Hessy & Saunders NCLEX Questions (use fill in the blank)

D

PN notes patient is pleasant and nods his head in agreement with all of the PN's statements, but he does not respond to simple requests. Which characteristic is best supported by the data available? A. Situational low self-esteem B. Disturbed personal identity C. Acute confusion D. Disturbed sensory function

234

A client has arrived back to the nursing unit from special procedures with an epidural catheter in place for pain control. The nurse is revising the plan of care to reflect the epidural catheter and the interventions needed to prevent infection at the site. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Monitor vital signs. 2. Change dressing as needed. 3. Change infusion tubing every 24 hours. 4. Use strict aseptic technique when caring for the catheter. 5. Contact the health care provider for a prescription for antibiotics.

C

After calming down a patient that is experiencing sun downers syndrome, when leaving the room which action should the PN implement? A. Keep the room door wide open. B. Leave the overhead light on. C. Turn on the bathroom light. D. Turn on the tv after the patient drifts off to sleep to provide background noise.

C

After patient accidentally places glass on edge of counter and it crashes to the floor, to follow up this situation, which technique will provide the most useful data?" A. Mini mental status exam. B. Vital signs and level of conciousness. C. Visual field and depth perception. D. Pupil size and accomodation.

CD

Patient becomes very angry when the PN provides the list of home safety checks, that suggest he remove his throw rugs. He yells "you think I'm a helpless old man and can't take care of myself anymore!" Which actions should the PN implement? (Select all) A. Advise the patient that he must gain control of his emotions B. Reassure the patient that he will not always be helpless. C. Ask the patient to explain what has made him so angry. D. Stay in the room with the patient and sit quietly. E. Change the topic of conversation to another subject.

C

The PN interprets the patients angry outburst as an indication that he is afraid he may become dependent upon others if his sensory deficits continure. Which problem should be added to the plan of care? A. Social Isolation B. Self-care deficit C. Risk for situational low self-esteem D. Impaired verbal communication

25

The hospice nurse is caring for five clients from various religious backgrounds. Which observations should the nurse expect for the clients of the various religious backgrounds? Select all that apply. 1. A priest hearing the confession of the client of the Methodist faith 2. A client of the Muslim faith having their bed positioned toward Mecca 3. An Asian client's family desiring the client to be moved to a room number of 44 4. Ensuring meals on Friday do not include warm-blooded meats for the client of the Baptist faith 5. A Hindu-believing family arranges to have the clients' body cremated within 24 hours of death

1456

The metabolic panel of a client reveals a calcium level of 6.5 mg/dL. Based on this laboratory finding, which additional data specific to this calcium level should the nurse collect? Select all that apply 1. Presence of Chvostek's sign 2. Presence of muscle weakness 3. Presence of decreased deep tendon reflexes 4. Presence of electrocardiogram abnormalities 5. Presence of tingling in the fingertips and around the mouth 6. Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes

123

The nurse at an outpatient cardiology clinic is reviewing the medical history of a 48-year-old man during a routine exam. The client is complaining of the inability to maintain an erection and asks the nurse what could be causing it. Which information should the nurse include as possible contributing factors to his erectile dysfunction? Select all that apply 1. Weight 245 lb 2. Total cholesterol 223 mg/dL 3. Serum creatinine 1.86 mg/dL 4. Blood pressure 117/68 mm Hg 5. Thyroid stimulating hormone (TSH) 1.54 mIU/L

2345

The nurse is assessing a client with bipolar disorder who is taking lithium carbonate and who has a lithium level of 1.7 mEq/L. The nurse would expect to find which sign/symptoms of lithium toxicity associated with this level? Select all that apply 1. Polyuria 2. Incoordination 3. Coarse not fine hand tremor 4. Mental confusion 5. Muscle hyperirritability

124

The nurse is aware that the American's with Disabilities Act provides which rights to individuals who are disabled? Select all that apply. 1. Labels asymptomatic HIV as a disability 2. Protects the privacy of individuals with HIV 3. Provides employment to persons with disabilities 4. Prohibits discrimination in employment and public services 5. Allows health care workers to refuse to care for a client with HIV

35

The nurse is reinforcing client education regarding symptoms of testicular cancer. The nurse encourages the client to report which symptoms as being associated with testicular cancer? Select all that apply. 1. Difficulty attaining an erection 2. Purulent discharge from the penis 3. A grainy mass palpated in a testicle 4. Difficulty initiating the urine stream 5. An enlargement of one of the testes

3456

The nurse is reinforcing discharge teaching to the client who was given a prescription for nifedipine (Adalat) for blood pressure management. Which instructions should the nurse reinforce? Select all that apply. 1. "Increase water intake." 2. "Increase calcium intake." 3. "Take pulse rate each day." 4. "Weigh at the same time each day." 5. "Palpitations may occur early in therapy." 6. "Be careful when rising from sitting to standing."

345

The nurse is reviewing the laboratory results from the lumbar puncture performed on a client with a diagnosis of meningitis. Which finding is indicative of a bacterial infection? Select all that apply 1. Clear fluid sample 2. Increased glucose level 3. Protein level of 20 mg/dL 4. Increased white blood cells 5. A cerebrospinal fluid (CSF) pressure of 250 mm H2O

15

The nurse prepares to give a bath and change the bed linens on a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. What should the nurse done? 1. Fetal distress 2. A soft abdomen 3. Painless bleeding 4. Normal blood pressure 5. Dark red vaginal bleeding

C

The patient reports their fingers often feel numb or like "pins and needles." Data reveals 3+ radial pulses bilaterally with capillary refill of 1 second. How will the PN document this finding? A. Altered circulation B. Loss of sensation C. Paresthesia D. Pain

136

The sister of a client with human immunodeficiency virus (HIV) asks the nurse to review once more what she needs to know in order to take care of her brother. Which instructions would be appropriate for the nurse to reinforce? Select all that apply 1. Wash soiled clothes in hot water. 2. Disinfect surfaces with 100% bleach. 3. Use gloves when handling body fluids. 4. Encourage a minimum of 12 hours sleep per day. 5. Other members of the household should not share a bathroom. 6. Soak cleaning rags, sponges and mops in 1:10 bleach solution for 5 minutes.

DE

Upon discharge, PN identifies patien as a risk for injury because of his visual and auditory sensory deficits. Which actions should the PN implement? (Select all that apply) A. Explain thta the patient will be admitted to the acute care center until his scheduled surgery. B. Ask the social worker about temporary placementin a long-term care center. C. Ask the patient about his confidence to safely return home until his scheduled surgery. D. Make plans with George and a family member to help him assess his home for safety hazards. (giving him a home safety checklist) E. Provide family with outside sources that can aide the family with safety equipment for the home.

126

A comatose client received therapeutic hypothermia after a cardiac arrest. The nurse anticipates which primary complications associated with this treatment? Select all that apply. 1. Infection 2. Bleeding 3. Hypoglycemia 4. Pressure ulcers 5. Renal insufficiency 6. Metabolic and electrolyte disturbances

1234

The nurse is caring for a client in the critical care unit. The nurse is reviewing the Critical Care Family Needs Inventory. The nurse knows that the most important issues of family members of critically ill clients include which factors? Select all that apply 1. Receiving assurance 2. Receiving information 3. Having support available 4. Remaining near the client 5. Talking to the doctor every day 6. Being given snacks to eat at the bedside

1234

The nurse is caring for a female 45-year-old client. The client has 3 healthy children, all born via spontaneous vaginal birth. The client has been diagnosed with mild uterine prolapse and asks the nurse what she can do to prevent further prolapse. The nurse should include which instruction in her teaching? Select all that apply 1. Lose weight. 2. Perform Kegel exercises. 3. Eat a diet high in fiber. 4. Take a stool softener daily as needed. 5. Engage in high-impact exercise 3 to 5 times weekly

245

The nurse is caring for a mother and her infant who was born 12 hours ago. Which statements made by the mother should prompt the nurse to have the baby evaluated for early heart failure? Select all that apply. 1. "My baby's cheeks turn red when he cries." 2. "I'm chilly but my baby's forehead is sweaty." 3. "My baby doesn't seem to have any difficulty breathing." 4. "I can feel my baby's heart rate when he's sleeping, it seems much faster than it did yesterday." 5. "My baby latches on to my nipple well and has a strong suck, but seems to get weak very quickly, then stops too soon."

35

The nurse is caring for a neonate that is 3 hours old and should assess for which signs/symptoms of cold stress? Select all that apply. 1. Tachycardia 2. Hyperactivity 3. Mottling of skin 4. Increased skin temperature 5. Increased respirations with apnea

B

What additional reinforcement should the PN provide to reduce the problems of the patients heightened sense of smell? A. Encourage the patient's friends to continue cooking meals in his home to promote socialization. B. Suggest that the meals be prepared at the friend's homes and then delivered to the patient's home. C. Advise George to use aromatherapy to overcome his current aversion to odors. D. Tell the patient to sniff foods before eating them to provide sensory stimulation.

245

A client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client for which symptom that correlates with this client's fluid imbalance? 1. Daily dressing change 2. Strict hand washing 3. Betadine skin antisepsis 4. Optimal catheter site selection 5. Strict sterile technique with maximal barrier precautions during placement 6. Infection control health care provider as a member of the client's health care team

25

The licensed practical nurse is considering leaving the nursing profession after caring for multiple clients who have been diagnosed with conditions that have poor outcomes. Which measures would most likely assist the nurse in relieving this distress? Select all that apply 1. Decrease opportunities for multidisciplinary rounds. 2. Share the frustrations at unit multidisciplinary meetings. 3. Tell stories about the experiences with other professionals. 4. Participate in continuing education that is restricted to nurses. 5. Engage in ethics discussions with both nurses and other health care practitioners

12356

The nurse is caring for an infant with a diagnosis of Hirschsprung's disease (absence at birth of the autonomic ganglia in a segment of the intestinal smooth muscle wall that normally stimulates peristalsis). The nurse should check for which clinical findings that are consistent with Hirschsprung's disease? Select all that apply 1. Fever 2. Constipation 3. Failure to thrive 4. Intolerance to wheat 5. Abdominal distention 6. Explosive, watery diarrhea

145

Which urinalysis findings indicate the presence of a urinary tract infection? 1. Nitrites, present 2. Turbidity, clear 3. Ketones, moderate 4. White blood cells, 10 5. Leukoesterase, present 6. Specific gravity, 1.025