RN NCLEX practice quiz

Which statement by a client with a diagnosis of dependent personality disorder would the nurse recognize as progress toward a positive therapeutic outcome? - I really appreciate all the time you have spent trying to help me - I think I really messed up at work today - My mother could not drive me here today, so I took the bus - When my parents go away on vacation, I'm planning to stay with my cousin.

"My mother could not drive me here today, so I took the bus.

The nurse is preparing to defibrillate a client who suddenly went into ventricular fibrillation. Which steps are essential prior to delivering a shock? Select all that apply - Apply defibrillator pads - Call out and look around to ensure that everyone is "all clear" - Continue chest compressions until ready to deliver shock - Ensure adequate IV sedation has been given - Ensure that the synchronization button is turned on

- Apply pads - All clear - continue chest compressions

Which instructions should the nurse include when providing discharge teaching to a client with peptic ulcer disease due to Helicobacter pylori infection? Select all that apply. - Avoid foods that may cause epigastric distress such as spicy or acidic foods - It is best if you refrain from consuming alcohol products - Report black tarry stools to your health care provider immediately - Take your amoxicillin, clarithromycin, and omeprazole for the next 14 days. - You may take over-the-counter drugs such as aspirin if you have mild epigastric pain

- Avoid spicy/acidic foods - no alcohol - report black tarry stools - Take the full dose of meds

A registered nurse (RN), licensed practical nurse (LPN), and unlicensed assistive personnel are working on the unit. A client who is about to be discharged home with tube feedings needs care. Which responsibilities should the RN delegate to the LPN? Select all that apply. - Cleaning the skin surrounding the gastrostomy tube stoma - Crushing and administering metoprolol through the gastrostomy tube - Programming the feeding pump to administer a prescribed bolus feeding - Teaching the client about home enteral feeding and gastrostomy tube care - Weighing the client using the bed scale.

- Cleaning the skin - Crushing and administer meds - Program feeding pump

A 12-month-old client has a high blood lead level of 18 mcg/dL. The nurse educates the parents about lead poisoning. Which statements made by the parent indicate that teaching is successful? Select all that apply. - I should get our home inspected for the source of the lead - I will vacuum our hard-surface floors daily - I will wash my child's hands often, especially before eating - We should use hot tap water for cooking - We will have to return for a follow-up lead level

- I should get our home inspected for the source of the lead - I will wash my child's hands often, especially before eating - We will have to return for a follow-up lead level.

The nurse reinforces teaching for the parents of a child with impetigo. Which of the following statements by a parent indicates correct understanding of teaching? Select all that apply. - I should wash my hands before and after touching the infected area - I will clean the infected area with alcohol before applying the antibiotic ointment - I will separate my child's towels from other laundry and wash them with hot water - My child's fingernails should be kept short and well-filed - The infection could easily spread to other children who come in contact with my child.

- I should wash my hands before and after touching the infected area - I will separate my child's towels from other laundry and wash them with hot water - My child's fingernails should be kept short and well-filed - The infection could easily spread to other children who come in contact with my child

A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply. - Ask a family member about the client's preferences for room arrangement - Offer the client an elbow to hold, and walk a half-step ahead for guidance - Say "goodbye when leaving the room to help orient the client - Speak slowly and slightly louder so the client can understand - Use a clock-face pattern to explain food arrangement on the client's meal tray

- Offer the client an elbow to hold, and walk a half-step ahead for guidance. - Say "goodbye" when leaving the room to help orient the client - Use a clock-face pattern to explain food arrangements on the client's meal tray.

The nurse is evaluating the plan of care for a client diagnosed with social anxiety disorder who has a fear of eating and drinking in public. Which of the following client statements demonstrate an improvement in coping? Select all that apply. - I plan dates involving outdoor activities, such as hiking, instead of going to dinner and a movie - I sat in the pizza shop and drank a cola while watching people eat and then bought a slice to go - I started having lunch with my coworkers even though I still become very anxious eating in public - I went out of town on the day of the company picnic instead of making excuses for not eating - I went to a coffee house with my boss and focused on an upcoming project while drinking a latte

- pizza shop - lunch with coworkers - project with latte

The health care provider prescribes a continuous IV infusion of regular insulin at 5 units/hr. The infusion bag contains 50 units of regular insulin in 100 mL of normal saline solution. At what rate in milliliters per hour (mL/hr) does the nurse set the IV pump?

10 ml/hr

The nursing team consists of a registered nurse, licensed practical nurse, and 2 unlicensed assistive personnel. The nurse considers the assignment appropriate if the LPN is assigned to care for which pediatric client?

A 6-month-old who had diaphragmatic hernia repair 5 days ago.

The nurse receives 4 prescriptions for a child diagnosed with hemophilia A who was brought to the emergency department following an injury on the school playground. The child has vomited once and has a headache. Which prescription should the nurse carry out first?

Administer IV factor VIII - clotting factor

White pupil (leukocoria)

Cat's eye reflex - one of the first signs of retinoblastoma, an intraocular malignancy of the retina

The nurse administers the prescribed dose of hydromorphone 2 mg to a client who is 2 days postoperative from a colostomy. Which assessment finding is most important for the nurse to follow-up? - Client has 1 emesis of green fluid - Client has had no bowel movement for 2 days - Client falls asleep while talking to the nurse - Client reports experiencing pruritis.

Client falls asleep while talking to the nurse

The home health nurse reviews the serum laboratory test results for a client with seizures. The phenytoin level is 27 mcg/mL. The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nurse to notify the health care provider? - I am feeling unsteady when I walk - I am getting up to urinate about 4 times during the night - I have a metallic taste in my mouth when I eat - My gums are getting so puffy and red.

I am feeling unsteady when I walk

The nurse provides discharge instructions to a client at 14 weeks gestation who has received a prophylactic cervical cerclage. which client statement indicates and understanding of teaching? - I need to be on bed rest for the duration of my pregnancy . - I will notify my health care provider if I start having low back aches - Pelvic pressure is to be expected after cerclage placement - The cerclage will be removed once my baby is at 28 weeks.

I will notify my health care provider if i start having low back aches. - sign of preterm labor

A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse? - Encourage the visitor to lie down to see if symptoms change - Initiate protocol to assist the visitor to the ED - Proceed to take the visitor's blood pressure - Suggest that the visitor call the health care provider

Initiate protocol to assist the visitor to the ED

The nurse is caring for a client after a lumbar puncture (spinal tap.) Which client assessment is most concerning and requires a nursing response? - Consumes 600 mL liquid over 4 hours - insertion site dressing saturated with clear fluid - Observed lying in the right-sided Sim's position - Reports a headache 6/10

Insertion site dressing saturated with clear fluid

The nurse is caring for a client in the immediate postoperative period following a carotid endarterectomy. The client is drowsy with slurred speech. Which assessment finding would cause the nurse to notify the healthcare provider immediately? - Diminished gag reflex after endotracheal tube removal - Increased agitation level and pulling at linens - Left arm drift during bilateral arm extension - Responds to verbal commands with eyes closed.

Left arm drift during bilateral arm extension

Umbilical cord prolapse

May occur after rupture of membranes if the presenting fetal part is not firmly applied to the cervix. Cord compression caused by a prolapsed cord will produce abrupt fetal heart rate deceleration, fetal bradycardia, and disruption of fetal oxygen supply. Priority action is to inspect the vaginal area and perform a sterile vaginal examination to assess for a prolapsed cord If a prolapsed cord if visualized or palpated, the nurse should then manually elevate the presenting fetal part off the umbilical cord, leave the hand in place, and call for help.

The nurse assesses a client who is 2 days postoperative breast reconstruction surgery. The client has 2 closed-suction Jackson Pratt bulb drains in place. There is approximately 10 mL of serosanguineous fluid in each one. One hour later, the nurse notices the bulbs are full of bright red drainage and measures a total output of 200 mL. What is the nurse's priority action? - Notify the HCP - Open the collection bulb to release excessive negative pressure - Record the amount in the output record as wound drainage - Reposition the client on the right side

Notify the HCP

A nurse conducting rounds checks on a client receiving continuous total parenteral nutrition (TPN). The infusion pump is found to be powered down, and TPN is no longer infusing. Which action should the nurse take first? - Notify the health care provider that the infusion has stopped - Obtain a blood specimen for serum electrolyte testing - Obtain a STAT finger-stick capillary blood glucose level - Remove the infusion pump and tag the device as malfunctioning

Obtain a STAT finger-stick capillary blood glucose level

A 6-month-old client has been diagnosed with cystic fibrosis. Which of the following would be appropriate for the registered nurse to teach to the parents? - Monitor for and report development of a "white pupil" - Perform manual chest physiotherapy - Place child in knee-chest position during hypercyanotic episode - provide a low-calorie diet to prevent obesity

Perform manual chest physiotherapy - bronchial hygiene therapy

A client calls the nurse to report exacerbation of chronic lower back pain after working in the yard all weekend. Knowing that this worsened back pain is probably due to acute inflammation, the nurse recommends which nonpharmacologic intervention? - Heating pad - Positioning for comfort - Rest from pain-aggravating activities - Stretching exercises.

Rest from pain-aggravating activities

The nurse inserts a small-bore nasogastric NG tube and prepares to initiate enteral feedings for a hospitalized client with laryngeal cancer. Which action should the nurse take first? - Crush and administer meds - Dilute enteral formula as prescribed - Flush the tube with 30 mL of water - Verify the tube placement with an x-ray

Verify tube placement with an x-ray

The nurse is making rounds on a medical/surgical floor. Which client should the nurse see first? - 32 year old admitted for opioid withdrawal reporting severe generalized body pains - 34 year old started on blood transfusion 10 minutes ago who reports chills, itching, and back pain - 42 year old admitted with acute pyelonephritis who needs a first dose of IV antibiotic - 67 year old admitted with hepatic encephalopathy who needs a fist dose of lactulose

blood transfusion reaction