NCLEX-RN

A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information:

"I know that I will not ever be able to socially drink alcohol again and will need the support of the AA group."

A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, "The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart." The nurse's best response is:

"I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner."

In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of the unit. A client with antisocial personality disorder makes the following remark, "Forget all those rules. I always get along well with the nurses." Which nursing response to him would be most effective?

"I'm pleased that you get along so well with the staff. You must still know and abide by the rules."

A 55-year-old man has recently been diagnosed with hypertension. His physician orders a low sodium diet for him. When he asks, "What does salt have to do with high blood pressure?'' the nurse's initial response would be:

"Large amounts of salt in your diet can cause you to retain fluid, which increases your blood

5 A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?

"When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices."

Three weeks following discharge, a male client is readmitted to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse admits him to the unit, he says, "I wish I were dead because I am worthless to everyone; I guess I am just no good." Which response by the nurse is most appropriate at this time?

"You've been feeling sad and alone for some time now?

A depressed client is seen at the mental health center for follow-up after an attempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that the drug must accumulate to an effective level before symptoms are totally relieved. Symptom relief is expected to occur within:

. 2-4 weeks

A client is now pregnant for the second time. Her first child weighed 4536 g at delivery. The client's glucose tolerance test shows elevated blood sugar levels. Because she only shows signs of diabetes when she is pregnant, she is classified as having:

. Gestational diabetes mellitus

A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?

. Hematocrit 60%

An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?

. Immerse both legs in cool water

he pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child?

. Observe for headaches, dizziness, and anorexia.

A client states to his nurse that "I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells." Based on this information, which drug might the nurse expect to be discontinued?

. Phenytoin (Dilantin)

The pediatric nurse charts that the parents of a 4-yearold child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents:

. Refusing to participate in the child's care

5 A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?

. Release restraints every 2 hours for client to exercise

A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is

. Respiratory obstruction

A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening

. Strabismus

The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is:

1600 mL/24 hr

A couple is planning the conception of their first child. The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is most likely to ovulate if she states that ovulation should occur on day:

20+2 days

The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 1-2 hours if needed. The most likely rationale for this order is:

Rapid neuroleptization is the most effective approach to care for the violent or potentially violent client

A physician's order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?

50 gtt/min

An 80-year-old widow is living with her son and daughter- in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin time test. The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following are signs of persons who are at risk for abusing an elderly person?

A family member who is having marital problems and is regularly abusing alcohol

The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:

A low birth weight

Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?

A milkshake

A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should

Administer the morning lithium dose as scheduled

The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a monoamine oxidase (MAO) inhibitor. Which of the following is she restricting from the client's diet?

Aged cheese

A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?

Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision

Priapism may be a sign of

Altered neurological function

A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:

Apply strong sacral pressure during the contraction

A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:

Auscultate the site for a bruit

Cystic fibrosis is transmitted as an autosomal recessive trait. This means that

Both parents must be carriers for a child to have the disease

The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by:

Continuing to monitor the FHR closely

An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observe which of the following:

C. Decreased or absent pedal pulse in the left leg

A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent:

Clot formation

A 32-year-old female client is being treated for Guillain- Barre syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?

Complaints of shortness of breath

A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:

Reinforce the dressing. Notify the physician.

A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to:

Decrease ammonia formation

A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs. She denies any pain previously or currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range. On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical diagnosis of placenta previa is made. The priority nursing diagnosis for this client would be:

Decreased cardiac output related to excessive bleeding

A 24-year-old client presents to the emergency department protesting "I am God." The nurse identifies this as a

Delusion

A schizophrenic client who is experiencing thoughts of having special powers states that "I am a messenger from another planet and can rule the earth." The nurse assesses this behavior as:

Delusions of grandeur

The healthcare team determines that an elderly client has had progressive changes in memory over the last 2 years that have interfered with her personal, social, or occupational functioning. Her memory, learning, attention, and judgment have all been affected in some way. These symptoms describe which of the following conditions?

Dementia

Diagnostic assessment findings for an infant with possible coarctation of the aorta would include

Diminished or absent femoral pulses

Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome?

Eating a low-carbohydrate diet

A 44-year-old female client is receiving external radiation to her scapula for metastasis of breast cancer.

Encourage her to avoid direct sunlight on the area being treated

A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems associated with his disease. However, he needs to be encouraged to participate in daily physical exercise. The ultimate aim of exercise is to:

Establish an effective, habitual breathing pattern

A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complication of wound healing is known as:

Evisceration

A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nagele's rule is:

February 27 ) February 27 is the correct answer. To calculate the estimated date of confinement using Nagele's rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result.

In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during:

First trimester

A 67-year-old client will be undergoing a coronary arteriography in the morning. Client teaching about postprocedure nursing care should include that:

The leg used for arterial puncture should be kept straight for 8-12 hours

A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about:

Giving aspirin and bismuth subsalicylate (Pepto-Bismol) to treat the symptoms

In acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe?

Haloperidol (Haldol)

A male client is considering having laser abdominal surgery and asks the nurse if there is any advantage in having this type of surgery? The nurse will respond based on the knowledge that laser surgery

Has a smaller postoperative infection rate than routine surgery

Which nursing implication is appropriate for a client undergoing a paracentesis?

Have the client void before the procedure.

Which of the following should be included in discharge teaching for a client with hepatitis C

He should avoid alcoholic beverages during his recovery period

A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure

Headache

A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report

Headache and facial flushing

On admission, the client has signs and symptoms of pulmonary edema. The nurse places the client in the most appropriate position for a client in pulmonary edema, which is:

High Fowler

After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered. Which statement shows that the client will properly care for her son's circumcision?

I'll make sure I soak the gauze with warm water first, before I take it off each time."

Respiratory function is altered in a 16-year-old asthmatic. Which of the following is the cause of this alteration?

Increased airway resistance

A 48-year-old female client is going to have a cholecystectomy in the morning. In planning for her postoperative care, the nurse is aware that a priority nursing diagnosis for her will be high risk for:

Ineffective breathing pattern

A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises.She will teach the client to:

Inhale slowly and deeply through the nose until the lungs are fully expanded, hold the breath a couple of seconds, and then exhale slowly through the mouth. Repeat 2-3 more times to complete the series every 1-2 hours while awake

The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:

Inspiration and expiration are equal

The nurse is collecting a nutritional history on a 28- year-old female client with iron-deficiency anemia and learns that the client likes to eat white chalk. When implementing a teaching plan, the nurse should explain that this practice:

Interferes with iron absorption because the iron precipitates as an insoluble substance

A male client received a heart-lung transplant 1 month ago at a local transplant center. While visiting the nursing center to have his blood pressure taken, he complains of recent weakness and fatigue. He also tells the nurse that he is considering stopping his cyclosporine because it is expensive and is causing his face to become round. He fears he will catch viruses and be more susceptible to infections. The nurse responds to this last statement by explaining that cyclosporine:

Is given to prevent rejection and makes him less susceptible to infection than other oral corticosteroids

A client had a transurethral resection of the prostate yesterday. He is concerned about the small amount of blood that is still in his urine. The nurse explains that the blood in his urine:

Is normal and he need not be concerned about it

A 27-year-old primigravida at 32 weeks' gestation has been diagnosed with complete placenta previa. Conservative management including bed rest is the proper medical management. The goal for fetal survival is based on fetal lung maturity. The test used to determine fetal lung maturity is

Lecithin-sphingomyelin ratio

One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:

Level of consciousness

A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice. He has a 20 year history of alcohol abuse. The client is diagnosed with cirrhosis. His serum ammonia level is high, indicating hepatic encephalopathy. He has esophageal varices. Which of the following may cause the varices to rupture?

Lifting heavy objects

Prior to an amniocentesis, a fetal ultrasound is done in order to:

Locate the position of the placenta and fetus

The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward:

Maintaining an adequate level of hydration

The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?

Mother calls infant by name.

The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?

Move furniture out of the way and place a blanket under his head.

A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care?

Observe for evidence of bleeding.

A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her daughter is very concerned about increasing her nutrition. The nurse helps the daughter devise a plan of care for her mother. The plan of care should include which of the following interventions to promote nutrition?

Offer her oral hygiene before and after meals.

To facilitate maximum air exchange, the nurse should position the client in

Orthopneic

Parents should be taught not to prop the bottle when feeding their infants. In addition to the risk of choking, it puts the infant at risk for:

Otitis media

To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following?

Positive inotropic therapy

A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum:

Potassium level of 6.3 mEq/L

A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:

Prevent air from entering the pleural space

A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to:

Protect the child from infection

A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?

Provide time for play and becoming acquainted.

A female client has just died. Her family is requesting that all nursing staff leave the room. The family's religious leader has arrived and is ready to conduct a ceremony for the deceased in the room, requesting that only family members be present. The nurse assigned to the client should perform the appropriate nursing action, which might include:

Respect the client's family's wishes.

A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate

Respirations are>16 breaths/min

Which of the following ECG changes would be seen as a positive myocardial stress test response?

ST-segment depression

The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis:

Seizure

The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client. The physician is notified and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic studies is monitored to assess for a major complication of this therapy?

Serum electrolytes

A 48-year-old client is in the surgical intensive care unit after having had three-vessel coronary artery bypass surgery yesterday. She is extubated, awake, alert and talking. She is receiving digitalis for atrial arrhythmias. This morning serum electrolytes were drawn. Which abnormality would require immediate intervention by the nurse after contacting the physician?

Serum potassium is low. The nurse should administer KCl as ordered

A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2 week period. Her husband asks, "Isn't that a lot?" The nurse's best response is:

Six to 10 treatments are common. Are you concerned about permanent effects?"

The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a fullstrength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?

The client aspirated tube feeding.

Plans for the care of a client with an ulcer caused by emotional problems need to take into consideration that:

The disorder is a threat to his physical well-being

After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the newborn and the mother has taken place in the delivery room, the RN will bring the newborn to the well-baby nursery. Before the newborn is taken from the delivery room and brought to the well-baby nursery, the RN makes sure that which of the following interventions was completed?

The nurse makes sure the mother and her newborn have been tagged with identical bands.

Based on your knowledge of genetic inheritance, which of these statements is true for autosomal recessive genetic disorders?

Two affected parents always have affected children.

5Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and full thicknesss burns to 25% of her body?

Urine output

During a client's first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus. This may be due to:

Urine retention or a distended bladder

A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure?

Validate that he is not allergic to iodine or shellfish.

The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing?

Vitamin C

A common complication of cirrhosis of the liver is prolonged bleeding. The nurse should be prepared to administer?

Vitamin K

A male client is experiencing extreme distress. He begins to pace up and down the corridor. What nursing intervention is appropriate when communicating with the pacing client?

Walk with him as he paces.

A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her to:

Wear a patch over one eye

When discussing the relationship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that:

When exercise is increased, insulin needs are decreased

One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The client's level is 1.3 mEq/L. The nurse recognizes that this level is considered to be:

Within therapeutic range