NCLEX-PN 2019 part 7 (final)

a 64 YO male who has been diagnosed with COPD and CHF exhibits an increase in total body weight of 10 lbs over the last few days. the nurse should:

Check the intake and output

an advance directive is written and notarized according to law in the state of Colorado. this document is legal and binding where?

In the state of Colorado only

after securing the clients safety from a faulty electric bed, the nurse should take which action?

Prepare an incident report.

The nurse is teaching a client about communicable diseases and explains a portal of entry is:

The respiratory system

if a client is suffering from thyroid storm, the PN can expect to find on assessment:

tachycardia and hyperthermia

a patient has recently been prescribed albuterol. which change is not associated with albuterol?

sensory changes.

Central Venous Pressure (CVP) normal range

0-8 cm

The nurse observes a staff member not following the plan of care for a client with an antisocial personality disorder. The nurse should:

Ask the staff member to talk in private, and reinforce how antisocial clients try to divide staff.

When al elder client asks a nurse whether he will be capable of sexual activity in old age, the best response by the nurse is?

Elder adults are psychologically and physically capable of engaging is sexual activity regardless of age related changes.

The nurse working with elderly clients should keep in mind that falls are most likely to happen to elderly who are:

Elderly are more likely to fall in hospitals (new situations and environments)

a 24 yo man has been admitted to the hospital due to work related back injury. the patients wife would like to see the patients chart. the nurse should:

Get written approval form the patient prior to providing the wife with chart information and call the MD about the patients request.

an adult who had been abused as a child is discussing the group therapy program. which statement indicates the client has gained insight?

I am now aware of how deep seated my anger is. before I did not realize I was angry.

a client reports that someone is in the room and trying to kill him. the nurses best response is:

I do not see anyone, but you seem to be very frightened.

a client with a spinal cord injury is preparing to return home from rehab unit. which statement by a family member indicates a need for further teaching regarding autonomic dysreflexia?

I should see whether symptoms worsen.

an infection in a central venous access device is not eliminated by giving antibiotics thru the catheter. how might bacterial glycocalyx contribute to this?

It protects the bacteria from antibiotic and immunologic destruction.

a 27 yo woman has delivered twins in the OB unit. the patine develops a condition of 5 centimeter diastasis recti abdominis. which statement is the most accurate when instructing the patient?

Guarding the abdominal region is important at this time.

the charge nurse on a cardiac unit tells you a patient is exhibiting signs of right sided heart failure. which of the following would not indicate right sided heart failure?

SOB (shortness of breath)

a client receiving preoperative instructions ask questions repeatedly about when to stop eating the night before the procedure. the nurse tries to refocus the client. the nurse notes that the client is frequently startled by noises in the hall, assessment reveals rapid speech, trembling hands, tachypnea, tachycardia and elevated blood pressure. the client admits to feeling nervous and having trouble sleeping. based on the assessment, the nurse documents the client has

Severe anxiety

which direction given to the nursing assistant is most likely to accomplish the task of getting a urine specimen delivery to the lab immediately after collection?

Take this client to the bathroom now and collect a urine specimen from this voiding. Take the specimen to the lab immediately.

a client needs to rapidly achieve a therapeutic plasma drug concentration of a medication. rather than wait for steady state to be achieved, the physician might order:

a loading dose

an example of a process standard on a med-surg unit is:

a procedure for changing IV tubing.

the factor that most determines drug distribution is:

a vascular perfusion of the tissue or organ.

A patient 3 hours post op from a a hysterectomy is complaining of intense pain at the incision site. when assessing the patient the nurse notes a BP of 169/93. Pulse 145 bpm and regular What action should the nurse take?

administer PRN Meperidine HCL and assess client's response.

a 22 yo patient in a mental health lock down unit under suicide watch appears happy about being discharged. what is probably happening?

The patients suicide plan has probably been decided.

A patient has fallen off a bicycle and fractured the head of the proximal fibula. A cast was placed on the patients lower extremity. which is the most probable result of the fall?

The peroneal nerve

a nurse is returning phone calls in a pediatric clinic. which report most requires the nurses immediate attention and phone call?

an 8 YO boy has been vomiting and appears to have slower movement and has a history of an atrioventricular shunt.

Metformin (Glucophage) is administered to clients with type 2 dm. it is an example of

an antihyperglycemic agent.

A nurse is caring for a patient who has recently been diagnosed with fibromyalgia and COPD. which tasks should the nurse delegate to a nursing assistant?

Transferring the patient to the shower

while repositioning a comatose client, the nurse senses a tingling sensation as she lowers the bed. what action should she take?

Unplug the beds power source

After group therapy, the female victim of intimate partner violence confides to the nurse that she does not feel in any immediate danger. which statement about victims of domestic violence is true?

Victims of domestic violence are often the best predictors of their risk of harm.

a patient has recently been prescribed Zidovudine (Retrovir) the patient has AIDS. which side effects should the patient specifically watch out for/

anemia and fever.

a nurse runs into the significant other of a patient with end stage AIDS crying during her smoke break. which is most appropriate action for the nurse to take?

approach her, offering tissues and encourage her to verbalize her feelings

An appraisal of self-care practices involves an assessment of:

caregiving needs and the potential for strain.

A 28 YO male has a diagnosis of AIDS. the patient has had a 2 year hx of AIDS. the most likely cognitive deficits include which?

confusion and disorientation

A small amount of bubbling is seen in the water seal of a pleural drainage system when a client coughs. what should the nurse do?

consider it a normal finding.

the token economy is a type of therapy that focuses on

behavior modification

the highest incident of child abuse occurs in children in which age group?

birth to 3 years old.

two staff nurses were considered for promotion to head nurse. the promotion is announced via a memo on the unit bulletin board. the nurse who was not promoted tells a friend, oh well, I really didn't want the job anyway. this is an example of:

rationalization.

a nurse is teaching a client about self administration of Haldol 15 mg PO hs. which side effect must the client seek medical attention for?

restlessness and muscle spasms

A nurse who is assessing the health-related physical fitness of a client as part of a health assessment should focus on which of the following aspects of the assessment?

risk factors

which is not considered one of the five rights of medication administration ?

routine

A 2 YO has been in the hospital for 3 weeks and seldom seen family members due to isolation precautions. which hospitalization changes is most like to be occurring?

separation anxiety

the mother of a newborn child is very upset. the child has a cleft lip and palate. they type of crisis this mother is experiencing is:

situational crisis.

A patient has recently been prescribed (Norvascs) which side effect should the patient specifically watch out for?

Hypotension and Anginga

when choosing a needle gauge for an IM injection in a 12 YO boy, which gauge would you choose?

22 gauge

a nurse is setting up a vision screening program for a new school. at what age will vision be 20/20 for children?

6 years of age

the only tine that an individual may receive medical care without giving informed consent is?

In an emergency, life or death situation

A thirty seven year old female in room 307 has diagnosis of acquired immune deficiency syndrome (AIDS) which situation requires nurse intervention?

A nursing student in the cafeteria states "Dr jones told the patient in room 307 that she is going to die" inappropriate to discuss personal patient info in public setting.

A mother that has never breast feed a child before is having trouble getting the baby to latch on to the breast. The baby has lost 3% of its birth weight within the first 2 days of life. the best statement is:

A small amount of weight loss after birth is normal (5-10%)

How does the ANA define the psychiatric nursing role?

A specialized are of nursing practice that employs theories of human behavior as its science and the powerful use of self as its art.

a nurse is caring for a retired MD. He asks "what type of cells create exocrine secretions?"

Acinar cells

The best definition of communication is:

An ongoing, interactive form of transmitting transactions.

Which intervention should the nurse take first to assist a woman who states that she feels incompetent as the mother of a teenage daughter?

Assist the mother to identify what she believes is preventing her success and what she can do to improve.

a nurse is caring for a retired MD. He asks the question "what type of cells secrete insulin?"

Beta cells

which syndromes associated with incomplete lesions of the spinal cord is a result of damage to one half of the spinal cord?

Brown squared Syndrome

A client has been placed in isolation because he is diagnosed with a contagious illness. the nurse should be aware that?

Linens should be double bagged.

a 55 YO female asks a nurse the following, which mineral/vitamin is most important to prevent progression of osteoporosis?

Calcium

a 64 YO Alzheimer's patient has exhibited excessive cognitive decline resulting in harmful behaviors. the physician orders restraints to be placed on the patient. which is the appropriate procedure?

Communicate with the patient and family the need for restraints.

A patient has recently been prescribed lidocaine hydrochloride. which symptoms may occur with over dosage?

Confusion and fatigue.

a nurse doing a home health visit consults with a male patient has a diagnosis of CAD and COPD. The patient is currently taking Ventolin, azmacort, Aspirin, and theophylline. The patient complains of upset stomach, nausea and feeling uncomfortable. the nurse should?

Contact the patient's physician immediately.

a 14 YO boy has been admitted to a mental health unit for observation and treatment. the boy becomes agitated and starts yelling at nursing staff members. what should the nurse do first?

Create an atmosphere of seclusion for the boy according to procedures.

the nurse seeks to assess the renal function of an elderly client who is about to receive a nephrotoxic medication. which lab provides the best indicator for renal function?

Creatinine clearance.

A nurse assess a 83 YO female venous ulcer for the second time that is located ear the right medial malleolus. the wound is exhibiting purulent drainage and has limited mobility in her home. which option is the best course of action?

Encourage warm water soaks to the right foot.

A client has chronic renal failure. which sexual complications is the client at risk of developing?

Decreased testosterone levels.

A nurse has been ordered to administer morphine to a patient. which effects is unrelated to morphine effect?

Decreased venous capacity.

which is one of the main goals for healthy people 2010?

Elimination of health disparities

the teaching plan for gay or lesbian parents who want to disclose their homosexuality to their children should include all of the following except:

Explain how your relationship with the child changes because of the discussion

a mother of a newborn notices a nurse placing liquid in her baby's eyes. which is an inaccurate statement about the need for eyedrops following birth?

Eye drops are required by law every 6 hours following birth (the MD establishes time frame, not the law)

Tricyclics (antidepressants)sometimes have which adverse affect on patients that have a diagnosis of depression?

Fainting and hypotension

A month after receiving a blood transfusion, an immunocompromised client develops fever, liver abnormalities, a rash, and diarrhea. The nurse should suspect this client has:

Graft-versus-host disease (GVHD)

A newborn has been delivered. an Apgar score is given. What does this scoring system indicate?

Heart rate, respiratory effort, color muscle tone, reflex irritability

The nurse assesses a client for physiological risk factors for falls. the nurse should conclude that the client is not at risk if which is discovered?

Intact recent and remote memory

Ten year old patient is admitted to the hospital with medical diagnosis of Rheumatic fever. She relates a hx of sore throat about a month ago. Bed rest w/ bathroom privileges is prescribed. which nursing assessment should be given the highest priority?

Her cardiac status

A client taking isotretinoin (Accutane) tells the nurse that she is pregnant. What should the nurse teach this client?

Her pregnancy is threatened, and the fetus is at risk for teratogenesis.

Acyclovir (zovirax) is the agent of choice for which infection?

Herpes

a nurse is assessing a patient in the ICU. the patient has signs: weak pulse, quick respiration, acetone breath and nausea. which is most likely occurring:

Hyperglycemic patient

Which symptoms is not indicative of autonomic dysreflexia in the client with a spinal cord injury?

Hypotension

a mother brings her 1 yo child to the clinic. the child has no record of previous immunizations. the mother confirms that the child has not been immunized. teaching by the nurse should include which?

Immunizations may be started at any age.

A violation of a patients confidentiality occurs if two nurses are discussing client information in which scenario?

In the hallway outside the patients room

A nurse is assessing an 18 YO female who has recently suffered a TBI. The nurse notes a slower pulse, impaired respiration. The nurse should report these findings immediately to the physician due to the possibility the patient is experiencing which condition?

Increased intracranial pressure (ICP)

a client has a 10% dextrose in water IV solution running. He is scheduled to receive his antiepileptic drug Phenytoin (Dilantin) at this time. The nurse knows that the phenytoin:

Is incompatible with dextrose solutions.

a nurse is teaching a client newly diagnosed with emphysema about the disease process. which statement best explains the problems associated with emphysema and could be adapted for the use in the nurses discussion with the client?

Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.

A 15 YO high school wrestler has been taking diuretics to loose weight to complete in a lower weight class. which medical test is most likely to be given:

Lab values of potassium and sodium.

a 62 yo female is being seen on a home visit by a nurse. the patient reports she has been taking Premarin for years. which would indicate an over-dosage?

Lower extremity edema

A patient asks a nurse the following questions. exposure to TB can be identified best with which procedure? which test is the most definitive of TB?

Mantoux is the most accurate test.

A nurse is screening patients for various vaccines. which vaccine is contraindicated during pregnancy?

Mumps and rubella

a client asks a nurse working in a dental office what type of drug the dentist uses to provide anesthesia during the extraction of the clients wisdom teeth. the gas is known as laughing gas, the name of this gas is:

Nitrous oxide

a nurse working in a ped clinic observes bruises on body of a 4 yo boy. parents states he fell riding his bike. bruises are located on his posterior chest wall and gluteal region. the nurse should?

Notify the case manager in the clinic about possible child abuse concerns.

a nurse is working in a pediatric clinic and a 25YO mother comes in with a 4 week old baby. the mother is stressed out about loss of sleep and the baby exhibits signs of colic. which technique should the nurse teach the mother?

Neural warmth technique

A client is 36 hours post op a TKR surgery. 270 CCs of serosanguinous accumulates in the surgical drains. What should the nurse do?

Notify the Physician due to excessive drainage.

A 32 YO female frequently comes to her primary care provider with vague complaints of headache, abdominal pain, trouble sleeping. in the past, the MD has dutifully prescribed medication, but little else. which comments by the nurse to the MD is appropriate?

Often women who are victims of domestic violence suffer vague symptoms such as abdominal pain.

while admitting a client to an acute care psychiatric unit. the nurse asks about substance abuse based on what knowledge?

People with psychiatric disorders are more prone to substance abuse.

a central venous pressure reading of 11 cm of an IV of normal saline is determined by the nurse caring for a patient. The Patient has a diagnosis of pericarditis. Which is the most applicable?

Pericarditis may cause pressures greater than 10 cm/H20 with testing of CVP

Which type of dressing is recommended to place over a site when a chest tube is removed by the physician?

Petrolatum gauze (it forms an airtight seal.)

a nurse is instructing a person who had a left CVA and right lower extremity hemiparesis to use a quad cane. which is the most appropriate gait sequence?

Place the cane in the patients left upper extremity, encourage cane, then right lower extremity. then left upper extremity gait sequence.

a young female teenager describes a brutal assault and rape to the nurse on duty. which actions should the nurse take first?

Provide an environment of concern and emotional stabilization.

the nurse notices that a family is waiting at the nursing station desk for its loved one to be brought to the unit for admission during a change of shift report. the nurse should:

Request that the family wait for its loved one in the clients room and wait to resume the report until the family has left the desk area.

A nurse is reviewing a patients arterial blood gas values. which conditions apply under the following values? PH 7.49 Hc03 24 Pac02 31 Pa02 52 Fi02 -.22

Respiratory Alkalosis

a paraplegic client is in the hospital to be treated for an electrolyte imbalance. which level of care is the client currently receiving?

Secondary prevention.

When a drug is listed a category X and prescribed to women of child bearing age. the nurse and interdisciplinary team should counsel the client that:

She must use a reliable form of birth control

A patient has experienced a severe third degree burn to the trunk in the last 36 hours. which phase of burn management is the patient in?

Shock phase (first 24-48 hours)

When a client describes their family as having multiple wives, all of whom are sisters, married to one man, the nurse documents the family structure as?

Soronal

a patient has suffered a left /CVA and has developed severe hemiparesis resulting in a loss of mobility. the nurse notices an assessment that an are over the patients left elbow appears as non-blanchable erythema and the skin is intact. the nurse should score the patient a shaving which?

Stage one pressure ulcer

A nurse is trying to motivate a client toward more effective management of a therapeutic regimen. which actions by the nurse is most likely to be effective in increasing the clients motivation?

Teaching the client about the disorder at the clients level of understanding.

a nurse is covering a pediatric unit and is responsible for a 15 yo male patient on the floor. the mother of the child states, I think my son is sexually interested in girls. the most appropriate course of action of the nurse is to respond by stating:

Teenagers often exhibit signs of sexual interest in females.

A nurse is working in an outpatient orthopedic clinic. During the patients history the patient reports, I tore 3 of my 4 rotator cuff muscles in the past. Which muscles cannot be considered as possibly being torn?

Teres Major

A 26 YO single woman is knocked down and robbed while walking her dog one evening. Three months later, she presents at the crisis clinic stating that she cannot put this experience out of her mind. she complains of nightmares, extreme fear of being outside or alone, and difficulty eating and sleeping. what is the best response by the nurse?

That must have been a very difficult and frightening experience. It might be helpful to talk about it.

The nurse supporting a family who has just experienced a sudden and unexpected death needs to know:

That survivors have greater emotional turmoil and shock than when death is expected.

to manage time most effectively, the nurse responds to which of the following stimuli first?

The care needs of the returning postoperative client just exiting the elevator.

When planning intervention for a client during a crisis, which outcome is most appropriate?

The client should use constructive coping mechanisms.

During the health screening of an adolescent, which finding by the nurse requires further teaching?

The client states she is currently on birth control pills. (teach about STD's)

A patient is scheduled for electro-convulsive therapy treatment scheduled in the Moring. what must the evening nurse do to provide the client ECT treatment possible

The patient signs an informed consent form.

Serum Vancomycin levels are taken to measure which?

Therapeutic range

Hos is the information documented on incident reports used?

To analyze risk categories, to make sure procedures are in compliance with regulations and to identify the educational needs of the staff.

A nurse is assigned to do pre-operative teaching on a blind patient who is scheduled for surgery the following morning. what teaching strategy would best fit the situation?

Verbal teaching in short sessions thru out the day.

the nurse is assessing an elder who the nurse suspects is being physically abused. the most important question for the nurse to ask is?

Who provides your physical care?

The PN is caring for a client with diabetes insipidus. the nurse can expect the lab work to show:

decreased urine osmolarity and elevated serum osmolarity.

A nurse caring for a 10Yo boy who has just been diagnosed with congenital heart defect. which clinical signs does not indicate CHF?

compulsive behavior

the nurse provides a postoperative client with an analgesic medication and darkens the room before the client goes to sleep for the night. the nurses actions:

decrease stimuli from the cerebral cortex.

a gastroenterologist should be consulted for clients suffering from:

digestive system diseases.

a client experienced a CVA with right hemiparesis and is ready for discharge from the hospital to a long term care facility for rehab. to provide optimal continuity of care, the nurse should do all the following:

document current functional status, copy appropriate parts of medical record for transport to the receiving facility, phone a report to the facility. **having the physician phone a report is not ideal or common.

a nurse is instructing a patient about the warning signs of digitalis side effects. which side effects should the nurse tell the patient are sometimes associated with excessive levels of digitalis?

muscle weakness and palpitations

the nurse belongs to a professional nursing organization hat provides a social, educational, and political venues for nurses. the nurses has been active in this organization for almost two years. during which time she meets and works with nurses form several different nursing agencies and health care institutions to achieve a variety of goals, including obtaining advice regarding a personal career choice. This is an example of:

networking

a high school nurse observes a 14 YO female rubbing her scalp excessively in the gym. the most appropriate course of action for the nurse to do is?

observe the hairline and scalp for possible signs of lice.

the nurse who was not promoted tells another friend, I knew id never get the job. the hospital administrator hates me. if she actually believes this of the administrator, who, in reality knows little of her, she is demonstrating:

projection