NCLEX practice test

The medication prescribed is methylprednisolone acetate 60 mg intramuscularly. The medication label states methylprednisolone acetate 40 mg/1 mL. How many milliliters will the nurse prepare to administer to the client?

1.5 mL

The nurse provides information to the mother of a toddler regarding toilet-training. The nurse would tell the mother what information? Select all that apply. "Bladder control is usually achieved before bowel control." "The child should not be forced to sit on the potty for long periods." "The ability of the child to remove clothing is a sign of physical readiness." "Waiting until the child is 24 to 30 months old makes the task considerably easier." "At the age of 24 to 30 months old, the toddler is usually less negative and more willing to control their sphincters to please their parents."

"The child should not be forced to sit on the potty for long periods." "The ability of the child to remove clothing is a sign of physical readiness." "Waiting until the child is 24 to 30 months old makes the task considerably easier." "At the age of 24 to 30 months old, the toddler is usually less negative and more willing to control their sphincters to please their parents."

A client with sickle cell anemia is being treated for sickle cell crisis. The primary health care provider prescribes morphine sulfate 2 mg. The concentration of the vial is 10 mg/mL of solution. How many milliliters of solution would the nurse administer?

0.2 mL

Morphine sulfate, 2.5 mg subcutaneously, is prescribed for a child postoperatively. The medication label reads 2 mg/mL. How many milliliters should the nurse administer?

1.25 mL

Morphine 8 mg IM has been prescribed by the primary health care provider. The medication label reads morphine 4 mg/mL. The nurse would prepare how many milliliters to administer the correct dose?

2 mL

A primary health care provider prescribes digoxin 0.5 mg orally daily for a client with heart failure. The medication label states "0.25 mg per tablet." How many tablet(s) will the nurse administer to the client?

2 tablets

The nurse is caring for a client who has had a spinal fusion with insertion of hardware. The nurse would be especially concerned with which finding? A. An oral temperature of 101°F orally B. Complaints of discomfort during repositioning C. Old bloody drainage outlined on the surgical dressing D. Discomfort during coughing and deep-breathing exercises

A. An oral temperature of 101°F orally

The nurse is ambulating a client with a known seizure disorder. The client says, "I'm seeing those flashing lights again," then loses consciousness and develops a clonic-tonic seizure. Which would be the nurse's initial action? A. Assist the client to the floor. B. Administer a dose of phenytoin. C. Stat page the primary health care provider. D. Insert an oral airway into the client's mouth.

A. Assist the client to the floor.

A client will undergo a barium swallow to confirm a diagnosis of a hiatal hernia. In preparation for the test, which instruction would the nurse provide the client? A. Avoid eating or drinking after midnight before the test. B. Take all routine medications on the morning of the test. C. Have a clear liquid breakfast only on the morning of the test. D. Smoke no more than two cigarettes on the morning of the test.

A. Avoid eating or drinking after midnight before the test.

Neuroleptic malignant syndrome is suspected in a client who is taking chlorpromazine. Which medication would the nurse prepare in anticipation of the prescription to treat this adverse effect related to the use of chlorpromazine? A. Bromocriptine B. Phytonadione C. Enalapril maleate D. Protamine sulfate

A. Bromocriptine

The emergency department nurse is gathering initial data on a child suspected of epiglottitis. Which is the nurse's highest priority? A. Check for a patent airway. B. Prepare the child for an x-ray. C. Prepare the child for tracheotomy. D. Assist the primary health care provider with intubation.

A. Check for a patent airway.

The nurse is caring for a client with long-term Alzheimer's disease (AD). Which are some of the behavioral manifestations the nurse would expect to observe? Select all that apply. Apraxia Aphasia Agnosia Hyperorality Somatization Operant conditioning

Apraxia (loss of ability to preform purposeful movements) Aphasia (difficulty in the formation of words) Agnosia (loss of knowledge/ cognitive loss) Hyperorality (desire to taste/chew/ everything)

The nurse is assessing a client diagnosed with posttraumatic stress disorder (PTSD). The nurse knows that according to current references, PTSD signs/symptoms can be grouped into which three main categories? Select all that apply. Anxiety Avoidance Flashbacks Hyperarousal Reexperiencing Difficulty concentrating

Avoidance Hyperarousal Reexperiencing

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. Which is the priority nursing action? A. Prepare for an oxytocin infusion. B. Keep the client in a side-lying position. C. Prepare the client for epidural anesthesia. D. Encourage the client to start pushing with the contractions.

B. Keep the client in a side-lying position. (ABCs- maintaining a side lying position will promote fetal oxygenation)

A hospitalized child with leukemia has received chemotherapy by the intravenous (IV) route, and a discharge to home is being planned. Laboratory values indicate that the child is neutropenic. The child is being treated daily by cleansing and the application of a topical antibiotic on an open area from an old IV site. The nurse reinforces instructions to the mother regarding the signs of infection at this affected site. Which statement by the mother indicates that the mother understands the instructions? A. "Pus at the site means that an infection is present." B. "I will clean the site and apply the topical ointment every day." C. "If I see redness at the site, I don't need to worry as long as there is no pus." D. "If the temperature is elevated, I don't need to be concerned, because this is normal with affected white blood cells."

B. "I will clean the site and apply the topical ointment every day."

A client has self-administered his first injection of regular insulin at 7:30 a.m., before breakfast. This client would be instructed to closely monitor for signs of hypoglycemia at which time? A. 7:30 a.m. B. 11:00 a.m. C. 2:30 p.m. D. 7:00 p.m.

B. 11:00 a.m. (peak time is 2-4 hours for regular insulin)

The nurse has just supervised a client who has newly diagnosed diabetes mellitus self-inject NPH insulin at 7:30 am. The nurse reviews the time frames for peak insulin action with the client, telling the client to be especially watchful for a hypoglycemic reaction during which time frame? A. 7:30 am and 9:30 am B. 1:30 pm and 7:30 pm C. 8:30 pm and 12:00 am D. 2:30 am and 4:30 am Submit

B. 1:30 pm and 7:30 pm (NPH peaks in 6-12 hours)

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states to report which occurrence immediately? A. Impaired sense of hearing B. Problems with visual acuity C. Gastrointestinal (GI) side effects D. Red-orange discoloration of body secretions

B. Problems with visual acuity (this medication causes optic neuritis)

The nurse is caring for a client who has undergone pelvic exenteration. In addressing psychosocial issues related to the surgery, which statement by the nurse would be therapeutic? A. "Would you like to talk?" B. "You are looking good today." C. "How do you feel about this surgery?" D. "Will your family and any friends help you deal with this?"

C. "How do you feel about this surgery?"

The nurse is reinforcing instructions to the client about insulin glargine. The nurse determines that the client understands the action of the medication if the client makes which statement? A. "I will add this medication to my insulin pump." B. "I will take this medication 30 minutes before each meal." C. "I will give myself this medication subcutaneously once each night before bed." D. "I will only need to monitor my blood glucose every other day with this medication."

C. "I will give myself this medication subcutaneously once each night before bed."

Nifedipine has been prescribed for a client with Raynaud's disease, and the nurse reinforces medication instructions with the client about the medication. Which statement by the client indicates a need for further teaching? A. "I will contact my doctor if I get short of breath." B. "I will call my doctor if I get headaches that worsen." C. "Nausea and drowsiness are expected, and if they occur, I don't really need to worry about it." D. "I need to get up slowly when I change positions because the medicine causes hypotension."

C. "Nausea and drowsiness are expected, and if they occur, I don't really need to worry about it."

The mother of a child who had a myringotomy with insertion of tympanostomy tubes calls the nurse and tells the nurse that the "tubes" fell out. The nurse would make which response to the mother? A. "Replace the tubes immediately so that the created opening does not close." B. "Soak the tubes in alcohol for 1 hour before replacing them in the child's ears." C. "This is not an emergency. I will speak to the primary health care provider and call you right back." D. "This is an emergency and requires immediate intervention. Bring the child to the emergency department."

C. "This is not an emergency. I will speak to the primary health care provider and call you right back."

The mother of a 2-year-old child asks the nurse if it is all right to give the child a bottle at naptime. Which response by the nurse is appropriate? A. "At this age, the child may have a bottle at any time." B. "A bottle may be given if the child isn't taking fluids well during the day." C. "You may give the child a bottle if necessary, but if you do, it should contain water." D. "The child may have a bottle at naptime, but it is best not to give a bottle at bedtime."

C. "You may give the child a bottle if necessary, but if you do, it should contain water."

A licensed practical nurse (LPN) is assigned to assist in caring for a hospitalized child who is receiving a continuous infusion of intravenous (IV) potassium for the treatment of dehydration. The LPN monitors the child closely and notifies the registered nurse if which finding is noted? A. Weight increase of 0.5 kg B. Temperature of 100.8° F rectally C. A decrease in urine output to 0.5 mL/kg/hr D. Blood pressure (BP) unchanged from baseline

C. A decrease in urine output to 0.5 mL/kg/hr

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is the nurse's most important intervention to maintain client safety? A. Request that a peer remain with the client at all times. B. Remove the client's clothing and place the client in a hospital gown. C. Assign a staff member to the client who will remain with him or her at all times. D. Admit the client to a seclusion room where all potentially dangerous articles are removed.

C. Assign a staff member to the client who will remain with him or her at all times.

A client has experienced pulmonary embolism. The nurse would assess for which symptom that is most commonly reported? A. Hot, flushed feeling B. Sudden chills and fever C. Chest pain that occurs suddenly D. Dyspnea when deep breaths are taken

C. Chest pain that occurs suddenly

A pregnant woman in the second trimester of pregnancy complains of constipation and describes the home care measures she is taking to relieve the problem. Which would the nurse determine is a harmful measure in preventing constipation? A. Drinking eight to 10 glasses of water daily B. Daily activity such as walking or swimming C. Increasing whole grains and fresh vegetables in the diet D. Adding 1 tablespoon of mineral oil to a bowl of cereal daily

D. Adding 1 tablespoon of mineral oil to a bowl of cereal daily

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times? A. Immediately before swimming B. 5 minutes before exposure to the sun C. Immediately before exposure to the sun D. At least 30 minutes before exposure to the sun

D. At least 30 minutes before exposure to the sun

A pilocarpine ocular system is prescribed for the client with glaucoma. The nurse reinforces instructions to the client regarding the medication. Which statement by the client indicates an understanding of the use of this medication? A. "I should apply ½ inch into my eye at bedtime." B. "I need to replace the ocular system every 48 hours." C. "I should apply 1 drop of the solution 4 times a day." D. "I should check my eye each morning to make sure that the medication system is in place."

D. "I should check my eye each morning to make sure that the medication system is in place."

A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse would make which therapeutic response to the client? A. "Go on...." B. "Sleeping?" C. "The last couple of nights?" D. "Tell me about your difficulty sleeping."

D. "Tell me about your difficulty sleeping."

The nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic? A. "Right! Why not just 'pack it in'?" B. "That seems rather unlikely to me." C. "I don't believe that, and neither do you." D. "You must be feeling all alone at this point."

D. "You must be feeling all alone at this point."

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse would monitor for which symptoms? A. Hypotension, ataxia, vomiting B. Stupor, agitation, muscular rigidity C. Hypotension, bradycardia, agitation D. Hypertension, disorientation, hallucinations

D. Hypertension, disorientation, hallucinations

The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for a potassium deficit? A. The client with Addison's disease B. The client with metabolic acidosis C. The client with intestinal obstruction D. The client receiving nasogastric suction

D. The client receiving nasogastric suction (Nasogastric suction not only results in a loss of body fluid, but also of electrolytes)

The nurse is caring for a client with a diagnosis of pneumonia and a history of bleeding esophageal varices. Based on this information, the nurse would plan care knowing that which could most result in a potential complication? A. Pain B. Diarrhea C. Frequent swallowing D. Vigorous coughing

D. Vigorous coughing (increases intrathoracic pressure)

The licensed practical nurse is assisting the registered nurse (RN) in the care of a child who is receiving a blood transfusion and notifies the RN if the child displays which signs/symptoms of fluid overload? Select all that apply. Chills Itching Back pain Dry cough Distended neck veins

Dry cough Distended neck veins

The nurse is reinforcing instructions to a client and family regarding home care following cataract removal with lens implantation in the left eye. The nurse would provide the client with instructions to contact the surgeon promptly for which signs or symptoms? Select all that apply. New floaters Improvement in vision clarity Increasing redness in the eye Sensation of mild grittiness in the eye Pain relieved by acetaminophen 500 mg

New floaters Increasing redness in the eye

The nurse has reviewed the primary health care provider's prescriptions for a child suspected of a diagnosis of neuroblastoma and is preparing to implement diagnostic procedures that will confirm the diagnosis. The nurse prepares to do which? A. Collect a 24-hour urine sample. B. Perform a neurological assessment. C. Assist with a bone marrow aspiration. D. Send the child to the radiology department for a chest x-ray.

A. Collect a 24-hour urine sample.

The nurse would anticipate the use of which medications in the treatment of the client with heart failure? Select all that apply. A. Diuretics B. Anticoagulants C. Anticholinergics D. Cardiac glycosides E. Phosphodiesterase (PDE) inhibitors F. Angiotensin-converting enzyme (ACE) inhibitors

A. Diuretics. D. Cardiac glycosides E. Phosphodiesterase (PDE) inhibitors F. Angiotensin-converting enzyme (ACE) inhibitors

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. Which would be the initial nursing action? A. Prepare the triage rooms. B. Activate the agency emergency response plan. C. Obtain additional supplies from the central supply department. D. Obtain additional nursing staff to assist with treating the casualties.

B. Activate the agency emergency response plan.

Which diagnostic test would verify the diagnosis of macular degeneration? A. Tonometer B. Snellen chart C. Amsler grid test D. Ishihara chart book

C. Amsler grid test

A child suspected of sickle cell disease is seen in the clinic, and laboratory studies are performed. The nurse reviews the results of the laboratory studies and expects to note which characteristic of this disease? A. Increased platelet count B. Increased hematocrit count C. Increased reticulocyte count D. Increased hemoglobin count

C. Increased reticulocyte count (this value occurs in kids w/ sickle cell)

While assisting with the measurement of fundal height, the client at 36 weeks' gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely a result of which reason? A. A full bladder B. Emotional instability C. Insufficient iron intake. D. Compression of the vena cava

D. Compression of the vena cava

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings would the nurse expect to note? A. Sweating and tremors B. Hunger and hypertension C. Cold, clammy skin and irritability D. Fruity breath odor and decreasing level of consciousness

D. Fruity breath odor and decreasing level of consciousness

The nurse walks into a client's room and notes what appears to be ventricular tachycardia on the monitor. The nurse cannot find a palpable pulse. After beginning cardiopulmonary resuscitation (CPR), what steps would the nurse take next? A. Attach the defibrillator and shock B. Call for help and wait until help arrives C. Attach the defibrillator and establish intravenous access D. Attach the defibrillator and determine if the rhythm is shockable

D. Attach the defibrillator and determine if the rhythm is shockable

To assess for the presence of the posterior tibialis pulse, the nurse would palpate which areas? A. In the groove just below the inguinal ligament B. Behind the knee and lateral to the medial tendon C. Lateral to and parallel with the extensor tendon of the big toe D. In the groove behind the medial malleolus and the Achilles tendon

D. In the groove behind the medial malleolus and the Achilles tendon

The nurse is reviewing the health care record of a client with a diagnosis of chronic pancreatitis. The nurse would determine that which data noted in the record indicate poor absorption of dietary fats? A. Steatorrhea B. Bloody diarrhea C. Electrolyte disturbances D. Gastrointestinal reflux disease

A. Steatorrhea (occurs when the absorption of fat is not possible)

The nurse would monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn? A. Tachypnea and retractions B. Acrocyanosis and grunting C. Hypotension and bradycardia D. The presence of a barrel chest with acrocyanosis

A. Tachypnea and retractions (The newborn infant with RDS may present with clinical signs of cyanosis, tachypnea, apnea, nasal flaring, chest wall retractions, or audible grunts)

The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which finding would the nurse expect to note documented in the infant's record regarding this condition? A. Hip joint laxity B. Symmetric thigh and gluteal folds C. Full range of motion in the affected hip D. An apparent short femur on the unaffected side

A.Hip joint laxity

A client taking metronidazole for the treatment of Trichomonas vaginalis calls the nurse employed in the primary health care provider's office concerned because of a feeling of tingling and numbness in the extremities. Which instructions would the nurse provide to the client? A. Increase fluid intake. B. Discontinue the medication. C. Numbness and tingling of the extremities is a harmless side effect. D. Report to the clinic to see the primary health care provider immediately.

D. Report to the clinic to see the primary health care provider immediately.

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse would identify which as a priority concern? A. The client's report of not eating or sleeping B. The presence of bruises on the client's body C. The client's report of self-destructive thoughts D. The family member's disapproval of the treatment

C. The client's report of self-destructive thoughts

This morning a client sustained a right proximal fibula and tibia fracture that was casted in a long leg plaster cast. During evening rounds, the nurse notes that the right lower extremity capillary refill is greater than 3 seconds and the toes are edematous and dusky. The client states that the pain medication is not working anymore and that the right foot feels like it is asleep. The nurse analyzes the data and determines that the client's signs/symptoms are indicative of which complication? A. Fat embolism B. Venous thrombosis C. Volkmann's thrombosis D. Compartment syndrome

D. Compartment syndrome

The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence several times. Based on the nurse practice act, the observing nurse would plan to take which action? A. Report the information to the police. B. Call the impaired nurse organization. C. Talk with the nurse who gave the medication. D. Report the information to a nursing supervisor.

D. Report the information to a nursing supervisor.

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action? A. Call the nursing supervisor to initiate a court order for the surgical procedure. B. Try calling the client's spouse to obtain telephone consent before the surgical procedure. C. Ask the friend who accompanied the client to the emergency department to sign the consent form. D. Transport the client to the operating department immediately without obtaining an informed consent

D. Transport the client to the operating department immediately without obtaining an informed consent

A child is brought to the emergency room, and the mother reports that the child accidentally swallowed paint thinner after mistaking it for water. The nurse would perform which action first? A. Begin resuscitation. B. Terminate exposure to the poison. C. Take measures to prevent absorption of the poison. D. Check the circulation, airway, and breathing status of the child.

D. Check the circulation, airway, and breathing status of the child.

The nurse is teaching a pregnant client how to perform Kegel exercises. The nurse would tell the client that these exercises are for which purpose? A. Reduce a backache. B. Prevent ankle edema. C. Prevent urinary tract infections. D. Strengthen the pelvic floor in preparation for delivery.

D. Strengthen the pelvic floor in preparation for delivery.

The nurse is reviewing the criteria for early discharge of a newborn infant with a new mother. Which data, if noted in the infant, indicate that the criterion for early discharge has not been met? A. The infant has evidence of significant jaundice. B. Vital signs are documented as normal and stable. C. The infant has urinated and passed at least one stool. D. The infant has completed at least two successful feedings.

A. The infant has evidence of significant jaundice.

The nurse is collecting data on a newborn admitted to the nursery with a diagnosis of subdural hematoma after a difficult vaginal delivery. Which intervention implemented by the nurse indicates an understanding of a subdural hematoma? A. Checking the urine for blood B. Monitoring urinary output patterns C. Observing for contractures of the extremities D. Testing for equality of extremities when stimulating reflexes

D. Testing for equality of extremities when stimulating reflexes

The nurse notes that a client in a long-term care facility is receiving a daily dose of furosemide. The nurse writes in the care plan to monitor which parameter on a daily basis? A. Weight B. Radial pulse C. Hemoglobin D. Serum creatinine clearance

A. Weight

The nurse obtains a health history from a mother of a 15-month-old child before administering a measles, mumps, and rubella (MMR) vaccine. Which is essential information to obtain before the administration of this vaccine? A. A recent cold B. Allergy to eggs C. The presence of diarrhea D. Any recent ear infections

B. Allergy to eggs

A client is admitted with an arterial ischemic leg ulcer. The nurse expects to note that this ulcer has which typical characteristic? A. Dark, pink base B. Deep and painful C. Accompanied by very slight pain D. Brown pigmentation of surrounding skin

B. Deep and painful

A client, who had experienced significant blood loss in an automobile crash, was admitted to the hospital 2 days earlier. The nurse observes the client for which signs/symptoms that indicate acute kidney injury (AKI)? Select all that apply. A. Hematuria B. Elevated urine specific gravity C. Severe spasmodic pain radiating to the groin area D. Rising serum blood urea nitrogen (BUN) and creatinine levels E. Urine output averaging 25 mL per hour while receiving an intravenous infusion at 150 mL/hour

B. Elevated urine specific gravity D. Rising serum blood urea nitrogen (BUN) and creatinine levels E. Urine output averaging 25 mL per hour while receiving an intravenous infusion at 150 mL/hour

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

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

The nurse is assisting in admitting a client with schizophrenia to an acute-care inpatient psychiatric unit from the emergency department; however, the client refuses admission. Which intervention would the nurse implement? A. Ask the client about future plans. B. Help the client with problem-solving. C. Stand by the door of the client's room. D. Request permission to apply security devices (restraints).

B. Help the client with problem-solving.

A client is admitted to the labor and delivery suite with an intrauterine fetal demise. The nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents make which response? A. State they have no questions B. Request to hold the infant following delivery C. Refuse a footprint and picture of the infant to take home D. Are surprised by the appearance of the infant following delivery

B. Request to hold the infant following delivery (only option that clearly identifies this preparedness)

A client has undergone a transurethral resection of the prostate (TURP) a few hours ago to treat symptoms of benign prostatic hypertrophy. The nurse notes bright red blood and clots in the urinary catheter drainage bag. Which response would be the nurse's initial action? A. Contact the client's surgeon to report the bleeding. B. Remove a small amount of fluid from the retention bulb. C. Increase the flow rate of the continuous bladder irrigation. D. Remove the indwelling catheter and encourage increased oral fluids.

C. Increase the flow rate of the continuous bladder irrigation.

A client is diagnosed with schizophrenia. The nurse is asked to assist in preparing a nursing care plan for the client. Which is important for the nurse to understand when planning? A. The client is allowed to set the goals for the plan of care. B. Letting the client act out and using the quiet room and restraints will be required initially. C. Until the client's thinking is cleared, the nurse may need to assist the client with grooming and nutrition. D. Refraining from pointing out the inconsistencies of the client's communication is essential to initial treatment.

C. Until the client's thinking is cleared, the nurse may need to assist the client with grooming and nutrition.

A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing? A. Uncaps the distal end of the tubing B. Uncaps the spike portion of the tubing C. Opens the roller clamp on the IV tubing D. Closes the roller clamp on the IV tubing

D. Closes the roller clamp on the IV tubing

The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item? A. Band-Aid B. Alcohol swab C. Betadine swab D. Sterile 2 × 2 gauze

D. Sterile 2 × 2 gauze

A client is admitted to the hospital with complaints of back spasms. The client states, "I have been taking 2 or 3 aspirin every 4 hours for the past week, and it hasn't helped my back." Aspirin intoxication is suspected. Which complaint would indicate aspirin intoxication? A. Tinnitus B. Constipation C. Photosensitivity D. Abdominal cramps

A. Tinnitus (ringing in the ears)

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which signs would the nurse expect to note in the health record when collecting data related to the respiratory system for this client? A. Stridor and cyanotic lips B. Diminished breath sounds and fever C. Wheezes and use of accessory muscles D. Pleural friction rub and inspirational chest pain

C. Wheezes and use of accessory muscles

The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse would take which appropriate action? A. Document the finding. B. Continue to monitor vital signs. C. Report the finding to the registered nurse (RN). D. Mark the drainage on the dressing and monitor for any increase in bleeding.

C. Report the finding to the registered nurse (RN). (bright red blood indicates active bleeding)

When checking a child's glossopharyngeal nerve function, the nurse would perform which data collection technique? A. Have the child shrug the shoulders while applying mild pressure. B. Have the child follow a light in the 6 cardinal positions of gaze. C. Test sense of sour or bitter taste on the posterior segment of the tongue. D. Test sense of sweet or salty taste on the anterior section of the tongue.

C. Test sense of sour or bitter taste on the posterior segment of the tongue.

Trimethoprim-sulfamethoxazole is prescribed for a client. The nurse would instruct the client to report which symptom if it developed during the course of this medication therapy? A. Nausea B. Diarrhea C. Headache D. Sore throat

D. Sore throat (this medication can cause blood dyscrasias - invloves lymph and phlegm)

A young adult college student begins to throw objects, shout insults, and stamp his feet after an instructor returned his work, noting it was substandard. Using Erikson's theory of personality development, which developmental stage has this individual unsuccessfully mastered? A. Initiative vs. guilt B. Industry vs. inferiority C. Identity vs. role confusion D. Autonomy vs. shame and doubt

D. Autonomy vs. shame and doubt

A hospitalized client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administers nitroglycerin, 0.4 mg sublingually. After 5 minutes, the client states, "My chest still hurts." If the vital signs have remained stable, which action would the nurse perform? A. Apply 10 L of oxygen via nasal cannula. B. Administer another nitroglycerin tablet. C. Call the resuscitation team immediately. Administer a second nitroglycerin tablet in 10 minutes.

B. Administer another nitroglycerin tablet.