2024 (February) Nclex Practice
A nurse is presenting an in-service training session about nutrition. How many of the amino acids must be obtained from dietary intake? a. 6 b. 9 c. 11 d. 15
9 - Proteins are made up of chains of amino acids, which are composed of carbon, hydrogen, oxygen and nitrogen 9 amino acids are considered essential for the human body and must be obtained from diet
A nurse on a medical unit is preparing to administer alendronate 40 mg PO for an older adult client who has Paget's disease of the bone. Which of the following actions should be the nurse's priority? a. administer the medication to the client before breakfast in the morning b. ambulate the client to a chair prior to administering the medication c. give the medication to the client with water rather than milk d. teach the client how to take the medication at home
Ambulate the client to a chair prior to administering the medication - the client must be able to sit or stand upright for 30 minutes after take the medication
The parents of a child with phenylketonuria (PKU) ask the nurse if there second unborn child could have the same condition. The nurse should base the response on which of the following inheritance patterns responsible for PKU? a. x-linked recessive b. x-linked dominant c. autosomal recessive d. autosomal dominant
Autosomal recessive
A nurse is triaging clients during a mass casuality event. Which of the following labels should the nurse assign to a client who has a head injury with fixed, dialated pupils. a. red tag b. yellow tag c. green tag d. black tag
Black tag Class IV label, to clients who are not expected to live and will be allowed to die naturally
A nurse is monitoring a client who is receiving phenytoin IV for the treatment of status epilepticus. Which of the following findings should the nurse identify as an adverse effect of the medication? a. hypertension b. cardiac dysrhythmias c. gastric discomfort d. tachycardia
Cardiac dysrhythmias
A nurse is preparing to provide umbilical cord care for a newborn 12 hours after delivery. Upon inspection, the nurse notes moderate bleeding from a blood vessel. Which of the following actions should the nurse take? a. check the newborn's heart rate b. place a pressure dressing on the cord stump c. administer vitamin K d. check the integrity of the cord clamp
Check the integrity of the cord clamp - the nurse should apply the clamp to the umbilical cord while detaching it from the placenta to stop blood flow from the cord to the placenta. When the placenta is no longer attached, the blood vessels in the cord with atrophy as the cord sump dries and shrivels. If blood is coming form a vessel prior to the cord stump necrotizing, the nurse should ensure the cord clamp has not loosened or opened. If it has, the nurse should apply a new clamp immediately.
A nurse is assessing the fine motor skill development of a 4-year-old child. The nurse should expect the child to be able to perform which of the following activities? a. tying shoelaces into a bow b. copying a square c. drawing a person with at least 8 parts d. printing the letters of her name
Copying a square - tying shoelaces into a bow (5yrs) - drawing a person with at least 8 parts (5yrs) - printing the letters of her name (5 yrs) - copy a circle (3yrs)
A nurse is reviewing the laboratory data for a client who has Alzheimer's disease and a new prescription for memantine. The nurse should identify that which of the following findings increases the clients risk for reduced clearance of the medication? a. Alanine aminotransferase (ALT) international units/L b. Creatinine clearance 35 mL/min c. HbA1c 5% d. BMI 31
Creatinine clearance 35 mL/min - estimate of the glomerular filtration rate (GFR) and the kidneys ability to filter waste, this is below expected range (87-139) and indicates moderate renal impairment Memantine is excreted by the kidneys, and decreased clearance occurs with moderate renal impairment - ALT is a liver function test (4-36) -HbA1C is lab value calculating the clients average blood glucose level or a period of time (usually 3 months), increased indicates diabetes (4-5.9)
A nurse is reviewing the medical record of a client who is receiving hydrochlorothiazide (HCTZ). The nurse should expect to find an improvement in which of the following conditions as a result of this medication? a. gouty arthritis b. dehydration c. diabetes insidpidus d. hypokalemia
Diabetes Insipidus - thiazide diuretic is administered to treat diabetes condition in which there is an overproduction of urine, it helps to reduce urine product
A nurse is assessing a client who has a head injury with a possible skull fracture. Which of the following findings should the nurse identify as an indication that the client might have a complication involving the eighth cranial nerve (CN VIII)? a. dizziness and hearing loss b. weakness of a side of the tongue c. facial droop and asymmetrical smile d. loss of the same visual field in both eyes
Dizziness and hearing loss
A nurse is caring for a newborn immediately following birth. WHich of the following actions should the nurse take first? a. weigh the newborn b. instill erythromycin ophthalmic ointment in the newborns eye c. administer vitamin K to the newborn d. dry the newborn
Dry the newborn - the greatest risk to the newborn immediately after birth is heat loss, which can cause cold stress, respiratory distress, and hypoglycemia. Therefore, the first actions the nurse should take is dry the newborn to prevent heat loss from evaporation
A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid or electrolyte imbalances should the nurse expect? a. Hypokalemia b. Hypernatremia c. Elevated Hct d. Decreased Hgb
Elevated Hct - client with third spacing resulting from a burn has elevated hematocrit level as blood volume is reduced by vascular dehydration
A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? a. elevated ST segments b. absent P waves c. depressed ST segments d. varying PP intervals
Elevated ST segments
A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the client's plan of care? a. maintain the client's knees and hips in a flexed position b. apply cold compresses to painful joints c. withhold opioids until the crisis is resolved d. encourage increase fluid intake
Encourage increase fluid intake - promotes hydration because dehydration increases the viscosity of blood, which can aggravate sickling and client discomfort - keep room warm during sickle cell crisis and apply warm moist compress to painful joints
A nurse is caring for a client who has severely elevated blood pressure. Which of the following findings should the nurse identify as a manifestation of hypertension? a. vertigo b. epistaxis c. exophthalmos d. spondylolisthesis
Epistaxis - a nosebleed - exophthalmos - protruding eyes caused by a thyroid disorder - spondylolisthesis - vertebra slips causing pressure on nerves creating pain
A nurse is caring for a client who takes warfarin to treat chronic atrial fibrillation and has early manifestations of Alzheimer's disease. The client's partner asks the nurse if the client would benefit from taking Ginkgo biloba. Which of the following responses should the nurse make? a. Ginkgo biloba will likely interfere with the effectiveness of his other medications b. you should ask his provider is Ginkgo biloba is safe c. Ginkgo biloba is most effective in the later stages of Alzheimer's disease d. people who have Alzheimer's disease should adhere to the medication regimen there provider prescribes
Ginkgo biloba will likely interfere with the effectiveness of his other medications - Ginkgo biloba increase risk of bleeding - Don't ask provider because it refers the client's partner to another professional without responding to the question
A nurse is caring for a client who has eclampsia and just had a tonic-clonic seizure. After turning the client's head to the side, which of the following actions should the nurse take next? a. administer magnesium sulfate 4g IV bolus b. insert an indwelling urinary catheter c. give oxygen at 10L/min via face mask d. keep the environment quiet and the lights dimmed
Give oxygen at 10L/min via face mask - note, the nurse should administer magnesium sulfate to prevent further seizure activity - however ABC (A) is first
A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take? a. administer the medication while the infant is supine b. give the medication at the side of the infant's mouth c. add the medication to a full bottle of the infants formula d. administer the medication slowly while holding the nares closed
Give the medication at the side of the infant's mouth - a needless oral syringe or medicine dropper is placed in teh side of the mouth (buccal cavity along tongue) to prevent gagging and aspiration
A nurse is checking laboratory values to determine if a client with diabetes mellitus is adhering to the treatment plan. Which of the following tests should the nurse use to make this determination? a. glycosylated hemoglobin levels b. urine sugar and acetone levels c. glucose tolerance test d. fasting serum glucose
Glycosylated hemoglobin levels (HbA1c) = method to determine if the client is an accurate method of determining if the client is routinely compliant. refers to hemoglobin that is connected to glucose, since the lifespan of an RBC is 4 months, this value will not be affected by recent changes in the clients diet or medication - urine sugar and acetone levels reflect how well-controlled the client has been for the last few hours - glucose tolerance test is used to diagnose diabetes mellitus and commonly identifies type 2 and gestational diabetes - a fasting serum glucose provides information about the previous 24 hours
A nurse is preparing to administer recommended immunizations to a 2 month old infant. Which of the following immunizations should the nurse plan to administer? a. Human papillomavirus (HPV) and hepatitis A b. Measles, mumps, and rubella (MMR) and tetanus, diphtheria, and acellular pertussis (TDaP) c. Haemophilus influenzae type B (Hib) and inactivated poliovirus (IPV) d. Varicella (VAR) and live attenuated influenza vaccine (LAIV)
Haemophilus influenzae type B (Hib) and inactivated poliovirus (IPV) - Human papillomavirus (HPV) age 11 - Hepatitis A age 12 months -Measles, mumps, and rubella (MMR) age 12 to 15 months -Tetanus, diphtheria, and acellular pertussis (TDaP) age 11 to 12 years - Varicella (VAR) age 12 months - Live attenuated influenza vaccine (LAIV) age 2
A nurse is preparing to test the function of cranial nerve X. Which of the following assessment procedures should the nurse use? a. have the client open his mouth and say "aah" b. ask the client to identify the scent of coffee c. use a tongue blade to provoke a gag reflex d. have the client smile and raise his eyebrows
Have the client open his mouth and say "aah"
A nurse is preparing to test the function of cranial nerve X. Which of the following assessment procedures should the nurse use? a. have the client open his mouth and say "ahh" b. ask the client to identify the scent of coffee c. use a tongue blade to provoke a gag reflex d. have the client smile and raise his eyebrows
Have the client open his mouth and say "ahh"
A nurse is caring for a client who is in skeletal traction following a femur fracture. On entering, the nurse finds that the client has slid toward the foot of the bed, and the traction weight is resting on the floor. Which of the following actions should the nurse take? a. remove the weight temporarily to reposition the client to the correct alignment in bed b. have the client use a trapeze to pull himself up while ensuring the weight hangs freely c. lift the rope off the pulley while the client rocks back and forth to reposition himself d. lift the weight manually while another staff member moves the client up in bed
Have the client use a trapeze to pull himself up while ensuring the weight hangs freely - the nurse should not lift or remove the weight without a prescription because this could interfere with the correct alignment of the extremity
A nurse is reviewing the medical history of a client who has spasticity due to multiple sclerosis and a new prescription for tizanidine. Which of the following comorbidities increases the client's risk of adverse effects while taking this medication? a. Pneumonia b. Benign prostatic hypertrophy (BPH) c. Hepatitis d. Diabetes mellitus
Hepatitis Tizanidine can cause liver damage - this medication should be used with extreme caution in a client who has a preexisting impairment of hepatic function
A nurse is caring for a client who has acute lymphocytic leukemia and reports a fever, chills, fatigue, and pallow over the past week. When checking the client's laboratory results, which of the following values should the nurse identify as contributing to the client's fatigue and pallor? a. magnesium 2.0 mEq/L b. Hgb 6.5 g/dL c. WBC count 9.6/mm3 d. Creatinine 0.8 mg/dL
Hgb 6.8 g/dL normal is 14-18 form men and 12-16 for women WBC 4,500-11,000 Magnesium 1.3-2.1 Creatinine 0.7-1.3
A nurse is caring for a client who has osteoporosis and has been taking a vitamin D supplement. The nurse notes that the client reports also taking a multivitamin daily. Which of the following findings should indicate to the nurse that the client might be experiencing vitamin D toxicity? a. hyperkalemia b. hypermagnesemia c. hypercalcemia d. hypernatremia
Hypercalcemia - vitamin D increases plasma calcium levels by increasing reabsorption from bone - multivitamin + vitamin D daily = too much calcium
A nurse is assessing a client who has adjustment disorder. Which of the following statements by the client should the nurse recognize as a manifestation of this disorder? a. i am unable to remember my address b. i feel like i am living in a fog c. i sometimes cannot remember large blocks of time d. i could have done something to prevent my cousin's death
I could have done something to prevent my cousin's death - indicates adjustment disorder, which occurs as a response to a stressful event
A nurse is teaching an adolescent about managing asthma and using a peak expiratory flow meter. Which of the following statements by the client demonstrates an understanding of the teaching? a. I will use my peak flow meter whenever I feel short of breath b. I will continue to take my medication when my peak flow rate is in the green zone c. I need to use the average of 3 readings when I measure my flow rate d. My asthma is being controlled if my flow rate is in the yellow zone
I will continue to take my medication when my peak flow rate is in the green zone -A peak flow rate in the green zone indicates the current treatment has been effective; therefore the adolescent should continue with their current medication regimen
A nurse is providing postoperative teaching to the parent of a 3-month-old infant who is recovering from an umbilical hernia repair. Which of the following statemnts by the parent indicates an understanding of the teaching? a. I will expect the site to bulge when my baby cries b. I will place a belly band around my baby's abdomen c. I will fold the baby's diaper away from the incision d. I will bathe my child in the bathtub daily
I will fold the baby's diaper away from the incision - to protect form contamination
A nurse is providing teaching to a client who has a new prescription for varenicline for smoking cessation. Which of the following statements by the client indicates an understanding of the teaching? a. If I fail to stop smoking after 12 weeks, I will have to try another product b. I will take the medication for 7 days before I try to stop smoking c. This medication will cause me to lose weight as I stop smoking d. I will take the medication after eating a meal
I will take the medication after eating a meal - will minimize nausea
A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? a. place non rebreather mask on the client and increase the oxygen flow to 3 L/min b. prepare the client for possible endotracheal intubation and mechanical ventilation c. increase the oxygen flow and request an arterial blood gas determination d. position the client supine and administer an anti anxiety medication
Increase the oxygen flow and request an arterial blood gas determination
A nurse is teaching a client with systemic lupus erythematosus who has a new prescription for prednisone. The nurse should instruct the client to monitor for which of the following adverse effects of this medication? a. Hypoglycemia b. Tendinitis c. Infection d. Weight loss
Infection - avoid people who are ill and monitor for manifestations of infection
A nurse in a substance use disorder treatment facility is reviewing the medication records of a group of clients. The nurse should expect to administer methadone for a client who has a substance use disorder for which of the following substances? a. amphetamines b. opiates c. barbiturates d. hallucinogens
Opiates
A nurse is caring for a toddler who has a fever, a high-pitched cry, irritability and vomiting. Which of the following actions should the nurse take? a. administer 81 mg of aspirin to the toddler b. give the toddler a cold bath c. place the toddler in a supine position d. pad the rails of the toddler's bed
Pad the rails of the toddler's bed
A nurse in a labor and delivery unit is preparing to teach a newly licensed nurse about intermittent auscultation of the fetal heart rate. Which of the following interventions should the nurse include? a. count the fetal heart rate for 15 seconds after contractions b. palpate and count the maternal radial pulse while listening to the fetal heart rate c. place the listening device over the fetal chest to hear the fetal heart rate d. percuss the maternal abdomen to verify the position of the fetus
Palpate and count the maternal radial pulse while listening to the fetal heart rate
A nurse is communicating with a client at an inpatient mental health facility. Which of the following actions by the nurse demonstrates teh proper use of active listening? a. offering self b. using silence c. paying attention to body language d. reflecting feelings
Paying attention to body language
A nurse is caring for a client who has asthma and requires long-term treatment. The nurse should identify that which of the following medications used for long-term treatment places the client at an increased risk of asthma-related death? a. Salmeterol b. Fluticasone c. Budesonide d. Theophylline
Salmeterol
A nurse is caring for a child who has suspected nephrotic syndrome. Which of the following laboratory values should the nurse expect? a. platelets 120,000/mm^3 b. serum sodium 160 mEq/L c. Hgb 9 g/dL d. serum cholesterol 700 mg/dL
Serum cholesterol 700 mg/dL - nephrotic syndrome is a kidney disorder that causes your body to pass too much protein in your urine - cholesterol findings higher than expected because of the increase in plasma lipids - platelet is below expected range and should be increased in nephrotic syndrome (150,000-450,000) - serum sodium is above and should be lower in nephrotic syndrome (135-145) - hemoglobin is below expected range and should be normal or elevated (12/14-16/18)
A nurse is providing teaching to a client who has type 1 diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include in the teaching? a. shakiness b. urinary frequency c. dry mucous membranes d. excess thrist
Shakiness - all others are hyperglycemia manifestations
A nurse is providing care to a client who is 2 hours postpartum and is receiving an oxytocin IV. The client asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse make? a. this could indicate a possible uterine infection b. the bleeding is minimal until I discontinue you're IV medication c. you might have retained some fragments of your placenta d. you will require additional medication to increase you're bleeding
The bleeding is minimal until I discontinue you're IV medication - the flow of lochia is often scant while receiving oxytocic medication until the effects of the medication wear off
A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. Which of the following pieces of information in the client's history is a contraindication to this procedure? a. the client has a new tattoo b. the client is unable to sit upright c. the client has a history of peripheral vascular disease d. the client has a pacemaker
The client has a pacemaker
A nurse is performing an assessment of a client who just arrived at the labor and delivery unit. Which of the following findings should the nurse identify as the priority? a. the client reports a pain level of 8 on a scale from 0 to 10 during contractions b. the client's blood pressure is 148/92 mmHg c. the clients temperature is 38.3 (101) d. the fetal heart rate is 90/min
The fetal heart rate is 90/min - fetal bradycardia - normal is 110-160
A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make? a. two tubes were necessary due to excessive bleeding from the area of the surgery b. the tubes drain blood from different lung areas c. the lower tube will drain blood, the higher tube will remove air d. the second tube will take over if blood clots blocks the first tube
The lower tube will drain blood, the higher tube will remove air - blood typically drains from the base of the lung, not the apex
A nurse is providing discharge teaching about improving gas exchange for a client who has emphysema. Which of the following instructions should the nurse include in the teaching? a. use pursed-lip breathing during periods of dyspnea b. limit fluid intake to 1,500 mL per day c. practice chest breathing each day d. wear home oxygen to maintain an SaO2 of at least 94%
Use pursed-lip breathing during periods of dyspnea - this method increases airway pressure and facilitates effective gas exchange - the nurse should instruct the client to drink 2,000 to 3,000 mL of fluid a day to keep respiratory secretions thin and easier to expectorate - practice diaphragmatic or abdominal breathing d. the nurse should instruct SaO2 maintained at least 88%
A nurse on a pediatric unit is caring for a preschooler who is prescribed an IV medication. Which of the following actions should the nurse take to prepare the child for the procedure? a. use role-play activities with the child b. provide the child with a detailed explanation of the procedure c. implement interactive sessions of 30 min each with the child d. give the child identical IV supplies to play with
Use role-play activities with the child
A nurse is monitoring a newborn who is receiving phototherapy. The nurse should identify which of the following findings as requiring intervetion? a. bilirubin level 5 mg/dL b. weight loss 12% of birth weight c. loose green stool d. auxiliary temperature of 36.6 (97.9)
Weight loss 12% of birth weight - an acceptable weight loss over 3-5 days is 10% - loose stools are common finding in newborns receiving phototherapy - temperature is within expected (36.5-37.5) - bilirubin level indicates phototherapy is no longer needed, so provider should discontinue treatment (5-6)
A nurse on a pediatric oncology unit is helping parents of a child who is terminally ill to prepare for the impeding loss of there child. Which of the following statements shold the nurse make? a. the nursing staff will bathe your child and take care of his daily needs b. you're child will be most comfortable in a low-stimulation environment c. would you like assistance in planning where you're child will die? d. would you like hospice to continue providing curative care in you're home?
Would you like assistance in planning where you're child will die? -the nurse should inform the parents that they can choose to keep the child in a hospital setting or take the child home to die
A nurse is caring for a client who was hospitalized several days ago following a suicide attempt. The client states "I do not want visitors today because I look and feel terrible." Which of the following responses should the nurse make? a. that is silly. you look just fine to me b. nobody expects you to look good in a hospital c. i understand. would you like to wash your hair? d. would you like to talk about why you feel this way?
Would you like to talk about why you feel this way?
A nurse is providing dietary teaching for a client with AIDS who has stomatitis of the mouth. Which of the following instructions should the nurse include in the teaching? a. you can suck on popsicles to numb your mouth b. season food with spices instead of salt c. avoid the use of a straw to drink liquids d. eat foods at hot temperatures
You can suck on popsicles to numb your mouth
A nurse is preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse give the client before the procedure? (select all that apply) a. you'll have to lie flat for several hours after the procedure b. you'll receive medication to relax you before the procedure c. you'll feel a cool sensation after the injection of the dye d. you'll have to keep your leg straight after the procedure e. you'll have to limit the amount of fluid you drink for the first 24 hr
a. you'll have to lie flat for several hours after the procedure b. you'll receive medication to relax you before the procedure d. you'll have to keep your leg straight after the procedure - you feel warm sensation from dye - you increase hydration IV and orally to excrete contrast medium
A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings indicates that a possible bowel perforation has occurred? a. elevated blood pressure b. bowel sounds increased in frequency and pitch c. rigid abdomen d. emesis of undigested food
c. Rigid abdomen - abdominal tenderness and rigidity indicate a bowel perforation. as fluid escapes into the peritoneal cavity, a reduction in circulating blood volume occurs, lowering blood pressure - bowel sounds are silent
A nurse is teaching a client who has diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include? (select all) a. bradycardia b. diaphoresis c. deep, rapid respirations d. palpitations e. shakiness
diaphoresis palpitations shakiness
