NCLEX Questions-Week 5

The nurse has provided instructions to a client scheduled for a mammography regarding the procedure. Which statement by the client indicates an understanding of the procedure?

"I should not wear deodorant on the day of the test."

The nurse is preparing to give a full bed bath to a client. Which question is most important for the nurse to ask the client before beginning the bed bath?

"Do you have any allergies?"

A nurse is precepting a new graduate nurse, and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management?

"I will be sure to cue in to any indicators that the client may be exaggerating pain."

The nurse is reviewing dental care with a client who is edentulous and wears dentures. Which client statement indicates an understanding of proper dental care?

"I will remove my dentures before bed and keep them in my labeled denture cup covered with water."

A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, "I don't feel any better than I did before surgery." Which response by the nurse is most appropriate?

"You are concerned that you don't feel any better after surgery?"

The nurse is caring for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On data collection, the nurse notes that the client is severely dysphagic. The nurse would include which in the plan of care? Select all that apply.

-Allowing the client sufficient time to eat -Providing oral hygiene after each meal -Maintaining a suction machine at the bedside

The nurse is reinforcing teaching with a client who is having difficulty sleeping. Which bedtime snacks will help the client achieve a restful night's sleep? Select all that apply.

-A glass of warm milk -A cube of Swiss cheese -A cup of caffeine-free tea

The nurse is preparing to provide mouth care to an unconscious client. The nurse collects which items to perform this procedure? Select all that apply.

-A soft toothbrush -Irrigation syringe -Bite stick or a padded tongue blade -Suction with oral suction catheter attached

A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measures are necessary when caring for this client? Select all that apply.

-Administering intermittent feeding through a 60-mL syringe with the plunger removed and the barrel attached to the gastrostomy tube -Monitoring the skin around the stoma site for skin irritation

A physician is caring for a client who is human immunodeficiency virus (HIV) positive and has delivered a newborn baby. The nurse anticipates that which interventions would be employed for the newborn to decrease the risk of HIV? Select all that apply.

-Antiretroviral prophylaxis for newborns testing HIV positive -Periodic testing for HIV at set intervals until the age of 6 months -HIV testing of the newborn within 48 hours

A client on the medical unit tells the nurse of back discomfort but states that they do not want any pain medication. Which nonpharmacologic interventions would the nurse offer the client to help reduce the pain? Select all that apply.

-Back massage -Relaxation breathing -Distraction

The nurse is performing an environmental assessment in the home of an older client. Which observations require immediate attention? Select all that apply.

-Cigarette pack and lighter on the bedside stand -Unsecured scatter rugs

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions would the nurse take? Select all that apply.

-Contact the RN and/or surgeon. -Instruct the client to remain quiet. -Prepare the client for wound closure. -Document the findings and actions taken.

The nurse is assisting in the care of a client diagnosed with acquired immunodeficiency syndrome (AIDS) who requires an injection. The nurse would include which actions to safely administer the medication? Select all that apply.

-Dispose of the needle and syringe in a puncture-resistant container. -Wear gloves while administering the injected medication.

A client admitted to the hospital with suspected seizure activity acknowledges to the nurse that they use the herbal supplement ginkgo. Which follow-up questions to the client by the nurse would be most appropriate? Select all that apply.

-Do you have a history of seizures? -Do you have a history of a clotting disorder? -How long and why have you been using ginkgo? -Have you been diagnosed with diabetes mellitus?

The nurse in the delivery room is caring for a newborn delivered 10 minutes ago. The nurse assists in preparing which medications that will be prescribed to be given within the first hour of life? Select all that apply.

-Erythromycin eye drops -Phytonadione

The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal surgery. Which instructions would be appropriate to include in the preoperative plan of care? Select all that apply.

-Frequent assessment of vital signs -Coughing and deep breathing exercises -Pain monitoring and medications to relieve pain

The nurse is inquiring about the client's use of complementary and alternative medicines (CAMs). The nurse would be most concerned with the client who uses which CAMs? Select all that apply.

-Homeopathy -Herbal supplements

A 0.9% normal saline intravenous (IV) solution is prescribed for a client. The IV is to run at 100 mL/hr. The nurse prepares the solution, understanding that which are characteristics of this type of solution? Select all that apply.

-Is the same solution as sodium chloride 0.9% -Is used to administer red blood cell transfusion -Is used to treat hypotension due to fluid volume deficit

A client with a diagnosis of tonic-clonic seizures is being admitted to the hospital, and the nurse needs to institute seizure precautions. During a seizure, which items are inappropriate to use and could cause harm to the client? Select all that apply.

-Restraints -Padded tongue blade

The nurse assists a physician with the insertion of a nasogastric tube. Which positions would the nurse place the client in to prepare for the procedure? Select all that apply.

-Slight extension of the neck -High-Fowler's position

The nurse is preparing to discontinue an indwelling urinary catheter. Which pieces of equipment would the nurse obtain to perform this procedure? Select all that apply.

-Sterile 10- or 12-mL syringe -Clean towel

The nurse reviews the laboratory values on a child with leukemia receiving chemotherapy. The nurse notes that the platelet count is 19,000 mm3. Based on this laboratory result, which actions would the nurse include in the plan of care? Select all that apply. Test and Results Platelet count 19,000 mm3

-Testing stools and urine for blood -Using a soft toothbrush for mouth care

The nurse admits a client who has seizure precautions prescribed. The client has a seizure just after the nurse has implemented the precautions. Which actions would the nurse take? Select all that apply.

-Time the start and stop of the seizure. -Apply oxygen at 2 L/min with nasal cannula. -Turn the client to the side, and do not restrain. -Note the distinguishing characteristics of the seizure. -Turn on the suction machine with oral catheter.

The nurse is caring for a Jewish client who follows a kosher diet. Which food items would the nurse consider in planning meals for the client? Select all that apply.

-Tuna -Chicken -Turkey

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results would the nurse report? Select all that apply. Tests and Results Platelets= 35,000/mm3 Sodium= 150 mEq/L Potassium= 5.0 mEq/L Neutrophils= 40% Creatinine= 1 mg/dL White blood cells= 3000/mm3

-White blood cells 3000/mm3 -Segmented neutrophils 40% -Sodium 150 mEq/L -Platelets 35,000/mm3

A client is complaining of abdominal pain and nausea. The prescription is as follows: give hydroxyzine 25 mg intramuscularly and meperidine 25 mg intramuscularly, stat. Hydroxyzine is available in 50 mg/mL. Meperidine is available in 25 mg/0.5 mL. The nurse would combine the doses in one syringe for administration to the ventrogluteal muscle. How many milliliters would the nurse administer in total? Fill in the blank.

1 mL

The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief?

Alternating air pad

A physician's prescription reads ciprofloxacin 0.5 g orally twice daily. The medication label reads ciprofloxacin 500-mg tablets. The nurse prepares how many tablet(s) to administer 1 dose? Fill in the blank.

1 tablet(s)

The physician's prescription reads "levothyroxine, 100 mcg orally daily." The medication label reads "levothyroxine, 0.1 mg/tableThe physician's prescription reads "levothyroxine, 100 mcg orally daily." The medication label reads "levothyroxine, 0.1 mg/tablet." The nurse prepares to administer how many tablet(s) to the client? Fill in the blank

1 tablet(s)

A prescription reads to administer an intravenous (IV) dose of 400,000 units of penicillin G benzathine to a client with an infection. The label on the 10 mL ampule sent from the pharmacy reads penicillin G benzathine, 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Fill in the blank. Record your answer using 1 decimal place.

1.3 mL

A primary health care provider (PHCP) prescribes potassium chloride (KCl) elixir, 20 mEq orally daily. The medication label states potassium chloride (KCl), 30 mEq/15 mL. How many milliliters would the nurse prepare to administer the dose? Fill in the blank.

10 mL

The nurse is preparing to administer 30 mEq of liquid potassium chloride (KCl) to an adult client. The label on the medication bottle reads 40 mEq/15 mL. The nurse prepares how many milliliters of KCl to administer the correct dose of medication? Fill in the blank. Round your answer to the nearest whole number.

11 mL

A primary health care provider prescribes 3000 mL of 5% dextrose to be administered over a 24-hour period. The nurse prepares to set the infusion rate, knowing that how many milliliters per hour are to be administered? Fill in the blank.

125 mL

A prescription reads potassium chloride 30 mEq to be added to 1000 mL normal saline (NS) and to be administered over a 10-hour period. The label on the medication bottle reads 40 mEq/20 mL. The nurse prepares how many milliliters of potassium chloride to administer the correct dose of medication? Fill in the blank.

15 mL

The nurse hangs a 1000-mL intravenous (IV) bag of 5% dextrose in water (D5W) at 0700. The IV is to infuse at 100 mL/hr, and the nurse places a time tape on the IV bag. At noon the nurse would expect that the infusion line on the IV bag would be at which point? Refer to figure.

2

The nurse is preparing a small dose of a medication for administration to an infant. The nurse selects which syringe for preparing the medication? Refer to figure.

2

A primary health care provider prescribes tetracycline hydrochloride 0.5 g orally 4 times daily. The medication label on the bottle of medication reads tetracycline hydrochloride 250-mg tablets. The nurse prepares how many tablet(s) to administer 1 dose? Fill in the blank.

2 tablet(s)

A physician prescribes 1000 mL of 0.9% NaCl to be infused over a period of 12 hours. The drop (gtt) factor is 15 drops (gtts)/mL. The nurse plans to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

21 gtts/min

The physician prescribes ibuprofen 5 mg per kg for a child who weighs 13 pounds. How many milligrams (mg) would the nurse administer to the child? Fill in the blank. Record your answer using one decimal place.

29.5 mg

A physician prescribes 3000 mL of 5% dextrose in water (D5W) to run over a 24-hour period. The drop (gtt) factor is 15 drops (gtts) per 1 mL. The nurse adjusts the flow rate to run at how many gtts per minute? Fill in the blank. Record your answer to the nearest whole number.

31 gtt/min

A physician prescribes 3000 mL of 0.9% NaCl to run over 24 hours. The drop (gtt) factor is 15 gtts/mL. The nurse plans to adjust the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

31 gtts

The nurse is preparing to administer a continuous tube feeding to a client with a nasogastric tube. The physician has prescribed an amount of 100 mL/hr. The tube feeding setup is an open system, a bag that has formula added at intervals. How much formula would the nurse plan to add to fill the feeding bag?

400 mL of formula

Which client is the safest one for a licensed practical nurse (LPN) to care for?

A client recovering from a scheduled cesarean delivery

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse would take which initial action?

Activate the emergency response plan specific to the facility.

A client is prescribed an eye drop and an eye ointment for the right eye. How would the nurse best administer the medications?

Administer the eye drop first, followed by the eye ointment.

The nurse is told that a client will be admitted to the hospital for a radiation implant. The nurse is asked to prepare for the admission of the client and plans which measure for this client?

Admit the client to a private room.

A client suspected of having a duodenal ulcer has undergone esophagogastroduodenoscopy. The nurse would place highest priority on which item as part of the client's care plan?

Assessing for the return of the gag reflex

The nurse is providing safety instructions to a group of parents who have children ages 8 and 9. Which car safety device would be used for a child who is 8 years old and is 4 feet tall?

Booster seat

A client has just undergone endoscopy. Which is the essential post procedure nursing intervention?

Check the gag reflex before giving oral foods or fluids.

The nurse is caring for a child following a cleft palate repair who has elbow restraints in place. The nurse assists in preparing a plan of care and determines that which nursing intervention would receive highest priority regarding the restraints?

Checking color, sensation, and pulses distal to the restraints

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention would the nurse take first?

Determine whether there are medication duplications.

The nurse is providing follow-up teaching after a client underwent an upper gastrointestinal (GI) series with diatrizoate used for contrast. The nurse instructs the client that which may occur from the diatrizoate?

Diarrhea

An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse would plan to do which as a first step for the prevention of future injury?

Explore the adolescent's knowledge of gun safety.

The nurse is reinforcing dietary instructions to a client with tuberculosis who has lost weight. The nurse reinforces instructions for the client to increase intake of protein and vitamin C. The nurse determines that teaching has been effective when the client selects which food items in the daily diet?

Hamburger and oranges

The nurse is reinforcing preprocedure instructions to a client scheduled for a barium swallow at 0800. Which statement by the client indicates a need for further teaching?

I will limit myself to two cigarettes only on the morning of the test.

A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is important?

Informing the surgeon of the situation

After attending the same social function 5 days ago, 50 individuals arrive at the hospital over a 4-day period with fever; an itchy, reddish-brown papule; and complaints of nausea, vomiting, and severe abdominal pain. Cutaneous anthrax is suspected by the health care team. Which is the nurse's priority for client care?

Institute contact precautions.

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse would assist the RN in taking which most appropriate action in the care of this client?

Obtain a telephone consent from a family member witnessed by a second RN, following agency policy.

A client who is recovering from a stroke has residual dysphagia and is prescribed nectar-thickened liquids. The licensed practical nurse has instructed the unlicensed assistive personnel (UAP) in feeding technique. The nurse would intervene if the UAP attempts to perform which activity?

Placing food on the affected side of the mouth

A physician writes a prescription to apply a heating pad to a client's back. The nurse implements the prescription and avoids which action?

Placing the heating pad under the client

The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). After administering the medication, the nurse would dispose of the used needle by which method?

Placing the needle and syringe in a puncture-resistant container

The nurse is instructing a group of unlicensed assistive personnel (UAP) in the principles of body mechanics. The nurse determines that a UAP is using the principles appropriately if the nurse observes the UAP doing which action?

Positioning a box that is to be lifted between the knees

The nurse is assigned to assist in caring for a client who has had surgery and has pneumatic sequential compression devices (SCDs) in place. The client asks about these devices. The nurse instructs the client that SCDs are used for which purpose?

Promoting venous return to the heart

A client is scheduled for a digital subtraction angiography (DSA). The nurse tells the client that the test is directed toward which outcome?

Providing information about the blood vessels

A client has been on total parenteral nutrition for 8 weeks. The physician prescribes that the total parenteral nutrition be weaned down by 50 mL/hr each day until discontinued. The client asks the nurse, "Why doesn't the doctor just stop the parenteral nutrition instead of dragging it on for 3 days?" The nursing response would be to explain that the physician is concerned about which phenomenon?

Rebound hypoglycemia

The nurse enters the room to find that the client's trash can is in flames. The client is in bed, and the edge of their gown is smoking. The nurse would take which action first?

Remove the gown from the client, and remove the client from the room.

A client who is found unresponsive has arterial blood gases drawn, and the results indicate the following: pH is 7.12, Pco2 is 90 mm Hg, and HCO3 is 22 mEq/L . The nurse recognizes the results as indicating which condition? Tests and Results pH= 7.12 Pco2 = 90 HCO3= 22

Respiratory acidosis without compensation

The nurse obtains a prescription from an RN and a primary health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the UAP?

Safely securing the safety device straps to the side rails

The nurse is preparing to instruct a client with hypertension on the importance of choosing foods low in sodium. The nurse would plan to teach the client to limit intake of which food?

Smoked salami

The nurse has just been told by the physician that a prescription has been written to administer a heparin injection to a client every 12 hours. The nurse anticipates using which technique to administer the medication?

Subcutaneous, using the abdomen

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse would include which piece of information in discussions with the client?

The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

The nurse is preparing to provide wound care to a client with a stage 1 pressure injury. Which dressing would the nurse expect to be prescribed in the treatment of this wound?

Transparent dressing

The nurse is caring for a hospitalized older client who has pulled out their IV for the second time. The nurse inserts a new IV. Which intervention would the nurse institute next for the client?

Wrap a light roll of gauze to cover the IV site.