Nclex 2

The nurse is gathering data from a pregnant client about physiological risk factors. The nurse should be sure to obtain which priority data? 1. Life stress 2. Self-care needs 3. Support systems 4. Weight and height

4

A client has been brought to the emergency department after attempting to commit suicide by hanging. The nurse should take which nursing action first? 1. Examine the neck area and assess the airway. 2. Encourage the client to talk about the experience. 3. Obtain a detailed history of events leading to the attempt. 4. Administer an anxiolytic medication as prescribed at once.

1

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse identifies which signs/symptoms or behaviors as requiring immediate intervention? 1. Constant physical activity and poor oral intake 2. Grandiose delusions of being the King of England 3. Constant, incessant talking with sexual innuendos 4. Outlandish behaviors and wearing odd, eccentric clothing

1

The nurse has inserted a nasogastric (NG) tube in a client and is checking for the correct placement of an NG tube. Which is the most reliable data to ensure that the end of the tube is in the stomach? 1. Placement is verified on x-ray. 2. The pH of the aspirated fluid is 5. 3. The aspirated fluid is bile green in color. 4. Air injection is auscultated in the left upper quadrant.

1

The nurse is assigned to care for a client being admitted to the mental health unit following a suicide attempt. The client attempted the suicide by lacerating both wrists. Which is the initial nursing action upon admission of the client? 1. Check the wound sites. 2. Administer the prescribed antianxiety agent. 3. Encourage and assist the client to ventilate feelings. 4. Ask the client about the reason that the suicide act was attempted.

1

The nurse is assisting in developing a plan of care for a child diagnosed with acute glomerulonephritis. The nurse should include which intervention in the plan of care? 1. Encourage limited activity and provide safety measures. 2. Force intake of oral fluids to prevent hypovolemic shock. 3. Catheterize the child to strictly monitor intake and output. 4. Encourage classmates to visit and to keep the child informed of school events.

1

The nurse is assisting in developing a plan of care for the client with immunodeficiency. The nurse should determine that which problem is a priority for the client? 1. Infection 2. Inability to cope 3. Lack of information about the disease 4. Feeling uncomfortable about body changes

1

n the well-child clinic, the nurse observes an infant, age 10 months, playing with toys, bringing them to his mouth, and passing the toys from one hand to the next. The nurse determines the child is in which Jean Piaget's first developmental stage? 1. Sensorimotor 2. Preoperational 3. Formal operational 4. Concrete operational

1

The client is diagnosed with pleurisy. The nurse should expect to see which signs and symptoms? Select all that apply. 1. Pleural friction rub 2. Sharp, knife-like pain 3. Cyanosis of lips and nailbeds 4. Pain that occurs on both sides of the chest 5. Pain that occurs most often during inspiration

1, 2, 5

A client has been diagnosed with cataracts. Which signs and symptoms should the nurse expect to note? Select all that apply. 1. Pain 2. Photophobia 3. Blurred vision 4. Decreased color perception 5. Progressive loss of peripheral vision 6. Flashes of colored light accompanied by showers of floaters

2, 3, 4

A client receives a dose of edrophonium. The client shows improvement in muscle strength for a period of time following the injection. The nurse should interpret this finding as indicative of which disease process? 1. Multiple sclerosis 2. Myasthenia gravis 3. Muscular dystrophy 4. Amyotrophic lateral sclerosis

2

A client with possible hiatal hernia complains of frequent heartburn and regurgitation. The nurse should gather further information about the presence of which sign or symptom? 1. Dizziness after meals 2. Difficulty swallowing 3. Left lower quadrant pain 2 hours after eating 4. Moderate right upper quadrant pain unrelated to eating

2

A nursing instructor asks a nursing student to describe Montgomery's tubercles of the breast. Which response by the student indicates successful learning regarding Montgomery's tubercles? 1. "These are lobes of glandular tissue that secrete milk." 2. "These are sebaceous glands that are located in the areola." 3. "These are small sacs that contain acinar cells to secrete milk." 4. "These are ducts containing milk from all areas of the breast."

2

The nurse is monitoring a client with a closed chest tube drainage system and notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, which conclusion should the nurse make? 1. There is a leak in the system. 2. The chest tube is functioning as expected. 3. The amount of suction needs to be decreased. 4. The occlusive dressing at the insertion site needs reinforcement.

2

A client asks the nurse to describe how her baby is developing at 12 weeks gestation. Which milestones should the nurse identify as present at this time? Select all that apply. 1. Can hear 2. Sex recognizable 3. Blood forming in marrow 4. Testes descend into scrotum 5. Kidneys able to secrete urine

2, 3, 5

A client is scheduled to have electroconvulsive therapy (ECT). Which problem should the nurse include in the plan as a priority? 1. Fear 2. Anxiety 3. Risk for aspiration 4. Altered health maintenance

3

The nurse has a prescription to give a client albuterol (two puffs) and beclomethasone dipropionate (two puffs) by metered-dose inhaler. How much time should the nurse place between administering the albuterol and then the beclomethasone dipropionate? 1. 1 minute 2. 2 minutes 3. 5 minutes 4. Administer immediately

3

The nurse is assessing a pediatric client with a diagnosis of retinoblastoma. The nurse assesses for which most common clinical finding for a child with this diagnosis? 1. Blindness 2. Strabismus 3. Cat's-eye reflex 4. Red, painful eye

3

The maternity nurse is describing the ovarian cycle to a group of nursing students and asks a nursing student to identify the phases of the cycle. Which phases stated by the nursing student indicate a need for further teaching in this area? Select all that apply. 1. Luteal phase 2. Ovulatory phase 3. Secretory phase 4. Proliferative phase 5. Preovulatory phase

3, 4

The nurse is reinforcing discharge instructions to a client with cancer of the prostate after a suprapubic prostatectomy. The nurse should reinforce which discharge instruction? Select all that apply. 1. Avoid driving a car for 1 week. 2. Restrict fluid intake to prevent incontinence. 3. Take the prescribed stool softener every day. 4. Avoid lifting objects heavier than 20 pounds for 6 weeks. 5. Inspect the incision on the scrotum every day for any redness. 6. Notify the primary health care provider (PHCP) if small blood clots are noticed during urination.

3, 4

The nurse is instructing a client about pursed lip breathing, and the client asks the nurse about its purpose. The nurse should tell the client that the primary purpose of pursed lip breathing is which? 1. Promote oxygen intake 2. Strengthen the diaphragm 3. Strengthen the intercostal muscles 4. Promote carbon dioxide elimination

4

A client who underwent a bronchoscopy was returned to the nursing unit 1 hour ago. The nurse determines that the client is experiencing complications of the procedure if the nurse notes which sign/symptom? 1. Oxygen saturation of 95% 2. Weak gag and cough reflex 3. Respiratory rate of 22 breaths per minute 4. Breath sounds greater on the right than the left

4

The client has a prescription for sucralfate 1 g by mouth 4 times daily. The nurse should best schedule the administration of the medication at which time? 1. With meals and at bedtime 2. Every 6 hours around the clock 3. One hour after meals and at bedtime 4. One hour before meals and at bedtime

4

The nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. Based on this finding, the nurse makes which determination? 1. An air leak is present. 2. The tubing is kinked. 3. The lung has reexpanded. 4. The system is functioning as expected.

4

The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student needs further teaching if which responses are made? Select all that apply. 1. Allows for fetal movement 2. Is a measure of kidney function 3. Surrounds, cushions, and protects the fetus 4. Maintains the body temperature of the fetus 5. Prevents large particles such as bacteria from passing to the fetus 6. Provides an exchange of nutrients and waste products between the mother and the fetus

5, 6

The nurse is caring for a hospitalized client following cystoscopy. Which discharge instructions are given to the client? Select all that apply. 1. Use antispasmodics for pain. 2. Restrict oral fluids for 1 to 2 days. 3. Expect pink-tinged urine for 1 week. 4. Take sitz baths for voiding discomfort. 5. Report severe pain to health care provider.

1, 4, 5

A client with endometrial cancer is receiving doxorubicin, an antineoplastic agent. The nurse should specifically collect data about which criteria? Select all that apply. 1. Electrocardiogram 2. Level of orientation 3. Neuromuscular reflexes 4. Pupillary response to light 5. Hematological laboratory values

1, 5

The nurse is caring for an older Appalachian client recovering from open heart surgery. In order to provide culturally appropriate care, the nurse should be aware that which aspects of reporting pain may be impacted by the Appalachian culture? Select all that apply. 1. Appalachian clients may want to appear to be stoic. 2. Appalachian clients may be afraid of addiction tendencies. 3. Appalachian clients may be very expressive in reporting pain. 4. Appalachian clients may not want to appear to be complainers. 5. Appalachian clients may not understand pain scale because of illiteracy.

1, 2, 4

The nurse is discharging a client with a diagnosis of gout. Which best practice guidelines should the nurse teach the client? Select all that apply. 1. Drink plenty of fluids. 2. Avoid taking diuretics. 3. Avoid taking acetaminophen. 4. Organ meats are allowed on your diet. 5. Avoid excessive physical or emotional stress.

1, 2, 5

A client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses the client 15 minutes after administering the medication and reminds the client to save all urine in the bathroom. Sixty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Which issues support the client's malpractice claim? Select all that apply. 1. Failure to replace body fluids 2. Increased risk of hypotension 3. Lack of follow-up nursing actions 4. Increased need to protect the client 5. Failure to teach the client adequately 6. Excessive bumetanide administration

2, 3, 4, 5

The nurse is assigned to assist in caring for a client with a chest tube drainage system. Which interventions should the nurse implement? Select all that apply. 1. Pin excess tubing to the bedclothes. 2. Check for subcutaneous emphysema. 3. Empty the chest tube drainage at the end of the shift. 4. Check to see that the chest tube drainage is fluctuating. 5. Maintain chest tube drainage container below the client's chest.

2, 4, 5

The nurse is giving discharge instructions to the client with varicose veins. The nurse realizes there is a need for further teaching when the client makes which statement? 1. "I need to watch my diet to lose weight." 2. "I should put my elastic support hose on when I get up." 3. "I want to start taking the herbal supplement, bilberry." 4. "I need to sit as much as possible with my legs elevated."

4

The nurse has received a client assignment for the day. In which priority order should the nurse see the clients? Arrange the clients in the order that they should be seen. All options must be used. Correct Answers: Your Answers:

4 yr, 2 yr, 9 yr, 15 yr

The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse plans care knowing that which facts are true with the use of a fenestrated tracheostomy tube? Select all that apply. 1. Enables the client to speak 2. Is necessary for mechanical ventilation 3. Must have the cuff deflated when capped 4. Eliminates the need for tracheostomy care 5. Prevents air from being inhaled through the tracheostomy opening

1, 3

A client with cancer has undergone a total abdominal hysterectomy and has an indwelling Foley catheter in place. The nurse should expect to note which types of urinary drainage immediately following this surgery? Select all that apply. 1. Pale 2. Purulent 3. Bright red 4. Light amber 5. Blood tinged

1, 4

The nurse is reinforcing instructions about psoriasis to a client with a high risk of the disorder. The nurse explains to the client the plaques of psoriasis most often appear in which areas? Select all that apply. 1. Face 2. Knees 3. Elbows 4. Abdomen 5. Base of the spine

2, 3, 5

A client who was recently prescribed warfarin is being instructed on diet changes necessary with this medication. The client reports enjoying all of these food items. Which items should the nurse instruct the client to limit consuming? Select all that apply. 1. Giblet gravy 2. Spinach salad 3. Fried chicken 4. Banana pudding 5. Mustard greens 6. Fresh orange juice

2, 5

An older client with a history of hyperparathyroidism and severe osteoporosis is hospitalized. The nurse caring for the client plans to address which problem first? 1. Constipation 2. Urinary retention 3. The possibility of injury 4. Need for teaching about the disorder

3

The nurse evaluates that the older client has a need for further teaching on how to promote sleep when the client makes which statements? Select all that apply. 1. "I swim three times a week." 2. "I have stopped smoking cigars." 3. "I drink hot chocolate before bedtime." 4. "I read for 40 minutes before bedtime." 5. "I plan out my goals for work for the next day"

3, 5

A client sustains a burn injury to the entire right and left arms, including the hands. Which emergency interventions should the nurse take before transferring the client to the burn center? Select all that apply. 1. Apply cool water to the area. 2. Place ice packs over the area. 3. Apply an absorbent material to the area. 4. Wrap burned fingers separately to prevent sticking together. 5. Cover the burns with a clean dry cloth as directed by a burn center.

1, 4, 5

A nurse working in a long-term care facility is assigned to care for four clients on the hospice unit. In planning client rounds, which client should the nurse collect data on first? 1. A client who was complaining of severe back pain on the previous shift 2. A client who is being moved to a different room and will need assistance packing 3. A client who is bed bound and needs to be turned and repositioned every 2 hours 4. A client who needs assistance dressing before transport to the dining room for breakfast

1

The nurse provides instructions to a parent of a toddler experiencing physiological anorexia. The nurse determines the need for further teaching if the parent makes which statement? 1. "I should not force feed my child." 2. "I should limit juice to 6 ounces per day." 3. "I should feed my child if she will not eat." 4. "I should limit snacks to two nutritious ones per day and give them only at my toddler's request.

3