NCLEX EXAM mock

The clinic nurse is discussing nutrition with a pregnant client who has lactose intolerance. Which food should the nurse instruct the client to eat to supplement the dietary source of calcium?

Broccoli

During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action?

Call the health care provider (HCP)

A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted?

Capillary refill is less than 2 seconds

When assessing a client for a possible physical dependency on alcohol, the nurse should ask which priority question?

How do you feel when you haven't had a drink all day?"

The nurse is caring for a client with an exacerbation of multiple sclerosis. Which medication(s) will the nurse expect to be prescribed to hasten recovery from the exacerbation?

Methylprednisolone and cyclophosphamide intravenously

A client has an "as needed" (PRN) prescription for trimethobenzamide. The nurse should assess the client for which sign or symptom to determine whether the client needs a dose of this medication?

Nausea and vomiting

The nurse has provided instructions to a pregnant client who is preparing to take iron supplements. The nurse determines that the client understands the instructions if she states that she will take the supplements with which item?

Orange juice

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. Which complication should the nurse immediately assess the client for?

Pulmonary embolism

A client has just been admitted to the hospital with a fractured femur and pelvic fractures. The nurse should plan to carefully monitor the client for which signs/symptoms?

Tachycardia and hypotension

The nurse is caring for a client diagnosed with bacterial meningitis. Which clinical manifestation should the nurse monitor for, indicating increased intracranial pressure?

altered mental status

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication?

hyperglycaemia

A client has been prescribed pindolol for hypertension. The nurse provides anticipatory guidance, knowing that which common side effect of this medication may decrease client compliance?

impotence

The nurse provides an educational session on client rights. Which statement by a member of the session demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected?

"Being respectful and concerned will ensure that I'm attentive to my clients' rights.

The student nurse is working with a registered nurse (RN) in the clinic. The RN is educating the student nurse on dysfunction in the area of the semicircular canals of the ear. Which statement by the student nurse indicates that the teaching has been effective?

"Disturbance in balance occurs.

During a nursing interview, a client says, "My daughter was murdered. I can't help wondering if her husband killed her, but he's been eliminated as a suspect." Which statement is a therapeutic nursing response?

"Have you shared your concerns with the police?"

A client with renal cancer is being treated preoperatively with radiation therapy. What statement by the client demonstrates understanding of proper care of the skin over the treatment field?

"I need to avoid skin exposure to direct sunlight and chlorinated water.

A client is prescribed nicotinic acid for hyperlipidemia and the nurse provides instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions?

"Ibuprofen IB taken 30 minutes before the nicotinic acid should decrease the flushing."

The nurse is preparing to administer an injection of vitamin K to a newborn and provides the mother with information about the injection. Which information should the nurse provide?

"The injection is extremely important to prevent bleeding in your baby."

The nurse provides instructions to a malnourished client regarding iron supplementation during pregnancy. Which statement, if made by the client, indicates an understanding of the instructions?

"The iron is best absorbed if taken on an empty stomach."

The nurse in the health care provider's office is reviewing the results of a client's phenytoin level determination performed that morning. The nurse identifies that a therapeutic medication level has been achieved if which result is noted?

15 mcg/mL (59.52 mmol/L)

The nurse has a prescription to administer whole blood to a client who does not currently have an intravenous (IV) line inserted. When obtaining supplies to start the blood infusion, the nurse should select an angiocatheter of at least which size?

19 gauge

The nurse is conducting home visits with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional?

A neuropsychologist

A nursing student is assisting a school nurse in performing scoliosis screening on the children in the school. The nurse assesses the student's preparation for conducting the screening. The nurse determines that the student demonstrates understanding of the disorder when the student states that scoliosis is characterized by which finding?

Abnormal lateral curvature of the spin

Which behavior would the nurse anticipate a client diagnosed with nyctophobia to demonstrate?

Always turns on the overhead light before entering a darkened room

The nurse is providing a health promotion session to a group of teenagers and is discussing the abuse of barbiturates. The nurse should provide which information to the teenagers?

Barbiturate abuse is the cause of many drug overdose deaths.

The nurse is monitoring a client with herpes simplex virus (HSV) who is receiving intravenous (IV) acyclovir. Which laboratory result would be of concern as a possible adverse effect of this medication?

Blood urea nitrogen (BUN) of 36 mg/dL (12.9 mmol/L)

The nurse is caring for a client with pancreatitis. Which finding should the nurse expect to note when reviewing the client's laboratory results?

Elevated level of amylase

The nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit?

Client with diabetes insipidus

The nurse is performing a measurement of fundal height in a client whose pregnancy has reached 36 weeks of gestation. During the measurement the client begins to feel lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the nurse understands that which is the cause of the lightheadedness?

Compression of the vena cava

The nurse is caring for a client after pulmonary angiography with catheter insertion via the left groin. Which assessment finding is related to an allergic reaction to the contrast medium?

Decreased blood pressure

The nurse is preparing an infant for surgery to treat Hirschsprung's disease. Which assessment finding is priority to identify and treat?

Decreased blood pressure and tachycardia

The nurse is assisting the health care provider (HCP) with insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse should take which action?

Document the accurate functioning of the tube.

A client with an external arteriovenous shunt in place for hemodialysis is at risk for bleeding. Which is the priority nursing intervention?

Ensure that small clamps are attached to the arteriovenous shunt dressing.

In the prenatal clinic, the nurse is interviewing a new client and obtaining health history information. Which action should the nurse plan to elicit the most accurate responses to the questions that refer to sexually transmitted infections?

Establish a therapeutic relationship.

The nurse performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome?

Generalized edema

A home care nurse provides medication instructions to a client. What is the appropriate nursing action to ensure safe administration of medication in the home?

Have the client verbalize and demonstrate the correct administration procedures.

The nurse is reviewing the laboratory test results for a client and notes that the serum sodium level is 150 mEq/L (150 mmol/L). The nurse understands that this value would be noted in which conditions?

Heart failure

A nurse has provided dietary instructions to a client with Addison's disease. Which statement made by the client indicates that the client understands instructions?

I will maintain a normal sodium intake in my diet."

Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? Refer to the figure (circled area) to determine the condition.

Patent ductus arteriosus

Which medication, if present in the client's history, indicates a need for teaching related to the woman's potential risk for carrying a fetus with a congenital cleft lip or cleft palate?

Phenytoin

The nurse is caring for a client who has just returned from having a right-sided renal biopsy. Which action by the unlicensed assistive personnel (UAP) requires immediate follow-up by the nurse?

Positioning the client on the left side

he nurse has just obtained a unit of blood from the blood bank to transfuse into a client as prescribed. Before preparing the blood for transfusion, the nurse looks for which member of the health care team to assist in checking the unit of blood?

RN

A client with preeclampsia is receiving magnesium sulfate. The nurse should assess the client closely for which sign of magnesium toxicity?

RR 10 breaths per min

A home health nurse is visiting a client who has been started on therapy with clotrimazole. The nurse determines the effectiveness of the medication by noting a decrease in which problem?

Rash

A client is diagnosed with external otitis. Which finding would the nurse expect to note on assessment of the client?

Redness and swelling in the ear canal

The industrial nurse is providing instructions to a group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees that which is the first consideration in immediate care?

Removing all clothing, including gloves, shoes, and any undergarments

The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position?

Side-lying

A client newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. A nurse prepares a discharge teaching plan regarding the insulin and plans to reinforce which concept?

Systematically rotate insulin injections within 1 anatomical site.

An emergency department nurse is caring for a conscious child who was brought to the emergency department after the ingestion of half a bottle of acetylsalicylic acid (aspirin). The nurse anticipates that which will be the initial treatment?

The administration of an emetic

The nurse is preparing to teach a client how to safely use crutches. Before initiating the teaching, the nurse performs an assessment on the client. The priority nursing assessment should include which information?

The client's vital signs, muscle strength, and previous activity level

Thyroid replacement therapy is prescribed for the client diagnosed with hypothyroidism. The client asks the nurse when the medication will no longer be needed. Which is the appropriate nursing response?

The medication will need to be continued for life.

The nurse is providing discharge instructions to the mother of a child who has been prescribed tetracycline hydrochloride. The nurse stresses to the mother the importance of which measure in giving this medication to the child?

Use a straw when giving the medication

Levofloxacin is prescribed for a client. While teaching the client about the medication, what should the nurse tell the client to take the medication with?

Water

A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication?

White blood cell count, 3000 mm3 (3.0 × 109/L)

To promote optimal cerebral tissue perfusion in the postoperative phase following cranial surgery, the nurse should place the client with an incision in the anterior or middle fossa, in which position?

With the head of the bed elevated at least 30 degrees

The ambulatory care nurse is providing instructions to a client who is scheduled for a colonoscopy to remove a polyp. Which instructions are appropriate for client preparation for this procedure?

A bowel preparation will be needed in preparation for the procedure.

The nurse is planning care for a client who has a history of violent behavior and is at risk for harming others. Which intervention presents a need for follow-up because it could potentially present a danger to the client, health care providers, and others on the nursing unit?

Assigning the client to a room at the end of the hall

A nursing student caring for a 6-month-old infant is asked to collect a sample for urinalysis from the infant. How should the student collect the specimen?

Attaching a urinary collection device to the infant's perineum for collection

The nurse is caring for a client who underwent an open reduction internal fixation to the right hip. When administering opioid analgesics for pain, the nurse should instruct the client that which are side and adverse effects of opioid analgesics?

Constipation, respiratory depression , sedation

The nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action?

Document the findings and continue to monitor fetal patterns.

The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27 mEq/L (27 mmol/L). The nurse interprets that the client has which acid-base disturbance?

Respiratory acidosis

The postpartum nurse is caring for a woman who just delivered a healthy newborn. The nurse should be most concerned about the presence of subinvolution if which occurs?

Retained placental fragments from delivery

The nurse has developed a plan of care for a client in traction and documents a problem of inability to perform self-care independently. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome?

The client assists in self-care as much as possible.

The nurse is evaluating the plan of care for a client with peptic ulcer disease (PUD) who is experiencing acute pain. The nurse determines that the expected outcomes have been met if the nursing assessment reveals which result?

The client has eliminated any irritating foods from the diet.

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client has made several sarcastic remarks and has an angry affect. Which is the most appropriate interpretation of the client's behavior?

The client is displaying typical behaviors

The nurse is preparing to provide preoperative teaching to a Spanish-speaking client and the client's family. Which nursing action would be most effective for teaching the client?

The nurse secures the assistance of a professional interpreter to communicate with the client

The nurse developing a teaching plan for a client being prescribed phenelzine sulfate should instruct the client to avoid which item?

aged cheeses

The nurse is assessing a newborn with heart failure before administering the prescribed digoxin. In reviewing the laboratory data, the nurse notes that the newborn has a digoxin blood level of 1.6 ng/mL (2.05 mmol/L) and an apical heart rate of 90 beats/min. The mother also tells the nurse that the newborn just vomited her formula. Which intervention should the nurse take?

Withhold the medication and notify the health care provider.

A client who is in the postanesthesia care unit (PACU) has received a dose of ondansetron. The nurse evaluates that an adverse effect is occurring if which problem arises?

headache

The nurse has been assigned to care for a neonate just delivered who has gastroschisis. Which concern should the nurse address in the client's plan of care?

infection

A client is diagnosed with an ST segment elevation myocardial infarction (STEMI) and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention?

monitor signs of bleeding

The nurse is preparing to care for a client who had a supratentorial craniotomy. The nurse should plan to place the client in which position?

semi Fowler's

The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention?

elevate legs higher than the heart

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action?

encourage the child to drink