NCLEX Questions

A psychiatric client diagnosed with schizophrenia approaches the nurses' station and shouts, "Shut up. I told you to be quiet." Looking at the nurse, the client says, "Can't you hear them shouting at me?" Which would be the nurse's *best* response?

"I don't hear the voices, but I can see how upsetting it must be for you."

A client is being discharged home after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement?

"I need to avoid getting the cast wet."

The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There's no one left to care about me. Everyone that I have loved is now gone." The nurse should make which appropriate response?

"It sounds as though you are feeling all alone right now."

The nurse is collecting data on a client who is actively hallucinating. Which nursing statement should be therapeutic at this time?

"Sometimes people hear things or voices others can't hear."

A client is unwilling to go out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has which?

Agoraphobia

The nurse is assisting a client with a closed chest tube drainage system to get out of bed to a chair. During the transfer, the chest tube gets caught in the leg of the chair and accidentally dislodges from the insertion site. Which action should the nurse implement?

Cover the insertion site with sterile Vaseline gauze.

The health care provider suspects a client has herpes zoster. To confirm the diagnosis of herpes zoster, for which diagnostic test does the nurse gather equipment?

Culture of the lesion

An emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. The client states, "I don't need that-my dad takes that for his heart. There's nothing wrong with my heart." Which description *best* describes the client's response?

Denial

The nurse has just been given a prescription to administer albuterol (Proventil HFA) to a client. The nurse evaluates the effectiveness of the medication by checking which parameters before and during therapy?

Dyspnea and lung sounds

The nurse has a prescription to give a client albuterol (Proventil HPA) (two puffs) and beclomethasone dipropionate (Qvar) (two puffs), bu metered-dose inhaler. How should the nurse administer these medications?

Give albuterol first and then the beclomethasone dipropionate.

Carbamazepine (Tegretol) is prescribed for a client with a diagnosis of psychomotor seizures. The nurse reviews the client's health history knowing that his medication is contraindicated if which disorder is present?

Liver disease

A client with acute nonlymphocytic anemia receives treatment with cytarabine (ARA-C). The nurse reinforces medication instructions to the client and tells the client that it is important to report which adverse effect to the health care provider?

Sore throat

A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse should make which interpretation about the client's behavior?

The client is at increased risk for suicide.

The nurse prepares to care for a client with acute cellulitis of the lower leg. Which treatment should the nurse anticipate being prescribed for the client?

Warm compresses to the affected area

The nurse is reviewing the arterial blood gas results of an assigned client. Which arterial blood gases indicate metabolic alkalosis?

ph of 7.48, Pco2 of 40 mm Hg, HCO3 of 36mEq/L

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? *Select all that apply*

-Communicate expected behaviors to the client. -Assist the client in developing means of setting limits on personal behavior. -Follow through about the consequences of behavior in a nonpunitive manner. -Be clear with the client regarding the consequences of exceeding limits set regarding behavior.

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate?

A client receiving diagnostic tests

The nurse reinforces instructions to a client who has been prescribed betaxolol eye drops for the treatment of glaucoma. The nurse instructs the client regarding the administration of the medication and about the importance of returning to the clinic for which assessment?

Blood pressure and apical pulse

The nurse notes that a client is receiving lamivudine (Epivir). The nurse determines that this medication has been prescribed to treat which condition?

Human immunodeficiency virus (HIV) infection

A client who has developed paralysis of the lower extremities is admitted to the hospital. The client shares information with the nurse regarding a severe emotional trauma that occurred 6 weeks ago. The nurse develops a plan of care, knowing which action is the *priority*?

Look for organic causes of the paralysis.

A client with a left arm fracture complains of severe, diffuse pain that is unrelieved with pain medication. Based on these findings, the nurse should take which action?

Notify the registered nurse.

The nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action?

Observing rigid rules and regulations

The nurse is assisting in planning care for a client being admitted to the nursing unit who has attempted suicide. Which *priority* nursing intervention should the nurse include in the plan of care?

One-to-one suicide precautions

The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method should be used to monitor the client for crepitus?

Palpating for the leakage of air into the subcutaneous tissues.

The nurse is assigned to assist the health care provider with the removal of a chest tube. The nurse should reinforce instruction the client to do which during the process?

Perform Valsalva's maneuver.

The nurse is reinforcing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item would provide the least amount of calcium?

Pork

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The nurse understands that a life-threatening complication of this condition is which?

Pulmonary embolism

A client is taking docusate sodium (Colace). The nurse monitors which result to determine whether the client is having a therapeutic effect from this medication?

Regular bowel movements

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, the nurse expects which?

The client presents a harm to self.

A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?

Use a picture or word board.