NCLEX-RN Exam Flash Cards

The nurse understands that which are judgmental statements? Select all that apply.

* "I don't think you need to do that." * "I'm not sure that's what is best for you."

The nurse is conducting a respiratory assessment and is determining respirations per minute. The nurse understands that which factors generally affect the character of respirations? Select all that apply.

* Anxiety * Exercise * Smoking * Acute Pain * Body position

Which communication strategies should the nurse use when working with a client who has difficulty speaking as a result of weakness? Select all that apply.

* Ask "yes" and "no" questions when able. * Have the client use a communication board. * Repeat what the client said to verify the message. * Use a pen and paper to communicate client needs.

The nurse understands that which are characteristics of anthrax? Select all that apply.

* Cutaneous lesions become a black eschar. * Gastrointestinal anthrax causes bloody diarrhea. * Flulike symptoms are a sign of pulmonary anthrax. * Person-to-person transmission of inhalation disease does not occur. * A person can become infected through skin contact, ingestion, or inhalation of the bacillus.

The nurse performing a home assessment on an older client would be concerned about which unsafe findings? Select all that apply.

* Electrical cords taped to the floor * Electrical appliances and cords near the sink

An older client has been lying in bed for 2 hours. The nurse who is repositioning this client would be most concerned with examining which areas of the client's body? Select all that apply.

* Heels * Sacrum * Back of the head * Greater trochanter

The nurse is analyzing laboratory values that were prescribed to determine nutrition status for the older adult client. Which laboratory values would be of concern to the nurse? Select all that apply.

* Hematocrit 30% (0.30) * Albumin 3.0 g/dL (30 g/L) * Hemoglobin 8 g/dL (80 mmol/L)

The nurse is caring for a client whose religious background is Seventh Day Adventist (Church of God). Which nursing actions are the most appropriate in terms of providing for the dietary needs for this client? Select all that apply.

* Removing coffee from the breakfast tray. * Ensuring that there is no pork on the dinner tray. * Ensuring that meals are delivered in a timely fashion.

The nurse is providing home care instructions to the client diagnosed with severe acute respiratory syndrome (SARS). Which statement, if made by the client, indicates a need for further instruction?

"It is okay to share eating utensils after a few days."

A postoperative client says to the nurse, "'Don't touch me. I'll take care of myself!!" Which response is therapeutic?

"Let's work together so you can do things for yourself."

A client is admitted to a medical unit with nausea and bradycardia. The family is upset and states, "That doctor doesn't know how to take care of my father." The most therapeutic response by the nurse is which statement?

"You are concerned that your loved one receives the best care."

The nurse is caring for a client whose religious background is Orthodox Judaism. The nurse is delivering the dinner tray to the client. Which nursing actions are most appropriate in order to provide for the dietary needs of this client? Select all that apply.

* Removing the milk if there is meat on the tray * Determining that any fish being served have scales or fins * Checking to be sure that any meat being served is from an herbivore * Asking the client about any specific dietary preferences that need to be followed

The nurse understands that which are examples of a nosocomial infection occurring in a health care facility? Select all that apply.

* Sepsis that results from contaminated intravenous fluid * A urinary tract infection that develops after catheter insertion. * A streptococci wound infection that develops in a postoperative client. * The development of Clostridium difficile in an immunocompromised client. * A respiratory tract infection that develops in a client receiving frequent respiratory treatments and requiring frequent suctioning.

The nurse understands that which procedures are used to detect the presence of dysrhythmias? Select all that apply.

* Telemetry * Holter monitor * Electrocardiogram

Which safety measures should be included in the plan of care for a client with an internal radiation implant? Select all that apply.

* Wear a lead shield when in the client's room. * Wear a dosimeter badge when entering the client's room. * Save bed linens and any dressings until the implant is removed.

The nurse determines that the client understands the elements of follow-up care after a bone scan if the client states that he or she should perform which actions? Select all that apply.

*Resume the usual diet. * Drink plenty of water for a day or 2 following the procedure.

The primary health care provider prescribes 500 mLl of 0.9% NS to run over 6 hours. The drop factor is 10 drops per 1 mL. The nurse safely adjusts the flow rate to run at how many drops per minute? Fill in the blank. Round to the nearest whole number.

14 gtt/min

Ampicillin sodium 250 mg in 50 mL of NS is being administered over a period of 30 minutes. The drop factor is 10 drops per 1 mL. The nurse determines that the infusion is running safely at the prescribed rate if the infusion is delivering how many drops per minute. Fill in the blank. Round to the nearest whole number.

17 gtt/min

The primary health care provider prescribes a bolus of 500 mL of 0.9% NS to run over 4 hours. The drop factor is 10 drops per 1 mL. The nurse plans to safely adjust the flow rate at how many drops per minute? Fill in the blank. Round to the nearest whole number.

21 gtt/min

The nurse is auscultating the apical heart rate of a client who is not taking any prescribed medications and notes that the heart rate is regular. To determine beats per minute, the nurse should measure the apical pulse for how many seconds?

30 seconds

The primary health car provider prescribes 1000 mLl of 0.9% NS to run over 8 hours. The drop factor is 15 drops per 1 mLl. The nurse safely adjusts the flow rate to run at how many drops (gtt) per minute? Fill in the blank. Round to the nearest whole number.

31 gtt/min

The nurse auscultates bowel sounds and suspects an intestinal obstruction in a client with a bowel tumor if which is heard?

High pitched sounds.

As prescribed, the nurse is applying a dressing to a client's wound that allows wound visualization, is waterproof, and is painless on removal. Which type of dressing material is being used.

Hydrocolloid

The nurse is caring for a client who is retaining carbon dioxide (CO2) due to respiratory disease. The nurse anticipates that as the client's CO2 level rises, the pH will most likely be which value?

7.30

The nurse understands that which identifies a correct principle of surgical sepsis?

A sterile package that becomes wet is unsterile.

The nursing instructor asks a nursing student to identify the type of isolation precautions necessary for the client with active tuberculosis (TB). The student understands the route of transmission if the student states that which type of isolation precaution should be maintained?

Airborne precuations

An adolescent client with a surgically wired jaw has a prescription for a full liquid diet. The nurse should implement which action to promote the client's compliance with this diet prescription?

Ask about food preferences and blend these foods into liquids.

The nurse is reviewing the plan of care for the client who has just undergone bilateral knee replacement. Which intervention, if noted in the plan of care, indicates the need for follow up?

Begin continuous passive range-of-motion exercises immediately.

The pulse point to use when assessing a pulse in an infant is located in which area?

Brachial

The nurse is conducting a cardiovascular physical assessment on a client. The nurse is shown palpating which pulse. Refer to the figure.

Carotid

The nurse prepares to bathe and change the bed linens of a client with localized herpes zoster. The lesions are open and draining a scant amount of serous fluid. Which precaution should the nurse ensure is followed by all health care workers?

Contact

The nurse is administering enteral feedings via a nasogastric (NG) tube. The nurse should take which action when caring for this client to maintain client safety?

Check for tube placement and residual at least every 4 hours.

The nurse is caring for an 18-month-old child who has been diagnosed with scabies. The primary health care provider has prescribed lindane to be applied to the skin to treat the infection. The nurse should take which most appropriate action at this time?

Contact the primary health care provider for clarification.

The nurse is analyzing the laboratory report for the client who had a specific gravity determination drawn. The report indicates a value of 1,030. The nurse understands that which conditions may potentially be causing this result?

Decreased renal perfusion

The nurse finds an infant unconscious and suspects a foreign-body airway obstruction (FBAO). The nurse plans to relieve the obstruction by performing which action?

Delivering 5 back slaps and 5 chest thrusts.

Which should be included in a change-of-shift report?

Describing objective measurements or observations about a client's condition.

The clinic nurse is discussing nutrition with a client who is lactose intolerant. The nurse should instruct the client to supplement the dietary source of calcium by eating which food?

Dried fruits

The prescription for a client reads "cleansing enemas until clear". The nurse has administered a total of 3 enemas, and the output is liquid brown. The nurse notifies the primary health care provider, understanding that continued administration can result in which outcome?

Electrolyte disturbances.

The nurse is preparing the client for transfer to the operating room (OR). The nurse should take which action in the care of this client at this time?

Ensure that the client has voided.

The nurse witnesses a construction worker fall from a ladder. The nurse rushes to the victim, who is unresponsive and uses which method to open the victim's airway?

Jaw thrust maneuver

The nurse is demonstrating adult cardiopulmonary resuscitation (CPR) chest compression techniques to health care team members. Which action performed by a member on return demonstration indicates the need for additional teaching in the performance of CPR?

Lets the fingers rest on the chest.

The nurse provides instructions to the client using an incentive spirometer and tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse incorporates the understanding that which action is the primary benefit?

Maintain inflation of the alveoli

The nurse is caring for a hospitalized child with a diagnosis of measles (rubeola). In preparing to care for the child, which supplies should the nurse bring to the child's room to prevent the transmission of the virus?

Mask, gown, and gloves

The nurse should take which action to accurately determine the length of a nasogastric tube for insertion in an adult client?

Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.

The nurse reviews the most current laboratory data for the 4 clients to whom the nurse is assigned. The nurse should first assess the client with which laboratory result?

Platelets 40,000 mm3

The nursing instructor is observing a nursing student transfer a client from the bed to the chair. The instructor intervenes if the student is observed performing which action?

Positioning self as far away from the client as possible.

The nurse should institute contact precautions for which disease?

Respiratory syncytial virus

Which client is at greatest risk for fluid volume deficit?

The client on diuretic therapy.

The nurse is assigned to the following 4 clients for total care during the day shift. Breakfast trays are arriving, and the common practice on the unit is to assist clients to the bedside chair to eat. Which client will require the greatest assistance from the nurse?

The client who underwent right hip replacement.

The nurse prepares to bathe and change the bed linens of a client with methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound covered by a dressing. Which protective action should the nurse take during the bathing of this client?

Wears a gown and gloves.

The nurse is performing catheter care for a client who has an indwelling urinary catheter. Which action, if performed by the nurse, is indicative of unsafe practice?

The nurse cleans from the area of most contamination to the area of least contamination.

The nurse is preparing to assist a client who is able to transfer with 2 assistants from the bed to the chair. The nurse requests assistance from staff members, but no staff members are able to help at this time. Which action by the nurse is most appropriate at this time?

Use a mechanical lift to transfer the client from the bed to the chair.