NCLEX QUESTIONS fundamentals

When caring for a client with a fractured hip, the nurse should place pillows around the injured leg to specifically maintain: abduction adduction traction elevation

Abduction

A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication?

Drinking alcohol daily can cause drug-induced hepatitis.

A nurse manager is evaluating the effectiveness of a disaster drill during which nurses were sent from their usual assignments to the emergency department. Which criterion should be used for the nurse manager to evaluate care during the disaster drill? 1Number of fatalities 2Cost of nurse overtime 3Nurse-to-client ratio on units 4Completion of critical pathways

3Nurse-to-client ratio on units

During a health screening event which assessment finding would alert the nurse to the possible presence of osteoporosis in a white 61-year-old female? a)The presence of bowed legs b) A measurable loss of height c) Poor appetite and aversion to dairy products d) Development of unstable, wide-gait ambulation

b) A measurable loss of height

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply. 1 Prayer 2 Hypnosis 3 Medication 4 Aromatherapy 5 guided imagery

prayer hypnosis aromatherapy guided imagery

Which nursing intervention is most appropriate when turning a patient following spinal surgery? -Placing a pillow between the patient's legs and turning the body as a unit -Having the patient turn to the side by grasping the side rails to help turn over -Elevating the head of bed 30 degrees and having the patient extend the legs while turning -Turning the patient's head and shoulders and then the hips, keeping the patient's body centered in the bed

Placing a pillow between the patient's legs and turning the body as a unit

A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply. 1 Clean the eyelid and eyelashes. 2 Place the dropper against the eyelid. 3 Apply clean gloves before beginning of procedure. 4 Instill the solution directly onto cornea. 5 Press on the nasolacrimal duct after instilling the solution.

1 Clean the eyelid and eyelashes. 3 Apply clean gloves before beginning of procedure. 5 Press on the nasolacrimal duct after instilling the solution.

A client is admitted to the hospital with ascites. The client reports drinking a quart of vodka mixed in orange juice every day for the past three months. To assess the potential for withdrawal symptoms, which question would be appropriate for the nurse to ask the client? 1"When was your last drink of vodka?" 2"What prompts your drinking episodes?" 3"Do you also eat when you drink?" 4"Why do you mix the vodka with orange juice?

1"When was your last drink of vodka?"

A plan of care for a client newly diagnosed with type 1 diabetes includes teaching how to self-administer insulin, adjust insulin dosage, select appropriate food on the prescribed diet, and test the serum for glucose. The client demonstrates achievement of these skills and is discharged five days following admission. What is the legal implication in this situation? 1-The nurse was functioning as a health teacher when providing the instructions. 2-A home health care nurse should have done the health teaching in the client's home. 3-Before discharge, family members also should have been taught how to administer insulin and perform other aspects of care. 4-Before implementation, the nurse should have the plan approved by all other members of the client's health ca

1-The nurse was functioning as a health teacher when providing the instructions.

1Rapid, thready pulse 2 Distended jugular veins 3 Elevated hematocrit level 4 Increased serum sodium level

2 Distended jugular veins Because of fluid overload in the intravascular space, the neck veins become visibly distended.

The nurse is caring for a client that is hyperventilating. The nurse recalls that the client is at risk for: 1 Respiratory acidosis 2 Respiratory alkalosis 3 Respiratory compensation 4 Respiratory decompensation

2 Respiratory alkalosis

A client with ascites is scheduled to receive albumin. To have the greatest therapeutic effect, the nurse expects what infusion rate and what oral fluid intake? 1 Slow intravenous (IV) rate and liberal fluid intake Slow IV rate and restricted fluid intake 3 Rapid IV rate and withheld fluid intake 4 Rapid IV rate and moderate fluid intake

2 Slow intravenous (IV) rate and liberal fluid intake

A client's serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first? 1Call the laboratory to repeat the test. 2 Take vital signs and notify the health care provider. 3Inform the cardiac arrest team to place them on alert. 4Take an electrocardiogram and have lidocaine available.

2 Take vital signs and notify the health care provider. Vital signs monitor cardiorespiratory status; hyperkalemia causes cardiac dysrhythmias. The health care provider should be notified because medical intervention may be necessary.

A client is admitted to the emergency department with a contaminated wound. The client is a poor historian, and the nurse realizes that it is impossible to determine whether the client is immunized against tetanus. Because it will produce passive immunity for several weeks with minimal danger of an allergic reaction, the nurse expects that what medication will be prescribed? 1 Tetanus toxoid (Td) 2 Equine tetanus antitoxin 3Human tetanus antitoxin 4 Diphtheria, tetanus, pertussis (DTaP) vaccine

3Human tetanus antitoxin Human tetanus antitoxin (tetanus immune globulin [TIG]) provides antibodies against tetanus; it is used for the individual who may be infected and never has received tetanus toxoid or has not received it for more than 10 years. It confers passive immunity.

An 89-year-old client with osteoporosis is admitted to the hospital with a compression fracture of the spine. The nurse identifies that a factor of special concern when caring for this client is the client's: 1Irritability in response to deprivation 2Decreased ability to recall recent facts 3Inability to maintain an optimal level of functioning 4Gradual memory loss resulting from change in environment

3Inability to maintain an optimal level of functioning The onset of disabling illness will divert an older person's energies, making it difficult to maintain an optimum level of functioning.

A nurse is caring for a client who is receiving serum albumin. What indicates that the albumin is effective? 1 Improved clotting of blood 2 Formation of red blood cells 3 Activation of white blood cells 4 Maintenance of oncotic pressure

4 Maintenance of oncotic pressure

Prednisone (Meticorten) is prescribed for a client with an exacerbation of colitis. Before administering the first dose, the nurse teaches the client that: 1Symptoms associated with the colitis will decrease slowly over time 2The client will be protected from getting an infection 3Although the medication causes anorexia, weight loss may not occur 4Although the medication decreases intestinal inflammation, it will not cure the colitis

4Although the medication decreases intestinal inflammation, it will not cure the colitis Prednisone inhibits phagocytosis and suppresses other clinical phenomena of inflammation; this is a symptomatic treatment that is not curative. The response usually is rapid. The drug suppresses the immune response and increases the potential for infection. Appetite is increased; weight gain may result from this or from fluid retention.

The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the nurse take? 1 Institute the prescribed blood transfusion because the client's survival depends on volume replacement. 2 Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. 3 Phone the health care provider for an administrative prescription to give the transfusion under these circumstances. 4 Give the spouse a treatment refusal form to sign and notify the health care provider that a court order now can be sought.

4Give the spouse a treatment refusal form to sign and notify the health care provider that a court order now can be sought. The client is unconscious. Although the spouse can give consent, there is no legal power to refuse a treatment for the client unless previously authorized to do so by a power of attorney or a health care proxy; the court can make a decision for the client

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? 1Stage I 2Stage II 3Stage III 4Unstageable

4Unstageable A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged.

The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: 1 A physiological response to stress 2 A conscious defense against anxiety 3 An intentional attempt to gain attention 4 An unconscious means of reducing stress

An unconscious means of reducing stress

A nurse manager uses a participative leadership approach to change. List the steps in order of priority that the manager should follow to create effective change processes. Introduce new information. 1Provide opportunities for 2ventilation 3Be supportive. 4Offer feedback.

Be supportive. Introduce new information. Provide opportunities for ventilation. Offer feedback.

The nurse is caring for a patient hospitalized with exacerbation of chronic bronchitis and herniated lumbar disc. Which breakfast choice would be most appropriate for the nurse to encourage the patient to check on the breakfast menu? Bran muffin Scrambled eggs Incorrect Puffed rice cereal Buttered white toast

Bran muffin Each meal should contain one or more sources of fiber, which will reduce the risk of constipation and straining with defecation, which increases back pain. Bran is typically a high-fiber food choice and is appropriate for selection from the menu.

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication? 1Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. 2Develop a chart for the client, listing the times the medication should be taken. 3Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. 4Instruct the client and client's children to put medications in a weekly pill organizer.

Contact the primary health care provider and discuss the possibility of simplifying the medication regimen.

To decrease abdominal distention following a client's surgery, what actions should the nurse take? Select all that apply. 1 Encourage ambulation. 2 Give sips of ginger ale. 3 Auscultate bowel sounds. 4 Provide a straw for drinking. 5 Offer an opioid analgesic

Encourage ambulation. Auscultate bowel sounds.

The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. Which symptom will the nurse most likely find on physical examination of the patient? Nausea and vomiting Localized pain and warmth Paresthesia in the affected extremity Generalized bone pain throughout the leg

Localized pain and warmth

An intravenous (IV) solution containing potassium inadvertently has infused too rapidly. The health care provider prescribes insulin added to a 10% dextrose in water solution. The nurse determines that the rationale for the insulin is: 1Potassium follows insulin and glucose into the cells of the body, thereby raising the intracellular potassium level. 2Increased insulin accelerates excretion of glucose and potassium, thereby decreasing the serum potassium level. 3Glucose with insulin increases metabolism, which accelerates potassium excretion. Increased potassium causes a temporary slowing of pancreatic production of insulin.

Potassium follows insulin and glucose into the cells of the body, thereby raising the intracellular potassium level.

A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? 1 Limits had to be set to control the child's crying. 2The child had a right to remain in the room with the other children. 3The child had to be removed because the other children needed to be considered. 4Segregation of the child for more than half an hour was too long a period of time.

The child had a right to remain in the room with the other children. Legally, a person cannot be locked in a room (isolated) unless there is a threat of danger either to the self or to others.

A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how gamma globulin provides passive immunity? 1It increases production of short-lived antibodies. 2It accelerates antigen-antibody union at the hepatic sites. 3The lymphatic system is stimulated to produce antibodies. 4The antigen is neutralized by the antibodies that it supplies.

The antigen is neutralized by the antibodies that it supplies. Gamma globulin, which is an immune globulin, contains most of the antibodies circulating in the blood. When injected into an individual, it prevents a specific antigen from entering a host cell.

The nurse is planning health promotion teaching for a 45-year-old patient with asthma, low back pain from herniated lumbar disc, and schizophrenia. What does the nurse determine would be the best exercise to include in an individualized exercise plan for the patient? Yoga Walking Calisthenics Weight lifting

walking

A nurse provides crutch-walking instructions to a client that has a left-leg cast. The nurse should explain that weight must be placed: 1In the axillae 2On the hands 3On the right side 4On the side that the client prefers

2On the hands

A nurse is teaching an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? Select all that apply. 1 "What is diabetes?" 2 "What will my friends think?" 3 "How do I give myself an injection?" 4 "Can you tell me how the glucose monitor works?" 5 "How do I get the insulin from the vial into the syringe?"

1 "What is diabetes?" 4 "Can you tell me how the glucose monitor works?"

The nurse suspects that an intraoperative client has a distended bladder. Which method is correct to assess for this condition? 1Inspect and palpate in the epigastric region. 2Auscultate and percuss in the inguinal areas. 3 Percuss and palpate in the hypogastric region. 4 Percuss and palpate bilaterally in the lumbar areas

3 Percuss and palpate in the hypogastric region.

A client comes to the medical clinic complaining of headaches. The nurse measures the blood pressure at 172/114. What should the nurse do first? Page the on-call health care provider and continue to monitor the blood pressure. 2 Administer ibuprofen and have the client rest quietly for 20 minutes. 3 Elevate the head of the bed, provide reassurance, and reassess the blood pressure. 4 Place the client in the supine position, administer oxygen, and notify the health care provider.

Elevate the head of the bed, provide reassurance, and reassess the blood pressure. Blood pressure increases with pain and stress; reevaluation is critical before determining if the health care provider should be notified. Assessment should be completed before notifying the health care provider.