Does the NCLEX-RN Expire? License vs. Exam, Explained

✓ Correct: C Inform the nursing supervisor about the colleague’s physical state.

Why. The correct answer is C. Finding a colleague asleep with pinpoint pupils and a slow response to alarms indicates significant impairment and immediate patient danger. Reporting to the nursing supervisor is the necessary action to remove the nurse from care and initiate testing. Option A is incorrect because assisting the nurse enables the behavior and leaves the impaired individual in a position of responsibility. Option B is inappropriate as a break does not address the underlying cause of the physical signs observed. Option D is unsafe because a nurse showing signs of opioid use (constricted pupils) or extreme fatigue cannot provide safe care, regardless of monitoring. The supervisor is the only person authorized to handle the legal and safety implications of this situation, ensuring the ventilator alarm and patient needs are addressed immediately.

✓ Correct: B Suggest the client consume the prep over a split-dose.

Why. A split-dose regimen (Option B) involves taking half the bowel preparation the night before and the other half the morning of the procedure. This method is the current standard of care because it improves mucosal visualization and is better tolerated by elderly clients or those with heart failure who may struggle with large fluid volumes in a short period. Drinking the solution too quickly (Option A) can trigger nausea or fluid overload in a Class III heart failure patient. Adding magnesium citrate (Option C) increases the risk of electrolyte disturbances, which can trigger arrhythmias in heart failure. Restricting all fluids (Option D) during the prep is dangerous, as the osmotic effect of the laxative requires adequate hydration to prevent dehydration and acute kidney injury, even in heart failure patients who are on fluid restrictions.

✓ Correct: A Obtain blood cultures from the catheter line.

Why. The presence of redness, warmth, purulent drainage, and fever in a client with a central venous catheter strongly suggests a catheter-related bloodstream infection. Obtaining blood cultures (Option A) is the priority to identify the pathogen and guide systemic antibiotic therapy. Option B is insufficient for a systemic infection and does not help in diagnosis. Option C is a routine maintenance task and does not address the acute infection. Option D is a cleaning step that should have been part of prevention but is not a treatment for an established infection with systemic symptoms. The cues of purulent drainage and a high temperature indicate that the infection is no longer localized, making diagnostic cultures the essential next step for managing the client’s care and preventing further complications like sepsis or endocarditis.

✓ Correct: A Initiate the high-risk safety protocol.

Why. The correct answer is A because a Hendrich II Fall Risk Model score of 5 or greater identifies a client at high risk for falls. This client’s score of 7, driven by cognitive impairment and pharmacological factors, necessitates immediate high-risk interventions. Option B focuses on skin integrity, which is important for post-surgical recovery but does not address the immediate safety risk identified by the assessment tool. Option C is a collaborative action that may be necessary later but does not provide the immediate protection required at the bedside. Option D is an assessment task that is already reflected in the Hendrich II score and does not constitute a preventive intervention. The combination of dementia and high-risk medications makes the high-risk protocol the most appropriate choice to prevent injury in this clinically complex scenario.

✓ Correct: B Serum phosphorus level of 5.2 mg/dL and low output.

Why. The correct answer is B because hypertonic sodium phosphate enemas are generally contraindicated in patients with advanced chronic kidney disease. These patients cannot effectively excrete the high phosphorus load absorbed from the enema, which can lead to life-threatening hyperphosphatemia and subsequent hypocalcemia. The cue of low urinary output further highlights the patient’s inability to manage significant electrolyte shifts. Option A is incorrect because a potassium level of 4.8 mEq/L is within normal limits and mild edema is a common finding in heart failure that does not preclude the enema. Option C represents a normal sodium level and dry mucosa suggests constipation, which is the condition the enema is intended to treat. Option D shows a normal calcium level and trace protein, which are common in elderly patients and do not pose the same immediate risk as the phosphorus load.