NCLEX Sample Questions from Saunders

The emergency department nurse is caring for a child suspected of acute epiglottitis. Which interventions apply in the the care of the child? SELECT ALL THAT APPLY: 1. obtain a throat culture 2. ensure a patient airway 3. prepare the child for a chest x-ray 4. maintain the child in a supine position 5. obtain a pediatric-size tracheotomy tray 6. place the child on an oxygen saturation monitor

2, 3, 5, 6 Acute epiglottitis is a serious obstructive inflammatory process that requires immediate intervention and that airway patency is a priority. A lateral neck and chest x-ray can determine the degree of obstruction. To reduce respiratory distress, the pt should sit upright. A oxygen saturation monitor is placed to monitor oxygenation status. Tracheotomy and intubation may be necessary if respiratory distress is severe.

The nurse should place the client in which position to administer an enema? [Answer]

2. Sims' position w/ the right knee flexed this allows for the enema solution to flow downward w/ gravity along the natural curve of the sigmoid colon and rectum

History and Physical: 1. has renal calculi 2. had thrombophlebitis 1 year ago Medication: 3. multivitamin oral daily Diagnostic results: 4. electrocardiogram normal The nurse reviews the history and physical examination documented in the medical record of a client requesting a prescription for oral contraceptives. The nurse determine that the oral contraceptives are contraindicated because of which documented item? REFER TO CHART ABOVE

2. had thrombophlebititis 1 year ago oral contraceptives are contraindicated when a woman has a history of: thrombophlebitis and thromboembolic disorders, cardiovascular or cerebrovascular diseases, any estrogen-dependent cancer or breast cancer, impaired liver function, hypertension, diabetic mellitus or vascular involvement

A client is scheduled for angioplasty. The client says to the nurse, "I'm so afraid that it will hurt and will make me worse off than I am." Which response by the nurse is therapeutic? a) "Can you tell me what you understand about the procedure?" b) "Your fears are a sign that you really should have this procedure" c) "Those are very normal fears, but please be assured that everything will be okay" d) "Try not to worry. This is well-known and easy procedure for the health care provider"

a) "Can you tell me what you understand about the procedure?" -this explores the client's feelings and determines their level of understanding while displaying care. c) is giving the client false reassurance and puts their feelings on hold. d) diminishes their feelings and direct their attention toward the importance of the health care provider

The nurse monitors a client receiving digoxin for which early manifestation of digoxin toxicity? a) anorexia b) facial pain c) photophobia d) yellow color perception

a) anorexia

The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. On the basis of these findings, the nurse should implement which action? a) remove the IV b) apply a warm compress c) check for blood return d) measure the area of infiltration

a) remove the IV

A client who experienced a myocardial infarction is being monitored via cardiac telemetry. The nurse notes the sudden onset of this cardiac rhythm on the monitor (refer to figure) and immediately takes which action? a) takes the client's blood pressure b) initiates cardiopulmonary resuscitation (CPR) c) places a nitroglycerin tablet under the client's tongue d) continues to monitor the client and then contacts the health care provider (HCP) [Answer]

b) CPR Key word is immediate, the rhythm indicates a ventricular fibrillation (VFib) and the client needs a defibrillator to shock the heart back into rhythm

A client with renal insufficiency has a magnesium level of 3.5 mEq/L (1.7 mmol/L). On the basis of this laboratory result, the nurse interprets which sign as significant? a) hyperpnea b) drowsiness c) hypertension d) physical hypertension

b) drowsiness

A magnetic resonance imaging (MRI) study is prescribed for a client with a suspected brain tumor. The nurse should implement which action to prepare the client for this test? a) shave the groin for insertion of a femoral catheter b) remove all metal-containing objects from the client c) keep the client NPO (nil per os; nothing by mouth) for 6 hours before the test d) instruct the client in inhalation techniques for the administration of the radioisotope

b) remove all metal-containing objects from the client

The nurse prepares to care for a client on contact precautions who has a hospital-acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that required irrigation and has a tracheostomy attached to a mechanical ventilator, which requires frequent suctioning. The nurse should assemble which necessary protective items before entering the client's room? a) gloves and gown b) gloves and face shield c) gloves, gown, and face shield d) gloves, gown, and shoe protectors

c) gloves, gown, and face shield

The nurse is choosing age-appropriate toys for a toddler. Which toy is the best for this age? a) puzzle b) toy soldiers c) large stacking blocks d) a card game with large pictures

c) large stacking blocks

A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which client statement indicates an understanding of this stress reduction measure? a) "this will help only if I play music at the same time" b) "this will work for e only if i am alone in a quiet area" c) "I need to do this when I lie down in case I fall asleep" d) "the best thing about this is that I can use it anywhere, anytime"

d) "the best thing about this is that I can use it anywhere, anytime"

A client with Parkinson's disease develops akinesia while ambulating, increasing the risk for falls. Which suggestion should the nurse provide to the client to alleviate this problem? a) use a wheelchair to move around b) stand erect and use a cane to ambulate c) keep the feet close together while ambulating and use a walker d) consciously thing about walking over imaginary lines on the floor

d) consciously thing about walking over imaginary lines on the floor

The nurse has received the client assignment for the say. Which client should the nurse assess first? a) the client who needs to receive subcutaneous insulin before breakfast b) the client who has a nasogastric tube attached to intermittent suction c) the client who is 2 days postoperative and is complaining of incisional pain d) the client who has blood glucose level of 50 mg/dL and complaints of blurred vision

d) the client who has blood glucose level of 50 mg/dL and complaints of blurred vision