NCLEX Questions

The nurse is reviewing the assessment data for a client with acute glomerulonephritis (AGN). Which of the following would be an expected finding? -Ketonuria -Hematuria -Polyuria -Glycosuria

-Hematuria

The nurse is caring for a client who has developed cardiac tamponade. Which of the following prescriptions should the nurse clarify with the primary healthcare provider (PHCP)? - Positive pressure ventilation -Pericardiocentesis -Echocardigraphy -0.9% saline bolus

- Positive pressure ventilation

The nurse is caring for a client experiencing an adrenal crisis (Addisonian crisis). The nurse should be prepared to administer which intravenous fluid? -Lactated Ringers (LR) -0.9% saline -Dextrose 5% in water and Lactated Ringers (D5LR) -Dextrose in 5% water (D5W)

-0.9% saline

The nurse is gathering supplies for a transfusion of packed red blood cells (PRBCs). The nurse should obtain which intravenous (IV) fluid to accompany this transfusion? -Lactated Ringers (LR) -0.9% saline -0.45% saline -3% saline

-0.9% saline

A 70-year old man in the ICU experiences sudden cardiac arrest. The code team arrives and performs CPR. After about five minutes, the patient obtains a return of spontaneous circulation (ROSC). A carotid pulse is found, but femoral and radial pulses are not. What is this patient's approximate minimum systolic blood pressure? -60 mmHg -70 mmHg -80 mmHg -90 mm Hg

-60 mmHg

The infection control nurse reviews guidelines with other nurses. Which of the following statements by the nurses would indicate a correct understanding of the teaching? -The nurse should wear a surgical mask when transporting a client with active pulmonary tubreculosis -Disposable utensils must be provided for a client infected with hepatitis B -A surgical mask should be worn when working within three feet of the client infected with Neisseria meningitidis -A surgical gown should be applied when entering a client's room with bacterial pneumonia

-A surgical mask should be worn when working within three feet of the client infected with Neisseria meningitidis

The nurse reviews prescriptions for assigned clients. Which prescription should the nurse question? -Albuterol via nebulizer for a client with hypokalemia -Clozapine for a client with severe schizophrenia -Lisinopril for a client with congestive heart failure -Verapamil for a client with migraine headaches

-Albuterol via nebulizer for a client with hypokalemia

The emergency department (ED) nurse cares for a client who reports persistent nausea and vomiting for three days. Which acid-based arrangement would the nurse expect based on the client's manifestations? -A decreased pH and an elevated CO2 -An elevated pH and a decreased CO2 -A decreased pH and a decreased HCO3- -An increased pH with an increased HCO3-

-An increased pH with an increased HCO3-

The nurse in the psychiatric unit notes that a client with paranoid schizophrenia is yelling and blocking the television. Other psychiatric clients around him are getting angry. What is the most appropirate action of the nurse? -Restrain the client -Escort the other clients from the room -Give Haloperidol IM -Approach the client calmly accompanied by two other staff

-Approach the client calmly accompanied by two other staff

The ICU nurse is caring for a sedated client on a ventilator. The ventilator alarm is beeping persistently for low pressure despite the fact the client is calm and has stable vitals. What is the most appropirate action for the RN to take first? -Suction secretions -Check the tubing for hole -Call respiratory therapy -Continue to monitor

-Check the tubing for hole

The nurse is caring for a child in the emergency department (ED) who sustained a bite by a rabid animal. The nurse should take which initial action? -Assess the wound's length and width -Cleanse the wound with soap and water -Obtain a prescription for an antibiotic -Report the bite to animal control

-Cleanse the wound with soap and water

Which form of therapy would most likely be used to treat a group of clients affected by phobias? -Behavioral psychotherapy -Cognitive behavioral psychotherapy -Psychoanalysis -Cognitive psychotherapy

-Cognitive behavioral psychotherapy

Which of the following would the nurse expect to be administered to treat a newborn with Respiratory Distress Syndrome (RDS) ? -Theophylline -Colfosceril -Dexamethasone -Albuterol

-Colfosceril

You are providing education to your 8 year old client diagnosed with sickle cell anemia. He has had three crisis events this year. Which of the following points do you enforce with him and his parents to help prevent more sickle cell crises? Select all that apply -Drink lots of water -Perform vigorous exercise for 60 minutes a day -Avoid flying on airplanes -Call the PCP if he becomes febrile -Encourage a diet high in calcium

-Drink lots of water -Avoid flying on airplanes -Call the PCP if he becomes febrile

While assisting the intra-disciplinary team with interventions for a toddler who has just had cleft palate repair, the nurse know which of the following are appropriate? Select all that apply -Pacifier with oral sucrose to reduce postoperative pain -Elbow restraints -Specialized bottle for feedings -Prone position -Oral suctioning

-Elbow restraints -Specialized bottle for feedings -Oral suctioning

The nurse is caring for a client with anemia and occult blood in the stool. Which of the following medications should the nurse question? -Iron sucrose -Enoxaparin -Sucralfate -Hydroxyurea

-Enoxaparin

The nurse is caring for a client who has nephrogenic diabetes insipidus. Which of the following medications should the nurse expect to be prescribed for the client? -Prednisone -Hydrochlorothiazide -Verapamil -Lithium

-Hydrochlorothiazide

A parent is sobbing loudly at the bedside of their infant, who was just born with an omphalocele. She wails, "I cannot believe my baby was born this way! He will surely die!" Which of the following statements by the nurse is most appropriate? -Oh, hush, this is not so bad -I understand you are upset. This is certainly serious, but there is a treatment that can repair the omphalocele, and we will take excellent care of your baby -Your baby will not die; this can be fixed -I understand you must be upset. Would you like to hold your baby while he is still here

-I understand you are upset. This is certainly serious, but there is a treatment that can repair the omphalocele, and we will take excellent care of your baby

You are taking care of a 7-year-old female in the pediatric bone marrow transplant unit. She has been in the hospital for about a year and is working on her school work with the hospital teacher. You note that she is growing increasingly frustrated with her math homework. You know that her successful completion of academic demands is vital to her psychosocial development, as she is in which stage of psychosocial development? -Industry vs. Inferiority -Autonomy vs. Shame and Doubt -Trust vs. Mistrust -Initiative vs. Guilt

-Industry vs. Inferiority

The nurse is assessing a 4 year old who was sent to the ED from urgent care. Assessment reveals' tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling. Vital signs Temp 39 C HR 188 RR 46 O2 82 Which of the following should the nurse do first -Keep the child calm and call for emergency airway equipment -Obtain IV access -Assess the throat for a cherry red epiglottis -Place the child on a high flow nasal cannula at 100% FiO2

-Keep the child calm and call for emergency airway equipment

The nurse observes a parent swaddling their infant with an unrepaired omphalocele. Which of the following statements would be appropirate? -Stop, you will kill your baby!!! -That is a nice, tight swaddle. It will really help sooth your new baby -May I help you? We will need to be careful with their intestines, we do not want the swaddle to push them back inside -Swaddling is not allowed for these babies, please stop

-May I help you? We will need to be careful with their intestines, we do not want the swaddle to push them back inside

The nurse is caring for a client newly admitted with infective endocarditis (IE). The nurse should plan for which intervention in the client's care plan? -initiating contact and droplet precautions -Obtain a prescription for intravenous antivirals -Obtain a prescription of enoxaparin -Monitor renal function

-Monitor renal function

The nurse is taking vital signs on a client with a diagnosis of acute lymphoblastic leukemia (ALL). The client's temperature is 38.7 degrees C. Which of the following actions should the nurse prioritize next? -Place cool washcloths on the client's head -Continue the assessment -Obtain intravenous access on the client -Assess the client's perfusion

-Obtain intravenous access on the client

An infant is admitted to the pediatric floor to rule out cystic fibrosis. The nurse assesses the infant's stool, concluding the stool is consistent with a diagnosis of cystic fibrosis. Which of the following would describe this infant's stool? -Small, hard, pellet-like stool -Green, malodorous stool -Oily, odorous, bulky stool -Loose, yellow stool

-Oily, odorous, bulky stool

Which assessment data should the nurse recognize as a sign of acute kidney injury (AKI)? -Hypernatremia -Metabolic alkalosis -Oliguria -Hypokalemia

-Oliguria

Which of the following findings would lead the nurse to believe their client could have a coarctation of the aorta? Select all that apply -1+ radial pulses and 3+ femoral pulses -Pale, cool feet and legs with warm pink hands and arms -Hypertensive brachial blood pressure -> 4 second capillary refill on the hands -Hypotension popliteal blood pressure

-Pale, cool feet and legs with warm pink hands and arms -Hypertensive brachial blood pressure -Hypotension popliteal blood pressure

The nurse is planning a staff development conference about mechanical ventilator modes. Which of the following information should the nurse include? -Assist-control allows spontaneous breathing at the client's rate and tidal volume between the ventilator breaths -Synchronized intermittent mandatory ventilation applies positive airway pressure throughout the respiratory cycle to prevent alveolar collapse -Pressure support ventilation delivers a set airway pressure and is used for spontaneously breathing clients -Continuous positive airway pressure is used to provide full ventilator support for clients not taking spontaneous breaths

-Pressure support ventilation delivers a set airway pressure and is used for spontaneously breathing clients

The nurse is performing an assessment on a 3-month-old child. Which of the following would be expected at this age? -Sit without support -Creep on hands and knees -Follow simple commands -Reach for objects

-Reach for objects

A nurse assigned to care for a client with bulimia nervosa. Which intervention should the nurse apply following the client's meals? -Instruct the client to get some exercise or go for a walk after meals -Restrict the client from going to the bathroom for 90 minutes -Ask the client to lie down for 2 hours after eating -Encourage client to start an intense exercise program

-Restrict the client from going to the bathroom for 90 minutes

The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with what finding? -Inflammation -Serous drainage -Pain at pin insertion site -Swelling of the extremity -Red streaks going up the patient's affected extremity

-Serous drainage

The nurse in the delivery room has just delivered a newborn from a 41-year-old mother. Which assessment finding would lead the nurse to suspect Down syndrome in the newborn? -Simian crease -Jitteriness -Acrocyanosis -Uneven skin folds in the newborn's buttocks when the legs are extended

-Simian crease

The nurse plans care for a client admitted with Haemophilus influenzae, type b Meningitis. When caring for this client, the nurse should gather which appropriate personnel protective equipment (PPE)? -Boot (shoe) covers -Face shield -Surgical mask -Gown

-Surgical mask

A client visits an antepartum clinic for a check-up and is prescribed iron supplements. Which instruction should the nurse provide to the client regarding her iron supplement therapy? -You must take the iron supplements with milk -Consume the iron supplements with meals -Take the iron supplement with orange juice -Avoid consuming large amounts of water when taking the iron supplement, as this can cause nausea

-Take the iron supplement with orange juice

The ICU nurse is taking care of a client who sustained a head injury due to a motorcycle accident. In the morning, the client is responsive to pain and assumes a decorticate position. After 4 hours , which assessment would indicate to the nurse the client needs immediate intervention. -The client displays purposeful movement when the nurse performs a sternal rub. -The client extends his arms and legs when the nurse rubs his sternum -The client flails his arms and legs when a noxious stimulus is applied -The client moves his fingers upon request

-The client extends his arms and legs when the nurse rubs his sternum

The nurse is interviewing a client who is pregnant in her first trimester, and the client inquires about their gestational age. The nurse understands which assessment will provide the most accurate gestational age? -Nagele's rule -Ultrasonography -Fundal height -Human chorionic gonadotropin (HCG) levels

-Ultrasonography

The nurse is assessing a client receiving peritoneal dialysis. Which laboratory result should immediately be reported to the primary healthcare provider (PCP)? -WBC 19,000 mm3 -Hemoglobin 9 mg/dL -Calcium 8.6 mg/dL -Serum pH 7.33

-WBC 19,000 mm3

The nurse is evaluating their client's lab results and notes that the potassium is 5.5 mEq/L. They review the telemetry monitor, looking for which of the following signs? Select all that apply -Inverted T waves -Widened QRS interval -Tall, peaked T waves -Prominent U-waves -Prolonged PR interval

-Widened QRS interval -Tall, peaked T waves -Prolonged PR interval

The nurse is assessing a client with systolic heart failure. Which of the following would be an expected finding of right-sided heart failure? -ascites -tachypnea -cough -orthopnea

-ascites

The nurse has been made aware of the following client situations. The nurse should first follow up with the client -receiving a chemotherapy infusion who reports nausea and vomiting -newly diagnosed with polycystic kidney disease reporting hematuria and flank pain -being treated for aplastic anemia and has a temperature of 101.1 (38.4 C) -being treated for pulmonary tuberculosis and ambulating in the hallway wearing a surgical mask

-being treated for aplastic anemia and has a temperature of 101.1 (38.4 C)

The nurse is caring for a client who recently had a partial gastrectomy. Which of the following medications should the nurse anticipate that the primary health care provider (PHCP) will order? -cyanocobalamin -metoclopramide -sucralfate -hydroxyzine

-cyanocobalamin

The nurse is teaching a client about newly prescribed metoclopramide for nausea and vomiting. It is a priority for the nurse to discuss which potential adverse reaction? -dystonia -fever -drowsiness -diarrhea

-fever

The nurse is reviewing a new prescription for amphotericin b. The nurse understands that this medication treats -autoimmune infections -fungal infections -viral infections -bacterial infections

-fungal infections

The nurse is performing a follow-up visit on an adolescent recently prescribed guanfacine. Which of the following assessments indicates a therapeutic response to the medication? -euthymic mood -less social anxiety -improved academic performance -no suicidal ideations

-improved academic performance

The nurse manager has been made aware of the following staff nurse issues. The manager should initially follow up on the staff nurse who -falsified their documentation on a client discharged within the last 24 hours -needs assistance completing an incident report about a medication error on the previous shift -was thirty minutes late to their scheduled shift and is not wearing the correct uniform -is suspected to be impaired with alcohol and is precepting a newly hired nurse

-is suspected to be impaired with alcohol and is precepting a newly hired nurse

The nurse has just inserted an indwelling urinary catheter for a male client. The nurse plans on securing the catheter to the client's -inner thigh -lower abdomen -outer thigh -medial thigh

-lower abdomen

The nurse is caring for a client with edentulous. It would be appropriate for the nurse to obtain an order for a -low sodium diet -mechanical soft diet -renal diet -high-fiber diet

-mechanical soft diet

The nurse is caring for a client diagnosed with hyperparathyroidism. Which laboratory data would support this diagnosis? A. Potassium 4.1 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L] B. Phosphorus 4.9 mEq/L (mmol/L) [2-4.5 mEq/L, 0.81-1.58 mmol/L] C. Calcium 11.2 mg/dL (2.8 mmol/L) [9-10.5 mg/dL, 2.12-2.52 mmol/L] D. Sodium 132 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]

C. Calcium 11.2 mg/dL (2.8 mmol/L) [9-10.5 mg/dL, 2.12-2.52 mmol/L]

The nurse is caring for a client who was prescribed prednisone. The nurse should instruct the client to take this medication at what time? -In the morning -Around noon -Before bed -Anytime, but at the same time every day

-In the morning

The nurse is reassessing their client diagnosed with appendicitis. The client expressed 8/10 pain at her last assessment, and now states they has no pain. The nurse did not administer any pain medication. What is the critical nursing action -Document the pain score -Assess the client's abdomen -Notify the healthcare provider -Palpate McBurney's point

-Notify the healthcare provider

The nurse is counseling a group of students on the dosing schedule of Rho(D) Immune Globulin. It would indicate effective understanding if the student states that Rho(D) Immune Globulin should be administered at -12 weeks of pregnancy and withing 72 hours of deliver -28 weeks of pregnancy and within 72 hours of delivery -25 weeks of pregnancy and within 96 hours of delivery -16 weeks of pregnancy and within 12 hours of delivery

-28 weeks of pregnancy and within 72 hours of delivery

The nurse is assessing a client with carbon monoxide (CO) poisoning. Which of the following would be an expected finding? -Decreased pulse oximetry (SpO2) -Hyperarousal -Bradycardia -Headache

-Headache

The nurse is caring for a client whose most recent serum sodium level was 152 mEq/L. Which of the following signs and symptoms do they suspect are caused by the clients sodium level. Select all that apply. -Lethargy -Dry mucous membranes -Tachypnea -Cyanosis -Dry mouth

-Lethargy -Dry mucous membranes -Dry mouth

A nurse known that in the event of an Addisonian crisis, it is most appropriate to administer which of the following medications intravenously? -Insulin -Normal saline solution -dextrose 5% in water -dextrose 5% in half-normal saline solution

-Normal saline solution

The nurse is counseling an adolescent who is pregnant and reports frequent eating at fast-food restaurants. The nurse should make which recommendation to help optimize her nutritional intake? -Choose french fries over a baked potato -Select a cheeseburger over a regular hamburger -Pick sandwiches instead of wraps -Breaded chicken is a better choice than broiled

-Select a cheeseburger over a regular hamburger

The nurse is assessing a client with scleroderma. Which of the following would be an expected finding? -Tophi -Janeway lesions -Shuffling gait -Taut and shiny skin

-Taut and shiny skin

The nurse is preparing to administer a unit of packed red blood cells (PRBCs). The nurse should -obtain a bag of 250mL of 0.9% saline -obtain a bag of 250 mL of Dextrose in 5% in water (D5W) -insert a 22 gauge intravenous (IV) catheter -initiate continuous telemetry monitoring

-obtain a bag of 250mL of 0.9% saline

The nurse preceptor supervises a new nurse caring for a child with epiglottitis. Which action by the new nurse would require the nurse preceptor to intervene? The new nurse -obtains a throat culture -positions the client high-Fowlers -initiates peripheral vascular access -places a bag-valve mask at the bedside

-obtains a throat culture

The nurse is assessing a child admitted with varicella zoster (chickenpox). Which of the following assessment findings would be expected? -linear cracks in the epidermis that extend into the dermis -painful blisters filled with clear fluid -nodules filled with either liquid or semisolid material -elevated, plateau-like patches

-painful blisters filled with clear fluid

An 11-week pregnant client is complaining to the nurse about her hemorrhoids. The nurse understands that hemorrhoids occur because of pressure on the rectal veins from the bulk of the growing fetus. All of the following are measures to alleviate hemorrhoid pain, except: A. Instruct the client to use mineral oil to soften her stools. B. Rest in a side-lying position daily. C. Increase the client's fiber and water intake. D. Apply a cold compress to the area.

A. Instruct the client to use mineral oil to soften her stools.

The nurse is caring for assigned clients. Which client should the nurse see first? A client A. with a right femur fracture who reports pain rated as 4 on a scale of 0 (no pain) to 10 (severe pain). B. with chronic obstructive pulmonary disease (COPD) who is reporting shortness of breath while ambulating in the hallway. C. with a history of T6 spinal injury 6 months ago, now reports a severe headache and is diaphoretic. D. one day postoperative from an open cholecystectomy with green drainage from the t-tube.

C. with a history of T6 spinal injury 6 months ago, now reports a severe headache and is diaphoretic.

The nurse is educating a client about newly prescribed aspart insulin. The nurse should instruct the client to self-administer this insulin -30-40 minutes before a meal -one hour after a meal -20-30 minutes before a meal -5-10 minutes before a meal

-5-10 minutes before a meal

The client is prescribed omeprazole. You know that the intended action of this medication is to: -Enhance intestinal motility -Reduce esophageal pressure -Eradication of H. pylori growth -Increase stomach pH

-Increase stomach pH

Which of the following maternal infections may increase the risk of developing congenital heart defects in the fetus? -Parainfluenza -Adenovirus -Rubella -Measles

-Rubella

A nurse is assigned to care for four clients who are each one day postpartum. Following the nurse performing an initial assessment on each client, which finding would prompt further evaluations by the nurse? -A client complaining of mild pain -A client with a pulse rate of 65 bpm A client with colostrum discharge from both breasts -A client with red, foul-smelling lochia

-A client with red, foul-smelling lochia

Which of the following meals would you offer to your client who practices Orthodox Judaism? -CHicken parmesan and spaghetti -Chilie con carne topped with queso fresco -A club sandwitch with low sodium ham and cheese -A cottage cheese salad with fresh fruit

-A cottage cheese salad with fresh fruit

The nurse is caring for a client with suspected placenta previa. The nurse anticipates a prescription for which diagnostic test to confirm this finding? -Manual cervical exam -Transvaginal ultrasound -Contraction stress test -Nonstress test

-Transvaginal ultrasound

The nurse is caring for a client following a stroke. The client can understand instructions but is unable to express himself verbally. The nurse anticipates that this stroke has impacted which lobe of the client's brain? -Frontal lobe -Parietal lobe -Temporal lobe -Occipital lobe

-Frontal lobe

The nurse is assessing a child with epiglottitis. Which of the following would be an expected finding? -Absence of spontaneous cough -Harsh, productive cough -Generalized skin flushing -Coarse tremors

-Absence of spontaneous cough

You are working in the Emergency Department when a client with a suspected stroke arrives. Which of the following essential nursing actions should the nurse perform? Select all that apply -Activate the stroke team -Check and treat the glucose -Order an immediate CT or MRI of the brain -Administer tPA -Administer morphine

-Activate the stroke team -Check and treat the glucose -Order an immediate CT or MRI of the brain

The nurse is preparing to assess a child with cystic fibrosis at the outpatient clinic. The nurse anticipates that the primary healthcare provider (PHCP) will order which routine laboratory test? -Blood glucose -Total cholesterol -24-hour urine -Blood cultures

-Blood glucose

A client suddenly develops syndrome of inappropriate antidiuretic hormone (SIDADH) after undergoing cranial surgery. Which manifestations should the nurse expect to see from the client? -Edema and weight gain -Decreased urine production -Hypotension -A low urine specific gravity

-Decreased urine production

The nurse is caring for a client in labor experiencing early decelerations. Which of the following actions should the nurse take? -Reposition the patient on her side -Document the findings -Discontinue oxytocin infusion -Prepare for an amnioinfusion

-Document the findings

The nurse is taking the history and physical of a woman who has just discovered that she is pregnant. This nurse knows that the purpose of asking a prenatal client about her history with rheumatic fever has the most to do with: -Cardiac stress related to a possible valvular lesion -Preventing transmission of this teratogenic condition to her infant -Preparing to deliver antibiotics during labor and post-birth -Monitoring lung sounds for reoccurrence of the disorder

-Cardiac stress related to a possible valvular lesion

The nurse performs a respiratory assessment on an older adult client and observes apnea alternates with periods of rapid breathing. The nurse should document this respiratory pattern as -Cheyne-Stokes -Kussmaul's -agonal -tachypnea

-Cheyne-Stokes

A Client that has sustained a sports injury has just finished an arthroscopy on his left knee. The nurse caring for him should FIRST assess the client for which of the following factors? -Skin and wound integrity -Mobility assessment -Vascular and skin assessments -Circulatory and neurologic assessments

-Circulatory and neurologic assessments

You are caring for a client in the step-down unit who tells you that they are an active member of the Seventh-Day Adventist churtch. When their breakfast tray comes up, you see the following items. Knowing the relgious dietary prefecnce of these clients, which items does the nurse remove from the breakfast tray? Select all that apply -Coffee -Bacon -Scrambled eggs -Pancakes

-Coffee -Bacon

Which of the following are symptoms of true labor? Select all that apply -Contractions that dissipate with walking -Contractions that come in regular intervals -Lower back pain -Contractions of consistent intensity

-Contractions that come in regular intervals -Lower back pain

The nurse is performing discharge teaching to the parents of a child diagnosed with cystic fibrosis. Which education should the nurse provide to the parents regarding at-home nebulizer treatments? -Clean your nebulizer tubing daily with warm, soapy water -Your tubing should be placed in the microwave for 30 seconds weekly to provide a deep clean -Clean your nebulizer mask or mouthpiece with warm, soapy water -Your nebulizer should be washed at least every two weeks

-Clean your nebulizer mask or mouthpiece with warm, soapy water

Which of the following signs and symptoms are expected for your patient experiencing placental abruption? Select all that apply. -Painless bleeding -Dark red bleeding -Hypotension -Rigid abdomen

-Dark red bleeding -Hypotension -Rigid abdomen

While assessing a newborn infant in the nursery, you observe bounding 3+ radial pulses and faint 1+ pedal pulses. You also notice that the feet are cold and pale, while the hands are warm and pink. Which cardiac defect do you suspect this infant has? -Tetralogy of Fallot (TOF) -Hypoplastic left heart syndrome -Coarctation of the aorta (COT) -Transposition of the great arteries

-Coarctation of the aorta (COT)

The nurse is caring for a client with herpes simplex virus who is experiencing an outbreak. Which medication does the nurse anticipate that the primary healthcare provider (PHCP) will prescribe? -Metronidazole -Acyclovir -Imiquimod -Fluconazole

-Acyclovir

During a prenatal visit, a pregnant client is found to have Rh-negative blood type. The nurse knows that Rh-negative clients are at risk for Rh isoimmunization. What intervention is essential for preventing Rh isoimmunization in this client? -Administer Rh immunoglobulin (RhoGAM) at 28 weeks -Initiate early induction of labor -Administer folic acid supplementation -Recommend avoiding travel during the third trimester

-Administer Rh immunoglobulin (RhoGAM) at 28 weeks

The nurse is caring for a client with Helicobacter pylori. The nurse should anticipate a prescription for which of the following medications? -Dicyclomine -Metoclopramide -Valacyclovir -Amoxicillin

-Amoxicillin

The nurse is discussing with a group of teenagers with cancer the side effects associated with prescribed chemotherapy. Which topic should the nurse consider prioritizing? -nausea and vomiting -mouth ulcers -alopecia -activity intolerance

-alopecia

The nurse observes that a fire has ignited in the client's room. After removing the client from the room, the nurse should then -activate the fire alarm -extinguish the fire -contact the nurse supervisor -close the door to the client's room

-activate the fire alarm

The nurse cares for many clients at the end of life who experience symptoms, such as pain, that are physically distressing to the client and their loved ones. Which statement reflects the American Nurses Association's position on pain management at the end of life? -Advocate for pain management unless life-threatening side effects occur -Advocate for pain management even if the life-threatening side effects hasten death -Prohibit the respiratory system from depression drugs because this is euthanasia -Allow families to administer respiratory system depressing drugs to hasten death

-Advocate for pain management even if the life-threatening side effects hasten death

While providing education to a group of expected mothers regarding the prevention of postpartum thrombophlebitis, you know they understand your teaching when they make which of the following statements? select all that apply -After we give birth, we are at an increased risk of clots for 6 to 8 weeks -We shouldn't go on car rides longer than4 hours for a few weeks after we give birth -After delivery, we should get up and walk as soon as we are able to prevent clots from forming -Trying not to cross our legs will help prevent clots from forming

-After we give birth, we are at an increased risk of clots for 6 to 8 weeks -We shouldn't go on car rides longer than4 hours for a few weeks after we give birth -After delivery, we should get up and walk as soon as we are able to prevent clots from forming -Trying not to cross our legs will help prevent clots from forming

The Nruse is assisting a client of the orthodox Jewish faith while serving lunch. A kisher meat has been delivered to the client. What is the next appropirate action to perform with this client? -Substitute plastic utensils with metal utensils -Unwrapping the eating utensils fro the client -Carefully transferring the food from a styrofoam tray to a ceramic plate -Allowing the clietn to unwrap the utenils and prepare his own meal

-Allowing the clietn to unwrap the utenils and prepare his own meal

The school nurse is performing the corneal light reflex test on a child suspected of having strabismus. Which finding does the nurse identify as a sign of this condition? -Symmetrical pin-point light on each pupil -Red reflex in both eyes -Asymmetrical pin-point on the pupils -Sun setting sign

-Asymmetrical pin-point on the pupils

Select an appropriate nursing diagnosis for your client who is affected with hyperalgesia. - At risk for inadvertent narcotic overdoses related to hyperalgesia -At risk for abnormal and irreversible pain related to hyperalgesia -At risk for somatic pain related to hyperalgesia -At risk for visceral pain related to hyperalgesia

-At risk for abnormal and irreversible pain related to hyperalgesia

The primary objective in identifying similarities and differences among cultural beliefs of a client is to -Communicate with their family -Make sure the proper diet is ordered -Perform a spiritual consult -Avoid making assumptions

-Avoid making assumptions

Which of the following special considerations should the nurse make when caring for a Hindu patient based on her religion? Select all that apply -Provide all vegetarian meals -Handle the client's temple garments with care -Be sure the bathroom is equipped with a shower and not just a tub -Be aware that the patient will likely refuse blood transfusion -Arrange for female nursing staff to provide care for the client as much as possible -Be aware that the patient will likely refuse pain medication

-Be sure the bathroom is equipped with a shower and not just a tub -Arrange for female nursing staff to provide care for the client as much as possible

You are triaging a new client in the antepartum unit. They tell you that they started bleeding this morning and were told to come in by their OB. They deny any pain or other symptoms. Which of the following nursing interventions do you anticipate initiating? Select all that apply -Bed rest -Pad count -Emergency vaginal delivery -Vaginal exam -Ultrasound

-Bed rest -Pad count -Ultrasound

The nurse is reviewing the discharge teaching with a family who will be taking their 12 year old diagnosed with pneumonia home today. Which of the following points should they review? Select all that apply -Encourage your child to drink logs of water -Administer the full course of antibiotics, even if your child starts to feel better -Call you pediatrician if their is tan sputum when the child coughs -Administer ibuprofen if your child has a temperature greeter than 100 degrees F -If your child is breathing harder or faster, call you PHCP immediately

-Encourage your child to drink logs of water -Administer the full course of antibiotics, even if your child starts to feel better -If your child is breathing harder or faster, call you PHCP immediately

The nurse is caring for a client who was prescribed lamotrigine. The nurse understands that this medication is intended to treat -Acute spinal shock -Epilepsy -Parkinson's disease -Multiple sclerosis

-Epilepsy

The nurse is taking vital signs for a client who has a chest tube in place. While counting the client's respirations, the nurse notes that the water in the water-seal-chamber is fluctuating. Which action by the nurse is most appropriate based on this finding? -Finish counting the client's respirations -Empty the water-seal chamber -Asist the client with incentive spirometry -Notify the charge nurse

-Finish counting the client's respirations

The client had just given birth and is resting in the postpartum unit when suddenly she feels a sharp pain in the chest and is having difficulty breathing. Upon assessment by the nurse, she has a heart rate of 120 and a respiratory rate of 24. She is suspected of having a pulmonary embolism. What should be the initial action of the nurse? -Start an IV line -Monitor the client's blood pressure -Draw up morphine sulfate -Give oxygen via face mask 8-10 liters per minute

-Give oxygen via face mask 8-10 liters per minute

The oncoming nurse is receiving a report on a pregnant patient with HELLP syndrome. This nurse knows that HELLP syndrome, a severe progression of preeclampsia stands for: -Half Eclipsed Lipase Levels and Preeclampsia -Hemolysis, elevated liver enzymes, and lowered platelets -Hematocrit elevation, low lipase, and pancreatitis -Hemoglobin, elevated lipids, and low plasma

-Hemolysis, elevated liver enzymes, and lowered platelets

The nurse is reviewing the diet of the client with hypoparathyroidism. The nurse understands that the client should be on what type of diet? -High-calorie, low calcium diet -Low-calcium, low phosphorus diet -High phosphorus, low calcium diet -High calcium, low phosphorus diet

-High calcium, low phosphorus diet

A pregnant women with preexisting hypertension is being seen in the clinic. Her blood pressure continues to rise despite attempting first-line therapy with anti-hypertensives. Which of the following medications will be used for the prenatal patient resistant to other blood pressure-lowering medications? -A calcium channel blocker -Methyldopa -Labetalol -Hydralazine

-Hydralazine

The nurse is caring for a pregnant client at 28 weeks' gestation who presents to the emergency department with signs of preeclampsia. The primary healthcare provider (PHCP) orders magnesium sulfate. What potential complication should the nurse closely monitor for during magnesium sulfate administration? -Pulmonary edema -Oliguria -Hyporeflexia -Increased fetal movement

-Hyporeflexia

Which of the following comments by the client reflects an understanding of the proper use of a metered-dose inhaler? Select all that apply -I will be careful not to shake the canister before using it -I will hold the canister upside-down when using it -I will inhale the medication through my nose -I will continue to inhale when the cold propellant is in my throat -I will only inhale one spray with one breath -I will activate the device while continuing to inhale

-I will continue to inhale when the cold propellant is in my throat -I will only inhale one spray with one breath -I will activate the device while continuing to inhale

A nurse is instructing a client about newly prescribed medication, phenytoin. Which statements, if made by the client, indicates effective teaching? -If my gums get irritated and large, I can stop this medication -I will need laboratory work to monitor the medication level -It is okay for me to increase this medication if I have a seizure -I should take this medication with low protein foods

-I will need laboratory work to monitor the medication level

The nurse is caring for a client newly diagnosed with Cushing's disease. Which of the following client statements requires follow-up? -I will need to eat more potassium rich foods -I will need more steroids during periods of stress -I will be at a higher risk for an infection -I should do weight bearing exercises

-I will need more steroids during periods of stress

The nurse is providing discharge instructions to a client with accelerated hypertension who has been newly started on Nifedipine. His home medications include calcium supplements for osteoporosis, omeprazole for heartburn, furosemide, and lisinopril. Which statement(s) by the client demonstrates the need for additional teaching regarding Nifedipine? Select all that apply. -My gums may swell because of this medication -I will avoid getting up to quickly from sitting or lying position -I will stop taking calcium supplements since they may negate the effects of Nifedipine -It is highly likely that I will get constipated from this drug -If I get cough and tongue swelling, I will hold Nifedipine

-I will stop taking calcium supplements since they may negate the effects of Nifedipine -It is highly likely that I will get constipated from this drug -If I get cough and tongue swelling, I will hold Nifedipine

The nurse is teaching a client about diabetes mellitus type I and exercise. Which statement, if made by the nurse, would be appropriate? -Increasing exercise would increase insulin requirements -Increasing exercise would decrease insulin requirements -Insulin needs do not change with exercise -Decreasing exercise would decrease insulin requirements

-Increasing exercise would decrease insulin requirements

The nurse is caring for a client at 29 weeks gestation who is at risk for delivering preterm. Which of the following medications would the nurse anticipate the primary healthcare provider (PHCP) to prescribe? -Methotrexate -Indomethacin -Oxytocin -Folic acid

-Indomethacin

A client presents to the obstetrics floor at 39 weeks gestation with irregular contractions. After you get the client situated in a labor, deliver, and recovery room, you notice the client's health care provider (HCP) enter the room to evaluate the client. Following the evaluation, the HCP exits the room, and shortly thereafter, you enter. During your discussion, the client states the HCP "went to order oxytocin." In anticipation of that order, you understand this client's oxytocin will be administered via which rout of administration? -Intramuscular administration -Intravenous administration via mainline infusion using an infusion pump -Intravenous administration via piggyback using an infusion pump -Oral administration

-Intravenous administration via piggyback using an infusion pump

The nurse is caring for a client who has a chloride level of 115 mEq/L. Which of the following maintenance IV fluids do they anticipate the primary healthcare provider will order? -3% NS -Normal Saline IVF -Lactated Ringers IVF -D5NS

-Lactated Ringers IVF

A client with peptic ulcer disease from chronic nonsteroidal anti-inflammatory drug (NSAID) use is prescribed misoprostol. In educating the client regarding this drug's mechanism of action, the nurse would be most accurate in informing the client that this medication: -Decreases gas formation -Increases the speed of gastric emptying -Lines the stomach for protection -Increases the lower esophageal sphincter pressure

-Lines the stomach for protection

Seizure p0recautions have been ordered for a client admitted to the psychiatric unit. Which of the following nursing interventions is not appropriate when initiating seizure precautions? Select all that apply -Pad the side rails of the bed -Lower side rails while the client sleeps -Remove hard or sharp objects from the bed -Use four point restraints to prevent injury -Adhere a fall risk bracelet to the seizure prone client -Ask the family to monitor the client 24/7

-Lower side rails while the client sleeps -Use four point restraints to prevent injury -Ask the family to monitor the client 24/7

A post-adrenalectomy client is admitted to the intensive care unit and is on intravenous hydrocortisone. Which nursing intervention should be included in the client's plan of care? -Monitor blood glucose levels frequently -Keep the client supine for 24 hours -Discontinue hydrocortisone once vital sign become stable -Educate the client on how to properly clean the wound at home

-Monitor blood glucose levels frequently

A primigravida patient at 38 weeks arrives at the hospital maternity triage unit reporting a "sudden gush of clear fluid" from her vagina shortly before arrival. The maternity triage nurse suspects the patient has experienced a prelabor rupture of membranes (PROM). Which of the following is the most appropirate method for the nurse to use to confirm her suspicion? -An internal vaginal examination -Ultrasound -Nitrazine paper test -A gram stain

-Nitrazine paper test

The nurse is taking care of a client in the fourth stage of labor. She notes that her fundus is firm but she is still bleeding profusely. What should be the nurse's first action? -Document the findings -Massage the client's fundus -Notify the physician -Put the client in Trendelenburg position

-Notify the physician

The nurse had provided teaching to a patient with an arm cast about the signs and symptoms of compartment syndrome. The nurse determines the patient understands the teaching when the patient is able to teach back what early sing of compartment syndrome? -Pain out of proportion to the severity of the fracture -Numbness and tingling in the fingers -Cold and blue tipped fingers -Pain that increased when the arm is dependent

-Numbness and tingling in the fingers

At 25 weeks gestation, a pregnant client presents with a uterine growth size that is less than expected, decreased fetal movement, and an easily palpable fetus. Which of the following is this likely related to? -Oligohydramnios -Macrosomia -Hydramnios -Amniotic fluid embolism

-Oligohydramnios

The nurse plans a staff developmental conference on total parenteral nutrition (TPN). It would be appropriate for the nurse to identify which indications for using TPN? -Appendicitis -Gastroesophageal reflux disease (GERD) -Diverticulosis -Pancreatitis

-Pancreatitis

A client presented to the clinic stating that her home pregnancy test was positive. The nurse understands that this is a -Positive sign of pregnancy -Presumptive sign of pregnancy -Possible sign of pregnancy -Probable sign of pregnancy

-Probable sign of pregnancy

The supervising nurse watches a newly hired nurse take care of a client who is at risk of developing a pressure ulcer. Which of the following interventiosn by the newly hired nurse requires follow-up? Select all that apply -Applies zinc oxide to the cleint's perineal skin -Provides a donut pillow while the client is sitting in the chair -Maintain the head of the client's bed at 90 degrees -Encourage the cient to consume foods rich in carbohydrates -Use a pillow to float the client's heels

-Provides a donut pillow while the client is sitting in the chair -Maintain the head of the client's bed at 90 degrees -Encourage the cient to consume foods rich in carbohydrates

A 16-year-old female client was recently diagnosed with Graves' disease and subsequently admitted. Which of the following orders, if written by the health care provider (HCP), should the nurse question? -Atenolol -Propylthiouracil -Radioactive iodine (I-131) -Methimazole

-Radioactive iodine (I-131)

The nurse is discharging a client that has been admitted due to subarachnoid hemorrhage. The client still has some speech and balance deficits. Which referral would the nurse expect for this client? -Refer the client to hospice care -Refer the client to speech therapy -Refer the client to physical therapy -Refer the client to a home health agency

-Refer the client to a home health agency

The nurse is caring for a client with a serum magnesium level of 3.2 mg/dL. They know that which of the following could have caused this electrolyte abnormality? Select all that apply -Renal failure -Alcoholism -Anorexia -Diarrhea -Malnutrition

-Renal failure

The nurse is reviewing their clients laboratory findings and notes that one of her clients has a serum calcium level of 7.2 mg/dL. They know that of each of the following clients, which ones are most likely to have this result? Select all that apply. -The client with breast cancer and bone metastases -The client with obesity -The client with Vitamin D toxicity -The client with hypoparathyroidism -The client with chronic renal failure

-The client with hypoparathyroidism -The client with chronic renal failure

While working in the Neonatal Intensive Care Unit (NICU), you are notified that a "small for gestational age" infant is being brought to the unit. Being a NICU nurse, you understand that this means which of the following-The infant's weight is less than 2500 grams -The infant's weight is below the 20th percentile -The infant's weight is less than1 1500 grams -The infant's weight is below the 10th percentile

-The infant's weight is below the 10th percentile

The client the delivery room has just delivered her third child. The physician ordered methylergonovine (Methergine) for the client and it was promptly administered. Which manifestation would indicate to the nurse that the medication is having its intended effect? -The client reports a decrease in pain -The nurse palpates a firm uterus on the client -The client states that she wants to empty her bladder -The client's blood pressure increases

-The nurse palpates a firm uterus on the client

The nurse has provided medication instruction to a client who has been prescribed formoterol. Which of the following statements would indicate a correct understanding of the teaching? -I will take this medication if I experience shortness of breath -I will need to rinse my mouth out after using this medication -This medication may make it hard for me to fall asleep -I should take this medication two hours before I go exercise

-This medication may make it hard for me to fall asleep

The nurse is caring for a client with a phosphorus level of 5.0 mg/dL. They know that which of the following are possible cases of this condition. Select all that apply -Tumor lysis syndrome -Hypoparathyroidism -Hypercalcemia -Renal failure -Superior Vena Cava syndrome

-Tumor lysis syndrome -Hypoparathyroidism -Renal failure

Which of the following are required for a nonstress test to be considered reactive? select all that apply -Two increases in the fetal heart rate of 15 beater per minute -Two decreases in the fetal heart rate of 15 beats per minute -Two increases in the fetal heart rate for 15 seconds -Two decreases in the fetal heart rate for 15 seconds -Moderate variability -Absent variability

-Two increases in the fetal heart rate of 15 beater per minute -Two increases in the fetal heart rate for 15 seconds

The nurse is helping a client prepare for a peritoneoscopy tomorrow. All of the following statements from the nurse are accurate regarding the procedure, except: -The doctor will inflate your abdomen using carbon dioxide gas -We will be injecting a dye into your vein in order for us to see the organs better -You need to avoid eating or drinking after midnight to prepare for the procedure -Expect to have some discomfort on your shoulders after the procedure; this is because of the air that's left inside your abdomen

-We will be injecting a dye into your vein in order for us to see the organs better

The nurse is performing a physical assessment on an adult client. The nurse should assess for tactile fremitus by -placing the thumbs on the clients spine at the level of the ninth ribs -asking the client to breath slowly and deeply through an open mouth while auscultating the lungs sounds -asking the client to say "ninety-nine" while palpating the intercoastal spaces beginning at the lung apex -tapping the chest over the distal interphalangeal joint with the middle finger of the opposite hand

-asking the client to say "ninety-nine" while palpating the intercoastal spaces beginning at the lung apex

The infection control nurse is responding to an outbreak of norovirus in the facility. The nurse should recommend that -staff wears a surgical mask when providing client care -disposable utensils and dishware are used for meals -dietary staff wears a face shield when preparing client meals -commonly touched surfaces be disinfected with bleach solution

-commonly touched surfaces be disinfected with bleach solution

The nurse is performing an assessment for a client who is pregnant in her third trimester. The nurse assessed several bruises in various stages of healing on her arms and upper back. The nurse plans on assessing the client for -major depressive disorder -iron-deficiency anemia -intimate partner violence -polycythemia vera

-intimate partner violence

The nurse is caring for a client with pneumothorax with a chest drainage system in place. On assessment, the system has become dislodged from the client. The nurse should initially -obtain an order for chest radiograph (x-ray) -prepare the client for intubation via an endotracheal tube (ETT) -notify the primary healthcare provider -place an occlusive dressing over the site and tape on three sides

-place an occlusive dressing over the site and tape on three sides

The nurse is caring for a client in the intensive care unit (ICU) being mechanically ventilated via an endotracheal tube (ETT) for head trauma following a mechanical vehicle crash. The primary healthcare provider (PHCP) prescribes famotidine 20 mg intravenous (IV) push. The nurse understands that this medication is intended to -decrease any gagging by the ETT -prevent the formation of stress ulcers -provide sedation -increase gastric motility

-prevent the formation of stress ulcers

The nurse is caring for a client who developed a thyroid storm. The nurse should obtain a prescription for -enalapril -calcium gluconate -levothyroxine -propranolol

-propranolol

The nurse takes a call at the antepartum clinic from a client who is pregnant at 19 weeks gestation. The client reports feeling a flutter in her abdomen. The nurse understands that this client is likely experiencing -quickening -lightening -ballottement -ambivalence

-quickening

The nurse is caring for a client scheduled for a thyroidectomy. The primary healthcare provider prescribes potassium iodide-iodine. The nurse understands that this medication is intended to -decrease risk of agranulocytosis postoperatively -prevent postoperative hypocalcemia -reduce the size and vascularity of the thyroid -decrease postoperative blood glucose levels

-reduce the size and vascularity of the thyroid

The nurse observes a student inserting an indwelling urinary catheter into a female client. Which action by the student requires follow-up by the nurse? The student.... (select all that apply) -applies clean gloves to clean ther perineal area with soap and water -asks the client to bear down and slowly insert the catheter through the urethral meatus -separate the labia with the fingers of the dominant hand when cleaning with antiseptic solution -secure the catheter tubing to the inner thigh -attaches the drainage bag to the side rails of bed

-separate the labia with the fingers of the dominant hand when cleaning with antiseptic solution -attaches the drainage bag to the side rails of bed

The nurse is caring for a client scheduled for an adrenalectomy after being diagnosed with pheochromocytoma. Which preoperative clinical data is essential for the nurse to monitor? -intake and output -blood glucose -vital signs -hemoglobin and hematocrit

-vital signs