NUR115: NCLEX-PN Prep 1

A nurse is caring for a post-surgical client. Identify the *most* common site for DVT for this client.

calf

The nurse is caring for a client following a thyroidectomy assessing for a possible low calcium level related to inadvertent removal of parathyroid glands. Identify the part of the body the nurse would assess to determine a positive or negative Chvostek's sign.

nerve at the angle of the jaw (see image)

A child's most recent diagnostic testing reveals elevated levels of T3 and T4. When assessing this child for exophthalmos, the nurse should inspect what region.

eyes

A client has a temporary pacemaker in place and requests pain medication. The nurse has an order to administer morphine sulfate 4 mg IV. What is the available is morphine sulfate 10 mg/mL. How many mL will the nurse administer? Round to the nearest tenth.

0.4 mL

A client presents to the emergency with a foot lesion. When documenting the foot lesion in the medical record, which medical terms wound a nurse use to classify the pictured lesion? SATA 1. linear 2. flat 3. fissure 4. crack 5. scale 6. ulcer

1. linear 3. fissure

The nurse is teaching a client about how to recognize when treatment for hypothyroidism if effective. Which statement from the client would indicate that the nurse's teaching has been effective? A. "I will start feeling more energetic" B. "I won't feel hot and sweaty anymore" C. "Hopefully I won't lose any more weight" D. "It will be a relief to be able to sleep more hours"

A. "I will start feeling more energetic"

"A client has a serum calcium level of 7.2 mg/dl. During the physical examination, the nurse expects to assess: A. Trousseau's Sign B. Homan's Sign C. Hegar's Sign D. Goodell's Sign

A. Trousseau's Sign

A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage, and finds it to be cooler and paler than the left leg. What should the nurse do next? A. assess the distal pulses B. elevate the extremity C. lower the head of the bed to 30 degrees D. notify the HCP of the finding

A. assess the distal pulses

The nurse administers lisinopril to a client. What assessment findings does the nurse document as evidence of a positive therapeutic response? A. blood pressure 118/74 mmHg B. apical heart rate 88 bpm C. potassium level 4.0 mEq/L (mmol/L) D. total cholesterol level of 200 mg/dL (5.2 mmol/L)

A. blood pressure 118/74 mmHg

A client twists his right ankle while playing basketball and seeking care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which client statement suggests that ice application has been effective? A. "I need something stronger for pain relief" B. "My ankle looks less swollen now" C. "My ankle appears redder now" D. "My ankle feels very warm"

B. "My ankle looks less swollen now"

A child is admitted with a 5-day history of severe vomiting and diarrhea. Which intervention is the priority for the nurse? A. collecting strict intake and output B. administering IV fluids C. begin oral rehydration D. start on a bland diet of bananas, rice, applesauce, and toast (BRAT diet)

B. administering IV fluids

Which finding would indicate bowel functioning is returning after anesthesia and surgery for a client with an NG tube? A. palpation around the surgical site indicated a soft, pliable abdomen B. auscultation indicated bowel sounds in all four quadrants C. percussion indicates tympany over the abdomen D. inspection of the contour of the abdomen indicates no distention

B. auscultation indicated bowel sounds in all four quadrants

The nurse caring for a client admitted with a DVT is reviewing the client's prepackaged medications delivered by the pharmacy. The nurse suspects a pharmacy omission when medication from which classification is missing. A. antibiotic B. antihypertensive C. anticoagulant D. antihyperglycemic

C. anticoagulant

To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site. A. radial B. apical C. carotid D. brachial

C. carotid

When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. What action should the nurse anticipate that the physician will order? A. incision and drainage B. culture C. debridement D. irrigation

C. debridement

A client experiences loss of consciousness, tongue biting, and incontince, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure? A. Jacksonian B. absence C. generalized D. sensory

C. generalized

A client tells the nurse he is experiencing dyspnea. Which position will the nurse place the client in? A. trendelenburg position B. Sims' position C. high Fowler's position D. supine position

C. high Fowler's position

A client has a wound with a drain. When performing wound cleansing around the drain, the nurse should cleanse in which direction? A. laterally, from one side of the wound to the opposite side B. from superior portion of the wound to the inferior C. in a widening circle around the drain, outward from the center D. laterally, from the distal area to the center

C. in a widening circle around the drain, outward from the center

The nurse is assessing the client's umbilicus (see the accompanying image). The nurse should document the umbilicus as being: A. inflamed B. everted C. midline D. herniated

C. midline

A nurse is teaching a client about the importance of increasing fluids when experiencing the early stages of dehydration. Which statement by the client would express understanding? A. "dehydration is only a problem in the summer months when it's hot outside" B. "if my skin becomes dry and itchy I can apply extra lotion" C. "vitamin hydration drinks would be good when I feel my heart pounding and become lightheaded" D. "I should drink more water when feeling thirsty or becoming irritable"

D. "I should drink more water when feeling thirsty or becoming irritable"

A client is prescribed metoprolol 25 mg by mouth twice per day for an atrial arrhythmia. Which should the nurse assess to determine the effectiveness of this medication? A. presence of peripheral edema B. peripheral pulses C. breath sounds D. heart rate

D. heart rate

A nurse is caring for a client who fell and fractured the neck of the femur. When documenting the site for the family members, indicate on the image the area where the fracture occurred.

view image

The nurse is caring for a client that had surgery this morning. What assessment finding would the nurse notify the HCP about? A. urinary output of 20 mL/hr over 2 hours B. temperature of 37.6 C (99.7 F) C. moderate amount of serous drainage on the surgical dressing D. blood pressure of 100/70 mm Hg

A. urinary output of 20 mL/hr over 2 hours

Which clinical signs wound indicate to a nurse caring for a terminally ill client that death may be imminent? A. diminished urine output and Cheyne-Stokes reparations B. narrow pulse pressure and a body temperature of 98.6 F (37 C) C. swallowing reflex and bowel sounds present D. respirations regular at 18 breaths/min and weak pedal pulses

A. diminished urine output and Cheyne-Stokes reparations

When preparing to deliver back slaps to an infant who is choking on a foreign body, the nurse should place the infant in which position? A. head down and lower than the trunk B. head up and raised above the trunk C. head to one side and even with eh trunk lower than the head D. head parallel to the nurse and supported at the buttocks

A. head down and lower than the trunk

The nurse is inspecting the client's abdomen (see image). The nurse should document that the client's abdomen: A. is flat and symmetrical B. has an aortic pulsation C. reveal a hernia D. shows striae

A. is flat and symmetrical

A client with cancer of the throat had a tracheostomy tube inserted 2 days ago. The client has moderate secretions and can take deep breaths without pain. When suctioning a client's tracheostomy tube, the nurse should take which action? A. oxygenate the client before suctioning B. insert a suction catheter about 5 cm (2 inches) into the cannula C. use a bolus of sterile water to stimulate coughing D. use clean gloves during the procedure

A. oxygenate the client before suctioning

The nurse is caring for a 5-year-old child who had a hernia repair 1 day ago. The child is vomiting, has an NG tube with low intermittent suction, and has diarrhea. Which of the following laboratory results would be the immediate *priority* for the nurse to assess? A. potassium level B. calcium level C. magnesium level D. chloride level

A. potassium level

Which finding in a client who recently underwent a total hip replacement would require a nurse to take *immediate* action? A. red painful area on the calf of the affect leg B. slight non tender edema in the non affected leg C. ecchymosis around the incision site D. three episodes of emesis in the past hour

A. red painful area on the calf of the affect leg

The nurse irrigates a client's colostomy. If the client has abdominal cramping after receiving about 150 ml of solution during the colostomy irrigation, the nurse should: A. stop the flow of solution B. have the client sit up in bed C. insert the cone or tube further into the colon D. remove the irrigating cone or tube

A. stop the flow of solution

A child with a tracheostomy suddenly becomes diaphoretic and has an increased heart rate, an increased work of breath, and a decreased oxygen saturation level. What should the nurse do *first*? A. suction the tracheostomy B. turn the child to a side-lying position C. administer pain medication D. perform chest physiotherapy

A. suction the tracheostomy

Which action must a nurse perform when cleaning the area around a Jackson-Pratt wound drain? A. clean from the center outward in a circular motion B. remove the drain before cleaning the skin C. clean briskly around the site with alcohol D. wear sterile gloves and a mask

A. clean from the center outward in a circular motion

The nurse is caring for a client with postoperative wound evisceration. Which action should the nurse take? A. offer the client reassurance that the compilation is common and treatable B. cover the area with sterile gauze that is moistened with sterile saline solution C. irrigate the area with warmed sterile saline and apply a sterile, dry dressing D. position the client supine with the legs extended and the head of the bed at 30 degrees

B. cover the area with sterile gauze that is moistened with sterile saline solution

A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first? A. calm the client, as the client is very upset and crying B. cover the protruding internal organs with sterile gauze, moistened with sterile saline solution C. push the protruding organs back into the abdominal cavity D. request the client to remain on bedrest until the HCP is notified

B. cover the protruding internal organs with sterile gauze, moistened with sterile saline solution

The nurse receives a change-of-shift report on the following four clients. Which client should the nurse assess *first*? A. client with cystic fibrosis who has an albuterol nebulizer treatment due in 10 minutes B. immobile client with a sudden onset of SOB C. client with atrial fibrillation who has a dose of diltiazem due in 15 minutes D. client with influenza who has a temp of 101.5 F (38.6 C)

B. immobile client with a sudden onset of SOB

A client had an appendectomy 2 days ago and is now presenting with a purulent drainage, pain in the mid-incision, and a temperature of 101.3 F (38.5 C). What would be the *most* appropriate action by the nurse? A. administer acetaminophen and reassess in 2 hours B. notify the surgeon as soon as possible C. take no action because these are normal findings D. ambulate the client in the hall

B. notify the surgeon as soon as possible

A client is returned to his room after subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside? A. indwelling urinary catheter kit B. tracheostomy set C. cardiac monitor D. humidifier

B. tracheostomy set

When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently? A. using a povidone-iodine wash on the ulceration three times per day B. using normal saline solution to clean the ulcer and applying a protective dressing as necessary C. Applying an antibiotic cream to the area three times per day D. massaging the area with an astringent every 2 hours

B. using normal saline solution to clean the ulcer and applying a protective dressing as necessary

The nurse is completing an initial assessment of a client admitted with chronic kidney disease. Which finding indicated the client has fluid volume excess? A. dry cough B. weight gain C. cool, dry skin D. poor tissue turgor

B. weight gain

A nurse is assessing a client with hyperthyroidism. What findings should the nurse expect? A. weight gain, constipation, and lethargy B. weight loss, nervousness, and tachycardia C. exophthalmos, diarrhea, and cold intolerance D. diaphoresis, fever, and decreased sweating

B. weight loss, nervousness, and tachycardia

A client receives morphine, 4 mg IV for relief of surgical pain. Thirty minutes later, the nurse asks the client whether the pain is relieved. Which step of the nursing process is the nurse using? A. assessment B. diagnosis C. implementation D. evaluation

D. evaluation

What would be an appropriate action for the nurse prior to performing deep tracheal suctioning due to increased secretions? A. deflate the cuff of the tracheostomy during suctioning B. instill acetylcysteine into the tracheostomy before suctioning C. apply negative pressure as the catheter is being inserted D. hyperoxygenate the client before suctioning

D. hyperoxygenate the client before suctioning

A nurse is teaching a group of middle-aged clients about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention A. a sedentary lifestyle and smoking B. a history of hemorrhoids and smoking C. alcohol abuse and a history of acute renal failure D. alcohol abuse and smoking

D. alcohol abuse and smoking

A client is being evaluated for hypothyroidism. During the assessment, the nurse should stay alert for A. exophthalmos and conjunctival redness B. flushed, warm, moist skin C. systolic murmur at the left sternal border D. decreased body temperature and cold intolerance

D. decreased body temperature and cold intolerance

The nurse is teaching an adolescent how to self-administer insulin. Which of the following is a *priority* for the nurse to emphasize about insulin administration? A. activity levels rarely determine insulin requirements B. meal sizes are not usually considered when determining insulin needs C. the need for insulin always decreased when strenuous sports are played D. insulin injections are administrated in subcutaneous tissue

D. insulin injections are administrated in subcutaneous tissue

A nurse is caring for a client who recently underwent a total hip replacement. The nurse should: A. ease the client onto a low toilet seat B. allow the clients legs to be crossed at the knees when out of bed C. use soft chairs when the client is sitting out of bed D. limit hip flexion of the clients hip when he sits

D. limit hip flexion of the clients hip when he sits

A client is one day postoperative from a total laryngectomy and radial neck dissection for cancer. What could be a *priority* goal by the nurse? A. encourage effective communication B. improve body image C. prevent aspiration D. maintain a patent airway

D. maintain a patent airway

A hospitalized client who has a living will is being fed through a NG tube. During a bolus feeding, the client vomits and begins choking. Which action should the nurse take? A. clean the clients airway B. make the client comfortable as specified in the clients living will C. start a cardiopulmonary resuscitation D. stop the feeding and remove the NG tube as specified in the clients living will

A. clean the clients airway

A client is hospitalized for a myocardial infarction. The nurse is teaching the client to do ankle pumps. What is the expected outcome of this exercise? A. prepare the client for ambulation B. promote urinary and intestinal eliminations C. prevent thrombophlebitis and blood clot formation D. decrease the likelihood of pressure ulcer formation

C. prevent thrombophlebitis and blood clot formation

During an assessment, a nurse measures a client's respiratory rate at 32 breaths/minute with a regular rhythm. When documenting this pattern, the nurse should use which term? A. eupnea B. bradypnea C. apnea D. tachypnea

D. tachypnea