Fundamentals of Nursing NCLEX PN Adaptive Quizzing
A client asks the nurse, "Should I tell my partner that I just found out I'm HIV positive?" How should the nurse respond?
"You are having difficulty deciding what to say.
A nurse teaches a client about wearing thigh-high anti-embolism elastic stockings. What would be appropriate to include in the instructions?
"You will need to apply them in the morning before you lower your legs from the bed to the floor."
A health care provider prescribes daily sputum specimens to be collected from a client. When is the most appropriate time for the nurse to collect these specimens?
A health care provider prescribes daily sputum specimens to be collected from a client. When is the most appropriate time for the nurse to collect these specimens?
A nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue and bleeding gums. The nurse recognizes that these clinical manifestations are most likely a result of what?
A nutritional deficiency
A client has been diagnosed with type 1 diabetes mellitus. When providing instructions on sharps disposal when the patient is at home, the nurse should instruct the client to place used insulin syringes where?
A plastic liquid detergent bottle with a screw-top lid
A nurse is administering serum albumin intravenously to a client with ascites. In response to this therapy, what does the nurse expect to decrease?
Abdominal girth
Which parameter does the nurse assess first while assessing a client with severe trauma?
Airway Airway is first assessed in a client with severe trauma because inadequate oxygen supply can lead to brain injury that can progress to anoxic brain death. Disability is assessed after the vital signs are assessed. Breathing is assessed after the airway is assessed and cleared. Circulation is assessed after effective breathing is ensured.
A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte?
Calcium
Which addictive drug may cause stuffy nose, bronchitis and asthma, lung cancer, decreased testosterone and sperm count, and diminished immune function in chronic users?
Cannabis
A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful?
Clear breath sounds
A child is being treated with oral ampicillin (Omnipen) for otitis media. What should be included in the discharge instructions that the nurse provides to the parents of the client?
Complete the entire course of antibiotic therapy.
The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client's pain does what?
Continues after rest and nitroglycerin
A client with Type I Diabetes complains of hunger, thirst, tiredness, and frequent urination. Based on these findings, the nurse should take what action?
Determine the client's blood glucose level
The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia?
End-stage renal disease
The nursing intervention for a client who is hyperventilating should focus on providing reassurance and what?
Having the client breathe into a paper bag
A nurse receives prescriptions for a newly admitted client and has difficulty reading the health care provider's writing. Who should the nurse ask for clarification of this prescription?
Health care provider who wrote the prescription
A client reports inability to see the objects that are in close range. This is described by the health care provider as which condition?
Hyperopia
What effect of anxiety makes it particularly important for the nurse to reduce the anxiety of a client with heart failure?
Increases the cardiac workload
A spouse of a client slips and falls on a wet floor in the hallway leading to the client's room. To meet the criteria of ethical practice, what action should the nurse that witnessed the occurrence take?
Initiate an agency incident report
What is objective information in SOAPIER documentation?
It includes what the nurse can factually describe.
Which diagnostic test may be used to distinguish vascular from nonvascular structures?
Magnetic resonance imaging
Which test helps to assess the neurological system in a client with impaired vestibular system? Select all that apply.
Past-point test Romberg test
A client has an order for a sublingual nitroglycerin tablet. The nurse should teach the client to use what technique when self-administering this medication?
Place the pill under your tongue and let it dissolve
When providing preoperative teaching, what should the nurse focus primarily on?
Providing general information to reduce client and family anxiety
A client with dehydration is prescribed an intravenous (IV) fluid infusion. Which healthcare professional would the nurse expect to be delegated this task?
Registered nurse (RN)
During chest examination in a healthy client, the nurse percusses and hears a low-pitched sound over the lungs. Which sound should the nurse document in the medical record?
Resonance
A client is receiving oxycodone postoperatively for pain. The health care provider's prescription indicates that the dose should be administered every three hours for eight doses. What should the nurse assess before administering each dose of oxycodone?
Respiratory rate and level of consciousness
A nurse understands that what is the primary purpose for a client to undergo reconstructive surgery?
Restore function and/or appearance.
A client with esophageal varices is admitted with hematemesis, and two units of packed red blood cells are prescribed. The client complains of flank pain halfway through the first unit of blood. What is the nurse's first action?
Stop the transfusion
What should the nurse include in the plan of care for a client who just had a total laryngectomy?
Suctioning the tracheostomy tube whenever necessary
Which withdrawal symptoms may be observed in a client addicted to opioids? Select all that apply.
Sweating Watery eyes Loss of appetite
A nurse is caring for an older adult who is taking acetaminophen for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen?
Alcohol
A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator?
Tissue turgor
A client with a dysrhythmia is admitted to telemetry for observation. In the morning, the client asks for a cup of coffee. What is the nurse's best response?
"Coffee has caffeine, which can affect your heart. It should be avoided."
An adolescent that had an inguinal hernia repair is being prepared for discharge home. The nurse provides instructions about resumption of physical activities. Which statement by the adolescent indicates that the client understands the instructions?
"I can't perform any weightlifting for at least 3 weeks."
A client with a history of hypertension has a blood pressure of 180/102 mm Hg. When the nurse asks whether the client has been taking any medications, the client replies, "I took the blood pressure pills the healthcare provider prescribed for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick." What is the best initial response by the nurse?
"It is important to take your medications daily to achieve optimal results."
An 80-year-old client is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated, because she is alert and able to care for herself. What is the nurse's best response?
"The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased."
The nurse manager of the unit comes to work obviously intoxicated. What is the staff nurse's ethical obligation?
3 Have the supervisor validate the observation
Which diagnostic test is performed to assess the functioning of the lacrimal gland?
3 Schirmer's test
Which quantity of iron, ingested by a child, would be considered in the range of mildly to moderately toxic?
35 mg/kg
Which assessment should the nurse obtain before administering digoxin (Lanoxin) to a client?
Apical heart rate
A nurse manager is evaluating the performance of the LPN/LVN who is supervising Unlicensed Assistive Personnel (UAP). What action indicates to the nurse manager that the LPN/LVN needs further instruction?
Asks the UAP to assess the client's response to a respiratory treatment.
When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication?
Aspiration pneumonia
Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do?
Assess the client's condition every hour
A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). What complications are associated most commonly with COPD?
Cardiac problems
The nurse assists with a client's yearly physical examination. After the examination is completed, the client is diagnosed with tuberculosis. Which action best reflects appropriate epidemiological follow-up?
Encouraging close family members, friends, and coworkers of the client to have a skin test
A client is scheduled to be transferred from the coronary care unit to a progressive care unit. The client asks a nurse, "Are you sure I'm ready for this move?" What does the nurse conclude the client most likely is experiencing?
Fear
A health care provider prescribes 0.2 mg of cyanocobalamin (vitamin B12) intramuscularly for a client with pernicious anemia. A vial of the drug labeled 100 mcg = 1 mL is available. How much solution should the nurse administer? Record your answer using a whole number. __________mL
First convert milligrams (mg) to micrograms (mcg) and then use ratio and proportion (0.2 mg = 200 mcg). 200 mcg x mL --------- = ------ 100 mcg 1 mL 100x = 200 x = 2 mL
Which factor can cause early morning awakening and fatigue in older adults?
Hypertension
A client with a history of hemoptysis and cough for the last six months is suspected of having lung cancer. A bronchoscopy is performed. Two hours after the procedure the nurse identifies an increase in the amount of bloody sputum. What is the nurse's priority?
Immediately contact the primary health care provider
For the first several hours after a cardiac catheterization, it is most essential for the nurse to do what?
Monitor the client's apical pulse and blood pressure
Which patient population should the nurse identify as having a high risk for amputation associated with the diagnosis of diabetes mellitus (DM)?
Native American The Native American population has a high risk for amputation associated with the diagnosis of DM. The other populations (Asian American, Alaskan American, and Hispanic American) do not have a high risk for amputation associated with DM.
The nurse is caring for a client who underwent a hysterectomy and who is admitted to a general medical-surgical unit. Which tasks can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply.
Oral hygiene Assistance with bathing
While receiving a blood transfusion, the client suddenly shouts, "I feel like someone is lowering a heavy weight on my chest. I feel like I'm going to die!" Which actions are priority?
Stop the transfusion and administer normal saline
The primary health care provider orders a Snellen's test for a client. What could be the rationale for this decision?
To assess for visual acuity
