nclex

The nurse is performing follow-up phone calls for clients recently discharged from the medical-surgical unit. Which client situation would require immediate follow-up? A client with

neutropenia reporting an oral temperature of 100°F (37.8°C).

The nurse is caring for a newborn. Which of the following actions would be appropriate for the nurse to take?

obtain the first outfit from the warmer

The nurse is reinforcing teaching to a client about newly prescribed carbamazepine. Which of the following information should the nurse include?

avoid taking the medicine with grapefruit

In which age group is child abuse most likely to occur?

birth to 3 years

The nurse administered prescribed six units of regular insulin. Which data collection finding requires follow-up?

cold sweats

What is the most important factor to consider when assessing a home health patient on fall risk?

correct the illumination of the environment

The nurse is caring for a client with end-stage renal disease who is receiving prescribed sevelamer. Which of the following findings would indicate a therapeutic response?

decreased serum phosphorus levels

The LPN is working with a child who has a learning disability. The child is ten years old and has trouble reading and interpreting words, letters, and symbols. This disorder is described as which of the following?

dyslexia

The nurse is preparing to measure the fundal height of a client at 16 gestational weeks. The nurse should prepare the client for this assessment by instructing the client to

empty their bladder

The nurse is monitoring a 10-year-old patient status post-tonsillectomy. Which of the following observations should be immediately reported to the healthcare provider?

frequent swallowing

The nurse detects an elevated temperature in a patient who is scheduled for surgery. The patient has been afebrile and has no other symptoms of fever. What should be the first nursing action?

validate the finding

Hospitalization may affect or delay the progression of which physical development in a 1-year-old patient?

walking

The nurse is teaching a client newly diagnosed with osteoporosis. The nurse should recommend that the client perform which type of exercise?

weight bearing

The parents of a 9-month-old bring their infant to the nurse who is choking on a foreign object. The infant is conscious and not making any noises. The nurse should immediately

give five back blows and five chest thrusts.

The nurse has become aware of the following client situations. It would be a priority for the nurse to follow up on the client who

had a transurethral resection of the prostate six hours ago and has urine output turned bright red in color.

The nurse working with geriatric clients understands that falls are likely to occur in elderly patients who are:

hospitalized

The nurse is reviewing labs for a patient with a serum potassium level of 3.3 mg/dL(3.5-5 mEq/L). Which action would the nurse recognize as the highest priority

implement telemetry monitoring

The licensed practical/vocational nurse (LPN/VN) reinforces medication instructions to a client prescribed phenytoin. Which statements, if made by the client, indicate effective understanding?

"I will need laboratory work to monitor the medication level."

Which of the following statements indicates body image distortion in a patient with anorexia nervosa?

"I'm so overweight"

The nurse is going over her assigned patients for the shift. She knows that which of the following patients is most at risk for experiencing a fluid volume deficit?

A patient with diabetes insipidus and an NG tube to low intermittent wall suction.

The nurse is preparing to administer penicillin V potassium to a child with pneumonia. The child weighs 18.5 kg. The prescription is for 50 mg/kg/day PO divided doses every six hours. How many milligrams should the child receive with each dose? Round your answer to the nearest whole number. Fill in the blank.

231 mg/dose

A patient is scheduled to have a thyroidectomy. The nurse understands that the primary reason for giving Lugol's solution to a patient preoperatively is:

Reduce the size and vascularity of the thyroid and prevent hemorrhage.

The nurse is reinforcing teaching with a client with Graves' disease regarding self-management. Which of the following should the nurse emphasize?

Report any weight gain while taking the antithyroid medication.

Which of the following clients should the LPN/LVN attend to first?

A patient in an arm cast that is 2 days post-op and reports feeling numbness and tingling in his affected arm.

The primary healthcare provider (PHCP) prescribes a regular insulin infusion. for a client. The prescription is for 2 units/hr. The label on the medication reads 250 mL of 0.9% saline containing 100 units of regular insulin. How many mL/hr should the client receive?

5

You are working in the intensive care nursery and are assigned to take care of an infant withdrawing from cocaine. At your first assessment, you appreciate the following: a high pitched cry, no tremors, increased muscle tone, sleeping for 3 hours in between feedings, no congestion, RR = 42, excessive sucking on the pacifier, poor feeding, no vomiting, and no loose stools. What is the NAS score for this patient?

7

Which of these would be an appropriate assignment for the LPN/LVN?

A 21-year-old client with cystic fibrosis that needs an early morning sputum sample collection.

Which of the following clients should the nurse assess first when preparing to do initial rounds?

A 32-year-old female with a tracheostomy that is experiencing copious secretions.

While working in the emergency department, the nurse sees the following clients, and recognizes which of them is at highest risk for elder abuse?

A 92-year-old male with late-stage Alzheimer's disease

When triaging clients who have existing infections, which of the following patients would be most appropriate to assign to the only private room available?

A client with a cough suspicious of Koch disease.

A patient tells the nurse that she is ashamed of the way her hair looks and wants a shower and hair washed before her daily routine tests and wound dressing changes. How should the nurse prioritize the patient's care?

Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing.

The nurse is caring for a client diagnosed with Multiple Sclerosis (MS). The nurse should anticipate a prescription for which medication?

Baclofen

A nurse is preparing the plan of care for a client with stage 2 ovarian cancer who is a Jehovah's witness. The client has been told that surgery is necessary. Taking into consideration the client's religious preferences in developing the plan of care, the nurse documents which of the following?

Blood transfusion or the administration of blood and blood products is forbidden for this group.

The nurse is collecting data on a client with Paget's disease. Which of the following would be an expected finding?

Bone deformities

Place the following stages of Piaget's Stages of Cognitive Development in the appropriate order:

Sensorimotor Preoperational Concrete operational Formal operational

Upon entering a client's room, the nurse finds the client lying on the floor. What is the first action the nurse should implement?

Establish if the client is responsive.

The LPN is caring for a client scheduled for surgery who has a diet order of nothing by mouth (NPO). Which of the following prescriptions should the LPN clarify with the primary healthcare physician (PHCP)?

Lispro insulin 5 units SubQ before meals TID

The nurse is visiting the home of a client with Clostridium difficile. Which infection control measure should the nurse include?

Obtain vital signs with a disposable blood pressure cuff.

The nurse is caring for an infant who presents with a congenital abnormality where their abdominal contents come through the umbilicus while remaining in the peritoneal sac. The nurse knows the infant will be diagnosed with which of the following?

Omphalocele

The licensed practical/vocational nurse (LPN/VN) is reinforcing teaching to a postpartum client about caring for her episiotomy. Which of the following statement by the client would indicate a correct understanding of the teaching?

I should increase my fluid and fiber intake."

The nurse is administering eye drops to a patient diagnosed with conjunctivitis. Place the following items in the correct sequence for the nurse to perform.

Tilt the patients head back Pull down the lower eyelid Administer the medication in the center of the lower eyelid Ask the patient to close their eyes

This nurse is caring for a client who is receiving prescribed tolvaptan. Which of the following findings would indicate a therapeutic response

Urine specific gravity 1.010

The nurse is discharging a client following knee arthroplasty. Which of the following information should the nurse reinforce in the discharge teaching?

you will need to resume your anticoagulants

The school nurse is assessing a 12-year old boy who came into her office for a nose bleed. She notices several bruises on his back and forearms that are in various stages of healing. When she asks the boy about them, he is very deceptive. The nurse notifies child protective services of her suspicion the next day. The boy's mother comes to the nurse's office and yells at her for calling child protective services. Which of the following responses is most appropriate?

"I am required by law to report any suspected violence."

The nurse reinforces discharge instructions to a client who underwent left eye cataract surgery with a lens implant. Which statement by the client would indicate a correct understanding of the teaching?

"I should avoid getting water in the eye for 3 to 7 days after surgery."

Which of the following statements made by a male cancer patient with hair loss secondary to chemotherapy indicates that the goal for new coping patterns is being met?

"I washed my wig today"

A nurse has received orders to administer a RhoGAM injection IM to a postpartum patient. Which situation is NOT a contraindication for administration of this injection?

Administration of the injection within 72 hours after delivery.

The nurse is caring for a client who experienced a myocardial infarction (MI) 24 hours ago. It would be necessary for the nurse to immediately notify the primary health care provider (PHCP) if the client has which of the following?

Crackles auscultated to the midline of the lung fields

The nurse observes a patient clutching her abdomen and complaining of cramping, accompanied by sharp pain. Which of the following types of pain is the client experiencing?

Cutaneous or superficial somatic

The nurse is observing the surgical aseptic technique of a nursing student. Which observation by the nurse requires follow-up?

Spills sterile water onto the sterile field

While caring for a 4-year-old child in the PICU, you develop a care plan to address his psychosocial development during his recovery. You know that he will be in which stage of development according to Erikson's stages of psychosocial development?

Initiative vs. guilt

The nurse is performing a verbal hand-off report for a client. Which essential information should the nurse include in the report?

Involuntary admission status

Increased levels of which of the following hormones is related to hyperemesis gravidarum?

estrogen

The nurse is caring for a client who has type 2 diabetes mellitus and hypertension. The client is nothing by mouth status (NPO) before a scheduled surgery. Which of the following prescribed medications should the nurse question?

glipizide

The licensed practical/vocational nurse (LPN/VN) conducts infection control audits in the nursing unit. Which client is at the greatest risk for infection? A client who

is receiving total parental nutrition

Which of the following formulas would the LPN correctly choose for an infant diagnosed with phenylketonuria?

lofenalac

The nurse has just inserted an indwelling urinary catheter for a male client. The nurse plans on securing the catheter to the client's

lower abdomen

The nurse is preparing a client for a scheduled colonoscopy. Which prescription should the nurse anticipate from the primary healthcare provider (PHCP) while the client is preparing for this procedure?

polyethylene glycol 3350

The nurse is working at the triage desk in the emergency department when a patient arrives and begins speaking in Spanish. The nurse asks if he would like an interpreter, and he shakes his head 'no.' What is the appropriate action for the nurse to take?

Request an interpreter from the hospital's interpreter service.

The LPN is preparing to distribute teaching handouts about developmental milestones to the parents of a 6-month-old male. He was born at 28 weeks gestation. Which of the following handouts are appropriate for their son's development?

Developmental milestones for 3-month-olds

Which of the following client room assignments should the nurse question?

Placement of an 89-year-old client with acute delirium at the end of the hallway.

A client newly diagnosed with diabetes mellitus has a glycosylated hemoglobin A1c level of 10% (<5.7%). Based on this laboratory value, the nurse should reinforce which teaching point?

prevent and recognize hyperglycemia

Which of the following is a cause of hyponatremia?

profound sweating

The nurse is assisting a client using a fracture bedpan. Which action should the nurse take?

raise hob to 30 degrees

The most effective way to perform hand hygiene is which of the following?

Either wash hands for 30 seconds in warm, soapy water or use hand sanitizer if hands are not visibly soiled.

The nurse is caring for a patient with suspected meningitis. Which action would the nurse recognize as the highest priority immediately following a lumbar puncture procedure?

Encourage oral fluid intake

The nurse working on a medical-surgical unit is assigned as a preceptor to work with a newly hired nurse. Which of the following, if performed first by the newly hired nurse, would indicate the ability to prioritize appropriately?

Obtains capillary blood glucose for a patient receiving continuous regular insulin.

The nurse is participating in a committee with the objective of promoting healthcare justice in the community. Which of the following recommendations should the nurse make to achieve the goal?

Offering free telehealth offerings in underserved areas of the community

At 25 weeks gestation, a pregnant client presents with a uterine growth size less than expected, absence of fetal ballottement and an easily palpable fetus. What is this likely related to the development of?

Oligohydramnios

The nurse is helping a patient with a chest tube ambulate to the bathroom. The patient turns suddenly and the chest tube becomes dislodged. Which of the following is the priority nursing action?

Place a sterile dressing taped on three sides over the chest tube site and call for help.

The nurse is caring for a patient who is experiencing acute mania. Which of the following actions should be prioritized by the nurse?

Provide high-calorie, small, frequent meals

The nurse is caring for assigned patients. The nurse should recognize that the patient at greatest risk for postpartum hemorrhage (PPH) is the patient who has which of the following?

Uterine atony and delivered with the assistance of forceps

A client with a history of falls is admitted to the medical-surgical unit. The nurse should plan to implement which intervention to reduce this client's risk of falling?

Verify that the bed alarm is enabled during client rounding.

When orienting an older patient to his hospital room's safety measures, what is the admission routine's priority component?

explain how to work the call light

The nurse observes sparks fly from a client's bathroom light. Which action should the nurse take first?

remove client from the room

The nurse reviews newly prescribed medications from the primary healthcare provider (PHCP). The nurse understands that the prescribed etanercept is intended to treat which condition?

rheumatoid arthritis

Which nursing diagnosis would be the highest priority for a patient with a medical diagnosis of Bell's palsy?

risk for disturbed sensory perception

Which stage of cognitive development does the nurse expect her 6-month-old patient to be in?

sensorimotor piaget's stages

The nurse is caring for an infant following a cheiloplasty. Which supply item should the nurse have at the bedside following this procedure?

suction equipment

The licensed practical/vocational nurse (LPN/VN) cares for assigned clients. The LPN/VN should initially follow up on the client

taking lithium that reports nausea and vomiting.

A client presents to the emergency department (ED) with a suspected ectopic pregnancy. The nurse anticipates which diagnostic test will confirm this finding?

transvaginal ultrasound

The nurse is assessing a child for physical abuse. Which finding would require follow-up?

unexplained bruising