NCLEX Preparation Question
The infant's parents ask the nurse about preventing otitis media. which of the following should be recommended? A. Avoid tobacco smoke B. Use nasal decongestant C. Avoid other children with otitis media D. Bottle feed or breastfeed in supine position
A. Avoid tobacco smoke
The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? A. Client pain level B. Inadequate urinary output C. Client perception of body changes D. Potential for imbalanced body fluid volume
A. Client pain level
A 4-year-old with leukemia is hospitalized for chemotherapy. The child is fearful of the hospital. Which intervention should be implemented to alleviate the child's fears? A. Encourage the child's parents to stay with the child B. Encourage play with other children of the same age C. Advise the family to visit only during the scheduled visiting hours D. Provide a private room allowing the child to bring favorite toys from home
A. Encourage the child's parents to stay with the child
A client arrives at the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. The priority nursing action is to: A. Obtain vital signs B. Ask the client about the precipitating events C. Complete an abdominal physical assessment D. Insert a nasogastric (NG) tube and Hematest the emesis
A. Obtain vital signs
The nursing instructor asks the student to describe formal operations of Paiget's theory. The correct response by the nursing student is which statement? A. The child can think abstractly B. The child begins to understand the environment C. The child can classify order and sort facts D. The child learns to think about past, present, and future
A. The child can think abstractly
The mother of a 4-year-old child calls the clinic nurse and expresses concern because the child has been masturbating. Using Freud's psychosexual stages of development, the nurse should make which response? A. This is a normal behavior at this stage B. Children usually begin this behavior at 8-years-old C. The child is very young to begin this behavior and should be brought to the clinic D. This is not normal behavior and the child should be seen by the HCP
A. This is a normal behavior at this stage
A nurse is teaching the parents of a 6-month-old infant about usual growth and development. Which statements about infant development are true? SELECT ALL THAT APPLY: A. 6 m.o. infants have difficulty holding objects B. 6 m.o. infants can usually roll prone to supine and supine to prone C. 6 m.o. infants can have teething rings D. Stranger anxiety usually peaks at 12-18 months E. Head lag is commonly noted at 6 months F. Lack of visual coordination usually resolves by age 6 months.
B C F
A nurse manager is planning the client assignments for the day. Which of the following clients would the nurse assign to the nursing assistant? A. 2-day postoperative client who had a below-the-knee amputation B. A client on a 24-hour urine collection who is on strict bedrest C. A client scheduled to be discharged after coronary artery bypass surgery D. A client scheduled for a cardiac catheterization
B. A client on a 24-hour urine collection who is on strict bedrest
In a lecture on sexual functioning, the nurse plans to include the fact that ovulation occurs when the: A. Oxytocin is high B. Blood level of LH is high C. Progesterone level is high D. Endometrial wall is sloughed off
B. Blood level of LH is high
After change shift, you are assigned to care for the following patients. Which patient should you assess first? A. A 60-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab B. A 55-year-old with COPD and a pulse oximetry reading from the previous shift of 90% saturation C. A 70-year-old with pneumonia who needs to be started on intravenous (IV) antibiotics D. A 50-year-old with asthma who complains of shortness of breath after using a bronchodilator
D. A 50-year-old with asthma who complains of shortness of breath after using a bronchodilator
A client is scheduled for an arteriogram using a radiopaque dye. The nurse assesses which most critical item before the procedure? A. Vital signs B. Intake and output C. Height and weight D. Allergy to iodine or shellfish
D. Allergy to iodine or shellfish
A community health nurse is working with older residents who were involved in a recent flood. Many of the residents are emotionally despondent, and they refused to leave their homes for days. When planning forth rescue and relocation of these older residents, what is the first item that the nurse needs to consider? A. Contacting the older resident's families B. Attending to the emotional needs of the older residents C. Arranging for ambulance transportation for the oldest residents D. Attending to the nutritional status and basic needs of the older residents
D. Attending to the nutritional status and basic needs of the older residents
A 7-year-old child is hospitalized with a fracture of the femur and is placed in traction. In meeting the psychosocial needs of the child, the nurse most appropriately selects which play activity for the child? A. Board game B. Large puzzle C. Finger painting D. Coloring book with crayons
D. Board game
The doctor suspects that the client has an ectopic pregnancy, which symptom is consistent with a diagnosis of an ectopic pregnancy? A. Painless vaginal bleeding B. Abdominal cramping C. Throbbing pain in the upper quadrant D. Sudden stabbing pain in lower quadrant
D. Sudden stabbing pain in lower quadrant
The nurse is monitoring the client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor? A. Variability B. Accelerations C. Early decelerations D. Variable decelerations
D. Variable decelerations
A group of health nurse is caring for a group of homeless people. When planning for the potential needs of this group, what is the most immediate concern? A. Peer support through structured groups B. Finding affordable housing for the group C. Setting up a 24-hour crisis center and hotline D. Meeting the basic needs to ensure that adequate food, shelter, and clothing are available
D. Meeting the basic needs to ensure that adequate food, shelter, and clothing are available
Which car safety device should be used for a child who is 8 years old and is 4 feet tall? A. Seat belt B. Booster seat C. Rear-facing convertible seat D. Front-facing convertible seat
B. Booster seat
A 16-year-old child is hospitalized. According to Erik Erickson, what is an appropriate intervention? A. Encourage parent to help the child learn lessons missed in class B. Encourage friends to visit the child C. Call the priest to intervene D. Tell his significant other to visit
B. Encourage friends to visit the child
When developing a care plan for an adolescent, the nurse considers the child's needs. During adolescence psychosocial development focuses on: A. Becoming industrious B. Establishing identity C. Achieving intimacy D. Developing initiative
B. Establishing identity
A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate? A. Elevate the client's legs. B. Massage the fundus until it is firm. C. Ask the client to turn on her left side. D. Push on the uterus to assist in expressing clots.
B. Massage the fundus until it is firm.
A nurse is scheduling a client for diagnostic studies of gastrointestinal (GI) system. Which of the following studies, if ordered, should the nurse schedule last? A. Ultrasound B. Colonoscopy C. Barium enema D. Computed tomography
C. Barium enema
The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last period was January 8th. When will the client's next fertile period occur? A. January 14th-15th B. January 22nd-23rd C. January 29th-30th D. February 6th-7th
C. January 29th-30th
A nurse is caring for a client with preeclampsia who suddenly progresses to an eclamptic state. The initial nursing action would be to: A. Check the fetal heart rate B. Check the maternal blood pressure C. Maintain an open airway D. Administer oxygen to the mother by face mask
C. Maintain an open airway
A mother has recently been informed that her child has Down's syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down's syndrome? A. Simian crease B. Brachycephaly C. Oily skin D.Hypotonicity
C. Oily skin
A neonate has been diagnosed with caput succendaeum. Which statement is true? A. Usually resolves in 3-6 weeks B. Is a collection of blood between skull and periosteum C. Doesn't cross the cranial suture line D. Involves swelling of the tissue over the presenting part of the head
D. Involves swelling of the tissue over the presenting part of the head
A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies which nursing diagnosis as the highest priority for this client? A. Diarrhea B. Risk for aspiration C. Risk for deficient fluid volume D. Imbalanced nutrition, less than body requirements
B. Risk for aspiration
Which of the following age groups has the greatest potential to regress when they are sick? A. Adolescents B. Toddlers C. Childhood D. Young adults
B. Toddlers
A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: A. Place the mother in the supine position B. Document the findings and continue to monitor the fetal patterns C. Administer oxygen via face mask D. Increase the rate of pitocin IV infusion
C. Administer oxygen via face mask
1 hour following a normal vaginal delivery, a newborn infant's axillary temperature is 96 F. His lower lip is shaking. When the nurse assesses for a Moro reflex, the infant's hands shake. Which intervention should the nurse implement first? A. Stimulate the infant to cry B. Wrap the infant in warm blankets C. Feed the infant formula D. Obtain a serum glucose level
D. Obtain a serum glucose level
The pituitary hormone that stimulates the secretion of milk from the mammary glands: A. Progesterone B. Oxytocin C. Estrogen D. Prolactin
D. Prolactin
