NCLEX Practice Quiz Fundamentals
A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and has ingested 4 oz of water and 1/2 pint of milk. What is the total 8-hour fluid intake in milliliters that the nurse should document for this client? (Fill in the blank with the numeric value only. Round the answer to the nearest whole number. Use a leading zero if applicable but do not use a trailing zero.)
1560
A nurse is reinforcing teaching with the parent of a child who is to take 10 mL of a liquid medication. The parent has a hollow medication spoon with marks to indicate teaspoons and tablespoons. How many teaspoons should the nurse instruct the parent to give the child? (Fill in the blank with the numeric value only. Round the answer to the nearest whole number. Use a leading zero if applicable but do not use a trailing zero.)
2 tsp
A nurse is calculating a client's intake for a 12-hr shift. The client had dextrose 5% in 0.45% sodium chloride infusing at 125 mL/hr, gentamicin 150 mg in 100 mL at 1400, famotidine 20 mg in 50 mL at 1000 and 1600, 250 mL of blood over 2 hr, and a nasogastric flush of 30 mL every 2 hr. What is the total intake in milliliters that the nurse should document for this client for this 12-hr period? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
2130
A nurse is caring for a client whose intake and output flow sheet for 0700 to 1500 indicates the following: voided x3: 350 mL, 200 mL, 150 mL; wound drainage 2 tsp; and emesis 2 oz. What is the total output in milliliters the nurse should document for this 8-hour period? (Fill in the blank with the numeric value only. Round the answer to the nearest whole number. Use a leading zero if applicable but do not use a trailing zero.)
770 mL Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: Set up an equation and solve for X. 1 tsp/5mL = 2 tsp/X mL X = 10 Step 3: Round if necessary. Step 4: Determine if the conversion to mL makes sense. If 1 tsp = 5 mL, then 2 tsp = 10 mL. Follow these steps for the conversions of oz to mL: Step 1: What unit of measurement should the nurse calculate? mL Step 2: Set up an equation and solve for X. 1 oz/30 mL = 2 oz/X mL X = 60 Step 3: Round if necessary. Step 4: Determine whether the conversion to mL makes sense. If 1 oz = 30 mL, then 2 oz = 60 mL. For the total intake, calculate: 350 mL + 200 mL + 150 mL + 10 mL + 60 mL = 770 mL
A nurse is auscultating breath sounds for a client who has fine crackles. At which of the following areas on the lung field should the nurse place the stethoscope? (Make a selection in the artwork below and choose only the hot spot that corresponds to the answer.)
A
A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A. A client who has heart failure and is receiving 100% O2 via partial rebreather mask. B. A client who has emphysema and is receiving O2 at 3L/min via transtracheal oxygen cannula. C. A client who has an old tracheostomy and is receiving 40% humidified O2 via tracheostomy collar. D. A client who has COPD and is receiving O2 at 2L/min via nasal cannula.
A. A client who has heart failure and is receiving 100% O2 via partial rebreather mask.
A nurse is collecting data from a client who is undergoing a physical examination. Following inspection, which of the following techniques should the nurse use next when evaluating the client's abdomen? A. Auscultation B. Light palpation C. Percussion D. Deep palpation
A. Auscultation
During a client care staff meeting, a charge nurse discusses potential problems with data security that affect confidential client information. Which of the following environments should the charge nurse identify as an acceptable area for discussing clients' information? A. In the unit medication room B. Outside the door of a client's room C. In the cafeteria during a break D. In the hallway near the nurses' station
A. In the unit medication room
A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? A. Pull back the suction catheter by 1 cm (0.5 in) if the client starts coughing B. Allow 30 seconds between suctioning passes C. Hyperventilate the client with 50% oxygen for 30 seconds D. Perform a maximum of 4 passes with the suction catheter
A. Pull back the suction catheter by 1 cm (0.5 in) if the client starts coughing
A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluids and assist with which of the following functions? A. Regulation of acid-base balance B. Reabsorption of nutrients for cellular growth C. Regulation of body temperature D. Secretion of hormones needed for growth
A. Regulation of acid-base balance
A nurse is preparing to administer a unit of packed RBCs to a client when she discovers that the IV line is no longer patent. The IV team can send someone in 30 minutes to initiate a new line. Which of the following actions should the nurse take? A. Return the blood to the laboratory B. Place the blood in the medication room C. Place the blood in the refrigerator D. Leave the blood at the client's bedside
A. Return the blood to the laboratory
A nurse in a provider's office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause of the client's sleeping difficulties? A. "I take a warm shower when getting ready to go to bed." B. "I often have a cup of coffee with my dessert before going to bed." C. "I usually read a chapter in a book before I go to bed." D. "I make sure I do my exercises in the morning."
B. "I often have a cup of coffee with my dessert before going to bed."
A nurse is instructing a client about collecting a 24-hour urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure? A. "The next time I urinate will be the first specimen of the collection." B. "I'll make sure to keep the collection bottle in the container of ice they gave me." C. "Once the container is half full, I no longer have to add any more urine." D. "It's okay if a piece of toilet paper gets in the bottle. They'll remove it when they do the test.
B. "I'll make sure to keep the collection bottle in the container of ice they gave me."
A nurse is reinforcing teaching with a client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "If I do this often, I won't experience muscle wasting." B. "If l do this often, I won't get pneumonia." C. "If I do this often, I won't get constipation." D. "If I do this often, I won't have a fast heartbeat."
B. "If l do this often, I won't get pneumonia."
A nurse on a pediatric unit is caring for a child who is 4 years old. To help with communication and play activities for this client, the nurse should consider which of the following characteristics of Piaget's preoperational period? A. Seriation B. Animism C. Reversibility D. Self-consciousness
B. Animism
A nurse is collecting data from a client who has asthma and reports several food allergies. Which of the following actions should the nurse perform first? A. Document the client's food allergies in the medical record B. Ask the client to identify the specific food allergies C. Monitor the client for indications of anaphylaxis D. Have epinephrine available for administration
B. Ask the client to identify the specific food allergies
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions is the nurse's priority? A. Administer a bronchodilator B. Assist the client to an upright position C. Encourage the client to use pursed-lip breathing D. Turn the client from side to side.
B. Assist the client to an upright position
A nurse rates a client's biceps reflex as 2+. Which of the following characteristics should the nurse document the client's reflexes? A. Diminished B. Average C. Brisk D. Hyperactive
B. Average
As part of a neurological examination, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique? A. Gustation B. Stereognosis C. Proprioception D. Kinesthesia
B. Stereognosis Rationale: Stereognosis is the ability to identify an object's size, shape, and texture via tactile sensation. Incorrect Answers: A. Gustation is the ability to taste. C. Proprioception is the awareness of the position of the body. D. Kinesthesia is the ability to sense the position and movement of body parts without visualizing them.
A nurse on a medical unit is caring for a client who has a seizure disorder. Which of the following items is the nurse's priority to keep near the client at all times? A. Oxygen equipment B. Suction equipment C. Clean gloves D. Extra linens
B. Suction equipment
A nurse is reinforcing teaching of postoperative deep breathing and coughing exercises with a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? A. The client asks the nurse to repeat the instructions before attempting the exercises. B. The client reports severe pain. C. The client asks the nurse how often deep breathing should be done after surgery. D. The client tells the nurse that this exercise will probably be painful after surgery.
B. The client reports severe pain.
A nurse is collecting data from a client who is postoperative following knee surgery. The nurse observes a frayed electrical cord on the continuous passive motion (CPM) machine. Which of the following actions should the nurse take? A. Consult the surgeon about discontinuing the client's CPM therapy B. Unplug the CPM device and remove it from the client's room C. Wrap electrical tape around the frayed portion of the cord securely D. Perform passive range-of-motion exercises of the client's knee
B. Unplug the CPM device and remove it from the client's room
A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin assisting with discharge planning? A. 1 week prior to discharge B. Upon admission to the care facility C. Once the discharge date is identified D. When the client addresses the topic with the nurse
B. Upon admission to the care facility
A nurse is reviewing the laboratory results of a client who is preoperative. Which of the following results should the nurse report to the surgeon? A. Platelet count 210,000/mm^3 B. WBC count 18,000/mm^3 C. Sodium 140 mEg/L D. Fasting glucose 92 mg/dL
B. WBC count 18,000/mm^3
A nurse is assisting a client who has dysphagia at mealtime. Which of the following actions should the nurse take? A. Assist the client into a semi-sitting position B. Have the client lean slightly backward C. Advise the client to tuck his chin downward D. Instruct the client to tilt his head slightly backward
C. Advise the client to tuck his chin downward
A home health nurse is visiting the home of a caregiver who says he is "exhausted" from working part-time in addition to caring for his mother, who is an older adult and has severe dementia. Which of the following options should the nurse suggest to the caregiver? A. Rehabilitation B. Assisted-living facility C. Respite care D. Adult day care facility
C. Respite care
A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors places the client at risk of developing complicated grief? A. The deceased was a close friend. B. The client lived far from the deceased. C. The death was sudden. D. The client has not visited the deceased in a long time.
C. The death was sudden.
A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? A. Deltoid B. Ventrogluteal C. Vastus lateralis D. Dorsogluteal
C. Vastus lateralis
A nurse is collecting data from a client who is postoperative following abdominal surgery. Which of the following findings is the nurse's priority to report to the surgeon immediately? A. Nausea with 1 episode of vomiting B. Incisional pain of 5 on a 0 to 10 scale C. Warm, tender area on the right calf D. Serosanguineous fluid from a surgical drain
C. Warm, tender area on the right calf
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse offer? A. "It's for your safety. Dentures can slip and block your airway during surgery." B. "You wouldn't want your teeth to be lost or broken during surgery, would you?" C. "The anesthesiologist requires everyone to remove their dentures." D. "What worries you about being without your teeth?"
D. "What worries you about being without your teeth?"
A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take? A. Tell the client the provider does not want her to remain in bed B. Allow the client to remain in bed until her pain subsides C. Instruct the family to perform ADLs for the client D. Advise the client to perform range-of-motion exercises while in bed
D. Advise the client to perform range-of-motion exercises while in bed
A nurse in a provider's office is collecting data from a 3-year-old client during a routine physical examination. Which of the following findings should the nurse report to the provider? A. Can skip B. Can identify 4 colors C. Cannot print their name D. Cannot walk-up stairs independently
D. Cannot walk-up stairs independently
A nurse is preparing to administer oral phenytoin to a client who has a seizure disorder. Before administering the medication, which of the following actions should the nurse take? A. Document the administration of the medication B. Count the available medication and sign for it C. Measure the client's respiratory rate D. Check the medication dose and the client's identification
D. Check the medication dose and the client's identification
A nurse is collecting baseline data of a client's peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse? A. Below the medial malleolus B. In the popliteal fossa C. In the antecubital space D. On the dorsum of the foot
A. Below the medial malleolus
After collecting data on a client's radial pulses, the nurse documents "radial pulses 4+ bilaterally." This finding indicates which of the following pulse qualities? A. Bounding B. Full C. Variable D. Weak
A. Bounding
A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse perform to convey empathy when using the therapeutic communication technique of active listening? A. Assume an open position B. Sit upright while leaning back into the chair C. Avoid direct eye contact until the client initiates it D. Sit next to the client
A. Assume an open position
A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss? A. Attempting to increase the clients' self-motivation B. Keeping detailed records of each client's progress C. Testing client learning after each teaching session D. Avoiding discussing topics that might cause client anxiety
A. Attempting to increase the clients' self-motivation
A nurse is assisting with an admission interview for a client. Which of the following items of data should the nurse collect during the introduction phase of the interview? A. Client's comfort and ability to participate in the interview B. Previous illnesses and surgeries C. Events surrounding the recent illness D. Sociocultural history
A. Client's comfort and ability to participate in the interview
A nurse is replacing the surgical dressing on a client who had abdominal surgery. Which of the following actions should the nurse take? A. Don clean gloves to remove the old dressing B. Loosen the dressing by pulling the tape away from the wound C. Remove the entire old dressing at once D. Open sterile supplies after applying sterile gloves
A. Don clean gloves to remove the old dressing
A nurse is reinforcing teaching with a client about how to obtain a capillary finger-stick blood sample. Which of the following actions by the client requires the nurse to intervene? A. Elevates the finger above heart level B. Rubs the fingertip with an alcohol pad C. Punctures the side of the fingertip D. Wraps the finger in a warm cloth
A. Elevates the finger above heart level
A nurse is collecting data for a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A. Evaluate pedal pulses B. Obtain a medical history C. Measure vital signs D. Ask the client if he is experiencing any pain in the leg
A. Evaluate pedal pulses
A new resident provider asks the nurse for an access code to review a client's online record. The resident is not scheduled to attend the facility's computer orientation class until next week. Which of the following actions should the nurse take? A. Explain that sharing access codes is against policy and refer the resident to the supervisor B. Access the client's online data and monitor the resident during usage C. Access the online client data system and allow the resident to locate the client's data D. Ask the client to give permission for the resident to access the medical records
A. Explain that sharing access codes is against policy and refer the resident to the supervisor
A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) items should the nurse don prior to providing client care? (Select all that apply.) A. Gown B. Gloves C. Mask D. Hair cover E. Goggles
A. Gown B. Gloves Rationale: The nurse should follow standard precautions when caring for a client who has AIDS. Because the bed linens might be soiled, the nurse should don a gown. Because the nurse's hands will come in contact with the soiled bed linens, the nurse should don clean gloves in addition to other necessary PPE.
A nurse is collecting data from a client as part of a neurological examination. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests? A. Romberg B. Kinesthetic sensation C. 2-point discrimination D. Weber
A. Romberg
A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia? A. The client watches television in bed during the day. B. The client drinks warm milk before bedtime. C. The client goes to bed at 2200 every night. D. The client gets up to use the bathroom once during the night.
A. The client watches television in bed during the day.
A nurse is helping a client perform range-of-motion exercises of the neck. For evaluating neck flexion, which of the following motions should the nurse instruct the client to perform? A. Touching his chin to his chest B. Moving his head sideways C Turning his head in a circle D. Moving his head to an erect position
A. Touching his chin to his chest
A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take? A. Apply a cold pack to an area that is edematous B. Check capillary refill before applying an ice pack to the affected area C. Fill an ice pack half full of crushed ice D. Apply an ice pack for 60 minutes intervals
B. Check capillary refill before applying an ice pack to the affected area
A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform immediately following the transfer? A. Administer pain medication B. Check the client's vital signs C. Instruct the client to use the incentive spirometer every 1 hr D. Provide ice chips as per provider prescription
B. Check the client's vital signs
A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse take? A. Wear sterile gloves when collecting the specimen B. Cleanse the wound with 0.9% sodium chloride irrigation C. Allow the collection swab to absorb old exudate D. Rotate the collection swab over the edges of the wound
B. Cleanse the wound with 0.9% sodium chloride irrigation The nurse should cleanse the wound with sterile water or 0.9% sodium chloride irrigation to remove any surface debris or old exudate. Incorrect Answers: A. The nurse should wear clean gloves to collect a wound culture specimen. The nurse's hands will not touch the wound or the culture swab.
A nurse is performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding? A. Obtain an audiology referral B. Document this as an expected finding C. Irrigate the ear with warm water D. Document mild inflammation
B. Document this as an expected finding
A nurse is contributing to the plan of care for a client who had a stroke and is scheduled to receive feeding via a gastrostomy tube. Which of the following actions should the nurse recommend prior to initiating each feeding? A. Warm the feeding in a microwave oven B. Elevate the head of the bed C. Flush the tube with 0.9% sodium chloride for irrigation D. Verity the gastric pH is above 4
B. Elevate the head of the bed
A nurse is caring for a client with a BMI of 29 who expresses a desire to lose weight. Which of the following actions should the nurse take first? A. Refer the client to a nutritionist B. Discuss eating strategies with the client C. Determine the client's intention to change current eating habits D. Instruct the client to perform 30 min of vigorous exercise daily
C. Determine the client's intention to change current eating habits
A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? A. Change the topic because the client is trying to divert attention from the illness to the nurse B. Encourage the client to express his thoughts about death and dying C. Tell the client that religious beliefs are a personal matter D. Offer to contact the client's minister or the facility's chaplain
B. Encourage the client to express his thoughts about death and dying
A nurse is collecting data for a client who has had diarrhea and decreased urination for several days. Which of the following actions should the nurse take to determine if the client is dehydrated? A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink B. Grasp a skinfold on the chest under the clavicle, release it, and note whether it springs back C. Press the skin in above the ankle for 5 sec, release it, and note the depth of the impression D. Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers
B. Grasp a skinfold on the chest under the clavicle, release it, and note whether it springs back
A nurse is reinforcing teaching about how to use an incentive spirometer with a client who is recovering from gallbladder surgery. Which of the following pieces of information should the nurse include in the teaching? A. Exhale slowly to reach goal volume B. Hold a breath for 5 seconds after goal volume is reached C. Continue to deep-breathe between each cycle D. Limit the repeat pattern of breathing to 5 breaths
B. Hold a breath for 5 seconds after goal volume is reached
A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take? A. Place the soiled linens on a chair while making the bed B. Hold the linens away from the body and clothing C. Place the linens on the floor before placing them in a linen bag D. Shake the clean linens to unfold
B. Hold the linens away from the body and clothing
A nurse is caring for a toddler at a well-child visit when the mother cries out, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction? A. Flushing of the skin B. Inability of the toddler to cry or speak C. Presence of nausea and mild emesis D. Capillary refill time 1.5 second
B. Inability of the toddler to cry or speak
A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse perform first when using the nursing process? A. Identify goals for client care B. Obtain client information C. Document nursing care needs D. Evaluate the effectiveness of care
B. Obtain client information
A nurse is caring for a client who, after multiple less restrictive interventions, continues to pick at and dislodge his nasogastric tube. The provider has prescribed wrist restraints. Which of the following actions should the nurse take? A. Tie the straps of the restraints to the bed's side rails B. Pad the client's wrists before applying the restraints C. Make sure three 3 fingers fit under each restraint after application D. Check the skin under the restraints every 3 to 4 hours
B. Pad the client's wrists before applying the restraints
A nurse is assisting with planning a community presentation for parents. When suggesting a discussion of controlling impulses and cooperating with others, the nurse should plan to relate it to Erikson's developmental task for which of the following age groups? A. Toddlers B. Preschoolers C. School-aged children D. Adolescents
B. Preschoolers
A nurse is contributing to the planning of an in-service session about nutrition. Which of the following pieces of information should the nurse recommend for the teaching? A. Fat breaks down into amino acids. B. Protein serves as an energy source when other sources are inadequate. C. Glucose breaks down into ammonia. D. Carbohydrates provide 9 cal/g of energy.
B. Protein serves as an energy source when other sources are inadequate.
A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff is which of the following? (Select all that apply.) A. Allowing the client to speak B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks E. Preventing tracheal injury
B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement? A. Place the client in a semi-private room B. Wear a mask when providing care C. Apply a gown when in the client's room D. Dispose of all bed linens used by the client
C. Apply a gown when in the client's room
A nurse in a provider's office is reinforcing teaching with a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? (Select all that apply.) A. Canned peaches B. White rice C. Black beans D. Whole-grain bread E. Tomato juice
C. Black beans D. Whole-grain bread
A nurse is reviewing adult cardiopulmonary resuscitation (CPR) with a newly licensed nurse. Which of the following steps should the nurse identify as the first response when performing CPR? A. Call for assistance B. Begin chest compressions C. Confirm unresponsiveness D. Give rescue breaths
C. Confirm unresponsiveness
During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data? A. Confrontation test B. Symmetry of palpebral fissures C. Corneal light reflex D. Accommodation test
C. Corneal light reflex
A nurse is measuring vital signs for a client and notices a pulse irregularity. Which of the following actions should the nurse take? A. Measure the pulse using a Doppler ultrasound stethoscope B. Check the client's pedal pulses C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart D. Take the pulse at each peripheral site and count the rate for 30 sec
C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart
A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk for which of the following health alterations? A. Increased intestinal motility B. Respiratory alkalosis C. Decreased cardiac output D. Hypocalcemia
C. Decreased cardiac output
A nurse is providing palliative care for a client who is at the end of life. The client is having difficulty breathing and has audible respiratory gurgling. Which of the following actions should the nurse take? A. Increase the amount of light in the room B. Reposition the client from side to side every 4 hours C. Elevate the head of the client's bed D. Apply an electric blanket
C. Elevate the head of the clients bed
A nurse is working with the facility's language interpreter to explain a wound-care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when explaining the procedure to the client? A. Make eye contact with the interpreter B. Break sentences into shorter segments to allow time for interpretation C. Ensure the interpreter and the client speak the same dialect D. Speak in a loud tone of voice
C. Ensure the interpreter and the client speak the same dialect
A nurse on a same-day procedure unit is caring for several clients undergoing different types of procedures. A client who has which of the following devices can safely undergo magnetic resonance imaging (MRI)? A. Coronary artery stents B. Aneurysm clip C. Hearing aids D. Automated internal defibrillator
C. Hearing aids
A nurse is collecting baseline data about a client's chest as part of a physical examination. Which of the following actions should the nurse take first? A. Auscultate the thorax B. Palpate the thorax C. Inspect the thorax D. Percuss the thorax
C. Inspect the thorax
A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. Which of the following actions should the nurse take? A. Inform the guard that the warden must request this information B. Ask the guard to sign a release of information form C. Instruct the guard to ask the inmate D. Complete an incident report
C. Instruct the guard to ask the inmate
A nurse is using the Braden scale to predict the pressure-ulcer risk for a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate? A. Incontinence B. Mental state C. Nutrition D. General physical condition
C. Nutrition
A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take? A. Raise the enema bag if the client experiences cramping B. Lubricate 2.54 cm (1 in) of the tip of the rectal tube prior to insertion C. Place the client in a left Sims' position D. Don sterile gloves prior to the procedure
C. Place the client in a left Sims' position
A nurse in a long-term care facility is feeding a client. Which of the following observations should the nurse identify as an indication that the client requires an evaluation for dysphagia? A. Speaking rapidly B. Hiccupping frequently C. Pocketing food D. Preferring clear liquids
C. Pocketing food
A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take? A. Remove the NG tube B. Advance the NG tube quickly C. Pull the NG tube back slightly D. Ask the client to tilt his head backward
C. Pull the NG tube back slightly
A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? A. Irrigate the tubing with sterile normal water once each shift B. Cleanse the opening with soap and water after emptying C. Maintain the tubing above the level of the surgical incision D. Collapse air from the device after emptying
D. Collapse air from the device after emptying
A nurse is caring for a client who has terminal cancer. The client is proceeding with plans to build a new house. This behavior would typically indicate which of the following stages of grief? A. Acceptance B. Bargaining C. Anger D. Denial
D. Denial
A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take? A. Select a 23-gauge needle B. Insert the needle into the skin at a 25° angle C. Massage the injection area following removal of the needle D. Circle the area of the injection with a pen
D. Circle the area of the injection with a pen
A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? A. Withdraw the specimen from the drainage bag B. Cleanse the collection port with soap and water C. Place the specimen in a clean specimen cup D. Clamp the tubing below the collection port
D. Clamp the tubing below the collection port
A nurse is inserting an indwelling urinary catheter into the penis of a client. Which of the following actions should the nurse take? A. Place the client supine with his knees flexed B. Put on clean gloves for the procedure C. Use the nondominant hand to grasp the penile shaft D. Cleanse the urinary meatus in a spiral motion from the shaft inward to the meatus
D. Cleanse the urinary meatus in a spiral motion from the shaft inward to the meatus
A nurse is assisting with the admission of a client to the medical unit and asks if he has advance directives. The client states, "I have a document with me that names someone who can make health care decisions for me if l am not able." The nurse should identify that the client is referring to which of the following documents? A. Informed consent form B. Living will document C. Do-not-resuscitate (DNR) directive D. Durable power of attorney document
D. Durable power of attorney document
A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the healthcare facility? A. Close the fire doors on the unit B. Spray a fire extinguisher on the fire C. Pull the nearest fire alarm D. Evacuate clients from the unit
D. Evacuate clients from the unit
A nurse is collecting data as part of a comprehensive physical examination of a client. The nurse should use inspection to evaluate which of the following? A. Liver size B. Pedal edema C. Skin texture D. Gait
D. Gait
A nurse is reviewing a client's 24-hour dietary recall. The client reports eating a slice of toasted white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken, 2 cups of steamed broccoli, and a glass of milk for dinner. The nurse should identify that this client's diet is deficient in which of the following food groups? A. Dairy B. Vegetables C. Fruits D. Grains
D. Grains
A nurse is collecting data from a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain? A. Diarrhea B. Pupillary constriction C. Flushing D. Grimacing
D. Grimacing
A nurse is administering a controlled substance to a client who is postoperative. The IM dosage requires the nurse to use only part of the amount of medication in the vial. Which of the following actions should the nurse take? A. Lock the vial in the controlled-substances cabinet for later use B. Crush the vial between two paper towels and place it in a sharps container C. Return the opened vial to the pharmacy D. Have another nurse witness the disposal of the medication
D. Have another nurse witness the disposal of the medication
A nurse in an urgent-care center is caring for a 15-year-old client whose symptoms suggest a sexually transmitted infection (STI). The client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take? A. Explain that the treatment can wait until the parent is available B. Inform the grandmother that she may give consent for the treatment C. Invoke the principle of implied consent and prepare the client for treatment D. Have the adolescent sign the consent form
D. Have the adolescent sign the consent form
A nurse is caring for a client who requires a chest X-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? A. Explain the X-ray procedure to the client B. Help the client into a wheelchair before the transporter arrives C. Ask if the client has any questions D. Identify the client using 2 identifiers
D. Identify the client using 2 identifiers
A nurse in an acute-care facility is assisting with planning care for a client who is alert but is temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse suggest to prevent a complication of immobility? A. Move the client from supine to a low-Fowler's position every 2 to 3 hours to help prevent orthostatic hypotension B. Limit fluid intake to 1 L (33.8 oz) in 24 hours to help prevent dependent edema C. Encourage the client to turn from side to side every 3 to 4 hours to help prevent respiratory complications D. Instruct the client to perform foot and leg exercises every 1 to 2 hours while awake to help prevent thrombophlebitis
D. Instruct the client to perform foot and leg exercises every 1 to 2 hours while awake to help prevent thrombophlebitis
A nurse is reviewing the laboratory results of a client and notes a WBC count of 3,600/mm^3. The nurse should identify this result as an indication of which of the following conditions? A. Leukoplakia B. Leukemia C. Leukocytosis D. Leukopenia
D. Leukopenia
A nurse is collecting data from a client. Which of the following actions should the nurse take to determine the client's tissue perfusion? A. Perform a Romberg test B. Check nails for Beau's lines C. Palpate for respiratory excursion D. Perform a blanch test
D. Perform a blanch test
A nurse is leading an education session about disposing of biohazardous materials. Which of the following instructions should the nurse include in the teaching? A. Use isopropyl alcohol to clean up blood spills B. Discard empty blood bags in a bedside trash can C. Break used needles before discarding D. Place soiled linen in a single linen bag
D. Place soiled linen in a single linen bag
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? A. Auscultate for the blood pressure at the dorsalis pedis artery B. Measure the blood pressure with the client sitting on the side of the bed C. Place the cuff 7.6 cm (3 in) above the popliteal artery D. Place the bladder of the cuff over the posterior aspect of the thigh
D. Place the bladder of the cuff over the posterior aspect of the thigh
A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring? A. Right task B. Right circumstance C. Right person D. Right communication
D. Right communication
A nurse at a screening clinic is collecting data for a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? A. Fifth intercostal space just medial to the midclavicular line B. Second intercostal space to the left of the sternum C. Fifth intercostal space to the left of the sternum D. Second intercostal space to the right of the sternum
D. Second intercostal space to the right of the sternum
A nurse enters a client's room and notices smoke coming from a wastebasket in the adjacent bathroom. Which of the following actions should the nurse take first? A. Close the door to the client's room B. Attempt to extinguish the fire C. Activate the facility's fire alarm system D. Transport the client to an area away from the smoke
D. Transport the client to an area away from the smoke
A nurse is collecting data from a client at admission. The client reports a latex allergy. Which of the following precautions should the nurse take when caring for this client? A. Snap gloves on and off to reduce any lingering allergens B. Wear powdered hypoallergenic latex gloves C. Rinse non-disposable items with ethylene oxide D. Wrap IV tubing with tape
D. Wrap IV tubing with tape
A nurse is obtaining a capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the client's finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take? A. Smear the small amount of blood onto the testing strip B. Hold the finger above heart level C. Massage the client's fingertip D. Wrap the client's finger in a warm washcloth
D. Wrap the client's finger in a warm washcloth
