NCLEX Quiz 2

A pre-op client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

"Can you share with me what you've been told about your surgery?"

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep?

"I drink hot chocolate before bedtime."

The nurse has conducted pre-op teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement?

"I need to continue to take the aspirin until the day of surgery."

The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions?

"I should sleep on my left side."

The nurse is teaching a client about coughing and deep-breathing techniques to prevent post-op complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques?

"Use of an incentive spirometer will help prevent pneumonia."

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which?

A blowing or swooshing noise.

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem?

A physical obstruction to the transmission of sound waves.

The nurse is performing a neuro assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation?

A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed.

The mother of a 3 year old asks a clinic nurse about appropriate and safe toys for the child. The nurse should tell the mother that the most appropriate toy for a 3 year old is which?

A wagon.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action?

Activate the fire alarm.

The nurse is instructing a client on how to perform a testicular self-exam (TSE). The nurse should explain that which is the best time to perform this exam?

After a shower or bath.

The mother of a 3 year old is concerned because her child still is insisting on a bottle at nap time and bed time. Which is the most appropriate suggestion to the mother?

Allow the bottle if it contains water.

A 16 year old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development post-op?

Allow the client to interact with others in the adolescent age group.

The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure?

Allow the newborn infant to signal a need.

The nurse is caring for an older client in a long-term care facility. Which action contributes to encouraging autonomy in the client?

Allowing the client to choose their social activities.

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate?

Check for an air leak, because the bubbling should be intermittent.

The nurse is preparing to administer medication using a client's NG tube. Which actions should the nurse take before administering the medication? Select all that apply.

Check for residual volume; Aspirate the stomach contents; Turn off the suction to the NG tube; Test the stomach contents for a pH indicating acidity.

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

Clamp the NG tube for 30 - 60 minutes following administration of the medication.

The nurse is preparing to initiate an IV line containing a high dose of potassium chloride and plans to use an IV infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action?

Contact the electrical maintenance department for assistance.

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse implement? Select all that apply.

Contact the surgeon; Instruct the client to remain quiet; Prepare the client for wound closure; Document the findings and actions taken.

The nurse is preparing to care for a 5 year old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child?

Crayons and a coloring book.

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several OTC medications that the client has been taking. Which intervention should the nurse take first?

Determine whether there are medication duplications.

The nurse is monitoring a 3 month old infant for signs of ICP. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate?

Document the findings.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply.

Drainage system maintained below the client's chest; 50 mL of drainage in the drainage collection chamber; Occlusive dressing in place over the chest tube insertion site; Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation.

The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a post-op plan of care for the client and should include which intervention in the plan?

Elevate and immobilize the grafted extremity.

The nurse is preparing to insert a NG tube into a client. The nurse should place the client in which position for insertion?

High Fowler's.

The nurse checks for residual before administering a bolus tube feeding to a client with a NG tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take?

Hold the feeding and re-instill the residual amount.

The nurse is providing medication instructions to an older client who is taking digoxin daily. The nurse explains to the client that decreased lean body mass, and decreased glomerular filtration rate, which are age-related body changes, could place the client at risk for which complication with medication therapy?

Increased risk for digoxin toxicity.

The nurse is monitoring the status of a post-op client in the immediate post-op period. The nurse would become most concerned with which sign that could indicate an evolving complication?

Increasing restlessness.

A mother arrives at a clinic with her toddler and tells the nurse that she has a difficult time getting the child to go to bed at night. Which measure is most appropriate for the nurse to suggest to the mother?

Inform the child of bedtime a few minutes before it is time for bed.

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? Select all that apply.

Looking at old snapshots of the family; Participating in a senior citizens program; Visiting the spouse's grave once a month; Decorating a wall with the spouse's pictures and awards received.

A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?

Lying in bed on the unaffected side.

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. Which information should the nurse include in the session? Select all that apply.

Moral development progresses in relationship to cognitive development; A person's ability to make moral judgments develops over a period of time; The theory provides a framework for understanding how individuals determine a moral code to guide their behavior.

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client?

Obtain a telephone consent from a family member, following agency policy.

The nurse is caring for a client who is 1 day post-op for a total hip replacement. Which is the best position in which the nurse should place the client?

On the non-operative side with the legs abducted.

A Spanish speaking client arrives at the triage desk in the ER and states to the nurse, "No speak English, need interpreter." Which is the best action for the client to take?

Page an interpreter from the hospital's interpreter services.

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action?

Perform the Valsalva maneuver.

The RN is preparing to insert a NG tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action?

Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.

The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial action should the nurse take?

Place the tube in a bottle of sterile water.

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan?

Placing the client in a semiprivate room at the end of the hallway.

The nurse is reviewing a surgeon's prescription sheet for a pre-op client that states that the client must be 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 meningitis and implements which transmission-based precautions for this client?

Private room or cohort client.

Which interventions are appropriate for the plan of care for an infant? Select all that apply.

Provide swaddling; Hang mobiles with black and white contrast design; Caress the infant while bathing or during diaper changes.

The nurse is inserting an NG tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate action?

Pull back on the tube and wait until the respiratory distress subsides.

The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse should tell the parent that which factor motivates good and bad actions for the child at the pre-conventional level?

Punishment and reward.

The nurse notes that a 6-year-old child does not recognize that objects exist when the objects are outside of the visual field. Based on this observation, which action should the nurse take?

Report the observation to the health care provider.

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding?

Rhythmic respirations with periods of apnea.

The nurse obtains a prescription from a health care provider to restrain a client and instructs the UAP to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the UAP?

Safely securing the safety device straps to the side rails.

The nurse assesses a client's surgical incision for signs of infection. Which findings by the nurse would be interpreted as a normal finding at the surgical site?

Serous drainage.

The parent of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, which instructions should the nurse provide to the parent? Select all that apply.

Set limits on the child's behavior; Provide a simple explanation of why the behavior is unacceptable.

The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client?

Stridor.

The visiting nurse observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take?

Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens center.

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position?

Supine, with the residual limb supported with pillows.

The nurse is testing the extraocular movement in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?

Test the 6 cardinal positions of gaze.

The nurse is conducting pre-op teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff. The nurse should tell the staff that which child behavior is characteristic of the formal operations stage?

The child has the ability to think abstractly.

The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

The client passively flexes the hip and knees in response to neck flexion and reports pain in the vertebral column.

The nurse is providing instructions to the UAP regarding care of an older client with hearing loss. What should the nurse tell the UAP about older clients with hearing loss?

They respond to low-pitched tones.

A nursing student is presenting a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student explains to the group that which characteristic relates to this stage of development?

This stage is associated with toilet training.

The nurse has just reassessed the condition of a post-op client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?

Urinary output of 20 mL/hr

The nurse is evaluating the developmental level of a 2 year old. Which does the nurse expect to observe in this child?

Uses a cup to drink.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on the client?

Wheezes.

The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response?

"At this age, the child is developing his own personality."

A 2 year old child is treated in the ED for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home?

"We will be sure not to leave hot liquids unattended."

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps employees to identify which client as most typically a victim of abuse?

A woman who has advanced Parkinson's disease.

The ED nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action?

Activate the emergency response plan.

The nurse receives a phone call from the post-anesthesia care unit stating the client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?

Assess the patency of the airway.

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply.

Auscultating lung sounds; Obtaining the client's temperature; Obtaining information about the client's respirations.

The nurse creates a plan of care for a client with a DVT. Which client position or activity in the plan should be included?

Bed rest with elevation of the affected extremity.

The nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral vessel. The nurse checks the HCP's prescription and plans to allow which client position or activity following the procedure?

Bed rest with head elevation no greater than 30 degrees.

Which car safety device should be used for a child who is 8 years old and 4 feet tall?

Booster seat.

The nurse is assessing for correct placement of the NG tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35. Based on this information, which action should the nurse take at this time?

Call the HCP to request a prescription for a chest radiograph.

The mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action?

Call the Poison Control Center.

The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin?

Crusting.

The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse should expect to note? Select all that apply.

Decline in visual acuity; Increased susceptibility to UTI; Increased incidence of awakening after sleep onset.

The nurse assesses the vital signs of a 12 month old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. On the basis of this finding, which action is most appropriate?

Document the findings.

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply.

Encourage expression of feelings, concerns, and fears; Touch and hold the client's or family member's hand if appropriate; Be honest and let the client and family know they will not be abandoned by the nurse.

A 4 year old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears?

Encourage the child's parents to stay with the child.

The nurse is giving a report to the UAP who will be caring for a client who has hand restrains. The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently?

Every 30 minutes.

Contact precautions are initiated for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?

Gloves, gown, goggles, and a mask or face shield.

While changing the tapes on a newly inserted tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action?

Grasp the retention sutures to spread the opening.

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?

Have the client void immediately before going into surgery.

A client who has undergone pre-admission testing has had blood drawn for serum lab studies, including a CBC, coagulation studies, and electrolyte & creatinine levels. Which lab result should be reported to the surgeon's office by the nurse, knowing that it would cause surgery to be postponed?

Hemoglobin, 8.0 g/dL (80 mmol/L)

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply.

Inhalation of bacterial spores; Through a cut or abrasion in the skin; Ingestion of contaminated undercooked meat.

The nurse working in the ED is assessing a client who recently returned from Liberia and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next?

Isolate the client in a private room.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position?

Left Sim's position.