Fundamentals: NCLEX

The nurse is providing instructions to an unlicensed assistive personnel (UAP) who is assigned to care for a client with hemiparesis of the right arm and leg. Where should the nurse instruct the UAP to place personal articles for morning care?

Within the client's reach on the left side

A filled blood specimen tube was dropped and broken in the client's room. Which action performed by the unlicensed assistive personnel (UAP) to clean up the blood spill is incorrect?

Blots up the spill with a face cloth or cloth towel

The nurse is preparing to initiate an intravenous line containing a high dose of potassium chloride and plans to use an intravenous infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action?

Contact the electrical maintenance department for assistance.

A nurse is helping to conduct a group therapy session. During the session, a client threatens to act out physically and states that he will punch another member of the group. Which is the appropriate initial nursing action?

Tell the client that he can talk about his anger but cannot act on it in during the group session.

A client with tuberculosis (TB) asks the nurse about precautions to take after discharge to prevent infection of others. The nurse develops a response to the client's question based on which correct understanding of TB transmission?

The disease is transmitted by droplet nuclei.

A homebound client confidentially discusses suicidal plans with the visiting nurse. Based on professional duty to observe confidentiality, which statement best describes the nurse's obligation to the client?

The nurse must override the duty to observe confidentiality and notify the client's health care provider (HCP) about the suicidal ideation.

Sildenafil (Viagra) is prescribed to treat a client with erectile dysfunction. The nurse reviews the client's medical record and should question the prescription if which data is noted in the client's history?

use of nitroglycerin

The nurse is planning to instruct a client with chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Which instruction should the nurse plan to include in the client's teaching plan?

Remove throw rugs and clutter in the home

An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response?

"As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

A client is scheduled for surgery, and the surgeon has explained the procedure and is about to obtain informed consent. Which statement by the client would indicate to the nurse that the client needs more information before giving informed consent to the procedure?

"I know my surgeon explained it, but I still don't know why surgery is needed."

A nurse is providing instructions to the mother of a child with croup regarding treatment measures if an acute spasmodic episode occurs. Which statement made by the mother indicates a need for further teaching?

"I should place a steam vaporizer in my child's room."

A client is being discharged to home after application of a plaster leg cast. Which statement indicates to the nurse that the teaching has been effective?

"I will avoid getting the cast wet."

A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client?

"I will call the nursing supervisor to seek assistance regarding your request."

The nurse is reinforcing instructions to the mother of a child who has a plaster cast applied to the left arm. Which statement by the mother indicates a need for further teaching?

"I will have to use a heat lamp to help the cast dry."

While making rounds a client asks the nurse, "What's wrong with that lady in the room next to me? She cries out all night long, and I hope she is okay." What is the nurse's best response?

"I'm sure it's upsetting to hear her cry, but I'm not able to discuss details about other clients."

A female client is scheduled to have a chest radiograph. Which question is most important when assessing this client?

"Is there any possibility that you could be pregnant?"

The nurse manager is giving a staff inservice on providing culturally sensitive education to clients. Which statements indicate to the nurse manager that the staff understands providing culturally sensitive education? Select all that apply.

"The population served will determine the culturally sensitive resources to use for teaching." "Assessment of a client's preferred learning approach is essential to facilitate the learning process." "It is important to have an accurate translator when the nurse and client do not speak the same language."

he 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home?

"We will be sure not to leave hot liquids unattended."

A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. What should the nurse should plan to tell the client?

"You will be evaluated at the time of delivery for herpetic genital tract lesions, and if any are present, a cesarean delivery will be needed."

The nurse in charge of a nursing unit is asked to select those hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply.

*The client who 24 hours earlier gave birth to her second child by caesarean delivery *The 48-hour postoperative client who has undergone an ileostomy because of ulcerative colitis *The 2-day postoperative client who has undergone total knee replacement and is ambulating with a walker *The 3-day postoperative client who has undergone coronary artery bypass grafting and is ready for rehabilitation

An emergency department nurse is preparing to receive four clients as a result of a motor vehicle crash. Which victim should the nurse attend to first?

A 45-year-old man with chest pain, shortness of breath, and diaphoresis

The prescription for an infusion of parenteral nutrition reads: Infuse 1800 mL bag over 24 hours. At what rate will the nurse set the infusion pump? Fill in the blank.

75 (no label)

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa?

A client undergoing diagnostic tests

The registered nurse (RN) is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has one RN, a licensed practical (vocational) nurse, and two unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse?

A client with an abdominal wound requiring frequent wound irrigations

Which client should the emergency department triage nurse classify as emergent?

A client with crushing substernal pain who is short of breath

A registered nurse (RN) is providing instructions to an unlicensed assistive personnel (UAP) assigned to give a bed bath to a client who is on contact precautions. The RN instructs the UAP to use which protective item when giving the bed bath?

A gown and gloves

A client with severe preeclampsia is admitted to the maternity department. Which room assignment would be most appropriate for this client?

A private room two doors away from the nurses' station

The nurse is the first responder at the scene of a six-car crash on a highway. Which victim should the nurse attend to first?

A victim experiencing dyspnea

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action?

Activate the fire alarm.

A nurse is preparing to administer 1 mg of hydromorphone (Dilaudid), a Schedule II opioid. The medication is available in a premeasured syringe of 2 mg/mL. Which action by the nurse is correct?

Ask a second nurse to witness disposal of the unused portion.

The nurse is preparing a subcutaneous dose of bethanechol (Urecholine) prescribed for a client with urinary retention. Before giving the dose, the nurse checks to see that which medication is available on the emergency cart for use if needed?

Atropine sulfate

The nurse attends an educational conference on leadership styles. A colleague at the conference who is employed at a large trauma center states that the leadership style at the trauma center is task oriented and directive. The nurse recognizes that what type of leadership style is used at the trauma center?

Autocratic

A client is being evaluated as a potential kidney donor for a family member. The client asks the nurse why separate teams are evaluating donor and recipient. In formulating a response, what should the nurse understand about this approach?

Avoids a conflict of interest between the team evaluating the recipient and those evaluating the donor

The nurse takes a newly admitted client's vital signs, completes an admission assessment history on the client, and assists the client to change into a hospital gown. By completing these tasks, the nurse is demonstrating which role of the nurse?

Caregiver

A nurse is interviewing a client in crisis to assess the risk for self-harm. The nurse interprets that the client is most at risk for suicide if which is assessed?

Client has an immediate plan for a suicide attempt.

A nurse is monitoring a client who is receiving a blood transfusion. After 30 minutes of the infusion, the client begins to have chills and back pain. His temperature is 100.1° F (37.8° C). What action should the nurse take first?

Discontinue the infusion and start an infusion of normal saline using new tubing.

The nurse employed on a medical unit in a hospital receives a telephone call from the admission office and is told that a client with a diagnosis of mycoplasmal pneumonia will be admitted to the unit. The nurse prepares for the admission and obtains the necessary supplies to place the client on which type of transmission-based precautions?

Droplet precautions

The nurse has a prescription to obtain a urinalysis specimen from a client with an indwelling urinary catheter. Which actions should the nurse include in performing this procedure? Select all that apply.

Explaining the procedure to the client 2. Clamping the tubing of the drainage bag 3. Aspirating a sample from the port on the drainage bag 5. Wiping the port with an alcohol swab before inserting the syringe

A mother tells the nurse in a pediatrician's office that she is concerned because her children must let themselves into the house after school each day while she is at work. The nurse explores which suggestion with the mother to decrease the children's sense of isolation and fear?

Find community after-school programs or activities.

The nurse is obtaining a pulse oximetry reading from a postoperative client who appears short of breath. The client has dark fingernail polish on top of artificial nails. What is the most appropriate action?

Obtain a pulse oximetry reading from another appropriate area, such as an earlobe.

As a home health case manager, the nurse functions as a coordinator of client care. The nurse understands that in this role he or she will perform which function?

Organize, manage, and balance health care services needed for the client.

The nurse educator presents an in-service training session on case management to nurses on the clinical unit. During the presentation the nurse educator clarifies that what is a characteristic of case management?

Promotes appropriate use of hospital personnel

A nurse is assigned to care for a hospitalized toddler. The nurse plans care, knowing that what should be the highest priority?

Protecting the toddler from injury

The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next?

Reassess the client.

The client with a cervical spine injury has cervical tongs applied in the emergency department. What should the nurse avoid when planning care for this client?

Removing the weights to reposition the client

The nurse has a prescription to give a first dose of hydrochlorothiazide (HydroDIURIL) to an assigned client. The nurse would question the prescription if the client has a history of allergy to which item?

Sulfa drugs

A client with severe acne is seen in the clinic and the health care provider (HCP) prescribes isotretinoin (Amnesteem or Claravis). The nurse reviews the client's medication record and would contact the HCP if the client is taking which medication?

Vitamin A

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique?

Wearing gloves and a gown only when giving direct care to the client