NCLEX Study Questions
A woman who is 2 wks postpartum calls the clinic stating "all I do is cry. I am so exhausted that I can't think clearly. I can't handle this anymore." What would be the most appropriate response by the nurse? - "You are being too hard on yourself. Being a mom is hard. Try to cheer up." - "It's normal to feel a little down after having a baby. Just give it some time." - "Have you had any thoughts of harming yourself of the baby?" - "When the baby starts sleeping better and you get some rest, your thinking will get better."
- "Have you had any thoughts of harming yourself of the baby?" This mother is experiencing more than the baby blues that many new mothers experience. There are clues in the stem of these statements that you should recognize as warning signs of something more significant than the baby blues. The mother states that she is no longer thinking clearly and expresses the inability to cope with the current situation. She seems to be experiencing postpartum depression that can include more severe symptoms such as suicidal ideation and thoughts of harming the baby. It is crucial to ask a very straightforward, direct question to assess the mother and infant's safety. Failure to do so could put the mother and/or the infant's life at risk.
A client diagnosed with glaucoma is being instructed on self-instillation of eye drops. What statement by the client would indicate the teaching was successful - "I should look into the mirror to be sure I am getting the drops in." - "I will put all drops in my eyes and then close my eyes for 5 minutes." - "I have to be sure not to touch the dropper to any part of my eye." - "I have to pull down the upper lid when putting the drops in."
- "I have to be sure not to touch the dropper to any part of my eye."
A renal transplant client has received discharge education. Which statement by the client indicates the need for FURTHER teaching? - "I will need to notify my primary healthcare provider if I develop a fever." - "I need to check my BP daily and report an increased BP." - "I will tell my primary healthcare provider if I become easily fatigued." - "I will be on steroids for 3 months, then I will not have to take them."
- "I will be on steroids for 3 months, then I will not have to take them." Immunosuppressive agent doses are often adjusted, but the patient will be required to take some form of it for the entire time they have the transplanted kidney. Signs of post-transplant rejection include fever, oliguria, edema, increasing BP, weight gain, flu-like symptoms, shortness of breath, fatigue, and swelling or tenderness over the transplanted kidney.
A nurse is caring for a patient taking lithium. Which comment by the client indicates LACK of understanding of the therapeutic regimen? - "I must keep my sodium intake steady over time." - "If I miss a does of my lithium, i should make it up with the next dose." - "I must check with my primary healthcare provider before changing my diet for weight loss." - "I must keep my exercise routine the same or discuss with my primary healthcare provider."
- "If I miss a does of my lithium, i should make it up with the next dose." If a dose is missed, the client should take the next dose as prescribed without doubling it. If sodium intake is reduced or the body is depleted of its normal sodium, lithium is reabsorbed by the kidneys, increasing the possibility of toxicity. Food intake and sodium should remain constant. changes in diet and exercise that cause sodium loss should be avoided and/or monitored closely.
A mother of a newborn is crying and tells the nurse, "I am worried about my baby. His Apgar score was 6 and the nurses had to help him breathe for a while." What response should the nurse make to this mother? - "Don't worry about what score your baby received on the Apgar, the nurses know how to take care of him." - "Stop crying. Your baby is fine now and will continue to get stronger as the day progresses." - "Your baby's Apgar score was normal. The score was 6 at 1 minute, which is typical." - "It is normal for you to feel this way. Let me explain what the Apgar score is used for."
- "It is normal for you to feel this way. Let me explain what the Apgar score is used for." This statement recognizes the mother's feelings and seeks to educate. Providing relevant information may decrease her anxiety and encourage further communication. An Apgar of 7-10 indicates a newborn is in good condition.
A nurse is planning to provide education to a client wishing to breastfeed. What instructions should the nurse include when teaching this client? Select all that apply. - Apply warm compresses to breasts just prior to breastfeeding. - Establish a routine for breastfeeding - Massage breasts during feeding - Wear a well-fitting bra continuously for the first 24-hrs after birth - Wash hands before breastfeeding.
- Apply warm compresses to breasts just prior to breastfeeding. - Massage breasts during feeding - Wash hands before breastfeeding. Warm compresses or warm showers prior to breastfeeding will help the let-down reflex. Massaging breasts during feeding can help with emptying. Emphasize hand hygiene prior to breastfeeding to prevent infection. Allow newborns to nurse on demand. Allow newborns to feed 15-20 mins per breast or until the breast softens. Begin next feeding session on the breast that was not completely emptied. A well-fitting bra should be worn continuously for at least 72-hrs after birth to avoid milk stasis.
A nurse is planning to educate diabetic clients on how to decrease their risk for developing renal failure. What educational point should the nurse include? Select all that apply. - Avoid daily use of NSAID medications. - Aggressive blood pressure management is necessary. - Aim to keep Glycosylated hemoglobin (HgbA1c) <7% - Have estimated glomerular filtration rate measured every five years. - Increase protein intake to 30% of total calories eaten per day.
- Avoid daily use of NSAID medications. - Aggressive blood pressure management is necessary. - Aim to keep Glycosylated hemoglobin (HgbA1c) <7% The eGFR should be assessed at least yearly if not more frequently. A diabetic client's diet should consist of no more than 15-20% caloric intake of protein because protein make the kidneys work harder.
The nurse manager of a long-term care facility notes an increase in pressure ulcers over the last 6 months. What new protocol developed by the nurse manager is MOST likely to decrease the occurrence of decubiti? - Bedfast clients must be repositioned every 2 hours - All clients should have egg crate mattress on the bed - Clients bathed in bed need lotion applied to all joints - Provide back massage daily to all clients on bed rest
- Bedfast clients must be repositioned every 2 hours Repositioning clients every 2 hours prevents excessive, prolonged pressure on skin and bony prominences. Such an action also provides an opportunity for visible inspection of the client's skin by staff. This repositioning applies not only to bedfast clients but also to those who sit in a chair for prolonged periods of time.
A 16 yr old female student is escorted to the school nurse after fainting in gym class. She tells the nurse, "I just got weak from running." Upon assessment, the nurse notes poor skin turgor, dry mucous membranes, and erosion of tooth enamel from her front teeth. Height is 5'4" and weight is 110 lbs. the student reports muscle pains in her legs. Based on this data, what should the nurse suspect? - Anorexia Nervosa - Bulimia Nervosa - Obesity - Physical Violence
- Bulimia Nervosa The patient is exhibiting signs of bulimia nervosa. Additionally, the client will binge on excess calories, then purge through vomiting and the use of laxatives, diuretics, and enemas. Weight fluctuates: usually within normal limits or is slightly over or under weight. Tears in the esophageal and gastric mucosa can occur. Due to vomiting, tooth enamel can erode.
A nurse is caring for a client who has been prescribed metoprolol. Wat education should the nurse provide to the patient? Select all that apply. - Information on skin turgor. - Check for edema in lower extremities. - Take medication 30 mins prior to a meal. - Do not use OTC nasal decongestants. - Notify primary healthcare provider if pulse is <60 bpm.
- Check for edema in lower extremities. - Do not use OTC nasal decongestants. - Notify primary healthcare provider if pulse is <60 bpm. Heart failure is one of the indications for metoprolol. If the patient is experiencing swelling in the lower extremities, the primary provider should be notified to evaluate the prescription. the client should not take OTC nasal decongestants because they contain alpha-adrenergic stimulants, when metoprolol is prescribed. The combination can increase the risk for orthostatic hypertension. Since dehydration is not a side effect of metoprolol, monitoring skin turgor is not included in medication education. Metoprolol should be taken with or right after meals. there is a decreased absorption rate with increased stomach contents.
The nurse is reinforcing teaching to a group of parents about the transmission of the chickenpox virus and the importance of vaccination. Which modes of transmission for chickenpox should be included in the discussion? Select all that apply. - Direct contact - Indirect contact - Airborne - Droplet - Common vehicle
- Direct contact - Indirect contact - Airborne
A community health nurse is planning to discuss how to prevent pesticide ingestion at a local health fair. What should the nurse include in the teaching session? Select all that apply. - Discard the outer leaves of lettuce. - Wash fruits and vegetables with dish soap. - Buy organic produce. - Peel fruits before eating. - Dry produce thoroughly after washing - Use a scrub brush when washing fresh fruits and vegetables.
- Discard the outer leaves of lettuce. - Buy organic produce. - Peel fruits before eating. - Dry produce thoroughly after washing - Use a scrub brush when washing fresh fruits and vegetables.
A nurse suspects a client admitted to the ED is in diabetic ketoacidosis. What data would lead the nurse to this conclusion? Select all that apply. - Dry mucous membranes - Fruity-smelling breath - Bidot's respirations - Glycosuria - Client report of abdominal pain
- Dry mucous membranes - Fruity-smelling breath - Glycosuria - Client report of abdominal pain Client with DKA will have signs of dehydration due to polyuria. Ketones occur with the breakdown of fat, are acids, and present as fruity-smelling breath. The client would be spilling glucose into the urine. Vomiting and abdominal pain are frequent presenting symptoms of DKA. The patient will have Kussmaul respirations.
A client on a surgical unit frequently quarrels with the staff. Which nursing intervention should the charge nurse implement? - Involve the client in their plan of care - Delegate two nurses to work with the client - Accept the client's behavior as confrontational - Encourage the client to be more cooperative
- Involve the client in their plan of care This action will promote the client's self-esteem and may reduce the quarrelsome behavior.
The nurse is providing discharge dietary instructions to a client diagnosed with full-thickness burns on the right hand. To promote tissue healing, which food examples should the nurse provide to the client? Select all that apply. - Pasta - Oranges - Brown Rice - Chicken Breast - Electrolyte Drink
- Oranges - Chicken Breast Vitamin C will promote collagen synthesis, decrease healing time, and decrease capillary fragility. The body requires increased protein intake during the wound healing process. Increased protein intake results in greater collagen formation. Other foods listed lack protein and vitamin C at needed levels
A nurse receives a client in the post anesthesia care unit following application of a long leg cast to the left leg due to a fractured tibia and fibula. Which interventions should the nurse initiate? Select all that apply. - Elevate foot of the bed 30° - Palpate bilateral pedal pulses - Apply ice packs to fracture site - Mark break through bleeding - Assess client's ability to move toes
- Palpate bilateral pedal pulses - Apply ice packs to fracture site - Mark break through bleeding - Assess client's ability to move toes Priority nursing assessments and interventions maintain good circulation to the extremity and prevents complications that can impair mobility. This must include checking distal pulses in both legs. decrease seslling and risk of compartment syndrome by applying ice to fracture site, assess for bleeding, and check for tingling, coldness, numbness, and ability to move toes (neurovascular/sensation checks)
How should the nurse interpret this ABG report? pH - 7.33 PaO₂ - 95% PaCO₂ - 28 HCO₃ - 18 - Partially Compensated Metabolic Acidosis - Fully Compensated Metabolic Acidosis - Partially Compensated Metabolic Alkalosis - Fully Compensated Metabolic Alkalosis
- Partially Compensated Metabolic Acidosis The pH, bicarb, and carbon dioxide are all abnormal, so compensation is beginning. The pH has not normalized yet, total compensation has not occurred.
A nurse is teaching a group of expectant parents bout epidural anesthesia. What information should the nurse include? Select all that apply. - Contraindications for an epidural include a previous C-section. - Post-procedure position should be side-lying. - Headache is a post-procedure side effect. - The major complication is hypotension. - Usually administered at 3-4 cm dilation.
- Post-procedure position should be side-lying. - The major complication is hypotension. - Usually administered at 3-4 cm dilation. The client should not lie supine but should position self in a side-lying position. this will prevent the compression of the vena cava. The major complication of epidural anesthesia is hypotension and a supine position increases that risk. If this occurs, a bolus with 1L NS or LR to increase BP by increasing vascular volume. Epidurals are usually placed during stage 1 of labor at 3-4 cm dilation.
A client is diagnosed with a duodenal ulcer due to H. Pylori. In addition to antibiotic therapy, the nurse anticipates that the client will also receive what class of pharmacologic agent? - Proton Pump Inhibitor - Mitotic Inhibitor - Serotonin Antagonist - Acetylsalicyclic Acid
- Proton Pump Inhibitor Antisecretory agents like PPIs are indicated for the treatment of peptic ulcer disease. Antisecretory agents decrease the secretion of gastric acids. PPIs, a combo of antibiotics and bismuth salts are most commonly used to treat H. Pylori
A client has been trying to implement a low fad diet for prevention of heart disease and enhance weight loss. he further reports that his wife shows her love by preparing rich foods and pastries. Which action should the nurse make? - Suggest that the client prepare all meals at home. - Schedule a meeting with husband and wife to discuss diet and health. - Suggest that the client limit intake to one serving of each food at meals. - Ask the client to give his wife a cookbook with low-fat recipes
- Schedule a meeting with husband and wife to discuss diet and health. the meeting with both husband and wife together may help to gain the support of the wife. She may not realize that rich meal preparation is actually serving as a barrier to successful change. Also, the importance of the opinions and behaviors of the wife are important to the client as he tries to engage in long-term behavioral change.
A client is to be discharged following a left modified-radical mastectomy. When reviewing ADL's to be completed at home, the nurse anticipates the client will experience the MOST difficulty doing what tasks? Select all that apply. - Cooking a meal - Shampooing hair - Doing laundry - Vacuuming carpets - Changing bed linens
- Shampooing hair - Doing laundry - Changing bed linens Following this surgery, most clients experience pain and stiffness particularly with tasks that require stretching the arm above the head or lifting.
A client is being discharged with halo traction. What should the nurse teach the client and family about the home management of this device? Select all that apply. - Showering is permitted once a week with assistance. - Apply baby lotion under the halo vest to prevent irritation. - Sleep in whatever position is most comfortable. - Never pull on any part of the halo traction. - Clean around the pins at least once daily with a new q-tip for each pin site.
- Sleep in whatever position is most comfortable. - Never pull on any part of the halo traction. - Clean around the pins at least once daily with a new q-tip for each pin site. the placement of a rolled up towel, or pillow, either under the neck, if on back or under the cheek if side lying may be helpful. Pulling on any part of the traction can damage or loosen the traction. Pin care is done to prevent infection. Do not use ointments or antiseptics unless prescribed. The client should never attempt to shower, as there is no reliable way to keep the vest liner dry. Take sponge baths and use towels of plastic to keep the vest from getting wet. Do not use soaps, creams, lotions, or powders beneath the vest as these may irritate the skin.
What does a non-stress test tell the nurse about a pregnant client? - That the baby is going to be a boy or a girl - The baby is doing well and the placenta is providing enough O2 at this time - That the baby's heart is healthy and there are no birth defects - That the mother is strong enough to undergo vaginal delivery
- The baby is doing well and the placenta is providing enough O2 at this time Non-stress tests identify whether an increase in the fetal heart rate occurs when the fetus moves, indicating adequate oxygenation, a healthy neural pathway from the fetal central nervous system to the fetal heart rate and the ability of the fetal heart to respond to stimuli. None of the others can be determined through a non-stress test
A nurse has completed education on safe sex practices to a group of college students. Which comments by the students would indicate that education has been successful? Select all that apply. - The best way to prevent HIV is to abstain from sex. - Contraceptives should contain spermicide N-9. - Douching is recommended after intercourse. - If my partner will not use a condom, I will. - Drinking too much alcohol can increase the risk of exposure to sexually transmitted infections (STIs).
- The best way to prevent HIV is to abstain from sex. - If my partner will not use a condom, I will. - Drinking too much alcohol can increase the risk of exposure to sexually transmitted infections (STIs). if one decides to have sex, know your HIV status and your partners. Practice monogamy. Limit sexual partners. Use protection for all kinds of sexual contact. Get screened for STIs. Don't abuse drugs or alcohol, which are linked to sexual risk taking.
A client diagnosed with Alzheimer's disease has been prescribed memantine. What should the nurse teach the caregiver about this medication? Select all that apply. - When beginning this medication, provide ambulatory assistance - This medication is prescribed to help improve mild dementia - This medication must be taken without food - If a dose is missed, double the next dose - If the client cannot swallow the capsule, you should sprinkle on applesauce.
- When beginning this medication, provide ambulatory assistance - If the client cannot swallow the capsule, you should sprinkle on applesauce. This medication can cause dizziness. It is used for moderate to sever dementia associated with Alzheimer's. Can be taken with or without food.
A 35 yr old client, concerned about weight asks a clinic nurse, "What's my BMI?" The client weighs 135lbs and is 5'2" tall Determine the client's BMI to the nearest tenth.
24.7 BMI= (703 x weight in lbs) ÷ (height in inches)² BMI= (703 x 135) ÷ (62)² BMI= (94,905) ÷ (3,844) BMI= 24.689 BMI= 24.7
How would a case manager best describe a clinical pathway to nursing students? 1. A decision-making flowchart that uses the if/then method to address client responses to treatment. 2. A set of practice guidelines developed by professional medical organizations such as the American College of Surgeons. 3. A standardized set of preprinted primary healthcare provider prescriptions for client care. which expedite the prescription process and can be customized to individual clients. 4. A set of client care guidelines based on specific client diagnosis, which provides an overview of the multidisciplinary plan of care.
4. A set of client care guidelines based on specific client diagnosis, which provides an overview of the multidisciplinary plan of care. It can be used to guide the plan of care and identify deviations from the plan of care. These clinical pathways reduce the degree of variation in clinical practice, improves outcomes, and promote organized and effective client care based on EBP. Clinical pathways are different from algorithms, practice guidelines, and protocols because they incorporate a multidisciplinary team approach and focus on the quality of care 1. Definition of an algorithm 2. Definition of a practice guideline
Place the steps in order that the nurse should take to administer a subcutaneous injection - Apply gloves and locate the injection site - Dispose the syringe in sharps container - Hold syringe and ping the skin with non-dominant hand - Cleanse site with antiseptic swab - Inject the needle and administer the medication - Remove the needle cap by pulling it straight off - Perform hand hygiene
Correct order: - Perform hand hygiene - Apply gloves and locate the injection site - Cleanse site with antiseptic swab - Remove the needle cap by pulling it straight off - Hold syringe and ping the skin with non-dominant hand - Inject the needle and administer the medication - Dispose the syringe in sharps container
After reviewing the client assignments, the LPN/VN tells the RN the assignment is very unfair and requests that some of the clients be redistributed to the other staff. What should the RN do first? - Ask the LPN/VN who the assignment should be adjusted. - Assign one of the LPN/VN's clients to another nurse. - Encourage the LPN/VN to use teamwork skills in caring for the patients. Develop a strategic plan to assist with client assignments.
Encourage the LPN/VN to use teamwork skills in caring for the patients. Explore their concerns; this is the most therapeutic and helpful response. Finding out what are LPN/VN's concerns first will help the RN address them and build trust in the healthcare team relationship.
Which ABG value would the nurse expect to see when monitoring a client in a hyperosmolar hyperglycemic state (HHS)? pH: 7.32 PaCO2: 47 HCO3: 22 PaO2: 78
HCO3: 22 Normal HCO3: 22-26. You would expect to see a normal bicarb level in this patient. A patient in DKA, would have an expected HCO3 below 22. In HHS, the patient would not be in acidosis. That is the primary difference between HHS and DKA. Normal pH is 7.35-7.45. a pH of 7.32 indicates acidosis and will e expected for DKA. Normal PaCO2: 35-45. increased CO2 level would be seen in DKA, not HHS. Normal PaO2: 80-100. Nornal or increased PaO2 is seen in HHS.
A client is preparing to be discharged after a total colectomy with the creation of an ileoanal reservoir for ulcerative colitis. The nurse recognizes that education has been successful if the client makes which statement? - Ulcerative colitis cannot be cured. - I look forward to having the ileostomy closed. - I am going to eat a hamburger and fries for dinner. - Because of this surgery, I am at a higher risk for developing colon cancer.
I look forward to having the ileostomy closed. Once the reservoir has closed, the ileostomy will be closed. A total colectomy is removal of the entire colon. It may take several days before solid foods are tolerated. The entire colon is removed so the client is not at risk for colon cancer.
A client who underwent a laparoscopic cholecystectomy is being discharged from an outpatient surgical center. Which statement by the client shows the nurse that discharge teaching has been effective? - I will need to eat a low-fat diet since I no longer have a gallbladder. - I can expect drainage from the incision for a few days. - I may have some mild pain from the procedure. - I should plan to limit my activities and not return to work for several weeks.
I may have some mild pain from the procedure. After a laparoscopic procedure, the client can expect to have some mild pain. Severe pain would indicate a problem. The client can resume their usual diet. the liver will produce enough bile to digest fats. The gallbladder stores bile without the gallbladder, the bile just drains from the liver. The client should not have drainage from the incisions. there are usually 2-3 small incisions on the abdomen that do not normally have drainage. The client can return to normal activities within 2-3 days. this is not considered a major surgical procedure.
After making rounds on clients, a primary healthcare provider hands the nurse a client record and gives the following verbal order: Administer cisplatin 1 mg IV over 6 hours. What should be the first action by the nurse following this verbal prescription? - Write down the prescription immediately. - Repeat the prescription back to the primary healthcare provider. - Ask the primary healthcare provider to spell the drug name for clarification. - Inform the healthcare provider that this medication requires a written prescription.
Inform the healthcare provider that this medication requires a written prescription. Cisplatin is a high alert drug that should be given careful consideration. Verbal orders for antineoplastic agents should NOT be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and have a narrow margin of safety.
A client diagnosed with a hemorrhagic stroke is being transferred to the medical unit from the ICU. Which nursing intervention should the nurse initially implement? - Administer an osmotic diuretic. - Complete a neurological assessment. - Maintain the head of the bed at 30 degrees. - Instruct the client to take a stool softener daily.
Maintain the head of the bed at 30 degrees.
middle-aged Client has a strong positive family history of T2DM. What should the nurse teach the client regarding the best method to prevent or delay the development of this disease? - Test serum glucose values monthly. - Avoid starches and sugars in the diet. - Obtain a normal body weight and exercise regularly. - Maintain a normal serum lipid panel.
Obtain a normal body weight and exercise regularly Genetics and body weight are the most important factors in the development of T2DM. The client cannot alter their genetics. therefore, normal body weight is imperative. Regular exercise reduces insulin resistance and permits increased glucose uptake by cells. This serves to lower insulin levels and reduces hepatic production of glucose. Monthly glucose monitoring is not sufficient. Starch & sugars should be decreased, not avoided. maintaining a normal serum lipid panel may not be achievable in some clients, but is always the goal. medication may be needed.
A nurse is assessing a terminally ill client who is restless with an O2 sat of 58%. Which nursing intervention would the nurse implement? - Monitor the client's breathing pattern. - Wipe the mouth with an oral care sponge. - Soothe the client by affirming your presence. - Initiate O2 via NC at 4L/min
Soothe the client by affirming your presence. As the O2 sat level decreases, the client becomes restless and anxious. the nurse should initiate calming interventions such as speaking to the client in a soothing tone and reassuring the client that there is someone present to support them.
A preeclamptic client is being treated with magnesium sulfate. The nursing assessment shows a respiratory rate of 10 with deep tendon reflexes of 0. what is the nurse's PRIORITY action? - Place the client in Trendelenburg position and apply oxygen. - Stop magnesium and prepare to give calcium gluconate. - Ask another nurse to verify the deep tendon reflexes. - Prepare the patient for an emergency C-section
Stop magnesium and prepare to give calcium gluconate. the nurse's findings indicate the client's central nervous system has been overly depressed, with a RR of 10 and absent DTRs. Stopping the magnesium is the priority because it is the cause of the problem and reversing its effects with calcium gluconate.
A parent of a 1 month old reports that their baby wakes up startled and stretches out the arms throughout the night. what suggestion should the nurse provide to the parent to decrease this reflex? - Rock to sleep. - Place in a baby swing. - Provide a pacifier. - Swaddle the baby.
Swaddle the baby. Swaddling makes the baby feel more secure and decreases the baby's sense of falling.
The nurse is caring for a client in the outpatient mental health clinic. The client recounts several incidences of spousal abuse. The client says to the nurse, "I know he loves me. Sometimes I can be quite irritating." which response is most appropriate by the nurse? - "You are not responsible for the abuse." - "Sometimes we can irritate your spouses." - "The worst is over now." - "You should think about leaving him."
"You are nor responsible for the abuse." Th perpetrator is responsible for their own actions, but the abused partner may take responsibility or make excuses for them. This mindset needs to be clarified and corrected to prevent further abuse and keep the client safe.