Fundamental NCLEX

A community health nurse has volunteered to assist in providing health care instructions to a Native American community group. The nurse plans instructions based on the common practices and rituals of this group, knowing that which are associated characteristics of this ethnic group? Select all that apply. 1.Alcohol abuse is common. 2.Vitamin D deficiency is a concern. 3.Many foods consumed are low in fat. 4.Corn is an important component of the diet. 5.This group is at increased risk for gallbladder disease.

1.Alcohol abuse is common. 2.Vitamin D deficiency is a concern. 4.Corn is an important component of the diet. 5.This group is at increased risk for gallbladder disease

Which clients have a high risk of obesity and diabetes mellitus? Select all that apply. 1.Latino American man 2.Native American man 3.Asian American woman 4.Hispanic American man 5.African American woman

1.Latino American man 2.Native American man 4.Hispanic American man 5.African American woman

The health care provider (HCP) has written a prescription to start progressive ambulation as tolerated in a hospitalized client who experiences periods of confusion because of bed rest and prolonged confinement to the hospital room. Which nursing intervention would be appropriate when planning to implement the HCP's prescription and address the needs of the client? 1.Progressively ambulate the client in the hall three times daily. 2.Ambulate the client in the room for short distances frequently. 3.Ambulate the client to the bathroom in his or her room three times daily. 4.Assist with range-of-motion exercises three times daily to increase strength.

1.Progressively ambulate the client in the hall three times daily.

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level? 1.Prolonged bed rest 2.Renal insufficiency 3.Hyperparathyroidism 4.Excessive ingestion of vitamin D

1.Prolonged bed rest

The nurse notes that an older client with dementia is unable to care for herself. Which is an appropriate goal for this client? 1.The client will function at the highest level of independence possible. 2.The client will be admitted to a long-term care facility to have activities of daily living (ADL) needs met. 3.The nursing staff will attend to all of the client's ADL needs during the hospital stay. 4.The client will complete all ADL independently within a 1-hour time frame.

1.The client will function at the highest level of independence possible.

The nurse is reviewing the white blood cell (WBC) count and differential on a client and notes that the results indicate a left shift. What are the possible indications for these laboratory results? Select all that apply. 1.The total number of WBCs 2.An increased number of bands 3.The presence of an acute infectious process 4.An increased number of mature neutrophils 5.An increased number of immature neutrophils

1.The total number of WBCs 2.An increased number of bands 3.The presence of an acute infectious process 5.An increased number of immature neutrophils

The prenatal clinic nurse is performing an assessment on a culturally diverse client. Besides conversational style, what are some of the most important cultural and communication considerations the nurse must be aware of? Select all that apply. 1.Touch 2.Eye contact 3.Personal space 4.Family presence 5.Time orientation 6.Facial expression

1.Touch 2.Eye contact 3.Personal space 5.Time orientation

The unlicensed assistive personnel (UAP) is assigned to care for a client who is of Asian heritage. The UAP tells the nurse, "I think that my assignment needs to be changed. Every time I try to talk, the client turns away." Which statement is the most appropriate teaching response from the nurse? 1."You are right. Your assignment needs to be changed." 2."If the client turns away, continue with the discussion." 3."If the client turns away, leave the room and return later to finish your care." 4."The client may have difficulty hearing. Speak up when talking to the client."

2."If the client turns away, continue with the discussion."

The nurse caring for an Orthodox Jewish client plans a diet that adheres to the practices of the client's faith. When planning care, the nurse recognizes that which principles are consistent with dietary kosher laws? Select all that apply. 1.Meat and milk can be eaten together. 2.Eating fish with scales and fins is allowed. 3.Unleavened bread is eaten during Passover week. 4.Meat from animals that are vegetable eaters is allowed. 5.Meat is allowed if the food animal is ritually slaughtered.

2.Eating fish with scales and fins is allowed. 3.Unleavened bread is eaten during Passover week. 4.Meat from animals that are vegetable eaters is allowed. 5.Meat is allowed if the food animal is ritually slaughtered.

The nurse is providing dietary instructions to a client with a diagnosis of hyperphosphatemia. The nurse determines that the client understands the instructions if the client states the importance of eliminating which item from the diet? 1.Tea 2.Fish 3.Coffee 4.Grape juice

2.Fish

The nurse is preparing the morning medications to be administered to assigned clients and is reviewing the health care provider's prescriptions. Which medication prescription should the nurse question? 1.Lanoxin 0.25 mg orally daily 2.Hydrochlorothiazide orally twice daily 3.Docusate sodium 100 mg orally twice daily 4.Enoxaparin sodium 20 mg subcutaneously daily

2.Hydrochlorothiazide orally twice daily

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply. 1.Bites from ticks or deer flies 2.Inhalation of bacterial spores 3.Through a cut or abrasion in the skin 4.Direct contact with an infected individual 5.Sexual contact with an infected individual 6.Ingestion of contaminated undercooked meat

2.Inhalation of bacterial spores 3.Through a cut or abrasion in the skin 6.Ingestion of contaminated undercooked meat

The nurse is caring for an abdominal surgical client who has a Jackson-Pratt drain in place. Which interventions should the nurse include in the plan of care for this drain? Select all that apply. 1.Secure the drain to the sheet. 2.Make sure suction is maintained. 3.Check that the drains are sutured in place. 4.Use clean technique to empty the reservoir. 5.Compress the reservoir to restore suction after emptying. 6.Record the amount and color of drainage according to agency protocol or health care provider's orders.

2.Make sure suction is maintained. 3.Check that the drains are sutured in place. 5.Compress the reservoir to restore suction after emptying. 6.Record the amount and color of drainage according to agency protocol or health care provider's orders.

The community health nurse is conducting an education session for community members regarding measures to prevent skin cancer and is providing instructions for use of sunscreen protection. The nurse determines that teaching was effective if a community member states that chemical sunscreens are most effective when applied at what time? 1.Immediately after swimming 2.One hour before exposure to the sun 3.Immediately before exposure to the sun 4.Five minutes before exposure to the sun

2.One hour before exposure to the sun

The nurse creates a plan of care for a client with a cervical-uterine radiation implant. Which intervention would be appropriate for the nurse to include in the plan? 1.Restrict all visitors. 2.Place a lead shield at the bedside. 3.Keep the client's room door open. 4.Place the client in a semi-private room.

2.Place a lead shield at the bedside.

A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action? 1.Increase fluid intake. 2.Resume full activity level. 3.Stay in a cool environment when possible. 4.Monitor voiding for adequacy of urine output.

2.Resume full activity level.

The nurse is explaining the process of bariatric surgery to a severely obese client who has attended a medically supervised weight loss program for approximately 6 months. The client is considering this procedure. What are some conditions that may interfere with a client's commitment to lifelong behavioral changes and that may lead to poor surgical outcomes? Select all that apply. 1.Anxiety 2.Untreated depression 3.Binge eating disorders 4.Drug and alcohol abuse 5.Lack of family resources 6.Inability to comply with nutritional recommendations

2.Untreated depression 3.Binge eating disorders 4.Drug and alcohol abuse 6.Inability to comply with nutritional recommendations

The nurse is preparing to administer an intramuscular injection to a 4-year-old child. The nurse plans to administer the injection in the ventral gluteal muscle, knowing that which indicates the maximum amount of medication volume that can be safely injected? 1. 0.5 mL 2. 1.0 mL 3 .1.5 mL 4. 2.0 mL

3. 1.5 mL

The nurse is administering an acetaminophen suppository to a child with a fever. The nurse inserts the suppository into the rectum a distance of no more than how many centimeters? 1. 0.5 2. 1 3. 2 4. 2.5

3. 2

The client with a history of lung disease is at risk for developing respiratory acidosis. The nurse asks this client about which symptoms that are characteristic of this disorder? 1."Do you have shallow breathing?" 2."Do you feel like you have a lot of energy?" 3."Do you have a headache or become confused?" 4."Do you feel dizzy or have tingling sensations?"

3."Do you have a headache or become confused?"

The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instruction? 1."I should cuddle my child after giving the medication." 2."I can give my child a frozen juice bar after he swallows the medication." 3."I should mix the medication in the baby food and give it when I feed my child." 4."If my child does not like the taste of the medicine, I should encourage him to pinch his nose and drink the medication through a straw."

3."I should mix the medication in the baby food and give it when I feed my child."

The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? 1."I should sleep on my left side." 2."I should sleep on my right side." 3."I should sleep with my head flat." 4."I should not wear my glasses at any time."

3."I should sleep with my head flat."

The home care nurse visits a child recently discharged from the hospital with a diagnosis of hepatitis A virus (HAV) infection. The mother asks the nurse when the child can return to school. The nurse should make which response to the mother? 1."In about 2 months." 2."When the jaundice disappears." 3."One week after the onset of jaundice." 4."At the beginning of the next academic year."

3."One week after the onset of jaundice."

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note? 1.Bradycardia 2.Elevated blood pressure 3.Changes in mental status 4.Bilateral crackles in the lungs

3.Changes in mental status

Following myelography, how should the nurse plan to best position the client? 1.On the left side 2.On the right side 3.Head slightly elevated 4.Head lower than the rest of the body

3.Head slightly elevated

The health care provider writes a prescription to apply a heating pad to a client's back. Which intervention is contraindicated and is unsafe? 1.Setting the heating pad on a low setting 2.Assessing the skin frequently for burns 3.Placing the heating pad under the client 4.Using tape to hold heating pad in place

3.Placing the heating pad under the client

A client preparing to go home 2 days following a right mastectomy with dissection of axillary lymph nodes asks the nurse, "What should I do to minimize my chance for complications from this surgery?" Which response should the nurse make? 1."Try to minimize moving your right arm." 2."Examine the surgical incision once a week." 3."Be sure to carry your purse over your right shoulder." 4."Avoid having blood pressures taken on your right arm."

4."Avoid having blood pressures taken on your right arm."

A client is scheduled to have a needle liver biopsy. During the procedure, the nurse should instruct the client to take which action? 1.Lie on the right side. 2.Assume a lithotomy position. 3.Breathe deeply as the needle is inserted. 4.Lie supine with the right arm over the head.

4.Lie supine with the right arm over the head.