NCLEX-PN Prep Questions (straight from ATI)

A nurse is collecting data from a client who has an acute myocardial infarction (MI). What clinical manifestations should the nurse expect to find?

-Nausea is correct. Nausea and vomiting are classic manifestations of acute MI. -Tachycardia is correct. Tachycardia and dysrhythmias are classic manifestations of acute MI. -Diaphoresis is correct. Profuse sweating and anxiety are classic manifestations of acute MI.

A nurse is contributing to the plan of care for a client who has a gastrostomy tube through which he is receiving continuous enteral feedings. Which of the following interventions should the nurse include in the plan?

-The nurse should flush the gastrostomy tube with 30 to 60 mL of water every four hours to provide free water to the client and prevent dehydration. -The nurse should change the feeding bag and tubing every 24 hr to limit the growth of bacteria within the system. -The nurse should elevate the head of the bed to 45 degrees (semi-Fowler's position) for a client who is receiving continuous enteral feedings to limit the risk of aspiration of the formula. -The nurse should limit the quantity in the feeding bag to provide feeding for a 4 hr time frame to limit bacterial growth within the system.

A client has neutropenia. What should the nurse include in the teaching?

-The nurse should inform the client to avoid crowds due to a suppressed immune system. -The nurse should inform the client to avoid fresh fruits and vegetables due to the bacteria they can carry. -The nurse should inform the client to take her temperature daily and report a temperature greater than 38° C (100° F). -The nurse should inform the client to avoid gardening due to the soil containing bacteria, which can infect the client.

A nurse is reinforcing discharge teaching with a client who has undergone a transurethral resection of the prostate (TURP). What should the nurse include in the teaching?

-The nurse should reinforce that strenuous activity, straining to have a bowel movement, and coughing may cause the urine to become blood tinged. If this should occur, the client should be instructed to stop the activity, rest, and increase fluid intake. If urine becomes increasingly blood tinged or does not clear, or the client has difficulty voiding, he should be instructed to notify the provider. -The nurse should reinforce teaching with the client that NSAIDs such as naproxen and ibuprofen may increase bleeding and are to be avoided. -The nurse should reinforce teaching with the client that sexual intercourse is not permitted for 6 weeks following surgery, as this may cause bleeding of the prostate tissues. The nurse should reinforce that following the TURP, ejaculate may flow back into the bladder and little to no semen may be expressed during sexual activity. -The nurse should reinforce teaching with the client that urinary dribbling may continue for as long as 6 months following surgery. The use of urinary protection pads should be recommended if the client has dribbling. The nurse should also recommend the client complete perineal strengthening exercises several times daily to enhance urinary continence.

A nurse is reinforcing teaching with a client who has a family history of hypertension. The nurse should inform the patient that a blood pressure reading of 124/84 mm Hg places him in which category?

A blood pressure reading of 124/84 mm Hg places this client in the prehypertension category. -Prehypertension includes a systolic pressure of 120-130 mm Hg and a diastolic pressure of 80-89 mm Hg.

A nurse is collecting data from a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Should the nurse expect: hyperactive reflexes, extreme thirst, weak irregular pulse, or hyperactive bowel sounds?

A weak, irregular pulse. Common manifestations of potassium depletion include: a weak and irregular pulse, muscle weakness, fatigue, and ventricular dysrhythmias.

A nurse is caring for a client who presents to urgent care with a laceration on his forearm. Which of the following activities is an example of primary prevention?

Administering a tetanus shot is an example of primary prevention. (Primary prevention is true prevention of the manifestations of illness through health promotion and disease prevention. This level of prevention includes immunizations because they provide protection against specific infections and diseases.) [Secondary prevention focuses on prompt intervention for health problems or issues.] -Suturing the client's wound is an example of secondary prevention. -Applying a sterile dressing to the client's wound is an example of secondary prevention. -Client teaching is an example of secondary prevention. -If the client's laceration has caused nerve damage and functional disability, follow-up care would include tertiary prevention activities, such as rehabilitation.

A nurse is caring for a client who has urinary incontinence. What should the nurse do to prevent the development of skin breakdown?

Apply a moisture barrier ointment to the skin to prevent further contact of the skin with urine.

A nurse is caring for a client who is suspected to have active laryngeal tuberculosis (TB). Which of the following actions should the nurse plan to take to safely care for the client?

Clients suspected to have active laryngeal tuberculosis are placed in private rooms with negative-pressure airflow via HEPA filtration systems. Negative pressure pulls air away from the hallway and exhausts it out of the room to areas away from the intake vents. -The nurse should place a client suspected to have TB on airborne precautions.

A nurse is verifying that a client is giving informed consent to undergo electroconvulsive therapy. Which of the following actions should the nurse take?

Confirm the client's signature is authentic. When verifying that a client is giving informed consent, the nurse's responsibilities include: identifying if the client's signature is authentic, that the client gave consent voluntarily, and that the client appears to be competent to give consent.

A nurse is caring for a client who has end-stage renal disease and must limit protein intake. Which of the following foods should the nurse plan to INCLUDE in the client's diet: eggs, lentils, nuts, or green vegetables?

Eggs. The protein in the protein-restricted diet of a client who has end-stage-renal disease must be of high biological value. A high biological value means the protein source should be a complete protein (providing a high percentage of amino acids), such as eggs, meat, fish, soy, or dairy products.

A nurse is monitoring a client following a hemodialysis treatment through an arteriovenous (AV) fistula. Which findings should the nurse report to the provider?

Headache and restlessness are manifestations of disequilibrium syndrome, which occurs during or after hemodialysis due to the rapid shift of fluids, pH, and osmolarity between fluid and blood that occurs during the dialysis treatment. This condition can lead to seizures and coma and should be reported to the provider. -The nurse should also monitor for and report hypotension or tachycardia following hemodialysis. -The nurse should monitor the AV fistula site by palpating for a thrill and auscultating for a bruit which are both expected, normal findings.

A nurse is preparing to administer megestrol to a client with breast cancer who is receiving chemotherapy. The nurse should identify that megestrol has what therapeutic effect?

Increased appetite

A nurse is contributing to the plan of care for a client who has a pressure ulcer on his heel. Should the nurse: keep the ulcer bed dry, clean the ulcer with hydrogen peroxide, provide the client a diet high in vitamin C, or reposition them every 4 hours?

Provide the client a diet that's high in vitamin C in order to promote wound healing and development of new tissue.

What are some classic findings of right-sided heart failure?

Right-sided heart failure raises the pressure and volume of blood within the jugular veins, making them visibly distended when the client is sitting or when the head of the bed is elevated more than 30 °. Right upper quadrant pain is a classic finding because venous engorgement causes hepatomegaly which results in tenderness over the liver. Pitting edema of lower legs is a classic sign. Dependent edema is a classic manifestation of right-side heart failure. Pressing edematous skin with a finger leaves a transient indentation (pitting).

A nurse is assisting with care for a client who is receiving diuretic therapy. The nurse should explain that which of the following medications put the client at risk for hyperkalemia: Furosemide, Hydrochlorothiazide, Mannitol, or Spironolactone?

Spironolactone is a potassium-sparing diuretic that blocks the effects of aldosterone in the renal tubules, causing a loss of sodium and water and retention of potassium. The nurse should instruct that spironolactone therapy can increase the risk of hyperkalemia and hyponatremia. -Furosemide is a high-ceiling (loop) diuretic that increases the risk of hyponatremia and hypokalemia, not hyperkalemia. -Hydrochlorothiazide is a thiazide diuretic that increases the risk of hypokalemia, not hyperkalemia. -Mannitol is an osmotic diuretic that can cause hyponatremia, not hyperkalemia.

A nurse is assigned care of a client who has HIV. Which of the following infection control precautions should the nurse plan to use while caring for this client?

Standard precautions. HIV is not spread through cough or casual contact.

A nurse is planning to perform passive range of motion to a client who is immobilized. Should the nurse: support extremities above and below joints, stretch the body part just beyond the existing range of motion, or continue moving body parts if muscle spasticity occurs?

Support extremities above and below the joints to prevent muscle strain or injury.

A nurse is caring for a client who had a cholecystectomy and has a T-tube drain. Which actions should the nurse take?

The T-tube drains by gravity and placing the client in a Fowler's position with the collection bag placed lower than the insertion site will aid in the drainage of bile. -The T-tube drains bile and should not be clamped without a provider's prescription to avoid causing increased abdominal pain and a backup of bile fluids. Instead, the tubing should be coiled and taped to the client's abdomen and the collection bag should be held below the level of the incision to facilitate drainage. -The nurse should apply a drain sponge or folded gauze dressing around the drainage tubing at the insertion site. This should be covered this with a sterile dressing. Dressings should be changed daily and as needed and the periwound skin should be cleansed and dried. -The nurse should coil the excess tubing and secure it to the client's abdomen. The T-tube is sutured into place and securing it to the client's gown may cause the tube to be accidentally pulled out.

A nurse is reinforcing teaching with a client who uses a nitroglycerine patch to treat angina. The client now has a new prescription for nitroglycerin sublingual tablets. What instructions should the nurse include?

The client should take nitroglycerin as soon as he feels pain, pressure, or tightness in his chest and not wait until his chest pain is severe. -The client can take a sublingual tablet without removing the nitroglycerine patch. -To promote chemical stability, the client should store the medication in a room with low moisture and in its original container.

A nurse is instructing a client with peripheral artery disease (PAD). Which of the following instructions should the nurse include in the teaching?

The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will help prevent vasoconstriction. -Clients who have PAD should not apply heat directly to a limb because sensation is diminished and burns could result. -Clients who have PAD should not wear any constrictive clothing. -Extreme elevation of the legs can slow the flow of arterial blood to the feet.

A nurse is preparing to help transfer a client who can partially assist to a gurney. Which of the following actions should the nurse take: place the bed in its lowest position, unlock the wheels on the bed, lower the head of the bed, or have two caregivers at the side of the bed?

The nurse should lower the head of the bed as much as the client can tolerate. It is safer for the client to move laterally if he is supine. -The nurse should raise the bed so that it is slightly higher than the gurney. This makes it easier for the client to move over and down to the gurney. -There should be one caregiver on the side of the bed between the client's shoulder and hip and two caregivers on the gurney's side, one between the client's shoulder and hip and one between the hip and the lower legs.

A nurse is caring for a client who has a postoperative incision. To support tissue repair the nurse should recommend that the client increase his dietary intake of which of the following: fats, complex carbohydrates, fiber, or vitamin E?

The nurse should recommend that the client increase his dietary intake of complex carbohydrates. -Carbohydrates are protein-sparing food sources that provide energy and allow the proteins to be used for tissue repair.

A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?

To help relieve constipation, the nurse should instruct the client to drink more water, hot liquids such as water with lemon juice, and eat foods that are high in fiber, such as whole-grain bread, bran, and raw fruits. -Establishing a regular aerobic exercise program, not merely putting joints through their range of motion, will help promote healthy defecation. -Gas-producing foods such as beans, broccoli, corn, and cabbage can help promote defecation. -Medications such as stool softeners and laxatives are a LAST RESORT for older adults who have constipation.

A nurse is caring for a client who is unconscious. The nurse has repositioned the client from a left lateral to a right lateral position. The client's daughter asks why the nurse keeps her father lying on his side. Which of the following rationales should the nurse give to the family member?

To prevent aspiration problems. With the client in a side-lying position, secretions and emesis he might otherwise aspirate will drain from his mouth. This is especially important during oral hygiene care.

A client with pneumonia is experiencing respiratory distress. The order states, "if respiratory distress occurs, apply a face mask with precise concentration of oxygen". Which of the following masks delivers precise oxygen concentration: partial rebreather mask, venturi mask, non-rebreather mask, or aerosol mask?

Venturi masks deliver the most precise concentration of oxygen. -Partial rebreather mask has a reservoir bag attached with no valve, which allows the client to rebreathe up to 1/3 of exhaled air together with room air. -Non-rebreather mask delivers the highest O2 concentration possible, not at a precise amount. -Aerosol mask is a face tent. This provides high humidification with oxygen delivery.

A nurse is reinforcing teaching about complete or incomplete protein. Which of the following is a complete protein: yogurt, fresh vegetables, nuts, or dried beans?

Yogurt is a complete protein. All nine essential amino acids in the quantities needed by the body are found in a complete protein for protein synthesis.

Fat embolism syndrome is a clinical diagnosis with a classic triad of presenting symptoms and signs consisting of:

hypoxemia, neurologic abnormalities, and a petechial rash on the chest, abdomen, neck, or upper arms -Reports of calf pain are a manifestation of deep-vein thrombosis.

Identify Erikson's stages of psychosocial development from birth through 18 years of age.

trust vs mistrust, autonomy vs shame and doubt, initiative vs guilt, industry vs inferiority, identify vs role confusion