NCLEX: STUDY
The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When describing a healthy stoma, which statement should the nurse be sure to include?
"At first, the stoma may bleed slightly when touched."
A nurse is caring for a client who is receiving spironolactone (Aldactone) to treat hypertension. Which instruction should the nurse give the client?
"Avoid salt substitutes."
A client asks a nurse if a large enteric-coated tablet can be cut in half. What is the best response by the nurse?
"Cutting the medication in half alters the medication's absorption."
A client is discharged following an extended stay on the surgical unit. On the way out, the client hands the nurse a card containing a twenty-dollar bill. The client states this money is a gift for the nurse. Which of the following statements made by the nurse demonstrates an understanding of accepting gifts from clients?
"I will let the nurse manager purchase something that all of the staff can enjoy.
A pregnant client with vaginal bleeding asks a nurse how the fetus is doing. Which response is best?
"I'll tell you what the monitors show."
The nurse is reinforcing nutritional counseling to the parent of a child with celiac disease. Which statement by the parent indicates understanding of the counseling?
"My son can't eat wheat, rye, oats, or barley."
A client states, "I am stressed by my job but enjoy the challenge. What is the best response by the nurse?
"Take stress management classes."
The nurse reinforces information about self-detection for cancer to a group of adolescent male clients. Which statement made by one of the participants indicates that the client understands the information?
"The best time to check for testicular changes is after a warm bath."
A child diagnosed with chickenpox is asked to stay home from school to avoid infecting other children. The caregiver of the child asks the nurse, "When is the infectious period?" What statement made by the nurse is most accurate?
"The client is infectious 1-2 days before the rash appears and until the blisters are crusted."
A client is prescribed a corticosteroid inhaler along with a bronchodilator inhaler. Which instruction about these drugs should the nurse give the client?
"Use the bronchodilator first, then wait about 5 minutes before using the corticosteroid."
A pregnant client in the first trimester comes to the clinic. During the visit, the client says, "My husband is so excited, but I'm worried because I'm not feeling the same way. Does this mean that I will be a bad mother?" Which response by the nurse would be most appropriate?
"What you're feeling right now is entirely normal for where you are at this stage."
A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
(ABC's) AIRWAY: Risk for aspiration related to general anesthesia
The nurse is preparing to give a 9-year-old client a preoperative I.M. injection. Which size needle should the nurse use?
22G, 1"
A nurse is caring for a client who has bacterial conjunctivitis. Which finding would lead the nurse to conclude that treatment for conjunctivitis was effective?
Absence of purulent discharge
Which intervention does the nurse educator include in his or her preparation as an example of primary prevention?
Administering a measles, mumps, and rubella immunization to an infant
A parent is preparing for the imminent death of a child due to sickle cell anemia. The parent has been unable to eat or sleep and talks only about the impending loss and feelings of guilt for the child's pain and suffering. Which nursing intervention has the highest priority?
Allow the parent to express feelings without judgement.
During a panic attack, a client runs to the nurse and reports breathing difficulty, chest pain, and palpitations. The client is pale with his mouth wide open and eyebrows raised. What should the nurse do first?
Assist the client to breathe deeply into a paper bag.
A nurse prepares to administer eardrops to an adult client. Which action should the nurse take before instilling the drops? A. yell to verify the PT name B. Gently pull the auricle up and back C. Warm the ear drops in tepid water
B. Gently pull the auricle up and back.
The nurse is reviewing the proper technique for obtaining a urine specimen from an indwelling urinary catheter. When collecting the urine, what is the most appropriate technique to use?
Clean the tubing's drainage port with alcohol and then insert a sterile needle with syringe to collect the specimen.
The nurse is interviewing an adolescent client at a drop-in clinic. The client reports that the client's caregivers do not believe in vaccines, but the client now wishes to receive the measles, mumps, and rubella vaccine (MMR) against the caregivers' wishes. What is the nurse's priority action?
Consult local legislation related to the age of consent for immunizations.
A client has a nasogastric (NG) tube. The physician prescribes an oral medication that is not available in liquid form. Which action should the nurse utilize to administer the tablet form to this client?
Crush the tablets and prepare a liquid form, and then insert it into the NG tube using a syringe.
A client's blood glucose level is 45 mg/dL. Which signs and symptoms should the nurse be alert for in this client?
Decreased level of consciousness (LOC), anxiety, confusion, headache, and cool, moist skin, sweating, dizziness
The parents of a pediatric client are waiting in the surgical family lounge while their son undergoes emergency surgery. A physician enters the family lounge and tells another family that surgery for their family member was unsuccessful. What should the nurse do to best serve these families?
Escort the family who received the discouraging news to a private area
The licensed practical nurse (LPN) instructs the nursing assistant to feed a client who has developed dysphagia after being admitted with a stroke. How should the nursing assistant position the client based on the LPN's instruction?
In bed with the head of the bed elevated to at least 45 degrees
A client with metastatic brain cancer is admitted to the oncology floor. According to the Patient Self-Determination Act of 1991 (PSDA), what is the hospital required to do concerning the execution of advance directives?
Inform the client or legal guardian of the right to execute an advance directive.
A nurse is caring for a client who has just had a liver biopsy. Which nursing intervention is the priority after the biopsy?
Keep the client on bed rest, lying on the right side.
The fetal monitor shows slowing of the fetal heart rate (FHR) that begins after the peak of each contraction, what should the PT do?
Lay on their side
A nurse is providing care for a client who experienced an extensive myocardial infarction (MI). The client exhibits behavior characteristic of the denial stage of the grieving process. What is the priority action by the nurse? A. Reinforce and support the client's denial. OR B. Let the client know that the nurse is available to talk.
Let the client know that the nurse is available to talk.
What is an appropriate nursing intervention for a client with a soft wrist restraint?
Monitoring circulatory status every 15 minutes if the client is agitated, or every 2 hours if the client is calm
Which information must the nurse know about the drip factor to verify the I.V. drip rate?
Number of drops in one milliliter
A 36-year-old client with a history of schizophrenia is admitted to the emergency department with a fever of 102° F (38.9° C), severe headache, photophobia, nuchal rigidity, and nausea. A physician believes that a lumbar puncture is necessary to help confirm his suspicions of meningitis. The nurse is asked to witness the informed consent. How can the nurse best assess the client's mental status before witnessing the consent?
Perform a brief mental status examination to determine whether the client is oriented to person, place, time, and purpose.
While driving home from work, a nurse realizes that she failed to communicate to the oncoming nurse that a client asked for more information about advance directives. Which action would be appropriate for the nurse to take?
Phone the nurse caring for the client and inform her of the client's request.
A nurse is caring for a bedridden older adult client. Which nursing intervention should the nurse include in this client's care?
Post an every 2 hour turn schedule at the bedside.
A client returns to the client care area after undergoing abdominal surgery. As the nurse inspects the client's dressing, she notes that it's completely saturated with bright-red blood. Which action should the nurse take?
Reinforce the dressing and contact the physician.
When checking a client's medication profile, the nurse notes that the client is receiving a drug that is contraindicated in clients with glaucoma. The nurse knows that this client has a history of glaucoma and has been receiving the medication for the past 3 days. What should the nurse do first?
Report the information to the physician to ensure client safety.
A nurse approaches a client who recently had a colostomy and finds the client crying. Which action is appropriate?
Sit down with the client and offer to talk about anything
A client with chronic obstructive pulmonary disease (COPD) tells the nurse, "I no longer have enough energy to make love to my husband." Which nursing intervention would be most appropriate?
Suggest methods and measures that conserve energy.
A nurse is caring for a client with myasthenia gravis. Which behavior during dinner indicates to the nurse that the client is having a therapeutic response to pyridostigmine?
The client swallows food without difficulty.
The nurse is administering sublingual nitroglycerin to the client. Immediately after administration, the nurse observes the client for which possible sign or symptom?
Throbbing headache or dizziness
The nurse is teaching a client how to rotate insulin injection sites. What is the purpose of rotating injection sites?
To prevent the formation of hard nodules
A nurse has been providing care to the same group of clients for 4 consecutive days. On day 5, she sees that her assignment has changed, and she is concerned about the continuity of care for these clients. What should the nurse do?
Voice her concerns about continuity of care with the charge nurse.
A 15-year-old girl visits the neighborhood clinic seeking information on how to prevent pregnancy. How should the nurse respond to her request?
What precautions are you taking now when you have sex?"
A nurse working in the triage area of an emergency department sees that several pediatric clients arrive simultaneously. Which child is treated first?
a 2-month-old infant with stridorous breath sounds, sitting up in his or her mother's arms and drooling
The nurse is obtaining data from a client with obsessive-compulsive disorder who reports not getting much sleep at night. What behavior does the nurse anticipate?
checking the door locks multiple times
A nurse is caring for a 16-year-old adolescent with aortic stenosis. Which finding is associated with aortic stenosis when the teen is active?
chest pain
While caring for a client with chronic obstructive pulmonary disease (COPD), a licensed practical nurse observes and reports that the client is short of breath, restless, irritable, and disoriented. After nursing interventions fail to reverse the client's escalating respiratory distress, what medical intervention should the nurse be prepared to assist with?
endotracheal intubation
The nurse assists in developing a list of nursing diagnoses for a client. This list should include:
factors influencing the client's problem.
The nursing staff on a medical surgical unit is involved in a quality improvement project to evaluate nursing care. Which task is most appropriate for the licensed practical nurse (LPN) on the team?
follow-up on client satisfaction surveys
A geriatric client is admitted to the facility after fainting while gardening on a hot summer day. Which nursing diagnosis takes highest priority for this client?
hyperthermia
A client who presents to the emergency department with reports of chest pain has been diagnosed with an acute myocardial infarction (MI). Which additional findings does the nurse expect in this client?
hypotension, rapid pulse, and shortness of breath
A licensed practical nurse (LPN) is assisting a registered nurse in caring for a primigravida client with acquired immunodeficiency syndrome (AIDS) who is at term and in early labor. When providing care to this client, which area would the LPN focus on as the priority?
infection control measures
A client has an I.V. line in place for 3 days and begins to report discomfort at the insertion site. Based on the client's progress notes shown, what condition has most likely occurred?
infiltration
diabetes mellitus
insulin is not secreted adequately or tissues are resistant to its effects
subcostal retractions with respiration
is a sign of breathing difficulty (in the lower lobes of the lungs)
Hyperglycemia symptoms
lots of eating, peeing, drinking. blurred vision, fatigue, weight loss
A nurse is caring for a client with acute pancreatitis who is exhibiting deficient fluid volume. What is the most appropriate nursing intervention for a client with this disease?
maintain IV fluids
aortic stenosis
narrowing of the aorta
A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. What is the priority action by the nurse?
notify the health care provider
Which nursing intervention would help a client diagnosed with Alzheimer's disease (AD) perform activities of daily living?
provide ample time for the client to complete basic tasks
A nurse is caring for a 10-year-old child with rheumatic fever. When obtaining the child's health history from the parent, the nurse should ask if the child recently had which illness?
strep throat
A child ingests a caustic toilet bowl cleaner during a visit to a friend's house. The child's caregiver tells the nurse about feelings of guilt. What would be an appropriate response by the nurse?
tell me more about your feelings
true or false: high fowlers position helps improve breathing
true
Dysfunctional grieving
unresolved grief or complicated mourning; overactive without a sense of loss
