Saunders NCLEX Questions

The nurse is caring for a client diagnosed with Ménière's disease. The nurse plans care, understanding that this disorder is characterized by which manifestation? 1. Dizziness 2. Photophobia 3. Hemianopsia 4. Blurred vision

1. Dizziness

The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) needs to be placed at the child's bedside? 1. Emergency cart 2. Tracheotomy set 3. Padded tongue blade 4. Suctioning equipment and oxygen

4. Suctioning equipment and oxygen

The nurse plans care for a client postoperatively following creation of a colostomy. Which potential client problem would the nurse include in the plan of care? 1. Fear 2. Anxiety 3. Inability to care for self 4. Upset about appearance

4. Upset about appearance

A client with Graves' disease has exophthalmos and is experiencing photophobia. Which nursing action would best assist the client with these manifestations? 1. Obtain dark glasses for the client. 2. Lubricate the eyes with tap water every 2 to 4 hours. 3. Administer methimazole every 8 hours around the clock. 4. Instruct the client to avoid straining or heavy lifting because this effort can increase eye pressure.

1. Obtain dark glasses for the client.

The nurse is caring for a client who is an athlete and has sustained an injury to the anterior cruciate ligament. The nurse is providing education to the client regarding the potential treatment measures for this injury. What would the nurse include in the teaching? Select all that apply. 1. Physical therapy 2. Knee immobilizer 3. Aspiration of joint fluid 4. Ambulation with a walker 5. Anti-inflammatory medications

( 1,2,3,5 ) 1. Physical therapy 2. Knee immobilizer 3. Aspiration of joint fluid 5. Anti-inflammatory medications

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic. 2. The client has weakness on the right side of the body. 3. The client has complete bilateral paralysis of the arms and legs. 4. The client has weakness on the right side of the face and tongue. 5. The client has lost the ability to move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe self without assistance.

( 1,2,4 ) 1. The client is aphasic. 2. The client has weakness on the right side of the body. 4. The client has weakness on the right side of the face and tongue.

The nurse is assessing a client diagnosed with acute gastritis. Which of the following clinical manifestations would the nurse expect? Select all that apply. 1. Nausea 2. Dyspepsia 3. Polyphagia 4. Hematemesis 5. Insidious onset of epigastric discomfort

( 1,2,4 ) 1. Nausea 2. Dyspepsia 4. Hematemesis

The nurse is providing education to a client diagnosed with acute laryngitis. Which client statement indicates a need for further teaching? 1. "I would only whisper to talk." 2. "I will run my humidifier at home." 3. "I can take acetaminophen as needed for pain." 4. "I will drink more fluids and will avoid caffeine and alcohol."

1. "I would only whisper to talk."

The nurse develops a plan of care for a client with a spica cast that covers a lower extremity and documents that the client is at risk for constipation. When planning for bowel elimination needs, the nurse would include which in the plan of care? 1. Administer an enema daily. 2. Use a fracture pan for bowel elimination. 3. Use a bedside commode for all elimination needs. 4. Use a regular bedpan to prevent spilling of contents in the bed.

2. Use a fracture pan for bowel elimination.

The nurse is providing discharge instructions to a client who has undergone treatment of cervical cancer with a radiation (cesium) implant. Which instruction would the nurse plan to provide to the client? 1. Avoid douching for at least 1 year. 2. Use a vaginal dilator 3 times a week. 3. Sexual activity can be resumed in about 2 months. 4. Bed rest is recommended for at least 1 week after discharge.

2. Use a vaginal dilator 3 times a week.

The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care? 1. "I change my pouch every week." 2. "I change the appliance in the morning." 3. "I empty the urinary collection bag when it is two-thirds full." 4. "When I'm in the shower, I direct the flow of water away from my stoma."

3. "I empty the urinary collection bag when it is two-thirds full."

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? 1. Call for help. 2. Extinguish the fire. 3. Activate the fire alarm. 4. Confine the fire by closing the room door.

3. Activate the fire alarm.

The primary health care provider writes prescriptions for a client with chronic kidney disease (CKD). Which prescription would the nurse question? 1. 1Insert a saline lock. 2. Obtain a daily weight. 3. Provide a high-protein diet. 4. Administer a calcium supplement with each meal.

3. Provide a high-protein diet.

The nurse is providing dietary instructions to a client hospitalized for pancreatitis. Which food would the nurse instruct the client to avoid? 1. Bagel 2. Watermelon 3. Lentil soup 4. Salsa and corn chips

4. Salsa and corn chips

The home care nurse provides instructions to a client with systemic lupus erythematosus (SLE) about home care measures. Which statements by the client indicate the need for further instruction? Select all that apply. 1. "I need to sit whenever possible." 2. "I need to be sure to eat a balanced diet." 3. "I need to take a hot bath every evening." 4. "I need to rest for long periods of time every day." 5. "I need to engage in moderate low-impact exercise when I am not tired."

( 3,4 ) 3. "I need to take a hot bath every evening." 4. "I need to rest for long periods of time every day."

The nurse assesses a client who is diagnosed with a stroke (brain attack). On assessment, the client is unable to understand the nurse's commands. Which condition would the nurse document? 1. Occipital lobe impairment 2. Damage to the auditory association areas 3. Frontal lobe and optic nerve tracts damage 4. Difficulty with concept formation and abstraction areas

2. Damage to the auditory association areas

In what area of the chest would the nurse expect to auscultate these breath sounds? Refer to audio. 1. Over the trachea 2. Over the peripheral lung fields 3. Posteriorly at the T4 level medial to the scapula 4. Between the first and second intercostal spaces at the sternal border anteriorly

2. Over the peripheral lung fields

The nurse is caring for a client diagnosed with breast cancer receiving combination chemotherapy. Which nursing intervention is the most appropriate? 1. Give two agents from the same medication class. 2. Give two agents with like nadirs at the same time. 3. Test the client's knowledge about each agent's nadir. 4. Avoid giving agents with the same nadirs and toxicities at the same time.

4. Avoid giving agents with the same nadirs and toxicities at the same time.

Assessment and diagnostic evaluation reveal that a client seen in the ambulatory care clinic has stage II Lyme disease. The clinic nurse identifies which assessment finding as most characteristic of this stage? 1. Arthralgias 2. Joint enlargement 3. Erythematous rash 4. Cardiac conduction deficits

4. Cardiac conduction deficits

The nurse is caring for a client with a suspected lower airway infection. The nurse determines that the client is experiencing a productive cough with clear sputum, voice hoarseness, and myalgia. The client's chest x-ray (CXR) demonstrates consolidation in the right and left lower lung lobes, and laboratory results indicate leukocytosis. Based on these data, which client finding would rule out bronchitis? 1. Leukocytosis 2. Voice hoarseness 3. Productive cough with clear sputum 4. Consolidation of the right and left lower lung lobes on CXR

4. Consolidation of the right and left lower lung lobes on CXR

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning

4. Exhaling during repositioning

A client has just had surgery to create an ileostomy for treatment of a bowel obstruction. The nurse assesses the client in the postoperative period for which most frequent complication of this type of surgery? 1. Folate deficiency 2. Malabsorption of fat 3. Intestinal obstruction 4. Fluid and electrolyte imbalance

4. Fluid and electrolyte imbalance

A 7-year-old child is seen in a clinic, and the pediatrician documents a diagnosis of nighttime (nocturnal) enuresis. The nurse would plan to provide which information to the parents? 1. Nighttime (nocturnal) enuresis does not respond to treatment. 2. Nighttime (nocturnal) enuresis is caused by a psychiatric problem. 3. Nighttime (nocturnal) enuresis requires surgical intervention to improve the problem. 4. Nighttime (nocturnal) enuresis is usually outgrown without therapeutic intervention.

4. Nighttime (nocturnal) enuresis is usually outgrown without therapeutic intervention.

A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse caring for the client uses which item as the best means to monitor respiratory status on an ongoing basis? 1. Apnea monitor 2. Oxygen flowmeter 3. Telemetry cardiac monitor 4. Oxygen saturation monitor

4. Oxygen saturation monitor

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which finding? 1. Slow, deep respirations 2. Rapid, deep respirations 3. Paradoxical respirations 4. Pain, especially with inspiration

4. Pain, especially with inspiration