nclex

An hour and a half after admission to the nursery, the nurse observes spontaneous jerky movements of the limbs in an infant born to a mother with gestational diabetes mellitus (GDM). The nurse suspects the infant is experiencing which condition? 1. Cold stress. 2. Hyperbilirubinemia. 3. Hypoglycemia. 4. Neurological impairment.

1

Which situation suggests a nurse is addicted to the use of alcohol or habit-forming medications? 1. The nurse cannot be found on the unit for half an hour during an assigned shift. 2. The nurse questions a client about pain before administering a narcotic analgesic. 3. The nurse volunteers to "float" to another unit at the hospital. 4. The nurse questions a client's medication order left by a health care provider.

1

The client hospitalized for treatment of a bleeding peptic ulcer reports substernal chest pain. The nurse finds the client diaphoretic and cool with vital signs: BP 110/56, T 98.4º F (36.8º C), P 76, R 28. The client's IV of 0.9% NaCl infuses at 80 mL/hr. Lab results show potassium 3.2 mEq/L (3.2 mmol/L), sodium 140 mEq/L (140 mmol/L), and chloride 93 mEq/L (93 mmol/L). Cardiac monitoring shows multifocal premature ventricular contractions (PVCs). The nurse identifies which condition is the most likely cause of the client's PVCs?

1. Hyponatremia. 2. Hypoxemia. 3. Hypokalemia. 4. Hypovolemia.

The nurse cares for a client diagnosed with primary adrenocortical insufficiency. The nurse expects to observe which laboratory finding? 1. Increased sodium and glucose; decreased potassium. 2. Decreased sodium and glucose; increased potassium. 3. Increased sodium and potassium; decreased glucose. 4. Decreased sodium and potassium; increased glucose.

2

The nurse cares for four clients. Which client does the nurse see first? 1. A 4-year-old child with pneumonia who has a temperature of 101° F (38.3° C). 2. A 5-year-old child with croup who has respirations of 35. 3. A 2-year-old child two days after surgical repair of a strangulated abdominal hernia. 4. A 3-year-old child receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC).

2

The parent brings the preschooler to the clinic for a routine check up. The parent claims that the child fears "monsters" and "bogeymen" in the bedroom at night. Which statement by the parent indicates the parents are dealing with their child's fears appropriately? 1. They let the child sleep with them occasionally. 2. They leave a night light on in the child's room. 3. They reassure the child there are no such things as monsters and bogeymen. 4. They tell the child these fears will go away.

2

The nurse teaches the client about ferrous sulfate. Which statement by the client indicates to the nurse that the client understands the education? 1. "I should take this medication when I take my antacid." 2. "I should take this medication with orange juice." 3. "I should increase my intake of foods that contain calcium." 4. "I should take this medication at bedtime."

3

The registered nurse observes the nursing student insert a urinary catheter in a preschool-age child. Which action, if observed by the nurse, requires an intervention? 1. The nursing student wipes around the circumference of the labia using a sterile cotton ball. 2. The nursing student selects a #10 French catheter. 3. The nursing student spreads the labia minora in an anterior direction. 4. The nursing student inserts the catheter 1-inch into the urethra.

3

The home health nurse changes dressings four times a week for the client diagnosed with a stage III pressure ulcer. The hospital admitting nurse notes that the dressing was not applied as ordered. Which action is most important for the nurse to take? 1. Contact the home health supervisor to report the discrepancy. 2. Contact the home health nurse who has been caring for the client to report the discrepancy. 3. Contact the nursing supervisor in the hospital to report the discrepancy. 4. Document the discrepancy between what was ordered and the condition of the dressing.

4

The nurse develops a care plan for a client diagnosed with acute phase rheumatoid arthritis. The nurse understands that which goal of nursing care is primary? 1. Reduce the client's pain and inflammation. 2. Help the client adjust to changes in self-concept. 3. Maintain optimal joint mobility and prevent further deformity. 4. Promote increased activity tolerance.

4

The adolescent client had surgery yesterday for repair of a torn rotator cuff in the right shoulder. Although fentanyl 100 mcg intravenously is ordered every 3 hours PRN, the client has refused the medication since surgery. During morning rounds, the nurse notes the client has teeth clenched and is diaphoretic. Which action does the nurse take first?

Administer the fentanyl 100 mcg intravenously as ordered. 2. Explain that taking medication will not lead to medication addiction. 3. Question the client, "Are you experiencing any pain?" 4. Ask the client, "Why have you refused pain medication?"

The nurse cares for the client diagnosed with Ménière's disease. Which signs and symptoms does the nurse expect the client to exhibit?

charge from the ear, pain, and conductive deafness. 2. Vertigo, tinnitus, and neurosensory hearing loss. 3. Fever, ear noises, and headache. 4. Severe headache, enlarged lymph nodes, and chills.