NCLEX RN practice quiz

The nurse recognizes which manifestations as signs of community-acquired pneumonia?

- Cough - Fever - Myalgia - Pleuritic chest pain.

A client with chronic arterial occlusive disease has a bypass graft of the left femoral artery. Postoperatively, the client develops left leg pain and coolness in the left foot. What is the priority action by the nurse?

Notify the primary healthcare provider

For a client with a major burn, which evaluation criterion identified by the nurse best indicates that fluid resuscitation has been effective during the first 24 hours of care?

Urine output of 860 mL/24 hours

The nurse, assessing the lung sounds of a client diagnosed with pneumonia, notes diminished lung sounds and dull percussion in the lower lungs bilaterally. What intervention is correct by the nurse?

Instruct the client to perform incentive spirometer every hour.

The nurse is examining a client in the emergency department who is suspected of having acute cholecystitis. What data obtained by the nurse would help to validate this problem?

- Abdominal guarding - Anorexia - Positive murphy's sign - Steady epigastric pain

When caring for a client on bedrest, which interventions should the nurse implement to decrease the risk of deep vein thrombosis?

- Apply compression hose - Assist client to perform active foot and leg exercises - Place client on intermittent pneumatic compression device.

A community health nurse is planning to discuss how to prevent pesticide ingestion at a local health fair. What should the nurse include in this teaching session?

- Discard the outer leaves of lettuce - Buy organic produce - Peel fruits prior to eating - Dry produce thoroughly with disposable paper towels after washing - Use a scrub brush when washing fresh fruits and vegetables.

Th nurse initiates sterile wound care on a client's newly debrided foot ulcer. After removing the dressing and beginning a betadine cleanse, the client mentions an allergy to iodine not previously reported. Place the nursing actions in order of priority.

1. Ask client about the type of "allergic response." 2. Remove betadine solution from found with normal saline 3. Cover wound with temporary sterile dressing 4. Observe client for signs or symptoms of reaction 5. Notify primary care physician.

The nurse is preparing to administer scheduled medications for a client. Which medication would require clarification prior to administration?

Bumetanide - is a loop diuretic - the client is allergic to sulfonamides, there is a cross sensitivity with thiazides and sulfonamides.

The nurse is preparing to discharge four clients from the unit. Which client is most likely to warrant a referral to other agencies or community outreach programs?

72-year-old client with diabetes and obesity

The nurse is performing sterile wound care for partial thickness burns on a client's lower right leg. Prior to initiating this procedure, what action should the nurse complete first?

Assess current pain level and medicate

An elderly client returns to a surgical room from the post anesthesia care unit (PACU) following an open reduction and fixation of a fractured ankle. Which nursing assessment of the client takes priority?

Complete vital signs

During a health fair, a client asks the nurse about the methods used to detect prostate cancer. What should the nurse tell the client about the detection process?

Digital rectal exam (DRE) and prostate-specific antigen (PSA) test to evaluate the prostate

A farm worker comes into the clinic reporting headache, dizziness, and muscle twitching after working in the fields. What condition does the nurse suspect?

Pesticide exposure

A client has arrived at the emergency room reporting tingling to both lower legs over the past 24 hours. The only significant health history is a cold for the past week. During the nursing assessment, the client indicates that both thighs are feeling numb. What priority action should the nurse initiate immediately.

Prepare for intubation. - Symptoms indicate the onset of Guillian-Barre syndrome - an acute inflammatory disease that may occur following a respiratory illness and is characterized by progressive, ascending paralysis.

A client is being evaluated for possible Rheumatoid Arthritis (RA). Which assessment finding by the nurse would be indicative of RA?

- Spindle shaped fingers - Ulnar drift.

Which signs and symptoms will the nurse include when teaching a client about indicators of recurrent nephrotic syndrome?

Foamy urine Periorbital edema

An elderly client comes to the clinic for a check-up. The clients daughter tells the nurse that her father's dementia symptoms become increasingly more difficult to handle in the evening. How would the nurse document this symptoms?

Sundowning

Four clients are admitted to the medical-surgical unit. The nurse is aware that what client will need standard precautions only.

The client with pancreatitis.

An elderly client is admitted to the floor with vomiting and diarrhea for three days. The client is receiving IV fluids at 200 mL/hr via pump. What would be the priority nursing action?

Frequent lung assessments.

A nurse is planning a teaching session for a group of clients diagnosed with irritable bowel syndrome. What points should the nurse include to help the clients control symptom flare-ups?

- If you are constipated, try to make sure you have breakfast - If you think a certain food is the problem, try cutting it out of your diet for about 12 weeks. - Drinks containing caffeine are more likely to contribute to symptoms.

A client reports dizziness and weakness while walking down the hall. The nurse notes the client's cardiac rhythm displayed on the telemetry monitor. What actions should the nurse take?

- Obtain client's blood pressure - Auscultate lung sounds

The community health nurse is planning to teach nutritional education to a group of adults attending a health fair. What tips about health eating should the nurse include?

- Pay attention to fullness cues during meals - Use a smaller plate for meals.

The nurse is caring for a client who has aphasia. What interventions should the nurse include in the plan of care to improve communication with this client?

- Present one thought at a time - Use and encourage use of gestures - Do not push communication if client is tired - Give client time to generate a response - Ask questions that can be answered with "yes" or "no"

Which discussion points should a nurse plan to include when teaching a group of college students on prevention of sexually transmitted infections?

- Safe sex practices - sexual abstinence - vaccinations for STIs