Comprehensive Review for the NCLEX-PN® Exam, 8e

The nurse provides information to a client regarding breast self-examination (BSE). Which client statement indicates a need for further teaching regarding BSE?

"I don't need to do that; I'm too old for that." Submit

The nurse is preparing to auscultate a client's abdomen for bowel sounds. The nurse listens for bowel sounds in which abdominal quadrant first? Refer to the figure.

3

Which observation indicates that the nurse is performing a whispered voice hearing assessment test procedure correctly?

Asks the client to block one ear at a time3

The nurse is auscultating bowel sounds. Which are appropriate data collection methods and actions? Select all that apply.

Divide the abdomen into four quadrants at the umbilicus.2 Do not feed the client if no sounds are audible in 5 minutes.3 Listen in each quadrant for gurgling sounds indicating movement.4

The nurse is teaching a mother how to administer eardrops to an infant. The nurse determines the mother understands instructions if the mother demonstrates pulling the ear in which manner?

Down and back and directing the solution toward the wall of the canal Submit

The nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What would the nurse tell the client about the purpose of the test?

Examines visual fields or peripheral vision Submit

The nurse in the emergency department is preparing to instill fluorescein into the eye of a client with the complaint of eye pain. Fluorescein dye is used to detect which conditions? Select all that apply.

Foreign object4 Corneal abrasion5

The nursing student is caring for a client scheduled for cataract surgery. The student reviews the preoperative prescriptions with the nursing instructor and notes that cyclopentolate eye drops are prescribed to be administered preoperatively. The unit nurse performed an admission health assessment on the client before surgery. Which condition contraindicates using cyclopentolate?

Glaucoma

To assess for the presence of the posterior tibialis pulse, the nurse would palpate which areas?

In the groove behind the medial malleolus and the Achilles tendon Submit

The nurse is preparing to collect client data by examining the abdomen. The nurse should begin the assessment by performing which action first?

Inspecting the abdomen3

The nurse is preparing to perform an abdominal examination. Which step would be taken first?

Inspection3

A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's poor nutritional intake. Which nursing intervention related to poor nutrition would be the initial choice?

Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times. Submit

The nurse is checking a dark-skinned client for the presence of petechiae. Which body area is best for the nurse to check in this client?

Oral mucosa3

A licensed practical nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the AP as being an appropriate method, indicates the need for further teaching?

Taking an oral temperature for a client with a cough and nasal congestion3

When checking a child's glossopharyngeal nerve function, the nurse would perform which data collection technique?

Test sense of sour or bitter taste on the posterior segment of the tongue.4

A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. How would the nurse interpret this result?

The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet. Submit

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse would identify which as a priority concern?

The client's report of self-destructive thoughts4

The nurse is asked to test the visual acuity of a client using a Snellen chart. The nurse prepares to perform the test, knowing that which procedure accurately identifies this visual acuity test?

The right eye is tested, followed by the left eye, and then both eyes are tested.2

The nurse is presenting a lecture on disasters and posttraumatic stress disorder (PTSD) to a group of new assistive personnel (AP). Which statements by the AP indicate that teaching has been effective? Select all that apply.

"PTSD can potentially last a lifetime."3 "Clients can be easily startled and have difficulty sleeping."4 "Flashbacks occur, causing the client to relive the experience."5 "PTSD only occurs in clients who already have a history of depression." Submit