Saunders NCLEX Questions

The nurse is caring for a client who is postoperative following a pelvic exenteration, and the surgeon changes the client's diet from NPO (nothing by mouth) status to clear liquids. The nurse would check which priority item before administering the diet? 1. Bowel sounds 2. Ability to ambulate 3. Incision appearance 4. Urine specific gravity

1. Bowel sounds

Betaxolol eye drops have been prescribed for a client with glaucoma. The nurse monitoring this client for side/adverse effects of the medication would place highest priority on which assessment? 1. Pulse rate 2. Blood glucose 3. Respiratory rate 4. Oxygen saturation

1. Pulse rate

When creating a mechanically ventilated client's plan of care for prevention of ventilator-associated pneumonia (VAP), the nurse would include which measures in the plan? Select all that apply. 1. Suction the oral cavity whenever needed. 2. Apply topical antibiotics to the oral cavity. 3. Change the ventilator circuit tubing every 2 hours. 4. Maintain the client in a supine position at all times. 5. Practice frequent oral hygiene, including toothbrushing. 6. Wear gloves when suctioning or handling the endotracheal tube.

1. Suction the oral cavity whenever needed. 5. Practice frequent oral hygiene, including toothbrushing. 6. Wear gloves when suctioning or handling the endotracheal tube.

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse would place the client in which position? 1. Supine position with a wedge under the right hip 2. Trendelenburg's position with the legs in stirrups 3. Prone position with the legs separated and elevated 4. Semi-Fowler's position with a pillow under the knees

1. Supine position with a wedge under the right hip

An older client diagnosed with delirium becomes agitated and confused at night. Which nursing action would be the most important strategy to minimize the client's risk for injury? 1. Turn off the television and radio, and use a night-light. 2. Keep soft lighting and the television on during the night. 3. Change the client's room to one nearer the nurses' station. 4. Play soft instrumental music all night, and do not turn down the lights.

1. Turn off the television and radio, and use a night-light.

A client who had surgery 3 days earlier is receiving heparin sulfate by subcutaneous injection every 12 hours. In planning for the client's morning care, the priority nursing intervention is which action? 1. Allow the client to sit only at the bedside. 2. Assist the client to shave using an electric razor. 3. Monitor the prothrombin time (PT) every 4 hours. 4. Tell the client that brushing the teeth is not allowed.

2. Assist the client to shave using an electric razor.

A client with medullary carcinoma of the thyroid has an excess function of the C cells of the thyroid gland. When reviewing the most recent laboratory results, the nurse would expect which electrolyte abnormality? 1. Sodium 2. Calcium 3. Potassium 4. Magnesium

2. Calcium

The nurse caring for a client who is taking an aminoglycoside would monitor the client for which adverse effects of the medication? Select all that apply. 1. Seizures 2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias 5. Hepatotoxicity

2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias

A primary health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse would plan to obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter? 1. Elastic wrap 2. Sterile 2 × 2 gauze 3. Adhesive bandage 4. Povidone-iodine swab

2. Sterile 2 × 2 gauze

The nurse is preparing to care for a client recovering from a subtotal thyroidectomy. Which supplies would the nurse have readily accessible for the care of this client? Select all that apply. 1. Tourniquet 2. Suction supplies 3. Calcium gluconate 4. Prefilled syringe of 50% glucose 5. Tracheostomy tube insertion set

2. Suction supplies 3. Calcium gluconate 5. Tracheostomy tube insertion set

A client received 20 units of Humulin N insulin subcutaneously at 08:00. At what time would the nurse plan to assess the client for a hypoglycemic reaction? 1. 10:00 2. 11:00 3. 17:00 4. 24:00

3. 17:00

The nurse is preparing to hang the first bag of parenteral nutrition (PN) solution via the central line of an assigned client. The nurse would plan to obtain which most essential piece of equipment before hanging the solution? 1. Urine test strips 2. Blood glucose meter 3. Electronic infusion pump 4. Noninvasive blood pressure monitor

3. Electronic infusion pump

The nurse is performing an assessment on a client with suspected irritable bowel syndrome (IBS). Which laboratory test would the nurse anticipate being ordered to confirm this diagnosis? 1. Urea breath test 2. Chloride sweat test 3. Hydrogen breath test 4. Complete blood cell count

3. Hydrogen breath test

A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing? 1. Eschar 2. Intact blisters 3. Liquefaction necrosis 4. Cherry-red, firm tissue

3. Liquefaction necrosis

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats per minute. Which action would the nurse take? 1. Check vital signs. 2. Check laboratory test results. 3. Monitor for any rhythm change. 4. Notify the primary health care provider.

3. Monitor for any rhythm change.

The nurse is reinforcing dietary management to prevent the formation of calcium oxalate renal calculi to a client with a history of recurrent renal calculi. Which client statement would indicate a need for further teaching? 1. "I will avoid vitamin C supplements." 2. "I will increase my daily water intake." 3. "I will limit my daily intake of sodium." 4. "I will increase the amount of spinach in my diet and be sure to eat nuts as snacks."

4. "I will increase the amount of spinach in my diet and be sure to eat nuts as snacks."

The nurse has given instructions about Kegel exercises to a client with a cystocele experiencing urinary incontinence. The nurse determines that the client needs further instruction if the client makes which statement? 1. "I need to stop and start my stream of urine during a voiding." 2. "I need to tighten my perineal muscles for up to 5 minutes, 3 or 4 times a day." 3. "I need to tighten my perineal muscles for up to 10 seconds several times a day." 4. "I would begin voiding and then stop the stream, holding residual urine for an hour."

4. "I would begin voiding and then stop the stream, holding residual urine for an hour."

The nurse educator is orienting a new nurse to the pediatric unit and is including tips for medication administration. Which statement by the new nurse indicates that the teaching has been effective? 1. "It helps to use magical thinking with the infant-age group." 2. "It helps to use magical thinking with the school-age group." 3. "It helps to use magical thinking with the toddler-age group." 4. "It helps to use magical thinking with the preschool-age group."

4. "It helps to use magical thinking with the preschool-age group."

The nurse is creating a plan of care for a client with a stroke (brain attack) who has global aphasia. The nurse would incorporate communication strategies into the plan of care because of which expected characteristic of the client's speech? 1. Intact 2. Rambling 3. Characterized by literal paraphasia 4. Associated with poor comprehension

4. Associated with poor comprehension

A complete blood cell (CBC) count is performed in a client with systemic lupus erythematosus (SLE). The nurse would suspect that which finding will be noted in the client with SLE? 1. Decreased platelets only 2. Increased red blood cell count 3. Increased white blood cell count 4. Decreased number of all cell types

4. Decreased number of all cell types

A 12-year-old is admitted to the hospital with a low-grade fever and joint pain. Which diagnostic test finding will assist to determine a diagnosis of rheumatic fever? 1. Absence of C-reactive protein 2. Presence of Reed-Sternberg cells 3. Decreased antistreptolysin O titer 4. Elevated erythrocyte sedimentation rate

4. Elevated erythrocyte sedimentation rate

A client with a bladder injury has had surgical repair of the injured area with placement of a suprapubic catheter. Which is the most appropriate nursing action to prevent complications of this procedure? 1. Monitor urine output once per shift. 2. Measure specific gravity once per shift. 3. Encourage an excessive intake of oral fluids. 4. Ensure that the catheter tubing is not kinked.

4. Ensure that the catheter tubing is not kinked.

A client has been taking pyrazinamide for 6 months. The nurse determines that the medication is effective if which cultures yield a negative result? 1. Urine 2. Blood 3. Wound 4. Sputum

4. Sputum

A parent and 6-year-old child come to the clinic because the child has developed a rash on the trunk and scalp. The parent reports that the child has had a low-grade fever, has not felt like eating, and has been tired. The child is diagnosed with chicken pox. The parent inquires about the communicable period associated with chicken pox, and the nurse bases the response on which statement? 1. The communicable period is unknown. 2. The communicable period ranges from 2 weeks or less to 4 weeks. 3. The communicable period is 10 days before the onset of symptoms to 15 days after the rash appears. 4. The communicable period is 1 to 2 days before the onset of the rash to 6 days, when crusts have formed.

4. The communicable period is 1 to 2 days before the onset of the rash to 6 days, when crusts have formed.

The school nurse is performing pediculosis capitis (head lice) assessments. Which assessment finding indicates that a child has a "positive" head check? 1. Maculopapular lesions behind the ears 2. Lesions in the scalp that extend to the hairline or neck 3. White flaky particles throughout the entire scalp region 4. White sacs attached to the hair shafts in the occipital area

4. White sacs attached to the hair shafts in the occipital area