NCLEX-PN Exam Book

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. What should the nurse look for on the cardiac monitor as a result of this laboratory value? 1. ST elevation 2. Peaked P waves 3. Prominent U waves 4. Narrow, peaked T waves

4. Narrow, peaked T waves

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included? 1. As-needed medications given that shift. 2. Normal vital signs that have been normal since admission. 3. All of the tests and treatments the client has had since admission. 4. Total number of scheduled medications that the client received on that shift.

1. As-needed medications given that shift.

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing response? 1. "I have a legal obligation to report this type of abuse." 2. "I promise I won't tell anyone, but let's see what we can do about this." 3. "Let's talk about ways that will prevent your daughter from hitting you. 4. "This should not be happening. If it happens again, you must call the emergency department."

1. "I have a legal obligation to report this type of abuse."

A nursing student is asked to identify the practices and beliefs of the Amish society. Which should the student identify? Select all that apply. 1. Many choose not to have health insurance. 2. They believe that health is a gift from God. 3. The authority of women is equal to that of men. 4. They remain secluded and avoid helping others. 5. They use both traditional and alternative health care, such as healer, herbs and massage. 6. Funerals are conducted in the home without a eulogy, flower decorations or any other display. Caskets are plain and simple, without adornment.

1. Many choose not to have health insurance. 2. They believe that health is a gift from God. 5. They use both traditional and alternative health care, such as healer, herbs and massage. 6. Funerals are conducted in the home without a eulogy, flower decorations or any other display. Caskets are plain and simple, without adornment.

The nurse reviews the client's serum calcium level endnotes that the level is 8.0 mg/dL. The nurse understands that which condition would cause this serum calcium level? 1. Prolonged bed rest 2. Adrenal insufficiency 3. Hyperparathyroidism 4. Excessive ingestion of vitamin D

1. Prolonged bed rest

The nurse consults with a dietician regarding the dietary preferences of an Asian American client. Which food should the nurse suggest to include in the diet plan? 1. Rice 2. Fruits 3. Red meats 4. Fried foods

1. Rice

Which identifies accurate nursing documentation notations? Select all that apply. 1. The client slept through the night. 2. Abdominal wound dressing is dry and intact without drainage. 3. The client seemed angry when awakened for vital sign measurement. 4. The client appears to become anxious when it is time for respiratory treatments. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage or edema.

1. The client slept through the night. 2. Abdominal wound dressing is dry and intact without drainage. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage or edema.

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply. 1. "An event is termed a mass casualty when it overwhelms local medical capabilities." 2. "Mass casualty events do not require an increase in the number of staff that are needed." 3. "A mass casualty event occurs only within the health care facility and could endanger staff." 4. "Mass casualty events may require the collaboration of many local agencies to handle the situation." 5. "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

2. "Mass casualty events do not require an increase in the number of staff that are needed." 3. "A mass casualty event occurs only within the health care facility and could endanger staff." 5. "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium? 1. Milk 2. Butter 3. Spinach 4. Collard greens

2. Butter

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit? 1. The client with cirrhosis 2. The client with ileostomy 3. The client with heart failure 4. The client with decreased kidney function

2. The client with ileostomy

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level would be noted with which condition? 1. Diarrhea 2. Traumatic burn 3. Cushing's syndrome 4. Overuse of laxatives

2. Traumatic burn

The clients asks the nurse about various herbal therapies available for treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the primary health care provider? 1. Garlic 2. Valerian 3. Lavender 4. Glucosamine

2. Valerian

The nurse is caring for a group of clients who are taking herbal medications at home. Which client should be given instructions with regard to avoiding the use of herbal medications? 1. A 60 year-old male client with rhinitis. 2. A 24 year-old male client with lower back pain. 3. A 10 year-old female with a urinary tract infection. 4. A 45 year-old female with history of migraine headaches.

3. A 10 year-old female with a urinary tract infection.

The nurse should institute which interventions for a client diagnosed with C Diff? Select all that apply. 1. Wear a mask if within 3 feet of the client 2. Place a mask on the client when client is outside 3. Wear gloves and gown when in room caring for the client 4. Use soap and water, not alcohol based hand rub for hygiene 5. Keep the door of the room shut except when entering or existing the client's room

3,4,5

A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement? 1. "I would try anything that I could if I had cancer." 2. "No, because it will interact with the chemotherapy." 3. "Tell me what you know about complementary therapies." 4. "You need to ask your primary health care provider about it."

3. "Tell me what you know about complementary therapies."

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action? 1. Call for help 2. Extinguish 3. Activate the fire alarm 4. Confine the fire by closing the room door

3. Activate the alarm

A mother calls a neighborhood nurse and tells the nurse that her 3 year old daughter has just ingested liquid furniture polish. Which of the action should the nurse instruct the mother to take first? 1. Induce vomiting 2. Call an ambulance 3. Call the poison center 4. Bring the child to the emergency department

3. Call the poison center

The licensed practical nurse enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back to bed. The LPN completes an incident report and the nursing supervisor and primary health care provider are notified of the incident. Which is the next nursing action regarding the incident? 1. Place the incident report in the clients chart. 2. Make a copy of the incident report for the PHCP 3. Document a complete entry in the client's record concerning the incident. 4. Document in the client's record that an incident report has been completed.

3. Document a complete entry in the client's record concerning the incident.

The nurse is planning to reinforce nutritional instructions to an African American client. When reviewing the plan, the nurse is aware that which food may be a common dietary practice of clients with African American heritage? 1. Raw fish 2. Red meat 3. Fried foods 4. Rice as basis for all meals

3. Fried foods

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which describes the team-based model of nursing practice? 1. A task approach method is used to provide care to clients. 2. Managed care concepts and tools are used when providing client care. 3. Nursing staff are led by the n nurse when providing care to a group of clients. 4. A single registered nurse is responsible for providing nursing care to to group of clients.

3. Nursing staff are led by the n nurse when providing care to a group of clients.

The nurse is reading the primary health care provider's progress notes in the client's record and sees that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss? 1. The client with draining wound 2. The client with urinary catheter 3. The client with fast respiratory rate 4. The client with nasogastric tube to low suction

3. The client with fast respiratory rate

A client has died, and the nurse asks the family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action? 1. Show acceptance of feelings. 2. Provide information needed for decision making. 3. Suggest a referral to a mental health professional. 4. Remain with the family member without discussing the funeral arrangements.

4. Remain with the family member without discussing the funeral arrangements.

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from first? 1. A client scheduled for chest x-ray. 2. A client requiring daily dressing changes. 3. A postoperative client preparing for discharge. 4. A client receiving oxygen who is having difficulty breathing.

4. A client receiving oxygen who is having difficulty breathing.

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client? 1. A client complaining of muscle ache, headache and malaise. 2. A client who twisted their ankle when they fell in line skating. 3. A client with a minor laceration on the index finger sustained while cutting an eggplant. 4. A client with chest pain who states that they just ate pizza the was made with a very spicy sauce.

4. A client with chest pain who states that they just ate pizza the was made with a very spicy sauce.

The nurse who is caring for a client with kidney failure notes that the client is dyspneic and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom should the nurse expect to note in this client? 1. Rapid weight loss 2. Flat hand and neck veins 3. A weak and thready pulse 4. An increase in blood pressure

4. An increase in blood pressure

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is an appropriate nursing action? 1. Call the hospital lawyer. 2. Call the nursing supervisor. 3. Refuse to float to the pediatric unit. 4. Report to the pediatric unit and identify tasks that can be safely performed.

4. Report to the pediatric unit and identify tasks that can be safely performed.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit? 1. The client with Addison's disease 2. The client with metabolic acidosis 3. The client with intestinal obstruction 4. The client receiving nasogastric suction

4. The client receiving nasogastric suction

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse expects that this sodium level would be noted in a client with which condition? 1. The client with watery diarrhea 2. The client with diabetes mellitus 3. The client with an inadequate daily water intake 4. The client with syndrome of inappropriate secretion of antidiuretic hormone

4. The client with syndrome of inappropriate secretion of antidiuretic hormone

A Hispanic American mother brings her child to the clinic for an examination. Which is most important when gathering data about the child? 1. Avoiding eye contact. 2. Using body language only. 3. Avoiding speaking to the child. 4. Touching the child during the examination.

4. Touching the child during the examination.

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action? 1. Call the nursing supervisor to initiate a court order for the surgical procedure. 2. Try calling the client's spouse to obtain telephone consent before surgical procedure. 3. Ask the friend who accompanied the client to the emergency department to sign the consent form. 4. Transport the client to the operating department immediately without obtaining an informed consent.

4. Transport the client to the operating department immediately without obtaining an informed consent.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is the least likely risk for the development of third-spacing? 1. The client with sepsis 2. The client with cirrhosis 3. The client with kidney failure 4. the client with diabetes mellitus

4. the client with diabetes mellitus

A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style? 1. Autocratic 2. Situational 3. Democratic 4. Laissez-faire

1. Autocratic

The nurse is caring for a client with a health care associated infection caused by MRSA. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions should the nurse use to perform this procedure? Select all that apply. 1. Put on a mask 2. Don gown and gloves 3. Apply shoe protectors 4. Wear a pair of protective goggles 5. Have the client wear a mask and goggles

1,2,4

The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL. Which prescribed medication should the nurse plant to assist in administering to the client? 1. Calcitonin 2. Calcium chloride 3. Calcium gluconate 4. Large doses of vitamin D

1. Calcitonin

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is most important to provide to the client? 1. "Herbal substances are not safe and should never be used." 2. " I will teach you how to take your blood pressure so that it can be monitored closely." 3. "You will need to talk to your primary health care provider before using an herbal substance." 4. "If you take an herbal substance, you will need to have your blood pressure checked frequently."

3. "You will need to talk to your primary health care provider before using an herbal substance."

The nurse had delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after delegation of tasks? 1. Document that the task was completed. 2. Assign the tasks that were not completed to the next nursing shift. 3. Allow each staff member to make judgements when performing the tasks. 4. Perform follow up with each staff member regarding the perforce and outcome of the task.

4. Perform follow up with each staff member regarding the perforce and outcome of the task.

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional sign/symptom should the nurse expect to note in this client id hyponatremia is present? 1. Intense thirst 2. Slow bounding pulse 3. Dry mucous membranes 4. Postural blood pressure changes

4. Postural blood pressure changes

The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed the same occurrence several times. Based on the nurse practice act, the observing nurse should plan to take which action? 1. Report the information to the police. 2. Call the impaired nurse organization. 3. Talk with the nurse who gave the medication. 4. Report the information to a nursing supervisor.

4. Report the information to a nursing supervisor.

The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply. 1. Wearing gloves when emptying the clients bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a film badge when entering the room 4. Wearing a lead apron when providing direct care to the client 5. Placing the client in a semiprivate room at the end of the hall

1,2,3,4

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing living will. The living will requires that the client's signature witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action? 1. Decline to sign the will. 2. Sign the will as a witness to the signature only. 3. Call the hospital lawyer before signing the will. 4. Sign the will, clearly identifying credentials and employment agency.

1. Decline to sign the will.

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first? 1. A client in skeletal traction. 2. A client who is dependent on a ventilator. 3. A prospective client preparing for discharge. 4. A client admitted during the previous shift with a diagnosis of gastroenteritis.

2. A client who is dependent on a ventilator.

The nurse employed in long-term care facility is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assertive personnel? 1. A client requiring a 24 hour urine collection. 2. A client who require twice daily dressing changes. 3. A client with diabetes mellitus who requires daily insulin and the reinforcement of dietary measures. 4. A client who has been placed on a bowel management program and requires rectal suppositories and a daily enema.

2. A client who require twice daily dressing changes.

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel? 1. A client who requires wound irrigation. 2. A client who requires frequent ambulation. 3. A client who is receiving continuous tube feedings. 4. A client who requires frequent vital signs after a cardiac cauterization.

2. A client who requires frequent ambulation.

The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client then calls the nursing supervisor and the primary health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose? 1. Providing clients with necessary stabilizing treatments. 2. A method of promoting quality care and risk management. 3. Determining the effectiveness of interventions in relation to outcomes. 4. The appropriate method of reporting to local, state and federal agencies.

2. A method of promoting quality care and risk management.

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. Which should be the initial nursing action? 1. Prepare the triage rooms 2. Activate the agency emergency response plan 3. Obtain additional supplies form the central supply department 4. Obtain additional nursing staff to assist with treating the casualties

2. Activate the agency emergency response plan

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed and the serum calcium level is 12.0 mg/dL. Based on this laboratory value, the nurse should take which action? 1. Document the value in the client's record 2. Inform the registered nurse fo the laboratory value 3. Place the laboratory result form in the client's record 4. Reassure the client that the laboratory result is normal

2. Inform the registered nurse fo the laboratory value

The nurse is assisting with collecting data form an African American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which information about the client is of the lowest priority during the data collection? 1. Respiratory 2. Psychosocial 3. Neurological 4. Cardiovascular

2. Psychosocial

A nurse layer provides an education session to the nursing staff regarding client rights with emphasis on invasion of client rights. The nurse lawyer asks the staff nurse to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1. Threatening to place a client in restraints 2. Performing a surgical procedure without consent. 3. Taking photographs of the client without consent. 4. Telling the client that he or she cannot leave the hospital.

3. Taking photographs of the client without consent.

The nurse is preparing to assist the client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal? 1. Unwrapping the eating utensils for the client. 2. Replacing the plastic utensils with metal utensils. 3. Carefully transferring the food from paper plates to glass plates. 4. Allowing the client to unwrap the utensils and prepare his own meal for eating.

4. Allowing the client to unwrap the utensils and prepare his own meal for eating.

An LPN attends a session about bioterrorism agents including anthrax. Which state by the attendee demonstrates the need for further teaching about anthrax? 1. Anthrax is treated with antibiotic medications 2. The most lethal form of anthrax is contracted by inhalation of the spores 3. Anthrax can be transmitted by consumption of meat from an infected animal 4. Anthrax bacteria produces a neurotoxin leading to a serious possibly fatal paralysis

4. Anthrax bacteria produces a neurotoxin leading to a serious possibly fatal paralysis

The nurse is caring for a client with a suspected diagnosis hypercalcemia. Which sign/symptom would be an indication of this electrolyte imbalance? 1. Twitching 2. Positive Trousseau's sign 3. Hyperactive bowel sounds 4. Generalized muscle weakness

4. Generalized muscle weakness

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse aspect to note as a result of this long-term use? 1. Gurgling respiration 2. Increased blood pressure 3. Decreased hematocrit level 4. Increased specific gravity of urine

4. Increased specific gravity of urine