NCLEX passpoint 1

The nurse is auscultating S1 and S2 in a client. Identify the area where the nurse should hear S1 the loudest?

5th spce btween ribs midclavicular line

A client with severe inflammatory bowel disease is receiving total parenteral nutrition (TPN). When administering TPN, the nurse must take care to maintain the ordered flow rate because giving TPN too rapidly may cause A. hyperglycemia. B. air embolism. C. constipation. D. dumping syndrome.

A. Hyperglycemia

Which client statement indicates a need for further instruction about a duodenal ulcer? A. "I will need to take an antacid before every meal." B. "To help my ulcer heal I should develop stress management strategies." C. "I will remove foods from my diet that cause abdominal pain." D. "Caffeine and alcoholic beverages may irritate my ulcer."

A. I will need to take an antacid before every meal

Which oral medication would the nurse anticipate being prescribed to prevent further thrombus formation? A. Warfarin B. Heparin C. Furosemide D. Metoprolol

A. Warfarin

A client is receiving oral prednisolone. Which side effects would the nurse expect to see from prolonged use of this medication? Select all that apply. A. weight loss B. hyperglycemia C. osteoporosis D. hirsutism E. cataract

B. Hyperglycemia C. Osteoporosis D. Hirsutism E. Cataract

A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention helps determine if TPN is providing adequate nutrition? A. Accelerating the infusion if it falls behind schedule B. Ensuring that the TPN tubing has an in-line filter C. Monitoring the client's weight every day D. Recording fluid intake and output

C. Monitoring the client's weight everyday

A client who received massive packed red blood cell (PRBC) blood transfusions due to trauma has a potassium level of 7.1 mEq/L (7.1 mmol/L). Which medication should the nurse expect to administer? A. I.V. insulin B. I.V. potassium chloride C. oral spironolactone D. oral lisinopril

A. IV Insulin

A client with bipolar disorder is prescribed lithium. What question should the nurse ask to best determine the risk for nonadherence to treatment? A. What is your understanding of your diagnosis of bipolar disorder? B. Do you have a regular pharmacy where you can fill the medication? C. Have you taken a medication on a daily basis for any other conditions? D. Do you experience a very irregular sleeping and eating schedule?

A. What is your understanding of your diagnosis of bipolar disorder?

The nurse receives report on the assigned clients at the beginning of the second shift. Which client should the nurse plan to assess first after receiving report? A. an elderly client with pneumonia who is exhibiting periods of confusion B. a client who is scheduled for an abdominal perineal resection in the morning and is visiting with the family C. a client receiving total parenteral nutrition (TPN) via a central line with 400 mL remaining in the IV fluid bottle D. a young client with chest tubes placed for treatment of a pneumothorax who is resting comfortably

A. an elderly client with pneumonia who is exhibiting periods of confusion

The nurse is preparing to administer the initial dose of digoxin PO to a client. What is the nurse's priority assessment before administering this medication? A. apical heart rate B.blood pressure C. radial heart rate D. respiratory rate

A. apical heart rate

A 5-year-old client was admitted to a pediatric unit 4 hours ago with reports of pain in the right ankle. Upon assessment, the nurse documents the following findings: VS: 102.8° F (39.3° C), P 112, R 16 BP 96/55, O2 99% on RA, moderate amount of erythema and +2 edema over the lateral aspect of the right ankle, warm to touch, limited range of motion noted. The nurse also reviews the laboratory values. Based on the assessment findings and laboratory data in the chart below, for what is this client at risk? CBC: WBC: 17.8 x 103/µl RBC: 4.8 million/mm3 Hgb: 13.5 gm/dl HCT: 38% Bands: 13 PMN% CRP: 2.8 ng/dl Blood Culture: Gram positive: Staphylococcus aureus A. aplastic anemia B. osteomyelitis C. osteogenesis D. developmental dysplasia of the hip (DDH)

B. Osteomyelitis

A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important? A. Assess the temperature, blood pressure, and check for blood in the urine. Then stop the transfusion. B. Slow the transfusion and monitor the client's vital signs. C. Stop the transfusion, notify the blood bank, and administer antihistamines. D. Stop the transfusion, infuse normal saline solution, and call the physician.

D. Stop the transfusion, infuse normal saline solution, and call the physician.

When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms should the nurse assess? Select all that apply. A. epigastric pain at night B. relief of epigastric pain after eating C. vomiting D. weight loss E. melena

C. Vomiting D. Weight loss E. Melena

A client with a history of bronchial asthma is prescribed propranolol to control hypertension. Before administering propranolol, which initial action should the nurse take? A. monitor apical pulse rate B. instruct the client to take the medication with food C. question the provider about the order D. caution the client to rise slowly when standing

C. question the provider about the order

A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has 300 mL of solution left. What should the nurse do? A. Continue the infusion until the remaining 300 mL is infused. B. Change the filter on the tubing and continue with the infusion. C. Notify the health care provider (HCP) and obtain prescriptions to alter the flow rate of the solution. D. Discontinue the current solution, change the tubing, and hang a new bag of TPN solution.

D. Discontinue the current solution, change the tubing, and hang a new bag of TPN solution.

A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product? A. no priming needed since blood products must be infused alone per currrent guidelines B. dextrose 5% in water as this is considered an isotonic solution C. lactated Ringer's solution as this is considered an isotonic solution D. normal saline solution as this is considered an isotonic solution

D. normal saline solution as this is considered an isotonic solution