Nursing.Com Simclex Questions

A nurse is caring for a postpartum client with a hematoma. What would be the most concerning development?

Urinary Obstruction by hematoma

Calcium channel blockers reduce high blood pressure by which of the following mechanisms?

dilate coronary arteries and arterioles, peripheral vessels

The nurse is caring for a client who is newly diagnosed with multiple sclerosis. Which of the following is appropriate teaching for this client?

"Make sure you're getting good fluid intake, around 2L/day" Multiple sclerosis (MS) can cause incontinence, and this is difficult to cope with. Many clients with MS will drink less to avoid episodes of incontinence, but this leads to dehydration and constipation. The client with MS must be taught to continue adequate fluid intake.

A nurse is utilizing effleurage as part of non-pharmacological pain management for a client in labor. Which describes the techniques of effleurage? Select all that apply.

-The process is distracting from the pain of labor for the client Effleurage is a form of gentle massage to the abdomen or back that can be used during labor to distract the client and help her relax. -The nurse lightly massages the abdomen or back Effleurage is a type of massage. The nurse applies pressure with the fingertips as lightly or firmly as the client wants. -The process promotes relaxation and pain relief This relaxation technique is done by applying pressure with the fingertips so that the laboring woman derives the comfort and benefits of touch. The client directs how firm or light the pressure will be.

There are four clients waiting in the surgical holding area and after the nurse reviews each of their charts which of the following would the nurse be most concerned about?

25-year-old with muscular dystrophy having a frenectomy under general anesthesia Clients with certain muscular dystrophies have an increased incidence of malignant hyperthermia

A nurse is caring for a client under general sedation who has paralyzed skeletal muscles. The nurse assesses the client to be cardiovascular and respiratory stable. The nurse knows that the client is in which of the following stages of general sedation?

3 The client's skeletal muscles are paralyzed. Cardiovascular and respiratory findings are stabilized.

A healthcare provider orders a cat scan of a client, requesting all sagittal views. How would the nurse expect to see the images divide?

A healthcare provider orders a cat scan of a client, requesting all sagittal views. How would the nurse expect to see the images divide? Transverse- upper and lower Front and back- frontal

A new nurse is applying concepts of the code of ethics for nurses. Which of the following scenarios demonstrates nonmaleficence?

A nurse gives pain meds 30 min before a procedure

Which of the following is the first link in the chain of survival for resuscitation of an adult cardiac arrest victim?

Activate the emergency response system

A pregnant client is in labor and the nurse is helping to deliver her baby. During delivery, the client experiences shortness of breath, hypotension, and altered mental status. Which action should the nurse perform first?

Administer 100% oxygen via facemask

The nurse is caring for a client who presents to the emergency department with angina. Which of the following is the first action the nurse will take?

Administer nitroglycerin 0.4 mg sublingual The first action the nurse will take out of the four choices is to administer a 0.4 mg sublingual nitroglycerin tab.

Which of the following is an element that describes pulsus bigeminus? Select all that apply.

Alternating strong and weak pulses, a pulse that comes in after a strong one that is weak

A client has a "lazy eye". The medical term for this condition is which of the following?

Amblyopia Myopia- Near sightedness Hyperopia- Far sightedness Strabismus- Ocular muscles weak on one side

A nurse is working with a client who is questioning her spiritual beliefs because of her terminal diagnosis. Which best describes how the nurse would assess the effects of the client's condition on her spirituality?

Ask the client if she still follows her previous spiritual practices A client who has been diagnosed with an illness may question long-held spiritual beliefs when given a diagnosis. Some people may even suffer from a spiritual crisis. The nurse can assess the effects of the client's condition on her spirituality by determining if she has changed any spiritual practices recently.

A nurse is assessing a client with a history of diabetes. The client tells the nurse that she does not feel well. The nurse checks her blood glucose levels and gets a result of 51 mg/dL. What signs or symptoms would the nurse expect to see with this blood glucose level? Select all that apply.

Anxiety, Tremor, Weakness The client in this example is suffering from mild hypoglycemia in which blood glucose levels are between 70 and 41 mg/dL. The nurse would expect to see signs or symptoms of restlessness and anxiety, weakness, sweating and tremor in this client. Once the glucose level falls to below 40 mg/dL, the client will experience confusion, double vision, drowsiness, headache, and slurred speech. When the glucose level falls below 20 mg/dL, the client can experience seizures and loss of consciousness

The nurse caring for a client with atrial fibrillation understands that all of the following are risks of this condition except which?

Aortic Aneurysm

When assessing a client for signs of stroke, which of the following are priority assessments? Select all that apply.

Aphasia, Hemiparesis, Facial droop

A physician has ordered the nurse to remove a client's central line. The line is a percutaneous non-tunneled central venous catheter placed in the client's subclavian vein. Which of the following principles should the nurse consider with the removal of this central line?

Assess the catheter after removal to ensure that the tip is intact Removal of a central line must be done very carefully to avoid complications such as bleeding, blood clots or an embolus. When the nurse removes the central line, she should inspect the tip of the catheter to ensure that it is intact, as there is a small chance that the catheter tip can break off, enter the bloodstream and caused an embolus.

After receiving report at the beginning of her shift, a nurse enters her client's room to begin her duties. The client is intubated and requires a mechanical ventilator with supplemental oxygen as treatment for pneumonia. Upon entering the client's room and starting the assessment, which action should the nurse perform first?

Assess the client's skin color When caring for a client who requires a mechanical ventilator, the nurse should initially look at the client. Specifically noting the skin color around the lips and nail beds gives the nurse an immediate idea of the client's respiratory status. The nurse then obtains a pulse oximetry reading, monitors arterial blood gas results, checks the ventilator settings, and ensures the alarms are set.

When preparing to administer a medication to a client, the nurse takes the dose out of a locked cart that keeps an electronic count of how many medications have been dispensed from the unit. Which of the following medication distribution systems is this nurse most likely using?

Automatic Dispensing

When the perioperative nurse assesses the client for surgery, the BMI is assessed as low. The nurse knows that which of the following could be a concern? Select all that apply.

Body temp regulation, delayed wound healing, risk of pressure ulcers, increase in surgical complications

The preceptor asks the nursing student to describe what occurs to cause diabetic ketoacidosis (DKA) in a client. Which of the following responses is correct?

Cells are starved for glucose so the body breaks down fats

A client has insomnia. The client asked the nurse how to improve their sleep. The nurse tells the client to first establish a sleep schedule. The nurse would best evaluate the effectiveness of the client's sleep schedule by which of the following actions?

Checking to see if the client gets up and goes to bed the same time each day

A nurse must obtain a blood sample from a client's central line. The client had IV fluid infusing into the line and the nurse has already disconnected the infusion. Which of the following describes the next step of the nurse?

Cleanse hub of catheter for 15 seconds

A nurse is caring for a client who has a pressure ulcer on the sacrum from immobility. The nurse ensures that the client is turned frequently while in bed. Which of the following would most likely demonstrate that the client is responding to this intervention?

Client does not develop any new pressure ulcers

A 70-year-old client with a terminal illness wants to remain at home with her family. The client has signed a Do Not Resuscitate order in the event of cardiac arrest. Which of the following factors must be considered for use of a DNR order outside of a healthcare facility? Select all that apply.

Client must be deemed competent at the time The action is to prevent unwanted resuscitation of a terminally ill client The client must be deemed competent at the time the DNR order is signed Rationale: Some clients with significant illnesses who live at home have signed DNR orders so that if they suffer cardiac arrest, they will not be resuscitated. If the client has not made his wishes known, rescue personnel could potentially start CPR without knowing what the client wants. The client should have the DNR order available and ready at hand in case something happens. A family member or someone with the client could assist by presenting the DNR to prevent unwanted resuscitation.

A two-week-old infant presents to the pediatrician's office with nystagmus. What is appropriate for the nurse to tell the parents?

Client should be assessed by pediatrician

A nurse is caring for a client complaining of pain. Which of the following critical thinking steps would the nurse utilize to respond to this situation? Select all that apply.

Collect facts, identify, set priorities, evaluate the clients response

A nurse is speaking with a 17-year-old diagnosed with phenylketonuria. Based on the child's developmental stage, the nurse identifies which of the following as the most appropriate educational topic? Select all that apply.

Compliance with diet, phenylalanine toxicity, stay away from artificial sweeteners

A nurse is speaking with a client who has talked about quitting smoking. The nurse assesses the client's readiness to learn and determines that the client has little to no interest in making a permanent change. Which step of self-management would the nurse most likely employ after learning of this client's level of readiness?

Continue to educate

A conscious or unconscious emotional response to a client based on the nurse's own inner needs and feelings is referred to as which of the following?

Countertransference

A provider has ordered a nurse to perform bladder irrigation on a client in the hospital. Which of the following describes a purpose of performing bladder irrigation in a client? Select all that apply.

Decrease bleeding, clear blood clots, promote healing

The nurse is caring for a patient diagnosed with dysthymia. Which of the following best describes dysthymia?

Depressed mood for the past two years

A nurse is giving education to the client following a nuclear medicine study to diagnose reflux. Which of the following should be included?

Drink a lot of fluids today

The nurse is caring for a client who has just been diagnosed with scarlet fever. Which of the following isolation precautions is appropriate for this client?

Droplet- report to CDC

A client with lymphedema is admitted to the hospital. Which best describes the difference between edema and lymphedema?

Edema involves dependent areas of the body, while lymphedema can occur in any body area The conditions of edema and lymphedema can seem similar but they have different physiological processes. Edema may develop when areas of the body develop excess fluid, which collects outside of the intravascular system. Lymphedema often occurs as a result of damage to the lymph system, in which lymph fluid collects in the subcutaneous tissues. Lymphedema can occur in any area of the body near a lymph node, and is not related to whether the area is dependent or not. Edema typically occurs in dependent areas of the body, such as a lower extremity.

The nurse is working a shift in the hospital and is assigned to care for a client with advanced multiple sclerosis. Which of the following would most contribute to the client's overall level of functioning

Encourage the clients activity independence

A nurse is obtaining a pulmonary artery wedge pressure (PAWP) on a client who has a Swan-Ganz catheter in place, and notes to inject 1 mL of air into the catheter to obtain the pressure reading. The nurse begins to inject air and notes a change on the contour of the pulmonary artery pressure. What should the nurse do next?

Ensure transducer is at 4th intercostal midaxillary line When measuring a pulmonary artery wedge pressure, the nurse inflates a small balloon at the tip of the catheter that is wedged in the pulmonary artery. After inflating the catheter, the nurse should ensure that the monitor transducer is in the correct location in order to best secure an accurate reading. If the wedge tracing appears at an injection less than what was ordered, the catheter requires repositioning because it has migrated to a distal branch, and can lead to pulmonary artery rupture.

A client in the healthcare clinic complains of feeling dizzy when standing after sitting for a period. The client's blood pressure is 136/78 mmHg while sitting and 102/58 mmHg after standing. Which types of treatment goals are most appropriate in this situation? Select all that apply.

Evaluate meds the client is taking Instruct client about getting adequate hydration

At one hour after delivery, what should the nurse expect to do for the newborn?

Eye prophylaxis

A nurse works in the medical-surgical unit of the hospital and is performing safety checks on medical equipment. Which of the following is an example of a device factor that would contribute to an adverse event? Select all that apply.

Faulty connecters on chest tube drainage system, hole in catheter tubing

A client is admitted to the hospital after falling at home. The nurse case manager reviews the client's information and meets with the client to discuss healthcare needs. Which of the following describes what the nurse case manager would perform during the planning stage of the case management process?

Finding the least restrictive level of care for the client The planning stage of the case management process is somewhat similar to the planning stage of the nursing process, in that the nurse has intentions for the client's care. When planning for client care services, the nurse case manager should find the least restrictive level of care for the client that would still allow the most independence possible for the health condition.

The nurse is caring for a client with depression who takes a selective serotonin reuptake inhibitor. The nurse knows these types of drugs include which of the following? Select all that apply.

Fluoxetine, Paroxetine, Sertraline

A nurse is preparing to move a 150-pound client with Alzheimer's disease from a chair to a stretcher in the emergency room. The client can help with the move but is uncooperative with the nurses. Which best describes how the nurse should move this client?

Full body sling and two people

A client who receives peritoneal dialysis has called the nurse to explain that he is unable to infuse the dialysate into the catheter. When the nurse arrives at the client's home, which method would the nurse use to assess for an occlusion?

Gently rotate the catheter to improve flow or check for kinks

Which of the following orders contains the appropriate route and dosing for the administration of vancomycin?

Give 0.125 grams PO q6 hours Vancomycin should never be given as an IV bolus or IM. If given orally, it is only for disorders of the GI tract, and the appropriate adult dose is 125 mg orally.

A nurse is caring for an older adult client with self-care deficits. Which of the following are appropriate nursing interventions for this situation? Select all that apply.

Give client plenty of time to get dressed Adequate equipment Privacy

A nurse is preparing to discharge a client with bronchitis to home from the hospital. The nurse has the client demonstrate that he understands how to use his inhaler appropriately. After successfully demonstrating use of the inhaler, the nurse says, "You are confidently using that inhaler." This is an example of which type of therapeutic communication?

Giving recognition that the client is one time competent An example of giving recognition is the following statement; "I noticed you took all your medications." This statement recognizes the client's accomplishments without giving an overt compliment, because compliments can sometimes be viewed as condescending.

After developing influenza, a 75-year-old client is suffering from severe diarrhea and dehydration. The nurse is providing help and guidance over the phone to the client's family. Which information should the nurse give to the family that would best help this client?

Help client drink fluids by taking frequent spoonfulls or small sips

During the physical assessment of a comprehensive exam, the nurse tells a diabetic client about the necessity to undergo several tests to determine if the diabetes has caused complications. The nurse performs glucose testing, a foot exam, an ankle-brachial index, and checks the client's blood pressure. In addition to these tests, which type of exam should also be included to check for complications?

Injection site inspection

The nurse is caring for a client that has Hashimoto's thyroiditis. Which of the following symptoms should the nurse expect to see with this client? Select all that apply.

Intolerance to cold, fatigue

Which of the following clients would likely require a dose adjustment for medications due to improper processing of the medication?

Kidney and Liver Failure

A 36-year-old client is being seen in the primary care clinic with symptoms of pain, numbness, and tingling in both wrists. The nurse is providing information to the client about the best ways to prevent repetitive strain injuries when working at a computer. Which information would the nurse include as part of this teaching? Select all that apply.

Light touch when typing frequent breaks keep hands warm

The nurse receives shift report on a client with increased intracranial pressure (ICP). The nurse steps into the room to assess the client and notes that the client is in high-Fowler's position. Which of the following actions is appropriate?

Lower the HOB to 30 degrees

A nurse is utilizing time management principles to organize tasks for the day. Which action is an example of what the nurse could do to improve time management? Select all that apply.

Make a list of everything, delegate small tasks, breaks

A nurse in a long-term care facility has many clients who have difficulties with urinary incontinence and immobility. Which methods could the nurse implement that would most likely reduce moisture content on the skin of these clients? Select all that apply.

Manage urinary and stool incontinence, training program, avoid little drops of moisture on skin, utilize skin barriers and absorbent materials

The nurse is reviewing the rhythm shown and knows that which of the following is the priority nursing intervention?

Monitor for stroke Preventing a stroke is a priority nursing intervention. Clients are at risk for a stroke in atrial fibrillation because blood is sitting and not being pumped through the way it should.

The nurse is caring for a client who is in premature labor. The client is being started on indomethacin to stop contractions. Which of the following aspects of the client's medical history would cause the nurse to question this order?

Multiple gastric ulcers Indomethacin is an NSAID and should not be used in clients with ulcers, because of the increased risk for bleeding.

A nurse mistakenly administered heparin after reading the order incorrectly, and the client started bleeding uncontrollably. The nurse is documenting the occurrence. Which elements should be included as part of documentation in this situation? Select all that apply.

Nurse involved, Details, Name of provider

A nurse is caring for a client who is at high risk of dehydration. Which parameter would the nurse use to assess whether this patient is dehydrated?

Orthostatic hypotension

The client is scheduled for a cholangiogram and asks about the purpose of the test. Which of the following responses from the nurse is correct?

Patency of hepatic & common bile duct

The parents of a 2-year-old child who died of leukemia are experiencing intense grief in the months following the death. Which of the following is a factor that would affect how these parents experience grief?

Personality of the grieving person

A client with hyperlipidemia is in for a follow-up appointment. The client has lost some weight, but lab work reveals that the client still has hyperlipidemia. Which of the following changes would help to lower this client's lipid levels? Select all that apply.

Plant based diet, stop smoking, take atorvastatin

A nurse is caring for a postpartum client who delivered vaginally a day ago and now has aches and chills and complains of pain during palpation of the uterus, which sits at U+1. Which condition should the nurse be most concerned for?

Postpartum Hemorrhage

A client who was injured in a fall at a construction site has been brought into the emergency room for care of a crush injury. The client's lower leg at the site of the injury is swollen and the client is screaming in pain. The nurse notes that the client has decreased sensation below the level of the injury and pale toes. Which intervention by the nurse is most appropriate?

Prepare to assist with surgical intervention Prepare to assist with surgical intervention The client with a crush injury is at risk of developing compartment syndrome, in which there is swelling and increased pressure within the compartment of a limb underneath the fascia membrane. The swelling may build to a point where it cuts off nerve sensation and occludes circulation. Emergency treatment involves a fasciotomy, which cuts into the affected tissue to relieve the pressure.

A client in the ICU has hemodynamic monitoring in place and has been showing ventricular irritability on the monitor as evidenced by changes in waveform configuration. What describes a potential cause of this condition?

Presence of excess catheter in the right ventricle Ventricular irritability occurs when there is irritation to the ventricular endocardium, typically because of catheter placement within the heart. There may be excess catheter looping in the ventricle that causes irritation, or the catheter is excessively long, which will show up on the monitor as changes in waveform. The nurse should notify the provider when this occurs.

The nurse is educating an older adult client on ways to prevent skin breakdown. Which of the following should the nurse include? Select all that apply.

Protein, Zinc, Stay Active

The nurse providing care to a client who has been experiencing otalgia and fever for 24 hours. Which of the following should be the top nursing priority?

Provide pain relief

The nurse knows that which of the following medications is commonly used to help prevent Exercise-induced bronchospasm?

Salmetrol- Long acting brochodilator to help prevent asthma exacerbations

The nurse is discharging a client who will be using crutches for the first time. The nurse is utilizing the teach-back method to confirm the client's understanding of using crutches. Which of the following indicates that more teaching is necessary?

Staring at leg Note- crutches should be placed 6-10 diagonally from foot

The nurse is caring for a 70-year-old client who has just started PO ciprofloxacin for a urinary tract infection. Which of the following statements by the client demonstrates understanding of this drug? Select all that apply.

Stay out of sun, take with full glass of water, report calf pain due to risk of tendon rupture

A nurse is caring for a 78-year-old client with severe, debilitating rheumatoid arthritis who lives at home with the spouse. The nurse assesses the client's level of safety in the home. Which aspects should be included as part of this home safety assessment? Select all that apply.

Sufficient lighting, space for caregiver, changes in floor levels, stairs in the home

A nurse is working in the emergency department when a client is brought in who has been suspected of being exposed to Ebola virus. What steps should the nurse take in response that are most appropriate for this situation? Select all that apply.

Take a thorough history, isolate, only essential employees allowed for care

A nurse is caring for a client who visits a tanning bed several times each week. The client's skin is brown and has a leathery texture. The nurse provides teaching to the client about tanning bed use, and includes which of the following factors as part of teaching? Select all that apply.

Tanning bed contains harmful UV rays No amount is safe in tanning bed

The nurse is caring for a client with diabetes insipidus and is preparing to administer a scheduled vasopressin injection. Which of the following is an anticipated outcome for a client with diabetes insipidus receiving this drug?

Urine output of 2000 cc/day When a client has diabetes insipidus (DI) they can have a urine output of up to 15,000 mL per day. With vasopressin injection, there should be less polyuria and polydipsia. A urine output of 2000 cc/day is a normal urine output, which indicates that the vasopressin is effective.

The nurse is caring for a client with a cardiac condition. The nurse knows that which of the following conditions put a client at risk for cardiogenic shock? Select all that apply.

V tach, Myocardial Infarction, V-fib

A student nurse is reviewing some of the most dangerous arrhythmias and presenting them in class. The student nurse would be correct in identifying which of the following rhythms as dangerous? Select all that apply

V tach, third degree av block, vfib

A nurse recognizes that the last two clients who received blood products developed some form of transfusion reaction. Which of the following steps could the nurse perform that would most likely prevent a transfusion reaction in the next client? Select all that apply.

Verify client info Inspect blood Use proper blood administration tubing with a filter

A nurse is taking a health history of a client during the admission assessment. Which of the following statements indicates that the nurse is using reflection?

What do you think would be a good goal for your care today