NCLEX questions

A client is suspected of having a pheochromocytoma. The nurse is explaining the process of a Vanillylmandelic acid (VMA) urine test to be complete at home. What statement made by the client indicates the need for further teaching? 1. "I need to keep the urine in the fridge during the 24 hours." 2. "I will have to stay well-hydrated to get enough urine to test." 3. "It does not matter what I eat or drink during this process." 4. "I need to throw away my first voiding when I start this test." 5. "I should void at the end of the 24 hours and keep that urine."

1. "I need to keep the urine in the fridge during the 24 hours." 2. "I will have to stay well-hydrated to get enough urine to test." 3. "It does not matter what I eat or drink during this process."

The unlicensed assistive personnel (UAP) reports to the nurse that a client who received morphine sulfate 4 mg IVP 30 minutes ago has a respiratory rate of 10 breaths/ minute. What is the nurse's priority intervention? 1. Administer naloxone 0.4 mg IVP. 2. Notify the primary healthcare provider of respiratory status. 3. Deliver breaths at 20 breaths/ minute via a bag-valve mask. 4. Instruct the UAP to ambulate the client.

1. Administer naloxone 0.4 mg IVP.

The nurse is caring for a Puerto Rican client. The client has several injuries from a car accident and is experiencing pain. Which behavior is likely to be noted? 1. Loud crying with pain. 2. Enduring the pain in order to bring honor. 3. Quiet and stoic responses to pain. 4. Refusing pain medication because it is God's will.

1. Loud crying with pain.

What is the priority nursing action for a client that was admitted with tingling of the toes and feet after having the flu for several days when the client begins to have numbness in the legs and hips? 1. Notify the primary healthcare provider 2. Monitor for paresthesia in the fingers and hands 3. Insert an indwelling urinary catheter 4. Assist the client with performing passive range of motion

1. Notify the primary healthcare provider

The nurse is working on a health promotion plan for a young family whose child has severe allergies and asthma symptoms. Which interventions would be important to include in the health promotion plan? 1. Wash stuffed animals/toys frequently in hot water. 2. Make sure that bathrooms and high humidity areas are properly vented. 3. Limit carpet in the bedrooms. 4. Use humidifiers regularly. 5. Vacuum floors and upholstered furniture regularly.

1. Wash stuffed animals/toys frequently in hot water. 2. Make sure that bathrooms and high humidity areas are properly vented. 3. Limit carpet in the bedrooms. 5. Vacuum floors and upholstered furniture regularly.

A client makes an initial visit to the prenatal clinic, informing nurse the probably date of conception was May 15th. The first day of the last menstrual cycle was on May 1st. Using Naegele's rule, the nurse determines the client's due date should be when? 1. February 22nd 2. August 8th 3. February 8th 4. August 22nd

3. February 8th **back three months, add seven days - FROM FIRST DAT OF LAST MENSTRUAL CYCLE

The nurse in the pediatric intensive care unit (PICU) is caring for a preschool child three days after open heart surgery. What assessment finding should the nurse report immediately to the primary healthcare provider? 1. Increased episodes of fussy crying. 2. A hacking, non-productive cough. 3. Oral temperature of 100.9°F (38.3°C). 4. Chest tube draining 30 mL per shift.

3. Oral temperature of 100.9°F (38.3°C).

Which immediate action should a nurse take if a client's chest tube is accidentally disconnected from the disposable water-seal system? 1. Have client hold breath 2. Administer oxygen 3. Place the tubing coming from the client into sterile water 4. Raise the head of the bed

3. Place the tubing coming from the client into sterile water

A 17 year old adolescent and girlfriend are being treated in the emergency room for moderate injuries following a motorcycle accident. The adolescent is unconscious and will need surgery but family cannot be located to give consent. What does the nurse know is true about informed consent? 1. Informed consent can be provided by the girlfriend. 2. Consent is not necessary in this particular situation. 3. Surgery must be delayed until the family is located. 4. Surgery cannot be done while client is unconscious.

3. Surgery must be delayed until the family is located.

A client who is sitting in a chair begins to have a tonic-clonic seizure. In what order should the nurse intervene? Push aside any furniture. Administer prescribed antiepileptic medication. Ease client to the floor. Position client on side.

Ease client to the floor. Administer prescribed antiepileptic medication. Position client on side. Push aside any furniture.