nclex fundamentals

A primary health care provider's prescription reads "cyanocobalamin 100 mcg intramuscular." The medication label reads "cyanocobalamin, 0.5 mg/mL." The nurse administers how many milliliters to the client? Fill in the blank. Record the answer to one decimal place.

0.2 mL

The nurse is caring for a postoperative client who has a Jackson-Pratt drain inserted into the surgical wound. Which actions should the nurse take in the care of the drain? Select all that apply. 1.Check the drain for patency. 2.Check that the drain is decompressed. 3.Observe for bright red, bloody drainage. 4.Maintain aseptic technique when emptying. 5.Empty the drain when it is half full and every 8 to 12 hours. 6.Secure the drain by curling or folding it and taping it firmly to the body.

1.Check the drain for patency. 4.Maintain aseptic technique when emptying. 5.Empty the drain when it is half full and every 8 to 12 hours.

Which cardiovascular sign should the nurse expect to note in a client with a diagnosis of hypocalcemia? 1.Hypotension 2.Increased heart rate 3.Bounding peripheral pulses 4.Shortened QT interval on electrocardiogram (ECG)

1.Hypotension

A client is admitted to the hospital with a diagnosis of suspected myocardial infarction (MI). The nurse is reviewing the laboratory results performed on the client. Which documented laboratory result specifically indicates the presence of an MI? 1.Increased creatine kinase (CK-MB) 2.Increased creatine kinase (CK-MM) 3.Increased blood urea nitrogen (BUN) 4.Decreased white blood cell (WBC) count

1.Increased creatine kinase (CK-MB) Rationale:The creatine kinase (CK-MB) is most specific in determining the presence of an MI. The creatinine kinase (CK-MM) reflects injury to the skeletal muscle. The white blood cell count is most likely elevated in the client with an MI. The blood urea nitrogen is unrelated to this disorder.

The nurse is reinforcing teaching to a client about an upcoming colonoscopy procedure. The nurse should include in the instructions that the client will be placed in which position for the procedure? 1.Left Sims' position 2.Lithotomy position 3.Knee-chest position 4.Right Sims' position

1.Left Sims' position

In preparing to care for a hospitalized child with a diagnosis of measles (rubeola), which supplies should the nurse bring to the child's room to prevent the transmission of the virus? 1.Mask and gloves 2.Gown and gloves 3.Goggles and gloves 4.Gown, gloves, and goggles

1.Mask and gloves

A client presents to the emergency department with lethargy; deep, regular respirations; and a fruity odor to the breath. The client's arterial blood gas (ABG) results are pH of 7.25, Pco2 of 34 mm Hg, Po2 of 86 mm Hg, and HCO3- of 14 mEq/L. The nurse interprets that the client has which acid-base disturbance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

1.Metabolic acidosis

A client who had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply.

1.Notify the registered nurse. 2.Document the client's complaint. 3.Instruct the client to remain quiet. 4.Prepare the client for wound closure.

The nurse is caring for a client who has a wound infection. Contact precautions are being followed. Which are correct actions by the nurse when using personal protective equipment (PPE)? Select all that apply. 1.Perform hand hygiene after removal of PPE. 2.Perform hand hygiene before donning any PPE. 3.When removing PPE, always remove gloves first. 4.Gloves should be applied under the sleeves of the gown. 5.Leaving the room wearing PPE for several minutes is permissible. 6.Protective eyewear and face shield are indicated if there is risk of splatter.

1.Perform hand hygiene after removal of PPE. 2.Perform hand hygiene before donning any PPE. 3.When removing PPE, always remove gloves first. 6.Protective eyewear and face shield are indicated if there is risk of splatter.

Which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq/L (2.7 mmol/L)? 1.U waves 2.Flat P waves 3.Elevated T waves 4.Prolonged PR interval

1.U waves

The nurse reviews an assigned client's laboratory report and notes a serum potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse should determine that this is an expected finding if the client had which health problems? Select all that apply. 1.Diarrhea 2.Ulcerative colitis 3.Severe burn injury 4.Cushing's syndrome 5.Untreated ketoacidosis

2,3,5

Intravenous (IV) lactated Ringer's (LR) solution is prescribed for a postoperative abdominal surgery client. A nursing student is caring for the client, and the nursing instructor asks the student about why this IV solution is prescribed. Which student response is correct? 1."The prescribed solution is hypotonic." 2."LR is isotonic to plasma and contains electrolytes" 3."This solution will help prevent further fluid losses." 4."Hypertonic fluids, such as LR, help replace fluid loss from surgery."

2."LR is isotonic to plasma and contains electrolytes"

The nurse is preparing to initiate a tube feeding for a client and the primary health care provider has prescribed that the feeding be infused at 50 mL per hour. The nurse brings an electronic feeding pump to the bedside and discovers that there is no available outlet in the wall socket to plug the pump into. Which action should the nurse implement? 1.Initiate the feeding without the use of a pump. 2.Contact the electrical maintenance department for assistance. 3.Use an extension cord from the nurse's lounge for the pump plug. 4.Plug the pump cord into the available outlet above the room sink.

2.Contact the electrical maintenance department for assistance.

A client is scheduled for an oral cholecystography. The nurse should plan to obtain what type of diet for the evening meal before the test? 1.Liquid 2.Fat-free 3.Low-protein 4.High-carbohydrate

2.Fat-free

A client is to be monitored for residual urine every 8 hours. Which are appropriate nursing actions for the nurse to complete this task? Select all that apply. 1.Obtain the bladder scan before the client voids. 2.Have the client void and then perform the bladder scan. 3.If residual urine is less than 100 mL, continue to monitor. 4.Reduce oral fluid intake to decrease amount of residual urine. 5.Straight catheterize the client if 100 mL of urine is viewed on the scan. 6.Notify the primary health care provider immediately if 30 mL of urine is viewed on the scan.

2.Have the client void and then perform the bladder scan. 3.If residual urine is less than 100 mL, continue to monitor.

The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit after abdominal surgery. The client has an indwelling urinary catheter in place. The vital signs are temperature 99.6° F (37.6° C), pulse 104 beats per minute, respirations 16 breaths per minute, and blood pressure (BP) 100/70 mm Hg. Urinary output is 20 mL for the past hour. Based on this data, which actions should the nurse take before notifying the registered nurse? Select all that apply. 1.Auscultate breath sounds. 2.Review vital signs from previous hour. 3.Observe the urinary catheter for patency and flow. 4.Observe the IV site for patency and correct flow rate. 5.Review when the client last received pain medication.

2.Review vital signs from previous hour. 3.Observe the urinary catheter for patency and flow. 4.Observe the IV site for patency and correct flow rate. 5.Review when the client last received pain medication.

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is most important to provide to the client? 1."Herbal substances are not safe and should never be used." 2."I will teach you how to take your blood pressure so that it can be monitored closely." 3."You will need to talk to your primary health care provider (PHCP) before using an herbal substance." 4."If you take an herbal substance, you will need to have your blood pressure checked frequently."

3."You will need to talk to your primary health care provider (PHCP) before using an herbal substance."

The nurse is reinforcing instructions to a client about safety measures while using oxygen in the home. The nurse determines that there is a need for further teaching if the client verbalized which statement? 1.Follow the oxygen prescription exactly. 2.Use a straight razor to shave while wearing the oxygen. 3.Keep the oxygen concentrator as close to the room wall as possible. 4.Forbid smoking or open flames within 10 feet of the oxygen source.

3.Keep the oxygen concentrator as close to the room wall as possible.

The nurse is assisting to admit a client with a diagnosis of acute Guillain-Barré syndrome. The nurse knows that if the disease progresses to a severe level, the client will be at risk for which acid-base imbalance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

3.Respiratory acidosis

A health care provider prescribes 1000 mL of normal saline 0.9% to infuse over 8 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Record your answer to the nearest whole number.

31

A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client? 1.Soft custard 2.Orange juice 3.Clam chowder 4.Fat-free beef broth

4.Fat-free beef broth

The nurse is caring for a client whose magnesium level is 3 mEq/L (1.5 mmol/L) and the client is being treated for the magnesium imbalance. The nurse interprets that the electrolyte imbalance is resolving if which signs or symptoms are no longer present? Select all that apply. 1.Tetany 2.Twitches 3.Chest pain 4.Hypotension 5.Muscular excitability 6.Loss of deep tendon reflexes

4.Hypotension 6.Loss of deep tendon reflexes

The nurse is explaining the concept of a time-out in the perioperative area. Which statement best describes the purpose of a time-out? 1.To give the client an opportunity to refuse the operative procedure 2.To provide a quiet time for the nurse to discuss discharge instructions with the client 3.To give the surgeon an opportunity to discuss the surgery and potential complications with the client 4.To allow the surgical team a chance to verbally verify its agreement about the client's name, the surgical procedure, and the site

4.To allow the surgical team a chance to verbally verify its agreement about the client's name, the surgical procedure, and the site

A client is admitted to the hospital with a fever and extreme weakness. Which laboratory studies are likely to be elevated if the client is experiencing an infection? Select all that apply. 1.Hematocrit 2.Hemoglobin 3.Red blood cell count 4.White blood cell count (WBC) 5.Erythrocyte sedimentation rate (ESR)

4.White blood cell count (WBC) 5.Erythrocyte sedimentation rate (ESR)

A client is to receive 1000 mL of 5% dextrose in water at a rate of 125 mL/hr. The drop (gtt) factor is 10 drops (gtt)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

8

The nurse is caring for a client who is receiving an intermittent feeding via a nasogastric (NG) tube. Before feeding the client via the NG tube, the nurse should take which actions? Select all that apply. 1.Check the client's temperature. 2.Check the placement of the tube. 3.Administer prescribed medications. 4.Warm the feeding to body temperature. 5.Aspirate the contents from the nasogastric tube. 6.Observe the characteristics and pH of the aspirate from the nasogastric tube.

Check the placement of the tube. Aspirate the contents from the nasogastric tube. Observe the characteristics and pH of the aspirate from the nasogastric tube.

A client is in respiratory alkalosis induced by gram-negative sepsis. The nurse assists in implementing which measure as the effective means to treat the problem? 1.Administer prescribed antibiotics. 2.Have the client breathe into a paper bag. 3.Administer prescribed as-needed (PRN) antipyretics. 4.Request a prescription for a partial rebreather oxygen mask.

1.Administer prescribed antibiotics.

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would suggest to the registered nurse the need for implementing neutropenic precautions if the client's white blood cell count was which value? 1.2000 mm3 (2.0 × 109/L) 2.5800 mm3 (5.8 × 109/L) 3.8400 mm3 (6.4 × 109/L) 4.11,500 mm3 (11.5 × 109/L)

1.2000 mm3 (2.0 × 109/L)

A client has returned to the nursing unit following abdominal hysterectomy. To gather data on the client's postoperative bleeding, the nurse should implement which interventions? Select all that apply. 1.Observing perineal pad drainage 2.Observing the abdominal dressing 3.Rolling the client to one side to view bedding 4.Monitoring output from the Jackson-Pratt drain 5.Auscultation of bowel sounds, especially lower quadrants 6.Observing for abdominal distention and presence of ecchymosis

1.Observing perineal pad drainage 2.Observing the abdominal dressing 3.Rolling the client to one side to view bedding 4.Monitoring output from the Jackson-Pratt drain

The nurse is reinforcing instructions to a Native-American client regarding the procedure for collecting a urine sample. The nurse observes that the client continually stares at the floor during the instructional session. The nurse interprets this as being indicative of which behavior? 1.Rudeness 2.Disinterest 3.Attentiveness 4.Embarrassment

3.Attentiveness

The nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which interventions should be included to accurately administer the medication? Select all that apply.

Clamp the NG tube for 30 minutes after medication administration. Before medication administration, verify correct placement of tube. Flush the NG tube with saline before and after medication administration. Discontinue the suction from the tube during administration of medication.

The nurse is told in a report that the client has hypocalcemia. Which signs should the nurse expect to note during the data collection? Select all that apply. 1.Coma 2.Tetany 3.A positive Chvostek's sign 4.Hypoactive bowel sounds 5.A positive Trousseau's sign

2.Tetany 3.A positive Chvostek's sign 5.A positive Trousseau's sign

The nurse is caring for a client with cirrhosis who is experiencing fluid overload. The nurse would determine that this problem is resolving if which data are obtained? Select all that apply. 1.Increasing pulse 2.Decreasing body weight 3.Decreasing urine output 4.Decreasing abdominal girth 5.Increasing central venous pressure

2.Decreasing body weight 4.Decreasing abdominal girth

The nurse should plan to reinforce instructions to which clients about the risk for transmission of disease through blood and sexual contact? Select all that apply. 1.A client diagnosed with hepatitis A virus 2.A client diagnosed with hepatitis B virus 3.A client diagnosed with hepatitis C virus 4.A client diagnosed with Rocky Mountain spotted fever 5.A client with a wound infection with Staphylococcus aureus 6.A client diagnosed with human immunodeficiency virus (HIV)

2.A client diagnosed with hepatitis B virus 3.A client diagnosed with hepatitis C virus 6.A client diagnosed with human immunodeficiency virus (HIV)

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin (aPTT) time is 65 seconds. The licensed practical nurse reviews the laboratory results with the registered nurse, anticipating that which action is needed? 1.Discontinuing the heparin infusion 2.Increasing the rate of the heparin infusion 3.Decreasing the rate of the heparin infusion 4.Leaving the rate of the heparin infusion as is

4.Leaving the rate of the heparin infusion as is

When positioning for a surgical procedure, the nurse understands that the client's respiratory system is most at risk for dysfunction in which position? 1.Sims' 2.Supine 3.Lateral 4.Lithotomy

4.Lithotomy

The nurse is caring for a client with kidney failure. The laboratory results reveal a magnesium level of 3.6 mEq/L (1.8 mmol/L). Which sign should the nurse expect to note in the client, based on this magnesium level? 1.Twitching 2.Irritability 3.Hyperactive reflexes 4.Loss of deep tendon reflexes

4.Loss of deep tendon reflexes

The nurse caring for a male client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's laboratory results and notes a hematocrit level of 30%. Which action should the nurse take? 1.Report the abnormally low level. 2.Report the abnormally high level. 3.Inform the client that the laboratory result is normal. 4.Place the normal report in the client's medical record.

1.Report the abnormally low level.

The nurse will perform a sterile dressing change after removing the old dressing with clean gloves. The nurse removes the gloves, uses alcohol-based hand sanitizer to perform hand hygiene, and prepares to perform open sterile gloving. The nurse removes the gloves from the outer package. The nurse is right-handed. The nurse opens the inner wrapper and flattens the wrapper to expose the gloves. Which is the next action the nurse takes when donning sterile gloves? 1.Insert left hand into left glove. 2.Insert right hand into right glove. 3.Place gloved right hand under the cuff of left glove. 4.Pick up right glove at cuff with left thumb and forefinger.

4.Pick up right glove at cuff with left thumb and forefinger.

The nurse is assigned to care for a client experiencing episodes of postural hypotension who will be discharged home soon. Which actions should the nurse take to ensure safety while transferring the client from the bed to the chair? Select all that apply. 1.Arrange for a transfer board to be used. 2.Perform the transfer using a hydraulic lift only. 3.Question the client about feelings of dizziness. 4.Put the client's shoes on to help the client avoid slipping on the floor during the transfer. 5.Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

3.Question the client about feelings of dizziness. 4.Put the client's shoes on to help the client avoid slipping on the floor during the transfer. 5.Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.