NCLEX RN #50

3

A client comes to the emergency department with crushing, substernal chest pain. Temperature is 98.6 F (37 C), blood pressure is 173/84 mm Hg, pulse is 92/min, and respiration are 24/min. Oxygen saturation is 95% on room air. What is the nurse's NEXT priority action? #69824297 (71) 1. Attach defibrillator pads to the client's chest 2. Check the lipid profile laboratory results 3. Obtain a 12 lead electrocardiogram 4. Prepare to administer a heparin drip.

1

A client who suffered a BURN INJURY has received fluid resuscitation and is now diuresing, indicating the end of the emergency phase. Which prescrip-tion is the HIGHEST PRIORITY at this time? #69824297 (64) 1. Administer enteral feedings at the return of bowel sounds. 2. Assist the client in activities of daily living as tolerated. 3. Contact the client's religious advisor for spiritual support. 4. Educate the client's family about dressings and medications.

1

A client with blunt head injury is admitted for observation, including hourly neurologic checks. At 01:00 AM, the client reports a headache, the nurse obtains a normal neurologic assessment and administers the PRN acetaminophen. At 02:00AM, the client appears to be sleeping. Which action should the nurse take? #69824297 (70) 1. Arouse the client and ask what the current month is 2. Document "relief apparently obtained" and recheck at 03:00 AM 3. Let the client sleep but verify respiratory rate 4. Wake the client up and check for paresthesia.

4

A client with coronary artery disease was discharged home with a prescription for sublingual nitroglycerin (NTG) to treat angina. Which statement by the client indicates that FURTHER TEACHING IS REQUIRED? #69824297 (63) 1. "I may experience flushing but will continue to take the medication as prescribed." 2. "I should lie down before taking the medication." 3. "I should not swallow the tablet." 4. "I will wait to call 911 if I don't experience relief after the third tablet."

1

A client with diabetes mellitus is admitted to the surgical unit after a vaginal hysterectomy. The client received 6 units of regular insulin subcutaneously and metoprolol 50 mg by mouth in the post-anesthesia care unit. Which statement by the unlicensed assistive personnel would require IMMEDIATE action by the nurse? #69824297 (66) 1. "I changed the client's perineal pad 3 times in the last 2 hours." 2. "I have been encouraging the client to exercise the legs while in bed." 3. "I thought you should know the client voided 500 mL of straw-colored urine. 4. "I just took the client's vital signs, which are blood pressure 108/60 mm Hg, pulse 58 and respirations 12"

2

A client with schizophrenia says to the nurse, "The world turns as the world turns on a ball at the beach. But all the world's a stagecoach and I took the bus home. " The nurse recognizes this statement as an example of which of the following? #69824297 (61) 1. Concrete thinking 2. Loose associations 3. Tangentiality 4. Word salad

1,3,4

A nurse is making a presentation on skin cancer prevention with special focus on melanoma at a community health forum. Which statements should the nurse include? SELECT ALL THAT APPLY. #69824297 (62) 1. Apply a broad-spectrum sunscreen, minimum SPF 15, before and during outdoor sports 2. Apply sunscreen immediately before partici-pating in outdoor activities. 3. Reapply sunscreen after swimming even if using waterprooof sunscreen earlier. 4. Serious sunburns can still occur on cloudy, overcast days. 5. Use of tanning beds for 15 minutes or less will provide a base tan less likely to burn.

3

After receiving a change of shift report, the nurse should assess with client FIRST? #69824297 (72) 1. Client recently admitted with a positive tuberculin skin test who reports hemop-tysis. 2. Client who had abdominal surgery yesterday and refuses incentive spirometry. 3. Client who has just returned to the floor after undergoing a bronchoscopy. 4. Client with a chest tube drainage system with air bubbles in the suction control chamber.

1

After receiving the hand off nurse to nurse evening shift report, which client should the nurse assess FIRST? #69823086 (07) 1. Client who is 3 days postoperative bowel resection, now reports shortness of breath and chest pain 2. Client who is 3 days postoperative right knee surgery, now reports fever, cough and shortness of breath 3. Client who was transferred from the post-anesthesia care unit (PACU) 15 minutes ago. 4. Client with a kidney stone who is requesting pain medication for severe flank pain.

2,3,5,6

After rolling the ankle outwards when jogging, a client develops ankle pain and swelling. The health care provider diagnoses a lateral ankle pain. Which intervention does the nurse include in the discharge instructions.? SELECT ALL THAT APPLY #69824297 (73) 1. Apply heat to reduce swelling during the first 24 hours. 2. Begin an exercise rehabilitation program when the pain subsides. 3. Elevate the leg above the heart level on 2 pillows 4. Flex and dorsiflex the foot to prevent stiffness during the first 24 hours. 5. Take ibuprofen every 6 hours as needed 6. Wrap the ankle with an elastic compression bandage.

3

Several children are brought to the emergency room after a boating accident in which they were thrown into the water. The children are now 6 hours post admission to the clinical observation unit. Which client should the nurse evaluate FIRST? #69824297 (55) 1. Client who did not require CPR but now has a new oxygen requirement of 2L via nasal cannula to maintain a saturation of 95%. 2. Client who did not require CPR but was coughing on arrival to the hospital and is now crying inconsolably and asking for the mother. 3. Client who received CPR for 2 minutes on the scene and whose respiratory rate has now dropped from 61/min to 18/min. 4. Client who was briefly submerged in water and received rescue breaths on the scene and is now irritable and refusing food and drink.

4

The charge nurse on the orthopedic unit has 4 semiprivate room beds available. Which room should the nurse assign to a client being transferred from the post anesthesia recovery unit following a total knee replacement? #69824297 (75) 1. Room 1 Client in skeletal traction following a fracture of the femur, who has erythema at the pin sites 2. Room 2 Client with cellulitis and osteo-myelitis following blunt trauma of the tibia. 3. Room 3 Client with compartment syndrome following a crush injury who is 1 day post fasciotomy 4. Room 4 Client with a long leg cast following open reduction of a fractured tibia.

1

The charge nurse on the telemetry unit is making client assignments. Which client is approprate to assign to the licensed practical nurse (LPN)? #69823086 (11) 1. Client 2 days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void. 2. Client being discharged after deep vein thrombosis who needs teaching on how to self administer enoxaparin injections 3. Client who has just been admitted to the telemetry unit from the emergency department with a rule-out-myocardial infarction. 4. Client with a nitroglycerin infusion with prescription to titrate to keep systolic blood pressure <150 mm Hg currently is 110/62 mm Hg.

2

The clinic nurse receives phone calls about the following 4 clients. Which call should the nurse return FIRST? #69823086 (02) 1. A 6 month old who received the diphtheria, tetanus, acellular pertussis vaccine 18 hours ago and developed fever of 102 F (38.9 C) and injection site redness. 2. An 11 month old with inconsolable crying and drawing up of the legs toward the abdomen. 3. A 4 year old diagnosed with right lung pneumonia 2 days ago who has chest pain when breathing deeply. 4. A 15 year old whose eyes are red and itchy and have a yellow discharge.

2

The health care provider (HCP) orders a small bowel-through (SBFT) for a client. Which instruction should the nurse include when teaching the client about this test? #69824297 (69) 1. "After the test, you may notice your stools are tarry black for a few days." 2. "During the test, a series of x-rays will be taken to assess the function of the small bowel." 3. "The HCP will use an endoscope to visualize your small bowel." 4. "Your examination is scheduled for 8:00 AM. Please drink all the polyethylene glycol by midnight."

3

The health care provider gives the preoperative nurse a signed consent form and walks away rapidly. The client turns to the nurse and states. "I don't know what is going on. Why do I need surgery?" What is the MOST appropriate action? #69823086 (10) 1. Call the nursing supervisor 2. Call the operating room scheduler and cancel the surgery. 3. Page the health care provider and request clarification on behalf of the client. 4. Report the incident to hospital administration.

4

The labor and delivery (L&D) nurse is floated to a medical-surgical floor for a shift. Which client is MOST appropriate for the charge nurse to assign to the L&D nurse? #69823086 (04) 1. Client with an occluded arteriovenous fistula receiving IV heparin infusion. 2. Client with cirrhosis and ascites who require beside paracentesis. 3. Client with diabetes who is one day postoperative below the knee amputation. 4. Client with pyelonephritis who is febrile and receiving IV antibiotics.

3

The nurse cares for a group of clients in a medical surgical unit. The client with which diagnosis and condition requires the MOST IMMEDIATE assistance by the nurse? #69824297 (68) 1. Post cholecystectomy, reporting incision pain of a 5 on a scale of 1-10 2. Post open reduction of the right femur, reporting nausea. 3. Type 1 diabetes mellitus with a blood glucose of 55 mg/dL 4. Type 2 diabetes mellitus with a blood glucose of 250 mg/dL

4,5,3,1,2,6

The nurse educates a client with obstructive lung disease in the correct use of a short-acting beta agonist metered dose inhaler without the use of a spacer. PLACE THE STEPS IN THE CORRECT ORDER. #69824297 (54) 1. Compress canister while inhaling slowly through the mouth for about 3-5 seconds 2. Hold breath for 10 seconds, if possible, before exhaling 3. Place mouthpiece between teeth and wrap lips around mouthpiece. 4. Shake canister well for 3-5 seconds. 5. Tilt head back slightly and exhale slowly for 3-5 seconds. 6. Wait at least 1-2 minutes before taking a second puff, if prescribed.

4

The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a PRIO-RITY for the nurse to report to the health care provider? #69824297 (65) 1. "I got short of breath this morning when I worked out." 2. "I have cut down on smoking to 1/2 pack per day." 3. "I haven't been feeling well, so I have been sleeping a lot." 4. "I took an acetaminophen in the waiting room for this bad headache."

2

The nurse is discharging a client with emphysema who is on continuous oxygen. The case manager alerts the nurse that the home oxygen will not be delivered until 2 hours later. What action should the nurse take? #69824297 (56) 1. Ask if the client can go without the oxygen for 2 hours. 2. Delay discharge until the oxygen is delivered. 3. Notify the health care provider (HCP) to see what action should be taken 4. Send a hospital oxygen tank home with the client.

3,5

The nurse is performing an initial assessment on a client diagnosed with ADDISON'S DISEASE. Which assessment findings should the nurse anticipate? SELECT ALL THAT APPLY #69823086 (03) 1. Acanthosis nigricans 2. Hirsutism 3. Hyperpigmented skin 4. Truncal obesity 5. Weight loss

3,5

The nurse is performing an initial assessment on a client diagnosed with ADDISON'S DISEASE. Which assessment findings should the nurse anticipate? SELECT ALL THAT APPLY #69824297 (60) 1. Acanthosis nigricans 2. Hirsutism 3. Hyperpigmented skin 4. Truncal obesity 5. Weight loss

4

The nurse is providing education to a 24 year old female client diagnosed with human papilloma-virus (HPV). which client statement indicates a need for FURTHER INSTRUCTION? #69824297 (58) 1. "I can transmit the virus when I dont' have symptoms." 2. "I know the virus can be spread through oral sex." 3. "I need to have a Papanicolaou test on an annual basis." 4. "My partner won't get HPV as long as we use a condom."

3

The nurse performs the first Apgar assessment of a newborn at 1 minute of life. The baby is completely blue, with a heart rate of 110/min and is emitting a weak cry. The baby is actively moving and grimaces when the nares are suctioned. What is the baby's Apgar score? #69824297 (59) 1. 4 2. 5 3. 6 4. 7

2

The nurse receives a report on 4 clients. Which client should the nurse assess FIRST? #69823086 (09) 1. A 29 year old heroin user admitted for arm cellulitis 24 hours ago has abdominal cramps and is restless. 2. A 34 year old admitted with femur fracture 24 hours ago is confused and has SpOs of 91% 3. A 65 year old admitted with serum sodium of 125 mEq/L 8 hours ago is confused. 4. A 78 year old admitted for urinary tract infection 6 hours ago is disoriented to time and place.

1

The nurse receives report on 4 clients. Which client should the nurse see FIRST? #69823086 (12) 1. Client 2 hours post foot amputation surgery has a surgical dressing saturated with bright red blood. 2. Client with scheduled for whirlpool bath in 20 minutes has the dressing on the infected foot ulcer fall off. 3. Client with arteriovenous graft for hemodialysis access has new-onset pain and redness at graft site. 4. Client with urinary retention and infection receiving antibiotics is confused and trying to pull out Foley catheter.

1

The nurse reviews the laboratory results for 4 assigned clients. Which results is MOST IMPORTANT for the nurse to report to the primary health care provider? #69823086 (01) 1. Client with atrial fibrillation receiving warfarin for 7 days with an international Normalized Ratio (INR) of 1.3 2. Client with chronic bronchitis who has a hematocrit of 56% and hemoglobin of 19g/dL 3. Client with clostridium difficile infection who has a white blood count of 15,000/mm 4. Client with sepsis receiving gentamycin who has a creatinine of 0.6 mg/dL

1,4

The nurse reviews the serum laboratory results and medication administration records for assigned clients. Which prescriptions should the nurse question and validate with the health care provider before administering? SELECT ALL THAT APPLY #69824297 (67) 1. Bumetanide in the client with heart failure who has hypokalemia. 2. Calcium acetate in the client with kidney disease who has hyperphosphatemia 3. Carvedilol in the client with heart failure who has an elevated B-type natriuretic peptide level. 4. isoniazide in the client with latent tuber-culosis who has elevated liver enzymes. 5. Metronizdazole in the client with Clostridium difficile infection who has leukocytosis.

3,4

The registered nurse (RN) is caring for a client with tuberculosis who is on airborne isolation precautions. The RN can delegate which tasks to the experienced unlicensed assistive personnel (UAP) ? SELECT ALL THAT APPLY #69823086 (13) 1. Alert the x-ray department about maintaining airborne isolation precautions. 2. Explain to the client why the client must wear a mask during transport to another department 3. Post signs for airborne isolation precautions on the client's door and stock necessary equipment. 4. Remind visitors to wear a respiratory mask and keep the door closed while in the client's room. 5. Talk with the family about the reasons for airborne isolation precaution in the client.

1,2,4

The unit staff consist of a registered nurse (RN), a licensed practical nurse (LPN) and unlicensed assistive personnel (UAP) . Which are the BEST tasks for the charge nurse to assign to the LPN? SELECT ALL THAT APPLY #69823086 (08) 1. Administer a client's daily dose of subcu-taneous heparin. 2. Administer a scheduled oral analgesic to a 2 days postoperative client 3. Complete an admission nursing interview for a client admitted for elective hysterectomy. 4. Reinforce teaching on self-administration of daily insulin to a new client with diabetes. 5. Tally the shift's intake and outputs for the entire unit.

1,2,5

There has been a major community disaster. Stable clients needs to be discharged to make more beds available for the victims. Which clients could be discharged safely? SELECT ALL THAT APPLY #69823086 (06) 1. Diagnosed with endocarditis on antibiotics with a peripherally inserted central catheter (PICC) line 2. History of multiple sclerosis with ataxia and diplopia 3. One day postoperative from a hemicolectomy. 4. Reporting abdominal pain with coffee ground emesis 5. Taking warfarin with prothrombin time/International Normalized Ratio of 2x control value.

1,2,4,6

Which clinical manifestations would the nurse identify with severe anorexia nervosa? SELECT ALL THAT APPLY #69824297 (74) 1. Amenorrhea 2. Fluid and electrolyte imbalances 3. Heat intolerance 4. Presence of lanugo 5. Refusal to exercise 6. Weight loss of 25% below normal weight.

4,5

Which nursing interventions for a client recovering from a gastroduodenostomy (Billroth1) are CONTRAINDICATED? SELECT ALL THAT APPLY #69824297 (57) 1. Applying a sequential compression device and antiembolism stockings. 2. Encouraging turn, cough, and deep breathing exercises every 2 hours. 3. Keeping the head of the bed raised and positioned at a 45 degree angle 4. Repositioning and irrigating a clogged nasogastric tube as needed. 5. Teaching the importance of small, frequent, high-carbohydrate meals

3

Which of the following task would the charge nurse on a surgical unit assign to the experienced unlicensed assistive personnel (UAP)? #69823086 (05) 1. Assisting a client in ambulating to the bathroom for the first time following surgery. 2. Explaining why using the incentive spirometer is important to a client with postoperative pneumonia. 3. Feeding a client with dementia who has a blood sugar of 70 mg/dL 4. Taking vital signs every 15 minutes on a client who was just transferred from the post-anesthesia recovery unit.