RN NCLEX practice exam

A client newly diagnosed with insulin dependent diabetes mellitus is started on insulin aspart protamine suspension/insulin aspart solution mixture. The nurse would teach the client that the insulin should start to lower the blood sugar within how many minutes? - 15 - 30 - 45 - 90

15 - insulin aspart mixture is a rapid-acting insulin and starts to work within 15 minutes after given subcutaneously

The client with obsessive-compulsive disorder (OCD) asks the nurse for help with a repetitive behavior. What is the most likely origin of this behavior? - Fear - Depression - Delusions - Anxiety

Anxiety

The nurse is preparing to bathe a client who is confined to the bed. Which action by the nurse is important to preserve client's self-esteem as the task is completed? - Closes the door for privacy - Introduces self and explains the procedure - Bathes the client without the help of others - Covers the client with a bath blanket

Covers the client with a bath blanket

A client arrives at the emergency room with 20% partial thickness burns to bilateral lower extremities following a grass fire. Prior to the arrival of the ambulance, friends had soaked the client's legs in cold water for pain relief. The client is now requesting more cold water on legs because of intense pain. Which statement by the nurse would be most accurate? - I can soak some towels in water to place on your legs - I will call the doctor to ask for an order to use wet gauze - I need to finish my nursing assessment first before treatment - I must cover your legs with dry gauze to prevent complications

I must cover your legs with dry gauze to prevent complications - Initial burn interventions involve stopping the burning process. In order to do so, the burned area should be submerged in cool (not cold) water for ten to fifteen minutes. Any longer may subject the client to hypothermia as well as allowing bacteria to enter the damaged tissue. Therefore, after the initial cooling period, the burn must be covered with dry sterile gauze to prevent further complications

A client hospitalized with a deep vein thrombosis (DVT) is on a heparin infusion. The client asks the nurse why it is necessary to have blood drawn every six hours. What is the best explanation for the nurse to provide to the client.? - The medicine might make your blood much too thin - It helps us monitor and adjust the dose to work better - It is required for anyone getting heparin intravenously - The test results tell us whether the treatment is working

It helps us monitor and adjust the dose to work better

The nurse is caring for a client who has hypercholesterolemia. When evaluating the effects of atorvastatin, the nurse should monitor the results of which laboratory tests? - AST - Alkaline phophatase - CBC - Serum cholesterol levels - Serum triglyceride levels

- AST - Alkaline phophatase - Serum cholesterol levels - Serum triglyceride levels

Which assessment finding would the nurse expect to see in a client diagnosed with idiopathic thrombocytopenic purpura (ITP)? - Ecchymosis - bleeding gums - Palpable spleen - Pain - Petechiae

- Ecchymosis - Bleeding gums - Palpable spleen - Petechiae

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? - The stockings should be applied when my legs are swollen - I will apply the anti-embolism stockings before getting out of bed - I will apply cortisone-10 ointment to skin on both legs every day - Prior to applying the stockings, I will look for reddened areas on my skin - When pulling up the stocking, I will allow for an extra roll of the stocking at my calves

- I will apply the anti-embolism stockings before getting out of bed - Prior to applying the stockings, I will look for reddened areas on my skin

A client in labor is placed on an external fetal monitor. Which interventions should the nurse perform if a late fetal heart rate deceleration occurs? - Turn the client to the left side - Administer oxygen - Start an intravenous line - Prep the mother for cesarian section - Notify the primary healthcare provider

- Turn the client to the left side - Administer oxygen - Notify the primary healthcare provider

A nurse has been assigned to care for five clients. In what order should the nurse assess these clients after shift report? Place in priority order from highest to lowest priority - Client with Bueger's disease reporting numbness, tingling and cold in toes - Client diagnosed with an arterial ulcer to the right leg who reports pain of 8/10 - Client diagnosed with peripheral vascular disease requesting information on smoking cessation - Client hospitalized to rule out abdominal aortic aneurysm who is reporting deep, aching pain in the flank area - Client whose BP is reported by the UAP to be 200/102 at present

- client hospitalized to rule out abdominal aortic aneurysm who is reporting deep, aching pain in the flank area - Client whose BP is reported by the UAP to be 200/103 at present - Client diagnosed with an arterial ulcer to the right leg who reports pain of 8/10 - Client with Bueger's disease reporting numbness, tingling and cold in toes - Client diagnosed with peripheral vascular disease requesting information on smoking cessation

The nurse is caring for a client in the emergency department. The primary healthcare provider prescribed penicillin 100,000 units IM The drug label reads penicillin 300,000 units/mL. The nurse would administer how many mL of this medication? Round answer using two decimal points.

0.33

The nurse is planning an activity for the client who has a diagnosis of paranoid schizophrenia. Which activity would be most appropriate for the client? - A game of Scrabble with peers - A group game of basketball - An individual art project - A card game with the nurse

An individual art project

A client has been given information about several complementary therapies for the treatment of anxiety disorder. Which therapy selected by the client would require the nurse to check for allergies? - Aromatherapy - Biofeedback - Guided imagery - Acupuncture

Aromatherapy

A client diagnosed with lung cancer is told that the client only has about 6 months to live. The spouse tells the nurse, "I pray every night that God will give me more time with my loved one." Which Kubler-Ross stage of grief does the nurse recognize the spouse to be exhibiting? - Anger - Acceptance - Bargaining - Depression

Bargaining

The nurse is evaluating an elderly bedridden client for possible fecal impaction. What sign/symptom should the nurse report as most indicative for a fecal impaction - Rigid, board-like abdomen - Absence of any bowel sounds - Diarrhea with severe cramping - Constipation with liquid seepage

Constipation with liquid seepage

An Asian client, who cannot speak or comprehend English, is brought to the emergency department by family. One family member is able to understand simple sentences of English. How would the nurse best explain how to obtain a clean catch urine to the client? - Have the family member repeat the nurse's explanation to the client - Contact Social Services to find an authorized interpreter - Use simple hand motions to explain the procedure to the client - Draw a diagram to demonstrate the use of the sterile cup when obtaining the specimen

Contact Social Services to find an authorized interpreter

Which comment by the mother indicates understanding of the diet needed to maintain health and adequate nutrition in the toddler? - It is important to give my child low fat milk after one year of age - If the child won't eat new foods after three tries, he is not going to eat it - I think that the sooner one starts to give vitamins to children, the better - I try to provide whole grains, fruits, vegetables, and meat daily

I try to provide whole grains, fruits, vegetables, and meat daily

Following amniotomy, what intervention should the nurse perform? - Administer oxygen to the client - Have client ambulate to promote labor - Obtain temperature every 4 hours - Monitor fetal heart rate

Monitor fetal heart rate - The fetal heart rate is assessed for at least 1 minute after amniotomy. The umbilical cord could be displaced in a large fluid gush, resulting in compression and interruption of blood flow through it.

A school-aged child is being admitted for probable viral meningitis. What arrangement does the nurse need to make in order to prepare for this client? - Private room - Negative air-flow room - Droplet precautions including mask - Needs standard precautions only

Needs standard precautions only

A toddler with a malfunctioning ventriculoperitoneal (VP) shunt has returned from surgery following new shunt placement. Which post-op assessment finding should the nurse report to the primary healthcare provider immediately? - Blood pressure of 90/45 with pulse of 100 - Urinary output of 30 mL over two hours - Sleeping soundly and difficult to arouse - Respirations deep and shallow at 20/min

Sleeping soundly and difficult to arouse. Difficulty arousing this client is one sign of increased intracranial pressure and should be reported immediately

A psychiatric client tells the day shift nurse, "The night nurses have been stealing from all of us while we are sleeping." What is the nurse's best response? - Can you prove what the nurses are stealing - No nurse working here would steal - You must have misunderstood what you were seeing - Tell me more about what you saw

Tell me more about what you saw

The nurse provides instructions on the proper use of crutches to a client. Which comment by the client indicates a need for additional instructions? - I move the crutches 6 to 12 inches ahead prior to moving foot forward - To descend stairs I will move crutches and my unaffected leg first, followed by the affected leg - When rising from a chair, I will place crutches on my affected side, lean forward, and push off from the chair with one hand - To climb stairs I will advance my unaffected leg past crutches, then place, then place weight on unaffected leg, and advance affected leg and the crutches to the step

To descend stairs I will move crutches and my unaffected leg first, followed by the affected leg

The woman's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which group of clients should she assign to the medical surgical nurse? - Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction - C-section planning discharge, post-partal infection, mastectomy - Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma - 28 week gestation of bed rest, post-partal with HELLP syndrome, breast reconstruction

Total abdominal hysterectomy, bladder suspension with A&P repair with breast reduction

The nurse is checking a nine month old's developmental status. What finding would be of concern to the nurse? - Unable to transfer a toy from one hand to the other hand - Cannot stand without support - Does not notice or mind when a parent leaves - Has not acquired a 6 word vocabulary

Unable to transfer a toy from one hand to the other hand

The school nurse suspects that a 5 year old ahs been physically abused. What would be the best way for the nurse to establish trust with this child? - Using play therapy - Asking the mother to come to the school - Hugging the child - Conducting an in-depth interview with the child

Using play therapy