Question

The emergency nurse is caring for a client with heart failure who is experiencing dyspnea. The nurse notes crackles in all lung fields and a pulse oximetry reading of 94% on 4 L/min via nasal cannula. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Request a prescription for IV furosemide.

Rationale :

💧Crackles in all lung fields indicate fluid overload in the lungs, which is a hallmark of acute decompensated heart failure.

💊Furosemide, a potent loop diuretic, helps remove excess fluid, relieve pulmonary congestion, and improve respiratory status.

📉Even though the pulse oximetry is 94%, it does not address the underlying cause—fluid accumulation—which is best managed with a diuretic.

🚫Increasing oxygen may temporarily improve saturation but does not resolve the hemodynamic burden causing the dyspnea.

📌Core Message

IV furosemide is indicated to relieve fluid overload and pulmonary congestion in clients with heart failure and respiratory distress.

Answer 2

Correct Answers:

"Use an insect repellent that contains DEET while outside."

Rationale :

🦟DEET-containing insect repellent is proven effective in preventing tick bites, the primary transmission route for Lyme disease.

🧢Wearing light-colored clothing rather than dark helps spot ticks more easily after outdoor activities.

🩺The bullseye rash (erythema migrans) is a hallmark early sign of Lyme, not pinpoint rashes.

❌Prompt tick removal with tweezers is essential; leaving a tick in place delays treatment and increases risk.

📌Core Message

Using DEET-based repellents significantly reduces the risk of tick bites and Lyme disease transmission.

Answer 3

Correct Answers:

type 2 diabetes mellitus

Rationale :

📉Polycystic ovarian syndrome (PCOS) involves insulin resistance, increasing the client’s risk for developing type 2 diabetes mellitus.

🧬It is a metabolic-endocrine disorder affecting hormone regulation and glucose metabolism.

👶Twin pregnancies are not directly related to PCOS unless ovulation-inducing medications are involved.

💊PCOS does not inherently increase the risk of pelvic inflammatory disease or uterine fibroids.

📌Core Message

Insulin resistance in PCOS increases the risk for type 2 diabetes mellitus.

Answer 4

Correct Answers:

Notify the health care provider.

Rationale :

👁️Blurred vision with halos suggests acute angle-closure glaucoma, a medical emergency.

🚨Immediate provider notification is necessary to prevent permanent vision loss.

📋A visual acuity test may be helpful but should not delay urgent intervention.

💊Pilocarpine may be prescribed, but it requires medical evaluation first before administration.

📌Core Message

Sudden visual changes with halos may indicate acute glaucoma, requiring immediate provider notification.

Answer 5

Correct Answers:

infant with atrial septal defect who underwent cardiac catheterization 2 hours ago and whose right leg is cool and blanching

Rationale :

💉A cool, blanching extremity post-catheterization indicates compromised circulation, requiring immediate assessment.

🕒This finding within 2 hours of the procedure is concerning for arterial occlusion or embolism.

⚖️Weight loss in a neonate with PDA or fever in a post-op client are concerning but not immediately life-threatening.

💦Tachycardia and diaphoresis during exertion should be evaluated, but loss of perfusion takes precedence.

📌Core Message

Cool and blanching limbs following cardiac catheterization suggest vascular compromise and require immediate intervention.

Answer 6

Correct Answers:

3-week-old with Hirschsprung disease who has explosive diarrhea and abdominal distention

Rationale :

🚨Explosive diarrhea and distention in Hirschsprung disease may indicate enterocolitis, a life-threatening complication.

💩It represents inflammation of the bowel and can rapidly progress to sepsis or bowel perforation.

🍼Projectile vomiting in pyloric stenosis is typical but less immediately dangerous than enterocolitis.

🧒Abdominal guarding or irritability in other cases may be urgent but not as critical.

📌Core Message

Explosive diarrhea with distention in Hirschsprung disease indicates enterocolitis, requiring urgent evaluation.

Answer 7

Correct Answers:

Waiting to reposition a paraplegic client until another nurse is available to assist

Rationale :

🛏️Delaying repositioning a paraplegic client puts them at risk for pressure injuries and impaired circulation.

🧍Proper positioning is essential for skin integrity and respiratory function, and should not be postponed.

🎧Helping a client with hearing loss visualize IV issues demonstrates appropriate adaptation.

👀Moving objects for a visually impaired client may be helpful if done safely and with notification.

📌Core Message

Timely repositioning of paraplegic clients is essential to prevent pressure injuries and other complications.

Answer 8

Correct Answers:

avocados and is scheduled for surgery

Rationale :

🥑Allergy to avocados may indicate latex allergy, which is critical to identify before surgery.

🏥Latex is used in many surgical tools, and unrecognized allergy can lead to anaphylaxis during procedures.

💊Levofloxacin is not a penicillin-based antibiotic, so cross-reactivity is unlikely.

🐚Shellfish allergy is not directly related to iodine sensitivity, contrary to popular belief.

📌Core Message

Avocado allergy may indicate latex sensitivity, which poses a serious risk during surgical procedures.

Answer 9

Correct Answers:

"Alarm parameters should be selected based on the individual condition of each client.

Rationale :

🔔Alarm settings are a critical safety tool and must be tailored to each client’s clinical status for accurate monitoring.

⚠️Using default or standard settings increases the risk of missed deterioration or unnecessary alarms.

🚫Storing equipment in hallways or running cords under rugs creates fire and fall hazards and violates safety policies.

🛑Faulty equipment should be removed from the room and reported promptly, not left at the bedside.

📌Core Message

Alarm settings must be individualized to promote accurate monitoring and reduce alarm fatigue and safety risks.

Answer 10

Correct Answers:

admitted for a myocardial infarction (MI) with a positive

Rationale :

🫀This client fits within a telemetry nurse's cardiac care skill set, including interpreting ECGs and monitoring for complications.

👩‍⚕️Caring for post-op CABG or intubated clients requires ICU-level critical care experience, which is beyond telemetry training.

💉Clients requiring IV insulin for DKA need frequent lab monitoring and titration, best managed by ICU-trained nurses.

📋Assigning clients based on nurse competency and experience ensures safe and effective care delivery.

📌Core Message

MI with positive troponin is the most appropriate ICU assignment for a telemetry nurse, given their cardiac expertise.

NCLEX RN-Readiness Assessment Test-5

No.

1 :
The emergency nurse is caring for a client with heart failure who is experiencing dyspnea. The nurse notes crackles in all lung fields and a pulse oximetry reading of 94% on 4 L/min via nasal cannula. Which of the following actions should the nurse take?

2 :
The nurse in a community-based setting is teaching clients about the prevention of Lyme disease. Which of the following information should the nurse include?

3 :
The nurse is assessing a female client who was diagnosed with polycystic ovarian syndrome. The client is at increased risk for developing

4 :
The nurse is caring for a client who reports sudden blurred vision and halos appearing around lights. Which of the following actions should the nurse take?

5 :
The pediatric nurse has been made aware of the following client situations. The nurse should first assess the

6 :
The pediatric nurse has been made aware of the following client situations. It would be a priority for the nurse to follow up with the

7 :
The nurse is observing a student nurse who is caring for four clients. Which of the following actions by the student would require the nurse to intervene?

8 :
The charge nurse has been made aware of the following situations. The charge nurse should first follow up with the client who has an allergy to

9 :
The nurse is planning a staff education program about the safe use of equipment. Which of the following information should the nurse include?

10 :
A telemetry nurse has been temporarily floated to the intensive care unit (ICU). It would be most appropriate for the charge nurse to assign the telemetry nurse to care for the client who is

NCLEX RN-Readiness Assessment Test-5

No.

1 : The emergency nurse is caring for a client with heart failure who is experiencing dyspnea. The nurse notes crackles in all lung fields and a pulse oximetry reading of 94% on 4 L/min via nasal cannula. Which of the following actions should the nurse take?

2 : The nurse in a community-based setting is teaching clients about the prevention of Lyme disease. Which of the following information should the nurse include?

3 : The nurse is assessing a female client who was diagnosed with polycystic ovarian syndrome. The client is at increased risk for developing

4 : The nurse is caring for a client who reports sudden blurred vision and halos appearing around lights. Which of the following actions should the nurse take?

5 : The pediatric nurse has been made aware of the following client situations. The nurse should first assess the

6 : The pediatric nurse has been made aware of the following client situations. It would be a priority for the nurse to follow up with the

7 : The nurse is observing a student nurse who is caring for four clients. Which of the following actions by the student would require the nurse to intervene?

8 : The charge nurse has been made aware of the following situations. The charge nurse should first follow up with the client who has an allergy to

9 : The nurse is planning a staff education program about the safe use of equipment. Which of the following information should the nurse include?

10 : A telemetry nurse has been temporarily floated to the intensive care unit (ICU). It would be most appropriate for the charge nurse to assign the telemetry nurse to care for the client who is

1 :
The emergency nurse is caring for a client with heart failure who is experiencing dyspnea. The nurse notes crackles in all lung fields and a pulse oximetry reading of 94% on 4 L/min via nasal cannula. Which of the following actions should the nurse take?

2 :
The nurse in a community-based setting is teaching clients about the prevention of Lyme disease. Which of the following information should the nurse include?

3 :
The nurse is assessing a female client who was diagnosed with polycystic ovarian syndrome. The client is at increased risk for developing

4 :
The nurse is caring for a client who reports sudden blurred vision and halos appearing around lights. Which of the following actions should the nurse take?

5 :
The pediatric nurse has been made aware of the following client situations. The nurse should first assess the

6 :
The pediatric nurse has been made aware of the following client situations. It would be a priority for the nurse to follow up with the

7 :
The nurse is observing a student nurse who is caring for four clients. Which of the following actions by the student would require the nurse to intervene?

8 :
The charge nurse has been made aware of the following situations. The charge nurse should first follow up with the client who has an allergy to

9 :
The nurse is planning a staff education program about the safe use of equipment. Which of the following information should the nurse include?

10 :
A telemetry nurse has been temporarily floated to the intensive care unit (ICU). It would be most appropriate for the charge nurse to assign the telemetry nurse to care for the client who is