Question

The nurse is teaching a client with anemia who is newly prescribed ferrous sulfate. Which of the following information should the nurse include?

Answer 1

Correct Answers:

"It's normal for this medication to make your stools black."

Rationale :

🩺Ferrous sulfate commonly causes dark or black stools as a harmless side effect due to unabsorbed iron.

💊This is an expected reaction and does not indicate internal bleeding or gastrointestinal distress.

📘Client education should include reassurance that this change is not dangerous and is a sign the iron is being metabolized.

🧪Educating patients about this effect helps promote medication adherence and prevents unnecessary concern.

📌Core Message

Ferrous sulfate can cause black stools due to unabsorbed iron, and this is a harmless, expected side effect.

Answer 2

Correct Answers:

Contact a social worker to discuss possible resources available for the client.

Rationale :

📞When a client expresses financial concerns regarding medication, a referral to a social worker is an appropriate first step.

💡Social workers are trained to assist with resource navigation including prescription assistance programs.

🔄This promotes equitable access to care by addressing barriers that can interfere with adherence.

🧾Rather than delay or continue discharge without support, involving a social worker ensures the client gets comprehensive discharge planning.

📌Core Message

Referring to a social worker addresses financial barriers and helps ensure access to prescribed treatments.

Answer 3

Correct Answers:

"When ambulating, extend the crutches and injured leg forward together, followed by the uninjured leg."

Rationale :

🦯Proper crutch walking technique includes moving the injured leg and crutches forward together to maintain balance and reduce strain.

💪The uninjured leg follows, supporting body weight as the client steps through.

⚠️Incorrect use, such as putting pressure on the axilla or moving the legs out of sequence, increases risk of falls and nerve damage.

🧍Teaching proper mechanics helps ensure safety and promotes recovery for clients with limited mobility.

📌Core Message

Clients using crutches should move the injured leg and crutches forward together, followed by the uninjured leg for safe ambulation.

Answer 4

Correct Answers:

Notify the health care provider.

Rationale :

🗣️A muffled voice in a febrile 2-year-old may indicate epiglottitis, a life-threatening airway obstruction.

🚨This is a medical emergency requiring immediate intervention—not diagnostic procedures or oral medication.

📞The priority is to notify the provider immediately for potential intubation or airway support.

🧫Invasive assessments (e.g., throat cultures or temperature checks) should be avoided to prevent airway collapse.

📌Core Message

A muffled voice in a young child may signal epiglottitis, and immediate provider notification is required to manage the airway.

Answer 5

Correct Answers:

has type 1 diabetes and takes scheduled insulin

Rationale :

💉Clients with type 1 diabetes who use insulin are at the highest risk for hypoglycemia, especially with missed meals or excessive dosing.

🔻Insulin lowers blood sugar, and if not matched with sufficient intake or activity changes, it can cause dangerous hypoglycemic episodes.

📉Symptoms include sweating, tremors, confusion, and even seizures or coma if left untreated.

🧪Unlike metformin, which rarely causes hypoglycemia, scheduled insulin poses a significant risk if not balanced properly.

📌Core Message

Scheduled insulin in type 1 diabetes presents the highest hypoglycemia risk, requiring close monitoring.

Answer 6

Correct Answers:

Apply barrier cream to affected areas after incontinence.

Rationale :

🧴Barrier creams protect the skin from moisture, irritants, and further breakdown associated with incontinence-associated dermatitis (IAD).

🩺Applying it after incontinence episodes helps maintain skin integrity in sensitive areas like the perineum and groin.

❌Other interventions like using hot water or corticosteroids may worsen irritation or mask infection.

🧼Proper hygiene with mild cleansers and protection is central to managing IAD and preventing complications.

📌Core Message

Barrier creams protect skin and are essential in managing incontinence-associated dermatitis.

Answer 7

Correct Answers:

Prepares to administer aspirin as needed to treat the child's fever

Rationale :

❌Aspirin should never be given to children with viral illnesses like varicella zoster due to the risk of Reye's syndrome, a potentially fatal condition.

⚠️Even though aspirin treats fever, safer alternatives like acetaminophen or ibuprofen should be used in pediatrics.

📋Supervising nurses must intervene immediately if contraindicated medications are about to be given.

📚Client education and staff oversight are essential to safe pediatric medication practices.

📌Core Message

Aspirin is contraindicated in children with viral infections like varicella due to the risk of Reye’s syndrome.

Answer 8

Correct Answers:

1+ femoral pulses, 3+ brachial pulses

Rationale :

💁‍♂️A discrepancy between upper and lower extremity pulses in an infant may indicate aortic coarctation, a critical congenital heart defect.

⚠️Diminished femoral pulses suggest obstructed blood flow, which requires immediate attention.

🩺Compared to murmurs or minor apnea, uneven perfusion is more urgent and may require imaging or surgical consultation.

📈Early identification of circulatory compromise can prevent complications like shock or cardiac failure.

📌Core Message

Weak femoral pulses compared to brachial suggest a critical perfusion issue and require immediate cardiac assessment.

Answer 9

Correct Answers:

Stage 4

Rationale :

🧷A Stage 4 pressure injury involves full-thickness tissue loss with exposed muscle, bone, or tendon, often with tunneling or undermining.

📸If the sacral wound shows deep tissue damage and visible structures, it is classified as Stage 4.

🧬These injuries require specialized wound care and may involve surgical debridement.

🩺Accurate staging helps guide appropriate treatment and pressure relief strategies.

📌Core Message

A Stage 4 pressure injury involves exposed deep structures and full-thickness skin loss requiring complex care.

Answer 10

Correct Answers:

takes bumetanide for pulmonary edema.

Rationale :

💊Bumetanide is a loop diuretic that can cause rapid fluid loss, leading to hypotension, dizziness, or electrolyte imbalances—risk factors for falls.

🩺This is particularly dangerous in older or ambulatory clients who may experience orthostatic changes.

📉Fall risk increases with medications that alter fluid or blood pressure balance.

🚨Other listed factors (like hearing aids or saline locks) do not pose as significant or direct a risk.

📌Core Message

Loop diuretics like bumetanide significantly increase fall risk due to fluid loss and hypotension.

NCLEX RN-Readiness Assessment Test-4

No.

1 :
The nurse is teaching a client with anemia who is newly prescribed ferrous sulfate. Which of the following information should the nurse include?

2 :
The nurse is performing discharge teaching for a hospitalized client who is scheduled for discharge. The client states, "I do not have money to get these prescriptions." Which of the following actions should the nurse take?

3 :
The nurse is teaching the client with a broken ankle how to ambulate with crutches. Which of the following information should the nurse include?

4 :
The nurse in the emergency department is caring for a 2-year-old client who is febrile and newly admitted with suspected croup. The nurse observes that the client is speaking with a muffled voice. Which of the following actions should the nurse take?

5 :
The nurse is screening clients for those at risk for hypoglycemia. At highest risk for hypoglycemia is the client who

6 :
The nurse is planning care for a client who is ambulatory and has incontinence-associated dermatitis (IAD) affecting the groin and perineum. Which of the following interventions should the nurse include in the plan of care?

7 :
The Kurse is observing a new nurse caring for a 7-year-old client with varicella zoster. Which of the following actions by the new nurse would require follow-up by the supervising nurse?

8 :
The nurse is caring for a 2-day-old infant with a suspected congenital heart defect. Which of the following findings should receive highest priority?

9 :
The wound care nurse is performing a skin assessment on admitted from a long-term care facility. The nurse notes a sacrum. A photo is placed in the client's Assessment flowsh medical record. Which of the following stages of pressure injury should the nurse document?

10 :
The charge nurse is conducting a fall-risk assessment on admitted clients. At highest risk for falls is the client who

NCLEX RN-Readiness Assessment Test-4

No.

1 : The nurse is teaching a client with anemia who is newly prescribed ferrous sulfate. Which of the following information should the nurse include?

2 : The nurse is performing discharge teaching for a hospitalized client who is scheduled for discharge. The client states, "I do not have money to get these prescriptions." Which of the following actions should the nurse take?

3 : The nurse is teaching the client with a broken ankle how to ambulate with crutches. Which of the following information should the nurse include?

4 : The nurse in the emergency department is caring for a 2-year-old client who is febrile and newly admitted with suspected croup. The nurse observes that the client is speaking with a muffled voice. Which of the following actions should the nurse take?

5 : The nurse is screening clients for those at risk for hypoglycemia. At highest risk for hypoglycemia is the client who

6 : The nurse is planning care for a client who is ambulatory and has incontinence-associated dermatitis (IAD) affecting the groin and perineum. Which of the following interventions should the nurse include in the plan of care?

7 : The Kurse is observing a new nurse caring for a 7-year-old client with varicella zoster. Which of the following actions by the new nurse would require follow-up by the supervising nurse?

8 : The nurse is caring for a 2-day-old infant with a suspected congenital heart defect. Which of the following findings should receive highest priority?

9 : The wound care nurse is performing a skin assessment on admitted from a long-term care facility. The nurse notes a sacrum. A photo is placed in the client's Assessment flowsh medical record. Which of the following stages of pressure injury should the nurse document?

10 : The charge nurse is conducting a fall-risk assessment on admitted clients. At highest risk for falls is the client who

1 :
The nurse is teaching a client with anemia who is newly prescribed ferrous sulfate. Which of the following information should the nurse include?

2 :
The nurse is performing discharge teaching for a hospitalized client who is scheduled for discharge. The client states, "I do not have money to get these prescriptions." Which of the following actions should the nurse take?

3 :
The nurse is teaching the client with a broken ankle how to ambulate with crutches. Which of the following information should the nurse include?

4 :
The nurse in the emergency department is caring for a 2-year-old client who is febrile and newly admitted with suspected croup. The nurse observes that the client is speaking with a muffled voice. Which of the following actions should the nurse take?

5 :
The nurse is screening clients for those at risk for hypoglycemia. At highest risk for hypoglycemia is the client who

6 :
The nurse is planning care for a client who is ambulatory and has incontinence-associated dermatitis (IAD) affecting the groin and perineum. Which of the following interventions should the nurse include in the plan of care?

7 :
The Kurse is observing a new nurse caring for a 7-year-old client with varicella zoster. Which of the following actions by the new nurse would require follow-up by the supervising nurse?

8 :
The nurse is caring for a 2-day-old infant with a suspected congenital heart defect. Which of the following findings should receive highest priority?

9 :
The wound care nurse is performing a skin assessment on admitted from a long-term care facility. The nurse notes a sacrum. A photo is placed in the client's Assessment flowsh medical record. Which of the following stages of pressure injury should the nurse document?

10 :
The charge nurse is conducting a fall-risk assessment on admitted clients. At highest risk for falls is the client who