NCLEX study plan

A nurse discusses the procedure for protective equipment isolation with the husband of a client who is receiving chemotherapy and has been hospitalized for neutropenia. Which statement made by the husband indicates the teaching was effective? 1-protective environment isolation helps prevent the spread of infection to my wife from the outside sources 2-protective environment isolation helps prevent the spread of infection from my wife to others 3-protective environment isolation helps prevent the spread of infection from my wife by using special techniques to destroy infectious fluid and secretions 4-protective environment isolation helps prevent the spread of infection to my wife by using special sterilization techniques for her linens and personal items before use

1

A nurse is teaching a community group about the basics of nutrition. A participant questions why fluoride is added to drinking water. The nurse should respond that it is a necessary element added to drinking water to promote? 1-dental health 2-growth and development 3-improved hearing 4-night vision

1

A nurse is teaching a new nursing assistant about ways to prevent the spread of infection. Included in the instruction would be the fact that the cycle of the infectious process must be broken, which may be accomplished primarily through? 1-handwashing before and between providing client care 2-cleaning all equipment with an approved disinfectant after use 3-wearing infection control approved protective equipment when providing client care 4-using medical and surgical aseptic techniques at all time

1

During an admission assessment the nurse discovers a stage 1 pressure ulcer on a client. Which of the following actions should the nurse implement immediately? 1-turning and reposition the client every 2 hours 2-covering with an occlusive transparent dressing 3-cleaning with hydrogen peroxide and leaving it open to air 4-providing the client with a diet high in vitamin C, zinc, and protein

1

The nurse is assessing an edematous client and is aware that edema occurs in what extracellular fluid compartment? 1-interstitial 2-intercellular 3-intravascular 4-intracellular

1

The professional obligation of a nurse to assume responsibility for actions is referred to as? 1-accountability 2-individuality 3-responsibility 4-bioethics

1

When caring for a client with a fractured hip, the nurse should place pillows around the injured leg to specifically maintain? 1-abduction 2-adduction 3-traction 4-elevation

1

A nurse is caring for a client with a nosocomial infection caused by methicillin resistant staphylococcus aureus (MRSA). The client has a new colostomy for which the nurse is preparing to provide care. Which protective items should the nurse use to perform the clients care? (select all that apply) 1-gloves 2-gown 3-mask 4-googles 5-shoe covers 6-hair bonnet

1,2,4

The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? (select all that apply) 1-whole grains 2-cooked fruit and vegetables 3-nuts and seeds 4-lean red meats 5-milk and eggs

1,2,5

A client is receiving a unit of placed red blood cells (PRBC). The client experiences tingling in the fingers and headache. What is the nurses priority action? 1-call the physician 2-stop the transfusion 3-slow the infusion rate 4-assess the IV site for infiltration

2

A client presents to an urgent care center after sustaining a muscle sprain on the left ankle. Upon examination the nurse notes a developing hematoma, edema and complaints of pain. The nurse should plan to apply which of the following? 1-binder 2-ice bag 3-elastic bandage 4-warm compress

2

A client reports smoke coming from a utility room on the nursing unit. What is the initial action the nurse should take? 1-pull the fire alarm on the unit 2-remove anyone in immediate danger 3-obtain a fire extinguisher and report to the fire area 4-close all windows and fire doors and await further instruction

2

A client with COPD reports steady weight loss and that he is too tired to eat. Which nursing diagnosis would be the most appropriate for this client? 1-fatigue related to weight loss secondary to COPD 2-imbalanced nutrition, less than body requirements, related to fatigue 3-imbalanced nutrition, less than body requirements, related to COPD 4-ineffective breathing pattern, related to alveolar hypoventilation

2

A client with a stage 3 pressure ulcer would benefit from which nursing intervention to prevent further injury by eliminating shearing force? 1-maintaining the head of the bed at 35 degrees or lower 2-lifting the client up in bed using a drawsheet with the help of another staff member 3-repositioning the client at least every 2 hours and supporting her with pillows 4-performing passive range of motion exercises of all extremities at least once per shift

2

A client with hyperthyroidism has been treated with radioactive iodine to destroy overactive thyroid gland cells. Which intervention is best for the nurse to use to reduce radiation exposure? 1-wear a lead shield apron 2-limit distance and time spent with the client 3-wear a radiation meter to measure exposure 4-remain at least 6 feet away from the client at all times

2

A hospitalized client is scheduled to have a sigmoidoscopy. What should the nurse anticipate will be ordered prior to the procedure? 1-keep the client NPO until after the procedure 2-administer a fleet enema 1 hour before the procedure 3-encourage increased intake of clear fluids 4-administer morphine a half hour before the procedure as a pre-op

2

A new nurse in orientation is approached by a surveyor from the department of health and is asked, "what is the best means to prevent the spread of infection?" What is the best answer for the nurse to provide? 1-let me get my preceptor 2-wash your hands before and after any client care 3-clean all instruments and work surfaces with an approved disinfectant 4-ensure proper disposal of all items contaminated with blood or body fluids

2

A nurse is instructing a disabled client regarding how to safely use a cane. The nurse should demonstrate proper use of the cane by holding it on? 1-alternating sides 2-the unaffected (stronger) side 3-the affected (weaker) side 4-the side of the clients choice

2

A nurse is preparing to administer an oil retention enema and understands that it works primarily by? 1-stimulating the urge to defecate 2-lubricating the sigmoid colon and rectum 3-dissolving the feces 4-softening the feces

2

A nurse is teaching a client regarding the correct method to use for walking with crutches. The nurse should explain that weight must be places? 1-in the axillae 2-on the hands 3-on the affected side 4-on the unaffected side

2

A nurse is teaching a spinal cord injured client who is being prepared for discharge home the proper technique for intermittent urinary self catheterization. Which instruction is most important for the nurse to include? 1-wear sterile gloves when doing the procedure 2-wash your hands before performing the procedure 3-perform the catheterization on yourself every 12 hours 4-dispose of the catheter after you have done the catheterization

2

A nurse observes a colleague preparing a medication for IV bolus administration. Which medication being prepared should prompt the nurse to immediately intervene? 1-saline flush 2-potassium chloride 3-naloxone (narcan) 4-adenosine (adenocard)

2

A nurse places a heating pad on a client and after 15 minutes realizes that the client has been burned because the settings were incorrect. Which principle would legally apply? 1-no one could be held liable for new equipment 2-the nurse could be held liable for the injury that occurred 3-the nurse did what a reasonable. prudent nurse would do 4-the manufacturer is liable for new equipment

2

A nurse receives report on the following clients. Which client should the nurse assess first? 1-25 year old client with a hemoglobin of 15.9 2-56 year old female client on warfarin (Coumadin) with an international normalized ratio (INR) of 7.5 3-38 year old female client with a serum calcium level of 9.4 4-45 year old male client with a blood urea nitrogen (BUN) of 20 and creatinine 0f 1.1

2

A nurse who promotes freedom of choice for clients in decision-making best supports which principle? 1-Justice 2-Autonomy 3-Beneficence 4-Paternalism

2

During an assessment the nurse pulls up on the clients skin, releases it, and looks to see if the skin returns immediately to its original position. What is this assessment technique? 1-assessing pain tolerance 2-checking skin turgor 3-checking for ecchymosis formation 4-measuring tissue mass

2

In all states of the United States, what is the professional nurses legal responsibility regarding child abuse? 1-honor the request of the parents not to report the suspected child abuse 2-report any suspected abuse to local law enforcement authorities 3-return the child to the legal parent even if he or she is suspected of abuse 4-provide the parents with a copy of the childs medical record

2

The nurse is caring for a client who is hyperventilating, the nurse knows this places the client at risk for which of the following disorders? 1-respiratory acidosis 2-respiratory alkalosis 3-respiratory compensation 4-respiratory decompensation

2

The nurse will be changing the soiled bed linens of a client with a stage 3 pressure ulcer that is draining seropurulent material. What personal protective equipment (PPE) is most essential for the nurse to wear? 1-mask 2-clean gloves 3-sterile gloves 4-shoe covers

2

Upon returning from lunch, a nurse is approached in the elevator by a hospital employee from another unit. The employee states that a close friend is a client on the nurses unit. She asks how the friend is doing and is all of her tests were normal. How should the nurse respond? 1-answer the employees questions softly so other people will not hear 2-decline to discuss her friends medical condition and suggest she visit her friend 3-give the employee the name of the clients physician and suggest she call for this information 4-tell the employee about the results of the clients tests only if they were within normal limits

2

When monitoring fluids and electrolytes, the nurse should have an understanding that the major cation-regulating intracellular osmolarity is? 1-sodium 2-potassium 3-calcium 4-calcitonin

2

When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? 1-skin breakdown 2-aspiration pneumonia 3-retention ileus 4-profuse diarrhea

2

When suctioning a client with a tracheostomy, what is the most important safety measure the nurse must remember? 1-hyperventilate the client with room air prior to suctioning 2-initiate suction only when the catheter is being withdrawn 3-insert the catheter until the cough reflex is stimulated 4-remove the inner cannula before inserting the suction catheter

2

Which nursing intervention is most appropriate for a client with a skeletal traction? 1-add and remove weights as the client desires 2-assess the pin site at least every shift and as needed 3-ensure that the knots in the rope catch on the pulley 4-perform range of motion to joints proximal and distal to the fracture at least once a day

2

Which of the following would be an inappropriate use of a restraint device? 1-preventing a confused client from pulling out an IV 2-preventing an older adult client from getting up at night due to a nursing staff shortage 3-maintaining immobilization of a clients leg to prevent dislodging a skin graft 4-preventing an older client from falling out of bed after a surgical procedure

2

While undergoing a soapsuds enema, the client complains of abdominal cramping. What is the best action for the nurse to take? 1- Immediately stop the infusion 2-Lower the height of the enema bag 3-Advance the enema tubing 2 to 3 inches 4-Clamp the tube for 2 minutes then restart the infusion

2

Which of the following is indicated when a nurse performs a neurovascular assessment? (select all that apply) 1-orientation 2-capillary refill 3-pupillary response 4-respiratory rate 5-pulse and skin temperature 6-movement and sensation

2,5,6

A 45 year old male client with a diagnosis of uncontrolled diabetes has been on the nursing unit for 5 days. Two days ago he was started on a diuretic. The clients morning potassium level is 2.8 mEq/L. What is the most appropriate action for the nurse to take? 1-hold the morning dose of the diuretic and have the lab repeat the test 2-do noting different because the potassium is within normal limits 3-notify the physician with the results because the potassium is below the normal range 4-notify the physician with the results because the potassium is above the normal range

3

A 62 year old female client being prepared for discharge is ordered to go home with a walker. The nurse has instructed the client regarding proper use of this assistive device. Which outcome is evidence that the instructions provided by the nurse were effective? 1-the client picks up the walker and carries it for short distances 2-the client uses the walker only when someone is present 3-the client moves the walker no more than 12 inches in front of her during use 4-the client states she will buy a walker on the way home from the hospital

3

A bite from a large dog would cause which type of injury? 1-abrasion 2-fracture 3-crush injury 4-incisional laceration

3

A client arrives at the health care providers office complaining of severable palpable elevated masses on his arms. Which term would most accurately describe these masses? 1-erosion 2-macule 3-papule 4-vesicle

3

A client diagnosed with AIDS. The nurse recognizes that an opportunistic infection is present when the oral cavity is examined and white plaques are discovered on the mucosa. What does this finding most likely represent? 1-cytonegalovirus 2-histoplasmosis 3-candidia albicans 4-human papillomavirus

3

A client had a liver biopsy performed. The nursing action of the highest priority to prevent post procedure hemorrhage would be to place the client? 1-supine and flat in bed 2-in a sitting position 3-on the right side 4-on the left side

3

A client is on a low carbohydrate diet in which there is decreased glucose available for energy. With this type of diet, fat is metabolized for energy and results in an increased production of which substance in the urine? 1-protein 2-glucose 3-ketones 4-uric acid

3

A client is ordered to receive morphine vis patient controlled analgesia (PCA). Before beginning administration of this medication, what should the nurse assess first? 1-temperature 2-neurological status 3-respirations 4-urinary output

3

A client is to receive a transfusion of packed red blood cells (PRBCs). The nurse should prepare for the transfusion by priming the blood IV tubing with which solution? 1- ringers lactate 2- 5% dextrose and water 3- 0.9% normal saline 4- 0.45% normal saline

3

A nurse assesses for hypocalcemia in a postoperative client. One of the initial signs that might be present is? 1-headache 2-pallor 3-paraesthesias 4-blurred vision

3

A nurse assisting in a research study calculates the risk benefit ratio and concludes that there were no harmful effects associated with a survey of diabetic clients. This researcher was applying which principle? 1-human dignity 2-human rights 3-beneficence 4-utilitarianism

3

A nurse has admitted to the labor and delivery unit a client who is 34 weeks gestation. After discovering that the client has been using heroin, what is the most appropriate action for the nurse? 1-notify the nurse manager of the unit 2-inform no one because the client information is confidential 3-inform the physician who will deliver the infant 4-alert the hospital security department because heroin is an illegal substance

3

A nurse is assessing a client with a pressure ulcer and finds it to be full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. These data would most describe which stage of pressure ulcer? 1-stage 1 2-stage 2 3-stage 3 4-stage 4

3

A nurse is caring for a postoperative client who has a nasogastric tube set to low intermittent suction. An IV of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium is ordered to primarily prevent which condition? 1-constipation 2-dehydration 3-electrolyte imbalance 4-nausea and vomiting

3

A nurse receives abnormal results of diagnostic testing. What is the nurses ethical and legal accountability? 1-inform the client of the results 2-ensure that the results are placed in the clients medical record 3-notify the clients physician with the results 4-obtain normal values of the results from the lab

3

A nurse speaking in support of the best interest of a vulnerable client reflects the nurse's duty of: 1-Caring. 2-Veracity. 3-Advocacy. 4-Confidentiality

3

If a hospital threatens to retain a newborn until the parents pay part of their bill, which legal term best describes the situation? 1-false threats 2-assault and battery 3-false imprisonment 4-breach of confidentiality

3

The nurse instructing an adolescent client states that in addition to building bones and teeth, calcium is also important for? 1-bile production 2-blood production 3-blood clotting 4-digestion of fats

3

The nurse is assessing a 56 year old male client who presents to the clinic for a routine physical and receives instruction about the need to obtain a stool sample specimen for occult blood testing (guaiac test). The primary reason for this test is due to? 1-the clients age and gender 2-a family history of polyps 3-a routine examination for colon cancer 4-a positive finding after a digital rectal examination

3

The nurse receives a report on a newly admitted client who is positive for C. Diff. Which category of isolation would the nurse implement for this patient? 1-Airborne precaution 2-Droplet precaution 3-Contact precaution 4-Protective environment

3

The nurse should instruct a client with an ileal conduit to empty the collection device frequently because it may? 1-force urine to back up into the kidneys 2-suppress production of urine 3-cause the device to pull away from the skin 4-tear the ileal conduit

3

The physician has declared a client to be "brain dead". The nurse understands that this means that the client has? 1-no reflexes and no breathing 2-slow reflexes and shallow breathing 3-no cortical functioning with some reflex breathing 4-deep tendon reflexes only with no independent breathing

3

What would be the best nursing intervention to prevent foot drop in a leg with a cast? 1-encourage complete bed rest 2-support the foot with 45 degrees of flexion 3-support the foot with 90 degrees of flexion 4-place an elastic stocking on the foot to provide support

3

When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as: 1- Evidence 2-Tort discovery 3-Proximate cause 4-Common cause

3

A camp counselor takes an 8 year old child to see the nurse after playing near what is believed to be poison ivy. On assessment the child has vesicles on the arms and legs. Which of the following best describes the findings? 1-a lesion filled with purulent drainage 2-an erosion into the dermis 3-a solid mass of fibrous tissue 4-a lesion filled with serous drainage

4

A client has a nursing diagnosis of rick for infection. What would be the most desirable expected outcome for this client? 1-all nursing suctions will be completed by discharge 2-all invasive intravenous lines will remain patent 3-the client will remain awake, alert, and oriented at all times 4-the client will be free of signs and symptoms of infection by discharge

4

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. Which type of room should this client be assigned to by the nurse? 1-private room 2-semiprivate room 3-room with windows that can open 4-negative airflow room

4

A client passes black tarry stools. The nurse recognizes that this may be an indication of? 1-hemorrhoids, internal and external 2-an overproduction of bile 3-lower gastrointestinal bleeding 4-upper gastrointestinal bleeding

4

A client refuses to follow the physicians orders and leaves the hospital against medical advice. What risk is the client assuming? 1-acting irresponsibly 2-violating the physicians orders 3-contributing to negligence 4-assuming the risk for his health state

4

A client who had a cardiac cauterization through the femoral artery is found to have a large amount of blood under his buttocks. After donning gloves, which action should the nurse take first? 1-apply pressure to the site 2-obtain vital signs 3-change the clients gown and bed linens 4-assess the catherization site

4

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by which of the following actions? 1-promotes analgesics and circulation 2-numbs the nerves and dilates the blood vessels 3-promotes circulation and reduction of muscle spasms 4-causes local vasoconstriction, prevents edema and muscle spasms

4

A nurse informs her client that he should give someone the authority to make medical decisions for him in the event that he is unable to do so. What is the specific document that allows for this? 1-advance directive 2-veracity 3-client rights proxy 4-durable power of attorney for healthcare

4

A surgical client develops a would infection during hospitalization. How is this type of infection classified? 1-primary 2-secondary 3-superinfection 4-nosocomial

4

The nurse assesses a. client with dry, brittle hair, flaky skin, a beefy red tongue and bleeding gums. The nurse should recognize that these clinical manifestations are most likely a result of? 1-a food allergy 2-noncompliance with medications 3-side effects from medications 4-a nutritional deficiency

4

The nurse understands that dietary teaching for a client with a colostomy should be based on the knowledge that? 1-liquids should be limited to 1 L per day 2-nondigestible fiber and fruits should be eliminated 3-a formed stool will result from a constipating diet 4-the diet should include foods that result in manageable stools

4

The physician orders tap water enemas until clear. The nurse should give no more than two enemas to prevent the occurrence of which condition? 1-hypercalcemia 2-hypocalcemia 3-hyperkalemia 5-hypokalemia

4

Which action by a home care nurse would be considered an act of euthanasia? 1-implementing a "do not resuscitate" order in the home health setting 2-abiding by the decision of a living will signed by the clients family 3-encouraging a client to consult an attorney to document and assign a power of attorney 4-knowing that a dying client is overmedicating and not acting on this information

4

Which assessment finding for a client who is receiving therapy for vitamin B12 deficiency should indicate to the nurse that the therapy is having the desired effect? 1-normal serum electrolyte levels 2-healthy skin integrity 3-resolution of peripheral edema 4-improved hemoglobin and hematocrit levels

4

Which of the following legal defenses is the most important for a nurse to develop? 1-dedication 2-certification 3-assertiveness 4-accountability

4

Which of the following nursing diagnosis is correct for a nonambulatory client with a reddened sacrum that is unrelieved by repositioning? 1-risk for pressure ulcer 2-risk for impaired skin integrity 3-impaired skin integrity, related to infrequent turning and repositioning 4-impaired skin integrity, related to the effects of pressure and shearing force

4

While performing a physical assessment on an immobilized client, the nurse notes that a client has shortened muscles over a joint, preventing full extension. What is this condition known as? 1-osteoarthritis 2-osteoporosis 3-muscle atrophy 4-contracture

4

A client has returned from surgery with a tracheostomy tube in place. After 10 minutes in postoperative recovery, the client begins to have noisy, increased respirations and an elevated heart rate. Which action should the nurse take immediately? 1-suction the tracheostomy 2-change the tracheostomy tube 3-readjust the tracheostomy tube and tighten the ties 4-perform a complete respiratory assessment

1

A client is determined to be having impending anaphylactic reaction secondary to a drug hypersensitivity. What should be the first action for the nurse to perform? 1-administer oxygen 2-insert an IV catheter 3-take the vital signs 4-obtain an arterial blood gas analysis

1

A client who experienced extensive burns is receiving IV fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload? 1-crackles in the lungs 2-decreased heart rate 3-increased blood pressure 4-decreased blood pressure

1

A client with limited mobility is ready for discharge. Which instruction should the nurse emphasize with the client to event urinary stasis and formation of renal calculi? 1-increase oral fluid intake to 2-3 L per day 2-maintain bedrest after discharge 3-limit fluid intake to 1 L per day 4-void at least every hour

1

Which activity would be the best for the nurse to take in preventing septic shock in the hospitalized client? 1-maintaining the client in a normothermic state 2-administering blood products to replace fluid losses 3-using aseptic technique during all invasive procedures 4-keeping the critically ill client immobilized to reduce metabolic demands

3

Which instruction should be included when teaching a client about back safety? 1-sleep on your side and carry object at arms length 2-sleep on your back and carry objects at arms length 3-sleep on your side and carry objects close to your body -sleep on tour back and carry objects close to your body

3

Which physical assessment finding is most indicative of a systemic infection? 1-white blood cell (WBC) count of 8200/mm 2-bilateral 3+ pitting pedal edema 3-oral temperature 0f 101.3 4-pale skin and nailed color

3

While the nurse moves a client from a lying to standing position, the client experiences a rapid drop in blood pressure. The nurse would report this finding as: 1-malignant hypotension 2-orthostatic dehydration 3-orthostatic hypotension 4-vasomotor instability

3

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as? 1-vesicular 2-bronchial 3-crackles 4-rhonchi

3

A nurse is instructing a community group regarding risk factors for coronary artery disease. Which risk factor should the nurse emphasize as not modifiable? 1-heredity 2-hypertension 3-cigarette smoking 4-diabetes mellitus

1

A nurse should employ which technique to maintain surgical asepsis? 1-change the sterile field after sterile water spilled on it 2-put on sterile gloves then open a container of sterile saline 3-place a sterile dressing no more than 1/2 inch from the edge of the sterile field 4-clean the surgical area with a circular motion, moving from the outer edge toward the center

1

A nurse understands that the primary purpose for a client to undergo reconstructive surgery is too? 1-restore function and/or appearance 2-replace an organ or tissue 3-relieve or redce symptoms 4-remove or exercise an organ or tissue

1

A physician has inserted a central venous catheter (CVC) in a client. What would the nurse anticipate being required for the client before using the catheter? 1-chest x-ray 2-flushing the line with heparin flush 3-withdrawing blood to ensure latency 4-chest fluoroscopy

1

In assessing fluid and electrolyte status, the nurse recognized that the regulator of extracellular osmolarity is? 1-sodium 2-potassium 3-chloride 4-calcium

1

When performing a postoperative assessment, which parameter would alert the nurse to common side effect of epidural anesthesia? 1-decreased blood pressure 2-increased oral temperature 3-diminished peripheral pulses 4-unequal bilateral breath sounds

1

A client is receiving total parental nutrition (TPN) through a subclavian triple lumen catheter. Upon evaluation, the nurse discovers that the TPN bag is empty and the next bag has not been received from the pharmacy. What is the most appropriate action for the nurse to take? 1-perform a fingerstick glucose test and call the physician with the results 2-hang a bag of 10% dextrose at the ordered TPN rate and call the pharmacy to expedite the order 3-discontinuing the infusion and flush the IV line with saline solution until the next TPN bag is ready 4-hang a bag of 5% dextrose at a keep open rate until the next TPN bag is ready

2

A nurse auscultates a murmur at the 2nd left intercostal space (ICS) along the sternal border. This reflects sound from which valve? 1-aortic 2-mitral 3-pulmonic 4-tricuspid

3

A nurse assesses the vital signs of a 50 year old female client and documents the results. Which of the following are considered within normal range for the client? (select all that apply) 1-oral temperature of 98.2 2-apical pulse 88 beats per minute and regular 3-respiratory rate of 30 per minute 4-blood pressure 116/78 mmHg while in a sitting position 5-oxygen saturation of 92%

1,2,4

A client is ordered to receive an IV infusion of potassium chloride (KCI) 40 mEq in 100mL of 5% dextrose and water to be infused over 2 hours. Before administering this IV medication it is priority for the nurse to asses which of the following? (select all that apply) 1-urinary output 2-deep tendon reflexs 3-last bowel movement 4-arterial blood gas results 5-last serum potassium level 6-patency of the intravenous access

1,5,6

A 58 year old adult client presents to the emergency department with a nosebleed. After applying pressure, what is the next nursing action? 1-collect a medication history 2-check the blood pressure 3-instruct not to pick the nose 4-check the pulse

2

A 62 year old male client is being discharged home from the hospital. During his stay, he acquired a nosocomial infection C. Diff. In preparing a teaching plan for the client and caretaker, which priority point would the nurse include? 1-report an constipation to your physical immediately 2-this infection causes diarrhea accompanied by flatus and abdominal pain 3-the client should consume a diet high in fiber and low in fat 4-no special cleaning or disinfection will be required in the home

2

A client has been admitted with a diagnosis of intractable vomiting and has only been able to tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L and a potassium level of 3.6 mEq/L. Based on the lab results and symptoms, what is the client experiencing? 1-hypernatremia 2-hyponatremia 3-hyperkalemia 4-hypokalemia

2

A client with a history of severe diarrhea for the past 3 days is admitted for dehydration. Which intravenous solution would the nurse anticipate the healthcare provider to order initially for this client? 1- 3% sodium chloride 2- 0.9% sodium chloride 3- 5% dextrose and 0.9% sodium chloride 4- 5% dextrose and lactated ringers

2

A nurse is caring for a client with pneumonia. Which of the following interventions is the highest priority? 1-increase fluid intake 2-employ breathing exercises and controlled coughing 3-ambulate as much as possible 4-maintain an NPO status

2

A nurse is performing preoperative teaching for a client and gives instruction regarding use of an incentive spirometer. Which procedure for using this device is correct? 1-inhale completely and exhale in short, rapid breaths 2-inhale deeply through the spirometer, hold it as long as possible and slowly exhale 3-exhale completely, take a slow, deep breath, hold it as long as possible and slowly exhale 4-exhale halfway, then inhale a rapid small breath, repeat several times

2

A nurse is providing preoperative teaching for a client who is scheduled for a cholecystectomy. Which postoperative routine should the nurse emphasize as initially the most important? 1-early ambulation 2-coughing and deep breathing 3-wearing antiembolic elastic stockings 4-maintenance of a nasogastric tube

2

A nurse teaches a client to apply anti embolism elastic stockings. What is the correct technique? 1-apply at bedtime and remove before getting out of bed in the morning 2-apply in the morning before legs are lowered from the bed to the floor 3-roll down thigh high stockings to the knees if the client is immobile 4-apply in the morning or at bedtime only after the legs are lowered to the floor

2

A nurse witnesses a client climbing over the side rails and falling out of bed to the floor. Restraints had been ordered for the client but were not in place. When the nurse completes the incident report, what information should the nurse include? 1-the fact that the nursing staff was not at fault because the client initiated the accident 2-the facts of the incident witnessed by the nurse as it occurred 3-the name of the nurse who was responsible for monitoring the restraints 4-the reason why the ordered restraints were not on the client

2

A nurses assess a client and determines that he has a closed soft tissue injury. Which term might the nurse use ton describe the injury? 1-an abrasion 2-a contusion 3-a laceration 4-an avulsion

2

A physician plans to remove a chest tube on a client. The nurse would anticipate which intervention before removal? 1-assist the physician to disconnect the drainage system from the chest tube 2-ensure the results of the chest x-ray are available, revealing lung re-expansion 3-obtain an arterial blood gas to document oxygenation status 4-sedate the client before the physician removes the chest tube

2

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)? 1-pregnancy 2-inactivity 3-aerobic exercise 4-tight clothing

2

The nurse understands that the action of antidiuretic hormone (ADH) is too? 1-reduce water volume 2-decrease water loss in urine 3-increase urine output 4-initiate the thirst mechanism

2

Upon auscultation, the nurse hears abnormal breath sounds that are high pitched, creaking and accentuated on expiration. Which term best describes this data? 1-rhonchi 2-wheezes 3-pleural friction rub 4-bronchovesicular

2

Which landmark is correct for a nurse to use when auscultating the mitral valve? 1-left 5th intercostal space, midaxillary line 2-left 5th intercostal space, midclavicular line 3-left 2nd intercostal space, sternal border 4-left 5th intercostal space, sternal border

2

A nurse fails to act in a reasonable, prudent manner. Which legal principle is most likely to be applied? 1-malice 2-tort law 3-malpractice 4-case law

3

A client on a mechanical ventilator is receiving positive end-expiratory pressure (PEEP). The nurse understands that this treatment improves oxygenation primarily by: 1-Providing more oxygen to lung tissue. 2-Adding pressure to lung tissue, which improves gas exchange. 3-Opening collapsed alveoli and maintaining them open. 4-Opening collapsed bronchioles, which allows more oxygen to reach lung tissue.

3

A clients chest tube has accidentally dislodged. What is the nursing action of highest priority? 1-lay the client down on the left side 2-lay the client down on the right side 3-apply the petroleum gauze dressing over the site 4-prepare to reinsert a new chest tube

3

A client who is HIV positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions knowing that HIV is high transmitted through? (select all that apply) 1-feces 2-blood 3-semen 4-urine 5-sweat 6-tears

2,3

A high protein diet is recommended for a client recovering from a fracture. What is the rationale for a high protein diet? 1-promotes gluconeogenesis 2-has an anti-inflammatory effect 3-promotes cell growth and bone union 4-decreases pain medication requirements

3

A client is receiving fresh frozen plasma (FFP). The nurse would expect to see improvement in which condition? 1-thrombocytopenia 2-oxygen deficiency 3-clotting factor deficiency 4-low hemoglobin

3

A client is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy. The nurse would anticipate the physician to order a prep with antibiotics before surgery primarily to? 1-decrease peristalsis 2-minimize electrolyte imbalance 3-decrease bacteria in the intestines 4-treat inflammation caused by malignancy

3

A nurse is assessing drainage on a surgical dressing. Which item of documentation is most informative regarding the findings? 1-moderate amount of drainage 2-no change in drainage since yesterday 3-a 10mm diameter area of drainage at 1900 hours 4-drainage is doubled in size since last dressing change

3

A nurse is measuring a clients vital signs and uses a pulse oximeter to obtain which of the following types of information? 1-respiratory rate 2-amount of oxygen in the blood 3-percentage of hemoglobin carrying oxygen 4-amount of carbon dioxide in the blood

3

A nurse should place the client in which position to obtain the most accurate reading of jugular vein distention? 1-upright at 90 degrees 2-supine position 3-raised to 30 degrees 4-raised to 10 degrees

3

A nurse working in the emergency department is assessing a 79 year old client who arrived via ambulance. Which of the following is found during assessment, is considered an early sign of dehydration? 1-sunken eyes 2-dry, flaky skin 3-change in mental status 4-decreased bowel sounds

3

Before endotracheal suctioning of a client, the nurse should perform which intervention? 1-have the client take several deep breaths 2-instruct the client to cough before suctioning 3-administer 100% oxygen to the client 4-change the suctioning equipment to ensure sterility

3

In the immediate postoperative period which action is most important for a nurse to include in a clients plan of care to prevent thrombophlebitis? 1-increase fluid intake 2-restrict fluids 3-encourage early mobility 4-elevate the knee gatch of the bed

3

Percussion may be performed on clients with respiratory problems. The primary purpose of this procedure is too? 1-relieve bronchial spasm 2-increase depth of respirations 3-loosen pulmonary secretions 4-expel carbon dioxide from the lungs

3

The amount of hemoglobin in the blood has what effect on oxygenation status? 1-the effect is none to little 2-more hemoglobin reduces respiratory rate 3-low hemoglobin levels cause reduced oxygen carrying capacity 4-low hemoglobin levels cause increased oxygen carrying capacity

3

The nurse would assess a client 24-48 hours postoperatively for which problem as a result of anesthetic agents? 1-colitis 2-stomatitis 3-paralytic ileus 4-gastrocolic reflux

3

A nurse instructs a client to breathe deeply to open collapsed alveoli. Which statement should the nurse offer the client to best explain how this procedure improves oxygenation? 1-the alveoli need oxygen to live 2-the alveoli have no direct effect on oxygenation 3-collapsed alveoli increase oxygen demands 4-oxygen is exchanged for carbon dioxide in the alveolar membrane

4

What are the best ways for a nurse to be protected legally (select all that apply) 1-follow hospital policy and procedure whenever possible 2-establish a therapeutic relationship with all the clients and families 3-provide care within the parameters of the states nurse practice act 4-carry at least $100,000 worth of liability insurance 5-document consistently and objectively 6-clearly document a clients nonadherence to the medical regimen

3,5,6

A nurse preparing to apply restraints to a client should understand which of the following principles? 1-the law prohibits restraining clients until a written order is obtained 2-charges of felony may be levied against the nurse who use restraints improperly 3-nurses are nor obligated to report Institutions that use restraints unlawfully 4-charges of assault and battery may be leveled against nurses who use restraints improperly

4

The circulating nurse in the operating room positions a client for surgery. Which of the following is incorrect regarding proper positioning during surgery? 1-proper positioning provides optimum exposure to the surgical site 2-proper positioning intraoperatively maintains body alignment and protects bony prominences 3-the clients position during surgery allows for airway maintenance and access for medication administration 4-the clients position for the surgical procedure is determined solely by the circulating nurse

4

When providing preoperative teaching for a client having surgery, the nurse should focus primarily on which area? 1-helping the client decide if surgery is necessary 2-providing emotional support to the client and family 3-giving minute by minute details of the surgery to the client and family 4-providing general information to reduce client and family anxiety

4

Which factor has the greatest influence on diastolic blood pressure? 1-renal function 2-cardiac output 3-oxygen saturation 4-peripheral vascular resistance

4

Which food should the client with a colostomy be advised most? 1-milk 2-cheese 3-coffee 4-cabbage

4