NCLEX Pre-Test Reviews
The nurse has determined that a postpartum client has physical findings consistent with uterine atony. The nurse should take action in which priority order? Arrange the action in the priority order that they should be done. All options must be used.
Massage the uterus attempting to achieve firmness. Contact the health care provider. Monitor vital signs. Check the amount of drainage on the peripad.
A client with recent-onset Bell's palsy is upset and crying about the change in facial appearance. The nurse plans to support the client emotionally by making which statement to the client? 1. "This is not a stroke, and many clients recover in 3 to 5 weeks." 2. "This is caused by a small tumor, which can be removed easily." 3. "This is similar to a stroke, but all symptoms will reverse without treatment." 4. "This is a temporary problem, with treatment similar to that for migraine headaches."
1. "This is not a stroke, and many clients recover in 3 to 5 weeks." Rationale: Clients with Bell's palsy should be reassured that they have not experienced stroke a (brain attack) and that symptoms often disappear spontaneously in 3 to 5 weeks. The client is given supportive treatment for symptoms. Bell's palsy usually is not caused by a tumor, and the treatment is not similar to that for migraine headaches.
A client diagnosed with depression is scheduled to receive three sessions of electroconvulsive therapy. The nurse should tell the client that he or she will likely start to see improvement in approximately what time frame? 1. 1 week after the 3rd treatment session 2. 3 weeks after the treatment sessions begin 3. Midway between the 2nd and 3rd treatment session 4. 8 weeks after the treatment sessions are completed
1. 1 week after the 3rd treatment session Rationale: Health care providers generally administer electroconvulsive therapy (ECT) treatments three times a week, with an average series including 8 to 12 treatments. After three sessions of ECT, the client should start to demonstrate improvement in 1 week. The remaining options are incorrect.
A new nursing graduate is caring for a client who is attached to a cardiac monitor. While assisting the client with bathing, the nurse observes the sudden development of ventricular tachycardia (VT), but the client remains alert and oriented and has a pulse. Which interventions would the nurse take? Select all that apply. 1. Administer oxygen. 2. Defibrillate the client. 3. Obtain an electrocardiogram (ECG). 4. Contact the health care provider (HCP). 5. Assess circulation, airway, and breathing. 6. Initiate cardiopulmonary resuscitation (CPR).
1. Administer oxygen. 3. Obtain an electrocardiogram (ECG). 4. Contact the health care provider (HCP). 5. Assess circulation, airway, and breathing.
A registered nurse is delegating activities to the nursing staff. Which activities are most appropriate for the unlicensed assistive personnel (UAP)? Select all that apply. 1. Collecting a urine specimen from a client 2. Obtaining frequent oral temperatures on a client 3. Accompanying a client being discharged to his transportation to home 4. Assisting a postcardiac catheterization client who needs to lie flat to eat lunch 5. Monitoring the amounts of fluid remaining in intravenous (IV) solution bags for a client receiving IV fluids
1. Collecting a urine specimen from a client 2. Obtaining frequent oral temperatures on a client 3. Accompanying a client being discharged to his transportation to home
An adolescent is admitted to the hospital after an accidental self-inflicted gunshot wound to the foot. The nurse should plan to take which action as a first step for the prevention of future injury? 1. Explore the client's knowledge of gun safety. 2. Assess the client for a history of risk-taking behaviors. 3. Refer the client to a firearm safety class sponsored by the hospital. 4. Have the client watch a video on the tragedies of improper firearm use.
1. Explore the client's knowledge of gun safety
Allopurinol has been prescribed for a client with a diagnosis of gout. The nurse develops a list of instructions for the client regarding the use of this medication. Which measures should be included on the list? Select all that apply. 1. Increase fluid intake. 2. Take the medication with food. 3. Consume items to maintain an alkaline urine. 4. Take vitamin C daily to enhance the effects of the medication. 5. Return to the health care clinic for liver and renal function tests.
1. Increase fluid intake. 2. Take the medication with food. 3. Consume items to maintain an alkaline urine. 5. Return to the health care clinic for liver and renal function tests.
The nurse is assessing the skin of a client with a history of malabsorption deficiency and discovers brittle nails. What type of nutritional deficiency should the nurse suspect based on this observation? 1. Iron deficiency 2. Protein deficiency 3. Fatty acid deficiency 4. Vitamin K deficiency
1. Iron deficiency Rationale: Brittle nails result from an iron deficiency. Protein deficiency leads to hair thinning and loss. Fatty acid deficiency can result in dermatitis, and vitamin K deficiency results in bruising.
The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? 1. Notify the health care provider (HCP). 2. Continue monitoring the fetal heart rate. 3. Encourage the client to continue pushing with each contraction. 4. Instruct the client's coach to continue to encourage breathing techniques.
1. Notify the health care provider (HCP). Rationale: A normal fetal heart rate is 110 to 160 beats/minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the HCP or nurse-midwife needs to be notified. Options 2, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention.
A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse anticipate to note as a result of increased abdominal pressure? Select all that apply. 1. Orthopnea and dyspnea 2. Petechiae and ecchymosis 3. Inguinal or umbilical hernia 4. Poor body posture and balance 5. Abdominal distention and tenderness
1. Orthopnea and dyspnea 2. Petechiae and ecchymosis 3. Inguinal or umbilical hernia 5. Abdominal distention and tenderness
The nurse is providing care for a client with new onset of a dysrhythmia. The nurse anticipates which prescriptions from the health care provider? Select all that apply. Refer to Figure. 1. Oxygen therapy 2. An echocardiogram 3. An intravenous dose of metoprolol 4. One dose of atropine to promote slowing of the rate 5. A bolus of intravenous heparin followed by a continuous infusion
1. Oxygen therapy 2. An echocardiogram 3. An intravenous dose of metoprolol 5. A bolus of intravenous heparin followed by a continuous infusion
The nurse is planning discharge instructions for the mother of a child following orchiopexy, which was performed on an outpatient basis. Which is a priority in the plan of care? 1. Wound care 2. Pain control measures 3. Measurement of intake 4. Cold and heat applications
1. Wound care Rationale: The most common complications associated with orchiopexy are bleeding and infection. Discharge instruction should include demonstrating wound cleansing and dressing and teaching parents to identify signs of infection, such as redness, warmth, swelling, or discharge. Testicles will be held in a position to prevent movement, and great care should be taken to prevent contamination of the suture line. Analgesics may be prescribed but are not the priority, considering the options presented. Measurement of intake is not necessary. Cold and heat application is not a prescribed treatment measure.
The nurse in the hospital is giving at-home feeding instructions to a family whose child is being discharged after being born with a cleft lip. Which statement by the mother would indicate that further teaching is indicated? 1. "I am so glad that I am able to breast-feed my baby." 2. "I must always feed my baby with a syringe and not use a nipple." 3. "I will feed my baby while sitting in a chair and holding her more upright." 4. "I will burp my baby very frequently so that she does not swallow a lot of air."
2. "I must always feed my baby with a syringe and not use a nipple." Rationale: Infants with a cleft lip are fed using a special nipple. Therefore, although all the interventions relate to feeding, option 2 should be clarified with the family because if they fed the baby using a syringe, the child's oral needs for sucking will not be met. Breast-feeding is always an option and should be done unless the child is having difficulty. Most children with a small cleft lip can be breast-fed. Newborns should be burped frequently and fed in a somewhat upright position. These interventions are applicable to the child with a cleft lip as well.
When a client develops neuroleptic malignant syndrome, the nurse ensures that which medication is available on the unit to address this complication? 1. Phytonadione 2. Bromocriptine 3. Protamine sulfate 4. Enalapril maleate
2. Bromocriptine Rationale: Clients taking antipsychotic medications are at risk for neuroleptic malignant syndrome. Bromocriptine, an antiparkinsonian prolactin inhibitor, is used in the treatment of neuroleptic malignant syndrome. Phytonadione is the antidote for warfarin overdose. Protamine sulfate is the antidote for heparin overdose. Enalapril maleate is an angiotensin-converting enzyme inhibitor used to treat hypertension.
Which assessment finding would be a manifestation associated with dementia? 1. Catatonia 2. Confabulation 3. Presence of ritualistic behaviors 4. Increased display of inhibited behaviors
2. Confabulation Rationale: The clinical picture of dementia varies from the development of mild cognitive defects to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or fabrication of events or experiences to fill in memory gaps is common. Ritualistic behaviors are associated with obsessive-compulsive disorder, while catatonia is a psychotic reaction. Often, lack of inhibition on the part of the client constitutes the first indication to the client's significant others that something is "wrong."
The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client? 1. Coma 2. Flushing 3. Dizziness 4. Tachycardia
2. Flushing Rationale: Carbon monoxide levels between 11% and 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 60% result in death.
A registered nurse (RN) is supervising a licensed practical nurse (LPN) administering an intramuscular (IM) injection of iron to an assigned client. The RN would intervene if the LPN is observed performing which action? 1. Using a Z-track method for injection 2. Massaging the injection site after injection 3. Preparing an air lock when drawing up the medication 4. Changing the needle after drawing up the dose and before injection
2. Massaging the injection site after injection Rationale: The site should not be massaged after injection because massaging could cause staining of the skin. Z-track technique and an air lock both should be used. Proper technique for administering iron by the IM route includes changing the needle after drawing up the medication and before giving it. The medication should be given in the upper outer quadrant of the buttock, not in an exposed area such as the arms or thighs.
The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information should the nurse include in the session? Select all that apply. 1. Individuals move through all 6 stages in a sequential fashion. 2. Moral development progresses in relationship to cognitive development. 3. A person's ability to make moral judgments develops over a period of time. 4. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. 5. In stage 1 (punishment-obedience orientation), children are expected to reason as mature members of society. 6. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.
2. Moral development progresses in relationship to cognitive development. 3. A person's ability to make moral judgments develops over a period of time. 4. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. 6. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.
The nurse caring for a client who is taking an aminoglycoside should monitor the client for which adverse effects of the medication? Select all that apply. 1. Seizures 2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias 5. Hepatotoxicity
2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias
A client with a fractured femur experiences sudden dyspnea, tachypnea, and tachycardia. A set of arterial blood gas tests reveals the following: pH, 7.35 (7.35); Paco2, 43 mm Hg (43 mm Hg); Pao2, 58 mm Hg (58 mm Hg); HCO3, 23 mEq/L (23 mmol/L). The nurse interprets that the client probably has experienced fat embolus because of the result of which parameter? 1. pH 2. Pao2 3. HCO3 4. Paco2
2. Pao2 Rationale: A significant feature of fat embolism is a significant degree of hypoxemia, with a Pao2 often less than 60 mm Hg (60 mm Hg). The data in the question indicate that the items in the remaining options are normal blood gas results.
The nurse is providing instructions to an adolescent prescribed phenytoin for the control of seizures. Which statement by the adolescent indicates a need for further teaching regarding the medication? 1. "The medication may cause acne or oily skin." 2. "Drinking alcohol may affect the medication." 3. "If my gums become sore and swollen, I need to stop the medication." 4. "Birth control pills may not be effective when I take this medication."
3. "If my gums become sore and swollen, I need to stop the medication." Rationale: The adolescent should not stop taking antiseizure medications suddenly or without discussing it with a health care provider (HCP) or nurse. Acne or oily skin may be a problem for the adolescent, and the adolescent is advised to call a HCP for skin problems. Alcohol will lower the seizure threshold, and it is best to avoid its use. Birth control pills may be less effective when the client is taking antiseizure medication.
A client is diagnosed with iron deficiency anemia, and ferrous sulfate is prescribed. The nurse should tell the client that it would be best to take the medication with which food? 1. Milk 2. Boiled egg 3. Tomato juice 4. Pineapple juice
3. Tomato juice Rationale: Ferrous sulfate is an iron preparation, and the client is instructed to take the medication with orange juice or another vitamin C-containing product or a product high in ascorbic acid to increase the absorption of the iron. Among the options presented, tomato juice is highest in vitamin C and ascorbic acid. Milk and eggs inhibit absorption of iron.
An adolescent is examined in the hospital emergency department after taking an overdose of acetylsalicylic acid. The adolescent has rapid breathing, nausea and vomiting, and lethargy. The health care provider prescribes arterial blood specimens for blood gas analysis to be drawn. Aspirin toxicity is suspected when the blood gas results are reported as which value? 1. pH 7.50, Pco2 60 mmHg, HCO3 30 mEq/L (30 mmol/L) 2. pH 7.44, Pco2 30 mmHg, HCO3 21 mEq/L (21 mmol/L) 3. pH 7.29, Pco2 29 mmHg, HCO3 19 mEq/L (19 mmol/L) 4. pH 7.33, Pco2 52 mmHg, HCO3 28 mEq/L (28 mmol/L)
3. pH 7.29, Pco2 29 mmHg, HCO3 19 mEq/L (19 mmol/L) Rationale: The client who has aspirin toxicity will manifest metabolic acidosis with respiratory compensation as seen when the pH is lower 7.35 mm Hg and the HCO3 is less than 22 mEq/L (22 mmol/L). In the correct option, the pH is acidotic and the HCO3 is decreased, indicating metabolic acidosis. The Pco2 is alkalotic, indicating partial compensation.
A clinic nurse is monitoring a client with anorexia nervosa. Which client statement should indicate to the nurse that treatment has been effective? 1. "I'll eat until I don't feel hungry." 2. "I no longer have a weight problem." 3. "I don't want to starve myself anymore." 4. "My friends and I went out to lunch today."
4. "My friends and I went out to lunch today." Rationale: In anorexia nervosa, the client tries to establish identity and control by self-imposed starvation. The correct option is a measurable action that can be verified. The remaining options are verbalizations of the client's intentions.
A client with a subarachnoid hemorrhage needs to have surgery delayed until a stable clinical condition is achieved. The nurse prepares to administer which medication as prescribed to prevent clot breakdown and dissolution? 1. Alteplase 2. Heparin sodium 3. Warfarin sodium 4. Aminocaproic acid
4. Aminocaproic acid Rationale: Aminocaproic acid is an antifibrinolytic agent that prevents clot breakdown or dissolution. It is commonly prescribed after subarachnoid hemorrhage if surgery is delayed or contraindicated, to prevent further hemorrhage. Alteplase is a fibrinolytic that actively breaks down clots. Warfarin sodium and heparin sodium are anticoagulants that interfere with propagation or growth of a clot.
A client recently admitted to the hospital in the manic phase of bipolar disorder is unkempt, taking antipsychotic medications, and complaining of abdominal fullness and discomfort. Which intervention addresses the priority sign/symptom? 1. Teach self-grooming skills. 2. Reward cleanliness with unit privileges. 3. Monitor the adequacy of the antipsychotic dosage. 4. Encourage frequent fluid intake and a high-fiber diet.
4. Encourage frequent fluid intake and a high-fiber diet. Rationale: Constipation is a common elimination problem with clients in a manic phase of bipolar disorder. Constipation may occur as the result of a combination of factors, including taking antipsychotic medications, suppressing the urge to defecate, and a decreased fluid intake as a result of the manic activity level. The symptoms listed in the question in combination with antipsychotic medications are indicators of constipation. A high-fiber diet and increased fluids can reduce constipation.
The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level? 1. Tetany 2. Twitches 3. Positive Trousseau sign 4. Loss of deep tendon reflexes
4. Loss of deep tendon reflexes Rationale: The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). A client with a magnesium level of 3.5 mEq/L (1.75 mmol/L) is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau sign are seen in a client with hypomagnesemia.
Pyrimethamine has been added to the medication regimen for a client with acquired immunodeficiency syndrome. On review of the client's record, the nurse notes this new prescription and plans care knowing that it has been prescribed to treat which condition? 1. Toxoplasmosis 2. Kaposi's sarcoma 3. Cardiac irregularities 4. Nausea and vomiting
4. Nausea and vomiting Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Pyrimethamine is an antimalarial and antiprotozoal medication used to treat toxoplasmosis or Pneumocystis jiroveci pneumonia. Pyrimethamine is not used to treat nausea, vomiting, cardiac irregularities, or Kaposi's sarcoma.
