NCLEX pracitce test
The nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further teaching?
"I need to be sure to place my cup of coffee on the counter."
The nurse is assisting in preparing a client for discharge to home. Daily cold therapy has been prescribed for the client, and the nurse reinforces instructions about this treatment. Which client statements indicate adequate understanding of cold therapy treatment?
"I will remove the ice pack if I start to feel numbness." "I should wrap the frozen ice pack in a towel to help adjust to the cold."
The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse would check the client's room to ensure that which priority item is at the bedside?
A pair of scissors
The nurse assists a primary health care provider (PHCP) with the insertion of a nasogastric tube. Which positions would the nurse place the client in to prepare for the procedure?
High-Fowler's position Slight extension of the neck
A licensed practical nurse (LPN) asks an assistive personnel (AP) to gather supplies in preparation for administering a tepid bath to a child with an elevated temperature. The LPN intervenes if the AP obtains which unnecessary item(s)?
A bottle of alcohol
Which client is the safest one for a licensed practical nurse (LPN) to care for?
A client recovering from a scheduled cesarean delivery
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?
Activate the fire alarm.
The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief?
Alternating air pad
Rho(D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition?
Being affected by Rh incompatibility
The nurse is caring for a client who is receiving an intermittent feeding via a nasogastric (NG) tube. Before feeding the client via the NG tube, the nurse would take which actions?
Check the placement of the tube. Aspirate the contents from the nasogastric tube. Observe the characteristics and pH of the aspirate from the nasogastric tube.
The nurse is preparing to discontinue an indwelling urinary catheter. Which pieces of equipment would the nurse obtain to perform this procedure?
Clean towel Sterile 10- or 12-mL syringe
The nurse is inquiring about the client's use of complementary and alternative medicines (CAMs). The nurse would be most concerned with the client who uses which CAMs?
Homeopathy Herbal supplements
The nurse is preparing to administer an acetaminophen suppository to a child. The nurse plans which action?
Insert the suppository 1 to 2 cm into the rectum.
The nurse is reinforcing instructions to a client about safety measures while using oxygen in the home. The nurse determines that there is a need for further teaching if the client verbalized which statement?
Keep the oxygen concentrator as close to the room wall as possible.
The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy?
Pedal pulses Capillary refill Color of the extremity Temperature of the skin Presence of numbness
The nurse is planning to get a client out of bed for the first time after having a total hip arthroplasty (THA). What specific actions would the nurse take?
Place a gait belt on the client. If stretch bands are used, reinforce the correct use. Observe for any signs/symptoms of dizziness the first time the client gets out of bed. After the client sits on the side of the bed, remind the client to stand on the unaffected leg.
The nurse is caring for a client who underwent a spinal fusion with a metal implant. The nurse notes that the back dressing is wet with clear drainage. Which actions would the nurse take?
Place the client flat in bed. Notify the registered nurse of the drainage.
The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How would the nurse determine that the restraints are not too constrictive?
Place two fingers under the restraint to determine snugness.
The nurse is caring for a home bound older postoperative cardiovascular client. The caregiver's daughter says to the nurse, "My mother has fallen out of bed three times." Which actions would the nurse reinforce to prevent falls?
Provide adequate lighting. Ensure that frequently used items are easily accessible. Have the bedside stand and over bed tray table within reach.
The nurse employed in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which is the immediate action of the nurse?
Remove the clients from the waiting room.
The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula at 2L. To provide a safe delivery of the oxygen the nurse would avoid which actions? S
Securing the oxygen tubing to the client's bottom sheet Positioning the nasal prongs in the nares and adjusting the plastic slide on the cannula so that the cannula fits as tight as possible
The nurse obtains a prescription to restrain a client using a belt (safety) restraint and instructs the assistive personnel (AP) to apply the restraint. Which observation, if made by the nurse, indicates unsafe application of the restraint?
The restraint straps are safely secured to the side rails.
The registered nurse (RN) and a licensed practical nurse (LPN) are discussing total parenteral nutrition (TPN) with a client who is receiving TPN through a peripherally inserted central catheter (PICC). The client asks why the solution is being infused through a central catheter IV. The nurses explain that TPN is preferably infused through a central line for which reason?
There is greater blood flow with a central line IV to dilute the TPN, which is a concentrated solution and needs to be diluted to avoid damage to the blood vessel.
The nurse admits a client who has seizure precautions prescribed. The client has a seizure just after the nurse has implemented the precautions. Which actions would the nurse take?
Time the start and stop of the seizure. Apply oxygen at 2L with nasal cannula. Turn the client to the side and do not restrain. Note the distinguishing characteristics of the seizure. Turn on the suction machine with oral catheter.
The nurse is assisting in the care of a client diagnosed with acquired immunodeficiency syndrome (AIDS) who requires an injection. The nurse would include which actions to safely administer the medication?
Wear gloves while administering the injected medication. Dispose of the needle and syringe in a puncture-resistant container.
The nurse is assisting with planning care for a client with an internal radiation implant. Which would be included in the plan of care?
Wearing gloves when emptying the client's bedpan Keeping all linens in the room until the implant is removed Wearing a film (dosimeter) badge when in the client's room Wearing a lead apron when providing direct care to the
The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client?
Eat a nutritious diet with adequate protein. Use a pressure relief pad while in a wheelchair. Check the bottom sheet for wetness and wrinkles.
The nurse is caring for a client who becomes agitated and begins to pull on a surgically placed abdominal drainage tube. The primary health care provider visits and prescribes restraints if needed. Which actions are appropriate to delegate to the assistive personnel (AP), who has completed the facility's education about care of the restrained client?
Socialize with the restrained client. Remove the restraint and perform range of motion activity. Reapply the restraint after assisting the client to the bathroom.
A client with chronic pain has been taught how to operate a transcutaneous electrical nerve stimulation (TENS) unit. Which client action shows understanding of the appropriate use of the device when the level of stimulation is uncomfortable?
The client adjusts the setting downward slightly.
The nurse determines that the client has a proper fitting of the crutches when which criteria have been fulfilled?
Hand grips are positioned so the elbows are bent approximately 30 degrees. The space between the axilla and the top of the crutch pad is 1½ to 2 inches. The nurse can place 3 to 4 fingerbreadths between the axilla and the crutch pad.
The nurse is assigned to assist in caring for a client who has had surgery and has pneumatic sequential compression devices (SCDs) in place. The client asks about these devices. The nurse instructs the client that SCDs are used for which purpose?
Promoting venous return to the heart
The nurse is caring for an older client who had surgery to repair a fractured hip. In the late evening the client becomes slightly confused and is moving about in bed. Which actions would the nurse take initially?
Turn on the bed alarm. Ask the client about needing to void or move bowels Turn on the nightlight in the hospital room and bathroom.
The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently?
Every hour
The nurse initiates a prescription from the primary health care provider and restrains a client who has a chest tube connected to suction. The client is confused and continues to remove the dressing around the tube and pulls at the tube. Which information would the nurse document in the client's medical record regarding restraints?
Adequacy of circulation in the body area that is restrained Type of restraint and body area where the restraint was applied Communication with client and family member about need for restraint The alternative measures that were attempted before restraints were applied
An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse would plan to do which as a first step for the prevention of future injury?
Explore the adolescent's knowledge of gun safety.
The nurse in the hospital is assisting in developing a plan of care for an older client to prevent a fall. Which actions would be least likely to prevent a fall?
Keeping the bathroom light off at nighttime Placing the client in the quiet area of the nursing unit in a room away from the nurse's station
The nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric (NG) tube. The nurse checks the residual and obtains an amount of 200 mL. Which actions would the nurse take?
Listen to the client's bowel sounds. Question the client regarding nausea. Determine whether the client has abdominal distension. Hold the feeding after flushing the tubing with 30 mL saline.
A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measures are necessary when caring for this client?
Monitoring the skin around the stoma site for skin irritation Administering intermittent feeding through a 60-mL syringe with the plunger removed and the barrel attached to the gastrostomy tube
the nurse is instructing a group of assistive personnel (AP) in the principles of body mechanics. The nurse determines that an AP is using the principles appropriately if the nurse observes the AP doing which action?
Positioning a box that is to be lifted between the knees
The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client. Which instructions would be included in the list?
Obtain a Medic-Alert bracelet. Prevent debris from entering the stoma. Avoid exposure to people with infections. Avoid swimming and use care when showering.
The nurse is assigned to the care of a client who is being admitted to a facility. The nurse notes which observations as indications the client likely has a hearing deficit?
The client answers questions incorrectly. The client states she quit attending social events. The client does not respond to a person unless facing the speaker.
While caring for a client admitted to the hospital with suspected seizure activity, the client acknowledges the use of the herbal supplement ginkgo, to the nurse. Which follow-up questions by the nurse would be most appropriate?
Do you have a history of seizures? Do you have a history of a clotting disorder? How long and why have you been using ginkgo? Have you been diagnosed with diabetes mellitus?
The nurse is reinforcing instructions to a client with chronic vertigo that is poorly controlled. The nurse stresses the importance of which safety measure to prevent injury or exacerbation of symptoms?
Removing throw rugs and clutter in the home
