Cliffs Test Prep NCLEX RN

Alternative Response Items

Multiple Choice Problems

1. The nurse is caring for a client with tuberculosis. Which of the following infection control precautions should

the nurse implement? Select all that apply.

❏ 1. ❏ 2. ❏ 3. ❏ 4. ❏ 5. Wear a particulate respirator mask when entering the client’s room.

Wear a gown when assessing the client’s peripheral pulses.

Wear gloves when checking the client’s blood pressure.

Wear sterile gloves when taking the client’s oral temperature.

Place the client in a reverse air flow room.

2. A diabetic client receives his morning insulin, but then eats only half of his breakfast. A few hours later, the

client complains of a headache and weakness. Which of the following interventions should the nurse

implement? Check all that apply.

❏ 1. Give the client another dose of insulin.

❏ 2. Check the client’s blood glucose.

❏ 3. Have the client exercise.

❏ 4. Offer the client some orange juice.

❏ 5. Encourage the client to eat a snack.

Fill-in-the-Blank (Calculation)

3. The physician orders a client to receive cefazolin sodium (Kefzol) 500 mg IM now. The nurse has 250 mg/ml

available. How many milliliters will the nurse give?

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4. The nurse is completing the intake and output record for a client who had a thoracotomy with chest tube

placement. The client had the following intake and output during the eight-hour shift.

Intake: 6 oz. of tea

1 cup of diced chicken salad

8 oz. of water

1⁄2 cup of green beans

4 oz. of sherbet

1000 ml of D5 1⁄2 NS IV fluid

Output: 1200 ml of urine from the urinary drainage bag

50 ml of drainage from the chest tube

How many milliliters should the nurse document as the client’s intake?

Fill-in-the-Blank (Ordered Response)

5. A nurse enters a client’s hospital room and discovers the client is cyanotic and is not breathing. Place the

interventions the nurse should perform in the order of priority.

1. Place the client on a cardiac monitor.

2. Call for help.

3. Check for a pulse.

4. Open the airway.

5. Begin cardiac compressions.

Insert your answer here: __________

6. A client walks into the emergency room stating he has just been stabbed in the neck. The nurse notes that he is

bleeding heavily from the right side of the neck. Put the nursing interventions in the correct order that the nurse

should perform them.

1. Administer a tetanus vaccine.

2. 3. 4. Check the client’s blood pressure.

Apply pressure to the site of bleeding.

Prepare the client for suturing by the physician.

Insert your answer here: __________

8Introduction

Hot Spot

7. Identify the area the nurse would place her stethoscope to best auscultate a cardiac murmur associated with

mitral valve regurgitation.

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8. The nurse is assessing a client’s peripheral pulses. Identify the area the nurse should place her fingers in order to

palpate the radial pulse.

Answers and Explanations

1.

❏ x 1. Wear a particulate respirator mask when entering the client’s room.

❏ 2. Wear a gown when assessing the client’s peripheral pulses.

❏ 3. Wear gloves when checking the client’s blood pressure.

❏ 4. Wear sterile gloves when taking the client’s oral temperature.

❏ x 5. Place the client in a reverse air flow room.

A special particulate mask is needed to filter out the small size bacteria of tuberculosis, which is spread by

inhaling respiratory droplets. A gown is not necessary to wear for assessing pulses, because there is no spread of

tuberculosis by contact. Gloves are not needed to check blood pressure, because tuberculosis is not spread by

contact with skin. The nurse does not need to wear sterile gloves when taking an oral temperature; clean gloves

will suffice if there will be potential contact with saliva, which is assumed to be a potential contaminant in all

clients. The client is placed in a reverse air flow room, so that bacilli are not carried via the air into the hallway,

to potentially expose other people to tuberculosis.

10Introduction

2.

❏ 1. Give the client another dose of