NCLEX-PN

he nurse is collecting data on a client with chronic sinusitis. Which are signs and symptoms of chronic sinusitis? Select all that apply. 1. Loss of smell 2. Chronic cough 3. Nasal stuffiness 4. Clear nasal discharge 5. Severe evening headache

1, 2, 3

The nurse working in an obstetrical-gynecological primary health care provider's office is instructing a small group of premenopausal female clients about breast self-examination (BSE). Which instruction should the nurse reinforce as the first step to begin the BSE? 1. BSE begins with palpation of the axilla with arm slightly raised. 2. BSE begins with inspection of the breast standing before a mirror. 3. BSE begins with a vertical pattern palpation of the breasts and axillary area. 4. BSE begins in a lying position with palpation of the breasts and axillary area with the arm raised above the head.

2

The nurse is planning to reinforce instructions to the Hispanic-American client about nutrition and dietary restrictions. When developing the plan for the instructions, the nurse is aware of which related fact? 1. This ethnic group eats primarily raw fish. 2. This ethnic group enjoys eating red meat. 3. This ethnic group views food as a primary form of socialization. 4. This ethnic group enjoys foods that lack color, flavor, and texture.

3

A resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." An appropriate response by the nurse is which? 1. "I need you to sign a form before leaving." 2. "If you try to leave, I will need to restrain you." 3. "How old are you? Your father must no longer be living." 4. "I'm glad you told me that. Let's have a cup of coffee and you can tell me about your father."

4

A cooling blanket is prescribed for a child with a fever. The nurse prepares to use the cooling blanket and should avoid which action? 1. Keeping the child uncovered to assist in reducing the fever 2. Placing the cooling blanket on the bed and covering it with a sheet 3. Keeping the child dry while on the cooling blanket to prevent the risk of frostbite 4. Checking the skin condition of the child before, during, and after the use of the cooling blanket

1

A primary health care provider (PHCP) has written a prescription for a preoperative client to have "enemas until clear." The nurse has administered three enemas and the client is still passing brown liquid stool. Which action should the nurse take next? 1. Notify the primary health care provider. 2. Continue to administer the enemas until the stool is clear. 3. Encourage the client to drink clear liquids and administer another enema in 1 hour. 4. Wait 30 minutes, check the client's electrolyte levels, and then administer another enema.

1

The nurse reinforces instructions regarding diet for a client at risk for hypokalemia. The nurse determines there is a need for further teaching when the client selects which foods as sources high in potassium? Select all that apply. 1. Bread and butter 2. Carrots and peas 3. Peppers and onions 4. Beef and potato salad 5. Avocados and mushrooms

1, 2, 3

A client with diabetes mellitus decides to exercise an extra 30 minutes. The client is now experiencing hypoglycemia. Hypoglycemia is supported by which noted data? Select all that apply. 1. Hunger 2. Shakiness 3. Cool, clammy skin 4. Fruity breath odor 5. Rapid, deep breathing

1, 2, 3

A client has returned to the nursing unit following abdominal hysterectomy. To gather data on the client's postoperative bleeding, the nurse should implement which interventions? Select all that apply. 1. Observing perineal pad drainage 2. Observing the abdominal dressing 3. Rolling the client to one side to view bedding 4. Monitoring output from the Jackson-Pratt drain 5. Auscultation of bowel sounds, especially lower quadrants 6. Observing for abdominal distention and presence of ecchymosis

1, 2, 3, 4

The nurse admits a client who has seizure precautions prescribed. The client has a seizure just after the nurse has implemented the precautions. Which actions should the nurse take? Select all that apply. 1. Time the start and stop of the seizure. 2. Apply oxygen at 2L with nasal cannula. 3. Turn the client to the side and do not restrain. 4. Note the distinguishing characteristics of the seizure. 5. Use a padded tongue blade to avoid tongue injury. 6. Turn on the suction machine with oral catheter.

1, 2, 3, 4, 6

The nurse is caring for a client diagnosed with Paget's disease. The nurse plans care knowing that this condition usually affects which bones? Select all that apply. 1. Femur 2. Skull 3. Tibia 4. Sternum 5. Shoulder 6. Vertebrae

1, 2, 3, 6

Fludrocortisone is prescribed for a client with Addison's disease. The primary health care provider needs to be notified if the client experiences which conditions? Select all that apply. 1. Edema 2. Chest pain 3. Weight loss 4. Muscle cramps 5. Abnormal lung sounds

1, 2, 4

The nurse has conducted dietary teaching with the client diagnosed with iron deficiency anemia. The nurse determines that the client understands the information if the client states the intention to increase intake of which foods? Select all that apply. 1. Oysters 2. Spinach 3. Pineapple 4. Egg whites 5. Kidney beans 6. Refined white bread

1, 2, 5

The nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is in a cephalic presentation. Which findings while performing Leopold's maneuvers support the identification of a cephalic presentation? Select all that apply. 1. Small parts are located on the left side of the uterus. 2. Small parts are located on the right side of the uterus. 3. A round hard ballottable shape is located in the fundus. 4. A round hard ballottable shape is located just above the symphysis pubis. 5. A soft, irregular non-ballottable shape is located just above the symphysis pubis.

1, 2, 5

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions by the nurse would be contraindicated? Select all that apply. 1. Restrain the client's limbs. 2. Loosen restrictive clothing. 3. Consider insertion of a padded tongue blade. 4. Remove the pillow and raise the padded side rails. 5. Position the client to the side, if possible, with head flexed forward.

1, 3

The nurse is encouraging an older client who has difficulties with incontinence to participate in recreational therapy. Which nursing interventions should the nurse consider performing before assisting the client to go to the recreational therapy session? Select all that apply. 1. Make sure the client is wearing a clean undergarment. 2. Hold all fluids for 4 hours before the scheduled activity. 3. Encourage the client to use the restroom just before the activity. 4. Explain to the client that others participating also have problems. 5. Administer the prescribed diuretic, which will not be effective for another hour.

1, 3

A client is receiving anticonvulsant therapy with phenytoin. The nurse plans to monitor the results of which laboratory tests closely? Select all that apply. 1. Urinalysis 2. Serum sodium 3. Serum calcium 4. Alkaline phosphatase 5. Complete blood cell count

1, 3, 4, 5

A client is being advanced to a full liquid diet on the second postoperative day. Which foods are allowed for this client? Select all that apply. 1. Tea 2. Crackers 3. Ice cream 4. Scrambled eggs 5. Cream of tomato soup 6. Cream of wheat cereal

1, 3, 5, 6

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which actions should the nurse take? Select all that apply. 1. Notify the RN. 2. Notify the Rapid Response Team. 3. Finish the suctioning as quickly as possible. 4. Discontinue suctioning until the client is stabilized. 5. Contact the respiratory department to suction the client.

1, 4

The critical care nurse is caring for a client with a subclavian central line catheter. The nurse knows that a specific central-line bundle was developed to reduce the client's risk for developing a catheter-related bloodstream infection (CLABSI). The interventions include which essential actions? Select all that apply. 1. Strict hand washing 2. Daily dressing change 3. Betadine skin antisepsis 4. Optimal catheter site selection 5. Strict sterile technique with maximal barrier precautions during placement 6. Infection control primary health care provider as a member of the client's health care team

1, 4, 5

What is included in the treatment of Addison's disease? Select all that apply. 1. Radiation 2. Prednisone 3. Spironolactone 4. Adrenalectomy 5. Fludrocortisone

1, 5

A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item? 1. Apples 2. Cheese 3. Oranges 4. Skim milk

2

A client has been treated for dehydration and pneumonia. The nurse evaluates that the client has been successfully treated if the blood urea nitrogen (BUN) level is which value? 1. 5 mg/dL 2. 19 mg/dL 3. 46 mg/dL 4. 32 mg/dL

2

A client's kidneys are retaining larger than normal amounts of sodium. The nurse is reviewing the most recent laboratory data. The nurse should expect which laboratory value to be abnormal since the client is retaining sodium? 1. Calcium 8.8 mg/dL 2. Chloride 112 mEq/L 3. Potassium 4.1 mEq/L 4. Bicarbonate 23 mEq/L

2

A hospitalized client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administers nitroglycerin, 0.4 mg sublingually. After 5 minutes, the client states, "My chest still hurts." If the vital signs have remained stable, which action should the nurse perform? 1. Apply 10 L of oxygen via nasal cannula. 2. Administer another nitroglycerin tablet. 3. Call the resuscitation team immediately. 4. Administer a second nitroglycerin tablet in 10 minutes.

2

The nurse is obtaining the report for a group of assigned clients. The nurse plans to monitor the serum potassium levels in which clients at risk for hyperkalemia? Select all that apply. 1. A client with ulcerative colitis 2. A client with a new burn injury 3. A client with Cushing's syndrome 4. A client diagnosed with acute kidney injury (AKI) 5. A client who has a history of long-term laxative abuse

2, 4

The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which actions should the nurse take to deal with this event? Select all that apply. 1. Turn the client to the side with the knees bent. 2. Apply a sterile dressing soaked with normal saline to the wound. 3. Notify the registered nurse (RN) and primary health care provider (PHCP) at once. 4. Explain to the client that obesity is a risk factor and weight loss should be a future goal. 5. Gently explore the wound with a cotton-tipped applicator to determine whether evisceration has occurred.

2, 3

A nursing student is asked to identify the layers of tissue found within the uterus. Which student responses are correct with regard to the tissue layers of the uterus? Select all that apply. 1. Ectometrium 2. Myometrium 3. Perimetrium 4. Endometrium 5. Transmetrium

2, 3, 4

The nurse caring for a Chinese-American client plans to use communication according to Chinese-American cultural beliefs and practices. Which techniques are considered disrespectful in the Chinese-American's view of communication? Select all that apply. 1. Sitting side-by-side 2. Maintaining eye contact 3. Closing the conversation abruptly 4. Touching the opposite sex in public 5. Allowing silent pauses during conversation

2, 3, 4

A client is receiving phenytoin. Which findings would indicate that the client is experiencing side/adverse effects related to this medication? Select all that apply. 1. Ataxia 2. Constipation 3. Bleeding gums 4. Decreased white blood cells 5. Decreased platelet count

2, 3, 4, 5

An older mental health client diagnosed with chronic neuropathic pain is starting therapy with a tricyclic antidepressant called imipramine hydrochloride. The client is complaining of constipation. The nurse knows that which signs/symptoms are other adverse effects of this medication? Select all that apply. 1. Nausea 2. Dry mouth 3. Drowsiness 4. Muscle spasms 5. Acute confusion 6. Urinary retention

2, 3, 5, 6

The nurse is observing a nursing student preparing to obtain a throat culture on a client suspected of having a beta-hemolytic Streptococcus infection. Which actions indicate the need for further teaching regarding collecting this specimen? Select all that apply. 1. The student instructs the client to tilt the head back. 2. The student asks the client to tilt the head forward and to open the mouth. 3. The student informs the client that the test will help identify microorganisms. 4. The student places the collection swab initially at the back of the client's tongue. 5. The student places a tongue depressor on the client's tongue before swabbing the throat.

2, 4

The nurse is administering a medication intramuscularly to an assigned client. The nurse should include which actions in administering the medication? Select all that apply. 1. Massage the site after injection. 2. Use a Z-track method for administration. 3. Wear sterile gloves to administer the medication. 4. Hold the syringe as if it is a dart to insert the needle. 5. Select an appropriate injection site such as the ventral gluteus. 6. Cleanse the injection site using a back-and-forth motion with an antiseptic pad.

2, 4, 4

he nurse is assigned to assist the primary health care provider (PHCP) with the removal of a chest tube. Which interventions should the nurse anticipate performing during this process? Select all that apply. 1. Reinforce instructions to breathe deeply while the tube is removed. 2. Cover the site with an occlusive dressing after the tube is removed. 3. Clamp the chest tube near the insertion site just before the removal. 4. Raise the drainage system to the level of the chest tube insertion site. 5. Have the client perform the Valsalva maneuver as the chest tube is pulled out.

2, 5

he nurse is assigned to care for a client with a diagnosis of detached retina. Which findings would indicate that bleeding has occurred as a result of retinal detachment? Select all that apply. 1. Total loss of vision 2. Vision may be cloudy 3. A reddened conjunctiva 4. A sudden sharp pain in the eye 5. Complaints of a burst of black spots or floaters 6. Vision is clear straight ahead but not to the right

2, 5

A client with spinal cord injury has experienced more than one episode of autonomic dysreflexia. The nurse should avoid which action that could trigger an episode of this complication? 1. Preventing pressure on the client's lower limbs 2. Rigidly adhering to a bowel retraining program 3. Allowing the client's bladder to become distended 4. Keeping the linen under the client free of wrinkles

3

The nurse admitting a client to the hospital is reviewing the client's history and medications taken at home. Which condition in the client's history is being treated with tamoxifen citrate? 1. Diabetes mellitus 2. Positive tuberculin test 3. Metastatic breast cancer 4. History of cholecystectomy

3

The nurse documents that the client has a stage 2 pressure injury on the decubitus area. Which describes a stage 2 pressure injury? 1. The area has a deep crater-like appearance. 2. There is tissue necrosis with damage to the muscle. 3. The ulcer is superficial and characterizes an abrasion. 4. The area is red and does not blanch with external pressure.

3

The nurse in an outpatient diabetes clinic is assisting in caring for a client on insulin pump therapy. Which statement by the client indicates a need for further teaching regarding insulin pump therapy? 1. "I'll need to check my blood sugars before meals in case I need a premeal insulin bolus." 2. "If my blood sugars are elevated, I can bolus myself with additional insulin as prescribed." 3. "Now that I have this pump, I don't have to worry about insulin reactions or ketoacidosis occurring again." 4. "I still need to follow an appropriate diet and exercise plan even though I don't have to inject myself daily anymore."

3

The nurse is assisting a client to ambulate when the client states he is feeling faint and cannot stand. Which action should the nurse take to assist the client now? 1. The nurse should bend at the waist to assist the client to the floor. 2. The nurse should stand with legs close together for added support. 3. The nurse should extend one leg to use to slide the client's body down to the floor. 4. The nurse should hold the client under the arms and hold the upper body off the floor.

3

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates and is unable to obtain any residual tube feeding. Which action should the nurse take next? 1. Administer the tube feeding slowly. 2. Contact the primary health care provider. 3. Turn the client to the side and attempt to aspirate again. 4. Auscultate bowel sounds and check for abdominal tenderness.

3

Which laboratory result would verify the diagnosis of bacterial meningitis? 1. Clear cerebrospinal fluid with high protein and low glucose levels 2. Cloudy cerebrospinal fluid with low protein and low glucose levels 3. Cloudy cerebrospinal fluid with high protein and low glucose levels 4. Decreased pressure and cloudy cerebrospinal fluid with a high protein level

3

Which statement made by the nursing student indicates a need for further teaching by the nursing instructor on the concept of ethnocentrism? 1. "It is a tendency to view one's own ways as best." 2. "It is believing that one's own ways are the only acceptable way." 3. "It is imposing one's beliefs on individuals from another culture." 4. "It is acting in a manner in which one's culture is superior to other cultures."

3

A licensed practical nurse (LPN) is assisting in the care of a client who is receiving oxytocin to induce labor. The LPN plans to notify the registered nurse immediately if which signs and symptoms are noted? Select all that apply. 1. Contractions increasing in intensity 2. Contractions increasing in frequency 3. Decreased blood pressure, increased pulse 4. Contractions greater than 1 minute in duration 5. Early decelerations on the fetal heart rate monitor

3, 4

A client is at risk for developing hypocalcemia. The nurse determines which signs are associated with this electrolyte disturbance? Select all that apply. 1. Increased heart rate 2. Increased blood pressure 3. Positive Trousseau's sign 4. Hypoactive bowel sounds 5. Fine tremors noted in hands

3, 4, 5

A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting. A gastric ulcer is suspected. The nurse should determine that which data would further support this diagnosis? 1. History of frequent intake of spicy foods 2. Frequent heartburn with a sour taste in the mouth 3. Complaints of stress with a history of chronic kidney disease 4. History of chronic obstructive pulmonary disease with weight loss

4

A client has the following laboratory values: a pH of 7.55, an HCO3- level of 22 mEq/L (22 mmol/L), and a Pco2 of 30 mm Hg (30 mm Hg). Which action should the nurse plan to take? 1. Perform Allen's test. 2. Prepare the client for dialysis. 3. Administer insulin as prescribed. 4. Encourage the client to slow down breathing.

4

A client with diabetes mellitus has a blood sample drawn for the determination of a fasting blood glucose level. When reviewing the client's results, the nurse determines that which requires a call to the primary health care provider for intervention? 1. 75 mg/dL (4.2 mmol/L) 2. 92 mg/dL (5.3 mmol/L) 3. 120 mg/dL (6.9 mmol/L) 4. 240 mg/dL (13.7 mmol/L)

4

An adult client with hypothyroidism is admitted to the hospital. When reviewing the client's health record, the nurse notes that the client is taking a maintenance dose of levothyroxine. The nurse is also reviewing instructions concerning taking levothyroxine with the client. There is a need for further teaching when the client makes which statement? 1. "I will monitor my pulse every day." 2. "I will always get the same brand every refill." 3. "I will take the pill in the morning when I get up." 4. "I will take the pill with milk to keep from upsetting my stomach."

4

The nurse has reinforced instructions about measuring blood glucose levels to a client newly diagnosed with diabetes mellitus. The nurse determines that the client understands the procedure when making which most accurate statement? 1. "I should check my blood glucose level once a day." 2. "I should check my blood glucose level 2 hours after each meal." 3. "I should check my blood glucose level before eating a big meal." 4. "I should check my blood glucose level before eating each meal regardless of how much I eat."

4

The nurse is assigned to care for a client who has experienced uterine rupture. The nurse plans care knowing that which is the priority concern in caring for the client? 1. Fear 2. Grieving 3. Acute pain 4. Impaired gas exchange

4

The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast was applied, the client began to report an increase in pain level even after administration of the prescribed dose of opioid analgesic. Which is the initial nursing action? 1. Elevate the casted leg. 2. Contact the primary health care provider. 3. Administer another dose of pain medication. 4. Check the neurovascular status of the toes on the casted leg.

4

The nurse is caring for a postoperative client who has been NPO and the primary health care provider (PHCP) has prescribed a clear liquid diet. When planning to initiate this diet, which priority item should the nurse place at the client's bedside? 1. A straw 2. Code cart 3. Blood pressure cuff 4. Suction equipment

4

The nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first? 1. Check the blood pressure. 2. Check the oxygen saturation level. 3. Have the client take some deep breaths. 4. Lower the head of the bed slowly until the dizziness is relieved.

4

The nurse is reinforcing instructions to the client on how to maintain optimal skin integrity during external radiation therapy. The nurse determines that there is a need for further teaching if the client states plans to do which action? 1. Eat a high-protein diet. 2. Avoid exposure to sunlight. 3. Wash the skin with a mild soap using the hand and pat dry. 4. Keep at least 6 feet away from pregnant women especially in the first 3 months.

4

The nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL through an indwelling urinary catheter for the last 2 hours. Based on this finding, which should be the nurse's actions at this time? Select all that apply. 1. Increase the rate of the IV fluid. 2. Call the primary health care provider. 3. Administer a 250-mL bolus of normal saline (0.9%). 4. Check the client's overall intake and output record. 5. Gather data about the urinary catheter and check for patency.

4, 5

The nursing instructor asks the student to describe isotonic dehydration. The student correctly responds by stating which pathophysiological processes are occurring? Select all that apply. 1. "The loss of electrolytes is greater than the loss of water." 2. "The loss of water is greater than the loss of electrolytes." 3. "Serum sodium level rises above 150 mEq/L (150 mmol/L)." 4. "The client is likely to have impaired mental status due to low sodium levels." 5. "Water and electrolytes are lost in approximately the same proportion as they exist in the body." 6. "A client who has a large blood loss due to an accident will initially have an isotonic dehydration."

5, 6