NCLEX PRACTICE EXAM QUESTIONS
On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the NEED FOR FURTHER instruction?
"Foods and fluids that will increase urine alkalinity need to be consumed." * The client would be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. Foods and fluids that acidify the urine need to be encouraged."
A sexually active young adult client has developed viral hepatitis. Which statement indicates the need for further teaching?
"I can go back to work right away." * To prevent transmission of hepatitis, vaccination of the partner is advised. In addition, a condom is advised during sexual intercourse. Alcohol needs to be avoided bc it is detoxified in the liver and may interfere with recovery.
The nurse teaches a client newly diagnosed with type 1 diabetes about storing Humulin N insulin. Which statement indicates to the nurse that the client understood the discharge teaching?
"I can store the open insulin bottle in the kitchen cabinet for 1 month."
A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client with care of the infant. Which client statement indicates the need for further instruction?
"I need to chest-feed with my milk, especially for the first 6 weeks postpartum."
A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests that no autopsy be performed. Which response to the family is most appropriate?
"I will contact the medical examiner regarding your request." * An autopsy is required by state law in certain circumstances. If an autopsy is not required by law, these oral or written requests will be granted.
During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem?
"I will eat fresh fruits and vegetables for snacks and for dessert each day." * Fresh fruits and vegetables provide vitamins and minerals needed for healthy gums.
An adolescent client is diagnosed with conjunctivitis, and the nurse provides info to the client about the use of contact lenses. Which client statement indicates the need for further info?
"My contact lenses can be worn if they are cleaned as directed."
The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse would make which statement to the client?
"Take a deep breath when I tell you, and hold it while I remove the tube."
The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions?
"The iron is best absorbed if taken on an empty stomach"
A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about therapy?
"This form of therapy provides a negative reinforcement when the stimulus is produced."
The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20?
"This is a normal finding."
The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction?
'I will limit sun exposure to 1 hour daily." * The client needs to be instructed to avoid exposure to the sun.
The community health nurse is creating a poster for an educational session for a group of community members and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer would the nurse list on the poster? (Select all that apply):
- Early menarche - Family history of breast cancer - High-dose radiation exposure to chest - Previous cancer of the breast, uterus, or ovaries
A breast-feeding/chest-feeding parent of an infant with lactose intolerance asks the nurse about dietary measures. What foods would the nurse tell the parent are acceptable to consume while breast-feeding/chest-feeding? (Select all that apply):
- Egg yolk - Dried beans - Green leafy vegetables * Breast-feeding or chest-feeding parents with lactose-intolerant infants need to be encouraged to limit dairy products.
The nurse would include which interventions in the plan of care for a client with hypothyroidism? (Select all that apply):
- Instruct the client about thyroid replacement therapy. - Encourage the client to consume fluids and high-fiber foods in the diet. - Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur.
The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are characteristics of this disorder? (Select all that apply):
- Nocturia - Incontinence - Enlarged prostate
The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care for client with laryngeal cancer who had a laryngectomy. Which instructions would be included in the list? (Select all that apply):
- Obtain a MedicAlert bracelet - Prevent debris from entering the stoma - Avoid exposure to people with infections - Avoid swimming and use care when showering
The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? (Select all that apply):
- Set the room temperature at a comfortable level. - Remove distracting objects from the interviewing area. - Ensure comfortable seating at eye level for the client and nurse.
The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? (Select all that apply):
- Sitting up and leaning on a table - Standing and leaning against a wall - Sitting up with the elbows resting on knees *These positions allow for maximal chest expansion. The client would NOT lie on the back bc this reduces movement of a large area of the client's chest wall. Sitting is better than standing, whenever possible.
The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? (Select all that apply):
- The nurse encourages the client and family to identify and discuss feelings openly. - The nurse assists the client and family in carrying out spiritually meaningful practices. - The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.
Which nursing actions apply to the care of a child who is having a seizure? (Select all that apply):
- Time the seizure - Stay with the child - Loosen clothing around the child's neck - Place the child in a lateral side-lying position
The primary health care provider's prescription reads levothyroxine, 150 mcg orally daily. The med label reads levothyroxine, 0.1 mg per tablet. The nurse would plan to administer how many tablet(s) to the client?
1.5 tabs -> 1 tab / 0.1 mg X 0.001 mg / 1 mcg X 150 mcg / 1 = 0.15 / 0.1 = 1.5
A client received 20 units of Humulin N insulin subcutaneously at 08:00. At what time would the nurse plan to assess the client for a hypoglycemic reaction?
17:00
When creating an assignment for a team consisting of a registered nurse (RN), a licensed practical nurse (LPN), and two assistive personnel (APs), which is the BEST client for the LPN?
A client with a spinal cord injury requiring urinary catheterization every 6 hours.
Levothyroxine is prescribed for a client diagnosed with hypothyroidism. Upon review of the client's record, the nurse notes that the client is taking warfarin. Which modification to the plan of care would the nurse review with the client's primary health care provider?
A decreased dosage of warfarin sodium
The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item?
Antacids
A client has refused to eat more than a few spoonfuls of breakfast. The primary health care provider has prescribed that tube feeding be initiated if the client fails to eat at least half of a meal bc the client has lost a significant amount of weight during the previous 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client begins to cry and tries to eat more. Based on the nurse's actions, the nurse may be accused of which violation?
Assault
A client presents to the emergency department with upper gastrointestinal bleeding & is in moderate distress. In planning care, what is the priority nursing action for this client?
Assessment of vital signs
A client returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage would the nurse expect?
Bloody
A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder?
Cardiovascular disease * Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma.
The nurse is caring for a client with resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube?
Checking for the presence of bowel sounds in all four quadrants
The nurse is caring for a client who is on a strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing?
Encouraging active range-of-motion exercises * Immobilized clients are at greater risk for deep vein thrombosis. Basic preventative measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential bc dehydration predisposes to clotting. A pillow under the knees may cause venous stasis.
Metformin is prescribed for a client with type 2 diabetes mellitus. What is the most common side effect that the nurse would include in the client's teaching plan?
Gastrointestinal disturbances
A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder?
Headache, restlessness, and confusion
The. nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data would alert the nurse to this occurrence?
Inability to pass flatus
What is an anaphylactic reaction?
It is a life threatening immediate allergic reaction that causes respiratory distress, severe bronchospasm, and cardiovascular collapse. Treat with epinephrine, bronchodilators, and antihistamines.
The nurse is creating a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concern regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client?
Lack of ability to cope effectively.
The nurse is caring for a teenage client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which lab result should the nurse expect to note if the client does have appendicitis?
Leukocytosis with a shift to the left
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which med would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure?
Metformin
The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action?
Nonstop physical activity and poor nutritional intake
The nurse is caring for a client with anorexia nervosa. Which behavior is a characteristic of this disorder and reflects anxiety management?
Observing rigid rules and regulations
The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the BEST nursing action based on this info?
Place a clock and calendar in the client's room
The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client?
Provide authority, action, and assistance with problem-solving.
A client comes to the ER after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?
Remain with the client until the anxiety decreases
The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, PaCo2 of 58 mm Hg, PaCo2 of 80 mm Hg, and HCO3 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance?
Respiratory acidosis * The normal pH is 7.35-7.45. Normal PaCo2 is 35-45 mm Hg. In respiratory acidosis, the PH is low and PaCo2 is elevated.
A client is about to undergo a lumbar puncture (LP). The nurse describes to the client that which position will be used during the procedure?
Side-lying with the legs pulled up and the head bent down onto the chest. * This position helps open the spaces between the vertebrae and allows for easier needle insertion by the primary health care provider.
The nurse is caring for a client who was involuntary hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this info, what is the nurse's best determination in planning care?
The informed consent needs to be obtained from the client
The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the MOST appropriate assessment for this client?
The need for sensory stimulation
A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor would the nurse include when responding to the client?
Three sputum cultures are negative
After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse would expect to note which finding?
Waves of loud gurgles auscultated in all four quadrants
Meats are an excellent source of
iron
Iron is needed to allow for
transfer of adequate iron to the fetus and to permit expansion of the maternal red blood cell mass.
