NCLEX Comprehensive Exam

A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder?

"Have you ever worked in a mine?"

A nurse provides instructions to a client who has been prescribed lithium carbonate for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction?

"I need to avoid salt in my diet." "It's fine to take any over-the-counter medication with the lithium." "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned."

A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction?

"I need to contact my surgeon immediately if I feel any numbness in my genital area."

A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction?

"I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium), which is administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30 minutes. No special preparation is necessary before a GI series, except that NPO status must be maintained for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to expel, leading to fecal impaction.

A rape victim being treated in the emergency department says to the nurse, "I'm really worried that I've got HIV now." What is the appropriate response by the nurse?

"Let's talk about the information that you need to determine your risk of contracting HIV."

A client who recently underwent coronary artery bypass graft surgery comes to the health care provider's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic?

"Tell me more about what you're feeling."

A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta?

"The placenta maintains the body temperature of my baby."

A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information?

"Wearing the brace is really important in curing the scoliosis."

A health care provider prescribes a dose of morphine sulfate 2.5 mg stat to be administered intravenously to a client in pain. The nurse preparing the medication notes that the label on the vial of morphine sulfate solution for injection reads "4 mg/mL." How many milliliters (mL) must the nurse draw into a syringe for administration to the client?

0.625 ml

A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which finding elicited during the assessment indicates that the condition has not yet resolved?

1

A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the client's Foley catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL. What is the client's total intake during the 24-hour period?

1670 The client's 24-hour total oral intake is 1570 mL, and the IV intake totals 100 mL (50 mL of normal saline solution every 12 hours). Therefore the 24-hour intake total is 1670 mL.

Lorazepam 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed and administers the medication over a period of:

3 minutes

An adult client with chronic kidney disease who is oliguric and undergoing hemodialysis is under a fluid restriction of 700 mL/day. How many milliliters of fluid does the nurse allow the client to have between 7 a.m. and 3 p.m.?

350

A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which observation indicates to the nurse that placental separation has occurred?

A sudden gush of dark blood from the introitus

NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should:

Administer the antihypertensive with a small sip of water

An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client?

Administering 100% oxygen

A nurse on the evening shift checks a health care provider's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the health care provider's answering service and is told that the health care provider is off for the night and will be available in the morning. The nurse should:

Ask the answering service to contact the on-call health care provider

An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is:

Asking the ED health care provider to check the client

A nurse notes documentation in the client's medical record indicating that the client has a stage II pressure ulcer. On the basis of this information, which finding does the nurse expect to note?

B

A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client's breast?

B

A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which substance does the nurse ensure is readily available?

Calcium gluconate

A nurse has assisted a health care provider in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to:

Call the radiography department to obtain a chest x-ray

A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, "I'm really thirsty — may I have something to drink?" Before giving the client a drink, the nurse should:

Check for the presence of a gag reflex

Enalapril maleate is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication?

Checking the client's blood pressure Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. One common side effect is postural hypotension. Therefore the nurse would check the client's blood pressure immediately before administering each dose. Checking the client's peripheral pulses, the results of the most recent potassium level, and the intake and output for the previous 24 hours are not specifically associated with this mediation.

A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which action should be the nurse's priority?

Contacting the health care provider

A nurse is monitoring a client receiving terbutaline by intravenous infusion to stop preterm labor. The nurse notes that the client's heart rate is 120 beats/min and that the fetal heart rate is 170 beats/min. The appropriate action by the nurse is:

Contacting the health care provider

A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk?

Count wet diapers to be sure that the infant is having at least six to 10 each day

A nurse is providing instructions to a client with glaucoma who will be using acetazolamide daily. Which finding, an adverse effect, does the nurse instruct the client to report to the health care provider?

Dark urine

A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority?

Decreased fluid volume

A client who is taking lithium carbonate complains of mild nausea, voiding in large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should:

Document the findings

The blood serum level of imipramine is determined in a client who is being treated for depression. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should:

Document the laboratory result in the client's record

A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which action should the nurse take as a result of this observation?

Documenting the finding

A nurse is providing information about home care to a client with acute gout. Which measures does the nurse tell the client to take?

Drinking 2 to 3 L of fluid each day Resting and immobilizing the affected area

A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, the nurse tells the client that this technique involves:

Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening

A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse's initial action should be:

Helping the woman empty her bladder

A client diagnosed with advanced chronic kidney disease (CKD) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that it is acceptable to use:

Herbs and spices

A client with myasthenia gravis is taking neostigmine bromide . The nurse determines that the client is gaining a therapeutic effect from the medication after noting:

Improved swallowing function

A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2017. Using Nagele's rule, the nurse determines that the estimated date of delivery (EDD) is:

July 2, 2018

A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the health care provider, which does the nurse specify as the first action in the event of shock?

Placing the client in a lateral position with the bed flat

A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client?

Positive result on d-dimer study

A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would:

Recheck the temperature in 4 hours

A postpartum nurse provides information about normal and abnormal characteristics of lochia to a client who has delivered a healthy newborn. Which finding does the nurse tell the client to report to the health care provider?

Reddish lochia on postpartum day 8

After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client?

Replacement of the uterus through the vagina into a normal position

A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which recommendations does the nurse include on the poster?

Seek medical advice if you find a skin lesion Wear a hat, opaque clothing, and sunglasses when out in the sun.

An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment?

Skin tenting flat neck veins weak peripheral pulses

A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client?

Spontaneous bruising

A client is receiving an intravenous infusion of oxytocin to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately:

Stops the oxytocin infusion

A client is taking prescribed ibuprofen , 300 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. The nurse should tell the client to:

Take the medication with food

The mother of an adolescent diagnosed with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose control, tells the mother:

That the child should eat a carbohydrate snack about a half-hour before each soccer game

A client undergoing therapy with carbidopa/levodopa calls the nurse at the clinic and reports that his urine has become darker since he started taking the medication. The nurse should tell the client:

That this is an occasional side effect of the medication

A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which finding would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy?

The client reports a history of sexual abuse by her father.

Risperidone is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client's medical record would prompt the nurse to contact the prescribing health care provider before administering the medication?

The client takes a prescribed antihypertensive.

A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse explains to the client that amniocentesis is often performed during the third trimester to determine:

The degree of fetal lung maturity

A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that:

Urine output must be measured and that the health care provider should be notified if output is less than 500 mL in a 24-hour period

A nurse is providing morning care to a client in end-stage kidney disease. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic?

What are your feelings right now?

A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through:

a lower abdominal incision

A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify?

anxiety

A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time?

anxiety

A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate. Which foods does the nurse tell the client to avoid while she is taking this medication?

beer yogurt pickled herring

A nurse is assessing a client who has been taking amantadine hydrochloride for the treatment of Parkinson's disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication?

bilateral lung wheezes

A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which menu selection by the client tells the nurse that the client understands the instructions?

cheeseburger

A client diagnosed with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally:

decrease

A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride . On the basis of this information, the nurse determines that the client most likely has a history of:

depression

A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the nurse would:

document the findings

A nurse in a health care provider's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to:

document the findings

Chlorpromazine has been prescribed to a client with Huntington's disease for the relief of choreiform movements. Of which common side effect does the nurse warn the client?

drowsiness

A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase. For which adverse effect of the medication does the nurse monitor the client?

epistaxis

A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note?

fatigue low-grade fever

A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record?

fever vasculitis abdominal pain

A client with cervical cancer is undergoing chemotherapy with cisplatin. For which adverse effect of cisplatin will the nurse assess the client?

hearing loss

A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid?

legumes spinach whole grains

Phenelzine sulfate is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the health care provider immediately if she experiences:

neck stiffness or soreness

A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that:

pitting edema is present

A client diagnosed with chronic kidney disease who requires dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem?

powerlessness

A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which diagnosis, if noted on the client's record, would indicate a need to contact the health care provider who is scheduled to perform the ECT?

recent stroke

A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is:

sardines

Ferrous sulfate is prescribed for a client. The nurse tells the client that it is best to take the medication with:

scrambled eggs

A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which risk factors does the nurse include in the pamphlet?

smoking high alcohol intake white or asian ethnicity

A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which finding would the nurse expect to note on assessment of the client?

soft, relaxed, nontender uterus

A client has been given a prescription for lovastatin. Which food does the nurse instruct the client to limit consumption of while taking this medication?

steak

A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client?

tachycardia diminished peripheral pulses

Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse, assisting the health care provider with the procedure, expect to note?

thick and opaque

A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which finding does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client?

tongue protrusion