mid term nclex questions end of lecture slides

A nurse is caring for a client recently diagnosed with breast cancer. Which statement would indicate that the client is coping well with the diagnosis? "Why is this happening to me?" "I wish I had a mammogram last year." "Chemotherapy is so expensive!" "I will need to start neo-adjuvant therapy next week."

"I will need to start neo-adjuvant therapy next week."

A 17-year-old girl with depression has been admitted to the psychiatric unit for an attempted suicide. The client states: "I hate my boyfriend so much. I can't believe he cheated on me." What is the most appropriate response from the nurse? "It sounds like your boyfriend has done some terrible things." "Don't worry, everything will be fine." "A boyfriend is nothing to hurt yourself over." "Tell me more about what happened."

"Tell me more about what happened."

The nurse is preparing to administer 0800 insulin to a client with type-2 diabetes. During what timeframe is the client most at risk for hypoglycemia? Medication administration record: Insulin aspart (Novolog) 5 units SC at 0800, 1200, 1700, 2100 Insulin glargine 10 units SC at 0800 1100 - 1200 1600 - 1700 1300 - 1400 0830 - 1100

0830 - 1100

A client admitted with an exacerbation of chronic obstructive pulmonary disease (COPD) is having a panic attack. What intervention is appropriate at this time? Administer prescribed PRN lorazepam. Coach the client to breathe using abdominal muscles. Increase the oxygen to 3L/minute. Assist the client into a tri-pod position.

Assist the client into a tri-pod position.

A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? Acute pain related to surgery Deficient fluid volume related to blood and fluid loss from surgery Impaired physical mobility related to surgery Ineffective airway clearance related to anesthesia

Ineffective airway clearance related to anesthesia

A client on a surgical unit provided consent for a liver biopsy. The nurse is in the process of taking the client to the operating room when the client states, "I've changed my mind." Which response by the nurse is accurate? a. "The surgical team performs biopsies several times a day. Everything will be all right." b. "Are you aware of the risks of not going through with the biopsy?" c. "I'm sure you are just feeling anxious about the procedure." d. "You have the right to withdraw consent. Would you like to discuss this further?"

d. "You have the right to withdraw consent. Would you like to discuss this further?"

A nurse is admitting a client with Guillain-Barré syndrome. Which of the following actions are appropriate to include in the nursing plan of care? (Select all that apply.) Assess respiratory status hourly. Provide prescribed morphine IVP. Obtain weight before and after plasmapheresis. Keep intubation equipment at bedside. Ensure adequate protein-energy intake. Assist with range-of-motion exercises.

✔ 1) Assess respiratory status hourly. ✔ 3) Obtain weight before and after plasmapheresis. ✔ 4) Keep intubation equipment at bedside. ✔ 5) Ensure adequate protein-energy intake. ✔ 6) Assist with range-of-motion exercises.

A nurse is working with an unlicensed assistive personnel (UAP). What activities can the nurse delegate to the UAP? (Select all that apply.) Vital signs on a client who returned from the post-anesthesia care unit 30 minutes ago Assistance with activities of daily living for a client who will be discharged later in the day A client with a new diagnosis of diabetes who is requesting insulin education when his wife visits A client who needs the indwelling urinary catheter bag emptied A client who started on metoprolol this morning and wants to take a walk

✔ 2. Assistance with activities of daily living (ADLs) for a client who will be discharged later in the day ✔ 4. A client who needs the indwelling urinary catheter bag emptied

The nurse has received shift reports on four clients. Which of the following clients should be seen first? A client 1-day post knee replacement surgery with a pain level of 4/10 requesting pain medication. A client with diabetes mellitus who has a fasting blood sugar of 206. A client with heart failure and a respiratory rate of 26 breaths per minute. A client who is ringing the call bell because the IV pump is beeping.

A client with heart failure and a respiratory rate of 26 breaths per minute.

Question 3: What order do you anticipate from the healthcare provider? A. Head CT B. Abdominal CT C. Blood transfusion D. Consult Social Services

B. Abdominal CT

A 24-year-old is brought to the ER with 2nd and 3rd-degree burns on 40% of his body. Which cardiovascular complications could the nurse observe with this injury? (Select all that apply.) Confusion Fluid volume deficit Hypothermia Decreased mean arterial pressure (MAP) Hypovolemic shock

Fluid volume deficit Decreased mean arterial pressure (MAP) Hypovolemic shock

The laboratory has just notified the nurse that a client on the unit has a phenytoin level of 32 mg/dL. Which symptoms should the nurse anticipate from this client? a. Ataxia and confusion b. Sodium depletion c. Tonic-clonic seizure d. Urinary incontinence

a. Ataxia and confusion

Which documentation would indicate nursing actions were effective in reducing breathing problems for a client? (Select all that apply.) a. Respirations at 26 breaths/min, circumoral cyanosis present, orthopneic b. Anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min c. Disoriented, oxygen saturation levels at 85%, coughing large amount thick, white sputum; dyspnea on exertion d. Edema of the extremities, labored respirations, color normal e. Lung sounds clear bilaterally with non-labored respirations noted

b. Anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min e. Lung sounds clear bilaterally with non-labored respirations noted

A patient who is 26 weeks pregnant and at risk for deep vein thrombosis (DVT) is prescribed prophylactic LMWH therapy. What patient education should the nurse include in the treatment plan? a. Weekly visits for INR levels are required b. Monitoring is not necessary in this therapy c. An injection is required every 12 hours d. Avoid leafy, green vegetables

b. Monitoring is not necessary in this therapy

A client is becoming progressively short of breath. The results of his arterial blood gas (ABG) tests are pH 7.13, Po₂ 48, Pco₂ 53, and Hco₃ 23. What do these values indicate? a. Metabolic acidosis b. Respiratory alkalosis c. Respiratory acidosis d. Metabolic alkalosis

c. Respiratory acidosis

A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client's records. Which would be the most appropriate action for the nurse? a. erase the erroneous entry b. overwrite the erroneous entry c. strike out with a single line and place initials d. use correction fluid to correct errors

c. strike out with a single line and place initials

A nurse is teaching a client about newly prescribed warfarin. Which statement by the client indicates that teaching has been effective? a) "It's ok if I have a salad now and then." b) "I will have my blood checked monthly." c) "I can shave with a regular razor." d) "I will take my medicine at specific times."

d) "I will take my medicine at specific times."

A client is being evaluated for Peripheral Venous Disease (PVD). Which of the following assessment findings are consistent with PVD? (Select all that apply.) a) Pain decreases with elevation b) Normal pulses c) Pale extremity d) Warm extremity e) No edema f) Thick, brittle nails

✔ a) Pain decreases with elevation ✔ b) Normal pulses ✔ d) Warm extremity

A client is being evaluated for Peripheral Arterial Disease (PAD). Which of the following assessment findings are consistent with PAD? (Select all that apply.) a) Pale extremity b) No edema c) Pain decreases with elevation d) Normal pulses e) Thick, brittle nails f) Warm extremity g) Dry, necrotic ulcers

✔ a) Pale extremity ✔ b) No edema ✔ e) Thick, brittle nails ✔ g) Dry, necrotic ulcers

A client with heart failure has been prescribed lanoxin (digoxin) 0.5 mg PO every evening. Which statement by the client requires follow-up by the nurse? "I like drinking green tea before bed." "I take echinacea when cold symptoms start." "I like to snack on licorice between meals." "I take valerian tablets when I can't fall asleep."

"I like to snack on licorice between meals."

You are a nurse working in the Emergency Department (ED). An elderly client was admitted following a fall at home and reports severe abdominal pain. Vital signs: Temperature: 98.4°F Heart Rate: 130 Respiratory Rate: 28 Blood Pressure: 88/50 Oxygen Saturation: 95% on room air The client has bilateral 18-gauge IV catheters infusing lactated ringers at KVO (keep vein open). Question 1: What do you suspect is the cause of the abdominal pain? A. Fractured pelvic bone B. Internal organ or vessel damage C. Myocardial infarction D. Urinary tract infection

B. Internal organ or vessel damage

Question 2: What do you anticipate assessing first? A. Neurologic status B. Lung sounds C. Abdomen D. Peripheral pulses

C. Abdomen

A nurse observes a physician sneeze into his hand when walking to an examination room. The physician does not wash the hands before entering the room to examine the next client. What is the nurse's first priority? Tell the physician to wash the hands before examining the client. Assume the physician knows whether the physician is contagious. Have the client wash their hands after the doctor's examination. Tell the client to come back if symptoms of sneezing begin.

Tell the physician to wash the hands before examining the client.

A staff nurse on a pediatric unit has a four-client assignment. Which child should the nurse assess first? an 8-year-old child admitted from the post-anesthesia care unit who's reporting pain a 10-year-old child with asthma whose oxygen saturation levels are dropping a 7-year-old child whose parent is waiting for discharge instructions a 9-year-old child with a broken leg who wants help moving from the bed to the chair

a 10-year-old child with asthma whose oxygen saturation levels are dropping

A charge nurse is preparing client care assignments for the next shift. A client who underwent femoral-popliteal bypass surgery is scheduled to return from the PACU. Which staff member would be best to receive this client? a. Registered nurse (RN) with 2 years of experience b. Vocational nurse (LPN) with 5 years of experience c. Registered nurse (RN) who just completed orientation d. Nursing manager with 10 years of experience

a. Registered nurse (RN) with 2 years of experience

A nurse is planning care for a client newly diagnosed with diabetes mellitus type 1. Which statement illustrates an appropriate outcome criterion? a. The client will correctly demonstrate blood glucose testing prior to discharge. b. The client will not experience any complications. c. The client will take medication as scheduled. d. The client will follow verbal instructions.

a. The client will correctly demonstrate blood glucose testing prior to discharge.

A nurse receives the assignment of clients for the shift. Following the report, which client should the nurse see first? a. A client with pinkish mucus discharge in the appliance bag 2 days after an ileal conduit b. A client with sodium level of 135 mEq/L and potassium level of 3.7 mEq/L, 7 days after a kidney transplant c. A client 3 days after a kidney transplant with sodium level of 110 mEq/L and potassium level of 2.0 mEq/L after dialysis d. A client experiencing mild pain from urolithiasis

c. A client 3 days after a kidney transplant with sodium level of 110 mEq/L and potassium level of 2.0 mEq/L after dialysis

The nursing team consists of one RN, one LPN, and one UAP (unlicensed assistive personnel). Which assignment should the RN delegate to the LPN? a. Passing dinner trays b. Emptying a Foley catheter bag c. Administering daily am medications d. Suctioning a client who is 1-day postoperative following a tracheostomy

c. Administering daily am medications

A nurse is making assignments for the pediatric unit. The shift's team members include: Licensed Practical Nurse (LPN) with 10 years of experience Registered Nurse (RN) with 3 months of experience Unlicensed Assistive Personnel (UAP) Which assignment is most appropriate for the LPN? a. An infant being discharged to home following placement of a gastrostomy tube b. An infant just returned from the post-anesthesia care unit (PACU) who requires hourly assessment of vital signs c. An infant requiring abdominal dressing changes for a wound infection d. An infant with agonal respirations who is receiving palliative care

c. An infant requiring abdominal dressing changes for a wound infection

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, jugular vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? a. Electrolyte disturbance b. Urinary retention c. Excess fluid volume d. Toileting self-care deficit

c. Excess fluid volume