NCLEX RN practice quiz

The out patient surgical unit has admitted multiple clients currently awaiting early morning procedures. What client should the nurse assess first?

The client awaiting repair of hiatal hernia reporting chest pain.

A client who is occasionally confused states that the medication is the wrong color when the nurse hands it to the client. What action should the nurse take?

Double check the medication before administering.

Kernig's sign

Elicited by placing the client in a supine position with one leg flexed up toward the abdomen. The lower leg is then gently extended upward, producing severe pain in the presence of meningitis.

A client is undergoing outpatient psychiatric treatment for somatization disorder. Prior to the beginning of group therapy, the client tells the nurse, "I keep having headaches that are killing me! This has never happened to me before." What is the nurse's best response to this client?

I will notify the primary healthcare provider about your headaches, after the group session.

An elderly, bed-bound client receiving G-tube feeding at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway?

Initiate seizure precautions. - Feeding tube clients tend to get dehydrated, especially if on bed rest, which induces diuresis. - if the client is already having neurological sign, a grand mal seizure may be next

A high school nurse is assessing multiple students reporting general flu-like symptoms. Which additional symptoms reported by a student would prompt the nurse to immediately call an ambulance?

Sensitivity to light and Kernig's sign - may indicate meningitis

A client with severe depression and a pervious history of attempted suicide has been receiving inpatient therapy for months. The nurse notes at breakfast the client is showered, in clean clothes with hair combed. What response by the nurse is most therapeutic at this time?

"I see you are wearing a bright blue sweater today."

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? pH - 7.49 PaO2 - 99% PaCO2 - 29 HCO3 - 23

Respiratory alkalosis

The nurse is caring for a client who has aphasia. What interventions should the nurse include in the plan of care to improve communication with this client?

- present one thought at a time - Use and encourage use of gestures - do not push communication if client is tires - Give client time to generate a response - Ask questions that can be answered with "yes" or "no"

The nurse is reviewing the plan of care for a client during the first day post-craniotomy. Which actions can the nurse delegate to an experienced LPN/LVN working in the ICU?

- Administer acetaminophen via nasogastric tube for temperature greater than 101 degrees F - Monitor intake and output every hour

What should the nurse include in the teaching plan for a client who has iron deficiency anemia?

- Consume iron rich foods such as dried lentils, peas, and beans - Notify primary care physician of glossitis, anorexia, and paresthesia - Educate about ferrous sulfate supplement

The nurse is teaching a group of client how to decrease the risk of developing osteoarthritis (OA). What should the nurse include?

- Control blood sugar - Use largest, strongest joints for lifting - Maintain a healthy weight - Wear joint padding with playing sports.

The nurse is caring for a client following a total thyroidectomy. What findings would alert the nurse to potential complications?

- Increased blood pressure and pulse - indicates thyroid storm - High-pitched harsh respirations indicate increasing edema and potential for airway obstruction - Left-sided cheek twitching: Chvostek's sign - indicates hypocalcemia

What interventions should the nurse include in the care plan of a client admitted with Guillain-Barre syndrome?

- Keep a sterile tracheostomy at the bedside - Monitor for heart rate about 120/min

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which clients should be assigned to the medical surgical nurse?

- Total abdominal hysterectomy - Breast reduction - Bladder suspension with anterior and posterior repair.

The nurse is planning an educational seminar on ophthalmic health. Which risk factors for cataract formation should be included in the discussion?

- diabetes mellitus - Cigarette smoking - Long-term use of corticosteroids.

A client is admitted to the Labor and Delivery Unit with severe preeclampsia. Which nursing intervention does the nurse include in the plan of care for this cient?

- monitor for headache - Place client in left recumbent position - Insert indwelling urinary catheter - Initiate external fetal heart monitoring

The community health nurse is developing a presentation for adolescents on dealing with gun violence in school. What initial action should the nurse take?

Survey students to determine attitudes toward weapons.

A client who is 20 weeks pregnant and diagnosed with pelvic inflammatory disease is given a prescription for metronidazole. What should the nurse inform the client to avoid in order to prevent an interaction with metronidazole?

Alcohol

A female client at the community health clinic seeking a form of contraceptive and tells the nurse that she really desires getting an intrauterine device (IUD). Following the assessment, the nurse realizes that the IUD would be contraindicated for this client. What factor would be an absolute contraindication for this client receiving an IUD?

Ongoing pelvic infection

The community health nurse is planning to teach nutritional education to a group of adults attending a health fair. What tips about health eating should the nurse include?

Pay attention to fullness cues during meals - Use a smaller plate for meals.

A client has been prescribed sodium polystyrene sulfonate 30 grams rectally every 6 hours times 2. Which laboratory value would indicate that the prescribed sodium polystyrene sulfonate has been effective?

Potassium 4.8 mEq/L

What would the nurse expect to see when performing a neurological assessment on a 1 day old neonate suspected of having asphyxia in utero?

Toes curl downward when soles of feet stroked - may be evidence that neurologic damage from asphyxia has occurred - a normal response would be for the toes to curl fan out

The family of a client recently placed on antipsychotic medications for the treatment of schizophrenia calls the nursing hot line and reports that the client's temperature is 105.1 F, and that the clients muscles are stiff. What should the nurse tell the family?

Transport the client to the emergency room - client may be experiencing neuroleptic malignant syndrome - s/s: high fever, unstable blood pressure, and myoglobinemia

A nurse educator has completed an educational program on interpreting arterial blood gases (ABGs). The educator recognizes that education has been successful when a nurse selects which set of ABGs as metabolic acidosis?

pH - 7.29, PaCO2 - 42, HCO3 - 19