NCLEX Practice
The nursing instructor is observing a nursing student transfer a client from the bed to the chair. The instructor intervenes if the student is observed performing which action?
A. Keeping the back, neck, pelvis, and feet alligned B. Flexing the knees and keeping the feet wide apart C. Encouraging the client to assist as much as possible D. Positioning self as far away from the client as possible
The nurse prepares to bathe and change the bed linens of a client with methicillin-resistant Staphyloccoccus aureus in an abdominal wound covered by a dressing. Which protective action should the nurse take during the athing of this client?
A. Wear gloves B. Wear a gown and gloves C. Wears a gown, gloves, and a mask D. Wears a gown and gloves to change the bed linens and gloves only for the bath
The nurse is administering enteral feedings via nasogastric (NG) tube. The nurse should take which action when caring for this client to maintain client safety?
A. Keep the client in a supine position B. Change the NG tube with every other feeding C. Check for tube placement and residual at least every 4 hours D. Increase the rate of the feeding if the infusion falls behind schedule
A client is diagnosed with myasthenia gravis and the nurse needs to administer a medication to this client. Number the actions in the options in order of priority with regard to how the nurse should perform the actions.
1. Check the medication prescription 2. Elevate the head of the bed 3. Check swallowing ability 4. Administer precisely at prescribed time 5. Document administration of the medication 6. Monitor response to medication as the day progresses
The health care provider's prescription reads cyanocobalamin (vitamin B12) 150 mcg intramuscularly. Th medication label reads cyanocobalamin (vitamin B12), 100 mcg per 1 mL. The nurse prepares to safely administer how many milliliters to the client? (FITB)
1.5 150mcg/100mcg*1=1.5 mL
The health care provider prescribes amoxicillin 9Augmentin) 500 mg orally every 6 hours. The medication is supplied as 200mg/5mL. How many milliliters will be administer in each dose? (FITB)
12.5 500mg/200mg*5=12.5 mL
The health care provider prescribes 500 mL of 0.9% normal saline to run over 6 hours. The drop factor is 10 drops per 1 mL. The nurse safely adjusts the flow rate to run at how many drops per minute? Fill in the blank. Round to the nearest whole number.
14 500*10/360
Ampicillin sodium 250 mg in 50 mL of normal saline is being administered over a period of 30 minutes. The drop factor is 10 drops per 1mL. The nurse determines that the infusion is running safely at the prescrived rate if the infusion is delivering how many drops per minute? Fill in the blank. Round to the nearest whole number.
17 gtts/min Totaly volume in mL * Drop factor / Time in minutes = gtts/min 50mL*10gtts/mL / 30 minutes = 16.6 ~ 17gtts/min
The health care provider's prescription reads ampicillin 250 mg to be administered orally. The label on the medication vial reads 125 mg/mL. The nurse should prepare how many mililiters of ampicillin to administer the correct dose of medication? (FITB)
2 D/D*V 250/125*1=2mL
The health care provider prescribes atenolol (Tenormin) 0.05g orally daily. The label on the medication bottle states atenolol (Tenormin) 25-mg tablets, How many tablets will the nurse safely administer to the client? (FITB)
2 ` Convert 0.05 m to mg Either * 1000 or move decimal over 3 places 0.05 g = 50mg
Which meal selections would be most appropriate for the nurse to deliver to a Mormon client?
A. Waffles, bacon, fruit, and coffee B.Steak and eggs, toast, fruit, and coffee C. Scrambled eggs, hash browns, fruit, and green tea D. Sausage and cheese omelet, muffin, and orange juice
The health care provider prescribes a bolus of 500mL of 0.9% normal saline to run over 4 hours. The drop factor is 10 per 1mL. The nurse plans to safely adjust the flow rate at how many drops per minute? Fill in the blank. Round to the nearest whole number?
21 500*10/240
The health care provider prescribes 1000 mL of 0.9% normal saline to run over 8 hours. The drop factor is 15 drops per 1 mL. The nurse safely adjusts the flow rate to run at how many drops (gtts) per minutes? Fill in the blank. Round to the nearest whole number.
31 gtts/min 1000*15/480
A client who develops oral candidiasis receives a prescription for nystatin (Mycostatin) 500,000 units swish and swallow four times daily. The medication contains 100,000 units/1 mL. How many teaspoons should the practical nurse (PN) administer daily? (Enter numeric value only.)
4 100,000 unit : 1 mL 500,000 unit : x mL 500,000/100,000*1=5 5mL=1tsp/dose four doses/day = 4tsp/day
A postoperative client says to the nurse, "Don't touch me. I'll take car of myself!" Which response is therapeutic?
A. "Fine! I won't touch you!" B. "Let's work together so you can do things for yourself." C. I have to change your dressing so I have to touch you." D. If that's what you want, but I need to report this to the surgeon."
The nurse understands that which are judgmental statements? (SATA)
A. "I don't think you need to do that." B. "I would like to be sure I understand." C. "Tell me about making that decision." D. "I'm not sure that's what is best for you." E. "When did you first notice you felt that way?"
The nurse is reinforcing home care instructions to the client diagnosed with severe acute respiratory syndrom (SARS). Which statement, if mafe by the client indicates a need for further instruction?
A. "I may develop a dry cough after a few days." B. "I should avoid having visitors for some time." C. 'I need to be sure to wash my hands frequently." D. "It is okay to share eating utensils after a few days."
A mother of a 13-year-old boy states that her son is shorter than his peers and she fears that he will always be short. She tells the practical nurse (PN) that her adult daughter grew only 2 inches after she was 12 years of age. Which question is most important for the PN to ask this mother in order to provide information about pubescence, normal growth, and adolescent health?
A. "Is your son's short stature a social embarrassment to him or to the family?" B. "What types of foods did your children eat during infancy and childhood?" C. "Did your son have any birth trauma or any major trauma during his childhood?" D. "Did your daughter also start her menstrual period at 12 years of age?"
A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the practical nurse (PN) offer to attempt to alleviate her anxiety?
A. "Some care is required when touching the large soft area on top of your baby's head until the bones fuse together." B. "That's just an old wives' tale so don't worry. You can't harm your baby's head by touching the soft spot." C. "The soft spot will disappear within 6 weeks and is very unlikely to cause any problems for your baby." D. "There's a strong, tough membrane that protects the baby, so you can wash the scalp and comb the hair without injury."
A mother is being discharged following the birth of her second child. The mother tells the practical nurse (PN) that her first child died at 6 weeks of age because of sudden infant death syndrome (SIDS), and she fears that this infant will also develop SIDS. Which response is best for the PN to provide to this mother?
A. "You can prevent SIDS if your baby sleeps on his side or back. You will have to monitor him carefully." B. "The fear of losing another child to SIDS is very realistic. Have you thought about what you are going to do?" C. "An apnea monitor will alert you if the baby stops breathing. This will give you the peace of mind you need." D. "My neighbor's baby died of SIDS last year, and she went to a SIDS support group. That really helped her."
A client is admitted to a medical unit with nausea and bradycardia. The family is upset and states, "That doctor doesn't know how to take care of my father." The therapeutic response by the nurse is which statement?
A. "You're right" B. Don't worry about this. I'll take care of everything C. "You are concerned that your loved one receives the best care." D. "I think you're wrong. The health care provider has been in practice more than 30 years."
The nurse is auscultating the apical heart rate of a client who is not taking any prescribed medications and notes that the heart rate is regular. To determine beats per minute, the nurse should measure the apical pulse for how many seconds?
A. 15 seconds B. 30 seconds C. 45 seconds D. 60 seconds
The nurse is caring for a client who is retaining carbon dioxide (CO2) due to respiratory disease. The nurse anticipates that as the client's CO2 level rises, the pH will most likely be which value?
A. 7.30 B. 7.50 C. 7.70 D. 7.88
The nurse monitoring the laboratory results for a client receiving an antineoplastic medication by intravenous (IV) route should be prepared to initiate bleeding precautions if which laboratory result is noted?
A. A clotting time of 10 minutes B. An ammonia level of 20 mcg/dL C. A platelet count of 50,000 cells/mm3 D. A white blood cell (WBC) count of 5000 cells/mm3
The nurse understands that which are examples of a nonsocomial infection occurring in a health care facility? (SATA)
A. A common cold noted on a day one of hospitalization B. Sepsis that results from contaminated intravenous fluid C. A urinary tract infection that develops after catheter insertion D. A streptococci wound infection that develops in a postoperative client E. The development of Clostridium difficile in an immunocompromised client F. A respiratory tract infection that develops in a client receiving frequent respiratory treatments and requiring frequent suctioning
The nurse understands that which identifies a correct principle of surgical asepsis?
A. A sterile package that becomes wet is unsterile B. The nurse should hold sterile objects below waist level C. A 3-inch border around the edges of a sterile field is considered contaminated D. Prolonged exposures to air will not contaminate a sterile field as long as the client's room windows and doors are kept closed
The prescription for a client read "cleansing enemas until clear." The nurse has administered a total of three enemas, and the output is liquid brown. The nurse notifies the health care provider understanding that continued administration can result in which outcome?
A. Acid-base imbalances B. Blood pressure changes C. Electrolyte disturbances D. Blood glucose alterations
The nurse is reviewing the plan of care for the client who has just undergone bilateral knee replacement. Which intervention, if noted in the plan of care; indicated the need for follow-op?
A. Administer analgesics for pain B. Monitor surgical sites for drainage and infection C. Begin continuous passive range-of-motion exercise immediately D. Avoid total weight-bearing and instruct in the use of assistive devices
The nurse is preparing to assist in examining a Hispanic child who was brought to the clinic by the mother. While collecting data on the child, the nurse should take which actions? (SATA)
A. Admiring the child B. Taking the child's temperature C. Including the child in the discussion D. Obtaining an interpreter if necessary E. Making direct eye contact with the mother F. Asking the mother questions about the child
The nurse notes that the client's mechanical ventilator is set to control mode. The nurse understands that this setting will achieve which action?
A. Allows the lungs to rest B. Allows for spontaneous respirations C. Hyperventilates the client to ensure adequate oxygenation D. Provides some breaths for the client but allows the client to breathe on his/her own also
The nurse is conducting a respiratory assessment and is determining respirations per minute. The nurse understands that which factors generally affect the character of respirations? (SATA)
A. Anxiety B. Exercise C. Smoking D. Acute pain E. Body position F. Musculoskeletal disorders
The nurse is caring for an 18-month-old child who has been diagnosed with scabies. The health care provider has prescribed Lindane to be applied to the skin to treat the infection. The nurse should take which most appropriate action at this time?
A. Apply the medication to the child's skin B. Contact the health care provider for clarification C. Assess the parent's knowledge of the use of this medication D. Provide instructions to the parents of the child for application of the medication
The nurse is preparing to assist a client who is able to transfer with two assistants from the bed to the chair. The nurse requests assistance from staff members, but no staff members are able to help at this time. Which action by the nurse is most approperiate at this time?
A. Ask the client's family member to assist with the transfer B. Assist the client to transfer with the aid of the nurse and a walker C. Use a mechanical lift designed for one person to transfer the client D Inform the client that it is necessary to wait until someone can assist
The nurse suspects a foreign-body airway obstruction (FBAO) in a responsive infant. The nurse plans to relieve the obstruction by performing which action?
A. Attempting ventilation B. Performing blind finger sweeps C. Performing a head-tilt/chin-lift technique D. Delivering five back slaps and five chest thrusts
The health care provider prescribes naloxone (Narcan) for a client in the immediate postoperative period. Which assessment data should the practical nurse (PN) identify that indicate the naloxone has been effective?
A. Chest pain is subsiding. B. Respiratory rate is 16 breaths/min. C. Seizure activity has stopped. D. Pupils are constricted bilaterally.
The nurse has a prescription to administer the morning medications to a client through a nasogastric (NG) tube that is connected to wall suction. The nurse should implement which action to perform this procedure correctly?
A. Clamp the NG tube for 5 minutes following medication administration B. Position the client in an upright position before medication administration C. Flush the NG tube with 5mL of water following medication administration D. Adjust the suction to low-intermittent setting after medication administration
Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The practical nurse (PN) inserts the catheter, but no urine is seen in the tubing. What action should the PN take next?
A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the health care provider of a possible obstruction.
The nurse understands that personal health information can be disclosed in which situations? (SATA)
A. Compliance with legal proceedings B. For research purposed in limited circumstances C. To a family member or significant other in an emeregency D. To nonessential medical personnel involved in client care E. To appropriate military authorities if a client is a member of the armed forces
The nurse prepares to bathe and change the bed linens of a client with localized herpes zoster. The lesions are open and draining a scant amount of serious fluid. Which precaution should the nurse ensure is followed by all health care workers?
A. Contact B. Droplet C. Airborne D. Standard
The nursing instructor asks a nursing student to identify the type of isolation precautions necessary for the client with active tuberculosis (TB). The student understands the route of transmission if he student states that which type of isolation precaution should be maintained?
A. Contacts precautions B. Airborne precautions C. Standard precautions D. Handwashing precautions
A client has been instructed to restrict the diet to low-purine foods. Which foods shoulld the nursrse instruct the client to avoid?
A. Dairy products such as ice cream B. Certain fish such as shrimp or scallops C. High carbohydrate food such as potatoes D. Dark green, leafy vegetables such as spinach
Which should be included in a change-of-shift report?
A. Describing routine tasks performed B. Describing basic steps of a procedure C. Reviewing all biographical information about each client D. Describing objective measurements or observations about a client's condition
The nurse reinforces instructions to the client using an incentive spirometer and tells the client to sustain the inhaled breath for 3 seconds When the client asks the nurse about the rationale for this action, the nurse incorporates the understanding that which action is the primary benefit?
A. Dilate the major bronchi B. Increase surfactant production C. Maintain inflation of the alveoli D. Enhance cilliary action in the tracheobronchial tree
The clinic nurse is discussing nutrition with a client who is lactose intolerant. The nurse should reinforce instructions to the client to supplement the dietary source of calcium by eating which food?
A. Dried fruit B. Hard cheese C. Creamed spinach D. Fresh-squeezed orange juice
A 26-year-old gravida 2, para 1 client is admitted to the hospital at 28 weeks' gestation in preterm labor. She is given three doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop labor contractions. The practical nurse (PN) should monitor for which primary side effects of terbutaline sulfate?
A. Drowsiness and paroxysmal bradycardia B. Depressed reflexes and increased respirations C. Tachycardia and a feeling of nervousness D. A flushed, warm feeling and a dry mouth
A woman whose mother died of pancreatic cancer asks the practical nurse (PN) how she can avoid this disease. Which lifestyle change is most important for the PN to suggest to avoid developing pancreatic cancer?
A. Eat a low-fat diet. B. Cease cigarette smoking. C. Avoid drinking alcohol. D. Decrease carbohydrate intake.
Which communication stratergies should the nurse use when working with a client who has difficulty speaking as a esult of weakness? (SATA)
A. Encourages the client to speak quickly B. Ask "yes" and "no" questions when able C. Have the client use a communication board D. Repeat what the client said to verify the message E. Use a pen and paper to communicate clients needs F. Encourage verbal communication to strengthen the client's voice
While caring for a client with trigeminal neuralgia, the practical nurse (PN) observes the client experiencing a facial spasm. What action should the PN implement?
A. Engage the client in conversation as a distraction. B. Apply a warm towel to the client's face. C. Notify the charge nurse of the finding. D. Darken the client's room.
The nurse is preparing the client for transfer to the operating room (OR). The nurse should take which action in the care of this client at this time?
A. Ensure that the client has voided B. Administer all the daily medications C. Practice postoperative breathing exercises D. Verify that the client has not eaten for the last 24 hours
A 12-month-old with a respiratory infection and possible pneumonia is admitted to the hospital and placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant?
A. Give small frequent feedings of fluids. B. Accurately chart observations regarding breath sounds. C. Have a bulb syringe readily available to remove secretions. D. Encourage older siblings to visit.
The nurse is caring for a hospitalized child with a diagnosis of measles (rubeola). In preparing to care for the child, which supplies should the nurse bring to the child's room to prevent the transmission of the virus
A. Gown and gloves B. Goggles and gloves C. Mask, gown, and gloves D. Gown, gloves, and goggles
The nurse witness a construction worker fall from a ladder. The nurse rushes to the victim, who is unresponsive, and uses which method to open the victim's airway?
A. Head tilt/chin lift B. Head tilt/jaw thrust C. Jaw thrust maneuver D. Neutral or sniffing position
The practical nurse (PN) is completing a health risk assessment for a 6-month-old in a low-income neighborhood clinic. Which information should the PN include in the well-baby assessment?
A. Hearing acuity B. Immunization history C. Weight and length D. Head circumference
An older client has been lying in bed for 2 hours. The nurse who is repositioning this client would be most concerned with examining which areas of the client s body? (SATA)
A. Heels B. Sacrum C. Back of the head D. Back of the knees E. Greater trochanter F. Palms of the hand
The nurse is revieweing labroratory values that were prescribed to determind nutrition status for the older adult client. Which laboratory values would be of concern to the nurse? (SATA)
A. Hematocrit 30% B. Albumin 3.0 g/dL C. Calcium 10 mg/dL D. Hemoglobin 8 g/dL E. Creatinine 0.6 mg/dL F. Blood urea nitrogen 20 mg/dL
As prescribed, the nurse is applyin a dressing to a cllient's wound that allows wound visualization, is waterproof, and is painless on removal. Which type of dressing material is being used?
A. Hydrogel B. Cotton gauze C. Hydrocolloidal D. Adhesive transparent
The nurse educator is conducting a teaching session regarding the risk factors for the development of pressure ulcers. The nurse plans to include which factors in the teaching session? (SATA)
A. Immobility B. Moisture on the skin C. Skin pressure and shearing E. Increased sensory perception F. Urinary and bowel incontinence
A client with cancer who has been receiving fentanyl (Duragesic) for several weeks reports to the practical nurse (PN) that the medication is not effectively controlling the pain. Which intervention should the PN initiate?
A. Instruct the client about indications of opioid dependence. B. Monitor the client for symptoms of opioid withdrawal. C. Notify the RN or health care provider of the need for dose adjustment. D. Administer naloxone (Narcan) per PRN protocol for reversal.
The practical nurse (PN) is reviewing growth and development milestones of a 2-year-old during a routine well-child clinic visit. What behavior indicates that the child's language development is within normal limits?
A. Is able to name four colors B. Can count five blocks C. Is capable of making a three-word sentence D. Half of the child's speech is understandable.
The nurse educator is conducting a teaching session on the types of dehydration. The nurse describes on type as water and dissolved electrolytes being lost in equal proportions. Which type of dehydration is being describes?
A. Isotonic B. Hypotonic C. Hypertonic D. Intracellular
The nurse understands that which are characteristics of anthrax? (SATA)
A. It is caused by the bacillus Yersinia pestis B. Cutaneous lesions become a black eschar C. Gastrointestional anthrax causes bloody diarrhea D. Flulike symptoms are a sign of pulmonary anthrax E. Person-to-person transmission of inhalation disease does not occur F. A person can become infected through skin contact, ingestion, or inhalation of the bacillus
A 6-month-old infant is admitted to the postsurgical unit with elbow restraints in place. What nursing intervention should the practical nurse (PN) include in this child's care?
A. Keep restraints on at all times to prevent dislodging any invasive lines. B. Remove restraints one at a time and provide range-of-motion exercises. C. Remove all restraints simultaneously and provide play activities. D. Document the reason for application of the restraints q72h.
The nurse is demonstrating adult cardiopulmonary resuscitation (CPR) chest compression techniques to health care team members. Which action performed by a member on return demonstration indicates the need for additional teaching in the performance of CPR?
A. Lets the finger rest on the chest B. Straightens the arms and locks the elbows C. Keeps the shoulders directly over the hands D. Places the heel of the hand over the lower half of the sternum
The nurse should institute contact precautions for which disease?
A. Measles B. Varicella C. Pulmonary tuberculosis D Respiratory syncytial virus
Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Based on the clinical manifestations of Cushing syndrome, which intervention should the practical nurse (PN) implement that is most appropriate for a client who is newly diagnosed with Cushing syndrome?
A. Monitor blood glucose levels daily. B. Increase intake of fluids high in potassium. C. Encourage adequate rest between activities. D. Offer the client a sodium-enriched menu.
The nurse performing an eye assessment notes that the client can see objects clearly that are far away but cannot see objects cllearly that are close-up. The nurse documents this finding as which condition?
A. Myopia B. Hyperopia C. Photophobia D. Accomodation
An adult client is admitted with a possible kidney tumor and is scheduled for an intravenous pyelogram (IVP) in the morning. The practical nurse (PN) should prepare the client before the IVP by implementing which protocol?
A. NPO after midnight. B. Strain all urine for sediment. C. Insert an indwelling catheter. D. Monitor for allergic responses to iodine.
The nurse collection data on the home environment of an older client would be concerned about which unsafe findings? (SATA)
A. Nonskid surfaces on slippers B. Nonskid backing on small rugs C. Electrical cords taped to the floor D. Bath mats on the shower stall floor E. Electrical appliances and cords near the sink
The practical nurse (PN) observes that a male client has removed the covering from an ice pack applied to his knee. What action should the PN take first?
A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin.
An adolescent client with a surgically wired jaw has a prescription for a full liquid diet. The nurse should implement which action to promote the client's compliance with this diet prescription?
A. Offer chocolate milkshakes between meals B. Explain to the adolescent the importance of good nutrition C. Offer commercial nutritional supplements 4 to 6 times per day D. Ask about food preferences and blenderize these foods into liquids
Following heparin treatment for a pulmonary embolism, a client is being discharged with a prescription for warfarin (Coumadin). During discharge teaching, the practical nurse (PN) reinforces the importance of having which diagnostic test regularly after discharge?
A. Perfusion scan B. Prothrombin time/international normalized ratio (PT/INR) C. Activated partial thromboplastin (APTT) D. Serum Coumadin level (SCL)
The nurse should take which action to accurately determine the length of a nasogastric tube for insertion in an adult client?
A. Place the tube at the tip of the nose and measure by extending the tube to the umbilicus B. Place the tube at the tip of the nose and measure y extending the tube midway between the umbilicus and symphysis pubis C. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process D. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum
The nurse understands that the dietary preferences of an African-American client may include which foods? (SATA)
A. Pork B. Rice C. Fruits D. Greens E. Red meat F. Fried food
The nurse reviews the most current laboratory datta for the four clients to whom the urse is assigned. The nurse should first collect data on the client with which laboratory result?
A. Potassium 5.0 mEq/L B. Hemoglobin 11.8 g/dL C. Platelets 40,000 cells/mm3 D. White blood cell (WBC) count 5000 cells/mm3
During the admission process, the practical nurse (PN) determines that a male client who is scheduled for surgery in the morning has a blood pressure of 160/85 mm Hg. He is drinking coffee and says his blood pressure has never been that high. The PN plans to retake the blood pressure in 30 minutes. This action indicates that the PN recognizes that the elevated blood pressure is likely to be caused by which factor?
A. Preoperative anxiety B. Lack of exercise C. Consuming caffeine D. Current medications
When a client is immobilized, which action should the practical nurse (PN) take to prevent alterations in urinary elimination?
A. Prepare to insert a urinary catheter. B. Provide oral fluids at frequent intervals. C. Place incontinent pads under the buttocks. D. Maintain the client in a supine position.
The nurse is caring for a client whose religious background is Seventh Day Adventist (Church of God). Which nursing actions are most appropriate in terms of providing for the dietary needs for this client? (SATA)
A. Providing snacks between each meals B. Providing wine with dinner as requested C. Removing coffee from the breakfast tray D. Ensuring that there is no pork on the dinner tray E. Ensuring that meals are delivered in a timely fashion
The nurse is applying and removing personal protective equipment (PPE) when providing care. Number the actions in the options in order of priority with regard to how the nurse should perform this procedure. (Number 1 is the first action and nuber 6 is the last action.)
A. Put on gown B. Put on gloves C.Puton mask D. Remove mask E. Remove gown F. Remove gloves
The pulse point to use when assessing a pulse in an infant is located in which area?
A. Radial B. Carotid C. Brachial D. Popliteal
Which safety measures should be included in the plan of care for a client with an internal radiation implant? (SATA)
A. Wear a lead shield when in client's room B. Place the client in a room with a cohort client C. Limit the time with the client to 1 hour per shift D. Wear a dosimeter badge when entering the client's room E Save bed linens and any dressings until the implant is removed
The nurse is caring for a client whose religious back background is Orthodox Judaism. The nurse is delivering the dinner tray to the client. Which nursing actions are most appropriate in order to provide for the dietary needs of this client? (SATA)
A. Removing the milk if there is meat on the tray B. Determining that any fish being served has scales or dins C. Ensuring that if there is pork on the tray, it is thoroughly cooked D. Checking to be sure that any meat being served is from an herbivore E. Asking the client about specific dietary preferences that need to be followed
The nurse is reviewing the laboratory report for the client who had a urine specific gravity determination done. The report indicates a value of 1.030. The nurse understands that which condition may potentially be causing this result?
A. Renal disease B. Diabetes insipidus C. Decreased renal perfusion D. Inability of the kidneys to concentrate urine
The nurse collects data and auscultates bowel sounds and suspects an intestinal obstruction in a client with a bowel tumor if which is heard?
A. Resonance B. Diminished-sounds C. High-pitched sounds D. Absent bowel sounds in all four quadrants
The nurse determines that the client understands the elements of follow-up care after a bone scan if the client states that he or she should perform which actions? (SATA)
A. Resume the usual diet B. Ambulate at least three times before the end of the day C. Drink plenty of water for a day or two following the procedure D. Report any feelings of nausea or flushing to the health care provider E. Remain isolated in a room for 24 hours to prevent exposure of the radioisotope materials to others
The nurse is gathering data by inspecting the lacrimal apparatus of a client's eye. Due to its anatomical location, the nurse should perform which action?
A. Retracts the lower eyelid and ask the client to look up B. Retract the upper eyelid and ask the client to look up C. Retract the upper eyelid and ask the client to look down D. Retracts the lower eyelid and ask the client to look down
The practical nurse (PN) should implement droplet precautions for a client admitted with which diagnosis?
A. Scabies B. Herpes simplex C. Meningococcal pneumonia D. Multidrug-resistant organism infection
The nurse should implement droplet precaustions for a client with which communicable disease? (SATA)
A. Scabies B. Pertussis C. Herpes simplex D. Respiratory syncytial virus E. Scarlet fever
When turning an immobile bedridden client without assistance, which action by the practical nurse (PN) best ensures client safety?
A. Securely grasp the client's arm and leg. B. Put the bed rails up on the opposite side. C. Correctly position and use a turn sheet. D. Lower the head of the client's bed.
A 46-year-old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test should the practical nurse (PN) review to determine the best indicator of adequate glomerular filtration?
A. Serum creatinine B. Blood urea nitrogen (BUN) C. Sedimentation rate D. Urine specific gravity
When discussing a health care plan with a female Amish client, the nurse should perform which actions? (SATA)
A. Speak only to the husband B. Avoid using medical terms C. Maintain adequate space D. Use complex scientific terminology E. Stand close to the client and speak loudly
The nurse understands that which procedures are used to detect the presence of dysrhythmias? (SATA)
A. Telemetry B. Holter monitor C. Pulse oximetry D. Electrocardiogram E. Blood pressure monitoring
During a well-child clinic visit, the practical nurse (PN) is teaching the parents of a toddler about prevention of accidental poisonings. What information should the PN reinforce?
A. Tell children they should not taste anything but food. B. Store all toxic agents and medicines in locked cabinets. C. Provide special play areas in the house and restrict play in other areas. D. Punish children if they open cabinets that contain household chemicals.
Which client is at greatest risk for fluid volume deficit?
A. The client on diuretic therapy B. The client on fertility medications C. The client on corticosteroid therapy D. The client on antiseizure medications
The nurse is assigned to the following four clients for total care during the day shift. Breakfast trays are arriving, and the common practice on the unit is to assist clients to the bedside chair to eat. Which client will require the greatest assistance from the nurses?
A. The client who underwent right hip replacement B. The client who underwent left knee replacement C. The client who underwent right ankle replacement D. The client who underwent repair of a rotator cuff, left shoulder
The nurse is performing catheter care for a client who has an indwelling urinary catheter. Which action, if performed by the nurse, is indicative of unsafe practice?
A. The nurse performs hand hygiene before and after the procedure B. The nurse removes the anchor device to free the catheter tubing before cleaning C. The nurse cleans from the area of most contamination to the area of least contamination D. The nurse places a waterproof pad under the client and applies clean gloves before the procedure
A 68-year-old client has been diagnosed with open-angle glaucoma. The health care provider prescribes pilocarpine (Isopto Carpine) eye drops. What action of this drug makes it a useful treatment for the client's condition?
A. The production of aqueous humor in the eyes is decreased. B. Ciliary muscles are paralyzed to decrease accommodation. C. Bilateral mydriasis with cycloplegia is accomplished. D. The outflow of aqueous humor in the eyes is increased.
The nurse notes that a 5-year-old child is choking but is awake and alert at this time. As the nurse rushes to aid the child, the nurse plans to plae the hands between which landmarks to perform the abdominal thrust maneuver?
A. The umbilicus and the groin B. The lower abdomen and chest C. The groin and the xiphoid process D. The umbilicus and xiphoid process
The nurse is performing closed catheter irrigtion on an assigned client. Which outcome, if noted by the nurse, indicates the need for follow-up?
A. The urine is noted to be cloudy and dark in color B. The prescribed rate is flowing into the bladder freely C. The instillation solution returns into the drainage bag D. There is no bladder distention noted during the procedure
The nurse is planning to reinforce teaching about home medications to reduce the risk of falls. Which recommendations should be included in the teaching plan? (SATA)
AA. Remove wall-to-wall carpeting B. Use nightlights during nighttime C. Place handrails in bathtubs and showers D. Check staircase railings for secureness and sturdiness E. Place scatter rugs on hardwood floors and at the bottom of a staircase
The nurse is collecting cardiovascular data on an assigned client.
Carotid
