NCLEX Practice Questions
Based on assessment findings, a nurse thinks an infant may have developed NEC and plans interventions. In what order should a nurse plan to intervene for the infant? __ notify the health care provider __ immediately stop feedings __ start prescribed antibiotics __ prepare the infant for an abdominal x-ray __ start prescribed IV fluids
2, 1, 4, 5, 3
A nurse begins the assessment of postpartum client, who is 5 hr post delivery. Initially the nurse is unable to palpate the uterine fundus. Which actions should the nurse take to locate the client's fundus? Place each step in the correct order: __ place the side of one hand just above the client's pubis __ press deeply into the abdomen __ place a hand at the level of the umbilicus __ massage in a circular motion __ position the client in a supine position __ if the fundus is not felt, move the upper hand lower on the abdomen and repeat massage
2, 4, 3, 5, 1, 6
The physician orders 1000 mL of Ringers Lactate IV over 8 hr for a 29 y/o primigravida client at 16 weeks with hyperemesdis. The drip factor is 12 gtts/mL. The nurse should administer the IV infusion at how many drops/ minute?
25 gtts/ minute
A primigravida client's baseline BP at her initial visit at 12 weeks was 110/70 mmHg. During an assessment at 38 weeks, which of the following data would indicate mild preeclampsia? a. BP of 160/110 mmHg on two separate occasions b. proteinuria, more than 5 g in 24 hr c. serum creatinine concentration of 1.4 mL/ dL d. weight gain of 2 lbs in the last week
a. BP of 160/110 mmHg on two separate occasions
A nurse is caring for a 24 y/o client whose pregnancy history is as follows: elective termination in 1998, spontaneous abortion in 2001, term vaginal delivery in 2001, and currently pregnant again. Which documentation by the nurse of the client's gravity and parity is correct? a. G4P1 b. G4P2 c. G3P1 d. G2P1
a. G4P1
A primigravida client has completed her first prenatal visit and bloodwork. Her lab test for the Hep B surface antigen is positive. The nurse can advise the client that the plan of care for the newborn will include: (SATA) a. Hep B vaccine at birth b. series of three Hep B vaccines per recommended schedule c. Hep B screening when born d. isolation of infant during hospitalization e. universal precautions for mother and infant f. contraindication for breastfeeding because the mother is Hep B positive
a. Hep B vaccine at birth b. series of three Hep B vaccines per recommended schedule e. universal precautions for mother and infant
Which lab results should a nurse monitor in evaluating the long term success of a child's control of TIDM? a. Hgb A1C levels b. blood insulin levels c. blood glucose levels d. urinary glucose levels
a. Hgb A1C levels
A 22 month old toddler is walking to the exam room independently in front of the toddler's mother. Which method should the nurse plan to use to weigh the child? a. a standing scale should be used because the child is able to stand independently b. weight using an infant scare because this is the method for all infants until the age of 2 y/o c. ask the mother which would be best for the child d. have the mother weigh herself and then weigh herself holding her child, then subtract the mother's weight from the combined weight
a. a standing scale should be used because the child is able to stand independently
The nurse assesses a primiparous client in labor for 20 hr. The nurse identifies late decelerations on the monitor and initiates standard procedures for the labor client with this wave pattern. Which interventions should the nurse perform? (SATA) a. administering oxygen via mask to the client b. questioning the client about the effectiveness of pain relief c. placing he client on her side d. readjusting the monitor to a more comfortable position e. applying an internal fetal monitor to help identify the cause of the decelerations
a. administering oxygen via mask to the client c. placing the client on her side e. applying an internal fetal monitor to help identify the cause of the decelerations
Which instructions should a nurse include when teaching a parent with a child diagnosed with contact dermatitis from poison ivy? (SATA) a. apply dressings moistened wit either saline or water b. apply a paste of baking soda and water c. apply calamine or Caladryl lotion d. remove scabs to promote healing e. inspect the yard for plants with three pointed leaflets that are different shapes
a. apply dressings moistened wit either saline or water c. apply calamine or Caladryl lotion e. inspect the yard for plants with three pointed leaflets that are different shapes
A client is admitted with suspected abruption placentae. The nurse should assess the client for which of the following signs and symptoms? (SATA) a. bleeding that is concealed or apparent b. abdominal rigidity c. painful abdomen d. painless bleeding e. large placenta f. bleeding that stops spontaneously
a. bleeding that is concealed or apparent b. abdominal rigidity c. painful abdomen
Four days after vaginal delivery, the client visits the clinic complaining of excessive lochia rub with clots. The physician orders Methergine 0.2 mg IM. Before administering this drug, the nurse should assess: a. blood pressure b. pulse rate c. breath sounds d. bowel sounds
a. blood pressure
A pediatric nurse is administering Metformin to a child at risk for developing T2DM. The nurse understands that an important use of Metformin in children is to: a. delay the development of T2DM in high risk children b. restore fertility in adolescent females c. reduce blood sugars in children who have T1DM d. restore renal function in children who have T1DM
a. delay the development of T2DM in high risk children
A nurse knows that maintaining a newborn's axillary body temp between 97.7 F and 98.9 F is an appropriate outcome. To accomplish this outcome the nurse should: (SATA) a. dry the infant immediately after birth b. place the infant skin to skin with the mother c. apply leggings to the infant's legs d. cover the infant's head with a stocking cap e. place the infant in a crib close to the delivery room wall f. wrap the infant in warm blankets and place him under a radiant heat source
a. dry the infant immediately after birth b. place the infant skin to skin with the mother d. cover the infant's head with a stocking cap f. wrap the infant in warm blankets and place him under a radiant heat source
A pediatric patient requires clean intermittent catheterization while at home. Which early signs of infection should the nurse teach the parents to report immediately? a. fever, pulse in the upper range of normal, foul smelling urine b. increased appetite anuria, sweet-smelling urine c. tachypnea, tachycardia, hypertension d. mental confusion, diarrhea, dehydration
a. fever, pulse in the upper range of normal, foul smelling urine
Which of the following anticoagulants would the nurse expect to administer when caring for a primigravida client at 12 weeks who has class II cardiac disease due to mitral valve stenosis? a. heparin b. warfarin (Coumadin) c. enoxaparin (Lovenox) d. ardeparin (Normiflo)
a. heparin
An experienced nurse is orienting a new nurse to the care of children in a clinic. Which immunizations should the experienced nurse inform the new nurse to plan to administer to normally healthy children between ages 1-5 y/o? (SATA) a. inactivated poliovirus b. diphtheria, tetanus, pertussis (DTaP) c. measles, mumps, rubella (MMR) d. hepatitis B (HepB) e. meningococcal
a. inactivated poliovirus b. diphtheria, tetanus, pertussis (DTaP) c. measles, mumps, rubella (MMR) d. hepatitis B (HepB)
An infant diagnosed with hypothyroidism is prescribed levothyroxine sodium (Synthroid). Which independent nursing intervention would assist the nurse in evaluation the effectiveness of this medicine? a. monthly assessments of growth and development b. monthly serum calcium and thyroxin levels c. bimonthly catecholamine levels and electrocardiogram d. absence of thyroid excess
a. monthly assessments of growth and development
A nurse is caring for a newly admitted 4 y/o client diagnosed with asthma who is pale, dry mucous membranes, cracked lips, and nasal flaring with inspiration. Which actions should the nurse perform? (SATA) a. obtain a pulse ox b. obtain vital signs c. assess lung sounds d. administer a nebulizer treatment e. offer oral fluids f. elevate the HOB
a. obtain a pulse ox b. obtain vital signs c. assess lung sounds f. elevate the HOB
A nurse is caring for a 17 y/o client with renal insufficiency from impaired blood flow to the kidneys sustained during a MVA. Which assessment finding related to renal insufficiency should be reported immediately to the health care provider? a. oliguria b. dysuria c. frequency d. urgency
a. oliguria
A nurse is managing the care of pediatric client in CHF. Which medically delegated interventions should be included in the care of the client? (SATA) a. oral positive inotropic agents b. diuretics c. ACE inhibitors d. hypolipidemic agents e. oral positive chronotrophic agents f. beta blockers
a. oral positive inotropic agents b. diuretics c. ACE inhibitors f. beta blockers
A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following action should the nurse take? a. position the client in an upright position, leaning over the bedside table b. explain the procedure to the client c. obtain ABGs from the client d. administer benzocaine spray to the client
a. position the client in an upright position, leaning over the bedside table
Which goal should a nurse deem as essential when caring for a 14 month old infant with bronchiolitis? a. promoting and maintaining adequate hydration b. setting up and facilitating the use of a mist tent c. ensuring that antibiotics are ordered d. providing a cough suppressant as necessary
a. promoting and maintaining adequate hydration
A nurse is caring for a pediatric patient who has congestive heart failure. The client is receiving digoxin. Which lab test result is most important to evaluate when preparing to administer digoxin? a. serum potassium levels b. serum magnesium levels c. serum sodium levels d. serum chloride levels
a. serum potassium levels
A nurse caring for an adolescent diagnosed with new onset generalized tonic-clonic seizures of unknown etiology. Which nursing actions should be initiated by the nurse? (SATA) a. teaching the parents care and safety measures should a seizure occur at home b. obtaining an oropharyngeal airway and placing it near the adolescent's bed c. paying the side rails of the bed d. placing the adolescent in droplet precaution isolation e. securing a tongue blade to the head of the bed f. setting up suction equipment in the adolescent's room
a. teaching the parents care and safety measures should a seizure occur at home b. obtaining an oropharyngeal airway and placing it near the adolescent's bed c. paying the side rails of the bed f. setting up suction equipment in the adolescent's room
An experienced nurse is observing a new nurse performing care to an 11 month old who is 12 hr post-op from a cleft palate repair. Which nursing action requires the experienced nurse to intervene? a. using a suction catheter to remove oral secretions b. feeding soft, blended foods c. removing an arm restraint to check the sin d. administering an analgesic
a. using a suction catheter to remove oral secretions
A nurse is providing education to a client who is to undergo an EEG the next day. Which of the following information should the nurse include in the teaching? a. "don't wash your hair the morning of the procedure" b. "try to stay awake most of the night prior to the procedure" c. "the procedure will take approximately 15 minutes" d. "you will need to lie flat for 4 hr after the procedure"
b. "try to stay awake most of the night prior to the procedure"
A nurse is preparing to administer an analgesic for short term mild pain in a pediatric client with a history of acute renal insufficiency. Which pharmacological agent should the nurse select from the list of standing orders from the HCP? a. ibuprofen (Motrin) b. acetaminophen (Tylenol) c. morphine sulfate d. meperidine (Demerol)
b. acetaminophen (Tylenol)
When assessing a child after heart surgery to correct TOF, which of the following should alert the nurse to suspect a low cardiac output? a. bounding pulses and mottled skin b. altered LOC and thready pulse c. capillary refill of 2 seconds and BP of 96/67 mmHg d. extremities warm to the touch and pale skin
b. altered LOC and thready pulse
A nurse is caring for a 5 y/o from Italy, the child is crying and the interpreter is taking the child has extreme pain. The nurse's first priority should be to: a. have the child's mother who knows limited English ask the child what hurts b. assess the level of the child's pain using an appropriate FACES pain rating scale c. administer morphine 1 mg IV as prescribed d. call the HCP to request a change in pain medication dosage as it is not adequately controlling the child's pain
b. assess the level of the child's pain using an appropriate FACES pain rating scale
A primigravida client in early labor tells the nurse that she was exposed to rubella at 14 weeks gestation. After delivery, the nurse should assess the neonate for which of the following? a. hydrocephaly b. cardiac disorders c. renal disorders d. bulging fontanels
b. cardiac disorders
Which of the following measures would the nurse expect to include in the teaching plan for a multiparous client who delivered 24 hr ago and is receiving IV antibiotics therapy for cystitis? a. limiting fluid intake to 1 L daily to prevent overload b. emptying the bladder every 2-4 hr while awake c. washing the perineum with butadiene after voiding d. avoiding the intake of acidic fruit juices until the treatment is discontinued
b. emptying the bladder every 2-4 hr while awake
A nurse is preparing a 4 y/o boy for surgery. Which nursing action is appropriate for preoperative teaching based on Erikson's developmental stages? a. allowing the child to make a project related to surgery b. having the child put a surgical mask on a doll c. asking the child how he feels about surgery d. allowing the child to listen to music without further instructions
b. having the child put a surgical mask on a doll
A clinic nurse is meeting with a mother and her 3 y/o son. The toddler is acting out and the mother asks the nurse what a good form of discipline would be for her son. The nurse recommends a time-out for the child. Which statement regarding a time-out is most accurate? a. the child should sit still for as many minutes as he misbehaved b. the child should sit still at a time-out for as many minutes as his age in years c. the child should be able to read a book during time-out d. children should not be expected to sit still until they are in school
b. the child should sit still at a time-out for as many minutes as his age in years
A primigravida at 8 weeks' gestation tells the nurse that she wants an amniocentesis because there is a history of Hemophilia A in her family. The nurse informs the client that she will need to wait until she is at 15 weeks' gestation for the amniocentesis. Which of the following provides the most appropriate rationale for the nurse's statement regarding amniocentesis at 15 weeks' gestation? a. fetal development needs to be complete before testing. b. the volume of amniotic fluid needed for testing will be available by 15 weeks c. cells indicating hemophilia A are not produced until 15 weeks' gestation d. fetal anomalies are associated with amniocentesis prior to 15 weeks' gestation
b. the volume of amniotic fluid needed for testing will be available by 15 weeks
Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 sec and occurring every 1 1/2 minutes. The uterine resting tone is greater than 20 mmHg with a nonreassuring FHR and pattern. Which of the following actions should the nurse take first? a. notify the HCP b. turn off the oxytocin infusion c. turn the client to her left side d. increase the maintenance IV fluids
b. turn off the oxytocin infusion
A nurse is developing a teaching plan for the parents of a 5 month old infant diagnosed with gastroenteritis caused by a rotavirus. Which instructions should the nurse include to reduce the risk for transmission? (SATA) a. vacuum carpets and upholstery daily to rid the house of the infectious organism b. wash the child's clothing soiled with stool separately from other family clothing c. tell family members to wash hands frequently, especially after changing the infant's diaper d. once the child is well take the child to the climate to complete the rotavirus immunization series e. use alcohol based wipes to cleanse the infant after a stool to disinfect the skin f. store toothbrushes, pacifiers, and other
b. wash the child's clothing soiled with stool separately from other family clothing c. tell family members to wash hands frequently, especially after changing the infant's diaper d. once the child is well take the child to the climate to complete the rotavirus immunization series f. store toothbrushes, pacifiers, and other
A nurse is preparing a 4 y/o child with CF for discharge to home. The nurse determines that a parent needs further education when the parent states: a. "playing on the backyard swings and hanging upside down are exercises that out child will enjoy" b. "if children at the daycare center have a cough, fever, or flu symptoms we should keep our child at home" c. "no pancreatic enzyme supplements will be necessary if our child has a good appetite and regular bowel movements" d. "three to four times everyday we will perform chest therapy and postural drainage, even if our child doesn't seem congested"
c. "no pancreatic enzyme supplements will be necessary if our child has a good appetite and regular bowel movements"
While assessing a full term newborn, a nurse notes molding on the infant's head. Considering this assessment finding, which information should the nurse expect to see on the mother's labor and delivery documentation? a. vaginal breech birth b. planned C-section, no labor c. 16 hr labor d. precipitous delivery after 30 min labor
c. 16 hr labor
The nurse is managing care of a primigrada at full term who is in active labor. What should be included in developing the plan of care for this client? a. oxygen saturation monitoring every half hour b. supine positioning on the back if it is comfortable c. anesthesia/ pain level assessment every 30 min d. vaginal bleeding, ROM assessment every shift
c. anesthesia/ pain level assessment every 30 min
A child is presenting with burn injuries. What should be the nurse's priority during an initial assessment? a. inspect location, extent, and shape of burn injuries b. assess the child and family's concerns regarding the child's appearance c. assess for signs of smoke inhalation and burns to the face and neck d. assess for signs and symptoms of infection
c. assess for signs of smoke inhalation and burns to the face and neck
While a client is being admitted to the birthing unit she states "my water broke last night but my labor started two hours ago." Which of the following is a concern? (SATA) a. maternal vitals: 99.5 F, 80 bpm, 130/80 mmHg b. blood and mucus on peripad c. baseline FHR of 140 bpm with a range between 110-160 d. peripad stained with green fluid e. the client states "this baby wants out, he keeps kicking me"
c. baseline FHR of 140 bpm with a range between 110-160 d. peripad stained with green fluid e. the client states "this baby wants out, he keeps kicking me"
A nurse is caring for a 3 y/o client who is post-op T&A surgery. The nurse should suspect complications when assessing: a. complains of sore throat and difficulty swallowing b. secretions and dried blood at the corners of the mouth c. frequent swallowing and caring of the throat d. the presence of "dark coffee ground" emesis
c. frequent swallowing and caring of the throat
An adolescent is admitted with a diagnosis of suspected Addison's disease. Which assessment manifestations should the nurse expect to find if Addison's disease is the correct diagnosis? a. long history of fatigue, weight loss, and muscle tetany b. sudden onset of skin hypo-pigmentation, polydipsia, and hyperactivity c. gradual onset of salt craving, decreased public and axillary hair, and irritability d. sudden onset of increasing weight gain and skin hyper-pigmentation
c. gradual onset of salt craving, decreased public and axillary hair, and irritability
Parent education by a clinic nurse for home management of a toddler with eczema should include: a. frequent bathing to remove flaking skin b. administering topical antibiotic medication c. identifying environmental triggers d. removal of the silvery scaling to promote healing
c. identifying environmental triggers
The physician orders Ringer's lactate solution to replace the fluid losses of a client. While the solution is infusing, the nurse should assess for which of the following symptoms that might indicate fluid overload is developing? a. increased abdominal girth b. rapid, thready pulse c. moist crackles on auscultation d. increased urinary output
c. moist crackles on auscultation
The nurse is administering an IV solution that contains potassium chloride to a patient in the critical care unit who has a severely decreased serum potassium level. Which action(s) by the nurse are appropriate? (SATA) a. administer the potassium by slow IV bolus b. administer the potassium at a rate of at least 40 mEq/ hr c. monitor the patient's cardiac rhythm with a heart monitor d. use an infusion pump for the administration of IV potassium chloride e. administer the potassium IV push
c. monitor the patient's cardiac rhythm with a heart monitor d. use an infusion pump for the administration of IV potassium chloride
A multiparous client at 24 hours postpartum demonstrates a positive Homan's sign with discomfort. The nurse should: a. place a cold pack on the client's perineal area b. place the client in a semi fowler's position c. notify the client's physician immediately d. ask the client to ambulate around the room
c. notify the client's physician immediately
A nurse and an LPN are working in the labor and birth unit. Of the activities that must be done immediately, which should the nurse assign to the LPN? a. complete an initial assessment on a client b. increase the oxytocin rate on a laboring client c. perform a straight cauterization for protein synthesis d. assess a laboring client for a change in labor pattern
c. perform a straight cath for protein synthesis
A triage nurse determines that a child brought to an emergency department is experiencing severe respiratory distress when observing: a. diaphoresis, restlessness, tachypnea, anorexia b. pallor, coughing, wheezing, confusion c. retractions, grunting, cyanosis, bradycardia d. agitation, decreased LOC, diarrhea, tachypnea
c. retractions, grunting, cyanosis, bradycardia
Before administering an enteral feeding to a 2 month old, the nurse aspirates 5 mL of gastric contents. Which action should the nurse take next? a. return the aspirate and withhold the feeding b. discard the aspirate before beginning the feeding c. return the aspirate before beginning the feeding d. discard the aspirate and add an equal amount of normal saline to the feeding
c. return the aspirate before beginning the feeding
When preparing an IV solution that contains potassium, the nurse knows that a contraindication to the potassium infusion would be a. diarrhea b. serum sodium level of 145 mEq/L c. serum potassium level of 5.6 mEq/L d. dehydration
c. serum potassium level of 5.6 mEq/L
A nurse is assessing a child who is presenting with burn injuries. Which injury would least likely trigger the need for further assessment or evaluation for the potential of child abuse and mandatory reporting? a. rope burn with edema b. cigarette burns c. splash burns on the front horse, face, and neck d. scald burns of the feet and legs
c. splash burns on the front horse, face, and neck
The parents of a healthy 15 hr term newborn are planning discharge from a hospital with their infant. The mother requests that the PKU test be done before the infant leaves the hospital. The nurses response to the mother is based on the knowledge that: a. the PKU test must be done when the infant is at least 1 month old b. the parents must sign a specific consent form if the PKU screening is done before the infant is 24 hr old c. the PKU screening is most accurate if performed after 24 hr of life but before the infant is 7 days old d. the PKU test is not needed as long as the infant tolerates feedings without diarrhea or vomiting
c. the PKU screening is most accurate if performed after 24 hr of life but before the infant is 7 days old
A nurse in a clinic is assessing the weight of an infant. Which infant's weight indicates to the nurse that the infant's weight I normal for the infant's age? a. the baby's weight has tripled in the first 6 months of life b. the baby's weight has doubled in the first year of life c. the baby's weight has doubled in the first 6 months of life and tripled in the first year d. the baby's weight has doubled in the first 6 months and doubled again in the next 6 months
c. the baby's weight has doubled in the first 6 months of life and tripled in the first year
A 30 y/o multigravida client at 8 weeks has a history of insulin dependent diabetes since 20 y/o. When explaining about the importance of blood glucose control during pregnancy, the nurse should tell the client that which o the following will occur regarding the clients insulin needs during the first trimester? a. they will increase b. they will decrease c. they will remain constant d. they will be unpredictable
c. they will remain constant
A postpartum client who is 24 hr post C-section, tells a nurse that she has had much less lochial discharge after this birth than she had with her vaginal birth 2 years ago. The client asks the nurse if this is a normal response to a C-section. Which statement should be the basis for the nurse's response? a. a decrease in lochia is not expected after c-section and further assessment is needed b. women usually have increased lochial discharge after c-section c. women normally have less lochia after c-section d. the amount of lochial discharge after c-section is related to method of placental delivery and whether surgery was emergent or planned
c. women normally have less lochia after c-section
A nurse completes teaching the parents of a 3 month old infant diagnosed with pyloric stenosis who underwent surgical correction. Which statement by the parents indicates teaching has been effective? a. "we should use a special infant nipple so our baby does not get too much air" b. "increasing the amount of formula at each feeding will help expand our baby's stomach" c. "after feedings, our baby should be handled as little as possible" d. "once put back to bed after the feeding, our baby should be positioned on the right side"
d. "once put back to bed after the feeding, our baby should be positioned on the right side"
A nurse is caring for a 5 y/o diagnosed with bronchial asthma. Which statement is most important for the nurse to make when teaching the parents? a. "bronchial asthma is also called hyperactive airway disease" b. "frequent occurrences of bronchiolitis before 5 years of age could be a sign of asthma" c. "severe respiratory alkalosis can result from respiratory failure in asthma" d. "severe bronchoconstriction can occur when exposed to cold air and irritating odors"
d. "severe bronchoconstriction can occur when exposed to cold air and irritating odors"
A postpartum client who just delivered a full term infant tells a nurse she has concerns about her Rh- status. She says she received RhoGAM during her pregnancy and she wonders if she is going to need it again. The nurse correctly replies: a. "to prevent you from building up antibodies against your next baby's blood you will need to have RhoGAM within 72 hr" b. "you will not need RhoGAM again since you got it during your pregnancy" c. "one dose of RhoGAM will last for a lifetime" d. "you will need RhoGAM if your newborn is Rh+"
d. "you will need RhoGAM if your newborn is Rh+"
The nurse is working on a busy L&D unit with the nurses and a LPN. Which of the following labor clients would the nurse assign to the LPN? a. a G4P3 client with a history of GDM b. a G3P1A1 client at 35 weeks gestation c. a G1P0 client with leaking green amniotic fluid d. a G2P1 client with a history of hyperemesdis gravidarum
d. a G2P1 client with a history of hyperemesdis gravidarum
The nurse is admitting a primigravida client at 37 weeks gestation who has been diagnosed with pregnancy-induced HTN to the L&D unit. Which of the following client care rooms is most appropriate for this client? a. a brightly lit private room at the end of the hall from the nurse's station b. a semiprivate room midway down the hall from the nurse's station c. a private room with many windows that is near the OR d. a darkened private room as close to the nurse's station as possible
d. a darkened private room as close to the nurse's station as possible
A nurse is assessing the fundal height for multiple pregnant clients. For which client should the nurse conclude that a fundal height measurement is most accurate? a. a pregnant client with uterine fibroids b. a pregnant client who is obese c. a pregnant client with polyhydramnios d. a pregnant client experiencing fetal movement
d. a pregnant client experiencing fetal movement
A nurse is preparing to perform an ECG on several pediatric clients. Which client would not benefit from an ECG? a. a 4 y/o with tachycardia b. a 3 y/o with bradycardia c. a 10 y/o with an irregular pulse d. an infant with splitting S2 heart sound when infant takes a deep breath
d. an infant with splitting S2 heart sound when infant takes a deep breath
A nurse explains to a parent who has a child with T1DM that the most important reason for counting the child's grams of carbohydrates is to: a. lower blood glucose levels b. supply energy for growth and development c. provide consistent glucose to prevent hypoglycemia d. attain metabolic control of glucose and lipid levels
d. attain metabolic control of glucose and lipid levels
A nurse is completing the 1 min APGAR on a full term newborn. The HR is 80 bpm. The response to this assessment, the nurse should: a. document a 2 for the HR parameter of the APGAR b. document a 0 for the HR parameter of the APGAR c. continue to evaluate the rest of the APGAR before determining HR score d. begin immediate positive pressure ventilation
d. begin immediate positive pressure ventilation
A postpartum client, who delivered a full term infant 2 days previously, calls a nurse to her room and states that she is concerned because her breasts "seem to be growing". She reports that the bra she wore during pregnancy is too small. She asks the nurse what is wrong with her. The nurse's response should be based on which of the following statements? a. enlarging breasts are a symptom of infection b. increasing breast tissue may be a sign of postpartum fluid retention c. thrombi may form in veins of the breast and cause increased breast size d. breast tissue increase in the early postpartum period as milk forms
d. breast tissue increase in the early postpartum period as milk forms
A nurse is caring for a child immediately following insertion of a VP shunt for treatment of hydrocephalus. The nurse's post-op care should include: a. maintaining the HOB in an elevated position b. ensuring that the child minimizes movement of the extremities c. providing a pressure dressing over the cephalic insertion site d. changing the child's position q2h
d. changing the child's position q2h
RhoGAM is ordered for a client before she is discharged after a spontaneous abortion. The nurse instructs the client that this drug is used to prevent which of the following? a. development of a future RH+ fetus b. an antibody response to Rh- blood c. a future pregnancy resulting in abortion d. development of Rh+ antibodies
d. development of Rh+ antibodies
What is the most important factor for a nurse to consider teaching a child with CP? a. age b. type of cerebral palsy c. the child's prior experiences with illness d. developmental level
d. developmental level
An adolescent who is receiving morphine via a PCA pump, complains of itching. Which medication should a nurse plan on administering to relieve the itching? a. naloxone hydrochloride (Narcan) b. diazepam (Valium) c. butenafine hydrochloride (Mentax) d. diphenhydramine (Benadryl)
d. diphenhydramine (Benadryl)
A pediatric patient presents with tachycardia, edema, dyspnea, orthopnea, and crackles. A nurse performs a physical assessment of the client and notifies a physician immediately. Which condition does the nurse most likely suspect? a. right sided heart failure b. rheumatic fever c. kawasaki disease d. left sided heart failure
d. left sided heart failure
A 10 month old child reaches the 9-12 month developmental stage. What nursing action is most appropriate for providing tactile stimulation for this child? a. caress the child while diaper changing b. give the child a soft squeeze toy c. swaddle the child at nap time d. let the child squash and mash food while sitting in a high chair
d. let the child squash and mash food while sitting in a high chair
A nurse is caring for a 3 month old. Based on the developmental age of the child, which motor skill should the nurse expect to see during an assessment? a. bangs objects held in hand b. begins to grab objects using a pincer grasp c. grabs objects using a palmar grasp d. looks and plays with own fingers
d. looks and plays with own fingers
A nurse is reviewing orders received for a newly admitted child with second and third degree burns over 10% of the total body surface. The child weights 20 kg. The nurse should seek further clarification from a physician when the physician's order is: a. LR @ 50 mL/hr for the next 8 hr b. insert a urinary catheter c. elevate the extremities above the level of the heart d. morphine IV PRN for pain control
d. morphine IV PRN for pain control
A client at 15 weeks gestation is admitted with dark brown vaginal bleeding and continuous nausea & vomiting. Her BP is 142/98 mmHg and fundal height is 19 cm. The nurse should prepare to do which of the following? a. transfer the client to the antenatal unit b. keep the client NPO for 24 hr c. administer magnesium sulfate d. obtain an ultrasound
d. obtain an ultrasound
A nurse is preparing to perform chest physiotherapy on a 7 y/o client diagnosed with CF. When should the nurse plan to perform the treatment? a. before performing postural drainage b. before a nebulizer aerosol treatment c. after suctioning the upper respiratory tract d. one hour before meals
d. one hour before meals
A nurse is monitoring for post-op complications in a client who had a kidney biopsy. Which of the following complications causes the most immediate risk to the client? a. infection b. hemorrhage c. hematuria d. kidney failure
b. hemorrhage
The nurse is caring for a primiparous client and her neonate immediately after delivery. The neonate was born at 41 weeks gestation and weighs 4082 g (9 lbs). Assessing for signs & symptoms of which of the following conditions should be a priority? a. anemia b. hypoglycemia c. delayed meconium d. elevated bilirubin
b. hypoglycemia
A nurse is developing a plan of care for a client who is scheduled for a cerebral angiogram with contrast dye. Which of the following statements by the client should the nurse report to the provider? (SATA) a. "I think I may be pregnant" b. "I take Coumadin" c. "I take antihypertensive medication" d. "I am allergic to shrimp" e. "I am allergic to latex"
a. "I think I may be pregnant" b. "I take Coumadin" d. "I am allergic to shrimp"
A client asks the nurse why taking folic acid is so important before and during pregnancy. The nurse should instruct the client that: a. "folic acid is important in preventing NTD in newborns an preventing anemia in mothers" b. "eating foods with moderate amounts of folic acid helps regulate blood glucose levels" c. folic acid consumption helps with the absorption of iron during pregnancy" d. "folic acid is needed to promote blood clotting and collagen formation in the newborn"
a. "folic acid is important in preventing NTD in newborns an preventing anemia in mothers"
A client has just had a C-section for a prolapsed cord. In reviewing the client's history, which of the following factors places a client at risk for cord prolapse? (SATA) a. -2 station b. low birth weight infant c. rupture of membranes d. breech presentation e. prior abortion f. low lying placenta
a. -2 station c. rupture of membranes d. breech presentation f. low lying placenta
Various children are being seen in the clinic for well-baby checks. By what age should nurse expect a child to begin to use simple words to communicate needs? a. 10-12 months b. 1-2 years c. 6-9 months d. 2-3 years
a. 10-12 months
A HCP prescribed a dose of acetaminophen (Tylenol) according to weight recommendations for a child. The package insert reads if the child weighs 48 lbs? a. 327 mg b. 327 mL c. 500 mg d. 500 mL
a. 327 mg
A 7 y/o child may have hydrocephalus secondary to malignancy. Which assessment findings should a nurse anticipate? (SATA) a. increased head circumference b. headache c. personality change d. vomiting e. angioedema
b. headache c. personality change d. vomiting
Previous administrations of chemo agents to a cancer patient have resulted in diarrhea. Which dietary modification should the nurse recommend? a. a bland, low fiber diet b. a high protein, high calorie diet c. a diet high in fresh fruits and vegetables d. a diet emphasizing whole and organic foods
a. a bland, low fiber diet
A nurse is planning care for a client who is to have an EMG. Which of the following should the nurse include in the plan of care? (SATA) a. assess the client for bruising b. apply ice to insertion sites c. determine whether the client takes a muscle relaxant d. instruct the client to flex muscles while the needle is inserted e. expect swelling, redness, and tenderness at the insertion sites
a. assess the client for bruising b. apply ice to insertion sites c. determine whether the client takes a muscle relaxant d. instruct the client to flex muscles while the needle is inserted
A nurse is having difficulty arousing a client following an EGD. Which of the following is the priority action by the nurse? a. assess the client's airway b. allow the client to sleep c. increase the rate of IV fluid administration d. evaluate pre-procedure lab findings
a. assess the client's airway
A client who has undergone outpatient nasal surgery is ready of discharge and has nasal packing in place. Which of the following discharge instructions would be appropriate for the client? a. avoid activities that elicit the Valsalva maneuver b. take aspirin to control nasal discomfort c. avoid brushing the teeth until the nasal packing is removed d. apply heat to the nasal area to control swelling
a. avoid activities that elicit the Valsalva maneuver
A nurse is reviewing the bowel prep using GOLYTELY with a client scheduled for a colonoscopy. Which of the following should be included in the teaching? a. check with the provider about taking current medications when consuming bowel prep b. consume a normal diet until starting the bowel prep c. the bowel prep will not begin acting until the day after it is consumed d. the bowel prep may be discontinued once feces start to be expelled
a. check with the provider about taking current medications when consuming bowel prep
A nurse is caring for a client who has T2DM and is to undergo excretory urography. Which of the following are appropriate nursing actions prior to this procedure? (SATA) a. identify client allergy to seafood b. hold metformin for 24 hr c. administer an enema d. obtain client's serum coagulation profile e. assess client for history of asthma
a. identify client allergy to seafood b. hold metformin for 24 hr c. administer an enema e. assess client for history of asthma
A client's arterial blood gas values are as follows: pH 7.24, PaCO2 35 mmHg, HCO3- 15 mEq/L. The client also has Kussmaul's respirations. These findings re indicative of which of the following acid-base imbalances? a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis
a. metabolic acidosis
A primigravida client at 32 weeks gestation is enrolled in a breastfeeding class. Which of the following statements indicate that the client understands the breastfeeding education? (SATA) a. "my milk supply will be adequate since I have increased a whole bra size during pregnancy" b. "I can hold my baby several different ways during breastfeeding" c. "if my infant latches on properly, I won't develop mastitis" d. "if I breastfeed, my uterus will return to pre-pregnancy size more quickly" e. "breast milk can be expressed and stored at room temperature since it is natural" f. "I need to feed my baby when I see feeding cues and not wait until she is crying"
b. "I can hold my baby several different ways during breastfeeding" d. "if I breastfeed, my uterus will return to pre-pregnancy size more quickly" f. "I need to feed my baby when I see feeding cues and not wait until she is crying"
A clinic nurse is caring for a 2 y/o client. During the exam, the child's parents ask the nurse when their toddler should be toilet trained. Which response by the nurse is most appropriate? a. "children should be placed on the potty chair often so they get used to the task and should be rewarded immediately for staying on the potty chair" b. "children need sphincter control, cognitive understanding of the task, and the ability to delay immediate gratification" c. "children should be ready to toilet train at about 2 y/o" d. "first put training pants on your child so the child gets used to not wearing a diaper"
b. "children need sphincter control, cognitive understanding of the task, and the ability to delay immediate gratification"
A nurse is providing instructions to a client before a mammogram. Which of the following should the nurse instruct the client to avoid prior to the procedure? a. multivitamins b. deodorant c. sexual intercorse d. exercise
b. deodorant
A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3 −, 36 mEq/ L. Which of the following signs or symptoms should the nurse expect? a. cyanosis b. flushed skin c. irritability d. anxiety
b. flushed skin
A 24 y/o client, G3P1, at 32 weeks gestation is admitted to the hospital because of vaginal bleeding. After reviewing the client's history, which of the following factors might lead the nurse to suspect placental abruption? a. several hypotensive episodes b. previous low transverse C-section c. one induced abortion d. history of cocaine use
b. previous low transverse C-section
A nurse is managing care of a pediatric client following renal trauma. The nurse should monitor the client first for: a. electrolyte imbalance b. profuse bleeding c. hypertension d. hypotension
b. profuse bleeding
A 27 y/o woman has had elective nasal surgery for a deviated septum. Which of the following would be an important initial clue that bleeding was occurring even if the nasal drip pad remained dry and intact? a. complaints fo nausea b. repeated swallowing c. increased respiratory rate d. increased pain
b. repeated swallowing
A multigravida client at 34 weeks is being treated with indomethacin to halt preterm labor. If the client delivers a preterm infant, the nurse should notify the nursery personnel about this therapy because of the possibility for which of the following? a. pulmonary HTN b. respiratory distress syndrome c. hyperbilirubinemia d. cardiomyopathy
b. respiratory distress syndrome
Which of the following compensatory actions by the body would occur a client were in respiratory acidosis? a. excretion of HCO3- by the kidneys b. retention of HCO3- by the kidneys c. increase in respiratory rate by the lungs d. decrease in respiratory rate by the lungs
b. retention of HCO3- by the kidneys
The patient is receiving an IV vesicant chemo drug. The nurse notices swelling and redness at the site. What should the nurse do first? a. ask the patient if the site hurts b. turn off the chemo infusion c. call the ordering health care provider d. administer sterile saline to the reddened area
b. turn off the chemo infusion
A child is being evaluated for possible increased ICP following head trauma. Which assessment finding associated with increased ICP should a nurse report in a HCP? a. increasing alertness b. widened pulse pressure c. tachycardia d. decreased SBP
b. widened pulse pressure
A nurse administered captopril to a client during venography. Which of the following is an appropriate action by the nurse? a. assess the client for HTN b. limit the client's fluid intake c. monitor the orthostatic hypotension d. encourage early ambulation
c. monitor the orthostatic hypotension
After being treated with heparin therapy for thrombophlebitis, a multiparous client who gave birth 4 days ago is to be discharged on oral warfarin. After teaching the client about the medication and possible effects, which of the following client statements indicates successful teaching? a. "I can take two aspirin if I get uterine cramps" b. "Protamine sulfate should be available if I need it" c. "I should use a soft toothbrush to brush my teeth" d. "I can drink an occasional glass of wine if I desire"
c. "I should use a soft toothbrush to brush my teeth"
During a home visit to primiparous client who delivered vaginally 14 days ago, the client says "I've been crying a lot the last few days. I just feel so awful; I'm a rotten mother. I just don't have any energy, plus my husband just got laid off from his job." The nurse observes that the client's appearance is disheveled. Which of the following would be the nurse's best response? a. "These feelings are commonly indicate symptoms of postpartum blues and are normal. They'll go away in a few days" b. "I think you're probably overreacting to the labor and delivery process. You're doing the best you can as a new mother" c. "It's not unusual for some mothers to feel depressed after the birth of a baby. I think I should contact your doctor" d. "This may be a symptom of a serious mental illness. I think you should probably go to the hospital"
c. "It's not unusual for some mothers to feel depressed after the birth of a baby. I think I should contact your doctor"
After instructing a multigravida client at 10 weeks diagnosed with chronic HTN about the need for frequent prenatal visits, the nurse determines that the instructions have been successful when the client states which of the following: a. "I may develop hyperthyroidism because of my high BP" b. "I need close monitoring because I may have a SGA infant" c. "It's possible that I will have excess amniotic fluid and may need a C-section" d. "I may develop placenta accrete, so I need to keep my clinic appointments'
c. "It's possible that I will have excess amniotic fluid and may need a C-section"
A clinic nurse is providing instructions to the parents of an 18 month old experiencing acute diarrhea. The child weighs 12 kg. When teaching the parents, which points should the nurse emphasize? (SATA) a. "have your child drink plenty of fluids, including apple juice and other fruit juices" b. "put your child on a diet of bananas, rice, applesauce, tea, and toast (BRATT) until diarrhea resolves" c. "encourage your child to eat small amounts of foods included in the child's normal diet, except cow's milk or milk products" d. "avoid using commercial baby wipes that contain alcohol to cleanse your child's skin" e. "wash your hands often especially after changing your toddler, and keep soiled articles away from clean areas" f. "give 1/2 glass (120 mL) or an oral replacement fluid, such as Pedialyte, for each diarrhea stool"
c. "encourage your child to eat small amounts of foods included in the child's normal diet, except cow's milk or milk products" d. "avoid using commercial baby wipes that contain alcohol to cleanse your child's skin" e. "wash your hands often especially after changing your toddler, and keep soiled articles away from clean areas" f. "give 1/2 glass (120 mL) or an oral replacement fluid, such as Pedialyte, for each diarrhea stool"
A nurse is providing teaching for a client who is to have a bone marrow biopsy of the iliac crest. Which of the following statements made by the client indicates a need for further teaching? a. "cancer can be detected in the fluid being tested" b. "I will feel a heavy pressure sensation in my hip bone" c. "the type of antibiotics I need to take can be determined by this test" d. "I will be awake during the procedure"
c. "the type of antibiotics I need to take can be determined by this test"
The female patient is having whole brain radiation for brain metastasis. She is concerned about how she will look when she loses her hair. What is the best response by the nurse to this patient? a. "when your hair grows back it will be patchy" b. "don't use your curling iron and that will slow down the loss" c. "you can get a wig now to match your hair so you will not look different" d. "you should contact "Look Good, Feel Better" to figure out what to do about this"
c. "you can get a wig now to match your hair so you will not look different"
The patient with breast cancer is having tele therapy radiation treatments after her surgery. What should the nurse teach the patient about the care of her skin? a. use dial soap to feel clean and fresh b. scented lotion can be used on the area c. avoid heat and cold to the treatment area d. what the new bra to comfort and support the area
c. avoid heat and cold to the treatment area
A client has the following arterial blood gas values, pH 7.52, PaO2 50 mmHg, PaCO2 28 mmHg, HCO3- 24 mEq/L. From the client's PaCO2 level, the nurse determines that the client is experiencing which of the following conditions? a. hypoxemia b. hypoventilation c. hyperventilation d. oxygen toxicity
c. hyperventilation
A 33 y/o patient has recently been diagnosed with stage II cervical cancer. What should the nurse understand about the patient's cancer? a. it is in situ b. it has metastasized c. it has spread locally d. it has spread extensively
c. it has spread locally
The patient is told that the adenoma tumor is not encapsulated but has normally differentiated cells and that surgery will be needed. The patient asks the nurse what this means. What should the nurse tell the patient? a. it will recur b. it has metastasized c. it is probably benign d. it is probably malignant
c. it is probably benign
A nurse is takin history of a 9 month old with altered urinary elimination. Which abnormal finding should the nurse report first? a. odorless urine b. dark amber urine c. not producing a wet diaper in a 24 hr period d. urinary output between 250-500 mL per day
c. not producing a wet diaper in a 24 hr period
A nurse is reviewing a client's lab findings for urinalysis. The findings indicate the urine is positive for leukoesterase and nitrates. Which of the following is an appropriate nursing action? a. repeat the test early the next morning b. start a 24 hr urine collection for creatinine clearance c. obtain a clean catch urine specimen for culture & sensitivity d. insert a urinary catheter to collect a urine specimen
c. obtain a clean catch urine specimen for culture & sensitivity
A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure is in the client's room? (SATA) a. oxygen equipment b. incentive spirometer c. pulse oximeter d. sterile dressing e. suture removal kit
c. pulse oximeter d. sterile dressing
A nurse is providing teaching to a client who is scheduled for a bone scan. Which of the following statements by the nurse is appropriate? a. "the procedure will take about 1 hr" b. "you will be placed in a tubelike structure during the procedure" c. "you will need to take precautions with your urine for 24 hr after the procedure" d. "a radioactive substance will be injected before the procedure"
d. "a radioactive substance will be injected before the procedure"
A new nurse asks an experienced nurse why the first dose of MMR vaccine is given only between 12-15 months of age and not any earlier. Which explanation by the experienced nurse is correct? a. "the second dose of the vaccine is given before a child reaches puberty, and giving the first dose of the vaccine at 12-15 months of age allows the correct interval between vaccinations" b. "because a live virus is administered, the chance of developing measles, mumps, or rubella is much higher if given at an earlier age" c. "a first dose at this age provides passive immunity and decreases the incidence of a child developing any of the diseases" d. "if administered earlier, the vaccine will neutralize the passive immunity to measles from the child's mother and no immunity will result"
d. "if administered earlier, the vaccine will neutralize the passive immunity to measles from the child's mother and no immunity will result"
A nurse in a clinic is instructing a client about a fecal occult blood test, which requires mailing three specimens. Which of the following statements by the client indicates understanding of the teaching? a. "I will continue taking my Coumadin while I complete these tests" b. "I'm glad I don't have to follow any special diet at this time" c. "this test determines if I have parasites in my bowel" d. "this is an easy way to rule out having colon cancer"
d. "this is an easy way to rule out having colon cancer"
Which item would be most beneficial when providing oral care to a patient with metastatic cancer who is at risk for oral tissue injury secondary to chemotherapy? a. firm-bristle toothbrush b. hydrogen peroxide rinse c. alcohol-based mouthwash d. 1 tsp salt in 1 L water mouth rinse
d. 1 tsp salt in 1 L water mouth rinse
The patient is receiving biological targeted therapy for ovarian cancer. What medication should the nurse expect to administer before therapy to combat the most common side effects of these medications? a. morphine b. ibuprofen c. ondansetron d. acetaminophen
d. acetaminophen
Which cellular dysfunction in the process of cancer development allows defective cell proliferation? a. proto-oncogenes b. cell differentiation c. dynamic equilibrium d. activation of oncogenes
d. activation of oncogenes
The nurse is caring for a patient suffering from anorexia secondary to chemo. Which strategy would be most appropriate for the nurse to use the increase the patient's nutritional intake? a. increase intake of liquids at mealtime to stimulate the appetite b. serve three large meals per day plus snacks between each meal c. avoid the use of liquid protein supplements to encourage eating at mealtime d. add items such as skim milk powder, cheese, honey, or peanut butter to selected foods
d. add items such as skim milk powder, cheese, honey, or peanut butter to selected foods
A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? a. blood-tinged sputum b. dry, non-productive cough c. sore throat d. bronchospasm
d. bronchospasm
A nurse in a clinic is caring for a client who has suspected anemia. The nurse should anticipate a prescription from the provider for which of the following tests? a. INR b. platelet count c. WBC count d. hemoglobin level
d. hemoglobin level
A child diagnosed with TOF becomes upset, crying, and thrashing around when a blood specimen is obtained. The child's color becomes blue and the respiratory rate increases to 44 breaths/ min. Which of the following actions should the nurse do first? a. obtain an order for sedation for the child b. assess for an irregular HR and rhythm c. explain to the child that it will only hurt for a short time d. place the child in a knee-to-chest position
d. place the child in a knee-to-chest position
Which nursing diagnosis is most appropriate for a patient experiencing myelosuppression secondary to chemo for cancer treatment? a. acute pain b. hypothermia c. powerlessness d. risk for infection
d. risk for infection
The patient is being treated with brachytherapy for cervical cancer. What factors must the nurse be aware of to protect herself when caring for this patient? a. the medications the patient is taking b. the nutritional supplements that will help the patient c. how much time is needed to provide the patient's care d. the time the nurse spends at what distance from the patient
d. the time the nurse spends at what distance from the patient
An 8 month baby girl is admitted to a pediatric unit for RSV. The baby is crying and being held by their mother. A nurse wants to provide appropriate care based on Erikson's developmental stages. In which stage is this baby in according to Erikson's theory? a. punishment vs obedience orientation b. oral stage c. initiative vs guilt d. trust vs mistrust
d. trust vs mistrust
A 36 y/o multigravida client is admitted to the hospital with possible ruptured ectopic pregnancy. When obtaining the client's history, which of the following would be most important to identify as a predisposing factor? a. UTI b. marijuana use during pregnancy c. episodes of pelvic inflammatory disease d. use of estrogen-progestin contraceptives
d. use of estrogen-progestin contraceptives
