Fundaentals NCLEX questions

A nurse is caring for a client who is 24 hours postoperative following abdominal surgery. The nurse finds the client lying on the bathroom floor. Which of the following nursing actions should be taken first? a) assess the client for injuries b) move hazardous objects away from the client c) pull the alarm to obtain assistance d) ask the client to describe how she felt prior to the fall

A

A nurse is caring for a client with a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Which of the following is the correct placement of the stethoscope? a) second intercostal space at the left sternal boarder b) fourth intercoastal space at the right sternal boarder c) fourth intercoastal space at the left sternal boarder d) second intercoastal space at the right sternal boarder

A

A nurse is working with an Orthodox Jewish client who has just given birth to a stillborn infant. Which of the following interventions is appropriate? a) ask the family if there are any special rituals that they would like to follow at this time b) inform the parents of the importance of conforming to hospital policy regarding the death of a fetus c) remain in the room, giving the parents the opportunity to initiate a discussion about cultural rituals d) take the fetus out of the room, and allow parents time to grieve together

A

The nurse is observing a newly licenced nurse who is preparing a sterile field for a dressing change. Which of the following actions by the newly licenced nurse should cause the nurse to intervene? a) the newly licenced nurse places the cap of the sterile saline bottle on the sterile field b) the newly licenced nurse places sterile objects 1 inch from the edge of the field c) the newly licenced nurse holds the bottle of sterile saline outside the edge of the sterile field when pouring d) the table is positioned at the level of the newly licenced nurse's waist

A

A nurse is caring for a client who had a fasting blood sugar drawn at 0600. The client tells the nurse "All I have had since midnight is water and some juice." Which of the following nursing actions is appropriate? a) document the caloric intake b) reschedule this lab test for the next morning c) notify the lab to obtain another specimen d) obtain a prescription for a glucose tolerance test

B

A nurse is caring for a group of clients who have communicable diseases. Which of the following actions is the appropriate manner for handling infectious waste? a) carry soiled linens out of the room to a mesh linen bag b) place the client who has TB in a room with negative pressure air system c) provide disposable plates and utensils to a client who is HIV positive d) dispose of blood-saturated dressing in a garbage bag placed in a second garbage bag

B

Which of the following actions by the nurse is a violation under the Health Insurance Portability and Accountability Act (HIPPA)? a) The nurse calls the client by her first and last name in a public waiting room b) the nurse takes home the report sheet on her team's clients c) the nurse places "allergy:sulfa" sticker inside the clients chart d) the nurse mails the clients results to a consultingfdfffcgv provider

B The daily report sheet contains the confidential information of multiple clients and should be shredded before they leave the workplace Removing documents containing client's information is considered a violation

A primary care provider prescribes IV fluids at 50 mL/hr. The nurse hangs a liter of fluid at 0800 via pump. At 1400, the nurse discovers that the bag is almost empty, and the client is reporting shortness of breath. The nurse should take which of the following actions first? a) notify the primary care provider b) slow the infusion c) calculate the intake and output d) obtain blood pressure

B The greatest risk to the client is fluid overload. Fluid-volume excess results when an IV solution has infused too rapidly. The nurse should first slow the infusion.

An older adult client newly diagnosed with diabetes is being discharged home and has a new prescription for repaglinide (Prandin). Which of the following interventions is the highest priority? a) reinforce the importance of exercise to the client b) ensure the client can monitor blood glucose levels c) discuss meal planning with the client d) make sure that the client can demonstrate proper foot care

B The greatest risk to the lcient is hypoglycemia; therefore, the highest priority is teaching the client how to self-monitor c=blood glucose

A nurse finds a client on the floor upon entering the client's room. The roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following is correct documentation of the incident? a) incident report completed b) client climbed over the bedrails c) client found lying on floor d) client was trying to get out of bed

C

A nurse is providing anticipatory guidance to the parent of an 11-month-old child. Which of the following types of play should the nurse instruct the parent to expect of the infant? a) parallel b) cooperative c) solitary d) pretend

C

A nurse will be irrigating a hospitalized client's indwelling urinary catheter using an open irrigation technique. When performing the procedure, the nurse should take which of the following actions? a) apply clean gloves after opening the irrigation supplies b) instill 5 mL of irrigation fluid into the catheter with each flush c) subtract the amount of irrigant used from the client's urine output d) perform irrigation using a 10 mL or smaller syringe

C

A nurse is inserting a nasogastric tube. When the tube has been inserted past the nares and is in the lower pharynx, the client begins to cough and gag forcefully. Which of the following actions should the nurse take? a) reassure the client while continuing the procedure b) offer the client some ice chips before continuing the procedure c) pause temporarily and pull the tube back slightly d) pull the tube completely out and start the procedure over

C Pulling the tube back slightly will stop the irritation causing the coughing and gagging, which will allow the client to relax

A client is scheduled for surgery. The intraoperative nurse finds a necklace on the client after anesthesia has been administered. Which of the following interventions should be initiated? a) leave the necklace on the client b) give the necklace to a family member c) place the necklace in the client's chart d) notify security for placement of necklace

D

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements by the client indicates a need for further teaching? a) "I will tape electrical cords to the baseboards in each room" b) "I will hire someone to trim the tree that overhangs the front porch stairs" c) I will remove the table from the hall" d) "I will replace the old throw rug in the kitchen with a new one"

D The use of rugs increases the client's risk for falls

A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items has the greatest protein value? a) 1 oz of cheddar cheese b) 1/2 cup of refried beans c) 2 tbsp of peanut butter d) 3 oz of tuna

D

The nurse is planning to teach a preschool child how to properly use a metered dose inhaler. Which of the following methods is appropriate for this client? a) hold the child in the lap while giving explanation b) help the child identify her feelings about using an inhaler c) encourage independent learning d) use role play and imitation while explaining

D

A nurse is obtaining admission data from a client who reports having a fever. The client's cheeks are red and her skin is warm. The tympanic thermometer reads 36.8 (98.2f). Which of the following actions should the nurse take next? a) verify the environmental temperature b) re-check the client's temperature with an alternative method c) document the temperature in the clients medical record d) assess the client's blood pressure, pulse, and respirations

B

A nurse is caring for a client who is combative in the emergency department. The provider orders wrist restraints after the client attempts to assault the admitting nurse. Which of the following actions is appropriate for the nurse to take? a) tie restraints to the lower edge of the side rail b) remove each restraint one at a time every 2 hr c) ensure 3 finger-widths of space between the restrain and the client's wrist d) use a square knot to securely tie the restraints to the bed

B This allows the client to perform range-of-motion exercises and the nurse to perform neurovascular checks. To maintain safety of the staff, only one restraint should be removed at a time

A nurse is evaluating a client's use of a cane. Which of the following actions by the client indicates correct usage? a) the top of the cane is parallel to the clients waist b) when walking, the client moves the cane 15 to 18 inches forward c) the client holds the cane on the stronger side of the body d) the client moves the stronger limb forward with the cane

C This allows the client's body weight to be divided between the ane and the stronger leg

Which of the following indicates that a nurse and a client are in the working phase of a nurse/client relationship? a) nurse reviews pertinent medical and nursing history b) nurse reviews and evaluates goal achievement c) client recognizes and expresses feelings appropriately d) client closely observes the nurse to determine caring and competency

C This is an activity performed during the pre-interaction phase, which occurs before the first meeting between the client and the nurse

A nurse caring for a 40-year-old man after a femur fracture. Based on Erikson's eight stages of life, the nurse should expect the client to make which of the following statements if he has met the appropriate age-related task? a) "I want to get better soon so I can play golf and have fun" b) "I want to take off this cast soon so I don't look so differently" c) "I want my leg to heal quickly so I can go to work again and feel useful" d) "I don't think I need the cast because my leg is not hurting anymore"

C This statement reflects middle adulthood, as it demonstrates the desire to maintain an active role in contributing to society