NCLEX Review

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply. 1. Contact the surgeon 2. Instruct the client to remain quite 3. Prepare the client for wound closure 4. Document the findings and actions taken 5. Place a sterile saline dressing and ice packs over the would. 6. Place the client in a supine position without a pillow under the head.

1,2,3,4.

A client rings the call bell and complains of pain at the site of an IV infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which action(s) in the care of this client? Select all that apply. 1. Notify the HCP. 2. Remove the IV catheter at that site. 3. Apply warm moist packs to the site. 4. Start a new IV line in a proximal portion of the same vein. 5. Document the occurrence, actions taken, and the client's response.

1,2,3,5.

The nurse should use which guideline(s) to plan delegation and assignment-making activities? Select all that apply. 1. Ensuring client safety. 2. Requests from the staff. 3. The clustering of the rooms on the unit. 4. The number of anticipated client discharges. 5. Client needs and workers' needs and abilities.

1,5.

The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food? 1. Pork 2. Milk 3. Chicken 4. Broccoli

1.

The nurse is performing rescue breathing on a 7-year-old child. The nurse delivers one breath per how many seconds to the child? 1. 6-8 2. 8-10 3. 10-12 4. 12-14

1.

The nurse notes documentation that a client is exhibiting Cheyene-Stokes respirations. On asessment of the client, the nurse should expect to note which finding? 1. Rhythmic respirations with periods of apnea 2. Regular rapid and deep, sustained respirations 3. Totally irregular respiration in rhythm and depth 4. Irregular respiration with pauses at the end of inspiration and expiration

1.

The nurse provides a list of instruction to a client being discharged to home with a PICC. The nurse determine that the client needs further instructions if the client made which statement. 1. "I need to wear a Medic-Alert tag or bracelet." 2. "I need to restrict my activity while this catheter is in place." 3. "I need to have a repair kit available in the home for use if needed." 4. I need to keep the insertion site protected when in the shower or bath."

2.

Which nursing action is essential prior to initiation a new prescription for 500 mL of fat emulsion to infuse at 50 mL/hr? 1. Ensure that the client doesn't have diabetes. 2. Determine whether the client has an allergy to eggs. 3. Add regular insulin to the fat emulsion, using aseptic technique. 4. Contact the health care provider to have a central line inserted for fat emulsion infusion.

2.

While changing the tapes on a tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? 1. Call the HCP to reinsert the tube 2. Grasp the retention sutures to spread the opening 3. Call the respiratory department to reinsert the tracheotomy 4. Cover the tracheostomy site with a sterile dressing to prevent infection.

2.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1. Twitching 2. Hypoactive bowel sounds 3. Negative Trousseau's sign 4. Hypoactive deep tendon reflexes

1.

The nurse is providing instructions to the UAP regarding care of an older client with hearing loss. Which should the nurse tell the UAP about older clients with hearing loss? 1. They are often distracted 2. They have middle ear changes 3. They respond to low-pitch tones 4. They develop moist cerumen production

3.

The nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway. The nurse opens the airway in this victim by using which method? 1. Flexed position 2. Head tilt-chin lift 3. Jaw thrust maneuver 4. Modified head tilt-chin lift

3.

A 16-year-old is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively? 1. Encourage the child to rest and read. 2. Encourage the parents to room in with the child. 3. Allow the family to bring in the child's favorite computer games. 4. Allow the child to interact with others in his or her same age group.

4.

The nursing instructor asks a nursing student to describe the formal operations stage of Piaget's cognitive developmental theory. The correct response by the nursing student is which statement? 1. "The child has the ability to think abstractly." 2. "The child begins to understand the environment." 3. "The child is able to classify, order, and sort facts." 4. "The child learns to think in terms of past, present, and future."

1.

The nurse develops a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? 1. Out-of-bed activites as desired 2. Bed rest with the affected extremity kept flat 3. Bed rest with elevation of the affected extremity 4. Bed rest with the affected extremity in a dependent position

3.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1. Muscle twitches 2. Decreased urinary output 3. Hyperactive bowel sounds 4. Increased specific gravity of the urine

3.

The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action? 1. Position the client supine to assist in medication absorption 2. Aspirate the nasogastric tube after medication administration to maintain patency 3. Clamp the nasogastric tube for 30 to 60 minutes following administration of medication 4. Change the suction setting to low intermittent suction for 30 minutes after medication administration.

3.

The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take? 1. Hold the feeding 2. Reinstill the amount and continue with administering the feeding 3. Elevate the client's head at least 45 degrees and administer the feeding 4. Discard the residual amount and proceed with administering the feeding

1.

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? 1. Urinary output of 20 mL/hour 2. Temperature of 99.6 F 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing

1.

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. 1. Peas 2. Raisins 3. Potatoes 4. Cantaloupe 5. Cauliflower 6. Strawberries

2,3,4,6.

A client is receiving a transfusion of packed red blood cells begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8 F orally from a baseline of 99.2 F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? 1. Septicemia 2. Hyperkalemia 3. Circulatory overload 4. Delayed transfusion reaction

1.

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 3pm. The nurse making rounds at 3:45 pm finds that the client is complaining of a pounding headache and is dyspneic, is experiencing chills, and is apprehensive, with an increased pulse rate. The IV bag has 400 mL remaining. The nurse should take which action first? 1. Slow the IV infusion. 2. Sit the client up in bed. 3. Remove the IV catheter. 4. Call the HCP.

1.

The nurse is preparing to instill medication into a client's nasogastric tube. Which actions should the nurse take before instilling the medication? Select all that apply. 1. Check the residual volume 2. Aspirate the stomach contents 3. Turn off the suction to the nasogastric tube 4. Removed the tube and place it in the other nostril 5. Test the stomach for a pH of less than 3.5

1,2,3,5.

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which abnormal laboratory test results should the nurse report? Select all that apply. 1. Calcium, 7 mg/dL 2. Magnesium, 1 mg/dL 3. Phosphorus, 3.6 mg/dL 4. Neutrophils, 1000 cells/mm3 5. Serum creatinine, 1 mg/dL 6. White blood cells, 3000 cells/mm3

1,2,4,6.

The nurse notes that a client's arterial blood gas results reveal a pH of 7.50 and a Pco2 of 30 mmHg. The nurse monitors the client for which chemical manifestations associated with these arterial blood gas results? Select all that apply. 1. Nausea 2. Confusion 3. Bradypnea 4. Tachycardia 5. Hyperkalemia 6. Lightheadedness

1,2,4,6.

A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggest to the client to take which action(s) to reduce the risk of possible transfusion complications? Select all that apply. 1. Ask a family member to donate blood ahead of time. 2. Give an autologous blood donation before the surgery. 3. Take iron supplements before surgery to boost hemoglobin levels. 4. Request that any donated blood be screened twice by the blood bank. 5. Take adequate amounts of vitamin C several days prior to the surgery date.

1,2.

Which intervention(s) are appropriate for the care of an infant? Select all that apply. 1. Provide swaddling 2. Talk in a loud voice. 3. Provide the infant with a bottle of juice at nap time. 4. Hang mobiles with black and white contrast designs. 5. Caress the infant while bathing or during diaper changes. 6. Allow the infant to cry for at least 10 minutes before responding.

1,4,5.

A client with parental nutrition infusing has disconnected the tubing from the central line catheter. The nurse asesses the client and suspects an air embolism. The nurse should immediately place the client in which position? 1. On the left side, with the head lower than the feet 2. On the left side, with the head higher than the feet 3. On the right side, with the head lower than the feet 4. On the right side, with the head higher than the feet

1.

The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure? 1. Allow the infant to signal a need. 2. Anticipate all the needs of the newborn infant. 3. Attend to the newborn infant immediately when crying. 4. Avoid the newborn infant during the first 10 minutes of crying.

1.

The nurse caring for a client with an ileostomy understands that the client is most at risk for developing which acid-base disorder? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1.

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L. Which pattern would the nurse note on the electrocardiogram as a result of the laboratory values? 1. U waves. 2. Absent P waves. 3. Elevated T waves. 4. Elevated ST segment.

1.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2 mg/dL. Which condition most likely caused this serum phosphorus level? 1. Alcoholism 2. Renal insufficiency 3. Hypoparathyroidism 4. Tumor lysis syndrome

1.

The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information should the nurse include in the session? Select all that apply. 1. Individuals move through all six stages in a sequential fashion. 2. Moral development progresses in relationship to cognitive development. 3. A person's ability to make more judgments develops over a period of time. 4. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. 5. In stage 1 (punishment-obedience orientation), children are expected to reason as mature members of society. 6. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.

2,3,4,6.

The community health nurse is providing a teaching session about terrorism to members of the community and is discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted by which route(s)? Select all that apply. 1. Bites form ticks or deer flies. 2. Inhalation of bacterial spores 3. Through a cut or abrasion in the skin 4. Direct contact with an infected individual 5. Sexual contact with an infected individual 6. Ingestion of contaminated undercooked meat.

2,3,6.

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time of 35 seconds. On the basis of the prothrombin time, the nurse anticipates which prescription? 1. Adding a dose of heparin sodium 2. Holding the next dose of warfarin 3. Increasing the next dose of warfarin 4. Administering the next dose of warfarin

2.

The nurse checks the laboratory result for a serum digoxin level that was prescribed for a client earlier in the day and notes that the result is 2.4 ng/mL. The nurse should take which immediate action? 1. Check the client's last pulse rate. 2. Notify the health care provider. 3. Record the normal value on the client's flow sheet 4. Administer the next does of the medication as scheduled.

2.

The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client? 1. Side-lying on the operative side 2. On the nonoperative side with the legs abducted 3. Side-lying with the affected leg internally rotated 4. Side-lying with the affected leg externally rotated

2.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

2.

A spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take? 1. Have one of the client's family members interpret. 2. Have the Spanish speaking triage receptionist interpret. 3. Page an interpreter from the hospital's interpreter services. 4. Obtain a Spanish-English dictionary and attempt to triage the client.

3.

An adult client with cirrhosis has been prescribed a diet with optimal amounts of protein. The nurse evaluates the client's status as being most satisfactory if the total protein is which value? 1. 0.4 g/dL 2. 3.7 g/dL 3. 6.4 g/dL 4. 9.8 g/dL

3.

Packed red blood cells have been prescribed to a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 F orally. Which action should the nurse take? 1. Begin the transfusion as prescribed. 2. Administer an antihistamine and begin the transfusion. 3. Delay hanging the blood and notify the HCP. 4. Administer two tablets of acetaminophen and begin the transfusion.

3.

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position? 1. Prone 2. Reverse Trendelenburg's 3. Supine, with the amputated limb flat on the bed 4. Supine, with the amputated limb supported with pillows

4.

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The ECG monitor displays tachycardia with a heart rate of 120 beats/minute. arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1. A decreased pH and increased CO2 2. An increased pH and a decreased CO2 3. A decreased pH and a decreased HCO3 4. An increased pH and an increased HCO3

4.

A client with the recent diagnosis of myocardial infarction and impaired renal function is recuperating on the step-down cardiac unit. The client's blood pressures has been borderline low and IV fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximatley 24 hours to increase renal output and maintain the blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that the client is most likely experiencing which complication of IV therapy? 1. Hematoma 2. Air embolism 3. Systemic infection 4. Circulatory overload

4.

A mother arrives at a clinic with her toddler and tells the nurse that she has a difficult time getting the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the mother? 1. Allow the child to set bedtime limits. 2. Allow the child to have temper tantrums. 3. Avoid letting the child nap during the day. 4. Inform the child of bedtime a few minutes before it is time for bed.

4.

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that planning care delivery will be based on which characteristic of this type of nursing model of practice? 1. A task approach method is used to provide care to clients. 2. Managed care concepts and tools are used in providing client care. 3. A single registered nurse is responsible for providing care to a group of clients. 4. A registered nurse leads nursing personnel in provided care to a group of clients.

4.

Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? 1. Gloves and gown 2. Gloves and goggles 3. Gloves, gown, and shoe protectors 4. Gloves, gown, goggles, and face shield

4.

The nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is most at risk for the development of a potassium value at this level? 1. The client with colitis 2. The client with Cushing's syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn

4.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? 1. A client complaining of muscle aches, a headache, and malaise. 2. A client who twisted her ankle when she fell while rollerblading. 3. A client with a minor laceration on the index finger sustained while cutting an eggplant. 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce.

4.

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. On the basis of this documentation, which pattern did the nurse observe? 1. Respirations that cease for several seconds 2. Respirations that are regular but slow 3. Respirations that are labored and increased in depth and rate 4. Respirations that are abnormally deep, regular, and increased in rate

4.

The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel enters the client's room and tells that nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? 1. Finish the bed bath and then administer the pain medication to the other client. 2. Ask the UAP to find out when the last pain medication was given to the client. 3. Ask the UAP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

4.

The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child? 1. A radio 2. A sports video 3. Large picture books 4. Crayons and a coloring book

4.

The nurse is preparing to change the parenteral nutrition solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change? 1. Breather normally. 2. Turn the head to the right. 3. Exhale slowly and deeply. 4. Take a deep breath, hold it, and bear down.

4.

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the HCP and the HCP prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid? 1. Peas 2. Nuts 3. Cauliflower 4. Processed oat cereals

4.

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq.L. Which finding would the nurse expect to noted on the electrocardiogram as a result of the laboratory value? 1. ST depression 2. Inverted T wave 3. Prominent U wave 4. Tall peaked T waves

4.

The nursing instructor asks a nursing student to describe the procedure for performing abdominal thrusts on an unconscious pregnant woman at 32 weeks' gestation. The student describes a component of the procedure correctly if the student states that he will take which action? 1. Place his hands on the pelvis to perform the thrust. 2. Perform abdominal thrusts until the object is dislodged. 3. Perform left lateral abdominal thrusts until the object is dislodged. 4. Place a rolled blanket under the right abdominal flank and hip area.

4.