner ear (endolymph). A low sodium diet will aid in reducing the fluid. Sodium restriction is also ordered as adjunct to diuretic therapy.

35. The nurse is teaching a mother who will breast feed for the first time. Which of the following is a priority?

A) Show her films on the physiology of lactation

B) Give the client several illustrated pamphlets

C) Assist her to position the newborn at the breast

D) Give her privacy for the initial feeding

The correct answer is C: Assist her to position the newborn at the breast

While all of the responses are helpful in teaching, the priority is placing the infant to breast as soon after birth as possible to establish contact and allow the newborn to begin to suck.

36. A postpartum client admits to alcohol use throughout the pregnancy. Which of the following newborn findings suggests to the nurse that the infant has fetal alcohol syndrome?

A) Growth retardation is evident

B) Multiple anomalies are identified

C) Cranial facial abnormalities are noted

D) Prune belly syndrome is suspected

The correct answer is C: Cranial facial abnormalities are noted

Characteristic facial abnormalities are seen in the newborn with fetal alcohol syndrome.

37. The nurse is caring for a client with congestive heart failure. Which finding requires the nurse's immediate attention?

A) pulse oximetry of 85%

B) nocturia

C) crackles in lungs

D) diaphoresis

The correct answer is A: pulse oximetry of 85%

An oxygen saturation of 88% or less indicates hypoxemia and requires the nurse''s immediate attention.

38. A 15 month-old child comes to the clinic for a follow-up visit after hospitalization for treatment of Kawasaki Disease. The nurse recognizes that which of the following scheduled immunizations will be delayed?

A) MMR

B) Hib

C) IPV

D) DTaP

The correct answer is A: MMR

Medical management of Kawasaki involves administration of immunoglobulins. Measles, mumps, rubella (MMR) is a live virus vaccine. Following administration of immunoglobulins, live vaccines should be held due to possible interference with the body''s ability to form antibodies.

39. The nurse is assessing a newborn delivered at home by a client addicted to heroin. Which of the following would the nurse expect to observe?

A) Hypertonic neuro reflex

B) Immediate CNS depression

C) Lethargy and sleepiness

D) Jitteriness at 24-48 hours

The correct answer is D: Jitteriness at 24-48 hours

Withdrawal signs may not be evident for 1-2 days after birth. Irritability and poor feeding also are evident.

40. The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered

A) Expected

B) Rude

C) Professional

D) Enjoyable

The correct answer is B: Rude

Native Americans consider direct eye contact to be impolite or aggressive among strangers.

NCLEX Practice 3

1. When suctioning a client's tracheostomy, the nurse should instill saline in order to

A) decrease the client's discomfort
B) reduce viscosity of secretions
C) prevent client aspiration
D) remove a mucus plug

The correct answer is D: remove a mucus plug
While no longer recommended for routine suctioning, saline may thin and loosen viscous secretions that are very difficult to move, perhaps making them easier to suction.

2. Decentralized scheduling is used on a nursing unit. A chief advantage of this management strategy is that it:

A) considers client and staff needs
B) conserves time spent on planning
C) frees the nurse manager to handle other priorities
D) allows requests for special privileges

The correct answer is A: considers client and staff needs

Decentralized staffing takes into consideration specific client needs and staff interests and abilities.

3. A client complains of some discomfort after a below the knee amputation. Which action by the nurse is most appropriate initially?

A) Conduct guided imagery or distraction
B) Ensure that the stump is elevated the first day post-op
C) Wrap the stump snugly in an elastic bandage
D) Administer opioid narcotics as ordered

The correct answer is B: Ensure that the stump is elevated the first day post-op.

This priority intervention prevents pressure caused by pooling of blood, thus minimizing the pain. Without this measure, a firm elastic bandage, opioid narcotics, or guided imagery will have little effect. Opioid narcotics are given for severe pain.

4. 70 year-old woman is evaluated in the emergency department for a wrist fracture of unknown causes. During the process of taking client history, which of these items should the nurse identify as related to the client’s greatest risk factors for osteoporosis?

A) History of menopause at age 50
B) Taking high doses of steroids for arthritis for many years
C) Maintaining an inactive lifestyle for the past 10 years
D) Drinking 2 glasses of red wine each day for the past 30 years

The correct answer is B: Taking high doses of steroids for arthritis for many years.

The use of steroids, especially at high doses over time, increases the risk for osteoporosis. The other options also predispose to osteoporosis, as do low bone mass, poor calcium absorption and moderate to high alcohol ingestion. Long-term steroid treatment is the most significant risk factor, however.

5. In addition to standard precautions, a nurse should implement contact precautions for which client?

A) 60 year-old with herpes simplex
B) 6 year-old with mononucleosis
C) 45 year-old with pneumonia
D) 3 year-old with scarlet fever

The correct answer is A: 60 year-old with herpes simplex.

Clients who have herpes simplex infections must have contact precautions in addition to standard precautions because of the associated, potentially weeping, skin lesions. Contact precautions are used for clients who are infected by microorganisms that are transmitted by direct contact with the client, including hand or skin-to-skin contact.

6. Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?

A) Venturi mask
B) Partial rebreather mask
C) Non-rebreather mask
D) Simple face mask

The correct answer is C: Non-rebreather mask
The non-rebreather mask has a one-way valve that prevents exhales air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent inhalation of room air but to allow exhalation of air. When a tight seal is achieved around the mask up to 100% of the oxygen is available.

7. A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be the best approach?

A) Vary the interview style for each candidate to learn different techniques
B) Use simple questions requiring "yes" and "no" answers to gain definitive information
C) Obtain an interview guide from human resources for consistency in interviewing each candidate
D) Ask personal information of each applicant to assure he/she can meet job demands

The correct answer is C: Obtain an interview guide from human resources for consistency in interviewing each candidate.

An interview guide used for each candidate enables the nurse manager to be more objective in the decision making. The nurse should use resources available in the agency before attempts to develop one from scratch. Certain personal questions are prohibited, and HR can identify these for novice managers.

8. Which of the following situations is most likely to produce sepsis in the neonate?

A) Maternal diabetes
B) Prolonged rupture of membranes
C) Cesarean delivery
D) Precipitous vaginal birth

The correct answer is B: Prolonged rupture of membranes

Premature rupture of the membranes (PROM) is a leading cause of newborn sepsis. After 12-24 hours of leaking fluid, measures are taken to reduce the risk to mother and the fetus/newborn.

9. A nurse assessing the newborn of a mother with diabetes understands that hypoglycemia is related to what pathophysiological process?

A) Disruption of fetal glucose supply
B) Pancreatic insufficiency
C) Maternal insulin dependency
D) Reduced glycogen reserves

The correct answer is A: Disruption of fetal glucose supply.

After delivery, the high glucose levels which crossed the placenta to the fetus are suddenly stopped. The newborn continues to secrete insulin in anticipation of glucose. When oral feedings begin, the newborn will adjust insulin production within a day or two.

10. The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding?

A) bounding pulse
B) rapid respirations
C) oliguria
D) neck veins are distended

The correct answer is C: oliguria
Kidneys maintain fluid volume through adjustments in urine volume.

11. The nurse is caring for a client with a myocardial infarction. Which finding requires the nurse's immediate action?

A) Periorbital edema
B) Dizzy spells
C) Lethargy
D) Shortness of breath

The correct answer is B: Dizzy spells
Cardiac dysrhythmias may cause a transient drop in cardiac output and decreased blood flow to the brain. Near syncope refers to lightheartedness, dizziness, temporary confusion. Such "spells" may indicate runs of ventricular tachycardia or periods of asystole and should be reported immediately.

12. The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding, the nurse should plan to

A) restrict visitors to immediate family
B) avoid arousal of the client except for family visits
C) keep client's hips flexed at no less than 90 degrees
D) apply a warming blanket for temperatures of 98 degrees Fahrenheit or less

The correct answer is A: restrict visitors to immediate family.

Maintaining a quiet environment will assist in minimizing cerebral rebleeding. When family visit, the client should not be disturbed. If the client is awake, topics of a general nature are better choices for discussion than topics that result in emotional or physiological stimulation.

13. A newborn delivered at home without a birth attendant is admitted to the hospital for observation. The initial temperature is 95 degrees Fahrenheit (35 degrees Celsius) axillary. The nurse recognizes that cold stress may lead to what complication?

A) Lowered BMR
B) Reduced PaO2
C) Lethargy
D) Metabolic alkalosis

The correct answer is B: Reduced PaO2
Cold stress causes increased risk for respiratory distress. The baby delivered in such circumstances needs careful monitoring. In this situation, the newborn must be warmed immediately to increase its temperature to at least 97 degrees Fahrenheit (36 degrees Celsius).

14. The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?

A) Neurotoxicity
B) Hepatomegaly
C) Nephrotoxicity
D) Ototoxicity

The correct answer is C: Nephrotoxicity
Nephrotoxicity is a common side effect of calcium disodium edetate, in addition to lead poisoning in general.


15. The nurse is at the community center speaking with retired people about glaucoma. Which comment by one of the retirees would the nurse support to reinforce correct information?

A) "I usually avoid driving at night since lights sometimes seem to make things blur."
B) "I take half of the usual dose for my sinuses to maintain my blood pressure."
C) "I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem."
D) "I take extra fiber and drink lots of water to avoid getting constipated."

The correct answer is D: "I take extra fiber and drink lots of water to avoid getting constipated."

Any activity that involves straining should be avoided in clients with glaucoma. Such activities would increase intraocular pressure.

16. A client with a fractured femur has been in Russell’s traction for 24 hours. Which nursing action is associated with this therapy?

A) Check the skin on the sacrum for breakdown
B) Inspect the pin site for signs of infection
C) Auscultate the lungs for atelectasis
D) Perform a neurovascular check for circulation

The correct answer is D: Perform a neurovascular check for circulation
While each of these is an important assessment, the neurovascular integrity check is most associated with this type of traction. Russell’s traction is Buck’s traction with a sling under the knee.

17. The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspects of this care is/are

A) sedation as needed to prevent exhaustion
B) antibiotic therapy for 10 to 14 days
C) humidified air and increased oral fluids
D) antihistamines to decrease allergic response

The correct answer is C: humidified air and increased oral fluids
The most important aspects of home care for a child with acute spasmodic croup are humidified air and increased oral fluids. Moisture soothes inflamed membranes. Adequate systemic hydration aids is mucociliary clearance and keeps secretions thin, white, watery, and easily removed with minimal coughing.

18. The nurse is performing a gestational age assessment on a newborn delivered 2 hour ago. When coming to a conclusion using the Ballard scale, which of these factors may affect the score?

A) Birth weight
B) Racial differences
C) Fetal distress in labor
D) Birth trauma

The correct answer is C: Fetal distress in labor
The effects of earlier distress may alter the findings of reflex responses as measured on the Ballard tool. Other physical characteristics that estimate gestational age, such as amount of lanugo, sole creases and ear cartilage are unaffected by the other factors.

19. A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse’s immediate attention?

A) Capillary refill of fingers on right hand is 3 seconds
B) Skin warm to touch and normally colored
C) Client reports prickling sensation in the right hand
D) Slight swelling of fingers of right hand

The correct answer is C: Client reports prickling sensation in the right hand
A prickling sensation is an indication of compartment syndrome and requires immediate action by the nurse. The other findings are normal for a client in this situation.

20. A couple trying to conceive asks the nurse when ovulation occurs. The woman reports a regular 32 day cycle. Which response by the nurse is correct?

A) Days 7-10
B) Days 10-13
C) Days 14-16
D) Days 17-19

The correct answer is D: Days 17-19
Ovulation occurs 14 days prior to menses. Considering that the woman''s cycle is 32 days, subtracting 14 from 32 suggests ovulation is at about the 18th day

21. A newborn has hyperbilirubinemia and is undergoing phototherapy with a fiberoptic blanket. Which safety measure is most important during this process?

A) Regulate the neonate’s temperature using a radiant heater
B) Withhold feedings while under the phototherapy
C) Provide water feedings at least every 2 hours
D) Protect the eyes of neonate from the phototherapy lights


The correct answer is C: Provide water feedings at least every 2 hours
Protecting the eyes of the neonates is very important to prevent damage when under the ultraviolet lights, but since the blanket is used, extra protection of the eyes is unnecessary. It is recommended that the neonate remain under the lights for extended periods. The neonate’s skin is exposed to the light and

the temperature is monitored, but a heater may not be necessary. There is no reason to withhold feedings. Frequent water or feedings are given to help with the excretion of the bilirubin in the stool.

22. Which client is at highest risk for developing a pressure ulcer?

A) 23 year-old in traction for fractured femur
B) 72 year-old with peripheral vascular disease, who is unable to walk without assistance
C) 75 year-old with left sided paresthesia who is incontinent of urine and stool
D) 30 year-old who is comatose following a ruptured aneurysm

The correct answer is C: 75 year-old with left sided paresthesia who is incontinent of urine and stool
Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.

23. A nurse is performing the routine daily cleaning of a tracheostomy. During the procedure, the client coughs and displaces the tracheostomy tube. This negative outcome could have avoided by

A) placing an obturator at the client’s bedside
B) having another nurse assist with the procedure
C) fastening clean tracheostomy ties before removing old ties
D) placing the client in a flat, supine position

The correct answer is C: fastening clean tracheostomy ties before removing old ties
Fastening clean tracheostomy ties before removing old ones will ensure that the tracheostomy is secured during the entire cleaning procedure. The obturator is useful to keep the airway open only after the tracheostomy outer tube is coughed out. A second nurse is not needed. Changing the position may not prevent a dislodged tracheostomy.

24. A 16 year-old boy is admitted for Ewing's sarcoma of the tibia. In discussing his care with the parents, the nurse understands that the initial treatment most often includes

A) amputation just above the tumor
B) surgical excision of the mass
C) bone marrow graft in the affected leg
D) radiation and chemotherapy

The correct answer is D: radiation and chemotherapy.

The initial treatment of choice for Ewing''s sarcoma is a combination of radiation and chemotherapy.

25. What is the best way that parents of pre-schoolers can begin teaching their child about injury prevention?

A) Set good examples themselves
B) Protect their child from outside influences
C) Make sure their child understands all the safety rules
D) Discuss the consequences of not wearing protective devices

The correct answer is A: Set good examples themselves

The preschool years are the time for parents to begin emphasizing safety principles as well as providing protection. Setting a good example themselves is crucial because of the imitative behaviors of pre-schoolers; they are quick to notice discrepancies between what they see and what they are told.

26. The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching?

A) "I'm going to try feeding my baby some rice cereal."
B) "When he wakes at night for a bottle, I feed him."
C) "I dip his pacifier in honey so he'll take it."
D) "I keep formula in the refrigerator for24 hours."

The correct answer is C: "I dip his pacifier in honey so he''ll take it."
Honey has been associated with infant botulism and should be avoided. Older children and adults have digestive enzymes that kill the botulism spores.

27. At a senior citizens meeting a nurse talks with a client who has Type 1 diabetes mellitus. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity?

A) "I give my insulin to myself in my thighs."
B) "Sometimes when I put my shoes on I don't know where my toes are."
C) "Here are my up and down glucose readings that I wrote on my calendar."
D) "If I bathe more than once a week my skin feels too dry."

The correct answer is B: "Sometimes when I put my shoes on I don''t know where my toes are."
Peripheral neuropathy can lead to lack of sensation in the lower extremities. Clients who do not feel pressure and/or pain are at high risk for skin impairment.


28. A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?

A) Drink small amounts of liquids frequently
B) Eat the evening meal just before retiring
C) Take sodium bicarbonate after each meal
D) Sleep with head propped on several pillows

The correct answer is D: Sleep with head propped on several pillows
Heartburn is a burning sensation caused by regurgitation of gastric contents. It is best relieved by sleeping position, eating small meals, and not eating before bedtime.

29. A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in an incubator. Which action is a nursing priority?

A) Protect the eyes of the neonate from the heat lamp
B) Monitor the neonate’s temperature
C) Warm all medications and liquids before giving
D) Avoid touching the neonate with cold hands

The correct answer is B: Monitor the neonate’s temperature

When using a warming device the neonate’s temperature should be continuously monitored for undesired elevations. The use of heat lamps is not safe as there is no way to regulate their temperature. Warming medications and fluids is not indicated. While touching with cold hands can startle the infant it does not pose a safety risk.

30. A client asks the nurse to explain the basic ideas of homeopathic medicine. The response that best explains this approach is that such remedies

A) destroy organisms causing disease
B) maintain fluid balance
C) boost the immune system
D) increase bodily energy

The correct answer is C: boost the immune system
The practitioner treats with minute doses of plant, mineral or animal substances which provide a gentle stimulus to the body''s own defenses.

31. A 78 year-old client with pneumonia has a productive cough, but is confused. Safety protective devices (restraints) have been ordered for this client. How can the nurse prevent aspiration?

A) Suction the client frequently while restrained
B) Secure all 4 restraints to 1 side of bed
C) Obtain a sitter for the client while restrained
D) Request an order for a cough suppressant

The correct answer is C: Obtain a sitter for the client while restrained
The plan to use safety devices (restraints) should be rethought. Restraints are used to protect the client from harm caused by removing tubes or getting out of bed. In the event that this restricted movement could cause more harm, such as aspiration, then a sitter should be requested. These are to be provided by the facility in the event the family cannot do so. This client needs to cough and be watched rather than restricted. Suctioning will not prevent aspiration in this situation. Cough suppressants should be avoided for this client.

32. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the provider ordering

A) pulmonary embolectomy
B) vena caval interruption
C) increasing the Coumadin therapy to an INR of 3-4
D) thrombolytic therapy

The correct answer is B: vena caval interruption

Clients with contraindications to Heparin, recurrentPE or those with complications related to the medical therapy may require vena caval interruption by the placement of a filter device in the inferior vena cava. A filter can be placed transvenously to trap clots before they travel to the pulmonary circulation.

33. A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?

A) Place the child in the nearest bed
B) Administer IV medication to slow down the seizure
C) Place a padded tongue blade in the child's mouth
D) Remove the child's toys from the immediate area

The correct answer is D: Remove the child''s toys from the immediate area
Nursing care for a child having a seizure includes, maintaining airway patency, ensuring safety, administering medications, and providing emotional support. Since the seizure has already started, nothing should be forced into the child''s mouth and the child should not be moved. Of the choices given, the first priority would be to provide a safe environment.

34. The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?

A) Irritability
B) Slight edema at site
C) Local tenderness
D) Seizure activity

The correct answer is D: Seizure activity
Other reactions that should be reported include crying for >3 hours, temperature over 104.8 degrees Fahrenheit following DPT immunization, and tender, swollen, reddened areas.

35. Included in teaching the client with tuberculosis taking isoniazid (INH) about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?

A) Liver function
B) Kidney function
C) Blood sugar
D) Cardiac enzymes

The correct answer is A: Liver function
INH can cause hepatocellular injury and hepatitis. This side effect is age-related and can be detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells.

36. A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?

A) Call the health care provider
B) Access the site by cutting a window in the cast
C) Simply record the findings in the nurse's notes only
D) Outline the spot with a pencil and note the time and date on the cast

The correct answer is D: Outline the spot with a pencil and note the time and date on the cast
This is a good way to assess the amount of bleeding over a period of time. The bleeding does not appear to be excessive and some bleeding is expected with this type of surgery. The bleeding should also be documented in the nurse’s notes.

37. The nurse is caring for a 1 year-old child who has 6 teeth. What is the best way for the nurse to give mouth care to this child?

A) Using a moist soft brush or cloth to clean teeth and gums
B) Swabbing teeth and gums with flavored mouthwash
C) Offering a bottle of water for the child to drink
D) Brushing with toothpaste and flossing each tooth

The correct answer is A: Using a moist soft brush or cloth to clean teeth and gums
The nurse should use a soft cloth or soft brush to do mouth care so that the child can adjust to the routine of cleaning the mouth and teeth.

38. A client who is 12 hour post-op becomes confused and says: “Giant sharks are swimming across the ceiling.” Which assessment is necessary to adequately identify the source of this client's behavior?

A) Cardiac rhythm strip
B) Pupillary response
C) Pulse oximetry
D) Peripheral glucose stick

The correct answer is C: Pulse oximetry
A sudden change in mental status in any post-op client should trigger a nursing intervention directed toward respiratory evaluation. Pulse oximetry would be the initial assessment. If available, arterial blood gases would be better. Acute respiratory failure is thesudden inability of the respiratory system to maintain adequate gas exchange which may result in hypercapnia and/or hypoxemia. Clinical findings of hypoxemia include these finding which are listed in order of initial to later findings: restlessness, irritability, agitation, dyspnea, disorientation, confusion, delirium, hallucinations, and loss of consciousness. While there may be other factors influencing the client''s behavior, the first nursing action should be directed toward maintaining oxygenation. Once respiratory or oxygenation issues are ruled out then significant changes in glucose would be evaluated.

39. Which contraindication should the nurse assess for prior to giving a child immunizations?

A) Mild cold symptoms
B) Chronic asthma
C) Depressed immune system
D) Allergy to eggs

The correct answer is C: Depressed immune system
Children who have a depressed immune system related to HIV or chemotherapy should not be given routine immunizations.

40. The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in the automobile. What is the nurse’s best response to the parents?

A) "Your child must use a care seat until he weighs at least 40 pounds."
B) "The child must be 5 years of age to use a regular seat belt."
C) "Your child must reach a height of 50 inches to sit in a seat belt."
D) "The child can use a regular seat belt when he can sit still."

The correct answer is A: "Your child must use a care seat until he weighs at least 40 pounds."
Children should use car seats until they weigh 40 pounds.

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