NCLEX Practice Test questions for exam 3
The nurse would take which action to protect the client from infection at the portal of entry? 1. Place sputum specimen in a biohazard bag for transport to the lab. 2. Empty Jackson- Pratt drain using sterile technique. 3. Dispose of soiled gloves in waste container. 4. Wash hands after providing client care.
Answer 2
Which assessment finding by the nurse warrants further investigation to determine if the client has rheumatoid arthritis ( RA)? 1. Negative family history 2. Reports of prolonged morning stiffness lasting for 1 hour 3. Occasional use of NSAIDs for aches and pains 4. Reports of pain with movement
Answer 2
The pediatric nurse would suspect severe combined immunodeficiency disorder ( SCID) when which child is admitted to the hospital nursing unit? 1. A 2- month- old with thrush and low white blood cell counts 2. A 2- year- old with history of recent repeated infections 3. A newborn with positive TORCH titer 4. A newborn admitted with positive ELISA test
Answer 1
The nurse is inserting an intravenous ( IV) line into a cli-ent. After piercing the skin and entering the vein, what manifestation should cause the nurse to refrain from advancing the catheter? 1. Blood backflow into the IV catheter 2. Mild resistance with advancement 3. No reports of client discomfort 4. IV catheter was inserted bevel side up
Answer 2
Which precaution would the nurse implement when admitting a client with herpes zoster to the nursing unit? 1. Airborne precautions 2. Contact precautions 3. Droplet precautions 4. Neutropenic precautions
Answer 2
The nurse would report to the charge nurse that an assigned client has hyperkalemia after noting that the serum potassium level drawn that morning was greater than how many mEq/ L? Provide a numerical answer. ____ mEq/ L
Answer 5.1
A client with vancomycin- intermediate- resistant Staphylococcus aureus ( VISA) is admitted to the nursing unit. What type of precautions should the nurse institute? 1. Standard precautions 2. Neutropenic precautions 3. Droplet precautions 4. Contact precautions
Answer 4
The nurse is preparing to start a peripheral intravenous ( IV) line in a client. The client's record indicates a latex allergy. What action should be taken by the nurse? 1. Utilize a new tourniquet for this client. 2. Use a blood pressure cuff to distend the vein. 3. Avoid putting povidone iodine on the skin. 4. Initiate a latex- free alternative therapy.
Answer 2
What instruction should the nurse include in an education program to prevent dehydration for a high school hiking club that is planning a 12- mile hike in early summer? 1. Take water and commercial sports drinks to sip often along the way. 2. Drink large amounts of water, at least 16 ounces every hour, while hiking. 3. Take salt tablets every 3- 4 hours, and drink plenty of water while in the heat. 4. Stop every 4 hours along the way, and drink a few ounces of water while resting.
Answer 1
Which finding in a client's history would alert the nurse to assess for signs of hypophosphatemia? 1. Alcohol abuse 2. The oliguric phase of acute tubular necrosis 3. Short- term gastric suction 4. Occasional use of aluminum- containing antacids
Answer 1
Which medication reported by a client during a nursing history could be associated with the development of hypocalcemia? 1. Phenytoin ( Dilantin) 2. Calcium carbonate ( TUMS) 3. Calcitriol 4. Hydrochlorothiazide ( HydroDIURIL)
Answer 1
While assessing a client's intravenous ( IV) line, the nurse notes that the area is swollen, cool, pale, and causes the client discomfort. What complication should the nurse document? 1. Infiltration 2. Phlebitis 3. Infection 4. Air embolism
Answer 1
The nurse is restarting an IV line on a client known to have hepatitis B. Which precautions should the nurse use to protect against exposure? Select all that apply. 1. Handwashing 2. Gloves 3. Mask 4. Face shield 5. Gown
Answer 1, 2
The nurse would take which actions to comply with principles of medical asepsis? Select all that apply. 1. Wash hands before and after assisting client with personal hygiene. 2. Wear gown and gloves when working with client on contact precautions. 3. Re- cap needle after administering insulin. 4. Insert needle into rubber port of a previously used multidose vial without swabbing it with alcohol. 5. Use surgical facemask while working with client who has tuberculosis.
Answer 1, 2
The nurse teaches a client that which factor might increase risk of developing an exacerbation of systemic lupus erythematosus ( SLE)? 1. Pregnancy 2. Hypotension 3. Fever 4. GI upset
Answer 1
The nurse would assess for which electrolyte imbalance as a common finding in a client with AIDS? 1. Hyponatremia 2. Hypernatremia 3. Hyperkalemia 4. Hypocalcemia
Answer 1
The nurse would suspect that a client who frequently uses which medication is at risk for developing metabolic alkalosis? 1. Calcium carbonate ( Tums) 2. Ibuprofen ( Motrin) 3. Acetylsalicylic acid ( aspirin) 4. Acetaminophen ( Tylenol)
Answer 1
The nurse writing a care plan determines that which nursing diagnosis is a priority early in the care of a client with scleroderma? 1. Impaired Skin Integrity 2. Disturbed Body Image 3. Activity Intolerance 4. Hopelessness
Answer 1
The nurse looks for results of which laboratory measure-ment that provides a reliable indicator of lymphocyte sta-tus in a client with HIV infection? 1. B lymphocytes 2. T- helper cells ( CD 4 ) 3. Natural killer cells ( NK) 4. T- cytotoxic cells
Answer 2
A client has been admitted for dehydration after fasting for five days. For which acid- base imbalance would the nurse assess this client? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
Answer 1
A client is admitted with severe diarrhea. Arterial blood gas ( ABG) results are pH 7.33; PaCO 2 42; HCO 3 - 20. The nurse concludes this client has which acid- base imbalance? 1. Uncompensated metabolic acidosis 2. Compensated respiratory acidosis 3. Compensated metabolic acidosis 4. Uncompensated respiratory acidosis
Answer 1
A client with end stage renal disease is experiencing hypermagnesemia. The nurse explains that which treatment will decrease the magnesium level most effectively? 1. Dialysis 2. Diuretics 3. Fluid restriction 4. High- volume IV fluids
Answer 1
A client with suspected severe acute respiratory syndrome ( SARS) arrives at the emergency department. Which physician order should the nurse implement first? 1. Airborne and contact precautions 2. IV D 5 NS at 100 mL/ hr 3. Nasopharyngeal culture for reverse- transcription polymerase chain reaction 4. Sputum for enzyme immunoassay testing
Answer 1
A client with tuberculosis asks the nurse if visitors will need to wear masks. What response by the nurse is most accurate? 1. " Everyone who enters your room must wear a mask to protect themselves from tuberculosis." 2. " Masks would not be necessary for visitors who have had tuberculosis before." 3. " It is less important for your family to wear masks, since they live in close contact with you." 4. " Only visitors who are at risk for tuberculosis need to wear a mask."
Answer 1
A client's arterial blood gas ( ABG) results are pH 7.36; PaCO 2 50; HCO 3 - 28. What do these results indicate to the nurse? 1. Compensated respiratory acidosis 2. Compensated metabolic acidosis 3. Uncompensated metabolic acidosis 4. Uncompensated respiratory acidosis
Answer 1
The client has a percutaneous jugular central venous line that is capped and used for intermittent infusions. After administering the medication, the best method to maintain patency is to do which of the following? 1. Flush the line first with 3- 5 mL of normal saline, then with 1- 3 mL of heparinized normal saline. 2. Flush the line with 3- 5 mL of normal saline. 3. Flush the line with 3- 5 mL of heparinized normal saline. 4. Flush the line first with 3- 5 mL of heparin, then with 1- 3 mL of normal saline.
Answer 1
The family of a client with hypercalcemia states that the client is " not acting like himself." The nurse focuses assessment on which manifestation? 1. Personality change 2. Anxiety 3. Seizure activity 4. Carpal spasms
Answer 1
The home health nurse is monitoring a client who performs self- care of a central line. The nurse observes the client doing all of the following activities. Which activity indicates the need for further education? 1. Flushing the central line with a 3 mL syringe 2. Cleaning the needleless injection cap with alcohol before accessing 3. Using sterile gloves to change the central line dressing 4. Wearing a mask while changing the central line dressing
Answer 1
The nurse assigned to the respiratory care unit is working with four clients who have pneumonia. The nurse should assign the only remaining private room on the nursing unit to the client infected with which organism? 1. Penicillin- resistant Streptococcus pneumoniae pneumonia 2. Pseudomonas aeruginosa pneumonia 3. Pneumocystis carinii pneumonia 4. Legionella pneumophila pneumonia
Answer 1
The nurse is caring for a pediatric client with acquired immunodeficiency syndrome ( AIDS). Which activity by the nurse should be reported to the employee health department as an exposure for the nurse? 1. While flushing out the used bedpan, fluid splashes in the nurse's eyes. 2. The nurse does not wear a mask while in the client's room. 3. During the bath, the nurse removes gloves when giving a backrub on intact skin. 4. The nurse is stabbed with a sterile syringe to be used to draw up the client's medications.
Answer 1
The nurse is caring for several clients with central venous catheters. While changing the tubing on the central lines, the nurse would not need to instruct the client to perform Valsalva maneuver when the client has which catheter? 1. Groshong 2. Single- lumen 3. Percutaneous 4. Accessed subcutaneous venous port
Answer 1
The nurse is caring for a client with hepatitis A. Which client statements indicate that teaching conducted by the nurse about disease transmission was effective? Select all that apply. 1. " We must avoid kissing." 2. " We can use the same bath towels." 3. " We must avoid eating with the same utensils." 4. " We must wear masks." 5. " No special precautions are needed."
Answer 1, 3
A client is admitted to the hospital with a diagnosis of respiratory acidosis secondary to overdose of barbiturates. Which assessment would the nurse anticipate? Select all that apply. 1. Slow, shallow respirations 2. Tetany symptoms 3. Increased deep tendon reflexes 4. Palpitations 5. Headache
Answer 1, 5
Medication instruction for the client with rheumatoid arthritis ( RA) should include which teaching points? Select all that apply. 1. Injection of gold salts requires monitoring for anaphylactic reactions every half- hour. 2. Treatment with sulfasalazine requires fluid restriction to avoid nausea and vomiting. 3. Acetaminophen may be used to decrease inflammation associated with RA. 4. Penicillamine may be safely used during pregnancy. 5. Nonsteroidal anti- inflammatory drugs ( NSAIDs) and aspirin may be used interchangeably to decrease inflammation.
Answer 1, 5
The nurse assesses the client with rheumatoid arthritis for which characteristic joint changes? Select all that apply. 1. Swan- neck deformity 2. Heberden's and Bouchard's nodes 3. Tophi 4. Charcot's joints 5. Ulnar deviation
Answer 1, 5
The nurse is caring for a client who has sustained partial and full thickness burns over 30% of his body 18 hours ago. The nurse assesses for which fluid and electrolyte imbalances at this time? Select all that apply. 1. Hyperkalemia 2. Hypokalemia 3. Hypervolemia 4. Hypercalcemia 5. Hypovolemia
Answer 1, 5
A 10- month- old infant is admitted to the emergency department with a 102° F rectal temperature and a history of vomiting and diarrhea for 48 hours. For what signs should the nurse look related to this client's likely fluid imbalance? 1. Bulging fontanels, tearless cry, and low urine output 2. Sunken eyes, lethargy, and dry, furrowed tongue 3. Weight loss, dilute urine, and peripheral edema 4. Dry skin, thready pulse, and neck vein distention
Answer 2
A 12- year- old boy is diagnosed with early human immunodeficiency virus ( HIV) infection secondary to factor transfusions for hemophilia. The family is very concerned about their ability to manage his care, risk of infection to family members, and whether the child should remain in the home. Which action by the nurse will best promote family coping at this time? 1. Explain to the family that the infection cannot be spread by casual contact. 2. Demonstrate positive acceptance of the child with each contact. 3. Explain that prophylactic drugs will prevent the virus from spreading. 4. Show the family how to wash their hands properly.
Answer 2
A client admitted to the hospital with a 30- pound weight gain over the past month has a fat pad at the back of the neck and moon facies. Admission laboratory results indicate decreased serum potassium and magnesium, and elevated serum chloride and sodium levels. The nurse interprets that which disorder is most consistent with these electrolyte abnormalities? 1. Addison's disease 2. Cushing's syndrome 3. Burns 4. Syndrome of inappropriate ADH ( SIADH)
Answer 2
A client diagnosed with scleroderma reports painful fingers that change colors ( pale to red) when washing dishes. Which suggestion by the nurse might help the client with this symptom? 1. Increase the water temperature. 2. Use gloves during dishwashing. 3. Start physical therapy to increase blood flow to the hands. 4. Take over- the- counter H 2 receptor antagonist medications.
Answer 2
A client is admitted to the hospital after vomiting for three days. Which arterial blood gas ( ABG) result would the nurse expect? 1. pH 7.30; PaCO 2 50; HCO 3 - 27 2. pH 7.47; PaCO 2 43; HCO 3 - 28 3. pH 7.34; PaCO 2 50; HCO 3 - 28 4. pH 7.48; PaCO 2 30; HCO 3 - 23
Answer 2
A client is admitted to the hospital with sudden onset of severe abdominal pain. Which arterial blood gas ( ABG) value would the nurse expect to see with this client? 1. PaCO 2 48 2. HCO 3 - 18 3. pH 7.32 4. SaO 2 90
Answer 2
A client is admitted with a diagnosis of renal failure. Which arterial blood gas ( ABG) result would the nurse expect to see with this client? 1. pH 7.49; PaCO 2 36; HCO 3 - 30 2. pH 7.30; PaCO 2 35; HCO 3 - 18 3. pH 7.31; PaCO 2 50; HCO 3 - 23 4. pH 7.43; PaCO 2 48; HCO 3 - 30
Answer 2
A client is to start taking prednisone for treatment of rheumatoid arthritis ( RA). Which client statement indicates that medication teaching was successful? 1. " I will take the medication on an empty stomach to maximize absorption." 2. " I will take the specific dose ordered at the same time every day." 3. " I will not have to limit my sodium intake." 4. " I will not have to adjust my insulin regimen."
Answer 2
A home health nurse is making a visit to an older adult client with a history of heart failure ( HF). The client was prescribed diuretics twice a day and a low- sodium diet. The nurse should be most concerned about which current laboratory result? 1. Sodium 145 mEq/ L 2. Chloride 90 mEq/ L 3. K + 4.2 mEq/ L 4. HCO 3 27 mEq/ L
Answer 2
A male client who has acquired immunodeficiency syndrome ( AIDS) asks why oral progesterone ( Megace) is being prescribed for treatment. What is the nurse's best response? 1. " Megace is used to treat the nausea associated with this infection." 2. " Megace is used as an appetite stimulant to boost nutritional support." 3. " Megace provides symptomatic relief of constipation." 4. " Megace is used as an antineoplastic agent for palliative treatment."
Answer 2
The nurse assessing a client for signs of hypocalcemia would conclude that this electrolyte imbalance exists after noting which finding? 1. Negative Chvostek's sign 2. Positive Trousseau's sign 3. Positive Kernig's sign 4. Hypoactive bowel sounds
Answer 2
The nurse concludes that a history of which condition places a client at risk for possible hypokalemia? 1. Chronic obstructive pulmonary disease (COPD) 2. Cirrhosis 3. Addison's disease 4. Chronic renal failure (CRF)
Answer 2
The nurse determines that a client with a nasogastric tube on low suction for five days is at risk for developing which acid- base imbalance? 1. Respiratory acidosis 2. Metabolic alkalosis 3. Metabolic acidosis 4. Respiratory alkalosis
Answer 2
Which suggestion by the nurse would be most helpful to a human immunodeficiency virus ( HIV) positive client who has altered taste perception? 1. Drink plenty of salty broths and other fluids to stimulate taste buds. 2. Try zinc supplementation to improve taste perception. 3. Increase intake of meat to at least one serving per day. 4. Avoid using plastic eating utensils.
Answer 2
The nurse would assess for which signs and symptoms in a client who has metabolic acidosis? Select all that apply. 1. Weight gain 2. Rapid, deep respirations 3. Drowsiness 4. Decreased respiratory rate and depth 5. Melena
Answer 2, 3
The nurse is preparing to leave the room of a client on transmission- based precautions. Place in the correct order the steps the nurse would follow to remove personal protective equipment and perform hand hygiene. 1. Remove gown. 2. Remove gloves. 3. Remove mask. 4. Remove eye protection. 5. Wash hands.
Answer 2, 3, 1, 4, 5
The nurse is leaving the room of a client who has methicillin- resistant Staphylococcus aureus ( MRSA) microorganisms in a wound and the urine. Place the following personal protective equipment in order of removal. 1. Eye protection 2. Gloves 3. Mask 4. Gown
Answer 2, 3, 4, 1
The nurse is admitting a client who has metabolic alkalosis. The nurse plans to assess for manifestations of which electrolyte imbalance? Select all that apply. 1. Hypernatremia 2. Hypochloremia 3. Hypermagnesemia 4. Hypocalcemia 5. Hypokalemia
Answer 2, 4, 5
The nurse concludes that which sign reliably indicates that ascites fluid is being effectively mobilized in response to therapy? Select all that apply. 1. Weight gain of 1 pound in 24 hours 2. Increase in urine output 3. Drop in blood pressure 4. Hand veins fill slowly 5. Abdominal girth has decreased by 1 inch in 24 hours
Answer 2, 5
Which assessment of an adult client is a reliable indicator that therapy for Fluid Volume Excess is achieving the desired outcome? Select all that apply. 1. Full, bounding peripheral pulses 2. Flat neck veins with the head of the bed elevated 3. Hand vein emptying longer than 20 seconds 4. S 3 heart sound clearly audible on auscultation 5. Lungs sounds are clear
Answer 2, 5
Which statement by the client indicates that discharge teaching for respiratory alkalosis is understood? 1. " I will not take so many antacids anymore." 2. " I will take a stress management class." 3. " I will not take my furosemide ( Lasix) without taking my potassium supplement." 4. " I will tell the doctor the next time I have diarrhea for so long." 5. " I am more aware of how my breathing changes when I get nervous."
Answer 2, 5
Which actions by the nurse comply with core principles of surgical asepsis? Select all that apply. 1. Wash hands before and after client care. 2. Keep sterile field in view at all times. 3. Wear personal protective equipment. 4. Add contents to sterile field holding package 6 inches above field. 5. Consider outer 1.5 inches of sterile field as contaminated.
Answer 2,4
The client is receiving 5% dextrose and 0.45% sodium chloride intravenously and is complaining of pain at the IV site. The nurse assesses the site and notes erythema and edema. What is the appropriate action for the nurse to take? Select all that apply. 1. Slow the infusion to a keep- open rate. 2. Discontinue the IV and apply a warm compress to the IV site. 3. Apply antibiotic ointment to the IV site. 4. Gently pull back on the IV catheter to attempt repositioning. 5. Relocate the IV site and document the event.
Answer 2,5
A 5- year- old child is brought into the clinic after being stung by an insect. The child appears to be going into anaphylactic shock. Which nursing action is of highest priority? 1. Assess urinary output to determine renal perfusion 2. Apply cold, wet compresses to the site 3. Position the child's head to maintain an open airway 4. Establish intravenous access for medication delivery
Answer 3
A client is admitted to the hospital with an acid- base imbalance. Arterial blood gas ( ABG) results are pH 7.33; PaCO 2 49; HCO 3 - 28. How would the nurse interpret these results? 1. Uncompensated respiratory acidosis 2. Metabolic alkalosis, uncompensated 3. Partially compensated respiratory acidosis 4. Partially compensated metabolic acidosis
Answer 3
A client is admitted to the hospital. Arterial blood gas ( ABG) results are pH 7.50; PaCO 2 40; HCO 3 - 29. Which question should the nurse ask the client to help determine an etiology for these results? 1. " Have you had diarrhea lately?" 2. " Do you have a history of COPD?" 3. " How long have you had nausea and vomiting?" 4. " Do you smoke?"
Answer 3
A client presents with dyspnea, pruritis, and localized swelling of the forearm after being stung by a bee. What is the priority nursing intervention? 1. Remove the stinger from the client's arm 2. Keep the client warm with soft blankets 3. Check the tongue for swelling and listen for stridor 4. Place client in the Trendelenburg position
Answer 3
A client will undergo scratch tests for allergies. In teaching the client about the planned tests, the nurse should include which statement? 1. " This test allows us to rule out one or two specific antigens." 2. " The scratch test is the most sensitive allergy test." 3. " Results can be obtained in 30 minutes." 4. " It involves drawing a small amount of blood for testing."
Answer 3
A client with hypocalcemia is taking supplemental vita-min D. When the client asks the purpose of this therapy, what explanation should the nurse give? 1. It directly opposes calcitonin. 2. It prevents renal disease in clients with hypocalcemia. 3. Calcium is absorbed in the intestines only under the influence of activated vitamin D. 4. The only way to obtain vitamin D is with oral supplementation.
Answer 3
A client's arterial blood gas ( ABG) results are pH 7.48; PaCO 2 30; HCO 3 - 23. How will the nurse interpret these results? 1. Compensated respiratory alkalosis 2. Uncompensated metabolic alkalosis 3. Uncompensated respiratory alkalosis 4. Compensated metabolic alkalosis
Answer 3
In establishing a plan of care to manage pain for a client with rheumatoid arthritis ( RA), what intervention would the nurse use to increase the client's mobility? 1. Have the client work through pain by continuing exercise in order to establish endurance. 2. Have the client use pain medication only when pain is present. 3. Teach the client that both heat and cold applications may help to relieve pain. 4. Teach the client to flex muscle groups when pain is felt in an extremity.
Answer 3
The client has a tunneled Groshong catheter for intermittent medication administration. After administering the medication, the nurse prepares to do which of the following? 1. Clamp the catheter after medication administration. 2. Flush the catheter with heparin at scheduled times. 3. Flush the catheter with saline after medication administration. 4. Initiate a Valsalva maneuver when disconnecting medication tubing.
Answer 3
The client is receiving 5% dextrose in 0.45% sodium chloride. The physician has ordered the client receive one unit of packed cells. Prior to hanging the blood, the nurse will prime the blood tubing with which solution? 1. 5% dextrose 2. Lactated Ringer's 3. 0.9% sodium chloride 4. 5% dextrose in 0.45% sodium chloride
Answer 3
The client is to receive the intravenous medication vancomycin ( Vancocin). To prevent adverse reactions from rapid infusion, by what method should the nurse plan to administer this drug? 1. Using gravity 2. With a regulator 3. Electronic infusion pump 4. Elastomeric pump
Answer 3
The following arterial blood gas ( ABG) results are on the client's chart: pH 7.50; PaCO 2 36; HCO 3 - 30. How will the nurse interpret this report? 1. Partially compensated metabolic alkalosis 2. Compensated respiratory alkalosis 3. Uncompensated metabolic alkalosis 4. Uncompensated respiratory alkalosis
Answer 3
The nurse concludes that a client does not have an increased magnesium level based on which finding? 1. Hypotension 2. Bradycardia 3. Supraventricular tachycardia ( SVT) 4. Flushing and sweating
Answer 3
The nurse is assisting a client who has methicillin- resistant Staphylococcus aureus in collecting a clean- catch urine specimen. Which protective equipment is unnecessary? 1. N95 particulate respirator 2. Gown 3. Eye protection 4. Sterile gloves
Answer 3
The nurse is caring for a client who has a sodium level of 149 mEq/ L. The nurse concludes that it is important to administer which of the following to this client? 1. Cough suppressant to treat symptomatic cough 2. 3 percent saline solution 3. Water 4. Lactulose ( Chronulac)
Answer 3
What information will the nurse include when explaining therapeutic measures to a client taking methotrexate ( Rheumatrex) for rheumatoid arthritis ( RA)? 1. Relief of symptoms will be assessed for within 1 week of starting medication. 2. Fluids should be restricted to prevent possible edema formation. 3. Drug doses will be adjusted for optimum effect at lowest dose once relief has been established. 4. Six months of therapy will be adequate to stop the disease process from progressing.
Answer 3
Which client medication should the nurse review first for its potential interaction in a client admitted to the hospital in a state of alkalosis? 1. Warfarin ( Coumadin) 2. Metformin ( Glucophage) 3. Digoxin ( Lanoxin) 4. Ibuprofen ( Motrin)
Answer 3
Which concurrent electrolyte imbalance should the nurse anticipate while caring for a client with hyperphosphatemia? 1. Potassium 2.8 mEq/ L 2. Sodium 131 mEq/ L 3. Calcium 6.8 mEq/ L 4. Magnesium 3.4 mEq/ L
Answer 3
Which postoperative client would be at risk for develop-ing a sodium imbalance? 1. A client who has just had a tonsillectomy 2. A client who has a primary cesarean section for failure to progress in labor 3. A client who has a transurethral resection of the prostate ( TURP) 4. A client who has a right knee arthroscopy
Answer 3
Which suggestion would the nurse give to a client with human immunodeficiency virus ( HIV) infection to best alleviate nausea? 1. Drink liquids with meals. 2. Eat high- fat foods. 3. Eat small, frequent meals. 4. Lie down after eating.
Answer 3
A child who must undergo skin testing for allergies takes an antihistamine to control symptoms. The nurse explains that the client must discontinue use of the antihistamine for _____ days before the skin testing to avoid false negative results. Provide a numerical answer.
Answer 3 days
A client is admitted to the hospital with respiratory acidosis. The nurse considers that which condition could be an etiology for this state? Select all that apply. 1. Severe diarrhea for several days 2. Diabetic ketoacidosis 3. Obesity 4. Diuretics 5. Sedative overdose
Answer 3, 5
The family of a home infusion client calls the home health nurse one night to report that the electronic infusion pump is alarming. What should the nurse anticipate as the cause of the infusion pump alarming? Select all that apply. 1. The client's pulse and blood pressure are falling. 2. The client is experiencing a reaction to the medication. 3. The prescribed infusion is complete. 4. There is an incompatibility with the medications. 5. An occlusion has interrupted the infusion.
Answer 3, 5
The nurse includes in the plan of care to periodically monitor which item for a client who is at risk for developing hypocalcemia? Select all that apply. 1. Blood urea nitrogen (BUN) and creatinine levels 2. Constipation 3. Serum albumin level 4. Fluid overload related to intravenous saline therapy 5. Serum magnesium level
Answer 3, 5
The nurse would review a client's electrolyte levels to detect a possible increase in magnesium if the client had which condition? Select all that apply. 1. Cushing's syndrome 2. Diabetes 3. Addison's disease 4. Splenomegaly 5. Dehydration
Answer 3, 5
A client asks, " How did I get scarlet fever?" What would be the nurse's best response? 1. " Scarlet fever is transmitted through sexual intercourse." 2. " You can get scarlet fever if you share contaminated needles or get a blood transfusion." 3. " Most people get it by eating contaminated food." 4. " You inhaled infected droplets in the air."
Answer 4
A client is admitted to the hospital with atelectasis and reports of chest pain. For which acid- base imbalance would the nurse assess this client? 1. Respiratory alkalosis 2. Metabolic acidosis 3. Metabolic alkalosis 4. Respiratory acidosis
Answer 4
A client is admitted to the hospital with numerous epi-sodes of muscle weakness and twitching. Arterial blood gas ( ABG) results are pH 7.44; PaCO 2 49; HCO 3 - 30. How would the nurse interpret these findings? 1. Uncompensated metabolic acidosis 2. Compensated respiratory alkalosis 3. Uncompensated respiratory alkalosis 4. Compensated metabolic alkalosis
Answer 4
An infant is admitted to the pediatric unit with a diagnosis of sepsis. The nurse is completing a nursing assessment. What would be the priority nursing assessment for this infant? 1. Skin Integrity 2. Temperature 3. Jaundice 4. Respiratory Function
Answer 4
The community health nurse is assigned to a client who recently was discharged from the hospital with resolving hypernatremia. During the initial assessment interview, what information would be of critical importance in determining a plan of care for this client? 1. The client lives on the second floor of an apartment building that has an elevator. 2. The client needs to walk 100 feet each day to reach the mailbox for the apartment building. 3. The client performs self- monitoring of blood glucose once a day. 4. The client uses Alka- Seltzer on a frequent basis for gastrointestinal complaints.
Answer 4
The nurse is caring for a client who has a sodium level of 128 mEq/ L. As part of the care, the nurse will restrict which item for this client? 1. Sports drinks, such as Gatorade 2. Eggs and cheese products 3. Salt on the diet tray 4. Water
Answer 4
The nurse is caring for a client with a Hickman central line. While changing the central line dressing, the nurse notes that the injection cap ( e. g., heplock adapter) is of the slip lock variety instead of a luer lock device. The nurse recognizes that this adapter puts the client at risk for which complication? 1. Sepsis 2. Occlusion 3. Phlebitis 4. Air embolism
Answer 4
The nurse is preparing to irrigate a wound infected with vancomycin- resistant enterococci. What personal protective equipment ( PPE) would the nurse wear? 1. Gloves, gown, and particulate respirator 2. Gloves and surgical mask 3. Gloves, eye protection, and shoe covers 4. Gloves, gown, eye protection, and surgical mask
Answer 4
The nurse reviews the laboratory test results for a client with preeclampsia, expecting to find which value? 1. Sodium 148 mEq/ L 2. Sodium 125 mEq/ L 3. Magnesium 3.1 mEq/ L 4. Magnesium 1.2 mEq/ L
Answer 4
The nurse who is providing care to a group of clients concludes that the client with which health problem exhibits a type III immune- complex- mediated hypersensitivity reaction? 1. Transfusion reaction 2. Goodpasture's syndrome 3. Transplant rejection 4. Systemic lupus erythematosus
Answer 4
The nurse would anticipate which finding in a client with an immunologic disorder associated with a human leukocyte antigen ( HLA)? 1. Acute course 2. Frequent effects on reproductive capacity 3. Genetic determination 4. Chronic and possibly subacute course
Answer 4
The nurse would expect to institute transmission- based precautions for a client with which infection? 1. Pneumonia caused by Pseudomonas aeruginosa 2. Pneumocystis carinii pneumonia 3. A sacral wound contaminated by Escherichia coli 4. A draining leg wound with methicillin- resistant Staphylococcus aureus
Answer 4
The nurse would implement which of the following as a requirement of care specific to the client who has tuberculosis? 1. Disposal of needles and syringes in a rigid, puncture- proof container 2. Handwashing after removing contaminated gloves 3. Wearing a gown if splashing is possible 4. A private room with negative air flow
Answer 4
The nurse's forearm becomes splattered with blood while inserting an intravenous catheter. What action should the nurse take? 1. Wash blood away with isopropyl alcohol. 2. Wipe blood away with a tissue. 3. Flush forearm with hot water, letting water flow from elbow toward fingers. 4. Wash forearm with soap and water.
Answer 4
The physician is going to order a hypotonic intravenous solution for a client with cellular dehydration. The nurse would expect which fluid to be administered? 1. 0.9% normal saline 2. 5% dextrose in normal saline 3. Lactated Ringer's solution 4. 0.45% sodium chloride
Answer 4
The white blood cell ( WBC) count of a client with systemic lupus erythematosus ( SLE) shows a shift to the left. Which nursing diagnosis reflects the highest priority for this client? 1. Ineffective Health Maintenance 2. Impaired Skin Integrity 3. Ineffective Individual Coping 4. Ineffective Protection
Answer 4
To enhance meeting the psychosocial needs of a client on transmission- based precautions, the nurse should place highest priority on which of the following? 1. Letting the client sleep to build up stamina 2. Maintaining strict precautions when entering and leaving the room so that the client feels he or she is getting the best care 3. Providing client care within a limited time frame to maintain isolation and keep client safe 4. Providing the client with diversional activities to enhance sensory input
Answer 4
Which health care provider order for potassium chloride ( KCl) should the nurse question regarding a client with severe hypokalemia? 1. Infuse 1000 mL normal saline with 20 mEq KCl IV over 8 hours. 2. Give KCl 20 mEq PO daily after meals. 3. Infuse 1000 mL normal saline with 40 mEq KCl IV at 200 mL/ hour. 4. Give 20 mEq KCl IV over 10 minutes.
Answer 4
Which treatment option does the nurse anticipate will be most appropriate for a client with a potassium level of 3.5 mEq/ L? 1. Give sodium polystyrene sulfate ( Kayexalate) per rectum. 2. Use salt substitutes in the diet. 3. Administer oral potassium chloride ( KCl). 4. Continue to monitor and offer foods high in potassium.
Answer 4
The nurse is preparing to enter the room of a client with pneumonia caused by penicillin- resistant Streptococcus pneumoniae ( PRSP). The client has a tracheostomy and requires suctioning. Put the following personal protective equipment in order of donning. 1. Eye protection 2. Gloves 3. Mask 4. Gown
Answer 4, 3, 1, 2
The nurse would perform which action when washing hands as part of medical asepsis before caring for a client in an outpatient clinic? Select all that apply. 1. Wash hands with the hands held higher than the elbows. 2. Adjust temperature of water to the hottest possible. 3. Scrub hands and nails with a scrub brush for 5 minutes. 4. Use a clean paper towel to turn water off. 5. Rub vigorously using firm circular motions.
Answer 4,5
The nurse is inserting a peripheral intravenous ( IV) line. Place the following steps in order to perform this procedure correctly. 1. Apply a tourniquet above insertion site. 2. Insert catheter at 5- 15 degree angle through skin. 3. Select a vein and cleanse the skin. 4. Attach tubing primed with IV solution. 5. Gather the appropriate equipment.
Answer 5,3,1,2,4
A client has a continuously running peripheral infusion. The physician orders an antibiotic as a piggyback infusion four times per day. In order to administer the antibiotic, the nurse should do which of the following? Select all that apply. 1. Avoid compatibility issues by starting an additional IV access. 2. Start a new IV access to eliminate the problem of too much volume for one site. 3. Flush the IV line before and after infusion of an incompatible drug. 4. Check to see if the antibiotic is compatible with the continuous infusion. 5. Change the flow rate to facilitate the administration of the antibiotic.
Answer: 3,4, 5
