NCLEX

The new breastfeeding mother has been seen in the clinic for the treatment of mastitis. Which comment by the mother indicates a need for further teaching?

"My left breast is sore, so I will offer only my right breast frequently for breastfeeding."

The nurse obtains a prescription to restrain a client using a belt (safety) restraint and instructs the unlicensed assistive personnel (UAP) to apply the restraint. Which observation, if made by the nurse, indicates unsafe application of the restraint?

The restraint straps are safely secured to the side rails.

In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops. The nurse administers the eye drops knowing that which is the purpose of this medication?

To dilate the pupil of the operative eye

The nurse is gathering data from a 16-year-old pregnant client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which client statement indicates a need for further investigation?

"I don't like my face anymore. I always look like I have been crying."

The nurse in the prenatal clinic is taking a nutritional history from a pregnant adolescent. Which statement by the client should alert the nurse to a potential concern regarding adequate nutritional intake during the pregnancy?

"I need to gain only 10 pounds so that my baby will be small like I am."

The nurse is working in the primary care office and is conducting an interview with the parents of a child. The parents of the child state that they would like some syrup of ipecac for use at home in case of an accidental poisoning. The nurse provides which appropriate instruction specific to the use of this medication?

"Ipecac syrup is not for home use and is administered only under medical supervision."

The nurse has just finished taking a course on disaster preparedness. Which statements by the nurse indicate that the teaching has been effective? Select all that apply.

"Nurses test plans by participating in disaster drills." "Nurses play key roles before, during, and after a disaster." "Nurses assist in developing internal and external emergency response plans."

The parents of a child with sickle cell disease ask the nurse why their child is always anemic. What is the best response by the nurse?

"The sickle cells are very fragile and break easily, which leads to anemia."

Atropine sulfate is prescribed for the client diagnosed with gastrointestinal hypermotility, and the nurse reviews the client's record before administering the medication. Which finding, if noted on the client's record, most indicates the need to contact the primary health care provider before administering the medication?

Contraction stress test

A client has just had surgery to deliver a nonviable fetus because of abruptio placentae. She has just been told that she is developing disseminated intravascular coagulopathy. She begins to cry and screams, "God, just let me die now!" Which problem would direct care for this client?

The client feels hopeless about the situation.

For the previous 4 hours, a client in labor has been experiencing hypertonic labor as documented by the primary health care provider. The nurse recognizes which findings to be characteristic of this type of labor? Select all that apply.

Contractions typically occur in the latent phase of labor. Contractions occurring every 2 minutes, lasting 70 seconds. Contraction force is felt in the midsection of the uterus rather than the fundus.

The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated?

A manual pelvic examination

The nurse who is reinforcing instructions to a client who has had a gastric resection should include which considerations? Select all that apply.

Eat small frequent meals. Take action to prevent dumping syndrome.

The nurse is monitoring a client with a diagnosis of gastric ulcer. Which finding would indicate perforation of the ulcer?

A rigid, boardlike abdomen

The client diagnosed with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been prescribed pentamidine isethionate. The nurse assisting in caring for the client should monitor the client most closely for which adverse effect?

Anemia

The nurse is monitoring a client with a spinal cord injury for signs of spinal shock. Which sign is indicative of this complication of a spinal cord injury?

Areflexia below the level of injury

Pilocarpine hydrochloride is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity?

Atropine sulfate

The nurse is reviewing the record of a newborn infant and notes that the primary health care provider has documented the presence of a cephalhematoma. Based on this documentation, the nurse expects to observe which indications on data collection of the infant? Select all that apply.

Edema caused from bleeding below the brain's periosteum Develops 24 to 48 hours following birth and may take 2 to 3 weeks to resolve

The nurse reinforces what information to a client who is scheduled for an electromyogram (EMG)?

Electrodes will be inserted into the skeletal muscles.

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action?

Encourage the child to drink liquids.

The nurse is caring for a client who had a total knee replacement and was put on a continuous passive motion (CPM) machine in the postanesthesia care unit (PACU). What are some of the actions the nurse needs to monitor to operate this machine? Select all that apply.

Ensure that the machine is well padded. Assess the client's response to the machine. Turn off the machine while the client is having a meal in bed. Make sure that the joint being moved is properly positioned on the machine.

An unlicensed assistive personnel (UAP) tells the nurse that she is becoming very frustrated trying to communicate with an older client who is severely hard of hearing and does not have his hearing aid. Which instructions should the nurse recommend to improve communication between the UAP and the client? Select all that apply.

Make sure the environment is well lit. Face the client and speak slowly and clearly. Ask the client to restate what has been said. Turn the television volume down while communicating.

The nurse has administered a dose of salmeterol to a client. Following administration, the client develops a generalized rash and urticaria and the eyelids begin to swell. Which action should the nurse take?

Notify the registered nurse immediately.

The nurse is checking a child for dehydration and documents that the child is moderately dehydrated. Which symptoms should be noted in determining this finding? Select all that apply.

Oliguria Slightly sunken fontanels Very dry, mucous membranes

A client comes to the emergency department following an assault and is extremely agitated, trembling, and hyperventilating. Which initial nursing action is appropriate?

Remain with the client until the anxiety decreases.

A client has undergone a right pneumonectomy. The nurse positioning this client following admission from the postanesthesia care unit avoids placing the client in which harmful position?

Right lateral

A client with a history of seizures is taking phenytoin for seizure control. The client arrives at the health care clinic, and a serum phenytoin drug level is drawn. The laboratory calls the nurse and reports a result of 10 mcg/mL. Which interpretation should the nurse make of this value?

The laboratory value is at the low end of therapeutic range.

The nurse is working with a new nurse employee in a hospice agency. The nurse recognizes the new employee needs further assistance in facilitating effective communication between a client and the family if the new nurse employee performs which action?

The new nurse employee makes decisions for the client and family in order to relieve them of unnecessary demands.

The nurse is reinforcing medication instructions to the client with a diagnosis of human immunodeficiency virus (HIV) who is prescribed saquinavir. Which instruction should the nurse most appropriately provide the client in regard to taking this medication?

Within 2 hours after a full meal

The client arrives at the health care clinic requesting to be tested for Lyme disease. The client tells the nurse that he removed the tick and flushed it down the toilet. The nurse should respond with which most appropriate action?

Arrange for the client to return in 4 to 6 weeks to be tested.

A urinalysis has been prescribed for an infant and the nurse plans to collect the specimen. The nurse implements which appropriate method to collect the specimen?

Attaches a urinary collection device to the infant's perineum

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle attached to a syringe containing a clear liquid into the antecubital area. Which action would be the appropriate initial action by the nurse?

Call the nursing supervisor.

The nurse is planning care for a child with type 1 diabetes. Which items should the nurse plan to use to treat an early mild hypoglycemic episode? Select all that apply.

Candy Orange juice Glucose tablets

The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse should take which action first?

Clear and maintain an open airway.

The nurse is caring for a new immigrant from the Philippines who is in labor. The client is 4 cm dilated and 30% effaced. This is her first child. The mother is grimacing. Her pulse, respiratory rate, and blood pressure are elevated. The nurse offers to check on a prescription for an epidural. The mother declines. The nurse hypothesizes the client may be declining the epidural for which reasons? Select all that apply.

Filipino mothers fear drug addiction. Filipino mothers believe pain is a form of spiritual atonement for one's past deeds.

The nurse monitors a 5-year-old child admitted to the hospital for a neuroblastoma for signs and symptoms related to the location of the tumor in the adrenal gland. Which descriptions would the nurse expect to be documented in the child's record specific to this tumor? Select all that apply.

Firm, nontender, irregular mass in the abdomen Urinary frequency or retention from compression on the bladder

An adult client with severe muscle spasticity is receiving intrathecal baclofen (ITB). The nurse knows that what adverse effects may occur if the medication is suddenly withdrawn. Select all that apply.

Hallucinations Seizures

A client with a diagnosis of acute pancreatitis is experiencing severe pain. After noting an absence of an analgesic prescription on the primary health care provider prescription sheet, the nurse should suggest contacting the primary health care provider to request a prescription for which medication?

Hydromorphone

An adult client is admitted to the emergency department with acute extensive partial thickness burns to the lower extremities. The nurse anticipates the primary health care provider will initially prescribe which medications and route for pain control? Select all that apply.

Hydromorphone intravenously Morphine sulfate intravenously

The nurse is gathering data from a prenatal client with heart disease. The nurse carefully evaluates vital signs, monitors for weight gain, and checks the fluid and nutritional status. For which complication is the nurse collecting data?

Increase in circulating volume

Insulin glargine is prescribed for a client with diabetes mellitus. The nurse tells the client that which is the best time to take the insulin?

Once daily at the same time each day

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that their food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?

Open-ended questions and silence

The nurse is assisting in planning a diet for a client with acute kidney injury (AKI). The nurse plans to restrict which dietary component from this client's diet?

Potassium

The nurse is assigned to care for a 2-year-old child who has been admitted to the hospital for surgical correction of cryptorchidism. What is the highest priority in the postoperative plan of care for this child?

Prevent tension on the suture.

A client is receiving heparin sodium by continuous intravenous (IV) infusion. The licensed practical nurse (LPN) is concerned that the client received a bolus of medication when the tubing was removed from the IV pump during a gown change. The LPN immediately notifies the registered nurse or health care provider and then checks to see whether which medication is available in the medication supply area in case it is prescribed?

Protamine sulfate

The nurse is observing a parent and child interacting in the clinic waiting room. The child begins to bounce on the couch. The parent removes the child from the couch stating firmly, "Couches are for sitting, not for jumping." The parent then gives the child a toy to play with on the carpet. The child plays with the toy until called by the nurse. The nurse determines the child is acting within which Kohlberg stage of moral development?

Punishment-obedience stage

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking nevirapine. The nurse should monitor for which side/adverse effects of the medication? Select all that apply.

Rash Hepatotoxicity

Sudden tachycardia The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted?

Severe, throbbing headache

A client asks the nurse to describe how her baby is developing at 12 weeks gestation. Which milestones should the nurse identify as present at this time? Select all that apply.

Sex recognizable Blood forming in marrow Kidneys able to secrete urine

Ask a family member to sit with the client. The nurse is assisting in caring for a client with a head injury who is restless and is pulling at the intravenous (IV) line. The client's primary health care provider does not want to sedate the client, and the family has requested that the client not be restrained. The nurse should implement which action?

Stay with the client and consult with the nurse manager about the situation.Encourage the child to drink liquids.

Avoid iron supplementation The nurse is reinforcing home care instructions to a client following a gastric resection. The nurse should include which instruction to the client?

Take actions to prevent dumping syndrome

The nurse is reviewing the laboratory results for the client receiving tacrolimus. Which laboratory result should indicate to the nurse that the client is experiencing an adverse effect of the medication?

Blood glucose of 200 mg/dL

A client undergoing diagnostic testing for cancer is scheduled for magnetic resonance imaging (MRI). The nurse reinforces to the client which information about the procedure?

Expect the MRI machine to make loud noises.

The child is withdrawn. The parents of a 2-year-old arrive at the hospital to visit their child. The child is in the play room and ignores the parents during the visit. The nurse tells the parents that this behavior in a 2-year-old child indicates which characteristic about the child?

The child is exhibiting a normal pattern.

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L (130 mmol/L). The nurse expects that this sodium level would be noted in a client with which condition?

The client with the syndrome of inappropriate secretion of antidiuretic hormone

The nurse is teaching a local women's church group about the risks of cervical cancer. The nurse determines that there is a need for further teaching if a group member states that which is a risk factor?

Intercourse with a circumcised male

A client with Parkinson's disease is developing dementia. Which action should the nurse plan to assist the client in maintaining self-care abilities?

Break down activities into small steps.

The nurse observes that a client's nasogastric tube has suddenly stopped draining. The tube is connected to suction, the machine is on and functioning, and all connections are snug. After checking placement, the nurse gently flushes the tube with 30 mL of normal saline, but the tube still is not draining. The nurse should conclude which is the problem and what action should be taken?

Channels of gastric secretions may be bypassing the holes in the tube; turning the client will promote stomach emptying.

The nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. Which action should the nurse implement?

Check the amount of suction pressure being applied.

The nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which meal best illustrates the most appropriate diet for a client with cystic fibrosis (CF)?

Chicken tenders and a baked potato with butter

The nurse is reinforcing instructions to the client on how to maintain optimal skin integrity during external radiation therapy. The nurse determines that there is a need for further teaching if the client states plans to do which action?

Keep at least 6 feet away from pregnant women especially in the first 3 months.

The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse should expect to document that the fundus of the uterus is located at which area?

Midway between the symphysis pubis and the umbilicus

A client has been diagnosed with pernicious anemia. In planning care for the client, the nurse anticipates that the client will be treated with which vitamin or mineral?

Vitamin B12

The nurse is caring for a client with gout who is taking colchicine. The client has been instructed to restrict the diet to low-purine foods. Which food would the nurse instruct the client to avoid while taking this medication?

Scallops