Coaching-NCLEX Practice #2
A patient arrives at the ambulatory surgery center for a scheduled laparoscopy procedure in outpatient surgery. Which information is of most concern to the nurse? a. The patient is planning to drive home after surgery. b. The patient had a sip of water 4 hours before arriving. c. The patient's insurance does not cover the outpatient surgery. d. The patient has not had surgery using general anesthesia before.
a
A patient who had knee surgery received intramuscular ketorolac (Toradol) 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which action is best for the nurse to take at this time? a. Administer the prescribed PRN IV morphine sulfate. b. Notify the health care provider about the ongoing knee pain. c. Reassure the patient that postoperative pain is expected after knee surgery. d. Teach the patient that the effectiveness of ketorolac typically last about 6 to 8 hours.
a
A test is scheduled for tomorrow. The student states, "I can't think about that test today." The student is using which defense mechanism: a. Suppression b. Repression c. Denial d. Rationalization
a
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? a. Weak, nonproductive cough effort b. Large amounts of greenish sputum c. Respiratory rate of 28 beats/minute d. Resting pulse oximetry (SpO2) of 85%
a
The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse? a. Blood pressure is 90/40 mm Hg. b. Urine output is 30 mL over the last hour. c. Oral fluid intake is 100 mL for the last 8 hours. d. There is prolonged skin tenting over the sternum
a
When planning postoperative care for an obese client prior to surgery, the nurse would develop which nursing diagnosis specific to the effect obesity has on postoperative recovery? a. Risk for ineffective tissue perfusion (cardiopulmonary) b. Excess fluid volume c. Risk for impaired skin integrity (pressure ulcers) d. Ineffective thermoregulation
a
Which of the following lab results warrants immediate attention in a preoperative client? a. PT of 1 min 20 sec b. HCT 38 ml/dL c. Hgb 14 g/dL d. WBC 6000/mm
a
The nurse is reviewing the medical records for five patients who are scheduled for their yearly pysical examinations in September. Which patients should receive the inactivated influenza vaccination (Select all that apply.) a. A 76-year-old nursing home resident b. A 36-year-old female patient who is pregnant c. A 42-year-old patient who has a 15 pack-year smoking history d. A 30-year-old patient who takes corticosteroids for rheumatoid arthritis e. A 24-year-old patient who has allergies to penicillin and cephalosporins
a,b,d
22. A 10-month-old is admitted to the ER for fever and history of vomiting and diarrhea for the past 48 hours. What signs and symptoms should the nurse look for related to the client's fluid imbalance? a. Bulging fontanels, tearless cry, and low urine output b. Sunken eyes, lethargy, and dry, furrowed tongue c. Weight loss, dilute urine, and peripheral edema d. Dry skin, thready pulse, and neck vein distention
b
A client takes 20 units of NPH at 0700. The nurse should observe for hypoglycemia at: a. 0800 b. 1000 c. 1500 d. 0500
b
A nurse assists a patient on the first postoperative day to ambulate, cough, deep breathe, and turn. Which action by the nurse is most helpful? a. Teach the patient to fully exhale into the incentive spirometer. b. Administer ordered analgesic medications before these activities. c. Ask the patient to state two possible complications of immobility. d. Encourage the patient to state the purpose of splinting the incision.
b
A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is most appropriate? a. Elevate the head of the bed to 80 to 90 degrees. b. Keep the patient NPO until the gag reflex returns. c. Place on bed rest for at least 4 hours after bronchoscopy. d. Notify the health care provider about blood-tinged mucus
b
Following a CT scan with contrast medium, the nurse should give attention to: a. Maintaining bedrest for 8 hours b. Forcing fluids c. Observing puncture site for hemorrhage d. Administering pain medications
b
The nurse is explaining the Bill of Rights for psychiatric patients to a client who has voluntarily sought admission to an inpatient psychiatric facility. Which of the following rights should the nurse include in the discussion? a. Right to select health care team members b. Right to refuse treatment c. Right to a written treatment plan d. Right to obtain disability e. Right to confidentiallity f. Right to personal mail
b,c,e,f
A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment findings should the nurse immediately report to the health care provider? (Select all that apply.) a. Patient is claustrophobic. b. Patient is allergic to shellfish. c. patient recently used a bronchodilator inhaler. d. Patient is not able to remove a wedding band. e. Blood urea nitrogen (BUN) and serum creatinine levels are elevated.
b,e
11. Which assessment finding alerts the nurse to provide patient teaching about cataract development? a. History of hyperthyroidism b. Unequal pupil size and shape c. Blurred vision and light sensitivity d. Loss of peripheral vision in both eyes
c
A 65-year-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patient's treatment? a. "I use aspirin when I have a sinus headache." b. "I have had frequent episodes of conjunctivitis." c. "I take metoprolol (Lopressor) daily for angina." d. "I have not had an eye examination for 10 years."
c
A client tells the nurse that she can't swallow her pill labeled SR. What is the best action by the nurse? a. Open capsule and mix with ice cream b. Crush med and mix with 8 oz of fluid c. Call pharmacist and request alternative preparation of med d. Stop medication and inform physician
c
During medication teaching regarding NSAID use, the nurse should tell the client that" a. Taking the medication with food will render it ineffective. b. Fluids should be restricted. c. Taking the medication with food will lessen gastric upset. d. Exposure to sunlight will cause bronzing of skin.
c
The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife usually answers most questions that are directed to the patient. Which action should the nurse take when doing the reaching? a. Use printed materials for instructions so that the patient will have more time to review the material. b. Direct the teaching toward the wife because she is the obvious support and caregiver for the patient. c. Provide additional time for the patient to understand preoperative instructions and carry out procedures. d. Ask the patient's wife to wait in the hallway in order to focus preoperative teaching to the patient himself.
c
The nurse would choose to use medical aseptic technique when collecting which of the following specimens? a. Culture and sensitivity from an abdominal wound b. Sputum specimen via a tracheostomy c. Stool specimen for ova and parasites d. Urine specimen via straight cath
c
Which action should the nurse take when providing patient teaching to a 76-year-old with mild presbycusis? a. Use patient education handouts rather than discussion. b. Use a higher-pitched tone of voice to provide instructions. c. Ask for permission to turn off the television before teaching d. Wait until family members have left before initiating teaching.
c
Which assessment finding would best indicate the presence of fluid volume deficit in an elderly client who has not been eating or drinking? a. Clear lung fields with unlabored respirations b. Tenting and dry, flaky skin c. Increased drowsiness, mild confusion, and concentrated urine d. Brisk capillary refill when hands held below the heart
c
Which breakfast option indicates to the nurse that the client with coronary artery disease requires further diet teaching? a. Orange juice, shredded wheat, skim milk, toast with jelly b. Grapefruit juice, oatmeal, 1 % milk, bagel with jelly c. Canned peaches, egg omelet, whole milk, fruited yogurt d. Applesauce, bagel with margarine, egg-white omelet, skim milk
c
Which of the following actions should the nurse take in caring for a Penrose drain? a. Ensure that the drain stays in the original position placed by the surgeon b. Place only one gauze dressing around the tube to allow easier assessment c. Assess surrounding skin for irritation or breakdown with dressing changes d. Notify physician for moderate amount of drainage
c
Which of the following concurrent electrolyte imbalances should the nurse anticipate while assigned to the care of a client with hyperphosphatemia? a. Potassium 2.8 mEq/L b. Sodium 131 mEq/L c. Calcium 6.8 mEq/L d. Magnesium 3.4 mEq/L
c
A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Three sputum smears for acid-fast bacilli are negative.
d
A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Suggest that the patient avoid orange juice with meals. d. Ask the health care provider to order a basic metabolic panel.
d
A patient who takes a diuretic and a β-blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the healthcare provider before surgery? a. Hematocrit 36% b. Blood pressure 144/82 c. pulse rate 58 beats/minute d. Serum potassium 3.2 mEq/L
d
An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Arrange for a friend to administer the medication on schedule. b. Give the patient written insgructions about how to take the medications. c. Teach the patient about the high risk for infecting others unless treatments is followed. d. Arrange for a daily noon meal at the community center where the drug is administered.
d
Before giving medication to a client with reduced hepatic functioning, the nurse should be aware that diminished hepatic functioning will: a. Decrease the possibility of drug toxicity b. Prevent analgesics from being given c. Rduce blood levels of certain drugs d. Increase possibility of drug toxicity
d
The nurse interviews a patient scheduled to undergo general anesthesia for a hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery? a. The patient drinks 3 or 4 cups of coffee every morning before going to work. b. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago. c. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital. d. The patient's father died after receiving general anesthesia for abdominal surgery.
d
The nurse knows that a client with right-sided hemiplegia understands teaching regarding ambulation with a cane if she states: a. "I will hold the cane in my right hand." b. "I will advance the cane and right leg together." c. "I will be able to walk only ysing a walker." d. "I will hold the cane in my left hand."
d
The nurse performing an eye examination will document normal findings for accommodation when: a. shining a light into the patient's eye causes pupil constriction in the opposite eye. b. a blink reaction follows touching the patient's pupil with a piece of sterile cotton. c. covering one eye for 1 minute and noting pupil constriction as the cover is removed. d. the pupils constrict while fixating on an object being moved closer to the patient's eyes.
d
The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan? a. Hand washing is the primary way to prevent spreading the condition to others. b. Use of oral antihistamines for 2 weeks before the allergy season may prevent reactions. c. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use. d. Identification and avoidance of environmental triggers are the best way to avoid it.
d
The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery in a few days. The results are white blood cell (WBC) count 10.2 x 103/μL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 x 103/μL. Which action should the nurse take? a. Call the surgeon and anesthesiologist immediately. b. Ask the patient about any symptoms of a recent infection. c. Discuss the possibility of blood transfusion with the patient. d. Send the patient to the holding area until operating room calls.
d
Which finding is most compatible with worsening respiratory distress? a. Increased respiratory rate b. Tachycardia c. Agitation d. Cyanosis
d
