Question

The nurse is planning care for a client with intra-arterial blood pressure monitoring of the right radial artery. Which of the following interventions should the nurse include in the client's plan of care?

Answer 1

Correct Answers:

Assess frequently the capillary refill time in the right upper extremity.

Rationale :

🩺Assessing capillary refill provides immediate feedback on distal perfusion in the extremity with the arterial catheter.

💓Intra-arterial blood pressure monitoring can compromise arterial blood flow, making it crucial to evaluate circulation regularly.

🔍Early detection of diminished neurovascular status allows prompt intervention to prevent ischemia and tissue damage.

💡Frequent perfusion checks are a standard part of arterial line management to ensure patient safety and catheter function.

📌Core Message

Assessing distal perfusion with capillary refill is essential for intra-arterial monitoring.

Answer 2

Correct Answers:

Encouraging a parent to stay with the client while hospitalized.

Rationale :

👥Having a parent present provides an immediate familiar communication resource for a child with hearing loss.

🗣️Parents often know the child's preferred communication methods, such as sign language or gestures, which enhances understanding.

💡Emotional support from a trusted caregiver reduces anxiety, allowing the child to focus on interpreting information.

✅Continuous parental involvement ensures message consistency between healthcare providers and the child, minimizing miscommunication.

📌Core Message

Parental presence supports communication and emotional security for a child with hearing loss.

Answer 3

Correct Answers:

Obtaining blood glucose level.
Collecting a urine sample.
Turning client every 2 hours.

Rationale :

🩸UAP can perform point-of-care blood glucose checks because it falls under routine data collection per policy.

🚽Collecting a urine sample is within the scope of UAP as it involves basic specimen collection.

🔄Turning the client every 2 hours helps prevent pressure injuries and is appropriate for UAP to perform.

❌UAP are not licensed to perform venipuncture or administer IM glucagon, which require advanced clinical judgment and skill.

📌Core Message

Delegate tasks to UAP that involve routine data collection and basic patient care, ensuring licensure level matches the task.

Answer 4

Correct Answers:

'II should limit my daily intake of hard alcohol to no more than 45ml."

Rationale :

🍷Women should limit alcohol consumption to ≤ 45 ml of hard liquor daily to reduce hypertension risk.

🧀The DASH diet recommends 2–3 servings of low‐fat dairy per day, not per week, to support blood pressure control.

🥜Nuts and seeds are beneficial but limited to about 4–5 servings per week, rather than 2 servings daily or weekly.

🥑Adhering to proper serving guidelines for all food groups is key for cardiovascular health.

📌Core Message

Limit alcohol intake and follow DASH diet serving guidelines for low‐fat dairy and nuts/seeds.

Answer 5

Correct Answers:

Coagulation studies

Rationale :

🩺Baseline coagulation studies (especially activated partial thromboplastin time) are required to determine the starting dose and monitor the therapeutic effect of heparin.

⏳Heparin’s primary action is to prolong clotting time, so knowing the client’s baseline clotting status prevents overdosing or underdosing.

📊Periodic coagulation monitoring ensures the aPTT remains within the therapeutic range, reducing the risk of bleeding or thrombosis.

🩸While a CBC is important for platelet counts, the immediate priority is to assess clotting function before heparin administration.

📌Core Message

Obtain baseline coagulation studies to safely initiate heparin therapy.

Answer 6

Correct Answers:

Administer diazepam
Initiate thiamine supplementation
Administer carbamazepine

Rationale :

💊Diazepam enhances GABA activity to reduce CNS hyperactivity and prevent seizures during acute withdrawal.

🍞Thiamine supplementation corrects vitamin B1 deficiency common in chronic alcohol use, preventing Wernicke encephalopathy.

⚡Carbamazepine provides anticonvulsant effects and can help stabilize neuronal activity when managing withdrawal seizures.

🔄Combining benzodiazepines, nutritional support, and anticonvulsants addresses both neurological symptoms and nutrient deficiencies in alcohol withdrawal.

📌Core Message

Administer benzodiazepines, thiamine, and anticonvulsants to manage alcohol withdrawal and prevent neurological complications.

Answer 7

Correct Answers:

Pain
Obesity
Dulaglutide
Physical inactivity

Rationale :

🩹Pain rated 8/10 in the LUQ that radiates to the back is characteristic of acute pancreatitis and requires immediate assessment and management to prevent complications.

⚖️Obesity is a modifiable risk factor that contributes to increased severity of pancreatitis and metabolic complications, warranting follow-up for weight management and long-term health.

💉Dulaglutide is a GLP-1 agonist known to exacerbate or precipitate pancreatic inflammation, so its use must be re-evaluated in the context of suspected pancreatitis.

🏃Physical inactivity promotes insulin resistance and contributes to metabolic syndrome, increasing the risk for pancreatic disease and requiring follow-up for lifestyle modification.

📌Core Message

Assess severe pain, review medications like dulaglutide, and address obesity and physical inactivity to reduce pancreatitis risk and improve outcomes.

Answer 8

Correct Answers:

Acute pancreatitis
Ectopic pregnancy

Rationale :

🩸Elevated amylase and lipase are hallmark markers of acute pancreatitis, indicating pancreatic inflammation and enzyme leakage into the bloodstream.

💥The client’s sudden LUQ pain radiating to the back and accompanying nausea and vomiting align with pancreatitis clinical presentation.

🤰In a woman of reproductive age with abdominal pain, an ectopic pregnancy must be considered until a negative HCG result rules it out.

📈The elevated WBC count reflects an inflammatory response, which can occur in both pancreatitis and early ectopic pregnancy complications.

📌Core Message

Elevated amylase/lipase confirms pancreatitis, and always rule out ectopic pregnancy with HCG testing in reproductive-aged women.

Answer 9

Correct Answers

Maintain the client nil per oral for 72 hours [ Not Appropriate ]
Administer an intravenous opioid analgesic for pain [ Appropriate ]
Insert a nasogastric (NG) tube for gastric decompression [ Appropriate ]
Administer pancrelipase 500 mg PO daily [ Not Appropriate ]

Rationale :

🍽️Recent guidelines favor early enteral nutrition over prolonged NPO status to maintain gut integrity and reduce complications.

💉Intravenous opioid analgesics effectively control severe pain without stimulating the pancreas.

🚰An NG tube relieves gastric distention and persistent vomiting, preventing further pancreatic stimulation.

🔬Pancrelipase is indicated for chronic pancreatic insufficiency, not acute inflammation, and can worsen acute pancreatitis.

📌Core Message

Early enteral nutrition, pain management, and gastric decompression are key in acute pancreatitis; avoid prolonged NPO and enzyme supplementation.

Answer 10

Correct Answers:

Oral intake
Respiratory status
Serum amylase level

Rationale :

🍽️Improved oral intake indicates the client’s gastrointestinal function is recovering, as tolerating a low-fat, high-carbohydrate diet without nausea reflects healing.

💨Enhanced respiratory status is evident by easy breathing on room air with minimal crackles, showing the resolution of ARDS and improved oxygenation.

🩸A decreasing serum amylase level from 300 U/L to 260 U/L demonstrates reduced pancreatic inflammation and effective treatment of acute pancreatitis.

✅Together, these findings reflect significant clinical improvement in both the client’s pancreatic function and pulmonary status.

📌Core Message

Oral intake, respiratory status, and serum amylase trends indicate clinical recovery.

Finding	Appropriate	Not Appropriate
Maintain the client nil per oral for 72 hours
Administer an intravenous opioid analgesic for pain
Insert a nasogastric (NG) tube for gastric decompression
Administer pancrelipase 500 mg PO daily

NCLEX RN-Readiness Assessment Test-2

No.

1 :
The nurse is planning care for a client with intra-arterial blood pressure monitoring of the right radial artery. Which of the following interventions should the nurse include in the client's plan of care?

2 :
The nurse is caring for a 10-year-old client with hearing loss. Which of the following would best facilitate communication with the client?

3 :
A registered nurse is delegating tasks to an unlicensed assistive personnel when caring for a client with hypoglycemia. Which tasks should the nurse assign the UAP? Select all that apply

4 :
A nurse has taught clients at a teaching center about multiple changes to decrease the risk of developing hypertension. Which of the following statements by a female client would indicate a correct understanding of the teaching?

5 :
A client is diagnosed with a pulmonary embolism (PE) and is scheduled to start intravenous heparin. Which lab panel is the priority to assess before initiating the medication?

6 :
A nurse is caring for a client experiencing alcohol withdrawal. Which of the following orders should the nurse anticipate? Select all that apply

7 :
The nurse in the emergency department (ED) is caring for a 45-year-old female client.

Answer Options

8 :
The nurse in the emergency department (ED) is caring for a 45-year-old female client.

Answer Options

9 :
The nurse in the emergency department (ED) is caring for a 45-year-old female client.

Correct Answers

10 :
The nurse in the emergency department (ED) is caring for a 45-year-old female client.

Answer Options

NCLEX RN-Readiness Assessment Test-2

No.

1 : The nurse is planning care for a client with intra-arterial blood pressure monitoring of the right radial artery. Which of the following interventions should the nurse include in the client's plan of care?

2 : The nurse is caring for a 10-year-old client with hearing loss. Which of the following would best facilitate communication with the client?

3 : A registered nurse is delegating tasks to an unlicensed assistive personnel when caring for a client with hypoglycemia. Which tasks should the nurse assign the UAP? Select all that apply

4 : A nurse has taught clients at a teaching center about multiple changes to decrease the risk of developing hypertension. Which of the following statements by a female client would indicate a correct understanding of the teaching?

5 : A client is diagnosed with a pulmonary embolism (PE) and is scheduled to start intravenous heparin. Which lab panel is the priority to assess before initiating the medication?

6 : A nurse is caring for a client experiencing alcohol withdrawal. Which of the following orders should the nurse anticipate? Select all that apply

7 : The nurse in the emergency department (ED) is caring for a 45-year-old female client.

Answer Options

8 : The nurse in the emergency department (ED) is caring for a 45-year-old female client.

Answer Options

9 : The nurse in the emergency department (ED) is caring for a 45-year-old female client.

Correct Answers

10 : The nurse in the emergency department (ED) is caring for a 45-year-old female client.

Answer Options

1 :
The nurse is planning care for a client with intra-arterial blood pressure monitoring of the right radial artery. Which of the following interventions should the nurse include in the client's plan of care?

2 :
The nurse is caring for a 10-year-old client with hearing loss. Which of the following would best facilitate communication with the client?

3 :
A registered nurse is delegating tasks to an unlicensed assistive personnel when caring for a client with hypoglycemia. Which tasks should the nurse assign the UAP? Select all that apply

4 :
A nurse has taught clients at a teaching center about multiple changes to decrease the risk of developing hypertension. Which of the following statements by a female client would indicate a correct understanding of the teaching?

5 :
A client is diagnosed with a pulmonary embolism (PE) and is scheduled to start intravenous heparin. Which lab panel is the priority to assess before initiating the medication?

6 :
A nurse is caring for a client experiencing alcohol withdrawal. Which of the following orders should the nurse anticipate? Select all that apply

7 :
The nurse in the emergency department (ED) is caring for a 45-year-old female client.

8 :
The nurse in the emergency department (ED) is caring for a 45-year-old female client.

9 :
The nurse in the emergency department (ED) is caring for a 45-year-old female client.

10 :
The nurse in the emergency department (ED) is caring for a 45-year-old female client.