Archer NCLEX

A At the 24 week visit, a pregnant woman demonstrates less than expected growth in uterine size, an easly palpable fetus that can be outlined by the nurse, and the absence of fetal ballottement. Which of the following is this most kely related to the development of? A. Hydramnios B. Oligohydramnios C. Amniotic fluid embolism D.Macrosomia

C. Oligohydramnios

What is the nurse's best response to a patient who says she had a positive over-the-counter pregnancy test? A. A possible sign of pregnancy. B. Presumptive sign of pregnancy. C. Probable sign of pregnancy. D. A positive sign of pregnancy.

C. Probable sign of pregnancy

The patient with tuberculosis is now on isoniazid. Which laboratory test should be monitored at least monthly? A. PT and PTT B. CBC C. BUN D. Liver enzymes

D. Liver enzymes

You are preparing for morning medication passes and have a patient with the following order: 18 mg Senna BID, PO. The bottle you pull from the medication bin reads: 8.8 mg/5mL How many mL of Senna do you administer to your patient? Round to the nearest tenth of a mL.

10.2 mL

The nurse is administering digoxin to her 15-year old patient with congestive heart failure. She knows to verify the pulse rate before administering the medication and holds it for a pulse less than____.

70

A patient is started on a daily amount of phenytoin 200 mg PO in two divided doses. What instruction from the nurse is incorrect? A. "You will need annual labs to determine the medication level in your body." B. "Remember never to skip a dose of this medication." C. "You need to increase your intake of vitamin D while taking this medication." D. "Maintain good oral hygiene and visit your dentist regularly."

A. "You will need annual labs to determine the medication level in your body.

The nurse is caring for assigned patients; which of the following patients should the nurse identify is at highest risk for falling? A. 88-year-old admitted with a chest tube secondary to pneumothorax and history of dementia. B. 44-year-old admitted with heart failure, has a peripheral IV, and receiving IV furosemide. C. 33-year-old admitted with cholecystitis, has a peripheral IV, and is receiving IV hydromorphone. D. 28-year-old admitted with bacteremia, is receiving intravenous fluids via central line, and is diaphoretic.

A. 88-year-old admitted with a chest tube secondary to pneumothorax and history of dementia.

The nurse is caring for a patient who is receiving prescribed varenicline. Which of the following statements, if made by the patient, would indicate a therapeutic response? A. " I am not smoking cigarettes anymore." B. "My depression has gotten better C. "I am sleeping eight hours a night" D. "I can focus on one task at a time."

A. "I am not smoking cigarettes anymore."

While caring for a patient who is suspected of having appendicitis, the nurse overhears his conversation with a loved one. Which of the following statements would prompt immediate intervention? A. "The pain doesn't feel as bad now, I think it was just a stomach ache." B. "Would you mind getting me an ice pack? C. I know I'm not supposed to eat anything right now, but I'm hungry." D. "1 wonder if I can play in the basketball game on Monday."

A. "The pain doesn't feel as bad now, I think it was just a stomach ache."

The nurse has provided medication instruction to a patient who has been prescribed metformin. Which of the following statements, if made by the patient, would indicate a correct understanding of the teaching? A. This medication may cause me to have bloating or loose stools. B. 1 will need to check my blood glucose prior to taking this medication." C. If i eat fewer carbohydrates in a day, I should skip a dose D. The goal o this medication is to increase my hemoglobin A1C.

A. "This medication may cause me to have bloating or loose stools."

The nurse is caring for the following assigned clients. The nurse should prioritize a patient with which of the following? A. A patient being evaluated for chest pain and requests an antacid for indigestion. B. A patient reporting nervousness following the administration of albuterol. C. A patient requesting pain medication for their chronic knee and back pain. D. A patient awaiting discharge teaching on their insulin pump and glucometer.

A. A patient being evaluated for chest pain and requests an antacid for indigestion.

A. A patient with hyperemesis gravidarum B. A patient in renal failure C.A patient in diabetic ketoacidosis D. A patient with third degree burns

A. A patient with hyperemesis gravidarum

When assessing a 4-month-old male infant, the LPN correctly evaluates his heart rate by performing the following actions? A. Auscultates the 4th intercostal space at the mid-clavicular line for 60 seconds. B. Palpates the 5th intercostal space at the mid-clavicular line for 30 seconds. C. Palpates the brachial pulse for 60 seconds. D. Auscultates the radial pulse for 30 seconds.

A. Auscultates the 4th intercostal space at the mid-clavicular line for 60 seconds.

You are caring for a 1 month-old infant who has a sudden cardiac arrest. Which pulse should you palpate to determine circulatory status? A. Brachial B. Femoral C. Carotid D. Popliteal

A. Brachial

The nurse is educating a new nurse starting on her unit about the causes of bacterial tonsillitis in children. She correctly explains that which of the following is the most common cause of bacterial tonsillitis. A. Group A beta hemolytic streptococcus B. Streptococcus pneumoniae C. Group B streptococcus D. Neisseria meningitidis

A. Group A beta hemolytic streptococcus

The nurse in caring for a patient exhibiting signs of poor muscle coordination, stooped posture, and slow movements. The medication most likely to cause these symptoms would be which of the following? A. Haloperidol B. Nifedipine C. Venlafaxine D. Prazosin

A. Haloperidol

The nurse is monitoring a patient on a continuous telemetry monitor. She notes a flattened P wave, prolonged PR interval, widened QRS complex, and a tall t-wave. Which of the following electrolyte abnormalties does she suspect? A.Hypermagnesemia B. Hypomagnesium C. Hyperphosphatemia D. Hypochloremia

A. Hypermagnesemia

The nurse is caring for a patient who has pertussis. Which infection control precaution should the nurse implement? A. Wear a surgical mask prior to entry B. Provide disposable dishes for meals C. Keep the patient's room door closed D. Provide the patient with a portable fan E. Maintain negative air pressure F. Apply an N95 mask to the patient during transport. G. Place the patient in a room near the nurse's station.

A. Wear a surgical mask prior to entry

The nurse is caring for a patient who intentionally overdosed on amitriptyline. What action should the nurse prioritize? A. Obtain a 12-lead electrocardiogram B. Request a prescription to consult psychiatry. C. Determine the reasoning for the overdose D. Establish a therapeutic relationship

A. Obtain a 12-lead electrocardiogram

When the nurse begins to irrigate a Salem Surmp tube, she notices that the gastric drainage is dark brown. What is the first intervention the nurse should take? A. Perform a hemoccult test on the contents. B. Irrigate the tube and check the returns. C. Remove the tube from the suction. D. Check the pH of the gastric contents.

A. Perform a hemoccult test on the contents.

Your 78-vear-old client, who has been receiving antibiotics for 10 days, tells you that he has frequent watery stools. Which action will you take first? A. Place the client on contact precautions. B. Instruct the client about correct handwashing techniques. C. Obtain stool specimens for culture. D. Notify the physician about the loose stools.

A. Place the client on contact precautions.

The nurse is caring for a child diagnosed with a coarctation of the aorta who is scheduled for a repair tomorrow morning When she auscultates his lung sounds, she notes crackdes and rales. The nurse knows this is a sign of which afthe following? A. Pulmonary congestion B. Foreign body aspiration C. Pneumonia D. Systemic congestion

A. Pulmonary congestion

The nurse is caring for a patient who that is prescribed enoxaparin. Which of the following findings in the medical history would require follow- up with the primary healthcare physician? A. Recent spinal surgery B. Diabetes mellitus C. Osteoarthritis D. Venous thromboembolism

A. Recent spinal surgery

Which of the following nursing actions reflects effective time management? A. The nurse ask the patient what their priority is to accomplish each day. B. The nurse includes a "nice to do" for every "need to do" task on the list C. The nurse " front- loads" the schedule with " must- do" priorities. D. The nurse avoids helping other nurses if scheduling does not permit it.

A. The nurse ask the patient what their priority is to accomplish each day.

Which of the following is a priority for the nurse to monitor during acute management of a patient with an aspirin overdose? A. The onset of pulmonary edema B. Metabolic alkalosis C. Respiratory alkalosis D. Symptoms that mimic Parkinson's disease

A. The onset of pulmonary edema

The nurse is caring for a patient with a tracheostomy. Which of the following items is essential to have at the bedside? A. Air humidifier B. Inner cannula C. Nasal cannula oxygen D. Tracheostomy brush

B. Inner cannula

The nurse is taking vital signs for a client who has a chest tube in place. While counting his respirations she notes that the water in the water-seal-chamber is fluctuating, Which of the following actions are appropriate based on this finding? A.Finish counting the cient's respirations B.Empty the water-seal chamber C. Assist the patient with incentive spirometry D.Notify the RN

A.Finish counting the cient's respirations

A gastrointestinal disease of childhood where a piece of bowel goes backward inside itself, forming an obstruction is called what? A. Intussusception B. Pyloric stenosis C. Hirschsprung's disease D. Omphalocele

A.Intussusception

The LPN is reinforcing education to a client about modifiable risk factors and risk factors that not. Which of the following is most likely able to be corrected? A. Genetic predisposition B. Lifestyle choices C. Depression D. All of the above

B. Lifestyle choices

Your newly assiggned clent has a history of chronic obstructive pulmonary dsease (COPO), When you enter his room you find his onggen is running at 6 Limin, his color is flushed, and his respirations are amin. What should you do. FIRST? A. Place the diert in high Fowler's position. B. Lower the oxygen rate. C. Take baseline vital sigs D. Obtain an EKG.

B. Lower the oxygen rate

A. The patient should be counseled to increase their fiuid intake." B. "A 24-hour urine will be needed to confirm the diagnosis." C. "Risk factors include frequent intercourse and douching." D. "Cranberry concentrate may be used to prevent future infections."

B. "A 24-hour urine will be needed to confirm the diagnosis." [46%]

The nurse is visiting a patient who was recently prescribed antihypertensive medications. Which statement, if made by the patient, requires follow-up? A. "My pulse decreases after taking my metoprolol." B. "I started taking my furosemide right before I went to sleep." C."1 am seasoning my foods without salt while on lisinopril." D. I wear my clonidine patch for seven days.

B. "I started taking my furosemide right before I went to sleep."

A client is diagnosed with a spontaneous pneumothorax, which results in the need to insert a chest tube. What is the BEST explanation for the nurse to provide this client? A. The tube will prevent you from having chest pains." B. "The tube will remove excess air from your chest." C. The tube controls the amount of air that enters your chest." D. "The tube will seal the hole in your lung."

B. "The tube will remove excess air from your chest."

COMBO While caring for an B-month-okd child admitted for dehydration, the nurse prepares to administer an V fluid bolus She knows that the appropriate amount of fluid to apply is based on the child's weight and would be which of the following? A. 10 mL/kg B. 20 mL/kg C 30 mL/kg D. 40 mL/kg

B. 20 mL/kg

Which advice is most appropriate for a patient on neutropenic precautions who wants to learn ways to prevent infection? A. Only brush your teeth once a day or every other day. B. Avoid the use of tampons for menstrual periods. C. Do not let visitors within 10 feet. D. Wash hands after handling pets.

B. Avoid the use of tampons for menstrual periods.

What behavior would the nurse expect to see in a couple that is over the age of 35 and expecting a baby? A. Increased financial concern related to costs associated with the birth. B. Increased confidence related to previous childbirth experiences. C. Increased anxiety of physical risk related to maternal age. D. Moderate anxiety related to uncertainty about fetal well being.

D. Moderate anxiety related to uncertainty about fetal well being.

When assessing the new stoma of a client diagnosed with Crohn's disease, which will alert the healthcare provider that the stoma has retracted? A. Narrowed and flattened B. Concave and bowl-shaped C. Dry and reddish-purple D. Pinkish-red and moist

B. Concave and bowl- shaped

The LPN is asked to check the client's respirations. Which of the following should the LPN perform? A. Place one hand over the patient's chest and count for 30 seconds. B. Count the respirations for one minute while simultaneously checking the client's pulse. C. Observe and count respirations for 30 seconds, then multiply by two without mentioning to the client that the respirations are being counted. D. If respirations are irregular, ask the patient to rest for 10 minutes, then reassess the respiratory rate.

B. Count the respirations for one minute while simultaneously checking the client's pulse.

Which of the following steps is the final step used during the physical assessment of the abdomen? A. Inspection B. Deep palpation C. Percussion D. None of the above

B. Deep palpation

Which of the following medications may be prescribed to control hypertension associated with nephroblastoma? A. Propranolol B. Enalapril C. Nitroprusside D. Digoxin

B. Enalapril

Which of the following findings would prompt immediate investigation when performing an assessment of a patient on a medical/surgical unit? A. Bowel sounds of 14 per minute. B. High-pitched bowel sounds at a rate of 4 per minute. C. Bowel sounds greater than 60 per minute. D. Low-pitched bowel sounds at a rate of 30 per minute. [14%]

B. High pitched bowel sounds at a rate of 4 per minute.

The nurse is reviewing newly prescribed medications for patient taking lithium. Which medication requires further follow-up? A. Venlafaxine B. Hydrochlorothiazide C. Gabapentin D. Losartan

B. Hydrochlorothiazide

Which of the following diseases decreases the metabolic rate? A. Cancer B. Hypothyroidism C. Chronic obstructive pulmonary disease D. Cardiac failure

B. Hypothyroidism

The LPN is attending to a client who presents to the emergency department after suffering a burn injury. He describes the burn as extremely painful. Select the zone corresponding to the area up to which the wound could be extending. See the exhibit. A.I B.II C.II D.IV

B. II

After failing a final anatomy exam, a student is angry with the instructor and talks negatively about her. What defense mechanism is this an example of? A. Acting out B. Projecting C. Compensation D. Reaction- formation

B. Projecting= Placing the blame on others and not taking responsibility.

The nurse is caring for a patient who has pulmonary tuberculosis (TB). Which infection control measure should the nurse implement? A. Restrict visitors who are pregnant. B. Remove any portable fans in the room. C. Wear a dosimeter badge during patient care. D. Place the patient further away from the nursing station.

B. Remove any portable fans in the room.

The nurse is caring for a patient with a pulmonary embolism (PE). Which of the following findings require immediate follow-up? A. Pleuritic chest pain B. Restlessness C. Cough D. Exertional dyspnea

B. Restlessness

The nurse is caring for a patient with a Sengstaken-Blakemore tube. She performs her safety checks at the beginning of the shift and ensures which af the following priority items is readily avalable at the bedside? A.Trach kit B. Scissors C.Obturator D. Yaunker

B. Scissors

The LPN is assisting the nurse in caring for a patient who is receiving a continuous opioid infusion. The LPN should understand which of the following, if detected, is a concerning finding? A. The patient has a respiratory rate of 10 breaths/min with normal depth. B. The patient's sedation level is 4. C. The patient experiences mild confusion. D. The patient reports constipation.

B. The patient's sedation level is 4.

E A The nurse is precepting a student nurse on a medical-surgical unit. The student collects a blood sample from a patient with TPN infusing, Which action by the student nurse would require immediate intervention by the nurse? A .The student flushes the port with saline prior to collecting blood. B. The student accesses the non-infusing port to obtain the blood sample. C .The student draws up 10ml blood, clamps line, and discards syringe. D. The student draws up 10mt blood, clamps line, and discards syringe.

B. The student accesses the non-infusing port to obtain the blood sample.

Which of the following lipid levels is out of range and should be reported to the physician? A. Triglycerides: 75 mg/dL B. Total cholesterol: 6.5 mmol/L C. High-density lipoprotein (HDL): 60 mg/dL D. Low-density lipoprotein (LDL): 95 mg/dL

B. Total cholesterol: 6.5 mmol/L

The nurse is caring for a patient with a jejunostomy tube receiving intermittent enteral feedings. Which intervention would be the highest priority to reduce the risk of aspiration for this patient? A. Flush tubing with 20 ml water after feeding is completed. B. Position patient in left-lying position after feedings. C. Assess blood glucose every 6 hours. D. Place the patient in semi-Fowler's following feedings.

D. Place the patient in semi-Fowler's following feedings.

The nurse is taking care of a client with Encopresis. Which of the following statements correctly describe Encopresis? A. Infrequent and hard to pass stools lasting greater than two weeks. B. Voluntary or involuntary fecal incontinence in children over the age of 4 who were previously toilet trained. C. Involuntary fecal incontinence in children over the age of 4 who were previously toilet trained. D. Inability to pass stool due to fecal impaction.

B. Voluntary or involuntary fecal incontinence in children over the age of 4 who were previously toilet trained.

The nurse is discussing acute osteomyelitis with staff members. The nurse would be correct to state which of the following? A. "IV ANTIBIOTIC THERAPY IS GIVEN FOR SEVEN TO FOURTEEN DAYS". B. " THE MOST COMMON CAUSE OF ACUTE OSTEOMYELITIS IS A VIRUS". C. " A FEVER IS PRESENT WITH TEMPERATURES TYPICALLY GREATER THAN 101 F". D. " PETECHIAE ON THE AFFECTED EXTREMITY IS A COMMON FINDING".

C. " A FEVER IS PRESENT WITH TEMPERATURES TYPICALLY GREATER THAN 101 F".

The son of a client with early Alzheimer's disease states, "I'm tired of hearing Dad talk about the all the time." What is the nurse's best response? A. "You should be more patient with your father and accepting of his disease." B. "He is quite anxious at this stage. Reliving the past helps him become calm again." C. "He has lost his short-term memory but can still remember events from long ago." D. "Just remind him when he repeats himself and that will reinforce better behavior."

C. "He has lost his short-term memory but can still remember events from long ago."

The nurse is working with an advocacy group to raise awareness about cystic fibrosis. Which of the following statements does she know best explains the condition? A. "It is an inherited disease that causes inflammation and hypersensitivity of the airway" B. "It is an infectious disease causing inflammation and fluid accumulation in the alveoli of the lungs." C. "It is an inherited disease causing excessive, thick mucus to build up in the body and cause blockages." D. "It is an acquired disease that causes inflammation and swelling of the epiglottis."

C. "It is an inherited disease causing excessive, thick mucus to build up in the body and cause blockages."

The LPN is tending to a client who is at 20 gestation and has completed patient education. Which of the client's following statements indicates that she has a good understanding of her babys development? A. " My baby is able to breathe now". B. " My baby can open his eyes". C. "MY baby is about 7 1/2 inches long". D. " My baby has fully grown fingernails".

C. "MY baby is about 7 1/2 inches long".

During a physical assessment, the nurse inspects the patient's abdomen. What assessment technique would the nurse perform next? A. Percussion B. Palpation C. Auscultation D. Whichever is most comfortable for the patient

C. Auscultation

A diabetic patient receives ten units of Regular insulin and 20 units of NPH insulin each day after breakfast. After following the usual preparation steps for administering insulin, what should the nurse do next? A. Draw up NPH insulin first because it is clear. B. Either insulin can be drawn first as long as 30 units are given. C. Draw up Regular insulin first because it is clear. D. Administer each type of insulin separately for accuracy.

C. Draw up Regular insulin first because it is clear.

While assessing a laboring mother during a contraction. The LPN notes a decrease in fetal heart rate from 150 to 120 bpm. The heart rate slows for about 10 seconds and increases back to 150 bpm as the contraction ends. Which of the following correctly classifies this observation? A.Late deceleration B.Moderate variability C.Early deceleration D.Marked variablity

C. Early deceleration

Which action should the nurse take to most effectively reduce the incidence of hospital-associated urinary tract infections? A. Teach assistive personnel how to provide good perineal hygiene. B. Ensure that clients have adequate fluid intake. C. Limit the use of an indwelling foley catheter (IFC). D. Perform dipstick urinalysis for clients with risk factors for a UTI.

C. Limit the use of an indwelling foley catheter (IFC).

The nurse is reassessing her female patient diagnosed with appendicitis. At her last assessment, the patient expressed 8/10 pain but now states that she has no pain. The nurse did not administer any pain medication. What is the priority nursing action? A.Document the pain score and continue monitoring B. Check the white blood cell count C.Notify the healthcare provider D. Palpate Mclurney's point

C. Notify the healthcare provider

While monitoring a client with myocardial infarction who is receiving tissue plasminogen activator (Activase, TPA), the nurse should prioritize which of the following? A. Observe for neurological changes. B. Monitor for any signs of renal failure. C. Observe for signs of bleeding. D. Check the client's food diary.

C. Observe for signs of bleeding.

he nurse is taking vital signs on a patient with a diagnosis of acute lymphoblastic leukemia (ALL). His temperature is 38.7 degrees C. What is the nurse's priority? A. Place cool washcloths on the patient's head. B. Continue with the assessment. C. Obtain intravenous access on the patient. D. Assess the patient's perfusion.

C. Obtain intravenous access on the patient.

A patient is scheduled to have a thyroidectomy. The nurse understands that the primary reason for giving Lugol's solution to a patient preoperatively is: A. Decrease the risk of agranulocytosis postoperatively. B. Prevent tetany while the client is under general anesthesia. C. Reduce the size and vascularity of the thyroid and prevent hemorrhage. D. Potentiate the other preoperative medication's effect less medicine can be used while the client is under anesthesia.

C. Reduce the size and vascularity of the thyroid and prevent hemorrhage.

Which of the following maternal infections can increase the risk of congenital heart defects in the fetus? A. Parainfluenza B. Adenovirus C. Rubella D. Measles

C. Rubella

Which of the following descriptions best defines general adaptation syndrome? A. Activation of brain signals followed by avoidance in response to a perceived threat. B. The arousal of the hippocampus after being triggered by a specific memory. C. The body's response to stress over both short and long-term periods. D. The development of depression over time as a result of a negative situation.

C. The body's response to stress over both short and long-term periods.

In Piaget's stages of Cognitive development, the______stage occurs from 7 to 11 years old

Concrete operational

A G3P3 client in labor asks the LPN, "I would like to breastfeed, but my breasts got so engorged last time. I could not take it. Do I have to go through that again?" Which of the following responses is most appropriate? A. "Keeping your baby on an every 4-hour schedule would help slow the milk production and lessen the engorgement. B. "You can feed your baby formula milk until your milk comes in. This will reduce stimulation and prevent engorgement." C. "You can take bromocriptine to stop your milk production and prevent engorgement." D. "You need to feed your baby as soon as possible. Also, feeding your baby often would prevent breast engorgement

D. "You need to feed your baby as soon as possible. Also, feeding your baby often would prevent breast engorgement

After receiving report on the medical-surgical floor, which of the following clients should the nurse see first? A. A client with a respiratory rate of 24 and an oxygen saturation of 92%. B. A client that is scheduled for stomach surgery in two hours related to peptic ulcer disease. C. A client that is six hours post-op from a hysterectomy and is complaining of nausea. D. A client that had a cast applied two hours ago and now has complaints of her arm feeling like it is "asleep".

D. A client that had a cast applied two hours ago and now has complaints of her arm feeling like it is "asleep".

The nurse is going over assigned patients for the shift. She knows that which of the following patients is most at risk for experiencing a fluid volume deficit? A. A patient with cirrhosis B. A patient with an ileostomy with a normal amount of output C.A patient with a BUN of 32 and Cr 2.7 D. A patient with DI and an NG tube to low intermittent wall suction

D. A patient with DI and an NG tube to low intermittent wall suction

The nurse is caring for a patient diagnosed with Multiple Sclerosis (MS). The nurse should anticipate a prescription for which of the following medications? A. Topiramate B. Risperidone C. Prazosin D. Baclofen

D. Baclofen

An 8-year-old boy diagnosed with hemophilia A is brought into the urgent care clinic for a prolonged episode of hematemesis. Which of the following describes this symptom? A. Bleeding into the joints B.Bleeding from the nose C. Dark, black, tar-like stools D. Bloody vomit

D. Bloody vomit

The most serious adverse effect of tricyclic antidepressant (TCA) overdose is: A. Seizures B. Hyperpyrexia C. Metabolic acidosis D. Cardiac arrhythmias

D. Cardiac arrhythmias

When caring for a client with a documented history of aggressive and violent behavior, what is the first thing the nurse should do to help prevent a violent event toward others? A. Restrain the client B. Place the client in seclusion C. Get an order for a sedating medication D. Establish trust with the client

D. Establish trust with the client

The nurse is teaching a group of students the causes of metabolic alkalosis. It would indicate a correct understanding of the student to state which condition causes this acid-base imbalance? A. Hyperventilation B. Urinary retention C. Opioid toxicity D. Excessive vomiting

D. Excessive vomiting

The nurse is assessing a patient who has a suspected retinal detachment. Which of the following patient statements would be consistent with this diagnosis? A "My vision has a cloudy appearance." B. 1 have intense pain above my eyebrow. C. " I am having trouble with my peripheral vision." D. I can see bright flashes of light."

D. I can see bright flashes of light."