MOCK NCLEX

A nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which finding would indicate a sign of a potential complication?

Increasing restlessness

Sodium chloride 0.9%

Isotonic - same as normal saline 0.9%

A nurse is caring for a client who had a small bowel resection, is 1 day postoperative, and has continuous gastric suction attached to the nasogastric tube. Which of the following intravenous solutions would the nurse anticipate would most likely be prescribed for the client?

Lactated Ringers solution

A client underwent creation of an ileostomy 2 days ago. The nurse checks the client for signs of which acid-base disorder that can occur in a client with an ileostomy?

Metabolic acidosis

A nurse has assisted with obtaining a set of arterial blood gases (ABG). The nurse avoids doing which of the following to properly obtain and send the specimen?

Obtains a 3-mL syringe from the medication supply area

A nurse is a certified basic life support (BLS) instructor and is conducting a BLS course for health care providers. The nurse determines that a student in the group correctly performs cardiopulmonary resuscitation (CPR) on an infant when the nurse observes that the rate of chest compression delivered to the infant manikin is:

One hundred times per minute

A client is admitted to the hospital with sickle cell crisis. The nurse checks this client for which frequent symptom of the disorder?

Pain

A nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response by the student indicates an understanding of the anatomy of this structure?

"The uterus weighs about 2 oz."

Food plan for persons with AIDS

- avoid fatty products, such as diary products and red meat.

normal therapeutic range for digoxin

0.5 to 2 ng/ml

A nurse is reviewing the record of a client in the labor room and notes that the nurse-midwife has documented that the fetus is at minus one station. The nurse determines that the fetal presenting part is

1 cm above the ischial spines

Magnesium levels

1.3-2.1

A pregnant client asks a nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between:

16 to 20 weeks' gestation

fetal heart sounds can be heard with a fetoscope by which week of gestation?

18 to 20 weeks

A male adult calls the emergency room and tells the nurse that he received a bee sting to the arm while weeding a garden. The client states that he has received bee stings in the past and is not allergic to bees. The client states that the site is painful and asks the nurse for advice to alleviate the pain. The nurse tells the client to first:

Apply ice and elevate the site

A blood glucose measurement is performed on a pregnant client, and the results indicate that the blood glucose is elevated. Which of the following would the nurse anticipate to be prescribed for the mother?

A 3-hour oral glucose tolerance test

A nurse is preparing a client scheduled for a bone marrow aspiration, and the client asks the nurse if the procedure will be painful. The nurse should make which response to the client?

A local anesthetic will be given

A nurse is caring for a hospitalized client with a mechanical heart valve who is receiving maintenance therapy of warfarin sodium. The client's international normalized ratio (INR) is 3.0. The nurse anticipates which of the following orders?

Administering the next dose of warfarin sodium

A nurse is monitoring a client who is in the active stage of labor. The nurse notes a late deceleration on the fetal monitor. Based on this observation, the nurse immediately:

Administers oxygen via face mask to the mother

A client has a serum sodium level of 151 mEq/L, and the nurse conducts dietary teaching with the client about the types of foods to avoid. The nurse determines that the client needs further information if the client later states that which of the following is a good food choice?

American cheese

A nurse is changing the abdominal dressing on a postoperative client following abdominal surgery. The nurse notes that the incision line is separated and notes the appearance of underlying tissue. Wound dehiscence is suspected. Which of the following is the appropriate initial nursing action?

Apply a sterile dressing soaked with sterile normal saline to the wound

A nurse is caring for a client with liver disease. Laboratory studies are performed, and the client's serum calcium level is 13.0 mg/dl. The nurse checks to see that which of the following medications is available in the stock medication supply area on the clinical nursing unit that may be needed to treat this calcium imbalance?

Calcitonin

A nurse is caring for a home-bound older postoperative cardiovascular client. The caregiver's daughter states to the nurse, "My mother has fallen out of bed three times." Which observation by the nurse would indicate the need for intervention to ensure safety?

Caregiver leaves one side rail down while the client is in bed

A client with heart failure who is taking furosemide and digoxin calls the nurse and complains of anorexia and nausea. The nurse should take which action?

Check the result of the potassium level drawn 3 hours ago

A client is brought to the labor unit and as the nurse is attaching the fetal heart monitor, the client's membranes rupture spontaneously. The nurse immediately:

Checks the fetal heart rate (FHR)

A nurse is assisting a client with a closed chest tube drainage system to get out of bed to a chair. During the transfer, the chest tube gets caught in the leg of the chair and accidentally dislodges from the insertion site. The immediate nursing action is to:

Cover the insertion site with sterile gauze

A physician places a Miller-Abbott tube in a client. Six hours later the nurse measures the length of the tube outside the nares and notes that the tube has advanced 6 cm since it was first placed. Based on this finding, which action would the nurse take next?

Document the finding in the client's record

A nurse is changing the diaper of a 1-day-old, full-term female newborn and notes that the genitalia is red and swollen and that a thick white mucoid vaginal discharge is present. Based on these findings, the nurse determines that the best action would be to:

Document the findings

A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client needs further instruction if the client states that which of the following foods is high in potassium?

Eggs

A nursing instructor asks a nursing student about the cause of hemophilia. The student responds by telling the instructor that:

Hemophilia A results from deficiency of factor VIII

The nurse determines that third-spacing of fluids is least likely to develop in the client with

Hypertension

A nurse is collecting data on a client who sustained circumferential burns of both legs. The nurse should check which of the following first?

Peripheral pulses

A nurse performs a vaginal assessment on a pregnant client in labor and notes the presence of the umbilical cord protruding from the vagina. The nurse immediately:

Places a gloved hand into the vagina and holds the presenting part off of the umbilical cord

A nurse is caring for a client with a closed chest tube drainage system. When repositioning the client, the chest tube disconnects. The immediate nursing action is to:

Reattach the chest tube to the drainage system

A nurse suspects that a co-worker is substance impaired and is self-administering narcotic medications rather than administering them to clients as prescribed. Which of the following actions will the nurse take?

Report the information to a supervisor

A physician is discussing the fluid balance of a postoperative client. The physician states that the client's insensible fluid loss is approximately 600 mL daily. The nurse interprets that the physician is referring to fluid loss that is occurring thorough the:

Skin and lungs

A nursing student prepares to administer sodium polystyrene sulfonate to a client, and the registered nurse asks the nursing student how the medication works. The student correctly responds that the medication works in the gastrointestinal tract by releasing:

Sodium ions in exchange for primarily potassium ions

A nurse is collecting data from a client and is observing the client ambulate with the use of a cane. The nurse would intervene and suggest a physical therapy referral if the nurse observed that

The client moves the cane and the unaffected side together

A nurse is preparing to administer an injection of vitamin K to a newborn. When administering the injection, the nurse would select which injection site?

The lateral aspect of the middle third of the vastus lateralis muscle

A nurse is preparing to get a tetraplegic client out of bed into a chair. The nurse places which of the following items on the seat of the chair as the best device for pressure relief?

Water pad

A client with multiple sclerosis is receiving diazepam, and the home care nurse provides instructions to the client regarding the side effects of the medication. The nurse tells the client that which of the following is a side effect of this medication?

Incoordination