mock nclex practice

A client with a knee-to-toe cast applied informs the nurse that they are having severe itching in the ankle area and need something to scratch it with. What is the priority nursing action?

Encourage the client to avoid scratching, and confer with the health care provider if severe itching persists.

The surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client's response, the surgeon should collaborate with which health team member?

Enterostomal nurse

A clinical nurse specialist (CNS) is orienting a new licensed practical nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic reaction would occur when giving:

A-positive blood to an A-negative client.

A child, age 2, with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To elicit the most pertinent information about the child's ear problems, the nurse should ask the parent:

" Does your child tug at either ear?"

A 1-year-old infant is pale, but the physical examination is normal. Blood studies reveal the infant's hematocrit is 24%. Which question by the nurse to the parents would be most useful in helping to establish a diagnosis of anemia?

" What's the infant's usual daily diet?"

Which statement reflects appropriate documentation in the medical record of a hospitalized client?

"Client's skin is moist and cool"

A client has come to the clinic for her first prenatal visit. The nurse should include which statement about using drugs safely during pregnancy in her teaching?

"Consult with your health care provider before taking any medications."

The nurse is caring for a client on the orthopedic unit. When preparing the client for discharge, which instructions should the nurse reinforce after surgical repair of a hip fracture?

"Do not flex the hip more than 90°, do not cross your legs, and get help putting on your shoes."

A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. Which of the following would be the nurse's best response?

"I can see that you're upset; however, you must wait at least 1 year before becoming pregnant again."

A nurse is reinforcing education for a client regarding the medication vardenafil. What statement made by the client demonstrates that education has been successful?

"I will take the medication 1 hour before sexual intercourse."

The nurse intervenes in the care of a client who is experiencing a postoperative wound evisceration. Which action should the nurse perform first?

Apply sterile saline moistened gauze over the area.

The health care provider has ordered a check of glycosylated hemoglobin (HbA1c) levels for a client with diabetes. Which statement by the client regarding this test indicates that education has been effective?

"It's used to monitor the control of my disease."

The parents of a 10-year-old child recently diagnosed with asthma ask if the child can continue to play sports. Which response is most appropriate?

"Physical activity and sports are encouraged as long as the asthma is under control."

A client in the early stages of labor asks the nurse whether it's really necessary for her to purchase a car seat, noting that they're very expensive. Which response by the nurse is best?

"The only way to safely transport your baby in a car is to have him restrained securely in a car seat."

The nurse is reinforcing education about home care with the parents of a child diagnosed with type 1 diabetes. The nurse determines the education has been successful when the parent makes which of the following statements? Select all that apply.

"We can dispose of used lancets and insulin syringes in a puncture-proof container such as a bleach bottle." "I will be sure my child wears a Medic Alert bracelet." "My child should receive immunizations for influenza and pneumonia."

Treatment for a child with sinus bradycardia includes atropine 0.02 mg/kg. If the child weighs 20 kg, how much is given per dose? Record your answer using one decimal place. __________ mg

0.4

A client who is at risk for blood clots after orthopedic surgery is scheduled to receive subcutaneous heparin. A multidose vial of heparin contains 10000 units in 1 mL. How many milliliters should the nurse administer for an ordered dose of 5,000 units?

0.5 mL

The health care provider orders olanzapine 15 mg orally once per day for bipolar mania. Available is olanzapine 7.5 mg. How many tablets will the nurse administer? Record your answer using a whole number.

2

A client in labor is prescribed an IV of 5% dextrose in lactated Ringer's solution to run at 125 mL/hour. The IV tubing delivers 10 drops per mL. At which infusion rate should the nurse set the IV? Record your answer using a whole number.

21

Which of the following effects is an advantage of the antipsychotic medication risperidone?

A lower incidence of extrapyramidal effects

The nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents?

A new cast is needed every 1 to 2 weeks

The charge nurse is making client care assignments. Which client is most appropriate for a licensed practical nurse?

A stable 6-month-old infant with pneumonia

A client with a chest tube refuses to get out of bed because of the discomfort caused by the tube. Which intervention should the nurse perform to increase this client's adherence with activity and deep breathing?

Administer analgesic medication as prescribed.

The nurse is teaching a client how to administer subcutaneous (subQ) insulin injections. Which injection site would be appropriate for the client to use?

Anterior aspect of the thigh

A client, confused and short of breath, is brought to the emergency department by a family member. The medical history reveals chronic bronchitis and hypertension. To learn more about the client's current respiratory problem, the physician orders a chest X-ray and arterial blood gas (ABG) analysis. When reviewing the ABG report, the nurse sees many abbreviations and interprets the lowercase "a" in an ABG value to represent which factor?

Arterial blood

A client is admitted to the emergency department frightened and reports hearing voices with instructions to do bad things. Which intervention should be the nurse's priority?

Assess the nature of the commands by asking the client what the voices are saying.

A client who had a nephrectomy 2 days ago is reporting abdominal pressure and nausea. Which action should the nurse take first?

Auscultate bowel sounds

A client with acute pyelonephritis is prescribed co-trimoxazole. Which finding best demonstrates that the client has followed the prescribed regimen?

Bacteria are absent on urine culture.

When collecting data on a neonate, the nurse observes a vaguely outlined area of scalp edema. Which term should the nurse use when documenting this observation?

Caput succedaneum

A client who's in labor and who attended natural childbirth classes is asking for something for pain. What should the nurse do?

Contact the physician and support the client until something can be ordered for pain.

The neurologic unit has identified a 30% occurrence of pressure ulcers in clients admitted with the diagnosis of stroke. Which of the following actions should be included in the unit's performance improvement plan?

Creating a spreadsheet on which nursing staff should document repositioning of clients admitted with a stroke

A client in labor is attached to an electronic fetal monitor (EFM). Which of the following data provided by an EFM most reliably indicates adequate uteroplacental and fetal perfusion?

Fetal heart rate variability within an acceptable range

A client with type 1 diabetes has a leg infection that is being treated with antibiotics, wet-to-dry dressings, and whirlpool therapy. Since the infection began, the client's blood glucose levels have been unstable. Which data collected by the nurse indicate a serious complication?

Flushed cheeks, dry mouth, and acetone breath odor

A client begins clozapine therapy after several other antipsychotic agents fail to relieve her psychotic symptoms. The nurse instructs her to return for weekly white blood cell (WBC) counts to assess for which adverse reaction?

Granulocytopenia

A nurse preceptor asks the graduate nurse what is the drug of choice for treating Tourette syndrome. The preceptor determines the graduate is aware of the correct medication when he accurately provides the name of which medication?

Haloperidol

The nurse is assigned to care for a client with dependent personality disorder. Which intervention should the nurse expect in this client's plan of care to promote independence?

Helping the client identify preferences, such as choosing which clothing item to wear

The physician prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

Heparin sodium

The nurse is caring for a 62-year-old client with type 2 diabetes. The client takes an oral antidiabetic to control blood glucose levels. The physician prescribed ramipril to help treat this client's elevated blood pressure. The nurse should be alert for which drug interaction?

Hypoglycemia

A client who was casted for a recent fracture of the right ulna reports severe pain, numbness, and tingling of the right arm. What would be the nurse's most appropriate response?

Immediately report the client's symptoms

A home health care nurse reviewing a client's medication record discovers tamsulosin has been prescribed, but the client is currently taking sildenafil. What is the nurse's best action?

Instruct the client to hold the sildenafil and contact the health care provider.

A nurse is caring for a client who just had surgery. What is the nurse's highest priority for this client?

Maintain a patent airway

An oncology nurse educator is speaking to a women's group about breast cancer. Questions and comments from the audience reveal a misunderstanding of some aspects of the disease. Various members of the audience have made all of the following statements. Which statement is accurate?

Man can develop breast cancer

A client with amebiasis, an intestinal infection, is prescribed metronidazole. The nurse is providing information about adverse reactions of this drug. Which information should the nurse include in his or her teaching plan?

Metallic taste

A client with Crohn's disease is admitted to a semiprivate room late in the afternoon. The next day, the client reports that he was not able to sleep during the night because the hallway lights bothered him. He asks that he be moved to a bed next to a window. What should the nurse do?

Move him to the next available window-side bed.

A client with an endotracheal tube has copious, brown-tinged secretions. Which intervention is a priority?

Obtain a sputum specimen.

A client, who is newly prescribed metoprolol, has a headache and asks the nurse what medication to take. The nurse should reinforce the health care provider's instructions to take which of the following medications?

acetaminophen

The nurse is caring for a client when the chest tube becomes dislodged. Which action by the nurse should be performed first?

Place a petroleum gauze dressing over the insertion site.

A client who has received an IM injection of ceftriaxone sodium calls the clinic and states "I think I am allergic to this medicine, there is a bump and it hurts at the injection site." What is the nurse's best response?

Place a warm compress on the area for 10 minutes.

Two staff nurses on the urology unit are responsible for the unit schedule. The holidays are nearing, and many staff members would like to take vacation days. Which method might fairly solve the holiday staffing problem?

Poll the staff to find out their preferences

Which steps should the nurse follow to insert a straight urinary catheter?

Prepare the client and the equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows.

The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:

rest in a room set at a comfortable temperature

A client is admitted to the emergency department with complaints of double vision, difficulty swallowing, dry mouth, and muscle weakness. A nurse also observes that the client has drooping eyelids and slurred speech. He states that he recently ate home-canned green beans. The nurse suspects exposure to botulism. What type of infection control precaution is necessary?

Standard precautions

A client with chronic renal failure plans to receive a kidney transplant. Recently the health care provider told the client that the client is a poor candidate for transplant because of chronic uncontrolled hypertension and diabetes. Now the client tells the nurse, "I want to go off dialysis. I'd rather not live than be on this treatment for the rest of my life." Which response by the nurse is appropriate? Select all that apply.

Take a seat next to the client and sit quietly. Say to the client, "You're feeling upset about the news you got about the transplant."

The nurse is caring for four clients on a medical surgical unit. Which interaction between the nurse and a client is the best example of the nurse using the ethical principle of fidelity?

The client asked for information regarding a new medication. The nurse provided written instructions.

The nurse is caring for a client on the fourth postpartum day. The nurse is expecting to observe which behavior in the client on the fourth postpartum day?

The client asks many questions about the baby's care.

When monitoring the closed-chest drainage system of a client who has just returned from a lobectomy, what should the nurse be sure is occurring?

The fluid in the water-seal chamber rises from inspiration and falls with expiration.

Which clinical characteristic affects client compliance?

The nurse-client relationship

A nurse plans to include the parents of a client with anorexia nervosa in therapy sessions along with the client. What fact should the nurse remember about the parents of clients with anorexia?

They tend to overprotect their children.

An 11-year old girl with reports of dysuria is suspected of having a urinary tract infection. Which findings on the laboratory report are consistent with a urinary tract infection?

WBCs: 20 per high-power field

The charge nurse is making assignments for nurses working on a medical surgical unit. Which clients could be assigned to the licensed practical nurse (LPN)? Select all that apply.

a client in need of tracheostomy dressing a client in need of Foley catheterization a client on tube feeding who needs the nasogastric tube checked for patency a diabetic client who needs reinforcement of teaching on insulin administration

The nurse is gathering information on a client who appears to be anxious. Which is important for the nurse to remember when questioning the anxious client?

be specific and direct

The nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to:

be taught about diet

The nurse is discussing transmission of human immunodeficiency virus (HIV) to a group of high school students. Which substance does the nurse inform the students most commonly transmits the virus?

blood

A pregnant client is admitted to the labor unit in early labor. When reviewing the plan of care for the client, which laboratory test would the nurse identify as being critical to obtain?

blood type

The clinic nurse is reviewing the laboratory results of a client diagnosed with acute renal failure. What two values reflect the kidney's ability to excrete waste?

blood, urea, and nitrogen (BUN) and creatine

A licensed practical nurse (LPN) is delegating responsibilities to a certified nursing assistant (CNA) on a busy postpartum unit. Which task would be appropriate for the LPN to delegate to the CNA?

bottle-feeding a 24-hour-old neonate

A 2-day-old boy is scheduled for circumcision without anesthesia. When reviewing the neonate's plan of care, which measure would the nurse likely find as most important after the procedure?

charting the time of the neonate's voiding

A client is admitted with diarrhea and dehydration. A stool culture shows Clostridium difficile. The nurse should institute which isolation precaution for this client?

contact

An unlicensed assistive personnel (UAP) is observed leaving the room of a client in isolation. The nurse recognizes the UAP is following proper technique when he or she removes which protective equipment first?

gloves

A nurse is caring for a client with borderline personality disorder. Which nursing intervention has priority?

maintaining consistent, realistic limits

A 30-year-old client whose mother died of breast cancer at age 44 and whose sister has ovarian cancer is concerned about developing cancer. A nurse who is a member of the oncology multidisciplinary team should suggest that the client ask the physician about which of the following actions?

obtaining genetic counseling

A nurse working as part of a multidisciplinary team is caring for a school-age child who has cerebral palsy. The child has difficulty eating using regular utensils and requires extensive assistance. The nurse advocating for the child would seek out which team member to assist in promoting the child's independence?

occupational therapist

A client has been admitted to the emergency department with severe right upper quadrant pain. Based on the signs and symptoms and laboratory data documented in the chart shown, the nurse would expect the client to have which diagnosis?

pancreatitis

A client who has chronic bronchitis has asked the nurse to identify things that will help to promote better oxygenation. Which of the following lifestyle factors does the nurse identify as affecting a client's oxygenation? Select all that apply.

physical exercise nutrition anxiety

A nurse receives laboratory results for a hospitalized adult client who has acute leukemia. Referring to the provided laboratory slip, which result requires immediate reporting by the nurse?

platelet count

The nurse reviews the results of a complete blood count (CBC) for a client who is scheduled to have surgery. Which finding requires the nurse to notify the health care provider?

platelet count 115 x10 ^microliter (115 x 10^9L)

A client with stage II ovarian cancer undergoes a total abdominal hysterectomy and bilateral salpingo-oophorectomy with tumor resection, omentectomy, appendectomy, and lymphadenectomy. During the second postoperative day, which data collection finding would raise concern in the nurse?

shallow breathing and increasing lethargy

The parents of a client who sustained a closed head injury in a motor vehicle accident voice their concerns about the distance and additional cost of the rehabilitation center which will not be covered by health care chosen for their son. Which health care team member can help the parents with their questions and concerns?

social worker

A client with Addison's disease comes to the clinic for a follow-up visit. When collecting data on this client, the nurse should stay alert for signs and symptoms of:

sodium and potassium abnormalities.

A multiparous client with pelvic thrombophlebitis is being treated with bed rest and anticoagulant therapy. The nurse should call for assistance immediately if the client experiences which symptom?

sudden onset of shortness of breath

A client with a fractured femur is in Russell's traction and asks the nurse to help with back care. Which nursing action is most appropriate?

telling the client to use the trapeze to lift his back off the bed

When a nurse is preparing to restrain a violent client, which nursing intervention is initially most important?

Ensuring that the restraints have been applied correctly

A nurse is caring for a child with severe scoliosis. For which complication should the nurse closely monitor the child?

diminished vital capacity

The nurse is gathering data from a client that is diagnosed with Kawasaki disease. What data does the nurse determine is associated with this diagnosis?

dry, cracked lips, strawberry tongue

Which aspect is most important for successful management of the child with Reye syndrome?

early diagnosis