NCLEX Review - Missed Questions
1, 2, 3, 4, 6
The nurse is discussing appropriate toys for preschoolers with a group of parents. What toys should the nurse include? 1. Six piece jigsaw puzzles 2. Puppets 3. Paint brush and paint set 4. Dress up clothes 5. Jump rope 6. Sewing cards
2, 4, 5
The nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) guidelines for immunization recommendations with a group of parents whose children are preparing to attend college in the fall. Which immunization recommendations should the nurse include? 1. Rotavirus 2. Meningococcal 3. Herpes zoster 4. Seasonal influenza 5. Human papilloma virus
3
The nurse is teaching a pregnant teenage client about resources available through the health department. The client says, "I am not sure that I want to have this baby. What do you think about an abortion?" What should the nurse say? 1. What does the baby's father think about an abortion? 2. I know this is a difficult decision. 3. What are your thoughts about abortion? 4. There are many options other than abortion.
2, 3, 4, 5
A client has been admitted to the psychiatric unit with a diagnosis of schizophrenia. Which client behaviors does the nurse anticipate? 1. Abstract reasoning 2. Waxy flexibility 3. Grandiose delusions 4. Anxiety 5. Agitated behavior
3
A client makes an initial visit to the prenatal clinic, informing nurse the probably date of conception was May 15th. The first day of the last menstrual cycle was on May 1st. Using Naegele's rule, the nurse determines the client's due date should be when? Naegele's rule for determining a client's expected due date is to count backward three months from the first day of the last menstrual cycle, then add seven days to that date. 1. February 22nd 2. August 8th 3. February 8th 4. August 22nd
4
Following hip replacement surgery, an elderly client is being transferred to a long term care facility for therapy. What priority action by the nurse best promotes continuity of care for the client? 1. Explain future care requirements to the family. 2. Call facility's nurse manager to give oral report. 3. Discuss client's needs with healthcare provider. 4. Send written summary of client needs to facility.
4
Two cognitively impaired siblings are clients in the same hospital room. During rounds, the nurse notes they have removed identification bracelets. Because of similar appearance, the nurse is unable to identify the correct client for blood work. What would be the most reliable method for the nurse to use to properly identify these clients? 1. Draw blood to type and crossmatch and compare with chart. 2. Call the primary healthcare provider to identify each client. 3. Ask nurses on the next shift to try to identify the clients. 4. Notify family to come in and identify clients in person.
1, 2, 3, 4
What developmental milestone does the nurse expect to see in an 18 month old toddler? 1. Says and shakes head "no". 2. Points to one body part. 3. Drinks from a cup. 4. Points to show someone what they want. 5. Kicks a ball. 6. Walks up and down stairs holding on.
1, 2, 3, 5
What discharge education should a nurse provide to a client post hip replacement with a metal joint? 1. Weight bearing limits. 2. Use of a high seated chair. 3. Sexual intercourse in dependent position for up to six months. 4. Avoid taking showers. 5. Use of long handled tongs to assist with dressing.
4, 5
What discharge instructions should the nurse provide to the parents of a child diagnosed with sickle cell anemia? 1. Provide high-calorie, low protein diet. 2. Inheritance is by autosomal dominate genes. 3. Restrict all activities for 3 months. 4. Deferasirox helps prevent liver damage from iron deposits. 5. Avoid high altitudes.
1, 3
What should the nurse include in the teaching plan for a client receiving external beam radiation? 1. Small marks will be placed on the skin to mark the treatment area. 2. Lotion may be used around the treatment area to decrease dryness. 3. The radiation therapist can see, hear, and talk with you at all times during treatment. 4. Stay away from babies for 24 hours. 5. You will have to hold your breath during radiation treatment.
2, 5
What task can the nurse assign to an unlicensed assistive personnel (UAP) while caring for a client diagnosed with a stroke? 1. Check the client's gag reflex. 2. Assist with feeding the client. 3. Monitor the client's headache pain level. 4. Encourage client to expression frustrations. 5. Maintain the head of the bed at 25 - 30 degrees.
1, 3, 4, 5
When shopping at the mall, a nurse witnesses an individual collapse in cardiac arrest. A bystander begins CPR while the nurse opens an automatic external defibrillator (AED) brought by security. What critical actions should the nurse perform before delivering a shock? 1. Apply defibrillator pads to bare skin. 2. Verify that synchronizer button is on. 3. Continue CPR until advised to deliver shock. 4. Stop CPR while machine analyzes the rhythm. 5. Shout "clear" prior to activating shock button. 6. Apply cream under de-fib pads to prevent burns.
3
A client diagnosed with major depression has been admitted to a psychiatric facility for medication management. During nighttime rounds, an LPN/VN notes the client is not in bed. Which behavior by the client should the LPN/VN report to the RN immediately? 1. Sitting in a chair crying. 2. Reports inability to sleep. 3. Rearranging furniture. 4. Pacing around the room.
3
A client is admitted to the emergency department following a motor vehicle accident (MVA). The client reports abdominal discomfort, weakness, and nausea. Vital signs: BP 88/52, HR 118/min, RR 24/ min. Which healthcare provider prescription should the nurse implement first? 1. Administer ondansetron 2 mg IV. 2. Insert a foley catheter in order to obtain hourly urinary outputs. 3. Infuse lactated ringers (LR) at 200 mL per hour. 4. Type and cross match for four units of packed red blood cells.
3
A client who is experiencing paranoia is very agitated with aggressive behavior and shouts at others when it is time for a group therapy session. Which action by the nurse is correct? 1. Ask the client to sit for a few minutes. 2. Explain that shouting is not allowed. 3. Redirect the client to another activity. 4. Inform the client that their actions are unacceptable.
1, 3, 4, 5
A client with distended and tortuous veins along the inner aspects of both legs asks the nurse how to decrease the development of these veins. What should the nurse advise? 1. Exercise 2. Follow a low protein diet 3. Wear low heeled shoes 4. Elevate legs above heart several times per day 5. Do not cross legs
4
A female client who identifies herself as a Muslim arrives at the outpatient clinic with abdominal pain. Which initial question should the nurse ask to obtain cultural information? 1. "Do you need a family member in the room with you?" 2. "What can you tell me about your culture?" 3. "Have I positioned you so that you are facing toward Mecca?" 4. "Are you comfortable being cared for by a male primary healthcare provider?"
2
The charge nurse is reviewing multiple events reported by staff during morning shift. The nurse is aware which event requires a written incident report? 1. A client yells loudly throughout the night shift. 2. A nurse discusses client's prognosis with family. 3. An unlicensed assistive personnel (UAP) spills water pitcher onto client. 4. A nurse tears sterile gloves and applies new gloves.
2
The community health nurse is developing a presentation for adolescents on dealing with gun violence in school. What initial action should the nurse take? 1. Design a booklet for school districts on handling aggression. 2. Survey students to determine attitudes towards weapons. 3. Provide information on anger management to grade schools. 4. Investigate existing safety procedures in the schools.
1, 4, 5
The emergency room nurse is assessing a client with an eye injury that occurred while chopping wood. The client states the chain saw caused a log to splinter, sending slivers of wood into the right eye. While waiting for the eye specialist, the nurse discusses future safety precautions for such an activity. What safety precautions are most important for the nurse to include in client teaching? 1. Wear heavy gloves. 2. Stand with feet together. 3. Use steel-toed boots. 4. Wear unbreakable googles. 5. Use ear covers and plugs. 6. Wear loose-fitting clothing.
1, 2, 3, 4, 5
The homecare nurse is providing family teaching on safety issues for a client diagnosed with Parkinson's disease. What adaptations should the nurse instruct the family to initiate? 1. Install grab bars on tub walls. 2. Place nightlights in hallways. 3. Add bran and fiber to daily diet. 4. Remove scatter rugs or loose cords. 5. Keep bedroom dark, cool and quiet. 6. Put tennis balls on legs of walker.
3
The nurse is caring for a client who presents to the mental health unit following a violent altercation with the spouse. The client has numerous bruises on the face, chest, and back. There is one laceration where spouse "came at me" with a knife. At this time, what is most likely to be the mood of the perpetrator in this situation? 1. Extreme anger 2. Anxiety 3. Kindness 4. Irritability
1, 2, 5
The nurse is developing a teaching plan covering emergency responses to smallpox. This presentation will be used with newly hired hospital employees. What information is essential for the presentation? 1. People may be exposed to smallpox but not get the disease. 2. People may contract the disease by handling contaminated clothing or bedding. 3. Smallpox is fatal is about 50% of cases. 4. Smallpox victims are contagious for two weeks. 5. Smallpox victims are isolated from others.
1, 2, 3, 5
The nurse is educating a group of sexually active teenagers about Chlamydia. What should the nurse teach these clients to prevent them from acquiring or transmitting this disease ? 1. Use a latex condom when having sex to protect against Chlamydia. 2. Seek the advice of a primary healthcare provider if there is vaginal discharge or burning on urination. 3. Suggest that the teens be screened for Chlamydia. 4. Reassure the teens that if they have no symptoms, they have no disease. 5. Take prescribed medication if diagnosed with Chlamydia, and repeat screening in three months.
1
The nurse is having an education class for pregnant women. A question is raised about exercise. What is the nurse's best response? 1. Discuss with healthcare provider your current exercise regimen and history. 2. You can continue any exercise that you have been doing before pregnancy. 3. If you haven't already started an exercise program, you should wait until after delivery. 4. Exercise is required during pregnancy for a minimum of 15 minutes each day.
4, 5
The nurse is reviewing the plan of care for a client during the first day post-craniotomy. Which actions can the nurse delegate to an experienced LPN/LVN working in the ICU? 1. Determine Glasgow Coma Score. 2. Check endotracheal tube (ET) cuff pressure every shift. 3. Reposition client from side to side every 2 hours. 4. Administer acetaminophen via nasogastric tube for temperature greater than 101ºF (38.3ºC). 5. Monitor intake and output every hour.
2, 3, 4
The nurse is teaching a group of teenagers about decreasing the risk of developing skin cancer. What information should the nurse include? 1. Use sunscreen with a sun protection factor (SPF) of at least 30. 2. A self-tanning product containing dihydroxyacetone (DHA) is safe to use. 3. Put on sunscreen every day, even on days when it is cloudy. 4. Stay in the shade between 9 AM and 4 PM. 5. Tanning beds are safer than outdoor tanning.
3
The nursing unit manager is reviewing cardiopulmonary resuscitation protocols with a group of new nurses. When the unit manager asks for an indication of effective CPR on an adult, what new nurse response would be most accurate? 1. Chest wall visibly rises with rescue breathing. 2. Skin color and temperature becomes pink and warm. 3. There is a palpable femoral pulse with a compression. 4. A sinus beat appears on monitor during compression.
1
The school nurse has educated a group of teens concerned about acquiring the Ebola virus. Which statement by the students would indicate to the nurse that further teaching is necessary? 1. "I can get a vaccine to prevent getting the Ebola virus." 2. "Ebola is not spread through casual contact, so my risk of getting the virus is low." 3. "The Ebola virus is passed from person to person through blood and body fluid." 4. "Ebola viruses are mainly found in primates in Africa."
1, 2, 3, 4, 5
A 19 year old client preparing to enter college asks the clinic nurse about immunizations. What immunizations should the nurse suggest the client discuss with the primary health care provider? 1. Meningococcal conjugate vaccine 2. Tdap vaccine 3. HPV vaccine 4. Seasonal flu vaccine 5. Hepatitis B 6. Polio
1
A client is admitted to the pediatric unit with a diagnosis to rule out tuberculosis (TB). What room assignment should the charge nurse make? 1. Private room. 2. Private room and place on protective isolation. 3. Room with a client diagnosed with a respiratory infection. 4. Room with a client who is 24 hours post appendectomy.
2
A client with hemophilia has been scheduled for extraction of wisdom teeth. The nurse anticipates that the client will receive what priority intervention before this procedure? 1. Prophylactic antibiotics 2. A unit of cryoprecipitate 3. Packed red blood cells 4. Fresh frozen plasma
4
A military veteran with a history of post-traumatic stress disorder (PTSD) has arrived at the Crisis Center reporting an increase in nightmares, depression and anxiety. The nurse is aware the client would obtain the most immediate relief with what intervention? 1. Increase dose of antianxiety medications. 2. Greater family support interaction. 3. Referral to community support group. 4. Opportunity to verbalize memories.
1, 2, 4, 5
A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions of at risk clients. What steps should the QA manager include? 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Ask staff what fall precautions are taken for at risk clients. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance.
2, 3, 4, 5
The nurse is educating a group of teenagers who have expressed an interest in using electronic cigarettes (e-cigarettes). What information about electronic cigarettes should the nurse include? 1. Electronic cigarettes are a safe alternative to smoking. 2. It is difficult for consumers to know what electronic cigarette products contain. 3. Nicotine can harm adolescent brain development. 4. Electronic cigarette aerosol generally contains fewer toxic chemicals than the smoke from regular cigarettes. 5. Defective electronic cigarette batteries can cause fires and explosions.
1
What is the priority nursing action for a pregnant client who has dilated to 6 centimeters while receiving an epidural? 1. Continuous monitoring of maternal blood pressure. 2. Frequent auscultation of the fetal heart rate. 3. Administer an IV fluid bolus of at least 500 mL. 4. Frequent monitoring of the maternal temperature.
1, 4, 5
When inspecting the equipment in a client's room, what would the nurse recognize as electrical safety hazard(s)? 1. Flickering overhead light 2. Ground-fault circuit interrupter electrical sockets 3. Hospital labeled UL power strip 4. Bent electrical bed cord 5. Cracked electrical socket
2, 4
Which client is legally able to sign a consent for surgery? 1. An 86 year old client who is disoriented. 2. A 62 year old client who speaks only Spanish. 3. A 41 year old client who just received midazolam. 4. A 17 year old client needing an emergency appendectomy whose parents cannot be contacted. 5. A 44 year old with schizophrenia who is hallucinating.
1, 4, 5
Which client would be appropriate for the RN to assign to the LPN? 1. Client requiring enemas and antibiotics. 2. Newly admitted client with diagnosis of diabetic ketoacidosis (DKA). 3. Client returning from surgery post right upper lobectomy. 4. Client with frequent reports of nausea and vomiting following chemotherapy. 5. Client requiring frequent sterile dressing changes.
3
Which lab value on a client who is one day postpartum should the nurse report to the primary healthcare provider immediately? 1. Hemoglobin of 11 g/dL (110 g/L) (6.8266 mmol/L) 2. White Blood Cell count of 22,000 mm3 3. Hematocrit of 18% 4. Serum glucose of 80 mg/dL (4.44 mmol/L)
2, 4, 5, 6
Which observations should the home health nurse discuss with the parents of a two year old regarding potential safety threats in the home? 1. Security gates at the stairs. 2. Cleaning supplies under sink cabinet. 3. No blinds on windows. 4. Use of space heaters. 5. Water heater temperature 140°F (60°C) 6. Use of tablecloths
2, 4
Which tasks would be appropriate for the RN to delegate to an unlicensed assistive personnel (UAP)? 1. Ask the client diagnosed with dementia memory-testing questions. 2. Monitor the urinary output hourly on the client with renal disease. 3. Demonstrate pursed lipped breathing to the client who has emphysema. 4. Give a tepid sponge bath to the client who as a fever. 5. Assess oxygen saturation on a client experiencing angina.
4
A 68-year-old client with a history of angina presents to the emergency department (ED) reporting flu like symptoms progressively worsening over the past 24 hours.What action is most important for the nurse to initiate? 1. Administer acetamenophen. 2. Initiate IV of Normal Saline at 250 mL/hour. 3. Notify radiology and lab of diagnostic test prescriptions. 4. Discuss IV prescription with primary healthcare provider.
2
A charge nurse is teaching a new nurse on the labor and delivery floor the proper positioning of a client following an epidural. The charge nurse knows the teaching was successful when the new nurse places the client in which position? 1. Lithotomy 2. Left-lateral 3. Semi-Fowler's 4. Right-lateral
1, 2, 5
A child weighing 75 lbs. (34.1 kg) is admitted to the unit with a diagnosis of bacterial meningitis. The child has been started on an IV of D5 NS at 100 mL per hour and IV antibiotic therapy has been initiated. Which assessment finding would need to be reported immediately to the healthcare provider? 1. Urinary output of 28 mL/hr. 2. Change in the level of consciousness. 3. Temperature of 101.2 degrees F (38.4 degrees C). 4. Increase of 5 mm Hg in systolic BP from baseline. 5. Sodium level of 130 mEq/L (130 mmol/L).
3
A client calls the prenatal clinic at 37 weeks gestation to report expelling large amounts of fluid. What instruction by the nurse is most appropriate at this time? 1. Lie on left side and take slow, deep breaths. 2. Call an ambulance and go to emergency room. 3. Come to the clinic for assessment and evaluation. 4. Go directly to the hospital emergency room.
3
A client in active labor has an epidural catheter inserted for management of pain. Which finding should the nurse report to the primary health care provider? 1. Early decelerations 2. Fetal heart rate (FHR) 160/min 3. Blood pressure 90/62 4. Temperature of 99.6° F (37.5° C).
1
A client who was diagnosed with paranoid delusions has been prescribed a chest x-ray. The client refuses the chest x-ray and states "No, they want to kill me with the rays from the x-ray machine." Which nursing response is appropriate? 1. "Do you think people want to kill you with rays?" 2. "You don't have to worry that someone is going to kill you." 3. "I don't want you to talk about the x-ray technicians." 4. "Where did you get the idea that someone was trying to kill you?"
1
Because of over-crowding, the charge nurse of a busy unit has been instructed to place two clients in each private room. An elderly client with early dementia is currently in one of the private rooms recovering from pneumonia. The nurse knows what client would make the most appropriate roommate? 1. A young adult for evaluation of severe recurrent migraines. 2. An adolescent s/p appendectomy going home tomorrow. 3. A terminal adult client admitted for pain management. 4. A bipolar client in the manic phase of major depression.
3, 4
The nurse is caring for a client with body dysmorphic disorder. The client tells the nurse, "My ugly ears make everyone sick!" Which defense mechanism is this client utilizing? 1. Sublimation 2. Somatization 3. Symbolism 4. Projection 5. Conversion
1, 2, 3, 4
The parents of a toddler tell the nurse that their child will not drink milk. What alternatives should the nurse recommend? 1. Frozen yogurt 2. Pudding 3. Hot cocoa in milk 4. Cheddar cheese 5. Watermelon
2
What is indicated when caring for a client admitted with meningitis? 1. The client should be placed in a negative pressure room and health care providers should wear a N95 protective mask when in contact with the client. 2. The client's room door may remain open and health care providers should wear a facemask within 3 to 6 feet of the client. 3. The client should be placed in a private room and no face mask is needed. 4. The only precaution needed is hand hygiene.
3, 4, 5
What measures should the school nurse implement for a child diagnosed with peanut allergies? 1. Keep a lidocaine auto-injector readily available. 2. Obtain assessment data about visual acuity, and health conditions that might affect food allergy management. 3. Maintain contact information for parents and primary healthcare provider. 4. Review history of known food allergens and the severity of previous reactions. 5. Train designated personnel to administer prescribed medication in an anaphylaxis emergency.
3
Which nursing action takes priority once a term infant has delivered vaginally? 1. Apply identification bands 2. Apply eye ointment 3. Dry the baby 4. Obtain footprints
2
While programming the client's IV infusion pump the nurse notes that the display screen on the infusion pump is cracked. What is the best action for the nurse to take? 1. Continue to use the infusion pump and request a replacement pump. 2. Stay with the client and monitor the infusion while another staff member obtains a replacement pump. 3. Clamp and disconnect the infusion tubing prior to obtaining a replacement pump. 4. Slow the infusion to a keep-open rate and obtain a replacement pump.
3
The client has been diagnosed with cutaneous anthrax in a cut on the right hand. What measure should be implemented by the nurse to prevent further spread of the disease? 1. Wear mask only. 2. There are no precautions necessary. 3. Standard precautions. 4. Limit interactions with client.
3, 4
The nurse manager of an Alzheimer's unit as completed inservice education to new nursing staff regarding guidelines for dealing with dementia. Which identified guidelines by the new nursing staff indicates to the nurse manager that education was successful? 1. Use a firm touch to guide the client to a different location when needed. 2. Be persistent when getting the client to do something. 3. Provide simple directions using gestures or pictures. 4. Do not argue with the client. 5. Play memory games to decrease dementia. 6. Require participation in daily activities.
4
Which initial behavior by the client on a mental health unit demonstrates to the nurse that the client is assuming responsibility for anger management? 1. Plans to use exercise to work off anger. 2. Apologizes to those individuals to whom anger has been directed. 3. Develops a plan on how to react when feeling stressed. 4. Identifies stressors of past violent behavior.
1, 4, 5
Which interventions are appropriate for the nurse to identify for a client admitted to the psychiatric unit for management of anorexia nervosa? 1. Weigh daily. 2. Allow only 20 minutes of exercise daily. 3. Allow the client to bargain for privileges as long as the client eats. 4. Stay with the client during the established time for meals. 5. Maintain visual observation for 1 hour following meals.
1
A client comes to an obstetric clinic for a routine prenatal checkup at 32 weeks gestation. The nurse palpates the client's abdomen to determine fetal position so that fetal heart sounds can be assessed. It is determined that the fetal position is left occipital anterior (LOA). Where should the nurse place the Doppler to hear fetal heart sounds? 1. Below the umbilicus, on the mother's left side. 2. Below the umbilicus, on the mother's right side. 3. Above the umbilicus, on the mother's right side. 4. Above the umbilicus, on the mother's left side.
1, 2, 3
A client diagnosed with a brain injury continues to attempt to get out of the bed without assistance. Which nursing interventions would the nurse implement? 1. Ask a familiar person to stay with the client. 2. Apply position change sensor to the bed. 3. Move client closer to the nursing station. 4. Reinstruct the client to not get out of the bed. 5. Provide positive and negative reinforcement.
2, 3, 4
A nurse is participating in a community health fair for middle aged individuals. Which points should the nurse stress for decreasing the risk of stroke? 1. Reduce dietary intake of unsaturated fat. 2. Swim or walk most days of the week. 3. Treat obstructive sleep apnea, if present. 4. Drink five or more 8 ounce glasses of water daily. 5. Decrease smoking to less than ½ pack a day.
4
Which client in the emergency department should the nurse identify as being the highest priority? 1. Client with emphysema reporting shortness of breath. 2. Client with a cut on the left calf with moderate bleeding. 3. Client with onset of confusion 1 hour prior to arrival. 4. Client with facial swelling and rash after taking azithromycin.
1
Which client should the nurse see first? 1. 53 year old client with chest pain scheduled for a stress test today 2. 62 year old client with mild shortness of breath and chronic obstructive pulmonary disease 3. 66 year old client with angina scheduled for a cardiac catheterization this AM 4. 78 year old client who had a left hemispheric stroke 4 days ago
1, 4, 5
Which discussion points should a nurse plan to include when teaching a group of college students on prevention of sexually transmitted infections (STI)? 1. Safe sex practices 2. Routine human immunodeficiency virus (HIV) testing 3. Proper use of birth control pills 4. Sexual abstinence 5. Vaccinations for STIs
4, 5
In which situation should the nurse consult the client's advanced directive? 1. Client scheduled for breast reconstruction after mastectomy. 2. Client with a T-5 spinal cord injury beginning rehabilitation therapy. 3. Client diagnosed with Guillain-Barre' who is receiving ventilator support. 4. Comatose client with end stage chronic obstructive pulmonary disease. 5. Client diagnosed with inoperative brain tumor who is confused.
2, 3, 4, 6
A lethargic client was admitted with encephalopathy secondary to cirrhosis. The client displayed a grossly distended abdomen, fine bibasilar crackles and +4 pitting edema to lower extremities. Following three days of treatment, the client is improved enough for discharge. Vital signs are now within normal limits and lungs clear. The client's elevated ammonia level has returned to normal, though PT/PTT levels are still elevated. The nurse knows discharge teaching should include what information? 1. How to measure and record abdominal girth daily. 2. Keep lower extremities elevated while out of bed. 3. Emphasize the need to eliminate alcohol intake. 4. Remind client to use an electric razor to shave. 5. Check weight daily and report gain over 10 lbs/4.536 kilograms. 6. Restrict protein intake to just 40 gm. daily.
4
A nurse has completed pre-operative instructions for an elderly client scheduled for a cholecystectomy. The following client's statement reflects a need for additional pre-operative instructions. 1. "I may have several small incisions." 2. "I may need to stay in the hospital overnight." 3. "I will ask my husband to bring my medications." 4. "My daughter had lots of problems after this surgery"
3
A nurse is assessing a terminally ill client who is restless with an O2 saturation of 58 mm Hg. Which nursing intervention would the nurse implement? 1. Monitor the client's breathing pattern 2. Wipe the mouth with oral care sponge 3. Soothe the client by affirming your presence 4. Initiate oxygen via nasal cannula at 4 L/minute
1, 2, 4, 5
A nurse is caring for a client diagnosed with the ebola virus who is experiencing vomiting and diarrhea. What personal protective equipment should be worn by the nurse while providing care to this client? 1. Single use impermeable gown 2. Powered Air Purifying Respirator (PAPR) or N95 respirator 3. One pair of sterile gloves 4. Single use boot covers 5. Single use apron
1, 2, 3, 4, 6
A nurse manager has several issues regarding staff maintaining proper infection control while caring for clients. What actions should the manager take regarding this issue? 1. Place colorful posters regarding infection control in conspicuous places on unit. 2. Monitor staff providing client care for the use of appropriate infection control. 3. Give staff a written test on proper infection control. 4. Have all staff read agency policy and procedures regarding infection control. 5. Dock pay of staff who do not maintain proper infection control. 6. Provide mandatory in-service sessions on infection control for every shift.
1, 2, 4, 5
A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level on a scale of 0-10. What strategies could the nurse manager initiate to improve performance? 1. Provide "just in time" posters outlining the critical importance and steps in pain assessment. 2. Conduct brief in-services for each shift. 3. Write nurses up when pain level scale is not utilized. 4. Ensure that a complete and clear performance standard exists. 5. Assess nurses' reasons for not using pain level scale.
3
A nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. Based on the information provided in report, which client condition should be the nurse's priority? 1. Potassium level of 3.4 mEq/L (3.4 mmol/L) in a child with vomiting and diarrhea. 2. Platelet count of 95,000/mm3 in a child with a nose bleed. 3. Absolute neutrophil count of 400/mm3 in a child with fever. 4. Hemoglobin level of 9 g/dL (90 g/L) in a child with reports of fatigue.
4
A pregnant woman who has just been admitted to the labor and delivery room states that her "water just broke". What should the nurse do immediately? 1. Confirm that fluid is amniotic fluid with a pH test strip 2. Obtain maternal vital signs 3. Observe amniotic fluid color 4. Check fetal heart rate (FHR) pattern
2
An elderly client is admitted to the floor with vomiting and diarrhea for three days. The client is receiving IV fluids at 200 mL/hr via pump. What would be the priority nursing action? 1. Obtaining Intake and Output 2. Frequent lung assessments 3. Vital signs every shift 4. Monitoring the IV site for infiltration
4
An elderly client is to be ambulated for the first time following a hip replacement. The client refuses to get out of bed, indicating an extreme fear of falling. What statement by the nurse is most therapeutic? 1. "Don't be afraid because I will not let you fall." 2. "Your doctor says you must walk twice today." 3. "I'll get another nurse to help so you won't fall." 4. "What worries you most about getting out of bed?"
1, 3, 5
During a yearly checkup, an adult client asks the Healthcare Provider to examine a mole which has recently become bothersome. The HCP is concerned about the appearance of the mole and refers the client to a specialist. The nurse is asked to assemble the documents to be sent with the client. The nurse knows what documents are important to send to the specialist? 1. The most recent history and physical findings. 2. History of childhood diseases and vaccinations. 3. List of all current medications and allergies. 4. X-ray results of last year's broken clavicle. 5. Insurance info with consent for release. 6. Current diagnoses and treatments.
1, 3
The Emergency Department triage nurse encounters a client who says that he has received exposure to a liquid hazardous chemical at work. He reports that he is only 1 of about 20 people. What should the nurse do? 1. Call the supervisor and inform of the possibility of contamination in the surrounding space. 2. Obtain vital signs immediately. 3. Call personnel trained in containment and decontamination immediately. 4. Direct the individual to a bed space immediately. 5. Instruct the client to remove clothing and put on disposable hospital gown.
