READINESS EXAM 1

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READINESS EXAM 1

This Readiness Exam Is Powered By ACHIEVERS NCLEX-RN CONSULT. Getting an average score is a GOOD INDICATOR of Preparedness/Readiness for the exam. However, we advice that you take ALL of our READINESS EXAM to know the True trend of your performance/Readiness.

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Q1. The parent of a 22-month-old toddler plans to begin toilet training
the child. Which is the most important factor for the nurse to stress to the mother?
*

1 point

1.Consistency in method.

2.Maintain a positive attitude.

3.Developmental readiness of the child.

4.Avoid comparing the child to peers.

Q2. The nurse reviews prescriptions from a health care provider for
a client's care. Which prescription will the nurse question before implementing?
*

1 point

1.Monitor intake and output.

2.Begin a 2 L/day fluid restriction.

3.Start heparin infusion by 0800 hours.

4.Continue intravenous fluids D5W at 150 mL/hour.

Q3. The nurse cares a client who is prescribed digoxin. Which lab
finding does the nurse identify as putting the client at risk for
digitalis toxicity?
*

1 point

1.Creatinine level of 7 mg/dL (238.6 umol/L).

2.Serum potassium level of 8 mEq/L (3.8 mmol/L).

3.Serum calcium level of 8.5 mg/dL (1.2 mmol/L).

4.Cholesterol level of 240 mg/dL (6.2 mmol/L)

Q4. The nurse provides care for a client on mechanical ventilation. The
nurse notes that the high-pressure alarm was triggered. Which
nursing action is appropriate?

(Select all that apply.)

1 point

1.Call the rapid response team.

2.Determine the need for sedation.

3.Call the health care provider.

4.Assess the need for suctioning.

5.Assess for disconnected tubing.

Required

Q5. The nurse prepares to flush a client's nasogastric (NG) tube. The

nurse meets resistance when using a syringe to push fluid through

the tube. Which nursing action is appropriate at this time?

(Select all that apply.)

1 point

1.Check for kinks in the tubing.

2.Turn the client to the left side.

3.Remove the NG tube.

4.Ask the health care provider for a prescription for an X-ray.

5.Use warm water in the syringe to flush the NG tube.

Required

Q6. The nurse assesses the coping skills of a client receiving
chemotherapy after a mastectomy for breast cancer. Which client
statement indicates effective coping?
*

1 point

1."I am glad the nausea and vomiting are subsiding."

2."I do not need as much pain medication as was prescribed."

3."I made an appointment to get fitted for prosthesis."

4."I will begin the next round of chemotherapy next week."

Q7. The nurse manager evaluates staff for understanding of standard
precautions when caring for clients with acquired immunodeficiency syndrome (AIDS) and human immunodeficiency virus (HIV). Which behavior indicates to the nurse manager that the staff understands standard precautions? (Select all that apply.)

*

1 point

1.Nursing assistive personnel (NAP) receiving chemotherapy refuses to care for a client with Kaposi sarcoma.

2.Laboratory technician performs a venipuncture and places the needle on a table while labeling the specimen tube.

3.Health care provider uses a personal stethoscope to assess a client with HIV and fever.

4.Nurse applies a mask and protective eyewear before providing tracheostomy care.

5.Nurse who is pregnant wears gloves and a gown to clean stool from a client who is incontinent for diarrhea.

Required

Q8. The nurse prepares to insert a rectal tube in a client experiencing
severe abdominal pain from flatus. Which approach does the
nurse use when inserting this device?
*

1 point

1.Tape the tube in place for 30 minutes.

2.Insert the tube 2 to 4 inches past both of the anal sphincters.

3.Place the client in the right lateral recumbent position.

4.Lubricate the tube with an oil-based lubricant

Q9. The nurse provides care to a client who experienced a stroke

1 day ago. Which action does the nurse safely delegate to the

nursing assistive personnel (NAP)?

1 point

1.Monitor neurologic status using the Glasgow Coma Scale.

2.Check and document oxygen saturation every 1 to 2 hours.

3.Complete morning bath, change linen, and perform range of motion by 1000 hours.

4.Notify the health care provider about the need for assistive walking device.

Q10. The nurse is unable to locate an older client's left popliteal pulse.
Which action will the nurse take next?
*

1 point

1.Check for the femoral pulse.

2.Check for the pedal pulse.

3.Ask another nurse to check for the popliteal pulse.

4.Measure the blood pressure on the left thigh.

Q11. The nurse provides care for an infant who has a fractured femur.
Which statement regarding pain in an infant is accurate? (Select all that apply.)
*

1 point

1.Infants cannot feel pain.

2.Infants cannot express pain.

3.Infants have the same sensitivity to pain as older children.

4.Pain scales do not work well with infants.

5.Absorption of pain medication is faster in an infant than an adult

Required

Q12. The nurse suspects that a client with a head injury is developing
Cushing triad. Which finding causes the nurse to make this clinical
determination? (Select all that apply.)
*

1 point

1.Respiratory rate 20 breaths/min.

2.Pulse oximeter 92%.

3.Pulse 52 beats/min and irregular.

4.Temperature 98.4ºF (36.9ºC).

5.Blood pressure 180/58 mm Hg.

Required

Q13. The nurse receives report on assigned clients. Which client will
the nurse assess first?
*

1 point

1.Client who had a myocardial infarction 3 hours ago and is experiencing two to three premature ventricular contractions per minute.

2.Client who had a lumbar puncture 2 hours ago and is reporting a headache rated as an 8 on a pain rating scale of 0 to 10.

3.Client who had a permanent pacemaker inserted 12 hours ago and is reporting dizziness.

4.Client who had a total hip replacement 8 hours ago and is in a semi-Fowler position.

Q14. The nurse provides care to a client with a neutrophil count of 1000
cells/mm3 (1 × 109/L). Which intervention will the nurse include
in this client's care plan?

(Select all that apply.)

1 point

1.Check gums for bleeding.

2.Omit uncooked foods from the diet.

3.Check temperature every 4 hours.

4.Drink only bottled water.

5.Microwave on high when reheating food.

Required

Q15. The nurse assesses the respiratory status of a 12-hour-old newborn. Which finding does the nurse report to the health care
provider? (Select all that apply.)
*

1 point

1.Nasal flaring.

2.Acrocyanosis.

3.Tachypnea.

4.Ten second periods of apnea.

5.Respiratory rate of 40 breaths per minute.

Required

Q16. Which activities can the nurse delegate to a nursing assistive
personnel (NAP) for a client in the postanesthesia unit (PACU)?
(Select all that apply.) *

1 point

1.Obtaining vital signs.

2.Assisting with positioning.

3.Suctioning the oropharynx.

4.Accompanying client transfer.

5.Measuring urine output.

Required

Q17. A middle-aged client, newly diagnosed with type 2 diabetes, expresses disbelief at this diagnosis. The nurse explains that the
development of diabetes in middle-age is most likely related to
which factor?
*

1 point

1.Obesity.

2.Increased sugar intake.

3.Viral infections.

4.Decreased cortisol level

Q18. The nurse provides care for a client diagnosed with aphasia.
Which action does the nurse implement when communicating
with this client? (Select all that apply.)

*

1 point

1.Have family members translate for the client as needed.

2.Ask questions that can be answered by "yes" or "no."

3.Decrease environmental stimuli that might be distracting.

4.Allow body contact such as clasp of hand or touching.

5.Provide the client with simple recorded instructions.

Required

Q19. The parent of a school-age child diagnosed with type 1 diabetes
mellitus reports that the child has been sick and has ketones in
the urine. Which instruction will the nurse provide to the parent?
*

1 point

1.Hold the next dose of insulin.

2.Administer an additional dose of regular insulin.

3.Encourage the child to drink calorie-free liquids.

4.Seek medical attention for additional assessment and treatment.

Q20. A client receiving a blood transfusion develops a cough, rales in

bilateral lower lung lobes, shortness of breath, and restlessness.

Which action will the nurse take? (Select all that apply.)

1 point

1.Slop the blood transfusion.

2.Place client on the left side.

3.Apply oxygen.

4.Administer prescribed furosemide.

5.Monitor vital signs every 2 to 4 hours.

Required

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