NCLEX RN the last random pull I'm going to do, I swear

The nurse is caring for a client with suspected pelvic inflammatory disease (PID). When the nurse is obtaining the client's health history, which of the following questions would provide pertinent data about the client's risk factors for PID? Select all that apply. - Are you currently taking oral contraceptives? - At what age did you experience your first menstrual cycle? - Do you engage in sexual intercourse with multiple partners? - Have you ever been diagnosed with a sexually transmitted infection? - Have you recently had an abortion or pelvic surgery?

- Do you engage in sexual intercourse with multiple partners? - Have you ever been diagnosed with a STI? - Have you recently had an abortion or pelvic surgery?

The nurse is assessing a 2 year old who has a blistered sunburn across the back and shoulders. Which of the following parent statements indicates an appropriate understanding of care for sunburn? Select all that apply. - I am allowing my child to play outdoors only very early in the morning and late in the evening since the sunburn - I am encouraging extra fluids since my child got sunburned - I have been giving my child acetaminophen to help relieve the pain - I have been placing cool, wet washcloths on my child's back - I have rubbed hydrocortisone on the area to help reduce inflammation and promote healing

- I am allowing my child to play outdoors only very early in the morning and late in the evening sicne the sunburn - I am encouraging extra fluids since my child got sunburned - I have been giving my child acetaminophen to help relieve the pain - I have been placing cool, wet washcloths on my child's back

A nurse is reinforcing teaching with a client newly diagnosed with human immunodeficiency virus (HIV) about actions to prevent complications. Which of the following statements indicate that teaching was effective? Select all that apply. - I should ask for my steak to be cooked thoroughly with no pink - I should receive the influenza vaccine every year - I will ask my roommate to change the cat litter box for me - If I travel to a developing country, I will use bottled water when brushing my teeth. - If my HIV viral load is undetectable, I do not need to wear condoms

- I should ask for my steak to be cooked thoroughly with no pink - I should receive the influenza vaccine every year - I will ask my roommate to change the cat litter box for me - If I travel to a developing country, I will use bottled water when brushing my teeth

The registered nurse (RN) is caring for a client with tuberculosis who is on airborne isolation precautions. The RN can delegate which tasks t the experienced unlicensed assistive personnel (UAP)? Select all that apply. - Alert the x-ray department about maintaining airborne isolation precautions - Explain to the client why the client must wear a mask during transport to another department - Post signs for airborne isolation precautions on the client's door and stock necessary equipment - Remind visitors to wear a respirator mask and keep the door closed while in the client's room - Talk with the family about the reasons for airborne isolation precautions in the client

- Post signs for airborne isolation precautions on the client's door and stock necessary equipment - Remind visitors to wear respirator mask and keep the door closed while in the client's room

The emergency department nurse is obligated to make a report for which situations? Select all that apply - To a client's employer that the client had a car crash while intoxicated - To the authorities that an elderly client has suspicious bruising but denies caregiver abuse - To the medical examiner of a death following trauma, even if the family refuses autopsy - To the spouse of a client that the client has a reportable sexually transmitted disease - To the supervisor that an oncoming health care provider has the smell of alcohol on the breath.

- To the authorities that an elderly client has a suspicious bruising but denies caregiver abuse - To the medical examiner of a death following trauma, even if the family refuses autopsy - To the supervisor that an oncoming health care provider has the smell of alcohol on the breath

The registered nurse is caring for a postoperative client who becomes short of breath on the night of surgery and initiates the prn prescription for oxygen at 3 L/min by nasal cannula. The client makes frequent requests to use the bathroom during the night. Which tasks can be delegated to the unlicensed assistive personnel? Select all that apply - Assisting the client to the bathroom - Deciding if supplemental oxygen is necessary when the client is ambulating - Documenting vital signs in the electronic medical record - Notifying the nurse immediately if the client's respirations exceed 20/min - Reapplying the nasal cannula if it accidentally comes off

- assisting the client to the bathroom - Documenting if supplemental oxygen is necessary when the client is ambulating - Notifying the nurse immediately if the client's respirations exceed 20/min - Reapplying the nasal cannula if it accidentally comes off.

Ankylosing spondylitis

An inflammatory disease affecting the spine, has no known cause or cure. Characterized by stiffness and fusion of the axial joints, leading to restricted spine mobility. Low back pain and morning stiffness that improve with activity are the classic findings. Involvement of the thoracic spine and costosternal junctions can limit chest wall expansion, leading to hypoventilation The client with AS should: - Promote extension of the spine with proper posture, daily stretching, and spine-stretching exercies - Stop smoking and practice breathing exercises to increase chest expansion and reduce lung complications - Manage pain with moist heat and NSAIDS - Take immunosuppressant and anti-inflammatory medications as prescribed to reduce inflammation and increase mobility

The home health nurse is providing long-term care to several clients. Which are examples of inappropriately crossing professional boundaries? Select all that apply - Accepting a birthday gift of a gold bracelet from a client - Making a visit to the hospital after a client has surgery - Offering to pray together if a client so wishes - Sending a sympathy card to a family after a client dies - Soliciting a wealthy client to invest in a company - Staying after work hours and drinking wine with a client

- Accepting a birthday gift of a gold bracelet from a client - Soliciting a wealthy client to invest in a company - Staying after work hours and drinking wine with a client.

A hospitalized client with acute pancreatitis has nausea, vomiting, epigastric pain, and tachycardia. Laboratory results show elevated serum lipase levels. Which interventions would the nurse anticipate being prescribed for the client? Select all that apply - Administer hydromorphone IV PRN for pain - Administer intravenous fluids - Insert a nasogastric tube for nasogastric suction - Maintain client in a supine position, with head of bed flat - Provide small, frequent, high-carb, high-calorie meals

- Administer hydromorphone IV PRN for pain - Administer intravenous fluids - Insert a nasogastric tube for nasogastric suction.

Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply. - Amenorrhea - Fluid and electrolyte imbalances - Heat intolerance - Presence of lanugo - Refusal to exercise - Weight loss of 25% below normal weight

- Amenorrhea - Fluid and electrolyte imbalances - Presence of lanugo - Weight loss of 25% below normal weight

A nurse cares for a frail, elderly client with osteoporosis in a nursing home. Which interventions are appropriate to include in the client's care plan to help prevent a hip fracture? Select all that apply. - Calcium supplements - Encourage bed rest - Use of full bed rails during the night - Vitamin D supplements - Weight-bearing exercies

- Calcium supplements - Vitamin D supplements - Weight-bearing exercises

The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis). Which of the following lifestyle changes should the nurse recommend? Select all that apply. - Avoid intake of dairy products - Drink large amounts of fluid with meals - Eat several small meals each day - Eliminate fried, fatty foods - Lie down on the left side after meals

- Eat several small meals each day - Eliminate fried, fatty foods

Which statement is most important to emphasize when teaching a 40-year-old female client newly diagnosed with fibrocystic breast changes? - Breast changes that are not related to your cycle should be reported to your provider - If your breasts become sore during the month, you may take ibuprofen as needed - Schedule yearly clinical breast examinations with your health care provider - These cysts are benign, and research shows that they do not increase the risk of cancer.

Breast changes that are not related your cycle should be reported to your provider

A student nurse asks why enteral (tube) feedings, rather than total parenteral nutrition (TPN), are being administered to a client with sepsis and respiratory failure. Which is the best response by the registered nurse? - Enteral feedings have no complications - Enteral feedings maintain gut integrity and help prevent stress ulcers - Enteral feedings provide higher calorie content - Risk of hyperglycemia is lower with enteral feedings than with TPN

Enteral feedings maintain gut integrity and help prevent stress ulcers

A nurse is assessing a 59-year-old client with blurred vision and reduced visual fields. Which manifestation is of most concern to the nurse? - Difficulty adjusting to dimmed lights - Extreme eye pain - Gradual loss of peripheral vision - Opaque appearance of lens

Extreme eye pain

The nurse preparing an educational seminar on sexually transmitted infections for female college students should advice that which 2 infections are leading causes of pelvic inflammatory disease and infertility? - Genital herpes and HIV - Gonorrhea and chlamydia - Human papillomavirus and syphilis - Yeast and trichomoniasis

Gonorrhea and chlamydia

A client is receiving an infusion of total parenteral nutrition (TPN) with 20% dextrose through a central line at 75 mL/hr. The nurse responds to the client's IV pump alarm, which indicates that the bag is empty. The new bag is not expected to arrive from the pharmacy for an hour. What is the most appropriate nursing action? - Hang 0.9% normal saline until new bag arrives, then increase TPN to 150 mL/hr for 1 hour. - Hang 10% dextrose in water until the new bag arrives, then resume TPN at 75 mL/hr - Hand dextran in saline until the new bag arrives, then resume TPN at 75 mL/hr - Hang Lactated Ringer's until the new bag arrives, then resume TPN at 75 mL/hr

Hang 10% dextrose in water until the new bag arrives, then resume TPN at 75 mL/hr

When caring for a client with severe burns, the nurse can expect to administer pain medication via which route? - Intramuscular - Intravenous - Oral - Subcutaneous

Intravenous

The nurse is discussing feeding and eating practices with the mother of a 1-year-old. Which statement made made by the mother indicates a need for further instruction? - I give my child chopped fruit rather than juice - I make sure my child drinks plenty of water between meals - My child is fussy at bedtime so I put him to sleep with a bottle of milk - When I give my child a new food, I wait a week before trying a second new food

My child is fussy at bedtime so I put him to sleep with a bottle of milk

The nurse is providing education to a 32 year old female client diagnosed with human papillomavirus (HPV). Which client statement indicates a need for further instruction? - I can transmit the virus when I don't have symptoms - I know the virus can be spread through oral sex - I need to have a Papanicolaou test on an annual basis - My partner won't get HPV as long as we use a condom.

My partner won't get HPV as long as we use a condom

An admitted emergency department client is waiting for an intensive care unit bed to be available for transfer to the inpatient unit. The ED is very crowded today. The ICU resident is currently too busy to request that an ICU client be transferred to telemetry so the bed can be available; the resident will be able to do so in about 6 hours. What action should the ED charge nurse take first? - Call the telemetry unit manager - Notify the nursing supervisor - Send the client to ICU to "hold" the client in the hallway - Wait until the resident has time to request the transfer

Notify the nursing supervisor

The nurse is caring for a client who has undergone a colonoscopy. Which client assessment finding should most concern the nurse? - Abdominal cramping - Frequent, watery stools - Positive rebound tenderness - Recurring flatus

Positive rebound tenderness - could indicate perforation

A 16 year old walks in unaccompanied by a parent and approaches the clinic nurse. The adolescent asks to be tested for a sexually transmitted infection. How should the clinic nurse respond? - Determine if the client wore protection - Inform that parental consent is required - Inform that the request is honored if the client has symptoms - Provide requested service

Provide requested service

A nurse in a pediatric clinic is preparing to administer ear drops to a 5-year-old. Which is an appropriate action by the nurse? - Have the child sit upright with the chin tilted down - Pull the pinna upward and back - Remove the medication from the refrigerator just before use - Touch the dropper to the entrance of the ear canal

Pull the pinna upward and back

The health care provider writes a prescription for hydromorphone 10 mg intravenous push every 2 hours prn for the post-operative client. The usual recommended dose is 0.2-1 mg every 2-3 hours prn. What action should the nurse take initially? - Administer the medication and monitor client frequently - Ask a nursing colleague if this drug amount is used - Check hydromorphone dose that the client had previously - Question the prescription with the prescriber

Question the prescription with the prescriber

The nurse working in an extended care facility transcribes a prescription from the health care provider for a single daily dose of 150 mg of ranitidine; this is to be taken orally at bedtime for treatment of gastroesophageal reflux disease. Of the following prescriptions, which one is transcribed correctly? - Ranitidine 150 mcg daily by mouth - Ranitidine 150 mg per os qhs - Ranitidine 150 mcg po qd nightly - Ranitidine 150 mg PO at bedtime

Ranitidine 150 mg PO at bedtime

A client is being discharged with plans to return home alone. The client cannot get up from a chair without help and is very unsteady when standing, even with a walker. The nurse expresses concern, but the primary health physician is adamant that the client be discharged today. Which team member would be most appropriate to assist the nurse in advocating for this client? - Clinical psychologist - Occupational therapist - Physical therapist - Social worker

Social worker.

A client comes to the emergency department after being assaulted. Imaging studies show a simple fracture of the mandible. The nurse assesses edema of the face and jaw, drooling, and bleeding in the mouth; the client rates pain as a 9 out of 10. What is the priority nursing intervention? - Administer nasal oxygen at 3 L/min - Administer opioids for pain - Apply ice pack to face for 20 minutes each hour - Suction the mouth and oropharynx

Suction the mouth and oropharynx

The graduate nurse is inserting an oropharyngeal airway into a client emerging from general anesthesia. Which action by the GN causes the nurse preceptor to intervene? - Measures the oropharyngeal airway against the cheek and jaw angle before insertion - Rotates the device tip downward once it reaches the soft palate - Suctions secretions from the mouth and pharynx prior to device insertion - Tapes the external portion of the inserted oropharyngeal airway to the client's cheek

Tapes the external portion of the inserted oropharyngeal airway to the client's cheek

A client comes to the clinic for a follow-up visit after Billroth II surgery (gastrojejunostomy). The client reports occasional episodes of sweating, palpitations, and dizziness 30 minutes after eating. Which nursing action is most appropriate? - Check serum blood glucose for hypoglycemia - Ensure that the client consumes fluids with meals - Take the client's blood pressure while lying and standing - Teach the client to lie down after eating

Teach the client to lie down after eating - clients are at risk for dumping syndrome after a gastrectomy and may experience abdominal cramping, nausea, vomiting, and diarrhea. To delay gastric emptying, clients should avoid fluids with meals and lie down after eating.

The nurse in a clinic is caring for an 8 month old with a new diagnosis of bronchiolitis due to respiratory syncytial virus (RSV). Which instructions can the nurse anticipate reviewing with the parent? - Administering a cough suppressant and antihistamine - Prophylactic treatment of family members - Temporary cessation of breastfeeding - Use of saline drops and a bulb syringe to suction nares.

Use of saline drops and a bulb syringe to suction nares.

The nurse is preparing a symptom management teaching plan for a client diagnosed with carpal tunnel syndrome. Which instruction is appropriate to include in the teaching plan> - Apply elastic compression hose to wrist - Avoid use of caffeinated or tobacco products - Perform repetitive hand exercises daily - Wear a wrist immobilization splint

Wear a wrist immobilization splint

The nurse has provided education for a client with newly diagnosed ankylosing spondylitis. Which client statements indicate a correct understanding of teaching? Select all that apply - I should continue strenuous exercise during flare-ups - I should include spine-stretching activities such as swimming - I should quit smoking and perform breathing exercises - I will sleep on a soft mattress to decrease my morning stiffness - I will take the prescribed ibuprofen on an empty stomach.

- I should include spine-stretching activities such as swimming - I should quit smoking and perform breathing exercises

The nurse is preparing for the admission of a 9-year-old client with new-onset tonic-clonic seizures. It is important for the nurse to ensure that what is in the room? Select all that apply. - Oral bite prevention device - Oxygen delivery system - Padding on the bed side rails - Soft arm and leg restraints - Suction equipment.

- Oxygen delivery system - Padding on the bed side rails - Suction equipment.

The nurse is teaching the mother of a newborn about gastroesophageal reflux. What does the nurse suggest to help prevent reflux? Select all that apply? - Burp during and after feeds - Engage baby in active play after the feeding - Feed baby in side-lying position - Hold baby upright 20-30 minutes after each feeding - Offer smaller but more frequent feeds - Place baby on tummy after feeding

- Burp during and after feeds - Hold baby upright 20-30 minutes after each feeding - Offer smaller but more frequent meals

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply. - Client admitted with white blood cell count of 28,000 and dies from sepsis - Client receives 1 mg morphine instead of the prescribed 0.5 mg morphine - Client refuses pneumonia vaccination and contracts pneumonia - Nurse did not report client's new hemoglobin result of 6 g/dL to oncoming nurse - Provider was not notified of client's positive blood culture results

- Client receives 1 mg morphine instead of prescribed 0.5 mg morphine - Nurse did not report client's new hemoglobin result of 6 g/dL to oncoming nurse - Provider was not notified of client's positive blood culture results.

Which of these instructions is appropriate teaching for a 60 year old woman? Select all that apply - Consume adequate sources of calcium and vitamin D and take supplements - Increase intake of food sources of iron and take supplements - Observe for unilateral leg swelling when taking hormone replacement therapy - Remain upright for 30 minutes when taking a biphosphonate - Vaginal spotting after menopause is a common, insignificant sign of aging

- Consume adequate sources of calcium and vitamin D and take supplements - Observe for unilateral leg swelling when taking hormone replacement therapy - Remain upright for 30 minutes when taking a biphosphonate

An adult was severely burned in a warehouse accident. The client has sustained partial-thickness burns to the back and to the anterior and posterior surfaces of the right arm and leg. Using the rule of nines, what percentage of the client's body surface area is burned?

45%

A nurse in the gynecology clinic is reviewing client histories. Which report would be most concerning to the nurse? - 25 year old client who reports a fish-like vaginal odor for the past month - 30 year old client with an intrauterine device who reports heavy bleeding with menses - 40 year old client with endometriosis who reports persistent pain during intercourse - 60 year old client who reports bloating and pelvic pressure for the past 2 months

60 year old client who reports bloating and pelvic pressure for the past 2 months.

The nurse is caring for the assigned clients on a pediatric unit Which client is the priority? -8 year old with sickle cell crisis who has sudden-onset unilateral arm weakness - 11-year-old with viral meningitis requesting pain medication for headache - Male child scheduled for surgery for intussusception who has reddish mucoid stool - Male child with hemophilia who has hemarthrosis and is receiving desmopressin

8 year old with sickle cell crisis who has sudden-onset unilateral arm weakness

A school nurse is educating the parent of a young client with pediculosis capitis. Which statement by the parent indicates understanding of the teaching? - I will launder recently worn clothing, sheets, and towels in hot water - I will make sure all eating utensils are placed in the dishwasher - I will spray the house with insecticide to control this problem - I will throw away stuffed animals and toys that cannot be washed

I will launder recently worn clothing, sheets, and towels in hot water. - pediculosis capitis - head lice

The nurse is teaching a client with insomnia about techniques to improve sleep habits. Which statement by the client requires further teaching? - I will avoid naps later in the day - I will keep the bedroom temperature cool - I will read in bed before trying to go to sleep - I will try to go to bed and wake up at the same time each day

I will read in bed before trying to go to sleep

A client is 1-day postoperative abdominoplasty and is discharged to go home with a Jackson-Pratt (JP) closed-wound system drain in place. The nurse teaches the client how to care for the drain and empty the collection bulb. Which statement indicates that the client needs further instruction? - I'll empty the JP bulb when it's totally full so that I don't have to unplug it so many times - I'll pull the plug on the JP bulb and pour the drainage into the measurable specimen cup - I'll squeeze the JP bulb from side-to-side as I hold it in my hand - While the JP bulb is totally compressed, I'll clean the spout with alcohol and replace the plug.

I'll empty the JP bulb when it is totally full so that I don't have to unplug it so many times

During assessment of a client who had major abdominal surgery a week ago, the nurse notes that the incision has dehisced and evisceration has occurred. The nurse stays with the client while another staff member gets sterile gauze and saline. How should the nurse position the client while waiting to cover the wound? - Low Fowler's position with knees bent - Prone to prevent further evisceration - Side-lying lateral position - Supine with head of the bed flat

Low Fowler's position with knees bent.

During change-of-shift report, the nurse going off duty notes that the nurse coming on has an alcohol smell on the breath and slurred speech. What actions are most important for the nurse too take? Select all that apply. - Do not continue the handoff report with the oncoming nurse - Document the incident according to facility policy - Notify the charge nurse - Say nothing but watch for impaired behavior - Tell the oncoming nurse that he/she is not fit for duty

- Do not continue the handoff report with the oncoming nurse - Document the incident according to facility policy - Notify the charge nurse

The nurse prepares a community education program about health promotion strategies for postmenopausal women. Which of the following teaching points are appropriate to include? Select all that apply. - Consider seeing a dietitian for help with healthy weight maintenance - Consult with a health care provider for cholesterol monitoring - Engage in a daily weight-bearing exercise regimen - Prioritize consumption of green, leafy vegetables and dairy products - Seek support to cope with any emotional symptoms

All options are correct

The clinic nurse receives phone calls about the following 4 clients. Which call should the nurse return first? - A 6 month old who received the diphtheria, tetanus, acellular pertussis vaccine 18 hours ago and developed fever of 102 F and injection site redness - an 11 month old with inconsolable crying and drawing up of the legs toward the abdomen - a 4 year old diagnosed with right lung pneumonia 2 days ago who has chest pain when breathing deeply - A 15 year old whose eyes are red and itchy and have a yellow discharge

An 11 month old with inconsolable crying and drawing up of the legs toward the abdomen.

The nurse who is caring for a client with acute diverticulitis will immediately report which finding to the health care provider? - Abdominal pain has progressed to the left upper quadrant - Hemoglobin of 11.2 g/dL - Lying on side with knees drawn up to abdomen and trunk flexed - White blood cell count of 12.000

Abdominal pain has progressed to the left upper quadrant. - indicates peritonitis

The nurse is teaching about the importance of dietary fiber at a community health fair. Which heath benefits of consuming a fiber-rich diet should the nurse include in the teaching plan? Select all that apply. - Helps prevent colorectal cancer - Improves glycemic control - Promotes weight loss - Reduces risk of vascular disease - Regulates bowel movements

All options are correct

The nurse reviews the chart of a client who gave birth 4 hours ago. Which contributing factor indicates that the client has an increased risk of postpartum hemorrhage? - Infant birth weight of 9 lb 2 oz - Labor and birth without pain medication - Labor that lasted 8 hours - Third stage of labor lasting 20 minutes

Infant birth weight of 9 lb 2 oz

The emergency nurse is admitting a 12-year-old client who reports palpitations. Which action should the nurse anticipate? Exhibit: Vital signs Temp: 97.1 F BP: 114/74 HR: 234/min RR: 24/min SpO2: 97% Physical assessment: Neurologic: Alert and oriented to person, place, and time. Follows commands Cardiovascular: Tachycardia noted. +1 radial pulses. +1 carotid pulses. Jugular veins 1 cm at 45-degree angle Respiratory: Clear to auscultation. No adventitious sounds. Even and unlabored breathing Extremities: No edema in upper or lower extremities - Administering epinephrine by rapid IV push - Assisting the client to a tripod position - Instructing the client to hold their breath and bear down - Sedating the client for immediate asynchronous defibrillation

Instructing the client to hold their breath and bear down.