NCLEX Review

The LPN is caring for a patient who is recovering from cataract surgery. Which of these statements, made by the patient, requires clarification from the nurse? - "I know it's normal for my eyes to feel irritated or itchy after surgery, so I will use my Visine eyedrops as needed." - "I know I may need glasses for a while after this surgery." - "My eye should be completely healed after about 8 weeks." - "I will call the office if I start to see "light flashes" or "floaters" in front of my eyes."

- "I know it's normal for my eyes to feel irritated or itchy after surgery, so I will use my Visine eyedrops as needed."

A client has been admitted for UTI and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? - 6 mg/dL - 15 mg/dL - 29 mg/dL - 35 mg/dL

- 15 mg/dL

How far down from the urinary meatus should you wash an indwelling catheter during perineal car for the female client? - 8 inches in a downward manner - 8 inches in an upward manner - 4 inches in a downward manner - 4 inches in an upward manner

- 4 inches in a downward manner

A patient is on a clear liquid diet. She drinks half of a 12-ounce juice, 4 ounces of soup, and has a 6-ounce Jell-O. How many milliliters of fluid did the patient ingest? - 440 mL - 480 mL - 660 mL - 22 mL

- 480 mL

During data collection, which behavior should the nurse expect a client diagnosed with agoraphobia to describe? - A fear of leaving the house - A fear of riding in elevators - A fear of speaking in public - A fear on uncleanliness and the need to bathe every hour

- A fear of leaving the house

Which of these patients should the LPN/LVN see FIRST? - A patient newly diagnosed with Hep A who reports stomach pain and itchy skin - A patient with a newly placed NG tube who is complaining of pain around the face and a plugged nose - A post-op prostatectomy patient who complains of bladder spasms and blood in his foley bag - A patient in an arm cast who is 2 days post-op and reports feelings of numbness and tingling in her affected arm

- A patient in an arm cast who is 2 days post-op and reports feelings of numbness and tingling in her affected arm

Bilirubin is?

- A yellowish substance found in bile - It is produced by the body when RBCs are broken down by the liver

A nurse is preparing to examine a preschool-age child. Which of the following actions should the nurse take to prepare the child? - Allow the child to role-play using miniature equipment. - Use medical terminology to describe what will happen. - Separate the child and the parent during the examination. - Keep the medical equipment visible to the child.

- Allow the child to role-play using miniature equipment. - This reduces fear and anxiety related to the examination.

The parent of a 5-year-old child calls the clinic to report the recurrence of a nosebleed for which the child was seen a week ago. Which of the following instructions should the nurse reinforce? (SATA) - Apply a cold cloth to the bridge of the nose - Apply continuous pressure to the nose for 10 minutes - Attempt to keep the child calm and quiet - Have the child lie down and turn to the left side - Take the child to the emergency department

- Apply a cold cloth to the bridge of the nose - Apply continuous pressure to the nose for 10 minutes - Attempt to keep the child calm and quiet

A newly diagnosed diabetic is receiving consultation about the disease process. The nurse explains that insulin is normally secreted from the? - Alpha cells of the liver - Alpha cells of the pancreas - Beta cells of the liver - Beta cells of the pancreas - Thymus

- Beta cells of the pancreas

A nurse is assisting with the care for a client who is at 32 weeks gestation and has a placenta previa and is actively bleeding. Which of the following medications should the nurse anticipate the provider will prescribe? - Betamethasone - Indomethacin - Nifedipine - Methylergonovine

- Betamethasone - Given to promote lung maturity if delivery is anticipated

A nurse is assisting with the care for a client who has a marginal abruptio placentae. Which of the following findings are risk factors for developing this condition? (SATA) - Fetal position - Blunt abdominal trauma - Cocaine use - Maternal age - Cigarette smoking

- Blunt abdominal trauma - Cocaine use - Cigarette smoking

A woman who is 36 weeks pregnant arrives at the L&D unit complaining of vaginal bleeding. Which signs/symptoms indicate that the client's bleeding is caused by placenta previa? (SATA) - Rigid, boardlike abdomen - Bright red vaginal bleeding - Lack of uterine contractions - Pain rating of 6 on a scale from 0 to 10 - FHR below 100 bpm

- Bright red vaginal bleeding - Lack of uterine contractions

What are the three types of normal breath sounds?

- Bronchial ("tracheal" or "tubular" - Bronchovesicular (heard over major bronchi) - Vesicular (heard over peripheral lung fields where the air enters the alveoli)

The nurse is collecting respiratory data from an adult client and is auscultating for normal breath sounds. The nurse should expect to hear bronchial breath sounds in which anatomical area?

- Bronchial breath sounds are heard over the trachea and larynx.

A client who experienced a missed abortion would report what?

- Brownish discharge and no pain

A client comes to a HCP's office complaining of a bite on the arm. The client reports that he recently removed a tick from the same location. Which characteristic is a classic sign of Lyme disease that can result from an infected tick? - Bull's-eye rash - Path of oval lesions - Painful rash around a necrotic lesion - Line of papules and vesicles that appear 1 to 3 days after exposure

- Bull's-eye rash

An LPN is taking care of an adult male diabetic patient who complains of feeling shaky and sweaty. What is the first thing the LPN should do? - Check his blood sugar. - Offer him 15-20 g of simple carbohydrates (raisins or crackers). - Give him his insulin dose. - Notify the RN on duty.

- Check his blood sugar

Which of these would be an appropriate meal for a patient with Celiac disease? - Chicken and rice, apple, and tapioca pudding - Granola and dried apricots with cow's milk - Egg noodles with cream sauce and broccoli, oat cookie, almond milk - Turkey sandwich with rye bread, carrots

- Chicken and rice, apple, and tapioca pudding

Numbness and tingling hours or days after a cast is applied may indicate what?

- Compartment syndrome

A mother of a child with cystic fibrosis asks the clinic nurse about the disease. How should the nurse respond to the mother about the disease? - Cystic fibrosis is transmitted as an autosomal dominant trait. - Cystic fibrosis is a chronic multisystem disorder affecting the exocrine glands. - Cystic fibrosis is a disease that cause the formation of multiple cysts in the lungs. - Cystic fibrosis is a disease that causes dilation of the passageways of many organs.

- Cystic fibrosis is a chronic multisystem disorder affecting the exocrine glands.

A client who has a hydatidiform mole usually has?

- Dark brown vaginal bleeding in the second trimester with no abdominal pain

Signs and symptoms of myxedema include?

- Decrease in appetite, but an increase in weight (slow metabolic rate) - Bagginess under the eyes - Swelling of the face

A nurse is assisting with the care of a client who is receiving nifedipine for prevention of preterm labor. The nurse should monitor the client for which of the following manifestations? - Blood-tinged sputum - Dizziness - Pallor - Somnolence

- Dizziness

Your older female patient has recently been prescribed long-acting tramadol for severe arthritis pain. She takes 200 mg PO daily in the morning and reports that her pain has decreased from 8/10 down to 3/10. However, she complains of drowsiness. What precautions should you advise this patient to take? - Increase her intake of caffeinated beverages to counteract drowsiness. - Do not drive or operate dangerous equipment until her body has adjusted and she no longer feels drowsy. - Stop taking the medication and make an appoint with her PCHP to discuss her drowsiness. - Decrease the dose to 100 mg daily to decrease drowsiness.

- Do not drive or operate dangerous equipment until her body has adjusted and she no longer feels drowsy.

A nurse in the ED is caring for a client who reports abrupt, sharp, right lower quadrant abdominal pain and bright red vaginal bleeding. The client states she missed one menstrual cycle and cannot be pregnant because she has an IUD. The nurse should suspect which of the following? - Missed abortion - Ectopic pregnancy - Severe preeclampsia - Hydatidiform mole

- Ectopic pregnancy

A postpartum nurse obtains the vital signs on a mother who delivered a healthy newborn 2 hours ago. The mother's temperature is 100 F (38 C). What is the initial nursing action? - Document the finding - Encourage oral fluid intake - Administer acetaminophen - Notify the PHCP

- Encourage oral fluid intake

How often should vitals be monitored during post-op period?

- Every 15 minutes in the first hour - Every 30 minutes for the next hour - Every hour thereafter

Hispanic American culture beliefs

- Eye behavior is significant ("bad/evil eye" can be given to a child if a person looks at and admires a child w/o touching the child.) - Avoiding eye contact indicates respect and attentiveness

The LPN is instructing a patient on post-op care after nasal surgery. Which of these statements would be incorrect? - Glasses may be worn with the nasal splint in place. - Feelings of numbness and facial fullness around the nose should be reported immediately. - Sleep propped up at a 45 degree angle for the first few post-op days. - Needing to change the gauze under the nose every 15 minutes for the first few hours after surgery is expected.

- Feeling of numbness and facial fullness around the nose should be reported immediately.

Signs and symptoms of abruptio placentae?

- Fetal distress - Rigid, boardlike abdomen - Painful contractions - Dark vaginal bleeding

A nurse is assisting with the care of a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication? (SATA) - Fetal distress - Preterm labor - Vaginal bleeding - Cervical dilation greater than 6 cm - Severe gestational hypertension

- Fetal distress - Vaginal bleeding - Cervical dilation greater than 6 cm

Obstructive Sleep Apnea (OSA)

- Found most often in older obese males - Lack of airflow due to an obstruction of the pharynx during sleep - Often report daytime tiredness, sore throat, and headaches

Infection control measures for contact precautions?

- Hand hygiene (soap & water for C. diff) - Nonsterile gloves - Gown - Private room preferred

The nurse is reviewing the health record of an infant with a diagnosis of gastroesophageal reflux. Which signs/symptoms of this disorder should the nurse expect to note documented in the record? - Excessive oral secretions - Bowel sounds heard over the chest - Hiccupping and spitting up after a meal - Coughing, wheezing, and short periods of apnea

- Hiccupping and spitting up after a meal

The graduate nurse is reinforcing education on sitting on and standing up from a chair to a client with crutches. Which instruction by the graduate nurse would cause the supervising nurse to intervene? - Hold a crutch in each hand for support when standing up from a chair - Move to the edge of the chair before standing and use the unaffected leg to rise - Touch the back of the unaffected leg to the chair before preparing to sit - Use an armrest or seat for assistance when lowering the body into a chair

- Hold a crutch in each hand for support when standing up from a chair

The LPN is about to give 100 mg Lopressor (metoprolol) to a patient. Before administering the drug, he takes the patient's vitals, which are as follows: - Pulse: 58 bpm - Blood Pressure: 90/68 mm Hg - Respirations: 18 breaths per minute Which actions should the LPN take? - Give the patient half the prescribed dose and report the findings to the RN on duty. - Give the patient double to the dose and report the findings to the RN on duty. - Administer the drug and report the findings to the RN on duty. - Hold the drug and report the findings to the RN on duty.

- Hold the drug and report the findings to the RN on duty.

A nurse at an antepartum clinic is caring for a client who is at 16 weeks gestation. The client reports continued nausea and vomiting and scant, prune-colored discharge. She has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse expect? - Hyperemesis gravidarum - Threatened abortion - Hydatidiform mole - Preterm labor

- Hydatidiform mole

Lopressor (metoprolol) is given to treat?

- Hypertension - A pulse of 58 bpm and a B/P of 90/68 mm Hg are considered low. - *Many facilities recommend holding B/P medication at 60 bpm and a systolic pressure of 90 or less.*

The LPN is caring for a 32-year-old female patient who is 8 hours post-op after a tonsillectomy. Which of these would be an appropriate action taken by the nurse? - Inform the patient that ear pain may occur and is normal. - Provide ice water and a straw to promote easy fluid consumption. - Provide hot tea to soothe the throat. - Monitor vitals every 15 minutes.

- Inform the patient that ear pain may occur and is normal. - Referred pain in the ear is normal because of related nerve pathways.

Insulin is synthesized and released from the beta cells of the?

- Islets of Langerhans

The nurse has given simple instructions on preventing some of the complications of bed rest to a client who experienced a myocardial infarction. The nurse should intervene if the client were performing which of these contraindicated activities? - Deep breathing and coughing - Repositioning self from side to side - Isometric exercises of the arms and legs - Ankle circles, plantar, and dorsiflexion exercises

- Isometric exercises of the arms and legs

A client with myxedema has changes in intellectual function such as impaired memory, decreased attention span, and lethargy. The client's husband is upset and shares his concerns with the nurse. Which statement by the nurse is helpful to the client's husband? - Give it time. I've seen dozens of clients with the problem that fully recover. - I don't blame you for being frustrated because the symptoms will only get worse. - Would you like me to ask the PHCP for a prescription for a stimulant? - It seems that you are concerned about your wife's condition, but the symptoms may improve with continued therapy.

- It seems that you are concerned about your wife's condition, but the symptoms may improve with continued therapy.

A nurse is reinforcing discharge teaching with a client who experienced premature rupture of membranes at 26 weeks gestation. Which of the following information should the nurse include in the instructions? - Use a condom with sexual intercourse - Avoid bubble bath solution when taking a tub bath - Wipe from back to front when performing perineal hygiene - Keep a daily record of fetal kick counts

- Keep a daily record of fetal kick counts

Neutropenia

- Less than normal amount of WBCs. - Transmission-based isolation precautions

An elevated bilirubin level may be a sign of? - Liver disease - Lung disease - Colon disease - Heart disease

- Liver disease

Contact precautions for which organisms?

- MDR organisms (MRSA, VRE) - Enteric organisms (C. diff) - Scabies

A 70-year-old obese male is admitted to the cardiac unit with new onset of atrial fibrillation. While in the hospital, the night shift nurse notes that the patient is snoring loudly, then waking abruptly. In the early morning, he reports being excessively tired during the day. The nurse is suspicious for which of the following? - Narcolepsy - Delayed phase sleep disorder - Circadian rhythm disturbance - Obstructive sleep apnea

- Obstructive sleep apnea

A patient placed under neutropenic precautions asks you how she can prevent infection. Which advice would be most appropriate? - Wash hands when finished cleaning up after pets. - Only brush teeth once a day or every other day. - Do not let visitors within 10 feet. - Only use pads for menstrual periods.

- Only use pads for menstrual periods. - Tampons may cause tears in the vagina that could lead to infection

Perineal care for females and males with indwelling urinary catheter includes?

- Performed with a clean washcloth and soap - Cleaning begin at the urinary meatus and 4 inches below it using short strokes in a downward manner. - Rinse in same direction - Clean from the "cleanest" area to the "dirtiest" area in order to prevent infection.

Home management of epistaxis includes?

- Prioritizing application of direct, continuous pressure to the soft, compressible area below the nasal bone for 10 minutes to promote clot formation - Hold a cold cloth or ice pack to the bridge of the nose to induce vasoconstriction and slow bleeding - Attempting to keep the client quiet and calm helps with implementing interventions and stopping bleeding

The nurse is caring for a homebound older post-op cardiovascular client. The caregiver's daughter says to the nurse, "My mother has fallen out of bed three times." Which actions should the nurse reinforce to prevent falls? (SATA) - Provide adequate lighting - Apply a restraint to keep her in bed at night - Ensure that frequently used items are easily accessible - Have the bedside stand and overbed tray table within reach - Leave the side rails down to reach books stacked on the floor by the bed

- Provide adequate lighting - Ensure the frequently used items are easily accessible - Have the bedside stand and overbed tray table within reach

The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate action? - Insert the tube quickly - Notify the PHCP immediately - Remove the tube and reinsert it when the respiratory distress subsides - Pull back on the tube and wait until the respiratory distress subsides

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

A 4-week-old infant is brought to the pediatrician's office with symptoms of weight loss, irritability, and projectile vomiting. On physical examination the infant appears dehydrated. From these symptoms the nurse suspects that the infant probably has? - Tetralogy of Fallot - Pyloric stenosis - Esophageal atresia - Intussusception

- Pyloric stenosis

A nurse is assisting with the care of a client who has a diagnosis of ruptured ectopic pregancy. Which of the following findings is expected with this condition? - No alteration in menses - Transvaginal ultrasound indicating a fetus in the uterus - Serum progesterone greater than the expected reference range - Report of severe shoulder pain

- Report of severe shoulder pain - Due to the presence of blood in the abdominal cavity, which irritates the diaphragm and phrenic nerve.

The nurse is caring for a client with Clostridium difficile colitis. Which of the following infection control measure by the nurse are appropriate? (SATA) - Applies sterile gloves before performing client care - Ensures surgical masks are worn by staff in the client's room - Requests that the client be assigned to a single-client room - Uses alcohol-based sanitizers for hand hygiene - Wears a single-use, disposable gown during client care

- Requests that the client be assigned to a single-client room - Wears a single-use, disposable gown during client care

An LPN works on an adult medical/surgical unit and has been pulled to work on the burn unit, which cares for patients of all ages. What should she do? - She should refuse to take the assignment, as caring for infant and child population is not within his scope of practice. - She should take the assignment but asked to be paired with a more experienced LPN. - She should take the assignment, but explain the situation to the charge nurse and ask for a quick orientation before starting. - She should take the assignment, but make it clear she will only care for adult patients.

- She should take the assignment, but explain the situation to the charge nurse and ask for a quick orientation before starting.

During the first 24 hours following delivery, the mother's temperature may rise to 100 F as a result of?

- The dehydrating effects of labor. - Initial nursing action is to encourage fluid intake.

The LPN is taking care of a female patient scheduled for an MRI later today. Which of these would require further action from the nurse? - The patient has a broken leg. - The patient ate juice and a bagel 5 hours ago. - The patient has a hemoglobin level of 11.8. - The patient has a cochlear implant.

- The patient has a cochlear implant.

The LPN is caring for a post-op patient who had an open appendectomy. Where would he look to check the incision site? - The right lower quadrant - The left upper quadrant - The left lower quadrant - The right upper quadrant

- The right lower quadrant

Why should a patient who experienced a MI avoid isometric exercises

- These increase intra-abdominal and intrathoracic pressures and can decrease the cardiac output. - They also trigger vagal stimulation causing bradycardia.

A Hispanic American mother brings her child to the clinic for an examination. Which is most important when gathering data about the child? - Avoiding eye contact - Using body language only - Avoiding speaking to the child - Touching the child during the examination

- Touching the child during the examination

The nurse is assessing a patient suspected of having a duodenal ulcer. The patient admits to having a family history of this disease. The nurse knows that another known risk factor for duodenal ulcers is which of the following blood types? - Type A - Type AB - Type B - Type O

- Type O

What are manifestations of an ectopic pregnancy?

- Unilateral lower quadrant pain with or without bleeding. - Use of an IUD is a risk factor

A nurse is reviewing the medical record of a client who reports indications of preterm labor. Which of the following client findings are risk factors of this condition? (SATA) - Urinary tract infection - Multifetal pregnancy - Oligohydramnior - Diabetes mellitus - Uterine abnormalities

- Urinary tract infection - Multifetal pregnancy - Diabetes mellitus - Uterine abnormalities

Clinical manifestations of gastroesophageal reflux include?

- Vomiting (spitting up) after a meal - Hiccupping - Recurrent otitis media r/t pooled secretions in the nasopharynx during sleep

A 27-year-old female patient comes in complaining of calf pain. Which question, if asked by the LPN, would be the least helpful? - Have you traveled recently? - What supplements do you take? - Are you on birth control? - Are you a smoker?

- What supplements do you take? - Vitamin supplements are not a risk factor for developing DVT.

The LPN is placing a foley in a female patient. What is the correct order of the procedure?

1. Place the patient in a supine position with flexed knees. 2. Prepare the sterile field. 3. Check catheter balloon for patency. 4. Place lubrication on catheter. 5. Separate labia with non-dominant hand. 6. Clean the urinary meatus using cleansing solution and forceps. 7. Place catheter in meatus with dominant (sterile) hand. 8. Inflate catheter balloon.

What is the normal blood urea nitrogen (BUN) reference range for an adult?

10-20 mg/dL

Agoraphobia

A fear of open spaces

Methylergonovine is prescribed for?

A client experiencing postpartum hemorrhage

Indomethacin is prescribed for?

A client in preterm labor

What is compartment syndrome?

A restriction of blood flow that occurs in or more muscle compartments of the extremities. Caused by external or internal pressure.

Myxedema

A very low thyroid production

Celiac disease

An immune disease that affects the gastrointestinal tract, which makes the individual intolerant to gluten products.

Pyloric stenosis

Narrowing of the opening from the stomach to the first part of the small intestine.

Cystic Fibrosis affects the exocrine glands, what is happening in these glands?

The mucus produced by these glands (particularly those of the bronchioles, small intestine, and the pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs.

Abruptio placentae

The placenta is separated from the uterus.

Placenta previa

The placenta's placement is over or partially covering the cervix.