NCLEX Question Trainer #3
The 8-year-old has been receiving chemotherapy for 6 months. The child asks, "Am I going to die?" Which response by the nurse is BEST? 1. "Are you afraid of dying?" 2. "Why do you ask that question?" 3. "Only God knows that answer." 4. "We won't leave you alone."
"Are you afraid of dying?"
The client with newly diagnosed type 1 diabetes says to the nurse, "I know I have to take good care of my feet. When I buy new shoes, is there anything special I should do?" Which response by the nurse is best? 1. "It is best to buy new shoes in the morning." 2. "Have each foot measured every time you buy new shoes." 3. "Buy shoes a half-size larger than your foot size so the fit is roomy 4. "Buy vinyl shoes because they won't lose their shape easily."
"Have each foot measured every time you buy new shoes."
A client is admitted to the neurosurgery unit for the removal of a cerebellar tumor. The nurse expects the client to make which statement about symptoms? 1. "I have been having difficulty with my hearing." 2. "I lose my balance easily." 3. "I can't tell the difference between a sweet and sour taste." 4. "It is not easy for me to remember names and faces."
"I lose my balance easily."
Which client statement indicates to the nurse the client is using the defense mechanism of conversion? 1. "I love my family with all my heart, even though they don't love me." 2. "I was unable to take my final exams because I was unable to write." 3. "I don't believe I have diabetes. I feel perfectly fine." 4. "If my spouse was a better housekeeper I wouldn't have such a problem."
"I was unable to take my final exams because I was unable to write."
The 11-year-old child falls off a bicycle and sustains a minor head injury. The injury is treated at the outpatient clinic. The nurse instructs the child's parent about care at home. The nurse determines further teaching is needed if the parent makes which statement? 1. "My child may have dizziness for 24 hours." 2. "My child can drink carbonated beverages if vomiting occurs." 3. "My child may report feeling nauseated." 4. "My child will probably have a headache."
"My child can drink carbonated beverages if vomiting occurs."
The older client is hospitalized with a fractured left hip. While awaiting surgery, the client is placed in Buck's traction with a 7-pound weight. Which instruction about moving does the nurse give to encourage the client to participate in care? 1. "Pull up on the overhead trapeze while you push down on your right foot to lift your body." 2. "With your right arm, grasp the bedside rail on the opposite side and pull yourself over gently." 3. "I'll raise the head of the bed 45 degrees, and then you'll lean forward and rotate your hips to the left." 4. "Swing your right leg over your left leg and turn from your waist down, keeping your legs straight."
"Pull up on the overhead trapeze while you push down on your right foot to lift your body."
The client asks what the difference is between a gastric ulcer and duodenal ulcer. Which response does the nurse give? 1. "Gastric ulcers have an increased association with clients who experience greater psychological pressures." 2. "The pain of a duodenal ulcer usually occurs 2 to 4 hours after meals." 3. "Client with gastric ulcers often gain weight, as food alleviates the pain." 4. "Antacids are seldom prescribed for clients with duodenal ulcers."
"The pain of a duodenal ulcer usually occurs 2 to 4 hours after meals."
The office nurse reinforces the healthcare provider's explanation for a myelogram. Which statement correctly describes a pyelogram for the client? 1. "The test involves x-ray examination of the entire spinal column to determine the extent of myelin breakdown." 2. "The test injection of a contrast medium into a suspected ruptured vertebral disk, allowing radiographic visualization of the disk." 3. "The test involves a lumbar puncture with injection of contrast medium, allowing x-ray visualization of the vertebral canal." 4. "The test involves x-ray examination of the vertebral column following injection of air into the subarachnoid space."
"The test involves a lumbar puncture with injection of contrast medium, allowing x-ray visualization of the vertebral canal."
The client is scheduled for electromyography (EMG). Which information does the nurse tell the client about the procedure? 1. "Your hair will be carefully washed prior to the procedure." 2. "This is a noninvasive procedure that takes about 30 minutes." 3. "A sedative will be given to you shortly before the procedure." 4. "You will not be allowed to eat 4 to 6 hours before the procedure."
"This is a noninvasive procedure that takes about 30 minutes."
The nurse obtains a history from the parent of the 6-year-old child with a history of epilepsy. The child was admitted with uncontrolled seizures. It is MOST important for the nurse to ask which question? 1. "What part of the body was affected by the seizure?" 2. "What is the family history of seizure disorders?" 3. "What was your child doing before the seizure?" 4. "How long has it been since the last episode of seizures?"
"What was your child doing before the seizure?"
The client experiences inflammation due to rheumatoid arthritis. Which nursing statement is correct? 1. "If you are having a 'bad' day, postpone your exercises until the next day." 2. "Passive exercises are better for you than active exercises." 3. "When inflammation is severe, decrease the number of repetitions of the exercise." 4. "You can substitute your normal household tasks for your exercises to provide variety."
"When inflammation is severe, decrease the number of repetitions of the exercise."
The nurse responds to a train derailment. After making initial assessments, in what order should the nurse see these clients? 1. The young client with blood pulsating from a cut on the right leg 2. The pregnant client who states clothing is wet 3. The unconscious client with the right leg shorter than the left leg 4. The preschool child who is screaming and crying uncontrollably
1, 3, 2, 4
The nurse cares for clients on a psychiatric unit and is suddenly faced with multiple issues. In which order does the nurse address these situations? 1. The client diagnosed with depression says to the nurse, "My plan is complete, and I'm ready to go." 2. The client diagnosed with bipolar disorder walks into he day room wearing only underwear. 3. The client with substance abuse reports harassment by another client. 4. The client diagnosed with schizophrenia tells the nurse the TV should be destroyed.
1, 3, 4, 2
The nurse cares for a client with a diagnosis of Guillain-Barre syndrome. Which symptoms support this diagnosis? 1. Respiratory failure 2. Pulmonary congestion 3. Hypertension 4. Flaccid paralysis 5. Hemiplegia 6. Urinary retention
Respiratory failure, flaccid paralysis, & urinary retention
The nurse receives report from the previous shift. In which order should the nurse see these clients? 1. The client 1 day postop with an epidural catheter in place 2. The client diagnosed with type 1 diabetes scheduled for a cardiac catheterization at 1400 3. The client post coronary artery bypass graft having the atrioventricular wires removed at 1500 4. The client diagnosed with cardiomyopathy being evaluated for a heart transplant
1, 4, 2, 3
The nurse in the pediatric office observes the child in the waiting room. The child can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet. Which does the nurse identify as the child's chronological age? 1. 1 year old 2. 2 years old 3. 3 years old 4. 5 years old
3 years old
The nurse receives report on these clients from the previous shift. In which order should the nurse see the clients? 1. The client scheduled to receive heparin and the aPTT is 70 seconds 2. The client receiving IV potassium infusion who reports burning at the IV site 3. The client receiving ciprofloxacin IV, reports a fine macular rash on the chest 4. The client receiving a blood transfusion who reports a dry mouth
3, 2, 1, 4
The elderly alcoholic client receives a long-acting benzodiazepine for 2 days for symptom management and reduction. The client states, "Get those bugs off of me and clean them out of here." The nurse knows the client is exhibiting symptoms of which problem? 1. A reaction to the sedative medication 2. A worsening course of the withdrawal syndrome 3. An exacerbation of the schizophrenia process 4. The process of aging and the effects of delirium
A worsening course of the withdrawal syndrome
The elderly client diagnosed with chronic schizophrenia is cared for in a partial hospitalization program. The client has been on long-term antipsychotic medication and recently developed symptoms of tardive dyskinesia. The nurse's documentation includes which finding? 1. Assessment of ADL ability 2. Mini-Mental Status Examination (MMSE) 3. Abnormal Involuntary Movement Scale (AIMS) 4. Modified Overt Aggression Scale (MOAS)
Abnormal Involuntary Movement Scale (AIMS)
The nurse cares for the client with dementia. Which plan of care is MOST successful? 1. Teach new skills for adjusting to the aging process 2. Adjust the environment to meet the client's individual needs 3. Encourage competitive activities to keep the client physically strong 4. Provide unstructured activities with frequent changes to increase stimulation
Adjust the environment to meet the client's individual needs
The client diagnosed with bipolar disorder is in a manic phase with combative behavior. Which is the INITIAL PRIORITY nursing action? 1. Provide adequate hygiene and nutrition 2. Decrease environmental stimuli 3. Slowly involve the client in unit activities 4. Administer and monitor sedative and mood-stabilizing medications
Administer and monitor sedative and mood-stabilizing medications
The client with bipolar illness is extremely angry. The client tells the nurse, "I just found out my spouse has filed for divorce. I need to use the phone right now!" Which action by the nurse is most appropriate? 1. Allow the client to use the phone 2. Confront the client about the anger and inappropriate plan of action 3. Do not allow the client to use the phone because this is an involuntary admission 4. Set limits on the client's phone use because of the inability to control behavior
Allow the client to use the phone
The client is diagnosed with an obsessive-compulsive ritual. The nurse recognizes the client is attempting to achieve with psychological status? 1. Control of other people 2. Increased self-esteem 3. Avoid severe levels of anxiety 4. Express and manage anxiety
Avoid severe levels of anxiety
The client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The client is diagnosed with a spinal cord injury at the level of C4. The client is tearful, constantly reports discomfort, and requests to be suctioned. The nurse understands the client's attention-seeking behaviors may be due to which feelings? 1. Anger and frustration 2. Awareness of vulnerability 3. Increased social isolation 4. Increased sensory stimulation
Awareness of vulnerability
The parent brings a 9-month-old infant to the pediatric office with a fever of 102.2° F (39° C) and frequent vomiting. The nurse expects to find which reflex? 1. Babinski reflex 2. Moro reflex 3. Tonic neck reflex 4. Grasp reflex
Babinski reflex
The client has a three-way indwelling urinary catheter following a transurethral resection. Which finding causes the nurse to infuse the irrigating solution rapidly? 1. The urinary output is increased 2. Bright-red drainage or clots are present 3. Dark-brown drainage is present 4. The client reports pain
Bright-red drainage or clots are present
The client is admitted for a series of tests to verify the diagnosis of Cushing's syndrome. Which nursing assessment finding supports this diagnosis? 1. Buffalo hump 2. Intolerance to heat 3. Hyperglycemia 4. Hypernatremia 5. Intolerance to cold 6. Irritability
Buffalo hump, hyperglycemia, & hypernatremia
The client receives aminophylline IV. The client has clear lung sounds and unlabored breathing. Which is the MOST important nursing action if the client's IV infiltrates? 1. Apply warm soaks to the infiltration site, start a new IV, and continue IV medications 2. Wait 2 hours, reassess the client, and restart the IV if the client has wheezing or labored breathing 3. Restart the IV and continue the previous medication schedule 4. Call the healthcare provider and recommend the IV medication be changed to PO
Call the healthcare provider and recommend the IV medication be changed to PO
The nurse observes the student nursing care for the client. The student nurse wears a gown and gloves in addition to following standard precautions. The nurse determines care is appropriate if the student nurse performs which activity? 1. Gives isoniazid to a client with TB 2. Administers an IM injection to a client with rubella 3. Delivers a food tray to a client with hepatitis 4. Changes the dressing for a client with a draining abscess
Changes the dressing for a client with a draining abscess
Which is the MOST appropriate nursing action to take before administering captopril? 1. Check the client's apical pulse for 60 seconds 2. Check the client's BP 3. Check the client's urine output 4. Check the client's temperature
Check the client's BP
The child has a closed transverse fracture of the right ulna. Which nursing action before the application of a cast is most important? 1. Check the radial pulses bilaterally and compare 2. Evaluate the skin temperature and tissue turgor in the area 3. Assess sensation of each foot while the child closes the eyes 4. Apply baby powder to decrease skin irritation under the cast
Check the radial pulses bilaterally and compare
The client is to have an intravenous pyelogram (IVP). Nursing management includes which action? 1. A fat-free meal the evening before the examination and radiopaque tablets at bedtime 2. Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter 3. Cleansing enemas the evening before to provide for adequate visualization of the urinary tract 4. Explaining the importance of following directions regarding voiding during the test
Cleansing enemas the evening before to provide for adequate visualization of the urinary tract
A newborn client at 32 weeks' gestation weighs 4 lb 10 oz (2.12 kg) and has mottling of the skin and acrocyanosis with irregular respirations of 60 breaths per minute. Which newborn problem does the nurse suspect this client is experiencing? 1. Hypoglycemia 2. Cold stress 3. Birth asphyxia 4. Hypovolemia
Cold stress
The nurse cares for the elderly client receiving IV fluids of 0.9% NaCl at 125 mL/h into the left arm. During a routine assessment, the nurse finds the client has distended neck veins, shortness of breath, and crackles in both lung bases. Which action does the nurse take FIRST? 1. Decrease the IV rate to 20 mL/h and notifies the healthcare provider 2. Decreases the IV rate to 100 mL/h and continues to monitor the client 3. Discontinues the IV and starts oxygen at 6 L/min 4. Assesses for infiltration of the IV solution
Decreases the IV rate to 20 mL/h and notifies the healthcare provider
The client is returned to the unit after surgery with a cuffed tracheostomy tube in place. The nurse knows the purpose of the cuff on the tracheostomy tube includes which reason? 1. Guarantees secure placement of the tracheostomy in the airway 2. Prevents ischemia of the tracheal wall by distributing the pressure applied to it 3. Decreases the chance of aspiration into the trachea 4. Protects the trachea from ischemia and edema
Decreases the chance of aspiration into the trachea
The nurse provides care for a 2-day-old client. The neonate will not take formula from the parent or the nurse. Which is the priority nursing diagnosis? 1. Swallowing difficulty 2. Failure to thrive 3. Dehydration 4. Altered bonding
Dehydration
The nurse assesses the client with severe bilateral peripheral edema. Which is the BEST way for the nurse to determine the degree of edema in a limb? 1. Measure both limbs with the tape measure and compare 2. Depress the skin and rank the degree of pitting 3. Describe the swelling in the affected area 4. Pinch the skin and note how quickly it returns to normal
Depress the skin and rank the degree of pitting
The parent brings 10-year-old and 3-year-old children to the pediatric office. The young child reports dysuria. The healthcare provider orders a catheterized urine specimen. The nurse takes which action? 1. Describes the procedure to the child in short, concrete terms while taking calmly. 2. Allows the child to play with the equipment during the procedure 3. Involves the older sibling in explaining the procedure 4. Shows the child a diagram of the urinary system
Describes the procedure to the child in short, concrete terms while taking calmly
The nurse prepares a dopamine infusion for the client. Which action does the nurse take FIRST? 1. Evaluates the urine output 2. Obtains the client's weight 3. Determines the patency of the IV line 4. Measures pulmonary artery pressures
Determines the patency of the IV line
The nurse teaches a health class to a group of senior citizens. Which behavior does the nurse emphasize to facilitate regular bowel elimination? 1. Avoid strenuous activity 2. Eat more foods with increased bulk 3. Decrease fluid intake to decrease urinary losses 4. Use oral laxatives so a bowel pattern emerges
Eat more foods with increased bulk
The nurse in the outpatient clinic assists with the application of a cast to the left arm of the preschool-aged child. After the cast is applied, the nurse takes which action FIRST? 1. Petals the edges of the cast to prevent irrigation 2. Elevates the child's left arm on two pillows 3. Applies cool, humidified air to dry the cast 4. Asks the client to move the fingers to maintain mobility
Elevates the child's left arm on two pillows
A client suspects she is pregnant because the last menstrual period began May 8 and ended May 12. Which estimated date of birth will the nurse calculate for this client? 1. February 1 2. February 15 3. February 19 4. March 14
February 15
The client is receiving imipramine. It is important for the nurse to instruct the client to immediately report which symptoms? 1. Fever 2. Dry mouth 3. Increased fatigue 4. Vomiting and diarrhea 5. Staggering gait 6. Sore throat
Fever, dry mouth, increased fatigue, vomiting and diarrhea, & sore throat
The client has a neurological disorder. Which nursing assessment is MOST helpful to determine subtle changes in the client's level of consciousness? 1. Client posturing 2. Glasgow coma scale 3. Client thinking pattern 4. Occurrence of hallucinations
Glasgo coma scale
The client has orders for cefoxitin 2 g IV piggyback in 100 mL 5% dextrose in water. The primary IV is 5% dextrose in lactated Ringer's and is infusing by gravity. It is most important for the nurse to take which action? 1. Administer the medication slowly, at 20 to 25 mL/h. 2. Change the primary IV solution 3. Hang the piggyback infusion bag higher than the primary infusion bag 4. Obtain an infusion pump prior to administration
Hang the piggyback infusion bag higher than the primary infusion bag
The nurse assesses the client's neurosensory cerebella functioning. Which assessment technique is correct? 1. Test the client's deep tendon reflexes to observe for weakness 2. Check the client's pupils with a penlight and observe for constriction 3. Have the client's stand with eyes closed and observe for swaying 4. Ask the client to show the teeth and stick out the tongue
Have the client's stand with eyes closed and observe for swaying
The client is treated in the telemetry unit for cardiac disease. The client receives propranolol hydrochloride 20 mg PO at 09:00. When the nurse enters the room to give the medication to the client, the nurse finds the client wheezing with a nonproductive cough and shortness of breath. Initially the nurse takes which action? 1. Holds the medication and counts the respirations 2. Holds the medication and calls the healthcare provider 3. Takes an apical pulse and then gives the medication 4. Gives the medication as ordered
Holds the medication and counts the respirations
The neonate weighing 7 lb 4 oz with Apgar scores of 7 and 8 at 1 and 5 minutes, respectively. Because the infant's mother is diagnosed with type 1 diabetes, the nurse knows the infant is at greatest risk for developing which problem? 1. Hypovolemia 2. Hypoglycemia 3. Hyperglycemia 4. Cold stress
Hypoglycemia
The 25-year-old primigravida is diagnosed with type 1 diabetes mellitus. The nurse reviews the insulin regimen with the client. The nurse explains insulin needs will change in which way? 1. Increase during pregnancy and decrease after delivery 2. Decrease during pregnancy and increase after delivery 3. Increase during pregnancy and remain increased after delivery 4. Decrease during pregnancy and fluctuate after delivery
Increase during pregnancy and decrease after delivery
The nurse cares for the client one day after a thoracotomy. Nursing actions in the care plan include turn, cough, and deep breathe Q2H. Which does the nurse understand to be the purpose of this nursing action? 1. Promote ventilation and prevent respiratory alkalosis 2. Increase oxygenation and removal of secretions 3. Increase pH and facilitate and balance of bicarbonate 4. Prevent respiratory alkalosis by increasing oxygenation
Increase oxygenation and removal of secretions
The nurse obtains the client's temperature of 103° F (39.4° C). The nurse knows body compensatory mechanisms include which mechanism? 1. Decreased respiratory rate and bradycardia 2. Normal BP and pulse 3. Increased respiratory rate and tachycardia 4. Diaphoresis with cool, clammy skin
Increased respiratory rate and tachycardia
The nurse teaches nutrition classes at the community center. Which food does the nurse encourage the low-income client to eat to satisfy essential protein needs? 1. Legumes 2. Red meat 3. Seafood 4. Cheese
Legumes
The client is admitted to the hospital for a hemiglossectomy with lymph node dissection. The client's preoperative care includes frequent oral hygiene with normal saline. The nurse knows the purpose of this treatment includes which reason? 1. Minimizes the bacterial count in the mouth 2. Softens the mucous membranes of the tongue before surgery 3. Stimulates the microcirculation of the mouth 4. Hydrates the tissues of the gums
Minimizes the bacterial count in the mouth
The nurse cares for the elderly client diagnosed with dementia. Which nursing action is BEST? 1. Place the client in soft hand restraints or chair restraints 2. Monitor wandering behaviors during a 7-day period 3. Keep the lounge's television volume on a low level 4. Encourage a diet high in protein, iron, and vitamins
Monitor wandering behaviors during a 7-day period
The client takes phenelzine. The nurse observes the client eat another client's lunch. After a few minutes, the client reports headache, nausea, and rapid heartbeat, and begins to vomit. The nurse anticipates administering which medication? 1. Buspirone 2. Fluoxetine 3. Prochlorperazine 4. Nifedipine
Nifedipine
The nurse cares for the child who is in Buck's traction. The nurse notes the foot of the uninjured leg feels warmer to touch than that of the broken leg. The nurse takes which action? 1. Records the observation 2. Encourages the child to move the foot 3. Covers the colder foot with a sock 4. Notifies the healthcare provider
Notifies the healthcare provider
The client has an irregular pulse rate of 81 and a potassium level of 3.0 mEq/L (3.0 mmol/L). The client has digoxin ordered. Which nursing action is BEST? 1. Give the digoxin 2. Hold the digoxin 3. Notify the healthcare provider 4. Recheck the pulse
Notify the healthcare provider
The client has a diagnosis of a ruptured lumbar disc. The nurse anticipates which assessment finding? 1. Sensation loss in an upper extremity 2. Clonic jerks in the affected foot 3. Paresthesia in the affected leg 4. Chorea in the upper and lower extremities
Paresthesia in the affected leg
The client is admitted with irritable bowel syndrome. The nurse anticipates the client's history will reflect which information? 1. Pattern of alternating diarrhea and constipation 2. Chronic diarrhea stools occurring 10 to 12 times per day 3. Diarrhea and vomiting with severe abdominal distention 4. Bloody stools with increased cramping after eating
Pattern of alternating diarrhea and constipation
The client has been taking propranolol 40 mg bid and furosemide 40 mg daily for several months. Two weeks ago, the health care provider added verapamil 80 mg tid to the client's medication regimen. It is MOST important for the nurse to assess the client for which symptom? 1. Tachycardia 2. Diarrhea 3. Peripheral edema 4. Impotence
Peripheral edema
The nurse provides care for a client who has had an above-knee amputation (AKA) with an immediate prosthetic fitting. It is IMPORTANT for the nurse to take which action? 1. Assess drainage from site drains 2. Observe dressings for signs of excessive bleeding 3. Elevate the residual limb for no less than 40 hours 4. Provide cast care on the affected extremity
Provide cast care on the affected extremity
The client has just indicated a wish to commit suicide. The client then asks the nurse not to tell anyone. Which action by the nurse is BEST? 1. Encourage the client not to do anything without thinking it through carefully. 2. Explain to the client that anything told to the nurse is kept strictly confidential 3. Reports this to staff members in order to protect the client. 4. Encourage the client to tell the nurse more about what is being felt.
Report this to staff members in order to protect the client
The client is diagnosed with a hiatal hernia. Which information is the nursing assessment MOST likely to reveal? 1. A bulge in the lower right quadrant 2. Pain at the umbilicus radiating down into the groin 3. A burning sensation in the midepigastric area each day before lunch 4. Reports of awakening at night with heartburn
Reports of awakening at night with heartburn
The nurse cares for the client receiving a continuous tube feeding. Which nursing action is MOST appropriate? 1. Rinse the bag and change the formula every 4 hours 2. Rinse the bag and change the formula every shift 3. Rinse the bag and change the formula every 12 hours 4. Rinse the bag and change the formula every 2 hours
Rinse then bag and change the formula every 4 hours
The young adult is immobilized for trauma to the spinal cord. The client has periods of diaphoresis, a draining abdominal wound, and diarrhea. On the basis of the nursing assessment, which is the MOST important nursing diagnosis? 1. Risk for constipation related to immobilization 2. Risk for impaired skin integrity related to immobilization and secretions 3. Risk for infection related to involuntary bowel secretions 4. Risk for fluid volume excess related to secretions
Risk for impaired skin integrity related to immobilization and secretions
The nurse cares for the client who has just had a prosthetic hip implant. The nurse places the client in which position? 1. With the affected hip internally rotated and flexed 2. With the affected hip adducted when turned 3. In the supine position with the knees elevated 90 degrees 4. Side-lying with the affected hip in a position of abduction
Side-lying with the affected hip in a position of abduction
The client has partial-thickness and full-thickness burns over 75% of the body. The nurse is most concerned if which symptom is observed? 1. Epigastric pain 2. Restlessness 3. Tachypnea 4. Lethargy
Tachypnea
The older client diagnosed with pneumonia is admitted to the medical/surgical unit. Which other client does the nurse place with the older client? 1. The 20-year-old in traction for multiple fractures of the left lower leg 2. The 35-year-old with recurrent fever of unknown origin 3. The 50-year-old recovering alcoholic with cellulitis of the right foot 4. The 89-year-old with Alzheimer's disease awaiting long term care facility placement
The 50-year-old recovering alcoholic with cellulitis of the right foot
The nurse assists a nursing assistive personnel (NAP) in providing a bed bath to the comatose client with incontinence. The nurse intervenes if which action is noted? 1. The NAP answers the phone while wearing gloves 2. The NAP log rolls the client to provide back care 3. The NAP places an incontinence pad under the client 4. The NAP positions the client on the left side, head elevated
The NAP answers the phone while wearing gloves
The school nurse observes a group of preschool children in the playroom. The nurse recognizes which activity as appropriate behavior for the 5-year-old client? 1. The child plays with a large truck with another child 2. The child talks on a toy telephone and imitates same-sex parent 3. The child works on a puzzle with several other children 4. The child holds and cuddles a large stuffed animal
The child talks on a toy telephone and imitates same-sex parent
The charge nurse makes client assignments on the maternity unit. The RN has been reassigned to the maternity unit from outpatient surgery. Which client does the charge nurse assign to the RN? 1. The client at 16 weeks gestation admitted with hyperemsis and receiving IV fluids 2. The client at 26 weeks in premature labor and receiving terbutaline 3. The client at 32 weeks gestation with a placenta prevue and ruptured membranes 4. The client at 37 weeks gestation with severe preeclampsia and epigastric pain
The client at 16 weeks gestation admitted with hyperemesis and receiving IV fluids
The nurse reviews client assignments on a medical surgical unit. The nurse determines the assignment is appropriate if the nurse assistive personnel provides care for which client? 1. The client diagnosed with AIDS dementia complex and who requires a urine specimen 2. The client reporting postop pain after repair of a torn rotator cuff 3. The client diagnosed with GI bleeding due to a duodenal ulcer and who is receiving packed cells 4. The client diagnosed with type 1 diabetes and who is receiving prednisone for a herniated disk
The client diagnosed with AIDS dementia complex and who requires a urine specimen
The nurse cares for the client after right cataract surgery. The nurse intervene if which observation is made? 1. Client is in the supine position 2. The head of the bed is elevated 30 degrees 3. The client is lying on the right side 4. An eye shield is over the right eye
The client is lying on the right side
The client is diagnosed with right-sided weakness. The nurse instructs the client how to walk down stairs using a cane. Which client behavior indicates the teaching is successful? 1. The client puts the right leg on the step, then the cane, followed by the left leg. 2. The client leads with the cane, followed by the right leg and then the left leg. 3. The client advances the right leg, followed by the left leg and the cane. 4. The client puts the cane on the step and advances the left leg, followed by the right leg.
The client leads with the cane, followed by the right leg and then the left leg
The nurse cares for the client several days after an above-knee amputation (AKA). Which symptom is characteristic of an infected residual limb wound? 1. The client is anxious and restless 2. There is a small amount of dark drainage on the dressing 3. The client reports persistent pain at the operative site 4. The skin is cool above the operative site
The client reports persistent pain at the operative site
The healthcare provider orders morphine sulfate 8mg IM Q3 to 3 hours for pain PRN. In which situation does the nurse consider withholding the medication until further assessment is completed? 1. The client's reports acute pain from a partial-thickness burn affecting the lower left leg 2. The client's BP is 140/90, pulse is 90, and respiration is 28 3. The client's level of consciousness fluctuates from alert to lethargic 4. The client exhibits restlessness, anxiety, and cold and clammy skin
The client's level of consciousness fluctuates from alert to lethargic
The nurse checks for placement of a NG tube prior to initiating a tube feeding for the client. Which result indicates the tube feeding can begin? 1. A small amount of white mucus is aspirated from the NG tube 2. The contents aspirated from the NG tube have a pH of 3 3. No bubbles are seen when the nurse inverts the NG tube in water 4. The client says the NG tube can be felt in the back of the throat
The contents aspirated from the NG tube have a pH of 3
The nurse checks the incision of the client 48 hours after surgery for a hernia repair. Which finding indicates a possible complication? 1. There is swelling under the sutures 2. There is crusting around the incision line 3. The incision line is red 4. The incision line is approximated
The incision line is red
The nurse administers Rho(D) immune globulin to prevent complications in which client situation? 1. The baby is Rh-negative, the mother is Rh-negative, and the father is Rh-positive. 2. The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs. 3. The mother is Rh-positive and previously sensitized, and the baby is Rh-negative. 4. The mother is Rh-positive, the baby is Rh-negative, and there is a history of one incomplete pregnancy.
The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs.
The nurse supervises care given to clients a medical surgical unit. The nurse intervene if which activity is observed? 1. The nurse and client wear masks during a dressing change for the central catheter used for total parenteral nutrition 2. The nurse injects insulin through a single-lumen percutaneous central catheter for the client receiving total parenteral nutrition 3. The nurse applies lip balm to the lips immediately after performing a blood draw to obtain a specimen 4. The nurse wears a disposable particulate respiratory when administering rifampin to the client with TB
The nurse applies lip balm to the lips immediately after performing a blood draw to obtain a specimen
The nurse cares for the male client diagnosed with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase test are to be done. Which statement best describes the rationale for doing these tests? 1. These tests are valuable screening tests for prostatic cancer 2. The level of PSA is decreased in clients with renal calculi 3. The tests reflect the level of renal involvement in acid-base problems 4. The level of PSA is elevated in clients in early-stage kidney failure
These tests are valuable screening tests for prostatic cancer
The 6-month-old infant has had all of the required immunizations for that age. The nurse knows this includes which immunizations? 1. Three doses of diphtheria, tetanus, and pertussis vaccine 2. Measles, mumps, and rubella vaccine 3. One dose of rotavirus 4. Varicella vaccine
Three of diphtheria, tetanus, and pertussis vaccine
The client has a total laryngectomy with a permanent tracheostomy. The nurse plans nutritional intake for the next 3 days. Which action is necessary for the nurse to consider regarding the client's nutrition? 1. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented. 2. The client will be unable to maintain any oral intake as long as the tracheostomy is in place. 3. Nutritional and/or gastric feedings will not be attempted for approximately 3 weeks to decrease the incidence of aspiration. 4. Because the client is dependent on the ventilator, nutritional intake will be delayed.
To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented.
The nurse cares for the client admitted with a diagnosis of acute hypoparathyroidism. It is MOST important for the nurse to have which items available? 1. Tracheostomy set 2. Cardiac monitor 3. IV monitor 4. Heating pad
Tracheostomy set
The nurse cares for the elderly client who is admitted with confusion, mood lability, impaired communication, and lethargy. Which order from the healthcare provider does the nurse question? 1. Dexamethasone suppression test 2. Thyroid studies 3. Drug toxicology screen 4. Trendelenburg test
Trendelenburg test
The nurse conducts a physical examination of the client suspected to have bulimia. Which nursing observation MOST likely indicates bulimia? 1. Edema of the lower extremities 2. The presence of lanugo 3. Ulcerated oral mucous membranes 4. Dry, yellowish colored skin
Ulcerated oral mucous membranes
The teenage client diagnosed with anorexia nervosa is admitted to the hospital. Which behavior does the nurse expects the client to present? 1. View appearance as "skinny." 2. Be hypoactive and withdrawn 3. Want to discuss and plan meals 4. Have a close relationship with a parent
Want to discuss and plan meals
