fundamentals NCLEX Style Questions practice a

A nurse is checking blood pressure at a community health screening. Which of the following clients is at high risk for primary hypertension?

A client who has an elevated LDL

The nurse is observing a newly licensed nurse who is preparing a sterile field for a dressing change. Which of the following actions by the newly licensed nurse should cause the nurse to intervene?

The newly licensed nurse places the cap of the sterile saline bottle on the sterile field

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter should be irrigated?

Bladder scan reveals 525 mL of urine.

A nurse is caring for a young child who is prescribed a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take?

Examine personal values about the issue.

A nurse is giving an end-of shift report about a client admitted earlier that day with pneumonia. Which of the following pieces of information is most essential to provide?

Breath sounds

A client is reporting pain at the insertion site of his IV catheter. The nurse observes a red line extending outward from the insertion site. Which of the following actions should the nurse take first?

Discontinue the infusion

A nurse is monitoring an older adult client who is receiving IV fluid therapy. Which of the following assessment findings should the nurse recognize as an adverse effect of excess fluid therapy? (Select all that apply.

Edema Crackles in lungs Elevated bp Jugular venous distention

Nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements by the client indicates a need for further instruction by the nurse?

I will replace the old throw rug in the kitchen with a new one

A nurse is caring for a client who has recently started using a hearing aid worn behind the ear. Which of the following client statements indicates to the nurse that he understands the use of this assistive?

I'll be sure to remove my hearing aid before taking a show

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

Is your pain sharp or dull?

A nurse is caring for a client who had a fasting blood sugar drawn at 0600. The client tells the nurse, "All I have since midnight is water and some juice. Which of the following nursing actions is appropriate?

Reschedule this lab test for the next morning.

A nurse is caring for a client who is postoperative following colostomy placement. Which of the following findings should the nurse report to the provider?

Stoma appears purple in color

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions is appropriate for the client and family?

Use tracheostomy cover when outdoors

A nurse is planning care for a client who has had stroke resulting in aphasia and dysphagia. Which of the following task should the nurse assign to an AP? Select all that apply

Assist the client with partial bed bath Measure the client's BP AFTER NURSE ADMINISTERS AN antihypertensive medication. Use communication board to ask what the client wants for lunch

A nurse finds a client on the floor upon entering the client's room. The roommate reports that the client was trying to get of bed and fell over the bedrail onto the floor. Which of the following is correct documentation of this incident?

Client found lying on floor

A nurse is caring for a client who is receiving medication intramuscularly. The nurse should recognize that this route?

Increase infection rates

Which of the following is the responsibility of a nurse who is caring for a client receiving PCA?

Instruct the family to refrain from pushing the button for the client while she is asleep

A Client demonstrates anger when the nurse does not respond within 5 min of ringing for the nurse. Which of the following is an appropriate response by the nurse?

It must be frustrating. I have a few minutes now

A nurse is planning to insert a peripheral IV catheter in an older adult client. Which of the following actions should the nurse plan to take?

Position the client's arm in the dependent position

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

Potassium 5.4 mEq/L

A nurse is reviewing laboratory data for a client who has contusion to the chest wall following a motor vehicle crash. Which of the following values should the nurse report?

SaO2 86%

A nurse is developing a plan of care for an African-American child who is preschool-age and experiencing pain. Which of the following is the best way for the nurse to assess the child's pain?

Show the child the Oucher Pain Scale

Following administration of levothyroxine 125 mcg at 0800, the nurse discovers the medication was given to a client for whom it was not prescribed. Which of the following is the correct way to document this error in the medical record of the client who received the medication?

Levothyroxine 125 mcg given at 0800 Provider notified

A nurse is preparing to perform nasopharyngeal suctioning for a client who is unable to cough up excessive secretions. Which of the following actions is appropriate?

Perform suctioning while removing the catheter