NCLEX Review
A client at 20 weeks gestation reports "running to the bathroom all the time" pain with urination, and foul-smelling urine. Which question is most important for the nurse to ask when assessing the client?
"Are you having any pain in your lower back or flank area?"
A client is scheduled for coronary artery bypass surgery in the morning. In the middle of the night, the nurse finds the client wide awake. The client demonstrates symptoms of extreme anxiety and tells the nurse about wanting to refuse the surgery. Which statement by the nurse would be most appropriate?
"Tell me about how you feel about your surgery."
The nurse cares for a client receiving intermittent dialysis who is prescribed strict intake and output monitoring with calculation of net fluid balance each shift. Calculate the total net fluid balance for the shift. Intake 0700 - 150 mL vancomycin IV 0900 - 240 mL coffee & 1500 mL dialysate 1100 - 120 mL tea 1300 - 100 mL cefepime IV 1500 - 180 mL juice Output 1300 - 1400mL
890 mL
A client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client?
A private room with negative airflow and contact and airborne precautions
The nurse is reinforcing discharge instructions with a client following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome? SATA
Add high-protein foods to diet Eat small frequent meals Lie down after eating
A client with a ventriculoperitoneal shunt has a dazed appearance and grunting and has not responded to the caregiver for 10 minutes. Status epilepticus is suspected. Which nursing intervention should be performed first?
Administer rectal diazepam
A nurse is caring for a client who had a vaginal birth 2 hours ago. The nurse notes that the client's perineal pad is saturated with blood 20 minutes after placing a new pad. The client's fundus is boggy, palpable above the level of the umbilicus, and deviated to the right. Which intervention should the nurse perform first?
Assist the client to void on a bedpan
While caring for a client in skeletal traction, which tasks can the nurse assign to experienced unlicensed assistive personnel to help prevent immobility hazards? SATA
Assist with active and passive range of motion exercise. Reapply pneumatic compression device after bathing the client. Remind the client to use the incentive spirometer.
The nurse is caring for a client with severe anorexia nervosa. Which of the following findings are consistent with this diagnosis? SATA
BMI of 16 kg/m2 Fine, downy hair on the face and back Has not menstruated in 3 months Potassium of 3.1 mEq/L
A parent call the clinic about a 3 year old who is sick with the flu. Which report by the parent would necessitate intervention by the nurse?
Bismuth subsalicylate being used for nausea
The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings?
Capillary glucose of 60 mg/dL Respirations of 56 breaths per minute White papules on bridge of the nose
A client with suspected foot osteomyelitis is scheduled for an MRI. Which client findings should the nurse report before the test? SATA
Cardiac pacemaker Retained metal foreign body in eye Total hip replacement
The medical surgical nurse cares for a group of clients. Which client situations would the nurse notify the health care provider during the middle of the night? SATA
Client develops right-sided upper and lower extremity drift Client found lying unconscious on the floor Client has order for heparin with surgery planned for the morning Client has serum sodium of 124 mEq/L
The nurse has received information from unlicensed assistive personnel about assigned client situations. Which of the following situations should the nurse address first?
Client who was recently admitted to a room that has a full sharps container on the wall
The health care provider (HCP) repeatedly makes unwanted sexual advances toward the nurse. Which of the following actions by the nurse are appropriate? SATA
Complete an incident report for each occurence Consult the facility's sexual harassment policies Report the behavior to the supervisor immediately Seek support from a licensed professional counselor Tell the HCP to stop the comments
A client with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia has been receiving IV vancomycin for the last 3 days. Which blood test trend is most important for the nurse to review when preparing to administer mendication?
Creatinine levels
A client admitted to the medical surgical unit was recently weaned from the mechanical ventilator and an IV infusion of lorazepam. The client has been alert and oriented for 24 hours but is now experiencing confusion. The practical nurse assists the registered nurse with the evaluation of new onset confusion by assessing the client's sense of place and time, difficulty focusing, short term memory loss, and increasing lethargy. The practical nurse suspects which condition in this client?
Delirium
The nurse is reinforcing teaching about hypoglycemia with a group of clients who have type 1 diabetes mellitus. Which of the following should the nurse include as signs or symptoms of hypoglycemia? SATA
Diaphoresis Pallor Trembling
The nurse on a pediatric unit is caring for a 2 year old client. Which of the following interventions are appropriate to reduce the distress of hospitalization on the child? SATA
Follow the child's home sleep schedule and routine Integrate preferred snack foods into the child's routine Provide various options when choosing toys
The nurse is caring for an 8 month old client with suspected acute otitis media. Which of the following findings would be consistent with the condition? SATA
Frequent pulling on the affected ear Purulent drainage from the affected ear Refusal to eat Restlessness and irritability
The pediatric nurse is reinforcing education about medication administration to the parents of a 4 year old client. Which statements made by the parents demonstrate correct understanding? SATA
I should measure liquid medications using an oral syringe I will encourage my child to help me as I prepare the medication
Which statements made by the client demonstrate a correct understanding of the home care of an ascending colostomy? SATA
I will clarify with my health care provider before taking enteric-coated medications I will limit eating foods such as broccoli and cauliflower to reduce odor
The parents of a 4 year old tell the nurse that the child won't go to sleep at night due to fear of tigers living under the bed. Which response by the nurse is most helpful?
Night fears are common at this age. Look under the bed with your child.
The nurse is caring for a client who just had a total thyroidectomy. Which finding does the nurse recognize as most important to report immediately?
Noisy breathing
The nurse is caring for a client diagnosed with generalized anxiety disorder. What behavior demonstrates that the client is building resilience toward improving anxiety symptoms?
Practices stress-reduction techniques daily
A charge nurse suspects that the unlicensed assistive personnel (UAP) is falsifying the documentation of clients' capillary glucose results rather than performing the test. What is the best action by the charge nurse to handle this situation?
Take a client's capillary glucose personally and compare it to the recorded result
Prior to discharge of a child with a ventriculoperitoneal (VP) shunt, the nurse reinforces teaching to the caregiver about when to contact the health care provider. The caregiver shows understanding of the instructions by contacting the health care povider about which symptom?
The child vomits after awakening from a nap and again 1 hour later
A nurse is caring for a child who is receiving oxygen at 2 L/min by nasal cannula and observes the current oxygen saturation and pulse plethysmographic waveform on the pulse oximeter. Which intervention should be the nurse's initial action?
Verify the position and integrity of the finger probe
A client with chronic kidney disease has received a continuous intravenous infusion of heparin for 5 days. The nurse reviews the coagulation studies and the medication administration record. Which prescription would the nurse question?
Vitamin K
A client is receiving end-of-life care is no longer able to make decisions. The client's appointed medical power of attorney (MPOA) is considering placement of a percutaneous enterogastric feeding tube. The MPOA asks the nurse, "What would you do if this was your family member?" How should the nurse respond?
What do you think are the advantages and disadvantages of a feeding tube?
