Nln Nex Exam

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Sample questions from Nln Nex Exam

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.At change of shift on a medical-surgical unit, the nurse receives report on four clients. Which client should the nurse assess first?

   • A.A 71-year-old 1 day after hip replacement who reports pain of 7/10 after physical therapy
   • B.A 58-year-old with chronic kidney disease whose potassium is 5.7 mEq/L and who has peaked T waves on the monitor
   • C.A 34-year-old with pneumonia whose temperature is 38.1 C and who is due for an antipyretic
   • D.A 46-year-old with diabetes whose glucose is 248 mg/dL before breakfast and who is asking when insulin will be given

   Rationale: The client with hyperkalemia and peaked T waves is at immediate risk for a lethal dysrhythmia and needs prompt assessment and intervention. The elevated glucose, postoperative pain, and fever require timely care, but none has the same immediate threat to cardiac stability. Treating pain or fever before addressing the ECG change would delay care for the most unstable client. Prioritize acute threats to life over expected or non-immediately dangerous findings.

2. 2.On a pediatric unit, a 2-year-old is admitted with dehydration after 2 days of vomiting. The child is lethargic but arousable, has dry mucous membranes, and has urine output of 0.4 mL/kg/hr. Which tasks may the registered nurse delegate to an experienced unlicensed assistive personnel (UAP)? Select all that apply.

   • A.Assess the child's level of alertness and report whether it has changed
   • B.Measure and record each diaper weight and report the total urine output
   • C.Evaluate whether the prescribed IV fluid bolus improved the child's perfusion
   • D.Obtain routine vital signs and immediately report values outside the specified parameters
   • E.Teach the parent how to offer small, frequent amounts of oral rehydration solution
   • F.Obtain and document the child's current weight using the same scale used on admission

   Rationale: Obtaining a weight, measuring diaper weights, and collecting routine vital signs are predictable tasks that a trained UAP can perform, with abnormal findings promptly reported. Assessing alertness and evaluating response to a fluid bolus require nursing judgment, so those tasks remain with the registered nurse. Teaching the parent also requires the nurse to assess understanding and tailor instruction. Delegation transfers task performance, not assessment, teaching, or evaluation accountability.

3. 3.A client's potassium is 6.1 mEq/L, and the client is receiving digoxin for heart failure. The client reports new nausea and blurred vision; the apical pulse is 54/min. Which action should the nurse take first?

   • A.Administer the scheduled digoxin with food to reduce nausea
   • B.Ask the UAP to repeat the apical pulse after the client rests
   • C.Give the prescribed potassium supplement and recheck the level in 1 hour
   • D.Hold the scheduled digoxin and notify the provider of the findings

   Rationale: The combination of bradycardia, visual changes, and nausea raises concern for digoxin toxicity, and the potassium result is also critically abnormal. The nurse should withhold the dose and promptly notify the provider so the client can be evaluated and treated. Giving digoxin could worsen bradycardia, while a potassium supplement is inappropriate with an already high potassium level. A UAP may obtain routine data but cannot replace the nurse's assessment or delay escalation of these findings.

4. 4.During a home visit, a 76-year-old taking warfarin for atrial fibrillation reports a fall with a head strike 2 hours ago. The client feels well, has no visible injury, and has an INR of 2.6. What should the nurse do?

   • A.Arrange immediate emergency evaluation and communicate the head strike and warfarin use
   • B.Document the fall and schedule a routine follow-up appointment for the next day
   • C.Ask the client's family to check the INR again tomorrow morning
   • D.Instruct the client to rest and call the clinic if a headache develops

   Answer and rationale are in the full material.

5. 5.In the emergency department, a 15-year-old with sickle cell disease has a temperature of 38.4 C, chills, and a central venous catheter. The client is alert, with BP 108/66 mm Hg and HR 118/min. Which action should the nurse take first?

   • A.Ask the family to confirm whether the client received the seasonal influenza vaccine
   • B.Give the prescribed oral antipyretic and reassess the temperature in 1 hour
   • C.Notify the provider promptly and initiate the facility's febrile immunocompromised-client protocol
   • D.Obtain a urine specimen before reporting the fever

   Answer and rationale are in the full material.