NCLEX

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? a. Numbness of the extremities b. Bradycardia c. Positive Chvostek's sign d. Abdominal cramping

d

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? A. Turn the client every 2 hr. B. Administer an antiemetic every 6 hr. C. Hold oral care. D. Increase the room's temperature.

B

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? A. Alginate B. Gauze C. Transparent D. Hydrocolloid

D

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? A. BUN 15 mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mEq/L D. Potassium 5.4 mEq/L

D

Identify the sequence in which the nurse should perform post mortem care -wash client's body -obtain pronouncement of death from provider -place name tag on body -ask client's family if they would like to view the body -remove tubes and indwelling lines

The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, "Every time you change my bandage, it hurts so much." which of the following interventions is the nurse's priority action? a. encourage the client to relax and take deep breaths during the dressing change.b. educate the client about the importance of the dressing change to prevent infectionc. assist the client to a comfortable position for the dressing change.d. administer pain medication 45 min before changing the client's dressing

d

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? A. Check the client for injuries. B. Move hazardous objects away from the client. C. Notify the provider. D. Ask the client to describe how she felt prior to the fall.

A

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? A. Contact B. Droplet C. Airborne D. Protective

B

A nurse is reviewing EBP principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. B. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. C. Make sure the reservoir bag of a partial rebreathing mask remains deflated. D. Use petroleum jelly to lubricate the client's nares, face, and lips.

B

A nurse is admitting a new client. which of the following actions should the nurse take while performing medication reconciliation? A. verify the client's name on his ID bracelet with the MAR B. call the pharmacy to determine if the client's medications are available C. compare the client's home medications with the provider's prescriptions D. place the client's home medication bottles in a secure location

C

A nurse is caring for a client who is postop and exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure vitals q 15 mins and report back in 1 h. Which of the following actions should the nurse take next? A. Document the provider's statement in the medical record. B. Complete an incident report. C. Consult the facility's risk manager. D. Notify the nursing manager.

D

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? a. During the admission process b. As soon as the client's condition is stable c. During the initial team conference d. After consulting with the client's family

a

A nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an AP? SATA a. Assist the client with a partial bed bath. b. Measure the client's BP after the nurse administers an antihypertensive medication. c. Test the client's swallowing ability by providing thickened liquids. d. Use a communication board to ask what the client wants for lunch. eIrrigate the client's indwelling urinary catheter.

a, b, d

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? a. Insert the needle at a 15° angle. b. Aspirate for blood return prior to administration. c. Administer the medication into the abdomen. d. Massage the site following the injection.

c

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? A. Place the client in a side-lying position. B. Instill 15 mL of irrigation fluid into the catheter with each flush. C. Subtract the amount of irrigant used from the client's urine output. D. Perform the irrigation using a 20-mL syringe.

C

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? a) use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain b) ensure the bladder of the blood pressure cuff surrounds 80% of the clients arm c) obtain an apical heart rate by auscultating at the third intercostal space left of the sternum d) palpate the clients abdomen before auscultating bowel sounds

b

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses would the nurse make? a. "We would consult the person appointed by your health care proxy to make decisions." b. "We would give you oxygen through a tube in your nose." c. "You would be unable to change your previous wishes about your care." d. "We would insert a breathing tube while we evaluate your condition."

b

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? SATA a. lacrimal apparatus b. pupil clarity c. appearance of bulbar conjunctivae d. visual fields e. visual activity

b, d, e

A nurse if performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? a. A lesion with uniform pigmentation b. New appearance of petechiae c. A mole with an asymmetrical appearance d. The presence of a papule

c

A nurse is assessing a client who has required bedrest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? a. Bladder distention b. Decreased blood pressure c. Calf swelling d. Diminished bowel sounds

c

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting NG tube? a. Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube. b. Remove the NG tube if the client begins to gag or choke. c. Apply suction to the NG tube prior to insertion. d. Have the client take sips of water to promote insertion of the NG tube into the esophagus.

d