NCLEX Practice Questions

Which client statement should prompt the nurse to request a primary cesarean birth from the provider?

"I lost my acyclovir prescription, and I've noticed lesions on my labia that are stinging and burning."

A middle-aged client is admitted to an inpatient psychiatric unit. The client reports a family member is trying to steal the client's property. The client is diagnosed with paranoid disorder. The nurse suspects the client is demonstrating which symptom? 1. Delusions of persecution 2. Command hallucinations 3. Delusions of reference 4. Persecution hallucinations

1. Delusions of persecution Rationale: The delusion of persecution is a strongly held belief that is not validated by reality, such as the idea that someone is spying on the client to inflict harm

The toddler diagnosed with lead poisoning is admitted to the pediatric unit. The HCP writes and order to encourage fluids. Which fluid is best for the nurse to offer to the toddler? 1. Milk 2. Water 3. Orange juice 4. Fruit punch

1. Milk Rationale: milk contains calcium; calcium binds to lead and inhibits its absorption

The nurse provides care for a client with a tracheostomy. Which is the priority nursing diagnosis for this client? 1. Problem with verbal communication 2. Inadequate airway clearance 3. Possible skin integrity impairment 4. Acute pain

2. Inadequate airway clearance Rationale: inadequate airway clearance is the top priority for clients with a tracheostomy because loss of the upper airway increases the amount and viscosity of secretions

The health care provider inserts a temporary pacemaker in a client following a myocardial infarction. The nurse knows that which outcome is the primary purpose of the pacemaker? 1. Increases the force of myocardial contraction 2. Increases the cardiac output 3. Prevents premature ventricular contractions (PVCs) 4. Prevents systemic overload

2. Increases the cardiac output Rationale: A pacemaker acts to regulate cardiac rhythm. This can be atrial, or ventricular, or both chambers. The outcome of the intervention is to increase the cardiac output.

The nurse cautions the client with hypothyroidism to avoid which implementation? 1. Warm environmental temperatures 2. Narcotic sedatives 3. Increased physical exercise 4. A diet high in fiber

2. Narcotic sedatives Rationale: The client with hypothyroidism is very sensitive to narcotics, barbiturates and anesthetics. This is likely related to the decrease in metabolic activity causing reduced ability to metabolize the medications

The nurse cares for the client diagnosed with a pneumothorax resulting from a motor vehicle accident three days ago. The client has a chest tube connected to a three-chamber water-seal drainage system with 20 cm suction. The nurse determines the lung has re-expanded if which observation is made? 1. There is no drainage in the collection chamber for 3 hours 2. The fluid in the water-seal chamber does not fluctuate with respirations 3. There is continuous bubbling in the water-seal chamber 4. There is gentle bubbling in the suction-control chamber

2. The fluid in the water-seal chamber does not fluctuate with respirations Rationale: Indicates no more air leaking into pleural space

The nurse is discussing growth and development with the parents of a 4-year old child. The nurse identifies which type of play as characteristic of this age group? 1. Solitary play 2. Parallel play 3. Associative play 4. Aggressive play

3. Associative play Rationale: Preschoolers are from 3-6 years of age. At this age, they begin to play with other children. They especially like to play at things representing adult behavior. This is called associative play.

A postoperative cataract client is cautioned about not making sudden movements or bending over. The nurse understands the rationale is to prevent which complication? 1. Impaired of cerebral blood flow and headaches 2. Decreased intracranial pressure 3. Increased fluid pressure compromising the surgical site 4. Displacement of the lens implant

3. Increased fluid pressure compromising the surgical site Rationale: Sudden changes in position, constipation, vomiting, stooping or bending over increase the intraocular pressure and damage the surgical site

The client in labor is monitored with an internal fetal monitor. The nurse knows which is the most important reason for the fetal monitor? 1. To evaluate the progress of the client's labor 2. To assess the strength and duration of the client's contractions 3. To monitor the oxygen status of the fetus during labor 4. To determine if an oxytocin drip is necessary

3. To monitor the oxygen status of the fetus during labor Rationale: Goal is early detection of mild fetal hypoxia

The nurse leads a parenting class for a group of expectant clients. How many extra calories a day does the nurse advise the clients to consume to support breastfeeding? 1. 200 2. 300 3. 400 4. 500

4. 500 Rationale: milk production requires an increase of 500 calories per day

The 18-month old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB). During the initial assessment, the nurse expects to find which early symptoms? 1. Kussmaul respirations and bradycardia 2. Elevated temperature and slow respiratory rate 3. Expiratory wheezing and substernal retractions 4. Inspiratory stridor and restlessness

4. Inspiratory stridor and restlessness Rationale: LTB or croup syndrome is characterized by edema and inflammation of upper airways. The inspiratory strider is often the first observable symptom of LTB.

A laboring client reports anxiety, vomiting & the need to have a bowel movement. What is the expected cervical examination finding?

8 cm dilate, 100% effaced

The 4 month old child is admitted with a tentative diagnosis of meningitis. To confirm the diagnosis, a lumbar puncture is ordered. While assisting the health care provider with procedure, it is most important for the nurse to take which action? 1. appropriately restrain the child 2. instruct the parents about the procedure 3. provide support to the child 4. elevate the head of the bed

Ans: 1 Rationale primary objective is to prevent trauma to child during the procedure; child must be restrained

The triage nurse in an urgent care center prioritizes clients. Which client does the nurse see first? 1.an infant who is very sleepy and has refused to nurse for 8 hours 2. a toddler who fell against the fireplace and continuously touches the right elbow 3. a preschool child who is flushed and has a temperature of 101.9 F 4. a school age child who reports a sore throat and has had two episodes of vomiting today

Ans: 1 Rationale: 1. This infant has a significant risk for dehydration and acidosis. An infant's rate of fluid exchange is significantly higher than an adult's, and the infant's metabolism rate is nearly twice that of an adult's. Acid forms more rapidly in infants and may lead to acidosis. The kidneys are not mature at this age and cannot adequately concentrate urine to conserve water

The client is withdrawing from alcohol dependence. Which assessment findings indicate to the nurse the need for more sedation? 1. steadily increasing vital signs 2. mid tremors and irritability 3. decreased respirations and disorientation 4. stomach distress and inability to sleep

Ans: 1 Rationale: indications the client is approaching delirium tremens, which can be avoided with additional sedation

The older client has acute gout. The nurse teaches the client to limit or avoid which foods? 1. red meat and shellfish 2. cottage cheese and ice cream 3. fruit juices and milk 4. fresh fruits and uncooked vegetables

Ans: 1 Rationale: should be aloud on low-purine diet; should avoid red and organ meats, shellfish, and oily fish with bones

The nurse cares for the client immediately delivering an 8 lb, 4oz baby. The client's history indicates a diagnosis of type 1 diabetes at age 12. The nurse expects which clients change to occur? 1. the blood glucose will fall because of a sudden decrease in insulin requirements 2. the blood glucose will rise because of a rapid decrease in circulating insulin 3. the blood glucose will gradually rise because of a decreased level of metabolic stress 4. the blood glucose will gradually fall because of a decrease in food intake

Ans: 1 Rationale: during pregnancy, the placenta produces human placental lactogen, which is an insulin antagonist. This allows more glucose and fatty acids to circulating in the maternal blood for use by the fetus. After the placenta is removed following the birth, the maternal glucose level will drop dramatically because the insulin antagonist is removed, and the full effect of the insulin will affect the client

Four clients are preparing for CT scans with oral and IV contrast. Which client statement requires n immediate follow-up by the nurse? 1. "I am feeling nauseated" 2. "my face gets red when I eat shrimp" 3. "I get claustrophobic when I am in a small space" 4. "I am having joint pain"

Ans: 2 Rationale: 2. allergies to iodine, seafood, or dye can cause an allergic reaction. Persons who are allergic to seafood are likely to be allergic to iodine, which is in most IV contrast mediums

The client is admitted to the surgical unit with a diagnosis of "rule our intestinal obstruction." The nurse prepares to insert a Salem sump NG tube as ordered. It is best for the nurse to place the client in which position? 1. head of bed elevated 30-45 2. head of elevated 60-90 3. side-lying with head elevated 15 4. lying flat with head turned to the left side

Ans: 2 Rationale: facilitates swallowing and movement of tube through gastrointestinal tract

The teenager is admitted with burns to 50% of the body. Which nursing action has the highest priority? 1. counseling regrading problems of body image 2. maintaining airborne precautions 3. maintaining aseptic technique during procedures 4. encouraging peers to visit on a regular basis

Ans: 3 Rationale: safety is priority for the client who is at high risk for infection

The nurse cares for the client with a nursing diagnosis of rape trauma syndrome, acute phase. The nurse considers which goal the most important initially? 1. within 3-5 months, the client will state the memory of the event is less vivid and distressing 2. the client will indicate a willingness to keep a follow-up appointment with a rape crisis counselor 3. the client will be able to describe the results of the physical examination that was completed in the ED 4. the client will begin to express reactions and feelings about the assault before leaving the ED

Ans: 4 Rationale: is nurse's initial priority to encourage client to begin dealing with what happened by verbalizing feelings and gaining some acceptance and perspective

The client is discharged with sublingual nitroglycerin. Which information does the nurse give to the client? 1. take the medication 5 min after the pain has started 2. stop taking the medication if a stinging sensation is absent 3. take the medication on an empty stomach 4, avoid abrupt changes in posture after taking the medication

Ans: 4 Rationale: nitroglycerin can cause hypotension; client should avoid changing positions quickly to decrease the chances of falling

The client is diagnosed with Addison disease. The nurse teaches the client before discharge. It is most important for the nurse to include which information? 1. signs and symptoms of infection 2. fluid and electrolyte balance 3. seizure precautions 4. steroid replacement

Ans: 4 Rationale: steroid replacement is life-long and the most important information the client needs to know. One of the major causes of Addisonian crisis is the sudden withdrawal of steroids by the client who does not understand the need for life-ling replacement

The client diagnosed with a peptic ulcer has a partial gastrectomy and vagotomy. Which statement is the priority caution to teach the client about? 1. sit up for at least 30 minutes after eating 2. avoid fluids between meals 3. increase the intake of high-carb foods 4. avoid eating large meals high in simple sugars and liquids

Ans: 4 Rationale: the basic guidelines to teach a postgastrectomy client are measures to prevent dumping syndrome. These include: lying down for 30 minutes after meals, drinking fluids between meals, and reducing intake of carbs

The nurse cares for clients in the pediatric clinic. Which client does the nurse see first? 1. a preschool client diagnosed with autistic spectrum disorder demonstrating finger-flapping 2. a school-age client diagnosed with enuresis and who often urinates in the underwear 3. a school-age client who is shy and has difficulty reading 4. a school-age client who has used a weapon toward a parent and caused physical harm to others

Ans: 4 Rationale: this client is psychologically unstable and is at risk for harm to self and others. This client is the priority at this time

Which action would the nurse take before administering meperidine hydrochloride to a client to relieve labor pain?

Monitor maternal vital signs and fetal heart rate

A client is receiving oxytocin infusion for labor augmentation. The provider asks the nurse to increase the oxytocin infusion rate. Which of the following actions should the nurse take?

Recommend that the infusion rate be decreased

A school-age child client is in the early stages of nephrotic syndrome. The nurse discusses which protein adjustments with the parents? 1. Adequate protein, low sodium intake 2. Low protein, low potassium intake 3. High protein, high potassium intake 4. Limited protein, high sodium intake

1. Adequate protein, low sodium intake Rationale: If the child can tolerate the protein intake, then this diet is encouraged to speed healing and sodium is usually restricted.

The client is evaluated for infertility, and the HCP prescribes clomiphene citrate 50 mg daily for 5 days. The client asks the nurse how the medication works. Which response by the nurse is best? 1. Clomiphene citrate induces ovulation by changing hormonal effects on the ovary 2. Clomiphene citrate changes the uterine lining to be more conducive to implantation 3. Clomiphene citrate alters the vaginal pH to increases sperm motility 4. Clomiphene citrate produces multiple pregnancy for those who desire twins

1. Clomiphene citrate induces ovulation by changing hormonal effects on the ovary Rationale: clomiphene citrate induces ovulation by altering estrogen and stimulating follicular growth to produce a mature ovum

The nurse recognizes which symptoms are early signs of lithium toxicity? (SATA) 1. Fine motor tremos 2. Involuntary muscle movements 3. Seizures 4. Nausea and vomiting 5. Orthostatic hypotension 6. Diarrhea

1. Fine motor tremors 2. Nausea and vomiting 6. Diarrhea Rationale: 1. A symptom of toxicity 4. An early symptom 6. An early symptom

The home care nurse visits a new parent and a 2 -week old infant. The client asks the nurse which solid foods to give the child first. Which response does the nurse give? 1. Solid foods are started at about 6 months when infant shows signs of readiness 2. Strained fruits are well tolerated as the first solid food, and infants like them 3. Introduction of solid foods is not important at this time 4. Begin with several foods at one time to see which the infant likes best

1. Solid foods are started at about 6 months when infant shows signs of readiness Rationale: The American Academy of Pediatrics recommends solid foods starting at about 6 months, when the infant shows signs of readiness. Solid foods should be started by 6 months

Prior to sending a client for a cardiac catheterization, it is most important for the nurse to report which information? 1. The client has an allergy to shellfish 2. The client has diminished palpable peripheral pulses 3. The client has cool lower extremities bilaterally 4. The client is anxious about the pending procedure

1. The client has an allergy to shellfish Rationale: Allergies to iodine and/or seafood must be reported immediately before a cardiac catheterization to avoid anaphylactic shock during procedure

The nurse prepares a teaching plan regarding colostomy irrigation. The nurse includes which information? 1. The colostomy needs to be irrigated at the same time every day 2. Irrigate the colostomy after meals to increase peristalsis 3. Insert the catheter about 10 inches into the stoma 4, The solution should be at least 110*F to increase dilation and flow

1. The colostomy needs to be irrigated at the same time every day Rationale: the colostomy irrigation should be done at the same time each day to assist in establishing a normal pattern of elimination

The client develops a postoperative infection and receives ceftriaxone sodium IV every day. It is most important for the nurse to monitor for which changes? 1. The surface of the tongue 2. Hemoglobin and Hematocrit 3. Skin surfaces in skin folds 4. Changes in urine characteristics

1. The surface of the tongue Rationale: Cephalosporin, long-term use of ceftriaxone sodium can cause overgrowth of organisms; monitoring of tongue and oral cavity is recommended

Several days after the delivery of a stillborn, the parent say, "We wish we could talk with other couples who have gone through this trauma." Which response by the nurse is best? 1. "First Candle will provide you with this opportunity." 2. "Share will provide you with this opportunity." 3. "Resolve will provide you with this opportunity." 4. "Candle lighters will provide you with this opportunity."

2. "Share will provide you with this opportunity." Rationale: Share pregnancy and Infant loss Support groups is a support group for parents who have lost a newborn or have experienced a miscarriage. It is a national organization. Many communities have additional groups designed for this purpose.

The nurse knows that according to Erikson's stages of psychosocial development, which developmental stage best represent a 50-year old client? 1. Integrity versus despair 2. Generativity versus stagnation 3. Intimacy versus isolation 4. Identity versus confusion

2. Generativity versus stagnation Rationale: this stage of development is appropriate for 45 to 64 years of age

The HCP orders hydromorphone hydrochloride 15 mg IM for a client. The nurse observes for which adverse effects? 1. Photosensitivity and constipation 2. Hypotension and respiratory depression 3. Tardive dyskinesia and diplopia 4. Dry mouth and tinnitus

2. Hypotension and respiratory depression Rationale: Narcotic analgesic used for moderate to severe pain, monitor vital signs frequently

An adolescent is brought to the hospital for treatment of deep partial thickness and full thickness burns sustained in a house fire. An intravenous infusion is started in the client's left forearm. The nurse identifies which reason as the primary purpose for the IV? 1. Provide a route for pain medications 2. Maintain fluid balance 3. Prevent gastrointestinal upset 4. Obtain blood specimens for analysis

2. Maintain fluid balance Rationale: loss of fluid occurs from open burn surfaces, therefore maintaining circulation is a life-saving requirement

The nurse cares for a 3-month old infant scheduled for a barium swallow in the morning. Prior to the procedure, it is most appropriate for the nurse to take which action? 1. Offer the infant only clear liquids 2. Make the infant NPO for 3 hours 3. feed the infant regular formula 4. Maintain the infant NPO for 6 hours

2. Make the infant NPO for 3 hours Rationale: The infant should be NPO 3 hours prior to the barium swallow procedure

The 6-month old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe which assessment findings? (SATA) 1. A pincer grasp 2. Sitting with support 3. Tripling of the birth weight 4. Presence of posterior fontanelle 5. Bears weight when held in standing position 6. Rolling from back to abdomen

2. Sitting with support 5. Bears weight when held in standing position 6. Rolling from back to abdomen Rationale: 2. Sitting with support should occur at this age 5. Weight bearing should be present at this time 6. The infant should be able to roll from back to front

Which statement is documented by the nurse to reflect a client's emotional adjustment to being hospitalized in the intensive care unit? 1. "The client is unable to complete activities of daily living without assistance." 2. "The client appears to be depressed and anxious regarding impending surgery." 3. "The client constantly calls for nurses and cries uncontrollably." 4. "The family is unable to visit more often than once a week because they live far away."

3. "The client constantly calls for nurses and cries uncontrollably." Rationale: This statement is objective and contains information that is observable. It gives an objective description of the client's behavior and affect

The parents of a child diagnosed with hemophilia ask the nurse to explain the cause of the disease. Which response by the nurse is best? 1. "The father transmits the gene to the son." 2. "Both the mother and the father carry a recessive trait" 3. "The mother transmits the gene to her son." 4. "There is a 50% chance that the mother will pass the trait to each of the daughters"

3. "The mother transmits the gene to her son." Rationale: Hemophilia is a sex-linked disorder located on the X chromosome. Since males have only 1 X chromosome, if that chromosome has the trait, it will be visible in that male

A 7-year old child is seen in the clinic with diagnosis of pituitary dwarfism. Which clinical manifestation is the nurse most likely to observe? 1. Abnormal body proportions 2. Early sexual maturation 3. Delicate features 4. Coarse, dry skin

3. Delicate features Rationale: The person's features appear delicate and younger than the chronological age. The person appears younger than the actual age because the features are delicate.

The HCP orders naproxen sodium for the elderly client. The nurse assess the client for which symptoms? 1. Stomatitis and photosensitivity 2. Bradycardia and dry mouth 3. Fluid retention and dizziness 4. Gynecomastia and impotence

3. Fluid retention and dizziness Rationale: NSAID is used as an analgesic. Adverse effects include headache, dizziness, edema, gastrointestinal distress, pruritus, and rash. Kidney and cardiovascular systems may be effected which exaggerates these effects

The client, gravida 2 para 1, is admitted with hypertension at 32 weeks gestation. The client reports her wedding band is tight. The nurse assesses for which additional indications of preeclampsia? 1. General edema and visual disturbances 2. Epigastric pain and headache 3. Proteinuria and retinal vascular constriction 4. Polyuria and hypertonic reflexes

3. Proteinuria and retinal vascular constriction Rationale: proteinuria and retinal vascular constriction are additional symptoms seen with preeclampsia

The nurse cares for the child diagnosed with pediculosis capitis (head lice) who is being treated with permethrin 1 % cream rinse. The nurse includes which information when instructing the child's parents? 1. Apply the cream rinse every other day for 1 week 2. Wash the child's clothing and personal belonging in soap and cool water 3. Repeat the application of the cream rinse in 7 days if nits are still present 4. Comb the child's hair weekly with a nit comb

3. Repeat the application of the cream rinse in 7 days if nits are still present Rationale: may be repeated 7 days after first application

The nurse prepares an older client for an intravenous pyelogram (IVP). The client asks the nurse to explain the reason why the procedure is performed. The nurse's response is based on which explanation? 1. The HCP is able to directly observe the kidney pelvis 2. An IVP assess the glomerular filtration rate 3. The HCP is able to examine the urinary tract by x-ray 4. Medication is injected into the urinary system

3. The HCP is able to examine the urinary tract by x-ray Rationale: During an IVP, x-rays are taken of the entire urinary tract and helps evaluate kidney function.

The nursing team consists of an RN who has been practicing for 6 months, an LPN who has been practicing for 15 years, and a nursing assistive personnel who has been caring for client for 3 years. The RN cares for which client? 1. The client 1 day postop after an internal fixation of a fractured left femur 2. The client receiving diltiazem and phenytoin 3. The client ordered to receive two units of packed cells 4. The client admitted yesterday with exhaustion and a diagnosis of acute bipolar disorder

3. The client ordered to receive two units of packed cells Rationale: requires the assessment and teaching skills of the RN

The nurse cares for the client admitted with cerebral vascular accident (CVA) and facial paralysis. Nursing care is planned to prevent which complication? 1. Inability to talk 2. Loss of the gag reflex 3. Inability to open the affected eye 4. Corneal abrasion

4. Corneal abrasion Rationale: A client will be unable to close the affected eye voluntarily when facial nerve is affected. The lacrimal gland will no longer supply secretions that protect the eye and can cause a corneal abrasion. Nursing care will include cool compresses and prescribed eye drops.

The nurse collects the following data: anger directed by the client toward staff in the form of frequent sarcastic or crude comments, increased wringing of hands, and purposeless pacing, particularly after the client has use the telephone. On the basis of the data, the nurse determines which client problem? 1. Difficulty with social interactions 2. Potential intolerance to activity 3. Loss of personal power 4. Difficulty with coping

4. Difficulty with coping Rationale: The client is displaying evidence of anger and anxiety and an inability to directly deal with concerns, which is the inability to cope with what ever is happening.

A client with an endotracheal tube requires suctioning. Which statement is an accurate description of how the nurse performs the procedure? 1. Inserts the suction catheter 4 in into the tubes. Applies suction for 30 seconds, then withdraws 2. Hyperoxygenates the client. Inserts the suction catheter into the tube, and suctions, then wipes catheter with alcohol swab after removal 3. Explains the procedure to the client. Inserts the catheter gently while apply suction, then assesses client status 4. Inserts the suction catheter until resistance is met, and then withdraws it slightly. Applies suction intermittently as the catheter is withdrawn

4. Inserts the suction catheter until resistance is met, and then withdraws it slightly. Applies suction intermittently as the catheter is withdrawn Rationale: insert suction catheter until resistance is met without applying suction then withdraw 0.4 to 0.8 inches, and apply intermittent suction during removal

The nurse performs range-of-motion (ROM) exercises for an older adult client inactive due to injury. The nurse identifies which statement as correct? 1. Passive ROM exercises increase muscle strength 2. A full ROM must be completed for the older adult client 3. Exercises should be completed to the point of discomfort 4. ROM assists the older adult in carrying out activities of daily living (ADLs)

4. ROM assists the older adult in carrying out activities of daily living (ADLs) Rationale: The emphasis should be on ROMs that support ADLs

The nurse cares for the client diagnosed with type 1 diabetes reporting decreased vision. The client asks the nurse what caused the visual changes. The nurse's response is based on which statement? 1. The client's decreased vision is caused by bleeding into the inner ocular chamber of the eye 2. The client's decreased vision is caused by gradual separation of the retina from the base of the eye 3. The client's decreased vision is caused by an increase in the size of the vessels in the back of the eye 4. The client's decreased vision is caused by gradual destruction and degeneration of the retina

4. The client's decreased vision is caused by gradual destruction and degeneration of the retina Rationale: Gradual destruction occurs because of deterioration of the retinal vessels

The nurse cares for clients on the pain management unit. Which client does the nurse see first? 1. a client receiving intraspinal anesthesia for pain control with a heart rate of 76 bpm and a respiratory rate of 8 breaths per minute 2. a client receiving patient-controlled analgesia with a heart rate of 112 bpm and a respiratory rate of 24 breaths per minute 3. a client requesting PRN IV medication for severe chronic back pain 4. a client requesting PRN IV medication for acute abdominal pain

Ans: 1 Rationale: 1. clients receiving intraspinal anesthesia must be closely monitored for signs of CNS depression. A respiratory rate of 8 breaths per minute is below the normal range of 12-20 breaths per minute for an adult

The psychiatric nurse sees clients in the emergency department. Which client requires immediate attention? 1. a client who failed medical school and say, "my pain will be over soon." 2. a client who reports hyperventilation and palpitations when giving a presentation 3. a client who hears voices saying to harm others 4. a client who is fearful after witnessing a muder

Ans: 1 Rationale: 1. this client is at risk for self-harm and may have made a plan. Determine if the client has the means to carry out the plan. Place the client on one-to-one observation, and stay with the client to help control self-destructive impulses

Four clients in the emergency department report adverse effects from prescribed medication. Which client does the nurse see first? 1. a client receiving clozapine and experiencing flu-like symptoms, fever, sore throat, and lethargy 2. a client receiving valproic acid and experiencing tremors 3. a client receiving lorazepam and experiencing abdominal discomfort 4. a client receiving methyl phenidate hydrochloride and who lost 5 lb in 4 weeks

Ans: 1 Rationale: 1. this client is unstable and may have agranulocytosis. Clozapine is an antipsychotic, and agranulocytosis is a serious adverse effect placing the client at risk for infections

The nurse triages pediatric clients in the clinic. Which client does the nurse see first? 1. an infant with failure to gain weight and a lead level of 70 mcg/dL 2. a preschool child scheduled for surgery and who fears body mutilation 3. a school age child who has repeated, involuntary urination at night 4. a school age child with a persistent fear of attending school

Ans: 1 Rationale: 1. this infant is at a high risk for injury. Acceptable lead levels below 10 mcg/dL. This child requires immediate attention to provide medical treatment and chelation therapy. The nurse needs to begin coordination of care, clinical management, environmental investigation, and lead hazard control

The 2 year old is admitted to the pediatric unit with numerous bruises, a fractured left humerus, and several lacerations with unexplained origin. The nurse identifies which nursing action as the priority nursing implementation? 1. report the findings to the child protection agency 2. share this information only with other HCPs 3. document this information in the medical record 4. share the information with the pediatric social worker

Ans: 1 Rationale: any suspicion of child abuse should be reported to the child protection agency

The nurse cares for clients in the antepartal clinic. The client at 34 weeks gestation comes to the clinic for treatment of a sprained ankle. The nurse questions which order? 1. aspirin 650 mg PO q4h prm for pain 2. return to the clinic in 2 weeks 3. apply ice to sprain for 20 minutes qh for 24 hours 4. teach client three-gait crutch walking

Ans: 1 Rationale: aspirin can cause fetal hemorrhage and it should not be used during pregnancy except in special circumstances when prescribed by the HCP. It should be avoided in the 3rd trimester. This client has no specific need for aspirin and acetaminophen should be given instead for pain

The 13 year old male diagnosed with muscular dystrophy develops nocturia. The client wants to know about external catheters. The nurse responds to the client based on which information? 1. the catheter can be removed during the day 2. external catheters are uncomfortable 3. the catheter would drain into a bag at the bedside or on the wheelchair 4. the external condom catheter is easy to apply

Ans: 1 Rationale: being free from any drainage bags during the day would appeal to a 13 year old. This would solve the nocturia problem as there is no indication a problem exists during the day

The nurse supervises the staff providing care for the 18 month old hospitalized with hepatitis A. The nurse determines the staff's care is appropriate if which action is observed? 1. The child is placed in a private room 2. the staff removes a toy from the child's bed and takes it to the nurse's station 3. the staff offers the child french fries and a vanilla milkshake for a mid-afternoon snack 4. the staff uses standard precautions

Ans: 1 Rationale: contact precautions required for diapered or incontinent clients

The client has a cesarean birth. Which nursing intervention is the priority to prevent complications? 1. encourage early ambulation 2. limit fluid intake 3. supply a high carb diet 4. evaluate skin integrity

Ans: 1 Rationale: early ambulation represents preventive care for respiratory congestion resulting from any type of anesthesia and shallow respirations due to the abdominal incision. Encouraging deep breathing and coughing are also encouraged

The nurse prepares to administer terbutaline to the client in labor. Prior to administration, the nurse assess the client's pulse to be 144. Which action does the nurse take first? 1. withholds the medication 2. decreases the dose by half 3. administers the medication 4. waits 15 minutes, and then rechecks the pulse

Ans: 1 Rationale: maternal tachycardia is an adverse effect of terbutaline: other maternal adverse effects include nervousness, tremors, headache, and possible pulmonary edema; fetal adverse effects include tachycardia and hypoglycemia; terbutaline is usually preferred over ritodrine because it has minimal effects on BP

The client at 38 weeks gestation comes to the emergency department reporting vaginal bleeding. Which client statement suggests the placenta previa is causing the bleeding? 1. "I feel fine, but the bleeding scares me" 2. "I've been more nauseated during the past few weeks" 3. "The bleeding started after i carried four bags of groceries" 4. "I've been having severe abdominal cramps"

Ans: 1 Rationale: placenta previa is characterized by painless vaginal bleeding

The nurse receives change-of-shift report. Which client does the nurse see first? 1. a client who took 10 methylphenidate tablets and has a blood pressure of 160/100 mm Hg 2. a client who requires instruction about how to use a metered-dose inhaler 3. a client with short arm cast on the left arm 4. a client diagnosed with hypothyroidism and who requires a TSH level

Ans: 1 Rationale: this client is unstable. Assess of restlessness, dilated pupils, tremors, and motor seizures related to the medication

The nurse sees clients in the med surg unit. Which client does the nurse see first? 1. a client diagnosed with heart failure and who has received 800 mL of IV fluids in 2 hours 2. a client diagnosed with lung cancer with a blood calcium level of 10.5 mg/dL 3. a client diagnosed with hypertension and who requires the 0900 dose of captopril 4. a client postop after a laminectomy and who requires supervision when ambulating

Ans: 1 Rationale: this client received a large amount of fluid in a short time. The nurse needs to assess for circulatory overload because the heart is not pumping well

The nurse assess the 8 year old child diagnosed with scoliosis. Which observation is expected with scoliosis? 1. the child's thoracic area is asymmetrical 2. the child walks with a waddling gait 3. the child's lower legs are edematous 4. the child has a protruding sternum

Ans: 1 Rationale: thoracic area becomes noticeably distorted

The client is scheduled for for a kidney transplant. The client is educated by the nurse during preadmission regarding which information? 1. remind the family and friends there is restricted visiting for at least 72 hours postop 2. arrange all live plants received postop in one section of the room 3. continue intermittent peritoneal dialysis for 3 months following surgery 4. limit consumption of sodium-free liquids for 1 year postop

Ans: 1 Rationale: transplant clients require protective isolation following surgery. So no visitors are allowed for at least 3 days. It may be longer in some cases

The nurse provides care for clients in the psychiatric emergency department. Which client does the nurse see first? 1. a client receiving haloperidol and experiencing an oculogyric crisis 2. a client receiving thioridazine and experiencing akathisisa 3. a client receiving risperidone and experiencing blurred vision 4. a client receiving fluphenazine and experiencing sedation

Ans: 1 Rationale: 1. an oculogyric crisis when the eyes are locked upward and is an acute dystonic reaction the medication. Notify the HCP for a prescription for an anti-cholinergic agent to correct this reaction

The client is going to self-administer continuous ambulatory peritoneal dialysis (CAPD) at home. Which statement does the nurse make? 1. "check your weight at the same time daily" 2. "keep a sterile dressing over the tube insertion site at all times" 3. "milk the catheter to encourage extra fluid removal from the abdomen" 4. "eat a well-balanced, low protein diet"

Ans: 1 Rationale: assessment. Daily weight at the same time every day is necessary with the peritoneum empty to assess fluid volume status. Guidelines for weight gain/loss are set by the HCP

When administering antipsychotic medications parenterally, which action does the nurse take first? 1. before and after giving each dose, monitor the client's blood pressure while the client is sitting and standing 2. for safety, caution the client not to drink alcohol or operate machinery that requires mental alertness 3. have an emergency cart available in case of an adverse reaction 4. reassure the client that adverse effects are only temporary

Ans: 1 Rationale: primary concern with postural hypotension caused by medication is preventing an injury from a fall; monitoring vital signs will provide data to address this concern; this is the immediate concern

The nurse completes client assignments for the day. The nurse assigns LPN/LVN to which client? 1. the client who had a total hip replacement yesterday and requires assistance with ambulation 2. the client with type 1 diabetes mellitus who has new bilateral 4+ pitting edema of the feet 3. the client with cholelithiasis scheduled for a cholecystectomy and receiving IV morphine 4. the client 6 hours postoperative after cystoscopy to remove a mass in the bladder

Ans: 1 Rationale: this is a stable client with expected outcomes. While a UAP might be able to do this, this is the only client that is stable and does not require assessment, just assistance

The nurse in the outpatient clinic has four phone messages. Which message does the nurse respond to first? 1. the parent of an adolescent report the child threatens to jump off a bridge and has access to a gun 2. the young adult client reports having lost 2 lb this week and eats only two meals a day 3. the middle-age client with a history of depression who is out of fluoxetine 4. the older adult client report insomnia and irritability after the death of the spouse

Ans: 1 Rationale: using Maslow's Hierarchy of Needs theory, prioritize physiological issues over psychological issue. However, this client is at risk for self-harm, and this call must be returned first. Safety is the issue here

A client at the health clinic asks the nurse if a "flu shot" should be obtained. Since the recommendation is for all persons over 6 months to receive an influenza vaccination every year, which health history factor is an additional reason for the client to receive the influenza vaccine? (SATA) 1. the client is 69 years old 2. the client plays poker with a group every week 3. the client volunteers at a preschool 4. the client lives with two large dogs 5. the client and sibling share an apartment 6. the client has chronic obstructive pulmonary disease

Ans: 1, 2, 3, 6 Rationale: 1. people over 65 are at higher risk for severe illness with influenza. They are encouraged to get the higher valence dose vaccine 2. people exposed to the general public are at higher risk for contracting influenza 3. people who come in contact with young children are at high risk for infecting the children. Young children are at high risk for developing complications from influenza and need to be protected from it. That includes a vaccination for them. 6. Influenza vaccine is highly recommended for people with chronic respiratory or cardiovascular disease. These conditions weaken the immune system and place the client at higher risk for complications from influenza.

A client returns to the room following a myelogram. The nurse care plan includes with intervention? (SATA) 1. encourage oral fluid intake 2. maintain the prone position for 12 hours 3. elevate head of bed 30 degrees 4. monitor vital and neurological signs 5. encourage the client to ambulate after the procedure 6. evaluate the client's distal pulses on the affected side

Ans: 1, 3, 4 Rationale: 1. this is an implementation. Fluids should be encouraged to facilitate dye excretion and to maintain normal spinal fluid 3. this is an implementation. Bed rest is usually 1 to 12 hours, but the head is elevated at about 30 degrees, and bathroom privileges are permitted 4. this is an assessment. IT will identify abnormalities early

The nurse cares for the post cholecystectomy client who had the T-tube removed this morning. Two hours after removal of the T-tube, the 4x4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is most appropriate for the nurse to take which action? 1. remove the dressing and replace it with a more absorbent dressing 2. collect a culture and sensitivity specimen of the drainage 3. observe the wound for dehiscence 4. reinforce the dressing with an 8x10 dressing

Ans: 1. Rationale: it is expected that a stab wound will continue to drain until the wound seals. The nurse should keep wound clean and dry changing the dressing as needed

The nurse provides care for a client in cardiogenic shock after a myocardial infarction. Which is the priority nursing diagnosis for the client? 1. Activity intolerance 2. Cardiac tissue death 3. Altered cardiac output 4. Fluid volume deficit

Ans: 2 Rationale: 2. priority nursing diagnosis, nothing else will work if you can not fix the heart muscle

The nurse care for the client who has just returned to the room after a scleral buckling procedure. Which nursing action is most important? 1. remove reading material to decrease eyestrain 2. ask the client if there is any nausea 3. assess color of drainage from the affected eye 4. maintain sterility during q3h saline eye irrigations

Ans: 2 Rationale: 2. this an assessment. It is important to prevent nausea and vomiting which would increase intraocular pressure and could cause damage to the repaired area. If the client is nauseated, vomiting could follow. So nausea needs to be relieved

The nurse finds a group of injured clients after a catastrophic event. Which client does the nurse see first? 1. a restless client with a rigid abdomen and absent bowel sounds 2. an unconscious client with a left-sided tracheal shift from the midline 3. a client reporting excruciating pain with an obvious deformity of the left leg 4. a client clutching the chest and reporting severe chest pain

Ans: 2 Rationale: a trachea deviated to the left is the first sign of a tension pneumothorax. Airway and breathing are the priority, and this is the first client to see

The nurse instructs clients on the emergency care of partial thickness burns during a first aid class. The nurse identifies which intervention best prevents infection? 1. wash the burn with an antiseptic soap and water 2. remove clothing, and wrap the victim in a clean sheet 3. leave the blister intact, and apply an ointment 4. take no action until the victim arrives in a burn unit

Ans: 2 Rationale: after fire is out, remove clothing and cover victim with a clean sheet

A client takes perphenazine by mouth for 2 days. The client now reports the head turned to the side, the neck arched at an angle, and stiffness and muscle spasms in the neck. The nurse expects to give which PRN medication? 1. promazine 2. benztropine 3. thiothixene 4. haloperidol

Ans: 2 Rationale: benztropine is an anti-parkinsonian agent. It is used to counteract the extra-pyramidal adverse effects the client is experiencing

Children from a school-bus accident are transferred to the hospital. The nurse performs triage in the emergency department (ED). Which client does the nurse see first? 1. An 8-year-old with a superficial burn to the arm. 2. A 7-year-old with burns on the face. 3. A 6-year-old with small lacerations to the arms and legs. 4. A 5-year-old complaining of elbow pain.

Ans: 2 Rationale: burns, especially to the face can be life-threatening to children. Airway, breathing, and circulation are major concerns. Burns to the face may indicate inhalation of fire and may compromise the lungs and trachea. Cardiopulmonary complications may result from exposure to electrical current, inhalation of toxic fumes, hypovolemia, and shock

An emergency department nurse arrives on the scene of a motor vehicle accident. Which client does the nurse attend to first? 1. alert client with a deformity of the right humerus with neurovascular systems intact distal to the site 2. unconscious client with a crushing chest wound 3. unconscious client with a regular heart rhythm at 64 bpm with even and unlabored respirations 4. alert client with multiple scalp lacerations

Ans: 2 Rationale: clients with crushing chest wounds are at risk for number of injuries that may compromise airway, breathing, circulation, cervical spine, and the nervous system. Immediate evaluation, stabilization, and transport are required

The nurse instructs a client diagnosed with multiple sclerosis to perform intermittent self-catheterization at home. The nurse will include which instruction? 1. use sterile technique when performing the catheterization 2. do not reuse single use catheters 3. perform the catheterization procedure every 8 hours 4. limit oral fluids to reduce the number of times a catheterization is needed

Ans: 2 Rationale: currently, no evidence-based guidelines are available on cleaning a reused catheter. Therefore, the client should be instructed to not reuse single use catheters

The nurse triages a group of clients in the ED. Which client does the nurse see first? 1. the 12 year old oozing blood from a laceration of the left thumb due to cut on a rusty metal can 2. the 29 year old with a fever of 103.8 who is able to identify a sibling but no the place and time 3. the 49 year old with a compound fracture of the right leg reporting severe pain 4. the 65 year old with a flushed face, dry mucous membranes and a blood glucose of 460 mg/dL

Ans: 2 Rationale: disoriented, requires immediate assessment to determine underlying cause

The parents of the 1 month old infant bring their infant to the clinic for evaluation of possible developmental dysplasia of the right hip. The nurse observes for which assessment? 1. limited adduction of the right leg 2. uneven gluteal folds and thigh creases 3. increase in length of the right limb 4. internal rotation of the right leg

Ans: 2 Rationale: folds and creases will be longer and deeper on affected side

The school aged child is diagnosed with asthma. The nurse in the outpatient clinic instructs the parent how to prevent future asthmatic attacks. The nurse is most concerned if the parent makes which statement? 1. "my child plays the tuba in the grade school band" 2. "my child loves to help my spouse rake leaves" 3. "my child participates in after-school activities 3 days a week" 4. "my child walks 1 mile to school every day with friends"

Ans: 2 Rationale: main cause of asthma is inhaled allergens (animal dander, mold, pollen, dust), would expose child to pollen and dust from leaves

The young adult is brought to the emergency department after a motorcycle accident. A closed head injury with suspected subdural hematoma is diagnosed. The client is alert and answers questions appropriately and reports a severe headache. The nurse questions which order? 1. promethazine 25 mg IM q3h 2. morphine sulfate 10 mg IM q 3-4h 3. docusate sodium 50 mg PO bid 4. famotidine 40 mg oral suspension once daily

Ans: 2 Rationale: morphine is a narcotic analgesic that causes CNS and respiratory depression. It is contraindicated in a head injury because it masks signs of increased intracranial pressure

A client diagnosed with multiple sclerosis is at 39 weeks gestation. The client is admitted to the labor and delivery unit in active labor. The client's vital signs are BP: 127/72 and P: 72 bpm. Cervix is 4 cm dilated with moderate contractions 4 minutes apart. Fetal heart rate 124 bpm. The nurse anticipates the need for which intervention? 1. prepare to administer IV oxytocin to the client 2. plan to administer prescribed pain medication 3. check the client's blood pressure every 5 min 4. arrange for emergency care of the newborn

Ans: 2 Rationale: no special resources are usually needed for clients with MS. Normal amounts of pain meds are usually required on a client by client basis

An old client is admitted to the hospital for treatment of a fractured femur. The client's spouse tells the nurse the client has become very hard of hearing. Which characteristic does the nurse expect the client to exhibit? 1. the client prefers to be left alone 2. the client has increased volume of speech 3. the client communicates best in writing 4. the client's speech is difficult to understand

Ans: 2 Rationale: people who have difficulty hearing often speak louder. This may be due to the persons not hearing themselves well and so speak louder.

The adolescent client is to take tetracycline HCL 250 mg PO bid. Which instruction does the nurse give the client? 1. take the medication on a full stomach or with a glass of milk 2. wear sunscreen and a hat when outdoors 3. continue taking the medication until you feel better 4. avoid the use of soaps or detergents for 2 weeks

Ans: 2 Rationale: photosensitivity occurs with the use of this med

The nurse provides care for a client who has a positive cytomegalovirus titer. Which is the most appropriate action for the nurse to take while caring for the client? 1. instruct the client to wear a mask when outside the room 2. wear eyewear when emptying a urinary drainage bag 3. place the client in a private room 4. keep the client's door shut at all times

Ans: 2 Rationale: positive CMV titer requires standard precautions; eyewear worn whenever there is a risk of splash or splatter

The nurse assess the development of the 3 month old child in the well-child clinic. Which behavior is unexpected? 1. the child raises head and shoulders from a prone position 2. the child tries to grasp a toy just out of reach 3. the child turns the head to try to locate a sound 4. the child smiles spontaneously when the parent is seen

Ans: 2 Rationale: reaching to grasp a toy is unexpected until 6 months of age

The client receives procainamide slowly by intravenous push. Which observation causes the nurse to withhold the next dose? 1. presence of premature ventricular contractions 2. occurrence of severe hypotension 3. recurring paroxysmal atrial tachycardia 4. a sedimentation rate of 10

Ans: 2 Rationale: severe hypotension and bradycardia are signs of an adverse reaction to this medication

The home health care nurse provides care for a client diagnosed with type 1 diabetes. The client is maintained on a regimen of intermediate-acting insulin and short-acting insulin and a 1800 calorie diabetic diet with normal blood glucose levels. Morning self-monitored blood glucose readings the past 2 days were 205 and 233 mg/dL. The nurse expects the health care provider to take which action? 1. reduce the client's diet to 1500 calorie ADA 2. order three additional units of intermediate acting insulin at 2200 3. order an additional 10 units of short acting insulin at 2000 4. eliminate the client's bedtime snack

Ans: 2 Rationale: the client is exhibiting dawn phenomena; treatment is to adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia

The nurse provides care for a client with left-sided hemiparesis from a stroke. The nurse notes a decrease in muscle tone on the client's left side. The nurse determines which client problem is the priority? 1. changes in mobility 2. skin integrity 3. depression 4. changes verbal communication

Ans: 2 Rationale: the leading causes of skin breakdown are a decrease in tissue perfusion and lack of movement. Loss of mobility contributes to this problem

The nurse receives report on the med surg unit. Which client does the nurse see first? 1. a client 2 days after a total hip replacement and who slid out of bed when trying to stand 2. a client with history of cardiomyopathy and who aspirated cooked cereal at breakfast 3. a client diagnosed with right-sided stroke and who requires assistance going to the bathroom 4. a client diagnosed with heart failure and who has been vomiting for 3 days

Ans: 2 Rationale: the nurse needs to ensure the client has a patent airway. This client is at risk to develop pneumonia and needs close monitoring

The nurse in a psychiatric emergency department cares for the client who is a victim of rape. Which action is the initial priority for the nurse? 1. encourage the client to verbalize feelings 2. assess for physical trauma in private setting 3. explain available legal proceedings available 4. help the client identify and mobilize resources and support systems

Ans: 2 Rationale: this is a physical action. The victim may have physical trauma and concealed injuries. Assessment is of utmost importance so that the client's physiological integrity is maintained. This must be conducted in a private setting.

The school nurse instructs a group of preschool parents about poison prevention in the home. Which parent statement indicates further teaching is necessary? 1. "the poison control center number is stored on all the phones in our house" 2. "I should induce vomiting if my child swallows lighter fluid" 3. "If I carry medication in with me, it should be in a child-proof container" 4. "proper storage is the key to poison prevention in the home"

Ans: 2 Rationale: vomiting contraindicated when child ingests hydrocarbons because of danger of aspiration

An older adult client receives IV fluids after surgery. The nurse monitors the fluid status. Which symptoms suggest the client has an overload of fluid? 1. temperature 101 F, BP 96/60 Hg, pulse 96 bpm and thready 2. cool skin, respiratory crackles, pulse 86 bpm and bounding 3. reports of a headache, abdominal pain, and lethargy 4. urinary output 700 mL/24 h, CVP of 5 mm Hg, and nystagmus

Ans: 2 Rationale: with an overload of fluid, the nurse will see a bounding pulse, elevated BP, distended neck veins, edema, headache, polyuria, diarrhea, and liver enlargement

The client exhibits symptoms of myxedema. The nursing assessment reveals which information? 1. increased pulse rate 2. decreased temperature 3. fine tremors 4. increased radioactive iodine uptake level

Ans: 2 Rationale: with myxedema there is a slowing of all body functions

The nurse cares for clients in a gynecological clinic. Which client does the nurse see first? 1. a client reporting dry vaginal walls and painful intercourse 2. a client reporting a generalized rash and tachycardia after a hysterosalpingogram 3. a client who requires preparation for a cervical biopsy 4. a client scheduled for a Pap smear

Ans: 2 Rationale: 2. a hysterosalpingogram is an x-ray of the cervix, uterus, and fallopian tubes and is performed after the injection of a contrast medium. Assessment for allergy to shellfish or iodine should be done before the medium is injected. This client requires immediate attention because the client is having an allergic reaction

The nurse receives shift report on the medical surgical unit. Which client does the nurse see first? 1. client with an IV infusing at 125 mL per hour and reporting sligh swelling at the insertion site 2. client 3 days post right knee replacement and reporting right lower leg pain with movement 3. client with a respiratory rate of 24 breaths per minute and an oxygen saturation of 94% on room air 4. client 12 hours after an abdominal hysterectomy reporting nausea

Ans: 2 Rationale: 2. an assessment for a possible DVT must be performed and reported to the HCP immediately

The clients develops right-sided heart failure. The nurse expects to observe which symptoms? (SATA) 1. increased respiration with exertion 2. peripheral edema and anorexia 3. polycythemia 4. cough producing large amount of thick, yellow mucus 5. twitching of extremities 6. distended neck veins

Ans: 2, 3, 6 Rationale: 2. edema caused by decreased heart pumping action and accumulation of fluid; malaise causing anorexia 3. increased RBC as compensation for decreased oxygenation 6. related to heart failure

The nurse comes upon a vehicle accident. Which client does the nurse see first? 1. an infant who is strapped in a car seat and crying uncontrollably 2. a child who is crying that the leg is broken 3. a restless client with pale, cool, clammy skin, and a rigid abdomen with absent bowel sounds 4. an alert, but mildly disoriented client with a scalp laceration with well-controlled bleeding

Ans: 3 Rationale: 3. this client likely has injuries to abdominal organs, resulting in hemorrhage and severe circulatory compromise. This client requires immediate evaluation

The nurse notes the child is able to sit unsupported, play "peek-a-boo" with the nurse, and is starting to say "mama" and "dada". The nurse determines the infant's behaviors are consistent with which age? 1. 5 months of age 2. 6 months of age 3. 9 months of age 4. 12 months of age

Ans: 3 Rationale: a child can pull self up and assume a sitting position at 8 months. Saying "dada" and "mama" begins at about 9 months and they begin comprehending what words mean about that age as well

The client is admitted to the labor and delivery unit in a vasoocclusive crisis. Which nursing action is the highest priority? 1. administer oxygen 2. turn client to the right side 3. provide adequate hydration 4. start antibiotics

Ans: 3 Rationale: adequate hydration is a priority for any client in vasoocclusive crisis. Fluids help "unblock" areas where cells have grouped together preventing adequate perfusion. After rehydration, oxygenation may be helpful

The client diagnosed with bipolar receives haloperidol 2 mg PO tid. The client tells the nurse "milk is coming out of my breasts." Which response by the nurse is best? 1. "you are seeing things that aren't real" 2. "why don't we go make some fudge?" 3. "you are experiencing an adverse effect of haloperidol" 4. "I'll contact your HCP to change your medication"

Ans: 3 Rationale: adverse effects include galactorrhea (Excessive or spontaneous flow of milk), lactation, gynecomastia (excessive growth of male mammary glands)

The nurse provides care for a client prescribed gemfibrozil. Which laboratory value does the nurse review based on this prescribed medication? 1. serum creatinine 2. erythrocyte sedimentation rate (ESR) 3. aspartate aminotransferase (AST) 4. arterial blood gases (ABG)

Ans: 3 Rationale: an AST is a lab that is monitored to assess liver function. The normal range is 10-30 units/L. Lipid-lowering agents such as gemfibrozil are prescribed for clients with high serum triglyceride levels. Adverse effects for this medication include abdominal pain and cholelithiasis. The client is instructed to take the medication 30 minutes before breakfast and dinner

The nurse receives report about these clients. Which client does the nurse see first? 1. a client just transferred from the emergency department with an oxygen saturation of 93% on 2 liters of oxygen per nasal cannula 2. a client who reports nausea while drinking contrast in preparation for a CT scan 3. a client who is a new direct admission from the health care provider's office with a hemoglobin of 6.9 g/dL 4. a client who reports abdominal pain and is requesting pain medication

Ans: 3 Rationale: assessment of the respiratory status is required because of low hemoglobin level. An acute onset of anemia and/or disease may cause shortness of breath, dyspnea, and/or chest pain. Oxygen supplementation is often indicated prophylactically even if the client is asymptomatic. This client is the most unstable

The psychiatric nurse is assigned to conduct an admission nursing history on a new client. Which information is necessary to obtain from the history? 1. the nurse's opinion regarding the mental and emotional status of the client 2. data addressing the client's emotional state 3. data addressing a biopsychosocial approach, including a family system assessment 4. specific data detailing the client's mental status

Ans: 3 Rationale: complete nursing history includes biopsychosocial data; client's psychosocial and physical status are evaluated along with an assessment of the client's family system and social support network; evaluation of the client's cognitive ability is important during the physiological status assessment

The nurse plans anticipatory guidance for parents of the beginning school aged child. it is most important for the nurse to include which information? 1. teach the child to read and write 2. teach the child sex education at home 3. give the child responsibilities around the house 4. expect stormy behavior

Ans: 3 Rationale: giving children responsibilities allows them to develop feelings of competence and self-esteem through their industry

The nurse cares for clients on the med surg unit. The nurse identifies which client is most at risk for developing herpes zoster? 1. The 19 year old with a broken tibia in Buck's traction 2. the 50 year old with a diabetic foot ulcer 3. the 62 year old heart transplant with suspected rejection 4. the 84 year old with chronic obstructive pulmonary disease

Ans: 3 Rationale: immunocompromised due to immune suppression therapy; clients with compromised immune system at risk for reactivation of the varicella zoster virus

The nurse plans assignments for the day after receiving report on the pediatric unit. Which client does the nurse see first? 1. a client diagnosed with leukemia and reporting fatigue 2. a client diagnosed with Wilms tumor and reporting thirst 3. a client diagnosed with hemophilia and reporting joint pain 4. a client diagnosed with gastroesophageal reflux and reporting abdominal pain

Ans: 3 Rationale: joint pain with hemophilia indicates bleeding and needs to be addressed as soon as possible. Treatment includes factor VIII, RICE (Rest, Ice, Compression, and Elevation)

The nurse learns a client has a history of heart failure, is on a low sodium diet, and is taking chlorothizide 500 mg. Diagnostic tests indicate sodium 127 mEq/L, potassium 3.8 mEq/L, glucose 110 mg/dL, and normal chest x-ray. It is most important for the nurse to assess for which signs? 1. sticky mucous membranes; decreased urinary output; and firm, rubbery tissues 2. cool, moist skin; fine hand tremors; and mental confusion 3. headache, apprehension, and lethargy 4. shortness of breath, chest pain, and anxiety

Ans: 3 Rationale: symptoms of hyponatremia along with muscle twitching, convulsions, diarrhea, fingerprinting of skin

The nurse uses ordered restraints for the agitated and aggressive client. Which item does not influence the nurse's actions during this intervention? 1. the restraints/seclusion policies set forth by the institution 2. the client's competence 3. the client's voluntary/involuntary status 4. the client's nursing care plan

Ans: 3 Rationale: the need for restraints is based on client's behavioral status and condition, not the client's voluntary/involuntary status

The community health nurse plans visits for the day. Which client does the nurse see first? 1. a preschooler who has experienced hyperactivity and impulsivity for 2 weeks 2. an adolescent who has been traunt from school for 3 days 3. an adolescent who has vomited every day for 3 months to lose weight for the summer 4. a young adult who drinks alcohol every day and is unable to control the amount of alcohol ingested

Ans: 3 Rationale: this client is at risk for fluid and electrolyte imbalances and also has a potential for decreased cardiac output and decreased nutritional intake. This client is the most unstable

Clients from a motor vehicle accident arrive in the emergency department. Which client does the nurse see first? 1. a client diagnosed with ecchymosis and lacerations to the facial area 2. a client reporting shortness of breath and pressure in the chest 3. a client with BP of 90/60 mm Hg and apical pulse of 120 bpm 4. a client reporting dizziness and nervousness

Ans: 3 Rationale: this client's vital signs indicate shock. This is the most unstable client who should be seen first

The client is treated for sexual abuse by one parent. Which does the nurse anticipate as an initial positive client outcome of treatment? 1. acknowledges willing participation in an incestuous relationship 2. re-establishes a trusting relationship with the other parent 3. verbalizes not being responsible for the sexual abuse 4. describes feelings of anxiety when speaking about sexual abuse

Ans: 3 Rationale: victim needs assistance to challenge "belief of victims," which includes "I am bad and deserve the abuse"

The parent brings the 2 year old to the office. Which symptom suggests to the nurse the child has strabismus? 1. the child places head close to the table when drawing 2. the child rubs the eyes frequently 3. the child closes on eye to see a poster on the wall 3. the child is unable to see objects in the periphery of the visual field

Ans: 3 Rationale: visual axes are not parallel, so the brain receives two images

The nurse observes the LPN/LVN perform a moist-to-dry dressing change on a 2 inch abdominal incision. Which LPN/LVN behavior indicates and understanding of proper technique? 1. a clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes 2. the incision is packed with sterile gauze and then sterile saline is poured over the dressing 3. moist gauze is packed into the incision without overlapping it on the skin 4. the old dressing is saturated with sterile saline before it is removed

Ans: 3 Rationale: if the moist dressing touches the skin, it could cause skin breakdown. Moist gauze is placed in the wound into the necrotic tissue

The nurse sees clients in the adolescent psychiatric unit. Which client does the nurse see first? 1. a client who reports impulsivity and poor attention span 2. a client who frequently loses the temper and argues with teachers 3. a client who wants to be a model and only drinks water and eats vegetables 4. a client who bullies, threatens, and intimidates other and initiates physical fights

Ans: 3 Rationale: the client is the most unstable. The nurse needs to assess the nutritional status and monitor for an eating disorder. The client's physiology may be compromised, and the client should be assessed for deficits

The nurse notes coupled premature ventricular contractions greater than 10 per minute on the client's EKG strip. The nurse expects to administer which IV medication? 1. Atropine sulfate 2. Isoproterenol 3. Verapamil 4. Lidocaine

Ans: 4 Rationale: 4. lidocaine is the med of choice for frequent premature ventricular contractions occurring in excess of 6 to 10 per min; for couple PVCs or for a consecutive series of PVCs that may result in ventricular tachycardia

Which symptoms are most likely to be observed by the nurse when the client is withdrawing from heroin? 1. severe cravings, depression, fatigue, hypersomnia 2. depression, disturbed sleep, restlessness, disorientation 3. nausea and vomiting, tachycardia, coarse tremors, seizures runny nose, yawning, fever, muscle and joint pain, diarrhea

Ans: 4 Rationale: 4. narcotic withdrawal is very much like the symptoms of the flu

The nurse sees clients in the gastrointestinal clinic. Which client does the nurse see first? 1. an adult diagnosed with irritable bowel syndrome and reporting cramping and loose stools 2. a young adult reporting not having a bowel movement in 2 days 3. a child diagnosed with gastroenteritis with five diarrheal stools in the last 3 days 4. a newborn experiencing projectile vomiting and irritability

Ans: 4 Rationale: 4. projectile vomiting in a newborn often indicates pyloric stenosis. This client is at risk for fluid and electrolyte imbalance as well as lack of nutrition

The nurse triages clients in the outpatient pain clinic. Which client does the nurse first? 1. a client with history of a herniated lumbar disc and who reports severe pain radiating down the left leg 2. a client with a history of migraine headaches and who reports a headache and light sensitivity 3. a client with a history of kidney stones and who tearfully reports severe right flank pain 4. a client with a history of coronary artery disease and who reports mid-epigastric pain radiating to the neck

Ans: 4 Rationale: 4. the client with a history of coronary artery disease is at increased risk of myocardial infarction. Pain that originates in the chest or abdomen and radiates to the neck, shoulder, or arm requires immediate evaluation

The community health nurse plans visits for the day. Which client does the nurse see first? 1. a client reporting a GI upset after taking chlorpropamide 2. a client reporting vomiting after chemotherapy 3. a client with a tonometer reading of 21 mm Hg 4. a client reporting a greenish-yellow discharge from a laryngectomy

Ans: 4 Rationale: 4. this client is unstable due to a possible infection and requires immediate attention. Assess breath sounds and amount, color, and character of drainage before reporting to the HCP

The nurse plans assignments for the day after receiving report. Which client does the nurse see first? 1. a client who requires a fasting blood glucose test before breakfast 2. a client who requires a urine test for ketone bodies 3. a client who will discharged this afternoon 4. a client with a fasting blood glucose of 517 mg/dL

Ans: 4 Rationale: a normal fasting blood glucose is 70 to 99 mg/dL. This level is extremely high and requires immediate attention. The nurse will administer regular insulin based on previous prescriptions

The triage nurse prioritize clients to be evaluated in the emergency department. Which client does the nurse see first? 1. a young adult reporting nausea and vomiting for the past several hours 2. a young adult at 8 weeks gestation and reporting vaginal spotting 3. a toddler with a temperature of 101 F 4. an infant with vomiting and diarrhea

Ans: 4 Rationale: an infant is at significant risk for dehydration, which may result in electrolyte imbalances, as well as shock, depending on the amount of fluid lost. This is the priority client

Which nursing action is important for safe administration of oxytocin to the client? 1. assess respirations and urine output 2. administer oxytocin parenterally as the primary IV 3. have calcium gluconate available as an antidote 4. palpate the uterus frequently

Ans: 4 Rationale: assessment; oxytocine stimulates the uterus to contract, which necessitates frequent assessment of the uterus; prolonged tetanic contraction can lead to a ruptured uterus

The nurse leads an in-service class on legal issues. The nurse identifies which act constitutes battery? 1. the nurse restrains the agitated, confused client in the emergency department with a HCPs order 2. the nurse chases the client who tries to run away while outside for a walk 3. the nurse holds the arms of the manic client who struck the nurse while the assistant calls for help 4. the nurse administers an injection to the schizophrenic client who refuses to take the medication by mouth because of believing it is poison

Ans: 4 Rationale: battery is harmful or offensive touching of another person; unless court ordered, clients have the right to refuse medication, even if client is psychotic

The client is diagnosed with medication-induced Cushing's syndrome. The nurse first instructs the client about which outcome? 1. compression fractures from increased calcium excretion 2. decreased resistance to stress 3. scheduled gradual withdrawal of the medication 4. change in secondary sex characteristics

Ans: 4 Rationale: if steroids are withdrawn suddenly, the client may die of acute adrenal insufficiency

The nurse receives shift report about med surg clients. Which client does the nurse see first? 1. a client who is scheduled to receive verapamil 2. a client who is scheduled to receive the prescribed metered-dose inhaler 3. a client's family threatening to sue the hospital if concerns are not addressed immediately 4. a client who is verbally abusive to staff and becomes increasingly more agitated

Ans: 4 Rationale: this client poses a potentially immediate physical threat to self, staff members, and/or other clients and visitors if the situation is allowed to escalate further. The nurse must attempt to intervene and initiate protocols prescribed by the facility to maintain a safe environment. This client also requires additional assessment to determine the underlying cause of the anger and agitation

The nurse works with the parents of the child diagnosed with mental disabilities. Which action does the nurse include in the care plan for the parents? 1. interpret the grieving process for the parents 2. discuss the reality of institutional placement 3. assist the parents in making decisions and long-term plans for the child 4. plan for a family assessment to assist in the planning of interventions

Ans: 4 Rationale: while planning for an assessment is an action, it is designed as an assessment and must be completed before any other actions can be taken. This will help the nurse to know where the family is in regard to grieving, coping, etc. Also, the mental status of the child needs further investigation to determine the severity

Four clients have signed in at urgent care center with each reporting a sore throat. Which client does the nurse see first? 1. a school age client whose sibling was recently treated for "strep throat" 2. a school age client with a history of chronic allergies 3. a young adult client with a history of chronic sinus infections 4. a middle age client receiving 5 fluorouracil

Ans: 4 Rationale: because many chemotherapy agents may cause neutropenia, clients receiving those medications are more susceptible to infection and are less likely to be able to fight the infection. Symptomatic clients require immediate evaluation and treatment

An epidural was administered 20 min ago and now the client reports feeling dizzy and nauseated. Which action should be performed first?

Obtain BP

A new nurse is evaluating the fetal monitoring strip of a client in labor who is receiving an oxytocin infusion. Which of the following actions should the nurse take next?

Reposition the client to side lying position. Provide oxygen. Initiate IV fluids. Notify HCP & prepare terbutaline.

A client is 6cm dilated and ready for epidural anesthesia. Which position will the nurse assist the client?

on left side, shoulders parallel, legs flexed, back arched