Free NCLEX-RN Readiness Diagnostic

Question 1

A nurse discovers that a client received a dose of insulin intended for the client in the next bed because of similar last names. The client now has a blood glucose of 58 mg/dL and reports feeling shaky. Which actions should the nurse take? Select all that apply.

Accepted Answer

Assess the client and treat the hypoglycemia per protocol

Accepted Answer

Notify the provider of the error and the client's status

Accepted Answer

Complete an incident or occurrence report

Answer

Document in the incident report that a medication error occurred and chart it as a near miss in the medical record

Answer

Omit the error from the client's chart to avoid alarming the family

Question 2

A client is two hours post thoracentesis of the right pleural space. Which assessment findings should prompt the nurse to suspect a complication and notify the provider? Select all that apply.

Accepted Answer

Sudden sharp chest pain with shortness of breath

Accepted Answer

Absent breath sounds over the right upper lung field

Accepted Answer

Oxygen saturation dropping from 96% to 88% on room air

Answer

Respiratory rate of 16 breaths per minute and unlabored breathing

Answer

A small dry dressing over the puncture site

Question 3

A nurse is providing perineal care for a female client who has an indwelling urinary catheter and is on bed rest. Which technique best reduces the client's risk of a catheter-associated urinary tract infection?

Accepted Answer

Clean the perineum from front to back and keep the drainage bag below bladder level

Answer

Clean from back to front to remove drainage away from the urethra

Answer

Coil the tubing and rest the drainage bag on the client's abdomen

Answer

Routinely irrigate the catheter with sterile saline every shift

Question 4

A nurse is teaching a client newly prescribed warfarin for atrial fibrillation. Which statements should the nurse include? Select all that apply.

Accepted Answer

Keep your vitamin K intake from foods like leafy greens consistent rather than suddenly changing it

Accepted Answer

Use a soft toothbrush and an electric razor to reduce bleeding

Accepted Answer

Have your INR checked regularly so the dose can be adjusted

Answer

Double the dose on any day you forget the previous day's dose

Answer

Take an over-the-counter aspirin daily for extra heart protection

Question 5

A client is in early hypovolemic shock after trauma. Which compensatory findings should the nurse anticipate before blood pressure drops significantly? Select all that apply.

Accepted Answer

Tachycardia

Accepted Answer

Cool, pale skin with delayed capillary refill

Accepted Answer

Decreasing urine output

Accepted Answer

Restlessness and anxiety

Answer

Bounding peripheral pulses with flushed skin

Question 6

A nurse is planning care for a client who reports chronic difficulty falling asleep in the hospital. Which non-pharmacological intervention should the nurse implement first to promote sleep?

Accepted Answer

Cluster nighttime care and dim lights to provide an uninterrupted rest period

Answer

Offer a cup of regular coffee in the evening so the client relaxes before bed

Answer

Encourage a long afternoon nap to make up for lost nighttime sleep

Answer

Keep the television on to provide background noise through the night

Question 7

A nurse is preparing to hang the first dose of IV ceftriaxone, a high-alert IV potassium infusion, and a heparin drip for different clients. Which safety actions apply to safe parenteral medication administration? Select all that apply.

Accepted Answer

Perform an independent double check with a second nurse for the heparin drip and the IV potassium

Accepted Answer

Use a programmable infusion pump for the high-alert continuous infusions

Accepted Answer

Stay with the client for the start of the first dose of ceftriaxone to watch for an allergic reaction

Accepted Answer

Verify the client using two identifiers before giving each medication

Answer

Administer IV potassium chloride by rapid IV push to save time

Question 8

A new graduate nurse asks the charge nurse to review the five rights of delegation. Which statements correctly describe these rights? Select all that apply.

Accepted Answer

The right task is one that can safely be delegated for a specific client

Accepted Answer

The right person is both qualified and competent to perform the task

Accepted Answer

The right communication includes clear directions and expected outcomes

Accepted Answer

The right supervision includes monitoring, intervening, and giving feedback

Answer

Once a task is delegated, the RN no longer holds accountability for the outcome

Question 9

A client receiving treatment for severe hyponatremia (serum sodium 116 mEq/L) is started on a 3% hypertonic saline infusion. Which nursing actions are appropriate during this therapy? Select all that apply.

Accepted Answer

Monitor serum sodium frequently to avoid raising it too quickly

Accepted Answer

Assess the lungs for crackles and watch for fluid overload

Accepted Answer

Perform frequent neurologic checks

Accepted Answer

Infuse the hypertonic saline through a controlled infusion pump

Answer

Encourage the client to drink large amounts of free water

Question 10

A nurse is caring for a client with active pulmonary tuberculosis who is on airborne precautions in a negative-pressure room. The nurse must enter the room to administer medications. Which piece of personal protective equipment is essential to don before entering?

Accepted Answer

A fit-tested N95 respirator

Answer

A surgical face mask

Answer

A face shield and gown

Answer

Sterile gloves

Question 11

A nurse reviews morning labs for a client receiving warfarin therapy. The international normalized ratio (INR) is 5.2. Which actions are appropriate? Select all that apply.

Accepted Answer

Hold the next scheduled warfarin dose

Accepted Answer

Notify the provider of the elevated INR

Accepted Answer

Assess the client for signs of bleeding

Accepted Answer

Keep vitamin K available in case the provider orders it

Answer

Administer an extra dose of warfarin to stabilize the level

Question 12

A client recovering from surgery received IV morphine 4 mg twenty minutes ago. The nurse now finds a respiratory rate of 7 breaths/min, pinpoint pupils, and difficulty arousing the client. After ensuring the airway and stimulating the client, which medication does the nurse anticipate administering?

Accepted Answer

Naloxone

Answer

Flumazenil

Answer

Acetylcysteine

Answer

Protamine sulfate

Question 13

A nurse is preparing to leave the room of a client on contact and droplet precautions. The nurse is wearing gloves, a gown, a surgical mask, and goggles. Which item should the nurse remove first when doffing the personal protective equipment?

Accepted Answer

The gloves

Answer

The goggles

Answer

The surgical mask

Answer

The gown

Question 14

Four clients call out needs at the start of the shift. Which client should the RN assess first?

Accepted Answer

A client reporting new shortness of breath and audible wheezing

Answer

A client requesting PRN pain medication for a headache rated 4 out of 10

Answer

A client asking for help to the bathroom

Answer

A client wanting to discuss discharge plans for tomorrow

Question 15

A charge nurse is determining which tasks may be delegated to a UAP. Select all tasks that are appropriate to delegate.

Accepted Answer

Assisting a stable client with a bed bath

Accepted Answer

Ambulating a stable client in the hallway

Accepted Answer

Collecting a routine clean-catch urine specimen

Answer

Adjusting the rate of a continuous IV infusion based on the client's blood pressure

Answer

Developing the nursing plan of care for a new admission

Question 16

A 50-year-old client with no personal or family history of colorectal cancer asks the nurse when routine colorectal cancer screening should begin for average-risk adults. Which response by the nurse is most accurate?

Accepted Answer

"Routine screening for average-risk adults generally begins at age 45."

Answer

"You only need screening if you start having symptoms such as bleeding."

Answer

"Screening is not recommended until age 70 for most adults."

Answer

"A single test in your twenties covers you for the rest of your life."

Question 17

A nurse is helping an older adult client use a standard cane for the first time after a left knee strain. The client asks which hand should hold the cane. What is the nurse's best response?

Accepted Answer

"Hold the cane in your right hand, on the side opposite your weaker leg."

Answer

"Hold the cane in your left hand, on the same side as your weaker leg."

Answer

"Hold the cane in whichever hand feels more comfortable to you."

Answer

"Hold the cane in front of you with both hands for the most stability."

Question 18

Immediately after a large-volume paracentesis removing 5 liters of ascitic fluid, a client becomes lightheaded with a blood pressure of 88/52 mm Hg and a heart rate of 112/min. What is the nurse's priority action?

Accepted Answer

Lower the head of the bed, ensure IV access, and notify the provider

Answer

Encourage the client to ambulate to restore circulation

Answer

Resume oral intake of solid food immediately

Answer

Apply a warm compress to the puncture site