NCLEX Questions

A 17-year-old client who has been taking an antidepressant for 6 weeks has returned to the clinic for a medication check. When the nurse talks with the client and her other, the mother reportsthat she has to remind the clinet to take her antidepressant every day. The client says, "Yeah, I'm pretty bad about remembering to take my meds, but I never miss a dose because Mom always bugs me about taking it." Which of the following responses would be effective for the nurse to make to the client? A. "It's a good thing your mom takes care of you by reminding you to take your meds." B. It seems there are some difficulties with being responsible for your medications that we need to address" C. "You'll never be able to handle your medication administration at college next year if you're so dependent on her." D. "I'm surprised your mother allows you to be so irresponsible."

B.

The nurse-manager of a home health facility includes which item in the capital budget? A. salaries and benefits for her staff B. a $1,200 computer upgrade C. office supplies D. client-education materials costing $300

B. 1,200 computer upgrade

A client with cholecystitis is taking Propantheline bromide (pro-Banthine). The expected outcome of this drug is: A. increased bile production B. decreased biliary spasm C. absence of infection D. relief of nausea

B. decreased biliary spasm

Which condition or characteristic is related to the cluster of symptoms associated with disorganized schizophrenia? A. odd beliefs B. flat affect C. waxy flexibility D. systematized delusions

B. flat affect

An Arab client with pneumonia has been admitted to the health care facility. What should the nurse avoid while conducting the interview of the client? A. giving a light handshake B. maintaining eye contact C. asking about the client's symptoms D. asking about the client's medical history

B. maintaining eye contact

Which of the following measures should the nurse include in the care plan for a child who is receiving high-dose methotrexate therapy? A. keeping the child in a fasting state B. obtaining a WBC count C. preparing for radiography of the spinal canal D. collecting a specimen for urinalysis

B. obtaining a WBC count

When a drug's effect is increased after a second is given, this interaction is called... A. absolution B. potentiation C. synergism D. antagonsim

B. potentiation

The nurse is caring for a multigravida client who speaks little English. As the nurse enters the client's room, the nurse observes the client squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which of the following actions should the nurse do next? A. tell the client to push between contractions B. provide gentle support to the fetal head C. apply gentle upward traction on the neonate's anterior shoulder D. massage the perineum to stretch the perineal tissues

B. provide gentle support to the fetal head

A primiparous client at 4 hours after a vaginal delivery and manual removal of the placenta voids for the first time. The nurse palpates the fundus, noting it to be 1 cm above the umbilicus, slightly firm, and deviated to the left side, and notes moderate amount of lochia rubra. The nurse notifies the physician based on the interpretation, the assessment indicates which of the following? A. perineal lacerations B. retained placental fragments C. cervical lacerations D. urine retention

B. retained placental fragments (At 4 hours the fundus should be midline at the umbilicus. Fragments are a common cause of postpartum hemorrhage and the pt will continue to bleed until the fragments are expelled. Perineal and cervical bleeding are bright red and a firmly contracted fundus.)

A 45-year-old single mother of 3 teenage boys has metastatic breast cancer. Her parents live 750 miles away and have only been able to visit twice since her initial diagnosis 14 months ago. The progression of her disease has forced her to consider high-dose chemotherapy. She is concerned about her children's welfare during the treatment. When assessing the client's present support systems, the nurse will be most concerned about the potential problems with: A. denial as a primary coping mechanism B. support systems and coping strategies C. decision-making abilities D. transportation and money for the boys

B. support systems and coping strategies

What should the HCP expect to find as an early clinical characteristic of MS? A. clonus B. vision loss C. dementia D. muscle atrophy

B. vision loss

After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the med-surg unit. Post op, how should the nurse position the client? A. with the affected hip flexed acutely B. with the leg on the affected side abducted C. with the leg on the affected side adducted D. with the affected hip rotated externally

B. with the leg on the affected side abducted

A neonate has a large amount of secretions. After vigorously suctioning the neonate, the nurse should assess for what possible result? A. bradycardia B. rapid eye movement C. seizures D. tachycardia

Bradycardia (due to potential vagus nerve stimulation from deep suctioning)

A physician has ordered penicillin G potassium IV for a client with a severe strep infection. A nurse determines that the client may be allergic to penicillin. When considering best practice, what should the nurse's priority intervention be? A. holding the penicillin G potassium and charting that it was held b/c the client is allergic B. Administering the penicillin G potassium and staying alert for any reaction C. holding the penicillin G potassium and notifying the physician that the client may have an allergy to penicillin D. Administer the penicillin G potassium but notifying the pharmacist that the client may experience an allergic reaction

C.

An 18-year-old high school senior wishes to obtain birth control through her parent's insurance but does not want the information disclosed. The nurse tells the client that under HIPPA parents... A. have the right to review a minor's medical records until HS graduation B. have the right to review a minor's medical record if they are responsible for the payment. C. May not view the medical record, but may learn of the visit through the insurance bill D. may not view the minor's medical record or the insurance bill

C. May not view the medical record, but may learn of the visit through the insurance bill

The HCP prepares to administer a corticosteroid to a pt with a diagnosis of asthma. the rationale for administering this drug to the patient is... A. promote expectoration of mucus B. promote bronchodilation C. decrease airway swelling D. prevent resp. infections

C. decrease airway swelling (Anit-imflammatory drug)

Before preparing a client for surgery, the nurse assists in developing a teaching plan. What is the primary purpose of preop teaching? A. to determine whether the client is psychiologically ready for surgery B. to express concerns to the client about the surgery C. to reduce the risk of postop complications D. to explain the risks associated with the surgery and obtain informed consent

C. to reduce the risk of post op complications

The HCP is seeing 4 patients at the clinic. Which of these pts should the HCP identify to be most at risk for iron deficiency anemia? A. pt who follows strict vegan diet B. pt who has a diagnosis of chronic renal failure C. woman of childbearing age reporting a craving for ice D. obese pt with a hx of gastric bypass surgery

C. woman of childbearing age reporting a craving for ice

A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicated effective teaching about this therapy? A. "I will receive parenteral vitamin b12 until my s/s disappear" B. "I will receive parenteral vitamin b12 unitl my level returns to normal." C. "I will receive parenteral vitamin b12 therapy monthly for 6 months to a year" D. "I will receive parenteral vitamin b12 therapy for the rest of my life"

D.

A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of ineffective coping related to DM? A. recent weight gain of 20 lb B. failure to monitor blood glucose levels C. skipping insulin doses during illness D. crying whenever DM is mentioned

D. crying whenever DM is mentioned

A nurse is performing a baseline assessment of a client's skin integrity. What's the nursing priority assessment parameter? A. family history of pressure ulcers B. presence of pressure ulcers on the client C. potential areas of pressure ulcer development D. overall risk of developing pressure ulcers

D. overall risk of developing pressure ulcers

A pt with Parkinsons states, I can't tie my shoelaces anymore. The HCP recognizes that this pt's problem is due to a deficiency in which of these neurotransmitters? A. glutamate B. norepinephrine C. dopamine D. serotonin

C. dopamine

Of the following findings in the client's history, which would be the least likely to have predisposed the client to renal calculi? A. having had several UTI's in the past 2 years B. having taken large doses of vitamin C over the past several years C. drinking less than the recommended amount of milk D. having been on prolonged bed rest after an accident the previous year

C. drinking less than the recommended amount of milk

12 hours after a vaginal delivery with epidural anesthesia, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. Which of the following would the nurse do next? A. document this as a normal finding in the client's record B. contact the physician for an order for Methylergonovine C. encourage the client to ambulate to the bathroom and void D. gently massage the fundus to expel the clots

C. encourage the client to ambulate to the bathroom and void

A client with chronic renal failure (CRF) has developed faulty RBC production. The nurse should monitor this client for: A. nausea and vomiting B. dyspnea and cyanosis C. fatigue and weakness D. thrush and circumoral pallor

C. fatigue and weakness

The nursing staff has finished restraining a client. In addition to determining whether anyone was injured, the staff is mandated to evaluate the incident to obtain which of the following ultimate outcomes? A. coordinate documentation of the incident B. resolve negative feelings and attitudes C. improve the use of restraint procedures D. clam down before seeing other patients

C. improve the use of restraint procedures

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brian tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant? A. decreased LOC B. elevated BP C. increased urine output D. decreased HR

C. increased urine output

Which medication is considered safe during pregnancy? A. aspirin B. magnesium hydroxide C. insulin D. oral antidiabetic agents

C. insulin

When assessing a pt diagnosed with OA the HCP looks for which characteristic condition? A. decreased grip strength B. bilateral joint swelling C. joint crepitus D. waddling gait

C. joint crepitus

A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, teh physician orders acetylcysteine (Mucomyst). Before administering the first dose, the nurse checks the client's history of asthma. Acetylcysteine must be used cautiously in a client with asthma because it... A. is a respiratory depressant B. is a respiratory stimulant C. may induce bronchospasm D. inhibits the cough refelx

C. may induce bronchospasm

A client with major depression sleeps 18-20 hours per day, shows no interest in activities he previously enoyed and reports a 17-lb (7.7 kg) weight loss over the past month. Because this is the client's first hospitalization, the physician is most likely to order: A. phenelzine (Nardil) B. thiothixene (Navane) C. nortiptyline (pamelor) D. trifluoperazine (stelazine)

C. nortiptyline (Pamelor)

The nurse is evaluating the pin insertion site of a client's skeletal traction. Which of the following indicate a complication? A. presence of crusts around the pin insertion site B. serous drainage on the dressing C. pin moves slightly at insertion site D. client does not feel pain at insertion site

C. pin moves slightly at insertion site

A nurse is monitoring a client for adverse reactions to atropine eye drops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction? A. tachycardia B. increased salivation C. hypotension D. apnea

A tachycardia

A client with esophageal cancer decides against placement of a jejunostomy tube. Which ethical principle is a nurse upholding by supporting the client's decision? A. autonomy B. fidelity C. nonmaleficence D. veracity

A. autonomy

A client who recently developed paralysis of the arms is diagnosed with conversion disorder after tests fail to uncover a physical cause for the paralysis. Which intervention should the nurse include in the care plan for this client? A. exercising the client's arms regularly B. isting that the client eat without assistance C. working with the client rather than with the family D. teaching the client how to use nonpharm pain-control methods

A. exercising the client's arms regularly

Pt diagnosed with UC is admitted to the unit. When assessing the pt, which of the following findings would be the most concern? A. rebound tenderness B. bloody diarrhea C. oral temp of 99 D> borborygmi

A. rebound tenderness (sign of peritonitis--> could be a result of colon rupture)

A nurse should expect a 3-year-old child to be able to perform which action? A. ride a tricycle B. tie his shoes C. roller-skate D. jump rope

A. ride a tricycle

A nurse is caring for a client receiving chemotherapy. Which action is most appropriate for handling chemo agents? A. wear disposable gloves and protective clothing B. break needles after the infusion is discontinued C. disconnect IV tubing with gloved hands D. throw IV tubing in the trash after the infusion is stopped

A. wear disposable gloves and protective clothing

Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and narcotizing fasciitis is suspected. Another manifestation that suggests narcotizing fascitis rather than cellulitis: A. erythema B. leukocytosis C. pressure-like pain D. swelling

C. pressure-like pain (erythema, leukocytosis, and swelling are BOTH indicative of cellulitis and narcotizing faciitis)

During assessment of a small infant admitted with a diagnosis of meningitis, the infant becomes less responsive to stimuli and exhibits bradycardia, slight hypertension, irregular respirations, and a temperature of 103.2 F. The infant's fontanel is more tense than at the last assessment. What should the nurse do first? A. ask another nurse to verify the findings B. notify the primary care provider of the findings C. raise the head of the bed D. administer an antipyretic

C. raise the head of the bed (first action is to reduce the ICP pressure)

A client with alcohol dependency is prescribed a B-complex vitamin. The client states, "why do I need a vitamin? my appetite is just fine." Which of the following responses by the nurse is most accurate? A. your doctor wants you to take it for at least 4 months B. you've been drinking alcohol and eating very little C. the vitamin is a nutritional supplement important to your health D. the amount of vitamins in the alcohol you drink is very low

C. the vitamin is a nutritional supplement important to your health

A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The primary care provider has ordered IV fluids of dextrose water with sodium and potassium. The baby's admission potassium level is 3.4 Meq/L. The nurse should... A. notify the HCP B. Administer the ordered fluids C. verify that the infant has urinated D. have the potassium level redrawn

C. verify that the infant has urinated

A father comes to the ED, with his 4-year-old. He tearfully reports that in the driveway he had his son on his shoulder and he began to fall. The father grabbed his leg, swinging him toward the grass to avoid the pavement. As the father swung the child, he hit his head on the pavement and twisted his right leg. After a complete exam, it is determined that the child has a skull fracture and a spiral fracture of the femur. Which of the following actions should the nurse take? A. restrict the father's visitation B. notify the police immediately C. refer the father for parenting classes D. record the father's story in the chart

D. record the father's story in the chart

A potential concern when caring for an older adult who has diminished hearing and vision is the client's... A. feelings of disorientation B. cognitive impairment C. sensory overload D. social isolation

D. social isolation

In preparing the client and the family for a postop stay in the ICU after open heart surgery, the nurse should explain that: A. the client will remain in the ICU for 5 days B. the client will sleep most of the time while in the ICU C. noise and activity within in the ICU are minimal D. the client will receive meds to relieve pain

D. the client will receive meds to relieve pain

A nurse should monitor a client receiving lidocaine for toxicity. Which signs or symptoms in a client suggest lidocaine toxicity? A. nausea and vomiting B. pupil changes C. confusion and restlessness D. hypertension

confusion and restlessness

A client receiving a blood transfusion begins to have chills adn headache within the first 15 minutes of the transfusion. The should first....

discontinue the transfusion

The nurse is assessing a client's testes. Which of the following findings indicate the testes are normal? A. soft B. egg-shaped C. spongy D. lumpy

egg-shaped (normal testes feel smooth, egg-shaped, and firm to the touch. NO lumps- usually indicate testicular malignancies and are non-tender/non-painful, hard lumps. the surface is smooth and rubbery.

What's an intradermal injection?

evidence of a bleb or wheal