NCLEX-PN Comprehensive Test

The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response by the student indicates an understanding of this physiological process? 1. "Ovulation ceases during pregnancy because the circulating levels of estrogen & progesterone are high" 2. Ovulation ceases during pregnancy because the circulating levels of estrogen & progesterone are low" 3. "The low levels of estrogen & progesterone increases the release of follic stimulating hormone & luteinizing hormone" 4. "The high levels of estrogen & progesterone promote the release of follic stimulating hormone & luteinizing hormone"

1. "Ovulation ceases during pregnancy because the circulating levels of estrogen & progesterone are high"

On data collection, which behavior should the nurse expect a client diagnosed with agoraphobia to describe? 1. A fear of leaving the house 2. A fear of riding in elevators 3. A fear of speaking in public 4. A fear of uncleanliness & the need to bathe every hr

1. A fear of leaving the house

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note in this client? Select all that apply 1. Hypocapnia 2. Dyspnea on exertion 3. Presence of a productive cough 4. Difficulty breathing while talking 5. Increased oxygen saturation with exercise 6. A shortened expiratory phase of respiration

2. Dyspnea on exertion 3. Presence of a productive cough 4. Difficulty breathing while talking

In planning activities for the depressed client, especially during the early stages of hospitalization, which is best? 1. Plan nothing until the client asks to participate in the milieu 2. Encourage the client to participate in a structured daily program of activities 3. Give the client a menu of daily activities & insist that the client participate in all activities offered 4. Provide an activity that is quiet & solitary in nature to avoid increased fatigue, such as drawing or reading a book

2. Encourage the client to participate in a structured daily program of activities

A depressed client verbalizes feelings of low self-esteem & self worth typified by statements such as "i'm such a failure. I cant do anything right!" Which action should the nurse take? 1. Tell the client that this is not true & that we all have a purpose in life 2. Remain with the client & sit in silence until the client verbalizes feelings 3. Identify recent behaviors or accomplishments that demonstrate skill or ability 4. Reassure the client that you know how the client is feeling & that things will get better

3. Identify recent behaviors or accomplishments that demonstrate skill or ability

A client who has begun taking fosinopril (Monopril) is very distressed, telling the nurse that he cannot taste food normally since beginning the medication 2 weeks ago. Which suggestion would provide the best support for the client? 1. Tell the client not to take the medication with food 2. Suggest that the client taper the dose until taste returns to normal 3. Inform the client that impaired taste is expected & generally disappears in 2 to 3 months 4. Tell the client that a request will be made to the health care provider (HCP) to change the prescription

3. Inform the client that impaired taste is expected & generally disappears in 2 to 3 months

The nurse should expect to note which interventions in the plan of care for a client with hypothyroidism? Select all that apply 1. Provide a cool environment for the client 2. Instruct the client to consume a high fat diet 3. Instruct the client about thyroid replacement therapy 4. Encourage the client to consume fluids & high fiber foods in the diet 5. Inform the client that iodine preparations will be prescribed to treat the disorder 6. Instruct the client to contact the health care provider if episodes of chest pain occur

3. Instruct the client about thyroid replacement therapy 4. Encourage the client to consume fluids & high fiber foods in the diet 6. Instruct the client to contact the health care provider if episodes of chest pain occur

The nurse is caring for a newborn diagnosed with down syndrome. The parents are asking questions about the disorder. The nurse should provide which information when discussing down syndrome? 1. The condition is characterized by above average intellectual functioning with deficits in adaptive behavior 2. The condition is characterized by average intellectual functioning & the absence of deficits in adaptive behavior 3. The condition is characterized by subaverage intellectual functioning with the absence of deficits in adaptive behavior 4. The condition is congenital & results in moderate to severe retardation & has been linked to an extra chromosome 21 (group G)

4. The condition is congenital & results in moderate to severe retardation & has been linked to an extra chromosome 21 (group G)

The nurse is preparing to administer 35 mg of a prescribed intramuscular (IM) dose of medication to a client. The medication label reads 50 mg/mL. How many milliliters should the nurse administer to the client? Fill in the blank _______mL

0.7 mL

The nurse is assisting in collecting data on a child with seizures. The nurse is interviewing the child's parents to establish their adjustments to caring for their child with a chronic illness. Which statement by the parents indicates a need for further teaching? 1. "Our child sleeps in our bedroom at night" 2. "We worry about injuries when our child has a seizure" 3. "Our child is involved in a swim program with neighbors & friends" 4. "Our babysitter just completed first aid & child resuscitation training"

1. "Our child sleeps in our bedroom at night"

A client asks the nurse about the cause of acne. The nurse should respond by making which statement to the client? 1. "It is caused by oily skin" 2. "The exact cause of acne is not known" 3. "It is caused as a result of exposure to heat & humidity" 4. "Acne is caused by eating chocolate, nuts, & fatty foods"

2. "The exact cause of acne is not known"

A client received 20 units of NPH insulin subcutaneously at 8:00 am. The nurse should check the client for a potential hypoglycemic reaction at which time? 1. 5:00 pm 2. 10:00 am 3. 11:00 am 4. 11:00 pm

1. 5:00 pm

The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? Select all that apply 1. Apply disposable gloves 2. Place the client in the right Sim's position 3. Lubricate the enema tube & insert it approximately 4 in 4. Clamp the tubing if the client expresses discomfort during the procedure 5. Hang the container containing the enema solution 24 in above the client's anus 6. Ensure that the temperature of the solution is between 100 F (37.8 C) & 105 F (40.5 C)

1. Apply disposable gloves 3. Lubricate the enema tube & insert it approximately 4 in 4. Clamp the tubing if the client expresses discomfort during the procedure 6. Ensure that the temperature of the solution is between 100 F (37.8 C) & 105 F (40.5 C)

The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should the nurse perform for this procedure? Select all that apply. 1. Apply suction for up to 10 to 15 seconds 2. Hyperoxygenate the client before suctioning 3. Set the wall suction unit pressure at 160 mm Hg 4. Apply suction while gently inserting the catheter 5. Apply intermittent suction while rotating and withdrawing the catheter 6. Advance the catheter until resistance is met and then pull the catheter back 1 cm

1. Apply suction for up to 10 to 15 seconds 2. Hyperoxygenate the client before suctioning 5. Apply intermittent suction while rotating and withdrawing the catheter 6. Advance the catheter until resistance is met and then pull the catheter back 1 cm

The nurse is assisting in caring for a client who has a placenta previa. The nurse understands that a cervical examination should not be performed on the client primarily because it could do which? 1. Cause hemorrhage 2. Initiate premature labor 3. Rupture the fetal membranes 4. Increase the chance of infection

1. Cause hemorrhage

The nurse has reinforced instructions to a client with tuberculosis about proper handling & disposal of respiratory secretions. The nurse determines that the client understands the instructions if the client verbalizes to take which measure? 1. Discard used tissue in a plastic bag 2. Wash hands at least 4 times a day 3. Brush teeth & rinse the mouth once a day 4. Turn the head to the side if coughing or sneezing

1. Discard used tissue in a plastic bag

The nurse prepares to administer a prescribed dose of scopolamine (Transderm-Scop). The nurse should monitor for which side effect of this medication? 1. Dry mouth 2. Diaphoresis 3. Excessive urination 4. Pupillary constriction

1. Dry mouth

A postoperative client has a prescription to receive an intravenous (IV) infusion of 1000 mL normal saline solution over a period of 10 hours. The drop (gtt) factor for the IV infusion set is 15 gtts/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank _______gtts/min

25 gtts/min

The nurse is assigned to care for an adult client who had a stroke & is aphasic. Which interventions should the nurse use for communicating with the client? Select all that apply. 1. Face the client when talking 2. Speak slowly & maintain eye contact 3. Use gestures when talking to enhance words 4. Avoid the use of body language when talking to the client 5. Give the client directions using short phrases & simple terms 6. Phrase what was said differently the second time, if there is a need to repeat it

1. Face the client when talking 2. Speak slowly & maintain eye contact 3. Use gestures when talking to enhance words 5. Give the client directions using short phrases & simple terms

The nurse is preparing to administer digoxin (Lanoxin), 0.125 mg orally, to a client with heart failure. Which vital sign is most important for the nurse to check before administering the medication? 1. Heart rate 2. Temperature 3. Respirations 4. Blood pressure

1. Heart rate

To ensure a safe environment for a child admitted to the hospital for a crainotomy to remove a brain tumor, the nurse should include which in the plan of care 1. Initiating seizure precautions 2. Using a wheelchair for out of bed activities 3. Assisting the child with ambulation at all times 4. Avoiding contact with other children on the nursing unit

1. Initiating seizure precautions

The nursing student is asked to discuss the topic of clubfoot at a clinical conference. The student plans to tell the group which fact about clubfoot? 1. It is a congenital anomaly 2. It always occurs bilaterally 3. It affects girls more often than boys 4. It is a rare deformity of the skeletal system

1. It is a congenital anomaly

The nurse is reinforcing discharge instructions to a client receiving sulfisoxazole. Which should be included in the plan of care for instructions? 1. Maintain a high fluid intake 2. Discontinue the medication when feeling better 3. If the urine turns dark brown, call the health care provider immediately 4. Decrease the dosage when symptoms are improving to prevent an allergic response

1. Maintain a high fluid intake

A client enters the emergency department confused, twitching, & having seizures. His family states he recently was placed on corticosteroids for arthritis & was feeling better & exercising daily. Upon assessment, he has flushed skin, dry mucous membranes, an elevated temperature, & poor skin turgor. His serum sodium level is 172 mEq/L. Which interventions would the health care provider likely prescribe? select all that apply. 1. Monitor the vital signs 2. Monitor intake & output 3. Increase water intake orally 4. Monitor the electrolyte levels 5. Provide a sodium-reduced diet 6. Administer sodium replacements

1. Monitor the vital signs 2. Monitor intake & output 3. Increase water intake orally 4. Monitor the electrolyte levels 5. Provide a sodium-reduced diet

A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, & seems to display increased anger. The nurse should make which interpretation about the clients behavior? 1. The client is at increased risk for suicide 2. The client is dealing with pertinent issues 3. The client may need some time off the unit 4. The client is responding normally to hospitalization

1. The client is at increased risk for suicide

The nurse should implement which in the care of a child who is having a seizure? Select all that apply. 1. Time the seizure 2 Restrain the child 3. Stay with the child 4. Insert an oral airway 5. Place the child in a supine position 6. Loosen clothing around the child's neck

1. Time the seizure 3. Stay with the child 6. Loosen clothing around the child's neck

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

1. U waves

The nurse reinforces instructions to the client about breast self examination (BSE). The nurse instructs the client to lie down & examine the left breast. Which is the correct area for placing a pillow when examining the left breast? 1. Under the left shoulder 2. Under the right scapula 3. Under the right shoulder 4. Under the small of the back

1. Under the left shoulder

A health care provider prescribes potassium chloride (KCI) elixir, 20 mEq orally daily. The medication label states potassium chloride (KCI), 30 mEq/15 mL. How many milliliters should the nurse prepare to administer the dose? ______mL

10 mL

The nurse is asked to regulate the flow rate of an intravenous (IV) solution being administered to a client. The IV bag contains 50 mL of solution & the solution is to be administered over 30 minutes. The administration set has a drop factor of 10 drops (gtt)/mL. The nurse should regulate the roller clamp on the infusion set to deliver how many drops per minute? Round answer to the nearest whole number. ________gtts/min

17 gtts/min

The nurse is assigned to care for a child with a compound (open) fracture of the arm that occurred as a result of a fall. The nurse plans care knowing that this type of fracture involves which specific characteristic? 1. The entire bone fractured straight across 2. A greater risk of infection than a simple fracture 3. The bone being fractured but not producing a break in the skin 4. One side of the bone being broken & the other side being bent

2. A greater risk of infection than a simple fracture

The nurse is caring for a client dying of ovarian cancer. During care, the client states "if i can just live long enough to attend my daughter's graduation, I'll be ready to die." Which phase of coping is this client experiencing? 1. Anger 2. Denial 3. Bargaining 4. Depression

3. Bargaining

The nurse is preparing a 2 year old child with suspected nephrotic syndrome for a renal biopsy to confirm the diagnosis. The mother asks the nurse, "will my child ever look thin again?" The nurse should respond by giving which statement? 1. "Do you feel guilty about your child's weight gain?" 2. "In most cases, medication & diet will control fluid retention" 3. " Wearing loose fitting clothing should help conceal the extra weight" 4. When children are little, it's expected that they'll look a little chubby"

2. "In most cases, medication & diet will control fluid retention"

The nurse is calculating a clients 24 hr fluid intake. The client consumed coffee (8oz), water (8oz), & orange juice (6oz) for breakfast; soup (4oz), & iced tea (8oz) for lunch; & milk (10oz), tea (8oz), and water (8oz) for dinner. The client also consumed 24oz of water during the day. How many milliliters of fluid did the client consume in the 24 hr period? Fill in the blank ________mL

2,520 mL

The nursing instructor asks a student to describe the pathophysiology that occurs in the Cushing's disease. Which statement by the student indicates an accurate understanding of this disorder? 1. "Cushing's disease is characterized by an oversecretion of insulin" 2. "Cushing's disease is characterized by an oversecretion of glucocorticoid hormones" 3. "Cushing's disease is characterized by an undersecretion of corticotropic hormones" 4. "Cushing's disease is characterized by an undersecretion of glucocorticoid hormones"

2. "Cushing's disease is characterized by an oversecretion of glucocorticoid hormones"

A client has just had a cast removed & the underlying skin is yellow brown & crusted. The nurse determines that further skin care instructions are required if the client makes which statement? 1. "I will soak the skin & then wash it gently" 2. "I need to scrub the skin vigorously with soap & water" 3. "I need to apply an emollient lotion to enhance softening" 4. "I need to use a sunscreen on the skin if it will be directly exposed to the sun"

2. "I need to scrub the skin vigorously with soap & water"

A 4 year old child is admitted to the hospital with suspected acute lymphocytic leukemia (ALL). The nurse understands that which diagnostic study should confirm this diagnosis? 1. A platelet count 2. A lumbar puncture 3. Bone marrow biopsy 4. White blood cell (WBC) count

3. Bone marrow biopsy

The nurse is planning to administer amlodipine (Norvasc) to a client. The nurse should plan to check which before giving the medication? 1. Respiratory rate 2. Blood pressure & heart rate 3. Heart rate & respiratory rate 4. Level of consciousness & blood pressure

2. Blood pressure & heart rate

A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, should offer which during an episode of nausea? 1. Low-calorie foods 2. Cool, clear liquid 3. Low-protein foods 4. The child's favorite foods

2. Cool, clear liquid

The nurse is assisting in identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? 1. Children in daycare centers 2. Individuals with spina bifida 3. Individuals with cardiac disease 4. Individuals living in a group home

2. Individuals with spina bifida

The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations? Select all that apply 1. Use a dry table that is below waist level 2. Open the distal flap of a sterile package first 3. Prepare the sterile field just before the planned procedure 4. Don clean gloves before touching items on the sterile field 5. Place the sterile field 1 foot behind the working area & out of view of the client 6. Avoid placing items within 1 in of any area surrounding the outer edge of the sterile field

2. Open the distal flap of a sterile package first 3. Prepare the sterile field just before the planned procedure 6. Avoid placing items within 1 in of any area surrounding the outer edge of the sterile field

Which data would indicate a potential complication associated with age-related changes in the musculoskeletal system? 1. Decrease in height 2. Overall sclerotic 3. Diminished lean body mass 4. Changes in structural bone tissue

2. Overall sclerotic

A client who has been taking isoniazid for 1 1/2 months complains to the nurse about numbness, paresthesia, & tingling in the extremities. The nurse interprets that the client is experiencing which adverse effect? 1. Hypercalcemia 2. Peripheral neuritis 3. Small blood vessel spasms 4. Impaired peripheral circulation

2. Peripheral neuritis

The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). After administering the medication, the nurse should dispose of the used needle by which method? 1. Asking the client to recap the needle 2. Placing the needle & syringe in a puncture resistant container 3. Recapping the needle before placing it in a ouncture resistant container 4. Laying the needle & syringe on the bedside table & carefully recapping the needle

2. Placing the needle & syringe in a puncture resistant container

A postoperative client requests medication for flatulence (gas pains). Which medication from the following PRN list should the nurse administer to this client 1. Ondansetron (zofran) 2. Simethicone (mylicon) 3. Acetaminophen (tylenol) 4. Magnesium hydroxide ( milk of mag)

2. Simethicone (mylicon)

A client is taking lansoprazole (Prevacid) for the chronic management of Zollinger-Ellison syndrome. If prescribed, which medication would be appropriate for the client if needed for a headache? 1. Naprosyn (Aleve) 2. Ibuprofen (Advil) 3. Acetaminophen (Tylenol) 4. Acetylsalicylic acid (Aspirin)

3. Acetaminophen (Tylenol)

The nurse is monitoring the laboratory results of a client preparing to receive chemotherapy. The nurse determines that the white blood cell count (WBC) is normal if which results is presents? 1. 2000 cells/mm3 2. 3000 cells/mm3 3. 5000 cells/mm3 4. 15,000 cells/mm3

3. 5000 cells/mm3

An adult client with hepatic encephalopathy has a serum ammonia level of 120 mcg/dL & receives treatment with lactulose (Chronulac) syrup. The nurse determines that the client has the best response if the level changes to which after medication administration? 1. 2 mcg/dL 2. 5 mcg/dL 3. 70 mcg/dL 4. 100 mcg/dL

3. 70 mcg/dL

The nurse checks the food on a tray delivered for an orthodox jewish client & notes that the client has received a cheeseburger & potato fries with whole milk as a beverage. Which action should the nurse take? 1. Deliver the food tray to the client 2. Replace the whole milk with lactose free milk 3. Call the dietary department & ask for a different meal 4. Ask the dietary department to replace the beef with pork

3. Call the dietary department & ask for a different meal

The nurse inspects the oral cavity of a client with cancer & notes white patches on the mucous membranes. The nurse interprets this occurrence as which? 1. Common 2. Suggests that the client is anemic 3. Characteristic of a thrush infection 4. Indicative that oral hygiene needs to be improved

3. Characteristic of a thrush infection

A client is brought to the emergency department by the ambulance team after collapse at home. Cardiopulmonary resuscitation is attempted but is unsuccessful. The wife of the client tells the nurse that the client is an organ donor & that his eyes are to be donated. Which action should the nurse take next? 1. Place dry, sterile dressings over the eyes of the deceased 2. Call the National Donor Association to confirm that the client is a donor 3. Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes 4. Ask the wife to obtain the legal documents regarding organ donation from the lawyer

3. Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes

The nurse is caring for an older client who is terminally ill. Which signs indicate to the nurse that death may be imminent? 1. Rubor & warm skin 2. Eupnea & normal body temperature 3. Irregular, noisy breathing & cold, clammy skin 4. Presence of swallowing reflex & active bowel sounds

3. Irregular, noisy breathing & cold, clammy skin

The nurse is assigned to care for an infant with cryptorchidism. The nurse anticipates that diagnostic studies will be prescribed to evaluate which? 1. DNA synthesis 2. Babinski reflex 3. Kidney function 4. Chromosomal analysis

3. Kidney function

A client has been placed in Buck's extension traction. Which technique by the nurse will provide countertraction? 1. Using a footboard 2. Providing an overheard trapeze 3. Slightly elevating the foot of the bed 4. Slightly elevating the head of the bed

3. Slightly elevating the foot of the bed

A client is admitted to the hospital with possible rheumatic endocarditis. The nurse should check for a history of which type of infection? 1. Viral infection 2. Yeast infection 3. Streptococcal infection 4. staphylococcal infection

3. Streptococcal infection

A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is reinforcing instructions to the client regarding the program. Which should the nurse include in the instructions 1. Try to exercise before mealtime 2. Administer insulin after exercising 3. Take a blood glucose test before exercising 4. Exercise should be performed during peak times of insulin

3. Take a blood glucose test before exercising

The nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further teaching? 1. We need to encourage adequate fluid intake 2. Coughing spells may be triggered by dust or smoke 3. We need to maintain respiratory precautions & a quiet environment for at least 2 weeks 4. Good hand-washing techniques need to be instituted to prevent spreading the disease to others

3. We need to maintain respiratory precautions & a quiet environment for at least 2 weeks

The nurse is caring for a client with a diagnosis of pemphigus vulgaris. The nurse understands that which is a characteristic of this condition? 1. Dry skin 2. Hard skin 3. Leathery skin 4. Blistering skin

4. Blistering skin

The nurse is caring for an older client with a diagnosis of myasthenia gravis & has reinforced self care instructions. Which statement by the client indicates a need for further teaching? 1. "I rest each afternoon after my walk" 2. "I cough & deep breathe many times during the day" 3. "If i get abdominal cramps & diarrhea, I should call my doctor" 4. "I can change the time of my medication on the mornings that i feel strong"

4. "I can change the time of my medication on the mornings that i feel strong"

The nurse reinforces medication instructions to a client with peptic ulcer disease. Which statement by the client indicates the best understanding of the medication therapy? 1. "Antacids will coat my stomach" 2. "Omeprazole (Prilosec) will coat the ulcer & help it heal" 3. "Sucralfate (Carafate) will change the fluid in my stomach" 4. "The nizatidine (Axid) will cause me to produce less stomach acid"

4. "The nizatidine (Axid) will cause me to produce less stomach acid"

A client had an aortic valve replacement 2 days ago. This morning the client tells the nurse " I don't feel any better than i did before surgery." Which response by the nurse is most appropriate? 1. "You will feel better in a week or 2" 2. "Its only the second day post op. Cheer up" 3. "This is a normal frustration. It'll get better" 4. "You are concerned that you don't feel any better after surgery"

4. "You are concerned that you don't feel any better after surgery"

The nurse is monitoring a client receiving glipizide (glucotrol). Which outcome indicates an ineffective response from the medication. 1. A decrease in polyuria 2. A decrease in polyphagia 3. A fasting plasma glucose of 100 mg/dL 4. A glycosylated hemoglobin level of 12%

4. A glycosylated hemoglobin level of 12%

A client with chronic kidney disease is receiving ferrous sulfate (Feosol). The nurse should monitor the client for which common side effect associated with this medication? 1. Diarrhea 2. Weakness 3. Headache 4. Constipation

4. Constipation

The nurse reinforces client instructions about ethambutol (Myambutol). The nurse determines that the client understands the instructions if the client indicates to report which occurrence? 1. Impaired sense of hearing 2. Distressing gastrointestinal side effects 3. Orange-red discoloration of body secretions 4. Difficulty discriminating the color red from green

4. Difficulty discriminating the color red from green

The nurse is admitting a client with Guillain Barre syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which items into the client's room? 1. Nebulizer & pulse oximeter 2. Blood pressure cuff & flashlight 3. Flashlight & incentive spirometer 4. Electrocardiographic monitoring electrodes & intubation tray

4. Electrocardiographic monitoring electrodes & intubation tray

The nurse is assisting in preparing a plan of care for a 4 year old child hospitalized with nephrotic syndrome. Which intervention is most appropriate for this child? 1. Provide a high salt diet 2. Provide a high protein diet 3. Discourage visitors at mealtimes 4. Encourage the child to eat in the playroom

4. Encourage the child to eat in the playroom

A client with diabetes mellitus who has been controlled with daily insulin has been placed on atenolol (Tenormin) for the control of angina pectoris. Because of the effects of atenolol, the nurse determines that which is the most reliable indicator of hypoglycemia? 1. Sweating 2. Tachycardia 3. Nervousness 4. Low blood glucose level

4. Low blood glucose level

The nurse is reviewing the health record of a pregnant client at 16 weeks gestation. The nurse should expect to note documentation that the fundus of the uterus is located at which area? 1. At the umbilicus 2. Just above the symphysis pubis 3. At the level of the xiphoid process 4. Midway between the symphysis pubis & the umbilicus

4. Midway between the symphysis pubis & the umbilicus

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 altered nutrition related to poor nutritional intake. Which nursing intervention related to altered nutrition should be the initial choice? 1. Weigh the client three times per week, before breakfast. 2. Explain to the client the importance of a good nutritional intake 3. Report the nutritional concern to the psychiatrist & obtain a nutritional consult as soon as possible 4. Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times

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

A mother is breastfeeding her newborn. The mother complains to the nurse that she is experiencing severe nipple soreness. The nurse should provide which suggestion to the client? 1. Avoid rotating breastfeeding positions so that the nipple will toughen 2. Stop nursing during the period of nipple soreness to allow the nipples to heal 3. Nurse the newborn infant less frequently & substitute a bottle feeding until the nipples become less sore 4. Position the newborn infant with the ear, shoulder, and hip in straight alignment & with the baby's stomach against the mother

4. Position the newborn infant with the ear, shoulder, and hip in straight alignment & with the baby's stomach against the mother

The nurse is caring for a postoperative client who has been NPO & the health care provider has prescribed a clear liquid diet. In planning to initiate this diet, which priority item should the nurse place at the clients bedside? 1. A straw 2. Code cart 3. Blood pressure cuff 4. Suction equipment

4. Suction equipment

A client who is taking hydrochlorothiazide has been started on triamterene (Dyrenium) as well. The client asks the nurse why both medications are required. Which response is the most accurate to give to the client? 1. Both are weak potassium excreting diuretics 2. The combination of the these medications prevents renal toxicity. 3. Hydrochlorothiazide is an expensive medication, so using a combination of diuretics is cost effective 4. Triamterene is a potassium retaining diuretic, whereas hydrochlorothiazide is a potassium excreting diuretic

4. Triamterene is a potassium retaining diuretic, whereas hydrochlorothiazide is a potassium excreting diuretic

The nurse observes that a client with a nasogastric tube connected to continuous gastric suction is mouth breathing, has dry mucous membranes, & has a foul breath odor. In planning care, which nursing intervention would be best to maintain the integrity of this client's oral mucosa 1. Offer small sips of water frequently 2. Encourage the client to suck on sour, hard candy 3. Use lemon glycerin swabs to provide oral hygiene 4. Use diluted mouthwash & water to rinse the mouth after brushing teeth

4. Use diluted mouthwash & water to rinse the mouth after brushing teeth

A client has had skeletal traction applied to the right leg & has an overheard trapeze available for use. The nurse should monitor which as a high risk area for pressure & breakdown? 1. Scapulae 2. Left heel 3. Right heel 4. Back of the head

2. Left heel

The nurse is preparing a list of home care instructions regarding stoma & laryngectomy care to a client. Which instructions should be included in the list? Select all that apply 1. Restrict fluid intake 2. Obtain a Medic Alert bracelet 3. Keep the humidity in the home low 4. Prevent debris from entering the stoma 5. Avoid exposure to people with infections 6. Avoid swimming & use care when showering

2. Obtain a Medic Alert bracelet 4. Prevent debris from entering the stoma 5. Avoid exposure to people with infections 6. Avoid swimming & use care when showering

The nurse is attempting to communicate with a hearing impaired client. Which strategy by the nurse would be least helpful when talking to this client? 1. Reducing any background noise 2. Smiling continuously during conversation 3. Facing the client so that there is light on the nurse's face 4. Avoiding showing frustration through facial expression

2. Smiling continuously during conversation

The nurse is caring for a client who has been prescribed furosemide (Lasix) & is monitoring for adverse effects associated with this medication. Which should the nurse recognize as potential adverse effect? Select all that apply 1. Nausea 2. Tinnitus 3. Hypotension 4. Photosensitivity 5. Increased urinary frequency

2. Tinnitus 3. Hypotension 4. Photosensitivity

The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made? 1. Skin color becomes cyanotic 2. Secretions are becoming bloody 3. Coughing occurs with suctioning 4. Heart rate decreased from 78 to 54 beats/min

3. Coughing occurs with suctioning

Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks for gastric residual volume. Which is the best rationale for checking gastric residual volume before administering the tube feeding? 1. Observe the digestion of formula 2. Check fluid & electrolyte status 3. Evaluate absorption of the last feeding 4. Confirm proper nasogastric tube placement

3. Evaluate absorption of the last feeding

The nursing instructor asks a nursing student about the cause of hemophilia. The student correctly responds by telling the instructor which fact about hemophilia. 1. Hemophilia is a Y-linked hereditary disorder 2. A splenectomy resolves the bleeding disorders 3. Hemophilia A results from deficiency of factor VIII 4. A bone marrow transplant is the treatment of choice

3. Hemophilia A results from deficiency of factor VIII

The nurse assist in developing a plan of care for the child with meningitis. Which would be the priority client problem for a child with a meningitis diagnosis? 1. Pain 2. Inadequate knowledge 3. Neurological dysfunction 4. Difficult family coping process

3. Neurological dysfunction

The nurse assist in developing a plan of care for a client with hyperparathyroidism receiving calcitonin-human (Cibacalcin). Which outcome has the highest priority regarding this medication? 1. Relief of pain 2. Absence of side effects 3. Reaching normal serum calcium levels 4. Verbalization of appropriate medication knowledge

3. Reaching normal serum calcium levels

The nurse reinforces home care instructions to the mother of a child recovering from Reye's Syndrome. Which statement by the mother indicates a need for further teaching? 1. "I need to check for jaundice skin & eyes every day" 2. "I need to have my child nap during the day to provide rest" 3. "I need to decrease the stimuli at home to prevent intracranial pressure" 4. "I need to give frequent, small, nutritious meals if my child starts to vomit"

4. "I need to give frequent, small, nutritious meals if my child starts to vomit"

A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. The nurse should tell the client which about the test? 1. The test may be painful 2. Fluids will be restricted after the test 3. The test takes approximately 2 to 3 hours 4. The dye injected may cause a warm, flushing sensation

4. The dye injected may cause a warm, flushing sensation