NCLEX test questions
A home health nurse is performing an initial assessment of a client who has Crohn's disease and is experiencing fecal incontinence which of the following action should take priority
- check the skin around the clients anus and rectum for indications of breakdown - The digestive enzymes and stool can irritate the client skin and cause, redness, and lesions
A nurse is to administer 10 mg of morphine sulfate to a client with three fractured ribs. The available concentration for this drug is 15 mg/mL. How many milliliters should the nurse administer
0.7 ML 10 MG xml = 15mg:1ml 15 mg x X ml = 10 mg X 1 ml 15x = 10 X = 0.667 or 0.7 ml
A nurse is assessing a child who has autism spectrum disorder which of the following findings should the nurse expect
Echolalia - repeating speech sounds usually in the meaningless way- can also include flipping toys in flexible to change and routines
Which of the following are elements of tier 1 for infection control
Wearing gloves when coming in contact with blood or body fluids Performing hand hygiene between client, care, encounters Bagging, contaminated, laundry before removing it from the room
The nurse is providing client teaching for a client newly diagnosed with diabetes which statement by the client indicates teaching has been effective
I will complete cardiovascular exercises five days a week for 30 minutes each time. I will also complete strengthening training exercises, three days a week in addition
A nurse is providing instructions to a client with a hiatal hernia concerning steps to prevent symptoms of gastric reflex, which of the following statements by the client indicates the teaching has been effective
I will need to quit drinking alcohol - smoking is also a cause issue Ys rest and decreasing stress important for general health
A nurse is providing medical teaching to a client who has Addison's disease and has been prescribed hydrocortisone, which of the following instructions should the nurse include
Notify the provider of any illness or stress Report any episodes of weakness or dizziness Do not discontinue the medication suddenly
A 22-year-old male comes to the emergency department, following a motor vehicle accident, his eyes open to speech he is confused and he localized to pain. What is his glass glucoma scale
12 -
The nurse is preparing to give report before transferring a client out of the emergency department to receiving floor which information listed below is the priority of the reporting nurse to provide to the nurse receiving the report?
The client has shortness of breath and has been giving albuterol breathing treatment
A nurse is providing teaching for a client who has a new prescription for raloxifene The nurse should advise the client about which side effects.
Hot flashes Leg cramps Diarrhea - Estrogen, regulates bone mass by inhibiting the activity of osteoclasts. This helps treat osteoporosis. - side effects include nausea, vomiting, diarrhea, hot flashes, peripheral edema, fluid like symptoms, joint pain, muscle spasms, leg cramps
A nurse is providing information to a couple who want to delay, starting a family about various types of family planning. The couple decides to use the basal body temperature method to avoid pregnancy. The nurse should explain that the length of fertility period surrounding ovulation last, for which of the following periods of time
72 hours before and 24 hours after ovulation
A nurse is counseling a client with bulimia Nosa. The client states that at times she feels helpless in relation to her eating disorder. The nurses assisting the client to set goals the most appropriate short-term goal for this client is.
Verbalizing the desire to increase control over stressful situations
Which of the following individuals would benefit from dietary management of diabetes mellitus by meal planning, using advanced carbohydrate, counting
A 19-year-old female with type one diabetes he uses insulin pump - this is used very much with a client with a insulin pump
A nurse beginning a shift at 7 PM receives the report from the nurse on the dayshift which of the following clients is the priority assessment for the evening nurse
A client just admitted from the ED without a current complaint
A nurse who is working in the emergency department, understands that which of the following clients cannot be allowed to sign out against medical advice
A client who states that the voice is telling him to kill his children A client who believes she is Marie Antoinette An intoxicated client who has been drinking heavily for 12 hours, and cannot walk without stumbling
A nurse needs help with moving clients quickly in a fire drill, which client will the nurse ask the nursing assistant to help first
A client with confusion
Authoritarian
A government in which one leader or group of people holds absolute power.
A disaster occurs involving mass casualties following an active shooter in the lobby of a hospital which of the following client. Should the nurse triage first.
A pregnant mother, with a gunshot to the arm - They are at most risk for hypovolemia, immediate triage, and then treatment with flu as well. Promote their survival. - The older man will not most likely not survive
A regressed 19-year-old is admitted to the behavioral unit after the end of a romantic relationship, the client has been refusing to get out of bed and has not been attending his college classes or taking care of his grooming needs. The nurses initial effort should be directed towards.
Encouraging the client to be a partner in his treatment Assist the client to tolerate stress without further regression Help the client find gratification in accomplishments and in the environment instead of fixating failure or inadequacy
And Nurse is caring for a neonate what attributes would most likely be seen during the first period of reactivity of a newborn infant
Alert and exploring
A nurse is teaching the guardian of a school-age child who has a new prescription for dextroamphetamine/amphetamine to treat ADHD, which of the following information should the nurse include in the teaching
And adverse effect of this medication is central nervous system simulation You should monitor your child's blood pressure while taking this medication You should limit your child's intake of caffeine containing products You should give the morning dose after breakfast -
A nurse is caring for a client with jaundice and epigastric pain who is undergoing in evaluation for possible pancreatic carcinoma The client asks the nurse how the diagnosis is made which of the following test is most likely to give an accurate diagnosis.
Endoscopic ultrasound with fine needle, aspiration biopsy
The nurses assessing a client with extra pulmonary tuberculosis, which of the following is true about this type of condition
Genitourinary system is affected Osteomyelitis occurs
A nurse is caring for a client who was just passed away which of the following steps are part of the initial physical assessment process of postmortem care
Verifying that respirations have ceased, and there's no pulse Checking the pupils for reaction to light -
A nurse is discussing acute grief process with a client. His partner recently died, which of the following statements made by the client indicates understanding of feeling that occurred during acute grieving.
I might experience feelings of resentment I might have some guilt over how my partner died I might have angry feelings that I should express
A nurse is assessing a client who has hypothyroidism and is receiving thyroid hormone replacement therapy which of the following findings should indicate to the nurse that need for a decrease in the medication dosage
Hand trimmers - Manifestation of hypothyroidism include hyponatremia, hyperglycemia, hypo, ventilation, hypotension, bradycardia, hypothermia, dry pale skin changes in mental status
Which of the following would be an indication for a blood product transfusion an adult? Client select all the apply.
Hemorrhage that causes 30% total volume blood loss Sickle cell disease that causes severe anemia
A nurse is caring for a hospitalized client after hip replacement after monitoring the client for postoperative complications, which of the following does, the nurse understand, is a sign of pulmonary embolism
Anxiety and chest pain - sense of dread crackles on oscillation fever, hemoptysis hypotension, pallor, syncope do a ventilation, perfusion, scan or dimer level treat with anticoagulation and supportive care, supplement oxygen
A nurse in an emergency department is admitting a client who is lethargic and unable to complete sentence. The client has a heart rate of 38 bpm and a blood pressure of 83/48. The nurse supplies electrodes to the clients chest and limbs and the electrocardiogram monitor shows complete heart block which of the following action should the nurse take first.
Apply transcutaneous pacemaker pads - To begin external pacing of the heart, and a temporary transvenous or permanent, implant, pacemaker can be placed only used for short periods of time
A nurse is performing discharge, teaching to a client who has cellulitis due to a bacterial infection, which of the following information should the nurse include in the teaching
Apply warm compression to the affected area
A nurse is caring for a client who has chronic polynephritis which of the following action should the nurse take
Arrange a consultation with the registered dietitian Palpate the costovertebral angles of the client And start the client to avoid every two hours Monitor the clients creatine level - can result in renal scarring and decreased kidney functioning. The client should consume a diet the provides nutrients controls, blood pressure and consistency of plenty fruits and vegetables can include changes in your color hypertension low-grade fevers, inflammation
The nurse is preparing to discharge an 80-year-old client who has a new prescription for warfarin for deep vein thrombosis which of the following instructions should be included in the nurses discharge teaching
Avoid alcohol due to enhanced anticoagulant effect
A client from India is vegetarian which religious group is associated with this dietary practice
Hindu Sikh
A nurse is caring for a client who was a prescription for a cleansing enema, which of the following action should the nurse take when administering the enema
Hope the container of solution 30 cm above the anus 12 inches -
A nurse is caring for a client on the telemetry unit and sees the following rhythm on the monitor which of the following is a priority action by the nurse
Begin chest compressions - this rhythm is particular fibrillation. It indicates cardiac arrest.
Erotomanic delusions
Believing that another person desires you romantically
A nurse is auscultating the lungs of a client who is two days postoperative open cholecystectomy which of the following breast sounds should the nurse expect to hear if the client has developed atelectasis
Do or absent sounds over the basis of the lungs due to incomplete alveolar expansion or collapse
A nurse is caring for a client who has a prescription for gentle myosin 10 mg. I am every 12 hours. The available dose is 20 mg./two ML. Calculate the dose that will be administered.
Dose ordered/have = amount to be given Ordered is 10 mg Concentration is 20mg/2ml or 10mg/ml 10mg/10mg/ml = 1 ml
A nurse is providing discharge instructions for a client who is undergone roux en Y gastric bypass, which of the following instructions should the nurse provide to help the client prevent dumping syndrome
Consume small, low carbohydrate, meals - They should also separate meals and fluids by at least 30 minutes
A nurse is working in the mental health facility is caring for a client who has psychosis the client states I can read your thoughts through the radio and speak to aliens on another planet. The nurse should document that the client is experiencing which type of delusion.
Control - They believe the others are trying to control them, and that they are forcing their thoughts into their brains
A nurse is caring for a client who has been admitted for treatment of heart failure, which of the following signs and symptoms is associated with ineffective tissue perfusion
Cool extremities Slow healing of extremity wounds - this can also include weaker absent pulses, decreased urine output, slow wound healing. Ischemic pain - altered sensation, altered skin characteristics, cold extremities, blue, purple skin, edema, decreased arterial, pulses, positive homans sign poor wound healing.
A nurse is caring for a client who is receiving a transfusion of whole blood and notes that the client has developed circulatory overload as a result of the infusion, which of the following symptoms with the nurse, considered to be a sign of circulatory overload
Cough Distended, neck veins - Increased Venus pressure cough dyspnea, distended, neck, pain, high blood pressure, crackles
A nurse is caring for a client with a nursing diagnosis of fluid volume excess related to heart failure, which of the following lab values. Will the nurse expect to see in a client with this diagnosis.
Decreased serum sodium
Which of the following precautions should be used by a nurse caring for a client who has a diagnosis of clostridium difficile colitis
Dedicate equipment only for this client to be disinfected before removing from the room - client needs a private room. Contact precautions must wear gloves when entering the room and wear a gown gown should be removed before leaving the room as of gloves, wash hands with soap and water before leaving the room.
A nurse is caring for a male client hospitalized with major depression and suicidal ideation. The client has improved over the course of two weeks but the nurse has just learned that the client spouse was seriously injured in a motor vehicle collision. The clients daughter asks that he not being informed about his wife's presence in the ICU the nurse would like to make the ethical response to this request
Defined a personal and professional moral position
A nurse is assessing a male client with urethral stricture which of the following findings does the nurse expect
Diminished urinary stream
A nurse is assessing a client with arterial blood gas values pH 7.4 9PA0 290 PA, CO2 31 what clinical manifestations may be associated with the clients arterial blood gas results
Dizziness Tingling in the hands Tetany - this indicate alkalosis which is caused by hyperventilation symptoms and signs tetany, dyspnea, numbness around the mouth, lightheaded, syncope, chest pain can cause cerebral vessel, construction can result neurological symptoms, including dizziness, confusion, seizures
A nurse is providing care for a client with acute milo leukemia, which of the following nursing diagnosis are appropriate for this client
Imbalanced nutrition Ineffective protection - Includes bone, pain, fatigue, headache, anorexia, ineffective protection, due to bleeding and thrombocytopenia anticipate grieving fluid excess hypothermia
A nurse is caring for a client who was just had a G.I. to placed which complication is most commonly associated with the G.I. tube
Infection
A nurse is preparing to collect the throat culture from a client with suspected strep infection, which action is most appropriate during this process
Instruct the client to tilt the head backward, and say aw - She should ask the client to sit comfortably till head back open mouth and say aw
S4 heart sound
Is an arterial gallop
The nurse is assessing a client with hepatitis, which of the following diagnostic tests will be recommended for this type of client
LDH lactic test HPV surface antigen ALP alkaline phosphate AST aspirate aminotransferase GTT gamma ALT
A nurse is positioning, a client after a liver biopsy which of the following is the correct position
Laying on the right side of the body
A nurse receives a call from a client husband requesting lab results for his wife. How should the nurse respond
Let me check whether you have permission to assess this information
A nurse is caring for a client who was admitted with Ebola virus infection which of the following is an appropriate action by the nurse
Limiting the use of sharps when possible, needles - Clients placed in a single client airborne isolation room door must remain closed standard droplet, and airborne precautions are required need a gown, face shield and 95 respirator, doubled gloves, extended cuffs, single use apron, single use shoe covers use of sharps limited when possible
A nurse is caring for a client diagnosed with ulcerative colitis who has a new prescription for sulfasalazine which of the following should the nurse include when developing teaching materials for the client
Maintain a fluid intake of 2000 ML/day minimum - Client should follow a low residue, high calorie, high protein, diet, supplement by vitamins and minerals, low residual foods limit the irritation of the G.I. tract and may decrease symptoms foods that are easily digested like rice, pasta, and rich bread, canned fruit, cooked vegetables, fluid intake, necessary to maintain fluid balance, hydration, and electrolyte balances 2000-3000 ML per day small frequent meals
A nurse is caring for 38-year-old, female and perimenopause who would like an effective method of contraception. She is single has multiple sexual partners and smokes, five cigarettes daily, which of the following methods of contraception should the nurse suggest.
Male condom
What symptoms is associated with manic behavior?
More talkative than usual Easily distracted Intense need for activity -
A school nurse is teaching parents about communicable diseases. She tells the group that encephalitis can occur from a complication of.
Mumps
Which of the following is a sign of progression towards therapeutic goals in the client diagnosed with dependent personality disorder
My spouse was not able to drive me to work so I took a bus
A nurse is caring for client who is postoperative following abdominal surgery and reports pain which of the following action should the nurse take
Offer the client to back-rub Remind the client to splint the incision Change the clients position - you can also hold a pillow against the incision coughing can also reduce incision pain, guided imagery and distraction
A 21 month old client is seen with his mother in the pediatric office for viral gastroenteritis And several episodes of vomiting. They are sent home with oral hydration liquids and told to call if the child shows any signs of dehydration or is not able to keep liquids down the mother ask the nurse what position the child should be sleeping in what is the best response?
On his side, to minimize the risk of aspiration
The nurses providing information to the public at community health event about screening for cancer, which of the following lab tests are used as a screening test for cancer
PSA prostate specific antigen PAP test
A nurse is assisting with the insertion of a pulmonary artery catheter for a client who needs invasive, hemodynamic monitoring, place each of the following steps, and the proper order for assisting with insertion of PAC
Prime. IV tubing and the transduction flush lines. Zero the transducer Connect transactors to the distal, proximal lumens Assist the provider with insertion by passing lines and catheters as needed Inflate the balloon on the catheter once inserted Secure the catheter to the client
A nurse in the long-term care facility is given an in-service presentation to a group of nurses about the management of clients who have Alzheimer's disease when the nurse describes the plan of care for a client who is in the moderate stage of A.D., which of the following intervention, should the nurse include
Provide protective undergarments - The client begins to have episodes of urinary and fecal incontinence, which become more prominent as the disease progresses can also help with skin breakdown - they become more frustrated and anxious changes in language, abilities, personality behavior, cognitive process, physical abilities, neurologic status, nurse should help maintain mobility and self-care and safety. They can liquids cut foods in the smaller pieces to help avoid choking, help to avoid wandering. Use a calm voice.
Treatment for a patient with anorexia nervosa
Provide the client with small, frequent meals Monitor their daily weight Stay with the client during meals for one hour after - Symptoms are low weight lanugo amenorrhea, muscle weakness, hypokalemia, decreased bone density, constipation, cold extremities - weighed the client the first week then three times per week vitals avoid conversations with the client that have food during mealtimes. Give client liquid supplements as prescribed.
A nurse is caring for a newborn client with tetralogy of fallot the client is cyanotic since birth, which of the following defects is a common for the clients condition
Pulmonary stenosis
A client is exposed to radiation following a bombing what action should the nurse perform immediately?
Remove the clients clothing
A nurse is preparing to initiate hemodialysis through AV fistula for a client who has end-stage kidney disease which of the following action should the nurse take
Review the clients current medication Assess the AV fistula for a brute Measure the clients weight
The nurse is teaching a newly licensed nurse about possible physical effects of alcohol withdrawal, which of the following findings should the nurse include in the teaching
Seizures, hypertension, tremors - Can can also have signs of nausea, vomiting, education, insomnia, perceptual, changes, impaired cognition, blood pressure, your heart rate, and temperature will be increased
A nurse is caring for a client who was admitted early in the shift with pancreatitis when they evaluating the clients laboratory results. What is the immediate priority?
Sodium 118 - normal range is 135 to 145 can result in hyponatremia and seizures
A nurse is caring for an adolescent who has a new diagnosis of ewings sarcoma, which of the following action should the nurse take
Spend time with the adolescence to answer any questions
The nurse is changing the ties on a recently placed tracheotomy tube. The tube suddenly becomes dislodged when the client moves unexpectedly. What is the nurses priority?
Spread the opening by grasping the retention sutures -
A nurse is caring for a client with diabetes mellitus and obesity, who is postoperative abdominal surgery, which of the following intervention should the nurse include to reduce the risk of poor wound, healing and potential dehiscence in the client
Strict glycemic control with close monitoring of blood glucose Use of abdominal binder Use of stool softener Use of an medication as needed for nausea
A nurse is caring for a client who has returned from the recovery room following the placement of a temporary pacemaker, the most important initial nursing assessment is
The client cardiac status
A charge nurse is admitting an elderly client with influenza which of the following precautions are necessary for preventing the transmission of influenza virus to other clients
The client should wear a facemask when leaving the room The client should be assigned to a private room Is your contact with the client should be limited - Contact and droplet precautions are necessary when caring for a client with influenza
Which client is at least risk for bone marrow transplant rejection
The client who received received a autologous transplant
A nurse is caring for a group of clients which of the following client should be the priority client for the nurse to assess first
The client with a blood pH of 7.0 this indicates they are acidotic while there is no further information provided it cannot be excluded that they have a respiratory issue. They are the priority assessment.
A nurse is collecting data from a client who has major depressive disorder. The nurse should I identify which of the following clients statements as a convert comment about suicide
The stress in my life is too much to handle I don't feel like I will ever be happy again
The best time in the menstrual cycle for a woman to perform breast self-examination is
The week after ministration
A client with asthma is scheduled for treatment with methylcanthine for nocturnal wheezing, which of the following drugs are appropriate for this client
Theophylline Aminophylline end in lline - Asthma is inflammatory condition causing airway obstructions causes wheezing, breathlessness chest tightness coughing this is a class of drug to treat. Asthma, side effects are nervousness, insomnia, tremors.
A client with a diagnosis of polyarteritis nodosa ask the nurse for information about this disorder. What information should the nurse include in her response?
This disordered is considered one of hypersensitivity, and the exact cause is unknown
The nurse is caring for an infant weighing 8 kg of measuring 70 cm from head to toe who has a prescription for antibiotics calculate the body surface area of the client
To calculate BSA the following formula is multiply, bodyweight and kilograms times height in centimeters divided by 3600 then apply the square root to that number - 8 x 70 /3600 = 0.155 then square = 0.39 m2
When drawing an arterial blood gas from the radio artery, why should the nurse perform an ALLEN test
To determine patency of the ulnar artery
Which of the following interventions to prevent hip fracture should be included in a care plan for 78-year-old woman with osteoporosis and hearing loss. He was supported by a home health nurse.
Use of vitamin D and calcium supplements Weight-bearing physical activity Use of hearing aids
A nurse is caring for a six-year client admitted to the treatment of pneumonia. The nurse has identified a nursing diagnosis of impaired gas exchange which of the following interventions are independent actions. The nurse can take to improve gas exchange
Use the incentive spirometer Instruct client on deep, breathing techniques and importance of coughing Encourage the client to remain in the seated or semi Fowler position
Passive
accepting or allowing what happens or what others do, without active response or resistance.
persecution delusion
belief that others are persecuting, spying on, or trying to harm them
Malingering
characterized by the intentional creation of false or grossly exaggerated physical or psychological symptoms
somatic symptom disorder
condition marked by excessive anxiety about physical symptoms with a medical or purely psychological origin
Nihilistic delusion
conviction that a major catastrophe will occur
authoritative
having the weight of authority; regarded as providing knowledge that can be trusted; reliable; peremptory and dictatorial; Ex. authoritative dictionary/manner; CF. definitive
factitious disorder
nonexistent physical or psychological disorder deliberately faked for no apparent gain except possibly sympathy and attention
permissive
parents submit to their children's desires. they make few demands and use little punishment
Which of the following abbreviations are on the joint commission on accreditation of health organizations do not use abbreviation list
ug, as, MS
Münchausen syndrome by proxy
• Second party (i.e. parent) induces symptoms in someone (i.e. child) because they enjoy taking care of someone
