Kaplan Practice Test Questions
where the valves are in the heart
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The nurse manager evaluates the care given by staff on a medical-surgical unit. The nurse manager should intervene if which action is observed? 1.An unlicensed assistive personnel (UAP) disposes of a client's used tissue in the bedside container before opening the roommate's milk carton. 2.A student nurse washes hands for 20 seconds after removing gloves following insertion of an indwelling urinary catheter. 3.A nurse puts on a gown, gloves, mask, and goggles prior to inserting a nasogastric (NG) tube. 4.An LPN/LVN visits with a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) wound infection while the client eats lunch.
1
The nurse reviews the charts of four antepartal women. The nurse recognizes that which woman is at most risk for having a child with a cleft lip and palate? 1.An Asian woman who is having a girl. 2.An African American woman who is having a boy. 3.A Native American woman who is having a boy. 4.A Caucasian woman who is having a girl.
2 NOTES: Medical definition of antepartum: relating to the period before parturition : before childbirth. Males are more likely to have a cleft lip with or without cleft palate. Cleft palate without cleft lip is more common in females. In the United States, cleft lip and palate are reportedly most common in Native Americans and least common in African-Americans.
The nurse cares for a client diagnosed with schizophrenia. The nurse recognizes that the client has developed parkinsonian adverse effects of chlorpromazine. The nurse expects which medication will be prescribed for the client? 1.Diazepam. 2.Haloperidol. 3.Amitriptyline. 4.Benztropine.
4
The nurse assesses a child diagnosed with attention deficit hyperactivity disorder (ADHD). The nurse expects to observe which of finding? 1.Feeding difficulties. 2.Head banging. 3.Easy distractibility. 4.Rigid arms and legs.
3
****A pregnant client is given an epidural anesthetic in preparation for cesarean section. After the administration of the epidural anesthetic, the client's blood pressure falls from 120/84 to 94/50 mm Hg. The nurse recognizes that it is essential to assist the client to which position? 1.Supine.2.Sitting.3.Side-lying.4.Trendelenburg.
1
A client is admitted to the hospital for a myelogram using a water-soluble dye. Which information is most important for the nurse to obtain about the client's medication history? 1.Is the client currently taking any antihypertensives? 2.Is the client currently taking any opioid analgesics? 3.Is the client currently taking any oral antibiotics? 4.Is the client currently taking any antidepressants?
1
A woman in her second trimester of pregnancy tells the clinic nurse that her 5-year-old son has been asking questions "about sex." The client asks the nurse what she should tell her child. Which of these statements, if made by the nurse, is best? 1."Buy a book about sex designed for young children and read it with your son." 2."Have your son touch your abdomen and tell him about your pregnancy." 3."Tell your son that this subject is complicated, and you will discuss it as he gets older." 4."Answer your son's questions matter-of-factly, in words that he can understand."
1
An older adult client is admitted to the hospital. On admission, the client appears disheveled and is restless and confused. It is most important that the nurse obtain the answer to which of these questions? 1.Which medications is the client taking? 2.What is the medical history of the client's family? 3.What was the client's previous occupation? 4.Has the client smoked cigarettes in the past?
1
At the advice of the health care provider, a client diagnosed with hypertension attends smoking cessation classes. One month later when the client visits the clinic, the nurse notes a package of cigarettes in the client's pocket. Which statement, if made by the nurse, is most appropriate? 1."I see that you have cigarettes in your pocket." 2."Please give me the cigarettes." 3."I will have to report this to the health care provider." 4."You need to enroll in another smoking cessation class."
1
The home care nurse cares for a child diagnosed with hemophilia who is recovering from the acute phase of spontaneous bleeding into the joints. It is most important for the nurse to give the parents which instruction? 1.Administer ibuprofen for pain.2.Apply ice to the joints.3.Use hard-bristle toothbrush.4.Encourage active range-of-motion exercises.
1
After assessing a 3-year-old, the nurse instructs the child's parent about safety precautions. The nurse determines teaching is effective if the parent makes which statement? (Select all that apply.) 1."My child wears a helmet while riding in the bike seat on the back of my bike." 2."Our cleaning products at home are in a closed cabinet below the kitchen sink." 3."Our medications are kept in childproof containers in a locked cabinet." 4."My child sits in a forward-facing seat with a harness while riding in the car." 5."Since we call vitamins 'candy,' our child eagerly takes them each day." 6."The telephone number of local poison control is posted on our refrigerator."
1, 3, 4, 6
The nurse performs discharge teaching for a client receiving trifluoperazine hydrochloride. The nurse determines that teaching is successful if the client makes which statement? 1."I should take an extra pill at night if I have difficulty sleeping."2."I cannot breastfeed my baby while I am taking this medication."3."I may experience frequent tearing in my eyes."4."I will have to increase my calorie intake daily."
3
The nurse screens clients for risk of developing deep vein thrombosis (DVT). Which of these clients has the lowest risk profile for DVT? 1.A 67-year-old carpenter undergoing a left total knee replacement. 2.A 22-year-old woman who weighs 230 lb (104.3 kg) and is 2 months pregnant with her second child. 3.A 44-year-old woman with ovarian cancer experiencing vomiting from chemotherapy. 4.A 50-year-old executive following removal of cataracts.
3
The nurse teaches a client receiving levothyroxine. The nurse identifies that further teaching is necessary if the client makes which statement? 1."If I have chest pain, I will call my health care provider."2."If my hands shake, I will call my health care provider."3."I will take the medication at night before I go to sleep."4."I will inform all my health care providers about medications that I take."
3
The nurse prepares to teach a client who is scheduled for an amniocentesis. It is most important for the nurse to include which statement? 1."The test assesses gestational age of the fetus using the biparietal circumference." 2."The test determines the gender of the baby." 3."The test is used to detect possible birth defects." 4."The test should not be completed if you have a history of previous miscarriages."
3 NOTES: A procedure performed during pregnancy to obtain amniotic fluid to test for chromosomal abnormalities and fetal infections. Amniocentesis is a procedure in which amniotic fluid is removed from the uterus for testing or treatment. Amniotic fluid is the fluid that surrounds and protects a baby during pregnancy. This fluid contains fetal cells and various proteins.
The nurse does preoperative teaching with the client scheduled to have a transurethral prostatectomy (TURP) under spinal anesthesia. Which statement about the result of the spinal anesthesia does the nurse include in the teaching? 1."You will be unable to move your arms or legs immediately after surgery." 2."You will require analgesics to relieve pain in your back." 3."You will be unable to move your legs immediately after surgery." 4."You will require a special machine to help you breathe immediately after surgery."
3 NOTES: A transurethral prostatectomy is surgery that is done to remove part or all of your prostate gland. This surgery is also called transurethral resection of the prostate (TURP). TURP surgery treats benign prostatic hypertrophy (BPH). BPH is a condition where the prostate gland grows too large. TURP = surgical treatment for difficult urination caused by enlarged prostrate without making incision.
The parents of the 6-month-old bring the infant to the pediatrician's office for a routine immunization. The nurse is to administer the immunization by intramuscular (IM) injection. Which of these is the preferred site for an IM injection in an infant? 1.Deltoid. 2.Vastus lateralis. 3.Dorsogluteal. 4.Gluteus maximus.
2
The home care nurse visits the client who has been receiving lithium carbonate for 3 weeks. The client reports blurred vision and intense dizziness. Which action does the nurse take first? 1.Encourage the client to increase fluid intake. 2.Notify the client's primary health care provider. 3.Instruct the client to breathe into a paper bag. 4.Teach the client about relaxation techniques.
2
The nurse cares for the client who returns to the nursing unit in stable condition after having a myelogram using a water-soluble dye. The client is receiving IV fluids. The nurse recognizes that which of these is the primary purpose of the IV fluids? 1.To replace blood lost during the procedure. 2.To enhance excretion of the dye. 3.To restore cerebrospinal fluid levels. 4.To increase blood flow to the brain.
1
The nurse conducts a physical assessment of a newly admitted client. When auscultating breath sounds over the trachea, the nurse normally expects to hear sounds that can be best characterized as which of these? 1.Soft and low pitched.2.Coarse and rumbling.3.Fine and crackling.4.Loud and high pitched.
1
The nurse evaluates the progress of a client diagnosed with depression. The nurse considers which statement by the client as an indication of improvement? 1."I slept well last night."2."I can't seem to stop eating."3."I feel tired."4."I am feeling sad."
1
The nurse in the same-day surgery department cares for a client after a sigmoidoscopy. Which symptom, if exhibited by the client an hour after the procedure, would most concern the nurse? 1.Fullness and pressure in abdomen.2.Grogginess and thirst.3.Lightheadedness and dizziness.4.Mild abdominal pain and cramping.
1
The nurse plans care for the client diagnosed with Graves' disease. The nurse includes which of these in the client's plan of care? 1.Frequent rest periods. 2.Two meals per day. 3.Extra clothing for warmth. 4.Caffeinated beverages.
1
The nurse teaches a group of parents of toddlers how to prevent accidental poisoning. Which of these suggestions does the nurse give regarding medications? 1.Lock all medications in a cabinet. 2.Childproof all the caps to medication bottles. 3.Store medications on the highest shelf in a cupboard. 4.Place medications in different containers.
1
The nurse teaches the client how to increase dietary potassium. The client knows bananas are high in potassium but does not like their taste. Which foods should the nurse recommend the client include in the diet? 1.Potatoes, spinach, and raisins.2.Rhubarb, tofu, and celery.3.Carrots, broccoli, and yogurt.4.Onions, corn, and oatmeal.
1
The school nurse observes a group of school-aged children playing. A child begins to cry and reports being stung by a bee. Which action does the nurse take first? 1.Administer IM epinephrine. 2.Remove the stinger. 3.Apply a warm compress. 4.Wash with soap and water.
2
The nurse teaches the parent of a child about readiness for toilet training. The nurse recognizes that further teaching is necessary if the parent makes which statement? 1."I can consider toilet training when my child's diaper is dry after naps." 2."I can begin toilet training when my child begins to walk." 3."I can consider toilet training when my child can pull his pants up and down." 4."I need to make sure that I have the time to spend in toilet training my child."
1
The nurse assesses a full-term newborn infant. Which finding requires an immediate intervention? 1.The infant's respirations are 36, shallow, and irregular in rate, rhythm, and depth.2.Rapid pulsations are visible in the fifth intercostal space, left midclavicular line.3.The infant's axillary temperature is 96.2 °F (35.6 °C).4.There is asynchronous, spontaneous movement of the infant's extremities.
2
The home care nurse is visiting the 82-year-old client living with the client's adult child. The client appears malnourished and has multiple bruises on the body. Which action by the nurse is most appropriate? 1.Request that the LPN/LVN document the suspected abuse. 2.Discuss the nurse's observation with the client's children. 3.Report the situation to the nursing supervisor. 4.Request that another nurse visit the client.
2
The client is admitted to the hospital for evaluation of a gangrenous right foot and venous stasis ulcers of the right leg. A right below-the-knee amputation is scheduled. The client asks, "Why can't they just amputate my foot instead of my leg?" Which response by the nurse is best? 1."It is necessary to have good circulation in your leg for healing to occur." 2."It will be easier to fit you with a prosthesis." 3."This is the best method to control the infection." 4."This will prevent further circulatory problems in your leg."
1
The nurse approaches the paranoid schizophrenic client on the psychiatric unit to perform a prescribed venipuncture to obtain a blood specimen. The client becomes agitated and says to the nurse, "You pretend to take blood, but I know you really want to inject me with a poison that will kill me." Which response by the nurse is best? 1."No, I do not want to kill you. Why do you think that drawing blood is going to kill you?" 2."Calm down. I drew your blood last week and nothing bad happened to you, did it?" 3."You sound frightened. The health care provider wants to ensure that your medications are working properly." 4."Look, the tube is empty. I can't inject you with anything if the tube is empty."
1
The nurse at the community mental health center cares for a client diagnosed with depression. The health care provider prescribes amitriptyline. One week after starting amitriptyline, the client reports to the nurse that there has been no improvement. Which statement, if made by the nurse, is most accurate? 1."It takes at least four weeks for the medication to work." 2."You may need to take more medication." 3."Your depression is probably worsening." 4."This medication probably is not the right one for you."
1
The nurse cares for a client at 37 weeks gestation. The nurse is most concerned by which finding? 1.The client reports right quadrant pain. 2.The client's BP is 150/95 mm Hg. 3.The client has 1+ proteinuria. 4.The client has 3+ pitting edema of the ankles.
1
The nurse cares for a client diagnosed with vaginal cancer who is being treated with an internal radium implant. The nurse determines that which action is appropriate? 1.The LPN/LVN wears a dosimeter film badge when in the client's room.2.The client is assigned to a roommate with radiation safety precautions posted on the door.3.The client's 10-year-old grandchild visits for 20 minutes.4.The unlicensed assistive personnel (UAP) stands next to the bed when talking with the client.
1
The nurse cares for clients in the psychiatric unit. When administering antipsychotic medication, the nurse observes for tardive dyskinesia. Which of these is characteristic of tardive dyskinesia? 1.Masklike face and shuffling gait. 2.Involuntary grimacing and protrusion of the tongue. 3.Motor restlessness and pacing. 4.Severe muscle contractions of the face.
1
The nurse cares for the client after an above-the-knee amputation. The client has a closed rigid cast dressing in place. Several days after surgery, the nurse enters the client's room and finds that the cast has come off. Which action does the nurse take first? 1.Wrap residual limb with a compression bandage.2.Monitor the residual limb for swelling.3.Contact the orthopedic surgeon.4.Ask the client how the cast came off.
1
The client receives morphine sulfate postoperatively for pain. Since the client is receiving morphine sulfate, which of these medications is most important for the nurse to have available? 1.Naloxone. 2.Disulfiram. 3.Methadone. 4.Epinephrine.
1 NOTES: One of the main morphine overdose antidotes is a drug called naloxone, sold under the brand name Narcan. Naloxone is an opioid antagonist, which means that it can reverse or block the effects of morphine and other opioids. Morphine overdose prognosis is greatly improved the quicker that naloxone is administered.
The nurse administers morphine sulfate as prescribed to the client reporting severe pain. Which of these indicates morphine toxicity? 1.The client has blurred vision. 2.The client's pupils are pinpoint. 3.The client's pupils are unequal. 4.The client's pupils are dilated.
1 NOTES: Morphine is a phenanthrene derivative which acts mainly on the CNS and smooth muscles. It binds to opiate receptors in the CNS altering pain perception and response. Common brand names: Avinza & DepoDur. Morphine is used to help relieve severe pain. Morphine is in a class of medications known as opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain. It is prescribed to relieve moderate to severe pain, especially for around-the-clock relief of pain that cannot be controlled by other pain medications. Knowing how long morphine remains in the system can help prevent an accidental overdose or dangerous interactions with other medications or alcohol. Even though morphine is an FDA-approved medication for pain treatment, its use is associated with serious and sometimes life-threatening side effects—even when taken as prescribed. Side effects most commonly occur within the first 1 to 3 days of taking morphine or whenever a dose is increased 1. Serious side effects to be aware of include 1: A bluish or purplish hue to the skin. Agitation or irritability. Changes in heartbeat (either rapid, irregular, or slowed). Confusion. Difficulty urinating or pain during urination. Drowsiness. Dry mouth. Extreme sleepiness. Fainting. Fever. Hallucinations (either visual or auditory). Irregular menstruation. Loss of appetite. Loss of coordination. Muscle stiffness. Nausea or vomiting. Nervousness. Seizures. Significant changes in mood or behavior. Small pupils********* Stomach pain or severe cramps. Sweating. Twitching. Unresponsiveness. Ignoring significantly severe symptoms like those listed above could have life-threatening consequences if you continue to abuse morphine. If an overdose occurs, you will likely see the previously listed symtpoms, as well as A cold or clammy feel to the skin. Bluish hue in the fingertips and lips. Constricted (small) pupils. Blurry vision. Nausea. Vomiting. Severe constipation. Severely slowed or irregular breathing. Slow heartbeat. Limp muscles. Severe sleepiness. Loss of consciousness. Coma.
The nurse plans to administer furosemide 20 mg IV to a client diagnosed with chronic kidney disease (CKD). Which of these is the primary purpose of furosemide? 1.To increase the blood flow to the renal cortex.2.To decrease serum potassium levels.3.To increase excretion of sodium and water.4.To decrease the workload on the heart.
2
The nurse prioritizes the needs of the client who has been raped. Which of these is most important initially? 1.Emotional needs.2.Physical needs.3.Hygiene needs.4.Legal needs.
2
A client is admitted to the unit for treatment of acute glomerulonephritis. The nurse teaches the client about the disease and the treatment required. The nurse determines that teaching is successful if the client makes which statement? 1."Who would have thought that a sore throat 2 weeks ago would cause this!" 2."I may have acquired the glomerulonephritis from unprotected sex decades ago." 3."I'm glad that I don't have to restrict my activities." 4."My roommate is going to bring me a double cheeseburger with bacon."
2
A client is placed in balanced suspension traction with a Thomas splint and Pearson attachment. The client's nurse is teaching a student nurse about traction. The student nurse asks, "Where is the pulling force of the traction applied?" Which response by the nurse is most accurate? 1."It is applied to the quadriceps muscle." 2."It is applied to the bone distal to the fracture site." 3."It is applied to the bone proximal to the fracture." 4."It is applied to the knee."
2
A woman is brought to the emergency department reporting severe left lower quadrant pain. She tells the nurse that she performed a home pregnancy test and believes she is 8 weeks pregnant. On admission, the client's vital signs are heart rate 90/minute, BP 110/70 mm Hg, respirations 20/minute, temperature 98 °F (36.7 °C). Thirty minutes later, her vital signs are heart rate 120/minute, BP 86/50 mm Hg, respirations 26/minute, temperature 98.2 °F (36.8 °C). The nurse recognizes that the change in the client's vital signs indicates which of these findings? 1.The client's pain may have increased. 2.The client may be bleeding internally. 3.The client may be frightened. 4.The client may have an infection.
2
In the dining room of the mental health center, the nurse observes a formerly homeless and malnourished client with chronic schizophrenia putting food into a plastic bag. Which action by the nurse is most appropriate? 1.Reprimand the client for behaving inappropriately.2.Ask the client why the food is being put into a bag.3.Inform the client that snacks will be available later.4.Distract the client and redirect to another activity.
2
The child is brought to the emergency department by the parents, who state the child fell off a bicycle. Upon examination, the nurse notes several bruises, lacerations, and burns in various stages of healing on the child's body, and the child is hypervigilant to touch. The nurse suspects child abuse. Which of these statements most accurately reflects the nurse's responsibility in cases of suspected child abuse? 1.The nurse should not report child abuse suspicion without actual proof. 2.The nurse should report a case of suspected child abuse to proper authorities. 3.The nurse should not report suspected child abuse without discussing it with the child's parents first. 4.The nurse should confirm the child abuse with at least two other staff members before reporting it.
2
The client scheduled for a cardiac catheterization says to the nurse, "I know you were in here when the doctor had me sign the consent form for the test. I thought I understood everything, but now I'm not so sure." Which response by the nurse is best? 1."Why didn't you listen more closely when the doctor was here?" 2."You sound as if you would like to ask more questions." 3."I'll get you a pamphlet about cardiac catheterization." 4."That often happens when this procedure is explained to clients."
2
The client with a history of heart failure (HF) is admitted with flu-like symptoms. The nurse learns that the client has been taking digoxin 0.125 mg PO daily for 3 years. Last month, the health care provider (HCP) changed the prescription for digoxin to 0.25 mg PO daily and prescribed furosemide 40 mg daily. The nurse expects the HCP to prescribe which laboratory tests? 1.Serum electrolytes and digoxin level.2.Complete blood count and differential.3.Cardiac enzymes and an arterial blood gas.4.Blood cultures and urinalysis.
2
The nurse cares for a 19-year-old client admitted to the emergency department after an automobile accident. Even though the client denies drinking alcohol, the nurse notes that the client's breath smells of alcohol, speech is slurred, reflexes are diminished, and the client has difficulty recalling the events of the evening. The health care provider prescribes a magnetic resonance imaging (MRI) scan. Which of these actions should the nurse take first? 1.Explain the MRI procedure and let the client sign the consent. 2.Instruct the client to remove his wrist watch. 3.Contact the client's next of kin to give consent for the MRI. 4.Restrict food and fluid intake for 4 hours.
2
The nurse cares for a client receiving heparin 5000 units subcutaneously every 12 hours. The nurse should assess the client for which of these? 1.Pallor.2.Ecchymosis.3.Varicose veins.4.Edema.
2
The nurse cares for a client who is prescribed nifedipine. The client asks how the medication works. Which is the best response by the nurse? 1."It constricts the coronary arteries."2."It increases myocardial contractility."3."It decreases myocardial oxygen demand."4."It promotes coronary artery spasms."
2
The nurse cares for clients in the outpatient clinic. Which is the most important, immediate nursing goal for a client just diagnosed with normal tension glaucoma? 1.Prepare for required surgery. 2.Prevent further deterioration of the vision. 3.Assist the client to deal with the inevitable blindness. 4.Improve vision by decreasing intraocular pressure.
2
The nurse cares for clients on the surgical unit. When planning care, the nurse anticipates that which client will have the most difficulty adjusting psychologically? 1.The 13-year-old girl who has a wart removed from her nose. 2.The 26-year-old man who has palliative surgery for stage IV cancer of the pancreas. 3.The 42-year-old woman who has an elective abdominal hysterectomy. 4.The 60-year-old man who has a colostomy for severe diverticular disease.
2
The nurse cares for the client diagnosed with genital herpes. After the client is informed of the diagnosis, the client begins crying. Which response by the nurse is best? 1."We have support groups that may help you talk about some of your feelings." 2."I see that you are upset. Share with me your thoughts." 3."While herpes is a difficult disease, at least you don't have AIDS." 4."I think the health care provider should give you more information about genital herpes."
2
The nurse cares for the client receiving phenytoin intravenously. The nurse recognizes that the medication is administered in which of these IV fluids? 1.5% dextrose in water (D5W).2.Lactated Ringer's (LR) solution.3.10% dextrose in water (D10W).4.Normal saline (0.9%).
2
The nurse cares for the woman who has just delivered her first child, a boy weighing 6 lb 2 oz. The Apgar scores at 1 and 5 minutes are 8 and 9. The nurse recognizes that these scores indicate which of these findings? 1.An isolette should be ready in the nursery for close observation of this infant. 2.The newborn is making an optimal transition to extrauterine life. 3.The parents will need emotional support to deal with a less than perfect infant. 4.Apgar scores correlate well with future emotional and intellectual development.
2
The nurse conducts the admission interview of a client scheduled for surgical repair of an inguinal hernia. Which client statement most concerns the nurse? 1."I am allergic to bananas." 2."I am allergic to shellfish." 3."I am allergic to peanuts." 4."I am allergic to milk."
2
The nurse conducts the family therapy session with a client being treated for depression. During the therapy session, the client verbally expresses love toward the mother, but has an angry facial expression and pounds the table with a fist. The nurse understands that the discrepancy between the client's body language and spoken language is best characterized as which of these? 1.Ambivalence. 2.Scapegoating. 3.Double-bind communication. 4.Loose associations.
2
The nurse counsels the client in the outpatient psychiatric clinic for treatment of aquaphobia. The nurse recognizes that a phobia can best be described as which of these? 1.A form of sublimation that is adaptive to the client.2.A persistent fear that is excessive and unrealistic.3.A persistent uncontrolled thought precipitated by anxiety.4.A manipulative behavior used to achieve secondary gain.
2
The nurse instructs the client on how to perform breast self-examination. The nurse should include which instructions about examining the breasts in front of a mirror? 1."Stand with arms at your sides. Bend from the waist to the left side. Bend from the waist to the right side." 2."Stand with both arms above your head. Lower the right arm and keep the left arm raised. Lower the left arm and raise the right arm." 3."Stand with your hands on your hips. Clasp you hands behind your back." 4."Stand with arms at your sides. Place hands on your hips and bow slightly toward the mirror. Clasp hands behind your head and press hands forward. "
2
The nurse manager notes that one of the staff members is frequently absent, and this has adversely affected the quality of care given to clients on the unit. When initially counseling the staff member, which of these approaches by the nurse manager is best? 1.Inform the staff member that the next missed day will be grounds for termination. 2.Talk with the staff member and remind the staff member of the standards of the facility. 3.Give the staff member a written reminder of the standards of the facility. 4.Document the staff member's absenteeism and inform Human Resources.
2
The nurse observes the newly licensed LPN/LVN prepare to administer iron dextran intramuscularly (IM) to a client with iron deficiency anemia. It is most important for the nurse to give which instruction to the LPN/LVN? 1."Massage the injection site for 1 minute after the injection of the medicine." 2."Tap out the air bubble prior to administering the medication." 3."Release the skin prior to withdrawing the needle." 4."Change the needle after drawing up the medication."
2
The nurse observes the student nurse caring for a client with a tracheostomy tube. The nurse intervenes if which action is observed? 1.The student nurse uses clean gloves to remove the tracheostomy dressing. 2.The student nurse cleans the inner cannula by soaking it in hydrogen peroxide. 3.The student nurse removes the soiled tracheostomy ties and then reattaches clean ties. 4.The student nurse replaces the tracheostomy dressing with a pre-cut, folded 4 x 4 gauze.
2
The nurse cares for the client diagnosed with asthma. The health care provider prescribes neostigmine IM. Which of these actions by the nurse is most appropriate? 1.Administer the medication. 2.Check the blood pressure and heart rate. 3.Ask the pharmacist if neostigmine can be given orally. 4.Contact the health care provider.
2 NOTES: Neostigmine injection is also used to prevent or treat certain kidney or intestinal problems. This medicine is also given after surgery to help reverse the effects of certain types of medicines that have been used to relax the muscles. This medicine is available only with your doctor's prescription. Neostigmine injection is also used to prevent or treat certain kidney or intestinal problems. This medicine is also given after surgery to help reverse the effects of certain types of medicines that have been used to relax the muscles. This medicine is available only with your doctor's prescription.
The nurse reviews client assignments made by the student nurse. The nurse determines that assignments are appropriate if an unlicensed assistive personnel (UAP) is assigned to which client? 1.The client who is scheduled for an MRI. 2.The unconscious client who requires mouth care. 3.The client admitted for uncontrolled seizures. 4.The client with diabetes mellitus who requires foot care.
2 NOTES: Although their scope of practice can vary between states, you should assume that, in the NCLEX hospital, they are able to obtain vitals and blood glucose levels and ambulate, bathe, feed and assist with the toileting of stable patients. Of course, this is not an exhaustive list. The term stable is quite important here. Unstable patients, like those who are freshly post-op and those in the intensive care units, should be cared for more closely by the RN. Assessments are outside of the UAP's scope of practice and should never be delegated to them. UAPs can count the heart rate and respiratory rate, but they cannot decide if it is appropriate for the patient. That is your job. Licensed practical nurses and licensed vocational nurses are able to administer medications, reinforce the teachings of the RN, provide wound care, carry out the interventions in the nursing care plan, and evaluate patients. Additionally, they can perform all the UAP's tasks. The RN must perform the initial assessment, but the LPN/LVN can perform follow-up assessments and alert the RN to changes in the patient.
The nurse cares for a toddler who is admitted to the hospital with a diagnosis of congenital hip dislocation. The toddler is placed in Bryant's traction. The nurse recognizes that the toddler should be maintained in which position? 1.Buttocks slightly elevated off the bed.2.Buttocks flat on the bed.3.Knee flexion 140 degrees.4.Hips fully extended.
3
One afternoon in the hospital day room, the nurse overhears the newly admitted client with chronic schizophrenia say to another client, "I hate you. Get away from me or I'll kill you." Which interpretation of the client's behavior is most accurate? 1.The client dislikes the other person.2.The client is very angry.3.The client feels threatened.4.The client feels powerful.
3
The emergency department (ED) nurse is assigned to care for four clients. Which client does the nurse see first? 1.The client who reports being raped 30 minutes ago and is exhibiting self-blame and anxiety.2.The client who reports a miscarriage last evening and has spotting of blood on her underwear.3.The client who told the family of intent to commit suicide and has easy access to a gun.4.The client who witnessed a child stabbed to death and is experiencing anxiety and difficulty coping.
3
The health care provider prescribes morphine sulfate to be administered using a patient-controlled analgesia (PCA) pump. Which explanation by the nurse best describes this method of pain medication administration? 1."You will contact your nurse when you feel pain, and the nurse will bring pain medication to add to your intravenous pump." 2."You will receive a large dose of pain medication continually from an intravenous pump." 3."You will be able to self-administer a preset dose of pain medication as needed by pressing a button connected to the intravenous pump." 4."You will be able to self-administer an unlimited amount of pain medication as needed by pressing a button connected to the intravenous pump."
3
The nurse cares for a 6-year-old child placed in Russell's traction due to a femur fracture. After repositioning the child, it is most important for the nurse to take which action? 1.Administer pain medication.2.Offer the child a book.3.Check the position of the left hip.4.Assess the pin site for infection.
3
The nurse cares for a client who experiences severe panic attacks when planning to go grocery shopping. The nurse expects which medication will be prescribed for the client? 1.Chlorpromazine. 2.Carbamazepine. 3.Flurazepam. 4.Imipramine.
3
The nurse cares for a client who will be taking phenelzine sulfate following discharge. Which of these is important information for the nurse to include in the teaching plan regarding this medication? 1.The effects of the medication will be seen immediately.2.I will follow a low fiber diet while taking the medication.3.Drinking coffee or carbonated beverages will decrease the effectiveness of the medication.4.Combining the medication with certain foods significantly increases blood pressure.
3
The nurse cares for a client with depression who frequently verbalizes a negative self-image. Which nursing intervention is most appropriate for the client? 1.Help the client identify areas of weakness. 2.Help the client identify unrealistic expectations. 3.Ask the client to identify goals for the next 2 years. 4.Tell the client to stop having negative thoughts.
3
The nurse cares for clients in the outpatient clinic. The client diagnosed with glaucoma experiences severe restrictions of peripheral vision and asks the nurse if the vision will improve. Which statement by the nurse is best? 1."If you continue to take your medication, the pressure in your eyes will decrease. Your vision will improve." 2."The health care provider will perform surgery to remove the lens in your eyes. This will increase your vision." 3."The current damage to your vision is permanent. Continued use of the eye drops will prevent further damage." 4."After the eye pressure is stabilized, the health care provider will reevaluate your vision. Your vision can possibly be corrected with glasses."
3
The nurse cares for the 4-year-old client with a fractured pelvis due to an automobile accident. The nurse prepares the child for the application of a hip spica cast. Which is most important for the nurse to include in the child's plan of care? 1.Obtain a doll with a hip spica cast in place.2.Tell the child that the cast will feel cold.3.Reassure the child that the cast application is painless.4.Introduce the child to another child who has a hip spica cast.
3
The nurse cares for the postoperative client who had an abdominal resection and insertion of a Jackson-Pratt drain. The nurse recognizes that which of the following is the primary purpose of the drain? 1.To irrigate the incision with a saline solution. 2.To prevent bacterial infection of the incision. 3.To prevent accumulation of drainage in the wound. 4.To measure the amount of fluid lost after surgery.
3
The nurse educator presents an in-service for staff on family dynamics. The nurse educator identifies which behavior as being associated with a functional family process related to communication? 1.Acknowledgment of personal needs and role responsibilities.2.Congruence between verbal and nonverbal messages.3.Ability to meet emotional needs of family members.4.Appropriate responsibility for other family members' needs.
3
A client is admitted to the hospital after sustaining a severe head injury in an automobile accident. After the client dies, the nurse observes the client's spouse comforting other family members. Which interpretation of the spouse's behavior is most accurate? 1.The spouse has already moved through the stages of the grieving process. 2.The spouse is repressing anger related to the client's death. 3.The spouse is experiencing shock and disbelief related to the client's death. 4.The spouse is demonstrating resolution of the client's death.
4
A client is recovering from a right below-the-knee amputation. The client asks the nurse why a "figure eight" bandage is applied to the residual limb. Which explanation by the nurse accurately explains the primary reason for applying the bandage? 1."It decreases the possibility of infection." 2."It helps to minimize postoperative pain." 3."It reduces the possibility of clot formation." 4."It reduces postoperative swelling."
4
A client is scheduled for a myelogram. The client asks the nurse if there will be any discomfort during the test. Which response by the nurse is most accurate? 1."No, this procedure will not hurt at all."2."Yes, this is one of the most painful procedures."3."This is an uncomfortable procedure, but you will receive general anesthesia so you will not be aware of the pain."4."This is an uncomfortable procedure, but you will be given medication before the test to lessen the discomfort."
4
A client tested positive for human immunodeficiency virus (HIV). The client asks the nurse what this means. Which of these statements accurately describes an HIV-positive test result? 1.The client has acquired immunodeficiency syndrome (AIDS). 2.The client will develop AIDS within the year. 3.The client has been exposed to the HIV virus. 4.The client has been infected with the HIV virus.
4
A client with a fractured right femur has traction applied through the use of a Steinmann. Balanced suspension traction is used with a Thomas splint and a Pearson attachment. The nurse explains to the client that the purpose of the pin is which of these? 1.To maintain alignment of the fracture. 2.To hold the Thomas splint in place. 3.To hold the Pearson attachment in place. 4.To immobilize the fractured femur.
4
A client with peripheral vascular disease is returned to the room after a right below-the-knee amputation (BKA). During the first 24 hours postoperatively, how should the nurse position the client's residual limb? 1.Elevate the stump by raising the foot of the bed on blocks. 2.Dangle the stump over the side of the bed. 3.Abduct the stump by placing pillows between the legs. 4.Place the stump in correct anatomical alignment.
4
A neighbor calls the nurse stating that a piece of glass is embedded in their child's eye. Which of these instructions by the nurse is most important? 1.Irrigate the injured eye with warm normal saline and apply a dressing. 2.Place a pressure dressing on the injured eye and take the child to the emergency department. 3.Remove the piece of glass from the child's eye using a gloved hand. 4.Put an eye patch over both eyes and immediately take the child to the emergency department.
4
The client is brought to the community mental health center by the spouse. One year ago, the client's youngest child was killed in a car accident. The graduation of the child's high school class triggered feelings of sadness and guilt. As a result, the client has been having severe headaches, insomnia, and poor appetite. In planning care for this client, the nurse recognizes that the symptoms are most likely an example of which of these? 1.Turning aggression inward.2.Receiving inadequate support.3.Displacement of anger.4.Delayed grief reaction.
4
The client is postoperative orthopedic surgery. The health care provider prescribes morphine sulfate to be administered using a patient-controlled analgesia (PCA) pump. The nurse checks the PCA pump to determine how many times the client has triggered the system. Which explanation best explains why the client triggered the PCA button 11 times but received only 6 injections? 1.The client is developing an addiction to morphine sulfate. 2.The client does not understand how to use the PCA. 3.The client is developing a tolerance to morphine sulfate. 4.The client's pain is not fully controlled by the PCA.
4
The client receiving paroxetine for obsessive-compulsive disorder reports feeling dizzy when standing up from a sitting or lying position. Which statement accurately explains the client's dizziness? 1.Paroxetine can cause hypoglycemia.2.Paroxetine directly affects the cerebellum.3.Paroxetine directly affects the auditory nerve.4.Paroxetine can cause orthostatic hypotension.
4
The client with a history of alcoholism is brought to the emergency department in an agitated state. The client is vomiting and diaphoretic. The client had the last drink 5 hours ago. The nurse expects to administer which medication? 1.Disulfiram.2.Methadone hydrochloride.3.Naloxone hydrochloride.4.Chlordiazepoxide hydrochloride.
4
The nurse cares for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which findings does the nurse recognize as consistent with this diagnosis? 1.Increased urine output; decreased serum sodium.2.Decreased urine output; increased serum sodium.3.Increased urine output; increased serum sodium.4.Decreased urine output; decreased serum sodium.
4
The nurse cares for the client 1 hour after a percutaneous liver biopsy. The nurse is most concerned if which of these is observed? 1.The client coughs frequently after deep breathing.2.The client lies on the right side with a pillow under the costal margin.3.The LPN/LVN obtains the client's vital signs every 15 minutes.4.The client reports mild pain radiating to the right shoulder.
4
The nurse cares for the client receiving morphine sulfate via patient-controlled analgesia (PCA) pump. When making rounds, the nurse observes the client is sleeping and the spouse is at the bedside. The nurse observes that each time the client grimaces, the spouse presses the button on the PCA machine. Which action is most appropriate for the nurse to take? 1.Encourage the spouse to continue this practice as long as the client agrees. 2.Explain to the spouse that this should be done only once every hour while the client is sleeping. 3.Explain the purpose of the patient-controlled analgesia to the spouse. 4.Instruct the spouse to awaken the client when client grimaces and ask if the client is in pain.
4
The nurse changes the dressing of a client who had a mastectomy two days ago. After the nurse removes the old dressing, the client turns her head away. Which of these nursing diagnoses is most appropriate? 1.Powerlessness. 2.Knowledge deficit. 3.Sexual dysfunction. 4.Body image disturbance.
4
The nurse has just administered a subcutaneous injection to a client. Which immediate follow-up action does the nurse take? 1.Remove and discard gloves in the designated receptacle.2.Perform hand hygiene, then discard the used syringe in the designated receptacle.3.Discard the uncapped needle with the syringe in the designated receptacle.4.Cap the needle, then discard the syringe in the designated receptacle.
4
The nurse manager observes the staff nurse assist the health care provider with a lumbar puncture (LP). The nurse manager determines that care is appropriate if the staff nurse does which of these? 1.Instructs the client to hyperventilate. 2.Instructs the client to maintain a full bladder. 3.Explains to the client that the LP is always painless. 4.Assists the client into a fetal position.
4
The nurse observes the behavior of a client seen in the emergency department. Which signs indicate that the client is experiencing a panic level of anxiety? 1.Unproductive relief behaviors, distorted perception, behavioral disorganization. 2.Behavioral disorganization, inability to negotiate simple life demands, increased ability to concentrate. 3.Improved self-control, impaired cognitive function, distorted perception. 4.Increased pulse, increased muscle tension, rate of speech and volume adequate for communication.
4
The parent of an adolescent being admitted to the psychiatric unit reports that the adolescent has become increasingly withdrawn at home. During the admission interview with the nurse, the client says, "When I look in the mirror, I cannot see myself." The nurse recognizes that the client is experiencing which of these? 1.Displacement. 2.Dissociation. 3.Denial. 4.Depersonalization.
4
A client is admitted to the hospital with a ruptured ectopic pregnancy. A laparotomy is scheduled. The nurse recognizes it is most important to include which goal on the client's preoperative care plan? 1.Fluid replacement. 2.Pain relief. 3.Emotional support. 4.Respiratory therapy.
4 NOTES: A laparotomy is a surgical procedure involving small incisions through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy.
The nurse in the well child clinic receives a call from a parent stating the parent's child attended a birthday party the day before with a child who had a facial rash and erythema infectiosum (fifth disease). The parent is concerned that the child may develop the disease. Which of these responses by the nurse is best? 1."Your child will not develop the disease." 2."Look for a rash in 4 to 14 days." 3."Bring your child into the clinic this afternoon." 4."Does your child have a facial rash now?"
4 NOTES: Fifth disease is a viral disease that often results in a red rash on the arms, legs, and cheeks. For this reason, it's also known as "slapped cheek disease." Fifth disease is contagious in the earliest phase of the infection, before telltale symptoms like a rash appear. It's transmitted through respiratory secretions, such as saliva or sputum. These fluids are commonly produced with a runny nose and sneezing, which are early symptoms of fifth disease.
The client diagnosed with multiple myeloma is admitted to the unit after developing pneumonia from Haemophilus influenzae. When the nurse enters the client's room wearing a mask, the client says in an irritated tone of voice, "Why are you wearing that mask?" Which of these responses by the nurse is best? 1."The chest x-ray taken this morning indicates you have pneumonia." 2."What have you been told about the x-rays that were taken this morning?" 3."You have been placed on contact precautions due to your infection." 4."I am trying to protect you from the germs in the hospital."
4 NOTES: multiple myeloma = Cancer of mature plasma cells in the bone marrow.
Two days after a hemicolectomy, the client awakens frightened and agitated. The client climbs out of bed, removes the indwelling urinary catheter, and runs down the hall screaming. Which of these actions is most appropriate for the nurse to take initially? 1.Call the health care provider and request a sedative for the client. 2.Return the client to bed and apply physical restraints immediately. 3.Replace the client's indwelling urinary catheter. 4.Return the client to bed and assess the client's condition.
4 NOTES: A hemicolectomy is a type of surgery done to remove part of your large intestine called your colon. Your colon can be partially removed without affecting the way it works in your digestive system. Once the affected part is removed, the remaining ends are joined together with almost no impact on your digestion. This procedure is done if your colon has been affected by a condition or has become cancerous.
