NCLEX practice Q&A

The nurse conducts the health assessment of a client who is a primigravida in the prenatal clinic. Which presumptive signs of pregnancy should the nurse expect to assess?

amenorrhea and quickening Presumptive signs, such as amenorrhea and quickening, are mostly subjective and may be indicative of other conditions or illnesses.

The nurse cares for several preterm infants in the special care nursery. Which action is most important for preventing nosocomial infections in these neonates?

performing thorough handwashing before giving infant care The number one cause of nosocomial infections in hospital units is not washing the hands.

A client two days postpartum was given a shot of RhoGAM. At the postpartum home visit, the client asks the nurse why she needed RhoGAM. What is the most appropriate response by the nurse?

"RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby." RhoGAM is indicated to suppress antibody formation in women with Rh negative blood after giving birth to an RH positive baby. It is also given to Rh negative women after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis.

The family member of a client diagnosed with dissociative identity disorder (DID) asks a nurse if hypnotic therapy might help the client. How should the nurse respond?

"Yes, a client is often not consciously aware of alter personalities."

The nurse cares for a client experiencing delirium. What intervention is essential to include in the plan of care?

identifying the underlying causative condition or illness The most critical aspect of caring for a client with delirium is to institute measures to correct the underlying causative condition or illness.

During a client-teaching session, which instruction should a nurse give to a client receiving kaolin and pectin for treatment of diarrhea?

"Drink 8 to 13 8-oz glasses (2 to 3 L) of fluid daily." The nurse should tell the client to drink 8 to 13 8-oz glasses of fluid daily to replace fluids lost through diarrhea.

Which statement made by a client who is taking misoprostol indicates a therapeutic outcome of therapy?

"My stomach feels better." Misoprostol is used to protect the stomach's lining when a client has a peptic ulcer. Misoprostol does not affect the cardiac or respiratory systems.

When assessing a client withdrawing from alcohol, the nurse notes that the client is anxious, experiencing nausea, is restless, and has a tremor when both arms are extended. What should the nurse do next?

Administer a benzodiazepine as prescribed. The client is exhibiting signs and symptoms of withdrawal, and the nurse should administer the benzodiazepine to manage the anxiety, nausea, and restlessness and to prevent seizures.

A 19-year-old client comes to the emergency department with acute asthma. His respiratory rate is 44 breaths/min, and he is in acute respiratory distress. What is the nurse's priority action?

Give a bronchodilator by nebulizer The client, having an acute asthma attack, needs to increase oxygen delivery to the lungs and body. Nebulized bronchodilators will open airways and increase the amount of oxygen delivered.

A client is admitted to undergo lumbar laminectomy for treatment of a herniated disk. Which action should the nurse take first to promote comfort preoperatively?

Help the client assume a more comfortable position.

A client diagnosed with acquired immunodeficiency disorder (AIDS) 10 years ago who is now receiving treatment for non-Hodgkin lymphoma asks the nurse, "Why am I getting both chemotherapy and radiation treatments?" What information is important for the nurse to know to answer this question?

Non-Hodgkin lymphoma occurring in clients with AIDS is usually fast growing and both treatments may bring about an initial positive result. Non-Hodgkin lymphomas in AIDS clients is usually an aggressive disorder and treatment typically consists of both chemotherapy and radiation therapy. Rapid treatment may produce an initial positive response; however, the duration of this positive response is a short period of time.

A 21-month-old child admitted with the diagnosis of croup now has a respiratory rate of 48 breaths/min, a heart rate of 120 bpm, and a temperature of 100.8°F (38.2°C) rectally. The nurse is having difficulty calming the child. What should the nurse do next?

Notify the health care provider (HCP) immediately. The nurse may be having difficulty calming the child because the child is experiencing increasing respiratory distress. The normal respiratory rate for a 21-month-old is 25 to 30 breaths/min. The child's respiratory rate is 48 breaths/min. Therefore, the HCP needs to be notified immediately.

The nurse is preparing to discharge a school-age child with asthma. Which intervention is most important for the nurse to perform prior to discharge?

Obtain additional equipment and medication that can be provided at the school. The child needs to have equipment and medication available at school to treat and prevent asthma attacks. This is the priority intervention at this time.

The nurse is caring for a client who had a cerebrovascular accident (CVA) and needs to be fed. What instruction would the RN give the unlicensed assistive personnel (UAP), who will feed the client?

Position the client in a sitting position before feeding Instructions to the UAP should include positioning the client in a sitting position, which will decrease the risk of aspiration for the client with CVA. The nursing assistant does not have the additional education to assess gag/swallow reflexes.

A client is recovering from an abdominal-perineal resection. To promote wound healing after the perineal drains have been removed, what should the nurse encourage the client to do?

Take sitz baths Sitz baths are an effective way to clean the operative area after an abdominal-perineal resection. Sitz baths bring warmth to the area, improve circulation, and promote healing and cleanliness. Most clients find them comfortable and relaxing. Between sitz baths, the area should be kept clean and dry.

A postpartum clinic nurse is assessing a client 4 weeks postpartum after a vaginal birth. What finding would indicate to the nurse that the client is experiencing normal hemodynamic changes occurring in the postpartum period?

The hematocrit rises from 34% to 40%. Hemoglobin and erythrocyte values vary during the early postpartum period but they should approximate or exceed prelabor values within 2 to 6 weeks. As extracellular fluid is excreted, hemoconcentration occurs with a concomitant rise in hematocrit.

A health care provider (HCP) is calling the pediatric unit and asking the nurse to go into the medical record for the test results of a fellow pediatrician. How should the nurse respond to this request?

Verify that the caller is the HCP of record or has a need to know. The nurse should determine if the HCP is the HCP of record and should have access to the information in the medical record. The medical record is not for public access.

A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse?

a wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearance A wound (regardless of its size) that contains tan, leathery tissue requires evaluation by the wound care nurse. This wound most likely requires debridement before wound healing can take place.

The nurse is planning care for a client with pain associated with renal colic. Which nursing action will provide the most relief?

administering morphine During episodes of renal colic, the pain is excruciating. It is necessary to administer opioid analgesics such as morphine to control the pain.

A 35-year-old female client is diagnosed with aplastic anemia. Which nursing measure should the nurse incorporate into the client's plan of care?

alternate periods of activity with periods of rest to decrease fatigue Activity intolerance is a common problem for clients with aplastic anemia due to decreased hemoglobin. Alternating activity with periods of rest and assisting the client with activities of daily living are appropriate nursing interventions.

A child is diagnosed with Wilms' tumor. During assessment, the nurse expects to detect

an abdominal mass The most common sign of Wilms' tumor is a painless, palpable abdominal mass, sometimes accompanied by an increase in abdominal girth.

A nurse is caring for a client receiving the fentanyl transdermal system for pain management. When applying a new system, the nurse should:

apply the system immediately after removal from a package. The fentanyl transdermal system should be applied immediately after removal from the sealed package. The nurse should press the system firmly in place with the palm for 10 to 20 seconds, not 30 to 60 seconds, to make sure the contact is complete, especially around the edges.

A nurse must monitor a client receiving chloramphenicol for adverse drug reactions. What is a toxic reaction to chloramphenicol?

bone marrow suppression The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol isn't known to cause lethal arrhythmias, malignant hypertension, or status epilepticus.

When developing a seminar on injury prevention to be presented to a group of parents of children from 2 to 18 years, the nurse should place priority on discussing the use of which measure?

child restraints in automobiles Motor vehicle injuries are a leading cause of death in children older than 1 year of age. Most fatalities are related to the nonuse of child restraints and seat belts.

The nurse is caring for an older adult who has been bedridden for an extended period. Which symptom indicates that the client has hypoxia?

confusion The predominant clinical finding in elderly or debilitated clients indicating that they have hypoxia is confusion.

A child has been prescribed a 3-day course of treatment with gentamicin sulfate while recovering from surgery. Which assessment of the child causes the nurse to be the most concerned?

decreased urine output Gentamicin sulfate is an antibiotic that can cause ototoxicity and nephrotoxicity. Therefore, a decrease in urine output would be concerning.

The nurse is teaching the client how to use crutches. The nurse should instruct the client to bear weight primarily on which part of the body?

hands The proper use of crutches requires supporting the body weight primarily on the hands. Improper use of crutches can cause nerve damage from excess pressure on the axillary nerve, and undue weight bearing on the elbows and arms.

The nurse is caring for a client with acute respiratory distress syndrome. What portion of arterial blood gas results does the nurse find most concerning, requiring intervention?

partial pressure of arterial oxygen (PaO2) of 69 mm Hg In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaCO2 is elevated and the pH and HCO3- are depressed.

A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped?

runs of ventricular tachycardia Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur.

Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"

standing order

A client of African descent is brought to the emergency department after sustaining injury in a vehicle accident. The client is bleeding profusely from the wounded leg. In which area would the nurse check for pallor in the client?

tongue In a client of African decent, the nurse should check the tongue for pallor. Face, hands, and abdomen are not appropriate places to check for pallor because these areas may have heavy pigmentation.

A client with human immunodeficiency virus/acquired immunodeficiency disorder (HIV/AIDS) reports to the nurse a loss of 15 pounds in the past month and asks, "Do you think that I could use marijuana to help get my appetite back?" Assuming that medical maijuana is legal in the area, what is the nurse's best response?

"There are medications in addition to medical marijuana that can stimulate your appetite and help you to regain weight." The use of appetite stimulants is useful in HIV/AIDS clients who have anorexia. There is evidence that medical marijuana is an appetite stimulant that has enabled people to gain weight, as well as relieve nausea. If a client has no appetite, the use of supplements and suggestions to eat more protein may not be very helpful.

A prenatal client tells the nurse that they have been eating ginger cookies to treat nausea and vomiting. Which response by the nurse is best?

"When consumed as a spice in foods, ginger is generally considered safe in pregnancy." The herbal supplement ginger is taken to reduce nausea and vomiting. When consumed as a spice in foods, such as ginger cookies, there is a general consensus that ginger is safe.

Every morning, a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain?

70% NPH insulin and 30% regular insulin

The nurse is assigned four clients. Which client is at highest risk for impaired skin integrity?

A client having reconstructive breast surgery Reconstructive breast surgery places the client at risk for insufficient blood supply to the muscle graft and skin, which can lead to tissue necrosis.

Which suggestion should the nurse give to an adolescent athlete with Osgood-Schlatter disease of the left knee?

Apply ice on the knee after playing. Most adolescents with Osgood-Schlatter disease are able to continue to exercise and use ice afterward. Ibuprofen also may be prescribed. Because Osgood-Schlatter disease is self-limited, crutches or physical therapy are usually unnecessary, and the adolescent usually does not need to stop playing sports. Only in severe cases would the adolescent have to stop playing sports.

A 12-year-old client needs lifesaving emergency surgery, but the relatives live an hour away from the hospital and cannot sign the consent form. What is the nurse's best response?

Call the family for a consent over the telephone, and have another nurse listen as a witness. While laws in states and provinces may vary, generally, when the client cannot sign the operative consent and it is a true lifesaving emergency, consent may be obtained over the telephone from the client's next of kin or guardian. The surgeon must obtain the telephone consent, but if it is a true lifesaving emergency, the surgeon often is already in surgery, so the nurse makes the telephone call, and another nurse witnesses the call.

A client has recently experienced an embolic stroke, and is now stable. The client has been started on dabigatran. What information should the nurse provide to this client?

Dabigatran helps prevent blood clots from forming in the presence of atrial fibrillation. Atrial fibrillation is the most common cause of embolic stroke. It is a newer anticoagulant medication approved for secondary stroke prevention in clients with atrial fibrillation of non heart valve origin. It helps prevent blood clots. Although anticoagulation is the standard of care for a client with stroke due to atrial fibrillation, antiplatelet medication remains the standard of care for non-cardiac thromboembolic stroke. Because of the increased risk of life-threatening bleeding, careful consideration is needed when ordering dabigatran.

A 7-year-old with a history of tonic-clonic seizures has been actively seizing for 10 minutes. The child weighs 22 kg and currently has an IV of D5 NS + 20 mEq KCl/L running at 60 mL/h. The vital signs are temperature 100.4°F (38°C), heart rate 120 bpm, respiratory rate 28 breaths/min, and oxygen saturation 92%. Using the SBAR (situation-background-assessment-recommendation) technique for communication, the nurse calls the health care provider (HCP) with the recommendation for which medication?

IV lorazepam IV lorazepam is the benzodiazepine of choice for treating prolonged seizure activity. IV benzodiazepines act to potentiate the action of the gamma-aminobutyric acid (GABA) neurotransmitter; stopping seizure activity.

A nurse is helping a client move up in the bed. Which action maintains good body mechanics?

having the client help as much as possible When moving up in bed, the client's assistance will reduce strain on the nurse. The nurse may have to adjust the bed to a higher position, so it isn't possible to always keep the bed in a low position. However, the low position is preferred unless the client's medical condition contraindicates it. With folded arms, the client can't help pull or push up in the bed.

The nurse is admitting a client with a history of bipolar mania. Which assessment finding is the priority when developing a plan of care?

hyperactivity, ignoring eating, and sleeping As the nurse plans the care for the client, the need most in jeopardy is the physiological need of nutrition, sleep, and mobility. These needs must be fulfilled before the higher needs of hygiene, cognition, and esteem can be met.

A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?

keep the stoma moist The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of petroleum jelly around the edges, because a dry stoma may become irritated. The nurse should recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma.

While caring for a pregnant adolescent client, a nurse should develop a care plan that incorporates the adolescent's:

level of emotional maturity.

The nurse is caring for a client who is scheduled for an adrenalectomy. Which drug may be included in the preoperative prescriptions to prevent Addisonian crisis following surgery?

methylprednisolone sodium succinate intravenously A glucocorticoid preparation will be administered intravenously or intramuscularly in the immediate preoperative period to a client scheduled for an adrenalectomy. Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addisonian crisis) that occurs as a result of the adrenalectomy.

A nurse is performing a respiratory assessment on a 5-year-old child diagnosed with pneumonia. Which assessment finding should be reported to the health care provider immediately?

moderate intercostal retractions Use of the accessory or intercostal muscles would indicate a respiratory problem and should be immediately reported to the physician.

Which assessment finding would advise the nurse of a need to change from the prescribed intranasal route to an injection of desmopressin acetate for a child with diabetes insipidus?

mucous membrane irritation Mucous membrane irritation, caused by a cold or allergy, can render the intranasal route unreliable.

A primigravida in active labor is about 10 days post-term. The client desires a pudendal block anesthetic before birth. After the nurse explains this type of anesthesia to the client, which location if identified by the client as the area of relief would indicate to the nurse that the teaching was effective?

perineum A pudendal block is used for vaginal births to relieve pain primarily in the perineum and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair.

A nurse is assessing a client with heart failure. To assess hepatojugular reflux, the nurse should

press the right upper abdomen As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux. Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree, not 90-degree, angle.

Which laboratory test should the nurse monitor when the client is receiving warfarin sodium therapy?

prothrombin time Warfarin sodium interferes with clotting. The nurse should monitor the PT and evaluate for the therapeutic effects of warfarin sodium. A therapeutic PT is between 1.5 and 2.5 times the control value; the PT should be established by the health care provider.

The nurse is completing a health assessment of a client with suspected Graves disease. When conducting a focused assessment, the nurse should assess the client for which finding?

tachycardia Graves disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors.

Nurses are aware that culture links a wide variety of behaviors and events uniquely. For Westerners, which is a culturally linked behavior to autopsy?

the cause of death can be discovered Westerners believe that autopsy is used to discover the causes of death.

A neonate admitted to the neonatal intensive care nursery for probable meconium aspiration syndrome (MAS) weighs 4650 g (10 lb, 4 oz) and is at 42 weeks' gestation. The neonate has a heart rate of 110 bpm and a respiratory rate of 40 breaths/min with periods of apnea. The nurse should further assess the neonate for which condition?

hypoglycemia MAS affects small-for-gestational-age, term, and postterm neonates who have experienced long labor. Meconium in the lungs allows inhalation but not exhalation. These neonates often require resuscitative efforts at birth to establish adequate respirations. Hypoglycemia is common due to low glucose reserves at birth. Manifestations of hypoglycemia can include apnea.

The client with preeclampsia asks the nurse why she is receiving magnesium sulfate. The nurse's most appropriate response to is to tell the client that the priority reason for giving her magnesium sulfate is to

prevent seizures The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyperstimulated neurologic system caused by preeclampsia by interfering with signal transmission at the neural musculature junction. Reducing blood pressure, slowing labor, and increasing diuresis are secondary effects of magnesium.

A client admitted with pneumonia and dementia has attempted several times to pull out the IV and Foley catheter. After trying other options, the nurse obtains a prescription for bilateral soft wrist restraints. Which nursing action is most appropriate?

Attach the ties of the restraints to the bed frame. Restraints should be secured to the bed frame, not the side rails, to ensure that the side rails can be raised and lowered safely. Circulation checks, reevaluating the need for restraints, and documentation should be done every 1 to 2 hours. Medical restraint prescriptions must be renewed and signed by an HCP every 24 hours.

A client with schizophrenia is mute, can't perform activities of daily living, and stares out the window for hours. What is the nurse's first priority?

Assist the client with feeding. According to Maslow's hierarchy of needs, the need for food is among the most important. Other needs, in order of decreasing importance, include hygiene, safety, and a sense of belonging.

After having a total hip replacement, a client receives morphine sulfate by patient-controlled analgesia (PCA) pump. The client says, "This pump doesn't help my pain at all." What should the nurse do in response to this statement?

Assess the client's understanding of the PCA pump. The nurse should assess the client's understanding of the PCA pump because the client may not correctly understand how to use it. If the client can be taught how to properly use the PCA, other measures may not be necessary.

A client is 41 weeks gestation and is admitted to the hospital in true labor. She has an external fetal monitor in place. What does the nurse recognize as a reassuring fetal heart rate (FHR) pattern?

spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15 seconds An increase of 15 bpm of the FHR for the duration of at least 15 seconds is a normal, reassuring FHR pattern. Late decelerations are periodic uniform changes in the FHR that are associated with uterine contractions. Multiple late decelerations may be a result of uteroplacental insufficiency or compromised uteroplacental perfusion requiring an intervention in attempts to enhance circulation and fetal oxygenation. Repetitive variable decelerations may be associated with umbilical cord compression and may require changes in maternal positioning to relieve the cord compression.