NCLEX Strategy Questions

4

The nurse is caring for a client in the 8th week of pregnancy. The client is spotting, has a rigid abdomen and is on bed rest. What is the most important assessment at this time? 1. Protein in the urine 2. Fetal heart tones 3. Cervical dilation 4. Hematocrit level

1

The nurse observes a client in the manic phase of bipolar disorder in group therapy. The client has interrupted the counselor's group session multiple times and states "I already know this information about dealing with others when you are down." Which nursing action is appropriate? 1. Ask the client to walk with the nurse to get a snack 2. Ask the group to reflect on the client's behavior to determine if it is appropriate. 3. Ask the group to tell the client how they feel about the disruptions 4. Instruct the client to perform jumping jacks to rid of some energy

3,4,5

A client is admitted to the medical unit with a diagnosis of Addison's disease. What nursing interventions should the nurse implement for this client? Select all that apply. 1. Monitor for decreased potassium levels 2. Assist the client to select food low in sodium 3. Administer fludrocortisone as prescribed 4. Monitor intake and output 5. Record daily weight

4

A client had surgery for cancer of the colon and a colostomy was performed. Prior to discharge, the client asks "Will I still be able to swim?" The nurse's response would be based on which understanding? 1. Swimming is not recommended. The client should begin looking for other areas of interest 2. Swimming is not restricted if the client wears a dressing over the stoma at all times 3. The client cannot go into the water that is over the stoma area, but can go into the water up to the stoma area 4. There are no restrictions on the activity of a client with a colostomy; all previous activities may be resumed

2

A client is admitted for evaluation of cardiac arrhythmias. What would be the most important information for the nurse to obtain when assessing the client? 1. Ability to perform isometric exercises 2. Changes in LOC or behavior 3. Recent blood glucose changes 4. Compliance with dietary fat restrictions

3,4,5

Which statements made by a client after receiving education regarding bleeding precautions would indicate to the nurse that teaching was successful? Select all that apply. 1. I cannot shave while I am at risk for bleeding 2. It is important to gargle with a commerical mouthwash three times a day 3. Stool softeners will help prevent rectal bleeding 4. Prior to sexual intercourse, I will use a water-based lubricant 5. I will use a soft toothbrush

2,5

Which tasks would be appropriate for the nurse to delegate to an LPN/VN? Select all that apply 1. Prepare a client's room for return from surgery 2. Observe for pain relief in a client after receiving acetaminophen with codeine 3. Assist a client with perineal care after having diarrhea 4. Clean nares around a client's NG tube 5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy

2

A client is hospitalized hundreds of miles from home for a bone marrow transplant. The client is in a protective environment while undergoing intense chemotherapy. The client's sibling comes to visit and has obvious manifestations of an upper respiratory infection. Which nursing action would be most appropriate at this time? 1. Do not allow the sibling to visit, and do not upset the client by mentioning the sibling's visit 2. Allow the sibling to wave at the client through the window or door, then offer the use of the unit phone so they can talk 3. Allow the sibling to visit after donning a sterile gown, mask, and gloves, but prohibit physical contact. 4. Allow the sibling to visit after donning a sterile gown, mask and gloves and have the client wear a mask.

4

The client has returned to the unit after an escharotomy of the forearm. What is the priority nursing assessment? 1. Infection 2. Incision 3. Pain 4. Tissue Perfusion

1

Which client should the nurse identify as being at highest risk for suicide? 1. Seventy six year old widower with chronic renal failure 2. Nineteen year old taking antidepressants 3. Twenty eight year old, post-partum crying weekly 4. Fifty year old with OCD

1

A client is reporting SOB and neck pressure following a thyriodectomy. What is the priority nursing intervention? 1. Elevate HOB, remove the dressing and stay with the client 2. Call a code, open the trach set and position the client supine 3. Have the client say EEE to check for laryngeal integrity and assess Chvostek's sign 4. Call the primary healthcare provider and assess vital signs

1

A six year old client has been receiving chemotherapy for two weeks. The laboratory results show a platelet count of 20,000. What is the priority nursing action? 1. Encourage quiet play 2. Avoid persons with infection 3. Administer oxygen PRN 4. Provide foods high in iron

2,3,4,5

A client with a T4 lesion is being cared for on the neuro rehabilitation unit. The client suddenly reports a severe, pounding headache. Profuse diaphoresis is noted on the forehead. The blood pressure is 180/112 and the heart rate is 56. What interventions should the nurse make? Select all that apply 1. Place the client supine with legs elevated 2. Assess bladder and bowel for distention 3. Examine skin for pressure areas 4. Eliminate drafts 5. Administer hydralazine if BP does not return to normal

4

A nurse is caring for a client diagnosed with HF. The client currently takes furosemide 40 mg every morning, potassium 20 mEq daily, and digoxin 0.25 mg every day. Which client comment should the nurse assess first in caring for this client? 1. My fingers and feet are swollen 2. My weight is up 1 pound 3. There is blood in my urine 4. I am having trouble with my vision

2

An elderly client is prescribed to begin ambulation with a walker following hip replacement surgery. What intervention by the nurse will best help the client? 1. Sit in a low chair for ease in getting up with a walker 2. Make sure rubber caps are present on all 4 legs of the walker 3. Begin weight-bearing on the affected hip immediately 4. Practice tying your shoes before using the walker

Respiratory acidosis

Progress Notes: Restless, picking at sheets. Disoriented to place and time. Dyspnea on exertion. Oxygen started at 2 liters per nasal cannula, incentive spirometry and deep breathing exercises initiated Head of bed elevated to 30 degrees Lab Reports: ph 7.30 PaO2 91 PaCO2 50 HCO3 24

1

The client is transferred to the rehabilitation facility following an ischemic stroke affecting the right side with aphasia. Which nursing action would promote communication with the client? 1. Encourage the client to shake head in response to questions 2. Speak in loud voice during interactions 3. Speak using phrases and short sentences 4. Encourage the use of a radio to stimulate the client

1,4,5

The nurse is admitting a client with new onset diabetes mellitus. Which findings does the nurse expect while completing the medical history and physical examination of this client? Select all that apply. 1. Recurrent yeast infections 2. Reports intolerance to cold 3. Slow, slurred speech 4. Prescription glasses changed twice in past year 5. Reports wanting to eat all the time 6. Absence of menses

1

The nurse is caring for a client that has metabolic acidosis secondary to acute renal failure. What is the initial client response to this problem? 1. Respiratory rate increase to blow off acid 2. Respiratory rate decrease to conserve acid and buffer the kidney response 3. Kidney will excrete hydrogen and retain bicarb 4. Sodium will shift to cells and buffer the hydrogen

3

The nurse is caring for a client with pneumonia. Which nursing observation would indicate a therapeutic response to the treatment for the infection? 1. Oral temperature of 101F; increased chest pain with non-productive cough 2. Productive cough with thick green sputum; states feeling tired 3. Respiration 20, with no reports of dyspnea; moderate amount of thick, white sputum 4. White cell count of 10,000, urine output at 40 ml/hr and no sputum

2,3,4

The nurse is evaluating whether a client understand the procedure for collecting a 24 hour urine sample. The nurse recognizes that teaching was successful when the client makes which statements? Select all that apply. 1. I should start the 24 hour urine collection at the time of my first saved urine specimen 2. If I forget to collect any urine, I will need to start over 3. It is important to ensure that no feces or toilet tissue mixes with the urine 4. When the 24 hours is up, I need to void and collect that specimen 5. The urine specimen should be stored in my refrigerator during collection