NCLEX Practice Questions #1

The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement? 1."I need to wear a MedicAlert tag or bracelet." 2."I need to restrict my activity while this catheter is in place." 3."I need to keep the insertion site protected when in the shower or bath." 4."I need to check the markings on the catheter each time the dressing is changed."

-2."I need to restrict my activity while this catheter is in place."

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? 1."I will watch for the evidence of the passage of tissue." 2."I will maintain strict bed rest throughout the remainder of the pregnancy." 3."I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad." 4."I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding."

-2."I will maintain strict bed rest throughout the remainder of the pregnancy."

The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client's record, should the nurse question? 1.Digoxin 2.Furosemide 3.Indomethacin 4.Propranolol hydrochloride

-3.Indomethacin

Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of blood, the client begins to shout, "You're all vampires. Let me out of here!" Which nursing response addresses the client's anxiety? 1."What makes you think that I am a vampire?" 2."I'll leave and come back later for the specimen." 3."Do you remember discussing the lab work earlier?" 4."It must be frightening to think that others want to hurt you."

-4."It must be frightening to think that others want to hurt you."

Silver sulfadiazine is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? 1."The medication is an antibacterial." 2."The medication will help heal the burn." 3."The medication is likely to cause stinging every time it is applied." 4."The medication should be applied directly to the wound."

3."The medication is likely to cause stinging every time it is applied."

Which client statements best demonstrate to the nurse that the client understands the concepts of an advance directive? Select all that apply. 1. "This document is a separate document from my final will." 2."This document is strictly for indicating if I want to be resuscitated." 3."I need to have my family sign this document in case my condition worsens." 4."This document describes the kind of treatment I want depending on how sick I am." 5."This document tells what I want and gives medical power of attorney to my doctor."

-1. "This document is a separate document from my final will." -4."This document describes the kind of treatment I want depending on how sick I am."

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1. Twitching 2.Hypoactive bowel sounds 3.Negative Trousseau's sign 4.Hypoactive deep tendon reflexes

-1. Twitching

The home care nurse has taught a client with a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided? 1."I will eat enough daily fiber to prevent straining at stool." 2."I will try to exercise vigorously to strengthen my heart muscle." 3."I will drink 3000 to 3500 mL of fluid daily to promote good kidney function." 4."Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels."

-1."I will eat enough daily fiber to prevent straining at stool."

The home care nurse is reviewing the record of a client newly diagnosed with glaucoma who is scheduled for a home visit. The nurse notes that the health care provider (HCP) has prescribed atropine sulfate and pilocarpine hydrochloride eye drops. The nurse should contact the HCP before the home visit for which reason? 1.Clarify the prescription for the atropine sulfate. 2.Clarify the prescription for the pilocarpine hydrochloride. 3.Determine the date of the scheduled follow-up HCP visit. 4.Determine the extent of the intraocular pressure caused by the glaucoma.

-1.Clarify the prescription for the atropine sulfate.

The nurse has a prescription to obtain a 24-hour urine collection in a client with a renal disorder. Which actions should the nurse take when collecting this specimen? (SATA) 1.Explain the procedure to the client. 2.Save all subsequent voidings after the first void during the 24-hour period. 3.During the collection period, place the main container on ice or in a refrigerator. 4.Have the client void at the end time, and place this specimen in the main container. 5.Have the client void at the start time, and place this specimen in the main container.

-1.Explain the procedure to the client. -2.Save all subsequent voidings after the first void during the 24-hour period. -3.During the collection period, place the main container on ice or in a refrigerator. -4.Have the client void at the end time, and place this specimen in the main container.

The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin? 1.Fine grayish red lines 2.Purple-colored lesions 3.Thick, honey-colored crusts 4.Clusters of fluid-filled vesicles

-1.Fine grayish red lines

A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? (SATA) 1.Giving tepid sponge baths 2.Applying a hypothermia blanket 3.Covering the client with blankets 4.Administering acetaminophen per protocol 5.Placing ice packs over the client's abdomen and in the axilla and groin

-1.Giving tepid sponge baths -2.Applying a hypothermia blanket -4.Administering acetaminophen per protocol

Cyclobenzaprine is prescribed for a client for muscle spasms and the nurse is reviewing the client's record. Which disorder, if noted in the record, would indicate a need to contact the health care provider about the administration of this medication? 1.Glaucoma 2.Emphysema 3.Hypothyroidism 4.Diabetes mellitus

-1.Glaucoma

Which is considered a normal finding in a newborn less than 12 hours old? 1.Has not passed meconium yet 2.Seesaw respirations of 28 breaths/minute 3.Total serum bilirubin level of 15.2 mg/dL (258 mcmol/L) 4.White blood cell (WBC) count of 50,000 mm3 (50 × 109/L)

-1.Has not passed meconium yet

A pediatric nurse has obtained ribavirin in powder form from the pharmacy to administer to a child with respiratory syncytial virus (RSV) infection. After preparing the medication, the nurse should administer it by which route? 1.Inhalation 2.Intravenous 3.Subcutaneous 4.Oral, in the child's formula

-1.Inhalation

The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent? 1.Palpation of a thrill over the fistula 2.Presence of a radial pulse in the left wrist 3.Visualization of enlarged blood vessels at the fistula site 4.Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand

-1.Palpation of a thrill over the fistula

A nurse is assessing the status of jaundice in a child with hepatitis. Which anatomical areas will provide the best data regarding the presence of jaundice? (SATA) 1.The sclera 2.The nail beds 3.The mucous membranes 4.The skin in the sacral area 5.The skin in the abdominal area

-1.The sclera -2.The nail beds -3.The mucous membranes

A 9-year-old child with leukemia is in remission and has returned to school. The school nurse calls the mother of the child and tells the mother that a classmate has just been diagnosed with chickenpox. The mother immediately calls the clinic nurse because the leukemic child has never had chickenpox. Which is an appropriate response by the clinic nurse to the mother? 1."There is no need to be concerned." 2."Bring the child into the clinic for a vaccine." 3."Keep the child out of school for a 2-week period." 4."Monitor the child for an elevated temperature, and call the clinic if this happens."

-2."Bring the child into the clinic for a vaccine."

The nurse provides a teaching session to the nursing staff regarding osteosarcoma. Which statement by a member of the nursing staff indicates a need for information? 1."The femur is the most common site of this sarcoma." 2."The child does not experience pain at the primary tumor site." 3."Limping, if a weight-bearing limb is affected, is a clinical manifestation." 4."The symptoms of the disease in the early stage are almost always attributed to normal growing pains."

-2."The child does not experience pain at the primary tumor site."

The nurse is caring for a Hispanic American client admitted with a diagnosis of diabetic ketoacidosis. Several family members are present. What examples of nonverbal communication would the nurse expect? (SATA) 1.Maintaining eye contact 2.Dramatic body language 3.Smiling and shaking hands 4.Avoiding any confrontations with staff 5.Consistently expressing negative feelings 6.Using gestures or facial expressions to express emotion or pain

-2.Dramatic body language -3.Smiling and shaking hands -4.Avoiding any confrontations with staff -6.Using gestures or facial expressions to express emotion or pain

The nurse is assigned to care for a client who is in Buck's traction. The nurse prepares a plan of care for the client and includes which nursing action in the plan? 1.Make sure that the knots are at the pulleys. 2.Inspect the skin under the boot at least every 8 hours. 3.Make sure the head of the bed is kept at a 45- to 90-degree angle. 4.Monitor the weights to be sure that they are resting on a firm surface.

-2.Inspect the skin under the boot at least every 8 hours.

The nurse has a prescription to give a client salmeterol, 2 puffs, and beclomethasone dipropionate, 2 puffs, by metered-dose inhaler. The nurse should administer the medication using which procedure? 1.Beclomethasone first and then the salmeterol 2.Salmeterol first and then the beclomethasone 3.Alternating a single puff of each, beginning with the salmeterol 4.Alternating a single puff of each, beginning with the beclomethasone

-2.Salmeterol first and then the beclomethasone

A mother brings her 5-week-old infant to the health care clinic and tells the nurse that the child has been vomiting after meals. The mother reports that the vomiting is becoming more frequent and forceful. The nurse suspects pyloric stenosis and asks the mother which assessment question to elicit data specific to this condition? 1."Are the stools ribbon-like, and is the infant eating poorly?" 2."Does the infant suddenly become pale, begin to cry, and draw the legs up to the chest?" 3."Does the vomit contain sour, undigested food without bile, and is the infant constipated?" 4."Does the infant cry loudly and continuously during the evening hours but nurses or takes formula well?"

-3."Does the vomit contain sour, undigested food without bile, and is the infant constipated?"

The nurse is monitoring for bleeding in a child following surgery for removal of a brain tumor. The nurse checks the head dressing and notes the presence of dried blood on the back of the dressing. The child is alert and oriented, and the vital signs and neurological signs are stable. Which nursing action is most appropriate initially? 1.Prepare to change the dressing. 2.Recheck the dressing in 1 hour. 3.Check the operative record to determine whether a drain is in place. 4.Document the findings and notify the health care provider immediately.

-3.Check the operative record to determine whether a drain is in place.

The nurse hears that a client receiving total parenteral nutrition (TPN) at 100 mL/hr has bilateral crackles and 1+ pedal edema during shift report. When the nurse obtains a daily weight, the nurse notes that the client has gained 4 lbs (1.8 kg) in 2 days. Which action should the nurse take first? 1.Administer the prescribed daily diuretic. 2.Encourage the client to cough and deep breathe. 3.Compare the intake and output records of the past 2 days. 4.Slow the TPN infusion rate to 50 mL/hr per infusion pump.

-3.Compare the intake and output records of the past 2 days.

The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate? 1.Document the findings. 2.Reinforce the dressing. 3.Notify the health care provider (HCP). 4.Mark the area of drainage with a pen and monitor for further drainage.

-3.Notify the health care provider (HCP).

The nurse is preparing a plan of care for an infant who will be returning from the recovery room following the surgical repair of a cleft lip located on the right side of the lip. On return from the recovery room, the nurse should plan to place the infant in which position? 1.Prone and flat 2.Supine and flat 3.On the left side 4.On the right side

-3.On the left side

The nurse is caring for a client who has just returned from the postanesthesia care unit after radical neck dissection. The nurse should assess for which characteristic of wound drainage expected in the immediate postoperative period? 1.Serous 2.Grossly bloody 3.Serosanguineous 4.Serous with sputum

-3.Serosanguineous

A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse? 1."Why do you believe your roommate would steal from you?" 2."I'll see if I can arrange for you to move in with a different roommate." 3."Tell me more about your belief that your roommate would steal from you." 4."I hear what you are saying, but I have no reason to believe your roommate steals."

-4."I hear what you are saying, but I have no reason to believe your roommate steals."

After surgical evacuation and repair of a paravaginal hematoma, a client is discharged 3 days postpartum. The nurse determines that the client needs further discharge instructions when the client makes which statement? 1."I will probably need my mother to help me with housekeeping." 2."Because I am so sore, I will nurse the baby while lying on my side." 3."My husband and I will not have intercourse until the stitches are healed." 4."The only medications I will take are prenatal vitamins and stool softeners."

-4."The only medications I will take are prenatal vitamins and stool softeners."

A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription? 1. Obtains a weight 2.Takes the temperature 3.Takes the blood pressure 4.Checks the amount of urine output

-4.Checks the amount of urine output

The nurse notes redness, warmth, and a yellowish drainage at the insertion site of a central venous catheter in a client receiving total parenteral nutrition. What is the nurse's initial action? 1.Administer diphenhydramine. 2.Decrease the rate of infusion. 3.Notify the health care provider (HCP). 4.Evaluate for signs of septicemia.

-4.Evaluate for signs of septicemia.

Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect? 1.Pruritus 2.Tachycardia 3.Hypertension 4.Impaired voluntary movements

-4.Impaired voluntary movements

When should the nurse advise a client being prescribed fluoxetine hydrochloride to take the medication? 1.Just before bedtime 2.With the evening meal 3.At noon with an antacid 4.In the morning on first arising

-4.In the morning on first arising

The nurse who is reviewing the record of a client admitted to the mental health unit notes that the client was admitted by voluntary status. Based on this fact, what assumption can the nurse make about the client? 1.The admission will last at least 21 days. 2.The client is not a danger to himself or to anyone else. 3.The admission is being financed by a third-party payer. 4.The client has the right to demand and obtain release from the hospital.

-4.The client has the right to demand and obtain release from the hospital.