NCLEX Practice Exam 1

A parent brings a child, age 3, to the clinic for an annual checkup. After plotting the child's height and weight on a pediatric growth chart, the nurse identifies which percentile range as normal?

5th to 95th percentile rationale: height and weight measurements that fall between the 5th and 95th percentiles represent normal growth for most children. children whose measurements fall outside this range require further evaluation.

Nursing staff are trying to provide for the safety of an older adult with moderate dementia. The client is wandering at night and has trouble keeping her balance. She has fallen twice but has had no resulting injuries. Which action by the nurse is most appropriate? Help the client to bed and raise all four bedrails. Have the client sleep in a reclining chair across from the nurse's station. Ask a family member to stay with the client at night. Move the client to a room near the nurse's station and install a bed alarm.

Move the client to a room near the nurse's station and install a bed alarm.

A child with type 1 diabetes is ordered to receive 25 ml/hr of 0.9% I.V. solution. The nurse is using a pediatric microdrip chamber to administer the medication. What is the correct drip rate for this medication? Record your answer using a whole number.

25 A pediatric microdrip chamber has a drop factor of 60 gtts/mL.

A health care provider (HCP) has prescribed carbidopa-levodopa four times per day for a client with Parkinson disease. The client wants "to end it all now that the Parkinson disease has progressed." What should the nurse do? Select all that apply. Determine if the client is at risk for suicide. Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors. Contact the HCP before administering the carbidopa-levodopa. Explain that the new prescription for carbidopa-levodopa will treat the depression. Encourage the client to discuss feelings as the carbidopa-levodopa is being administered.

Contact the HCP before administering the carbidopa-levodopa. Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors. Determine if the client is at risk for suicide. the nurse should contact the health care provider before administering sinemet because this medication can cause further symptoms of depression. suicide threats in clients with chronic illness should be taken seriously. the nurse should also determine if the client is on an mao inhibitor because concurrent use with sinemet can cause a hypertensive crisis. sinemet is not a treatment for depression. having the client discuss his feelings is appropriate when the prescription is finalized.

A nurse is assessing a client's blood pressure 8 hours after surgery. The client's blood pressure before surgery was 120/80 mm Hg, and on admission to the postsurgical nursing unit it was 110/80 mm Hg. The client's blood pressure is now 90/70 mm Hg. After determining that other vital signs are normal, what should the nurse do first? Elevate the head of the bed. Notify the health care provider (HCP). Call the rapid response team. Administer pain medication.

Notify the health care provider. The client's systolic blood pressure is dropping, and the pulse pressure is narrowing, indicating impending shock. The nurse should immediately notify the HCP . Elevating the head of the bed will not increase the blood pressure. Administering pain medication could cause the blood pressure to drop further. It is not necessary to activate the rapid response team unless the client's vital signs change before the HCP evaluates the client.

Which condition is commonly seen in clients who abuse cocaine? Panic attacks Expressive aphasia Attention deficits Bipolar cycling

Bipolar cycling Explanation: Clients who abuse cocaine experience the rapid cycling effect of excitement then severe depression. These clients don't tend to experience panic attacks, expressive aphasia, or attention deficits.

The client was diagnosed with hypertension 7 years ago. In the last 6 months, after diet and exercise, the client's blood pressure has consistently ranged around 160/95. What should the nurse include in the client's teaching about the side effects of clonidine? Select all that apply. "Clonidine may cause dry mouth." "Clonidine may cause fatigue." "Clonidine may cause low blood pressure when you stand up." "Clonidine may cause blood in your urine." "Clonidine may cause pain in your joints."

"Clonidine may cause low blood pressure when you stand up." "Clonidine may cause fatigue." "Clonidine may cause dry mouth." The nurse should explain that side effects of clonidine include orthostatic hypotension, drowsiness, peripheral edema, fatigue, urinary retention, dry mouth, and constipation. Hematuria and arthralgia are not side effects of clonidine.

When teaching about prevention of infection to a client with a long-term venous catheter, the nurse determines that the client has understood discharge instructions when the client makes which statement? "My spouse will change the dressing three times a week, using sterile technique." "I will monitor my temperature every other day." "I won't remove the dressing until I return to the clinic next week." "I know it's very important to wash my hands after irrigating the catheter."

"My spouse will change the dressing three times a week, using sterile technique." The most important intervention for infection control is to continue meticulous catheter site care. Dressings are to be changed two to three times per week depending on institutional policies. Temperature should be monitored at least once a day in someone with a vascular access device. Hand washing before and after irrigation or any manipulation of the site is a must for infection prevention.

Which parent statements demonstrate an understanding of feeding priorities with their 4-month-old? Select all that apply. "My baby will be obese if I give solid foods." "Solid foods will not meet my baby's nutritional needs." "I gave my first baby solid foods at 3 months and it didn't produce ill effects." "Solid foods aren't compatible with my baby's immature gastrointestinal (GI) tract." "Giving my baby solid foods before 4-6 months can contribute to protein allergies."

"Solid foods aren't compatible with my baby's immature gastrointestinal (GI) tract." "Solid foods will not meet my baby's nutritional needs." "Giving my baby solid foods before 4-6 months can contribute to protein allergies."

A client with breast cancer is prescribed tamoxifen 20 mg daily. The client states they do not like taking medicine and asks the nurse if the tamoxifen is worth taking. What should the nurse tell the client? "This drug: will act as an estrogen in your breast tissue." is part of your chemotherapy program." has been found to decrease metastatic breast cancer." will prevent hot flashes since you cannot take hormone replacement."

"This drug has been found to decrease metastatic breast cancer" Tamoxifen is an antiestrogen drug that has been found to be effective against metastatic breast cancer and to improve the survival rate. The drug causes hot flashes as an adverse effect.

A client who is allergic to penicillin has a prescription to receive cefazolin. What should the nurse do first? Ask if the client has taken cefazolin before without an adverse response. Administer the cefazolin as prescribed. Verify the prescription with the health care provider (HCP). Observe the client closely for urticaria.

Ask if the client has taken cefazolin before without an adverse response.

A client undergoes intense rehabilitation after a cerebrovascular accident (CVA) and is being discharged with residual hemiparesis. What is the most important responsibility of the case manager? Reinforce the importance of optimal nutritional intake and increased fluid intake to promote recovery. Assess and reduce fall risk factors and implement measures to prevent a subsequent CVA. Assess ability to perform instrumental activities of daily living and reinforce the importance of preventing complications of immobility. Assess capabilities, demonstrate the use of assistive devices, and assess how the client will manage at home.

Assess capabilities, demonstrate the use of assistive devices, and assess how the client will manage at home.

The nurse is developing a teaching plan for the client with aplastic anemia. Which instruction is most important to include in the plan? Eat animal protein and dark green, leafy vegetables every day. Practice yoga and meditation to decrease stress and anxiety. Avoid exposure to others with acute infections. Get 8 hours of sleep at night, and take naps during the day.

Avoid exposure to others with acute infections. Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and reverse isolation are important measures to prevent infection. Although diet, reduced stress, and rest are valued in supporting health, the potentially fatal consequence of an acute infection places it as a priority for teaching the client about health maintenance. Animal meat and dark green leafy vegetables, good sources of vitamin B12 and folic acid, should be included in the daily diet. Yoga and meditation are good complementary therapies to reduce stress. Eight hours of rest and naps are good for spacing and pacing activity and rest.

A nurse is caring for a client who has several medications ordered to treat the diagnosed condition. The client is refusing the medications, stating that the benefits do not outweigh the side effects. What is the nurse's best response to this situation? Consult with the prescribing physician. Disguise the medication in the client's food. Tell the client that the medications are important to take. Document the client's decision in the health record.

Consult with the prescribing physician.

The parent of a toddler with nephrotic syndrome asks the nurse what can be done about the child's swollen eyes. Which is the best measure that the nurse should suggest? Apply cool compresses to the child's eyes. Elevate the head of the child's bed. Limit the child's television watching. Apply eye drops every 8 hours.

Elevate the head of the child's bed. The child's swollen eyes are caused by fluid accumulation. Elevating the head of the bed allows gravity to increase the downward flow of fluids in the body, away from the face. Applying cool compresses or eye drops, or limiting television, may be comforting but will not relieve the swelling.

The nurse is providing discharge instructions to a client with peripheral venous disease. The nurse should include which information in the discussion with this client? Select all that apply. Keep extremities elevated on pillows. Avoid prolonged standing and sitting. Use a heating pad to promote vasodilation. Limit walking so as not to activate the "muscle pump." Keep the legs in a dependent position.

Keep extremities elevated on pillows. Avoid prolonged standing and sitting.

The nurse examines a 6-week-old dark-skinned infant. There are large spots of deep blue pigmentation across the infant's buttocks. The nurse should identify this sign as characteristic of which finding? infant milia Mongolian spots telangiectatic nevi nevus flammeus

Mongolian spots

After surgical repair of a cleft lip, an infant exhibits difficulty breathing. Which measure should the nurse institute first? Turn the infant onto the abdomen. Raise the infant's head. Open the infant's airway. Administer oxygen by mask.

Open the infant's airway.

A nurse on a surgical unit is caring for a client who needs to provide informed consent for surgery. When the surgeon arrives on the unit to obtain consent, which client condition must the nurse immediately bring to the surgeon's attention? The client was given morphine 6 mg IM 20 minutes ago. The client has a temperature of 100.4 degrees F (38 degrees C). The client is diagnosed with malignant hypertension. The client states a pain rating of 8 out of 10.

The client was given morphine 6 mg IM 20 minutes ago. The nurse is aware that a client is unable to provide informed consent if the client has been given sedation or a narcotic. These medications may cause mental status changes, such as disorientation, which could interfere with the ability to provide consent. The other options, on their own, do not lead to disorientation and, therefore, would not prevent the client from providing informed consent.

A nurse is caring for a client with an intraosseous infusion. Which order should the nurse question? administer sodium bicarbonate 1mEq/Kg intraosseous calcium chloride 20mg/Kg acetaminophen 500mg dopamine 2mcg/Kg/min

acetaminophen 500mg Explanation:The nurse should question an order to administer acetaminophen by intraosseous infusion because the drug can only be administered orally or rectally. Any medication that can be administered via I.V. can be administered by intraosseous infusion. Therefore, sodium bicarbonate, dopamine, and calcium chloride can all be administered by way of intraosseous infusion.

A nurse is completing a prenatal assessment on a woman who is 28 weeks' pregnant with gestational hypertension. Which finding(s) should be reported to the primary health care provider? Select all that apply. dull headache 1+ urine protein weight gain of 1 lb (500 g) per week fundal height of 28 cm blurred vision

dull headache blurred vision 1+ urine protein The nurse must be alert for any signs and symptoms of superimposed preeclampsia in women with gestational hypertension. Dull headache, blurred vision, and protein in urine are all classic signs of preeclampsia in pregnancy and must be reported to the primary care provider immediately. Weight gain of 1 lb (500 grams) per week is an expected finding. Fundal height of 28 cm is an expected finding.

The nurse evaluates the client's ability to instill eye drops correctly. Which behavior indicates the client understands how to instill the eye drops? lies on the right side to instill the eye drops wipes the tip of the eye drop applicator with a disposable tissue instills the eye drops into the conjunctival sac blows the nose immediately after administering the eye drops

instills the eyedrops into the conjunctival sac.

The nurse is teaching a client with diabetes insipidus about using desmopressin nasal spray. The therapeutic effects of desmopressin nasal spray are obtained when the client no longer has which symptom? nasal congestion blurred vision headache polydipsia

polydipsia the therapeutic effects of desmopressin (ddvap) nasal spray are relief of polydipsia and control of polyuria and nocturia in clients with diabetes insipidus.

A physician orders metaproterenol/orciprenaline by metered-dose inhalation four times daily for a client with acute bronchitis. Which statement by the client indicates effective teaching about this medication? "I can stop using this drug when I begin to feel better." "I need to hold my breath as long as possible after I take a deep inhalation." "I should use this inhaler whenever I get short of breath." "I need to call the physician right away if I feel my heart beating fast after using the drug."

"i need to hold my breath as long as possible after i take a deep inhalation." correct explanation: the client demonstrates effective teaching if he states that he'll hold his breath for as long as possible after inhaling the drug. holding the breath increases the absorption of the drug into the alveoli.

The parents of a 9-month-old bring the infant to the clinic for a regular checkup. The infant has received no immunizations. Which vaccine if prescribed would the nurse question? diphtheria, tetanus, and acellular pertussis (DTaP) Haemophilus influenzae type B (Hib) measles, mumps, and rubella (MMR) inactivated influenza (Flu)

. measles, mumps, rubella (mmr) mmr is a live vaccine that is not given to children until 1 year of age

After striking their head on a tree while falling from a ladder, a client is admitted to the emergency department. The client is unconscious and their pupils are nonreactive. Which intervention should the nurse question? performing a lumbar puncture elevating the head of their bed placing the client on mechanical ventilation giving the client a barbiturate

performing a lumbar puncture the client's history and assessment suggest that he may have increased intracranial pressure (icp). if this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system, causing additional damage. after a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce icp.