UWorld NCLEX-RN TEST 2

The nurse is performing a 12-lead ECG on a client suspected of having a myocardial infarction. The nurse notes significant interference on lead V2. Which electrode will the nurse troubleshoot? Left-clicking the mouse will put an X to show the answer before submitting the question.

*look at word doc*

The nurse is reviewing telemetry strips of clients. Which rhythm requires further assessment by the nurse? 1. 2. 3. 4.

*look at word document*

A nurse is screening clients for skin cancer. Which assessment would be most concerning? 1. Client with a blue and black, irregular papule on the hand 2. Client with a pearly, pink papule with ulceration on the ear 3. Client with a pink patch with silvery scales on the neck 4. Client with a red, scaly patch with rough edges on the forehead

1

The following 4 clients are assigned to the emergency department nurse. Which client should the nurse see first? 1. Client in a motor vehicle collision whose head hit the steering wheel 2. Client who is 6 months pregnant and slipped and fell on icy stairs 3. Client who sustained a stab wound through the hand during a fight 4. Client with a 1-in (2.5 cm) leg laceration acquired during a soccer game

1

The nurse in a psychiatric unit is approached by an aggressive client who grabs the nurse's stethoscope and attempts to strangle the nurse with it. The nurse is able to escape the client's grasp unharmed. Which action should the nurse take first? 1. Begin escorting other clients out of the room 2. Calmly ask the client to verbally express feelings 3. Escort the client into a secluded room 4. Place the client in restraints until calm

1

The nurse is teaching a client about newly prescribed cyclosporine. Which client statement indicates a need for further teaching? 1. "I am going to a concert with my friends this weekend." 2. "I can use a hair removal cream for excess hair growth." 3. "I will need to check my blood pressure regularly at home." 4. "I will stop drinking grapefruit juice every morning."

1

The nurse is caring for a client who began receiving continuous tube feeding a week ago. Which assessment findings suggest that the client is experiencing a tube feeding complication? Select all that apply. 1. 2 episodes of emesis 2. 3 episodes of brown, liquid stool today 3. 7-lb (3.18-kg) weight gain in 1 week 4. Low gastric residuals 5. Serum glucose of 110 mg/dL (6.1 mmol/L) IncorrectCorrect answer 1,2,3

1, 2, 3

The nurse is preparing to discharge a client 4 days after colostomy placement. Which of the following findings are concerning and require further investigation? Select all that apply. 1. Areas of excoriation are noted on the skin surrounding the stoma. 2. No bowel sounds are present and the client reports nausea. 3. The client states, "I will call home health to come empty the pouch." 4. The client states, "There is a little gas in the colostomy bag." 5. The stoma is red, edematous, and smaller than the previous day.

1, 2, 3

The nurse suspects that a client with cirrhosis is developing hepatic encephalopathy based on which assessment findings? Select all that apply. 1. Breath has musty, sweet odor 2. Excessively sleepy 3. Flapping tremors when arms and hands are extended 4. Had 2 soft bowel movements in 24 hours 5. Pinpoint pupils

1, 2, 3

A client is diagnosed with septic arthritis of the knee. What manifestations does the nurse expect to find? Select all that apply. 1. Fever 2. Joint swelling with effusion 3. Limited range of motion 4. Moderate to severe pain 5. Numbness in the extremity

1, 2, 3, 4

The nurse cares for a client with end-stage liver disease who is not a candidate for a liver transplant. The client is considering participation in a research study investigating an experimental therapy. In discussing possible enrollment in the study with the client, which of the following statements by the nurse are appropriate? Select all that apply. 1. "Ask the research team about the risks, consequences, and benefits before signing consent." 2. "Before signing consent, make sure you understand the study's duration and your obligations." 3. "In your own words, can you tell me what you have been told about the study and what you will be required to do?" 4. "Remember that if you participate, you are not obligated to stay in the study. You may withdraw at any time." 5. "To maintain the integrity of the study, certain information may be withheld, such as potential for harm or discomfort."

1, 2, 3, 4

The nurse determines that a client with incontinence and limited mobility is at increased risk for skin breakdown and pressure injury. While caring for this client, which of the following nursing interventions are appropriate? Select all that apply. 1. Applying moisture barrier cream to the skin after performing perineal care 2. Providing a diet that is high in protein and contains adequate calories 3. Repositioning the client using a turn sheet every 2 hours 4. Restricting fluid intake to ≤2 L/day to reduce number of incontinent episodes 5. Using foam padding placed under the client's legs to elevate the heels

1, 2, 3, 5

The nurse is assisting the health care provider (HCP) with insertion of a central venous access device for a client scheduled to receive chemotherapy. Which nursing actions are appropriate? Select all that apply. 1. Applying a sterile, occlusive dressing to the site once insertion is completed 2. Asking family members to refrain from entering the room during the procedure 3. Donning a face mask and providing one to the HCP before the procedure 4. Infusing only normal saline until catheter placement is confirmed by x-ray 5. Verifying that the client has signed informed consent before the procedure begins

1, 2, 3, 5

A nurse is caring for a client with a long leg cast applied to treat a tibial fracture. Which interventions can be delegated to unlicensed assistive personnel? Select all that apply. 1. Alert the nurse of client reports of a tingling sensation 2. Assist client in performing range-of-motion exercises 3. Check the pulse distal to the cast 4. Elevate the casted limb above heart level 5. Monitor skin integrity around the cast

1, 2, 4

A pregnant client in the third trimester completes an intake form for a clinic visit. The nurse understands that which signs and symptoms warrant further investigation? Select all that apply. 1. Copious amounts of watery, clear vaginal discharge 2. Dysuria and right flank pain 3. Ear fullness and nasal stuffiness 4. Headache and blurred vision 5. Yellowish discharge from both nipples

1, 2, 4

The clinic nurse instructs a female client on how to collect a clean-catch urine specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply. 1. "l will be very careful not to touch the inside or rim of the container." 2. "I will begin to urinate before passing the container into the stream for collection." 3. "I will carefully cap the container and repeat the process later if I cannot fill it." 4. "I will cleanse the area with single-use antiseptic wipes prior to urinating." 5. "I will have to collect the specimen when I first urinate tomorrow morning."

1, 2, 4

The nurse is admitting a client with a seizure disorder and delegates preparation of the client's room to the student nurse. Which of the following actions by the student nurse indicate a correct understanding of seizure precautions? Select all that apply. 1. Ensures that suction equipment is present and operable 2. Ensures that supplemental oxygen and a bag valve mask are present 3. Places an oral airway at the head of the bed 4. Places padding on the side rails of the bed 5. Tapes a padded tongue blade at the head of the bed

1, 2, 4

During a follow-up visit to the primary care clinic, the nurse evaluates a client's understanding about prevention of complications from varicose veins. Which client statements indicate a correct understanding? Select all that apply. 1. "I have been dieting and have lost 10 pounds (4.5 kg)." 2. "I have started wearing elastic compression hose." 3. "I quit my retail job and now sit at a desk instead." 4. "I try to elevate my legs as often as possible." 5. "I try to walk at least 1 mile (1.6 km) every day."

1, 2, 4, 5

The nurse is reinforcing education to a client prescribed methadone for management of chronic pain. Which of the following client statements indicate a correct understanding? Select all that apply. 1. "I should not consume alcohol while taking this medication." 2. "I will stand up slowly when getting out of a bed or a chair." 3. "If my pain is not managed with one tablet, I can take an additional tablet." 4. "My family should learn to use the naloxone auto-injector in case I am oversedated." 5. "This medication can cause problems with my heart, so I will need regular checkups."

1, 2, 4, 5

The nurse provides teaching for a client newly diagnosed with Addison disease. Which of the following client statements indicate that teaching has been effective? Select all that apply. 1. "I may need more medication during times of extreme emotional stress." 2. "I should avoid being around people who are sick with colds or flu." 3. "I will begin decreasing the amount of sodium that I consume." 4. "I will have to take the prescribed medications for about a year." 5. "I will wear a medical alert bracelet to advise others of my diagnosis."

1, 2, 5

The nurse is reinforcing education about good sleep hygiene to a client with chronic insomnia. Which instructions should the nurse include? Select all that apply. 1. "Avoid caffeine-containing beverages for at least 4 hours before bedtime." 2. "Drink a glass of red wine before you go to bed." 3. "If you are still awake 20 minutes after going to bed, get out of bed and read a book." 4. "Prepare the bedroom environment by making it dark, quiet, and cool." 5. "Watch television in bed until you feel tired enough to fall asleep."

1, 3, 4

A nurse assists a student nurse in formulating a care plan for a nonverbal hospice client who demonstrates restlessness and facial grimacing during repositioning. Which statements by the student nurse indicate a correct understanding of the goals of end-of-life care? Select all that apply. 1. "I can observe the client's agitation as an indicator of the client's pain level." 2. "I should ask the family to leave the client alone if the client becomes restless." 3. "I should continue to explain interventions I am performing even though the client is unresponsive." 4. "I will ask the family if they would like to hold the client's hand while I administer pain medication." 5. "Managing pain rather than treating disease is the priority goal for this client."

1, 3, 4, 5

The nurse on the pediatric unit conducts a staff in-service program about adapting nursing care to support clients' psychosocial development. Which of the following examples are appropriate for the nurse to include? Select all that apply. 1. Allow a 4-year-old to plan a fun activity after the nurse completes a dressing change 2. Ask parents to avoid bringing blankets and plush toys from home for a 2-year-old 3. Encourage visits and social media contact from a 16-year-old's peers 4. Have a 10-year-old participate in care by keeping track of oral fluid intake with the nurse 5. Remind the parent of a 2-month-old to respond quickly to the infant's cries

1, 3, 4, 5

A nurse in the intensive care unit is responding to a low-pressure limit mechanical ventilator alarm. The nurse will assess for which conditions that can trigger a low-pressure alarm? Select all that apply. 1. Client has pulled out endotracheal tube 2. Client is coughing or gagging 3. Endotracheal tube cuff is leaking 4. Secretions are built up in endotracheal tube 5. Ventilator tubing is disconnected

1, 3, 5

The charge nurse is making assignments on a medical-surgical telemetry unit. Which clients are appropriate to assign to the licensed practical nurse? Select all that apply. 1. Client admitted after a suicide attempt and started on oral lorazepam 2. Client with a second-degree type II atrioventricular block admitted for observation 3. Client with active gastrointestinal bleeding receiving a blood transfusion 4. Client with diabetes requiring blood glucose checks and subcutaneous mealtime insulin 5. Client with paroxysmal atrial fibrillation requiring scheduled oral diltiazem

1, 4, 5

The nurse is caring for a client in labor at 37 weeks gestation and notes a baseline fetal heart rate of 180 beats per minute. Which interventions should the nurse perform? Select all that apply. 1. Measure maternal blood pressure 2. Reassess fetal heart rate in an hour 3. Reduce IV fluid rate 4. Review medication administration record 5. Take maternal temperature

1, 4, 5

A medical-surgical nurse with no critical care experience has been assigned to float to the intensive care unit for the shift. Which clients would be appropriate for the charge nurse to assign to this nurse? Select all that apply. 1. Client 3 days postoperative from a femoral-popliteal bypass graft 2. Client in restraints to prevent self-extubation of an endotracheal tube 3. Client receiving a continuous IV norepinephrine infusion for septic shock 4. Client with acute stroke receiving tissue plasminogen activator 5. Client with diabetic ketoacidosis receiving insulin before meals

1, 5

A client's family member reports to the charge nurse that the nurses on the unit are not responding appropriately to the client's report of pain. What is the charge nurse's priority action? 1. Ask the client to rate current pain on a scale of 0-10 2. Discuss the concerns with the nurse assigned to the client 3. Evaluate the client's medication administration record 4. Review the narcotic count and look for discrepancies

1.

After a traumatic head injury, a 36-year-old client on a mechanical ventilator is declared braterm-62in dead. The client's spouse states, "Maybe this happened for a reason. Do you think organ donation is possible?" Which response by the nurse is appropriate? 1. "A specialized team reviews each case for eligibility. I will contact them to review your spouse's history." 2. "It depends on whether your spouse gave consent to be an organ donor before the injury." 3. "Organ donation often provides comfort to family members who are grieving the loss of a loved one." 4. "You seem to be thinking the worst. Your spouse was young and healthy, and we are doing everything we can."

1.

After assessing 4 clients in the pediatric emergency department, the nurse should alert the health care provider to see which client first? 1. 4-month-old who is lethargic with fever and vomiting 2. 2-year-old who is alert and calm with an occasional barking cough 3. 8-year-old with cola-colored urine and generalized edema 4. 15-year-old who is withdrawn and having painful urination

1.

An unconscious 22-year-old client is brought to the emergency department after being hit in the head by a steel rod. The nurse should monitor for which assessment findings that are most characteristic of markedly increased intracranial pressure with impending brainstem herniation? 1. Bradycardia and widening pulse pressure 2. Irregular respirations and hypothermia 3. Sluggish pupil response and otorrhea 4. Sudden increase in alertness and hypertension

1.

The nurse is caring for a client with chronic pancreatitis. Which meal should the nurse recommend when assisting the client in selecting food items from a menu? 1. Baked tilapia with lemon wedge, sweet potatoes, and green peas 2. Cream of potato soup and roast beef sandwich on a croissant 3. Sautéed salmon, macaroni and cheese, string beans, and a biscuit 4. Shrimp enchiladas with tomato salsa, rice, cornbread, and refried beans

1.

The nurse is caring for an older adult client who has a blistering rash newly diagnosed as disseminated herpes zoster. What personal protective equipment should the nurse wear while assisting the client with a shower and linen change? 1. Eye shield, gloves, gown, and N95 respirator mask 2. Eye shield, gloves, gown, and surgical mask 3. Gloves, gown, N95 respirator mask, and surgical cap 4. Gloves, gown, surgical cap, and surgical mask

1.

The nurse is teaching a group of clients about the use of complementary and alternative therapies. Which client statement indicates that further teaching is needed? 1. Client on apixaban who states, "I think I will try acupuncture for my arthritis." 2. Client on atorvastatin who states, "I have been taking garlic to help with my cholesterol." 3. Client with lupus who states, "I see a massage therapist for my muscle pain and stiffness." 4. Postpartum client who states, "I found a biofeedback coach for pelvic muscle training."

1.

The nurse is teaching a seminar about atypical presentation of myocardial infarction. The nurse teaches about which factor that increases a client's risk of experiencing atypical symptoms? 1. Female gender 2. History of smoking 3. Hyperlipidemia 4. Hypertension

1.

The nurse receives report on a client with chronic atrial fibrillation who had an episode of torsades de pointes during the night. The client spontaneously converted back to the baseline rhythm of atrial fibrillation and is now stable. Which information should the nurse immediately report to the health care provider? 1. Client is scheduled to receive a dose of sotalol this morning 2. Client is scheduled to receive a dose of warfarin this afternoon 3. Client's magnesium level is 2.2 mEq/L (1.1 mmol/L) 4. Client's potassium level is 4.5 mEq/L (4.5 mmol/L)

1.

The nurse working in a gastrointestinal clinic is reviewing the list of walk-in clients. Which client should the nurse see first? 1. Client reporting constipation since having a barium enema 3 days ago 2. Client reporting moderate flatulence after a resolved bowel obstruction 3. Client with irritable bowel syndrome reporting 3 or 4 loose stools a day for the past 3 days 4. Client with ulcerative colitis reporting 2 or 3 loose, bloody stools a day

1.

The unlicensed assistive personnel (UAP) reports being splashed in the eye while emptying urine from the catheter bag of a client with AIDS. The UAP is afraid of becoming infected with HIV and requests immediate testing. What is the nurse's priority action? 1. Direct the UAP to immediately flush the eye with water at the unit's eyewash station 2. Reassure the UAP that the risk for HIV is low as urine does not transmit the virus 3. Refer the UAP to the occupational health department for postexposure prophylaxis 4. Send the UAP to the facility's emergency department for medical evaluation

1.

Using SBAR (Situation, Background, Assessment, Recommendation/Request) to communicate with the health care provider, which statement should the nurse include to describe the situation? 1. "I'm calling about the client in 711 who has low blood pressure and is symptomatic." 2. "The client has a limited code status and requests no intubation or compressions." 3. "The client was admitted for acute respiratory failure and intubated on September 16." 4. "The client's blood pressure was 97/45 mm Hg an hour ago and is now 88/40 mm Hg."

1.

When performing a head-to-toe assessment, the nurse has difficulty hearing the client's heart sounds. What should the nurse do to better auscultate the S1 and S2 heart sounds? 1. Ask the client to lean forward in a sitting position 2. Have the client inhale deeply and hold the breath 3. Instruct the client to raise the left arm over the head 4. Use the bell of the stethoscope instead of the diaphragm

1.

The nurse reinforces teaching to the parents of a 12-month-old who has begun weaning from breastfeeding. Which statement by the parents indicates that teaching has been effective? 1. "I can allow my child to sleep with a bottle for comfort while weaning." 2. "I can start substituting breastfeeding sessions with whole cow's milk." 3. "I should discourage my child from drinking milk to increase solid food intake." 4. "I will stop breastfeeding completely to expedite the weaning process."

2.

A nurse is sent to triage victims at a mass casualty incident site following a disaster and correctly identifies which client as the priority for transport to a hospital? 1. Client who has no respirations or palpable pulses and is receiving CPR by bystanders 2. Client who is cool and clammy with a glass shard penetrating the chest wall 3. Client with an open tibial fracture and palpable distal extremity pulses 4. Client with superficial burns and minor lacerations on the forearms bilaterally

2

The nurse has just received report on 4 clients. Which client should the nurse see first? 1. Client 2 days post hip replacement who is reporting intense itching at the incision site 2. Client receiving normal saline IV at 250 mL/hr who is reporting puffy legs and a new cough 3. Client who is becoming increasingly angry due to a 2-hour delay in being discharged 4. Client with a potassium level of 5.0 mEq/L (5.0 mmol/L) receiving NS with 20 mEq/L (20 mmol/L) potassium chloride

2

The nurse responds to a neighbor's calls for help and finds the neighbor's infant is choking but still responsive. Which intervention is most appropriate at this time? 1. Call 911 and begin cardiopulmonary resuscitation 2. Perform 5 back slaps followed by 5 downward chest thrusts 3. Perform a finger sweep of the mouth to assess for foreign objects 4. Place the infant on the nurse's lap and perform abdominal thrusts

2

The nurse reinforces teaching for a client newly diagnosed with primary open-angle glaucoma. Which of the following client statements indicate that teaching has been effective? Select all that apply. 1. "After a few months of using the eye drops, my vision will be near normal." 2. "I need to keep all follow-up appointments with my health care provider." 3. "I will check with my health care provider before using allergy or cold medications." 4. "I will need to use prescribed eye drops for the rest of my life." 5. "If I see colored halos around lights, I should notify my health care provider."

2, 3, 4, 5

The nurse is assisting with a presentation on protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? Select all that apply. 1. A family member informs the registered nurse that the client has not been taking the prescribed metformin at home 2. An oncology nurse reviews the electronic health record of a client in the emergency department who was the victim of a recent mass shooting event 3. The licensed practical nurse (LPN) leaves the client's report sheet in the cafeteria after lunch 4. The LPN tells the unlicensed assistive personnel (UAP) who is pregnant to not enter the room of a client with toxoplasmosis 5. The UAP tells a client that the hospital roommate will return to the room after receiving hemodialysis

2, 3, 5

The labor and delivery nurse is caring for a client whose unborn child has been diagnosed with anencephaly. Which of the following nursing actions are appropriate for supporting the client in preparation for birth? Select all that apply. 1. Avoid bringing up the newborn's prognosis to prevent upsetting the client 2. Discuss the newborn's expected appearance with the client 3. Educate the client that grieving cannot truly begin until one cries 4. Explore the client's preferences for social and spiritual support 5. Remind the client of the ability to conceive again in the future

2, 4

The nurse on a medical-surgical unit prepares scheduled daily medications for a client and places them in a pill cup. After receiving the pill cup, the client states, "I take a whole tablet of metoprolol at home. Why did you cut this one in half?" What is the best response by the nurse? 1. "Do you know how many milligrams of metoprolol you normally take at home every day?" 2. "Show me which pill you're talking about so I can verify your prescriptions again." 3. "This is the same dose you received the past 3 days in the hospital, so we know it's safe to take." 4. "Your health care provider has prescribed a half-dose of metoprolol while you're in the hospital."

2.

Dozens of clients arrive in the emergency department with chemical burns and inhalation injuries from exposure to anhydrous ammonia gas released from a tanker truck on a highway. What is the priority action by the nurse? 1. Administer 100% oxygen to all clients with evidence of inhalation injuries 2. Assist clients to remove contaminated clothing and shower with copious amounts of water 3. Estimate the extent of the clients' burn injuries using the rule of nines 4. Rapidly assess the clients' vital signs, respiratory effort, and neurological status

2.

The emergency department nurse assesses an intubated client with multiple trauma injuries who recently arrived via emergency medical services. Which intervention should the nurse perform first? 1. Administer PRN pain medication 2. Assist with central line placement 3. Cover with warm blankets 4. Obtain prescribed x-rays

2.

The emergency department nurse is caring for a client with diabetic ketoacidosis. Which new prescription should the nurse implement first? Click on the exhibit button for more information. Exhibit Laboratory resultsSerum glucose451 mg/dL (25 mmol/L)Serum pH6.9PaO291 mm Hg (12.1 kPa)PaCO227 mm Hg (3.6 mmol/L)HCO312 mEq/L (12 mmol/L) 1. Administer 50 mEq sodium bicarbonate IVP 2. Give 1 L bolus of 0.9% sodium chloride IV 3. Initiate a continuous infusion of regular insulin 4. Insert and maintain an indwelling urinary catheter

2.

The infection control nurse observes a new graduate nurse in the intensive care unit. Which action by the graduate nurse requires intervention by the infection control nurse? 1. Graduate nurse removes gloves prior to removing mask when leaving client's room 2. Graduate nurse scrubs underneath artificial nails while performing hand hygiene 3. Graduate nurse uses alcohol-based hand sanitizer when entering client's room 4. Graduate nurse washes hands with soap and water for 20 seconds

2.

The nurse completes a follow-up assessment on a client with sickle cell crisis who has just received a blood transfusion. The nurse notifies the health care provider and receives the following new prescriptions. Which prescription is the priority for the nurse to administer? Click on the exhibit button for additional information. Exhibit The client reports pain "all over" and rates the pain as 9 on a scale of 0-10. The client reports anxiety and is short of breath when walking to the bathroom. The client is also scratching the arms and reports itching. Auscultation of the client's lungs reveals crackles in the bilateral lower lobes. Notified the health care provider, prescriptions received. 1. Diphenhydramine 25 mg IV every 8 hours, PRN for itching 2. Furosemide 20 mg IV once, now 3. Lorazepam 1 mg IV once, now 4. Morphine 2-4 mg IV every 4 hours, PRN for pain

2.

The nurse is caring for a client diagnosed with acute pericarditis. Which assessment finding would cause the nurse to immediately contact the health care provider? 1. Chest pain, worse when in supine position 2. Muffled heart sounds and narrow pulse pressure 3. Pericardial friction rub on auscultation 4. ST-segment elevation on all ECG leads

2.

A nurse caring for a client following a right femoral angiogram is unable to palpate the right pedal pulse. What should the nurse do next? 1. Apply a heating pad to increase circulation 2. Call the health care provider 3. Document "0" for right pedal pulse strength 4. Obtain a Doppler ultrasound

4

A 16-year-old client arrives at the emergency department experiencing an asthma exacerbation. The client's parent is visibly upset and shouts that the client smells like cigarette smoke. What is the nurse's best action? 1. Allow the client and parent to finish the conversation privately 2. Ask the parent to leave the room until able to remain calm 3. Redirect the parent to instruct the client to perform deep-breathing techniques 4. Reinforce education about the importance of smoking cessation

3.

The nurse is caring for a client who is 2 days postoperative craniotomy with bone flap removal. The nurse notes clear wound drainage saturating the dressing over the incision. Which action by the nurse is most appropriate at this time? 1. Cleanse the incision site with saline and apply a new, sterile dressing 2. Mark the edges of the drainage on the dressing and continue to monitor 3. Notify the health care provider of the color and amount of drainage 4. Turn the client onto the nonoperative side using the log-rolling technique

3

Which client presenting to the women's health clinic should the nurse assess first? 1. Client at 9 weeks gestation who reports intractable nausea and vomiting for past 6 hours 2. Client at 37 weeks gestation with twins who reports irregular contractions 3. Client whose last menstrual period was 7 weeks ago and reports severe pelvic pain 4. Primigravida client at 19 weeks gestation who has not yet felt fetal movement

3

A female client is visiting the clinic for an annual well-woman examination. The client reports having had sex with women. Which question will help the nurse determine the client's risk for sexually transmitted infections? 1. "Are you a lesbian, or do you have sex with both men and women?" 2. "Are you in a monogamous relationship with a female partner?" 3. "What barrier methods do you and your partner(s) use?" 4. "What types of sexual acts do you engage in with your partner(s)?"

3

The monitor tech on the telemetry unit notifies the charge nurse that there are no more client telemetry boxes available for new admissions. Which client should the charge nurse consider for discontinuation of telemetry monitoring? 1. Client awaiting pacemaker battery replacement with a heart rate of 72/min 2. Client on observation to rule out myocardial infarction who has no ST elevation 3. Client with chronic atrial fibrillation prescribed warfarin with an INR of 3.0 4. Client with second-degree type 2 heart block with a blood pressure of 126/78 mm Hg

3

The clinic nurse gathers data from the parent of an adolescent client with suspected bulimia nervosa. Which of the following communications by the parent support this diagnosis? Select all that apply. 1. "I can now see my child's ribs and spine after so much weight loss." 2. "I have noticed that my child has developed fine hair on the back." 3. "My child ate a large container of chocolate ice cream in one evening." 4. "My child frequently leaves the table during meals to go to the bathroom." 5. "The dentist informed me that my child's tooth enamel is wearing away."

3, 4, 5

The nurse is reviewing home instructions with a client who just underwent cataract surgery with intraocular lens implantation. Which of the following client statements indicate appropriate understanding of the teaching? Select all that apply. 1. "I am concerned because my vision is still blurry." 2. "I can expect a lot of pain in the next few days." 3. "I need to wear an eye patch at night." 4. "I should avoid sexual intercourse until I'm healed." 5. "I will increase my fluid intake and take docusate daily."

3, 4, 5

The nurse provides discharge teaching for family members of a client going home following a suicide attempt. Which of the following instructions are appropriate for the nurse to include? Select all that apply. 1. "Avoid initiating discussion about suicide as this may increase risk for additional attempts." 2. "If the client hints at self-harm, redirect the conversation to positive subjects." 3. "Maintain a list of community resources and a suicide hotline for quick reference." 4. "Remove excess and unused medications, firearms, and knives from the home." 5. "Sudden positive outlook or calmness may indicate an impending suicide attempt."

3, 4, 5

The clinic nurse evaluates the ongoing treatment plan for a client with major depressive disorder. Which of the following client statements indicate a positive response to treatment? Select all that apply. 1. "I am trying to force myself to eat more, but I have still lost 5 pounds." 2. "I have been getting about 13 hours of sleep at night, and I still feel tired." 3. "I joined a book club with some of the parents from my kids' school." 4. "Physical intimacy doesn't interest me like it used to, but my spouse is patient." 5. "This haircut and color are very different, but I think I like the new look."

3, 5

The clinic nurse is discussing injury prevention with the parent of a 6-month-old infant. Which statements by the parent indicate that teaching has been effective? Select all that apply. 1. "I can switch to a front-facing car seat as my baby is in the 99th percentile for height." 2. "I do not need a childproof gate by the stairs as my baby cannot walk yet." 3. "I should place safety locks on the cabinets under the bathroom and kitchen sinks." 4. "I use the restraining belt on the changing table if I leave the room to get more supplies." 5. "I will need to move sharp or breakable objects onto high shelves, out of reach."

3, 5

The nurse has provided teaching to the parents of a 6-month-old child who is being discharged with a new prescription for a liquid iron supplement. Which statements by a parent indicate a need for additional instruction? Select all that apply. 1. "Our child might become constipated while taking this medication." 2. "Our child's stools might become black and tarry." 3. "We can give the dose with milk to prevent stomach irritation." 4. "We will administer the dose into the back of our child's cheek." 5. "We will administer the dose with meals to increase absorption."

3, 5

A nurse coworker is called into work from home to help care for an influx of clients being admitted after a bus accident. While assisting the coworker prepare for incoming clients, the nurse becomes concerned that the coworker may be under the influence of an impairing substance. Which action by the nurse is best? 1. Ask another coworker to observe the individual to confirm the suspicion 2. Confront the coworker about the concern and offer emotional support 3. Speak with the nursing supervisor about the concern 4. Telephone the appropriate regulatory agency and make a report

3.

A nurse is administering a rituximab infusion to a client with lymphoma in an oncology clinic. Which client symptom would be a priority to report to the health care provider? 1. Dizziness and sudden diarrhea 2. Nausea and onset of vomiting 3. New-onset tachypnea and dyspnea 4. Temperature of 101 F (38.3 C)

3.

A nurse is providing teaching to a client newly prescribed verapamil for chronic migraine headaches. Which statement by the client indicates the need for further teaching? 1. "I will avoid taking this medication with grapefruit or grapefruit juice." 2. "I will make sure my pulse is greater than 60 before I take this medicine." 3. "I will take this medication at the first sign of a migraine." 4. "I will take this medicine with plenty of water and increase my intake of fiber."

3.

Four clients enter the emergency department at the same time. Which client should the nurse alert the health care provider to see first? 1. 6-year-old who is crying and reports a headache after hitting the head 2. 17-year-old who cannot raise arm above head after a football injury 3. 40-year-old with a first-degree burn and singed beard from a campfire 4. 70-year-old experiencing severe diarrhea and a poor appetite

3.

Four clients enter the pediatric emergency department at the same time. Which client should the nurse see first? 1. 2-week-old with tricuspid atresia who has dusky lips and nailbeds 2. 5-week-old with forceful vomiting after every feeding who is crying 3. 12-month-old who was wheezing at home and is now lethargic with no wheezing 4. 3-year-old with fever who had a brief seizure at home and is asleep

3.

The charge nurse is rounding on clients in restraints. Which of the following situations would require immediate intervention by the nurse? 1. Client in a belt restraint in the semi-Fowler position 2. Client in mitten restraints in the side-lying position 3. Client in soft wrist restraints in the supine position 4. Client in vest restraint in the high-Fowler position

3.

The clinic nurse is caring for a 76-year-old client who has heart failure and is experiencing sudden weight gain and orthopnea. Which question would be the most beneficial for the nurse to ask at this time? Click the exhibit button for additional information. Exhibit Daily Medications Digoxin: 0.125 mg by mouth, once daily Furosemide: 40 mg by mouth, once daily Sucralfate: 1 g by mouth, 4 times daily as needed for heartburn 1. "Are you continuing to exercise regularly?" 2. "Do you check your heart rate before taking your medications?" 3. "When are you taking each of your medications?" 4. "When was your most recent visit to the primary care clinic?"

3.

The emergency department nurse is assigned 4 clients. Which client needs to be seen first? 1. 1-week-old with redness and swelling at the umbilicus and temperature of 100.1 F (37.8 C) 2. 2-year-old with a cough and post-tussive emesis with a respiratory rate of 27/min 3. 9-year-old with recent pacemaker insertion with dizziness and purulent drainage at the incision site 4. 14-year-old who reports a dull and constant headache after hitting the head while ice skating

3.

The home health nurse is discussing the care needs of a client in the last stage of Huntington disease with the family. When the nurse recommends a hospital bed, the client's spouse becomes visibly upset and says, "No hospital bed. I'm just not ready for it yet." What is the best response by the nurse? 1. "A hospital bed will make your spouse's care easier." 2. "Are you not ready for this particular change?" 3. "What upsets you about having a hospital bed?" 4. "You seem upset. We don't have to talk about this right now."

3.

The home health nurse visits a client with inflammatory bowel disease who recently underwent a total colectomy with ileostomy creation. Which statement by the client indicates that the client understands ileostomy care? 1. "I can irrigate the stoma daily to help regulate stool drainage." 2. "I change the ostomy appliance and bag every morning." 3. "I cut the appliance opening slightly larger than my stoma." 4. "I restrict how much I drink to make the stool drainage less watery."

3.

The nurse assesses the heart sounds of a 77-year-old client with chronic heart failure. Which heart sound should the nurse document? Listen to the audio clip. (Headphones are required for best audio quality.) 1. Pericardial friction rub 2. S1, S2, no adventitious sounds 3. S3 extra heart sound 4. Systolic murmur

3.

The nurse is caring for a client 1 hour after receiving the first electroconvulsive therapy treatment for severe major depressive disorder. The client reports a headache, is disoriented to place, and cannot recall the spouse's name. What is the appropriate nursing action? 1. Call the spouse to ask about memory problems prior to admission 2. Complete a full neurological examination and stroke assessment 3. Document the findings in the client's medical record 4. Request a prescription for a CT scan of the head

3.

The nurse is caring for a client taking escitalopram who reports no improvement of depressive feelings since starting the medication 2 months ago. What is the best response by the nurse? 1. "Have you had any recent changes or added stresses in your life?" 2. "It is too early to notice any difference. Please continue to take the medicine as prescribed." 3. "Let's talk more about how you have been taking this medication." 4. "We will talk with your health care provider about changing the prescription."

3.

The nurse is caring for a client with chronic kidney disease who has a scheduled dose of epoetin alfa. Which of the following laboratory results would cause the nurse to hold the medication and contact the health care provider? 1. Blood urea nitrogen: 26 mg/dL (9.3 µmol/L) 2. Creatinine: 2.5 mg/dL (221 µmol/L) 3. Hemoglobin: 13 g/dL (130 g/L) 4. Platelets: 120,000/mm 3 (120 × 109/L)

3.

The nurse is caring for a client with non-Hodgkin lymphoma who is starting chemotherapy. What assessment findings alert the nurse that the client is developing the potential complication of tumor lysis syndrome? 1. Facial and upper body edema 2. Generalized edema and hyponatremia 3. Hyperkalemia and hyperuricemia 4. Hypotension and elevated lactic acid

3.

The nurse reviews self-care strategies for a client with overflow urinary incontinence. Which client statement indicates a need for further teaching? 1. "I should increase the amount of fiber in my diet so that I do not become constipated." 2. "I should leave my desk every 2 hours to walk around a bit and to use the bathroom." 3. "I will decrease my fluid intake to 6 glasses each day and avoid drinking fluids after 7 PM." 4. "I will use my hand to apply pressure over my lower abdomen when I urinate."

3.

The student nurse plans postmortem care for an Orthodox Jewish client hospitalized for the last week with heart failure who did not sign consents for any postmortem actions. Which statement by the student would require further education by the supervising nurse? 1. "I will allow the family to remain with the client at all times." 2. "I will call the next of kin before providing any postmortem care." 3. "I will prepare the client for transfer to the morgue for autopsy." 4. "I will provide a sheet to be placed over the client's face."

3.

Which of the following methods would the nurse use to collect a urine sample for culture and sensitivity testing in a 16-month-old client? 1. Apply a urine collection bag to the perineum 2. Aspirate a specimen from an indwelling catheter collection bag 3. Insert a sterile intermittent urinary catheter 4. Place cotton balls inside the diaper

3.

An elderly client with diabetes comes to the clinic in winter reporting numbness of the feet. After removing the client's shoes and socks, the nurse notes that the feet are ice cold to the touch and appear waxy and pale. What is the appropriate nursing action? 1. Assist the client with ambulation to promote circulation 2. Bring the client warm blankets and a warm beverage 3. Massage the client's hands and feet to promote warming 4. Soak the client's lower legs in a warm water bath

4

The client admitted to the psychiatric unit with severe anxiety is pacing rapidly in the room, crying, and hyperventilating. The client yells, "I can't believe you took my belongings! Where are you keeping them? This is so frustrating!" What is the appropriate response by the nurse? 1. "I understand that you are frustrated. I will give you some time to yourself to decompress." 2. "This is frustrating for me too. I wish I could give you your belongings right now, but I can't." 3. "Would you like to sit down so we can talk? Pacing like this will make you feel worse." 4. "Your belongings are locked in a safe place to ensure that they are protected while you are here."

4

The clinic nurse is listening to voicemail messages in the office. Which client should the nurse call back first? 1. Client started on capsaicin cream 2 days ago reports sudden burning in the eyes 2. Client started on carbidopa-levodopa a day ago reports dizziness on standing 3. Client started on hydroxyzine 3 days ago reports urinary difficulty and hesitancy 4. Client started on phenytoin a week ago reports blistered lesions on the face and trunk

4

The nurse checks a client's blood pressure using an automatic, noninvasive machine. The nurse notes that the machine inflates for an unusually long amount of time, and the client reports intense pain in the arm with the cuff. The device suddenly stops inflation and displays an error message. Which action by the nurse is appropriate? 1. Place a soft washcloth under the cuff and repeat the measurement 2. Repeat the measurement after moving the cuff to the opposite arm 3. Repeat the measurement using a new cuff that is a size larger than the client needs 4. Send the machine for maintenance and repeat the measurement manually

4

The nurse is preparing to reposition several clients. For which clients should the nurse elevate the affected extremity? Select all that apply. 1. Client 2 days after above-the-knee amputation 2. Client scheduled for a right hip fracture repair 3. Client who just returned from femoral-approach percutaneous coronary intervention 4. Client with edema and a history of deep venous thrombosis in the left calf 5. Client with weeping cellulitis of the right foot

4, 5

A client comes to the emergency department after being bitten by a bat. The nurse observes 2 small, nondraining puncture wounds resembling pinpricks on the fingertip. Which action should the nurse implement first? 1. Administer an intramuscular injection of human rabies vaccine 2. Administer an intramuscular tetanus toxoid vaccine if client not immunized within 5 years 3. Inject human rabies immunoglobulin into the proximal wound area 4. Scrub the wound with povidone-iodine solution or soap and water

4.

A nurse is preparing to administer a unit of packed red blood cells to a critically ill client. Two nurses have performed the verification process, and the unit label indicates that it is in-date and unexpired. On inspection, the nurse notices a large air bubble at the top of the bag. What is the appropriate action by the nurse at this time? 1. Call the blood bank to verify the expiration date and the safety of the blood for administration 2. Call the health care provider for further instruction and file an incident report 3. Proceed with administration as any air will be caught by the drip chamber of the tubing 4. Return the blood to the blood bank, notify them that air is present, and obtain a new bag

4.

The new nurse, caring for a 3-month-old client who is sedated in the intensive care unit following surgery, needs to prevent skin breakdown. Which action performed by the new nurse would cause the charge nurse to intervene? 1. Applying barrier cream when changing the diaper 2. Changing the pulse oximetry site 3. Elevating the head of the bed 30 degrees 4. Placing a donut pillow under the head

4.

The nurse assesses a client who is intubated and mechanically ventilated after a cerebrovascular accident. Which assessment finding is most important for the nurse to report to the health care provider? 1. Flaccid right hand and arm 2. Impaired gag reflex when suctioning 3. Presence of urinary incontinence 4. Rigid flexion of arms at the elbows

4.

The nurse conducts telephone screenings with several clients who are scheduled for CT scan of the abdomen with oral contrast. The nurse should notify the health care provider about which client before the CT scan is performed? 1. Client in remission from breast cancer who has abdominal pain 2. Client who had a total hip arthroplasty with a titanium implant 3. Client with a history of heart disease and an implanted pacemaker 4. Client with a history of stroke who has dysphagia and is drooling

4.

The nurse is reviewing health history information for a client who is being seen for a routine physical examination. Which of the following clinical findings indicate that the client is at risk for latex allergy? 1. Had an etonogestrel implant inserted 9 months ago for birth control 2. Is allergic to shellfish, which cause throat swelling and rash 3. Reports a positive family history of spina bifida 4. Sought care 1 year ago for vaginitis after using a condom

4.

The staff nurse is preparing a presentation about strategies to reduce horizontal violence. The nurse educator is reviewing the presentation beforehand. Which recommendation included in the presentation indicates a need for further teaching? 1. Creating a behavior code of conduct outlining communication 2. Creating a suggestion box for anonymously reporting bullying 3. Providing consistent education regarding bullying 4. Working toward diversification of staff age and gender

4.

What nursing intervention is most appropriate when caring for a client with impairment to cranial nerve II? 1. Ensure that the client has a mechanical soft diet 2. Raise the head of the bed to prevent aspiration 3. Use pen and paper to write instructions 4. Verbally explain nursing interventions in detail

4.

The nurse is caring for a client prescribed 500 mg of daptomycin in 50 mL of normal saline IV to be administered over 30 minutes every 24 hours. The nurse has IV tubing with a drip factor of 45 gtt/mL. At what rate in drips per minute (gtt/min) should the nurse administer the IV daptomycin? Record your answer using a whole number. Answer: (gtt/min)

Answer: 75 (gtt/min)

The nurse prepares to administer a client's scheduled prandial regular insulin plus a correctional dose based on a sliding scale as the client's breakfast tray arrives. The client's fasting blood glucose level is 210 mg/dL (11.7 mmol/L). How many total units of regular insulin should the nurse administer? Click the exhibit button for additional information. Record your answer using a whole number. EXHIBIT: Medication administration record: Allergies: NKA Medications: -Regular insulin: 4 units subcutaneously with each meal (0800, 1200, 1700) -Regular insulin: per sliding scale, subcutaneously with each meal and before bed (0800, 1200, 1700, 2100) Sliding-Scale Blood Glucose Levels: <150 mg/dL - 0 units 150-199 mg/dL - 3 units 200-249 mg/dL - 6 units 250-299 mg/dL - 9 units 300-349 mg/dL - 12 units ≥350 mg/dL - 15 units; notify HCP

Answer: 10 (units)

The nurse is preparing to change the dressing of a client's subclavian central venous catheter using a chlorhexidine gluconate (CHG)-impregnated patch and transparent adhesive dressing. Place the procedural steps in the correct order. All options must be used. Apply CHG patch over catheter insertion site and cover with a sterile transparent dressing Cleanse the site with CHG for at least 30 seconds using friction; allow to air dry completely Discard the clean gloves, perform hand hygiene, and apply sterile gloves Perform hand hygiene, don face mask, place a mask on the client, and apply clean gloves Remove old dressing and CHG-impregnated patch; assess insertion site

Perform hand hygiene, don face mask, place a mask on the client, and apply clean gloves Remove old dressing and CHG-impregnated patch; assess insertion site Discard the clean gloves, perform hand hygiene, and apply sterile gloves Cleanse the site with CHG for at least 30 seconds using friction; allow to air dry completely Apply CHG patch over catheter insertion site and cover with a sterile transparent dressing