NCLEX Prep Exam 1

The nurse is preparing to administer an intramuscular (IM) injection to a client receiving a continuous heparin infusion. Which action should the nurse prepare to do?

Apply prolonged pressure to the IM site after the injection.

A client has been given a prescription for benzonatate. Which observation should the nurse look for to evaluate the effectiveness of the medication?

Calming the client's persistent cough

The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action?

Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication.

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply

Depressed ST segment Inverted T waves U waves

A client has a urine specific gravity level of 1.034. The nurse determines that which causes or conditions can be related to this level? Select all that apply.

Glycosuria Albuminuria Dehydration

A client with a urinary tract infection is receiving ciprofloxacin by the intravenous (IV) route. The nurse appropriately administers the medication by performing which action?

Infusing slowly over 60 minutes

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld?

Prednisone

The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply.

Prolonged ST segment Prolonged QT interval

A client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred?

Rapid heartbeat or anxiety

The nurse is reviewing the laboratory blood test results for a client and notes that the hemoglobin S (Hgb S) value is elevated. The nurse determines that this laboratory finding is associated with which condition?

Sickle cell anemia

Oral bethanechol chloride is prescribed for the client. The nurse should instruct the client to take this medication at which time?

Two hours after meals

A client with acute myelocytic leukemia is being treated with busulfan. Which laboratory value would the nurse specifically monitor during treatment with this medication?

Uric acid level

The nurse is preparing to care for a client with esophageal varices who needs a Sengstaken-Blakemore tube inserted because other treatments were unsuccessful. The nurse gathers supplies, knowing that which item must be kept at the bedside at all times?

a pair of scissors

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply.

broth coffee gelatin

A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The health care provider prescribes an enteral tube feeding of a standard formula to run at 40 mL/hour. A nursing student is assigned to care for the client, and the nursing instructor asks the student to describe the nursing considerations related to a tube feeding. Which statement, if made by the student, indicates an understanding of this dietary treatment?

"Enteral feedings require the normal digestive capabilities of the gastrointestinal tract."

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client?

"Take a deep breath when I tell you, and hold it while I remove the tube."

Butorphanol tartrate is prescribed for a woman in labor, and the woman asks the nurse about the purpose of the medication. The nurse should make which appropriate response?

"The medication provides pain relief during labor."

A client is donating blood for a family member who is having surgery. The nurse tells the client that an indirect Coombs' test will be performed on the blood. The client asks the nurse about the purpose of the test. Which response should the nurse provide to the client?

"The test detects circulating antibodies against red blood cells (RBCs)."

The nurse in the respiratory care unit completes a lung assessment and reviews the laboratory results of a serum medication level assay for a client receiving theophylline. The nurse determines that a therapeutic medication level has been achieved by indication of which value?

18mcg/mL

A client is undergoing a series of diagnostic tests. The laboratory results indicate an increased blood urea nitrogen (BUN) to creatinine ratio. The nurse determines that which potential conditions could contribute to these results? Select all that apply.

Dehydration Catabolic state High-protein diet Obstructive uropathy

The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide and metformin. The nurse should provide which instructions to the client? Select all that apply.

Diarrhea may occur secondary to the metformin. The repaglinide is not taken if a meal is skipped. The repaglinide is taken 30 minutes before eating. A simple sugar food item is carried and used to treat mild hypoglycemia episodes.

A client is to undergo weekly intravesical chemotherapy for bladder cancer for the next 8 weeks. What instruction should the nurse provide to the client regarding management of the urine as a biohazard?

Disinfect the toilet with bleach after voiding for 6 hours after a treatment.

The nurse is administering a bolus feeding through nasogastric (NG) tube. Which position should the nurse use for the client after the tube feeding?

Fowler's on the right side

The nurse is performing a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine. Which information would be important for the nurse to obtain during this client visit regarding the side and adverse effects of the medication?

Gastrointestinal dysfunctions

The nurse is caring for a postoperative general surgery foreign-speaking client with a history of poor nutrition. What are some reasonable issues that can impact this client? Select all that apply.

Impaired wound healing and increased risk of postoperative infection Impaired functioning of the gastrointestinal (GI) tract, cardiovascular system, respiratory system, and immune system Longer hospital stays and increased medical costs Reduced quality of life and increased mortality rate

The nurse is discharging a client after an arthroscopy. The nurse needs to teach the client to watch for which potential complications? Select all that apply.

Infection Swelling Thrombophlebitis Increased joint pain related to mechanical injury

The nurse is preparing to administer exogenous surfactant to a premature infant who has respiratory distress syndrome. The nurse prepares to administer the medication by which route?

Intratracheal

The client is suspected of having a skeletal muscle disorder. Which isoenzyme value reported with the creatine kinase (CK) level should the nurse assess for elevation?

MM

The nurse plans care for an older client admitted with a fractured hip. Which analgesic prescribed by the health care provider at standard doses and frequencies would the nurse question?

Meperidine hydrochloride by intramuscular route

Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. For which side and adverse effects of the medication should the nurse monitor? Select all that apply.

Ocular pain or blurred vision Signs of hepatitis Flulike syndrome Low neutrophil count

The nurse is assessing the status of pain in an alert elderly client who was recently admitted to the hospital with a diagnosis of ruptured lumbar disc. What are some of the beliefs and concerns older adults have about pain? Select all that apply.

Pain is something that must be lived with. Nurses are too busy to listen to reports of pain. Pain signifies a serious illness or impending death. Reporting pain will result in being labeled as a "bad" client.

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?

Peripheral neuritis

The ambulatory care nurse is reviewing an adult client's laboratory test results and notes that the hematocrit level is 60% (0.60). The nurse recognizes that this level is most likely to be found in clients with which diagnosis?

Pernicious anemia

The nurse is reviewing the laboratory test results for a client and notes that the differential white blood cell (WBC) count indicates a shift to the right. The nurse suspects that the client's diagnosis is most likely to be which one?

Pernicious anemia

To determine whether the client is experiencing akathisia as an adverse effect of the medication haloperidol, what should the nurse observe the client for?

Restlessness or constant generalized movement

The nurse is reviewing the blood tests of a generally healthy client who is scheduled for orthopedic surgery under general anesthesia. Besides a complete blood count (CBC), what preadmission blood tests would the preoperative nurse expect to be prescribed? Select all that apply.

Serum creatinine and blood urea nitrogen (BUN) levels Clotting studies Glucose fasting Electrolyte levels

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply.

Tall peaked T waves Widened QRS complexes

Tamsulosin hydrochloride has been prescribed for a client with benign prostatic hypertrophy (BPH). How should the nurse instruct the client to take the medication?

Thirty minutes after a meal

Tamsulosin hydrochloride is prescribed for a client. The nurse should suspect that this medication is prescribed to relieve which condition?

Urinary obstruction

An unconscious client has an impaired corneal reflex on one side. The nurse should demonstrate the best understanding of how to protect the client's eye by performing which action?

Using sterile saline drops every few hours to keep the eye moist

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history, and determines it is necessary to contact the health care provider (HCP) if the client is also taking which medications, that are contraindicated for use with ibuprofen? Select all that apply.

Warfarin Glimepiride Amlodipine

Terbutaline is prescribed for a client with bronchitis. The nurse checks the client's medical history for which disorder in which the medication should be used with caution?

diabetes mellitus

The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food?

legumes

Glimepiride is prescribed for a client with diabetes mellitus. The nurse instructs the client that which food items are most acceptable to consume while taking this medication? Select all that apply.

red meat whole grain cereal carbonated beverages

A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse determines that which fibrinogen level is normal?

400 mg/dL

The nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The nurse should take which appropriate action?

Aspirate the fluid, advance the catheter farther, and reinflate the balloon.