NCLEX-PN Practice Questions

should begin the day after surgery.

The nurse is developing a teaching plan for a client who must undergo an above-the-knee amputation of the left leg. After a leg amputation, exercise of the remaining limb:

wash and inspect feet daily.

The nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:

Red, warm, tender incision

The nurse is evaluating a postoperative client for infection. Which sign or symptom would be most indicative of infection?

Reporting signs of impaired circulation

The nurse is giving instructions to a client who's going home with a cast on his leg. Which point is most critical?

forcing blood into the deep venous system.

The nurse is instructing a client about the use of antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:

immediately after her menses.

The nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination:

"I must keep your door closed to prevent the spread of infection. I'll open the curtains so that you don't feel so closed in."

The nurse is placing a client on airborne precautions. The client asks the nurse to leave his door open. The best reply to this is:

establish unresponsiveness.

The nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first:

avoid administering more than the prescribed dose.

The nurse is preparing to remove a previously applied topical medication from a client. The rationale for removing previously applied topical medications before applying new medications is to:

The wound should remain moist from the dressing.

The nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-dry dressing. Which guideline is appropriate for a wet-to-dry dressing?

walk from his room to the end of the hall and back before discharge.

The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to:

protect the graft from direct sunlight.

The nurse is providing home care instructions to a client who has recently had a skin graft. It's most important that the client remember to:

obesity, inactivity, diet, and smoking.

The nurse is providing teaching to a client who's at risk for coronary artery disease (CAD). The nurse tells the client that CAD has many risk factors. Risk factors that can be controlled or modified include:

have a mammogram annually.

The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society guidelines, the nurse should recommend that the women:

use only a water-soluble lubricant when inserting a suppository.

The nurse is teaching a client about using vaginal medications. The nurse should instruct the client to:

exposure to the sun.

The nurse is teaching a client diagnosed with basal cell epithelioma. The most common cause of basal cell epithelioma is:

increase his activity level.

The nurse is teaching a client with a family history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:

the importance of informing his partner of the disease.

The nurse is teaching a client with genital herpes. Education for this client should include an explanation of:

changes from previous self-examinations.

The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:

washing hands.

The nurse is with a group of patient-care attendants reviewing infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is:

Following safer-sex practices

The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point about preventing transmission of the human immunodeficiency virus (HIV) is most important for the nurse to stress?

laminectomy.

The nurse is working on a surgical floor. The nurse must logroll a client following a:

inelastic skin turgor is a normal part of aging.

The nurse must assess skin turgor of an elderly client. When evaluating skin turgor, the nurse should remember that:

"What do you mean when you say...?"

To maintain a therapeutic environment with a client and his family, the nurse can use communication techniques such as the clarification technique. An example of the clarification technique is:

destroys the odor-proof seal.

The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:

obtain a physician's order to restrain the client when less restrictive interventions fail.

The nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to get out of bed. The nurse should:

keeping the bed in the lowest possible position.

The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is:

apply it immediately after the injury occurs.

The nurse is caring for a client with a right ankle sprain. When applying cold to the client's injury, the nurse should:

Because they debride the wound and promote healing by secondary intention.

For a diabetic client with a foot ulcer, the physician orders bed rest, a wet-to-dry dressing change every shift, and blood glucose monitoring before meals and at bedtime. Why are the wet-to-dry dressings used for this client?

place the client on his side, remove dangerous objects, and protect his head.

A client with seizure disorder is having a grand mal seizure. During the active seizure phase, the nurse should:

Decreased level of consciousness (LOC), anxiety, confusion, headache, and cool, moist skin.

A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?

Teach the client how to prevent problems caused by immobility.

A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan?

before age 20.

A male client should be taught about testicular examinations:

hepatitis B (HBV).

A nurse received an accidental needle stick while giving an I.M. injection. The greatest threat for the nurse is:

flexible visitation, participation in client care, and rest breaks.

A person's psychosocial needs during the dying process of a relative may include:

continuous inflow and outflow of irrigation solution.

A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to balloon inflation, the functions of the three lumens include:

client.

In community-based nursing, primary responsibility for decisions related to health care belongs to the:

depression.

In the stages of death and dying as defined by Elizabeth Kubler-Ross, feelings of loss, grief, and intense sadness are symptoms of:

every month, 7 to 10 days after menses starts.

A 25-year-old client asks the nurse how often and when she should perform breast self-examinations. The nurse should tell her:

use a 45- to 90-degree angle to insert.

A client has an order for 5,000 units of subcutaneous heparin every 12 hours. When injecting heparin subcutaneously, the nurse should:

Keep your right leg elevated above heart level.

A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide regarding cast care?

an extended family.

A client has three children and his mother lives with them. This is called:

place saline-soaked sterile dressings on the wound.

A client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to:

Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?

allow room for the client to turn.

A client is confused and continuously attempts to get out of bed. The physician prescribes a vest restraint. When applying a vest restraint, the nurse should:

block painful stimuli traveling over small nerve fibers.

A client is prescribed transcutaneous electrical nerve stimulation (TENS) for pain relief. The rationale for using TENS is to:

Evaluation

A client is to be discharged from an acute care facility following treatment for right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process?

start after a known voiding.

A client receiving total parental nutrition is prescribed a 24-hour urine test. When initiating a 24-hour urine specimen, the collection time should:

atelectasis.

A client undergoes a surgical procedure that requires the use of general anesthesia. Following general anesthesia, the client is most at risk for:

Avoid straining during bowel movements.

A client underwent cataract removal with an intraocular lens implant. The nurse is giving the client discharge instructions. These instructions should include which of the following?

Encouraging the client to discuss concerns with the clergy

A client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward God, his church, and the clergy. Which intervention is appropriate for this client?

distribute weight away from the involved side.

A client who recently had a stroke requires a cane to ambulate. When teaching about cane use, the rationale for holding a cane on the uninvolved side is to:

Dyspnea, tachycardia, and pallor

A client with iron deficiency anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of this type of anemia?

Take piroxicam with food or an antacid.

A client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?

Identify alternative ways for the client to lose weight.

An obese client is admitted to the hospital for abusing amphetamines in an attempt to lose weight. Which nursing intervention is appropriate for this client?

stay with him but not intervene at this time.

As a nurse is talking to a client, the client begins choking on his lunch. He's coughing forcefully. The nurse should:

"A living will allows my decisions for health care to be known if I'm not able to speak for myself."

The nurse is caring for a client with end-stage heart failure. Which statement by the client best demonstrates understanding of an advanced directive?

15 to 20 g of a fast-acting carbohydrate such as orange juice.

The nurse is caring for a client with type 1 diabetes mellitus who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse should first administer:

Bone fracture

The nurse is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication?

Frequent hand washing reduces transmission of pathogens from one client to another.

Policy and procedure dictate that hand washing is a requirement when caring for clients. Which statement about hand washing is true?

failing eyesight, especially close vision.

The nurse is collecting data on a 47-year-old client who has come to the physician's office for his annual physical. One of the first physical signs of aging is:

Flexible sigmoidoscopy beginning at age 50

The American Cancer Society recommends routine screening to detect colorectal cancer. Which screening test for colorectal cancer should the nurse recommend?

count the apical or radial pulse for 60 seconds.

The nurse is collecting data on a client admitted with a diagnosis of small bowel obstruction. When assessing the client's pulse rate, the nurse should:

hypoactive

The nurse is collecting data on a client who has developed a paralytic ileus. The client's bowel sounds will be:

diminished reflexes.

The nurse is collecting data on an elderly client. When collecting data, the nurse should consider that one normal aging change is:

Lock the medications in the medicine preparation area until the client returns.

The nurse delivers a client's 10 a.m. medications. The client is away from his room for a diagnostic study. Which action is most appropriate for the nurse to take?

check the client's identification bracelet.

The nurse is about to administer a medication to a client. To verify the client's identity, the nurse should:

less subcutaneous tissue and muscle mass than a younger client.

The nurse is administering I.M. injections to an older client. The nurse should remember that an older client has:

auricle up and back.

The nurse is administering eardrops to an adult client. To straighten the ear canal in an adult client before instilling the drops, the nurse should gently pull the:

conjunctival sac.

The nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, the nurse should instill the eyedrop into the:

under the tongue.

The nurse is administering sublingual nitroglycerin to a client with chest pain. The nurse should place the medication:

throbbing headache or dizziness.

The nurse is administering sublingual nitroglycerin to a client. Immediately afterward, the client may experience:

thirst or confusion.

The nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:

Post a turning schedule at the client's bedside.

The nurse is caring for a bedridden, elderly adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

inserting an indwelling urinary catheter.

The nurse is caring for a client admitted to the hospital with a bowel obstruction. The nurse should wear sterile gloves when:

Ensuring that personnel wash their hands before and after contact with every client

The nurse is caring for a client infected with methicillin-resistant Staphylococcus aureus (MRSA). What's the major infection control measure to reduce MRSA and other nosocomial pathogens in a health care setting?

Pain relief is initiated by the client as needed.

The nurse is caring for a client receiving patient-controlled analgesia (PCA) for pain management. Which statement about PCA is true?

Limit foods high in vitamin K.

The nurse is caring for a client taking an anticoagulant. Which instruction regarding anticoagulant therapy should the nurse give the client?

progressively deeper breaths followed by shallower breaths with apneic periods.

The nurse is caring for a client who has suffered a severe stroke. During data collection, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are:

limit client hip flexion while sitting.

The nurse is caring for a client who recently underwent a total hip replacement. The nurse should:

keeping his airway patent.

The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:

irrigate the NG tube gently with normal saline solution as prescribed.

The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should:

Notify the physician that the client is continuing to complain of pain.

The nurse is caring for a client who was given pain medication before leaving the postanesthesia care unit. Upon returning to her room, the client complains of pain and requests more pain medication. Which is the best action for the nurse to take?

below 70 mg/dl.

The nurse is caring for a client who's showing signs of hypoglycemia. This client will most likely have a blood glucose level:

Rotate the injection sites.

What can the nurse do to prevent lipodystrophy when administering insulin to a diabetic client?

balance the client's periods of activity and rest.

When caring for a client who's being treated for hyperthyroidism, it's important to:

elevate the head of the bed 90 degrees during meals.

When caring for a client with a nursing diagnosis of Impaired swallowing related to neuromuscular impairment, the nurse should:

Adjusting to retirement, deaths of family members, and decreased physical strength

When developing a care plan for an older adult (age 65 and older), the nurse should consider which challenges faced by clients in this age-group?

during the first meeting.

When developing a therapeutic relationship with a client, the nurse should begin preparing the client for termination of the relationship:

breathe deeply.

When inserting a urinary catheter, the nurse can facilitate the insertion by asking the client to:

Inspection, auscultation, percussion, and palpation

When performing an abdominal assessment, the nurse should follow which examination sequence?

Impaired mobility

When performing an assessment, the nurse collects the following data: impaired coordination, decreased muscle strength, limited range of motion, and the client's reluctance to move. This data indicates which nursing diagnosis?

left-lateral Sims' position.

When preparing a client for an enema, the nurse should help him into the:

administering pain medication.

When prioritizing a client's care plan based on Maslow's hierarchy of needs, the nurse's first priority would be:

Strawberries

When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?

The client no longer scratches his arms.

Which behavior suggests that a client has obtained relief from urticaria?

Provide the client with sleep aids, such as pillows, back rubs, and snacks.

Which intervention should the nurse try first with a client who exhibits signs of sleep disturbance?

Acute pain related to sickle cell crisis

Which nursing diagnosis should the nurse expect to see in a care plan for a client in sickle cell crisis?

Preventing bone injury

Which nursing intervention is most appropriate for a client with multiple myeloma?

Diphenhydramine hydrochloride (Benadryl)

While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand?