NCLEX review questions

A client with an ischemic stroke was prescribed warfarin 5 mg daily by mouth 48 hours ago. At 0830 the international normalized ratio (INR) reading was 2.0. What action should the n. urse take? 1. Administer warfarin. 2. Administer phytonadione. 3. Request the lab to run another INR. 4. Notify the primary healthcare provider about the INR level.

1. Administer warfarin

The nurse is assisting the client on the correct procedure for applying anti-embolism stockings. Which statement by the client indicates that the client understands the procedure?

2 "I will apply antiembolism stockings before I get out of bed 4 "prior to applying the stocking I will reddened areas on my skin

The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which observation would indicate the need to slow the irrigation? 1. Clots in urine 2. Bladder pressure 3. Clear urine 4. Bladder spasms

3

14

5 10 kg x 50 mg =500 100 mg: 1 mL:: 500: x mL 100 x/100= 500/100 x=5

A client diagnosed with heart failure has been prescribed a 2 gm sodium diet. Which food choices selected by the client would indicate to the nurse that the client understands this diet? Select all that apply 1. Pork loin 2. Frozen cheese ravioli dinner 3. Instant vanilla pudding 4. Thin crust pepperoni and ham pizza 5. Fresh salad with fresh citrus juice dressing 6. Bottled tomato juice

1,5

A nurse working in a clinic is planning to assess a client for any sensory deficits. What assessments should the nurse include? 1. Ask the client about any recent changes in vision. 2. Observe the client's conversation with others. 3. Assess two-point discrimination. 4. Perform the Rinne test 5. Test near vision with the Snellen chart.

1,2,3,4 Physical assessment determines whether the senses are impaired. During the physical examination, the nurse assesses vision and hearing and olfactory, gustatory, tactile, and kinesthetic senses. The exam should reveal the client's specific visual and hearing abilities, perception of heat, cold, light, touch, pain in the limbs, and awareness of the position of body parts. Start with a history and ask about recent changes in vision. Observing client conversation with others can indicate hearing or communication problems. Two-point discrimination will assess tactile sense. The Rinne test assesses hearing.

The nurse is caring for a trauma client who is receiving a unit of whole blood. The client begins to experience lower back pain. What actions should the nurse take? Select all that apply 1. Administer diphenhydramine. 2. Collect a urine specimen. 3. Stop the transfusion. 4. Take the client's vital signs. 5. Change the IV tubing

2,3,4,5

A client receiving 50 mL/hr of enteral feedings has a gastric residual volume of 200 mL and is reporting nausea. What is the appropriate nursing intervention? 1. Stop the feeding and assess gastric residual volume in 1 hour. 2. Reduce the infusion rate to 25 mL/ hour and reevaluate residual volume in 4 hours. 3. Change the feeding schedule from continuous to intermittent delivery. 4. Discard the 200 mL and continue the feedings at the same rate.

1,

The nurse is caring for a client on the surgical unit. Which prescriptions could the nurse safely administer to the client? Select all that apply 1. Chlordiazepoxide 10 mg p.o. q 4h p.r.n. for agitation 2. Regular insulin 10 U stat 3. MS 2 mg IVP every 2 hours as needed for pain 4. Cefepime 1 gram IVPB every 8 hours 5. Diphenhydramine 25 mg p.o. hour of sleep for three nights

1, 4, 5 These medication prescriptions are correctly written following approved joint commission abbreviations

An unconscious client is admitted to the ICU with a closed head injury suffered in a fall. Despite aggressive efforts, the client expired within 24 hours. The nurse must complete postmortem care while awaiting the coroner. The nurse knows what action is not appropriate in this situation? Select all that apply 1. Remove indwelling catheter 2. Disconnect the ET tube from ventilator 3. Remove hospital ID band 4. Cap all intravenous lines 5. Wash body head to toe

1,3,5 The client expired of injuries within 24 hours of being admitted to the hospital, which requires investigation by a coroner. It must be determined if death resulted from fall injuries, or whether any action, or lack therof, by medical personnel contributed to the client's demise. When completing postmortem care on a "coroner's case" the nurse must leave all invasive lines and tubes in place for investigation purposes. Therefore, it would not be appropriate for the nurse to remove the foley cath, although the urine can be emptied from the bag. It is also incorrect to remove any hospital identification bands. Washing the body should never be done since evidence could be disturbed or even removed.

A client becomes progressively cyanotic and unresponsive post central line insertion. Which action should the nurse take? 1. Place the client on the left side with the client's head down. 2. Administer a thrombolytic agent. 3. Auscultate the client's heart sounds. 4. Have the client bear down and perform valsalva maneuver.

1. The nurse should immediately place the client in the left side lying position with the head down. This position will trap a bubble in the right ventricle preventing it from passing into the pulmonary circulation.

The nurse is working in the term nursery. Which task should be performed first on a newborn? 1. Prepare the circumcision equipment for a two day old newborn. 2. Assess the five minute APGAR of a newborn. 3. Perform the gestational age assessment on a 30 minute old newborn. 4. Obtain a blood sample for metabolic testing on a 24 hour old newborn.

2

A client has been taking tranylcypromine for approximately two weeks. The client is visiting the nurse at the local mental health center for follow-up and group therapy. Which client comment indicates a lack of understanding of the medication that could result in a medical emergency? 1. I know that I must take this medication until my primary healthcare provider tells me to stop. 2. It is frustrating to have to follow dietary restrictions. 3. I am getting a cold, and I am going to take some over-the-counter cold medicine. 4. I am going to have broccoli salad and roasted turkey for lunch today.

3

The nurse is talking to the parent of a 3 year old child who was constipated 1 week earlier. The child is on a regular diet. What statement by the parent indicates to the nurse that the prescribed treatment for constipation has been effective?

4. My child has had a soft, formed brown stool every day for 6 days without straining

A child is being discharged home following a bone marrow transplant. When providing discharge instructions to the parents, what information is most important for the nurse to include? 1. Clean toothbrush weekly with alcohol. 2. Avoid eating raw fruits and vegetables. 3. Drink bottled water the day. 4. Apply heating pad to bruised areas of the skin.

2

A nurse wants to find out a better way to perform oral care on unresponsive clients. What is the best first action for the nurse to take in order to achieve this goal?

2. Discuss issue with the leader of "best practices" committee

A nurse is caring for a client who has been prescribed sucralfate. Which client education intervention would the nurse include for the client prescribed sucralfate? 1. Take medication 1 hour after meals. 2. Crush tablets prior to taking medication. 3. Consume 1000 mL of fluid every 24 hours. 4. Avoid antacids 1 hour before and after this medication.

4. Sucralfate is absorbed more effectively in an acidic state. SInce an antacid medication will increase the alkaline state, the client should avoid taking antacids within 1 hour before or after taking sucralfate to increase the absorption rate.

Which nursing statements about a client reflect correct documentation in the hospital medical record? Select all that apply 1. 20% of breakfast consumed. 2. 4 inch by 2 inch wound noted on right arm. 3. Enema administered. 4. Appears upset at spouse. 5. Lying in bed.

1,2

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? Select all that apply 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."

1,2,3

A client diagnosed with rheumatoid arthritis has been prescribed dexamethasone orally as part of initial treatment therapy. What side effects should the nurse teach the client are expected? Select all that apply 1. Fatigue 2. Insomnia 3. Hypoglycemia 4. Truncal obesity 5. Increased appetite 6. Low blood pressure

1,2,4,5 Dexamethasone (Decadron) is a corticosteroid used short term to treat severe inflammation occurring in RA. Expected side effects are associated with the body's response to excessive steroids in the system. Even short term use of corticosteroids will produce fatigue, secondary to insomnia. Truncal obesity accompanied by thin extremities, and an increased appetite resulting in weight gain. Despite the short and intermittent use of corticosteroids for this auto-immune disease, some side effects remain permanently.

The family of a bedfast 80 year old is providing care in the home. Which reports by the family indicate adequate understanding of interventions that will reduce the risk for skin breakdown? Select all that apply 1. I make sure that the sheets and the foam pad in the chair stay dry. 2. I will not encourage my parent to turn in the bed at night. 3. The perineal area should be kept dry and clean. 4. My parent eats 2 meals per day and drinks a supplement. 5. I may reposition my parent more than every 2 hours if their perception of pressure is intact.

1,3,4,5

What medications should the nurse anticipate the primary healthcare provider prescribing for the client with portal hypertension and bleeding esophageal varices associated with advanced cirrhosis? Select all that apply 1. Oxygen 2. Clopidogrel 3. Propranolol 4. Vitamin K 5. Lactulose

1,3,4,5 We know that they need oxygen because they may have been bleeding. Propranolol acts to reduce portal venous pressure and reduce esophageal varices bleeding. Vitamin K is a clotting factor and helps to correct clotting abnormalities because of the damaged liver. Lactulose decreases what? Ammonia, which is elevated with cirrhosis.

A client admitted to ICU has a prescription for an arterial line insertion to the right radial artery. What assessment findings by the nurse would be of concern? Select all that apply 1. Right sided mastectomy 2. Inability to abduct fingers of right hand 3. Negative Allen's test 4. Radial pulse 3+/4+ 5. Presence of A-V shunt to right forearm

1,3,5

A nurse is teaching a client who has frequent urinary tract infections how to prevent future infections. What statement by the client would indicate to the nurse that treatment has been successful? Select all that apply 1. "I will go to the bathroom as soon as the urge to void hits me." 2. "It is important for me to drink five to six 8 ounce glasses of water every day." 3. "I should eat foods such as plums and prunes to increase the acidity of my urine." 4. "Nylon underwear should be worn when I am free from infection." 5. "When I clean after voiding, I will discard toilet paper after each swipe."

1,3,5

A client diagnosed with gout has received instruction on maintaining a low-purine diet. Which statements, if made by the client, would indicate to the nurse that teaching was successful? Select all that apply 1. "I will eliminate foods from my diet that contain 150 mg or more of purine per serving." 2. "Rather than drinking a glass of wine, I should drink a glass of beer." 3. "Losing weight can help reduce the uric acid levels in my blood." 4. "Potatoes, rice, and barley are high in purine and should be eliminated from my diet." 5. "Vegetables that should be limited to 2 times/week include cauliflower, spinach, and mushrooms." 6. "Increasing fluid intake to 8-10 cups/day will help to eliminate purines through my urine."

1,3,5,6

An elderly client has been admitted to the hospital with a diagnosis of cerebral vascular accident (CVA) with right-sided paralysis. When the nurse instructs staff to reposition client every two hours, the family asks about the purpose of this action. What is the best explanation by the nurse? 1. Improves circulation to the affected side of the body. 2. Decreases potential skin breakdown from immobility. 3. Prevents blood stasis in the client's lower extremities. 4. Alleviates sensory deprivation by varying environment.

2

How should a nurse prepare to administer a Measles, Mumps, Rubella (MMR) vaccination to a 6 year old child? 1. 3 mL syringe with 23 gauge, 1" needle for IM injection 2. Use a 25 gauge, ¾" needle for subcutaneous (Sub-Q) injection. 3. Prime intranasal spray for administration. 4. Tuberculin (TB) syringe with 28 gauge, 3/8" needle for intradermal injection.

2

The nurse is discharging a client who had a kidney transplant and the primary healthcare provider has prescribed mycophenolate. Which nursing instruction is priority regarding this medication? 1. Take the medication with food 2. Notify primary healthcare provider at first signs of an infection 3. Nausea, vomiting, and diarrhea are common side effects 4. Use sunscreen when planning to be outdoors

2

Which meal option should the client diagnosed with gout select? 1. Tuna salad on bed of lettuce, apple slices, coffee 2. Vegitable soup, whole wheat toast, skim milk 3. Roast beef with gravy sandwich, baked chips, diet coke 4. Spinach salad with chick peas and asparagus, apple, tea

2 Goud is pain and inflammation that occurs when too much uric acid crystallizes and deposits in the joints. This is a good choice as it is low in purine and fat. Purines are broken down into uric acid. A diet rich in purines can raise uric acid levels. Meat and seafood increase risk of gout. Dairy products may lower risk for gout.

The charge nurse is observing a new LPN preparing to irrigate a client's indwelling urinary catheter. The nurse must intervene when the LPN initiates what action? 1. Gathers all sterile equipment for procedure. 2. Opens bottle of sterile distilled water to flush. 3. Allows return flow to be achieved by gravity. 4. Uses gentle pressure when flushing catheter.

2, The charge nurse is observing the lpns ability to complete this invasive procedure, monitoring for any action can harm the client. The charge nurse should intervene to prevent the lpn from using sterile distilled water. Only sterile normal saline (NS) can be used to flush out the catheter to prevent an alteration in the pH balance of the bladder.

What should the nurse include when planning discharge teaching for a client post scleral buckling of the right eye?

2, teach to report of seeing flashes of light immediately 4, wear eye shields during naps and at night 5, have client demonstrate the correct technique for instilling eye drops

What should the nurse teach the client following a right knee arthroscopy? Select all that apply 1. Apply ice to right knee continuously for the first 24 hours. 2. Elevate the right knee when sitting. 3. Notify the primary healthcare provider of tingling in the right leg. 4. Gradually start an exercise program to prevent scarring. 5. Place a plastic bag over wound when showering.

2,3,4,5

After a thoracotomy, which interventions will the nurse initiate to reduce the risk of acute respiratory distress? Select all that apply 1. Allow 4 hours of rest between deep breathing and coughing exercises. 2. Splint the incision during deep breathing and coughing exercises. 3. Have the client drink a glass of water before coughing. 4. Perform percussion and vibration every 2 hours. 5. Promote incentive spirometer use several times per hour while awake.

2,5

A nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. Based on the information provided in report, which client condition should be the nurse's priority? 1. Potassium level of 3.4 mEq/L (3.4 mmol/L) in a child with vomiting and diarrhea. 2. Platelet count of 95,000/mm3 in a child with a nose bleed. 3. Absolute neutrophil count of 400/mm3 in a child with fever. 4. Hemoglobin level of 9 g/dL (90 g/L) in a child with reports of fatigue

3

A client admitted with a diagnosis of portosystemic encephalopathy secondary to Laennec's cirrhosis is scheduled for the insertion of a pigtail catheter. The family asks the nurse the purpose of the catheter. What should the nurse tell the family? 1. Obtains an hourly assessment of urinary output. 2. Instills antibiotics to decrease internal bacteria. 3. Drains excess fluid from the abdominal cavity. 4. Obtains liver tissue for a diagnostic biopsy.

3, drains excess fluid from the abdominal cavity

The nurse is caring for a client who is taking an antipsychotic medication for the treatment of schizophrenia. The nurse is told in report that the client has akathisia, as side effect of their antipsychotic medication. What symptom should the nurse expect this client to have? 1. Upward gaze of they eyes. 2. Involuntary movements of the tongue. 3. Reports of restlessness. 4. Lack of movement or slowed movement.

3. Report of restlessness, inability to sit still, and nervous energy indicate akathisia. These symptoms respond poorly to treatment. If possible, the does of the medication may be reduced.

A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. Which preoperative prescription should the nurse question? 1. Administer tap water enemas until clear at 6 AM. 2. Nothing by mouth (NPO). 3. IV of D5 ½ NS at 75 mL/hour with a 20 gauge catheter. 4. Give magnesium citrate 296 mL at 3 PM today.

4

A client with a history of angina has returned to the unit following a cardiac catherization. What nursing action has the highest priority? 1. Obtain vital signs every thirty minutes. 2. Assess pedal pulses every ten minutes. 3. Place the call bell within client's reach. 4. Keep affected extremity immobilized for 6 hours.

4

Which action by an unlicensed nursing assistant would require the nurse to intervene? 1. Collecting I & O totals for unit clients at the end of shift. 2. Elevating the head of the bed 30°- 40° for the client post thoracotomy 3. Ambulating a client who is 2 days post vaginal hysterectomy 4. Turning off continuous tube feeding to reposition a client, then turning the feeding back on

4.

A client admitted with a diagnosis of end stage kidney disease (ESKD) has been prescribed a diet containing no more than 1 gram of phosphate per day. Which food item, if found on the client's meal tray should be removed by the nurse? 1. Skinless chicken breast 2. Green beans 3. Asparagus 4. Ice cream

4. Ice cream, a milk product is high in phosphate

A three year old weighing 13.6 kg is scheduled to receive a dose of digoxin elixir. The prescribed dose is 25 micrograms/kg How many mL will the nurse administer to the child? Round to 1 decimal place. Use numbers and decimals only.

6.8 Rationale: Step 1: Determine how many mcg's per kg should be given. 25 mcg/kg x 13.6=340 Step 2: Think: You will want to give less than 7 mL, since one mL is 50 mcg. Step 3: D/H x Q =340 mcg/50 x 1mL=34/5=6 4/5= 6.8 mL

A child admitted to the ed due to suspected appendicitis with perforation. What would be the priority nursing assessment for this client?

Monitor for increasing pain and rigidity Increasing pain and rigid, board like abdomen are signs that the appendix may be ruptured, with resulting peritonitis developing