NCLEX QUESTIONS(?)
2. A physician prescribes morphine sulfate, gr 1/8 intramuscular stat, for a client with cancer. The medication ampule reads, "Morphine sulfate 10 mg/mL." How many milliliters of medication does the nurse prepare to administer the correct dose? Please write the number only on the back of your scantron.
0.75
10. A nurse is caring for a client who has just undergone cardioversion. Which of the following interventions is the nurse's priority after this procedure? A. Administering oxygen B. Monitoring the blood pressure C. Administering antidysrhythmic medications D. Monitoring the client's level of consciousness
A
18. A client has just been found to have deep vein thrombosis (DVT) of the right leg. Which of the following interventions does the nurse immediately implement? A Elevating the foot of the bed 6 inches B Placing ice packs on and under the right leg C Documenting the need for hourly calf measurements D Performing passive range-of-motion exercises of the right leg
A
24. A man calls the emergency department and tells the nurse that he sustained a bee sting on his leg while working in his yard. The client states that he is not allergic to bees and wants to know how to treat the sting. The nurse tells the client to first: A Place a cool compress on the sting site B Apply an antipruritic lotion to the sting site C Apply a topical corticosteroid to the sting site D Take an oral antihistamine such as diphenhydramine (Benadryl)
A
26. A nurse stops at the scene of an automobile accident. One of the victims is sitting in the driver's seat, complaining of severe muscle spasms in the neck area. The nurse must first: A Stabilize the neck area B Firmly massage the neck area C Assist the victim out of the automobile and lay the victim on the ground D Tell the victim that she is leaving to call an ambulance but will be right back
A
28. A nurse assesses the chest tube drainage system of a client who has undergone surgery and notes intermittent bubbling in the water seal chamber. One hour later, the nurse notes the presence of continuous bubbling in the chamber. On the basis of this finding, the nurse would first check: A The chest tube connection sites B For bubbling in the suction-control chamber C The amount of drainage in the collection chamber D The amount of suction being applied to the chest tube system
A
32. A nurse is assessing a client who has undergone radical neck dissection for the treatment of cancer. The nurse hears this sound when auscultating over the trachea. On the basis of this finding, the priority nursing action is to: A Contact the physician B Assess the client's pulse oximetry C Place the client in a supine position D Administer a nebulizer treatment with the use of a bronchodilator
A
49. A nurse is assessing a client during her first prenatal visit to the clinic. The nurse takes the client's temperature: 100.8° F. Which of the following actions on the part of the nurse is appropriate? A Notifying the physician B Documenting the temperature C Retaking the temperature rectally D Informing the client that a temperature of 100.8 °F is normal during pregnancy
A
5. A nurse on the telemetry unit is caring for a client who has had a myocardial infarction and is now attached to a cardiac monitor. The nurse, monitoring the client's cardiac rhythm, notes the rhythm depicted in the image. Which of the following nursing actions should the nurse take? A. Calling the rapid response team B. Preparing the client for cardioversion C. Asking the client to bear down and cough D. Preparing to administer diltiazem (Cardiazem)
A
53. A nurse is performing an initial assessment of a pregnant adolescent client with diabetes mellitus. The client says to the nurse, "I've stopped my insulin and cut back on my food." Which client concern does the nurse recognize as the priority? A Concern about gaining weight B Concern about getting stretch marks C Concern about being able to care for the infant D Concern about what her friends might think about her wearing maternity clothes
A
60. A client who was recently sexually assaulted is self-contained and calm. The client says to the nurse, "It doesn't seem real." Which defense mechanism is the client using? A Denial B Projection C Rationalization D Intellectualization
A
71. A child with osteosarcoma who required amputation of a lower limb is experiencing phantom limb pain. The nurse attempts to comfort the child by explaining that: A The pain is a normal, temporary condition B The pain occurs because nerves have been cut C This pain will go away once a prosthesis is used D Pain medication may be needed for life to alleviate the discomfort
A
73. The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think that the twins should come to the funeral service for their grandfather. What do you advise?" Which response by the nurse would be therapeutic? A "What do you and your husband believe is the right thing for your children?" B "By all means have them attend. Keeping them home will only prolong their grief. " C "I agree with your mother-in-law. Just tell your children that their grandfather is in heaven." D "It's a difficult decision, but given their young age, maybe it would be best to keep them home from the wake and just let them attend the funeral."
A
4. A nurse is caring for the client who begins to exhibit seizure activity while in bed. Which of the following actions does the nurse implement to care for the client? Select all that apply. A. Observing and timing the seizure B. Loosening any restrictive clothing C. Turning the client's head to the side D. Removing the pads on the side rails E. Inserting an airway into the client's mouth
A, B, C
1. A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis through an internal arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse implement in caring for the client? Select all that apply. A. Assessing the radial pulse in the right extremity B. Using the left arm to take blood pressure readings C. Drawing predialysis blood specimens from the left arm D. Assessing the area over the AV fistula for a bruit and thrill each shift E. Placing a pressure dressing over the site after each dialysis treatment
A, B, C, D
57. A nurse provides instructions to a pregnant woman about foods that contain calcium. Which of the following foods does the nurse recommend? Select all that apply. A. Cheese B. Yogurt C. Spinach D. Sardines E. Shellfish
A, B, D
19. A nurse provides instruction to a client with chronic obstructive pulmonary disease (COPD) about home oxygen therapy. Which statement by the client indicates a need for further instruction? Select all that apply. A."I should limit activity as much as I possibly can." B. "If I have trouble breathing, I need to call the doctor." C. "I need to drink lots of fluids to keep my mucus thin." D. "I can apply Vaseline to my nose if the oxygen dries it out." E. "I should wear a scarf over my nose and mouth in cold weather."
A, C
55. A pregnant woman is being admitted to the maternity unit. The woman tells the nurse that she felt a large gush of fluid from her vagina on the way to the hospital. The nurse detects a fetal heart rate of 90 beats/min. On physical examination, the nurse finds that the umbilical cord is protruding from the vagina. Which of the following actions should the nurse perform? Select all that apply. A. Placing the woman in knee-chest position B. Administering oxygen at 2 to 4 L/min by nasal cannula C. Administering terbutaline (Brethine) to stop contractions D. With two gloved fingers, exerting upward pressure, into the vagina, on the presenting part E. Wrapping the cord loosely in a sterile towel saturated with warm sterile normal saline solution
A, D, E
11. A client with diabetes mellitus who is scheduled to have blood drawn for determination of the glycosylated hemoglobin (HbA1C) level asks the nurse why the test is necessary if he is performing blood glucose monitoring at home. The nurse tells the client that this test is used specifically to: A. Detect diabetic complications B. Assess long-term glycemic control C. Determine whether the client is at risk for hypoglycemia D. Determine whether the prescribed insulin dosage is adequate
B
14. A nurse performing an otoscopic examination of an adult client: A. Uses a small speculum to decrease the discomfort B. Pulls the pinna up and back before inserting the speculum C. Tilts the client's head forward before inserting the speculum D. Pulls the earlobe down and back before inserting the speculum
B
16. After a nonimmunocompromised client undergoes a Mantoux test for tuberculosis (TB) infection, an area of induration 6 mm wide develops. The client asks the nurse what this result means. The nurse's best response is: A."We'll have to repeat the test, because the result is inconclusive." B. "The swollen area is small, so that means your test result is negative." C. "You've been exposed to tuberculosis, so you'll need to have a chest x-ray." D. "You need to get started on medication right away, because you've got tuberculosis."
B
21. A nurse is caring for a client in labor who is receiving an oxytocin (Pitocin) infusion. The nurse notes that the client is experiencing uterine hypertonicity. The nurse should immediately: A Contact the physician B Stop the oxytocin infusion C Check the client's blood pressure D Place the client in a side-lying position
B
33. As a nurse is providing care, the client suddenly experiences a tonic-clonic seizure. The nurse would immediately: A Call the physician B Turn the client to the side C Restrain the client's limbs D Insert an airway in the client's mouth
B
36. A client with skeletal traction applied to the right leg complains to the nurse of severe pain in the leg. The nurse realigns the client's position, but this intervention does not relieve the pain. Which action would the nurse take next? A Providing pin care B Calling the physician C Removing some of the traction weights D Medicating the client with the prescribed analgesic
B
37. A nurse is caring for a hospitalized child with newly diagnosed type 1 diabetes mellitus who received NPH and regular humulin insulin at 7:30 am. At 11 am the child suddenly complains of dizziness, headache, and a shaky feeling. The nurse immediately: A Contacts the physician B Gives the child milk to drink C Arranges to have the child's lunch tray delivered early D Prepares to administer intravenous 5% dextrose solution
B
40. A female client is examined in the clinic, and gonorrhea is diagnosed. The nurse provides information to the client about the disease and tells the client that: A Condoms will not help prevent transmission of the infection B Healthcare providers are legally responsible for reporting all cases of gonorrhea to the health authorities C It is not necessary for sexual partners to be examined, because the disease is not highly communicable D Treatment includes the administration of an antibiotic, but it is not necessary for sexual partners to be treated
B
41. A primigravida is admitted to the labor unit. During assessment, the client's membranes rupture spontaneously. What is the priority nursing action? A Checking the amniotic fluid B Checking the fetal heart rate C Assessing the contraction pattern D Preparing for immediate delivery
B
44. A nurse provides information to a pregnant client about foods that are high in iron. Which food, suggested by the client after this discussion, indicates that the client requires further instruction? A Spinach B Tomatoes C Lima beans D Whole-grain bread
B
45. A nurse performing a fundal assessment after a vaginal birth notes that the fundus is above the umbilicus and displaced from the midline. What should the nurse do first? A Massage the fundus B Help the client void C Document the findings D Help the client ambulate
B
47. A client who has just received a diagnosis of asthma says to the nurse, "This is just another nail in my coffin." Which response by the nurse is therapeutic? A "Do you think that having asthma will kill you?" B "You seem very distressed at learning that you have asthma." C "I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your coffin.'" D"Asthma is a very treatable condition, but it's important to learn how to properly administer your medications. Let's practice with your inhalant."
B
58. During a preoperative assessment, a nurse notices the client is crying. In light of this observation, which statement by the nurse is appropriate? A"You seem upset. Would you rather be alone?" B "You're crying. Tell me more about how you are feeling." C "Your surgeon is the best and has done many of these operations." D "Crying before a serious operation is common, but everything will be okay."
B
6. A nurse developing a plan of care for a client with a spinal cord injury includes measures to prevent autonomic dysreflexia (hyperreflexia). Which of the following interventions does the nurse incorporate into the plan to prevent this complication? A. Keeping a fan running in the client's room B. Keeping the linens wrinkle-free under the client C. Limiting bladder catheterization to once every 12 hours D. Avoiding the administration of enemas and rectal suppositories
B
66. An HIV-positive child is scheduled to receive a mumps, measles, and rubella (MMR) vaccine. The laboratory results show the CD4+ as 1000 cells/mm3. Which of the following nursing actions is appropriate? A Contacting the physician B Administering the vaccine C Asking the laboratory to repeat the CD4+ test D Informing the child's mother that the vaccine must not be administered at this time
B
70. A nurse provides home care instructions to an adolescent with sickle cell disease about measures to prevent vaso-occlusive crisis. The nurse should tell the adolescent to: A Restrict fluid intake B Take ibuprofen (Motrin) for discomfort C Take acetylsalicylic acid (aspirin) immediately if a fever develops D Be sure to spend plenty of time in the fresh air and sun each day
B
72. A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his belongings from where he always kept them. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic? A "I know just how you feel, because I lost my husband last summer." B "It's OK to grieve and be angry with your daughter and anyone else for a time." C "You need to focus on the many good years you enjoyed together and move on." D "I know it's a troubling time for you, but try to focus on your children and grandchildren."
B
9. A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should: A. Assess the clear fluid for protein B. Check the clear fluid for the presence of glucose C. Place cotton balls or dry gauze loosely in the ears D. Use an otoscope to assess the tympanic membrane for rupture
B
15. Which of the following infection-control measures would the nurse implement for a client in whom smallpox is diagnosed? Select all that apply. A. Enteric B. Droplet C. Contact D. Standard E. Protective isolation
B, C, D
12. A nurse caring for a client with AIDS is monitoring the client for signs of complications. Which of the following findings would cause the nurse to suspect infection with Pneumocystis jiroveci? Select all that apply. A. Diarrhea B. Tachypnea C. Pedal edema D. Intermittent fever E. Dyspnea when ambulating
B, D, E
38. A nurse is preparing client assignments for the day. Which assignments would be appropriate for a registered nurse who is pregnant? Select all that apply. A. A client with active herpes virus lesions in the perianal area B. A client who requires frequent abdominal wound irrigations C. A client with a solid sealed implanted radiation source who is restricted to bed rest D. A client with methicillin-resistant Staphylococcus aureus (MRSA) under contact precautions E. A client undergoing mechanical ventilation through a tracheostomy who requires frequent suctioning
B, D, E
13. Zidovudine (AZT, Retrovir) is prescribed for a client with AIDS. The nurse tells the client that it is important to report back to the clinic as scheduled for follow-up: A. Blood glucose checks B. Blood pressure checks C. Complete blood counts (CBCs) D. Electrocardiographic (ECG) studies
C
22. A nurse on the day shift receives the client assignment for the day. Which assigned client will the nurse assess first? A A client who has been fitted with a closed chest tube drainage system B A client with a nasogastric tube who underwent bowel resection 2 days ago C A client who was admitted during the night because of congestive heart failure D A client on nothing-by-mouth (NPO) status who is scheduled for a barium enema at 10 a.m.
C
23. An emergency department nurse is caring for an older client who may have been physically abused by her caregiver. In planning care for the client, the nurse makes a priority of: A Notifying the police department B Obtaining psychiatric help for the caregiver C Contacting adult protective services to investigate the situation DTelling the caregiver that he or she is not allowed to care for the client
C
25. A nurse responds to an external disaster in a large city involving an explosion at a shopping mall. Numerous victims require treatment. Which victim will the nurse attend to first? A A victim with multiple bruises who is alert and oriented B A victim who has sustained multiple lacerations with minor bleeding C A victim who is alert and wandering around yelling that he cannot see D A victim with a crush injury to the abdomen who has no pulse or blood pressure
C
30. A nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. On assessing of the client, the nurse notes an apical pulse rate of 58 beats/min and the client complains of anorexia and nausea. Which action should the nurse take first on the basis of these assessment findings? A Contacting the physician B Administering an as-needed antiemetic C Checking the most recent digoxin level D Administering the digoxin with an antacid
C
35. A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes an audible wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. After immediately disconnecting the suction source from the catheter, which intervention does the nurse implement next? A Calling a code B Administering an inhaled bronchodilator C Connecting oxygen to the suction catheter D Encouraging the client to take deep breaths
C
39. A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity. The first action on the part of the nurse is: A Calling the physician B Inserting an oral airway C Turning the client on her side D Noting the time of the seizure
C
42. A postpartum nurse is caring for a client who had a placenta previa. Which nursing intervention does the nurse, reviewing the plan of care, identify as the priority for this client? A Fundal assessment B Monitoring of urine output C Frequent assessment of lochia D Inclusion of iron in every meal
C
43. A rubella titer is performed on a woman who has just been told that she is pregnant. The results of the titer indicate that the mother is not immune to rubella. The nurse tells the client that: A A therapeutic abortion should be considered B Immunization against rubella is required immediately C Immunization against rubella is required after delivery D Antibiotics will be prescribed to prevent the infection
C
48. A nurse is preparing to administer an injection of vitamin K to a newborn. At which site would the nurse select to administer the medication? Write the answer on the back of your scantron. A. Femur B. Femoral vein C. Vastus lateralis D. Patella
C
50. A clinic nurse reviews the record of a pregnant client and notes that the physician has documented that the client exhibits the Hegar sign. The nurse understands that: A Fetal movement is being felt by the mother B A soft blowing sound can be heard when the uterus is auscultated C Softening and compressibility of the lower uterine segment has been detected D The client is experiencing irregular painless contractions during the pregnancy
C
61. A nurse completes an initial assessment of a client admitted to the mental health unit. Which assessment finding is the matter of greatest concern? A Bruises on the client's neck B The client's report of not sleeping well C The client's report of suicidal thoughts D The spouse's statement "I don't approve of this treatment."
C
62. A client who is delusional says to the nurse, "Terrorists have been sent here to kill me." How should the nurse respond to the client? A"No one is going to kill you." B "Your medication is making you feel like this." C "Are you worried that people are trying to hurt you?" D "What makes you think that terrorists were sent to hurt you?"
C
64. A nurse provides information to the mother of a child with diarrhea about signs and symptoms that indicate the need to call the physician. Which statement by the mother indicates the need for further instruction? A"I'll call the doctor if she gets dizzy and acts sick." B "I'll call the doctor if she has severe stomach cramps." C "I'll call the doctor if her temperature is 102° or higher." D "I'll call the physician if she goes longer than 6 hours without urinating."
C
65. A nurse reviewing the medical history of an infant experiencing gastroesophageal reflux (GER) would expect to note documentation of: A Refusal to suck B Frequent diarrhea C Recurrent otitis media D Inability to pass stools
C
67. A nurse reviewing the record of a child with suspected acute poststreptococcal glomerulonephritis notes that the child recently had a streptococcal throat infection that was treated with antibiotics. Which of the following physician prescriptions that will confirm the presence of acute poststreptococcal glomerulonephritis does the nurse expect to find? A Throat culture B Blood urea nitrogen (BUN) C Antistreptolysin (ASO) titer D White blood cell (WBC) count
C
68. In caring for a child admitted to the hospital with Kawasaki disease, the nurse should monitor the child most closely for signs of: A Anemia B Renal failure C Thrombus formation D Gastrointestinal disturbances
C
7. A nurse provides home care instructions to a client who has been fitted with a halo device to treat a cervical fracture. Which statement by the client indicates the need for further instruction? A."I need to get more fluids and fiber into my diet." B. "I should cut my food into small pieces before I eat." C. "I need to put powder under the vest twice a day to prevent sweating." D. "I have to check the pin sites every day and watch for signs of infection."
C
46. A contraction stress test is scheduled, and the nurse provides instructions to the client regarding the test. Which of the following pieces of information should the nurse give to the client? Select all that apply. A. An internal fetal monitor is attached. B. The client will walk on a treadmill until contractions begin. C. A positive test result indicates a need for further evaluation. D. Special body movements will be performed to stimulate contractions. E. The client may be asked to massage one or both nipples to stimulate uterine contractions.
C, E
17. A client's arterial blood gases (ABGs) are analyzed: pH 7.49, Paco2 31 mm Hg, Pao2 97 mm Hg, HCO3- 22 mEq/L. Which of the following acid-base disturbances does the nurse identify from these results? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
D
20. A nurse is monitoring the neurological status of a client who underwent craniotomy 3 days ago. Which of the following signs or symptoms would prompt the nurse to notify the surgeon immediately? A Disorientation to date B Pupils equal and reactive at 4 mm C Mild headache relieved by codeine sulfate D Pain with forward flexion of the neck onto the chest
D
27. A nurse is assigned to conduct an admission assessment of a client who was treated in the emergency department after attempting suicide by cutting her wrists with a razor blade. When the client arrives at the nursing unit, the nurse should first: A Ask the client to sign a no-harm contract B Ask the client to report any suicidal thoughts immediately C Place the client under suicide precautions with 15-minute checks D Check the dressings that were placed over the client's wrists in the emergency department
D
29. A client in a manic state emerges from her room and quickly enters the dayroom. She announces to the group that she is the star of a burlesque show and will begin her performance shortly. The priority nursing action is to: A Ask the client to go to her room and to change her clothes B Tell the client firmly that burlesque shows are not allowed in the nursing unit C Tell the client that her bathroom privileges are being suspended because of her behavior D Quietly and firmly assist the client to her room and help her dress in appropriate clothes
D
3. A nurse is evaluating outcomes for a client with Guillain-Barré syndrome. Which of the following outcomes does the nurse recognize as optimal respiratory outcomes for the client? Select all that apply. A. Normal deep tendon reflexes B. Improved skeletal muscle tone C. Absence of paresthesias in the lower extremities D. Clear sounds in the lower lung fields bilaterally E. Po2 of 85% and Pco2 of 40 mm Hg
D
31. A nurse on the day shift is assigned to care for four clients. Which client will the nurse assess first after receiving report from the night shift? A A client scheduled for an electrocardiogram (ECG) at 11 am B A client on nothing-by-mouth (NPO) status who is for bronchoscopy at 9 am C A client who has undergone above-the-knee amputation who is scheduled for discharge home D A client who had a seizure at 2 a.m. and was treated with intravenous (IV) diazepam (Valium) and phenytoin (Dilantin)
D
34. A nurse is providing care to a client with a closed chest tube drainage system. When the nurse assists the client in turning onto his side, the chest tube is accidentally dislodged from the insertion site. The nurse must immediately: A Contact the physician B Reinsert the chest tube C Turn the client onto his back D Apply pressure over the chest tube insertion site
D
51. A nurse is providing dietary instructions to a pregnant client with diabetes mellitus. The nurse tells the client that: A Fat intake must be increased to ensure that the baby gains weight B A high-protein, high-fat diet is necessary to help control the blood glucose level C Glucose must be increased in the diet because additional calories are needed during pregnancy D It is important to increase fiber in the diet to help control the blood glucose level and prevent constipation
D
52. A nurse performs a bedside glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 35 mg/dL. The nurse would first: A Ask the mother to breastfeed the newborn B Bottle-feed the newborn with diluted glucose C Start an intravenous line for the administration of glucose D Ask the laboratory to perform a blood glucose test immediately
D
54. A nurse is monitoring a client in precipitous labor. The nurse would contact the physician on noting: A Fetal descent of 1 cm/hr B A reassuring fetal monitoring pattern C Cervical dilation of 2 to 4 cm/hr during the active phase D Shortening periods of uterine relaxation between contractions
D
56. A pregnant client complains of heartburn, and the nurse provides instruction regarding measures to alleviate the problem. The nurse tells the client to: A Lie down right after meals B Take antacids as often as necessary C Eat three meals a day and avoid eating between meals D Sleep with an extra pillow under the head and shoulders
D
59. A client hospitalized on a mental health unit with schizophrenia tells the nurse, "The voices in my head say that I'm worthless and that I don't deserve to be alive." What is the nurse's priority concern for this client? A Ineffective coping skills B Perceptual disturbances C Chronic low self-esteem D Risk for self-directed violence
D
63. A client with a manic disorder monopolizes group therapy. What should the nurse leading the group say to the client? A "Leave the room." B "Go to the nurses' station until our group therapy session is finished." C "I will recommend that group therapy be eliminated from your treatment plan." D "Thank you for your comments. Now, try to stop talking and listen to the others."
D
69. A nurse provides dietary instructions to the mother of a child with iron-deficiency anemia. The nurse should tell the mother that the food highest in iron is: A Milk B Cheese C Orange juice D Cream of Wheat
D
8. A nurse is caring for client with increased intracranial pressure (ICP). In which position should the nurse maintain the client? A. Supine, with the head extended B. Side-lying, with the neck flexed C. Supine, with the head turned to the side D. Head midline and elevated 30 to 45 degrees
D
