Soal Latihan NCLEX-RN

Two approved identifiers, such as name and date of birth, must be checked before every medication administration. Family members are not a substitute for approved identifiers, and checking once at the beginning of the shift does not verify the right client at the moment of administration. Consistent verification at the bedside reduces wrong-client and wrong-medication errors.

Chills and lower back pain during a blood transfusion suggest a possible transfusion reaction, which can progress rapidly. The nurse should stop the transfusion, maintain IV access, and notify the health care provider. The other clients are stable and can be assessed after the transfusion reaction is addressed.

RACE stands for rescue, alarm, confine, and extinguish. Removing clients from immediate danger is the first priority because client safety takes precedence over fire-fighting tasks. The alarm, containment, and extinguishing efforts follow rescue.

The outer 1-inch border of a sterile field is considered contaminated, so sterile items should be placed in the center of the field. Solutions should be poured from about 4 to 6 inches above the receptacle, sterile items should be kept at or above waist level, and the field should remain in view. These actions preserve sterility and reduce infection risk.

Two approved identifiers, typically name and date of birth, must be used to confirm client identity before medication administration. Room numbers, bed labels, and family statements are not acceptable identifiers. This verification is a core medication safety practice.

Hepatitis B is often given as a birth dose and continued during infancy. MMR is routinely given as a first dose at 12 to 15 months with a second dose at 4 to 6 years. Tdap is recommended at 11 to 12 years with catch-up for older adolescents and adults, while the rotavirus series starts at 2 months and is completed by 8 months.

Fresh or minimally processed foods such as grilled chicken, steamed vegetables, and a baked potato are naturally lower in sodium. Canned soups, deli meats, pickles, frozen breaded foods, and instant mixes are common high-sodium sources. Choosing fresh foods supports blood pressure management.

Clear walking paths, night lights, secure handrails, and low storage for frequently used items reduce fall risk in older adults. Throw rugs, high shelving, and avoiding handrails increase the chance of falling. Home safety education should emphasize environmental and behavioral changes that support safe mobility.

Nicotine replacement therapy provides a controlled dose of nicotine to reduce withdrawal symptoms and cravings during smoking cessation. It does not guarantee abstinence or eliminate all nicotine-related health risks. Counseling and behavioral support improve success but are not required for the product to have benefit.

Influenza vaccination, balance and strength training, and medication reviews are evidence-based health promotion strategies for older adults. Regular physical activity is generally encouraged and modified for chronic conditions rather than avoided. Social engagement supports physical and mental health, so isolation should not be recommended.

Reflecting the client's feeling validates the emotion and encourages further exploration without arguing or judging. Telling the client that the feeling is untrue dismisses the client's experience, while asking why can feel critical. Focusing on positives too quickly can minimize the client's distress.

A calm, low-stimulation environment reduces sensory overload and helps the client regain control during acute mania. Long discussions, busy rooms, and caffeine increase stimulation and can worsen agitation. Structured, simple activities provide safe outlets without overstimulating the client.

Moving to a quiet area and modeling slow breathing helps lower arousal and provides a calming, supportive intervention. Telling a client to calm down invalidates the experience, and leaving the client alone removes needed support. Complex choices should be delayed until anxiety is reduced.

Directly assessing suicidal ideation, intent, plan, and means is the priority when a client expresses hopelessness. Asking about suicide does not plant the idea and is essential for safety. Reassurance, activity suggestions, and scheduled observation are not substitutes for a direct risk assessment.

Suicide risk can change quickly, so clients with suicidal thoughts need a safety plan and monitoring even when no immediate plan is identified. Risk should be reassessed regularly by a qualified professional. Removing the safety plan or monitoring prematurely increases risk.

Hypokalemia commonly causes muscle weakness, fatigue, decreased reflexes, ileus, and cardiac dysrhythmias that may produce a weak or irregular pulse. Dry mucous membranes are more typical of fluid deficit, and circumoral tingling suggests hypocalcemia. Potassium levels should be monitored closely because low levels can precipitate lethal dysrhythmias.

Visible bowel through separated wound edges is an evisceration, a surgical emergency. The nurse should cover the wound with sterile saline-soaked dressings, keep the client on nothing by mouth, and notify the health care provider immediately. Moderate pain, a low-grade fever, and an oxygen saturation of 95% do not have the same urgency.

Fluid volume deficit reduces circulating volume, causing tachycardia, dry mucous membranes, poor skin turgor, and decreased urine output. Jugular venous distention, crackles, edema, and hypertension are findings of fluid volume excess. Recognition of these signs guides fluid replacement and monitoring.

Orthopnea and paroxysmal nocturnal dyspnea indicate worsening heart failure and pulmonary congestion. Placing the client in high Fowler's position improves ventilation, and oxygen saturation should be assessed immediately. Fluid restriction is a provider-directed intervention, not an independent first action, and other diagnostics should not delay oxygenation.

Hyperkalemia above 6.0 mEq/L or hyperkalemia with peaked T waves is life-threatening and requires immediate treatment to prevent ventricular dysrhythmias. A potassium of 5.0 mEq/L with no ECG changes is less urgent but still requires follow-up. Normal sodium and glucose levels do not require immediate intervention in this setting.

Using the formula desired dose divided by available dose per milliliter: 5,000 units divided by 10,000 units/mL equals 0.5 mL. The nurse should independently recalculate the dose and have a second nurse verify high-alert medications when required by policy. Correct calculation prevents anticoagulant dosing errors.

Digoxin slows conduction through the atrioventricular node, so the apical pulse should be counted for a full minute before administration. In an adult, the dose is typically withheld and the provider notified when the apical rate is below 60 beats/min. Bradycardia and other signs of toxicity should also be monitored.

Levothyroxine should be taken on an empty stomach at the same time each day, and a missed dose should be taken as soon as remembered unless the next dose is due. Doubling a dose can cause signs of hyperthyroidism such as palpitations and nervousness. Taking it with milk can reduce absorption.

Warfarin reduces vitamin K-dependent clotting factors, and clients should not independently take extra vitamin K because it can reduce the drug's effect and make INR management difficult. Aspirin and other antiplatelet agents increase bleeding risk and should be avoided unless prescribed. Electric razors and prompt reporting of bleeding signs are appropriate safety measures.

Aluminum and magnesium antacids chelate fluoroquinolones and significantly reduce their absorption. Ciprofloxacin should be taken 2 hours before or 6 hours after antacids, iron, or sucralfate. Taking the drug with an antacid can result in subtherapeutic antibiotic levels.

Airborne precautions require a negative-pressure room and an N95 or higher-level respirator for diseases such as tuberculosis. Droplet precautions require a mask and eye protection when working within about 3 feet of a client with pertussis or influenza. Contact precautions require gown and gloves for clients with Clostridioides difficile or a draining MRSA wound, while standard precautions apply to all clients and include hand hygiene and PPE based on anticipated exposure.

Measuring and recording urine output is a stable, predictable task that UAPs are educated to perform under RN supervision. Admission assessment, IV push medication administration, and client teaching require nursing judgment and cannot be delegated to UAPs. Delegation decisions should preserve client safety and match the task to the worker's scope.

In many states, LPNs may administer oral medications to stable clients under RN supervision. Initial comprehensive assessment, care planning and evaluation, and blood transfusion administration require the education and judgment of an RN. The RN remains accountable for supervision and follow-up after delegation.

Regular repositioning and pressure-reducing support surfaces relieve pressure and prevent pressure injuries. Reddened areas should not be massaged because this can damage fragile tissue. High Fowler's positioning increases shear and should not be maintained continuously.

Accurate documentation reflects care that has actually been provided and is recorded promptly after the intervention. Charting in advance is inaccurate and can mislead other members of the health care team. Documentation should be factual, timely, and free of judgmental language.

Nasal flaring and grunting indicate respiratory distress in a newborn and require prompt evaluation. A heart rate of 140 beats/min, acrocyanosis of the extremities, and respirations of 46 breaths/min with brief pauses are expected findings in a full-term newborn. Respiratory distress can progress quickly, so oxygen saturation and work of breathing should be assessed.

A firm fundus with heavy bleeding suggests the blood may be coming from a vaginal or cervical laceration or another site rather than uterine atony. The nurse should inspect the perineum and vagina, monitor vital signs, and notify the provider. Delaying assessment can allow hemorrhage to progress.

Fetal movement counts are usually performed while lying on the side, and fewer than 10 movements in 2 hours should be reported to the provider. Movement does not normally stop in late pregnancy, and a 24-hour wait is too long when movements are reduced. Consistent maternal perception of fetal activity is an important fetal surveillance tool.

Variable decelerations are most often caused by umbilical cord compression, so the first action is to change maternal position to relieve pressure on the cord. The nurse should also assess the tracing, consider oxygen and IV fluids, and notify the provider. Increasing oxytocin and waiting 30 minutes could worsen fetal compromise.

Preeclampsia with severe features includes systolic blood pressure of 160 mm Hg or higher, diastolic blood pressure of 110 mm Hg or higher, thrombocytopenia, new or worsening neurologic symptoms, and oliguria. Trace protein alone does not define a severe feature. Magnesium sulfate and antihypertensives may be indicated to prevent complications.

Parallel play and negativism, including frequent use of the word no, are typical toddler behaviors. Toddlers typically use two- to three-word phrases, while complete sentences develop later in the preschool years. Riding a bicycle without training wheels is a school-age milestone, not a toddler milestone.

An oral syringe directed toward the side of the mouth lets the infant swallow slowly and reduces aspiration risk. Mixing medication into a full bottle can result in an incomplete dose if the infant does not finish it. Giving medication while flat or squirting toward the back of the throat increases the risk of choking and aspiration.

For a 6-month-old infant, a temperature of 38.3 C (101 F) can be managed at home with fluids, light clothing, and weight-based acetaminophen while watching for concerning signs. Aspirin must be avoided in children because of the risk of Reye syndrome. Dehydration and delayed care can complicate febrile illness.

Epiglottitis is a medical emergency because the swollen epiglottis can suddenly obstruct the airway. The nurse should keep the child calm, avoid throat inspection or anything that increases agitation, and have airway equipment ready. Lying flat, oral intake, and tongue blade examination can worsen obstruction.

Sunken fontanelle, absent tears, and decreased urine output are signs of dehydration in infants. Capillary refill less than 2 seconds and moist mucous membranes indicate adequate perfusion and hydration. Severe dehydration can progress to shock, so prompt rehydration and monitoring are needed.

Positive identification requires at least two identifiers such as the client's full name and date of birth. Room and bed numbers are location identifiers and are not considered reliable client identifiers. Diagnosis, tray number, age, and physician name do not satisfy the two-identifier standard.

C. difficile is transmitted by spores on hands and contaminated surfaces, so contact precautions, including gown and gloves, are required. Hand hygiene with soap and water is preferred because alcohol-based hand rub is not sporicidal. Droplet and airborne precautions are used for respiratory pathogens.

The post-surgical client with hypoxemia and tachycardia is at greatest risk for respiratory or hemodynamic deterioration and should be seen first. The other clients are stable or have scheduled, nonurgent needs. Prioritization is guided by the ABCs and risk of physiologic instability.

Using the formula desired divided by available times volume: 5,000 units / 10,000 units per mL equals 0.5 mL. Administering 2, 0.05, or 5 mL would give 20,000, 500, or 50,000 units respectively. Always verify high-alert medication calculations with an independent double-check.

Pulmonary tuberculosis requires airborne precautions with an N95 or higher respirator and negative-pressure room. Meningococcal meningitis requires droplet precautions. C. difficile requires contact precautions plus soap-and-water hand hygiene. Neutropenic clients need protective precautions to reduce exposure to infections.

The 2-month schedule includes hepatitis B, rotavirus, DTaP, Hib, PCV, and inactivated polio vaccine. MMR and varicella begin at 12 months, Tdap and HPV are recommended later in childhood or adolescence, and zoster vaccine is for older adults.

Daily folic acid of 400 to 800 mcg is recommended before conception and through early pregnancy because it reduces the risk of neural tube defects. Continuing throughout pregnancy supports fetal growth. Folic acid does not prevent gestational diabetes, and it is recommended for all women of childbearing age.

Average-risk adults should begin colorectal cancer screening around age 45 to 50 using colonoscopy, fecal immunochemical testing, or other recommended modalities. Screening is preventive and does not require symptoms. Recommendations for other cancers depend on sex, risk factors, and guidelines.

By 12 months, most infants stand alone and may take first steps. Walking backward and kicking a ball are later toddler skills, stair climbing with alternating feet develops around age 3, and running and jumping are preschool milestones. Development should be assessed against age-appropriate ranges.

Sunscreen with SPF 30 or higher should be applied generously and reapplied every 2 hours and after swimming, sweating, or towel drying. A base tan provides little protection, UV exposure occurs on cloudy days, and water-resistant products still need reapplication. Sun protection reduces lifetime skin cancer risk.

The nurse should acknowledge the client's distress, express genuine concern, and explore the client's feelings without false reassurance or platitudes. Dismissing the statement, advising positivity, or using guilt can increase isolation. This statement should also prompt suicide risk assessment.

A specific plan combined with access to lethal means signals imminent risk and requires immediate protective action, including a safe environment, close observation, and psychiatric consultation. Hopelessness, anger, and insomnia are important but do not alone indicate imminent risk without a plan or intent.

The nurse should acknowledge the emotion behind the delusion without arguing with or confirming the belief. Challenging the delusion can increase distrust, while ignoring it dismisses the client's experience. Medication adherence and ongoing assessment of safety remain important.

Suicide precautions include removing sharps, cords, and other potentially harmful items and maintaining close observation, often one-to-one supervision, until risk is reduced. Constant observation prevents attempts and allows early intervention. The environment is checked routinely for safety hazards.

Staying with the client and guiding slow breathing helps break the hyperventilation cycle and reduces anxiety. Asking for a detailed stress inventory is overwhelming during acute anxiety, caffeine worsens symptoms, and leaving the client alone is unsafe. Once the client calms, explore triggers and coping strategies.

Loop diuretics such as furosemide increase potassium excretion and can cause hypokalemia, which increases the risk of dysrhythmias and digoxin toxicity. The other values are within normal ranges. The nurse should report hypokalemia and anticipate potassium replacement.

Urine output of at least 0.5 mL/kg/hour with improving mentation reflects restored renal perfusion and tissue oxygenation. Prolonged capillary refill, weak pulses, cool extremities, and low urine output indicate continued hypoperfusion. Trends in vital signs and laboratory values should also be monitored.

Calf pain, swelling, and warmth after major orthopedic surgery suggest deep vein thrombosis, which requires prompt evaluation and anticoagulation therapy. Scant drainage, controlled pain, and a low-grade temperature can be expected in the early postoperative period. Early ambulation, hydration, and compression devices help prevent DVT.

Crackles, dyspnea, and edema indicate fluid overload, so the infusion should be stopped and the provider notified promptly. Increasing fluids or giving a bolus would worsen the condition. The nurse should elevate the head of bed, monitor oxygenation, and prepare for diuretic therapy as ordered.

IV calcium gluconate stabilizes the cardiac cell membrane and protects against dysrhythmias, but it does not remove potassium from the blood. Treatments that lower potassium include insulin with glucose, beta-agonists, diuretics, binding agents, and dialysis. Calcium should be used with ECG monitoring when cardiotoxicity is present.

The dose ordered is 0.25 mg and the concentration is 0.5 mg in 2 mL, so each milliliter contains 0.25 mg. The nurse should administer 1 mL. Digoxin is a high-alert medication, so the calculation should be independently double-checked and the client's potassium level reviewed.

Metformin is taken with meals to reduce gastrointestinal effects and is generally weight-neutral or may promote modest weight loss. It should not be stopped just because glucose is normal. Severe GI symptoms or fatigue may signal lactic acidosis, a rare but serious complication that should be reported.

Heparin is a high-alert medication because dosing errors can cause serious bleeding or thrombosis, so an independent double-check is required. Acetaminophen, multivitamins, and polyethylene glycol have lower risk profiles, although acetaminophen still requires careful dosing. The nurse should follow organizational policy for high-alert drugs.

Warfarin inhibits vitamin K-dependent clotting factors, so supratherapeutic INR with bleeding is treated with vitamin K and, in serious cases, prothrombin complex concentrate or fresh frozen plasma. Protamine reverses heparin, calcium gluconate treats hyperkalemia, and naloxone reverses opioids.

Safe IV administration includes two-client identification, allergy verification, aseptic technique, labeling, flushing, documentation, and monitoring for adverse effects. The nurse must personally verify or prepare medications and never administer an unverified product prepared by another person. Following these steps reduces medication errors and infection risk.

Routine vital signs on stable clients are within the UAP scope of practice when delegated and supervised by the RN. The initial assessment, IV push medications, and evaluation of client responses require nursing judgment and cannot be delegated. The RN remains accountable for the delegated task.

Under HIPAA, the nurse must verify the caller's identity and obtain the client's consent before sharing protected health information. Family relationship alone does not authorize disclosure. The nurse can confirm that the client is present and ask whether information may be shared, and privacy protections continue after discharge.

Correct body mechanics use a wide base of support, bending at the hips and knees, and keeping the load close to the center of gravity. Bending at the waist, twisting, and holding objects away from the body increase strain on the spine. Using assistive devices is preferred when a load is heavy.

Previous falls, orthostatic hypotension, sedating medications, urinary urgency, and environmental barriers increase fall risk. Full independence without gait changes does not increase risk. The nurse should implement individualized fall precautions, keep the call light within reach, and reassess after medication changes.

The RN is accountable for assessment, care planning, and evaluation. The LPN/LVN can administer certain medications and reinforce teaching within scope under supervision. UAPs perform delegated routine tasks for stable clients. Physical therapists evaluate mobility and provide gait training as part of the interprofessional team.

Moderate variability indicates a well-oxygenated fetal nervous system, and accelerations are reassuring. Absent variability with late decelerations suggests uteroplacental insufficiency, recurrent variable decelerations suggest cord compression, and bradycardia may indicate fetal compromise. The nurse should continue to monitor and report nonreassuring patterns.

Early hunger cues include rooting, mouthing, hand-to-mouth movements, and increased alertness. Crying is a late hunger cue that can make latching more difficult. Deep sleep and turning away are not feeding cues. Feeding in response to early cues supports successful breastfeeding.

A boggy uterus with heavy bleeding indicates uterine atony, the most common cause of early postpartum hemorrhage, and requires fundal massage, medications such as oxytocin, and provider notification. A fundus at the umbilicus on day one, mild perineal discomfort, and scant lochia rubra are expected findings.

This temperature is below the normal newborn range, and hypothermia increases oxygen and glucose consumption, putting the newborn at risk for cold stress. The nurse should immediately provide warmth through skin-to-skin contact, warm blankets, or a radiant warmer and recheck the temperature frequently. Hypothermia does not resolve by waiting.

Preoperative antibiotics, skin antisepsis, hand hygiene, and early ambulation reduce surgical site infection risk. Surgical dressings should remain clean and dry and are changed using aseptic technique when indicated; leaving a wound open is not an infection prevention measure. The nurse should also assess the incision for redness, swelling, drainage, and warmth.

At 6 months, infants typically sit with support and roll over. Walking with assistance occurs near 9 to 12 months, pincer grasp develops around 9 to 10 months, and two-word sentences are typical of 2-year-olds. Milestones that are significantly delayed should be reported.

Keeping a child with croup calm and upright reduces airway obstruction; cool mist and prescribed corticosteroids or nebulized epinephrine are standard treatments. Crying and flat positioning can worsen stridor, and sedatives may depress respiratory drive. The nurse should monitor oxygen saturation and work of breathing.

Pediatric doses are weight-based, and every order must be checked against the recommended mg/kg range using the child's current weight. Adult doses and rounding up are unsafe. Accurate weight measurement is required before dose calculation. Independent double-checks are especially important for pediatric medications.

Decreased urine output, a sunken fontanel, dry mucous membranes, and absent tears indicate dehydration. Increased urine output is not a sign of dehydration. Parents should also watch for lethargy, poor skin turgor, and decreased activity and should seek care early because infants can dehydrate quickly.

A complete asthma action plan includes daily controller medications, trigger avoidance, recognition of worsening symptoms, rescue inhaler instructions, and clear emergency steps. Listing only rescue medication and emergency contact is incomplete. The nurse should review the plan with the family and confirm the child can use the inhaler or spacer correctly.